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LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 1  |  Page : 211-214

Surgical considerations for intramedullary conus medullaris metastatic tumors with origin from primary lung lesions: A review of the literature


1 Department of Neurosurgery, San Giovanni Hospital, Rome, Italy
2 Department of Pathology, San Giovanni Hospital, Rome, Italy

Date of Web Publication12-Jan-2017

Correspondence Address:
Giorgio M Callovini
Department of Neurosurgery, San Giovanni Hospital, Rome
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.198218

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How to cite this article:
Callovini GM, Bolognini A, Giordano M, Gazzeri R. Surgical considerations for intramedullary conus medullaris metastatic tumors with origin from primary lung lesions: A review of the literature. Neurol India 2017;65:211-4

How to cite this URL:
Callovini GM, Bolognini A, Giordano M, Gazzeri R. Surgical considerations for intramedullary conus medullaris metastatic tumors with origin from primary lung lesions: A review of the literature. Neurol India [serial online] 2017 [cited 2017 Feb 23];65:211-4. Available from: http://www.neurologyindia.com/text.asp?2017/65/1/211/198218


Sir,

A metastatic lesion in the conus medullaris (CM) from primary lung cancer represents one of the rarest sites of central nervous system involvement. [1],[2] The radiological appearance on magnetic resonance imaging (MRI) of this CM metastatic deposit may often mimic the commonly occurring conus glial tumors occurring in this region, especially in cases where the metastatic lesion has been the first manifestation of the primary cancer. We report two cases, one of whom was without a previous history of cancer. A literature search for CM metastasis from a primary lung cancer yielded 12 cases, which had been surgically treated. Two distinct patterns of CM involvement are observed based on whether or not a concomitant brain metastasis is also observed. Microsurgical excision permits a histological diagnosis and also seems to improve the neurological symptoms and the quality of life. However, the extent of resection does not influence the length of survival, which is mainly linked to the pattern of evolution of the primary lesion.

Case 1

A 70-year-old man was operated in 2003 and a lesion within the CM (with an eventual histopathological diagnosis of pulmonary small cell carcinoma) was excised. Postoperatively, he received adjuvant radio-chemotherapy. An MRI of the spine [Figure 1] revealed an enhancing intramedullary lesion at the level of CM, measuring 2.5 cm in its craniocaudal, and 1.5 cm, in its anteroposterior extent. The histopathologic examination revealed a small cell lung metastasis [Figure 2]. Following surgery, his lower extremity weakness and sensory loss improved, allowing him to walk with assistance, although his bladder dysfunction remained unchanged.
Figure 1: Post-contrast sagittal (a) and axial (b) T1-weighted magnetic resonance (MR) images revealing an enhancing T12-L1 lesion, measuring 2.5 cm in craniocaudal and 1.5 cm in anteroposterior extent

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Figure 2: Histopathological specimen of case 1: metastatic small cell carcinoma: malignant epithelial cells infiltrating the white matter (TTF1 20×)

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Case 2

A 44-year-old female patient without relevant issues in her medical history was detected on a spinal MRI scan to be having a 2.7 × 1.6 cm mass lesion within the CM, with marked contrast enhancement and perilesional edema [Figure 3]a and [Figure 3]b. A T12-L2 laminectomy was performed, the lesion was excised, and the postoperative histopathological examination revealed a poorly differentiated carcinoma [Figure 4]. A total body computed tomography (CT) scan showed a mass that was 3 cm in diameter with adenopathy in the left apical segment of the lung. No additional lesions were found. Following surgery, the low backache and radicular pain were relieved but the bladder and bowel dysfunction remained unchanged.
Figure 3: (a and b) Post contrast sagittal (a) and axial (b) T1-weighted MR images of the dorsolumbar spine showing the 2.7 × 1.6 cm, enhancing lesion at the L1 level

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Figure 4: Histopathological specimen of case 2 showing a metastatic poorly differentiated carcinoma. (Glial fibrillary acidic protein 10×)

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A Medline search of English medical literature for the keywords “conus medullaris metastasis” and “intramedullary metastasis” yielded 12 cases [3],[4],[5],[6],[7],[8],[9] that had been surgically treated [Table 1]. Our two surgically treated patients are an addition to this number.
Table 1: Summary of the operated cases with conus medullaris lung metastasis

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The rapid progression of symptoms appears to be the most distinctive feature that helps to differentiate these metastatic lung lesions from primary intramedullary tumors.[10] Two distinct patterns of metastatic involvement of CM are observed based upon the presence or absence of brain metastases. Only two cases (cases 5 and 13) in the literature review, had a history of coexisting brain metastasis, and in both these patients, the posterolateral surface of the conus was involved; a leptomeningeal carcinomatosis may have led to a direct extension of the brain tumor from the subarachnoid space into the cord. The hematogenous dissemination, through arterial emboli to the posterior horn or deep white matter could have also been the preferred pathway of dissemination, owing to greater arterial perfusion and increased density of capillary networks prevalent in this region.[2]

In rarer cases, these lesions represent the first appearance of malignancy (seen in 22–39% of the patients).[1],[11] In our experience, this event has been observed in 42% of the cases.

The overall median survival among the reported cases of CM metastasis from lung malignancies has been 7.4 months (with a range of 2 to 15 months); in most cases, following surgery, an improvement of symptoms has been reported, especially with regard to the intensity of pain and the severity of the motor disorder. Surgery may be recommended only in a limited number of cases due to the inherent risk of development of additional neurological deficits in patients in an advanced stage of the disease, which may explain the limited number of cases reported in the literature. The decision on whether or not to operate depends on the patient's life expectancy (the coexisting morbidities, general condition, the presence of multi-organ metastatic involvement and the severity of neurological deficits)[9] Surgery should also be considered in patients who have had a rapid neurological deterioration despite a well-controlled primary tumor; and, in those with a solitary intramedullary metastasis. The expectation from surgery would be to possibly bring about an improvement in the quality of life and survival of the patient.[1],[6],[11],[12] When CM metastasis is the first appearance of malignancy (in the present review this event was observed in 42% of the cases), the main goal of surgery is to obtain a tissue sample for a histological diagnosis, thus differentiating this metastatic disease from the more commonly occurring intramedullary glial tumors.[10]

The current evidence suggests that pain, neurological symptoms and quality of life do improve in selected patients with CM metastasis, who are surgically treated early and aggressively. However, the selection of the appropriate therapy depends on several factors, including the primary histology, extent of systemic disease, existing comorbidities, prior treatment modalities adopted, the patient's age, performance status, and predicted life expectancy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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Costigan D, Winkelman MD. Intramedullary spinal cord metastasis. A clinicopathological study of 13 cases. J Neurosurg 1985;62:227-33.  Back to cited text no. 2
    
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Dam-Hieu P, Seizeura R, Mineoa F, Metgesb JP, Meriot P, Simonb H. Retrospective study of 19 patients with intramedullary spinal cord metastasis. Clin Neurol Neurosurg 2009;111:10-7.  Back to cited text no. 3
    
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Faillot T, Roujeau T, Dulou R, Chedru F. Intramedullary spinal cord metastasis: Is there a place for surgery? Case report and review of the literature. Neurochirurgie 2002;48:533-6.  Back to cited text no. 4
    
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Nguyen BD, Fletcher GP, Patel AC. PET/CT Imaging of conus medullaris metastasis from lung cancer. Clin Nucl Med 2005;30:253-6.  Back to cited text no. 5
    
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Guppy KH, Wagner F. Metastasis to the conus medullaris: Case report. Neurosurgery 2006;59:1164-8.  Back to cited text no. 6
    
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Riviero-Garvia M, Boto GR. Metastatic squamous cell carcinoma of the lung to the conus medullaris. Neurol India 2011;59:645-6.  Back to cited text no. 7
    
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Mavani SB, Nadkarni TD, Goel NA. Intramedullary conus metastasis from carcinoma lung. J Craniovertebr Junction Spine 2013;4:40-2.  Back to cited text no. 8
    
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Payer S, Mende KC, Pract M, Westhal M, Eiker SO. Intramedullary spinal cord metastasis: An increasingly common diagnosis. Neurosurg Focus 2015;39:E15.  Back to cited text no. 9
    
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Ebner FH, Roser F, Acioly MA, Schoeber W, Tatagiba M. Intramedullary lesions of conus medullaris: Differential diagnosis and surgical management. Neurosurg Rev 2009;32:287-301.  Back to cited text no. 10
    
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Gasser T, Sendalcioglu IE, El Hamalawi B, van de Nes JA, Stolke D, Wiedemayer H. Surgical treatment of intramedullary spinal cord metastasis of systemic cancer: Functional outcome and prognosis. J Neuroncol 2005;73:163-8.  Back to cited text no. 11
    
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Gazzeri R, Galarza M, Faiola A, Gazzeri G. Pure intramedullary spinal cord metastasis secondary to gastric cancer. Neurosurg Rev 2006;2:173-7.  Back to cited text no. 12
    


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