Metastatic Spinal Cord Compression – a primer

  • Metastatic spinal cord compression (MSCC) may be the presenting feature of cancer in up to 20% of patients.
  • A history of persistent worsening back pain in a patient with cancer warrants urgent investigation.
  • Immediate MRI of the whole spine is the imaging modality of choice.
  • Patients with a clinical suspicion of MSCC are routinely commenced on corticosteroids, typically oral dexamethasone 8 mg twice daily, although there is limited evidence to support this practice.
  • Although there was no difference in survival, the use of steroids was associated with a significant improvement in ambulatory status at 6 months.
  • Direct decompressive surgical resection followed by radiotherapy has been shown to be superior to radiotherapy alone.
  • Failure of immediate diagnosis and treatment is associated with significant morbidity and compromised quality of life.

MSCC indications

Postgrad Med J 2008;84:418-427 doi:10.1136/pgmj.2007.067033

Hyperviscosity Syndrome

Clinical Manifestations

Hyperviscosity syndrome, seen in approximately 15% of patients with Waldenstrom macroglobulinemia, is the most serious and potentially fatal complication of macroglobulinemia.

Hyperviscosity syndrome commonly manifests as skin or mucosal bleeding, visual abnormalities, headache, vertigo, dizziness, nystagmus, deafness, ataxia and in severe cases confusion, dementia, stroke or coma. Pulmonary edema and congestive heart failure have also been reported. However, uncommonly, hyperviscosity syndrome may manifest with exertional chest pain and dyspnea without other symptoms. Tyically, symptoms improve with initiation of chemotherapy and reduction in plasma viscosity..

Elevated plasma viscosity along with characteristic symptoms can be diagnostic of hyperviscosity syndrome. Although it is usually seen with the plasma viscosity > 4 cP, the level at which patients become symptomatic is quite variable (“symptomatic threshold”). The presence of anemia or hypoxia may contribute to symptom manifestations at a marginally elevated plasma viscosity.

Diagnosis

Laboratory evaluation of a suspected hyperviscosity syndrome should include serum protein electrophoresis and immunofixation, quantitative immunoglobulin levels and plasma viscosity measurements. Additionally, a complete blood count, kidney and liver function tests, lactate dehydrogenage and disease-specific evaluation are performed.

Treatment

The immediate treatment relies on the physical removal of the IgM protein from the blood stream by plasmapheresis, while long-term management is aimed at the control of underlying disease.

Rituximab, an IgG(1)-kappa monoclonal antibody that targets the CD20 antigen on the surface of malignant and normal B lymphocytes, has been utilized in treatment as a single agent or in combination with chemotherapy.

Bendamustine hydrochloride, a novel alkylating agent, has shown efficacy in treatment of indolent non-Hodgkin lymphoma and can be administered in combination with rituximab with good outcomes.

Adapted from: World Journal of Oncology, ISSN 1920-4531 print, 1920-454X online. Creative Commons License.