Clinical Features, Treatments, and Prognosis of Intramedullary Spinal Cord Metastases From Lung Cancer: A Case Series and Systematic Review

Incorporation of Whole-Body Metabolic Tumor Burden into Current Prognostic Models for Non-Small Cell Lung Cancer patients with Spine metastasis

BACKGROUND CONTEXT

Numerous prognostic models are utilized for surgical decision and prognostication in metastatic spine tumors. However, these models often fail to consider the whole-body tumor burden into account, which may be crucial for the prognosis of metastatic cancers. A potential surrogate marker for tumor burden, whole-body metabolic tumor burden (wMTB), can be calculated from total lesion glycolysis (TLG) obtained from 18F-Fludeoxyglucose positive emission tomography (18F-FDG PET) images.

PURPOSE

We aimed to improve prognostic power of current models by incorporating wMTB for non-small cell lung cancer (NSCLC) patients with spine metastases.

DESIGN

Retrospective analysis using a review of electrical medical records and survival data.

PATIENT SAMPLE

In this study, we included 74 NSCLC patients with image proven spine metastases.

OUTCOME MEASURES

Increase in Integrated Discrimination Improvement (IDI) index after incorporation of wMTB into prognostic scores.

METHODS

Enrolled patients' baseline data, cancer characteristics and survival status were retrospectively collected. Five widely used prognostic scores (Tomita, Katagiri, Tokuhashi, Global Spine Tumor Study Group [GSTSG], New England Spine Metastasis Score [NESMS]), and TLG indexes were calculated for all patients. The relationships among survival time, prognostic models and TLG values were analyzed. Improvement of prognostic power was validated by incorporating significant TLG index into significant current models.

RESULTS

Among current prognostic models, Tomita (EGFR wild-type), Katagiri, GSTSG and Tokuhashi were significantly related to patient survival. Among TLG indexes, LogTLG3 was significantly related to survival. Incorporation of LogTLG3 into significant prognostic models resulted in positive IDI index until three years in all models.

CONCLUSION

This study showed that incorporation of wMTB improved prognostic power of current prognostic models of metastatic spine tumors.

Characteristics and Outcome of Surgically Treated Patients with Intradural Extra- and Intramedullary Spinal Metastasis-A Single-Center Retrospective Case Series and Review

OBJECTIVE

Intradural spinal metastases are considered rare. At present, limited information is available on incidence, surgical management, and outcomes.

METHODS

We conducted a retrospective patient chart review from 2002 to 2024, identifying all patients surgically treated for intradural spinal metastases. Clinical, surgical and survival data were collected and compared to literature data for patients surgically treated for extradural spinal metastases.

RESULTS

A total of 172 patients with spinal metastases were identified with 13 patients meeting inclusion criteria (7.6%). The mean age at diagnosis of intradural spinal metastases was 52 ± 22 years, with diverse primaries including lung (n = 3), breast (n = 2), sarcoma (n = 2), and six unique entities. Intradural spinal metastasis was diagnosed on average of 3.3 years after primary diagnosis. In total, we observed five (38%) intradural-extramedullary and eight (62%) intramedullary metastases, located in the cervical (38.5%), thoracic (46.1%) and lumbar spine (15.4%). The most common preoperative symptoms were pain, sensory changes, and gait ataxia (each 76.9%). Gross total resection was achieved in 54%, and local tumor control in 85%. Postoperatively, 92% exhibited clinical improvement or stability. Most frequent adjuvant treatment was radio- and/or chemotherapy in 85%. The average survival after operation for spinal intradural metastases was 5 months, ranging from 1 month to 120 months. The location of the intradural metastasis in the cervical spine was associated with a significantly more favorable survival outcome (compared to thoracic/lumbar location, p = 0.02).

CONCLUSIONS

Intradural location of spinal metastases is rare (7.6%). Even so, surgical resection is safe and effective for neurological improvement, and survival appears lower compared to the reported survival of extradural spinal metastases.

Survival and neurological outcomes following management of intramedullary spinal metastasis patients: a case series with comprehensive review of the literature

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.

Leptomeningeal Metastasis From Neuroblastoma Revealed by 123 I-MIBG SPECT/CT

ABSTRACT

A 2-year-old girl with history of high-risk neuroblastoma underwent 123 I-MIBG, which showed increased 123 I-MIBG in the left side of the head. Contrast-enhanced MRI and cerebral spine fluid cytology confirmed the diagnosis of leptomeningeal metastasis.

Impact of surgical treatment for intramedullary spinal cord metastasis on neurological function and survival: A multicenter retrospective study by the Neurospinal Society of Japan

BACKGROUND

This retrospective multicenter study aimed to analyze the characteristics and surgical outcomes of intramedullary spinal cord metastasis (ISCM) and to discuss the controversy regarding its surgical indications.

METHODS

This study included 29 ISCM patients who underwent surgery between 2009 and 2020. Biopsy cases were excluded from analysis. For functional and neurological functional assessments, Karnofsky Performance Status (KPS, %) and modified McCormick Scale (MMS, 5-grade scale) scores were determined before and after surgery. Patients were divided into two groups: a mild-to-moderate disability group with preoperative MMS grades 1 to 3, and a severe disability group with preoperative MMS grades 4 to 5.

RESULTS

The mean preoperative KPS was 45.9, and the mean duration from symptom onset to surgical intervention was 1 month. The ISCM was located in the cervical spine in 10 cases and the thoracic spine in 19 cases. The access route (myelotomy) for ISCM removal was via the posterior median sulcus in 9 cases and via the posterior lateral sulcus in 11 cases, while others were not recorded. The degree of removal was gross total resection in 20 patients (69%), subtotal resection in 0 patients, and partial removal in 9 patients (31%). No significant complications related to the surgical procedures were recorded. Postoperative adjuvant therapy included radiotherapy in 17 patients (58.6%) and chemotherapy or molecular targeted therapy in 13 patients (44.8%). Pathological findings of ISCM showed that colorectal cancer was the most common in 9 cases, followed by lung cancer in 7, renal cell carcinoma in 5, and breast cancer in 2. Twenty-one of the 29 patients (72.4%) were confirmed to have survived 6 months after surgery: 8 of the 10 patients (80%) in the mild-to-moderate disability group and 13 of the 19 patients (68.4%) in the severe disability group. At 6 months after surgery, 3 of the 8 patients (38%) in the mild-to-moderate group were able to maintain or improve their function. Eleven of the 13 patients (85%) in the severe disability group maintained their function despite being severely disabled.

CONCLUSIONS

This study suggests that surgical treatment can maintain or improve neurological function in a limited number of patients with ISCM, although it had minimal impact on improving the survival rate after surgery.

Clinical Characteristics and Treatment Outcomes of Long-Level Intramedullary Spinal Cord Tumors: A Consecutive Series of 43 Cases

Objective: Long-level intramedullary spinal cord tumors (LIMSCTs) cause complex treatment issues. However, LIMSCTs have rarely been analyzed separately. The authors reported a large case series of LIMSCTs and analyzed the clinical characteristics and treatment outcomes.Methods: The medical data of patients with LIMSCTs at our institution between January 2015 and December 2019 were retrospectively reviewed. Demographics, tumor size and location, pathology, extent of resection, and neurological functional status were collected.Results: A total of 43 consecutive cases were included. Twenty-three cases (53.5%) of LIMSCTs were ependymal tumors. All patients with ependymal tumors achieved gross total resection (GTR). In ependymal tumor cases, 3 cases (13%) of ependymal tumors experienced postoperative neurological deterioration, and 66% of them showed an improvement at follow-up; 25.6% were low-grade astrocytic tumors. The rates of GTR, subtotal resection (STR) and partial resection (PR) were 63.6%, 27.3%, and 9.1%, respectively. Twenty-seven percent cases showed postoperative neurological worsening, and 33% of them had an improvement at follow-up; 20.9% were high-grade astrocytic tumors. The excision rates were 44.4% for GTR, 44.4% for STR, and 11% for PR, respectively. Fifty-five percent cases showed postoperative neurological worsening, and none of them had an improvement at follow-up.Conclusion: In this series, all LIMSCTs were gliomas. Aggressive tumor resection did not increase the risk of long-term functional deterioration in ependymal tumors and low-grade astrocytic tumors, but in high-grade astrocytic tumors, patients had a higher risk of neurological deterioration and difficulty in recovery. In ependymal tumors and low-grade astrocytic tumors, patients can achieve long-time survival after performing aggressive tumor resection.

Intramedullary spinal cord metastases from non-small cell lung carcinoma (NSCLC) associated with carcinomatous meningitis: a case report

Background:

Carcinomatous meningitis with metastases to the spinal cord [intramedullary spinal cord (IMSC)] is very rare, and a quick intervention to management of these patients is important in preventing neurological deterioration.

Methods:

We report a case of IMSC metastases from a stage IV non-small cell lung carcinoma in a 57-year-old man who presented with Brown-Sequard syndrome along with multiple brain metastases with associated carcinomatous meningitis and managed with urgent palliative external beam radiation therapy.

Conclusion:

A quick, short course of palliative radiation therapy for inoperable patients with IMSC metastases provides improvement in neurological function in the management of these oncologic emergencies in patients with short survival times.

Palliative Radiation Therapy for Intramedullary Spinal Cord Metastasis

BACKGROUND/AIM

The purpose of this study was to retrospectively review the outcomes of intramedullary spinal cord metastasis (ISCM) and identify predictors for ambulation after radiotherapy (RT).

PATIENTS AND METHODS

We analyzed 16 lesions in 15 patients treated with RT for ISCM at our clinic from October 2009 to April 2020 to evaluate predictors for improved ambulation following RT.

RESULTS

The primary diseases included nine cases of lung cancer, two cases of breast cancer, and several others. The RT schedule was primarily 30 Gy/10 fractions in seven cases, while others were applied to nine cases. The median overall survival time was 99 days. After RT, all seven patients who could walk prior to RT were still able to walk (100%), whereas only two of nine patients who could not walk prior to RT were able to walk (22%, p=0.004).

CONCLUSION

Ambulation prior to RT was a significant predictor of ambulation ability after RT.