Recurrence rates and functional outcome after resection of intrinsic intramedullary tumors

https://doi.org/10.1016/j.clineuro.2015.04.006Get rights and content

Highlights

  • Recurrence of spinal tumors correlates with age, histology/grading, mitotic activity.

  • Neurologic performance deteriorates postoperatively but recovers during follow-up.

  • Pain and sensitivity improves faster than paresis and vegetative functions.

Abstract

Introduction

Intramedullary tumors account for 2–4% of all CNS neoplasms. Surgical resection is challenging because of aggravated neurological impairment in up to 64% of patients. We analyzed a consecutive series of patients with intramedullary tumors and focused on the extent of resection, functional outcome, and tumor recurrence.

Methods

53 patients (23 women and 30 men; mean age 46.3 years) were included who had undergone microsurgical resection for intramedullary spinal tumors. We reviewed the patient records for tumor size, edema, intratumoral hemorrhage, consistency, midline detection, resection method, extent of resection, histopathology, and recurrence. Outcome was measured by the Karnofsky Score (KPI), the McCormick score (MCS), and the Medical Research Council Neurological Performance Score (MRC-NPS).

Results

The most frequent diagnosis was ependymoma (37.7%), lymphoma (13.2%) and astrocytoma (11.3%). The majority of tumors were located in the thoracic spine (62.2%). Gross total resection was achieved in 73.6% and most successful in patients with ependymal histology (p < 0.01). Tumor recurrence – observed in 11.3% – was significantly associated with age >65 years, astrocytic histology, higher tumor grades, and higher Ki-67 labeling. At follow-up, MCS and MRC-NPS showed significantly better results than prior to resection (p < 0.001), and pain and sensory deficits had improved in 67.9% and 64.2% of patients, respectively. Microsurgical resection improved the neurological status significantly. Pain and sensory deficits showed higher improvement rates than paresis and vegetative dysfunction.

Conclusion

Our data help identify patients at risk of tumor recurrence and classify the course of postoperative neurological performance.

Introduction

Intramedullary tumors are exceedingly rare, accounting for only 2–4% of all CNS neoplasms [13], and the majority of these tumors are classified as benign lesions [11]. Irrespective of the tumor histology, surgical removal is only recommended in case of clearly demarcated borders [13]. On the other hand, gross-total resection (GTR) is associated with increased overall survival (OS) in patients with spinal cord astrocytomas [14]. Several recent reports have focused on the impact of maximal resection (EOR) on OS and progression-free survival (PFS) in patients with spinal cord tumors. If GTR is considered a safe treatment option, complete surgical resection is viewed as the primary treatment goal [2], [6] for patients with malignant spinal cord tumors, such as metastases [3], astrocytomas, and ependymomas [1].

However, despite intensive intraoperative neuromonitoring (IOM), surgical resection is challenging because of a significant risk of transient or permanent neurological deterioration [7], [9], [10], [12], [16]. Some authors have reported rates of up to 64% of new neurological deficits or worsening of pre-existing neurological impairment, or both, due to the surgical resection of intrinsic spinal cord tumors [4], [7], [17], [19], [22].

To provide insight into the relation between EOR, histology, and functional and oncologic outcome, we analyzed a consecutive series of patients with intramedullary spinal cord tumors who had presented for treatment at our department. We particularly focused on the extent of resection (EOR), functional outcome, and the frequency of recurrence.

Section snippets

Patients and methods

We included 53 consecutive patients (23 women and 30 men) in this retrospective analysis. All patients had undergone microsurgical resection for an intramedullary spinal tumor at our neurosurgical department between 2003 and 2011. Inclusion criteria were spinal intradural tumors encased by the spinal cord. We reviewed the patient records for demographic data, the neurological condition and performance at admission, after surgery, at discharge, and during follow-up, as well as for the duration

Baseline data

The baseline data are summarized in Table 2. The mean age was 46.3 years (ranging from 9 months to 82.7 years). The mean duration of symptoms to admission was 17.8 months (ranging from 0 month to 120.4 months).

62.2% (n = 33) of the tumors were localized in the thoracic spine, 18.9% (n = 10) in the lumbar spine, and 18.9% (n = 10) in the cervical spine. The mean tumor size was 10.0 mm (ranging from 1.0 mm to 43.0 mm). Perifocal edema was present in 11.3% of patients (n = 6). Preoperative intratumoral

Conclusions

Treatment of spinal cord tumors is challenging because such lesions often require an interdisciplinary approach combing neurosurgery, radiology, radiotherapy, neurooncology, and rehabilitation medicine. The primary goal of neurosurgical resection is to alleviate pain, improve neurological dysfunction, prevent tumor progress, provide a histopathological result, and boost adjuvant radiation treatment and chemotherapy.

Functional outcome

In 2009, Matsuyama et al. presented the results of 106 patients with intramedullary spinal cord tumors that were resected in surgical interventions guided by intraoperative spinal cord monitoring. GTR was achieved in 79% of the patients, of whom 31.5% showed significant postoperative neurological deterioration [12]. Earlier studies had reported even higher procedure-related morbidity rates for the treatment of intrinsic spinal cord tumors, for instance, newly developed neurological impairment

Limitations

Due to the retrospective character of this study, some important data, such as tumor texture or type of resection, are missing in a subset of patients. Secondly, our previous surgical protocol did not include IOM which had thus not been conducted in the majority of patients. However, in 2010, IOM became a routine procedure in all patients with spinal tumors. Finally, this study does not provide any data on the development of postoperative spinal deformities, an important clinical parameter in

Conflict of interest

None.

Funding

None.

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