The role of combination surgery and radiotherapy in patients with metastatic spinal cord compression: What are the remaining grey areas? A systematic review

Objective: Traditional management of patients with metastatic epidural spinal cord compression (MESCC) consists of radiotherapy (RT) with or without surgical decompression. With extensive literature and the introduction of clinical frameworks, such as the neurologic, oncologic, mechanical, and systemic criteria and the epidural spinal cord compression scale, progress has been made in refining the appropriate treatment regimen. In this review, we analyze the existing literature to identify the consensus frameworks and the remaining gaps in clinical knowledge. Methods: PubMed, Embase, Cochrane, Web of Science, Scopus, and ClinicalTrials.gov were queried in January 2023. Only articles comparing combination therapy (surgery plus RT) to RT alone and assessing neurological and/or survival outcomes in patients with MESCC were retained for full-text review. Results: Out of 2157 unique articles, 29 met inclusion criteria. The most common primary cancer locations included lung (n=1031, 20.0 %), breast (n=747, 14.5 %), and prostate (n=712, 13.8 %), and back pain was the most common symptom reported (n=1186/1622, 73.1 %). While baseline patient characteristics were not controlled between the different treatment regimens, the included studies demonstrated a median survival of 4.0 months (interquartile range [IQR] 3.0–6.1 months) in patients receiving RT alone compared to 7.7 months (IQR 6.3–11.1 months) in the cohort receiving combination therapy. Similarly, in patients undergoing RT alone, a median of 29.0 % (IQR 16.0–37.9 %) of patients experienced a neurologic improvement, compared to 38.0 % (IQR 31.5–64.4 %) of patients undergoing combination therapy. Conclusions: In patients with high-grade, symptomatic MESCC, combination therapy with direct circumferential decompression is superior to RT alone in patients with less radiosensitive tumors. In patients with high-grade asymptomatic MESCC, RT alone can be pursued for patients with the most radiosensitive tumors, such as myeloma and lymphoma; however, more research is needed on the treatment of less radiosensitive tumors. A major grey area exists in the treatment of patients with intermediate grade epidural involvement.