Loblaw and Mitera are to be congratulated for their ongoing efforts to provide systematic guidelines in the palliative management of patients with malignant spinal cord compressions (MSCC). Highlighted in this review are recent reports that can help determine an appropriate radiotherapy (RT) dose. Loblaw and Mitera explore the various considerations important to the multidisciplinary team when reviewing treatment options. As a result of a lack of significant progress in the management of MSCC, unanswered questions remain.

When a patient is given a poor prognosis, it is difficult to modulate treatment to alleviate the side effects of MSCC and the risk of toxicity and to improve quality of life. However, many symptoms arising from a tumor's mass require some measure of tumor response to therapy. Such is the case with the neurologic compromise that arises from MSCC.

Standard palliative RT doses alleviate the pain associated with MSCC. Reversing and maintaining ambulation can be limited and is likely dependent upon achieving sufficient tumor response to therapy. RT dose intensification may provide effective tumor response and disease control at the MSCC site, preventing future loss of neurologic function. However, there are major impediments for such studies: (1) the RT toxicities associated with the use of large traditional nonconformal RT fields often used to expedite care, (2) the time required (of the patient especially), and (3) the limited prognosis of the palliative patient.