21st June 2023

Management of MSCC

MSCC may be an acute presentation of metastatic disease. In which case, the underlying diagnosis and stage of the cancer should be ascertained.

The nature of treatment is dependent on a number of patient and biological factors. The Gold standard of treatment for the definitive management of MSCC is anterior direct decompression surgery followed by radiotherapy. However, in practice few patients are suitable for surgery. Factors affecting this include a patient’s comorbidities, perioperative morbidity, life expectancy, burden of disease and degree of spinal instability. Typically, those patients who are young, have a good performance status, have few comorbidities, have a good prognosis, have a single site of disease and for whom surgery might be the best method of tissue diagnosis should be considered for surgery.

In whom surgery is not practical or feasible, palliative radiotherapy is the typical treatment of choice. A single fraction of palliative radiotherapy has been shown to be non-inferior to multiple treatments. In some cases, the underlying biology of the malignancy might be conducive to primary systemic therapy as the treatment of choice e.g. high-grade lymphoma or small cell lung cancer. It is also worth considering that in some circumstances if lymphoma is suspected but a tissue diagnosis has yet to be obtained, if the patient has no neurological deficit, a biopsy may be prioritised over the initiation of steroids due to the exquisite sensitivity of high-grade lymphomas to steroid therapy. However, this should be considered on a case-by-case basis.