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Journal of Craniovertebral Junction and Spine
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CASE REPORT
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 77-80  

Intramedullary spinal cord metastasis of gastric cancer


1 Department of Neurosurgery, Cerebrovascular Research Institute, Yoshida Hospital, Hyogo, Japan
2 Department of Neurosurgery, Tsukazaki Hospital, Hyogo, Japan
3 Department of Neurosurgery, Osaka Medical College, Osaka, Japan

Date of Submission01-Oct-2020
Date of Acceptance22-Dec-2020
Date of Web Publication4-Mar-2021

Correspondence Address:
Hiroaki Matsumoto
Department of Neurosurgery, Cerebrovascular Research Institute, Yoshida Hospital, 9-2-6 Daikai-dori, Hyogo-ku, Kobe, Hyogo 652-0803
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvjs.jcvjs_163_20

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   Abstract 


The incidence of intramedullary spinal cord metastasis (ISCM) has been increasing because the overall survival of patients with cancer has improved thanks to recent advanced therapies, such as molecular targeted drugs, anticancer agents, and various irradiation techniques. ISCM from lung and breast cancer is the most common form among cases of ISCM. We report an extremely rare form of ISCM from gastric cancer. This 83-year-old man who had a past medical history of gastric adenocarcinoma presented with acute onset of paraparesis. Spinal magnetic resonance imaging revealed an intramedullary lesion at the upper thoracic level. Due to rapid worsening of his paresis, we decided to perform tumor extirpation. Gross total resection of the tumor was successfully performed. Pathological examination revealed poorly differentiated adenocarcinoma, suggesting the diagnosis of ISCM from gastric cancer. He demonstrated gradual improvement of paraparesis soon after surgery, although his overall survival was limited to about 6 months after surgery. When examining the etiology of acute paraparesis in elderly patients with a past medical history of cancer, ISCM should be considered in the differential diagnosis. The prognosis of ISCM from gastric cancer is still extremely limited. Unfortunately, there is currently no treatment with proven efficacy. Surgery for ISCM from gastric cancer, although a challenging procedure for spine surgeons, should be considered as a therapeutic option in these patients.

Keywords: Adenocarcinoma, gastric cancer, intramedullary metastasis, paraparesis, spinal cord


How to cite this article:
Matsumoto H, Shimokawa N, Sato H, Yoshida Y, Takami T. Intramedullary spinal cord metastasis of gastric cancer. J Craniovert Jun Spine 2021;12:77-80

How to cite this URL:
Matsumoto H, Shimokawa N, Sato H, Yoshida Y, Takami T. Intramedullary spinal cord metastasis of gastric cancer. J Craniovert Jun Spine [serial online] 2021 [cited 2021 Apr 17];12:77-80. Available from: https://www.jcvjs.com/text.asp?2021/12/1/77/310734




   Introduction Top


Although intramedullary spinal cord metastasis (ISCM) is rare, the incidence of ISCM has been recently increasing because of improvement in overall survival of cancer patients thanks to recent advanced therapies, such as molecular targeted drugs, anticancer agents, and various irradiation techniques.[1] In most cases of ISCM, lung and breast carcinomas are the common primary cancers,[2] and ISCM from gastric carcinoma has only rarely been reported in the literature. Due to the difficulty in radiological diagnosis, the extremely low frequency of treated cases and poor prognosis, the optimal treatment strategy for ISCM from gastric cancer has not been established, although palliative treatment with steroid administration, radiation therapy, or surgery might be viable options.[1],[3],[4] Here, we describe a case of ISCM from gastric adenocarcinoma presenting with acute onset of progressive paraparesis that was treated surgically. The prognosis of ISCM from gastric cancer is still extremely limited. Unfortunately, there is currently no therapy with proven efficacy in these cases.


   Case Report Top


An 83-year-old man presented with acute onset of gait disturbance. He had a past medical history of partial gastrectomy and adjuvant chemotherapy for gastric cancer 3 years before this admission to our institution. His performance score (PS) according to the Karnofsky PS had been maintained at about 90 after the gastric cancer treatment. Neurological evaluation at his current admission indicated sensory loss at the T3 level with grade 3/5 paraparesis. Bladder and rectal dysfunction was also detected. Spinal magnetic resonance imaging (MRI) revealed an intramedullary mass lesion at the upper thoracic level. The intramedullary lesion showed relative hyperintensity on T1-weighted images [Figure 1]a and hypointensity on T2-weighted images, along with long-axis syringomyelia [Figure 1]b and [Figure 1]c. The mass lesion showed homogenous contrast enhancement on T1-weighted images [Figure 1]d. His paraparesis showed rapid deterioration from grade 3/5 to grade 1/5 at 3 days after admission. After careful discussion, he finally decided to undergo surgical removal of the intramedullary tumor. Operative exposure revealed extensive swelling of the spinal cord itself [Figure 2]a. Myelotomy via a dorsal midline approach revealed a grayish-red tumor [Figure 2]b. Gross total resection was successfully performed in a piecemeal fashion [Figure 2]c. Pathological diagnosis after surgery suggested poorly differentiated adenocarcinoma secondary to gastric cancer [Figure 2d]. Fortunately, he showed a gradual improvement of paraparesis and he could walk with assistance. MRI obtained 1 week after surgery demonstrated no apparent lesion enhancement, with diminution of syringomyelia [Figure 3]a,[Figure 3]b,[Figure 3]c. Although local radiation therapy of the spinal cord was highly recommended, he refused adjuvant therapy. During subsequent postoperative follow-up, the patient presented again with paraparesis with neurological deterioration from grade 3/5 to grade 1/5. MRI performed 1.5 months after the primary surgery demonstrated local recurrence of the intramedullary tumor [Figure 3]d and [Figure 3]e. He opted for palliative supportive care and died 6 months after the primary surgery.
Figure 1: Preoperative magnetic resonance imaging. The intramedullary lesion showing relative hyperintensity on T1-weighted magnetic resonance images (a) and hypointensity on T2-weighted magnetic resonance images accompanying the long-axis syringomyelia (b and c). The mass lesion showed homogenous contrast enhancement on T1-weighted images (d)

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Figure 2: Intraoperative photographs. Operative exposure showing extensive swelling of the spinal cord itself (a). Myelotomy via a dorsal midline approach showed presence of a grayish-red tumor (b). Gross total resection was successfully performed in a piecemeal fashion (c). Pathological diagnosis after surgery suggested poorly differentiated adenocarcinoma secondary to gastric cancer (H and E, ×400) (d)

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Figure 3: Postoperative magnetic resonance imaging. Magnetic resonance images obtained 1 week after surgery showed no apparent lesion enhancement, with diminution of syringomyelia (a-c). Magnetic resonance images obtained 1.5 months after surgery showed local recurrence of the intramedullary tumor (d and e)

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   Discussion Top


ISCM is recognized clinically in about 0.1%–0.4% of all patients with cancer and accounts for about 1%–3% of intramedullary spinal cord neoplasms.[5] The most common primary lesion leading to ISCM is lung cancer in 54%, followed by breast cancer in 13%, melanoma in 9%, lymphoma in 5%, and renal cell carcinoma in 4% of cases.[6] ISCM is usually seen in the cervical and thoracic regions.[1],[6] Brown-Sequard syndrome or asymmetric myelopathy might be a common form of clinical presentation.[6] The neurological manifestations often progress very rapidly, and it has been suggested that 75% of ISCM cases might develop complete paraparesis within a month from the diagnosis.[3] Since ISCM is typically recognized in the later stage of cancer treatment, the prognosis of patients with ICSM is usually extremely poor and median survival time is reported as 3–4 months on average.[2],[3],[6]

ISCM from gastric cancer is an extremely rare form of ISCM, and only six such cases, including our case, have been reported in the literature [Table 1].[7],[8],[9],[10],[11] The reported patients were predominantly male (five males and one female) and middle aged, except our case. Although ISCM from gastric cancer can be found both during and after the course of treatment of gastric cancer, the neurological symptoms of ISCM preceded the clinical condition in only 1 case. In half of the reported cases, other metastatic lesions were recognized. With regard to the location of the metastatic spinal lesion, the cervical region was involved in three cases, thoracic in two cases, and lumbosacral in one case. Worsening of neurological symptoms occurred very rapidly, ranging from 3 days to 2 months. All patients except one underwent tumor extirpation. Only one patient received adjuvant therapy using radiation. The prognosis was very poor and most patients died within 6 months after the operation. The clinical characteristics of ISCM from gastric cancer appear to be much worse compared to those from other malignant tumors.
Table 1: Literature review of ISCM from gastric cancer

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The main goal in treating ISCM is to stop the acute worsening of neurological function despite limitation of the patient's life expectancy. Due to the small number of treated cases, there is still no consensus regarding the treatment of ISCM.[2] Therapeutic options include steroid administration, radiotherapy, chemotherapy, and surgical extirpation, with radiation therapy and steroid administration probably being selected most often.[12] However, there is controversy regarding the effect or risk of radiation therapy because the maximum permissible radiation dose for the spinal cord is limited.[12],[13] Chemotherapy might not be effective because of the existence of the blood–spinal barrier in the spinal cord.[4] When patients with ISCM show rapid and severe deterioration of neurological deficits, surgical treatment should be considered as one of the treatment options for the purpose of decompression of the spinal cord and confirmation of histopathological diagnosis.[12] Harada et al.[14] reported a favorable prognosis in patients with brain metastasis from gastric cancer treated with stereotactic radiosurgery. Stereotactic radiosurgery, if available, might be suitable as adjuvant therapy for ISCM from gastric cancer. Recently, cancer immunotherapy, such as nivolumab, an anti-programmed cell death-1 antibody, has been approved for limited cancers, including gastric cancer.[15] The efficacy of nivolumab for brain metastasis from melanoma, lung, and gastric cancer has also been reported.[16],[17],[18],[19] Hence, although nivolumab might be effective for ISCM, there is only one report of the efficacy of nivolumab for ISCM. Phillips et al. reported a case of ISCM from lung cancer treated with nivolumab.[20] Takao et al. treated advanced gastric cancer with metastatic lesions, including bone metastasis, with nivolumab, and reported that long-term stability of the cancer could be maintained when nivolumab treatment was initiated in a patient with good PS.[19] Ahn et al. reported the efficacy of combination of nivolumab and stereotactic radiosurgery for brain metastasis from gastric cancer.[21] In the case presented here, surgical extirpation of ISCM was selected first because the patient showed a rapid deterioration of paraparesis. Since postoperative adjuvant treatment was not introduced in this case, local recurrence was finally recognized 1.5 months after surgery. Use of postoperative radiation therapy along with nivolumab should be assessed in future studies to determine their efficacy as adjuvant therapy in such cases.


   Conclusions Top


When examining the etiology of acute paraparesis in elderly patients with a past medical history of cancer, ISCM should be considered in the differential diagnosis. The prognosis of ISCM from gastric cancer is still extremely limited. Unfortunately, there is currently no proven effective therapy. Surgery for ISCM from gastric cancer, although a challenging procedure for spine surgeons, should be considered as a therapeutic option in these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Hashii H, Mizumoto M, Kanemoto A, Harada H, Asakura H, Hashimoto T, et al. Radiotherapy for patients with symptomatic intramedullary spinal cord metastasis. J Radiat Res 2011;52:641-5.  Back to cited text no. 13
    
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Harada K, Hwang H, Wang X, Ahmed A, Masaaki I, Murphy MA, et al. Brain metastases in patients with upper gastrointestinal cancer is associated with proximally located adenocarcinoma and lymph node metastases. Gastric Cancer 2020;23:904-12.  Back to cited text no. 14
    
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Kang YK, Boku N, Satoh T, Ryu MH, Chao Y, Kato K, et al. Nivolumab in patients with advanced gastric or gastro-oesophageal junction cancer refractory to, or intolerant of, at least two previous chemotherapy regimens (ONO-4538-12, ATTRACTION-2): A randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2017;390:2461-71.  Back to cited text no. 15
    
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Lanier CM, Hughes R, Ahmed T, LeCompte M, Masters AH, Petty WJ, et al. Immunotherapy is associated with improved survival and decreased neurologic death after SRS for brain metastases from lung and melanoma primaries. Neurooncol Pract 2019;6:402-9.  Back to cited text no. 17
    
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Phillips KA, Gaughan E, Gru A, Schiff D. Regression of an intramedullary spinal cord metastasis with a checkpoint inhibitor: A case report. CNS Oncol 2017;6:275-80.  Back to cited text no. 20
    
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