Malignant Cervical Spine Tumors

Operative treatment

G. SAPKASProfessor in Orthopedics

Orthopaedic Departmentfor

Spinal and Musculoskeletal Disorders“Metropolitan” Hospital

Epidemiology Epidemiology

Lung metastasisLung metastasis

Primary tumors Primary tumors of the spine are rare of the spine are rare especially of the especially of the cervical spine.cervical spine.However it is quite However it is quite consideralbeconsideralbethe incidence the incidence of metastasisof metastasis

A.B.C A.B.C

Benign tumors of the spineBenign tumors of the spine

The most common benign tumors The most common benign tumors are:are:– HemangiomaHemangioma– OsteoblastomaOsteoblastoma– Giant cell tumorGiant cell tumor– ChondroblastomaChondroblastoma– Osteoid osteomaOsteoid osteoma

Their incidence is estimated to be Their incidence is estimated to be 11% – 14%11% – 14%

A lot of them remain asymptomatic A lot of them remain asymptomatic and are diagnosed accidentally and are diagnosed accidentally

Osteochondroma

Malignant tumors of the spineMalignant tumors of the spine(primary and metastatic)(primary and metastatic)

The primary malignant tumors are The primary malignant tumors are rare in the spinerare in the spineThe most common are:The most common are:– OsteosarcomaOsteosarcoma– ChondroblastomaChondroblastoma– Ewing’s sarcomaEwing’s sarcoma– ChordomaChordoma– Lymphoma Lymphoma

Ewing’s sarcoma

Are the most common Are the most common in the spine in the spine The life expectancy The life expectancy contributes contributes to the increased to the increased incidence incidence of spinal metastasesof spinal metastases

Breast metatstasis

Metastatic spinal tumorsMetastatic spinal tumors

Incidence

Skeletal Skeletal MetastasesMetastases

Breast 45-85%

Pneumon 35-60%

Kidney 35-40%

Prostate 35-85%

Thyroid 30-60%

Skull 35%Cervical spine 22%

Humerus 10%Ribs 57%Thoracic spine 37%

Lumbar spine 53%

Sacrum 6%Pelvis 19%Femur 22%

The most common location The most common location for skeletal metastasis: for skeletal metastasis:

• Thoracolumbar Thoracolumbar region region ~ ~ 70%70%

• Lumbar and sacral Lumbar and sacral spine spine ~ ~ 20%20%

• Cervical spine Cervical spine ~ ~ 10%10%

Gilbert R.W. et al. Ann. Neural. 1998 Stomach metastasisStomach metastasis

Clinical symptoms Clinical symptoms of spinal of spinal

metastasismetastasis

PainNeurologic deficit

Stomach metastasisStomach metastasis

PAIN

Is the most common

symptom related to the existence of a primary or

metastatic spinal tumor

Breast metastasisBreast metastasis

The spinal pain may be due:The spinal pain may be due:In destruction of the anatomic In destruction of the anatomic vertebral elements as a result vertebral elements as a result of metastases of metastases

Resulting spinal instabilityResulting spinal instability

The pain is possible to occur The pain is possible to occur as a result of compression or as a result of compression or infiltration of the spinal infiltration of the spinal cord – nerves from cord – nerves from neoplasmatic masses.neoplasmatic masses.

Stomach metastasisStomach metastasis

Pathologic spinal Pathologic spinal fracturefracture

Spinal painSpinal pain

InstabilityInstability Compression Compression of the neural of the neural

tissuestissues

Neurologic Neurologic deficitdeficit

Thyroid metastasis

Neurologic deficitNeurologic deficit

Diagnosis Diagnosis of of

spinal tumorsspinal tumors

Plain x-rays

CT - scan

3D

M.R.I.

SCANNINGTc 99 MDP

P.E.T.P.E.T.

C.T. – guided percutaneous needle - biopsy

Biopsy of the spine

Angiography

Management Management

ChemotherapyChemotherapy

Radiation therapy Radiation therapy

Surgery Surgery

Pre - radiation Post - radiation

Chordoma

Radiotherapy 60g(proton therapy)

Courtesy Ath. Dimopoulos (Metropolitan)

RadiotherapyRadiotherapy

Stereotactic radio intervention following kyphoplasty

Courtesy Ath. Dimopoulos (Metropolitan)

Malignant primary tumors Malignant primary tumors of the of the

cervical spinecervical spine

Factors for evaluationFactors for evaluation::– The biology of the tumorThe biology of the tumor– The locationThe location– The painThe pain

– The neurologic deficitThe neurologic deficit

– The spinal instabilityThe spinal instability

– Life expectancy Life expectancy – Overall condition of the patientOverall condition of the patient

Aboulafia A. Levine A., OKU Spine 2, 2004

1. Spinal instability2. Pain resistible to

conservative treatment (radiotherapy – chemotherapy)

3. Incomplete neurologic deficit resistible to any type of conservative treatment

4. Rapid deterioration of the neurologic deficit

Indications for operative treatmentIndications for operative treatment

Enneking’s surgical Enneking’s surgical staging classification systemstaging classification system

Enneking, WF et al, Clin Orth, 1980

Weinstein-Boriani-Biagnini Weinstein-Boriani-Biagnini Surgical classification systemSurgical classification system

Weinstein et al, 21st ISSSL annual meeting 1994

Tomita’s staging classification system Tomita’s staging classification system for the primary tumors of the spinefor the primary tumors of the spine

Intra-compartmental Extra-compartmental Multiple skip lesion

Type 1

Type 2

Type 3

Type 4

Type 5

Type 6

Type 7

Site (1 or 2 or 3)

Anterior or posteriorLesion in situ

Site (1 +2 or 3 + 2)

Extension to pedicle

Site (1 +2 +r 3)

Anterio-posterior development

(any site + 4)Epidural extension

(any site + 5)Paravertebral development

Involvement toadjacent vertbra

Tomita T, et al, Spine 2001

Chondrosarcoma Chondrosarcoma

The most common The most common malignant tumor of malignant tumor of the bone in the the bone in the spinespine

7% - 12% of all 7% - 12% of all spine tumors spine tumors

M. Riz.

F 41

15-6-1997

Metastatic tumors Metastatic tumors of the of the

cervical spinecervical spine

Lung metastasisLung metastasis

Tokuhashi scoring system

Tomita surgical staging

Karnofsky performance status scale definitions rating (%) criteria

Methods of evaluation

E. Kar.

F 52

4-6-1991

Tokuhashi’sTokuhashi’s Evaluation System for Evaluation System for prognosis of metastatic spinal tumorsprognosis of metastatic spinal tumors

Symptoms Symptoms 00 11 22

General condition General condition performance statusperformance status

Poor Poor (PS 10% to 40%)(PS 10% to 40%)

ModerateModerate(50% to 70%)(50% to 70%)

GoodGood(80% to 100%)(80% to 100%)

No of extraspinal No of extraspinal skeletal metastasesskeletal metastases

>3>3 1 to 21 to 2 00

Metastases to Metastases to internal organsinternal organs

UnremovableUnremovable RemovableRemovable No metastasesNo metastases

Primary site of tumorPrimary site of tumor Lung stomachLung stomach Kidney liver uterus Kidney liver uterus unknownunknown

Thyroid prostate Thyroid prostate breast rectumbreast rectum

Number of Number of metastases metastases

>3>3 22 11

Spinal cord palsySpinal cord palsy CompleteComplete IncompleteIncomplete None None

Tokuhashi, Y. et al, Spine 1990

Total score versus survival period:

9 to 12 points > 12 months survival

0 to 5 points < 3 months survival

These criteria allow the definition of a pre-operative strategy and therefore considerable variability in the choice of treatment ranging:

• excisional operation should be performed on those who scored above 9 points

• a palliative operation should be performed on those who scored under 5 points

Tokuhashi Y. et al. Spine 1990

Simpler system of preoperative evaluation based on only three parameters:

• the degree of malignacy

• the presence of visceral metastases

• the presence of bony metastases.

Tomita K. et al. Spine 2001

Bauer H. et al. Spine 2002

Tomita’s classification systemTomita’s classification systemIntra-compartmental Extra-compartmental Multiple skip

lesion

Type 1

Type 2

Type 3

Type 4

Type 5

Type 6

Type 7

Site (1 or 2 or 3)

Anterior or posteriorLesion in situ

Site (1 +2 or 3 + 2)

Extension to pedicle

Site (1 +2 +r 3)

Anterio-posterior development

(any site + 4)Epidural extension

(any site + 5)Paravertebral development

Involvement toadjacent vertbra

Tomita T, et al, Spine 2001

Palliative treatment, generally produces modest results, but contributes greatly to the quality of life.

Moreover, it is reasonable to use palliative means when life expectancy is only:

4 to 15 months.

Wise J.F. et al Spine 1999.

Bouer H. et al. Spine 2002.

Palliative treatmentPalliative treatment

Pneumon’ s metastasis

Posterior decompression & stabilization

Surgical procedures

Vast majority can be managed Vast majority can be managed with dorsal fixationwith dorsal fixationRarely is ventral decompression Rarely is ventral decompression indicated or necessary indicated or necessary Preoperative spinal fracture Preoperative spinal fracture reduction may be attempted reduction may be attempted with awake tractionwith awake tractionVentral decompression may be Ventral decompression may be indicated to decompress indicated to decompress significant ventral tumor causing significant ventral tumor causing persistent spinal cord persistent spinal cord compression compression

Moulopoulos et al, Clin Imaging 1997Poynton Asley et al, Cancer in the spine, 2006

Atlanto-axial metastatic Atlanto-axial metastatic spinal tumorsspinal tumors

Breast’s cancer

A. St.F: 81N(+)

Mastectomies 35 yrs ago

a. Posterior decompression and Occipitocervical stabilization

b. Post-operative adjuvant chemotherapy - radiotherapy

N(-)N(-)

3 yrs pop

A. StF-84 yrs

14-7-2011

Metastastic disease of the Metastastic disease of the subaxial cervical spine is subaxial cervical spine is more common than the more common than the atlanto-axial spineatlanto-axial spine

As with atlanto-axial tumors As with atlanto-axial tumors the majority of the patients the majority of the patients can be managed with can be managed with radiation therapyradiation therapy

Sub-axial cervical spine Sub-axial cervical spine metastatic tumorsmetastatic tumors

El. ZaM 5614-10-2009

N(+)vePneumon’s metastasis

Anterior procedureAnterior procedure– Corpectomy Corpectomy – Vertebral body Vertebral body

replacement by replacement by expandable cage - expandable cage - Peek E.C.S. (Zimmer)Peek E.C.S. (Zimmer)

– Stabilization with plate Stabilization with plate and screws and screws Zephyr (Medtronic)Zephyr (Medtronic)

1st op.

Posterior Posterior procedureprocedure– Cervico thoracic Cervico thoracic

level level

– StabilizationStabilization

Complications Complications

Intra-operative Postoperative

Intra-operative Intra-operative complicationscomplications

Wound dehiscenceNeurologic deteriorationImplants dislodgement or brokeninfections

Post-operative complications

Post-operative complementary

treatment

Radiation therapy

of spinal metastases

Tombolini Y. et al 1994

Ortho - Athens

Best to start > 3wks post - op

Conclusions:Conclusions:

is treated successfully only by operative

procedure

Spinal instability due to bone destruction

Breast’s metastasisBreast’s metastasis

C3

Prosthetic replacement Prosthetic replacement is indicated in case of is indicated in case of vertebral destructionvertebral destruction

at one or two at one or two consecutive vertebraeconsecutive vertebrae

Benign spinal tumorsBenign spinal tumorsMalignant primary spinal Malignant primary spinal tumorstumorsSelected cases of Selected cases of metastatic spinal tumorsmetastatic spinal tumors

Posterior stabilization is recommended:

• For multiple metastases

• Poor general condition

• Short life expectancy

Thyroid metastasis

Anterior vertebral replacement and Anterior vertebral replacement and anterior – posterior stabilizationanterior – posterior stabilization

1. Is indicated in excessively unstable spineand

2. It gives the best overall results

University Hospital “ATTIKON”