Stereotactic body radiotherapy for intramedullary metastases: a retrospective series at the Oscar Lambret center and a systematic review.

BACKGROUND: Intramedullary metastasis (IMM) is a rare disease with poor prognosis. The incidence of IMMs has increased, which has been linked to improved systemic treatment in many cancers. Surgery and/or radiotherapy are the most commonly used treatments; only small-sample retrospective studies and case reports on stereotactic body radiotherapy (SBRT) have reported acceptable results in terms of local control and clinical improvement, with no reported toxicity. Thus, we performed this monocentric retrospective study on five cases treated with SBRT for IMMs, which we supplemented with a systematic review of the literature. METHODS: We included all patients treated for IMM with SBRT. The target tumor volume, progression-free survival, prescription patterns in SBRT, survival without neurological deficit, neurological functional improvement after treatment, and overall survival were determined. RESULTS: Five patients treated with a median dose of 30 Gy in a median number of fractions of 5 (prescribed at a median isodose of 86%) included. The median follow-up duration was 23 months. Two patients showed clinical improvement. Three patients remained stable. Radiologically, 25% of patients had complete response and 50% had stable disease. No significant treatment-related toxicity was observed. CONCLUSION: SBRT appears to be a safe, effective, and rapid treatment option for palliative patients.

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.

Carcinoma microcítico pulmonar con afectación intramedular como primera manifestación clínica / Microcitic pulmonary carcinoma with intramedular affection as the first clinical manifestation

Las metástasis intramedulares son generalmente raras y se asocian a enfermedad neoplásica avanzada. Dentro de ellas, las más frecuentes son el carcinoma no microcítico de pulmón, el cáncer de mama y el melanoma. Además es poco habitual que se trate de la primera manifestación de la enfermedad. Debido a la sintomatología tan aguda que presentan estas lesiones, es importante realizar el diagnóstico diferencial con la compresión medular. Ambas entidades producen una sintomatología muy similar, siendo la debilidad la manifestación más frecuente. A continuación, presentamos un caso clínico de metástasis intramedular como primera manifestación de una neoplasia pulmonar (AU)

Intramedullary metastases are generally rare and are associated with advanced neoplastic disease. Among them, the most frequent are non-small cell lung carcinoma, breast cancer and melanoma. It is also unusual that it is the first manifestation of the disease. Due to the acute symptoms that these lesions present, it is important to perform a differential diagnosis with spinal cord compression. Both entities produce very similar symptoms, with weakness being the most frequent manifestation. Next, we present a clinical case of intramedullary metastasis as the first manifestation of a lung neoplasm (AU)

Intramedullary spinal cord metastasis of gastric cancer.

The incidence of intramedullary spinal cord metastasis (ISCM) has been increasing because the overall survival of patients with cancer has improved thanks to recent advanced therapies, such as molecular targeted drugs, anticancer agents, and various irradiation techniques. ISCM from lung and breast cancer is the most common form among cases of ISCM. We report an extremely rare form of ISCM from gastric cancer. This 83-year-old man who had a past medical history of gastric adenocarcinoma presented with acute onset of paraparesis. Spinal magnetic resonance imaging revealed an intramedullary lesion at the upper thoracic level. Due to rapid worsening of his paresis, we decided to perform tumor extirpation. Gross total resection of the tumor was successfully performed. Pathological examination revealed poorly differentiated adenocarcinoma, suggesting the diagnosis of ISCM from gastric cancer. He demonstrated gradual improvement of paraparesis soon after surgery, although his overall survival was limited to about 6 months after surgery. When examining the etiology of acute paraparesis in elderly patients with a past medical history of cancer, ISCM should be considered in the differential diagnosis. The prognosis of ISCM from gastric cancer is still extremely limited. Unfortunately, there is currently no treatment with proven efficacy. Surgery for ISCM from gastric cancer, although a challenging procedure for spine surgeons, should be considered as a therapeutic option in these patients.

Image-Guided Robotic Radiosurgery for the Management of Intramedullary Spinal Cord Metastases-A Multicenter Experience.

BACKGROUND: Intramedullary metastases are rare and bear a dismal prognosis. Limited data are available on the treatment of such lesions. As surgery may be the mainstay of treatment for patients with resectable and localized metastatic spread, previous case reports and case series suggest radiosurgery to be another viable treatment modality. This multicenter study analyzes the efficacy and safety of robotic radiosurgery (RRS) for intramedullary metastases. METHODS: Patients who received RRS for the treatment of at least one intramedullary metastasis were included. RESULTS: Thirty-three patients with 46 intramedullary metastases were treated with a median dose of 16 Gy prescribed to a median isodose of 70%. The local control was 79% after a median follow-up of 8.5 months. The median overall survival (OS) was 11.7 months, with a 12- and 24-month OS of 47 and 31%. The 12-month progression-free survival was 42% and at 24 months 25%. In addition, 57% of patients showed either an improved or stable neurological function after treatment delivery. Systemic disease progression was the main cause of death. No significant treatment-related toxicities were observed. CONCLUSIONS: RRS appears to be a safe, time-saving and effective treatment modality for intramedullary metastases, especially for patients with unresectable lesions and high burden of disease.

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.

Intramedullary Spinal Metastatic Renal Cell Carcinoma: Systematic Review of Disease Presentation, Treatment, and Prognosis with Case Illustration.

OBJECTIVE: Renal cell carcinoma (RCC) metastases to the intramedullary spinal cord carry a grim prognosis. The purpose of this review is to provide the reader with a comprehensive and systematic review of the current literature, and to present an illustrative case that would aid in the future management of similar scenarios. METHODS: A systematic review of the literature using the PubMed electronic database was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only human clinical reports of intramedullary RCC metastasis were included. We also present an illustrative case that was treated at our institution. RESULTS: We identified 23 reports with a total of 31 patients. Of the tumors, 47% were located at the cervical level. Brain metastases were present in 41% of cases. Limb weakness (72%), urinary incontinence (41%), dysesthesia (47%), and localized spinal pain (38%) were the most frequently reported symptoms. Surgical resection alone was used in 34% of cases, followed by a combination of surgery and radiotherapy (31%), and radiotherapy alone (25%). Spinal metastases were detected an average of 32.1 months after the diagnosis of RCC, and mean patient survival after that was 8 months (range, 0-65 months). Reported survival after radiotherapy appeared to be the longest (11.2 months) compared with surgery (9.1 months) and combination therapy (5 months). CONCLUSIONS: Intramedullary spinal metastatic RCC is a rare entity with debilitating neurologic potential. Survival appears to be affected by the treatment method but is also likely influenced by the stage of discovery of the disease.

Intramedullary Spinal Cord Metastases of Malignant Melanoma: A Rare Case Report on Paraplegia in Palliative Care.

Rates of malignant melanoma have been increasing in frequency. Studies have shown that up to 46% of patients with melanoma will experience metastases to the central nervous system. Intramedullary spinal cord metastasis of malignant melanoma is rare. In advanced cancers, surgery might not be possible, and radiotherapy with corticotherapy is a viable option. In the following case, a 54-year-old male presented to the clinic with an intramedullary tumor in the D1 region. He was successfully managed with an integrated palliative care approach with concomitant cancer-directed therapy.

Surgical Treatment of Intramedullary Spinal Metastasis in Medulloblastoma: Case Report and Review of the Literature.

BACKGROUND: Medulloblastomas are common childhood central nervous system tumors that are prone to leptomeningeal spread. Intramedullary dissemination is rare with very few case reports existing in the available literature. CASE DESCRIPTION: The authors here present a case of a 14-year-old boy with Li-Fraumeni syndrome and medulloblastoma who underwent surgical resection of spinal intramedullary spread. Histopathology revealed the tumor to be anaplastic medulloblastoma, same as the intracranial lesions. Genetic testing of the metastatic deposit revealed loss of functions mutations in SUFU, NOTCH3, and TP53 and TERC amplification. An improvement in ambulatory function at short-term follow-up was noted before the patient died of disseminated disease. CONCLUSIONS: Intramedullary metastasis of medulloblastoma remains a rare disease. Surgical resection might play a possible role in management in addition to radiation and chemotherapy.

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.

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.

[Intramedullary spinal cord metastasis from gastric adenocarcinoma: Case report and review of literature]. / Metástasis intramedular de adenocarcinoma gástrico: caso clínico y revisión de la literatura.

Intramedullary spinal cord metastases are very rare and usually associated with lung or breast cancer, with gastric origin being exceptional. Their clinical onset tends to be faster than that of primary intramedullary tumours. The most common early symptoms of intramedullary spinal cord metastasis are motor deficit in one or more limbs, pain, sensory loss, and sphincter disturbances. The appearance of a rapidly progressive Brown-Séquard syndrome in an oncology patient should orientate the diagnosis of this condition. The prognosis is very poor, with a median survival of 4 months. However, recent research has shown that surgery could offer a slight benefit in survival and functionality. The case is reported of a 61-year-old man with an intramedullary spinal cord metastasis from a gastric carcinoma, as well as a literature review of this topic. It has been found that this case is the fourth one reported in the literature.

Intramedullary conus metastasis from carcinoma lung.

A 46-year-old male presented with progressive paraparesis and sensory impairment in both lower limbs since 2 months. He had urinary and bowel incontinence. On examination he had flaccid paraplegia with a sensory level at 11(th) dorsal vertebral level. Magnetic resonance imaging (MRI) scans of the lumbosacral spine showed an enhancing intramedullary lesion in the conus. The patient underwent excision of the conus mass. Histopathology confirmed the tumor to represent a poorly differentiated metastatic carcinoma from an unknown primary. A positron emission tomography-computed tomography (PET-CT) scan of the whole body revealed hypermetabolic activity in the hilum of the right lung confirmed to be a lung carcinoma on a CT-guided biopsy. The patient was undergoing chemoradiation at 1 month follow-up. The author's literature search has yielded only four other case reports of conus metastasis of which only one is in English literature. The present case report and review of literature are presented.

Intramedullary Spinal Cord Metastasis: Case Report

The authors report two cases of intramedullary metastasis from breast cancer and melanoma respectively. Both patients presented with rapidly progressing paraparesis. They were treated by laminectomy with microsurgical extirpation of the tumor and whole spine irradiation. The patient with melanoma died at 3 months postoperatively and the other with breast cancer is still alive for 40 months after being diagnosed of spinal cord metastasis. The prognosis of intramedullary spinal cord metastasis is known to be poor, however, early diagnosis and radical surgery before irreVersible deterioration of neurologic status can prolong functional survival.

Intramedullary Spinal Cord Metastasis

Intramedullary spinal cord metastasis is rare and the treatment remains controversial. The authors report a case of thoracic intramedullary spinal cord metastasis in a 74-years-old man. The patient was admitted to our hospital due to the weakness of both lower extremities and urinary difficulty. The thoracic magnetic resonance image revealed the enhanced intramedullary mass in T11-12 level. With the conservative management, the symptoms got worsen and he underwent the removal of thoracic mass. The pathologic finding was small cell cancer from the lung. After tumor removal, radiation therapy was done. We discuss the diagnosis, pathophysiology and treatment of the intramedullary spinal cord metastasis.