Case report
Fractionated radiosurgical management of intramedullary spinal cord metastasis: A case report and review of the literature

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Abstract

Objective and importance

Intramedullary spinal cord metastasis (ISCM) comprises 8.5% of central nervous system metastases and confers significant morbidity. Radioresistant histologies such renal cell carcinoma and melanoma are not generally amenable to long-term palliation with conventional radiotherapy while surgery has often been found to be technically challenging and frequently morbid. In this report, we present a patient with a C5 ISCM from renal cell carcinoma treated with fractionated stereotactic radiosurgery.

Clinical presentation

A 50-year-old gentleman with metastatic renal cell carcinoma presented with profound bilateral shoulder pain and upper extremity paresthesias. Magnetic resonance imaging revealed an intramedullary lesion at the level of fifth cervical vertebra (C5). Medical management and chiropractic manipulation proved to be ineffective. The patient was then treated with external beam radiation therapy, but continued to experience severe pain, paresthesias, and progressive, profound neurologic symptoms.

Intervention

The patient was referred to radiation oncology and neurosurgery for evaluation. Consideration was given to cordotomy and resection but the location and procedure was deemed to be high-risk and therefore was deferred. The decision was made to treat with fractionated stereotactic radiosurgery. A dose of 15 Gy was successfully delivered in 3 fractions to the 80% isodose line without complication or adverse effects. Twenty-six months following treatment, the patient was still alive, fully functional, and reported no pain and rare of paresthesias.

Conclusion

Fractionated stereotactic radiosurgery is a feasible, safe, and effective modality for the treatment of ICSM and should be carefully considered in the management of this difficult to treat condition.

Section snippets

Objective and importance

Renal cell cancer has a propensity to metastasize to the central nervous system. Intramedullary spinal cord metastasis (ISCM) comprises up to 8.5% of all central nervous system metastasis and as such can cause great morbidity with motor deficits, pain, paresthesias, bowel and bladder dysfunction, and paralysis as the outcome of this entity [2], [3]. ISCM heralds a grave prognosis with a median survival following diagnosis of 3.9 months [6]. Surgical management is often of limited value because

Case report

The patient, a 50-year-old man with a history significant for seizures and hypertension, initially presented with headaches and dizziness in February 2006. He was seen and evaluated at a local Emergency Department. The diagnostic evaluation included an MRI of the brain. This study revealed a right-sided temporal lobe lesion. He underwent craniotomy and the pathology revealed a clear cell neoplasm. The staging work-up included an abdominal CT that revealed a right-sided renal mass and

Discussion

Intramedullary spinal cord metastases are an uncommon presentation of CNS metastatic disease that is associated with great morbidity and loss of function. Secondary to its location, surgical management is of limited value because of difficulty in achieving a complete resection. Furthermore, because of the poor prognosis of patients with ISCM, an invasive surgical procedure has the potential to further impair the patients’ quality of life without much hope for durable palliation. External beam

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