Brown-Séquard Syndrome in a Desmoplastic Malignant Mesothelioma Patient: A Rare Complication

Abstract

Reviewer 1: Did the patient improve at all after radiation? Practicing clinicians may want to know. Desmoplastic cancers of all types, including mesothelioma, are not as responsive to this modality. Were steroids administered and did they help as well?We agree that desmoplastic mesothelioma cells are only modestly radiosensitive. Our patient was treated with radiation therapy (25Gy on the primary MM tumor and 20Gy on the spinal metastasis) instead of second-line systemic therapy because of the rather localized aspect of malignant disease and to achieve additional pain control in his right shoulder/neck. Steroids (methylprednisolone 16mg/day for 1 week and methylprednisolone 8mg/day for 1 week) were added during the radiation therapy as an adjunctive anti-inflammatory treatment. There was no significant clinical improvement after this therapy and repeat CT one month later showed stable disease. In the months thereafter, his neurological status deteriorated and he received best supportive care.Reviewer 2: Dr. Ralki and colleagues present an interesting case of desmoplastic mesothelioma with spine metastases causing neurologic symptoms. While the ability of mesothelioma to metastasize distantly is well recognized, it is not reflected well in the literature and this case report thoughtfully adds to that literature. My only comment would be to more specifically discuss what has been reported about this for mesothelioma, albeit not desmoplastic, in the introduction.We fully agree that the ability of mesothelioma to spread hematogenously is underestimated both in the literature and in clinical practice. Postmortem studies are sparse, the largest and most recent postmortem study (n=318) found extrathoracic metastases in 55.4% and central nervous metastases in 3% of mesothelioma patients (1). In living patients, only one retrospective cohort study (n=165) addressed this issue. Distant metastases were reported in up to 27% of all mesothelioma patients, depending on the affected organ site (2). One report (n=27) suggests that desmoplastic mesothelioma tend to metastasize more frequently than non-desmoplastic mesothelioma (3).