Metachronous presentation of metastasis from renal cell carcinoma: evaluation and management of spinal metastasis

Surgical treatment of metastatic cancer in the appendicular skeleton is well supported in the literature. Straightforward indications include pathologic fracture and impending pathologic fracture [1, 2]. More controversial indications for operative treatment exist regarding resection or en-bloc removal for solitary metastases or other painful metastases [3]. Overall, surgical decision making must be tempered by the patient’s overall performance status (ECOG, Eastern Cooperative Oncology Group), tumor type (with relation to expected survival and relative radiosensitivity) and the patient’s perceived ability to recover from surgery [A, 4]. As controversial as surgical indications are in the appendicular skeleton, they are at times even more contentious in the axial skeleton. Issues such as established neurologic deficit as well as impending neurologic decline are compounded by uncertain criteria for stability and pathologic fracture. The purpose of this current report is to describe the unusual presentation of a symptomatic spinal metastasis in the setting of systemic disease, review the indications and treatment and then consider what was done using an “evidence-based medicine approach”.