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  • Renal Cell Carcinoma Spine Metastases: Surgical Management and Tokuhashi Prognostic Score

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    Rory J. Petteys MD; Steven Spitz MD; Patricia L. Zadnik BA; Rachel Sarabia-Estrada PhD, DVM; Mari L. Groves MD; Ali Bydon MD; Timothy F. Witham MD, BS; Jean-Paul Wolinsky MD; Ziya L. Gokaslan MD; Daniel M. Sciubba BS MD

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    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: Renal cell carcinoma is an aggressive neoplastic disease that frequently metastasizes to the vertebral column. Surgery is frequently required to obtain preservation of neurologic function, mechanical stabilization, and pain relief. However, selecting the appropriate degree of surgical intervention for patients can be challenging. The Tokuhashi score is a prognostic scoring system that can be used to predict survival and determine the surgical strategy.

    Methods: Records of all patients undergoing spinal surgery for metastatic disease at a single institution between January 2000 and December 2011 were retrospectively reviewed to determine the preoperative Tokuhashi score. Statistical calculations, including Kaplan-Meier estimates and log-rank test for univariate analysis, were performed with R version 2.15.12 (The R Foundation for Statistical Computing, 2012).

    Results: Thirty patients were identified who underwent 40 spinal operations for metastatic RCC. Overall survival was 11.4 months for all patients. Tokuhashi scores were as follows: 12-15, fifteen patients; 9-11, seven patients; 0-8, eight patients. Extraspinal osseus metastases (p = 0.01), visceral metastases (p = 0.005), and Karnofsky performance score (p = 0.002) were all significant factors affecting survival. Kaplan-Meier survival estimate revealed that the median survival of each group was: score 12-15, 32.9 months; score 9-11, 11.7 months; score 0-8, 5.4 months. The Tokuhashi score was a significant predictor of survival (p=0.016); survival was significantly different between the high and low score groups (p=0.006).

    Conclusions: Renal cell carcinoma is an aggressive disease with a short overall life expectancy when metastatic to the spine. However, patients with low systemic disease burden and solitary spinal metastases can be expected to have relatively long survival and may benefit from aggressive excisional surgery. The Tokuhashi score can be useful in selecting patients for surgical intervention.

    Patient Care: Our results demonstrate the importance of preoperative patient selection and the use of the Tokuhashi score in patients with spinal metastases of RCC. This can help inform the surgical decision making and may call for aggressive resection in select patients.

    Learning Objectives: By the conclusion of this session, participants should be able to 1) identify the elements of the Tokuhashi score, 2) understand how the elements of the Tokuhashi score affect survival in metastatic RCC patients, 3) understand how the Tokuhashi score can inform surgical decision making.


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