Prognostic Factors, Surgical Outcomes, and Guidelines for Managing Metastatic Spine Cancer

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Chapter 108 Prognostic Factors, Surgical Outcomes, and Guidelines for Managing Metastatic Spine Cancer

Vertebral metastases constitute a major event in the course of many tumors. Quite often revealing the metastatic nature of the disease, they also constitute a new crossroads in treatment orientation and provoke a marked emotional modification in the caregiver-patient relationship.

The spine is the most common site for skeletal metastasis.1 Approximately 5% to 10% of all cancer patients develop spine metastasis.2,3 Although Jaffee1 reported in 1958 a 70% incidence of vertebral metastasis, others asserted that spinal involvement ranges from 33.4% to 56%.46 Spinal cord compression occurs in 10% to 25% of treated patients with preexisting spinal metastasis.2,612 It is well established that if metastatic vertebral disease is left untreated, it may lead to paraplegia,1316 which is the most dreadful complication of metastatic vertebral disease. In this situation, surgery plays an important role. Several surgical options exist; however, their indications and outcomes must be scrutinized for better medical care. The discovery of vertebral metastases intensifies an already complex situation requiring highly technical management, sustained coherence of the entire care-provider team, and their awareness of the patient’s increased need to be heard, informed, and supported.

Constructing reasonable guidelines for monitoring patients with vertebral metastases, it is important to understand the patient’s expectations after surgery and what constitutes prognostic factors.

Surgical Outcomes

The following are essential when evaluating surgical outcomes for vertebral metastases:

According to published reports, the anticipated improvement after surgery is expected to range from 55% to 87% of cases as a result of overall upgrade of neurologic deficit (Table 108-1); 36% to 89% because of restoration of sphincter control (Table 108-2); 47% to 100% due to pain relief (Table 108-3); and 40% to 100% as a result of restoration of ambulation (Table 108-4). Apparently restoration of ambulation after dorsal decompression alone fares worse. The anticipated survival rates are depicted in Table 108-5. The complication rates range from 12% to 32% (Table 108-6). In our series of 70 patients, the complication rate was 25%, including two deaths. In one case, surgery was aborted, while in progress, because of massive intraoperative bleeding, despite preoperative transarterial embolization of the region.17 Other complications were profuse bleeding in nine patients, infections in three, wound dehiscence in three, and incomplete surgery in three patients. The 4- to 6-week mortality rates after surgery, reoperation rates for complications, and local recurrences after surgery are listed in Tables 108-7, 108-8, and 108-9, respectively. Local tumor recurrence is more likely to occur in patients with certain tumors and particularly in those for whom chemotherapy and radiation therapy are ineffective. This is particularly the case in such cancers as renal cell carcinoma, in which the reported recurrence is expected to be as high as 40% to 50%.1821 The overall patient satisfaction was rated in the range of 55% to 80%.18,22

TABLE 108-1 Reported Overall Neurologic Improvement after Surgery

Study Improvement
Kostuik J et al.68 55%
Ernstberger T et al.80 57%
Weigel B et al.18 58%
King GJ et al.19 60%
Villavicencio AT et al.81 60%
Rompe JD et al.82 63%
Atanasiu JP et al.30 64%
O’Neil J et al.32 68%
Harrington KD37 68%
Hatrick N et al.83 69%
Tomita T et al.72 73%
Hammerberg KW66 74%
Bauer HCF84 76%
Gokalsan ZL et al.46 76%
Onimus M et al.85 79%
Hosono N et al.86 81%
King et al.19 88%
Hertlein H et al.87 88%
Shimizu K et al.34 87%

TABLE 108-2 Restoration of Sphincter Control after Surgery

Study Successful Restoration
King GJ et al.19 36%
Kocialkowski A, Webb JK88 43%
Kostuik J et al.68 47%
Sinardet D et al.89 51%
Tomita T et al.72 77%
Klekamp J, Samii H31 89%

TABLE 108-3 Pain Relief

Study Success Rate
Sinardet D et al.89 47%
Touboul E et al.90 71%
Hirabayashi H et al.25 77%
Kocialkowski A, Webb JK88 79%
Kostuik J et al.68 81%
Sundaresan N et al.91 85%
Ernstberger T et al.80 85%
Villavicencio AT et al.81 85%
King GJ et al.19 88%
Weigel B et al.18 89%
Hatrick N et al.83 90%
Hammerberg KW66 91%
Gokalsan ZL et al.46 92%
Hertlein H et al.87 92%
Harrington KD37 94%
O’Neil J et al.32 94%
Hosono N et al.86 94%
Atanasiu JP et al.30 95%
Tomita T et al.72 95%
Shimizu K et al.34 100%
Bilsky MH et al.92 100%

TABLE 108-4 Restoration of Ambulation after Ventral or Dorsal Approach

Study Successful Restoration
Livingston KE, Perrin RG93 40%
Kostuik J et al.68 44%
Gokalsan ZL et al.46 51%
Sinardet D et al.89 52%
Tomita T et al.72 60%
Patchel RA et al.94 62%
Hosono N et al.86 64%
King GJ et al.19 64%
Weigel B et al.18 70%
Onimus M et al.85 70%
Hammerberg KW66 76%
Hatrick NC et al.83 78%
Siegal T, Siegal T95 80%
O’Neil J et al.32 82%
Villavicencio AT et al.81 100%
Sundaresan N et al.91,96 100%
Restoration of Ambulation after Laminectomy Alone
Klekamp J, Samii H31 23%
Kennady JC, Stern WE97 23%
Schoeggl A et al.98 33%
Wright RL99 35%
White WA et al.100 36%
Siegal T, Siegal T95 47%

TABLE 108-5 Anticipated Survival Rates after Surgery

Study Survival Rate
3 month
Kocialkowski A, Webb JK88 50.0%
Wai EK et al.52 76.0%
6 month
Klekamp J, Samii H31 58.8%
Rompe JD et al.82 72.0%
Hosono N et al.86 78.0%
9 month
Falicov A et al.33 50.0%
12 month
Kocialkowski A, Webb JK88 25.0%
Klekamp J, Samii H31 48.8%
Rompe JD et al.82 50.0%
Villavicencio AT et al.81 65.0%
Gokalsan ZL et al.46 62.0%
19 month
Rompe JD et al.82 4.7%
60 month
Klekamp J, Samii H31 5%
Median month
Schoeggl A et al.98 6.5%
Sioutos PJ et al.35 10%
Hirabayashi H et al.25 10.6%
Lewandrowski KU et al.101 14%
Sundaresan N et al.102 30%
Mean month
Chataigner H, Onimus M20 8%
Hertlein H et al.87 8.5%
O’Neil J et al.32 9%
Livingston KE, Perrin RG93 9%
Atanasiu JP et al.30 11%
Ernstberger T et al.80 15.6%
Weigel B et al.18 13.1%
Wise JJ et al.67 15.9%
Cahill DW, Kumar R103 15.9%
Kocialkowski A, Webb JK88 12.0%

TABLE 108-6 Complication Rates

Study Percentage Experiencing Complications
Bilsky MH et al.7 12%
Wai EK et al.52 12%
Hosono N et al.86 16%
Weigel B et al.18 19%
Jansson KA, Bauer HC104 20%
Wise JJ et al.67 25%
Klimo P Jr et al. (review of 24 surgical reports)105 23%
Falicov A et al.33 29%
Gokalsan ZL et al.46 32%

TABLE 108-7 Postsurgery Mortality Rates (4 to 6 weeks)

Study Mortality Rate
Gokalsan ZL et al.46 3.0%
Klimo PJr et al.105 6.3%
Wise JJ et al.67 6.0%
Siegal TJ et al.106 6.0%
Weigel B et al.18 7.0%
Sundaresan N et al.96 8.0%
Harrington KD37 8.0%
Sinardet D et al.89 9.0%
Sioutos PJ et al.35 11.0%
Turner PL et al.78 10.0%
Hertlein H et al.87 10.0%
Chataigner H, Onimus M20 10.2%
Bilsky MH et al.92 12.0%
Jansson KA, Bauer HC104 13.0%
Kocialkowski A, Webb JK88 16.0%
Fidler MW107 18.0%

TABLE 108-8 Reoperation Rates for Complications or Local Recurrences

Study Percentage Undergoing Reoperation
Weigel B et al.18 7.0%
Jansson KA, Bauer HC104 10.2%
Hertlein H et al.87 12.1%
Bauer HCF84 24.0%
Chataigner H, Onimus M20 15.8%
King GJ et al.19 56.2%

TABLE 108-9 Local Recurrences after Surgery

Study Percentage Experiencing Recurrence
Falicov A et al.33 3.5%
Review of 9 surgical reports 8.0%
Klimo P Jr et al.105
Bilsky MH et al.92
Foumey DR et al.108
Hammerberg KW66
Hosono N et al.86
King GJ et al.19
Muhlbauer M et al.109
Siegal T et al.106
Weigel B et al.18
Chataigner H, Onimus M20 8.4%
Nazarian S110 11.0%
King GJ et al.19 12.1%
Hirabayashi H et al.25 21.0%
Weigel B et al.18 22.0%
Bridwell KH et al.71 (after laminectomy) 31.6%
Sundaresan N et al.102 32.0%
Hertlein H et al.87 49.0%

Therefore, it is reasonable to assume that these data can be used as the basis for what should be considered acceptable outcomes. The reported wide variation of survival rates after surgery probably reflects nonuniform representation of aggressive tumors in different series.

Prognostic Factors

It has been observed that certain factors, irrespective of treatment selection, may influence the prognosis when malignant tumors develop spinal metastases. The original claim that the histopathology of the tumor had no bearing on the ultimate prognosis23 has not been duplicated by others.

Origin of Tumor

The origin of the primary tumors was postulated by several authors to influence the prognosis. Thus, metastatic vertebral tumors from unsuspected adenocarcinoma, stomach, esophagus, pancreas, and lungs, portend the worst possible prognosis, whereas carcinoid, thyroid, breast, prostate, and myeloma carry the best prognosis. Distinction should also be made between the different types of lung cancer.24 In general, non–small cell lung cancer (NSCLC) patients with spinal metastases had survival rates of 37.1%, 14.6%, and 2.1% at follow-up of 6 months, 1 year, and 2 years, respectively. The median survival time was 4.5 months, and the mean, 6.2 months. However, for small-cell lung cancer (SCLC), the corresponding survival rates were 36.8%, 5.3%, and 0% at 6 months, 1 year, and 2 years follow-up, respectively. In both NSCLC and SCLC with spinal metastases, the presence of hypercalcemia or hypoalbuminemia was indicative of a gloomy prognosis, with a survival period of less than 3 months.24

The aggressiveness of cancer can also be classified as slow growth (breast, thyroid, prostate), moderate growth (kidney, uterus), and rapid growth (lung, stomach, liver, colon, unknown).2529

Concurrent Visceral Metastases

The influence on survival with visceral metastasis was also observed by Tokuhashi et al.28 and Tomita et al.29 The average survival with no visceral metastases was 36.8 months (range, 5–84 months), treatable visceral metastases, 16.5 months (4–31 months), and untreatable visceral metastases, 8.9 months (range, 1–24 months). The grave prognostic factor of extraskeletal metastatic lesions on the survival rate is also in agreement with Weigel et al.,18 who demonstrated that a patient survival period without extraskeletal metastases at surgery was significantly longer than with extraskeletal metastases (23.5 months vs. 5.8 months; P < .0001).

Location of Spinal Lesion

The location of the metastatic lesion was also implicated as a survival factor. Atanasiu et al.30 reported that lesions in the upper cervical spine had an adverse effect on life expectancy, with average survival of 1.8 months; however, this was challenged by Klekamp and Samii,31 who found no differences in prognosis between the upper and lower spine.

Neurologic Deficit

Neurologic dysfunction was observed to be associated with survival rates. Some believe that ambulatory patients survive longer than nonambulatory patients with sphincter incontinence.19,35 The state of sphincter incontinence as a bad prognostic sign is also emphasized by some.36 The rate of neurologic deterioration was related to prognosis; slow progression had a good prognosis as opposed to rapid progression, which was correlated with dismal results. The latter was compounded when the onset of treatment was delayed.36,37 However, the notion of preoperative intact neurologic status (ambulatory vs. nonambulatory) as a predictor of longer survival was challenged by others.18,38

Likewise, timing for adjunctive radiation treatment (preoperative radiation vs. postoperative radiation) was also questioned as a significant prognostic predictor for outcomes.39 Weigel18 and Hirabayashi et al.25 emphasized that postoperative ambulation definitely has a positive prognostic influence on survival, rather than preoperative ambulation.

Timing of Surgery

The timing of treatment can also influence the results. Some authors36,37 observed that delayed onset of treatment may compromise the effectiveness of neurologic recovery. More specifically, Fürstenberg et al.40 addressed the timing of surgery and concluded that the effectiveness of decompression, when undertaken less than 48 hours after the development of symptoms, was significantly better for neurologic recovery (71.4%, unchanged 28.6%), compared with those with delayed surgical treatment (improvement 28.6%, unchanged 42.8%, deterioration 28.6%). Furthermore, they noted that normal bladder function may be considered a good prognostic factor for neurologic recovery after appropriate decompression.

Age

Weigel et al.18 also reported that the patient age can be considered as a prognostic factor for survival, because patients younger than 60 years survived significantly longer than older patients (20.1 months vs. 6.2 months; P = .028). Age as a prognostic factor has not been incorporated into the Tokuhashi scoring system and needs to be duplicated by others.

More Than Two Prognostic Factors

A report indicates that when more than two of the “prognostic factors” are present, they have a compounding adverse effect on survival.35 For example, lung cancer, neurologic deficit, and involvement of multiple vertebrae in the same patient would have a greater adverse effect on survival than the combined effect of the same type of lung cancer involving a single vertebra and without neurologic deficit. However, these findings have not been substantiated by others. When estimating survival, one should take into consideration that, invariably, most of the data from different reports were based on metastatic tumor of the spine that became symptomatic.

Clinical practice in surgical results and prognostic factors of metastatic spinal tumors has not undergone adequate scrutiny. The surgical information provided in this article must be available and known to everyone concerned with spinal tumors (e.g., physicians, patients, insurance) to form the basis of what should be considered acceptable surgical outcomes. Inferior results, therefore, are not acceptable, and well-designed guidelines should strive to achieve the best possible outcomes.

Instruments for Outcomes Assessment

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