Abstract
Background/Aim: Personalized cancer care can improve patient outcomes and is facilitated by scoring systems. This study aimed to create an instrument to estimate ambulatory status after radiotherapy for metastatic spinal cord compression (MSCC) from head-and-neck cancer. Patients and Methods: In 60 patients, fractionation regimen plus 10 pre-treatment factors were analyzed for post-treatment ambulatory status. Significant factors were used for the scoring system by dividing the ambulatory rate (in %) by 10. Patients' scores were received by adding the factor scores. Results: Time developing motor deficits >7 days (p=0.011), being ambulatory prior to radiotherapy (p<0.001) and ECOG performance score 1-2 (p<0.001) showed significant associations with post-treatment ambulatory status. Patients' scores were 7, 12, 15, 20, 22 and 27 points. Three groups were designed (7-12, 15-20 and 22-27 points) with post-treatment ambulatory rates of 11%, 62% and 96% (p<0.001). Conclusion: This scoring system helps predict ambulatory status after radiotherapy for MSCC from head-and-neck cancer.
- Metastatic spinal cord compression
- head-and-neck cancer
- radiotherapy
- post-treatment ambulatory status
- scoring system
Metastatic spinal cord compression (MSCC) is generally associated with neurologic dysfunction mainly with motor deficits (1, 2). For these patients, maintaining or regaining the ability to walk, either with or without aid, is a very important endpoint. This may be achieved with radiotherapy alone, which still is the most frequent treatment for MSCC (3-5). In case of inadequate response to radiotherapy patients may not be able to walk after treatment and might have done better with upfront decompressive surgery plus stabilization (6, 7). However, upfront surgery has been reported to be associated with severe complications in more than 10% of the patients and is generally reserved for selected patients with a good performance status and a relatively favorable survival prognosis (6-8). In order to assign the most appropriate treatment protocol to a patient with MSCC, it would be helpful to be able to estimate the patient's ambulatory status following radiotherapy alone. Since MSCC is considered an oncologic emergency and, therefore, treatment decisions have to be made fast, a simple scoring system would be of great value for clinicians that helps predict post-treatment ambulatory status following radiotherapy alone (1, 2).
It has been previously stated that it is reasonable to identify predictive factors and develop scoring systems specifically for single tumor entities associated with MSCC due to differences, for example, with respect to tumor biologies, patterns of metastatic spread and survival prognoses (9-15). Therefore, the present study aims to create a scoring system that supports clinicians to estimate the post-treatment ambulatory status of patients irradiated for MSCC, particularly for those patients with MSCC from head-and-neck cancer.
Patients and Methods
Sixty patients who had been treated with radiotherapy alone for motor deficits due to MSCC from head-and-neck cancer between 1997 and 2015 were retrospectively evaluated for ambulatory status at 1 month following irradiation. The fractionation regimen (short-course radiotherapy (1×8 Gy or 5×4 Gy) vs. 10×3 Gy vs. longer-course radiotherapy with total doses >30 Gy (15×2.5 Gy or 20×2 Gy)) plus 10 pre-treatment factors were analyzed. The pre-treatment factors included age (≤59 years vs. ≥60 years, median 59 years), interval between first diagnosis of head-and-neck cancer and radiotherapy of MSCC (≤15 months vs. >15 months (4, 16)), visceral metastasis (no vs. yes), other bone metastasis (no vs. yes), cancer site (nasopharynx vs. oropharynx vs. hypopharynx vs. larynx vs. other sites), gender, time developing motor deficits (1-7 days vs. >7 days (17)), ambulatory status prior to radiotherapy (not ambulatory vs. ambulatory), number of vertebrae affected by MSCC, (1-2 vs. ≥3, median 3), and performance score according to the Eastern Cooperative Oncology Group (ECOG) (1-2 vs. 3-4, median 3). Distributions of all 11 factors are summarized in Table I.
The statistical analyses regarding the post-treatment ambulatory status were performed with the Chi-square test. Factors that achieved significance (p<0.05) were used for the scoring system developed to estimate the probability of being ambulatory at 1 month following irradiation. For each significant factor, a factor score was calculated by dividing the ambulatory rate in percent by 10. The individual score for each patient was received by adding the factor scores.
Results
Three of the investigated factors showed a significant positive association with the post-treatment ambulatory status, namely time developing motor deficits of >7 days (p=0.011), being ambulatory prior to radiotherapy (p<0.001), and an ECOG performance score 1-2 (p<0.001). The post-treatment ambulatory rates of all investigated factors are summarized in Table II. The post-treatment ambulatory rates of the three significant factors were used to develop the scoring system (Table III). The individual scores for the 60 patients were 7 points, 12 points, 15 points, 20 points, 22 points and 27 points, respectively (Figure 1). Three prognostic groups were designed, namely 7-12 points (group A), 15-20 points (group B) and 22-27 points (group C), respectively. The corresponding post-treatment ambulatory rates at 1 month following radiotherapy were 11% for group A, 62% for group B and 96% for group C, respectively (p<0.001). The p-values for the comparisons of groups A vs. B and B vs. C were 0.027 and 0.034, respectively. In group C, ambulatory rates at 3 months and at 6 months following radiotherapy were 100% (24 of 24 patients) and 100% (20 of 20 patients), respectively.
Discussion
The survival prognosis of patients with locally advanced head-and-neck cancer has been improved due to novel treatment approaches including surgery, radiotherapy and systemic therapies (18-20). Since the risk of developing distant metastasis increases with lifetime, the number of patients presenting with metastatic disease such as MSCC is growing. Radiotherapy alone is the most common treatment for MSCC (1, 2). In 2005, a randomized trial of 101 patients that compared radiotherapy alone to radiotherapy plus upfront decompressive surgery showed that selected patients (MSCC from a solid tumor, Karnofsky performance score of 70 or greater, survival prognosis of 3 months or longer, involvement of only one spinal segment by MSCC and paraplegia lasting for not longer than 48 h) could benefit from the addition of surgery with respect to post-treatment ambulatory status and survival (6). In general, these criteria are met by 10-15% of patients with MSCC. Insufficient response to radiotherapy is considered another good indication for decompressive surgery plus stabilization (1, 2). Therefore, it would be helpful to be able to predict the response prior to the start of treatment. From the patient's point of view, post-treatment ambulatory status is a major key point with respect to their quality of life. From the physician's point of view, it is very important to know prior to assigning a treatment to a patient whether the ability to walk can be achieved with radiotherapy alone or upfront surgery is required. This information can be provided with the help of a scoring system predicting the probability to be ambulatory following radiotherapy alone. Two systems have already been developed for patients with MSCC in general, but not for specific tumor entities (4, 21). Therefore, the present study has been conducted in order to develop such a scoring system particularly for MSCC from head-and-neck cancer. Based on three predictive factors, time developing motor deficits prior to radiotherapy, pre-treatment ambulatory status and ECOG performance score, three prognostic groups were designed with significantly different post-treatment ambulatory rates of 11% (group A), 62% (group B) and 96% (groups C), respectively. Patients of group A have a low probability of being ambulatory following radiotherapy alone and would likely benefit from the addition of upfront decompressive surgery, particularly if they meet the criteria of the randomized trial of Patchell et al. (6). The post-treatment ambulatory rate of group B patients is also not optimal. Thus, for these patients, upfront surgery may be considered. In group C, the post-treatment ambulatory rates at 1, 3 and 6 months following radiotherapy were extremely high with 96%, 100% and 100%, respectively. Therefore, these patients appear well treated with radiotherapy alone and may not require upfront surgery. When following these suggestions, the retrospective nature of the data used to create the scoring system should be taken into consideration. Retrospective data are always associated with a risk of hidden selection biases. However, due to the fact that patients with MSCC from head-and-neck cancer are rare, prospective studies focusing on this group of patients will be very unlikely in the near future.
Distributions of the evaluated factors.
Post-treatment ambulatory status.
Post-treatment ambulatory rates related to the scoring points.
Points for the factors included in the scoring system received by dividing post-treatment ambulatory rates (on %) by 10.
In this study, three predictive factors were identified regarding the ambulatory status after radiotherapy for MSCC from head-and-neck cancer. Based on these factors, a scoring system including three prognostic groups was developed. This system can help predict the probability of being ambulatory after radiotherapy alone and identify patients who could benefit from upfront decompressive surgery in this particular group of cancer patients.
Footnotes
Conflicts of Interest
On behalf of all Authors, the corresponding Author states that there is no conflict of interest related to this study.
- Received June 20, 2018.
- Revision received June 22, 2018.
- Accepted June 25, 2018.
- Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
References
In this issue
Jump to section
Related Articles
Cited By...
- Palliative Local Radiotherapy for Advanced Squamous Cell Carcinoma of the Head-and-Neck: Prognostic Factors of Survival
- Accelerated Fractionation With Concomitant Boost vs. Conventional Radio-chemotherapy for Definitive Treatment of Locally Advanced Squamous Cell Carcinoma of the Head-and-Neck (SCCHN)