Recognition & Treatment of Malignant Spinal Cord Compression Study Day 11 th May 2017 Dr Bernie Foran Consultant Clinical Oncologist & Honorary Senior Lecturer Weston Park Hospital
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Recognition & Treatment of Malignant
Spinal Cord Compression Study Day
11th May 2017 Dr Bernie Foran
Consultant Clinical Oncologist & Honorary Senior Lecturer
Weston Park Hospital
Outline of Talk
Clinical case
Non Surgical Treatments
Outcomes
Clinical Case
70yr old man
Fit and well, No PMH
Hobbies – golf, guitar
7/52 - worsening mid thoracic pain
Right hand weakness
Night pain
MRI 22 03 17
Summary
Multiple spinal mets
Cord compression at T2 –
no signal change
Patient transferred to A&E
Patient needs body CT
scan
Clinical Case
CT body
Looks like lymphoma
Commenced dexamethasone
Biopsy from right axilla 23 03 17
Transferred to WPH 24 03 17
Commences RT 24 03 17
20Gy 5 fractions
Clinical Case
Clinical Case
Clinical Case
Biopsy result - 06 04 17
High grade B cell lymphoma
Seen by me in OPC – 06 04 17
No deterioration in condition
Referred on to Haematology DRI for further
management
Clinical Case
It is an
oncological emergency
Requires very prompt diagnosis & treatment to try and prevent
catastrophic consequences of paralysis & incontinence
Treatment
Until spinal stability is confirmed patients should be managed on bed
rest
BUT wherever possible keep the patient moving
Treatment Objectives
• Pain control
• Avoidance of complications
• Preserve or improve neurological function
Treatment options include:
1. Steroids & gastric protection
2. Analgesia
3. Surgery – decompression & stabilisation
of the spine
4. Radiotherapy
5. Chemotherapy
6. Hormonal manipulation
WPH Reducing regimen for
Spinal Cord Compression
Day Dexamethasone
daily dose
Administration
1-3 16mg 16mg OM or 8mg BD
(8am & 12noon)
4-6 8mg 8mg OM
7-9 4mg 4mg OM
10-12 2mg 2mg OM
13 Discontinue
• While the patient is on steroids commence PPI (e.g. Lansoprazole) for
gastric protection.
• A slower reducing regimen may be required for patients who have
received previous courses of steroids.
X-ray treatment
Strong electromagnetic waves carrying high amounts of energy
– 1000 times more energy than standard diagnostic X rays
– energy is deposited in the water inside the cells
free radicals (DNA damage)
Damage to normal cells
side-effects of RT
Normal cells can repair if tolerance not
exceeded
Radiotherapy
Radiotherapy
Urgent access 24/7
Dose & schedule
Depends on neurological deficit, PS,
previous treatment & cancer features
Single dose V multi dose (fractionated)
typically 8-20Gy in 1-5 fractions
SCORAD trial – awaiting results
Radiotherapy
Radiotherapy
Pre operatively – no
Post operatively – routinely
Definitive – all pts unsuitable for surgery
Unless
Total paraplegia (>24hrs) & no pain
Very poor prognosis
Chemotherapy
Can be successful in chemosensitive tumours
– Hodgkin’s lymphoma
– Non-Hodgkin’s lymphoma
– Neuroblastoma
– Germ cell
– Breast cancer (hormonal manipulation)
– Prostate cancer (hormonal manipulation)
Other considerations
1. Bed rest V mobilisation
Rehabilitation
Braces & collars
2. Psychological issues
3. Urinary catheter
4. Bowel function
5. Nutrition
6. Discharge issues
Anticoagulation
Cancer is a hypercoaguable state
synergistic effect with chemo
High burden of tumour in metastatic disease
Value in prophylaxis against venous
thromboembolism
If patient not mobile
– s/c low molecular weight heparin +/-
compression devices
– Follow hospital guidelines
Constipation Factors
– Autonomic dysfunction
– Limited mobility
– Opiate analgesic
Risk of perforation
– Masked by corticosteroids
Bowel regimen needed
Prognosis
Median survival with MSCC is 6 months
Ambulatory patients with radiosensitive tumours have the best prognosis
– Likely to remain mobile
Sorensen, PS, Borgesen, SE, Rohde, K, et al. Metastatic epidural spinal cord compression. Results of treatment and survival. Cancer 1990; 65:1502.
MSCC is a poor prognostic indicator in cancer patients
Need better detection rates
Number of days survival
following admission with
spinal cord compression
Data from WPH audit
Number of days from admission with spinal cord compression to death
Range = 2 days to 319 days
Mean = 58.6 days
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