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Adler et al. J Cancer Metastasis Treat 2019;5:45 I http://dx.doi.org/10.20517/2394-4722.2019.03 Page 5 of 12

Table 7. Tomita-Score [50]
Prognostic factor Score
Tumor growth
Slow (Breast, Prostata, Thyroid) 1
Moderate (Kidney, Uterus) 2
Rapid (Lung, Liver, Stomach, Colon, CUP) 3
Viscerale metastases
None 0
Treatable 2
Not treatable 4
Bone metastases
Solitary 1
Multiple 2

Table 8. Interpretation of the Tomita-Score [50]
Score Mean survival time (months) Treatment goal Recommendation
2-3 50 Local long-term monitoring Wide or marginal excision
4-5 23.5 Local mid-term monitoring Tumor bordering or intralesional excision
6-7 15 Local short-term monitoring Palliative surgery
8-10 6 Terminal supply phase Limited palliative surgery or no operative intervention

THERAPEUTIC OPTIONS REGARDING SPINAL METASTASES
With an incidence of 85% breast cancer metastases to the spine may lead to instability with pain, pathologic
fractures and neurologic deficits in up to 10% [21,29,46] . Furthermore, there are severe socioeconomic aspects
with 50% of woman have to change the working environment and 37% of woman involved can temporarily
[4]
or permanently work no longer . The primary therapy of painful metastases to the spine without relevant
loss of stability is radiation and spine surgeons are not necessarily involved. Potentially unstable and painful
[42]
lesions with a SIN Score > 7 (+/-neurological deficits) are demonstrated to the consulting spine surgeons.
Mandatory in every patient is a critical individual evaluation of prognosis to choose correct therapy
options [4,8,11,14,21,29,35,38,45-48] . Improving or maintaining the quality of life is the decisive therapeutic target in an
incurable palliative situation. Wishes and priorities of these patients beside the status of metastases, previous
[4]
therapy lines and general condition mainly influence the appropriate treatment .

Beside local radiation orthotic devices are the main conservative treatment tools to stabilize the spinal
column and reduce pain. Concomitantly as systemic osteoprotective therapy a bisphosphonate in
combination with calcium and Vitamin D or Denosumab (monoclonal antibody) mark the standard additive
medication in advanced breast cancer with bone metastases. With the best response in diverse tumor entities
up to 62% of recalcification post radiatio is described in breast cancer spinal metastases [4,8,21,47,49,50] .

Various surgical treatment options can reduce pain and stabilize the spine. Bilateral, percutaneous balloon
kyphoplasty as a minimal invasive treatment tool [13,36,46,47,49,51-54] may not restore vertebral height but
correlates with pain reduction. Thermal ablation of vertebral metastases with radio frequency ablation
(RFA) [50,53,55-57] may be combined with kyphoplasty to reduce the likelihood of tumor recurrence. Posterior
instrumentation with a screw and rod system is the gold standard in spine surgery to stabilize unstable
tumor lesions. In case of spinal stenosis due to tumor the decompression of neural structures is reached via
[19]
laminectomy and tumor debulking [13,29,43,46,47,50,52-55] . According to Tomita et al palliative anterior surgery
with vertebral body replacement (VBR) [Figures 1-3] can be recommended in patients with a life expectancy
> 12 months [46,47,58,59] . Highly invasive surgical options like en-bloc spondylectomy in Tomita technique or
vertebral column resection with a mandatory 360 reconstruction [Figure 4] mark curative treatment options
in case of solitary spinal metastases [46,47,58,59] .