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|LETTER TO EDITOR
|Year : 2012 | Volume
| Issue : 4 | Page : 436-437
Esthesioneuroblastoma with early drop metastasis to spinal cord
Pradipta Tripathy1, Debahuti Mohapatra2, GS Sarangi1, Sureswar Mohanty1
1 Department of Neurosurgery, Institute of Medical Science (IMS) and SUM Hospital, Kalinga Nagar, Bhubaneswar, Odisha, India
2 Department of Pathology, Institute of Medical Science (IMS) and SUM Hospital, Kalinga Nagar, Bhubaneswar, Odisha, India
|Date of Web Publication||6-Sep-2012|
Department of Neurosurgery, Institute of Medical Science (IMS) and SUM Hospital, Kalinga Nagar, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Tripathy P, Mohapatra D, Sarangi G S, Mohanty S. Esthesioneuroblastoma with early drop metastasis to spinal cord. Neurol India 2012;60:436-7
Esthesioneuroblastoma (ENB) is an uncommon aggressive neuro-ectodermal tumor that arises from the olfactory mucosa in the nasal vault.  The tumor tends to grow locally. Distant metastasis is extremely rare. Spinal cord metastasis of ENB is particularly unusual and usually very late occurring over 5 years after surgery for ENB. We report a case of a single drop metastasis to the spinal cord occurring just 1 year after initial diagnosis and treatment of ENB.
A 27 year old man was admitted with the complaints of low back pain and paraparesis for last 1 month. On examination he had Gr-1 weakness of both legs, a sensory level at L 1 and retention of urine.
One year earlier he was operated for a right anterior basifrontal mass involving the frontal and ethmoid sinuses [Figure 1]a. Near total excision was done. The histopathological diagnosis was olfactory neuroblastoma (ONB) [Figure 1]b. Following surgery, the patient had received radiotherapy. Magnetic Resonance Imaging of spine [Figure 2]a at this admission showed a high signal intensity intradural mass extending from D 12 to L 1. . Intradural-extramedullary firm tumor, which could easily be separated from conus, was excised completely. The biopsy was ENB Grade-IV (Hyam's classification) [Figure 2]b with more pleomorphism compared with right basifrontal ONB.
|Figure 1: (a) Magnetic resonance imaging brain showing globular large enhancing mass in right anterior basifrontal area involving frontal and ethmoid sinus area having solid as well as cystic component, (b) microphotograph showing lobular arrangement of small, round, hyperchromatic cells with central Homer-Wright rosettes (H and E, x400)|
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|Figure 2: (a) Magnetic resonance imaging of spine showing high signal intensity intradural extramedullay mass extending from D12 to L1 vertebral level, (b) Micro photograph of spinal metastatic tumor showing abundant necrosis separating the pleomorphic tumor cells. (H and E, x400)|
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Post operatively the patient showed improvement in motor power. Patient was advised chemotherapy. He received chemotherapy, 6 cycles of intravenous cisplatinum and etoposide over a period of 6 months, which was well tolerated. On follow up at 6 months he came walking and had no radiologic evidence of metastasis any where in the body.
ENB accounts for approximately 2%-3% of all intracranial neoplasm. The incidence has bimodal peak between 11-20 years and 51-60 years, predominantly occurring in male. The common presenting symptoms include nasal obstruction, recurrent epistaxis, anosmia, headache, and visual field defects. 
The current treatment recommendation for ONB is craniofacial resection followed by radiotherapy primarily for low- to- moderate grade tumors with additional chemotherapy for high-grade tumors. 
Despite aggressive therapy, local recurrence and distant metastatic rates were 50%-60% and 10%-20% respectively. The common metastatic sites are cervical lymph nodes or lungs.  Metastatic disease has been reported anywhere between 1 month and 10 years after disease diagnosis and drop metastasis to spine, with a total 22 documented cases spread over the vertebral bodies, spinal cord, and leptomeninges have been documented 15-18 years after primary disease. , The present case is the second reported case of symptomatic intradural extramedullary spinal cord metastasis; occurring at thoracolumbar area, first one was at the cervical area. 
Adjuvant or neo-adjuvant platinum-based chemotherapy for ENB generally has been used for local control of recurrence or distant metastasis.  In our case, the patient received adjuvant chemotherapy after surgical resection of single drop metastasis to spinal cord which he tolerated well and the response was good. This case demonstrates that cases of ENB may require regular follow up and periodic radiographic surveillance after initial diagnosis and treatment for early detection and treatment of metastatic lesions, including drop metastasis to spine.
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[Figure 1], [Figure 2]