Post on 17-Jan-2018
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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?