What is the benefit of EBRT alone given for malignant spinal cord compression?

From Cancer Guidelines Wiki

What is the benefit of EBRT alone given for malignant spinal cord compression?

Spinal cord compression/nerve root compression (with or without surgery)

Spinal cord compression is an oncological emergency. It is a potentially devastating complication of metastatic prostate cancer that can result in pain, paraplegia, incontinence and loss of independence. It is not uncommon for sequelae of metastatic disease to occur in between 1% and 12% of patients.[1] No randomised controlled trials were found that examined treatments for spinal cord compression specifically for prostate cancer patients. Therefore, the systematic reviews were broadened to cover any trials that included prostate cancer patients.

Radiotherapy is an effective and well-tolerated treatment for metastatic bone pain. It has been the cornerstone of management for malignant spinal cord compression (MSCC) for decades as it is a noninvasive approach and associated with relatively low toxicity. Its effectiveness is based largely on retrospective outcomes from single institution series. There are no randomised trials comparing radiotherapy alone with either surgery alone or dexamethasone alone for malignant spinal cord compression. There is one randomised trial of 276 patients comparing two fractionation schedules (16Gy/2f vs 30Gy/8f) that gives outcome data of radiation alone.[2] In this trial only 14% of the entire cohort were prostate patients.

The Maranzano[2] trial confirms the importance of radiotherapy in the management of spinal cord compression, with 90% of ambulatory patients still walking at one month and 28% of non-ambulatory patients regaining ability to walk.[2] However, regaining ambulation if paraplegic is rare. More thanhalf of patients experienced pain relief but overall survival was poor, with median survival of four months. Although no significant differences in the fractionation schedules were seen, clinically significant differences could not be excluded. One-year survival was 18% for the longer fractionation versus 10% with the shorter approach. Five (versus none) infield recurrences were seen in the shorter fractionation group.

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Evidence summary and recommendations

Evidence summary Level References
There are no randomised trials comparing radiotherapy with either surgery or dexamethasone alone for spinal cord compression. There is one randomised trial comparing two different fractionation schedules for unfavourable risk malignant spinal cord compression. It demonstrated no significant differences between the schedules, though clinically important differences cannot be excluded II [2]
Evidence-based recommendationQuestion mark transparent.png Grade
For patients with malignant spinal cord compression the use of radiation is recommended. The optimal fractionation schedule of radiotherapy is unknown.
D
Evidence-based recommendationQuestion mark transparent.png Grade
Patients being treated with radiation for spinal cord compression should be given

dexamethasone at time of diagnosis.

B


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References

  1. Tazi H, Manunta A, Rodriguez A, Patard JJ, Lobel B, Guillé F. Spinal cord compression in metastatic prostate cancer. Eur Urol 2003 Nov;44(5):527-32 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14572749.
  2. 2.0 2.1 2.2 2.3 Maranzano E, Bellavita R, Rossi R, De Angelis V, Frattegiani A, Bagnoli R, et al. Short-course versus split-course radiotherapy in metastatic spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol 2005 May 20;23(15):3358-65 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15738534.

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Appendices