A retrospective review was performed of 30 consecutive patients surgically treated for metastatic SCC secondary to SCLC in our spine tumor center between January 2009 and January 2019. This study was approved by the ethics committee of Changzheng Hospital, confirmation of patient written informed consent was obtained from all patients. All procedures performed in studies involving human participants were in accordance with the Declaration of Helsinki.

The clinical and operative records, radiographic images, and pathological reports of all 30 patients were reviewed by two individual researchers. Visual Analogue Scale (VAS), Frankel Grade, and Eastern Cooperative Oncology Group performance score (ECOG-PS) were used to evaluate the degree of pain, neurological status, and performance status, respectively. Positron emission tomography-computed tomography (PET-CT) was done to find possible metastatic sites.

The surgical decision-making was made on the guidance of NOMS framework,14,15 SINS classification system,16 and Bilsky epidural SCC scale.17 Generally, indications for surgery were neurologic deficits caused by SCC, spinal instability or a combination of these, and all operative patients were considered to have the ability to tolerate the proposed intervention based on the extent of systemic comorbidities and tumor burden, and a life expectancy of more than 3 months. The surgical protocol was circumferential decompression of the spinal cord, tumor excision, reconstruction and stabilization of the spine. Cisplatin dissolved in distilled water was applied to soak the surgery field for intraoperative chemotherapy except when the dura was broken.

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Clinical management of metastatic SCC caused by SCLC requires a multidisciplinary approach which integrates surgeons, oncologists, radiotherapists and histologists, etc. The combination of cisplatin and etoposide was used as first-line chemotherapy. Postoperative radiotherapy was performed for local control of the residual tumor. Bisphosphonate (zoledronic acid) was administered to help prevent skeletal-related events. Immunotherapy (PD-1 immune checkpoint inhibitor, pembrolizumab, nivolumab, and toripalimab) was also selected on the basis of personalized evaluation. Chemotherapy, radiotherapy, bisphosphonate therapy, and immunotherapy were performed by our multidisciplinary team.

Patients were followed up at 2, 6, and 12 months after surgery, every 6 months for the next 2 years, and once a year thereafter. Overall survival (OS) was defined as the interval between the date of the spinal surgery for metastatic SCLC in our center and the date of death or until June 2019 for alive patients. The last status of patients was obtained from office visit or telephone interview.

Patient-reported QoL was evaluated by the three‐level EuroQol-five-Dimensions (EQ-5D-3L) instrument, which is one of the most frequently applied QoL measurements with five dimensions (mobility, self‐care, usual activities, pain/discomfort, and anxiety/depression). The Chinese-language version of the EQ-5D-3L questionnaire was administered before surgery and at 2-months follow-up for our patients. All EQ-5D-3L questionnaire data were collected and checked by two individual researchers, and missing data were minimized through telephone calls. The overall EQ-5D-3L utility scores (range −1 to 1) were calculated based on the Chinese utility values,18 in which an overall utility score of zero represents death, 1 represents full health, and a negative value indicates that the health state may be even worse than death.

All statistical calculations were performed by SPSS Statistics, version 22.0 (IBM corp., New York, USA). The Kaplan–Meier method was adopted to estimate the OS time, with Log-rank test to identify the difference. Factors with P values less than 0.05 were considered statistically significant and subjected to multivariate analysis using the Cox proportional hazards model to further identify factors that independently predicted survival. Comparison between preoperative EQ-5D-3L utility scores with utility scores at 2-months follow-up was conducted by Student’s t test. All tests of significance were two‐sided, and P < 0.05 was considered statistically significant.


Patient Descriptions

The characteristics of 30 patients are shown in Table 1. The series was comprised of 26 men and 4 women, with a mean age of 60.8 years (median 61.5, range 30 to 80). Before finding their primary foci in lung, 24 (80%) patients identified metastatic disease in the spine initially with the common symptom of persistent back or radiative pain. Notably, 13 (43%) patients presented with incomplete paralysis before surgery. SCC of 4 patients located in the cervical spine, 15 patients in the thoracic spine, 11 patients in the lumbar spine. Vertebral tumors were identified in 21 patients, and intraspinal tumors were observed in 9 patients (5 extramedullary-intradural and 4 intramedullary). All patients with vertebral tumor scored higher than 7 in SINS system (range 8 to 17), and the scores of 8–12 and 13–17 were documented in 9 and 12 patients, respectively. According to Bilsky epidural SCC score, all patients with vertebral tumor were classified as Grade 2.

Table 1


All patients in our series received urgent surgical treatment within 72 hours after diagnosis of SCC. Total resection of spinal tumor was performed in 22 patients, while 8 patients underwent subtotal resection. Postoperative radiotherapy was further performed in 12 patients. For the primary lung tumor, surgery and radiotherapy were performed in 4 and 3 patients, respectively. Systematic chemotherapy was prescribed to all patients, but 2 of them failed to receive chemotherapy due to the poor general condition. 20 patients were treated with bisphosphonate to inhibit osteolysis. After assessment by oncologists and pulmonary physicians, 11 patients further received immunotherapy of PD-1 immune checkpoint inhibitor.

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