Spinal neuro-oncology – not an appendix of neuro-oncology

The idea and concept of this special issue began during the 2022 SNO Meeting in Tampa, Florida. The intention was to promote education and awareness of spinal tumors in memory of one patient who donated funds for that purpose. She had an intramedullary tumor that could not be identified by tissue, yet she was treated empirically with radiation and adjuvant temozolomide. She lived for 6 years, worked and traveled for 5, until disease progression in the spinal cord with bone metastases. A biopsy of one vertebral metastasis revealed a glioma.1 Tumors involving the spinal cord, spinal dura, and the spinal bony structures represent a complex spectrum of diseases that cause significant morbidity and mortality due to neurological deficits and mechanical instability. Neuro-oncology in general has evolved and advanced significantly over the past few decades in the clinical and research domains because of a coordinated multi-disciplinary approach. However, spinal neuro-oncology remains an orphan field due to the lack of unifying multi-disciplinary programs dedicated to managing the wide range of oncological and mechanical issues arising from tumor growth. In this special issue, we highlight that neuro-oncology does not stop at the foramen magnum and that the spine and spinal cord are not simple extensions of the brain. We have included reviews that update on the current state of spinal oncology and on areas of unmet need for basic science research, translational research, and clinical management to improve treatment outcomes. This set of articles will review the full spectrum of benign, malignant, and metastatic tumors. Firstly, we will explore the neuropathological features and diagnostic criteria of spinal tumors with an emphasis on molecular biomarkers. The field of neuropathology has been rapidly changing with the integration of molecular signatures into the diagnostic criteria, and we will explore how this dynamic evolution will impact the diagnosis and classification of spinal tumors. Second, we will explore the advances in imaging modalities and their role in diagnostics and therapeutics. Progress in imaging technology has led to more precise diagnosis and treatment by providing detailed visualization of tumor location, size, and surrounding neurological structures, aiding clinicians in minimally invasive interventions and enhancing postoperative monitoring for better patient outcomes. We will also explore the advances in treatment including the increasing and evolving role of radiation oncology and medical oncology. Third, we will examine some of the more common spinal tumors in depth and discuss the clinical nuances in diagnosis, management, prognosis, and future advances. Metastatic tumors are the most common spinal tumors in adults, representing over 98% of all tumors in the spine. In 2 separate articles, we will review the advances in surgical management, including minimally invasive separation surgery, and stereotactic body radiotherapy. The role of separation surgery has become more prominent, with a goal of partial surgical resection to alleviate direct spinal compression and make it safer for aggressive radiation therapy. Spinal metastasis is a complex pathology that requires the collaboration of a multi-disciplinary team to improve quality of life and prolong survival. It is important that we improve communication between the many subspecialties and involve spine surgeons early in the discussion of the management of patients with spinal metastasis. Spinal intradural tumors present a diverse array of neoplasms that can affect neurological function and require careful management for optimal outcomes. We will review what is new in spinal meningiomas and spinal nerve sheath tumors (neurofibromas, schwannomas, and malignant peripheral nerve sheath tumors). There have been significant advances in our understanding of tumor biology, which have led to promising targets for novel therapies. In this series of articles, we will explore the future of targeted therapies for this set of tumors. Finally, spinal intramedullary tumors pose unique and formidable challenges in diagnosis and treatment due to their intricate location and potential to impact neurological function. We will review the important diagnostic and management considerations in spinal astrocytomas and hemangioblastomas. In conclusion, we hope that this special issue will shed light on the complexities surrounding spinal tumors, from their diverse origins to the range of diagnostic and treatment modalities available to clinicians. More now than ever, the right management of spinal tumors requires a cohesive multidisciplinary approach that integrates the expertise from neurosurgery, orthopedic surgery, radiation oncology, medical oncology, and rehabilitation. While advancements in imaging and surgical innovations have improved outcomes, we still have a long path ahead. With this special issue, we hope to highlight the unique management dilemmas caused by spinal tumors and drive more dedicated research to understand spinal tumorigenesis and refine therapeutic interventions.

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