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Primary Bone Tumors: Spine Surgery Live -Video Techniques Mobile Spine Christopher Ames MD Professor of Neurosurgery and Orthopedic Surgery Director of Spine Tumor And Deformity Surgery UCSF Department of Neurosurgery Disclosures DePuy
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Christopher Ames MD Professor of Neurosurgery and Orthopedic Surgery Director of Spine Tumor And Deformity Surgery UCSF Department of Neurosurgery
DePuy Medtronic Stryker Docters Research Group Fish & Richardson StrykerBiomet Spine Consultant Consultant Consultant Stock Shareholder (excluding mutual funds) P.C. Consultant
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Background of Grading and Staging Examples with Treatment Implications (Mobile Spine)
Metastatic Spine Tumors Primary Spine Tumors
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Primary tumors rely more on
surgical treatment at initial surgery
Diagnosis Histology Staging System Oncological Location Surgical Treatment Planning Adjuvant yes/no/pre/post Surgery
wide/marginal/intralesional (part/whole)
Surgical Technique
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Stage Definition 1 G0 T0 M0 Benign latent 2 G0 T0 M0 Benign active 3 G0-1 T0-1 M0 Benign aggressive I A G1 T1 M0 Malignant, low grade, intracompartmental I B G1 T2 M0 Malignant, low grade, extracompartmental II A G2 T1 M0 Malignant, high grade, intracompartmental II B G2 T2 M0 Malignant, high grade, extracompartmental III G any T any M1 Malignant, any grade, any extent, distant metastasis
Enneking et al,1983
1 G0 T0 M0 Latent 2 G0 T0 M0 Active 3 G0 T1/2 M0/1 Aggressive
1.Capsule, 2.Pseudocapsule
C B A D E
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Low grade Benign Symptomatic Marginal
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NSAIDS RFA Intralesional
Associated
Modern Tx
Serial Embolization Intralesional embolization Intralesional resection
Not able to embolize Mechanical Instabiliy
Denosumab?
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Bx - GCT vs ABC Rebx- GCT vs OS 3 months denosumab
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Semin Spine Surg 21:76-85
En bloc resections without tumor-free margins
Intralesional: The tumor periphery is violated and the tumor is not covered by healthy tissue. Marginal: The pathologist describes histologically a thin layer of healthy muscle, bone, or an endothelial membrane continuously covering the tumor mass Wide: A fascial barrier represents a wide margin… 1 cm of muscle or cancellous bone sometimes is not enough and a 2 cm barrier may be required to consider the margin wide.
Boriani Seminars in Oncology
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Benign
Type 3 20% recurrence
intralesional
En Bloc Excision Associated ABC
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Denosumab
patients who had the opportunity to be
months.
free of disease progression based on subjective assessment of disease status
20 40 60 80 100 No Disease Progression Disease Progression Proportion of Patients (%)
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IA Intra-comp; thin capsule, tumor in pseudocapsule IB Extra-comp (Zone A,D,E) chordoma, chondrosarcoma IIA Intra-comp; tumor in PC, Osteosarcoma, ES IIB Extra-comp (Zone A,D,E)
1.Capsule, 2.Pseudocapsule, 3.Tumor invation to pseudocapsule, 4.Skip metastases
C B A D E
High grade Low grade
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How to access contralateral
Lateral retraction of specimen
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1. Single stage, posterior
High to mid thoracic, sacrectomy 2. 2 stage, posterior/anterior Cervical, Lower thoracic, lumbar, ? Vessel or
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IVC Filter PSF/I T2-T11, posterior osteotomy and nerve
Left Thoracotomy, aortic dissection, 3.25 level Right Thoracotomy, esophageal dissection,
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SAC Preserve
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32 yo male Needle biospy with chondrosarcoma
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Preoperative adjuvant
therapy
Response to therapy
predictive of outcome
Refinement of surgical
margins
ral
Preoperative Adjuvant Therapy
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Ex: Leiomyosarcoma
Adjuvant therapy P32 to margin Dural margin Shape radiation targets
for SRS
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Beta emitting radioisotope
(1-2 Gy/minute)
Embedded in thin plastic
polymer
Half-life 14 days
the target
FDA approved
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Vedat Deviren Orthopedics Igor Barani Rad Onc Pierre Theodore Thoracic Ivan El Sayed ENT Mika Varma Colorectal Bill Hoffman Plastics Charles Eichler Vascular Rebecca Mustille PT