A Long-Term Control of Intramedullary Thoracic Spinal Cord Metastasis from Small Cell Lung Cancer

Long-term survival in extensive-stage small-cell lung cancer treated with different immune checkpoint inhibitors in multiple-line therapies: A case report and literature review

Background

Extensive-stage small-cell lung cancer (ES-SCLC) is highly malignant, is highly prone to recurrence, and has a short survival period. It is very difficult to achieve long-term survival in ES-SCLC, which has not been significantly improved in the last 20 years. For a long time, platinum-based chemotherapy has occupied the core position in the treatment of small-cell lung cancer (SCLC), but there are few options for treatment drugs or regimens, and if disease progression occurs, the options for follow-up regimens are obviously limited. The advent of immunotherapy has changed this situation to some extent, and immunotherapy has shown some effects in improving efficiency and prolonging survival, whether in first- or third-line therapy, but it is still unsatisfactory.

Case presentation

A 57-year-old patient with ES-SCLC experienced disease progression after four lines of treatment including synchronous radiotherapy, chemotherapy, and antiangiogenesis. However, the patient still benefited when switching to the programmed cell death receptor-1 (PD-1) inhibitor toripalimab in combination with chemotherapy in the fifth line. Even after the development of immune resistance, the patient still benefited after switching to tislelizumab in combination with different chemotherapy regimens or alone in the sixth and seventh lines. Following the progression of tislelizumab in combination with chemotherapy, the patient again profited after switching to durvalumab in combination with anlotinib and again achieved a progressive-free survival (PFS) of 11 months. Overall, the patient achieved a total of 45 months of PFS and 50 months of overall survival (OS), with a shocking and exciting 30 months of PFS achieved in the immune combination phase alone.

Conclusion

We report a patient with ES-SCLC who achieved long-term survival after at least eight lines of therapy including chemotherapy, antiangiogenesis, and different immune checkpoint inhibitors (ICIs). This suggests that long-term survival in SCLC is possible with aggressive, combined, and standardized treatment. Otherwise, immunotherapy postline enablement can still benefit patients, rechallenge after immune resistance is also possible in SCLC, and combination with chemotherapy or antiangiogenic therapy can improve the efficacy and prolong the survival. This will provide new ideas and options for the selection of treatment options for SCLC.

Intramedullary Spinal Cord Metastasis Mimicking Astrocytoma: A Rare Case Report

Intramedullary spinal cord metastases (ISCMs) are infrequent lesions. Their incidence is estimated to range from 0.9 to 2.1%, found in autopsies of cancer patients. However, as the life expectancy of malignant tumour patients constantly increases, the reported incidences of ISCMs are consequently rising. This report presents a case of the misdiagnosis of an anaplastic astrocytoma type of tumour due to its similarities to small-cell neuroendocrine carcinoma. Therefore, we would like to underline the importance of further investigation that could assist and support the surgeon in the making of the differential diagnosis. We present the clinical case of a 73-year-old woman with a solitary intramedullary spinal cord metastasis as the initial manifestation of a carcinoid type of tumour. The patient was admitted to our department while presenting a rapid onset of paraparesis. Magnetic resonance imaging was performed, which showed an intramedullary mass at the C2–C6 vertebral level with a heterogeneous contrast enhancement. In light of these findings, the patient underwent surgery for a partial tumour resection. The lesion resulted in being a small-cell neuroendocrine type of carcinoma. This peculiar type of tumour presents similar radiological characteristics to the anaplastic astrocytoma type, which is why our diagnostical mismatch occurred. This is the report of a rare case of solitary intramedullary spinal cord metastasis, which is the result of an initial presentation of a lung small-cell neuroendocrine type of carcinoma. We conclude that ISCMs should be regularly considered as a part of the differential diagnosis of intramedullary lesions, especially in the case of a rapid onset and deterioration of neurological symptoms.

Surgical Treatment of Spinal Cord Compression Caused by Metastatic Small Cell Lung Cancer: Ten Years of Experience in a Single Center

Purpose

Metastatic spinal cord compression (SCC) secondary to small cell lung cancer (SCLC) is a disastrous oncological emergency, but it is poorly understood due to the small numbers of patients and their short survival times. Whether patients suffered from SCC caused by metastatic SCLC benefit from spinal surgery remains unknown. The aim of this study was to evaluate the role of surgical treatment and prognostic factors in patients with SCC caused by metastatic SCLC.

Methods

From 2009 to 2019, 30 consecutive patients surgically treated for metastatic SCC from SCLC were enrolled in this retrospective analysis. Kaplan–Meier method and Cox regression analysis were used to estimate overall survival (OS) and identify prognostic factors. Quality of life (QoL) was assessed by the three-level EuroQol-five-Dimensions (EQ-5D-3L) instrument and compared using Student’s t test.

Results

The median OS time was 9 months in our series. Relief of pain, preservation of neurological function, and improvement of performance status were achieved after surgical intervention. The mean EQ-5D-3L utility score showed a significant improvement after surgery (0.3394 preoperatively vs 0.5884 postoperatively). According to Cox regression analysis, postoperative ECOG-PS and immunotherapy were identified to be independent prognostic factors for patients with SCC caused by metastatic SCLC.

Conclusion

Despite the short life expectancy, prompt surgical decompression is extremely necessary for patients with SCC caused by SCLC, for surgery played a critical role in improving patients’ QoL. Better performance status after surgery and receiving immunotherapy were associated with a longer OS.

Intramedullary spinal cord metastasis in malignancies: an institutional analysis and review

Background: Intramedullary spinal cord metastases (ISCM) in malignancies is a devastating issue with limited research. This study aims to identify the clinical features, management, prognostic factors, and outcomes of this special entity.

Methods: A retrospective review of 61 patients of ISCM diagnosed and treated in our institute from June 2010 to March 2018 was conducted (lost to follow-up: 3). Data were retrieved according to the items including age, gender, primary tumor, interval to the ISCM occurrence, ISCM segments, and other synchronous metastases. The interventions, response, prognostic factors, and outcomes of ISCM were systematically analyzed.

Results: Lung cancer (67.21%) was the commonest ISCM source, followed by breast cancer (14.75%). In total, 9.84% of patients presented with ISCM initially. The mean span from the primaries to ISCM was 18.77 months (range=0–10 years). The thoracic segment was most commonly involved (77.05%), followed by cervical (39.34%), lumbar level (34.43%), and conus medullaris (6.56%). The management of ISCM was challenging, since 55.74% of individuals had a poor physical condition (PS=3–4) and 72.41% had widespread dissemination synchronously (≥2 organs). Radiotherapy (RT) attained an objective response rate (ORR) of 61.90% or 62.50% and a local control rate (LCR) of 90.48% or 87.50% for symptoms used alone or with other strategies, respectively. ISCM bears a dismal prognosis, with a median overall survival (OS) of 4 months. Patients with only one segment involved had an apparently better prognosis than those with 2–4 involved segments (median OS=7.0 vs 3.0 months) (P<0.01). The OS of patients treated was remarkably superior to those without any intervention (median OS=5.0 vs 2.0 months) (P<0.01).

Conclusion: ISCM is a distinct entity needing more attention for high cancer incidence, prolonged survival, and lack of research. RT is the mainstay with satisfactory effect. Multiple spinal cord segments involvement and no treatment are poor prognostic factors of OS.