Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series

Neurologic pathologies of the vertebral spine

At some institutions, musculoskeletal and general radiologists rather than neuroradiologists are responsible for reading magnetic resonance imaging (MRI) of the spine. However, neurological findings, especially intrathecal ones, can be challenging. Intrathecal neurological findings in the spine can be classified by location (epidural, intradural extramedullary, and intramedullary) or etiology (tumor, infection, inflammatory, congenital). In this paper, we provide a succinct review of the intrathecal neurological findings that can be seen on MRI of the spine, primarily by location and secondarily by etiology, in order that this may serve as a helpful guide for musculoskeletal and general radiologists when encountering intrathecal neurological pathologies.

Conventional and Advanced Imaging of Spinal Cord Tumors

Spinal cord tumors are best identified by conventional MR imaging with contrast. Most intramedullary spinal cord tumors have characteristic MR imaging features that allow an accurate preoperative diagnosis. The spinal cord tumors reviewed in this article include the most common tumors, ependymomas and astrocytomas, as well as the less common tumors such as hemangioblastomas and metastases. Rare tumors such as primary CNS lymphoma and melanocytic tumors are also described. Advanced imaging techqniques of more common intramedullary tumors are also reviewed.

Nonbrain metastases seen on magnetic resonance imaging during metastatic brain tumor screening

Although metastases found during head magnetic resonance imaging (MRI) are not limited to metastatic brain tumors, the MRI is a very common method for “brain metastasis screening,” a modality that is being increasingly performed. In this review, we describe MRI findings of nonbrain metastases and discuss ways to avoid missing these lesions. Metastatic cranial bone tumors are among the most common nonbrain metastatic lesions found on head MRI, followed by leptomeningeal carcinomatosis. The other less-frequent metastatic lesions include those in the ventricle/choroid plexus, the pituitary gland and stalk, and the pineal gland. Metastases in the head and neck area, as well as cranial and intracranial lesions, should be carefully evaluated. Furthermore, direct geographical invasion, perineural spread, and double cancers should also be considered. While it is important to recognize these metastatic lesions on MRI, because they may necessitate a change in treatment strategy that could lead to an improvement in prognosis due to early introduction of therapy, nonbrain lesions should also be given greater attention, given the increasing survival of patients with cancer and advances in MRI technology, such as contrast-enhanced-3D T1-weighted imaging.

Neuroimaging features in inflammatory myelopathies: A review

Spinal cord involvement can be observed in the course of immune-mediated disorders. Although multiple sclerosis (MS) represents the leading cause of inflammatory myelopathy, an increasing number of alternative etiologies must be now considered in the diagnostic work-up of patients presenting with myelitis. These include antibody-mediated disorders and cytotoxic T cell-mediated diseases targeting central nervous system (CNS) antigens, and systemic autoimmune conditions with secondary CNS involvement. Even though clinical features are helpful to orient the diagnostic suspicion (e.g., timing and severity of myelopathy symptoms), the differential diagnosis of inflammatory myelopathies is often challenging due to overlapping features. Moreover, noninflammatory etiologies can sometimes mimic an inflammatory process. In this setting, magnetic resonance imaging (MRI) is becoming a fundamental tool for the characterization of spinal cord damage, revealing a pictorial scenario which is wider than the clinical manifestations. The characterization of spinal cord lesions in terms of longitudinal extension, location on axial plane, involvement of the white matter and/or gray matter, and specific patterns of contrast enhancement, often allows a proper differentiation of these diseases. For instance, besides classical features, such as the presence of longitudinally extensive spinal cord lesions in patients with aquaporin-4-IgG positive neuromyelitis optica spectrum disorder (AQP4+NMOSD), novel radiological signs (e.g., H sign, trident sign) have been recently proposed and successfully applied for the differential diagnosis of inflammatory myelopathies. In this review article, we will discuss the radiological features of spinal cord involvement in autoimmune disorders such as MS, AQP4+NMOSD, myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and other recently characterized immune-mediated diseases. The identification of imaging pitfalls and mimics that can lead to misdiagnosis will also be examined. Since spinal cord damage is a major cause of irreversible clinical disability, the recognition of these radiological aspects will help clinicians achieve a correct and prompt diagnosis, treat early with disease-specific treatment and improve patient outcomes.

Imaging Features of Intramedullary Spinal Cord Lesions with Histopathological Correlation

Purpose Most of the intramedullary spinal cord lesions have a component of insidious myelopathic changes at the time of diagnosis. Among the spinal cord lesions, intramedullary neoplasms are rare (25%). They represent 4 to 10% of all central nervous system tumors. But due to involvement of tracts, they are associated with significant neurological symptoms. Their imaging features can help early diagnosis and predict prognosis. We aim to narrow down differential diagnoses of intramedullary lesions based on imaging findings.

Materials and Methods This retrospective study included 40 patients as a sample that underwent magnetic resonance imaging spine at our institution (on 3T machine). Patient population had varied clinical complaints, ranging from headache, nausea, vomiting, motor weakness, bladder and bowel involvement, progressive paraparesis to paraplegia. Lesions were evaluated site, size, margin, associated cysts, signal intensity, enhancement, and associated syringohydromyelia.

Results This study obtained majority of the lesions to be ependymoma (15) and astrocytoma (11), followed by infection (4), hemangioblastoma (3), and metastasis (2). Five patients were either lost to follow-up or not operated on.

Conclusion Most of the intramedullary lesions were malignant and were showing postcontrast enhancement. Ependymomas were more frequently present in cervical region, central in location with well-defined margins and focal postcontrast enhancement. Among the total of 15 ependymomas, three cases were associated with neurofibromatosis-2. Ependymomas were more frequently associated with syringohydromyelia and peripheral hemorrhage (cap sign). Astrocytoma was more frequently seen in children, thoracic and eccentric in location with ill-defined margins. Enhancement in astrocytoma was dependent on the grade of tumor. Metastasis was a differential, with imaging characteristics dependent on type of primary. Intramedullary granuloma due to infection can also be confusing mimics of neoplasm. High-velocity signal loss due to flow voids is seen in the hemangioblastomas.

[18F]FDG-PET Evaluation of Spinal Pathology in Patients in Oncology: Pearls and Pitfalls for the Neuroradiologist

[¹⁸F]FDG-PET is a widely used technique for specific evaluation of disease and treatment response in oncology. However, the principles behind [¹⁸F]FDG-PET imaging allow a wide-ranging array of benign and malignant pathologies to be identified on both initial and routine surveillance imaging. This is important for clinicians and radiologists, alike, in that effective and accurate evaluation of malignancy and metastatic disease, specifically involving the spine and central nervous system, is crucial. In this article, we review the normal and posttherapy appearance of the spine on [¹⁸F]FDG-PET, the various types and patterns of metastatic disease that involve the spine and spinal cord, and, finally, important spinal pathologies that may mimic malignancy on [¹⁸F]FDG-PET.

Spine MRI: A Review of Commonly Encountered Emergent Conditions

Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.

Neuroimaging of Spinal Cord and Cauda Equina Disorders

PURPOSE OF REVIEW

This article reviews the neuroimaging of disorders of the spinal cord and cauda equina, with a focus on MRI. An anatomic approach is used; diseases of the extradural, intradural-extramedullary, and intramedullary (parenchymal) compartments are considered, and both neoplastic and non-neoplastic conditions are covered. Differentiating imaging features are highlighted.

RECENT FINDINGS

Although T2-hyperintense signal abnormality of the spinal cord can have myriad etiologies, neuroimaging can provide specific diagnoses or considerably narrow the differential diagnosis in many cases. Intradural-extramedullary lesions compressing the spinal cord have a limited differential diagnosis and are usually benign; meningiomas and schwannomas are most common. Extradural lesions can often be specifically diagnosed. Disk herniations are the most commonly encountered mass of the epidural space. Cervical spondylotic myelopathy can cause a characteristic pattern of enhancement, which may be mistaken for an intrinsic myelopathy. A do-not-miss diagnosis of the extradural compartment is idiopathic spinal cord herniation, the appearance of which can overlap with arachnoid cysts and webs. Regarding intrinsic causes of myelopathy, the lesions of multiple sclerosis are characteristically short segment but can be confluent when multiple. Postcontrast MRI can be particularly helpful, including when attempting to differentiate the long-segment myelopathy of neurosarcoidosis and aquaporin-4 (AQP4)-IgG-seropositive neuromyelitis optica spectrum disorder (NMOSD) and when characterizing spinal cord tumors such as primary neoplasms and metastases. Spinal dural arteriovenous fistula is another do-not-miss diagnosis, with characteristic MRI features both precontrast and postcontrast. Tract-specific white matter involvement can be a clue for diseases such as subacute combined degeneration, paraneoplastic myelopathy, and radiation myelitis, whereas gray matter-specific involvement can suggest conditions such as cord infarct, viral myelitis, or myelin oligodendrocyte glycoprotein (MOG)-IgG associated disorder.

SUMMARY

Knowledge of the neuroimaging findings of the many causes of spinal cord and cauda equina dysfunction is critical for both neurologists and neuroradiologists. A structured approach to lesion compartmental location and imaging feature characterization is recommended.

Epidemiology of spinal cord and column tumors

The spine is a frequent location for metastatic disease. As local control of primary tumor pathology continues to improve, survival rates improve and, by extension, the opportunity for metastasis increases. Breast, lung, and prostate cancer are the leading contributors to spinal metastases. Spinal metastases can manifest as bone pain, pathologic fractures, spinal instability, nerve root compression, and, in its most severe form, spinal cord compression. The global extent of disease, the spinal burden, neurologic status, and life expectancy help to categorize patients as to their candidacy for treatment options. Efficient identification and workup of those with spinal metastases will expedite the treatment cascade and improve quality of life.

Intramedullary Spinal Cord Metastasis from Primary Lung Neuroendocrine Carcinoma: A Case Report and Operative Video

BACKGROUND

Intramedullary spinal cord metastasis (ISCM) account for a minority of all spinal cord tumors. Rarely, symptoms from ISCM may be the initial presentation of an unknown primary carcinoma. Intramedullary metastasis from a second malignancy or from an unknown neuroendocrine malignancy is extremely rare and has never been reported in the literature. Because of the rarity of these tumors and the low volume of cases, well-defined treatment guidelines do not exist for the management of ISCM. Here we present a rare and one of the first reports of an intramedullary metastatic neuroendocrine tumor.

CASE DESCRIPTION

A 66-year-old woman with a history of breast cancer presented with worsening bilateral lower extremity numbness for 2 months. Imaging revealed an intramedullary spinal cord tumor at the T4 level. The patient underwent microsurgical resection of the intramedullary spinal cord tumor. At operation, the tumor had an exophytic component. Subtotal resection was achieved. Pathology revealed a neuroendocrine metastasis, likely pulmonary in origin. She achieved partial resolution of neurologic symptoms at follow-up.

CONCLUSIONS

Neuroendocrine ISCM are rare and lack well-defined treatment guidelines. Care should be individualized in these cases. Whenever feasible, surgical resection should be considered. Despite multidisciplinary care, the prognosis is dismal with limited life expectancy. Larger, multiinstitutional, or national database studies are needed that compare treatment modalities in the management of ISCM to identify the therapy with the best outcomes.

Intramedullary tumours and tumour mimics

Spinal cord lesions are traditionally classified as either extradural or intradural extramedullary or of intramedullary origin. Intramedullary spinal cord tumours are histopathologically similar to cranial tumours with a diverse range of pathologies. Astrocytomas and ependymomas account for approximately 80% of all intramedullary tumours, with other primary and secondary lesions accounting for the remaining 20%. Magnetic resonance imaging is the preferred imaging modality for diagnosing and characterising spinal cord lesions; however, accurate characterisation of tumour histology can be challenging, and is further confounded by intramedullary non-neoplastic lesions, such as demyelinating vascular, inflammatory, infectious, or traumatic lesions. This review illustrates the spectrum of intramedullary tumours and tumour mimics with emphasis on the imaging findings.

Intramedullary-Extramedullary Breast Metastasis to the Caudal Neuraxis Two Decades after Primary Diagnosis: Case Report and Review of the Literature

BACKGROUND

Intramedullary metastases to the caudal neuraxis with exophytic extension to the extramedullary space are rare. We describe the unique case of a patient with locally recurrent breast cancer who developed an intramedullary-extramedullary metastasis to the conus medullaris and cauda equina 22 years after primary diagnosis, the longest interval between primary breast cancer and intramedullary spread to date. We also reviewed the published literature on focal breast metastases to the conus medullaris or cauda equina.

CASE DESCRIPTION

A 66-year-old woman with a history of node-positive estrogen receptor/progesterone receptor-positive, infiltrating ductal carcinoma diagnosed in 1997 and locally recurrent in 2007. Initial treatment included lumpectomy and targeted chemoradiation with mastectomy and hormonal therapy at recurrence. Twelve years later, she developed 6 weeks of bilateral buttock and leg pain without motor or sphincter compromise. Magnetic resonance imaging of the total spine revealed a 2 x 1.7 cm bilobed intradural, intramedullary-extramedullary, homogenously enhancing, T1-and T2-isointense lesion involving the conus medullaris and cauda equina. She underwent subtotal resection of a hormone receptor-positive breast metastasis. Her pain improved postoperatively and she was stable at 5 months.

CONCLUSIONS

We provide evidence that patients who present with symptoms of spinal neurologic disease and a history of hormone receptor-positive breast cancer require high suspicion for metastatic pathology, despite significant time lapse from primary diagnosis. The tumor may involve both the intramedullary and extramedullary space, complicating resection. Symptom relief and quality of life should guide resection of metastatic lesions to the caudal neuraxis.

The Central Dot Sign : A Specific Post-gadolinium Enhancement Feature of Intramedullary Spinal Cord Metastases

PURPOSE

Peripheral enhancement characteristics on magnetic resonance imaging (MRI), namely the rim and flame signs, are specific for intramedullary spinal cord metastases (ISCM) compared to primary cord masses. The study compared the frequency of a novel finding-the central dot sign-in ISCMs versus primary intramedullary masses.

METHODS

In this study 45 patients with 64 ISCMs and 64 control patients with 64 primary intramedullary cord masses were investigated and 2 radiologists blinded to lesion type independently evaluated MR images for the presence of a central dot sign: a punctate focus of enhancement in/near the center of an enhancing intramedullary mass. The frequency of this sign in the two patient groups was compared.

RESULTS

A total of 63 enhancing ISCMs in 44 patients and 54 enhancing primary cord masses in 54 patients were included. The central dot sign was identified in 6% (4/63) of enhancing ISCMs in 9% (4/44) of patients and in none (0/54) of the enhancing primary cord masses (p = 0.038, per patient). The specificity for diagnosing ISCMs among spinal cord masses was 100%. The central dot sign was present in the axial plane only in two ISCMs and in the axial and sagittal planes in two ISCMs. The two ISCMs harboring the central dot sign also demonstrated both the previously described rim and flame signs, and two also demonstrated the rim sign alone.

CONCLUSION

The central dot sign is not sensitive but highly specific for ISCMs compared to primary spinal cord masses. The rim and/or flame signs may or may not be concurrently present in ISCMs.

An intramedullary "flame" recognized as being an intramedullary spinal cord metastasis from esophageal cancer

Intramedullary spinal cord metastases are rarely encountered in patients suffering from extra - central nervous system primary cancer, with only 2 described cases reported in the literature deriving from esophageal cancer. Intramedullary spinal cord metastases may occur at any level of the spinal cord but cervical location is the most frequent. We report the first case of intramedullary metastasis affecting the thoracic spinal cord from esophageal squamous cell carcinoma in a 35-year-old patient.

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.

Spinal Manifestations of Systemic Disease

The spine is frequently involved in systemic diseases, including those with neuropathic, infectious, inflammatory, rheumatologic, metabolic, and neoplastic etiologies. This article provides an overview of systemic disorders that may affect the spine, which can be subdivided into disorders predominantly involving the musculoskeletal system (including bones, joints, disks, muscles, and tendons) versus those predominantly involving the nervous system. By identifying the predominant pattern of spine involvement, a succinct, appropriate differential diagnosis can be generated. The importance of reviewing the medical record, as well as prior medical imaging (including nonspine imaging), which may confer greater specificity to the differential diagnosis, is stressed.

Metastatic Complications of Cancer Involving the Central and Peripheral Nervous Systems

Neurologic complications of cancer may involve both the central nervous system and peripheral nervous system manifesting as brain, leptomeningeal, intramedullary, intradural, epidural, plexus, and skull base metastases. Excluding brain involvement, neurologic complications affecting these other sites are relatively infrequent, but collectively they affect more than 25% of patients with metastatic cancer causing significant morbidity and mortality. Early diagnosis and intervention optimize quality of life and improve survival.

Intramedullary spinal cord metastasis from thyroid carcinoma: Case report and a systematic pooled analysis of the literature

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.

The surgical treatment of metastatic spine tumors within the intramedullary compartment

OBJECTIVE Metastasis to the spinal cord is rare, and optimal management of this disease is unclear. The authors investigated this issue by analyzing the results of surgical treatment of spinal intramedullary metastasis (IM) at a major cancer center. METHODS The authors retrospectively reviewed the medical records of 13 patients who underwent surgery for IM. Patients had renal cell carcinoma (n = 4), breast carcinoma (n = 3), melanoma (n = 2), non-small cell lung cancer (n = 1), sarcoma (n = 1), adenoid cystic carcinoma (n = 1), and cervical cancer (n = 1). Cerebrospinal fluid was collected before surgery in 11 patients, and was negative for malignant cells, as was MRI of the neuraxis. Eleven patients presented with neurological function equivalent to Frankel Grade D. RESULTS Radiographic gross-total resection was achieved in 9 patients, and tumor eventually recurred locally in 3 of those 9 (33%). Leptomeningeal disease was diagnosed in 4 patients after surgery. In the immediate postoperative period, neurological function in 6 patients deteriorated to Frankel Grade C. At 2 months, only 2 patients remained at Grade C, 8 were at Grade D, and 1 had improved to Grade E. One patient developed postoperative hematoma resulting in Frankel Grade A. Radiotherapy was delivered in 8 patients postoperatively. The median survival after spine surgery was 6.5 months. Three patients are still living. CONCLUSIONS Surgery was performed as a last option to preserve neurological function in patients with IM. In most patients, neurological function returned during the immediate postoperative period and was preserved for the patients' remaining lifetime. The data suggest that surgery can be effective in preventing further decline in selected patients with progressive neurological deficit.

Fulminant Acute Ascending Hemorrhagic Myelitis Treated with Eculizumab

We describe an 18-year-old patient who developed back pain, rapidly ascending sensomotory deficits, bladder dysfunction, Lhermitte’s sign, absent abdominal reflexes of all three levels, brisk tendon reflexes, and positive Babinski’s sign. Magnetic resonance imaging of the spinal cord showed a long segment of cervical and thoracic intramedullary signal hyperintensity suggesting a longitudinally extensive transverse myelitis possibly within the course of a fast progressing ascending immune-mediated hemorrhagic myelopathy. Throughout his illness, the patient deteriorated with tetraplegia, cardiac arrest, and respiratory failure although he received, after exclusion of infective causes, therapy with steroids, immunoglobulins, plasmapheresis, and cyclophosphamide. Interestingly, treatment with the C5-inhibitor eculizumab to prevent complement-mediated spinal cord injury achieved an arrest of clinical deterioration. We propose eculizumab as treatment in fast progressive and potentially fatal immune-mediated spinal cord injury. Furthermore, this case raises awareness for the process of clinical decision-making in severe myelopathies.

Intramedullary spinal cord metastasis from laryngeal carcinoma: case report and review of literature

Laryngeal cancer metastases are relatively rare and mainly affect the lung. The medullary localization remains exceptional. We report the case of a patient followed for operated laryngeal cancer and whose oncologic control revealed a medullary localization. A patient followed for squamous cell carcinoma of the larynx, treated in 2010 by a partial surgery whose endoscopic control at 5 years revealed the presence of right arytenoid edema without suspicious lesions, multiple biopsies were made and which returned negative. A month later, the patient presented a rebel cervical spine pain and a feeling of heaviness of the upper limbs, for which a radiological assessment was done finally objectifying a right hypopharyngeal process and a suspicious right internal jugular lymphadenopathy (biopsy confirmed the squamous type), as well as an intramedullary metastasis. This case is an illustration of an exceptional evolution of this type of cancer and a are metastatic localization difficult to highlight, which leads us to ask the question on the need of simultaneous and systematic radiological and endoscopic control treatment for operated laryngeal cancer.

Intramedullary spinal cord metastases: an increasingly common diagnosis

OBJECT Intramedullary spinal cord metastases (ISCM) represent a small proportion of intramedullary tumors. However, with the lifespans of patients with malignant tumors increasing, incidents of ISCM are on the rise. Due to threateningly severe disabilities in patients, accompanied by limited life expectancy, every attempt should be made to treat these tumors the same way as metastases elsewhere in the CNS, with the goal of complete removal of the ISCM and preservation of neurological functions. The object of this study is to retrospectively analyze the experiences of 22 patients who were surgically treated for ISCM over a 22-year period. METHODS Hospital charts of 22 patients, who were surgically treated for ISCM between 1992 and 2014, were reviewed retrospectively. Demographic data, histopathological diagnoses of primary cancer, chronological sequence of the disease, and neurological status using the simplified McCormick functional classification were collected and reanalyzed. RESULTS The most frequent histology was metastasis of lung cancer, followed by brain and breast cancers. The time span from primary cancer diagnosis to the development of symptomatic spinal metastases ranged from 0 to 285 months, with a mean interval of 38 months. The leading presenting sign was dysesthesia (77% of the population), followed by paresis (68%). Only 5 patients (23%) showed urinary retention. Initial performance status represented by the McCormick Scale was on average 2.47. Total or near-total removal was achieved in 87% of cases. Compared with the clinical status 1-2 days after surgery, there was an improvement in the McCormick Scale grade at the last follow-up from 2.47 to 2.12 (p = 0.009). Likewise, an improvement was detected when comparing the preoperative status with the last follow-up (from 2.45 to 2.12; p = 0.029). The mean survival time after surgery was 11.6 months. CONCLUSIONS These results suggest that surgery for intramedullary metastases-with all of the challenges of a rare and potentially risky procedure-can be beneficial to patients with advanced stages of cancer. Surgery can be performed with minimal new morbidity and results in maintaining neurological performance status.

Imaging of metastases from breast cancer to uncommon sites: a pictorial review

There are three types of breast cancer recurrence which can occur after initial treatment: local, regional, and distant. Distant metastases are more frequent than local and regional recurrences. It usually occurs several years after the primary breast cancer, although it is sometimes diagnosed at the same time as the primary breast cancer. Although the common distant metastases are bone, lung and liver, breast cancer has the potential to metastasize to almost any region of the body. Early detection and treatment of distant metastases improves the prognosis, therefore radiologists and clinicians should recognize the possibility of metastasis from breast cancer and grasp the imaging characteristics. In this report, we demonstrate the imaging characteristics of metastases from breast cancer to uncommon sites.

Case of intramedullary spinal cord metastasis of renal cell carcinoma

Intramedullary spinal cord tumors are rare. The improved survival resulting from more effective treatments for many cancers has led to an increased number of publications concerning intramedullary spinal cord metastasis (ISCM), including case reports and literature reviews; however, ISCM remains extremely rare in renal cancer. A 69-year-old man with a medical history of renal cell carcinoma (RCC) presented with urinary retention and bilateral paralysis of the lower extremities. A neurological examination revealed bilateral paraparesis below L1. Although brain magnetic resonance imaging (MRI), bone scintigraphy, and abdominal contrast-enhanced computed tomography revealed no abdominal findings, the thracolumbar MRI indicated a spot on the spinal cord at the Th12 level that exhibited hyperintensity on T2-weighted imaging and gadolinium diethylenetriaminepentaacetic acid enhancement on T1-weighted imaging. Accordingly, an ISCM of RCC was diagnosed. The patient rejected all treatments for these metastases except the steroid therapy. The patient’s condition deteriorated owing to metastatic progression, and he died 3 mo after the appearance of ISCM symptoms. The prognosis of this condition was poor. The mean survival durations were 8 mo with surgical treatment, 4 mo with irradiation, and 2 mo with palliative treatments. In cases involving neurological features and if brain or bone metastasis or spinal cord compression is not clearly observed, gadolinium-enhanced MRI should be performed to determine the existence of ISCM. Recently, some authors have reported the efficacy of ISCM resection. Surgical treatment could potentially yield improvements in the nervous symptoms or a longer survival after treatment. Although the prognosis was poor in most cases of ISCM, surgical treatment may improve the patient’s quality of life.

Neuroimaging of spine tumors

Intramedullary, intradural/extramedullary, and extradural spine tumors comprise a wide range of neoplasms with an even wider range of clinical symptoms and prognostic features. Magnetic resonance imaging (MRI), commonly used to evaluate the spine in patients presenting with pain, can further characterize lesions that may be encountered on other imaging studies, such as bone scintigraphy or computed tomography (CT). The advantage of the MRI is its multiplane capabilities, superior contrast agent resolution, and flexible protocols that play an important role in assessing tumor location, extent in directing biopsy, in planning proper therapy, and in evaluating therapeutic results. A multimodality approach can be used to fully characterize the lesion and the combination of information obtained from the different modalities usually narrows the diagnostic possibilities significantly. The diagnosis of spinal tumors is based on patient age, topographic features of the tumor, and lesion pattern, as seen at CT and MRI. The shift to high-end imaging incorporating diffusion-weighted imaging, diffusion tensor imaging, magnetic resonance spectroscopy, whole-body short tau inversion recovery, positron emission tomography, intraoperative and high-field MRI as part of the mainstream clinical imaging protocol has provided neurologists, neuro-oncologists, and neurosurgeons a window of opportunity to assess the biologic behavior of spine neoplasms. This chapter reviews neuroimaging of spine tumors, primary and secondary, discussing routine and newer modalities that can reduce the significant morbidity associated with these neoplasms.

Intramedullary Spinal Cord Tumors: Part I-Epidemiology, Pathophysiology, and Diagnosis

Study Design Broad narrative review. Objectives Intramedullary spinal cord tumors (IMSCT) are rare neoplasms that can potentially lead to severe neurologic deterioration, decreased function, poor quality of life, or death. As such, a better understanding of these lesions is needed. The following article, part one of a two-part series, addresses IMSCT with regards to their epidemiology, histology, pathophysiology, imaging characteristics, and clinical manifestations. Methods The authors performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives. Results Numerous IMSCT exist with varying epidemiology. Each IMSCT has its own hallmark characteristics and may vary with regards to how aggressively they invade the spinal cord. These lesions are often difficult to detect and are often misdiagnosed. Furthermore, radiographically and clinically, these lesions may be difficult to distinguish from one another. Conclusions Awareness and understanding of IMSCT is imperative to facilitate an early diagnosis and plan management.

[Intramedullary metastasis of lung adenocarcinoma: about a case]

Les métastases de la moelle épinière sont extrêmement rares. Elles surviennent chez 0,1 à 0,4% des patients cancéreux et représentent 1% de toutes les tumeurs de la colonne vertébrale et 1-3% des tumeurs intramédullaires. Le cancer du poumon est le primitif le plus fréquent. Nous rapportons le cas d'un patient de 51 ans, suivi pour un adénocarcinome pulmonaire et qui après la 1ère cure de chimiothérapie a développé des métastases intramédullaires et cérébrales. Une radiothérapie sur la moelle et le cerveau associée à une corticothérapie par voie générale ont été débutées. Le patient est décédé 3 mois après la survenue des métastases intramédullaires. A travers ce nouveau cas de métastases intarmédullaires d'un adénocarcinome pulmonaire et revue de la littérature, les auteurs insistent sur leur rareté ainsi que sur ses difficultés diagnostiques et thérapeutiques.

Longitudinally extensive transverse myelitis as presenting manifestation of small cell carcinoma lung

Longitudinally extensive transverse myelitis (LETM) is an unusual manifestation of systemic malignancy. It has been mainly reported with lung cancers and lymphoproliferative malignancy. LETM in systemic malignancy can be caused by either intramedullary metastases or paraneoplastic syndrome. We report an unusual case of small-cell carcinoma lung, who presented with LETM without having any cardinal manifestations of lung malignancy. This case report highlights the important differentiating features between intramedullary metastasis and paraneoplastic syndrome.

Intramedullary spinal cord metastasis of cholangiocarcinoma: a case report

Background

Cholangiocarcinomas are rare tumors, and metastasis to the intramedullary spinal cord is also rare. To the best of our knowledge, this is the first case of simultaneous cholangiocarcinoma and intramedullary spinal cord metastasis to be described in the medical literature.

Case presentation

A 62-year-old Caucasian male with a cholangiocarcinoma presented pain around his left shoulder without any other symptoms. The results by magnetic resonance imaging and F18 fluorodeoxyglucose positron emission tomography/computer tomography revealed an intramedullary metastasis at the C4 level, with spinal cord compression, and numerous secondary parenchymal brain metastases.

Conclusion

This patient was treated successfully with a combination of radiotherapy, corticosteroids, and chemotherapy. He experienced complete relief of the symptoms and showed improvements upon subsequent radiological evaluations.

Intramedullary spinal cord metastases: prognostic value of MRI and clinical features from a 13-year institutional case series

BACKGROUND AND PURPOSE

In patients with intramedullary spinal cord metastases, the impact of MR imaging and clinical characteristics on survival has not been elucidated. Our aim was to identify MR imaging and clinical features with prognostic value among patients with intramedullary spinal cord metastases from a large retrospective series.

MATERIALS AND METHODS

The relevant MR imaging examination and baseline clinical data for each patient from a consecutive group of patients with intramedullary spinal cord metastases had previously been reviewed by 2 neuroradiologists. Additional relevant clinical data were extracted. The influence of clinical and imaging characteristics on survival was assessed by Kaplan-Meier survival curves and log-rank tests for categoric characteristics.

RESULTS

Forty-nine patients had 70 intramedullary spinal cord metastases; 10 (20%) of these patients had multiple metastases. From the date of diagnosis, median survival for all patients was 104 days (95% CI, 48-156 days). One clinical feature was associated with decreased median survival: lung or breast primary malignancy (57 days) compared with all other malignancy types (308 days; P < .001). Three MR imaging features were associated with decreased median survival: multiple intramedullary spinal cord metastases (53 versus 121 days, P = .022), greater longitudinal extent of cord T2 hyperintensity (if ≥3 segments, 111 days; if ≤2, 184 days; P = .018), and ancillary visualization of the primary tumor and/or non-CNS metastases (96 versus 316 days, P = .012).

CONCLUSIONS

Spinal cord edema spanning multiple segments, the presence of multifocal intramedullary spinal cord metastases, and ancillary evidence for non-CNS metastases and/or the primary tumor are MR imaging features associated with decreased survival and should be specifically sought. Patients with either a lung or breast primary malignancy are expected to have decreased survival compared with other primary tumor types.

Intramedullary spinal cord metastases: visibility on PET and correlation with MRI features

BACKGROUND AND PURPOSE

Studies systematically evaluating the detection of intramedullary spinal cord metastasis with PET are lacking. Our purpose was to evaluate the visibility of intramedullary spinal cord metastasis on PET in a single institutional series and to correlate PET and MR imaging features.

MATERIALS AND METHODS

Patients were included if pretreatment MR imaging identifying an intramedullary spinal cord metastasis and an [(18)F] FDG-PET examination near the time of MR imaging were available. PET examinations were retrospectively reviewed, with reviewers blinded and then unblinded to the PET report and MR imaging findings. PET intramedullary spinal cord metastasis features were compared with and correlated with previously analyzed MR imaging lesion characteristics. Original clinical PET reports were reviewed.

RESULTS

The final study sample was 10 PET examinations in 10 patients with 13 intramedullary spinal cord metastases. In 7 (70%) patients, retrospective blinded review demonstrated convincing evidence of 10 (77%) intramedullary spinal cord metastases. Three MR imaging features correlated with intramedullary spinal cord metastases being visible on PET compared with those nonvisible, respectively: larger lesion enhancement size: mean size: 32.1 mm versus 6.0 mm (P = .038); larger longitudinal extent of T2 signal abnormality: mean 5.6 versus 1.0 segments (P = .0081); and larger ratio of extent of T2 signal abnormality to contrast enhancement: 3.8 versus 1.0 (P = .0069). Intramedullary spinal cord metastasis was confidently reported clinically in 2 (20%) patients, accounting for 5 (38%) intramedullary spinal cord metastases.

CONCLUSIONS

Most intramedullary spinal cord metastases can be detected on PET when performed near the time of pretreatment MR imaging. However, intramedullary spinal cord metastases may not be clinically reported on PET. Larger lesions with more edema are more likely to be visible. The spinal cord should be specifically and carefully assessed on PET for evidence of intramedullary spinal cord metastases to provide timely diagnosis.