Management of vertebral body metastatic tumors typically involves a multidisciplinary approach. Spinal metastases are common, with up to 70% of cancer patients developing spinal metastases. Modern treatments include surgery, radiation therapy such as stereotactic body radiotherapy, and medical therapies like chemotherapy and hormone therapy. The goals of treatment are palliation through pain relief and preservation of neurological function and quality of life. Surgical indications include spinal instability, pain resistant to other therapies, and neurological deficits. Outcomes are often improved when surgery is combined with radiation.

1. Management of Vertebral Body
Metastatic Tumours

2. Introduction
Spinal Metastasis is the most common malignant
lesion of the spine
The spine is the commonest site for bone metastases
Up to 70% of cancer patients have spinal
metastases, and 10% of cancer patients develop
metastatic cord compression
* Jacobs WB, Perrin RG (2001) Evaluation and treatment of spinal
metastases: an overview. Neurosurg Focus

3. INTRODUCTION:
Multidisciplinary approach provides improved outcome as compared to
radiation therapy alone *
Recent evidence has shown that modern surgery (including anterior and
posterolateral approaches with stabilisation) result in a better outcome than
radiotherapy alone**
Currently, limited decompression and stabilization followed by postoperative
SBRT for local tumor control are associated with less morbidity and may be
referred to as the current standard of care in these patients.
With improvements in chemotherapy, radiotherapy and hormonal therapies,
survival times have increased over the years
*Patchell RA, et al. Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer: a randomised trial. The Lancet 2005; 366: 643–8.
** Steinmetz MP, Mekhail A, Benzel EC (2001) Management of metastatic tumors of the spine: strategies
and operative indications. Neurosurg Focus 11(6):e2

4. EPIDEMIOLOGY
Wagner, A., Haag, E., Joerger, AK. et al. Comprehensive surgical treatment
strategy for spinal metastases. Sci Rep 11, 7988 (2021).
https://doi.org/10.1038/s41598-021-87121-1

5. Distribution of Vertebral Metastasis

6. The overall survival ranges
between 3-16 months
Aim of treatment is almost always
aimed at palliation rather than
cure
Vertebral metastasis are the 1st
sign of malignant disease in 12-20%
of the cases
No primary found in 12% of cases
Drop metastasis - 3%
Schick, U., Marquardt, G. & Lorenz, R. Intradural and extradural spinal
metastases. Neurosurg Rev 24, 1–5 (2001).
https://doi.org/10.1007/PL00011959

7. Clinical symptoms
Pain
Neurological
deficit

8. Pain
 Pain may be due to:
 Destruction of anatomic vertebral elements
 Resulting in Spinal instability
 Pain may also occur due to:
 Compression
 Infiltration of the spinal cord/ spinal nerves

9. Pathological Spine fracture
Pathological Spine
Fracture
Compression of
the neural tissues
-Neurologic deficit
Instability
-Spinal pain

10. Diagnosis of Spinal Metastasis
NCCT with 3D Recon
MRI
PET CT
Biopsy: Open or CT guided

11. Management
 Radiation Therapy
 Surgery
 Medical treatment
 Chemotherapy
 Hormone Therapy
 Immunotherapy

12. Pre-treatment Imaging
 Patient Immobilization:
 Adequate patient immobilization in
a near rigid body frame for pre-
treatment planning CT and MRI.
 The BodyFIX (Elekta AB,
Stockholm, Sweden): Improve
reproducibility of patient
positioning to within 1.2 mm and
0.9◦.

13. Standard Imaging for Pre-treatment planning:
 Patients with multilevel fusion
hardware may obscure visualization
of the spinal canal, metal artifact
reduction techniques can be
employed, however, these techniques
may be insufficient.
 Other options include scanning on a
lower field-strength (1.5 T) MRI
scanner or if susceptibility artifact is
still limiting, CT myelography may be
performed.
 Other groups also recommend the
performance of pre-SBRT CT for:
1. Evaluating bony anatomy and
depicting and characterizing spinal
metastases as osteoblastic or
osteolytic
2. Characterize the electron density of
tissues.
 Another frequent approach to pre-
treatment MRI is the performance of:
1. Sagittal T1W, T2W,
2. STIR, and fat-saturated post-contrast
T1W and
3. Axial T2W and T1W sequences.

14. Advanced Pre-treatment Spine Metastasis Imaging:
 Spine Dynamic Contrast-enhanced (DCE) perfusion: Gadolinium bolus
 Diffusion Imaging

15. Integrated approach to treatment planning:

18. The Epidural Spinal Cord Compression Classification (ESCC) (Bilsky grade):
Scores for epidural tumor encroachment
 The Spine Oncology Study
Group modified a 4-point
surgical compression scale
into a 6-point scale to better
account for degree of thecal
sac impingement for the
purpose of better assessment
of SBRT feasibility.
 ESCC Grades 0–1b are
generally considered safe for
primary SBRT,
 ESCC Grades 1 c–3 may
have increased risk of spinal
cord injury with SBRT, and
thus, unless the tumor is very
radiosensitive, surgery is a
better first treatment option.

19. NOMS Framework
(Neurologic, Oncologic, Mechanical Instability and Systemic disease)
*Ilya Laufer, David G. Rubin, Eric Lis, Brett W. Cox, Michael D. Stubblefield, Yoshiya Yamada, Mark H. Bilsky,
The NOMS Framework: Approach to the Treatment of Spinal Metastatic Tumors,
The Oncologist, Volume 18, Issue 6, June 2013, Pages 744–751

20. Radiotherapy
 Indications:
1) Palliative
2) Postoperative
 Relative contraindications: Neurologic deficit
 Absolute contraindication: Vertebral collapse

21.  Spine metastatic disease therapy poses unique challenge due to close
proximity of the spinal cord
 Historically, conventional EBRT was the standard treatment
 Only limited amount of radiation could be given
 Significant proportion developed subsequent pain or tumour progression
 Sterotactic body Radiotherapy (SBRT) can deliver ablative dose while sparing
the cord

22. Conventional EBRT(cEBRT):
 RADIOSENSITIVE
 Most hematologic malignancies
 Metastases from breast, prostate,
ovary, neuroendocrine tumors and
seminoma.
 RADIORESISTENT
 Renal cell carcinoma(RCC), colon,
lung, thyroid, liver (hepatocellular
carcinoma; HCC), melanoma and
sarcoma.
 Delivers wide-field radiation in small additive doses administered over
multiple sessions (usually 30 Gy in 10 fractions).
 To avoid injuring the spinal cord, a smaller dose of radiation is administered
which may be inadequate to destroy tumors that require larger doses of
radiation.
 Based on their response to cEBRT (30 Gy in 10 fractions), spinal
metastases have been classified as radiosensitive or radioresistant.

23. Stereotactic Body Radiotherapy (SBRT)
 SBRT delivers ablative doses of radiation to a target volume using advanced
radiotherapy techniques
 By exploiting a very steep dose gradient from the target volume to the spinal
cord, it is possible to deliver a much higher dose of radiation to a target volume
in the spine without causing a high risk of radiation myelopathy (>10 Gy per
fraction)
 Accurate delineation of the critical structures such as the spinal cord and nerve
roots/plexuses as avoidance structures for treatment planning is paramount.

24. Intact Spinal Metastasis Targeting
 CT is used for treatment planning as the radiation dose computation is based
on the electronic densities of different body structures.
 However, CT does not allow for the evaluation of soft tissue involvement such
as bone marrow and epidural involvement.
 MRI provides such details and is fused to the treatment planning CT to facilitate
target delineation.
 SPIne response assessment in Neuro-Oncology (SPINO) group recommends
Axial T1 and T2-weighted sequences with slice thickness ≤ 3 mm.

25.  The International Spine Radiosurgery Consortium has developed consensus
guidelines for target volume delineation.
 Gross tumor volume (GTV) is defined as the metastatic tumor identified on
the MRI, including all epidural and paraspinal diseases.
 Clinical target volume (CTV) includes GTV, abnormal marrow signal
suspicious for microscopic invasion and an adjacent normal bony expansion
that may contain subclinical disease. The next adjacent normal space is also
usually included in the CTV.
 A planning target volume (PTV) is expanded around the CTV to account for
set-up variations. The expansion is variable between different centers and
ranges from 0 to 3 mm. Some centers trim the PTV to generate a planning PTV
to avoid hotspots in the spinal cord.

26. Arterial Embolisation in Spinal metastasis
Damante, Mark A. Jr MD‡,*‡,**. Neoadjuvant Arterial Embolization of Spine
Metastases Associated With Improved Local Control in Patients Receiving
Surgical Decompression and Stereotactic Body Radiotherapy. Neurosurgery; 2023
 Selectively block tumour
blood supply
 Necrosis/shrinkage
 Reduce intaoperative
blood loss
 Recommended that
embolization be done a
day prior to surgery
 Hypervascular tumours:
1. RCC
2. Thyroid
3. NET

27. Surgical Intervention
 Primary approach of Spinal metastasis: Radiation therapy and/or Surgery
 Historically, Only decompression of neural elements
 Contemporary approach incorporates hardware fixation/stabilization
 Recent advances incudes:
1. Minimally invasive Surgical approaches
2. Image guided targeted ablative therapy

28. Indications for Surgery
 Three primary indications for
surgery:
1. Spinal Instability
2. Pain resistible to other treatment
(RT/CT)
3. Neurologic deficit
 Recurrence of tumour in an area
previously radiated (at the maximum
permitted levels)
 Ambiguous histological diagnosis
 Goals of Surgery:
1. Preserves functional status
2. Preserves QOL while limiting the
negative effects of the lesion.

29. Patchell Trial (2005):
Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. Direct decompressive surgical resection in the treatment of spinal cord compression
caused by metastatic cancer: a randomised trial. The Lancet 2005; 366: 643–8. doi: https:// doi. org/10. 1016/ S0140- 6736( 05) 66954-1
*Sx +RT > RT alone

30. Methods of Evaluation
 Revised Tokuhashi Scoring System
 Tomita Surgical Staging
 SINS
 Karnofsky performance status

31. Revised Tokuhashi Scoring System: For preoperative evaluation of
metastatic spine tumor prognosis
Tokuhashi, Y., Matsuzaki, H., Oda, H., Oshima, M. & Junnosuke, R. A revised
scoring system for preoperative evaluation of metastatic spine tumor prognosis.
Spine 2005, 30 (19), 2186–2191

32. Revised Tokuhashi Scoring System
Offers considerable variability in the
choice of treatment

33. Tomita’s classification system
 Simpler
 Only three parameters
1) Degree of malignancy
2) Presence of visceral metastasis
3) Presence of visceral metastasis
*Tomita, Katsuro MD, PhD; Kawahara, Norio MD, PhD; Kobayashi, Tadayoshi MD; Yoshida, Akira MD; Murakami, Hideki
MD; Akamaru, Tomoyuki MD. Surgical Strategy for Spinal Metastases. Spine 26(3):p 298-306, February 1, 2001.

34. Tomita’s classification system

35. Spine instability neoplastic score (SINS)
 Surgical decision making in large part relies
on spinal stability.
 The Spine Oncology Study Group defined
spinal instability as the “loss of spinal
integrity as a result of a neoplastic process
that is associated with movement-related
pain, symptomatic or progressive deformity
and/or neural compromise under
physiological loads.”
 Surgical consultation is recommended for
patient with SINS ≥ 7.

36. Karnofsky Performance Status

37. Operative treatment: Types
 PIECEMEAL (Intralesional surgery)
 Palliative Debulking
 Vertebrectomy
 Enbloc with marginal or wide
margins
 Challenging
 Increased complications

38. Global Spine Tumour Study Group

39. Global Spine Tumour Study Group

40. Boriani et al., 1997.

42. Total en bloc Vertebrectomy

43. Spinal Decompression
 Subaxial: Anterior Vertebrectomy
 Thoracic: Posterolateral
transpedicular, costotransverse and
lateral extra-cavitary approaches
with anterior column reconstruction
and stabilization
 Lumbar: Vertebrectomy or
posterolateral transpedicular
approaches.
 Current Standard of Care:
 Resection + Decompression + EBRT
 SBRT if available: Debulking +
separation surgery (2-3 mm zone) +
SBRT

44. Anterior Reconstruction
 Upto 3 Vertebral
metastasis
 Options:
1) Strut autografts
2) Allografts
3) Cement spacers- PMMA
4) Interbody cages-
Titanium, Ceramic,
PEEK(polyethyether
ketone), carbon fiber
induced PEEK.
 Diminishing role

45. Posterior procedure
 Posterior multilevel pedicle screw
constructs are the preferred option for
spine stabilization
 Cegment augmented fenestrated screws
enhances purchase
 Vertebral #
 Posterior vertebral element involvement
 Poor general condition
 Posterior decompression ± Stabilization
 Posterior decompression ± Occiput
Cervical Stabilization

46. Combined Procedures
 Anterior + Posterior

47. Minimally invasive and Percutaneous Techniques:
 Minimize injury to dorsal musculoligamentous complex
 Indications: Painful vertebral fractures, impending fractures and large
intraosseus tumours
 PERCUTANEOUS PROCEDURES:
1. Pain: Vertebroplasty and Kyphoplasty are used in conjunction with medical and
radiotherapy for treatment of uncomplicated painful spine metastasis and
Anterior column instability
2. Cement augmentation for pathological fractures (Percutaneous > Open)

48. *Berenson J, et al.Balloon kyphoplasty versus non-surgicalfracture management for treatment of
painful vertebral body compression fracturesin patients with cancer: a multicentre,randomized
controlled trial. Lancet Oncol 2011; 12: 225–35.
 Level I evidence to support the use of balloon kyphoplasty as opposed to non-surgical
management for cancer patients with painful vertebral compression fracture.
 Showed significant improvement in back pain, activity, analgesic requirements and quality-
of-life measures.

49.  Osteolytic pathological fracture: Vertebroplasty is associated with increased risk
of cement leakage and less predictable pain relief
 Kyphoplasty allows for controlled cement injection for metastatic vertebral
compression fractures and decreased likelihood of leakage.
 Percutaneous cement augmentation is now more widely offered for the
treatment of spine metastatic pain from symptomatic vertebral compression
fractures without neurologic deficits.

50. Image-guided percutaneous ablation:
 Palliative option
 In setting of RT failure with disease recurrence
1. Cryoablation
2. RFA
3. Laser Ablative Techniques
4. Thermal ablation

51. Chemotherapy
 Anti-tumour medication
 Steroids
 Biphosphonates

52. Chemotherapy
 Highly sensitive
 Childhood tumours: ALL, Wilm’s tumour, Ewing’s, RB, Rhabdomyosarcoma
 Hodgkin’s lymphoma
 Ca Testis
 Choriocarcinoma
 Burkitt’s tumour

53. Biphosphonates
 Inhibit Osteoclast reabsorbtion of bone matrix and
decrease bone turnover
 Three generations of bisphosphonate currently
available

54. Targeted/Immunotherapy:
 Androgen-deprivation therapy (ADT) + RT
 Monoclonal Antibodies: Bevacizumab, Panitumumab
 Small-Molecule Inhibitors: Erlotinib, Bortezomib
 Immunomodulators: checkpoint inhibitors anti-CTLA-4 and anti-PD-L1/PD-1
 The risk of radiosensitization near the spinal cord by these agents is a concern—
lack of clarity regarding whether radiotherapy can be safely combined with these
chemotherapeutic and immunotherapeutic agents
* Bitterman, D. S., Du, K. L. 2020. Safety and efficacy of combination targeted therapy and radiotherapy

55. Conclusions
 Spinal Instability and Neurologic deficit due to metastasis is treated
successfully at operative procedure
 Prosthetic replacement is indicated for metastasis upto 3 consecutive
Vertebrae
 Posterior stabilization is recommended:
1. For multiple metastasis
2. Poor general condition
3. Short life expectancy

56.  Anterior vertebral replacement and Anterior-Posterior stabilization
1. Is indicated in excessively unstable spine
2. It gives the overall best results.
 The minimal invasive techniques (Vertebroplasty-Kyphoplasty) are
recommended methods of treatment