An Overview of Decision Making in the Management of Metastatic Spinal Tumors

IntroductionSpinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern ‘separation’ surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors.MethodsA MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed.DiscussionTreatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatmentConclusionThe management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.     

External validation of the SORG machine learning algorithms for predicting 90-day and 1-year survival of patients with lung cancer-derived spine metastases: a recent bi-center cohort from China

BACKGROUND CONTEXTThe survival prediction of lung cancer-derived spinal metastases is often underestimated by several scores. The SORG machine learning (ML) algorithm is considered a promising tool to predict the risk of 90-day and 1-year mortality in patients with spinal metastases, but not been externally validated for lung cancer.PURPOSEThis study aimed to externally validate the SORG ML algorithms on lung cancer-derived spinal metastases patients from two large-volume, tertiary medical centers between 2018 and 2021.STUDY DESIGN/SETTINGRetrospective, cohort study.PATIENT SAMPLEPatients aged 18 years or older at two tertiary medical centers in China are treated surgically for spinal metastasis.OUTCOME MEASURESMortality within 90 days of surgery, mortality within 1 year of surgery.METHODSThe baseline characteristics were compared between the development cohort and our validation cohort. Discrimination (receiver operating curve), calibration (calibration plot, intercept, and slope), the overall performance (Brier score), and decision curve analysis was used to assess the overall performance of the SORG ML algorithms.RESULTSThis study included 150 patients with lung cancer-derived spinal metastases from two medical centers in China. Ninety-day and 1-year mortality rates were 12.9% (19/147) and 51.3% (60/117), respectively. Lung Cancer with targeted therapies had the lowest Hazard Ratio (HR=0.490), showing an optimal protecting factor. The AUC of the SORG ML algorithm for 90-day mortality prediction in lung cancer-derived spinal metastases is 0.714. While the AUC for 1-year mortality prediction is 0.832 (95CI%, 0.758–0.906). The algorithm for 1-year mortality was well-calibrated with an intercept of 0.13 and a calibration slope of 1.00. However, the 90-day mortality prediction was underestimated with an intercept of 0.60 and a slope of 0.37. The SORG ML algorithms for 1-year mortality showed a greater net benefit than the “treats all or no patients” strategies.CONCLUSIONSIn the latest cohort of lung cancer-derived spinal metastases in China, the SORG algorithms for predicting 1-year mortality performed well on external validation. However, 90-day mortality was underestimated. The algorithm should be further validated by single primary tumor-derived metastasis treated with the latest comprehensive treatment in diverse populations.     

Evaluating ambulatory function as an outcome following treatment for spinal metastases: a systematic review

BACKGROUND CONTEXTStudies regarding treatment of spinal metastases are critical to evidence-based decision-making. However, variation exists in how a key outcome, ambulatory function, is assessed.PURPOSETo characterize the sources and tools investigators have used to evaluate ambulatory function as an outcome following treatment of spinal metastases. We also sought to understand the ways ambulatory function has been conceptualized in prior studies.STUDY DESIGNSystematic review of the literature.PATIENT SAMPLEWe identified 44 published studies for inclusion. Samples within these investigations ranged from 20 to 2,096 subjects.OUTCOME MEASURESWe describe the methods investigators have used to evaluate ambulatory function following treatment for spinal metastases.METHODSWe conducted a systematic review through PubMed, Scopus and Web of Science following PRISMA guidelines. We included studies that consisted of adult patients receiving operative or non-operative treatment for spinal metastases. We also required that study investigators specified post-treatment ambulatory function as an outcome. We recorded year of publication, study design, types of spinal metastases included in the study, treatments employed, and sample size. We also described the source (medical record, study-specific observer and/or provider, patient and/or participant), tool (standardized measure, quantitative, qualitative) and concept (eg, ambulatory vs. non-ambulatory; independent ambulation vs. ambulatory with assistance vs. non-ambulatory) used to assess ambulatory function.RESULTSWe found the plurality of studies relied on medical record documentation as their source. Amongst prospective studies, only a minority used a quantitative measure (eg, prespecified degree of walking ability) to assess ambulatory function. Most studies conceptualized ambulatory function as a dichotomized outcome, typically ambulatory versus non-ambulatory or a similar equivalent.CONCLUSIONSWide variation exists in how ambulatory function is defined in studies involving patients with spinal metastases. We suggest several improvements that will allow a more robust assessment of the quality and quantity of ambulatory function among patients treated for spinal metastases.     

“Reading the room:” A qualitative analysis of pediatric surgeons’ approach to clinical counseling

BackgroundIn our prior analysis of parental preferences for discussions with pediatric surgeons, we identified that parents prefer more guidance from surgeons when discussing cancer surgery, emergency surgery, or surgery for infants, and they prefer to engage surgeons by asking questions. In this study, we investigate surgeon preferences for decision making discussions in pediatric surgery.MethodsWe conducted a thematic content analysis of interviews of pediatric surgeons regarding their preferences for discussing surgery with parents. Board certified/board eligible pediatric surgeons who had been in practice for at least one year and spoke English were eligible. Fifteen surgeons were invited, and twelve 30-minute semi-structured interviews were completed (80%). Interviews were recorded and transcribed. Thematic content analysis was performed using deductive and inductive methods.ResultsData saturation was achieved after 12 interviews [6 women (50%), median years in practice 6.25, 10 in academic practice (83%), 8 from Midwest (67%)]. 5 themes emerged: (1) Collaboration to promote parental engagement; (2) “Cancer is distinct but not unique;” (3) “Read the room:” tailoring discussions to specific parental needs; (4) Perceived role of the surgeon; (5) Limited experience with decision support tools in pediatric surgery.ConclusionsPediatric surgeons prefer a collaborative approach to counseling that engages parents through education. They prioritize tailoring discussions to meet parental needs. Few have utilized decision support tools, however most expressed interest. Insight gained from our work will guide development of a decision support tool that empowers parental participation in counseling for pediatric surgery.Level of EvidenceIII     

Updated external validation of the SORG machine learning algorithms for prediction of ninety-day and one-year mortality after surgery for spinal metastasis

BACKGROUND CONTEXTSurgical decompression and stabilization in the setting of spinal metastasis is performed to relieve pain and preserve functional status. These potential benefits must be weighed against the risks of perioperative morbidity and mortality. Accurate prediction of a patient's postoperative survival is a crucial component of patient counseling.PURPOSETo externally validate the SORG machine learning algorithms for prediction of 90-day and 1-year mortality after surgery for spinal metastasis.STUDY DESIGN/SETTINGRetrospective, cohort studyPATIENT SAMPLEPatients 18 years or older at a tertiary care medical center treated surgically for spinal metastasisOUTCOME MEASURESMortality within 90 days of surgery, mortality within 1 year of surgeryMETHODSThis is a retrospective cohort study of 298 adult patients at a tertiary care medical center treated surgically for spinal metastasis between 2004 and 2020. Baseline characteristics of the validation cohort were compared to the derivation cohort for the SORG algorithms. The following metrics were used to assess the performance of the algorithms: discrimination, calibration, overall model performance, and decision curve analysis.RESULTSSixty-one patients died within 90 days of surgery and 133 died within 1 year of surgery. The validation cohort differed significantly from the derivation cohort. The SORG algorithms for 90-day mortality and 1-year mortality performed excellently with respect to discrimination; the algorithm for 1-year mortality was well-calibrated. At both postoperative time points, the SORG algorithms showed greater net benefit than the default strategies of changing management for no patients or for all patients.CONCLUSIONSWith an independent, contemporary, and geographically distinct population, we report successful external validation of SORG algorithms for preoperative risk prediction of 90-day and 1-year mortality after surgery for spinal metastasis. By providing accurate prediction of intermediate and long-term mortality risk, these externally validated algorithms may inform shared decision-making with patients in determining management of spinal metastatic disease.     

Complications of spine surgery for metastasis

The spinal column represents the third most common site for metastases after the lungs and the liver, and the most common site for metastatic bone disease. With life-extending advances in the systemic treatment of cancer patients, the surgical procedures performed for spinal metastases will increase, and their related complications will increase unavoidably. Furthermore, considering the high complication rates reported in the spinal literature regarding spine surgery overall, it becomes clear that a better understanding of complications that the cancer patients with spinal metastases may experience is necessary. This article aims to summarize and critically examine the current evidence for complications after spine surgery for metastatic spinal disease, in both the perioperative and postoperative period. This paper would be useful for the treating physicians of these patients in their clinical practice.

     

Spinal instability as defined by the spinal instability neoplastic score is associated with radiotherapy failure in metastatic spinal disease

Background contextAlthough radiotherapy is effective in achieving pain relief in most patients, it is not completely understood why some patients respond well to radiotherapy and others do not. Our hypothesis was that metastatic bone pain, if predominantly caused by mechanical instability of the spine, responds less well to radiotherapy than metastatic bone pain caused by local tumor activity. Recently, the spinal instability neoplastic score (SINS) was proposed as a standardized referral tool for nonspine specialists to facilitate early diagnosis of spinal instability.PurposeTo investigate the association between spinal instability as defined by the SINS and response to radiotherapy in patients with spinal metastases.Study designA retrospectively matched case-control study in an academic tertiary referral center, conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.Patient sampleThirty-eight patients with spinal metastases who were retreated after initial palliative radiotherapy from January 2009 to December 2010 were matched to 76 control patients who were not retreated.Outcome measuresRadiotherapy failure as defined by retreatment (radiotherapy, surgery, and conservative) after palliative radiotherapy for spinal metastases.MethodsRadiotherapy planning computed tomography scans were scored by a blinded spine surgeon according to the SINS criteria. The association between SINS and radiotherapy failure was estimated by univariate and multivariate conditional logistic regression analysis.ResultsMedian SINS was 10 (range 4–16) for cases and 7 (range 1–16) for controls. The SINS was significantly and independently associated with radiotherapy failure (adjusted odds ratio, 1.3; 95% confidence interval, 1.1–1.5; p=.01).ConclusionsThis study shows that a higher spinal instability score increases the risk of radiotherapy failure in patients with spinal metastases, independent of performance status, primary tumor, and symptoms. These results may support the hypothesis that metastatic spinal bone pain, predominantly caused by mechanical instability, responds less well to radiotherapy than pain mainly resulting from local tumor activity.     

Preoperative embolization in surgical treatment of spinal metastases originating from non–hypervascular primary tumors: a propensity score matched study using 495 patients

BACKGROUND CONTEXTPreoperative embolization (PE) reduces intraoperative blood loss during surgery for spinal metastases of hypervascular primary tumors such as thyroid and renal cell tumors. However, most spinal metastases originate from primary breast, prostate, and lung tumors and it remains unclear whether these and other spinal metastases benefit from PE.PURPOSETo assess the (1) efficacy of PE on the amount of intraoperative blood loss and safety in patients with spinal metastases originating from non–hypervascular primary tumors, and (2) secondary outcomes including perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality.STUDY DESIGNRetrospective propensity-score matched, case-control study at 2 academic tertiary medical centers.PATIENT SAMPLEPatients 18 years of age or older undergoing surgery for spinal metastases originating from primary non–thyroid, non–renal cell, and non–hepatocellular tumors between January 1, 2002 and December 31, 2016 were included.OUTCOME MEASURESThe primary outcomes were estimated amount of intraoperative blood loss and complications attributable to PE, such as neurologic injury, wound infection, thrombosis, or dissection. The secondary outcomes included perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality.METHODSIn total, 495 patients were identified, of which 54 (11%) underwent PE. After propensity score matching on 21 variables, including primary tumor, number of spinal levels, and surgical treatment, 53 non–PE patients were matched to 53 PE patients. Matching was adequate measured by comparing the matched variables, testing the standardized mean differences (<0.25), and inspecting Kernel density plots. The degree of embolization was noted to be complete, until stasis, or successful in 43 (80%) patients.RESULTSIntraoperative blood loss did not differ between both groups with a median blood loss in liters of 0.6 (IQR, 0.4–1.2) for non–PE patients and 0.9 (IQR, 0.6–1.2) for PE patients (p=.32). No complications occurred during embolization or the time between embolization and surgery. No differences were found in terms of the secondary outcomes.CONCLUSIONSOur data suggest that, although no complications occurred and the embolization procedure can be considered safe, patients with non–hypervascular spinal metastases might not benefit from PE. A larger, prospective study could confirm or refute these study findings and aid in elucidating a subset of spinal metastases that might benefit from PE.     

Surgery and survival outcomes of 22 patients with epidural spinal cord compression caused by thyroid tumor spinal metastases

Purpose

The aim of this study was to discuss the clinical presentation, imaging findings, treatments received, and outcome of therapies for patients with epidural spinal cord compression caused by thyroid spinal metastases, with the goal of emphasizing the importance of surgery in this setting and discussing therapeutic plan for treating these patients.

Methods

A total of 22 patients with spinal cord compression due to thyroid tumor spinal metastases who received surgery in our department were identified from 2004 to 2011. The series of 22 patients collected from our institution over the past 7 years was used to discuss treatment options for thyroid cancer spinal metastases on the basis of literature review and our own extensive experience.

Results

The mean age of the patients in this study was 57 years (range 37–78 years). The duration of the preoperative symptoms was 1–24 months, with an average of approximately 6 months. All patients attained improvement of at least one level of the Frankel classification after surgery. Two patients received more than one operation at our institution. Two patients died during follow-up, two patients had stable disease, and all other patients maintained a disease-free status during follow-up.

Conclusions

As thyroid tumor spinal metastases have a favorable prognosis, a radical therapeutic attitude should be considered in decision-making. Dorsal spinal decompression through curettage and stabilization can preserve or restore neurological function for most patients. For patients who have more than one metastatic lesion of the spine, surgeries can be sequentially performed based on the urgency of the case. In addition to treatment of primary disease, surgery and bisphosphonate treatment are the most important therapies for these patients.     

Development and external validation of predictive algorithms for six-week mortality in spinal metastasis using 4,304 patients from five institutions

BACKGROUND CONTEXTHistorically, spine surgeons used expected postoperative survival of 3-months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics, and advanced radiotherapy. Recent studies have suggested that a life expectancy of 6 weeks may be enough to achieve significant improvements in postoperative health-related quality of life.PURPOSEThe purpose of this study was to develop a model capable of predicting 6-week mortality in patients with spinal metastases treated with radiation or surgery.STUDY DESIGN/SETTINGA retrospective review was conducted at five large tertiary centers in the United States and Taiwan.PATIENT SAMPLEThe development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions.OUTCOME MEASURESThe primary outcome was 6-week mortality.METHODSFive models were considered to predict 6-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis, and overall performance was integrated into an open access web-based application.RESULTSThe most important variables for prediction of 6-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. The model is available here: https://sorg-apps.shinyapps.io/spinemetssurvival/.CONCLUSIONSWhile this study does not advocate for the use of a 6-week life expectancy as criteria for considering operative management, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making in spinal metastasis patients with shorter life expectancy.     

A systematic review of MIS and open decompression surgery for spinal metastases in the last two decades

ObjectiveThe primary intention of this review being to produce an updated systematic review of the literature on published outcomes of decompressive surgery for metastatic spinal disease including metastatic spinal cord compression, using techniques of MIS and open decompressive surgery.MethodsThe authors conducted database searches of OVID MEDLINE and EMBASE identifying those studies that reported clinical outcomes, surgical techniques used along with associated complications when decompressive surgery was employed for metastatic spinal tumors. Both retrospective and prospective studies were analysed. Articles were assessed to ensure the required inclusion criteria was met. Articles were then categorised and tabulated based on the following reported outcomes: predictors of survival, predictors of ambulation or motor function, surgical technique, neurological function, and miscellaneous outcomes.Results2654 citations were retrieved from databases, of these 31 met the inclusion criteria. 5 studies were prospective, the remaining 26 were retrospective. Publication years ranged from 2000 to 2020. Study size ranged from 30 to 914 patients. The most common primary tumors identified were lungs, breast, prostate and renal cancers. One study ( Lo and Yang, 2017)¹³ reported that in those patients with motor deficit, survival was significantly improved when surgery was performed within 7 days of the development of motor deficit compared to situations when surgery was carried out 7 days after onset. This was the only study that showed that the timing of surgery plays a significant role w.r.t. survival following the onset of spinal cord compression symptoms. Four articles identified that a pre-operative intact motor function and or ambulatory status conferred a higher likelihood of a better post-operative outcome, not just in relation to survival but also in relation to post-operative ambulation as well as a greater tendency towards suitability for adjuvant treatment. Even for the same scoring system e.g. tokuhashi and its effectiveness in predicting survival, results from different studies varied in their outcome. The Karnofsky Performance Status (KPS) being the most commonly used tool to assess functional impairment, the Eastern Cooperative Oncology Group (ECOG) performance status being used in two studies. 23 studies identified an improvement in neurological function following surgery. The most common functional scale used to assess neurological outcome was the Frankel scale, 3 studies used the American Spinal Injury Association (ASIA) impairment scale for this purpose. Wound problems including infection and dehiscence appeared to be the most commonly reported surgical complication. (25 studies). The most commonly used surgical technique involved a posterior approach with decompression, with or without stabilisation. Less commonly employed techniques included percutaneous pedicle screw fixation associated with or without mini-decompression as well as anterior approaches involving corpectomy and instrumentation. 9 studies included in their data, the effect of radiation therapy in combination with surgery or as a comparison used as an alternative to surgery in spinal metastases.ConclusionsWe provide a systematic literature review on the outcomes of decompressive surgery for spinal metastases. We analyse survival data, motor function, neurological function, as well as the techniques of surgery used. Where appropriate complications of surgery are also highlighted. It is the authors’ intention to provide the reader with a reference text where this information is ready to hand, allowing for the consideration of means and methods to improve and optimise the standard of care in patients undergoing surgical intervention for metastatic spinal disease.     

Does the SORG algorithm generalize to a contemporary cohort of patients with spinal metastases on external validation?

BACKGROUND CONTEXTThe SORG machine-learning algorithms were previously developed for preoperative prediction of overall survival in spinal metastatic disease. On sub-group analysis of a previous external validation, these algorithms were found to have diminished performance on patients treated after 2010.PURPOSEThe purpose of this study was to assess the performance of these algorithms on a large contemporary cohort of consecutive spinal metastatic disease patients.STUDY DESIGN/SETTINGRetrospective study performed at a tertiary care referral center.PATIENT SAMPLEPatients of 18 years and older treated with surgery for metastatic spinal disease between 2014 and 2016.OUTCOME MEASURESNinety-day and one-year mortality.METHODSBaseline patient and tumor characteristics of the validation cohort were compared to the development cohort using bivariate logistic regression. Performance of the SORG algorithms on external validation in the contemporary cohort was assessed with discrimination (c-statistic and receiver operating curve), calibration (calibration plot, intercept, and slope), overall performance (Brier score compared to the null-model Brier score), and decision curve analysis.RESULTSOverall, 200 patients were included with 90-day and 1-year mortality rates of 55 (27.6%) and 124 (62.9%), respectively. The contemporary external validation cohort and the developmental cohort differed significantly on primary tumor histology, presence of visceral metastases, American Spinal Injury Association impairment scale, and preoperative laboratory values. The SORG algorithms for 90-day and 1-year mortality retained good discriminative ability (c-statistic of 0.81 [95% confidence interval [CI], 0.74–0.87] and 0.84 [95% CI, 0.77–0.89]), overall performance, and decision curve analysis. The algorithm for 90-day mortality showed almost perfect calibration reflected in an overall calibration intercept of −0.07 (95% CI: −0.50, 0.35). The 1-year mortality algorithm underestimated mortality mainly for the lowest predicted probabilities with an overall intercept of 0.57 (95% CI: 0.18, 0.96).CONCLUSIONSThe SORG algorithms for survival in spinal metastatic disease generalized well to a contemporary cohort of consecutively treated patients from an external institutional. Further validation in international cohorts and large, prospective multi-institutional trials is required to confirm or refute the findings presented here. The open-access algorithms are available here: https://sorg-apps.shinyapps.io/spinemetssurvival/.     

External validation of the SORG 90-day and 1-year machine learning algorithms for survival in spinal metastatic disease

BACKGROUND CONTEXTPreoperative survival estimation in spinal metastatic disease helps determine the appropriateness of invasive management. The SORG ML 90-day and 1-year machine learning algorithms for survival in spinal metastatic disease were previously developed in a single institutional sample but remain to be externally validated.PURPOSEThe purpose of this study was to externally validate these algorithms in an independent population from another institution.STUDY DESIGN/SETTINGRetrospective study at a large, tertiary care center.PATIENT SAMPLEPatients 18 years or older who underwent surgery between 2003 and 2016.OUTCOME MEASURESNinety-day and 1-year mortality.METHODSBaseline characteristics of the validation cohort were compared to the developmental cohort for the SORG ML algorithms. Discrimination (c-statistic and receiver operating curve), calibration (calibration slope, intercept, calibration plot, and observed proportions by predicted risk groups), overall performance (Brier score), and decision curve analysis were used to assess the performance of the SORG ML algorithms in the validation cohort.RESULTSOverall, 176 patients underwent surgery for spinal metastatic disease, of which 44 (22.7%) experienced 90-day mortality and 99 (56.2%) experienced 1-year mortality. The validation cohort differed significantly from the developmental cohort on primary tumor histology, metastatic tumor burden, previous systemic therapy, overall comorbidity burden, and preoperative laboratory characteristics. Despite these differences, the SORG ML algorithms generalized well to the validation cohort on discrimination (c-statistic 0.75–0.81 for 90-day mortality and 0.77–0.78 for 1-year mortality), calibration, Brier score, and decision curve analysis.CONCLUSION and RELEVANCEInitial results from external validation of the SORG ML 90-day and 1-year algorithms for survival prediction in spinal metastatic disease suggest potential utility of these digital decision aids in clinical practice. Further studies are needed to validate or refute these algorithms in large patient samples from prospective, international, multi-institutional trials.     

What do patients want to know about surgery for low-risk thyroid cancer? A qualitative study

BackgroundShared decision-making about treatment for low-risk thyroid cancer requires patients and surgeons to work together to select treatment that best balances risks and expected outcomes with patient preferences and values. To participate, patients must be activated and ask questions. We aimed to characterize what topics patients prioritize during treatment decision-making.MethodsWe identified substantive questions by patients with low-risk (cT1-2, N0) thyroid cancer during audio-recorded consultations with 9 surgeons at 2 unique health care systems. Logistics questions were excluded. Qualitative content analysis was used to identify major themes among patients’ questions and surgeon responses.ResultsOverall, 28 of 30 patients asked 253 substantive questions, with 2 patients not asking any substantive questions (median 8, range 0–25). Patients were 20 to 71 years old, mostly White (86.7%) and female (80.0%). The questions addressed extent of surgery, hormone supplementation, risk of cancer progression, radioactive iodine, and etiology of thyroid cancer. When patients probed for a recommendation regarding extent of surgery, surgeons often responded indirectly. When patients asked how surgery could impact quality of life, surgeons focused on oncologic benefits and surgical risk. Patients commonly asked about hormone supplementation and radioactive iodine.ConclusionPatient questions focused on the decision regarding extent of surgery, quality of life, and nonsurgical aspects of thyroid cancer care. Surgeon responses do not consistently directly answer patients’ questions but focus on the risks, benefits, and conduct of surgery itself. These findings suggest an opportunity to help surgeons with resources to improve shared decision-making by providing information that patients prioritize.     

Cranial irradiation after surgical excision of brain metastases in melanoma patients

Background: Brain metastases account for 20–54% of reported deaths from melanoma. Duration and quality of survival depend on the extent of metastatic disease and response to treatment. Treatment goals are palliation of symptoms and prolongation of life. No studies have directly compared surgery alone and surgery with adjunctive cranial irradiation in patients with solitary brain metastases. Methods: We evaluated postoperative adjunctive cranial irradiation in 34 patients with solitary brain metastases. Results: Overall survival was significantly improved in the 22 patients who received adjunctive cranial irradiation versus that in the 12 patients who had surgery alone. Twenty-eight patients subsequently relapsed. Nine of 10 patients with surgery alone had brain recurrence as a component of failure. Six of 10 patients not receiving irradiation had brain recurrences as a component of relapse at multiple sites whereas only 1 of 18 patients receiving irradiation relapsed with the brain. Conclusions: Adjunctive cranial irradiation is justified for melanoma patients who undergo surgical therapy for solitary brain metastases. Survival in patients presenting with solitary brain metastases was improved by a reduction of relapse in the brain as a component of failure by combined surgery and irradiation.     

Positron Emission Tomography Affects Surgical Management in Recurrent Colorectal Cancer Patients

Background: We determined the effect of positron emission tomography (PET) on surgical decision-making in patients with metastatic or recurrent colorectal cancer.Methods: A total of 114 patients with advanced colorectal cancer were imaged with computed tomography (CT) and PET scans. The PET and CT scans were independently interpreted before surgery and recorded.Results: Forty-two of the 114 patients had resectable disease on the basis of CT. PET altered therapy in 17 (40%) of these 42 patients on the basis of the following results: extrahepatic disease (n = 9), bilobar involvement (n = 3), thoracic involvement (n = 5), retroperitoneal lymphadenopathy (n = 2), bone involvement (n = 1), and supraclavicular disease (n = 1). In 25 patients with liver metastases only, PET found additional disease in 18 (72%), extrahepatic disease in 11, chest disease in 13, retroperitoneal lymphadenopathy in 4, and bone disease in 3. In five patients, both scans underestimated small-volume peritoneal metastases discovered at laparotomy.Conclusions: PET altered therapy in 40% of patients. In patients with isolated liver involvement, 72% had more extensive disease that precluded surgical resection. PET scans should be used in the management of patients with recurrent colorectal cancer who are being considered for potentially curative surgery.     

Preferences for bariatric surgery: comparing surgeons and patients using a discrete choice experiment

BackgroundIncreased attention to shared decision-making is particularly important in bariatric surgery. It is unclear whether the large shift toward sleeve gastrectomy is evidence of good alignment between patient and surgeon preferences.ObjectiveTo identify surgeon preferences for risks, benefits, and other attributes of treatment options available for bariatric surgery and to compare results with patient preferences.SettingOnline survey.MethodsA discrete choice experiment of weight loss procedures. Each procedure was described by the following set of attributes: (1) treatment method, (2) recovery and reversibility, (3) years treatment has been available, (4) expected weight loss, (5) effect on other medical conditions, (6) risk of complication, (7) side effects, (8) changes to diet, (9) out-of-pocket costs. Participants chose between surgical profiles by comparing attributes. A convenience sample of providers for the online survey was recruited via LISTSERVs of professional associations.ResultsRespondents (n = 121) were most likely to select profiles of hypothetical procedures based on the resolution of existing medical conditions and higher expected weight loss. These results align with patient preferences. However, surgeons selected profiles based on lower risk of complications than did patients and surgeons were less sensitive to out-of-pocket costs than patients.ConclusionsResults show strong alignment between the preferences of patients and the preferences of surgeons when they are asked to stand in the place of their patients. Some differences, especially those related to sensitivity to risk of complications and out-of-pocket costs indicate that shared decision-making would benefit from providers explaining their concerns about surgical risk and from appreciating the concern many patients have about financial costs.     

Laboratory markers as useful prognostic measures for survival in patients with spinal metastases

BACKGROUND CONTEXTLaboratory values have been found to be useful predictive measures of survival following surgery. The utility of laboratory values for prognosticating outcomes among patients with spinal metastases has not been studied.PURPOSETo determine the prognostic capacity of laboratory values at presentation including white blood cell count, serum albumin and platelet-lymphocyte ratio (PLR) in patients with spinal metastases.STUDY DESIGNRetrospective review of records from two tertiary care centers (2005–2017).PATIENT SAMPLEPatients, aged 40 to 80, who received operative or nonoperative management for spinal metastases.OUTCOME MEASURESSurvival, complications, or hospital readmissions within 90 days of treatment and a composite measure for treatment failure accounting for changes in ambulatory function and mortality at 6 months following presentation.METHODSMultivariable Cox proportional hazard regression analysis was used to analyze the relationship between laboratory values and length of survival, adjusting for confounders. Multivariable logistic regression was used in analyses related to 6-month and 1-year mortality, complications, readmissions, and treatment failure. A scoring rubric was developed based on the performance of laboratory values in the multivariable tests. Internal validation was performed using a bootstrap simulation that consisted of sampling with replacement and 1,000 replications.RESULTSWe included 1,216 patients. Thirty-seven percent of patients received a surgical intervention and 63% were treated nonoperatively. Median survival for the cohort as a whole was 255 days (interquartile range 93–642 days). The PLR (hazard ratio [HR] 1.53; 95% confidence interval [CI] 1.29, 1.80; p<.001) and albumin (HR 0.54; 95% CI 0.45, 0.64; p<.001) were significantly associated with survival, whereas WBC count (HR 1.08; 95% CI 0.86, 1.36; p=.50) was not associated with this outcome. Similar findings were encountered for 6-month and 1-year mortality as well as the composite measure for treatment failure. The PLR and albumin performed well in our scoring rubric and findings were preserved in the bootstrapping validation.CONCLUSIONSIndividuals with low serum albumin and elevated PLR should be advised regarding the impact of these laboratory markers on outcomes including survival, irrespective of treatments received. An effort should also be made to optimize nutrition and PLR, if practicable, before treatment to minimize the potential for development of adverse events.