Treatment-naïve lung cancer presenting with spinal metastases: a national study of survival, surgery, and the role of predictive biomarkers

Abstract Purpose Spinal metastasis as the first manifestation of lung cancer, presents challenges in diagnosis, prognosis, and treatment planning. This study aims to evaluate postoperative survival outcomes and to identify prognostic factors in treatment-naïve patients undergoing surgery for spinal metastases, focusing on clinical and molecular variables. Methods This retrospective cohort study included 149 patients who underwent surgery for spinal metastases from lung cancer between 2011 and 2023. Data were obtained from the Swedish National Register for Spine Surgery (Swespine) and the Swedish National Lung Cancer Register (SNLCR). Patients were grouped based on whether spinal metastasis was the initial manifestation of lung cancer or occurred during known disease. Kaplan–Meier analysis and Cox proportional hazards models were used to assess postoperative survival and prognostic factors. Results Of the 149 patients, 114 (77%) presented with spinal metastasis as the initial sign of lung cancer. Median survival in this group was 6 months, compared to 3 months in patients with a prior confirmed lung cancer diagnosis ( p = 0.022). In the initial presentation group, longer survival after surgery was observed in patients with predictive biomarkers (8 vs. 5 months, p = 0.003), preserved ambulatory function (8 vs. 3 months, p = 0.002), and better WHO performance status ( p < 0.001). In multivariable analysis, biomarker status, WHO performance status, ambulatory function, and age were independently associated with post-operative survival. Conclusion Patients undergoing surgery for spinal metastases as the initial manifestation of lung cancer form a distinct subgroup. Early functional and molecular assessment may improve patient selection and surgical outcome in this population.