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Surgery for Primary Spine Tumors: How Radical Must We Operate?
Accepted Manuscript Surgery for primary spine tumors: How radical must we operate? Perspective Mehmet Zileli, M.D. PII:
S1878-8750(17)30113-4
DOI:
10.1016/j.wneu.2017.01.090
Reference:
WNEU 5187
To appear in:
World Neurosurgery
Received Date: 16 January 2017 Accepted Date: 19 January 2017
Please cite this article as: Zileli M, Surgery for primary spine tumors: How radical must we operate? Perspective, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.01.090. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Surgery for primary spine tumors: How radical must we operate? Perspective Mehmet Zileli, M.D. Professor of Neurosurgery Izmir, Turkey
RI PT
E mail: [email protected] Address: 1416 sok No: 7 Kahramanlar Izmir 35230 TURKEY
M AN U
SC
Primary tumors of the spine are not common compared to metastatic tumors. The indications of surgery and its timing are affected by many factors such as neurological status, histology of the tumor, localization of the tumor, stability of the spine, and general condition of the patient. If there is significant spinal cord compression, if the neurological deficits are progressing rapidly, or if there is significant instability immediate surgery may be performed. However, if the spinal canal is not compromised by tumor the initial surgical step must be to take a biopsy (1, 2, 3).
TE D
Traditionally we usually tried to remove primary tumors with aggressive surgeries (3, 4). However, by the years we learned that we must change the management strategies according to their histologies and their localizations, and not to perform aggressive surgeries in every instance. Some osteoid osteomas or hemangiomas may be treated with more conservative techniques (5, 6). Radiofrequency ablation of for osteoid osteomas (5), transpedicular cavitation and cement augmentation with radiosurgery for vertebral body tumors (7, 8), thermometry using coblation and radiofrequency ablation for metastasis (9) are examples for such surgeries.
EP
Particularly stereotactic radiosurgery has been used as either a primary or adjuvant treatment modality (10, 11). This has been achieveed with advances of radiotherapy. Radiosurgery has beeen more widely used as a supplement to surgical decompression. The main advantages are to carry minimal morbidity and to provide effective local tumor control. Some others have advocated external beam radiation through the use of brachytherapy delivered by radioactive plaque or seeds (2).
AC C
However, some forms of the primary tumors, must still have gone to a total removal without entering the tumor. These are some benign aggressive tumors (giant cell tumor, osteoblastoma) and malignant tumors (chordoma, chondrosarcoma). Besides, radiotherapy is still not avaliable in many countries in the world and it also needs special expertise. Wide en bloc resection has, however, difficulties in spine, since those tumors impinge on vascular and neural structures, they pose a technically challenging surgical problem. So the results of primary spine surgeries are better in centers that are specialized in surgery of such tumors. The paper presented by Dr.Luzzati and coworkers (12) stress an important problem that many patients with primary spine tumors are having first surgeries in departments that are not specialized in spine tumor surgery. Such surgeries are mostly intralesional and inappropriate. A second surgery, even in the hands of experienced tumor surgeons are resulting with less
ACCEPTED MANUSCRIPT
satisfactory results and shorter survival rates. They could achieve wide and marginal excisions in 66% of the cases, complication rates were more than 70%, there were excessive bleedings, and 5 year survival rate was 42%. These results give us an impression that a radical surgery should better be not applied in case primary surgery is intralesional.
RI PT
I believe more comprehensive studies with longer follow ups are necessary to see if specific histologies are giving different results. We can expect the outcomes and recurrence free intervals will be quite different with chordomas, chondrosarcomas, giant cell tumors and osteoblastomas (2, 3, 13). Besides, adding some adjuvant therapies such as radiosurgery and proton beam radiation in those revision surgeries may change outcomes.
M AN U
SC
Conclusions: Management of primary spine tumors have unique problems. First surgeon should take a biopsy and if the histology is a primary malignant tumor or an aggressive benign tumor, the patient should better be referred to a center that is specialized with tumor surgery. The knowledge and experience must be gathered to deal with problems of such tumors. Current trends forces us to prioritize two points for management of primary spine tumors: (a)Histology of the tumor is the most important part. (b)Additional radiosurgery for the remaining part of the tumor in selected cases. Radical surgeries with wide en bloc resections may be criticized and alternatives should be searched for primary malignant spine tumors especially if it is a revision surgery. We need further studies examining results of specific pathologies.
References
TE D
1-Isik HS, Cagli S, Zileli M. Percutaneous Biopsy of the Spine: Analysis of 84 Cases. J Neurological Sciences [Turkish] 29:(2)# 31; 258-265, 2012 2-Liu JK, Laufer I, Bilsky MH. Update on management of vertebral column tumors. CNS Oncol 3(2):137-47, 2014
EP
3-Zileli M, Kilincer C, Ersahin Y, Cagli S. Primary tumors of the cervical spine: a retrospective review of 35 surgically managed cases. The Spine Journal 7:165-173, 2007 4-Zileli M, Hoscoskun C, Brastianos P, Sabah D. Surgical treatment of primary sacral tumors: complications associated with sacrectomy. Neurosurg Focus 15 (5):Article 9, 2003
AC C
5-Faddoul J, Faddoul Y, Kobaiter-Maarrawi S, Moussa R, Rizk T, Nohra G, Okais N, Samaha E, Maarrawi J. Radiofrequency ablation of spinal osteoid osteoma: a prospective study. J Neurosurg Spine 2:1-6, 2016 [Epub ahead of print] 6-Zileli M, Cagli S, Basdemir G, Ersahin Y. Osteoid osteomas and osteoblastomas of the spine. Neurosurg Focus 15 (5):Article 5, 2003 7-Gerszten PC, Monaco EA 3rd. Complete percutaneous treatment of vertebral body tumors causing spinal canal compromise using a transpedicular cavitation, cement augmentation, and radiosurgical technique. Neurosurg Focus 27(6):E9, 2009 8-Gerszten PC, Chen S, Quader M, Xu Y, Novotny J Jr, Flickinger JC. Radiosurgery for benign tumors of the spine using the Synergy S with cone-beam computed tomography image guidance. J Neurosurg 117 Suppl:197-202, 2012
ACCEPTED MANUSCRIPT
9-Groetz SF, Birnbaum K, Meyer C, Strunk H, Schild HH, Wilhelm KE. Thermometry during coblation and radiofrequency ablation of vertebral metastases: a cadaver study. Eur Spine J 22(6):1389-93, 2013
RI PT
10-Bydon M, De la Garza-Ramos R, Bettagowda C, Gokaslan ZL, Sciubba DM. The use of stereotactic radiosurgery for the treatment of spinal axis tumors: a review. Clin Neurol Neurosurg 125:166-72, 2014
11-Miller JA, Balagamwala EH, Angelov L, Suh JH, Djemil T, Magnelli A, Qi P, Zhuang T, Godley A, Chao ST. Stereotactic Radiosurgery for the Treatment of Primary and Metastatic Spinal Sarcomas. Technol Cancer Res Treat 2016 Apr 12. pii: 1533034616643221. [Epub ahead of print]
SC
12-Luzzati A, Scotto G, Perrucchini G, Baaj AA, Zoccali C. Salvage revision surgery after inappropriate approach for primary spine tumors: long term follow-up in 56 cases. World Neurosurgery, 2016
AC C
EP
TE D
M AN U
13-Sarsik B, Doganavsargil B, Basdemir G, Zileli M, Sabah D, Oztop F. Chordomas: Is It Possible to Predict Recurrence? Turkish Journal of Pathology 25(2):27-34, 2009
S1878-8750(17)30113-4
DOI:
10.1016/j.wneu.2017.01.090
Reference:
WNEU 5187
To appear in:
World Neurosurgery
Received Date: 16 January 2017 Accepted Date: 19 January 2017
Please cite this article as: Zileli M, Surgery for primary spine tumors: How radical must we operate? Perspective, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.01.090. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Surgery for primary spine tumors: How radical must we operate? Perspective Mehmet Zileli, M.D. Professor of Neurosurgery Izmir, Turkey
RI PT
E mail: [email protected] Address: 1416 sok No: 7 Kahramanlar Izmir 35230 TURKEY
M AN U
SC
Primary tumors of the spine are not common compared to metastatic tumors. The indications of surgery and its timing are affected by many factors such as neurological status, histology of the tumor, localization of the tumor, stability of the spine, and general condition of the patient. If there is significant spinal cord compression, if the neurological deficits are progressing rapidly, or if there is significant instability immediate surgery may be performed. However, if the spinal canal is not compromised by tumor the initial surgical step must be to take a biopsy (1, 2, 3).
TE D
Traditionally we usually tried to remove primary tumors with aggressive surgeries (3, 4). However, by the years we learned that we must change the management strategies according to their histologies and their localizations, and not to perform aggressive surgeries in every instance. Some osteoid osteomas or hemangiomas may be treated with more conservative techniques (5, 6). Radiofrequency ablation of for osteoid osteomas (5), transpedicular cavitation and cement augmentation with radiosurgery for vertebral body tumors (7, 8), thermometry using coblation and radiofrequency ablation for metastasis (9) are examples for such surgeries.
EP
Particularly stereotactic radiosurgery has been used as either a primary or adjuvant treatment modality (10, 11). This has been achieveed with advances of radiotherapy. Radiosurgery has beeen more widely used as a supplement to surgical decompression. The main advantages are to carry minimal morbidity and to provide effective local tumor control. Some others have advocated external beam radiation through the use of brachytherapy delivered by radioactive plaque or seeds (2).
AC C
However, some forms of the primary tumors, must still have gone to a total removal without entering the tumor. These are some benign aggressive tumors (giant cell tumor, osteoblastoma) and malignant tumors (chordoma, chondrosarcoma). Besides, radiotherapy is still not avaliable in many countries in the world and it also needs special expertise. Wide en bloc resection has, however, difficulties in spine, since those tumors impinge on vascular and neural structures, they pose a technically challenging surgical problem. So the results of primary spine surgeries are better in centers that are specialized in surgery of such tumors. The paper presented by Dr.Luzzati and coworkers (12) stress an important problem that many patients with primary spine tumors are having first surgeries in departments that are not specialized in spine tumor surgery. Such surgeries are mostly intralesional and inappropriate. A second surgery, even in the hands of experienced tumor surgeons are resulting with less
ACCEPTED MANUSCRIPT
satisfactory results and shorter survival rates. They could achieve wide and marginal excisions in 66% of the cases, complication rates were more than 70%, there were excessive bleedings, and 5 year survival rate was 42%. These results give us an impression that a radical surgery should better be not applied in case primary surgery is intralesional.
RI PT
I believe more comprehensive studies with longer follow ups are necessary to see if specific histologies are giving different results. We can expect the outcomes and recurrence free intervals will be quite different with chordomas, chondrosarcomas, giant cell tumors and osteoblastomas (2, 3, 13). Besides, adding some adjuvant therapies such as radiosurgery and proton beam radiation in those revision surgeries may change outcomes.
M AN U
SC
Conclusions: Management of primary spine tumors have unique problems. First surgeon should take a biopsy and if the histology is a primary malignant tumor or an aggressive benign tumor, the patient should better be referred to a center that is specialized with tumor surgery. The knowledge and experience must be gathered to deal with problems of such tumors. Current trends forces us to prioritize two points for management of primary spine tumors: (a)Histology of the tumor is the most important part. (b)Additional radiosurgery for the remaining part of the tumor in selected cases. Radical surgeries with wide en bloc resections may be criticized and alternatives should be searched for primary malignant spine tumors especially if it is a revision surgery. We need further studies examining results of specific pathologies.
References
TE D
1-Isik HS, Cagli S, Zileli M. Percutaneous Biopsy of the Spine: Analysis of 84 Cases. J Neurological Sciences [Turkish] 29:(2)# 31; 258-265, 2012 2-Liu JK, Laufer I, Bilsky MH. Update on management of vertebral column tumors. CNS Oncol 3(2):137-47, 2014
EP
3-Zileli M, Kilincer C, Ersahin Y, Cagli S. Primary tumors of the cervical spine: a retrospective review of 35 surgically managed cases. The Spine Journal 7:165-173, 2007 4-Zileli M, Hoscoskun C, Brastianos P, Sabah D. Surgical treatment of primary sacral tumors: complications associated with sacrectomy. Neurosurg Focus 15 (5):Article 9, 2003
AC C
5-Faddoul J, Faddoul Y, Kobaiter-Maarrawi S, Moussa R, Rizk T, Nohra G, Okais N, Samaha E, Maarrawi J. Radiofrequency ablation of spinal osteoid osteoma: a prospective study. J Neurosurg Spine 2:1-6, 2016 [Epub ahead of print] 6-Zileli M, Cagli S, Basdemir G, Ersahin Y. Osteoid osteomas and osteoblastomas of the spine. Neurosurg Focus 15 (5):Article 5, 2003 7-Gerszten PC, Monaco EA 3rd. Complete percutaneous treatment of vertebral body tumors causing spinal canal compromise using a transpedicular cavitation, cement augmentation, and radiosurgical technique. Neurosurg Focus 27(6):E9, 2009 8-Gerszten PC, Chen S, Quader M, Xu Y, Novotny J Jr, Flickinger JC. Radiosurgery for benign tumors of the spine using the Synergy S with cone-beam computed tomography image guidance. J Neurosurg 117 Suppl:197-202, 2012
ACCEPTED MANUSCRIPT
9-Groetz SF, Birnbaum K, Meyer C, Strunk H, Schild HH, Wilhelm KE. Thermometry during coblation and radiofrequency ablation of vertebral metastases: a cadaver study. Eur Spine J 22(6):1389-93, 2013
RI PT
10-Bydon M, De la Garza-Ramos R, Bettagowda C, Gokaslan ZL, Sciubba DM. The use of stereotactic radiosurgery for the treatment of spinal axis tumors: a review. Clin Neurol Neurosurg 125:166-72, 2014
11-Miller JA, Balagamwala EH, Angelov L, Suh JH, Djemil T, Magnelli A, Qi P, Zhuang T, Godley A, Chao ST. Stereotactic Radiosurgery for the Treatment of Primary and Metastatic Spinal Sarcomas. Technol Cancer Res Treat 2016 Apr 12. pii: 1533034616643221. [Epub ahead of print]
SC
12-Luzzati A, Scotto G, Perrucchini G, Baaj AA, Zoccali C. Salvage revision surgery after inappropriate approach for primary spine tumors: long term follow-up in 56 cases. World Neurosurgery, 2016
AC C
EP
TE D
M AN U
13-Sarsik B, Doganavsargil B, Basdemir G, Zileli M, Sabah D, Oztop F. Chordomas: Is It Possible to Predict Recurrence? Turkish Journal of Pathology 25(2):27-34, 2009