Vertebral metastasis of renal carcinoma at diagnosis: mechanical and clinical evaluation: surgical management / Metástasis vertebral de carcinoma renal en el momento del diagnóstico: evaluación mecánica y clínica: manejo quirúrgico

Renal cell carcinoma accounts for 2-3% of all malignant neoplasms. Metastatic disease of the spine is common and 50% of bone metastases are already present at the time of primary diagnosis. Bone metastases from renal cell carcinoma are difficult to manage, especially vertebral localization.A 48-year-old woman was diagnosed with renal cell carcinoma in the context of low back pain. The patient presented two skeleton metastases at diagnosis (T11 and 5th rib). The patient received neoadjuvant treatment with cabozantinib, followed by removal of the renal tumor. Radiotherapy was administered for the lumbar lesion. In spite of the radiotherapy treatment, increased low back pain limiting mobility and ambulation. MRI showed an occupation of the spinal canal, without neurological lesion. The SINS scale revealed a score of 14 (vertebral instability). The patient's prognosis was greater than 12 months according to the Tokuhashi score. Based on clinical and mechanical criteria, surgical treatment of the vertebral lesion was decided. T11 vertebrectomy was performed, the reconstruction was made with an expandable cage, and T8 a L2 posterior spinal arthrodesis. A partial resection of the fifth rib was performed in order to remove the whole macroscopic tumor. After 3 months, she was diagnosed with a local infection, treated by irrigation, debridement and antibiotherapy, with good evolution. At 1-year follow-up, she has no low back pain or functional limitation. Follow-up chest-abdomen-pelvis computed CT scan showed absence of disease progression, furthermore, the vertebral arthrodesis shows fusion signs. At the time of this report, there are no clinical or radiological data of infection

El carcinoma de células renales representa el 2-3% de todas las neoplasias malignas. La enfermedad metastásica de la columna vertebral es frecuente y el 50% de las metástasis óseas ya están presentes en el momento del diagnóstico. Las metástasis óseas del carcinoma de células renales son difíciles de manejar, especialmente en localización vertebral.Una mujer de 48 años fue diagnosticada de carcinoma de células renales en el contexto de un dolor lumbar. La paciente presentaba dos metástasis óseas en el momento del diagnóstico (T11 y 5ª costilla). Inicialmente recibió tratamiento neoadyuvante con cabozantinib, seguido de la extirpación quirúrgica del tumor renal. Se administró radioterapia para la lesión lumbar. A pesar del tratamiento radioterápico, aumentó el dolor lumbar con limitación para la movilidad y la deambulación. La RM mostró una ocupación del canal espinal, sin lesión neurológica. La escala SINS reveló una puntuación de 14 (inestabilidad vertebral). El pronóstico de la paciente era superior a 12 meses según la puntuación de Tokuhashi. Basándose en criterios clínicos y mecánicos, se decidió el tratamiento quirúrgico de la lesión vertebral. Se realizó una vertebrectomía de T11, para la reconstrucción se usó una caja extensible, junto con una artrodesis vertebral T8-L2. Se realizó una resección parcial de la quinta costilla para eliminar todo el tumor macroscópico. A los 3 meses de la cirugía la paciente fue diagnosticada de infección local, tratada mediante irrigación, desbridamiento y antibioterapia, con buena evolución. Al año de seguimiento, no presenta dolor lumbar ni limitación funcional. La tomografía computarizada de tórax-abdomen-pelvis de seguimiento mostró ausencia de progresión de la enfermedad, además, la artrodesis vertebral muestra signos de fusión. En el momento de este informe, no hay datos clínicos ni radiológicos de infección.

Enfermedad metastásica de la columna vertebral / Metastatic spine disease

Siendo el cáncer la segunda causa de muerte en el mundo, las metástasis óseas son su tercera localización más frecuente, junto con la columna vertebral, ocupando el 65% de ellas. Lo anterior, sumado a una población envejeciendo y un abismante progreso en los tratamientos de quimio, radio y hormonoterapia, junto con técnicas quirúrgicas cada vez menos invasivas exige abordar este tema. Se realiza una revisión narrativa, con la literatura actual y consensos internacionales en el área, describiendo los factores que generan las metástasis vertebrales, sus síntomas de alarma (dolor y compromiso neurológico), métodos de estudio y diagnóstico (Rx, TAC, RMN, cintigrama óseo, Pet CT, biopsia) y método de clasificación de la compresión medular. Además, se revisan diferentes tipos de puntuación para la toma de decisión quirúrgica y se exponen las técnicas más modernas de tratamiento combinado de cirugía separación más radioterapia esterotáctica que ofrecen menor invasión al paciente con mejores resultados de control local de la enfermedad.

Being cancer the second cause of death in the world, bone metastases are its third most frequent location, along with the spine, occupying 65% of them. The aforementioned, added to an aging population and an abysmal progress in the treatments of Chemo, Radio and Hormone therapy, together with increasingly less invasive surgical techniques requires addressing this issue. A narrative review is carried out, with current literature and international consensus in the area, describing the factors that generate vertebral metastases, their alarm symptoms (pain and neurological compromise), study and diagnostic methods (Rx, CT Scan, MRI, Bone Scan, PET CT, needle Biopsy) and method of classification of spinal compression. In addition, different types of punctuation for surgical decision making are revised and the newer combine treatment with less invasive surgery plus Sterotactic High dose radiation is presented as the todaýs gold standard for the best local control for the Metastatic Spine Disease.

CT spectral curve in differentiating spinal tumor metastasis and infections / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the value of CT spectral curve in differentiating spinal tumor metastasis (STM) from spinal infections (SI).@*METHODS@#In the study, 29 STM and 18 SI patients proved pathologically and clinically were examined by dual energy spectral CT (DESCT). The monochromatic images and CT spectral curves were generated automatically by GSI Viewer software. The attenuation values at different energy levels (40-140 keV, every 10 keV), the attenuation values of the lesions on the conventional polychromatic CT images and the gradients of the curve were calculated and compared between STM and SI.@*RESULTS@#The median age of STM and SI (58 years vs. 64 years) were not significantly different (U=171, P=0.4). The attenuation values of STM at 40-100 keV were 281.79 (143.67, 446.19) HU, 199.68 (100.04, 321.49) HU, 151.54 (81.47, 243.49) HU, (122.64±27.72) HU, (99.90±23.88) HU, (85.82±21.61) HU, and (75.94±20.27) HU, respectively, which were significantly higher than SI: 185.29 (164.19, 277.03) HU, 138.44 (124.98, 238.56) HU, 105.46 (92.94, 169.53) HU, (93.77±15.55) HU, (79.15±12.84) HU, (68.99±11.75) HU, and (62.22±11.71) HU (all P < 0.05). The attenuation values at 110-140 keV and the attenuation value on the conventional CT images were not significantly different between STM and SI. The gradient of CT spectral curve of STM was 2.43±0.58, which was higher than the value of 1.50±0.40 for SI (P < 0.001). Using 1.72 and 248.80 HU as the threshold value for CT spectral curve slope and the attenuation value at 40 keV, could obtain the area under receiver operating characteristic (ROC) curve of 0.905 and 0.892, sensitivity of 88.0% and 80.0%, and specificity of 76.9% and 92.3%.@*CONCLUSION@#CT spectral curve provides valuable semi-quantitative information for the differential diagnosis of STM and SI, which can be used as a supplement to traditional CT imaging.

Experiencia inicial de radioterapia estereotáxica (SBRT) en metástasis óseas de columna vertebral / Stereotactic body radiation therapy (SBRT) for pain management in spine bone metastases

Background: Treatment of spine bone metastases with stereotactic radio-therapy (SBRT) may produce greater pain relief than palliative radiotherapy. Aim: To evaluate the analgesic response to SBRT. Material and Methods: A search was made in an electronic database of all patients treated by SBRT in our center. We found 20 patients that were treated with SBRT in the spine on 24 sites (lesions). Analgesic response was evaluated at 3 and 6 months after SBRT. Other factors such as age, sex, functional status, diagnosis, metastasis location, dosimetry and toxicity of the treatment were also described. Results: The median follow-up was 8.1 months. Complete pain relief occurred at three months in 74% of the treated sites. At three months, 78% of the patients presented a functional status 0 (ECOG). The median dose used was 24 Gy in 2 fractions. No cases of G3 or greater toxicity were recorded. Conclusions: The analgesic response to SBRT seems to be better than that reported for palliative radiotherapy.

Linfoma anaplásico de columna cervical: doble reto diagnóstico para el otorrinolaringólogo / Cervical spine anaplastic lymphoma: double diagnostic challenge for the otorhinolaryngologist

RESUMEN Las metástasis de la columna vertebral cervical no se ven comúnmente en el área otorrinolaringológica, y por lo tanto corren el riesgo de pasar por alto durante la evaluación del paciente. Presentamos un caso inusual evaluado debido a las metástasis de la columna cervical de un tumor primario desconocido. Después de extensos procedimientos de estudio que no eran diagnósticos, se obtuvo una biopsia mediante un abordaje cervical extendido. El paciente fue diagnosticado con un linfoma anaplásico, una enfermedad muy rara en la región de cabeza y cuello. Discutimos los hallazgos histológicos y la presentación clínica de esta condición.

ABSTRACT Cervical spine metastases are not commonly seen in the otolaryngology clinic and therefore run the risk of being overlooked during patient evaluation. We report an unusual case evaluated due to cervical spine metastases from an unknown primary tumor. After extensive workup procedures that were non-diagnostic, a biopsy was obtained through an extended cervical approach. The patient was diagnosed with an anaplastic lymphoma, a very rare disease in the head and neck region. We discuss the histologic findings and clinical presentation of this condition.

Spinal tumors in children / Tumores de coluna em crianças

Summary Introduction: Spinal tumors are rare in the pediatric population, presenting many specific peculiarities when compared to adults. We have performed a broad narrative review to describe the most common spinal tumors in children, discussing their main characteristics and management options. Method: The authors have performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives. Results: Multimodality radiological studies (plain films, 3D computed tomography scan and magnetic resonance imaging) are necessary for proper evaluation and differential diagnosis of spinal tumors in children. In selected cases nuclear medicine imaging is used to improve the chances of a more accurate diagnosis. As a general rule, a fine needle biopsy is recommended after radiological evaluation to confirm the tumor's histology. Primary bone tumors can be divided into benign bone tumors, mostly represented by vertebral hemangiomas, osteoid osteomas, osteoblastomas, aneurismal bone cysts, and eosinophilic granulomas, and malign or aggressive tumors, such as Ewing's or osteogenic sarcomas. Secondary bone tumors (spinal metastases) comprise different tumor histologies, and treatment is mainly based on tumor's radiosensitivity. The characteristics and treatment options of the main spinal tumors are discussed in details. Conclusion: Spinal tumors in children are rare lesions that demand a thorough understanding of their main characteristics for their proper management. Understanding the nuances of spinal tumors in children is of paramount importance for improving outcomes and chances of cure.

Resumo Introdução: Os tumores de coluna em crianças são raros, apresentando peculiaridades únicas quando comparados com os da população adulta. Método: Dada a escassez de trabalhos que avaliem o tema, realizou-se extensa revisão de literatura objetivando descrever os tumores de coluna que acometem a população pediátrica, discutindo características e opções de manejo. Resultados: A utilização de exames radiológicos combinados (radiografias, tomografia computadorizada com reconstrução em 3D e ressonância magnética) é necessária para avaliação adequada e diagnóstico diferencial dessas lesões. Em casos selecionados, exames de medicina nuclear aumentam as chances do diagnóstico preciso. Como regra geral, biópsia por agulha é recomendada para confirmação da histologia tumoral e tratamento subsequente. As lesões primárias de coluna podem ser benignas, representadas principalmente pelos hemangiomas, osteomas osteoides, osteoblastomas, cistos ósseos aneurismáticos e granulomas eosinofílicos, enquanto as lesões malignas são geralmente representadas por tumores agressivos, como o sarcoma de Ewing ou os sarcomas osteogênicos. Metástases de coluna podem ter diferentes etiologias, sendo o tratamento dependente principalmente da radiossensibilidade do tumor de origem. As opções de tratamento dessas lesões são descritas em detalhes. Conclusão: Tumores de coluna em crianças são raros e o seu manejo requer um conhecimento amplo e variado das diferentes possibilidades diagnósticas. Conhecer os nuances envolvidos no tratamento dessas lesões e os sintomas iniciais é fundamental para melhorar o prognóstico e as chances de cura.

Bone metastasis from ovarian cancer.

We report a case of epithelial ovarian cancer, which presented with lumbar vertebral metastasis soon after treatment, as a part of distant spread. This patient was then treated by palliative radiotherapy and put on second line chemotherapy i.e, Topotecan. She responded to treatment well.

Variance in the treatment of vertebral haemangiomas.

Vertebral haemangiomas constitute an infrequently encounterd entity in clinical practice. Although x-ray, computerised tomography scan and magnetic resonance Imaging scan provide a pathognomic picture confirming the diagnosis of vertebral haemangiomas, angiography constitutes an important tool for diagnosis and helps in deciding and execution of treatment. Various treatment modalities like surgery, radiotherapy, pre-operative embolisation, percutaneous vertebroplasty and intralesional ethanol have been discussed in the setting of asymptomatic vertebral haemangiomas to those presenting with features of cord compression.

Prognosticating factors in the surgery of intramedullary cervical tumour

A young girl presented with features of Brown Sequard plus syndrome. Radiological imaging revealed an intramedullary tumour. The lesion was operated upon and the tumour was found to be intramedullary with a small exophytic component going through a rent in the anterior fissure. The intramedullary component of the tumour was totally excised. The case is discussed and factors influencing a radical excision of such tumours are reviewed

Intraspinal epidermoid cysts

In this study, five patients with the rare epidermoid cyst of the intraspinal lumbosacral region were evaluated clinically and radiologically. All patients were presented by progressive neurological impairment of varying severity that m and ated surgical management for the removal of the cystic mass. Postoperative excellent improvement was obtained for four patients showing a restoration of normal muscle power with a return to normal daily activities. One patient got a residual neurologic deficit that did not improve during the follow up period, while another patient developed an asymptomatic leptomeningeal cyst that required no further management. Minor transient forms of meningismus occurred in two patients, in spite of the adequate hydrocortisone medication perioperatively. The pathology, etiology, epidemiology, clinical features, imaging characteristics and surgical treatment of such rare tumors were discussed. Magnetic resonance imaging [MRI] reduced the delay in the diagnosis of intraspinal tumors but it should be guided by the clinical judgment

Carcinoma oesophagus--an unusual presentation.

We report a 32 years old female who had carcinoma of the oesophagus and who presented with unusual features.