The impact of complete surgical resection of spinal metastases on the survival of patients with thyroid cancer.

Spinal metastases (SMs) from thyroid cancers significantly reduce the quality of life by causing pain and neurological deficits and increase mortality. Complete surgical resection of isolated thyroid SMs is a promising treatment option; however, the postoperative outcome is unknown. This study aimed to compare the postoperative courses of patients undergoing complete resection of thyroid SMs with those of patients undergoing incomplete resection, with a minimum 4-year follow-up. We performed a retrospective analysis of 32 patients who underwent tumor excision surgery for thyroid SMs at our medical center during a 28-year period. Twenty patients underwent complete excision, and 12 underwent incomplete excision. Survival was defined as the time from the first spinal surgery to death or last follow-up. Kaplan-Meier analysis with the long-rank test was used to compare the overall survival rates between the groups. For all patients, the overall 5- and 10-year survival rates were 71% and 31%, respectively. The median overall survival time was 6.4 years. The patients undergoing complete excision survived longer than those undergoing incomplete excision (5-year survival: 84% vs. 50%; 10-year survival: 52% vs. 8%; P < 0.01). Only one patient undergoing complete excision experienced local tumor recurrence in the operated spine, whereas all long-term survivors (>18 months after surgery) in the incomplete excision group experienced local tumor recurrence and a consequent deterioration in performance status. Complete surgical resection of thyroid SMs, if achievable, has the potential not only to maintain performance status, but also to prolong survival.

Spinal metastasectomy of renal cell carcinoma: A 16-year single center experience with a minimum 3-year follow-up.

BACKGROUND AND OBJECTIVES: Metastasectomy of spinal lesions from renal cell carcinoma (RCC) is a promising strategy. However, its clinical outcome after spinal metastasectomy is unknown owing to the difficulty of curative surgical resection. This is the first study to examine the survival rates of patients who underwent metastasectomy of solitary spinal metastases from RCC. METHODS: A retrospective cohort study of 36 consecutive patients with RCC who underwent nephrectomy and complete removal of solitary spinal lesions between 1995 and 2010 at our institution. Cancer-specific survival (CSS) time from the spinal metastasectomy to death or last follow-up was the main endpoint. Potential factors associated with survival were evaluated with Kaplan-Meier analysis and the long-rank test. RESULTS: For all patients, the estimated median CSS time was 130 months. The 3, 5, and 10-year CSS rates were 77.8%, 69.1%, and 58.0%, respectively, for all patients, and 72.7%, 54.5%, and 27.3%, respectively, for patients with lung metastases at the time of surgery. Only the presence of liver metastases was significantly associated with short-term survival after spinal metastasectomy. CONCLUSIONS: Liver metastases were associated with short-term survival, although lung metastases were not. For selected patients, curative resection of solitary spinal metastases can potentially prolong survival. J. Surg. Oncol. 2016;113:587-592. © 2016 Wiley Periodicals, Inc.

Reconstruction using a frozen tumor-bearing vertebra in total en bloc spondylectomy can enhance antitumor immunity.

PURPOSE: Distant metastases from thyroid carcinoma are successfully cured if they take up radioiodine ((131)I), are of small size, and located in the lungs. Bone metastases have the worst prognosis because (131)I therapy and external beam radiotherapy are less effective. Our propose here is to report a patient with solitary spinal metastasis and multiple lung metastases from thyroid carcinoma, whose spinal metastasis was treated by total en bloc spondylectomy (TES) enhancing antitumor immunity using frozen tumor-bearing bone for spinal reconstruction. METHODS: The patient was a 37-year-old male who had solitary spinal metastasis at T4 and multiple lung metastases from thyroid carcinoma. (131)I therapy for the multiple lung metastases resulted in no effect because the apparent (131)I uptake was observed only in T4 metastasis. We performed a TES of T4 with cryotreatment. After en bloc excision of T4, the excised tumor-bearing vertebra was frozen by liquid nitrogen. In spinal reconstruction, the frozen vertebra was used in a mesh cage inserted into the anterior defect. RESULTS: After surgery, the thyroglobulin level decreased without any other adjuvant therapy and the serum levels of INF-γ and IL-12 increased. This indicates antitumor immunity was activated. Then, (131)I therapy became effective to the lung metastases causing the tumors to decrease in size and number. Three years after surgery, progression in the lung metastases, other metastasis, and local recurrence have not been observed. CONCLUSIONS: TES with cryotreatment as presented is a novel surgery which can enhance antitumor immunity against other visible or non-visible metastases.

The influence of steroid administration on systemic response in laminoplasty for cervical myelopathy.

INTRODUCTION: The excessive systemic inflammatory response caused by surgery has been associated with the development of major complications, such as postoperative confusion and acute respiratory distress syndrome. The serum IL-6 has been used as a predictor in the extent of surgical trauma. Several trials have reported that steroid administration reduced excessive systemic response. We investigated the systemic response caused by surgical trauma in patients with cervical laminoplasty and evaluated the influence of steroid administration on systemic response. MATERIALS AND METHODS: Thirty patients were included in this study. The patients were divided into three groups of ten each: preoperative steroid group, intraoperative steroid group, and non-steroid group. The same dose of steroid was administered to the patients in preoperative group and intraoperative group. Venous blood samples were taken at the following times: before surgery, at the end of surgery, 6 h after the surgery, the first, the third and the seventh day after the surgery. Outcome measures were serum IL-6, IL-10, C-reactive protein (CRP), white blood cells including neutrophil and lymphocyte counts. RESULTS: The mean serum IL-6 levels on the first day in preoperative and intraoperative steroid groups were significantly lower than in control group. The serum IL-6 levels in preoperative steroid group were lower than the serum levels in the intraoperative steroid group from the end of surgery to the third day after surgery. The CRP levels in steroids groups were also lower than in control group on the third day. There were no significant differences in the postoperative neutrophil count between the three groups. There was no postoperative infectious complication or suture failure. CONCLUSIONS: This study shows that the preoperative administration of steroids modified the systemic inflammatory response caused by surgical trauma in patients with cervical laminoplasty.

Effects on spinal cord blood flow and neurologic function secondary to interruption of bilateral segmental arteries which supply the artery of Adamkiewicz: an experimental study using a dog model.

STUDY DESIGN: Segmental arteries including the level of Adamkiewicz artery were interrupted bilaterally for up to 4 levels to study the effects on spinal cord blood flow and neurologic function in dogs. OBJECTIVE: To examine how many ligations of bilateral segmental arteries including the level of Adamkiewicz artery cause ischemic spinal cord dysfunction. SUMMARY OF BACKGROUND DATA: Interruption of bilateral segmental arteries at >or=5 consecutive levels without the level of Adamkiewicz artery has been reported to risk producing ischemic spinal cord dysfunction in dog model. However, the effects of ligating including the level of Adamkiewicz artery have not been elucidated. METHODS: The 25 dogs in which Adamkiewicz artery originated from L5 level were taken in this study. There were 15 dogs divided into 5 groups: sham group, no ligation; group 1, ligation of bilateral segmental arteries at 1 level (L5); group 2, at 2 levels (L4-L5); group 3, at 3 levels (L4-L6); and group 4, at 4 levels (L3-L6). Spinal cord blood flow at the L5 spinal cord segment by laser-Doppler flowmetry, and spinal cord-evoked and compound muscle action potentials were measured simultaneously until 10 hours after ligation. Neurologic function was assessed using a modified Tarlov grading system 1 week after operation in 10 other dogs divided into 2 groups: 3 pairs group, ligation at 3 levels (L4-L6); 4 pairs group, at 4 levels (L3-L6). RESULTS: Spinal cord blood flow was 98.2%, 76.1%, 66.6%, 61.4%, and 53.5% in the sham group, groups 1, 2, 3, and 4, respectively, 10 hours after ligation. Abnormal spinal cord-evoked and compound muscle action potentials were observed in 1 out of 3 dogs in group 4. Postoperative neurologic evaluation identified all 5 dogs in 3 pairs group and 4 in 4 pairs group as having grade 5. There was 1 dog in 4 pairs group that had grade 4. CONCLUSION: Interruption of bilateral segmental arteries at >or=4 consecutive levels including the level of Adamkiewicz artery risks producing ischemic spinal cord dysfunction.

Circumspinal decompression with dekyphosis stabilization for thoracic myelopathy due to ossification of the posterior longitudinal ligament.

STUDY DESIGN: Circumspinal decompression with dekyphosis stabilization was prospectively performed with thoracic myelopathy due to ossification of posterior longitudinal ligament (OPLL). Neurologic outcome was reviewed. OBJECTIVE: To evaluate how easily, safely, and completely the thoracic OPLL can be removed or floated by circumspinal decompression with dekyphosis stabilization. SUMMARY OF BACKGROUND DATA: Anterior decompression is the best for the spinal cord recovery to treat thoracic myelopathy caused by OPLL on the concave side of the spinal cord. However, anterior approach for removal of OPLL plaque is technically demanding. METHODS: This is an operative procedure. Wide laminectomy is performed. Bilateral gutters along the dural tube are made using a diamond drill into the vertebral body covering the extent of the OPLL to be removed anteriorly. Posterior instrumentation is applied for stabilization of the spine and reducing thoracic kyphosis by approximately 5 to 10 degrees (dekyphosis stabilization). Four weeks after the first step, anterior decompression is performed with direct vision with the landmark of gutters using an operative microscope, followed by interbody fusion. Fifteen patients with thoracic myelopathy due to OPLL had the first-step operation, and 11 patients underwent circumspinal decompression (both the first and second operation). RESULTS: Kyphosis in the stabilization area reduced from 30.7 to 24.7 degrees on average in 15 patients. In 2 of the 15 patients, the spinal cord was shifted posteriorly and completely decompressed by only the first-step operation in the postoperative myelography or magnetic resonance imaging. The second-step operation was cancelled, and their Japanese Orthopedic Association scores improved from 6 to 10 points and from 4 to 10.5 point, respectively at final follow-up. In other 13 patients, the spinal cord was still compressed by the OPLL plaque. In 2 of the 13 patients, the second-step operation was cancelled because their general condition was impaired. Their preoperative Japanese Orthopedic Association scores were 2.0 and 2.5, and final scores were 5.5 and 5.5 points, respectively. Remaining 11 patients who underwent circumspinal decompression (both the first and second operation) neurologically improved and maintained from 4.0 points to 9.1 points on average at final follow-up. CONCLUSION: The OPLL plaque in the thoracic spine might be most easily, safely, and completely removed or floated, and the spinal cord is circumferentially decompressed through circumspinal decompression with dekyphosis stabilization.

How many ligations of bilateral segmental arteries cause ischemic spinal cord dysfunction? An experimental study using a dog model.

STUDY DESIGN: Segmental arteries were interrupted bilaterally for up to 7 levels to study the effects on spinal cord blood flow and neurologic function in dogs. OBJECTIVE: To examine how many ligations of bilateral segmental arteries cause ischemic spinal cord dysfunction. SUMMARY OF BACKGROUND DATA: Interruption of bilateral segmental arteries for up to 3 levels has been reported not to damage spinal cord function. However, to our knowledge, the effects of ligating more than 3 levels have not yet been clearly determined. METHODS: There were 15 dogs divided into 5 groups: sham group, no ligation; group 1, ligation of bilateral segmental arteries at 3 levels (T11-T13); group 2, at 4 levels (T10-T13); group 3, at 5 levels (T10-L1); and group 4, at 7 levels (T9-L2). Spinal cord blood flow at T12 measured by laser Doppler flowmetry, and spinal cord-evoked and motor-evoked potentials were measured simultaneously until 10 hours after ligation. Neurologic function was assessed using a modified Tarlov grading system 1 week after operation in 20 other dogs divided into 4 groups (1, 2, 3, and 4). RESULTS: Spinal cord blood flow was 99.3%, 80.7%, 71.5%, 44.3%, and 25.0% in the sham group, and groups 1, 2, 3, and 4, respectively, 10 hours after ligation. Abnormal spinal cord-evoked potentials were observed in 2 of 3 dogs in group 3 and all 3 in group 4. Abnormal motor-evoked potentials were observed in 1 of 3 dogs in group 3 and all 3 in group 4. Postoperative neurologic evaluation identified all 5 dogs in groups 1 and 2, respectively, and 3 in group 3 as having grade 5. There were 2 dogs in group 3 and 3 in group 4 that had grade 4, and 2 in group 4 had grade 3. CONCLUSION: Interruption of bilateral segmental arteries at > or =5 consecutive levels risks producing a spinal cord ischemia capable of injuring the spinal cord.

[Surgical treatment for metastatic bone tumor].

Conventionally, palliative surgery has been commonly performed as pain management for bone metastasis which is regarded as terminal. Recently, medical treatment in this area has made great advances and so life expectancy of patients with cancer has been prolonged. The objective of surgical treatments is to maintain activities of daily living. Radical resection and reconstruction are used for the patients with long life expectancy, though palliative surgery is for the patients with short life expectancy.