International Basic Neurosurgery

Course is designed for residents in

training and junior neurosurgeons.

Daniel M. Sciubba, MD, PhD,

Johns Hopkins University,
Department of Neurosurgery, School of Medicine

IBNC, March 14-18, 2014

 Spinal and other secondary
(metastasis) extradural tumors
Objectives:

1. Develop framework for managing metastatic spine disease

2. Review NOMS algorithm

IBNC, March 14-18, 2014

Neoplastic Disease

Extradural Intradural-Extramedullary Intramedullary

Gonzales R. 2002
Extradural Neoplasms
• Thecal sac migrates away from mass

• Narrowing of subarachnoid space above and

below lesion

Extradural
 T2WI

T2WI
Neoplastic Disease
I. Extradural
A. Metastases F. Giant Cell Tumor K. Chordoma
B. Myeloma G. Osteoid Osteoma L. Osteosarcoma
C. Lymphoma H. Osteoblastoma M. Chondrosarcoma
D. Hemangioma I. Eosinophilic Granuloma N. Osteochondroma
E. ABC J. Ewing’s Sarcoma

II. Intradural-Extramedullary
A. Nerve sheath tumors D. Lipoma
(Neurofibroma > Schwannoma) E. Epidermoid
B. Meningiomas F. Dermoid
C. Subarachnoid seeding
(Metastases)

III. Intramedullary
A. Ependymoma
B. Astrocytoma
C. Hemangioblastoma
Walker HS. Radiographics 1987;7(6):1129-1152.
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 Vertebral Metastases Epidemiology

• Currently, roughly 30% of patients with cancer develop

symptomatic spinal metastases during the course of their
illness.
• Up to 90% of cancer patients possess metastatic lesions
within the spine at the time of death.
• With advances in the treatment of systemic oncologic
disease, patient survival has increased over the last few
decades.
Spine Surgery Experience
(1993-2010)

• Approximately 3500 spine tumor operations

– Metastatic - 91%
– Primary – 9%
Case Review - Options for Therapy
■ Chemo-, Immuno-, Hormonal Therapy

■ RT
Conventional EBRT (30 Gy in 10 fractions)
Hypofractionated RT (eg. 27 Gy in 3 fractions)
Single Fraction Stereotactic Radiosurgery (eg 24 Gy
single fraction)

■ Surgery
Kyphoplasty
Percutaneous Pedicle Screws
Open: Anterior, Posterolateral, Combined
Minimally Invasive, En bloc resection
 What are the most important factors in evaluating a spine
tumor patient?
• Neurologic

• Oncologic

• Mechanical

• Systemic

NOMS (Bilsky et al)

12
50 yo M s/p nephrectomy for RCC now
with new back pain & thigh parasthesias
50 yo M s/p nephrectomy for RCC now
with new back pain & thigh parasthesias
Neurologic
• Ambulation/Weakness/Paralysis

• Bowel and bladder function

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 Management of Metastatic Epidural
Spinal Cord Compression (MESCC)

1950’s-1980’s: laminectomy used to provide posterior

decompression of the spinal cord
Drawbacks:
• indirect decompressive procedure (given that most tumors are anteriorly
situated)
• increased risk of instability and pain given pre-excisting anterior disease
• less than 30% showed improvement in ambulation
• more than 70% of patients eventually became paralyzed
Results of Treatment for Spinal Cord Compression:
Posterior decompressive laminectomy alone
Results of Year
Authors Treatment
Patients (n)for Spinal Cord
% success
barron et al. 1959 38 29
Compression:
Wild & Porter 1963 22 26
Wright 1963 21 14
Radiotherapy
Brice & McKissock.
Smith
1965 Alone
1965
139
52
32
25
Auld & Buerman 1966 41 42
Hall & MccKay 1973 129 30
Livingston & Perrin 1978 100 58
Baldini et al. 1979 140 30
Dunn et al. 1980 104 33
Stark et al. 1982 32 16
Findlay 1987 80 24
Sorensen et al. 1989 105 34

Mean 30% 30%

Results of Treatment for Spinal Cord Compression:
Radiotherapy Alone
Authors Year Patients (n) % improved
Mones et al. 1966 41 34
Khan et al. 1967 82 41
Posner 1977 75 47
Cobb et al. 1977 18 50
Gilbert et al. 1977 170 49
Greenberg et al. 1980 83 57
Stark et al. 1982 32 35
Constans et al. 1983 108 39
Martenson et al. 1984 42 64
Ruff & Lanska 1985 41 73
Sorensen et al. 1990 149 38
Maranzano 1995 209 76
Mean - 47
Total 996
Results of Treatment for Spinal Cord Compression:
Vertebral Body Resection and Stabilization

% improved % improved %
Authors Year Patients (n) Motor Pain Mortality
Slatkin and Posner 1982 29 56 60 7
Harrington 1984 52 65 80 6
Siegal and Siegal 1985 61 80 91 6
Sundaresan et al. 1985 101 70 85 8
Onimus et al. 1986 36 72 97 6
Perrin & McBroom et al. 1987 21 95 90 5
Moore & Uttley 1989 26 62 71 30
Sundaresan et al. 1991 54 100 90 6
Hall & Webb 1991 15 86 - 20
Fidler 1994 18 93 94 20
Hosono et al. 1995 90 81 94 0
Gokaslan et al. 1998 72 78 92 3
Mean 76 85 10
Total 575
Sciubba et al., 2005
 Patchell et al., 2005

• Randomized, prospective trial comparing results of standard

radiation therapy (XRT) to decompressive surgery plus XRT
for treatment of metastatic epidural spinal cord compression
(MESCT)

• Primary endpoint - ambulation status

• Surgical + XRT group was found to have:
– Greater maintenance of ambulation post op
– More patients regaining ambulation post op
– Greater maintenance of continence post op
– More patients regaining continence post op
– Lower requirements for opioids and corticosteroids
– Greater survival
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Oncologic
• Radiation Sensitivity

• Survival

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Radiation/Chemo Sensitivity
Metastatic Spinal Tumors

• Very Sensitive • Not Sensitive

– Lymphoma – Colon
– Myeloma – Renal Cell
– Small Cell Lung – Melanoma
• Sensitive – Sarcoma
– Breast – Squamous/Adeno (Lung)
– Prostate
– Thyroid
NOMS N: ESCC O: Radiation Sensitivity

Radiation Tumor
0 1
Sensitivity Histology

Sensitive Myeloma
Lymphoma
Moderately
Sensitive Breast
2 3 Moderately
Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma
NOMS N: ESCC O: Radiation Sensitivity
Radiation Tumor
0 1 Sensitivity Histology

Sensitive Myeloma
Lymphoma
Moderately
Sensitive Breast
Moderately
2 3 Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma

cEBRT
30 Gy in 3 Gy/fraction
Radiosensitive Tumor
Multiple Myeloma

300 cGy x 8

7/22/08 7/31/08
NOMS N: ESCC O: Radiation Sensitivity
Radiation Tumor
0 1 Sensitivity Histology

Sensitive Myeloma
Lymphoma
Moderately
Sensitive Breast
Moderately
2 3 Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma

SRS
 Stereotactic Radiosurgery
High-dose Conformal Photons

Image-guided Intensity Modulated RT: IGRT

Novalis
Trilogy
Tomotherapy
Cyberknife

0 1
 Radioresistant Tumor

11/4/11 12/12/11 2/16/12

• 77F T12 RCC metastasis, radicular pain
• 24 Gy single-fraction SRS
• Resolution of radicular pain within 2 weeks of SRS, f/u MRI
significant reduction in tumor size
NOMS N: ESCC O: Radiation Sensitivity
Radiation Tumor
0 1 Sensitivity Histology

Sensitive Myeloma
Lymphoma
Moderately
Sensitive Breast
Moderately
2 3 Resistant Colon
NSCLC
Highly
Resistant Thyroid
Renal
Sarcoma
Melanoma

Surgery + SRS
 Median Survival (Months)
Metastatic Tumors
• Lung Ca 4
• Melanoma 4
• Sarcoma 8-12
• Renal Ca >12
• Breast Ca
24-36
• Prostate Ca
• Thyroid Ca >48
• Lymphoma/Myeloma >48
>60

34
Mechanical
Pain

Deformity

Neurological Deficit

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SINS: Spine Instability Neoplastic Scale

Stable 0-6 pts

Potentially unstable 7-12 pts
Unstable 13-18 pts

Spine, June18 2010

SINS: Spine Instability Neoplastic Scale

Instability points 3 pts

SINS: Spine Instability Neoplastic Scale

Instability points 6 pts

SINS: Spine Instability Neoplastic Scale

Instability points 8 pts

SINS: Spine Instability Neoplastic Scale

Instability points 8 pts

SINS: Spine Instability Neoplastic Scale

Potentially Unstable 9 pts

Systemic & Medical Co-morbidities

Overall survival

Ability to undergo surgery, radiation and/or chemotherapy

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 NOMS
High-grade spinal cord compression (N) from radioresistant tumors (O) or
mechanical instability (M)
= surgery followed by radiation

Minimal or no spinal cord compression (N) and stable (M) are treated with radiation
therapy

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Surgical Options
• Laminectomy?

• Anterior Decompression and Fusion?

• Posterior Decompression and Fusion?

• Combined Anterior-Posterior?

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Minimally invasive an option?

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Vascular Metastatic Lesions

• Renal Cell Carcinoma*

• Thyroid Cancer (Follicular) *
• Hepatocellular Cancer *
• Pheochromocytoma *
• Melanoma
• Sarcoma *
• Hemangiopericytoma *
• Myeloma
Pre-operative
embolization

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 Stereotactic Radiation

Spinal Cord dose kept under 10 Gy

NOMS Review

 Gross instability +/- high grade cord compression from solid tumors
= surgical decompression and stabilization

 Minimal epidural tumor extension and no/minimal instability =

radiosurgery/EBRT

 Standard approaches can be modified:

 MIS, MAS, separation surgery
Thank you