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Case History

Image not available. A 56-year-old previously fit woman presents with paraparesis of 24 hours duration on a background of 4 weeks of mild malaise and progressive back pain. An urgent magnetic resonance scan of the spine reveals destructive vertebral lesions at T8-T9 causing spinal cord compression (Figure 11.1). A chest radiograph shows a right lower lobe infiltrate.

What underlying malignancies would you consider in the differential diagnosis?

What is the immediate management?

What are the treatment options and how should the decision be based?

Figure 11.1

Detail from magnetic resonance scan showing an epidural soft tissue metastasis encroaching on the spinal canal and cord at the level of a thoracic vertebra.

Background

What underlying malignancies would you consider in the differential diagnosis?

Image not available. Breast cancer is common in women of this patient's age and may present like this. The chest radiograph appearances may be due to an obstructing bronchial lesion, so primary lung carcinoma metastatic to the spine should be considered. The picture of localized destructive bony lesions also fits with multiple myeloma, which may present with concurrent respiratory tract infection due to associated immune suppression.

Other less common malignancies that have an affinity for bone and may present as spinal cord compression include renal and thyroid cancers. Of course lymphoma may present with almost any clinical picture and should always be considered in the differential diagnosis of metastatic spinal cord compression.

Discussion

What is the immediate management?

Image not available. Metastatic spinal cord compression (MSCC) is an oncological emergency as the process and consequent neurological deficits are remediable if treated early enough. Extrinsic compression of the cord, either by bony fragments or metastatic tumour, leads to vasogenic oedema. At this stage the process is potentially reversible but if the oedema progresses to ischaemia, neuronal death and permanent neurological deficit will occur.

High-dose dexamethasone should be initiated immediately as steroids can play a vital role in reducing oedema, inhibiting prostaglandin synthesis and possibly downregulating vascular endothelial growth factor. Some evidence suggests that patients treated with very high-dose corticosteroids (i.e. dexamethasone 100 mg) have improved motor function and longer maintenance of ambulation compared to those receiving moderate doses (e.g. dexamethasone 10–30 mg) (reviewed in Loblaw et al.1). This is at the expense of more frequent serious adverse events related to steroid use. One phase II study suggested that in patients with good motor function at the time of diagnosis of MSCC, corticosteroids might not be necessary prior to radiotherapy treatment,2 but their omission is not standard practice.

What are the treatment options and how should the decision be based?

The choice of definitive initial emergency treatment for MSCC lies between surgery and radiotherapy. ...

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