J Pain Manage 2013;6(4):319-322 ISSN: 1939-5914 Nova Science Publishers, Inc. Spinal cord compression as a first presentation of cancer: A case report Nicholas Lao, BMSc(C), Michael Poon, MD(C), Marko Popovic, BHSc(C), Cheryl Yip, BMSc(C), and Edward Chow, MBBS Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada Abstract Bone metastases occur in up to 90% of patients with advanced breast or prostate cancer. Spinal cord compression (SCC) is an oncologic emergency and is considered a complication of bone metastases. If SCC is left untreated, it can result in a loss of feeling, motor control, and eventually paralysis. In most cases, cancer will be first diagnosed in early stages. We present the case of a 71 year-old male who, upon initial presentation, had a spinal cord compression and associated lower extremity weakness and gait difficulty. At this time, he had no prior history of cancer or confirmed tissue diagnosis of cancer. Keywords: Cancer, palliative radiotherapy, spinal cord compression Introduction Correspondence: Professor Edward Chow MBBS, MSc, PhD, FRCPC Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto ON, Canada. E-mail: Edward.Chow@sunnybrook.ca In 2011, there were 240,890 new diagnoses of prostate cancer with 33,720 deaths from the disease in the United States (1). Men with well-differentiated prostate cancer have an excellent prognosis, often surviving 10-20 years without intervention (1). Prostate cancer often presents with localized symptoms such as bladder outlet obstruction, but terminal stages can be associated with bone pain and weight loss (1). One of the most common sites of prostate cancer metastasis is the bone. Bone metastases can cause extreme pain and skeletal-related events (SRE) such as fracture and spinal cord compression (SCC) (2). Spinal cord compression is an unfortunate complication that results from extradural tumor growth along the spinal cord or vertebral collapse from tumour growth within the vertebrae (3). Metastatic epidural SCC occurs in 5-14% of cancer patients (4).
320 Nicholas Lao, Michael Poon, Marko Popovic et al. In the case of prostate cancer, men who are at risk are screened regularly using a prostate-specific antigen (PSA) test. If cancer is suspected, an ultrasound in addition to a biopsy may help confirm the diagnosis. The use of both of these tools increases the chance of detecting prostate cancer early. As a result of appropriate screening regimens, SCC is infrequently the first presentation of prostate cancer. However, even if not shown by a PSA test, patients may detect local symptoms of prostate cancer, including bladder outlet obstruction. In the rare case of an undetected cancer metastasizing to bone, bone pain is often the first symptom that triggers diagnosis of the underlying malignancy. In this report we present the case of a 71 year-old male with spinal cord compression as his first presentation of cancer. Subsequently, the patient started hormonal therapy for his prostate cancer. Case report A 71 year-old male was referred to the Rapid Response Radiotherapy Program (RRRP), Odette Cancer Centre at Sunnybrook Hospital. He presented on June 18, 2013 with lower extremity weakness and increased gait difficulty beginning roughly 24 hours prior to his visit. A MRI scan performed showed probable diffuse metastatic bone disease and cord compression at T3 (figures 1 and 2). However, the patient neither had a prior tissue diagnosis nor a prior history of cancer, which created a challenge in determining whether to radiate or not. However, given the impending risk of paralysis, an operative opinion was needed. As a result, the neurosurgeon was consulted and agreed to perform a surgical decompression of the spinal cord as well as retrieve a tissue diagnosis. The surgical decompression was performed the same day. The spinous processes were removed from T2, T3 and T4, and a laminectomy was performed at T3 and T4. Soft tissue specimens of the spinal cord compression were sent out for tissue analysis. The surgical pathology returned indicating that the tissue was positive for cancerous malignancy from a likely prostatic origin. The patient returned to the RRRP on July 15 for post-operative radiation therapy and received 20 Gy in five fractions to the T1-T5 thoracic area for palliative consolidation. Figure 1. Axial MRI of the spine showing mildly compressive right lateral pedicle epidural soft tissue at T3. Figure 2. MRI of the spine showing metastatic disease present from T3-T5 and mildly compressive right lateral pedicle epidural soft tissue at T3.
Case report 321 Discussion This case report was unique in that no symptoms of primary prostate cancer or bone metastases were experienced before the onset of SCC. In the case of prostate cancer, symptoms such as bladder outlet obstruction are common (1). When the cancer metastasizes to bone, bone pain is a common symptom that is usually treated using palliative radiotherapy. In the literature, there are few articles discussing patients who present with SCC as their first indication of cancer. In patients with prostate cancer, only one article outlined an approximate incidence of SCC as the first presentation of cancer (5). Iacovou et al. reported that, of 37 men who underwent laminectomy for SCC, 11 (29%) were previously undiagnosed with cancer (5). Patients with SCC often present with local or radicular pain, numbness and motor weakness in the lower extremities. Treatment of spinal cord compression in patients with prostate cancer has a relatively favourable clinical course compared to other types of tumours (3). Over 50% of patients see improvements in neurological symptoms with the median survival above 1 year (3). The keys to obtaining these results are rapid diagnosis and treatment. Treatment options include laminectomy to decompress the spinal cord followed by postoperative radiation therapy. However, radiation therapy alone can be administered directly to the site of SCC. Patchell et al performed a randomised trial exploring the effectiveness of each treatment regimen. Surgery followed by radiotherapy in selected patients was found to be significantly superior in survival time, continence, muscle strength, and functional ability. In some patients however, surgical decompression may not be an option. Patients with poor performance status may also not be suitable candidates for surgery. To provide tumour shrinkage and promote bone healing, multiple fraction treatment regimens may be given. Common schedules include 2000cGy in five fractions or 3000cGy in ten fractions. In a phase III randomized trial, Marazano et al. compared 16Gy in 2 weeks (short course) with 30Gy in 2 weeks (split course) radiotherapy regimens. They were both found to be effective and carry acceptable toxicity, however, it was concluded that the short course regimen would provide more convenience to patients and allow for greater machine-time for other patients because of the fewer fractions needed in patients with poor prognosis (6). In the case of this 71 year-old gentleman, no tissue diagnosis had been performed previous to his initial presentation of SCC and he had no prior history of cancer. This created a challenge when deciding whether to proceed with radiotherapy. However, surgical decompression and tissue diagnosis were performed because of the impending risk of paralysis. Only later was it revealed that the patient did in fact have bone metastases from a prostate origin. In patients with SCC that have no confirmed malignancy, there is always the possibility of a benign tumour as a differential diagnosis. Performing radiotherapy to a benign tumour may increase the risk of malignancy at that site. Conclusion It is not common for a patient to experience SCC as their first presentation of cancer. More often, patients with cancer experience local symptoms at the primary site of cancer or bone pain at the site of bone metastases before symptoms of SCC are experienced. When treating SCC, two main treatment modalities exist: surgical decompression followed by postoperative radiotherapy, or radiotherapy alone in an attempt to shrink the lesion. In patients with SCC and who are good surgical candidates, the former is favoured. In patients with impending SCC, the latter is common. Patients with SCC and without tissue diagnosis benefit from the option of surgical decompression and tissue diagnosis to prevent the possible radiation of a benign tumour. Acknowledgments We thank the generous support of the Bratty Family Fund, Michael and Karyn Goldstein Cancer Research Fund, Joseph and Silvana Melara Cancer Research Fund, and the Ofelia Cancer Research Fund.
322 Nicholas Lao, Michael Poon, Marko Popovic et al. References [1] Albertsen PC. What is the risk posed by prostate cancer? J Natl Cancer Inst Monogr 2012;2012(45):169-74. [2] Sun L, Yu S. Efficacy and safety of denosumab versus zoledronic acid in patients with bone metastases. Am J Clin Oncol 2013;36(4):399-403. [3] Smith JA Jr, Soloway MS, Young MJ. Complications of advanced prostate cancer. Urology 1999;54(6A Suppl):8-14. [4] Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005;366(9486):643-8. [5] Iacovou JW, Marks JC, Abrams PH et al. Cord compression and carcinoma of the prostate: is laminectomy justified? BJU Int 1985;57(6):733-6. [6] Maranzano E, Bellavita R, Rossi R et al. Short-course versus split-course radiotherapy in metastatic spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol 2005;23(15):3358-64. Received: July 06, 2013. Revised: August 10, 2013. Accepted: August 21, 2013.
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