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Review Article Intramedullary Spinal Cord Metastasis from Renal Cell Carcinoma: a Systematic Review of the Literature

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Review Article Intramedullary Spinal Cord Metastasis from Renal Cell Carcinoma: a Systematic Review of the Literature Hindawi BioMed Research International Volume 2018, Article ID 7485020, 7 pages https://doi.org/10.1155/2018/7485020 Review Article Intramedullary Spinal Cord Metastasis from Renal Cell Carcinoma: A Systematic Review of the Literature Yuxiang Weng, Renya Zhan, Jian Shen, Jianwei Pan, Hao Jiang, Kaiyuan Huang, Kangli Xu, and Hongguang Huang Department of Neurosurgery, Te First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China Correspondence should be addressed to Hongguang Huang; [email protected] Received 31 August 2018; Revised 28 October 2018; Accepted 28 November 2018; Published 16 December 2018 Guest Editor: Rong Xie Copyright © 2018 Yuxiang Weng et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Intramedullary spinal cord metastases from renal cell carcinomas (RCCs) are rare and can cause serious diagnostic and therapeutic dilemmas. Te related reports are very few. Tis review was aimed to perform an analysis of all reported cases with intramedullary spinal cord metastases from RCCs. In January 2018, we performed a literature search in PubMed database using a combination of the keywords “intramedullary spinal cord metastasis” and “renal cell carcinoma”. In addition, we present the clinical, neuroradiological, and histopathological fndings in our patient with an intramedullary metastasis from a RCC. 17 cases were generated in our research. Te mean interval from diagnosis of RCC to diagnosis of ISCM was 22 months. Te median survival of surgically treated patients was 8.6 months and 8 months in patients who underwent radical surgery. Based on our review, RCCs can invade the medulla of the spinal cord several years afer removal of the primary lesion. Te prognosis of ISCMs from RCCs was poor. Retrograde passage of tumor cells into the spinal cord from the inferior vena cava via the epidural venous sinuses may have been the pathological mechanism for ISCM in our patient. Radical resection and radiation are efective ways of achieving recovery of neurologic function and improving quality of life. More reports are needed to enable exploration of the mechanisms of metastasis and the optimal forms of therapy. 1. Introduction 2. Methods Intramedullary spinal cord metastases (ISCMs) are rare. In January 2018, we performed a literature search which Tey mostly originate from lung and breast cancers but can reported the patient with intramedullary spinal cord metas- originate from a wide variety of other solid tumors, including tases from renal cell carcinoma in PubMed database using melanoma, malignant lymphoma, and colon, ovarian, and a combination of the keywords “intramedullary spinal cord metastasis” and “renal cell carcinoma”. renal cell carcinomas (RCCs) [1]. ISCMs are generally asso- ciated with poor survival. Because they are rare and there are no pathognomonic symptoms, diagnosis is ofen unduly 3. Results delayed [2]. Recommended treatments include surgery and 3.1. Our Case. A 58-year-old man presented with numbness radiotherapy; however, there is no consensus on optimal and aching pain of both lower extremities without weakness treatment. Heightened awareness of this entity may lead that had been progressive over the previous 2 months and to earlier diagnosis and thus treatment at a stage when development of paraparesis 3 days before presentation. Phys- neurological defcits may be reversible and more efective ical examination revealed muscle strength of 0/5 below the palliation may be achieved. Tere are only a few published knee with absence of sensation and 3/5 for the proximal lower reportsofISCMsfromRCCs.Wehereprovideanoverview limbs.HegaveahistoryofarightRCCwithlungmetastasis of clinical data about this rare entity. approximately 3 years previously. Te renal mass had been 2 BioMed Research International (a) (b) Figure 1: (a) Abdominal MRI demonstrating right renal cell carcinoma (arrow). (b) MRI also demonstrating tumor thrombosis in the inferior vena cava. discovered by MRI, which had also shown tumor thrombosis 41%, thoracic in 41%, and lumbar in 18% of patients. Five in both the renal vein and inferior vena cava (Figures 1(a)- of 17 reported patients with ISCMs from RCCs had lef- 1(b)). Te patient had undergone right radical nephrectomy sided primary tumors, eight right-sided, and two bilateral; the and inferior vena cava dissection with embolectomy and the localization of the remaining two was not reported. Weakness diagnosis of RCC had been confrmed pathologically. He was present at diagnosis of ISCM from RCC in 71% of had also received treatment with interlukin-2 and interferon patients. Backache (41%), dysesthesia (41%), and sphincter postoperatively. dysfunction (35%) were also common. Radicular pain and Magnetic resonance imaging (MRI) of the spine demon- Brown-Sequard´ syndrome were each seen in 18%. Most strated a 15 mm × 7 mm intramedullary mass at the T12 level patients were diagnosed by MRI (94%), the exception being with high signals on T2WI, hypointense signals on T1WI, one by myelography. Contrast enhancement was seen in 92% and signifcant enhancement with intravenous gadolinium of patients to whom gadolinium was administered. Te mean (Figures 2(a)–2(c)). Considering the history of RCC and interval from diagnosis of RCC to diagnosis of ISCM was 22 rapid progression of his neurological defcit, the provisional months (0 months–15 years). Lung (59%) and brain (47%) diagnosis was ISCM. Te patient underwent a T11 and T12 were the most common sites of simultaneous metastases. laminectomy during which the spinal dura mater was opened Bone (n=3), liver (n=1), contralateral kidney (n=1), adrenal through a midline posterior sulcus incision under magnifca- gland (n=1), and systemic organ metastasis (n=1) were the tion and a tumor identifed at the T12 level. Afer gentle and other reported sites. Conservative therapy was selected in careful dissection, the lesion was completely removed. Te 37.5% of cases and surgery in 62.5%. Te median survival pathological diagnosis was RCC. Immunochemical staining of surgically treated patients was 8.6 months (n=10) and 8 demonstrated the following: CD10(+), paired box protein months in patients who underwent radical surgery (n=4). 8 (PAX8)(+), creatine kinase (CK) (pan)(+), vimentin(+), and P504S(+)(Figures 3(a)–3(d)). A postoperative MRI con- 4. Discussion frmed complete removal of the lesion (Figure 4(a)). Te muscle power improved to 3/5 below the knee in both lower ISCMs are rare, accounting for 0.1% to 2% of all spinal cord limbs and sensation recovered partially. Te patient received tumors [14]. Lung and breast cancer are the commonest a course of focal radiation therapy. MRI of the spinal cord sources of ISCMs, with RCCs accounting for only 4%–9% revealed no recurrence at a 6-month follow-up (Figure 4(b)). of such tumors [1, 15]. According to our review, eleven of the patients we reviewed developed ISCM within one year of 3.2. Patients Characteristics. Te characteristics of reported diagnosis of RCC; in fve patients the ISCM was present at the cases with ISCMs that originated from RCCs, including our time of diagnosis of RCC [6, 9, 12, 13]. Five patients developed patient,arepresentedinTable1[3–13].Teaverageageof metastases a year or more afer diagnosis of RCC occurrence presentation is 51 (37–70) years; 65% of reported patients were [3, 6–8]; all had undergone nephrectomy similarly to our male and 35% female. Cervical localization was reported in patient whose metastasis was diagnosed 34 months afer BioMed Research International 3 (a) (b) (c) Figure 2: (a) Preoperative T2-weighted sagittal MRI demonstrating increased signal intensity. (b) Preoperative T1-weighted sagittal MRI revealing a well-defned tumor with signifcant enhancement afer gadolinium injection. (c) Preoperative T1-weighted axial MRI showed well-circumscribed lesion inside the spinal cord at the T12 level. nephrectomy. Tese data suggest that nephrectomy may delay second mechanism is associated with meningeal carcino- ISCMs from RCCs. matosis. Tumor cells from carcinomatous meningitis may Tree possible pathological mechanisms have been infltrate blood vessels, penetrate the spinal cord, and fnally suggested for how RCCs metastasize to the spinal cord invade the spinal cord parenchyma. Te third mechanism is parenchyma [1]. Te most common mechanism is likely direct invasion through invasion of metastatic tumor cells hematogenous spread via one of two pathways. One is from the spinal extradural space, cerebrospinal fuid, or nerve an arterial route, which is supported by coexistence of roots. As Kamerath et al. [16] have reported, absence or lung and brain metastases. Another hematogenous route is thrombosis of the inferior vena cava can cause epidural through the vertebral venous plexus (Batson’s venous plexus), venous plexus enlargement. Moreover, the epidural plexus which extends from the pelvis to the cranial venous sinuses, system has no valves, allowing considerable collateral fow. enabling retrograde transportation to the spinal cord. Te Terefore, it is possible for tumor cells to travel in a retrograde 4 BioMed Research International (a) (b) (c) (d) Figure 3: (a) Photomicrograph demonstrating clear tumor cells. Hematoxylin and eosin, original magnifcation × 100. Immunohistochemical staining for (b) PAX8, (c) CK(pan), and (d) vimentin showing strong cytoplasmic reactions within tumor cells. Original magnifcation
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