Updated: 6/22/2021

Metastatic Disease of Spine

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Flashcards
8
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Questions
29
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Evidence
20
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Videos / Pods
3
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Cases
1
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  • Introduction
    • Metastatic cancer is the most common reason for a destructive bone lesion in adults
      • carcinomas that commonly spread to bone include
        • breast (16-37% of breast cancer patients develop spine mets)
        • lung (12-15%)
        • thyroid (4%)
        • renal (3-6%)
        • prostate (9-15%)
  • Epidemiology
    • Incidence
      • bone is the 3rd most common site for metastatic disease (behind lung and liver)
    • Demographics
      • metastatic bone lesions are usually found in older patients (> 40 yrs)
    • Anatomic location
      • common sites of metastatic lesions include spine>proximal femur>humerus
        • most common site of mets is spine
          • thoracic spine is most common site of bony metastasis
        • 2nd most common site of mets is proximal femur
          • proximal femur is most common site of fracture secondary to metastatic bone lesions
            • 65% nonunion rate
          • 50% in femoral neck, 20% pertrochanteric, 30% subtrochanteric
  • Etiology
    • Pathophysiology
      • mechanism of bone destruction (osteolysis)
        • osteolytic bone lesions are caused by tumor induced activation of osteoclasts
          • occurs through the RANK, RANK ligand (RANKL), osteoprotegrin pathway
          • PTHrP positive breast cancer cells activate osteoblastic RANKL production
        • osteoblastic bone metastases are due to tumor-secreted endothelin 1
    • Associated conditions
      • metastatic hypercalcemia
        • a medical emergency
        • symptoms include
          • confusion
          • muscle weakness
          • polyuria & polydipsia
          • nausea/vomiting
          • dehydration
        • treatment
          • hydration (volume expansion)
          • loop diuretics
          • bisphosphonates
  • Principles of metastasis
    • Mechanism of metastasis
      • tumor cell intravasation
        • E cadherin cell adhesion molecule (on tumor cells) modulates release from primary tumor focus into bloodstream
      • avoidance of immune surveillance
      • target tissue localization
        • attaches to target organ endothelial layer via integrin cell adhesion molecule (expressed on tumor cells)
      • extravasation into the target tissue
      • induction of angiogenesis
        • via vascular endothelial growth factor (VEGF) expression
      • genomic instability
      • decreased apoptosis
    • Vascular spread
      • Batson's vertebral plexus
        • valveless venous plexus of the spine that provides a route of metastasis from organs to axial structure including vertebral bodies, pelvis, skull, and proximal limb girdles
    • Mechanism of bone lysis
      • oncogenic cell releases cytokines IL-6, IL-11, PTHrP, TGF-beta
      • PTHrP and TGF-beta activate osteoblasts
      • osteoblasts secrete RANKL, that binds to RANK on osteoclasts and activates osteoclasts
    • Mechanism of bone sclerosis (prostate and breast mets)
      • prostate cancer cells secrete endothelin 1 (ET-1)
      • ET-1 binds to endothelin A receptor (ETAR) on osteoblasts and stimulates osteoblasts
      • ET-1 decreasesWNT suppressor DKK-1
        • activates WNT pathway, increasing osteoblast activity
  • Classification
    • Tokuhashi score specific to metastatic disease to spine
      • prognostic score based on 6 elements: general condition, extraspinal bony metastasis, number of vertebral bodies with metastasis, visceral metastasis, primary tumor, neurologic compromise
      • score of 0-8: <6 months; 9-12 > 6 months, 12-15 >1 year
  • Symptoms
    • Symptoms
      • pain
        • axial night pain
          • may be mechanical pain due to bone destruction or tumorigenic pain which often occurs at night
        • metastatic hypercalcemia
    • Physical exam
      • neurologic deficits
        • caused by compression of the spinal cord with metastatic disease to the spine
      • hyper-reflexia
  • Evaluation
    • Workup for older patient with single bone lesion and unknown primary includes
      • imaging
        • AP and lateral of spine in region of pain
        • CT of chest / abdomen / pelvis
        • technetium bone scan to detect extent of disease
          • myeloma and thyroid carcinoma are often cold on bone scan - evaluate with a skeletal survery
      • labs
        • CBC with differential
        • ESR
        • basic metabolic panel
        • LFTs, Ca, Phos, alkaline phosphatase
        • serum and urine immunoelectrophoresis (SPEP, UPEP)
      • biopsy
        • in patients where a primary carcinoma is not identified, obtaining a biopsy is necessary to rule out a primary bone lesion
          • should not treat a bone lesion without tissue diagnosis of the lesion
        • metastatic adenocarcinoma not identified by CT of the chest, abdomen, and pelvis is most likely from a small lung primary tumor
    • See table of evaluation algorithms based on patient factors
  • Imaging
    • Radiographic
      • recommended views
        • AP and lateral of involved area off spine
      • findings
        • purely lytic or mixed lytic/blastic lesions
          • lung, thyroid, and renal are primarily lytic
          • 60% of breast CA is blastic
          • 90% of prostate CA is blastic
    • CT scan
      • helpful to identify metastatic lesions to the spine
    • MRI
      • useful to show neurologic compromise of the spine
  • Studies
    • Histology
      • characteristic findings
        • epithelial cells in clumps or glands in a fibrous stroma
      • immunohistochemical stains positive
        • Keratin
        • CK7 (breast and lung cancer)
        • TTF1 (lung cancer)
  • Treatment 
    • General considerations
      • NOMS framework: neurologic, oncologic, mechanical instability, systemic illness
        • neurologic: measure of epidural spinal cord compression (ESCC)
          • 0-1 low grade, 2-3 high grade
        • oncologic: responsiveness to radiation
        • mechanical instability: spinal instability neoplastic score (SINS)
          • SINS: 0-6 no surgical consultation required, 7-18 surgical consultation advisable
        • systemic illness: formulation of prognosis from disease burden, medical comorbidities, functional status
    • Nonoperative
      • palliative care
        • indications
          • life expectancy of < 6 months
            • Tokuhashi scoring system can be used to determine life expectancy
      • radiation alone
        • indications
          • may be indicated in patients who are not surgical candidate
          • no signs of neural compression, neurologic deficit, or instability
    • Operative
      • neurologic decompression, spinal stabilization, and postoperative radiation
        • indications
          • metastatic lesions to spine with neurologic deficits in patients with life expectancy of > 6 months
        • technique
          • preoperative embolization indicated in metastatic renal and thyroid CA to spine
  • Complications
    • Recurrence
    • Hardware failure and spinal instability
    • Nonunion of fracture
    • Wound complications
      • Immediate soft tissue reconstruction has a lower complication rate than delayed reconstruction in patients undergoing revision metastatic spine tumor surgery
  • Prognosis
    • Median survival in patients with metastatic bone disease
      • thyroid: 48 months
      • prostate: 40 months
      • breast: 24 months
      • kidney: variable depending on medical condition but may be as short as 6 months
      • lung: 6 months
    • Tokuhashi score (see classification section)
Flashcards (8)
Cards
1 of 8
Questions (29)

(SBQ18SP.49) What factor has been shown to improve outcomes in revision metastatic spine surgery?

QID: 211641
1

Preoperative radiation therapy

38%

(506/1342)

2

Surgery at greater than 6 levels

11%

(152/1342)

3

Tobacco use by patient

6%

(75/1342)

4

Immediate soft tissue reconstruction

34%

(459/1342)

5

Utilization of posterior approach

11%

(143/1342)

L 5 A

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(OBQ18.230) A 48-year-old woman with a history of chronic low back pain, narcotic dependence for 2 years, and recent IV drug abuse presents to the emergency room with worsening low back pain. She denies fever and chills, pain in her neck, or pain in her lower extremities. Physical exam shows normal strength, a negative Hoffman sign, 2+ patellar reflexes, and flexion of the 1st toes with a Babinski exam. Laboratory studies show a WBC of 12,000, a CRP of 3 mg/L, and an ESR of 13 mm/h. Plain radiographs are obtained and depicted in Figures A and B. What is the most appropriate next step in management?

QID: 213126
FIGURES:
1

CT of the chest, abdomen, and pelvis

52%

(834/1603)

2

MRI of the cervical spine

8%

(133/1603)

3

Blood cultures and empiric IV antibiotics

18%

(289/1603)

4

NSAIDS and physical therapy with close follow-up with a spine surgeon in 2 weeks

21%

(330/1603)

5

Kyphoplasty

0%

(4/1603)

L 4 A

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(SBQ12SP.100) Which of the following tumors are most likely to cause the condition seen in Figure A?

QID: 3798
FIGURES:
1

Breast, Renal, Osseous, Lung

6%

(141/2518)

2

Breast, Hepatic, Colon, Lung

3%

(80/2518)

3

Breast, Osseous, Renal, Hepatic

1%

(21/2518)

4

Breast, Renal, Prostate, Lung

84%

(2121/2518)

5

Breast, Renal, Prostate, Colon

6%

(139/2518)

L 2 C

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(SBQ12SP.78) A 60-year-old female presents with a 2-month history of low back pain. Imaging is seen in Figures A and B. Which of the following is LEAST likely to be true?

QID: 3776
FIGURES:
1

This patient is positive for mutations in the BRCA1 gene

9%

(261/2965)

2

The patient is positive for mutations in the APC gene and has a positive guaiac-based fecal occult blood test (gFOBT)

33%

(990/2965)

3

The patient has a 30 pack year smoking history

7%

(196/2965)

4

The patient presents with an ataxic gait, limb weakness, and is found to have a mutations of the von Hippel–Lindau tumor suppressor (VHL) gene

35%

(1047/2965)

5

The patient presents with confusion, generalized weakness, and total serum calcium level of 12.1 mmol/L

15%

(449/2965)

L 5 C

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(SBQ12SP.65) Which of the following metastatic tumours should be treated with embolisation prior to surgical management?

QID: 3763
1

Renal, thyroid

94%

(2907/3094)

2

Breast, renal

2%

(67/3094)

3

Liver, breast

1%

(35/3094)

4

Lung, colon

1%

(33/3094)

5

Prostate, thyroid

1%

(42/3094)

L 1 B

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(OBQ12.162) A 62-year-old male patient presents with severe lower back pain radiating to his right lower abdomen and right leg. He previously underwent a right nephrectomy for renal cell carcinoma. On physical exam, he has weakness with right knee extension which is affecting his ability to ambulate. An MRI is performed and is shown in Figures A and B. Staging studies determine this to be an isolated metastatic lesion. What is the next best step in this patient's treatment?

QID: 4522
FIGURES:
1

Chemotherapy alone

1%

(34/5231)

2

Radiation alone

3%

(137/5231)

3

Vertebroplasty

1%

(46/5231)

4

Embolization, surgical decompression and stabilization followed by radiation

87%

(4564/5231)

5

Surgical decompression and stabilization followed by radiation

8%

(419/5231)

L 1 A

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(OBQ12.124) A 68-year-old male presents to the emergency room with neck pain and progressive weakness to the point that he is unable to walk. Prior to this event he was in good health and active. On physical exam he is an ASIA C. Radiographs, computed tomography, and an MRI are show in Figure A,B, and C respectively. A CT of the chest, abdomen, and pelvis shows a single resectable lesion in the rectum consistent with a primary malignancy. Sagittal images of the spine show a single metastatic lesion in the thoracic spine, but no signs of thoracic canal compromise. He has no other metastatic bone lesions. What is the best treatment for this patient?

QID: 4484
FIGURES:
1

Surgical decompression and stabilization followed by radiation

75%

(3273/4354)

2

Radiation followed by surgical decompression and fusion

15%

(642/4354)

3

Radiation alone

5%

(218/4354)

4

Chemotherapy alone

1%

(44/4354)

5

Palliative measures

3%

(142/4354)

L 3 A

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(SBQ09SN.21.1) A 50-year-old woman with a history of metastatic breast cancer reports progressive back pain and lower extremity weakness over the past 2 weeks. The weakness has progressed to a point where she can only ambulate short distances with a walker. A sagittal T2-weighted MRI scan is shown in Figure A, and a sagittal contrast-enhanced T1-weighted MRI scan is shown in Figure B. Her cancer is found to be positive for a chromosomal translocation and the oncology team expects her to respond well to targeted therapy with a life expectancy of more than 3 years. What would be the most appropriate definitive treatment for this patient?

QID: 9110
FIGURES:
1

Palliative chemotherapy and radiation

1%

(13/1505)

2

Targeted radiation therapy

2%

(25/1505)

3

Laminectomy alone with posterior instrumented fusion with immediate pre-operative and post-operative radiation therapy

11%

(171/1505)

4

Corpectomy and anterior column reconstruction, followed by posterior instrumented fusion

82%

(1240/1505)

5

Kyphoplasty with TLSO bracing, followed by biopsy-targeted medical management

3%

(39/1505)

L 2 B

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(OBQ09.83) You are caring for a 63-year-old female with metastatic breast cancer to the lumbar spine. Her neurological examination shows significant weakness in leg function and she is having difficulty ambulating. Imaging shows significant neural element compression by the tumor and complete erosion of the L1 vertebrae. She has no other sites of metastatic disease and is otherwise healthy. What treatment option do you recommend to best maintain her function?

QID: 2896
1

Palliative therapy

1%

(36/3444)

2

Complete neural element decompression

0%

(12/3444)

3

Complete neural element decompression with instrumentation to stabilize the spine

9%

(320/3444)

4

Complete neural element decompression, instrumentation, and postoperative chemotherapy

24%

(818/3444)

5

Complete neural element decompression, instrumentation, and postoperative radiotherapy

65%

(2250/3444)

L 3 A

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(OBQ09.51) A 59-year-old female with a history of biopsy proven metastatic renal cell carcinoma presents with a thoracic spine lesion consistent with renal cell carcinoma. She has lower extremity weakness and sustained clonus bilaterally. What is the most appropriate management prior to surgery?

QID: 2864
1

Blood cultures

0%

(11/2456)

2

High dose IV methylprednisone

3%

(74/2456)

3

Arterial embolization

89%

(2181/2456)

4

CT guided cryotherapy

2%

(45/2456)

5

Radiation therapy

6%

(139/2456)

L 1 B

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(OBQ08.66) A 47-year-old female, otherwise in good general condition, has intractable back pain from metastatic breast cancer isolated to her spine. She has failed progressive multi-agent chemotherapy and hormone therapy. Her exam is normal except for slight sensory dysesthesia, hyperreflexic patellar tendons, and mild gait instability which she reports has been worsening. Cervical, thoracic, and lumbar MRI show an isolated metastatic lesion involving the T9 vertebral body with moderate cord compression of the ventral spinal cord. At this stage what is the best treatment?

QID: 452
1

Change chemotherapy protocol to Cyclophosphamide, Hydroxydanurubicin, Oncovin, Prednisone

1%

(10/1565)

2

Posterior spinal decompression after vertebral body kyphoplasty

5%

(82/1565)

3

Thoracic corpectomy, instrumented spinal fusion, and postoperative radiotherapy

82%

(1276/1565)

4

Radiation therapy

11%

(174/1565)

5

Palliative care unit

1%

(15/1565)

L 1 B

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(OBQ08.204) A 67-year-old retired male custodian complains of progressively worsening low back pain over the past 6 months. He has not seen a doctor in the past 15 years. He admits to a 40 pack year smoking history, fatigue, and an unintentional 15 pound weight loss over the past year. A radiograph of the pelvis is provided in Figure A. Which of the following would most likely confirm the diagnosis?

QID: 590
FIGURES:
1

Urine immunoelectrophoresis (UPEP)

13%

(208/1613)

2

Thyroid biopsy

1%

(11/1613)

3

CBC and blood smear

3%

(49/1613)

4

Prostate biopsy

81%

(1302/1613)

5

Renal ultrasound

2%

(36/1613)

L 2 B

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(OBQ05.207) A 59-year-old female presents with a metastatic spinal tumor and has a lytic lesion in the T12 vertebral body. The process of bone resorption in her lytic lesion is mediated by

QID: 1093
1

Direct resorption of bone by tumor cells

2%

(23/1033)

2

Neoangiogenesis of the vertebral body

1%

(15/1033)

3

Macrophage-mediated bony destruction

6%

(66/1033)

4

Tumor induced activation of osteoclasts

89%

(915/1033)

5

Necrosis of the vertebral body

1%

(8/1033)

L 1 D

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