Radiotherapy or surgery for spine metastases?

Figures & data

Table 1. Motor impairment ^a at the start of treatment according to the primary cancer diagnosis (p < 0.001) ^b

Primary cancer diagnosis	Normal motor status (Frankel E)	Motor impairment
		Ambulation with minor motor deficit (Frankel D)	No ambulation (Frankel A–C)
Breast	124	18	6
Prostate	170	55	30
Lung	117	37	16
Kidney	30	3	7
Myeloma/Lymphoma	46	20	12
Other	120	43	27
Total	607	176	98

^a Motor status was unknown for 22 patients

^b Pearson chi-square 2-sided test.

Table 2. Comparison of the use of multiple-fraction (MF) and single-fraction (SF) radiotherapy (RT) as primary treatment for spinal metastatic disease in 845 patients ^a

	n	MF	SF	p -value	OR (95% CI)
Primary cancer diagnosis				< 0.001
Myeloma/lymphoma	60	56	4		1
Breast	149	135	14	0.7	0.8 (0.3–3.0)
Prostate	249	200	49	0.02	0.2 (0.1–0.8)
Lung	172	128	44	0.002	0.2 (0.1–0.5)
Kidney	37	34	3	0.5	0.5 (0.1–2.8)
Other	178	151	27	0.1	0.3 (0.1–1.1)
Age				0.04
70+	407	323	84		1
50–69	375	325	50	0.01	1.8 (1.1–2.8)
19–49	63	56	7	0.4	1.4 (0.6–3.5)
Sex				0.5
Female	345	294	51
Male	500	410	90
Motor impairment ^b				< 0.001
Non-ambulatory (Frankel A–C)	73	69	4		1
Ambulatory with minor motor deficit (Frankel D)	154	141	13	0.4	0.6 (0.2–1.9)
Normal motor status (Frankel E)	596	486	110	0.005	0.2 (0.1–0.6)
Multiplicity of spine metastases				0.6
One vertebra affected	116	99	17
Multiple vertebra	729	605	124
RT center				< 0.001
Center 1	90	47	43		1
Center 2	429	385	44	< 0.001	8.3 (4.7–14.8)
Center 3	204	169	35	< 0.001	5.0 (2.7–9.2)
Center 4	122	103	19	< 0.001	5.4 (2.7–10.9)

OR: odds ratio for choice of MF RT vs. SF RT; 95%CI: 95% confidence interval.

^a Binary logistic regression model.

^b Motor impairment was unknown for 22 patients.

Table 3. Comparison of the use of surgery and radiotherapy (RT) as primary treatment of spinal metastatic disease in 903 patients ^a

	n	Primary surgery	Primary RT	p-value	OR (95% CI)
Primary cancer diagnosis				0.006
Myeloma and Lymphoma	79	19	60		1
Breast	152	3	149	0.1	0.3 (0.1–1.5)
Prostate	260	11	249	0.008	0.2 (0.1–0.7)
Lung	179	7	172	< 0.001	0.1 (0.04–0.7)
Kidney	40	3	37	0.1	0.3 (0.07–1.4)
Other	193	15	178	0.003	0.2 (0.1–0.6)
Age				0.4
70+	433	26	40		1
50–69	400	25	375	0.2	1.6 (0.8–3.2)
19–49	70	7	63	0.4	1.7 (0.5–6.0)
Gender				0.03
Female	361	16	345		1
Male	542	42	500	0.03	2.5 (1.1–5.7)
Time from primary cancer diagnosis to treatment for SM ^b				0.6
Within one year	396	40	356		1
Between one and 5 years	279	11	268	0.2	0.6 (0.3–1.3)
6 years or more	204	5	199	0.08	0.4 (0.1–1.1)
Motor impairment ^c				< 0.001
Normal motor status (Frankel E)	607	11	596		1
Ambulating with minor motor deficit (Frankel D)	176	22	154	< 0.001	9 (4–21)
Non-ambulatory (Frankel A–C)	98	25	73	< 0.001	21 (9–50)
Multiplicity of spine metastases				< 0.001
One vertebra affected	142	26	116		1
Multiple vertebra	761	32	729	< 0.001	0.2 (0.1–0.4)

OR: odds ratio for choice of surgery vs. RT; 95% CI: 95% confidence interval.

^a Multiple binary logistic regression model.

^b Time from primary cancer diagnosis to treatment for SM was unknown for 24 patients.

^c Motor impairment was unknown for 22 patients.

Table 4. Median survival from start of treatment according to the primary cancer diagnosis, motor impairment, multiplicity of metastases in the spine, and age

	n	Median survival, months	95% CI
Primary tumor
Myeloma/Lymphoma ^a	79	–	–
Breast	152	18.8	13.5–24.2
Prostate	260	7.6	6.0–9.2
Kidney	40	4.0	2.4–5.6
Other	193	2.7	2.0–3.4
Lung	179	2.0	1.7–2.4
Motor impairment ^b
Normal neurological status	607	7.0	5.9–8.2
Ambulatory with minor motor deficit (Frankel D)	176	3.4	2.2–4.6
Non-ambulatory	98	1.8	1.2–2.4
Multiplicity in spine
Single	142	9.1	5.1–13.1
Not single	761	4.7	4.1–5.3
Age
19–49	70	12.0	3.5–20.6
50–69	400	5.6	4.4–6.7
70+	433	4.0	3.2–4.8
All included patients	903	5.1	4.4–5.7

^a 42 of 79 patients with myeloma/lymphoma were alive at the follow-up.

^b Motor impairment was unknown for 22 patients.

Figure 1. Kaplan-Meier plots with results of log-rank tests of survival related to pretreatment factors. A. Primary tumor (p < 0.001). B. Age (p < 0.001). C. Motor impairment ^a (p < 0.001). D. Multiplicity of metastases in spine (p < 0.001). E. Time from diagnosis of cancer to treatment ^b (p < 0.001). F. Metastases in spine at the time of primary cancer diagnosis ^c (p = 0.6).

Figure 2. Kaplan-Meier plots with results of log-rank test of overall survival after surgery and radiotherapy (RT) for patients without motor impairment (Frankel E) (panel A; p = 0.03), and for patients with motor impairment (Frankel A–D) (panel B; p < 0.001).