Management of malignant spinal cord compression

1. Management of Malignant Spinal
Cord Compression
Dr. Shreya Singh
JR – III
Department of Radiation Oncology
IMS, BHU

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. 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. 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
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5. Method of Spread
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6. Pathophysiology
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7. CAUSES
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8. 8

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
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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
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12. Types of Pain in Spine Metastsis
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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 :
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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. MRI
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16. MRI
MRI of epidural spinal cord compression
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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)
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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
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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. 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
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21. • Pain control
• Avoidance of complications
• Preserve or improve neurological function
• Provide adequate analgesia
Treatment Objectives
Patient should be kept on bed rest
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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
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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
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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.
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25. Surgery
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Patchell et al , The Lancet 2005

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
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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
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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)
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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
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31. Improvement in Motor Deficits
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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)
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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
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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
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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
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• 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. Role of Chemotherapy
May be useful in :
o Germ cell tumours
o Lymphomas
o Multiple myeloma
o Breast and prostate cancer (hormonal manipulation)
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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
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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
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40. Recurrence After Long Course RT
• Surgery if possible and indicated
• If surgery is not feasible, re-irradiation
with high precision
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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
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42. Assessment for Suitability for SBRT
• Patient factors
• Oncological factors
• Treatment factors
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43. Patient Factors
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44. Oncological Factors
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45. Treatment Factors
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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
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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
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49. Toxicity of Spine EBRT
• Pain flare
• Radiation induced VCF (vertebral compression
fracture)
• Radiation induced myelopathy
• Myelosuppression
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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
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