Radicular involvement and medullary invasion from a malignant mesothelioma

Intramedullary Metastasis to the Cervical Spinal Cord from Malignant Pleural Mesothelioma: Review of the Literature and Case Reports

Context:

Malignant mesothelioma is an aggressive tumor; median survival of patients following diagnosis is 12 months.

Aims:

Pleural malignant mesothelioma tends to spread along preexisting tissue planes and has the rare ability to spread along the nerve root into the spinal cord. In our case, there is an evidence of exceptional direct hematogenous spread to the spinal cord by the spinal branch of the intercostal arteries or the veins of Batson's plexus.

Settings and Design:

The authors report a case of intramedullary hematogenous metastasis to the cervical spinal cord from malignant mesothelioma, with a review of the literature.

Materials and Methods:

A 68-year-old male was admitted to our department because of a slowly progressive mild weakness of both low extremities, more pronounced on the left side. The patient has been treated for a malignant mesothelioma with left thoracotomy and subsequently underwent radiotherapy. Magnetic resonance imaging of the cervical-thoracic spine revealed a contrast-enhancing intramedullary expansive lesion of the left half of the spinal cord at the C6–C7 level.

Results:

The patient underwent surgical treatment through a C6–C7 laminectomy. Through a median posterior spinal cord incision, an intramedullary grayish lesion was completely removed. The paraparesis progressively improved and 20 days after surgery, the patient had regained normal lower extremity function.

Conclusions:

Malignant mesothelioma can spread to the spinal canal by the direct extension through the intervertebral foramina, by hematogenous spread to the spinal meninges, and by perineural growth along a single nerve root. The cleavage plane of the tissue may determine whether a successful gross total resection can be achieved with a good outcome for the patient.

Primary Spinal Malignant Mesothelioma: A Case Report and Literature Review

BACKGROUND

Malignant mesotheliomas are aggressive and rapidly fatal neoplasms arising from the mesothelial cells. The most common sites of origin are the pleural and peritoneal cavities; the pericardium and the tunica vaginalis are infrequently involved, and malignant mesothelioma in the spinal canal is extremely rare. Here we report a case of primary spinal malignant mesothelioma. We also report the results of a literature search conducted in PubMed with specific key terms, inclusion criteria, and exclusion criteria, with a comparison of elected case studies and case series, and statistical analysis as appropriate.

CASE DESCRIPTION

A 35-year-old man presented with a 3-month history of swelling and pain in the left lower extremity. Neurologic examination revealed a loss of sensation below the L5 dermatome. Magnetic resonance imaging (MRI) showed a mass at the L4-5 level. A diagnosis of schwannoma was suspected, and surgical resection was performed. Histopathological findings were consistent with sarcomatoid malignant mesothelioma. Thoracic and whole-abdomen computed tomography yielded normal results. The patient refused adjuvant radiotherapy or chemotherapy. Positron emission tomography-computed tomography performed at 3 months postoperatively showed no abnormality. At 8 months postoperatively, the patient developed back pain and difficulty with defecation; MRI demonstrated tumor recurrence. During a second operation, invasion of the vertebra and cauda equina was noted. A subtotal resection was achieved, and the pain was partially alleviated. Two months later, the patient succumbed to a traffic accident.

CONCLUSIONS

Spinal malignant mesothelioma is an extremely rare but highly aggressive entity. Preoperative identification is challenging, and definitive diagnosis depends on histopathological evidence. Surgical resection can help relieve the symptoms, but the overall prognosis is poor.

Malignant mesothelioma and central nervous system metastases. Report of two cases, pooled analysis, and systematic review

RATIONALE

The incidence and patterns of metastatic disease to the central nervous system (CNS) from malignant mesothelioma are not well characterized.

OBJECTIVES

We describe the treatment of two cases of pleural mesothelioma with CNS metastases. We also report the results of a systematic review with pooled data analysis of CNS metastases from malignant mesothelioma.

METHODS

PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Inclusion criteria for the pooled analysis were any clinical or autopsy study in which patients had a confirmed histological diagnosis of malignant mesothelioma and CNS metastasis was identified by autopsy, clinical pathological specimen, or compelling radiographic imaging. Case reports were excluded from the pooled analysis but were incorporated into the discussion. One hundred forty-one potentially relevant references were identified. Seven studies including 655 patients were included in the pooled analysis. Ninety-seven additional cases were identified and incorporated into the discussion. A systematic review of the literature is provided with pooled data analysis.

MEASUREMENTS AND MAIN RESULTS

CNS involvement of malignant mesothelioma may occur by hematogenous spread or by local extension. Some cases may represent tumor dedifferentiation to a more aggressive histologic subtype. Surgery or stereotactic therapies may play a role for select patients; however, rapid recurrence has been reported.

CONCLUSIONS

The prognostic significance of CNS disease is not well characterized. Clinicians should consider and identify CNS involvement in patients with new or evolving neurologic symptoms because early identification may allow for palliative intervention.

[Spinal cord compression from a malignant pleural mesothelioma]

Thoracoscopy-talc led to the diagnosis of epithelial pleural mesothelioma in a 58-year-old man who presented with pleurisy. The course was rapidly unfavorable despite systemic chemotherapy. Dorsal pain revealed invasion of the spine and spinal canal leading to cord compression three months after the diagnosis of mesothelioma.

The role of new imaging techniques in diagnosis and staging of malignant pleural mesothelioma

This review highlights the different imaging modalities for the detection of malignant pleural mesothelioma. The chest film is the initial diagnostic tool of choice because it is easy to perform, inexpensive, and widely available. Unfortunately, it demonstrates malignant pleural mesothelioma in later stages of disease and is not suitable for an early sensitive and specific diagnosis. Computed tomography is capable of distinguishing the different forms of pleural abnormalities. The knowledge of computed tomography findings is important for differentiation of malignant pleural diseases from benign diseases. Contrast-enhanced magnetic resonance imaging in three planes can be clinically useful to differentiate pleural mesothelioma from other malignancies or from benign pleural diseases. Furthermore, magnetic resonance imaging offers the possibility to differentiate invasion of the diaphragm from transdiaphragmatic tumor growth, and, in patients who are surgical candidates and who have questionable areas of local tumor extension on computed tomography, magnetic resonance imaging may provide additional information to plan or avoid surgery. Improvements in the detection of regional and distant metastases are needed to identify patients most likely to benefit from aggressive combined modality treatment regimes. In this context, positron emission tomography is a metabolic imaging technique that offers the possibility to evaluate active malignant cells. Drawbacks to this technique include false-positive findings, which may occur at sides of inflammation, and lesser anatomic detail information. A complete and accurate staging of malignant pleural mesothelioma is essential to evaluate the efficacy of new therapeutic strategies. This implies the need to be familiar with the most recently developed staging system from the International Mesothelioma Interest Group.