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The Management of Malignant Spinal Cord Compression. Dr H.K.Lord Consultant Clinical Oncologist. Aim – ambulatory patients. Introduction. 2-5% of cancer patients have an episode of SCC Commoner in myeloma, prostate, lung and breast cancer (15-20%)

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the management of malignant spinal cord compression

The Management of Malignant Spinal Cord Compression

Dr H.K.Lord

Consultant Clinical Oncologist

introduction
Introduction
  • 2-5% of cancer patients have an episode of SCC
  • Commoner in myeloma, prostate, lung and breast cancer (15-20%)
  • Initial presentation in 8% cancer patients, sometimes of unknown primary
  • 10% of patients diagnosed with SCC may have a second episode
presentation
Presentation
  • Depends on level (77% in T spine) (1)
  • Radicular back pain in 85-95%
  • Worsened by lying flat, weight bearing, coughing and sneezing, relieved by sitting

1. Levack P, Graham J, Collie D, Grant R, Kidd J, Kunkler I, Gibson A, Hurman D, McMillan N, Rampling R, Slider L, Statham P, Summers D (2001) A prospective audit of the diagnosis, management and outcome of malignant spinal cord compression. Clinical Resource and Audit Group (CRAG) 97/08

presentation1
Presentation
  • Motor weakness
  • Sensory disturbance
  • Sphincter disturbance
  • However localisation of pain poorly correlates with site of disease – 16%
aetiology
Aetiology

3 routes:

  • Vertebral mets invading the epidural space, or causing bone destruction and fragments of bone compressing the cord
  • Retroperitoneal tumours grow through the intervertebral foramina
  • Compression of blood supply to cord causing ischemia and oedema and hence loss of function
diagnosis
Diagnosis
  • In the history - especially in a known cancer patient.
  • MRI spine – urgent
  • Referral to Oncology - urgent
treatment
Treatment
  • Steroids – dexamethasone 16mg po with PPI or H2 antagonist – to reduce oedema

Thereafter:

  • Depends on histology
  • Depends on patient age

performance status

and if disease is controlled elsewhere

options
Options
  • Surgery
  • XRT
  • Chemo
  • BSC
surgery
Surgery
  • Anterior laminectomy – allows better removal of tumour and re-construction of vertebral body
  • Suitable for patients who are fit for surgery, have unstable spine, or radio-resistant tumour, and disease at only one level, with disease elsewhere either absent or controlled
surgery xrt 1
Surgery + XRT (1)
  • Trial 2005: surgery + radiotherapy (XRT) vs XRT alone. US, 7 centres, 101 pts.
  • Those receiving surgery + XRT vs XRT
    • Able to walk: 84% vs 57%
    • Median time able to walk: 122 vs 13 days
    • Continent: 156 vs 17 days
    • Regained ability to walk: (n= 32) 62% vs 19%
    • Survival: 126 vs 100 days

Ref: 1. Patchell 2005 Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer a randomised trial” Lancet 366(9986): 643-8

radiotherapy alone
Radiotherapy alone
  • Remains the majority, despite evidence above
  • In patients unfit for surgery; with multi-level disease; with disease elsewhere that may or may not be controlled; with some residual neurological function
radiotherapy
Radiotherapy
  • Lack of randomised trials – literature review only (1)
  • 20Gy in 5 # over 1 week
  • Started as soon as is reasonably practical
  • Direct field, prescribed to the depth of the cord

Ref: 1. Emergency treatment of malignant extradural spinal cord compression: an evidence-based guideline DA Loblaw and NJ Laperriere Journal of Clinical Oncology, Vol 16, 1613-1624,

radiotherapy1
Radiotherapy
  • May use higher dose if post op or if only site of metastasis ( 30Gy in 10#)
  • If plasmacytoma, use radical dose of 40Gy in 25#
side effects
Side effects
  • Exit dose: bowel: diarrhoea oesophagus: odynophagia
  • Skin reaction - mild
outcomes
Outcomes
  • No immediate benefit
  • Some neurological improvement over following weeks; improved pain control; or halting of further deterioration
  • Glasgow study: 74% patients died within 3 months of diagnosis (1)
  • A McLinton and C Hutchison Malignant spinal cord compression: a retrospective audit of clinical
  • practice at a UK regional cancer centre British Journal of Cancer (2006)
chemotherapy
Chemotherapy
  • Perhaps as follow up to initial treatment but rarely as first line management
  • e.g. in lymphoma or small cell lung cancer or teratoma
best supportive care
Best Supportive Care
  • Once neurological function lost, recovery unlikely.
  • If disease elsewhere is advanced, may be appropriate not to treat actively.
  • Steroids, physiotherapy, analgaesia, good nursing care
multidisciplinary care
Multidisciplinary care
  • Rehabilitation
  • Nursing care – pressure sores; thromboembolic disease; analgaesia
  • Personal dignity
  • Lack of autonomy
  • End stage of illness
  • If discharge planned, OT, SW and PT input
multidisciplinary care1
Multidisciplinary care
  • Keeping patient and family informed
  • Financial assistance (DS1500)
prevention
Prevention
  • Listen to patient history – early detection
  • If known to have bony metastases, role of bisphosphonates - prostate and breast cancer patients (1)
  • Early referral to Oncology

1: J R Ross   Systematic review of role of bisphosphonates on skeletal morbidity in metastatic cancer

BMJ  2003;327:469

thank you
Thank you
  • Any questions?