Clinical features and natural history of intramedullary spinal cord metastasis

Survival and neurological outcomes following management of intramedullary spinal metastasis patients: a case series with comprehensive review of the literature

Intramedullary spinal cord metastasis (ISCM), though rare, represents a potentially debilitating manifestation of systemic cancer. With emerging advances in cancer care, ISCMs are increasingly being encountered in clinical practice. Herein, we describe one of the larger retrospective single institutional case series on ISCMs, analyze survival and treatment outcomes, and review the literature. All surgically evaluated ISCMs at our institution between 2005 and 2023 were retrospectively reviewed. Demographics, tumor features, treatment, and clinical outcome characteristics were collected. Neurological function was quantified via the Frankel grade and the McCormick score (MCS). The pre- and post-operative Karnofsky performance scores (KPS) were used to assess functional status. Descriptive statistics, univariate analysis, log-rank test, and the Kaplan-Meier survival analysis were performed. A total of 9 patients were included (median age 67 years (range, 26-71); 6 were male). Thoracic and cervical spinal segments were most affected (4 patients each). Six patients (75%) underwent surgical management (1 biopsy and 5 resections), and 3 cases underwent chemoradiation only. Post-operatively, 2 patients had an improvement in their neurological exam with one patient becoming ambulatory after surgery; three patients maintained their neurological exam, and 1 had a decline. There was no statistically significant difference in the pre- and post-operative MCS and median KPS scores in surgically treated patients. Median OS after ISCM diagnosis was 7 months. Absence of brain metastasis, tumor histology (renal and melanoma), cervical/thoracic location, and post-op KPS ≥ 70 showed a trend toward improved overall survival. The incidence of ISCM is increasing, and earlier diagnosis and treatment are considered key for the preservation of neurological function. When patient characteristics are favorable, surgical resection of ISCM can be considered in patients with rapidly progressive neurological deficits. Surgical treatment was not associated with an improvement in overall survival in patients with ISCMs.

Metastatic Lesions of the Brain and Spine

Brain and spinal metastases are common in cancer patients and are associated with significant morbidity and mortality. Continued advancement in the systemic care of cancer has increased the life expectancy of patients, and consequently, the incidence of brain and spine metastasis has increased. There has been an increase in the understanding of oncogenic mutations, and research has also demonstrated spatial and temporal mutations in patients that may drive overall treatment resistance and failure. Combinatory treatments with radiation, surgery, and newer systemic therapies have continued to increase the life expectancy of patients with brain and spine metastases. Given the overall complexity of brain and spine metastases, this chapter aims to give a comprehensive overview and cover important topics concerning brain and spine metastases. This will include the molecular, genetic, radiographic, surgical, and non-surgical treatments of brain and spinal metastases.

Intramedullary pancreatic adenocarcinoma metastasis: The first case in literature

BACKGROUND

Pancreatic cancer is a common gastrointestinal malignancy, and is often associated with a poor prognosis. Although liver is generally seen as a distant metastasis point, it has been shown that it can metastasize to any organ, especially the gastrointestinal tract, and approximately 0.3% of metastases are observed in spinal cord.

CASE DESCRIPTION

We report a 36-year-old woman with a prior history of pancreatic adenocarcinoma who presented to us with a thoracic intramedullary lesion and recent onset of neurological deficits. She underwent surgery with histological confirmation of a diagnosis of metastatic adenocarcinoma.

CONCLUSION

To our knowledge there is no prior report of pure intramedullary spinal cord metastasis from a pancreatic adenocarcinoma in the literature. We report the present patient in view of the rarity of intramedullary spinal cord metastasis and its clinical significance. Although intramedullary metastases are rare, they should be investigated in every patient with malignancy and progressive neurological deficit. While its general prognosis is poor regardless of the type of treatment, early diagnosis and treatment is important in terms of quality of life and survival.

Bilateral Posterolateral Sulcus Approach for the Removal of Spinal Intramedullary Metastatic Adenocarcinoma: A Technical Case Report

Spinal intramedullary metastasis is an extremely rare event that occurs in advanced cancer. The surgical indications for spinal intramedullary metastasis are highly limited because of surgical difficulty and poor prognosis. In this technical case report, we present a rare case of spinal intramedullary metastasis from the lung that recurred late after local radiation to the spinal cord. The patient progressively experienced relapsed buttock pain and developed gait and urination disorders late after treatment for lung cancer. Imaging examinations suggested the recurrence of spinal intramedullary metastasis in the conus medullaris. Systemic examinations revealed no apparent recurrence in other organs, including the primary lung lesions. Gross total resection of the tumor within the conus medullaris was safely performed using the unilateral posterolateral (PLS) approach and by addition of the contralateral PLS approach. To the best of our knowledge, this is the first case in which a spinal intramedullary metastatic tumor was successfully removed using a bilateral PLS approach.

Intramedullary pancreatic adenocarcinoma metastasis: The first case in literature

BACKGROUND

Pancreatic cancer is a common gastrointestinal malignancy, and is often associated with a poor prognosis. Although liver is generally seen as a distant metastasis point, it has been shown that it can metastasize to any organ, especially the gastrointestinal tract, and approximately 0.3% of metastases are observed in spinal cord.

CASE DESCRIPTION

We report a 36-year-old woman with a prior history of pancreatic adenocarcinoma who presented to us with a thoracic intramedullary lesion and recent onset of neurological deficits. She underwent surgery with histological confirmation of a diagnosis of metastatic adenocarcinoma.

CONCLUSION

To our knowledge there is no prior report of pure intramedullary spinal cord metastasis from a pancreatic adenocarcinoma in the literature. We report the present patient in view of the rarity of intramedullary spinal cord metastasis and its clinical significance. Although intramedullary metastases are rare, they should be investigated in every patient with malignancy and progressive neurological deficit. While its general prognosis is poor regardless of the type of treatment, early diagnosis and treatment is important in terms of quality of life and survival.

Intramedullary spinal cord metastasis of gastric cancer

The incidence of intramedullary spinal cord metastasis (ISCM) has been increasing because the overall survival of patients with cancer has improved thanks to recent advanced therapies, such as molecular targeted drugs, anticancer agents, and various irradiation techniques. ISCM from lung and breast cancer is the most common form among cases of ISCM. We report an extremely rare form of ISCM from gastric cancer. This 83-year-old man who had a past medical history of gastric adenocarcinoma presented with acute onset of paraparesis. Spinal magnetic resonance imaging revealed an intramedullary lesion at the upper thoracic level. Due to rapid worsening of his paresis, we decided to perform tumor extirpation. Gross total resection of the tumor was successfully performed. Pathological examination revealed poorly differentiated adenocarcinoma, suggesting the diagnosis of ISCM from gastric cancer. He demonstrated gradual improvement of paraparesis soon after surgery, although his overall survival was limited to about 6 months after surgery. When examining the etiology of acute paraparesis in elderly patients with a past medical history of cancer, ISCM should be considered in the differential diagnosis. The prognosis of ISCM from gastric cancer is still extremely limited. Unfortunately, there is currently no treatment with proven efficacy. Surgery for ISCM from gastric cancer, although a challenging procedure for spine surgeons, should be considered as a therapeutic option in these patients.

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.

Intramedullary-Extramedullary Breast Metastasis to the Caudal Neuraxis Two Decades after Primary Diagnosis: Case Report and Review of the Literature

BACKGROUND

Intramedullary metastases to the caudal neuraxis with exophytic extension to the extramedullary space are rare. We describe the unique case of a patient with locally recurrent breast cancer who developed an intramedullary-extramedullary metastasis to the conus medullaris and cauda equina 22 years after primary diagnosis, the longest interval between primary breast cancer and intramedullary spread to date. We also reviewed the published literature on focal breast metastases to the conus medullaris or cauda equina.

CASE DESCRIPTION

A 66-year-old woman with a history of node-positive estrogen receptor/progesterone receptor-positive, infiltrating ductal carcinoma diagnosed in 1997 and locally recurrent in 2007. Initial treatment included lumpectomy and targeted chemoradiation with mastectomy and hormonal therapy at recurrence. Twelve years later, she developed 6 weeks of bilateral buttock and leg pain without motor or sphincter compromise. Magnetic resonance imaging of the total spine revealed a 2 x 1.7 cm bilobed intradural, intramedullary-extramedullary, homogenously enhancing, T1-and T2-isointense lesion involving the conus medullaris and cauda equina. She underwent subtotal resection of a hormone receptor-positive breast metastasis. Her pain improved postoperatively and she was stable at 5 months.

CONCLUSIONS

We provide evidence that patients who present with symptoms of spinal neurologic disease and a history of hormone receptor-positive breast cancer require high suspicion for metastatic pathology, despite significant time lapse from primary diagnosis. The tumor may involve both the intramedullary and extramedullary space, complicating resection. Symptom relief and quality of life should guide resection of metastatic lesions to the caudal neuraxis.

Intramedullary Spinal Cord Metastases of Malignant Melanoma: A Rare Case Report on Paraplegia in Palliative Care

Rates of malignant melanoma have been increasing in frequency. Studies have shown that up to 46% of patients with melanoma will experience metastases to the central nervous system. Intramedullary spinal cord metastasis of malignant melanoma is rare. In advanced cancers, surgery might not be possible, and radiotherapy with corticotherapy is a viable option. In the following case, a 54-year-old male presented to the clinic with an intramedullary tumor in the D1 region. He was successfully managed with an integrated palliative care approach with concomitant cancer-directed therapy.

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.

Thoracic radiculopathy as initial symptoms of hepatocellular carcinoma: A case report

RATIONALE

Among the patients who complain of neuralgia in the upper extremities, it is very rare to be caused by the first thoracic (T1) spinal nerve dermatome.

PATIENT CONCERNS

A 65-year-old presented with neuropathic pain of the left medial antebrachial cutaneous nerve and the medial brachial cutaneous nerve for 2 months.

DIAGNOSES

Electrodiagnostic study revealed left thoracic radiculopathy mainly involving the T1 nerve root. Cervical spine magnetic resonance imaging revealed a metastatic tumor of T1 vertebral body compressing the left spinal cord and nerve root. After a systemic diagnostic work-up, he was finally diagnosed with primary hepatocellular carcinoma.

INTERVENTIONS

He received transarterial chemoembolization in the liver and radiotherapy to the T1 spine.

OUTCOMES

After radiotherapy, the neuropathic pain was slightly improved.

LESSONS

If the patient is suspected of having thoracic radiculopathy, the physician should consider not only a herniated disc disease but also systemic disease. Because the prevalence of thoracic radiculopathy is very low and there is a high incidence of cancer that can spread to the spine in the elderly.

Intramedullary spinal cord metastasis from thyroid carcinoma: Case report and a systematic pooled analysis of the literature

Intramedullary spinal cord metastasis (ISCM) is rare and occurs most commonly in the setting of advanced malignancy. The optimal management pathways are not well defined and treatment outcomes from contemporary therapies remain variable. We report a case of a 49-year-old woman with known primary papillary thyroid carcinoma, who presented with rapidly progressive clinical features of Brown-Sequard syndrome. A detailed pooled analysis of the literature was conducted to characterise the clinical and demographic features, management options, and expected survival outcomes for cases of ISCM. We secondarily performed a subgroup analysis on the incidence, clinical and management characteristics of thyroid carcinoma ISCM.

The surgical treatment of metastatic spine tumors within the intramedullary compartment

OBJECTIVE Metastasis to the spinal cord is rare, and optimal management of this disease is unclear. The authors investigated this issue by analyzing the results of surgical treatment of spinal intramedullary metastasis (IM) at a major cancer center. METHODS The authors retrospectively reviewed the medical records of 13 patients who underwent surgery for IM. Patients had renal cell carcinoma (n = 4), breast carcinoma (n = 3), melanoma (n = 2), non-small cell lung cancer (n = 1), sarcoma (n = 1), adenoid cystic carcinoma (n = 1), and cervical cancer (n = 1). Cerebrospinal fluid was collected before surgery in 11 patients, and was negative for malignant cells, as was MRI of the neuraxis. Eleven patients presented with neurological function equivalent to Frankel Grade D. RESULTS Radiographic gross-total resection was achieved in 9 patients, and tumor eventually recurred locally in 3 of those 9 (33%). Leptomeningeal disease was diagnosed in 4 patients after surgery. In the immediate postoperative period, neurological function in 6 patients deteriorated to Frankel Grade C. At 2 months, only 2 patients remained at Grade C, 8 were at Grade D, and 1 had improved to Grade E. One patient developed postoperative hematoma resulting in Frankel Grade A. Radiotherapy was delivered in 8 patients postoperatively. The median survival after spine surgery was 6.5 months. Three patients are still living. CONCLUSIONS Surgery was performed as a last option to preserve neurological function in patients with IM. In most patients, neurological function returned during the immediate postoperative period and was preserved for the patients' remaining lifetime. The data suggest that surgery can be effective in preventing further decline in selected patients with progressive neurological deficit.

Regression of an intramedullary spinal cord metastasis with a checkpoint inhibitor: a case report

Intramedullary spinal cord metastasis is an increasingly common diagnosis in patients with cancer largely owing to new imaging techniques and the increase lifespan of patients with malignant tumors. The diagnosis confers significant morbidity and a poor prognosis. Mainstay palliative treatment options include corticosteroids, fractionated radiotherapy and surgery in select cases. In the modern era of immunotherapy for the treatment of several tumor types, the efficacy of these agents against parenchymal CNS tumors remains unanswered. Here, we report a case of regression of an intramedullary spinal cord metastasis with a checkpoint inhibitor.

Multimodality therapy improves survival in intramedullary spinal cord metastasis of lung primary

BACKGROUND

Most metastatic spinal cord lesions are located either in the intradural, extramedullary, or in the epidural compartments. Intramedullary spinal cord metastasis (ISCM) is a rare central nervous system spread of cancer. The aim of this report was to evaluate ISCM in the published literature.

METHODS

A literature review of PubMed from 1960 to 2016 was undertaken for the publications having demographic, clinical, histological, and outcome data.

RESULTS

A total of 59 relevant papers were identified, showing 128 cases of intramedullary metastasis from lung cancer. The incidence of lung cancer as the primary malignancy with intramedullary metastasis was 56%. The median time from diagnosis of primary to intramedullary metastasis was 6months. Survival improved with multimodality therapy compared to monotherapy (4monthsvs. 6.3months) (hazard ratio=0.501; 95% confidence interval, 0.293-0.857).

CONCLUSION

Lung cancer is the predominant cause of intramedullary involvement of the spinal cord. Overall prognosis is poor, although a multimodality approach was associated with improved survival.

Intramedullary spinal cord metastasis from laryngeal carcinoma: case report and review of literature

Laryngeal cancer metastases are relatively rare and mainly affect the lung. The medullary localization remains exceptional. We report the case of a patient followed for operated laryngeal cancer and whose oncologic control revealed a medullary localization. A patient followed for squamous cell carcinoma of the larynx, treated in 2010 by a partial surgery whose endoscopic control at 5 years revealed the presence of right arytenoid edema without suspicious lesions, multiple biopsies were made and which returned negative. A month later, the patient presented a rebel cervical spine pain and a feeling of heaviness of the upper limbs, for which a radiological assessment was done finally objectifying a right hypopharyngeal process and a suspicious right internal jugular lymphadenopathy (biopsy confirmed the squamous type), as well as an intramedullary metastasis. This case is an illustration of an exceptional evolution of this type of cancer and a are metastatic localization difficult to highlight, which leads us to ask the question on the need of simultaneous and systematic radiological and endoscopic control treatment for operated laryngeal cancer.

Neural Axis Metastasis from Metachronous Pulmonary Basaloid Carcinoma Developed after Chemotherapy & Radiation Therapy of Uterine Cervical Carcinoma

Multiple primary or secondary malignancies after anticancer therapy were recently reported to be increasing in frequency. The authors describe a case of metachronous metastatic pulmonary basaloid carcinoma to the central nervous system that was discovered after chemotherapy and radiation therapy for cervical uterine carcinoma. Two different types of cancer developed within some interval. There's the possibility that a secondary pulmonary neoplasm developed after the chemotherapy and radiotherapy conducted as cervical cancer treatment.

A case of long-term survival after multimodal local treatments of intramedullary spinal cord metastasis of squamous cell lung cancer

Intramedullary spinal cord metastasis of non-small cell lung cancer is rare, and it has a short prognosis. We report a 53-year-old man diagnosed with cT4N0M0, stage IIIA squamous cell lung cancer. Ten months after left pneumonectomy (pT4N0M0), an intramedullary spinal cord tumor developed at the axis level. The intramedullary spinal cord tumor was resected, and he was diagnosed with metastatic squamous cell lung cancer. Radiotherapies and another tumor resection were conducted, as he had a good performance status and the discrete lesion was associated with the risk of brain stem compression. Multimodal local treatments for intramedullary spinal cord metastasis caused the tumor to shrink, and he lived for 25 months after the spinal metastasis occurred.

The 100 most cited articles in metastatic spine disease

OBJECTIVE

Despite the growing neurosurgical literature, a subset of pioneering studies have significantly impacted the field of metastatic spine disease. The purpose of this study was to identify and analyze the 100 most frequently cited articles in the field.

METHODS

A keyword search using the Thomson Reuters Web of Science was conducted to identify articles relevant to the field of metastatic spine disease. The results were filtered based on title and abstract analysis to identify the 100 most cited articles. Statistical analysis was used to characterize journal frequency, past and current citations, citation distribution over time, and author frequency.

RESULTS

The total number of citations for the final 100 articles ranged from 74 to 1169. Articles selected for the final list were published between 1940 and 2009. The years in which the greatest numbers of top-100 studies were published were 1990 and 2005, and the greatest number of citations occurred in 2012. The majority of articles were published in the journals Spine (15), Cancer (11), and the Journal of Neurosurgery (9). Forty-four individuals were listed as authors on 2 articles, 9 were listed as authors on 3 articles, and 2 were listed as authors on 4 articles in the top 100 list. The most cited article was the work by Batson (1169 citations) that was published in 1940 and described the role of the vertebral veins in the spread of metastases. The second most cited article was Patchell's 2005 study (594 citations) discussing decompressive resection of spinal cord metastases. The third most cited article was the 1978 study by Gilbert that evaluated treatment of epidural spinal cord compression due to metastatic tumor (560 citations).

CONCLUSIONS

The field of metastatic spine disease has witnessed numerous milestones and so it is increasingly important to recognize studies that have influenced the field. In this bibliographic study the authors identified and analyzed the most influential articles in the field of metastatic spine disease.

BRCA2-positive spinal intramedullary ovarian metastatic disease: case report

BACKGROUND CONTEXT

Ovarian cancer is the fourth leading cause of cancer death in women, but advances in treatment have led to longer survival among these patients. Tied to these advances and increased survival, however, have been new patterns of metastatic spread.

PURPOSE

The authors discuss the management and surgical decision making in patients with intramedullary ovarian metastatic disease using a case illustration and relevant literature.

STUDY DESIGN/SETTING

A case report was used.

METHODS

The authors describe a case of a 59-year-old woman with Breast Cancer gene (BRCA) 2-positive ovarian cancer who developed progressive myelopathy from a T10 to T11 intramedullary metastatic lesion.

RESULTS

The patient underwent a standard open T10-T11 laminectomy for intramedullary tumor resection. Intraoperative ultrasound was used to direct the dural opening over the lesion. After a posterior midline myelotomy, microsurgical dissection revealed the intramedullary tumor with a discolored fibrous capsule, which was carefully dissected off of the spinal tracts, and a gross total resection was achieved. Postoperative magnetic resonance imaging at 6 months demonstrated no evidence of residual or recurrent intramedullary tumor. The patient underwent adjuvant external beam radiation to the thoracic spine but succumbed to her primary disease 1 year after surgery.

CONCLUSION

Although central nervous system involvement of ovarian cancer confers a poor prognosis, patients presenting with a solitary lesion and neurologic deficit may benefit from surgical resection followed by steroids and radiation therapy, especially when tissue diagnosis is necessary.

[Intramedullary spinal cord metastasis from gastric adenocarcinoma: Case report and review of literature]

Intramedullary spinal cord metastases are very rare and usually associated with lung or breast cancer, with gastric origin being exceptional. Their clinical onset tends to be faster than that of primary intramedullary tumours. The most common early symptoms of intramedullary spinal cord metastasis are motor deficit in one or more limbs, pain, sensory loss, and sphincter disturbances. The appearance of a rapidly progressive Brown-Séquard syndrome in an oncology patient should orientate the diagnosis of this condition. The prognosis is very poor, with a median survival of 4 months. However, recent research has shown that surgery could offer a slight benefit in survival and functionality. The case is reported of a 61-year-old man with an intramedullary spinal cord metastasis from a gastric carcinoma, as well as a literature review of this topic. It has been found that this case is the fourth one reported in the literature.

[Intramedullary metastasis of lung adenocarcinoma: about a case]

Les métastases de la moelle épinière sont extrêmement rares. Elles surviennent chez 0,1 à 0,4% des patients cancéreux et représentent 1% de toutes les tumeurs de la colonne vertébrale et 1-3% des tumeurs intramédullaires. Le cancer du poumon est le primitif le plus fréquent. Nous rapportons le cas d'un patient de 51 ans, suivi pour un adénocarcinome pulmonaire et qui après la 1ère cure de chimiothérapie a développé des métastases intramédullaires et cérébrales. Une radiothérapie sur la moelle et le cerveau associée à une corticothérapie par voie générale ont été débutées. Le patient est décédé 3 mois après la survenue des métastases intramédullaires. A travers ce nouveau cas de métastases intarmédullaires d'un adénocarcinome pulmonaire et revue de la littérature, les auteurs insistent sur leur rareté ainsi que sur ses difficultés diagnostiques et thérapeutiques.

Intramedullary conus medullaris metastasis from prostate carcinoma: A case report and review of the literature

Intramedullary spinal cord metastases (ISCMs) are rare and account for 4–8.5% of central nervous system metastases. Only one case of biopsy-proven ISCM due to prostate cancer has previously been reported. The current study presents an additional unique case of a 74-year-old male who developed symptoms from an intramedullary conus medullaris metastasis as the first manifestation of prostate adenocarcinoma. To the best of our knowledge, this scenario is even more rare and has not previously been reported. The tumor was radically resected, followed by androgen blockade treatment. The patient’s neurological deficit significantly improved, with no tumor recurrence during the follow-up period. In addition, the present study provides an overview of the previous literature concerning ISCMs from prostate cancer, and discusses the treatment options.

Intramedullary conus metastasis from carcinoma lung

A 46-year-old male presented with progressive paraparesis and sensory impairment in both lower limbs since 2 months. He had urinary and bowel incontinence. On examination he had flaccid paraplegia with a sensory level at 11^th dorsal vertebral level. Magnetic resonance imaging (MRI) scans of the lumbosacral spine showed an enhancing intramedullary lesion in the conus. The patient underwent excision of the conus mass. Histopathology confirmed the tumor to represent a poorly differentiated metastatic carcinoma from an unknown primary. A positron emission tomography-computed tomography (PET-CT) scan of the whole body revealed hypermetabolic activity in the hilum of the right lung confirmed to be a lung carcinoma on a CT-guided biopsy. The patient was undergoing chemoradiation at 1 month follow-up. The author's literature search has yielded only four other case reports of conus metastasis of which only one is in English literature. The present case report and review of literature are presented.

Intramedullary spinal cord metastasis in renal cell carcinoma: a case report of the surgical experience

Intramedullary spinal cord metastasis (ISCM) from renal cell carcinoma (RCC) is rare manifestation and most of them are treated by adjuvant treatment modalities like radiotherapy. Despite the radio-resistance of RCC itself, focal radiotherapy has been preferred as the first-line treatment modality of ISCM from RCC and only a few cases underwent surgical treatment. We describe a case of ISCM from RCC, which underwent surgical excision and pathologically confirmed. A 44-yr-old man was presented with rapid deterioration of motor weakness during focal radiotherapy for ISCM from RCC. After the surgery for removal of the tumor mass and spinal cord decompression, his motor power was dramatically improved to ambulate by himself. We report the first published Korean case of ISCM from RCC confirmed pathologically and describe our surgical experience and his clinical characteristics.

Intramedullary spinal cord metastases from breast cancer: detection with (18)F-FDG PET/CT

A 35-year-old woman, already treated with surgery, chemotherapy, and radiotherapy for a ductal carcinoma of the left breast, underwent an ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) scan for an increase of the serum markers carcinoembryonic antigen (CEA) and cancer antigen 15.3 (CA15.3). The scan showed multiple FDG-avid lesions in the liver and bone. The images also detected two areas of uptake in the dorsal and lumbar spinal cord, which were suspicious for metastases; magnetic resonance imaging (MRI) confirmed these lesions.

Complete response of 7 years' duration after chemoradiotherapy followed by gefitinib in a patient with intramedullary spinal cord metastasis from lung adenocarcinoma

Intramedullary spinal cord metastasis is a rare but serious complication which causes rapid progression of neurological deficits. Here we report a 35-year-old man presenting with increasing leg pain and gait disturbance, 8 months after surgery for lung adenocarcinoma. Spinal magnetic resonance imaging revealed an intramedullary tumor at the Th7/8 level. Radiotherapy at 35 Gy resulted in transient symptomatic improvement, but during chemotherapy with vinorelbine and cisplatin, symptoms worsened again. Gefitinib was then administered; the patient improved after 2 weeks and has now maintained a complete response for 7 years.

Intramedullary spinal cord metastasis in a patient with colon cancer: a case report

INTRODUCTION

Intramedullary spinal cord metastasis (ISCM) is both a rare and devastating event, since it is clinically evident in 0.1-0.9% of cancer patients and the mortality rate at 3-4 months is 80%.

MATERIALS AND METHODS

We present the case of a woman with colon cancer who developed ISCM while on chemotherapy for metastatic disease. The patient presented with paralysis of both legs, weakness in the upper arms, and urinary retention.

RESULTS

The diagnosis of ISCM at the level of C6-C7 was made with magnetic resonance imaging of the whole spine. Due to the fact that the patient had an established lower limb paralysis and a poor overall clinical status, external beam radiotherapy (RT) was administered, achieving stabilization of symptoms.

CONCLUSIONS

ISCM should be diagnosed and managed as early as possible, since this may result in improvement of neurological deficits. RT is the treatment of choice in most cases, with surgery reserved for selected patients. Recent published data suggest that surgery may result in an improved survival. However, no firm recommendations can be made due to the lack of controlled comparative clinical trials.

Metachronous brain and intramedullary spinal cord metastases from nonsmall-cell lung cancer: a case report

A 44-year-old man had a brain tumor secondary to lung adenocarcinoma and underwent craniectomy to remove the brain tumor. After postoperative whole-brain radiation therapy, he underwent pneumonectomy followed by chemotherapy, mediastinal radiotherapy, and target therapy for lung cancer. Thirty-six months after the initial brain surgery, he suffered from neck pain and right upper limb numbness that rapidly progressed to upper extremity weakness and paralysis in 2 months. Magnetic resonance imaging demonstrated an intramedullary spinal cord lesion at the C4 level. Laminectomy and gross intramedullary tumor removal were performed. The patient's neurological function improved after the operation. Nevertheless, 4 months after the intramedullary tumor removal, he began to show multiple metastases. Unfortunately, the patient died from respiratory failure 8 months after diagnosis with intramedullary spinal cord metastasis. In this case, early diagnosis and aggressive surgical treatment combined with postoperative radiotherapy and chemotherapy might have provided this patient with a prolonged survival and better quality of life.

Intramedullary spinal cord metastases: a 20-year institutional experience with a comprehensive literature review

OBJECTIVES

To review previous reports as well as our institutional experience to address the issues regarding patient management and also to assess the predisposing factors that might influence outcome and survival.

METHODS

We undertook a 20-year (1989-2009) retrospective study of a series of eight patients diagnosed with intramedullary spinal cord metastases (ISCMs) in our institute. We further reviewed 293 cases of ISCMs reported in the English literature since 1960. Characteristics regarding the site of the primary cancer, location of ISCM, the presence of other metastases, presenting neurological symptoms/signs, duration of symptoms, and the time interval from diagnosis of the primary tumor to ISCM were pooled. We analyzed the different treatment approaches, the functional outcome, and the factors influencing survival.

RESULTS

Lung and breast cancers appear to be the most frequent source of ISCM with cervical, thoracic, and lumbar spine being equally affected. Motor weakness predominates as the commonest symptom at presentation, followed by pain and sensory disturbance. At diagnosis, most patients with ISCM have a known primary cancer often associated with cerebral and other systemic metastases. Overall survival of ISCM is poor (median: 4 months from the time of diagnosis). Survival in surgical patients is 6 months, compared with 5 months in those conservatively managed. Clinical improvement was observed in more than one-half of those treated surgically, whereas neurological status was maintained in most patients treated conservatively.

CONCLUSION

ISCM is an unusual site for metastasis. Regardless of the treatment, its prognosis is generally poor as its presence often signifies end-stage cancer. However, with early diagnosis and appropriate treatment, selected patients may benefit from improved neurological outcome and quality of life.

Survival and functional outcome after surgical resection of intramedullary spinal cord metastases

OBJECTIVE

Intramedullary spinal cord metastasis (ISCM) is a rare manifestation of systemic cancer and data about the optimal management of these lesions are lacking. To clarify the role of surgery, we investigated survival and neurological outcomes after surgical resection of ISCMs.

METHODS

Between 2003 and 2010, we surgically treated 10 ISCMs in 9 patients. For each patient, we retrospectively collected the following data: demographic variables, history of prior cancer, site of primary cancer, extent of cancer on presentation, degree of resection, preoperative and postoperative spinal cord impairment (American Spinal Injury Association [ASIA] grade), and postoperative survival. We investigated the relationship between these variables, overall survival, and preservation of function.

RESULTS

Eight ISCMs were treated with gross total resection and two were treated with subtotal resection. Overall postoperative survival was 6.4 ± 9.4 months (mean ± standard deviation), with one patient still alive at last follow-up. Patients with a diagnosis of melanoma had higher mean survival than those with nonmelanoma histology (20.5 ± 13.4 vs. 2.4 ± 1.7 months, P < 0.01). Degree of resection, number of organ systems affected, ambulatory status, and ASIA grade pre operatively or postoperatively, were not significantly associated with survival. Of the nine patients, seven (78%) demonstrated no change in ASIA grade postoperatively, one (11%) improved, and one patient (11%) deteriorated. All patients who were ambulatory preoperatively remained ambulatory postoperatively and at last follow-up.

CONCLUSIONS

Although ISCM is associated with poor prognosis, survival appears to be greater in patients with melanoma. Surgical resection does not appear to significantly lengthen survival but may be indicated to preserve ambulatory status in symptomatic patients.

Intramedullary spinal cord metastasis from colonic carcinoma presenting as Brown-Séquard syndrome: a case report

Introduction

Intramedullary spinal cord metastasis is very rare. The majority are discovered incidentally during autopsy. Most symptomatic patients present with rapidly progressive neurological deficits and require immediate examination. Few patients demonstrate features of Brown-Séquard syndrome. Radiotherapy is the gold-standard of therapy for Intramedullary spinal cord metastasis. The overall prognosis is poor and the mortality rate is very high. We present what is, to the best of our knowledge, the first case of Intramedullary spinal cord metastasis of colorectal carcinoma presenting as Brown-Séquard syndrome.

Case presentation

We present the case of a 71-year-old Caucasian man with colonic adenocarcinoma who developed Intramedullary spinal cord metastasis and showed features of Brown-Séquard syndrome, which is an uncommon presentation of Intramedullary spinal cord metastasis.

Conclusion

This patient had an Intramedullary spinal cord metastasis, a rare form of metastatic disease, secondary to colonic carcinoma. The metastasis manifested clinically as Brown-Séquard syndrome, itself a very uncommon condition. This syndrome is rarely caused by intramedullary tumors. This unique case has particular interest in medicine, especially for the specialties of medical, surgical and radiation oncology. We hope that it will add more information to the literature about these entities.

Intramedullary spinal cord metastases in breast cancer are associated with improved longer-term systemic control

Intramedullary spinal cord metastases are a rare complication of malignancy, associated with a poor prognosis. We describe three cases with extensively pretreated advanced breast cancer developing intramedullary spinal cord metastases two of whom were receiving trastuzumab, one of whom was a male. As therapeutic advances increase overall survival for patients with metastatic breast cancer, patterns of disease are changing with improved systemic control. The incidence of intramedullary spinal cord metastases is likely to increase but management strategies remain unclear.

Two separate episodes of intramedullary spinal cord metastasis in a single patient with breast cancer

Intramedullary spinal cord metastases are very rare. Patients with breast cancer as the primary source of intramedullary spinal cord metastases tend to do better than other types of cancer. We report the very unusual case of a woman with breast cancer who had two separate episodes of intramedullary spinal cord metastasis.

Diagnosis and management of metastatic spine disease. A review

With continued growth of the elderly population and improvements in cancer therapies, the number of patients with symptomatic spinal metastases is likely to increase, and this is a condition that commonly leads to debilitating neurological dysfunction and pain. Advancements in surgical techniques of resection and spinal reconstruction, improvements in clinical outcomes following various treatment modalities, generally increased overall survival in patients with metastatic spine disease, and a recent randomized trial by Patchell and colleagues demonstrating the superiority of a combined surgical/radiotherapeutic approach over a radiotherapy-only strategy have led many to suggest increasingly aggressive interventions for patients with such lesions. Optimal management of spinal metastases encompasses numerous medical specialties, including neurosurgery, orthopedic surgery, medical and radiation oncology, radiology, and rehabilitation medicine. In this review, the clinical presentation, diagnosis, and management of spinal metastatic disease are discussed. Ultimately, the goal of treatment in patients with spinal metastases remains palliative, and clinical judgment is required to select the appropriate patients for surgical intervention.

Coexistent intramedullary spinal cord and choroidal metastases in ovarian cancer

Involvement of intramedullary spinal cord and the choroid by ovarian cancer is rare, and coexistence of metastases at these sites is extremely rare and has never been reported. This condition rapidly progresses to a neurological emergency; however, an efficient standard treatment method is not available for this rare condition. The case presented herein is of a female patient with stage II, poorly differentiated serous cystadenocarcinoma of the ovary. She presented with blindness and other neurologic complaints during the course of treatment for a recurrence at 50 months after the primary surgical treatment for the tumor. Magnetic resonance imaging (MRI) revealed intramedullary spinal cord metastasis and choroidal metastasis, coexisting with multiple brain metastases and intra-abdominal lesions. Neurological emergency was prevented by administering whole-brain irradiation therapy followed by systemic chemotherapy. Early diagnosis and multidisciplinary treatment, including radiotherapy and chemotherapy, may offer good palliation for such unusual metastases of ovarian cancer.

Metastatic renal cell carcinoma initially presented with an intramedullary spinal cord lesion: a case report

Introduction

One of the rare manifestations of systemic neoplasia is intramedullary spinal cord metastasis that causes serious diagnostic and therapeutic dilemma. It has been very rarely reported as the initial manifestation of carcinoma. This is report of a metastatic renal cell carcinoma initially presented with intramedullary spinal cord lesion, to our knowledge there are few similar reports in literature.

Case presentation

We report a 51-year-old Iranian woman who presented with back pain and paraparesis. MR imaging study of her spine showed an enhancing cystic lesion at the level of conus medullaris. Despite detailed investigation, no specific aetiology was found till a bone scan obtained to evaluate an agonizing pain on the dorsum of the left hand revealed photon deficient area within the left kidney in addition to oseoblastic bony lesions. After thorough imaging investigation she underwent radical nephrectomy which confirmed renal cell carcinoma.

Conclusion

Considering the prevalence of cancer, it is imperative that clinicians be mindful of occult carcinoma as the cause of suspicious intramedullary spinal cord lesion.

Lung cancer single intramedullary metastasis vs delayed radionecrosis. A case report

Intramedullary metastases are rare, accounting for 0.9-5% of spinal metastases. Radiation myelopathy is considered one of the most distressing complications of radiotherapy. In both cases symptoms are aspecific, and there are no characteristic neuroradiologic findings. We describe a case of single intramedullary metastasis from lung microcytoma in a 55-year-old man with a history of malignancy, treated by radiotherapy five years previously. The patient returned to our observation complaining of pain and paraesthesia in the left C7 area. Spinal MRI and rachicentesis findings were aspecific. Ten days later a new MRI showed that the lesion size had increased, and neoplastic cells were found in CSF. Intramedullary metastases are extremely rare, accounting for 0.1-0.4% of all CNS tumors. The risk of developing delayed radionecrosis varies with the total dose administered. In both cases diagnosis is histological, while contrast-enhanced MRI is highly sensitive and specific in identifying and characterizing the lesion. In case of metastatic lesions the prognosis is unfavorable. Differential diagnosis is important because it has a strong effect on patient management.