Decision Making in Patients With Metastatic Spine. The Role of Minimally Invasive Treatment Modalities

Abstract

Spine metastases affect more than 70% of terminal cancer patients that eventually suffer from severe pain and neurological symptoms. Nevertheless, in the overwhelming majority of the cases, a spinal metastasis represents just one location of a diffuse systemic disease. Therefore, the best practice for treatment of spinal metastases depends on many different aspects of an oncological disease, including the assessment of neurological status, pain, location, and dissemination of the disease as well as the ability to predict the risk of disease progression with neurological worsening, benefits and risks associated to treatment and, eventually, expected survival. To address this need for a framework and algorithm that takes all aspects of care into consideration, we reviewed available evidence on the multidisciplinary management of spinal metastases. According to the latest evidence, the use of stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT) for spinal metastatic disease is rapidly increasing. Indeed, aggressive surgical resection may provide the best results in terms of local control, but carries a significant rate of post-surgical morbidity whose incidence and severity appears to be correlated to the extent of resection. The multidisciplinary management represents, according to current evidence, the best option for the treatment of spinal metastases. Noteworthy, according to the recent literature evidence, cases that once required radical surgical resection followed by low-dose conventional radiotherapy, can now be more effectively treated by minimally invasive spinal surgery (MISS) followed by spine SRS with decreased morbidity, improved local control, and more durable pain control. This combination allows also extending this standard of care to patients that would be too sick for an aggressive surgical treatment.

Treatment Strategy for Metastatic Spinal Tumors: A Narrative Review

“…When considering the surgical techniques used for spinal metastasis, the literature shows a trend toward the adoption of less invasive techniques, which is thought to have primarily resulted from recent advances in radiotherapy, as previously described [8]. With the use of advanced radiation techniques, surgeons can minimize surgical morbidities by avoiding extensive debulking surgery [61] (Fig. 1).…”

Separation surgery for metastatic epidural spinal cord compression: A qualitative review

“…Historically, cERBT with palliative intent (30 Gy in 10 fractions, 20 Gy in 5 fractions or 8 Gy in one fraction) have been considered the main treatment options for spinal metastases [20] . In a recent review, Barzilai et al underlined the wide range of response duration and recurrence rate after adjuvant cERBT and its strong dependency from tumor histology of primary tumor, with poorly responses in radioresistant tumors [36] , [42] , [51] . Pain relief, neurological status and LC were the outcomes analyzed in different series [42] .…”

“…Throughout the years, many prognostic scoring systems have been developed in order to helping decision making. Tomita and Tokuhashi scores [34] , [35] have represented real cornerstones for surgeons, but have become progressively out of date because the stability assessment and the impact of new advancements in from radiotherapy/radiosurgery and systemic treatment targeted therapy/immunotherapy were not considered [3] , [22] , [36] . Furthermore, the decision making was based only on survival prognostic factors.…”

SBRT in single or multiple spinal metastases: 36 Gy in 3 fractions given to GTV

“…La incidencia de metástasis en las vertebras es del 30-70 % en pacientes con diagnóstico de cáncer metastásico (1) y constituyen el 90 % de todos los tumores vertebrales (2). Se originan a partir de múltiples tumores primarios, con mayor frecuencia en los de próstata, de tiroides, de riñón, de pulmón y de mama.…”