Xinghai Yang

Preoperative scoring systems and prognostic factors for patients with spinal metastases from hepatocellular carcinoma.

Study Design. A retrospective study had been conducted to compare the existing preoperative scoring systems and to find useful prognostic factors for patients with spinal metastases from hepatocellular carcinoma (HCC). Objective. To evaluate different preoperative scoring systems and prognostic factors for patients with spinal metastases from HCC. Summary of Background Data. Different scoring systems for metastatic spinal tumor have been designed for prognostic evaluation. However, these scoring systems were formulated from many different types of tumors, so that their efficacy for a certain type of cancer needs to be validated. Furthermore, some serologic test results may enhance the accuracy of the scoring system. Methods. We conducted a retrospective study to evaluate 4 prognostic scoring systems and factors in a series of 41 cases with spinal metastases from HCC in a single center. These scoring systems include Tokuhashi revised score, Tomita score, Bauer score, and a revised van der Linden score by the authors. Serologic test items including serum albumin, aspartate aminotransferase, alanine transaminase, and lactate dehydrogenase (LDH) were also evaluated. Results. The revised Tokuhashi scoring system provided statistically significant differences in survival time between different groups (P = 0.012), while the Tomita and Bauer systems did not show statistically significant differences (P = 0.918 and P = 0.754, respectively). Significantly improved survival was found in patients with good performance status and no visceral metastases (Group C, P = 0.008) in revised van der Linden scores. Univariate and multivariate analyses showed serum albumin and LDH were independent prognostic factors for survival time. Conclusion. Revised Tokuhashi scoring system is practicable and highly predictive, while serum albumin and LDH also have prognostic value in patients with spinal metastases from HCC, especially those without visceral metastases. More accurate prognosis may be obtained if the scoring systems include clinical and laboratory data in future.

Aneurysmal bone cyst secondary to giant cell tumor of the mobile spine: a report of 11 cases.

Study Design. A retrospective analysis was performed. Objective. To analyze the characteristics of aneurysmal bone cyst arising from giant cell tumor of the mobile spine and to discuss the outcome of corresponding surgical and nonsurgical treatment. Summary of Background Data. Giant cell tumors are generally benign neoplasms that exhibit aggressive behavior with a tendency to recur locally. Aneurysmal bone cysts are benign, highly vascular osseous lesions. Although both of them have been described separately in previous literatures, few reports have described aneurysmal bone cyst secondary to giant cell tumor of the mobile spine. Methods. Between January 2004 and December 2009, 11 patients were identified with an aneurysmal bone cyst arising from giant cell tumor of the mobile spine. Four patients underwent subtotal tumor resection followed by radiotherapy, and the other 7 patients underwent total tumor resection. Patients with lesions located below T6 were treated with selective arterial embolization before surgery. Clinical data and the efficacy of surgery were analyzed via chart review Results. Of the eleven patients identified for inclusion in this study, the average age was 33 months (range ∇ 14–65 months). The mean length of follow-up was 31 months. Seven patients kept disease-free during the follow-ups. The remaining four patients recurred and one died of local re-recurrence and lung metastasis. Conclusion. Unlike primary aneurysmal bone cyst, secondary aneurysmal bone cyst arising from giant cell tumor of the mobile spine has a more aggressive tendency to recurrence locally. Complete resection with systematic radiotherapy should be undertaken for the treatment of aneurysmal bone cyst secondary to giant cell tumor of the mobile spine, which is associated with a good prognosis for local tumor control. As complete or as radical an operation as possible should be performed at first presentation. The best chance for the patient is the first chance. Selective preoperative embolization is advised to minimize intraoperative blood loss.

Surgery and prognostic factors of patients with epidural spinal cord compression caused by hepatocellular carcinoma metastases: retrospective study of 36 patients in a single center.

Study Design. A retrospective study of 36 patients with metastatic hepatocellular carcinoma (HCC) of the mobile spine was performed by survival analysis. Objective. To discuss the factors that may affect outcomes of patients with HCC spinal metastases. Summary of Background Data. HCC is a rare tumor in Western countries. However, HCC is common in Far East (Taiwan, Korea, mainland China), where the hepatitis B virus is epidemic. As the mean survival time of patients with HCC has largely increased in recent years, it is now more common to encounter a patient with epidural spinal cord compression caused by HCC spinal metastases in clinic. Methods. The univariate and multivariate analyses of various clinical factors were performed to identify independent variables that could predict prognosis. The survival rate was estimated by the Kaplan-Meier method, and differences were analyzed by the log-rank test. Factors with P values of 0.1 or less were subjected to multivariate analysis for survival rate by multivariate Cox proportional hazards analysis. Results. A total of 36 patients with metastatic HCC of the mobile spine were included in the study. Age (⩽45 yr/>45 yr), duration of preoperative symptoms (<6 mo/≥6 mo), preoperative Frankel score (A–C/D–E), Tomita score (5–7/8–10), and bisphosphonate treatment were suggested as the potential prognostic factors through univariate analysis. However, as they were submitted to the multivariate Cox regression model, only Tomita score was found as an independent prognostic factor. Conclusion. Tomita score no more than 7 is a favorable prognostic factor for HCC metastases in the mobile spine. Level of Evidence: 4

Chondrosarcomas of the cervical and cervicothoracic spine: surgical management and long-term clinical outcome.

Study Design A retrospective review study. Objectives To estimate the clinical outcome of various resection protocols in patients with chondrosarcoma (CHS) at the challenging region of cervical and cervicothoracic spine (CCT). Summary of Background Data It is challenging to surgically manage CHS of the spine. Although total en-bloc resection has proven to be an ideal treatment, this option is not always feasible in the spine because of the constrains of critical neurovascular structures in the vicinity. Lesions at the CCT region pose even more difficulties, and few large clinical series concerning various protocols and long-term outcomes of these lesions exist at present. Methods Fifteen patients with CHS at the CCT region who underwent surgical management in our institute were retrospectively studied. Twelve piecemeal resections and 3 en-bloc resections were performed. Intraoperative local chemotherapy and postoperative cyberknife radiotherapy were given as adjuvant therapy. Neurologic status, local recurrence, distant metastasis, and treatment-related complications were evaluated. Results The mean follow-up time was 58.7 months (median 37 mo; ranging from 18 to 141 mo). Local recurrence was detected in 5 of 5 cases (100%) treated by intracapsular piecemeal resection, and in 1 of 7 cases (14.3%) treated by extracapsular piecemeal resection, whereas no recurrence was found in 3 cases treated by en-bloc resection. Of the 6 recurrent patients, 5 died of disease 24 to 46 months after present surgery, and the remaining patient was alive with disease in the final follow-up. There were no signs of recurrence in the remaining 9 patients. Conclusions For CHS at the CCT region, intralesional piecemeal resection has a poor prognosis and should be avoided. Oncologically, en-bloc resection remains the best form of disease management and should be the primary treatment of choice. For cases in which an uncontaminated en-bloc resection could not be achieved, the extracapsular piecemeal resection with adjuvant therapy including local chemotherapy and cyberknife radiotherapy is an effective and achievable option.

Sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal-posterior approach: surgical technique and results in 11 patients.

BACKGROUND Surgical treatment of C2 tumors remains challenging. Because of the deep location and unique anatomical complexity, anterior exposure in this region is considered difficult and dangerous, and few reports concerning anterior tumor resection and reconstruction exist. OBJECTIVE To describe a technique of sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal–posterior approach. METHODS Eleven patients with C2 tumors underwent sequentially staged tumor resection and 2-column reconstruction in our institute. Eight primary lesions and 3 metastases were involved. Tumor resections and anterior reconstructions with conventional constructs were accomplished by an anterior retropharyngeal approach, and occipitocervical fusions through posterior access were performed in the same anesthesia. RESULTS No operative mortality occurred in this series. All patients experienced pain relief and neurological improvement after surgery. Except for 1 incidence of screw pullout, which was corrected by revision surgery, solid fusion was achieved in all patients. A follow-up period of 12 to 37 months was available for this study. Two patients with chordoma relapsed; 1 died of disease, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases. No evidence of local recurrence was found in the other patients. CONCLUSION The anterior retropharyngeal approach is a favorable route to treat tumor lesions of the C2 vertebral body that allows tumor resection and placement of anterior constructs between C1 and the subaxial vertebral body. Tumor resection and 2-column reconstruction could safely be accomplished simultaneously through the combined anterior retropharyngeal–posterior approach.

Solitary plasmacytoma of cervical spine: treatment and prognosis in patients with neurological lesions and spinal instability.

Study Design. A consecutive series of 19 cases of solitary plasmacytoma (SP) of cervical spine that underwent surgical treatment and one case that underwent pure radiotherapy were observed from 1995 to 2006. Objective. To discuss the clinical characteristics, therapeutic methods and factors affecting prognosis of SP in the cervical spine. Summary of Background Data. SP of bone is a rare plasma cell tumor which represents the proliferation of monoclonal plasma cells without evidence of significant bone marrow plasma cell infiltration. Although radical radiotherapy is the treatment of choice for SP of the bone, recommendations for treatment methods of this disease have been solely based on limited data from retrospective studies. Methods. Data of 20 patients with SP of the cervical spine that were identified and treated between January 1995 and December 2006 were reviewed retrospectively. There were 13 men and 7 women ranging in age from 32 to 76 years with a mean of 56 years. Among them, 1 patient underwent radiotherapy alone, and the other 19 patients received surgery with adjuvant radiotherapy. According to the Weinstein-Boriani-Biagini staging system, the surgical procedures consisted of subtotal resection and gross-total resection. All cases were managed using an anterior approach or a combined anterior and posterior approach in 1 stage. Reconstruction of the cervical spine was achieved through an anterior cervical titanium plate and titanium mesh cage filled with autoiliac graft or bone cement, or anterior and posterior combined instrumented fusion. All surgery patients received radiotherapy as adjunctive therapy postoperatively. Results. Follow-up of the 20 patients ranged from 25 to 132 months with a mean of 61 months. Neck pains improved significantly, and motor or sensory deficits disappeared or improved in varying degrees after surgery. Neurologic function level of the patients improved by 1 to3 grades based on the Frankel grading system 3 months after surgery. All the internal fixations fused well, stability of the cervical vertebrae was secure, and no spinal instability was observed in our series. The bone graft fusion rate reached 100%. During the follow-up period, 4 surgery cases progressed to multiple myeloma (MM), in which 2 elderly patients died of respiratory and circulatory failure at 90 and 43 months, respectively. The other 15 patients achieved disease-free survival after surgery with adjunctive radiotherapy. No significant abnormity was detected on M protein, bone marrow aspiration, and emission computed tomography or positron emission tomography/computed tomography examinations. Conclusion. SP of the cervical spine is relatively rare, and no typical early symptoms are present. Gross total tumor resection or total spondylectomy by piecemeal manner with adjuvant radiotherapy can markedly reduce local recurrences and lower the possibility of progressing to MM. Patients with progression to MM should be treated with individualized chemotherapy, but the prognosis may be poor.

Combined Pre- and Retrovascular Extraoral Approach for Tumors at Lateral Mass of the Atlas

Study Design. A series of 9 patients surgically treated with a novel combined pre-and retrovascular extraoral approach to lateral mass of the atlas (LMA) is examined. Objective. To describe the efficacy of combined pre- and retrovascular extraoral approach in achieving a wide exposure and aggressive resection of tumors at the LMA. Summary of Background Data. The anatomic complexity and closeness to vital neurovascular structures raise technical difficulties in the surgical access to the LMA. Although various approaches, such as transoral approach, high anterior cervical approach, anterior lateral approach, and far lateral approach, have been reported in literature, wide exposure for the tumors at the LMA remains a unique challenge. Methods. For our experience in the surgical exposure of the upper cervical spine, we have developed a combined pre- and retrovascular extraoral approach to the atlas since 2001. Nine patients with neoplastic lesions at the LMA were surgically treated through this combined approach. Reconstruction of stability was achieved by a posterior occipitocervical fusion through a posterior approach under the same anesthesia. Results. This combined approach provided an excellent surgical field exposure to ensure the successful tumor resection while preventing the vertebral artery or nerve from injury. There was no operative mortality or severe morbidity in this series. Complications included 1 instance of transient dysphagia and 2 instances of transient trouble swallowing liquids. The symptoms of local pain and pharyngeal discomfort relieved, and patients suffering from spinal cord compression recovered well with 1 level of the Frankel scale when reevaluated 3 months after operation. With a follow-up period of 16 to 100 months, 1 patient with chondrosarcoma developed local recurrence at the 14th month of postoperation and died of respiratory and circulatory failure 39 months after surgery. No evidence of local recurrence was found in other patients. Conclusion. The combined pre- and retrovascular extraoral approach provides an advantageous alternative to previous reported approaches. For selected cases with tumor lesions at the LMA, this combined approach offers more benefits, through which a wide exposure with well-protected vertebral artery favoring radical excision could be achieved without complications normally associated with transoral surgery.

Recurrent upper cervical chordomas after radiotherapy: surgical outcomes and surgical approach selection based on complications.

Study Design. Retrospective review of a case series. Objective. To present and analyze our surgical results of recurrent chordomas in the upper cervical spine after radiotherapy and compare 2 surgical strategies. Summary of Background Data. Surgical treatment of recurrent chordomas in the upper cervical spine after radiotherapy is clinically rare but extremely challenging. No reports are found in the literatures focusing on the surgical results and strategies of such recurrent chordomas. Methods. Clinical data of 8 patients with recurrent chordomas in the upper cervical spine after radiotherapy were retrospectively reviewed. Results. Preoperative symptoms were relieved after our surgical procedures in 7 of the 8 patients. Total tumor removal was achieved in 6 of the 8 patients. Surgical complications mainly including cerebrospinal fluid leak and incision disunion were observed in 6 of the 8, and all the 3 patients after transoral operation had those complicated surgical complications, whereas the other 3 of the 5 patients after anterior retropharyngeal operation had relatively slighter complications. The disease free survival rates 1 year and 2 years after the surgery in this series were 50% and 12.5%, respectively, comparing with the general survival rates 1 year and 2 years after the surgery 87.5% and 37.5%. Conclusion. Revised surgery is effective for improving quality of life of patients with recurrent upper cervical chordomas after radiotherapy before further tumor recurrence. However, the prognosis of those patients is usually poor and surgical complications mainly including incision disunion and cerebrospinal fluid leak are common. To reduce the risk of surgical complications, anterior retropharyngeal approach may be superior to the transoral approach. Level of Evidence: N/A

Osteosarcoma of the spine: surgical treatment and outcomes

BackgroundThe goal of this study was to determine whether there are correlations between various options of surgical treatment and long-term outcome for spinal osteosarcoma.MethodsThis was a retrospective review of 16 patients with spinal osteosarcoma, who underwent surgical treatment from 1999 to 2010. Seven patients were given total en bloc spondylectomy (TES), while nine received piecemeal resection (there were seven cases of total piecemeal spondylectomy, one of sagittal resection, and one of vertebrectomy). The outcome and prognosis of the patients were evaluated, grouped by surgical treatment.ResultsAll 16 cases were followed for an average of 42.4 months. At follow-up, all patients noted that pain had eased or had gradually disappeared. Three months after surgery, eight patients (50.0%) had improved 1 to 2 grades in their neurological status, based on Frankel scoring. Six (37.5%) patients experienced local recurrence of the tumor, nine (56.3%) had metastases, and five (31.3%) died of the disease. Of the six patients who received a wide or marginal en bloc resection, none developed local recurrence or died from the disease. Conversely, of the ten patients who received intralesional or contaminated resections, six (60%) relapsed and five (50%) died from the disease.ConclusionsTES, with a wide margin, should be planned for patients with osteosarcoma of the cervical and thoracolumbar spine, whenever possible. When the patients are not candidates for en bloc resection, total piecemeal spondylectomy is an appropriate choice for osteosarcoma in the mobile spine.

Natural killer/T-cell nasal-type lymphoma: unusual primary spinal tumor.

Study Design. A natural killer/T-cell lymphoma originating in the spine of a 60-year-old man is first reported, along with a brief review of the literature on the topic. Objective. To describe the presentation and diagnosis of this disorder along with an emphasis on the importance of this type of rare tumor, needing early and accurate immunophenotypic profiling to make a right diagnosis. Summary of Background Data. Natural killer (NK)/T-cell lymphomas represent a rare type of lymphoma derived from either activated NK cell or rarely cytotoxic T cells. It usually originates in the nasal cavity/nasopharynx and invades the surrounding tissues, which is aggressive and, usually, a delay in diagnosis could result in a fatal outcome. Methods. A 60-year-old man presented with severe pain in his chest and back for 3 weeks and developed paralysis soon. After we got a negative result of lymphomatous from a bone marrow biopsy, we took a piecemeal excision of the 10th thoracic vertebra. Titanium mesh with bone cement filling-in and mass screw internal fixation system were used for reconstructing the stability of the spine. The histopathology was consistent with NK/T-cell lymphomas. Result. The condition of the patient became worse suddenly after he regained some strength in his both lower limbs a week after the operation. He was not suitable for any aggressive chemotherapy or radiation therapy because of his poor condition and died 20 days later. Conclusion. NK/T-cell lymphomas originated at other sites but nasal cavity/nasopharynx do not present typical clinical features and symptoms in the absence of lymphadenopathy. There are possibilities for misdiagnosis of NK/T-cell lymphoma that originates at other sites. The unfavorable prognosis of this tumor emphasized the need for novel molecular targets and more effective therapies.