Extended pelvic resection of iliacus muscle and femoral nerve for isolated recurrent uterine cancer.
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Female↗
Biomedical subjects
Patrick J Boland
Publications and source records attributed to Patrick J Boland.
Superior pubic rami resection for isolated recurrent uterine cancer.
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Female↗
Treatment algorithm for locally recurrent osteosarcoma based on local disease-free interval and the presence of lung metastasis.
BACKGROUND: Local recurrence in osteosarcoma is clinically distinct from metastasis, although associated with a similar reduction in survival. The prognostic factors in locally recurrent osteosarcoma were investigated and these factors were translated into a management strategy. METHODS: In all, 407 consecutive patients with skeletal osteosarcoma between 1977 and 2002 were analyzed. Twenty-three patients with resectable local recurrence were analyzed. Clinical and tumor-related factors were assessed for significance in relation to survival and a management strategy was formulated based on factors found to be independently significant for survival. RESULTS: Seventeen of the 23 patients underwent primary resections and initial treatment, yielding an overall local recurrence rate of 4.2% for resectable cancer. Median time to local recurrence was 13 months (95% confidence interval, 9-16 months). The 5-year and 10-year survival rates in the recurrent cases were 29% and 10%, respectively. All patients received chemotherapy both for their primary and recurrent disease. Increased risk of local recurrence (P < .0001) was strongly correlated with positive margins of resection. The rate of local recurrence was not related to chemotherapy-associated necrosis in the primary tumor. Nevertheless, neoadjuvant therapy halved the risk of local recurrence (odds ratio, 1.92; P = .3, power 10%). The strongest correlate with poor survival was local recurrence within the first year after primary resection (P = .001), followed by metastasis at the time of first local recurrence (P = .04) and failure to achieve clinical remission after disease recurrence (P = .04). Chemotherapy-associated necrosis and margins of resection of the primary tumor were not significant prognostic variables for survival. Survival differed significantly among patients defined by local disease-free interval and lung metastasis (P = .0001). They required an individualized approach as captured in the management algorithm. CONCLUSION: There is a residual risk of local recurrence in patients despite favorable chemotherapy-associated necrosis and negative margins of resection. A treatment strategy emphasizing clinical remission at all identifiable sites offers the highest likelihood of survival in this patient population.
Adolescent↗
Sacral resection for recurrent rectal cancer: analysis of morbidity and treatment results.
PURPOSE: Composite sacropelvic resection for locally advanced recurrent rectal cancer is a high-risk procedure that benefits select patients. We reviewed our recent institutional experience to evaluate case selection, morbidity, and outcomes. METHODS: Between 1987 and 2004, 29 patients underwent composite resection for recurrent locoregional rectal cancer (17 females; median age, 60 years). Clinicopathologic indicators were evaluated as indicators of survival by log-rank test and Cox proportional hazards model. RESULTS: Of 29 total patients, 27 (93 percent) received radiotherapy with their previous surgery (n = 10; 34 percent) or before sacrectomy (n = 17; 59 percent), and 12 (41 percent) received intraoperative therapy. Sacral resections were performed at S2/S3 (55 percent) or S4/S5 (45 percent) using anterior (41 percent) or combined anterior-posterior approach (59 percent), with adherence to (62 percent) or cortical invasion in (38 percent) the sacrum. A majority of those who had undergone previous abdominoperineal resection had total exenteration (9/13), whereas most patients who had undergone a previous sphincter-preserving procedure had abdominoperineal resection (12/16) and none had exenteration. Pedicle flaps (omental, 11; abdominal rectus, 7) often were used. A median of five (range, 1-33) units of blood was given intraoperatively. Transfusions were associated with previous abdominoperineal resection (P < 0.03), correlating strongly with postoperative morbidity (P < 0.02). There were 33 complications in 17 (59 percent) patients, most commonly perineal wound breakdown (9 (31 percent)) and pelvic abscess (5 (17 percent)). Median hospital stay was 18 (range, 7-56) days, significantly longer in patients with previous abdominoperineal resection (P < 0.02) or postoperative morbidity (P < 0.03). The only postoperative death was from pelvic sepsis. Resection was complete (R0) in 18 patients (62 percent), with microscopically positive margins (R1) in 10 (34 percent) and grossly positive margins (R2) in 1 (3 percent). Two-year and five-year recurrence rates were 47 and 85 percent, respectively; disease-specific survival was 63 and 20 percent, respectively. Less transfusion (P = 0.03), R0 resection (P = 0.005), lack of anterior organ involvement (P = 0.02), and absence of cortical bone invasion (P < 0.001) were associated with better survival on univariate analysis; original colorectal cancer stage was not. CONCLUSIONS: Sacrectomy for rectal cancer is a high-risk procedure that can achieve clear resection margins with low mortality in select patients. This procedure has a low cure rate but may provide local disease control with acceptable morbidity.
Adenocarcinoma↗
Infiltrative MRI pattern and incomplete initial surgery compromise local control of myxofibrosarcoma.
UNLABELLED: Myxofibrosarcoma (MFS) has a high local failure rate of up to 79%. We conducted a retrospective analysis on all patients with the diagnosis of myxofibrosarcoma seen between 1990 and 2004 to assess whether improved imaging with MRI reduced local recurrence, increased survival, and whether radiotherapy following resection influenced outcome. Twenty-one patients were treated for MFS with a median followup of 52 months (range, 18-122). All patients were surgically treated, with 19 receiving limb-sparing surgery. All patients with high grade disease, positive margins, or a pre-referral procedure received radiation therapy. The local recurrence rate was 57% for patients with a prior outside procedure (8 of 14), while patients with no prior surgery had a rate of 14% (1 of 7). Prior marginal excision and diffuse fascial spread on MRI predicted an increased local recurrence rate. The disease-free survival at 5 years was 43% (SE, 22%) for low-grade disease and 39% (SE, 18%) for high- grade disease. Magnetic resonance imaging observations suggest a unique pattern of diffuse spread along fascial planes that could be responsible for the high local recurrence. Radiation did not compensate for positive margins, nor did it reduce recurrence after negative margins. LEVEL OF EVIDENCE: Therapeutic study, level IV (case series).
Aged↗
Function correlates with deltoid preservation in patients having scapular replacement.
Advocates of scapular replacement suggest sparing the deltoid should be a prerequisite for use of a scapular prosthesis. We evaluated the importance of a functioning deltoid in scapular replacement for malignant tumors. We retrospectively reviewed 19 patients who received scapular prostheses after resection of a malignant tumor. The median followup was 18 months (range, 12-124 months). The axillary nerve was resected in eight patients and spared in 11 patients. The average International Society of Limb Salvage score was 25 of 30 points (range, 21-27 points). The average scores for patients with and without axillary nerve resection were 24 points (range, 21-25 points) and 26 points (range, 23-27 points), respectively. There was a difference between the two groups in hand positioning, overall function, and pain. However, there were no differences in emotional acceptance, lifting ability, or hand dexterity. We favor using a scapular prosthesis if there is a functioning deltoid; however resection of the deltoid should not be considered an absolute contraindication for scapular replacement.
Adolescent↗
Limb salvage of infected knee reconstructions for cancer with staged revision and free tissue transfer.
UNLABELLED: Periprosthetic infections of oncologic reconstructions have an amputation rate between 37% and 87%. Eleven patients with an infected knee reconstruction following limb salvage surgery for cancer were treated with the staged protocol. All patients underwent prosthetic removal and implantation of an antibiotic-impregnated cement spacer, i.v. antibiotic therapy, repeat debridement and spacer change, and delayed prosthetic reconstruction and free tissue transfer. At the time of reconstruction, the median bone defect was 185 mm. The mean soft tissue defect was 112 cm2. Coverage was obtained with a free musculocutaneous flap. All limbs were spared without amputation or flap loss. The mean functional outcome as measured by the Musculoskeletal Tumor Society lower extremity score was 23 of 30. Infections of large prosthetic reconstructions about the knee can be salvaged successfully with repetitive debridement, staged prosthetic reimplantation, and free tissue transfer. Free tissue transfer improves the soft tissue envelope and allows restoration of joint motion. LEVEL OF EVIDENCE: Case Series. Level IV.
Adult↗
Proximal deep vein thrombosis after hip replacement for oncologic indications.
BACKGROUND: Patients with cancer who undergo surgery about the hip are at increased risk for the development of deep vein thrombosis. We implemented a program of chemical and mechanical prophylaxis to prevent this problem. This study was performed to assess the effectiveness of that program. METHODS: Eighty-seven consecutive patients with an active malignant tumor who underwent hip replacement surgery at our institution over a two-year period were included in the study. All patients were treated with intermittent pneumatic compression devices. Seventy-eight patients received anticoagulants, and nine did not. Postoperative surveillance for proximal deep vein thrombosis was routinely performed on all patients with duplex Doppler ultrasonography. RESULTS: Four patients had proximal deep vein thrombosis, and one patient, who did not receive anticoagulation, had a nonfatal pulmonary embolism. The use of prophylactic low-molecular-weight heparin (dalteparin) was associated with a 4% rate of proximal deep vein thrombosis (three of seventy-eight patients). Proximal deep vein thrombosis developed in three of eight patients with pelvic disease, one of nineteen patients with femoral disease, and zero of sixty patients with hip disease (p < 0.00001). The prevalence of proximal deep vein thrombosis was significantly higher (p < 0.02) following replacements in patients with sarcoma (three of twenty-one) than it was after replacements in patients with carcinoma (zero of fifty-seven) or hematologic malignant disease (one of nine). On multivariate analysis, only the location of the disease (the pelvis, femur, or hip) was found to be independently significant for an association with deep vein thrombosis. A wound complication developed in four of twenty-one patients with sarcoma and no patient with carcinoma or hematologic malignant disease (p < 0.001). The pathologic type was the only factor studied that was independently significant for an association with wound complications on multivariate analysis. CONCLUSIONS: The rate of proximal deep vein thrombosis in patients who had undergone hip replacement for oncologic indications was low when the use of an intermittent pneumatic compression device was supplemented with prophylaxis with low-molecular-weight heparin.
Aged, 80 and over↗
Patellar complications following distal femoral replacement after bone tumor resection.
BACKGROUND: Patellar complications following endoprosthetic reconstruction can occur as a result of anatomic, physiologic, and surgical reasons. Patellar impingement on tibial polyethylene is a complication of distal femoral replacement, and it is frequently related to inaccurate restoration of the joint line and to soft-tissue contracture. The purpose of our study was to determine the prevalence and type of patellar complications following distal femoral replacements after excisions of bone tumors. METHODS: The results of reconstruction with use of a rotating-hinge endoprosthesis following excision of a distal femoral tumor in forty-three patients were retrospectively reviewed. Patients were followed clinically and radiographically for a minimum of forty-eight months or until death. Pain status, functional scores, and the range of motion were determined from a prospectively maintained database. The ratio of the patellar tendon length to the height of the patellar tendon insertion, as described by Insall and Salvati, was calculated. In addition, we attempted to determine whether the position of the patella was associated with anterior knee pain or with the functional scores derived with use of the International Society of Limb Salvage (ISOLS) scoring system. RESULTS: Thirty-five patellar complications, including eleven cases of impingement, occurred in twenty-seven patients (63%). We found no difference, on the basis of our sample size, with regard to the presence of patellar pain, the range of motion, or the Insall-Salvati ratio between the patients with and those without impingement. The ratio of the patellar tendon length to the height of the patellar tendon insertion averaged 0.9 in the group with impingement and 1.4 in the group without impingement (p = 0.07). The ISOLS score averaged 21.2 points in the group with impingement compared with 24.2 points in the group without impingement (p = 0.01). Patella baja occurred in nine patients. The average ISOLS score (and standard deviation) was 20.1 +/- 4.4 points for the patients with patella baja compared with 24.8 +/- 3.9 points in the group with a normal patellar position (p = 0.004). Patellar fracture occurred in two patients, and osteonecrosis occurred in two patients. These patients were treated nonoperatively. CONCLUSIONS: Patellar complications are common after distal femoral resection and endoprosthetic reconstruction. Patellar impingement on the polyethylene tibial bearing surface is a more common and important complication of distal femoral replacement than has been reported to date. Patella baja is also a relatively common complication, which has a negative impact on knee function.
Adult↗
Radiation therapy for Ewing's sarcoma: results from Memorial Sloan-Kettering in the modern era.
PURPOSE: To evaluate the outcomes of patients with Ewing's sarcoma family of tumors (ESFT) treated with modern radiotherapy techniques with MRI along with optimal chemotherapy. METHODS AND MATERIALS: The records of all 60 patients with ESFT who received radiation to the primary site between 1990 and 2004 were reviewed. All patients received chemotherapy, including vincristine, doxorubicin, cyclophosphamide, ifosfamide, and etoposide. Radiation was used as the sole modality for local control in 31 patients and was given either before (n=3) or after surgical resection (n=26) in the remainder. All patients had MRI and CT scan-based treatment planning, and 43% received intensity-modulated radiation therapy. Radiation doses ranged from 30 Gy to 60 Gy (median, 51 Gy), and 35% received hyperfractionated radiotherapy. RESULTS: Median age was 16 years (range, 2-40 years). Because of selection bias for radiotherapy, the majority of primary tumors were centrally located (72%): spine (n=18), pelvis (n=15), extremities (n=12), chest wall (n=5), head and neck (n=5), and other (n=5). Thirty-eight percent of patients presented with metastatic disease, and 52% of primary tumors were >or=8 cm. Actuarial 3-year local control was 77%. The presence of metastases at diagnosis was an adverse prognostic factor for local control (84% vs. 61%, p=0.036). No other predictive factors for local failure were identified. In patients without metastatic disease, 3-year disease-free and overall survival rates were 70% and 86%, respectively, whereas in patients with metastases they were both 21%. Follow-up of surviving patients was 6-178 months (median, 41 months). CONCLUSION: In this unfavorable cohort of ESFT patients, radiation therapy was an effective modality for local control, especially for patients without metastases. The presence of metastases at diagnosis is a predictive factor not only for death but also for local failure.
Adolescent↗
Survival in patients operated on for pathologic fracture: implications for end-of-life orthopedic care.
PURPOSE: Life expectancy is routinely used as part of the decision-making process in deciding the value of surgery for the treatment of bone metastases. We sought to investigate the validity of frequently used indices in the prognostication of survival in patients with metastatic bone disease. METHODS: The study prospectively assessed 191 patients who underwent surgery for metastatic bone disease. Diagnostic, staging, nutritional, and hematologic parameters cited to be related to life expectancy were evaluated. Preoperatively, the surgeon recorded an estimate of projected life expectancy for each patient. The time until death was recorded. RESULTS: Kaplan-Meier survival analyses indicated that the survival estimate, primary diagnosis, use of systemic therapy, Eastern Cooperative Oncology Group (ECOG) performance status, number of bone metastases, presence of visceral metastases, and serum hemoglobin, albumin, and lymphocyte counts were significant for predicting survival (P < .004). Cox regression analysis indicated that the independently significant predictors of survival were diagnosis (P < .006), ECOG performance status (P < .04), number of bone metastases (P < .008), presence of visceral metastases (P < .03), hemoglobin count (P < .009), and survival estimate (P < .00005). Diagnosis, ECOG performance status, and visceral metastases covaried with surgeon survival estimate. Linear regression and receiver-operator characteristic assessment confirmed that clinician estimation was the most accurate predictor of survival, followed by hemoglobin count, number of visceral metastases, ECOG performance status, primary diagnosis, and number of bone metastases. Nevertheless, survival estimate was accurate in predicting actual survival in only 33 (18%) of 181 patients. CONCLUSION: A better means of prognostication is needed. In this article, we present a sliding scale for this purpose.
Aged↗
Cell proliferation of cultured human cancer cells are affected by the elevated tumor pressures that exist in vivo.
Elevated interstitial fluid pressure (IFP) is observed in most solid tumors. However, the study of the cellular processes of tumors and the development of chemotherapy are routinely studied using in vitro culture systems at atmospheric pressure. Using a new pressurized cell culture system, we investigated the influence of hydrostatic pressure on population dynamics of three primary osteosarcoma (HOS, U2OS, SaOS2) and two metastatic tumor cell lines (MCF7 breast, H1299 lung) that invade bone. Values of IFP in normal human bone and muscle, and in osteosarcoma tumors obtained during their surgical biopsy established the hydrostatic pressure range for the in vitro cell studies. The IFP values were obtained from a retrospective review of patient records. IFP from confirmed osteosarcoma was 35.9+/- 16.2 mmHg. Tumor IFP was significantly higher than muscle IFP (p < 0.001) and bone IFP (p < 0.003). The in vitro study measured the cell-line proliferation using hydrostatic pressures of 0, 20, 50 and 100 mmHg. The findings suggest that hydrostatic pressure either increases or decreases tumor proliferation rates depending on cell type. Furthermore, cell death was not associated with apoptosis.
Cell Death↗
De novo osteogenic sarcoma in patients older than forty: benefit of multimodality therapy.
UNLABELLED: The treatment of primary osteogenic sarcoma is well established in younger patients; however, controversy surrounds the treatment of this disease in the older population. To confirm multimodality therapy results in longer survival than surgery alone, 58 patients older than 40 years with primary osteogenic sarcoma were assessed retrospectively for the benefits of multimodality treatment versus surgery alone. We then asked whether specific patient and tumor characteristics and treatment modalities affected the rates of survival. Finally, we questioned whether pulmonary metastatectomy increased survival. The 5-year and 10-year overall survival for the group was 58% and 44%, respectively. Multimodality therapy increased survival compared with surgery alone in patients with high-grade disease. On multivariate analysis, considerable prognostic factors for improved overall survival for the entire group were age younger than 60 years, volume less than 100 cm, normal alkaline phosphatase, localized disease, negative surgical margins, and absence of recurrence. Pulmonary metastatectomy improved survival in selected patients. LEVEL OF EVIDENCE: Therapeutic study, Level III-1 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.
Adult↗
Biomechanical analysis of anterior poly-methyl-methacrylate reconstruction following total spondylectomy for metastatic disease.
STUDY DESIGN: Three reconstruction options were evaluated biomechanically following total spondylectomy using human cadaveric spine specimens. OBJECTIVES.: To evaluate and compare the stability of combined anterior and posterior fixation incorporating poly-methyl-methacrylate with alternative accepted reconstruction techniques. SUMMARY OF BACKGROUND DATA: Total spondylectomy represents the most radical option for decompression in metastatic spinal cord compression. Poly-methyl-methacrylate is considered a useful adjunct in spinal column stabilization and arthrodesis; however, there is little published biomechanical data to support its use in this setting. METHODS: Ten fresh-frozen human cadaveric spines (T9-L3) were used. After intact analysis, a total spondylectomy was performed at T12. Three potential reconstruction techniques were tested for their ability to restore stiffness to the specimen: 1) multilevel posterior pedicle screw instrumentation from T10-L2; 2) anterior instrumentation (ATL Z plate II) and rib graft at T11-L1 with multilevel posterior pedicle screw instrumentation from T10-L2; and 3) anterior cement (Simplex P) and pins construct (T12) with multilevel posterior pedicle screw instrumentation from T10-L2. Each of the three potential reconstruction techniques was tested on each specimen in random order using nondestructive testing under load control. RESULTS: Only combined stabilization techniques (e.g., anterior instrumentation and rib graft with multilevel posterior pedicle screw instrumentation and anterior cement-and-pins construct with multilevel posterior pedicle screw instrumentation) restored stiffness to a level equivalent to or higher than that of the intact spine in all loading modes (P < 0.05). Anterior cement-and-pins construct with multilevel posterior pedicle screw instrumentation provided more stability to the specimen than anterior instrumentation and rib graft with multilevel posterior pedicle screw instrumentation in compression and flexion testing (P < 0.05). Posterior instrumentation alone did not restore stiffness to the intact level in compression and flexion testing (P < 0.005). CONCLUSIONS: Combined anterior and posterior reconstruction using a cement construct provides equal to or more stability than the intact spine in all testing modes. Posterior stabilization alone is an inferior method of reconstruction following total spondylectomy. Poly-methyl-methacrylate has the advantage over traditional anterior reconstruction techniques in that it can be inserted using a posterior approach.
Aged↗
Antifibrinolytic therapy and perioperative blood loss in cancer patients undergoing major orthopedic surgery.
BACKGROUND: Aprotinin has been reported to reduce blood loss and transfusion requirements in patients having major orthopedic operations. Data on whether epsilon amino-caproic acid (EACA) is effective in this population are sparse. METHODS: Sixty-nine adults with malignancy scheduled for either pelvic, extremity or spine surgery during general anesthesia entered this randomized, double-blind, placebo-controlled trial, and received either intravenous aprotinin (n = 23), bolus of 2 x 10(6) kallikrein inactivator units (KIU), followed by an infusion of 5 x 10(5) KIU/h, or EACA (n = 22), bolus of 150 mg/kg, followed by a 15 mg/kg/h infusion or saline placebo (n = 24) during surgery. Our goal was to determine whether prophylactic EACA or aprotinin therapy would reduce perioperative blood loss (intraoperative + first 48h) >30% when compared to placebo. RESULTS: The mean age of the study population was 52 +/- 17 yr. The groups did not differ in age, duration of surgery, perioperative blood loss or number of packed erythrocyte units transfused. When compared to the placebo group, the two treated groups had a significantly lower D-Dimer level immediately after surgery, P < 0.01. CONCLUSIONS: Under the conditions of this study, we were unable to find a clinical benefit to using aprotinin or EACA to reduce perioperative blood loss or transfusion requirements during major orthopedic surgery in cancer patients.
Aged↗
Prospective identification of risk factors for wound infection after lower extremity oncologic surgery.
BACKGROUND: Surgical site infections (SSI) are frequent causes of morbidity and mortality after orthopaedic oncologic procedures. This study was conducted to identify the surgical site infection rate following a lower extremity or pelvic procedure and assess the risk factors for acquiring SSI by direct observation of orthopaedic oncology patients' wounds at a comprehensive cancer center. METHODS: One hundred ten consecutive patients were prospectively studied. The surveillance of surgical site infections was carried out by a surgeon-trained nurse from the Infectious Disease Service. Nineteen variables were analyzed as risk factors. RESULTS: The overall SSI rate was 13.6% (15 of 110). Excluding those patients with known preoperative infections, the SSI rate was 9.5% (10 of 105). Two statistically significant risk factors for surgical site infection in these patients emerged in the multivariate analysis: blood transfusion (P =.007) and obesity (P =.016). Procedure category was significant in univariate analysis only. Preoperative length of stay, length of procedure, prior adjuvant treatment (chemotherapy or radiotherapy), prior surgery, and use of an implant or allograft were not statistically significant risk factors for wound infection. Antibiotic usage patterns did not influence SSI rate. CONCLUSIONS: Blood transfusion and obesity should be considered individual risk factors for the development of wound infection in patients having orthopaedic oncologic procedures.
Blood Transfusion↗
Results of preoperative embolization for metastatic spinal neoplasms.
OBJECT: Arterial embolization reduces blood loss in patients undergoing surgery for hypervascular spinal tumors. The objectives of this study were twofold: 1) to evaluate the role of magnetic resonance (MR) imaging in predicting tumor vascularity and 2) to assess the effectiveness of preoperative embolization in devascularizing these tumors. METHODS: Fifty-one patients with metastatic spinal neoplasms underwent angiography, preoperative embolization, and excision of the lesion between 1995 and 2000. The MR imaging studies were correlated with tumor vascularity on angiograms. Embolization was angiographically graded on a five-point scale ranging from no embolization (Grade A) to total embolization (Grade E). The embolization grade was correlated with intraoperative blood loss. The mean age was 57 years, the male/female ratio was 1.2:1, and back pain was present in all patients. Metastatic renal cell carcinoma (30 cases) and thoracic spine involvement (33 cases) were most frequent. The positive predictive value of MR imaging in determining tumor vascularity was 77%, whereas the negative predictive value was 21%. Total embolization (Grade E) was achieved in 34 patients. A shared vascular pedicle between a radiculomedullary artery (RMA) and a tumor diminished the likelihood of complete embolization (p = 0.02). Small asymptomatic cerebellar infarctions were demonstrated in two cases. The mean intraoperative blood loss was 2,586 ml. Following Grade D or E embolization, intraoperative bleeding was largely related to unembolized epidural veins. CONCLUSIONS: Tumor histology and MR imaging findings are predictive of hypervascularity, however, hypervascular tumors may not be detected by standard MR imaging sequences. Superselective catheterization permits Grade D or E embolization in 80% of patients. Shared blood supply with an RMA is the most important factor precluding complete embolization.
Angiography↗
Diagnosis and management of a metastatic tumor in the atlantoaxial spine.
STUDY DESIGN: A retrospective review of a prospectively maintained spine database was conducted. OBJECTIVES: To review the experience of a large multidisciplinary tertiary referral oncology center in diagnosing and managing metastatic disease of the atlantoaxial spine in the era of magnetic resonance imaging, and to establish treatment parameters. SUMMARY OF BACKGROUND DATA: Published literature on the topic is limited, with conflicting opinions. Although external beam radiation therapy has proven value, some clinicians support aggressive surgical management. METHODS: This study included all the patients who presented over a 6-year period to Memorial Sloan-Kettering Cancer Center with metastatic disease to the atlantoaxial spine. Demographics and diagnoses were obtained. Magnetic resonance images, computed tomography scans, and plain radiographs were reviewed. At presentation, patients with normal alignment or minimal subluxation were considered for nonoperative therapy, either external beam radiation therapy or chemotherapy. Surgery was reserved for patients with significant fracture subluxations, including atlantoaxial displacement more than 5 mm or angulation exceeding 11 degrees with displacement more than 3.5 mm. Additional operative indications were prior external beam radiation therapy administered to overlapping spinal ports, unknown primary pain, and persistent pain after nonoperative therapy. Patient outcome was evaluated for pain relief, neurologic outcomes, degree of spine involvement, and survival. RESULTS: Symptomatic metastatic tumor involving the atlantoaxial spine was diagnosed in 33 patients. The mean age at presentation was 57 years. Histologic diagnoses varied widely. All the patients presented with severe mechanical neck pain, but no patient had myelopathy related to epidural tumor or fracture subluxation. Of these 33 patients, 25 patients initially were treated nonoperatively with either external beam radiation therapy (n = 23) or chemotherapy (n = 2), and 8 patients underwent initial operation. In this nonoperatively treated group, 23 of the 25 patients had significant pain resolution until death or last follow-up assessment. Five patients required subsequent operation: three for significant fracture subluxations and two after neoadjuvant chemotherapy. Of the fracture subluxations, two were present before external beam radiation therapy, and one was delayed from rapid tumor progression. Posterior instrumentation was performed in the 13 patients who underwent surgery. No patient required anterior decompression and stabilization. Significant pain resolution was achieved in all the surgically treated patients. CONCLUSIONS: External beam radiation therapy was used successfully to treat patients with normal alignment or minimal subluxation. Selected patients warrant immediate stabilization. Patients with persistent pain and inability to wean from a hard collar after nonoperative therapy also should be considered for surgery. Posterior stabilization provides pain relief and neurologic preservation or recovery without the need for anterior decompression.
Adolescent↗