Frequency of neurological disease in a cancer hospital

The spectrum of malignancies presenting with neurological manifestations: A prospective observational study

Introduction

A neurological consultation is needed in nearly 45% of patients suffering from cancer. The present study was planned to evaluate the clinical, radiological and histopathological spectrum of patients with an underlying malignancy and presenting with a neurological complaint.

Materials and Methods

We prospectively evaluated all patients provisionally diagnosed either with a primary or secondary malignancy of the brain on the basis of clinical, radiological and/or histopathological features.

Results

A total of 155 patients were enrolled from a total of 4893 admissions done from January 2015 to July 2016. The common presenting symptoms were headache, back pain and paraparesis. Around 26% of patients presented with an altered sensorium, 19.4% with seizures and 21% had at least one cranial nerve involvement. The most common site of involvement was the brain noted in 49.7% of patients. Primary malignancies constituted 78 cases (50.7%) while secondary malignancies included 77 cases (49.3%). Magnetic resonance imaging (MRI) revealed 92 (59.4%) intra-axial lesions and 59 (38.1%) extra-axial lesions, with five cases having both. The most common diagnoses were intra-cerebral metastases and glioblastoma (intra-axial), and vertebral metastases and meningioma (extra-axial). Histopathological confirmation was obtained in 59 patients (38.1%) with 12 primary and 47 secondary lesions. Ten (6.45%) patients had an unknown primary with secondary metastases. The three most common histopathologically confirmed diagnoses were adenocarcinoma lung, plasma cell dyscrasia and adenocarcinoma prostate.

Conclusion

Primary neurological consultations with an unknown primary are common hence a high index of suspicion can prevent an inadvertent delay in the diagnosis and appropriate treatment of a malignant lesion. Developing a neuro-oncology register may help us in gaining more insight into such situations.

The position of the neurologist in neuro-oncology

Neuro-oncology is a growing new subspeciality with a strong interdisciplinary character. This position paper explains the role of neurology in the multidisciplinary field of neurosurgeons, radiotherapists and general oncologists, dealing with neuro-oncological patients. The paper delineates the varied spectrum of the field of neuro-oncology which expands from primary brain tumours, to metastatic and non-metastatic effects of systemic cancer on the central and peripheral nervous system, neurotoxicity due to cancer treatment and issues of quality of life. It has been written by the scientific neuro-oncology panel of the European Federation of Neurological Societies (EFNS) to delineate the situation of neuro-oncology in Europe, and facilitate the understanding and implementation of this subspeciality in the future.

Intraneural nerve metastasis with multiple mononeuropathies

Although cancer is a frequent condition, neoplastic involvement of the peripheral nervous system is rare. The mechanisms are heterogeneous and include lesions within the cerebrospinal fluid (CSF) space, local invasion (e.g. brachial plexus), compression, rarely direct infiltration, perineurial spread and even rarer intranerval metastasis. A 47-year-old woman had been treated for a carcinoid 10 years earlier and had received axillar irradiation. At presentation she suffered from weakness of the biceps brachii and was experiencing pain radiating from the axilla into the forearm and thumb. MR scans of the brachial plexus were negative and her symptoms were primarily considered to stem from a postradiation brachial plexopathy, Because of increasing pain, the brachial plexus was explored and a metastasis in the left musculocutaneous nerve was resected. Several months later, numbness and pain appeared in the ulnar nerve and another intrafascicular metastasis in the ulnar nerve was discovered. Resection with preservation of remaining fascicles was performed. This rare case report demonstrates that multiple mononeuropathies, resembling multiplex neuropathy, may be caused by intranerval metastasis.

Pain due to epidural tumor in cancer patients. Report of two cases and differential diagnosis

The cases of two patients with inguinal pain as the only symptom of a T12 metastatic lesion is reported. The patterns of pain referrals from tumor lesions to the spine, epidural space, and spinal cord are reviewed. Focal back pain and pain reported in a distal distribution can both be associated with epidural or cord disease. The differential diagnosis of back pain in patients with cancer can be difficult but may be crucial in differentiating important neurological complications of systemic neoplasms.

Cardiovascular, pulmonary, and cancer rehabilitation. 3. Cancer rehabilitation

This self-directed learning module highlights several important rehabilitation aspects in the care of persons with cancer. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the organization of a cancer rehabilitation team, unique rehabilitation issues presented by specific common tumors, and the impact of common complications on successful rehabilitation outcomes.

The spectrum of neurological disease in patients with systemic cancer

To ascertain the range of neurological problems in patients with systemic cancer, we prospectively evaluated neurological symptoms, neurological diagnoses, and primary tumors in all patients with a history of systemic cancer examined by the Department of Neurology at the Memorial Sloan-Kettering Cancer Center, from Jul 1, 1990, to Dec 31, 1990. Of the 815 patients seen for neurological symptoms, less than half (45.2%) had metastatic involvement of the nervous system. The three most common symptoms were back pain (18.2%), altered mental status (17.1%), and headache (15.4%). The most common neurological diagnosis was brain metastasis (15.9%), followed by metabolic encephalopathy (10.2%), pain associated with bone metastases only (9.9%), and epidural extension or metastasis of tumor (8.4%). Of 133 patients with undiagnosed back or neck pain, 44 (33%) had epidural extension or metastases from tumor and 40 (30%) had pain associated with vertebral metastases only. In 15 (11%) the cause for the back pain was unrelated to metastatic disease. Of 132 patients seen on initial consultation for altered mental status, metabolic encephalopathy was the major neurological diagnosis (80; 61%); 20 (15%) had intracranial metastases. Of 97 patients with undiagnosed headache, 59 (61%) had a nonstructural cause. Fifty-three of these patients had either migraine, tension headache, or headache related to systemic illness (e.g., fever, sepsis). These results indicate that even in patients with systemic cancer, a group particularly prone to developing neurological disease that can be diagnosed radiologically, the role of clinicians remains important in helping distinguish noncancer-related and nonmetastatic neurological problems.