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Spinal Cord and Spinal Intradural Metastasis from a Testicular Neoplasm 2007

General Spine

Ryan D Murtagh, MD, MBA,
Judith Post, MD, ASSR Member
Sklar Evelyn, MD, ASSR Member

Excerpta Extraordinaire

Excerpta

Spinal cord, spinal intradural space, vertebral body, and brain metastasis in a patient with testicular cancer.

Purpose

To describe the magnetic resonance imaging (MRI) features of an unusual case of metastasis to the spinal cord, spinal intradural space, vertebral body, and brain from a testicular neoplasm.

Methods & Materials

This is a 24 year old male who was initially diagnosed with testicular cancer in 2003 at an outside hospital. Orchiectomy was performed at that time, with findings of a stage I pure seminoma. He underwent prophylactic radiation treatment and was subsequently lost to follow up.
In September of 2004, he returned to his oncologist with a cough and back pain. Workup at that time revealed a large right lower lobe mass. He did not have insurance and was therefore referred to Jackson Memorial Hospital. Here, several cycles of chemotherapy were administered in an effort to reduce the size of the right lower lobe mass. An attempted resection was performed in November of 2005, but it was felt that the mass was too large to be safely removed. Further attempts to reduce the size of the mass with chemotherapy and stem cell transplant were successful, with repeat thoracotomy performed in March of 2006. Pathology revealed no residual viable tumor cells in the lung mass. He was discharged to home shortly thereafter.
He returned to the emergency deparment approximately three weeks later with complaints of nausea and vomiting. MRI of the brain revealed a large enhancing mass in the right occipital lobe. He was taken to the operating room for craniotomy and resection of the mass. Pathology revealed dense cellularity with embryonal cell carcinoma with elements of seminoma and yolk sac tumor. After surgery, he was discharged to home without complications. Follow-up MRI performed one month after the surgery revealed a large enhancing mass in the operative bed consistent with tumor recurrence. He was again taken to the operating room with similar results and again discharged to home.
He was seen in clinic shortly after discharge with complaints of severe back pain and right sided weakness. MRI of the spine was ordered. This study showed widespread metastatic disease with numerous intramedullary and intradural spinal lesions throughout the cervical, thoracic, and lumbar spine. Given the extent of his disease, he was given palliative radiation treatment to the entire spine and discharged to home with Hospice care.

Results

MRI of the brain shows a large right parieto-occipital mass. The lesion is isointense to slightly hyperintense on FLAIR images and enhances heterogeneously following contrast administration.
MRI of the entire spine showed several large intramedullary lesions in the cervical and thoracic cord, as well as multiple intradural, extramedullary lesions through the cervical, thoracic, and lumbar spine. The lesions are isointense to cord on pre-contrast T1 images and enhance avidly following administration of contrast (Magnevist). The lesions are predominately isointense on T2 weighted images. Vertebral body involvement was noted as well. One month follow-up MRI of the lumbar spine shows marked interval progression of intradural disease.

Conclusion

Germ cell tumors of the testis most frequently metastasize to the lungs, liver, brain and bone (1). Several case reports have documented cord compression as a result of epidural metastasis (2, 3). However, the MRI characteristics of intramedullary spinal cord metastasis of testicular tumors has not been well described in the literature. Of particular interest is the relative isointensity of the lesions on T2 weighted images which may be related to the dense cellularity of the tumor.

References

1. Bredael JJ, Vugrin D, Whitmore WF. Autopsy findings in 154 patients with germ cell tumors of the testis. Cancer. 1982 Aug 1; 50(3): 548-51
2. Lee JK, Kim SH, Kim JH. Metastatic spinal cord compression of testicular yolk sac tumor. Childs Nerv Syst. 2002 Apr;18(3-4):171-4. Epub 2002 Mar 2.
3. Colak A, Benli K, Berker M, Onol B. Epidural metastasis of testicular yolk sac tumor: an unusual cause of spinal cord compression. Case report. Pediatr Neurosurg 1991-1992;17(3):139-41.

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