Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further. In this episode, we talk all about our third oncologic emergency: new brain mets.
Cord compression:
- If someone has a pathologic fracture, think about the following differential as underlying etiologies:
- Females: rule out breast cancer
- Males: Prostate cancer
- Others: multiple myeloma, lymphoma, lung cancer, renal cell carcinoma, bladder
- If cord compression, administer steroids; may require radiation to help with shrinking; also may need involvement of neurosurgery if there is lack of spine stability.
Role of radiation in cord compression:
-MRI is beneficial to help with radiation planning
-Where is the disease in proximity to the spinal cord? In the bone? In the epidural space? Or pushing against the spinal cord +/- blocking CSF?
-Is the spine stable? Use SINS scoring (https://radiopaedia.org/articles/spinal-instability-neoplastic-score-sins-2?lang=us)
-If good spine stability (low SINS) or is not surgical candidate or radio-sensitive tumor: radiation up front
-If poor spine stability (high SINS) then may need surgery up front
Radiosensitive tumors examples:
Lymphoma
Germ cell tumors
Small cell lung cancer
Radio-resistant tumor examples (resistant does not mean that radiation cannot be used, however):
Melanoma
Colorectal
Renal cell
Continue steroids as they are undergoing radiation to prevent flare up from inflammation and acute worsening from the mass on the spinal cord
Role of neurosurgery:
- What is a reasonable time that we can wait before operating for a new cord compression?
- As noted above, cord compression has various degrees
- Questions to ask: What neurologic symptoms? Over what time period?
- Asymptomatic: You have time! Perhaps investigate why mass may be there.
- Progressive over a couple of weeks: You have a little bit of time (a few days to get them to surgery)
- Acutely having symptoms: You should intervene.
- Spinal stability: are the weight-bearing components (ligaments) intact? Assessed via upright X-rays
- If the tumor is radio-sensitive, may opt for radiation first (if diagnosis is known)
A HUGE thank you to our special guests:
Ryan Miller, MD, MS: PGY5 in Radiation Oncology at Thomas Jefferson University Hospital, Philadelphia, PA
Joshua Lowenstein, MD, MBA: Neurosurgery Attending, REX Neurosurgery and Spine Specialists, Raleigh, NC
Please visit our website (TheFellowOnCall.com) for more information
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