Modern Treatment of Spinal metastases Maxwell Boakye, MD MPH FACS FAANS Associate Professor of Neurosurgery Nelson Endowed Chair Center for Advanced Neurosurgery, University of Louisville
My Background Neurosurgeon Residency 2002 Fellowships-complex spine-Emory and Spine Oncology-Sloan Kettering-2003 Stanford-2003-2010-worked with cyberknife Special interest in spine tumors and spine radiosurgery
Goals Epidemiology Presentation Imaging Role of Surgery Emerging Treatment paradigms Decision making and Frameworks Memorial Sloan Kettering NOMS criteria Cases
Epidemiology 20000 new cases of metastatic epidural cord compression each year 10% of cancer patients will develop spinal metastatic About 70% of all cancer deaths occur in elderly patients aged over 65 Postmortem studies metastases present in 90% of patients with systemic cancer
Epidemiology Number of elderly patients dying from cancer will double by 2030 By age 2050, the number of newly diagnosed patients aged 85 will quadruple
Myelopathy-Motor, Sensory, Bowel/Bladder Pain Signs and symptoms Myelopathy-Motor, Sensory, Bowel/Bladder Usually from epidural cord compression Pain Biologic nocturnal/early morning-resolves during day-usually from tumor infiltration, Steroid responsive Mechanical-movement related Radicular-usually epidural disease in foramen Other Symptoms e.g LOC or AMS from brain
Imaging X-rays CT MRI PET
Imaging findings Imaging Epidural disease only Vertebral disease only Vertebral disease with epidural Cord compression Mechanical instability Pathological fractures Single level, Multiple level, Distant metastases
Treatment options Surgery Radiation therapy Radiosurgery Chemotherapy
Main surgical approaches Anterior Transthoracic, Retroperitoneal Posterior Laminectomy Posterior transpedicular, costotransversectomy approach
Epidural Compression: Surgery is superior to radiation Patchell et. al, Lancet Vol 366: 643-648, 2005
Patchell study
Surgery vs. radiation-Patchell
Surgery improves quality of life outcomes Quan et. Al., Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery: High Morbidity and mortality Complication rates-20-40%
Emerging Treatment Patterns Vertebral augmentation Vertebroplasty Kyphoplasty Radiosurgery Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFÉ TRIAL
CAFÉ trial
Berenson et. Al., Lancet Oncology 2011 Mar;12(3):225-35.
CYBERKNIFE RADIOSURGERY The CyberKnife® a robotic manipulator to move a compact linear accelerator with six degrees of freedom Real-Time Image Guidance Throughout the Treatment Dynamic Motion Tracking Allows for accuracy and conformality Louisville is getting one!!
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING Who should be operated on? Frameworks for prognosis Algorithms and Decision aids
Tokuhashi score ≥9:•Excision•Survival > 12 months ≤5:•Palliative•Survival < 3 months
Decision Making-NOMS criteria Neurologic Oncologic Mechanical Systemic
NOMS criteria Neurologic-myelopathy, degree of epidural cord compression Oncologic- radiosensitivity of tumor Mechanical instability-movement related pain Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317
Oncologic-Radiosensitivity –Myeloma & Lymphoma: most radiosensitive –Prostate, Breast, Lung and Colon: moderately –Thyroid, Kidney, Melanoma: not radiosensitive
Mechanical Instability
Systemic factors
SINS score Ranges 0-18 0-6, Stable 7-12, indeterminate, possibly impending instability 13-18-Instability Surgical consultation is recommended for SINS score > 7. Fisher CG, Spine Vol 35(22): 1221-1229, 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival VAriable Hazard ratio 95% CI P-value Age 1.001 0.99-1.02 0.90 Ambulatory status 2.355 1.52-3.66 0.0001 Cervical mets 1.07 0.69-1.65 0.76 Comorbidity 2.96 1.34-6.51 0.007 Epidural compression 1.20 0.69-2.09 0.52 Pathologic fracture 1.41 0.95-2.08 0.08 Radiosensitivity 2.56 1.67-3.91 <0.0001 Radiotherapy 0.98 0.67-1.43 0.91 Urinary incontinence 1.16 0.78-1.71 0.47 Visceral mets 1.09 0.75-1.57 0.65
NOMS decision framework. Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317