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%) Initial presentation in 8% cancer patients, sometimes of unknown primary 10% of patients diagnosed with SCC may have a second episode

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

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

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

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 Surgery XRT Chemo BSC

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) 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 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 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,

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 Exit dose: bowel: diarrhoea oesophagus: odynophagia Skin reaction - mild

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 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 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 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 care Keeping patient and family informed Financial assistance (DS1500)

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

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

Thank you Any questions?