Perineural Spread of Malignant Mesothelioma Resulting in an Intradural Spinal Cord Mass: Case Report

Abstract

Spinal cord involvement by perineural spread of malignant mesothelioma is rare. We report a case of malignant mesothelioma that spread locally to invade the bony spine with both extradural and intradural perineural spread into the spinal canal that resulted in spinal cord compression. A 61-year-old man with a history of malignant mesothelioma presented with progressive leg weakness and right-sided arm weakness. Magnetic resonance imaging showed an enhancing lesion in the apex of the right lung with extension through the C7-T1 foramina with right hemicord enhancement. The patient underwent a C7-T1 laminectomy and right-sided C7-T1 and T1-T2 foraminotomies for neural decompression and biopsy of the lesion. Intraoperatively, tumor extended epidurally, and intradural perineural tumor spread along the C8 and T1 nerve roots into the spinal cord. Because it adhered to the spinal cord, no dissectible plane could be identified that would allow for safe total removal of the tumor. The epidural portion of the tumor, the adjacent involved bone, and the T1 nerve root were resected. Pathologic examination revealed malignant mesothelioma with bony invasion and perineural spread along the T1 nerve root. After decompression of the spinal cord, the patient had moderate improvement of his hand and leg function. Perineural spread of malignant mesothelioma resulting in spinal cord compression is an unusual clinical presentation. Intimate involvement of the spinal cord may prohibit aggressive tumor resection.

Pleural Malignant Mesothelioma Causing Cord Infiltration Through the Nerve Root -Case Report-

“…However, the pattern of the extension along the nerve root is difficult to determine. Intradural involvement is rare, with a few reported cases, 4,8,13,19) and intramedullary involvement is extremely rare, with five cases including the present case, all occurring in the thoracic spine (Table 1). 3,8,9,15) Most patients with intramedullary metastatic mesothelioma who underwent surgery did not achieve any improvement in their neurological condition.…”

“…7,13,15,19) Infiltration of structures within the spinal canal is very rare, with only 14 reported cases. 3,4,[7][8][9][10][11][12][13][14][15][17][18][19][20] Initial symptoms are usually spinal pain and paresthesia, and weakness and dysfunction of the bladder and bowels. 17) There have been previous case reports of pleural malignant mesothelioma invading the spinal cord through the intervertebral foramen or vertebral body, hematogenous spread via the intercostal arteries or the veins of Batson's plexus, and direct extension along the nerve root.…”

“…8) Radiotherapy and chemotherapy such as cisplatin, irinotecan, doxorubicin, ifosfamide, 7) and methotrexate 17) have failed to significantly prolong patient survival with a median survival of less than 1 year after symptom onset. 5,7,8,10) Recently, management of patients with pleural malignant mesothelioma has used antifolate (pemetrexed or raltitrexed)-platinum combinations and new radiotherapy techniques such as intensity-modulated radiation therapy. 2) In general, there is no standard treatment for intramedullary spinal cord metastasis.…”

“…10) In general, pleural malignant mesothelioma is locally invasive, and progression tends to occur by direct extension of tumor into the pulmonary parenchyma and hilar lymph nodes, the chest wall forming a layer that will compress the lung, the contralateral pleura and other structures within the mediastinum, and through the diaphragm into the abdominal cavity, internal mammary, and supraclavicular lymph nodes, and distant organs via hematogenous dissemination in the later stages of the disease. [7][8][9][10]16) Tumor extension to the spinal cord is uncommon, and usually occurs by direct extension through the intervertebral foramen or the invaded vertebral body and by hematogenous spread to the surrounding meninges, or rarely by infiltration along the nerve roots. 1,15) We report a case of pleural malignant mesothelioma that started with nerve root involvement and subsequently infiltrated the spinal cord.…”

Sarcomatoid Malignant Mesothelioma Presenting with Intramedullary Spinal Cord Metastasis: A Case Report and Literature Review

“…[6][7][8][9] Intradural spinal mesothelioma is extremely rare, and only eight cases have been reported to date (►Table 1). [8][9][10][11][12][13][14][15] In most of these cases, metastases were considered to result from direct perineural spread into the dura of the spinal cord, with continuity of the pleural lesion. In only two cases (case 1 10 and the present case), intramedullary tumors were considered to result from hematogenous or leptomeningeal spread, without continuity with the pleural lesion.…”