Abstract
Strategy means coordination of techniques and technicians facing a problem in which the solution is unclear and uncertain.
The only secured point is that there is no hope for curing the patient, and thus, his own opinion will have to be included in the decision making process.
Situations in which that question arises are extremely different from one case to the other and we will be able only to give our own guidelines.
In emergency, if a neurologic deficit occurs and increases, the goal is to decompress and limit the surgery to the most limited aggression and then to return to a more comfortable situation to take the proper decisions.
Elements to be taken in account
The vertebrae:
Situation is different according to the type of scattering.
Regional scattering accessible by a single approach ( similar if this scattering is associated to a second localization treatable by an isolated radiotherapy plus vertebroplasty if necessary) which is a situation closed to a single level metastasis, or general diffusion leading to a whole spine metastasis where radiotherapy plus general treatment if any are the only solutions. The schedule for these will be decided according to the risks of fracture or neurologic compression and the pain
The other localizations:
The whole question is about the potential risks induced by these. Bone fracture, brain oedema, hypoxemia, increased bleeding linked to liver incapacity.
The time to obtain a complete map of localizations is usually too long in these situations and therefore clinical situation should guide complementary exams to remain reasonable. When looking at the scoring of the patient with Tokuashi score When having no clinical significance, others metastases should be underscored and compared to the potential risk benefit comparison of surgery. One should not refuse surgery just because of a low Tokuashi grading since some surgeries like a two level cervical corpectomy through an anterior approach induces a minimal “cost” for the patient.
The cancer
Sometimes, the cancer is already known and the strategy has to be decided according to the treatments already done locally and in general (hormonotherapy, chemotherapy…). The primary response to these treatments is usually a good predictive key for the future. Depending on the expectable response to the other therapies, surgery could be the only technique that could help the patient or on the contrary only a second line technique if you may hope a good result from others.
In other cases, the metastases reveal the cancer. If no primary tumor can be easily found, the lesions should be treated first to ensure the best quality of life since it is known that the risk for a short life expectancy is high (same in case of a large lung cancer).
Conclusion In that goal multidisciplinary decision making process is the only way of offering these tools and finding the right order of use.
Participation of the patient in this decision is mandatory.
Theses abstracts were prepared by Professor Roger Lemaire. Correspondence should be addressed to EFORT Central Office, Freihofstrasse 22, CH-8700 Küsnacht, Switzerland.
