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Year : 2020  |  Volume : 35  |  Issue : 4  |  Page : 353-354  

Unsuspected intramedullary spinal cord metastasis detected by FDG PET/CT


1 Department of Nuclear Medicine, Mohammed V Military Teaching Hospital, Mohammed V University of Rabat, BP, Morocco
2 Department of Radiotherapy, Mohammed V Military Teaching Hospital, Mohammed V University of Rabat, BP, Morocco

Date of Submission10-Jul-2020
Date of Decision31-Jul-2020
Date of Acceptance07-Aug-2020
Date of Web Publication21-Oct-2020

Correspondence Address:
Dr. Omar Ait Sahel
Avenue des FAR, Hay Ryad, 11001, Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_150_20

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   Abstract 


Intramedullary spinal cord metastases (SCMs) are extremely rare. Here, we report a case of a 60-year-old man with a history of right nonsmall cell lung cancer treated by concomitant radiochemotherapy who complained, 9 months after treatment completion, of chest pain, breath shortness, and more recently back pain. An 18F-FDG PET/CT was performed as part of the restaging process and showed a hypermetabolic mass of the right lung in addition to ipsilateral mediastinal hypermetabolic lymph nodes. There was also an FDG avid lesion of thoracic spinal cord at the T11–T12 level consistent with SCM as confirmed by MRI.

Keywords: 18F-FDG, intramedullary spinal cord metastasis, lung cancer, PET/CT


How to cite this article:
Sahel OA, Bazine A, Nabih SO, Benameur Y, Biyi A, Doudouh A. Unsuspected intramedullary spinal cord metastasis detected by FDG PET/CT. Indian J Nucl Med 2020;35:353-4

How to cite this URL:
Sahel OA, Bazine A, Nabih SO, Benameur Y, Biyi A, Doudouh A. Unsuspected intramedullary spinal cord metastasis detected by FDG PET/CT. Indian J Nucl Med [serial online] 2020 [cited 2020 Nov 26];35:353-4. Available from: https://www.ijnm.in/text.asp?2020/35/4/353/298741



A 60-year-old man with a locally advanced right nonsmall cell lung cancer was treated in 2018 with concomitant radiochemotherapy. He had partial remission and remained under surveillance. Nine months after completion of treatment, he complained of chest pain, breath shortness, and more recently back pain. As a disease progression was suspected, an 18 F-FDG PET/CT was performed for restaging [Figure 1]. MIP (a) and coronal (b) PET images showed a gross hypermetabolic mass of the right lung, associated with ipsilateral mediastinal hypermetabolic pathologic lymph nodes, in addition to an intense and diffuse uptake in bowel consistent with metformin use for type 2 of diabetes.
Figure 1: 18F-FDG PET/CT: MIP (a) and coronal (b) PET images showing a gross hypermetabolic mass of the right lung associated with ipsilateral mediastinal hypermetabolic pathologic lymph nodes, in addition to an intense and diffuse uptake on bowel consistent with metformin use. Sagittal fused TEP (c), axial CT (d), corresponding PET (e), and fused (f) images showing an intense FDG avid lesion of the thoracic spinal cord along T11–T12

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Sagittal fused TEP (c), axial CT (d), corresponding PET (e), and fused (f) images revealed an intense FDG avid lesion of the thoracic spinal cord (white arrow) along T11–T12 with SUVmax of 22.9, which was highly suspicious for spinal cord metastasis (SCM).

Gadolinium-enhanced medullary MRI was performed. Sagittal (a), coronal (b), and axial (c) fat saturated T1 images showed an intramedullary lesion having contrast enhancement in the spine at the level of 11th and 12th thoracic vertebrae [Figure 2]. Differential diagnosis was made with astrocytoma, ependymoma, and hemangioblastoma.
Figure 2: Gadolinium-enhanced medullary MRI: sagittal (a), coronal (b), and axial (c) fat-saturated T1 images showing an enhancing intramedullary lesion in the spine at the level of 11th and 12th thoracic vertebrae (white arrow)

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Intramedullary SCMs are devastating neurological complications of cancer. They are extremely rare constituting only about 3%–5% of myelopathies in cancer patients and 1%–3% of all intramedullary spinal metastatic lesions.[1],[2] Most of them originate from lung cancer (50%), especially small cell carcinoma, followed by breast cancer (11%), kidney cancer (10%), melanoma (8%), lymphoma (4%), and colorectal cancer (3%).[3],[4],[5] Metastatic lesions are usually solitary but may be multifocal.[6] Early diagnosis can prevent paralysis and improve the patient's prognosis and quality of life. Most intramedullary metastases are diagnosed with gadolinium-enhanced MRI. In our case, metastasis was discovered by PET/CT imaging and confirmed by spinal MRI.18 F-FDG PET has a sensitivity of 96% and a specificity of 50% for SCMs in patients with cancer.[7],[8] Mostardi et al. in a study with the purpose to evaluate the visibility of intramedullary SCMs on PET and to correlate PET and MRI features showed that most intramedullary SCMs can be detected on PET when performed near the time of MRI.[9] The authors concluded that spinal cord should be specifically and carefully assessed on PET for the evidence of intramedullary SCMs to provide timely diagnosis. As such, FDG PET/CT represents a promising tool for early diagnosis of SCMs, leading to appropriate treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Schiff D, O'Neill BP. Intramedullary spinal cord metastases: Clinical features and treatment outcome. Neurology 1996;47:906-12.  Back to cited text no. 1
    
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Kalayci M, Caǧavi F, Gül S, Yenidünya S, Açikgöz B. Intramedullary spinal cord metastases: Diagnosis and treatment-An illustrated review. Acta Neurochir (Wien) 2004;146:1347-54.  Back to cited text no. 3
    
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Potti A, Abdel-Raheem M, Levitt R, Schell DA, Mehdi SA. Intramedullary spinal cord metastases (ISCM) and non-small cell lung carcinoma (NSCLC): Clinical patterns, diagnosis and therapeutic considerations. Lung Cancer 2001;31:319-23.  Back to cited text no. 4
    
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Watanabe M, Nomura T, Toh E, Sato M, Mochida J. Intramedullary spinal cord metastasis: A clinical and imaging study of seven patients. J Spinal Disord Tech 2006;19:43-7.  Back to cited text no. 5
    
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Chi JH, Parsa AT. Intramedullary spinal cord metastasis: Clinical management and surgical considerations. Neurosurg Clin N Am 2006;17:45-50.  Back to cited text no. 6
    
7.
Laufer I, Lis E, Pisinski L, Akhurst T, Bilsky MH. The accuracy of [(18) F] fluorodeoxyglucose positron emission tomography as confirmed by biopsy in the diagnosis of spine metastases in a cancer population. Neurosurgery 2009;64:107-13.  Back to cited text no. 7
    
8.
Metser U, Lerman H, Blank A, Lievshitz G, Bokstein F, Even-Sapir E. Malignant involvement of the spine: Assessment by 18F-FDG PET/CT. J Nucl Med 2004;45:279-84.  Back to cited text no. 8
    
9.
Mostardi PM, Diehn FE, Rykken JB, Eckel LJ, Schwartz KM, Kaufmann TJ, et al. Intramedullary spinal cord metastases: Visibility on PET and correlation with MRI features. AJNR Am J Neuroradiol 2014;35:196-201.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2]



 

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