At the outset of their article, Drs. Gerszten and Welch state that their primary goal is to review factors that affect surgical intervention in patients with metastatic spinal disease. On their way to achieving this goal, the authors touch on some of the more salient points regarding the initial work-up and nonsurgical treatment of metastasis to the spine. By so doing, they present an overview of the treatment of metastatic spinal disease that provides a short, but good, review for the radiation and medical oncologist. In addition, the authors provide a concise overview of the surgical approach to metastatic spinal disease.
Bone metastases to the spinal column are common, and in the future, likely to increase. This increase will primarily result from improvements in diagnostic capabilities, as well as improvements in the therapeutic outcomes for the most frequent primary sites of spinal metastasesincluding the breast, lung, and prostate.
The most important manifestation of spinal disease is compression of the spinal cord (and the attendant neurologic sequelae). Therefore, it is important for all physiciansnot only oncologiststo be cognizant of the presenting signs and symptoms of spinal disease. They must also be aware of the treatment options for spinal disease, especially since numerous studies have shown a positive relationship between preserved pretreatment neurologic function and outcome.
Work-up of the Patient With Spinal Disease
Drs. Gerszten and Welch review several important topics regarding the evaluation of a patient with metastatic spinal disease. The authors discuss the most significant points of the history and physical, adding that painthe most common presenting symptom of metastatic spinal diseaseshould be immediately investigated in any patient with a cancer diagnosis. The value and appropriateness of each diagnostic radiologic procedure are also discussed; the authors note that magnetic resonance imaging (MRI) appears to be the most sensitive. Ultimately, the intent of the work-up should be to rule out metastases, as well as any degree of spinal cord compression.
Nonsurgical and Surgical Approaches
The authors do mention the role of radiation therapy and its importance in the treatment of pain associated with bone metastases. Radiation therapy has been shown to be an effective modality for the palliation of pain in at least 75% to 80% of patients with pain from bone metastases. The most effective dose schedule is still being investigated, for example, by the Radiation Therapy Oncology Group (RTOG), which is comparing two fractionation schedules3,000 cGy in 10 fractions vs 800 cGy in 1 fraction.
The final section of the article covers the current surgical management of metastatic spinal disease. The authors provide an excellent and complete overview of the indications for surgery and general guidelines for the most efficient surgical procedures for diagnosis, neural decompression, and pain relief. The article is noteworthy in that it discusses the specifics of surgical management as they apply to the cervical, thoracic, and lumbar spine.
Results of surgical management are discussed in terms of what is and what is not available in the literature. Unfortunately, no trials have compared surgical and nonsurgical techniques. For each treatment approach, success has been measured in terms of the resulting degree of neurologic function. Of course, this outcome depends on the neurologic function at presentation. Moreover, it may be fruitless to consider a study comparing each modality since each offers its own benefits and indications (as presented in Table 1 of the article). Therefore, it is incumbent upon all physicians to understand and apply these guidelines when faced with a patient with metastatic spinal disease.
Radiation therapy and surgery are both appropriate for the management of metastatic spinal disease. As stated in the article, the overall goals of treatment are decompression of neural structures through tumor cytoreduction, prevention of neurologic progression, relief of pain, and prevention of local recurrence.
The complete, yet succinct, article by Drs. Gerszten and Welch provides an excellent reference for all physicians on the options for treating spinal disease in the cervical, thoracic, and lumbar spine. The authors discussion will allow the oncologist to make a more informed decision regarding the need for and appropriateness of surgical intervention for the management of metastatic spinal disease.