ReviewSpine metastases: Current treatments and future directions
Introduction
The World Health Organisation (WHO) estimates that 10 million people were diagnosed with cancer worldwide in 2000 and expects cancer rates to increase by 50% to 15 million by 2020. As treatment options improve and patients have an increased survival,1, 2 the incidence and prevalence of spinal metastases, which are known to occur in 30–50% of cancer patients,3, 4, 5 will also rise. Often, these tumours can significantly impact a patient’s quality of life as a result of disabling pain, fractures or even paralysis due to spinal cord compression.6, 7 Both early detection and appropriate intervention are essential to minimise the sequelae of spinal metastases and maximise patient function and quality of life.
Section snippets
Demographics
The vast majority of spinal metastases arise from breast, lung, prostate or renal primaries reflecting both the prevalence of these cancer types and their predilection to bone.8, 9, 10 Metastatic tumours are the most frequent spine tumours and are estimated to be 20 times more frequent than primary spine tumours.11 Whilst spinal metastases can develop at any age, the highest incidence is between 40 and 70 years of age related to an increased cancer risk during this time. There is also a male
Signs and symptoms
Up to 10% of cancer patients present with spinal metastases as the initial disease presentation.22 Pain is the most common manifestation, occurring in 90% of the patients.8, 23, 24 Spinal tumour pain can present as local pain exaggerated by palpation or percussion, radicular in nature, implying compression or invasion of the nerve roots, or mechanical pain that is relieved by rest, provoked by movement and warranting spinal instability precautions.8, 22, 25, 26 Night pain or pain when recumbent
Diagnostic evaluation
All cancer patients complaining of back pain or neurological involvement and patients presenting with symptoms and positive “red flags” should be evaluated by laboratory studies and proper imaging. Routine blood studies consisting of a complete blood count, albumin, electrolyte panel, liver enzyme assays, blood urea nitrogen and serum creatinine can shed light on the general and metabolic condition of the patient, and occasionally hint towards a diagnosis or metastatic spread.10, 27
Several
Steroids
Corticosteroids are used routinely in the treatment of spine tumours, especially when spinal cord compression occurs, although indications for their use and the appropriate dose remain controversial. Steroids reduce oedema in the spinal cord and have been shown to reduce the size of metastases from haematogenous tumours and, occasionally, of breast cancer.8, 20 Vecht et al.33 conducted a randomised trial in patients with metastatic epidural spinal cord compression (MESCC) comparing
Radiation therapy
Before radiation therapy became available, surgical dorsal decompression in the form of laminectomy was the only alternative for patients with metastatic cord compression. Spine radiotherapy was introduced in the 1950s and several large retrospective studies and one small prospective randomised trial comparing it to laminectomy failed to show benefit of surgical decompression.36, 37, 38, 39 As a result, for many years, conventional radiation alone for patients with metastatic spine tumours was
Chemotherapy
The long-term control of spine metastases entails systemic chemotherapy. Chemotherapy can be administered as monotherapy or involve a combination of agents and largely depends on the histology of the tumour and its chemosensitivity or specific receptor status.50, 51 Typically, hormonal drugs are used for prostate and breast metastases, and cytotoxic agents for most other cancers and also when hormonal therapy begins to fail in patients initially treated with it.
Bisphosphonates
Bisphosphonates are a group of
Surgical treatment
Spinal stability must be maintained in order to achieve the normal spine functions of a body support system and a protective housing for the neural elements. Infiltration of the spinal column with metastases results in the replacement of the bony architecture with tissue lacking weight-bearing properties. The initial treatments described for spinal column tumours were in an era before radiotherapy was introduced. Decompressing of the spinal cord was performed via a dorsal approach laminectomy
Surgical advancements
As the prevalence of surgery for spinal metastases is rising, new techniques are utilised to ease the procedure and diminish the risks to the patient.
Stereotactic spine radiosurgery
The role of radiation is well established in the treatment of metastatic spine tumours where it has been shown to reduce pain, control local disease progression and potentially prevent or reverse neurological dysfunction.3, 93 Further, it has been found that a higher radiation dosage to the tumour area results in a greater tumour control rate.48 Yet, one of the main limitations associated with conventional radiotherapy for spinal metastases is the low radiation tolerance of the spinal cord and
Proposed treatment algorithm
Standard guidelines for treating spinal metastases are not available, and treatment regimens vary widely according to availability of treatment modalities, geographical variations, health insurance coverage and medical costs, as well as personal and religious beliefs. We share here our spine tumour treatment algorithm used successfully at our institution over the past five years. It outlines a general approach to managing patients with suspected spinal metastases and we believe it could be
Future directions incorporating combination therapies
Although patients with spinal metastases are perceived to have a short survival time, recent studies have shown the benefit of aggressive treatment for sub-populations.6, 7, 61, 62 As cancer treatment improves, and patients live longer, the benefits of aggressive treatment outweigh the associated risks and costs.1, 19 Successful cancer treatment combines the use of surgery, chemotherapy and irradiation.128 Combining surgical resection and stabilisation with irradiation has been shown to be
Conclusion
In the future, advancements in imaging modalities, surgical skills and instruments, chemotherapy and radiation therapy will continue to improve the quality of life and overall survival of patients with spine metastases. However, improved systemic control of many malignancies, increased surgical treatment options and proliferation of novel spine tumour treatment modalities have resulted in patient referrals to an ever-broadening variety of specialists. Yet, patients with spine tumours frequently
Conflict of interest statement
None declared.
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