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The role of radiotherapy for metastatic epidural spinal cord compression

Abstract

Radiotherapy alone is the most common treatment for metastatic epidural spinal cord compression (MESCC). Decompressive surgery followed by radiotherapy is generally indicated only in 10–15% of MESCC cases. Chemotherapy has an unclear role and may be considered for selected patients with hematological or germ-cell malignancies. If radiotherapy alone is given, it is important to select the appropriate regimen. Similar functional outcomes can be achieved with short-course radiotherapy regimens and longer-course radiotherapy regimens. Longer-course radiotherapy is associated with better local control of MESCC than short-course radiotherapy. Patients with a more favorable survival prognosis (expected survival of ≥6 months) should receive longer-course radiotherapy, as they may live long enough to develop a recurrence of MESCC. Patients with an expected survival of <6 months should be considered for short-course radiotherapy. A recurrence of MESCC in the previously irradiated region after short-course radiotherapy may be treated with another short-course of radiotherapy. After primary administration of longer-course radiotherapy, decompressive surgery should be performed if indicated. Alternatively, re-irradiation can be performed using high-precision techniques to reduce the cumulative dose received by the spinal cord. Larger prospective trials are required to better define the appropriate treatment for the individual patient.

Key Points

  • Radiotherapy alone is the most common treatment modality for metastatic epidural spinal cord compression (MESCC), whereas decompressive surgery is indicated only for 10–15% of patients with MESCC

  • Short-course radiotherapy regimens are as effective as longer-course radiotherapy regimens with respect to post-treatment motor function; however, longer-course radiotherapy confers better local control of MESCC than short-course radiotherapy

  • Patients with a poor expected survival should receive short-course radiotherapy, and those patients with a relatively favorable prognosis should receive longer-course radiotherapy or even high-precision radiotherapy

  • Whenever possible, radiotherapy should be supplemented by administration of dexamethasone at an intermediate dose level with a tapered dose during or immediately after completion of radiotherapy

  • A recurrence of MESCC in the previously irradiated region after short-course radiotherapy may be treated with another short-course of radiotherapy

  • After primary administration of longer-course radiotherapy, decompressive surgery or, alternatively, re-irradiation with high-precision techniques should be performed for recurrence

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Figure 1: Metastatic epidural spinal cord compression.
Figure 2
Figure 3: Stereotactic body radiotherapy carried out in the University of Lubeck, Germany.

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Acknowledgements

D. Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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D. Rades and J. L. Abrahm contributed equally to the literature review and writing of this manuscript.

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Correspondence to Dirk Rades.

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D. Rades declares he is on the speaker's bureau and is an Advisory Board member/consultant for Amgen and Astra Zeneca, and is also on the speaker's bureau and receives grant/research support from Novartis and Merck Serono. J. L. Abrahm declares she is on the speaker's bureau for Janssen–Cilag, Merck, Ortho Biotech and Purdue Pharma.

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Rades, D., Abrahm, J. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol 7, 590–598 (2010). https://doi.org/10.1038/nrclinonc.2010.137

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