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Consider ambulatory status prior to metastatic spine disease treatment
Oncologic status is a key consideration when selecting surgical, radiation therapy or steroid treatment.
NEW ORLEANS — An array of protocols and grading scales have evolved over time to help orthopedic surgeons and neurosurgeons select the best treatment approaches for patients with metastatic spine disease. But, some new ways of looking at the same factors that those systems take into account — neurologic, oncologic, mechanical and systemic — may lead to improved survival rates and a better quality of life for patients.
“None of the algorithms are perfect. But what our algorithms do is they help you split, help you decide what is the best thing for these patients,” Rex A.W. Marco, MD, said in a presentation at the American Academy of Orthopaedic Surgeons Annual Meeting.
In his approach to treatment of metastatic spine disease, Marco said he considers some slightly different factors than the factors used in usual protocols. He said he considers — in this order — the patient’s medical status, oncologic status, neurologic status and spinal stability.
“But I always give the patient the choice,” Marco said. Marco said he puts a lot of weight on the first two factors.
This 54-year-old woman with metastatic spinal cord compression associated with myeloma presented with 4/5 strength in the bilateral lower extremities. Staging studies confirmed the solitary nature of her disease. A biopsy was obtained to confirm the presence of myeloma.
Image: Marco RAW
Ambulatory status
Ambulatory status is important, Marco said. Historic studies show 90% of patients with metastatic spinal cord compression who are ambulatory upon presentation remain so, he said. Therefore, he uses it to initially stage his patients. It is often an accurate indicator of mechanical spine issues and sometimes of the extent of any spinal cord compression a patient has.
“If the patients are walking and you treat them with external beam radiation therapy and steroids, they are probably going to walk,” he said. “If they are walking, they probably do not need surgery.”
Medical and oncologic status
Marco discussed how medical status factors into whether the patient is ultimately a candidate for surgery, radiotherapy, steroids or a combination of those. Often, he said, the medical status should be evaluated in conjunction with the patient’s oncologic status to determine how to proceed.
For example, even a patient with a lymphoma or myeloma and grade 3 spinal cord compression can do well with nonoperative treatment, he said.
“It is unusual for me to take my myeloma, lymphoma patients to surgery,” Marco said.
Decision chart
Myeloma and lymphoma are the two most radiosensitive tumors listed on a chart Marco uses and discussed at the meeting. The chart lists the radiosensitivity of metastatic tumors from most to least radiosensitive in Marco’s estimation.
“[It] will help you decide which patients are going to benefit more or you are going to lean toward the surgery. On the more relatively radioresistant side, if they are healthy enough, you might be leaning more towards aggressive open surgery,” Marco said.
Osteosarcoma and chondrosarcoma are found at the end of the chart with the more radioresistant tumors, such as melanoma, chordoma and radioresistant and chemoresistant renal cell carcinoma. Depending on other factors, a patient with either an osteosarcoma or chondrosarcoma may benefit more from a surgical rather than a nonsurgical intervention, he said.
Steroid treatment
Marco discussed the case of a woman with multiple myeloma who had back pain, lower extremity weakness, urinary retention, diabetes and hypertension in whom he used an intermediate dose of steroids, starting with 10-mg decadron, and the patient did well. She was also walking before treatment, he noted.
“I almost use steroids all the time on patients with spinal cord compression. The only time I do not do it is if I don’t have a diagnosis yet,” Marco said. “If I don’t have a diagnosi s yet and it might be myeloma or lymphoma, then I just try to get an immediate biopsy either myself or through interventional radiology.”
Marco said he learned in his training that starting steroids at an intermediate dose provides the ability to increase the dosage if needed, but noted he actually tapers the dose down drastically whenever treatment — either radiation or surgery — begins. – by Susan M. Rapp