Diagnostic and Therapeutic Strategies for Patients with Malignant Epidural Spinal Cord Compression

Abstract

Malignant epidural spinal cord compression (MESCC) is an oncologic emergency with the potential for devastating consequences for patients if not promptly diagnosed and treated. MESCC is diagnosed by imaging. MRI is by far the most sensitive test, preferably with gadolinium. Once the diagnosis of MESCC is suspected, patients with neurologic deficits should receive prompt administration of dexamethasone with a 10-mg IV loading dose followed by 4 mg every 6 h. Quick taper is recommended once the definitive treatment is established. Consultation with medical oncology, radiation oncology, and neurosurgery is imperative in order to facilitate a multidisciplinary approach. Although spine surgery is the most effective method for relief of cord compression and is necessary if there is spinal instability, surgery is only used in selected patients because most patients have a poor overall condition and short life expectancy. Radiation therapy, therefore, is the most commonly used therapy for patients with MESCC after surgical decompression or in patients who are not surgical candidates. Conventional fractionated radiation alone can achieve modest neurologic outcomes in selected radiosensitive tumors. Radiosurgery techniques which deliver intense focal irradiation to a delimited area with imaging guidance and contoured radiation delivery to the shape of the tumor have recently emerged as increasing effective treatments in MESCC, especially in radioresistant tumors. Stereotactic radiosurgery and different radiation technologies have been studied in recent clinical trials.

Kompresi Medulla Spinalis akibat Metastasis

“…3,6 Di Amerika Serikat, insidens KMSM lebih dari 20.000 kasus per tahun. 5,7 Sebanyak 50% KMSM berasal dari penyakit primer kanker payudara, paru, prostat, diikuti kanker sel ginjal, traktus gastrointestinal, tiroid, sarkoma, dan keganasan limforetikuler. 5 Suatu studi di Kanada memperkirakan setidaknya 2,5% penderita kanker mengalami minimal satu episode kompresi medula spinalis dalam lima tahun sebelum kematian.…”

“…1 Sebagian besar KMSM terjadi di regio vertebra torakal (60-70%), lalu di vertebra lumbal (20-25%), dan yang lebih jarang di vertebra servikal (15%) dan sakral. 1,7…”

“…Sebanyak 51-80% pasien mengeluhkan defisit fungsi sensoris, misalnya kesemutan pada ekstremitas dan batang tubuh. Disfungsi otonom biasanya tidak dirasakan sebagai gejala tunggal namun menyertai gejala nyeri, kelemahan, dan defisit sensoris 7,8 Bukti radiologis minimal untuk diagnosis kompresi medula spinalis adalah indentasi theca yang disesuaikan dengan gejala dan tanda klinis. MRI adalah modalitas pencitraan terpilih untuk deteksi dini KMSM.…”

“…Pada kasus KMSM, pencitraan diagnostik harus mencakup seluruh vertebra karena pada 40-50% pasien, lesi dapat terjadi multifokal dan multilevel. 3,7,8 Pada pasien dengan kecurigaan KMSM namun keganasan primer belum diketahui, direkomendasikan biopsi terbuka ataupun perkutan (dibantu CT). 1…”

“…Hal ini menunjukkan pentingnya tatalaksana optimal penyakit ini untuk mempertahankan kualitas hidup yang baik. 3,7…”