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Treatment of Patients With Spinal Metastases From Head and Neck Neoplasms
Diego A. Preciado, MD;
Leslie A. Sebring, MD, PhD;
George L. Adams, MD
Arch Otolaryngol Head Neck Surg. 2002;128:539-543.
ABSTRACT
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Background Spinal metastases are uncommon in patients with advanced head and neck
cancer. Treatment strategies in this patient group have not been defined.
Although it has been established that neurologic dysfunction in patients with
spinal metastases and cord compression constitutes an oncologic emergency,
the role of surgical treatment remains controversial.
Objective To clarify the treatment options in patients with head and neck cancer
who develop spinal metastases.
Methods The clinical course of patients seen at our institution with head and
neck neoplasms and spinal metastases from January 1992 to January 2000 was
reviewed.
Results Eleven patients were identified. Nine developed spinal metastases more
than 3 months after the diagnosis of advanced head and neck cancer. The other
2 presented with synchronous spinal involvement and skull base neoplasms.
Patients without neurologic symptoms were offered intravenous steroids and
palliative radiation. Patients with neurologic symptoms were treated with
either intravenous steroids and radiation or surgical decompression and spinal
fusion. In 1 patient, no improvement occurred within the first 2 days of radiotherapy,
and the patient underwent surgical decompression. Patients with an unstable
spine underwent surgical decompression and spinal fusion. Patients with a
life expectancy of more than 6 months and neurologic symptoms were offered
surgical therapy. In the 9 patients with advanced cancer, the average survival
time was 3 months. Two of these patients have survived longer than 6 months.
Conclusions We propose that surgical decompression is a viable, justifiable option
for selected patients with advanced head and neck cancer and spinal cord compression.
Furthermore, we recommend surgical decompression as a first option in patients
with an unstable bony spine and/or in whom survival is expected to be longer
than 6 months. Finally, we propose a patient management algorithm in these
cases.
INTRODUCTION
EPIDURAL SPINAL cord compression from metastatic disease constitutes
a major source of morbidity for cancer patients. More than one third of patients
with spinal compression and neurologic symptoms will develop complete, irreversible
paraplegia within 1 week if treatment is delayed.1-2
Early detection and treatment of spinal compression result in improved quality
of end-stage life in patients with advanced cancer. The most important factor
in determining neurologic outcome in this setting is the degree of preserved
neurologic function before treatment.2-4
Overall, the incidence of spinal metastases from cancer is approximately 5%1, 5; in certain malignancies, such as lung
and breast carcinomas, it may be as high as 12% to 20%.6
The incidence of spinal metastases from head and neck cancer seems to be lower,
with previous reports4, 7 estimating
it to be less than 2%. Most of the literature dealing with spinal compression
in head and neck cancer is limited to case reports and small case series.
Management strategies in this patient population have not been defined.
In general, treatment modalities for spinal compression from metastatic
cancer include intravenous steroids, radiation therapy, and/or surgical decompression.
Although individual tumor and case-specific characteristics may help determine
which treatment modality to use, the management decision is not always clear.
It has been shown that the average length of survival after spinal metastases
varies significantly, depending on the primary cancer site. Enkaoua et al8 showed that patients with spinal metastases from thyroid
tumors survived significantly longer than those with metastases from unknown
primary or renal tumors. It has been proposed that radioresistant malignancies
(such as lymphoma and small cell lung cancer) with cord compression should
be treated with surgery as the first step if there are no contraindications
and the life expectancy is longer than 6 months.9
If no known history of cancer exists, then surgery should be performed, not
only as a therapeutic but also as a diagnostic measure. On the other hand,
because of potential associated morbidity, it has been argued that surgery
should be deferred in patients with a short life expectancy, comorbid disease,
or poor performance status.9-10
These characteristics are common in patients with advanced head and neck cancer,
and therefore, primary surgical treatment of the spinal metastases remains
controversial. The purpose of our study is to clarify the treatment options
in patients with head and neck cancer who develop spinal metastases by reviewing
our experience and analyzing the established literature.
METHODS
A retrospective review was performed of all patients with spinal involvement
from head and neck neoplasms at our institution from January 1992 to January
2000. Patient age, stage of primary tumor, treatment of primary tumor, location
of spinal metastases, presenting symptoms, treatment of spinal metastases,
outcome, and survival were recorded in each case. The motor function scale
as outlined by Greenberg et al11 was used as
an index to determine neurologic response to treatment.
RESULTS
Eleven patients were identified. Nine developed spinal metastases with
epidural compression at least 3 months after the diagnosis of advanced (stage
III through stage IV) head and neck cancer. Two others presented with synchronous
spinal involvement and skull base neoplasms. Specifically, the primary sites
(before discovery of metastases) consisted of 7 stage IV squamous cell carcinomas
of the head and neck (which in turn included 4 of the oropharynx, 1 of the
larynx, 1 of the hypopharynx, and 1 of the parotid gland), 2 stage IV adenoid
cystic carcinomas of the maxillary sinus, 1 temporal bone epithelioma, and
1 skull base chordoma. In the 9 patients with advanced cancer, the average
survival time was 3 months (range, 2 weeks to 9 months). Two of these patients
survived longer than 6 months. The location of the spinal metastases was varied,
involving the cervical spine in 4 cases, both the cervical and thoracic spine
in 4 cases, and the thoracolumbar spine in 3 cases. Synchronous metastases
were present in 4 patients. Three of these patients had adenoid cystic carcinoma
as their primary malignancy. The average survival time of the patients with
multiple metastatic sites at the time of spinal metastasis presentation was
3.5 months. One other patient developed multiple other metastatic sites months
after treatment to the spinal metastasis site.
All patients presented with severe, progressive spinal or back pain
requiring high doses of narcotic medication. The pain improved in all cases,
regardless of treatment. It, however, continued to be a source of morbidity
for all 11 patients. Patients with life expectancies of longer than 6 months,
unstable spinal cords, or good performance statuses were treated primarily
with surgery. All patients were given intravenous steroids once neurologic
dysfunction developed. The 4 patients without neurologic compromise were treated
for pain, primarily with radiation therapy. Of these, 1 did not respond and
underwent surgical tumor extirpation and spinal decompression.
Of the 7 patients with neurologic dysfunction, 5 presented with grade
I (ambulatory without assistance and weakness), 1 with grade II (not ambulatory
but able to move legs against gravity), and 1 with grade IV (paraplegia) neurologic
function on the Greenberg scale. The grade I patients had numbness and weakness
in the involved spinal dermatome. Of these, 3 patients underwent surgery,
1 underwent radiation therapy (2000 rad [20 Gy] with 2.2 mCi [81.40 MBq] of
strontium chloride Sr 89), and 1 refused radiation or surgery. All of these
patients resolved their neurologic symptoms except for the patient who refused
treatment, who progressed to a grade III (unable to move legs against gravity
but can contract muscles) Greenberg score and died after 3 months. One patient
presented with the spinal metastasis while undergoing treatment, in the form
of radiation and chemotherapy, to the primary site. He presented with grade
II function and underwent decompressive laminectomy with spinal fusion. He
improved to grade I postoperatively, but died 1 month later. The patient who
presented with nonacute paraplegia (grade IV neurologic function) had metastatic
adenoid cystic carcinoma. He underwent emergent, high-dose (6000 rad [60 Gy])
radiotherapy and improved to grade I, regaining his ability to ambulate. These
results are summarized in Table 1.
The following is an illustrative case example.
Patient 1 was a 50-year-old man who presented with an exophytic mass
of his left tonsil and tongue base and had multiple, ipsilateral, enlarged
neck nodes. A biopsy specimen confirmed the oropharyngeal mass to be a squamous
cell carcinoma. On clinical and radiologic examination, the lesion was staged
as T3 N2b M0 according to the TNM staging system. The patient was randomized
in a study protocol to receive radiation therapy (7000 rad [70 Gy] to the
primary and neck metastases) and chemotherapy (3 cycles of cisplatin and 5-fluorouracil)
as primary treatments. The masses resolved with treatment. Six weeks after
completion of radiation, a left modified radical neck dissection was performed.
No residual tumor remained in the neck. Six months after original presentation,
the patient developed severe pain behind his left ear along with a rapidly
growing mass of his left mastoid. The mass was diagnosed as metastatic squamous
cell carcinoma. The patient underwent left lateral temporal bone resection,
which provided him with good pain relief. One month later, the patient returned
with numbness and weakness of his right arm and posterior low cervical spine
pain. Magnetic resonance imaging of his spinal cord showed a mass at the C6
through T1 vertebrae, causing collapse of the T1 vertebral body and secondary
central spinal stenosis. He underwent anterior spinal decompression and fusion
of the involved segments. As an inpatient, his cervical pain was treated with
intravenous morphine. Postoperatively, his pain was much improved, and the
patient was prescribed oral oxycodone elixir and discharged from the hospital.
Four months after his spinal surgery, the patient developed another spinal
metastasis at the high dens process of C2 (Figure 1). He again underwent decompression and fusion. Two months
later (13 months after his original presentation), he died with diffuse distal
metastases.
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Figure 1. Sagittal T1-weighted magnetic
resonance contrast-enhanced image showing metastases to the high cervical
spine with secondary spinal stenosis.
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COMMENT
The treatment of patients with spinal metastases is difficult. Consideration
must be given to the patients' overall survival expectancy, health status,
and degree of neurologic involvement. Few series have addressed this problem
in patients with head and neck cancer, and this review attempts to clarify
the issue. Unfortunately, with only a small number of patients in the series,
it is not possible to arrive at clear-cut conclusions based on hard statistical
data. However, by combining our experience with proposed treatment plans in
patients with spinal metastases from other neoplasms described in the literature,
a preliminary management algorithm can be formulated for patients with head
and neck cancer.
Some authors8, 12-13
have argued that the choice of surgical treatment depends on the type of primary
cancer and the extent of disease spread. These reviews have shown that spinal
metastases from certain primary tumors, such as thyroid and renal cancers,
are associated with survival times of longer than 8 months. On the other hand,
patients with spinal metastases from unknown primary sites seem to fare poorly,
with survival times of less than 3 months. Average survival rates for patients
with advanced head and neck cancer are between 22% and 48%, depending on the
primary site of the cancer.14 For obvious reasons,
survival in patients with advanced head and neck cancer with spinal metastases
is expectedly much worse. In our series, the average survival time was 3 months.
Two of 9 patients, however, did survive longer than 6 months. It is not always
clear what the actual survival will be in individual cases.
Harrington15 proposed management principles
in these patients based on the degree of neurologic impairment and/or evidence
of spinal bony collapse. He proposed that patients with bony collapse and
neurologic involvement should undergo surgical decompression. His review,
however, did not take into account overall expected survival as a decision
making factor. Tokuhashi et al16 proposed a
scoring system that took into account multiple variables for facilitating
the decision of whether to operate. They stressed the following categories:
general condition, number of extraspinal bone metastases, number of vertebral
metastases, metastases to internal organs, primary site of cancer, and spinal
cord deficit. In general, the more widespread the disease, the lower the score
and the less inclined a surgeon would be to operate. They did not look at
evidence of bony instability or acuteness of neurologic presentation. In a
classic study, Tarlov and Klinger17 used dog
experiments to show that the acuity of spinal compression should dictate the
aggressiveness in reversing the compression. This work has lead to the general
conception that acute neurologic decompensation (throughout less than 24 hours)
dictates rapid, aggressive treatment.
The role of chemotherapy in these patients is not established. In our
series, 1 patient presented with the spinal metastasis while undergoing radiation
and 3 rounds of fluorouracil with cisplatin for treatment to the primary tumor.
Because of acute neurologic compromise, this patient underwent surgical decompression
and debulking of the tumor. Although the patient did regain neurologic function,
it is not clear whether the chemotherapy conferred any benefit. He died 1
month later. Chemotherapy was used in one other case. This was in a patient
with a history of adenoid cystic carcinoma of the tongue base who presented
with lower back pain as his only symptom. He was given etoposide in attempts
to treat the metastasis and palliate his pain. However, the pain worsened
through treatment and the patient underwent radiation 4 months later. Progression
of pain while undergoing chemotherapy has been noted in other studies. These
studies18 suggest that that the relief of symptoms
from radiotherapy seem to be better than with combined chemotherapy and radiation
therapy or from chemotherapy alone. Furthermore, it seems that chemotherapy
adds little benefit in patients with neurologic impairment.15, 19
In general, spinal metastases from tumors that are notoriously relatively
resistant to chemotherapy are unlikely to respond to chemotherapy.20
Combining these treatment proposals with our experience, we propose
a simple management algorithm that includes most of the variables discussed
herein (Figure 2). Because of individual
variability, the algorithm may not be applicable in every case. Nevertheless,
the algorithm is applicable to most patients with head and neck cancer. In
summary, once the diagnosis of spinal metastasis is made, the first and most
important determination is the degree of neurologic involvement. If none is
present and the patient presented because of pain, intravenous steroids and/or
radiation therapy should be adequate palliation. Second, the stability of
the spine should be determined. An unstable spine represents a neurosurgical
emergency that should be fixed, because radiation cannot stabilize the vertebral
framework. Third, the acuity of the presentation should be established. Rapidly
progressive neurologic compromise warrants surgical intervention. The next
2 decision questions are the most open to subjectivity and variability. The
overall health status of the cancer patient should be determined and clinical
judgment must be used to evaluate surgical candidacy. Factors addressed by
Enkaoua et al8 and Tokuhasi et al,16 such as degree of generalized metastatic spread,
are to be considered at this point in the decision tree. Finally, an estimate
of the patient's overall survival expectancy must be made.
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Figure 2. Management of algorithm for spinal
involvement from head and neck neoplasia.
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In conclusion, it is proposed that surgical decompression is a viable,
justifiable option for selected patients with advanced head and neck cancer
and spinal compression. We propose surgical decompression as a first option
in patients with an unstable bony spine, acute and rapidly progressive neurologic
deterioration, and/or expected survival times of longer than 6 months. Individual
case variables must be analyzed in each particular instance to arrive at the
most appropriate clinical decision.
AUTHOR INFORMATION
Accepted for publication October 26, 2001.
This study was presented as a poster at the Fifth International Conference
on Head and Neck Cancer, San Francisco, Calif, August 1, 2000.
Corresponding author and reprints: Diego A. Preciado, MD, Department
of Otolaryngology–Head and Neck Surgery, University of Minnesota, Box
396, Mayo Memorial Building, 420 Delaware St SE, Minneapolis, MN 55455 (e-mail: preci001{at}tc.umn.edu).
From the Departments of Otolaryngology–Head and Neck Surgery
(Drs Preciado and Adams) and Neurosurgery (Dr Sebring), University of Minnesota,
Minneapolis.
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