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Epidural cord compression and Bone metastasis.

Epidural cord compression and Bone metastasis. Amr Amin Lecturer of Radiation Oncology NCI Cairo Univ. Why bone metastasis and cord compression. It is serious. It is common. It seriously affects oncologic patient ’ s QOL. Bone metastasis pain.

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Epidural cord compression and Bone metastasis.

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  1. Epidural cord compression andBone metastasis. Amr Amin Lecturer of Radiation Oncology NCI Cairo Univ.

  2. Whybone metastasis and cord compression. • It is serious. • It is common. • It seriously affects oncologic patient’s QOL Amr Amin

  3. Bone metastasispain • The most common cause of intractable pain in cancer patients. • Bone is the third most common site of metastases after lung and liver. • In up to 23% of patients it is the presenting problem. • Bone pain results in immobility, anxiety, and depression and severely impacts on a patient's quality of life. Amr Amin

  4. The Primary In patients with bone metastases, the primary was: • prostate (32%) • breast (22%) • kidney (16%) • thyroid , lung and testes (10% each) • others Amr Amin

  5. Mechanism of bone metastasis • Invasion of vascular channels. • Detachment from tumor. • Dissimination with blood. • Endothelial attachment at certain sites. • Homing and growth (colonization). Amr Amin

  6. Why ? • In bones: Only 7% of cardiac output -- but favouring bone microstructure (stagnation, rich venous sinusoidal system) • Occasional late appearance: colony growth needs angiogenesis. • Commoner with certain primaries: ? Secretion of humoral mediators (e.g.PDGF, TNF ..) • More axial: ? Circulatory factors Amr Amin

  7. Diagnosis Biopsy: • No or > 1 primary. • 1 primary when metastasis is solitary, 1st incedence, no other metastasis or clinically and radiologically equivocal. Lab: routine + alk ph (non sp), s ca, s creat. Amr Amin

  8. Imaging • Plain x ray; less sensitive and late detection (medulla is usually affected before cortex and vertebral body before pedicle). • Bone scan: • more sensitive, less specific. • Entire skeleton Amr Amin

  9. Bone scan (cont.) • ++ uptake  osteoblastic response • -- upatke  destruction> formation bone infarction. Early vascular phasein highly vascular t. Super scan  wide spread mets (-- normal renal uptake). Not for myeloma & some lymphomas (no osteoblastic response) Amr Amin

  10. Why plain after +ve BS • Pathological or impending fracture. • Sclerotic prostate, GIT, Bladder lytic  all primaries mixed  breast Amr Amin

  11. Why CT • +ve BS and –ve plain  50% mets detected(bt). • Soft tissue comp. • DD degenerative joint disease. Why Arteriography.. Before S for vascular mets +/- pre-op embolization. Amr Amin

  12. Why MRI Best Choice • Spine mets > BS in early medullary lesions. • DD benign/malig vertebral collapse. • Suspected neurologic compression. < risky not invasive Vs CT myelography. Please do whole spine (10% multiple levels). Amr Amin

  13. It could be that serious • Plain x ray cervical spine showing completely eaten up body of C3. Amr Amin

  14. Plain x ray cervical spine showing complete destruction of the spinous process of C3 and C4 Amr Amin

  15. A T2 saggital view of cervical spine showing a huge mass compressing the spinal canal mainly at the level of C2. Amr Amin

  16. T2 saggital view of lumbar vertebrae showing LV 1 destruction with soft tissue mass compressing the spinal canal at this level. Amr Amin

  17. Treatment of bone metstasis • Goals: ++ QOL , -- pain & ++ mobility with least ttt time, comp and cost with longest duration of effect. • Survival considerations: • long  solitary renal(48 ms) br, prost • Short  lung (12 ws) multiple (24 ws) Amr Amin

  18. Treatment of bone metstasis • Medical. • Surgical. • Radiotherapy. • Radionuclid. Amr Amin

  19. Medical treatment • Hormonal • Chemotheapy • Bisphosphonates • Analgesics. Amr Amin

  20. Hormonal (Prost 80%,br 50%) • Orchiectomy/ LHRH [+ antiandrogen in 1st 4 ws to avoid flare (20%)]  80 % response (rapid) • TAS ++ PFS & median S (NCI),,, in low burden disease only (EORTC). • 2nd line ( ketokonazole  20 % < 6 ms Amr Amin

  21. Hormonal (Prost 80%,br 50%) • Nolvadex  50 % response in ER +ve for 18+ ms. • Aromatase inhibitors  0-50% • Megesterol acetate  +/- same • lHRH or Ov ablation in premenopausal Amr Amin

  22. Chemotherapy • Curative in germ cell , HD and NHL • 50 % in MM (main line) both subjective and – paraptn. • 15% PR for 10 ms ( br and SCLC) Amr Amin

  23. Bisphosphonates ( Br & Prost) • IV drip Q 4 ws for 9-12 ms. • Binds tightly to calcified bone matrix • -- osteoclast mediated bone resorption.  50 % pain relief 50 % -- fracture and deformity 25% bone healing radiologically Amr Amin

  24. Analgesics • assess & score pain • Who ladder ( better before severe pain) • Step I non opioid +/- adj, eg NSAID • Step II add mild opioid e.g. codeine. • Step III opioid e.g. morphine +/- non opioid or adj Nerve block and intradural pumps Amr Amin

  25. Treatment of bone metstasis • Medical. • Surgical. • Radiotherapy. • Radionuclid. Amr Amin

  26. Surgery • Impending/pathological fracture. • -- functional loss and pain • Allow for healing and faster mobilization. femur 65% humerous 15% acetabulum/tibia 7% Amr Amin

  27. Surgery (cont) prophylactic fixation. • Peritrochanteric , lytic, >/= 50 % cortical destruction, > 2.5 cm of shaft length, mechanical pain. • With : life expectancy > 3 ms. fit for major S. expected ++ mobilization enough good bone prox & distal. Amr Amin

  28. Othopedic intervention (impending fracture) • Plain x ray lt femur showing big osteolytic lesion of lesser trochanter and sub-trochanteric area of shaft Amr Amin

  29. Othopedic intervention (impending fracture) • Nail and screw fixation for the same patient. Amr Amin

  30. Othopedic intervention (impending fracture) • Plain x ray of Rt femer showing multiple osteolytic lesions of neck and trochanteric area that required Rt hip replacement. Amr Amin

  31. Surgery (cont) spine fractures • Body affected 1st & up to 40 % of it can be destroyed before detected by conv radiology. • Symptomatic only when - breaks through cortex to paravert tiss - nerve root or cord comp. - path. fracture. Amr Amin

  32. Metastalic colon carcinoma saggital MRI image • T1 pre-contrast scan abnormal low signal intensity lesions are identified in the body of T12, L1, and L2 vertebrae. A pathologic fracture is noted at T12. Amr Amin

  33. Metastalic colon carcinoma saggital MRI image • the post-contrast scan shows heterogeneous enhancement with soft tissue masses at T12 and L2 that compromise the spinal canal Amr Amin

  34. Metastalic colon carcinoma saggital MRI image • T2 shows increased signal intensity at the lesions with good delineation of the epidural tumors which at T12 displace the conus of the cord posteriorly. Amr Amin

  35. An axial MRI T1 image with contrast showing a Rt sided soft tissue mass eroding tansverse process, pedicle, lamina, spine and body of a DV with cord compression. Amr Amin

  36. Surgery (cont) spine fractures • Bed rest and bracing • Spinal stabilization (major- high risk) if • Progressive cord comp. & radioresistant tumor. • Progressive spinal deformity. • Solitary. Amr Amin

  37. Treatment of bone metstasis • Medical. • Surgical. • Radiotherapy. • Radionuclid. Amr Amin

  38. Palliative radiotherapy • 55% CR while 80 % PR • I) Local field – fractionation RTOG same results in 266 pts with solitary mets: 40 GY/15 Fx Vs 20 Gy/ 5 Fx 750 pts with multiple mets: 30 Gy/10 -- 25 Gy/5 -- 20 Gy/5-- 15 Gy/5 Amr Amin

  39. Palliative radiotherapy (cont) • Price et al 288 pts randomized 30 Gy/ 10 Fx Vs 8 Gy/1 fx  same However reanalysis by RTOG, protracted courses ? Longer duration of pain relief. Amr Amin

  40. Palliative radiotherapy (cont) • HBI • As local but 1) rapid onset (1 day compared to 1-2 ws) 2) delay prog. New lesions, rettt. • Higher morbidity NVD, --BM, pneumonitis if > 7 GY Amr Amin

  41. Treatment of bone metstasis • Medical. • Surgical. • Radiotherapy. • Radionuclid. Amr Amin

  42. Radionuclids • 25% CR 75 % PR after 2ws for +/- 9 ms.( selective absorp -- normal t. tox) • Adv.  all sites in single IV • Indications: adj to Rth in wide spread 1st line in wide spread+ non painful after Rth exhausion. Amr Amin

  43. Radionuclids • Contraindications: life expectancy < 3 ms, TLC <2400 plat < 100.000, impending fracture or cord comp. • Examples: P32 (historical), St 89 (most popular), Rhenium 186 and Samarium 153 • Popular in met. prostatic ca. 11 % alone 80% with local Rth.(nearly replaced HBI) but not in met. Breast ca.(concerns about BM reserve) Amr Amin

  44. Extradural cord compression. • Incidence : 5% of ca pts 20% if vert mets, 10 % multiple. • 95 % extramedullary, mostly ant comp. • Primary: br, prost, renal, lymphoma, myeloma, sarcoma. Amr Amin

  45. Extradural cord compression. • Pain (initial symptom in 95%) preccds neurological symptoms by ws to ms. • Suspect in pts with vert. Mets,, MRI is most important. Amr Amin

  46. Amr Amin

  47. Amr Amin

  48. Extradural cord compression.(ttt) • High dose steroids 20 mg then 4 mg 4 times/day with gradual withdrowal. • Rt 15 % ++ ambulation, 75 % pain relief. • Laminectomy before Rt if: • no pathology • Radioresistant or previous Rth. • Mechanical instability otherwise no added value. Amr Amin

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