Primary Spine Tumors: Diagnosis and Treatment

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

Disclosures

Cancer Control. 2014;21(2):114-123. 

In This Article

Poorly Responsive Tumors

Chordomas and chondrosarcomas are poorly sensitive to chemotherapeutic agents and radiation. The mainstay of their treatment is en bloc surgical resection. Protocols for upfront proton-beam radiation and neoadjuvant therapies are currently being studied,[17] and they may be beneficial in cases where en bloc resection is impossible or technically challenging to reduce intraoperative tumor spillage. The importance of avoiding seeding the surrounding area must be underscored, because survival is frequently affected by local recurrence rather than metastatic disease progression.[3,18,19]

General Surgical Strategies

The preferred surgical approach to a lesion is dictated by tumor pathology, morphology, and metastatic status. The 2 main surgical goals involve resecting the tumor and reconstructing the load-bearing capacity of the spine. A general approach is outlined in Fig 1.

Figure 1.

A general algorithm for the en bloc primary tumor via costotransversectomy is shown. Although each step is important, operative location, approach, pathology, and adjacent structures will dictate the order of the intervention. The basic surgical principles may also be applied to en bloc resections in other locations.

In general, a trade-off exists between surgical morbidity and the completeness of resection. Surgical options can range from intralesional curettage/debulking to wide en bloc resection. Complex resections require larger operative corridors to appropriately visualize the tumor and neighboring structures in order to achieve negative margins. Limb or nerve root sacrifice with associated permanent morbidity may be planned in these larger procedures to optimize tumor resection.

En bloc resections involve the removal of the tumor in 1 nonviolated piece (Fig 2). En bloc resection conveys a survival advantage,[1,18,20–23] but the procedure is far more technically demanding than removing a lesion piece by piece. In general, these cases are longer and more demanding than similar piecemeal intralesional resections. There may be a planned morbidity because adjacent structures may require sacrifice to remove the tumor in 1 piece. Nerve roots, major vessels, and dura are commonly resected along with the tumor mass to remove the lesion in en bloc fashion. In addition, planned tracheostomy, feeding tube placement, and ileostomy or colostomy may be necessary. The patient should be thoroughly counseled prior to surgery as to the expected permanent loss of function. Thus, the decision to continue with en bloc resection must be based on a tradeoff between expected increased survival and planned surgical morbidity rates.

Figure 2.

A 54-year-old man presented with a chordoma incidentally found using fine-needle aspirate biopsy. (A) He underwent high sacrectomy, including thecal sac ligation below the S1 nerve roots with anticipated loss of bowel and bladder continence. (B) The tumor was hemisected following resection and is compared with preoperative T2-weighted magnetic resonance imaging.

Biomechanical stability and spinal column reconstruction can be challenging. In complex cases, limbs, portions of the chest wall, and the pelvic ring may be resected along with the tumor. In general, the goal of reconstruction is to allow adequate load transfer while protecting the nearby spinal cord, remaining nerve roots, and other vital organs. It is worth noting that the patient may permanently rely on implanted instrumentation to maintain stability, as bony union in the face of massive reconstruction and cytotoxic adjuvant therapy is challenging to achieve. Despite the odds, long-term survivors are expected; therefore, fusion should be attempted. In the presence of radiation and other therapies, anterior load-bearing constructs are more likely to achieve fusion than posterior constructs, and it may be worth revising the surgical plan to encompass this type of reconstruction. In general, en bloc resection of large spinal tumors and their subsequent reconstruction are among the most challenging spinal procedures.

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