Decision Making in the Management of Metastatic Spinal Tumors

Abstract

The advent of newer systemic therapies has resulted in improved survival of cancer patients. Increased life expectancy necessitates strategies not only for palliation to improve quality of life but also for lasting local control of the spinal metastasis. In patients with a short life expectancy, palliative surgery involves decompression of neural structures by debulking the tumor and spine stabilization followed by conventional external beam radiotherapy (cEBRT). Ablative surgery involves more aggressive tumor resection followed by cEBRT. The introduction of stereotactic body radiotherapy (SBRT) has challenged traditional paradigms for decision-making further. With SBRT, hitherto radioresistant tumors can also be successfully treated with radiotherapy alone, in selected cases without spinal instability or severe epidural spinal cord compression. Minimally invasive surgical techniques such as percutaneous cement augmentation, percutaneous stabilization, and minimally invasive decompression and tumor resection have further reduced the surgical morbidity, enabling extension of treatment to more sick patients. The eventual decision regarding the treatment strategy is made on a case-by-case basis by a multidisciplinary team along with the patient and his/her family.