Journal List > J Korean Soc Spine Surg > v.26(Suppl 1) > 1135080

Kim, Ha, Oh, Park, Kang, Jeon, and Kim: Surgical Extent of Metastatic Spine Tumor Excision and Its Effects on Postoperative Ambulatory Function: Comparison of Extensive Wide versus Palliative Excision Surgery

Abstract

Study Design

Retrospective study.

Objectives

To compare surgical outcomes such as the ambulatory period and survival according to different surgical excision tactics for metastatic spine tumors (MSTs).

Summary of Literature Review

Surgical outcomes, such as pain relief and survival, in patients with MSTs have been reported in several studies, but the effects of differences in surgical extent on the ambulatory period have rarely been reported.

Materials and Methods

Ninety-six patients with MSTs who underwent palliative (n=60) or extensive wide excision (n=36) were included. Palliative excision was defined as partial removal of the tumor as an intralesional piecemeal procedure for decompression. Extensive wide excision was defined as a surgical attempt to remove the whole tumor at the index level as completely as possible. The primary outcome was the ambulatory period following surgery. Other demographic and radiographic parameters were analyzed to identify the risk factors for loss of ambulatory ability and survival. Perioperative complications were also assessed.

Results

The mean postoperative ambulatory period was longer in the extensive wide excision group (average 14.8 months) than in the palliative excision group (average 11.7 months) (p=0.021). The survival rates were not significantly different between the two surgical excision groups (p=0.680). However, postoperative ambulatory status and major complications within 30 days postoperatively were significant prognostic factors for survival (p=0.003 and p=0.032, respectively).

Conclusions

The extent of surgical excision affected the ambulatory period, and the complication rates were similar, regardless of surgical excision tactics. A proper surgical strategy to achieve postoperative ambulatory ability and to reduce perioperative complications would have a favorable effect on survival.

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Fig. 1.
Distribution of primary solid cancers. The most common primary cancer was lung cancer (n=35, 36.5%), followed by hepatobiliary cancer (n=25, 26.0%).
jkss-26-84f1.tif
Fig. 2.
Kaplan-Meier curve of the postoperative ambulatory period according to the extent of surgical excision. Patients in the W group could walk for an average of 14.8±1.5 months after surgery (95% CI, 11.9-17.7 months), and patients in the P group could walk for an average of 11.7±1.7 months after surgery (95% CI, 8.3-15.0 months). Surgical extent significantly affected the postoperative ambulatory period (p=0.021).
jkss-26-84f2.tif
Fig. 3.
Kaplan-Meier curve of the survival rate according to the extent of surgical excision. Surgical extent did not affect the survival rate (p=0.689).
jkss-26-84f3.tif
Table 1.
Summary of preoperative patient data
  Total (n=96) P group (n=60) W group (n=36) p
Age (range) 57.1±12.8(21-86) 56.2±13.4(21-86) 58.6±11.6(23-79) NS
Male (n, [%]) 62(64.6) 46(76.7) 16(44.4) 0.001
Surgical level        
  Cervical 10 4 6 NS
  Thoracic 56 36 20  
  Lumbosacral 30 20 10  
Tumor diagnosis to surgery, median (month) 11.0(0-170) 11.0(0-154) 12.0(1-170) NS
Symptom to surgery, median (day) 24.5(0-330) 21(1-240) 36.5(0-330) NS§
Metastasis (n)        
  None 9 6 3  
  Non-spinal bone 19 15 4 NS
  Visceral 37 21 16  
  Both 31 18 13  
No. of metastatic spine segments (n)        
  1-2 32 17 15 NS
  ≥3 64 43 21  
Preop. ECOG-PS (n)        
  1 39 22 17  
  2 25 11 14 NS
  3 25 20 5  
  4 7 7 0  
Ambulatory (n, [%]) 73(76.0) 41(68.3%) 32(88.9%) 0.022
ASA physical status classification (n)        
  1-2 75 50 25 NS
  3 21 10 11  
Preop. serum albumin (g/dL) 3.4±0.5 3.4±0.5 3.6±0.6 0.010
  ≥3.0 (n)
<3.0 (n)
  50
10
30
6
NS
Preop. embolization (n) 45 19 26 <0.001

ECOG-PS: the Eastern Cooperative Oncology Group-Performance Status, AS: American Society of Anesthesiologist, NS: not significant.

Student t-test

Chi-square test

lineary by linear test, and

§ Mann-Whitney test were performed.

Table 2.
Epidural cord compression scale on MRI suggested by Bilsky et al.21
  Total (n=96) P group (n=60) W group (n=36) p
0 7(7.3%) 4(6.7%) 3(8.3%)  
1 19(19.8%) 11(18.3%) 8(22.2%) NS
2 19(19.8%) 10(16.7%) 9(25%)  
3 51 (53.1%) 35(58.3%) 16(44.5%)  

NS: not significant.

Linear by linear test was performed.

Table 3.
Summary about preoperative and postoperative chemotherapy radiotherapy
  P group (n=60) W group (n=36) p
Postop. RT 33(55%) 27(75%) NS
Preop. CT 32(53.3%) 19(52.8%)  
  PD 23 15 NS
  SD or PR 9 4  
Postop. CT 27(45%) 21(58.3%) NS

Postop: postoperative, RT: radiotherapy, CT: chemotherapy, PD: progres sive disease, SD: stable disease, PR: partial remission, NS: not signif cant.

Chi-square test was performed.

Table 4.
Risk factor analysis for ambulatory outcome
  Loss of ambulatory status during follow-up Survival
P for univariate analysis P for multivariate analysis HR (95% CI) P for univariate analysis P for multivariate analysis HR (95% CI)
Sex 0.288     0.886    
Age (≥60 vs. <60 y) 0.128 0.589   0.740    
Location of metastasis 0.407     0.911    
Wide excision vs. Palliative excision 0.030 0.034 0.418(0.187-0.935) 0.689    
Adjuvant RT (Yes vs. No) 0.441     0.007 0.191  
Preop. CT (No vs. PD or SD/PR) 0.056 0.170   0.362    
Postop. CT (Yes vs. No) 0.333     0.486    
Preop. ECOG-PS (1-2 vs. 3-4) 0.583     0.002 0.499  
Preop. ambulatory (Yes vs. No) 0.264     <0.001 0.951  
Postop.(within 30d) ambulatory (Yes vs. No) 0.602     <0.001 0.003 2 2.675(1.408-5.083)
ASA (1-2 vs. 3-4) 0.358     0.578    
ESCC scale (0-1 vs. 2-3) 0.470     0.268    
Number of metastatic spine (1-2 vs. ≥3) 0.307     0.795    
Extraspinal bone metastasis (Yes vs. No) 0.343     0.480    
Visceral metastasis (Yes vs. No) 0.280     0.233    
Preop. serum albumin (<3.0 vs. ≥3.0 g/dL) 0.072 0.675   0.857    
Intraop. bleeding (≥2000 vs. <2000 cc) 0.377     0.908    
Perioperative major complication (Yes vs. No) 0.120 0.129   0.003 0.032 0.491 (0.256-0.940)

Preop: preoperative, RT: radiotherapy, CT: chemotherapy, PD: progressive disease, SD: stable disease, PR: partial remission, ECOG-PS: the Eastern Co-operative Oncology Group-Performance Status, ASA: American Society of Anesthesiologist, ESCC: epidural cord compression, HR:hazard ratio, CI: confi-dence interval, N/A: not applicable.

Cox bioharzard proportional model was performed.

Table 5.
Perioperative complications analysis (within postoperative 30-day)
  Total (n=96) P group (n=60) W group (n=36) P
Total 23 15 8  
  Pneumonia 9 6 3  
  Wound problems 7 4 3  
  Thromboembolism 3 3 0 NS
  GI bleeding 2 1 1  
  Sepsis 3 1 2  
  CVA 1 1 0  
Death 10 7 3 NS

GI: gastrointestinal, CVA: cerebrovascular accident, NS: not significant.

Chi-square was performed.

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