Retrospective study of 19 patients with intramedullary spinal cord metastasis

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Abstract

Object

Intramedullary spinal cord metastasis (ISCM) is a rare but devastating complication of cancer. Due to both widespread MRI availability and longer survival of cancer patients, the probability of discovering an ISCM during the course of the disease has increased and raised issues regarding the management of these patients, and particularly the place of surgery. In this study, we assess predictive factors for surgical outcome and survival.

Patients and methods

We retrospectively reviewed a series of 19 patients consecutively admitted in our institution from 1993 to 2006 for ISCM, representing the second largest series published in the literature. MRI was performed on all patients. Thirteen underwent microsurgical excision of ISCM. Functional outcome was evaluated and factors influencing survival were statistically analyzed.

Results

Median survival was statistically longer when surgery was performed (7.4 vs. 2.6 months). Preoperative neurological status, nature of primary cancer, presence of systemic and/or CNS metastases influenced survival, but differences were without statistical significance. Neurological status improved in 58% (11/19) of operated patients.

Conclusions

Optimal management of patients with ISCM is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of different therapeutic options. Diagnosis should be made as early as possible and surgical resection should be considered as the primary treatment whenever feasible, particularly in the case of rapidly progressive neurological deficits and when a clear cleavage plane exists. Our study shows that surgery could result in both increased survival rate and significant improvement of neurological function.

Introduction

Intramedullary spinal cord metastases (ISCM) are infrequently observed. According to a recent review of all cases previously published in the English literature [29], ISCM clinically affects only 0.1–0.4% of all cancer patients. They represent 8.5% of central nervous system (CNS) metastases (91.5% brain metastases) and 1–3% of all intramedullary tumors. Before the era of MRI, most cases of ISCM were diagnosed only upon autopsy [9], [24], [28], [42], [45] and only 5% were recognized before death [45]. With the advent of MRI and its current availability, ISCM is more readily detected and accounts for 6% of myelopathies in cancer patients compared to 94% of spinal cord epidural metastases (SEM) [52].

Published cases are rare and include case reports [1], [2], [3], [4], [5], [8], [11], [12], [16], [19], [20], [23], [25], [26], [27], [31], [32], [33], [34], [38], [40], [41], [43], [44], [47], [48], [53], [55], [58], [59], [61], [63], short series of up to 10 patients [6], [7], [13], [14], [15], [17], [22], [35], [39], [49], [50], [56], [60], [62], [64] and autopsy series [9], [24], [28], [45]. Three case series were reported on more than 10 patients [21], [36], [49] and one case series on more than 20 patients [52].

Due to both widespread MRI availability and therapeutic advances allowing for longer survival of cancer patients, the probability of discovering an ISCM during the course of the disease has increased and raises issues regarding the management of these patients. Therapeutic options include microsurgical excision, fractioned external beam radiotherapy (RT) and palliative care. Prognosis of ISCM remains poor (7 months) but median survival varies from 9.4 months when patients have undergone surgery to 5 months when conservative treatment has been adopted [29]. Surgery, performed in 34% of published cases [29] could be considered as the optimal therapeutic approach [11], [13], [17], [21], [44] but obviously carried high risks of postoperative functional impairment [21], [60].

We reviewed our experience involving a series of 19 consecutive cases of ISCM observed in our institution from 1993 to 2006, representing the second largest reported series of ISCM. Thirteen patients underwent surgical treatment. From this experience and after reviewing the pertinent English literature previously published, we attempted to draw lessons in order to address the management of patients affected by ISCM, and particularly to select those who might benefit from microsurgical excision of ISCM.

Section snippets

Materials and methods

Nineteen patients with ISCM were retrospectively analyzed. Patients were consecutively admitted to our academic neurosurgical units over a 14-year period from January 1, 1993 to December 31, 2006. Five patients were admitted during the first half of the study period (1993–1999) and 14 patients were admitted during the second half (2000–2006).

Inclusion criteria for the study were as follows: adult patients over 18 having an intramedullary lesion diagnosed by MRI, and history of primary cancer

Patient characteristics (summarized in Table 1)

Of the 19 patients, 10 were male and nine were female. Mean age at presentation was 56, with a range of 35–75 years. Male patients were older than female patients (mean ages 59 and 50 years respectively). Lung cancer (68%, 13/19) and small cell carcinoma (6/13 patients with lung cancer in our series) was the most frequently observed primary cancer followed by breast carcinoma (16%, 3/19), digestive carcinoma (colorectal and oesophagus) (11%, 2/19) and thyroid carcinoma (5.5%, 1/19). ISCM was

Discussion

Intramedullary spinal cord metastases are very rare, although chances of discovering an ISCM along the course of the cancer have increased over the last decade due to both widespread MRI availability and therapeutic advances allowing for longer survival in cancer patients.

Conclusions

ISCM is a rare but devastating complication of malignant disease. Prognosis is poor with an overall median survival time of 6 months. The optimal management of these patients is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of the different therapeutic options. However, diagnosis should be made as early as possible and surgical resection should be considered as the primary treatment whenever feasible, particularly in the case of

Acknowledgement

The authors are grateful to Mrs Tracey Montagnon for her excellent editorial assistance

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