Original Paper Received: July 20, 2015 Accepted: September 13, 2015 Published online: November 19, 2015
Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
Incidence and Prognosis of Spinal Hemangioblastoma: A Surveillance Epidemiology and End Results Study Harrison J. Westwick a, b Jean-François Giguère a, b Mohammed F. Shamji c–e
a
Department of Surgery, Hôpital du Sacré-Coeur de Montréal, and b Department of Surgery, Division of Neurosurgery, Université de Montréal, Montreal, Que., c Toronto Western Hospital, Division of Neurosurgery, d University of Toronto, Department of Surgery, and e Techna Research Institute, Toronto, Ont., Canada
Key Words SEER · Spine · Hemangioblastoma · Incidence · Radiation · Surgery · Survival
Abstract Objective: Intradural spinal hemangioblastoma are infrequent, vascular, pathologically benign tumors occurring either sporadically or in association with von Hippel-Lindau disease along the neural axis. Described in fewer than 1,000 cases, literature is variable with respect to epidemiological factors associated with spinal hemangioblastoma and their treatment. The objective of this study was to evaluate the epidemiology of intradural spinal hemangioblastoma with the Surveillance, Epidemiology and End Results (SEER) database while also presenting an illustrative case. Methods: The SEER database was queried for cases of spinal hemangioblastoma between 2000 and 2010 with the use of SEER*Stat software. Incidence was evaluated as a function of age, sex and race. Survival was evaluated with the Cox proportionate hazards ratio using IBM SPSS software evaluating age, sex, location, treatment modality, pathology and number of primaries (p = 0.05). Descriptive statistics of the same factors were also calculated. The case of a 43-year-old patient with a surgical upper cervical intramedullary hemangioblastoma is also presented. Results: In the data set between 2000 and
© 2015 S. Karger AG, Basel 0251–5350/15/0461–0014$39.50/0 E-Mail [email protected] www.karger.com/ned
2010, there were 133 cases with an age-adjusted incidence of 0.014 (0.012–0.017) per 100,000 to the standard USA population. Hemangioblastoma was the tenth most common intradural spinal tumor type representing 2.1% (133 of 6,156) of all spinal tumors. There was no difference in incidence between men and women with an female:male rate ratio of 1.05 (0.73–1.50) with p = 0.86. The average age of patients was 48.0 (45.2–50.9) years, and a lower incidence was noted in patients 75 years was the reference value for age, with the lowest level of survival. This was of significance for 2 age groups over 45–54 and 65–74 years, but not significant for the other age groups. There was a statistically significant difference in survival between the groups as calculated by the log-rank test, p = 0.02. There was, however, a small patient population in the >75 years age group. There were an insufficient number of cases in the respective groups for location and pathology to conclude about mortality within these factors. Location in the spinal cord was the most common in 123 (92.5%) cases; there was no significant difference in Cox hazard ratios between locations; however, the one patient with a tumor of the cauda equina died (100% mortality). This difference in mortality was significant with the log-rank test; however, there was only 1 patient with a cauda equine tumor. The diagnosis 9161/1 hemangioblastoma was the most common pathology in 127 (95.5%) cases. One primary tumor was the most common in 104 (78.2%) cases; however, patients had up to 4 tumors. Hemangioblastoma Treatment Frequency of use and hazard ratios were calculated for the treatment modalities used, as tabulated in table 2. Tumor size was not noted in any of the cases in the SEER data set, and could not be calculated as a factor. Surgical resection alone was the most common treatment modality in 106 (79.7%) cases. No treatment was the second Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
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Fig. 2. Intraoperative images of hemangioblastoma with dura opened and tacked with sutures. The cystic component noted on preoperative T2-weighted sequences had been opened. Note the yellow abnormal hemangioblastoma tumor tissue indicated with the microdissector. The abnormal vascular supply to the tumor noted in (a) has been coagulated in (b). Note that rostral is oriented to the left.
Table 2. Mortality outcomes for different factors, breakdown of total numbers of patients are tabulated between demographic factors
Variable of interest
Number of cases (%)
Age, years 0–14
Mortality Cox hazards ratio within (95% CI) subgroup (%)
2 (1.5)
15–44 45–54 55–64 65–74 75+ Sex Male Female Race White Black American Indian Asian Unknown Location Spinal meninges Spinal cord Cauda equina Treatment Radiation and surgery Surgery alone Radiation alone No treatment Unknown Number of primaries 1 2 or more Pathology 9161/0 acquired tufted hemangioblastoma 9161/1 hemangioblastoma 9161/3 hemangioblastoma, malignant
Cox hazards ratio p value
log-rank Kaplan–Meier chi-square (p value) 19.4 (0.002)
0 (0)
0.013 (NS)
1.0
53 (39.8) 27 (20.3) 28 (21.1) 15 (11.3) 8 (6.0)
1 (1.9) 3 (11.1) 2 (7.1) 2 (13.3) 4 (50)
6 × 10–7 (NS) 0.1 (0.01–0.9) 0.011 (0.0004–0.30) 0.08 (0.008–0.8) Reference
0.9 0.04 0.007 0.04
62 (47) 71 (53)
7 (11.3) 5 (7)
0.4 (0.07–2.2) Reference
0.3
0.75 (0.4)
106 (79.7) 12 (9.0) 4 (3.0) 8 (6.0) 3 (2.3)
11 (10.4) 0 (0) 1 (25.0) 0 (0) 0 (0)
NS 0.357 (NS) NS Reference NA
1.0 1.0 1.0
4.7 (0.2)
9 (6.8) 123 (92.5) 1 (0.8)
1 (11.1) 10 (8.1) 1 (100)
NS NS Reference
0.9 0.9
7 (5.3) 106 (79.7) 1 (0.8) 17 (12.8) 2 (1.5)
2 (28.6) 10 (9.4) 0 (0) 0 (0) 0 (0)
NS NS NS Reference NA
1.0 1.0 1.0
3.1 (0.4)
104 (78.2) 29 (21.8)
10 (9.6) 2 (6.9)
0.906 (0.2–5.0) Reference
0.9
0.09 (0.8)
4 (3.0) 127 (95.5) 2 (1.5)
0 (0) 11 (8.7) 1 (50)
0.00002 (NS) 2.5 (0.15–42.2) Reference
1.0 0.5
2.6 (0.3)
NA 41.5 (9 × 10–9)
most common in 17 (12.8%) cases, radiation in combination with surgery was used in 7 (5.3%) cases and radiation alone was used in only 1 (0.8%) case. There was no statistically significant difference in hazard ratios for mortality between the treatment modalities. Literature Review Between 2000 and January 2015, there were 28 reported series totaling 711 cases of spinal hemangioblastomas, tabulated in table 3 [1, 2, 4–22, 24–30]. The average age range was 37.1–41.9 years with a male predominance 18
Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
(51.0–62.0%). VHL syndrome was present in 40–60% of cases, excluding those series where VHL was either selected or excluded as the focus of their study. Treatment was primarily surgical in 24 of the 28 series targeting gross total resection of the hemangioblastoma. Radiosurgery was the primary treatment modality for hemangioblastomas in 4 case series, totaling 45 cases [4–7]. Although not described in detail, radiosurgery was used as an adjunct to surgery in only one series [28]. Clinical deterioration was most frequently reported in describing outcomes of the case series, occurring in 10.7– Westwick/Giguère/Shamji
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Breakdown of the mortality of the 12 patients within subgroups of demographic factors, with percent mortality for each subgroup. Cox hazard function for hemangioblastoma for 133 cases in SEER database. Kaplan–Meier log-rank function calculated chi-square value and p value for comparison between mortality within different factors. Significant differences are in bold. NS = Not significant; NA = not applicable.
SEER Spinal Hemangioblastoma
Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
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19
5
9
17 59
16 59
Serban and Exergian [11], 2013
Selch et al. [4], 2012
Harati et al. [13], 2012
Park et al. [12], 2012
30
38
42
19 47
35 71
108 53
20 65
34 44
12 58
Daly et al. [5], 2011
Takai et al. [15], 2010
Mehta et al. [16], 2010
Clark et al. [17], 2010
Parker et al. [18], 2009
Moss et al. [6], 2009
Mandigo et al. 15 47 [2], 2009
41
49
32
45*
42
43
43
51
43
32
Age, average age, years
Imagama et al. 26 58 [14], 2011
22
40
92 64
Deng et al. [1], 2014
Sex, %, male
n
Author/year
cervical, % 50
38
45
47
42
63
Y
Y
76
40
Y
thoracic, % 87
42
34
27
44
33
74
Y
Y
17
50
Y
lumbar, % 8
5
15
25
5
Y
Y
20
Y
intradural/ intramedullary NS
Y
*
42
Y
64
NS
Y
NS
Y
65
sensory, %
NS
NS
NS
NS
74
85
NS
NS
10
NS
41
motor, % NS
42
Y
36
NS
N
NS
66
Y
38
pain, % Y
NS
85
Y
NS
N
NS
66
Y
Y
53
27
NS
73
55
100
51
74
23
25
64
56
40
*
Y
N
Y
Y
Y
Y
N
Y
Y
Y
N
Y
Y
35
gross total resection, % 100
0
85
99
0
85
62
NS
0
80
94
radiosurgery, % 0
100*
0
0
0
0
100*
0
0
0
100
0
0
other *
**
Outcome
7
**
25
37
**
19
18
86
NS
65
93*
53
56
7
NS
17
10
6
10
17
15
25
20
*
15 20
82
43
80
41
improved, %
Treatment
*
VHL, %
other
Chief complaint
surgical
Location
stable, %
surgical treatment, radiosurgery and other adjunctive treatment options
deterioration, %
0
***
0
0
9**
0
0
0
0
6*
0
0
0
* 80% posterior-lateral
* CyberKnife ** Clinical NS, radiological regression *** 9 of 31 total patients died from VHL
* 19% medulla oblongata
* 78% stable at 15 years ** 5% of mortality due to renal cell carcinoma
* Average age 32 in patients with VHL
* CyberKnife ** 86% tumor control at 3 years
Deterioration also noted with IONM
Average 2.8 operations per patient
* Mortality alcoholism
* Tumor size stability
* Spinal cord compression
* Sphincter ** Evaluation of DSA
Notes
Table 3. Literature review of case series of spinal hemangioblastoma between 2000 and 2015 tabulating demographic variables, tumor location and treatment including
mortality, %
Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
Westwick/Giguère/Shamji
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20 60
23 52
9
4
Shin et al. [20], 2008
Boström et al. [21], 2008
Na et al. [24], 2007
Biondi et al. [8], 2005
47
5
44 59
Ryu et al. [7], 2003
Lonser et al. [3], 2005; [22], 2003
25 48
14 79
20 76
19 NS
Lefranc and Brotchi [26], 2003
Lee et al. [10], 2003
Xu et al. [27], 2003
Malis [28], 2002
NS
32
37
40
34
38
Van Velthoven 28 50 et al. [25], 2003
60
43
38
44
49
33
50
44
48 43
Kanno et al. [19], 2009
74
100
56
*
60
54*
56
13
30
40
cervical, %
Location
26
24
20
21
44
35*
55
54
thoracic, %
Age, average age, years lumbar, % 76
20
4
100*
5
intradural/ intramedullary Y
90
20
25
100
67
75
NS
Chief complaint
sensory, % NS
Y
NS
50
Y
NS
motor, % NS
NS
Y
Y
NS
NS
NS
Y
29
Y
Y
NS
pain, %
Sex, %, male
other *
**
0*
NS
NS
100
80
64
25
56
35
10
100
VHL, %
Treatment
Y
Y
Y
Y
Y
N*
Y
Y
Y
Y
Y
Y
surgical
n
Y
100
71
96
N*
Y
100
67*
100
90
83
gross total resection, %
Author/year
radiosurgery, % Y**
0
0
100
0
0
0
0
0
other *
**
*
***
Outcome
57
14
50
13
improved, %
Table 3. (continued)
***
21
64
84
80
79
50
70
stable, %
20 deterioration, % ***
5
21
20
9
20
7
0
4
15
17
NS
0
0
4
2
20**
0
0
0
0
0
0
mortality, %
* VHL excluded ** Radiotherapy used, frequent NS *** 100% ‘improved or stable’
* Study of cervical tumors
* Angioembolization
* 56% McCormick I 36% McCormick II
* 66% posterior ** 3 patients prior radiotherapy
* 60% had prior surgery ** 20% mortality unrelated to tumors
* 21% medulla oblongata
* Study of conus tumors ** Sphincter/mild cauda equine *** 100% angioembolization
* 33% subtotal
* 30% multiple thoracic
Notes
* 10% angioembolization 0
Discussion
Incidence of Hemangioblastoma Spinal hemangioblastomas are rare lesions with fewer than 1,000 cases in the literature and 711 cases tabulated in table 3. The SEER data set establishes the lesion incidence at 0.014 (0.012–0.017) per 100,000. Previous case studies have noted a predominance of intradural spinal hemangioblastomas in males, including a recent case series by Deng et al. [1] with a female:male ratio of 1:1.8. Review of the included case series revealed male predominance, although this was reversed in the SEER data set with a slight female predominance (gender ratio 1.05:1 (0.73–1.50)). The average age range among included case series was 37.1–41.9 years, whereas the SEER data set reveals an average age of 48.0 years (45.2– 50.9). Association of spinal hemangioblastoma with VHL could not be extracted from the SEER data set, but in the included case series it occurs in approximately half of the patients.
stable, % improved, % 0 Y Y 87
0 Y Y 70
0 100
gross total resection, % surgical
0*
Y
radiosurgery, % VHL, %
*
other
NS
Y
NS
Y
sensory, % intradural/ intramedullary
15 93 Pietila et al. [30], 2000
27
43 10 Conway et al. [9], 2001
Y
Y
Y 68 31 Roonprapunt 19 68 et al. [29], 2001
Age, average age, years Sex, %, male n
cervical, %
Author/year
thoracic, %
Location
lumbar, %
Table 3. (continued)
Y = Yes (positive); N = no (negative); NS = not specified.
100
Y
Y
motor, %
NS
pain, %
Chief complaint
other
SEER Spinal Hemangioblastoma
Incidence of Spinal Tumors The relative rate of spinal hemangioblastomas has been described in single institution case series [1, 2, 21, 22] and multicenter studies [28, 31] in about 1.5–15% of spinal tumors. In the present SEER data set, an overall age-adjusted incidence of spinal tumors including all pathologies was 0.68 (0.66–0.70) per 100,000 population with a total of 6,156 tumors. Hemangioblastoma was the tenth most common pathology with 133 cases representing 2.16% (133 of 6,156) of all spinal tumors. Hemangioblastoma Outcome Observed mortality was low, both among the reviewed literature and the SEER data set. Oncologic mortality was only attributed in 3 cases for the SEER group, and similarly, among the case series, death was most frequently attributed to factors unrelated to the spinal tumors. Of the factors studied influencing survival with the Cox hazards model, only age >75 years was associated with limited survival, most presumably because of shortened expected lifespan in elderly patients. Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
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17
10 NS
0
* VHL excluded deterioration, %
Outcome
10
Notes
mortality, % Treatment
16.0% of patients following treatment. Mortality occurred in 6 case series (median 7.5%, range 2–20%); however, in 3 of the series, mortality was not related to the spinal cord tumors, but rather to systemic VHL with renal cell carcinoma [16], alcoholism [13] and other factors that are not related to the tumor [7].
SEER Studies and Limitations The use of the SEER database has advantages in the study of tumors of uncommon etiology, providing sufficient patient volume to study numerous variables in a large sample size, given that the sample size reflects 26% of the population of the USA. This present series is larger than any of the previous single case series reported in the literature, as tabulated in table 3. It is clearly advantageous in the facile study of incidence and specific incidence related to epidemiological factors. It has the advantage of being a prospective database with a larger quantity of variables, and its format offers the benefit of removing patient selection bias and bias from institutional practices. Limitations are clear in this type of study, the use of the SEER database and database studies in general. The most evident limitation of this database for the study of neurosurgical patients, unlike tumors of other systems of the body, is that neurological morbidity (rather than mortality) is the most important outcome variable. Neurological 22
Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
status, comorbidities and specifics of operative procedures are not included in this database. Many specific features that guide the decision process of surgeons in the case of spinal tumors are not available in this database. Other factors such as tumor size and level in the spine were not available in this data. While being a prospective database, it is not randomized, and outcomes may be influenced by many factors in choosing optimized treatment for patients [32]. As previously discussed, hemangioblastoma is a typically benign pathology, and in the cases where mortality occurred in the present study and reported mortality rates in the literature, cause of death was frequently related to other factors and other cancerous manifestations of VHL. VHL status was also not available, which would have been an important factor to consider in the survival analysis. This study was also limited in its power of data given the small sample size.
Conclusion
Spinal hemangioblastoma epidemiology was studied using the SEER database, and it was identified that this pathology was the tenth most common spinal tumor and represented 2% of all spinal tumors. Demographically, spinal hemangioblastomas were less common in younger patients, but there were no differences in terms of incidence between gender and racial groups. Surgery alone was the most common treatment modality, and low mortality of 9% occurred over 10 years of follow-up. There were no significant differences in mortality between sex, race, treatment modality, pathology or number of primaries. Disclosure Statement No external funding was obtained in the preparation of this article, and the authors have no competing interest.
References
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SEER Spinal Hemangioblastoma
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Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
Incidence and Prognosis of Spinal Hemangioblastoma: A Surveillance Epidemiology and End Results Study Harrison J. Westwick a, b Jean-François Giguère a, b Mohammed F. Shamji c–e
a
Department of Surgery, Hôpital du Sacré-Coeur de Montréal, and b Department of Surgery, Division of Neurosurgery, Université de Montréal, Montreal, Que., c Toronto Western Hospital, Division of Neurosurgery, d University of Toronto, Department of Surgery, and e Techna Research Institute, Toronto, Ont., Canada
Key Words SEER · Spine · Hemangioblastoma · Incidence · Radiation · Surgery · Survival
Abstract Objective: Intradural spinal hemangioblastoma are infrequent, vascular, pathologically benign tumors occurring either sporadically or in association with von Hippel-Lindau disease along the neural axis. Described in fewer than 1,000 cases, literature is variable with respect to epidemiological factors associated with spinal hemangioblastoma and their treatment. The objective of this study was to evaluate the epidemiology of intradural spinal hemangioblastoma with the Surveillance, Epidemiology and End Results (SEER) database while also presenting an illustrative case. Methods: The SEER database was queried for cases of spinal hemangioblastoma between 2000 and 2010 with the use of SEER*Stat software. Incidence was evaluated as a function of age, sex and race. Survival was evaluated with the Cox proportionate hazards ratio using IBM SPSS software evaluating age, sex, location, treatment modality, pathology and number of primaries (p = 0.05). Descriptive statistics of the same factors were also calculated. The case of a 43-year-old patient with a surgical upper cervical intramedullary hemangioblastoma is also presented. Results: In the data set between 2000 and
© 2015 S. Karger AG, Basel 0251–5350/15/0461–0014$39.50/0 E-Mail [email protected] www.karger.com/ned
2010, there were 133 cases with an age-adjusted incidence of 0.014 (0.012–0.017) per 100,000 to the standard USA population. Hemangioblastoma was the tenth most common intradural spinal tumor type representing 2.1% (133 of 6,156) of all spinal tumors. There was no difference in incidence between men and women with an female:male rate ratio of 1.05 (0.73–1.50) with p = 0.86. The average age of patients was 48.0 (45.2–50.9) years, and a lower incidence was noted in patients 75 years was the reference value for age, with the lowest level of survival. This was of significance for 2 age groups over 45–54 and 65–74 years, but not significant for the other age groups. There was a statistically significant difference in survival between the groups as calculated by the log-rank test, p = 0.02. There was, however, a small patient population in the >75 years age group. There were an insufficient number of cases in the respective groups for location and pathology to conclude about mortality within these factors. Location in the spinal cord was the most common in 123 (92.5%) cases; there was no significant difference in Cox hazard ratios between locations; however, the one patient with a tumor of the cauda equina died (100% mortality). This difference in mortality was significant with the log-rank test; however, there was only 1 patient with a cauda equine tumor. The diagnosis 9161/1 hemangioblastoma was the most common pathology in 127 (95.5%) cases. One primary tumor was the most common in 104 (78.2%) cases; however, patients had up to 4 tumors. Hemangioblastoma Treatment Frequency of use and hazard ratios were calculated for the treatment modalities used, as tabulated in table 2. Tumor size was not noted in any of the cases in the SEER data set, and could not be calculated as a factor. Surgical resection alone was the most common treatment modality in 106 (79.7%) cases. No treatment was the second Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
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Fig. 2. Intraoperative images of hemangioblastoma with dura opened and tacked with sutures. The cystic component noted on preoperative T2-weighted sequences had been opened. Note the yellow abnormal hemangioblastoma tumor tissue indicated with the microdissector. The abnormal vascular supply to the tumor noted in (a) has been coagulated in (b). Note that rostral is oriented to the left.
Table 2. Mortality outcomes for different factors, breakdown of total numbers of patients are tabulated between demographic factors
Variable of interest
Number of cases (%)
Age, years 0–14
Mortality Cox hazards ratio within (95% CI) subgroup (%)
2 (1.5)
15–44 45–54 55–64 65–74 75+ Sex Male Female Race White Black American Indian Asian Unknown Location Spinal meninges Spinal cord Cauda equina Treatment Radiation and surgery Surgery alone Radiation alone No treatment Unknown Number of primaries 1 2 or more Pathology 9161/0 acquired tufted hemangioblastoma 9161/1 hemangioblastoma 9161/3 hemangioblastoma, malignant
Cox hazards ratio p value
log-rank Kaplan–Meier chi-square (p value) 19.4 (0.002)
0 (0)
0.013 (NS)
1.0
53 (39.8) 27 (20.3) 28 (21.1) 15 (11.3) 8 (6.0)
1 (1.9) 3 (11.1) 2 (7.1) 2 (13.3) 4 (50)
6 × 10–7 (NS) 0.1 (0.01–0.9) 0.011 (0.0004–0.30) 0.08 (0.008–0.8) Reference
0.9 0.04 0.007 0.04
62 (47) 71 (53)
7 (11.3) 5 (7)
0.4 (0.07–2.2) Reference
0.3
0.75 (0.4)
106 (79.7) 12 (9.0) 4 (3.0) 8 (6.0) 3 (2.3)
11 (10.4) 0 (0) 1 (25.0) 0 (0) 0 (0)
NS 0.357 (NS) NS Reference NA
1.0 1.0 1.0
4.7 (0.2)
9 (6.8) 123 (92.5) 1 (0.8)
1 (11.1) 10 (8.1) 1 (100)
NS NS Reference
0.9 0.9
7 (5.3) 106 (79.7) 1 (0.8) 17 (12.8) 2 (1.5)
2 (28.6) 10 (9.4) 0 (0) 0 (0) 0 (0)
NS NS NS Reference NA
1.0 1.0 1.0
3.1 (0.4)
104 (78.2) 29 (21.8)
10 (9.6) 2 (6.9)
0.906 (0.2–5.0) Reference
0.9
0.09 (0.8)
4 (3.0) 127 (95.5) 2 (1.5)
0 (0) 11 (8.7) 1 (50)
0.00002 (NS) 2.5 (0.15–42.2) Reference
1.0 0.5
2.6 (0.3)
NA 41.5 (9 × 10–9)
most common in 17 (12.8%) cases, radiation in combination with surgery was used in 7 (5.3%) cases and radiation alone was used in only 1 (0.8%) case. There was no statistically significant difference in hazard ratios for mortality between the treatment modalities. Literature Review Between 2000 and January 2015, there were 28 reported series totaling 711 cases of spinal hemangioblastomas, tabulated in table 3 [1, 2, 4–22, 24–30]. The average age range was 37.1–41.9 years with a male predominance 18
Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
(51.0–62.0%). VHL syndrome was present in 40–60% of cases, excluding those series where VHL was either selected or excluded as the focus of their study. Treatment was primarily surgical in 24 of the 28 series targeting gross total resection of the hemangioblastoma. Radiosurgery was the primary treatment modality for hemangioblastomas in 4 case series, totaling 45 cases [4–7]. Although not described in detail, radiosurgery was used as an adjunct to surgery in only one series [28]. Clinical deterioration was most frequently reported in describing outcomes of the case series, occurring in 10.7– Westwick/Giguère/Shamji
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Breakdown of the mortality of the 12 patients within subgroups of demographic factors, with percent mortality for each subgroup. Cox hazard function for hemangioblastoma for 133 cases in SEER database. Kaplan–Meier log-rank function calculated chi-square value and p value for comparison between mortality within different factors. Significant differences are in bold. NS = Not significant; NA = not applicable.
SEER Spinal Hemangioblastoma
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19
5
9
17 59
16 59
Serban and Exergian [11], 2013
Selch et al. [4], 2012
Harati et al. [13], 2012
Park et al. [12], 2012
30
38
42
19 47
35 71
108 53
20 65
34 44
12 58
Daly et al. [5], 2011
Takai et al. [15], 2010
Mehta et al. [16], 2010
Clark et al. [17], 2010
Parker et al. [18], 2009
Moss et al. [6], 2009
Mandigo et al. 15 47 [2], 2009
41
49
32
45*
42
43
43
51
43
32
Age, average age, years
Imagama et al. 26 58 [14], 2011
22
40
92 64
Deng et al. [1], 2014
Sex, %, male
n
Author/year
cervical, % 50
38
45
47
42
63
Y
Y
76
40
Y
thoracic, % 87
42
34
27
44
33
74
Y
Y
17
50
Y
lumbar, % 8
5
15
25
5
Y
Y
20
Y
intradural/ intramedullary NS
Y
*
42
Y
64
NS
Y
NS
Y
65
sensory, %
NS
NS
NS
NS
74
85
NS
NS
10
NS
41
motor, % NS
42
Y
36
NS
N
NS
66
Y
38
pain, % Y
NS
85
Y
NS
N
NS
66
Y
Y
53
27
NS
73
55
100
51
74
23
25
64
56
40
*
Y
N
Y
Y
Y
Y
N
Y
Y
Y
N
Y
Y
35
gross total resection, % 100
0
85
99
0
85
62
NS
0
80
94
radiosurgery, % 0
100*
0
0
0
0
100*
0
0
0
100
0
0
other *
**
Outcome
7
**
25
37
**
19
18
86
NS
65
93*
53
56
7
NS
17
10
6
10
17
15
25
20
*
15 20
82
43
80
41
improved, %
Treatment
*
VHL, %
other
Chief complaint
surgical
Location
stable, %
surgical treatment, radiosurgery and other adjunctive treatment options
deterioration, %
0
***
0
0
9**
0
0
0
0
6*
0
0
0
* 80% posterior-lateral
* CyberKnife ** Clinical NS, radiological regression *** 9 of 31 total patients died from VHL
* 19% medulla oblongata
* 78% stable at 15 years ** 5% of mortality due to renal cell carcinoma
* Average age 32 in patients with VHL
* CyberKnife ** 86% tumor control at 3 years
Deterioration also noted with IONM
Average 2.8 operations per patient
* Mortality alcoholism
* Tumor size stability
* Spinal cord compression
* Sphincter ** Evaluation of DSA
Notes
Table 3. Literature review of case series of spinal hemangioblastoma between 2000 and 2015 tabulating demographic variables, tumor location and treatment including
mortality, %
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20 60
23 52
9
4
Shin et al. [20], 2008
Boström et al. [21], 2008
Na et al. [24], 2007
Biondi et al. [8], 2005
47
5
44 59
Ryu et al. [7], 2003
Lonser et al. [3], 2005; [22], 2003
25 48
14 79
20 76
19 NS
Lefranc and Brotchi [26], 2003
Lee et al. [10], 2003
Xu et al. [27], 2003
Malis [28], 2002
NS
32
37
40
34
38
Van Velthoven 28 50 et al. [25], 2003
60
43
38
44
49
33
50
44
48 43
Kanno et al. [19], 2009
74
100
56
*
60
54*
56
13
30
40
cervical, %
Location
26
24
20
21
44
35*
55
54
thoracic, %
Age, average age, years lumbar, % 76
20
4
100*
5
intradural/ intramedullary Y
90
20
25
100
67
75
NS
Chief complaint
sensory, % NS
Y
NS
50
Y
NS
motor, % NS
NS
Y
Y
NS
NS
NS
Y
29
Y
Y
NS
pain, %
Sex, %, male
other *
**
0*
NS
NS
100
80
64
25
56
35
10
100
VHL, %
Treatment
Y
Y
Y
Y
Y
N*
Y
Y
Y
Y
Y
Y
surgical
n
Y
100
71
96
N*
Y
100
67*
100
90
83
gross total resection, %
Author/year
radiosurgery, % Y**
0
0
100
0
0
0
0
0
other *
**
*
***
Outcome
57
14
50
13
improved, %
Table 3. (continued)
***
21
64
84
80
79
50
70
stable, %
20 deterioration, % ***
5
21
20
9
20
7
0
4
15
17
NS
0
0
4
2
20**
0
0
0
0
0
0
mortality, %
* VHL excluded ** Radiotherapy used, frequent NS *** 100% ‘improved or stable’
* Study of cervical tumors
* Angioembolization
* 56% McCormick I 36% McCormick II
* 66% posterior ** 3 patients prior radiotherapy
* 60% had prior surgery ** 20% mortality unrelated to tumors
* 21% medulla oblongata
* Study of conus tumors ** Sphincter/mild cauda equine *** 100% angioembolization
* 33% subtotal
* 30% multiple thoracic
Notes
* 10% angioembolization 0
Discussion
Incidence of Hemangioblastoma Spinal hemangioblastomas are rare lesions with fewer than 1,000 cases in the literature and 711 cases tabulated in table 3. The SEER data set establishes the lesion incidence at 0.014 (0.012–0.017) per 100,000. Previous case studies have noted a predominance of intradural spinal hemangioblastomas in males, including a recent case series by Deng et al. [1] with a female:male ratio of 1:1.8. Review of the included case series revealed male predominance, although this was reversed in the SEER data set with a slight female predominance (gender ratio 1.05:1 (0.73–1.50)). The average age range among included case series was 37.1–41.9 years, whereas the SEER data set reveals an average age of 48.0 years (45.2– 50.9). Association of spinal hemangioblastoma with VHL could not be extracted from the SEER data set, but in the included case series it occurs in approximately half of the patients.
stable, % improved, % 0 Y Y 87
0 Y Y 70
0 100
gross total resection, % surgical
0*
Y
radiosurgery, % VHL, %
*
other
NS
Y
NS
Y
sensory, % intradural/ intramedullary
15 93 Pietila et al. [30], 2000
27
43 10 Conway et al. [9], 2001
Y
Y
Y 68 31 Roonprapunt 19 68 et al. [29], 2001
Age, average age, years Sex, %, male n
cervical, %
Author/year
thoracic, %
Location
lumbar, %
Table 3. (continued)
Y = Yes (positive); N = no (negative); NS = not specified.
100
Y
Y
motor, %
NS
pain, %
Chief complaint
other
SEER Spinal Hemangioblastoma
Incidence of Spinal Tumors The relative rate of spinal hemangioblastomas has been described in single institution case series [1, 2, 21, 22] and multicenter studies [28, 31] in about 1.5–15% of spinal tumors. In the present SEER data set, an overall age-adjusted incidence of spinal tumors including all pathologies was 0.68 (0.66–0.70) per 100,000 population with a total of 6,156 tumors. Hemangioblastoma was the tenth most common pathology with 133 cases representing 2.16% (133 of 6,156) of all spinal tumors. Hemangioblastoma Outcome Observed mortality was low, both among the reviewed literature and the SEER data set. Oncologic mortality was only attributed in 3 cases for the SEER group, and similarly, among the case series, death was most frequently attributed to factors unrelated to the spinal tumors. Of the factors studied influencing survival with the Cox hazards model, only age >75 years was associated with limited survival, most presumably because of shortened expected lifespan in elderly patients. Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
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17
10 NS
0
* VHL excluded deterioration, %
Outcome
10
Notes
mortality, % Treatment
16.0% of patients following treatment. Mortality occurred in 6 case series (median 7.5%, range 2–20%); however, in 3 of the series, mortality was not related to the spinal cord tumors, but rather to systemic VHL with renal cell carcinoma [16], alcoholism [13] and other factors that are not related to the tumor [7].
SEER Studies and Limitations The use of the SEER database has advantages in the study of tumors of uncommon etiology, providing sufficient patient volume to study numerous variables in a large sample size, given that the sample size reflects 26% of the population of the USA. This present series is larger than any of the previous single case series reported in the literature, as tabulated in table 3. It is clearly advantageous in the facile study of incidence and specific incidence related to epidemiological factors. It has the advantage of being a prospective database with a larger quantity of variables, and its format offers the benefit of removing patient selection bias and bias from institutional practices. Limitations are clear in this type of study, the use of the SEER database and database studies in general. The most evident limitation of this database for the study of neurosurgical patients, unlike tumors of other systems of the body, is that neurological morbidity (rather than mortality) is the most important outcome variable. Neurological 22
Neuroepidemiology 2016;46:14–23 DOI: 10.1159/000441147
status, comorbidities and specifics of operative procedures are not included in this database. Many specific features that guide the decision process of surgeons in the case of spinal tumors are not available in this database. Other factors such as tumor size and level in the spine were not available in this data. While being a prospective database, it is not randomized, and outcomes may be influenced by many factors in choosing optimized treatment for patients [32]. As previously discussed, hemangioblastoma is a typically benign pathology, and in the cases where mortality occurred in the present study and reported mortality rates in the literature, cause of death was frequently related to other factors and other cancerous manifestations of VHL. VHL status was also not available, which would have been an important factor to consider in the survival analysis. This study was also limited in its power of data given the small sample size.
Conclusion
Spinal hemangioblastoma epidemiology was studied using the SEER database, and it was identified that this pathology was the tenth most common spinal tumor and represented 2% of all spinal tumors. Demographically, spinal hemangioblastomas were less common in younger patients, but there were no differences in terms of incidence between gender and racial groups. Surgery alone was the most common treatment modality, and low mortality of 9% occurred over 10 years of follow-up. There were no significant differences in mortality between sex, race, treatment modality, pathology or number of primaries. Disclosure Statement No external funding was obtained in the preparation of this article, and the authors have no competing interest.
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