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Journal of Medical Cases

Case Report

Volume 8, Number 1, January 2017, pages 11-13

Intramedullary Spinal Cord Solitary Metastasis as the Inaugural Presentation of Colorectal Cancer: A Case Report

Intramedullary spinal cord metastasis (ISCM) occurs in only 0.1-0.4% of all cancer patients [1-4]. It is more often associated with primary lung cancer, especially small-cell carcinoma, or breast cancer [3]. Colorectal cancer (CRC) represents only 3-5% of cases [3], with very few cases reported in the literature so far [2, 5]. ISCM may represent a diagnostic challenge, particularly in the rare cases where it is the first manifestation of the malignancy. This occurred in 22.5-39% of ISCM cases [3, 6]. However, the diagnosis tends to become more frequent and easier with the development of newer and better imaging methods, mainly spinal cord magnetic resonance imaging (MRI) [1-3, 5-12].

Yet, ISCM still has a very poor prognosis because at diagnosis patients usually have very advanced disease with widespread metastasis [5, 6, 8, 11, 13], with median survival rates of 4 months since the first symptoms [12].

ISCM should thus be promptly considered in the differential diagnosis of every patient with new onset spinal cord symptoms.

A 67-year-old Caucasian male with no relevant medical history was admitted to the emergency department with paresthesias in the lower limbs and paraparesis with progressive worsening over the last 7 days.

On initial medical examination, the patient presented mild wasting and had adequate color and hydration of skin and mucous membranes. Neurological examination showed mild paraparesis, lower limb hyporreflexia, absent superficial abdominal reflexes, hypoesthesia and hypopalesthesia bellow D12 level and inability to walk without bilateral assistance.

Blood analytical evaluation revealed mild normocytic normochromic anemia. CSF examination showed a slight increase in protein count without neoplastic cells. There were no significant changes in computed tomography (CT) scan of the brain and spine.

The patient was admitted to the neurology ward with the diagnosis of transverse myelopathy of undetermined etiology. Treatment was immediately initiated with high doses of steroids (intravenous methylprednisolone 1 g for 5 days); nevertheless, his neurological condition kept deteriorating and he became paraplegic in less than a week. He also developed lower limb neuropathic pain and urinary and fecal incontinence 3 days later.

Thoracic spinal cord MRI demonstrated an oval intramedullary lesion causing medullary mild expansion in the level of D12 associated with extensive hypersignal from the medullary cone to approximately D3 (Fig. 1). The features of this intramedullary expansive lesion were suggestive of metastatic lesion.

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Figure 1. Sagittal view of magnetic resonance imaging with enhancement showing an intramedullary spinal cord lesion at D12 level (arrow).

The search for a primary tumor was initiated. A thoracic-abdominal-pelvic CT scan demonstrated the presence of a lesion with neoplastic characteristics in the rectosigmoid transition zone with various lymph nodes conglomerates and several subpleural nodules, suggesting metastatic lesions. Whole-body positron emission tomography with 18 fluorodeoxyglucose (PET-18 FDG) was also performed and confirmed the findings of the CT scan and also the presence of a focal hypermetabolic lesion at D12.

Rectosigmoidoscopy confirmed the presence of rectosigmoid transition zone adenocarcinoma with extraparietal invasion and several lymph nodes conglomerates staged preoperatively as T4aN2 (TNM staging system) in pelvic MRI (Fig. 2).

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Figure 2. Sagittal view of pelvic magnetic resonance imaging revealing primary tumor at rectosigmoid transition zone.

The case was discussed by a multidisciplinary team (Neurosurgery, Oncology, General Surgery, Radiology and Radiotherapy) concluding that there was no indication for neurosurgical intervention, given the advanced stage of the primary tumor with spread metastasis and the fact that the patient was paraplegic. The patient completed five spinal cord radiotherapy (20 Gy/F5/1S) treatments associated with oral corticotherapy to relieve severe pain in the lower limbs. Later, the patient underwent laparotomy but the primary tumor was considered unresectable and only a derivative colostomy was performed. In a further multidisciplinary team meeting, adjuvant palliative chemotherapy was proposed but never carried out because of the patient’s poor general condition.

The patient attended a convalescence home for 3 months and his clinical condition continued worsening with multiple infectious complications until he died 4 months after ISCM diagnosis.

ISCM represents only 1-3% of spinal cord tumors [4] and CRC is one of the less frequent tumors associated with it. According to Sung et al [12], the median age at presentation of ISCM is 56 years (range: 4 - 82 years) and it usually manifests by muscle weakness, back pain and radicular pain. Sensory loss and bowel and bladder dysfunction are typically seen at a later stage [4, 6], although there are cases (1%) of asymptomatic patients [6].

ISCM as etiology of medullary lesion can be difficult to diagnose, especially in situations with no known primary tumor, as our case report. However, thanks to advances and wider use of imaging techniques, especially MRI, increase in the diagnosis of ISCM is happening [8]. As MRI is highly sensitive and many patients have a poor performance status to undergo a neurosurgical intervention, we can go without histological analysis and assume ISCM diagnosis only by imaging [2]. Our patient had no indication for neurosurgical intervention, even for biopsy, and the ISCM diagnosis was made by MRI confirmed by PET-18-FDG, which can be used to evaluate this clinical situation when MRI is unavailable [11].

The presence of ISCM usually appears associated with widespread metastasis [5, 7, 12, 13], including brain involvement in 61% of cases [12], with 80% mortality rates in first 3 - 4 months after the onset [11]. Our patient had already lung and pelvic but not brain metastasis at ISCM diagnosis.

As far as the treatment is concerned, there is no consensus because of the rarity of this entity [2, 12] and the lack of controlled studies [6]. The main objective is to try to preserve motor function in patients with rapid neurologic deterioration, considering conservative approach for patients with little or no cord function [6, 12]. There are three main therapeutic tools: radiotherapy, chemotherapy and surgery. Radiotherapy with or without corticotherapy represents the gold standard to reduce edema in radiosensitive tumors [11]. The conservative treatment is often chosen because of advanced stage of disease and poor clinical condition of patients. On the other hand, we can consider surgery in certain patients, accordingly to their age, physical condition, location and severity of the primary tumor, other metastasis and surgical risk [4] and may offer some improvement in neurologic condition and quality of life in some patients [4, 5, 10, 12].

Despite an early diagnosis, our patient had already advanced disease, with disseminated metastasis and irreversible neurological deficits and so a very poor prognosis. He was in no condition to undergo neurosurgical intervention. Thus, only palliative approach to control his pain was performed.

ISCM from CRC is a rare condition, but thanks to therapies’ improvement, cancer patients are living longer. This, associated with more advanced imaging methods, explains the fact that ISCM is being increasingly diagnosed. It is of uttermost importance to consider this diagnosis even in patients whose primary tumor is not usually associated with ISCM, such as in CRC, or even in undiagnosed primary tumors, as demonstrated by our case report. The management of these patients needs a multidisciplinary approach, requiring early spinal cord MRI and whole-body imaging for tumoral staging, in order to achieve timely diagnosis and treatment. The aim is to avoid irreversible neurologic deficits, preserving patients’ quality of life.

Grant Support

None.

Conflicts of Interest

None.

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