Spine Tumor Treatment

Tumors that start in the spine are called primary spine tumors. They are rare, representing less than 5% of all central nervous system tumors. They can be benign or malignant (cancerous).

Spine tumors that spread to the spine from cancer in other parts of the body are more common than primary spine tumors. Some people with metastatic cancer will experience spread of the cancer to their spine.

Your spinal cord is made up of bundles of nerve fibers that control your extremities, sensations, body functions and unconscious activities such as breathing. The cord is about the thickness of your index finger and passes through a canal made up of vertebrae of your spine. The vertebrae protect the spinal cord’s delicate fibers. The spinal cord and nerve roots float in a fluid-filled, balloon-like tube surrounded by a protective layer called the dura — also known as the meninges — wraps around the spinal cord as another layer of protection. 

Spine tumors are identified by the region of the spine where they occur (cervical, thoracic, lumbar and sacrum) and by their location within the spine.

• Extradural tumors growing in the bone (spinal column) are by far the most common spine tumors. Ninety percent are metastatic cancers originating somewhere else in the body. They are “seeded” in the spine by traveling through the blood vessels. About 10% of tumors originating in the spine are primary tumors that could be benign or malignant (sarcomas).
   
• Intradural-extramedullary — the second most common primary spine tumors start inside the dura covering the spinal cord and include myxopapillary ependymomas, schwannomas and meningiomas. These tumors are usually benign. The most common initial symptom is pain, but other symptoms may include weakness, tingling and numbness. Typically, these tumors include those that arise from nerve roots (called nerve sheath tumors) and tumors growing from the dura (called meningiomas) among others.
   
• Intramedullary tumors grow inside the spinal cord. They can be benign or malignant (cancerous) and are very rare — more rare even than primary brain tumors. These are the hardest tumors to treat because some are invasive and located in a critical area. They can extend up and down the length of the spinal cord like octopus tentacles. They include ependymomas (less invasive to the surrounding spinal cord) and astrocytomas.

Multispecialty Approach to Spine Tumor Treatment

Because spine tumors affect the nervous system’s vital functioning, a multispecialty approach to treating you is vital – meaning we consider every aspect related to your tumor before we decide on treatment. That includes the location of the tumor, the type of tumor, its progression (how far it has spread), your health and any co-conditions, and how treatment could affect your daily functions. Each patient has a unique situation requiring a highly personalized approach. Our first priority is to give you good quality of life with the best possible management of the tumor. We carefully balance aggressive treatment with preservation of function.

Your neuro-oncologist will coordinate your treatment to make sure all the relevant experts are involved — radiation oncologists, surgeons, medical oncologists, and physical and occupational therapists to address disruption of your motor skills, sensation and balance. These spine tumor specialists will use the utmost care in selecting appropriate treatment not only to control your symptoms but also to remove the tumor with surgery when possible or shrink the tumor with radiation or chemotherapy. Treatment side effects such as swelling of the spinal cord, must be managed, and our physical and occupational therapists help you learn how to cope with physical challenges.

Spine Tumor Radiation Therapy

For spine tumors, as for brain tumors, radiation therapy can be combined with other treatments or it may be the only treatment. Your radiation oncologist will plan this therapy in collaboration with other experts on your team so it is sequenced for maximum effectiveness. Your therapy will be carefully designed to deliver the highest safe dose of radiation precisely to the tumors while limiting radiation exposure to healthy surrounding tissues. The goal is to avoid neurological deficits that would affect your quality of life.

Your doctor will also plan to minimize treatment-related side effects and help you manage them as much as possible. Side effects depend on the part of your spine that is treated. For instance, you may experience a sore throat if the upper part of your spine is treated.

The goals of radiation therapy for spine tumors are:

• Eliminate or reduce the size of spine tumors.
• Increase long-term control of the disease and prevent tumors from coming back.
• Relieve symptoms such as pain

Many of the radiotherapy techniques we use to treat people with brain tumors — image-guided radiation therapy (IGRT), intensity modulated radiation therapy (IMRT), RadiXact and volumetric modulated arc therapy — are standards for treating spine tumor patients.

A few types of radiation therapy are not used for spine tumors. They include Gamma Knife radiotherapy (designed for tumors that invade the anatomy from the neck up), and Elekta Unity MR-linac, which is currently only available to treat brain tumors. Our use of MR-linac continues to grow, and physicians anticipate applying this technology in clinical trials investigating its capabilities for tumors of the spine.

In some cases, instead of surgery, tumors of the spinal cord can be treated aggressively with radiation therapy. Radiation therapy is the “back bone” of spine tumor treatment. It is non-invasive and can be precisely targeted to the tumor, avoiding damage to healthy tissues and organs. It will slow the progression of tumor growth and symptoms related to tumors that are beginning to grow. Eventual tumor growth (recurrence) is typical of malignant spine tumors.

Surgery for Tumors of the Bone (Vertebrae), Dura and Spinal Cord

Tumors that grow in and around the spinal cord (inside the dura) are usually primary tumors that usually start in the spine. They can occur anywhere from the neck to the tailbone. Most are benign, low-grade tumors but they can cause life-disrupting neurological symptoms. When they cause symptoms or increase in size, surgery can be an option for a cure, depending on the location and type of tumor. Because spinal cord tumor surgery is an extremely intricate operation, it must be performed by a highly experienced spine surgery team that does a high volume of such operations and understands all the nuances of a safe operation.

Some spinal cord tumors grow within the membrane that lines the spinal cord, but not within the cord itself. When tumor tissue is growing within the substance of the cord, microsurgical techniques are used to remove as much of the tumor as possible while preserving neurological function. Some can be surgically removed but others are of a type too risky for surgery due to the high likelihood of the surgery causing neurological damage. Spinal stabilization with screws and rods may also be required when the tumor causes fractures or extensive bone destruction.

If they are not causing symptoms, schwannomas and meningiomas can be managed followed by your neuro-oncologist with observation using periodic MRI scans. If they are large, growing, causing pain or causing spinal cord compression, surgery is considered to confirm the diagnosis with the help of pathology (tumor analysis in the lab). It can be used to alleviate pressure on the spinal cord and relieve neurologic deficits. If there are multiple tumors, we will remove only specific tumors that are causing problems.

Minimally Invasive Surgical Techniques for Spine Tumors

Minimally invasive surgical techniques are used whenever possible, guided by sophisticated CT-based imaging (neuronavigation) right in the operating room. This type of surgery only requires small incisions and is used to remove a tumor, relieve pressure on the spinal cord. Our spine surgeons also use neuromonitoring and microsurgery to preserve nerve roots and avoid irritating the spinal cord. The small incisions made in minimally invasive surgery can even be used to place screws in the spine to stabilize it rather than using a large incision.

Embolization Reduces the Spine Tumor's Blood Supply

In certain types of spinal tumors, blocking the blood vessels feeding the tumor helps minimize blood loss during surgery to remove the tumors, including surgery for kidney and thyroid metastatic cancers. On the day before or the morning of the tumor removal, an interventional neurologist inserts a catheter into an artery in the groin and advances it to where the tumor is located in the spine. Using digital subtraction, the interventional neurologist identifies the blood vessels feeding the tumor. Microparticles of poly-vinyl alcohol are injected through the catheter. The particles form a block cutting off the blood flow to the tumor. Limiting the blood supply lessens the blood loss during surgery, resulting in a shorter surgery and less risk.

Percutaneous Radiofrequency Ablation for Inoperable Tumors

Metastatic tumors in the vertebrae can cause significant pain when they compress the spinal cord. For many people, these tumors can’t be removed with surgery. Percutaneous radiofrequency ablation uses heat energy for carefully selected patients to relieve pain or to disrupt a tumor that is slow-growing but causing symptoms.

The procedure uses CT image guidance. A radiofrequency probe is guided into a tumor, where it delivers heat waves that damage tumor cells. The goal is not to destroy the entire tumor. Instead, it is used to target the area between the tumor and bone and destroy nerve endings. Percutaneous ablation must be performed with extreme caution by a vascular and interventional radiologist. The spinal cord and nerves are heat sensitive, and heat can be toxic to bone marrow and peripheral nerves.

Cementing Stabilizes the Spine to Treat Spine Fractures From Tumors

Cementing can also be used to treat painful spine fractures from metastatic tumors unless they are too severe and require surgery. Two techniques for stabilizing the spine with cement are vertebroplasty and kyphoplasty.

• Vertebroplasty. Using imaging guidance, a special cement is injected into the fractured vertebra. The cement seals the fracture and restores the stability of the bone. For some patients, pain goes away within 24 hours.
• Kyphoplasty. A special balloon is introduced into the fractured vertebra. The balloon is then inflated and filled with special cement, stabilizing the bone and providing significant pain relief.

Chemotherapy, Targeted Therapies, Immunotherapy

Chemotherapy is not used often for spine tumors, but can be used in certain cases, such as:

• Fast-growing cancerous tumors to decrease the risk of spreading
• To destroy cancer that was not accessible during surgery
• To address spine tumors that have spread to other parts of the body
• To treat pain
• To treat recurrent spinal tumors.

Chemotherapy may also be considered when other treatments like surgery or radiation therapy haven’t been effective.

Targeted therapies and immunotherapies are not used to treat spine tumors because there is not yet any conclusive data to prove that they offer benefit.

Watchful Waiting — Monitoring Tumors

In a small percentage of spine tumor patients, aggressive treatment is not an option because of their age, the extent of the tumor and other health conditions. Treatment could result in more debilitating symptoms and could be life-threatening. Watchful waiting is also used for people who have tumors that are not likely to grow or spread and are not causing disruptive symptoms. In these cases, we carefully monitor for tumor changes, symptoms and pain and intervene when possible.

Research to Improve Spine Tumor Treatment

Our focus on spine tumor research involves studying genetic mutations found in spine tumor patients to learn more about how spine tumors arise, what triggers their development with the goal of finding therapies that will directly target these mutations.

The rarity of spine tumors presents a challenge for research. Nationally, there is very little data from clinical trials to guide treatment improvements because it is hard for any single center to gather enough patients to participate in a trial that is large enough to result in meaningful conclusions.