Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further. In this episode, we talk all about our third oncologic emergency: new brain mets.

Cord compression:

- If someone has a pathologic fracture, think about the following differential as underlying etiologies:

- Females: rule out breast cancer

- Males: Prostate cancer

- Others: multiple myeloma, lymphoma, lung cancer, renal cell carcinoma, bladder

- If cord compression, administer steroids; may require radiation to help with shrinking; also may need involvement of neurosurgery if there is lack of spine stability.

Role of radiation in cord compression:

-MRI is beneficial to help with radiation planning

-Where is the disease in proximity to the spinal cord? In the bone? In the epidural space? Or pushing against the spinal cord +/- blocking CSF?

-Is the spine stable? Use SINS scoring (https://radiopaedia.org/articles/spinal-instability-neoplastic-score-sins-2?lang=us)

-If good spine stability (low SINS) or is not surgical candidate or radio-sensitive tumor: radiation up front

-If poor spine stability (high SINS) then may need surgery up front

Radiosensitive tumors examples:

Lymphoma

Germ cell tumors

Small cell lung cancer

Radio-resistant tumor examples (resistant does not mean that radiation cannot be used, however):

Melanoma

Colorectal

Renal cell

Continue steroids as they are undergoing radiation to prevent flare up from inflammation and acute worsening from the mass on the spinal cord

Role of neurosurgery:

- What is a reasonable time that we can wait before operating for a new cord compression?

- As noted above, cord compression has various degrees

- Questions to ask: What neurologic symptoms? Over what time period?

- Asymptomatic: You have time! Perhaps investigate why mass may be there.

- Progressive over a couple of weeks: You have a little bit of time (a few days to get them to surgery)

- Acutely having symptoms: You should intervene.

- Spinal stability: are the weight-bearing components (ligaments) intact? Assessed via upright X-rays

- If the tumor is radio-sensitive, may opt for radiation first (if diagnosis is known)

A HUGE thank you to our special guests:

Ryan Miller, MD, MS: PGY5 in Radiation Oncology at Thomas Jefferson University Hospital, Philadelphia, PA

Joshua Lowenstein, MD, MBA: Neurosurgery Attending, REX Neurosurgery and Spine Specialists, Raleigh, NC

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