Do you refer all patients with new findings of CNS or epidural mets/tumor to ED for evaluation or are there some that can be managed completely outpatient?

Interesting question:

1. Sending patients to the ED for non-emergent conditions is not advised. Our EDs around the country are struggling for a variety of reasons (e.g., they are often holding patients awaiting placement or admission), thus our society will benefit by us avoiding sending patients to the ED.
2. Certainly, an asymptomatic patient should essentially never go to the ED.
3. Indeed, an asymptomatic patient with brain mets and/or epidural disease likely can avoid admission to the hospital as well and be evaluated and treated as an outpatient.
4. I understand that many providers send patients to the ED to expedite tests and/or admission, but that approach often unnecessarily strains our ED and should be avoided whenever possible.

Respectfully,

Larry Marks

I think that a decision to refer to the ER depends on the patient's symptoms, the size/type of CNS lesion, and your practice setting. Small asymptomatic or incidentally discovered brain metastases may not require management in an ER or inpatient setting. Leptomeningeal disease, by comparison, is something that can progress quickly and LP for cytology and treatment planning should be done expediently (in some systems, it might be difficult on an outpatient basis). I generally reserve steroids unless the patient is symptomatic, but there are exceptions (significant mass effect on imaging even in the absence of symptoms). Please see Dr. @Dr. First Last's answer to a similar question on antiepileptic prophylaxis.

Agree with the comments above and Dr. @Dr. First Last' concerns regarding not only the broader implications of ED overuse but also the long wait times and poor experiences generally experienced by cancer patients.

I will add that one commonly encountered issue that can result in the inappropriate escalation of care is the overcall of "cord compression" on an MRI spine report. I have seen "cord compression" mentioned on MRI spine reports and referrals for consultation for even a Bilsky grade 1a, where a tumor has merely contacted the epidural surface, and there is no need for emergent management. Any consideration of cord compression should be taken seriously. However, before referring a patient for emergent/inpatient evaluation for cord compression, I would personally review the MRI to assess the extent/concern for a true neurosurgical emergency. Along with this, often pain is mistaken for a neurologic deficit. Patients often refuse or do not want to move in the setting of pain. However, from a practical standpoint, this is less of a concern since if the pain is that severe, inpatient/urgent pain management in a hospital setting may be helpful and appropriate.

It is helpful to use an objective scale when discussing cord compression; the "Bilsky" scale or "Epidural Spinal Cord Compression" (ESCC) scale is the most commonly used. I teach residents: "Contact, push, crunch" to help them remember the higher grades of compression (1c, 2, 3), which respectively indicate contact with the cord, deformation/pushing of the cord, and complete loss of surrounding CSF. Clinical/neurologic status should primarily be used to guide management, but a grade 2 or 3 can quickly turn into an emergency and is also appropriate for emergent evaluation regardless of symptoms.

Bilsky et al., PMID 20809724 

I would bet that most rad oncs do NOT routinely send people with brain mets to the ER. It would be an interesting poll question.

If the patient has no impending neurologic emergency, we manage as an outpatient with steroids and radiation. Why send to ED where the doctors are busy with trauma and patients are likely to be exposed to COVID-19? If there's impending cord compression then admit and treat inpatient.