Intramedullary metastasis in breast cancer – A comprehensive literature review

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.

Effect of MRI on breast tissue expanders and recommendations for safe use

INTRODUCTION

Ferromagnetic port-containing breast tissue expanders are currently labeled MRI-unsafe because of the presumption that magnets should not enter the machine. However, designating these devices as MRI-unsafe can lead to unnecessary procedures or suboptimal imaging choices. This study provides an ex vivo analysis of how breast tissue expanders behave when subjected to strong magnetic fields to determine which variables might affect clinical risk.

METHODS

Three different brands of tissue expanders were evaluated in three MRI environments. Translational force was determined using the deflection angle method. Torque on empty, saline-filled, and air-filled expanders was evaluated on a 0-4 scale. Magnetic field was measured using a gaussmeter. The weight required to prevent displacement of the expanders was determined for both air- and saline-filled expanders. Temperature over time was measured using an alcohol thermometer.

RESULTS

Magnetic field strength, deflection angle, and torque were the greatest in 3T MRI environments and varied by device manufacturer (Sientra > Mentor > Allergan). Saline-filled expanders required 240 mL and air-filled required 360 mL volume to make the torque undetectable, and the effect of torque could be mitigated with prone positioning. A weight of 120 g was required to prevent displacement of a saline-filled tissue expander and 870 g for an empty expander. There were no appreciable changes in temperature.

CONCLUSIONS

Previously described risks may be reduced by using a 1.5T MRI, device selection, filling expanders with saline, and prone positioning. MRI can be considered in patients with breast tissue expanders when appropriate peri-procedural choices have been made so that the benefits of undergoing MRI outweigh the risks.

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 metastases: an increasingly common diagnosis

OBJECT Intramedullary spinal cord metastases (ISCM) represent a small proportion of intramedullary tumors. However, with the lifespans of patients with malignant tumors increasing, incidents of ISCM are on the rise. Due to threateningly severe disabilities in patients, accompanied by limited life expectancy, every attempt should be made to treat these tumors the same way as metastases elsewhere in the CNS, with the goal of complete removal of the ISCM and preservation of neurological functions. The object of this study is to retrospectively analyze the experiences of 22 patients who were surgically treated for ISCM over a 22-year period. METHODS Hospital charts of 22 patients, who were surgically treated for ISCM between 1992 and 2014, were reviewed retrospectively. Demographic data, histopathological diagnoses of primary cancer, chronological sequence of the disease, and neurological status using the simplified McCormick functional classification were collected and reanalyzed. RESULTS The most frequent histology was metastasis of lung cancer, followed by brain and breast cancers. The time span from primary cancer diagnosis to the development of symptomatic spinal metastases ranged from 0 to 285 months, with a mean interval of 38 months. The leading presenting sign was dysesthesia (77% of the population), followed by paresis (68%). Only 5 patients (23%) showed urinary retention. Initial performance status represented by the McCormick Scale was on average 2.47. Total or near-total removal was achieved in 87% of cases. Compared with the clinical status 1-2 days after surgery, there was an improvement in the McCormick Scale grade at the last follow-up from 2.47 to 2.12 (p = 0.009). Likewise, an improvement was detected when comparing the preoperative status with the last follow-up (from 2.45 to 2.12; p = 0.029). The mean survival time after surgery was 11.6 months. CONCLUSIONS These results suggest that surgery for intramedullary metastases-with all of the challenges of a rare and potentially risky procedure-can be beneficial to patients with advanced stages of cancer. Surgery can be performed with minimal new morbidity and results in maintaining neurological performance status.

Spinal intramedullary metastasis of breast cancer

Objective. Breast cancer accounts for approximately one-third of all cancers in females. Approximately 8.5 % of all central nervous system metastases are located in the spinal cord. These patients have rapidly progressing neurological deficits and require immediate examination. The aim of surgery is decompression of neural tissue and histological evaluation of the tumor. In this paper, we present a case of breast cancer metastasis in thoracic spinal intramedullary area which had been partially excised and then given adjuvant radiotherapy. Case. A 43-year-old female patient with breast cancer for 8 years was admitted to our hospital with complaints of weakness in both legs. Eight years ago, she received chemotherapy and radiotherapy. On her neurological examination, she had paraparesis (left lower extremity: 2/5, right lower extremity: 3/5) and urinary incontinence. Spinal MRI revealed a gadolinium enhancing intramedullary lesion. Pathologic examination of the lesion was consistent with breast carcinoma metastasis. The patient has been taken into radiotherapy. Conclusion. Spinal intramedullary metastasis of breast cancer is an extremely rare situation, but it has a high morbidity and mortality rate. Microsurgical resection is necessary for preservation or amelioration of neurological state and also for increased life expectancy and quality.

Brain metastasis from ovarian cancer: a systematic review

To review the existing literature on brain metastasis (BM) from ovarian cancer and to assess the frequency, anatomical, clinical and paraclinical information and factors associated with prognosis. Ovarian cancer is a rare cause of brain metastasis with a recently reported increasing prevalence. Progressive neurologic disability and poor prognosis is common. A comprehensive review on this subject has not been published previously. This systematic literature search used the Pubmed and Yale library. A total of 66 publications were found, 57 of which were used representing 591 patients with BM from ovarian cancer. The median age of the patients was 54.3 years (range 20-81). A majority of patients (57.3 %) had multiple brain lesions. The location of the lesion was cerebellar (30 %), frontal (20 %), parietal (18 %) and occipital (11 %). Extracranial metastasis was present in 49.8 % of cases involving liver (20.7 %), lung (20.4 %), lymph nodes (12.6 %), bones (6.6 %) and pelvic organs (4.3 %). The most common symptoms were weakness (16 %), seizures (11 %), altered mentality (11 %) visual disturbances (9 %) and dizziness (8 %). The interval from diagnosis of breast cancer to BM ranged from 0 to 133 months (median 24 months) and median survival was 8.2 months. Local radiation, surgical resection, stereotactic radiosurgery and medical therapy were used. Factors that significantly increased the survival were younger age at the time of ovarian cancer diagnosis and brain metastasis diagnosis, lower grade of the primary tumor, higher KPS score and multimodality treatment for the brain metastases. Ovarian cancer is a rare cause of brain metastasis. Development of brain metastasis among older patients and lower KPS score correlate with less favorable prognosis. The more prolonged survival after using multimodality treatment for brain metastasis is important due to potential impact on management of brain metastasis in future.