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Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach
D Schiff1, B P O'Neill, V J Suman
1Department of Neurosurgery, University of Pittsburgh Medical Center, PA 15213, USA.
Abstract:
The objective of our study was to delineate clinical features and specific diagnostic and therapeutic implications of spinal epidural metastasis (SEM) occurring as the initial manifestation of malignancy (IMM)-a less common event than SEM in the setting of previously established malignancy (PEM). We performed a retrospective review of the clinical histories of 337 patients seen at Mayo Clinic with a radiographically verified diagnosis of SEM between January 1, 1985, and December 31, 1993. Twenty percent of all cases of SEM occurred as SEM-IMM. Carcinoma of the lung, cancer of unknown primary site, multiple myeloma, and non-Hodgkin's lymphoma were disproportionately represented in SEM-IMM, together accounting for 78% of SEM-IMM patients and only 26% of SEM-PEM patients. Inversely, breast and prostate carcinoma contributed only 12% of SEM-IMM patients but 51% of SEM-PEM patients. Only 27% of patients with SEM-IMM had nonspecific symptoms suggesting malignancy, and in only 24% did the history or physical examination suggest the primary site of malignancy. Percutaneous needle biopsy of the vertebral lesion was diagnostic of malignancy in 18 of 19 patients (95%), and no complications ensued. Fifteen patients underwent diagnostic laminectomy with biopsy, and one had a fatal complication. Survival after the diagnosis of SEM did not differ between patients with SEM-IMM and those with SEM-PEM; the median survival was 6.6 months. SEM not uncommonly occurs as the presentation of malignancy, and often it produces the only symptoms or signs of malignancy. The great majority of neoplasms presenting with SEM are carcinomas of the lung, unknown primary lesions, and hematologic malignancies. Computed tomography-guided needle biopsy is a safe, efficacious means of diagnosing malignancy, allowing for rational diagnostic workup and staging. In most patients it obviates a diagnostic spinal surgical procedure.
Insights
Spinal epidural metastasis (SEM) often presents as the first sign of cancer, particularly lung, unknown primary, or blood cancers. CT-guided needle biopsy is a safe and effective diagnostic tool for SEM.
Area of Science:
- Oncology
- Neurosurgery
- Radiology
Background:
- Spinal epidural metastasis (SEM) can be the initial manifestation of malignancy (IMM), a less common scenario than in patients with previously established malignancy (PEM).
- Understanding the clinical features and diagnostic implications of SEM-IMM is crucial for timely diagnosis and management.
- Certain cancers, like lung, unknown primary, myeloma, and lymphoma, are disproportionately represented in SEM-IMM cases.
Purpose of the Study:
- To delineate the clinical features of SEM presenting as IMM.
- To evaluate the diagnostic and therapeutic implications of SEM-IMM.
- To compare SEM-IMM with SEM-PEM regarding cancer types, diagnosis, and survival.
Main Methods:
- Retrospective review of 337 patients with radiographically verified SEM between 1985 and 1993.
- Analysis of patient histories, presenting symptoms, physical examination findings, and diagnostic procedures.
- Comparison of cancer types, diagnostic methods (needle biopsy vs. laminectomy), and survival rates between SEM-IMM and SEM-PEM groups.
Main Results:
- Twenty percent of SEM cases occurred as SEM-IMM.
- Lung carcinoma, unknown primary, multiple myeloma, and non-Hodgkin's lymphoma were common in SEM-IMM (78% of cases).
- Percutaneous needle biopsy was highly accurate (95%) and safe for diagnosing SEM-IMM, often avoiding surgical procedures.
Conclusions:
- SEM frequently presents as the initial manifestation of malignancy, often with nonspecific symptoms.
- Lung, unknown primary, and hematologic malignancies are the most common types presenting with SEM.
- CT-guided needle biopsy is a safe and effective method for diagnosing SEM, guiding further workup and staging.