Spine Tumors: Drug Therapy

Therapeutic Targets

  • Relief of pain
  • Prevention or improvement of existing neurological deficits.
  • Stabilization of fracture-prone spinal sections

Therapy recommendations

  • Analgesia according to WHO staging scheme:
    • Non-opioid analgesic (paracetamol, first-line agent).
    • Low-potency opioid analgesic (e.g., tramadol) + non-opioid analgesic.
    • High-potency opioid analgesic (eg, morphine) + non-opioid analgesic.
  • Chemotherapeutic agents are used as an independent form of therapy with a curative (curative) or palliative (palliative) approach in the treatment of malignant (malignant) bone tumors. If necessary, they are combined with surgical measures or radiation therapy (radiotherapy, radiatio).
  • Osteosarcoma: due tohigh risk of metastases (formation of daughter tumors) first cytoreductive (“cell-reducing”) chemotherapy; then tumor extirpation (surgical removal of the tumor) (> 80% of patients can be operated arm and leg preserving); postoperatively, further chemotherapy is given.
  • Group of Ewing sarcomas: due tohigh risk of metastases first cytoreductive chemotherapy; followed by surgery, radiotherapy or a combination of both procedures.
  • Osseous metastases (bone metastases):
    • Radiation therapy and bisphosphonates as well:
      • Anti-hormonal therapy for hormone-sensitive primary tumors such as breast carcinoma or prostate carcinoma (for more information, see the diseases mentioned).
      • Denosumab (monoclonal antibody that mimics the effects of osteoprotegerin (OPG) in bone metabolism) for the prevention of skeletal-related complications (SRE; pathologic fracture (“spontaneous fracture,” i.e., fracture of the bone during normal weight-bearing without an identifiable traumatic cause), radiation therapy to the bone, spinal cord compression (constriction of the spinal cord), or surgical procedures on the bone) in adults with bone metastases due to solid tumors
  • Glucocorticoids may help improve neurological findings.
  • See also under “Other Therapy.”

Corticosteroids and bisphosphonates.

  • Glucocorticoids can help improve neurologic findings. Furthermore, glucocorticoids are used in malignancies (malignant tumors) to lower calcium levels in hypercalcemia (excess calcium).
  • Bisphosphonates are used in tumor-associated hypercalcemia (calcium excess), tumor osteolysis (tumor-induced dissolution of bone), and also increasingly in osseous metastasis (bone metastasis). They lead to inhibition of osteoclast-induced resorption of the bone (osteoclasts = cells that break down bone). This leads to a reduction in pain caused by bone metastases. Furthermore, they also lead to a reduction in the risk of pathological fracture (“spontaneous fracture”, i.e. bone fracture during normal loading without an identifiable traumatic cause). Side effects: Therapy with bisphosphonates is usually well tolerated, but occasionally gastrointestinal complaints (nausea, vomiting, esophagitis / esophagitis), arthralgia (joint pain) or “influenza-like” syndrome occur.

Denosumab

  • Denosumab is used to prevent skeletal-related complications (SRE) (pathologic fracture, radiation to the bone, spinal cord compression (narrowing of the spinal cord), or surgical procedures to the bone) in adults with bone metastases due to solid tumors. It reduces the risk of occurrence of the first skeletal-related event in adults with bone metastases due to solid tumors by approximately 5% in absolute terms compared with zoledronic acid, and by approximately 17% in relative terms
  • Contraindications: denosumab, 120 mg solution for injection is contraindicated in:
    • Patients who have unhealed lesions from dental surgery or oral surgery.
    • A patient reminder card is introduced to increase patient awareness of the risk of osteonecrosis of the jaw (death (necrosis) of bone of the jaw) and the precautions needed to minimize it.
    • Patients treated with XGEVA must be given the patient reminder card with information about osteonecrosis of the jaw and the package insert.
  • Side effects: Risk of osteonecrosis of the jaw and hypocalcemia (calcium deficiency).
  • Caveat:
    • Osteonecrosis (death (necrosis) of bone) of the jawbone and external auditory canal during therapy with bisphosphonates and denosumab.
    • In clinical trials in patients with advanced cancers, occurrence of increased incidence of new primary malignancies with denosumab compared with zoledronic acid.
  • No active ingredients with dosages are mentioned for the above drug groups due to the diversity in the therapy of bone tumors.