Malignant epidural spinal cord compression associated with a paravertebral mass: its radiotherapeutic outcome on radiosensitivity

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.

Radiotherapy and radiosurgery for metastatic spine disease: what are the options, indications, and outcomes?

STUDY DESIGN

Systematic literature review.

OBJECTIVE

To determine the options, indications, and outcomes for conventional radiotherapy and radiosurgery for metastatic spine disease.

METHODS

Three research questions were determined through a consensus among a multidisciplinary panel of spine oncology experts. A systematic review of the literature was conducted regarding radiotherapy and radiosurgery for metastatic spine disease using PubMed, Embase, the Cochrane Evidence Based Medicine Database, and a review of bibliographies of reviewed articles.

RESEARCH QUESTIONS

1. What are the clinical outcomes of the current indications for conventional radiotherapy alone and stereotactic radiosurgery for metastatic spine disease? 2. What are the current dose recommendations and fractionation schedules for conventional spine radiotherapy and stereotactic radiosurgery for metastatic spine disease? 3. What are the current known patterns of failure and complications after conventional spine radiation and stereotactic radiosurgery for metastatic spine disease?

RESULTS

For conventional radiotherapy, the initial literature search yielded a total of 531 potentially relevant abstracts. Each of these abstracts was reviewed for relevance, and 62 were selected for in-depth review. Forty-nine studies met all the inclusion criteria. References from the articles included in the analysis and review articles were also examined for potential inclusion in the study. For conventional radiotherapy, 3 randomized trials (high-quality evidence), 4 prospective studies (moderate-quality evidence), and over 40 nonprospective data sets (low- or very-low-quality evidence) that included over 5000 patients in the literature were included in this review. Drawing from the same databases, a systematic search for radiosurgery yielded 195 abstracts, of which 29 met all inclusion criteria. They all represented single-institution reports (low- or very-low-quality data). No randomized data are available for spine radiosurgery.

CONCLUSION

A systematic review of the available evidence suggests that conventional radiotherapy is safe and effective with good symptomatic response and local control, particularly for radiosensitive histologies. A strong recommendation can be made with moderate quality evidence that conventional fractionated radiotherapy is an appropriate initial therapy option for patients with spine metastases in cases in which no relative contraindication exists. A systematic review of the available evidence suggests that radiosurgery is safe and provides an incremental benefit over conventional radiotherapy with more durable symptomatic response and local control independent of histology, even in the setting of prior fractionated radiotherapy. A strong recommendation can be made with low-quality evidence that radiosurgery should be considered over conventional fractionated radiotherapy for the treatment of solid tumor spine metastases in the setting of oligometastatic disease and/or radioresistant histology.

A score predicting posttreatment ambulatory status in patients irradiated for metastatic spinal cord compression

PURPOSE

To create a scoring system to predict ambulatory status after radiotherapy (RT) for metastatic spinal cord compression (MSCC).

METHODS AND MATERIALS

On the basis of a multivariate analysis of 2096 MSCC patients, a scoring system was developed. This included the five prognostic factors significantly associated with post-RT ambulatory status: primary tumor type, interval between tumor diagnosis and MSCC, visceral metastases, motor function before RT, and time developing motor deficits before RT. The score for each factor was determined by dividing the post-RT ambulatory rate (as a percentage) by 10. Total scores represented the sum of the scores for each factor and ranged between 21 and 44 points. Patients were divided into five groups according to this score.

RESULTS

The post-RT ambulatory rates were 6% (24 of 389) for patients with scores of </=28 points, 44% (121 of 278) for those with 29-31 points, 70% (212 of 303) for those with 32-34 points, 86% (315 of 266) for those with 35-37 points, and 99% (750 of 760) for those with >/=38 points. The 3-month survival rates were 29%, 62%, 77%, 84%, and 98%, respectively. The 6-months survival rates were 6%, 31%, 42%, 61%, and 93%, respectively.

CONCLUSIONS

Because patients with scores of </=28 points had poor functional outcome after RT and extraordinarily poor survival rates, short-course RT to decrease pain or best supportive care may be considered. Patients with scores of 29-37 points should be considered surgical candidates, because RT-alone results were not optimal. Patients with scores of >/=38 points seem to have excellent results with RT alone.

Stereotactic radiosurgery for spinal metastases from renal cell carcinoma

Object. The role of stereotactic radiosurgery in treating renal cell carcinoma (RCC) metastases to the spine has previously been limited. In this study the authors evaluated the clinical outcome in patients with spinal RCC who underwent single-fraction radiosurgery.

Methods. Forty-eight patients with 60 RCC metastases to the spine (six cervical, 26 thoracic, 18 lumbar, and 10 sacral) were treated with a single-fraction radiosurgery technique and were followed for a period of 14 to 48 months (median 37 months).

All patients were successfully treated in an outpatient setting. The tumor volume ranged from 5.5 to 203 cm3 (mean 61.9 cm3). Forty-two of the total 60 lesions had been previously treated with external-beam radiation therapy (EBRT). The maximum tumor dose was maintained at 17.5 to 25 Gy (mean 20 Gy). The volume of the spinal cord exposed to greater than 8 Gy ranged from 0.01 to 3 cm3 (mean 0.64 cm3); the volume of the spinal canal at the cauda equina level exposed to greater than 8 Gy ranged from 0.01 to 2.2 cm3 (mean 0.65 cm3). No radiation-induced toxicity occurred during the follow-up period. Axial and radicular pain improved in 34 (89%) of 38 patients who were treated primarily for pain. Tumor control was demonstrated in seven of eight patients treated primarily for radiographically documented tumor progression. In time six patients required open surgical intervention for tumor progression that had caused neurological dysfunction after radiosurgery.

Conclusions. Spinal radiosurgery can be a successful therapeutic modality for the delivery of large-dose single-fraction radiation to RCC spinal metastases that are often poorly controlled with conventional EBRT modalities.

Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression

PURPOSE

To study five radiotherapy (RT) schedules and potential prognostic factors for functional outcome in metastatic spinal cord compression (MSCC).

PATIENTS AND METHODS

One thousand three hundred four patients who were irradiated from January 1992 to December 2003 were included in this retrospective review. The schedules of 1 x 8 Gy in 1 day (n = 261), 5 x 4 Gy in 1 week (n = 279), 10 x 3 Gy in 2 weeks (n = 274), 15 x 2.5 Gy in 3 weeks (n = 233), and 20 x 2 Gy in 4 weeks (n = 257) were compared for motor function, ambulatory status, and in-field recurrences. The following potential prognostic factors were investigated: age, sex, performance status, histology, number of involved vertebra, interval from cancer diagnosis to MSCC, pretreatment ambulatory status, and time of developing motor deficits before RT. A multivariate analysis was performed with the ordered logit model.

RESULTS

Motor function improved in 26% (1 x 8 Gy), 28% (5 x 4 Gy), 27% (10 x 3 Gy), 31% (15 x 2.5 Gy), and 28% (20 x 2 Gy); and posttreatment ambulatory rates were 69%, 68%, 63%, 66%, and 74% (P = .578), respectively. On multivariate analysis, age, performance status, primary tumor, involved vertebra, interval from cancer diagnosis to MSCC, pretreatment ambulatory status, and time of developing motor deficits were significantly associated with functional outcome, whereas the RT schedule was not. Acute toxicity was mild, and late toxicity was not observed. In-field recurrence rates at 2 years were 24% (1 x 8 Gy), 26% (5 x 4 Gy), 14% (10 x 3 Gy), 9% (15 x 2.5 Gy), and 7% (20 x 2 Gy) (P < .001). Neither the difference between 1 x 8 Gy and 5 x 4 Gy (P = .44) nor between 10 x 3 Gy, 15 x 2.5 Gy, and 20 x 2 Gy (P = .71) was significant.

CONCLUSION

The five RT schedules provided similar functional outcome. The three more protracted schedules seemed to result in fewer in-field recurrences. To minimize treatment time, the following two schedules are recommended: 1 x 8 Gy for patients with poor predicted survival and 10 x 3 Gy for other patients. Results should be confirmed in a prospective randomized trial.

A prospective evaluation of two radiotherapy schedules with 10 versus 20 fractions for the treatment of metastatic spinal cord compression

BACKGROUND

The optimal treatment of patients with metastatic spinal cord compression (MSCC) is still being debated. The current observational multicenter study, performed prospectively by the authors, evaluated two radiotherapy (RT) schedules and prognostic factors with respect to functional outcome

METHODS

In the current study, 214 patients with MSCC were irradiated between April 2000 and September 2003 with 30 gray (Gy) per 10 fractions per 2 weeks (n = 110) or with 40 Gy per 20 fractions per 4 weeks (n = 104). Motor function and ambulatory status were evaluated before RT and until 6 months after RT. The following potential prognostic factors were investigated: RT schedule, performance status, age, number of irradiated vertebrae, type of primary tumor, pretreatment ambulatory status, and length of time developing motor deficits before RT.

RESULTS

Both groups were balanced for patient characteristics and potential prognostic factors. Motor function improved in 43% of patients after 30 Gy and in 41% of patients after 40 Gy (P = 0.799). Posttreatment ambulatory rates were 60% and 64% (P = 0.708), respectively. A multivariate analysis demonstrated that a slower progression of motor deficits before RT (P < 0.001), a favorable histology of the primary tumor (P < 0.001), and being ambulatory before RT (P = 0.035) were associated with a better functional outcome. RT schedule (P = 0.269) and other variables had no significant impact. Acute toxicity was mild, and late toxicity was not observed during the period of follow-up. Follow-up was 12 (6-28) months in patients surviving >/= 6 months.

CONCLUSIONS

Thirty gray per 10 fractions was preferable to 40 Gy per 20 fractions, because it was associated with similar outcome, less treatment time, and lower costs. The type of tumor, pretreatment ambulatory status, and length of time developing motor deficits before RT were relevant prognostic factors and should be considered in future studies.

Role of radiotherapy in the treatment of motor dysfunction due to metastatic spinal cord compression: comparison of three different fractionation schedules

PURPOSE

The optimum fractionation schedule for radiotherapy (RT) of metastatic spinal cord compression (MSCC) is still debated in the literature. Several reports have compared different fractionation schedules for pain relief. To our knowledge, this retrospective analysis is the first to compare three different schedules for functional outcome.

METHODS AND MATERIALS

For posttreatment functional and ambulatory outcome, three schedules, 30 Gy in 10 fractions (n = 93), 37.5 Gy in 15 fractions (n = 80), and 40 Gy in 20 fractions (n = 74), were compared. Motor function was evaluated by a 6-point scale before and at the end of RT and 3, 6, and 12 months later. A multivariate analysis was performed for functional outcome, including fractionation schedule and the three relevant prognostic factors (primary tumor type, time of developing motor deficits before RT, and ambulatory status).

RESULTS

No significant difference was observed for posttreatment motor function or ambulatory rates among the three schedules. According to the multivariate analysis, the radiation schedule had no significant impact on functional outcome (p = 0.223) in contrast to the three prognostic factors (p <0.001, p <0.001, and p = 0.012).

CONCLUSION

The three fractionation schedules were comparable for functional outcome. The least time-consuming schedule (30 Gy in 10 fractions) should be considered for patients with a markedly reduced life expectancy.

Final results of a prospective study of the prognostic value of the time to develop motor deficits before irradiation in metastatic spinal cord compression

PURPOSE

Metastatic spinal cord compression often requires urgent treatment selection, which could be facilitated by strong prognostic factors. Because only the type of primary tumor and pretreatment ambulatory status are known as prognostic factors for functional outcome, we investigated the prognostic value of the time of motor deficit development before radiotherapy (RT).

METHODS AND MATERIALS

Ninety-eight patients were included between November 1998 and April 2000. Three subgroups were formed, according to time of motor deficit development before RT: 1-7 days (n = 31), 8-14 days (n = 31), and >14 days (n = 36). Ambulatory rates and motor function were evaluated for < or =24 weeks after RT. In a multivariate analysis, all three prognostic factors and radiation parameters were included.

RESULTS

In the >14-day subgroup, improvement occurred significantly (p < 0.001) more often than in the other subgroups (86% vs. 29% and 10%) and the posttreatment ambulatory rate was significantly higher (86% vs. 55% and 35%, p = 0.026). Multivariate analysis revealed the time of development of motor deficits before RT to be the strongest prognostic factor.

CONCLUSION

Functional outcome is significantly better with slower development of motor deficits before RT. This new, independent, prognostic factor must be considered in future trials aiming to define an optimal RT schedule.

Evaluation and treatment of spinal metastases: an overview

Metastases to the spine are a common and somber manifestation of systemic neoplasia. The incidence of spinal metastases continues to increase, likely a result of increasing survival times for patients with cancer. Historically, surgery for spinal metastases has consisted of simple decompressive laminectomy. Results obtained in retrospective case series, however, have shown that this treatment provides little benefit to the patient. With the advent of better patient-related selection practices, in conjunction with new surgical techniques and improved postoperative care, the ability of surgical therapy to play an important and beneficial role in the multidisciplinary care of cancer patients with spinal disease has improved significantly. Controversy remains, however, with respect to the relative merits of surgery, radiotherapy, chemotherapy, or a combination of these treatments.

In this topic review, the literature on spinal column and spinal cord metastases is collated to provide a description of the presentation, investigations, indications for surgical therapy, and the role of adjuvant cancer therapies for patients with spinal metastases. In addition, the authors discuss the different surgical strategies available in the armamentarium of the neurosurgeon treating patients with spinal metastasis.

Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression

STUDY DESIGN

A retrospective chart review was performed.

OBJECTIVE

To determine whether preoperative spinal radiation increases the number of major wound complications in patients with cancer who have symptomatic spinal cord compression.

SUMMARY OF BACKGROUND DATA

Many factors have increased the number of patients hospitalized with symptomatic spinal cord compression after spinal irradiation. The surgical management of metastatic spinal cord compression may be complicated by preoperative radiation.

METHODS

A retrospective review of 123 patients admitted with symptomatic metastatic spinal cord compression from 1970 through 1996 was conducted. The final study population of 85 patients was separated into three treatment groups: 1) radiation only, 2) radiation followed by surgery, and 3) de novo surgery followed by radiation.

RESULTS

The major wound complication rate for patients who had radiation before surgical decompression and stabilization was 32%, or threefold, higher than the 12% observed in patients who had de novo surgery (P < 0.05). No other clinical factor or condition predicted the development of a major wound complication. Patients treated initially with surgery had superior functional outcomes in an analysis stratified by Frankel grade (P < 0.05). Of the ambulatory patients who underwent de novo surgery, 75% remained ambulatory and continent 30 days after treatment, whereas only 50% of those treated with radiation before surgery had similar outcomes.

CONCLUSIONS

Spinal radiation before surgical decompression for metastatic spinal cord compression is associated with a significantly higher major wound complication rate. In addition, preoperative spinal irradiation might adversely affect the surgical outcome.

MRI in the diagnosis and treatment of suspected malignant spinal cord compression

It remains unclear whether MRI is essential in all patients with suspected malignant spinal cord compression (MSCC), or whether some patients can be treated on the basis of plain radiographic findings and neurological examination. A prospective study was carried out of 280 consecutive patients with suspected MSCC, and the results of neurological examination plus plain radiographs were compared with MRI. 201 patients had MSCC (186 extradural, 5 intradural extramedullary and 10 intramedullary) and 11 patients had thecal sac compression without evidence of spinal cord compression. 25% of patients with MSCC had two or more levels of compression, 69% of these involving more than one region of the spine. A paraspinal mass was noted at the site of extradural spinal cord compression in 28%, and only one-third of these were detected on plain radiography. Focal radiographic changes and consistent neurology were present in 91 (33%) patients who had not had previous radiotherapy. MRI confirmed the presence of MSCC in 89/91 patients (specificity and positive predictive value of radiographic/clinical findings 98%) and the level of disease in all. MRI led to a change in the radiotherapy plan in 53% of patients (21% major change). The sensory level when present was four or more segments below the MRI level in 25/121 (21%) patients, and two or more levels above in 8/121 (7%) patients. Although focal radiographic abnormalities with consistent neurological findings, when present, accurately predicted the presence and level of MSCC, whole spine MRI is indicated in most patients with suspected MSCC because the additional information may alter the management plan. Treatment may be appropriately initiated on the basis of focal radiographic changes and consistent neurology if MRI is contraindicated or delayed, and in patients with a poor prognosis. In patients in whom there are no focal radiographic abnormalities and consistent neurological findings, urgent MRI is mandatory before radiotherapy is commenced.

Prognostic significance of the time of developing motor deficits before radiation therapy in metastatic spinal cord compression: one-year results of a prospective trial

PURPOSE

To investigate prospectively the prognostic value of the time of developing motor deficits before radiation therapy (RT) for post-treatment functional outcome in metastatic spinal cord compression.

METHODS AND MATERIALS

From November 1998 until October 1999, 57 patients were included. Two subgroups were formed according to the time of developing motor deficits before RT: 1-14 days (n = 29) and > 14 days (n = 28). Therapeutic effect on motor function was evaluated by an 8-point scale directly, 6, 12, and 24 weeks after RT. Patients with rapid deterioration of motor function within 48 h before RT (n = 14) were evaluated separately.

RESULTS

Directly after RT, 26/28 patients (93%) of the group developing motor deficits > 14 days showed improvement of motor function, in comparison to 3/29 patients (10%) of the group 1-14 days (p < 0.001). Deterioration rates were 0% (> 14 days) and 45% (1-14 days). In patients with rapid deterioration of motor function within 48 h before RT, prognosis was poor (improvement 0%, no change 43%, deterioration 57%). Results were comparable 6, 12, and 24 weeks after RT.

CONCLUSION

A slower development of motor deficits before RT predicts a better post-treatment functional outcome. In patients with rapid deterioration of motor function within 48 h before RT, prognosis was extraordinarily poor. These results support the findings of our preceding retrospective analysis.

Spinal cord compression in prostate cancer: treatment outcome and prognostic factors

BACKGROUND AND PURPOSE

Spinal cord compression (SCC) is an important complication of metastatic prostate cancer. We have analysed patients treated at the Royal Marsden Hospital to assess treatment outcome and prognostic factors in this patients group.

MATERIALS AND METHODS

We performed retrospective analysis of 69 patients with spinal cord compression and prostate cancer treated at the Royal Marsden Hospital.

RESULTS

At presentation 40 (58%) patients were non-ambulant and 52% were catheterised. Diagnosis was established by myelography in 42% and magnetic resonance imaging (MRI) in 47% of patients. MRI detected significantly more patients with multiple sites of compression (51 versus 7%, P < 0.001). SCC was present at the initial diagnosis of prostatic cancer in 13 patients and 17 patients had received no hormone treatment prior to diagnosis. Following treatment 36 (52%) patients had a functional improvement of motor power with 25/40 (63%) non-ambulant patients becoming ambulant. Seventy-seven percent of patients who had eventual improvement had some improvement in power within 7 days. On multivariate analysis a single level of compression, no previous hormone therapy and a young age (<65 years) predicted for better outcome. When these factors were included an increased radiation dose (>30 Gy) or the addition of surgery did not improve the functional outcome. Following initial recovery; there was a 45% risk of developing a further episode of cord compression at the same or new site by 2 years with a median time to progression of 236 days (range 47-1215 days). The median survival was 115 days (range 5-2016 days) with 25% of patients surviving for 2 years. Patients with no prior hormone therapy had a median survival of 627 days (range 46-1516 days). Other predictors of improved survival on multivariate analysis were a single site of compression and a haemoglobin over 12 g.

CONCLUSIONS

Treatment of SCC in prostate cancer results in improved motor function in the majority of patients. Long-term survival is possible, especially in good performance status patients with no prior hormone treatment. Survivors remain at high risk of subsequent neurological relapse. An early improvement in motor power is a strong predictor of subsequent functional improvement. MRI detects additional sites of asymptomatic SCC which makes it the investigation of choice.

Radiotherapeutic management of spinal metastases

Radiotherapy remains the primary treatment of malignant epidural spinal cord compression. Therapeutic success depends on diagnosis before the development of neurological compromise and the prompt initiation of radiotherapy. Radiotherapy alone is effective in over 85% of cases of spinal cord compression that occur in highly radioresponsive tumors (multiple myeloma, germ cell or lymphoproliferative tumors). In the more common tumors, like breast, prostate, and lung cancer, response to radiotherapy is based on presenting neurologic deficits, extent of disease, duration of symptoms, and overall clinical status, including other sites of metastatic involvement. Surgery is recommended in addition to radiotherapy in selected cases, and further study is needed to better define the prognostic and neurological parameters for the surgical management of spinal cord compression. Improvements in outcome in the treatment of spinal cord compression will require approaches like combined modality therapy because of the limitations primarily imposed by the radiation tolerance of the spinal cord.