The Brain and Spine Metastases Clinic at Fred Hutchinson Cancer Center allows for close collaboration between spinal surgeons and radiation oncologists. Together, these specialists offer rapid evaluations and a hybrid treatment that involves minimally invasive surgery plus radiation therapy. Learn more about this unique treatment and other surgical advances that help some patients avoid open surgery.
At least 30% of people with cancer will develop spine metastases during their lifetime. Metastatic spinal tumors can grow quickly and cause fractures and spinal cord compression, so early diagnosis and treatment are important. Fred Hutch’s Brain and Spine Metastases Clinic provides rapid, multidisciplinary assessments for patients with spinal tumors.
“Our surgeons, radiation oncologists and neuro-oncologists work together to evaluate patients and develop a treatment plan— usually the same day,” says Fred Hutch spinal surgeon, Anubhav Amin, MD. “Our streamlined approach helps some patients avoid invasive spinal surgery.”
A multidisciplinary evaluation at the Brain and Spine Metastases Clinic
An evaluation at Fred Hutch includes back-to-back visits with a spinal surgeon and radiation oncologist. Patients with neurological symptoms or no prior history of cancer may also see a neuro-oncology specialist. In-person and virtual evaluations are available.
A standard part of the evaluation process involves full-spine imaging to look for multiple spinal lesions, which are common. For patients receiving virtual evaluations, Amin works with referring providers to order MRI imaging of the entire spine.
Specialists review findings together with patients and together determine the best treatment option. The final decision depends on the patient’s preferences, overall health and primary cancer care. Treatment may include:
- Radiation therapy
- Hybrid of minimally invasive surgery plus radiation
- Open surgery plus radiation
“A unique aspect of our program is the close collaboration among our team to figure out the next best steps,” says Amin. “By knowing the radiation plan, I am often able to design a smaller surgery. This is a huge benefit to the patient.”
Stereotactic body radiation therapy for spinal tumors
When treating spinal tumors, providers have traditionally used low-dose radiation therapy to protect the spinal cord and nerve roots. At Fred Hutch, radiation oncologists use stereotactic body radiation therapy (SBRT), which delivers a high dose of contoured radiation to the tumor while minimizing radiation to the surrounding organs. With SBRT, patients receive three to five days of radiation therapy — instead of five weeks — with better tumor control.
For small tumors, SBRT may be the only treatment a patient needs. If the tumor causes spinal instability or cord compression, they may also need spinal surgery.
Minimally invasive surgery for spine metastases
Open surgery requires large incisions. The surgeon separates the muscles from the bones to resect the tumor and stabilize the spine.
Every year, Amin performs fewer open surgeries. Some of the surgical advancements driving this trend toward more minimally invasive procedures include:
- Tumor separation surgery: Instead of cutting through the muscles to reach the spinal tumor, Amin dilates the muscles and inserts a port. With a microscope, he dissects and removes the tumor to decompress the spinal cord. He then removes the dilators and port. The muscles come back together unharmed.
- Image-guided navigation and percutaneous screws: Amin uses an intraoperative CT scan and surgical navigation software to create a GPS map of the patient's body. Instead of using long incisions to find surgical landmarks, he makes very small (half-inch to one inch) openings. He then inserts screws through the skin (percutaneously).
- Fenestrated screws: Patients with cancer often have weak bones, which puts them at higher risk of hardware failure. In the past, surgeons counteracted bone weakness by performing a larger surgery to insert more screws. Fenestrated screws have holes for injecting cement. They allow surgeons to use less hardware with smaller incisions while still achieving a strong construct to stabilize the spine.
Planning hybrid spinal tumor treatment
A hybrid approach tailors the surgical plan around what’s possible with radiation therapy. The surgeon performs a less invasive resection, focused on decompressing the spinal cord by removing epidural tumor, which creates a safer radiation target for the residual tumor.
The surgeon and radiation oncologist work together to develop a plan that involves a minimum amount of downtime between treatments. The typical steps include:
1. Minimally invasive tumor separation surgery
2. Post-surgical imaging to plan SBRT
3. One to two weeks of recovery
4. Three to five SBRT treatments
Fred Hutch radiation oncologists use special MRI protocols and CT myelograms to plan radiation treatments. Both types of imaging reduce artifacts from the metal implants, allowing better views of the spinal cord, thecal sac and nerve roots. They are also helpful surveillance tools to detect recurrent tumors earlier.
A new approach: Endoscopic spinal surgery
Fred Hutch is in the early phases of offering endoscopic spinal surgery for tumor resection. This innovative procedure uses centimeter-long incisions and an endoscopic camera equipped with tiny tools. Patients usually go home the same day.
“We are the only center in the US offering a comprehensive endoscopic spinal surgery program. While this technique was pioneered for treatment of degenerative spinal conditions, we have now been adapting this new technology for treatment of patients with spine tumors,” says Amin. “So far, it’s only an option for people who cannot undergo conventional surgery due to severe illness, but our indications are rapidly expanding as the endoscopic technology advances.”
Robotic surgery is also on the horizon for Fred Hutch. Robotics allow for more precisely guide procedures and make spinal surgeries even less invasive.
The urgency of spine metastases
Chemotherapy has a limited ability to penetrate bone. This means that even when a patient’s primary cancer is well controlled with chemotherapy, spinal tumors can occur. The most common types of spine metastases are lung, breast, prostate and kidney cancers.
Patients with spine metastases often share a similar story. They overlook mild back pain in the bustle of their busy lives or other cancer treatments. The pain slowly gets worse until they reach a tipping point — a fracture occurs or there’s enough compression to cause symptoms. Once a spinal tumor reaches that point, it’s much harder to treat.
Providers can help by talking to patients who have a history of cancer about the importance of recognizing back pain, says Amin. He also recommends ordering an MRI sooner than later for these patients to rule out spinal tumors and avoid treatment delays.
Spinal metastases care at Fred Hutch
The Brain and Spine Metastases Clinic features a large team of physicians, advanced practice providers, nurses and support staff. Patients also access a wide range of supportive care services, including working with rehabilitation or pain physicians and palliative care specialists.
“We collaborate with referring providers to make treatment decisions and provide care that is not available locally,” says Amin. “We also coordinate closely with the primary cancer team to make sure our treatments fit within the overall cancer care plan.”
Consultations are available 7 days per week. To consult with Amin or another spinal tumor specialist, call 800.4UW.DOCS or explore our physician resources.
For patient referrals, contact:
Phone: 206.606.1062
Fax: 206.606.5125
Email: pccneuro@fredhutch.org
