Prognostication - metastatic spinal tumour

Old scoring system

General

Of these systems, the Tomita and Tokuhashi systems have the most abundant validity data, with several studies demonstrating their ability to predict patient survival accurately.7–11

Tokuhashi

Described in 1989 and revised in 2005

tokuhashi 2005.pdf

Evaluates patient condition, number of spinal and extra spinal bony metastasis, operability of visceral metastasis, and neurologic status. It has been shown to be widely applicable, and its validity has been shown in multiple countries.

General condition (performance status)	ㅤ
Poor (PS 10%–40%)	0
Moderate (PS 50%–70%)	1
Good (PS 80%–100%)	2

Metastases to the major internal organs	ㅤ
Unremovable	0
Removable	1
No metastases	2

General condition (performance status)	ㅤ
Poor (KPS 10%–40%)	0
Moderate (KPS 50%–70%)	1
Good (KPS 80%–100%)	2

Primary site of the cancer	ㅤ
Lung, osteosarcoma, stomach, bladder, esophagus, pancreas	0
Liver, gallbladder, unidentified	1
Others	2
Kidney, uterus	3
Rectum	4
Thyroid, breast, prostate, carcinoid tumor	5

No. of metastases in the vertebral body	ㅤ
≥3	0
2	1
1	2

Palsy	ㅤ
Complete (Frankel A, B)	0
Incomplete (Frankel C, D)	1
None (Frankel E)	2

No. of extraspinal bone metastases foci	ㅤ
≥3	0
1–2	1
0	2

Total Score	Predicted Prognosis	Recommended Treatment
0 – 8	> 6 months	Conservative treatment OR Palliative surgery
9 – 11	≤ 6 months	Palliative surgery OR Excisional surgery if - Single lesion - No metastases to major internal organs
12 – 15	≤ 1 year	Excisional surgery

High tokuhashi score

The better the prognosis
The more for aggressive management

Study limitation

Study design and how it is presented to the reader.

Has a retrospective analysis old data and also a a retrospective analysis of prospective data
The data collected prior to 1998 was scored differently under the original scoring system, and the treatment associated with the original Tokuhashi score differed from the present study, which may confound the comparison of predicted to actual survival period.

The only truly prospective data was the rate of consistency between the prognostic score and the actual length of survival for 118 patients;

KPS Score	Description
100	Normal, no complaints, no evidence of disease
90	Able to carry on normal activity; minor signs or symptoms of disease
80	Normal activity with effort, some signs or symptoms of disease
70	Cares for self; unable to carry on normal activity or to do active work
60	Requires occasional assistance, but is able to care for most of his personal needs
50	Requires considerable assistance and frequent medical care
40	Disabled; requires special care and assistance
30	Severely disabled; hospital admission is indicated although death not imminent
20	Very sick; hospital admission necessary; active supportive treatment necessary
10	Moribund; fatal processes progressing rapidly
0	Dead

Rades

first described in 2008

has a narrower focus than the other systems and is applicable only in patients with advanced metastatic disease resulting in neurologic deficits that underwent radiotherapy.

Its components are primary tumor type, presence of extraspinal bony metastasis, presence of visceral metastasis, interval time to spinal cord compression, ambulatory status, and timing of onset of neurologic deficits.

van der Linden

described in 2005

the simplest system and evaluates performance status, primary tumor type, and presence of visceral metastasis

It does not account for the extent of chemotherapy administration or the chemosensitivity of the cancer, which has resulted in problems with versatility and objectivity.

Bauer

first described in 1998

includes primary cancer site, skeletal metastasis, visceral metastasis, and presence of spinal pathologic fracture.

This system was revised to exclude pathologic fracture because this is often difficult to judge on imaging.

The main drawback of this system is that it was derived from a multicenter cohort in which surgical indications varied widely, which could negatively affect its validity.

Despite this fact, however, it has been shown to have good prognostic power in patients four or more years after treatment

Katagiri

Described in 2005, is unique among these systems in that it incorporates prior chemotherapy use.

Tomita system

Only tomita has predict survival in patients and have specific treatment recommendations.

Tomita.pdf

937.3 KB

Higher the tomita score

Poorer prognosis
more palliative

Synonym: Tom ate one bony rat into his tummy

Limitations

Fails to incorporate patient comorbidities into the treatment algorithm.

A comorbidity index, for example, the Charlson Comorbidity Index, could prove a salient additional factor to further delineate treatment groups.

Since inclusion and exclusion criteria were not stated in the study, it is unclear how patients deemed too sick for surgery owing to comorbid conditions were managed or if and how this treatment system can be applied in these patients.

This may affect the generalizability of this system; therefore, careful consideration must be taken on a patient-by-patient basis.

Patient prognostic scores were not strictly adhered to with regard to the recommended surgical intervention.

For example, 5 of the 11 patients that received decompression and stabilization surgery had scores of 8 or greater, for which this system recommends conservative palliative management.

Numerous patient and surgeon-specific factors likely account for this discordance; however, the authors fail to acknowledge these discrepancies and how it could affect the interpretation of their results.

Failure to report the impact that radiotherapy and chemotherapy have on patient survival.
It is not clear which patients had tumors sensitive to these adjunctive therapies and how many received these treatments in each of the four groups.

The authors acknowledge the importance of these therapies on patient survival, but no discussion is offered

Prognostic Factors	Points
Primary tumor	ㅤ
Slow growth (breast, thyroid, etc.)	1
Moderate growth (kidney, uterus, etc.)	2
Rapid growth (lung, stomach, etc.)	4
Visceral metastases	ㅤ
Treatable	2
Untreatable	4
Bone metastases	ㅤ
Solitary or isolated	1
Multiple	2

Total Points	Predicted Prognosis
2-4	>2 years
4-6	1-2 years
6-8	6-12 months
8-10	<3 months

Prognostic Score	Predicted Prognosis	Treatment Goal	Surgical Strategy
2 - 3	>2 years	Long-term local control	Wide or Marginal excision
4 - 5	1-2 years	Middle-term local control	Marginal or Intralesional excision
6 - 7	6-12 months	Short-term palliation	Palliative surgery
8 -10	<3 months	Terminal care	Supportive care

Modern scoring system

New England Spinal Metastasis Score (NESMS)

Contents:

Modified Bauer score
Ambulatory status (intact/impaired)
Serum albumin (cutoff 3.4 g/dL)

Pros:

Simple and easy to use for predicting 1-year survival after surgery
Integrates basic biochemical and functional parameters

Cons:

May lack granularity for complex cases
Limited external validation across diverse populations

Schoenfeld 2023

NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS

Ghori 2015

NESMS Score	1-Year Mortality % (95% CI)	3-Month Mortality % (95% CI)	3-Month Independent Ambulatory Function % (95% CI)	6-Month Independent Ambulatory Function % (95% CI)
0	93 (78, 99)	60 (41, 77)	7 (1, 22)	10 (2, 27)
1	69 (55, 82)	41 (27, 56)	14 (6, 27)	12 (5, 25)
2	45 (34, 57)	8 (3, 16)	59 (47, 70)	40 (29, 51)
3	13 (5, 27)	4 (1, 15)	67 (51, 80)	53 (38, 68)

Modified Bauer score components	ㅤ
Primary tumor is not lung	1
Primary tumor is breast or kidney	1
Solitary skeletal metastasis	1
No visceral metastasis	1
Modified Bauer score	ㅤ
≤2	0
≥3	2

Serum albumin (g/dL)	ㅤ
<3.5	0
≥3.5	1

Ambulatory status	ㅤ
Non-ambulatory	0
Intact or impaired	1

Score	Combinations
0	Modified Bauer ≤ 2, impaired ambulatory status, albumin ≤ 3.4 g/dL
1	Modified Bauer ≤ 2, intact ambulatory status, albumin ≤ 3.4 g/dL
ㅤ	Modified Bauer ≤ 2, impaired ambulatory status, albumin ≥ 3.5 g/dL
2	Modified Bauer ≥ 3, impaired ambulatory status, albumin ≤ 3.4 g/dL
ㅤ	Modified Bauer ≤ 2, intact ambulatory status, albumin ≥ 3.5 g/dL
3	Modified Bauer ≥ 3, intact ambulatory status, albumin ≥ 3.5 g/dL

Skeletal Oncology Research Group (SORG) Nomogram

Pros:

Highly detailed; incorporates multiple clinical and laboratory variables
Provides survival predictions at 30, 90, and 365 days

Cons:

Complexity may limit use in routine clinical practice
Requires more information and calculation effort

AO Spine Metastasis Calculator

Nater 2020.pdf

1.4 MB

Calculation

1-year survival

S(t)=S0(t)exp(BX)

BX=(SF36-PCS×coefficientsf36pcs)+(prim×coefficientprim)+(met×coefficientmet)+(RT×coefficientrt)+(sex×coefficientsex)

Improvement in QoL @ 3months:

P = \frac{\exp(4.9654 + UK + SF36\text{-}PCS + SF36\text{-}MCS + KPS)}{1 + \exp(4.9654 + UK + SF36\text{-}PCS + SF36\text{-}MCS + KPS)}

Pros:

Predicts survival and quality of life at multiple postoperative intervals
Web-based, user-friendly implementation for fast use

Cons:

Requires internet access and several input variables
Limited by self-reported physical/mental scores

Metastatic Spinal Tumor Frailty Index (MSTFI)

Ramos 2016.html

172.6 KB

Pros:

Highlights perioperative and postoperative risk (complications, mortality)
Useful for surgical risk assessment and shared decision-making

Cons:

Does not directly predict long-term survival
Some frailty elements may be subjective or population-specific

The maximum score is 10.

A score of 0 indicates “no frailty”
Score of 1 indicates “mild frailty”
Score of 2 indicates “moderate frailty”
Score of 3 or greater indicates “severe frailty”

Component	Points
Anemia	1
Chronic lung disease	1
Coagulopathy	1
Electrolyte abnormalities	1
Pulmonary circulation disorders	2
Renal failure	1
Malnutrition	1
Emergent/urgent case	1
Anterior or combined surgical approach	1