Malignancy in Blood and Its Clinical Relevant to the Spinal Cord Amaylia OehadianHematology and Medical Oncology Division, Departement of Internal MedicineHasan Sadikin Hospital , Bandung, Indonesia

CaseA 60-year old woman came with low extremities paraplegy since 2 weeks She has low back pain since 1 monthShe also has fatique , lightheadedness , easy bruissingPhysical examination shows anemic, purpura in low extremities , motoric defisit : 5/5 2/2

CaseLab : Hemoglobin 5 gr% White blood cell count : 3500 /mm3 Platelet : 75.000/mm3Peripheral blood smear : roulleoux (+)

Peripheral blood smear : roulleoux

Case Hematologic malignancy ?Spinal cord compression?

Malignancy in Blood and Its Clinical Relevant to the Spinal Cord Incidence PatophysiologyManifestationDiagnostic Treatment

Malignancy in Blood and Its Clinical Relevant to the Spinal Cord Incidence PatophysiologyManifestationDiagnostic Treatment

IncidenceSpinal cord compression in the five years before death : 2.5 percent 0.2 percent in pancreatic cancer 7.9 percent in myeloma Schiff D. April 2014 ,available from: www.uptodate.com

IncidenceLeukemic epidural spinal cord compression (ESCC) : 1% Burkitts lymphoma and lymphoblastic lymphoma (incidence 10-18%)Approximately 20 percent of cases of ESCC are the initial manifestation of malignancy

Mughal TI, International Journal of General Medicine 2014:7 8910

Malignancy in Blood and Its Clinical Relevant to the Spinal Cord Incidence PatophysiologyManifestation DiagnosticTreatment

Patophysiologyhematogenous spread to the vessels of the arachnoid or choroid plexusdirect extension from parenchymaldural and bone-based metastases and/or via perineural route along cranial nervesSchiff D. April 2014 ,available from: www.uptodate.com

Patophysiology

tumor invades the epidural space Schiff D. April 2014 ,available from: www.uptodate.com

Malignancy in Blood and Its Clinical Relevant to the Spinal Cord Incidence PatophysiologyManifestation DiagnosticTreatment

Leukemia

Chloroma

Chamberlain MC, Leukemia and the Nervous System, Department of Neurology University of Southern California

Chloroma

Goh DH. J Korean Med Sci 2007; 22: 1090-3

Lymphoma

hematolymphoid neoplasm, primarily of B cell lineageGrimmS, Advances in Hematology Volume 2011, Article ID 624578, 7 pages doi:10.1155/2011/624578

LymphomaDirect neurologic dysfunction

GrimmS, Advances in Hematology Volume 2011, Article ID 624578, 7 pages doi:10.1155/2011/624578

Multiple myeloma and plasmacytoma

malignant plasma cell proliferation derived from a single B-cell lineageproduce monoclonal immunoglobulinsChakraborti , Journal of Medical Case Reports 2010, 4:251-3

Myelofibrosisrare chronic BCR-ABL1 (breakpoint cluster region-Abelson murine leukemia viral oncogene homologue 1)-negative myeloproliferative neoplasm Goh DH, J Korean Med Sci 2007; 22: 1090-3

Malignancy in Blood and Its Clinical Relevant to the Spinal Cord Incidence PatophysiologyManifestation DiagnosticTreatment

Manifestation ESCCSchiff D. April 2014 ,available from: www.uptodate.com

ManifestationLeptomeningeal metastaseSchiff D. April 2014 ,available from: www.uptodate.com

Malignancy in Blood and Its Clinical Relevant to the Spinal Cord Incidence PatophysiologyManifestationDiagnostic Treatment

DiagnosticRadiologic confirmationSchiff D. April 2014 ,available from: www.uptodate.com

MRIproduces anatomically faithful images of the spinal cord and intramedullary pathology. defines the adjacent bone and soft tissues.can image the entire thecal sac regardless of whether a spinal subarachnoid block is presentSchiff D. April 2014 ,available from: www.uptodate.com

MRInot contraindicated in patients with brain metastases, thrombocytopenia, or coagulopathyavoids the need for a lumbar or cervical puncture, which is required with myelographySchiff D. April 2014 ,available from: www.uptodate.com

MRILeptomeningeal metastase

MRIepidural lesion compressing the spinal cord Schiff D. April 2014 ,available from: www.uptodate.com

CT myelographylaterally located lesions, in which CT myelogram demonstrates abnormalities that are not visualized with MRIPatients with mechanical valves, pacemakers, paramagnetic implantsbetter tolerated by patients in considerable painA myelogram permits cerebrospinal fluid (CSF) analysis, which is the cornerstone of the diagnosis of leptomeningeal metastasesSchiff D. April 2014 ,available from: www.uptodate.com

DiagnosticOther modalitiesSchiff D. April 2014 ,available from: www.uptodate.com

Severe/progresive myelopathyMild/stable myelopathy/radiculopathyBack pain without myelopathy/radiculopathyBone scanDiagnostic approach to back pain in patient with cancerSchiff D. April 2014 ,available from: www.uptodate.com

Diagnostic approach to back pain in patient with cancerMRISpinal/epidural mass with neural compressionNo tumorNo neurologic signLimited to vertebral pathologySchiff D. April 2014 ,available from: www.uptodate.com

Malignancy in Blood and Its Clinical Relevant to the Spinal Cord Incidence PatophysiologyManifestationDiagnostic Treatment

Treatment : Leptomeningeal metastase RadiotherapyChemotherapyLeal T, Curr Cancer Ther Rev. 2011 November ; 7(4): 319327

Treatment : ESCCPrimary treatmentDefinitive treatmentSchiff D,, Mar 2014 ,available from : www.uptodate.com.

Treatment : ESCCGlucocorticoid High-dose corticosteroid therapy (dexamethazone 96 mg intravenously followed by 24 mg four times daily for three days and then tapered over 10 days)limited documented evidence of benefit and a significant risk of serious side effects. lower doses can be effective but they have not been assessed in randomized trialsSchiff D,, Mar 2014 ,available from : www.uptodate.com.

Management of ESCCESCCSchiff D,, Mar 2014 ,available from : www.uptodate.com.

SINS ( Spinal Instability Neoplastic Score)Schiff D,, Mar 2014 ,available from : www.uptodate.com.

Component scores for clinical and radiographic findingsScoreSpine location Junctional (occiput-C2, C7-T2, T11-L1, L5-S1)3 Mobile spine (C3-C6, L2-L4)2 Semi-rigid (T3-T10)1 Rigid (S2-S5)0Pain relief with recumbence and/or pain with movement/loading of the spine Yes3 No (occasional pain but not mechanical)1 Pain-free lesion0Bone lesion quality Lytic2 Mixed lytic/blastic1 Blastic0Radiographic spinal alignment Subluxation/translation present4 De novo deformity (kyphosis/scoliosis)2 Normal alignment0Vertebral body collapse >50 percent collapse3 50 percent body involved1 None of the above0Posterolateral involvement of spinal elements (facet, pedicle, or costovertebral joint fracture or replacement with tumor) Bilateral3 Unilateral1 None of the above0

SINS ( Spinal Instability Neoplastic Score)

Schiff D,, Mar 2014 ,available from : www.uptodate.com.

ScoreClassificationAction0 to 6Stable spine7 to 12 IndeterminantPossible impending instabilitywarrants surgical consultation13 to 18Instabilitywarrants surgical consultation

CaseA 60-year old woman came with low extremities paraplegy since 2 weeks She has low back pain since 1 monthShe also has fatique , lightheadedness , easy bruissingPhysical examination shows anemic, purpura in low extremities , motoric defisit : 5/5 2/2

CaseLab : Hemoglobin 5 gr% White blood cell count : 3500 /mm3 Platelet : 75.000/mm3Peripheral blood smear : roulleoux (+)

Peripheral blood smear : roulleoux

M protein

Bone marrow aspiration: plasma cell infiltration

Schedel : Punch out lession

(A) The plain film compression of L4 and T11 (yellow arrows), and lytic disease with a soft tissue mass of the posterior elements ofL2 (red arrow). (B) CT multiple lytic changes in all of the visualized vertebral bodies, destructive soft tissue process in the posterior elements of L2 (red arrow).

Case Multiple myeloma with spinal cord compression ( conus cauda syndrome)

Take home message Spinal cord abnormalities could be caused by hematologic malignancies

Take home message Spinal cord abnormalities

Take home message Spinal cord abnormalities

Take home message Spinal cord abnormalities

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