Patrick Hsieh, MD, a neurosurgeon and spine surgeon at Keck Medicine of USC, provides a comprehensive overview of complex spine tumors, including early diagnosis, a multidisciplinary approach to care, treatment options and surgical management.
Yeah, My name is Patrick A. Today I'm gonna talk about surgical considerations, uh, in treatment for spine tumors. It's an area that I'm passionate about. It's an area that I believe it's relatively under served in the old surgery as well. Spine surgery today. So spine tumors come from a variety of sources. Manage stacked tumors or secondary tumors that come from other primary sites primary spine tumors or tumors that arise either from the bone or the soft tissue surrounding the spy itself. The important thing to know is that we should not lump all spine tumors together as a single group. The biology of these tumors are very different, and the treatment is really based on the differences in the different type of tumors. So the first thing I'm gonna talk about mass tax fine tumors thes are the most common type. You'll see. Metastatic spine tumors really comes from cancer diagnosis, and you have about a million new cancer diagnosis a year. About 10 to 20% of them are gonna have spy involvement. In fact, many of them will initially present what spying symptoms as their cancer diagnosis. And that's because spying is the most common sight of muscular skeletal metastases when you look at the source is the most common tumors that causes Mesic. Spine tumors are your most common cancers. Lung cancer, breast cancer, prostate cancer, renal cell cancer as well as malnic. The other thing that we're facing is that they're actually increasing number of long term survivors. Medical colleges are doing a great job keeping patients are alive, but they're not cure the disease. As a result, we have a higher burden of patients who may be symptomatic for metastatic spine tumors that may require treatments. So treatment for metastatic spine tumor is not depend on surgery. Surgery itself, not the primary treatment for most Mattis tax fine tumors most of the time you depending on medical treatment, such a systemic chemotherapy or targeted molecular therapy that we have today. We're also dependent on the radiation therapy to provide local tumor control in cases that are going to respond to radiation and do not need surgery. Pain management is an option for patients who have presentation of mainly back pain. More and more, we're doing mawr. These interventional treatments are bridges between the traditional medical treatment, like radio frequency ablation, laser and official therapy, cryotherapy and even for Tebow plastic Ifo plastic. Thes air treatments are less invasive than your traditional surgery, but can offer local tumor control or can offer local stabilization of the spy itself. Surgery, in my opinion, is a critical component of treatment for a very select group of patients. These air, usually patients who are later in their disease and have neurological symptoms or they have intractable paying from spinal instability. The surgery is performed thio to improve the neurological symptoms or neurological function, and also to provide pain relief from re stabilizing the structural integrity of the spine. So treatment, mass acts. Fine Tumor has been argued by many generations in decades to be ineffective with surgery, and that's because traditional surgery is really 11 ectomy that does not address the location of the tumor. It also does not address any spinal instability that often comes from involvement. Mattis tax buying disease in addition, with surgery, introduced wound complications, infections, wound breakdown and even mortality rate. That's not seeing what systemic or chemotherapy or radiation therapy. And because of this, many have argued that surgeries and ineffective and in addition there is also concerned about the added cost of surgery. Ultimately, surgery does not improve the long term survivor outcome for most patients. Mass tax fine tumors. So these arguments are relative valid, depending on the patient's symptoms and disease status. I do think that we're still a stage where we got to consider surgery for, like, the group of patients we talked about, uh, many stack spine tumors and not well treated when you're treating it with chemotherapy or medical treatment when there's epidural core compression. Already, medical treatment also can address severe structural instability of the spine. You may be of address the pain, but you have to address the structural stability of spine to protect a smile core, uh, thio. Make sure that their patients aren't risk with smaller core or neurological injury. Most people are. We agreed that there are some specific specific benefits with surgery that comes from the direct and immediate decompression, the smile core. And that's why whenever patients have acute neurological function, dysfunctions or acute neurological problems, they will call the surgical team to evaluate a patient for surgery. In addition, surgery is the only treatment that can truly restore the structural stability of spine. In cases of gross instability. So just because patients may benefit from surgery doesn't mean all patients should have surgery. Patients should be considered surgery only if they have reasonable risk, and that the minimum should have a reasonable life expectancy from their cancers from metastatic disease and generally arbitrarily. Most people believe that 3 to 6 months is the minimum of survival that these patients should be considered for surgery. Obviously, we take into account their previous response to medical treatment. We also taking account the extent and the sites of the metastases. If patients have a large burden of disease in their lungs or in their livers that result in an organ disease or an organ failures these patients are not likely to do on survive from their surgical recovery. Functional status is actually very important prognosticator for life expectancy. Patients who are dependent on others for their day to day care are generally have john. We have a shorter and poor life expectancy compared to patients who are independent in their functions. Besides their cancer, many patients, particularly in the L A group, will have medical co morbidity such as cardiovascular diseases, pulmonary diseases that need to be taken into account as part of the surgical morbidity. Then you have cancers that are very radio resistance. They're not effective to be treated by radiation. Uh, eso cancer, such as reading sale, melanoma If there's, uh, symptoms of epidural core compression even before their, uh, at a severe neurological compromise should be considered for surgery. Eso In general, I think that, you know surgery should be considered whenever there are epidural. Core compressions are symptomatic and or, uh, smile instability that patients have either paying or at risk for neurological injury. And these patients, as long as they're surgical can, that should be considered for surgery. All right, so what's to be expected for the results of surgery in these patients? The goal is to preserve neurological function or restore any neurological injury. The goal is also to provide pain relief from restoring the structural integrity of the spine. So in these patients, what you gang is the improvement of function and quality of life because they're able to ambulance and improving their pain function. Their studies also show significant improved local tumor control. They're also study that shows improvement in survival in some of these cases. Now, in these cases of improvement survival. It's not because surgery improves the overall burden of the metastatic disease. What it's doing is improving the systemic function of the patients so that patients are able to live independent and relatively paying free so that they can avoid some of the other medical complications that could lead to morbidity and mortality. Overall, it's important to focus on the goal of treatment for metastatic spine disease, as in Palley Ation on Lee, the goal is not to improve long term survival. It's important, Thio point out, the study by Patrick All, which is really the most defended study and looking at mass tax spine disease treatment with surgery followed by radiation, uh, comparing to radiation. So it's important to make a distinction that this is not a study that compared surgery or radiation on Lee. This is a certain This is a study that compared surgery with radiation afterwards, comparing to radiation alone in this randomized control study, which is considered to be the best level of experience or at best level evidence in scientific clinical studies. The end point to study that they measure was ability to walk. So this was a very easily measurable outcome. And then they also looked at other secondary outcome that includes your inane comments, muscle strength, functional status, all these air related to other measures of neurological preservation of function. And they also look a survival time. Now, one of the most important distinction fact factor about the study is that the name of the surgery is to provide immediate circumferential decompression, the smile core as well, a stabilization the spinal column. So this is more of a modern concept. That was not the goal for, uh, surgery for metastatic spine tumor for many decades in the 20th century. So when you look at the results of the study, there's clearly difference between surgical group, where patients treated with surgery followed by radiation compared to radiation alone. You can see that after their treatment, about 84% of the patient on the surgical group retain their ability to ambulance, whereas in radiation group it was only 57. If you look at the details more closely in the patient's air, ableto retain their ability to walk the surgical patients actually able to retain the ability to walk for 122 days Ah, in the medium days. And that's actually pretty much how long these patients survive after their treatment. On the other hand, if you look at the radiation therapy, even if they maintain the ability to walk after surgery, the median days off of that maintenance of function is only about 13 days. So less than two weeks so many of these patients actually deteriorate subsequently following the initial recovery from their radiation. So overall, you know, you know, in terms of treatment for metastatic spine tumor, it's clear that surgery is not the primary treatment modality. Whenever you can, you want to improve tumor local control, and this can be achieved through medical treatment, such a systemic therapy or radiation therapy and even less invasive treatment such as radio frequency ablation or laser therapy. It's also important to maintain spot instability when you can, and there are medications like this fascinate that can prevent progression of pathological fractures. Bracing can help to reduce some of the pain and prevent further fractures and then vertebra. Kifle plastic can be used to augment a fractured that is mildly or moderately fracture without gross instability. I think the key to improving these patients outcome in terms of treatment, mass accident and disease is to identify symptomatic patients early and identify those patients at risk from neurological injury or progressive epidural disease. Earlier, thes patients generally will have progressive pain or progressive Mueller sensory loss what we call Mile opti when there's dysfunction off the spying, spying, compression or spine, UH, injury, if you will. Now, more and more we're going toward Mormon invasive spine techniques, and I have time to go into the details of this. This has been very widely practiced in the giant spine surgery. We're taking more of these techniques to achieve very similar outcomes in terms of surgical goals. But it's done in a much less much less invasive techniques, so there's overall reduction in blood loss and pain. I think the critical elements to improve patient outcome from metastatic spine tumor is to provide multi discipline care team or delivery system for metastatic spine tumor patients. In the past, most, um, practices operate in silos between the medical oncology, the radiation and the surgical community, and we only really work at each other when there are progression of the disease to a point where it may require surgery acutely, urgently and and does many of these patients present in the emergency room or in acute setting. On the other hand, when you have a multidisciplinary care team that addresses many of these patients needs for metastatic spine tumor early from a medical oncology or radiation oncology or surgical perspective, patients are gonna be identified much quicker when they're at risk for neurological compromise or spinal instability that is going to require a sooner intervention. So when I deal with spine tumors in general, I think about this principle of maximizing Uncle logical outcome and minimizing treatment. Morbidity. Before I talk about primary spine tumors, I wanna finish up on talking about mass attack tumors and treatment algorithm, and that is to that, you know, in mass tax, spine disease or goes palley ation. So we want to minimize the treatment morbidity by improving our infection right, improving our blood loss rate, improving our post operative neurological medical complication rates. And we do this by doing the smallest operation possible for these patients and many which are being performed Do Min invasive techniques when we can. But these patients are best identify early if they're gonna have a less invasive treatment rather than when they present acutely, with paralysis for days at presentation. Now moving on to an area of a little more sub specialization. Spine tumor treatment are the primary spine tumors. Primary spine tumor treatments are very different. Our goal is to maximize uncle Logical outcome, and we might accept a little bit higher treatment morbidity as long as not permanently disabling or at risk for mortality. So private spine tourists arise from the bone or the tissues within the immediate area surrounding the spine, if you will. So for most common primary spine tumors there are benign or the vertebral hemangioma is. Rarely do these need treatment, whether it's medical or surgical treatment. On the other hand, core DOMA, which is really the most common malignant primary spine tumors. Uh, these patients are extremely challenging, uh, tree, and we'll talk a little bit more detail in the coming slides. We also deal a fair amount of intradermal tumors that are within the Spinal canal and inside the dural sac. Most comedy you have nursery tumors such a swan, oma and horrified Roma, and then you have been Ngoma. These were commonly treated, and our center we treat these pretty much to minimize the techniques on Lee and are able to get these patients home within 24 to 48 hours. In most cases, uh, intermediary tumors, arm or rare tumors. But their, uh, their tumors that include a pendant, MoMA, Astro site, oma or other glial tumors thes are much more rare in presentation but generally is part off a spectrum tumor retreat in a complex fine tumor program. So I'm gonna focus on next portion my talking primary spine tumors. So the extent of surgery has been shown in primary spine tumors to correlate with improvement, disease free and overall survival. And actually, in some cases, surgery can be curative, particularly most of the benign tumors. In fact, medical treatment. Radiation therapy, on the other hand, generally have more limited efficacy in many of these prime primary tumors. And because of this surgeries is, um, a big portion of the conservation whenever you're addressing primary spine tumors. So I'm gonna talk about the core doma, uh, or doma is, ah, a relatively rare tumor, but it is actually the most common, uh, primary Milligan spine tumors in adults. It's an area of my interests on expertise. Here at USC. Cordova's can occur in the sacrum, most commonly in the spine, but they also incur in the rest of the mobile spines, including the cervical, thoracic and lumbar spine. They also occur in the skull base A to Clive Assess. As many of you may be aware, thes Cordova's air slow growing and they look relatively benign on the microscopic slide. However, they're actually quite locally invasive and have a propensity for recurrence, and they can actually metastasize. And ultimately there are life threatening to the patients that have cord Omagh's. Unfortunately, there are no effective chemo radiation therapy available for Corrado Mont. Despite our vast experience in treating core DOMA over the years, three extent of surgeries really been shown to best correlate with the disease free survival as well as overall survival in these patients, where core doma, the goal of the treatment for Cordova is maximizing our surgical recession of the tumor without leaving residual microscopic diseases behind. So in the skull base, it's a little bit tough, given that most, uh, skull base urges would have to be done intelligently and by definition you will leave microscopic disease behind. On the other hand, in spying. We have a little more latitude because we don't have significant or critical neurological structure at times near the tumor, and we have a little more latitude to resect and remove some of the tissues that could improve our ability to treat these tumors. So in Cordova cases, we follow classification scheme and treatment scheme that many with use in orthopedic long bone primary tumor surgery. In these cases, our goal is to aim for on block excisions at the minimum on block just means that you've removed tumors. The whole that itself is not quite enough. We actually need to remove a rim of normal tissue surrounding the tumor where you can. That's called Why tumor unblock excision when we remove at least 1 to 2 millimeters of normal tissue surrounding the tumor. And what that actually does is avoid microscopic and satellite legions, uh, surrounding the tumor. In many cases, however, in the spine were only able to achieve what we call marginal tumor resection. And that's because, uh, tumor sessions can be achieved through dissection off the suit capsule or the capsule the tumor. But it puts, uh, patient risk for having some micro satellite or skip lesions that could be left behind. Uh, nevertheless, that is the best that we can do in many of these cases when it involves critical nerves or structures as such as vessels or the nerve roots. So this is an example of what we could dio with modern technology and treatment for core DOMA. This is a patient with a large, uh, C seven to t three uh, core DOMA. This is the primary site of the tumor, and the first diagnosis patient underwent biopsy and confirmed this to be a core DOMA. If you look at the image in Critically, his tumor is already up against the spinal course. Severe spinal cord compression clearly likely involving the dura as well as the surrounding nervous. And because of this were on Lee able to achieve marginal reception of best and know that we're gonna leave Michael satellite or skip lesions behind. As a result, we prescribe what we call New Age of in Proton radiation to minimize that risk and then perform an on block excision with marginal on block excision in a stage fashion with reconstruction of his spinal column with a long segment, cervical thoracic fusion and this is the result of surgery. You can see we can remove the tumor specimen a za whole without spilling the tumor. And we subsequently reconstructed spine, connecting his neck back up to the rest of the spine. Do a complex instrument instrumentation skiing, infusion. And this patient is now four years out and has been working full time since his recovery of surgery and continues to live disease free. So as daunting as high risk of these procedures can be thes air. Extremely gratifying procedures, because you can really make a difference in keeping these patients alive longer than your traditional treatment algorithm. So we, uh, have actually published a number of study on this, And this is one of our initial study when I was a Johns Hopkins, where we show that with unblock excision if you don't achieve wire marginal unblock excision, your survival benefits are not necessarily there, even when unblock excision. So in all of these cases we attempted on block, but there were some cases we actually enter into the tumor in inadvertently identify either at the time surgery or by the pathologist, and what we're able to show in the study is that those that were ableto achieve wire marginal Umbach excision have a significant, longer live survival. They reach a median survival almost six years, whereas those, uh, that have contaminate interregional excision. The medium disease free survival was on Lee about two years, so significant disease free survival is achieved when whenever we do these wire marginal on block excisions. Similar results are also seeing when we treat cervical spying cord. Omagh's thes are actually high risk because the involvement of important cervical nerve roots that are important for armed function as well as the vertebral artery. Even in these cases, there are a bit more complex and risky. What we saw was that complication rates may be higher, but the survival benefits in terms of disease free survival was similar to the sacred Corrado MMA that that is seeing with the extent of our unblock excision. So, in summary, treatments find tumors could be fairly complex as tumors come from wide variety of sources that could be mass static from many sources, or primary uh, from the bone or the primary from the soft tissues surrounding the bone for surgical treatment, respond matter of fact tumors. The goal is Palley ation in nature. So our goal is to really preserve or improve these patients, uh, from their neurological compromise and improve their neurological function. We want to improve their quality of life and paying. And ultimately, the patient selection is critical, because patients only patients that can live long enough and have minimal surgical risk are gonna benefit from the results of metastatic spine tumor surgery. On the other hand, primary spine tumors are very different. We could make a huge difference improving disease free and overall survival in many of these cases. So for cord Omagh's and similarly malignant primary spine tumors, our goal is to achieve the most aggressive, radical excision that it's safe on with relatively acceptable risk. And when we're able to achieve on block excisions with why or marginal on block excisions, there are significant improvement, disease free and overall survival in these cases. Thank you very much for your attention. Um, I also wanted to acknowledge and thank the colleagues have worked me along the, uh, along with me through the years in this fine tumor program. Our medical oncologists, as well as our radiation oncologist on our new radiologists, are critical part off our multidisciplinary, uh, spine tumor program. Thank you. Mhm.