Symptomatic Spinal Metastases from Intracranial High-grade Glioma – Report of Four Cases and Review of the Literature

European Oncology & Haematology, 2011;7(3):179-82

Abstract:

Intraspinal (leptomeningeal or intramedullary) metastases from primary intracranial gliomas have been well documented in several clinical and pathological series; however, symptomatic intraspinal metastases remain rare. We conducted a retrospective search of cases of intraspinal metastases treated at our centre and report four cases of symptomatic intraspinal leptomeningeal and intramedullary metastases from an intracranial glioma. The mean age of the four cases was 43 years (range 28–55 years). The intraspinal metastases were detected after a median time of 18.5 months after onset of the disease and the median survival time of the four patients from detection of spinal metastases was one month. Median overall survival of the four patients was 19 months. One patient was treated with surgery and all received radiotherapy treatment. Radiotherapy provided good initial palliation of pain but improvement in neurological deficits was limited.Overall, prognosis in cases of leptomeningeal and intramedullary metastases from primary intracranial glioma is very poor; however, this diagnosis should be considered in patients with malignant glioma presenting with new back pain and/or associated spinal neurological signs or symptoms. Radiotherapy provided relief of pain and some improvement in neurological function but no survival advantage. Clinical awareness and recognition of this entity will become increasingly important as local control of primary malignant glioma improves and corresponding improvements in outcome and prognosis of this disease are observed.
Keywords: Intramedullary metastases, leptomeningeal metastases, glioma, radiotherapy
Disclosure: The author has no conflicts of interest to declare.
Received: January 31, 2011 Accepted April 05, 2011 Citation European Oncology & Haematology, 2011;7(3):179-82
Correspondence: James Powell, Specialist Registrar, 53 Westbourne Road, Penarth, Vale of Glamorgan, CF64 3HB, Wales. E: jpowell77@doctors.org.uk

Intraspinal (leptomeningeal or intramedullary) metastases from primary intracranial gliomas have been well documented in several clinical and pathological series.1–5 Post-mortem and cytological incidence of meningeal and cerebrospinal fluid (CSF) dissemination of up to 40 % has been demonstrated in these studies. Symptomatic intraspinal metastases in patients with primary intracerebral gliomas occur rarely however – roughly 1–5 % in published series6–9 – with the reduced incidence of symptomatic metastases primarily attributed to poor survival in this group of patients.

In this case series, we report four cases of symptomatic intraspinal leptomeningeal and intramedullary metastases from an intracranial glioma. Two cases of primary anaplastic astrocytoma, one case of glioblastoma multiforme (GBM) and one unspecified grade 3 glioma are presented. Three cases are of leptomeningeal metastases only, while one case is of simultaneous leptomenigeal and intramedullary metastases. We report the clinical findings, radiographic evaluation, treatment and subsequent clinical course of these patients.

Case Reports
The mean age of the four cases in our series was 43 years (28–55 years). The intraspinal metastases were detected after a median time of 18.5 months after onset of the disease and the median survival time of the four patients from detection of intraspinal metastases was one month. Median overall survival of the four patients was 19 months.

Case 1
In April 1993, this 28-year-old man presented following a generalised seizure. Computed tomography (CT) head scan demonstrated a large mass in the right temporal lobe with moderate surrounding oedema and compression of the lateral ventricle. Subtotal resection was performed with histopathology demonstrating low-grade astrocytoma and no adjuvant treatment was given. He developed recurrent seizures in 1996 and clinical examination demonstrated bilateral papilloedema; he underwent a further craniotomy and debulking for recurrent high-grade astrocytoma. He proceeded to cranial radiotherapy, 60 Gy in 2 Gy fractions commencing six weeks after surgery given with concurrent procarbazine, lomustine and vincristine (PCV) chemotherapy. Post-radiotherapy CT scan showed residual disease. Chemotherapy was completed in May 1997 and four months later the patient attended his general practitioner (GP) complaining of back pain, progressive leg weakness and numbness in the legs and one week later was admitted to hospital with urinary retention. Spinal magnetic resonance imaging (MRI) scan revealed a posterior intradural mass lesion at the T8/9 level compressing the spinal cord. In October 1997 he underwent a T7–T10 thoracic laminectomy and histopathology confirmed recurrent malignant astrocytoma consistent with the histopathology of the primary tumour. Following surgery, radiotherapy was delivered to T7–T10 of the spinal cord to a total dose of 54 Gy in 30 fractions in 1.8 Gy fractions. On completion of radiotherapy improvement in back pain, leg weakness and numbness was observed and bladder function returned to normal. These effects lasted for one month when his condition deteriorated and he noticed worsening leg weakness and bladder function. He was managed with best supportive care and died in January 1998, two months following completion of radiotherapy.

Case 2
In August 2002, this 55-year-old woman was admitted to hospital with a one-month history of expressive dysphasia and right facial, arm and leg weakness. Brain MRI scan demonstrated a 6 cm cystic mass structure in the left frontal lobe associated with surrounding oedema and midline shift (see Figure 1). She underwent craniotomy and subtotal resection and histopathology demonstrated a World Health Organization (WHO) grade 3 glioma. She received post-operative radiotherapy to a dose of 54 Gy in 30 fractions followed by four cycles of PCV chemotherapy, which was completed in June 2003; an MRI brain scan post treatment showed residual disease. In November 2003, she attended her GP surgery complaining of pain in her left buttock and leg with associated bilateral leg weakness but with no sensory level and no disturbance of bowel or bladder function. MRI scan of brain and spine showed stable intracerebral disease but several intradural metastases in the thoracolumbar spinal region (see Figure 2). Histopathological confirmation was not sought and she underwent a course of palliative radiotherapy planned to the thoracolumbar spine to a total dose of 50 Gy over five weeks. Pain and leg weakness initially responded; however, radiotherapy was discontinued after 14 fractions due to pancytopenia. Her leg weakness deteriorated following this and she died from progressive disease in January 2004, one month after the diagnosis of intraspinal metastases.
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Keywords: Intramedullary metastases, leptomeningeal metastases, glioma, radiotherapy
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