How to Manage Metastatic Spinal Cord/Thecal Sac Compression in Oncologic Patients? Case Number: RT2008 - 06(M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: To present an oncologic case with thecal sac compression and to discuss how to manage Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 71–year-old male patient, 王 OO, was referred to us for radiotherapy assessment for ‘colon ca s/p LAR with lung metastasis. Back pain was noted, and spinal MRI revealed T2 and T3 vertebral metastases with thecal sac compression’. S: 1. In recent 2-3 days, ataxia and bilateral lower limbs weakness were noted. 2. In 2008/04, spinal MRI and bone scan confirmed upper T-spinal metastases with thecal sac compression. 3. A planned spinal surgery will be performed on 2008/05/05. Histories: NDKA Review of systems: mild dysurea after pain control medications; no limbs numbness; no incontinence; mild bilateral lower limbs weakness O: 1. General Condition: ECOG: 2-3, sitting on bed, speech: OK, mild weakness. 2. Physical Examinations: (1). HEENT & SCF: neg. (2). CHE: neg. (3). ABD: mild tenderness on the epigastric region. (4). Back & Spine: no knocking pain (5). Extremities: free movement with muscle power 4-5 on the four limbs (6). Others: no limbs numbness on the four limbs 3. ***Pathology: no prior malignant pathology report available at visiting. 4. Images: (1). Spinal MRI in 2008/04: T2-3 spinal metastases with spinal cord/thecal sac compression (2). Bone scan in 2008/04: T1-T4 bone metastases (3). ABD CT in 2008/04, LMC: no noted intra-pelvic cancer disease. 5. Others: neg. Key Image(s): Fig. 1. Spinal MRI Fig. 2. Panel A. Bone Scan Fig. 2. Panel B. SPECT scan Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis and/or other Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) Q7: Why this case was planned a spinal surgery first then assessment for RT? Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: The initial stage is stage IV (due to lung metastases, 2003/07) but no detail information on initial T&N classification; the current recurrent stage is rT0N0M1(bone), r-stage IV (AJCC 2006, 2008/04) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no pathologic stage available now due to no prior post-surgical data (2003/07) Q4: What are your Oncology Diagnosis and/or other Assessments for this case? A4: Oncology Diagnosis: Colon cancer (histology type unknown) s/p LAR (2003/07/21) with lung metastasis, stage IV, post chemotherapy with spinal metastases (T1-2-3-4), with spinal cord compression (2008/04, T2-3), rT0N0M1(bone), r-stage IV (AJCC 2006, 2008/04) Q5: What is your Oncology Plan for this case? A5: Suggest: (1). performed the planned spinal surgery first (2). planned post-op RT 2 weeks later following the spinal surgery. Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: colon cancer with spinal cord/thecal sac compression (2). Goal: palliative; consolidated treatment effect of spinal surgery. (3). Target & Volume: C7-T1-2-3-4-5, with adequate margin (4). Technique: 2DRT (5). Dose & Fractionation: 3060-4500 cGy in 17-25 fractions. Q7: Why this case was planned a spinal surgery first then assessment for RT? A7: In this case and other similar cases that presented with acute-onset neurologic symptoms induced by spinal cord/thecal sac compression, planned spinal surgery first with relieving compression is effective for symptoms alleviation and recovery. Post-surgery radiotherapy to the surgical bed with adequate margin is a adjuvant therapy for consolidating surgery effect. Further Readings & References: NCCN 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2008/09/08 Key Image(s): (with marked) Fig. 1. Spinal MRI Fig. 1 Spinal MRI: T2 bone metastasis with posterior extension with compression on thecal sac/spinal cord (as the white arrow). Fig. 2. Panel A. Bone Scan Fig. 2. Panel A. Bone scan: increasing bone uptake over the T1T2-T3-T4, compatible with bone metastases (as the white arrows). Fig. 2. Panel B. SPECT scan Fig. 2. Panel B. SPECT scan: increasing isotope uptake over the T2-T3 bone metastatic location (as the white arrow).