Abstract
Simple SummaryIn a retrospective matched-pair study including data of prospectively evaluated patients who were treated for metastatic spinal cord compression, 79 patients assigned to surgery plus radiotherapy were compared to 79 patients receiving radiotherapy alone. Improvement of motor function occurred more significantly often after surgery plus radiotherapy, whereas no significant differences were found for post-treatment ambulatory rates, local progression-free survival, overall survival, and freedom from in-field recurrence. Ten patients died within 30 days after radiotherapy alone and 12 patients within 30 days after surgery. More than one third of surgically treated patients did not complete their radiotherapy due to early death or decreased performance score following surgery. Thus, when selecting a patient for upfront surgery, the individual patient’s prognosis must be considered and weighed against the risk of perioperative complications and 30-day mortality.In 2005, a randomized trial showed that addition of surgery to radiotherapy improved outcomes in patients with metastatic spinal cord compression (MSCC). Since then, only a few studies compared radiotherapy plus surgery to radiotherapy alone. We performed a retrospective matched-pair study including data from prospective cohorts treated after 2005. Seventy-nine patients receiving radiotherapy alone were matched to 79 patients assigned to surgery plus radiotherapy (propensity score method) for age, gender, performance score, tumor type, affected vertebrae, other bone or visceral metastases, interval tumor diagnosis to MSCC, time developing motor deficits, and ambulatory status. Improvement of motor function by ≥1 Frankel grade occurred more often after surgery plus radiotherapy (39.2% vs. 21.5%, p = 0.015). No significant differences were found for post-treatment ambulatory rates (59.5% vs. 67.1%, p = 0.32), local progression-free survival (p = 0.47), overall survival (p = 0.51), and freedom from in-field recurrence of MSCC (90.1% vs. 76.2% at 12 months, p = 0.58). Ten patients (12.7%) died within 30 days following radiotherapy alone and 12 patients (15.2%) died within 30 days following surgery (p = 0.65); 36.7% of surgically treated patients did not complete radiotherapy as planned. Surgery led to significant early improvement of motor function and non-significantly better long-term control. Patients scheduled for surgery must be carefully selected considering potential benefits and risk of perioperative complications.
Highlights
Metastatic spinal cord compression (MSCC) is considered an oncologic emergency and occurs, depending on the primary tumor type, in up to 10% of patients with cancer or malignant hematological disease [1–3]
In 2005, a randomized trial showed that the addition of upfront decompressive surgery to radiotherapy was associated with improved outcomes, including post-treatment ambulatory status and survival in selected patients with a good performance status, an expected survival of at least 3 months, involvement of a single area, and paraplegia for no longer than 48 h [4]
After final propensity-score matching, 79 patients receiving radiotherapy alone remained for comparisons with the cohort of 79 patients assigned to surgery plus radiotherapy
Summary
Metastatic spinal cord compression (MSCC) is considered an oncologic emergency and occurs, depending on the primary tumor type, in up to 10% of patients with cancer or malignant hematological disease [1–3]. In an additional retrospective matched-pair study of 201 patients with MSCC from an unfavorable primary tumor matched 1:2 (similar approach as in the previous study), post-treatment outcomes were not significantly different [6]. In a small retrospective cohort study (n = 88) reported in 2019, aggravation of impending paralysis was observed in 16.7% of 18 patients receiving decompression and stabilization, in 13.3% of 15 patients receiving stabilization without decompression and in 16.7% of 55 patients treated with radiotherapy [7]. Considering the low number of studies comparing surgery plus radiotherapy and radiotherapy alone for MSCC and their significant limitations, it becomes obvious that additional studies are required. Techniques of both surgery and radiotherapy have significantly improved since 2005 [8–10]
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