Kaohsiung J Med Sci November 2007 • Vol 23 • No 11 573
In 1997, we presented an analysis of intraspinal tumors in south Taiwan [1]. In total, 120 cases of intraspinal tumors diagnosed and surgically treated at Kaohsiung Medical College Hospital between 1988 and 1995 were assessed, and the results were compared with those from other series. This previous study showed that the four most common histologic types of spinal tu-mors were nerve sheath tutu-mors (40%), metastatic tumors (23.3%), meningiomas (11.7%) and neuroepi-thelial tumors (8.3%).
The next decade was marked by improved avail-ability and quality of noninvasive imaging modalities, especially magnetic resonance imaging (MRI), which has facilitated diagnosis and management [2]. Because the age of the patient population in Taiwan is increasing rapidly [3], the epidemiology of spinal tumors may change. The purpose of this survey was to assess spinal tumor occurrence in Taiwan during a recent 5-year pe-riod and compare this assessment with the one we re-ported in 1997, and with those of other rere-ported series.
M
ATERIALS ANDM
ETHODSThe medical histories of 117 consecutive patients who were surgically treated for intraspinal tumors between January 1999 and April 2004 in the Department of Received: March 19, 2007 Accepted: July 11, 2007
Address correspondence and reprint requests to: Dr Chih-Jen Wang, Department of Neurosurgery, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan.
E-mail: suyufeng2000@yahoo.com.tw
A
NALYSIS OF
S
URGICALLY
T
REATED
I
NTRASPINAL
T
UMORS IN
S
OUTHERN
T
AIWAN
Yu-Feng Su,1,3Ann-Shung Lieu,1,2,3Chih-Lung Lin,1,2,3Kung-Shing Lee,1,2Yen-Fen Hwang,1
Chun-Po Yen,2,3,4Chih-Zen Chang,1,2,3Joon-Khim Loh,1,2,3Tzuu-Yuan Huang,1,2Shiuh-Lin Hwang,1,2
Aij-Lie Kwan,1,2Sheng-Long Howng,1,2and Chih-Jen Wang1,2
1Department of Neurosurgery, Kaohsiung Medical University Hospital, 2Department of Surgery, Faculty of Medicine, and 3Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University,
and4Department of Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan.
The medical records of 117 patients with spinal tumors who underwent surgery with pathologic confirmation from January 1999 to April 2004 at Kaohsiung Medical University Hospital were reviewed. Data from this review were compared with those obtained from the same institution 10 years earlier (covering the period 1988–1995) and from other reported series. There were 69 male and 48 female patients aged from 13 to 87 years old (mean age, 51.9). The most common patho-logic findings were metastasis in 45.3% (53/117), nerve sheath tumors in 28.2% (33/117), menin-giomas in 12% (14/117) and neuroepithelial tumors in 6% (7/117). The peak ages at diagnosis were 41–50 years and 61–70 years. A slight male predominance was noted for all tumors, except meningiomas. Motor weakness, even paralysis, was the major clinical presentation (64–86%), fol-lowed by sensory deficits (50%) and pain (42%). The location of tumors was most often in the thoracic (50.4%; 59/117), lumbosacral (27.4%; 32/117) and cervical spine (22.2%; 26/117) seg-ments. Among the metastatic tumors, the lung (22.6%) and breast (15.1%) were the most common primary sites of origin, followed by unknown origin, the liver (hepatocellular carcinoma), the gastrointestinal tract and the nasopharynx (nasopharyngeal cancer).
Key Words:intraspinal tumor, spinal metastasis, statistics, Taiwan (Kaohsiung J Med Sci 2007;23:573–8)
Neurosurgery of Kaohsiung Medical University Hos-pital were reviewed. Basic personal profiles, topogra-phy and anatomic location of the tumors, histologic classification, and primary site of metastatic tumor ori-gin were obtained from the clinical records. The data were compared with data from our previous report in 1997, and also with data from the series reported by Shih, Lin and Changchien in Taiwan [4,5], Chi and Khang [6] and Suh et al [7] in Korea, Cheng [8] and Huang [9] in China, and Ardehali in Iran [10].
R
ESULTSThere were 69 male and 48 female patients aged from 13 to 87 years old (mean, 51.9 years). The relative fre-quencies of the 117 intraspinal tumors are given in Table 1. The pathologic findings (in the order of most to least frequent) revealed metastatic tumors in 45.3% (53/117), nerve sheath tumors in 28.2% (33/117), meningiomas in 12% (14/117), neuroepithelial tumors in 6% (7/117) and others (Table 2).
A slight male predominance was noted for all tumors (overall male/female ratio of 69/48= 1.44:1), except for meningiomas which had an M/F ratio of 3/11 (1:3.6).
Peak frequencies of spinal tumors occurred in two age groups: 41–50 years old (23.1%) and 61–70 years old (19.7%) (Table 3). The average age of the patients at the time of surgery was 51.9 years old (48.1 in females and 53.8 in males). Only 2.6% (3/117) of spinal tumors occurred in persons under 20 years of age. Histologic results revealed ependymoma, epi-dermal cyst and thoracic spinal seeding of cerebellar medulloblastoma.
Tumors were most often located in the thoracic (50.4%; 59/117), lumbosacral (27.4%; 32/117) and cervical spine (22.2%; 26/117) segments (Table 4). Metastatic tumors were the most frequent histologic finding in the cervical segment (42.3%; 11/26) and thoracic segment (47.5%; 28/59). In the lumbosacral segment, the two most frequent histologic findings were metastatic tumor (43.8%; 14/32) and nerve sheath tumor (40.6%; 13/32). Meningiomas tended to be found in the thoracic spine (71.4%; 10/14).
Most intraspinal tumors occurred in the extra-dural (ED) space (51.3%; 60/117) or the intraextra-dural– extramedullary (ID–EM) space (38.5%, 45/117) Table 1.Histologic classification, sex distribution,
num-ber of cases and relative incidence of 117 intraspinal tumors
Male Female n (%)
Metastasis 35 18 53 (45.3) Nerve sheath tumor 21 12 33 (28.2) Meningioma 3 11 14 (12.0) Ependymoma 4 2 6 (5.1) Epidermal cyst 1 2 3 (2.6) Lipoma 0 1 1 (0.9) Multiple myeloma 1 0 1 (0.9) Hemangioma 1 0 1 (0.9) Astrocytoma 1 0 1 (0.9) Chordoma 0 1 1 (0.9) Fibrous histiocytoma 1 0 1 (0.9) Tendosheath fibroma 1 0 1 (0.9) Glomangioma 0 1 1 (0.9) Total 69 48 117 (100)
Table 2.Clinical presentation and relationship with major pathologic classifications
Pain (%) Sensory deficit (%) Weakness (%) Paralysis (%) Cases (%) All intraspinal tumors 37.5 44.6 55.4 16.1 100 Metastasis 29.6 33.3 44.4 33.3 45.3 Nerve sheath tumor 62.5 43.8 43.8 28.2 Meningioma 18.2 72.7 90.9 12.0 Neuroepithelial tumor 50.0 75.0 6.0
Table 3.Incidence of 117 intraspinal tumors according to age and sex
Age (yr) Male Female Cases, n (%) 1–10 11–20 2 1 3 (2.6) 21–30 2 2 4 (3.4) 31–40 12 11 23 (19.7) 41–50 15 12 27 (23.1) 51–60 12 9 21 (17.9) 61–70 13 10 23 (19.7) 71–80 11 3 14 (12.0) > 80 2 0 2 (1.7) Total 69 48 117 (100)
(Table 5). The most common ED tumors were metasta-tic tumors (86.7%; 52/60). Nerve sheath tumors (64.4%; 29/45) and meningiomas (31.1%, 14/45) were the most commonly found ID–EM tumors. Intramedullary (IM) tumors accounted for 8.5% (10/117). Neuroepithelial tumors, including ependymoma and astrocytoma, were the most common IM tumors (70%; 7/10). In only two cases (1.6%) did tumors occur in both the ED and ID spaces, and both of these were neurilemmomas.
In this series, there were 53 cases with metastatic tumors. The most often involved segment was the tho-racic spine (52.8%; 28/53). The most common primary sites of origin for metastasized spinal tumors were lung (22.6%, 12/53) and breast (15.1%; 8/53) (Table 6), with unknown primary cancers accounting for 15.1% (8/53), and hepatic cell carcinoma (HCC), gastroin-testinal tract cancer, nasopharyngeal cancer, thyroid cancer, and others accounting for the rest.
A comparison of the histologic classification, num-ber of cases and relative incidence of intraspinal tumors in other reports is shown in Table 7. In our series, metastatic tumors have become the most common spinal lesions rather than nerve sheath tumors. The distribution of the histologic classification in this series was similar to that reported by Ardehali in Iran [10].
Nerve sheath tumors were the main intraspinal tumor surgically treated in Korea and China [6–9].
D
ISCUSSIONThe anatomic and gender distribution of spinal tumors found in this study are similar to those in our previous study and other reported series [1,7,11–14]. However, Table 5.Incidence of 117 spinal tumors according to sites
ED ED+ ID IDEM IM Cases, n (%)
Metastasis 52 1 53 (45.3)
Nerve sheath tumor 2 2 29 33 (28.2)
Meningioma 14 14 (12.0)
Ependymoma 6 6 (5.1)
Epidermal cyst 3 3 (2.6)
Others 6 1 1 8 (6.8)
Total 60 (51.3%) 2 (1.7%) 45 (38.5%) 10 (8.5%) 117 (100)
ED= extradural; ID = intradural; IDEM = intradural–extramedullary; IM = intramedullary.
Table 6.Metastatic tumors and their primary sites Site of primary tumor Cases, n (%) Lung 12 (22.6) Breast 8 (15.1) Unknown 8 (15.1) Hepatocellular carcinoma 6 (11.3) Gastrointestinal tract 6 (11.3) Nasopharyngeal cancer 3 (5.7) Thyroid 2 (3.8) Ureter 2 (3.8) Kidney 2 (3.8) Sarcoma 2 (3.8) Lymphoma 1 (1.9) Skin SCC 1 (1.9) Total 53 (100)
SCC= squamous cell carcinoma.
Table 4.Distribution of spinal tumors by segmental location and pathology classification
C T LS Cases, n (%) Metastasis 11 28 14 53 (45.3) Nerve sheath tumor 7 13 13 33 (28.2) Meningioma 2 10 2 14 (12.0)
Ependymoma 2 4 0 6 (5.1)
Epidermal cyst 1 2 0 3 (2.6)
Others 3 2 3 8 (6.8)
Total 26 (22.2%) 59 (50.4%) 32 (27.4%) 117 (100)
several important changes have taken place during the recent 5-year period.
First, metastatic tumors have become the most com-mon spinal lesions, rather than nerve sheath tumors. The frequency of metastatic tumors is clearly increas-ing, especially in Taiwan (see Table 7) [1,5,15]. This may be the result of increased availability and improved quality of noninvasive imaging modalities, especially MRI [2]. A much lower incidence of metastatic tumors was noted in Korea [6,7], Japan and China. Some epi-demiologic surveys have tried to assess the trends in central nervous system tumor occurrence over time, and the differences in their incidence. However, these surveys vary in their uniformity of case definition and ascertainment or in study methodologies [6,16,17].
Second, since our 1997 report [1], the age distribu-tion of patients with spinal tumors has changed by a decade. The average age at diagnosis and surgery has increased (44.4 vs. 51.9 years). This may be a result of advances in technology and care, aging of the popu-lation, and the trend toward more aggressive treatment of older patients in recent years. Male patients were older than female patients (53.8 vs. 48.1 years). This is the opposite of our 1997 result (40.2 vs. 49.3 years). In the present study, more than half of the intraspinal tumors occurred between age 30 and 60 years (60.7%). There were two peak ages: 41–50 and 61–70 years old. Since the 1997 report, the percentage of patients aged > 60 years old has increased (20% vs. 33.4%). Both this and our previous study showed that, most commonly, intraspinal tumors in patients aged > 60 years old are metastatic.
Third, the two most common primary sites of me-tastatic spinal tumor origin were lung and breast, fol-lowed by unknown origin, HCC, gastrointestinal tract, and nasopharynx. Lung and breast were also reported to be the most common primary sites of origin in
industrialized countries [18–21]. However, it has also been suggested that the incidence of spinal epidural metastases depends on the incidence of the primary tumor [22]. Our results reflect the fact that the incidence of HCC and nasopharyngeal cancer is higher in Taiwan than other industrialized countries. With improve-ments in cancer diagnosis and management, metastatic cancers of unknown origin became less frequent and fell to third place among metastatic cancers, compared with our data in 1997 (Table 7).
Finally, motor weakness and even paralysis were diagnosed in a high percentage of patients (Table 2), especially in patients with metastatic tumors (77.7%) and meningiomas (90.9%). MRI and computed tomog-raphy remain the two most useful tools for diagnosis and management. Sagittal T1-weighted MRI of the entire spine is a rapid and sensitive screening test that can be performed at modest cost [22].
Although epidemiologic surveys of the occurrence of central nervous system tumors to determine trends over time are difficult to carry out, we assessed the occurrence of intraspinal tumors during a recent 5-year period and compared it with a similar assessment at the same institute in 1997. Anatomic and gender dis-tributions were similar between studies. Changes in the relative frequencies of histologic classification, primary site of metastatic tumor origin, and age distribution at diagnosis were demonstrated.
A
CKNOWLEDGMENTSThis study received assistance from the patient-registry system of the Neurosurgery Department in Kaohsiung Medical University Hospital and from Lin Pei-Chen R.N., Ms Lin Yen-Chin, Shu Yue-Hua R.N., Yen Yi-Chin R.N., and Cheng Yu-Hsin R.N.
Table 7.Histologic classification, number of cases and relative incidence of spinal tumors in comparison to other reports
Country Taiwan Taiwan Taiwan Korea Iran China Author Su Cheang Shih Suh Ardehali Huang Reference This study 1 4 7 10 9 Year 2004 1997 1978 2002 1990 1982 Cases, n 117 120 277 151 179 2,355 Metastasis 45.3 23.2 17.3 4.6 39.6 4.6 Nerve sheath tumor 28.2 40.0 40.3 37.1 24.5 47.1 Meningioma 12.0 11.7 11.5 23.8 20.1 14.0 Neuroepithelial tumor 6.0 9.2 4.0 17.2 10.0 10.8
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