An update in the management of spinal metastases

Abstract

Advances in cancer treatment over the past decade, such biologics and immunotherapy are improving patient outcomes and consequently life expectancy. The most common sites for metastases in the general population with cancer are the liver and lungs, followed by bone. Considering bone metastases, the majority will affect the spine 1 . Some studies estimate that up to 40% of all patients with cancer will have spinal metastases (SM) during the course of their disease 2,3 . The most frequent histologic types of cancer that give rise to bone metastases are breast, prostate and lung cancer 4 . Most of the spinal metastases are diagnosed following the diagnosis of the primary cancer. However, in about 10% of the patients, SM is the first manifestation of an unknown primary tumor 1 . Spinal cord compression is expected in up to 20% of the patients with SM. Approximately 95% of the patients with SM will demonstrate epidural metastases, mainly affecting the vertebral body and the pedicle regions, whereas 5% will present with intradural and less than 1% with intramedullary metastases 5,6 . Symptomatic spinal cord compression occurs more frequently in the thoracic spine, followed by cervical and then lumbar. The greater incidence of SM in the thoracic spine is attributed to the higher number of vertebrae and small canal diameter AbstrActThe best clinical treatment for spinal metastases requires an integrated approach with input from an interdisciplinary cancer team. The principle goals of treatment are maintenance or improvement in neurologic function and ambulation, spinal stability, durable tumor control, and pain relief. The past decade has witnessed an explosion of new technologies that have impacted our ability to reach these goals, such as separation surgery and minimally invasive spinal procedures. The biggest advance, however, has been the evolution of stereotactic radiosurgery that has demonstrated durable tumor control both when delivered as definitive therapy and as a postoperative adjuvant even for tumors considered markedly resistant to conventional external beam radiation. In this paper, we perform an update on the management of spinal metastases demonstrating the integration of these new technologies into a decision framework NOMS that assesses four basic aspects of a patient's spine disease: Neurologic, Oncologic, Mechanical Instability and Systemic disease.Keywords: spinal metastases, bone metastases, diagnosis, management, treatment, NOMS.resumo O tratamento dos pacientes com metástases na coluna requer uma abordagem multidisciplinar por equipe especializada em oncologia. Os objetivos básicos do tratamento são a manutenção/ melhora da função neurológica com preservação da deambulação, manutenção da estabilidade da coluna, controle tumoral e alívio da dor. A última década testemunhou uma explosão de novas tecnologias que auxiliaram a atingir os objetivos terapêuticos, como a cirurgia de separação e procedimentos minimamente cirúrgicos minimamente invasivos. Contudo, o maior avanço terapêutico constitui-se d...

Bone graft options for spinal fusion following resection of spinal column tumors: systematic review and meta-analysis

“…With a growing understanding of the biology of spinal tumors and the advent of novel adjunctive treatment options and reconstruction techniques, the overall survival of patients with spinal column tumors has been increasing. 28,29,37 Thus, in addition to survival outcomes, other clinical considerations such as fusion outcomes, neurological outcomes, and pain outcomes should be taken into consideration to improve quality of life of the patients. Achieving solid arthrodesis is an important factor in the setting of resection of spinal column tumors, given the potentially long overall survival with likely instrumentation failure in the absence of arthrodesis.…”

“…24,28,29,37 Also, due to novel reconstruction techniques, such as titanium mesh cages and expandable cages, and various bone graft and bone graft extender options, more complex reconstructions have become feasible for patients following spinal column tumor resection. Hence, not only overall survival but also other clinical outcomes such as fusion rates, perioperative complications, postoperative neurological deficits, and long-term pain outcomes need to be taken into account to optimize functional outcomes.…”

Spinal Metastasis: Diagnosis, Treatment and Prognosis - Integrative Review From 2012 to 2017

“…Thus, the expected overall survival of the patient is based on the extent of the disease and the histology of the tumor. 98,99 The objective of NOMS is to provide a dynamic infrastructure for the treatment of spinal metastases with the ability to incorporate advances in interventionist radiology, radiation, medical oncology, and surgical techniques to optimize patient outcomes. In addition, NOMS provides a single language for all the professionals, since as these treatment decisions become more complex, an evidence-based, multidisciplinary approach, including oncologists, physicians, radiation oncologists, surgeons, interventionists, and pain specialists is necessary.…”

“…97,98 Regarding the thematic unit "prognostic scale effectiveness", in the articles found there is a predominantly greater probability that these scales indicate the survival of patients with bone metastases more accurately, even though they are many times exhaustive because they involve various measures and time availability, which led one of the articles to advise against the use of scales. [97][98][99] However, the use of scales is useful and essential as it often helps professionals to broaden their ability to predict cancer patient survival, although this expectancy is relative and may be lengthened or shortened, regardless of the clinical experience of the professional or the overall knowledge about the patient. 100…”

Establishment of a Disease-Specific Graded Prognostic Assessment for Hepatocellular Carcinoma Patients with Spinal Metastasis

“…Spinal metastasis (SM) occurs in 50% to 75% of cases of bone metastases of HCC and can lead to neurologic deficits and a reduced quality of life 4–8. Surgery can provide restoration of mechanical instability and emergent decompression,9,10 while chemotherapy can be used to treat systemically with targeted agent such as sorafenib 11–14. Radiotherapy (RT) can effectively provide palliation of painful SM in approximately 60% to 97% of patients, with up to 32% of patients experiencing a complete response in terms of pain relief 4,15,16.…”