Metastatic Tumors of the Spinal Column: Diagnosis and Management

1. Metastatic Tumors
of the
Spinal Column:
Diagnosis and Management
GEORGE SAPKAS
PROFESSOR AT ORTHOPAEDICS
Metropolitan Hospital Athens

2. Epidemiology
Pneumon’s metastasis

3. Συχνότητα άνα περιοχή
Metastasis
 CA- breast 45-85%
 CA- lung 35-60%
 CA-kidney 35-40%
 CA- prostate 35-85%
 CA- thyroid 30-60%

Skull 35%
Cervical spine 22%
Humerus 10%
Ribs 57%
Thoracic spine 37%
Lumbar spine 53%
Sacrum 6%
Pelvis 19%
Femur 22%

4. Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004

5. Sites of primary tumors
Breast
Pneumon
Prostate
Renal
Thyroid
75%
Pneumon’s metastasis

6. The most common
location for skeletal
metastasis:
• Thoracolumbar region
~ 70%
• Lumbar and sacral
spine ~ 20%
• Cervical spine ~ 10%
Gilbert R.W. et al.
Ann. Neural. 1998 Pneumon’s metastasis

7. European Review for medical and Pharmacological sciences 2004

8. Vertebral metastases are
the first sign of
malignant disease in 12%
to 20% of the cases.
Schick V. et al.
Neurosurg. Rev. 2001
Schiff D. et al.
Neurology 1997
Pneumon’s metatstasis

9. Clinical
symptoms of
spinal metastasis
Pain
Neurologic deficit

10. The spinal pain may be due:
In destruction of the anatomic
vertebral elements as a result
of metastases
Resulting spinal instability
The pain is possible to occur
as a result of:
compression
or
infiltration of the spinal
cord – nerves from neoplasmatic
masses.
Pain

11. Pathologic spinal
fracture
Spinal pain
Instability Compression
of the neural
tissues
Neurologic
deficit

12. Diagnosis of
spinal metastases
M.K.
F 81
2yrs POP
Thyroid metastasis
L3
L3
T12
T12

13. CT
3-D

14. Kidney’s metastasis
M.R.I.

15. Tc 99 MDP
SCANNING

16. Lemphoma
P.E.T.

17.  Graig’s trocar
 C.T. – guided
percutaneous
needle - trocar
Biopsy of the spine

18. Treatment
Medical treatment
Chemotherapy
Hormone therapy
Immunotherapy
Radiotherapy
Operative

19. Medical treatment
Chemotherapy
Anti-tumor medication
Steroids
Bi-phosphonates

20. Chemotherapy
Highly sensitive
Childhood cancers like
acute lymphocytic leukemia
Wilms tumor
Ewing’s tumor
Retinoblastoma
Rhabdomyosarcoma
Hodgkin’s lymphoma.
Carcinoma of the testis.
Choriocarcinoma.
Burkitts tumor.
Acute promyelocytic leukemia.
Costachescu E. et al 2010

21. Chemotherapy
Moderately sensitive
Adenocarcinoma of breast.
Non-Hodgkin’s lymphoma.
Lung cancer.
Osteosarcoma.
Adult myeloid and lymphocytic leukemia.
Carcinoma of the prostate.
Colorectal carcinoma.
Female cancers of the ovary, endometrium,
and cervix.
Costachescu E. et al 2010

22. Chemotherapy
Minimally sensitive
Endocrine gland cancers.
Malignant melanoma.
Hepatocellular carcinoma.
Renal carcinoma.
Pancreatic carcinoma.
Costachescu E. et al 2010

23. Hormonal therapy
Is administered in breast and prostate cancer.
In breast cancer
tamoxifen,
aromatase inhibitors
fulvestrant
In prostate cancer
LHRH-analoges,
anti-androgens
novel hormonal compounds
(abiraterone and enzalutamide)

24. Targeted therapies
Are used in various tumors and include monoclonal antibodies and TKIs
(tyrosine kinase inhibitors).
In breast cancer anti-HER2 agents (trastuzumab, pertuzumab, TDM1 and
lapatinib) are used, in combination with chemotherapy or hormonal
therapy, in patients with HER2-positive disease.
In hormone-sensitive breast cancer the mTOR inhibitor everolimus is
used in combination with aromatase inhibitors for reversal of the
resistance to hormonal therapy.
In renal cell carcinoma anti-angiogenic TKIs (sunitib, pazopanib, axitinib)
and mTOR inhibitors (temsirolimus and everolimus) are used.
In NSCLC anti EGFR TKIs (gefitinib, erlotinib, afatinib) and ALK-inhibitors
(crizotinib) are effective agents.

25. Bi-phosphonates
Tend to inhibit osteoclast
re-absortion of bone matrix and
decrease bone turnover.
There are three generations of
bi-phosphonate currently
available.
Costachescu E. et al 2010

26. Bi-phosphonates
Bisphosphonates and denosumab are used in
combination with other treatments (systemic or
radiotherapy or surgery).
They reduce skeletal-related events and improve the
quality of life of patients.
Bisphosphonates are used:
breast,
prostate cancer
other solid tumors (e.g. NSCLC, renal cell cancer etc).
Denosumab is used:
Breast
prostate cancer.
The main side effect of the above compounds is
osteonecrosis of the jaw.

27. Radiotherapy
Relevant contraindication : Neurologic deficit
Absolute contraindication : Vertebral collapse
Indications
• Palliative
• Post-operative

28. Radiosensitivity of metastatic
lesions
Squamous cell carcinomas
Lymphomas
Adenocarcinomas
Sarcomas
Melanoma

29. • Provide pain relief (in more than 80% of patients)
• Improve or maintain neurologic function
• Restore or maintain the structural integrity of S.C.
External Beam Radiotherapy for
Symptoms

30. Short course Vs. Long course:
 Same results in pain relief and functionality
 More often re-irradiation with short course
 Long course more effective for bone re-calcification
Long course is better for patients with longer life expectancy
(e.g. Breast or prostate cancer)
Short course 1 × 8 Gy ή 5 × 4 Gy
Long course 10 × 3 Gy, 15 × 2.5 Gy, ή 20 × 2 Gy

31. - At diagnosis compression of spinal cord
and bone destruction
- 6 months after radiotherapy
2 weeks of radiotherapy
Bone re-modeling

32.  Intensity Modulated Radiotherapy (IMRT)
 Extracranial Body Radiotherapy (SBRT)
Advanced Radiotherapy Techniques

33. • Oligometastases
• Re-irradiation
Indications for IMRT & SBRT

34.  Protection of spinal cord
 Option of re-irradiation
Postoperative EBRT with IMRT

35. Fractions Dose Definition Intications
1-5 12-20 Gy Extracranial Body
Stereotactic
Radiotherapy
(SABRT)
Radical treatment
>5 5 × 5-6 Gy
10 × 3 Gy
15 × 2.5 Gy
20 × 2 Gy
Fractionated
Extracranial Body
Stereotactic
Radiotherapy
(FSBRT)
Lesions near spinal cord
Re-irradiation
Extracranial Body Stereotactic
Radiotherapy

36. Breast
Prostate
Myeloma
Lemphoma
• Long survival ship
10x3 Gy vs 1x 8 Gy.
•More effective for re-calcification
(Koswig et al. 1999)
10x3 Gy & 20x2 Gy
•Lesser local recurrences
Rades et al. JCO 2005
Cortizone versus Placebo & Radiotherapy):
•Motor fucntion 81% with cortizone versus 63% without
cortizone
Sørensen et al. 1994.
Bone Metastasis
Radiotherapy

37. One metastatic lesion
 20 Gy 4 x 5 Gy
 (SIB) 25 Gy 5 X 5 Gy
Oligometastatic lesions of S.C.
Extracranial Body Stereotactic Radiotherapy

38. CA Thyroid to 1st lumbar vertebra
Post – Radiotherapy following Kyphoplasty
Radiotherapy of the spine

39. Radiotherapy
EXPECTED LIFE TIME
QUALITYOFLIFE
WITHOUT
THERAPY
PALLIATIVE
THERAPY
Spinal metastasis

40. Timetable of palliative radiotherapy
Time
Painintensity
Radiotherapy
???
Radiotherapy
Spinal metastasis

41. 1. Spinal instability
2. Pain resistible to conservative
treatment (radiotherapy –
chemotherapy)
3. Incomplete neurologic deficit
resistible to any type of
conservative treatment
4. Rapid deterioration of the
neurologic deficit
Indications for operative treatment

42. 5. Recurrence of tumor in
an area that has been
already submitted in
radiotherapy (at the
maximum permitted
levels)
6. Ambiguous histological
diagnosis

43. The biology of the tumor
The location
The pain
The neurologic deficit
The spinal instability
Life expectancy
Overall condition of the
patient
Aboulafia A. Levine A., OKU Spine 2, 2004
Factors for evaluation:

44.  Tokuhashi
scoring system
 Tomita surgical staging
Karnofsky performance status
scale definitions rating (%) criteria
Methods of evaluation

45. Tokuhashi’s Evaluation System for
prognosis of metastatic spinal tumors
Symptoms 0 1 2
General condition
performance status
Poor
(PS 10% to 40%)
Moderate
(50% to 70%)
Good
(80% to 100%)
No of extraspinal
skeletal metastases
>3 1 to 2 0
Metastases to
internal organs
Unremovable Removable No metastases
Primary site of
tumor
Lung stomach Kidney liver uterus
unknown
Thyroid prostate
breast rectum
Number of
metastases
>3 2 1
Spinal cord palsy Complete Incomplete None
Tokuhashi, Y. et al, Spine 1990
Total score versus survival period:
9 to 12 points > 12 months survival
0 to 5 points < 3 months survival

46. Tokuhashi’s criteria allow the
definition of a pre-operative strategy
and therefore considerable variability
in the choice of treatment ranging:
excisional operation should be performed
on those who scored above 9 points
a palliative operation should be
performed on those who scored under 5
points
Tokuhashi Y. et al.
Spine 1990

47. Simpler system of preoperative
evaluation based on only three
parameters:
the degree of malignacy
the presence of visceral metastases
the presence of bony metastases.
Tomita K. et al.
Spine 2001
Bauer H. et al.
Spine 2002

48. Tomita’s classification system
Intra-compartmental Extra-compartmental Multiple skip
lesion
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Site
(1 or 2 or 3)
Anterior or posterior
Lesion in situ
Site
(1 +2 or 3 + 2)
Extension to pedicle
Site
(1 +2 +r 3)
Anterio-posterior
development
(any site + 4)
Epidural extension
(any site + 5)
Paravertebral
development
Involvement to
adjacent vertbra

50. Surgical procedures

51. Types of operative treatment
Decompression
Decompression– spondylodesia
Debulking
Piecemeal excision
En block excision
(marginal or wide)

52. Boriani S. et al Spine 1997

53. 1-2 vertebral
metastases
Anterior procedure

54. Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004

55. Breast’s metastasis
• Vertebrectomy
• Vertebral substitution
by cylinder
and
• Stabilization

57. .

58. Posterior procedure
1.  Vertebrae
2. Posterior vertebral
elements involvement
3. Poor general condition

59. Posterior decompression
±
stabilization
Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004

60. Breast’s cancer
A. St.
F: 81
N(+)
Mastectomies
35 yrs ago

61. a. Posterior decompression
and Occipitocervical
stabilization
b. Post-operative adjuvant
chemotherapy -
radiotherapy
N(-)
N(-)

62. Breast’s metastasis
Posterior decompression
±
stabilization
Thoracic spine

63. Posterior decompression
and
stabilization

64. Combined procedures
(anterior – posterior)
Breast metastasis

66. Breast’s metastasis

67. Global Spine Tumor Study Group

68. Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004
Total en block Vertebrectomy

69. Total vertebrectomy
Stener 1971
Stener and Johnsen 1971
Sundaresan et al 1988
Roy-Camille et al 1990
Boriani et al 1994
Tomita et al 1994
Total en Bloc spondylectomy (TES)
for solitary spinal metastases
Int. Orthopedics, 1994

70. Total Vertebrectomy
according to Tomita

71. Total en Bloc Spondylectomy (TES)
Harmful
Not useful
Useful
Asymptomatic, Inactive aneurysmal bone
cyst T11 , 65 yrs
Primary osteosarcoma L3, 40 yrs
Meta Ca Lung,
T4, T7, meta liver,
>72 yrs, Karnofsky 20

72. En Block Vertebrectomy
Indications
Primary malignant tumors stage Ι - ΙΙ
Aggressive benign tumors stage 3 (GCT)
Isolated metastasis with long life expectancy

73. Metastatic disease of the Spine
indications for En Block total Vertebrectomy
Tomita’s suggestions according to prognostic
score
2-3 : wide excision
4-5 : marginal or intralesional excision
6-7 : palliative surgery
8-10 : non-surgical supportive care
Tokuhashi’s suggestions according to prognostic
score
12–15 : excisional
9–11 : palliative surgery
<8 : conservative management
Tomita: Spine 26: 2001

74. Anatomical
restrictions
•Anterior longitudinal ligament
•Posterior longitudinal ligament
•Periosteum of spinal canal
•Ligament flavum
•Periosteum of lamina
•Periosteum of spinal process
•Intrespinous ligament
•Spinous ligament
•End plate
•Nucleous polposus

75. Anatomical restrictions for
Total En Block Vertebrectomy

76. Total En block Vertebrectomy
(TEBV)
operative technique

77. The two theories need not be mutually exclusive
Total En block Vertebrectomy
(TEBV)
surgical approach
Posterior
– Above L4 vertebra who have no contact wth great vessels (Type 3 – 4)
– Straight control of the spinal canal
Combined procedure
Anterior – Posterior Type 5-6
– Close contact to great vessels
Posterior – Anterior
– For tumors of L5 vertebra (posterior procedure is impossible due to iliac crest and the anteriorly
located great vessels )

78. Total En block Vertebrectomy
(TEBV)
surgical approach

79. The two theories need not be mutually exclusive
Total En block Vertebrectomy
(TEBV)
surgical technique

80. The two theories need not be mutually exclusive
Total En block Vertebrectomy
(TEBV)
surgical technique

81. Total En block Vertebrectomy
(TEBV)
surgical technique

82. Total En block Vertebrectomy
(TEBV)
surgical technique

83. Total En block Vertebrectomy
(TEBV)
surgical technique

84. Total En block Vertebrectomy
(TEBV)
surgical technique

85. Uncontrollable hemorrhage
Injury of great vessels
Spinal cord injury
Dissemination of cancerous cells
Total instability
Total En block Vertebrectomy
(TEBV)
intra-operative complications

86. Local recurrence due to remaining malignant and
dispersion cancerous cells intra-operatively
Talac et al, Relationship between surgical margins and local
recurrence in sarcomas of the spine, CORR 397:127 - 132
Tomita et al,J Orthop Sci (2006) 11:3–12

87. Revision due to local recurrence
Extremely difficult
Postoperative scars with adhisions
to nearby sensitive anatomical
stractions
– meninges
– Aorta
– vena cava
Therefore the first operation should
be and the final
Talac et al, Relationship between surgical margins and local
recurrence in sarcomas of the spine, CORR 397:127 - 132

88. The two theories need not be mutually exclusive
Tomita et al,J Orthop Sci (2006) 11:3–12
Total En block Vertebrectomy

89. Material
(open procedures)
 2006 - 2012
 45 patients :
28 women and 17 men
 Age: 58.8 yrs (range 22-72)
 Neurologic deficit 15 pts

90. Material
The primary tumors were:
Breast 12 pts
Lung 11 pts
Thyroid 4 pts
Colon 2 pts
Kidney 4 pts
Uterus 5 pts
Lymphoma 4 pts
Gastric 2 pts
Hepatocellular 1 pt

91. The main lesion of the
spinal metastases were
located in the:
Thoracic spine: 38 pts
Lumbar -//-: 5 pts
Cervical -//-: 2 pts
Material
Breast’s metatstasis

92. Operative
treatment
• Spondylectomy 32 pts
• Decompression
& Stabilization 13 pts

93. Results

94. Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004

95. Follow-up:
62 months ( 6 - 115 ).

96.  Operative time:
 one session: 13½ h (9 - 21)
 two stages: 11 h (9 - 14)
Combined
Procedures
 blood loss: 1500 ± 500 ml

97. A. Pain
B. Neurological
status - paresis
C. Gait
Clinical evaluation

98. Clinical results of prosthetic replacement surgery. The
improvement rate was 94% for pain, 82% for motor
function and 73% for ambulation.
Prosthetic replacement of spinal metastasis

99. Posterior stabilization
Clinical results of posterior stabilization. The positive
recovery rate was 52% for ambulation, 50% for motor
function and 84% for pain.

100. Neurologic Evaluation:
Improvement in 80%
of the patients.

101. Complications
Intra-operative
Early postoperative < 3wks
Late postoperative > 3 wks

102. Major
Intra-operative
complications
N(-)ve

103. Early post-operative
complications
< 3weeks
Wound dehiscence
Neurologic deterioration
Implants dislodgement
infections

104. Late post-operative
complications
> 3 weeks
Wound dehiscence
Neurologic deterioration
Implants dislodgement or broken
infections

105. Late post-operative instability
(spinal destabilization)
Breast’s metatstasis

106. Late post-operative instability
(implants failure)
Breast’s metatstasis

107. Post-operative
complementary
treatment
Radiation therapy
of spinal metastases
Tombolini Y. et al 1994
Ortho - Athens
Best to start
> 3wks post - op

108. Vertebroplasty -
Kyphoplasty
Minimal invasive
techniques

109. Vertebral fractures
(compression ± burst)
Osteoporotic fractures
(compression ± burst)
Pathologic fractures of the
spinal vertebra (metastasis)
Haemangioma of the vertebra
Multiple myeloma
Pneumon’s metastasis
Vertebroplasty – Kyphoplasty
Indications

110. Destruction of the posterior spinal
elements
Burst fractures (±)
Neurologic compression
syndromes
(due to dislocated bony fragments)
Destruction of dorsal structures
(vertebral arch and facet joints)
Vertebra plana
Spinal infection
Allergy
(methylmethacrylate etc)
Coagulopathy
Untreated cardiovascular
disturbances Thyroid metastasis
Vertebroplasty – Kyphoplasty
Contraindications

111. 18 cases
Vertebroplasty

112. Kyphoplasty
(single level)
kidney’s metastasis
10 cases

113. Kyphoplasty
(multiple levels)
11 cases
Pneumon’s metastasis

114. Conclusions:

115. Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004

116. is treated successfully only
by operative procedure
Breast’s metatstasis
Spinal instability
and
neurologic deficit
due to metastasis

117. Prosthetic replacement
is indicated for
metastasis at one or
two consecutive
vertebrae

118. Pneumon’s metatstasis
Posterior
stabilization is
recommended:
• For multiple
metastases
• Poor general
condition
• Short life
expectancy

119. Anterior vertebral replacement
and
anterior – posterior stabilization
1. Is indicated in excessively
unstable spine
and
2. It gives the best overall
results

120. For the metastatic spinal lesions:

121. The minimal invasive techniques
(Verterboplasty – Kyphoplasty)
are recommended methods of
treatment.