18ournal of Neurology, Neurosurgery, and Psychiatry 1992;55: 1188-1193

Early diagnosis and treatment of spinal epiduralmetastasis in breast cancer: a prospective study

W Boogerd, J J van der Sande, R Kroger

Netherlands CancerInstitute (Antoni vanLeeuwenhoekZiekenhuis),Amsterdam, TheNetherlandsDepartment ofNeurologyW BoogerdJ J van der SandeDepartment ofDiagnostic RadiologyR KrogerCorrespondence to:Dr Boogerd, TheNetherlands CancerInstitute, Plesmanlaan 121,1066 CX Amsterdam, TheNetherlandsReceived 28 November 1991and in revised form23 March 1992.Accepted 26 March 1992

AbstractThis prospective study evaluated the use-fulness of myelography in breast cancerpatients who present with radiculopathyor myelopathy. A total of 124 consecutivemyelograms were performed in 100patients. Epidural metastasis (EM) wasdiagnosed in 67 myelograms (54%). Multi-ple epidural metastases were diagnosed in15 (22%) of those, resulting in a total of 87epidural lesions. A complete block wasfound in 13 EM (15%) and an incompleteblock in 14 EM (16%). Clinical data couldnot predict the site of EM in 29 cases(33%). Fifteen asymptomatic EM weredetected in myelograms with multipleEM. Plain radiographs were ofno value indetermining the site of EM in 29 cases(33%), including 13 cases (15%) withoutvertebral metastasis at the site of EM.Treatment consisted ofradiotherapy (RT)with or without systemic treatment in 52cases (80%), systemic treatment alone in11 cases (17%) and surgery in two patients(3%). Clinical improvement was noticedin 72%, no change in 13%, and deteriora-tion in 15%. No difference in response wasnoticed between RT and systemic therapy.Before treatment 21% and after treatment15% of the patients could not walk. Theone year survival was 42%. The ambula-tory status at presentation was the mostimportant prognostic factor. Examinationof the spinal fluid, obtained at myelog-raphy, disclosed meningeal carcinomato-sis in 9/o of the patients. Imaging of thewhole spinal canal with cytological exam-ination ofthe spinal fluid is recommendedin breast cancer patients suspected ofepidural tumour with features of radicu-lopathy or myelopathy, irrespective offurther clinical data and plain spinalradiographs.

(7 Neurol Neurosurg Psychiatry 1992;55: 1188-1193)

Spinal epidural metastases (EM) develop inapproximately 5% of patients with systemiccancer.' These epidural lesions are a commoncause of serious morbidity: at diagnosis abouthalf of the patients have already lost the abilityto walk because of compression of the spinalcord or the cauda equina and this proportiondoes not usually change significantly aftertreatment.26 Epidural carcinomas are usuallydirect extensions ofvertebral metastases. Verte-bral metastases occur in as much as 60% of

patients with breast cancer.7'8Since the neurological outcome and results

of treatment depend primarily on the neuro-logical status at the time of diagnosis, an earlyand accurate identification of epidural tumouris of major importance. This study wasdesigned to analyse prospectively the benefit ofperforming myelography in any breast cancerpatient who presents with symptoms or signs ofradiculopathy or myelopathy irrespective of theseverity of the clinical signs and the radio-graphic findings.

Patients and methodsThis prospective study contains the myelo-grams, performed in breast cancer patientswho presented with symptoms or signs ofradiculopathy or myelopathy from December1984 to February 1989. Plain spinal radio-graphs were performed before myelography.Bone scans were not performed routinely butrecent bone scans were available in about halfof the patients.Myelography was performed via lumbar

puncture with a 20 gauge spinal needle.9 Weattempted to image the whole lumbosacral andthoracic, and, when possible, cervical spinalcanal to determine the occurrence of addi-tional asymptomatic EM. In the case of acomplete spinal epidural block the upperborder was visualized following an additionalcisternal puncture. Dexamethasone wasadministered to a maximum of an intravenousbolus of 16 mg, followed by 4 mg four timesper day. Radiotherapy (RT) ports included twovertebrae above and below the epiduraltumour.The clinical findings and the results of plain

spinal radiographs were compared with theresults of myelography and considered ofadequate diagnostic value when they predictedthe epidural lesion correctly within a margin oftwo vertebral bodies. Survival was analysedusing the Kaplan Meier method. Survivalcurves were compared with the logrank test.

ResultsMyelographyA total of 124 consecutive myelograms wereperformed in 100 patients. Myelograms wererepeated because of suspected recurrent EM in14 patients. These showed recurrent EM in sixcases and EM at a new site in two cases. Onehundred and eight nyelograms (87%) includedat least the lumbosacral and the whole thoracicspinal canal (table 1), demonstrating EM in 63

188group.bmj.com on April 6, 2018 - Published by http://jnnp.bmj.com/Downloaded from

Early diagnosis and treatment of spinal epidural metastasis in breast cancer: a prospective study

Table I Spinal segments visualised by myelography

Number ofSpinal Segment myelograms Percentage

Lumbar 7 6Lumbar + Thoracic 91 73Lumbar +Thoracic + Cervical 17 14Cervical 8 6Cervical + Thoracic 1 1Total 124 100

instances, including 15 myelograms showingmultiple EM. Sixty seven myelograms (54%)of the entire series of 124 consecutive myelo-grams were found positive for EM. These 67myelograms were performed in 55 of the 100patients, and showed a total of 87 EM. Acomplete or nearly complete epidural blockwas noticed in about one third of the myelo-grams showing tumours and in about the same

percentage the epidural tumour extended over

more than 2 vertebrae (table 2). The majorityof asymptomatic EM was found in the thoracicarea (fig 1). Cytological examination of the

Table 2 Characteristicsmyelography

of 87 epidural metastases on

Number ofepidural lesions Percentage

Complete block 13 18Incomplete block 14 16Extent of epidural tumour

1 vertebra 46 532 vertebrae 17 203 vertebrae 14 164 vertebrae 9 106 vertebrae 1 1

Figurel Distribution of87 asymptomatic andsymptomatic spinalepidural metastases. LevelL4 is involved mostfrequently.

asymptomatic

CSF from cases with EM demonstrated intra-dural metastases as well in 3 cases. Complica-tions related to myelography did not occur;particularly no neurological deterioration wasobserved after a spinal tap below an epiduralblock.

Characteristics of cases with and without epiduralmetastasisThe patient characteristics are summarised intable 3. Only four patients with EM had noevidence of bone metastases. Tbe presentingsymptoms amd signs are outlined in table 4.Pain was a presenting symptom in all caseswith EM. As a result of our study design almostall patients had radicular pain; we did notroutinely examine breast cancer patients withback pain only. Weakness and sensory loss werepresent in about a half of the patients and wereusually segmental as a result of radiculopathy.Bladder dysfunction was rather uncommonbut in all instances caused by metastaticdisease: it occurred in four patients with EMand in one patient with meningeal carcinoma-tosis. No significant difference was seen inpresenting symptoms or signs between patientswith single and those with multiple EM. Therewas no particular symptom or sign that con-vincingly predicted the presence or absence ofEM.

Clinical data, plain radiographs and epiduraltumour characteristicsClinical findings predicted the site of EMcorrectly (within a margin of 2 vertebrae) in 58(67%) of the 87 EM. Fifteen of the 29 EM thatwere not correctly anticipated were asympto-matic and occurred in twelve myelograms withmultiple EM. Epidural tumour at the level ofthe conus medullaris (vertebraTh 12) appearedto cause false localising symptoms and signsrather frequently; it caused sciatica as the onlysymptom in five patients mimicking an epi-dural lesion at the lumbosacral level. Extensionof the epidural tumour beyond two vertebraeof the predicted level and psoas paresis withEM at ThO or L5 were other causes ofincorrectly predicted EM. The non-ambula-tory status in patients with EM was notexclusively caused by epidural compression:two patients with EM could not walk becauseof serious osteolysis in the hip. Thus 12 (18%)of the 67 cases with EM were non-ambulatorydue to epidural compression.

Plain spinal radiographs were of no addi-tional localising value in 29 (33%) of the 87epidural lesions. Spinal radiographs were nor-mal in four cases, and showed only onemetastatic lesion (however, not at the level ofEM) in four other cases. Spinal radiographsshowed several vertebral metastases, but not atthe level of EM in five cases. Sixteen cases ofclinically incorrectly predicted EM, showeddiffuse vertebral metastasis. A recently per-formed bone scan was available in 35 of the 67tumour positive cases. It showed abnormalitiesin all instances. However, in 4 cases (11%) thiswas not within a margin of 2 vertebrae of theEM. Usually a bone scan showed diffusevertebral lesions.

1189

group.bmj.com on April 6, 2018 - Published by http://jnnp.bmj.com/Downloaded from

Boogerd, van der Sande, Kroger

Table 3 Patient characteristics in tumour-positive and tumour-negative myelograms

Single Multiple NoEpidural Epidural EpiduralMetastasis Metastasis Metastasis

Number of myelograms 52 15 57Age, median (year) 55 59 52

range 37-73 35-84 32-77Interval primary tumour-myelogram,median (months) 52 54 60range 5-240 30-126 3-183

Bone metastases 48 15 29Other systemic metastases 16 7 24No systemic metastasis 1 - 13

Treatment and outcomeTreatment was instituted in 65 of the 67 cases

with EM. Treatment was not given in twoseriously ill patients because of coexistentbrain metastases and meningeal carcinomato-sis and because of recurrence of multiple EM.The majority of the patients were treated withRT (table 5). Systemic treatment, that is,chemotherapy and/or hormonal therapy, was

instituted in 11 patients as a primary and soletreatment of EM. Surgical anterior decom-pression of the EM with vertebral body resec-

tion and stabilisation was performed in twopatients for recurrent EM after RT.

All patients who were able to walk atdiagnosis were ambulatory after treatment.Four out of 14 patients became ambulatoryafter treatment. One of these patients becameambulatory after RT for osteolysis in the hip,

given simultaneously with treatment of theEM.Given the small size of the various treatment

groups no clear difference in efficacy was

found between the various treatment mod-alities. Outcome was not related to the dura-tion of neurological symptoms. Outcome was

also not related to the extent of the epidurallesion or to the number ofEM (fig 2). Medianduration of neurological improvement or sur-

vival in patients with a complete block was 6months (range 2-22 months) and in those withan incomplete block 4 months (range 2 weeks-31 months). Outcome was significantly affec-ted by the pretreatment ambulatory status (fig3): median survival of the patients who couldnot walk at diagnosis was 1 month versus 7months for the ambulatory patients (p <

0O001). Median survival of those whoremained non-ambulatory was 2 months(range 2 weeks-12 months). The four patientswho became ambulatory all died in one month.Six patients got a relapse of EM; one of thesepatients suffered two relapses and two patientsthree relapses. The duration of the response totreatment of recurrent EM was not signifi-cantly different from the response to the firsttreatment. Two patients developed a new

EM.The majority of the patients with EM died of

progressive systemic disease, whilst in a neuro-logically stable or improved condition. More-over, most patients who did not respond to

Table 4 Neurological symptoms and signs in cases with and without epidural metastasis

Single Epidural Multiple Epidural No EpiduralMetastasis (n = 52) Metastasis (n = 15) Metastasis (n = 57)Number % Number % Number %

PainRadicular pain 48 92 15 100 51 89Back pain only 4 8 - 2 4No pain - -4 7

Symptoms, but no signs 5 10 3 20 14 25Sensory loss 31 60 5 33 24 42Weakness 22 42 6 40 27 47Bladder dysfunction 3 6 1 7 1 2Reflex changes 36 69 10 67 30 53Signs of radiculopathy 47 90 14 93 54 95Signs of myelopathy 8 15 2 13 3 5Status at myelography

ambulatory 41 79 12 80 52 91not ambulatory 11 21 3 20 5 9

Duration of symptomsmedian (months) 1.5 1 1range 1 day-10 months 1 wk-8 months 2 days-30 months

Table 5 Results of treatment of epidural metastasis

Duration ofimprovement(or survival*)

Mode of Improved No change Worse median Rangeratment Number % Number % Number % (month) (month)

RT alone (n = 28) 21 75 2 7 5 18 3 0-5-20RT + chemotherapy (n = 13) 8 62 2 15 3 23 3 0-5-23RT + hormonal therapy (n = 8) 8 100 - - 16 1-44RT + chemotherapy + hormone therapy (n=3) 3 100 - - 12 4-31Chemotherapy alone (n = 8) 4 50 4 50 - 6 2-22Hormonal therapy alone (n = 2) 1 50 1 50 - 13Chemotherapy + hormone therapy (n = 1) 1 100 - - 18tSurgery (n = 2) 2 100 - - 16t 11-22tNo treatment (n = 2) - - 2 100 2Total 67 48 72 9 13 10 15 7 0 5-44

* In case of sustained improvement until deatht Still alive

1190

group.bmj.com on April 6, 2018 - Published by http://jnnp.bmj.com/Downloaded from

Early diagnosis and treatment of spinal epidural metastasis in breast cancer: a prospective study

DiscussionDU ._In this study we analysed the usefulness of

myelography with CSF examination in breastXL Sscancer patients who present with radiculopathy

75 .ior myelopathy. Following this approach a non-ambulatory status at diagnosis of EM wasfound in only 21% of the patients, whichcompares favourably to the figure of 40-60%

so 50|mentioned in large retrospective studies.2" 'OThis difference, however, should be inter-

ir_s preted cautiously because the other studiesincluded more aggressive primary tumoursthan breast cancer. Sphincter dysfunction,

25 usually occurring later in the course of epiduralcompression and indicative of a poor prog-

| nosis, was noticed less often than reported byothers.2 '0-1 The possibly early diagnosis of

o _,_,_,_,_,_| EM in our patients is also suggested by theO 5 10 15 20 25 30 extent of the epidural lesions. In a retrospective

months study of breast cancer patients with EM,'350% of the patients with EM showed a

Figure 2 Survival curves of patients with single epidural metastasis -- -) and with complete block, versus 15% in this study. Themultiple epidural metastases ~ ~-). site of EM in our patients may have contrib-

uted to the relatively good neurological condi-tion at diagnosis. The lumbar area was

o100o _ frequently involved by epidural tumourwhereas in other reports the majority of EM

2 1. involve the thoracic area.1-3 10 Lesions below0CL 1l ! § the conus medullaris may become sympto-

matic earlier, in comparison with lesions at the> rl : | thoracic level. In a certain sense this is also

suggested by our finding that asymptomaticEM was found predominantly at the thoraciclevel.

CQ so P g > | Two other prospective studies have beenperformed that analysed the relevance ofmyelography in relation to clinical findings andspinal radiography for early identification of

25 1 s EM.25

%Rodichok et al evaluated in two complemen-tary studies'4 '5cancer patients with back pain

! s. and vertebral metastases on plain films andalso those with features of radiculopathy or

0 myelopathy regardless of the findings on plain0 10 20 34050 meoah eadeso h idnso limontths films. The study concerned patients with vari-

ous primary tumours, including 24% withFigure 3 Survival curves of patients who could walk -- -) and of patients who could breast cancer. Epidural tumour was found innot walk before treatment (-J. 59% of the myelograms. Similar to our find-

ings, about 75% of the patients with myelop-athy and 60% of those with radiculopathy hadEM. As many as 63% of the patients with back

treatment for their epidural tumour, died of pain and vertebral metastases but withoutsystemic disease (table 6). As expected, abnormalities on neurological examinationpatients with EM and visceral metastases had a appeared to have EM. This group of patients,worse outcome than those with only bone however, also included patients with neuro-metastases (table 6). Overall median survival logical symptoms, but without signs. In ourwas 7 months and the one year survival 42%. study, 36% of the patients with neurologicalThe median time of follow up in the 13 symptoms but without signs had EM. Asymp-patients who were still alive or lost to follow up tomatic lesions were less frequently diagnosedwas 15 months (range 3-5-31 months). in the study of Rodichok et al, that is, in 7% of

their tumour-positive myelograms versus 18%Findings in cases without epidural metastasis in our study. The difference in myelographicFifty seven myelograms were negative for EM. procedures explains this clinically importantThey were performed in 53 patients. Eight difference: almost all our myelograms encom-of these 53 patients had more than one passed the lumbar and whole thoracic seg-myelography. Intervertebral disc disease was ment. As recently reported, asymptomatic EMdiagnosed most frequently. Meningeal carcino- are common and easily missed when myelog-matosis was diagnosed in 8 cases (14%). The raphy or MRI is confined to the symptomaticmedian survival of the 45 patients without EM area.'6 17was 5 months (range 1 week-39 months). Ruff and Lanska"8 evaluated prospectively

1 191

A

j

group.bmj.com on April 6, 2018 - Published by http://jnnp.bmj.com/Downloaded from

Boogerd, van der Sande, Kroger

Table 6 Survival and cause of death related to the systemic disease status at diagnosis* and to the neurological response totreatment in 55 patients with epidural metastasis

Survival Bone Bone and Neurological responseand cause metastasis only visceral metastasist Improved No change Worseof death (n =41) (n = 13) (n =40) (n =8) (n = 7)

Survival (months)median 7 months 3 months 12 months 3 months 1 monthrange 0 5-44 0 5-20 0 5-44 1-5-12 0-5-13

Cause of deathsystemicdisease (n = 26) 19/41 7/13 18/40 4/8 4/7neurological+disease (n = 12) 8/41 4/13 7/40 2/8 3/7complication oftreatm. (n = 3) 2/41 1/13 2/40 1/8intercurrentdisease (n = 1) 1/41 1/8alive (n = 10) orlost to f-up (n = 3) 11/41 1/13 13/40

* One patient only regional lymph node metastasis.t 12/13 bone and visceral metastasis; 1/13 only visceral metastasis.+ Including brain metastasis and meningeal carcinomatosis.

95 male veterans with cancer and back pain byspinal radiograms and myelograms with imag-ing of the entire spinal canal for the presence ofepidural tumour. Most of those patients hadlung cancer or prostate cancer. About 75% ofthe patients with myelopathy and 50% of thosewith radiculopathy had EM, while none of the29 patients with only back pain had EM.Similar to our approach, myelography encom-passed the entire spinal canal; 12% ofEM wereasymptomatic. As much as 68% of the patientswith EM had a complete or nearly completeblock and 51% of the patients were notambulatory at the diagnosis of EM. Thesedifferences with our study probably reflectdifferences in patient populations: particularlyin lung cancer epidural tumour may progressrapidly.

It is questionable whether our diagnosticapproach for early detection of EM in breastcancer patients can be improved in a practicalway. Evaluation by spinal CT scanning withintrathecal contrast administration or myelog-raphy has been advocated in patients with backpain only and even in asymptomatic patientswith a suspect bone scan.19 20 This would,however, imply that invasive techniques shouldbe performed and possibly repeated in morethan a half of all breast cancer patients withmetastatic disease, with the profit of diagnos-ing EM at an earlier stage in only a smalladditional number of patients. In view of this,it is noted that in a retrospective analysis ofbreast cancer patients who had myelographyfor suspected epidural tumour 54%, that is, 42of the 78 myelograms showed EM,13 similar tothe 54%, that is, 67 of the 127 myelograms inour prospecthve study.With the introduction of MRI, however, a

highly sensitive technique has become availablewhich can visualise the entire spinal canal, thevertebrae and the paravertebral space withoutthe use of intrathecal contrast. However, MRIhas some limitations, particularly in patientswith metastatic epidural disease. With thepresent MRI scanners imaging of the entirespinal canal can take too long for a patient withpain to remain still, resulting in an inadequateinvestigation.18 In areas of scoliosis, forinstance due to vertebral metastasis, MRI maybe unable to image an epidural lesion accu-

rately. In addition, it has as yet not beendemonstrated convincingly that MRI issuperior to myelography in identifying epidurallesions; particularly small EM may be betterdetected by myelography.2' However, techno-logical advances and increasing use of para-magnetic contrast media will undoubtedlyimprove the usefulness of MRI in the nearfuture. The major disadvantage of myelog-raphy is the discomfort and possibly hazardouslumbar or cervical puncture. Lumbar puncturemight carry a major risk of acute neurologicaldeterioration when performed below an epi-dural block.22 Myelography was well toleratedin all our patients and without subsequentdeterioration. Rodichok'4 '5 and Ruff"8 repor-ted the same experience, which means that nodeterioration was observed by lumbar punc-ture in a total of 86 prospectively evaluatedmyelograms with a complete or nearly com-plete epidural block. Also, in large retro-spective studies2 1 23 no neurologicaldeterioration was documented following lum-bar puncture below an epidural lesion. Itindicates that a lumbar puncture below a spinalblock carries at most only a small chance ofneurological deterioration.

Obtaining spinal fluid for cytological exam-ination seems an important factor in favour ofmyelography, at least in breast cancer patients.Meningeal carcinomatosis is a frequent com-plication, particularly in breast cancer,24 andhas important implications for further manage-ment. In this study spinal fluid cytology wastumour positive in 11 of the 124 samples.Whatever technique is being used to visual-

ise EM, as much of the spinal canal as possibleshould be examined because of the highproportion of asymptomatic EM that might bethe cause, if left unrecognised, of neurologicaldeterioration.17 25 Moreover, symptomaticlesions can show false localising signs.The outcome of patients with EM is mainly

dependent on the degree of deficit beforetreatment and on the nature of the primarytumour.2 6 26 Apparently, both factors contrib-uted to the comparatively favourable outcomeof our patients. In contrast with other studieswe found no relation between outcome andpresence of an epidural block.26 This finding,however, should be interpreted carefully

1192

group.bmj.com on April 6, 2018 - Published by http://jnnp.bmj.com/Downloaded from

Early diagnosis and treatment of spinal epidural metastasis in breast cancer: a prospective study

because of the presence of a complete block inonly 13 of our patients.There are two established modes of treat-

ment for EM, namely, RT and surgery. Duringthe last decade a number of retrospectivestudies reported that RT is as effective as

surgery combined with RT.2 13 Comparison oftreatment results, however, is difficult becauseof variations in the distribution of radio-sensitive and radioresistent primary tumours,differences in diagnostic methods and in prog-

nostic factors like ambulatory status and sys-

temic disease status. The only randomisedprospective study comparing RT with surgery

plus RT27 did not show significant differencein outcome, but the small number of patientsand the heterogeneity of the primary tumoursin that study do not allow firm conclusions.Furthermore, in those comparative reports thesurgical approach was a decompressive lam-inectomy. Since the majority (85%) of EMarise from the vertebral body and invade theepidural space anteriorly, the more recentlydeveloped anterior decompression28-30 hasbecome the surgical method of choice, thoughonly feasible in a selected group of patients;laminectomy as surgical treatment is usuallyonly considered in case of posterior cordcompression.31 Although there is by far no

consensus about the mode of primary treat-ment in epidural tumour, it is generally agreedthat EM from radiosensitive tumours likemyeloma and also breast carcinoma should betreated primarily with RT, unless there is bonycompression of the spinal cord. The results ofRT in this study are comparable with thosereported by others in breast cancer

patients.2 10 26

Diagnosing EM when the patient was not inan emergency status clinically, allowed us todevelop new treatment strategies: a number ofpatients were successfully treated with systemictherapy as the sole treatment even in the case

of a complete epidural block.32 The response tosystemic therapy in our study was comparablewith the response to RT, whereas systemictherapy was often given for recurrent EM afterRT.

In conclusion, imaging of the whole spinalcanal in breast cancer patients, presenting withsymptoms or signs of radiculopathy or myelop-athy, irrespective of the severity of the clinicalsigns and the results of plain spinal radio-graphs, reveals EM in more than 50% of thepatients and also asymptomatic EM in a

substantial number of patients. Spinal fluidexamination disclosed meningeal carcinomato-sis in 9% of our patients.

Finally, systemic therapy appears a valuablenew mode of treatment for EM from breastcancer and can be important particularly inrecurrence after RT.

We thank Drs P Cohen, F de Leeuw and R Steinmetz, whoperformed a number of myelographies, Mr H van Tinteren forstatistical assistance, and Mrs C J Kamp for secretarialassistance.

1 Barron KD, Hirano A, Araki S, Terry RD. Experiences withmetastatic neoplasms involving the spinal cord. Neurology1959;9:91-106.

2 Gilbert RW, Kim JH, Posner JB. Epidural spinal cordcompression from metastatic tumor: Diagnosis and treat-ment. Ann Neurol 1978;3:40-51.

3 Livingston KE, Perrin RC. The neurosurgical cord andcauda equina compression. J Neurosurg 1978;49:839-43.

4 Constans JP, De Divitiis E, Donzelli R, Spaziante R, MederJF, Haye C. Spinal metastases with neurological manifes-tations. Review of 600 cases. Jf Neurosurg 1983;59:111-118.

5 Dunn RC, Kelly WA, Wohns RNW, Howe JF. Spinalepidural neoplasia. A 15 year review of the results ofsurgical therapy. Jf Neurosurg 1980;52:47-5 1.

6 Sorensen PS, Borgesen SE, Rohde K, et al. Metastaticepidural spinal cord compression: Results of treatmentand survival. Cancer 1990;65: 1502-8.

7 Fornasier VL, Horne JG. Metastases to the vertebralcolumn. Cancer 1975;36:590-4.

8 Viadana E, Bross LDJ, Pickren JW. An autopsy study ofsome routes of dissemination of cancer of the breast. BrJCancer 1973;27:336-40.

9 Kelly WM, Badami P, Dillon W. Epidural block: myelo-graphic evaluation with a single-puncture technique usingmetrizamide. Radiology 1984;151:417-419.

10 Stark RJ, Henson RA, Evans JW. Spinal metastases aretrospective survey from a general hospital. Brain 1982;105:189-213.

11 Black P. Spinal metastasis: Current status and recom-mended guidelines for management. Neurosurgery 1979;5:726-46.

12 Greenberg HS, Kim JH, Posner JB. Epidural spinal cordcompression from metastatic tumor: Results with a newtreatment protocol. Ann Neurol 1980;8:361-6.

13 Harrison KM, Muss HB, Ball MR, McWhorter M, CaseM. Spinal cord compression in breast cancer. Cancer1985;55:2839-44.

14 Rodichok LD, Harper GR, Ruckdeschel JC, et al. Earlydiagnosis of spinal epidural metastases. Am J7 Med 1981;70:1181-8.

15 Rodichok LD, Ruckdeschel JC, Harper GR, et al. Earlydetection and treatment of spinal metastases the role ofmylegraphy. Ann Neurol 1986;20:696-702.

16 Van der Sande JJ, Kroger R, Boogerd W. Multiple spinalepidural metastases; an unexpectedly frequent finding. JNeurol Neurosurg Psychiatry 1990;53:1001-3.

17 Bonner JA, Lichter AS. A caution about the use of MRI todiagnose spinal cord compression. N Engl J? Med 1990;322:556-7.

18 Ruff RL, Lanska DJ. Epidural metastases in prospectivelyevaluated veterans with cancer and back pain. Cancer1989;63:2234-4 1.

19 O'Rourke T, George CB, Redmond J, et al. Spinal com-puted tomography and computed tomographic metriza-mide myelography in the early diagnosis of metastaticdisease. J7 Clin Oncol 1986;4:576-83.

20 Redmond J, Friedl K, Cornett P, Stone M, O'Rourke T,George CB. Clinical usefulness of an algorithm for earlydiagnosis of spinal metastatic disease. J Clin Oncol1988;6: 154-7.

21 Hagenau C, Grosh W, Currie M, Wiley KRG. Comparisonof spinal magnetic resonance imaging and myelography incancer patients. J7 Clin Oncol 1987;5:1663-9.

22 Hollis P, Malis LI, Zappulla RA. Neurological deteriorationafter lumbar puncture below complete spinal subar-achnoid block. J Neurosurg 1986;64:253-6.

23 Bernat JL, Greenberg ER, Barrett J. Suspected epiduralcompression of the spinal cord and cauda equina bymetastatic carcinoma: Clinical diagnosis and survival.Cancer 1983;51:1953-7.

24 Yap HY, Yap BS, Tashima CK, Distefano A, BlumenscheinGR. Meningeal carcinomatosis in breast cancer. Cancer1978;42:283-6.

25 Loeffler JS, Glicksman AS, Tefft M, Gelch M. Treatment ofspinal cord compression: a retrospective study. MedPediatr Oncol 1983;11:347-51.

26 Maranzano E, Latini P, Checcaglini F, et al. Radiationtherapy in metastatic spinal cord compression. Cancer1991;67:1311-17.

27 Young RF, Post EM, King GA. Treatment of spinal epiduralmetastasis. Randomized prospective comparison of lam-inectomy and radiotherapy. J Neurosurg 1980;53:741-8.

28 Harrington KD. Anterior cord decompression and spinalstabilization for patients with metastatic lesions of thespine. J Neurosurg 1984;61:107-1 17.

29 Sundaresan N, Galicich JH, Bains MS, et al. Vertebral bodyresection in the treatment of cancer involving the spine.Cancer 1984;53:1393-6.

30 Fidler MW. Anterior decompression and stabilisation ofmetastatic spinal fractures. J Bone Joint Surg 1986;68:83-90.

31 Siegal T, Siegal T. Surgical decompression of anterior andposterior malignant epidural tumors compressing thespinal cord: a prospective study. Neurosurgery 1985;17:424-31.

32 Boogerd W, Van der Sande JJ, Kroger R, Bruning PF,Somers R. Effective systemic therapy for spinal epiduralmetastases from breast carcinoma. EurI Canc Clin Oncol1989;25: 149-53.

1193group.bmj.com on April 6, 2018 - Published by http://jnnp.bmj.com/Downloaded from

prospective study.epidural metastasis in breast cancer: a Early diagnosis and treatment of spinal

W Boogerd, J J van der Sande and R Kröger

doi: 10.1136/jnnp.55.12.11881992 55: 1188-1193 J Neurol Neurosurg Psychiatry

http://jnnp.bmj.com/content/55/12/1188Updated information and services can be found at:

These include:

serviceEmail alerting

box at the top right corner of the online article. Receive free email alerts when new articles cite this article. Sign up in the

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:

group.bmj.com on April 6, 2018 - Published by http://jnnp.bmj.com/Downloaded from