Approach to Spinal Approach to Spinal MetastasisMetastasis

byby

Nawaz Hussain b Mohd AmirNawaz Hussain b Mohd Amir

Spine UnitSpine UnitDept. of OrthopaedicsDept. of Orthopaedics

HUSMHUSM

88thth August 2006 August 2006

IntroductionIntroduction

Bone is a common site for carcinoma Bone is a common site for carcinoma metastasismetastasis

Approximately 70% of pts with cancer have Approximately 70% of pts with cancer have evidence of metastasis at the time of their evidence of metastasis at the time of their deathdeath

Spinal Column is the most common location for Spinal Column is the most common location for osseous sites for metastatic depositsosseous sites for metastatic deposits

Up to 40% of pts with cancer has spinal column Up to 40% of pts with cancer has spinal column involvement.involvement.

IntroductionIntroduction

Not all spinal metastasis lead to Not all spinal metastasis lead to neurologic disorderneurologic disorder

Spinal cord compression from Spinal cord compression from epidural metastasis occurs in 5-10 % epidural metastasis occurs in 5-10 % of cancer ptsof cancer pts

10-20% of this will be symptomatic10-20% of this will be symptomatic (25 000 pts a year in US –Klimo and Schmidt-2004)(25 000 pts a year in US –Klimo and Schmidt-2004)

Metastatic spine disease can involve Metastatic spine disease can involve one of 3 locationsone of 3 locations

- Vertebral column – 85% - post. halfVertebral column – 85% - post. half- Paravertebral region – 10-15%Paravertebral region – 10-15%- Epidural/subarachnoid/intramedullary Epidural/subarachnoid/intramedullary

space - < 5%space - < 5%

Intradural metastasis – extremely Intradural metastasis – extremely rare but there are reported casesrare but there are reported cases

Multiple level at noncontiguous levels Multiple level at noncontiguous levels – 10-40%– 10-40%

Primary sitePrimary site

Coleman - 1994Coleman - 1994 Breast – 73%Breast – 73% Prostate -68% 80%Prostate -68% 80% Lung-36%Lung-36% Thyroid , kidney , GIT ,endometrium, Thyroid , kidney , GIT ,endometrium,

cervix,bladder -< 20%cervix,bladder -< 20%

- Klimo and schimdt -2004- Klimo and schimdt -2004- Prostate ,breast, melanoma, lung – 90.5%,74.3%,54.5%,44.9%- Prostate ,breast, melanoma, lung – 90.5%,74.3%,54.5%,44.9%

Primary sitePrimary site

Frequency of neurologic deficit secondary to Frequency of neurologic deficit secondary to epidural spinal cord compression varies with the site epidural spinal cord compression varies with the site of primary diseaseof primary disease

- Breast – 22%Breast – 22%- Lung - 15%Lung - 15%- Prostate -10%Prostate -10%

Some pts present with neurologic dysfunction and Some pts present with neurologic dysfunction and spinal pain without knowing primary site – in old spinal pain without knowing primary site – in old

literature literature frequency is up to 70% and 50% of them found to be frequency is up to 70% and 50% of them found to be

fromfromlunglung

ApproachApproach HistoryHistoryi. General / conventional symptomsi. General / conventional symptoms - bony pain , back pain ,numbness , - bony pain , back pain ,numbness , weakness – bladder / bowel controlweakness – bladder / bowel control - LOA , LOW- LOA , LOW

ii Specific history ii Specific history -Breast – past history ,lumps ,pain, similiar family hx-Breast – past history ,lumps ,pain, similiar family hx -prostate – past hx , urinary Sx-prostate – past hx , urinary Sx -lung - past hx , smoking,cough,hemoptysis-lung - past hx , smoking,cough,hemoptysis - thyroid – past hx, swelling , hyperthyroidism - thyroid – past hx, swelling , hyperthyroidism

Physical Examination.Physical Examination.i.i. General – general conditionGeneral – general condition - cachexia, anemia , hydration,- cachexia, anemia , hydration, nutritionalnutritional

ii.ii. Potential primary site – Potential primary site – - breast , prostate, lung ,thyroid ,- breast , prostate, lung ,thyroid , abdomen ,etcabdomen ,etc - lymph nodes- lymph nodes

Approach…..Approach…..

P/E……P/E……

iii. Full neurological examinationiii. Full neurological examination

motor , sensory…etc.motor , sensory…etc.

InvestigationInvestigation

1 . Blood 1 . Blood

- Anemia- Anemia

- thrombocytopenia- thrombocytopenia

- Increase LDH / u.acid / cal. /ALP/- Increase LDH / u.acid / cal. /ALP/

Acid Phophotase(prostate)/ TFTAcid Phophotase(prostate)/ TFT

-Serum markers – CEA , Ca 125 , PSA-Serum markers – CEA , Ca 125 , PSA

IxIx

ImagingImaging Plain x-rayPlain x-ray- Bone mets can be purely lytic, blastic ,mixed- Bone mets can be purely lytic, blastic ,mixed

i. Most metastasis are predominantlyi. Most metastasis are predominantly lytic

- lung,kidney,breast,GIT,melanoma ii Blastic – prostate , bronch.

carcinoids,bladder,stomach iii. Mixed – breast ,lung,GIT

Plain X-rayPlain X-ray- In cancellous bone lytic lesion remain occult until In cancellous bone lytic lesion remain occult until

it completely destroys trabaculae and reach 2-3 it completely destroys trabaculae and reach 2-3 cm incm in

diameter. Needs 30 – 50 % of destruction.diameter. Needs 30 – 50 % of destruction.

- In cortical bone – small lytic lesion can de - In cortical bone – small lytic lesion can de detected earlierdetected earlier

Plain x-rayPlain x-rayDepends on whether the primary is known or notDepends on whether the primary is known or not

I . Primary is knownI . Primary is known

Asymptomatic – not for skeletal surveyAsymptomatic – not for skeletal survey

- bone scan is method of choice- bone scan is method of choice

- if bone scan positive confine x-ray - if bone scan positive confine x-ray to to

site of localisation site of localisation

Symptomatic - Localised x-ray , skeletal surveySymptomatic - Localised x-ray , skeletal survey

ii. Primary is unknownii. Primary is unknown

- usually has local symptoms- usually has local symptoms

- local x-ray , skeletal survey- local x-ray , skeletal survey

During follow ups , course of tumour therapyDuring follow ups , course of tumour therapy

IxIx

ImagingImaging

Bone ScanBone Scan- Most sensitive diagnostic toolMost sensitive diagnostic tool- But it gives multiple levels of involvement without But it gives multiple levels of involvement without

clarifying the levelclarifying the level- All cancer pts regardless primary All cancer pts regardless primary

known ,unknownknown ,unknown- Follow upsFollow ups

Ct scanCt scan-Allows visualization of-Allows visualization of i. even small areas of vertebral destructioni. even small areas of vertebral destruction ii. Assessment of extent of paravertebral soft tissue ii. Assessment of extent of paravertebral soft tissue

massesmassesiii. Extent and direction of impingement of spinal cordiii. Extent and direction of impingement of spinal cord by bone debris / tumourby bone debris / tumour

- Limitation – failure to identify second site of mets.Limitation – failure to identify second site of mets. - 10% of pts- 10% of pts

MRIMRISuperior in evaluating Superior in evaluating

i.i. soft tissue masssoft tissue mass

ii.ii. Neural elementsNeural elements

iii.iii. Multiple level of vertebral involvementMultiple level of vertebral involvement

Findings – Hypointense T1 , hyperintense in T2 and Findings – Hypointense T1 , hyperintense in T2 and

gadolinium enhanced T1gadolinium enhanced T1

BiopsyBiopsy

- Most literature suggest some type e.g ct - Most literature suggest some type e.g ct guided biopsyof biopsy in order to specify guided biopsyof biopsy in order to specify correctly the type of malignancycorrectly the type of malignancy

- Even in known primary- Even in known primary - However , here the problem of consent - However , here the problem of consent

limits the use of this method in establishing limits the use of this method in establishing diagnosisdiagnosis

due to its invasiveness .due to its invasiveness .

ManagementManagement

General MxGeneral Mx Medical Mx / Radiotherapy MxMedical Mx / Radiotherapy Mx Surgical MxSurgical Mx Pain MxPain Mx

General Mx.General Mx.- Anemia Anemia - Nutritional StatusNutritional Status- Hydrational statusHydrational status- SupplementsSupplements

Medical MxMedical Mx

i.Chemotherapyi.Chemotherapy

ii.Hormonalii.Hormonal

iii Biphosphonateiii Biphosphonate

ChemotherapyChemotherapyGiven as therapeutic and palliative treatment Given as therapeutic and palliative treatment

especially in especially in

Breast , lung , Renal cell ca. , prostate(less)Breast , lung , Renal cell ca. , prostate(less)

Needs multi disciplinary approachNeeds multi disciplinary approach

HormonalHormonal- Breast , prostate and endometrial ca.- Breast , prostate and endometrial ca.

- Endocrine dependant organs.- Endocrine dependant organs.

- Regulate and manipulate regulatory - Regulate and manipulate regulatory hormones as anti -tumour therapyhormones as anti -tumour therapy

BiphosphonateBiphosphonate

- Inhibit osteoclast-mediated resorptionInhibit osteoclast-mediated resorption- Induce osteoclast apoptosisInduce osteoclast apoptosis- Standard treatment in hypercalcemia in Standard treatment in hypercalcemia in

malignancy malignancy - Reduces metastatic bone pain esp. clodronate and Reduces metastatic bone pain esp. clodronate and

pamidronate ( Ernst et al-1992 , Coleman et al -pamidronate ( Ernst et al-1992 , Coleman et al -1996)1996)

- Recalcification Recalcification

RadiotherapyRadiotherapy- Pain relief – mode of action not really Pain relief – mode of action not really

understood – reduces tumour bulk, understood – reduces tumour bulk, reduces pain mediator (PG)releasing reduces pain mediator (PG)releasing cellscells

- Post fixation irradiationPost fixation irradiation- Prevention of spinal cord compression-Prevention of spinal cord compression-

recent vertebral collapserecent vertebral collapse- Pts with contraindication for surgeryPts with contraindication for surgery

Surgical MxSurgical Mx

Mostly PalliativeMostly Palliative

IndicationsIndications

i.i. Intractable pain unresponsive to non Intractable pain unresponsive to non operative measuresoperative measures

ii.ii. Obvious spinal instabilityObvious spinal instability

iii.iii. Clinically significant neural compression Clinically significant neural compression from retropulsed bone or spinal instabilityfrom retropulsed bone or spinal instability

iv.iv. Radioresistant tumoursRadioresistant tumours

Depends on Depends on

i.i. Pts tolerability to surgery e.g Pts tolerability to surgery e.g general medical conditiongeneral medical condition

ii.ii. Estimated life expectancyEstimated life expectancy

Goals of SurgeryGoals of Surgery

i.i. Correct and prevent deformity by Correct and prevent deformity by stabilizing deformitystabilizing deformity

ii.ii. Decompressing neural structuresDecompressing neural structures

iii.iii. Open biopsy if primary unknownOpen biopsy if primary unknown

Pre-operative prognostic values/scoringPre-operative prognostic values/scoring

Score = < 5 dies within 3 monthsScore = < 5 dies within 3 months > 9 survives average 12 mths> 9 survives average 12 mthsSurgery = <5 non surgical , > 9 surgicalSurgery = <5 non surgical , > 9 surgical

Category iii – grey area , either medical or surgical .

- if there is severe epidural cord compression

non radiosensistive , needs surgery

ScoreScore2-3 – wide / marginal for long term survival2-3 – wide / marginal for long term survival4-5 – marginal/intralesional4-5 – marginal/intralesional6-7 – palliative surgery for short term palliation6-7 – palliative surgery for short term palliation8-10 – non operative supportive care8-10 – non operative supportive care

Surgical approachSurgical approach

Anterior approachAnterior approach

- modern era- modern era- Predominant area of metastasisPredominant area of metastasis- Does not disturb posterior stability in Does not disturb posterior stability in

presence of the kyphosis presence of the kyphosis - Pain relief in 80 – 95% of ptsPain relief in 80 – 95% of pts- Neurologic improvement in 75% of ptsNeurologic improvement in 75% of pts

Surgical approach……Surgical approach……

Post decompressive laminectomyPost decompressive laminectomy

- old era- old era

- limited value in regaining - limited value in regaining neurologic functionneurologic function

- Laminectomy + radiotx no more - Laminectomy + radiotx no more effective than radiotx alone.effective than radiotx alone.

Anterior –posterior approachAnterior –posterior approach- High grade instabilityHigh grade instability- Ant and posterior compressionAnt and posterior compression- Contiguous vertebral involvementContiguous vertebral involvement- Need for en-bloc resection of tumourNeed for en-bloc resection of tumour

Other approchesOther approches

-costotransversectomy – thoracic region-costotransversectomy – thoracic region

-pt unable to tolerate-pt unable to tolerate

thoracotomythoracotomy

-Postolateral approach – cervical / lumbar -Postolateral approach – cervical / lumbar

regionregion

VERTEBROPLASTY ( deramound VERTEBROPLASTY ( deramound 1990)1990)

- Good stabilisation and analgesia to Good stabilisation and analgesia to the diseased vertebra.the diseased vertebra.

- But must have intact cortexBut must have intact cortex- Used if contraindicated for surgery Used if contraindicated for surgery

eg post irradiated patienteg post irradiated patient

ConclusionConclusion

Spine is the most frequent location for skeletal Spine is the most frequent location for skeletal metastasismetastasis

Mode of treatment and can be chosen by using the Mode of treatment and can be chosen by using the many scoring systems(Tokuhashi , Harrington , many scoring systems(Tokuhashi , Harrington , Tomita etc) but it must be tailored according to each Tomita etc) but it must be tailored according to each patientpatient

Advances in imaging and instrumentation allowed Advances in imaging and instrumentation allowed improvements in the techniques of excision of improvements in the techniques of excision of tumour and stabilisation.tumour and stabilisation.

Surgical decision making is a complex issue but the Surgical decision making is a complex issue but the treatment of spinal mets. remains largely palliative.treatment of spinal mets. remains largely palliative.