There are a lot of differences between hospitals and even within hospitals when it comes to primary spine tumor surgery. Often, these complex operations are performed by spine surgeons who do not have the proper background and experience. If we want to improve the lives of spine cancer patients, this practice must change. In Toronto, an advocacy event motivated to raise awareness of the complexity of spinal cancer care is starting to show impact.

 

"There is no guideline or recommendation as to who should do these complex surgeries", explains Arjun Sahgal, steering committee member of the AOSpine Knowledge Forum Tumor, and Professor of Radiation Oncology at the University of Toronto. "If you go in first with the wrong operation, you can severely compromise the patient's ability to be cured."

 

Dr. Stefano Boriani from IRCCS Istituto Ortopedico Galeazzi in Milan, Italy, has performed over 250 en bloc resections, 40 of them on chordomas, and knows you only have one shot to heal these patients. "A wrong biopsy by laminectomy, spreading the tumor in the epidural space; an intralesional excision performed in the conviction that the disease is a metastasis; or performing a minimally invasive procedure can all lead to progression of the tumor. Later on, even the most aggressive en bloc resection will not be able to prevent recurrence, nor has a combination of high dose radiotherapy shown sufficient evidence to prevent disease progression."

 

The clinician deciding on the first treatment has an enormous responsibility. This first decision will affect the final outcome.

 

Advocacy event delivered by the AOSpine tumor experts

To improve outcomes, Sahgal brought international experts from the AOSpine Knowledge Forum Tumor to educate 30 invited staff surgeons from Toronto's University affiliated hospitals on the current state-of-the-art surgical management of primary osseous spine tumors. "You have to respect that these are not simple cases, and that the complexity requires a team approach. You need proper multidisciplinary discussions and appropriate resources."

 

The one-on-one staff-to-staff education allowed participants to understand what these major resections and reconstructions mean.

 

"The result was phenomenal! The in-depth, dedicated knowledge of primary spine tumors, especially chordomas and chondrosarcomas, within the AOSpine Knowledge Forum Tumor is unparalleled in the world", Sahgal says. In his view, the only way to teach surgeons at such a high academic level is to bring the leading world experts to them. "These people actually perfected the detailed en bloc resection techniques and have performed hundreds of cases. You can't get the same by reading an article or by listening to a talk."

 

Every tumor is different

The workshop was preceded by an evening session, where Boriani reflected on his 25-year experience with en bloc resection. Boriani carefully plans each procedure in advance, so every step is clear in his mind. "It is impossible to standardize. Every tumor is different, by location, and by compartment extension."

 

From a surgical point of view, an en bloc resection with a tumor-free margin should be performed as first treatment, but this is not always feasible. In some cases, accidental or incidental transgressions to oncological principles can be expected because of cervical localizations, tumor size, tumor growth in the epidural space or inside muscles such as psoas or piriformis, previous incorrect approach, or patient refusing to sacrifice functions. "Especially in these cases, a multidisciplinary approach is mandatory", Boriani stresses. "Radiation oncology and soon also targeted therapy based on genomic studies must be considered."

 

Network of experts will lead to better patient outcomes

The workshop was the first step – something the organizers hope will lead to a standardized approach and spawn a body of experts, a "virtual tumor board" for the Greater Toronto Area. The four participating hospitals have already agreed to this in principle. Each would designate two people to take on primary spine tumors with a commitment to sustained education. AOSpine and the Global Spine Congress with Knowledge Forum precourses could play a major role.

 

According to the AOSpine Knowledge Forum Tumor, hospitals are increasingly recognizing that these operations cannot be performed unless the surgeon really knows how to do them. "The best way is to create the expertise within your home centers", Sahgal sees. "But if they are not available, instead of just anyone operating, you would transfer the patient to a hospital with specially trained primary spine experts in orthopedic and neurosurgery." In the Greater Toronto Area, triaging to appropriate surgeons can already be seen. "Now it's time to formalize this, to optimize outcome for our patients."

 

 

​ In a Spine Rounds evening session, Stefano Boriani talked about his 25-year experience with en bloc resection. Residents and trainees continued discussing this in their journal clubs - an excellent outcome.