While this patient does have metastatic breast cancer and will likely eventually succumb to her disease, she has a life-expectancy of greater than one year (see below), is in intractable pain, and has a progressing neurologic deficit. Therefore surgical treatment is indicated. Because her compression is anterior, a thoracic corpectomy, instrumented spinal fusion, and postoperative radiotherapy is indicated.
A scoring system by Tokuhashi et al has been shown to be a valuable method to predict life expectancy. In this revised system, scores are given according to the table shown in illustration A. Total scores of 0 to 8, 9 to 11, and 12 to 15 predict a life expectancy of less than 6 months, 6 months or more, and 1 year or more, respectively. This patient is in good general condition (2 points), has no extraspinal bone mets (2 points), has an isolated spinal lesion (2 points), has no mets to internal organs (2 points), has breast cancer (5 points), and has a mild incomplete palsy (1 point). Therefore using the system by Tokuhashi et al, her total score is 14 points, and she has a life expectancy greater than 1 year.
Klimo et al emphasize that decompressive laminectomy alone carries all the risks associated with an invasive procedure and offers the patient little benefit unless it is used to remove disease isolated to the posterior elements.
Patchell in a landmark randomized clinical trial showed that direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.
Schmidt et al review the epidemiology and treatment of metastatic cancer to the spine, and point out that spinal cord compression may develop in 5% to 10% of cancer patients.
Advanced chemotherapy likely will not help as she has already failed multiagent chemo. Because the lesion is primarily anterior, a posterior decompression is not adequate and would remove any remaining intrinsic stability in her spine. While radiation therapy would eliminate some of her pain, it would not address the spinal compression, and is inferior to surgery plus postoperative radiotherapy. Finally, palliative care is always a consideration, but should be reserved for patients who desire that treatment or have a life expectancy of less than six months.
Schmidt MH, Klimo P Jr, Vrionis FD. Metastatic spinal cord compression. J Natl Compr Canc Netw. 2005 Sep;3(5):711-9. Review.
PMID:16194459 (Link to Abstract)
Klimo P Jr, Kestle JR, Schmidt MH. Clinical trials and evidence-based medicine for metastatic spine disease. Neurosurg Clin N Am. 2004 Oct;15(4):549-64. Review.
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Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005 Aug 20-26;366(9486):643-8.
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Tokuhashi Y, Ajiro Y, Umezawa N. Outcome of treatment for spinal metastases using scoring system for preoperative evaluation of prognosis. Spine (Phila Pa 1976). 2009 Jan 1;34(1):69-73.
PMID:19127163 (Link to Abstract)