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| LETTER TO EDITOR |
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| Year : 2013 | Volume
: 61
| Issue : 5 | Page : 555-556 |
Intramedullary spinal cord metastasis detected with whole body diffusion-weighted imaging
Yan Zhang1, Yongbo Huang2, Xixing Wang3, Jun Wang4
1 Department of Radiology, The Second Hospital of Shanxi Medical University; Department of Radiology, Shanxi Province Hospital of Traditional Chinese Medicine, Taiyuan, Shanxi, China
2 Department of Orthopedics, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
3 Department of Oncology, Shanxi Province Hospital of Traditional Chinese Medicine, Taiyuan, Shanxi, China
4 Department of Radiology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| Date of Submission | 27-Aug-2013 |
| Date of Decision | 01-Sep-2013 |
| Date of Acceptance | 13-Oct-2013 |
| Date of Web Publication | 22-Nov-2013 |
Correspondence Address:
Jun Wang
Department of Radiology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.121954
How to cite this article:
Zhang Y, Huang Y, Wang X, Wang J. Intramedullary spinal cord metastasis detected with whole body diffusion-weighted imaging. Neurol India 2013;61:555-6 |
Sir,
Intramedullary spinal cord metastasis (ISCM) is an extremely rare and often difficult to diagnose. Early diagnosis and institution of therapy may improve the prognosis and quality of life for patients with ISCM. Several cases of ISCM were reported with whole body imaging techniques such as positron emission tomography/computed tomography (PET/CT). [1],[2] But to the best of our knowledge, there is no report based on the whole body diffusion-weighted imaging (DWI). We report one such case.
A 58-year-old man diagnosed with small cell lung cancer presented to us in September, 2008, with complaints of persistent dizziness. Brain CT revealed multiple brain metastases. He underwent whole brain radiation treatment at a dose of 40 Gy combined with traditional Chinese medicine (TCM). On day-4 of radiation treatment, he complained of numbness and weakness in the limbs. Whole body DWI was done to exclude metastasis elsewhere using b values of 0 and 600 mm²/s (Philips Healthcare, 1.5T Intera Scanner). Whole body DWI revealed a hyperintense signal in the conus medullaris [Figure 1]a and b. This was confirmed by conventional magnetic resonance imaging (MRI) [Figure 2]a and b, which revealed an increased diameter of the spinal cord conus and hyperintensity on T2-weighted images. Radiotherapy, 40 Gy was given to the conus medullaris metastasis in February, 2009. The tumor size and intramedullary high signal area decreased on magnetic resonance images after radiotherapy [Figure 3]a and b. However, the neurologic manifestations improved and his quality of life was restored. Four months later, he noticed rapidly progressive weakness, sensory disturbances of the lower limbs, and bowel/bladder dysfunction. He died from respiratory failure nine months after the diagnosis of ISCM. | Figure 1: (a) Whole-body DWI images in a 58-year-old man with small-cell lung carcinoma metastasis to the conus medullaris. Coronal whole-body DWI image shows a hyperintense signal in the conus medullaris, as well as multiple hyperintense signals in the bilateral neck, supraclavicular fossa, hilum, and mediastinum (white arrow). (b) Axial DWI image shows multiple hyperintense signals at the level of the conus medullaris (black arrow)
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 | Figure 2: (a) Sagittal T2-weighted MR image shows a hyperintense signal in the conus medullaris (white arrow). (b) Axial T2-weighted MR image shows a hyperintense signal in the conus medullaris (white arrow). (c) Axial CT soft tissue window image shows a right hilar mass, a thicker bronchus wall and bronchostenosis in the right inferior lobar bronchus. (d) Axial CT soft tissue window image shows subcarinal lymph node enlargement. (e) Axial CT soft tissue window image shows mediastinal lymph node enlargement. (f) Axial CT soft tissue window image shows left hilar lymph node enlargement. (g) Axial CT soft tissue window image shows right hilar lymph node enlargement
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 | Figure 3: (a) Sagittal T2-weighted image shows tumor size and intramedullary high-signal area were decreased after radiotherapy. (b) Axial T2-weighted image shows tumor size and intramedullary high-signal area were decreased after radiotherapy
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Conventional MRI is sufficiently sensitive for detecting intramedullary lesions, but its field of view is limited. As whole body imaging technologies, PET/CT could be used to detect ISCM. Nevertheless, it requires radiation use. Takahara et al., [3] reported a unique whole body DWI concept which had the advantages of a wider coverage range and without radiation exposure. In the present case, whole body DWI allowed lesions of the primary lung cancer [Figure 2]c, subcarinal [Figure 2]d, mediastinal, [Figure 2]e bilateral hilar lymph nodes [Figure 2]f and g and entire spinal cord, including distant metastases in the conus medullaris to be imaged simultaneously compared to MRI and CT. The mean apparent diffusion coefficient (ADC) values for the conus medullaris on whole body DWI were lower than those elsewhere in the spinal cord (0.781 × 10 -3 mm²/s vs. 0.825 × 10 -3 mm²/s), consistent with results in the literature.
The diagnosis of ISCM seems reliable. The patient's clinical history and rapidly progressing neurological symptoms allowed us to distinguish ISCM from a primary intramedullary tumor, which typically presents with slower symptom progression. [4] Optimal treatment for ISCM remains controversial. We adopted a treatment approach of chemoradiotherapy combined with TCM. The patient died in 2009 June, 9 months from the diagnosis of ISCM. In summary, this report shows that early diagnosis by whole body DWI allows detection of the suspected ISCM, enabling timely treatment prior to the development of neurological symptoms which might improve the patients' prognoses. However, further large-scale studies are needed to come up with general conclusions concerning the value of whole body DWI in ISCM.
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| 2. | Pellegrini D, Quezel MA, Bruetman JE. Intramedullary spinal cord metastasis. Arch Neurol 2009;66:1422.
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| 3. | Takahara T, Imai Y, Yamashita T, Yasuda S, Nasu S, Van Cauteren M. Diffusion weighted whole body imaging with background body signal suppression (DWIBS): Technical improvement using free breathing, STIR and high resolution 3D display. Radiat Med 2004;22:275-82.
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[Figure 1], [Figure 2], [Figure 3]
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