1. Total en bloc Spondylectomy If not for primary malignant tumors, for what else then? Sohail Bajammal, MBChB, MSc, FRCS(C) October 29, 2008

2. Above Knee Amputation

3. Nakamura S., Kusuzaki K., Murata H. et al. More than 10 years of follow-up of two patients after total femur replacement for malignant bone tumor. International Orthopaedics. 24(3):176-8, 2000.

4. Evidence-Based Practice Haynes et al. BMJ 2002 Clinical State Research Evidence Patient Preference Clinical Expertise

5. Hierarchy of Evidence

6. Primary Tumors of the Spine CategoryType% Benign Hemangioma30 Eosinophilic granuloma15-25 Osteoid osteoma10-12 Aneurysmal bone cyst10 Chondroma4 Benign, locally aggressive Giant cell tumor5 Chordoma2-4 Malignant Plasmacytoma20-30 Chondrosarcoma7-12 Osteosarcoma<5 Ewing’s sarcoma4-10 Incidence: 2.5 to 8.5 cases per 100,000 persons / yr Chi JH, Bydon A, Hsieh P, et al. Epidemiology and Demographics for Primary Vertebral Tumors. Neurosurgery Clinics of North America. 19(1): 1-4, 2008.

7. Enneking Principles of Orthopaedic Oncology

8. Intralesional

9. Enneking Principles of Orthopaedic Oncology Marginal

10. Enneking Principles of Orthopaedic Oncology Wide

11. Surgical Options Intralesional resection Removal of the tumor, with violation of the capsule and piecemeal removal of the growth, with margins defined by the tumor itself Acceptable for metastatic tumors and benign tumors Familiar approach Risk of recurrence En bloc resection Complete removal of the tumor without violation of its capsule, and with clearly defined normal tissue as margins Ideal for primary malignant & locally aggressive tumors Technically demanding Less risk of recurrence

12. Total en bloc Spondylectomy Stener (1971): chondrosarcoma Roy-Camille (1981-1990): popularized the procedure Tomita et al. and Fidler (1994): further popularized

13. Decision Making Degree of difficulty Complications Feasibility of en bloc resection Patient’s preference Surgeon’s expertise

14. Staging Systems WBB Staging System Tomita Classification System

15. Weinstein JN, McLain RF. Primary tumors of the spine. Spine 1987;12:843–51. 82 cases (31 benign & 51 malignant) The mean follow-up: 9.7 yr in benign and 3.8 yr in malignant lesions Five-year survival: 86% for benign lesions Five-year survival in malignant lesions: –undergoing curettage: nil –undergoing incomplete resection: 18.7% –undergoing complete excision: 75%

16. Weinstein JN, McLain RF. Primary tumors of the spine. Spine 1987;12:843–51.

17. Boriani et al. En bloc resections of bone tumors of the thoracolumbar spine. A preliminary report on 29 patients. Spine. 21(16):1927-31, 1996. 29 patients: –25 primary malignant & aggressive benign –4 solitary metastases Surgical time was 3-21 hr (average, 12 hr) Surgical margin: –wide in 20, marginal in 8, intralesional in 1 No local recurrence was found at follow-up evaluation after 6-134 mo (average, 30 mo)

18. Tomita K, et al. Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors. Spine 1997;22:324–33.

19. Hasegawa K, et al. Margin-free spondylectomy for extended malignant spine tumors: surgical technique and outcome of 13 cases. Spine. 32(1):142-8, 2007 3 chondrosarcoma, 3 giant cell tumor, 1 osteosarcoma, 1 chordoma, and 5 metastases No local recurrence, except in 2 cases (chondrosarcoma with extirpation of 5 vertebrae, chordoma with multiple previous surgeries) Two cases of chondrosarcoma were disease- free 14 &13 years after surgery

20. Hasegawa et al. Spine 2007

21. Abe E, et al. Total spondylectomy for primary tumor of the thoracolumbar spine. Spinal Cord. 38(3):146-52, 2000 Mar. 6 patients Approach: –Posterior in 3 (T1 osteosarcoma, L1 osteosarcoma and L1 chordoma) –Combined single stage anterior and posterior (T6 ± 8 recurrent giant cell tumor, L4 chordoma and L5 giant cell tumor) Surgical Margins: wide in 1, marginal in 4, intralesional in 1.

22. Abe E, et al. Total spondylectomy for primary tumor of the thoracolumbar spine. Spinal Cord. 38(3):146-52, 2000 Mar. Five patients were alive without evidence of tumor and one was alive with disease at follow- up evaluation after 2.0 ± 4.8 years. Local recurrence was found in one case of T1 osteosarcoma with an intralesional margin.

23. Junming M, et al. Giant cell tumor of the cervical spine: a series of 22 cases and outcomes. Spine. 33(3):280-8, 2008 22 patients: –8 subtotal resection, 13 total spondylectomy, 1 en bloc posterior element Postoperative radiation in 18 cases Local recurrence: –5 of 7 cases (71.4%) subtotal resection, –1 of 13 cases (7.7%) total spondylectomy. 4 cases died within follow-up and all were recurrent cases.

24. Melcher I, et al. Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: results by management with total en bloc spondylectomy. European Spine Journal. 2007. 15 patients (3 primary malignant & 12 solitary metastases)

25. Tomita K, et al. Total en bloc spondylectomy for spinal tumors: improvement of the technique and its associated basic background. Journal of Orthopaedic Science. 11(1):3-12, 2006. From 1989 to 2003, 284 spinal tumors –primary tumors in 86 patients –metastasis in 198 patients TES was performed in 33 of the 86 patients with a primary tumor: –17 patients with a malignant tumor –16 with aggressive benign tumors

26. Tomita et al. Journal of Orthopaedic Science 2006 The 5-year survival: –For the 17 patients with primary malignant tumors was 67% –For the16 patients with aggressive benign tumors (stages 2 and 3) was 100%

27. Liljenqvist U, et al. En bloc spondylectomy in malignant tumors of the spine. European Spine Journal. 17(4):600-9, 2008 Apr. 1997 and 2005, 21 consecutive patients: –13 patients had primary malignant lesions –8 patients had solitary metastases Combined posteroanterior (n = 19) or all posterior approach (n = 2) Out of 11 patients with primary Ewing or osteosarcoma seven patients are alive without any evidence of disease.

28. Liljenqvist et al. European Spine Journal 2008

30. Major Risks of en bloc resection 1.Mechanical and vascular spinal cord injury 2.Injury to the major vascular structures 3.Tumor margin violation during resection 4.Significant operative blood loss because of epidural venous bleeding

31. Adjuvant Therapy Unlike the popular Pitchell trial for metastatic tumors In primary malignant tumors of the spine, preoperative radiotherapy and/or chemotherapy to shrink the tumor mass

32. Tomita et al. Journal of Orthopaedic Science 2006

33. Thank You