Features and risk factors for recurrence of intradural spinal tumors

Spinal cord tumors include a variety of nosological units and are classified according to their localization and histological type. The search for literature sources in the Pubmed, EMBASE and eLibrary databases demonstrated the absence of studies devoted to study of the features and risk factors for the recurrence of intradural spinal tumors. the purpose of this study was to reveal features and risk factors of recurrence of intradural spinal tumors after microneurosurgical resection. material and methods. The study included medical records of 196 patients with intradural extramedullary and intramedullary spinal tumors. The extent of microneurosurgical tumor resection, clinical efficacy of surgery, and risk factors for recurrence of intradural spinal cord tumors were been analyzed. results. Improvement in neurologic deficit after surgery was noted in 116 (59.1 %) cases, neurologic status remained the same in 47 (24.0 %) patients, and worsening of neurological deficit was observed in 33 (16.8 %) cases. Total microneurosurgical resection of intradural spinal tumors was performed in 140 (71.4 %) patients, subtotal resection in 22 (11.2 %) patients, partial resection in 25 (12.7 %) patients and spinal cord decompression or biopsy and/or its roots were performed in 9 (4.6 %) of patients. The likelihood of recurrence-free survival of patients with benign intradural spinal cord tumors was significantly higher than that of patients with malignant tumors (p<0.001). Benign tumors (χ2=34.7, p<0.05), thoracic and lumbosacral tumors (χ2=10.3, p<0.05), low degree of neurological deficit (χ2=31.5, p<0.05), absence of syringomyelia/syringobulbia signs (χ2=13,2, p<0,05), as well as extramedullary tumors (χ2=12,6, p<0.05) allowed us to perform total degree microneurosurgical resection. Malignant tumors (χ2=34.8, p<0.05), cervical and thoracic tumors (χ2=8,4, p<0,05), high degree of neurological deficit (χ2=12,9, p<0.05), partial resection, biopsy or decompression of neural structures (χ2=9.7, p<0.05) and intramedullary tumors statistically significantly increased the risk of their recurrence. conclusion. Histological pattern, tumor localization, preoperative clinical and neurological deficit according to the McCormick classification and the extent of surgery are significant risk factors for recurrence of intradural spinal tumors.

intradural spinal tumors, microneurosurgical resection, recurrence, risk factors, clinical and morphological features

1. Bhat A.R., Kirmani A.R., Wani M.A., Bhat M.H. Incidence, histopathology, and surgical outcome of tumors of spinal cord, nerve roots, meninges, and vertebral column – Data based on single institutional (Sher‐i‐ Kashmir Institute of Medical Sciences) experience. J Neurosci Rural Pract. 2016; 7 (3): 381−391. doi: 10.4103/0976‐3147.181489.

2. Бывальцев В.А., Степанов И.А., Белых Е.Г., Алиев М.А. Анализ отдаленных результатов хирургического лечения пациентов с интрадуральными опухолями спинного мозга. Вестник РАМН. 2018; 73: 88–95. [Byvaltsev V.A., Stepanov I.A., Belykh E.G., Aliyev M.A. Long‐term Results of Surgical Treatment in Patients with Intradural Spinal Tumors. Annals of the Russian Academy of Medical Sciences. 2018; 73: 88–95. (in Russian)]. doi: 10.15690/vramn945.

3. Hirano K., Imagama S., Sato K., Kato F., Yukawa Y., Yoshihara H., Kamiya M., Deguchi M., Kanemura T., Matsubara Y., Inoh H., Kawakami N., Takatsu T., Ito Z., Wakao N., Ando K., Tauchi R., Muramoto A., Matsuyama Y., Ishiguro N. Primary spinal cord tumors: review of 678 surgically treated patients in Japan. A multicenter study. Eur Spine J. 2012 Oct; 21 (10): 2019–26. doi: 10.1007/s00586‐012‐2345‐5.

4. Бывальцев В.А., Сороковиков В.А., Дамдинов Б.Б., Белых Е.Г., Середа Э.В., Панасенков С.Ю., Григорьев Е.Г. Факторы, влияющие на исход хирургического лечения экстрамедуллярных опухолей спинного мозга: мультицентровое исследование. Вопросы нейрохирургии им. Н.Н. Бурденко. 2014; 6: 15−23. [Byval’tsev V.A., Sorokovikov V.A., Damdinov B.B., Belykh E.G., Sereda É.V., Panasenkov S.Iu., Grigor’ev E.G. Factors affecting the outcome of surgical management for extramed‐ ullary spinal cord tumors: a multicenter study. Problems of Neurosurgery named after N.N. Burdenko. 2014; 6: 15−23. (in Russian)]. doi: 10.17116/ neiro201478615‐23.

5. Samartzis D., Gillis C.C., Shih P., O’Toole J.E., Fessler R.G. In‐ tramedullary Spinal Cord Tumors: Part I – Epidemiology, Pathophysiology, and Diagnosis. Global Spine J. 2015 Oct; 5 (5): 425–35. doi: 10.1055/s‐ 0035‐1549029.

6. Бывальцев В.А., Степанов И.А., Алиев М.А. Сравнение открытых и минимально‐инвазивных методик в хирургическом лечении интрадуральных экстрамедуллярных опухолей спинного мозга у пациентов пожилого и старческого возраста. Успехи геронтологии. 2018; 3: 400–407. [Byvaltsev V.A., Stepanov I.A., Aliyev M.A. Compari‐ son of open and minimally invasive techniques in the surgical treatment of intradural extramedullary spinal tumors in elderly and senile patients. Successes of gerontology. 2018; 3: 400–407. (in Russian)].

7. Vyas D., Cronin S. Peer Review and Surgical Innovation: Robotic Surgery and Its Hurdles. Am J Robotic Surg. 2015; 2 (1): 39–44. doi: 10.1166/ajrs.2015.1018.

8. Hariri O., Takayanagi A., Miulli D.E., Siddiqi J., Vrionis F. Mini‐ mally Invasive Surgical Techniques for Management of Painful Metastatic and Primary Spinal Tumors. Cureus. 2017; 9 (3): e1114. doi: 10.7759/ cureus.1114.

9. Iacoangeli M., Gladi M., Di Rienzo A., Dobran M., Alvaro L., Nocchi N., Maria L.G., Somma D., Colasanti R., Scerrati M. Minimally invasive surgery for benign intradural extramedullary spinal meningiomas: experience of a single institution in a cohort of elderly patients and review of the literature. Clin Interv Aging. 2012; 7: 557–564. doi:10.2147/CIA. S38923.

10. Vogelbaum M.A., Jost S., Aghi M.K., Heimberger A.B., Sampson J.H., Wen P.Y., Macdonald D.R., Van den Bent M.J., Chang S.M. Ap‐ plication of novel response/progression measures for surgically delivered therapies for gliomas; Response Assessment in Neuro‐Oncology (RANO) working group. Neurosurg. 2012 Jan; 70 (1): 234–43. doi: 10.1227/ NEU.0b013e318223f5a7.

11. Бывальцев В.А., Ступак В.В., Степанов И.А., Кичигин А.И. Применение коэффициента диффузии в предоперационной оценке пролиферативного потенциала опухолей позвоночного канала. Хирургия позвоночника. 2017; 3: 93−99. [Byval’tsev V.A., Stupak V.V., Stepanov I.A., Kichigin A.I. Application of the apparent diffusion coef‐ ficient in preoperative assessment of the proliferative potential of spinal tumors. Spine Surgery. 2017; 3: 93−99. (in Russian)]. doi: 10.14531/ ss2017.3.93‐99.

12. Потапов А.А., Горяйнов С.А., Охлопков В.А., Пицхелаури Д.И., Кобяков Г.Л., Жуков В.Ю., Гольбин Д.А., Свистов Д.В., Мартынов Б.В., Кривошапкин А.Л., Гайтан А.С., Анохина Ю.Е., Варюхина М.Д., Гольдберг М.Ф., Кондрашов А.В., Чумакова А.П. Клинические рекомендации по использованию интраоперационной флуоресцент‐ ной диагностики в хирургии опухолей головного мозга. Вопросы нейрохирургии им. Н.Н. Бурденко. 2015; 79 (5): 91. [Potapov A.A., Goryainov S.A., Okhlopkov V.A., Pitskhelauri D.I., Kobyakov G.L., Zhukov V.Yu., Gol’bin D.A., Svistov D.V., Martynov B.V., Krivoshapkin A.L., Gaitan A.S., Anokhina Yu.E., Varyukhina M.D., Gol’dberg M.F., Kondrashov A.V., Chumakova A.P. Clinical guidelines for the use of intra‐ operative fluorescence diagnosis in brain tumor surgery. Problems of Neurosurgery named after N.N. Burdenko. 2015; 79 (5): 91. (in Russian)]. doi: 10.17116/neiro201579591‐101.

13. Louis D.N., Perry A., Reifenberger G., von Deimling A., FigarellaBranger D., Cavenee W.K., Ohgaki H., Wiestler O.D., Kleihues P., Ellison D.W. The 2016 World Health Organization histological classification of tumors of the central nervous system: a summary. Acta Neuropathologica. 2016; 131 (6): 803–820. doi: 10.1007/s00401‐016‐1545‐1.

14. Williams J.R. The Declaration of Helsinki and public health. Bulletin of the World Health Organization. 2008; 86 (8): 650−652. doi: 10.2471/BLT.08.050955.

15. Kaplan E.L., Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958; 53: 457–481.

16. Royston P., Parmar M.K.B. Augmenting the logrank test in the design of clinical trials in which non‐proportional hazards of the treatment effect may be anticipated. BMC Med Res Methodol. 2016 Feb 11; 16: 16. doi: 10.1186/s12874‐016‐0110‐x.

17. Claus E.B., Abdel-Wahab M., Burger P.C., Engelhard H.H., Ellison D.W., Gaiano N., Gutmann D.H., Heck D.A., Holland E.C., Jallo G.I., Kruchko C., Kun L.E., Maria B.L., Rumboldt Z., Seminara D., Spinella G.M., Stophel L., Wechsler-Reya R., Wrensch M., Gilbertson R.J. Defining future directions in spinal cord tumor research: Proceedings from the National Institutes of Health workshop. J Neurosurg Spine. 2010 Feb; 12 (2): 117–21. doi: 10.3171/2009.7.SPINE09137.

18. Vera-Bolanos E., Aldape K., Yuan Y., Wu J., Wani K., NecesitoReyes M.J., Colman H., Dhall G., Lieberman F.S., Metellus P., Mikkelsen T., Omuro A., Partap S., Prados M., Robins H.I., Soffietti R., Wu J., Gilbert M.R., Armstrong T.S.; CERN Foundation. Clinical course and progression‐free survival of adult intracranial and spinal ependymoma patients. Neuro Oncol. 2015 Mar; 17 (3): 440–7. doi: 10.1093/neuonc/ nou162.

19. Goldschlager T., Dea N., Boyd M., Reynolds J., Patel S., Rhines L.D, Mendel E., Pacheco M., Ramos E., Mattei T.A., Fisher C.G. Giant cell tumors of the spine: has denosumab changed the treatment para‐ digm? J Neurosurg Spine. 2015 May; 22 (5): 526–33. doi: 10.3171/2014.10. SPINE13937.

20. Zhang S., Yang L., Peng C., Wu M. Logistic regression analysis of risk factors for postoperative recurrence of spinal tumors and analysis of prognostic factors. Oncol Lett. 2018 Feb; 15 (2): 1716–1722. doi: 10.3892/ol.2017.7509.

21. Jahangiri A., Chin A.T., Wagner J.R., Kunwar S., Ames C., Chou D., Barani I., Parsa A.T., McDermott M.W., Benet A., El-Sayed I.H., Aghi M.K. Factors predicting recurrence after resection of clival chordoma using variable surgical approaches and radiation modalities. Neurosurgery. 2015; 76 (2): 179–185. doi: 10.1227/NEU.0000000000000611.

22. Xu W., Li X., Huang W., Wang Y., Han S., Chen S., Xu L., Yang X., Liu T., Xiao J. Factors affecting prognosis of patients with giant cell tumors of the mobile spine: retrospective analysis of 102 patients in a single center. Ann Surg Oncol. 2013 Mar; 20 (3): 804–10. doi: 10.1245/ s10434‐012‐2707‐6.

23. Fehlings M.G., Nater A., Zamorano J.J., Tetreault L.A., Varga P.P., Gokaslan Z.L., Boriani S., Fisher C.G., Rhines L., Bettegowda C., Kawahara N., Chou D. Risk Factors for Recurrence of Surgically Treated Conventional Spinal Schwannomas: Analysis of 169 Patients from a Multicenter International Database. Spine (Phila Pa 1976). 2016 Mar; 41 (5): 390–8. doi: 10.1097/BRS.0000000000001232.

24. Ahmed R., Menezes A.H., Awe O.O., Torner J.C. Long‐term dis‐ ease and neurological outcomes in patients with pediatric intramedullary spinal cord tumors. J Neurosurg Pediatr. 2014 Jun; 13 (6): 600–12. doi: 10.3171/2014.1.PEDS13316.

25. Klekamp J. Treatment of intramedullary tumors: analysis of sur‐ gical morbidity and long‐term results. J Neurosur: Spine. 2013; 19 (1): 12–26. doi: 10.3171/2013.3.SPINE121063.

26. Verma N., Cowperthwaite M.C., Burnett M.G., Markey M.K. Dif‐ ferentiating tumor recurrence from treatment necrosis: a review of neuro‐ oncologic imaging strategies. Neuro Oncol. 2013 May; 15 (5): 515–34. doi: 10.1093/neuonc/nos307.

27. Sohn S., Kim J., Chung C.K., Lee N.R., Sohn M.J., Kim S.H. A Nation‐Wide Epidemiological Study of Newly Diagnosed Primary Spine Tumor in the Adult Korean Population, 2009–2011. J Korean Neurosurg Soc. 2017 Mar; 60 (2): 195–204. doi: 10.3340/jkns.2016.0505.011.

28. Lee C.S., Jung C.H. Metastatic Spinal Tumor. Asian Spine J. 2012 Mar; 6 (1): 71–87. doi: 10.4184/asj.2012.6.1.71.

29. Ciftdemir M., Kaya M., Selcuk E., Yalniz E. Tumors of the spine. World J Orthop. 2016 Feb 18; 7 (2): 109–16. doi: 10.5312/wjo. v7.i2.109.

30. Nair S., Gobin Y.P., Leng L.Z., Marcus J.D., Bilsky M., Laufer I., Patsalides A. Preoperative Embolization of Hypervascular Thoracic, Lumbar, and Sacral Spinal Column Tumors: Technique and Outcomes from a Single Center. Interven Neuroradiol. 2013; 19 (3): 377–85. doi: 10.1177/159101991301900317.