Spinal Metastases and the Evolving Role of Molecular Targeted Therapy, Chemotherapy, and Immunotherapy

Abstract

Metastatic involvement of the spine is a common complication of systemic cancer progression. Surgery and external beam radiotherapy are palliative treatment modalities aiming to preserve neurological function, control pain and maintain functional status. More recently, with development of image guidance and stereotactic delivery of high doses of conformal radiation, local tumor control has improved; however recurrent or radiation refractory disease remains a significant clinical problem with limited treatment options. This manuscript represents a narrative overview of novel targeted molecular therapies, chemotherapies, and immunotherapy treatments for patients with breast, lung, melanoma, renal cell, prostate, and thyroid cancers, which resulted in improved responses compared to standard chemotherapy. We present clinical examples of excellent responses in spinal metastatic disease which have not been specifically documented in the literature, as most clinical trials evaluate treatment response based on visceral disease. This review is useful for the spine surgeons treating patients with metastatic disease as knowledge of these responses could help with timing and planning of surgical interventions, as well as promote multidisciplinary discussions, allowing development of an individualized treatment strategy to patients presenting with widespread multifocal progressive disease, where surgery could lead to suboptimal results.

Survival and Neurological Outcomes Following Corpectomy for Spinal Metastatic Disease: A Single Institutional Experience

“…It allows for greater local disease control than EBRT and has efficacy against EBRT-resistant tumors [28]. Similarly, systemic medical therapies have also shown promise in treating SM [36]. Patients that received neoadjuvant therapy in this cohort had a lower OS, likely due to these patients having more advanced disease.…”

The Role and Clinical Outcomes of Endoscopic Spine Surgery of Treating Spinal Metastases; Outcomes of 29 Cases From 8 Countries

“…Spinal metastasis is considered one of the significant challenges in spine care worldwide [ 1 ]. Although most are asymptomatic, symptomatic spinal metastases can severely affect the patient’s quality of life by causing excruciating pain, neurological deficit, and deteriorating ambulation status [ 2 , 3 ]. The mainstay of treatment consists of palliative radiation and spine surgery in appropriately selected patients [ 4 , 5 ].…”

Advances in the Treatment of Spinal Metastasis: Commentary on “Spinal Metastases and the Evolving Role of Molecular Targeted Therapy, Chemotherapy, and Immunotherapy”

“…In their review, Fomchenko et al [ 1 ] summarize the incidence and treatment options for spinal metastasis from primary non-small cell lung cancer, breast cancer, melanoma, renal cell carcinoma, prostate cancer, and thyroid cancers. Collectively, these primary cancers account for over 55% of all spine metastases diagnosed in the United States [ 2 ].…”

“…With the advent of genomic analysis, an increasing percentage of patients can be identified with a targetable mutation. The review by Fomchenko et al [ 1 ] provides a comprehensive collation of targetable mutations including therapies for BRAF V600E mutations in melanoma (MEK inhibitors); T790M EGFR mutations in non-small cell lung cancer (crizotinib), VEGFR/AXL/cMet mutations in renal cell carcinoma (cabozantinib), and mutations in damage repair pathways in prostate cancer (PARP inhibitors). Surgeons should be aware of the molecular subtype of their patient’s primary cancer and be cautious of using these older prognostic scoring systems, which might exclude patients from surgery based on predictions calculated using old data.…”

“…Further recognition of predictors of which patients will respond to treatment will continue to evolve as new molecular targets are identified and therapies are approved, and it is important for the spine surgeon to be aware of this prognostic data when counseling patients. The review by Fomchenko et al [ 1 ] provides a comprehensive summary of current treatment options available for patients with spinal metastasis that will serve as a useful reference for spinal surgeons.…”