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Zaki P, Barbour A, Zaki MM, Tseng YD, Amin AG, Venur V, McGranahan T, Vellayappan B, Palmer JD, Chao ST, Yang JT, Foote M, Redmond KJ, Chang EL, Sahgal A, Lo SS, Schaub SK. Emergent radiotherapy for spinal cord compression/impingement-a narrative review. Ann Palliat Med 2023; 12:1447-1462. [PMID: 37817502 DOI: 10.21037/apm-23-342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Malignant epidural spinal cord compression (MESCC), often presenting with back pain and motor/sensory deficits, is associated with poor survival, particularly when there is loss of ambulation. The purpose of this review is to evaluate the literature and discuss appropriate workup and management of MESCC, specifically in the emergent setting. METHODS A PubMed search was conducted on "spinal cord compression" and "radiation therapy." Articles were analyzed for the purpose of this narrative review. KEY CONTENT AND FINDINGS If MESCC is suspected, neurologic examination and complete spine imaging are recommended. Emergent treatment is indicated if there is radiographic evidence of high-grade compression and/or clinically significant motor deficits. Treatment involves a combination of medical management, surgical decompression, radiation therapy (RT), and rehabilitation. For motor deficits, emergent initiation of high dose steroids is recommended. Circumferential surgical decompression ± stabilization followed by RT provides superior clinical outcomes than RT alone. For patients whom surgery is not reasonable, RT alone may provide significant treatment response which depends on radioresponsiveness of the pathology. Systemic therapy, if indicated, is typically reserved till after primary treatment of MESCC, but patients with chemoresponsive tumors may receive primary chemotherapy. The selected RT schedule should be personalized to each patient and commonly is 30 Gy in 10 fractions (fx), 20 Gy in 5 fx, or 8 Gy in 1 fx. MESCC recurrence may be treated with additional RT, if within the spinal cord tolerance, or surgery. Stereotactic body radiation therapy (SBRT) has been used for high grade MESCC in patients with relatively intact neurologic function at a few centers with a very robust infrastructure to support rapid initiation of treatment within a short period of time, but is generally not feasible for most clinical practices. SBRT may be advantageous for low grade MESCC, recurrence, or in the post-operative setting. Detection of MESCC prior to development of high-grade compression or deterioration of neurologic function may allow patients to benefit more from advanced therapies and improve prognosis. CONCLUSIONS MESCC is a devastating condition; optimal treatment should be personalized to each patient and approached collaboratively by a multidisciplinary team.
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Affiliation(s)
- Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Andrew Barbour
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Mark M Zaki
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Anubhav G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Vyshak Venur
- Division of Medical Oncology, Fred Hutchinson Cancer Center/University of Washington, Seattle, WA, USA
| | - Tresa McGranahan
- Department of Neurology, Alvord Brain Tumor Center/University of Washington, Seattle, WA, USA
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute of Singapore, Singapore, Singapore
| | - Joshua D Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital/The Ohio State University, Columbus, OH, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, and ICON Cancer Centre, Brisbane, Queensland, Australia
| | - Kristin J Redmond
- Department of Radiation and Molecular Oncology, John Hopkins University, Baltimore, MD, USA
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine and Norris Cancer Center at University of Southern California, CA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
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Gueiderikh A, Ung M, Lazarovici J, Danu A, Ghez D, Saleh K, Dragani M, Noël N, Bigenwald C, Willekens C, Ribrag V, Michot JM, Martin V. Incidence, characteristics, management and outcome of patients with follicular lymphoma with tumor epidural compression, a study on 22 cases. Cancer Radiother 2023; 27:370-375. [PMID: 37156711 DOI: 10.1016/j.canrad.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/30/2023] [Accepted: 04/15/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Follicular lymphoma (FL) is one of the most common lymphoma. Occasionally, FL is associated with tumoral epidural compression and management of these patients remain poorly codified. This study aims to report incidence, clinical characteristics, management and outcomes of patients with FL and tumoral epidural compression. MATERIAL AND METHODS Observational, retrospective cohort study of adult patients with FL and epidural tumor compression, treated in a French Institute over the last 20 years (2000-2021). RESULTS Between 2000 and 2021, 1382 patients with FL were followed by the haematological department. Of them, 22 (1.6%) patients (16 men and 6 women) had follicular lymphoma with epidural tumor compression. At epidural tumor compression occurrence, 8/22 (36%) patients had a neurological clinical deficit (motor, sensory or sphincter function) and 14/22 (64%) had tumor pain. All patients were treated with immuno-chemotherapy; the main regimen being used was R-CHOP plus high dose IV methotrexate in 16/22 (73%) patients. Radiotherapy for tumor epidural compression was performed in 19/22 (86%) patients. With a median follow-up of 60 months (range=[1-216]), 5 year local tumor relapse free survival was achieved in 65% (95% CI 47-90%) of patients. The median PFS was of 36 months (95% CI 24-NA) and 5 years OS estimate was 79% (95% CI 62-100%). Two patients developed a relapse at a second epidural site. CONCLUSION FL with tumoral epidural compression reached 1.6% of all FL patients. Management based on immuno-chemotherapy with radiotherapy appeared to produce comparable outcomes with the general FL population.
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Affiliation(s)
- A Gueiderikh
- Radiation therapy department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France.
| | - M Ung
- Radiation therapy department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - J Lazarovici
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - A Danu
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - D Ghez
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - K Saleh
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - M Dragani
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - N Noël
- Internal medicine department, hôpital Bicêtre, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - C Bigenwald
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - C Willekens
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - V Ribrag
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - J-M Michot
- Hematology department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - V Martin
- Radiation therapy department, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
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Champeaux C, Abi-Lahoud G, Larousserie F. An odd and serious "disc bulging"! Neurochirurgie 2019; 65:187-190. [PMID: 31100350 DOI: 10.1016/j.neuchi.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/16/2018] [Accepted: 04/03/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND IMPORTANCE Cauda equina syndrome is a common acute medical condition, usually caused by large degenerative disc herniation or metastatic lumbar disease. We describe a patient who presented with a lesion featuring both discal and tumoral characteristics. CLINICAL PRESENTATION A 41-year-old woman presented with ongoing back pain, progressive lower-limb weakness and sphincter disorder. Magnetic resonance imaging showed a very odd-looking large anterior epidural lesion originating from the L3-L4 space and severely compressing the roots of the cauda equina. Partial surgical decompression was performed in emergency. At a later time, redo surgery was performed to maximize resection, and was unfortunately followed by several complications. After 6 surgical procedures including a ventriculo-peritoneal shunt insertion and intensive rehabilitation, the patient could walk independently with the aid of one crutch. Following collegial review, the diagnosis of low-grade chondrosarcoma of the intervertebral disc was suggested. CONCLUSION We report on a very unusual and therapeutically challenging spinal tumor diagnosed as low-grade chondrosarcoma of discal origin, an entity never previously described.
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Affiliation(s)
- C Champeaux
- Department of neurosurgery, Lariboisière hospital, 75010 Paris, France; Department of neurosurgery, Sainte-Anne hospital, 75014 Paris, France; Department of neurosurgery, NHNN, university college London hospitals, NHS foundation trust, WC1N 3BG London, UK.
| | - G Abi-Lahoud
- Department of neurosurgery, Lariboisière hospital, 75010 Paris, France
| | - F Larousserie
- Département de pathologie, université Paris Descartes, Sorbonne Paris Cité, hôpital Cochin, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
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Telera S, Gorgoglione N, Raus L, Vidiri A, Villani V, Pace A, Fabi A, Crispo F, Castiglione M, Sperduti I, Boccaletti R. Open Kyphoplasty for Metastatic Spine Disease: A Retrospective Clinical Series. World Neurosurg 2019; 127:e751-60. [PMID: 30951918 DOI: 10.1016/j.wneu.2019.03.258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Symptomatic metastatic spine disease (MSD), is a challenging disease involving 3%-20% of patients with bone metastases. Different surgical options are available and must be tailored to the general and neurologic conditions of the patients. Open kyphoplasty (OKP) refers to decompressive hemilaminectomy, associated with a contralateral percutaneous kyphoplasty, and in some cases, to a posterior stabilization. The aim of the study was to critically review our experience during the last decade with OKP in patients with cancer. METHODS Fifty-three patients with cancer underwent OKP for symptomatic MSD. The Tokuhashi score and Spinal Instability Neoplastic Score were calculated for each patient. Length of hospital stay, perioperative complications, incidence of adjacent-level fractures, and median survival after surgery were evaluated. Karnofsky Performance Status, visual analog scale, and Dennis Pain Score were calculated preoperatively, postoperatively, and at last follow-up. RESULTS Median Tokuhashi score and Spinal Instability Neoplastic Score were 10 and 10, respectively. The mean volume of filling material inserted was 3.6 mL. Median operative time was 180 minutes. Complications included 8 leakages (15%), 2 permanent motor deficits (3.8%), and 2 asymptomatic pulmonary embolisms (3.8%). Mean length of hospital stay was 7 days. A significant improvement was observed in Karnofsky Performance Status, visual analog scale score, and Dennis Pain Score (P < 0.0001). Median follow-up was 16 months and overall survival 22 months. CONCLUSIONS OKP was an effective treatment of symptomatic MSDs in selected oncologic patients with low Tokuhashi scores. It relieved lateral epidural compressions, expanded indications of palliative surgery in patients who were not otherwise surgical candidates, and rapidly dealt with cement leakages.
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Suffia C, Sorrentino S, Vetrella S, Bifano D, Nantron M, De Bernardi B, Gandolfo C. Neuroblastoma presenting with symptoms of epidural compression at birth: a case report. Ital J Pediatr 2016; 42:52. [PMID: 27209026 PMCID: PMC4875711 DOI: 10.1186/s13052-016-0263-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Five to 10 % of children with neuroblastoma present with symptoms of epidural compression (EC). More than half these patients are diagnosed in the first year of life. The case of a neuroblastoma presenting symptoms of EC at birth is exceptional and deserves to be reported. Case presentation We describe a case of female born at the 36th week of pregnancy by caesarian section decided following ultrasonographic discovery of oligohydramnios. At birth, she was noted to have motor deficit involving both legs and continuous urinary dripping. These symptoms were found to be secondary to a paraspinal neuroblastoma infiltrating the spinal canal. Tumor responded well to chemotherapy, but neurologic deficit only slightly improved and bladder dysfunction remained unchanged. At 2 years of age, patient is able to walk with help of leg orthoses, suffers chronic constipation requiring daily medications, and has neurologic bladder necessitating multiple daily catheterizations. Conclusions The finding of a newborn presenting with symptoms of EC secondary to a neuroblastoma invading the spinal canal is quite uncommon. The case described herewith confirms that these rare patients have an excellent survival probability, but almost always develop severe functional sequelae.
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Affiliation(s)
- Chiara Suffia
- Departments of Hematology-Oncology, Istituto Giannina Gaslini, Genoa, Italy.
| | | | - Simona Vetrella
- Department of Hematology-Oncology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Delfina Bifano
- Department of anatomopathology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Marilina Nantron
- Departments of Hematology-Oncology, Istituto Giannina Gaslini, Genoa, Italy
| | - Bruno De Bernardi
- Departments of Hematology-Oncology, Istituto Giannina Gaslini, Genoa, Italy
| | - Carlo Gandolfo
- Pediatric Interventional Radiology and Neuroradiology Unit, Istituto Giannina Gaslini, Genoa, Italy
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Abstract
Back pain is a common presenting complaint to the emergency department. The key to proper evaluation is a history and physical examination focused on determining if any red flags for serious disease are present. If no red flags are present, the patient most likely has nonspecific back pain and their symptoms will resolve in 4 to 6 weeks. No diagnostic testing is required. For patients with red flags, a focused history and examination in conjunction with diagnostic laboratory tests and imaging determine whether the patient has an emergent condition such as herniated disc, epidural compression, or spinal infection.
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Affiliation(s)
- David Della-Giustina
- Emergency Medicine, Yale School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519-1315, USA.
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Anand AK, Venkadamanickam G, Punnakal AU, Walia BS, Kumar A, Bansal AK, Singh HM. Hypofractionated stereotactic body radiotherapy in spinal metastasis - with or without epidural extension. Clin Oncol (R Coll Radiol) 2015; 27:345-52. [PMID: 25726363 DOI: 10.1016/j.clon.2015.01.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 12/11/2014] [Accepted: 01/30/2015] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- A K Anand
- Department of Radiation Oncology, Max Super Speciality Hospital, New Delhi, India.
| | - G Venkadamanickam
- Department of Radiation Oncology, Max Super Speciality Hospital, New Delhi, India
| | - A U Punnakal
- Department of Radiation Oncology, Max Super Speciality Hospital, New Delhi, India
| | - B S Walia
- Department of Neurosurgery, Max Super Speciality Hospital, New Delhi, India
| | - A Kumar
- Department of Radiodiagnosis, Max Super Speciality Hospital, New Delhi, India
| | - A K Bansal
- Division of Medical Physics, Max Super Speciality Hospital, New Delhi, India
| | - H M Singh
- Division of Medical Physics, Max Super Speciality Hospital, New Delhi, India
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