Postoperative survival and functional outcomes for patients with metastatic gynecological cancer to the spine: case series and review of the literature

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OBJECT

Spinal metastases from gynecological cancers are rare, with few cases reported in the literature. In this study, the authors examine a series of patients with spinal metastases from gynecological cancer and review the literature.

METHODS

The cases of 6 consecutive patients who underwent spine surgery for metastatic gynecological cancer between 2007 and 2012 at a single institution were retrospectively reviewed. The recorded demographic, operative, and postoperative factors were reviewed, and the functional outcomes were determined by change in Karnofsky Performance Scale and the American Spine Injury Association (ASIA) score during follow-up. A systematic review of the literature was also performed to evaluate outcomes for patients with similar gynecological metastases to the spine.

RESULTS

In this series, details regarding metastatic gynecological cancers to the spine are as follows: 2 patients with cervical cancer (both presented at age 46 years, mean postoperative survival of 32 months), 2 patients with endometrial cancer (mean age of 40 years, mean postoperative survival of 26 months), and 2 patients with leiomyosarcoma (mean age of 44 years, mean postoperative survival of 20 months). All patients presented with pain, and no complications were noted following surgery. All patients with known follow-up had stable or improved neurological outcomes, performance status, and improved pain, without local recurrence of tumor. Overall median survival after diagnosis of metastatic spine lesions for all cases in the literature as well as those treated by the authors was 15 months. When categorized by type, median survival of patients with cervical cancer (n = 2), endometrial cancer (n = 26), and leiomyosarcoma (n = 16) was 32, 10, and 22.5 months, respectively.

CONCLUSIONS

Gynecological cancers metastasizing to the spine are rare. In this series, overall survival following diagnosis of spinal metastasis and surgery was 27 months, with cervical cancer, endometrial cancer, and leiomyosarcoma survival being 32, 26, and 20 months, respectively. Combined with literature cases, survival differs depending on primary histology, with decreasing survival from cervical cancer (32 months) to leiomyosarcoma (22.5 months) to endometrial cancer (10 months). Integrating such information with other patient factors may more accurately guide decision making regarding management of such spinal lesions.

ABBREVIATIONSASIA = American Spine Injury Association; DVT = deep vein thrombosis; KPS = Karnofsky Performance Scale; UTI = urinary tract infection.

Abstract

OBJECT

Spinal metastases from gynecological cancers are rare, with few cases reported in the literature. In this study, the authors examine a series of patients with spinal metastases from gynecological cancer and review the literature.

METHODS

The cases of 6 consecutive patients who underwent spine surgery for metastatic gynecological cancer between 2007 and 2012 at a single institution were retrospectively reviewed. The recorded demographic, operative, and postoperative factors were reviewed, and the functional outcomes were determined by change in Karnofsky Performance Scale and the American Spine Injury Association (ASIA) score during follow-up. A systematic review of the literature was also performed to evaluate outcomes for patients with similar gynecological metastases to the spine.

RESULTS

In this series, details regarding metastatic gynecological cancers to the spine are as follows: 2 patients with cervical cancer (both presented at age 46 years, mean postoperative survival of 32 months), 2 patients with endometrial cancer (mean age of 40 years, mean postoperative survival of 26 months), and 2 patients with leiomyosarcoma (mean age of 44 years, mean postoperative survival of 20 months). All patients presented with pain, and no complications were noted following surgery. All patients with known follow-up had stable or improved neurological outcomes, performance status, and improved pain, without local recurrence of tumor. Overall median survival after diagnosis of metastatic spine lesions for all cases in the literature as well as those treated by the authors was 15 months. When categorized by type, median survival of patients with cervical cancer (n = 2), endometrial cancer (n = 26), and leiomyosarcoma (n = 16) was 32, 10, and 22.5 months, respectively.

CONCLUSIONS

Gynecological cancers metastasizing to the spine are rare. In this series, overall survival following diagnosis of spinal metastasis and surgery was 27 months, with cervical cancer, endometrial cancer, and leiomyosarcoma survival being 32, 26, and 20 months, respectively. Combined with literature cases, survival differs depending on primary histology, with decreasing survival from cervical cancer (32 months) to leiomyosarcoma (22.5 months) to endometrial cancer (10 months). Integrating such information with other patient factors may more accurately guide decision making regarding management of such spinal lesions.

In the United States, the estimated incidence of gynecological cancer is approximately 11%,32 with 71,500 new diagnoses and 26,500 deaths each year.7 The 3 most common types are uterine (53%), ovarian (25%), and cervical (14%).32 Management depends on the site and extent of disease but typically involves a combination of surgery, chemoradiation, and hormone therapy. Ovarian cancer carries the poorest prognosis with a 5-year survival of 44.6% as compared with 67.9% for cervical cancer and 81.5% for endometrial cancer.25–27 Leiomyosarcoma is a rare, malignant connective tissue tumor originating from smooth muscle cells 8 and most frequently arises in the uterus, gastrointestinal tract, or retroperitoneum.31 Due to its high rate of metastatic recurrence and resistance to radiation and chemotherapy, prognosis is poor.

Metastasis of gynecological cancers varies depending on the type. Cervical cancer, endometrial cancer, and leiomyosarcoma most commonly metastasize to the lung and liver,16,22 while ovarian cancer spreads locally within the peritoneum and pelvis.20 Bone metastases are seen more commonly in cervical cancer but are infrequent in endometrial cancer and leiomyosarcoma. Among bone metastases, the spine is a common site; however, due to the rarity of this occurrence, surgical management of spinal metastases has not been well described. We retrospectively reviewed the medical records of patients who underwent surgery for spinal metastases of gynecological cancer at our institution and performed a literature review to identify other published reports to obtain more accurate prognostic information on such rare lesions.

Methods

Case Series

After obtaining approval from the institutional review board, a database of patients who underwent spine surgery for metastatic cancer from 2007 to 2012 at our institution was screened, and 6 patients were identified with primary tumors of gynecological origin that metastasized to the spine. Medical, imaging, and operative records for each of these patients were retrospectively reviewed.

Demographic factors, including age, race, smoking history, and comorbidities were reviewed. Additionally, prior cancer history, preoperative interventions, operative approach and techniques, postoperative factors, interventions, adjuvant therapies, functional outcome, and survival were assessed. The prior cancer history included primary tumor histological diagnosis, time from primary diagnosis, history of adjuvant therapies (chemotherapy, radiotherapy, etc.), time to diagnosis of spinal metastasis, and presenting symptoms. Operative factors included indication for surgery, type of surgical procedure, approach, instrumentation, levels involved, vertebrectomy, intraoperative complications, and estimated blood loss. Postoperative factors included need for blood transfusion, hospital length of stay, discharge location, adjuvant treatment, local recurrence, and survival. Functional outcome was determined by change in Karnofsky Performance Scale (KPS) score, and neurological outcome was evaluated by change in the American Spine Injury Association (ASIA) score.

Literature Review

A review of the literature was performed using PubMed as well as a review of the bibliographies of eligible articles. The search string employed for cervical cancer was (“uterine cervical neoplasms”[MeSH Terms] OR (“uterine”[All Fields] AND “cervical”[All Fields] AND “neoplasms”[All Fields]) OR “uterine cervical neoplasms”[All Fields] OR (“cervix”[All Fields] AND “cancer”[All Fields]) OR “cervix cancer”[All Fields]) AND (“spine”[MeSH Terms] OR “spine”[All Fields]) AND (“neoplasm metastasis”[MeSH Terms] OR (“neoplasm”[All Fields] AND “metastasis”[All Fields]) OR “neoplasm metastasis”[All Fields] OR “metastasis”[All Fields]). The search string for endometrial cancer was (“endometrial neoplasms”[MeSH Terms] OR (“endometrial”[All Fields] AND“neoplasms”[AllFields])OR“endometrialneoplasms” [All Fields] OR (“endometrial”[All Fields] AND “cancer” [All Fields]) OR “endometrial cancer”[All Fields]) AND (“spine”[MeSH Terms] OR “spine”[All Fields]) AND (“neoplasm metastasis”[MeSH Terms] OR (“neoplasm”[All Fields] AND “metastasis”[All Fields]) OR “neoplasm metastasis”[All Fields] OR “metastasis”[All Fields]). For Leiomyosarcoma, we used (“leiomyosarcoma” [MeSH Terms] OR “leiomyosarcoma”[All Fields]) AND (“spine” [MeSH Terms] OR “spine”[All Fields]) AND (“neoplasm metastasis”[MeSH Terms] OR (“neoplasm”[All Fields] AND “metastasis”[All Fields]) OR “neoplasm metastasis” [All Fields] OR “metastasis”[All Fields]).

Criteria for inclusion were articles written in English or those having an English translation; articles describing patients with confirmed gynecological leiomyosarcoma, endometrial cancer, or cervical cancer and metastases to the spine; and fully published, peer-reviewed studies including randomized controlled trials, nonrandomized trials, cohort studies, case control studies, case series, and case reports. Criteria for exclusion were articles with no extractable data specific to metastatic spine disease, articles looking at primary spine tumors, and studies of cases with unconfirmed primary tumor pathology.

Statistical Analysis

Survival statistics and Kaplan-Meier curves were calculated using GraphPad Prism 5.0. Cases from the literature as well as our institution were included. Cases with unknown follow-up or survival times were excluded from the analysis.

Results

Summary of Cases

Our series (Table 1) consisted of 2 patients with cervical cancer (both presented at age 46 years, mean postoperative survival of 32 months), 2 patients with endometrial cancer (mean age of 40 years, mean postoperative survival of 26 months), and 2 patients with leiomyosarcoma (mean age of 44 years, mean postoperative survival of 20 months). There were no patients with metastatic ovarian cancer to the spine. None of the patients had other medical comorbidities, although 3 patients had a smoking history. Only 1 patient had undergone prior radiation therapy for her primary tumor; none of the women received preoperative chemotherapy or neoadjuvant radiotherapy to the spine. All patients presented with focal spine pain, with 1 patient having concurrent paresthesias and another having concurrent motor weakness and gait difficulties. All patients had a preoperative ASIA score of D or E.

TABLE 1.

Individual characteristics of 6 patients with gynecological métastases to the spine

Case No.Cancer TypePatient PresentationNeurologic ExamTime to Spine Metastasis (yrs)Primary Tumor TreatmentOther Metastases at Time of SurgerySpine LocationMRI Findings
1Cervical37-yo F w/ back painNI0NoneLymph node, mediastinum, retroperitoneumT-6T-6 lesion w/ epidural extension & collapse of VB w/ fracture
2Cervical54-yo F w/1 mo of worsening back pain, tingling & numbness of leg3 of 5 strength in ilio-psoas; otherwise NI0NoneNoneL1–2Lesion at L1–2 compromising thecal sac
3Endometrial32-yo F w/1.5 yrs of It LE painNI4Hyst & BSONoneL2–3Lytic lesion at L-2 causing compression of thecal sac
4Endometrial48-yo F w/ recent neck painNI1Resection, chemoradiation, tamoxifenNoneT-1Pathologic fracture w/ expansile lesion at T-1
5Leiomyosarcoma41-yo F w/ progressive rt hip pain leading to imaging findings of spinal metsNI2Hyst w/o BSOLung, iliac boneC5–7; L-4Compression at C-6, compression at L-4 w/ epidural extension
6Leiomyosarcoma47-yo F w/1 mo history of back painNI4tastLung, liverT-9Lesion at T-9 w/ epidural & CC

BSO = bilateral salpingo-oophorectomy; CC = cord compression; Hyst = hysterectomy; LE = lower-extremity; met = metastasis; NI = neurologically intact; VB = vertebral body; yo = year-old.

Metastases were most commonly located in the thoracic spine (n = 5, 83%) and were also seen in the cervical spine (n = 1, 17%) and lumbar spine (n = 3, 50%). Indications for surgery included cord compression alone (n = 2, 33%), instability and cord compression (n = 3, 50%), and severe pain (n = 1, 17%). The 6 patients underwent a total of 8 surgeries, and all underwent tumor resection and spinal fusion (Table 2). Four patients underwent a single surgery. One leiomyosarcoma patient underwent an additional staged surgery for new spinal metastases, and 1 patient with cervical cancer underwent a staged procedure. Median blood loss for cervical cancer, endometrial cancer, and leiomyosarcoma was 200, 2425, and 550 ml, respectively. No intraoperative complications were noted, and postoperative complications included DVT, atelectasis, UTI, and intractable pain. No patients experienced instrument failure, required postoperative blood transfusion, or required revision. Median hospital stay was 7 days (range 3–9 days). Four patients were discharged to home and 2 were discharged to inpatient rehabilitation.

TABLE 2.

Patient operative characteristics

Cancer TypeTotal SurgeriesIndication for SurgerySurgery DescriptionStagedApproachInstrumentationVertebrectomyEBL (ml)
Cervical1Instability & CCT-6 vertebrectomy w/ tumor resection; T5–7 discectomy, anterior reconstruction, & arthrodesisNoAnteriorYesYes200
Cervical1Instability & CCStage 1: T11–L3 laminectomy & arthrodesis w/ L1–2 tumor resection; Stage 2: L1–2 vertebrectomy, T12–L3 anterior reconstruction, & arthrodesisYesAnterior & posteriorYesYes200
Endometrial1CCL1–3 laminectomy, L2–3 vertebrectomy, T11–L5 arthrodesisNoPosteriorYesYes4000
Endometrial1Severe painT-1 corpectomy w/ C6–T2 discectomy & arthrodesisNoAnteriorYesYes850
Leiomyosarcoma3CCC5–7 laminectomy w/ tumor resection; C5–7 posterior cervical segmentai fixationNoPosteriorYesNoNK
CCStage 1: L-4 corpectomy, tumor resection, & decompression w/ L3–5 anterior lumbar fusionYesAnteriorYesYes800
CCStage 2: L2–5 arthrodesisYesPosteriorYesNo400
Leiomyosarcoma1Instability & CCT-9 vertebrectomy w/ tumor resection, T8-T10 arthrodesis, & spinal reconstructionNoAnteriorYesYes300

EBL = estimated blood loss.

All 5 patients with follow-up had improvement or complete resolution of their pain postoperatively. Baseline KPS and ASIA scores remained stable or improved in 5 patients (83%) but was unknown in 1 patient at last follow-up (patient died 6 months after surgery). One patient received no postoperative adjuvant treatment and 5 patients received adjuvant radiation. As seen in Table 3, the total dose ranged from 3000 cGy to 3750 cGy. No patients had local recurrence of tumor as evaluated on MRI. Mean postoperative survival for leiomyosarcoma, endometrial cancer, and cervical cancer was 20, 26, and 32 months, respectively, with 2 patients (endometrial, cervical) alive at 28 and 37 months postoperatively (Table 4).

TABLE 3.

Patient postoperative characteristics

Case No.Cancer TypeTotal SurgeriesPostop ComplicationLOS (days)Discharge LocationPostop Adjuvant Therapy*Total Radiation Dose (cGy)Radiation Treatment SummaryLevels Treated
1Cervical1DVT8HomeRT3500250 cGy per day in 14 fractions to 100% isodose lineT4–8
2Cervical1None8Inpatient rehabRT3000273 cGy per day in 11 fractions to 95% isodose lineT11–L4
3Endometrial1None5Inpatient rehabRT3750250 cGy per fraction in 15 fractions delivered to 100% isodose lineT12–L4
4Endometrial1Atelectasis6HomeRTNKNK; treatment at outside hospitalNK
5Leiomyosarcoma3None3HomeRT300010 fractions; further details NK; treatment occurred at outside hospitalNK
None10Home
None10Home
6Leiomyosarcoma1Intractable postop pain; UTI9HomeNoneNANANA

LOS = length of stay; NA = not available; N K = not known; rehab = rehabilitation; RT = radiation therapy.

For spine metastases.

TABLE 4.

Patient outcomes

Case No.Cancer TypeTotal SurgeriesTime to Last Follow-Up or Death (mos)Preop KPS ScorePostop KPS ScoreChange in KPS ScorePreop ASIA ScorePostop ASIA ScoreChange in ASIA ScoreImproved PainLocal RecurrenceOutcome
1Cervical1379010StableEEStableYesNoAlive; NI
2Cervical126808)StableDEImprovedYesNoDeceased
3Endometrial1288080StableEEStableYesNoAlive
4Endometrial1259090StableEEStableYesNoDeceased
5Leiomyosarcoma3348090ImprovedDEImprovedYesNoDeceased
6Leiomyosarcoma1690No follow-upNo follow-upENo follow-upNo follow-upNo follow-upNo follow-upDeceased

Literature Review

For patients with cervical cancer, a total of 3 articles described a total of 13 cases of metastasis to the spine (Table 5). Median age at presentation was 53 years (range 30–84 years). The lumbar spine was the most common location of metastasis (10 of 13). Treatment and time to follow-up was reported for only 1 patient, who received chemoradiation and survived a few months. Only 6 (46%) of 13 patients were alive at last follow-up.

TABLE 5.

Characteristics of previously published cases of cervical cancer métastases to the spine

AuthorPatient PresentationTime to Spine MetastasisPrimary Tumor TreatmentHistologyStageLocationOther MetastasesImaging FindingsOperationAdjuvant TherapyTime to Last Follow-UpOutcome
Bassan & Glaser, 198253-yo FNKRT & hystPD SCC1BLumbarYesNKNKNKNKDeceased
48-yo FNKRT & hystPD SCC1ALumbarNoNKNKNKNKDeceased
53-yo FNKRTPD SCC1ALumbarYesNKNKNKNKAlive at last follow-up
45-yo FNKRTPD SCCIIIDorsalNoNKNKNKNKDeceased
30-yo FNKRT&hystPD SCCIBLumbarYesNKNKNKNKDeceased
84-yo FNKRTPD SCCIIBDorso-lumbarNoNKNKNKNKAlive at last follow-up
63-yo FNKRTPD SCCIIALumbarYesNKNKNKNKAlive at last follow-up
45-yo FNKChemoradiationPD SCCIIALumbarYesNKNKNKNKAlive at last follow-up
72-yo FNKRTPD SCCIIBDorsalNoNKNKNKNKAlive at last follow-up
78-yo FNKRTPD SCCIIBLumbarNoNKNKNKNKDeceased
70-yo FNKRTWell differentiated secIIBLumbarNoNKNKNKNKDeceased
George & Lai, 199560-yo F w/ a lt flank mass & weight lossNKNKNKNKL1–3NoRadiography: sclerotic L-1 VB, osteopenic L-2, & L-3 VBsNKNKNKNK
Ferroir et al., 200137-yo F w/ neck pain, paresthesias of the face & neck, & difficulty w/ phonation & swallowingOyrBrachytherapy w/ colpohysterectomyInvasive epidermoid carcinomaNKOccipito-ver-tebral junctionYesCT: osteolysis of clivus, mass at C-1NoneRT & systemic chemo: 6 courses of cisplatin & 5-FUFew mosDeceased

Chemo = chemotherapy; PD = poorly differentiated; SCC = squamous cell carcinoma; 5-FU = 5-fluorouracil.

For patients with endometrial cancer, 6 articles described a total of 25 cases of metastasis to the spine (Table 6). Median age at presentation was 62 years (range 47–80 years). Of the 16 cases with described metastasis location, the most common location involved was the thoracic spine (7 of 16), followed by the sacrum (6 of 16). Two patients were treated surgically: 1 patient underwent a sacrectomy through a posterior approach from S2, with en bloc excision of metastasis, and the other patient underwent T12 vertebrectomy and anterior spinal fusion. Of the 24 patients with known survival, median survival was 9 months (range 1–199 months). The 1-year and 5-year survival rates were 38% and 8.3%, respectively. Only 4 patients (16%) were alive at last follow-up, including the 2 patients who were treated surgically.

TABLE 6.

Characteristics of previously published cases of endometrial cancer métastases to the spine

AuthorPatient PresentationTime to Spine Metastasis (mos)Primary Tumor TreatmentHistologyStage/GradeLocationOther MetastasesImaging FindingsOperationAdjuvant TherapyTime to Last Follow-Up (mos)Outcome
Albareda et al., 200862-yo F w/ sacral met found on imaging36TAH/BSOACIB/G1SacrumNoMRI: 3.5 massSacrectomy through posterior approach from S-2 w/ en bloc excision of metPalliative treatment w/ external radiotherapy (30 Gy) & external beam (37 Gy); medroxyprogesterone at 140 mg/day.26Disease free & asymptomatic
Arnold et al., 200363-yo F w/ 6-mo history of LBP, & 3-wk history of leg weakness0TAH/BSOACIVB/G1T-12NoRadiography: lysis of T-12 & 12th ribT12 Vertebrectomy & anterior spinal fusionPostop RT to thoracolumbar spine for 2 mos; medroxyprogesterone 500 mg/day60Disease free & asymptomatic
Kararmaz et al., 200267-yo F w/ complete paraplegia after spinal epidural anesthesia0NKNKNKT-6NoMRI: tumor at T-6 compressing cordNoneRT & chemoNKNK
Kehoe et al., 201061-yo F44TAH/BSO, WPRTACIIIA/G1VertebraeNKNKNKRT12Deceased
65-yo F3WPRT, interstitial RTACIIIB/G3VertebraeYesNKNoneChemo9Deceased
58-yo F10TAH/BSOACIA/G3L4–5NKNKNKRT & chemo199Alive w/ disease
47-yo F0TAH/BSO, chemoACIVB/G2VertebraeYesNKNoneRT & chemo27Deceased
55-yo F25TAH/BSOACUnstaged/G2VertebraeYesNKNoneChemo7Deceased
71-yo F16SCH/BSO, chemoACIVB/G2L1, L3–4NKNKNoneNone1Deceased
74-yo F8TAH/BSO, WPRTACIB/G3VertebraeYesNKNoneRT & chemo5Deceased
62-yo F1TAH/BSO, WPRT, IVRTACIVB/G3VertebraeNKNKNoneRT & chemo16Deceased
62-yo F11TAH/BSO, WPRT, IVRTACIIIC/G2VertebraeYesNKNKNone54Deceased
52-yo F148TAH/BSO, WPRTNKUnstaged/NKVertebraeNKNKNKNone7Deceased
77-yo F0TAH/BSO, WPRTACIVB/G3SacrumYesNKNoneRT & chemo8Deceased
Loizzi et al., 200651 -yo F w/ 3-mo history of cervical pain0TAH/BSOACIVB/G3C5–7NoCT: metastatic lesions to C5–7 &C-3 fractureNoneChemo: 1 cycle of cisplatin, doxorubicin, & zoledronic acid2Deceased
Uccella et al., 201365-yo F w/ weakness, decreased sensation8NKACUnstaged/G2T-5NoNKNKRT & HT9Deceased
66-yo F w/ pain, inflammation18NKSerousIIIC/G3T-12YesNKNoneBisphosphonates6Deceased
71-yo F w/ pain3NKACIC/G3SacrumYesNKNoneRT6Deceased
69-yo F w/ pain49NKACIB/G3SacrumYesNKNoneHT31Deceased
62-yo F w/ pain14NKACIIIC/G3T-4, T-11, sacrumYesNKNoneRT6Deceased
62-yo F w/ pain, limp20NKACIB/G2SacrumNoNKNoneRT & HT11Deceased
70-yo F w/ pain20NKACIB/G2T-9, L-3YesNKNoneRT5Deceased
59-yo F w/ pain13NKACIC/G1T-10NoNKNoneRT119No evidence of disease
80-yo F w/ pain0NKACIVB/G3SacrumYesNKNoneHT2Deceased
60-yo F w/ pain34NKSerousIB/G3L-3NoNKNoneRT14Deceased

AC = adenocarcinoma; HT = hormone therapy; IVRT = intravaginal radiotherapy; SCH = supracervical hysterectomy; TAH = total abdominal hysterectomy; WPRT = whole pelvic radiation therapy.

For patients with leiomyosarcoma of gynecological origin, a total of 11 articles describing 18 cases of spine metastasis were found (Table 7). Median age at presentation was 49 years (range 35–64 years). The most common location involved was the thoracic spine (10 of 18), followed by the lumbar spine (9 of 18). Thirteen patients were treated surgically. Four patients developed postoperative recurrence in the spine. Of the 14 patients with known survival, the median survival was 22.5 months (range 3.3–120 months). The 1-year and 5-year survival rates were 64% and 21%, respectively. Ten patients were alive at last follow-up.

TABLE 7.

Characteristics of previously published cases of leiomyosarcoma metastasis to the spine

AuthorPatient PresentationTime to Spine Metastasis (yrs)Primary Tumor TreatmentPhysical ExamLocationOther MétastasesImaging FindingsOperationAdjuvant TherapyTime to Last Follow-Up (mos)Outcome
Arnesen & Jones, 199256-yo F w/ LE pain & tetraplegia5HystNKT11–12NoneMRI: destructive lesion involving the posterior elementsDecompressive surgeryRT6Alive at last follow-up
Elhammady et al., 200745-yo F w/ history of lumbosacral pain, found to have spine mets on imaging0NoneNormalL-2NoneMRI: low signal on T1-weighted images, heterogeneous signal on T2-weighted signal, & enhancementL-2 corpectomy, gross total resection, reconstruction & fusionChemo & RT: Adriamycin & cisplatin, cyberknife42Alive at last follow-up
46-yo F w/ LBP, LE numbness14HystNKT-11, L-2NoneCT/MRI: lytic lesion involving vertebrae; PET: hypometabolicBilat transpedicu-lar decompression & instrumentation at T-11 & L-2None36Alive at last follow up
36-yo F w/ LBP, rt LE pain6HystNKL-5NoneCT/MRI: multiple blastic lesions & a lytic lesion involving L-5 vertebrae w/ retroperitoneal & epidural componentsDecompressive laminectomy & instrumented fusionChemo: adriamycin108Deceased
42-yo F w/ LBP, It LE pain12HystNKL-3NoneMRI: hypointense lesion on T-1, heterointense on T-2, lesion involving the vertebraeDecompressive laminectomy & instrumented fusionNone96Alive at last follow-up
Gardner, 191755-yo F w/ pain, tetraplegia1HystNKT-1, T-3RibsNKNKNone48Deceased
Nanassis et al., 199946-yo F w/ 2 wks of neck pain, rapidly progressive paraplegia3HystIncomplete spastic paraplegia, complete loss of sensory function distal of T5–6 dermatomesT2–3NoneMRI: extramedullary lesion in extradural space at T2–3 dorsal to cordDecompressive surgery & tumor resectionNone2213 mos after surgery: free of clinical symptoms. She developed widespread mets 9 mos after this w/ lesions in skull, L-2, sacral bone, & It ischiadic bone.
Robbins, 194356-yo F w/ back pain radiating to the legs1HystNKL-2NoneBlastic lesion, myelographie block at L-2NKRT12Deceased
51-yo F w/ LBP3HystNKL-4NKBlastic lesionNKRT120Deceased
Schjott-Rivers, 194951-yo F w/ LBP3HystNKL-5NKCompression fractureNKRTNKNK
Shapiro, 199264-yo F w/ progressive tetraparesis15HystNKT-5NoneMyelographie block at T-5, mass arising from laminaDecompressive surgeryRT12Alive at last follow-up
Takemori et al., 199347-yo F w/ back pain for 2 mos2HystNKT-8NoneMRI: solitary met in T-8T-8 corpectomy w/ ceramic prosthesis & anterior spinal stabilizationChemo: 4 courses of cyclophos-phamide, vincristine, adriamycin, dacarbazineNKAlive at last folllow-up w/ no evidence of recurrence
Tan et al., 201344-yo F w/ 1-mo history of It LE monoplegia, decreased sensation below T-4 dermatome, urinary incontinence3HystQuadriparesis, decreased sensation below T-4 dermatomeC6–T2NoneMRI: diffusely enhancing intra-medullary lesion from C-6 to T-2C5–T2 reconstructive laminoplasty w/ tumor resectionRT & chemo: EBRTw/ 5000 cGy in 25 fractions; doxorubicin & ifosfamideNKNK
Willis, 197347-yo F w/ back pain immediately following treatment for primary cancer (leiomyosarcoma)0HystNKLumbar spineNoneLytic lesionNKNoneWksDeceased
Ziewacz et al, 201235-yo F w/ radiating pain in arm & backNKNKNKT1–3NKNKT-2 hemilaminectomy w/ tumor resection, C6–T4 posterior fusionChemo & RT11.5Tumor recurred at 7 mos w/ repeat surgery at 9 mos postop
57-yo F w/ back pain, sensory changes, loss of function in hand, autonomie dysfunction, inability to ambulateNKNKNKT-1NKNKC7-T2 laminectomy, T-1 corpectomy, C5–T3 posterior fusionChemo & RT20.3Tumor recurred at 9 mos postop requiring repeat surgery
57-yo F w/ rt foot tingling, radicular pain in buttocks & thighNKNKNKL4–S1NKNKL4–S1 hemilaminectomyChemo & RT23Tumor recurred at 13.8 mos requiring repeat surgery
51-yo F w/ bilat LE weakness, tingling, & numbnessNKNKNKT2–4NKNKT2–4 laminectomy, T1–5 posterior fusionNone3.3Deceased

EBRT = external beam radiotherapy; LBP

Patient Survival

Among our cases and the cases found in the literature, 2 cases of cervical cancer, 26 cases of endometrial cancer, and 16 cases of leiomyosarcoma had known survival after diagnosis of spinal metastasis. Of note, for cervical cancer, our case series is the first to report known survival times for spinal metastasis; the prior 13 cases found in the literature did not report survival. Overall median survival for all cases was 15 months (Fig. 1). Based on our cases and the cases found in the literature, median survival of cervical cancer, endometrial cancer, and leiomyosarcoma patients was 32, 10, and 22.5 months, respectively (Fig. 2).

FIG. 1.
FIG. 1.

Graph showing overall survival of all patients with gynecological metastases to the spine.

FIG. 2.
FIG. 2.

Graph showing survival of patients with gynecological metastases to the spine by cancer type. For cervical cancer, survival is based on the 2 patients in our case series; the 13 cases found in the literature did not report survival and were excluded. For endometrial cancer, survival was calculated from our 2 cases as well as 24 cases from the literature with known survival; 1 case from the literature was excluded. For leiomyosarcoma, survival was calculated from our 2 cases and 14 cases from the literature; 4 cases from the literature were excluded. Figure is available in color online only.

Discussion

In our series, overall survival following spine surgery for such lesions was 27 months, with cervical cancer, endometrial cancer, leiomyosarcoma survival being 32, 26, and 20 months, respectively. Combined with cases from the literature, median survival of cervical cancer (n = 2), endometrial cancer (n = 26), and leiomyosarcoma (n = 16) patients was 32, 10, and 22.5 months, respectively. Although surgery for leiomyosarcoma spine metastases has shown benefit in improving pain and neurological function,9,38 similar to other spinal metastases,6,13 to the best of our knowledge, the surgical outcomes of patients with cervical or endometrial metastases to the spine has not been reported. Here, we present a case series of patients who underwent resection of a gynecological metastasis spinal lesion and combine our series with all reported cases in the literature.

Surgery for Spinal Metastasis From Cervical Cancer

For cervical cancer, the reported prevalence of spine metastases ranges from 0.6% to 6.5%, with the lumbar spine being the most common site.4,10,12,19,23,28,35 Once diagnosed with bone metastases from cervical cancer, treatment is focused on palliation as prognosis is poor, with the majority of patients dying within 1 year.23 Interestingly, the primary tumor of both of our patients with cervical cancer was diagnosed after presenting with spine metastases. They survived an average of 32 months; however, their survival is difficult to compare with prior studies, which examine length of survival of all patients with bone metastases rather than survival of those with spine metastases alone. In these studies, survival from discovery of bony metastases ranges from 2 to 7 months.10,23,28,35 From case reports (Table 5), 6 (46%) of 13 reported patients were alive at last follow-up, but survival rates at specific time points could not be calculated as length of survival was not reported in these cases.

Surgery for Spinal Metastasis From Endometrial Cancer

The majority of endometrial spine metastases are presented as case reports or case series (Table 6).1,3,17,18,21,36 Based on these studies, there appears to be no predilection of location within the spine, and treatment is typically non-surgical. Prognosis is similarly poor, with the majority of patients dying from their disease, with a median survival in the literature of 6–9 months after diagnosis of spine metastasis.18,36 From the reported literature cases alone (Fig. 2), 1-year and 5-year survival rates were 38% and 8.3%, respectively, with an overall median survival of 9 months. Our patients with endometrial spine lesions survived for a median of 26 months after discovery of their spine metastasis. Of note, our series showed a substantially larger blood loss with such lesions compared with the cases of cervical cancer and leiomyosarcoma. Such a finding can likely be explained by the high vascularity of the primary organ itself, namely the endometrium, and thus concern for increased blood loss should be expected when operating on such lesions.

Surgery for Spinal Metastasis From Leiomyosarcoma

Leiomyosarcoma metastases to the spine have been well-described, affecting younger patients and having a predilection for the thoracic or lumbar spine.9,38 Our patients had a mean age of 44 years, which is younger than the mean age of 50.9 and 53.8 years as described by Elhammady et al. and Ziewacz et al., respectively.9,38 Previously reported survival ranges from weeks to 13 years 9 (Table 7) and generally seems to be longer than that for other gynecological malignancies. One-year and 5-year survival of patients from case reports (Fig. 2) is 64% and 21%, respectively, with an overall median survival of 22.5 months. In our series, patients with leiomyosarcoma had the shortest survival, dying 20 months after spine metastasis diagnosis. This may be due to the fact that our patients had widespread metastases at the time of diagnosis. As has been previously shown,9,38 surgery with intralesional resection and stabilization improved pain and neurological function in our patients.

Surgical Outcomes for All Gynecological Cancers

In all of our patients with spine metastasis secondary to gynecological cancer, surgery was safe and without postoperative complications. All of our patients with known follow-up had stable or improved neurological outcomes, performance status, and improved pain, without local recurrence of tumor. Due to the limited number of cases in our study, the variation in survival as compared with the literature may be due to several factors such as differences in the grading, stage, and treatment of the primary tumor; involvement of the spine metastases; and baseline health of the patients at presentation. Another limitation of our study is that due to its retrospective nature, formal quality of life measures via instruments like the SF-36 or QoL5 could not be obtained and evaluated.

Spinal metastases of gynecological cancer are relatively rare, and because of this, prior reports are generally described within the context of all bony metastases, regardless of location. Additionally, few reports exist on the surgical outcomes for these patients, and thus the survival, complications, and patient satisfaction following surgery for spinal metastases from such malignancies are not clearly defined. Although our experience shows that surgery can be effective in improving pain and neurological function in a small number of patients with gynecological metastases to the spine, further prospective studies that include formal quality of life measures are needed to understand the outcomes following surgery for patients affected by these rare lesions.

Conclusions

Gynecological cancers rarely metastasize to the spine. Combining such information with other preoperative factors may more accurately aid in surgeon management of these rare spinal lesions. When combined with previously reported cases in the literature, overall survival of all patients following diagnosis of gynecological metastasis to the spine was 15 months. Survival differs depending on primary histology, with decreasing survival from cervical cancer (32 months) to leiomyosarcoma (22.5 months) to endometrial cancer (10 months).

Author Contributions

Conception and design: Sciubba, Liu, Sankey, Goodwin. Acquisition of data: Sciubba, Liu, Sankey, Bydon, Witham, Wolinsky, Gokaslan. Analysis and interpretation of data: Sciubba, Liu, Sankey, Goodwin. Drafting the article: Sciubba, Liu, Sankey, Goodwin. Critically revising the article: Sciubba, Liu, Sankey, Goodwin, Kosztowski, Elder. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Sciubba. Statistical analysis: Liu, Sankey. Administrative/technical/material support: Sciubba. Study supervision: Sciubba, Goodwin, Elder, Bydon, Witham, Wolinsky, Gokaslan.

References

Article Information

Correspondence Daniel M. Sciubba, Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-109, Baltimore, MD 21287. email: dsciubb1@jhmi.edu.

* Ms. Liu and Mr. Sankey contributed equally to this work.

INCLUDE WHEN CITING Published online September 11, 2015; DOI: 10.3171/2015.3.SPINE15145.

Disclosure Ms. Liu reports being a Howard Hughes Medical Institute Research Fellow. Dr. Goodwin reports being a UNCF Merck postdoctoral fellow and receiving an award from the Buroughs Wellcome Fund. Dr. Witham reports receiving support from Eli Lilly and Company and the Gordon and Marilyn Macklin Foundation for non-study-related clinical or research effort as well as honoraria from AO Spine North America for CME courses. Dr. Bydon reports receiving a research grant from DePuy Spine and serving on the clinical advisory board of MedImmune, LLC. Dr. Gokaslan reports stock ownership in US Spine and Spinal Kinetics; consulting, speaking, and teaching for the AO Foundation; and receiving research support from DePuy, NREF, AOSpine, and AO North America. Dr. Sciubba reports being a consultant for DePuy Synthes, Medtronic, NuVasive, Stryker, and Globus.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Graph showing overall survival of all patients with gynecological metastases to the spine.

  • View in gallery

    Graph showing survival of patients with gynecological metastases to the spine by cancer type. For cervical cancer, survival is based on the 2 patients in our case series; the 13 cases found in the literature did not report survival and were excluded. For endometrial cancer, survival was calculated from our 2 cases as well as 24 cases from the literature with known survival; 1 case from the literature was excluded. For leiomyosarcoma, survival was calculated from our 2 cases and 14 cases from the literature; 4 cases from the literature were excluded. Figure is available in color online only.

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