spinal metastasis

Views:
 
Category: Education
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

Spinal Metastasis:

Spinal Metastasis Presenter: Dr. Ankur Mittal

Introduction:

The axial skelton is 3 rd most common site for carcinoma metastasis after liver and lung Approximately 70% of patients with cancer have evidence of metastasis at the time of their death Spinal Column is the most common location for osseous sites for metastatic deposits Up to 40% of patients with cancer has spinal column involvement. Introduction

Introduction:

Not all spinal metastasis lead to neurologic disorder Spinal cord compression from epidural metastasis occurs in 5-10 % of cancer patients 10-20% of this will be symptomatic Introduction

PowerPoint Presentation:

Metastatic spine disease can involve one of 3 locations Vertebral column – 85% - post. half Paravertebral region – 10-15% Epidural/subarachnoid/intramedullary space - < 5%

PowerPoint Presentation:

Intradural metastasis – extremely rare but there are reported cases Multiple level at noncontiguous levels – 10-40%

Pathophysiology:

Hematogenous Spread: Batson ’ s plexus Arterial embolization Seed and Soil Theory Direct invasion Pathophysiology

PowerPoint Presentation:

The venous plexus of Batson

Primary Sites MD Anderson 1984-1994 (n=11,884):

Primary Sites MD Anderson 1984-1994 (n=11,884) Breast (30.2%) Lung (20.3%) Blood (10.2%) Prostate (9.6%) Urinary tract (4%) Skin (3.1%) Unknown 1° (2.9%) Colon (1.6%) Other (18.1%)

PowerPoint Presentation:

In children, metastasis from following tumors have been reported: Neuroblastoma Retinoblastoma Leukemia Ewing sarcoma

Level of Metastases:

Thoracic 70% Lumbar 20% Cervical 10% Level of Metastases

Approach:

Approach CLINICAL FEATURES

PowerPoint Presentation:

SPECIFIC HISTORY

Investigation:

1 . Blood - Anemia - Thrombocytopenia - Increase LDH / uric acid / calcium /ALP/ Acid Phophotase(prostate) -Serum markers – CEA , Ca 125 , PSA Investigation

IMAGING:

Plain x-ray - Bone metastasiss can be purely lytic, blastic ,mixed i. Most metastasis are predominantly lytic - lung,kidney,breast,GIT,melanoma ii Blastic – prostate , bronchial carcinoids,bladder,stomach iii. Mixed – breast ,lung,GIT IMAGING

PowerPoint Presentation:

Plain X-ray In cancellous bone lytic lesion remain occult until it completely destroys trabaculae and reach 2-3 cm in diameter. Needs 30 – 50 % of destruction. In cortical bone – small lytic lesion can de detected earlier Typically metastasis causes vertebral collapse with sparing of disc space which is an imp differentiating feature from infection Asymetrical destruction of the pedicles shows up as ‘ WINKING OWL SIGN ’

PowerPoint Presentation:

WINKING OWL SIGN ’

PowerPoint Presentation:

Plain x-ray Depends on whether the primary is known or not I . Primary is known Asymptomatic – not for skeletal survey - bone scan is method of choice - if bone scan positive confine x-ray to site of localisation Symptomatic - Localised x-ray , skeletal survey ii. Primary is unknown - usually has local symptoms - local x-ray , skeletal survey

Sclerotic metastases of L221 :

Sclerotic metastases of L2 21 Common signs of spinal metastases found on conventional radiographs include: Destruction of the pedicle Associated soft-tissue mass Angular or irregular deformity of the endplates.

PowerPoint Presentation:

Imaging Bone Scan Most sensitive diagnostic tool But lacks specificity FALSE POSITIVES: Degenerative disease Trauma. Metabolic bone disease FALSE NEGATIVES: Plasmacytoma Myeloma In case of where infection is d/d LEUKOCYTE LABELED BONE MARROW SCAN is done to confirm diagnosis

PowerPoint Presentation:

Ct scan -Allows visualization of i. Bony anatomy of vertebral body metastasis and extremely useful in surgical plannning ii. Assessment of extent of paravertebral soft tissue masses iii. Extent and direction of impingement of spinal cord by bone debris / tumour Limitation – failure to identify second site of mets. - 10% of pts

PowerPoint Presentation:

MRI Superior in evaluating soft tissue mass Neural elements Multiple level of vertebral involvement Findings – Hypointense T1 , hyperintense in T2 and gadolinium enhanced T1

Sagittal MR Images27:

Sagittal MR Images 27 Vertebral metastasis at L1 (arrows) Acute compression fractures at T11 and T12 (arrowheads) A. T1 MRI – hypointense fractures B. T2 MRI - hyperintense fractures C/D. Diffusion weighted MRI - hyperintense fractures/metastasis E. Apparent Diffusion Coefficient Map showing both metastasis / fractures

Biopsy:

Indicated if diagnosis is unclear after workup: Remote history of cancer with long disease-free interval Options: CT-guided: most accessible lesion, minimal morbidity, tattoo tract for later excision Accuracy: 93% for lytic lesions, 76% for sclerotic lesions Open: cost, delay, definitive for benign tumors Culture every tumor and biopsy every infection Biopsy

PowerPoint Presentation:

DIFFERENTIAL DIAGNOSIS Degenerative changes Infection(commonly Tb) Fractures(osteoporotic or others) Primary bone tumor

Management:

General Mx Medical Mx / Radiotherapy Mx Surgical Mx Pain Mx Management

PowerPoint Presentation:

General Mx. Anemia Nutritional Status Hydrational status Supplements

PowerPoint Presentation:

Medical Mx i.Chemotherapy ii.Hormonal iii Biphosphonate

PowerPoint Presentation:

Chemotherapy Given as therapeutic and palliative treatment especially in Breast , lung , Renal cell ca. , prostate(less) Needs multi disciplinary approach Indications: 1. Patients with - no symptoms positive bone scan radiographic evidence of spinal matastases without vertebral collapse 2. Diffuse metastatic involvement with widespread spinal pain with signs of impending collapse and neurogical deficit Chemotherapy has no role in restoration of cancellous or cortical bone destroyed by tumor.

PowerPoint Presentation:

High dose intravenous corticosteriods are beneficial in many round cell tumors like lymphoma and neuroblasoma Hormonal - Breast , prostate and endometrial ca. - Endocrine dependant organs. Regulate and manipulate regulatory hormones as anti -tumour therapy Like Progesterone/estogen in CA breast Orchidectomy for CA prostate

PowerPoint Presentation:

Biphosphonate Inhibit osteoclast-mediated resorption Induce osteoclast apoptosis Standard treatment in hypercalcemia in malignancy Reduces metastatic bone pain esp. clodronate and pamidronate Recalcification

PowerPoint Presentation:

Pain relief – mode of action not really understood – reduces tumour bulk, reduces pain mediator (PG)releasing cells INDICATIONS Radio responsive tumors minimal or no neurologic deficits with no neural compression by bone and no evidence of spinal instability Like Breast, Prostate and haemopoetic tumors like lymphomas Lung and thyroid metastasis are intrmediately responsive Melanoma, renal cell and gastrointestinal tumors are radioresistent. Radiotherapy

PowerPoint Presentation:

Complications: Radiation myelopathy presenting as cord dysfunction post radiation due to cord atrophy/devascularization Radiation osteitis presenting as intractable pain with vertebral collapse Problems in wound healing and bone graft incorporation Used alone in cases where only pain is the predominant symptom Combined with surgical decompression in cases with neurological deficit to erradicate and suppress residual tumor and provide pain relief

Surgical Mx:

Mostly Palliative Indications Intractable pain unresponsive to non operative measures Obvious spinal instability Clinically significant neural compression from retropulsed bone or spinal instability Radioresistant tumours Surgical Mx

PowerPoint Presentation:

Depends on Pts tolerability to surgery e.g general medical condition Estimated life expectancy

PowerPoint Presentation:

Goals of Surgery Correct and prevent deformity by stabilizing deformity Decompressing neural structures Open biopsy if primary unknown

PowerPoint Presentation:

Pre-operative prognostic values/scoring Score = < 5 dies within 3 months > 9 survives average 12 mths Surgery = <5 non surgical , > 9 surgical

PowerPoint Presentation:

• Class I —Destruction; no deformity; moderate pain 1a <50% of vertebral body destruction 1b >50 % of vertebral body destruction 1c pedicle destruction Consider surgery only for grade 1a and ab • Class II —Moderate deformity and collapse; immune competent Consider good risk for surgery • Class III —Moderate deformity and collapse; immune suppressed Greater risk for surgery • Class IV —Marked deformity and collapse; paralysis; immun competent Relative surgical emergency • Class V —Marked deformity and collapse; paralysis; immune suppressed Not consider a good operative risk DeWald Spinal Malignancies Classification

PowerPoint Presentation:

Category iii – grey area , either medical or surgical . - if there is severe epidural cord compression non radiosensistive , needs surgery

Score 2-3 – wide / marginal for long term survival 4-5 – marginal/intralesional 6-7 – palliative surgery for short term palliation 8-10 – non operative supportive care:

Score 2-3 – wide / marginal for long term survival 4-5 – marginal/intralesional 6-7 – palliative surgery for short term palliation 8-10 – non operative supportive care

Surgical approach:

Anterior approach Predominant area of metastasis Does not disturb posterior stability in presence of the kyphosis Pain relief in 80 – 95% of patients Neurologic improvement in 75% of patients Surgical approach

PowerPoint Presentation:

Post decompressive laminectomy - limited value in regaining neurologic function - Laminectomy + radiotherapy no more effective than radiotherapy alone.

PowerPoint Presentation:

Anterior –posterior approach High grade instability Ant and posterior compression Contiguous vertebral involvement Need for en-bloc resection of tumour

PowerPoint Presentation:

Other approches -costotransversectomy – thoracic region -patient unable to tolerate thoracotomy -Postolateral approach – cervical / lumbar region

PowerPoint Presentation:

VERTEBROPLASTY Good stabilisation and analgesia to the diseased vertebra. But must have posterior intact cortex Used if contraindicated for surgery eg post irradiated patient

Conclusion:

Spine is the most frequent location for skeletal metastasis Mode of treatment and can be chosen by using the many scoring systems(Tokuhashi , Harrington , Tomita etc) but it must be tailored according to each patient Advances in imaging and instrumentation allowed improvements in the techniques of excision of tumour and stabilisation. Surgical decision making is a complex issue but the treatment of spinal mets. remains largely palliative. Conclusion

THANK YOU:

THANK YOU