European Spine Journal

, Volume 27, Issue 4, pp 868–873 | Cite as

Surgeon’s perception of margins in spinal en bloc resection surgeries: how reliable is it?

  • Ran Lador
  • Alessandro Gasbarrini
  • Marco Gambarotti
  • Stefano Bandiera
  • Riccardo Ghermandi
  • Stefano Boriani
Original Article

Abstract

Purpose and Background

En bloc resections aim at surgically removing a tumor in a single, intact piece, fully encased by a continuous shell of healthy tissue—the “margin”. Intraoperative continuous assessment of the plane of resection regarding the tumor’s margins is paramount. The goal of this study was to evaluate the accuracy of experienced spinal tumor surgeons’ perception of these margins.

Methods

A retrospective analysis of a prospectively collected data of 1681 patients affected by spine tumors of whom 217 en bloc resections was performed. Surgeons’ intraoperative assessment was compared to the histopathological assessment.

Results

Most were primary—163 (42 benign and 121 malignant), metastases occurred in 54 cases. ‘Wide’ margins were obtained in 126 cases; ‘marginal’ in 60 cases, and ‘intralesional’ in 31 cases. Surgeons assessed clear margins in 109 cases and contaminated in 108 cases. When considering marginal margins as a contaminated resection, the surgeon’s assessment of clear resection had a sensitivity of 76.89%, specificity of 86.81%, PPV and NPV (positive and negative predictive values) were 88.99 and 73.15%, respectively. Inter-observer agreement was 0.62. When considering marginal margins as a clear resection, the surgeon’s assessment of clear resection had a sensitivity of 64.5%, specificity of 100%, PPV and NPV were 100 and 0%, respectively. Inter-observer agreement was 0.29.

Conclusion

Surgeons are fairly accurate in their intraoperative assessment of clear margins achieved; however, this accuracy is not perfect and exploring ways to improve this intraoperative assessment is of major importance possibly impacting the outcome of the treatment.

Keywords

Margins Spine tumors En bloc resection Intraoperative assessment Recurrence 

Notes

Compliance with ethical standards

Conflict of interest

None.

Financial disclosure

There are no financial disclosures that relate to this paper by any of the attributing authors. There was no material support related to this study.

Funding

No funding or Grant was received for this study, and no NIH Grant was applied for or received.

References

  1. 1.
    Enneking WF (1983) Musculoskeletal tumor surgery, vol 1. Churchill LivingstoneGoogle Scholar
  2. 2.
    Enneking WF (1983) Musculoskeletal tumor surgery. Churchil Livingstone Inc, New YorkGoogle Scholar
  3. 3.
    Stener B (1989) Complete removal of vertebrae for extirpation of tumors: a 20-year experience. Clin Orthop Relat Res 245:72–82Google Scholar
  4. 4.
    Roy-Camille R, Mazel CH, Saillant G, Lapresle PH (1990) Treatment of malignant tumors of the spine with posterior instrumentation. Tumors of the spine: diagnosis and clinical management Saunders, Philadelphia:473–487Google Scholar
  5. 5.
    Tomita K, Kawahara N, Baba H, Tsuchiya H, Fujita T, Toribatake Y (1997) Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors. Spine 22(3):324–333CrossRefPubMedGoogle Scholar
  6. 6.
    Sundaresan N, DiGiacinto GV, Krol G, Hughes JE (1989) Spondylectomy for malignant tumors of the spine. J Clin Oncol 7(10):1485–1491CrossRefPubMedGoogle Scholar
  7. 7.
    Charles GF, Ory K, Michael CB (2005) The surgical management of primary tumors of the spine. Spine 30(16):1899–1908CrossRefGoogle Scholar
  8. 8.
    Boriani S, Schwab J, Bandiera S, Colangeli S, Ghermandi R, Gasbarrini A (2014) Sub-total and total vertebrectomy for tumours. In: European Surgical Orthopaedics and Traumatology. Springer, pp 661–675Google Scholar
  9. 9.
    Boriani S, Biagini R, Bertoni F, Malaguti MC, Di Fiore M, Zanoni A (1996) En bloc resections of bone tumors of the thoracolumbar spine: a preliminary report on 29 patients. Spine 21(16):1927–1931CrossRefPubMedGoogle Scholar
  10. 10.
    Liljenqvist U, Lerner T, Halm H, Buerger H, Gosheger G, Winkelmann W (2008) En bloc spondylectomy in malignant tumors of the spine. Eur Spine J 17(4):600–609CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Biagini R, Casadei R, Boriani S, Erba F, Sturale C, Mascari C, Bortolotti C, Mercuri M (2003) En bloc vertebrectomy and dural resection for chordoma: a case report. Spine 28(18):E368–E372CrossRefPubMedGoogle Scholar
  12. 12.
    Keynan O, Fisher CG, Boyd MC, O’Connell JX, Dvorak MF (2005) Ligation and partial excision of the cauda equina as part of a wide resection of vertebral osteosarcoma: a case report and description of surgical technique. Spine 30(4):E97–E102CrossRefPubMedGoogle Scholar
  13. 13.
    Murakami H, Tomita K, Kawahara N, Oda M, Yahata T, Yamaguchi T (2006) Complete segmental resection of the spine, including the spinal cord, for telangiectatic osteosarcoma: a report of 2 cases. Spine 31(4):E117–E122CrossRefPubMedGoogle Scholar
  14. 14.
    Druschel C, Disch AC, Melcher I, Engelhardt T, Luzzati A, Haas NP, Schaser KD (2012) Surgical management of recurrent thoracolumbar spinal sarcoma with 4-level total en bloc spondylectomy: description of technique and report of two cases. Eur Spine J 21(1):1–9CrossRefPubMedGoogle Scholar
  15. 15.
    Rhines LD, Fourney DR, Siadati A, Suk I, Gokaslan ZL (2005) En bloc resection of multilevel cervical chordoma with C-2 involvement: case report and description of operative technique. J Neurosurg Spine 2(2):199–205CrossRefPubMedGoogle Scholar
  16. 16.
    Bailey CS, Fisher CG, Boyd MC, Dvorak MFS (2006) En bloc marginal excision of a multilevel cervical chordoma: case report. J Neurosurg Spine 4(5):409–414CrossRefPubMedGoogle Scholar
  17. 17.
    Amendola L, Cappuccio M, De Iure F, Bandiera S, Gasbarrini A, Boriani S (2014) En bloc resections for primary spinal tumors in 20 years of experience: effectiveness and safety. Spine J 14(11):2608–2617CrossRefPubMedGoogle Scholar
  18. 18.
    Boriani S, Gasbarrini A, Bandiera S, Ghermandi R, Lador R (2016) Predictors for surgical complications of en bloc resections in the spine: review of 220 cases treated by the same team. European Spine Journal:1–10Google Scholar
  19. 19.
    Hart RA, Boriani S, Biagini R, Currier B, Weinstein JN (1997) A system for surgical staging and management of spine tumors: a clinical outcome study of giant cell tumors of the spine. Spine 22(15):1773–1782CrossRefPubMedGoogle Scholar
  20. 20.
    Boriani S, Bandiera S, Biagini R, Bacchini P, Boriani L, Cappuccio M, Chevalley F, Gasbarrini A, Picci P, Weinstein JN (2006) Chordoma of the mobile spine: 50 years of experience. Spine 31(4):493–503CrossRefPubMedGoogle Scholar
  21. 21.
    Boriani S, De Iure F, Bandiera S, Campanacci L, Biagini R, Di Fiore M, Bandello L, Picci P, Bacchini P (2000) Chondrosarcoma of the mobile spine: report on 22 cases. Spine 25(7):804–812CrossRefPubMedGoogle Scholar
  22. 22.
    Stener B, Henriksson C, Johansson S, Gunterberg B, Pettersson S (1984) Surgical removal of bone and muscle metastases of renal cancer. Acta Orthopaedica 55(5):491–500CrossRefGoogle Scholar
  23. 23.
    Sakaura H, Hosono N, Mukai Y, Ishii T, Yonenobu K, Yoshikawa H (2004) Outcome of total en bloc spondylectomy for solitary metastasis of the thoracolumbar spine. J Spinal Disorders Techniq 17(4):297–300CrossRefGoogle Scholar
  24. 24.
    Matsumoto M, Tsuji T, Iwanami A, Watanabe K, Hosogane N, Ishii K, Nakamura M, Morioka H, Toyama Y (2013) Total en bloc spondylectomy for spinal metastasis of differentiated thyroid cancers: a long-term follow-up. J Spinal Disorders Techniq 26(4):E137–E142CrossRefGoogle Scholar
  25. 25.
    Boriani S, Bandiera S, Casadei R, Boriani L, Donthineni R, Gasbarrini A, Pignotti E, Biagini R, Schwab JH (2012) Giant cell tumor of the mobile spine: a review of 49 cases. Spine 37(1):E37–E45CrossRefPubMedGoogle Scholar
  26. 26.
    Boriani S, Weinstein JN, Biagini R (1997) Primary bone tumors of the spine: terminology and surgical staging. Spine 22(9):1036–1044CrossRefPubMedGoogle Scholar
  27. 27.
    Bacci G, Ferrari S, Mercuri M, Bertoni F, Picci P, Manfrini M, Gasbarrini A, Forni C, Cesari M, Campanacci M (1998) Predictive factors for local recurrence in osteosarcoma 540 Patients with extremity tumors followed for minimum 2.5 years after neoadjuvant chemotherapy. Acta Orthopaedica 69(3):230–236CrossRefGoogle Scholar
  28. 28.
    Boriani S, Bandiera S, Donthineni R, Amendola L, Cappuccio M, De Iure F, Gasbarrini A (2010) Morbidity of en bloc resections in the spine. Eur Spine J 19(2):231–241CrossRefPubMedGoogle Scholar
  29. 29.
    Roy-Camille R, Monpierre H, Mazel Ch SG (1990) Technique de vertebrectomie totale lombaire. Rachis Dorsal et Lombaire Septieme Journees d’Orthopedie de la Pitié Masson, Paris:49–52Google Scholar
  30. 30.
    Di Fiore M, Lari S, Boriani S, Fornaro G, Perin S, Malferrari A, Zanoni A (1997) Major vertebral surgery: intra-and postoperative anaesthesia-related problems. La Chirurgia degli organi di movimento 83(1–2):65–72Google Scholar
  31. 31.
    Otsuka NY, Hey L, Hall JD (1998) Postlaminectomy and postirradiation kyphosis in children and adolescents. Clin Orthop Relat Res 354:189–194CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Ran Lador
    • 1
  • Alessandro Gasbarrini
    • 2
  • Marco Gambarotti
    • 3
  • Stefano Bandiera
    • 2
  • Riccardo Ghermandi
    • 2
  • Stefano Boriani
    • 2
  1. 1.Unit of Spine SurgeryTel-Aviv Medical CenterTel-AvivIsrael
  2. 2.Unit of Oncologic Spine Surgery, Department of Oncologic and Degenerative Spine SurgeryRizzoli InstituteBolognaItaly
  3. 3.Unit of PathologyRizzoli InstituteBolognaItaly

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