Radiation myelopathy of cervical spinal cord simulating intramedullary neoplasm

Radiation myelopathy after radioactive iodine therapy for spine metastasis

A case of radiation myelopathy after radioactive iodine therapy is reported. This is the first report to describe radiation myelopathy after I-131 therapy. A 62-year-old female with spinal metastasis of T10 received I-131 therapy. She presented with radiation myelopathy 34 months after the irradiation. We need to recognize the possibility of this serious complication even in the case of I-131 therapy. There is a risk of radiation myelopathy even after I-131 therapy, especially in cases with spinal cord compression such as this.

Radiation-induced Spinal Cord Glioma Subsequent to Treatment of Hodgkin’s Disease: Case Report and Review

Radiation-induced neoplasms of the central nervous system generally present as meningioma or sarcoma. Spinal cord glioma after radiation therapy is rare and half of the cases documented occurred after treatment of Hodgkin's disease.A 39-year-old male presented with a 1-month history of gradually worsening neck ache and paraparesis. The patient had been treated for stage IB Hodgkin's disease 9 years previously with combined therapy: MOPP-ABV and a 40-Gray mediastinal radiotherapy from T1 to T10. Magnetic resonance imaging disclosed an intramedullary lesion from C6 to T2 and histopathological examination from biopsy demonstrated a malignant glioma. Despite chemotherapy and additional radiotherapy, the patient's neurological status worsened and he died 11 months after initial presentation. We suggest a strategy aimed solely at obtaining a tissue diagnosis to differentiate myelitis from tumor, and, in the event of tumor, confirming the strong likelihood of a high histopathological grade. The very limited survival associated with these tumors regardless of therapy advocates palliative therapies without attempting complete resection.

MRI of spinal cord radiation necrosis simulating recurrent cervical cord astrocytoma and syringomyelia

BACKGROUND

Although primary intramedullary tumors of the spinal cord with syrinx formation are well documented, there have been no reports of extensive syrinx formation or cystic degeneration associated with radiation necrosis.

METHODS

We report a case of radiation necrosis and syrinx formation in a 49-year-old woman with a 5-year history of astrocytoma grade II of the cervical cord, who progressed to quadriparesis following surgery and radiation therapy. Magnetic resonance imaging (MRI) of the cervical and thoracic spine demonstrated enlargement of upper cervical cord (C1-C6) with diffuse increased signal enhancing mass by gadolinium, as well as appearance of syrinx from T4-T10.

RESULTS

Autopsy findings indeed revealed a small, residual, infiltrating glioma in the upper cervical areas, but the diffuse parenchymal abnormality seen on MRI as prolonged T2 characteristics on double-echo spin-echo sequence was revealed to be radiation necrosis.

CONCLUSION

What appeared to be a cystic cavity or syrinx at the thoracic level was also diagnosed as radiation necrosis with cyst formation on histologic examination.

Radiation myelopathy: significance of gadolinium-DTPA enhancement in the diagnosis

We described two cases of chronic progressive radiation myelopathy (CPRM), in which magnetic resonance imaging (MRI) was of great value for the diagnosis. Gadolinium-DTPA (Gd-DTPA) enhancement delineated precise lesions responsible for Brown-Séquard syndrome caused by CPRM in both cases. This safe, sensitive procedure will be a requisite study in patients who are suspected of CPRM.

The incidence of myelitis after irradiation of the cervical spinal cord

To further define the tolerance of the cervical spinal cord, the dose of radiation to the cervical spinal cord was calculated for all 2901 patients with malignancies of the upper respiratory tract treated at the University of Florida between October 1964 and December 1987. To further define the population evaluated, certain criteria were used: (a) a minimum of 3000 cGy to at least 2 cm of cervical spinal cord and (b) a minimum of 1 year of follow-up, unless a neurological complication occurred before 1 year. A total of 1112 patients were evaluable, of which 2 (0.18%) developed radiation myelitis. One received 4658 cGy to the cervical cord at 172.5 cGy per day, and the other patient received 4907 cGy to the cord at 169.2 cGy per day. The risk of myelitis at each dose level was 0/124 at 3000-3999 cGy, 0/442 at 4000-4499 cGy, 2/471 at 4500-4999 cGy, and 0/75 at a cord dose of 5000 cGy or greater.

MRI of radiation induced spinal cord glioma

Radiation induced neoplasms of the spinal cord are rare lesions. This report details the MR evaluation of a patient with radiation induced astrocytoma of the cervical cord. The diagnosis of second primary neoplasm should be considered in patients with prior radiation therapy when MRI demonstrates an intramedullary lesion.

Analysis of the histopathology of radiation myelopathy

An analysis of published histopathology reports of patients with radiation myelopathy was performed. Radiation lesions in the spinal cord were classified as primarily white matter parenchymal lesions (type 1), primarily vascular lesions (type 2), or a combination of vascular and white matter lesions (type 3). The presence or absence of a mononuclear inflammatory reaction was also noted. Type 1 and type 3 lesions had comparable latent periods, both significantly shorter than those observed for type 2 lesions. The anatomical level of the irradiation did not appear to influence the type of lesion. Inflammatory reaction was observed with greater frequency in type 3 lesions. For all types of lesions, the average latent periods in patients with inflammatory reactions were shorter than in those without inflammation. In the cases in which disease status was evaluated, 70% of the patients were free of disease or had no evidence of recurrence at autopsy.

Benign tumors and tumorlike conditions of the spine. Radiological features, treatment, and results

A series of 44 benign tumors and tumorlike conditions of the spine treated surgically between 1952 and 1982 is reported. We have focused on their radiodiagnosis, treatment, and long-term results. The radiologic features considered pathognomonic of skeletal tumors, and frequently found in tumors outside the spine, are less common in the spinal variety. In fact, the radiologic findings in spinal tumors are, as a rule, nonspecific. The long-term results in this series are considered satisfactory, despite two recurrences of a giant cell tumor and late malignant degeneration of an osteochondroma. The prognosis was good, and recurrence rare even after conservative excision of the lesion. More aggressive treatment is nonetheless recommended nowadays for giant cell tumors and osteoblastomas, even if vertebral stability has to be sacrificed and fusion performed, as this affords the best chance of permanent cure. Conservative excision without radiotherapy remains the treatment of choice for other benign tumors. Spinal instability is a serious risk especially in younger patients who have undergone radiotherapy and have residual neurological deficits. Provision should be made against this risk by planning a fixation procedure either in the same operation as ablative surgery or at a later stage.

The latent period in clinical radiation myelopathy

Seventy-seven papers containing data on more than 300 cases of radiation myelopathy have been analyzed. The data suggest that the latent periods are similar in the cervical and thoracic levels of the spinal cord and are bimodally distributed. Myelopathy of lumbar cord apparently has a shorter latent period. As in controlled animal experiments, the latent period decreases with increasing dose. Furthermore, the variation in latent periods also decreases with dose. It is also seen that retreated patients and pediatric or adolescent patients have greatly reduced latent periods. The implications of these findings as they compare with the animal data are discussed.

Spinal cord lesions after diagnostic and therapeutic procedures

This paper is dealing with spinal cord lesions following diagnostic and therapeutic procedures according to the literature and some personal observations. It becomes quite clear what prices have to be payed using modern methods. There are not only surgical procedures involved. Spinal cord lesions following medical activities cannot be judged as malpractice in any case. Some of these accidents can be avoided by strong indications and sophisticated performance of any procedure.

Diffuse cord enlargement in radiation myelopathy

Radiation myelopathy is a well-documented complication of the irradiation of neoplasms adjacent to the spinal cord. Myelography has been used to distinguish intraspinal metastases with the diagnosis of radiation myelopathy being made if the study is normal. Four cases of radiation myelopathy are here described which were associated with swelling of the spinal cord and, in three cases, this was demonstrated at myelography. The fusiform expansion of the cord, which is indistinguishable from an intrinsic tumour or hydromyelia, is maximal in the irradiated zone, but may extend beyond it. The demonstration of swelling was associated with an abrupt clinical deterioration and, in two patients, followed a recent normal examination. The severe degree of damage underlying the cord enlargement was reflected in the poor prognosis.

Monkey brain damage from radiation in the therapeutic range

Twelve Macaca mulatta monkeys received 200 rads of supervoltage radiation to the whole brain per day, 5 days a week. The course in 4 monkeys was 4 weeks for a total dose of 4000 rads; in 4 monkeys, 6 weeks for 6000 rads; and in 4 monkeys, 8 weeks for 8000 rads. Four unirradiated monkeys served as controls. One from each group, sacrificed at 6 and 12 months from start of irradiation, are reported here. The results from 4000 rads were negligible; those from 8000 rads, profound, with gross brain destruction. The results from 6000 rads, within the therapeutic range, included at 6 months punctate necrotic lesions, 1 mm or less, widely scattered but with a predilection for the forebrain white matter. The reaction to these lesions ranged from an early macrophage response to calcification. Some were accompanied by focal edema. There were occasional examples of vascular endothelial proliferation. In addition, there were patches of dilated capillaries or telangiectasia. Twelve months after 6000 rads there were a few mineralized lesions and innumerable minute deposits of calcium and iron. A more active process was suggested by widely disseminated areas of telangiectasia, 6 to 12 mm in extent. The clinical course from this exposure included papilledema from the third to the sixth month and depressed visual evoked response accompanied by delta activity in the electroencephalogram from the sixth to the twelfth month.