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Pagano A, Iaquinandi A, Fraioli MF, Bossone G, Carra N, Salvati M. Cauda equina syndrome from intradural metastasis of a non-neural tumor: case report and review of literature. Br J Neurosurg 2023; 37:1487-1494. [PMID: 34330176 DOI: 10.1080/02688697.2021.1958155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cauda equina syndrome (CES) is a challenging condition and it can be caused by variable entities. Leptomeningeal carcinomatosis (LC) is a multifocal seeding of the leptomeninges by malignant cells and it is observed in 1-8% of patients with solid tumors. Diagnosis of intradural metastases of the cauda equina is often delayed due to the non-specific characteristics of this condition but also to the delay of presentation of many patients. Cauda equina metastases usually occur in advanced cancers, but rarely can be the first presentation of disease. CASE DESCRIPTION A 63-year-old man presented with 6 months history of low back pain and 20 d history of bilateral sciatica, hypoesthesia of the legs and the saddle, flaccid paraparesis and bowel incontinence determine by multiple nodular small lesions on the entire cauda equina with contrast-enhancement. Total-body CT showed a millimetric lesion at the lung. The patient underwent L2-L5 laminectomy and subtotal removal and histological examination showed a small cell lung carcinoma metastasis. CONCLUSIONS In the literature, 54 cases of CES from non-CNS tumor metastasis are described. The diagnosis is challenging, back pain, with or without irradiation to the lower limbs, is the most frequently reported disturbance. In about 30% of patients there is no known malignancy and CES is the first clinical presentation. Treatment of choice is surgery, followed by radiotherapy and less frequently adjuvant chemotherapy. The surgical removal is almost always incomplete and functional outcome is often not satisfactory. Prognosis is poor.
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Affiliation(s)
- Andrea Pagano
- Department of Neurosurgery, Policlinico 'Tor Vergata', University of Rome 'Tor Vergata', Rome, Italy
| | - Andrea Iaquinandi
- Department of Neurosurgery, Policlinico 'Tor Vergata', University of Rome 'Tor Vergata', Rome, Italy
| | - Mario Francesco Fraioli
- Department of Neurosurgery, Policlinico 'Tor Vergata', University of Rome 'Tor Vergata', Rome, Italy
| | | | | | - Murizio Salvati
- Department of Neurosurgery, Policlinico 'Tor Vergata', University of Rome 'Tor Vergata', Rome, Italy
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Jalali S, Renduchintala K, Afiat TP, Pabbathi S. Schwannomas Mimicking Leptomeningeal Spread in the Setting of Breast Cancer: A Case Report. In Vivo 2023; 37:2835-2839. [PMID: 37905625 PMCID: PMC10621423 DOI: 10.21873/invivo.13398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/19/2023] [Accepted: 08/25/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Breast cancer is currently the most diagnosed cancer globally. For patients who complete breast cancer treatment, developing a survivorship plan is important, including serial history, physical examinations, and annual mammograms to look for recurrence and metastasis. CASE REPORT This is a case report of a 76-year-old female with a history of recurrent breast cancer who presented with lower-back pain and found to have MRI findings initially concerning for intradural extramedullary metastatic disease. Biopsy was later found to be consistent with benign spinal schwannomas. CONCLUSION We present a unique case of spinal masses in the setting of breast cancer initially concerning for leptomeningeal spread, later found to have benign schwannomas that mimicked leptomeningeal spread on imaging. To our knowledge, this is the first reported case of schwannomas mimicking leptomeningeal spread in a patient with a history of recurrent breast cancer. After metastasis is excluded, schwannomas should be considered in the differential of benign spinal lesions.
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Affiliation(s)
- Samuel Jalali
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL, U.S.A.;
| | | | - Thanh-Phuong Afiat
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL, U.S.A
| | - Smitha Pabbathi
- Department of Survivorship, Moffitt Cancer Center, Tampa, FL, U.S.A
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Abstract
Though metastasis and malignant infiltration of the peripheral nervous system is relatively rare, physicians should have a familiarity with their presentations to allow for prompt diagnosis and initiation of treatment. This article will review the clinical presentations, diagnostic evaluation, and treatment of neoplastic involvement of the cranial nerves, nerve roots, peripheral nerves, and muscle. Due to the proximity of the neural structure traversing the skull base, metastasis to this region results in distinctive syndromes, most often associated with breast, lung, and prostate cancer. Metastatic involvement of the nerve roots is uncommon, apart from leptomeningeal carcinomatosis and bony metastasis with resultant nerve root damage, and is characterized by significant pain, weakness, and numbness of an extremity. Neoplasms may metastasize or infiltrate the brachial and lumbosacral plexuses resulting in progressive and painful sensory and motor deficits. Differentiating neoplastic involvement from radiation-induced injury is of paramount importance as it dictates treatment and prognosis. Neurolymphomatosis, due to malignant lymphocytic infiltration of the cranial nerves, nerve roots, plexuses, and peripheral nerves, deserves special attention given its myriad presentations, often mimicking acquired demyelinating neuropathies.
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Oki N, Seki H, Sakurai T, Horiuchi Y, Kodaka K, Shimizu K. Intramedullary spinal cord metastasis to the cauda equina in a patient with HER2-positive metastatic breast cancer: A case report. Breast Dis 2022; 41:155-161. [PMID: 35094983 DOI: 10.3233/bd-210032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The rate of metastasis to the central nervous system is high in human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer patients. Metastatic cauda equina tumors are characterized by rapid progression of symptoms, thus signifying the requirement of their early treatment. However, these tumors are rarely reported, and their optimal treatment options have not been established yet. Here, we report a case study of a patient with HER2-positive breast cancer that metastasized to the cauda equina. The patient underwent urgent surgery to relieve the spinal cord compression. The pain in her back and lower limbs was greatly reduced. Unfortunately, her ability to walk did not improve sufficiently. Overall, surgical treatment may be a favorable option to improve a patient's quality of life.
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Affiliation(s)
- Naohiko Oki
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirohito Seki
- Department of Breast Surgery, Saitama Medical Center, Saitama, Japan
| | - Takashi Sakurai
- Department of Breast Surgery, Saitama Medical Center, Saitama, Japan
| | - Yosuke Horiuchi
- Department of Orthopedics, Saitama Medical Center, Saitama, Japan
| | - Keiko Kodaka
- Department of Anesthesiology, Saitama Medical Center, Saitama, Japan
| | - Ken Shimizu
- Department of Pathology, Saitama Medical Center, Saitama, Japan
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Abstract
The spine is a frequent location for metastatic disease. As local control of primary tumor pathology continues to improve, survival rates improve and, by extension, the opportunity for metastasis increases. Breast, lung, and prostate cancer are the leading contributors to spinal metastases. Spinal metastases can manifest as bone pain, pathologic fractures, spinal instability, nerve root compression, and, in its most severe form, spinal cord compression. The global extent of disease, the spinal burden, neurologic status, and life expectancy help to categorize patients as to their candidacy for treatment options. Efficient identification and workup of those with spinal metastases will expedite the treatment cascade and improve quality of life.
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Affiliation(s)
- Joshua T Wewel
- Atlanta Brain and Spine Care, Piedmont Healthcare, Atlanta, Georgia
| | - John E O'Toole
- Department of Neurosurgery, University Medical Center, Chicago, Illinois, US
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Anand SK, Garling RJ, Johns J, Shah M, Chamiraju P. Intradural extramedullary spinal metastases from uterine carcinosarcoma: A case report. Surg Neurol Int 2020; 11:354. [PMID: 33194287 PMCID: PMC7656037 DOI: 10.25259/sni_621_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/28/2020] [Indexed: 12/02/2022] Open
Abstract
Background: In recent years, improvements in oncological care have led to an increased incidence of intradural extramedullary spinal metastases (IESMs) attributed to uterine carcinosarcoma (UCS). When such lesions occur, they typically carry a poor prognosis. Here, we have evaluated newer treatments, management strategies, and outcomes for IESM due to UCS. Case Description: A 59-year-old female with a history of recurrent UCS presented with the new onset of the left lower extremity pain, numbness, and episodic urinary incontinence. When the MR revealed an enhancing intradural extramedullary mass posterior to the L1 vertebral body, she underwent a focal decompressive laminectomy. Although she improved neurologically postoperatively, she succumbed to the leptomeningeal spread of her disease within 2 postoperative months. Conclusion: Management of IESM due to UCS requires multifaceted, individualized treatment modalities, including neurosurgery, radiation therapy, and medical oncologic management to maximize outcomes.
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Affiliation(s)
- Sharath Kumar Anand
- School of Medicine, Wayne State University, Detroit, Michigan, United States,
| | | | - Jessica Johns
- School of Medicine, Wayne State University, Detroit, Michigan, United States,
| | - Manan Shah
- Department of Neurosurgery, Detroit Medical Center, Detroit, Michigan, United States
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Mackel CE, Alsideiri G, Papavassiliou E. Intramedullary-Extramedullary Breast Metastasis to the Caudal Neuraxis Two Decades after Primary Diagnosis: Case Report and Review of the Literature. World Neurosurg 2020; 140:26-31. [PMID: 32437992 DOI: 10.1016/j.wneu.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intramedullary metastases to the caudal neuraxis with exophytic extension to the extramedullary space are rare. We describe the unique case of a patient with locally recurrent breast cancer who developed an intramedullary-extramedullary metastasis to the conus medullaris and cauda equina 22 years after primary diagnosis, the longest interval between primary breast cancer and intramedullary spread to date. We also reviewed the published literature on focal breast metastases to the conus medullaris or cauda equina. CASE DESCRIPTION A 66-year-old woman with a history of node-positive estrogen receptor/progesterone receptor-positive, infiltrating ductal carcinoma diagnosed in 1997 and locally recurrent in 2007. Initial treatment included lumpectomy and targeted chemoradiation with mastectomy and hormonal therapy at recurrence. Twelve years later, she developed 6 weeks of bilateral buttock and leg pain without motor or sphincter compromise. Magnetic resonance imaging of the total spine revealed a 2 x 1.7 cm bilobed intradural, intramedullary-extramedullary, homogenously enhancing, T1-and T2-isointense lesion involving the conus medullaris and cauda equina. She underwent subtotal resection of a hormone receptor-positive breast metastasis. Her pain improved postoperatively and she was stable at 5 months. CONCLUSIONS We provide evidence that patients who present with symptoms of spinal neurologic disease and a history of hormone receptor-positive breast cancer require high suspicion for metastatic pathology, despite significant time lapse from primary diagnosis. The tumor may involve both the intramedullary and extramedullary space, complicating resection. Symptom relief and quality of life should guide resection of metastatic lesions to the caudal neuraxis.
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Affiliation(s)
- Charles E Mackel
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Ghusn Alsideiri
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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