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Journal of Neurosurgery. Spine Mar 2017OBJECTIVE Although postoperative stereotactic body radiation therapy (SBRT) for spinal metastases is increasingly performed, few guidelines exist for this application....
OBJECTIVE Although postoperative stereotactic body radiation therapy (SBRT) for spinal metastases is increasingly performed, few guidelines exist for this application. The purpose of this study is to develop consensus guidelines to promote safe and effective treatment for patients with spinal metastases. METHODS Fifteen radiation oncologists and 5 neurosurgeons, representing 19 centers in 4 countries and having a collective experience of more than 1300 postoperative spine SBRT cases, completed a 19-question survey about postoperative spine SBRT practice. Responses were defined as follows: 1) consensus: selected by ≥ 75% of respondents; 2) predominant: selected by 50% of respondents or more; and 3) controversial: no single response selected by a majority of respondents. RESULTS Consensus treatment indications included: radioresistant primary, 1-2 levels of adjacent disease, and previous radiation therapy. Contraindications included: involvement of more than 3 contiguous vertebral bodies, ASIA Grade A status (complete spinal cord injury without preservation of motor or sensory function), and postoperative Bilsky Grade 3 residual (cord compression without any CSF around the cord). For treatment planning, co-registration of the preoperative MRI and postoperative T1-weighted MRI (with or without gadolinium) and delineation of the cord on the T2-weighted MRI (and/or CT myelogram in cases of significant hardware artifact) were predominant. Consensus GTV (gross tumor volume) was the postoperative residual tumor based on MRI. Predominant CTV (clinical tumor volume) practice was to include the postoperative bed defined as the entire extent of preoperative tumor, the relevant anatomical compartment and any residual disease. Consensus was achieved with respect to not including the surgical hardware and incision in the CTV. PTV (planning tumor volume) expansion was controversial, ranging from 0 to 2 mm. The spinal cord avoidance structure was predominantly the true cord. Circumferential treatment of the epidural space and margin for paraspinal extension was controversial. Prescription doses and spinal cord tolerances based on clinical scenario, neurological compromise, and prior overlapping treatments were controversial, but reasonable ranges are presented. Fifty percent of those surveyed practiced an integrated boost to areas of residual tumor and density override for hardware within the beam path. Acceptable PTV coverage was controversial, but consensus was achieved with respect to compromising coverage to meet cord constraint and fractionation to improve coverage while meeting cord constraint. CONCLUSIONS The consensus by spinal radiosurgery experts suggests that postoperative SBRT is indicated for radioresistant primary lesions, disease confined to 1-2 vertebral levels, and/or prior overlapping radiotherapy. The GTV is the postoperative residual tumor, and the CTV is the postoperative bed defined as the entire extent of preoperative tumor and anatomical compartment plus residual disease. Hardware and scar do not need to be included in CTV. While predominant agreement was reached about treatment planning and definition of organs at risk, future investigation will be critical in better understanding areas of controversy, including whether circumferential treatment of the epidural space is necessary, management of paraspinal extension, and the optimal dose fractionation schedules.
Topics: Consensus; Dose Fractionation, Radiation; Humans; Neoplasm Metastasis; Postoperative Period; Practice Guidelines as Topic; Radiosurgery; Spinal Cord Compression; Spinal Neoplasms; Surveys and Questionnaires
PubMed: 27834628
DOI: 10.3171/2016.8.SPINE16121 -
The Oncologist Jun 2013Spinal metastases frequently arise in patients with cancer. Modern oncology provides numerous treatment options that include effective systemic, radiation, and surgical...
BACKGROUND
Spinal metastases frequently arise in patients with cancer. Modern oncology provides numerous treatment options that include effective systemic, radiation, and surgical options. We delineate and provide the evidence for the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which is used at Memorial Sloan-Kettering Cancer Center to determine the optimal therapy for patients with spine metastases.
METHODS
We provide a literature review of the integral publications that serve as the basis for the NOMS framework and report the results of systematic implementation of the NOMS-guided treatment.
RESULTS
The NOMS decision framework consists of the neurologic, oncologic, mechanical, and systemic considerations and incorporates the use of conventional external beam radiation, spinal stereotactic radiosurgery, and minimally invasive and open surgical interventions. Review of radiation oncology and surgical literature that examine the outcomes of treatment of spinal metastatic tumors provides support for the NOMS decision framework. Application of the NOMS paradigm integrates multimodality therapy to optimize local tumor control, pain relief, and restoration or preservation of neurologic function and minimizes morbidity in this often systemically ill patient population.
CONCLUSION
NOMS paradigm provides a decision framework that incorporates sentinel decision points in the treatment of spinal metastases. Consideration of the tumor sensitivity to radiation in conjunction with the extent of epidural extension allows determination of the optimal radiation treatment and the need for surgical decompression. Mechanical stability of the spine and the systemic disease considerations further help determine the need and the feasibility of surgical intervention.
Topics: Combined Modality Therapy; Decision Making; Humans; Neoplasm Grading; Radiosurgery; Spinal Neoplasms; Treatment Outcome
PubMed: 23709750
DOI: 10.1634/theoncologist.2012-0293 -
Cancer Apr 2017Epidural metastases occur in 5% to 10% of cancer patients and represent a neurological emergency. Patients most commonly present with an acute onset of motor weakness,... (Review)
Review
Epidural metastases occur in 5% to 10% of cancer patients and represent a neurological emergency. Patients most commonly present with an acute onset of motor weakness, and restoration of neurological function is critically dependent on prompt diagnosis and treatment. This review discusses the clinical, epidemiological, and radiological features associated with epidural metastases and resulting spinal cord compression. Moreover, current treatment paradigms are reviewed. The timely initiation of radiation as well as surgery in select cases is critical for preserving neurological function and achieving local tumor control and pain control. Future studies investigating surgical and radiation treatment for metastatic epidural cord compression are urgently needed. Cancer 2017;123:1106-1114. © 2016 American Cancer Society.
Topics: Combined Modality Therapy; Epidural Neoplasms; Humans; Magnetic Resonance Imaging; Neoplasms; Prognosis; Treatment Outcome
PubMed: 28026861
DOI: 10.1002/cncr.30521 -
Cancer Apr 2008The most frequent nervous system complications of multiple myeloma are peripheral neuropathy and epidural spinal cord compression. Myelomatous meningitis (MM) has been...
BACKGROUND
The most frequent nervous system complications of multiple myeloma are peripheral neuropathy and epidural spinal cord compression. Myelomatous meningitis (MM) has been considered rare. The current study was performed to characterize the clinical presentation, treatment, and outcome of MM.
METHODS
The study was a case series of 14 patients with cerebrospinal fluid (CSF)-positive MM who were treated at a tertiary care university medical center.
RESULTS
Fourteen patients with advanced multiple myeloma were treated with involved-field radiotherapy (to the brain in 5 patients and the spine in 6 patients) and intra-CSF chemotherapy (ventricular in 10 patients and lumbar in 4 patients). The best response to treatment included 6 partial responses and 8 patients with progressive disease. The median duration of response was 2.5 months (range, 0-6 months). Cause of death was progressive neurologic disease in 6 patients, combined systemic and neurologic disease in 6 patients, and systemic disease progression in 2 patients.
CONCLUSIONS
MM is rare and morbid entity (6-month neurologic disease progression-free survival rate of 7%), and appears to be no more responsive to treatment than solid tumor carcinomatous meningitis.
Topics: Aged; Aged, 80 and over; Antineoplastic Combined Chemotherapy Protocols; Central Nervous System Neoplasms; Chemotherapy, Adjuvant; Combined Modality Therapy; Cranial Irradiation; Female; Humans; Male; Meningitis, Aseptic; Middle Aged; Multiple Myeloma; Neoplasm Invasiveness; Prospective Studies; Survival Rate
PubMed: 18260094
DOI: 10.1002/cncr.23330 -
Anesthesiology Sep 2021Regional anesthesia and analgesia reduce the stress response to surgery and decrease the need for volatile anesthesia and opioids, thereby preserving cancer-specific... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Regional anesthesia and analgesia reduce the stress response to surgery and decrease the need for volatile anesthesia and opioids, thereby preserving cancer-specific immune defenses. This study therefore tested the primary hypothesis that combining epidural anesthesia-analgesia with general anesthesia improves recurrence-free survival after lung cancer surgery.
METHODS
Adults scheduled for video-assisted thoracoscopic lung cancer resections were randomized 1:1 to general anesthesia and intravenous opioid analgesia or combined epidural-general anesthesia and epidural analgesia. The primary outcome was recurrence-free survival (time from surgery to the earliest date of recurrence/metastasis or all-cause death). Secondary outcomes included overall survival (time from surgery to all-cause death) and cancer-specific survival (time from surgery to cancer-specific death). Long-term outcome assessors were blinded to treatment.
RESULTS
Between May 2015 and November 2017, 400 patients were enrolled and randomized to general anesthesia alone (n = 200) or combined epidural-general anesthesia (n = 200). All were included in the analysis. The median follow-up duration was 32 months (interquartile range, 24 to 48). Recurrence-free survival was similar in each group, with 54 events (27%) with general anesthesia alone versus 48 events (24%) with combined epidural-general anesthesia (adjusted hazard ratio, 0.90; 95% CI, 0.60 to 1.35; P = 0.608). Overall survival was also similar with 25 events (13%) versus 31 (16%; adjusted hazard ratio, 1.12; 95% CI, 0.64 to 1.96; P = 0.697). There was also no significant difference in cancer-specific survival with 24 events (12%) versus 29 (15%; adjusted hazard ratio, 1.08; 95% CI, 0.61 to 1.91; P = 0.802). Patients assigned to combined epidural-general had more intraoperative hypotension: 94 patients (47%) versus 121 (61%; relative risk, 1.29; 95% CI, 1.07 to 1.55; P = 0.007).
CONCLUSIONS
Epidural anesthesia-analgesia for major lung cancer surgery did not improve recurrence-free, overall, or cancer-specific survival compared with general anesthesia alone, although the CI included both substantial benefit and harm.
Topics: Aged; Analgesia, Epidural; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, General; Disease-Free Survival; Female; Follow-Up Studies; Humans; Lung Neoplasms; Male; Middle Aged; Pain, Postoperative; Thoracic Surgery, Video-Assisted
PubMed: 34192298
DOI: 10.1097/ALN.0000000000003873 -
Cancer Oct 2020Lung cancer and its associated treatments can cause various neurologic complications, including brain and leptomeningeal metastases, epidural spinal cord compression,... (Review)
Review
Lung cancer and its associated treatments can cause various neurologic complications, including brain and leptomeningeal metastases, epidural spinal cord compression, cerebrovascular events, and treatment-related neurotoxicities. Lung cancer care has significantly changed in the last 5 to 10 years, with novel therapies that have affected aspects of neurologic complication management. Herein, the authors review the potential neurologic complications of lung cancer, including important clinical and therapeutic aspects of care.
Topics: Humans; Lung Neoplasms; Nervous System Diseases
PubMed: 33460079
DOI: 10.1002/cncr.32772 -
The American Journal of Medicine Jan 2020Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency...
BACKGROUND
Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED.
METHODS
We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality.
RESULTS
We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess).
CONCLUSION
We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed.
Topics: Catheters, Indwelling; Cauda Equina Syndrome; Emergency Service, Hospital; Epidural Abscess; Humans; Low Back Pain; Prevalence; Risk Factors; Spinal Cord Compression; Spinal Fractures; Spinal Neoplasms; Substance Abuse, Intravenous; Vascular Access Devices
PubMed: 31278933
DOI: 10.1016/j.amjmed.2019.06.005 -
Turkish Neurosurgery 2017Paragangliomas of the spine are rare tumors. Clinical presentations and courses of spinal paragangliomas are varied, and there are no standard principles of treatment to...
AIM
Paragangliomas of the spine are rare tumors. Clinical presentations and courses of spinal paragangliomas are varied, and there are no standard principles of treatment to date. The purpose of this study was to explore the diagnosis, treatment and prognosis of spinal paragangliomas.
MATERIAL AND METHODS
The clinical data of 7 consecutive cases, with complete medical records and follow-up results that were treated in our institutions from October 2000 to October 2011, was retrospectively reviewed.
RESULTS
There were 6 males and 1 female with a mean age of 40 years (range, 16?61). The follow-up period ranged from 40 to 98 months (mean, 72 months). Of the 6 primary spinal paragangliomas, one lesion was in the cervical intradural extramedullary space, one in the thoracic epidural space and four in the lumbar intradural extramedullary space. All tumors were totally resected and no recurrence was detected during the follow-up period. Of the metastatic case, the lesion of the spine was located in the first lumbar epidural space and vertebra. The patients underwent surgical resection two times with radiotherapy, but the tumor recurred and the patient suffered from the paraplegia of lower limbs and urine and stool incontinence during the follow-up period. No patient died.
CONCLUSION
Spinal paragangliomas are rare lesions and seldom considered in the presurgical differential diagnosis due to its rarity and non-specific clinical symptoms and imaging features. Clinical follow-up was necessary to determine the outcome. Complete resection is necessary to prevent recurrence. The role of radiotherapy in the management of these lesions needs further assessment.
Topics: Adolescent; Adult; Female; Follow-Up Studies; Humans; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Middle Aged; Neoplasm Recurrence, Local; Paraganglioma; Retrospective Studies; Spinal Neoplasms
PubMed: 27593782
DOI: 10.5137/1019-5149.JTN.16276-15.1 -
Chinese Clinical Oncology Sep 2017Spine is a common site of metastases in cancer patients. Spine surgery is indicated for select patients, typically those with mechanical instability and/or malignant... (Review)
Review
Spine is a common site of metastases in cancer patients. Spine surgery is indicated for select patients, typically those with mechanical instability and/or malignant epidural spinal cord (or cauda equina) compression. Although post-operative conventional palliative external beam radiation therapy has been the standard of care, technical improvements in radiation planning and image-guided radiotherapy have allowed for the application of stereotactic body radiotherapy (SBRT) to the spine. Spine SBRT is intended to ablate residual tumor and optimize local control by delivering several fold greater biologically effective doses. Early clinical experience of postoperative spinal SBRT report encouraging results in terms of safety and efficacy. In this review, we summarize the clinical and technical aspects pertinent to a safe and effective practice of postoperative SBRT for spinal metastases.
Topics: Humans; Neoplasm, Residual; Postoperative Period; Radiosurgery; Radiotherapy Dosage; Radiotherapy Planning, Computer-Assisted; Spinal Cord Compression; Spinal Neoplasms; Treatment Outcome
PubMed: 28917256
DOI: 10.21037/cco.2017.06.27 -
Anesthesiology Mar 2022Surgery is the main curative treatment for colorectal cancer. Yet the immunologic and humoral response to surgery may facilitate progression of micro-metastases. It has...
BACKGROUND
Surgery is the main curative treatment for colorectal cancer. Yet the immunologic and humoral response to surgery may facilitate progression of micro-metastases. It has been suggested that epidural analgesia preserves immune competency and prevents metastasis formation. Hence, the authors tested the hypothesis that epidural analgesia would result in less cancer recurrence after colorectal cancer surgery.
METHODS
The Danish Colorectal Cancer Group Database and the Danish Anesthesia Database were used to identify patients operated for colorectal cancer between 2004 and 2018 with no residual tumor tissue left after surgery. The exposure group was defined by preoperative insertion of an epidural catheter for analgesia. The primary outcome was colorectal cancer recurrence, and the secondary outcome was mortality. Recurrences were identified using a validated algorithm based on data from Danish health registries. Follow-up was until death or September 7, 2018. The authors used propensity score matching to adjust for potential preoperative confounders.
RESULTS
In the study population of 11,618 individuals, 3,496 (30.1%) had an epidural catheter inserted before surgery. The epidural analgesia group had higher proportions of total IV anesthesia, laparotomies, and rectal tumors, and epidural analgesia was most frequently used between 2009 and 2012. The propensity score-matched study cohort consisted of 2,980 individuals in each group with balanced baseline covariates. Median follow-up was 58 months (interquartile range, 29 to 86). Recurrence occurred in 567 (19.0%) individuals in the epidural analgesia group and 610 (20.5%) in the group without epidural analgesia. The authors found no association between epidural analgesia and recurrence (hazard ratio, 0.91; 95% CI, 0.82 to 1.02) or mortality (hazard ratio, 1.01; 95% CI, 0.92 to 1.10).
CONCLUSIONS
In colorectal cancer surgery, epidural analgesia was not statistically significantly associated with less cancer recurrence.
Topics: Aged; Analgesia, Epidural; Cohort Studies; Colorectal Neoplasms; Denmark; Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Registries; Retrospective Studies
PubMed: 35045154
DOI: 10.1097/ALN.0000000000004132