Radiotherapy Without Steroids in Selected Metastatic Spinal Cord Compression Patients

Abstract

A phase II trial was planned to investigate the feasibility of radiotherapy (RT) without steroids in 20 consecutive patients with metastatic spinal cord compression (MSCC), no neurologic deficits, or only radiculopathy, and no massive invasion of the spine at magnetic resonance imaging (MRI) or computed tomography (CT). Aiming at an early diagnosis, MRI or CT was prescribed for all cancer patients with back pain and osteolysis, even when there were no signs of neurologic spinal compression. All patients were given 30 Gy in 10 fractions over 2 weeks with no steroids. Back pain and motor capacity were the parameters adopted to verify response to RT. Sixteen of 20 patients (80%) were able to walk without support, and 14 (70%) had no radiculopathy. Seventeen of 20 cases (85%) achieved relief from back pain. Regarding motor function, all patients (100%) responded to RT because the 16 patients able to walk without support at diagnosis did not deteriorate and the other 4, who needed support, became ambulatory without motor impairment. Median survival time was 14 months. Eight of 20 (40%) treated patients are still alive (14 to 36 months after end of RT), fully ambulatory, and free from relapse in the treated spine. Acute side effects were documented in only 2 patients (10%) and were managed without steroids. The results of this study suggest that RT without steroids is a feasible regimen for MSCC patients with good motor function. Elimination of steroids from the standard treatment for MSCC avoids cortisone side effects above all in those patients with diabetes, hypertension, peptic ulcer, and other steroid-sensitive medical problems.

Malignant spinal cord compression: a retrospective audit of clinical practice at a UK regional cancer centre

“…Steroids are an effective adjunct to radiotherapy, reducing spinal cord oedema and inflammation and improving neurologic deficits and pain control (Held and Peahota, 1993;Maranzano et al, 1996;Bucholtz, 1999;Quinn and DeAngelis, 2000). Based on patients' signs and symptoms and a high index of suspicion for MSCC, steroid administration should be initiated prior to the completion of all necessary diagnostic tests (Bucholtz, 1999;Quinn and DeAngelis, 2000).…”

“…However, documentation received from referring DGHs and community sources did not always include information on the commencement of steroid therapy. Steroid therapy could have been initiated earlier in some patients prior to diagnosis, however, fair evidence exists suggesting that steroids do not have to be given routinely where a patient has good motor function at time of presentation, (Maranzano et al, 1996). It is common practice in the UK for 16 mg of Dexamethasone to be prescribed per day for MSCC (Levack et al, 2001).…”

Treatment of Metastatic Spinal Cord Compression: cepo Review and Clinical Recommendations

“…In this regard, Maranzano et al 24 showed a pretreatment ambulation rate of 47% in mscc patients with poor prognosis (low radioresponsive primary tumour, paraplegic or paraparetic, poor performance status, poor life expectancy) and a post-radiotherapy (16 Gy in 2 fractions) total motor function response rate of 63%. In mscc patients with good prognosis (without neurologic deficit at diagnosis), a 30-Gy regimen resulted in an adequate motor function response for all patients 23 .…”

Spinal Cord Compression

“…Given the rapidity with which myopathy and other steroid-associated complications can arise, the importance of tapering steroids rapidly as tolerated (eg, if starting with 96 mg daily, halving the dose every 3 days) cannot be overstated. Patients with relative corticosteroid contraindications who have small epidural deposits that are not producing significant neurologic deficits can safely initiate treatment without corticosteroids [40].…”

“…In order of decreasing importance, these are (1) the degree of functional limitation when radiotherapy is instituted, (2) the tumor type, and (3) the extent of subarachnoid impingement. The importance of pretreatment neurologic status is reflected in the finding that radiotherapy preserved the ability to ambulate in 80 to 100% of patients treated in several series who had treatment instituted while still ambulatory [1,12,16,40,45]. Approximately one-third of patients who are nonambulatory but not paraplegic prior to treatment onset will regain the ability to walk, as will 2-6% of paraplegic patients.…”