The Management of The Management of Malignant Spinal Cord Malignant Spinal Cord

CompressionCompressionDr H.K.LordDr H.K.Lord

Consultant Clinical Consultant Clinical OncologistOncologist

Aim – ambulatory patientsAim – ambulatory patients

IntroductionIntroduction 2-5% of cancer patients have an 2-5% of cancer patients have an

episode of SCCepisode of SCC Commoner in myeloma, prostate, lung Commoner in myeloma, prostate, lung

and breast cancer (15-20%)and breast cancer (15-20%) Initial presentation in 8% cancer Initial presentation in 8% cancer

patients, sometimes of unknown patients, sometimes of unknown primaryprimary

10% of patients diagnosed with SCC 10% of patients diagnosed with SCC may have a second episodemay have a second episode

PresentationPresentation Depends on level (77% in T spine) Depends on level (77% in T spine) (1)(1)

Radicular back pain in 85-95%Radicular back pain in 85-95%

Worsened by lying flat, weight Worsened by lying flat, weight bearing, coughing and sneezing, bearing, coughing and sneezing, relieved by sittingrelieved 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

PresentationPresentation Motor weaknessMotor weakness Sensory disturbanceSensory disturbance Sphincter disturbanceSphincter disturbance However localisation of pain poorly However localisation of pain poorly

correlates with site of disease – 16% correlates with site of disease – 16%

AetiologyAetiology3 routes3 routes::

Vertebral mets invading the epidural space, or Vertebral mets invading the epidural space, or causing bone destruction and fragments of bone causing bone destruction and fragments of bone compressing the cordcompressing the cord

Retroperitoneal tumours grow through the Retroperitoneal tumours grow through the intervertebral foraminaintervertebral foramina

Compression of blood supply to cord causing Compression of blood supply to cord causing ischemia and oedema and hence loss of functionischemia and oedema and hence loss of function

In the history - In the history - especially in a known especially in a known cancer patient.cancer patient.

MRI spine – urgentMRI spine – urgent

Referral to Oncology - urgentReferral to Oncology - urgent

DiagnosisDiagnosis

TreatmentTreatment Steroids – dexamethasone 16mg po with Steroids – dexamethasone 16mg po with

PPI or H2 antagonist – to reduce oedemaPPI or H2 antagonist – to reduce oedema

Thereafter:Thereafter:

Depends on histologyDepends on histology Depends on patient age Depends on patient age

performance statusperformance status and if disease is controlled and if disease is controlled

elsewhereelsewhere

OptionsOptions SurgerySurgery XRTXRT ChemoChemo BSCBSC

SurgerySurgery Anterior laminectomy – allows better Anterior laminectomy – allows better

removal of tumour and re-removal of tumour and re-construction of vertebral body construction of vertebral body

Suitable for patients who are fit for Suitable for patients who are fit for surgery, have unstable spine, or surgery, have unstable spine, or radio-resistant tumour, and disease radio-resistant tumour, and disease at only one level, with disease at only one level, with disease elsewhere either absent or controlledelsewhere either absent or controlled

Surgery + XRT Surgery + XRT (1)(1)

Trial 2005: surgery + radiotherapy (XRT) Trial 2005: surgery + radiotherapy (XRT) vs XRT alone. US, 7 centres, 101 pts.vs XRT alone. US, 7 centres, 101 pts.

Those receiving surgery + XRT vs XRTThose receiving surgery + XRT vs XRT– Able to walk: 84% vs 57%Able to walk: 84% vs 57%– Median time able to walk: 122 vs 13 daysMedian time able to walk: 122 vs 13 days– Continent: 156 vs 17 daysContinent: 156 vs 17 days– Regained ability to walk: (n= 32) 62% vs 19%Regained ability to walk: (n= 32) 62% vs 19%– Survival: 126 vs 100 daysSurvival: 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 aloneRadiotherapy alone Remains the majority, despite Remains the majority, despite

evidence aboveevidence above

In patients unfit for surgery; with In patients unfit for surgery; with multi-level disease; with disease multi-level disease; with disease elsewhere that may or may not be elsewhere that may or may not be controlled; with some residual controlled; with some residual neurological functionneurological function

RadiotherapyRadiotherapy Lack of randomised trials – literature Lack of randomised trials – literature

review only review only (1)(1)

20Gy in 5 # over 1 week20Gy in 5 # over 1 week Started as soon as is reasonably Started as soon as is reasonably

practicalpractical Direct field, prescribed to the depth Direct field, prescribed to the depth

of the cordof the cordRef: 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,

RadiotherapyRadiotherapy May use higher dose if post op or if May use higher dose if post op or if

only site of metastasis ( 30Gy in only site of metastasis ( 30Gy in 10#)10#)

If plasmacytoma, use radical dose of If plasmacytoma, use radical dose of 40Gy in 25#40Gy in 25#

Side effectsSide effects Exit dose: bowel: diarrhoea Exit dose: bowel: diarrhoea

oesophagus: odynophagia oesophagus: odynophagia

Skin reaction - mildSkin reaction - mild

OutcomesOutcomes No immediate benefitNo immediate benefit Some neurological improvement over Some neurological improvement over

following weeks; improved pain following weeks; improved pain control; or halting of further control; or halting of further deteriorationdeterioration

Glasgow study: 74% patients died Glasgow study: 74% patients died within 3 months of diagnosis within 3 months of diagnosis (1)(1)

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)

ChemotherapyChemotherapy Perhaps as follow up to initial Perhaps as follow up to initial

treatment but rarely as first line treatment but rarely as first line managementmanagement

e.g. in lymphoma or small cell lung e.g. in lymphoma or small cell lung cancer or teratomacancer or teratoma

Best Supportive CareBest Supportive Care Once neurological function lost, Once neurological function lost,

recovery unlikely.recovery unlikely.

If disease elsewhere is advanced, If disease elsewhere is advanced, may be appropriate not to treat may be appropriate not to treat actively.actively.

Steroids, physiotherapy, analgaesia, Steroids, physiotherapy, analgaesia, good nursing caregood nursing care

Multidisciplinary careMultidisciplinary care RehabilitationRehabilitation Nursing care – pressure sores; Nursing care – pressure sores;

thromboembolic disease; analgaesiathromboembolic disease; analgaesia Personal dignityPersonal dignity Lack of autonomyLack of autonomy End stage of illnessEnd stage of illness If discharge planned, OT, SW and PT If discharge planned, OT, SW and PT

inputinput

Multidisciplinary careMultidisciplinary care Keeping patient and family informedKeeping patient and family informed Financial assistance (DS1500)Financial assistance (DS1500)

PreventionPrevention Listen to patient history – early Listen to patient history – early

detectiondetection

If known to have bony metastases, If known to have bony metastases, role of bisphosphonates - prostate role of bisphosphonates - prostate and breast cancer patients and breast cancer patients (1)(1)

Early referral to OncologyEarly referral to Oncology1: J R Ross   Systematic review of role of bisphosphonates on skeletal morbidity in metastatic cancer BMJ  2003;327:469

Want our patients out walking, with Want our patients out walking, with the dog carrying the stick!the dog carrying the stick!

Thank youThank you Any questions?Any questions?