Total En Bloc Spondylectomy for Lumbar Renal Cell Carcinoma and Review of the Literature
Affiliation(s)
Neurosurgical Department, Nepean Hospital, Kingswood, NSW, Australia. Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. Australian School of Advanced Medicine, Macquarie University, Sydney, Australia. Researcher, Private Neurosurgical Practice, Penrith, NSW, Australia.
Neurosurgical Department, Nepean Hospital, Kingswood, NSW, Australia. Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. Australian School of Advanced Medicine, Macquarie University, Sydney, Australia. Researcher, Private Neurosurgical Practice, Penrith, NSW, Australia.
ABSTRACT
Introduction: Total en bloc spondylectomy (TES) is gaining increasing favour as a treatment of choice for cancers of the spine that are resistant to radiological and chemotherapeautic intervention such as renal cell carcinoma (RCC). Until recently, RCC of the lumbar spine has presented a surgical challenge due to anatomical and vascular constraints. The development of the combined posterior-anterior en bloc spondylectomy offers improved access to the lumbar region. This case report and review of the literature presents a combined posterior-anterior lumbar en bloc spondylectomy for RCC involving L3 vertebra, which we believe is the first reported in Australia. Methods: A 46-year-old male with a seven-year history of renal cell carcinoma resulting in a left nephrectomy presented with a lytic lesion involving the L3 vertebral body, extending to the epidural space and compressing the cauda equina and left L3 and L4 nerve roots on MRI. A literature review revealed ten previous cases of the posterior-anterior TES in the lumbar spine for cancerous lesions but none from Australia. Results: A posterior-anterior TES and L2-L4 fusion was performed to remove a cancerous renal cell carcinoma of L3 with wide margins. Blood loss was the major complication. The patient remains recurrence free at nineteen months post procedure. Conclusion: Despite being an aggressive and invasive procedure, TES is rapidly becoming the treatment of choice for curative and palliative care in select patients with isolated metastatic tumours of the lumbar spine.
Introduction: Total en bloc spondylectomy (TES) is gaining increasing favour as a treatment of choice for cancers of the spine that are resistant to radiological and chemotherapeautic intervention such as renal cell carcinoma (RCC). Until recently, RCC of the lumbar spine has presented a surgical challenge due to anatomical and vascular constraints. The development of the combined posterior-anterior en bloc spondylectomy offers improved access to the lumbar region. This case report and review of the literature presents a combined posterior-anterior lumbar en bloc spondylectomy for RCC involving L3 vertebra, which we believe is the first reported in Australia. Methods: A 46-year-old male with a seven-year history of renal cell carcinoma resulting in a left nephrectomy presented with a lytic lesion involving the L3 vertebral body, extending to the epidural space and compressing the cauda equina and left L3 and L4 nerve roots on MRI. A literature review revealed ten previous cases of the posterior-anterior TES in the lumbar spine for cancerous lesions but none from Australia. Results: A posterior-anterior TES and L2-L4 fusion was performed to remove a cancerous renal cell carcinoma of L3 with wide margins. Blood loss was the major complication. The patient remains recurrence free at nineteen months post procedure. Conclusion: Despite being an aggressive and invasive procedure, TES is rapidly becoming the treatment of choice for curative and palliative care in select patients with isolated metastatic tumours of the lumbar spine.
Cite this paper
D. Al-Khawaja, T. Mahasneh, J. Li and S. Holmes, "Total En Bloc Spondylectomy for Lumbar Renal Cell Carcinoma and Review of the Literature," Open Journal of Modern Neurosurgery, Vol. 4 No. 1, 2014, pp. 26-30. doi: 10.4236/ojmn.2014.41006.
D. Al-Khawaja, T. Mahasneh, J. Li and S. Holmes, "Total En Bloc Spondylectomy for Lumbar Renal Cell Carcinoma and Review of the Literature," Open Journal of Modern Neurosurgery, Vol. 4 No. 1, 2014, pp. 26-30. doi: 10.4236/ojmn.2014.41006.
References
[1] Tomita, K., Kawahara, N., Baba, H., Tsuchiya, H., Fujita, T. and Toribatake, Y. (1997) Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors. Spine, 22, 324-333. http://dx.doi.org/10.1097/00007632-199702010-00018 [2] Tomita, K., Kawahara, N., Baba, H., Tsuchiya, H., Nagata, S., Toribatake, Y. (1994) Total en bloc spondylectomy for solitary spinal metastases. International Orthopaedics, 18, 291-298.
http://dx.doi.org/10.1007/BF00180229 [3] Tomita, K., Kawahara, N., Kobayashi, T., Yoshida, A., Murakami, H. and Akamaru, T. (2001) Surgical strategy for spinal metastases. Spine, 26, 298-306.
http://dx.doi.org/10.1097/00007632-200102010-00016 [4] Tomita, K., Toribatake, Y., Kawahara, N., Ohnari, H. and Kose, H. (1994) Total en bloc spondylectomy and circumspinal decompression for solitary spinal metastasis. Paraplegia, 32, 36-46.
http://dx.doi.org/10.1038/sc.1994.7 [5] Cloyd, J.M., Acosta, F.L., Polley, M.Y. and Ames, C.P. (2010) En bloc resection for primary and metastatic tumors of the spine: A systematic review of the literature. Neurosurgery, 67, 435-445. [6] Fottner, A., Szalantzy, M., Wirthmann, L., Stahler, M., Baur-Melnyk, A., Jansson, V. and Roland Dürr, H. (2010) Bone metastases from renal cell carcinoma: Patient survival after surgical treatment. BMC Musculoskeletal Disorders, 11, 145-151. http://dx.doi.org/10.1186/1471-2474-11-145 [7] Jung, S.T., Ghert, M.A., Harrelson, J.M. and Scully, S.P. (2003) Treatment of osseous metastases in patients with renal cell carcinoma. Clinical Orthopaedics and Related Research, 409, 223-231. http://dx.doi.org/10.1097/01.blo.0000059580.08469.3e [8] Mut, M., Schiff, D. and Shaffrey, M. (2005) Metastasis to nervous system: Spinal epidural and intramedullary metastases. Journal of Neuro-Oncology, 75, 43-56. http://dx.doi.org/10.1007/s11060-004-8097-2 [9] Garcia-Picazo, A., Capilla, R.P., Pulido, R.P., Garcia de Sola, R. (1990) Utility of surgery in the treatment of epidural vertebral metastases. Acta Neurochirurgica, 103, 131-138.
http://dx.doi.org/10.1007/BF01407520 [10] Melcher, I., Disch, A.C., Khodadadyan-Klostermann, S.T., Smolny, M., Stockle, U., Haas, N.P., et al. (2007) Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: Result by management with total en bloc spondylectomy. European Spine Journal, 16, 1193-1202. http://dx.doi.org/10.1007/s00586-006-0295-5 [11] Disch, A., Druschel, C., Melcher, I., Luzzati, A. and Shaser, K. (2011) En-bloc spondylectomy for thoracolumbar primary tumours and solitary metastases of the spine. Argospine News & Journal, 23, 163-170. http://dx.doi.org/10.1007/s12240-011-0030-x [12] Enneking, W.F., Spanier, S.S. and Goodmann, M.A. (1980) A system for the surgical staging of musculoskeletal sarcoma. Clinical Orthopaedics, 153, 106-120. [13] Fuchs, B., Trousdale, R.T. and Rock, M.G. (2005) Solitary bony matastasis from renal cell carcinoma: significance of surgical treatment. Clinical Orthopaedics and Related Research, 431, 187-192. http://dx.doi.org/10.1097/01.blo.0000149820.65137.b4 [14] Patchell, R.A., Tibbs, P.A., Regine, W.F., Payne, R., Saris, S., Kryscio, R.J., Mohiuddin, M. and Young, B. (2005) Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: A randomised trial. The Lancet, 366, 643-648. http://dx.doi.org/10.1016/S0140-6736(05)66954-1 [15] Tokuhashi, Y., Matsuzaki, H., Oda, H., Oshima, M. and Junnosuke, R.A. (2005) Revised scoring system for pre-operative evaluation of metastatic spine tumor prognosis. Spine, 30, 2186-2191. http://dx.doi.org/10.1097/01.brs.0000180401.06919.a5 [16] Mollahoseini, R., Farhan, F., Khajoo, A., Jouibari, M.A.M. and Gholipour, F. (2011) Is Tokuhashi score suitable for evaluation of life expectancy before surgery in Iranian patients with spinal metastases? Journal of Research in Medical Sciences, 16, 1183-1188. [17] Yao, K.C., Boriani, S., Gokaslan, Z.L. and Sundaresan, N. (2003) En bloc spondylectomy for spinal metastases: A review of the techniques. Neurosurgical Focus, 15, 1-5.
http://dx.doi.org/10.3171/foc.2003.15.5.6 [18] Abe, E., Kobayashi, T., Murai, H., Suzuki, T., Chiba, M. and Okuyama, K. (2001) Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine. Journal of Spinal Disorders, 14, 237-246. http://dx.doi.org/10.1097/00002517-200106000-00009 [19] Tomita, K., Kawahara, N., Murakami, H. and Demura, S. (2006) Total en bloc spondylectomy for spinal tumours: Improvement of the technique and its associated basic background. Journal of Orthopaedic Science, 11, 3-12. http://dx.doi.org/10.1007/s00776-005-0964-y
[1] Tomita, K., Kawahara, N., Baba, H., Tsuchiya, H., Fujita, T. and Toribatake, Y. (1997) Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors. Spine, 22, 324-333. http://dx.doi.org/10.1097/00007632-199702010-00018 [2] Tomita, K., Kawahara, N., Baba, H., Tsuchiya, H., Nagata, S., Toribatake, Y. (1994) Total en bloc spondylectomy for solitary spinal metastases. International Orthopaedics, 18, 291-298.
http://dx.doi.org/10.1007/BF00180229 [3] Tomita, K., Kawahara, N., Kobayashi, T., Yoshida, A., Murakami, H. and Akamaru, T. (2001) Surgical strategy for spinal metastases. Spine, 26, 298-306.
http://dx.doi.org/10.1097/00007632-200102010-00016 [4] Tomita, K., Toribatake, Y., Kawahara, N., Ohnari, H. and Kose, H. (1994) Total en bloc spondylectomy and circumspinal decompression for solitary spinal metastasis. Paraplegia, 32, 36-46.
http://dx.doi.org/10.1038/sc.1994.7 [5] Cloyd, J.M., Acosta, F.L., Polley, M.Y. and Ames, C.P. (2010) En bloc resection for primary and metastatic tumors of the spine: A systematic review of the literature. Neurosurgery, 67, 435-445. [6] Fottner, A., Szalantzy, M., Wirthmann, L., Stahler, M., Baur-Melnyk, A., Jansson, V. and Roland Dürr, H. (2010) Bone metastases from renal cell carcinoma: Patient survival after surgical treatment. BMC Musculoskeletal Disorders, 11, 145-151. http://dx.doi.org/10.1186/1471-2474-11-145 [7] Jung, S.T., Ghert, M.A., Harrelson, J.M. and Scully, S.P. (2003) Treatment of osseous metastases in patients with renal cell carcinoma. Clinical Orthopaedics and Related Research, 409, 223-231. http://dx.doi.org/10.1097/01.blo.0000059580.08469.3e [8] Mut, M., Schiff, D. and Shaffrey, M. (2005) Metastasis to nervous system: Spinal epidural and intramedullary metastases. Journal of Neuro-Oncology, 75, 43-56. http://dx.doi.org/10.1007/s11060-004-8097-2 [9] Garcia-Picazo, A., Capilla, R.P., Pulido, R.P., Garcia de Sola, R. (1990) Utility of surgery in the treatment of epidural vertebral metastases. Acta Neurochirurgica, 103, 131-138.
http://dx.doi.org/10.1007/BF01407520 [10] Melcher, I., Disch, A.C., Khodadadyan-Klostermann, S.T., Smolny, M., Stockle, U., Haas, N.P., et al. (2007) Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: Result by management with total en bloc spondylectomy. European Spine Journal, 16, 1193-1202. http://dx.doi.org/10.1007/s00586-006-0295-5 [11] Disch, A., Druschel, C., Melcher, I., Luzzati, A. and Shaser, K. (2011) En-bloc spondylectomy for thoracolumbar primary tumours and solitary metastases of the spine. Argospine News & Journal, 23, 163-170. http://dx.doi.org/10.1007/s12240-011-0030-x [12] Enneking, W.F., Spanier, S.S. and Goodmann, M.A. (1980) A system for the surgical staging of musculoskeletal sarcoma. Clinical Orthopaedics, 153, 106-120. [13] Fuchs, B., Trousdale, R.T. and Rock, M.G. (2005) Solitary bony matastasis from renal cell carcinoma: significance of surgical treatment. Clinical Orthopaedics and Related Research, 431, 187-192. http://dx.doi.org/10.1097/01.blo.0000149820.65137.b4 [14] Patchell, R.A., Tibbs, P.A., Regine, W.F., Payne, R., Saris, S., Kryscio, R.J., Mohiuddin, M. and Young, B. (2005) Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: A randomised trial. The Lancet, 366, 643-648. http://dx.doi.org/10.1016/S0140-6736(05)66954-1 [15] Tokuhashi, Y., Matsuzaki, H., Oda, H., Oshima, M. and Junnosuke, R.A. (2005) Revised scoring system for pre-operative evaluation of metastatic spine tumor prognosis. Spine, 30, 2186-2191. http://dx.doi.org/10.1097/01.brs.0000180401.06919.a5 [16] Mollahoseini, R., Farhan, F., Khajoo, A., Jouibari, M.A.M. and Gholipour, F. (2011) Is Tokuhashi score suitable for evaluation of life expectancy before surgery in Iranian patients with spinal metastases? Journal of Research in Medical Sciences, 16, 1183-1188. [17] Yao, K.C., Boriani, S., Gokaslan, Z.L. and Sundaresan, N. (2003) En bloc spondylectomy for spinal metastases: A review of the techniques. Neurosurgical Focus, 15, 1-5.
http://dx.doi.org/10.3171/foc.2003.15.5.6 [18] Abe, E., Kobayashi, T., Murai, H., Suzuki, T., Chiba, M. and Okuyama, K. (2001) Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine. Journal of Spinal Disorders, 14, 237-246. http://dx.doi.org/10.1097/00002517-200106000-00009 [19] Tomita, K., Kawahara, N., Murakami, H. and Demura, S. (2006) Total en bloc spondylectomy for spinal tumours: Improvement of the technique and its associated basic background. Journal of Orthopaedic Science, 11, 3-12. http://dx.doi.org/10.1007/s00776-005-0964-y