Primary Spine Tumors: Diagnosis and Treatment

Michelle J. Clarke, MD; Ehud Mendel, MD; Frank D. Vrionis, MD, PhD


Cancer Control. 2014;21(2):114-123. 

In This Article

Strategies for Capsular Violation

Patients commonly present following partial resection or open biopsy, which is often a diagnostic procedure (Fig 5). Although capsular violation precludes true en bloc resection as the margins are already contaminated, using the en bloc techniques to eliminate tumor spillage is the preferred approach in these situations. If it is possible to widen the margin or include a portion of the surgical tract in the specimen, then there may be a reduced likelihood of local and distant recurrence; however, no data exist on this patient population, so the approach is inferred but commonly agreed upon.

Figure 5.

(A) A 74-year-old farmer presented with leg weakness, mild incontinence, and a palpable abdominal mass. Via fine-needle aspirate biopsy a 12 × 12 × 21 cm L2 to S1 chordoma was diagnosed, which had arisen from the L3 vertebral body. (B) The patient developed acute cauda equina syndrome due to the pathological fracture and was emergently decompressed posteriorly with gross violation of the tumor. He underwent posterior fusion in this setting. Multidisciplinary discussion resulted in neoadjuvant proton-beam and intensity-modulated radiotherapy followed by laparotomy and pseudo en bloc tumor resection. The L3 vertebral body tumor was not resected. After 2 years of postoperative follow-up, the patient is alive with stable disease and no neurological deficits.

Another frequent scenario involves unintended capsular violation during the initial en bloc resection in a previously unviolated tumor. If possible, oversewing the tear in the tumor capsule can preserve the structural integrity of the tumor, because further manipulation is often necessary during removal. Regardless of whether or not the tear is reparable, the area can be coated in a fibrin sealant to prevent spillage. Oftentimes the soft internal structure of the tumor will extrude through the tear. In such a case, thoroughly removing the extruded component and inspecting the nearby area are both imperative.

In some cases, tumor morphology may require modified en bloc resection in which tumor violation is planned to protect nearby neural and vascular structures ("planned transgression"). For instance, if the tumor wraps around the spinal cord and no window wide enough exists for the spinal cord to slip through when the mass is removed, either the spinal cord or the mass must be incised. Although such a scenario is neurologically devastating, planned paraplegia with en bloc resection and spinal cord sacrifice in the setting of aggressive sarcoma is arguably an option; commonly, however, it is the tumor that is incised. In these cases, the same techniques apply. Oftentimes it is possible to achieve a useful exposure window by removing the posterior elements, violating the tumor as it extends through the pedicles. In such a scenario, carefully protecting surrounding structures and promptly coating the remaining pedicle with bone wax is the appropriate option. Because a patient in this case has contaminated tumor margins, any instruments in contact with the tumor must be considered contaminated and, thus, be permanently removed from the field.

Clearly communicating tumor violation to radiation and medical oncologists is important. Depending on tumor pathology, close imaging follow-up may be the standard therapy following en bloc resection; however, upfront adjuvant therapy may be desirable in cases of contaminated margins.