Sir,
Glioblastoma multiforme (GBM) is a common primary malignancy of the central nervous
system. Development of extracranial metastasis in GBM is a rarity.[1],[2] Although spinal dissemination from intracranial GBM via cerebrospinal fluid has
been clinically validated in many reports, a much higher incidence was reported in
an autopsy series.[3] Here, we report a case of GBM presenting with a drop-like metastasis to the spine
on disease progression.
A 43-year-old male presented with the complaints of headache and giddiness of 5 days'
duration. Imaging of the brain revealed a right temporal lobe mass lesion with significant
perilesional edema. He underwent craniotomy and near-total excision of the tumor.
Histopathology was reported as WHO Grade IV glioma (GBM, not otherwise specified).
The patient completed postoperative concurrent chemoradiation (60 Gy in 30 fractions
with concurrent temozolomide) and adjuvant chemotherapy with temozolomide for 6 months,
which he completed by July 2019.
In November 2019, the patient presented with the complaints of severe low back ache
and headache. A magnetic resonance imaging (MRI) brain with whole spine was done.
Coronal T2-weighted MRI brain showed a recurrent mass lesion of size 6.1 cm × 8.7
cm × 7.7 cm in the right ganglionic region and the right temporal lobe, invading the
base of the skull and infratemporal fossa [Figure 1]a]. Axial T2-weighted MRI image at the level of the middle cranial fossa showed a large
recurrent mass in the right temporal lobe associated with the surrounding edema [Figure 1]b].
Figure 1: (a) Coronal T2-weighted magnetic resonance imaging showing recurrent mass
lesion of size 6.1 cm × 8.7 cm × 7.7 cm in the right ganglionic region and the right
temporal lobe invading the base of the skull and infratemporal fossa. (b) Axial T2-weighted
magnetic resonance imaging at the level of middle cranial fossa showing a large recurrent
mass in the right temporal lobe associated with marked perilesional edema and mass
effect
MRI spine revealed multiple lesions suggestive of metastasis involving the thoracic,
lumbar, and sacral vertebrae. Sagittal T2-weighted MRI of the spine showed altered
signal intensity and collapse of the T7 vertebral body, suggestive of metastasis with
the associated soft tissue, causing mild cord compression [Figure 2].
Figure 2: Sagittal T2-weighted magnetic resonance imaging of the spine showing multiple
vertebral metastases and collapse of T6–T7 vertebral bodies with the associated soft-tissue
component
In view of the extensive metastatic lesions, the patient was evaluated with a whole-body
18fluoro-2-deoxyglucose- positron emission tomography-computed tomography (FDG-PET-CT).
Axial PET-CT image showed a metabolically active recurrent brain lesion in the right
temporal lobe and a metabolically active vertebral body lesion suggestive of metastasis
and a FDG-avid right Level II lymph node [Figure 3]a], [Figure 3]b], [Figure 3]c].
Figure 3: (a-c) Axial positron emission tomography-computed tomography image showing
a metabolically active recurrent brain lesion in the right temporal lobe and a metabolically
active vertebral body lesion suggestive of metastasis and a fluoro-2-deoxyglucose-avid
right Level II lymph node
PET-CT was suggestive of progression of the cranial lesion with multiple spinal metastases.
FDG-avid right Level II lymph node did not reveal any significant pathology on biopsy.
The patient and his relatives were reluctant to take biopsy from the spinal lesion.
As the patient had severe pain in the region of spinal metastasis, palliative radiation
therapy was given to the region of spinal metastasis and pain management was done
in the form of morphine and analgesics and antiepileptics. After explaining the poor
prognosis of the disease to the patient and his family, the patient was started on
palliative chemotherapy with single-agent bevacizumab intravenously at the dose of
10 mg/kg for every 2 weeks. After three cycles of bevacizumab, he had a dramatic improvement
in pain especially while on movements, and he was continued on treatment. After completing
five cycles of bevacizumab, the patient had clinical and radiological progression
with features of cavernous sinus involvement in the form of ophthalmoplegia, proptosis,
conjunctival congestion, and Horner's syndrome and was continued on best palliative
and supportive care.
The incidence of drop metastasis to spinal cord in glioblastoma is estimated at around
2% at relapse, but symptomatic spinal metastasis at progression is very rare.
Spinal metastases occur as a result of cellular spread in the subarachnoidal space
or hematogenous dissemination. They disseminate via the cerebrospinal fluid onto the
spine owing to the effect of gravity.[4] Drop metastases usually occur in the dorsal aspect of the lower thoracic, upper
lumbar, and lumbosacral spine.
Patients with such drop metastasis tend to do poorly and usually progress despite
second-line treatment with a median duration of survival between 2 and 4 months.[5]
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