Malignant Epidural Spinal Cord Compression Research Articles

Emergent radiotherapy for spinal cord compression/impingement—a narrative review.

Malignant epidural spinal cord compression (MESCC), often presenting with back pain and motor/sensory deficits, is associated with poor survival, particularly when there is loss of ambulation. The purpose of this review is to evaluate the literature and discuss appropriate workup and management of MESCC, specifically in the emergent setting. A PubMed search was conducted on "spinal cord compression" and "radiation therapy." Articles were analyzed for the purpose of this narrative review. If MESCC is suspected, neurologic examination and complete spine imaging are recommended. Emergent treatment is indicated if there is radiographic evidence of highgrade compression and/or clinically significant motor deficits. Treatment involves a combination of medical management, surgical decompression, radiation therapy (RT), and rehabilitation. For motor deficits, emergent initiation of high dose steroids is recommended. Circumferential surgical decompression ± stabilization followed by RT provides superior clinical outcomes than RT alone. For patients whom surgery is not reasonable, RT alone may provide significant treatment response which depends on radioresponsiveness of the pathology. Systemic therapy, if indicated, is typically reserved till after primary treatment of MESCC, but patients with chemoresponsive tumors may receive primary chemotherapy. The selected RT schedule should be personalized to each patient and commonly is 30 Gy in 10 fractions (fx), 20 Gy in 5 fx, or 8 Gy in 1 fx. MESCC recurrence may be treated with additional RT, if within the spinal cord tolerance, or surgery. Stereotactic body radiation therapy (SBRT) has been used for high grade MESCC in patients with relatively intact neurologic function at a few centers with a very robust infrastructure to support rapid initiation of treatment within a short period of time, but is generally not feasible for most clinical practices. SBRT may be advantageous for low grade MESCC, recurrence, or in the post-operative setting. Detection of MESCC prior to development of high-grade compression or deterioration of neurologic function may allow patients to benefit more from advanced therapies and improve prognosis. MESCC is a devastating condition; optimal treatment should be personalized to each patient and approached collaboratively by a multidisciplinary team.

Narrative review—diagnosing and managing malignant epidural spinal cord compression: an evidence-based approach

Narrative review—diagnosing and managing malignant epidural spinal cord compression: an evidence-based approach

Personalization of Radiation Therapy in the Primary Treatment of Malignant Epidural Spinal Cord Compression (MESCC)

"True" malignant epidural spinal cord compression (MESCC) is used here to describe a lesion compressing of infiltrating the spinal cord associated with neurologic deficits. Radiotherapy alone is the most common treatment, for which several dose-fractionation regimens are available including single-fraction, short-course and longer-course regimens. Since these regimens are similarly effective regarding functional outcomes, patients with poor survival are optimally treated with short-course or even single-fraction radiotherapy. Longer-course radiotherapy results in better local control of malignant epidural spinal cord compression. Since most in-field recurrences occur 6 months or later, local control is particularly important for longer-term survivors who, therefore, should receive longer-course radiotherapy. It is important to estimate survival prior to treatment, which is facilitated by scoring tools. Radiotherapy should be supplemented by corticosteroids, if safely possible. Bisphosphonates and RANK-ligand inhibitors may improve local control. Selected patients can benefit from upfront decompressive surgery. Identification of these patients is facilitated by prognostic instruments considering degree of compression, myelopathy, radio-sensitivity, spinal stability, post-treatment ambulatory status, and patients' performance status and survival prognoses. Many factors including patients' preferences must be considered when designing personalized treatment regimens.

Stereotactic Body Radiation Therapy for High-Grade Malignant Epidural Spinal Cord Compression from Solid Tumor Metastases

<h3>Purpose/Objective(s)</h3> While upfront surgical decompression is the gold standard for malignant epidural spinal cord compression (MESCC) from solid tumor metastases, not all patients are surgical candidates or undergo successful surgical Bilsky downgrading. We report oncologic and functional outcomes for patients treated with SBRT to high-grade MESCC. <h3>Materials/Methods</h3> Patients with Bilsky grade 2-3 MESCC from solid tumor metastases treated with SBRT from 2009 - 2020 were retrospectively reviewed. Patients who received upfront surgery were eligible but included only if post-surgical Bilsky grade remained ≥2. Neurologic exams, MRI imaging, pain assessments, and oral morphine equivalent (OME) opioid usage were assessed every 3-4 months in follow up. Pain response was defined as <i>complete</i> (pain level 0 on Visual Analog Scale), <i>partial</i> (pain level decrease ≥2 and at least stable OME; or stable pain level and ≥25% OME decrease), <i>stable</i> (same pain level and OME), or <i>worse</i> (higher pain level). Cumulative incidence of local recurrence (LR) was reported with death as a competing event, and overall survival (OS) was estimated with Kaplan-Meier. <h3>Results</h3> We included 143 patients with median age of 62 years (range: 14-94). The most common histologies were NSCLC (17.4%), breast (16.7%), prostate (11.1%) and sarcoma (11.1%). The majority (75.5%) of metastases were in the T-spine, 22.3% in the C-spine, and 2.1% in the L-spine. Bilsky grade 2 represented 90.9% of cases. The median prescription dose was 25 Gy (range: 12-40) in a median of 5 fractions (range: 1-5). The median prescription isodose line was 60% (range: 50-85). One-fifth (20.2%) of cases were in the re-irradiation setting. The median follow up was 8.0 mo (range: 0.4-116.9). At first post-SBRT follow-up imaging, 53.8% patients with Bilsky grade 2 were stable while 16.2% improved to grade 1. Five of 13 patients (38.4%) with Bilsky grade 3 improved to grade 1-2. Cumulative incidence of LR was 5.1%, 7.5%, and 14.1% at 6, 12 and 24 mo respectively. Of the 18 crude LRs occurring at a median of 9.7 mo (range: 0.4-43.7), the most common histologies were RCC (4), NSCLC (3), sarcoma (2) and uterine (2). Only 10.5% of patients underwent salvage surgery, at a median of 3.1 mo after SBRT (range: 0.7-35.9). Median OS was 10.7 mo, and OS was 47.2% and 32.5% at 1 yr and 2 yrs. At 3 and 6 mo after SBRT, there were 118 and 76 evaluable patients for pain/functional outcomes. Pain response in reference to pre-SBRT was complete in 45.4% and 55.7%, partial in 26.9% and 13.1%, stable in 24.1% and 27.9%, and worse in 3.7% and 3.3% of patients at 3 and 6 mo respectively. At 3 months post-SBRT, 62.7% of evaluable patients ambulated with no assistance, compared to 48.3% of the same cohort pre-SBRT. No patients developed spinal cord myelopathy. <h3>Conclusion</h3> We report the largest series to date of high-grade MESCC from solid tumor metastases treated with SBRT. Our excellent control and functional outcomes suggest SBRT is a reasonable approach in inoperable patients or cases unable to be successfully surgically downgraded.

Deep Learning Model for Classifying Metastatic Epidural Spinal Cord Compression on MRI.

BackgroundMetastatic epidural spinal cord compression (MESCC) is a devastating complication of advanced cancer. A deep learning (DL) model for automated MESCC classification on MRI could aid earlier diagnosis and referral.PurposeTo develop a DL model for automated classification of MESCC on MRI.Materials and MethodsPatients with known MESCC diagnosed on MRI between September 2007 and September 2017 were eligible. MRI studies with instrumentation, suboptimal image quality, and non-thoracic regions were excluded. Axial T2-weighted images were utilized. The internal dataset split was 82% and 18% for training/validation and test sets, respectively. External testing was also performed. Internal training/validation data were labeled using the Bilsky MESCC classification by a musculoskeletal radiologist (10-year experience) and a neuroradiologist (5-year experience). These labels were used to train a DL model utilizing a prototypical convolutional neural network. Internal and external test sets were labeled by the musculoskeletal radiologist as the reference standard. For assessment of DL model performance and interobserver variability, test sets were labeled independently by the neuroradiologist (5-year experience), a spine surgeon (5-year experience), and a radiation oncologist (11-year experience). Inter-rater agreement (Gwet’s kappa) and sensitivity/specificity were calculated.ResultsOverall, 215 MRI spine studies were analyzed [164 patients, mean age = 62 ± 12(SD)] with 177 (82%) for training/validation and 38 (18%) for internal testing. For internal testing, the DL model and specialists all showed almost perfect agreement (kappas = 0.92–0.98, p < 0.001) for dichotomous Bilsky classification (low versus high grade) compared to the reference standard. Similar performance was seen for external testing on a set of 32 MRI spines with the DL model and specialists all showing almost perfect agreement (kappas = 0.94–0.95, p < 0.001) compared to the reference standard.ConclusionA DL model showed comparable agreement to a subspecialist radiologist and clinical specialists for the classification of malignant epidural spinal cord compression and could optimize earlier diagnosis and surgical referral.

Adjunctive Topical Tranexamic Acid for Blood Salvage Does Not Reduce Postoperative Blood Loss Compared with Placebo in Patients Who Undergo Palliative Decompressive Spinal Metastasis Surgery: A Randomized Controlled Trial.

Randomized controlled trial. To evaluate the efficacy of adjunctive topical tranexamic acid (tTXA) in reducing postoperative blood loss and packed red cell (PRC) transfusion in patients who underwent palliative decompressive spinal metastasis surgery for malignant epidural spinal cord compression. Palliative decompressive spinal metastasis surgery is associated with massive postoperative blood loss and increased transfusion rate. tTXA reduces blood loss in traumatic or degenerative spinal surgery; however, the role of topical TXA in decompressive spinal metastasis surgery remains controversial. A total of 65 patients who underwent palliative decompressive thoracolumbar spinal metastasis surgery were included in this study. In 33 patients, 1 g of tTXA (20 mL) was soaked in an absorbable gelatin sponge and placed lateral to the decompressive site. The remaining 32 patients in the control group received the same procedures with normal saline at the same volume, instead of TXA. All of the patients received standard 1 g intravenous TXA, just before initiating the operation. The primary outcome was postoperative blood loss, and the secondary outcomes were postoperative PRC transfusion and complications. No differences were found in postoperative blood loss between tTXA and placebo group (P50 778 mL [IQR 347, 1,122 mL] versus P50 490 mL [IQR 295, 920 mL]; P = 0.238). The number of patients requiring postoperative PRC transfusion were quite similar in tTXA and placebo groups (PRC transfusion in 15 patients [45.45%] versus 16 patients [50%]; P = 0.585). No complications related to TXA and absorbable gelatin sponge were observed. We do not recommend tTXA as an adjunctive treatment for patients undergoing decompressive spinal metastasis surgery since it does not provide additional benefit to prophylactic intravenous TXA in postoperative blood loss and transfusion rate.Level of Evidence: 2.

Postoperative Stereotactic Body Radiotherapy for Spinal Metastasis and Predictors of Local Control.

Spine surgery is indicated for select patients with mechanical instability, pain, and/or malignant epidural spinal cord compression, with or without neurological compromise. Stereotactic body radiotherapy (SBRT) is an option for durable local control (LC) for metastatic spine disease. To determine factors associated with LC and progression-free survival (PFS) for patients receiving postoperative stereotactic spine radiosurgery. We analyzed consecutive patients from 2013 to 2019 treated with surgical intervention followed by SBRT. Surgical interventions included laminectomy and vertebrectomy. SBRT included patients treated with 1 to 5 fractions of radiosurgery. We analyzed LC, PFS, overall survival (OS), and toxicity. Univariate and multivariate analyses were performed. A total of 63 patients were treated with a median follow-up of 12.5 mo. Approximately 75% of patients underwent vertebrectomy and 25% underwent laminectomy. One-year cumulative incidence of local failure was 19%. LC was significantly improved for patients receiving radiosurgery ≤40 d from surgery compared to that for patients receiving radiosurgery ≥40 d from surgery, 94%vs 75%, respectively, at 1 yr (P=.03). Patients who received preoperative embolization had improved LC with 1-yr LC of 88%vs 76% for those who did not receive preoperative embolization (P=.037). Significant predictors for LC on multivariate analysis were time from surgery to radiosurgery, higher radiotherapy dose, and preoperative embolization. The 1-yr PFS and OS was 56% and 60%, respectively. Postoperative radiosurgery has excellent and durable LC for spine metastasis. An important consideration when planning postoperative radiosurgery is minimizing delay from surgery to radiosurgery. Preoperative embolization and higher radiotherapy dose were associated with improved LC warranting further study.

A pilot study of stereotactic boost for malignant epidural spinal cord compression: clinical significance and initial dosimetric evaluation

PurposeMetastatic epidural spinal cord compression (MESCC) is a devastating complication of advanced malignancy, which can result in neurologic complications and significant deterioration in overall function and quality of life. Most patients are not candidates for optimal surgical decompression and as a result, receive urgent 3D conformal radiotherapy (3DCRT) to prevent or attempt to reverse neurologic progression. Multiple trials indicate that response and ambulatory rates after 3DCRT are inferior to surgery. The advent of stereotactic body radiation therapy (SBRT) has created a method with which a “radiosurgical decompression” boost may facilitate improve outcomes for MESCC patients.MethodsWe are conducting a pilot study to investigate SBRT boost after urgent 3D CRT for patients with MESCC. The aim of the study is to establish feasibility of this two-phase treatment regimen, and secondarily to characterize post-treatment ambulation status, motor response, pain control, quality of life and survival.DiscussionWe describe the study protocol and present a case report of one patient. A quality assurance review was conducted after the first seven patients, and resultant dose-constraints were revised to improve safety and feasibility of planning through more conservative organ at risk constraints. There have been no severe adverse events (grade 3–5) to date. We have illustrated clinical and dosimetric data of an example case, where a patient regained full strength and ambulatory capacity.ConclusionsOur study aims to determine if SBRT is a feasible option in addition to standard 3DCRT for MESCC patients, with the goal to consider future randomized trials if successful. Having a robust quality assurance process in this study ensures translatability going forward if future trials with multicenter and increased patient representation are to be considered.Trial registration clinicaltrials.gov; registration no. NCT03529708; https://clinicaltrials.gov/ct2/show/NCT03529708; First posted May 18, 2018.

Retrospective Audit of Malignant Epidural Spinal Cord Compression (MESCC) in an Inner-City Safety Net Hospital

Retrospective Audit of Malignant Epidural Spinal Cord Compression (MESCC) in an Inner-City Safety Net Hospital

(ICORG 05-03): prospective randomized non-inferiority phase III trial comparing two radiation schedules in malignant spinal cord compression (not proceeding with surgical decompression); the quality of life analysis

Background: The optimal primary external beam radiation therapy (EBRT) radiation schedule for malignant epidural spinal cord compression (MSCC) remains to be determined. The ICORG 05-03 trial assessed if a 10 Gy single fraction radiation schedule was not inferior to one with 20 Gray (Gy) in five daily fractions, in terms of functional motor outcome, for the treatment of MSCC in patients not proceeding with surgical decompression. This article reports on two of the secondary endpoints, Quality of life (QoL), assessed according to the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) version 3.0 (EORTC Data Center, Brussels, Belgium) and pain control assessed using a visual analog scale.Methods: A randomized, parallel group, multicenter phase III trial was conducted by Cancer Trials Ireland (formerly All-Ireland Cooperative Oncology Research Group, ICORG), across five hospital sites in Ireland and Northern Ireland. Patients were randomized to 10 Gy single fraction of EBRT or 20 Gy in five fractions in a 1:1 ratio. Patients with baseline and 5-week follow up QoL data are included in this analysis.Findings: From 2006 to 2014, 112 eligible patients were enrolled for whom 57 were evaluated for this secondary analysis. After adjusting for pre-intervention scores, there was no statistically significant difference in post-treatment Summary scores (excl. FI and QL), or pain scores between the two RT schedules at 5 weeks and 3 months following EBRT. There was a statistically significant relationship between the pretreatment and post-treatment Summary scores (p = .002) but not between the pre-treatment and post-treatment pain scores.Interpretation: Primary radiotherapy for the treatment of MSCC significantly improves QoL in patients not proceeding with surgical decompression. After adjusting for pre-intervention scores, there was no statistically significant difference between a 10 Gy single fraction radiation schedule and one with 20 Gy in five daily fractions on post-treatment QoL Summary scores. For most patients, an effective treatment with low burden would be desirable. A single fraction schedule should be considered for this group of patients.

Survival analysis of malignant epidural spinal cord compression after palliative radiotherapy using Tokuhashi scoring system and the impact of systemic therapy.

Previous studies have shown similar clinical outcomes of both single and multi-fraction (Fr) radiation therapy among malignant epidural spinal cord compression (MSCC) patients with poor prognosis; whereas, patients expected to have longer survival may require long-course radiotherapy to prevent local failure. However, such a poor prognosis risk group has not yet been clearly identified for use in daily clinical practice. We examined if the known predictive Tokuhashi scoring system could be adapted in MSCC patients treated with palliative radiation therapy. A retrospective review of the treatment outcomes of MSCC patients who received palliative radiotherapy from January 2014 to May 2015 was conducted. The patients were stratified into two groups according to the Tokuhashi scoring system: group 1 (score <9), expected survival <6 months, and group 2 (score >8), expected survival >6 months. Their survival was tested against subsequent systemic therapy (chemotherapy, targeted or hormonal therapy) and other risk factors including age, primary site, visceral metastasis, baseline motor function, prior radiotherapy and radiotherapy fractionation (single or multiple). The outcomes of 119 patients were studied, 116 (97.5%) patients had already succumbed. The overall median survival was 55 days (range, 4-576 days). Ninety-three patients (78.2%) belonged to group 1. The median dose delivered was 25 Gy in 5 Frs [range, 7 Gy in 2 Frs-40 Gy in 10 Frs (to the cauda equina)]. Only nine patients (7.6%) received single-Fr radiotherapy, all belonging to Tokuhashi group 1. Patients belonging to group 1 had shorter median survival than group 2; 49 and 108 days, respectively (P=0.003). Among all the patients, subsequent systemic treatment [hazard ratio (HR) =0.407; 95% confidence interval (CI), 0.236-0.702; P=0.001], non-visceral metastasis (HR =0.608; 95% CI, 0.387-0.956; P=0.031) and primary lung or breast or prostate cancer (P=0.029) were associated with better survival in multivariate analysis. For patients in group 1, primary breast or prostate cancer (HR =0.264; 95% CI, 0.122-0.572; P=0.001) or lung cancer (HR =0.421; 95% CI, 0.246-0.719; P=0.002), non-visceral metastasis (HR =0.453; 95% CI, 0.264-0.777; P=0.004), multi-Fr (HR =0.455; 95% CI, 0.217-0.956; P=0.038) and subsequent systemic therapy (HR =0.460; 95% CI, 0.252-0.842; P=0.012) were associated with better survival. The survival of a subset of patients in group 1 without subsequent systemic therapy was dismal (median survival only 40 days) and not altered by radiotherapy schedule (P=0.189). MSCC comprises a very heterogenous group of patients, even under the Tokuhashi grouping. Systemic therapy or visceral metastasis may be more important prognostic factors. Further studies are necessary to better select the poor prognosis risk group. In clinical practice, single-Fr radiotherapy could be considered in Tokuhashi group 1 patients due to their expected short survival, especially for those without reasonable systemic treatment options.

Postoperative stereotactic body radiotherapy for spinal metastases

Spine is a common site of metastases in cancer patients. Spine surgery is indicated for select patients, typically those with mechanical instability and/or malignant epidural spinal cord (or cauda equina) compression. Although post-operative conventional palliative external beam radiation therapy has been the standard of care, technical improvements in radiation planning and image-guided radiotherapy have allowed for the application of stereotactic body radiotherapy (SBRT) to the spine. Spine SBRT is intended to ablate residual tumor and optimize local control by delivering several fold greater biologically effective doses. Early clinical experience of postoperative spinal SBRT report encouraging results in terms of safety and efficacy. In this review, we summarize the clinical and technical aspects pertinent to a safe and effective practice of postoperative SBRT for spinal metastases.

Diagnostic and Therapeutic Strategies for Patients with Malignant Epidural Spinal Cord Compression.

Malignant epidural spinal cord compression (MESCC) is an oncologic emergency with the potential for devastating consequences for patients if not promptly diagnosed and treated. MESCC is diagnosed by imaging. MRI is by far the most sensitive test, preferably with gadolinium. Once the diagnosis of MESCC is suspected, patients with neurologic deficits should receive prompt administration of dexamethasone with a 10-mg IV loading dose followed by 4mg every 6h. Quick taper is recommended once the definitive treatment is established. Consultation with medical oncology, radiation oncology, and neurosurgery is imperative in order to facilitate a multidisciplinary approach. Although spine surgery is the most effective method for relief of cord compression and is necessary if there is spinal instability, surgery is only used in selected patients because most patients have a poor overall condition and short life expectancy. Radiation therapy, therefore, is the most commonly used therapy for patients with MESCC after surgical decompression or in patients who are not surgical candidates. Conventional fractionated radiation alone can achieve modest neurologic outcomes in selected radiosensitive tumors. Radiosurgery techniques which deliver intense focal irradiation to a delimited area with imaging guidance and contoured radiation delivery to the shape of the tumor have recently emerged as increasing effective treatments in MESCC, especially in radioresistant tumors. Stereotactic radiosurgery and different radiation technologies have been studied in recent clinical trials.

Simulated Consult and Treatment of Malignant Epidural Spinal Cord Compression Improves Trainee Confidence and Knowledge Prior to Taking Radiation Oncology Call

Simulated Consult and Treatment of Malignant Epidural Spinal Cord Compression Improves Trainee Confidence and Knowledge Prior to Taking Radiation Oncology Call

Survival Analysis of Malignant Epidural Spinal Cord Compression After Palliative Radiation Therapy Using Tokuhashi Scoring System and the Impact of Systemic Therapy

Survival Analysis of Malignant Epidural Spinal Cord Compression After Palliative Radiation Therapy Using Tokuhashi Scoring System and the Impact of Systemic Therapy

Surgery Versus Radiation Therapy in Symptomatic Malignant Spinal Cord Compression

Malignant epidural spinal cord compression is an oncologic emergency that often results in pain and neurologic dysfunction, which may be permanent. Few prospective studies have been performed to determine whether surgical intervention confers a significant benefit over radiation therapy. We believe the small amount of existing evidence to support surgical intervention or radiation therapy alone suffers from patient selection bias, and that such bias tends to bear out in practice as well. In addition to the objective benefits achieved by surgical decompression, practitioners need to consider the subjective benefits such as increased ambulatory ability, increased spine stability, and improved pain management provided by timely surgical decompression of metastatic spinal cord lesions.

How Effective Is a Virtual Consultation Process in Facilitating Multidisciplinary Decision-Making for Malignant Epidural Spinal Cord Compression?

The purpose of this study was to assess the accuracy of a virtual consultation (VC) process in determining treatment strategy for patients with malignant epidural spinal cord compression (MESCC). A prospective clinical database was maintained for patients with MESCC. A virtual consultation process (involving exchange of key predetermined clinical information and diagnostic imaging) facilitated rapid decision-making between oncologists and spinal surgeons. Diagnostic imaging was reviewed retrospectively (by R.R.) for surgical opinions in all patients. The primary outcome was the accuracy of virtual consultation opinion in predicting the final treatment recommendation. After excluding 20 patients who were referred directly to the spinal surgeon, 125 patients were eligible for virtual consultation. Of the 46 patients who had a VC, surgery was recommended in 28 patients and actually given to 23. A retrospective review revealed that 5/79 patients who did not have a VC would have been considered surgical candidates. The overall accuracy of the virtual consultation process was estimated at 92%. The VC process for MESCC patients provides a reliable means of arriving at a multidisciplinary opinion while minimizing patient transfer. This can potentially shorten treatment decision time and enhance clinical outcomes.

Spinal Cord Compression

Malignant epidural spinal cord compression (MESCC) remains a common neuro-oncologic emergency with high associated morbidity. Despite widespread availability of MRI, the diagnosis frequently goes unmade until myelopathy supervenes, which is unfortunate because the strongest predictor of neurologic outcome with treatment is the neurologic status when treatment is initiated. Once the diagnosis of MESCC is suspected, patients with neurologic deficits should be started on high-dose corticosteroids (eg, dexamethasone, 10-100mg intravenously, followed by 16 to 100mg/d in divided doses). Definitive therapy of MESCC almost always includes radiation therapy and in some cases surgical intervention; factors considered include the patient's performance status and extent of visceral and skeletal disease, spinal stability, the tumor's underlying radiosensitivity, and the degree of spinal cord compression. Patients with spinal instability or radioresistant tumors are likely to have a much better neurologic outcome with tumor resection and spinal stabilization prior to radiation; the same may also pertain to patients with moderately radiosensitive tumors who have good life expectancy in terms of their systemic tumor. Conventional radiation has historically been beneficial after surgery and in patients who are not surgical candidates. Recent studies suggest a role for stereotactic body radiation therapy in patients with spinal metastasis from radioresistant tumors and in patients who have received prior standard radiotherapy, so long as the spinal cord has been decompressed.

Malignant extradural spinal cord compression in men with prostate cancer

Malignant epidural spinal cord compression (MESCC) is a dreaded complication of malignancy and is fortunately not common. Approximately 7% of men dying of prostate cancer will have at least one episode of MESCC during their lifetime. Treatment needs to be individualized and estimating the prognosis is critical to achieving a balance between effectiveness therapy and the burden of treatment. A consortium of multiple centers has defined prognosis scales, and multiple randomized studies have helped define the optimal dose fractionation schedule for patients getting radiotherapy. Simple prognosis scales available to assist the clinician are reviewed. For poor prognosis patients, a single fraction of 8 Gy is just as effective as multiple fractions, however, are much more convenient. For good prognosis patients, surgery and radiation should be considered. For patients not getting surgery, enrollment in clinical trials of single vs. multiple fractions of radiation should be a priority. For high-risk patients, screening strategies are being developed and hold promise for maintaining ambulation throughout the patients' lifetime.

A Systematic and Evidence-Based Approach to the Management of Vertebral Metastasis

Diagnosis and management of vertebral metastasis requires a systematic approach to patient identification as well as selection of appropriate therapy. Rapid identification and prompt intervention in the treatment of malignant epidural spinal cord compression (MESCC) is key to maintaining quality of life. This paper provides a series of tools as well as guidance in selecting effective and evidence-based therapy individualized to the specific patient.