Prostate-specific antigen in the cerebrospinal fluid leads to diagnosis of solitary cauda equina metastasis: a unique case report and review of the literature

Abstract

Summary A 79-year-old male patient presented with a subacute cauda syndrome caused by an intradural metastasis of the lumbosacral caudate fibres from an adenocarcinoma of the prostate, which had been treated 5 years earlier with external beam radiation therapy.Diagnosis could not be established by repeated magnetic resonance images (MRIs) during a 2-year period of increasingly severe radicular pain. Eventually, a small tumour mass could be visualized on the fourth MRI. Repeated normal serum prostate-specific antigen (PSA) did not hint at a prostate cancer metastasis (range 2.4-5.1 ng ml-1); however, PSA in the cerebrospinal fluid was found to be elevated (29.1 ng ml-'). Empirical radiation therapy of the caudate region did not improve radicular pain. Therefore, an exploratory surgical procedure was conducted, which confirmed the suspicion of an intradural prostate cancer metastasis. In conclusion, PSA in the cerebrospinal fluid provides a useful diagnostic tool for detecting intradural prostate cancer metastasis.Keywords: intradural spinal metastasis; caudate fibres; prostate-specific antigen; prostate cancer; alpha-i-anti-chymotrypsin Clinically occult carcinoma of the prostate has been found at autopsy series in around 70% of men over the age of 80 (Grant et al, 1994;Oschmann et al, 1994). In manifest disease with metastatic spread, skeletal, pulmonary as well as hepatic metastases predominate (Elkin and Mueller, 1954), but intradurally located metastases of the spinal axis are uncommon. Since 1950, 59 patients with histologically confirmed intradural spinal metastasis have been found in scattered reports (Perrin et al, 1982;Chow and McCutcheon, 1996), containing only one case of prostate cancer. It is, however, generally accepted that the blood-brain barrier has to be disrupted in intradural carcinomatosis (Siegal et al, 1987), and therefore that haematogenous dissemination from the primary tumour as well as spinal or epidural metastases by embolization may be the most important and common mechanism for spread of tumour cells into the spinal subrachnoid space (Perrin et al, 1982;Chow and McCutcheon, 1996). CASE REPORTA 79-year old man was evaluated for a 3-year history of increasingly severe radicular pain projecting into the left lumbosacral dermatomes. His medical history included a prostate cancer (T3, NO, MO) diagnosed 5 years earlier by a needle biopsy (moderately differentiated adenocarcinoma of the prostate) and treated with fractionated external beam radiation therapy (45 MeV, 6000 cGy cumulative). Two years later, a radicular pain syndrome developed insidiously, projecting into the left-sided lumbosacral dermatomes [prostate-specific antigen (PSA), prostate-specific acid phosphatase (PAP), cerebro-spinal fluid (CSF) cytology, CSF infection] were repeated every 6 months over the next 2 years with no pathological findings. Radiological investigations using abdominal ultrasound, excretory urography, skeletal scintigraphy and abdominal computerized tomography (CT) could not detect metastatic disease; ev...

Disseminated Leptomeningeal Carcinomatosis; Presenting With Cauda Equina-conus Syndrome

“…[1][2][3][4][5] Disk hernisi, tümör, penetran travma, cerrahi manipulasyon, ankilozan spondilit, serbest epidural ya dokusu bas s , lomber spondilozis, dar kanal ve nadiren bu bölgeyi tutan metastazlar KES nedenleri aras ndad r. [6][7][8] Literatürde artan s kl kla KES' e neden olan ve kauda equinay tutan metastaz olgular bildirilmektedir. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] Biz, akci er kanseri tan s ile izlenen ve kauda equina-konus sendromu ile gelen, beyin metastaz olmadan, lomber düzeyde dissemine tarzda intradural ekstrameduller, leptomeningeal metastazlar saptanan olguyu sunmak istedik.…”

“…[1][2][3][4][5]9] Bu bölgede en s k, primer komponentlerinden kaynaklanan tümörler görülmekle beraber, metastazlar gittikçe artan s kl kta bildirilmektedir. [1][2][3][4][5][9][10][11][12][13][14][15][16][17] Beyin metastaz olmadan spinal leptomeningeal karsinomatozise oldukça nadir rastlanmakla beraber, nadir bir tabloyla, kauda equina-konus sendromu olarak kar m za ç kan bu olguyu sunmak istedik.…”

“…%2-4 olguda primer odak saptanamamaktad r. [2,6] Spinal metastazlar da son y llarda artan s kl kta KES nedenleri aras nda bildirilmektedir. [1][2][3][4][5][9][10][11][12][13][14][15][16][17] Kotil ve ark [3] primer maligniteye ait bulgular saptanmadan, L4/5 düzeyinde kitle ve KES sendromu ile ortaya ç kan …”

Leptomeningeal Involvement in Prostate Cancer: A Case Report

“…Most patients died with metastatic bone disease, node disease or, less frequently, visceral metastases. Brain involvement was not relevant [2] and leptomeningeal affectation was extremely rare [3]. Intra-Dural extra-medullar affectation is unusual in any cancer, about 5% [4] and referred to prostate cancer is exceptional, so very few cases were reported to literature in the last years.…”

Intradural-Extramedullary Metastatic Tumor from Lung Cancer-A Case Report and Review

“…Of 102 cases, including ours, 94 received surgery. Non-surgical methods were used in eight patients because of a poor general condition [19,22,26,34]. According to our review of an intraduralextramedullary metastasis, the life expectancy was more than 8.6 months and a functional improvement was expected.…”