at: inbox

Oncology - Metastatic Spinal Cord Compression & Brain Metastases - Fast Facts | NEJM Resident 360

Metastatic Spinal Cord Compression (MSCC)

Epidural spinal cord compression secondary to metastases is an oncologic emergency and one of the most feared complications of malignancy. If acute cord compression is suspected, workup and management must not be delayed. The most common cancers associated with spinal cord compression are:

• prostate cancer

• lung cancer

• breast cancer

• less-common cancers, including lymphoma, melanoma, renal cancer, sarcoma, and multiple myeloma

Acute Cord Compression Due to Metastatic Cancer to a Vertebral Body

An axial view (Panel A) shows a thoracic vertebral body infiltrated by a metastatic tumor. The tumor extends from the bone and narrows the spinal canal, causing distortion and compression of the spinal cord (see the interactive graphic, available at NEJM.org). A parasagittal view of a T2-weighted MRI (Panel B) shows metastasis of renal cancer to the T10 vertebral body and pedicle, causing severe narrowing of the spinal canal.
(Source: Acute Spinal Cord Compression. N Engl J Med 2017.)

Symptoms

Pain is typically the first symptom. It may be referred or radicular in nature. Pain from cord compression can be confused with degenerative joint disease (DJD), but the following factors help distinguish the two conditions:

• Pain from metastatic epidural compression can occur at any vertebral level; DJD pain is usually cervical or lumbar.

• Patients with DJD usually have a history of similar-type pain.

• Lying down usually alleviates pain from DJD but often aggravates pain from metastatic cord compression.

Other symptoms that typically follow onset of pain from metastatic cord compression include:

• weakness

• sensory loss

• incontinence

• lower-extremity weakness, saddle anesthesia, and urinary retention/overflow incontinence; indicate compression at the level of the cauda equina (cauda equina syndrome)

Review the examination technique for spinal cord compression in an interactive graphic here. 

The following table provides an overview of the clinical features, investigations, and management plan for differential diagnoses of acute spinal cord compression:

(Source: Acute Spinal Cord Compression. N Engl J Med 2017.)

Diagnosis & Management

• Review recent bone scan/positron-emission tomography (PET) scan or other imaging for spinal metastases.

• Perform full neurological examination, and if patient is not neutropenic, rectal exam for rectal tone.

• If there is high suspicion of cord compression, intravenous (IV) dexamethasone should be administered immediately, without waiting for confirmational imaging.

• MRI is the test of choice; CT-based myelography is an alternative when there are contraindications or delays in obtaining an MRI.

• Radiotherapy used to be standard of care for cord compression treatment, but a 2005 randomized, controlled trial showed improved outcomes with surgical decompression plus radiotherapy.

• Radiation oncology and spine surgery should be consulted immediately upon confirmation of cord compression.

• Evidence is weak to guide the decision to adopt bed rest or recommend mobilization following a diagnosis of metastatic spinal cord compression. A Cochrane review found insufficient evidence to support bed rest, mobilization, or use of a spinal brace in the management of metastatic spinal cord compression. The authors recommend that the patient’s overall prognosis including their personal preferences guide whether palliative care is a suitable option.

Brain Metastases

Brain metastases are an important cause of morbidity and mortality among cancer patients and are more common than primary brain tumors.

The most common cancers that metastasize to the brain include:

• lung

• renal cell cancer

• melanoma

• colorectal cancer

Presentation

Patients can present acutely with symptoms of raised intracranial pressure resulting from brain metastases. Other presenting symptoms associated with brain metastases include:

• nausea and vomiting

• headache

• syncope

• seizures

• visual symptoms (e.g., diplopia)

• other neurological symptoms

Management

Management of patients who present with acute symptoms of brain metastases includes:

• steroid treatment (evidence of efficacy is strongest when symptoms are present)

• aim for euvolemia

• review need for antiemetics (see Symptom Management)

• antiepileptic therapy for symptoms of seizure but not as prophylactic treatment

Management by surgery, radiotherapy (stereotactic vs. whole-brain radiotherapy) or palliative care will depend on:

• location of the lesions

• number of metastatic brain lesions

• histological diagnosis (i.e., type of cancer)

• performance status (using ECOG/ WHO or Karnofsky measures)

• control and presence of extracranial metastases

inbox