MALIGNANT SPINAL CORD

COMPRESSION

MANAGEMENT

The Facts

Incidence is variable More common in breast, lung cancer

and multiple myeloma May occur in patient with known

diagnosis of malignancy May be first presenting feature of

malignancy Initial management very important

The Facts

May occur in Hodgkins, NHL, Plasmacytoma, Spinal Cord Glioma

May represent curable, localised disease in the above

Case 1

45 years female Previous right breast cancer 8 years ago 3 month history of mid lumbar back pain

Key Symptoms

Pain – localised, severe, unremitting, escalating, positional, worsened by coughing/sneezing

Power loss Paraesthesiae Sphincter disturbance

Key Symptoms

Pain may be the only symptom

Case 1

What signs would you look for?

Key Signs

THERE MAY BE NONE APART FROM PAIN ON MOVEMENT

Power loss Sensory level Saddle anaesthesia Reduced anal tone Distended abdomen Urinary retention

Management

Diagnosis Treatment Rehabilitation Ongoing Care

Case 1

What are the key features in the history?

Diagnosis - History

PAIN on background of known previous or current malignancy

Pain with no previous history of malignancy but with other suspicious symptoms/signs

Power loss Sensory disturbance Sphincter disturbance

Diagnosis - Examination

Pain on movement Motor dysfunction Sensory abnormalities/sensory level Reflexes Sphincter tone Distended abdomen Urinary retention

Diagnosis - Examination

General clinical examination Breast examination Chest signs Palpable adenopathy

Case 1

How would you investigate further ?

Diagnosis - Investigations Plain radiology – CXR and spinal X rays MRI spine CT Bone scan (Histology) FBC, ESR Biochem – bone, Ca, Igs/PPE

Diagnosis - Histology

Crucial in all new cases Some patients with SCC are curable

Case 1

What do you look for in the MRI report or better still, what do you ask when you discuss with the radiologist?

Diagnosis - Radiology

Beware of reports stating “ no SCC ” when clinical suspicion is to the contrary

Loss of vertebral height Soft tissue mass Angulation Subluxation Cord/nerve root impingement Meningeal disease

Case 1

SCC at L3 No other spinal metastases Slight angulation of spine and degree of

anterior subluxation No other disease on CT How do you proceed?

Treatment

Discuss with Oncologist and/or Neurosurgeon at earliest possible opportunity

Commence Dexamethasone 16mg daily with gastric protection

Lie “ flat “ Laxatives/catheter ANALGESIA Bone scan

Treatment

Role of neurosurgery – isolated lesion, unstable spine with low volume disease

Always discuss if in doubt

Treatment - Radiotherapy Generally palliative May be curative Provides pain relief also Fractionated from 1 to 5 weeks May cause nausea, diarrhoea, sore

throat depending on level being treated

Treatment - Chemotherapy NHL, Hodgins disease, Multiple

Myeloma, SCLC May be used in other solid tumours

where site already irradiated

Case 1

Describe the roles of rehab and ongoing care in this case

Rehabilitation

Crucial role to play Should begin early, pain permitting Physio prevents muscle wasting and

assists improving power Physio improves morale OT important particularly for those

patients returning home

Ongoing Care

Rehab care Gradual tailing off of steroids Specific anti cancer therapies Bisphosphonates Analgesia Bowel and bladder care

Neutropenia

NEUTROPENIC SEPSIS

Neutropenia

Neutropenic Sepsis

FactsIncidence is variable in patients receiving

chemotherapyAffects adjuvant and palliative patientsPotentially life threatening medical

emergencyOccurs within 1 to 3 weeks of

chemotherapy*

Case 153 years femaleGP requests assessment in A and EReceiving adjuvant chemo for breast

cancer10 days post chemoNon specific malaise for 5 daysAfebrileNot acutely unwell

PresentationFebrile neutropeniaAfebrile malaise with stomatitis and non

specific symptomsPlease listen to patient and GP

DefinitionNeutrophils <0.5 or <1 and fallingPyrexia greater/same as 38 C on 2

occasions or 38.5 C on one occasion or hypothermia < 36 C

Clinically unwell

Case 1Define cardinal features of neutropenic

sepsis

Clinical FeaturesTemp as describedMay be afebrileHypothermia is a serious signMalaiseFever, sweats, chillsTachypnoea > 20/minTachycardia >90bpmHypotensiveMay appear well perfused even if

hypotensive

Be awareSepsis may occur with normal neutrophils

in immunocompromised patientsSteroids may mask symptoms of sepsisHypotension may be due to

antihypertensives

Case 1Patient has temp of 37.8NormotensivePulse 100Neutrophils 0.1How do you manage her?

Case 2Patient has temp 37.6ClammyHypotensive BP 80/65Tachycardia 130O2 sats 94%Neutrophils 0.01How do you manage her?

ManagementGeneral clinical examCheck mouthChest examCheck Hickman line site if presentSkin lesions eg. herpetic, unhealed woundsPerianal area eg. fissures, haemarrhoidsArrange CXR

ManagementIV access and fluidsCommence O2FBCU and E, LFT, Ca, CRP, glucoseCoag screenBlood culturesMSSU, sputum if possible, swab Hickman lineCommence IV Tazocin 4.5g 6 hourly and IV

Gentamicin as per nomogramIf Penicillin allergy, commence IV Vancomycin as per

nomogram plus Gentamicin and CiprofloxacinDiscuss with microbiology if in doubt or for advice

ManagementContinue to monitor vital signsFluid balance chartCatheter for urinary outputConsider repeat FBC, coag, renal function in

sick patientMonitor Gentamicin / Vancomycin levelsMonitor haematology and biochemistry

dailyCommence GCSF in sick or unstable

patients

ManagementIf neutropenic sepsis in spite of

Ciprofloxacin prophylaxis, give Vancomycin and Gentamicin

Vancomycin in suspected line sepsis and remove line

Clarithromycin if suspected atypical pneumonia

Fluconazole in suspected fungaemia

Case 2Patient has dry coughFine bi basal cracklesO2 94% on air ( non smoker )CXR shows ground glass appearance and

reticular shadowingHow would you proceed?What are your thoughts?Receiving palliative chemotherapy for

metastatic breast cancer

Case 2HRCTRespiratory opinionBALCommence Septin and Prednisolone whilst

awaiting results of BALConsider adding in Fluconazole alsoTazocin and GentamicinClarithromycinConsider HDU transfer for assisted

ventilation if necessary

GCSFMay not prevent sepsisHave a low threshold for using in patients

admitted with sepsis particulary if profoundly neutropenic or unwell

PreventionGrowth factors given prophylactically

reduce but do not eliminate the riskDrug dose modificationOral hygieneEducation

SVCO

MechanismSVC compression by right upper lobe

tumour

SVC compression by mediastinal adenopathy ( usually right paratracheal or pre carinal )

Case 163 years male, ex smoker of 5 years3 month history of cough and weight loss2 weeks of neck swellingWhat other clinical features might you look

for?What other symptoms might he describe?

Clinical SignsDistended neck veinsDistended chest wall veinsVenous collateralsFacial swelling/Plethoric/conjunctival

injectionArm swelling (uni and bilateral)Cyanosis in more advanced casesHypoxic in more advanced cases

SymptomsDyspnoeaHeadacheSensation of facial fullness worse on

coughing and stooping

Causes of SVCOWhat malignant causes might you

consider?Any other causes?

Malignant causesLung cancer ( both SCLC and NSCLC )NHLHodgkins diseaseMetastatic disease ( eg. breast )MesotheliomaThymoma

Non malignant causesSVC thrombosis secondary to central line or

as a consequence of extrinsic compression

Assessment of the patientWhat does this involve ?

Assessment of the patientFull history including oncology history if

existsAssessment of severity of SVCOGeneral clinical exam ( palpable

adenopathy )CXRDiscuss with on call oncology teamDiscuss with respiratory physicians if first

presentation and CXR suspicious of primary lung lesion

Meanwhile organise CT CAP

ImagingWhat do you look for on CT?

ImagingMediastinal massRight upper lobe mass/diseaseAssociated thrombusCollateralsAssociated tracheal/main airway

compression

Assessment of patientIf no previous oncology history and imaging

suggestive of lung primary, arrange bronchoscopy+/- mediastinoscopy

If no previous oncology history and imaging suggestive of malignancy, ?origin, discuss with oncology and cardiothoracics, re mediastinoscopy.

If imaging, age and history suggestive of lymphoma/Hodgkins, discuss with Haem

Biopsy /FNA of palpable nodes

Management of patientHow do you manage?

Management of patientManage as you investigateOxygenSteroids – Dexamethasone 16 mg daily

with gastric protectionConsider SVC stent insertion +/-

thrombolysis to buy time whilst awaiting tissue diagnosis

Specific treatmentWhat tumours are chemosensitive?

Chemosensitive tumoursSCLCNHLHodgkins diseaseThymomaBreast, colon and others some extent

Potentially curable tumoursWhat are they?

Potentally curable tumoursNHLHodgkins Disease??? SCLCThymoma

RadiotherapyGenerally palliative but may effect good

relief of signs and symptoms

Cannot be repeated

Recurrent SVCOConsider chemotherapy depending on

tumour typeConsider SVC stentConsider anticoagulation