Spine Metastasis Radiation Therapy

A cancer deposit in the spine hurts, weakens the bone and threatens the spinal cord. Radiation answers all three, and in two sessions it can now abolish the pain outright in a third of patients. Timing is what decides the outcome.

Cancer spreads to the spine more often than to any other bone, and radiation remains the treatment nearly every patient with a painful spinal deposit receives. Conventional radiation over one to ten sessions relieves pain in about six patients in ten (Chow and colleagues, Clinical Oncology, 2012). Stereotactic body radiation therapy, which delivers a much higher dose in two sessions with millimeter precision, produced a complete pain response at three months in 35 percent of patients against 14 percent with the conventional course in the randomized SC.24 trial (Sahgal and colleagues, Lancet Oncology, 2021). When the deposit presses on the spinal cord, surgery followed by radiation kept 84 percent of patients walking against 57 percent with radiation alone (Patchell and colleagues, Lancet, 2005). This page explains what radiation does for spine metastases, the emergency of cord compression, how conventional radiation, stereotactic radiation and surgery compare, who qualifies for each, what the course involves, and how patients from abroad arrange it at Biruni Hospital in Istanbul.

What radiation does for a spine metastasis

Cancer reaches the spine through the blood, most often from the breast, the prostate, the lung, the kidney and the thyroid, and from myeloma. A deposit in a vertebra does three things. It hurts, with a deep ache that is worse at night and on lying flat. It weakens the bone, which can collapse. And it can grow backward into the canal that carries the spinal cord. Radiation addresses each.

• Pain. Radiation kills the tumor cells that inflame the bone and stretch its lining, and pain begins to ease within one to two weeks. Six in ten respond. Two to three in ten become pain free after a conventional course. Stereotactic treatment raises the pain-free proportion.
• Cord and nerve protection. A deposit that has begun to press on the spinal cord or the nerve roots is treated within days, with steroids started at once, to preserve walking, bladder control and sensation. Radiation stops the tumor growing further and shrinks it over weeks.
• Tumor control. In a patient with a few metastases and a cancer otherwise controlled, a high dose to each spinal deposit aims to destroy it rather than to soothe it, and local control at one year exceeds 85 percent in most stereotactic series.

Cord compression, the one emergency in radiation oncology

New weakness in the legs, numbness rising from the feet, difficulty passing urine or a band of pain around the chest or abdomen in a patient known to have cancer signals possible compression of the spinal cord. Same-day treatment. Every hour of delay costs nerve fibers that do not return.

Surgery first, when it is possible

The result applies to a patient with one site of compression, a life expectancy of at least three months, and a spine and a general condition that can withstand an operation. A patient with compression at several levels, a very radiosensitive tumor such as lymphoma or myeloma, or a prognosis of weeks receives radiation alone, started within 24 hours, with dexamethasone. The spine surgeon and the radiation oncologist decide together, on the day, with the MRI in front of them. Both see the patient before the sun sets. For the patient who is far from a hospital when the weakness begins, the practical advice is simple and worth stating plainly. Take the steroid the local doctor prescribes, lie flat rather than sit, do not wait for a scheduled appointment, and get to any emergency department with an MRI scanner, because the treatment that saves walking is the one given within a day, wherever it is given, and the transfer to a center abroad can follow once the cord is safe.

Conventional, stereotactic or surgery

Three tools, chosen by what the deposit is doing and what the patient needs from the next months.

Side by side

What the trials show

Decades ago, the trials settled pain relief. Two questions remained. Whether surgery adds to radiation when the cord is compressed, answered above. And whether the higher stereotactic dose does anything conventional radiation cannot.

Who gets stereotactic treatment

The patient who will live long enough to benefit from a treatment that lasts.

Eligible patients had painful MRI-confirmed spinal metastasis, no more than three consecutive vertebral segments in the treatment volume, a performance status of 0 to 2, a spinal instability score of less than 12, and no neurologically symptomatic spinal cord or cauda equina compression (Sahgal and colleagues, 2021).

• Cord compression with symptoms rules SBRT out because the dose the cord can take is the same dose that would leave the tumor against it undertreated, and surgery to separate them comes first.
• A prognosis of weeks rules it out because the benefit of stereotactic treatment appears over months, and a single conventional session relieves pain just as fast.

The course

Fast for conventional treatment. A week of preparation for stereotactic.

1. Assessment. Pain score, neurological examination, MRI of the whole spine with contrast, the instability score, and a review of the cancer's state elsewhere and of any previous radiation to the same region, which changes the dose that can be given.
2. Planning. For conventional radiation, a CT in the treatment position on the same day and treatment the same day or the next. For SBRT, a CT in a body mold with the MRI fused to it, outlining of the tumor and the cord, a plan checked by a physicist and delivered to a phantom before the patient, which takes five to seven days.
3. Treatment. Conventional sessions take ten minutes. Stereotactic sessions take thirty to forty-five minutes, most of it imaging, with a cone beam CT before the beam and sometimes during it, and the patient still in the mold throughout.
4. Afterward. Steroids for a few days around stereotactic treatment to prevent pain flare. A review at four to six weeks. MRI at three months and then every three to six months for stereotactic patients.

Pain relief begins within a week for the majority and reaches its fullest at four to six weeks. A pain flare, a temporary worsening in the first three days, occurs in about a third of stereotactic patients and settles with dexamethasone.

Side effects

Coming from abroad

Two kinds of patients travel. One has a painful deposit and a cancer under control, and comes for stereotactic treatment planned in advance. The other has developed weakness and needs surgery and radiation within days, and is brought by air ambulance or on the first flight with a doctor's clearance. The length of stay is a week for a stereotactic course and two to three weeks when surgery comes first. Two days after the last session, patients are fit to fly. After spinal surgery the wait is ten to fourteen days, with the surgeon's clearance, and the coordinator books the return flight only once that clearance has been given, because an airline will refuse a patient with a fresh spinal wound without a medical certificate and the certificate is written after the wound check on the tenth day.

One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number once you are back home. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages. It arranges the visa invitation letter, airport transfers, a stretcher or wheelchair transfer where needed, daily transport and accommodation near the hospital. The kitchen prepares halal, vegetarian and diabetic meals, a prayer room is on site, and a request for a female physician is met wherever the rota allows.

What to send, and what happens when

Cost

An estimate follows the file review and depends on whether the course is conventional or stereotactic, the number of levels and sessions, and whether surgery or a cement injection comes first. Hospitals in this market quote spinal radiation as a package for the course, with surgery, the hospital stay and rehabilitation priced separately when they are needed, and a patient who is likely to need both the operation and the radiation should ask for a single figure that covers the whole admission rather than two estimates from two departments, since the second is easier to compare with quotes from elsewhere and leaves less room for items that appear on the final bill unannounced.

Confirm what the figure includes and whether the three-month MRI review is part of it.