Malignant Spinal Cord Compression Research Articles

Malignant Spinal Cord Compression: Atypical Presentation, False Localizing Signs, Time Course, and Implications for the Emergency Medicine Physician.

Malignant Spinal Cord Compression: Atypical Presentation, False Localizing Signs, Time Course, and Implications for the Emergency Medicine Physician.

Treatment and Management of the Clinical Manifestations of Advanced Breast Cancer

ObjectivesPeople with advanced breast cancer (ABC) experience complex and debilitating physical symptoms of their disease that can have a profound effect on quality of life. This report provides an overview of the clinical manifestations related to different metastatic sites in ABC and potential oncologic emergencies. Data SourcesDate sources include peer-reviewed papers sourced in electronic databases (CINAHL, MEDLINE, Google Scholar) and national and international best practice guidelines. ConclusionPeople living with ABC experience multiple symptoms of disease that can impact on quality of life and physical functioning. The most common sites of metastatic disease are bone, lung, liver and brain. Clinical manifestations of ABC include pain, pathologic fractures, pleural effusions, and ascites. Potential oncologic emergencies related to these metastatic sites include hypercalcemia, malignant spinal cord compression, superior vena cava obstruction, and raised intracranial pressure. Implications for Nursing PracticeIt is important for nurses to have informed knowledge and understanding of these clinical manifestations. This will enable them to be vigilant and perform targeted patient evaluation to assess signs and symptoms with a view to identifying potentially life-threatening emergencies and initiating interventions or appropriate referral or follow-up accordingly.

Local malignant spinal cord compression (MSCC) audit and potential benefits of introducing an electronic assessment form

Local malignant spinal cord compression (MSCC) audit and potential benefits of introducing an electronic assessment form

Local malignant spinal cord compression (MSCC) audit and potential benefits of introducing an electronic assessment form

Local malignant spinal cord compression (MSCC) audit and potential benefits of introducing an electronic assessment form

Evaluation of a Remote Curriculum to Improve Internal Medicine Resident Knowledge and Confidence in Oncologic Emergency Identification and Management

Background Oncologic emergencies (OEs) are life-threatening complications of malignancy that can present in multiple clinical settings and necessitate early recognition and intervention. Most medical resident training is experiential, but variability in exposure can yield gaps in medical knowledge that could result in delayed patient care. Remote curricula are commonly used to fill these gaps and reduce classroom burden on trainees. Given their time-sensitive nature, OEs are a prime target to augment clinical experience with a supplementary curriculum to prepare residents for new scenarios. This study evaluates whether an original, remote curriculum improves internal medicine resident knowledge of and confidence in recognition and management of OEs. Methods With expert faculty input, we developed a remote curriculum for first-year internal medicine residents at a tertiary care academic medical center. The curriculum includes 6 OEs: tumor lysis syndrome (TLS), hypercalcemia (hyperCa), neutropenic fever (NF), hyperviscosity syndrome and leukostasis (HVS/LS), superior vena cava (SVC) syndrome, and malignant spinal cord compression (CC). OEs were selected based upon prominence in the literature, morbidity and mortality, need for urgent management, and association with malignancy. We created an online lesson in Qualtrics for each OE. Each lesson was designed to be completed in 15 minutes via computer or smartphone. Lessons were delivered by email every 10 days, with reminders every 5 days. Learning objectives for each OE lesson were to 1) identify concerning signs and symptoms, 2) order appropriate workup, and 3) provide prompt management in the appropriate clinical setting. Lessons included clinical questions and evidence-based information delivery contextualized by case presentations. We evaluated the curriculum's efficacy with a randomized, controlled study. First-year residents were randomly assigned to two groups (“Intern A” and “Intern B”). We built assessments of knowledge and confidence with expert faculty input. Confidence in identifying and managing each OE was assessed by Likert scale (“1 - completely confident,” “5 - not at all confident”). Knowledge was evaluated with 3 multiple choice questions per OE, for a maximum knowledge score of 18. After both groups completed the pre-test, Intern A received the curriculum. After curriculum completion, both groups completed the post-test. All interns were required to complete the curriculum, but research participation was optional. Residents consented to participation prior to each test administration. All lessons and research activities were anonymous. Analysis was completed in GraphPad Prism 9 using the unpaired t-test or one-way ANOVA with post-hoc testing, as appropriate. Results Thirty-nine internal medicine residents completed the curriculum. Twenty were assigned to Intern A and 19 to Intern B. Intern A had 10 pre-test respondents (50.0%) with a mean knowledge score of 9.13 (50.7% correct), and Intern B had 13 pre-test respondents (68.4%) with a mean knowledge score of 9.35 (51.9% correct). There were no differences by OE-specific score. Baseline confidence was similar between groups (Table 1). Comparison of mean knowledge scores is shown in Figure 1. Intern A and B had 9 (45.0%) and 10 (52.6%) post-test respondents, respectively. Both Intern A (mean 14.2; 95% CI, 12.8 to 15.7; 78.9% correct) and Intern B (mean 12.2; 95% CI, 10.5 to 13.9; 67.8% correct) significantly improved their knowledge scores compared to prior, though Intern A had a more marked effect size (Intern A mean difference 5.02; 95% CI, 2.84 to 7.21; P<0.0001; Intern B mean difference 2.66; 95% CI, 0.660 to 4.66; P=0.006). Intern A confidence significantly improved from the pre-test in both the identification and management of HVS/LS and SVC syndrome. Intern A confidence was significantly better than Intern B confidence in management of SVC syndrome at the time of the post-test (Table 1). Conclusions Baseline intern OE knowledge scores were sub-optimal. Intern participation in a remote OE curriculum improved knowledge acquisition to a greater degree than experiential learning alone. Confidence in identification and management of OEs with low pre-existing confidence, such as HVS/LS and SVC syndrome, improved in the remote curriculum. Further study should evaluate knowledge retention over time, resident clinical performance, and patient outcomes.

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

The Inpatient Consultation Experience in Radiation Oncology: A Contemporary Evaluation of a Single Academic Institution

Participating in an inpatient consultation service is an essential aspect of radiation oncology residency training. However, there are no reports in the literature describing the inpatient on-call experience. To better describe the clinical burden and define the learning opportunities associated with inpatient consultation service participation, inpatient on-call data were tracked and assessed. From July 1, 2022, through Dec. 31, 2022, radiation oncology residents covering the on-call pager for the inpatient consultation service spanning two hospitals at a single academic institution prospectively self-reported the total number of pages, new consultations, inpatient treatment starts, and treatment indications. Patient billing records and paging logs were reviewed to confirm self-reported cases and track the number of business days between simulation and the first fraction of treatment. A new inpatient consultation was defined as a novel encounter requiring independent evaluation; as such, patients admitted during an ongoing course of radiotherapy who continued the planned course while inpatient were not included. During the initial six months of tracking, on-call residents received a total of 607 pages with an average of 23.1 pages per week (range: 14-38). Of these pages, 212 were for new inpatient consultations with an average of 8.1 consultations per week (range: 2-15). Out of these 212 new consultations, 75 patients (35%) were treated on an inpatient basis. Nine patients (12%) received their first fraction of treatment on the same day as simulation, 13 (17%) on the next day, 11 (15%) two days after, 22 (29%) three days after, and 20 (27%) four or more days after simulation. The most common indications for urgent treatment were malignant spinal cord compression (27%), brain metastases (24%), tumor-related bleeding (8%), malignant obstruction of the airway or vasculature (8%), painful bone metastases (7%), and heterotopic ossification prophylaxis (7%). The most common primary sites of disease were leukemia/lymphoma (16%), gastrointestinal (13%), breast (11%), lung (9%), gynecologic (9%), sarcoma (9%), and benign (9%). Each individual resident's caseload differed greatly in quantity, indication, treatment site, and primary site over this six-month time period. In this longitudinal analysis at a single academic institution, the radiation oncology inpatient consultation service experience was highly variable and diverse in clinical volume and treatment indication on a week-to-week and resident-to-resident basis. Exposure to radiation oncology emergencies is a vital component of residency training. However, the unpredictable nature of inpatient on-call scenarios can lead to variable educational experiences. Tracking inpatient on-call cases during residency may help identify areas needing improvement to enhance both patient care and residency training.

Quality of Palliative Radiation Therapy Assessed Using Quality Indicators: A Multicenter Survey

Clinical practice is not always performed in accordance with guideline recommendations. Quality indicators (QIs) are valuable tools for evaluating the quality of healthcare systems. We sought to identify potential gaps between clinical practice and evidence using QIs previously developed using a modified Delphi method. We used seven QIs (Table 1) to assess the quality of radiation therapy for bone (BoM) and brain metastases (BrM) at 29 centers; 13 (45%) were academic (12 university hospitals and 1 cancer center) and 16 (55%) were nonacademic hospitals. Compliance rate was calculated as the percentage of patients for whom recommended medical care was conducted. Random effects models were used to estimate pooled compliance rates. Mixed effects models with a Q test were used to compare compliance rates between academic and nonacademic centers. The estimates of the compliance rates with 95% confidence intervals are presented in Table 1. For BoM-1, the compliance rate was higher in academic hospitals (100% [100-100%]) than in non-academic hospitals (96% [89-100%]) (P = 0.021). For BrM-3, the compliance rate was lower in academic hospitals (92% [81-99%]) than in nonacademic hospitals (100% [98-100%]) (P = 0.016). A quality assessment based on these seven QIs is feasible. Overall, compliance rates were high; however, for BoM-3, the practice remains to be improved in some centers. Based on BoM-4 compliance rates, steroids are infrequently used concurrently with radiation therapy for malignant spinal cord compression. Extended fractionation for BoM was less frequently performed in academic than in nonacademic centers. The initiation of radiation therapy for brain metastases was more frequently delayed in academic than in nonacademic centers.

Design and Implementation of a Multidisciplinary High-Fidelity Simulation Course for the Management of Malignant Spinal Cord Compression.

High-fidelity simulation (HFS) training is suited to high-stakes, uncommon situations such as malignant spinal cord compression (MSCC), allowing for rare hands-on practice. This pilot study was created as the first of its kind to examine educational outcomes of a radiation therapist (RTT)-led multidisciplinary radiation oncology (RO) emergency simulation course. A multidisciplinary course design team composed of RO residents, radiation oncologists, RTT course instructors, and medical physicists created a high-fidelity MSCC simulation course using collaboratively developed learning goals. Fifteen learners including RO residents, senior RTT students, and a medical physics (MP) resident participated in a live, RTT-facilitated simulation. Participants completed anonymized pre- and post-simulation standard interdisciplinary education perception (IEP) scales and a course evaluation assessing educational outcomes. Standard IEP questionnaire results showed highly favorable perceptions of respondents' own specialty and other allied specialties, with mean total pre-simulation scores of 91.76 and post-simulation scores of 94.23. The course evaluation assessed 10 learning objective domains, with significant improvements seen in self-rated post-course knowledge in 9 domains. Pre-course evaluations showed that 6/15 participants agreed or strongly agreed that they felt comfortable in their knowledge of all included domains; after course completion, 14/15 participants agreed or strongly agreed they felt comfortable in all domains. Collaboratively designed and led HFS courses are not only viable but can be an effective means of improving learning outcomes for RO residents, RTT students, and MP residents.

Oncologic and Functional Outcomes After Stereotactic Body Radiation Therapy for High-Grade Malignant Spinal Cord Compression

Although surgical decompression is the gold standard for metastatic epidural spinal cord compression (MESCC) from solid tumors, not all patients are candidates or undergo successful surgical Bilsky downgrading. We report oncologic and functional outcomes for patients treated with stereotactic body radiation therapy (SBRT) to high-grade MESCC. Patients with Bilsky grade 2 to 3 MESCC from solid tumor metastases treated with SBRT at a single institution from 2009 to 2020 were retrospectively reviewed. Patients who received upfront surgery before SBRT were included only if postsurgical Bilsky grade remained ≥2. Neurologic examinations, magnetic resonance imaging, pain assessments, and analgesic usage were assessed every 3 to 4 months post-SBRT. Cumulative incidence of local recurrence was calculated with death as a competing risk, and overall survival was estimated by Kaplan-Meier. One hundred forty-three patients were included. The cumulative incidence of local recurrence was 5.1%, 7.5%, and 14.1% at 6, 12, and 24 months, respectively. At first post-SBRT imaging, 16.2% of patients with initial Bilsky grade 2 improved to grade 1, and 53.8% of patients were stable. Five of 13 patients (38.4%) with initial Bilsky grade 3 improved to grade 1 to 2. Pain response at 3 and 6 months post-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, respectively. At 3 and 6 months after SBRT, 17.8% and 25.0% of patients had improved ambulatory status and 79.7% and 72.4% had stable status. We report the largest series to date of patients with high-grade MESCC treated with SBRT. The excellent local control and functional outcomes suggest SBRT is a reasonable approach in inoperable patients or cases unable to be successfully surgically downgraded.

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.

183 - Surgical decompression of malignant spinal cord compression (MSCC) in lung cancer: the Manchester experience

183 - Surgical decompression of malignant spinal cord compression (MSCC) in lung cancer: the Manchester experience

Malignant Cord Compression and Timing of Post-Operative Radiotherapy

<h3>Purpose/Objective(s)</h3> Malignant spinal cord compression (MSCC) warrants prompt intervention that often involves neurosurgical decompression followed by radiation therapy (RT). However, post-surgical management including rehabilitation and time for wound healing can delay initiation of post-operative RT. This study aims to retrospectively review the time to initiation (TTI) of RT after surgical intervention for MSCC and its association with ambulatory status at 3 months post-treatment. We also compare TTI in patients discharged to home versus inpatient rehabilitation or skilled nursing facility. <h3>Materials/Methods</h3> We queried our institutional database for patients with solid malignancies and spinal metastases with Bilsky 2 or 3 MSCC who underwent surgical intervention and post-operative RT between 2015-2021. In patients who were ambulatory peri-operatively, we computed the relative risk of decreased ambulation at 3-month follow up using different TTI cutoff values of 30, 42, and 56 days. P values were generated using a 2-sided Fisher's Exact Test. TTI was also evaluated in all patients who underwent post-operative RT based on their discharge to home, skilled nursing facility, or inpatient rehabilitation. <h3>Results</h3> We found 128 patients with MSCC who underwent surgery. Within this group, 68 were ambulatory peri-operatively, received post-operative RT, and had at least 3 months of follow up. Three-month ambulatory rates for TTI of ≤ 30 vs >30 days, ≤ 42 vs > 42 days, and ≤ 56 vs > 56 days were 86% vs 70% (p=0.218), 85% vs 59% (p=0.032), and 83% vs 50% (p=0.028), respectively. Relative risks for inability to ambulate are shown in Table 1. For all patients who received post-operative RT without wound complications causing delays in RT, TTI based on discharge to home (n=42), skilled nursing facility (n=3), or inpatient rehab (n=26) was 28 days (IQR 19-36.75), 21 days (IQR 15-21), and 37 days (IQR 25.25-52.5), respectively. Nine patients were found to have locally recurrent disease-causing cord compression; two recurred after post-operative RT while seven recurred prior to post-operative RT. <h3>Conclusion</h3> The relative risk of inability to ambulate after surgical resection for MSCC was significantly higher if RT was initiated at >42 days after surgery, and even lower at >56 days after surgery. Patients discharged to inpatient rehab had the longest interval between surgery and RT. Further studies evaluating the optimal timing of post-operative RT and causes for delay are needed.

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.

Association of Inpatient Radiation Oncology Consult Timing with Length of Hospitalization and Opioid Utilization

<h3>Purpose/Objective(s)</h3> Inpatient providers responsible for placing radiation oncology inpatient consult requests (ICR) during hospital admission may not be as aware of potential indications for palliative radiotherapy as are radiation oncologists. We hypothesized that earlier ICR was associated with reduced length of hospitalization (LOH) and daily opioid usage (DOU). We also hypothesized that placement of ICR later in the week was associated with increased LOH. <h3>Materials/Methods</h3> Inpatients who received ICR at a tertiary academic center were identified using call logs from the radiation oncology on-call pager. Consecutively evaluated patients from July 2020 - March 2021 were selected for retrospective cohort analysis. Timing of ICR by pager notification, including day of week, was recorded. LOH was determined using dates of admission and discharge. ICRs were categorized into early in week (Monday-Wednesday) vs. later in week (Thursday-Sunday). Home and hospital opioid regimens were recorded and converted to morphine milligram equivalents (MME) for calculation of change in DOU. It was noted if ICR was for malignant spinal cord compression (mSCC) or if patients ultimately received same-day simulation and delivery of first treatment fraction ("sim & treat"). Patients receiving elective ICR for heterotopic ossificans prophylaxis were omitted for time-to-event analyses. Multivariable linear regression assessed associations between time-to-event predictors with outcome variables, including LOH and DOU. <h3>Results</h3> 270 patients were reviewed. 79 (29.3%) ICRs were for pain, 113 (41.9%) for neurologic compromise (e.g., headache/sensorimotor deficits), 31 (11.5%) for thoracic symptoms (e.g., dysphagia/dyspnea), 20 (7.4%) for bleeding, 10 (3.7%) for obstructive symptoms (e.g., bowel obstruction/urinary retention), and 26 (6.3%) for elective indications. 47 (18.0%) received ICR for cord compression and 130 (49.8%) received same-day sim & treat. Controlling for timing in week of ICR and mSCC/same-day treatment, each additional day from inpatient admission to ICR was associated with 1.3 days longer LOH (95% CI: .98-1.57, p<0.0001), and ICRs placed later in the week were associated with 2.3 days longer LOH (95% CI: .43-4.25, p=.02). mSCC was independently associated with longer LOH (OR: 3.95; 95% CI: .76-7.13, p=.004). A trend towards significance was observed for association of longer LOH with increase in DOU (6.0 mg/day increase in MME; p=.06). <h3>Conclusion</h3> Later ICR during admission and timing of consult in week are associated with longer LOH. The latter may reflect reduced availability of departmental personnel and resources. Informing inpatient providers of common treatment indications and encouraging earlier ICR placement may mitigate delays in ICR while potentially preventing increases in DOU, with further data and validation for this needed.

Identifying patients with malignant spinal cord compression (MSCC) near end of life who can benefit from palliative radiotherapy

BackgroundA previous score predicted death ≤ 2 months following radiotherapy for MSCC. For patients with a high probability of early death, best supportive care was recommended. However, some of these patients may benefit from radiotherapy regarding preservation or improvement of motor function. To identify these patients, an additional score was developed.MethodsPre-treatment factors plus radiotherapy regimen were retrospectively evaluated for successful treatment (improved motor function or remaining ambulatory without aid) and post-treatment ambulatory status in 545 patients who died ≤ 2 months. Factors included age, interval from tumor diagnosis until MSCC, visceral metastases, further bone metastases, primary tumor type, sex, time developing motor deficits, pre-treatment ambulatory status, and number of affected vertebrae. Factors significant on both multivariable analyses were included in the score (worse outcomes 0 points, better outcomes 1 point).ResultsOn multivariable analyses, myeloma/lymphoma, time developing motor deficits > 14 days, and pre-treatment ambulatory status were significantly associated with both successful treatment and ambulatory status, affection of 1–2 vertebrae with successful treatment only. On univariable analyses, 1 × 8 and 5 × 4 Gy were not inferior to 5 × 5 Gy and longer-course regimens. Considering the three factors significant for both endpoints, three groups were designed (0, 1, 2–3 points) with treatment success rates of 4%, 15% and 39%, respectively (p < 0.0001), and post-treatment ambulatory rates of 4%, 43% and 86%, respectively (p < 0.0001).ConclusionThis score helps identify patients with MSCC who appear to benefit from palliative radiotherapy in terms of improved motor function or remaining ambulatory in spite of being near end of life.

A New Clinical Instrument for Estimating the Ambulatory Status after Irradiation for Malignant Spinal Cord Compression.

Simple SummarySince 2005, upfront surgery has been increasingly used in addition to radiotherapy for patients with malignant spinal cord compression (MSCC). As spinal surgery includes significant risks, careful patient selection is crucial. Individual risks and benefits should be considered when choosing an optimal treatment strategy. Benefits include preserving or regaining a patient’s ambulatory function. To facilitate the decision pro or contra upfront surgery, a new prognostic score was developed to predict ambulatory status after radiotherapy alone. This clinical score was created from data of patients previously treated in prospective trials. It includes three prognostic groups (17–21, 22–31, and 32–37 points) with post-radiotherapy ambulatory rates of 10%, 65%, and 97%, respectively. Patients of the 32–37 points group may not require upfront surgery. The new instrument achieved very high accuracy in predicting post-radiotherapy ambulatory and non-ambulatory status and was more precise than a previous prognostic score in predicting non-ambulatory status.Estimating post-treatment ambulatory status can improve treatment personalization of patients irradiated for malignant spinal cord compression (MSCC). A new clinical score was developed from data of 283 patients treated with radiotherapy alone in prospective trials. Radiotherapy regimen, age, gender, tumor type, interval from tumor diagnosis to MSCC, number of affected vertebrae, other bone metastases, visceral metastases, time developing motor deficits, ambulatory status, performance score, sensory deficits, and sphincter dysfunction were evaluated. For factors with prognostic relevance in the multivariable logistic regression model after backward stepwise variable selection, scoring points were calculated (post-radiotherapy ambulatory rate in % divided by 10) and added for each patient. Four factors (primary tumor type, sensory deficits, sphincter dysfunction, ambulatory status) were used for the instrument that includes three prognostic groups (17–21, 22–31, and 32–37 points). Post-radiotherapy ambulatory rates were 10%, 65%, and 97%, respectively, and 2-year local control rates were 100%, 75%, and 88%, respectively. Positive predictive values to predict ambulatory and non-ambulatory status were 97% and 90% using the new score, and 98% and 79% using the previous instrument. The new score appeared more precise in predicting non-ambulatory status. Since patients with 32–37 points had high post-radiotherapy ambulatory and local control rates, they may not require surgery.

Oncologic emergencies and urgencies: A comprehensive review

Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.

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.