Spinal metastases are seen in 10–30% of cancer patients. Twenty percent of these metastases occur in the lumbo-sacral spine. Lumbo-sacral spine has different mechanical properties and encloses the cauda equina. Few studies took interest in this spinal segment. The objective of this study is to evaluate prognostic factors of lumbo-sacral spinal metastasis treated in our center. We retrospectively reviewed 376 patients who were operated in our center from 2010 to 2018. Eighty-nine patients presented lumbo-sacral metastases and thus were included. Data collected included age, smoking, tumor histology, American spinal injury association (ASIA) score, modified Tokuhashi score, modified Bauer score, ambulation status and adjuvant treatment. The mean population age was 60.9 years old (35–85). The tumor histology was predominantly lung (19 patients, 21.3%), breast (13 patients, 14.6%), kidney (11 patients, 12.4%) and prostate (9 patients 10.1%). Twenty-two patients (24.7%) were unable to walk preoperatively. Seventy-nine patients (88.8%) underwent a posterior open approach with corpectomy in 65 patients (73%). Eighteen patients regained ambulation post-operatively (81.8%). The mean survival was 24.03 months (CI95% 17,38–30,67, Range 0–90) and the median of survival was 9 months (CI95% 4.38–13.62). Better preoperative ASIA score had a significant favorable effect (p=0.03) on survival. Patients who regained their ability to walk had better survival (25.1 months (CI95% 18.2–32) VS 0.5 months (CI95% 0–1.1). Postoperative radiotherapy had a benefic effect on survival (p=0.019): Survival Increased from 10.5 months (CI95% 2.4–18.7) to 27.6 months (CI95% 19.5–35.8). The modified Tokuhashi and the modified Bauer scores underestimated the survival of the patients with lumbosacral metastases. Lumbosacral spinal metastases has better survival than expected by Tokuhashi and Bauer score. Surgical procedure have an important impact on survival and the ability to walk

Background. Loss of muscle mass (sarcopenia) and function in ageing are associated with reduced functional ability, quality of life and reduced life expectancy. In cancer patients, age related muscle loss may be exacerbated by cachexia and poor nutritional intake. Individuals with widespread disseminated disease are most prone to increasing functional decline, increased morbidity and accelerated death. However subjective assessments of physical performance have been shown to be poor indicators of life expectancy in these patients. Aims. To develop an objective measure to aid calculation of life expectancy in cancer by investigating the association between objectively measured lean muscle mass and longevity, in 41 patients with known spinal metastases from all cause primaries. Methods. Lean muscle mass was calculated as total psoas area (TPA)/height (m)2. Two blinded doctors independently calculated TPA from CT images at the L3 level, performed routinely within 7 days of diagnosis of spinal metastases. Time to death was recorded from retrospective analysis of hospital notes. Results. Of patients within the highest tertile for muscle mass 85% were alive at one year, compared with 50% in the lowest tertile. Conclusion. Death within one year in individuals with spinal metastases is significantly higher in patients with low lean muscle mass at presentation

National Institute of Clinical Excellence guidelines on Metastatic Spinal Cord Compression recommend urgent consideration of patients with spinal metastases and imaging evidence of structural spinal failure with spinal instability for surgery to stabilise the spine and prevent Metastatic Spinal Cord Compression. We aimed to compare neurological outcomes of patients managed operatively and non-operatively. Prospective collection of 397 patients' data over a 4-year period. Males represented 59.2% of patients. Median age was 69 years. Non-operative intervention in 62.2% of patients. Prostate, lung, Breast, Myeloma, Renal Cell Carcinoma and Lymphoma accounted for over 75% of all primary tumours (n=305). Median Length of hospital stay was longer in the operative group of 15 days compared to 10 days in the non-operative group (p<0.0001). Patients who were ambulating on presentation maintained their ambulation in 70.2% of cases in the operative group compared to 90.9% in the non-operative group (p<0.0001). However, upon discharge 41% of patients managed operatively were ambulatory compared to the non-operative group rate of 36.5% (p<0.0001). In Prostate, Breast, Myeloma, RCC and Lymphoma 100% of patients managed non-operatively maintained ambulation. Lung primaries managed operatively had an 80% chance of maintaining ambulation compared to 76.9% in the non-operative group (p<0.05). A higher proportion of patients managed non-operatively maintained ambulation than those managed operatively. With operative intervention, more patients regained ambulatory status. Whilst we have mainly focused on ambulatory status in this paper there are other factors to consider including pain relief and spinal stability which may be an indication for surgical intervention

Purpose. To develop a low complexity highly-automated multimodal approach to segment vertebral structure and quantify mixed osteolytic/osteoblastic metastases in the rat spine using a combination of CT and MR imaging. We hypothesize that semi-automated multimodal analysis applied to 3D CT and MRI reconstructions will yield accurate and repeatable quantification of whole vertebrae affected by mixed metastases. Method. Mixed spinal metastases were developed via intra-cardiac injection of canine Ace-1 luciferase transfected prostate cancer cells in a 3 week old rnu/rnu rat. Two sequential MR images of the L1-L3 vertebral motion segments were acquired using a 1H quadrature customized birdcage coil at 60 m isotropic voxel size followed by CT imaging at a 14m isotropic voxel size. The first MR image was T1 weighted to highlight the trabecular structure to ensure accurate registration with the CT image. The second MR image was T2 weighted to optimize differentiation between bone marrow and osteolytic tumour tissue. Samples were then processed for undecalcified histology and stained with Goldners Trichrome to identify mineralized bone and unmineralized new bone formation. All images were resampled to 34.9 m and manually aligned to a global axis. This was followed by an affine registration using a Quasi Newton optimizer and a Normalized Mutual Information metric to ensure accurate registration. The whole individual vertebrae and their trabecular centrums were then segmented from the CT images using an extended version of a previously developed atlas based registration algorithm. An intensity-based thresholding method was used to segment the regions corresponding to osteoblastic tumor predominantly attached to the outside of the cortical shell. The whole vertebral segmentation from the CT was warped around the T2 weighted MR to define the bone boundaries. An intensity-based thresholding approach was then applied to the T2 weighted MR segment the osteolytic tumor. Results. The customized MR coil acquired good quality images of both the bone and soft tissue structures in the spine. The CT based automated segmentation of the whole vertebrae and the trabecular centrums yielded high volumetric concurrency (∼90%) when compared to manually refined segmentations. Automated thresholding was even more robust in segmenting the individual trabecular networks and osteolytic tumours. The automation of the osteoblastic tumor segmentation was more challenging yielding concurrencies of ∼80% when compared to manually refined segmentations. Conclusion. We successfully combined CT and μMR imaging to accurately segment mixed metastatic lesions within rat vertebrae using a highly-automated algorithm. These segmentations could readily be used for quantitative evaluation of new and existing treatments aimed at skeletal metastases or to generate finite element models to evaluate biomechanical behaviour or fracture risk

Purpose. Maintenance of vertebral mechanical stability is of paramount importance to prevent pathologic fractures and resultant neurologic compromise in individuals with spinal metastases. Current non-surgical treatments for vertebral metastases (i.e. chemotherapy, bisphophonates (BP) and radiation) yield variable responses in the tumour and surrounding bone. Photodynamic therapy (PDT) is a novel, minimally-invasive technology that utilizes a drug activated by light at a specific non-thermal wavelength to locally destroy tumour cells. Previously, we observed that PDT can ablate cancer cells within bone and yield short-term (1-week) improvements in vertebral architecture and biomechanical strength, particularly when combined with BP therapy. This study aims to evaluate the effects of PDT in vertebral bone over a longer (6-week) time period, alone and combined with previous BP treatment, to determine if improvements in skeletal architecture and strength are maintained. Method. Fourty healthy rnu/rnu rats were randomly assigned to four treatment groups: (i) untreated control, (ii) BP only, (iii) PDT only and (iv) PDT following BP. BP treatments were administered on day 0 via subcutaneous injection of zoledronic acid. PDT was administered on day 7 via an intravenous injection of BPD-MA photosensitizer. A flat-cut optical fiber was inserted percutaneously adjacent to lumbar vertebra L2. After a 15-minute drug-light interval, 75J of light energy was delivered from a 690nm laser. Six weeks later, animals were euthanized. Structural properties of excised L2 vertebral bodies were quantified through semi-automated analysis of micro-CT images. In of the specimens, mechanical properties were evaluated by loading the L2 vertebral body to failure in axial compression. The remaining L2 vertebrae were analyzed for morphology, osteoid formation and osteoclast activity using histological methods. Results. Combined PDT+BP treatment yielded the largest increases in bone volume fraction (31%), trabecular thickness (45%) and vBMD (37%) and decreases in trabecular number (14%) and separation (26%) compared to untreated controls (n=10, all p<0.05). The cortical shell mass fraction was significantly lower than that of controls (24%) indicating increases in bone structure were primarily due to trabecular changes. Mechanically, PDT+BP treatment demonstrated a trend towards an increase in ultimate force compared to controls (n=5, p=0.176). BP-only and PDT-only treatments demonstrated similar trends to the combined treatment, but with a lower magnitude of effect. Qualitatively, histological analysis suggested more osteoid formation in groups receiving PDT, and a higher proportion of bone in BP-treated groups. Conclusion. PDT has a sustained positive effect on the mechanical and structural integrity of bone, particularly in combination with BP treatment. By ablating tumour tissue and strengthening bone, combined PDT+BP treatment presents as an attractive adjuvant minimally-invasive therapy for spinal metastasis