- How Advances in Radiation Therapy are Improving Care for Brain and Spine Tumors
- Understanding Proton Therapy Benefits
- Researching Radiation Effects and New Techniques
- Valuing the Patient Perspective
- Spinal Cancer and Spinal Tumors
- Primary and Metastatic Spinal Tumors
- Spinal Tumor Types by Aggressiveness
- Spinal Cancer: Malignant Spinal Tumors
- Benign Spinal Tumors
- Benign Epidural Tumors
- Benign Intradural Tumors
- Spinal Tumor and Spinal Cancer Diagnosis
- Spinal Tumors and Spinal Cancer Treatment
- Spinal Tumors: Background, Anatomy, Prognosis
- Metastatic Brain or Spine Cancer Treatment
- Laser Interstitial Thermal Therapy for Brain Tumors and Radiation Necrosis
- Awake Craniotomy for Brain Tumors
- Spinal Cord Decompression and Stabilization
- Targeted Therapy
- Palliative Care
- Rehabilitation Therapy
- Surgery for Spinal Tumors
- Surgery Goals
- Possible Surgical Procedures for Spinal Tumors
- Minimally invasive versus conventional spine surgery for vertebral metastases: a systematic review of the evidence
- Search strategy
- Eligibility criteria
- Study eligibility
- Direct comparisons of MIS and conventional techniques
How Advances in Radiation Therapy are Improving Care for Brain and Spine Tumors
December 20, 2019, by NCI-CONNECT Staff
Dr. Christina Tsien
Radiation oncologist Dr. Christina Tsien is a cancer survivor. She discusses the advances in radiation therapy that are improving brain and spine tumor patient outcomes and how her personal experience has impacted the care she provides.
Radiation oncologist Christina Tsien, M.D., learned at a young age the impact of radiation therapy, a type of cancer treatment that uses beams of intense energy to kill cancer cells. At age 19, she was diagnosed with a rare sarcoma. After multiple surgeries and recurrences, she received radiation treatments that ultimately stopped her cancer from returning.
Now, as a physician, the experience of being a cancer patient has been an important part of her career. “I learned firsthand the impact of radiation therapy on curing cancer.
Later, I gained insight into the impact of cancer care on long-term survivorship and it is this understanding that now shapes many of the treatment decisions I recommend,” says Dr.
Tsien, Medical Director of the Johns Hopkins Proton Therapy Center at Sibley Memorial Hospital in Washington, D.C.
Dr. Tsien received her medical degree from McGill University’s Faculty of Medicine in Montreal. She completed a radiation oncology residency and fellowship, then became a professor at the University of Michigan.
In 2014, she joined the radiation oncology department at Washington University in St.
Louis where she served as chief of the central nervous system service, director of clinical research, and as co-medical director of stereotactic radiosurgery and the gamma knife center. In October 2019, she joined John Hopkins Medicine.
“We are now able to cure many types of cancer, but this often requires multiple types of therapies such as surgery, radiation, and systemic therapy. It is important that we, as cancer specialists, organize ourselves as teams to practice multidisciplinary medicine,” Dr. Tsien says.
Over half of all cancer patients will receive some form of radiation treatment.
For people with rare brain and spine tumors, radiation treatment is often ideal because of its precision in targeting areas of the brain that are otherwise difficult to access.
Proton beam therapy kills cancer cells by causing DNA damage while minimizing damage to the healthy surrounding tissue. Cancer cells whose DNA is damaged beyond repair stop dividing or die.
Understanding Proton Therapy Benefits
Proton therapy is a type of advanced radiation technology. It takes advantage of a remarkable and unique characteristic of high energy particle beams and how they deposit ionizing radiation as they move through tissue.
Un conventional gamma or X-ray beams, which do not stop as they pass through the body, the depth of proton therapy beams can be controlled.
As the charged particles come to a stop, all their energy is deposited within the tumor with little to no exit dose to the surrounding tissues.
The most advanced type of proton therapy delivery is pencil beam scanning technology. Pencil beam technology allows for “dose painting” with a precise proton beam only a few millimeters wide to target the unique shape of individual tumors.
This is really key for treating rare tumors that are close to critical structures, such as the brain stem and spinal cord.
Radiation therapy that treats the brain and spine is called craniospinal radiation. This form of radiation may be used for rare tumors, including medulloblastomas, germ cell tumors, pineal region tumors, and other rare tumors.
“Patients are living longer than ever following a cancer diagnosis. The goal now is to find ways to lower the risk of treatment-related side effects, some of which do not become apparent until long after treatment has ended. Proton therapy can help achieve these goals,” Dr. Tsien says.
With the precision of proton therapy, radiation oncologists are better able to minimize the long-term impact of radiation treatment on cognition, vision, hearing, and brainstem and endocrine function. “Proton therapy can often better integrate with other kinds of treatments and allow completion of more treatment cycles with less harm to patients,” Dr. Tsien says.
Proton therapy is not recommended in all clinical situations and patients can often benefit from other types of highly conformal radiotherapy.
“Focal treatments stereotactic radiosurgery using photon radiation are exceptionally precise and effective,” Dr. Tsien says. “Each patient’s disease is unique.
We aim to understand the individual as well as the disease, so we can provide a personalized treatment plan.”
Researching Radiation Effects and New Techniques
Dr. Tsien’s research focuses on understanding the implications of proton therapy to achieve better outcomes. “Technology has allowed us to do things we could not do before.
Advanced imaging techniques allow us to monitor treatment changes in real time and adapt radiotherapy treatment plans,” Dr. Tsien says.
Additional tools optical surface imaging and real-time fluoroscopic gating improve the precision of proton therapy and limit the movement of organs during treatment.
She is also developing novel methods to increase the therapeutic effectiveness of proton therapy. “We need to understand the effects of radiation on the tumor and its surrounding environment, as well as its effect on normal tissues, to find ways to improve effectiveness of novel therapies, including immunotherapy,” Dr. Tsien explains.
Dr. Tsien’s research involves advanced neuroimaging to improve image guidance and better direct how to safely increase the strength of radiotherapy in high grade gliomas to improve its effect.
She studies biomarkers in patients to predict a patient’s response to proton treatment.
“Understanding a patient’s response to treatment earlier – whether it’s working or not – can be used to better predict patient outcomes,” Dr. Tsien says.
To further move the neuro-oncology field forward, Dr. Tsien is working across disciplines and institutions. “We need to design innovative clinical trials incorporating novel translational science, and hypothesis-driven clinical trials strong preclinical science,” she says.
Dr. Tsien is collaborating with the NCI’s Center for Cancer Research, Neuro-Oncology Branch, to refer patients to its Natural History study, which collects and analyzes tissue to discover mutations and learn more about each type of rare brain and spine tumor.
Valuing the Patient Perspective
Learning from her personal cancer experience, Dr. Tsien goes to great lengths to ensure the patient is considered in every treatment decision. “I aim to understand their personal situations and goals. This helps me shape their treatment plan and share it with them,” Dr. Tsien says.
“Patients need to understand their options and the risks and benefits, so they are very informed and can make decisions that are best for them. It is important to take the time to get to know the patient and their families and help them choose a treatment plan that is right for them, whether it is at our center or closer to their home,” Dr. Tsien says.
Her personal experience has made her more understanding of the decision process. “Radiation can be scary and overwhelming at first, but a physician can help coach families through it.
A key part of the cancer care is encouraging patients and caregivers to ask questions and to be candid with their care team about their needs and aims,” Dr. Tsien says. “I often call on my experience as a cancer survivor.
It has given me a better perspective of the important relationship between a physician and a patient.”
Spinal Cancer and Spinal Tumors
A spinal tumor is an abnormal growth arising from any of the tissues that make up the spine. There are many different types of spinal tumors and not all of them are malignant (spinal cancer).
Primary and Metastatic Spinal Tumors
Primary spinal tumors are those that originate in the spine. They are relatively rare, typically benign (noncancerous) and represent a small percentage of spinal tumors. Malignant tumors may also originate in the spine, although more often they spread to the spine from elsewhere in the body.
Metastatic spinal tumors are those that have spread to the spine from other areas of the body. If a tumor is able to spread, this usually means it is malignant. Between 30 and 70 percent of cancer patients develop metastatic spine cancer during the course of their disease. Lung, prostate, and breast cancers are the three most common cancers that tend to spread to the spine.
The spine is not a single location. It is made of different types of tissues that span the entire length of your back and into your neck and pelvis. A tumor can form in almost every type of tissue.
Starting with the outer layers of the spinal column, here are some of the tissues that may develop tumors and cancer in the spine:
- Bones that form the spinal vertebrae, including the bone marrow inside them
- Cartilage that protects the joints in the vertebrae
- Spinal discs that cushion the space between the vertebrae
- Blood vessels that supply nutrients to the spine
- Peripheral nerves that exit the vertebrae
- Dura mater, pia mater and arachnoid mater — three layers of membranes that encase the spinal cord
- Spinal cord
the location of the tumor in relation to the spinal cord, spinal tumors are classified into three groups:
- Extradural tumors (also known as epidural tumors) form inside the spinal column and may involve the vertebrae, but typically don’t affect the spinal cord. They are often located in the epidural space, which is the area surrounding the outer – dura – membrane that protects the spinal cord.
- Intradural tumors form inside the dura and may or may not involve the spinal cord.
- Intramedullary tumors are intradural tumors that grow inside the spinal cord.
Spinal Tumor Types by Aggressiveness
There are several types of masses that can be found in the spine:
- Some are malignant tumors (spinal cancer), which means they can spread to other areas of the body.
- Some are benign tumors, which means they are not aggressive and don’t spread, but it doesn’t mean they are harmless.
- Some may look tumors but are actually cysts, plaques or similar masses.
Spinal Cancer: Malignant Spinal Tumors
Most spinal cancer occurs inside the spinal column and usually doesn’t affect the spinal cord. Some of the cancers that may involve the spine include:
- Osteosarcoma: a type of bone cancer that may originate in the spine but is more common in the thigh and shin bones.
- Chondrosarcoma: a tumor that arises from cartilage cells around the bone. Although uncommon in the spine, it can sometimes develop as a primary cancer in the bones that form the spinal column.
- Multiple myeloma: a cancer that affects plasma cells in the blood. The affected cells collect in the bone marrow and the outer layer of the bone — often in the spine.
- Lymphoma: a group of cancers that affect the cells of the immune system called lymphocytes. It may develop in the spine as a primary tumor, but more often it arises elsewhere and spreads to the spine.
- Chordoma: a malignant bone tumor that can develop inside the spinal column anywhere along its length, however it is most commonly seen in the sacrum (a bone in the base of the spine).
- Ewing sarcoma: a cancer that can affect both the bone and the surrounding soft tissue. It is rare in adults and represents about 1 percent of childhood cancers.
Benign Spinal Tumors
Although in the majority of cases these spinal tumors are benign, a small percentage of them may become malignant. Benign spinal tumors can cause problems when they grow large enough to press against the tissues of the spinal cord or other structures.
Benign Epidural Tumors
- Hemangioma: a growth that forms from the tissues of blood vessels inside the spinal column. These tumors are more common on the surface of the skin, especially in infants, but may also affect internal organs.
- Osteoid osteoma: a small tumor in the bone that is more common in children and younger adults.
- Osteoblastoma: similar to osteoid osteoma but typically larger and more aggressive.
- Osteochondroma: an overgrowth of cartilage and bone that usually occurs at the end of the bone near the growth plate.
- Giant cell tumor (GCT): a tumor that is named for the way it looks under the microscope. It typically contains “giant” cells with multiple nuclei that formed as several cells fused together. GCTs in the spine typically affect the bones of the vertebrae.
Benign Intradural Tumors
- Meningioma: a tumor that is more common in the brain, but may also affect the dura mater, which is one of the meninges — the linings of the spinal cord.
- Nerve sheath tumors such as schwannomas and neurofibromas can form on peripheral nerve roots exiting the spine.
- Glioma: a tumor that grows from glial cells that support the function of the brain and spinal cord. In the spine, the more common types of gliomas are:
- Ependymoma and subependymoma: tumors that develop in the lining of the passageways in the brain and spinal cord. They can sometimes block the flow of the cerebral spinal fluid, which increases the pressure in the brain.
- Astrocytoma: the most common spinal cord tumor in children, which can be malignant or benign.
Hemangioblastoma: a tumor that arises from blood vessels connected to the central nervous system, including the brain and the spinal cord.
After turning in bed, Arrington heard a snap and felt instant pain. MRI results showed a broken neck — and a large spinal tumor. Arrington and his fiancée sought out spine neurosurgeon Timothy Witham at Johns Hopkins for care.
- Eosinophilic granuloma: benign lesions, rare in adults, that affect bones and may cause a collapse of the vertebrae; they are more common in the mid-back.
- Epidural lipomatosis: excessive growth of fat inside the epidural space.
- Synovial cyst: a fluid-filled sac that typically forms in the lumbar spine (lower back) around the vertebral joints, usually from a degenerative process, and is benign.
- Arachnoid cyst: a fluid-filled sac that may cause separation in the membranes enveloping the spinal cord and may protrude into the epidural space.
- Aneurysmal bone cyst: a fluid-filled lesion that affects primarily children and is the third most frequent benign bone tumor.
- Epidermoid and dermoid cysts: hollow growths composed of skin elements that have become implanted in the spinal canal.
- Syringomyelia: a cyst within a spinal cord that may mimic a tumor but is usually benign.
- Multiple sclerosis (MS): plaques that may develop in progressive MS can sometimes cause the same symptoms as spinal tumors.
- Transverse myelitis: an inflammatory disease that causes lesions to form on the spinal cord that may mimic the symptoms and appearance of a spinal tumor.
Symptoms of spinal cancer and spinal tumors may vary depending on the tumor type and location. They may include but are not limited to:
- Back pain and neck pain, which are the most common symptoms of spinal tumors. The pain can be related to the tumor pressing on the nerves or the spinal cord. Or, it can be caused by changes in the alignment of the spine affected by the tumor.
- Neurologic problems related to spinal tumors. These may include:
- Radiculopathy (pinching of the nerve roots)
- Myelopathy (spinal cord compression)
- Bowel and bladder issues due to compression of the nerves that provide sensation and function to these organs
- Numbness, tingling and muscle weakness
- Difficulty walking
If the tumor grows large enough to shift the spinal alignment, it may also cause scoliosis, kyphosis and similar deformities.
Spinal Tumor and Spinal Cancer Diagnosis
When a tumor is found anywhere in the spine, the first step is usually to determine whether it is a primary or a metastatic tumor. Your doctor will ly order a variety of tests to check your spine, as well as other major organs and systems where cancer may develop. These tests and other diagnostic methods may include:
A biopsy may be necessary to confirm the exact type of tumor, especially if it is a primary tumor. Biopsy may require surgery, but in some cases a needle may be used to reach the tumor and extract a sample.
Spinal Tumors and Spinal Cancer Treatment
Treatment for spinal cancer and spinal tumors will differ the tumor type, aggressiveness and many other factors. Your treatment options may include:
- Radiation therapy, including new advances in therapeutic radiology such as targeted proton therapy
- Full or partial surgical removal of the tumor
- Steroids to help with swelling and back pain
Certain benign spinal tumors and cysts may not need treatment if they don’t cause any symptoms.
Spinal Tumors: Background, Anatomy, Prognosis
Andrew A Sama, MD Associate Professor of Clinical Orthopedic Surgery, Weill Cornell Medical College; Associate Attending Orthopedic Surgeon, Associate Director of Spine Surgery Fellowship, Hospital for Special Surgery; Associate Attending Orthopedic Surgeon, New York-Presbyterian Hospital
Andrew A Sama, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: DePuy Spine; Clariance, Inc.
Received royalty from Orthodevelopment Corporation for implant design & development; Received consulting fee from DePuy Synthes for consulting; Received royalty from Pagoda Pedicle Screw System for inventor/designer; Received consulting fee from Clariance, Inc.
for advisory board/consultant; Received ownership interest from Paradigm Spine, LLC, and Sentio LLC for investment interest; Received grant/research funds from Spinal Kinetics for principal investigation paid to institution.
Federico P Girardi, MD Associate Professor of Orthopaedic Surgery, Weill Medical College of Cornell University; Associate Attending Orthopaedic Surgeon, The Hospital for Special Surgery; Director of Research, Spinal Surgical Service, The Hospital for Special Surgery
Federico P Girardi, MD is a member of the following medical societies: Medical Society of the State of New York
Disclosure: Nothing to disclose.
Frank P Cammisa, MD Chief, Spine Service, Associate Attending Orthopedic Surgeon, Assistant Scientist, Research Division, Hospital for Special Surgery; Associate Professor, Department of Surgery (Orthopedics), Weill Cornell Medical College; Assistant Attending Surgeon, New York Hospital
Frank P Cammisa, MD is a member of the following medical societies: American Association for the Advancement of Science, American Medical Association, American Spinal Injury Association, Eastern Orthopaedic Association, Medical Society of the State of New York, New York Academy of Sciences, New York County Medical Society, North American Spine Society
Disclosure: Received royalty from Nuvasive, Inc. for consulting; Received consulting fee from Alphatec Spine, Inc., Centinel Spine, Inc., Disc Motion Technologies, Inc., Healthpoint Capital Partners, LP., IVY Healthcare Partners, LP.
, Mazor Surgical Technologies, Nuvasive, Inc. Orthogem, Ltd., Orthovita Inc., Paradigm Spine, LLC., Spinal Kinetics, Spinal Partners III, Viscogliosi Brothers, LLC. for consulting; Received ownership interest from Alphatec Spine, Inc.
, BI Members, LLC, Centinal Spine, Inc., Dis.
Darren R Lebl, MD Clinical Instructor of Spinal Surgery, Weill Cornell Medical College of Cornell University; Assistant Attending Orthopaedic Surgeon, Hospital for Special Surgery
Darren R Lebl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Neurological Surgeons, North American Spine Society, Scoliosis Research Society
Disclosure: Nothing to disclose.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons
William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association
Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.
Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center
Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health
Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.
Lee H Riley III, MD Chief, Division of Orthopedic Spine Surgery, Associate Professor, Departments of Orthopedic Surgery and Neurosurgery, Johns Hopkins University School of Medicine
Disclosure: Nothing to disclose.
Metastatic Brain or Spine Cancer Treatment
Duke provides metastatic brain and spine cancer treatments to extend life for those who may have been told their prognosis is poor and their treatment options limited.
Each year, experts in the Duke Center for Spine and Brain Metastasis provide care to hundreds of people whose cancer has spread to the brain or spine. We offer new treatments that may make it possible for you to live longer, with a better quality of life.
We focus on your metastatic brain or spine cancer while partnering with your oncologists as they treat your primary cancer.
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Cancers that Spread to the Brain or Spine
Cancer that starts in one area of the body can metastasize, or spread, to the spine or brain. Cancers that commonly spread to the brain include lung, breast, melanoma, and colon cancers. Cancers that most commonly spread to the spine include lung, breast, and prostate cancer.
Brain or Spine Tumors May Be Difficult to Reach
Depending on the stage, size, and location of the brain or spine tumor, this secondary cancer is typically considered advanced and may be life-threatening. Because these tumors are often difficult to reach, some people are told by doctors elsewhere that their tumors are inoperable and untreatable.
Advanced Treatment Options
We use advances in medical therapy, radiation therapy, and minimally invasive surgery to remove or treat spine or brain metastases or to slow or halt the spread of cancer. Treatments can also lessen symptoms such as pain, seizures, memory problems, trouble speaking, and loss of strength or mobility. Many of our patients lead productive lives several years after treatment.
A Patient Navigator Guides Your Care
Our patient navigator guides you and your loved ones through the complexities of receiving cancer care from multiple specialists within our cancer center. Often, more than one appointment can be scheduled on the same day. The patient navigator facilitates your access to the comprehensive support services available at Duke.
New Patient Consultations Available Within 72 Hours
Our nurse navigator can also guide you through the process if you are seeking a second opinion for yourself or a loved one.
Our first step is to conduct a series of comprehensive exams and tests. Our team reviews your results and uses them to create your personalized treatment plan.
MRI, CT, PET
Imaging tests — including MRI, CT, PET, bone scans, and angiography — accurately pinpoint the location, size, and stage of your brain or spine tumor.
A small sample of your brain or spine tumor may be removed and examined to confirm a diagnosis.
Our nurse navigator can guide you through the process if you are seeking a second opinion for yourself or a loved one. Call 919-681-3038.
Whenever possible, we use minimally invasive techniques that require small incisions to remove all or part of the tumor. In some cases, open brain surgery may be necessary. Surgery may also be an option for patients whose tumors return after treatment.
Laser Interstitial Thermal Therapy for Brain Tumors and Radiation Necrosis
When a brain tumor is difficult to reach or remove through open surgery, this relatively new advance in minimally invasive surgery may be an option.
It is also the preferred option for recurrent brain metastases and for radiation necrosis, a complication that can occur after radiation treatment.
With MRI guiding his or her path, the neurosurgeon makes a 1-centimeter incision in the scalp, then uses a cooled laser probe to deliver a targeted and lethal dose of laser energy directly into the brain tumor. Most patients return home the next day with minimal pain.
Awake Craniotomy for Brain Tumors
A craniotomy requires the removal of a piece of skull to access the brain. When a brain tumor is near an area of the brain that controls a vital function, you may remain awake and pain-free during this procedure so that you can communicate with your surgeon.
Spinal Cord Decompression and Stabilization
This surgical procedure relieves pressure on the spinal cord. Successful decompression of the spinal cord may create adequate space between the tumor and spinal cord to safely receive high-dose radiation. If you have significant spinal cord compression or a collapsed vertebra, your surgeon may need to stabilize your spine using rods and screws.
When fractured or collapsed vertebrae result from a metastatic spine tumor, a surgical bone cement may be injected into the collapsed vertebra to stabilize the spine. The minimally invasive procedure is intended to relieve pain, reduce spinal deformity, and restore mobility.
Duke Health offers locations throughout the Triangle. Find one near you.
Duke radiation oncologists use stereotactic radiosurgery — the gold standard of radiation care — to precisely focus narrow, high-dose radiation beams that destroy difficult-to-reach spine or brain tumors without the need for incisions.
Stereotactic radiosurgery can destroy multiple tumors and, in some cases, only one treatment session is needed.
Careful mapping and planning ensure the radiation targets cancer cells while sparing the healthy tissue, nerves, and blood vessels surrounding the tumor.
Immunotherapy drugs help your immune system identify and attack cancer cells while leaving healthy cells unharmed. Several immunotherapy drugs have already received FDA approval. Others are under investigation and may be available to eligible candidates through clinical trials.
Chemotherapy, given orally or by infusion into a vein, may be prescribed to kill cancer cells after surgery and/or radiation therapy.
This new generation of therapies targets molecules inside your cells that help cancer grow and spread. They block the ways cancer cells multiply while leaving healthy cells alone. There are many different types of targeted therapies; some are approved by the FDA. Others are being studied in clinical trials that are open to eligible candidates.
Palliative care focuses on preventing, managing, and relieving the symptoms of cancer and the side effects of cancer treatment. It helps you and your loved ones address symptoms and clarify goals of treatment along the way. You and your loved ones will be offered the opportunity to meet with a member of our palliative care team.
Rehabilitation will be an important part of your recovery. Our physical and occupational therapists and speech pathologists can help you strengthen your muscles, improve your mobility, speak more clearly, or learn easier ways to perform everyday tasks.
Our Focus Is Brain and Spine Metastasis
Our neurosurgeons, spine surgeons, radiation oncologists, medical oncologists, pathologists, radiologists, pain management specialists, palliative care specialists, and other providers meet weekly to create treatment plans for our patients. This team approach means several specialists contribute their expertise to your care.
Close Collaboration with Your Oncologist
People come to Duke from across the country for the treatment advances we offer. Whether you live close by or far away, we work with your oncologist so any treatments you receive at Duke will supplement your ongoing cancer care.
Planning and Navigation Tools Ensure Surgical Accuracy
Our advanced technology helps make brain and spine surgery safer and more effective. For example, our surgeons use “tractography” to visualize the complex wiring within the brain at the highest resolution possible.
They use this technology to create a path to your tumor that avoids critical structures involved in language, memory, and motor control. wise, intraoperative MRI gives your surgeon detailed images of your brain or spine during surgery, to ensure they remove as much of the tumor as possible.
Leaders and Teachers
Duke doctors and surgeons are among a handful of specialists in the country who are refining, performing, and teaching new treatments for brain and spine metastases.
Our team includes leaders in studying the benefits of using stereotactic radiosurgery instead of whole-brain radiation.
And our neurosurgeons train their peers at other centers in how to perform laser interstitial thermal therapy.
Nationally Recognized Brain Tumor Program
Our experts are at the forefront of brain tumor research and treatment. That recognition extends to the specialists who treat people with metastatic brain and spine tumors.
Clinical Trial Access
People with brain and spine metastases have historically been excluded from cancer clinical trials. As a Duke patient, you may have the opportunity to participate in studies that are testing medical and radiation advances not yet available elsewhere.
Ongoing Research Leads to New Developments
Some of our ongoing research focuses on brain tumor immunobiology. We’re working to create immune-based therapies such as vaccines that will train the immune system to fight brain metastases as if they were infections.
Where you receive your cancer care is important. Duke University Hospital's cancer program is ranked among the nation's best by U.S. News & World Report for 2019–2020.
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Surgery for Spinal Tumors
Not all spinal tumors require immediate surgical treatment. Sometimes the tumor is observed over time for change. This is a common approach in small benign (non-cancerous) tumors.
Larger benign tumors, certain types of spine cancer (malignant), and progressive tumors may require surgical intervention.
Spine surgery may be recommended to remove a benign or malignant tumor, reduce its size, and/or relieve persistent back or neck pain, balance problems, difficulty walking, and bowel or bladder dysfunction. When and if surgery is performed depends on many factors, such as:
- Type of spinal tumor; benign, malignant
- Tumor size and its location
- Neurologic deficit such as spinal cord or nerve compression
- Spinal instability, vertebral fracture, or destruction of vertebral bone
- Bowel or bladder dysfunction
- Unrelenting pain unresponsive to non-surgical therapies
- General health, immunity, and infection risk*
*Some patients who have undergone radiation therapy and/or chemotherapy may be at risk for infection and poor wound healing.
These therapies reduce the body's normal white cell blood count and may make healing more difficult; chemotherapy and/or radiation therapy may also increase resistance to infection.
Nutrition is a concern as many cancer patients experience poor appetites and significant weight loss causing poor health.
The goals of surgery to treat spinal tumors include:
- Remove the spinal tumor, or as much of it as possible
- Stabilize the spine
- Reduce pain
- Improve function and quality of life
Possible Surgical Procedures for Spinal Tumors
Be assured that your spine surgeon will explain the recommended procedure, including how to prepare for surgery, if hospitalization is necessary, and basically what to expect. Of course, he will answer all of your questions so you can make a fully informed decision.
Depending on the type of spinal tumor and its location, surgery may include one or more of the following procedures:
Decompression: Remove the entire tumor or part of it. Medical terms used include debulk (make smaller), excise (complete removal), or resection (partial removal). These types of procedures decompress or relieve pressure to the spinal cord and nerve roots, thereby helping to reduce pain and other symptoms.
Embolization: An interventional technique, usually performed by a radiologist, that slows or cuts off the tumor's blood supply. Embolization (embolotherapy) causes the tumor to shrink.
Kyphoplasty or Vertebroplasty: Both are minimally invasive surgical procedures that stabilize a fractured vertebra and help relieve pain.
A spinal tumor that develops within or invades (metastasize, spread) a vertebra may cause bony compression or fracture.
While kyphoplasty and vertebroplasty both involve injection of a surgical bone cement into the fracture to stabilize it, each procedure is different.
- Kyphoplasty uses orthopaedic balloons that are inserted into the fracture, inflated to create a hole or cavity, and removed before the bone cement is injected.
- Vertebroplasty does not use balloons. However, a newer technique combines vertebroplasty with radiofrequency ablation to remove the tumor tissue and create a cavity for the bone cement. Radiofrequency ablation uses radio wave energy to break the tumor's cellular molecular bonds to help remove tissue and create the cavity.
- Both procedures provide immediate fracture stabilization.
Radiosurgery (CyberKnife): This is a non-surgical procedure that delivers precisely targeted radiation to treat certain spine tumors1. Radiosurgery treatment is administered during one or more sessions using high-dose of radiation. This treatment does not immediately remove the tumor surgery. Rather, the tumor disappears with time.
Spinal Stabilization: A spinal tumor can cause your spine to become unstable, especially after a decompression procedure (or other surgery) removes bony parts or tissues, such as an intervertebral disc. Spinal instability increases the risk for serious neurologic injury, such as bowel or bladder dysfunction or paralysis.
Spinal stabilization may be included with another surgical procedure to treat your tumor. Stabilization usually involves spinal instrumentation and bone graft.
Instrumentation may include implantation of plates, interbody devices, and screws to immediately stabilize the spine.
Bone graft, either taken from your body (autograft), donor bone (allograft), or other type, helps to stimulate new bone growth to join the spinal segment together as it heals. Fusion occurs when new bone growth joins vertebrae together.
- Spinal decompression and stabilization may be performed as a minimally invasive procedure or by using a more traditional open approach (longer incision, longer recovery time).
Most patients need some rehabilitation after surgery. Whether you are transferred to a rehab center directly from the hospital or go as an outpatient, rehab can help you get back to your regular activities of daily living.
Certain treatments may be prescribed as part of your continued care. If your spinal tumor is malignant, radiation therapy and / or chemotherapy may be recommended.
Updated on: 07/30/19
Minimally invasive versus conventional spine surgery for vertebral metastases: a systematic review of the evidence
Each year more than 1.5 million Americans are diagnosed with some form of cancer (1) and 40–70% of these patients will develop vertebral metastases (2-7). This makes for upwards of 1 million Americans annually who are diagnosed with vertebral metastases.
These lesions may develop through direct extension, lymphatic spread, dissemination through nutrient arteries, or most commonly through Batson’s venous plexus (8,9).
Any tumor has the potential to seed the vertebral column, but spinal metastases are most common secondary to lung (24% of cases), breast (24%), liver (12%), prostate (11%), and kidney (11%) primary tumors (10-22).
Though the majority of these lesions are subclinical, as much as 10% of patients may present with symptoms of mechanical instability or epidural cord compression (10,23,24), including weakness, sensory disturbances, bowel or bladder dysfunction, and gait disturbance.
Treatment of spinal metastases is dependent upon the patient’s clinical pictures and expected survival, as well as the location and focality of the spinal tumor (25). In the overwhelming majority of cases, the symptomatic spinal metastasis represents just one of many sites of disease.
Consequently, the goal of surgery is not cure, but rather palliation (12,13,18,21,22,25-33). As patients are being considered for surgery, one of the key selection criteria is expected patient survival.
Multiple prognostic scoring systems have been developed to aid providers in determining post-operative live expectancy, including the Tokuhashi (34,35), Sioutos (18), van der Linden (31), Tomita (20), and Bauer scales (36,37).
In general, guidelines suggest that patients with life expectancies less than 3 months be treated non-surgically (19,21,30,38-46), as the procedure-associated morbidity outweighs the potential therapeutic benefits.
However, new advances in minimally invasive (MIS) surgical approaches promise to reduce the morbidity associated with the surgical treatment of spinal metastases. Consequently, surgery may become an option in patients for whom conventional approaches are deemed too morbid. The goals of this review are to: (I) report the extant literature directly comparing MIS and conventional approaches to the operative management of spinal metastases; and (II) perform a meta-analysis of the results.
A systematic review of the English literature available on PubMed was performed, along with a review of the bibliographies of the examined articles. The query utilized in the PubMed search was designed to include as many articles as possible pertaining to the pathology and interventions of interest.
The final search string was: (minimally invasive surgery OR MIS OR MISS OR VAST OR mini-open spine surgery OR endoscopic thoracoscopy) AND (spine OR vertebra OR vertebrae OR spinal) AND (metastasis OR bone neoplasm OR bone tumor OR spine neoplasm OR spine tumor OR metastatic epidural spinal cord compression OR MESCC OR ESCC OR spinal instability)
- Criteria used for the inclusion of articles were:
- Articles published prior to October 1, 2017;
- Full-text availability in English or full-English translation;
- Article reports surgical treatment of vertebral metastases or epidural metastases;
- Adult population (all patients ≥18 years old);
- Articles directly compared a MIS technique with a conventional approach;
- Article reports clinical and intra-operative results for both conventional and MIS cohorts;
- Format of the article is a randomized controlled trial, nonrandomized trial, case series (≥ two patients), case-control study, or cohort study;
- Article is prospective or retrospective;
- Metastases involve mobile spine (C1-L5).
- Criteria used for exclusion of articles were:
- Article reports primary spinal tumors;
- Article reports intradural tumors;
- Article reports outcomes of stereotactic radiosurgery, vertebroplasty, or kyphoplasty;
- Article reports on patients with lumbosacral pathology;
- Study population includes patients less than 18 years of age;
- Article fails to report intra-operative and quantifiable clinical data for both approaches (study either pools results or performs only qualitative analysis of results).
Abstracts were screened by two reviewers (Z Pennington and AK Ahmed) using the inclusion and exclusion criteria stated above. In cases of disagreement, a third review (CA Molina) was involved to make the final decision.
Full-text versions of articles meeting the criteria were gathered and reviewed in full to determine eligibility for inclusion in the final analysis. Data relevant to the questions of this review were then extracted and tabulated.
The inclusion and exclusion of studies was performed according to the latest version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement (www.prisma-statement.org).
The results of our search are summarized in the PRISMA flow diagram shown in Figure 1. In brief, our search returned 1,564 records from the PubMed database; an additional 21 records were identified through other sources, which led to a total of 1,568 articles after elimination of duplicates.
The abstracts of 187 articles were screened based upon their title, of which 137 were excluded. Full-text versions of the remaining 50 studies were gathered and screened for further eligibility. Of these 50 studies, 9 studies were found to meet inclusion criteria for the study and were included in the qualitative analysis.
Of the 41 excluded articles, 25 were excluded because they did not directly compare MIS and open groups, 5 were excluded because the data for the tumor patients could not be separated from those with other pathologies, 3 studies were found to be case reports, 2 studies were review articles, 2 studies investigated vertebroplasty-alone, 2 studies examined only primary tumors, 1 study reported pathology of the sacrum only, and 1 study reported on the use of technique equivalent to conventional open approaches.
Figure 1 PRISMA statement summarizing collection of articles related to the primary research questions.
The main outcomes we extracted from the reports included the MIS technique utilized, mean blood loss, operating time, hospital length of stay, prevalence and extent of neurological improvement, complication rate, and degree of pain palliation.
Additionally, for articles directly comparing open and MIS techniques, we also extracted inferential statistics comparing the outcomes of the two groups with respect to blood loss, operative time, length of stay, complication rate, and neurological recovery.
For classification of the level of evidence, we utilized the “Levels of Evidence for Primary Research Question” adopted by the North American Spine Society.
Direct comparisons of MIS and conventional techniques
Our search criteria yielded nine studies directly comparing MIS and open approaches for the treatment of unstable or symptomatic vertebral metastases (Tables 1,2).
Seven of the nine studies are retrospective case series of patients operated with minimally-invasive or open techniques, one study is a prospective case series, and one study, that by Hansen-Algenstaedt et al., is case-control study directly comparing the two classes of treatments.
All results were classified as level III evidence and reported between 8 and 60 total patients. The earliest of these comparative studies was reported by Huang and colleagues in 2006 (51). These authors reported a retrospective series of 29 patients (68.
9% male; mean 58 years old) undergoing minimal access thoracotomy and anterior decompression and 17 patients (47.1% male; mean 57 years old) undergoing standard thoracotomy. In the MIS cohort, mean blood loss was 1,100 mL (200–4,300 mL) and mean operative time was 179 minutes (120–250 minutes).
Sixty-nine percent of patients improved by one or more Frankel grades and complications were seen in 20.7% of patients.
The open cohort had statistically similar outcomes, with a mean blood loss of 1,162 mL (300–3,000 mL), a mean operative time of 180 minutes (120–315 minutes), neurological improvement ≥1 Frankel grade in 70.8% of patients, and complications in 23.5% of patients. The groups were similar for all endpoints examined except the need for post-operative intensive care unit (ICU) stay; only 6.9% of the minimal access group required a post-operative ICU stay compared to 88% of the open cohort (P