Spinal Cord Metastasis Research Articles

The Role of the Surgery in the Case of an Intramedullary Spinal Cord Metastasis as a Primary Presentation of a Malignant Disease

Introduction: Spinal cord metastases represent a small proportion of intramedullary tumors. The occurrence of such lesion over the course of malignant disease is usually a predictor for shortened life expectancy and is often associated with severe neurological deficits. Treatment options include microsurgical excision, radio-, chemo- or palliative therapy. Despite these possibilities the optimal management of patients with intramedullary spinal cord metastases (ISCM) is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of different therapeutic options. Materials: We are presenting a case of a 68-year-old male with gradually increasing spinal neurological deficit – axial low back pain, numbness and muscle weakness in both legs and gait disturbance. Arterial hypertension was pointed as the only comorbidity of the patient. The MRI showed an intramedullary solitary lesion in the lumbar intumescence at the level of Th12 and L1 vertebra. Results: The patient underwent surgery and the tumor was totally excised. The symptoms improved dramatically. The histology evidence a metastasis from a lung adenocarcinoma. Six months later he presented with severe back pain, progression of the paresis and urinary retention. Tumour recurrence was detected by MRI. After careful decision making and taking into consideration the risk of permanent neurological deficit a reoperation was performed. The lesion was gross-totally removed with improvement in functions and no neurological deterioration registered in the postoperative period. Conclusion: It is possibly the symptoms from an intramedullary metastatic lesion to precede the detection of the primary tumour. The low frequency of occurrence and the absence of a manifested and diagnosed primary malignant process should not stop us thinking in the direction of metastasis. Surgical resection with function preservation is highly aimed. Operation and even reoperation in some cases is acceptable.

Microsurgical Resection of Lung Carcinoma Spinal Cord Metastasis: 2-Dimensional Operative Video.

This video demonstrates microsurgical resection of intramedullary spinal cord metastasis of lung adenocarcinoma. Lung cancer is the predominant cause of rare metastatic intramedullary involvement of the spinal cord.1-4 Because of severe disabilities, these tumors should be considered for treatment with the goal of complete removal to preserve neurological functioning.5-9 Surgical resection improves symptoms, preserves ambulatory status, and increases survival time twice that of nonsurgical treatments.3,8,10 Surgery can be effective in arresting neurological decline.11,12 To our knowledge, this is the first video report of an intramedullary spinal cord metastasis resection. A 69-yr-old male with history of lung cancer presented with acute onset left arm abduction, forearm flexion, and hand weakness (3/5) and gait disturbance. Cervical spine MRI revealed C4/C5 nonhomogenously enhancing intramedullary tumor measuring 22×10×7 mm. Sagittal T2-weighted image demonstrated extensive cord edema. The C4 and C5 laminectomies were performed. Microsurgical techniques were employed.13-15 Metastasis involved the left lateral aspect of the cord with invasion of 2 left dorsal sensory nerve roots, which were resected. Further transection of the dentate ligament relaxed the spinal cord, enabling safer tumor resection. Pial dissection using bipolar forceps, microscissors, and microdissector enabled tumor delivery. Following resection, dural closure was reinforced with previously harvested fat tissue graft to prevent CSF leak.16 Postoperative MRI revealed complete macroscopic resection with improvement of spinal cord swelling. Patient improved his gate and his left arm motor strength was stable. Subsequently, patient received focal adjuvant radiotherapy. Written consent was obtained directly from the patient.

Unsuspected Intramedullary Spinal Cord Metastasis Detected by FDG PET/CT.

Intramedullary spinal cord metastases (SCMs) are extremely rare. Here, we report a case of a 60-year-old man with a history of right nonsmall cell lung cancer treated by concomitant radiochemotherapy who complained, 9 months after treatment completion, of chest pain, breath shortness, and more recently back pain. An 18F-FDG PET/CT was performed as part of the restaging process and showed a hypermetabolic mass of the right lung in addition to ipsilateral mediastinal hypermetabolic lymph nodes. There was also an FDG avid lesion of thoracic spinal cord at the T11–T12 level consistent with SCM as confirmed by MRI.

Spinal cord metastasis of anaplastic oligodendroglioma of the brain without recurrence of primary tumor. Ccase report and literature review

Spinal cord metastases of brain gliomas are rare. However, incidence of these tumors has been increasing recently. The vast majority of neurosurgeons and oncologists recognize spinal cord metastasis of malignant brain glioma followed by symptoms of transverse spinal cord lesion as non-curable terminal stage of malignant process. In this paper, we report a rare clinical case of metastatic spinal cord lesion in a patient after previous surgery for anaplastic oligodendroglioma of the right frontal lobe. There were no signs of local recurrence of the primary tumor. Active surgical strategy followed by radio- and chemotherapy significantly improved the patient's quality of life. Postoperative follow-up is 6 months by the moment of writing the manuscript, no clinical signs of progression are observed.

Recurrent Renal Carcinoma with Solitary Intramedullary Spinal Cord Metastasis.

We report a case of an elderly male who has undergone right radical nephrectomy for renal cell carcinoma (RCC). Six months later, he presented with gradually progressive low backache and mild lower limb weakness. 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET-CT) was done that revealed a suspected area of mild metabolic activity in the spinal cords at the L1–L2 vertebral level. Magnetic resonance imaging revealed intramedullary spinal cord metastasis (ISCM). Solitary ICSM is a rare presentation of RCC on FDG PET-CT, and only a few case reports exist in the literature. This case highlights that adequate clinical history and careful examination of the PET images may reveal it.

Concomitant Acute Motor Sensory Axonal Neuropathy and Squamous Lung Cancer-induced Intramedullary Spinal Cord Metastasis

Intramedullary Spinal Cord Metastases (ISCMs) are rare, especially in squamous non-small cell lung cancer simultaneous with Acute Motor and Sensory Axonal Neuropathy (AMSAN); diagnosing these phenomena may be challenging. We report a 56-year-old man presenting with rapidly symmetrical progressive ascending weakness and paresthesia, especially in lower extremities, urinary and fecal incontinence, without any pain or respiratory symptoms. Thoracic spine MRI with and without gadolinium revealed an enhancing intramedullary lesion at the T3-T5 level. Chest CT discovered subpleural pulmonary lesion. The result lung biopsy was consistent with poorly differentiated squamous cell carcinoma, and electrodiagnosis noted severe axonal loss in motor and sensory studies with significant membrane instability and neurogenic findings in electromyography. After 8 months, the patient received just one cycle of chemotherapy and died 6 months later. AMSAN was associated with ISCM of nonsmall cell lung cancer in this case, who has not been previously reported in the literature.

Intramedullary Spinal Cord Metastasis as the Presenting Feature of Papillary Thyroid Carcinoma

The objective of this report is to present an unusual case of intramedullary spinal cord metastasis (ISCM) as the presenting feature of papillary thyroid carcinoma (PTC). The presented case includes clinical, biochemical, and imaging findings as well as surgical and pathology reports. Treatment with radioactive iodine (RAI) and the response to this treatment are presented. A 71-year-old woman was evaluated for debilitating low back pain and walking disability. Magnetic resonance imaging demonstrated an oval, lumbar, intramedullary mass with benign features and surgery was scheduled. On preoperative evaluation for the lumbar mass, a multinodular thyroid goiter (unfortunately overlooked previously) was noticed, causing severe narrowing of the trachea. Total thyroidectomy was performed with a pathology diagnosis of PTC. In a second operation, the lumbar lesion was removed and proved to represent metastatic PTC. External beam radiation was subsequently administered to the thyroid bed, lumbar spine, and other skeletal metastases, followed by 150 milliCurie of RAI. A post-treatment scan showed high uptake over the lumbar spine, and skeletal and lung lesions. Clinically, the patient restored her walking ability and back pain improved. ISCM rarely is the presenting feature of PTC. Our patient presented with back pain which is the typical, though non-specific symptom, of ISCM. She showed good clinical response to multimodal treatment which is in line with the few other differentiated thyroid cancer patients with ISCM reported in the literature. Prompt surgical resection, followed by external beam radiation and RAI, may improve neurological signs, alleviate pain, and improve quality of life.

Abstract 692: Treating spinal cord metastases with tumor treating fields

Abstract Introduction: Tumor Treating Fields (TTFields) is an anti-mitotic technology utilizing low-intensity (1-3 V/cm) electric fields within the medium frequency range (100-300 kHz) to treat solid tumors. TTFields are currently approved for the treatment of Glioblastoma (GBM). Some cancer types, such as breast cancer, lung cancer, and melanoma, frequently result in metastases to the spinal cord. Transducer array positioning used to treat abdominopelvic diseases (e.g. pancreatic cancer), in which one pair of arrays are placed on the anterior and posterior of the patient, and another pair of arrays placed on the lateral aspects of the patient have been shown to be inefficient for treating the spinal cord because the clinical threshold for field intensity of 1V/cm is not reached in the spine when these layouts. The structure of the spine, in which a relatively resistive bone structure encapsulates a highly conductive layer of fluid (cerebrospinal fluid), shunts the current delivered across the body by the arrays away from the spine, reducing the field within the spine to below the therapeutic threshold. To overcome this limitation, a new approach of array placement on the body is needed. Here we present a simulation-based study designed to identify array layouts that effectively deliver TTFields to the spine. Methods: To simulate delivery of TTFields to the spine, we used a human male 34 years old realistic computerized model (DUKE v3.1 by ITI’S, Zurich). In order to generate TTFields, an alternating current with current density of 200mA/disk with a frequency of 150 kHz was imposed on the outer surfaces of the disks of each pair of arrays. The simulations were performed using ZMT's Sim4Life v4.0 electro-quasi-static solver. Results: One of the array layouts tested was placement of a pair of arrays on the back of the patient. One array is placed above the target region in the spine to which treatment would be delivered, and the other array is placed below the region. With this configuration, a high electric field is induced within the spinal cord and surrounding CSF. Mean field intensity within the spine and nerves in between vertebrae T8-T9 at the top, and L3-L4 at the bottom were calculated at a value of 1.77 V/cm. It is important to note that the electric field is oriented along the spine in this instance (a vertical field). In general, the whole spine could be treated by placing one array on the neck, and one at the bottom of the spine. Conclusions: Placing two transducer arrays on the patient’s back allows single-direction treatment of the spinal cord and nerves. Further work should be conducted to find an effective treatment in the perpendicular direction. Citation Format: Ofir Yesharim, Ariel Naveh, Ze'ev Bomzon. Treating spinal cord metastases with tumor treating fields [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 692.

Intramedullary spinal cord metastasis in malignancies: an institutional analysis and review.

Background: Intramedullary spinal cord metastases (ISCM) in malignancies is a devastating issue with limited research. This study aims to identify the clinical features, management, prognostic factors, and outcomes of this special entity.Methods: A retrospective review of 61 patients of ISCM diagnosed and treated in our institute from June 2010 to March 2018 was conducted (lost to follow-up: 3). Data were retrieved according to the items including age, gender, primary tumor, interval to the ISCM occurrence, ISCM segments, and other synchronous metastases. The interventions, response, prognostic factors, and outcomes of ISCM were systematically analyzed.Results: Lung cancer (67.21%) was the commonest ISCM source, followed by breast cancer (14.75%). In total, 9.84% of patients presented with ISCM initially. The mean span from the primaries to ISCM was 18.77 months (range=0–10 years). The thoracic segment was most commonly involved (77.05%), followed by cervical (39.34%), lumbar level (34.43%), and conus medullaris (6.56%). The management of ISCM was challenging, since 55.74% of individuals had a poor physical condition (PS=3–4) and 72.41% had widespread dissemination synchronously (≥2 organs). Radiotherapy (RT) attained an objective response rate (ORR) of 61.90% or 62.50% and a local control rate (LCR) of 90.48% or 87.50% for symptoms used alone or with other strategies, respectively. ISCM bears a dismal prognosis, with a median overall survival (OS) of 4 months. Patients with only one segment involved had an apparently better prognosis than those with 2–4 involved segments (median OS=7.0 vs 3.0 months) (P<0.01). The OS of patients treated was remarkably superior to those without any intervention (median OS=5.0 vs 2.0 months) (P<0.01).Conclusion: ISCM is a distinct entity needing more attention for high cancer incidence, prolonged survival, and lack of research. RT is the mainstay with satisfactory effect. Multiple spinal cord segments involvement and no treatment are poor prognostic factors of OS.

Dominant hemisphere and upper cervical cord tumefactive multiple sclerosis in a Nigerian teenager initially misdiagnosed and managed

A 13-year old right handed Nigerian girl presented with eleven weeks history of progressive visual loss, three weeks right hemi-body weakness which progressed to quadriparesis, dysphasia, severe headache, tonic-clonic seizures, neck pain, vomiting and fever.Examination revealed Glasgow Coma Score (E4M6V2), expressive dysphasia and depressed mood. Visual Acuity was counting finger bilaterally. Neck was supple. She had global hypotonia, grade 3 hyper-reflexia and extensor Babinski bilaterally. Power was 0/5 in the right upper limb and right lower limb, 2/5 in the left lower limb and 4/5 in the left upper limb. Other examinations were unremarkable.Contrast enhanced brain MRI revealed three cystic ring enhancing masses at left fronto-parieto-occipital region, associated oedema, midline shift and C2-C4 intramedullary mass with cord oedema. The ring enhancement was incomplete towards the cortex.Following initial suspicions of cystic brain tumour with spinal cord metastasis, she had decompression biopsy. Histology was inflammatory lesion, clinically assumed to be from brain abscess. Failure of antibiotic treatment and the deteriorating neurology prompted mini-craniectomy and biopsy of the cyst wall. Final diagnosis was tumefactive multiple sclerosis. She was successfully managed with methylprednisolone. Follow-up clinical condition has been satisfactory.Keywords: TMS, cranial masses, multiple sclerosis, visual loss

A clinicopathologic study of surgically resected metastatic lesions of brain: A single institutional experience

One of the most common tumors of the brain are metastatic lesions. They can present as cancer of unknown primary (CUP) and require careful determination of the site of origin of the primary. Histopathologic and immunohistochemical analysis helps to determine the primary site. To study the clinicopathological features of metastatic tumors of the brain. All cases of surgically resected brain metastasis (solid tumor metastasis) from January 2013 to April 2015 were included in the study. The clinical details including age, gender, clinical features, and location were taken from medical records. The histopathology slides were retrieved and reviewed along with clinical and imaging findings from medical records. Immunohistochemistry was performed wherever necessary. Out of 1662 resected brain lesions during the study period, 69 accounted for central nervous system metastasis, of which 36 were brain metastasis and 33 were isolated spinal cord metastasis. In the 36 brain metastasis cases, 19 were cases with an unknown primary. Carcinoma lung (47.2%) was found to be the most common primary malignancy. Immunohistochemistry with cytokeratin (CK)7, CK20, and thyroid transcription factor (TTF) 1 as a primary panel in metastatic tumors is highly recommended. Metastatic tumors accounted for 4.1% of intracranial lesions. Histopathologic pattern and immunohistochemistry aid in the accurate diagnosis of the original site of malignancy.

Clinical features and treatment analysis of intracranial extraventricular ependymomas

Objective To study the clinical features, imaging demonstration and treatment outcomes of intracranial extraventricular ependymomas. Methods A total of 17 patients with intracranial extraventricular ependymoma underwent surgical treatment at Department of Neurosurgery, Renmin Hospital of Wuhan University from March of 2010 to June of 2016 and were enrolled into this retrospective study. Pre-operative MR scan showed single lesion located at supratentorial region in all cases. Those lesions were located in occipital lobe (5 cases), occipitoparietal lobe (2 cases), temporal lobe (3 cases), frontal lobe (4 cases) and parietal lobe (3 cases). Among those, 7 were solid and 10 were cystic lesions. Surgical excision was performed for all lesions. Post-operative follow-up was performed for every patient through telephone and outpatient review. Results Of those cases, total resection was achieved in 15 cases, including 10 cases of WHO grade Ⅱ and 5 case of WHO grade Ⅲ, and partial resection in 2 (WHO grade Ⅲ). Intraoperative pathological diagnosis suggested that 10 cases were ependymoma (WHO gradeⅡ) and 7 cases were anaplastic ependymoma (WHO grade Ⅲ). All patients′ clinical symptoms were relieved following surgery. Four cases (grade Ⅲ), including 2 cases undergoing partial resection, received post-operative radiotherapy. The follow-up time of those patient were from 14 to 74 months, with a median of 33.2 months. During the follow-up, no case showed any signs of spinal cord metastasis. Recurrence was reported in 7 cases and 4 of them (grade Ⅲ) received post-operative radiotherapy. Among those, 1 case underwent the second tumor total resection and postoperative radiotherapy, 1 case died 3 months after the second tumor total resection, 2 cases of tumor partial resection rejected the second operation and died after 4 and 6 months, respectively, and the other 3 recurrent cases included 2 (grade Ⅱ) and 1 (grade Ⅲ) undergoing the second tumor total resection without postoperative radiotherapy and 1 (grade Ⅲ) that died of postoperative hemorrhage. Conclusions As intracranial extraventricular ependymoma has non-specific clinical and imaging features, accurate pre-operative diagnosis is difficult. Total tumor resection is the primary method of treatment, if it is possible. The choice of resection type and pathological grading could be predictive factors in postoperative evaluation. Key words: Ependymoma; Neurosurgical procedures; Treatment outcome; Intracranial extraventricular

Intramedullary Spinal Cord Metastasis from Renal Cell Carcinoma: A Systematic Review of the Literature

Intramedullary spinal cord metastases from renal cell carcinomas (RCCs) are rare and can cause serious diagnostic and therapeutic dilemmas. The related reports are very few. This review was aimed to perform an analysis of all reported cases with intramedullary spinal cord metastases from RCCs. In January 2018, we performed a literature search in PubMed database using a combination of the keywords “intramedullary spinal cord metastasis” and “renal cell carcinoma”. In addition, we present the clinical, neuroradiological, and histopathological findings in our patient with an intramedullary metastasis from a RCC. 17 cases were generated in our research. The mean interval from diagnosis of RCC to diagnosis of ISCM was 22 months. The median survival of surgically treated patients was 8.6 months and 8 months in patients who underwent radical surgery. Based on our review, RCCs can invade the medulla of the spinal cord several years after removal of the primary lesion. The prognosis of ISCMs from RCCs was poor. Retrograde passage of tumor cells into the spinal cord from the inferior vena cava via the epidural venous sinuses may have been the pathological mechanism for ISCM in our patient. Radical resection and radiation are effective ways of achieving recovery of neurologic function and improving quality of life. More reports are needed to enable exploration of the mechanisms of metastasis and the optimal forms of therapy.

Treatment outcomes of intracranial germinoma: a retrospective analysis of 170 patients from a single institution.

To perform a retrospective analysis of patients with intracranial germinoma treated in our department to evaluate treatment outcomes and determine optimal treatment strategies. We reviewed the treatment outcomes of 170 patients with intracranial germinoma who were treated in our department from January 1996 to January 2017. The median patient age was 15years old. Among the patients, 56 (33%) were pathologically diagnosed, and 114 (67%) were diagnosed clinically. Various radiation fields and doses were used. Cerebrospinal fluid (CSF) and serum beta-human chorionic gonadotropin (β-HCG) levels were examined before treatment in 114 patients. Endocrinological evaluation was performed in 141 patients before and after treatment. A total of 38 patients received chemotherapy prior to radiotherapy (RT). The median follow-up time was 64.5months (range 4-260.5months). The 5- and 10-year overall survival (OS) rates were 94.5% and 91.3%, respectively. The relapse-free survival (RFS) rates at 5- and 10-years were 91.9% and 78.1%, respectively. Relapses occurred in 18 patients within 6months-10years. The spinal cord metastasis rate was 3.4% in patients with a localized lesion who did not receive spinal cord irradiation and 16.7% in patients with bifocal disease who were treated using whole ventricular irradiation (WVI) or whole brain radiotherapy (WBRT). Treatment failure did not occur in patients receiving chemoradiotherapy or in patients receiving three-dimensional conformal radiation therapy (3D-CRT)/intensity-modulated radiation therapy (IMRT). The RFS rate did not have a statistically significant correlation with the CSF/serum β-HCG level. After RT, 19.1% of the patients developed newly impaired pituitary function and required hormone replacement therapy. WVI or WBRT+ primary boost (PB) is a sufficient irradiation field for localized intracranial germinoma, while patients with bifocal disease should undergo craniospinal irradiation (CSI), especially when treated with RT alone. CSF β-HCG is not a prognostic marker for intracranial germinomas. The treatment results of chemotherapy followed by reduced-dose RT are comparable to those of RT alone. IMRT is recommended for intracranial germinoma to improve the target volume accuracy and decrease the complications of RT.

Postoperative radiation for primary melanoma of the cervical spinal cord in a pregnant patient: A case report &amp; review of the literature

Abstract Only 1% of melanomas present with isolated involvement of the central nervous system. Primary melanoma of the spinal cord is especially rare. There are only a handful of cases reported and only one reported during pregnancy. The patient was a 27-year-old female who presented with 16 weeks of neck pain and numbness in the distal upper extremities when she was 31 weeks pregnant. MRI revealed a mass in the cervical spine. The plan was for delivery at term followed by surgical resection. However, due to progression of symptoms, she underwent emergent Cesarean section. The procedure was performed without complications, but the patient demonstrated quadriplegia post-operatively. She then underwent surgical resection. Final post-operative imaging showed no gross disease. Pathology revealed malignant melanoma. She slowly regained neurologic function with no significant residual deficits. She received post-operative radiotherapy (37.5 Gy in 15 fractions using 3D-CRT) with minimal toxicity. Due to the rarity of primary melanoma of the spinal cord, there are no standardized guidelines for treatment. Presentation during pregnancy adds more complexity. Based on prior reports, primary melanoma of the spinal cord appears to have a better overall prognosis compared to primary cutaneous melanoma with spinal cord metastasis. Surgical resection is the mainstay of treatment. The role for radiotherapy is not clear. As a result, the optimal treatment for these patients should be determined on a case-by-case basis.

Intraoperative Spinal Navigation for the Removal of Intradural Tumors: Technical Notes.

In recent years, spinal surgery has incorporated the many advantages of navigation techniques to facilitate the placement of pedicle screws during osteosynthesis, mainly for degenerative diseases. However, spinal intradural tumors are not clearly visible by intraoperative fluoroscopy or computed tomography scans, thereby making navigation necessary. To evaluate the use of spinal navigation for the removal of intradural and spinal cord tumors using spinal magnetic resonance imaging (MRI) merged with intraoperative 3-dimensional (3-D) fluoro images. After fixing the patient reference frame on the spinous process, the 3-D fluoro images were obtained in the surgical room. Using this image as the reference, the preoperative volumetric MRI images and intraoperative 3-D fluoro images were merged using automated software or manually. From January to July 2016, we performed 10 navigated procedures for intradural spinal tumors by merging MRI and 3-D fluoro images. Nine patients had an intradural extramedullary tumor, 6 had neurinomas, and 3 had meningiomas; 1 patient had an intramedullary spinal cord metastasis. The surgically demonstrated benefits of spinal navigation for the removal of intradural tumors include the decreased risk of surgery at the wrong spinal level, a minimal length of skin incision and muscle strip, and a reduction in bone removal extension. Furthermore, this technique offers the advantage of opening the dura as much as is necessary and, in the case of intrinsic spinal cord tumors, it allows the tumor to be centered. Otherwise, this would not be visible, thus enabling the precise level and the posterior midline sulcus to be determined when performing a mielotomy.

Métastase rachidienne d’un cancer de la prostate

Introduction Prostate cancer is second only to lung cancer as the leading cause of cancer related deaths in men. Although most men with prostate cancer have asymptomatic, indolent disease, central nervous system complications are rare and often occur with advanced metastatic disease. Material and methods We report the case of a 66-year-old man, 3 years after the initial diagnosis of advanced metastatic prostate cancer. Despite endocrine therapy initiated immediately after diagnosis, the patient developed back pain and heaviness of both lower limbs. He developed flaccid paraplegia in five days. The spinal CT scan performed on an emergency basis, showed a large lesion in the T5 and T6 vertebral bodies with extradural compression. A laminectomy T5 T 6 T7 was performed and removal of the neoplasm. Histopathological examination confirmed that it was a spinal cord metastasis from prostate cancer. Conclusion Spinal cord compression occurs in up to 12% of prostate cancer patients and results in devastating morbidity. Combined treatment by laminectomy and radiotherapy seem to be associated with improved neurological function and longer survival.

Lung adenocarcinoma presenting as intramedullary spinal cord metastasis: Case report and review of literature

Intramedullary spinal cord metastasis (IMSCM) is a rare entity which lacks well-defined treatment guidelines, yet sees rising incidence. We report a case of a 67-year-old man who presented with severe neck pain and numbness in his right fourth and fifth digits, and was found to have a C5-7 IMSCM of previously unknown lung adenocarcinoma. He underwent gross total resection of the IMSCM, afatinib, and radiation treatment. He had full reversal of his pain and sensory deficit, and remained ambulatory without any focal neurological deficit. Additionally, we conducted a literature review of original case series of IMSCM published between 1983 and 2016, representing 138 unique cases, and discuss various treatments with a focus on surgical resection and general treatment of stage IV lung adenocarcinoma. 18.75% of cases of IMSCM were an initial presentation of underlying malignancy. Rapidly progressive pain and weakness was the most common presentation, often compromising ambulatory status. Median survival ranged from 3.8 to 11.6 months after treatment in patients who were deceased at time of publication. Treatments included corticosteroids, chemotherapy, various radiotherapies, and surgical resection. Surgical resection was found to greatly improve symptoms and preserve ambulatory status, and was associated with increased survival time up to double that of non-surgical treatments. Most authors recommended surgical resection only in symptomatic patients with reversible deficits, to palliate symptoms and preserve ambulation. IMSCM can herald an underlying malignancy, and surgical resection can preserve ambulatory status and palliate symptoms as well increase survival time in a subset of patients.

Merkel cell carcinoma with intramedullary spinal cord metastasis: a very rare clinical finding.

Key Clinical MessageThis clinical image teaches readers that a rare finding such as intramedullary spinal metastasis could exist even in the rarest tumors. It adds to the literature how it was managed. It also might reflect the improvement of our cancer treatment allowing us to follow patients longer to find those rare findings in rare tumors.

Symptomatic spinal cord metastasis of glioblastoma multiforme

Symptomatic spinal cord metastasis from glioblastoma multiforme (GBM) has rarely been reported in the literature. We report the case of a 27-year-old man that presented with back and bilateral leg pain nine months after the primarydiagnosis of intracranial GBM. A magnetic resonance imaging (MRI) of the lumbar spine showed a L1-L2 tumor that was removed successfully and histopathological examination was consistent with GBM metastasis. Spinal metastasis should be investigated and included in the differential diagnosis if a patient with a previous history of intracranial GBM presentswith spinal symptoms.