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Update on the Management of Sacral Metastases

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Update on the Management of Sacral Metastases | Update on the Management of Sacral Metastases Aleksander Mika, BS Abstract Addisu Mesfin, MD » Sacral metastases have increased over the past decades as chemotherapy improves and more patients survive common cancers. » Sacral metastases can present with cauda equina syndrome, Investigation performed at the radiculopathy, and instability. Department of Orthopaedic Surgery, University of Rochester School of » Sacral metastases are often treated with radiation therapy, a surgical Medicine and Dentistry, Rochester, procedure, or sacroplasty. New York » Patient-reported outcomes are of increasing importance when evaluating patients for the management of sacral metastasis. n the United States, there were to bowel or bladder incontinence8. nearly 1.6 million cases of cancer in Decreased ambulation associated with 2016. In the last several decades, radicular symptoms and/or pathological 5-year survival rates have increased fractures can increase the risk of thrombo- fromI 49.1% in 1980 to 57.7% in 1990, embolism that is already increased because 9 66% in 2000, and 68.9% in 20081. of the history of malignancy . Metastatic sacral disease is rare, represent- ing 1% to 7% of metastatic spine disease2. Anatomy of the Sacrum Although rectal carcinoma can metastasize Thesacrum iscomposed ofa concave surface and directly invade the sacrum, most sacral (facing the pelvis) and convex outer surface, metastatic tumors are the result of hema- which articulates superiorly with L5 via the L5-S1 facet, inferiorly with the coccyx, and togenously spread tumor cells3. The spread bilaterally with the iliac bones via the sacro- of metastasis often occurs via the Batson iliac joint. The sacrum projects posteriorly venous plexus, especially in the thoracic and forms the lumbosacral angle. Because of spine4. In recent years, bone metastases this projection, the articulation at this angle have been attributed to the increased is subject to shearing forces. Sacral nerve number of chemotherapy drugs used in roots help to control the sphincters of the metastatic colorectal cancer5. Additionally, rectum, bladder, and sexual organs, as well as because of the effectiveness of systemic the motor and sensory contributions to the therapy, patients are living longer, and lower extremities10. more symptomatic spinal metastases are 6 being identified . Sacral metastases are Clinical Presentation often diagnosed late when they have already Metastatic tumors are the most common extended beyond the osseous margins malignancy of the sacrum and can signify around the sacral nerves and other sur- advanced disease. These are often charac- rounding organs7. Patients commonly terized by radicular pain due to nerve root present with pain due to sacral nerve root compression or even tumor infiltration7,11. compression and pathological fractures. Pain may radiate into the buttocks, poste- Also, sacral nerve root compression can lead rior aspect of the leg, and perineal region12. Disclosure: There was no source of external funding for this study. On the Disclosure of Potential which are provided with the online version of the article COPYRIGHT © 2018 BY THE Conflicts of Interest forms, , one or more of the JOURNAL OF BONE AND JOINT authors checked “yes” to indicate that the author had a relevant financial relationship in the SURGERY, INCORPORATED biomedical arena outside the submitted work (http://links.lww.com/JBJSREV/A348). JBJS REVIEWS 2018;6(7):e8 · http://dx.doi.org/10.2106/JBJS.RVW.17.00130 1 | Update on the Management of Sacral Metastases Clinical findings include changes in enough tissue is not obtained, then an metastases to major organs, primary sensation, radiculopathy, motor deficits, open biopsy can be performed. How- cancer site, and extent of neurological bladder and bowel incontinence, and ever, in cases of localized extension of deficits25. A score of 0 to 8 points pre- sexual dysfunction13. Cauda equina tumor into the sacrum such as in the dicts ,6 months to live, a score of 9 to syndrome can be the initial presentation setting of colon cancer or endometrial 11 points predicts $6 months to live, of sacral metastases. The clinical pre- cancer, a biopsy may not be needed. and a score of 12 to 15 points predicts a sentation can include severe back pain, Also, in the setting of acute neurological life expectancy of $1 year. urinary retention, constipation, and, at deterioration or cauda equina syndrome, A palliative surgical procedure or later stages of presentation, bowel and surgical intervention should not be de- nonsurgical options may be considered bladder incontinence. Bowel and blad- layed and intraoperative biopsy would for patients with a low score. The To- der incontinence is a surgical emergency suffice. mita score is another validated scoring and prompt decompression should be system for prognosis in spine tumors. performed14. Management It has 3 components that evaluate the Conventional radiation therapy remains type of tumor, the presence of visceral Imaging the first-line intervention for sacral metastases, and the presence of bone Radiographs are often the first imaging metastasis, and doses for conventional metastases. Scores of 2 to 10 points can modality performed. However, these radiation therapy include 30 to 40 Gy be generated, with a higher score indi- may remain inadequate because of the over multiple fractions19. Stereotactic cating worse prognosis and a lower score difficulty in evaluating the sacrum on radiosurgery for the spine and sacrum is indicating consideration for excisional radiographs11. Additionally, radio- being increasingly used in the United surgical procedures26. Tumors can be graphic evaluation has proven unreliable States20. Recurrent sacral lesions fol- divided into 3 categories based on the even in patients with confirmed sacral lowing conventional radiation therapy Tomita scoring system: slow, moderate, pathology. Instead, clinicians should can also be addressed with stereotactic and fast-growth tumors27. There is a focus their attention on the loss of sacral radiosurgery21. Gerszten et al. demon- minimal role for an excisional surgical arcuate lines, which more strongly cor- strated in 103 cases of sacral metastasis procedure in the setting of metastatic relates with the presence of metastatic that spinal stereotactic radiosurgery is sacral lesions; however, a palliative sur- disease15. In the case of sacral insuffi- effective in decreasing pain and with gical procedure can be considered, ciency fractures, these are often not fewer complications22. Additionally, especially if neurological deficits such as displaced and can be challenging to be precise control and treatment volume cauda equina syndrome are present. visualized in radiographs16.Thegold increase success and decrease the risk of Spinal stability serves as a critical deci- standard for evaluating a metastatic neural element injury. Radiosurgery is sion criterion when evaluating patients lesion to the sacrum is magnetic reso- not indicated in cases of neurological for a sacral surgical procedure. The Spi- nance imaging (MRI) with and with- deficit caused by osseous compression nal Instability Neoplastic Score (SINS) out contrast17. Computed tomography to neural structures. Also, it may not is a validated instrument that provides (CT) helps to evaluate the degree of be indicated as the only treatment mo- an objective means of grading spinal lytic or blastic involvement by the dality when spinal instability is present. stability. A score of 0 to 6 points is a lesion. Lastly, when treating larger lesions, stable spine, a score of 7 to 12 points radiosurgery may not deliver enough suggests impending instability, and a Diagnosis radiation22,23. score of 13 to 18 points is an unstable A tissue diagnosis is always fundamen- Indications for a surgical procedure spine28. The SINS can help to guide tally critical to establish prior to treat- include neurological deficits, failed treatment for symptomatic upper sacral ment and must distinguish among radiation therapy, and spinal instabil- lesions. infection, sarcoma, and other metastatic ity24. Surgical intervention relies heavily With some minor exceptions, a histologies. Histological examination on the individual pathology of each surgical procedure for sacral metastases will differentiate metastases from un- patient. Several scoring systems are is performed via laminectomy with or common infectious conditions17,18. available to help to guide the type of without instrumentation and/or fusion. However, culture specimens should also surgical intervention and to determine if A decompression surgical procedure be sent along with the biopsy specimen a patient’s prognosis precludes surgical generally involves laminectomy for the to rule out any concurrent infections. intervention. The modified Tokuhashi evacuation of a tumor causing nerve root Biopsies can be performed as open in- score is composed of 6 sections, includ- compression or cauda equina syndrome, cisional procedures, percutaneously or ing general condition of the patient and instrumentation (lumbopelvic fixa- with CT guidance. CT-guided biopsy (performance status), number of tion) and fusion are employed for im- is the most frequently used biopsy extraspinal bone metastases, number pending instability with concurrent modality and carries a minimal risk18.If of metastases in the vertebral body, nerve root compression. 2 JULY 2018 · VOLUME 6, ISSUE 7 · e8 Update on the Management of Sacral Metastases | For the majority of sacral metastases, months, reinforcing
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