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| LETTER TO EDITOR |
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| Year : 2013 | Volume
: 61
| Issue : 4 | Page : 444-446 |
A rare intramedullary spinal cord metastasis from prostate carcinoma
Liemei Guo, Chunlong Zhong, Jiyao Jiang, Yongming Qiu
Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai 200127, China
| Date of Submission | 15-Jun-2013 |
| Date of Decision | 25-Jun-2013 |
| Date of Acceptance | 21-Jul-2013 |
| Date of Web Publication | 4-Sep-2013 |
Correspondence Address:
Yongming Qiu
Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai 200127
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.117604
How to cite this article:
Guo L, Zhong C, Jiang J, Qiu Y. A rare intramedullary spinal cord metastasis from prostate carcinoma. Neurol India 2013;61:444-6 |
Sir,
A 74-year-old man presented with a 2-week history of decreased sensation and weakness of bilateral lower extremities along with urinary incontinence. Neurologic examination showed decreased sensation from the lumbar one dermatome below. Thoracic magnetic resonance imaging (MRI) revealed a solitary intramedullary lesion located at thoracic 12 levels with homogeneous contrast enhancement [Figure 1]a, c and e. With the aid of intraoperative neuromonitoring, the tumor was resected radically after dorsal midline myelotomy and post-operative thoracic MRI demonstrated total resection of intramedullary spinal cord tumor [Figure 1]b, d and f. Histopathological examination with hematoxylin and eosin revealed a malignant tumor consisting of nests of cells with abundant cytoplasm and prominent mitoses [Figure 2]a. Immunochemistry examination further showed prostatic specific acid phosphatase was positive [Figure 2]b, which indicated the diagnosis of metastatic prostate adenocarcinoma. A needle aspiration biopsy of the prostate confirmed the diagnosis of prostate carcinoma and systemic bone scan showed numerous sites of metastases involved pelvis, thigh bones and vertebrae [Figure 3]. Post-operative period was uneventful and patient remained at his baseline neurological status except improved sensation. After receiving hormonal therapy, he remained neurologically stable for 6 months. | Figure 1: Pre‑.and post‑operative magnetic resonance imaging of the patient with an intramedullary spinal cord metastasis from prostate carcinoma. Thoracic revealed a solitary intramedullary lesion located at thoracic 12 levels with homogeneous contrast enhancement (a, saggital view; c, coronal view; e, horizontal view). Post‑operative MRI revealed the tumor was totally removed (b, saggital view; d, coronal view; f, horizontal view)
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 | Figure 2: Histopathological and immunochemistry examinations of the tumor. H and E staining revealed a malignant tumor consisting of nests of cells with abundant cytoplasm and prominent mitoses (a, ×200). Immunochemistry examination further demonstrated prostatic specific acid phosphatase was positive, which indicated the diagnosis of metastatic prostate carcinoma (b, ×200)
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 | Figure 3: Systemic bone scans of the patient. Systemic bone scan indicated numerous sites of metastases located at pelvis, thigh bones and vertebrae
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Intramedullary spinal cord metastasis (ISCM) is an unusual presentation of systemic malignancies, accounting for only 0.9-5.0% of all spinal cord metastases. [1],[2] In general, lung carcinoma is the most common origin of ISCM, with the remainder originating from primary cancers of the breast, kidney, melanomas or lymphomas. [2],[3] Prostate carcinoma is the second leading cause of cancer-related death in men and its systemic metastasis usually involves bones and lymph nodes. [4] To the best of our knowledge, there has been only one report of an ISCM arising from prostate carcinoma in the English literature. [5]
The diagnosis of ISCM can be difficult because MRI and clinical manifestations do not help to distinguish ISCM from primary intramedullary spinal cord tumors. However, there are two major features to differentiate clinically between ISCM and the primary spinal tumor: Acute presentation with rapidly worsening symptoms and the presence of metastases in other organs. [1] In the present case, ISCM was not suspected until the diagnosis of prostate carcinoma was confirmed. The unknown of the primary carcinoma increased the difficulty in the diagnosis of ISCM.
Without prospective clinical trials, the treatment for ISCM remains controversial. Radiotherapy with or without concomitant corticosteroids has been the most effective method of treating both ISCM and extramedullary spinal cord compression as it can both halt the progression of neurological symptoms and decrease the pain. [3] Until date, the newer modalities for delivering radiation to intramedullary tumors such as stereotactic radiosurgery (SRS) has been shown to be effective in ISCM. [5],[6]
Microsurgical resection is a treatment option but not appropriate in most patients, as it is mainly limited by the fact that the metastasis is widespread and the life expectance is short after diagnosis. [3],[7] Notwithstanding, surgical treatment seems to be reasonable option in cases with a radioresistant single metastasis, in the early stage of the diagnostic process and in absence of multiple systemic metastases as microsurgical removal of ISCM can not only provide a firm diagnosis, but also improve neurological function and the quality-of-life. [3],[8] With the aid of intraoperative neuromonitoring, the risk of post-operative neurological deterioration could be mostly reduced.
Because of the rarity of ISCM, there are no controlled prospective clinical studies comparing various treatment options. As a result, the treatment algorithm remains highly individualized. In the present patient, conventional radiation and SRS were suggested, but he refused, only to accept the hormonal therapy. Fortunately, the patient remained neurologically stable for 6 months after surgery.
In conclusion, ISCM arising from prostate carcinoma is extremely rare. ISCM should be suspected in patients of intramedullary spinal cord tumor with rapidly worsening neurological symptoms, especially in patients with presence of primary carcinoma. Recognition and early diagnosis of an ISCM is clinically important for pre-operative counseling and therapeutic prognosis.
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[Figure 1], [Figure 2], [Figure 3]
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Intramedullary spinal cord metastases: an increasingly common diagnosis |
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