Modern Treatment of Spinal metastases Maxwell Boakye, MD MPH FACS FAANS Associate Professor of Neurosurgery Nelson Endowed Chair Center for Advanced Neurosurgery,

Modern Treatment of Spinal metastases

Maxwell Boakye MD MPH FACS FAANSAssociate Professor of Neurosurgery

Nelson Endowed ChairCenter for Advanced Neurosurgery University of

Louisville

My Background

bull Neurosurgeonbull Residency 2002bull Fellowships-complex spine-Emory and Spine

Oncology-Sloan Kettering-2003bull Stanford-2003-2010-worked with cyberknifebull Special interest in spine tumors and spine

radiosurgery

Goals

bull Epidemiologybull Presentationbull Imagingbull Role of Surgery bull Emerging Treatment paradigms bull Decision making and Frameworksbull Memorial Sloan Kettering NOMS criteriabull Cases

Epidemiology

bull 20000 new cases of metastatic epidural cord compression each year

bull 10 of cancer patients will develop spinal metastatic

bull About 70 of all cancer deaths occur in elderly patients aged over 65

bull Postmortem studies metastases present in 90 of patients with systemic cancer

Epidemiology

bull Number of elderly patients dying from cancer will double by 2030

bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple

Signs and symptoms

bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression

bull Painndash Biologic

bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive

ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen

bull Other Symptoms eg LOC or AMS from brain

Imaging

bull X-raysbull CTbull MRIbull PET

Imaging findings

bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases

Treatment options

bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy

Main surgical approaches

bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull 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

bull Mortality-5-6bull Complication rates-20-40

Emerging Treatment Patterns

bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty

bull Radiosurgerybull Combined kyphoplasty and radiosurgery

KYPHOPLASTY

KYPHOPLASTY

CAFEacute TRIAL

CAFEacute trial

Berenson et Al Lancet Oncology 2011 Mar12(3)225-35

CYBERKNIFE RADIOSURGERY

bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom

bull Real-Time Image Guidance Throughout the Treatment

bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one

Other radiosurgery systems

Concept of Separation surgery

Separation surgery

DECISION MAKING

bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids

Tokuhashi score

1048707ge9bullExcisionbullSurvival gt 12 months

1048707le5bullPalliativebullSurvival lt 3 months

Decision Making-NOMS criteria

bull Neurologicbull Oncologicbull Mechanicalbull Systemic

NOMS criteria

bull Neurologic-myelopathy degree of epidural cord compression

bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities

Neurologic-Classification of Epidural compression

Neurologic-Classification of epidural compression

Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317

Oncologic-Radiosensitivity

bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not

radiosensitive

Mechanical Instability

Systemic factors

SINS score

bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending

instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS

score gt 7bull 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 1001 099-102 090

Ambulatory status

2355 152-366 00001

Cervical mets 107 069-165 076

Comorbidity 296 134-651 0007Epidural compression

120 069-209 052

Pathologic fracture 141 095-208 008

Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091

Urinary incontinence

116 078-171 047

Visceral mets 109 075-157 065

NOMS decision framework

Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317

• Modern Treatment of Spinal metastases
• My Background
• Goals
• Epidemiology
• Epidemiology (2)
• Signs and symptoms
• Imaging
• Imaging findings
• Treatment options
• Main surgical approaches
• Slide 11
• Epidural Compression Surgery is superior to radiation
• Patchell study
• Surgery vs radiation-Patchell
• Surgery improves quality of life outcomes
• Surgical complications
• Price of surgery High Morbidity and mortality
• Slide 18
• Emerging Treatment Patterns
• KYPHOPLASTY
• KYPHOPLASTY (2)
• CAFEacute TRIAL
• CAFEacute trial
• Slide 24
• CYBERKNIFE RADIOSURGERY
• Slide 26
• Slide 27
• Other radiosurgery systems
• Slide 29
• Slide 30
• Concept of Separation surgery
• Separation surgery
• Slide 33
• Slide 34
• DECISION MAKING
• Tokuhashi score
• Decision Making-NOMS criteria
• NOMS criteria
• Neurologic-Classification of Epidural compression
• Neurologic-Classification of epidural compression
• Oncologic-Radiosensitivity
• Mechanical Instability
• Slide 43
• Systemic factors
• SINS score
• Oncologic factors-Impact of Comorbidities
• Oncologic and Systemic factors-survival
• Slide 48
• Slide 49
• Predictors of Survival
• NOMS decision framework
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59