SPINE-1
aBiopsy if remote history of cancer.
bIf the patient is unable to have an MRI, then a CT myelogram is recommended, which may also be useful for SRT planning.
c15%–20% of patients have additional lesions. Highly recommend complete spine imaging.
dSee Principles of Brain and Spine Tumor Imaging (BRAIN-A).
eSee Principles of Brain and Spinal Cord Tumor Radiation Therapy (BRAIN-C).
fSee Principles of Brain and Spinal Cord Tumor Systemic Therapy (BRAIN-D).
gIncludes cauda equina syndrome.
PRESENTATION WORKUP TREATMENT
Patient diagnosed with cancer
or patient with newly discovered abnormality suspicious for spine metastasis
Asymptomatic (Incidental finding)
Symptomatic:
• Severe, new, or progressive pain or neurologic symptoms or myelopathy
• Systemic imaging (ie, contrast-enhanced chest/abdominal/
pelvic CT or whole body PET/
CT, bone scan as indicated for metastatic workup)
• Biopsya if it alters management
• Observation
Spine MRId in 6–8 weeks, then every 2–3 months until the nature of the lesion is established
• Surgery/focal RTe or chemotherapyf are options for patients with
asymptomatic epidural disease
Spinal MRIb,c,d
(urgent in the event of neurologic symptoms)
See SPINE-2 No tumor
Spinal cord compressiong
No spinal cord compressiond
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 5.2020 , 04/15/21 © 2021 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
SPINE-2
fSee Principles of Brain and Spinal Cord Tumor Systemic Therapy (BRAIN-D).
gIncludes cauda equina syndrome.
hThe recommended minimum dose of steroids is 4 mg of
dexamethasone every 6 hours, although dose of steroids may vary (10–100 mg). A randomized trial supported the use of high-dose steroids (Sorensen PS, et al. Eur J Cancer 1994;30A:22-27).
iSpinal instability is grossly defined as the presence of significant kyphosis or subluxation (deformity), or of significantly retropulsed bone fragment.
jConsider alternative diagnosis of leptomeningeal disease (See LEPT-1).
kTumor resection with or without spinal stabilization. Surgery should be focused on anatomic pathology.
PRESENTATION TREATMENT ADJUVANT TREATMENT
No tumor Evaluate for other causes of pain and/or neurologic symptomsj
Spinal cord
compressiong Steroidsh
Surgeryk,l,m ± stabilization followed by RTn (category 1)
orPrimary RTn
orIn the absence of clinical myelopathy, primary chemotherapyf if chemosensitive tumor (eg, lymphoma, germ cell tumor, myeloma)
No spinal cord compressiong
Fracture or spinal instabilityi
No fracture or spinal instability
Surgical stabilization
orVertebral augmentationo Followed by RTn
RTn (preferred)
orChemotherapyf (if chemosensitive tumor) or Surgerym (selective cases) followed by RT
Consider surgerymor SRSn if:
• Deterioration during RT
• Intractable pain
• Tumor progression
lRegarding surgery, note the following:
• Category 1 evidence supports the role of surgery in patients with a solitary epidural spinal cord compression by a tumor not known to be radiosensitive and who are willing to undergo surgery. (Patchell RA, et al. Lancet 2005;366(9486):643-648)
• For surgery, patients with hematologic tumors (ie, lymphoma, myeloma, leukemia) should be excluded, life expectancy should be ≥3 mo, and the patient should not be paraplegic for >24 h.
• Surgery is especially indicated if the patient has any of the following: spinal instability, no history of cancer, rapid neurologic deterioration during RT, previous RT to site, and single-site spinal cord compression.
mPostoperative spine MRI should be delayed by at least 2–3 weeks to avoid post-surgical artifacts. See Principles of Brain Tumor Surgery (BRAIN-B).
nRecommend SRS if oligometastases and radioresistant. See Principles of Brain and Spinal Cord Tumor Radiation Therapy (BRAIN-C).
oVertebral augmentation: vertebroplasty, kyphoplasty.
See Follow-up (SPINE-3)
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 5.2020 , 04/15/21 © 2021 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
Metastatic Spine Tumors
SPINE-3
dSee Principles of Brain and Spine Tumor Imaging (BRAIN-A).
mPostoperative spine MRI should be delayed by at least 2–3 weeks to avoid post-surgical artifacts. See Principles of Brain Tumor Surgery (BRAIN-B).
nRecommend SRS if oligometastases and radioresistant. See Principles of Brain and Spinal Cord Tumor Radiation Therapy (BRAIN-C).
pGary AK, et al. Prospective evaluation of spinal reirradiation by using stereotactic body radiation therapy: The University of Texas MD Anderson Cancer Center experience. Cancer 2011;117:3509-3516.
FOLLOW-UP PRESENTATION
(Symptom- or MRI-based) TREATMENT FOR RECURRENCE
OR PROGRESSIVE DISEASE
Spine MRI/CTd
1–3 mo after treatment, then every 3–4 mo for 1 y, then as clinically indicated indefinitely
Progressive disease or Recurrent disease
If previously treated with:
RT or
Surgery and RT
If previously treated with:
Chemotherapy
Consider surgerym or SRSn,p Consider re-irradiation if recurrent
Consider surgerym with or without RTn
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 5.2020 , 04/15/21 © 2021 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
Metastatic Spine Tumors
BRAIN-A PRINCIPLES OF BRAIN AND SPINE TUMOR IMAGING1
1The imaging modalities listed may not be available at every institution.
2Wen PY, Macdonald DR, Reardon DA, et al. Updated response assessment for high-grade gliomas: Response assessment in neuro-oncology working group. J Clin Oncol 2010;28:1963-1972.
• MRI2of the brain and spine (with and without contrast):
Gold standard
Provides a “static” picture of tumors
Benefits: Provides a reasonably good delineation of tumors; higher grade tumors and brain leptomeningeal metastasis usually enhance; lower grade tumors usually do not enhance
Limitations: Sensitive to movement, metallic objects cause artifact, implantable devices are unsafe for MRI, claustrophobia may be an issue, or renal insufficiency may occur
Postoperative brain MRI should be performed within 48 hours for gliomas and other brain tumors to determine extent of resection.
Postoperative spine MRI should be delayed by at least 2–3 weeks to avoid post-surgical artifacts.
Follow-up brain MRI should be performed at the frequency and intervals stated in the treatment algorithms. More frequent imaging may be done as clinically indicated by the treating physician, such as in the event of a clinical change such as development of seizures or neurologic deterioration.
• CT of the brain and spine (with and without contrast):
Should be used in patients who cannot have an MRI
Benefits: Claustrophobia or implantable devices are not an issue, can be done faster than an MRI
Limitations: Lacks resolution of MRI, especially in posterior fossa, or renal insufficiency
• MR spectroscopy: Assess metabolites within tumors and normal tissue
May be useful in differentiating tumor from radiation necrosis; may be helpful in grading tumors or assessing response
Area most abnormal would be the best place to target for a biopsy
Limitations: Tumors near vessels, air spaces, or bone. Extra time in MRI and others as noted under MRI
• MR perfusion: Measures cerebral blood volume in tumors
May be useful in differentiating grade of tumor or tumor versus radiation necrosis. Area of highest perfusion would be the best place to biopsy.
Limitations: Tumors near vessels, air spaces, bone, small-volume lesions, or tumors in the spinal cord. Extra time in MRI and others as noted under MRI.
• Brain PET scanning: Assess metabolism within tumor and normal tissue by using radiolabeled tracers
May be useful in differentiating tumor from radiation necrosis but has some limitations; may also correlate with tumor grade or provide the optimal area for biopsy
Limitations: Accuracy of interpretations, availability of equipment and isotopes
This is a list of imaging modalities available and used in neuro-oncology primarily to make treatment decisions. The most common use for MR
spectroscopy, MR perfusion, and PET scanning is to differentiate radiation necrosis from active tumor, as this might obviate the need for surgery or the discontinuation of an effective therapy. Imaging is always recommended to investigate emergent signs or symptoms.