|Year : 2022 | Volume
| Issue : 2 | Page : 199-208
Spinal metastases: Clinical scenarios
Gautam R Zaveri1, Venkatesh Krishnan2
1 Jaslok Hospital & Research Centre, Mumbai, Maharashtra, India
2 Department of Spine Surgery, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||25-Sep-2021|
|Date of Decision||31-Jan-2022|
|Date of Acceptance||25-Feb-2022|
|Date of Web Publication||08-Jun-2022|
Gautam R Zaveri
Jaslok Hospital & Research Centre, 302 Bhaveshwar Kutir, 4th Road Rajawadi, Ghatkopar East, Mumbai 400077, Maharashtra
Source of Support: None, Conflict of Interest: None
The goal of treatment in patients with spinal metastasis is palliation, that is, to improve the quality of remaining life as judged by alleviation of pain, preservation or restoration of neurology, and improvement in function. Local control of the spinal metastasis not only influences the overall survival of a cancer patient but is vital to maintain treatment benefits for the duration of the patient`s survival. However, cancer therapy––both surgical and nonsurgical––carries a significant risk of complications, morbidity, and even mortality. Decision-making regarding the most appropriate treatment strategy is vital when treating terminally ill patients with spinal metastatic disease.
Keywords: Cases, decision-making pathway, spine metastases
|How to cite this article:|
Zaveri GR, Krishnan V. Spinal metastases: Clinical scenarios. Indian Spine J 2022;5:199-208
| Introduction|| |
Spine surgeons are being increasingly called upon to treat patients with metastatic spinal disease (MSD). Decision-making regarding the treatment strategy is often tricky, with the dilemma being between doing too little and too much. The literature is replete with scores, flowcharts, and algorithms that aid management decisions. However, the eventual treatment strategy is individualized and must be a shared decision made by a multidisciplinary team comprising of medical and radiation oncologists, interventional radiologists, and spine surgeons together with the patients and their families. This article aims to highlight systematic decision-making for patients with spinal metastasis on a case-to-case basis.
| Case 1: Solitary L1 Metastasis from RCC Treated with Intralesional Spondylectomy + Cebrt + Immunotherapy|| |
A 59-year-old man without any medical comorbidities presented with continuous, severe back pain which had gotten worse over the past one month. Any movement resulted in aggravation of the pain. He denied any pain, paresthesia, or numbness in the lower limbs and was continent of bladder and bowel. He was able to ambulate independently. A left nephrectomy had been performed one year back for renal cell cancer (RCC). Examination revealed a healthy individual, conscious and oriented with normal vital parameters. He had tenderness over the upper lumbar spine and paraspinal muscle spasm. Neurology was intact in the lower limbs (Frankel E).
Magnetic resonance imaging (MRI) revealed an osteolytic tumor occupying >75% of the L1 vertebral body resulting in a superior endplate fracture. The tumor had extended into the left pedicle at D12 and L1 and into the spinal canal Figure 1]A–H. A PET-CT scan showed metastases within the liver and multiple enlarged paraaortic lymph nodes. A computed tomography (CT)-guided biopsy confirmed that the vertebral lesion was a metastasis from the old RCC.
|Figure 1: Case 1 (A–H) Radiographs, MRI, and CT scans of a 59-year-old man with metastatic renal cell carcinoma showing pathological fracture of L1 with involvement of the left pedicle at D12 and L1. ESCC is grade 2 and tumor occupancy within the L1 body is >50%. (I): The Epidural Spinal Cord Compression scale: Grade 0: Intracompartmental osseous lesion without epidural disease. Grade I a–c: Minimal epidural disease with no spinal cord compression. Grade 2: high-grade ESCC with spinal cord displacement/compression but with visible CSF. Grade 3: high-grade ESCC with spinal cord displacement/compression and no visible CSF. (J and K) Postoperative X-rays following a total intralesional vertebrectomy and reconstruction for metastatic RCC (L) 24-month follow-up X-ray showing excellent position of implants without any recurrence of tumor|
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The epidural spinal cord compression (ESCC) [Figure 1I] on MRI was Bilsky Grade 2 and the spinal instability neoplastic (SIN) [Table 1] score was 11/18, placing the stability of the spine in the indeterminate range. The modified Tokuhashi score [Table 2] was 11/15 indicating that the predicted survival was likely 6–12 months. Tomita recommends that the treatment goal for such a patient should be medium-term local control with marginal or intralesional surgical excision [Table 3]. The NOMS (neurologic, oncologic, mechanical, and systemic) decision-making framework [Table 4] recommends surgery for decompression and stabilization followed by stereotactic body radiotherapy (SBRT) in patients with radioresistant tumors who have severe ESCC and spinal instability.
|Table 2: Tokuhashi scoring system for preoperative evaluation of survival in spinal metastatic disease|
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|Table 3: Tomita scoring system for preoperative evaluation of spinal metastases|
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The treatment options in this patient included intralesional total vertebrectomy followed by conventional (2D) external beam radiotherapy (cEBRT), en bloc spondylectomy ± radiation, SBRT alone, and separation surgery + SBRT. Radiotherapy alone (cEBRT or SBRT) is not recommended in patients with significant spinal instability. In patients with >50% tumor occupancy within the vertebral body, radiotherapy, especially single-fraction SBRT has been reported to result in a higher incidence of post-radiation vertebral collapse. En bloc spondylectomy is not recommended in patients with multiple metastases with potentially limited survival because of higher morbidity and risk of complications.,
We chose to perform an intralesional piecemeal total vertebrectomy and stabilization. He underwent preoperative embolization of the tumor 24 h before surgery. Through a standard posterior approach, pedicle screws were inserted. The posterior elements of L1 and the left D12 pedicle were excised in a piecemeal fashion. The tumor was gradually debulked and removed preserving both the L1 nerve roots. The anterior longitudinal ligament was identified and removed in a piecemeal fashion. The PLL was identified and cut from the D12 lower endplate to the L2 upper endplate after achieving hemostasis of the epidural veins. The space was reconstructed with an expandable cage [Figure 1J and K]. cEBRT and targeted therapy were initiated at 3 weeks post-surgery.
The patient did well postoperatively. He was relatively pain free, ambulant, and free of local recurrence [[Figure 1L]] until his death 26 months later.
| Case 2: solitary T7 Metastasis from a Synovial Sarcoma of the Thigh Treated with En bloc Spondylectomy + Chemotherapy|| |
A 45-year-old gentleman without any medical comorbidities presented with a slowly progressive right thigh swelling followed by a short history of backpain. He had developed weakness of both lower limbs over the past 2 weeks and was unable to stand and walk since the past 3 days. He was continent of bladder and bowel. On examination, he had a large soft tissue mass in the right thigh with dilated superficial veins. There was tenderness in the dorsal spine. Muscle power was MRC grade 2/5 in the right lower limb and grade 1/5 in the left lower limb across all joints. Sensory examination was normal for light touch and reduced for pin prick in all dermatomes below T9 and per-rectal examination revealed intact sensations but weak voluntary anal contraction (Frankel C).
MRI of the right thigh revealed a large mass in the anteromedial thigh which was eroding the underlying femur [Figure 2]A. MRI of the spine with contrast showed contrast-enhancing lesion in T7 vertebra causing pathological fracture with expansion of posterior cortex and paravertebral and epidural soft tissue [Figure 2]B–D. CT thorax and abdomen did not show any visceral or pulmonary metastasis. Biopsy from the right thigh revealed that the lesion was a high-grade monophasic synovial cell sarcoma.
|Figure 2: Case 2 (A) MRI showing a tumor in the thigh eroding the underlying femur. (B–D) MRI and CT scan revealing a pathological fracture of D7 with kyphotic deformity and extension of the tumor into the spinal canal. (E and F) Intraoperative pictures during en bloc spondylectomy showing a D7 en bloc spondylectomy. (G) Postoperative lateral radiograph showing en bloc spondylectomy with reconstruction and stabilization|
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The ESCC on MRI was Bilsky Grade 3 and the SIN score was 13/18, indicating an unstable spine. The modified Tokuhashi score was 10/15 indicating that the anticipated survival was likely between 6 and 12 months. Tomita recommends that the treatment goal for such a patient should be middle-term local control with marginal or intralesional surgery. The NOMS decision-making framework recommends surgery for decompression and stabilization followed by SBRT in patients with radioresistant tumors who have severe ESCC and spinal instability.
In view of the significant neurologic deficit and spinal instability, the patient required spinal cord decompression with stabilization. Since synovial sarcomas are relatively resistant to cEBRT and our institution does not have facilities for SBRT, it was decided to perform a total en bloc vertebrectomy for local tumor control followed by chemotherapy for systemic control of the tumor. A high above-knee amputation of the right thigh was planned at the same sitting.
Preoperative embolization was not done since the lesion was not very vascular. Through a standard posterior approach after placement of pedicle screw anchors, medial two inches of the seventh and eighth ribs were excised bilaterally. T7 transverse process was excised followed by en bloc excision of T7 lamina and both T7 pedicles. T7 nerve roots were ligated and divided bilaterally to create an access for the anterior part of the vertebra. Anterior dissection in the plane between pleura and vertebra was done and segmental vessels were ligated. Using a gigli saw, en bloc removal from lower half of T6 body to upper half of T8 body was done. Anterior column was reconstructed using mesh cage and structural rib graft adjacent to the cage [[Figure 2E–G]].
Complete excision of the tumor was confirmed by postoperative CT scan of the excised tissue. As the tumor margins were clear at both sites, postoperative radiotherapy was considered unnecessary. Chemotherapy was administered starting 2 weeks after surgery. He went on to have significant neurologic recovery and was ambulant with support at the 6-month follow-up (Frankel D). Contrast MRI of the spine at 1-month post-surgery did not show any evidence of residual tumor.
| Case 3: Solitary L5 Metastasis from Breast Cancer Treated with Intralesional Spondylectomy and Posterior Stabilization + CEBRT + Chemotherapy|| |
A 48-year-old female police officer, without any comorbidities, presented with unrelenting back pain radiating to both lower limbs for one week. She was comfortable in the supine position, but had excruciating pain on movement and was unable to sit, stand or walk because of the pain. She had been operated for breast cancer 3 years back, and was on tamoxifen since then. Examination revealed severe tenderness and muscle spasm in the lower back with normal neurology (Frankel E).
MRI revealed a pathological fracture of L5 with retropulsion of the posterior 1/3 of the vertebra resulting in compression of the cauda equina [[Figure 3]A and B]. A PET CT scan and a CT-guided biopsy revealed that the L5 metastasis was a solitary metastasis from the previous breast cancer.
|Figure 3: Case 3 (A and B) MRI showing a pathological fracture of L5 with grade 3 ESCC. (C and D) Postoperative radiographs following anterior vertebrectomy with reconstruction and posterior stabilization|
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Although she was neurologically intact, the MESCC was graded as 3 on the Bilsky scale. Her SIN score was 13 indicating an unstable spine. The modified Tokuhashi score was 15/18, indicating that the estimated survival was >12 months. Tomita recommends wide or marginal excision of the tumor in order to obtain long-term local control. The NOMS decision-making framework recommends surgical stabilization followed by cEBRT for a radiosensitive tumor with high-grade ESCC and instability. Although breast metastases are radiosensitive, in view of the spinal instability, we decided to offer the patient surgical stabilization followed by cEBRT.
She underwent short-segment posterior stabilization from L4 to S1 followed by an intralesional vertebrectomy and anterior column reconstruction at the same sitting. A mesh cage packed with bone cement was used to bridge the anterior defect. The absence of metastases involving adjacent vertebral levels and the excellent bone quality enabled us to limit pedicle screw fixation to one segment above and below the pathological segment. The fixation may be extended to multiple segments or cement augmented pedicle screws may be employed in case the bone quality is poor resulting in the compromised purchase of the pedicle screws [Figure 3C and D]. Three and a half weeks after surgery, she underwent cEBRT and was also started on chemotherapy.
Her back and leg pain was completely relieved. She returned to her duties as a police officer. She survived for 10 years and was ambulant and working until the end. There was no symptomatic local recurrence.
| Case 4: Multiple Spinal Metastases from Lung Cancer Treated with Palliative Posterior Surgery + CEBRT + Targeted Therapy|| |
A 69-year-old hypertensive woman presented with severe back pain and bilateral anterior thigh pain. She was unable to stand straight because of the pain and was unable to walk more than a few steps. Examination revealed spinal tenderness, spasm, and restricted movements. The patient was able to stand only with a forward stoop and flexed hips and knees. Neurology was normal (Frankel E). She had been diagnosed with non-small cell lung cancer about 3 months ago and was receiving targeted therapy for the same.
X-rays showed a mild scoliosis with the apex in the upper lumbar spine. MRI scan revealed multiple vertebral metastases with a pathological fracture at L2 that resulted in secondary spinal stenosis [Figure 4]A–D. Her PET CT showed lesions in the lung, a solitary metastasis in the liver, and multiple vertebral metastases. No other visceral or skeletal metastases were detected.
|Figure 4: Case 4 (A–D) Preoperative MRI showing multilevel spinal metastases with pathological fracture at L2 resulting in spinal stenosis and scoliosis. (E) Lateral X-ray at 6-month following posterior decompression and stabilization|
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This woman had ESCC grade 3 metastases resulting in symptomatic lumbar canal stenosis. Her SIN score was 12/18 indicating borderline instability and her anticipated survival as per the modified Tokuhashi scoring was <6 months. Tomita recommends that the goal of treatment for this patient should be short-term palliation with palliative surgery. The NOMS framework recommends decompression and stabilization be performed followed by SBRT for a radioresistant tumor with high-grade ESCC and instability. Since the patient was in relatively good health, the tumor board at our hospital recommended a palliative decompression and stabilization to relieve her pain and improve her ambulation and function.
She underwent a laminectomy at L1–L2 with long posterior stabilization to bridge the multiple weak segments in between. Although the authors prefer conventional pedicle screw fixation with multiple level stabilization, cement augmented pedicle screw fixation may also be considered to limit the extent of the posterior construct. Three weeks later, after the surgical wound had completely healed, she was given cEBRT and targeted therapy [Figure 4E and F].
Her back and leg pain significantly improved. She was able to walk straight and unaided and was functional until her death 9 months later.
| Case 5: Solitary Metastasis from Renal Cell Cancer Treated with Surgery Followed by SBRT + Immunotherapy|| |
A 72-year-old hypertensive woman presented with progressive weakness in both lower limbs over 7 days and inability to walk for the last 12 hours. She denied bladder/ bowel incontinence. Examination revealed Frankel C neurologic deficit with grade 2 power in both lower limbs, hypoesthesia below D8, brisk reflexes in the lower limbs and upgoing plantars. She had no medical comorbidities and no past history of cancer.
MRI [Figure 5]A–C revealed a SOL involving the posterior half of D7, destroying the left pedicle of D7 and resulting in spinal cord compression. The MRI also picked up a mass involving the lower pole of the left kidney, which was diagnosed as an RCC. A skeletal survey and CT scans of the chest, abdomen, and pelvis did not reveal any other metastatic lesions.
|Figure 5: Case 5 (A and B) Preoperative MRI images of a 72-year-old woman with spinal metastasis from RCC. (C) CT scan showing an RCC of lower pole of left kidney. (C and D) Postoperative X-rays after separation surgery. Patient was started on SBRT 3 weeks after surgery|
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The ESCC on the Bilsky scale was grade 3. The SIN score was 8/18 indicating that the spine was relatively stable. The modified Tokuhashi score was 11/15, indicating that she had an estimated survival of 6–12 months. However, targeted therapy has resulted in a significant increase in life expectancy of patients with stage 3 or 4 RCC, necessitating strategies for improved local control of the spinal metastasis. Tomita recommends long-term local control for this patient with wide or marginal excision. The NOMS framework recommends decompression and stabilization followed by SBRT for a radioresistant tumor with high-grade ESCC and a stable spine.
Treatment options in this patient include SBRT alone,, en bloc spondylectomy with or without postoperative radiation, total intralesional spondylectomy + radiation, and separation surgery followed by SBRT. Grade 3 ESCC with neurologic deficit is a contraindication to treatment with SBRT alone. The advanced age and the relatively poor anticipated survival are relative contraindications for a total en bloc spondylectomy. Since we had access to SBRT at our institution, it was decided to proceed with separation surgery followed by SBRT in this patient. The advantage of separation surgery + SBRT is that it results in less perioperative morbidity and complications compared to an en bloc spondylectomy while allowing a similar degree of local tumor control.
Since metastases from RCC are known to be hypervascular, the patient was taken up for embolization immediately prior to the surgery. A transpedicular approach was used to debulk the tumor in order to decompress the spinal cord and create a zone of separation (2–3 mm wide) between the spinal cord and the vertebral body. Long posterior stabilization was performed using titanium rods. Cement augmented screws may be used to augment screw purchase in diseased, osteoporotic bone [Figure 5D and E] 3 weeks post-surgery, the patient underwent SBRT which was delivered in 3 fractions.
The patient`s neurologic deficit improved significantly. She was ambulant with a walker and continent of bladder and bowel until her death 17 months after the surgery.
| Case 6: c2 Metastasis from Breast Cancer Treated with Posterior Stabilization + CEBRT|| |
A 72-year-old obese woman with hypertension and diabetes presented to us with spontaneous onset severe neck pain of four months duration. The pain was so severe that she was confined to bed since four months. She had not approached a doctor thus far because of the COVID lockdown. She was unable to sit, stand or walk or even turn in bed comfortably because of the pain. She denied any upper or lower limb pain, paraesthesia, numbness, or weakness. Examination revealed severe upper cervical tenderness and paraspinal spasms. She was unable to lift her head off from the bed. Neurology was normal (Frankel E). She had undergone mastectomy for right-sided breast cancer seven years back.
CT scans revealed a pathological fracture of C2 and a lytic lesion in the C3 vertebral body. MRI showed mild right-sided spinal cord compression [Figure 6]A–D. The PET CT scan revealed that there were no lesions aside from those in the cervical spine.
|Figure 6: Case 6 (A–D) CT scans and MRI of 72-year-old woman with metastatic breast cancer presenting with a pathological fracture at C2. (E) Postoperative X-rays following posterior occipitocervical stabilization. (F) X-rays at 6-month follow-up showing early posterior fusion and stable fixation|
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The ESCC was grade 1b. The SIN score was 12/18 indicating borderline instability. The modified Tokuhashi score was 14/15 indicating >12 month survival. Tomita recommends long-term local control for the spinal metastases with wide or marginal excision. The NOMS framework recommends spinal stabilization followed by cEBRT for a radiosensitive tumor with low-grade ESCC and spinal instability.
The patient underwent a transoral C2 biopsy followed by a long posterior occipitocervical stabilization [Figure 6E]. Postoperatively, her severe neck pain was completely relieved and she was mobilized immediately following the surgery with a cervical orthosis. She underwent cEBRT at 3 weeks following surgery.
At the 6-month follow-up, the patient was pain free and mobile. X-rays showed early posterior fusion with stable fixation [Figure 6F and G].
| Case 7: Ewing’s Sarcoma at D7 Treated with Chemotherapy + Radiotherapy|| |
A 15-year-old boy was brought into the emergency room by his parents on a Saturday night during the first COVID lockdown. He complained of a dull backache for the past two months and progressive difficulty in walking over ten days. He was unable to stand and walk for the last three days and had been unable to move his lower limbs for the last 18 hours. He had passed urine and stools 8 h back. There was no history of fever, weight loss, anorexia, tuberculosis, or tuberculosis contact.
Examination revealed a healthy, conscious, and alert boy with normal vital parameters. There was mild tenderness in the lower dorsal spine. Neurological examination revealed spasticity with grade 0 power in both his lower limbs, hypoaesthesia below D10, brisk ankle and knee reflexes with clonus and an upgoing plantar reflex. The urinary bladder was palpable per abdomen, the perianal sensations were diminished and anal tone was weak.
Radiological investigations revealed a pathological fracture of D9 due to a tumor involving the D9 vertebral body extending into the epidural space and resulting in severe spinal cord compression (ESCC grade 3). The tumor also had a large extension (>8 cm) into the left thorax, occupying the lower ½ of the left thorax [Figure 7]A–E. The SIN score was estimated to be 9 indicating indeterminate instability.
|Figure 7: Case 7 (A–E) MRI images of a 15-year-old boy showing a large tumor involving the D8 and D9 vertebrae with a pathological fracture of D9. The tumor has extended into the epidural space resulting in severe (grade 3) epidural spinal cord compression. There is a large intrathoracic extension of the tumor within the left hemithorax. Contrast images reveal that the tumor is hypervascular. (F–H) MRI images after six cycles of chemotherapy revealing significant reduction in the size of the intrathoracic component of the tumor and the epidural spinal cord compression. The pathological fracture of the vertebra too appears to have healed|
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The management dilemma was whether to perform an emergency surgical decompression in view of the profound and rapidly deteriorating neurological deficit or to investigate the patient in order to determine the histopathological diagnosis and stage the tumor. The size and appearance of the tumor indicated that this was a primary malignant tumor. The most common diagnosis in a 15-year-old would be a malignant round cell tumor. Ewing`s sarcoma is a malignant round cell tumor that originates from bone or the surrounding soft tissue and commonly presents in the second decade of life. It is extremely sensitive to chemotherapy and radiotherapy. Even in patients with significant neurological deficit, radiotherapy plus chemotherapy followed by surgery, when necessary has shown excellent neurological recovery. Further, studies have shown that the outcomes of decompression laminectomy without complete tumor excision are worse than the results of radiotherapy plus chemotherapy. In case surgery is to be performed, preoperative embolization of the tumor is recommended because Ewing`s sarcoma is an extremely vascular tumor.
In this instance, we started the patient on intravenous methyl prednisolone to stabilize the neurology. The next morning, a CT-guided biopsy was performed from the soft thoracic component of the tumor which yielded a diagnosis of Ewing`s sarcoma. A PET CT scan showed no other lesions. Our treatment strategy was to shrink the tumor size with chemotherapy and then administer radiotherapy to the residual tumor. Surgery would be performed only if there was instability or for residual tumor after chemotherapy and radiotherapy. The patient was started on chemotherapy. After 6 cycles of chemotherapy over 3 months, the patient`s general health significantly improved, the back pain disappeared, the power in his lower limbs improved to grade 4/5 and he started ambulating with a walker. He also regained control over his bladder and bowel. A repeat MRI showed that the intrathoracic component of the tumor had significantly reduced in size with complete resolution of the ESCC [Figure 7F–H]. The compression fracture of the vertebra too appeared to be healed. The residual tumor was treated with radiotherapy.
Although this patient had a primary malignant tumor, this case has been included here to emphasize the role of chemotherapy for both systemic and local tumor control in patients with round cell tumors and hematologic malignancies which are usually extremely sensitive to chemotherapy and radiotherapy.,
| Discussion|| |
A number of factors are taken into consideration when planning the most appropriate treatment for a patient with spinal metastasis. Significant spinal instability as judged by a SIN score of >12 necessitates surgical stabilization if the patient is healthy enough to tolerate the procedure. Another indication for surgery is a patient who presents with a significant neurologic deficit (inability to ambulate, loss of continence of bladder or bowel or ESCC grade 2/3). Finally, surgery is also indicated for radioresistant vertebral metastasis in centers where SBRT is unavailable.
For most patients with spinal metastasis, the goal of surgery is short-term palliation with intralesional surgery for neural decompression and spinal stabilization followed by adjuvant radiotherapy. En bloc surgery is reserved for relatively younger/ healthier patients with solitary spinal metastasis from a cancer with a good prognosis for long term survival.
Conventional external beam radiotherapy alone is indicated only for radiosensitive tumors without spinal instability or significant neurologic impairment. SBRT has been shown to be effective for both radiosensitive and radioresistant tumors in the absence of spinal instability and significant neurological deficit.
Systemic therapies are primarily meant for systemic control of the cancer and are not commonly used as the sole modality for local control of the spinal metastases except for hematologic malignancies or round cell tumors in children.
| Declaration of patient consent|| |
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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| Conflicts of interest|| |
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4]