Littérature scientifique sur le sujet « Spinal cord metastasis »

Background: Bone metastases occur in most patients with advanced hormone-refractory prostate cancer causing pain, pathologic fractures, and spinal cord compression. Few studies specifically address surgical treatment of metastatic spinal cord compression (MSCC) in prostate cancer. Criteria for identifying patients who may benefit from surgery are poorly defined. Most of the current knowledge regarding tumor biology in prostate cancer is based on studies of primary tumors or soft tissue metastases. The mechanisms regulating growth of bone metastases are not fully established. Aims: a) to evaluate outcome after surgery for MSCC in prostate cancer and to identify prognostic factors for survival and functional recovery; b) to evaluate current practice for referral of prostate cancer patients with MSCC; c) to analyze expression of androgen receptor (AR), cell proliferation, apoptosis, and prostate-specific antigen (PSA) in bone metastases with regard to survival after surgery for complications of bone metastases. Patients and Methods: We retrospectively evaluated the hospital records of 68 consecutive patients operated for metastatic spinal cord compression. Tumor tissue from bone metastases was obtained on spinal surgery (54 patients), fracture surgery (4 patients) and biopsy (2 patients), and analyzed by immunohistochemistry. Results: Study I: Mortality and complication rate after surgery was high. Patients with hormone-naïve disease and those with hormone-refractory disease with good performance status and without visceral metastases had more favorable survival. The ability to walk after surgery was related to better survival. Study II: A new score for prognosis of survival after surgery for spinal cord compression includes: hormone status of prostate cancer, Karnofsky performance status, evidence of visceral metastasis, and preoperative serum PSA. The score is simple, tumor specific, and easy to apply in clinical practice. Study III: Our results suggest that delays in diagnosis and treatment may have negative impact on functional outcome. Pretreatment ability to walk, hormone status of prostate cancer, and time from loss of ambulation influenced neurological recovery after surgery for spinal cord compression. Study IV: High nuclear AR immunostaining in bone metastases and high preoperative serum PSA were associated with a poor outcome after metastasis surgery in patients with hormone-refractory prostate cancer. Short-term effect of castration therapy disclosed that nuclear AR immunostaining was decreased and apoptosis was increased, but cell proliferation remained largely unaffected. Conclusion:  Prostate cancer patients with metastatic spinal cord compression represent a heterogeneous group. We identified prognostic factors for survival and functional outcome, which may help clinicians in making decisions about treatment. Our results also implicate the need for development of local and regional guidelines for treatment of patients with spinal cord compression, as well as the importance of information to patients at risk.

Metastatic epidural spinal cord compression (MESCC) occurs when tumour invades the epidural space and compresses the spinal cord. Despite Level 1 evidence that surgery is the most effective treatment for MESCC, there is controversy regarding the role of surgery because of fear that patients who have a short survival will spend a large fraction of their remaining life recovering from surgery and potential complications. This controversy could be resolved by decision-analysis of MESCC treatments using quality-adjusted-life-years (QALYs). There have been two barriers to conducting decision-analysis of QALYs for MESCC: (a) lack of utility data, and (b) skepticism regarding decision-analysis. The first four research chapters in this thesis address these barriers. The final research chapter reports a decision-analysis of QALYs on the role of surgery in MESCC. Chapter 1 provides background information on the controversy regarding surgical treatment for MESCC and the rationale for each of the subsequent chapters. Chapter 2 reports a psychometric validation study of a web-based utility valuation module for MESCC. In Chapter 3, application of this module to a general population utility valuation study with a market research panel is described. In Chapter 4, the beneficial properties of Bayesian statistical analysis to minimizing “arbitrariness” in probabilistic sensitivity analysis are described in relation to prognostication for MESCC. Chapter 5 presents a strategy for simplifying and enhancing the transparency of Markov cohort simulation. Finally, the work presented in the research chapters is applied in Chapter 6 to conduct Markov cohort simulation to determine if patients with short survival derive net health-related quality-of-life benefit from surgery. Pragmatic research around barriers to decision-analysis of QALYs for MESCC was conducted to resolve the controversy regarding the role of surgery in the treatment of MESCC. Under most circumstances, MESCC patients who can ambulate prior to treatment derive net HRQoL benefit from surgery, even if prognosis is poor. Non-ambulatory patients can derive net HRQoL benefit but only if the morbidity of surgery is relatively low. It is my hope that the work used to address barriers to decision-analysis of QALYs will be disseminated and applied in other clinical problems.

Background: Metastatic spinal cord compression (MSCC) can result in paralysis and is an oncology emergency. Prognosis is poor if not treated early. There are an estimated 1200-2500 new cases of MSCC per year in Scotland. At 2013 there are limited studies which have explored the issues experienced by patients, carers and/or family members and healthcare professionals in the management of MSCC. Aim: The aim of this study was to explore the perceptions and experiences of patients, carers and/or family members and healthcare professionals in the management of metastatic spinal cord compression. Research Design and Methods: A case study design approach involving two phases was used. Phase One involved three focus groups with healthcare professionals (n=25) and one-to-one interviews with healthcare professionals (n=7). Phase Two involved interviews with patients (n=8), carers (n=6) and healthcare professionals (n=42). Patients and carers were interviewed twice over a period of six months. Braun and Clarke's (2006) thematic inductive-data approach was used for data analysis. Findings: Phase One identified an overarching theme of ‘negotiating the care pathway' with four main themes: what can we do for patients with MSCC; what do we need to ‘trade-off' to meet the needs of patients; how can guidelines help anyway; and how can we deliver optimum care in the midst of uncertainty? The majority of healthcare professionals viewed the existing National Institute for Clinical Excellence (NICE) guidelines (2008) as inadequate and lacking in a strong evidence base. Healthcare professionals acknowledged the importance of meeting the patient's preferred needs and goals given the nature of this condition and the short life expectancy of many patients with MSCC. Phase Two identified three main themes: facing uncertainty in MSCC; finding a balance in MSCC and support beyond the treatment of MSCC. A focus on acute management is often at odds with the palliative nature of the patient's condition and this contributes to the complexity for patients, carers and healthcare professionals. The findings demonstrate the intricacies of uncertainty which affect all the key stakeholders when MSCC presents. There is a constant movement between uncertainty (of the future) and enduring inconsistencies (of information, treatment and advice for the future), which results in a struggle to find a balance. Conclusions: Caring for patients with metastatic spinal cord compression is challenging with uncertainties surrounding the diagnosis of MSCC, spinal instability, treatment and support beyond the treatment of MSCC. A theory of collaborative decision making based on the findings in this thesis is proposed to help reduce uncertainty and enable key stakeholders to make decisions in their journey with MSCC.

Material und Methode: In einer retrospektiven Analyse wurden die Daten von 53 konsekutiven Patienten, 31 Männer und 22 Frauen, mit klinisch oder röntgenologisch präsenten metastatischen epiduralen Spinalkanalkompression ausgewertet. Das mediane Alter war 60 Jahre. Als Primärtumor waren Bronchialkarzinome (13 Patienten), Mammakarzinome (10) und Prostatakarzinome (10) am häufigsten zu finden. Ergebnisse: Die Therapieergebnisse hinsichtlich der Schmerzlinderung waren mit der Literatur vergleichbar (Ansprechrate= 66%). Als wichtigster prognostischer Faktor hinsichtlich der Gehfähigkeit hat sich der prätherapeutische Status erwiesen. Patienten, die Anfang der Therapie gehfähig waren, blieben in 94% der Fälle auch gehfähig, während nur ein Patient seine Gehfähigkeit bis Ende der Therapie wiedergewann (p< 0,001). Im Chi-Quadrat Test war auch der diagnosestellende Arzt prognostisch relevant: Patienten, deren Diagnose durch einen onkologisch tätigen Arzt gestellt wurde, hatten eine höhere Chance gehfähig zu bleiben (p=0,04). Das Gesamtüberleben (8 Monate median, Range 1-27 Monate ) entsprach den Literaturangaben. Nicht ambulante Patienten und Patienten mit Bronchialkarzinom hatten eine signifikant schlechtere Prognose (p<br>Materials and Methods: therapy charts of 53 consecutive patients, 31 male and 22 female, with metastatic epidural spinal cord compression treated with radiation therapy only have been analyzed. Median age was 60 ys. The most frequent primary tumours were bronchogenic carcinoma (13 patients), breast cancer (10 patients) and prostate cancer (10 patients),respectively.Results: MRI was the most sensitive diagnostic tool in detecting spinal cord compression. Plain X-ray films were not useful.Pain symptoms improved in 66% of the patients. The most important prognostic factor was the pretreatment mobility status. 94% of the ambulatory patients kept their walking ability but only one plegic patient could walk again after radiation therapy. (p=0.001) Patients whose back pain was presented to an oncologist were more likely to keep walking ability by the end of the therapy. (p=0.04) Patients with bronchogenic cancer and plegic patients had a significant worse survival. Conclusion: Patients with a known malignant tumor and progressive or axial back pain should undergo MRI scan to rule out spinal cord compression. For patients without severe neuorologic deficit and MRI proven epidural compression radiation therapy is able to preserve walking ability and reduce pain. General practitioners and patients should be informed about the symptoms and the therapeutic and diagnostic possibilities of spinal cord dompression.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-08-08T20:45:16Z No. of bitstreams: 1 daniellezacaronsantos.pdf: 1089910 bytes, checksum: c826630c6083dd96be8ff3a550b429b6 (MD5)<br>Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-08-09T11:43:27Z (GMT) No. of bitstreams: 1 daniellezacaronsantos.pdf: 1089910 bytes, checksum: c826630c6083dd96be8ff3a550b429b6 (MD5)<br>Made available in DSpace on 2017-08-09T11:43:27Z (GMT). No. of bitstreams: 1 daniellezacaronsantos.pdf: 1089910 bytes, checksum: c826630c6083dd96be8ff3a550b429b6 (MD5) Previous issue date: 2017-03-28<br>A síndrome de compressão medular metastática (SCMM) é uma urgência oncológica. A independência funcional é uma das maiores preocupações dos indivíduos que enfrentam o processo de morrer. O nível funcional é um dos itens do índice prognóstico de Tokuhashi (IPT) que é uma ferramenta utilizada para nortear o tipo de tratamento para a SCMM de acordo com a sobrevida. O objetivo deste estudo é avaliar a sobrevida, a funcionalidade e os seus fatores associados em pacientes com SCMM de uma unidade de referência oncológica na cidade do Rio de Janeiro, Brasil. O recrutamento dos casos foi através de busca ativa nas enfermarias das unidades hospitalares do serviço de referência em oncologia e/ou pesquisa no banco de dados dos atendimentos realizados pela equipe de fisioterapia, parte do sistema de prontuário e informação médica do serviço. Foi analisada a sobrevida de 163 pacientes e foi efetuada avaliação da capacidade funcional em até 48 horas após o diagnóstico da SCMM para 47 pacientes. A correlação entre ASIA e grau de dependência funcional foi calculada através do teste da correlação de Sperman. A diferença na pontuação da MIF de acordo com ASIA foi avaliada pelo teste de Kruskall-Wallis. As funções de sobrevida foram estimadas pelo método de Kaplan-Meier e o modelo de riscos proporcionais de Cox foi utilizado para avaliação prognóstica. A concordância entre o tempo de sobrevida observado e o estimado pelo IPT foi avaliada pelo coeficiente de Choen'sKappa. O tempo de sobrevida global foi de 4,54 meses (IC95%: 2,60-6,64). Os fatores prognósticos associados à sobrevida foram o estadiamento do câncer IV (HR:2,20; IC95%: 1,3-3,72) e III (HR:2,50; IC95%: 1,47-4,25), o atendimento de urgência (HR=1,7; IC95%: 1,18-2,26) e o KPS:80-100% (HR: 0,55; IC95%: 0,38-0,80) e 5070% (HR: 0,53; IC95%: 0,36-0,78). O valor preditivo positivo total do IPT foi de 55,8% e a concordância entre os tempos de sobrevida foi de 0,24 (p< 0,01). O grau de dependência funcional foi associado ao KPS, a ASIA, à capacidade de deambular, ao tempo de sobrevida e à cor da pele (p<0,05). Houve diferença na MIF (p= 0,04) e MIFmotor (p=0,01) segundo ASIA. A correlação entre MIF e ASIA foi de 0,35 (p<0,02) e entre esta e MIFmotor foi de 0,40 (p<0,01). O IPT pode auxiliar no manejo terapêutico da SCMM, considerando também o estadiamento o tipo do primeiro atendimento e o KPS apesar de necessária revisão dos seus parâmetros, além de auxiliar no planejamento da reabilitação. A MIF é apropriada para avaliar a funcionalidade na SCMM A reabilitação paliativa é indicada para esses pacientes e as estratégias devem estar aliadas ao prognóstico de sobrevida.<br>Metastatic spinal cord compression syndrome (MSCC) is an oncology emergency. Functional independence is a major concern for individuals facing the process of dying. The functional level is an item of Tokuhashi Prognostic Index (TPI), which is a tool used to guide the type of treatment for MSCC in accordance with survival. The aim of this study is to evaluate the survival, function and its associated factors patients with MSCC of an oncology reference unit in the city of Rio de Janeiro, Brazil. The recruitment of cases on the search for diseases of hospital units of reference service in oncology and / or research without database of the consultations performed by physiotherapy team, part of the system of medical records and information of the service. The survival of 163 patients was analyzed and functional capacity evaluation was performed within 48 hours after the diagnosis of SCMM for 47 patients. The correlation between ASIA and functional dependence degree was calculated using the Sperman correlation test. The difference in FIM scores according to ASIA was assessed by the Kruskall-Wallis test. Survival functions were estimated using the Kaplan-Meier method and the Cox proportional hazards model was used for prognostic evaluation. The agreement between the observed survival time and the estimated TPI was evaluated by the Choen'sKappa coefficient. The overall survival time was 4.54 months (95% CI: 2.60-6.64). The prognostic factors associated with survival were cancer staging IV (HR: 2.20, 95% CI: 1.3-3.72) and III (HR: 2.50, 95% CI: 1.47-4.25) (HR = 1.7, 95% CI: 1.18-2.26) and KPS: 80-100% (HR: 0.55; 95% CI: 0.38-0.80) and 50-70% (HR: 0.53, 95% CI: 0.36-0.78). The total positive predictive value of the TPI was 55.8% and the agreement between the survival times was 0.24 (p <0.01). The degree of functional dependence was associated with KPS, ASIA, gait ability, survival time and skin color (p <0.05). There was difference in FIM (p = 0.04) and FIM motor (p = 0.01) according to ASIA. IPT can help in the therapeutic management of MSCC, also considering staging the type of first care and KPS despite the necessary revision of its parameters, besides assisting in rehabilitation planning. MIF is appropriate for assessing functionality in MSCC Palliative rehabilitation is indicated for these patients and strategies should be combined with the prognosis of survival.