Abstract
INTRODUCTION
The prognosis of patients with lung cancer metastasis to the spine is not very promising and a palliative approach is often suggested by scales such as the Tomita score. The choice of surgery for these patients is questionable based on the aggressiveness of the disease. However, certain patient characteristics can be sought out to determine if surgery is indicated.
PRESENTATION OF CASE
Here, we present a case of a 59 year old male which consulted for back pain, numbness of the upper left thigh, and weakness corresponding to an L2 lesion. It was later discovered that he was suffering from non small cell lung cancer (adenocarcinoma) with a single metastasis to the spine at the level of L2. The patient also presented an EGFR mutation. Thus, the patient presented two good prognosis characteristics: adenocarcinoma and an EGFR mutation.
DISCUSSION
An aggressive treatment was chosen. This included an EGFR inhibitor, surgical treatment, and radiotherapy thereafter. The patient had no complications due to surgery and to date, the patient has survived over 12 months and is free of any symptoms. This case demonstrates that surgical intervention can be considered for certain patients with lung cancer metastasized to the spine.
CONCLUSION
This case demonstrates that surgical intervention can be considered for certain patients with lung cancer metastasized to the spine. We hope spine surgeons in general will start verifying the EGFR mutation status of adenocarcinoma lung cancer patients to determine if surgery is indicated.
Keywords: EGFR mutation, Spine surgery, Lung cancer, Metastasis, Adenocarcinoma
1. Introduction
The prognosis of patients with lung cancer metastasis to the spine is not very promising and a palliative approach is often suggested by scales such as the Tomita score. The choice of surgery for these patients is questionable based on the aggressiveness of the disease. Sugiura et al.1 reported that the survival rates of patients afflicted with lung cancer metastasized to the spine was 59.9% at 6 months, 31.6% at 1 year, and only 11.3% at 2 years. Although these survival rates are low, the identification of patients with better prognosis becomes essential for their clinical management. Thus, the identification of patient characteristics that can help identify those with higher survivorship is required. Fortunately, new advancements in the field have identified markers that can help identify those with better prognosis and allow for new treatment options which have also been shown to improve survivorship. We suggest that cancer type and presence of Epithelial Growth Factor Receptor (EGFR) mutation can be used to identify those with better survivorship and those who can benefit from more aggressive treatment such as surgery. We suggest that these prognosis indicators be considered while assessing the potential surgical treatment of patients.
2. Presentation of case
Here we present a case of a 59 year old male which consulted for back pain (Visual Analog Scale of 5/10), numbness of the upper left thigh, and weakness corresponding to an L2 lesion. The patient had no other signs or symptoms, no significant past medical history, but did have a history of smoking (9 pack-years) 35 years ago. Upon arrival to the emergency room a CT scan and X-ray of the spine were taken. An abnormal mass was noted at the level of L2 and the left upper lobe of the lung. Further investigation with MRI, PET scan, and biopsies of the vertebral and pulmonary lesions confirmed the diagnosis of single metastasis lesion at the level of L2. The primary site was the lung with staging of T1N0M1. The lesion was confirmed to be NSCLC (adenocarcinoma). A mutation to the EGFR gene was identified (deletion of Exon 19). The MRI showed pedicle involvement and spinal canal stenosis. The vertebral lesion spanned the entire L2 vertebrae and was estimated to measure 4.2 cm in width, 3.3 cm in length, and 3 cm in height (refer to Fig. 1).
Fig. 1.
Pre-operative MRI showing a lesion at the level of L2 (lung cancer adenocarcinoma metastasis). Left: transverse view of L2. Right: sagital view.
Despite the aggressiveness of the disease, this patient presented two good prognosis characteristics: adenocarcinoma and an EGFR mutation. Therefore, an aggressive treatment was chosen. This included an EGFR inhibitor, surgical treatment, and radiotherapy thereafter.
The surgical treatment consisted of an anterior vertebrectomy of L2 via retroperitoneal approach followed by installation of a cage placed between L1 anmd L3 and posterior transcutaneous pedicle screw placement from T12 to L4 (refer to Fig. 2). The patient's total length of stay for the surgery was 6 days. He fully recovered and had no complications due to surgery. His post-operative VAS was reduced to 1. The patient's numbness and weakness was fully recovered immediately following surgery. He was followed at 2 weeks, 1 month, 4 month, and 7 months without recurrence of numbness or weakness or any other complication. He was also treated with radiotherapy (45 Gy) localized to the spine and lung after surgery. The patient supported radiotherapy without any associated complications.
Fig. 2.
Post-operative X-ray showing vertebrectomy of L2, cage placed between L1 and L3 and posterior pedicle screws placed at T12, L1, L3, and L4. Left: sagital view of L2. Right: coronal view.
3. Discussion
Here we presented case of lung cancer adenocarcinoma metastasized to the spine with EGFR mutation. We treated this patient aggressively based on the good prognosis characteristics he presented. To date, the patient has survived over 12 months and is free of any symptoms. He can walk on his own and does not have any respiratory complications. This case demonstrates that surgical intervention can be considered for certain patients with lung cancer metastasized to the spine. Although survivorship of these patients can be very low,1 certain patient characteristics should be sought out to determine if surgery can be a good treatment option. We suggest that surgical intervention should be considered for patients with lung cancer metastasized to the spine who have EGFR mutation and adenocarcinoma. It is evident that other factors should be considered before surgical intervention, such as number and location of metastases and overall patient health. However our results demonstrate that these characteristics should be verified and used to determine if surgical intervention is justified.
Our observations and results concur with the literature. For instance, it has been shown that better survivorship was found for patients with adenocarcinoma and those treated with Epithelial Growth Factor Receptor (EGFR) inhibitors.1 In fact, several reports have shown the effectiveness of EGFR inhibitors for the treatment of lung cancer (especially adenocarcinoma).2–5 In addition, patients with lung cancer and mutation to the EGFR gene can further benefit from EGFR inhibitors.6 Other studies have also demonstrated reduced lung cancer cell proliferation and tumor regression with a combination of an EGFR inhibitor and antiestrogens7,8; suggesting that estrogen receptors (ER) and EGFR have a role in the carcinogenesis of non-small cell lung cancer (NSCLC).7–10 Yet another study has demonstrated that the presence of ERβ can be used as a prognosis indicator for patients with surgically resected NSCLC such as adenocarcinoma.11 These encouraging oncology findings should become familiar to most spine surgeons.
We suggest that these prognosis indicators be considered while assessing the potential surgical treatment of our patients. More specifically, EGFR mutations should be verified for patients with lung cancer adenocarcinoma metastasized to the spine. As demonstrated in this case, these can be indication for surgery and improve quality of life. Our study is limited to one case and a study looking at correlation of survivorship and EGFR mutation should be considered to determine the true relationship between presence of EGFR mutation and survivorship. However, the positive outcomes of this case should motivate surgeons to verify oncological markers to optimize treatment choice for their patients.
4. Conclusion
Here we show a case with good results and good recovery based on surgical treatment, an option that is normally overlooked for patients with lung cancer metastasized to the spine. We suggest that EGFR mutation be verified for patients with lung cancer metastasized to the spine. We also encourage spine surgeons to consider surgical treatment of patients with both EFGR mutation and identified adenocarcinoma based on the good results we observed.
Conflict of interest statement
None.
Funding
None.
Ethical approval
Obtained.
Author contributions
Both authors equally contributed to the paper. Both were involved in manuscript write-up, design and data collection.
Contributor Information
Ahmed Adel Aoude, Email: ahmed.aoude@gmail.com.
Louis-Philippe Amiot, Email: Louis-Philippe.Amiot@zimmercas.com.
References
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