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Kritikos M, Vivanco-Suarez J, Teferi N, Lee S, Kato K, Eschbacher KL, Bathla G, Buatti JM, Hitchon PW. Survival and neurological outcomes following management of intramedullary spinal metastasis patients: a case series with comprehensive review of the literature. Neurosurg Rev 2024; 47:75. [PMID: 38319484 DOI: 10.1007/s10143-024-02308-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/12/2024] [Accepted: 01/20/2024] [Indexed: 02/07/2024]
Abstract
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.
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Affiliation(s)
- Michael Kritikos
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Juan Vivanco-Suarez
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Nahom Teferi
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sarah Lee
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Kyle Kato
- College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Kathryn L Eschbacher
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Girish Bathla
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John M Buatti
- Department of Radiation Oncology, College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Patrick W Hitchon
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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Houlihan LM, Ledingham C, O'Sullivan MGJ. Deceptive Features on Surveillance Imaging of Intraneural Metastatic Deposits in Metastatic Renal Cell Cancer. World Neurosurg 2020; 143:147-151. [PMID: 32730973 DOI: 10.1016/j.wneu.2020.07.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/19/2020] [Accepted: 07/21/2020] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Lena Mary Houlihan
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland; Edith and Loyal Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Centre, Phoenix, Arizona, USA.
| | - Conor Ledingham
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
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Intramedullary Spinal Cord Metastasis from Renal Cell Carcinoma: A Systematic Review of the Literature. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7485020. [PMID: 30643818 PMCID: PMC6311310 DOI: 10.1155/2018/7485020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/28/2018] [Accepted: 11/28/2018] [Indexed: 12/27/2022]
Abstract
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.
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O'Neill AH, Phung TB, Lai LT. Intramedullary spinal cord metastasis from thyroid carcinoma: Case report and a systematic pooled analysis of the literature. J Clin Neurosci 2017; 49:7-15. [PMID: 29248379 DOI: 10.1016/j.jocn.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 12/03/2017] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Anthea H O'Neill
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Teik Beng Phung
- Department of Anatomical Pathology, Monash Health, Melbourne, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia.
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Saeed H, Patel R, Thakkar J, Hamoodi L, Chen L, Villano JL. Multimodality therapy improves survival in intramedullary spinal cord metastasis of lung primary. Hematol Oncol Stem Cell Ther 2017; 10:143-150. [PMID: 28834695 DOI: 10.1016/j.hemonc.2017.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/29/2017] [Accepted: 07/19/2017] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Hayder Saeed
- Department of Internal Medicine, Division of Hematology/BMT, Lexington, KY 40536, USA.
| | - Reema Patel
- Department of Internal Medicine, Division of Medical Oncology, Lexington, KY 40536, USA
| | - Jigisha Thakkar
- Department of Neurology, University of Kentucky, Lexington, KY 40536, USA
| | - Lames Hamoodi
- Department of Pathology, University of Kentucky, Lexington, KY 40536, USA
| | - Li Chen
- Biostatistics and Bioinformatics Shared Resources, Markey Cancer Center, University of Kentucky, Lexington, KY 40536, USA
| | - John L Villano
- Department of Internal Medicine, Division of Medical Oncology, Lexington, KY 40536, USA
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Sung WS, Sung MJ, Chan JH, Manion B, Song J, Dubey A, Erasmus A, Hunn A. Intramedullary spinal cord metastases: a 20-year institutional experience with a comprehensive literature review. World Neurosurg 2012; 79:576-84. [PMID: 22484768 DOI: 10.1016/j.wneu.2012.04.005] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Revised: 10/30/2011] [Accepted: 04/03/2012] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Wen-Shan Sung
- Department of Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia.
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Hrabalek L. Intramedullary spinal cord metastases: review of the literature. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2010; 154:117-22. [PMID: 20668492 DOI: 10.5507/bp.2010.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Lumir Hrabalek
- Department of Neurosurgery, Palacky University and University Hospital Olomouc.
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Metastatic renal cell carcinoma initially presented with an intramedullary spinal cord lesion: a case report. CASES JOURNAL 2009; 2:7805. [PMID: 19918485 PMCID: PMC2769375 DOI: 10.4076/1757-1626-2-7805] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 06/11/2009] [Indexed: 11/16/2022]
Abstract
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.
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