Timothy Ryken, MD
Department of Neurosurgery
University of Iowa Hospitals and Clinics

First Published: September 2000
Last Revised: march 2004
Peer Review Status: Internally Peer Reviewed

On a recent myelogram it noted a 5-6 mm sclerotic focus in the right side of L3 vertebral body, consistent with bone island...what does that mean?

While I can't say for certain, this sounds as though it represents a benign reactive process occurring in the bone of the spine at that level. I think it is always wise to review findings and radiology reports with the physician who ordered the study but this does not sound very concerning as described.

Is radiation the final step in the treatment of brain cancer?

Radiation is certainly a mainstay of brain tumor treatment and can be given in a variety of fashions. Standard brain tumor radiation would be given in small doses over typically two to six weeks. For any tumor judged to be growing aggressively, radiation will be a good choice. At the University of Iowa and at other major universities, an extensive effort is under way to examine the role of more focused radiation and how it can best be incorporated into the treatment pattern. You may have encountered the terms "gamma knife" or "cyber knife." These are various types of radiation delivery machines designed to focus radiation in a discrete location. The results utilizing these newer technologies are very encouraging. With that background, I would answer your question by saying the role of radiation is a central part of most brain tumor therapies and can be incorporated at various stages.

could this reactive process be a result of trauma?

This question relates back to the sclerotic lesion noted on a x-ray report. Based on the report as described, a sclerotic area in bone could be the result of a natural aging process as well as from a variety of traumatic insults. It is difficult for me to comment further. If there are specific concerns, I certainly encourage you to review your x-rays with your physician.

What is the most commonly used treatment for brain and spinal tumors? Is surgery the first step in both?

That is a good question. The initial step in starting treatment for any tumor is obtaining a correct diagnosis. This applies to brain and spinal tumors as well as tumors anywhere in the body. If the patient is known to have metastatic cancer, it is not always necessary to re-biopsy before initiating other treatment. However, almost always, as an initial step, a portion of tissue will need to be obtained in order to guide appropriate therapy.

Bone scan showed abnormal uptake at L3. could that be a result of natural aging?

A bone scan, as they may have explained to you, is a process which typically identifies areas of increased cell metabolism, so they can be nonspecific and need to be interpreted in the setting of all other clinical information. I have had a number of patients with positive bone scans who have had no evidence of tumor in the spinal bones but have had evidence of "wear and tear" disease throughout the spine. I would agree that a positive bone scan coupled with abnormal x-rays would raise concern for an ongoing process but to try and predict what that process is would require additional evaluation.

Are all spinal tumors a sign of cancer or that cancer is inevitable...?

There are many different types of spinal tumors. One category is related to tumors that involve the spinal bones and a second broad category involves tumors of the spinal cord and its coverings. There are many spinal tumors that are not aggressive in their growth potential but still cause problems because of their mass and location. So, spinal tumors are not necessarily a sign of metastatic cancer. In the strictest sense, all tumors can be considered a form of cancer as they are abnormal collections of cells. Many of the spinal tumors are easily treated with surgical resection alone and require no additional therapy. A metastatic tumor that has spread to the spine often is difficult to remove surgically and nearly always requires radiation therapy.

What about new ways of diagnosing brain tumors?

The processing of diagnosing primary brain tumors is based on examining the tissue within the tumor under a microscope. This system relies substantially on the ability of the pathologist to recognize cellular patterns. It also has remained essentially unchanged since the 1950's. One exciting field of study in all oncology is attempting to isolate the genes that are active in these tumors and reclassify the tumors based on these more sophisticated tests. This is currently being done in a variety of tumors, most notably the subgroup called oligodendroglioma. I would predict that in the next five years, we will see a substantial change in the way these tumors are classified.

The therapy of brain tumors and spinal tumors is changing rapidly. We see advancements in surgery, radiation and chemotherapy on a month-by-month basis. While many of the more aggressive tumors continue to have a poor survival rate, we are encouraged by the advances in treatments of tumors showing improved response to stereotactic radiosurgery, as well as new chemotherapy agents. The biggest challenge from the patient's standpoint is deciding what is the best treatment for them individually. I believe all patients with malignant tumors should strongly consider entering clinical studies to try and answer questions about what treatment is best. This also allows patients access to medications and treatments that may not be available for many years. It is estimated that less than 5 percent of all cancer patients are enrolled in any type of clinical trial. This is disappointing and remains a significant challenge for all physicians treating these unfortunate patients. Better education and better information about the opportunities in clinical trials will hopefully turn this trend around for the benefit of everyone.