All right, I think we'll get started. So this is going to be a really amazing set of speakers coming up. So the topic today is going to be Advancements in the Management of Spinal Oncology. We have a great panel. So I'm just going to give you a glance at what we're doing today. First is going to be a discussion by Dr. Gokoslin on the relevance of metastatic spinal tumors to a neurosurgeon, followed by a discussion by Dr. Bilski on advancements in spinal oncology focusing on separation surgery, and then Dr. Tatsui will discuss laser ablation, and then Dr. Rines will come back and discuss on-block resection of primary spinal tumors. Afterwards, we'll have an interactive spinal tumor board discussion where we'll kind of in a multidisciplinary way discuss different tumors. It'll be involving audience polling. So afterwards, we'll do a beverage break and come back at 4 o'clock for our abstract session. So for the audience polling, I'll need your interaction, please. So what you'll do is you'll go to this website, PollEV.com slash AANS2018525. You can also use text message. So I'll come back to it. Here's the Wi-Fi access info if you need it. The network is WNS. The password is AANSMTGS. So again, if you want to get access to it, either your phone, your computer, you type in PollEV.com slash AANS2018525. And if you want to use a text message, send a text to this, 22333, and in the body of the text, put in AANS2018525. The actual website is easier to manage. So once you get on, it'll ask for your name. You can skip that. And we'll just, we can, if you guys have time now, we'll do a quick sample poll and see if you can access this poll. All right, I'll give people a minute just to try it out. And then the next poll, just to kind of try it out, is just a quick question, who makes the best beignets? Alright, so it looks like people have access. Okay, so let's get started. I'd like to invite Dr. Gokaslan. Thank you so much for joining us. Thank you. Good afternoon, everyone. Thank you very much for including me in the program. So I'll be introducing the topic, and we'll make an argument that the metastatic spying tumors are really relevant to neurosurgeons, particularly in this new age of precision medicine and cancer treatment. It's obvious that this is a very common problem. This is American Cancer Society data. This year alone, there will be about 1.6 million people diagnosed with cancer, and of those, 650,000 people will actually die as a result of their illness, mainly due to metastatic disease. And if you look at the cancer patients, at the end of their course, somewhere up to 70% of the people will have a metastatic involvement in their spinal column. So if your cancer spine is a final destination for most people for the tumors to go to. And this is even a bigger problem as the years go by. This is because of the fact that the U.S. population is aging, so the proportion of older people, the people that are older than 55 years of age, is increasing progressively, and hence cancer is going to be even a more common problem as we move forward. If you have a spine metastasis, about 30% of those individuals become symptomatic from the spinal disease. When they become symptomatic, 90% of the time they present with pain, and about 20% of the time they present with epidural spinal cord compression, which is, as you know, a neurosurgical emergency. Now if you look at the numbers across the board, this is an enormous problem, and if you compare it to some of the more common neurosurgical conditions that we treat, you will see even the scale of the problem. If you calculate the number of spinal metastases, it's about 176,000 per year. Calculated brain metastases, it's about 170,000 per year. In comparison, all CNS tumors, the brain tumors and spinal cord tumors included, about 24,000 cases a year. New GBM cases, it's about 13,000 a year. And ruptured aneurysms, about 30,000 a year. Half of those patients, as you know, don't even make it to the hospital, so they do not really necessarily become a neurosurgical entity. And so in scale, the metastatic spine disease, and for that matter, metastatic brain disease, is a very, very significant issue. If you convert these numbers to the patients who are symptomatic, so you're looking at 176,000 people who have symptomatic spine involvement, 90% of the time with pain. You're looking at almost 160,000 people presenting to the emergency rooms around the country with metastatic spine disease-related pain, and 35,000 patients with spinal cord compression. Now, we don't really see necessarily all of these patients. Many of them go to a medical oncologist and radiation oncologist, but we will be consulted at some point during the course of their illness. So this is just the incidence of the disease. And if you look at the prevalence, the evil problem is bigger. If you look at the trends in terms of what's happening in the male patients, as far as the cancer deaths are concerned, there's progressive decline of mortality in many different types of cancers, including lung, prostate, and colorectal primaries. So the surviving number of patients in these primaries will progressively increase. And this is also true for female patients. The breast cancer incidence over the decades have been progressively declining, and it will continue to decline as we go. So that means that the proportion of patients who are alive will be even bigger. This is, again, data from Wall Street Journal, as a matter of fact, looking at cancer survivors. And if you look at that here, currently, in 2014, several years ago, we had 7 million male and 7, almost 8 million female cancer survivors, almost 15 million people out there with diagnostic cancer. And if you look at the projected numbers for 2024, between males and female patients, it will be about 20 million people out there with cancer. As you can imagine, many of these patients will develop spinal metastasis, and it will come to our attention. On top of that, we have a whole spectrum of options in treating patients with metastatic disease, and this is just really a small set of options, anywhere from conventional radiation to minimally invasive decompression to open surgical procedures, serotactic radiosurgery, rheumatoplasty, kyphoplasty, lead, and block resection of the tumors. And many of the speakers who will follow me will be discussing some of these in more detail. But we have a whole spectrum of treatment options available for cancer patients. The role of surgery has been quite well established for patients with solid tumors or with significant epidural spinal cord compression. The PATCHOS data, which is now almost 15 years old, clearly demonstrated that the patient with significant epidural cord compression can benefit from surgical decompression in many situations with spinal stabilizations. And also, secondary outcomes from this paper clearly illustrated that the pain can be very effectively managed as well, and narcotic consumption can be reduced significantly on top of that. And bowel and bladder function is much better maintained in the surgical category. In terms of films, the mnemonic has been introduced. As a matter of fact, I would say Dr. Mark Bielski and the audience is credited for that, Approaching Metastatic Spine Disease in a systematic way, looking at the neurological status of the patient, the primary tumor type, the instability of the spine, and systemic disease and medical status of the patient. We sort of synthesize all that information and make a decision in a given patient with metastatic disease. And so we have gotten very sophisticated in looking at the patient's metastatic tumors. Of course, at the end, systemic disease, status of that, the patient's overall medical status and survival are important prognostic factors that we factor in in determining whether or not a given patient is a candidate for surgery. This is Mark's paper looking at the degree of epidural spinal cord compression, describing that progressively more of the spinal cord is compressed, and the less the patient becomes a candidate for direct pseudotechnic-related surgery, which is, again, a very powerful tool in treating these patients, and separation surgery that he will be talking about is really a way to address this issue when you are trying to treat solid tumors that are really resistant, and the tumor is making contact with the spinal cord. Assessing spinal instability in patients with metastatic disease has also been well-studied now, since it has been developed by Spinal Oncologist Study Group, looking at a variety of factors determining if a given patient with metastatic involvement is stable or unstable, or to what degree they have instability. This is one of the most significant factors determining whether or not the patient is going to need a surgical stabilization procedure done. And then finally, this is an important data looking at the overall survival of the patient, and we were able to classify that based on the patient's primaries, and this is the data from many years ago when I was on the faculty at MD Anderson Cancer Center. We extracted various primary tumor types, and we noted that, for example, the patients with lung cancer did very poorly. Majority of them died after they presented with spinal metastasis within four months. The same was true for melanoma patients. Actually, four-month survival here was generous. In many cases, the patients actually died within two and a half, three months after they presented with spinal metastasis, and the renal cell carcinoma had a survival of about a year. These have changed dramatically now, and I'll show you some data to illustrate that. In the meantime, since then, we sequenced the human genome completely. Many of the cancers have been sequenced as well, and many of the genetic alterations have been recognized, and then not only that, it became clear that classifying the tumors based on the organ of origin may no longer be relevant. Perhaps a better way to classify these tumors based on genotyping or genomic abnormalities of the tumors, and with that, for example, the breast cancer, endometrial CA, and ovarian cancer are more alike than and different, and hence, they are more or less treated the same way from a chemotherapeutic perspective. In the meantime, our cancer specialists have become very sophisticated, started taking advantage of these mutations that have been recognized in a variety of tumors, and in melanoma, for example, BRAF had been recognized as an important genetic alteration, and patients who had metastatic melanoma that were BRAF positive had a drug targeting this mutation, and really, this paper is not that old, from 2011. A patient with widely metastatic disease like that in melanoma case can be really converted to a patient, the one on the left, targeting one single mutation with a single drug in metastatic melanoma, and that alone really improved the patient's survival from somewhere two and a half months after they presented with spinal metastasis. Now, the average survival of a patient with melanoma metastasis is about a year. We also, for example, learned that one can target EGFR amplification in patients with lung cancer, and that had a huge impact in overall survival, and if you look at the genotyping of these tumors, in some patients with specific genetic alteration, the survival rates had improved significantly in this category, and this is using another agent in patients with EGFR mutation, showing that the survivals can even be further improved. For example, here, you're looking at almost 50% 24-month survival in patients with lung cancer. And then the final story is here, the PD-1 checkpoint inhibitors. As a matter of fact, this became so popular, this is just an article in the New England Journal of Medicine showing that the T cells can recognize, actually, the cancer cells, they are histocompatibility antigens, but they are silenced due to the fact that the cancer cells are able to, with a PD-1 ligand, is able to shut off the activity of the T cells, and hence making this tumor destruction null. And as a result of that, I think we have gotten smarter, and by treating the patients with PD-1 inhibitors, we learned that we can outsmart the cancer and actually have very significant improvement in survival. And this is using a PD-1 inhibitor in patients with metastatic melanoma, showing how the survival has improved dramatically compared to those previously. Not only that, as a matter of fact, this really became a part of the decision-making process in patients with metastatic melanoma with spinal involvement. Not only are we now applying the NOMS classification system to this, but also the patients are getting first-line and second-line treatment based on their genetic mutations that they carry in this patient population. And so this is really becoming an integral part of the treatment paradigm. And this is also true for metastatic renal cell carcinoma. As a matter of fact, if you look at the first-line and the second-line treatments, not only REGEP inhibitors, but also PD-1 inhibitors are included here, and resulted in significant improvement in renal cell carcinoma patients with metastasis, increasing the median survival from somewhere a year to almost two years now. And then finally, this is a New York Times article that came out last week, showing that patients with non-small cell lung cancer, when they are treated with PD-1 inhibitor, a checkpoint inhibitor here, compared to the placebo group, you can achieve very substantial improvement in survival, almost two years median survival here, which was really unheard of in patients with lung cancer. And so now in decision-making, not only do we use the NOMS mnemonic in order to analyze the patient, but also we need to be including the genotyping and molecular profiling of the primary tumors in decision-making here, just not the patient's primary tumor type and associated survival, but all of the other factors that have really impacted the patient's outcome already significantly. So in summary, it's fair to say that metastatic spine disease is a very common problem. Both the incidence and the prevalence of the disease is increasing. Highly sophisticated treatment algorithms have been already developed. We have a variety of very effective palliative therapeutic options. Genotyping and molecular profiling of the tumors and targeted therapies are now an integral part of cancer and managing spinal metastases and prognostication. And thus we need, as neurosurgeons, we should be familiar with these recent advances in cancer care and managing spinal metastases. Thank you.

spinal oncology

metastatic spinal tumors

precision medicine

treatment options

neurosurgeons