Robot-assisted stereotactic multiple brain abscesses' puncture: technical case report.

We report a case of multiple brain abscesses' puncture, employing the ROSA™ Brain surgical robot (Zimmer Biomet) and the O-arm® O2 Imaging System (Medtronic). A 51-year-old man was diagnosed with multiple supratentorial ring enhancing cystic lesions consistent with brain abscesses. A neurological deterioration occurred despite broad spectrum antibiotic therapy, due to mass effect of the abscesses. Stereotactic aspiration was performed using the described technique, allowing a single stage puncture of the cerebral lesions. In this case, the robot-assisted and image-guided procedure permitted an accurate, quick, and efficient targeting of the multiple abscesses for drainage.

Spine metastasis in patients with prostate cancer: Survival prognosis assessment.

BACKGROUND: Patients presenting spine metastasis (SpM) from prostate cancer (PC) form a heterogeneous population, through this study, we aimed to clarify and update their prognostic assessment. METHODS: The patient data used in this study was obtained from a French national multicenter database of patients treated for PC with SpM between 2014 and 2017. A total of 72 patients and 365 SpM cases were diagnosed. RESULTS: The median overall survival time for all patients following the event of SpM was 28.8 months. First, we identified three significant survival prognostic factors of PC patients with SpM: good Eastern Cooperative Oncology Group/World Health Organization personnel status (Status 0 hazard ratio [HR]: 0.031, 95% confidence interval [CI]: 0.008-0.127; p < .0001) or (Status 1 HR: 0.163, 95% CI: 0.068-0.393; p < .0001) and SpM radiotherapy (HR: 2.923, 95% CI: 1.059-8.069; p < .0001). Secondly, the presence of osteolytic lesions of the spine (vs. osteoblastic) was found to represent an independent prognosis factor for longer survival [HR: 0.424, 95% CI: 0.216-0.830; p = .01]. Other factors including the number of SpM, surgery, extraspinal metastasis, synchrone metastasis, metastasis-free survival, and SpM recurrence were not identified as being prognostically relevant to the survival of patients with PC. CONCLUSION: Survival and our ability to estimate it in patients presenting PC with SpM have improved significantly. Therefore, we advocate the relevance of updating SpM prognostic scoring algorithms by incorporating data regarding the timeline of PC as well as the presence of osteolytic SpM to conceive treatments that are adapted to each patient.

Meningiomas and cyproterone acetate: a retrospective, monocentric cohort of 388 patients treated by surgery or radiotherapy for intracranial meningioma.

PURPOSE: Meningiomas are the most common intracranial tumors, accounting for 20-30% of central nervous system tumors. Recently, the European Medicines Agency issued an alert on cyproterone acetate (CPA) based on the results of a study that found an increased risk of meningioma 7 to 20 times higher when a patient is on CPA. The primary objective of this study was to determine the prevalence of CPA exposure in patients who had one or more intracranial meningiomas treated surgically or with radiation therapy. The secondary objectives were to establish a description of the patients who had intracranial meningioma in Nantes and to establish whether there was a difference in the intrinsic and tumoral characteristics of patients exposed to CPA compared with patients who had no hormonal exposure and patients who had been exposed to other hormones. METHODS: Monocentric, retrospective study including all patients treated by surgery or radiotherapy for intracranial meningioma from 2014 to 2017 excluding those with a history of exposure to ionizing radiation or neurofibromatosis type 2. RESULTS: 388 patients were included, 277 were treated by surgery and 111 by radiotherapy. 3.9% of the patients had a history or current use of CPA, 16.2% were taking other hormonal treatment. Compared with the group without hormonal exposure, the CPA-exposed group had significantly an earlier onset of meningiomas at 48.9 vs. 61.9 years (p = 0.0005) and had more multiple meningiomas, 26.7% vs. 6.1% (p = 0.0115). CONCLUSIONS: In our study, patients with a history or current use of CPA had significantly more meningiomas and were significantly younger at the onset.

Switch from parenteral to oral antibiotics for brain abscesses: a retrospective cohort study of 109 patients.

OBJECTIVES: Brain abscess is one of the most serious diseases of the CNS and is associated with high morbidity and mortality. With regard to the lack of data supporting an optimal therapeutic strategy, this study aimed to explore the prognostic factors of brain abscess, putting emphasis on the impact of therapeutic decisions. METHODS: We retrospectively included patients hospitalized for brain abscess during a period of 13 years. Comorbidities (Charlson scale), clinical presentation, microbiology culture, radiological features and therapeutic management were collected. Glasgow Outcome Scale (GOS) at 3 months and length of hospital stay were, respectively, the main and the secondary outcomes. Logistic regression was used to determine factors associated with outcome independently. RESULTS: Initial Glasgow Coma Scale (GCS) ≤14 and comorbidities (Charlson scale ≥2) were associated with poor neurological outcome while oral antibiotic switch was associated with better neurological outcome. Oral switch did not appear to be associated with an unfavourable evolution in the subset of patients without initial neurological severity (GCS >14) on admission. Duration of IV regimen and time to oral switch were associated with the length of inpatient stay. CONCLUSIONS: This study confirms the role of GCS and comorbidities as prognostic factors and presents reassuring data regarding the safety of oral switch for the antibiotic treatment of brain abscesses. Oral switch could prevent catheter-induced iatrogenic complications and allow a higher quality of life for patients.

Spinal cord stimulation of the conus medullaris for refractory pudendal neuralgia: a prospective study of 27 consecutive cases.

AIMS: Thirty percent of patients with pudendal neuralgia due to pudendal nerve entrapment obtain little or no relief from nerve decompression surgery. The objective was to describe the efficacy of spinal cord stimulation of the conus medullaris in patients with refractory pudendal neuralgia. METHODS: This prospective study, conducted by two centers in the same university city, described the results obtained on perineal pain and functional disability in all patients with an implanted conus medullaris stimulation electrode for the treatment of refractory pudendal neuralgia. Twenty-seven consecutive patients were included by a multidisciplinary pelvis and perineal pain clinic between May 2011 and July 2012. Mean follow-up was 15 months. The intervention was an insertion of a stimulation electrode was followed by a test period (lasting an average of 13 days) before deciding on permanent electrode implantation. Maximum and average perineal pain scores and the pain-free sitting time were initially compared during the test and in the long-term (paired t-test). The estimated percent improvement (EPI) was evaluated in the long-term. RESULTS: Twenty of the 27 patients were considered to be responders to spinal cord stimulation and 100% of implanted patients remained long-term responders (mean tripling of sitting time, and mean EPI of 55.5%). CONCLUSIONS: Spinal cord stimulation of the conus medullaris is a safe and effective technique for long-term treatment of refractory pudendal neuralgia. Routine use of this technique, which has never been previously reported in the literature in this type of patient, must now be validated by a larger scale study.

Interest of repetitive transcranial magnetic stimulation of the motor cortex in the management of refractory cancer pain in palliative care: Two case reports.

BACKGROUND: Non-drug treatments should be systematically associated to the medical analgesic treatment during the terminal phase of cancer. CASES PRESENTATION: Patient 1, a 23-year-old woman, presented an adenocarcinoma of the rectum, with liver and lung metastases. Pain was initially treated by oral morphine and a combination of pregabalin and amitriptyline. Ketamine and intrathecal administration of morphine were both ineffective. Patient 2, a 69-year-old woman, presented a cutaneous T-cell lymphoma. She was admitted to the palliative care unit with mixed pain related to cutaneous lymphomatous infiltration. World Health Organization (WHO) step 3 analgesics had not been tolerated. CASES MANAGEMENT: Both patients received five consecutive 20-min sessions of repetitive transcranial magnetic stimulation to the right motor cortex. CASES OUTCOME: Patient 1 experienced a marked improvement of her pain over the days following the first repetitive transcranial magnetic stimulation session. Medical treatment was able to be rapidly decreased by about 50%, which restored an almost normal level of consciousness and lucidity. Patient 2's pain was also markedly decreased over the days following these five consecutive sessions, and repetitive transcranial magnetic stimulation also appeared to have had a beneficial effect on the patient's anxiety and mood. CONCLUSION: In the context of palliative care of cancer patients experiencing refractory pain that is difficult to control by the usual treatments, motor cortex repetitive transcranial magnetic stimulation, due to its noninvasive nature, can be used as an adjuvant therapy to improve various components of pain, including the emotional components. By reducing the doses of analgesics, repetitive transcranial magnetic stimulation decreases the severity of their adverse effects and improves the patient's quality of life.

Study of the long-term results of decompressive craniectomy after severe traumatic brain injury based on a series of 60 consecutive cases.

BACKGROUND: Decompressive craniectomy can be proposed in the management of severe traumatic brain injury. Current studies report mixed results, preventing any clear conclusions on the place of decompressive craniectomy in traumatology. METHODS: The objective of this retrospective study was to evaluate the results of all decompressive craniectomies performed between 2005 and 2011 for refractory intracranial hypertension after severe traumatic brain injury. Sixty patients were included. Clinical parameters (Glasgow scale, pupillary examination) and radiological findings (Marshall CT scale) were analysed. Complications, clinical outcome, and early and long-term Glasgow Outcome Scale (GOS) were evaluated after surgery. Finally, the predictive value of preoperative parameters to guide the clinician's decision to perform craniectomy was studied. RESULTS: Craniectomy was unilateral in 58 cases and the mean bone flap area was 100 cm(2). Surgical complications were observed in 6.7% of cases. Mean followup was 30 months and a favourable outcome was obtained in 50% of cases. The initial Glasgow Scale was the only statistically significant predictive factor for long-term outcome. CONCLUSION: Despite the discordant results in the literature, this study demonstrates that decompressive craniectomy is useful for the management of refractory intracranial hypertension after severe traumatic brain injury.

Benefits of repetitive transcranial magnetic stimulation (rTMS) for spastic subjects: clinical, functional, and biomechanical parameters for lower limb and walking in five hemiparetic patients.

Introduction. Spasticity is a disabling symptom resulting from reorganization of spinal reflexes no longer inhibited by supraspinal control. Several studies have demonstrated interest in repetitive transcranial magnetic stimulation in spastic patients. We conducted a prospective, randomized, double-blind crossover study on five spastic hemiparetic patients to determine whether this type of stimulation of the premotor cortex can provide a clinical benefit. Material and Methods. Two stimulation frequencies (1 Hz and 10 Hz) were tested versus placebo. Patients were assessed clinically, by quantitative analysis of walking and measurement of neuromechanical parameters (H and T reflexes, musculoarticular stiffness of the ankle). Results. No change was observed after placebo and 10 Hz protocols. Clinical parameters were not significantly modified after 1 Hz stimulation, apart from a tendency towards improved recruitment of antagonist muscles on the Fügl-Meyer scale. Only cadence and recurvatum were significantly modified on quantitative analysis of walking. Neuromechanical parameters were modified with significant decreases in H max⁡ /M max⁡ and T/M max⁡ ratios and stiffness indices 9 days or 31 days after initiation of TMS. Conclusion. This preliminary study supports the efficacy of low-frequency TMS to reduce reflex excitability and stiffness of ankle plantar flexors, while clinical signs of spasticity were not significantly modified.

Motor cortex stimulation in refractory pelvic and perineal pain: report of two successful cases.

AIMS: In some patients, with refractory chronic pelvic and perineal pain, pain and quality of life are barely alleviated despite optimal medical treatment, infiltrations and surgical release of the pudendal nerve. The management of these patients is complex, especially after failure of neuromodulation techniques (spinal cord stimulation. S3 nerve root stimulation and direct stimulation of the pudendal nerve). We report the first two cases illustrating the value of motor cortex stimulation (MCS), in this new indication. METHODS: The history, decision-making process, intraoperative findings and results of this technique are presented. The perineal cortical area was identified by intraoperative motor evoked potentials in the external anal sphincter, confirming its location in the primary motor cortex between the inferior and superior limb positions. As predictive value of repetitive transcranial magnetic stimulation (rTMS) in the identification of responders to MCS for pain is now established, we performed pre-operative rTMS sessions for both patients. RESULTS: The first patient was a 74-years-old woman who reported an 11-year history of left lateral perineal pain. The second patient was a 45-year-old woman who reported a 4-year history of perineal pain following hysterectomy with ovariectomy. After respectively 40 months and 19 months of follow up, both patients reported an improvement of pain ranging from 40 to 50%. Time to onset of pain on sitting was markedly improved from a few minutes to 90 minutes, and largely contributing to improvement of activities of daily living and of quality of life. CONCLUSION: These two first cases suggest that motor cortex stimulation constitutes a new treatment for refractory pelvic and perineal pain, and should be considered after failure of conventional neuromodulation techniques, especially spinal cord stimulation.

Long-term neuromechanical results of selective tibial neurotomy in patients with spastic equinus foot.

BACKGROUND: The neuromechanical consequences of tibial neurotomy have not been extensively studied. METHODS: Fifteen patients were evaluated before and after selective tibial neurotomy (after 2 months and after 15 months) by means of clinical, neurophysiological [tendon (T) reflexes, Hoffmann (H) reflexes and maximum motor response, Mmax] and mechanical parameters (passive stiffness of plantar flexors at the ankle). The neurotomy concerned the soleus (100 % of cases), gastrocnemius (20 % of cases), posterior tibial (60 % of cases) and flexor digitorum longus (47 % of cases) nerves. RESULTS: Neurotomy provided more than 90 % improvement of clinical spasticity scores, 20 % improvement of walking scores and the angle of passive dorsiflexion (APDF) of the ankle (mean angle: 7°), temporary reduction of the soleus Mmax (18 % at 2 months with return to the preoperative value at 15 months), and lasting reduction of the soleus Hmax/Mmax (68 % at 2 months, 78 % at 15 months) and T/Mmax (84 % at 2 months, 80 % at 15 months). M and H responses of the gastrocnemius (whether or not they were included in the neurotomy) were not modified, while T/Mmax decreased to the same degree as for soleus. Passive stiffness was lastingly decreased from 64.0 Nm/rad to 49.0 Nm/rad (2 months) and 49.5 Nm/rad (15 months). CONCLUSION: Selective tibial neurotomy of the soleus nerve induces long-term reduction of reflex hyperexcitability and passive stiffness of plantar flexors in spastic patients, with no lasting impairment of motor efferents. In parallel, it modifies the tendon reflexes of synergistic muscles (gastrocnemius) not concerned by the neurotomy.

Time course of the soleus M response and H reflex after lidocaine tibial nerve block in the rat.

AIMS: In spastic subjects, lidocaine is often used to induce a block predictive of the result provided by subsequent surgery. Lidocaine has been demonstrated to inhibit the Hoffmann (H) reflex to a greater extent than the direct motor (M) response induced by electrical stimulation, but the timecourse of these responses has not been investigated. METHODS: An animal (rat) model of the effects of lidocaine on M and H responses was therefore developed to assess this time course. M and H responses were recorded in 18 adult rats before and after application of lidocaine to the sciatic nerve. RESULTS: Two to five minutes after lidocaine injection, M responses were markedly reduced (mean reduction of 44%) and H reflexes were completely abolished. Changes were observed more rapidly for the H reflex. The effects of lidocaine then persisted for 100 minutes. The effect of lidocaine was therefore more prolonged on the H reflex than on the M response. CONCLUSION: This study confirms that lidocaine blocks not only alpha motoneurons but also Ia afferent fibres responsible for the H reflex. The authors describe, for the first time, the detailed time course of the effect of lidocaine on direct or reflex activation of motoneurons in the rat.

Spine Metastasis: Patients With Poor Performance Status (ECOG) Could benefit From Palliative Surgical Care! A Prospective Cohort Study.

STUDY DESIGN: This study used a French prospective national multi-center database of patients with spine metastasis (SpM). OBJECTIVE: The main challenge was to clarify if SpM patients presenting poor ECOG-PS could benefit from a surgical intervention. BACKGROUND: Spine metastases (SpM) are debilitating lesions commonly found in the evolution of cancer. At present, patients with poor ECOG-PS do not benefit from surgical care. MATERIALS AND METHODS: Between 2014 and 2017, 176 SpM patients with poor initial ECOG-PS (3 or 4) were identified. RESULTS: The median overall survival of patients was 2.1 months (SD 0.2). Seventy-one patients (40.3%) underwent surgery: for 49 patients (27.8%) the intervention consisted of a simple decompression and for 22 patients (12.5%) the previous was associated with an osteosynthesis. Patients who underwent surgery demonstrated significantly longer median overall survival than those who did not: 3.5 months (SD 0.4) versus 1.6 (SD 0.2) ( P <0.0001). No significant differences between operated/nonoperated patients were noted concerning median age (66.4 vs. 64.2 y, P =0.897), the median number of SpM (4.1 vs. 4.2, P =0.374), ECOG-PS 4 ratio (41.6 vs. 39.3%, P =0.616), or for primary tumors ( P =0.103). Patients who underwent surgery statistically improved their neurological impairment according to the Frankel score: 5/11 (45.4%) from A to C, 5/17 (29.4%) from B to C or D, 6/11 (54.5%) from C to D and 2/4 (50%). Twelve patients (16.9%) presented a postoperative complication. CONCLUSION: Patients with poor ECOG-PS could benefit from surgery. Even though survival gain is small, it permits the preservation of their neurological function. By making ambulation possible, pain is decreased during the last months of their lives.

Multiple Myeloma Spinal Lesion Care: Management of a Primary Bone Malignancy Rather Than a Spinal Metastasis.

OBJECTIVE: Multiple myeloma (MM) is too often wrongly categorized as a spinal metastasis (SpM), although it is distinguishable from SpM in many aspects, such as its earlier natural history at the time of diagnosis, its increased overall survival (OS), and its response to therapeutic modalities. The characterization of these 2 different spine lesions remains a main challenge. METHODS: This study compares 2 consecutive prospective oncologic populations of patients with spine lesions: 361 patients treated for MM spine lesions and 660 patients treated for SpM between January 2014 and 2017. RESULTS: The mean time between the tumor/MM diagnosis and spine lesions was respectively 0.3 (standard deviation [SD] 4.1) and 35.1 months (SD 21.2) for the MM and SpM groups. The median OS for the MM group was 59.6 months (SD 6.0) versus 13.5 months (SD 1.3) for the SpM group (P < 0.0001). Regardless of Eastern Cooperative Oncology Group (ECOG) performance status, patients with MM always have a significantly better median OS than do patients with SpM: ECOG 0, 75.3 versus 38.7 months; ECOG 1, 74.3 versus 24.7 months; ECOG 2, 34.6 versus 8.1 months; ECOG 3, 13.5 versus 3.2 months and ECOG 4, 7.3 versus 1.3 months (P < 0.0001). The patients with MM had more diffuse spinal involvement (mean, 7.8 lesions; SD 4.7) than did patients with SpM (mean, 3.9; SD 3.5) (P < 0.0001). CONCLUSIONS: MM must be considered as a primary bone tumor, not as SpM. The strategic position of the spine in the natural course of cancer (i.e., nurturing cradle of birth for MM vs. systemic metastases spreading for SpM) explains the differences in OS and outcome.

Spinal metastases from thyroid cancer: Some prognostic factors.

BACKGROUND: Spinal metastases (SpMs) from thyroid cancers (TC) significantly reduce quality of life by causing pain, neurological deficits in addition to increasing mortality. Moreover, prognosis factors including surgery remain debated. METHODS: Data were stored in a prospective French national multicenter database of patients treated for SpM between January 2014 and 2017. Fifty-one consecutive patients affected by TC with 173 secondary SpM were included. RESULTS: Mean overall survival (OS) time for all patients from the diagnosis of a thyroid SpM event was 9.1 years (SD 8.7 months). The 1-year, 5-year and 10-year survival estimates were 94% (SD 3.3), 83.8.0% (SD 5.2), and 74.5% (SD 9.9). The median period of time between primary thyroid tumor diagnosis and the SpM event was 31.4 months (SD 71.6). In univariate analysis, good ECOG-PS (status 0 and 1) (p < 0.0001), ambulatory status (Frankel score) (p < 0.0001) and no epidural involvement (p = 0.01), were associated with longer survival, whereas cancer subtype (p = 0.436) and spine surgery showed no association (p = 0.937). Cox multivariate proportional hazard model only identified good ECOG-PS: 0 [HR: 0.3, 95% CI 0.1-0.941; p < 0.0001], 1 [HR: 0.8, 95% CI 0.04-2.124; p = 0.001] and ambulatory neurological status: Frankel E [HR: 0.262, 95% CI 0.048-1.443; p = 0.02] to be independent predictors of better survival. CONCLUSION: For cases presenting SpM from TC, we highlighted that the only prognostic factors were the progression of the cancer (ECOG-PS) and the clinical neurological impact of the SpM (Frankel status). Surgery should be discussed mainly for stabilization and neurological decompression.

Continuous controlled-infusion of hypertonic saline solution in traumatic brain-injured patients: a 9-year retrospective study.

INTRODUCTION: Description of a continuous hypertonic saline solution (HSS) infusion using a dose-adaptation of natremia in traumatic brain injured (TBI) patients with refractory intracranial hypertension (ICH). METHODS: We performed a single-center retrospective study in a surgical intensive care unit of a tertiary hospital. Fifty consecutive TBI patients with refractory ICH treated with continuous HSS infusion adapted to a target of natremia. In brief, a physician set a target of natremia adapted to the evolution of intracranial pressure (ICP). Flow of NaCl 20% was a priori calculated according to natriuresis, and the current and target natremia that were assessed every 4 hours. RESULTS: The HSS infusion was initiated for a duration of 7 (5 to 10) (8 ± 4) days. ICP decreased from 29 (26 to 34) (31 ± 9) mm Hg at H0 to 20 (15 to 26) (21 ± 8) mm Hg at H1 (P < 0.05). Cerebral perfusion pressure increased from 61 (50 to 70) (61 ± 13) mm Hg at H0 up to 67 (60 to 79) (69 ± 12) mm Hg at H1 (P < 0.05). No rebound of ICH was reported after stopping continuous HSS infusion. Natremia increased from 140 (138 to 143) (140 ± 4) at H0 up to 144 (141 to 148) (144 ± 4) mmol/L at H4 (P < 0.05). Plasma osmolarity increased from 275 (268 to 281) (279 ± 17) mmol/L at H0 up to 290 (284 to 307) (297 ± 17) mmol/L at H24 (P < 0.05). The main side effect observed was an increase in chloremia from 111 (107 to 119) (113 ± 8) mmol/L at H0 up to 121 (117 to 124) (121 ± 6) mmol/L at H24 (P < 0.05). Neither acute kidney injury nor pontine myelinolysis was recorded. CONCLUSIONS: Continuous HSS infusion adapted to close biologic monitoring enables long-lasting control of natremia in TBI patients along with a decreased ICP without any rebound on infusion discontinuation.

Spine Metastasis in Elderly: Encouraging Results for Better Survival.

MINI: The incidence of spinal metastasis (SpM) is increasing, and life expectancy for patients with malignancy is also rising. The "elderly" represent a population with steady growth in SpM proportion. Bracing is associated with lower survival. We believe that surgery should be considered, regardless of the patient's age.

Multicentric prospective study. Through this study, we aimed to clarify and update the prognostic assessment of elderly with spine metastasis (SpM). The incidence SpM is rising, in parallel life expectancy is getting longer and the number of elderly patients presenting malignancy is increasing. Elderly patients with SpM constitute a growing heterogeneous population The patient data used in this study were obtained from a French national multicenter database of patients treated for SpM between 2014 and 2017. Two hundred and forty-three consecutive patients >70 years' old were diagnosed. Median overall survival (OS) time for elderly patients following the event of SpM was 16.3 months. First, we identified significantly worse survival prognostic factors for elderly patients with SpM: poor WHO status 3/4: (hazard ratio [HR]: 2.245, 95% confidence interval [CI] 1.899­2.655; P  < 0.0001), >80 years (HR: 1.758, 95% CI 1.117­2.765; P  = 0.015) no-ambulatory neurological status (Franckel A/B status [HR: 3.219, 95% CI 1.621­6.390; P  < 0.0001)], gastrointestinal cancer (HR: 3.530, 95% CI 1.75­7.1; P  < 0.0001), lung cancer (HR: 3.452, 95% CI 1.784­6.680; P  < 0.0001), orthopedic brace treatment (HR: 1.329; 95% CI 1.050­1.683; P  = 0.018), and epiduritis (HR: 1.52, 95% CI 1.041­2.22; P  = 0.03) were independently poor prognostic factors of survival. The only good prognosis factor identified was thyroid cancer (HR: 0.257, 95% CI 0.07­0.952; P  = 0.04). Prognosis factors concerning the survival of elderly patients seem to be the same as those for the general population such as primary cancer histology, neurological status, WHO status, and epiduritis. Age >80 years also appears to be an independently poor prognosis factor. Our data suggest that orthopedic brace treatment is also associated with lower survival. Level of Evidence: 2.

Are spine metastasis survival scoring systems outdated and do they underestimate life expectancy? Caution in surgical recommendation guidance.

OBJECTIVE: Survival scoring systems for spine metastasis (SPM) were designed to help surgical practice. The authors sought to validate the prognostic accuracy of the main preoperative scoring systems for SPM. METHODS: It was hypothesized that true patient survival in SPM was better than that predicted using prognosis scores. To investigate this hypothesis, the authors designed a French national retrospective study of a prospectively collected multicenter database involving 739 patients treated for SPM between 2014 and 2017. RESULTS: In this series, the median survival time for all patients from an SPM diagnosis was 17.03 ± 1.5 months. Sensitivity and specificity were estimated using the area under the curve (AUC). The AUC of Tomita's prognosis score was the lowest and poorest (0.4 ± 0.023, range 0.35-0.44), whereas the AUC of the Tokuhashi score was the highest (0.825). The Lei score presented an AUC of 0.686 ± 0.022 (range 0.64-0.7), and the Rades score showed a weaker AUC (0.583 ± 0.020, range 0.54-0.63). Differences among AUCs were all statistically significant (p < 0.001). The modified Bauer score and the Rades score had the highest rate of agreement in predicting survival, with a weighted Cohen's kappa of 0.54 and 0.41, respectively, indicating a moderate agreement. The revised Tokuhashi and Lei scores had a fair rate of agreement (weighted Cohen's kappa = 0.24 and 0.22, respectively). The van der Linden and Tomita scores demonstrated the worst performance, with only a "slight" rate of agreement (weighted Cohen's kappa = 0.19 and 0.16, respectively) between what was predicted and the actual survival. CONCLUSIONS: The use of prognostic scoring systems in the estimation of survival in patients with SPM has become obsolete and therefore underestimates survival. Surgical treatment decisions should no longer be based on survival estimations alone but must also take into account patient symptoms, spinal instability, and quality of life.

Survival in breast cancer patients with spine metastases: Prognostic assessment involving molecular markers.

BACKGROUND: To clarify and update the prognostic assessment for heterogeneous population of patients with breast cancer and spine metastases (SpM), using molecular markers. METHODS: The patient data used in this study was obtained from a French national multi-center database of patients treated for breast cancer with SpM between 2014 and 2017. 556 SpM cases were diagnosed. RESULTS: Median overall survival (OS) time for all patients following the SpM event was 43.9 months. First, we confirmed 3 previously known significant prognostic factors for survival of patients with SpM: young age [HR: 2.019, 95% CI 1.343-3.037; p = 0.001], good WHO status [ Status 0 HR: 2.823, 95% CI 1.231-3.345; p < 0.0001] or [ Status 1 HR: 1.956, 95% CI 0.768-2.874; p = 0.001] and no-ambulatory neurological status: Frankel A-C [HR: 0.438, 95% CI 0.248-0.772; p = 0.004]. Secondly, we determined the effect of gene mutations on survival in patients with SpM, and we identified that HER2+ cancer subtype [HR: 1.567, 95% CI 0.946-2.557; p = 0.008] was an independent predictor of longer survival, whereas basal cancer subtype [HR: 0.496, 95% CI 0.353-0.699; p < 0.0001] was associated with a poorer prognosis. Other factors including the number of SpM, surgery, extraspinal metastases, synchrone metastases, metastasis-free survival, and SpM recurrence were not identified as prognostically relevant to survival. CONCLUSION: Survival and our ability to estimate it in breast cancer patients with SpM has improved significantly. Therefore, SpM prognostic scoring algorithms should be updated and incorporate genotypic data on subtypes to make treatment more adaptive.

Spinal metastases from lung cancer: Survival depends only on genotype, neurological and personal status, scarcely of surgical resection.

BACKGROUND: For patients with non-small cell lung cancer (NSCLC), the spinal column is the most common site for bone metastasis. Studies that assess survival prognostic factors associated with specific lung spinal metastases (SpM) are weak and required the incorporation of genotype mutations. METHODS: A prospective French national multicenter database of patients treated for SpM between January 2014 and 2017.818 lung SpM were diagnosed over the course or at the time of diagnosis of 210 consecutive patients with NSCLC. RESULTS: Median overall survival (OS) time for all patients from the lung SpM event was 5.9 months (SD 0.609). For 122 patients (61%), lung tumor and SpM were diagnosed synchronously. In univariate analysis, good World Health Organisation (WHO) status (p < 0.0001), ambulatory status (Frankel score) (p < 0.0001), the absence of spine epiduritis (p < 0.0001), immunotherapy after SpM diagnosis (p < 0.0001), ALK gene rearrangement (p < 0.0001) and EGFR mutation (p < 0.0001) were associated with longer survival, whereas spine surgery showed no association (0.141). Cox multivariate proportional hazard model identified that EGFR + status (HR: 0.339, 95% CI 0.166-0.693; p = 0.003), good WHO status (p < 0.0001) and good neurological status (Frankel E; p < 0.001 and D; p = 0.018) were associated with higher median OS. Whereas the other factors, including ALK + status, epiduritis and immunotherapy were not independent prognostic factors of survival. CONCLUSION: Survival in SpM must be prognosticated from general health performance status: clinical (WHO) and neurological (Frankel) as well as the EGFR mutation status. Immunotherapy, surgery and epiduritis have not demonstrated prognostic value. Therefore, surgical prognostic scoring algorithms should incorporate genotype subtypes in NSCLC cancers to adapt surgical treatment.

Trigeminal Ganglion Metastasis of Renal Clear Cell Carcinoma: Cases Report and Review of the Literature.

BACKGROUND: The trigeminal ganglion is an atypical site for metastasis, especially for renal clear cell carcinoma. CASE DESCRIPTION: We report 2 clinical cases of a 66-year-old man and a 58-year-old man with trigeminal symptoms. Both patients had a history of renal clear cell (RCC) that was considered to be cured at 6 and 9 years, respectively. Brain magnetic resonance imaging (MRI) showed a trigeminal ganglion lesion with increased gadolinium enhancement associated with petrous apex erosion. The main diagnostic hypothesis based on MRI was trigeminal schwannoma for both patients. One patient underwent subtotal removal, the other a biopsy. Histologic examinations resulted in the diagnosis of RCC metastasis. Body computed tomography revealed pancreatic metastasis for both but no renal recurrence. The patients were treated by local radiotherapy, and 1 of the patients had associated chemotherapy. We added to these clinical cases a literature review of skull base metastasis of RCC. Trigeminal ganglion metastasis of RCC is very rare and can persist until 10 years after the first RCC diagnosis. It seems that the best treatment is surgical removal. To date, the role of local radiotherapy is not demonstrated, and the prognosis seems to be poor. CONCLUSIONS: In the case of trigeminal symptoms, rapid tumoral growth on brain MRI, or a history of RCC, we think that a body computed tomography should be performed, and surgery should be considered.