Timing of surgery and radiotherapy in the management of metastatic spine disease: A systematic review

Abstract

Abstract. The last decade has witnessed a dramatic change in management of metastatic spine disease, with an increased role for surgery and emerging use of stereotactic radiotherapy, often in combination. Patients may be treated with radiotherapy followed by surgery, or have surgery and then adjuvant radiotherapy. In both cases, the surgeon and oncologist need to select the optimal timing for surgery and radiotherapy to minimize wound complications while obtaining maximum oncolytic effects. The purpose of this review was to determine the optimal timing of surgery and radiotherapy in patients surgically treated for spinal metastases. A systematic review utilizing Medline, Embase, Paper First, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews was performed. References were screened to further identify relevant studies and basic science literature reviewed. A total of 46 reports discussing the timing of surgery after radiotherapy, describing experience in 5836 patients, were identified. Only one retrospective study addressed the research question and suggested that surgery within seven days of radiation increases the rate of postoperative wound complications. Timing of adjuvant radiotherapy following surgery was addressed in 51 reports describing 7090 patients. None of the studies specifically answered the research question. The time interval between radiotherapy and surgery was reported as 5-21 days in nine studies. Based on this systematic review together with the understanding of general principles of wound healing and effects of radiation on wound healing, the optimal radiotherapy-surgery/surgery-radiotherapy time interval should be at least one week to minimize wound complications.

Survival analysis in patients with metastatic spinal disease: the influence of surgery, histology, clinical and neurologic status

“…Dorsal spinal decompression and stabilization are the most frequent surgical techniques used to treat metastatic disease of the thoracic and lumbar spine 1,2,3,4,5,6,7,8,9,10 . For patients with a solitary spinal metastasis without vertebral canal invasion and who are in good general health with a long life expectancy, tumor resection through en bloc spondylectomy/total vertebrectomy with primary stabilizing instrumentation has been suggested 9,10,11,12,13 . A recent paper reported that candidates for en bloc spondylectomy are not frequently encountered 14,15,16 .…”

“…Quantification of vertebral involvement, vertebral canal invasion, neurological status, general health status, and malignancy prognosis determined by primary tumor histology are paramount factors for surgical planning and definition of therapeutic targets 6,7,8,9,10 .…”

Decision Making in Patients With Metastatic Spine. The Role of Minimally Invasive Treatment Modalities

“…Despite the relevance of this topic, the timing between surgery and RT has not yet been investigated thoroughly. Itshayek et al (46) recommended a minimum interval of 1 week between pre-operative or post-operative RT and surgery based on a literature review (46). When urgent surgery is indicated after RT, Ghogawla et al (47) have reported a wound complication in 46% of cases when the procedure is done within a week from RT.…”

Stereotactic Radiotherapy Followed by Surgical Stabilization Within 24 h for Unstable Spinal Metastases; A Stage I/IIa Study According to the IDEAL Framework

“…Precise targeting is limited with conventional EBRT and, as a consequence, the tolerance of the spinal cord limits the radiation dose to the vertebral body with pain relief achieved in only 60% of patients and local tumor control in only 30% of the patients after 1 year (5–7). Furthermore, to reach adequate radiation doses to the metastasis, hotspots of >120% of the prescribed dose are common in the subcutaneous tissues, which impairs wound healing (8). As such, a minimum time interval of 1–2 weeks between surgery and EBRT is considered necessary but thereby also delays radiotherapy-induced pain relief (8).…”

“…Furthermore, to reach adequate radiation doses to the metastasis, hotspots of >120% of the prescribed dose are common in the subcutaneous tissues, which impairs wound healing (8). As such, a minimum time interval of 1–2 weeks between surgery and EBRT is considered necessary but thereby also delays radiotherapy-induced pain relief (8).…”