Spine Tumors: Primary and Secondary

“Tumor” is a word about which nothing good can be said. It can cause terror in the mind of the listener, especially if the person speaking is their doctor. The word “Tumor” is an ancient Latin word that meant “swelling” on or in the human body. It was thought to be one of the five signs of inflammation (i.e., pain (dolor), heat (calor), redness (rubor), tumor (swelling), and loss of function (functio laesa)). In the contemporary medical lexicon, tumor still means an abnormal swelling of the flesh. It is also considered synonymous with neoplasm, which is a medical term for an abnormal, uncontrolled growth of new cells.

TumGraphic of a Spine Tumorors & Cancer

To the lay person, a tumor is more often than not considered to be synonymous with cancer. However, a tumor can be non-cancerous (benign), pre-cancerous (carcinoma in-situ), or cancerous (malignant). A benign tumor does not consume other tissues and will not become malignant overtime. It will, however, continue to grow in size and can cause pain and system dysfunction. A pre-cancerous tumor falls somewhere in between a benign tumor and a malignant tumor. It has the potential to become cancerous, but its growth has not yet become uncontrolled. In its pre-cancerous state the tumor should be a cause for concern and periodically monitored. Pre-cancerous tumors often appear as moles or uterine fibroids.

In a malignant tumor the cells grow uncontrollably and more quickly than benign tumor cells. They seek out other tissue to consume. Unlike a self-contained or non-spreading benign tumor, a malignant tumor will continue to spread to other parts of the body. Malignant tumors are, by definition, always cancerous. Fortunately they are not contagious, but they are also not preventable.

Q: Where are tumors most often located?

A: Tumors, either benign or malignant, can be located anywhere in the body. They can occur in the vital organs (e.g., brain, liver, lungs, kidney, etc.), soft tissues, bone/bone marrow, blood vessels, etc. Tumors in bone, including the spine, are classified as being primary or secondary. The primary spinal tumor first appears in the bones of the spine, whereas a secondary spinal tumor (always malignant) first appears elsewhere in the body and metastasizes (spreads) to the spine. Some spinal tumors occur as a result of genetic defects (e.g., neurofibromatosis 2), for the remainder the pathogenesis or cause is unknown.

Q: How often does spine cancer occur?

A: The answer to this is difficult to quantify. However, the spine is the most common site for bone metastasis. There are estimates that suggest between 30 and 70% of all patients with cancer will have spinal involvement.

Q: Where are the spinal tumors located?

A: Primary and secondary spinal tumors can occur (1) inside the spinal cord (intramedullary), (2) in the membrane (the meninges) that covers the spinal cord (extramedullary-intradural), or (3) between the meninges and the bones of the spine (extradural). Although a small number of tumors occur in the nerves of the spinal cord (e.g., ependymomas and gliomas), the majority of spinal tumors are extradural. Primary spinal tumors are much less common than primary brain tumors. As a spine tumor grows it can place pressure on the spinal cord as well as the bones of the spine, spinal blood vessels, nerve roots and the meninges.

In men, the secondary tumors that most often spread to the spine originate in the prostate and lung. In women, the secondary spine tumors most often originate in the breast and lung. Malignant spine tumors can also originate in the kidney, thyroid, and malignant melanoma. The cancerous cells are then transported to the spine via the lymphatic system or blood.

Q: Is there more than one type of spinal tumor?

A: There are a number of different types of both benign and malignant spinal tumors.

Among the benign tumors that may be present in the spine are:

Aneurysmal bone cyst – an abnormal growth that affects the vertebrae. Treatment includes embolization (cutting off blood flow) and surgical removal

Hemangioma – usually found in the thoracic and lumbar spine. Treatment includes embolization (cutting off blood flow), surgical removal and radiation

Giant cell tumor – an uncommon tumor found in the sacrum and lumbar spine. Treatment includes embolization (cutting off blood flow), surgical removal and possibly radiation

Osteoblastoma – found in the vertebrae and sacrum. Treatment is most often surgical removal

Osteoid Osteoma – found in the spinal column. Treatment is most often surgical removal.

More than 70% of all spine tumors are malignant, of which only 10% originate in the spine.

Among the primary malignant tumors that may be present in the spine are:

Multiple myeloma (cancer of the bone marrow) – most common malignancy of the spine. Treatment includes surgical removal, radiation and chemotherapy. The chemotherapy may be administered before the surgery to shrink the tumor (neoadjuvant chemotherapy) or after the surgery (adjuvant chemotherapy) to destroy any remaining cancerous cells.

Chondrosarcoma – most commonly found in the thoracic spine. Treatment is most often surgical removal

Chordoma – usually found in the lumbar spine and sacrum. Treatment is most often surgical removal if it can be done without affecting nearby nerve structures. Radiation may also be used for treatment.

Non-Hodgkin’s lymphoma – sometimes found in a vertebra and spinal canal. Treatment includes surgical removal, radiation and chemotherapy

Osteosarcoma – rarely found, affects the lumbar and sacral spine. Treatment includes surgical removal, radiation and chemotherapy

Ewing’s sarcoma – rare in persons over 30. Found in the sacrum, lumbar and thoracic vertebrae. Treatment is most often surgical removal combined with radiation and chemotherapy

Plasmacytoma – affects the thoracic vertebrae and can cause compression fracture. Treatment includes surgical removal and radiation

Astrocytomas – affect the nerve cells of the spinal cord. Treatment includes surgery and radiation.

Q: What are the symptoms of a spinal tumor?

A: The symptoms of a spinal tumor depend on the location, type of the tumor and rate of growth. Non-mechanical pain in the thoracic and lumbosacral regions of the back is the most frequent symptom. However, pain in the back is common to many spinal pathologies (cysts, infections, compression fractures, herniated discs, medication complications, etc.) and therefore an accurate diagnosis of a spinal tumor is critical. Other symptoms of a spinal tumor include bone fracture, swelling and inflammation, sciatica, loss of sensation, loss of bowel or bladder function, scoliosis or other spinal deformity. To isolate and pinpoint the spinal tumor the back and neck specialist will usually order a variety of lab tests to be performed (e.g., complete blood count with diff, comprehensive metabolic panel, serum protein electrophoresis, acid phosphatase, urinalysis with Bence Jones Protein, etc.).

In addition, one or more imaging studies may be undertaken, e.g., plain x-ray, MRI with contrast medium, CT Scan with Myelogram, Technetium bone scan or other nuclear medicine bone scans, or positron emission tomography (PET) scan.

Q: Assuming a tumor is found, what next?

A: To determine the exact type of tumor the back and neck specialist will have the patient undergo a needle biopsy (with image guidance) to obtain a sample of the tumor tissue so that the exact type, stage (severity) and grade (how quickly the cancer is likely to spread – low grade tumors being the least aggressive) of the cancer can be determined. Once this is done, a decision is made as to the treatment that will be pursued. This may mean a non-surgical treatment approach such as observation, the use of corticosteroids, palliative drug therapy, radiation, chemotherapy (administered in pill form, injection, intravenously, or via an implanted vascular access device (VAD)), bone marrow aspiration, radio-frequency ablation, or, in some cases, stem cell transplants.

Surgery is recommended when (1) other treatments have failed, (2) it is deemed necessary to stabilize the spine, or (3) the spinal nerves are being compressed. In this case all or a part of the tumor will be removed. During this procedure the surgeon will attempt to stabilize and reconstruct the spine by performing a spinal fusion with bone grafts, use of bone cement and instrumentation. Tumors that were found to have aggressive microscopic (histopathological) characteristics are subject to post-operative radiation therapy.

Q: Is spinal tumor surgery a high risk operation?

A: There are risks associated with any spinal surgery. These include infection, post-operative neurological problems, residual pain, failure to excise the entire tumor due to structural considerations, etc.

Q: If the decision is for the spine tumor to be removed by surgery, how long can I expect to be in the hospital?

A: Hospital stay can be up to 10 days or longer depending on complications, followed by bed rest and possibly rehabilitation.

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