Intradural cauda equina metastases from renal cell carcinoma

Intradural Cauda Equina Metastasis of Colorectal Adenocarcinoma: A Case Report

Intradural spinal metastasis of non-neurogenic tumors is rare. Even more uncommon is intradural metastasis involving the cauda equina. Among these, colorectal adenocarcinoma metastasizing to the cauda equina is exceedingly rare, with no previously documented cases. We report a case of a 44-year-old male with a history of descending colon adenocarcinoma, initially treated with laparoscopic resection in 2011, followed by radical proctectomy for recurrent sigmoid adenocarcinoma in 2013. Over time, he developed progressive left-sided sciatica and foot drop. Imaging revealed an intradural extramedullary lesion at the cauda equina. The patient underwent L4-S2 left hemilaminectomy and S2 foraminectomy, with histopathology confirming metastatic adenocarcinoma. His postoperative recovery was uneventful, with significant pain relief and partial motor function improvement. However, local recurrence occurred at 16 months postoperatively, and the patient passed away 5.8 years after surgery. This case represents the first reported instance of intradural cauda equina metastasis from colorectal adenocarcinoma. The presumed metastatic route was via the Batson venous plexus, as systemic metastases were absent. Despite surgical resection improving symptoms, the long-term prognosis remains poor. Contrast-enhanced T1-weighted MRI is crucial for diagnosis, and total resection may contribute to prolonged survival in select patients.

The "Pigmented Side" of Nerve Sheaths: Malignant Melanotic Nerve Sheath Tumor

Malignant melanotic nerve sheath tumor (MMNST) represents a highly aggressive neoplasm arising both in peripheral and cranial nerves. It accounts for < 1% of all nerve sheath tumors, but the real incidence may not be well defined yet because of the evolution of its nomenclature. To date, it is considered a distinct tumor type, no longer as the pigmented variant of schwannoma, with a different clinical course and biological behavior. MMNSTs exhibit a specific genetic hallmark related to the PRKAR1A gene, which explains the major incidence in Carney Complex-affected patients. One of the more frequent localizations is the paravertebral region, where it poses diagnostic concerns with both primary tumors arising from soft tissues and the meningeal covering, as well as metastatic ones (ie, melanoma). Herein we present a patient with an MMNST accompanied by the main clinical, radiological, histopathological, and molecular findings, stressing the need for a multidisciplinary diagnostic approach. To the best of our knowledge, this is the first report of proton beam therapy for MMNST. We also performed a literature review to collect and compare the more recent data in English literature and to highlight the "keep-in-mind" concepts to apply in a multidisciplinary diagnostic algorithm, with a focus on histopathology and related pitfalls.

Perioperative management of antithrombotic therapy in elderly patients undergoing lumbar discectomy: a retrospective study on 163 patients

BACKGROUND CONTEXT

The prevalence of lumbar disc herniation (LDH) has risen alongside the aging population, often necessitating neurosurgical intervention. However, managing antithrombotic medications in elderly patients with a history of major cardiovascular events (MACE) presents challenges, as treatment may require modification or cessation. This study aims to compare surgical outcomes among elderly patients receiving antithrombotic drugs and assess their impact and potential complications. The findings aim to inform the management of elderly patients with cardiovascular and spinal conditions undergoing neurosurgery.

METHODS

This retrospective, observational study was conducted at a single center. A total of 163 patients aged 60 or above who underwent lumbar discectomy for LDH were included. Patients were categorized into three groups based on their antithrombotic drug management: Group A (46 patients) replaced antiplatelet agents with low-dose aspirin for secondary prevention, Group B (54 patients) discontinued antiplatelet agents for primary prevention one week preoperatively and replaced them with LMWH, and Group C (63 patients) did not receive antithrombotic medication. Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed across all three groups. Continuous variables were compared between groups using the two-tailed Mann-Whitney test, with significance set at p < 0.05.

RESULTS

No significant differences were found in intraoperative blood loss or surgical time among groups A, B, and C. Similarly, no significant differences were observed between groups B and C across all analyzed variables. No early or delayed hemorrhagic complications occurred perioperatively or during the 3-month postoperative follow-up period.

CONCLUSIONS

The study suggests that elective discectomy surgery in patients receiving anticoagulant and antiplatelet therapies may proceed without early complications and can be safely continued perioperatively. These findings have implications for the management of elderly patients requiring neurosurgical intervention in the context of cardiovascular comorbidities.

Sacral nerve root metastasis in a patient with lung carcinoma resembling neurinoma - a case report and literature review

Intradural extramedullary metastases from systemic neoplasms are very rare, with an incidence ranging from 2% to 5% of all secondary spinal diseases. We present the case of a 53-year-old man diagnosed with lung adenocarcinoma with symptoms of severe back pain and tibial paresis. The magnetic resonance imaging (MRI) revealed an intradural lesion originating from the right S1 nerve root mimicking neurinoma. Total tumor removal was achieved via posterior midline approach. The histological examination was consistent with lung carcinoma metastasis. Due to the rarity of single nodular nerve root metastases, MRI images may be misinterpreted as nerve sheath tumors, such as schwannomas or neurofibromas. We performed a brief literature review outlining the mainstay of diagnosis, therapeutic approach, and the prognosis of these rare lesions.

Sporadic Spinal Hamartoma in Adults: A Rare Pathologic Entity

BACKGROUND

Sporadic spinal hamartomas in adults are extremely rare tumor-like lesions, without defined guidelines of treatment. The aim of this study is to investigate the peculiar features of this pathologic entity to support a more accurate diagnosis and management.

METHODS

A comprehensive and detailed literature review of sporadic spinal hamartomas in adults, including a personal case, was performed. Demographic (sex and age), clinical (presenting symptoms), radiologic and pathologic (size, localization, dural and spinal cord relationship of lesion) features, as well as treatment (time to surgery, extent of resection, perioperative and postoperative complications) and outcome (clinical) data were analyzed.

RESULTS

Seven studies, including 7 patients, were eligible for the review. A personal case was also added. Sporadic adult spinal hamartomas equally affect males and females, in a range of age from 18 to 75 years; sensory radicular deficits were detected in all patients at clinical onset; thoracic segment (4/8) of the spine and intradural compartment (6/8) were most involved. All patients underwent surgery and just one experimented postoperative complication; gross total resection was achieved in only 3 patients, mainly in an extradural localization; clinical improvement at last follow-up was reported in all but 1 patient.

CONCLUSIONS

Spinal hamartomas in adults may sometimes account for progressive worsening of neurologic symptoms and lead to potentially irreversible neurologic deficit; therefore, prompt and adequate diagnosis and treatment are mandatory. Surgical resection represents the only curative treatment and is indicated for symptomatic lesions to achieve neurologic symptoms restoration or arrest/prevent their progressive deterioration.

The Role of Surgery in Spinal Intradural Metastases from Renal Cell Carcinoma: A Literature Review

BACKGROUND

Due to the few reported cases of spinal intradural metastases from renal cell carcinoma (RCC), there is no unanimous consensus on the best treatment strategy, including the role of surgery.

METHODS

A wide and accurate literature review up to January 2022 has disclosed only 51 cases of spinal intradural metastases from RCC. Patients with extramedullary (19) and those with intramedullary (32) localization have been separately considered and compared. Demographics, clinical, pathological, management, and outcome features have been analyzed.

RESULTS

Extramedullary lesions more frequently showed the involvement of the lumbar spine, low back pain, and solitary metastasis at diagnosis. Conversely, the intramedullary lesions were most often detected in association with multiple localizations of disease, mainly in the brain. Surgery resulted in improvement of clinical symptoms in both groups.

CONCLUSION

Several factors affect the prognosis of metastatic RCC. The surgical removal of spinal metastases resulted in pain relief and the arresting of neurological deficit progression, improving the quality of life and overall survival of the patient. Considering the relative radioresistant nature of the RCC, the surgical treatment of the metastasis is a valid option even if it is subtotal, with a consequent increased risk of recurrence, and/or a nerve root should be sacrificed.