CASE 14063 Published on 13.10.2016

Intradural and intramedullary spinal metastases from lung neoplasm

Section

Neuroradiology

Case Type

Clinical Cases

Authors

María José Raya Núñez, Luis Gijón de la Santa, Alfredo Joaquín Laguna, Ainhoa Camarero de Miguel.

Calle Donante De Sangre S/N
19002 Guadalajara;
Email:cotefi83@hotmail.com
Patient

56 years, male

Categories
Area of Interest Thorax, Neuroradiology brain, Neuroradiology spine ; Imaging Technique Digital radiography, CT, MR, MR-Angiography
Clinical History
A 56-year-old man presented with back pain, paresthesias and weakness in the lower extremities. He was diagnosed six months before of small cell lung cancer with a cerebral metastasis, with good response to chemotherapy. Thereafter, cranial and spinal cord MRI were done in order to complete the study.
Imaging Findings
Chest X-ray showed mediastinal widening, right perihilar opacification extended to the upper right lobe and right pleural effusion (Fig. 1a).

Chest contrast-enhanced CT revealed right anterior soft tissue density mediastinal mass, corresponding with small cell lung neoplasm, infiltrating the pericardium and extending to the upper right lobe that abutted the right pulmonary artery, upper right lobe bronchus and intermediary bronchus (Fig.1b). Pulmonary consolidation in the anterior segment of the right pulmonary lobe and right pleural effusion.

Cerebral MRI showed small round lesion in right frontal lobe in the convexity with mild hypointense in T1-weighted images and mild T2 and FLAIR signal, with rim contrast enhancement and peripheric oedema (Fig. 2).

Lumbar spine MRI:
In spinal cord and nerve roots there were intradural extramedullary metastasis nodules, isointense in T1-weighted sequences and hyperintense in T2 weighted-images filling the thecal sac (Fig. 3b-c), with diffuse enhancement after contrast administration and an intramedullary component in film terminale (Fig. 3d).
Discussion
Leptomeningeal metastases represent 8.5% of central nervous system metastases and account for 5% of all intramedullary lesions [1, 4]. Intradural disease can originate in primary central nervous system tumours like anaplastic astrocytoma, GBM or ependymoma as well as from distant tumours (breast cancer, lung cancer and melanoma) [2, 3].
Spread of malignant cells to the region is variable and includes: growth along the Virchow-Robin spaces, haematogenous dissemination or direct extension from leptomeninges, typically of paraspinal, retroperitoneal of pulmonary malignancies, and lymphatic (along the root sleeves) [3].

The metastatic localization may appear like nodular foci, micro- or macro-nodular or linear along the surface of the central nervous structures. They generally appear isointense with the spinal cord in T1-weighted sequences, hyper-intense in the T2-weighted sequences and enhancing nodules after contrast administration [4].

Differential diagnosis includes drop metastases from CNS primaries (ependymoma, astrocytoma, oligodendroglioma), piogenic meningitis and multifocal primary tumour [1, 3].
Presentation is highly variable. As the most commonly affected site is the lumbosacral spine, symptoms and signs include back or radicular pain, weakness, paraesthesias, gait disturbance, cauda equina syndrome and symptoms/signs of meningeal irritation [2].
Treatment is usually radiotherapy and chemotherapy [3].
Differential Diagnosis List
Intradural (extra and intramedullary) spinal metastases from small cell lung cancer
Drop metastases from CNS primaries (ependymoma
astrocytoma)
Piogenic meningitis
Final Diagnosis
Intradural (extra and intramedullary) spinal metastases from small cell lung cancer
Case information
URL: https://eurorad.org/case/14063
DOI: 10.1594/EURORAD/CASE.14063
ISSN: 1563-4086
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