- Email: [email protected]
The authors reply as follows
Clinical Oncology (1996) 8:64-65 © 1996 The Royal College of Radiologists
Clinical Oncology
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author o f the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instruction to Authors at the front o f the Journal.
Controversies in the Management of Metastatic Spinal Cord Compression SIR - While Drs Makris and Kunkler [1] have produced an excellent review of the current information on the treatment of spinal cord compression, they have fallen into the trap of 'the radiotherapy view', which dismisses chemotherapy as an effective treatment in chemosensitive tumours. I believe that it is not appropriate to state in 1995 that 'currently . . . most of these patients will be treated by initial radiotherapy as long as the extent of irradiation does not compromise the bone marrow reserve necessary for chemotherapy', despite the known efficacy of chemotherapy for tumours such as lymphoma, germ cell tumours and myeloma. Patients with chemosensitive tumours should receive the treatment appropriate for the disease and its stage [2], and we should not propagate the unfounded myth that radiotherapy is the correct initial treatment for all patients. This is clearly of particular importance in the treatment of patients with germ cell tumours and lympbomas presenting with spinal cord compression.
References 1. Makris B, Kunkler IH. Controversies in the management of metastatic spinal cord compression. Clin Oncol 1995;7:77-81. 2. Eeles TA, O'Brien P, Horwich A, et al. NonHodgkin's lymphoma presenting with spinal cord compression: Functional outcome and survival. Br J Cancer 1991;63:126-9. M. BRADA
Institute o f Cancer Research Royal Marsden NHS Trust Downs Road Sutton SM2 5PT
The authors reply as follows: SIR - We would like to thank Dr Brada for his helpful comments and for raising the important issue of the most appropriate treatment of spinal cord compression in patients with chemosensitive tumours such as lymphoma, germ cell tumours and myeloma. The use of chemotherapy as the primary treatment for patients with chemosensitive tumours and spinal cord compression is indeed based on sound principles [1], and there is also experimental evidence to support this [2]. Although the clinical presentation is similar, the mechanism of compression is often different, particularly with lymphomas, which usually enter the epidural space by contiguous spread from a paravertebral mass through
the vertebral foramen, instead of metastasizing to the vertebral body and expanding into the epidural space [3]. The early initiation of therapy is important in patients with spinal cord compression in order to avoid permanent neurological dysfunction. Experience with primary chemotherapy as the initial treatment, even in chemosensitive tumours, is limited; in most published reports, initial surgery or radiotherapy has been used [1,4-6]. However, Hayes et al. have reported a series of children with either neuroblastoma or Ewing's sarcoma treated with chemotherapy alone, who did well, while those treated with laminectomy as initial management did less well until they received chemotherapy [7]. Our concern is that the response to chemotherapy in restoring neurological function may not be as rapid as with radiotherapy. However, we agree with Dr Brada that primary chemotherapy should be considered in patients with chemosensitive tumours, provided that patients are closely monitored and either surgery or radiotherapy rapidly instituted if there is no response. With the increasing use of magnetic resonance imaging for the investigation of back pain, it is likely that more patients will present with minor involvement of the epidural space, where chemotherapy may be more appropriate as the initial treatment, particularly in the presence of other sites of metastatic disease.
References 1. Eeles RA, O'Brien PO, Horwich A, et al. Non-Hodgkin's lymphoma presenting with spinal cord compression: Functional outcome and survival. Br J Cancer 1991;63:126-9. 2. Ushio Y, Posner R, Kim JH, et al. Treatment of experimental spinal cord compression caused by extradural neoplasms. J Neursurg 1977;47:380-90. 3. Burch PA, Grossman SA. Treatment of epidural cord compression from Hodgkin's disease with chemotherapy: A report of two cases and review of the literature. Am J Med 1988;84:555-8. 4. Perry JR, Deodhare SS, Bilbao J, et al. The significance of spinal cord compression as the initial manifestation of lymphoma. Neurosurgery 1993;32:15%62. 5. Friedman HM, Sheetz S, Levine HL, et al. Combination chemotherapy and radiation therapy: The medical management of epidural spinal cord compression from testicular cancer. Arch Intern Med 1986;146:509-12. 6. Friedman M, Kim TH, Pnahon AM. Spinal cord compression in malignant lymphoma: Treatment and results. Cancer 1976;37:148591.
7. Hayes FA, Thompson EI, Hvidzala E, et al. Chemotherapy as an alternative to laminectomy and radiation in the management of epidural tumor. J Pediatr 1984;104:221-4.
Breast Unit Royal Marsden Hospital I. H. KUNI~LER Western General Hospital Edinburgh
A. MAKRIS
Neurological Assessment of High Grade Astrocytomas Following High Dose Radiotherapy as Sole Treatment SIR As a neurologist interested in the neurological assessment of patients with brain tumours, I felt obliged to comment on several aspects of the paper by Fuentes et al. [1]. Assessment of patients following therapeutic intervention in high grade gliomas is an extremely important topic. This requires the use of tests that have been validated, are reproducible and measure specific aspects of outcome, which can largely be divided up into impairment, disability, handicap and quality of life. Clinical impairments are any abnormalities of psychological, physiological or anatomical function (symptoms and signs). Clinical impairments are used to identify the underlying anatomical problem and it is these symptoms or signs that are most sensitive to changes in brain tumours as a result of treatment. Disability is the lack of ability to perform an activity as a result of an impairment (e.g. dressing, bathing, toileting, etc.). Handicap is the social or societal consequence of the disability and impairment (e.g. a right hemiparesis may result in difficulty in walking and a handicap is that the patient is unable to go out shopping by himself/herself). Quality of life is the evaluation of life satisfaction and is a concept that can be appreciated and commented on only by the patient or perhaps by a close relative. Fuentes et al., in their discussion comment that 'the objective of this study was to evaluate the quality of life using the functional capacity described by Order et al.'[2]. The scale that they have selected does not measure quality of life and indeed is a ranked scale, which must be completed by the physician; it has poor discrimination, and has never been used, to my knowledge, in brain tumour patients in a serial fashion. The inter- and intraobserver variation is unknown and the sensitivity of the test will not identify the kind of changes that the authors were looking for. This rank scale is particularly difficult to interpret, as different people will have different ideas on whether someone is 'intellectually intact' or 'physically able to work'. This is relevant, - -
Clinical Oncology
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author o f the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instruction to Authors at the front o f the Journal.
Controversies in the Management of Metastatic Spinal Cord Compression SIR - While Drs Makris and Kunkler [1] have produced an excellent review of the current information on the treatment of spinal cord compression, they have fallen into the trap of 'the radiotherapy view', which dismisses chemotherapy as an effective treatment in chemosensitive tumours. I believe that it is not appropriate to state in 1995 that 'currently . . . most of these patients will be treated by initial radiotherapy as long as the extent of irradiation does not compromise the bone marrow reserve necessary for chemotherapy', despite the known efficacy of chemotherapy for tumours such as lymphoma, germ cell tumours and myeloma. Patients with chemosensitive tumours should receive the treatment appropriate for the disease and its stage [2], and we should not propagate the unfounded myth that radiotherapy is the correct initial treatment for all patients. This is clearly of particular importance in the treatment of patients with germ cell tumours and lympbomas presenting with spinal cord compression.
References 1. Makris B, Kunkler IH. Controversies in the management of metastatic spinal cord compression. Clin Oncol 1995;7:77-81. 2. Eeles TA, O'Brien P, Horwich A, et al. NonHodgkin's lymphoma presenting with spinal cord compression: Functional outcome and survival. Br J Cancer 1991;63:126-9. M. BRADA
Institute o f Cancer Research Royal Marsden NHS Trust Downs Road Sutton SM2 5PT
The authors reply as follows: SIR - We would like to thank Dr Brada for his helpful comments and for raising the important issue of the most appropriate treatment of spinal cord compression in patients with chemosensitive tumours such as lymphoma, germ cell tumours and myeloma. The use of chemotherapy as the primary treatment for patients with chemosensitive tumours and spinal cord compression is indeed based on sound principles [1], and there is also experimental evidence to support this [2]. Although the clinical presentation is similar, the mechanism of compression is often different, particularly with lymphomas, which usually enter the epidural space by contiguous spread from a paravertebral mass through
the vertebral foramen, instead of metastasizing to the vertebral body and expanding into the epidural space [3]. The early initiation of therapy is important in patients with spinal cord compression in order to avoid permanent neurological dysfunction. Experience with primary chemotherapy as the initial treatment, even in chemosensitive tumours, is limited; in most published reports, initial surgery or radiotherapy has been used [1,4-6]. However, Hayes et al. have reported a series of children with either neuroblastoma or Ewing's sarcoma treated with chemotherapy alone, who did well, while those treated with laminectomy as initial management did less well until they received chemotherapy [7]. Our concern is that the response to chemotherapy in restoring neurological function may not be as rapid as with radiotherapy. However, we agree with Dr Brada that primary chemotherapy should be considered in patients with chemosensitive tumours, provided that patients are closely monitored and either surgery or radiotherapy rapidly instituted if there is no response. With the increasing use of magnetic resonance imaging for the investigation of back pain, it is likely that more patients will present with minor involvement of the epidural space, where chemotherapy may be more appropriate as the initial treatment, particularly in the presence of other sites of metastatic disease.
References 1. Eeles RA, O'Brien PO, Horwich A, et al. Non-Hodgkin's lymphoma presenting with spinal cord compression: Functional outcome and survival. Br J Cancer 1991;63:126-9. 2. Ushio Y, Posner R, Kim JH, et al. Treatment of experimental spinal cord compression caused by extradural neoplasms. J Neursurg 1977;47:380-90. 3. Burch PA, Grossman SA. Treatment of epidural cord compression from Hodgkin's disease with chemotherapy: A report of two cases and review of the literature. Am J Med 1988;84:555-8. 4. Perry JR, Deodhare SS, Bilbao J, et al. The significance of spinal cord compression as the initial manifestation of lymphoma. Neurosurgery 1993;32:15%62. 5. Friedman HM, Sheetz S, Levine HL, et al. Combination chemotherapy and radiation therapy: The medical management of epidural spinal cord compression from testicular cancer. Arch Intern Med 1986;146:509-12. 6. Friedman M, Kim TH, Pnahon AM. Spinal cord compression in malignant lymphoma: Treatment and results. Cancer 1976;37:148591.
7. Hayes FA, Thompson EI, Hvidzala E, et al. Chemotherapy as an alternative to laminectomy and radiation in the management of epidural tumor. J Pediatr 1984;104:221-4.
Breast Unit Royal Marsden Hospital I. H. KUNI~LER Western General Hospital Edinburgh
A. MAKRIS
Neurological Assessment of High Grade Astrocytomas Following High Dose Radiotherapy as Sole Treatment SIR As a neurologist interested in the neurological assessment of patients with brain tumours, I felt obliged to comment on several aspects of the paper by Fuentes et al. [1]. Assessment of patients following therapeutic intervention in high grade gliomas is an extremely important topic. This requires the use of tests that have been validated, are reproducible and measure specific aspects of outcome, which can largely be divided up into impairment, disability, handicap and quality of life. Clinical impairments are any abnormalities of psychological, physiological or anatomical function (symptoms and signs). Clinical impairments are used to identify the underlying anatomical problem and it is these symptoms or signs that are most sensitive to changes in brain tumours as a result of treatment. Disability is the lack of ability to perform an activity as a result of an impairment (e.g. dressing, bathing, toileting, etc.). Handicap is the social or societal consequence of the disability and impairment (e.g. a right hemiparesis may result in difficulty in walking and a handicap is that the patient is unable to go out shopping by himself/herself). Quality of life is the evaluation of life satisfaction and is a concept that can be appreciated and commented on only by the patient or perhaps by a close relative. Fuentes et al., in their discussion comment that 'the objective of this study was to evaluate the quality of life using the functional capacity described by Order et al.'[2]. The scale that they have selected does not measure quality of life and indeed is a ranked scale, which must be completed by the physician; it has poor discrimination, and has never been used, to my knowledge, in brain tumour patients in a serial fashion. The inter- and intraobserver variation is unknown and the sensitivity of the test will not identify the kind of changes that the authors were looking for. This rank scale is particularly difficult to interpret, as different people will have different ideas on whether someone is 'intellectually intact' or 'physically able to work'. This is relevant, - -