Intramedullary spinal cord metastasis as a first manifestation of a renal cell carcinoma: report of a case and review of the literature

Intramedullary spinal cord metastasis of clear cell renal carcinoma in a Von Hippel–Lindau patient

Background:

Intramedullary spinal cord metastasis is uncommon and represents only 0.6% of all spinal tumors. Renal cell carcinoma is even less frequent in this group than in lung and breast cancer. Patients with Von Hippel– Lindau disease (VHLd) present spinal hemangioblastoma more frequently.

Case Description:

A 59-year-old female patient presented with medullary syndrome. There was a previous history of VHLd, with a cerebellar hemangioblastoma resection years ago. The radiological investigation showed a cervical intramedullary solid-cystic lesion. The patient has submitted a tumor resection, and a pathological and immunohistochemistry study confirmed clear cell renal carcinoma metastasis.

Conclusion:

In patients with VHLd, the presence of an intramedullary solid-cystic lesion may not represent always a hemangioblastoma. Other diagnostic possibilities must be evaluated, despite being epidemiologically less frequent. Inside the group of patients with VHLd, only a previous case of intramedullary spinal cord renal cell carcinoma was reported in the literature.

The Role of Surgery in Spinal Intradural Metastases from Renal Cell Carcinoma: A Literature Review

BACKGROUND

Due to the few reported cases of spinal intradural metastases from renal cell carcinoma (RCC), there is no unanimous consensus on the best treatment strategy, including the role of surgery.

METHODS

A wide and accurate literature review up to January 2022 has disclosed only 51 cases of spinal intradural metastases from RCC. Patients with extramedullary (19) and those with intramedullary (32) localization have been separately considered and compared. Demographics, clinical, pathological, management, and outcome features have been analyzed.

RESULTS

Extramedullary lesions more frequently showed the involvement of the lumbar spine, low back pain, and solitary metastasis at diagnosis. Conversely, the intramedullary lesions were most often detected in association with multiple localizations of disease, mainly in the brain. Surgery resulted in improvement of clinical symptoms in both groups.

CONCLUSION

Several factors affect the prognosis of metastatic RCC. The surgical removal of spinal metastases resulted in pain relief and the arresting of neurological deficit progression, improving the quality of life and overall survival of the patient. Considering the relative radioresistant nature of the RCC, the surgical treatment of the metastasis is a valid option even if it is subtotal, with a consequent increased risk of recurrence, and/or a nerve root should be sacrificed.

Intradural extramedullary spinal metastasis of renal cell carcinoma: illustrative case report and comprehensive review of the literature

STUDY DESIGN

Literature review.

OBJECTIVES

Intradural metastasis of renal cell carcinoma (RCC) has rarely been reported. We describe a case of an intradural extramedullary spinal metastasis to the cervical spine in a 68-year-old male treated for RCC 22 years prior. Additionally, we review the known reports of both intradural extramedullary and intramedullary of RCC.

METHODS

Case report and literature review.

RESULTS

A 68-year-old male with a history of right-sided nephrectomy for RCC preformed 22 years prior now presents with a MRI of the cervical spine showing a 1.5 cm contrast enhancing intradural extramedullary lesion at the level of C3-C4. Surgical resection of the lesion was performed. The tumor's histological and immunohistochemical profile was consistent with metastatic RCC. There are 18 reported cases of intradural extramedullary metastases of sporadic RCC. The average age at diagnosis was 61.6 ± 14.3 years. The interval from diagnosis of primary RCC to diagnosis metastasis ranged from 0 to 264 months (mean 46.8 ± 74.0 months). Sixteen cases of intramedullary renal cell carcinoma metastasis are reported. The average age at time of diagnosis was 53.6 ± 10.2 years. The interval from diagnosis of primary RCC to diagnosis of metastasis ranged from 0 to 180 months (mean 20.9 ± 53.4 months).

CONCLUSION

The 22-year interval from diagnosis of primary RCC to intradural metastasis is the longest latency reported in the literature. Intramedullary metastases tend to have a younger age at diagnosis and shorter interval from diagnosis of primary RCC compared to extramedullary lesions.

Deceptive Features on Surveillance Imaging of Intraneural Metastatic Deposits in Metastatic Renal Cell Cancer

BACKGROUND

Spinal renal cell metastases are a common insidious pathological manifestation of the oncological process but less common are intramedullary and intraneural spinal metastases. The differential diagnosis of such pathological features can be difficult in the presence of conflicting radiological evidence.

CASE DESCRIPTION

In the present case report, we have detailed the clinical, diagnostic, surgical, and therapeutic progression of a 54-year-old man diagnosed with metastatic renal cell carcinoma. After the initial presentation and treatment, he had presented with symptomatic right lower limb radiculopathy. Magnetic resonance imaging identified a well-defined cystic lesion expanding in the right exit foramina at L5-S1, suggestive of a benign schwannoma. After a multidisciplinary review, he was treated symptomatically and imaging surveillance for a 19-month period, with static lesion findings. Failure of symptomatic management resulted in operative intervention and subsequent histological diagnosis of the metastatic deposit.

CONCLUSION

To the best of our knowledge, the present report is the first documented case of intraneural metastatic deposits from renal cell carcinoma that showed benign radiographic features and demonstrated a stable appearance on surveillance imaging studies for a significant period. These findings suggest that clinicians should have a high index of suspicion for a metastatic process in symptomatic patients with a known renal cell cancer regardless of the lesion's radiographic or temporal characteristics.

Intramedullary craniovertebral junction metastasis leading to the diagnosis of underlying renal cell carcinoma

Background:

Intramedullary spinal cord metastases represent 4–8.5% of the central nervous system metastases and affect only 0.1–0.4% of all patients. Those originating from renal cell carcinoma (RCC) are extremely rare. Of the eight patients described in the literature with metastatic RCC and intramedullary cord lesion, only five were found in the cervical spine. Here, the authors add a 6^th case involving an RCC intramedullary metastasis at the C1–C2 level.

Case Description:

A 78-year-old male patient presented with intermittent cervicalgia of 5 months duration accompanied by few weeks of a progressive severe right hemiparesis, up to hemiplegia. The magnetic resonance imaging (MRI) examination revealed an intramedullary expansive lesion measuring 10 mm×15 mm at the C1–C2 level; it readily enhanced with contrast. A total body computed tomography (CT) scan documented an 85 mm mass involving the right kidney, extending to the ipsilateral adrenal gland, and posteriorly infiltrating the ipsilateral psoas muscle. The subsequent CT-guided fine-needle biopsy confirmed the diagnosis of an RCC (Stage IV). The patient next underwent total surgical total removal of the C1–C2 intramedullary mass, following which he exhibited a slight motor improvement, with the right hemiparesis (2/5). He died after 14 months due to global RCC tumor progression.

Conclusion:

The present case highlights that a patient without a prior known diagnosis of RCC may present with an intramedullary C1–C2 metastasis. In such cases, global staging is critical to determine whether primary lesion resection versus excision of metastases (e.g., in this case, the C1–C2 intramedullary tumor) are warranted.

Intramedullary Spinal Metastatic Renal Cell Carcinoma: Systematic Review of Disease Presentation, Treatment, and Prognosis with Case Illustration

OBJECTIVE

Renal cell carcinoma (RCC) metastases to the intramedullary spinal cord carry a grim prognosis. The purpose of this review is to provide the reader with a comprehensive and systematic review of the current literature, and to present an illustrative case that would aid in the future management of similar scenarios.

METHODS

A systematic review of the literature using the PubMed electronic database was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only human clinical reports of intramedullary RCC metastasis were included. We also present an illustrative case that was treated at our institution.

RESULTS

We identified 23 reports with a total of 31 patients. Of the tumors, 47% were located at the cervical level. Brain metastases were present in 41% of cases. Limb weakness (72%), urinary incontinence (41%), dysesthesia (47%), and localized spinal pain (38%) were the most frequently reported symptoms. Surgical resection alone was used in 34% of cases, followed by a combination of surgery and radiotherapy (31%), and radiotherapy alone (25%). Spinal metastases were detected an average of 32.1 months after the diagnosis of RCC, and mean patient survival after that was 8 months (range, 0-65 months). Reported survival after radiotherapy appeared to be the longest (11.2 months) compared with surgery (9.1 months) and combination therapy (5 months).

CONCLUSIONS

Intramedullary spinal metastatic RCC is a rare entity with debilitating neurologic potential. Survival appears to be affected by the treatment method but is also likely influenced by the stage of discovery of the disease.

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.

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.

A case of an anaplastic meningioma metastasizing to the mediastinal lymph nodes

CONTEXT

Grade II and III (World Health Organization classification) meningiomas rarely develop in the spinal cord. However, we experienced a case with an anaplastic meningioma that developed in the spinal cord at the cervicothoracic junction and metastasized to the mediastinal lymph nodes. No such cases have previously been reported.

FINDINGS

The patient was a 68-year-old man who developed back pain that did not affect his daily living. He developed left lower limb paralysis, and was admitted after magnetic resonance imaging (MRI) revealed an intramedullary tumor at the level of cervical vertebra 7 and thoracic vertebra 1. Positron emission tomography revealed tracer uptake in the intramedullary tumor and the mediastinal lymph nodes, suggesting a metastatic spinal cord tumor or malignant lymphoma. A lymph node biopsy was then performed. Although the tumor was highly malignant, its primary site was not identified. Detailed examinations by several other departments revealed no abnormalities. On hospital day 30, his left lower limb paralysis deteriorated, and MRI revealed that the tumor had grown. Thus, laminaplasty, laminectomy, and tumor resection were performed. The tumor was an anaplastic meningioma that resembled mediastinal lymph node tissue, and other tumor lesions were not found. These findings suggested that an anaplastic meningioma had metastasized to the mediastinal lymph nodes. The patient did not respond to radiotherapy, and he was transferred to another hospital.

CONCLUSION

In cases of intramedullary spinal tumors with metastasis without other potential primary tumor lesions, early diagnosis and treatment should be performed while considering anaplastic meningioma.

Metastatic renal cell carcinoma initially presented with a longitudinally extensive spinal cord lesion on MRI

A 48-year old male patient developed numbness in the lower half of the body 5 months after the curative operation of left renal cell carcinoma. Neurological examinations revealed the sensory disturbance below the T10 dermatome. A sagittal T2WI of the spinal MRI demonstrated a longitudinally extensive spinal cord lesion (LESCL) ranging from the C7 to L1 vertebral level. The neurological deficits rapidly deteriorated to paraplegia with bladder bowel disturbance. The high dose steroid pulse therapy showed temporary effect. The Gd enhanced T1WI of the spinal MRI taken on the 24th hospital day demonstrated a solitary intramedullary mass in the T8-9 level with ring enhancement, and a subsequent total resection of the tumor was performed. The histopathological studies of the tumor lead to the diagnosis of intramedullary spinal cord metastasis of the renal cell carcinoma. The post-operative T2WI of the spinal MRI revealed disappearance of the longitudinally extensive lesion. On the 112 hospital day, he was discharged with ambulatory aid. While solitary intramedullary spinal cord metastasis of renal cell carcinoma is quite rare, it should be suspected when the LESCL is revealed on a spinal MRI, even after the curative operation of the primary tumor.

Neuroimaging of spine tumors

Intramedullary, intradural/extramedullary, and extradural spine tumors comprise a wide range of neoplasms with an even wider range of clinical symptoms and prognostic features. Magnetic resonance imaging (MRI), commonly used to evaluate the spine in patients presenting with pain, can further characterize lesions that may be encountered on other imaging studies, such as bone scintigraphy or computed tomography (CT). The advantage of the MRI is its multiplane capabilities, superior contrast agent resolution, and flexible protocols that play an important role in assessing tumor location, extent in directing biopsy, in planning proper therapy, and in evaluating therapeutic results. A multimodality approach can be used to fully characterize the lesion and the combination of information obtained from the different modalities usually narrows the diagnostic possibilities significantly. The diagnosis of spinal tumors is based on patient age, topographic features of the tumor, and lesion pattern, as seen at CT and MRI. The shift to high-end imaging incorporating diffusion-weighted imaging, diffusion tensor imaging, magnetic resonance spectroscopy, whole-body short tau inversion recovery, positron emission tomography, intraoperative and high-field MRI as part of the mainstream clinical imaging protocol has provided neurologists, neuro-oncologists, and neurosurgeons a window of opportunity to assess the biologic behavior of spine neoplasms. This chapter reviews neuroimaging of spine tumors, primary and secondary, discussing routine and newer modalities that can reduce the significant morbidity associated with these neoplasms.

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.

Intradural cauda equina metastasis of renal cell carcinoma: a case report with literature review of 10 cases

STUDY DESIGN

Case report with literature review.

OBJECTIVE

To describe a rare case of intradural spinal metastasis from renal cell carcinoma (RCC) spread to the cauda equina, and to discuss the clinical features of metastatic RCC in the cauda equina from the data available in the literature.

SUMMARY OF BACKGROUND DATA

Intradural spinal metastasis is rare, representing 6% of all spinal metastasis. Indeed, intradural metastasis from a RCC to the cauda equina is extremely rare with previously only 9 case reports.

METHODS

A 68-year-old male presented with a 2-month history of worsening lower back pain radiating to both legs. The patient had undergone nephrectomy for the treatment of the clear cell RCC 16 years before admission. Magnetic resonance imaging showed a well-defined intradural extramedullary mass in the cauda equina at T12 to L1.

RESULTS

The pathological examination displayed metastatic clear cell RCC. Additional imaging studies showed no metastatic in other locations. The patient was discharged without neurological deficit and pain after the operation, and maintained an optimal condition for 2 years.

CONCLUSION

When a lesion of the cauda equina presents, intradural metastasis should be in the differential diagnosis in patients who had been previously treated for RCC although any other metastatic lesion was not observed.

LEVEL OF EVIDENCE

N/A.

Surgical treatment options and management strategies of metastatic renal cell carcinoma to the lumbar spinal nerve roots

Spinal nerve root metastasis of renal cell carcinoma is a rare occurrence. In addition to treatment of the primary lesion, surgical resection of the nerve root metastasis, occasionally with sacrifice of the involved nerve, is the accepted standard of treatment. Resection often resolves presenting motor and pain symptoms due to relief of neural compression. We describe two patients with nerve root metastasis of renal cell carcinoma and their management. While locally advanced and metastatic renal cell carcinoma has been shown to be chemo- and radio-resistant, immunotherapy is a promising treatment. Given the high prevalence of systemic disease in patients with intradural metastases, systemic (and possibly intracranial) imaging can be used to identify other potential areas of disease.

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.

Isolated solitary intramedullary spinal cord metastasis presenting as the first manifestation of small-cell lung cancer: report of a rare case

Background. Intramedullary spinal cord metastases presenting as the first manifestation of malignancies are extremely rare lesions. Case Description. The authors report a 74-year-old woman who presented with an isolated intramedullary spinal cord metastasis which presents as first manifestation of malignancy without central nervous system and/or other organ involvement. She went under surgery, and after histopathological evaluation, primary focus was determined in lung in positron emission tomography. She is still alive after 9 months since the first diagnosis of primary focus. Conclusion. In patients with solitary intramedullary lesion in the spinal magnetic resonance imaging, whole-body investigation might help for diagnosis of primary focus and approach to treatment.

The occult nature of intramedullary spinal cord metastases from renal cell carcinoma

Renal cell carcinomas (RCC) are characterised by a tendency to metastasise widely, often while remaining occult. Intramedullary spinal cord metastases (ISCM) from RCC may be the presenting feature of the disease or present at any time in the disease course. This case report discusses an ISCM from RCC which became manifested at the time of resection of the primary tumour. We review the literature published on ISCM from RCC from 1990 to date comparing disease characteristics and presentations.

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.

Intramedullary spinal cord metastases: review of the literature

AIMS

To review the epidemiology, dissemination, clinical presentation, diagnosis, treatment, survival and functional outcome of intramedullary spinal cord metastases (ISCM).

METHODS

Literature review of all surgically treated cases of ISCM and all described cases of ISCM of breast carcinoma.

RESULTS

42 references to 87 surgically treated cases of ISCM were found, 13 references to 27 cases with diagnosed and treated ISCM of breast carcinoma. In only 9 cases of spinal cord metastases of breast cancer was surgical resection of ISCM done (10% of all surgically treated ISCM).

CONCLUSIONS

Three treatment modalities are available for ISCM: radiotherapy, chemotherapy, and surgery. The gold standard remains radiotherapy. Microsurgical resection of a focal intramedullary mass appears to be feasible and should be considered in selected cases. Patients who have no evidence of widespread organ metastases or multiple intramedullary lesions and who have a life expectancy of at least a few months with tumours of non-lymphoma histology should be considered for tumor resection. In conclusion, ISCM are difficult to treat lesions, but early diagnosis, careful surgical management and maintenance therapy may substantially contribute to a satisfactory functional outcome and prolonged survival.

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.

Intradural spinal metastasis of renal cell cancer. Report of a case and review of 26 published cases

Metastatic disease in the intradural compartment of the spine is a rare manifestation of cancer. We report the case of an 82-year-old patient with an intradural, extramedullary metastasis of renal cell carcinoma in the cervical spine. A literature search for intradural spinal metastases of renal cell carcinoma yielded a total of 26 further cases. 18 patients had sporadic renal cell carcinoma, and 9 patients had von Hippel-Lindau disease (VHL) in which the metastases of the renal cell carcinoma were embedded within spinal haemangioblastomas. Patients presented with paresis, back pain, altered sensation or, less frequently, bladder dysfunction. Intradural spinal metastases were diagnosed at an earlier age in VHL patients than in sporadic cases (mean 43 +/- 5 years vs. 60 +/- 14.5 years). The metastasis was surgically removed in 81% of patients. Pain improved in all patients, paresis in 90%, hypaesthesia in 38% and bladder dysfunction in 50%. Death occurred as a result of systemic cancer progression. 93% of patients in the sporadic renal cell cancer group died within 1.5 years, whereas two thirds of the VHL patients were alive after 2 years.

Retrospective study of 19 patients with intramedullary spinal cord metastasis

OBJECT

Intramedullary spinal cord metastasis (ISCM) is a rare but devastating complication of cancer. Due to both widespread MRI availability and longer survival of cancer patients, the probability of discovering an ISCM during the course of the disease has increased and raised issues regarding the management of these patients, and particularly the place of surgery. In this study, we assess predictive factors for surgical outcome and survival.

PATIENTS AND METHODS

We retrospectively reviewed a series of 19 patients consecutively admitted in our institution from 1993 to 2006 for ISCM, representing the second largest series published in the literature. MRI was performed on all patients. Thirteen underwent microsurgical excision of ISCM. Functional outcome was evaluated and factors influencing survival were statistically analyzed.

RESULTS

Median survival was statistically longer when surgery was performed (7.4 vs. 2.6 months). Preoperative neurological status, nature of primary cancer, presence of systemic and/or CNS metastases influenced survival, but differences were without statistical significance. Neurological status improved in 58% (11/19) of operated patients.

CONCLUSIONS

Optimal management of patients with ISCM is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of different therapeutic options. Diagnosis should be made as early as possible and surgical resection should be considered as the primary treatment whenever feasible, particularly in the case of rapidly progressive neurological deficits and when a clear cleavage plane exists. Our study shows that surgery could result in both increased survival rate and significant improvement of neurological function.

METASTASIS TO THE CONUS MEDULLARIS

OBJECTIVE

Metastasis from lung cancer to the conus medullaris has never been reported in the English literature, although three cases have appeared in the French and Japanese literature. Our case report is unique because the patient presented with a lumbar radiculopathy, an atypical presentation that was found to be caused by metastasis from lung cancer to the conus medullaris. A critical review of the pertinent literature related to metastatic neoplasms to the conus medullaris is also presented.

CLINICAL PRESENTATION

We report the case of a 54-year-old man who presented with an L5 radiculopathy and was initially found to have a small disc herniation at L4–L5 on magnetic resonance imaging scans, which was ruled out as the case of his initial symptoms. In 3 weeks, the symptoms progressed with the development of urinary incontinence and right leg weakness. A magnetic resonance imaging scan of the lumbar spine showed a tumor at the conus medullaris.

INTERVENTION

The patient underwent a laminectomy with removal of the tumor. Pathological examination of the tumor showed infiltrating differentiated adenocarcinoma. A 2.5 cm lung mass in the right middle lobe with surrounding adenopathy was found on a computed tomographic scan of the chest. The patient died 4 months later from systemic involvement and progression of his lung disease.

CONCLUSION

This case report illustrates the rare presentation of a lumbar radiculopathy caused by a metastatic tumor to the conus medullaris. This was the first presentation for the diagnosis of lung cancer in this patient.

Solitary intramedullary spinal cord tumor presenting as the initial manifestation of metastatic renal cell carcinoma: case report

STUDY DESIGN

We present the case of a patient with a solitary neoplasm of the intramedullary spinal cord.

OBJECTIVE

The tumor caused findings of Brown-Séquard syndrome and was the initial presentation of widely metastatic renal cell carcinoma (RCC).

SUMMARY OF BACKGROUND DATA

Metastasis of the intramedullary spinal cord has been uncommonly reported and is extremely rare as the initial sign of a disseminated carcinoma.

METHODS

The tumor was resected, and the patient's neurologic deficits slowly improved. The histopathology suggested an epithelioid neoplasm. However, despite expert review, the diagnosis was nonspecific, and the tumor appeared benign.

RESULTS

It soon recurred in the spinal cord, and repeat imaging studies showed numerous new metastases and a primary renal neoplasm. Biopsy and a repeat histopathologic analysis confirmed RCC, and the patient died of disseminated disease within another 2 months.

CONCLUSIONS

Despite being uncommon, spinal cord metastases should be considered in some patients before surgery because it may expedite diagnosis, mitigate the need for surgery, and improve the quality of life for these patients. Clinical factors suggesting metastasis include a personal or family history of malignancy or conditions predisposing to it, the presence of multiple tumors in the spinal cord or elsewhere, nonspecific constitutional symptoms, such as weight loss or decreased appetite, and, specifically for RCC, an abnormally increased hematocrit.

[Intramedullary spinal cord metastasis from thyorid carcioma: case report]

We report a case of intramedullary spinal cord metastasis from thyroid cancer in a 70-year-old woman complaining for three months an intense cervical pain, without motor or sensitive deficits. Six months before the onset of symptoms, the patient underwent total thyroidectomy for a thyroid cancer. Magnetic resonance imaging with gadolinium enhancement showed an intramedullary spinal cord lesion. A partial resection of the medullar tumor was performed and the pathological findings showed an metastatic adenocarcinoma. Post operatively the patient developed a left crural monoplegia.

Surgical treatment of intramedullary spinal cord metastases of systemic cancer: functional outcome and prognosis

OBJECTIVE

Intramedullary spinal cord metastases (ISCM) of systemic cancer are rare. To date, patients with ISCM tend to benefit only to a limited extend from surgery and adjuvant therapy. Subject of this investigation is to assess predictive factors for surgical outcome and survival and to evaluate the value of surgical radicality in the treatment of ISCM.

PATIENTS AND METHODS

Between 1990 and 2004, a series of 146 patients with intramedullary tumors underwent surgical treatment in our institution. Among these, 13 patients with intramedullary cancer metastases (7 adenocarcinomas, 3 poorly differentiated carcinomas, 3 sarcomas) were identified. Standard microsurgical removal of the ISCM was performed. Functional outcome was graded according to a standardized scale and factors influencing outcome and survival were statistically analyzed.

RESULTS

Median progression-free survival was 13 weeks and median overall survival was 31 weeks. In 5 patients (38) the intramedullary lesion was the initial manifestation of the malignant disease. All poorly differentiated carcinomas and all sarcomas were resected incompletely. Surgical radicality presented a negative predictive factor for functional outcome, increasing radicality leading to functional deterioration. Age, sex, tumor localization, surgical radicality and the presence of neoplastic meningeosis did not affect survival.

CONCLUSION

Surgery of ISCM can be performed with an acceptable operative morbidity. Radicality depended on tumor histology. However, radical tumor removal did not affect survival and was correlated with a poor functional outcome. Therefore, complete surgical removal of ISCM should only be intended in patients in whom an unproblematic excision is feasible.

Spinal cord hemangioblastoma with extensive syringomyelia

We present the case of a 20-year-old male with intermittent right upper extremity numbness for 3 months. His pain perception and temperature sensation were severely disturbed. An incidental magnetic resonance imaging (MRI) finding of one small intramedullary enhancing nodule at spinal cord level T10-11 with long-segment syrinx formation suggested the diagnosis of spinal hemangioblastoma with syringomyelia. Surgical removal of the tumor and decompression of the spinal cord with opening of the syrinx were performed smoothly, and the pathology confirmed the diagnosis of spinal hemangioblastoma. Reviewing the literature, MRI is the examination of choice for spinal hemangioblastomas, and is helpful in preoperative planning and the differential diagnosis of spinal cord neoplasms and vascular lesions.

Clinical trials and evidence-based medicine for metastatic spine disease

Treatment of metastatic epidural spinal disease has undergone significant changes over the last 20 years. No longer is indiscriminate decompressive laminectomy offered as the only surgical treatment. It carries all the risks associated with an invasive procedure and offers the patient little benefit unless it is used to remove disease isolated to the posterior elements. The existing literature suggests that surgery that frees the spinal cord at the site of compression in addition to reconstructing and stabilizing the spinal column is more effective at preserving and regaining neural function, notably ambulatory function and sphincter function, than conventional radiotherapy. It is also highly effective in relieving pain. The preliminary results ofa recent RCT provide the first class I evidence to support a reversal in the current philosophy of primary treatment for many patients with meta-static disease. Conventional radiotherapy has a clearly defined role as adjuvant therapy and as primary therapy in those who are unable to tolerate or benefit significantly from surgery. The role of nonconventional radiation therapy, such as IMRT and SRS, remains to be elucidated.

Surgical Management of Spinal Metastases

Metastatic spread to the spinal column is a growing problem in patients with cancer. It can cause a number of sequelae including pain, instability, and neurologic deficit. If left untreated, progressive myelopathy results in the loss of motor, sensory, and autonomic functions. Except in rare circumstances, treatment is palliative. Traditionally, conventional fractionated external beam radiotherapy has been the treatment of choice. "Surgery" for metastatic spinal disease was, and generally continues to be, equated with laminectomy by many physicians. However, there has been a remarkable evolution in surgical techniques over the last 20 years. Today, the goal of surgery is to achieve circumferential decompression of the neural elements while reconstructing and immediately stabilizing the spinal column. This has been made possible by the use of different surgical approaches and the exploitation of a burgeoning array of internal fixation devices. More recently, minimally invasive surgical techniques, such as endoscopy, kyphoplasty/vertebroplasty, and stereotactic radiosurgery, have been added to the surgeon's armamentarium. As the number of treatment options for metastatic spinal disease grows, it has become clear that effective implementation of treatment can only be achieved by a multidisciplinary approach. This will provide the surest means of maximizing the quality of the remainder of the patient's life.

Intramedullary spinal cord metastasis of lung adenocarcinoma presenting as brown-sequard syndrome

BACKGROUND

It is extremely rare for cancer to present first as an intramedullary spinal cord metastasis. Furthermore, because it is unlikely for spinal cord neoplasm to present acutely, an acute presentation may signify metastatic disease and should be considered in the initial differential diagnosis.

METHODS

The authors present a case of a 59-year-old man presenting with Brown-Sequard syndrome and in whom metastatic lung adenocarcinoma to the spinal cord was subsequently discovered. Review of the literature reveals this case to be one of only a very few where intramedullary tumor was the first manifestation of metastatic disease.

RESULTS

The mainstay of treatment for intramedullary spinal metastases remains steroids, radiation, and chemotherapy, though no well-designed study compares these modalities by long-term survival and functional results. This patient underwent local radiation and systemic chemotherapy following surgical resection.

CONCLUSIONS

This patient had no preoperative signs suggesting disease in other organs, making the diagnosis of lung adenocarcinoma metastatic to the intramedullary cord surprising, especially given the extremely rare incidence of spinal intramedullary metastatic disease. However, the patient had an acute presentation, uncommon for primary neoplasm, which may be an indication of metastatic disease.

Treatment of metastatic spinal epidural disease: a review of the literature

OBJECT

Spinal cord compression is one of the most dreaded complications of metastatic cancer. It can lead to a number of sequelae, including pain, spinal instability, neurological deficits, and a reduction in the patient's quality of life. Except in selected circumstances, treatment is palliative. Treatment options include surgery, radiation, and chemotherapy. The goal of this study was to summarize the existing data on the outcomes of various treatment methods for metastatic spinal epidural disease and to make appropriate recommendations for their use.

METHODS

The authors used a search strategy that included an electronic database search, a manual search of journals, analysis of bibliographies in relevant review papers, and consultation with the senior author. There is good evidence, including Class I data, that steroid drugs constitute a beneficial adjunctive therapy in patients with myelopathy from epidural compression. Historically, conventional radiation therapy has been viewed as the first-line treatment because it has been shown to be as effective as a decompressive laminectomy, with a lower incidence of complications (Class II data). Nevertheless, in the last 20 years there has been remarkable progress in surgical techniques and technology. Currently, the goals of surgery are to achieve a circumferential decompression of the spinal cord, and to reconstruct and immediately stabilize the spinal column. Results in a large body of literature support the belief that surgery is better at retaining or regaining neurological function than radiation and that surgery is highly effective in relieving pain. Most of the data on the treatment of metastatic spinal disease are Class II or III, but the preliminary results of a well-designed, randomized controlled trial in which surgery is compared with standard radiation therapy represents the first Class I data.

CONCLUSIONS

As the number of treatment options for metastatic spinal disease has grown, it has become clear that effective implementation of these treatments can only be achieved by a multidisciplinary approach.

Atypical presentation of intramedullary spinal cord lesion

We report a patient who presented with atypical clinical manifestations including worsening abdominal pain from an intramedullary spinal cord lesion. It is important to consider non-abdominal causes of abdominal pain for patients with an atypical presentation. The described case demonstrates the challenges facing the physician with the early diagnosis of acute abdominal pain. Spinal cord lesions, although uncommon, remain a potentially disabling and life-threatening cause of abdominal pain.

Unusual metastasis to the cauda equina from renal cell carcinoma

STUDY DESIGN

This is a case report of a patient with renal cell carcinoma and intradural metastasis to the cauda equina.

OBJECTIVE

To present a rare case of an intradural metastasis from renal cell carcinoma and to discuss the clinical features of metastatic tumors in the cauda equina and the possible mechanism of the tumor spread to the cauda equina.

SUMMARY OF BACKGROUND DATA

Intradural spinal metastasis has been rarely reported in the English literature. Only two reports that describe the spread of metastatic renal cell carcinoma to the cauda equina have been published.

METHODS

A 61-year-old man who underwent a nephrectomy for the treatment of renal cell carcinoma presented with worsening low back pain that radiated to both legs. Magnetic resonance imaging showed an ill-defined tumor mass in the cauda equina at L3. After a recapping T-saw laminoplasty of L3 was performed, the tumor was excised and the nerves involved in the tumor were transected.

RESULTS

Pathologic examination showed papillary renal cell carcinoma with identical histology to the primary tumor. The patient's low back pain and radiating leg pain were relieved after operating.

CONCLUSION

The majority of cauda equina tumors are primary tumors, and metastases are very rare. Intradural spinal metastasis pain is a characteristic cramping pain provoked by light percussion on the lumbar spine, becoming severe when sleeping in the flexion or sitting position. Magnetic resonance imaging is a useful tool for detecting intraspinal metastasis when the patient is complaining of a unique pain. A recapping T-saw laminoplasty to preserve posterior elements with tumor removal is feasible for relieving pain and demonstrating the pathology.