Spinal Intradural Intramedullary Dissemination in the Absence of Intracranial Relapse of a Previously Radically Treated Temporal Lobe Glioblastoma Multiforme

Abstract

Intracranial glioblastoma multiforme (GBM) constitutes the most frequent and unfortunately aggressive primary central nervous system malignancy. Despite the high tendency of these tumors to show local relapse within the brain after primary therapy, dissemination into the spinal axis is an infrequent event. If spinal metastases occur they are leptomeningeal in the vast majority of cases and always in the context of intracranial progressive disease. Spinal intramedullary metastases of intracranial GBM have rarely been described to date. We report the unique case of a young woman with subacute progressive paraparesis due to spinal intramedullary metastases of a temporal lobe GBM despite the remarkable absence of intracranial tumor relapse. The patient had undergone gross total resection of a left temporal GBM in contact with the ventricles and cisternal space followed by radio- and chemotherapy 13 months before. At the moment of diagnosis of spinal intramedullary metastases, there were no signs of intracranial tumor recurrence as revealed by MRI scans. Since a high level of suspicion may be needed to detect this rare evolution of intracranial GBM and other differential diagnoses must be ruled out at presentation, we discuss the important features of this case regarding clinical manifestation, diagnosis, surgery, and management. Furthermore, we mention possible factors that may have contributed to the development of these metastases in the context of intracranial remission.

Keywords: Spinal intradural intramedullary dissemination; Temporal lobe glioblastoma multiforme.

Fig. 1

Presurgical MRI images at the diagnosis of a left temporal lobe GBM, 13 months before the presentation of spinal metastases (a). Immediately after tumor removal, MRI scans show a minimal residual contrast-enhancing lesion on the left temporal lobe (b). Brain MRI performed 13 months later, at the moment of diagnosis of spinal intramedullary metastasis, showing no evidence of intracranial recurrence (c).

Fig. 2

Spinal MRI images obtained at the moment of presentation of progressive paraparesis 13 months after intracranial tumor removal followed by adjuvant therapy. T1 contrast-weighted images (a) and T2 sequences (b) reveal a large intraspinal tumor at the level of Th8/9, corresponding to intramedullary metastasis of temporal lobe GBM.

Fig. 3

Surgical approach to the spinal tumor through a laminectomy performed at the Th8/9 level. Spinal canal exposure revealed no macroscopic infiltration of the dura mater (a). After durotomy, an infiltrating, highly vascularized intradural intramedullary tumor lacking recognizable edges in regard to the normal tissue was observed (b, c). A biopsy was carefully performed and further histological examination confirmed the diagnosis of GBM metastasis (c). Duroplasty using a graft interposition was performed with the aim of widening the spinal canal and ameliorate the local compressive effect induced by the tumor (d).