What management modalities are appropriate for a 64-year-old patient with progressive mid back pain and leg weakness, recently started on combined immunotherapy with nivolumab (Neva) and ipilimumab (move up) for advanced melanoma, with MRI revealing a lesion in the T spine body associated with a pathological fracture and invasion into the epidural space causing moderate spinal cord compression?

Management of Spinal Cord Compression in a Patient with Advanced Melanoma on Immunotherapy

Decompressive surgery followed by radiation therapy is the most appropriate management for this 64-year-old patient with progressive mid-back pain, leg weakness, and moderate spinal cord compression due to metastatic melanoma while on nivolumab and ipilimumab immunotherapy. 1

Clinical Assessment and Rationale

This patient presents with:

• Progressive worsening mid-back pain
• Leg weakness with impaired ability to work
• MRI showing T-spine lesion with pathological fracture
• Epidural invasion causing moderate spinal cord compression
• Currently on combined immunotherapy (nivolumab + ipilimumab) for advanced melanoma

Surgical Management Priority

The ACR Appropriateness Criteria clearly states that surgery is the standard of care for pathologic vertebral compression fractures (VCF) complicated by:

1. Spinal instability (pathological fracture in this case)
2. Neurological deficits (leg weakness in this case) 1

For patients with pathologic fracture with neurologic effects (Variant 8), surgical consultation and radiation oncology consultation are specifically designated as "usually appropriate" 1.

Management Algorithm

1. Immediate Intervention:

   • Start corticosteroid therapy immediately to reduce edema and inflammation
   • Arrange urgent decompressive surgery 1

2. Surgical Approach:

   • Decompressive surgery with tumor excision and spinal stabilization
   • This approach has been shown to improve neurological status from non-ambulatory to ambulatory 1

3. Post-Surgical Management:

   • Radiation therapy following surgery
   • This combination has been shown to benefit patients with symptomatic spinal cord compression 1

4. Immunotherapy Considerations:

   • Continue immunotherapy after recovery from surgery
   • Nivolumab plus ipilimumab has shown significant survival benefits in advanced melanoma 2, 3, 4

Evidence Supporting This Approach

In the setting of metastatic spinal cord compression, particularly due to osseous compression, surgery is more likely to allow recovery compared to radiation therapy alone 1. Observational studies demonstrate that surgical decompression, tumor excision, and stabilization improve neurological status and provide pain relief 1.

The combination of decompression surgery followed by radiation therapy is particularly beneficial for patients with:

• Single level of compression (as in this case)
• Neurologic deficits (leg weakness in this case)
• Predicted survival of at least 3 months 1

Why Other Options Are Less Optimal

1. Multimodal analgesia alone: Inadequate for addressing neurological compromise and spinal instability; would not prevent progression of neurological deficits 1

2. Corticosteroids alone: While indicated as initial therapy, they are insufficient as definitive treatment for moderate cord compression with neurological symptoms 1

3. Chemotherapy adjustment: Not the primary management for acute spinal cord compression; would not address the immediate mechanical compression 1

4. Radiation therapy alone: Less effective than surgery for osseous compression causing neurological deficits 1

Important Considerations and Pitfalls

• Timing is critical: Surgery should be performed as soon as possible after presentation with neurological deficits to prevent further deterioration 1

• Age consideration: While decompressive surgery followed by RT is particularly beneficial in patients <65 years of age (this patient is 64), the presence of neurological deficits makes surgery the priority regardless 1

• Avoid delay: The longer the duration of neurological deficits before intervention, the less likely full recovery becomes 1

• Immunotherapy continuation: The patient's immunotherapy regimen (nivolumab + ipilimumab) has shown significant survival benefits in advanced melanoma with 5-year overall survival of 52% 3 and should be continued after recovery from surgery

By following this approach, the patient has the best chance of neurological recovery, pain relief, and continued benefit from the immunotherapy regimen for the underlying advanced melanoma.