Spine metastasis

1. SPINE -METASTSIS
DR. MANISH AGRAWAL
Moderator : DR. Amol Rege
Deenanath Mangeshkar hospital & research centre.

2. SPINE IS MOST COMMON SITE FOR METASTSIS
IN SKELETON ( metastasis 40 times more common than primary
tumors of spine )
( MOST COMMON SITE IS THORACIC SPINE )
MOST COMMON SITES FROM WHERE METASTSIS OCCURS
-BREAST
-LUNG
-PROSTATE
-THYROID
-MELANOMA
-MYELOMA
-LYMPHOMA
-CLORECTAL CANCER

3. ROUTES OF SPREAD:
BREAST
THYROID BY ARTERIAL ROUTE
RENAL
PROSTATE
BLADDER BY BATSON’S PLEXUS
PELVIC TUMOR
RETROPERITONEUM DIRECT SPREAD

4. CLINICAL FEATURES:
PAIN
NEUROLOGICAL INVOLVEMENT
-Motor weakness
Sensory blunting

5. INVESTIGATIONS :
1. BLOOD –
- Anemia
- Thrombocytopenia
- Increase LDH/ U. acid / Sr. cal/ ALP/ Acid Phosphatase
(Prostate)/ TFT
- Serum markers – CEA/CA 125/PSA

6. 1. XRAYS – Bone Mets can be LYTIC – kidney, melanoma ,
BLASTIC – Prostate , Bronchial Carcinoids,
MIXED – Breast , Git , Lung, Thyroid
Winking awl –Lysis of pedicle, seen on AP view X-rays
2. CTSCAN – Allows Visualization of even small area of vertebral
destruction,
3. MRI SCAN – Can evaluate soft tissue mass , neural elements , multiple
level of involvement
Characteristics – hypointense on T1, enhancement on T2
4. BONE SCAN – Most sensitive , gives multiple level of involvement
without clarifying level
5. BIOPSY – CT guided biopsy

7. MANAGEMENT
FACTORS TO BE ASSESSED FOR MANAGEMENT
1. BIOLOGY OF TUMOR
. Small cell lung carcinoma
. Choriocarcinoma RADIOSENSITIVE
. Breast carcinoma
. Colon cancer
. Non small cell lung cancer Mod. RADIORESISTANT
. Rcc
. Melanoma RADIORESISTANT
- High grade malignant lesion with rapid progressive destruction
require early surgery

8. 2. NEUROLOGICAL :
. Extent of involvement
. Exact level and direction of compression
. Fracture compression or isolated cord compression
. Staging of epidural extension BY WEINSTEIN BORIANI BIAGINI SYSTEM
3. MECHANICAL PAIN :
. Whether spine is stable /unstable
4. SYSTEMIC CONSIDERATIONS :
. Systemic tumor Burdon
. Life Expectency
. General medical condition

9. TREATMENT
1. MEDICAL - Chemotherapy
- Hormone therapy
- Bisphosphonates
2. RADIOTHERAPY
3. OPERATIVE

10. METHODS OF EVALUATION :
1. MODIFIED TOKUHASHI SCORING SYSTEM
2. TOMITA SURGICAL STAGING
3. KARNOFSKY PERFORMANCE STATUS

11. REVISED TOKUHASHI PROGNOSTIC SCORE
CRITERIA 0 1 2
1.Karnofsky’s
Performance Poor 10-40 Modertae 50-70 Good 80-100
2. Extraspinal
Bony metastasis > 3 1- 2 0
3.Vertebral metastasis > 3 2 1
4. Visceral metastasis Unremovable removable none
5. Spinal cord palsy complete incomplete none
Frankle A,B Frankle C,D Frankle E
6. Primary site score Total score 0-15
Of tumor 0 – lung score 12-15 - surgery
1 - liver score 9-11 - palliative surgery
2 - uterus , unknown score less - conservative
3 - kidney or equal to 8 management
4 - rectum
5 - breast

12. MODIFIED FRANKLE CLASSIFICATION OF NEUROLOGICAL FUNCTION :
GRADE DISCRIPTION
A No motor or sensory function
B Preserved sensation only , no motor function
C Nonambulatory , wheelchair bound , some motor function
D Ambulatory but with neurological function
E Normal neurological function

13. KARNOFSKY PERFORMANCE STATUS SCALE CRITERIA ;
80-100% - Able to carry on normal activity
50-70% - Unable to work, able to live at home and care for most personal needs
0-40% - Unable to care for self , requires hospital care ,

14. TOMITA’S SURGICAL STAGING SYSTEM :
Based on only three parameters –
1. Degree of malignancy
2. Presence of visceral metastasis
3. Presence of bony metastasis

17. RADIOTHERAPY :
- Pain relief
- Reduces tumor bulk
- Post fixation irradiation
- Pts with contraindication for surgery
Doses :
- 5 fractions of total doses of 20 Gy
- 10 fractions of total doses of 30 Gy
- Recent studies says 1 fraction of 8 Gy is also equally effective as multiple settings.