Outcome of embolised vascular metastatic renal cell tumours causing spinal cord compression

Abstract

Purpose To present the results of the surgical management of metastatic renal cell tumours of the spine with cord compression who underwent pre-operative embolisation. Methods We conducted a retrospective cohort study of all embolised vascular metastatic renal cell tumours of the spine that underwent urgent surgical intervention over a 7-year period (2005)(2006)(2007)(2008)(2009)(2010)(2011). All medical notes, images and angiography/embolisation details were studied. We recorded the timing (immediate vs. delayed) and grade of embolisation and compared this to the estimated blood loss (EBL); extent of metastatic spinal cord compression (using the Tomita score and Bilsky scores) was also compared to EBL. Finally, neurological (Frankel grade), surgical outcome and complications were reviewed in all patients. Results During the study period, we operated on 25 emergency patients with metastatic renal cell carcinoma causing spinal cord compression who had received preoperative embolisation (mean age 59.6 (24-78) years; 8 females, 17 males). All but one of our patients had hypervascularisation/arterio-venous fistulae on angiography. We were able to achieve greater than 90 % embolisation in the majority (17/25, 68 %) The estimated blood loss was 1,696 (400-5,000) ml; mean operating time was 276 (90-690) min and an average of 2.3 (0-7) units of whole blood was transfused. Nine patients had a posterior only decompression/stabilisation, nine patients had a posterior decompression ± cement augmentation, six had combined anterior/posterior procedures and one had anterior corpectomy/reconstruction alone. There was no statistical difference in the EBL between immediate versus delayed surgery after embolisation or the grade of embolisation. Immediate surgery after embolisation and interestingly less complete embolisation showed a trend towards less EBL. The extent of the tumour as graded by the Bilsky score correlated with increased EBL (p = 0.042). No complications occurred during the embolisation procedure. The surgical complication rate was 32 % (8/25) including two major complications (septicaemia (1) and metal work failure (2)) and five minor complications. Postoperatively, 52 % (13/25) had no change in neurological status, 36 % (9/25) improved by at least one Frankel grade and 12 % (3/25) had neurological deterioration by one Frankel grade. The average survival following surgery was 14.1 (0.5-72) months. Conclusion Blood loss (mean 1,696 ml) and complications (32 %) remain a concern in the operative treatment of vascular metastatic spinal cord compression. Most patients remained the same neurologically or improved by at least 1 grade (22/25, 88 %). Paradoxically, greater embolisation showed a trend to more blood loss which could be due to more extensive surgery in this group, a rebound 'reperfusion' phenomena or even the presence of arterio-venous fistulae. Interestingly, we also found that the extent of the tumour, as graded by the Bilsky score, correlated with increased blood loss suggesting that more extensive...

Factors associated with improved survival following surgery for renal cell carcinoma spinal metastases

“…Ulmar et al 31 reported a median length of survival of 13.6 months in 37 of such patients, and Quraishi et al 19 noted a median survival of 14.1 months in 25 patients. Tatsui et al have studied the largest patient cohort to date, consisting of 267 patients who underwent surgical treatment for RCC spinal metastases.…”

“…Several studies have demonstrated the benefits of surgery combined with systemic and adjuvant local therapies in alleviating pain and maintaining neurological function. 7,11,13,19 Furthermore, some patients with RCC can be expected to have long, disease-free survival if their systemic disease burden is low and if aggressive resection is used. 27 Here, in an effort to identify prognostic factors for RCC survival, we present demographic and survival data on 30 patients who underwent 40 spinal operations for metastatic RCC at a single institution over a 12-year period.…”

Combined treatment of metastatic renal cell carcinoma in spine

“…В работе N. A. Quraishi и соавт. средняя выживаемость была 12,3 мес [15]. В исследовании S. Kato и соавт.…”

Mini open tumor resection and percutaneous instrumentation for T11 renal cell carcinoma metastasis

“…The principle of combining a minimal access technology and percutaneous instrumentation seems interesting [4]. However, an efficient intraoperative bleeding control by embolization seems mandatory in renal cell carcinoma metastases [5,6]. The application of several hemostatic agents appears helpful, and an augmentation of the vertebral body defect can be performed using the same procedure.…”

“…Minimally invasive transpedicular tumor resection through a tubular retractor, combined with percutaneous instrumentation, has been recently described for unstable compressive lesions [4]. Additionally, metastases of well-vascularized primary tumors, such as renal cell carcinoma, present an intraoperative risk of hemorrhage and require a preoperative transarterial embolization [5,6]. A limited open approach, focused on the tumor area, may further reduce intraoperative bleeding and operating time, which represents a theoretical advantage with regard to the patient's morbidity.…”