Advertisement

Surprising complete response of intramedullary spinal cord metastasis from breast cancer: a case report and literature review

Abstract

Purpose

Intramedullary spinal cord metastases (ISCM) are considered rare but their incidence is rising. Most ISCM cases are recognized to occur in patients with stage IV lung cancer or breast cancer (BC).

Methods

We report a rare case of cervical BC-ISCM in 60-year-old woman, documented by magnetic resonance imaging and positron emission tomography–computed tomography and treated with volumetric modulated arc therapy with daily image-guided radiation therapy (VMAT/IGRT).

Results

An unexpected clinical and radiologic complete response in absence of neurologic side effects was recorded 4 months after VMAT/IGRT.

Conclusions

The present case report shows the feasibility of advanced RT and its optimal response in a case of ISCM from BC. Despite the short follow-up, in comparison with available literature data concerning the management of BC-ISCM, we found an early complete response, in contrast with other reported experiences.

Tumori 2017; 103(Suppl. 1): e28 - e30

Article Type: CASE REPORT

DOI:10.5301/tj.5000647

Authors

Dario Aiello, Rosario Mazzola, Fabiana Gregucci, Francesco Ricchetti, Niccolò Giaj Levra, Luigi Romano, Giovanni Carbognin, Matteo Salgarello, Alberto Beltramello, Filippo Alongi

Article History

Disclosures

Financial support: No financial support was received for this submission.
Conflict of interest: None of the authors has conflict of interest with this submission.

This article is available as full text PDF.

Download any of the following attachments:

Introduction

In the last few years, the incidence of breast cancer (BC) brain metastases has increased, with reported rates between approximately 10% and 42% (1). Moreover, around 8.5% of all CNS metastases involve the spinal cord; in this setting, the incidence of intramedullary spinal cord metastases (ISCM) from BC remains not well-recognized (2). Autopsy studies showed an incidence of ISCM within 2%. However, due to the increase in survival in patients with metastatic disease after the introduction of new drugs, the development of ISCM is on the rise (3). Few ISCM are symptomatic and therefore diagnosis remains challenging (4). Because of the low frequency of treated cases, the standard treatment approach is still to be assessed. Literature data regarding the use of radiotherapy (RT) in ISCM are scarce.

We report a rare case of cervical BC-ISCM in a 60-year-old woman, documented by magnetic resonance imaging (MRI) and positron emission tomography–computed tomography (PET-CT) and treated with an advanced RT modality, obtaining an unexpected clinical and radiologic complete response in absence of neurologic side effects. Despite the relatively short follow-up, no early complete response has been reported previously. Available literature data are also discussed.

Case report

In January 2015, a 60-year-old patient complained of bone and abdominal pain. In March of the same year, a CT scan revealed bone, hepatic, and pulmonary metastatic spread. A subsequent axillary biopsy showed multiple lymph node metastases by infiltrating ductal BC (ER 90%, PgR 90%, Ki67 20%, HER2 positive).

From April 2015 to September 2015, the patient was submitted to first-line systemic therapy with taxotere, pertuzumab, and trastuzumab. In September 2015, an MRI revealed 3 brain metastases and disappearance of body metastases. The patient was a candidate for stereotactic radiosurgery (SRS) (single dose of 21 Gy for each brain lesion), followed by maintenance with aromatase inhibitors in association with pertuzumab and trastuzumab.

In November 2015, an MRI showed complete response of the previously treated brain metastases and the appearance of 3 new brain lesions. The patient was referred to our Radiation Oncology Department and, after a multidisciplinary evaluation within the Cancer Care Center, she was deemed a candidate for whole brain radiotherapy with hippocampal avoidance and simultaneous integrated boost to brain metastases in progression, with a subsequent complete response documented by MRI scan 2 months thereafter.

In December 2016, MRI spine done owing to progressive lower limb weakness and pain revealed an intramedullary pathologic enhancement with a longitudinal extension of 4 cm (between C6 andD2), compatible with ISCM and confirmed at 18F-fluorodeoxyglucose PET-CT (Fig. 1). A neurosurgical approach was excluded; thus, the patient was treated with RT for a total dose of 20 Gy in 5 fractions by means of volumetric modulated arc therapy with daily image-guided RT (VMAT/IGRT), in order to minimize dose to organs at risk such as larynx and esophagus (5).

Sagittal T1/T2-weighted magnetic resonance imaging with contrast medium (A, B) and 18F-fluorodeoxyglucose positron emission tomography (C) preradiotherapy.

Magnetic resonance imaging and PET-CT (Fig. 2) 4 months after RT showed a complete response and a subsequent neurologic symptoms benefit.

Sagittal T1/T2-weighted magnetic resonance imaging with contrast medium (A, B) and 18F-fluorodeoxyglucose positron emission tomography (C) postradiotherapy.

Discussion

Management of ISCM represents a challenging clinical scenario in which clear guidelines are lacking. Treatment choice usually is based on physician experience. Therapeutic options include surgical excision, external beam RT, chemotherapy, or palliative care. Generally, the appearance of ISCM affects patients’ quality of life due to neurologic symptoms and BC prognosis (6). Breast cancer ISCM represent a rare event. The available literature data deriving from single-center small case series are not conclusive in terms of best treatment option or oncologic outcomes. To our knowledge, few clinical cases evaluating the role of exclusive RT have been published in the literature (6-7-8-9). Of note, none of the published reports has shown a complete response after RT alone. In contrast, in the current clinical case, a complete radiologic response as well as neurologic symptoms benefit were recorded 4 months after our approach consisting of a schedule of 20 Gy in 5 fractions by means of VMAT/IGRT. The choice to prescribe 20 Gy in 5 fractions was related to the specific request of the patient to reduce treatment duration, for logistical needs, because she lives in another region. Compared to 30 Gy in 10 fractions, more commonly proposed for palliation, 20 Gy in 5 fractions can be more prone to enhance the reduced possibility to recover damage by tumor cells after radiation due to treatment time acceleration. Despite the patient's need for reduced time for logistical reasons, we avoided prescribing the single fraction. We supposed that from the radiobiological point of view, with multiple fractions, the re-oxygenation counterpart effect could have influenced lesion control.

Similarly, Veeravagu et al (8) described outcomes of 5 BC-ISCM cases treated with fractionated stereotactic RT. Only in 3 cases were RT specifics detailed. Patients were treated with the following schedules: 18 Gy/2, 20 Gy/2, 21 Gy/3 using Cyberknife platform. No case of complete response was registered in these series. Shin and colleagues (7) reported 3 cases of cervical BC-ISCM treated with linac-based SRS for a mean dose of 14.4 Gy for each lesion with a clinical outcome improvement and a radiologic decrease, but not complete response. Three BC-ISCM case reports, in addition to ours, presented HER2-positive patients (6, 9). HER2 overexpression is a well-established risk factor for central nervous system metastases. Approximately 20%-25% of all BCs overexpressing HER2 were associated with a more aggressive phenotype and shorter overall survival than nonamplified tumors. As in our case, a propensity for patients with BC who receive monoclonal antibodies to develop ISCM, due to inability to cross the blood-brain barrier, could be hypothesized. Furthermore, in addition to the differences described concerning the treatment approach and clinical outcome, the timing of ISCM presentation in relation to BC diagnosis is different (6-7-8-9). In the present case, ISCM started metachronously at 10 months after symptomatic brain metastases treated by whole brain RT. However, a link between the timing of RT beginning and BC-ISCM diagnosis was demonstrated and only an RT seems to improve the clinical outcome (10). In the case described here, the patient was submitted to RT a few days from ISCM diagnosis, which could be a reason for complete neurologic remission and radiologic and metabolic complete response.

A limitation of the current case report is the limited follow-up. Nevertheless, in comparison with literature data concerning the management of BC-ISCM, an early unexpected disappearance of a treated lesion was shown; this response has not been reported by other available series or cases.

Conclusion

The present case report shows the feasibility of advanced RT and its optimal response in a case of ISCM from BC. Despite the short follow-up, in comparison with available literature data concerning the management of BC-ISCM, we found a surprising early complete response.

Disclosures

Financial support: No financial support was received for this submission.
Conflict of interest: None of the authors has conflict of interest with this submission.
References
  • 1. Bendell JC Domchek SM Burstein HJ et al. Central nervous system metastases in women who receive trastuzumab-based therapy for metastatic breast carcinoma. Cancer 2003 97 12 2972 2977 Google Scholar
  • 2. Hashizume Y Hirano A Intramedullary spinal cord metastasis. Pathologic findings in five autopsy cases. Acta Neuropathol 1983 61 3-4 214 218 Google Scholar
  • 3. Dam-Hieu P Seizeur R Mineo JF Metges JP Meriot P Simon H Retrospective study of 19 patients with intramedullary spinal cord metastasis. Clin Neurol Neurosurg 2009 111 1 10 17 Google Scholar
  • 4. Wiedemayer H Fauser B Sandalcioglu IE Schäfer H Stolke D The impact of neurophysiological intraoperative monitoring on surgical decisions: a critical analysis of 423 cases. J Neurosurg 2002 96 2 255 262 Google Scholar
  • 5. Mazzola R Ricchetti F Fersino S et al. Predictors of mucositis in oropharyngeal and oral cavity cancer in patients treated with volumetric modulated radiation treatment: A dose-volume analysis. Head Neck 2016 38 S1 Suppl 1 E815 E819 Google Scholar
  • 6. Kosmas C Koumpou M Nikolaou M et al. Intramedullary spinal cord metastases in breast cancer: report of four cases and review of the literature. J Neurooncol 2005 71 1 67 72 Google Scholar
  • 7. Shin DA Huh R Chung SS Rock J Ryu S Stereotactic spine radiosurgery for intradural and intramedullary metastasis. Neurosurg Focus 2009 27 6 E10. Google Scholar
  • 8. Veeravagu A Lieberson RE Mener A et al. CyberKnife stereotactic radiosurgery for the treatment of intramedullary spinal cord metastases. J Clin Neurosci 2012 19 9 1273 1277 Google Scholar
  • 9. Zebrowski A Wilson L Lim A Stebbing J Krell J Intramedullary spinal cord metastases in breast cancer are associated with improved longer-term systemic control. Future Oncol 2010 6 9 1517 1519 Google Scholar
  • 10. Schiff D ONeill BP Intramedullary spinal cord metastases: clinical features and treatment outcome. Neurology 1996 47 4 906 912 Google Scholar

Authors

Affiliations

  • Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar (Verona) - Italy
  • Radiology, Sacro Cuore Don Calabria Cancer Care Center, Negrar (Verona) - Italy
  • Nuclear Medicine Department, Sacro Cuore Don Calabria Cancer Care Center, Negrar (Verona) - Italy
  • University of Brescia, Brescia - Italy

Article usage statistics

The blue line displays unique views in the time frame indicated.
The yellow line displays unique downloads.
Views and downloads are counted only once per session.

No supplementary material is available for this article.