A 65-year-old Caucasian woman underwent surgery for papillary serous ovarian adenocarcinoma involving both ovaries and with extensive metastases (stage IIIC). An exploratory laparotomy with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with cancer staging was performed. She also underwent chemotherapy including carboplatin, paclitaxel, and cisplatin. Her CA-125 level was normal and there was no evidence of disease progression at her last clinic visit at our center. Then, two years later, she re-presented with progressive neurological symptoms starting initially with limb dysesthesias and numbness and progressing to quadriparesis with urinary retention.
Imaging studies of her spine revealed an enhancing heterogeneous C2-C5 intramedullary lesion with cord expansion and edema extending rostrally into the medulla and caudally to the thoracic spinal cord (Figure ). Serum CA-125 was normal at presentation and a computed tomography (CT) scan of the chest, abdomen, and pelvis were negative for other lesions. An investigation for possible sources of infection was negative.
Figure 1 Sagittal cervical spine MRI. (a) Pre-surgical resection, T1 post-contrast demonstrating a 1.3 × 4.4 cm intramedullary enhancing mass (left panel). (b) Post-surgical resection, T1 pre-contrast (middle panel). (c) Post-surgical resection, T1 post-contrast (more ...)
Informed consent was obtained from our patient for open surgical biopsy and possible debulking. C2-C5 laminectomies were performed for planned ultrasound-guided dorsal midline biopsy and debulking of the intramedullary mass. The tumor was debulked and the remnants of the tumor capsule dissected along the rostral and caudal margins with care taken not to injure the surrounding spinal cord. Somatosensory and motor evoked potentials did not change during surgery. A post-operative MRI scan showed the expected near total resection and expected post-laminectomy changes without any associated hematoma (Figure ). Pathologic analysis revealed histological and cytological features consistent with papillary serous ovarian adenocarcinoma (Figure ), similar to the pathological specimen from her prior surgery. She made functional improvements after surgery and was transferred to the rehabilitation service. She gained the ability to stand with assistance using a walker, had antigravity strength in her lower extremities and 4/5 strength in her upper extremities. Fractionated radiotherapy was initiated immediately in the post-operative period during her rehabilitation.
Figure 2 Hematoxylin and eosin stained section of cervical intramedullary tumor. This metastatic neoplasm was compared with prior hysterectomy and salpingo-oophorectomy of our patient and reveals similar histologic and cytologic features to the ovarian papillary (more ...)
Our patient had improvement in strength post-operatively but required an emergency re-operation three weeks later due to sudden paraplegia secondary to spinal epidural hematoma, after therapy with prophylactic subcutaneous heparin administration. On discharge a week after epidural hematoma evacuation, she experienced numbness below the umbilicus and slightly improved to left toe movement. Unfortunately, our patient died five months after discovery of her spinal metastasis, presumably from a pulmonary embolism.