Clinical Practice Guidelines for the management of locally advanced ...

half of patients experienced pain relief but overall survival was poor, with median survival of four
months. Although no significant differences in the fractionation schedules were seen, clinically
significant differences could not be excluded. One-year survival was 18% for the longer fractionation
versus 10% with the shorter approach. Five (versus none) infield recurrences were seen in the shorter
fractionation group.
Evidence summary Level References
There are no randomised trials comparing radiotherapy with either
surgery or dexamethasone alone for spinal cord compression. There
is one randomised trial comparing two different fractionation
schedules for unfavourable risk malignant spinal cord compression.
It demonstrated no significant differences between the schedules,
though clinically important differences cannot be excluded
Recommendation
II 82
For patients with malignant spinal cord compression the use of radiation is recommended.
The optimal fractionation schedule of radiotherapy is unknown.
Grade D
Patients being treated with radiation for spinal cord compression should be given
dexamethasone at time of diagnosis.
Grade B
The role for surgery has long been controversial in malignant spinal cord compression from metastatic
prostate cancer. It is acknowledged that the outcomes with radiotherapy alone are suboptimal,
especially if patients are non-ambulatory or paraplegic at presentation. However, clinicians had
concerns subjecting patients who are often unwell with a poor median survival to the rigors of surgery
for a non-quantifiable degree of benefit. Also, it was not known whether surgery should consist of a
decompression laminectomy alone (to relieve pressure on the spinal cord) or the more aggressive
circumferential decompression laminectomy where the entire affected vertebrae is removed.
Decompressive laminectomy should be considered when radiotherapy cannot be given due to
previous treatment or progression during or shortly after radiotherapy.
There are only two randomised trials comparing surgery with radiotherapy versus radiotherapy
alone. 83, 84 The Patchell study of 101 patients (16% with prostate cancer) compared radiotherapy alone
with direct circumferential decompression (with spinal stabilisation if spinal instability present)
followed by radiotherapy.
The Patchell study demonstrated a clinically significant improvement with the addition of aggressive
surgery to radiation only and was stopped early as it met pre-set termination criteria. For ambulatory
patients at presentation, 94% versus 74% were walking post-treatment in the surgery and radiotherapy
arms respectively. For non-ambulatory patients, the rates were 62% versus 19%. There was a median
survival improvement of 126 versus 100 days (p=0.03) and a significant improvement in pain levels
as judged by median mean daily morphine doses (p=0.002) with surgery.
63
Overt metastatic disease and/or loco-regional progressive disease