The surgical treatment of metastatic spine tumors within the intramedullary compartment

Spinal intradural microsurgery in a nascent neurosurgical department: Lessons learned from the first 25 cases

BACKGROUND

Between 2017 and 2021, the newly established Department of Neurosurgery at Shaare Zedek Medical Center in Jerusalem, a high volume metropolitan hospital, operated on 25 intradural lesions in 24 patients (one patient had multiple tumors). In this retrospective study, we review results and lessons learned as experienced surgeons opened a new service line.

METHODS

A multidisciplinary team was assembled and led by experienced neurosurgeons with skills in both microneurosurgery and complex spine care. Standard operative techniques were used. A chart review was done to assess complications and outcome.

RESULTS

25 lesions were reviewed in 24 patients (14 female; 10 male) between the ages of 11-82 years of age. In 14 cases, gross total resection (GTR) was achieved; 11 cases underwent partial resection. Of the 11 non-GTR cases, 3 were initially planned as biopsies. In one case, there was a significant neurologic decline directly related to surgery. In a separate case, there was iatrogenic instability, necessitating further treatment.

CONCLUSIONS

We identify six lessons learned in a nascent neurosurgical department, noting that surgical excellence is of paramount importance, but that the surgeon must also expand his/her role from master technician to team leader. Both microsurgical expertise for neural anatomy and understanding of spinal biomechanics for osseous anatomy is mandatory for surgery of SIDT. This retrospective analysis of our case series demonstrates experienced neurosurgeons can successfully deploy a new service line for challenging cases to the benefit of the hospital and local community.

Spinal intramedullary uterine carcinosarcoma metastasis

Intramedullary spinal cord metastases (ISCM) are a rare and challenging manifestation of metastatic cancer that have devastating impacts on the individual's neurological function, survival expectancy and overall quality of life. Given the rarity and poor prognosis, there is a lack of consensus in management. Uterine carcinosarcoma itself is a rare cancer, accounting for less than 3% of all uterine cancers. It carries a poor prognosis, with only one-third of patients surviving beyond 5 years. There are no previous reports of uterine carcinosarcoma metastases to the spinal cord. Here, we present the case of a woman in her late 70s with a uterine carcinosarcoma intramedullary metastasis that was refractory to radiotherapy treatment and responded favourably to surgical debulking.

Impact of surgical treatment for intramedullary spinal cord metastasis on neurological function and survival: A multicenter retrospective study by the Neurospinal Society of Japan

BACKGROUND

This retrospective multicenter study aimed to analyze the characteristics and surgical outcomes of intramedullary spinal cord metastasis (ISCM) and to discuss the controversy regarding its surgical indications.

METHODS

This study included 29 ISCM patients who underwent surgery between 2009 and 2020. Biopsy cases were excluded from analysis. For functional and neurological functional assessments, Karnofsky Performance Status (KPS, %) and modified McCormick Scale (MMS, 5-grade scale) scores were determined before and after surgery. Patients were divided into two groups: a mild-to-moderate disability group with preoperative MMS grades 1 to 3, and a severe disability group with preoperative MMS grades 4 to 5.

RESULTS

The mean preoperative KPS was 45.9, and the mean duration from symptom onset to surgical intervention was 1 month. The ISCM was located in the cervical spine in 10 cases and the thoracic spine in 19 cases. The access route (myelotomy) for ISCM removal was via the posterior median sulcus in 9 cases and via the posterior lateral sulcus in 11 cases, while others were not recorded. The degree of removal was gross total resection in 20 patients (69%), subtotal resection in 0 patients, and partial removal in 9 patients (31%). No significant complications related to the surgical procedures were recorded. Postoperative adjuvant therapy included radiotherapy in 17 patients (58.6%) and chemotherapy or molecular targeted therapy in 13 patients (44.8%). Pathological findings of ISCM showed that colorectal cancer was the most common in 9 cases, followed by lung cancer in 7, renal cell carcinoma in 5, and breast cancer in 2. Twenty-one of the 29 patients (72.4%) were confirmed to have survived 6 months after surgery: 8 of the 10 patients (80%) in the mild-to-moderate disability group and 13 of the 19 patients (68.4%) in the severe disability group. At 6 months after surgery, 3 of the 8 patients (38%) in the mild-to-moderate group were able to maintain or improve their function. Eleven of the 13 patients (85%) in the severe disability group maintained their function despite being severely disabled.

CONCLUSIONS

This study suggests that surgical treatment can maintain or improve neurological function in a limited number of patients with ISCM, although it had minimal impact on improving the survival rate after surgery.

Intramedullary spinal cord metastasis of clear cell renal carcinoma in a Von Hippel–Lindau patient

Background:

Intramedullary spinal cord metastasis is uncommon and represents only 0.6% of all spinal tumors. Renal cell carcinoma is even less frequent in this group than in lung and breast cancer. Patients with Von Hippel– Lindau disease (VHLd) present spinal hemangioblastoma more frequently.

Case Description:

A 59-year-old female patient presented with medullary syndrome. There was a previous history of VHLd, with a cerebellar hemangioblastoma resection years ago. The radiological investigation showed a cervical intramedullary solid-cystic lesion. The patient has submitted a tumor resection, and a pathological and immunohistochemistry study confirmed clear cell renal carcinoma metastasis.

Conclusion:

In patients with VHLd, the presence of an intramedullary solid-cystic lesion may not represent always a hemangioblastoma. Other diagnostic possibilities must be evaluated, despite being epidemiologically less frequent. Inside the group of patients with VHLd, only a previous case of intramedullary spinal cord renal cell carcinoma was reported in the literature.

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.

Clinical Features, Treatments, and Prognosis of Intramedullary Spinal Cord Metastases From Lung Cancer: A Case Series and Systematic Review

Objective

Intramedullary spinal cord metastasis from lung cancer (ISCM-LC) are increasing in prevalence. We aim to investigate its clinical features, treatments and prognosis.

Methods

We reported 6 ISCM-LC cases and conducted a systematic review. Descriptive summarization, survival analysis, and multivariate Cox regression analysis were performed to comprehensively study the disease.

Results

All 6 patients had surgery. One used chemotherapy and the other had targeted drugs. Two patients died of ISCM-LC, 1 died of pulmonary embolism, 1 was alive, and 2 were lost to follow-up. We identified 197 ISCM-LC cases in literature with a mean age of 58 years and male preponderance. Small cell lung cancer accounted for 39.1%. The median interval from lung cancer to ISCM-LC was 7 months. Limb weakness was the most common symptom, and 45% cases progressed rapidly. Concomitant brain, leptomeningeal, and vertebral metastasis occurred to 55.8%, 20%, and 19.5%, respectively. Peritumoral edema appeared in 83.3%. Through survival analysis, we found sex, extraspinal metastasis, pathology, and improved symptoms affected the overall survival. Additionally, gross total resection (GTR) shared similar effectiveness with non-GTR, and other treatments following surgery hardly added extra effect. Surgery, improved symptoms, and sex were 3 independent prognostic factors after adjusting for confounding. The estimated median survival time was 5 months.

Conclusion

The overall survival of ISCM-LC remains poor. Surgery is an independent protective factor for survival. Surgery should be considered once tolerated, and GTR might not be necessary. In addition, female patients with improved symptoms after intervention might have better overall survival.

Stereotactic body radiotherapy for intramedullary metastases: a retrospective series at the Oscar Lambret center and a systematic review

BACKGROUND

Intramedullary metastasis (IMM) is a rare disease with poor prognosis. The incidence of IMMs has increased, which has been linked to improved systemic treatment in many cancers. Surgery and/or radiotherapy are the most commonly used treatments; only small-sample retrospective studies and case reports on stereotactic body radiotherapy (SBRT) have reported acceptable results in terms of local control and clinical improvement, with no reported toxicity. Thus, we performed this monocentric retrospective study on five cases treated with SBRT for IMMs, which we supplemented with a systematic review of the literature.

METHODS

We included all patients treated for IMM with SBRT. The target tumor volume, progression-free survival, prescription patterns in SBRT, survival without neurological deficit, neurological functional improvement after treatment, and overall survival were determined.

RESULTS

Five patients treated with a median dose of 30 Gy in a median number of fractions of 5 (prescribed at a median isodose of 86%) included. The median follow-up duration was 23 months. Two patients showed clinical improvement. Three patients remained stable. Radiologically, 25% of patients had complete response and 50% had stable disease. No significant treatment-related toxicity was observed.

CONCLUSION

SBRT appears to be a safe, effective, and rapid treatment option for palliative patients.

Image-Guided Robotic Radiosurgery for the Management of Intramedullary Spinal Cord Metastases-A Multicenter Experience

Simple Summary

Due to recent medical advancements, patients suffering from metastatic cancer have a prolonged life expectancy compared to several decades ago. Thus, the number of patients who experience metastasis to the spinal cord is increasing. Intramedullary metastases bear a dismal prognosis and cause considerable morbidity. Limited data are available on the treatment of such lesions. As surgery may be the mainstay of treatment for resectable and localized metastatic spread, previous case reports and series suggest radiosurgery to be a treatment alternative. This first multicenter study analyzes the efficacy of robotic radiosurgery (RRS) for the management of intramedullary metastases. Outcomes provide evidence that RRS is a safe, time-saving and effective treatment modality, especially for patients with unresectable lesions. Most patients die from systemic disease progression, while the majority of treated lesions remain controlled until death. Most symptoms improve or stay stable after treatment. These findings may guide further palliative care of affected patients.

Abstract

Background: Intramedullary metastases are rare and bear a dismal prognosis. Limited data are available on the treatment of such lesions. As surgery may be the mainstay of treatment for patients with resectable and localized metastatic spread, previous case reports and case series suggest radiosurgery to be another viable treatment modality. This multicenter study analyzes the efficacy and safety of robotic radiosurgery (RRS) for intramedullary metastases. Methods: Patients who received RRS for the treatment of at least one intramedullary metastasis were included. Results: Thirty-three patients with 46 intramedullary metastases were treated with a median dose of 16 Gy prescribed to a median isodose of 70%. The local control was 79% after a median follow-up of 8.5 months. The median overall survival (OS) was 11.7 months, with a 12- and 24-month OS of 47 and 31%. The 12-month progression-free survival was 42% and at 24 months 25%. In addition, 57% of patients showed either an improved or stable neurological function after treatment delivery. Systemic disease progression was the main cause of death. No significant treatment-related toxicities were observed. Conclusions: RRS appears to be a safe, time-saving and effective treatment modality for intramedullary metastases, especially for patients with unresectable lesions and high burden of disease.

Presentation of spinal cord and column tumors

Metastatic spine disease occurs in more than 10% of all cancer patients. Advances in systemic treatment for cancer has led to improved overall survival for many types of cancer, which has increased the overall incidence of spinal metastases. The most common presenting complaint of patients with spinal metastases is pain. Pain originating from spinal metastases can be oncological, mechanical, and/or neurological in nature. Early recognition of these symptoms is helpful to guide treatment and accurately gauge patient prognosis. Unfortunately, the prevalence of degenerative back pain in the general population can complicate early clinical recognition of patients with metastatic spine disease. Therefore, back pain in any patient with a history of malignancy should prompt clinicians to perform an expedited workup for metastatic disease of the spine. Diagnostic imaging and laboratory studies are part of the initial work up. Obtaining pathology via biopsy to establish tumor histology is essential to determine the appropriate treatment.

Intramedullary Spinal Cord Metastasis from Primary Lung Neuroendocrine Carcinoma: A Case Report and Operative Video

BACKGROUND

Intramedullary spinal cord metastasis (ISCM) account for a minority of all spinal cord tumors. Rarely, symptoms from ISCM may be the initial presentation of an unknown primary carcinoma. Intramedullary metastasis from a second malignancy or from an unknown neuroendocrine malignancy is extremely rare and has never been reported in the literature. Because of the rarity of these tumors and the low volume of cases, well-defined treatment guidelines do not exist for the management of ISCM. Here we present a rare and one of the first reports of an intramedullary metastatic neuroendocrine tumor.

CASE DESCRIPTION

A 66-year-old woman with a history of breast cancer presented with worsening bilateral lower extremity numbness for 2 months. Imaging revealed an intramedullary spinal cord tumor at the T4 level. The patient underwent microsurgical resection of the intramedullary spinal cord tumor. At operation, the tumor had an exophytic component. Subtotal resection was achieved. Pathology revealed a neuroendocrine metastasis, likely pulmonary in origin. She achieved partial resolution of neurologic symptoms at follow-up.

CONCLUSIONS

Neuroendocrine ISCM are rare and lack well-defined treatment guidelines. Care should be individualized in these cases. Whenever feasible, surgical resection should be considered. Despite multidisciplinary care, the prognosis is dismal with limited life expectancy. Larger, multiinstitutional, or national database studies are needed that compare treatment modalities in the management of ISCM to identify the therapy with the best outcomes.

Intramedullary-Extramedullary Breast Metastasis to the Caudal Neuraxis Two Decades after Primary Diagnosis: Case Report and Review of the Literature

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.

Initial Report of an Intradural Extramedullary Metastasis of a Pancreatic Neuroendocrine Tumor to the Cervical Spine: A Case Report and Review of the Literature

BACKGROUND

Pancreatic neuroendocrine tumors (pNETs) are known to frequently metastasize to the liver and lymphatics; however, metastasis to the spine is exceedingly rare. We report the first case of an intradural, extramedullary pNET metastasis to the upper cervical spine.

CASE DESCRIPTION

A 75-year-old Hispanic male patient with history of stage IV pNET with metastasis to the liver and lymph nodes and new-onset lymphadenopathy seen on CT of the chest was found on positron emission tomography scan to have a lesion in the cervical spine. The patient was neurologically intact on physical examination, yet given the patient's medical history, magnetic resonance imaging of the cervical spine was performed, revealing a right-sided intradural, extramedullary mass at the C1-C2 level with associated mass effect on the spinal cord, likely representing a schwannoma. Due to the tumor size, mass effect, and the need for definitive tissue diagnosis, a partial C1-C2 laminectomy with intradural resection of the tumor was performed. The histology was consistent with the patient's known pNET.

CONCLUSIONS

As treatment for pNETs has evolved, there has been a surge in unique presentations of systemic well-differentiated pNETs being reported. It is vital that patients diagnosed with pNET be monitored for metastases, and when discovered, treated promptly.

Microsurgical Resection of Lung Carcinoma Spinal Cord Metastasis: 2-Dimensional Operative Video

This video demonstrates microsurgical resection of intramedullary spinal cord metastasis of lung adenocarcinoma. Lung cancer is the predominant cause of rare metastatic intramedullary involvement of the spinal cord.1-4 Because of severe disabilities, these tumors should be considered for treatment with the goal of complete removal to preserve neurological functioning.5-9  Surgical resection improves symptoms, preserves ambulatory status, and increases survival time twice that of nonsurgical treatments.3,8,10 Surgery can be effective in arresting neurological decline.11,12 To our knowledge, this is the first video report of an intramedullary spinal cord metastasis resection.  A 69-yr-old male with history of lung cancer presented with acute onset left arm abduction, forearm flexion, and hand weakness (3/5) and gait disturbance. Cervical spine MRI revealed C4/C5 nonhomogenously enhancing intramedullary tumor measuring 22 × 10 × 7 mm. Sagittal T2-weighted image demonstrated extensive cord edema.  The C4 and C5 laminectomies were performed. Microsurgical techniques were employed.13-15 Metastasis involved the left lateral aspect of the cord with invasion of 2 left dorsal sensory nerve roots, which were resected. Further transection of the dentate ligament relaxed the spinal cord, enabling safer tumor resection. Pial dissection using bipolar forceps, microscissors, and microdissector enabled tumor delivery. Following resection, dural closure was reinforced with previously harvested fat tissue graft to prevent CSF leak.16  Postoperative MRI revealed complete macroscopic resection with improvement of spinal cord swelling. Patient improved his gate and his left arm motor strength was stable. Subsequently, patient received focal adjuvant radiotherapy. Written consent was obtained directly from the patient.

Intramedullary Spinal Metastatic Renal Cell Carcinoma: Systematic Review of Disease Presentation, Treatment, and Prognosis with Case Illustration

OBJECTIVE

Renal cell carcinoma (RCC) metastases to the intramedullary spinal cord carry a grim prognosis. The purpose of this review is to provide the reader with a comprehensive and systematic review of the current literature, and to present an illustrative case that would aid in the future management of similar scenarios.

METHODS

A systematic review of the literature using the PubMed electronic database was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only human clinical reports of intramedullary RCC metastasis were included. We also present an illustrative case that was treated at our institution.

RESULTS

We identified 23 reports with a total of 31 patients. Of the tumors, 47% were located at the cervical level. Brain metastases were present in 41% of cases. Limb weakness (72%), urinary incontinence (41%), dysesthesia (47%), and localized spinal pain (38%) were the most frequently reported symptoms. Surgical resection alone was used in 34% of cases, followed by a combination of surgery and radiotherapy (31%), and radiotherapy alone (25%). Spinal metastases were detected an average of 32.1 months after the diagnosis of RCC, and mean patient survival after that was 8 months (range, 0-65 months). Reported survival after radiotherapy appeared to be the longest (11.2 months) compared with surgery (9.1 months) and combination therapy (5 months).

CONCLUSIONS

Intramedullary spinal metastatic RCC is a rare entity with debilitating neurologic potential. Survival appears to be affected by the treatment method but is also likely influenced by the stage of discovery of the disease.

Prognostic significance of pretreatment plasma D-dimer levels in patients with spinal chordoma: a retrospective cohort study

PURPOSE

Plasma D-dimer levels, a marker of hypercoagulation, have not only been used as an indicator for cascaded reaction in the coagulation process but are also reported to be an underlying biomarker in several types of cancers. This retrospective cohort study was designed to evaluate the prognostic value of preoperative plasma D-dimer level in patients with spinal chordoma.

METHODS

We enrolled 224 patients who underwent surgery for spinal chordoma between 2002 and 2015 at Changzheng Orthopedic Oncology Center. Preoperative clinical parameters were recorded and evaluated by univariate and multivariate Cox regression models. The correlation between preoperative plasma D-dimer levels and survival was assessed using the Kaplan-Meier method.

RESULTS

The optimal cutoff value of pretreatment D-dimer was 840 μg/L determined by X-tile. DFS (disease-free survival) was 64.7% and OS (overall survival) was 75% in the cohort. Multivariate Cox regression model identified D-dimer level as an independent prognostic factor of DFS and OS, as well as treatment history, preoperative Karnofsky Performance Scale, preoperative Frankel score, pathology classification and adjuvant radiotherapy (p < 0.05). In addition, D-dimer level may also be an effective supplement for defining tumor Enneking staging (p < 0.05).

CONCLUSIONS

Higher pretreatment plasma D-dimer level was associated with a poor prognosis in chordoma and could be used as an independent prognostic factor for the survival of the patients with spinal chordoma. With supplementation of D-dimer level, Enneking stage may be more able to accurate stratify individualized risk and determine clinical management. These slides can be retrieved under Electronic Supplementary Material.

Intradural spinal tumors in adults-update on management and outcome

Among spinal tumors that occur intradurally, meningiomas, nerve sheath tumors, ependymomas, and astrocytomas are the most common. While a spinal MRI is the state of the art to diagnose intradural spinal tumors, in some cases CT scans, angiography, CSF analyses, and neurophysiological examination can be valuable. The management of these lesions depends not only on the histopathological diagnosis but also on the clinical presentation and the anatomical location, allowing either radical resection as with most extramedullary lesions or less invasive strategies as with intramedullary lesions. Although intramedullary lesions are rare and sometimes difficult to manage, well-planned treatment can achieve excellent outcome without treatment-related deficits. Technical advances in imaging, neuromonitoring, minimally invasive approaches, and radiotherapy have improved the outcome of intradural spinal tumors. However, the outcome in malignant intramedullary tumors remains poor. While surgery is the mainstay treatment for many of these lesions, radiation and chemotherapy are of growing importance in recurrent and multilocular disease. We reviewed the literature on this topic to provide an overview of spinal cord tumors, treatment strategies, and outcomes. Typical cases of extra- and intramedullary tumors are presented to illustrate management options and outcomes.