Surgery of non-spinal skeletal metastases in renal cell carcinoma

Background and purpose — Surgery for metastases of renal cell carcinoma has increased in the last decade. It carries a risk of massive blood loss, as tumors are hypervascular and the surgery is often extensive. Preoperative embolization is believed to facilitate surgery. We evaluated the effect of preoperative embolization and resection margin on intraoperative blood loss, operation time, and survival in non-spinal skeletal metastases of renal cell carcinoma.

Patients and methods — This retrospective study involved 144 patients, 56 of which were treated preoperatively with embolization. The primary outcome was intraoperative blood loss. We also identified factors affecting operating time and survival.

Results — We did not find statistically significant effects on intraoperative blood loss of preoperative embolization of skeletal non-spinal metastases. Pelvic localization and large tumor size increased intraoperative blood loss. Marginal resection compared to intralesional resection, nephrectomy, level of hemoglobin, and solitary metastases were associated with better survival.

Interpretation — Tumor size, but not embolization, was an independent factor for intraoperative blood loss. Marginal resection rather than intralesional resection should be the gold standard treatment for skeletal metastases in non-spinal renal cell carcinoma, especially in the case of a solitary lesion, as this improved the overall survival.     

Treatment of neoplastic spinal cord compression: results of a prospective study

Currently, external radiation and steroid therapy are used in most patients with neoplastic spinal cord compression. Surgery is generally used to treat those who do not respond to radiation therapy. To determine the role of de novo surgery in patients with spinal metastases, a prospective study was undertaken. Over a 4 1/2-year period, the cases of 54 patients with radiologically documented spinal metastases were studied. The sites of tumor origin included soft tissue sarcoma (8 patients), kidney (6 patients), lung (5 patients), breast (5 patients), spine (6 patients), unknown primary site (6 patients), and others (18 patients). Sites of compression included the cervical spine segments in 15 patients, thoracic segments in 23, lumbar in 14, and sacral in 2. Before surgery, 24 patients (44%) were nonambulatory. Three surgical approaches were used: anterior vertebral body resection in 45 patients, laminectomy in 7, and lateral osteotomy in 2. After surgery, 37 patients received external radiation therapy. All patients improved (became ambulatory) after surgery, with 23 of 25 patients surviving at 2 years continuing to be ambulatory. The 30-day mortality rate was 6% (three patients); eight patients (15%) sustained various surgical complications. These results are superior to those reported after external radiation therapy and steroids alone, and they support the concept that de novo surgery be considered in selected patients with spinal metastases.     

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.     

Pulmonary resection for metastatic breast cancer.

Thirty-three patients treated primarily with surgical excision of pulmonary metastases from breast cancer were compared with 30 patients treated primarily with systemic chemohormonal therapy. Treatment for patients in the surgical group included pulmonary resection alone in 20, resection plus adjuvant systemic therapy in nine, and resection plus adjuvant radiation therapy in four. Treatment for patients in the medical group included systemic therapy alone in 22 and systemic therapy plus local radiation therapy in eight. Mean survival in the surgical group was significantly longer than that in the medical group, even when only those patients who manifested single pulmonary nodules were compared (58 months vs 34 months). The overall 5-year survival rate after treatment of lung metastasis was significantly greater for the surgical group than for the medical group (36% vs 11%). The results of this study indicate that surgical resection should be considered in patients with breast cancer who develop operable pulmonary metastases without evidence for concomitant extrapulmonary disease. In selected patients, such therapy may result in a survival benefit.     

Survival after surgery for spinal and extremity metastases: Prognostication in 241 patients

We assessed the survival after surgery in 153 patients with extremity metastases and 88 with spinal metastases. The survival rate for the whole series of 241 patients was 0.30 at 1 year, 0.15 at 2, and 0.08 at 3 years. The 1-year survival rate was the same for the extremity metastases group and the spinal group. Univariate analysis showed that 1-year survival was related to metastatic load, site of primary tumor, and presence of pathologic fracture. Multivariate regression analysis showed that pathologic fracture, visceral or brain metastases, and lung cancer were negative prognostic variables. Solitary skeletal metastases, breast and kidney cancer, myeloma, and lymphoma were positive variables. A prognostication model based on these variables stratified the patients into 3 groups with a 1-year survival ranging from 0.5 to 0.0. These prognostic variables can be used for differentiating the treatment of cancer patients with pathologic fracture or epidural compression.     

The role of preoperative transarterial embolization in spinal tumors. A large single-center experience

Background contextPatients with spinal tumors are often referred for preoperative angiography and embolization before surgical resection to minimize intraoperative bleeding.PurposeThe purpose of the present study was to investigate the angiographic appearance of a variety of spinal tumors, assess the safety and efficacy of preoperative embolization in relation to the amount of intraoperative blood loss, and correlate intraoperative tumor histology with the degree of gadolinium enhancement on spinal magnetic resonance imaging (MRI) and tumor vascularity visualized during angiography.Study design/settingRetrospective and single-institution cohort study.Patient sampleOne hundred four patients with spinal tumors referred for preoperative embolization.Outcome measuresEffectiveness of preoperative embolization in relation to intraoperative blood loss and number of transfused packed red blood cell units in perioperative period (72 hours).MethodsFrom 2000 to 2009, 104 patients with spinal tumors underwent 114 spinal angiographies with the intent to embolize feeder vessels before surgery. The effectiveness of embolization was compared with the documented intraoperative blood loss. Angiographic tumor vascularity was graded from 0 (avascular) to 3 (highly vascular). Ninety-four patients had a pre– and post–gadolinium-enhanced MRI of the spine before transarterial embolization. Magnetic resonance imaging vascular enhancement was classified as Grade 3 (avid contrast enhancement), Grade 2 (moderate), or Grade 1 (mild).ResultsTransarterial tumor embolization was angiographically complete in 63 (66%) and partial in 33 procedures (34%). In 18 cases, the target was not deemed suitable for embolization. A limited statistical analysis did not reveal a statistical difference in documented intraoperative blood loss between patients with complete versus partial embolization for the entire cohort or when stratified into renal cell carcinoma (RCC; p=.64), multiple myeloma (p=.28), malignant (p=.17) and benign tumor groups (p=.26). There were no clinical complications associated with embolization. There was poor correlation between MRI enhancement and angiographic vascularity.ConclusionsPreoperative embolization was angiographically effective in most cases. Avid gadolinium enhancement (Grade 3) on MRI was not predictive of hypervascularity on angiography. Furthermore, hypervascularity was not restricted to classically vascular tumors, such as RCC, as it was noted in some patients with breast and prostate cancer. However, with the available numbers, the quality of preoperative embolization did not significantly affect intraoperative blood loss. A future prospective randomized controlled study may be warranted to better characterize the benefits of preoperative embolization for spinal tumors.     

Surgical treatment for multiple colorectal metastases: efficacy of ablation therapy

Either hepatic resection, microwave coagulonecrotic therapy (MCN), or a combination of liver resection and MCN was performed in 166 patients with liver metastases from colorectal cancer. In 53 patients who underwent liver resection, the 1-, 3-, and 5-year actual survival rates were 85.0%, 51.2%, and 42.2%, respectively. In 77 who underwent MCN, the 1-, 3-, and 5-year actual survival rates were 82.8%, 46.7%, and 36.0%, respectively. In 34 who underwent both liver resection and MCN, the 1-, 3-, and 5-year actual survival rates were 84.2%, 41.6%, and 21.1%, respectively. The survival rates among the three groups did not differ significantly. Of 166 patients with liver metastases, 44 showed multiple liver metastases (H3). Of 44 patients with multiple liver metastases, 27 underwent MCN (mean tumor diameter 27.2 mm, mean number of tumors 11.2), and the 1-, 3-, and 5-year actual survival rates were 73.1%, 31.3%, and 25.1%, respectively. Of 44 patients with multiple liver metastases, 17 underwent both liver resection and MCN (mean tumor diameter 41.9mm, mean number of tumors 8.1), and the 1-, 3-, and 5-year actual survival rates were 66.3% and 14.7%, respectively. To perform MCN more effectively in the treatment of liver metastases, surgical margins around tumors should be from 10 mm to 15 mm, and both the feeding artery and drainage vein should be coagulated before MCN.     

Preoperative transarterial embolization of vertebral metastases

The aim of this study was to evaluate the impact of preoperative devascularization of spinal metastases in relation to the preembolization tumor vascularization degree and in relation to the intraoperative blood loss. Twenty-four patients underwent preoperative transarterial embolization of hypervascular spinal metastases. Each tumor was assigned a vascularization grade (I–III) according to tumor blush after contrast agent injection in the main feeding artery. Embolization was performed with polyvinyl alcohol particles in all patients. Surgical reports were reviewed in terms of estimated blood loss. A mild hypervascularization was found in three patients (group I), medium in six patients (group II) and extensive in 15 patients (group III). In 22 out of 24 patients embolization could be performed with a complete devascularization. In two patients, only partial embolization could be performed, due to the main feeding artery arising from the artery of Adamkiewicz. In patients with complete devascularization the mean intraoperative blood loss was 1,900 ml, whereas in the two patients who were not embolized it was 5,500 ml. Intraoperative blood loss was not correlated to the vascularization grade. Angiography and embolization could be performed in all patients without causing permanent neurologic deficit, skin or muscle necrosis. The surgeons concluded that radical tumor resection after embolization was facilitated. Intraoperative blood loss is not correlated with the pre-interventional vascularization degree, if complete devascularization can be achieved with embolization. Preoperative embolization of vertebral hypervascular tumors is safe, effective and facilitates tumor resection.     

Oligodendrogliomas: the Mayo Clinic experience.

Eighty-one patients with pure supratentorial oligodendrogliomas underwent surgery alone (19 patients) or surgery plus postoperative radiation therapy (63 patients) between the years 1960 and 1982. The median survival time and the 5-, 10-, and 15-year survival rates for these 82 patients were 7.1 years, 54%, 34%, and 24%, respectively; these values were significantly different from those for an age- and sex-matched normal reference population. Univariate and multivariate survival analyses were performed on 13 possible prognostic factors including: patient age and sex; presence of seizures; site, size, side, computerized tomography (CT) enhancement, grade, and calcification of the tumor; and treatment (extent of surgical resection, lobectomy, radiation dose, and radiation field). Of these factors, tumor grade as classified by the Kernohan and St. Anne-Mayo methods was most strongly associated with survival. Patients with Grade 1 or 2 tumors by either grading method had a median survival time and 5- and 10-year survival rates of approximately 9.8 years. 75%, and 46%, respectively, compared to 3.9 years, 41%, and 20% for those with Grade 3 or 4 tumors. The extent of surgical resection was also associated with survival. The 19 patients who underwent gross total resection of their tumor had a median survival time and 5- and 10-year survival rates of 12.6 years, 74%, and 59%, compared to 4.9 years, 46%, and 23%, respectively, for the 63 who had subtotal resection. When comparing the 19 patients who underwent surgery alone with the 63 who had surgery plus postoperative radiation therapy, there did not appear to be a survival benefit to be gained from the addition of postoperative radiation therapy. However, the patients who had surgery alone tended to have gross total resections and lower tumor grades. Analysis of the subset of 63 patients who underwent subtotal resection alone or with radiation therapy showed that the median survival time and 5- and 10-year survival rates were: 2 years, 25%, and 25% for the eight patients with subtotal resection alone; 4.5 years, 39%, and 20% for the 26 patients with surgery and low-dose (less than 5000 cGy) radiation therapy; and 7.9 years, 62%, and 31% for the 29 patients receiving surgery and high-dose radiation therapy (greater than or equal to 5000 cGy), respectively.     

Surgical treatment of hepatic metastases from colorectal cancer.

From 1980 to 1984, 48 patients were subjected to liver resection for hepatic metastases from colorectal cancer. The disease was staged according to the original staging system proposed by the authors: stage I, single metastasis involving less than 25% of hepatic parenchyma (21 patients); stage II, multiple metastases involving less than 25% of hepatic parenchyma or single metastasis involving between 25-50% (9 patients); and stage III, multiple metastases involving between 25-50% or more than 50% of hepatic parenchyma, irrespective of the number of metastases (18 patients). The extent of hepatic resection was generally related to that of liver disease; a typical lobectomy was performed in 28 patients and segmentectomies in 20. One patient died after operation (mortality, 2.1%), and major complications occurred in seven patients (morbidity, 14.9%). Morbidity was related to operatory blood loss: 45% of patients with blood replacement of more than 2000 cc developed major complications versus 5.4% with blood replacement of less than 2000 cc (p less than 0.05). The actuarial 3-year survival for stages I, II, and III was 73%, 60%, and 29%, respectively (p less than 0.05). Twenty-two patients (45%) have had recurrences, all stage III patients within 2 years of resection versus 28% of stage I patients (30 months disease-free survival, 49%). The liver only was the site of recurrence in 10 patients, distant sites in seven, and both liver and distant in five. Analysis of the different features of the primary tumor, the interval between bowel resection and detection of hepatic metastases, and the number and extent of liver secondaries demonstrated that prognosis after surgery was mainly related to the latter; they are considered in the staging system adopted in this study. It is a simple system and shows a good prognostic correlation. The results reported here are in agreement with those of the literature; the low mortality and morbidity and the survival benefit support the growing acceptance of surgery in treatment of hepatic metastases from colorectal cancer, in particular stage I patients. For the other stages, surgery should represent, when applicable, only the first step of a multimodality treatment.     

胃癌肝转移外科治疗的临床分析

目的 评价胃癌肝转移的外科治疗效果及病理因素对其预后的影响。方法 本组834例胃癌患者中共有91例诊断为肝转移，其中79例为同时性肝转移，12例术后发现异时转移，共21例行胃癌肝转移灶切除术。结果 胃癌肝转移灶切除后1年、3年生存率分别为69％、30％。单转移灶及异时性转移是其有利的预后因素。13例肝转移灶有假包膜形成。结论 单转移灶及异时转移、肿瘤假包膜形成预示胃癌肝转移切除患者有较好的预后。     

Embolization of Spinal Metastases Reduces Peroperative Blood Loss: 21 Patients Operated on for Renal Cell Carcinoma

We evaluated the peroperative blood loss in 21 patients who were treated with 29 operative procedures for thoracolumbar spinal renal cell carcinoma metastases. Embolization was undertaken prior to 11 operations. At posterior surgery the average blood loss was one third after embolization compared with when embolization had not been performed. The blood loss was also lower during anterior surgery, although this difference was smaller. We recommend that preoperative embolization should precede surgical treatment of spinal metastases of renal cell carcinoma where it can be anticipated that the operation will extend into the pathological tissue.     

肺转移瘤的诊断与外科治疗

目的探讨肺转移瘤的诊断、手术指征、切除方式及影响预后的因素,以提高患者的生存率。方法125例肺转移瘤患者均行手术治疗,共行肺转移瘤切除术138次,其中行一次手术116例,二次手术5例,三次手术4例。手术方式为肺部分切除66次,肺段切除2次,肺叶切除53次,肺叶加部分胸壁扩大切除2次,全肺切除3次,肿瘤剜除12次;行开胸手术130次,电视胸腔镜手术（VATS）8次。结果本组患者中原发肿瘤为上皮组织来源的94例,肉瘤类26例,其它种类5例。全组患者无围术期死亡,随访122例,随访时间1～10年,1年、3年和5年生存率分别为90．4％、53．3％和34．8％;其中结、直肠癌、肾癌和软组织肉瘤的预后较好,5年生存率分别为43．8％、37．5％和33．3％。105例肺转移瘤完全切除患者的5年生存率为38．9％,20例不完全切除患者为16．7％。89例行常规肺门及纵隔淋巴结摘除患者仅有12例术后病理证实有淋巴结转移,无淋巴结转移患者和有淋巴结转移患者的5年生存率分别为41．5％和14．3％。结论对诊断明确、符合标准的肺转移瘤患者行积极的手术治疗可取得满意的效果,手术径路以后外侧小切口为主,能否完全切除肿瘤和肺门纵隔淋巴结的转移状况是影响预后的重要因素。     

影响结直肠癌肝转移手术切除患者预后的多因素分析

目的 探讨影响结直肠癌肝转移患者手术切除的预后因素。方法 收集1995-2001年间收治的结直肠癌肝转移手术切除患者103例的资料，用Kaplan-Meier法计算术后生存率，以Cox模型进行多变量分析。结果 患者术后1、3年无瘤生存率分别为73．8％和43．7％，术后1、3年累积生存率分别为7g．6％和49．5％。单因素分析显示：术前血清CEA水平、转移灶与原发灶的治疗间隔时间、术中切缘情况、肝门淋巴结转移、肝内卫星灶的存在与否、肝转移灶的最大直径、数目及有无包膜影响患者的术后肝内复发和术后累积生存率，而术后化疗可以提高患者的累积生存率。多因素分析显示：转移灶与原发灶的治疗间隔时间、切缘情况、肝内卫星灶的存在与否和肝转移灶的最大直径是影响肝内复发和累积生存率的独立因素，而肝门淋巴结转移是影响累积生存率的独立因素，有无包膜是影响肝内复发的独立因素。结论 手术切除是结直肠癌肝转移有效的治疗手段。转移灶与原发灶的治疗间隔时间、切缘情况、肝内卫星灶、肝转移灶的大小和包膜、肝门淋巴结转移等是患者预后的独立影响因素。     

Metastatic neuroendocrine hepatic tumors: resection improves survival

BACKGROUND: The optimal treatment for hepatic metastases from neuroendocrine tumors remains controversial because of the often indolent nature of these tumors. We sought to determine the effect of 3 major treatment modalities including medical therapy, hepatic artery embolization, and surgical resection, ablation, or both in patients with liver-only neuroendocrine metastases, with the hypothesis that surgical treatment is associated with improvement in survival. DESIGN: Retrospective study. SETTING: Tertiary care center. PATIENTS: Patients with metastatic liver-only neuroendocrine tumors were identified from hospital records. INTERVENTIONS: Patients were subdivided into those receiving medical therapy, hepatic artery embolization, or surgical management. MAIN OUTCOME MEASURES: Effect of treatment on survival and palliation of symptoms was analyzed. RESULTS: From January 1996 through May 2004, 48 patients with liver-only neuroendocrine metastases were identified (median follow-up, 20 months), including 36 carcinoid and 12 islet cell tumors. Seventeen patients were treated conservatively, which consisted of octreotide (n = 7), observation (n = 6), or systemic chemotherapy (n = 4). Hepatic artery embolization was performed in 18 patients. Thirteen patients underwent surgical therapy, including anatomical liver resection (n = 6), ablation (n = 4), or combined resection and ablation (n = 3). No difference was noted in the percentage of liver involved with tumor between the 3 groups. An association of improved survival was noted in patients treated surgically, with a 3-year survival of 83% for patients treated by surgical resection, compared with 31% in patients treated with medical therapy or embolization (P = .01). No difference in palliation of symptoms was noted among the 3 treatment groups (P = .2). CONCLUSION: In patients with liver-only neuroendocrine metastases, surgical therapy using resection, ablation, or both is associated with improved survival.     

Preoperative embolization in spinal and pelvic metastases

The role of preoperative embolization should be evaluated for the surgical treatment of spinal and pelvic metastases. Selective embolization was perfomed in 32 patients (19 men, 13 women; mean age 63.4 years) before surgery by anterior resection of spinal metastases (n = 21) or pelvic metastases (n = 11). Evaluation parameters consisted of the intraoperative blood loss, the need for blood replacement, and the operating time. There was a significant difference in blood loss and transfusion requirements in the spinal group (P = 0.02) as well as in the pelvic group (P = 0.05) compared to a nonembolized control group of spinal (n = 20) and pelvic (n = 10) metastases. The operating time in the embolized group was shorter, but the difference was not significant. Surgical revision was required in two cases in the embolized spinal group owing to necrosis of the psoas muscle. No neurological deficit was observed that could be attributed to the embolization procedure. Preoperative embolization is thus a suitable method for reducing intraoperative blood loss and transfusion requirements in hypervascularized spinal and pelvic metastases.     

Delayed surgical resection reduces intraoperative blood loss for embolized meningiomas

OBJECTIVE: Embolization before surgical resection of tumors has been demonstrated to reduce intraoperative blood loss, but the optimal time that should elapse between embolization and tumor resection has not been established. We evaluated whether immediate surgical resection (< or =24 h) after embolization or delayed surgical resection (>24 h) was more effective in minimizing intraoperative blood loss. METHODS: We retrospectively analyzed the records for 50 patients with meningiomas who underwent preoperative embolization between 1993 and 1999. We divided the patients into two groups, i.e., those who underwent surgical resection of their meningiomas < or =24 hours after embolization and those who underwent surgery more than 24 hours after embolization. The extent of embolization, intraoperative blood loss, duration of surgery, and length of the hospital stay were compared for the two groups. Postoperative pathological specimens were examined for assessment of the extent of vascularity and necrosis caused by embolization. RESULTS: Intraoperative blood loss was greater for the immediate group than for the delayed group (29% with blood loss of >1000 ml [median, 475 ml] versus 0% with blood loss of >700 ml [median, 337.5 ml]; P = 0.01). There were no statistically significant differences between the groups with respect to tumor volume, extent of embolization, degree of devascularization, necrosis, duration of surgery, or length of the hospital stay. CONCLUSION: Contrary to previous studies that emphasized a need for tumor removal immediately after embolization, to prevent revascularization, surgical resection of meningiomas should be delayed more than 24 hours after embolization, because there is less intraoperative blood loss.     

Utility of expanded anterior column resection versus decompression-alone for local control in the management of carcinomatous vertebral column metastases undergoing adjuvant stereotactic radiotherapy

Background ContextWith improvements in adjuvant radiotherapy and minimally invasive surgical techniques, separation surgery has become the default surgical intervention for spine metastases at many centers. However, it is unclear if there is clinical benefit from anterior column resection in addition to simple epidural debulking prior to stereotactic body radiotherapy (SBRT).PurposeTo examine the effect of anterior column debulking versus epidural disease resection alone in the local control of metastases to the bony spine.Study DesignRetrospective cohort study.Patient SampleNinety-seven patients who underwent open surgery followed by SBRT for spinal metastases at a single comprehensive cancer center.Outcome Measures: Local tumor recurrence following surgery and SBRT.MethodsData were collected regarding radiation dose, cancer histology, extent of anterior column resection, and recurrence. Tumor involvement was categorized using the International Spine Radiosurgery Consortium guidelines. Univariable analyses were conducted to determine predictors of local recurrence and time to local recurrence.Results: Among the 97 included patients, mean age was 60.5±11.4 years and 51% of patients were male. The most common primary tumor types were lung (20.6%), breast (17.5%), kidney (13.4%) and prostate (12.4%). Recurrence was seen in 17 patients (17.5%) and local control rates were: 85.5% (1-year), 81.1% (2-year), and 54.9% (5-year). Overall predictors of local recurrence were tumor pathology (p<.01; renal cell carcinoma and colorectal adenocarcinoma associated with poorest PFS) and undergoing anterior column debulking versus epidural decompression-alone (p=.03). Only tumor pathology predicted time to local recurrence (p<.01), though inspection of Kaplan-Meier functions showed superior long-term local control in patients with radiosensitive tumor pathologies, no previous irradiation of the metastasis, and who underwent anterior column resection versus epidural removal alone. Median time to recurrence was 288 days with 100% of lesions showing anterior column recurrence and recurrence in the epidural space.Conclusions: With the increasing shift towards surgery as a neoadjuvant to radiotherapy for patients with spinal column metastases, the role for surgical debulking has become less clear. In the present study, we find that anterior column debulking as opposed to epidural debulking-alone decreases the odds of local recurrence and improves long-term local control.     

Incidence and prognostic factors of Japanese breast cancer patients with bone metastasis

Background Few previous studies have analyzed the incidence of bone metastases in a defined population of Japanese breast cancer patients and their prognosis after chemotherapy. Methods This is a retrospective cohort study. We investigated 695 patients who underwent surgery for breast cancer. The strategy of adjuvant therapy was as follows. Patients with both estrogen receptors (ERs) and progesterone receptors (PgRs) had endocrine therapy as initial adjuvant therapy (n = 239). Patients with neither ERs nor PgRs had chemotherapy. When metastasis to other organs, including bone, was identified, patients received chemotherapy. The survival rates after surgery and after the onset of bone metastasis, as well as the incidence of bone metastasis, were calculated. We also evaluated the prognostic and predictive factors. Results Bone metastases developed in 148 of 695 patients. All 148 received chemotherapy, and 121 of them developed spinal metastases. The 5-year survival rate after bone metastases was 26.1%. Prognostic factors for bone metastases were visceral metastases and PgR status. Cord compression was observed in 17 of the 148 patients, with the thoracic spine being the most common. The 1-year survival rate for patients with bone metastases who received chemotherapy was 66.3%, whereas that of patients with paralysis after spinal metastases was 17.6%. Within 6 months of the development of spinal cord compression, 70.6% of the patients died. Conclusions We reported the incidence and prognostic factors for a defined population of Japanese breast cancer patients with bone and spinal metastases. Our results suggest that the expected survival time for patients with paralysis who received adequate endocrine therapy or chemotherapy is generally poor. However, to detect a predictive factor of long survival after paralysis and establish the indications for surgery, a comparative study among large groups of patients with paralysis and with different backgrounds is necessary.