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Semin Neurol 2012; 32(02): 137-145
DOI: 10.1055/s-0032-1322584
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Neoplastic Myelopathy

Seema Nagpal
1   Division of Neuro-oncology, Department of Neurology, Stanford University, Stanford, California
,
Jennifer L. Clarke
2   Department of Neurology and Neurosurgery, University of California, San Francisco, California
› Author Affiliations
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Publication History

Publication Date:
08 September 2012 (online)

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Abstract

Neoplastic myelopathy may be due to external compression or to direct intraparenchymal involvement of the spinal cord. In this review, the authors discuss the most common cause for compressive neoplastic myelopathy, metastatic disease. They also review other compressive lesions and discuss primary intramedullary spinal tumors. In the acute setting, compressive metastatic disease should be treated with high-dose steroids when clinically necessary; surgery should be considered for selected patients, followed by radiation therapy. For most primary intramedullary spinal tumors, surgical resection remains the standard initial therapy. Patients with incomplete resection of infiltrative tumors, high-grade pathology, or recurrent tumors may benefit from radiation, but most spinal tumors are relatively insensitive to traditional chemotherapy. Neoplastic myelopathy from either compressive or intraparenchymal causes remains a diagnostic and therapeutic challenge. In complex cases, referral to a specialty center with access to neurosurgeons, neuroradiologists, neuropathologists, and neurooncologists is recommended.

Keywords

spinal cord tumors - neoplastic myelopathy - malignant spinal cord compression
 

  • References

  • 1 Wong DA, Fornasier VL, MacNab I. Spinal metastases: the obvious, the occult, and the impostors. Spine (Phila Pa 1976) 1990; 15 (1) 1-4
    CrossrefPubMedGoogle Scholar
  • 2 Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol 2010; 7 (10) 590-598
    CrossrefPubMedGoogle Scholar
  • 3 Schellinger KA, Propp JM, Villano JL, McCarthy BJ. Descriptive epidemiology of primary spinal cord tumors. J Neurooncol 2008; 87 (2) 173-179
    CrossrefPubMedGoogle Scholar
  • 4 Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol 2005; 6 (1) 15-24
    PubMedGoogle Scholar
  • 5 Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the spinal cord and filum terminale: radiologic-pathologic correlation. Radiographics 2000; 20 (6) 1721-1749
    PubMedGoogle Scholar
  • 6 Schiff D, O'Neill BP, Suman VJ. Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach. Neurology 1997; 49 (2) 452-456
    CrossrefPubMedGoogle Scholar
  • 7 Li KC, Poon PY. Sensitivity and specificity of MRI in detecting malignant spinal cord compression and in distinguishing malignant from benign compression fractures of vertebrae. Magn Reson Imaging 1988; 6 (5) 547-556
    CrossrefPubMedGoogle Scholar
  • 8 Raby N. Cord compression. Imaging 2009; 21 (1) 63-77
    CrossrefPubMedGoogle Scholar
  • 9 Osborn A. Diagnostic Neuroradiology. Vol 1. First ed. St. Louis, MO: Mosby; 1993
    Google Scholar
  • 10 Cohen-Gadol AA, Zikel OM, Miller GM, Aksamit AJ, Scheithauer BW, Krauss WE. Spinal cord biopsy: a review of 38 cases. Neurosurgery 2003; 52 (4) 806-815 , discussion 815–816
    CrossrefPubMedGoogle Scholar
  • 11 Dillon WP, Norman D, Newton TH, Bolla K, Mark A. Intradural spinal cord lesions: Gd-DTPA-enhanced MR imaging. Radiology 1989; 170 (1 Pt 1) 229-237
    CrossrefPubMedGoogle Scholar
  • 12 Schweitzer JS, Batzdorf U. Ependymoma of the cauda equina region: diagnosis, treatment, and outcome in 15 patients. Neurosurgery 1992; 30 (2) 202-207
    CrossrefPubMedGoogle Scholar
  • 13 Karantanis D, O'eill BP, Subramaniam RM , et al. 18F-FDG PET/CT in primary central nervous system lymphoma in HIV-negative patients. Nucl Med Commun 2007; 28 (11) 834-841
    CrossrefPubMedGoogle Scholar
  • 14 Setzer M, Murtagh RD, Murtagh FR , et al. Diffusion tensor imaging tractography in patients with intramedullary tumors: comparison with intraoperative findings and value for prediction of tumor resectability. J Neurosurg Spine 2010; 13 (3) 371-380
    CrossrefPubMedGoogle Scholar
  • 15 Vargas MI, Delavelle J, Jlassi H , et al. Clinical applications of diffusion tensor tractography of the spinal cord. Neuroradiology 2008; 50 (1) 25-29
    CrossrefPubMedGoogle Scholar
  • 16 DeAngelis LM, Posner JB. Neurologic Complications of Cancer. 2nd ed. New York, NY: Oxford University Press; 2009
    Google Scholar
  • 17 Ruff RL, Lanska DJ. Epidural metastases in prospectively evaluated veterans with cancer and back pain. Cancer 1989; 63 (11) 2234-2241
    CrossrefPubMedGoogle Scholar
  • 18 Siegal T. Spinal cord compression: from laboratory to clinic. Eur J Cancer 1995; 31A (11) 1748-1753
    PubMedGoogle Scholar
  • 19 Vecht CJ, Haaxma-Reiche H, van Putten WL, de Visser M, Vries EP, Twijnstra A. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology 1989; 39 (9) 1255-1257
    CrossrefPubMedGoogle Scholar
  • 20 Heimdal K, Hirschberg H, Slettebø H, Watne K, Nome O. High incidence of serious side effects of high-dose dexamethasone treatment in patients with epidural spinal cord compression. J Neurooncol 1992; 12 (2) 141-144
    PubMedGoogle Scholar
  • 21 Patchell RA, Tibbs PA, Regine WF , et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366 (9486) 643-648
    CrossrefPubMedGoogle Scholar
  • 22 George R, Jeba J, Ramkumar G, Chacko AG, Leng M, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev 2008; (4) CD006716
    PubMedGoogle Scholar
  • 23 Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: what are the options, indications, and outcomes?. Spine (Phila Pa 1976) 2009; 34 (22, Suppl) S78-S92
    CrossrefPubMedGoogle Scholar
  • 24 Maiuri F, De Caro ML, de Divitiis O, Vergara P, Mariniello G. Spinal meningiomas: age-related features. Clin Neurol Neurosurg 2011; 113 (1) 34-38
    CrossrefPubMedGoogle Scholar
  • 25 Cohen-Gadol AA, Zikel OM, Koch CA, Scheithauer BW, Krauss WE. Spinal meningiomas in patients younger than 50 years of age: a 21-year experience. J Neurosurg 2003; 98 (3) (Suppl) 258-263
    CrossrefPubMedGoogle Scholar
  • 26 Solero CL, Fornari M, Giombini S , et al. Spinal meningiomas: review of 174 operated cases. Neurosurgery 1989; 25 (2) 153-160
    CrossrefPubMedGoogle Scholar
  • 27 Sade B, Chahlavi A, Krishnaney A, Nagel S, Choi E, Lee JH. World Health Organization Grades II and III meningiomas are rare in the cranial base and spine. Neurosurgery 2007; 61 (6) 1194-1198 , discussion 1198
    CrossrefPubMedGoogle Scholar
  • 28 Jo K, Park HJ, Nam DH , et al. Treatment of atypical meningioma. J Clin Neurosci 2010; 17 (11) 1362-1366
    CrossrefPubMedGoogle Scholar
  • 29 Guideline Version NCCN. 2.2011 for Central Nervous System Cancers. National Comprehensive Cancer Network 2011. Available at: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp . Accessed February 15, 2011
    PubMedGoogle Scholar
  • 30 Chamberlain MC, Glantz MJ, Fadul CE. Recurrent meningioma: salvage therapy with long-acting somatostatin analogue. Neurology 2007; 69 (10) 969-973
    CrossrefPubMedGoogle Scholar
  • 31 Grimm SA, Chamberlain MC, Chandler J , et al. A Phase II Trial of PTK787/ZK 222584 (PTK787) in recurrent high-grade meningioma. J Clin Oncol 29: 2011 (suppl):abstr 2046
    PubMedGoogle Scholar
  • 32 Wen PY, Yung WK, Lamborn KR , et al. Phase II study of imatinib mesylate for recurrent meningiomas (North American Brain Tumor Consortium study 01-08). Neuro-oncol 2009; 11 (6) 853-860
    PubMedGoogle Scholar
  • 33 Kaley TJ, Wen P, Karimi S, Lieberman F, Schiff D, Abrey L. Phase II Trial of Sunitinib (SU011248) for recurrent or inoperable meningioma. Paper presented at: 13th Annual Meeting of the Society for Neuro Oncology; November 20–23, 2008; Las Vegas, NV
    PubMedGoogle Scholar
  • 34 Conti P, Pansini G, Mouchaty H, Capuano C, Conti R. Spinal neurinomas: retrospective analysis and long-term outcome of 179 consecutively operated cases and review of the literature. Surg Neurol 2004; 61 (1) 34-43 , discussion 44
    CrossrefPubMedGoogle Scholar
  • 35 Gerszten PC, Ozhasoglu C, Burton SA, Kalnicki S, Welch WC. Feasibility of frameless single-fraction stereotactic radiosurgery for spinal lesions. Neurosurg Focus 2002; 13 (4) e2
    PubMedGoogle Scholar
  • 36 Murovic JA, Gibbs IC, Chang SD, Mobley BC, Park J, Adler Jr JR. Foraminal nerve sheath tumors: intermediate follow-up after cyberknife radiosurgery. Neurosurgery 2009; 64 (2, Suppl) A33-A43
    CrossrefPubMedGoogle Scholar
  • 37 Evans DG, Birch JM, Ramsden RT, Sharif S, Baser ME. Malignant transformation and new primary tumours after therapeutic radiation for benign disease: substantial risks in certain tumour prone syndromes. J Med Genet 2006; 43 (4) 289-294
    PubMedGoogle Scholar
  • 38 Anghileri M, Miceli R, Fiore M , et al. Malignant peripheral nerve sheath tumors: prognostic factors and survival in a series of patients treated at a single institution. Cancer 2006; 107 (5) 1065-1074
    CrossrefPubMedGoogle Scholar
  • 39 Helseth A, Mørk SJ. Primary intraspinal neoplasms in Norway, 1955 to 1986. A population-based survey of 467 patients. J Neurosurg 1989; 71 (6) 842-845
    CrossrefPubMedGoogle Scholar
  • 40 Milano MT, Johnson MD, Sul J , et al. Primary spinal cord glioma: a surveillance, epidemiology, and end results database study. J Neurooncol 2010; 98 (1) 83-92
    CrossrefPubMedGoogle Scholar
  • 41 Schiff D, O'Neill BP. Intramedullary spinal cord metastases: clinical features and treatment outcome. Neurology 1996; 47 (4) 906-912
    CrossrefPubMedGoogle Scholar
  • 42 Harrop JS, Ganju A, Groff M, Bilsky M. Primary intramedullary tumors of the spinal cord. Spine (Phila Pa 1976) 2009; 34 (22, Suppl) S69-S77
    CrossrefPubMedGoogle Scholar
  • 43 McGuire CS, Sainani KL, Fisher PG. Incidence patterns for ependymoma: a surveillance, epidemiology, and end results study. J Neurosurg 2009; 110 (4) 725-729
    CrossrefPubMedGoogle Scholar
  • 44 Kurimoto M, Nagai S, Hamada H , et al. Malignant transformation of supratentorial clear cell ependymoma. Neuropathology 2009; 29 (3) 299-302
    CrossrefPubMedGoogle Scholar
  • 45 Reni M, Gatta G, Mazza E, Vecht C. Ependymoma. Crit Rev Oncol Hematol 2007; 63 (1) 81-89
    CrossrefPubMedGoogle Scholar
  • 46 Yang S, Yang X, Hong G. Surgical treatment of one hundred seventy-four intramedullary spinal cord tumors. Spine (Phila Pa 1976) 2009; 34 (24) 2705-2710
    CrossrefPubMedGoogle Scholar
  • 47 Halvorsen CM, Kolstad F, Hald J , et al. Long-term outcome after resection of intraspinal ependymomas: report of 86 consecutive cases. Neurosurgery 2010; 67 (6) 1622-1631 , discussion 1631
    CrossrefPubMedGoogle Scholar
  • 48 Waldron JN, Laperriere NJ, Jaakkimainen L , et al. Spinal cord ependymomas: a retrospective analysis of 59 cases. Int J Radiat Oncol Biol Phys 1993; 27 (2) 223-229
    PubMedGoogle Scholar
  • 49 Volpp PB, Han K, Kagan AR, Tome M. Outcomes in treatment for intradural spinal cord ependymomas. Int J Radiat Oncol Biol Phys 2007; 69 (4) 1199-1204
    CrossrefPubMedGoogle Scholar
  • 50 Schild SE, Nisi K, Scheithauer BW , et al. The results of radiotherapy for ependymomas: the Mayo Clinic experience. Int J Radiat Oncol Biol Phys 1998; 42 (5) 953-958
    CrossrefPubMedGoogle Scholar
  • 51 Vanuytsel L, Brada M. The role of prophylactic spinal irradiation in localized intracranial ependymoma. Int J Radiat Oncol Biol Phys 1991; 21 (3) 825-830
    CrossrefPubMedGoogle Scholar
  • 52 Guidetti B. Intramedullary tumours of the spinal cord. Acta Neurochir (Wien) 1967; 17 (1) 7-23
    CrossrefPubMedGoogle Scholar
  • 53 Wahab SH, Simpson JR, Michalski JM, Mansur DB. Long term outcome with post-operative radiation therapy for spinal canal ependymoma. J Neurooncol 2007; 83 (1) 85-89
    CrossrefPubMedGoogle Scholar
  • 54 Gomez DR, Missett BT, Wara WM , et al. High failure rate in spinal ependymomas with long-term follow-up. Neuro-oncol 2005; 7 (3) 254-259
    PubMedGoogle Scholar
  • 55 Chamberlain MC, Johnston SK. Temozolomide for recurrent intracranial supratentorial platinum-refractory ependymoma. Cancer 2009; 115 (20) 4775-4782
    CrossrefPubMedGoogle Scholar
  • 56 Bouffet E, Capra M, Bartels U. Salvage chemotherapy for metastatic and recurrent ependymoma of childhood. Childs Nerv Syst 2009; 25 (10) 1293-1301
    CrossrefPubMedGoogle Scholar
  • 57 Chamberlain MC. Salvage chemotherapy for recurrent spinal cord ependymona. Cancer 2002; 95 (5) 997-1002
    CrossrefPubMedGoogle Scholar
  • 58 Sandri A, Massimino M, Mastrodicasa L , et al. Treatment with oral etoposide for childhood recurrent ependymomas. J Pediatr Hematol Oncol 2005; 27 (9) 486-490
    CrossrefPubMedGoogle Scholar
  • 59 Green RM, Cloughesy TF, Stupp R , et al. Bevacizumab for recurrent ependymoma. Neurology 2009; 73 (20) 1677-1680
    CrossrefPubMedGoogle Scholar
  • 60 Epstein FJ, Farmer JP, Freed D. Adult intramedullary astrocytomas of the spinal cord. J Neurosurg 1992; 77 (3) 355-359
    CrossrefPubMedGoogle Scholar
  • 61 Garcés-Ambrossi GL, McGirt MJ, Mehta VA , et al. Factors associated with progression-free survival and long-term neurological outcome after resection of intramedullary spinal cord tumors: analysis of 101 consecutive cases. J Neurosurg Spine 2009; 11 (5) 591-599
    CrossrefPubMedGoogle Scholar
  • 62 Fernandez C, Figarella-Branger D, Girard N , et al. Pilocytic astrocytomas in children: prognostic factors—a retrospective study of 80 cases. Neurosurgery 2003; 53 (3) 544-553 , discussion 554–555
    Google Scholar
  • 63 Eroes CA, Zausinger S, Kreth FW, Goldbrunner R, Tonn JC. Intramedullary low grade astrocytoma and ependymoma. Surgical results and predicting factors for clinical outcome. Acta Neurochir (Wien) 2010; 152 (4) 611-618
    CrossrefPubMedGoogle Scholar
  • 64 Abdel-Wahab M, Etuk B, Palermo J , et al. Spinal cord gliomas: A multi-institutional retrospective analysis. Int J Radiat Oncol Biol Phys 2006; 64 (4) 1060-1071
    CrossrefPubMedGoogle Scholar
  • 65 Minehan KJ, Brown PD, Scheithauer BW, Krauss WE, Wright MP. Prognosis and treatment of spinal cord astrocytoma. Int J Radiat Oncol Biol Phys 2009; 73 (3) 727-733
    CrossrefPubMedGoogle Scholar
  • 66 Massimino M, Spreafico F, Riva D , et al. A lower-dose, lower-toxicity cisplatin-etoposide regimen for childhood progressive low-grade glioma. J Neurooncol 2010; 100 (1) 65-71
    CrossrefPubMedGoogle Scholar
  • 67 Chamberlain MC. Temozolomide for recurrent low-grade spinal cord gliomas in adults. Cancer 2008; 113 (5) 1019-1024
    CrossrefPubMedGoogle Scholar
  • 68 Chamberlain MC, Johnston SK. Recurrent spinal cord glioblastoma: salvage therapy with bevacizumab. J Neurooncol 2011; 102 (3) 427-432
    CrossrefPubMedGoogle Scholar
  • 69 Tago M, Terahara A, Shin M , et al. Gamma knife surgery for hemangioblastomas. J Neurosurg 2005; 102 (Suppl) 171-174
    CrossrefPubMedGoogle Scholar
  • 70 National Cancer Institute. Non Hodgkin Lymphoma. PDQ Adult Non Hodgkin Lymphoma. 2010 . Available at: http://www.cancer.gov/cancertopics/types/non-hodgkin . Accessed January 26, 2011
    PubMedGoogle Scholar
  • 71 Central Brain Tumor Registry of the United States (CBTRUS). Statistical Report CBTRUS. Primary Brain and Central Nervous System Tumors Diagnosed in the United States in 2004–2007. 2010 . Available at: http://www.cbtrus.org Accessed March 1, 2011
    PubMedGoogle Scholar
  • 72 Bekar A, Cordan T, Evrensel T, Tolunay S. A case of primary spinal intramedullary lymphoma. Surg Neurol 2001; 55 (5) 261-264
    CrossrefPubMedGoogle Scholar
  • 73 Machiya T, Yoshita M, Iwasa K, Yamada M. Primary spinal intramedullary lymphoma mimicking ependymoma. Neurology 2007; 68 (11) 872
    CrossrefPubMedGoogle Scholar
  • 74 Nieder C, Ataman F, Price RE, Ang KK. Radiation myelopathy: new perspective on an old problem. Radiat Oncol Investig 1999; 7 (4) 193-203
    CrossrefPubMedGoogle Scholar
  • 75 van der Kogel A. Radiation response and tolerance of normal tissues. In: Steele GG, ed. Basic Clinical Radiobiology. London: Arnold; 1997: 30-39
    Google Scholar
  • 76 Levin VA, Bidaut L, Hou P , et al. Randomized double-blind placebo-controlled trial of bevacizumab therapy for radiation necrosis of the central nervous system. Int J Radiat Oncol Biol Phys 2011; 79 (5) 1487-1495
    CrossrefPubMedGoogle Scholar
  • 77 Watterson J, Toogood I, Nieder M , et al. Excessive spinal cord toxicity from intensive central nervous system-directed therapies. Cancer 1994; 74 (11) 3034-3041
    CrossrefPubMedGoogle Scholar
  • 78 Gangji D, Reaman GH, Cohen SR, Bleyer WA, Poplack DG. Leukoencephalopathy and elevated levels of myelin basic protein in the cerebrospinal fluid of patients with acute lymphoblastic leukemia. N Engl J Med 1980; 303 (1) 19-21
    CrossrefPubMedGoogle Scholar
  • 79 Dalmau JRM. Paraneoplastic syndromes affecting the spinal cord and dorsal root ganglia. UpToDate 2010; Review Article. Available at: http://www.uptodate.com . Accessed July 21, 2012
    PubMedGoogle Scholar
  • 80 Harrop JS, Schmidt MH, Boriani S, Shaffrey CI. Aggressive “benign” primary spine neoplasms: osteoblastoma, aneurysmal bone cyst, and giant cell tumor. Spine (Phila Pa 1976) 2009; 34 (22, Suppl) S39-S47
    CrossrefPubMedGoogle Scholar
  • 81 Wang VY, Potts M, Chou D. Sarcoma and the spinal column. Neurosurg Clin N Am 2008; 19 (1) 71-80
    CrossrefPubMedGoogle Scholar
  • 82 Yamazaki T, McLoughlin GS, Patel S, Rhines LD, Fourney DR. Feasibility and safety of en bloc resection for primary spine tumors: a systematic review by the Spine Oncology Study Group. Spine (Phila Pa 1976) 2009; 34 (22, Suppl) S31-S38
    CrossrefPubMedGoogle Scholar