It is extremely rare for cancer to present as an intramedullary spinal cord metastasis. The authors report on a case of a 74-year-old woman presenting with progressive tetraparesis to metastatic colon adenocarcinoma in the spinal cord. A r eview of the literature reveals that intramedullary localization is associated with a very short life expectancy , with a median survival of 3 - 4 months from the time of the diagnosis ; nevertheless microsurgical removal of tumor can improve quality of life.
Intramedullary spinal cord metastasis (ISCMs) is an unusual complication of the cancer, representing 8.5% of CNS metastasis [
Spinal colorectal carcinoma related metastasis is extremely rare with only few cases reported in the literature so far. We report on a patient with an intramedullary metastasis from colon carcinoma. Total resection of the tumor has improved the quality of life of the patient. The aim of our paper is to emphasize the role of surgery, when there is an indication for improving the quality of life in patients with a very short life expectancy.
A 74-year-old woman had undergone colectomy, without adjuvant chemotherapy for adenocarcinoma 1 year previously. Two months before admission she developed progressive weakness of her left leg and urinary hesitancy, she also noted oppressive burning and dysesthetic pain in the neck radiating in to both arms, and back pain that persist in recumbency.
Over 3 - 4 days the patient reported progressive right lower limb weakness and a severe deterioration in the left leg, that makes impossible standing, also referred progressive weakness in the upper limbs.
Neurological findings included spastic tetraparesis with severe paresis on the left leg (2/5), the right leg had a marked weakness (3/5), in the arms she had slight bilateral weakness (4/5), hyperactive tendon reflex more prominent on the left than on the right, bilateral Babinski sign, and hypoesthesia to vibration on the left hemibody and for pinprick and temperature on the right hemibody below T1. Urinary retention and reduced anal sphincter tone were also noted.
MRI images of the spine in toto showed a solitary intramedullary lesion at C7 level, the lesion measured about 1.5 cm in cranio-caudal dimension, occupying almost the entire spinal cord (
The lesion appeared slightly hypointense on T1-w image, and hyperintense on T2-w image associated with a large proximal and distal edema extending from C3 to T3 vertebral body (
A preoperative chest radiograph showed no abnormalities, and MRI of the brain was negative for other lesions. Cerebrospinal fluid (CSF) analysis showed an elevated
protein level, but cytology was negative. Based on the progressive neurological worsening, surgical treatment was performed.
The patient underwent C6-T1 laminectomy and the dural sac exposed was opened at the midline. Once exposed, the spinal cord appeared expanded.
A median posterior myelotomy was performed and disclosed the lesion as light yellow-reddish in color with a pseudocapsule distinguishing it from surrounding spinal cord parenchyma. It was sharply dissected out and totally removed.
The histological examination showed the pathological features of adenocarcinoma metastasizing from colon cancer. No radiotherapy was planned because adenocarcinoma is unlikely to be radiosensitive.
Postoperatively, the patient progressively showed improvement in neurological function. For both arms, the muscle strength rose to 5/5; the muscle strength of the right lower limb improved up to 4/5. However, the severe paresis on the left leg did not improve and her sphinterical disturbance and urinary hesitancy were only slightly improved. After 14 months, the patients died of local recurrence of the colon carcinoma, with invasion of sigmoid colon, uterus and bladder.
ISCM is a rare clinical entity, comprising 1% - 3% of all intramedullary spinal cord tumors and accounting for only 0.1% - 0.4% of all cancer patients [2,3].
Furthermore, they account for 3% - 5% of cases of myelopathy in patients affected by cancer [
Several theories have been postulated to explain the discrepancy between the frequencies of brain and intramedullary metastasis. Arterial seeding is believed to be the most common mechanism of intramedullary metastasis. Indeed, the brain receives about one-third of the cardiac output through large vessels under high pressure, while the spinal cord receives its arterial supply from small vessels under low pressure [8,9]. Moreover, the medullary arteries branch off the aorta at the right angles, while the cerebral arteries are almost a direct extension of the aorta, thus favoring embolic seeding [
The most common origin of the ISCMs is lung cancer, especially small cell carcinoma followed, by breast cancer, melanoma, lymphoma, and renal cell carcinoma [5, 7,12]. ISCM from colorectal adenocarcinoma is extremely rare, with only few cases reported in the literature so far [4,8,11,13-20].
An exact diagnosis of an ISCM can be difficult even when the primary tumor is known, because clinical findings do not help to distinguish ISCM from other spinal cord lesions or non compressive myelopathies that can occur in cancer patients [
The differential diagnosis should include primary intramedullary tumor, spinal epidural metastasis (SEM), radiation myelopathy, paraneoplastic necrotizing myelopa
NS: not specified; Time interval: interval between colon surgery and onset of spinal symptoms; Symptoms: symptoms at onset.
thy, vascular malformations, syringomyelia, demyelinating plaques and meningeal carcinomatosis [11,18].
The most important factors to consider in diagnosis are time of clinical course, pain, and CSF cytology [
ISCMs are much less common than metastatic epidural disease, which involves the dura in 10% of all cancer patients [
The clinical pictures of radiation myelopathy and necrotizing myelopathy are usually that of a painless hemicord syndrome [
CSF findings in ISCM are usually negative or show only an increase in protein and a mild pleocytosis. If positive, meningeal involvement may have occurred [
However when a spinal lesion is suspected in a patient with a history of malignancy, MRI with gadolinium enhancement is mandatory.PET has a sensitivity of 96% in detecting spinal metastasis, and this is even more sensitive when combined with CT scan [
The prognosis of a patient who has an intramedullary spinal cord lesion is grave. Intramedullary localization is associated with a very short life expectancy with a median survival of 3 - 4 months from the time of the diagnosis [7,11]. Death is due to complications of neurologic damage and progressive systemic cancer.
The management of ISCM remains controversial since the recurrent recommendations are based on anecdotal experiences described on retrospective reports [
Modern radiotherapy techniques, such as intensity-modulated radiation therapy, cyberknife, and tomotherapy can hold promise in efficacy; however, so far, no considerable data support their use [
Several factors are important when considering surgical treatment such as patient’s age, physical condition, location, and severity of the primary neoplasm, as well as other metastasis, and surgical risk [
Like intracranial metastasis, ISCMs are often discrete, well-circumscribed deposits and subject to gross total resection.
One should consider microsurgical resection of ISCMs in patients with well-controlled radioresistant primary tumors a discrete, solitary, intramedullary metastasis, without leptomeningeal involvement [
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