Intramedullary Metastasis to the Cervical Spinal Cord from Malignant Pleural Mesothelioma: Review of the Literature and Case Reports

Our plain-English summary of Intramedullary Metastasis to the Cervical Spinal Cord from Malignant Pleural Mesothelioma: Review of the Literature and Case Reports, by F. Kalfas, C. Scudieri (Asian Journal of Neurosurgery, 2020).

The study

• Authors: F. Kalfas, C. Scudieri
• Journal: Asian Journal of Neurosurgery
• Published: 2020;15(1):70-75
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Context: Malignant mesothelioma is an aggressive tumor; median survival of patients following diagnosis is 12 months.

Aims: Pleural malignant mesothelioma tends to spread along preexisting tissue planes and has the rare ability to spread along the nerve root into the spinal cord. In our case, there is an evidence of exceptional direct hematogenous spread to the spinal cord by the spinal branch of the intercostal arteries or the veins of Batson's plexus.

Settings And Design: The authors report a case of intramedullary hematogenous metastasis to the cervical spinal cord from malignant mesothelioma, with a review of the literature.

Materials And Methods: A 68-year-old male was admitted to our department because of a slowly progressive mild weakness of both low extremities, more pronounced on the left side. The patient has been treated for a malignant mesothelioma with left thoracotomy and subsequently underwent radiotherapy. Magnetic resonance imaging of the cervical-thoracic spine revealed a contrast-enhancing intramedullary expansive lesion of the left half of the spinal cord at the C6-C7 level.

Results: The patient underwent surgical treatment through a C6-C7 laminectomy. Through a median posterior spinal cord incision, an intramedullary grayish lesion was completely removed. The paraparesis progressively improved and 20 days after surgery, the patient had regained normal lower extremity function.

Conclusions: Malignant mesothelioma can spread to the spinal canal by the direct extension through the intervertebral foramina, by hematogenous spread to the spinal meninges, and by perineural growth along a single nerve root. The cleavage plane of the tissue may determine whether a successful gross total resection can be achieved with a good outcome for the patient.

Copyright: © 2020 Asian Journal of Neurosurgery.

In plain English

This was a case report with a review of published cases. The patient, a 68-year-old man, had worked 20 years at a fiber cement factory, was diagnosed with asbestosis in 1989, and was treated for malignant pleural mesothelioma with a left thoracotomy and local radiotherapy. In March 2000 the patient was admitted with three weeks of worsening weakness in both legs. MRI showed a tumor inside the spinal cord in the neck, at C6 to C7. Surgeons removed it completely, though a clear plane between tumor and cord was difficult to identify. Pathology showed sarcomatous-type malignant mesothelioma. The patient regained normal leg function 20 days after surgery and died eight months after surgery from progressing chest disease. Of 11 reported cases of mesothelioma inside the spinal dura, including this one, 6 were sarcomatous type. The authors concluded that spinal metastasis must be considered when a patient with pleural mesothelioma worsens neurologically and MRI shows an abnormal lesion in the cervical or, more commonly, the thoracic cord. They noted too few cases exist to predict which tumor type tends to spread this way.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report of one patient with a review of the literature on intradural (including intramedullary) spinal spread of pleural malignant mesothelioma
• Who was studied: One 68-year-old right-handed man with a history of malignant mesothelioma, admitted in March 2000 to a neurosurgery department in Italy. The review covered previously published cases: 10 other intradural cases, 8 of them intramedullary.
• Exposure: Occupational asbestos exposure from 20 years of work at a fiber cement factory; asbestosis diagnosed in 1989. No fiber type was stated.
• Main results:
  • In the patient, MRI showed a left-sided tumor inside the spinal cord at the C6 to C7 level.
  • The lesion was completely removed at surgery, although a clear plane between tumor and spinal cord was difficult to identify.
  • Staining of the removed tissue was consistent with sarcomatous-type malignant mesothelioma.
  • 20 days after surgery the patient had completely regained normal lower extremity function.
  • The patient died eight months after surgery from progression of the thoracic disease.
  • In 6 of the 11 intradural cases reported so far, including this one, the tumor was sarcomatous-type malignant mesothelioma.
  • In only three intramedullary cases, including this one, was the tumor considered to have arisen from spread through the blood or leptomeninges, without continuity with the pleural lesion.
  • Across the reported cases, the median time from symptoms or treatment of pleural mesothelioma to diagnosis of the spinal cord tumor was 13.3 months.
  • Where follow-up was available, survival after diagnosis and treatment of the spinal cord tumor ranged between 3 and 11 months.
• The authors' conclusion: The authors concluded that spinal metastasis must be considered when a patient with pleural malignant mesothelioma shows neurological worsening and MRI shows an abnormal lesion in the cervical or, more commonly, the thoracic cord. They regarded sarcomatous-type tumors as prone to intradural spread. They recommended surgery in selected cases, and stated that the tissue cleavage plane may determine whether complete removal with a good outcome is possible.
• Limitations the authors state:
  • Because so few cases exist, the authors stated that no prediction can be made about which histological type tends to spread inside the dura.
  • The authors stated that treatment is poorly defined because there have been no prospective trials, so the literature reflects expert opinion, case series and reviews.

Topics

Medical terms in this study, explained in our Lexicon: Metastasis, Pleural Mesothelioma, Mesothelioma, Median Overall Survival, Hematogenous Spread, Thoracotomy.

Related studies

• Sarcomatoid malignant mesothelioma presenting with intramedullary spinal cord metastasis: a case report and literature review — J. Yamamoto, K. Ueta, et al. (2014)
• Intradural intramedullary spinal cord metastasis due to mesothelioma — M.C. Chamberlain, K.D. Eaton, et al. (2010)
• Malignant mesotheliomas in spermatic cords: reports of two cases and a brief review of literature — X. Meng, T.J. Guzzo, et al. (2013)
• Perineural spread of malignant mesothelioma with spinal intramedullary involvement — M. Tanwar, C.B. Simone, et al. (2014)
• Extensive epidural cufflike growth of malignant pleural mesothelioma causing spinal cord compression — J.M. Gijtenbeek, H.I. Brouwer, et al. (2002)
• Spinal cord stimulation alleviates intractable pain due to malignant pleural mesothelioma: a case report — A. Maeda, M. Watanabe, et al. (2020)

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