Malignant extradural spinal cord compression in men with prostate cancer

Does T1- and diffusion-weighted magnetic resonance imaging give value-added than bone scintigraphy in the follow-up of vertebral metastasis of prostate cancer?

PURPOSE

To evaluate the effectiveness of limited Magnetic Resonance (MR) images including T1- and diffusion-weighted image (DWI) for monitoring vertebral metastasis in patients with prostate cancer.

MATERIALS AND METHODS

From July 2014 to November 2016, patients diagnosed with spinal metastasis from prostate cancer using 99mTc bone scintigraphy were enrolled. Regardless of the primary local therapy, the changes in spinal metastasis were followed up using bone scan and biparametric MR (T1+DWI). All tests were followed up for more than 3 months.

RESULTS

Among the 14 follow-ups of 10 patients, 6 and 10 (including all progressed cases on bone scan) follow-ups were determined to show progressive disease using bone scan and biparametric MR, respectively. Otherwise, we could have predicted neurologic sequela earlier using biparametric MR. Examination time for biparametric MR was 15 minutes, and it was 4 hours for bone scan, respectively.

CONCLUSIONS

Although bone scan has been considered the standard test for bony metastasis in men with prostate cancer, limited MR including T1 and DWI has an additional benefit in monitoring spinal metastasis in patients who are already diagnosed as having spinal metastasis. The limited MR is more sensitive in detecting progressive disease. In addition, it can reduce neurologic complications caused by spinal metastasis.

Intensity modulated stereotactic body radiation therapy for single or multiple vertebral metastases with spinal cord compression

PURPOSE

The purpose of this study was to evaluate the efficacy and toxicity of intensity modulated radiation therapy with simultaneous integrated boost (SIB-IMRT) for single or multiple vertebral metastases (VM) with spinal cord compression using tomotherapy.

METHODS AND MATERIALS

Thirty patients with 40 VM were treated with SIB-IMRT as initial radiation therapy. Either 40 Gy in 8 fractions or 48 Gy in 16 fractions was prescribed depending on the Katagiri prognostic index. The radiation doses to the spinal cord and other risk organs were reduced to tolerance levels using intensity modulation. One to 4 lesions in consecutive vertebrae were treated in 1 course of SIB-IMRT. Radiologic and physical examinations were performed at 1-3 month intervals after SIB-IMRT. The Barthel index (BI) and numerical rating scale (NRS) were used to evaluate activities of daily living (ADL) and pain status, respectively.

RESULTS

The median follow-up period was 8 months. The NRS significantly dropped at 1 month after SIB-IMRT (P < .0001) and the effect continued for over 2 months. No significant BI decrease was observed at 2 months after SIB-IMRT (P = .7). The 1-year local control rate was 84% (95% confidence interval, 70%-100%). No grade≥2 neurologic toxicity resulting from SIB-IMRT was observed.

CONCLUSIONS

SIB-IMRT could be successfully applied to VM with spinal cord compression in up to 4 consecutive vertebrae. Good ADL preservation and pain control were achieved with acceptable toxicity.

Early diagnosis and treatment is crucial for neurological recovery after surgery for metastatic spinal cord compression in prostate cancer

BACKGROUND

Spinal cord compression is an oncological and surgical emergency. Delays in referral and diagnosis may influence functional outcome. It is therefore important to identify patients who will regain or maintain the ability to walk after surgery. The aim of the present study was to examine current practice for referral and diagnosis of prostate cancer patients with spinal cord compression and to identify prognostic factors for neurological outcome after surgery.

PATIENTS AND METHODS

The study includes 68 consecutive patients with prostate cancer who underwent surgery due to neurological compromise. Intervals from onset of neurological symptoms to referral, diagnosis, and treatment were analyzed in relation to functional outcome. The prognostic significance of preoperative clinical parameters on gait function one month after surgery was evaluated.

RESULTS

Patients who were referred from local hospitals had longer delay to surgery than those who directly presented to the cancer center (p = 0.004). The rate of diagnosis with MRI increased through the week and peaked on Friday, with few patients being diagnosed during weekends. The ability to walk before surgery, hormone-naive prostate cancer, and/or shorter time from loss of ambulation were associated with more favorable neurological outcome. In patients with hormone-refractory disease who were unable to walk before surgery regaining ambulation was associated with: duration of paresis < 48 hours (p = 0.005), good preoperative performance status (p = 0.04), preoperative PSA serum level < 200 ng/ml (p = 0.03), and surgery with posterior decompression and stabilization (p = 0.03).

CONCLUSION

Early diagnosis and rapid treatment of spinal cord compression in prostate cancer patients is crucial for neurological recovery. Raising awareness of the condition among patients at risk and among physicians is of outmost importance as well as improving local and regional guidelines for treatment.

Radium-223 chloride: a potential new treatment for castration-resistant prostate cancer patients with metastatic bone disease

Background

Radium-223 chloride (²²³Ra; Alpharadin) is an alpha-emitting radioisotope that targets areas of osteoblastic metastasis and is excreted by the small intestine. When compared with beta-emitters (eg, strontium-89, samarium-153), ²²³Ra delivers a high quantity of energy per track length with short tissue penetration.

Objective

This review describes the mechanism, radiobiology, and preclinical development of ²²³Ra and discusses the clinical data currently available regarding its safety and efficacy profile.

Methods

Data from clinical trials including abstracts were collected and reviewed using the PubMed Database, as well as the American Society of Clinical Oncology abstract database.

Conclusion

Current bone-targeted therapies fall into two main categories: antiresorptive agents (eg, zoledronic acid, denosumab), which have been shown to delay skeletal-related events, and radiopharmaceuticals (eg, samarium-153), which may have a role in pain palliation. Historically, neither antiresorptive agents nor radiopharmaceuticals have shown definitive evidence of improved overall survival or other antitumor effects in metastatic castrate-resistant prostate cancer (mCRPC). Radiopharmaceuticals are limited by myelosuppresion, thrombocytopenia, and renal excretion. In a recently reported randomized Phase III trial in men with symptomatic bone-metastatic CRPC who had received or were ineligible for docetaxel chemotherapy, ²²³Ra treatment resulted in improved overall survival and delayed skeletal-related events. Toxicity consisted of minor gastrointestinal side effects and mild neutropenia and thrombocytopenia that were rarely severe. Pending regulatory approval, ²²³Ra may represent a unique and distinct option for an important subgroup of patients with mCRPC; future trials should address its use in combination or in sequence with existing and novel agents.