Aims. With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values. Methods. We prospectively analyzed 101 patients with spinal metastases who underwent palliative surgery from 2013 to 2016. These patients were divided into two groups based on age (< 70 years and ≥ 70 years). The Eastern Cooperative Oncology Group (ECOG) performance status (PS), Barthel index (BI), and EuroQol-5 dimension (EQ-5D) score were assessed at study enrolment and at one, three, and six months after surgery. The survival times and complications were also collected. Results. In total, 65 patients were aged < 70 years (mean 59.6 years; 32 to 69) and 36 patients were aged ≥ 70 years (mean 75.9 years; 70 to 90). In both groups, the PS improved from PS3 to PS1 by spine surgery, the mean BI improved from < 60 to > 80 points, and the mean EQ-5D score improved from 0.0 to > 0.7 points. However, no significant differences were found in the improvement rates and values of the PS, BI, and EQ-5D score at any time points between the two groups. The PS, BI, and EQ-5D score improved throughout the follow-up period in approximately 90% of patients in each group. However, the improved PS, BI, and EQ-5D scores subsequently deteriorated in some patients, and the redeterioration rate of the EQ-5D was significantly higher in patients aged ≥ 70 than < 70 years (p = 0.027). Conclusion. Palliative surgery for spinal metastases improved the PS, activities of daily living, and quality of life, regardless of age. However, clinicians should be aware of the higher risk of redeterioration of the quality of life in advanced-age patients. Cite this article: Bone Joint J 2020;102-B(12):1709–1716

Surgical site infections following spinal surgery profoundly influence continued treatment, significantly impacting psychological and economic dimensions and clinical outcomes. Its reported incidence varies up to 20%, with the highest incidence amongst neuromuscular scoliosis and metastatic cord compression patients. We describe the first reported biphasic osteoconductive scaffold (Cerament G) with a logarithmic elution profile as a cumulative strategic treatment modality for adjacent spinal surgery infections. All patients who developed surgical site infections following instrumented fusion (May 2021-December 2021) had their demographics (age, sex), type and number of procedures, isolated organism, antibiotics given, comorbidities, and WHO performance status analysed. The infected wound was debrided to healthy planes, samples taken, and Cerament g applied. Thirteen patients were treated for deep SSI following spinal instrumentation and fusion procedures with intraoperative Cerament G application. There were four males and nine females with an average age of 40 ranging between 12 and 87. Nine patients underwent initial surgery for spinal deformity, and four were treated for fractures as index procedure. 77% of infections were attributable to MSSA and Cutibacteriousm acnes; others included Klebsiella, Pseudomonas and Streptococcus and targeted with multimodal cumulative therapy. A WHO performance score improved in 11 patients. In addition, there was no wound leak, and infection was eradicated successfully in 12/13 with a single procedure. This series shows the successful eradication of the infection and improved functional outcomes with Cerament G. However, the low numbers of patients in our series are an essential consideration for the broader applicability of this device

Aims

Advances in treatment have extended the life expectancy of patients with metastatic bone disease (MBD). Patients could experience more skeletal-related events (SREs) as a result of this progress. Those who have already experienced a SRE could encounter another local management for a subsequent SRE, which is not part of the treatment for the initial SRE. However, there is a noted gap in research on the rate and characteristics of subsequent SREs requiring further localized treatment, obligating clinicians to extrapolate from experiences with initial SREs when confronting subsequent ones. This study aimed to investigate the proportion of MBD patients developing subsequent SREs requiring local treatment, examine if there are prognostic differences at the initial treatment between those with single versus subsequent SREs, and determine if clinical, oncological, and prognostic features differ between initial and subsequent SRE treatments.

Aims

Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS.

Periarticular metastasis may be treated with endoprosthetic reconstruction. The extensive surgery required may not, however, be appropriate for all patients. Our aim was to establish if the outcome of locking plate fixation in selected patients with periarticular metastases. Prospective data collection was performed. Twenty one patients underwent surgery for periarticular metastatic tumours. The median duration of follow-up for surviving patients was one year. There have been no cases of implant failure and no requirement for revision surgery. Pain relief was excellent or good in the majority of patients. Patients who had sustained a fracture prior to fixation had restoration of their WHO performance status. All patients had a dramatic improvement in their MSTS scores. The median pre-operative score was 15% (0%-37%) improving to a median score of 80% (75% -96%) post operatively. Locking plates provide reliable fixation and excellent functional restoration in selected patients suffering from periarticular metastatic bone disease

A prospective study was performed to evaluate the efficacy and safety of percutaneous kyphoplasty in patients with osteolytic tumours of thoracic and lumbar spine. To our knowledge this is the only study so far that has followed a cohort of patients prospectively until death. Prospective study of patients with lytic tumours of spine treated with kyphoplasty. A total of 13 patients with osteolytic tumours of spine were treated with kyhpoplasty. There were 8 female and 5 male patients. The age range was 52-81 years with average age of 65 years. A total of 25 vertebrae, from T2 to L3, were treated. The types of tumours included; non-Hodgkin lymphoma (2), myeloma (2), gastric-carcinoma (1), cervix-carcinoma (1), breast-carcinoma (3), prostate-carcinoma (2), small cell lung-carcinoma (1), bladder-carcinoma (1). Outcome was assessed prospectively by visual analogue scale (VAS) for pain, ECOG performance status, walking distance, standing and sitting time. The preoperative average VAS was 7.5 (range: 2.6 – 10). This dropped to 3.0 five days postoperatively and remained below 5 for the duration of follow-up. Average walking distance, standing and sitting time and ECOG performance score showed improvement. The survival time ranged from 2 to 293 weeks. The average survival time was 82 weeks. All patients were able to return home following the procedure. No patient required reoperation or readmission for spinal metastasis. Kyphoplasty is a suitable palliative treatment option for patients with advanced metastatic disease of the spine

Endoprosthetic replacement is often the preferred treatment for neoplastic lesions as internal fixation has been shown to have a high failure rate. Due to anatomical location, disease factors and patient factors internal fixation may be the treatment of choice. No reports exist in the literature regarding the use of locking plates in the management of neoplastic long bone lesions. Data was collected prospectively on the first 10 patients who underwent locking plate fixation of neoplastic long bone lesions. Data was collected on the nature of the lesion, surgery performed, complications and outcome. The patients mean age was 56.6 (15–88). Six lesions were metastatic, one haematological (myeloma) and 3 were primary bone lesions (lymphoma, Giant cell tumour, simple bone cyst). In nine cases a fracture through the lesion had occurred. Anatomical locations of the lesions were; proximal humerus (four), proximal tibia (three), distal femur (two) and distal tibia (one). Cement augmentation of significant bone defects was necessary in seven cases. The mean hospital stay was 8 days (3–20). There were no inpatient complications. Five patients received adjuvant radiotherapy and one patient received neo-adjuvant radiotherapy to the lesion. There have been 3 deaths. All were due to metastatic disease and occurred between 6 and 12 months after surgery. The mean follow up in the surviving patients is currently 9 months (5–16). There have been no fixation related complications. Patients who had suffered a fracture had restoration of their WHO performance status. At last follow up the mean MSTS was 78% (57–90) for lower limb surgery and 70% (63–76) for upper limb surgery. These figures compare favourably with the results of endoprosthetic replacement. The early results of locking plate fixation for neoplastic long bone lesions are excellent. Follow up continues to observe how these devices perform in the long term

Aims: Primary non-Hodgkin lymphoma of bone account for 5% of extra nodal lymphomas. The Authors report their experience referring to the results obtained with a multidisciplinary approach. Materials: 18 cases of lymphoma of bone were included. Medium age was 63 yrs. All cases have been classified according to the REAL classification system. Patients have been staged with: total body CT scan, bone marrow aspirate, bone marrow biopsy, LDH serum level, skeletal survey and MRI of the skeletal segments involved. We treated 10 cases with solitary localization and 8 with multiple ones. Three patients presented with a pathologic fracture at diagnosis. Chemotherapy protocols were:. MACOP-B < 60 yrs. VNCOP-B > 60 yrs. Seven patients received the PROMACE-CYTABOM protocol. 13 patients received EBRT (40 Gy). Ten patients received a surgical treatment: internal fixation in 7 cases and of spine stabilization in 3 cases. Results: At a medium follow-up of 40 months overall survival was 34,6 months and 14,5 months respectively for solitary or multiple localizations. Surgical treatment has been useful in improving performance status and in some cases to obtain a better control of the disease. Discussion: In our experience bone lymphomas have always a high grade histology. Chemotherapy constitutes the treatment of choice. Surgical treatment have to be considered as a support treatment. Prognosis is worse in multiple localizations

Palliative therapy of Malignant Fibrous Histiocytoma (MFH) is mainly based on conventional chemotherapy using anthracyclines and ifosfamide. Intervals between therapies allow abundant recovery of tumour vasculature. An unspecific antiangiogenic effect of chemotherapy can be induced by continuously administering low doses of drug referred to as Metronomic Chemotherapy (MCT). MCT may be combined with specific VEGF targeting drugs in order to increase the antiangiogenic impact on the tumour. We report on a 57 y.o. male patient with heavily pre-treated advanced stage MFH. Previous polychemotherapies consisted of 8 cycles EIA in adjuvant setting in 2002, 4 cycles ICE in recurrent situation in 2003 and 6 cycles of Dacarbacine plus Epirubicine in 2006. In 2005 and 2006 radiation therapy of paravertebral tumour lesions was done. In September 2006 the patient was admitted to our hospital with multilocular metastatic progressive disease. Performance status was WHO1. A moderate asymptomatic anthracycline induced cardiomyopathy was detected. The cumulative dosage threshold for anthracyclines had been exceeded before. We initiated oral MCT with Trofosfamide 150 mg pd plus iv. – antiangiogenic therapy with Bevacizumab 5 mg/kg q 2w. Follow up (FU) was done via F18-PET-CT. First FU after 8 weeks of combined therapy showed metabolic partial remission (PR) (48% decrease in mean Maximum Standard Uptake Valule (SUVmax) of target lesions) and metric stable disease (SD) (5% decrease in sum of diameters according to RECIST criteria). Trofosfamide was tolerated well. Treatment with Bevacizumab had to be stopped after 8 weeks because of symptomatic deterioration of cardiomyopathy (Ejection Fraction now 25%). Trofosfamide was continued as monotherapy. After 8 weeks of Trofosfamide alone PET-CT showed one new lesion indicating progressive disease according to RECIST but persistent metabolic remission of all pre-existing lesions. Bevacizumab then was added again but couldn’t stop further tumour progression (FU in March 2007). In summary disease control was achieved for 4 months. Combined metronomic and antiangiogenic therapy led to disease stabilisation and even metabolic remission measured by F18-PET-CT in a heavily pre-treated patient with soft tissue sarcoma. A pre-existing anthracycline-induced cardiomyopathy deteriorated under treatment with Bevacizumab. Whether response duration could have been prolonged by administering Bevacizumab without interruption remains speculative. The role of PET-CT in early detection of response is still to be determined

Objectives

In this prospective cohort study, we investigated whether patient-specific finite element (FE) models can identify patients at risk of a pathological femoral fracture resulting from metastatic bone disease, and compared these FE predictions with clinical assessments by experienced clinicians.

The December 2014 Oncology Roundup³⁶⁰ looks at: metaphyseal and diaphyseal osteosarcoma subtly different beasts; sports and endoprosthetic reconstruction of the knee; is curettage without tissue diagnosis sensible in cartilaginous tumours?; autoclaved autograft in bone tumour reconstruction; vascularised graft a step too far in bone defects?; interdigitated neoadjuvant chemoradiotherapy in high-grade sarcoma; predicting life expectancy in patients with painful metastasis; and osteolytic lesions of the hands and feet.

The August 2012 Spine Roundup³⁶⁰ looks at: neural tissue and polymerising bone cement; a new prognostic score for spinal metastases from prostatic tumours; recovery after spinal decompression; spinal tuberculosis; unintended durotomy at spinal surgery; how carrying a load on your head can damage the cervical spine; and how age changes your lumbar spine.