Spinal Metastasis Follow-up
- Author: Victor Tse, MD, PhD; Chief Editor: Stephen A Berman, MD, PhD, MBA more...
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- Leptomeningeal metastatic disease: Metastatic disease to the neuraxis other than the brain parenchyma and the spinal column is uncommon. The metastatic tumors are occasionally found to have deposited onto the meninges and the cranial nerves (CNs). This accounts for less than 5% of metastasis tumors. Spread to the pituitary gland has been documented, but it accounts for less than 0.5% of cases of metastatic disease in the neuraxis.
- Metastatic plexopathy is documented in the literature. Lung carcinoma, breast carcinoma, and non-Hodgkin lymphoma can metastasize to the brachial plexus.
- In most of these cases, the tumors spread from the surrounding axillary lymph nodes to the neuronal structures.
- Clinical features are pain in the upper shoulder girdle and the medial aspect of the forearm.
- The lower plexus is most commonly involved; this involvement may be associated with Horner syndrome.
- Direct infiltration is by far the most common cause of neoplastic plexopathy. The other common presentation is Pancoast tumor, in which tumor invades the nerve roots as they exit the paravertebral space close to the apex of the lung.
- Peripheral neuropathy secondary to metastatic disease is unusual; it most probably is related to paraneoplastic syndromes. Isolated cranial neuropathy is uncommon. In most cases, such neuropathies are associated with carcinomatous meningitis.
- Carcinomatous meningitis is found in 8% of autopsies in patients with systemic carcinoma. The most common cancers involved in carcinomatous meningitis are those of the breast, lung, and GI, followed by melanoma, non-Hodgkin lymphoma, and leukemia.
- About 48% of cancers manifest as carcinomatous meningitis.
- On clinical evaluation, carcinomatous meningitis affects several levels of the neuraxis. It has a predilection for the CNs, particularly affecting CNs VII, III, V, and VI.
- The most common symptoms are headache, mental status changes, seizures, ataxia, nonobstructive hydrocephalus, and painful radiculopathy.
- The workup, including MRI, usually but not always demonstrates meningeal enhancement at the basal cisterns. The ventricular lining is often involved. CSF analysis requires 10 mL of CSF. The yield of abnormal cells is 45%, rising to 85% with repeat lumbar puncture. The glucose level is low, with a high protein level. Carcinoembryonic antigen is reported with meningeal spread of lung (89%) or breast (67%) carcinomas.
- If untreated, the median survival is less than 2 months. With radiotherapy and chemotherapy, the median survival is 5-8 months.
- Chemotherapy is primarily given intrathecally, usually delivered by using an Ommaya reservoir. A commonly used drug is methotrexate 12 mg twice weekly with oral leucovorin rescue therapy and cytarabine and thiotepa, 50 mg and 10 mg twice weekly. Monoclonal antibodies, lymphokine-activated killer cells, and oral etoposide were recently tried.
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- The outcome of metastatic disease to the spine and associated structures is uniformly bleak.
- The ultimate goals are to maintain the patient's independence and dignity and to optimize his or her comfort level.
- Surgical intervention with extensive reconstruction should be performed only after thorough evaluation of the extent of the systemic disease and only with a clear understanding of the realistic expectation of the patients and their caretakers.
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