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J Thorac Cardiovasc Surg 2002;124:200-202
© 2002 The American Association for Thoracic Surgery
Brief Communications |
From the Department of Neurology, University Medical Center, Nijmegen,a the Department of Neurology, Rijnstate Hospital, Arnhem,b the Departments of Radiotherapyc and Neurology,d Medical Center Haaglanden, The Hague, and the Department of Neuro-Oncology, Dr Daniel den Hoed Cancer Center/University Hospital, Rotterdam,e The Netherlands.
Received for publication Dec 14, 2001. Accepted for publication Jan 8, 2002. Address for reprints: Johanna M. M. Gijtenbeek, MD, Department of Neurology, University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
Despite multimodal therapy, the prognosis of pleural malignant mesothelioma remains dismal, with a median survival of less than 1 year.
1,2 The disease usually progresses locally by direct extension into the pulmonary parenchyma, the chest wall, and mediastinum, and most patients ultimately die of respiratory failure. 2,3 Hematologic spread may occur in the late stages of the disease, but neurologic complications have only rarely been reported. We describe 4 patients with spinal epidural extension of a paravertebral malignant mesothelioma, resulting in signs of spinal cord compression. The neurologic complication developed 4 months and 2, 6, and 7 years after diagnosis, indicating a remarkably indolent course of malignant mesothelioma in most of these patients.
Clinical summaries
PATIENT 1. A 56-year-old woman was referred because of progressive low back pain radiating to the back of her legs. She had been treated for pleural effusion for the previous 7 years, and although a pleural tumor was suspected, repeated pleural biopsies were not diagnostic. She had been exposed to asbestos by way of her husband's working clothes. Computed tomographic scan of the lumbar spine showed masses in the left intervertebral foramina at L2-L3 and L3-L4, with thickening of the left psoas muscle. A muscle biopsy specimen revealed malignant mesothelioma. Three months later, the patient had uncontrollable pain and weakness in both legs. A computed tomographic scan of the spine (T7-L5) showed paravertebral masses growing into the intervertebral foramina at all levels. After 4 months, intolerable neck pain, progressive leg weakness, and ataxic gait had developed. Magnetic resonance imaging (MRI) showed epidural tumor growth at the thoracic and cervical levels, extending through the foramen magnum into the skull (Figure 1). One week later, the patient's condition deteriorated, and she died of respiratory failure. At autopsy, tumor was found in the left thoracic wall, the pericardium, the diaphragm, and the left psoas muscle. At all levels the tumor extended through the intervertebral foramina into the spinal canal. Microscopic examination of the dura at the foramen magnum showed malignant mesothelioma.
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, D). One month later, the patient died of respiratory failure. Autopsy was not performed.
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PATIENT 4. A 53-year-old man sought treatment with severe back pain radiating to the right loin and abdomen. Four months earlier, a right pleural malignant mesothelioma that extended retroperitoneally had been diagnosed. The patient had received four cycles of cisplatin and ifosfamide chemotherapy when the back pain occurred. The lower thoracic spine was tender on percussion. Results of the neurologic examination were otherwise normal.
MRI demonstrated a large paravertebral mass invading multiple thoracic vertebrae and intervertebral foramina. At the T10 level, an epidural cuff caused spinal cord compression. The patient was treated with dexamethasone and received 30 Gy of radiotherapy. Within 1 month of radiotherapy, the patient died of respiratory failure. Autopsy was not performed.
Discussion
In general, pleural malignant mesothelioma is locally invasive, and progression tends to occur by direct extension of tumor into the pulmonary parenchyma, into the chest wall, into the mediastinum, and through the diaphragm into the abdominal cavity. 3 Distant metastases, mostly to the lungs, may occur in later stages of the disease. Malignant mesothelioma rarely metastasizes to the nervous system, and only a few cases have been reported of malignant mesothelioma invading the spinal canal. 4,5
Here we present the cases of 4 patients with pleural malignant mesothelioma and neurologic complications resulting from spinal epidural tumor growth. A remarkable growth pattern consisting of widespread cufflike epidural extension was observed with MRI and confirmed by autopsy in 2 cases. In these patients, the tumor respected anatomic boundaries and spread upward through the epidural space, initially causing root pain and only in later stages causing signs of spinal cord compression. A feature of malignant mesothelioma is its tendency to spread along preexisting tissue planes. The reason for the extensive spinal extension in our patients is unclear, but it may be related to the relatively protracted course of the disease. Although median survival is less than 1 year after onset of symptoms, 2 2 of the patients survived for more than 6 years.
Malignant mesothelioma can spread to the spinal canal by direct extension through the intervertebral foramina (as in our patients), by hematogenous spread to the spinal meninges, 4 and by perineural growth along a single nerve root. 5 The patients initially had back pain and radicular pain (arm, leg, loin, or thoracic radiating pain). Radicular pain should alert the clinician to the possibility of epidural tumor in patients with known or suspected malignant mesothelioma. In case of epidural extension, radiotherapy should be immediately instituted to save neurologic function. New symptoms arising along the spinal axis indicate further extension of the tumor and should be promptly evaluated.
References
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