Recognition & Treatment of Malignant Spinal Cord Compression Study Day

Transcription

1 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

2 Outline of Talk Clinical case Non Surgical Treatments Outcomes

3 Clinical Case 70yr old man Fit and well, No PMH Hobbies golf, guitar 7/52 - worsening mid thoracic pain Right hand weakness Night pain

4 Clinical Case MRI Summary Multiple spinal mets Cord compression at T2 no signal change Patient transferred to A&E Patient needs body CT scan

5 CT body

6 Clinical Case Looks like lymphoma Commenced dexamethasone Biopsy from right axilla Transferred to WPH Commences RT Gy 5 fractions

7 Clinical Case

8 Clinical Case

9 Clinical Case Biopsy result High grade B cell lymphoma Seen by me in OPC No deterioration in condition Referred on to Haematology DRI for further management

10 It is an oncological emergency Requires very prompt diagnosis & treatment to try and prevent catastrophic consequences of paralysis & incontinence

11 Treatment Until spinal stability is confirmed patients should be managed on bed rest BUT wherever possible keep the patient moving

12 Treatment Objectives Pain control Avoidance of complications Preserve or improve neurological function

13 Treatment options include: 1. Steroids & gastric protection 2. Analgesia 3. Surgery decompression & stabilisation of the spine 4. Radiotherapy 5. Chemotherapy 6. Hormonal manipulation

14 WPH Reducing regimen for Spinal Cord Compression Day Dexamethasone daily dose Administration mg 16mg OM or 8mg BD (8am & 12noon) 4-6 8mg 8mg OM 7-9 4mg 4mg OM mg 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.

15 Radiotherapy 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 Damage to normal cells free radicals (DNA damage) side-effects of RT Normal cells can repair if tolerance not exceeded

16 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

17 Radiotherapy

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19 Radiotherapy Pre operatively no Post operatively routinely Definitive all pts unsuitable for surgery Unless Total paraplegia (>24hrs) & no pain Very poor prognosis

20 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)

21 Other considerations 1. Bed rest V mobilisation Rehabilitation Braces & collars 2. Psychological issues 3. Urinary catheter 4. Bowel function 5. Nutrition 6. Discharge issues

22 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

23 Factors Constipation Autonomic dysfunction Limited mobility Opiate analgesic Risk of perforation Masked by corticosteroids Bowel regimen needed

24 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

25 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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