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PURPOSE: To evaluate the safety and effectiveness of preoperative embolization in reducing blood loss with n-Butyl cyanoacrylate (n-BCA) performed for metastatic spinal cord compression (MSCC). MATERIALS AND METHODS: In this IRB-approved retrospective study, clinical records from 2017 to 2022 were reviewed. Twenty consecutive patients (11 men, 9 women; mean age 65.8 +/− 10.0, range 45–82) underwent 21 preoperative spine tumor embolizations with n-BCA. Angiograms were used to calculate the percentage reduction in tumor vascularity, and relevant clinical data (levels studied and embolized, fluoroscopy time [FT], reference dose [RD], Kerma area product [Kap]) and operative data (blood loss [BL], operative time [OT]) were analyzed. Adverse events and outcomes were recorded. RESULTS: On average, two levels were embolized per procedure (1–5), but 4.9 studied (1–10). After embolization, tumor blush was reduced by 87.3% (50–90%) on average. The mean FT was 41 min +/−15.4 (16–67); the mean RD was 1977.1 mGy +/− 1794.3 (450.2–6319); and the mean Kap was 180.5 Gy.cm2 +/− 166.2 (30.4–504). The adverse event rate was 1/21 (4.7%) as a weakness of lower extremities related to swelling was observed. Surgery was performed a mean 1.4 +/− 1 (1–5) days after embolization. The average surgical estimated BL was 432.5 +/− 328.5 mL (25–1100) and the average OT was 210.1 +/− 97.4 min (57–489). CONCLUSION: Preoperative embolization of tumors resected for MSCC with n-BCA is a safe procedure allowing for performance of surgery with acceptable blood loss.

OBJECTIVE The cervicothoracic junction (CTJ) is a challenging region to stabilize after tumor resection for metastatic spine disease. The objective of this study was to describe the outcomes of patients who underwent posterolateral decompression and instrumented fusion (i.e., separation surgery across the CTJ for instability due to metastatic disease). METHODS The authors performed a single-institution retrospective study of a prospectively collected cohort of patients who underwent single-approach posterior decompression and instrumented fusion across the CTJ for metastatic spine disease between 2011 and 2018. Adult patients (≥ 18 years old) who presented with mechanical instability, myelopathy, and radiculopathy secondary to metastatic epidural spinal cord compression (MESCC) of the CTJ (C7–T1) from 2011 to 2018 were included. RESULTS Seventy-nine patients were included, with a mean age of 62.1 years. The most common primary malignancies were non–small cell lung (n = 17), renal cell (11), and prostate (8) carcinoma. The median number of levels decompressed and construct length were 3 and 7, respectively. The average operative time, blood loss, and length of stay were 179.2 minutes, 600.5 ml, and 7.7 days, respectively. Overall, 58 patients received adjuvant radiation, and median dose, fractions, and time from surgery were 27 Gy, 3 fractions, and 20 days, respectively. All patients underwent lateral mass and pedicle screw instrumentation. Forty-nine patients had tapered rods (4.0/5.5 mm or 3.5/5.5 mm), 29 had fixed-diameter rods (3.5 mm or 4.0 mm), and 1 had both. Ten patients required anterior reconstruction with poly-methyl-methacrylate. The overall complication rate was 18.8% (6 patients with wound-related complications, 7 with hardware-related complications, 1 with both, and 1 with other). For the 8 patients (10%) with hardware failure, 7 had tapered rods, all 8 had cervical screw pullout, and 1 patient also experienced rod/screw fracture. The average time to hardware failure was 146.8 days. The 2-year cumulative incidence rate of hardware failure was 11.1% (95% CI 3.7%–18.5%). There were 55 deceased patients, and the median (95% CI) overall survival period was 7.97 (5.79–12.60) months. For survivors, the median (range) follow-up was 12.94 (1.94–71.80) months. CONCLUSIONS Instrumented fusion across the CTJ demonstrated an 18.8% rate of postoperative complications and an 11% overall 2-year rate of hardware failure in patients who underwent metastatic epidural tumor decompression and stabilization.

Chordomas are rare tumors of the embryologic spinal cord remnant. They are locally aggressive and typically managed with surgery and either adjuvant or neoadjuvant radiation therapy. However, there is great variability in practice patterns including radiation type and fractionation regimen, and limited high-level data to drive decision making. The purpose of this manuscript was to summarize the current literature specific to radiotherapy in the management of spine and sacral chordoma and to provide practice recommendations on behalf of the Spine Tumor Academy. A systematic review of the literature was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) approach. Medline and Embase databases were utilized. The primary outcome measure was the rate of local control. A detailed review and interpretation of eligible studies is provided in the manuscript tables and text. Recommendations were defined as follows: (1) consensus: approved by >75% of experts; (2) predominant: approved by >50% of experts; (3) controversial: not approved by a majority of experts. Expert consensus supports dose escalation as critical in optimizing local control following radiation therapy for chordoma. In addition, comprehensive target volumes including sites of potential microscopic involvement improve local control compared with focal targets. Level I and high-quality multi-institutional data comparing treatment modalities, sequencing of radiation and surgery, and dose/fractionation schedules are needed to optimize patient outcomes in this locally aggressive malignancy.

The objective of this study was to investigate the feasibility and safety of delivering a third course of radiation to patients with multiply recurrent metastatic disease to the spine.Between 2009 and 2011, 10 patients received a third course of radiation to spinal metastases at Memorial Sloan-Kettering Cancer Center using image-guided intensity-modulated radiation therapy (IMRT). Patient and tumor characteristics, dosimetry details, and outcomes were obtained using retrospective chart review. Spinal imaging was performed prior to treatment and at regular follow-up intervals. The cumulative biologically effective dose (BED) to the spinal cord and cauda equina was calculated and was normalized to 2 Gy equivalents (Gy(2/2)). Toxicity and local control were assessed.The median time between the first and second courses of radiation was 18.5 months and the median time between the second and third courses was 11.5 months. The median follow-up from the third course of radiation was 12 months and the median overall survival was 13 months. Pain or neurological symptoms were improved in 80% of patients. The median spinal cord maximum dose normalized BED (nBED) for the whole cohort was 70.73 Gy(2/2) (range 51.9-101.7 Gy(2/2)). The median dose to 5% of the spinal cord D(05) nBED for the entire cohort was 59.4 Gy(2/2). Acute toxicity was most commonly fatigue and dermatitis, with 1 patient experiencing Grade 3 fatigue and 1 patient Grade 3 dermatitis. Late toxicity was limited to 2 cases of Grade 1 dysphagia. There was 1 case of Grade 1 neuropathy and 1 case of Grade 2 neuropathy. The crude rate of local control was 80% with 1 in-field failure and 1 marginal failure.In this cohort of patients, a third course of IMRT to the spine was well tolerated with no significant late toxicities. Used as salvage therapy for select patients, a third course of radiation is a safe and effective treatment strategy.

A variety of tumors arise in or extend to the infratemporal fossa. We investigated the outcome of surgical management of these tumors.We conducted a retrospective review of a craniofacial approach to resection of infratemporal fossa tumors from 1992 to 2008 in a cancer center.Forty-three patients underwent resection of a infratemporal fossa tumors (68% men). Median age was 46 years (range, 1-81 years). The most common pathology was sarcoma (13; 30%). Twenty-two tumors (51%) were recurrent. Twenty patients (46%) underwent resection of tumors from the infratemporal fossa, 5 (12%) required resection of the anterior skull base, and 18 (42%) required orbital exenteration, additionally. Thirty-one patients (72%) required reconstruction with free tissue transfer. Twenty-seven patients (62.8%) required further treatment with radiation and/or chemotherapy. Complications occurred in 9 patients (21%). Six patients (14%) underwent salvage operations. Median follow-up was 24 months. Median overall survival and 3-year survival were 40 months and 59.6%.Tumors involving the infratemporal fossa can be resected with acceptable morbidity and long-term survival.

Because of the proximity of the spinal cord, effective radiotherapy of paraspinal tumors to high doses requires highly conformal dose distributions, accurate patient setup, setup verification, and patient immobilization. An immobilization cradle has been designed to facilitate the rapid setup and radiation treatment of patients with paraspinal disease. For all treatments, patients were set up to within 2.5 mm of the design using an amorphous silicon portal imager. Setup reproducibility of the target using the cradle and associated clinical procedures was assessed by measuring the setup error prior to any correction. From 350 anterior/posterior images, and 303 lateral images, the standard deviations, as determined by the imaging procedure, were 1.3 m, 1.6 m, and 2.1 in the ant/post, right/left, and superior/inferior directions. Immobilization was assessed by measuring patient shifts between localization images taken before and after treatment. From 67 ant/post image pairs and 49 lateral image pairs, the standard deviations were found to be less than 1 mm in all directions. Careful patient positioning and immobilization has enabled us to develop a successful clinical program of high dose, conformal radiotherapy of paraspinal disease using a conventional Linac equipped with dynamic multileaf collimation and an amorphous silicon portal imager.

BACKGROUND Brain metastases from soft tissue sarcoma (STS) are uncommon. To the authors' knowledge limited information is available regarding the influence of the initial STS site, the significance of parenchymal versus leptomeningeal metastases, and the role of surgical resection. METHODS STS patients evaluated between July 1982 and March 1999 who presented with or developed brain metastases were identified from a prospective database. Association between factors was determined using the Fisher exact test. Survival was estimated using the Kaplan–Meier method. The influence of factors on the endpoint (disease specific survival [DSS]) was analyzed using the log-rank test. Significance was defined at P ≤ 0.05. RESULTS A total of 3829 STS patients were evaluated during the study interval; 21 patients presented with and 19 patients subsequently developed brain metastases, accounting for < 1% (40 of 3829 patients) of the total patient group. The STS presentation status for this group of patients (n = 40) included 15 patients with primary STS, 1 patient with local recurrence, and 24 patients with metastatic disease. The most frequent types of STS metastasizing to the brain were leiomyosarcoma (eight patients), liposarcoma (five patients), rhabdomyosarcoma (four patients), and malignant fibrous histiocytoma (MFH) (four patients). Fourteen other sarcoma types were determined in the remaining 19 patients. Of the 19 patients who developed subsequent brain metastases, 18 had lung metastases as the immediate prior site of disease. The median overall follow-up for the 40 patients was 14 months (range, 1–128 months); for survivors (n = 5), the median overall follow-up was 18 months. During follow-up, 34 patients died of disease and 1 patient died of other causes. Brain metastasectomy was performed in 27 of the 40 patients and was highly associated with the initial site of STS; 20 of the 27 patients who underwent resection versus 2 of the 13 patients who did not undergo resection initially had extremity or trunk STS (P < 0.001). No association was observed between parenchymal versus leptomeningeal site of metastases and any outcome factor. The 1-year and 2-year overall DSS for the 40 patients was 55% and 25%, respectively, with a median survival of 15 months. The 1-year and 2-year postmetastasis survival rates were 34% and 20%, respectively, with a median survival of 7 months. Metastasectomy (n = 27) was associated with an improved median postmetastasis survival (9.6 months vs. 2.7 months for unresected patients; P < 0.01). The 2-year postmetastasis survival was 27% for those patients who underwent resection and 0% for the unresected patients. CONCLUSIONS Although brain metastases from STS are rare, vigilance is warranted. Symptomatic patients should be examined neurologically and investigated thoroughly for metastases. Surgical resection may be an appropriate treatment for selected patients; however, survival is dismal. Cancer 2002;94:2706–11. © 2002 American Cancer Society. DOI 10.1002/cncr.10554