Yonsei Med J.  2009 Oct;50(5):689-696. 10.3349/ymj.2009.50.5.689.

Survival Rate and Neurological Outcome after Operation for Advanced Spinal Metastasis (Tomita's Classification > or = Type 4)

• Kwon YM
• Kim KS
• Kuh SU
• Chin DK
• Jin BH
• Cho YE

• KMID: 1103824
• DOI: http://doi.org/10.3349/ymj.2009.50.5.689

Abstract

PURPOSE
We investigated whether primary malignancy entities and the extent of tumor resection have an effect on the survival rate and neurological improvement in patients with spinal metastases that extend beyond the vertebral compartment (Tomita's classification > or = type 4). MATERIALS AND METHODS: We retrospectively reviewed 87 patients with advanced spinal metastasis who underwent surgery. They were divided into groups 1 and 2 according to whether they responded to adjuvant therapy or not, respectively. They were subdivided according to the extent of tumor resection: group 1, gross total resection (G1GT); group 1, subtotal resection (G1ST); group 2, gross total resection (G2GT); and group 2, subtotal resection (G2ST). The origin of the tumor, survival rate, extent of resection, and neurological improvement were analyzed. RESULTS: Group 1 had a better survival rate than group 2. The G1GT subgroup showed a better prognosis than the G1ST subgroup. In group 2, the extent of tumor resection (G2GT vs. G2ST) did not affect survival rate. In all subgroups, neurological status improved one month after surgery, however, the G2ST subgroup had worsened at the last follow-up. There was no local recurrence at the last follow-up in the G1GT subgroup. Four out of 13 patients in the G2GT subgroup showed a local recurrence of spinal tumors and progressive worsening of neurological status. CONCLUSION: In patients with spinal metastases (Tomita's classification > or = type 4), individuals who underwent gross total resection of tumors that responded to adjuvant therapy showed a higher survival rate than those who underwent subtotal resection. For tumors not responding to adjuvant therapy, we suggest palliative surgical decompression.

Keyword

Bone neoplasm; decision making; metastasis; prognosis

MeSH Terms

Adolescent
Adult
Aged
Child
Combined Modality Therapy
Diagnostic Techniques, Neurological
Female
Humans
Male
Middle Aged
Neoplasm Recurrence, Local
Prognosis
Retrospective Studies
Spinal Neoplasms/mortality/*secondary/surgery
Survival Rate

Figure

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  Fig. 1 Comparison of the postoperative survival rate between groups 1 and 2. Kaplan-Meier survival curves of patients with spinal metastases in group 1 (breast cancer, thyroid cancer, hematopoietic malignancy, and prostate cancer) and group 2 (lung cancer, hepatocellular cancer, renal cell cancer, colon cancer, pancreas cancer, rectal cancer, etc) showed a significantly higher survival rate for patients in group 1 (p < 0.01).

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  Fig. 2 Comparison of the postoperative survival rate between gross total resection and subtotal resection subgroups of group 1. Kaplan-Meier survival curves revealed a significantly higher survival rate for patients who received gross total resection of tumor when compared with subtotal resection (p = 0.049).

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  Fig. 3 Illustration of a case of metastatic thyroid cancer involving the T9 vertebra. A 53-year-old female patient, who had severe back pain and paraparesis, underwent gross total resection of the tumor using an anterior and posterior combined approach and instrumentation. (A) T1-weighted MR axial image shows metastatic spinal tumor extended to the right paraspinal space (Tomita's classification type 5). (B) Preoperative bone scintigraphy image shows single metastatic lesion on T9. (C) Postoperative X-ray image shows posterior pedicle screw fixation after total T9 spondylectomy. The mesh cage was filled with polymethylmethacrylate. (D) Bone scintigraphy image taken 39 months after surgery shows resected T9 vertebra and ribs without recurrent lesion.

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  Fig. 4 Comparison of postoperative survival rate between gross total resection and subtotal resection subgroups of group 2. Kaplan-Meier survival curves show absence of statistical differences between patients who received gross total and subtotal resection of tumor (p = 0.115).

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  Fig. 5 Neurological grade assessed by conversion of Frankel's grade system to a point system. The neurological status of the G1GT and G2GT subgroups was significantly improved one month after surgery and at the last follow-up. In contrast, the G1ST and G2ST subgroups improved shortly after surgery but worsened at the time of last follow-up; in particular, the neurological status of the G2ST subgroup became even worse than at the preoperative stage. *Significantly improved neurological status when compared with the preoperative stage (p < 0.05). †Significantly worsened neurological status when compared with the preoperative stage (p < 0.05).

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