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The incidence of vertebral metastasis deposit from carcinoma is second only to pulmonary and hepatic metastases. The choice of the most appropriate treatment is of crucial importance for the patient. It is commonly accepted that bone metastases are an expression of a systemic disease, and require multi-disciplinary approach. The indications for surgical treatment are intractable pain, the onset of neurological deficit, pathological fractures and spinal instability.

A 70-year-old man with a painful vertebral metastasis was treated with combined percutaneous cryoablation and vertebroplasty therapy (CVT) in one session. The patient was suffering from diffuse visceral metastasized cholangiocarcinoma. After several weeks of back pain, magnetic resonance imaging documented a single L2 bone metastasis. In consultation with the oncologists, palliative combined CVT was administered with the aim of obtaining pain relief and bone stabilization. In our experience this combined treatment is safe and effective for immediate pain relief in painful bone metastases when other standard palliative treatments have failed.

Struma ovarii (SO) is a subtype of ovarian teratoma that contains mostly thyroid tissue comprising more than 50% of the tumor volume [1]. It is the most common type of monodermal teratoma of the ovary, accounting for approximately 2.7% of all teratomas [1]. Most cases of typical SO are benign with exceptional cases showing malignant features of papillary carcinoma, vascular invasion, or invasion into surrounding tissue. However, there are rare cases of histologically benign SO with malignant biological behavior, variously designated as peritoneal strumosis, malignant SO, metastatic SO, or highly differentiated follicular carinomas [2,3]. Here, we report on a patient who developed a vertebral metastasis ten years after oophorectomy for SO that finally proved to be malignant.

A 71-year-old man presented with a 4-month history of severe atraumatic monolateral hip pain. Radiographs were normal, and MRI had to be aborted owing to heating up of a remnant of an old spinal cord stimulator. CT revealed squamous cell lung carcinoma with widespread metastases of the spine and pelvis, causing L1 nerve root compression. In retrospect, a lytic lesion consistent with spinal metastasis was found on CT taken 5 months previously, soon after the onset of hip pain, but this was missed by the reporting radiologist at that time. This case highlights that errors in radiology reporting are inevitable, but can be minimized by using a systematic approach to carefully review all available images to avoid missing unexpected pathology.

We report a patient with paralysis and severe lumbago due to a vertebral metastasis from rectal cancer, who was successfully treated with thermo-radiotherapy plus chemotherapy and hyperbolic oxygen therapy. The patient underwent 40Gy of radiotherapy, 12 sessions of hyperthermia and 16 sessions of hyperbolic oxygen therapy combined with weekly chemotherapy. His symptoms were gradually improved after start of the treatment, lumbago was relieved at the end of radiotherapy, and he became ambulatory. The patient was also treated for other distant metastases with radiotherapy, hyperthermia and chemotherapy continuously with keeping good quality of life during eight months after the completion of the treatments for vertebral metastasis. Combination of radiotherapy, hyperthermia, chemotherapy and hyperbaric oxygen therapy may be effective for complete paralysis due to vertebral metastasis in inoperative cases.

The purpose of this study was to describe the clinical presentation of bone metastases in patients with carcinoid tumors and to determine the diagnostic value of imaging techniques and markers of bone metabolism. Methods: This retrospective study was performed on the entire group of patients with carcinoid tumors treated in our hospital from January 1992 to May 1999 Only patients with metastasized tumors were included. Results: Eleven of 90 patients (12%) (95% confidence interval [Cl], 5%-19%) with a metastasized carcinoid tumor had symptomatic bone metastases. All bone metastases occurred in 55 patients with midgut carcinoids (20%; 95% Cl, 9%-31 %). Plain radiography had a sensitivity of 44% (95% Cl, 12%-76%); MRI, 100% (95% Cl, 61%-100%); bone scintigraphy, 90% (95% Cl, 72%-100%); and octreotide scintigraphy, 60% (95% Cl, 35%-93%). In 9 patients, both octreotide scintigraphy and bone scintigraphy were performed. Of 45 bone lesions, 22 (49%) were visualized by both modalities, 13 (29%) were visualized with octreotide scintigraphy but not with bone scintigraphy, and 10 (22%) were visualized with bone scintigraphy but not with octreotide scintigraphy, In 2 patients, octreotide scintigraphy and bone scintigraphy provided complementary results. Markers of bone metabolism could not discriminate carcinoid patients from those without bone metastases, The markers of bone metabolism did not reflect the osteolytic or osteoblastic appearance of metastases. Conclusion: Pain is the principal symptom of bone metastases in patients with carcinoid tumors. Plain radiography and markers of bone metabolism do not contribute to the diagnosis of bone metastases. MRI has a high sensitivity for bone metastases. Both bone scintigraphy and octreotide scintigraphy have acceptable sensitivity and can provide complementary results.

Background: Gallbladder carcinoma spreads commonly by direct invasion. Hematogenous spread to liver, lungs, skin are known but vertebral metastasis has rarely been reported earlier. Method: We are reporting a case of 38 years old male who presented to us with surgical jaundice due to gallbladder carcinoma. Computed tomogram revealed lumbar vertebral metastasis. Patient succumbed to his disease very rapidly.

Metastatic disease in the vertebral column compromises the structural stability of the spine leading to increased risk of fracture. The complex patterns of osteolytic and osteoblastic disease within the bony spine have motivated a multimodal approach to better characterize the biomechanics of tumor-involved bone. This review presents our current understanding of the biomechanical behavior of metastatically involved vertebrae, and experimental and computational image-based approaches that have been employed to quantify structural integrity in preclinical models with translation to clinical data sets.

The extra-hepatic metastasis of hepatocellular carcinoma (HCC) usually hints late disease stage and poor prognosis. However, we treated 5 unusual HCC patients with isolated para-vertebral metastasis by tumor excision and the surgical result is satisfactory during 3.5 years follow-up in mean. To explain why the unusual situation of isolated metastasis of HCC occurred, an alternative spreading route of cancer cells bypass pulmonary circulation and avoid pulmonary vascular filtration, the Batson’s plexus, was highly suspected. We supposed that isolated para-vetebral metastases seems not to mean a late disease stage, aggressive management made longer survival possible, and it was confirmed by our clinical experience.

Background and Objectives: The quality of life of patients with vertebral metastases from breast cancer treated with surgery was evaluated. Methods: Seven such patients underwent surgery for vertebral metastases following chemoendocrine treatment. They presented with pain and some with neurological compromise. Results: Following posterior stabilization with a segmental instrument, pain was alleviated in all seven women, two showed improvements in neurological compromise, and performance status was improved in five. In no patient was there neurological deterioration secondary to surgical intervention. They were out of bed on the 4th postoperative day and discharged on the 14th day on average. Conclusions: The quality of life was improved for these surgically treated patients. We recommend surgical stabilization for selected patients with a vertebral metastasis from breast cancer.

Tumors of the paraganglionic system include pheo- chromocytomas, carotid body tumors (chemodectoma), jugulo- tympanic paragangliomas (glomus jugulare tumors), and the rare aorticopulmonary and aorticosympathetic paragangliomas. Paragangliomas are generally well-differentiated tumors, with only a minority (7% to 10%) behaving in a malignant fashion by causing distant spread. The case report of a 37-year-old male patient, with a medical history of glomus jugulare tumor resected 1 year ago, attending with a spinal column metastasis is presented. Surgical resection of the metastases, combined with radiotherapy, was performed on the patient. Paragangliomas have the potential to be malignant and although rare, the spinal column is one of the targets of spread.

OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties. METHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient. RESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases. CONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.

Oncology guidelines currently recommend against performing colonoscopies in the workup of adenocarcinoma of unknown primary unless colonic malignancy is otherwise suggested by clinical signs or symptoms. We present 2 cases of metastatic colonic adenocarcinoma that presented only with neurologic symptoms from vertebral metastasis. Although bony metastases are a rare presentation of colon cancer and colonoscopy is not warranted in the initial workup of adenocarcinoma of unknown primary, we describe these cases as a reminder that bony metastases do not rule out a colon cancer diagnosis.

Fluid-fluid level in bone metastases is an extremely rare finding, with only five case reports published in the literature. Here we report a case of an atypical isolated bone metastasis presenting with a fluid-fluid level revealing lung cancer in a 47-year-old patient without history of cancer. The differential diagnosis and imaging features are discussed with reference to the relevant literature.

Answers to the following two quiz questions can be found on page 79 ### Theme: Neck Select one option from the following: 1. Acute crush fracture 2. Infective spondylodiscitis 3. Langerhans Cell Histiocytosis 4. Pharyngotonsillitis 5. Retropharyngeal infection 6. Retropharyngeal tumour 7. Vertebral metastasis This 4-year-old boy presented to the emergency department with neck pain …

Background Myxoid liposarcoma occurs in middle age, and is characterized by extrapulmonary metastasis, including bone metastasis. Bone scans and [18F]-2-fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) are widely used for assessment of tumor extension, including vertebral metastasis. However, both methods have a low positive rate with regard to vertebral metastasis arising from myxoid liposarcoma. This is particularly true for bone scans for intramedullary lesions that have no cortical involvement. Case presentation We present the case of a 53-year-old male with myxoid liposarcoma in the leg. He had been treated for multiple metastases over a ten-year period, and was experiencing back pain due to a pathological fracture in the second lumbar vertebra (L2). Magnetic resonance imaging of all the vertebrae showed abnormal signal intensity suggestive of metastasis in eight vertebrae, and revealed extraskeletal extension in three vertebrae. Bone scans and FDG-PET were negative except for the L2 fracture which was indicated on a bone scan. Conclusions Both bone scans and FDG-PET can be negative in cases of vertebral metastasis that arise from myxoid liposarcoma, even when extraskeletal extensions are present. Similarly, even a fractured vertebra may not always be visible on FDG-PET.

Mullerian tumors are extremely rare malignancies in the retroperitoneum. We report a case of a 46-year old woman who presented with an eight year history of lower abdominal mass. Ultrasonography (US) and computed tomography (CT) demonstrated a 15×10 cm cystic mass in the left lower retroperitoneum. As serial percutaneous needle aspiration cytology was negative for malignancy, she was observed for seven years. Eleven months ago, the mass was excised. The histopathology was reported as mucinous adenocarcinoma of the retroperitoneum. Six cycles of intraperitoneal (IP) chemotherapy was administered during the last six months after diagnosis of recurrence by aspiration cytology and high serum tumor markers (CEA, CA19-9). A few days ago, positron emission tomographic (PET) scanning showed evidence of local recurrence and single vertebral metastasis, so she was admitted again for systemic chemotherapy. Meticulous revision of additional sections of the tumor revealed papillary, serous, mucinous, and endometrioid subtypes of the mullerian adenocarcinoma. To our knowledge, there has been no similar case described in the literature.

Background: The secretory epithelial cells of the prostate gland use sophisticated vehicles named prostasomes to relay important information to sperm cells in semen. This prostasome-forming and secretory ability of the epithelial cells is also preserved in poorly differentiated prostate cancer cells. Aim: The aim of this thesis was to examine different characteristics of prostasomes, especially those derived from malignant prostate cells, linked to their potential role in diagnosis and prognostication of prostate cancer. Results: Serum samples of prostate cancer patients contained autoantibodies against seminal prostasomes in a higher concentration than did control sera. These autoantibodies were most frequently directed against 25 prostasome-associated proteins, but no one was prostate specific. Clusterin was one of the most frequently occurring prostasomal proteins. Elevated titers were however seen in both patients´ and control sera. Clusterin turned out to be a major antigen of seminal prostasomes. No prostate specific or prostate cancer specific protein was discovered upon proteomic analysis of prostasomes deriving from malignant cells of vertebral metastases of prostate cancer patients. Human chromosomal DNA was identified in both seminal prostasomes and PC-3 cell prostasomes and strong evidence existed that the DNA was localized inside the prostasomes. Four out of 13 DNA clones of seminal prostasomes featured gene sequences (31%). The corresponding figures for PC-3 cell prostasomes were 4 out of 16 clones (25%). Conclusions: Prostasomes are immunogenic and give rise to serum autoantibodies. The most frequently occurring autoantibodies were directed against 25 prostasomal proteins but none of these was exclusively prostate specific. Thirty different proteins were identified in prostate cancer metastasis-derived prostasomes but none of these proteins was prostate cancer specific. Human chromosomal DNA was identified in prostasomes of both normal and malignant cell origin.

Orthopaedic and spinal surgery can provide significant palliation to patients with symptoms arising for bony metastatic involvement in addition to patients that are at risk for skeletally related events (SREs). This chapter will review the role of surgery in the management of bone metastases and discuss factors that need to be considered prior to surgery. The treatment of pathologic fractures and the evaluation of pre-critical bony lesions will be presented. An overview of assessing the need for potential surgical intervention(s) by different criteria and reported scoring systems will be reviewed as well as a synopsis of the surgical treatment and management for appendicular, pelvic, and vertebral metastasis. Novel approaches to more accurately guide fracture risk prediction radiologically will be presented and the role of emergent surgery discussed.

As survival time increases for many cancers, it is likely that the incidence and prevalence of spinal metastases will increase also. Given that most patients first present with solitary lesions in the spine, proper initial diagnosis and management are of paramount importance in minimizing pain, improving neurologic function, and potentially lengthening survival. Although pain control and standard radiation are still used, spinal stereotactic radiosurgery, vertebroplasty and kyphoplasty, and spinal cord decompression and fusion are now consistently used in aggressive management and offer exciting preliminary results.

Purpose: Kyphoplasty is an effective procedure to alleviate pain in vertebral metastases. However, it has no proven anticancer activity. Samarium-153-ethylene diamine tetramethylene phosphonate ({sup 153}Sm-EDTMP) is used for palliative treatment of bone metastases. A standard dose of 1 mCi/kg is administrated intravenously. The present study was conducted to determine the feasibility of intravertebral administration of {sup 153}Sm with kyphoplasty. Methods and Materials: A total of 33 procedures were performed in 26 patients. Of these 26 patients, 7 underwent procedures performed at two vertebral levels. The mean age of the cohort was 64 years (range, 33-86). The kyphoplasty procedure was performed using a known protocol; 1-4 mCi of {sup 153}Sm was admixed with the bone cement and administered under tight radiation safety measures. Serial nuclear body scans were obtained. Pain assessment was evaluated using a visual analog pain score. Results: All patients tolerated the procedure well. No procedure-related morbidities were noted. No significant change had occurred in the blood counts at 1 month after the procedure. One case was not technically satisfactory. Nuclear scans revealed clear radiotracer uptake in the other 32 vertebrae injected. Except for the first patient, no radiation leakage was encountered. The mean pain score using the visualmore » analog scale improved from 8.6 before to 2.8 after the procedure (p < .0001). Follow-up bone scans demonstrated a 43% decrease in the tracer uptake. Conclusion: The results of our study have shown that the combination of intravertebral administration of {sup 153}Sm and kyphoplasty is well tolerated with adequate pain control. No hematologic adverse effects were found. A reduction of the bone scan tracer uptake was observed in the injected vertebrae. Longer follow-up is needed to study the antineoplastic effect of the procedure.« less

Hemangiopericytoma is a rare tumor, arising from pericytes. Its outcome is difficult to foretell, as the usual criteria for malignancy are unreliable in this neoplasm. Three cases of primary pulmonary hemangioperi-cytoma are presented and the pathologic and clinical aspects are briefly reviewed. All three patients were surgically treated, and two are still alive after 7 and 18 years without sign of recurrence or metastasis. The third patient, although still alive, has had three recurrences within 22 months and vertebral metastasis.

Objective To investigate the use of magnetic resonance imaging in the detection of metastatic tumors involving the discovertebral junction of the spine in cadaveric specimens and patients, with histologic findings as the reference standard. Methods Magnetic resonance imaging studies were performed on 30 DVJs in 10 cadavers with documented metastatic bone disease. Anatomic sectioning and histologic evaluations were performed, and anatomic slices were correlated with the magnetic resonance images. For clinical study, magnetic resonance imaging examinations in three patients with vertebral metastasis were reviewed. Results On magnetic resonance imaging, the signal intensity characteristics of vertebral body metastases were variable. Magnetic resonance imaging failed to detect metastatic foci invading the cartilaginous endplates. On microscopic examination, infiltration of the discovertebral junction by tumorous tissue was found in 11 (69%) of the 16 discovertebral junctions that had an irregular contour, and in 5 (31%) disrupted discovertebral junctions. In three specimens and three patients, microscopic examination revealed tumor metastasis to the intervertebral disc. In no specimen magnetic resonance imaging afforded depiction of discal invasion by tumor. Conclusions Our results lend further support to the theory that metastatic tumors can invade the cartilaginous endplate through defects in its substance, allowing direct contact of tumor and disc. Minimal tumor invasion of the discovertebral junction may not be identified at magnetic resonance imaging or gross anatomic inspection, or both, because small metastatic foci may be obscured by abnormalities in the morphology of the cartilaginous endplate.

A 27-year-old man with metastatic Ewing sarcoma presented with acute-onset paraplegia after percutaneous cryoablation of T10 vertebral metastasis. He had completed three cycles of systemic chemothe...

Las metástasis espinales representan una manifestación común de las neoplasias sólidas. La incidencia continúa incrementándose, probablemente como resultado de una sobrevida más larga en pacientes con cáncer. Estas lesiones pueden provocar dolor y déficit neurológico. La radioterapia ha sido el tratamiento de elección para las metástasis vertebrales, pero avances en la terapia radiante, cirugía, quimioterapia y la combinación de estas terapias, han permitido mejorar la calidad de vida de los pacientes. La meta de la cirugía es la de descomprimir los elementos neurales, reconstruir y estabilizar la columna vertebral. Recientemente, han estado disponibles técnicas mínimamente invasivas. Actualmente, la quimioterapia juega un rol importante como parte de la estrategia de tratamiento de las metástasis vertebrales no complicadas. Los bifosfonatos en combinación con terapia antineoplásica sistémica, han permitido reducir o retrasar los eventos esqueléticos. Sin embargo, es importante que el diagnóstico y el tratamiento se realicen antes que se desarrolle un déficit neurológico significativo, ya que, esto mejora el pronóstico y calidad de vida de los pacientes. Con el aumento del número de opciones terapéuticas, está claro que la implementación de un tratamiento efectivo sólo se puede lograr con una aproximación multidisciplinaria. Metastases to the spine are a common manifestation of systemic neoplasias. The incident of spinal metastases continues to increase, as a result of increasing survival of patients with cancer. It may cause a number of disabling symptoms including pain and neurological deficits. Treatment decisions require appraisal by a multidisciplinary team. Radiation therapy has been the treatment of choice for metastastic spinal tumors, but advances in radiation therapy, surgery, chemotherapy and the combination of these therapies have lead to improved patient outcomes. The goal of surgery is to achieve decompression of the neural elements while immediately stabilizing the spine. Recently, minimally invasive techniques have become available. Chemotherapy can play a role in the treatment of uncomplicated spinal metastases in certain conditions. Bisphonates in combination with systemic antitumor therapy has shown to reduce or delay skeletal events. Prompt decisions and effective treatment need be instituted without delay to prevent the establishment of permanent neurological deficits. As the number of treatment options for metastatic spinal increase, it has become clear that effective implementation of treatment can only achieved by a multidisciplinary approach.

F-18 FDG PET imaging provides a great clinical advance in the evaluation and staging of solitary pulmonary nodules. It may detect overlooked or unexpected locoregional and distant dissemination related to lung malignancy.The authors present a case of bronchopulmonary carcinoid tumor with a vertebral metastasis exhibiting positive PET findings and negative somatostatin receptor scintigraphy.

To assess the impact of bladder instillations of hyaluronic acid (HA) on the prevalence of urinary tract infection (UTI) in patients receiving emergency radiotherapy for metastatic spinal cord compression.Patients were recruited consecutively at one center and assigned to usual care (UC) (n = 34, mean age 62.2 years) or UC with once-weekly HA instillation (UC + HA) (Cystistat: 40 mg in 50 mL phosphate-buffered saline) (n = 37; mean age, 63.1 years). All patients had an indwelling catheter and received radiotherapy. UTI status was assessed at baseline and during hospitalization.At baseline, patient groups were comparable, except for the prevalence of UTI at baseline, which was 11.8% and 0% in the UC and UC + HA patients, respectively (p = 0.0477). During hospitalization, 76.5% (vs. 11.8% at baseline, p0.0001) of the UC patients had a UTI compared with 13.5% (vs. 0% at baseline, p = 0.0541) of the UC + HA patients (p0.0001). Both groups were hospitalized for similar periods (19.8 days [UC] vs. 18.5 days, p = 0.4769) and received equivalent radiotherapy sessions (4.6 [UC] vs. 5.8 sessions, p = 0.2368).Patients receiving UC + HA had a 5.7-fold decrease in UTI prevalence over the hospitalization period compared to UC patients, suggesting that bladder instillations of HA effectively prevent UTI in patients with indwelling catheters receiving radiotherapy for nerve compression.

Summary Cervical vertebral involvement of clear cell meningioma is very rare. We report a case of clear cell meningioma in the cervical vertebral body in a 72-year old male. Seven years prior to this presentation, the patient underwent palliative surgery and posterior instrumentation for a cervical vertebral tumor at C5, which had been diagnosed as a metastatic renal cell carcinoma. On this admission, the patient presented with severe neck pain. Examination revealed hypesthesia on the left in a C6 nerve root distribution. Plain X-rays and MRI revealed an enlarging tumor in the C5 and C6 vertebral bodies. The tumor was resected via an anterior approach followed by fusion using a strut bone graft. Histological examination of the surgical specimen diagnosed a clear cell meningioma. Postoperatively, the patient achieved pain relief and resolution of the neurological deficit. At follow-up two years postoperatively, he remains asymptomatic. We emphasize that cervical clear cell meningioma with involvement of the vertebral bodies may mimic metastatic renal cell carcinoma.

Percutaneous cementoplasty (PC) consists of injecting acrylic cement (polymethylmethacrylate) in bone and is a perfect example of a minimally invasive technique in the musculoskeletal system. PC has been performed since 1984. Its role is to consolidate weight-bearing bone and to treat pain. Bone packing with acrylic cement is a procedure aimed at preventing pathological fractures and pain in patients with vertebral body lesions and acetabular metastasis.

La compresión medular es una urgencia oncológica y neurológica, cuyo diagnóstico y tratamiento precoz son los factores clave para evitar el daño neurológico severo e irreversible. La parálisis, la pérdida de la sensibilidad y la alteración del control de los esfínteres, son la consecuencia final del proceso, y supone una fuente de morbilidad importante del paciente oncológico, además de estar relacionado con un menor tiempo de supervivencia. La invasión del cuerpo vertebral por diseminación hematógena, es la causa más frecuente de la compresión medular. En ocasiones llega a crear inestabilidad mecánica vertebral que supone una verdadera urgencia ortopédica. El dolor es el síntoma más precoz y frecuente. Los signos y síntomas van apareciendo a medida que el proceso avanza, pasando por la debilidad motora, alteración en la sensibilidad hasta llegar a la parálisis e incontinencia de esfínteres, como consecuencia del daño neurológico completo. La historia clínica y exploración física deben hacer sospechar el nivel donde se puede estar desarrollando la compresión medular, y la exploración complementaria más importante es la RM de la columna completa, que debe ser solicitada de inmediato para decidir e iniciar el tratamiento. El tratamiento es individualizado y debe de instaurarse con precocidad. En general, los corticoides en combinación con el tratamiento oncológico radioterápico y/o la cirugía son las armas terapéuticas a utilizar. Medullar compression is an oncological and neurological emergency, whose diagnosis and early treatment are key factors for avoiding severe and irreversible neurological damage. Paralysis, loss of consciousness and alteration in control of the sphincters are the final consequence of the process, and represent an important source of morbidity of the oncology patient, besides being related to a shorter time of survival. The invasion of the vertebral body by haematogenous dissemination is the most frequent cause of medullar compression. On occasions it can create mechanical vertebral instability which represents a real orthopaedic emergency. Pain is the earliest and most frequent symptom. The signs and symptoms appear to the degree that the process advances, passing through motor weakness, alterations in consciousness until paralysis and incontinence of the sphincters are reached, as a result of complete neurological damage. Clinical history and physical exploration should lead to suspicion about the level at which medullar compression is developing, and the most important complementary exploration is MR of the entire spine, which should be requested immediately in order to decide on starting treatment. Treatment is individualised and must be started early. In general, corticoids in combination with radiotherapeutic oncological treatment and/or surgery are the therapeutic weapons to employ.

A paraganglioma is a rare tumor, composed of chromaffin cells, groups of cells associated to the autonomous system. When the tumor occurs in the adrenal gland, it is called pheochromocitoma. The malignant paraganglioma is a very rare presentation; it is diagnosed by local recurrence after total resection of the primary mass, or findings of distant metastases. We present a case report of a 29-year-old woman with cervico-brachial pain. In 1995 she underwent a carotid body tumor resection. Magnetic resonance imaging (MRI), plain X-rays and computerized tomography scan revealed multiple lesions in C5, T5 and T12. She underwent a surgical procedure to correct the cervical lesion. The histological and immunohistochemical assays revealed a malignant paraganglioma. She received adjuvant radiotherapy, showing clinical improvement after treatment, presenting no symptoms after one year. The therapeutic approach is based on the total resection of the tumor. The treatment of distant metastases can be made with adjuvant measures such as conventional radiotherapy, I¹³¹-MIBG, or chemotherapy, especially in malignant pheochromocitomas. O paraganglioma é tumor raro, composto de células cromafins, associado ao sistema nervoso autônomo. Quando localizado na glândula supra-renal, o tumor é chamado feocromocitoma. Descreve-se um caso de paciente do sexo feminino, 29 anos, que se apresentou com cervicobraquialgia e que havia sido operada em 1995 para exérese de tumor glômico da carótida cervical. RM, RX e TC revelaram múltiplas lesões acometendo o corpo vertebral de C5, T5 e T12. Foi submetida à ressecção cirúrgica radical da lesão cervical, com substituição do corpo vertebral por prótese de titânio. A histopatologia e o estudo imunohistoquímico da lesão confirmaram o diagnóstico de paraganglioma maligno. As outras lesões foram tratadas com radioterapia. Um ano após os procedimentos, a paciente apresenta-se assintomática. O tratamento destas lesões consiste na associação da ressecção cirúrgica radical do tumor e medidas complementares como radioterapia convencional, aplicação de I131-MIBG, ou quimioterapia, principalmente nos paragangliomas malignos.

The purpose of this study was to describe the clinical presentation of bone metastases in patients with carcinoid tumors and to determine the diagnostic value of imaging techniques and markers of bone metabolism. Methods: This retrospective study was performed on the entire group of patients with carcinoid tumors treated in our hospital from January 1992 to May 1999 Only patients with metastasized tumors were included. Results: Eleven of 90 patients (12%) (95% confidence interval [Cl], 5%-19%) with a metastasized carcinoid tumor had symptomatic bone metastases. All bone metastases occurred in 55 patients with midgut carcinoids (20%; 95% Cl, 9%-31 %). Plain radiography had a sensitivity of 44% (95% Cl, 12%-76%); MRI, 100% (95% Cl, 61%-100%); bone scintigraphy, 90% (95% Cl, 72%-100%); and octreotide scintigraphy, 60% (95% Cl, 35%-93%). In 9 patients, both octreotide scintigraphy and bone scintigraphy were performed. Of 45 bone lesions, 22 (49%) were visualized by both modalities, 13 (29%) were visualized with octreotide scintigraphy but not with bone scintigraphy, and 10 (22%) were visualized with bone scintigraphy but not with octreotide scintigraphy, In 2 patients, octreotide scintigraphy and bone scintigraphy provided complementary results. Markers of bone metabolism could not discriminate carcinoid patients from those without bone metastases, The markers of bone metabolism did not reflect the osteolytic or osteoblastic appearance of metastases. Conclusion: Pain is the principal symptom of bone metastases in patients with carcinoid tumors. Plain radiography and markers of bone metabolism do not contribute to the diagnosis of bone metastases. MRI has a high sensitivity for bone metastases. Both bone scintigraphy and octreotide scintigraphy have acceptable sensitivity and can provide complementary results.

Vertebral metastases constitute a major event in the course of many tumors. Quite often revealing the metastatic nature of the disease, they also constitute a new crossroads in treatment orientation and provoke a marked emotional modification in the caregiver-patient relationship. At the same time for the person being treated, there takes place an exacerbation of the frightful uncertainty of what lies ahead and a definitive encounter with pain, which may have seemed more fleeting or sporadic during the initial treatments. The discovery of vertebral metastases intensifies an already complex situation requiring highly technical management, sustained coherence of the entire care-providing team, and their awareness of the patients increased need to be heard, informed and supported.

Before the 1970s, the appearance of a vertebral metastasis meant rapid deterioration and death for the patient; the only treatment was prescription of major analgesic drugs. Patients suffered dramatic and precocious paralyses secondary to radiculo-spinal cord compression. The introduction of spinal internal fixation, in the 1970s, has allowed stabilisation of the metastatic spine, with unexpected disappearance of pain. The use of osteosynthesis enables paralysed patients to recuperate. If the surgical procedure is carried out before the nervous compression has begun, osteosynthesis prevents the development of paralysis. Patients have been able to continue their activities and remain comfortable for the remainder of their lives.

The management of a patient with vertebral metastases is necessarily multidisciplinary. The anesthesiologist is somewhat at the crossroads between the general practitioner, surgeon, oncologist, radiotherapist and psychologist.

In France, lung cancer is the principal cause of death by cancer in men and the fifth cause of death by cancer in women. It causes 21,500 deaths per year corresponding to approximately 16% of deaths by cancer and 23% of male deaths by cancer [16]. This mortality is directly correlated with figures of cigarette smoking [16, 24]. Less than 10% of patients survive more than 5 years, the mortality rate of this cancer being close to its incidence [13, 16, 24].

Pain and neurological compromise are the two principal symptoms leading to diagnosis of vertebral metastasis. Nonetheless, in roughly 10% of subjects with vertebral metastases, there is no suggestive sign and discovery is made during the course of systematic surveillance after treatment of the primary tumor or during the extension work-up that follows discovery of a primary cancer [3].

Although, with the preoperative use of complete spinal MRI, the percentage of patients who develop subsequent metastatic vertebral lesions calling for treatment has decreased to 5%, the rate of recurrence in the previously operated vertebra remains stable at approximately 10%.

Since the first publications on resection of a thoracic herniated disc by thoracoscopy [5, 11], numerous other studies have reported the usefulness of this technique in the treatment of various lesions of spinal pathology.