131Radiotherapy dose fractionation Third edition
Background
Patients with symptoms suggestive of spinal cord compression, particularly severe back or
root pain, should be investigated urgently with whole spine magnetic resonance imaging
(MRI) to dene sites and levels of compression accurately.
1
Multiple levels of compression
are seen in up to one-third of patients.
2–4
On clinical suspicion of MSCC or once a diagnosis has been established, all patients
should be started on steroids; the UK convention is to give dexamethasone in 16 miligrams
(mg) daily. There is evidence from one randomised trial that higher initial doses of 96 mg are
superior to no steroids (Level 2b).
5,6
No dose comparison between 16 mg and higher doses
has been undertaken.
Systemic anti-cancer treatment may be more appropriate than radiotherapy for some
malignancies, for example, lymphomas, plasma-cell tumours, germ cell tumours or
untreated small cell cancers.
Long-term outcome from MSCC depends on the degree of paralysis and overall prognosis
for the cancer; with poorer outcomes associated with non-ambulatory status, poor
performance status, ≥3 involved vertebrae, presence of other bone metastases, presence
of visceral metastases and shorter time to developing motor decits. Non-breast/prostate/
haematological primaries also confer a worse prognosis (Level 2c).
7,8
Ideally, the prognosis of patients should be objectively assessed using validated scores
such as the Tokuhashi Score (Level 2b).
6,8,9
Patients with a good expected prognosis, especially those who are ambulatory, should
be discussed with a spinal- or neurosurgeon to consider spinal decompression and
stabilisation surgery followed by radiotherapy. This intervention has been shown to improve
neurological status and overall survival in patients with MSCC (Level 1b) compared to
radiotherapy alone.
6,10
For good prognosis or ambulatory patients who are not suitable for surgery, urgent
radiotherapy should be given before further neurological deterioration.
3,4,8
For poor prognosis or non-ambulatory patients, radiotherapy should be considered either
to preserve neurological function (in ambulatory patients) or for pain relief only if paraplegia
has been established for >24 hours.
3,4,8
Current evidence on dose and fractionation for MSCC largely consists of retrospective
series, prospective non-randomised studies looking at several dierent treatment
schedules or prospective randomised control trials (RCTs) using schedules not commonly
used in UK, including split course schedules (Level 2b).
6,8,11–13
The current evidence suggests no benet for doses higher than 30 Gray (Gy) in ten daily
fractions. More hypofractionated regimes (8 Gy in a single exposure, 20 Gy in ve daily
fractions) are most commonly used in the UK and are as eective as longer schedules
in terms of pain relief, neurological benet and survival. There may be fewer in-eld
recurrences with longer schedules and fewer patients treated with longer courses are
treated with further radiotherapy to the same area for recurrent MSCC (Level 2b), however,
a recent randomised trial found that 20 Gy in ve fractions was not inferior to 30 Gy in ten
fractions for motor function or ambulatory status.
14–16
21.
Metastatic spinal cord
compression (MSCC)
132Radiotherapy dose fractionation Third edition
Ambulant patients with an expected better prognosis may, therefore, benet from longer
courses of treatment to prevent recurrence and need for retreatment.
The SCORAD III prospective RCT is currently recruiting and randomising patients with an
expected prognosis of >12 weeks to either a single exposure of 8 Gy or 20 Gy in ve daily
fractions. The results of this trial will inform decisions regarding the optimal schedule in the
future [UKCRN ID 7952].
16
Recommendations
Metastatic spinal cord compression: non-ambulant patients or ambulant
patients with a poor prognosis:
8 Gy single dose (Grade B)
or
20 Gy in 5 daily fractions over 1 week (Grade B)
Metastatic spinal cord compression: ambulant patients with a good prognosis
or post-spinal surgery:
20 Gy in 5 daily fractions over 1 week (Grade B)
or
30 Gy in 10 daily fractions over 2 weeks (Grade B)
The types of evidence and the grading of recommendations used within this review are based on
those proposed by the Oxford Centre for Evidence-based Medicine.
6
There is response to retreatment after initial benet from radiotherapy for recurrent MSCC.
The absolute maximum retreatment dose has not been established, but a cumulative
biologically equivalent dose (BED) (initial + reirradiation) of 120 Gy
2
appears to be safe
and eective. Evidence indicates that the eect of previous radiation, time to develop
motor decit, presence of visceral metastases and performance status have an impact on
eectiveness of repeat treatment but schedule of treatment does not (Level 2c).
6,17
Recommendation
Metastatic spinal cord compression: re-irradiation:
8 Gy single dose or 20 Gy in 5 daily fractions prescribed at depth.
Maximum cumulative BED <120 Gy2 (Grade C)
The types of evidence and the grading of recommendations used within this review are based on
those proposed by the Oxford Centre for Evidence-based Medicine.
6
133Radiotherapy dose fractionation Third edition
1. Levack P, Graham J, Collie D et al. Don’t wait for a sensory level – listen to the symptoms: a prospective
audit of the delays in diagnosis of malignant cord compression. Clin Oncol (R Coll Radiol) 2002; 14(6):
472–480.
2. Hoskin PJ, Grover A, Bhana R. Metastatic spinal cord compression: radiotherapy results and dose
fractionation. Radiother Oncol (R Coll Radiol) 2003; 68(2): 175–180.
3. Metastatic Spinal Cord Compression: Diagnosis and management of adults at risk of and with
metastatic spinal cord compression. NICE Clinical Guideline 75, November 2008
4. National Institute for Health and Care Excellence. Metastatic spinal cord compression in adults: risk
assessment, diagnosis and management. London: National Institute for Health and Care Excellence,
2008.
5. Sorensen PS, Helweg-Larsen SH, Mouridsen H, Hansen HH. Eect of high dose dexamethasone in
carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial. Eur J
Cancer 1994; 30A(1): 22–27.
6. www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009
(last accessed 30/9/16)
7. Rades D, Fehlauer F, Schulte R et al. Prognostic Factors for local control and survival after radiotherapy
of metastatic spinal cord compression. J Clin Oncol 2006; 24(21): 3388–3393.
8. Prewett S, Venkitaraman R. Metastatic spinal cord compression: review of the evidence for a
radiotherapy dose fractionation schedule. Clin Onc (R Coll Radiol) 2010; 22(3): 222–230.
9. Tokuhashi Y, Matsuzaki H, Ods H, Oshima M, Ryu J. A revised scoring system for preoperative
evaluation of metastatic spine tumor prognosis. Spine 2005; 30(19): 2186–2191.
10. Patchell RA, Tibbs PA, Regine WF et al. Direct decompressive surgical resection in the treatment of
spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366(9486):
643–648.
11. Rades D, Stalpers LJ, Veninga T et al. Evaluation of ve radiation schedules and prognostic factors for
metastatic spinal cord compression. J Clin Oncol 2005; 23(15): 3366–3375.
12. Maranzano E, Trippa F, Casale M et al. 8 Gy single-dose radiotherapy is eective in metastatic spinal
cord compression: results of a phase III randomized multicentre Italian trial. Radiotherapy Oncol 2009;
93(2): 174–179.
13. Maranzano E, Bellavita R, Rossi R et al. Short-course versus split-course radiotherapy in metastatic
spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol 2005; 23(15):
3358–3365.
14. Rades D, Rudat V, Veninga T, Stalphers LJ, Hoskin PJ, Schild SE. Prognostic factors for functional
outcome and survival after reirradiation for in-eld recurrences of metastatic spinal cord compression.
Cancer 2008; 113(5): 1090–1096.
15. Rades D, Šegedin B, Conde-Moreno AJ et al. Radiotherapy With 4 Gy × 5 versus 3 Gy × 10 for
metastatic epidural spinal cord compression: nal results of the SCORE-2 Trial (ARO 2009/01). J Clin
Oncol 2016; 34(6): 597–602.
16. www.ucl.ac.uk/cancertrials/trials/scorad (last accessed 13/10/16)
17. Rades D, Stalpers L, Veninga T, Hoskin PJ. Spinal re-irradiation after short-course RT for metastatic
spinal cord compression. Int J Radiat Oncol Biol Phys 2005; 63(3): 872–875.
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