Patient: 78-year-old female Presentation: 15-year history of chronic mechanical back pain, 3-month history of new-onset right thigh pain radiating to knee, associated with new-onset difficulty walking and progressive weakness, unintentional 8kg weight loss Relevant history: No known prior malignancy, 30-pack-year smoking history (ceased 10 years ago), no previous spinal surgery Examination findings:
| Test | Result | Normal Range | Interpretation |
|---|---|---|---|
| Haemoglobin | 98 g/L | 120-160 | Anaemia of chronic disease |
| WCC | 8.2 × 10⁹/L | 4-11 | Normal |
| Platelets | 345 × 10⁹/L | 150-400 | Normal |
| ESR | 78 mm/hr | 0-20 | Elevated - malignancy/inflammation |
| CRP | 45 mg/L | <5 | Elevated |
| Sodium | 141 mmol/L | 135-145 | Normal |
| Potassium | 4.2 mmol/L | 3.5-5.0 | Normal |
| Creatinine | 95 μmol/L | 60-110 | Normal |
| Calcium (corrected) | 2.85 mmol/L | 2.15-2.55 | Hypercalcaemia |
| Albumin | 28 g/L | 35-50 | Low (malnutrition/chronic disease) |
| ALP | 245 U/L | 30-120 | Elevated - bone/liver |
| LDH | 380 U/L | 120-250 | Elevated |
| PSA | N/A | - | Not applicable (female) |
| CA 15-3 | 145 U/mL | <30 | Elevated (breast marker) |
| CEA | 8.5 ng/mL | <5 | Mildly elevated |
| Protein electrophoresis | No paraprotein | - | Myeloma excluded |
Image 1: Plain Radiograph Lumbar Spine - AP and Lateral
Radiological features:
Image 2: MRI Whole Spine with Gadolinium
MRI findings:
Image 3: CT Chest/Abdomen/Pelvis
CT staging findings:
What is your differential diagnosis and what investigations would you order to identify the primary tumour?
How do you assess prognosis in metastatic spinal disease? What scoring systems are used?
What is the role of biopsy? How would you obtain tissue for diagnosis?
What are the treatment options for this patient? Discuss the role of surgery, radiotherapy, and systemic therapy.
The patient develops acute worsening of leg weakness (now 2/5 bilaterally). What is your management?
What factors predict neurological recovery after surgery for MSCC? How would you counsel this patient's family?
This pattern suggests Metastatic Spinal Disease:
Comparison - Primary vs Metastatic Spinal Tumour:
| Feature | Primary Tumour | Metastatic |
|---|---|---|
| Age | Often younger | Usually >50 |
| History of cancer | No | Often yes |
| Number of lesions | Usually single | Often multiple |
| Systemic symptoms | Less common | Common |
| Visceral disease | No | Often present |
| Treatment intent | Often curative | Usually palliative |
Q: "What is the difference between Tokuhashi and Tomita scores?"
| Aspect | Tokuhashi | Tomita |
|---|---|---|
| Focus | Survival prediction | Treatment strategy |
| Factors | 6 parameters | 3 parameters |
| Primary | Specific types listed | Grouped by growth rate |
| Output | Predicted survival | Treatment recommendation |
| Use | Deciding treatment intensity | Surgical planning |
Q: "What is 'separation surgery'?"
| Concept | Description |
|---|---|
| Goal | Create 2-3mm gap between tumour and spinal cord |
| Technique | Posterior decompression, epidural tumour removal |
| Purpose | Allow high-dose SBRT without cord injury |
| Indication | Radioresistant tumours (RCC, melanoma, lung) |
| Outcome | Better local control than RT alone |
Q: "When would you consider en bloc resection for spinal metastasis?"
| Criterion | Requirement |
|---|---|
| Solitary metastasis | Only spinal lesion |
| No visceral disease | Or completely resected |
| Good prognosis | Tokuhashi ≥9, life expectancy >12 months |
| Radioresistant primary | RCC, thyroid, where RT less effective |
| Technically feasible | Contained lesion, experienced team |
En bloc is rarely performed - most patients have disseminated disease.