submit to the journals

Advancing the Care of Cancer Patients with Vertebral Compression Fractures—A Radiation Oncology Expert Panel Discussion

Oncology & Hematology Review, 2012;8(1):12–7 DOI: http://doi.org/10.17925/OHR.2012.08.1.12

Abstract:

A closed roundtable discussion on ‘Advancing the Care of Cancer Patients with Vertebral Compression Fractures’ was held in Denver, Colorado, on November 16, 2010. The attendees included six invited local experts—four radiation oncologists, an interventional radiologist, and an orthopedic surgeon. The moderator, Jon Strasser, MD, a radiation oncologist, opened the meeting by explaining that its goal was to identify the barriers to managing vertebral compression fractures (VCFs) in cancer patients and discuss available treatment options. The focus would be on three topics: current treatment practice for spinal metastases; treatment goals in the presence of VCFs; and minimally invasive procedures for VCFs. Each topic is allocated a separate section of the following report of the discussion.
Keywords: Radiation oncology vertebral compression fracture, cancer patients, spinal metastases, cancer treatment options
Disclosure: Jon Strasser, MD, is a consultant for Medtronic. The Kyphon Products Division of Medtronic hosted and supported the expert panel discussion.
Received: October 05, 2011 Accepted: January 09, 2012
Correspondence: Jon Strasser, MD, Thomas Jefferson University and Helen F Graham Cancer Center, Radiation Oncology, 4701 Ogletown-Stanton Rd., S-1110, Newark, DE 19713. E: jstrasser@christianacare.org
Support: The publication of this article was funded by Medtronic. The views and opinions expressed are those of the panel members and not necessarily those of Medtronic.

Section 1. Current Treatment Practice for Spinal Metastases
Dr Strasser, a radiation oncologist, initiated the presentation with an overview of the manifestation of spinal metastases, stating that these develop in about half of all cancer patients. The median survival after bone metastases is 12 months with prostate cancer and five months with lung cancer, but it is two to three years in patients with breast cancer and multiple myeloma.1–4 Therefore, it is important to address bone metastases in these patients. Treatment is especially important if patients develop fractures and experience pain.
Bone metastases lead to skeletal-related events, including fractures, pain, spinal cord compression, and hypercalcemia. Spinal metastases can be classified as osteolytic or osteoblastic; radiosensitive or radioresistant; or by spinal cord location. Osteoblastic vertebral lesions, which are common in patients with prostate cancer, are characterized by increased bone density and decreased bone stiffness. Osteolytic bone lesions, which are common in patients with multiple myeloma, are characterized by decreased bone density, bone stiffness, and bone strength. Patients with osteolytic lesions have a higher risk of fractures.
When managing patients with spinal metastases, it is important to consider neurological aspects (e.g., degree of epidural cord compression, myelopathy, or radiculopathy), oncological aspects (e.g., tumor histology, radiosensitivity, and prognosis), mechanical instability, systemic disease, and patient preference for treatment.
Treatment goals are generally achieved by using a combination of complementary systemic and local therapies. Systemic therapy is used to improve patient survival, slow the progression of the disease, and prevent future events. Systemic therapy options for spinal metastases include steroids, bisphosphonates, chemotherapy, hormonal agents, and radiopharmaceuticals. Local therapies include surgery (e.g., spine stabilization) and radiation. Local therapy is used to control pain, restore anatomy, ablate a systemic tumor, and stabilize a fracture.
Reasons for performing open surgery for spinal metastases include tissue confirmation, pain relief, spine stabilization, anterior decompression, and neurologic decompression. Open surgery is a major procedure—patients need a prolonged rehabilitation (four to six weeks of recovery)—and it may not be suitable for some of them. Surgery can decompress nerves and restore anatomy, but it generally cannot treat the tumor.
Reasons for using conventional radiation to treat patients with bone metastases are that radiation treats the tumor, provides local pain control, delays or prevents local progression, and is relatively non-invasive. Problems with radiation therapy are that compression fractures are still possible after radiation; the bone is weakened; radiation is myelosuppressive; and it does not stabilize the fracture.
References:
  1. Selvaggi G, Scagliotti GV, Management of bone metastases in cancer: a review, Crit Rev Oncol Hematol, 2005;56:365–78.
  2. Nielsen OS, Munro AJ, Tannock IF, Bone metastases: pathophysiology and management policy, J Clin Oncol, 1991;9:509–24.
  3. Koenders PG, Beex LV, Kloppenborg PW, et al., Human breast cancer: survival from first metastasis. Breast Cancer Study Group, Breast Cancer Res Treat, 1992;21:173–80.
  4. Body JJ, Effectiveness and cost of bisphosphonate therapy in tumor bone disease, Cancer, 2003;97(3 Suppl.):859–65.
  5. Gasbarrini A, Cappuccio M, Mirabile L, et al., Spinal metastases: treatment evaluation algorithm, Eur Rev Med Pharmacol Sci, 2004;8:265–74.
  6. Chow E, Harris K, Fan G, et al., Palliative radiotherapy trials for bone metasases: a systematic review, J Clin Oncol, 2007;10:1423–36.
  7. Hortobagyi GN, Theriault RL, Porter L, et al., Efficacy of pamidronate in reducing skeletal cimplications in patients with breast cancer and lytic bone metastases, New Engl J Med, 1996;335:1785–91.
  8. Berenson JR, Lichtenstein A, Porter L, et al., Efficacy of pamidronate in reducing skeletal events in patients with advanced multiple myeloma, New Engl J Med, 1996;334:488–93.
  9. Brincker H, Westin J, Abildgaard N, et al., Failure of oral pamidronate to reduce skeletal morbidity in multiple myeloma: a double-blind placebo-controlled trial. Danish-Swedish co-operative study group, Br J Haematol, 1998;101:280–6.
  10. McCloskey EV, MacLennan ICM, Drayson MT, et al., A randomized trial of the effect of clodronate on skeletal morbidity in multiple myeloma, Br J Haematol, 1998;100:317–25.
  11. Melton LJ, Kyle RA, Achenbach SJ, et al., Fracture risk with multiple myeloma: a population-based study, J Bone Miner Res, 2005;20:487–93.
  12. Mhaskar R, Redzepovic J, Wheatley K, et al., Bisphosphonates in multiple myeloma (review), Cochrane Database Syst Rev, 2002:CD003188:1–32.
  13. Berruti A, Dogliotti L, Bitossi R, et al., Incidence of skeletal complication in patients with bone metastatic prostate cancer and hormone refractory disease: predictive role of bone resorption and formation and formation markers evaluated at baseline, J Urol, 2000;164:1248–53.
  14. Diamond TH, Bucci J, Kersley JH, et al., Osteoporosis and spinal fractures in men with prostate cancer: risk factors and effects of androgen deprivation therapy, J Urol, 2004;172:529–32.
  15. Han S, Wan S, Ning L, et al., Percutaneous vertebroplasty versus balloon kyphoplasty for treatment of osteoporotic vertebral compression fracture: a meta-analysis of randomised and non-randomised controlled trials, Int Orthop, 2011;35:1349–58.
  16. Gerszten PC, Germanwala A, Burton SA, et al., Combination kyphoplasty and radiosurgery: a new treatment paradigm for pathological fractures, J Neurosurg Spine, 2005;3:296–301.
  17. Berenson J, Pflugmacher R, Jarzem P, et al., Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicenter, randomised controlled trial, Lancet Oncol, 2011;12:225–35.
  18. Gerszten PC, Germanwala A, Burton SA, et al., Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures, J Neurosurg Spine, 2009;3:296–301.
Keywords: Radiation oncology vertebral compression fracture, cancer patients, spinal metastases, cancer treatment options