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 Pressure on the cord from an infection or a pocket of pus, rather than a tumour. It does not fit worsening back pain, then leg weakness with a clear sensory level, in a cancer patient.
2. Transverse myelitis Inflammation of the spinal cord itself, rather than pressure from outside it. Here, worsening back pain, then leg weakness with a clear sensory level, in a cancer patient points elsewhere.
3. Disc prolapse with radiculopathy A slipped disc pressing on a nerve root, without a problem in the cord itself. But worsening back pain, then leg weakness with a clear sensory level, in a cancer patient does not point to it.
4. Vertebral osteoporotic fracture A crumbled spine bone from thin bones (osteoporosis), without the cord being squeezed. That does not match worsening back pain, then leg weakness with a clear sensory level, in a cancer patient.
5. Spinal cord compression correct Correct. Worsening back pain, then weakness in both legs with a clear sensory level, in a cancer patient, is metastatic spinal cord compression.

The point: Metastatic spinal cord compression is a cancer emergency in which a tumour deposit, usually in one of the spine's bones (a vertebral body), squeezes the spinal cord or the bundle of nerves below it (the cauda equina). If it is not treated urgently, this threatens permanent paralysis and loss of bladder and bowel control. It most often complicates cancers of the breast, prostate and lung, and a blood cancer called myeloma. The warning symptom is new or worsening back pain, classically severe, worse when lying down, coughing or straining, and sometimes spreading round the body in a band (radicular pain). This pain can come days or weeks before any nerve symptoms show up. Later features are weakness in the limbs, loss of sensation with a clear level on the body below which feeling changes (a sensory level), and problems controlling the bladder or bowel. The pattern of nerve signs is upper motor neurone (stiffness, brisk reflexes, an upgoing big toe on testing the sole of the foot) if the spinal cord itself is being squeezed, and lower motor neurone, with numbness around the saddle area and urine retention, if the cauda equina is affected instead. The key to keeping function is to act on the pain before any nerve damage becomes fixed: an urgent MRI scan of the whole spine is the best test, and while it is being arranged, high-dose steroids (dexamethasone) are given to reduce swelling around the cord. The definitive treatment is urgent radiotherapy or surgery to relieve the pressure, and the choice is decided by the type of tumour, how stable the spine is, the patient's overall outlook, and how fast things are moving. How well the patient recovers depends heavily on how the nerves are working at the moment treatment starts, so spotting the warning pain and scanning early is what protects the spinal 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 A plain X-ray while waiting for the MRI, useful as an extra but never a replacement for it. That does not match worsening back pain, then leg weakness with a clear sensory level, in a cancer patient.
2. Urgent whole-spine MRI correct Correct. An urgent MRI of the whole spine is the best test to confirm the diagnosis and find exactly where the compression is.
3. Bloods including calcium Blood tests including calcium, to check for a raised calcium level that often goes with cancer. Here, worsening back pain, then leg weakness with a clear sensory level, in a cancer patient points elsewhere.
4. Assessment of bladder and bowel function Checking bladder and bowel function, which points to whether the cord or the cauda equina is involved. It does not fit worsening back pain, then leg weakness with a clear sensory level, in a cancer patient.
5. Neurological examination for a sensory level and weakness A nerve examination to find the level of any sensory loss and how weak the limbs are. But worsening back pain, then leg weakness with a clear sensory level, in a cancer patient does not point to it.

The point: Metastatic spinal cord compression is a cancer emergency in which a tumour deposit, usually in one of the spine's bones (a vertebral body), squeezes the spinal cord or the bundle of nerves below it (the cauda equina). If it is not treated urgently, this threatens permanent paralysis and loss of bladder and bowel control. It most often complicates cancers of the breast, prostate and lung, and a blood cancer called myeloma. The warning symptom is new or worsening back pain, classically severe, worse when lying down, coughing or straining, and sometimes spreading round the body in a band (radicular pain). This pain can come days or weeks before any nerve symptoms show up. Later features are weakness in the limbs, loss of sensation with a clear level on the body below which feeling changes (a sensory level), and problems controlling the bladder or bowel. The pattern of nerve signs is upper motor neurone (stiffness, brisk reflexes, an upgoing big toe on testing the sole of the foot) if the spinal cord itself is being squeezed, and lower motor neurone, with numbness around the saddle area and urine retention, if the cauda equina is affected instead. The key to keeping function is to act on the pain before any nerve damage becomes fixed: an urgent MRI scan of the whole spine is the best test, and while it is being arranged, high-dose steroids (dexamethasone) are given to reduce swelling around the cord. The definitive treatment is urgent radiotherapy or surgery to relieve the pressure, and the choice is decided by the type of tumour, how stable the spine is, the patient's overall outlook, and how fast things are moving. How well the patient recovers depends heavily on how the nerves are working at the moment treatment starts, so spotting the warning pain and scanning early is what protects the spinal 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 oncology and spinal surgery referral Urgent referral to a cancer specialist and a spine surgeon, for expert decision-making. But worsening back pain, then leg weakness with a clear sensory level, in a cancer patient does not point to it.
2. Analgesia for the back pain Pain relief for the back pain, as supportive care. That does not match worsening back pain, then leg weakness with a clear sensory level, in a cancer patient.
3. Lie the patient flat until the spine is assessed Keeping the patient lying flat until the spine has been checked for stability. It does not fit worsening back pain, then leg weakness with a clear sensory level, in a cancer patient.
4. Immediate high-dose dexamethasone correct Correct. High-dose steroids given straight away reduce swelling around the cord while the scan is arranged.
5. Urgent whole-spine MRI without delay An urgent scan of the whole spine, to confirm the diagnosis and find exactly where the problem is. Here, worsening back pain, then leg weakness with a clear sensory level, in a cancer patient points elsewhere.

The point: Metastatic spinal cord compression is a cancer emergency in which a tumour deposit, usually in one of the spine's bones (a vertebral body), squeezes the spinal cord or the bundle of nerves below it (the cauda equina). If it is not treated urgently, this threatens permanent paralysis and loss of bladder and bowel control. It most often complicates cancers of the breast, prostate and lung, and a blood cancer called myeloma. The warning symptom is new or worsening back pain, classically severe, worse when lying down, coughing or straining, and sometimes spreading round the body in a band (radicular pain). This pain can come days or weeks before any nerve symptoms show up. Later features are weakness in the limbs, loss of sensation with a clear level on the body below which feeling changes (a sensory level), and problems controlling the bladder or bowel. The pattern of nerve signs is upper motor neurone (stiffness, brisk reflexes, an upgoing big toe on testing the sole of the foot) if the spinal cord itself is being squeezed, and lower motor neurone, with numbness around the saddle area and urine retention, if the cauda equina is affected instead. The key to keeping function is to act on the pain before any nerve damage becomes fixed: an urgent MRI scan of the whole spine is the best test, and while it is being arranged, high-dose steroids (dexamethasone) are given to reduce swelling around the cord. The definitive treatment is urgent radiotherapy or surgery to relieve the pressure, and the choice is decided by the type of tumour, how stable the spine is, the patient's overall outlook, and how fast things are moving. How well the patient recovers depends heavily on how the nerves are working at the moment treatment starts, so spotting the warning pain and scanning early is what protects the spinal cord.

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