A Comparative Study on the Effects of Postoperative ¹²⁵I Brachytherapy and Irradiation After Surgical Decompression and Stabilization for Metastatic Spinal Cancers

Figures & data

Figure 1 The study profile. SCC indicates spinal cord compression; MESCC indicates metastatic epidural spinal cord compression.

Figure 2 A 47-year-old female diagnosed with lung cancer treated with surgical decompression and pedicle stabilization combined with ¹²⁵I brachytherapy seeds implantation. (A) Preoperative lateral X-ray showed T6 and T8 vertebral collapse. (B) Preoperative anteroposterior X-ray showed T6 and T8 vertebral collapse. (C) Preoperative lateral CT showed T6 and T8 bone destruction. (D) Preoperative lateral MRI showed T6 and T8 spine metastases. (E) Preoperative transverse CT showed bone destruction at T8. (F) Preoperative transverse MRI showed deformation of the dural sac due to metastatic tumor.

Figure 3 (A) Postoperative lateral X-ray showed ¹²⁵I brachytherapy seeds implantation and pedicle stabilization with screws. (B) Postoperative anteroposterior X-ray showed ¹²⁵I brachytherapy seeds implantation and pedicle stabilization with screws. (C) Anterior bone scan at postoperative 10 months. (D) Posterior bone scan at postoperative 19 months. (E) Anterior bone scan at postoperative 19 months. (F) Posterior bone scan at postoperative 19 months. The above bone scan indicated no disease progression at 19 months after surgery.

Table 1 Patient’s Characteristics of the Brachytherapy and Irradiation Group

Characteristics	The Brachytherapy Group (n=60)	The Irradiation Group (n=62)	P-values
Age (mean, years)	58.3±11.0	57.3±14.4	0.66
Gender
Female	31	34	0.73
Male	29	28
Primary cancer sites
Slow growth	15	7	0.13
Moderate growth	14	23
Rapid growth	31	32
Preoperative ambulatory status
Ambulatory	42	39	0.41
Not Ambulatory	18	23
ECOG performance status
1–2	21	28	0.25
3–4	39	34
Visceral metastases
No	37	29	0.10
Yes	23	33
Bone metastasis at cancer diagnosis
No	33	33	0.84
Yes	27	29
Extraspinal bone metastases
No	33	34	0.99
Yes	27	28
Time developing motor deficits
≦14 days	31	30	0.72
>14 days	29	32

Abbreviations: ECOG, Eastern Cooperative Oncology Group; VAS, visual analogue score; MESCC, metastatic epidural spinal cord compression.

Table 2 The Comparison of Intraoperative Variables and Postoperative Clinical Outcomes Between the Brachytherapy and Irradiation Group

Characteristics	The Brachytherapy Group	The Irradiation Group	P-values
	Patients (n=60)	Patients (n=62)
Operation time (mean, min)	206±36	190±34	0.017
Intraoperative blood loss (mean, mL)	562±117	420±94	˂0.001
Preoperative VAS (mean)	7.93±1.44^a	7.69±1.13^b	0.32
Postoperative VAS at the time of discharge	2.72±1.12^a	3.02±1.50^b	0.20
Postoperative VAS at 1 months	1.75±0.78^a	2.95±1.31^b	˂0.001
Postoperative VAS at 3 months	2.35±0.83^a	3.53±1.77^b	˂0.001
Postoperative VAS at 6 months	3.39±1.00^a	4.00±1.42^b	0.039
Postoperative ambulatory status
Ambulatory	54	52	0.32
Not ambulatory	6	10
Postoperative survival time (median, months)	7.27	7.43	0.37
Complications
Yes	15	29	0.0086
No	47	33
Surgery-related complications
Yes	8	5	0.35
No	52	57
Radiation-related complications
Yes	5	24	˂0.001
No	55	38
Systematic complications
Yes	6	7	0.82
No	54	55
The length of hospitalization (mean, days)	21.2±5.8	19.7±6.2	0.17

Notes: VAS, visual analogue score; ^aAll P ˂0.001, as compared with the preoperative VAS in the brachytherapy group; ^bAll P ˂0.001, as compared with the preoperative VAS in the irradiation group.

Figure 4 The mean VAS score in a 24-hour period before surgery and at the time of discharge, 1 month, three months, and six months after surgery in both groups. “pre-” indicates pre-operation; “disch-” indicates discharge; “m” indicates months; *Indicates P˂0.05; ***Indicates P˂0.01.

Figure 5 The postoperative overall survival curves for the two groups (P=0.37, Log rank test).

Table 3 Univariate and Multivariate Analyses of Preoperative Factors for Postoperative Overall Survival in MESCC Patients

Factors	Patients (n)	The Simple Cox Regression		The Multiple Cox Regression
		HR (95% CI)	P-values	HR (95% CI)	P-values
Age	122	1.01(0.99–1.03)	0.15	Not included
Gender
Female	65	1.03 (0.70–1.52)	0.87	Not included
Male	57
Primary cancer sites
Slow growth	22	1.55 (1.19–2.03)	0.001	1.38 (1.02–1.87)	0.038
Moderate growth	37
Rapid growth	63
Preoperative ambulatory status
Ambulatory	81	1.32 (0.88–1.99)	0.18	Not included
Not Ambulatory	41
ECOG performance status
1–2	49	2.19 (1.43–3.34)	˂0.001	1.82 (1.13–2.93)	0.014
3–4	73
Visceral metastases
No	66	1.73 (1.17–2.55)	0.006	1.89 (1.27–2.79)	0.0016
Yes	56
Bone metastasis at cancer diagnosis
No	66	0.96 (0.65–1.41)	0.83	Not included
Yes	56
Extraspinal bone metastases
No	67	0.79 (0.53–1.16)	0.22	Not included
Yes	55
Time developing motor deficits
≤14 days	61	1.39 (0.95–2.04)	0.09	Not included
>14 days	61
Groups
The brachytherapy group	60	0.84 (0.57–1.24)	0.37	Not included
The irradiation group	62

Abbreviations: MESCC, metastatic epidural spinal cord compression; ECOG, Eastern Cooperative Oncology Group; HR, hazard ratio; CI, confidence interval.