Spinal Cancer Treatment

Contents

Introduction

Primary spinal cancer develops from cells within the spinal cord or in the bones, tissues, fluid, and nerves that surround it. In addition to the brain, the spinal cord is a component of the central nervous system (CNS). From the base of the brain down the back, the spinal cord is a column of nerve tissue. It is encompassed by vertebrae (bones of the spine) and encircled by three protecting membranes. It transmits vital communications between the brain and the rest of the body. According to the American Cancer Society, approximately 25,050 new cases of brain or spinal cord cancer are predicted to be detected in the US in 2022. About 1 in 140 men and 1 in 180 women will acquire spinal cancer in their lifetimes. Primary tumours of the spinal cord or column arise from cells inside the spinal cord or its surrounding components. The majority of spinal cancers are metastatic tumours, which spread to the spine from elsewhere in the body. Metastatic tumours are approximately 10-times more prevalent in the CNS than original tumours.

Spinal Cancer

A spinal tumour is a mass of abnormal tissue in or around the spinal cord and/or spinal column. These cells appear to be unregulated by the systems that regulate normal cell growth and division. Tumours of the spine can be benign (noncancerous) or malignant (cancerous). Primary tumours arise from the spine or spinal cord, whereas metastatic or secondary tumours are caused by the spread of malignancy from another place to the spine. Spinal tumours can be  classified in two ways:

  • According to the location of the spine where they occur. These are the cervical, thoracic, lumbar, and sacral regions. 
  • According to their placement within the spine.

Types of Spinal tumours

Intradural-extramedullary cancers begin in the dura layer of the tissue that lines the spinal cord. As they become larger, they tend to crush the nerves. Even though many are benign, some may be difficult to remove and may recur, while others may become malignant in the future. Low back pain or pain radiating through the extremities, hips, and/or spine are symptoms. These symptoms are caused by the tumour's compression of nearby nerves or bones. Possibly due to hormonal fluctuation that raises the risk of tumours in this location, women are somewhat more prone to get them. Childhood exposure to ionising radiation increases the likelihood of intradural-extramedullary cancers. Obesity, tobacco use, and hormone excess have also been demonstrated to increase the risk slightly. Spinal tumours may be detected using magnetic resonance imaging (MRI) or computed tomography (CT) scans to obtain images of the body's interior. The standard treatment for cancer is surgical resection, in which the entire tumour is removed. 

Intramedullary tumours begin within the nerves that comprise the spinal cord, typically in glial cells. Typically benign, they may return following removal. About 5%  of the time, spinal cancers occur here. Neurofibromatosis type 2 is an inherited disorder that increases the likelihood of developing glial cell tumours. In this case,  tumours can cause numbness, limb paralysis, or the inability to move limbs. Spinal tumours can produce non-injury-related back pain that intensifies when lying down. It is possible to obtain images of the interior of the body and detect spinal tumours using MRI or CT scans. The optimal treatment option for these tumours is surgical resection. 

Approximately 55% of spinal tumours are extradural tumours, which are located outside of the spinal cord's dura and frequently in the bones. Even at their earliest stages, breast, lung, prostate, renal, gastrointestinal, and thyroid cancer frequently metastasis to the spine. These tumours produce comparable symptoms to intradural-extramedullary tumours due to the compression of spinal nerves. Pain may be localised or radiate to the extremities, and numbness or paralysis may be experienced in the limbs. X-rays or bone scans may be prescribed to detect spinal malignancies or to look for alternative causes of spinal discomfort, such as fractures. Surgical removal of the tumour is preferred whenever possible. Additionally, radiation and chemotherapy may be utilised to reduce the tumour. Metastatic cancers may be treated differently from localised original tumours. When cancer spreads, the spine is frequently affected. It is predicted that 30 to 70% of cancer patients may develop spinal metastases. 

In the majority of instances, benign tumours are unlikely to cause harm. However, despite not being cancerous, a benign brain or spinal cord tumour can produce life-threatening consequences. Cancerous tumours are dangerous because they can invade other tissues, develop rapidly, and recur. Rarely do benign tumours spread to other tissues, but they may return following removal. Tumours that are not malignant can generate many of the same symptoms as cancerous ones. Typically, benign tumours are treated with surgery. 

Primary spinal cancer (cancer beginning in the spine) is rather uncommon. Nonetheless, various forms of cancer can grow in bone cells or the spinal column. These tumours of the spinal cord frequently have unclear causes, while some may be the result of exposure to carcinogens such as chemicals or pollution. 

  • Osteosarcoma, the most prevalent kind of bone cancer, often develops near the knee or upper arm bone, but it can also arise in the spinal bones. It can occur at any age, but is more prevalent in children, adolescents, and young adults. 
  • Chondrosarcoma is a type of bone cancer that develops in cartilaginous bones. The likelihood of having this type of cancer increases with age, making it more prevalent in adults. 
  • Chordoma: When notochord cells are not eliminated after birth, they can develop chordomas in the spine. This uncommon cancer typically develops around the base of the spine (lower back). It is twice as frequent in men and often develops after age 30. 
  • Ewing sarcoma: This is the second most prevalent form of juvenile bone cancer. These tumours react to radiation better than other types of bone malignancies. 
  • Lymphoma: This cancer begins in immune cells known as lymphocytes. Primary CNS lymphomas originate in the brain and central nervous system, or in their vicinity. This malignancy is more prevalent in patients with impaired immune systems, such as those with HIV or AIDS. There are numerous lymphoma subtypes, each with distinct prognoses and treatment choices. 
  • Multiple myeloma: This malignancy begins in immune cells known as plasma cells, which normally resides in the bone marrow. The malignancy causes calcium levels and blood counts to be abnormal. Symptoms of a weakened immune system include easily shattered bones, bruising and bleeding, and infections.

Symptoms

Variable signs of spinal cancer include urinary incontinence, nerve and muscle control difficulties, and weakness. The onset of symptoms may be influenced by the type of spinal tumour (whether vertebral or spinal cord tumour), its size, the patient's age, and overall health history. Symptoms of spine cancer may develop very gradually. Occasionally, they occur rapidly, within hours or days. Spinal tumours that have metastasized to the spine from another part of the body, such as the prostate or kidneys, typically develop rapidly. 

Pain is the most prominent symptom of spine cancer. The tumour's presence in the spinal column may cause pain by pressing on sensitive nerve endings or causing spinal instability. When the spine is misaligned, other noticeable physical complaints may ensue (e.g., changes in posture, Kyphosis or hunchback). When the tumour presses on the spinal cord, arm or leg numbness or tingling may be the initial sign. Patients may also report clumsiness, inability to locate their feet, and difficulties with buttons and keys. As the disease develops, spinal cancer symptoms may include increasing weakness, inability to move the legs, and ultimately paralysis. Additional symptoms include: 

  • Back pain and/or neck discomfort, arm, and/or leg pain 
  • Weakness or numbness of the arms or legs' muscles 
  • Having trouble walking 
  • General lack of feeling 
  • Having trouble urinating (incontinence) 
  • Variation in bowel habits (retention) 
  • Diverse degrees of paralysis 
  • Spinal deformities 
  • discomfort or trouble standing

Risk factors

Spinal tumour aetiology is still mainly unclear. Although genetic abnormalities may have a role in the development of spine cancer, the risk factors for spinal cancer are far less well-defined than those for other malignancies of the body. Among the known risk factors are: 

  • Cancers of the breast, lung, and prostate, in addition to multiple myeloma, are more likely to spread to the spine if they have occurred previously. 
  • Some individuals whose immune systems are impaired develop lymphomas of the spinal cord. 
  • Von Hippel-Lindau disease and Neurofibromatosis (NF2) are hereditary illnesses linked with spinal cord tumours. 
  • Radiation therapy and industrial pollutants may raise the risk of spinal cancer.

Diagnosis

A complete treatment plan for spine cancer begins with a precise diagnosis. Cancer specialists utilise a number of imaging technologies and diagnostic tools to detect spine cancer. Once the doctors have confirmed an accurate diagnosis of spinal cancer and determined the tumour's location, type, and grade, they collaborate with the patient to develop a treatment plan that is tailored according to their needs, preferences, and goals. Due to the complexity of spinal tumours, treatment should be customised and custom-tailored. Included among the diagnostic tests for spine cancer are: 

  • A lumbar puncture, often known as a spinal tap, is a technique in which a needle is placed into the lower portion of the spinal column to withdraw cerebrospinal fluid or inject medication. A lumbar puncture collects cerebrospinal fluid (CSF) for laboratory evaluation. Additionally, it can be used to inject pharmaceuticals, such as spinal anaesthetic and chemotherapeutic treatments. 
  • For nuclear medicine bone scans, a little amount of radioactive material is injected into a blood artery, where it travels through the bloodstream, accumulates in the bones, and is identified by a scanner using nuclear imaging. By recording images of bones on a computer screen or film, a nuclear medicine bone scan may indicate the location and progression of spine cancer to the bone. 
  • Spinal cancer imaging produces images of the spine to assess the location and severity of spinal malignancies. It is possible to apply a contrast dye to highlight the spinal cord and nerve components. Other imaging studies used to diagnose spine cancer include: 
    • MRI or CT scan 
    • PET/CT scan

Treatments

Treatments for spinal cancer differ according to cancer kind, disease stage, and disease site. Surgery, chemotherapy, and radiation therapy are common therapies for spinal cancer.(1) 

Surgery

The gold standard treatment for tumours that can be removed without endangering the spinal cord or nerves is typically surgery. Neurosurgeons are now able to differentiate cancers from healthy tissue and remove tumours from previously inaccessible regions of the spine, thanks to new surgical techniques employing high-powered microscopes and other technologies. In rare instances, high-frequency sound waves may be utilised during surgery to fragment tumours and remove the fragments. 

Consider the considerable risk of surgical complications. Infection of the surgical wound is the most frequent complication of metastatic spine surgery. Several risk factors for wound infection have been identified, including morbid obesity, postoperative incontinence, and posterior approach.(2)

Chemotherapy

When a tumour cannot be safely or completely removed, surgery may be followed by alternative treatments, such as chemotherapy. Chemotherapy is the use of drugs to eliminate or inhibit the growth of cancer cells. It has been the mainstay treatment for many forms of cancer for many years. Chemotherapy medications may be delivered intravenously or orally. The medicine may be administered directly into the cerebrospinal fluid for certain spinal tumours. Fatigue, nausea, vomiting, decreased appetite, an increased risk of infection, and hair loss are possible side effects.(3) Chemotherapy targets cancer cells that divide fast. Yet, some healthy cells in the body, such as those in the hair follicles, mouth, stomach, and bone marrow, also divide rapidly. When these healthy cells are harmed by chemotherapy medications, the following side effects may occur: 

  • Hair loss 
  • Sickness and vomiting 
  • Diarrhoea 
  • Enhanced likelihood of infection (from low white blood cell counts) 
  • Fatigue (from low red blood cell counts) 
  • Easy bruising and bleeding (from low blood platelet counts) 

Before beginning chemotherapy, the care team will meet with you to answer your questions and discuss what to expect from the treatment, including how to manage side effects. For example, your doctor may give anti-nausea or anti-infection medications prior to and throughout your treatment. Routine blood testing can also monitor your blood cell count. In addition, your physician may give steroids to improve brain function and stimulate hunger. Supportive care therapies, such as dietary therapy, naturopathic support, pain management, and oncology rehabilitation, may help lessen chemotherapy-related side effects and keep you healthy so that you can preserve as much of your quality of life as possible during treatment.

Radiotherapy

In certain instances, radiation therapy is used to treat spinal malignancies, most commonly external radiotherapy. Typically, it is used in conjunction with surgery and/or chemotherapy.  Radiation therapy is often performed to eradicate any remaining malignancies following surgery. It is also used to treat cancers that are inoperable or when surgery is too hazardous. The specific radiation therapy strategy is determined by the type and size of the spinal tumour. The most popular treatment for spine cancer, external radiation therapy irradiates the tumour and its surroundings. For metastatic spinal malignancies, the complete spine is occasionally irradiated. If a tiny spine tumour is identified, stereotactic radiosurgery (SRS), a precise kind of radiation therapy, can direct radiation solely to the tumour, reducing radiation exposure to the remainder of the spinal cord. The Gamma Knife is a type of SRS. The adverse effects of radiation therapy may include nausea, vomiting and exhaustion.(4) Radiotherapy side effects may include exhaustion, hair loss, skin irritation, and nerve damage, depending on the radiation dose, treatment site, and other variables. 

To lessen the adverse effects of radiation and help retain physical strength and quality of life, doctors may prescribe steroids to minimise swelling or blood thinners to prevent blood clots from getting to the lungs. Patients may also have the opportunity to receive supportive treatment such as nutrition therapy, naturopathic assistance, pain management, cancer rehabilitation, and mind-body medicine. These therapies are intended to help preserve strength so that therapy can be continued while preserving the quality of life.

Kyphoplasty and vertebroplasty

Vertebroplasty and kyphoplasty are minimally invasive procedures that are identical. Both are conducted by inserting a hollow needle into the fractured vertebra through the skin of the back. Through the hollow needle, polymethylmethacrylate bone cement is injected into the shattered bone during vertebroplasty. Before filling the space with bone cement, a balloon is introduced and inflated during kyphoplasty to restore the natural height of the compressed vertebra. For each damaged vertebra, the operations are repeated. The cement-reinforced vertebra enables you to stand upright, alleviates your pain, and avoids subsequent fractures. The fractures will eventually heal, but in a collapsed position if no therapy is administered. Your vertebra is returned to its normal position before the bone hardens, which is an advantage of kyphoplasty. Patients who have undergone kyphoplasty report much decreased pain following the procedure. Studies indicate that individuals with a history of osteoporotic fractures are five times more likely to sustain further fractures. Before fractures occur, it is crucial for individuals to seek treatment for osteoporosis. 

Bleeding, infection, blood clots, and responses to anaesthesia are typical consequences of every surgery. Less than 2% of patients with spinal compression fractures develop complications during treatment, compared to 5-10% of patients with malignancies. The following dangers should be taken into consideration: 

  • Bone cement leaking; along the needle's exterior, there is a small chance that bone cement could leak into the surrounding soft tissues. When the needle is removed from the vertebra, this can also occur. Cement can enter the veins around the vertebra. The surgeon stops injecting cement if this begins to occur by continuously monitoring the fluoroscope. Cement can seep into the neural foramen, where spinal nerves leave the spinal cord. This may necessitate further therapy as it can cause nerve discomfort (radiculopathy). 
  • Nerve injury; any operation on the spine carries the danger of injuring the spinal nerves or cord, resulting in numbness or paralysis.

Targeted Therapy

The aim of targeted therapy for spinal cancer is to target specific pathways or anomalies in tumour cells of the spine that contribute to tumour growth. Targeted therapy will likely be used with conventional spine cancer treatments, such as chemotherapy. This treatment is frequently an option for people with recurrent tumours following earlier spine cancer treatments. A monoclonal antibody is a sort of targeted therapy for spinal tumours that inhibits the development of new blood vessels required for tumour growth (a process known as angiogenesis). 

Low blood counts, fatigue, mouth sores, nausea, diarrhoea, high blood pressure, and fluid retention are some of the side effects associated with targeted therapies (usually in the legs). Throughout your treatment for spine cancer, your care team provides a variety of services to keep you healthy, prevent side effects, and enhance your quality of life.

Maintaining the quality of life after treatment

The data in the table comes from the Central Brain Tumour Registry of the United States (CBTRUS) and is based on the number of patients who had treatment between 2001 and 2015. As seen in the table below, survival rates for some forms of brain and spinal cord cancers may vary significantly by age, with younger patients generally having a better prognosis. Survival rates for individuals aged 65 and older are often lower than those for the ages given in the table. These statistics pertain to many of the most prevalent forms of brain and spinal cord cancers. Statistics are not easily accessible for many forms of tumours, mainly because such tumours are uncommon or difficult to diagnose.

Periodic office visits and reassessment by the treating physician are used to monitor the patient's treatment. This is significant because benign or malignant tumours may recur. Radiation and/or chemotherapy may be used in treatment. Radiation may have significant adverse effects, including reddish or irritated skin at the treatment site, nausea, vomiting, appetite loss, and exhaustion. Similar side effects may accompany chemotherapy. Nevertheless, many of these adverse effects are treatable with medication. Typically, after the therapy term has over, the symptoms disappear. Analgesics are used to treat post-operative and cancer-related pain. The agony caused by cancer may be difficult to manage (e.g., "breakthrough pain"). If standard medications (e.g., pill, skin patch) do not offer relief, a pain management professional may be able to help. Any surgical procedure, radiation therapy, or chemotherapy might deplete a patient's nutritional reserves. Therefore, a healthy diet is essential for regaining lost strength, weight, and a measure of health. A skilled dietitian may give help. A course of physical therapy may be given, depending on the degree of the operation and the patient's medical condition. The patient may improve strength, endurance, and flexibility via exercise and rehabilitative techniques.

Some survivors have been characterised as "disease-free, but not disease-free." The physical symptoms that one encounters may be connected to the kind of cancer and the therapy. It is crucial to realise that no two individuals are identical, so even if they had the same kind of cancer and therapy, one may suffer completely different side effects. It may take time to overcome these consequences. You may ask how your body should feel at this period and if symptoms indicate a recurrence of the malignancy. This section covers some of the issues that may arise after therapy has concluded. Among the most often reported difficulties are: 

  • Tiredness 
  • Changes in memory and attention n Pain 
  • Nervous system modifications (neuropathy) 
  • Lymphedema, or puffiness 
  • Oral or dental issues 
  • Changes in weight and dietary practices 
  • Difficulty swallowing 
  • Bladder or bowel control difficulties 
  • Menopause symptoms

You will need to choose which physician will offer your cancer follow-up care and which physician(s) you will visit for additional medical treatment. For follow-up cancer care, this may be the same physician who first treated your cancer. For routine medical treatment, you may elect to visit your primary provider, such as a family doctor. For particular issues, it may be necessary to see a professional. This is something you may address with your physician. They can assist you to determine how to make care transfers. Depending on your location, it may make more sense to get cancer follow-up treatment from your primary care physician rather than an oncologist. It is crucial to realise that many insurance plans only cover follow-up treatment with certain providers for a limited number of visits. You may want to verify your health insurance plan to determine what kind of follow-up treatment it covers before creating your timetable. Regardless of your health insurance position, you should seek out physicians with whom you feel comfortable. Always inform any new physicians you encounter about your cancer history. The kind of cancer you have and the therapy you received might influence future care choices. 

The prognosis for Spinal Cancer

The prognosis for spine cancer relies on the patient's general condition and whether or not the spinal tumour is aggressive or metastatic. The prognosis for survival is contingent on the type of spinal tumour. The two-year survival rate for patients with spinal tumours caused by other cancers ranges from 9% (lung cancer) to 44% (breast and prostate cancer). (5) Numerous people with metastatic malignancies undergo palliative care to improve their quality of life and extend their lifespan. Patients with spinal cancer now have a stronger chance of controlling metastatic cancer of the spine, thanks to treatment and technological developments. (6)

Summary

A diagnosis of spine cancer might be frightening, but you do not have to face it alone. Spine surgeons, oncologists, radiation oncologists, and your primary care physician will typically be a part of your treatment team when you begin treatment for spinal cancer. They will have similar treatment and remission objectives. Whether you are still undergoing treatment for spine cancer or have completed treatment, it is essential to stay in touch with your healthcare specialists. Your healthcare experts will want to confirm that your body is reacting to therapy and healing as it should at each scheduled session. You may require more ongoing treatments, such as physical therapy, mobility aids, and pain and inflammatory medications. Discuss with your healthcare practitioner any available services and support, including social and emotional needs that frequently arise during and after cancer treatment.

References

  1. Raj V, Lofton L. Rehabilitation and treatment of spinal cord tumors. The Journal of Spinal Cord Medicine. 2013;36(1):11-4.
  2. Dunning E. Complications in the management of metastatic spinal disease. World Journal of Orthopedics. 2012;3(8):114.
  3. Altun İ, Sonkaya A. The most common side effects experienced by patients were receiving first cycle of chemotherapy. Iran J Public Health. 2018;47(8):1218-1219. 
  4. Radiation therapy side effects [Internet]. National Cancer Institute. 2018
  5. Lagrèze W. In Reply. Deutsches Ärzteblatt international. 2011;.                                                                  
  6. Laufer I, Bilsky M. Advances in the treatment of metastatic spine tumors: the future is not what it used to be. Journal of Neurosurgery: Spine. 2019;30(3):299-307.

Author: Sara Maria Majernikova

Bachelor of Science - BSc, Biomedical Sciences: Drug Mechanisms, UCL (University College London)
Experienced as a Research Intern at Department of Health Psychology and Methodology Research, Faculty of Medicine, Laboratory Intern at Department of Medical Biology, Faculty Medicine Biomedical Sciences Research Intern and Pharmacology Research Intern.

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