Metastatic Spinal Cord Compression

Transcription

1 Metastatic Spinal Cord Compression Dr Zacharias Tasigiannopoulos Clinical Oncologist Colney centre Department of Oncology Norwich, UK

2 Introduction 2-5% of cancer patients have an episode of MSCC Initial presentation in 8% cancer patients, sometimes of unknown primary 10% of patients diagnosed with MSCC may have a second episode

3 Modes of compression Diagram from Cancer and its Management Souhami & Tobias

4 Location 60-80% thoracic* 15-30% lumbosacral <10% cervical Up to 50% have > 1 area involved *Due to natural kyphosis and the spinal cord occupying most of the intrathecal cross section

5 First symptom Pain 95% Weakness 5% Ataxia 1% Sensory loss 1%

6 Pain May be mild to begin with Lasts for more than 1-2 weeks Pain may feel like a 'band' around the chest or abdomen (radicular) Can radiate over the lower back, into the buttocks or legs

7 Motor weakness Weakness: 60-85% Tends to be symmetrical Severity greatest with thoracic mets At or above conus medularis Extensors of the upper extremities Above the thoracic spine Weakness from corticospinal dysfunction Affects flexors in the lower extremities Patients may be hyper reflexic below the lesion and have extensor plantars Greenberg, HS, Kim, JH, Posner, JB. Epidural spinal cord compression from metastatic tumor: Results with a new treatment protocol. Ann Neurol 1980; 8:361.

8 Sensory disturbance Less common than motor findings Still present in majority of cases Ascending numbness and paraesthesias Feeling unsteady on feet, having difficulty with walking, or legs giving way Numbness or 'pins and needles' in toes and fingers or over the buttocks Sensory level Saddle anaesthesia

9 Sphincter function Loss of function is late finding Problems passing urine may include difficulty controlling bladder function passing very little urine or passing none at all Constipation or problems controlling bowels Autonomic neuropathy presents usually as urinary retention Rarely sole finding

10 Impending cord compression is an oncological emergency - it may be too late if its established Need to diagnose before neurology alerts you Be alert to radicular back pain Don t wait for sensory level Low threshold for MRI Outcome related to walking at time of treatment

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12 (Impending) cord compression on current imaging - refer for advice Imaging essential to define level MRI ideal If found on CT etc - that is fine If in doubt - phone We might treat without an MRI scan

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14 Treatment of MSCC Steroids Steroids improve functional outcome with RT* No agreement on optimal dose/schedule More complications with higher doses Use 16 mg dexamethasone/24 hours (8mg bd) Continue during RT then taper rapidly (< 2/52) Eg. 8 mg od 3/7, 4 mg od 3/7, 2 mg od 3/7, stop? * Sorensen et al Eur J Cancer 1994; 30A:22-27

15 Steroid side effects GI ulcers / bleeding / perforation Psychosis Osteoporosis / fractures Proximal myopathy Skin thinning / ulcers Diabetes

16 Reducing Steroid regimen for Day Spinal Cord Compression Dexamethasone daily dose Administration mg 16mg OD or 8mg BD (8am & 12noon) 4-6 8mg 8mg OD 7-9 4mg 4mg OD mg 2mg OD 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.

17 Treatment of MSCC Surgery + RT vs RT alone Patchell et al Proc Am Soc Clin Oncol 21:1, 2003 (abstr 2) Regine WF, Tibbs PA, Young A, et al. Int J Radiat Oncol Biol Phys 2003; 57 (suppl 2): S125 Randomised trial Decompressive surgery + RT vs RT alone 30 Gy in 10# both arms 101 patients (terminated at 50% accrual) Median ambulation 126 v 35 days (p=0.006) 3/16 (19%) v 9/16 (58%) paraparetic pts regained ambulation Better pain control Trend toward better survival with surgery (p=0.08)

18 RT is the treatment of choice for some cord compressions but oncologists need to think of spinal surgery first

19 ECOG (WHO) PS 0 Fully active and able to carry out pre-disease activities without restriction 1 Restricted in strenuous activity but ambulatory and able to carry out light work 2 Ambulatory and self-caring, but unable to do light work. Up and about more than 50% of the time 3 Limited self care. In bed for more than 50% of the time 4 Unable to self care. Confined to bed or chair

20 Prognosis? Two best predictors probably History of the cancer in that patient Nick factor - from the end of the bed

21 Oligometastases A few metastases - <5? May be picked up much earlier than in the past with new imaging eg PET-CT Stage migration - everyone a winner Means we are seeing a different population with metastatic disease who need innovative approaches

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23 Prognosis Good: ambulatory, radiosensitive, 1 level of compression Not good: multiple levels, brain/liver mets, lung cancer, etc

24 Prognosis Median survival historically 3-6 months Recurrence occurs in 10-25% of patients Recurrence in 50% of 2 year survivors; nearly all 3-year survivors

25 Ambulation post RT Deficit before RT Ambulatory after RT Ambulatory 92% Assistance needed 65% Paraparetic 43% Paraplegic 14%

26 Radiotherapy Technical capabilities have advanced more than our biological knowledge Can put RT dose (not DXT) exactly where you want it

27 Radiotherapy for MSCC Palliative - often need to be quick and simple High dose per fraction as not so concerned about late effects eg 8/1, 20/5, 30/10 Solitary metastases?

28 Radiotherapy for MSCC No limit to radiation dose An excellent pain killer Can help preserve continence

29 Solitary metastasis

30 What does RT for MSCC entail? Move patient from bed to hard CT couch Scan (or simulate) Move patient back to bed 1hr calculation time Move patient from bed to hard Linac couch Align (5 min) Treat (2 min) Move patient back to bed

31 Need to know about your AOS No perfect patient selection tool - but patient selection is the most important decision Radiotherapy technically advanced, biologically limited but a good painkiller

32 The ideal pathway Patient with metastatic cancer knows of warning symptoms Warning symptoms spotted by patient - contacts coordinator MRI within a few days - shows cord comp Oncologist alerted - liases with spinal surgeon as appropriate RT starts that day within clinical trial (SCORAD) Remains an outpatient

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35 We can and do give out of hours RT but it takes some organising 8.30am - 8pm Mon-Fri On call Sat 9-5 On call Sun 9-1

36 We can give radiotherapy more than once Balance of potential benefits and risks May well be worth re-treatment RT is worth repeating if it worked before and you are likely to do more good than harm

37 Other considerations Bed rest V mobilisation Rehabilitation Braces & collars Psychological issues Urinary catheter Bowel function Nutrition Discharge issues

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

39 Anticoagulation High tumour burden Possible value in prophylaxis against VTE If patient not mobile subcutaneous low molecular weight heparin

40 Best Supportive Care Once neurological function lost, recovery unlikely. If disease elsewhere is advanced, may be appropriate not to treat actively. Steroids, physiotherapy, analgesia, good nursing care

41 Multidisciplinary care Rehabilitation Nursing care pressure sores Personal dignity - Lack of autonomy End stage of illness If discharge planned, OT/PT and SW input Keeping patient and family informed Financial assistance (DS1500) Gold Standards Framework