SURVIVAL IN SPINAL CANCER SURGERY: ANALYSIS OF CASES OPERATED IN 2020ABSTRACT
Objective: To analyze the survival time of patients diagnosed with malignant neoplasms who were recommended surgical spine treatment.
Methods: For survival analysis, in March 2024, all cases that underwent spinal surgery in 2020 were collected from the Instituto do Câncer do Estado de São Paulo (ICESP), a reference hospital in the city of São Paulo, to analyze the survival of this population.
Results: 62 cases were identified; 35 (56.5%) died in the follow-up period of up to 54 months after surgery, with 29 (44.5%) deaths occurring in the first 12 months of post-operative follow-up, with a median of 17.5 months.
Conclusions: The first 12 months after surgery are critical in relation to death and non-smoking, and the absence of systemic treatment had a statistically significant impact on postoperative survival. Level of Evidence III; Retrospective Study.
Keywords:
Survival; Spinal Cord Compression; Spine
RESUMO:
Objetivo: Analisar o tempo de sobrevida dos pacientes com diagnóstico de neoplasias malignas que receberam indicação de tratamento cirúrgico da coluna vertebral
Métodos: Para análise de sobrevida, em março de 2024 foram levantados todos os casos que foram operados da coluna vertebral no ano de 2020, do Instituto do Câncer do Estado de São Paulo (ICESP), hospital de referência da cidade de São Paulo, com o objetivo de analisar a sobrevida desta população.
Resultados: Foram identificados 62 casos, 35 (56,5%) foram a óbito, no período de seguimento de até 54 meses após a cirurgia, sendo que 29 (44,5%) óbitos ocorreram nos primeiros 12 meses de seguimento pós operatório, com mediana de 17,5 meses.
Conclusões: Os primeiros 12 meses após a cirurgia são críticos em relação ao óbito e o não tabagismo e a ausência de tratamento sistêmico impactaram de maneira estatisticamente significativa na sobrevida pós-operatória. Nível de Evidência III; Estudo Retrospectivo.
Descritores:
Sobrevida; Compressão da Medula Espinhal; Coluna Vertebral
RESUMEN:
Objetivo: Analizar el tiempo de supervivencia de los pacientes diagnosticados de neoplasias malignas a quienes se les recomendó tratamiento quirúrgico de la columna.
Métodos: Para el análisis de supervivencia, en marzo de 2024, se recogieron todos los casos sometidos a cirugía de columna en 2020 en el Instituto do Câncer do Estado de São Paulo (ICESP), hospital de referencia de la ciudad de São Paulo, con el objetivo de analizar la supervivencia de esta población.
Resultados: Se identificaron 62 casos, 35 (56,5%) fallecieron, en el período de seguimiento de hasta 54 meses después de la cirugía, ocurriendo 29 (44,5%) muertes en los primeros 12 meses de seguimiento postoperatorio, con una mediana 17,5 meses.
Conclusiones: Los primeros 12 meses después de la cirugía son críticos en relación con la muerte y el no fumar y la ausencia de tratamiento sistémico tuvo un impacto estadísticamente significativo en la supervivencia postoperatoria. Nivel de Evidencia III; Estudio Retrospectivo.
Descriptores:
Sobrevida; Compresión de la Médula Espinal; Columna Vertebral
INTRODUCTION
Survival after surgery for spinal cancer can vary significantly depending on several factors, including the stage, type of cancer, degree of tumor invasion, and effectiveness of treatment. Generally, surgery is an integral part of the treatment of spinal cancer, especially when there is compression of the spinal cord or risk of neurological damage.
Surgery can be both curative and relieve symptoms, improve quality of life, and prolong survival. In the last two decades, advances in treatment and early diagnosis have significantly increased the overall expected survival for cancer patients, with the 5-year relative survival rate improving from 35% in the 1950s to 70% between 2009 and 2015.1, 2
The improvement in cancer treatments has allowed for greater survival for patients with metastatic disease and primary tumors in the spine. Decompression surgery has been considered viable and with good results, especially in patients with a minimum life expectancy of 3 months.3 The selection of treatment depends on several factors, including the type of primary tumor, the patient’s performance status, and the degree of tumor metastasis.4, 5
The prognosis becomes more challenging when the type of primary tumor is unknown, as in cases where metastatic spinal disease is the initial manifestation of malignancy. Furthermore, when the patient presents with symptoms of spinal cord compression, there is little time for additional investigations to be conducted before a treatment decision is made, as the duration of neurological impairment is an important prognostic factor. In these cases, surgery (when applicable) should occur early and under the safest possible circumstances.6
The present study, designed as a retrospective cohort, aims to gather data on the survival of patients treated during the year 2020 at the Instituto do Câncer do Estado de São Paulo (ICESP) and evaluate the record of complications, correlating with comorbidities, use of systemic and adjuvant radiotherapy treatment to surgical treatment in order to demonstrate the prognosis of patients in the period and correlate with the current literature.
MATERIALS AND METHODS
This study was duly approved by the ethics committee of the Hospital das Clínicas of the Faculty of Medicine of the Universidade de São Paulo (HCFMUSP), with opinion number - 5.918.796 and CAAE number - 66594923.8.0000.0068, study conducted at the Instituto do Câncer do Estado de São Paulo (ICESP), evaluating data from patients operated by the Spine Group. The data was collected in the Tasy® system of the Instituto do Câncer do Estado de São Paulo (ICESP) and was stored in a Google Sheets spreadsheet online. For data analysis, the Jamovi® application, which uses the R language, was used. Continuous demographic and clinical data were described by the mean and its respective standard deviation, and categorical data by their absolute frequency and their proportion among the categories.
For survival analysis, a ClinicoPath® package within Jamovi® was used, and univariate analysis was performed. The Kaplan-Mier curve was used to better illustrate survival. It was accepted as statistically significant when the p-value was less than or equal to 0.05.
RESULTS
The 62 cases diagnosed with various neoplasms that were indicated for spinal surgery in the year 2020 and were operated on at ICESP had a mean + standard deviation (sd) age of 55.1+13.9 years, with 34 (54.8%) cases being female, 25 (14.2%) being smokers, 47 (75.8%) of the individuals receiving systemic treatment, and 39 (62.9%) receiving radiotherapy treatment.
In most cases, 45 (72.6%), were operated on electively, and among the surgeries performed, two categories were identified: surgeries without the need for decompression, 11 (17.7%), and surgeries with the need for decompression, 51 (82.3%), with 30 cases of decompression surgeries involving arthrodesis procedures. The average surgery time was 6+1.7 hours. (Table 1)
At the time of data collection, 35 (56.5%) deaths were identified during the 54-month follow-up period after surgery, between the years 2020 and 2024. In Table 2, we can observe the univariate survival analysis, where the probability of survival at 6 months was 66.1% [95% CI 55.3 to 79%], at 12 months was 53.2% [95% CI 42.1 to 67.2%], and the median was 17.5 months [95% CI 7 to not calculable]. In this way, we can observe that in the period after 12 months, the probability of survival remains relatively stable, with few deaths until the end of the observed follow-up.
For a better understanding of factors that could interfere with survival, a multivariate analysis was conducted with data collected on the characteristics of the patients and the surgery. Sex, age, nature of surgery (elective or emergency), and duration of surgery. The analysis showed that most factors did not interfere with survival, but smoking and whether or not they were under systemic treatment showed a statistically significant decrease in patient survival, with an HR of 5.34 for smokers and an HR of 6.15 for systemic treatment. (Table 3) The Kaplan-Meier plot, Chart 1a, clearly shows the effects of variables with the shortest survival when the data were divided between smokers vs. non-smokers and Chart 1b whether or not under systemic treatment, p<0.05.
Multivariate survival analysis, showing only the variables that modify the survival analysis.
Kaplan-Meier survival curve, showing the influence of smoking and systemic treatment. a. Green curve (Yes) indicates the survival adjusted for smoking, and b. The curve indicates survival adjusted by the systemic treatment variable, green (Yes) and red (No).
DISCUSSION
The mortality rate after elective spinal surgeries, according to literature, is around 0.5 to 28.5% of cases, depending on the location and complexity of the procedure, as well as events considered as complications.7 A retrospective study conducted by Knapp et al. evaluated the risk factors for negative outcomes in patients with spinal metastases treated with surgery. The primary outcome assessed was mortality over a 180-day period; in this study, 30 of 128 patients (23%) died before 180 days.8 Some risk factors for mortality, as raised in the literature, include advanced age, male gender, associated infection, and presence of metastatic tumors.9, 10, 11, 12
The results of this study provide valuable parameters on the survival of patients undergoing surgery for spinal cancer, highlighting significant risk factors and relevant clinical implications. In this discussion, we will address the importance of the findings, their limitations, and possible directions for future research. Risk Factor Identification: The analysis revealed that smoking and systemic treatment were associated with lower survival. These results corroborate the existing literature, highlighting the importance of assessing and intervening in modifiable risk factors to improve outcomes in patients with spinal cancer.
Smoking has been independently associated with greater volumes of blood loss during surgery, longer hospital stays, and higher reoperation rates.13, 14, 15 Furthermore, pain control and functional outcomes have been less favorable in smoking patients. The present study showed a decrease in the survival of smoking patients.16, 17
The receipt of preoperative therapy had a variable prognostic value in previous studies and was predictive of survival in our cohort. The high proportion of patients receiving systemic treatment and radiotherapy reflects the multidisciplinary approach in the management of spinal cancer. However, it is crucial to consider the potential effects of these therapies on patients’ survival and quality of life, especially when combined with surgery. The meta-analysis was conducted by Zhu et al. A significant result was reached regarding the complications of surgical wounds in patients with preoperative chemotherapy. Generally, patients with worse preoperative functional status have worse overall survival. One of the limitations of the study was correlating the degree of aggressiveness and disease progression with the functional status and the use of preoperative therapy with the lower survival of patients.18, 19
The predominance of decompression surgeries highlights the importance of relieving spinal cord compression and preventing neurological damage in patients with cancer in the spine. The performance of these surgeries in a specialized environment, such as ICESF¦ indicates a multidisciplinary and experienced approach to managing complex cases. However, it is essential to consider the challenges associated with surgery, such as prolonged operation time and risks of complications, when making clinical decisions. The literature shows that the age of the patient at the time of surgery was associated, the older it was, with a higher probability of mortality in 180 days. In the present study, however, sex, age, nature of surgery (elective or emergency), and duration of surgery did not influence the survival of the cases, possibly due to the limited analysis.20
Although this study provides important information, it is important to recognize its limitations, such as the sample size and the limited follow-up period. Future research may focus on expanding the sample, detailing patient and disease characteristics (such as Eastern Cooperative Oncologic Group performance scale and cancer type), and extending the follow-up period to capture a broader range of clinical outcomes. Furthermore, additional investigations can explore intervention strategies to modify identified risk factors and develop new treatment modalities to improve outcomes in patients with spinal cancer. Another important factor to be analyzed is the quality of life index of patients in follow-up, which provides an important overview of survival and has gained increasing importance in research in the field.21
CONCLUSION
In the year 2020, 62 patients with spinal cancer were operated on at ICESF Mortality at 4 years was 56.5%, concentrated in the first 12 months of postoperative follow-up. The presence of smoking and the absence of systemic treatment had a statistically significant impact on postoperative survival. In the future, other aspects, such as quality of life in the postoperative period, may be elucidated for better evaluation of the oncological cohort.
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Study conducted by the Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil.
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Edited by
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Reviewed by:
Robert Meves
