| Japanese Journal of Clinical Oncology | Pages |
Pain-relieving Posterior Rod Fixation with Segmental Sublaminar Wiring for Pancoast Tumor Invading the Vertebrae
Introduction
Case Report
Discussion
References
Pain-relieving Posterior Rod Fixation with Segmental Sublaminar Wiring for Pancoast Tumor Invading the Vertebrae
We describe the case of a 44-year-old male patient with Pancoast lung cancer invading the vertebrae. Because irradiation did not relieve his symptoms, we conducted tumor resection with posterior rod fixation with segmental sublaminar wiring of the vertebrae. This enabled the patient to walk and to discontinue morphine immediately after surgery. Although the tumor recurred within the region of the fixation 4 months after surgery, the patient complained of no pain until his death. Although Pancoast lung cancer with extensive vertebral invasion cannot be cured surgically, posterior rod fixation with segmental sublaminar wiring with tumor resection can improve a patient's quality of life by providing immediate, long-term pain relief.
Key words: Pancoast tumor - lung cancer - vertebra - spine - posterior rod fixation
INTRODUCTION
Pancoast lung cancer invades surrounding structures, including the pleura, chest wall, adjacent vertebrae, brachial plexus, major vessels and cervical sympathetic plexus, causing agonizing pain in most patients (1,2). In particular, those whose vertebrae have been extensively destroyed by tumor invasion are unable even to get out of bed because of the pain caused by their body weight pressing on the damaged vertebrae. Although high-dose irradiation is the treatment of choice for pain relief, particularly in patients with extensive local invasion or distant metastasis (3-5), tumors which have invaded bone often cause local failure with pain recurrence (5). We describe a patient with Pancoast lung cancer which had extensively invaded the vertebrae, who underwent tumor resection with posterior rod fixation with segmental sublaminar wiring of the vertebrae. This procedure resulted in immediate, long-term pain relief until the patient's death, even after local tumor recurrence in the vertebrae.
CASE REPORT
A 44-year-old man complained of back and right shoulder pain in February 1997, then of weakness and numbness of the right arm in July 1997. His symptoms deteriorated gradually and he was hospitalized upon diagnosis of Pancoast squamous cell carcinoma of the right lung on September 3, 1997.
On admission, he could not sit up in bed because of back pain. Chest X-ray and computer tomography (CT) showed a tumor in the right lung apex, which invaded the first to third ribs and thoracic vertebrae and crossed over the median line (Figs 1 and 2). Magnetic resonance imaging (MRI) showed tumor invasion of the first and second thoracic vertebrae and protrusion into the spinal canal (Fig. 3), but there was no neurological deficit. MRI also revealed metastasis to the fourth thoracic vertebra. Further examinations did not show other metastasis. The patient's inability to sit up was found to be caused by pain due to the weight of his body pressing on the extensively damaged thoracic vertebrae upon sitting. Continuous epidural analgesia with morphine 10 mg/day and oral administration of morphine sulfate 160 mg/day provided insufficient pain relief to allow him to get up. Irradiation at a total dose of 50 Gy did not abolish the pain entirely. Although the patient had distant metastases, we decided to resect the tumor and perform instrumental fixation of vertebrae in order to relieve the pain, after obtaining the informed consent of the patient and his family. The day before surgery, the first and third intercostal arteries were embolized to reduce intraoperative blood loss.
Figure 1. Chest X-ray showing a tumor shadow in the right lung apex (arrow).
Figure 2. Chest CT showing that the tumor had invaded the thoracic vertebrae and crossed over the median line.
During the operation on October 7, 1997, posterior rod fixation with segmental sublaminar wiring was conducted using the Isola Spinal System (Depuy Motech AcroMed, Cleveland, OH, USA) between the fourth cervical vertebra and the eighth thoracic vertebra. The rod and segmental wires were fixed to each other using bone cement. The primary tumor had invaded the spinal canal around the first and second thoracic vertebrae and these were resected via the posterior approach. The metastatic lesion in the fourth thoracic vertebra was resected by laminectomy. After closure of the back wound, the primary lesion was excised via a posterolateral thoracotomy by wedge lung resection with combined rib resection, subtotal spondylectomy and blunt dissection from the brachial plexus. This resulted in grossly complete tumor resection. The resected vertebral bodies were supplemented with bone cement. The operation took 10 h and 40 min and intraoperative blood loss was 1800 g.
Figure 3. Magnetic resonance imaging showing that the tumor protruded into the spinal canal (arrow).
The postoperative course was satisfactory and back pain was reduced immediately (Fig. 4). No neurological deficit was seen after surgery. The patient was able to walk with almost no pain 3 days after surgery and morphine administration could be discontinued 7 days after surgery. The patient was discharged 3 weeks after surgery.
Figure 4. Chest X-ray after surgery showing posterior rod fixation with segmental sublaminar wiring.
The patient suffered tumor recurrence at the fourth lumbar vertebra 3 months after surgery. Despite irradiation therapy, the patient suffered paraplegia 1 month later. Four months after surgery, local recurrence was also seen in the cervical and thoracic vertebrae, but the patient suffered no further neurological deficit and complained of no pain at this site until his death on June 18, 1998, 8 months after surgery. Death was due to primary tumor plus lung, liver and bone metastasis. Autopsy revealed extensive tumor-invaded bone destruction between the sixth cervical and sixth thoracic vertebrae, which lay within the region of the posterior rod fixation (Fig. 5).
Figure 5. Autopsy showing extensive local tumor recurrence from the sixth cervical vertebra to the sixth thoracic vertebra, with invasion of the spinal cord.
DISCUSSION
In inoperable Pancoast lung cancer, irradiation alone is usually given for pain palliation and satisfactory results are obtained in 63-86% of patients for a median of 7-12 months (3-6). Tumors which have led to bone destruction, however, often cause treatment failure, resulting in uncontrollable pain (5). In the present patient, irradiation alone would not have been sufficient to resolve his inability to get up owing to the extensive vertebral destruction that caused pain on weight loading. Posterior rod fixation with segmental sublaminar wiring of the vertebrae relieved the pain immediately and enabled the patient to get up and walk without pain 3 days after surgery. The resection of the tumor also relieved the shoulder pain caused by brachial plexus compression due to the tumor. Despite local postoperative recurrence in the cervical and thoracic vertebrae within the region of the rod fixation, the patient complained of no pain at these sites until his death. This immediate, long-term pain relief appears to be due to the release of weight loading on the destroyed vertebrae after rod fixation.
Posterior rod fixation with segmental sublaminar wiring for neuromuscular spinal deformity provides segmental correction and fixation by applying a transverse force to every vertebra, thus providing stability in the frontal, sagittal and transverse planes (7). In the present patient, we resected the tumor and used additional bone cement with the rod and segmental wires to prevent instability of the instrumentation in case of tumor recurrence in the vertebrae. While local recurrence eventually caused extensive vertebral destruction by the tumor, the patient complained of no pain at the recurrence sites until death, because the vertebrae were firmly fixed by bone cement, rod and segmental wires. Although metastatic spine tumors have been treated by instrumental fixation without the use of bone cement (8), we believe that bone cement combined with segmental spinal instrumentation is useful in preventing pain caused by instability of the instrumentation after local tumor recurrence.
The surgical procedure for malignant spinal tumors include stabilization with spinal instruments alone, stabilization in addition to decompression by tumor resection and decompression alone. We performed both stabilization and decompression by tumor resection for the following reasons: (1) tumor resection could also relieve the shoulder pain caused by brachial plexus compression by the tumor and (2) a tumor that has invaded the spinal canal should be resected for certain vertebral reconstruction and prevention of paraplegia. Although the present patient suffered paraplegia due to tumor recurrence at the fourth lumbar vertebra 3 months after surgery, we believe that vertebral stabilization in addition to tumor resection could relieve pain more effectively than stabilization alone.
Pancoast tumor with invasion of the vertebral body or subclavian vessels is defined as T4 disease and conveys a poor prognosis in patients undergoing resection. Of 22 patients with vertebral body involvement, Ginsberg et al. found only two 5-year survivors (9%) after resection (8). Others have reported no 5-year survivors (9,10). In addition, surgical therapy combined with vertebral resection leads to some risk of postoperative complications. Sundaresan et al. conducted surgery in 110 patients with metastatic spine tumors, resulting in postoperative complications in 48% (11). These included wound breakdown, infection, stabilization failure, bleeding, respiratory failure and cerebrospinal fluid leakage. The present patient complained of no pain even after local tumor recurrence in vertebrae within the region of the fixation. We therefore consider that, for Pancoast lung cancer patients with extensive vertebral destruction, who are at high risk of surgery, posterior rod fixation with segmental wiring alone without tumor resection is an option for pain relief. We believe that, although Pancoast lung cancer with extensive vertebral invasion cannot be cured surgically, posterior rod fixation with segmental sublaminar wiring of the vertebrae improves the patient's quality of life as it immediately relieves pain by releasing the weight loading on the destroyed vertebrae. It can also prevent pain even after local tumor recurrence in the vertebrae.
References
Received July 21, 1999; accepted September 14, 1999
For reprints and all correspondence: Hiroaki Nomori, Department of Thoracic Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan
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Copyright© 1999 Foundation for the Promotion of Cancer Research.
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