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Management of malignant spinal cord compression

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Management of malignant spinal cord compression

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Management of malignant spinal cord compression

  1. 1. Management of Malignant Spinal Cord Compression Dr. Shreya Singh JR – III Department of Radiation Oncology IMS, BHU
  2. 2. Malignant Spinal Cord Compression (MSCC) • Occurs when cancer cells grow in/near to spine and press on the spinal cord & nerves • Results in swelling & reduction in the blood supply to the spinal cord & nerve roots • The symptoms are caused by the increasing pressure (compression) on the spinal cord & nerves 2
  3. 3. Epidemiology • Affects 5-10% of the cancer patients (ByrneTN , N Eng J Med,1992) • 20 % patients lack a history of cancer (Bach et al ,Acta Neurochir (Wien) 1990 ) % of MSCC Primary Site 25% Lung 16% Prostate 11% Multiple Myeloma 7% Breast (Prasad et al, LancetOncology , 2005) 3
  4. 4. Method of Spread Primarily develops in one of four ways : o Continued growth and expansion of vertebral bone mets into epidural space o Neural foramina extension by any paraspinal mass o Destruction of vertebral cortical bone, causing vertebral body collapse with displacement of bony fragments into the epidural space o Rarely primary hematogenous seeding to the epidural space 4
  5. 5. Method of Spread 5
  6. 6. Pathophysiology 6
  7. 7. CAUSES 7
  8. 8. 8
  9. 9. Spinal Cord Metastasis o Epidural type of compression o Throacic spine is most common site of involvment o Lumbar and Sacral spine – Prostate and ovarian o Synchronous, multifocal lesions may be present o MRI is the standard modality for imaging 9
  10. 10. 10
  11. 11. Clinical Features o Common symptoms in decreasing order of frequency :  Back pain (70-90%) – precedes neurologic deficits by 7 weeks  Motor deficits (60-90%)  Sensory deficits (45-90%)  Autonomic dysfunction (40-75%) o Pain is aggravated by lying down o New onset back pain in cancer patients : RED FLAG SIGN o Oncological emergency - Requires very prompt diagnosis & treatment to try and prevent catastrophic consequences of paralysis & incontinence 11
  12. 12. Types of Pain in Spine Metastsis 12
  13. 13. • History of onset and progression • History of primary cancer stage and control • General assessment of patient’s health status • Examination – sensory, motor and autonomic symptoms • Rule out – herniated disc, trauma, osteoporosis, abscess • Imaging – whole spine • Blood chemistry – Hypercalcemia in extensive vertebral mets Workup : 13
  14. 14. MRI o Gadolinium enhanced MRI of whole spine is the investigation of choice provided there are no specific contra-indications o Sagittal T2 supplemented with axial T1 or T2 weighted scans o Detects paraspinous & intramedullary masses o Ensures that spinal cord compression at other levels is not missed and identifies metastases affecting asymptomatic vertebrae o Features : o Hypodense in T1 o Does not cross the adjacent disc space o Thecal sac indentation in T2 14
  15. 15. MRI 15
  16. 16. MRI MRI of epidural spinal cord compression 16
  17. 17. Other Imaging Modalities • Multi-slice CT scan – Quick and has the ability to image the whole spine less sensitive than MRI for detecting metastases may be needed to provide additional information on bone integrity and stability to help plan surgery • CT Myelography -  For patients with specific contraindication to MRI ( those who have a cardiac pacemaker or in whom there is already metal work in the spine which degrades MR image quality by metal artifact) 17
  18. 18. Other Imaging Modalities • PET-CT –  Both sensitive and specific in the diagnosis of MSCC  No evidence that PET-CT provides additional relevant information to MRI • Radioisotope bone scanning –  Very sensitive for the detection of metastases  Does not show the extent of soft tissue compression of the cord  Not reliable in detecting the level of cord compression • Plain radiology –  Not as sensitive for detecting metastatic bone disease as MRI and does not readily show soft tissue abnormalities 18
  19. 19. Grading - Bilsky MSCC grading scale o Grade 0 – • Only bony vertebral lesion o Grade 1 - • 1a : Grade 0 + Epidural extension • 1b : 1a + Thecal sac indentation • 1c : 1b + Touching cord o Grade 2 – • Grade 1+ SCC without blocking CSF o Grade 3 – • Grade 2 + Blockage of CSF flow Ref : Bilsky MH, Laufer I, Fourney DR, et al. Reliability analysis of the Epidural Spinal Cord Compression Scale. J Neurosurg Spine 2010;13(3):324–328 19
  20. 20. Prognostic Features • Rapidity of symptom onset • Radiosensitive histology – Multiple myeloma – Germ cell tumors – Small cell carcinoma • Pre-therapy ambulatory status • Status of primary disease • Performance status 20
  21. 21. • Pain control • Avoidance of complications • Preserve or improve neurological function • Provide adequate analgesia Treatment Objectives Patient should be kept on bed rest 21
  22. 22. Steps to be followed • Step 1 : Histologic diagnosis : necessary to get biopsy from the spinal cord lesion when the primary in unclear (unknown or lower stage tumour diagnosed long back) before starting radiotherapy/chemotherapy /steroids • Step 2 : Initiation of corticosteroids • Step 3 : Evaluate life expectancy, performance status and extent of disease to decide from the treatment options 22
  23. 23. Corticosteroids • Must be started as soon as possible in suspected case of MSCC, even before radiographic diagnosis • Decrease cord edema and serve as an effective bridge to definitive treatment • Very high doses of corticosteroids are associated with significant side effects – gastric ulcer, rectal bleeding, intestinal perforations 23
  24. 24. Dosage • Loading dose : 10 mg of IV dexamethasone • Maintenance dose : 4 to 6 mg every 6 to 8 hours before being tapered • Patients can be safely switched to an oral regimen after 24 to 48 hours because there is good oral bioavailability of corticosteroids • Patients should be started on a PPI for GI prophylaxis. 24
  25. 25. Surgery 25 Patchell et al , The Lancet 2005
  26. 26. Surgery CONCLUSION : Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer Patchell et al , The Lancet 2005 26
  27. 27. Indications for Surgery • KPS at least 40 • Unstable spine • At least 3 months life expectancy • Duration of paraplegia less than 24 hours • Intractable pain • Rapid progression in spite of RT • Unknown primary tumour • Relapse post RT • Relatively radioresistant cancer • Bony fragment impinging on cord 27
  28. 28. Surgical Procedure • Traditionally used posterior laminectomy is now obsolete due to high rate of complications • 360 degree decompression and concomitant stabilization done with modern techniques has best outcomes • Kyphoplasty or vertebroplasty are relatively contraindicated in MSCC (NCCN) 28
  29. 29. • Palliative radiotherapy has been the standard of care in the treatment of patients with MSCC • Although a total of 30 Gy in 10 fractions is the most frequently employed fractionation schedule, multiple fractionation schemes have been employed which include : – 37.5 Gy in 15# – 40 Gy in 20# – 30 Gy in 10# – 20 Gy in 5# – 8 Gy in 1# Radiotherapy 29
  30. 30. 30
  31. 31. Improvement in Motor Deficits 31
  32. 32. Long Course ( 10 x 3 Gy, 15 x 2.5 Gy, 20 x 2 Gy) vs Short Course RT (1 x 8 Gy, 5 x 4 Gy) 32
  33. 33. Conclusion • The five RT schedules provided similar functional outcome • The three more protracted schedules seemed to result in fewer in-field recurrences • Short course RT schedules are associated with more re-treatment rates because of high incidence of local recurrences along with requirement of higher dose of analgesics afterwards 33
  34. 34. Radiotherapy • For patients receiving radiotherapy for MSCC, 30 Gy in 10 fractions is considered the standard of care • Shorter fractionation schedules, such as 8 Gy × 1 or 4 Gy × 5 are reserved for those with clear evidence of progressive disease refractory to systemic therapy in whom survival expectations are poor 34
  35. 35. Radiotherapy • If patient has a good performance status, oligometastatic disease and controlled primary disease – consider for dose escalation beyond 30 Gy to achieve greater long-term gross tumor control while respecting dose constraints • Special techniques such as IMRT or fractionated SBRT should be considered to safely escalate the total dose 35
  36. 36. 36 • EBRT with Portal 8 cm wide • Direct posterior field • Prone position • Centered on spine • Extends one to two vertebral bodies above and below the lesion • Prescription depth : 3 cm- cervical spine – 3 cm Dorsal spine – 4 cm Lumbosacral spine – 5 to 6 cm RT Technique Cervical spine can be treated with two lateral parallel opposed fields to avoid unnecessary exit dose to oral cavity
  37. 37. Role of Chemotherapy May be useful in : o Germ cell tumours o Lymphomas o Multiple myeloma o Breast and prostate cancer (hormonal manipulation) 37
  38. 38. Paediatric MSCC • Primary disease - Neuroblastomas (commonest), Ewing’s sarcoma, Wilm’s tumour • Pathogenesis - Tumour extension to the epidural space through the neural foramina , so called “dumbell tumour” • Usually chemotherapy plays main role in treatment (French Society of Pediatric Oncology Protocol NBL-90) • Tumours rapidly progressing despite chemotherapy should be operated • RT is used for palliation when all modalities fail 38
  39. 39. Intramedullary Spinal Cord Metastasis (ISCM) • Most commonly secondary to a lung primary followed by breast cancer • Sensory deficits, sphincter dysfunction, and weakness are more common in ISCM • High incidence of synchronous brain metastasis • Corticosteroids as well as radiation therapy should be promptly initiated • Limited role of surgery due to high morbidity • Poor prognosis with median survival of 1 to 5.5 months 39
  40. 40. Recurrence After Long Course RT • Surgery if possible and indicated • If surgery is not feasible, re-irradiation with high precision 40
  41. 41. SBRT in MSCC • SBRT is effective in providing adequate local disease control in combination with surgery or as a sole treatment in carefully selected cases • It has become the preferred mode of treatment when complete local ablation of a metastatic lesion is indicated • It is currently being practiced as an alternative to conventional palliative radiation in primary treatment, re-irradiation, and in the postoperative setting at several centers 41
  42. 42. Assessment for Suitability for SBRT • Patient factors • Oncological factors • Treatment factors 42
  43. 43. Patient Factors 43
  44. 44. Oncological Factors 44
  45. 45. Treatment Factors 45
  46. 46. Dose De novo spine metastasis : o 18 to 24 Gy in 1 fraction o 24 Gy in 2 fractions o 30 Gy in 3 fractions Spine Re-irradiation : o 30 Gy in 4 fractions Post-op Spine RT : o 24 Gy in 2 fractions 46
  47. 47. Outcomes of SBRT • Acute toxicity is mild and very limited in spine SBRT with 5% or less reported rates of severe and undesirable (grade 3 or higher) adverse events • Complications of radiation-induced myelopathy are extremely rare with SBRT • Doses ≥ 20 Gy per fraction must be used with great caution as they are associated with significantly higher risks of VCF 47
  48. 48. 48
  49. 49. Toxicity of Spine EBRT • Pain flare • Radiation induced VCF (vertebral compression fracture) • Radiation induced myelopathy • Myelosuppression 49
  50. 50. Supportive Care and Rehabilitation • Braces and collars for support • Paraplegic patients - thigh length compression stockings • If treated by surgery - high risk of thromboembolism. So, LMWH should be used prophylactically (Dose :Enoxaparin 40 mg S.C. OD) • Paraplegic patients should be provided with air mattresses or cushions with every 2-3 hourly posture changing to prevent decubitus ulcer • Catheterization of urinary bladder for bladder dysfunction • Judicious use of laxatives for constipation • Psychological support 50
  51. 51. 52
  • yashkirandhillon

    Jun. 18, 2021
  • ShreyaSingh396

    Feb. 11, 2021
  • SAFEEDAK

    Jan. 13, 2021

Management of malignant spinal cord compression

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