cEBRT: conventional external beam radiation therapy; SBRT: stereotactic body radiation therapy.
* Spine stability is primarily determined by imaging. Spine Instability Neoplastic Score (SINS) scores ≥7 are generally considered to indicate high risk for spinal instability and warrant surgical consultation; pain caused by movement suggests spinal instability unless proven otherwise. Refer to UpToDate topics on ESCC for further details.
¶ Examples of relatively radioresistant neoplasms for the purposes of ESCC decision-making include melanoma, renal cell carcinoma, non-small cell lung cancer, sarcoma, and gastrointestinal malignancies; relatively radiosensitive neoplasms include lymphoma, myeloma, small cell lung cancer, germ cell tumors, breast cancer, prostate cancer, and ovarian cancer.
Δ Although solid tumors such as breast and prostate cancer generally respond well to cEBRT, response can take time, and surgery should at least be considered in those patients with neurologic deficits due to high-grade ESCC to allow rapid decompression of the spinal cord.
◊ High-grade ESCC refers to patients with an ESCC radiologic grade of 2 or 3, even if asymptomatic. Grade 2 ESCC tumors displace or compress the spinal cord, without circumferential epidural extension or obliteration of the cerebrospinal fluid (CSF) space; grade 3 ESCC tumors cause severe spinal cord compression with obliteration of the CSF space. Many patients with high-grade ESCC have deficits attributable to spinal cord compression (ie, myelopathy) or nerve root compression (ie, radiculopathy).
§ Patients who are not suitable candidates for surgery or who decline surgery may be treated by cEBRT, preceded by noninvasive stabilization if spine is unstable. Selected patients with grade 2 ESCC may be candidates for hypofractionated SBRT.
¥ Stabilization options include percutaneous cement augmentation, percutaneous pedicle screw instrumentation, and open instrumentation.