PRISE EN CHARGE CHIRURGICALE DES LESIONS METASTATIQUES OSSEUSES. Dr Frédéric ZADEGAN Praticien Hospitalier Service Orthopédie LARIBOISIERE

PRISE EN CHARGE CHIRURGICALE DES LESIONS METASTATIQUES OSSEUSES Dr Frédéric ZADEGAN Praticien Hospitalier Service Orthopédie LARIBOISIERE

Contexte!! Cancer du sein: grand pourvoyeur de lésions secondaires osseuses: 8% des localisations secondaires, 69% chez patients ayant une maladie avancée!! Affinité particulière pour le rachis: 2/3 des locations osseuses secondaires, 1/3 symptomatiques (douleur, neurologique, instabilité)!! Maladie chronique: efficacité du traitement médical!! Evolution du traitement avec progrès des traitements médicaux, augmentation de la survie!! Chirurgie palliative pour encore combien de temps?

Place de la chirurgie

!! Chirurgie + radiothérapie VS Radiothérapie seule!! Programme chirurgical lourd: décompression circonférentielle!! Sélection des malades +++!! Malades ambulatoires après traitement:!! Groupe chirurgie: 84%!! Groupe radiothérapie: 57%!! Comparaison des 2 taux (Cochran Mantel Haenszel): p 0,001, OR: 6,2 (95%, CI: 2-19,8)!! Capacité à marcher: 122 jours (chirurgie) vs 13 jours p=0,0017!! Dans le groupe de malades marchant avant le traitement:!! 94% continue à marcher dans le groupe chirurgie!! 74% dans le groupe radiothérapie!! Analyse multivariée: chirurgie (p=0,0048), score Frankel (p=0,016), cancer du sein (p=0,029) associés à une durée maximale de malade ambulatoires

!! Analyse appariées comprenant 11 facteurs pronostics potentiels!! 324 patients!! Haut niveau de preuve!! 122 patients traités pour compression médullaire entre 2000 et 2009 par chirurgie décompressive + radiothérapie ont été revus retrospectivement!! Appariement avec 2 patients issus d une cohorte de 2 296 patients traité par radiothérapie seule!! Appariement selon 11 critères

!! Après traitement:!! 69% des patients du groupe chirurgie restent ambulatoire!! 68% du groupe radiothérapie le restent!! P:0,99!! Parmi les patients non ambulatoires avant le traitement!! 30% ont récupéré dans le groupe chirurgie!! 26% dans le groupe radiothérapie p!! p:0,86

3 Situations!! Lésions diaphysaires pré-fracturaires ou fracturaires!! Lésions péri-articulaires!! Lésions rachidiennes

Lésions diaphysaires!! Pré-fracturaires:!! Douleur, impotence fonctionnelle!! Bilan radiologique concordant!! Envisager une stabilisation chirurgicale rapide pour éviter l événement fracturaire

Lésions diaphysaires!! Fracture pathologique: LA RECONNAÎTRE!! Douleur avant la fracture!! Contexte néoplasie!! Ostéolyse!! Mécanisme faible énergie!! Prise en charge adaptée en urgence!! Chirurgie de stabilisation simple

Lésions péri-articulaires!! Lésions épiphysaires ou métaphysaires!! Potentielle indication à une chirurgie prothétique!! Avantages:!! Appui immédiat!! Chirurgie quasiment carcinologique!! Inconvénient:!! Délai de récupération parfois plus long!! Problème si infection secondaire!! Compétence chirurgicale

Lésions rachidiennes!! Situation délicate!! Objectif premier: éviter l événement neurologique!! Objectif secondaire: soulager les douleurs et carcinologique!! Méfiance face à des douleurs rachidiennes (surtout thoracique) dans un contexte de néoplasie active!! Place de la chirurgie préventive!! Sélection des patients

Lésions rachidiennes!! Bilan radiologiques:!! TDM: tissu osseux, planification extension ostéolyse!!aspect MECANIQUE!! IRM rachis entier: parties molles, envahissement canalaire, radiculaire!!aspect NEUROLOGIQUE!!Les 2 examens sont indispensables pour la prise de décisions chirurgicales

Lésions rachidiennes!! Prise de décisions:!! Pas de déficit neurologiques: urgence relative!! RCP +++!! Echange d informations sur le patients!! Déficit neurologique: Evénement grave!! Décision prise souvent par téléphone!! Patients souvent mal évalués!! Maladie évoluée!! Tenter d orienter le patients vers les équipes avec lesquelles vous avez des liens et des habitudes: la décisions sera plus concertée

Lésion rachidiennes!! ANTICIPER!! EVITER L EVENEMENT NEUROLOGIQUE!! EVALUER LES MALADES!! PUIS RCP:!! Choix de la prise en charge!! Eventail de possibilités chirurgicales selon situation du patient!! Cimentoplastie, associées à une fixation percutanée!! Libération simple!! Libération et fixation postérieure!! Chirurgie d éxérèse circonférentielle

Lésions rachidiennes!! Comment sélectionner les patients? The Oncologist 3/;-)N4*&)$)OP 12/ 3456 7-'"/8)-90 :##-)'&2 () (2/ 1-/'("/*( ), 6#%*'$ 5/('+('(%& 1;")-+!<=: <:>7?@A 'A/ B:C!B DE @>F!3A /?@!G <!6A H F@?11 IE G4JA & 5!GK:?< BE 61>FF<?7!?<BA L =46K!=: =:5:B:A & 5:@M KE F!<6M= 'A/ Departments of a Neurosurgery, b Radiology, c Radiation Oncology, and d Rehabilitation Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA; e Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA Disclosures of potential conflicts of interest may be found at the end of this article.!"#$%!&$ Background. Spinal metastases frequently arise in patients with cancer. Modern oncology provides numerous treatment options that include effective systemic, radiation, and surgical options. We delineate and provide the evidence for the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which is used at Memorial Sloan-Kettering Cancer Center to determine the optimaltherapyforpatientswithspinemetastases. Methods. We provide a literature review of the integral publications that serve as the basis for the NOMS framework and report the results of systematic implementation of the NOMSguided treatment. Results. The NOMS decision framework consists of the neurologic, oncologic, mechanical, and systemic considerations and incorporates the use of conventional external beam radiation, spinal stereotactic radiosurgery, and minimally invasive and surgical literature that examine the outcomes of treatment of spinal metastatic tumors provides support for the NOMS decision framework. Application of the NOMS paradigm integrates multimodality therapy to optimize local tumor control, pain relief, and restoration or preservation of neurologic function and minimizes morbidity in this often systemically ill patient population. Conclusion. NOMS paradigm provides a decision framework that incorporates sentinel decision points in the treatment of spinal metastases. Consideration of the tumor sensitivity to radiation in conjunction with the extent of epidural extension allows determination of the optimal radiation treatment and the need for surgical decompression. Mechanical stability of the spine and the systemic disease considerations further help determine the need and the feasibility of surgical

Lésions rachidiennes!! NOMS!! Neurologique: degré d extension épidural, signes neurologiques!! Oncologique: Pronostic, agressivité, ligne de traitement, radiosensibilité!! Mécanique: extension ostéolyse, statique rachidienne, déformation, ostéoporose!! Systémique: âge, comorbidités (CP ischémique, diabète), anticoagulant, effets secondaires chimiothérapie (NFS, TP, TCA)

Objective. The evolution of imaging techniques, along with highly effective radiation options has changed the way metastatic epidural tumors are treated. While high-grade epidural spinal cord compression (ESCC) frequently serves as an indication for surgical decompression, no consensus exists in the literature about the precise definition of this term. The advancement of the treatment paradigms in patients with metastatic tumors for the spine requires a clear grading scheme of ESCC. The degree of ESCC often serves as a major determinant in the decision to operate or irradiate. The purpose of this study was to determine the reliability and validity of a 6-point, MR imaging based grading system for ESCC. Methods. To determine the reliability of the grading scale, a survey was distributed to 7 spine surgeons who participate in the Spine Oncology Study Group. The MR images of 25 cervical or thoracic spinal tumors were distributed consisting of 1 sagittal image and 3 axial images at the identical level including T1-weighted, T2-weighted, and Gd-enhanced T1-weighted images. The survey was administered 3 times at 2-week intervals. The inter- and intrarater reliability was assessed. Lésions rachidiennes!! Evaluation neurologique: J Neurosurg Spine 13:324 328, 2010 Reliability analysis of the epidural spinal cord compression scale Clinical article MARK H. BILSKY, M.D., 1,2 ILYA LAUFER, M.D., 2 DARYL R. FOURNEY, M.D., F.R.C.S.C., 3 MICHAEL GROFF, M.D., 4 MEIC H. SCHMIDT, M.D., 5 PETER PAUL VARGA, M.D., 6 FRANK D. VRIONIS, M.D., M.P.H., PH.D., 7 YOSHIYA YAMADA, M.D., 8 PETER C. GERSZTEN, M.D., 9 AND TIMOTHY R. KUKLO, M.D., J.D. 10 Departments of 1 Neurosurgery and 8 Radiation Oncology, Memorial Sloan Kettering Cancer Center; 2 Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York; 4 Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; 5 Department of Neurosurgery, University of Utah, Salt Lake City, Utah; 7 Department of Neurosurgery, H. Lee Moffitt Cancer Center, Tampa, Florida; 9 Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 10 Department of Orthopaedics, Washington University, St. Louis, Missouri; 3 Department of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and 6 Department of Orthopaedics, National Center of Spinal Disorders, Budapest, Hungary

indicated bone involvement only; 1, epidural impingement; 2, spinal cord compression but CSF visible; and 3, spinal cord compression but no CSF seen. Based on the need to further delineate epidural impingement for SRS purposes, the Grade 1 category was subdivided into Grades 1a c where 1a indicated epidural impingement but no deformation of the thecal sac; 1b, deformation of the thecal sac, but without spinal cord abutment; and 1c, deformation of the thecal sac with spinal cord abutment, but without compression (Figs. 1 and 2). Lésions rachidiennes scale ranged between fair and good (0.569 0.665) during the 3 iterations of the survey. While the ICC ranged between poor and good for the T1-weighted images with or without contrast administration (0.395 0.633), the ICC for T2-weighted images yielded superior results ranging from good to excellent (0.701 0.782). The intrarater reliability ranged between good and excellent (0.619 0.819), with T2-weighted images resulting in excellent correlation during both comparisons. Furthermore, the confidence intervals of the T1-weighted images without contrast and FIG. 1. Schematic representation of the 6-point ESCC grading scale. A grade of 0 indicates bone-only disease; 1a, epidural impingement, without deformation of the thecal sac; 1b, deformation of the thecal sac, without spinal cord abutment; 1c, deformation of the thecal sac with spinal cord abutment, but without cord compression; 2, spinal cord compression, but with CSF visible around the cord; and 3, spinal cord compression, no CSF visible around the cord. J Neurosurg: Spine / Volume 13 / September 2010 325

FIG. 2. Axial T2-weighted MR images representing progressive grades of ESCC. M. H. Bilsky et

tumor histologies include breast, prostate, ovarian, and neuroendocrine carcinomas. Renal, thyroid, hepatocellular, colon, and non-small cell lung carcinomas, sarcoma, and cinoma, with a durability of 1 3 months [16]. Katagiri et al. showed a 33% success rate in treating radioresistant histologies[11]. This is due to limitation of cebrt in delivering tumori- Lésions rachidiennes!! Evaluations oncologiques:!! Pronostic!! Agressivité!! Ligne de traitement!! Radiosensibilité Laufer, Rubin, Lis et al. +"89' :; Summary of expected radiation response based on histology 6),#< =<->0%-"? &'-$(%-"? -<'9%-" @.'"&) A.%&)")' 6".B%-" C'9"(%-" 4"&).%$()'&)$("9 D67=7!'("9 Gilbert et al. [8] F F U U U U U U Maranzano et al. [9] F F F U U U U U Rades et al. [13] F I I I U I U I Rades et al. [12] F F F U U U U U Katagiri et al. [11] F F F U U U U U Maranzano et al. [10] F F F U U U U U Rades et al. [14] F I I I U I U I Adapted from [7]. Abbreviations: F, favorable; I, intermediate; NSCLC, non-small cell lung cancer; U, unfavorable. 747

OLUME 29 NUMBER 22 AUGUST 1 2011 Lésions rachidiennes OURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T!! Evaluation mécanique: Spinal Instability Neoplastic Score: An Analysis of Reliability and Validity From the Spine Oncology Study Group Daryl R. Fourney, Evan M. Frangou, Timothy C. Ryken, Christian P. DiPaola, Christopher I. Shaffrey, Sigurd H. Berven, Mark H. Bilsky, James S. Harrop, Michael G. Fehlings, Stefano Boriani, Dean Chou, Meic H. Schmidt, David W. Polly, Roberto Biagini, Shane Burch, Mark B. Dekutoski, Aruna Ganju, Peter C. Gerszten, Ziya L. Gokaslan, Michael W. Groff, Norbert J. Liebsch, Ehud Mendel, Scott H. Okuno, Shreyaskumar Patel, Laurence D. Rhines, Peter S. Rose, Daniel M. Sciubba, Narayan Sundaresan, Katsuro Tomita, Peter P. Varga, Luiz R. Vialle, Frank D. Vrionis, Yoshiya Yamada, and Charles G. Fisher liations appear at the end of. January 16, 2011; accepted 11; published online ahead of w.jco.org on June 27, 2011. closures of potential conflicts nd author contributions are e end of this article. ing author: Daryl R. Fourney, FACS, Associate Professor of ry, Director, Neurosurgery Resiing Program, University of an, Royal University Hospital, al Dr, Saskatoon, Saskatchewan, 0W8; e-mail: daryl.fourney@ A B S T R A C T Purpose Standardized VOLUME indications 29 NUMBER for treatment 22 AUGUSTof1tumor-related 2011 spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, JOURNAL intraobserver OFreliability, CLINICAL and ONCOLOGY predictive validity of the O RSpinal I G Instability N A L Neoplastic R E P O RScore T (SINS). Methods Clinical and radiographic data from 30 patients with spinal tumors were classified as stable, potentially unstable, and unstable by members of the Spine Oncology Study Group. The median category for each patient Spinal case (consensus Instabilityopinion) Neoplastic was Score: used asan theanalysis gold standard of Reliability for predictive validity testing. On two occasions at least 6 weeks apart, each rater also scored each patient using and Validity From the Spine Oncology Study Group SINS. Each total score was converted into a three-category data field, with 0 to 6 as stable, 7 to Daryl R. Fourney, Evan M. Frangou, Timothy C. Ryken, Christian P. DiPaola, Christopher I. Shaffrey, 12 as potentially unstable, Sigurd andh. 13 Berven, tomark 18 H. asbilsky, unstable. James S. Harrop, Michael G. Fehlings, Stefano Boriani, Dean Chou, Meic H. Schmidt, David W. Polly, Roberto Biagini, Shane Burch, Mark B. Dekutoski, Aruna Ganju, Results

Spinal Instability Neoplastic Score SINS Component Table 1. SINS Score Location Junctional (occiput-c2, C7-T2, T11-L1, L5-S1) 3 Mobile spine (C3-C6, L2-L4) 2 Semirigid (T3-T10) 1 Rigid (S2-S5) 0 Pain Yes 3 Occasional pain but not mechanical 1 Pain-free lesion 0 Bone lesion Lytic 2 Mixed (lytic/blastic) 1 Blastic 0 Radiographic spinal alignment Subluxation/translation present 4 De novo deformity (kyphosis/scoliosis) 2 Normal alignment 0 Vertebral body collapse 50% collapse 3 50% collapse 2 No collapse with 50% body involved 1 None of the above 0 Posterolateral involvement of spinal elements Bilateral 3 Unilateral 1 None of the above 0 NOTE. Data adapted. 14 Abbreviation: SINS, Spinal Instability Neoplastic Score. Pain improvement with recumbency and/or pain with movement/loading of spine. Facet, pedicle, or costovertebral joint fracture or replacement with tumor. An evidence-based process using the best available literature and Table 2. Patient Cases Level Stable Potentially Unstable Unstable Total Score de 0 à 18 Cervical 3 2 5 10 Thoracic 2 5 3 10 Lumbar 3 3 4 10 Total 0 à 6: stabilité 8 10 12 30 NOTE. Final case series was selected to represent range of spinal levels and grades of stability. Stability was determined by anonymous voting by panel of experts (consensus opinion). 7 à 12: intermédiaire, instabilité potentielle A total of 50 de-identified patient cases were obtained. Patient cases that did 13 not contain à 18: sufficient instabilité history or quality imaging were excluded. To obtain a SINS score, the history must include a description of pain, especially as it relates to patient movement. Imaging must include computed tomography (CT) Un scan avis or magnetic chirurgical resonance imaging; est however, if it is the latter, x-ray films nécessaire (or preferably CT) pour are also required un score to determine > bone à lesion quality (ie, lytic, blastic, or mixed). In the case of multiple spinal lesions, contributors identified 7 the specific lesion they intended for scoring. Thirty patient cases were chosen, with roughly equal representation of cervical, thoracic, and lumbar spinal levels as well as a broad range of neoplastic instability (Table 2). Patient cases were classified as stable, potentially unstable, or unstable on the basis of anonymous voting by SOSG members. The median category for each patient case was termed the consensus opinion and was used as the gold standard for reference in the predictive validity analysis of SINS. Next, each SOSG member was provided with a CD-ROM that included the case series, a scoring sheet, and instructions on SINS scoring. Twenty-four members independently applied SINS in the 30 patient cases. Scoring was repeated at least 6 weeks later using the same patient cases, presented in different order. On the basis of preliminary analysis results and after further discussion among SOSG members, SINS was modified to improve reliability by simplifying the scoringmethodsothattheminimumscoreineachcategorywas0.inaddition, regions of the spine were defined more clearly: junctional levels were occiput-c2, C7-T2, T11-L1, and L5-S1; mobile levels were C3-6 and L2-4; semi-rigid spine was T3-T10; and rigid spine was S2-S5. On the basis of data from the evidence-based 12,13

Lésions rachidiennes!! Evaluation systémique:!! Tolérance du patient!! Risque de complications secondaires!! Tendance à surestimer ses patients et à minimiser l acte chirurgical

750 Treatment of Spinal Metastatic Tumors 3456% 72 Current NOMS decision framework 8%/0"6",($ 9#$"6",($ :%$;4#($46 <=+'%>($ *%$(+("# Low-grade ESCC no myelopathy Radiosensitive Stable cebrt Radiosensitive Unstable Stabilization followed by cebrt Radioresistant Stable SRS Radioresistant Unstable Stabilization followed by SRS High-grade ESCC myelopathy Radiosensitive Stable cebrt Radiosensitive Unstable Stabilization followed by cebrt Radioresistant Stable Able to tolerate surgery Decompression/stabilization followed by SRS Radioresistant Stable Unable to tolerate surgery cebrt Radioresistant Unstable Able to tolerate surgery Decompression/stabilization followed by SRS Radioresistant Unstable Unable to tolerate surgery Stabilization followed by cebrt Low-grade ESCC is defined as grade 0 or 1 on Spine Oncology Study Group scoring system [5]. High-grade ESCC is defined as grade 2 or 3 on the ESCC scale [5]. Stabilization options include percutaneous cement augmentation, percutaneous pedicle screw instrumentation, and open instrumentation. For patients with significant systemic comorbidities that affect the ability to tolerate open surgery, stabilization may be limited to cement augmentation and/or percutaneous screw augmentation. Abbreviations: cebrt, conventional external beam radiation; ESCC, epidural spinal cord compression; NOMS, neurologic, oncologic, mechanical, and systemic; SRS, stereotactic radiosurgery.

Radioresistant Unstable Able to tolerate surgery Decompression/stabilization followed by SRS Radioresistant Unstable Unable to tolerate surgery Stabilization followed by cebrt Low-grade ESCC is defined as grade 0 or 1 on Spine Oncology Study Group scoring system [5]. High-grade ESCC is defined as grade 2 or 3 on the ESCC scale [5]. Stabilization options include percutaneous cement augmentation, percutaneous pedicle screw instrumentation, and open instrumentation. For patients with significant systemic comorbidities that affect the ability to tolerate open surgery, stabilization may be limited to cement augmentation and/or percutaneous screw augmentation. Abbreviations: cebrt, conventional external beam radiation; ESCC, epidural spinal cord compression; NOMS, neurologic, oncologic, mechanical, and systemic; SRS, stereotactic radiosurgery..(,/0% 12 Schematic depiction of the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework. Abbreviations: cebrt, conventional external beam radiation; SRS, stereotactic radiosurgery.!"#!$%&'"#& Modern framework for treatment of metastatic spine tumors must emphasize durable tumor control while minimizing treatto provide a separation of the tumor from the spinal cord to optimize the radiation dose that can be safely delivered to the tumor volume. Minimizing the extent of surgical intervention makes surgery safer for the patients. Consideration of spinal stability,

Conclusions!! Chirurgie palliative!! Objectifs futurs:!! Apprendre à sélectionner!! Certains malades peuvent bénéficier de traitement agressif comme dans le cadre des métastases du rein ou de le thyroïde!! Utiliser toutes les procédures: cimentoplastie, ostéosynthèse percutanée!! Eviter les situations d urgence: fractures pathologiques, compressions médullaires