Spinal Cord Compression Superior Vena Cava Obstruction

Spinal Cord Compression
and
Superior Vena Cava Obstruction
Devin Schellenberg MD FRCPC
Radiation Oncology
Fraser Valley and Vancouver Centres
British Columbia Cancer Agency

Aims of the Talk
1. Med school level: Describe the pathologic process
What is actually going on
2. Resident Level: Learn how to recognize these
emergencies
Clinical symptoms
Xray and CT findings
3. Your Level: Understand how to treat these emergencies
What should I give the patient
What should I order
Who should I call

Part 1: Spinal Cord Compression

Spinal Cord Compression: Incidence
Loblaw D, et al Clinical Oncology 2003
population study to review incidence, management and
outcome of Spinal cord compression (SCC) in Ontario
(1990-1995)
cumulative probability of experiencing at least one episode
of SCC in the 5 years preceding death from cancer was
2.5% overall (ranged by cancer site)
median survival following the first episode of SCC was 2.9
months

Function of Anatomy
Tumour grows in epidural space, obstruct epidural plexus /
direct compression of cord, vasogenic edema and ensuing
spinal cord infarction
Intramedullary
Cerebrospinal Fluid

Both cause similar clinical features
1. Back pain 85-95%
The most common first symptom
Can be radicular
2. Motor Findings
Weakness 60-85%
Hyper-reflexia (cauda equina depressed DTR)
3. Sensory Changes
4. Bowel and Bladder dysfunction
Late finding, up to 50%

Xray
Cord Compression Suspected
What next?
Urgent CT scan (specify level)
Urgent MRI provides more accurate view of
compression (but is harder to get)
If Cancer diagnosis – call oncologist
If no cancer diagnosis – start looking for one and
call neurosurgery

CT Scan images
10
With and Without bone disease
MRI imaging is more detailed (accurate)
but harder to get urgently

11
SCC – With Bony Disease

12
SCC – With Bony Disease

13
SCC – Without Bony Disease

14
SCC – Without Bony Disease

15
MRI – Cord Compression

Good prognostic factors
‣ Responsive tumor to Radiotherapy or Chemotherapy
‣ Lymphoma/Myeloma, Small Cell
‣ Gradual onset with slow progression
‣ Able to walk, normal bladder function
‣ Good general condition

Aims of Management
Return blood flow to spinal cord
Reduce swelling
•Steroids - dexamethasone
Decrease pressure from mass
1. Surgery and Radiation
2. Radiation treatment alone

Management - Steroids
Steroids beneficial in retaining motor function
No evidence to support use of high dose steroids
(>16mg/day)
High dose steroids associated with more adverse
events
OK to start 10 mg IV
Then 16 mg/day
Select patients may not require steroids (e.g.
asymptomatic with radiographic finding alone)

Management: Surgery
Patchell et al: Radiation vs Surgery + Radiation
Patient Characteristics
• 3m life expectancy, Medically
operable, Surgery within 24 hours
Tumour
• 1 site of compression
• No cauda equina syndrome
• Not Lymphoma
Results
Surgery + RT gave better: Return of ambulation, duration of
ambulation, continence, functional ability & overall survival
Issues
Most patients do not meet inclusion criteria

Management: Radiotherapy
Most common treatment for Cord Compression
Multiple studies examine role of radiotherapy alone
in management
Radiotherapy effective in treatment of SCC
decrease pain
increase functional outcomes
increase sphincter function
Final gait function dependent on gait at time of
diagnosis

Radiotherapy: the sooner the better
% of ambulatory pts who are ambulatory post 95%
% of assisted ambulation who are ambulatory post 60%
% of paraparetic who are ambulatory post 40%
% of paraplegic who are ambulatory post 10%
Loblaw et. al. 2004

The Surgery vs. Radiation Decision
Surgery
Spinal instability
Bony compression
Patients with no/remote cancer
diagnosis (establish Path)
Prior RT or neurological
progression while on RT
Radiation
Medically inoperable
Diffuse disease
Radioresponsive tumors
(lymphoma, myeloma, germ
cell…)
Have cancer diagnosis

SCC Conclusions
Decisions regarding treatment should consider
Medical status, ambulatory status, structural factors, anticipated
outcome, treatment goals
Treatment goals should be to improve or maintain highest
quality of life possible
Pain relief
Restoration of function
Refer for management early to obtain best results
High index of suspicion (hx of cancer & back pain)
Steroids
CT or MRI spine

Part 2: Superior Vena Cava
Obstruction

Superior Vena Cava Obstruction
“One of your take away points should be that this is
not an emergency most of the time.”
Dr. Leong

SVC Obstruction - Anatomy

SVCO - Definition
UpToDate: SVCO is often a prolonged process
developing over a period of weeks or longer prior
to clinical presentation. The duration of symptoms
has no influence on treatment outcomes [7].
Deferring therapy until a full diagnostic work-up
has been completed does not pose a hazard for
most patients, provided the evaluation is efficient
and the patient is clinically stable…

When is SVCO an Emergency?
Emergency if:
Stridor, tachypnea
Laryngeal edema (voice changes)
Hemodynamically unstable
Altered level of consciousness
If only dilated veins/swelling
Urgent, but not emergent
If only an imaging diagnosis of SVCO
Even less urgent
SVC is still largely a Clinical diagnosis!

Not SVCO

Not SVCO -
The report will say: tumor is against or compressing SVC

SVCO – On XRay
Very little to see in terms of widened mediastinum

SVCO – Swelling and Dilated veins
Lots to see clinically

SCVO – My Case

SVCO – Arm Swelling (into hand)

SVCO – “I’ve lost by elbow”

SVCO Symptoms and Signs
Edema
Altered consciousness
http://www.scielo.br/pdf/jbpneu/v31n6/en_27958.pdf

SVCO: Clinical diagnosis
Clinical symptoms
Flushing
Edema
Venous engorgement
Hoarseness (laryngeal edema)
Impaired Mental Status (reduced perfusion)
CT Scans
Confirm diagnosis/plan treatment
Venography and MR venography (rarely needed)

38
SVCO Suspected – CT ordered

SVCO – CT findings

SVCO – CT findings

SVCO – CT findings

SVCO found: What should you do?
42
1. Make the diagnosis clinically and order an urgent
CT
2. If known cancer – call the oncologist (or to ER)
3. If no pathology then we will need some…
Respirology: Bronchoscopy +/- EBUS
Thoracic Surgery : Bronch +/- EBUS
CT guided biopsy
Non-Thoracic primary: Can biopsy another site

Should I give steroids?
SVCO
Less helpful if lung cancer or non-lymphoma
Can be very helpful in setting of KNOWN lymphoma
BUT… If you suspect lymphoma and haven’t made a
diagnosis then DO NOT give steroids
Given if you think it can reduce symptoms from
XRT/Chemo
Given if you think there is laryngeal edema

Should I Give Diuretics
SVCO
Not well studied
Likely of limited benefit (and of limited harm)
We tend not to give them

Should I give something else?
Try to control symptoms
Pain Control
Breathing symptoms
• Puffers
• Oxygen
Dizziness (reduce BP meds)
Edema (comfort compression)
• Gloves

Definitive Treatment
46
Most commonly Radiation
Chemotherapy for lymphomas/Small Cell Lung
Interventional Radiology – SVC stent
Good: Quick symptom relief
Bad: Doesn’t treat underlying cause
Problem: Often not an emergency so questionable if
you need rapid relief

SVCO Conclusions
47
Recognize the symptoms and signs
Understand if this is an EMERGENCY or just an urgency
Order appropriate CT
(and/or Ultrasound if clot suspected)
Refer promptly

Thanks to:
48
Drs. Chad Lund / Paris-Ann Ingledew for slides
Drs. Anand Karvat / Frances Wong for forwarding
patients

Symptoms
Dyspnea
Distension
edema of face with erythema (plethora)
edema of arms
Dilated chest wall veins
Impaired mental status
Decreased cerebral perfusion pressure
• CPP = MAP – ICP or SVP (whichever is greater)
Hoarseness
Vocal cord edema

Management
• Steroids (dexamethasone

SVCO – Clinical Picture (Internet)

SVCO - Stenting
52
http://www.ajronline.org/doi/abs/10.2214/AJR.08.1904

SVCO - Etiology
Benign 20% Malignant 80%
Aortic aneurysm
Bronchogenic
Sarcoidosis
SCLC
Mediastinitis
NSCLC
Thrombosis
Lymphoma
Retrosternal thyroid Germ cell
Other

Cumulative Incidence

Radiotherapy
Radiotherapy effective in treatment of MSCC
decrease pain
increase functional outcomes
increase sphincter function
Earlier institution of radiotherapy prior to decreased
functional status preferred

SVCO – My patient

Poor prognostic factors
Vertebral collapse
Radioresistant /chemoresistant tumour
• Melanoma
• Renal cell
Acute onset with rapid progression
Inability to walk, loss of bladder function
Poor general condition