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

Surgical resection is generally favored because it usually results in the greatest improvement from presenting symptoms.[5,6] In particular, one case series of intradural spinal metastases from RCC found that patients presenting with motor or pain symptoms were more likely to improve postoperatively compared with those who have paresthesia or urinary incontinence.[5] Moreover, early surgical intervention has been associated with longer overall survival and improved prognosis.[7]

Unfortunately, not all patients are appropriate surgical candidates because of comorbidities or functional status. These factors must be considered when determining the appropriate treatment for the patient. In these patients who are not deemed appropriate for surgery, radiation therapy, such as stereotactic radiosurgery, can be considered as a second-line option.

Unfortunately, RCC is generally radioresistant; however, some studies have found that radiation resulted in improvement of symptoms without an increased survival rate.[8,9,10,11,12] Owing to the rarity of these lesions, management is often dictated by case reports and series in the literature, as well as severity of symptoms. Given that this often presents as an advanced disease process with limited life expectancy, the goal of treatment should be to improve symptoms and enhance quality of life.

Only 18 cases of intradural extramedullary spinal metastasis from RCC have been reported to date.[5,6,13,14,15,16,17,18,19,20,21,22,23,24,25] Among these cases, the mean age was 62 years (±14 years) at diagnosis of metastasis. The mean latency period from diagnosis of RCC to diagnosis of metastasis is 3.9 years (±6.2 years), with the longest reported latency being 16 years.[13,14]

In the two cases that reported a latency of 16 years, the patients only had a single metastatic tumor to the spinal cord without diffuse disease.[13,14] Similar to these patients, our patient's initial presentation was from the spinal tumor. However, in our case, the patient had diffuse systemic disease not limited to the spinal cord. Despite advanced cancer, our patient described only bilateral upper-extremity pain from the spinal cord tumor, without additional symptoms or physical examination findings from his other metastases.

Regarding disease extent, less than one third of patients were found to have metastases to other areas outside the spine, with 17% of patients also having brain metastases. Metastasis to the lumbar spine was most common (59%), especially in the cauda equina. Nearly one quarter of patients presented with metastasis as the initial sign of primary RCC. Half of the patients were managed surgically, five patients (28%) were treated with radiation, and the remaining four patients (22%) received a combination of the two therapies. Nearly all patients (89%) were alive at the last follow-up, with a mean overall survival of 2 years (±2.1 years).

Appropriate patient selection for surgical intervention is essential because surgery may provide symptom relief, thus enhancing quality of life in these patients who otherwise have a dismal prognosis. Our patient reported complete resolution of his pain postoperatively and did not have evidence of disease recurrence 3 years after surgery.

Although intradural spinal metastasis is an unlikely cause of upper-extremity pain, imaging is essential to identify the underlying pathology. Moreover, given this patient's history of RCC, metastatic disease should certainly be considered despite a remote history of the primary cancer. Pathologic assessment ultimately confirms the diagnosis. Patients should also be evaluated for other areas of metastasis with imaging to assess the extent of tumor spread.

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