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The role of embolization in radical surgery of renal cell carcinoma spinal metastases

  • Clinical Article
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Abstract

Background

Radical surgery of renal cell carcinoma spinal metastases carries a high risk due to potentially life-threatening extreme blood loss. Radical preoperative embolization of renal cell carcinoma metastases alone is not necessarily a guarantee of extreme blood loss not occurring during operation.

Methods

A retrospective analysis of 15 patients following radical surgery for a spinal metastases of a renal cell carcinoma was performed. Eight patients were embolized preoperatively and 7 were not. We analysed features influencing peroperative blood loss: size and extent of tumour, complexity of surgical approaches and radicality of embolization.

Results

The embolized and non embolized groups were not comparable before treatment. They differed markedly in size of tumour as well as the complexity of approach. In the embolized group the size of the tumour was, on average, twice as large as that in non embolized patients and more complex approaches were used twice as frequently. Despite findings suggesting that embolization was effective, blood loss was greater in the embolized group of 8 patients (4750 ml), compared to the non-embolized group of 7 patients (1786 ml).

Conclusion

Metastasis size, extent of tumour, technical complexity of surgery and the completeness of preoperative embolization had an important effect on the amount of peroperative blood loss. The evaluation of the benefits of preoperative embolization only on the basis of blood loss is not an adequate method.

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Acknowledgment

This study was supported by a grant of the Ministry of Health, Czech republic (grant No: IGA MZCR NR 7953–3/2004).

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Charles University, Teaching Hospital, Hradec Kralove, Czech Republic

    S. Řehák, M. Kanta & M. Bartoš

  2. Department of Radiology, Charles University, Teaching Hospital, Hradec Kralove, Czech Republic

    A. Krajina, L. Ungermann & P. Ryška

  3. Department of Anaesthesiology, Resuscitation and Intensive Medicine, Charles University, Teaching Hospital, Hradec Kralove, Czech Republic

    V. Černý

  4. Department of Neurology, Charles University, Teaching Hospital, Hradec Kralove, Czech Republic

    R. Taláb

Authors
  1. S. Řehák
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  2. A. Krajina
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  3. L. Ungermann
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  4. P. Ryška
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  5. V. Černý
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  6. R. Taláb
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  7. M. Kanta
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  8. M. Bartoš
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Corresponding author

Correspondence to S. Řehák.

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Comment

Rehak et al. retrospectively analyzed 15 cases of spinal renal cell carcinoma metastases, operated on during a 9 year period. One major problem of this kind of secondary tumour manifestation close to the spinal cord is its hypervascularization, which risks extensive, sometimes life-threatening, bleeding and/or post-operative neurological deterioration. Therefore, pre-operative embolization is favoured by many surgeons prior to attempting complete tumour removal or even before decompressive surgery. The available scientific literature on pre-surgical embolization does suggest lower operative complication rates and better patient outcomes after pre-surgical embolization. Unfortunately, past reports are based on small case series and have not led to any widely accepted recommendations about when or when not to embolize RCC etastases. The strength of this paper from Rehak et al. is that it begins to develop reflections on the process of decision making concerning pre-operative tumour embolization, its effectiveness and limits, and the risk of blood loss despite embolization of metastases. Even with embolization, surgery with the aim of complete removal of a hypervascuralized spinal tumour remains a risky procedure, as the 1 mortality from 8 embolized patients in the authors’ series showed. The authors did not find any statistically significant predictors of whether or not to embolize, except the estimated risk of intraoperative blood loss according to the surgeon’s personal opinion. Thus, 2 of 7 cases without embolization had to be stopped before complete tumour removal because of extreme blood loss. So what we can learn from this study is that surgeons should seriously consider pre-operative embolization, at least when there are hypervascularized spinal metastasis exceeding the bony structures of the affected vertebra with infiltrating paravertebral tumour extension, and when the surgical aim is complete resection via a combined dorso-ventral approach. But it still remains unclear whether there is any benefit from embolization for smaller tumours (which can be removed via a posterior approach alone). Rehak et al. have made a valuable contribution by reporting their cases and initiating renewing discussion on the surgical treatment of RCC metastases. Now studies with larger sample sizes or metaanlyses of past studies are needed to determine more clearly the benefits and risks of performing pre-operative embolization or not.

Olaf Suess

Department of Neurosurgery, Charité,

Berlin, Germany

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Řehák, S., Krajina, A., Ungermann, L. et al. The role of embolization in radical surgery of renal cell carcinoma spinal metastases. Acta Neurochir (Wien) 150, 1177–1181 (2008). https://doi.org/10.1007/s00701-008-0031-5

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  • DOI: https://doi.org/10.1007/s00701-008-0031-5

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