What is the efficacy of steroids for the treatment of malignant spinal cord compression?

From Cancer Guidelines Wiki

What is the efficacy of steroids for the treatment of malignant spinal cord compression?

Steroids such as dexamethasone are commonly utilised for patients with malignant spinal cord compression, often in conjunction with radiotherapy. They are thought to decrease oedema and thus prevent further impediment of blood supply. An anti-tumour effect in some cases may also play a role. Transient reductions in pain and improvement in neurologic function are well recognised with steroids alone. However, the absolute degree of benefit when combining steroids with radiotherapy is unknown and the recommended dosages are controversial.

There are three small low-quality randomised controlled trials evaluating the efficacy of steroids for malignant spinal cord compression. The Sorensen 1994 study[1] randomised 57 patients to receive high-dose dexamethasone (96mg initial bolus) combined with radiotherapy versus no dexamethasone and radiotherapy. Two trials compared the effects of different doses of dexamethasone as an adjuvant to radiotherapy[2][3] The Vecht 1989 trial randomised 37 patients to an initial dose of either 100mg or 10mg of dexamethasone in addition to radiotherapy.[3] The Graham 2006 trial[2] randomised 20 patients to an initial dose of either 96mg or 16mg dexamethasone combined with radiotherapy but was terminated prematurely because of poor accrual.[2] These studies included only a small (9%) or unspecified percentage of prostate patients and had wide variety of clinical presentations and imaging performed.

Even with small numbers, the Sorensen paper[1] demonstrated the importance of dexamethasone for malignant spinal cord compression, with 59% of those treated with dexamethasone (96mg initialbolus) in addition to radiotherapy ambulant at six months compared with 33% of those treated with radiotherapy alone (p=0.05). The addition of dexamethasone significantly (p=0.046) improved the probability of surviving with gait function in the year following treatment without a significant increase in serious toxicities. The Vecht trial comparing high and low doses of dexamethasone showed no difference in pain, ambulation rates or bladder function between the two arms but the low power of the study (37 patients) cannot exclude clinically important differences.

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Evidence summary and recommendations

Evidence summary Level References
There is one small trial of high-dose dexamethasone and radiotherapy versus radiotherapy alone. This demonstrated a significant improvement in ambulation rates in the steroid arm. II [1]
The optimal dose of steroids is unknown, with one small trial demonstrating no significant difference in efficacy of higher-dose dexamethasone over lower doses. II [3]
Evidence-based recommendationQuestion mark transparent.png Grade
Patients being treated with radiotherapy for malignant spinal cord compression should also receive dexamethasone.
C


Evidence-based recommendationQuestion mark transparent.png Grade
The optimal dose of dexamethasone remains to be defined.
D


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References

  1. 1.0 1.1 1.2 Sorensen D, McCarthy M, Baumgartner B, Demars S. Perioperative immunonutrition in head and neck cancer. Laryngoscope 2009 Jul;119(7):1358-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19459146.
  2. 2.0 2.1 2.2 Graham PH, Capp A, Delaney G, Goozee G, Hickey B, Turner S, et al. A pilot randomised comparison of dexamethasone 96 mg vs 16 mg per day for malignant spinal-cord compression treated by radiotherapy: TROG 01.05 Superdex study. Clin Oncol (R Coll Radiol) 2006 Feb;18(1):70-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16477923.
  3. 3.0 3.1 3.2 Vecht CJ, Haaxma-Reiche H, van Putten WL, de Visser M, Vries EP, Twijnstra A. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology 1989 Sep;39(9):1255-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2771077.

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Appendices