Safety of percutaneous vertebroplasty for the treatment of metastatic spinal tumors in patients with posterior wall defects.

PURPOSE: To assess the clinical effect of percutaneous vertebroplasty (PVP) in the treatment of metastatic spinal tumors in patients with posterior wall defect. METHODS: The treated vertebrae bodies were divided into four groups: group A, non-posterior vertebral wall defect; group B, posterior vertebral wall with cribriform defects; group C, posterior vertebral wall with local fragmentation defects; group D, posterior vertebral wall with severe defects. The injected volume of bone cement, visual analogue scale (VAS) score, Karnofsky Performance Scale (KPS), cement leakage and survival were analyzed. RESULTS: The injected volume of bone cement for group A was significantly higher than posterior wall defect group (including group B, C, and D). No significant differences about the injected volume of bone cement among the posterior wall defect groups. The incidence of bone cement leakage for group A was not significantly different as compared to posterior vertebral wall defect group. However, there were significant differences with respect to the incidence of bone cement leakage among the posterior wall defect groups. In four groups the postoperative VAS pain scores and KPS were statistical different as comparison to the preoperative values. No statistical difference with respect to the VAS pain scores and KPS was observed at any time point between the non-posterior wall defect group and posterior wall defect group. CONCLUSION: PVP can be an effective treatment for metastatic spinal tumors in patients with posterior wall deficiency; however, care should be taken to control the distribution of the bone cement due to the relatively high risk of cement leakage.

Minimal access versus open spinal surgery in treating painful spine metastasis: a systematic review.

STUDY DESIGN: The study design of this paper is a systematic review of literature published in the recent 10 years. OBJECTIVE: It is the objective of this paper to compare the clinical efficacy and safety of minimal access (MIS) spinal surgery and open spinal surgery for treating painful spine metastasis. METHODS: Two research questions below were determined through a consensus among a panel of spine experts. A systematic review of literature on spinal surgery was conducted by searching PubMed with a combination of keywords including "metastatic", "metastasis", "metastases", "spinal", and "spine". Independent reviewers selected the articles for analysis after screening the titles, abstracts, and full texts, then extracted data and graded the quality of each paper according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Specific clinical questions were as follows: 1. In patients with spine metastatic disease, what is the impact of different surgical approaches (MIS versus open) on pain relief and functional outcome? 2. In patients with metastatic disease, what is the impact of different surgical approaches (MIS versus open) on local recurrence, survive rate, and complication? RESULTS: A total of 1,076 abstracts were identified using various keywords. 5 prospective (level II) and 12 retrospective articles (level III) were eligible for inclusion, involving a total of 979 cases of spine metastasis. There were 345 cases in 8 studies regarding the clinical evaluation of MIS spinal surgery and 634 cases in 9 studies regarding the clinical evaluation of open spinal surgery for spine metastasis. CONCLUSION: Both open spinal surgery and MIS seem to achieve the improvement of pain and neurological dysfunction through decompression and stabilization for patients with spine metastasis, but open surgery may involve more major complications with a trend of lower survival rates and higher recurrence rates compared to MIS.

Percutaneous vertebroplasty combined with interstitial implantation of 125I seeds in banna mini-pigs.

BACKGROUND: Although brachytherapy is one of the most effective ways to treat metastatic spinal tumor with little damage to surrounding healthy tissue, it may cause radiation myelopathy if an overdose occurs. Establishing a valuable animal model can help to find a method to overcome its complications. In the current study, we set up a banna mini-pig model to mimic percutaneous vertebroplasty with 125I seed implantation. METHODS: Percutaneous vertebroplasty (PVP) combined with interstitial implantation of 125I seeds, 125I seeds were transplanted into the vertebral body at the T13 level of the spine in banna mini-pigs. After raising them for up to eight months, the spinal cord and vertebral body were collected for pathological analysis. RESULTS: A potential animal model had been successfully established, no case of radiation myelopathy was found in any of the treated banna pigs, and no significant cellular impairment was noted by pathological analysis. CONCLUSIONS: It proves that PVP with 125I brachytherapy is an effective method to treat metastasis spinal tumor, and that the banna mini-pig can be a suitable model to investigate the mechanism of brachytherapy complications.

Treatment of MM-associated spinal fracture with percutaneous vertebroplasty (PVP) and chemotherapy.

PURPOSE: To investigate the effect of treatment of multiple myeloma (MM)-associated spinal fracture with percutaneous vertebroplasty (PVP) and chemotherapy. METHODS: Patients with MM-associated spinal fracture were randomly divided into combined (PVP and chemotherapy) treatment group (n = 38) and single chemotherapy group (n = 38). For the combined treatment group, bone cement was injected into vertebral body via DSA guided-percutaneous puncture. M2 scheme was used for both groups. And a 5-year follow-up was conducted for the study. RESULTS: At the 1-year follow-up visits, PVP combined with chemotherapy achieved complete remission (CR) in six patients (15.8%); near complete remission (nCR) in ten patients (26.30%); partial remission (PR) in nine patients (23.7%); minimal response (MR) in three patients (7.9%); no change (NC) in four patients (10.5%), and disease progression (DP) in five patients (13.2%). Only chemotherapy alone resulted in 3 CR (7.9%); 8 nCR (26.30%); 19 PR (77.5%); 4 MR (17.5%); 4 NC (17.5%), and 2 DP (5.0%). While the overall response rate (ORR) in the combined treatment group (65.8%) and the single chemotherapy group (50.0%) were significantly different, their visual analog pain scales (3.01 ± 0.62 and 5.97 ± 0.40, respectively) and Karnofsky performance scores (89.4 ± 6.3 and 80.3 ± 7.2, respectively) were significantly improved after treatment (P = 0.032 and P = 0.002, respectively). And the ORR between the two groups were significantly different (P = 0.001). CONCLUSION: Percutaneous vertebroplasty is a minimally invasive surgery for MM-associated pathologic fracture. PVP had the characteristics of minimal trauma, easy operation and less complication. PVP can achieve long-term analgesic effect, and enhance the spinal stability.

Study of treatment using percutaneous acetabuloplasty and interstitial implantation of (125)I seeds for patients with metastatic periacetabular tumors.

BACKGROUND: The periacetabular area is one of the primary sites of metastatic tumors, which often present as osteolytic bone destruction. Bone destruction in the acetabulum caused by metastatic tumors will cause hip pain and joint dysfunction. It results in decreased quality of life for patients. The aim of our study was to explore the clinical effect of metastatic periacetabular tumors treated with percutaneous cementoplasty and interstitial implantation of (125)I seeds. METHODS: A retrospective analysis was performed on 24 patients with metastatic periacetabular tumors who underwent combined therapy of percutaneous acetabuloplasty and interstitial implantation of (125)I seeds between February 2003 and June 2011. There were 13 males and 11 females aged 19-80 years with a mean age of 57.3. The primary tumor site was the lung in eight cases, the breast in six, the prostate cancer in eight, and the liver in two. The amount of implanted (125)I seeds was 12-20 seeds/person, with a mean of 16.5 seeds/person, and the matching peripheral dosage (MPD) was 80~100Gy. Routine postoperative chemotherapy and other combined treatments were applied to patients after the surgical operation. Changes in the Karnofsky Score(KPS), Harris Hip Score(Harris), and Visual Analog Scale(VAS) were observed during the follow-up period. RESULTS: The 24 patients' operations were all successful. No major complications occurred. Complete pain relief was achieved in 58% (14 of 24) of patients, and pain reduction was achieved in the 42% remaining (10) patients. The mean duration of pain relief was 8.3 months. Pain recurred in one patient 3 months after surgery. Six patients had died and 18 patients were alive at the time of the 1-year follow-up. Comparing the KPS, Harris and VAS scores pre- and postoperativelyat 1, 6, and 12 months, the combined therapy method was significantly effective in metastatic periacetabular tumor patients (P<0.05). CONCLUSIONS: Percutaneous cementoplasty with interstitial implantation of (125)I seeds is an effective treatment method for metastatic periacetabular tumor patients, providing tumor resistance, pain relief, increased bone stability, and improved quality of life for patients.

Pathological impairments induced by interstitial implantation of 125I seeds in spinal canal of banna mini-pigs.

BACKGROUND: Use a banna mini-pig to set up 125I implantation model, and investigate the consequence of radiation-related impairments. METHODS: In present study, 125I seeds were implanted into spinal canal of T13 level of spine in banna mini-pigs. After operation, the pigs were raised up to 8 months, behavior changes were recorded within this period. After 8 months, spinal cords were collected for pathological analysis. RESULTS: In this study, a 125I brachytherapy animal model had been successfully established, in the model group, the banna pigs' Tarlov scale decreased from 5 to 2.57 ± 0.36, significant cellular impairments were noted by pathological analysis. CONCLUSIONS: Without any protection and operation improvement, 125I implantation can cause serious histological impairments and moving difficulty for banna mini-pigs; this present research provides an alternative tool to study spinal 125I brachytherapy.

Total femur replacement with 18 years of follow-up: A case report.

BACKGROUND: Osteosarcoma is one of the most common primary malignant bone tumors and is more common in adolescents. The femur is the most common site of osteosarcoma, and many patients require total femur replacement. We reviewed the relevant literature and case findings, summarized and analyzed this case in combination with relevant literature, and in doing so improved the understanding of the technology. CASE SUMMARY: The case we report was a 15-year-old patient who was admitted to the hospital 15 days after the discovery of a right thigh mass. The diagnosis was osteosarcoma of the right femoral shaft. After completion of neoadjuvant chemotherapy and preoperative preparation, total right femoral resection + artificial total femoral replacement was performed. Then, chemotherapy was continued after surgery. The patient recovered well after treatment, and the function of the affected limb was good. No recurrence, metastasis, prosthesis loosening, dislocation, fracture or other complications were found during 18 years of follow-up. At present, the patient can still work and lives normally. The results of the medium- and long-term follow-up were satisfactory. CONCLUSION: Artificial total femur replacement is a feasible limb salvage operation for patients with femoral malignant tumors, and the results of medium- and long-term follow-up are satisfactory.

Treatment of metastatic spinal tumors by percutaneous vertebroplasty versus percutaneous vertebroplasty combined with interstitial implantation of 125I seeds.

BACKGROUND: As the most frequent bone metastasis, spinal metastases cause severe pain and damage to vertebral bodies such as spinal osteolytic destruction and compression fractures. To avoid the trauma and complications of open surgery, a minimally invasive procedure, percutaneous vertebroplasty (PVP), has recently been developed to treat metastatic spinal tumors. PURPOSE: To analyze the treatment outcomes of metastatic spinal tumors by percutaneous vertebroplasty (PVP) alone or PVP combined with interstitial implantation of 125I seeds. MATERIAL AND METHODS: 80 patients with metastatic spinal tumors were randomized to receive PVP alone (40 cases) or PVP combined with 125I seed implantation (40 cases). Digital subtraction angiography (DSA)-guided vertebroplasty was performed under local anesthesia, and acrylic bone cement was injected into the vertebra through a bone trocar to the center of the lesion, with or without simultaneous interstitial implantation of 125I seeds. RESULTS: At 6-month follow-up, PVP combined with 125I seed implantation resulted in zero cases with complete relief (CR), 36 with partial relief (PR), four with no changes (NC), and zero with progression of disease (PD), while PVP alone without seed implantation resulted in 0 CR, 31 PR, 7 NC, and 2 PD. While the combined-treatment group and the single-PVP group showed overall clinical benefit rates without significant difference (100% and 95.0%, respectively), their visual analogue pain scales (VAS; 2.26+/-1.05 and 5.41+/-0.94, respectively) and Karnofsky performance scores (KPS; 92.5+/-7.1 and 87.7+/-7.3, respectively) were significantly different after treatment (P = 0.028 and P = 0.009, respectively). Patients in both groups had 1-year follow-up, and the mean time to tumor progression (TTP) was 9.0 and 8.9 months, respectively (not significant). CONCLUSION: PVP is a minimally invasive procedure with small wounds and minor complications. It is effective in the alleviation of pain in metastatic spinal tumor patients, and its clinical outcomes can be enhanced by the combination of interstitial implantation of 125I seeds.

Clinical investigations on the spinal osteoblastic metastasis treated by combination of percutaneous vertebroplasty and (125)I seeds implantation versus radiotherapy.

To investigate the clinical efficacy of combining digital subtraction angiography-guided percutaneous vertebroplasty (PVP) and (125)I seeds implantation for the treatment of spinal osteoplastic metastasis. A combination of PVP and (125)I implantation was conducted for 50 patients with spinal osteoplastic metastasis, while the other 50 patients who received regular radiation therapy were used as a comparison. Visual analogue pain scale (VAS) and score of life quality (EORTCQLQ-30) were determined for all the patients. Surgery was successful in 89 spinal segments of vertebral body in 50 patients. Each segment of vertebral body was injected with 1-5 mL (2.8 mL for thoracic and 3.1 mL for lumbar vertebral body on average) of bone cement. Postoperative X-ray and CT examination showed that all the patients in the PVP group achieved spinal stability. During the follow-up examination from 6 months to 5 years, 49 patients (98.0%) had significantly relieved back pain, and only 1 case (2.0%) had no obvious improvement. Postoperative VAS score and Karnofsky performance score (KPS) were significantly different from the preoperative scores (p<0.05); and compared to the regular treatment group, PVP combined (125)I seeds showed much better clinical efficacy (p<0.05). PVP is a minimally invasive treatment with easy operation and less complications. PVP can effectively relieve the pain, stabilize the spine, improve the life quality, and reduce the occurrence of paraplegia in patients with spinal osteoplastic metastasis. Utilization of (125)I seeds with PVP can enhance the clinical efficacy.

Regulation of autophagy via PERK-eIF2α effectively relieve the radiation myelitis induced by iodine-125.

Radiation myelitis is the most serious complication in clinical radiotherapy for spinal metastases. We previously showed that (125)I brachytherapy induced apoptosis of spinal cord neurons accompanied by autophagy. In this study, we further investigated the mechanism by which (125)I radiation triggered autophagy in neural cells. We found that autophagy induced by (125)I radiation was involved in endoplasmic reticulum (ER) stress and mainly dependent on PERK-eIF2α pathway. The expressions of LC3II, ATG12 and PI3K were significantly suppressed in PERK knockout neural cells. Meanwhile, the expressions of phosphorylated-Akt s473 and caspase3/8 all significantly increased in neural cells transfected with a PERK siRNA and which enhanced apoptosis of neurons after (125)I radiation. The results were consistent with that by MTT and Annexin-FITC/PT staining. In animal model of banna pigs with radiation myelitis caused by (125)I brachytherapy, we have successfully decreased PERK expression by intrathecal administration of the lentivirus vector. The apoptosis rate was significantly higher than that in control group and which deteriorated radiation myelitis of banna pigs. Thus, autophagy caused by (125)I radiation was mainly as an attempt of cell survival at an early stage, but it would be a self-destructive process and promoted the process of apoptosis and necrosis radiated by (125)I for more than 72 hours. The study would be useful and helpful to maximize efficiency of radiation therapy in clinical therapy.

Changes in cell cycle, apoptosis and necrosis following the establishment of a (125)I brachytherapy model in the spinal cord in Banna mini-pigs.

Brachytherapy is regarded as the most effective method in the treatment of metastatic spinal tumors since little damage is caused to surrounding healthy tissue. However, this method may cause radiation myelopathy if an overdose occurs. In the present study, we established a Banna mini-pig (125)I spinal cord implantation model to provide a tool for the study of how to reduce these types of side effects. Cell cycle alteration, apoptosis and necrosis of spinal cord neurons in the presence of various doses and durations of (125)I brachytherapy were also investigated. The pigs were randomly divided into four groups, A, B, C and D. In group A, four (125)I seeds (total radioactivity, 4.0 mCi) were implanted into the dura mater of the spinal canal at the level of T13. In groups B and C, eight (125)I sources (total radioactivity, 8.0 mCi) were inserted at the same location. Groups A and C were raised for up to 8 months and group B for only 2 months. Neurons from the swine spinal cord at the T13 level were collected and cell cycle analysis was performed. Apoptosis and necrosis were tested by a terminal deoxynucleotidyl transferase dUTP nick end-labeling (TUNEL) assay. The Banna mini-pig brachytherapy model was successfully established. Radiation myelopathy was closely associated with radiation dose and duration, more neurons were blocked in the G2 and S phases as dose and time increased, and an increase in apoptosis and necrosis was detected. Ratios of apoptosis and necrosis were reduced as lower doses and shorter durations of radiation were applied. Our results demonstrate that the Banna mini-pig is an ideal animal to study (125)I brachytherapy. Low-dose and short-term brachytherapy may effectively decrease apoptosis and necrosis in spinal cord cells in Banna mini-pigs.

Clinical features of malignant melanoma of the finger and therapeutic efficacies of different treatments.

The purpose of this study was to explore the clinical features of malignant melanoma of the finger and therapeutic efficacies of different treatments. The clinical data of 22 patients with malignant melanoma of the finger (confirmed by pathological examination), admitted and treated in our hospital between February 1995 and October 2007, were analyzed retrospectively. The primary site of the tumor was the thumb in 12 cases, index finger in 3 cases, middle finger in 3 cases, ring finger in 2 cases and little finger in 2 cases. The most common presenting symptoms were pain and black patches on the fingers. A total of 15 of the 22 patients had subungual disease, 12 had a history of trauma and 2 had osteolytic bone lesions of the phalanx. The main treatments employed were surgery, chemotherapy and immunotherapy. Finger amputation was performed for all 22 patients and axillary lymph node dissection in the same side was performed for 13 patients. Nineteen cases were followed up for 1-10 years with an average of 5.5 years. Three patients were lost to follow-up 2 years after treatment. The 1-, 3- and 5-year survival rates were 86.4% (19/22), 42.1% (12/19) and 31.2% (6/19), respectively. In conclusion, malignant melanoma of the finger is a rarely occurring tumor. Comprehensive treatment, including surgery, chemotherapy and immunotherapy, is the key approach for malignant melanoma of the finger. Prognosis of the disease is associated with the size of the tumor, depth of infiltration and clinical stages.

[Application of medial head gastrocnemius muscle flap to limb-salvage operation of proximal tibial malignant tumor].

OBJECTIVE: To evaluate the efficacy of transposition of the medial gastracnemius muscle flap in the limb-salvage operation of the proximal tibial tumors. METHODS: From January 2001 to September 2005, 13 patients (8 males, 5 females; aged 14-57 years, averaged 29.7 years) suffering from the proximal tibial tumors were treated with a limb-salvage operation. Among them, there were 4 patients with osteosarcoma, 6 with malignant fibrous histocytoma, 1 with malignant giant cell tumor, 1 with synovial sarcoma, and 1 with Ewing's sarcoma. According to the Enneking staging system, 1 case was in Stage I B, 9 in Stage II A, and 3 in Stage II B. One or two cycles of neoadjuvant chemotherapy were used to each of the patients before operation. All of the patients underwent the medial head of the gastrocnemius muscle flap transposition to reconstruct the soft tissues after resection of the tumors and reconstruction of the bone defect by prothesis or bone-graft or the two methods combined. RESULTS: The follow-up for 7-47 months (average, 19. 2 months) in all the patients revealed that. there was no flap necrosis, no skin necrosis at the incision margins, and no infection or fracture of the implanted bone. The patient with malignant fibrous histocytoma died of systemic metastasis 20 months after operation. The patient with Ewing's sarcoma had a local tumor recurrence 18 months after operation; though treated with the focal cleaning and the bone cement filling, the patient still developed lung metastasis of the tumor 26 months after operation. The patient with osteosarcoma underwent amputation 12 months after operation because of the tumor recurrence. According to the function assessment by the Mankin system, there were 6 patients who had an excellent result, 4 had a good result, and 3 had a poor result, with a satisfaction rate of 77%. CONCLUSION: The flap transposition of the medial head of the gastrocnemius muscle can reconstruct the soft tissue defect, decrease the local complication rate and improve the clinical outcome of the limb salvage for the proximal tibia malignant tumor.