Modern approach and pitfalls in metastatic spine surgery Jeremy Reynolds Spine Lead Oxford Bone and Soft Tissue Sarcoma Service MSCC Lead Thames Valley Cancer Network Clinical Lead Oxford Spine 1 Disclosures None.. 2 2 Disclosures None.. 3 3 1
Introduction Up to 70% of cancer patients will harbor spinal metastatic disease Cancer will become leading cause of death in western hemisphere 4 4 5 6 2
Clinical Experience has Expanded Orthopaedic Spine Surgery Principles of Musculoskeletal Oncology Neurosurgery Spine Oncology Surgery 7 The Changing Face of Spine Oncology: Key Developments and an Innovative Research Model Key Developments Surgical, Biologic, Radiation, Research Models Spine Oncology has become truly Multidisciplinary Knowledge Translation and Expansion Is it occurring in Spine Tumors? 8 SPINAL TUMOURS Primary Metastatic 9 3
SPINAL TUMOURS Decision Making Primary Metastatic 10 SPINAL TUMOURS Primary Metastatic 11 SPINAL TUMOURS Primary Metastatic 12 4
Patient reports symptoms suggestive of Malignant Spinal Cord Compression: Patient has history of cancer and one of the following: Severe Intractable Progressive Pain Especially Thoracic New Spinal Nerve Root Pain (Burning, Numb, Shooting) Any New Difficulty Walking Reduced Power/Altered Sensation in Limbs Bowel/Bladder disturbance Aim to start treatment within 24 hours. General Practitioner District Nurse/AHP Specialist (could also include OOH Secondary Care Macmillan Suspects Nurses & NHS 24) Suspects MSCC Nurses MSCC Suspects MSCC suspects MSCC Phones (add tel number) MSCC Coordinator 9-5 Monday Friday or to Out of Hours on-call Clinical Oncology SpR Information needed (see TVCN Referral form) Name and date of birth of patient Symptoms suggesting MSCC and onset History of cancer (type, stage) Signs on examination Coordinator ensures: Admitted to appropriate local acute service and acute service are made aware. MRI arranged/already performed. Steriods started (16mg Dexamethasone stat and 8mg b.d.) as soon as possible after assessment (unless contraindicated). Advice sought from relevant oncologist. Assessment will help inform Clinical Oncology SpR if MRI is required Patients should not be informed of possibility of MRI until referrer discusses symptoms with Clinical Oncology SpR. MSCC unlikely MSCC likely or Patient fit enough for treatment if known patient is not fit enough for treatment or fitness unknown Clinical Oncology SpR: Patients will be treated as potentially unstable spines and Advises on management of patient appropriate transport arranged to local acute medical unit by referrer or Arranges review of patient Spine unstable transport arranged by referrer or Acute local service confirms steroid commenced and updates Discusses case with appropriate specialist clinical assessment as per referral proforma. MRI -ve MRI reported to admitting team. Team informs MSCC Coordinator. MSCC Coordinator completes the referral proforma. Images tranferred to appropriate Oncology Consultant. MRI +ve Treatment decision made in consultation with Oncology Consultant. Organise urgent CT if appropriate i.e. patient suitable for surgical treatment Surgery not option Surgery option Clinical Oncology SpR proceeds with treatment planning Spinal Consultant proceeds with treatment planning 13 Pitfall - Lack of consistency Oncological Disease specific vs site specifc Heterogenous repertoire Entrenched opinion Surgical Lack of awareness Challenging surgery Lack of capacity Entrenched opinion 14 Decision Making in Spine Metastases What have we firmly established? Surgery + Radiation Is better than Radiation alone 15 5
Decision Making in Spine Metastases What have we firmly established? Surgery + Radiation Is better than Radiation alone Health Related Quality of Life is improved with surgery 16 Decision Making in Spine Metastases What have we firmly established? Surgery + Radiation Is better than Radiation alone Health Related Quality of Life is improved with surgery Less than $50 per day to maintain ambulation 17 Decision Making Patients feel more empowered when allowed to participate in decisions about treatment options. In other words patients want to have a say in their treatment plans. Kirsti A. Dyer : Defining Good Death 19 6
Decision Making Patients feel more empowered when allowed to participate in decisions about treatment options. In other words patients want to have a say in their treatment plans. Kirsti A. Dyer : Defining Good Death Approach to Spine Mets 3 factors Neurology 20 Neurology Timing <1 day OR 15 1 3 OR 10 21 22 7
Pitfall - speed and adequacy Delays Awareness Capacity/infrastructure Circumferential compression 360 decompression 23 Metastatic spinal cord compression (MSCC): Radiotherapy alone 24 MSCC: Laminectomy ± Radiotherapy 25 8
MSCC: Laminectomy/Decompression & Stabilisation 26 MSCC: Vertebral body resection and stabilisation 27 MSCC: Summary of treatment outcomes 28 9
29 30 Posterolateral Vertebrectomy 31 10
Posterolateral Vertebrectomy Reliable & safe exposure for 3 column reconstruction and neurologic decompression Acceptable complication rate Favourable patient outcome Bilsky, M.H. Et al. Spine. 2000 sep 1;25(17):2240-9 Wang et al. J of neurosurgery 2004 Street, fisher et al J of spinal disorders 2006 32 33 34 11
35 Decision Making Patients feel more empowered when allowed to participate in decisions about treatment options. In other words patients want to have a say in their treatment plans. Kirsti A. Dyer : Defining Good Death Approach to Spine Mets 3 factors Neurology Patient 36 Decision Making Patients feel more empowered when allowed to participate in decisions about treatment options. In other words patients want to have a say in their treatment plans. Kirsti A. Dyer : Defining Good Death Approach to Spine Mets 3 factors Neurology Patient 37 12
Decision Making in Spine Metastases That biology is dictating decision making. PATIENT PROFILE The underestimation of life expectancy and subsequent inadequate treatment of spinal metastases may lead to dramatic alteration of the quality of life. 38 Many pre-operative scoring systems try and tell you if and how to operate, but none are particularly valid or reliable, especially in light of all the new developments in oncology. That biology is dictating decision making The only consistent factors for prognosis or life expectancy are GENERAL CONDITION and PRIMARY SITE! The importance of molecular markers! Over 4 year period found Lung and Renal Cell CA Patients living significantly longer! 39 40 Influence of histopathologic parameters in the management of metastatic disease of the spine secondary to lung cancer a systematic review. Batista, N. Fisher C. et al. GS 2015 Survival of Lung Ca Patients Systemic Control Small Cell = 8 mos NSCLC - Adenocarcinoma = 11 mo - EGFR = 17.8mos - Large cell = 11 mo - Squamous = 9 mo - NOS = 5 mo Not otherwise specified (NOS) Not all spine met patients secondary to Lung Ca are bad surgical candidates. Similar variations for Renal Cell, Breast, GI. Molecular analysis is changing prognosis dramatically. Talk to named oncologist! 13
Breast Cancer Genome 43 Why curing cancers with drugs is difficult!! 1. Cancer genome is almost identical to normal genome (compare to bacteria) 2. Variation among cancers 44 Breast Cancer Genome Sample 45 14
Breast Cancer Genome Sample - 34C vs. 10C Genomes 46 Personalized Medicine aka Precision Medicine aka Genome-based Medicine 47 Pancreatic Cancer Pa34C Genome BRAF mutation 48 15
49 Implications of the cancer genome for non-conventional therapeutic approaches 50 Considerations for Surgery Histology Neurological condition/pain/symptoms Performance status Instability Patient s wishes Systemic Disease Status Prognosis 51 51 16
We are now able to impact survival in patients with advanced metastatic disease that have failed prior therapies. 52 52 Lung Cancer 53 53 Spine SBRT An Alternative to CRT: Local Control 54 17
Radiosensitivity U = unfavourable I = intermediated F = Favorable CRT No instability Sensitive Histology Multilevel Disease Lymphoma Breast Prostate Sarcoma Melanoma GI NSCLC Renal Seminoma Myeloma F U U U U U U U F F F U U U U U F I I I U I U I F F F U U U U U F F F U U U U U F F F U U U U U F I I I U I U I 55 Radiosensitivity U = unfavourable I = intermediated F = Favorable CRT No instability Sensitive Histology Multilevel Disease SBRT Degree of Epidural Disease No instability Resistant Histology Progression after CRT Lymphoma Breast Prostate Sarcoma Melanoma GI NSCLC Renal Seminoma Myeloma F U U U U U U U F F F U U U U U F I I I U I U I F F F U U U U U F F F U U U U U F F F U U U U U F I I I U I U I 56 Radiosensitivity U = unfavourable I = intermediated F = Favorable CRT No instability Sensitive Histology Multilevel Disease SBRT Degree of Epidural Disease No instability Resistant Histology Progression after CRT Lymphoma Breast Prostate Sarcoma Melanoma GI NSCLC Renal Seminoma Myeloma F U U U U U U U F F F U U U U U F I I I U I U I F F F U U U U U F F F U U U U U F F F U U U U U F I I I U I U I 57 18
Bilsky Epidural Disease Grade 1a 1b 1c 2 3 Kumar,..Fisher, Sahgal, Neuro-Onc Pract. 2015 58 59 Predictors of VCF Pitfall 60 19
61 62 63 20
64 65 Embolization Neurologic complications (4% + 2.5%) 50% improvement in blood loss Better outcomes with particle +/- coil 66 21
Embolization Neurologic complications (4% + 2.5%) 50% improvement in blood loss Better outcomes with particle +/- coil 67 68 Radiosensitivity U = unfavourable I = intermediated F = Favorable CRT No instability Sensitive Histology Multilevel Disease SBRT Degree of Epidural Disease No instability Resistant Histology Progression after CRT Lymphoma Breast Prostate Sarcoma Melanoma GI NSCLC Renal Seminoma Myeloma F U U U U U U U F F F U U U U U F I I I U I U I F F F U U U U U F F F U U U U U F F F U U U U U F I I I U I U I 69 22
70 71 72 23
73 74 75 24
76 What is en bloc? It is NOT complete macroscopic resection of lesion It is NOT total spondylectomy Resection of lesion without transgression of tumour 77 77 Enbloc: marginal 78 25
Why consider en bloc? Solitary lesion RT insensitive Hormone secreting lesion Solitary lesion failing to respond to other therapies 79 79 Why consider en bloc? Solitary lesion RT insensitive Hormone secreting lesion Solitary lesion failing to respond to other therapies Low morbidity en bloc Thoracic Posterior element 80 80 Evidence.. MSCC intervention generally well supported 81 81 26
Evidence.. MSCC intervention generally well supported Evidence for en bloc..?? 82 82 Evidence.. MSCC intervention generally well supported Evidence for en bloc..?? = Majority would choose this most of the time 83 Systematic Review - Search Last 10yr PubMed, Google Scholar, OVID and the Cochrane and a review of the references of the reviewed articles. Spine, metastasis and en bloc connected with the Boolean operator AND 84 84 27
Systematic Review - Inclusion articles published 1 Jan 2008-1 Jan 2018 articles in English/English translation adults (aged 18+) articles describing en bloc resection for isolated spinal metastasis. 85 85 Systematic Review - Exclusion patient recruitment prior to 2000 local tumour invasion rather than metastasis paediatric subjects articles with <5 reported en bloc resections articles not published in English. 86 86 Systematic Review - Results 66% for pain vs 34% for neurological compromise Tokuhashi score was 9.8 (SD 1.9) = 6-12/12 89.4% posterior only vs 9.3% anterior approach TBL mean 1596ml (SD 784ml) Operating time 6.5hrs (SD 0.8hrs) LOS (Lee) 84.2 days (SD 59 days) 87 87 28
Complications 35.1% Dural tear 18.5% Infection 5.3% Unplanned neurological injury 3.7% Local recurrence 8.5% Metastatic progression 54.5% at 9.7 months Death 55.7% at FU (12.1 months SD 10.7) Peri-operative (30 day) death 3.84% 88 88 Complications 35.1% Dural tear 18.5% Infection 5.3% Unplanned neurological injury 3.7% Local recurrence 8.5% Metastatic progression 54.5% at 9.7 months Death 55.7% at FU (12.1 months SD 10.7) Peri-operative (30 day) death 3.84% 89 89 90 90 29
91 92 93 30
En Bloc? Risks remain high vs conventional surgery Therefore consider: Referral to high volume oncology centre Only highly selective use of en bloc surgery Some Renal Some Thyroid Secreting tumours Post RT Selected low risk en bloc 94 95 J Bone Joint Surg Am. 2016 Jan 20;98(2):117-26. doi: 10.2106/JBJS.N.01353.Quality of Life and Surgical Outcomes After Soft-Tissue Reconstruction of Complex Oncologic Defects of the Spine and Sacrum Dolan RT, Butler JS, Wilson-MacDonald J, Reynolds J, Cogswell L, Critchley P, Giele H 96 31
97 Minimally Invasive T11 Vertebrectomy 98 Intra-operative Imaging 99 32
Decision Making Patients feel more empowered when allowed to participate in decisions about treatment options. In other words patients want to have a say in their treatment plans. Kirsti A. Dyer : Defining Good Death Approach to Spine Mets 3 factors Neurology Patient Stability 100 What is stable? 101 Stability = system handling of perturbation Unstable = the disturbed behavior differs significantly from the old behavior Effect of neoplastic replacement? 102 The neoplastic spine may be stable but not usually robust 33
Spinal Instability Neoplastic Score (SINS) Stable Potentially unstable Unstable 0-6 pts 7-12 pts >12 pts 103 Spinal Instability Neoplastic Score (SINS) Stable Potentially unstable Unstable 0-6 pts 7-12 pts >12 pts 104 Decision Making 105 34
57yo male Progressive neuro deterioration 5 wks Male L1 ASIA C Mechanical TL pain Lymphoma 106 13 pts Stable Potentially unstable Unstable 0-6 pts 7-12 pts 13-18 pts 107 57yo male Progressive neuro deterioration 5 wks Male L1 ASIA C Mechanical TL pain Lymphoma 108 35
55 yo female Severe LBP with mobility No neurology Lung Ca 109 9 pts Stable Potentially unstable Unstable 0-6 pts 7-12 pts >12pts 110 Vertebral Augmentation (VA) Is VA effective for pain relief and improving function? Is VA safe? VA is effective and safe and should be used in the management of metastatic disease of the spine. Strong Recommendation 111 Moderate Evidence 36
Known primary vs CUP Staging CT Whole spine MRI Biopsy ASAP Steroids 112 113 114 37
115 116 117 38
Summary New Paradigm for Evidence Based Care Decision: Multidisciplinary Patient Factors Neurology Stability CRT SRS or IMRT Surgery Vertebral Augmentation Standardized Outcomes and Multicenter Research Palliative Care 118 Cost Effective? Expensive treatment for incurable disease?? Baseline results = $60 per additional day of ambulation 119 When survival used as measure of effect, translates to $30 940 per life year gained Compares favorably to: vaccination programs Implantable cardioverters Screening for colorectal cancer Abdominal aortic aneurysm surgery 39