Surgical treatment of sacral metastases: indications and results

Clinical article

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Object

Hematogenous metastases to the sacrum can produce significant pain and lead to spinal instability. The object of this study was to evaluate the palliative benefit of surgery in patients with these metastases.

Methods

The authors retrospectively reviewed all cases involving patients undergoing surgery for metastatic disease to the sacrum at a single tertiary cancer center between 1993 and 2005.

Results

Twenty-five patients (21 men, 4 women) were identified as having undergone sacral surgery for hematogenous metastatic disease during the study period. Their median age was 57 years (range 25–71 years). The indications for surgery included palliation of pain (in 24 cases), need for diagnosis (in 1 case), and spinal instability (in 3 cases). The most common primary disease was renal cell carcinoma.

Complications occurred in 10 patients (40%). The median overall survival was 11 months (95% CI 5.4–16.6 months). The median time from the initial diagnosis to the diagnosis of metastatic disease in the sacrum was 14 months (95% CI 0.0–29.3 months). The numerical pain scores (scale 0–10) were improved from a median of 8 preoperatively to a median of 3 postoperatively at 90 days, 6 months, and 1 year (p < 0.01). Postoperative modified Frankel grades improved in 8 cases, worsened in 3 (due to disease progression), and remained unchanged in 14 (p = 0.19). Among patients with renal cell carcinoma, the median overall survival was better in those in whom the sacrum was the sole site of metastatic disease than in those with multiple sites of metastatic disease (16 vs 9 months, respectively; p = 0.053).

Conclusions

Surgery is effective to palliate pain with acceptable morbidity in patients with metastatic disease to the sacrum. In the subgroup of patients with renal cell carcinoma, those with the sacrum as their solitary site of metastatic disease demonstrated improved survival.

Article Information

Address correspondence to: Laurence D. Rhines, M.D., The University of Texas, M.D. Anderson Cancer Center, Department of Neurosurgery–Unit 442, P.O. Box 301402, Houston, Texas 77230-1402. email: lrhines@mdanderson.org.

Please include this information when citing this paper: published online August 17, 2012; DOI: 10.3171/2012.7.SPINE09351.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    This 42-year-old man presented with severe back, buttock, and right leg pain when upright. His pain was not relieved with medication, and he was unable to ambulate. A CT scan revealed a destructive tumor at S-1 (A). The arrows show a fracture through the sacrum. Sagittal bone window reconstruction of the CT scan (B) showed fracture of S-1 through the superior endplate and ventral cortex (arrows). A needle biopsy revealed renal cell carcinoma. The patient underwent a gross-total resection of the sacral metastasis with modified Galveston fixation and allograft fusion (C and D). The right sacral ala and S-1 vertebra were removed, with complete decompression and preservation of the S-1 and S-2 nerve roots (E).

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    Graph depicting overall survival after surgery for hematogenously disseminated metastases to the sacrum in 12 patients. The estimate of median overall survival using the Kaplan-Meier method was 11.0 months (95% CI 5.4–16.6 months).

  • View in gallery

    Kaplan-Meier plots of sacral progression as a function of the type of resection. Among patients undergoing resection of their sacral tumor (n = 23), gross-total resection (GTR) was associated with improved local control as demonstrated in the longer median time to sacral progression (TTSP) of 24 months (95% CI 0.0–48.7 months) versus 12.0 months (95% CI 5.5–18.5 months) in those who underwent subtotal resection (STR). This difference was not significant, although a trend was noticed favoring gross-total resection (p = 0.07, log-rank test).

  • View in gallery

    Graph depicting overall survival in patients with single-site versus multiple-site metastases. In cases in which the sacral metastasis was the sole site of metastatic disease, the median overall survival (17.0 months [95% CI 8.37–25.63 months]) was greater than in cases in which there were multiple sites of metastasis (4.0 months [95% CI 0.0–8.07 months]). This difference was not statistically significant, however (p = 0.53).

References

  • 1

    American Spinal Injury Association/International Medical Society of Paraplegia: International Standards for Neurological and Functional Classification of Spinal Cord Injury Revised 1996 ChicagoAmerican Spinal Injury Association1996

    • Search Google Scholar
    • Export Citation
  • 2

    Arcangeli GGiovinazzo GSaracino BD'Angelo LGiannarelli DArcangeli G: Radiation therapy in the management of symptomatic bone metastases: the effect of total dose and histology on pain relief and response duration. Int J Radiat Oncol Biol Phys 42:111911261998

    • Search Google Scholar
    • Export Citation
  • 3

    Chang ELShiu ASMendel EMathews LAMahajan AAllen PK: Phase I/II study of stereotactic body radiotherapy for spinal metastasis and its pattern of failure. J Neurosurg Spine 7:1511602007

    • Search Google Scholar
    • Export Citation
  • 4

    Ernst DSTannock IFWinquist EWVenner PMReyno LMoore MJ: Randomized, double-blind, controlled trial of mitoxantrone/prednisone and clodronate versus mitoxantrone/prednisone and placebo in patients with hormone-refractory prostate cancer and pain. J Clin Oncol 21:333533422003

    • Search Google Scholar
    • Export Citation
  • 5

    Gerszten PCBurton SAOzhasoglu CWelch WC: Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976) 32:1931992007

    • Search Google Scholar
    • Export Citation
  • 6

    Gerszten PCBurton SAWelch WCBrufsky AMLembersky BCOzhasoglu C: Single-fraction radiosurgery for the treatment of spinal breast metastases. Cancer 104:224422542005

    • Search Google Scholar
    • Export Citation
  • 7

    Gerszten PCOzhasoglu CBurton SAWelch WCVogel WJAtkins BA: CyberKnife frameless single-fraction stereotactic radiosurgery for tumors of the sacrum. Neurosurg Focus 15:2E72003

    • Search Google Scholar
    • Export Citation
  • 8

    Gokaslan ZLAladag MAEllerhorst JA: Melanoma metastatic to the spine: a review of 133 cases. Melanoma Res 10:78802000

  • 9

    Guo YPalmer JLShen LKaur GWilley JZhang T: Bowel and bladder continence, wound healing, and functional outcomes in patients who underwent sacrectomy. J Neurosurg Spine 3:1061102005

    • Search Google Scholar
    • Export Citation
  • 10

    Hall JHFleming JF: The “lumbar disc syndrome” produced by sacral metastases. Can J Surg 13:1491561970

  • 11

    Halperin ECHarisiadis L: The role of radiation therapy in the management of metastatic renal cell carcinoma. Cancer 51:6146171983

    • Search Google Scholar
    • Export Citation
  • 12

    Hamilton AHortobagyi G: Chemotherapy: what progress in the last 5 years?. J Clin Oncol 23:176017752005

  • 13

    Harvey HA: Issues concerning the role of chemotherapy and hormonal therapy of bone metastases from breast carcinoma. Cancer 80:8 Suppl164616511997

    • Search Google Scholar
    • Export Citation
  • 14

    Huguenin PUKieser SGlanzmann CCapaul RLütolf UM: Radiotherapy for metastatic carcinomas of the kidney or melanomas: an analysis using palliative end points. Int J Radiat Oncol Biol Phys 41:4014051998

    • Search Google Scholar
    • Export Citation
  • 15

    Huland EHeinzer H: Renal cell carcinoma: novel treatments for advanced disease. Curr Opin Urol 13:4514562003

  • 16

    Jackson RJGokaslan ZL: Spinal-pelvic fixation in patients with lumbosacral neoplasms. J Neurosurg 92:1 Suppl61702000

  • 17

    Laskin JJSandler AB: State of the art in therapy for non-small cell lung cancer. Cancer Invest 23:4274422005

  • 18

    Lee MLTomsu KVon Eschen KB: Duration of survival for disseminated malignant melanoma: results of a meta-analysis. Melanoma Res 10:81922000

    • Search Google Scholar
    • Export Citation
  • 19

    Lipton A: Management of bone metastases in breast cancer. Curr Treat Options Oncol 6:1611712005

  • 20

    Lokich JJHarrison JH: Renal cell carcinoma: natural history and chemotherapeutic experience. J Urol 114:3713741975

  • 21

    Miles WKChang DWKroll SSMiller MJLangstein HNReece GP: Reconstruction of large sacral defects following total sacrectomy. Plast Reconstr Surg 105:238723942000

    • Search Google Scholar
    • Export Citation
  • 22

    Nader RRhines LDMendel E: Metastatic sacral tumors. Neurosurg Clin N Am 15:4534572004

  • 23

    Ozdemir MHGürkan IYildiz YYilmaz CSaglik Y: Surgical treatment of malignant tumours of the sacrum. Eur J Surg Oncol 25:44491999

    • Search Google Scholar
    • Export Citation
  • 24

    Payer M: Neurological manifestation of sacral tumors. Neurosurg Focus 15:2E12003

  • 25

    Randall RLBruckner JLloyd CPohlman THConrad EU III: Sacral resection and reconstruction for tumors and tumor-like conditions. Orthopedics 28:3073132005

    • Search Google Scholar
    • Export Citation
  • 26

    Reddy SHendrickson FRHoeksema JGelber R: The role of radiation therapy in the palliation of metastatic genitourinary tract carcinomas. A study of the Radiation Therapy Oncology Group. Cancer 52:25291983

    • Search Google Scholar
    • Export Citation
  • 27

    Richtig ELudwig RKerl HSmolle J: Organ- and treatment-specific local response rates to systemic and local treatment modalities in stage IV melanoma. Br J Dermatol 153:9259312005

    • Search Google Scholar
    • Export Citation
  • 28

    Ritschl PHelwig UKotz R: [Surgical therapy of metastases of the pelvis and sacrum.]. Z Orthop Ihre Grenzgeb 130:2022061992. (Ger)

    • Search Google Scholar
    • Export Citation
  • 29

    Salehi SAMcCafferty RRKarahalios DOndra SL: Neural function preservation and early mobilization after resection of metastatic sacral tumors and lumbosacropelvic junction reconstruction. Report of three cases. J Neurosurg 97:1 Suppl88932002

    • Search Google Scholar
    • Export Citation
  • 30

    Seegenschmiedt MHKeilholz LAltendorf-Hofmann AUrban ASchell HHohenberger W: Palliative radiotherapy for recurrent and metastatic malignant melanoma: prognostic factors for tumor response and long-term outcome: a 20-year experience. Int J Radiat Oncol Biol Phys 44:6076181999

    • Search Google Scholar
    • Export Citation
  • 31

    Serafini ANHouston SJResche IQuick DPGrund FMEll PJ: Palliation of pain associated with metastatic bone cancer using samarium-153 lexidronam: a double-blind placebo-controlled clinical trial. J Clin Oncol 16:157415811998

    • Search Google Scholar
    • Export Citation
  • 32

    Simmonds PC: Palliative chemotherapy for advanced colorectal cancer: systematic review and meta-analysis. BMJ 321:5315352000

  • 33

    Stener BHenriksson CJohansson SGunterberg BPettersson S: Surgical removal of bone and muscle metastases of renal cancer. Acta Orthop Scand 55:4915001984

    • Search Google Scholar
    • Export Citation
  • 34

    Sundaresan NScher HDiGiacinto GVYagoda AWhitmore WChoi IS: Surgical treatment of spinal cord compression in kidney cancer. J Clin Oncol 4:185118561986

    • Search Google Scholar
    • Export Citation
  • 35

    Tatsui HOnomura TMorishita SOketa MInoue T: Survival rates of patients with metastatic spinal cancer after scintigraphic detection of abnormal radioactive accumulation. Spine (Phila Pa 1976) 21:214321481996

    • Search Google Scholar
    • Export Citation
  • 36

    Todd LT JrYaszemski MJCurrier BLFuchs BKim CWSim FH: Bowel and bladder function after major sacral resection. Clin Orthop Relat Res (397) 36392002

    • Search Google Scholar
    • Export Citation
  • 37

    Tokuhashi YMatsuzaki HOda HOshima MRyu J: A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976) 30:218621912005

    • Search Google Scholar
    • Export Citation
  • 38

    Tomita KKawahara NKobayashi TYoshida AMurakami HAkamaru T: Surgical strategy for spinal metastases. Spine (Phila Pa 1976) 26:2983062001

    • Search Google Scholar
    • Export Citation
  • 39

    Tu SMMillikan REMengistu BDelpassand ESAmato RJPagliaro LC: Bone-targeted therapy for advanced androgen-independent carcinoma of the prostate: a randomised phase II trial. Lancet 357:3363412001

    • Search Google Scholar
    • Export Citation
  • 40

    Wang JCBoland PMitra NYamada YLis EStubblefield M: Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. J Neurosurg Spine 1:2872982004

    • Search Google Scholar
    • Export Citation
  • 41

    Yagoda ANew cytotoxic single-agent therapy for renal cell carcinoma. Johnson DELogothetis CHvon Eschenbach AC: Systemic Therapy for Genitourinary Cancers ChicagoYear Book Medical Publishers1989. 112119

    • Search Google Scholar
    • Export Citation

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