1. The Management of Malignant Spinal Cord Compression
Dr H.K.Lord
Consultant Clinical Oncologist

3. Aim – ambulatory patients

4. 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

5. 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

6. Presentation Motor weakness Sensory disturbance Sphincter disturbance
However localisation of pain poorly correlates with site of disease – 16%

8. 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

10. Diagnosis In the history - especially in a known cancer patient.
MRI spine – urgent
Referral to Oncology - urgent

11. 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

12. Options
Surgery
XRT
Chemo
BSC

13. 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

14. 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

15. 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

16. 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, ,

17. 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#

18. Side effects Exit dose: bowel: diarrhoea oesophagus: odynophagia
Skin reaction - mild

19. 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)

20. 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

21. 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

22. 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

23. Multidisciplinary care
Keeping patient and family informed
Financial assistance (DS1500)

24. 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

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

26. Thank you
Any questions?