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Table of Contents    
LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 5  |  Page : 561-563

Renal small cell carcinoma presenting with solitary lumbar intradural metastasis


1 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission11-Sep-2014
Date of Decision14-Sep-2014
Date of Acceptance28-Sep-2014
Date of Web Publication12-Nov-2014

Correspondence Address:
Sivashanmugam Dhandapani
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.144494

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How to cite this article:
Srinivasan A, Dhandapani S, Chatterjee D, Simha V. Renal small cell carcinoma presenting with solitary lumbar intradural metastasis. Neurol India 2014;62:561-3

How to cite this URL:
Srinivasan A, Dhandapani S, Chatterjee D, Simha V. Renal small cell carcinoma presenting with solitary lumbar intradural metastasis. Neurol India [serial online] 2014 [cited 2018 Nov 20];62:561-3. Available from: http://www.neurologyindia.com/text.asp?2014/62/5/561/144494


Sir,

Primary neoplastic lesions constitute a small number of patients with cauda-equina syndrome. [1] Metastasis with cauda-equina syndrome is even rarer with only few cases reported in literature, mostly as a result of central nervous systemdrop metastases. This report presents a case of renal small cell carcinoma with solitary lumbar intradural metastases.

A 40-year-old male presented with progressive sensorimotor deficit in both lower limbs of six months duration and urinary incontinence. Neurologic examination revealed lower motor neuron paralysis of both lower limbs with sacral anesthesia and sphincter dysfunction. Magnetic resonance imaging of lumbosacral spine revealed contrast enhancing intradural space occupying lesion extending from L4 to S2 [Figure 1]. Patient underwent L4 to S1 laminectomy and subtotal excision of the tumor. Tumor adherent to the nerve roots was left behind. Histopathological examination of the tumor revealed tumor cells arranged in sheets, moderatelypleomorphic, negative for PAS with and without diastase and negative for CD 99, suggestive of metastatic small cell carcinoma [Figure 2] and [Figure 3]. Post operative PET-CT revealed a focus of intense FDG uptake in the lower pole of right kidney suggestive of primary malignant lesion [Figure 4]. Patient was given palliative radiotherapy andstarted on chemotherapy with cisplatin and irinotecan. There was gradual improvement in the power of lower limbs. However during the course of his second cycle of chemotherapy, he succumbed to his illness.
Figure 1: Contrast MRI LS Spine showing homogenously enhancing intradural lesion extending from L4 to S2

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Figure 2: Synaptophysin immunohistochemistry showing strong cytoplasmic positivity in tumor cells

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Figure 3: Some of the tumor cells showing cytoplasmic CD56 positivity

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Figure 4: Whole body PET CT showing evidence of abnormal metabolism in the lower pole of right kidney suggestive of primary

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Spinal metastases are predominantly extradural and rarely breach the dura and may be the first manifestation of malignancy in ~20%, mostly representing tertiary spread from cerebral secondary sites. [2] It represents roughly 2-6% of all spinal metastases, [2] and can befound in 2% of cancer patients during autopsy. [2] In the majority the primary lesion in lung, followed by breast. [2] Intradural metastases are commonly thought tooriginate from cerebrospinal fluid (CSF) seeding. First, tumor cells are transferredto the brain (secondary drop metastasis), and then they enterthe CSF. This spreading causes either multifocal or diffuse infiltration of the leptomeninges and is known as leptomeningeal carcinomatosis. Finally, metastatic tumors arise in intradural extra-medullary (IDEM) lesions (tertiary drop metastasis). In the literature review, the development of IDEM metastasis was divided into earlier and later cases. The delayed metastasis may be related with tertiary dropmetastasis. However, early metastasis could not be explained by tertiary drop hypothesis. It may also be due to concurrent tumors from cell rests of neurulation. [3]

Primary renal small cell carcinomas are extremely rare with less than 30 cases reported in literature. [4] A review of patients with small cell carcinoma of the kidney revealed a median age at diagnosis of 62 years, women more commonly affected than men. The diagnosis of a small cell carcinoma, whether of pulmonary or extrapulmonary origin, can be established by light microscopic and immunohistochemical examination of tumor tissue. Extra pulmonary small cell carcinomas are invariably aggressive, with a tendency to develop early nodal and disseminated metastatic disease. Because of the unfavorable prognosis, multimodal therapy has been used increasingly to prolong life. [5] Chemotherapeutic regimens used in treating extrapulmonary small cell carcinomas are the same as those employed in small cell carcinomas of the lung. The severity of disease at diagnosis represents the most sensitive predictor of survival. [5]

Early diagnosis is important as it reducessurgical invasion and helps adequate recovery from neurological sequelae. Surgical treatment of metastatic cancer involvingintraduralcompartment is associated with highmorbidity and mortalityaccording to the primary lesion. Surgical intervention is appropriatewhen there is diagnostic uncertainty or for healthy patientswith good quality of survival or for patients with progressive neurological deficit.

 
  References Top

1.
Dhandapani S, Anirudh S, Garg R, Vasishta RK, Vyas S. Subependymoma causing conus-cauda syndrome: Cured by total excision. Neurol India 2013;61:675-7.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Grant R, Papadopoulos SM, Greenberg HS. Metastaticepidural spinal cord compression. Neurol Clin 1991;9:825-41.  Back to cited text no. 2
    
3.
Dhandapani S, Mehta VS, Sharma BS. "Horseshoe cord terminus" sans filum around a bone spur: a rare composite of faulty gastrulation with agenesis of secondary neurulation: Case report. J Neurosurg Pediatr 2013;12:411-3..  Back to cited text no. 3
    
4.
Si Q, Dancer J, Stanton ML, Tamboli P, Ro JY, Czerniak BA, et al. Small cell carcinoma of the kidney: A clinicopathologic study of 14 cases. Hum Pathol 2011;42:1792-8.  Back to cited text no. 4
    
5.
Masuda T, Oikawa H, Yashima A, Sugimura J, Okamoto T, Fujioka T. Renal small cell carcinoma (neuroendorine carcinoma) without features of transitional cell carcinoma. Pathol Int 1998;48:412-5.  Back to cited text no. 5
    


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