Spine Metastasis in Elderly

Encouraging Results for Better Survival

Quentin Beaufort, MD; Louis-Marie Terrier, MD; Arnaud Dubory, MD, PhD; Louis-Romée Le Nail, MD; Ann-Rose Cook, MD; Joseph Cristini, MD; Kévin Buffenoir, MD, PhD; Hugues Pascal-Moussellard, MD, PhD; Alexandre Carpentier, MD, PhD; Bertrand Mathon, MD; Aymeric Amelot, MD, PhD

Disclosures

Spine. 2021;46(11):751-759. 

In This Article

Results

Series Characters

A total of 243 consecutive patients were included. A total of 986 SpM were identified at the time of spinal localization diagnosis. As summarized in Table 1, 150 (61.7%) patients were men and 93 (38.3%) were women. All patients were older than 70 years with a median age of 75.3 (range, 70.0–97.1 years).

Overall Survival

Median overall survival (OS) from cancer diagnosis was 46.7 months (SD 6.3), whereas median survival from the SpM event was 16.3 months (SD 1.7). The 3-month, 1-year, 2-year, and 5-year survival rates from SpM were respectively 78.3% (SD 3.5), 55.6% (SD 5.3), 38.5 (SD 7.1), and 14.5% (SD 6.1). The median time between the primary tumor diagnosis and SpM was 16.03 months (SD 1.6) (Figure 1A). For 101 patients (41.5%), SpM and the primary tumor were synchronously diagnosed.

Figure 1.

Kaplan-Meier (KM) survival analysis for elderly patients: (A) since SpM diagnosis, (B) according to primary tumor, and (C) according to different elderly age groups.

Survival Analysis

We sought to identify prognostic factors associated with OS using a univariate analysis. The results are presented in Table 2.

OS according to primary tumor were as follows: non-small cell lung cancer (61 patients (25.1%), median OS 5.8 months, SD 0.7); breast cancer (29 patients (11.9%), median OS 22.0 months, SD 6.0), blood cancer (29 patients (11.9%), median OS 43.1 months, SD 6.8); gastrointestinal cancer (27 patients [11.1%], median OS 3.9 months, SD 1.9); urinary cancer (23 patients [9.4%], mean OS 8.6 months, SD 2.8); thyroid cancer (20 patients [8.2%], mean OS 87.3 months, SD 6.8); and other cancers (larynx, surrenaloma) (14 patients [5.7%], median OS 3.1 months, SD 1.9) (P < 0.0001) (Figure 1B).

We analyzed the influence of age on OS by subgrouping our series: 70 to 75 years' old (n = 114, 17.1 months, SD 2.7), 75 to 80 years' old (n = 70, 17.9 months, SD 2.0) and >80 years' old (n = 59, 9.2 months, SD 2.9). There was a significant difference between patients >80 years and older (P = 0.003) (Figure 1C).

Good World Health Organization (WHO) status was significantly associated with longer median OS: 26.5 months (SD 3.7) for the 92 patients with WHO status 1, 7.2 months (SD 1.0) for the 41 patients with WHO status 2; 2.9 months (SD 0.5) for the 38 patients WHO status 3; and 1.3 months (SD 0.2) for the 28 patients with WHO status 4 (P < 0.0001) (Figure 2A).

Figure 2.

Kaplan-Meier (KM) survival analysis for elderly patients according to: (A) WHO performance status at SpM diagnosis; (B) neurological function status (Frankel score); (C) spine epiduritis associated, and (D): spine treatment associated.

Preserved neurological function at SpM diagnosis was significantly associated with longer median OS: 24.0 months (SD 3.5) for the 164 patients Frankel E; 7.6 months (SD 0.9) for the 22 patients Frankel D; 5.0 months (SD 0.7) for the 25 patients with Frankel C; 2.4 months (SD 0.5) for the 19 patients with Frankel B and 1.2 months (SD 0.4) for 13 patients Frankel A (P < 0.0001) (Figure 2B).

Women had better median OS than men: 19.3 months (SD 2.2) versus 11.5 months (SD 2.7) (P = 0.037). Likewise, patients whose disease was not controlled (n = 154; 63.4%) had a lower OS (12.7 vs. 20.0 months, P = 0.028).

There was no survival difference for patients with synchronous SpM and primary cancer diagnosis (P = 0.941). Furthermore, the number of SpM had no influence (P = 0.088) and there were no differences whether or not the patient had bone (P = 0.694) or visceral metastasis (P = 0.123).

The spine metastasis-free survival (MFS) did not improve survival: 13.5 months (SD 3.1) for the 127 patients with MFS <6 months; 7.0 months (SD 3.0) for the 18 patients with MFS <1 year; 8.7 months (SD 5.2) for the 12 patients with MFS between 1 and 2 years; 13.2 months (SD 5.7) for the 19 patients with MFS between 2 and 4 years; 12.9 months (SD 6.1) for the 16 patients with MFS between 4 and 6 years and 36.4 months (SD 12.1) for the 51 patients with MFS >6 years (P = 0.159).

Treatment Modality

According to the treatment modality, we observed significant differences in OS: 63 patients were supported with symptomatic treatment (OS 24.0 months, SD 8.2), 52 patients (21.4%) received posterior decompression surgery (14 patients, 5.7% with associated fixation) (OS: 19.3 months, SD 7.9), and 128 patients were treated with an orthopedic brace (OS: 12.7 months, SD 2.5) (P < 0.009). Patients with epiduritis (n = 128; 52.7%) associated with SpM had lower OS than the others (median 6.1 [SD 1.1] vs. 27.6 (SD 6.1) months; P < 0.0001) (Figure 2C). In addition, 47 patients (19.3%) underwent cementoplasty in association with surgery.

Treatment Study

As summarized in Table 3, between the symptomatic treatment group (77.7 years, SD 6.01), the surgery group (76.2 years, SD 4.6), and the brace treatment group (76.4 years, SD 5.4), no statistical difference was observed concerning median age (P = 0.253). No WHO status repartition (P = 0.07) and no Frankel score difference (P = 0.270) were demonstrated between these three groups (Figure 2D). However, there were more patients with spine epiduritis (41, 78.8%) in patients that underwent surgery treatment than in other groups (P < 0.0001). Concerning primary tumor repartition, we observed a significant difference: more breast cancers (17.4%) in symptomatic treatment group, more patients with blood cancer (myeloma and lymphoma, 25%) benefited surgery, and more lung (29.6%) and prostate (20.3%) cancers were found in the brace subgroup.

Multivariate Survival Analysis

All clinical characteristics involved in the OS (based on statistically significant results from univariate analyses) were further applied to multiple analyses (Table 2).

Cox multivariate proportional hazard model identified that poor WHO status, status 3/4 (HR: 2.245, 95% CI 1.899–2.655; P < 0.0001), patients > 80 years (HR: 1.758, 95% CI 1.117–2.765; P = 0.015), no-ambulatory neurological status (Frankel A/B status [HR: 3.219, 95% CI 1.621–6.390; P < 0.0001]), visceral cancer (HR: 3.530, 95% CI 1.75–7.1; P < 0.0001), lung cancer (HR: 3.452, 95% CI 1.784–6.680; P < 0.0001), orthopedic brace treatment (HR: 1.329; 95% CI 1.050–1.683; P = 0.018), and epiduritis (HR: 1.52, 95% CI 1.041–2.22; P = 0.03) were independently poor prognostic factors of survival.

The only good prognosis factor identified was thyroid cancer (HR: 0.257, 95% CI 0.07–0.952; P = 0.04).

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