What is the treatment for metastatic cancer to the spine?

Treatment for Metastatic Cancer to the Spine

Treatment for spinal metastases requires a multidisciplinary approach with treatment selection based on four key factors: neurological status, oncologic characteristics (tumor histology and radiosensitivity), mechanical spinal instability, and systemic disease burden, with the primary goals being preservation of neurological function, pain relief, and maintenance of spinal stability. 1

Treatment Selection Framework

The Dutch national guideline emphasizes that treatment decisions must account for: 1

• Spinal instability status (assessed via imaging and clinical criteria)
• Neurological prognosis (presence or absence of spinal cord compression)
• Life expectancy (predicted survival based on primary tumor type and systemic disease)
• Patient preferences (shared decision-making is mandatory)

Primary Treatment Modalities

Radiation Therapy

• Radiotherapy alone is the primary treatment for patients without spinal instability or significant neurological compromise 1
• Stereotactic body radiation therapy (SBRT) achieves approximately 90% local control at 1 year and 50% complete pain response with low serious adverse event rates 2
• SBRT is particularly effective for radioresistant tumors like renal cell carcinoma 2
• Conventional external beam radiation remains appropriate for radiosensitive tumors and patients requiring rapid treatment 1

Surgical Intervention

Surgery followed by radiotherapy is indicated for: 1

• Patients with spinal instability requiring stabilization
• Metastatic epidural spinal cord compression (MESCC) with neurological deficits
• Patients with life expectancy sufficient to benefit from intervention (typically >3 months)
• Radioresistant tumors requiring debulking

Surgical goals include: 3, 4

• Decompression of neural elements
• Spinal stabilization and reconstruction
• Maximum tumor resection when feasible
• Preservation or restoration of ambulatory function (maintained in 91% of surgical patients) 4

Systemic Therapy

• Chemotherapy or hormonal therapy should be considered for chemosensitive tumors (lymphoma, multiple myeloma, breast cancer, prostate cancer) to address neurological deficits, pain, and quality of life 1
• Bisphosphonates (zoledronic acid) or RANK ligand inhibitors (denosumab) are recommended for all patients with spinal metastases to reduce skeletal morbidity and prolong time to bone lesion progression 2

Percutaneous Interventions

• Vertebroplasty and radiofrequency ablation are options for pain control in patients with mechanical pain from vertebral collapse without significant epidural disease or instability 1
• These minimally invasive procedures should be reserved for carefully selected patients based on tumor location, extent, and patient comorbidities 1

Common Primary Tumors

The most frequent primary cancers metastasizing to spine are: 5

• Breast cancer (65-75% develop bone metastases)
• Prostate cancer (65-85% develop bone metastases)
• Lung cancer (30-40% develop bone metastases)
• Renal cell carcinoma (20-40% develop bone metastases)
• Multiple myeloma (95% have spinal involvement)

Essential Supportive Care Components

Pain management requires dedicated pain team involvement throughout the treatment trajectory 2

Rehabilitation specialist consultation is mandatory for patients undergoing surgical intervention or experiencing neurological deficits to optimize functional recovery 4, 6

Psychosocial support must be systematically assessed and provided, as spinal metastases profoundly impact quality of life 7

Critical Pitfalls to Avoid

• Do not delay multidisciplinary consultation for symptomatic spinal metastases—proactive management prevents irreversible neurological damage 1
• Do not rely solely on clinical symptoms—systematic screening with pain scores and neurological functional scales should be implemented 5
• Do not perform surgery without considering life expectancy—validated prognostication systems should guide surgical candidacy 8
• Do not treat spinal metastases in isolation—coordinate with medical oncology for systemic disease management 1, 6

Diagnostic Workup

For patients with known cancer presenting with back pain or neurological symptoms: 2

• Immediate MRI or CT of the spine is mandatory
• Bone scan if alkaline phosphatase elevated or radiographic findings suggest bony involvement
• Do not perform routine bone scans in asymptomatic patients without elevated alkaline phosphatase (yield <1%)

Follow-up Strategy

Imaging frequency should be: 2

• Baseline imaging before treatment initiation
• Follow-up every 6-16 weeks based on disease activity and clinical status
• Additional spine imaging as clinically indicated for new symptoms
• Interval adjusted according to rate of disease progression