En bloc vertebrectomy for the treatment of spinal lesions. Five years of experience in a single institution: a case series

OBJECTIVES: The objective of this study is to describe the experience of a Brazilian public university hospital regarding the treatment of metastatic or benign spine lesions with en bloc vertebrectomy of the thoracic and lumbar spines. METHODS: This study was a retrospective case series and included all medical records of patients with benign aggressive, primary malignant, or metastatic spine lesions who underwent en bloc vertebrectomy from 2010 to 2015. RESULTS: A total of 17 patients were included in the analysis. Most of them (71%) were indicated for surgery based on an oncologic resection for localized disease cure. Overall, 10 of the 17 patients (59%) underwent vertebrectomy via an isolated posterior approach using the technique described by Roy-Camille et al. and Tomita et al., while 7 patients (41%) underwent double approach surgeries. Of the 17 patients who underwent the en bloc resection, 8 are still alive and in the outpatient follow-up (47%), and almost all patients with metastatic lesions (8/9) died. The average survival time following the surgical procedure was 23.8 months. Considering the cases of metastatic lesions and the cases of localized disease (malignant or benign aggressive disease) separately, we observed an average survival time of 15 months and 47.6 months respectively. CONCLUSION: This study demonstrates and reinforces the reproducibility of the en bloc vertebrectomy technique described by Tomita et al.

Survival analysis in patients with metastatic spinal disease: the influence of surgery, histology, clinical and neurologic status / Análise de sobrevida em pacientes com doença metastática espinhal: influência da cirurgia, histologia, status clínico e neurológico

Spine is the most common site for skeletal metastasis in patients with malignancy. Vertebral involvement quantification, neurological status, general health status and primary tumor histology are factors to set surgical planning and therapeutic targets. We evaluated the impact of general clinical and neurological status, histologic type and surgery in survival. Method : The study sample consisted of consecutive patients admitted from July 2010 to January 2013 for treatment. Results : Sixty eight patients were evaluated. 23 were female and 45 were male. Main primary neoplasic sites were: breast, prostate, lung/pleura and linfoproliferative. Thirty three out of 68 received surgical treatment, 2 received percutaneous biopsy and 33 had nonsurgical treatment. Survival : Log Rank curves revealed no statistical significant difference according to histological type, surgical approach and Frankel Score. Karnofsky Score was statistically different. Conclusion : Histological type and clinical status were statistically associated with life expectancy in vertebral metastatic disease. .

A coluna vertebral é o sítio mais comum de metastases ósseas. A quantificação do acometimento vertebral, o status neurológico, status clínico e histologia do tumor primário são fatores importantes para planejamento cirúrgico e metas terapêuticas. Nós avaliamos o impacto do status clinico geral e neurológico, tipo histológico e cirurgia na sobrevida de pacientes com metástases espinhais. Método : A amostra consistiu de pacientes consecutivamente admitidos de Julho de 2010 a Janeiro de 2013. Resultados : Sessenta e oito pacientes foram avaliados. 23 eram mulheres e 45 eram homens. Os principais sítios primários foram mama, próstata, pulmão e linfoproliferativos. Trinta e três realizaram tratamento cirúrgico, 2 realizaram biópsia percutânea e 33 tiveram tratamento conservador e radioterapia. Conclusão As curvas Log Rank não revelaram significância quanto à cirurgia e escore de Frankel, mas revelaram associação com Karnofsky e tipo histológico. .

Factors Affecting Survival in Patients Undergoing Palliative Spine Surgery for Metastatic Lung and Hepatocellular Cancer: Dose the Type of Surgery Influence the Surgical Results for Metastatic Spine Disease?

BACKGROUND: Surgical treatment for metastatic spine disease has been becoming more prominent with the help of technological advances and a few favorable reports on the surgery. In cases of this peculiar condition, it is necessary to establish the role of surgery and analyze the factors affecting survival. METHODS: From January 2011 to April 2015, 119 patients were surgically treated for metastatic spine lesions. To reduce the bias along the heterogeneous cancers, the primary cancer was confined to either the lung (n = 25) or the liver (n = 18). Forty-three patients (male, 32; female, 11; mean age, 57.5 years) who had undergone palliative surgery were enrolled in this study. Posterior decompression and fusion was performed in 30 patients (P group), and anteroposterior (AP) reconstruction was performed in 13 patients (AP group) for palliative surgery. Pre- and postoperative (3 months) pain (visual analogue scale, VAS), performance status (Karnofsky performance score), neurologic status (American Spinal Injury Association [ASIA] grade), and spinal instability neoplastic score (SINS) were compared. The survival period and related hazard factors were also assessed by Kaplan-Meier and Cox regression analysis. RESULTS: Most patients experienced improvements in pain and performance status (12.3% +/- 17.2%) at 3 months postoperatively. In terms of neurologic recovery, 9 patients (20.9%) graded ASIA D experienced neurological improvement to ASIA E while the remainder was status quo. In an analysis according to operation type, there was no significant difference in patient demographics. At 12 months postoperatively, cumulative survival rates were 31.5% and 38.7% for the P group and the AP group, respectively (p > 0.05). Survival was not affected by the pre- and postoperative pain scale, Tokuhashi score, neurologic status, SINS, or operation type. Preoperative Karnofsky performance score (hazard ratio, 0.93; 95% confidence interval [CI], 0.89 to 0.96) and improvement of performance status after surgery (hazard ratio, 0.95; 95% CI, 0.92 to 0.97) significantly affected survival after operation. CONCLUSIONS: There was no significant difference in surgical outcomes and survival rates between posterior and AP surgery for metastatic lesions resulting from lung and hepatocellular cancer. Preoperative Karnofsky score and improvement of performance status had a significant impact on the survival rate following surgical treatment for these metastatic spine lesions.

Predictive Factors of Palliative Radiotherapy Response and Survival in Patients with Spinal Metastases from Hepatocellular Carcinoma

BACKGROUND/AIMS: Spinal metastases often severely limit the quality of life by causing severe pain and neurological deficits. The purpose of this study was to evaluate the palliative effect of radiotherapy (RT) for spinal metastases from hepatocellular carcinoma (HCC) and to identify factors predictive of survival in HCC patients with spinal metastases who received RT. METHODS: A retrospective analysis was performed on 192 patients with spinal metastases from HCC who received RT. RESULTS: Of 192 patients with spinal metastases from HCC, an overall pain response to palliative RT occurred in 187 patients (97.4%), with a complete pain response (CR) in 41 patients (21.4%) and a partial response in 151 patients (78.6%). A higher biologically effective dose (BED) and more advanced RT techniques were identified as predictive factors for a CR. The 1- and 2-year overall survival (OS) rates were 18.1% and 6.3%, respectively, and the median survival time was 4.5 months. A long OS was associated with good performance status, controlled primary HCC, absence of extrahepatic metastases, and a higher BED. CONCLUSIONS: RT provided effective palliation for patients with painful spinal metastases from HCC. Our results provide information regarding pain control, survival outcomes, and predictive factors for the prognosis of HCC patients with spinal metastases treated with RT.

Natural history and surgical treatment of chordoma: a retrospective cohort study / História natural e tratamento cirúrgico de cordoma: um estudo retrospectivo de coorte

CONTEXT AND OBJECTIVE: Chordoma is a rare tumor with a high risk of locoregional recurrences. The aim of this study was analyze the long-term results from treating this pathological condition. DESIGN AND SETTING: Cohort study in a single hospital in São Paulo, Brazil. METHODS: This was a retrospective cohort study on 42 patients with chordoma who were treated at Hospital A. C. Camargo between 1980 and 2006. The hospital records were reviewed and a descriptive analysis was performed on the clinical-pathological variables. Survival curves were estimated using the Kaplan-Meier method and these were compared using the log-rank test. RESULTS: Nineteen patients were men and 23 were women. Twenty-five tumors (59.5%) were located in the sacrum, eleven (26.2%) in the skull base and six (14.3%) in the mobile spine. Surgery was performed on 28 patients (66.7%). The resection was considered to have negative margins in 14 cases and positive margins in 14 cases. The five-year overall survival (OS) was 45.4%. For surgical patients, the five-year OS was 64.3% (82.2% for negative margins and 51.9% for positive margins). In the inoperable group, OS was 37.7% at 24 months and 0% at five years. CONCLUSION: Complete resection is related to local control and definitively has a positive impact on long-term survival. .

CONTEXTO E OBJETIVO: Cordoma é um tumor raro e com alto risco de recidiva locorregional. O objetivo deste estudo foi analisar os resultados a longo prazo do tratamento dessa doença. TIPO DE ESTUDO E LOCAL: Estudo de coorte realizado em um único hospital em São Paulo, Brasil. MÉTODOS: Estudo de coorte retrospectivo com 42 pacientes com cordoma tratados de 1980 e 2006 no Hospital A. C. Camargo. Os prontuários foram revistos e foi realizada a análise descritiva das variáveis clínicas e patológicas. As curvas de sobrevida foram estimadas pelo método de Kaplan-Meier e a comparação entre elas, pelo teste de log-rank. RESULTADOS: Dezenove pacientes eram homens e 23, mulheres. Vinte e cinco tumores (59,5%) estavam localizados no sacro, 11 (26,2%) na base do crânio e 6 (14,3%), na coluna móvel. A cirurgia foi realizada em 28 pacientes (66,7%). A ressecção foi considerada como tendo margens negativas em 14 casos e margens comprometidas em 14 pacientes. A sobrevida global (SG) em 5 anos foi de 45,4%. Para os pacientes cirúrgicos, a SG em 5 anos foi de 64,3% (82,2% para as margens negativas e 51,9% de margens positivas). No grupo inoperável, a SG em 24 meses foi de 37,7% e 0% em 5 anos. CONCLUSÃO: A ressecção completa está relacionada com o controle local e, definitivamente, tem impacto positivo na sobrevida a longo prazo. .

Tokuhashi Scoring System has limited applicability in the majority of patients with spinal cord compression secondary to vertebral metastasis / A Escala de Tokuhashi possui aplicabilidade limitada na maioria dos pacientes com compressao medular secundaria a metastase vertebral

Spine is the primary bone site affected by systemic metastasis. Although there are scales that attempt to manage these patients, their real applicability is unknown. The Tokuhashi Scoring System (TSS) is a widely used prognostic tool. At the time of treatment, the data necessary to complete TSS may be incomplete, making its application impossible. Objective To evaluate the number of TSS scores completed by the time the clinical therapeutic decision was made. Methods From July 2010 to January 2012, we selected patients who were diagnosed with spinal metastases. Results Sixty spinal metastasis patients (21 female, 39 male) were evaluated between July 2010 and January 2012. At the time of the treatment decision, only 25% of the patients had completed the TSS items. Conclusion In the majority of patients with vertebral metastasis, TSS variables cannot be applied. .

A coluna vertebral é o sítio ósseo mais acometido na doença neoplásica metastática. Embora haja escalas que buscam normatizar o tratamento destes pacientes, sua real aplicabilidade é incerta. A Escala de Tokuhashi (TSS) é uma ferramenta prognóstica vastamente empregada. No momento do tratamento, os dados necessários ao preenchimento da escala podem estar incompletos, tornando sua aplicação inviável. Objetivo Avaliar o número de TSS completos até a tomada de decisão terapêutica. Métodos De Julho de 2010 a Janeiro de 2012, selecionamos pacientes diagnosticados com metástases espinhais. Resultados Sessenta pacientes foram avaliados durante o período; destes, 21 eram mulheres e 39, homens. Até a tomada de decisão, foi possível completar os itens da TSS em apenas 25% dos pacientes. Conclusão Na maioria dos pacientes com metástases espinhais, a TSS não pôde ser aplicada. .

Survival Rate and Neurological Outcome after Operation for Advanced Spinal Metastasis (Tomita's Classification > or = Type 4)

PURPOSE: We investigated whether primary malignancy entities and the extent of tumor resection have an effect on the survival rate and neurological improvement in patients with spinal metastases that extend beyond the vertebral compartment (Tomita's classification > or = type 4). MATERIALS AND METHODS: We retrospectively reviewed 87 patients with advanced spinal metastasis who underwent surgery. They were divided into groups 1 and 2 according to whether they responded to adjuvant therapy or not, respectively. They were subdivided according to the extent of tumor resection: group 1, gross total resection (G1GT); group 1, subtotal resection (G1ST); group 2, gross total resection (G2GT); and group 2, subtotal resection (G2ST). The origin of the tumor, survival rate, extent of resection, and neurological improvement were analyzed. RESULTS: Group 1 had a better survival rate than group 2. The G1GT subgroup showed a better prognosis than the G1ST subgroup. In group 2, the extent of tumor resection (G2GT vs. G2ST) did not affect survival rate. In all subgroups, neurological status improved one month after surgery, however, the G2ST subgroup had worsened at the last follow-up. There was no local recurrence at the last follow-up in the G1GT subgroup. Four out of 13 patients in the G2GT subgroup showed a local recurrence of spinal tumors and progressive worsening of neurological status. CONCLUSION: In patients with spinal metastases (Tomita's classification > or = type 4), individuals who underwent gross total resection of tumors that responded to adjuvant therapy showed a higher survival rate than those who underwent subtotal resection. For tumors not responding to adjuvant therapy, we suggest palliative surgical decompression.

Osseous adenocarcinoma of unknown primary site: study of survival and prognostic factors.

A prospective study of 149 patients suffering from adenocarcinoma of unknown primary site (ACUPS) of bone was carried out. The tumors are classified as 63 extraspinal, 67 spinal and 19 mixed involvement. Upon meticulous physical examination, Virchow's node was detected in 15 cases, rectal shelf in 11 cases and hepatomegaly in 44 cases. Blood chemistry showed elevation of alkaline phosphatase (> 3 sigma units) in 98 cases and chest roentgenogram showed pulmonary lesions in 23 cases. Treatment was surgery and radiotherapy in 64 and two cases respectively. In all of these patients histological findings of the biopsy or resection specimen had confirmed the diagnosis of adenocarcinoma. Among 124 evaluable patients, overall survival was analysed using Kaplan-Meier life table analysis. Survival rates at one, two and four months after diagnosis were 80.7, 60.5 and 25 per cent with a mean and median survival times of 90 and 77 days respectively. Statistical analysis was also performed to ascertain the prognostic importance of the following variables: age, gender, Virchow's node, rectal shelf, hepatomegaly, serum alkaline phosphatase, pulmonary lesion, and multiplicity and site of the osseous lesions. The presence of pulmonary lesion or hepatomegaly significantly produced unfavorable impact on the duration of survival (p = 0.0004 and 0.0150, respectively) while other remaining factors had not.