Perioperative blood transfusion: does it influence survival and cancer progression in metastatic spine tumor surgery?

Perioperative blood transfusion: does it influence survival and cancer progression in metastatic spine tumor surgery?

S18 BASS 2017 abstracts / The Spine Journal 17 (2017) S3–S22 performed to assess influence of blood transfusion on postoperative complications and i...

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BASS 2017 abstracts / The Spine Journal 17 (2017) S3–S22

performed to assess influence of blood transfusion on postoperative complications and infections. Further adjustment for potential confounders was made in these analyses. RESULTS: Of 247 patients, 133 patients (54%) received ABT. The adjusted odds of developing any postoperative complication was 2.27 times higher in patients with transfusion (95% CI: 1.17–4.38, p=.01) and 1.24 times higher odds per every unit increase in blood transfusion (95% CI: 1.05– 1.46, p<.01). Exposure to blood transfusion also increase the odds of having overall postoperative infections (OR: 3.58, 95% CI: 1.15–11.11, p=.02) and there were 1.24 times higher odds per every unit increase in transfusion (95% CI: 1.01–1.54, p=.04). CONCLUSIONS: The current study adds evidence to the literature implicating ABT to be influential on postoperative complications and infections in patients undergoing MSTS. Appropriate blood management measures should, therefore, be given a crucial place in the care of these patients so as to reduce any putative effect of blood transfusion. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None.

48. Preoperative embolization in spine tumour surgery Naresh Kumar, Aye Sandar Zaw, Barry Tan, Karthikeyan Maharajan; National University Health System, 1 E Kent Ridge Rd, Singapore 588998 BACKGROUND CONTEXT: Majority of studies investigating preoperative embolization have preferentially selected highly vascularized spinal metastases from renal & thyroid. There is paucity of literature describing utility of embolization in other tumours. PURPOSE: To determine the factors that can influence the impact of embolization on blood loss & transfusion requirements in spine tumour surgery(STS). STUDY DESIGN/SETTING: Retrospective analysis. PATIENT SAMPLE: 221 patients who underwent STS. OUTCOME MEASURES: Blood loss, Transfusion requirements. METHODS: Analysis was done for the effect of embolization agents, extent, level of embolization & timing between embolization & surgery, on estimated blood loss. Estimated blood loss & transfusion requirements were compared between embolized& non-embolized cases for different spine tumour types(metastatic lung, breast, renal, hepatocellular, thyroid, other epithelial tumours, myeloma/lymphoma & primary spine tumours) and surgical approaches(I:Cervical spine surgery either anterior and/or posterior stabilization with or without corpectomy, II:Thoracolumbar posterior instrumentation and decompression & III:Thoracolumbarcorpectomy). RESULTS: Total embolization (>80% reduction of tumour blush) was achievable in more than half of the embolized patients (61%). Their median blood at 900 mL loss was significantly (p=.05) less compared to those who had partial (<50%) and subtotal (50–80%) embolization (median blood loss 1,600 mL and 1,350 mL respectively). The median blood loss was lower in patients who underwent surgery between 13–24 hours after embolization. When stratified by tumour type and surgery, blood loss and transfusion requirements were lower in embolized metastases from HCC and thyroid; as well as primary spine tumours. CONCLUSIONS: Success of embolization in reducing blood loss depends on the extent of embolization, which should be total; and time interval between embolization and index surgery, which should be within 13–24 hours. Preoperative embolization is a useful modality in decreasing intraoperative blood loss in cases of spinal metastases from HCC, thyroid and primary spine tumours. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None.

49. Metastatic spinal cord compression: effects of tumour type on survival Sheweidin Aziz, Sanjay Dhiran, Partha Basu, Jason Braybrooke, Omar Gabbar, Phillip Sell, Wai Yoon; University Hospitals of Leicester, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW BACKGROUND CONTEXT: Metastatic spinal cord compression (MSCC) is defined radiographically as an epidural metastatic lesion causing true displacement of the spinal cord from its normal position in the spinal canal. Spinal cord compression may develop in 5%–10% of cancer patients and up to 40% of patients with pre-existing non-spinal bone metastasis. PURPOSE: Determine whether primary tumour types affect survival in those treated surgically and conservatively. STUDY DESIGN/SETTING: Prospective/Teaching hospital. PATIENT SAMPLE: Patients presenting with suspected MSCC. OUTCOME MEASURES: Survival. METHODS: Prospective data collection of 192 patients referred with suspected MSCC of whom 151 constituted the most common tumour types (breast, prostate, lung, myeloma, renal cell carcinoma and malignancy of unknown origin). Record of surgical intervention and survival times were collected over a 2 year period. RESULTS: A total of 151 patients were identified, 64% males, 36% females. Mean age 67.4 (range 32–94 years). Conservative treatment in 87%; overall mortality of 84.7%. Mortality rates at 6 months for breast, prostate and lung primary patients were 50%, 67% and 93% respectively (p<.0001). Surgical intervention performed in 13% of patients; overall mortality of 45%. The mortality rates at 6 months for breast, prostate and lung primary patients were 12.5%, 33% and 100 respectively (p<.0001). CONCLUSIONS: Operative intervention has a role in the management of patients with MSCC, however, the natural history of primary tumours should be taken into account when deciding whether to intervene surgically. The cost effectiveness of any intervention should be considered, especially in the current economic climate and financial pressures on the National Health Service. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None.

50. Perioperative blood transfusion: does it influence survival and cancer progression in metastatic spine tumor surgery? Aye Sandar Zaw, Dhiraj Sonawane, Karthikeyan Maharanjan, Dennis Hey, Aravind Kumar, Naresh Kumar; University Spine Centre, National University Hospital of Singapore, 1E Kent Ridge Rd, NUHS Tower Block, Level 11, Singapore 119228 BACKGROUND CONTEXT: Allogeneic blood transfusion (ABT) may have deleterious consequences on cancer related outcomes. PURPOSE: To evaluate the influence of perioperative ABT on disease progression and survival in patients undergoing metastatic spinal tumour surgery (MSTS). STUDY DESIGN/SETTING: Retrospective study of prospectively collected data. PATIENT SAMPLE: 247 patients who underwent MSTS at a single tertiary institution between 2005–2014. OUTCOME MEASURES: Overall survival and disease progression (preexisting lesion or appearance of new lesion). METHODS: Statistical analyses were performed using STATA. Data collection included ECOG score for preoperative general condition, and comorbidities categorized by Charlson comorbidity index. Cox regression analyses were carried out first including the blood transfusion exposure (transfused vs. non-transfused) variable. RESULTS: Of 247 patients, 133 patients (54%) received ABT. The overall median unit of blood transfused was 2 units (range: 0–10 units). Neither blood transfusion exposure nor quantities of transfusion were found to be associated with overall survival (Hazard ratio [HR]:1.15, p=.35) & (HR: 1.10,

Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.

BASS 2017 abstracts / The Spine Journal 17 (2017) S3–S22 p=.11) and progression-free survival (HR: 0.87, p=.18) & (HR: 0.98, p=.11) respectively. The factors influencing overall survival were primary tumour type and preoperative ECOG while primary tumour type was the only factor having impact on progression-free survival. CONCLUSIONS: Oncological outcomes are more likely to be caused by the clinical circumstances necessitating blood transfusion but not transfusion itself. However, given that ABT can have propensity towards developing postoperative infections including surgical site infection, utilization of patient blood management interventions would be worthwhile rather than relying solely on allogeneic blood transfusions for these patients. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None.

51. Survival and mobility after metastatic spinal cord compression Anantharaju Prasad, Aprajay Golash, Arupratan Ray, Kaushik Ghosh, Ruth Broad, Sandra Curtis; Royal Preston Hospital, Fulwood, Preston PR2 9HT BACKGROUND CONTEXT: Surgeons often in dilemma whether surgery would alter mobility or survival in MSCC patients. PURPOSE: To evaluate outcome of MSCC, both with and without surgery, in terms of mobility and survival. STUDY DESIGN/SETTING: Retrospective analysis of patients referred from January 2013 to December 2015 at a tertiary referral centre. PATIENT SAMPLE: 354 patients were referred to MSCC service. 118 patients had confirmed MSCC. 19 patients had an impending MSCC. OUTCOME MEASURES: functional measures. METHODS: Retrospective review of data from MSCC database. RESULTS: 65.2% were males. 71% with MSCC had a previous diagnosis of Cancer. 91% of the patients were referred within 24 hours of diagnosis. Thoracic spine was affected in 70%. 42% were mobile unaided, 26% walking aided, 16% wheelchair bound and 16% paraplegic at the time of referral. 28% had surgery first. Surgery was performed in 43% in 2013 and 28% in 2015. 42% had a complex procedure. 26% of the patients had surgery within 24 hours. 28 out of 56 patients had functional grade at 3 months. 2 patients who were walking unaided deteriorated. None of the patients who were not walking improved to walking state. 25% were alive at 3 months. 9% mortality within 30 days of surgery. 22% of the patients who had surgery in 2013 survived at 2 years compared to 13% with radiotherapy and 0% with supportive care. CONCLUSIONS: Early diagnosis and surgery before neurological deficits improves outcomes in a select group of patients. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None.

52. Are the SINS and NOMS classifications useful in predicting the need for surgery in patients with metastatic vertebral body involvement? Asif Alrawi, Rachel Maguire, Mathew Sewell, Donald Buchanan, Waleed Hekal, Raman Kalyan, Simon Tizzard, Richard Williams; The James Cook University Hospital, Middlesbrough, UK BACKGROUND CONTEXT: The Spinal Instability Neoplastic Score (SINS) categorises tumour-related spinal instability. The neurologic, oncologic, mechanical, and systemic (NOMS) framework incorporates sentinel qualitative decision points to guide the treatment of spinal metastases to determine treatment. PURPOSE: This study assesses the utility of the SINS and NOMS framework for predicting the need for surgery for patients with metastatic tumourrelated spinal instability. STUDY DESIGN/SETTING: Retrospective review of prospectively collected data.


PATIENT SAMPLE: 140 patients with metastatic vertebral body tumour between 2012 to 2016 from our prospectively collected metastatic tumour database. OUTCOME MEASURES: Sensitivity and specificity of SINS and NOMS frameworks and factors affecting treatment decision. METHODS: SINS, NOMS and performance status data were compared between operative and non-operative groups. Forty patients underwent surgery. RESULTS: The SINS showed a low positive predictive value and high negative predictive value indicating it is useful for excluding surgical candidates. When analysing the NOMS framework, in the operative group 70% had neurological compromise, 52.5% unstable vertebrae, 52.5% had fractures, 67.5% radiosensitive tumours and 40% required some degree of assistance with activities of daily life (ADL). In the non-operative group, 30% had neurological compromise, 22% unstable vertebrae, 19% had fractures, 70% had radiosensitive tumours and 80% required some degree of assistance with ADLs. There was a statistically significant difference in the rates of neurological compromise, instability and performance status (p<.05) between groups, suggesting that these are key indicators for surgical intervention. Oncological parameters were not different between groups. CONCLUSIONS: The SINS is predictive for ruling out surgery in patients with scores <12, but is less useful in determining the need for surgery for other patients. Whilst the NOMS framework incorporates multiple factors in assessing the need for surgery, not all of these factors are weighted evenly. Performance status, rates of neurological compromise and instability were important, whereas tumour histology and radiosensitivity were less influential in the decision to perform surgery. Future quantitative scoring systems to predict surgical intervention must consider the role of neurological compromise, mechanical instability and current performance status primarily over other factors. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None.

53. Presentation and management of spinal arachnoid cysts; a single centre experience Ali Nader-Sepahi, A.R. Sadek, M. Trevidi; Department of Neurosurgery, Wessex Neurological Centre, University Hospitals Southampton BACKGROUND CONTEXT: Intradural extramedullary arachnoid cysts are uncommon lesions with sparse literature documenting their presentation and management. PURPOSE: Evaluation of the presentation and outcomes associated with surgical marsupialisation of spinal arachnoid cysts. STUDY DESIGN/SETTING: Retrospective single centre case series. PATIENT SAMPLE: Fourteen patients were identified. Paediatric cases and those secondary to trauma or haemorrhage were excluded. OUTCOME MEASURES: Clinical improvement following surgery. METHODS: Cases were identified from electronic and theatre records. Patients underwent pre-operative assessment and radiographic evaluation with subsequent spinal multidisciplinary discussion. Following surgery patients were reviewed at 6, 12 weeks and at 6 months. RESULTS: A total of 14 patients with dorsal thoracic arachnoid cysts with a mean age at time of surgery of 60 years with a male to female ratio of 1.1:1 were identified. Paraesthesia (79%), neuropathic pain (79%), weakness (57%) and unsteadiness (57%) were the commonest presenting complaints. Abnormal gait (85%), altered sensation (62%) and weakness (31%) were the most commonly observed signs. Average cyst volume was observed to be 544 mm3, spanning a median of 3 thoracic levels, with a resultant reduction of cord volume of 34% (sd 14%). All cases underwent marsupialisation of the arachnoid cyst. Over two-thirds of cases had immediate improvement in symptoms following surgery. At 6 months symptoms of weakness (100%), gait disturbance (82%), paraesthesia (64%) were more likely to improve than neuropathic pain (58%). Improvements correlated with an average 49% (sd 20%) volume increase in previously compressed cord.

Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.