The importance of multidisciplinary care for spine metastases: initial tumor management

Integrated management of metastatic spinal tumors: current status and future directions

With improved cancer survivorship, the incidence of metastatic bone disease has risen, and metastatic spinal tumors (MSTs) have emerged as a common yet significant clinical challenge. These tumors may compromise the integrity of vertebral bodies leading to pathological fractures and neurological compromise from nerve root or spinal cord compression dramatically affecting the patient's quality of life. Despite the associated morbidity and mortality, optimal treatment strategies remain elusive. Here, in our review, we provide a comprehensive analysis of the contemporary MST treatment strategies, encompassing surgical interventions, advanced radiotherapy modalities, and evolving systemic therapies including chemotherapeutic and immunotherapeutic approaches. We critically evaluate each modality's development trajectory, clinical efficacy, therapeutic advantages, and inherent limitations. Our analysis reveals a definitive shift toward precision-guided radiotherapy and minimally invasive surgical techniques that balance therapeutic efficacy with reduced morbidity. These findings underscore the necessity for multidisciplinary management and highlight promising avenues for therapeutic innovation. As treatment paradigms evolve, integration of these advanced modalities offers new hope for this vulnerable patient population facing a challenging oncological complication.

Poroelastic Characterization of Human Vertebral Metastases to Inform a Transdisciplinary Assessment of Spinal Tumors

Background and Objectives: Vertebral metastases often lead to pathological fractures and spinal cord compression, thus impacting patient quality of life. This study aimed to quantify the poroelastic mechanical properties of vertebral metastatic tissue explanted during spine surgery and correlate it with clinical data. Methods: Nine patients (61.7 ± 13.1 years) were prospectively recruited from April 2021 to February 2022, where 78% had a vertebral fracture. Demographic and metastases data, including primary origin, spinal level, lesion volume, and SINS score, were collected, and tissue specimens were explanted during surgery. Using a newly developed portable experimental setup, confined compression creep tests were conducted to measure the aggregate modulus and permeability of each sample. Dealing with limited samples, the results were expressed as the median (min; max). Results: Specimens from the unfractured vertebrae had higher aggregate modulus (200.35 (149.80; 250.90) kPa vs. 14.47 (8.27; 35.89) kPa) and higher permeability (0.02 (0.01; 0.03) mm4/N·s vs. 0.41 (0.10; 4.68) mm4/N·s) compared with the specimens from the fractured vertebrae. Histology revealed prominent levels of neoplastic cell infiltration and disruption of typical bone matrix architecture. Specimens with low neoplastic cellularity had comparable or slightly higher poroelastic properties compared to high cellularity. No clear trend was observed between the mechanical properties and SINS score, nor between the mechanical properties, percentage lesion volume, and fractures. Conclusions: Despite the limited sample size, the poroelastic characterization revealed relevant insights to investigate in future research. A transdisciplinary assessment of vertebral metastases, incorporating poroelastic testing, deserves further attention and could enhance the treatment options.

State-of-the-art of multidisciplinary approach of bone metastasis-directed therapy: review and challenging questions for preparation of a GEMO practice guidelines

Bone is a common secondary site of dissemination during the course of cancer. Bone metastases (BM) can be associated with skeletal-related events (SRE) such as disabling pain, hypercalcemia, and bone instability that leads to pathological fractures or spinal cord compression. SRE contribute to high morbidity as well as, mortality, and have a negative economic impact. Modern management of BM integrates focal treatments (such as radiotherapy, surgery, and interventional radiology), orthoses, and antiresorptive and systemic oncological treatment. The choice of a metastasis-directed therapy depends on the objective of the treatment, the patient characteristics, and the complete assessment of the bone lesion (pain, neurological risk, and instability). In the narrative review present herein, we aim to provide an updated summary of the literature, with description of the advantages and disadvantages of current and emerging strategies in the multimodal treatment of BM and, based on these data, an updated algorithm for the management of BM.

Hybrid Therapy with SBRT Target-Tailored Tumor Resection for High-Grade Metastatic Epidural Spinal Cord Compression (MESCC): Illustrative Case

Background: Spinal metastases affect approximately 40% of patients with systemic cancers; metastatic epidural spinal cord compression (MESCC) occurs in up to 20% of cases and leads to potential significant morbidity. Recent advancements in high-dose conformal radiation techniques, such as Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS), enable histology-independent ablative treatments, yet optimal dose fractionation remains undetermined. Methods and Results: This case of vertebral metastases with high-grade ESCC exemplifies the model of a comprehensive treatment workflow that emphasizes interdisciplinary collaboration, within the framework of a personalized medicine. The "Hybrid Therapy" combines Separation Surgery, aimed at achieving circumferential spinal cord decompression, with SBRT/SRS. The oncologic resection has been performed in a navigation-assisted technique that is tailored to the SBRT target, pre-operatively defined on the neuronavigation station. Conclusions: This seamless integration during initial planning of surgery with the ideal radio-oncological target is aimed at avoiding delays in referral and limitations in subsequent treatment options. This integrative holistic strategy not only prioritizes functional preservation, minimizing surgical invasiveness, but also promotes tumor control, thus offering potential promising new avenues for patient-centered oncologic care. Future high-quality studies are warranted to validate the widespread potential utility and safety of this approach.

Radiotherapy and surgery: can this combination be further optimized for patients with metastatic spine disease?

This narrative review provides a comprehensive overview of the current status, recent advancements, and future directions in the management of metastatic spine disease using both radiotherapy and surgery. Emphasis has been put on the integrated use of radiotherapy and surgery, incorporating recent developments such as separation surgery, active dose sparing of the surgical field, and the implementation of carbon fiber-reinforced polymer implants. Future studies should explore the effects of minimizing the time between radiotherapy and surgery and investigate the potential of vertebral re-ossification after radiotherapy to obviate the need for stabilization surgery. Concerted efforts should be directed toward fostering multidisciplinary collaboration among radiation oncologists, spine surgeons, and medical oncologists.

Complication avoidance, rehabilitation, pain therapy and palliative care for patients with metastatic spine tumors: WFNS spine committee recommendations

OBJECTIVE

This review aims to formulate the most current, evidence-based recommendations regarding complication avoidance, rehabilitation, pain therapy and palliative care for patients with metastatic spine tumors.

METHODS

A systematic literature search in PubMed and MEDLINE, and was performed from 2013 to 2023 using the search terms "complications" + "spine metastases", "spine metastases" + + "rehabilitation", "spine metastases" + "pain therapy" + "palliative care". Screening criteria resulted in 35, 15 and 56 studies respectively that were analyzed. Using the Delphi method and two rounds of voting at two separate international meetings, nine members of the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated nine final consensus statements.

RESULTS

Preoperative assessment for complications following surgery in patients with metastatic spine tumors should include estimation of Karnofsky score, site of primary tumor, number of spinal and visceral metastasis, ASA score and preoperative Hb (Hemoglobin) value. Complication risk factors are age > 65 years, preoperative ASA score of 3 and 4 and greater operative blood loss. Pain management using WHO analgesic concept and early mobilization are needed, starting with non-opioids, weak opioids followed by strong opioids. Morphine is the first choice for moderate to severe pain whereas IV-PCA may be used for severe breakthrough pain with monitoring. Use of bisphosphonates is considered in cases of non-localized pain and not accessible radiation therapy.

CONCLUSIONS

These nine final consensus statements provide current, evidence-based guidelines on complication avoidance, rehabilitation, pain therapy and palliative care for patients with spinal metastases.

Posterior-only 2-level vertebrectomy and fusion in a medically complex patient with lumbar metastasis: illustrative case

BACKGROUND

Spinal metastases are commonly seen in patients with cancer and often indicate a poor prognosis. Treatment can include curative or palliative surgery, chemotherapy, and radiation therapy. The surgical approach varies widely on the basis of the affected region of the spine, the location of the tumor (anterior versus posterior), the goal of surgery, the health of the patient, and surgeon preference.

OBSERVATIONS

The authors present a case of a 68-year-old male with intractable lower-back pain and substantially diminished ambulation. Diagnostic imaging revealed a lumbar metastasis from a cholangiocarcinoma primary at L2-3 (4.5 cm anteroposterior × 5.7 cm transverse × 7.0 cm craniocaudal). The patient underwent a 2-level vertebrectomy with expandable cage placement and T10 to S2 fusion via a posterior-only approach. The patient regained much of his mobility and quality of life after the surgery.

LESSONS

Although this was a high-risk surgery, the authors show that a posterior-only approach can be used for lumbar vertebrectomies and fusion when necessary. Palliative surgeries carrying a high risk, especially in the setting of a limited prognosis, should include multidisciplinary deliberations and a thorough discussion of the risks and outcome expectations with the patient.