Amaylia Spinal Revisi 060614

Malignancy in Blood
and
Its Clinical Relevant to the Spinal Cord
Amaylia Oehadian
Hematology and Medical Oncology Division,
Departement of Internal Medicine
Hasan Sadikin Hospital , Bandung, Indonesia

Case
A 60-year old woman came with low
extremities paraplegy since 2 weeks
She has low back pain since 1 month
She also has fatique , lightheadedness , easy
bruissing
Physical examination shows anemic, purpura
in low extremities , motoric defisit : 5/5
2/2
Case
Lab : Hemoglobin 5 gr%
White blood cell count : 3500 /mm3
Platelet : 75.000/mm3
Peripheral 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
Patophysiology
Manifestation
Diagnostic
Treatment

Incidence
Patophysiology
Manifestation
Diagnostic
Treatment

Incidence
Spinal 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
Incidence
Leukemic 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
Incidence
Patophysiology
Manifestation
Diagnostic
Treatment

Patophysiology
hematogenous spread
to the vessels of the
arachnoid or choroid
plexus
direct
extension from
parenchymal
dural and bone-
based metastases
and/or via
perineural route
along cranial
nerves
tumor spread into the
leptomeninges
Patophysiology

tumor invades the
epidural space
compresses the thecal sac
Epidural spinal cord
compression
Incidence
Patophysiology
Manifestation
Diagnostic
Treatment

Leukemia

Chloroma

Chamberlain MC, Leukemia and the Nervous System, Department
of Neurology University of Southern California
most often occur in
bone
epidural spinal cord
compression
solid tumors consisting of
myeloid leukemic blasts
Chloroma

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

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

Indirect
neurologic
dysfunction

Direct neurologic
dysfunction

Treatment
related

Lymphoma
Direct neurologic dysfunction

GrimmS, Advances in Hematology Volume 2011, Article ID 624578, 7 pages
doi:10.1155/2011/624578
epidural metastases
causing spinal
cord/cauda equina
compression
leptomeningeal
metastases
intradural
intramedullary
spinal cord
metastases
metastatic
intracranial spinal
disease
Multiple myeloma and plasmacytoma

malignant plasma cell
proliferation derived
from a single B-cell
lineage
produce monoclonal
immunoglobulins
Chakraborti , Journal of Medical Case Reports 2010, 4:251-3
Myelofibrosis
rare 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
inefficient
hematopoiesis
progressive bone
marrow fibrosis
shortened
survival
extramedullary hematopoiesis
spinal cord compression
Incidence
Patophysiology
Manifestation
Diagnostic
Treatment

Manifestation
ESCC
Bladder and
bowel
dysfunction

Ataxia
Motor findings
Sensory findings
Pain
Manifestation
Leptomeningeal
metastase
Cranial nerve
involvement
Cerebral
involvement
Spinal
involvement
Incidence
Patophysiology
Manifestation
Diagnostic
Treatment

Diagnostic
Radiologic confirmation
MRI
Myelography /CT
myelography
MRI
produces 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
present
MRI
not contraindicated in patients with brain
metastases, thrombocytopenia, or
coagulopathy
avoids the need for a lumbar or cervical
puncture, which is required with myelography
MRI
Leptomeningeal metastase
MRI
epidural lesion compressing the spinal cord
CT myelography
laterally located lesions, in which CT myelogram
demonstrates abnormalities that are not visualized
with MRI
Patients with mechanical valves, pacemakers,
paramagnetic implants
better tolerated by patients in considerable pain
A myelogram permits cerebrospinal fluid (CSF)
analysis, which is the cornerstone of the diagnosis of
leptomeningeal metastases
Diagnostic
Other modalities
Plain spinal
radiographs
CT of the spine Bone scan
Severe/progresive
myelopathy
Mild/stable
myelopathy/radiculopathy
Back pain without
myelopathy/radiculopathy
Bone scan
Diagnostic approach to back pain in patient with cancer
MRI
emergent
MRI
within 24
hours
X ray
Consider extraaxial
causes
IV
dexamethasone
Diagnostic approach to back pain in patient with cancer
MRI
Spinal/epidural
mass with
neural
compression
No tumor
No
neurologic
sign
Limited to
vertebral
pathology
XRT, steroid,
decompression
and stabilization
Radiculopathy,
myelopathy, headache
or meningismus
Consider extraaxial
causes
CSF analysis
XRT/intrahecal
chemotherapy
Ealuate peripheral
nerve/plexi
XRT,
/stabilization
Incidence
Patophysiology
Manifestation
Diagnostic
Treatment

Treatment : Leptomeningeal metastase
Radiotherapy
Chemotherapy
Leal T, Curr Cancer Ther Rev. 2011 November ; 7(4): 319327
High dose
Methotrexate
Cytarabine
Thiotepa
2430 Gy in 815
fractions
Treatment : ESCC
Primary
treatment
Definitive
treatment
Schiff D,, Mar 2014 ,available from : www.uptodate.com.

Pain management
Bedrest
Anticoagulant
Prevention of
constipation
Glucocorticoid
Treatment : ESCC
Glucocorticoid
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 trials

Management of ESCC
ESCC
Spine unstable ?
EBRT or SRS
EBRT
No
SRS /conventional
fractination EBRT
No
Vertebroplasty
/Kyphoplasty/
surgical
decompression
No
Surgical
decompression
Yes
High grade
ESCC
Yes
Surgical
decompression,
EBRT/SRS
Yes
Radioresistant
neoplasm
No
Epidural disease or
retropulsion of bone
fragments into spinal cord ?
Yes
Chemosensitive
neoplasm
No
No
Chemotherapy
Yes
SINS ( Spinal Instability Neoplastic Score)
Component scores for clinical and radiographic findings Score
Spine 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) 0
Pain relief with recumbence and/or pain with movement/loading of the spine
Yes 3
No (occasional pain but not mechanical) 1
Pain-free lesion 0
Bone lesion quality
Lytic 2
Mixed lytic/blastic 1
Blastic 0
Radiographic spinal alignment
Subluxation/translation present 4
De novo deformity (kyphosis/scoliosis) 2
Normal alignment 0
Vertebral body collapse
>50 percent collapse 3
<50 percent collapse 2
No collapse with >50 percent body involved 1
None of the above 0
Posterolateral involvement of spinal elements (facet, pedicle, or
costovertebral joint fracture or replacement with tumor)
Bilateral 3
Unilateral 1
None of the above 0

SINS ( Spinal Instability Neoplastic Score)

Score Classification Action
0 to 6 Stable spine
7 to 12 Indeterminant Possible impending instability
warrants surgical consultation
13 to 18 Instability warrants surgical consultation

Case
A 60-year old woman came with low
extremities paraplegy since 2 weeks
She has low back pain since 1 month
She also has fatique , lightheadedness , easy
bruissing
Physical examination shows anemic, purpura
in low extremities , motoric defisit : 5/5
2/2
Case
Lab : Hemoglobin 5 gr%
White blood cell count : 3500 /mm3
Platelet : 75.000/mm3
Peripheral 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 of L2 (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

Leukemia
Multiple myeloma
Plasmacytoma
Lymphoma
Myelofibrosis
Take home message
Spinal cord abnormalities

Epidural spinal cord
compression
Leptomeningeal
metastase
Take home message

Diagnostic :
MRI
CT myelography
Take home message

Spine Instability Neoplastic
Score
Radiotherapy
Chemotherapy
Surgical
Terima kasih
Hematologi Onkologi Medik Bandung

Amaylia Spinal Revisi 060614

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Malignancy in Blood

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