We retrospectively analyzed thirty-three patients (21 males, 12 females) with malignancy induced spinal cord compression (SCC). The mean age of the patients was 42.8 years and almost half (51%) of them presented with SCC. Mean duration of symptoms was 4.5 months and the mean interval between the original diagnosis of cancer and the development of SCC was 14.6 months. Back pain was the most frequent (97%) symptom with an equal number of patients having subjective or objective evidence of lower limb weakness. Majority (73%) of the patients were non-ambulatory at the time of diagnosis. Spinal level involvement was mostly thoracic (62%) followed by lumber (38%). Breast cancer was the commonest underlying malignancy (21%). Lung (12%), prostrate (12%), multiple myeloma (9%), and carcinoma with unknown primary (12%) were also frequently encountered. There was an overall response rate of 22% to the therapeutic interventions: mostly observed in the ambulatory patients. Only 7% of the non-ambulatory patients regained ability to walk. None of the responders had bladder or bowel dysfunction. Twenty-two percent of the responders are still ambulatory with a mean follow-up of six months

Abubakar, S

Alam, F

Altafullah, I

Khan, A

Malik, I

Shaheen, H

English

eCommons@AKU

eCommons@AKUSection of Nephrology Department of MedicineMarch 1991Epidural spinal cord compression from metastaticcancer: clinical features and managementH ShaheenAga Khan UniversityS AbubakarAga Khan UniversityI MalikAga Khan UniversityI AltafullahAga Khan UniversityF AlamAga Khan UniversitySee next page for additional authorsFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_nephrolPart of the Nephrology CommonsRecommended CitationShaheen, H., Abubakar, S., Malik, I., Altafullah, I., Alam, F., Khan, A. (1991). Epidural spinal cord compression from metastatic cancer:clinical features and management. Journal of Pakistan Medical Association, 41(3), 60-62.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_nephrol/23AuthorsH Shaheen, S Abubakar, I Malik, I Altafullah, F Alam, and A KhanThis article is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_med_nephrol/23EPIDURAL SPINAL CORD COMPRESSION FROMMETASTATIC CANCER: CLINICAL FEATURES ANDMANAGEMENTPages with reference to book, From 60 To 62 Hina Shaheen, Saleem Abubakar, Imtiaz Malik, Irfan Altafullah, Feroz Alam, Ata Khan ( Department of Medicine, The AgaKhan University Hospital, Karachi. ) ABSTRACT We retrospectively analyzed thirty-three patients (21 males, 12 females) with malignancy inducedspinal cord compression (SCC). The mean age of the patients was 42.8 years and almost half (51%) ofthem presented with SCC. Mean duration of symptoms was 4.5 months and the mean interval betweenthe original diagnosis of cancer and the development of SCC was 14.6 months. Back pain was the mostfrequent (97%) symptom with an equal number of patients having subjective or objective evidence oflower limb weakness. Majority (73%) of the patients were non-ambulatory at the time of diagnosis.Spinal level involvement was mostly thoracic (62%) followed by lumber (38%). Breast cancer was thecommonest underlying malignancy (21%). Lung (12%), prostrate (12%), multiple myeloma (9%), andcarcinoma with unknown primary (12%) were also frequently encountered. There was an overallresponse rate of 22% to the therapeutic interventions: mostly observed in the ambulatory patients. Only7% of the non-ambulatory patients regained ability to walk. None of the responders had bladder orbowel dysfunction. Twenty-two percent of the responders are still ambulatory with a mean follow-up ofsix months (JPMA 41: 60, 1991).INTRODUCTION Spinal cord compression (SCC) is one of the commonest neurologic complications seen in patientssuffering from cancer. At autopsy, its occurrence is documented in approximately 5% of patients withmalignancy1. SCC is an oncologic emergency because delay in recognition and without urgenttreatment, permanent neurologic damage may occur. SCC usually occurs in the setting of previouslydiagnosed malignancy but a sizeable proportion (8% - 47%) may present with SCC as the initialclinical manifestation of underlying cancer1-3. Management and the results of treatment depend uponthe duration of symptoms prior to the diagnosis, degree of neurologic deficit, promptness ofintervention, type of treatment and the underlying malignancy. At the Aga Khan University Hospital,we performed a retrospective analysis of thirty-three patients with malignancy induced SCC. Westudied the clinical features, site of vertebral involvement, type of underlying malignancy, subsequentmanagement and survival. We also compared these data with the study from Memorial Hospital2.PATIENTS AND METHODS All patients developing SCC who had a prior diagnosis of cancer or those presenting with SCC inwhom malignancy was subsequently found to be the cause of SCC were eligible for this study. On apre-set format, .information was collected regarding the clinical features at the time of diagnosis.Origin of the primary neoplasm was ascertained from review of the clinical findings and the availablepathologic material. Level of the cord compression was determined on the basis of clinical findings,plain x-rays, CT scan and myelogram when available. Details of management, response to treatmentand follow-up data were obtained from the case records.RESULTS Thirty three patients were eligible for the study. The clinical features are presented in Table I.Almost two-thirds of the patients were male. Median age was 42.8 years. Slightly more than half (52%)presented with SCC as the initial manifestation of underlying malignancy; in the remainder itdeveloped after a mean interval of 11.8 months (range 0-5 years) after the original diagnosis of cancer.Patients had symptoms related to SCC for an average of 4.5 months (range 1 day -2 years). Back pamwas the commonest finding. Sensory deficit and autonomic dysfunction were frequently observed(45.5% each), whereas ataxia was uncommon (6%). Most of the patients (73%) were non-ambulatoryat the time of diagnosis. Level of spinal involvement was mainly thoracic (62%), followed by lumbar(38%). One patient had compression at more than one site. Primary tumours causing SCC are listed inTable II.Breast cancer was the commonest cause of SCC in females. In males, lung and prostrate werefrequently encountered. The results of treatment are summarized in Table III.Only eighty-two percent of the patients received treatment. Rest were felt to have SCC for too long atime period to benefit from any treatment. Majority (85%) received steroids, followed by chemotherapy(74%) and radiotherapy (33%). Decompression laminectomy was performed in fifteen percent of thepatients. Follow-up is available on 67% of patients, 22% of them are still fully ambulatory. Best resultswere achieved in those who were ambulatory at the time of presentation and did not have bladder orbowel dysfunction. Fifty percent of the patients who were ambulatory remained so, however only 9%of the patients who were non-ambulatory were able to walk again. Of those who remained or regainedambulatory status, none had bladder or bowel dysfunction. Seventy-two percent of the patients diedwithout resolution of SCC, 22% are alive and ambulatory, rest alive but non-ambulatory. The medianduration of follow-up is six months.DISCUSSION SCC can be a devastating neurologic complication of cancer. Delay in diagnosis and initiation oftherapy may result in jrreversible neurologic deficit4. Hence early recognition and prompt interventionis essential for a favourable clinical outcome. Autopsy studies indicate that approximately 5% of thecancer patients develop extra-dural spinal metastases, many of them remain asym-ptomatic duringlife1. Vast majority of the cases of SCC are caused by extra-dural rather than intra-medullarycompression of the spine2. Primary tumours causing SCC most commonly arise from lung, breast,prostrate and kidney3. In this study, two-thirds of the patients were males. This is similar to Memorialstudy2. However, our patients had a mean age of 42.8 years which is much lower than 58 years reportedin that study. Reason for this observation remain unknown although it may be related to lower lifeexpectancy. Almost half of our patients presented with SCC as compared to less than ten percent in theMemorial study2. However, others have observed this mode of presentation in upto 47% of theirpatients1,3. The earliest and the most important symptom of SCC is back pain. It has been observed in96% of cases in the Memorial study2 and 97% of our patients. It precedes the onset of SCC by 7 weeksto almost 7 months5. Hence the development of back pain in patients with cancer should be taken veryseriously and may possibly be an early indicator of SCC. Motor dysfunction (subjective or objectiveweakness) was observed equally frequently in ours and Memorial studies2 (97% vs 87%). Distributionof sensory dysfunction (45% vs 59%) and ataxia (6% vs 3%) is also very similar. Duration of thesymptoms due to SCC prior to the establishment of the diagnosis varied from 1 day to 2 years.Similarly, time interval between the initial diagnosis of cancer and development of SCC varied from oto 5 years, the longest interval was observed in patients with carcinoma of breast. Level of spinalinvolvement waâthoracic in 62% and lumbar in 38% of the cases. In the Memorial series2 15% of theblocks were cervical, 69% thoracic and 16% lumbosacral. Absence of cervical SCC in our seriesremains unexplained although small size of this study and lower number of lung cancer patients may bepartly responsible for this finding. Commonest cause of SCC in our study is breast cancer which differsfrom the Memorial study2. Since Aga Khan Hospital is not a radiation oncology centre and lung cancermore often requires radiotherapy, the pattern of referral of patients may explain this difference. It wouldbe interesting to look at data from Jinnah Postgraduate Medical Centre, Karachi or other radiotherapycentres in the country. Distribution of other tumours is quite similar to the Memorial study2. Outcomeof the treatment depends upon the degree of neurologic deficit already present and its duration prior tothe diagnosis6-10. Fifty percent of our patients who were ambulatory remained so for a period of 2months to over one year. Only seven percent of the non-ambulatory patients became ambulatory (50%vs 7%). This is similar to the Memorial study2 (60% vs 7%). Our study also demonstrates thatdevelopment of autonomic dysfunction is a poor prognostic factor and none of our patients withbladder or bowel dysfunction responded to any measures. This has been shown in other studies as wellwhere two-thirds of the patients with autonomic dysfunction failed to achieve any benefit4. This is inmarked contrast to those without autonomic dysfunction where more than fifty percent remainambulatory4. Steroids are commonly used for the SCC to decrease vasogenic edema in the compressedcord11-14 and results in stabilization of the neurologic deficit. Decompression laminectomy may notoffer any additional advantage over radiotherapy alone2,11,15. Its role may be confined to the patientswho have received prior radiation, require a diagnostic procedure and those with pathologiccompression fracture, known radioresistant tumours (melanoma, sarcoma etc) or with destruction of thespine by a paraspinous tumour. However, more recent introduction of vertebral body resection, tumourexcision and immediate stabilization of spine has shown excellent responses16-18. Most of our patientshad dense paraplegia at the time of diagnosis. Vast majority of these patients did not respond to steroidsand no radiotherapy was given. However, almost half of the ambulatory patients remained so aftertreatment with steroids and radiotherapy. Twenty-two percent of our patients are still alive andambulatory with a mean follow-up of six months. In conclusion, malignancy induced SCC must be partof the differential diagnosis ofa patient who presents with back pain and leg weakness. In those withprior cancer, back pain is usually the earliest sign. The condition requires prompt diagnosis and earlyintervention to prevent irreversible neurologic damage. Commonest tumour causing SCC is breast infemales and lung in males. If diagnosed early, and treatment started while the patient is still ambulatory,the clinical outcome may be significantly improved.REFERENCE 1. Barrons, K.D., 1-lirano, A., Araki, S. and Terry, RD. Experiences with metastalic neoplasmsinvolving the spinal cord. Neurology, 1959; 9: 91.2. Gilbert, R.W., Kim, J.H and Posner, J.B. Epidural spinal cord compression from metastatic tumor;diagnosis and treatment. Ann. Neurol., 1978; 3: 40.3. Stark, R.J., Henson, R.A. and Evans, S.J.W. Spinal metastases. A retrospective sur from a generalhospital. Brain, 1982; 105: 189.4. Delaney,T.F. and Oldfield, E.H. Spinal cord compression, in cancer principlesand practice ofOncology. Edited by Devita, Heliman, Rosenberg. Philadelphia, Lippincott, 1989, p. 1978.5. Rodriguez, M. and Dinapoli, R.P. Spinal cord compression; with repeated reference to metastaticepidural tumors. Mayo Clin. Proc., 1980; 55:442.6. Posner, J.B. Spinal cord compression; a neurologic emergency. Clin. Bull., 1971; 1: 65.7. Tarlov, LM., Klinger, H. and Vitale. S. Spinal cord compression studies. 1. Experimental techniquesto produce acute and gradual compression. Arch. Neurol. Psychiatry, 1957; 70: 813.8. Tarlov, l.M. and Kiinger, H. Spinsl cord compression studies. II. Time limits for recovery after acutecompression in dogs. Arch. Neurol. Psychiatry, 1954: 71: 271.9. Tarlov, LM. Spinal cord compression studies, Ill. Time limits for recovery after gradual compressionin dogs. Arch. Neurol. Psychiatry, 1954; 71: 588.10. Martenson, J.A. Jr., Evans, R.G., Lie, M.R., llstrup. D.M.. Dinapoli, R.P., Ebersold, M.J. and Earle,J.D. Treatment outcome and complications in patients treated for malignant epidural spinal cordcompression (SCC).). Neurooncol., 1985; 3: 77.11. Ushio, Y., Posner, R., Posner, J.B. and Shaprio, W.R. Experimental spinal cord compression byextradural neoplasms. Neurology, 1977; 27: 422.12. Ikeda, H., Ushio, Y., Hayakawa, T. and Mogami, H. Edema and circulatory disturbances in thespinal cord compressed by epidural neoplasms in rabbits. J. Neurosurg,, 1980; 52:203.13. Kato, A., Ushio, Y., Hayakawa, T., et al. Circulatory disturbances of the spinal cord with epiduralneoplasms in rats.). Neurosurg., 1985; 63: 260.14. Weissman, D.E. Glucocorticoid treatment for brain metastases and epidural spinal cordcompression; a review.). Clin. Oncol., 1988; 6: 543.15. Young. R.F., Post, EM. and King. GA. Treatment of spinal epidural metastases; randomizedprospective comparison of laminectorny and radiotherapy. 3. Neurosurg,, 1980; 53: 741.16. Harrington, K.D. Anterior cord decompression and spinal stabilization for patients with metastaticlesions of the spine.). Neurosurg., 1984; 61: 107.17. Siegel. T., Siegel, T. Surgical decompression of anterior and posterior malignant epidura! tumorscompressing the spinal cord; a prospective study. Neurosurgery, 1985; 17: 424.18. Sundaresan, N., Galicieb, J.H., Lane, 3M., et al. Treatment of neoplastic epidural cord compressionby vertebral body resection and stabilization.). Neurosurg., 1985; 63: 676.

Epidural spinal cord compression from metastatic cancer: clinical features and management

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Epidural spinal cord compression from metastatic cancer: clinical features and management

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