2. Metastatic tumour - most common malignancy of
bone
Spine - most common site of osseous metastases
5-10% of the patients with cancer develop spine
metastases*
All age groups with highest age incidence in
between 40 and 65 years
Male:Female – 3:2
*Ries LAG, Melbert D, Krapcho M, et al, eds. SEER Cancer
Statistics Review,1975–2005. National Cancer Institute. Bethes
4. PRIMARY*
◦ Unknown(33%)
◦ Breast (21%)
◦ Lung (14%)
◦ Prostate(8%)
◦ Gastrointestinal (5%)
◦ Thyroid (3%)
*Ries LAG, Melbert D, Krapcho M, et al, eds. SEER Cancer
Statistics Review,1975–2005. National Cancer Institute.
Bethesda
5. Basis of anatomic location*
Intradural - 5%
◦ Intramedullary
◦ Extramedullary – tertiary drop
metastases
Extradural - 95%
◦ Pure epidural – rare
◦ Arising from the vertebrae -
most frequent
*Perrin RG, Laxton AW. Metastatic spine disease:
epidemiology, pathophysiology, and evaluation
of patients. Neurosurg Clin N Am 2004;15:365–373
Intramedullary extradural
metastases entrapped in cauda equina
6. Metastatic properties of primary neoplasia
Anatomic properties of the host organism
Biologic properties of the skeletal host
7. Posterior half of the body is seeded first, anterior
half, pedicles and lateral masses are involved
later
Local spread to adjacent vertebra
Spread to epidural space
Induce osteoblastic or lytic lesions, diffuse
osteopenia or variable combination
Replacement of marrow tissue with neoplasm,
progressive collapse and finally spinal instability
8. Pain – 85%
◦ Constant and localised
◦ Radicular
◦ Axial
Spinal deformity
Neurologic deficit
Constitutional
symptoms
RED FLAG features
– Gradual onset,
progressive, constant, night
time or recumbency pain
and axial pain exaberated
by movement in all
directions
15. Bone scan
Polyostotic Monostotic
CT scan/MR imaging
Perform biopsyImpending fracture
No impending
fracture
Perform biopsy
and stabilise
Observe, radiate or
perform biopsy
16. Biopsy
Primary sarcoma Metastatic carcinoma
Refer to sarcoma surgeon
Renal or thyroid primary
Non Renal or thyroid
primary
Treat as indicated
17. History and physical examination
Chest radiographs and Laboratory tests
Myeloma Primary not identified Primary identified
Stage and as
indicated
Bone scan, CT scan
of chest, abdomen
and pelvis
Skeletal survey; Refer
to medical oncologist
18. Bone scan; CT scan of chest,
abdomen and pelvis
Primary
identified
Solitary lesion
and primary not
identified
Multiple bone lesions
and Primary n0t
identified
Assume sarcoma;
Refer to orthopaedic
oncologist
Perform biopsy on
most appropriate site
Stage and treat
as indicated
20. PLAIN RADIOGRAPHS
◦ Location
◦ Pattern of bone destruction
◦ Vertebral collapse
◦ Winking owl sign
◦ Difficult to detect early lesions
21. BONE SCAN
◦ Superior sensitivity
◦ Extent of dissemination
◦ Define the most accessible lesion
to biopsy in cases of unknown
primary
SPECT
22. COMPUTED
TOMOGRAPHY
◦ Improved specificity
◦ Sensitive to alterations in
bone mineralisation
◦ Osseous details
◦ Evaluation of cortical
penetration
23. MAGNETIC RESONANCE
IMAGING
◦ Superior sensitivity and specificity
◦ Method of choice to evaluate spine
◦ Define the intramedullary, intradural
and extramedullary lesions
◦ Extent of the lesion
◦ Differentiation from other pathologies
such as infection and osteoporotic
◦ Fat suppression and Gadolinium
enhancement to improve the delineation
24. POSITRON EMISSION
TOMOGRAPHY
◦ Uses Flourine-18-Flouro deoxy glucose
◦ MRgIc calculation by Patlak analysis in
ROI
◦ Detection of primary and metastatic
tumours
◦ Recurrences of tumour
◦ Differentiation of osteoporotic VCF from
pathologic VCF’s
25. Tissue diagnosis of lesion guides the treatment
FNAC or needle biopsy
Core biopsy
Incisional biopsy
Excisional biopsy
26. PER CUTANEOUS APPROACHES FOR BIOPSY
Posterior
cervical
C 1 – 3= Transoral
Sub axial cervical Anterior or posterior to sternocleidomastoid
Thoracic and
Lumbar
Transpedicular or Postero lateral
Sacral Posterolateral
28. LUNG CANCER
Metastatic stage IV – dismal
prognosis, median survival
< 6 months
◦ Small cell LC
Chemotherapy
Radiotherpy
◦ Non small cell LC
Combined chemo and radiotherapy
Resection of the tumour with
vertebrectomy
29. PROSTATE CANCER
Hormone withdrawal –
bilateral orchidectomies or
androgen deprivation
(LHRH agonists, flutamide
etc)
Radiation therapy
Chemotherapy
Surgery
Average survival around 12
months
30. BREAST CANCER
Metastatic cancer – median
survival 3 years
Chemotherapy
Hormonal therapy –
Tamoxifen
Bisphosphonates
31. THYROID CANCER
Thyroidectomy followed by
iodine – 131 at therapeutic
doses
Palliative radiotherapy
Overall 10 year survival rate –
35%
32. RENAL CELL
CARCINOMA
Metastatic – median
survival 6 to 9 months
Combined
chemo/immune therapy
Radiotherapy
Pre operative
Embolisation and Surgery
34. Early 1900’ s – surgical treatment such as
decompressive laminectomy
1953 - first patient was treated with a linear
accelerator
1980’ s – advent of spinal implants
Recent developments - Intensity-modulated
radiation therapy (IMRT), stereotactic
radiosurgery, and stereotactic radiotherapy
35. Life expectancy
Biopsy – Histology to predict the response to non
operative management
Stability
Clinical presentation – Pain and Neurological
status
36. Analgesic treatment
Physical therapy and bracing
Bisphosphonates
Vertebroplasty or Kyphoplasty
Radiofrequency ablation
Radiation therapy
Surgical stabilization in patients with life expectancy
of more than 3 months
PATIENTS PRESENTING WITH PAIN
AND NO NEUROLOGICAL DEFICIT
37. ANALGESIC TREATMENT
Three Step model of analgesia
◦ NSAIDS
◦ Short acting opioids
◦ Pure opioid agonists
Disease-modifying therapies,
coanalgesic/adjuvant administration, and
interventional strategies (cognitive, behavioral,
physiatric etc)
38. BISPHOSPHONATES
Treat hypercalcemia
Potent inhibitors of normal and
pathological bone resorption.
Antiangiogenic effects and
Antitumoral activity*
PHYSICAL THERAPY AND BRACING
Orthoses
Bracing
*Diel IJ, Solomayer EF, Costa SD, et al: Reduction in new
metastases in breast cancer with adjuvant clodronate
treatment. N Engl J Med 339:357–363, 1998
39. Emergency whole spine MRI
Dexamethasone
Radiosensitivity+ -
Unstable spine
Vertebroplasty
Or
Kyphoplasty
Radiotherapy
Neurological
deficit<24 hrs
Surgical candidate
_
+
-
Surgical decompression and
stabilization followed by
radiotherapy
+
40. CORTICOSTEROIDS
Should be prescribed in all
patients presenting with
neurological deficit
◦ High dose dexamethasone
◦ Standard dose
◦ Methyl prednisolone
43. IMRT, STEREOTACTIC RADIOSURGERY AND
STEREO TACTIC RADIOTHERAPY*
◦ Deliver high doses safely
◦ Possible to irradiate spine without affecting spinal cord
*De Salles AA, Pedroso AG, Medin P, Agazaryan N, Solberg T,
Cabatan-Awang C, et al: Spinal lesions treated with Novalis
shaped beam intensity-modulated radiosurgery and stereotactic
radiotherapy. J Neurosurg 101 (3 Suppl):435–440, 2004
44. (A) Target planning image. The thick dark pink line surrounds the target volume.
The thick dark green line represents the thecal sac (main organ at risk). The
remaining lines represent isodose lines. (B) Dose-volume histograms
demonstrating steep falloff of radiation, with high doses being applied to the lesion
and a low volume of the thecal sac being exposed to significant dose.
45. SYSTEMIC
RADIOISOTOPE THERAPY
◦ Strontium – 89, Samarium - 153
and Rhenium – 186
◦ Affinity to osteoblastic bone
◦ Local antitumour activity and
analgesic affect*
*Serafini AN: Systemic metabolic radiotherapy with samarium-15
EDTMP for the treatment of painful bone metastasis. Q J Nucl
Med 45:91–99, 2001
46. Injection of PMMA into the
involved vertebral body under
fluoroscopic guidance.
Reinforcement of the bone and
stabilization of anterior column
relieves pain
PMMA – Anti tumour activity
47. MECHANISM OF PAIN RELIEF*
◦ Stabilization of microfractures
◦ Reduction of mechanical forces
◦ Destruction of the nerve terminals by the cytotoxicity of
PMMA
*Cotten A, Dewatre F, Cortet B, et al. Percutaneous
vertebroplasty for osteolytic metastases and myeloma:
effects of the percentage of lesion filling and the leakage of
methyl methacrylate at clinical follow-up. Radiology
1996;200:525–530
48. Percutaneous introduction of a KyphX balloon
Inflated to reduce the fracture and deflation
Void filled with PMMA
49. Low extravasation rate
Pain relief equivalent to that of vertebroplasty
Can restore the lost vertebral height
Can correct the sagital balance
Can use more viscous cement
Increases the vertebral body strength
Increases the vertebral body stability
Can provide tissue for diagnosis
ADVANTAGES
50. Uses thermal energy to destroy the tumour cells
Combined treatment with vertebroplasty*
*Schaefer O, Lohrmann C, Markmiller M, Uhrmeister P,
Langer M. Technical innovation: combined treatment of
a spinal metastasis with radiofrequency heat ablation
and vertebroplasty. Am J Roent 2003;180:1075–1077
51. Radiofrequency Ablation Probe at T9
Anterior-posterior (a) and lateral (b) fluoroscopic images of the
radiofrequency ablation probe in the T9 vertebral body
52. Radiofrequency ablation combined with
vertebroplasty/kyphoplasty
Tumour debulking combined with VB
augmentation
◦ Ablation using LITT (laser induced thermotherapy) before
cement placement *
*Ahn H, Mousavi P, Chin L, et al. The effect of pre-
vertebroplasty tumor ablation using laser-induced
thermotherapy on biomechanical stability and cement fill in the
metastatic spine. Eur Spine J 2007;16:1171–78. Epub 2007
Apr 20
53. A 71-year-old woman with undifferentiated cancer and a lesion at L4. B and
C, A void is created in the vertebral body by debulking the spinal tumor using
the plasma radio-frequency– based wand before vertebral body
augmentation with bone cement. D–F, Axial (D and E) and sagittal (F) views
by using MR imaging show excellent anterior placement
54. Vertebral body augmentation combined with
hardware*
◦ Short segment pedicle screw fixation combined with
vertebroplasty/kyphoplasty in lieu of traditional long
segment fusion
*Cho DY, Lee WY, Sheu PC. Treatment of thoracolumbar burst
fractures with polymethyl methacrylate vertebroplasty and short-
segment pedicle screw fixation.Neurosurgery 2003;53:1354–60,
discussion 1360-61
55. GOALS
◦ Obtaining tissue in case of
an unknown diagnosis
◦ Relief of neurologic
symptoms by
decompression
◦ Relief of pain by
stabilization and
reconstruction of the spinal
column
56. Pre operative for vascular metastatic lesions such as
renal cell, thyroid carcinoma, squamous and
adenocarcinomas of lung
58. Radiation- and chemotherapy-resistant tumors (e.g., squamous and renal
cell)
Acute or progressive spinal cord compression
Recurrent tumor in patients who have already received maximal doses of
chemotherapy/radiation
Pain associated with collapse in vertebral height of greater than 50%, a 50%
kyphotic deformity, or more than 70% of the vertebral body destroyed
Isolated metastases in which durable remissions can potentially be achieved (e.g.,
renal, breast, thyroid)
Impending fracture
59.
60. SCORING SYSTEMS
Karnofsky score estimates a patient's ability to carry
out normal activities, work, and care for themselves.
The Tokuhashi index
◦ Karnofsky index
◦ Neurologic status
◦ Metastatic disease
◦ Cancer type
◦ Surgical resectability.
61.
62.
63. Total Tokuhashi score Life expectancy
0–4 <3 mo
5–8 <6 mo
9–12 >6 mo
Tokuhashi score is developed as an assessment tool to select
the most suitable surgical procedure with respect to predicted
prognosis
64. Tomita classification- built on Enneking oncological
system
Description of the affected site
Metastatic extent
◦ Intracompartmental(1-3)
◦ Extracompartmental(4-7)
1. Vertebral body
2. One or both pedicles
3. Lamina and spinous process
4. Epidural canal
5. Paravertebral area
6. Adjacent vertebra
7. Skip lesions
65. Tokuhashi
score Life expectancy
Tomita
classification Surgical procedure (all receive radiation)
0–4 <3 mo 1–7 Laminectomy and stabilization
5–8 3–6 mo 1–7 Posterior decompression, stabilization, and
reconstruction
9–12 >6 mo 1–3 En bloc with vertebrectomy and 360-degree
reconstruction
4–6 Intralesional vertebrectomy and 360-degree
reconstruction
7 Posterior decompression and stabilization
66. Location of the tumour
Spinal instability
Neurological status
67. James weinstein model
Zones IB to IVB – Extraosseous extensions of the tumour beyond cortical bone
Zones IC to IVC - Associated regional or distant metastases
68. • Zones I and II lesions - posterior or
posterolateral surgical approach
Zone III lesions – anterior surgical approach
Zone IV lesions - combined anterior and posterior
approach
70. RECONSTRUCTION AND STABILIZATION
◦ Anterior
◦ Posterior
Subclassified according to the level
71. THORACIC SPINE
Disease involving vertebral body at 1 or 2 levels-
Transthoracic vertebrectomy and anterior
reconstruction
Single stage posterolateral decompression and
stabilisation – patients with specific
contraindication to thoracotomy
Significant kyphosis with VB collapse, disease
involving DL junction – posterior stabilization with
anterior reconstruction
72. Inclusion of significant portion of chest wall in
tumour resection – posterior stabilization to
prevent the risk of kyphoscoliosis
Cases of tumours involving VB posterior elements
and chest wall – combined approach for resection
and VB reconstruction, anterior and posterior
stabilization
73. INSTRUMENTATION
Fixation using rods and screws
Vertebral body reconstruction – metal cage, cement,
ceramic spacer, or grafts( autologous or allograft)
74. 57 year old female of lung carcinoma with metastases D5 underwent
circumferential tumor resection and simultaneous anterior and posterior
reconstruction by combined approach.
75. LUMBAR SPINE
Standard retroperitoneal approach – excellent
exposure
Single level L1-3 disease – vertebrectomy and
anterior reconstruction
Disease limited to L5 – posterolateral
decompression and stabilisation
Multilevel disease – palliative posterolateral
decompression
76. LUMBOSACRAL JUNCTION AND SACRUM
Resection and reconstruction by pedicle screws and
rods by modified Galveston technique
77. Cure is not the goal
Multidisciplinary approach
Surgery vs Radiotherapy*
Management often not clear cut
Patchell RA, Tibbs PA, Regine WF et al. Direct decompressive
surgical resection in the treatment of spinal cord
compression caused by metastatic cancer: a randomised
trial. Lancet 2005;366:643-8.
78. Adult and Pediatric spine, 3rd
edition
Spinal Extradural metastases; Review of current
treatment options.CA Cancer J Clin 2008;58;245-
259
Spinal instability and deformity due to neoplastic
conditions.Neurosurg Focus 14 (1):Article 8, 2003
Bone metastases.Tumors
