My Strangest Case: A Man With Worsening Pain in Both Arms

Elizabeth E. Ginalis, MD; Arthur Carminucci, MD; Nitesh V. Patel, MD; Simon Hanft, MD

Disclosures

July 22, 2020

Presentation and Physical Examination

A 68-year-old man presented to us with a 2-month history of progressively worsening bilateral upper-extremity pain. His previous history was significant for renal cell carcinoma (RCC) and right-sided nephrectomy performed 22 years prior.

Physical examination findings, including neurologic examination findings, were unremarkable. Subsequently, the patient underwent MRI with gadolinium contrast of the cervical spine (Figure 1).

Figure 1.

T1-weighted imaging revealed a 1.5-cm contrast-enhancing intradural, extramedullary lesion at the level of C3-C4. The tumor was causing compression of the spinal cord. Ultimately, we offered surgical resection of the tumor.

Operative Procedure

The patient underwent a C3 and C4 laminectomy and surgical resection of the tumor. The tumor had a red appearance on gross inspection. It was present along the left lateral aspect of the spinal cord and was also attached to the lateral aspect of the dura. A biopsy sample was obtained and sent to pathology for frozen section.

Frozen section revealed features of a high-grade neoplasm. Consequently, a more aggressive surgical resection was done. We achieved a near gross total resection. Only a part of the tumor capsule remained; it was adherent to the spinal cord, which could be injured with further dissection.

Postoperative Care

The patient did well after the operation. Postoperatively, his physical examination findings were unchanged, and he remained neurologically intact. Fortunately, he also reported complete resolution of his pain from initial presentation. Postoperative MRI with contrast demonstrated excellent resection of the lesion (Figure 2a). The patient was discharged on the third postoperative day.

Figure 2.

Subsequently, he underwent PET/CT and MRI of the brain, which found several areas of metastatic disease, including the brain, right mediastinum, bilateral pulmonary nodules, and liver lesions. He began systemic chemotherapy with temsirolimus and focused proton therapy to the cervical spine. At 3 months and 6 months of follow-up, he had no evidence of recurrent disease on MRI of the cervical spine with contrast (Figure 2b, 2c).

He is currently monitored with MRI of the cervical spine every 6 months. At 3 years of follow-up, he has no evidence of disease recurrence of the intradural spinal metastasis, and his systemic disease is controlled as well.

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