Intramedullary spinal cord metastasis of choriocarcinoma

The authors describe a case of choriocarcinoma that metastasized to the cerebral cortex, vertebral body, and intramedullary spinal cord. A 21-year-old woman presented with sudden headache, vomiting and a visual field defect. Brain computed tomography and magnetic resonance examinations revealed an intracranial hemorrhage in the left temporo-parietal lobe and two enhancing nodules in the left temporal and right frontal lobe. After several days, the size of the hemorrhage increased, and a new hemorrhage was identified in the right frontal lobe. The hematoma and enhancing mass in the left temporo-parietal lobe were surgically removed. Choriocarcinoma was diagnosed after histological examination. At 6 days after the operation, her consciousness had worsened and she was in a state of stupor. The size of the hematoma in the right frontal lobe was enlarged. We performed an emergency operation to remove the hematoma and enhancing mass. Her mental status recovered slowly. Two months thereafter, she complained of paraplegia with sensory loss below the nipples. Whole spine magnetic resonance imaging revealed a well-enhancing mass in the thoracic intramedullary spinal cord and L2 vertebral body. Despite chemotherapy and radiotherapy, the patient died 13 months after the diagnosis.     

Intramedullary spinal cord metastasis. Diagnostic and therapeutic considerations

The diagnosis of intramedullary spinal cord metastasis (ISM) is difficult, and treatment is usually ineffective. We review our own experience with ISM as well as the pertinent medical literature, and suggest a practical diagnostic and therapeutic approach. The problem of the diagnosis of ISM is essentially that of the differential diagnosis of a noncompressive myelopathy in a patient with systemic cancer. Most such patients prove to have ISM, meningeal carcinomatosis, radiation myelopathy, or paraneoplastic necrotizing myelopathy. Neurologic features of value in this differential diagnosis are pain, the tempo and mode of progression of symptoms, and tumor cells in the spinal fluid. Oncologic features of value are the location of the primary tumor, the past exposure to therapeutic radiation, cerebral metastases, and the extent of systemic metastatic disease. The myelogram in ISM is either normal or nonspecifically abnormal; therefore, the diagnosis must be made on clinical grounds. Although no single finding is diagnostic of ISM, a careful clinical analysis will lead to the correct diagnosis in most cases. Radiation therapy is effective treatment for ISM, but only if it is administered early, before paraplegia supervenes. Thus, the diagnosis should be made and treatment begun as soon as possible. Intramedullary spinal cord metastasis is often multifocal rather than solitary; therefore, whole-cord rather than local spinal radiation should be given, if possible. If local radiotherapy is chosen, the construction of the portal can be based on the myelogram or, in the event of a normal study, on the clinical localization of the tumor.     

Intramedullary spinal cord metastasis documented by MR imaging

A 63-year-old woman with progressive paraparesis was found to have an intramedullary spinal cord metastasis from the primary rectal cancer. Myelography and post myelography CT showed an enlargement of the spinal cord at level of the sixth to seventh thoracic vertebra. MR imaging disclosed a localized mass in the spinal cord at the same level. T2-weighted images showed an oval high signal intensity area with central low intensity, and gadolinium-DTPA-enhanced T1-weighted images demonstrated a ring enhancement. Histological examination of the spinal cord revealed an intramedullary spinal cord metastasis with intra-tumorous necrosis at T7 to T8 cord level.     

Intramedullary spinal cord metastasis as the first manifestation of a renal carcinoma

We present the case of a 69 year-old male without known antecedente who presented a clinical loss of distal force in his lower limbs during the last two months. Magnetic resonance imaging (MRI) showed an intramedullary spinal cord mass at the level of the medullaris cone. The patient was operated on; the histological diagnosis was clear cells carcinoma suggestive of metastasis from an unsuspected renal tumor that was later confirmed with an abdominal CT. When the patient's state is good, surgery can correct the neurological deficit produced by an intramedullary spinal cord lesion. The neurological state of our patient improved after the intervention, and 14 months after surgery, he has no neurological deficit in the lower limbs.     

Intramedullary spinal cord metastases

Summary Seven autopsy cases of intramedullary metastases, four in the cervical spinal cord, are reported and the literature reviewed. Whereas lung and breast cancer, malignant melanomas and lymphomas are reported as the most common primary tumors, the present series included three cases of breast carcinoma and two cases each of colon and oat cell carcinoma of the lung. Neither the clinical symptoms nor the neurological signs distinguished intramedullary metastases from the more common extradural deposits, but radiological evidence of vertebral metastases and myelographic stop were present in only one case each, and CSF cytology was negative. Intramedullary deposits in this series were neither associated with extradural tumor nor with spread into the subarachnoid space, while cerebral metastases were present in four cases. This favors hematogenous dissemination rather than direct trans-dural or perineural spread of these lesions.

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Zusammenfassung Es wird über 7 Autopsiefälle von intramedullären Metastasen, davon 4 im Halsmark, berichtet und ein Überblick des Schrifttums gegeben. Während Bronchus- und Mammakarzinome, maligne Melanome und Lymphome die häufigsten Primärgeschwülste darstellen sollen, lagen in dieser Serie 3 Mammakarzinome und je 2 Kolon- und Haferzellkarzinome des Bronchus vor. Weder der klinische Verlauf noch die neurologische Symptomatik gestatten eine eindeutige Abgrenzung gegenüber den häufigeren extraduralen Metastasen, doch lagen röntgenologisch faßbare Wirbelmetastasen und positive Myelographie nur je einmal vor; die Liquorzytologie war negativ. Intramedulläre Metastasen unserer Serie waren weder mit extraduralen Absiedelungen noch mit Befall des Subarachnoidalraumes, in 4 Fällen aber mit Hirnmetastasen verbunden. Das spricht eher für ihre hämatogene Entstehung als ein direktes transdurales oder perineurales Einwachsen des Tumors.

     

Intramedullary spinal cord abscess

We report a patient with a chronic intramedullary spinal cord abscess who suffered an episode of acute meningitis due to rupture of the abscess into the subarachnoid space.     

Intramedullary spinal cord metastasis and multiple brain metastases from urothelial carcinoma

Intramedullary spinal cord metastases (ISCM) are rare spinal cord neoplasms associated with severe neurological deterioration and poor life expectancy. However, their incidence is expected to increase as a result of advances in diagnostic techniques and longer survival of patients with cancer due to improvements in cancer therapy. Reports on ISCM from primary urothelial carcinoma are virtually non existent. We report a 74-year-old male patient with a significant history of a high-grade urothelial carcinoma who presented with progressive back pain and concomitant weakness, grade 3–4/5 proximally and 0–1/5 distally, and distal hyperesthesia and hyperalgesia, particularly of the left lower limb. MRI revealed a contrast-enhancing intramedullary lesion at Th11/Th12. Laminectomies of Th11/Th12 and lesion resection were performed. Postoperative histopathological examinations confirmed the metastatic nature of the lesion. Subsequently the patient developed multiple brain metastases. Radiation therapy was refused by the patient. We conclude that ISCM are devastating complications of systemic cancer. Early and thorough diagnosis, as well as carefully considered and prompt therapy, is important for minimizing the patient’s functional deficit, thus improving quality of life.     

Intramedullary spinal cord metastasis detected through intrathecal contrast medium computerized tomography

A case of intramedullary spinal cord metastasis is reported in which the diagnosis was possible through intrathecal contrast medium computerized tomography. The case described suggests that this method of radiologic investigation can provide a prompt identification of ISM from other noncompressive complications of systemic cancers. This is very important for radiation treatment which can be effective in the early stages of ISM.     

Intramedullary spinal cord metastasis as initial presentation of systemic cancer--report of a rare case

We report the rare case of a 74-year-old man who was admitted to our hospital with rapid progression of tetraparesis, which was most apparent in the lower right limb, sensory disturbances from C3 to S1 on the left side and recent onset of constipation and urinary retention. There was no known history of cancer. As MRI of the neck disclosed a cervical intramedullary mass lesion at C 4/5 level suspicious for a primary glial tumour, the patient underwent surgery. After microsurgical excision the histological analysis of the lesion unexpectedly revealed an intramedullary spinal cord metastasis (ISCM) of a poorly differentiated carcinoma, immunohistochemically consistent with a bronchial carcinoma. As intramedullary spinal cord metastases are generally associated with poor survival, a palliative irradiation of the levels C1-6 was additionally performed. Unfortunately tetraparesis and numbness remained. The very rare occurrence of intramedullary spinal cord metastasis and the absence of pathognomonic symptoms often lead to a delay until an underlying malignancy is discovered. Although rare, intramedullary spinal cord metastasis should be considered as a differential diagnosis of a spinal intramedullary lesion. Surgery and radiation are both options in the controversially discussed treatment of ISCM.     

Intramedullary sarcoidosis of the cervical spinal cord.

A 26-year-old male with a history of pulmonary sarcoidosis showed clinical, myelographic and intra-operative evidence of a C5-C6 spinal cord tumour, which was diagnosed by biopsy as a pure intramedullary granuloma. Among the 29 published cases of histologically proven cord sarcoidosis, only five presented with pure parenchymatous infiltration without meningeal involvement. Corticosteroids are the most useful therapy, and surgery is indicated only for minimal biopsy when the parenchyma is invaded.     

Intramedullary spinal cord glioma with intracranial seeding.

Two cases of intracranial dissemination of primary intramedullary spinal cord gliomas are reported, with a review of the literature. One patient had a post mortem confirmation and in the second, cerebral CT scan and CSF examination demonstrated the occurrence of intracranial dissemination. CSF protein was elevated on both patients and malignant cells were found late in only the one patient. Both patients had raised intracranial pressure. The mechanisms of dissemination and of raised intracranial pressure are discussed. Such dissemination may be more common than previously realised.     

Intramedullary spinal cord abscess: a case report

An 11-year-old boy presented with pain in the back, urinary retention, paraplegia and loss of sensations below L1. Investigations revealed an intramedullary lesion. An intramedullary spinal cord abscess was found at surgery. The pus was evacuated and abscess was excised. Minimal recovery was seen following surgery. Early intervention and a high index of suspicion is required in such cases.