metastatic spine disease moderator jack rock, md department of neurosurgery henry ford health system

Metastatic Spine Disease

Moderator Jack Rock, MD

Department of Neurosurgery

Henry Ford Health System

• 61 year old female• History of breast Cancer, HTN• Back pain for 1 week

Case Presentation

• No detectable weakness • Hypereflexia in lower extremities • Babinski

Case Presentation

Case Presentation ( Please Choose appropriate case)

Case Presentation

What would you do?

1- Medical treatment (Steroids, Pain Rx, Brace)2- Radiation therapy3- Surgical treatment (laminectomy ,Fusion) 4- Bone augmentation for non-surgical mets

Electronic Voting

Treatment options for Spine Metastasis and Spinal Cord Compression

Samuel Ryu, MDProfessor, Director of Radiosurgery

Radiation Oncology and NeurosurgeryHenry Ford Health System

Treatment Pros Cons

Steroid Immediate neurologic relief Short duration

External beam radiotherapy

Main-stay treatmentPain reliefNeurologic improvementNon-invasive

Protracted coursePain recurrenceNeurologic progressionKnocks down bone marrow

Surgery (Circumferential decompression, Laminectomy)

Rapid neurologic improvementTissue diagnosis

Invasive Reconstruction is neededLong recovery timeNeeds radiotherapy

VertebroplastyPain reliefImprove spinal stability?

No tumor controlChemical leakage

Treatment of spine metastasis cord compression

Radiosurgery

Rapid pain & neurologic reliefSpinal cord decompressionNon-invasiveConvenienceBone marrow sparing

Cannot correct compression fracture or Spine instability

Radiotherapy30 Gy in 10 fractions

Radiosurgery

Rapid Pain Relief Durable Pain relief

1-yr pain control 84%

Phase II - Radiosurgery of Vertebral mets

Months after RS%

Pai

n re

lief

Median time to pain

relief 14 days

(Ryu et al. Pain Symp Manag, 2008)

RTOG 0631Randomized Phase II/III Study ofRadiosurgery vs. EBRT for Localized Spine Metastasis

Solitary (1-3) spine metastasis

Radiosurgery (16 Gy)

Follow-up1. Pain score & QOL q month2. Clinical and neuro exams q month3. Imaging (MRI) q 2 months

EBRT8 Gy single dose

Single arm lead-in (49 pts)

Radiosurgery (16, 18 Gy)

2:1 Randomized (240 pts)

(1) (2) (3)

12/4/04Breast cancer 16 Gy

1/29/05

Control of Spinal Cord Compression

90%

50%

65 14% Epiduralvolume reduction

Thecal sac patency 553 % 773 %

Decompressive Radiosurgery

Epidural tumor size 0.840.07 mm2 0.410.06 mm2

Thecal sac area 1.060.06 mm2 1.390.10 mm2

Patchel’s Phase III Trial Ryu’s Phase II Trial

S+RT RT Alone Radiosurgery

Overall Ambulatory rate

84% (42/50)

57% (29/51)

Overall Intact rate

81% (50/62)

Duration ambul 122 d 13 d

Ambulatory rate in ambulat pts

94% (32/34)

74% (26/35)

Intact rate in intact pts

88% (31/35)

Ambulatory rate from nonambulat

62% (10/16)

19% (3/16)

Intact rate from deficit

59% (19/27)

Comparison of Neurological Outcome

Neurological Outcomeby Radiosurgical Decompression

Neuro before radiosurgeryNeuroafter RS No deficit Deficit

Normal 31 pts 16 pts

Improved - 3 pts Stable - 3 pts

Progressed 4 pts 5 pts

Total 35 pts 27 pts

19% (12/62)Progress

81% of total ptsimprove

(Ryu, Cancer 2010)

Radiographic Grade

0I

IIIV, V

III

Dual grading system of metastatic epidural compression

a No abnormality

b Minor symptoms (eg, pain, radiculopathy, sensory change)

c Functional paresis Muscle power ≥ 4/5.

-nerve root sign or spinal cord sign-functional in the upper extremity-ambulatory in the lower extremity

d Non-Functional paresisMuscle power ≤3/5.

-non-functional in the upper extrem-non-ambulatory in the lower extrem

e Paralysis, Incontinence

Neurological Grade

0 Spine bone involved only

I Thecal sac impinged

II Thecal sac compressed

III Spinal cord impinged

IV Cord displaced/compressed, CSF visible between cord and tumor, Partial block

V CSF not visible, Complete block

Treatment for Canal Compromise at Henry Ford

7/08 10/08

Renal cell ca, T12, Grade 4b, 18 Gy

For radiosurgery

Spinal cord compression in ambulatory patients (≥ 4/5 power)

Imaging : No upper limit to the extent of spinal cord compression at this time

For surgery

Significant neurological deficit (≤ 3/5 motor power)

Compression fracture with bony retropulsion

Spinal instability

Grade 2a, Neuro intact

3 mon

Surgical Options for Spine Metastases

Ian Lee, MDStaff Neurosurgeon

Hermelin Brain Tumor CenterHenry Ford Health System

September 21, 2012Comprehensive Spine Symposium

Disclosures

None

Surgery for Spine Metastases

Up to 35% of cancer patients will develop spine metastases

>20,000 new cases each year

Multiple levels of involvement in 40-70%

12-20% of patients will present with spine symptoms as first manifestation of cancer

Spine Metastases

Because most mets originate in the vertebral body, the site of compression is usually ventral

Tumor infiltration can also cause mechanical instability due to weakening of the bone


In the past, treatment was primarily radiation

Surgery sometimes offered, but without significant benefit

Retrospective studies demonstrated laminectomy resulted in neurologic improvement in a minority of patients and unsustained (Sorensen et al 1990, Constans et al 1983)


In addition, outcomes compared to EBRT were equivalent with or without laminectomy (Byrne 1992, Young et al 1980)

Thus, nihilistic attitude regarding role of surgery in metastatic spine disease


In 1980’s, newer techniques of surgery allowed for more aggressive extirpation of disease and reconstruction


RCT recently demonstrated superiority of sugical decompression + EBRT vs. EBRT alone (Patchell, Lancet 2005)

Surgery + EBRT both preserved and regained ambulation better than EBRT

First Class I study demonstrating advantage of surgery in treatment of metastatic disease


However, surgery is not without drawbacks– Morbidity as high as 20% in some series– Prolonged hospital time, rehabilitation time

Many patients cannot or are unwilling to tolerate surgery

Surgery for Spine metastasesRecommendations

Indications for surgery:– Rapid neurologic deterioration– Mechanical instability– Intractable radicular pain/myelopathy– Compression due to bony retropulsion– Relatively limited extant of bony disease/compression– Relatively limited extraspinal disease/good performance status– Prognosis > 3 months


Surgical Approaches now available:– Posterior

Laminectomy

– PosterolateralTranspedicular

Costotransversectomy

Lateral Extracavitary

– Lateral/AnteriorRetroperitoneal

Transthoracic

Posterior approach

Advantages: Familiar approach, less invasive/morbidDisadvantages: Does not directly address pathology, can cause instability

Has fallen out of favor in the surgical treatment of metastatic disease

from “Review: complications of surgery for thoracic disc disease”.Fessler RG, Sturgill M.Surg Neurol. 1998 Jun;49(6):609-18

Anterior/Lateral Approach

Advantages: Directly address pathology

Disadvantages: Requires two-stage operation

Posterolateral Approaches

Surgical Approach

Posterolateral approaches (transpedicular, costotransversectomy) have become increasing popular

Allows for circumferential decompression and stabilization

Posterolateral approach

Requires working around the spinal cord and sacrifice of nerve roots– Less common surgical approach, technically

demanding– Small risk of cord infarct with nerve root

sacrifice (esp. mid-lower thoracic)

Surgical technique – Transpedicular/Costotransversectomy

From Wang et al. March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.

Surgical technique – Transpedicular decompression


Surgical technique - Stabilization


Surgery for Spine Metastases Conclusions

For patients with good performance status and relatively limited disease, surgery should be strongly considered

Order of surgery vs RT should be considered as well– Preop RT increases complication rate of

surgery

Surgery for Spine MetastasesCurrent/Future InvestigationsMore aggressive surgical extirpation – e.g. en bloc spondylectomy– Does histology matter?

Less aggressive surgical decompression followed by SRS

Intraoperative radiotherapy

Phase III trials comparing SRS and surgery

Spine Metastases - ReferencesConstans JP, de Divitiis E, Donzelli R, et al: Spinal metastases with neurological manifestations. Review of 600 cases.

J Neurosurg 59:111–118, 1983

Sorensen S, Borgesen SE, Rhode K, et al: Metastatic epidural spinal cord compression. Results of treatment and survival. Cancer 65:1502–1508, 1990

Byrne TN: Spinal cord compression from epidural metastases. N Engl J Med 327:614–619, 1992

Young RF, Post EM, King GA: Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg 53:741–748, 1980

Patchell RA, Tibbs PA, Regine WF, et al: Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005 Aug 20-26;366(9486):643-8

Ghogawala Z, Mansfield FL, Borges LF: Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression. Spine (Phila. Pa 1976) 26(7), 818–824, 2001

Shiue K, Sahgal A, Chow E, Lutz ST, Chang EL, Mayr NA, Wang JZ, Cavaliere R, Mendel E, Lo SS: Management of metastatic spinal cord compression . Expert Rev Anticancer Ther. 10(5):697-708, 2010

Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 15;11(6):e10, 2001

Fessler RG, Sturgill. Review: complications of surgery for thoracic disc disease. M.Surg Neurol. 1998 Jun;49(6):609-18

Wang JC, Boland P, Mitra N, Yamada Y, Lis E, Stubblefield M, Bilsky MH. Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.

Bone Augmentation For Non-surgical Mets

Yahya Albeer, MD

Department of Radiology

Henry Ford Health System

Metastatic Bone DiseaseTreatment Goals

• Reduce pain• Eradicate or reduce tumor when primary

tumors are involved • Prevent neurologic complications • Treat pathologic fractures and prevent

recurrent fracture

Primary and Metastatic Bone DiseaseAvailable Treatments - Other1

• Radiation Therapy– Therapeutic: Reduce tumor in primary bone

cancer– Palliative: Relieve pain related to bone metastasis

• Surgery– To provide stability to compromised bone– To prevent neurologic deterioration after fracture

1. American Cancer Society, 2006.

Results for Tumor Treatment

• Kyphoplasty and Vertebroplasty similar• Pain relief in 75-85% of malignant lesions

treated with vertebroplasty• The presence of epidural tissue does NOT

preclude treatment*• Shimony et al Radiology 2004;232:846-853• Fourney et al J Neurosurg (Spine 1) 2003; 98:21-30• J Clin Neurosci 2011 Jun;18(6):763-7. Epub 2011 Apr 19.• J Surg Oncol 2010 Jul 1;102(1):43-7.• Radiology 2010;254(3):882-890• AJNR 2007;28: 570-574

Q&A

Jack Rock, M.D.

Department of Neurosurgery

Metastatic Spine Disease: Conclusions

Most patients with metastatic disease involving the spine will be managed effectively either with observation or radiation

For patients with spinal cord compression and rapidly progressing neurological deterioration or significant neurological compromise (i.e., non-ambulatory), tailored surgical decompression +/- fusion remains the gold standard

For ambulatory patients with spinal cord compression, radiosurgery is proving to be effective in most cases

As a treatment for painful spinal metastases vertebro- and kyphoplasty are effective augmentation procedures

Thank you

metastatic spine disease moderator jack rock, md department of neurosurgery henry ford health system

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