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Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 119-123

Prognostic evaluation of patients with metastatic spinal tumors using modified Tokuhashi's score: A retrospective study

Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission09-Oct-2019
Date of Acceptance03-Nov-2019
Date of Web Publication10-Jan-2020

Correspondence Address:
Dr. Aiman Mohammed
Department of Radiation Oncology, Nizamfs Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJNO.IJNO_16_19

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Introduction: Tokuhashi's scoring has been used as a presurgical tool for prediction of survival in patients with spinal metastases (SM). It evaluates prognostic factors such as performance status, number of extraspinal bone metastasis, metastasis to visceral organs, site of primary, and neurological status that determine the survival in these patients. To the best of our knowledge, only limited studies are available to use this scoring system to determine survival outcomes in patients with SMs undergoing palliative radiotherapy.
Aim: The purpose of our study was to determine the patient characteristics and usefulness of modified Tokuhashi's score in determining survival in patients with SM.
Methods: This is a retrospective study of patients who underwent radiotherapy for SM from January 2013 to December 2017.
Results: Seventy patients with SM from solid tumors were included in the study. The male to female ratio was 1.3:1. The median ageat diagnosis of SM was 50 years. The median survival was 7 months. The modified Tokuhashi's score ranged from 0 to 13, and the mean score was 6. In our study, 46 belonged to the poor prognostic group, 20 belonged to the moderate prognostic group, and 4 patients belongedto good prognostic group with a median survival of 4.8, 13.5, and 28 months, respectively. There was a statistical significance in the difference in survival in three prognostic groups.
Conclusion: Our study confirms the usefulness of modified Tokuhashi's score in determining the survival outcomes in patients with metastatic spinal tumors.

Keywords: Metastatic cord compression, prognostic evaluation, spinal tumors

How to cite this article:
Mohammed A, Irukulla MM, Ahmed SF, Valiyaveettil D. Prognostic evaluation of patients with metastatic spinal tumors using modified Tokuhashi's score: A retrospective study. Int J Neurooncol 2019;2:119-23

How to cite this URL:
Mohammed A, Irukulla MM, Ahmed SF, Valiyaveettil D. Prognostic evaluation of patients with metastatic spinal tumors using modified Tokuhashi's score: A retrospective study. Int J Neurooncol [serial online] 2019 [cited 2023 Mar 26];2:119-23. Available from: https://www.Internationaljneurooncology.com/text.asp?2019/2/2/119/275533

  Introduction Top

The spine is the most common location for bone metastases.[1] Symptomatic spinal metastasis afflicts up to 10% of cancer patients.[2] Spinal involvement occurs in up to 40% of patients with cancer during the progression of the disease, with 5%–10% of these patients developing epidural compression at some points of their progression.[3] More than 90% of the spinal metastases (SM) are extradural, whereas about 5% are intradural and <1% is intramedullary.[4] Symptomatic compression occurs more frequently in the thoracic spine, followed by the lumbar spine and the cervical spine.[5] In addition, important is the fact that by the time of diagnosis, multiple lesions can be found at noncontiguous levels in up to 40% of the patients.[6]

The combination of several imaging techniques affords higher sensitivity and specificity.[7] In carefully selected patients, surgery remains the treatment of choice improving the pain, function, and quality of life.[8],[9],[10],[11] Conservative management can be offered for patients with short predictive survival.

Tokuhashi et al. developed a preoperative scoring system for prognostic evaluation of patients with SM in 1990.[12] This was modified in 2005.[13] Many studies have attempted to identify prognostic factors that predict the survival of patients with spinal metastasis, and some handy scores have been established such as Tokuhashi, Tomita,[14] Bauer and Wedin,[15] van der Linden et al.[16] Tokuhashi's score is one of the most popularly used score systems for SM and most commonly reported in literature.

The modified Tokuhashi's score evaluates several prognostic criteria such as Karnofsky's performance status (KPS), number of extraspinal bone metastases, number of metastases in the spine, metastases to visceral organs, the primary site of malignancy and the neurological status of the patient at presentation using Frankel grading. The survival periods were predicted from the total score using prognostic criteria. The survival period was predicted according to the total scores as < 6 months for a score of 0-8 months, ≥6 months for a score of 9-11 and ≥ 1 year for a score of ≥ 12

  Methods Top

This was a retrospective study of patients who underwent palliative radiotherapy for SM from January 2013 to December 2017. Data were collected from the patient records. The date of imaging (magnetic resonance imaging [MRI]/computed tomography [CT]/positron emission tomography [PET] scan) to detect the SM was considered as the date of diagnosis. The date of death or the last follow-up was considered as endpoint for calculation of overall-survival. Preradiation[17] neurological status was graded using Frankel grading and the following Tokuhashi's score components were collected: neurological status, performance status of the patient, number of extraspinal bony metastases (measured with a PET scan or technetium-99 bone scan), the number of metastases in the vertebral bodies (measured by a PETCT or MRI of entire spine or a bone scan), number of metastases in visceral organs (by an ultrasonography scan or CT), and information regarding primary cancer site.

Statistical analysis was done using Microsoft Excel and IBM SPSS version 20 software (Armonk, NY: IBM Corp). Survival data were analyzed using Kaplan–Meir survival curves. Various parameters such as age, sex, performance status of the patient, presence of epidural soft-tissue component, cord compression, visceral metastases, number of extraspinal bony metastases, number of SM, level of SM, neurological status were analyzed by univariate analyses by Cox regression model and a P <0.05 was considered statistically significant.

  Results Top

In our study, a total of 92 patients were studied. Of these, 20 patients were excluded from the study due to lack of sufficient information, and 3 patients were excluded as they were referred for radiotherapy after decompression laminectomy. Finally, 70 patients were retained for analysis.

We had 30 females and 40 males. The median age at diagnosis of SM was 50 years (range of 24–75 years). Most of the patients had moderate KPS. The most common site of primary cancer was lung (n = 28; 40%) followed by breast (n = 14; 20%). [Table 1] shows patient characteristics.
Table 1: Modified Tokuhashi's scoring for survival prognosis in spinal metastases of our patients

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The most common region of metastatic involvement was thoracic spine; n = 28 (41%). Seventeen (24%) patients had SM in more than one region. Thirty-six (50%) patients developed SM at the time of recurrence or progression and 34 (48%) patients had SM at presentation. Thirty-seven patients (54%) patients had epidural soft-tissue component and 25 patients (68%) of these patients developed subsequent spinal cord compression. Forty-five (64.2%) patients had extraspinal bony metastases, and 30 patients (42.8%) had metastases to major organs at presentation.

The median overall survival was 6.7 months [Table 1]. The modified Tokuhashi's score ranged from 0 to 13, and the median score being 6. In our study, 46 patients belonged to the poor prognostic group (modified Tokuhashi's score 0–8) with a median survival of months 4.8 months; 20 belonged to the moderate prognostic group (modified Tokuhashi's score 9–11) with a median survival of 13.5 months and four patients belonged to good prognostic group (modified Tokuhashi's score >12) with a median survival of 28 months [Table 1] and [Table 2]. There was a statistical significance in the difference in survival in three prognostic groups (P = 0.001) depicted in [Figure 1].{Table 1}
Table 2: Survival

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Figure 1: Kaplan–Meier survival curves

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Group concordance analysis is represented in [Figure 2]. In Group A (n = 46) with an expected survival of <6 months, there was a concordance of 82.2% (n = 37) of Tokuhashi's score. Six patients survived >6 months, and two patients survived >1 year (one patient had invasive carcinoma of the breast, and another had follicular carcinoma thyroid).
Figure 2: Concordance analysis of Tokuhashi groups

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In intermediate prognostic group (Group B; n = 20), with an expected survival of 6 12 months, there was a median survival of 13.5 months. We found a low Tokuhashi's score concordance rate of 40% (n = 8) in this group. None of the patients had survival <6 months and 12 patients had survival >1 year.

Group C (n = 4) with an expected survival of >1 year, there was a median survival of >1 year, there was a median survival of 28 months and resulted in 100% concordance.

Univariate analysis by Cox regression model [Table 3] showed the presence of epidural soft-tissue component, cord compression and the site of metastases did not affect the survival. Number of SM, extraspinal bone metastases, performance status, Frankel grade, sex, and Tokuhashi's score were found to affect survival in these patients. Our study reported that the presence of visceral metastases had an impact on overall survival of the patient and is a statistically significant prognostic indicator (P = 0.002). In addition, our study did establish performance status' statistical significance in univariate analysis (P≤ 0.01), which was compatible with the results of other studies such as studies by Tomita et al., Wibmer et al., Yamashita et al., and van der Lin et al.
Table 3: Univariate analyses by Cox regression model

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  Discussion Top

The Tokuhashi's scoring system is a tool used to determine prognosis in patients with metastatic spinal tumors. Many of these patients have reduced life expectancy, and the main goal of treatment is to improve the quality of life. Response to nonsurgical treatment like radiotherapy and chemotherapy depends on the biology of the primary tumor. The overall management in these patients depends on the survival and life expectancy. It is recommended that patients with estimated survival of <6 months should be offered conservative management like palliative radiotherapy and patients with life expectancy of >6 months are generally offered surgical modalities such as more extensive spinal cord and nerve decompression, gross tumor resection, and instrumented fixation should be performed to minimize the risk of local tumor recurrence and need for further procedures. Some studies have demonstrated that there was a better improvement in the ambulatory status of the patient after decompression, followed by radiation compared to radiation alone.[18] Patients with pathological fracture involving the spine due to SM should be considered for spinal fixation and instrumentation. However, surgical risks should be weighed against predicted life survival to justify surgical approach in this group of patients. Many a times, patients prefer nonsurgical approach for the disease management, and a clinician is asked frequently about the prognosis and survival. Tokuhashi's scoring system was originally designed as a presurgical prognostic evaluation tool. However, this can also be utilized in predicting survival in patients with metastatic spinal disease undergoing palliative radiotherapy.

Multiple prognostic evaluation systems for metastatic spinal tumors have been developed such as Tokuhashi's prognostic evaluation system, modified Tomita score, Bauer scoring system, van der Linden scoring system, and Rades score.

The Tokuhashi's scoring system was originally developed in 1990 and modified in 2005. It is one of the most popular scoring systems used for prognostic evaluation in this group of patients and most frequently reviewed for its precision and validity. Tokuhashi et al. reported in 118 patients with metastatic spinal tumors in a prospective study with a reliability of 86.4% in 2005. Ulmar et al. conducted a study involving 37 patients with renal carcinoma metastasized to the spine and examined the effectiveness of the Tokuhashi and Tomita scores in predicting prognosis.[19] According to their study, the Tokuhashi's score was more valuable than the Tomita score for predicting survival. Chen et al. reported that the revised Tokuhashi's score was the most practical and provided the most accurate prognosis in 41 patients with spinal metastasis of hepatocellular carcinoma among four scoring systems: the revised score, Tomita score, Bauer score, and revised van der Linden score.[20]

In another study by Ulmar et al., the modified Tokuhashi's scoring system demonstrated statistically significant predicted survival in patients with breast carcinoma.[21]

In a prospective study by Yamashita et al., it was reported that Tokuhashi's scoring system has a reliability of 79% and concluded that patients with poor general performance status and presence of visceral metastases had poor survival outcomes.[22]

However, the effect of performance status on survival is controversial. KPS has been used for the assessment of the general condition of the patient in the modified Tokuhashi's score. Studies have shown that KPS is not a good prognostic factor in determining the survival.[23] Our study showed that patients with good KPS do better than patients with poor KPS.

The presence of neurological deficits is associated with poor survival outcomes. There are studies which concluded that the presence of visceral metastases has an impact on overall survival in these patients.[16],[24]

The type of primary cancer is the main prognostic factor affecting the survival in this group of patients. The original Tokushashi scoring system was revised by diversifying the different sites of primary. Our study also supported this factor in prognostication.

In addition, there are studies comparing various prognostication scores for patients with spinal bone metastases. They have concluded that the modified Tokuhashi's score is one of the best scoring systems to be performed for survival analysis and has robust validation data and have comparable predictive performance.[25],[26]

Recently, the inclusion of molecular and genomic profile of tumor has been proposed for prognostication of survival in these groups of patients. Tumor histological subtype is crucial in predicting survival in patients with breast cancer with metastatic spine tumors. As oncologists move toward treating the tumor based on molecular and genomic characteristics, an attempt was made to improve the accuracy of modified Tokuhashi's score. A revised score was published in 2014 which suggested that estrogen/progesterone receptor-negative and triple-negative breast cancer patients be given a modified histological score of 3 instead of 5.[27] Similarly, many molecular and genomic prognostic determinants are available for carcinoma lung, which can be included in prognostic tools.

  Conclusion Top

Acceptable Tokuhashi concordance was seen in our study, particularly in the good and prognostic groups. Low concordance was observed in intermediate group which could be related to various factors such as performance status of the patient and tumor biology. With current advances in molecular cytogenetics, these should be considered when prognosticating the survival in these patients.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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