Prolonged survival of extensive spinal metastases stabilization in patients

Prolonged survival of metastatic stabilization

Keywords 

Spinal metastasis, spinal cord compression, non-small cell lung cancer, targeted therapy, surgery, epidermal growth factor tyrosine kinase inhibitor, quality of life

Abstract 

Contiguous spinal metastasis poses a challenge for spine surgeons. In patients with a short remaining life expectancy, surgery may be discouraged. However, in select cases, surgery may be inevitable to eliminate pain and improve the patient’s quality of life. Additionally, with advancements in systemic cancer therapy, the efficacy and duration of tumor control have improved significantly. Consequently, a patient’s life expectancy may be difficult to estimate with existing prognostic scores. Because patients may achieve prolonged survival, spinal metastasis surgery could greatly benefit a patient’s quality of life. 

In this report, we present the details of two patients with non-small lung cancer with contiguous spinal metastasis who underwent spinal surgery for their metastatic disease. After surgery and targeted therapy with epidermal growth factor tyrosine kinase inhibitors (EGFR TKI), the patients attained substantial healing of their previously lytic spines and achieved prolonged survival of up to 42 months. With modern systemic therapy for lung cancer, the treatment of spinal metastatic disease can achieve decent outcomes, even in poor surgical candidates.

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Introduction 


Spinal metastases affect up to 14% of all cancer patients.1 However, in lung cancer, the incidence of spinal invasion may reach as high as 40%. Spinal canal decompression and instrumentation for spinal metastasis can prevent neurological deterioration or promote neurological recovery in patients with spinal canal compromise caused by tumor invasion. Additionally, fixation of the unstable spinal segment may relieve a patient’s pain and maintain or improve their quality of life. However, surgery in certain patients may be precluded by a short life expectancy, where the surgical risks outweigh the benefits. 

Moreover, the presence of contiguous level spinal metastases may prevent achieving stable spinal stabilization, which may lead to catastrophic instrument failure. Nevertheless, advancements in systemic therapy for lung cancer, especially the development of targeted therapy, could help prolong life expectancy and promote the healing of bony lytic lesions in responsive candidates. 

Therefore, the improved prognosis could lead to changes in therapeutic decision-making. In this report, we present the details of two patients with nonsmall cell lung cancer who achieved long-term stable spinal fixation in contiguous level metastases after surgery, combined with adjuvant targeted therapy and radiation. The reporting of this study conforms to the CARE guidelines.

Discussion 

Metastatic lung cancer was previously associated with a short life expectancy, with a reported median overall survival of 7 months without treatment.15 The quality of life in patients with metastatic lung cancer may be negatively affected by spinal metastasis, which occurs in up to 40% of patients. 

In cases where surgery is warranted, it is crucial to accurately determine the patient’s life expectancy to plan the aggressiveness of the surgical intervention. Several prognostic scoring systems have been proposed to quantify a patient’s life expectancy, which assists in therapeutic decision-making. The modified Tokuhashi score has been used widely; however, its accuracy is questioned in the era of targeted therapy.

Conclusion 

In this report, we presented two cases of extensive contiguous spinal metastatic disease in non-small cell lung cancer patients who achieved prolonged survival and stable spinal fixation after treatment with first-generation EGFR TKIs.

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