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PURPOSE: In this study, we analyzed the use of a validated capture system (Spinal Adverse Events Severity system, SAVES V2) as a first non-technical skill to properly face the relevant problem of surgical complications (SCs) and adverse events (AEs) in spinal surgery. METHODS: We retrospectively collected AEs occurring in a tertiary referral center for spine surgery from January 2017 to January 2018 and classified them according to SAVES V2 system. We compared this collection of AEs with a prospective collection performed without any classification system. Univariate and multivariate logistic regression models were used to determined odds ratio (ORs) for selected potential risk factors of AEs and prolonged length of stay. RESULTS: Overall a higher number of AEs was retrospectively recorded using SAVES system compared to the prospective recording without the use of any capture system (97/336 vs 210/336, p < 0.001). The length of stay (LOS) increased in the group of complicated patients for all the procedures examined. In the non-oncological group, LOS was significantly higher for complicated patients compared to uncomplicated patients (F = 44.11, p = 0.0000). Similar results have been obtained in the oncological group of patients. In the multivariate regression model surgical time and postoperative AEs emerged as risk factors for prolonged LOS, while only the presence of previous surgeries was confirmed as risk factor for AEs. CONCLUSION: Considering that the rate of AEs and SCs in spinal surgery is still high despite the improvement of technical skills, we suggest the use of SAVES V2 capture system as a first-line tool to face the problem.
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Complicações Pós-Operatórias , Coluna Vertebral , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Coluna Vertebral/cirurgiaRESUMO
PURPOSE: In the present report it is described the design, the manufacturing and the successful surgical implant of one of the first 3D custom titanium vertebra realized with Additive Manufacturing technique and its use for the spinal reconstruction after en-bloc resection for primary osteogenic sarcoma. METHODS: Clinical case presentation and the design of the 3D custom titanium vertebra was reported. It was also described the complex procedures adopted to evaluate the retrieved device from the histological point of view, as a tumor relapse hit the patient, one year after the reconstruction procedure. RESULTS: The histological evaluation confirmed that the resection technique exerts an important role in promoting bone formation: vertebral body osteotomies favored the reconstruction procedure and maximized the contact area between host bone/vertebral prosthesis thus favoring the bone tissue penetration and device colonization. CONCLUSION: The sharing of these results is very important as they represent the starting point for improving the knowledge starting from the evidence obtained in a challenging clinical condition and with post-operative treatments that could be never reproduced in preclinical model.
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Neoplasias da Coluna Vertebral , Titânio , Vértebras Cervicais , Humanos , Recidiva Local de Neoplasia , Impressão Tridimensional , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/cirurgiaRESUMO
INTRODUCTION: Biopsy of affected tissue is required for lymphoma diagnosis and to plan treatment. Open incisional biopsy is traditionally the method of choice. Nevertheless, it requires hospitalization, availability of an operating room, and sometimes general anesthesia, and it is associated with several drawbacks. Fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) can be potentially used to drive biopsy to the most metabolically active area within a lymph node or extranodal masses. METHODS: A study of diagnostic accuracy was conducted to assess the performance of a PET-driven needle biopsy in patients with suspect active lymphoma. RESULTS: Overall, 99 procedures have been performed: three (3.0%) were interrupted because of pain but were successfully repeated in two cases. Median SUVmax of target lesions was 10.7. In 84/96 cases, the tissue was considered adequate to formulate a diagnosis (diagnostic yield of 87.5%) and to guide the following clinical decision. The target specimen was a lymph node in 60 cases and an extranodal site in 36. No serious adverse events occurred. The sensitivity of this procedure was 96%, with a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 75%. CONCLUSION: Patients can benefit from a minimally invasive procedure which allows a timely and accurate diagnosis of lymphoma at onset or relapse.
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Linfoma , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Biópsia , Fluordesoxiglucose F18 , Humanos , Linfoma/diagnóstico por imagem , Recidiva Local de Neoplasia , Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos , Estudos RetrospectivosRESUMO
INTRODUCTION: Radiotherapy (RT) is frequently applied as an adjuvant therapy during spinal tumors treatment. Metallic implants can interfere with RT planning and execution, as it is known that metallic implants produce a backscattering effect that can limit RT accuracy and their presence can be associated with unwanted dose increase. PEEK/carbon fiber implants are designed to reduce these problems but their application in the cervical spine is limited, due to the reduced number and types of implants, the screw dimensions and the absence of lateral mass screws. We propose a hybrid system made of carbon rods and screws coupled with subliminal polyester bands with titanium clamps. We designed this hybrid construct to enclose the cervical region in the area of instrumentation without limiting the application of postoperative radiotherapy. MATERIALS AND METHODS: Six patients in which the hybrid hardware was implanted were retrospectively examined. Data on demographics, intraoperative and postoperative events, tumor details and staging and cervical alignment were collected pre- and postoperatively. RESULTS: No intraoperative complications occurred. En bloc resection was performed in two patients, while the remaining four received an intralesional resection. Three out of six patients received postoperative RT, without any alteration in its planning and administration. DISCUSSION AND CONCLUSIONS: Hybrid implants made of composite PEEK/carbon fiber screws and rods and sublaminar bands are a helpful solution for spinal reconstruction in the cervical and cervico-thoracic regions after spine tumor surgery. The implants do not produce artifacts at postoperative images, easing the planning and execution of postoperative radiotherapy.
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Neoplasias do Colo do Útero , Benzofenonas , Fibra de Carbono , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Feminino , Humanos , Cetonas , Polietilenoglicóis , Polímeros , Estudos RetrospectivosRESUMO
PURPOSE: To investigate whether the World Health Organization Safety Surgical Checklist (SSC) is an effective tool to reduce complications in spinal surgery. METHODS: We retrospectively evaluated the clinical and radiological charts prospectively collected from patients who underwent a spinal surgery procedure from January 2010 to December 2012. The aim of this study was to compare the incidence of complications between two periods, from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist's effectiveness. RESULTS: The sample size was 917 patients with an average of 30-month follow-up. The mean age was 52.88 years. The majority of procedures were performed for oncological diseases (54.4%) and degenerative diseases (39.8%). In total, 159 complications were detected (17.3%). The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. No correlation was observed between the type of pathology and the complication incidence. We observed a reduction in the overall incidence of complications following the introduction of the SSC: In 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%). CONCLUSIONS: The SSC seems to be an effective tool to reduce complications in spinal surgery. We propose to extend the use of checklist system also to the preoperative and postoperative phases in order to further reduce the incidence of complications. These slides can be retrieved under Electronic Supplementary Material.
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Lista de Checagem , Segurança do Paciente , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Organização Mundial da SaúdeRESUMO
Unfortunately, the affiliation for the following authors was incorrectly published in the original publication.
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PURPOSE: Primary vascular bone tumors of the spine represent a challenge for oncology surgeons, due to the need of planning a surgical strategy appropriate to the tumor behavior. But these tumors represent a challenge also for pathologists, as immunohistochemical and molecular analyses have recently refined the terminology. METHODS: A cohort of 81 cases was retrospectively reviewed, targeting the evolution of diagnoses and the treatment-related outcome. Sixty-six cases (including one case originally diagnosed as chordoma) were diagnosed before 2011, and 15 were diagnosed and treated in the period 2011-2017. Fully documented outcome studies are available for 46 patients whose immunohistochemical and molecular analyses were available. The follow-up ranges from 6 months of the early patient death to 300 months of the longest disease-free survival. RESULTS: The outcome was related not only to the treatment performed, but also to the evolution of diagnoses. The term Hemangioendothelioma that defined a benign aggressive (Enneking stage 3) tumor is now obsolete and replaced by the diagnosis of Epithelioid Hemangioma for benign aggressive tumor and Epithelioid Hemangioendothelioma for low-grade malignant tumor. En bloc resection was appropriate for local control, but 2 out of 7 cases of epithelioid Hemangioendotheliomas died due to the spread of the disease None of the Hemangiomas recurred after intralesional excision with or without radiotherapy, or after vertebroplasty. Both cases of Angiosarcoma had a fast and lethal evolution. CONCLUSIONS: Surgeons must be aware of the evolution of terminology to decide the most appropriate treatment options. These slides can be retrieved from Electronic Supplementary Material.
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Neoplasias Ósseas/patologia , Hemangioendotelioma Epitelioide/patologia , Hemangioma/patologia , Hemangiossarcoma/patologia , Neoplasias da Coluna Vertebral/patologia , Adulto , Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/terapia , Estudos de Coortes , Feminino , Hemangioendotelioma Epitelioide/diagnóstico por imagem , Hemangioendotelioma Epitelioide/mortalidade , Hemangioendotelioma Epitelioide/terapia , Hemangioma/diagnóstico por imagem , Hemangioma/mortalidade , Hemangioma/terapia , Hemangiossarcoma/diagnóstico por imagem , Hemangiossarcoma/mortalidade , Hemangiossarcoma/terapia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/mortalidade , Neoplasias da Coluna Vertebral/terapia , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: Metastatic epidural spinal cord compression (MESCC) is radiologically defined as an epidural metastatic lesion causing the displacement of the spinal cord from its normal position in the vertebral canal. The purpose of this paper is the evaluation of the influence of timing of surgery on the chance of neurological recovery. METHODS: This is a retrospective observational case-control study performed on patients with MESCC from solid tumors surgically treated at our institute from January 2010 to December 2016. Patients included were divided in two groups depending on surgery that was performed within or after 24 h the admission to the hospital. Neurological status was assessed with American Spine Injury Association (ASIA) Impairment Scale. RESULTS: No statistically significant difference was observed in the variation of ASIA if surgery is performed within or after 24 h from the admission to the hospital. A statistically significant difference was observed after surgery in each group in the improvement of neurological status. A statistically significant difference was reported in the early post-operative complications in patients surgically treated within 24 h. CONCLUSION: MESCC management is challenge for spine surgeons and may represent an oncologic emergency and if not promptly diagnosed can lead to a permanent neurological damage. According to this study, there is no difference in the chance of neurological recovery if surgery is performed within or after 24 h the admission to hospital, but there is a greater rate of early post-operative complications when surgery is performed within 24 h from the admission to the hospital.
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Descompressão Cirúrgica/métodos , Complicações Pós-Operatórias/etiologia , Compressão da Medula Espinal/complicações , Neoplasias da Coluna Vertebral/secundário , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Compressão da Medula Espinal/cirurgia , TempoRESUMO
PURPOSE AND BACKGROUND: En bloc resections aim at surgically removing a tumor in a single, intact piece, fully encased by a continuous shell of healthy tissue-the "margin". Intraoperative continuous assessment of the plane of resection regarding the tumor's margins is paramount. The goal of this study was to evaluate the accuracy of experienced spinal tumor surgeons' perception of these margins. METHODS: A retrospective analysis of a prospectively collected data of 1681 patients affected by spine tumors of whom 217 en bloc resections was performed. Surgeons' intraoperative assessment was compared to the histopathological assessment. RESULTS: Most were primary-163 (42 benign and 121 malignant), metastases occurred in 54 cases. 'Wide' margins were obtained in 126 cases; 'marginal' in 60 cases, and 'intralesional' in 31 cases. Surgeons assessed clear margins in 109 cases and contaminated in 108 cases. When considering marginal margins as a contaminated resection, the surgeon's assessment of clear resection had a sensitivity of 76.89%, specificity of 86.81%, PPV and NPV (positive and negative predictive values) were 88.99 and 73.15%, respectively. Inter-observer agreement was 0.62. When considering marginal margins as a clear resection, the surgeon's assessment of clear resection had a sensitivity of 64.5%, specificity of 100%, PPV and NPV were 100 and 0%, respectively. Inter-observer agreement was 0.29. CONCLUSION: Surgeons are fairly accurate in their intraoperative assessment of clear margins achieved; however, this accuracy is not perfect and exploring ways to improve this intraoperative assessment is of major importance possibly impacting the outcome of the treatment.
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Competência Clínica/estatística & dados numéricos , Margens de Excisão , Procedimentos Neurocirúrgicos/métodos , Neoplasias da Coluna Vertebral/cirurgia , Cirurgiões/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Estudos Retrospectivos , Sensibilidade e Especificidade , Neoplasias da Coluna Vertebral/patologia , Coluna Vertebral/patologia , Coluna Vertebral/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: Chordoma is a low-grade malignant tumor with recurrence and metastasis tendency that originates from embryonic notochordal remnants. The sacrococcygeal region is the most commonly involved site. The aim of this paper is to report the results of the use of cryosurgery in the excision of a giant recurrent sacral chordoma and review of pertinent literature. METHODS: A 64 years old female patient with a locally recurrent sacral chordoma came to our attention after ten interventions performed at another institute. A surgical treatment was performed using argon cryosurgery. RESULTS: In this case, it was not possible to perform a marginal or wide excision, but it was intralesional with the removal of three major blocks. The fragments sent for the histological analysis measured total 35 × 30 × 8 cm with a weight of 4.260 g. CONCLUSIONS: Given the gelatinous structure of the tumor and the possibility of contamination of operatory field, cryosurgery may be indicated when previous surgeries and the dimensions of tumor mass do not allow a resection with negative margins improving radiotherapy efficacy in the local control of tumor.
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Cordoma/cirurgia , Criocirurgia/métodos , Recidiva Local de Neoplasia/cirurgia , Neoplasias da Coluna Vertebral/cirurgia , Cordoma/diagnóstico por imagem , Cordoma/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/patologia , Reoperação/métodos , Sacro , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/patologia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Protocols including combination of surgery and radiotherapy are more and more frequent in the treatment of bone tumors of the spine. In metastatic disease, combination of surgery and radiotherapy is since long time accepted, as based on clinical evidence. In primary tumors, combination of surgery and radiotherapy can be considered in all the cases in which a satisfactory oncological margin cannot be achieved: high-grade malignancies, recurrent tumors, huge tumors expanding in an extracompartimental area, and when tumor-free margin requires unacceptable functional sacrifices. However, metal implants are an obstacle in the collaboration between surgeons and radiation oncologists. Carbon-fiber-reinforced polyethil-ether-ether-ketone (CFR-PEEK) composite implants could make easier and more effective the treatment as radiolucent and not interfering with ionizing radiation and accelerated particles. The purpose of this article is to report the preliminary results from a cohort of patients treated with CFR-PEEK and to evaluate the safety and the non-inferiority of the device respect the commonly used titanium implants. MATERIALS AND METHODS: This study concerns an ambispective cohort series of 34 tumor patients (14 metastases and 20 primaries, most of them recurrent) submitted to thoracic and lumbar spine fixation with a CFR-PEEK composite implants. Oncologic surgery was palliative decompression and fixation in 9 cases, tumor excision in 21, and enbloc resection in 4. Data collected for this preliminary report were all intraoperative remarks, incidence of complications, changes in neurological status, local control, and survival. All the cases were followed 6-36 months (mean 13 months). RESULTS: Only one intraoperative screw breakage occurred out of 232 implanted screws. Pain control and neurological improvement were the early clinical results. Two sacral screws loosening were found at 9 and 12 months in multilevel constructs performed on multirecurrent tumors. Six local recurrences were early found thanks to the implant radiolucency. Radiation oncologists' opinion was favourable as concerning better treatment planning on CT and lacking of scattering effect during the treatment. CONCLUSIONS: No artifacts on imaging studies mean early local recurrence detection. For radiation oncologists, no artifacts on imaging studies mean easier planning and no scattering effect means more effective and safe radiotherapy, particularly when particles are used. Moreover, it seems that the clinical use of CFR-PEEK composite implants may be safe and at least comparable with the commonly used titanium implants in terms of intraoperative complications, stability at weight bearing and at functional recovery. Larger patient series and longer follow-up are required to confirm these data.
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Materiais Biocompatíveis/efeitos adversos , Parafusos Ósseos/efeitos adversos , Procedimentos Ortopédicos/instrumentação , Neoplasias da Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Benzofenonas , Materiais Biocompatíveis/uso terapêutico , Fibra de Carbono/efeitos adversos , Feminino , Humanos , Cetonas/efeitos adversos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Polietilenoglicóis/efeitos adversos , Polímeros , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Desenho de Prótese/efeitos adversos , Desenho de Prótese/métodos , Neoplasias da Coluna Vertebral/radioterapia , Coluna Vertebral/patologia , Coluna Vertebral/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: Various techniques for anterior column reconstruction have been described after en bloc resection of spinal tumors. Limited evidence exists regarding one being superior to another. The purpose of this study is to evaluate 3D-printed vertebral bodies for spinal reconstruction after en bloc resection in the thoracolumbar spine. METHODS: Prospective observational study on custom-made 3D-printed titanium reconstruction of vertebral bodies after en bloc resection for spinal tumor was conducted between November 2015 and June 2017. 3D-printed vertebral bodies were monitored for mechanical complications such as (1) migration, (2) subsidence into the adjacent vertebral bodies, and/or (3) breakage. Complications and related details were recorded. RESULTS: Thirteen patients (7 females and 6 males) were enrolled, and reconstruction of the anterior column was performed using custom-made 3D-printed titanium prosthesis after en bloc resection for spinal tumor (8 primary bone tumors and 5 solitary metastases). Subsidence into the adjacent vertebral bodies occurred in all patients at both proximal and distal bone-implant interfaces; however, it was clinically irrelevant (asymptomatic, and no consequences on posterior instrumentation), in 11 out of 12 patients (92%). In 1 patient (#4), severity of the subsidence led to revision of the construct. At an average 10-month follow-up (range 2-16), 1 implant was removed due to local recurrence of the disease and 1 was revisioned due to progressive distal junctional kyphosis. CONCLUSION: Preliminary results from this series suggest that 3D printing can be effectively used to produce custom-made prosthesis for anterior column reconstruction. These slides can be retrieved under Electronic Supplementary Material.
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Biomimética/métodos , Vértebras Lombares/cirurgia , Impressão Tridimensional , Desenho de Prótese , Neoplasias da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Adolescente , Adulto , Idoso , Feminino , Humanos , Vértebras Lombares/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Estudos Prospectivos , Implantação de Prótese/métodos , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/secundário , Vértebras Torácicas/diagnóstico por imagem , Titânio , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
PURPOSE: We describe a rare case of solitary bone cyst involving the vertebral body of L4. INTRODUCTION: To the best of the authors' knowledge, only 15 cases of solitary bone cysts involving the spine have been reported previously. All the reported cases were treated surgically, including resection and curettage with or without bone grafting. In the current case, treatment was with steroid injection alone. METHOD: A cystic lesion involving the vertebral body of L4 was identified in a 16-year-old girl with persistent low back pain of 2 years' duration. According to the radiological characteristics of the lesion, a diagnosis of solitary bone cyst was suspected. The patient underwent surgical intervention with percutaneous steroid injection alone since there was no evidence of thinned cortex or pathological fracture. The patient was discharged 2 days after this intervention with resolution of the low back pain. RESULT: At the final follow-up 7 months after treatment, the patient was asymptomatic and the beginning of bony healing was evident. CONCLUSION: Herein, we reported an extremely rare case of solitary bone cyst involving the body of the fourth lumbar vertebra. Local steroid injection should be considered as a minimally invasive intervention for a solitary bone cyst involving the spinal column with no evidence of thinned cortex or pathological fracture.
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Cistos Ósseos/tratamento farmacológico , Cortisona/administração & dosagem , Vértebras Lombares/patologia , Esteroides/administração & dosagem , Adolescente , Feminino , Humanos , Injeções , Dor Lombar/tratamento farmacológico , Resultado do TratamentoRESUMO
PURPOSE: ABC is a benign lesion with unpredictable behavior. Its treatment is challenging, especially in poorly accessible surgical areas, such as spine and pelvis. Currently, the first-line treatment of ABC is repeated selective arterial embolization (SAE) until healing. Other options have been used with variable success rates. We propose an alternative treatment for spine aneurysmal bone cyst (sABC) based on the injection of concentrated autologous bone marrow. METHODS: We retrospectively report and analyze here two cases of patients, a 14-year-old girl and a 16-year-old boy, both affected by ABC in C2 vertebra which were impossible to treat by SAE. They were treated with single or repeated injection of concentrated autologous bone marrow into the lesion. Their follow-up period is 27 months for both patients. RESULTS: In the two cases reported here we observed a progressive ossification of the lesion, which was slow in one case, requiring three subsequent injections of concentrated bone marrow, and fast in the other case, beginning 1 month after the procedure. In both cases, the healing of the lesion was associated with symptom relief and the clinical status of the patients remains stable after 2 years. CONCLUSIONS: Although SAE can still be considered the first line in the treatment of ABC in the axial skeleton, new promising therapeutic procedures involving the use of mesenchymal stem cells are developing.
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Vértebra Cervical Áxis/diagnóstico por imagem , Cistos Ósseos Aneurismáticos/terapia , Transplante de Medula Óssea/métodos , Embolização Terapêutica/métodos , Adolescente , Angiografia , Cistos Ósseos Aneurismáticos/diagnóstico por imagem , Feminino , Humanos , Injeções Intralesionais , Imageamento por Ressonância Magnética , Masculino , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Transplante Autólogo , Resultado do TratamentoRESUMO
PURPOSE: Identify risk factors, enabling reduction of the rate of complications and improve outcome in en bloc resection surgeries. METHODS: A retrospective study of prospective collected data of 1681 patients affected by spine tumors treated from 1990 to 2015 by the same team. RESULTS: A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary-165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. Median FU was 45 months (0-371). 153 complications were observed in 100 patients (46.2 %). 64 (30 %) suffered one complication, while the rest had two or more. There were 105 major and 48 minor complications. Seven patients (4.6 %) died as a result of complications. The combined approach, neoadjuvant chemotherapy and neoadjuvant radiotherapy were statistically significant independent risk factors for complications occurrence. 33 patients (15.2 %) suffered from local recurrence. Reoperations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection. CONCLUSION: The rate of complication is higher in multisegmental resections and when double combined approach is performed. Reoperations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed. The high risk of complications should not discourage surgeons from performing en bloc resection when needed. Most of the patients who sustain complications benefit from the better local control resulting from en bloc resection.
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Procedimentos Neurocirúrgicos , Complicações Pós-Operatórias/epidemiologia , Neoplasias da Coluna Vertebral/cirurgia , Coluna Vertebral/cirurgia , Humanos , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Estudos Retrospectivos , Fatores de RiscoRESUMO
PURPOSE: Chordoma is a rare, locally aggressive neoplasm of the bone that arises from embryonic notochordal remnants. In less than 5 % of cases, chordomas contain a highly malignant sarcomatous component. Because of the rarity of such tumors, little is known about their clinical features and optimal treatment options. Herein, we report two chordoma cases with malignant sarcomatoid areas, consistent with high-grade osteosarcoma in the primary spine lesions, and discuss the presentation and characteristics of this disease. METHODS AND RESULTS: In both patients, the diagnosis on the first computed tomography (CT)-guided trocar biopsy of the tumor was a conventional chordoma. The two cases represent dedifferentiated chordomas with a sharp demarcation between the conventional chordoma and the high-grade sarcomatous component, which was identified on T2-weighted magnetic resonance imaging (MRI). One patient experienced a symptomatic tumor recurrence 4 months after carbon-ion radiotherapy, and underwent en bloc wide resection of the tumor following chemotherapy. The patient remained well 36 months after surgery without tumor recurrence. The other patient underwent a gross total excision as the second surgery followed by carbon-ion radiotherapy. At the 39-month follow-up, there was no evidence of active disease. CONCLUSIONS: Accurate analyses of MRI and positron emission tomography scans should suggest the most representative section for histological assessment. Unlike the treatment of conventional chordomas, the treatment of this disease should include chemotherapy first, followed by en bloc resection and/or carbon-ion radiation.
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Cordoma/patologia , Neoplasias Primárias Múltiplas/patologia , Osteossarcoma/patologia , Neoplasias da Coluna Vertebral/patologia , Idoso , Biópsia , Desdiferenciação Celular , Cordoma/diagnóstico por imagem , Cordoma/terapia , Terapia Combinada , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/terapia , Neoplasias Primárias Múltiplas/diagnóstico por imagem , Neoplasias Primárias Múltiplas/terapia , Osteossarcoma/diagnóstico por imagem , Osteossarcoma/terapia , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/terapia , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Epithelioid hemangioma is recognized by the World Health Organization as a distinct benign neoplasm; however, it is characterized by locally aggressive and rarely metastasizing behavior. Epithelioid vascular tumors are rare bony vascular lesions with varying degrees of malignant potential that remain controversial because of their rarity, unusual morphological features, and unpredictable biological behavior. The application of new molecular tools, such as massive parallel sequencing technologies, have provided new diagnostic markers and an opportunity to further refine the classification of bone vascular neoplasms. Very few cases of EH of the spine have been reported in the literature; therefore, it is difficult to make evidence-based therapeutic decisions for these patients. We report herein our experience with eleven patients suffering from EH of the spine. The study population included three males and eight females treated in our center from 2016 to the present; the average age was 44.8 years (range 14-75 years). The surgical, clinical, and radiographic data were retrospectively analyzed. The mean follow-up was 34.8 months. All patients presented lytic vertebral body lesions, six of them with pathological fracture. The majority of patients (80%) presented myelo-radicular compression. All patients were surgically treated, and preoperative embolization was performed in all cases. In light of the literature review and the clinical experience of our center, we can consider EH a locally aggressive tumor that requires surgical treatment in case of symptoms. Here, we propose a treatment algorithm that could be useful in the management of patients with this rare disease.
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Background/Objective: Surgical treatment of aneurysmal bone cysts (ABCs) can be challenging, especially in the spine. Non-surgical treatments such as with denosumab have shown promising results in different osteolytic pathologies. This retrospective observational study aimed to evaluate the long-term clinical and radiologic response of patients with ABCs of the mobile spine treated with denosumab and propose an updated treatment algorithm. Methods: Six patients with relapsed and symptomatic ABCs of the mobile spine were treated with denosumab (120 mg subcutaneously on days 1, 8, 15, 29, and every 4 weeks thereafter) between 2012 and 2023. Disease assessments were conducted using CT and MRI at 3, 6, 9, and 12 months post-treatment. Clinical data, including pain levels, symptoms, and adverse events, were documented from patients' charts. Results: Patients underwent an initial phase of treatment with denosumab, receiving a mean of 22 administrations (range 13-42) over a median follow-up period of 41 months (range 15-98 months). Clinical improvement was observed in all patients after 4 weeks of treatment, and all patients demonstrated a radiological response after 12-24 weeks on denosumab. Three patients were progression-free after discontinuing denosumab following 13, 15, and 42 administrations, respectively. At the last follow-up, after 38, 43, and 98 months, these patients remained stable without relapse of the disease. Three patients had a relapse of disease after denosumab; two of them underwent denosumab re-challenge, while one patient received one mesenchymal stem cells (MSCs) injection. All patients showed clinical and radiological improvement and were resulted to be disease-free at the last follow-up. Conclusions: This study demonstrates the long-term efficacy and safety of denosumab in treating ABCs of the mobile spine, as well as the potential of re-challenge in managing recurrence. A treatment algorithm is proposed, positioning denosumab as a viable therapeutic option after other local treatments. Careful patient selection, monitoring, and further research are necessary to optimize denosumab use for ABCs.
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(1) Background: this case series and literature review aims to evaluate the efficacy and safety of electrochemotherapy in the management of aggressive spinal hemangiomas, presenting two distinct cases. (2) Methods: we present two cases of spinal aggressive hemangioma which were refractory to conventional treatments and underwent electrochemotherapy. Case 1 involves a 50-year-old female who presented with an aggressive spinal hemangioma of L1, who previously underwent various treatments including surgery, radio-chemotherapy, and arterial embolization. Case 2 describes a 16-year-old female with a T12 vertebral hemangioma, previously treated with surgery and stabilization, who faced limitations in treatment options due to her young age and the location of the hemangioma. (3) Results: in Case 1, electrochemotherapy with bleomycin was administered following the failure of previous treatments and resulted in the reduction of the lesion size and improvement in clinical symptoms. In Case 2, electrochemotherapy was chosen due to the risks associated with other treatments and was completed without any adverse events. Both cases demonstrated the potential of electrochemotherapy as a viable treatment option for spinal hemangiomas, especially in complex or recurrent cases. (4) Conclusions: electrochemotherapy with bleomycin is a promising treatment for aggressive spinal hemangiomas when conventional therapies are not feasible or have failed. Further research is needed to establish definitive protocols and long-term outcomes of electrochemotherapy in spinal hemangioma management.
RESUMO
The partial loss of SMARCB1/INI1 expression has recently been reported in skull base conventional chordomas, with possible therapeutic implications. We retrospectively analyzed 89 patients with conventional spinal chordomas to investigate the differences in the immunohistochemical expression of SMARCB1/INI1 and the underlying genetic alterations in the SMARCB1 gene. Moreover, we assessed the correlation of clinicopathological features (age, gender, tumor size, tumor location, surgical margins, Ki67 labelling index, SMARCB1/INI1 pattern, previous surgery, previous treatment, type of surgery, and the Charlson Comorbidity Index) with patient survival. Our cohort included 51 males and 38 females, with a median age at diagnosis of 61 years. The median tumor size at presentation was 5.9 cm. The 5-year overall survival (OS) and 5-year disease-free survival (DFS) rates were 90.8% and 54.9%, respectively. Partial SMARCB1/INI1 loss was identified in 37 (41.6%) patients with conventional spinal chordomas (27 mosaic and 10 clonal). The most frequent genetic alteration detected was the monoallelic deletion of a portion of the long arm of chromosome 22, which includes the SMARCB1 gene. Partial loss of SMARCB1/INI1 was correlated with cervical-thoracic-lumbar tumor location (p = 0.033) and inadequate surgical margins (p = 0.007), possibly due to the high degree of tumor invasiveness in this site. Among all the considered clinicopathological features related to patient survival, only tumor location in the sacrococcygeal region and adequate surgical margins positively impacted DFS. In conclusion, partial SMARCB1/INI1 loss, mostly due to 22q deletion, was detected in a significant number of patients with conventional spinal chordomas and was correlated with mobile spine location and inadequate surgical margins.