Neuroimaging and treatment implications of patients with multiple epidural spinal metastases

Synchronous versus metachronous spinal metastasis: a comparative study of survival outcomes following neurosurgical treatment

PURPOSE

Patients with spinal metastases (SM) from solid neoplasms typically exhibit progression to an advanced cancer stage. Such metastases can either develop concurrently with an existing cancer diagnosis (termed metachronous SM) or emerge as the initial indication of an undiagnosed malignancy (referred to as synchronous SM). The present study investigates the prognostic implications of synchronous compared to metachronous SM following surgical resection.

METHODS

From 2015 to 2020, a total of 211 individuals underwent surgical intervention for SM at our neuro-oncology facility. We conducted a survival analysis starting from the date of the neurosurgical procedure, comparing those diagnosed with synchronous SM against those with metachronous SM.

RESULTS

The predominant primary tumor types included lung cancer (23%), prostate cancer (21%), and breast cancer (11.3%). Of the participants, 97 (46%) had synchronous SM, while 114 (54%) had metachronous SM. The median overall survival post-surgery for those with synchronous SM was 13.5 months (95% confidence interval (CI) 6.1-15.8) compared to 13 months (95% CI 7.7-14.2) for those with metachronous SM (p = 0.74).

CONCLUSIONS

Our findings suggest that the timing of SM diagnosis (synchronous versus metachronous) does not significantly affect survival outcomes following neurosurgical treatment for SM. These results support the consideration of neurosurgical procedures regardless of the temporal pattern of SM manifestation.

Sociodemographic Characteristics of Patients Undergoing Surgery for Metastatic Disease of the Spine

INTRODUCTION

Some patients, particularly those who are socioeconomically deprived, are diagnosed with primary and/or metastatic cancer only after presenting to the emergency department. Our objective was to determine sociodemographic characteristics of patients undergoing surgery for metastatic spine disease at our institution.

METHODS

This retrospective case series included patients 18 years and older who presented to the emergency department with metastatic spine disease requiring surgery. Demographics and survival data were collected. Sociodemographic characteristics were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI) for the state of California. Univariate log-rank tests and Kaplan-Meier curves were used to assess differences in survival for predictors of interest.

RESULTS

Between 2015 and 2021, 64 patients underwent surgery for metastatic disease of the spine. The mean age was 61.0 ± 12.5 years, with 60.9% being male (n = 39). In this cohort, 89.1% of patients were non-Hispanic (n = 57), 71.9% were White (n = 46), and 62.5% were insured by Medicare/Medicaid (n = 40). The mean SDI and ADI were 61.5 ± 28.0 and 7.7 ± 2.2, respectively. 28.1% of patients (n = 18) were diagnosed with primary cancer for the first time while 39.1% of patients (n = 25) were diagnosed with metastatic cancer for the first time. During index hospitalization, 37.5% of patients (n = 24) received palliative care consult. The 3-month, 6-month, and all-time mortality rates were 26.7% (n = 17), 39.5% (n = 23), and 50% (n = 32), respectively, with 10.9% of patients (n = 7) dying during their admission. Payor plan was significant at 3 months ( P = 0.02), and palliative consultation was significant at 3 months ( P = 0.007) and 6 months ( P = 0.03). No notable association was observed with SDI and ADI in quantiles or as continuous variables.

DISCUSSION

In this study, 28.1% of patients were diagnosed with cancer for the first time. Three-month and 6-month mortality rates for patients undergoing surgery were 26.7% and 39.5%, respectively. Furthermore, mortality was markedly associated with palliative care consultation and insurance status, but not with SDI and ADI.

LEVEL OF EVIDENCE

Retrospective case series, Level III evidence.

Personalization of Radiation Therapy in the Primary Treatment of Malignant Epidural Spinal Cord Compression (MESCC)

"True" malignant epidural spinal cord compression (MESCC) is used here to describe a lesion compressing of infiltrating the spinal cord associated with neurologic deficits. Radiotherapy alone is the most common treatment, for which several dose-fractionation regimens are available including single-fraction, short-course and longer-course regimens. Since these regimens are similarly effective regarding functional outcomes, patients with poor survival are optimally treated with short-course or even single-fraction radiotherapy. Longer-course radiotherapy results in better local control of malignant epidural spinal cord compression. Since most in-field recurrences occur 6 months or later, local control is particularly important for longer-term survivors who, therefore, should receive longer-course radiotherapy. It is important to estimate survival prior to treatment, which is facilitated by scoring tools. Radiotherapy should be supplemented by corticosteroids, if safely possible. Bisphosphonates and RANK-ligand inhibitors may improve local control. Selected patients can benefit from upfront decompressive surgery. Identification of these patients is facilitated by prognostic instruments considering degree of compression, myelopathy, radio-sensitivity, spinal stability, post-treatment ambulatory status, and patients' performance status and survival prognoses. Many factors including patients' preferences must be considered when designing personalized treatment regimens.

Postoperative prolonged mechanical ventilation correlates to poor survival in patients with surgically treated spinal metastasis

Objective

Patients with spinal metastasis (SM) are at advanced stages of systemic cancer disease. Surgical therapy for SM is a common treatment modality enabling histopathological diagnosis and the prevention of severe neurological deficits. However, surgery for SM in this vulnerable patient cohort may require prolonged postoperative intensive care treatment, which could adversely affect the anticipated benefit of the surgery. We therefore assessed postoperative prolonged mechanical ventilation (PMV) as an indicator for intensive care treatment with regard to potential correlations with early postoperative mortality and overall survival (OS).

Methods

Between 2015 and 2019, 198 patients were surgically treated for SM at the author´s neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 hours. A multivariate analysis was performed to identify pre- and perioperative collectable predictors for 30 days mortality.

Results

Twenty out of 198 patients (10%) with SM suffered from postoperative PMV. Patients with PMV exhibited a median OS rate of 1 month compared to 12 months for patients without PMV (p < 0.0001). The 30 days mortality was 70% and after one year 100%. The multivariate analysis identified “PMV > 24 hrs” (p < 0.001, OR 0.3, 95% CI 0.02-0.4) as the only significant and independent predictor for 30 days mortality (Nagelkerke’s R2 0.38).

Conclusions

Our data indicate postoperative PMV to significantly correlate to high early postoperative mortality rates as well as to poor OS in patients with surgically treated SM. These findings might encourage the initiation of further multicenter studies to comprehensively investigate PMV as a so far underestimated negative prognostic factor in the course of surgical treatment for SM.

Application of Artificial Intelligence Methods for Imaging of Spinal Metastasis

Spinal metastasis is the most common malignant disease of the spine. Recently, major advances in machine learning and artificial intelligence technology have led to their increased use in oncological imaging. The purpose of this study is to review and summarise the present evidence for artificial intelligence applications in the detection, classification and management of spinal metastasis, along with their potential integration into clinical practice. A systematic, detailed search of the main electronic medical databases was undertaken in concordance with the PRISMA guidelines. A total of 30 articles were retrieved from the database and reviewed. Key findings of current AI applications were compiled and summarised. The main clinical applications of AI techniques include image processing, diagnosis, decision support, treatment assistance and prognostic outcomes. In the realm of spinal oncology, artificial intelligence technologies have achieved relatively good performance and hold immense potential to aid clinicians, including enhancing work efficiency and reducing adverse events. Further research is required to validate the clinical performance of the AI tools and facilitate their integration into routine clinical practice.

Surgical management and prognostic factors of spinal metastatic tumors

Objective

This study aims to evaluate different prognostic factors after surgical management of metastatic spinal tumors regarding clinical condition, preoperative investigations, histopathological results, and surgical data.

Methods

Seventy patients diagnosed as metastatic spinal tumors with neurological deficits and/or unstable spine operated for spinal decompression with or without instrumental fixation according to Spinal Instability Neoplastic Score (SINS) at our institute during the period from May 2014 to October 2018 with follow-up at least 9 months.

Results

Lymphoma metastases were the commonest spinal metastases of 23% with significant p value = 0.001, males and ages above 50 years old were significantly affected. High vascularity and bone invasion were significant operative findings. Significant good prognostic factors for both survival and Klekampe score improvement were paretic patients, > 15 preoperative Klekampe score, early surgery, ≤ 3 vertebral affection, extradural tumor location, gross total resection, and metastatic tumors from multiple myeloma, thyroid gland, lymphoma, and prostatic gland.

Conclusion

Early surgeries aiming neural decompression and keeping spinal stability according to Spinal Instability Neoplastic Score for patients with spinal metastases are the main hope for better survival and neurological improvement.

Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review

Purpose

Metastatic spinal cord compression (MSCC) can be a catastrophic manifestation of advanced cancer that causes immobilizing pain and significant neurologic impairment. Oncologists can protect their patients by having a high index of suspicion for MSCC when patients present with new or worsening back pain before motor, sensory, bowel, or bladder deficits develop. We provide an updated, evidence-based narrative review of the presentation, diagnosis, and treatment of MSCC.

Methods

This narrative review was conducted by searching MEDLINE and Cochrane Database of Systematic Reviews for relevant literature on the presentation, diagnosis, and treatment of patients with MSCC. The article addresses the key elements of MSCC management germane to the medical oncologist, with special attention given to pain and symptom management, decision making with regard to surgery and radiation therapy, the importance of rehabilitative care, and the value of a multidisciplinary approach.

Results

Magnetic resonance imaging of the entire spine is recommended for the diagnosis of MSCC. Treatment includes glucocorticoid therapy, pain management, radiation therapy with or without surgery, and specialized rehabilitation. When formulating a treatment plan, clinicians should consider the patient’s care goals and psychosocial needs.

Conclusion

Prompt diagnosis and treatment of MSCC can reduce pain and prevent irreversible functional loss. Regular collaboration among multidisciplinary providers may streamline care and enhance achievement of treatment goals.

Metastatic Complications of Cancer Involving the Central and Peripheral Nervous Systems

Neurologic complications of cancer may involve both the central nervous system and peripheral nervous system manifesting as brain, leptomeningeal, intramedullary, intradural, epidural, plexus, and skull base metastases. Excluding brain involvement, neurologic complications affecting these other sites are relatively infrequent, but collectively they affect more than 25% of patients with metastatic cancer causing significant morbidity and mortality. Early diagnosis and intervention optimize quality of life and improve survival.

Epidural and intramedullary spinal metastasis: clinical features and role of fractionated radiotherapy

Metastases involving the spinal epidural space and cord parenchyma are major sources of neurological impairment and decreased quality of life in cancer patients. Herein we review the clinical manifestations, pathophysiology, importance of early diagnosis and initiation of treatment, and role of fractionated radiotherapy of these disorders.

Prevalence of thoracic spine lesions masquerading as cauda equina syndrome: yield of a novel magnetic resonance imaging protocol

Our objective was to describe the yield of actionable thoracic spine lesions for a novel magnetic resonance imaging (MRI) protocol including evaluation of the thoracic spine among patients presenting to the Emergency Department (ED) with symptoms consistent with epidural compression syndrome. Our ED and Department of Radiology together designed a novel rapid MRI protocol entailing 3D volumetric T2 weighted sequences through both the thoracic and lumbar spine obtained in the sagittal plane to assess for both lumbar and thoracic spine lesions. We recorded study outcomes for all patients undergoing this protocol or conventional lumbar MRI during May 2014-May 2015 to determine the prevalence of actionable thoracic spine lesions. We defined an actionable thoracic lesion as any pathology requiring treatment (e.g., medication, admission, surgery) not otherwise indicated on the basis of lumbar spine findings. During the study period, 112 of 124 (90.3%) of ED patients undergoing MRI evaluation for epidural compression syndrome underwent the novel protocol. The remaining patients underwent evaluation of the lumbar spine using only a conventional MRI protocol. Of the 112 patients undergoing the novel protocol, 6 (5.4%) patients had thoracic spine lesions indicating therapy not otherwise indicated by lumbar spine findings. The etiologies of these six lesions were: neoplasms (2), de-myelination (2), compression fracture (1), and degeneration due to pernicious anemia (1). Emergency providers should strongly consider the routine use of MRI protocols including thoracic spine evaluation in patients presenting to the ED with symptoms consistent with epidural compression syndrome.

Modern approaches to the management of metastatic epidural spinal cord compression

Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency requiring prompt treatment to maximize neurologic function, ambulatory function and local control. Traditionally, options for MESCC included external beam radiation therapy with or without surgery. Surgery has usually been reserved for the patient with optimal performance status, single level MESCC or mechanical instability. Advances in external beam radiation therapy such as the development of stereotactic body radiation therapy have allowed for the delivery of high-dose radiation, allowing for both long-term pain and local control. Surgical advances, such as separation surgery, minimal access spine surgery and percutaneous instrumentation, have decreased surgical morbidity. This review summarizes the latest advances and evidence in MESCC to enable modern management.

Emergencies in Hematology and Oncology

The development of medical emergencies related to the underlying disease or as a result of complications of therapy are common in patients with hematologic or solid tumors. These oncological emergencies can occur as an initial presentation or in a patient with an established diagnosis and are encountered in all medical care settings, ranging from primary care to the emergency department and various subspecialty environments. Therefore, it is critically important that all physicians have a working knowledge of the potential oncological emergencies that may present in their practice and how to provide the most effective care without delay. This article reviews the most common oncological emergencies and provides practical guidance for initial management of these patients.

Management of neuro-oncologic emergencies

Patients with brain tumors and systemic malignancies are subject to diverse neurologic complications that require urgent evaluation and treatment. These neurologic conditions are commonly due to the tumor's direct effects on the nervous system, such as cerebral edema, increased intracranial pressure, seizures, spinal cord compression, and leptomeningeal metastases. In addition, neurologic complications can develop as a result of thrombocytopenia, coagulopathy, hyperviscosity syndromes, infection, immune-related disorders, and adverse effects of treatment. Patients may present with typical disease syndromes. However, it is not uncommon for patients to have more subtle, nonlocalizing manifestations, such as alteration of mental status, that could be attributed to other systemic, nonneurologic complications. Furthermore, neurologic complications are at times the initial manifestations of an undiagnosed malignancy. Therefore a high index of suspicion is essential for rapid assessment and management. Timely intervention may prolong survival and improve quality of life. In this chapter, we will discuss the common neuro-oncologic emergencies, including epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment.

Detection of vertebral metastases: a meta-analysis comparing MRI, CT, PET, BS and BS with SPECT

OBJECTIVE

To perform a meta-analysis to compare the diagnostic value of magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), bone scintigraphy (BS) and BS with single-photon emission computed tomography (SPECT) in detecting vertebral metastases.

METHODS

Relevant original articles published from January 1995 to December 2015 were searched. Two reviewers independently extracted data. Software called "META-DiSc" was used to obtain pooled estimates of sensitivity, specificity, diagnostic odds ratio (DOR) and summary receiver operating characteristic (SROC) curves.

RESULTS

Twenty-three articles consisting of 33 studies fulfilled all inclusion criteria. On per-patient basis, for sensitivity, MRI = PET = SPECT > CT = BS ("=" indicated no significant difference, P > 0.05; ">" indicated significantly higher, P < 0.05). For specificity, MRI = CT = BS > SPECT > PET. For DOR, MRI > SPECT > BS > CT = PET. SROC curves for SPECT and MRI showed better diagnostic accuracy than others. On per-lesion basis, for sensitivity, PET = SPECT = MRI > BS > CT. For specificity, MRI = CT > PET = SPECT = BS. For DOR, MRI > SPECT > CT = PET > BS. SROC curves showed MRI had the best while CT had the lowest diagnostic accuracy.

CONCLUSION

For diagnosis of vertebral metastases, MRI was found to be the best modality and also better than other techniques on both per-patient and per-lesion basis.

A review in the treatment of oncologic emergencies

AIM

Oncologic emergencies are often categorized as a group of metabolic abnormalities associated with the diagnosis of cancer or the initiation of chemotherapy for treatment. These syndromes often arise in the acute setting, demanding an accurate knowledge of the associated condition and current treatment. In this review, we evaluate five oncologic emergencies: tumor lysis syndrome, hypercalcemia, hyponatremia, spinal cord compression, and disseminated intravascular coagulation.

SUMMARY

Oncologic emergencies are often diverse in etiology and are often associated with the initiation of chemotherapy. Tumor lysis syndrome presents as severe electrolyte abnormalities that need to be addressed urgently, sometimes prior to initiation of chemotherapy. Hypercalcemia of malignancy is treated with aggressive rehydration, furosemide, and intravenous bisphosphonates. If a patient with cancer presents with normovolemic hyponatremia, syndrome of inappropriate antidiuretic hormone should be suspected. Malignant spinal cord compression happens when cancer cells grow in, or near to, the spine and press on the spinal cord and nerves. This causes swelling and a reduction in the blood supply to the spinal cord and nerve roots. Disseminated intravascular coagulation is characterized by systemic activation of blood coagulation, which results in generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome.

CONCLUSION

Knowledge of oncology emergencies is critical to the understanding of these emergent syndromes in oncology patients. Each of these disease states requires careful evaluation of the patient's symptoms, monitoring parameters for conditions and supportive care measures and interventions.

Hypofractionated stereotactic body radiotherapy in spinal metastasis - with or without epidural extension

AIMS

To evaluate clinical outcome and the effect of malignant epidural compression (MEC) in the treatment of spine metastasis with stereotactic body radiotherapy (SBRT).

MATERIALS AND METHODS

Seventy-six lesions in 52 patients with spinal metastasis received SBRT during the period July 2010 to December 2012. MEC was detected in 20 patients (38.4%) and was separately contoured. The median dose prescribed to involved vertebra (planning target volume) was 24 Gy (range 24-27 Gy) in a median of three fractions (range 1-3). Uninvolved elements were prescribed 21 Gy in three fractions. In 59 lesions (77.6%), the entire vertebra was treated and in 17 lesions (22.4%) only the anterior elements were treated. All patients were treated with volumetric modulated arc therapy with image guidance on a Novalis Tx linear accelerator with the ExacTrac system. Dosimetric and clinical outcomes were compared in patients with or without MEC.

RESULTS

At a median follow-up of 8.48 months (range 3-40 months), 1 year local control and overall survival was 94 and 68%, respectively. In patients with or without epidural extension, the median dose to the gross tumour volume (GTV; 95%) was 23.48 Gy (range 13.70-25.75) and 22.99 Gy (range 13.55-26.84), the median spinal cord Dmax was 17.36 Gy (range 8.47-21.63) and 15.71 Gy (range 8.39-23.33). The median GTV epidural (D95%) was 21.16 Gy (range 15.43-23.92). Complete pain relief was seen in 90% of patients with MEC and 93.75% without MEC (P=NS) and neurological improvement was seen in 60% of patients in both groups of patients.

CONCLUSION

It is feasible to deliver a high dose of radiation (∼90% of the prescription dose) to the epidural component with volumetric modulated arc therapy SBRT and image guidance. It yielded high rates of pain control and local control in patients with spine metastases with or without MEC.

Estudo epidemiológico de 55 pacientes portadores de doença vertebral metastática sintomática em Santo André - SP, Brasil

OBJETIVO: Apresentar o perfil epidemiológico dos pacientes portadores de doença vertebral metastática sintomática de serviço público de atenção terciária na região do ABC. MÉTODO: Avaliamos de Janeiro de 2008 a Janeiro de 2011, 55 pacientes com diagnóstico de metástase vertebral e coletamos dados de idade no diagnóstico de lesão metastática, sexo, tipo de tumor, topografia vertebral e sintomatologia. A evolução da doença foi observado nas datas: biópsia da neoplasia primária; início de sintomas vertebrais; diagnóstico de doença vertebral metastática (imagem) e data da cirurgia. RESULTADOS: A idade dos pacientes variou de 28 a 85 anos; 40% homens e 60% mulheres. Os principais tumores foram carcinoma de mama (32,7%), mieloma múltiplo (25,4%) e carcinoma de próstata (14,5%). Observamos 25 pacientes (45,4%) com lesões na coluna torácica; 13 pacientes (23,6%) lombares ou sacrais; 11 pacientes (20%) difusas e 6 pacientes (10,9%) cervicais. 34 pacientes (61,8%) apresentavam somente dor, os demais (38,2%) apresentavam também alteração neurológica. O intervalo entre a lesão primária e a manifestação clínica de lesão vertebral apresentou mediana de 190 dias; entre a sintomatologia na coluna e o diagnóstico por imagem teve mediana de 70 dias; aos submetidos a cirurgia, entre o diagnóstico e o procedimento foi de 288 dias. CONCLUSÃO: Observamos os dados epidemiológicas, compatíveis a literatura: predomínio do sexo feminino (60%), com idade média de 55 anos; metástases predominantemente toracolombares (69%) por neoplasia de mama, mieloma múltiplo e próstata (72%). Observamos ampla variação no intervalo de tempo na descrição cronológica dos eventos clínico-diagnósticos e cirúrgicos.

Oncologic emergencies

OBJECTIVES

To provide an up-to-date review of current literature on the pathophysiology, diagnosis, and management of five key malignancy-related complications: superior vena cava syndrome, malignant pericardial effusion, malignant spinal cord compression, hypercalcemia, and acute tumor lysis syndrome.

DATA SOURCES

Database searches and review of relevant medical literature.

DATA SYNTHESIS

Malignancy-related complications demand increased attention from intensivists due to their frequency and increasing cancer prevalence. Although such complications portend a poor prognosis, proper acute management can improve short-term outcomes by facilitating either definitive care of the underlying malignancy or the institution of appropriate palliative measures.

CONCLUSIONS

Knowledge of malignancy-induced complications in critically ill patients expedites the ability of the intensivist to properly manage them. Five complications commonly requiring emergency management are addressed in this review. Specifically, superior vena cava syndrome may warrant radiation, chemotherapy, vascular stenting, or surgical resection. Malignant pericardial effusion may require emergency pericardiocentesis if cardiac tamponade develops. Malignant spinal cord compression demands immediate spinal imaging, glucocorticoids, and either surgery or radiation. Hypercalcemia requires aggressive intravenous hydration and a bisphosphonate. Acute tumor lysis syndrome necessitates intravenous hydration, rasburicase, and management of associated electrolyte abnormalities.

Imaging of spinal metastatic disease

Metastases to the spine can involve the bone, epidural space, leptomeninges, and spinal cord. The spine is the third most common site for metastatic disease, following the lung and the liver. Approximately 60-70% of patients with systemic cancer will have spinal metastasis. Materials/Methods. This is a review of the imaging techniques and typical imaging appearances of spinal metastatic disease. Conclusions. Awareness of the different manifestations of spinal metastatic disease is essential as the spine is the most common site of osseous metastatic disease. Imaging modalities have complimentary roles in the evaluation of spinal metastatic disease. CT best delineates osseous integrity, while MRI is better at assessing soft tissue involvement. Physiologic properties, particularly in treated disease, can be evaluated with other imaging modalities such as FDG PET and advanced MRI sequences. Imaging plays a fundamental role in not only diagnosis but also treatment planning of spinal metastatic disease.

Neurologic emergencies in patients who have cancer: diagnosis and management

The nervous system can be significantly affected by cancer. Neurologic symptoms are present in 30% to 50% of oncologic patients presenting to the emergency department or in neurologic consultation at teaching hospitals. Evaluation and treatment require collaborative effort between specialties. The causes of neurologic emergencies in patients with cancer are mostly related to effects of cancer, toxicities of treatments, infections, and paraneoplastic syndromes. These complications cause significant morbidity and mortality and require prompt and accurate diagnostic and treatment measures. This article reviews the common neurologic emergencies affecting patients with cancer and discusses epidemiology, clinical presentation, diagnosis, and treatment modalities.

A Systematic and Evidence-Based Approach to the Management of Vertebral Metastasis

Diagnosis and management of vertebral metastasis requires a systematic approach to patient identification as well as selection of appropriate therapy. Rapid identification and prompt intervention in the treatment of malignant epidural spinal cord compression (MESCC) is key to maintaining quality of life. This paper provides a series of tools as well as guidance in selecting effective and evidence-based therapy individualized to the specific patient.

The role of radiotherapy for metastatic epidural spinal cord compression

Radiotherapy alone is the most common treatment for metastatic epidural spinal cord compression (MESCC). Decompressive surgery followed by radiotherapy is generally indicated only in 10-15% of MESCC cases. Chemotherapy has an unclear role and may be considered for selected patients with hematological or germ-cell malignancies. If radiotherapy alone is given, it is important to select the appropriate regimen. Similar functional outcomes can be achieved with short-course radiotherapy regimens and longer-course radiotherapy regimens. Longer-course radiotherapy is associated with better local control of MESCC than short-course radiotherapy. Patients with a more favorable survival prognosis (expected survival of ≥6 months) should receive longer-course radiotherapy, as they may live long enough to develop a recurrence of MESCC. Patients with an expected survival of <6 months should be considered for short-course radiotherapy. A recurrence of MESCC in the previously irradiated region after short-course radiotherapy may be treated with another short-course of radiotherapy. After primary administration of longer-course radiotherapy, decompressive surgery should be performed if indicated. Alternatively, re-irradiation can be performed using high-precision techniques to reduce the cumulative dose received by the spinal cord. Larger prospective trials are required to better define the appropriate treatment for the individual patient.

Clinical Approach to Metastatic Epidural Spinal Cord Compression

Metastatic epidural spinal cord compression (MESCC) is a devastating complication of cancer that occurs when cancer metastasizes to the spine and then secondarily compresses the spinal cord. It is a relatively common complication of cancer and. in the United States, more than 20,000 cases of MESCC are diagnosed annually. If left untreated, virtually 100% of these patients would become paraplegic; therefore, it is considered a true medical emergency and immediate intervention is required. Even with aggressive therapy, results can often be unsatisfactory. Although most patients with MESCC have limited survival, up to one third will survive beyond one year. Thus. it is essential to consider aggressive therapy to preserve or improve the quality of life and prevent paraplegia.

Oncologic emergencies: diagnosis and treatment

Patients with malignancies are subject to developing a unique set of complications that require emergent evaluation and treatment. With the increasing incidence of cancer in the general population and improved survival, these emergencies will be more frequently encountered. Physicians must be able to recognize these conditions and institute appropriate therapy after a focused initial evaluation. The approach to definitive therapy is commonly multidisciplinary, involving surgeons, radiation oncologists, medical oncologists, and other medical specialists. Prompt interventions can be lifesaving and may spare patients considerable morbidity and pain. In this review, we discuss the diagnosis of and initial therapy for common emergencies in hematology and oncology.

Back pain emergencies

Most adults in the United States will experience an episode of back pain at some point during their lifetime. Most will present to their primary care physician for evaluation and treatment. Many patients have non-life-threatening etiologies and recover within 4 to 6 weeks. A small percentage, however, have back pain due to a potentially life-threatening emergency. AD,rupturing AAA, SEM, cauda equina syndrome, vertebral osteomyelitis,and SEA are just some of the medical emergencies that can present with back pain. Clinical suspicion for these diagnoses begins with a thorough history and physical examination. It is imperative that the office-based physician search for and accurately identify any red flag within the history or physical examination. Appropriate laboratory studies and diagnostic imaging are obtained based on the suspected etiology.

Radiation Oncology Emergencies

Radiation therapy is an important and effective treatment modality when used in the management of oncologic emergencies. For any patient who has MSCC, ISCM, SVC syndrome, or life-threatening hemoptysis/obstruction, optimal management hinges on efficient multidisciplinary evaluation and communication to arrive at a treatment plan tailored to the individual patient. Optimal management may include steroids, surgery, chemotherapy, or bronchoscopic intervention. When radiation therapy is used, the total dose and fractionation schedule should be tailored to the disease setting and life expectancy of the patient.

A Pilot Randomised Comparison of Dexamethasone 96mg vs 16mg per day for Malignant Spinal-cord Compression Treated by Radiotherapy: TROG 01.05 Superdex Study

AIM

To test the viability of a full-scale randomised comparison of two steroid doses given with radiotherapy for malignant spinal-cord compression (MSCC), to test Internet randomisation and to compare different functional outcome measures.

MATERIALS AND METHODS

A log of screened patients at eight recruiting centres was maintained. Patients were randomised via the Superdex website to either 96 mg or 16 mg daily of dexamethasone. Radiotherapy treatment was 30 Gy in 10 fractions. Outcomes assessed used ambulation, Barthel Index ambulation, Functional Independence Measure (FIM) ambulation and Functional Improvement Score (FIS) at 1 month.

RESULTS

One hundred and thirty-one patients were screened. Ninety-three (71%) were ineligible, 65% of these were because duration of prior steroid use was greater than 12 h, failure to meet strict definition of magnetic resonance imaging, defined MSCC, multi-level disease or previous spinal-cord compression treatment. Twenty of the 38 eligible patients were randomised, including seven outside standard office hours. There was a high rate of serious adverse events (n = 9), but only one was considered likely to be related to study medication. At baseline, 75% were ambulant, 70% had FIM ambulation scores greater than 5 and 50% had Barthel Index ambulation scores greater than 2. At day 28, including all randomised patients (by scoring four dead patients as non-ambulant), ambulation scores by the various definitions were 60%, 45% and 40%, respectively. For the 16 patients evaluable at day 28, the mean FIS was -1.4. Median survival was 69 days and 1-year survival 13%.

CONCLUSION

Web randomisation was successful; however, the high ineligibility rate precludes a full-scale dexamethasone dose trial in Australia. Choice of measure of ambulation has potentially significant effects on outcomes and implications for the design of any future MSCC trials. Referral delays are of concern.

Metastasis to nervous system: spinal epidural and intramedullary metastases

Spinal cord epidural metastasis (SEM) is a common complication of systemic cancer with an increasing incidence. Prostate, breast and lung cancer are the most common offenders. Metastasis usually arises in the posterior aspect of vertebral body with later invasion of epidural space. Pathophysiologically, vascular insufficiency is more important than direct spinal cord compression. The most common complaint is pain, and two thirds of patients with SEM have motor signs at initial diagnosis. Currently magnetic resonance imaging is the most sensitive diagnostic tool. The optimal management of SEM is still arguable, but recent advances in surgical management of SEM and higher complication rate of surgery following radiotherapy should persuade clinicians to consider de novo surgery where possible. Radiotherapy has an important role, particularly in treatment of radiosensitive tumors and in patients who are not candidates for surgery. Novel approaches such as stereotactic radiosurgery are promising; however, response to chemotherapy depends on inherent properties of primary tumor. Recurrent SEM is a substantial problem for which surgery or repeat radiotherapy may be options. Intramedullary metastasis is rare but should be considered in patients with systemic malignancy and asymmetrical presentation of myelopathic symptoms. The prognosis is usually poor and preferred modality of treatment is radiotherapy.

Epidural spinal cord compression

Spinal cord compression from epidural metastases (epidural spinal cord compression, ESCC) is the most common neurological complication of cancer after brain metastases. Extradural compression represents 97% of spinal cord metastatic lesions. ESCC usually occurs in patients with disseminated disease. The most common tumours associated with ESCC are lung and breast cancers, followed by lymphoma, myeloma, prostate cancer and sarcoma. ESCC represents a medical emergency because delayed treatment can be responsible for irreversible deficits, such as paralysis and loss of sphincter control. Patients with ESCC require a multidisciplinary diagnostic and therapeutic approach. Clinical suspect is radiologically detected for confirmation. The median expected survival time from diagnosis usually ranges from 3 to 6 months. The nature of the primary tumour and the degree of the neurological deficit are the most important factors affecting survival. The lack of prospective randomized trials makes the optimal treatment of ESCC controversial and the decision is to be tailored to the individual. Treatment options include: bed rest, administration of corticosteroids, surgery followed by radiation therapy, radiotherapy alone and, to a limited extent, chemotherapy and hormonal therapy.

Diagnosis and treatment of vertebral column metastases

The vertebral column is recognized as the most common site for bony metastases in patients with systemic malignancy. Patients with metastatic spinal tumors may present with pain, neurologic deficit, or both. Some tumors are asymptomatic and are detected during screening examinations. Treatment options include medical therapy, surgery, and radiation. However, diversity of patient condition, tumor pathology, and anatomical extent of disease complicate broad generalizations for treatment. Historically, surgery was considered the most appropriate initial therapy in patients with spinal metastasis with the goal of eradication of gross disease. However, such an aggressive approach has not been practical for many patients. Now, operative intervention is often palliative, with pain control and maintenance of function and stability the major goals. Surgery is reserved for neurologic compromise, radiation failure, spinal instability, or uncertain diagnosis. Recent literature has revealed that surgical outcomes have improved with advances in surgical technique, including refinement of anterior, lateral, posterolateral, and various approaches to the anterior spine, where most metastatic disease is located. We review these surgical approaches for which a team of surgeons often is needed, including neurosurgeons and orthopedic, general, vascular, and thoracic surgeons. Overall, a multimodality approach is useful in caring for these patients. It is important that clinicians are aware of the various therapeutic options and their indications. The optimal treatment of individual patients with spinal metastases should include consideration of their neurologic status, anatomical extent of disease, general health, age, and qualilty of life.

Metastatic spine disease: epidemiology, pathophysiology, and evaluation of patients

Spinal metastasis is the most commonly en-countered tumor of the spine and represents an ominous extension of neoplastic disease. Symptomatic spinal metastases produce a characteristic clinical syndrome beginning with local back or neck pain. All too often, the significance of presenting pain is not appreciated and correct diagnosis is delayed until more blatant manifestations of spinal cord or nerve root dysfunction are manifest. Pain is followed by weakness,numbness, and sphincter dysfunction. The natural history is one of relentless progression to complete and irreversible paralysis unless timely treatment is undertaken. Plain radiographs provide a simple and useful screening test. MRI is, however, the imaging method of choice, providing information concern-ing the level, location, and geometry of the spinal tumor as well as details concerning the bony integrity of the spine, particularly adjacent to a culpable tumor, all of which is essential to determine the management options and treatment strategies. Percutaneous image-guided biopsy is a useful test to establish a tissue diagnosis.

Epidural spinal cord compression

Epidural spinal cord compression is a neurologic emergency requiring immediate attention. The therapy instituted depends on several factors, including the patient's condition at the time of presentation, the nature of the underlying malignancy, the extent of systemic disease burden, and patient prognosis. The most essential aspect of treatment is the establishment of the diagnosis. If one suspects malignant cord compression an emergency, magnetic resonance imaging of the entire spinal axis is indicated. If magnetic resonance imaging is unavailable, post-myelographic computed tomography is an alternative. However, treatment should not be delayed until imaging is performed, particularly if neurologic deficits are present. Pain should be adequately addressed and opioids administered if necessary. Steroids should be given. If significant neurologic deficits are present, a high-dose corticosteroid bolus, followed by standing doses, should be given. However, if pain is the predominant symptom, steroids can be withheld pending immediate imaging or lower doses can be given without a bolus. Neurosurgical consultation should be obtained, and surgery should be considered if the patient's condition permits. This is particularly true if spinal instability or significant kyphosis is present or compression is secondary to bony fragments. Other indications include patients with limited systemic disease burden in whom better survival is predicted and possibly those with radioresistant tumors. The type of surgery performed should be tailored to the distribution of disease within the spine and accessibility through anterior body cavities. Radiation therapy, an effective noninvasive treatment that can be delivered quickly and safely, is an appropriate option as well. This is particularly true in radio-responsive tumors, such as myeloma and lymphoma, in which surgery may be avoided entirely. Chemotherapy may play a role as adjuvant therapy in some tumors.

Neurologic complications of solid tumors

This article reviews the neurologic complications of the most common solid tumors, including lung, breast, gastrointestinal, genitourinary, gynecologic, head and neck cancers, melanoma and sarcomas. As systemic therapy improves for many of these tumors, patients are surviving longer and the incidence of neurologic complications is increasing.

Spinal cord compression

Back pain and suspected spinal cord compression remains one of the most frequent reasons for neurologic consultation in cancer patients. While treatment generally results in stabilization or improvement, early diagnosis remains the cornerstone of improving neurologic outcome. This article reviews the clinical features, differential diagnosis, and management of neoplastic epidural spinal cord compression.