Oncology for MRCP Part 1

A 66-year-old man with known prostate cancer has two weeks of worsening thoracic back pain that is worse lying down and on coughing. Over two days he has developed weakness in both legs, a sensory level at the umbilicus, brisk knee reflexes and difficulty passing urine. What is the most likely diagnosis?

1. Spinal infection or abscess Compression from infection rather than tumour. Progressive back pain then leg weakness with a sensory level in a cancer patient makes it a consideration.
2. Transverse myelitis Inflammatory cord disease. Progressive back pain then leg weakness with a sensory level in a cancer patient redirects it.
3. Disc prolapse with radiculopathy Nerve root compression without a cord lesion. Progressive back pain then leg weakness with a sensory level in a cancer patient points elsewhere.
4. Vertebral osteoporotic fracture A collapse fracture without cord compression. Progressive back pain then leg weakness with a sensory level in a cancer patient raises it.
5. Spinal cord compression correct Correct. Progressive back pain then bilateral leg weakness with a sensory level in a cancer patient is metastatic spinal cord compression.

The point: Metastatic spinal cord compression is an oncological emergency in which a tumour deposit, usually in a vertebral body, compresses the spinal cord or cauda equina, threatening permanent paralysis and loss of continence if not treated urgently. It most often complicates cancers of the breast, prostate and lung, and myeloma. The warning symptom is new or progressive back pain, classically severe, worse on lying, coughing or straining, and sometimes with a band-like radicular component; this may precede neurological signs by days or weeks. Later features are limb weakness, sensory loss with a sensory level, and bladder or bowel dysfunction; the neurological pattern is upper motor neurone (spasticity, brisk reflexes, upgoing plantars) if the cord is compressed, and lower motor neurone with saddle anaesthesia and retention if the cauda equina is involved. The key to preserving function is to act on the pain before the deficit becomes fixed: an urgent whole-spine MRI is the investigation of choice, and while it is arranged high-dose corticosteroids (dexamethasone) are given to reduce oedema. Definitive treatment is urgent radiotherapy or surgical decompression, decided by the tumour type, spinal stability, prognosis and the speed of onset. The functional outcome depends heavily on the neurological status at the time treatment begins, so recognising the pain and imaging early is what saves the cord.

Source: NICE NG234 — spinal metastases and metastatic spinal cord compression NICE · tier 1, national regulator or guidance

A 66-year-old man with known prostate cancer has two weeks of worsening thoracic back pain that is worse lying down and on coughing. Over two days he has developed weakness in both legs, a sensory level at the umbilicus, brisk knee reflexes and difficulty passing urine. What is the most appropriate investigation?

1. Plain imaging while awaiting MRI As an adjunct, not a substitute. Progressive back pain then leg weakness with a sensory level in a cancer patient makes it supportive.
2. Urgent whole-spine MRI correct Correct. An urgent whole-spine MRI is the investigation of choice to confirm and localise the compression.
3. Bloods including calcium For associated hypercalcaemia. Progressive back pain then leg weakness with a sensory level in a cancer patient makes them useful.
4. Assessment of bladder and bowel function For cord or cauda equina involvement. Progressive back pain then leg weakness with a sensory level in a cancer patient makes it important.
5. Neurological examination for a sensory level and weakness Localises and grades the deficit. Progressive back pain then leg weakness with a sensory level in a cancer patient makes it central.

The point: Metastatic spinal cord compression is an oncological emergency in which a tumour deposit, usually in a vertebral body, compresses the spinal cord or cauda equina, threatening permanent paralysis and loss of continence if not treated urgently. It most often complicates cancers of the breast, prostate and lung, and myeloma. The warning symptom is new or progressive back pain, classically severe, worse on lying, coughing or straining, and sometimes with a band-like radicular component; this may precede neurological signs by days or weeks. Later features are limb weakness, sensory loss with a sensory level, and bladder or bowel dysfunction; the neurological pattern is upper motor neurone (spasticity, brisk reflexes, upgoing plantars) if the cord is compressed, and lower motor neurone with saddle anaesthesia and retention if the cauda equina is involved. The key to preserving function is to act on the pain before the deficit becomes fixed: an urgent whole-spine MRI is the investigation of choice, and while it is arranged high-dose corticosteroids (dexamethasone) are given to reduce oedema. Definitive treatment is urgent radiotherapy or surgical decompression, decided by the tumour type, spinal stability, prognosis and the speed of onset. The functional outcome depends heavily on the neurological status at the time treatment begins, so recognising the pain and imaging early is what saves the cord.

Source: NICE NG234 — spinal metastases and metastatic spinal cord compression NICE · tier 1, national regulator or guidance

A 66-year-old man with known prostate cancer has two weeks of worsening thoracic back pain that is worse lying down and on coughing. Over two days he has developed weakness in both legs, a sensory level at the umbilicus, brisk knee reflexes and difficulty passing urine. What is the most appropriate management?

1. Urgent radiotherapy or surgical decompression Definitive treatment is urgent radiotherapy or surgical decompression, and progressive back pain then leg weakness with a sensory level in a cancer patient here points elsewhere.
2. Analgesia for the back pain For symptom control. Progressive back pain then leg weakness with a sensory level in a cancer patient makes it supportive.
3. Lie the patient flat until the spine is assessed For suspected instability. Progressive back pain then leg weakness with a sensory level in a cancer patient makes it a safety step.
4. Immediate high-dose dexamethasone correct Correct. Immediate high-dose dexamethasone reduces cord oedema while imaging is arranged.
5. Urgent whole-spine MRI without delay To confirm and localise. Progressive back pain then leg weakness with a sensory level in a cancer patient makes it decisive.

The point: Metastatic spinal cord compression is an oncological emergency in which a tumour deposit, usually in a vertebral body, compresses the spinal cord or cauda equina, threatening permanent paralysis and loss of continence if not treated urgently. It most often complicates cancers of the breast, prostate and lung, and myeloma. The warning symptom is new or progressive back pain, classically severe, worse on lying, coughing or straining, and sometimes with a band-like radicular component; this may precede neurological signs by days or weeks. Later features are limb weakness, sensory loss with a sensory level, and bladder or bowel dysfunction; the neurological pattern is upper motor neurone (spasticity, brisk reflexes, upgoing plantars) if the cord is compressed, and lower motor neurone with saddle anaesthesia and retention if the cauda equina is involved. The key to preserving function is to act on the pain before the deficit becomes fixed: an urgent whole-spine MRI is the investigation of choice, and while it is arranged high-dose corticosteroids (dexamethasone) are given to reduce oedema. Definitive treatment is urgent radiotherapy or surgical decompression, decided by the tumour type, spinal stability, prognosis and the speed of onset. The functional outcome depends heavily on the neurological status at the time treatment begins, so recognising the pain and imaging early is what saves the cord.

Source: NICE NG234 — spinal metastases and metastatic spinal cord compression NICE · tier 1, national regulator or guidance