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Chapter 20: Primary spinal cord tumor
Terms in this set (39)
At what level does the spinal cord end in adults? In newborns?
In adults ends at L1-2. In newborns at L3-4.
What is the filum terminale?
The filum terminale is the filamentous process that anchors the dural sack inferiorly to the coccyx.
What is the conus medullaris?
The conus medullaris is the inferior or tapering portion of spinal cord.
What percent of all primary CNS malignancies arise in the spinal cord?
15% of all primary CNS malignancies arise in the spinal cord.
What is the age range for primary spinal cord tumors?
Primary spinal cord tumors occur in the age range of 10-40 years.
Are most primary spinal cord tumors intra or extradural?
Intradural. If extradural, spinal cord tumors are most likely to be metastatic not primary.
What are the most common and 2nd most common intradural / extramedullary primary spinal cord tumors?
Two thirds are schwannomas and one third are meningiomas.
What percentage of primary spinal cord tumors are intramedullary?
10% of primary spinal cord tumors are intramedullary
What are the most common intramedullary spinal cord tumors and what age group do they typically affect?
Astrocytomas are more common than ependymomas, affect children and adults younger than 30.
What type of tumor typically arises at the filum terminale?
Myxopapillary ependymomas arise at the filum terminale
From what anatomic portion of the meninges do meningiomas arise?
Meningiomas arise from the arachnoid layer.
What is a common age range and location for spinal cord meningiomas?
Spinal cord meningiomas most often occur at age 50-70 years, with most presenting in the thoracic spine.
What grade is most common for primary spinal cord astrocytomas?
90% are low grade, WHO grade 1 to 2, mostly pilocytic or fibrillary
What is the 3rd most common intramedullary spinal cord tumor and with what syndrome can it be associated?
Hemangioblastoma is the 3rd most common intramedullary spinal cord tumor, with 25% of cases associated with von Hippel-Lindau syndrome
What is the most common presenting symptom of primary spinal cord tumors and over what time frame do symptoms present?
primary spinal cord tumors most commonly present with pain (75%), with symptoms presenting over months to years with a long prodrome.
What is particularly important as part of the workup for a spinal cord tumor?
Detailed neurologic exam and spinal cord imaging, MRI or CT myelogram
What is the difference between astrocytomas and ependymomas on MRI in terms of location and appearance?
Astrocytomas appear as an eccentric and asymmetric expansion of the spinal cord. Ependymoma appear as an eccentric and symmetric expansion of spinal cord
What is the MRI appearance of spinal cord lipomas?
on MRI, spinal cord lipomas appear on T1 without contrast and signal disappears on fat suppression
Which primary spinal cord tumors requires imaging of the entire craniospinal axis?
Ependymomas, glioblastoma multiforme, and anaplastic astrocytomas
What is the treatment paradigm for primary spinal cord tumors?
max safe resection plus or minus radiation vs definitive radiation alone
What are the 2 main advantages of upfront surgical resection?
Histologic confirmation and decompression of the cord.
After gross total resection, which meningiomas spinal or intracranial, have higher rates of recurrence?
Intracranial meningiomas have a 10-20% recurrence rate, while spinal meningiomas have a 5% recurrence rate.
What is the most important predictor for recurrence of meningiomas and ependymomas?
Extent of resection is the most important predictor for recurrence. There are few recurrences after gross total resection.
In what percentage of spinal cord meningiomas or ependymomas patients is gross total resection achievable?
Gross total resection is achievable in more than 90% of patients. (Retrospective series: Gezen Spine 1976, Peker J neurosurg 2005)
In what proportion of spinal cord astrocytoma patients is gross total resection possible?
Gross total resection is possible in fewer than one third of patients.
Why is radiation therapy controversial for most spinal cord tumors, even after subtotal resection?
Most spinal cord tumors are indolent or slow growing and there is potential for spinal cord toxicity with radiation therapy.
What radiation therapy options are available after subtotal resection for meningiomas or ependymomas?
Standard external beam to 50.4 Gy 1.8 Gy per fraction or 1 Gy BID or SBRT to 16 Gy to 80% isodose line (Bhatnagar Technol cancer res treat 2005)
What treatment options are available for spinal cord astrocytomas?
For low grade: Observe after gross total resection or 50.4 Gy after subtotal resection.
For high grade, 54 Gy.
What retrospective studies support use of radiation therapy in spinal cord astrocytomas?
Rodrigues IJROBP 2000 and Abdel-Wahab IJROBP 2006, Progression free survival was significantly influenced by radiation therapy radiation in low and intermediate grade tumors, however, the radiation group had fewer complete resections as compared to surgery alone. (13% vs 53%)
What data supports the radiation dose response for spinal cord epndymomas?
Garcia IJROBP 1985: <40 Gy overall survival was 23%, >40 Gy overall survival was 83%. Mayo data (Shaw IJROBP 1986) 35% local failure for <50 Gy vs 20% for >50 Gy
For what type of spinal cord tumor has adjuvant radiation been shown to be beneficial regardless of extent of resection?
Adjuvant radiation has been shown to be beneficial with myxopapillary epndymomas. MDACC data (Akyurek J Neuooncol 2006). +/- 50.4 Gy radiation 10 year local control 55% and 0% vs GTR or STR + radiation 90% and 67%
What radiation schedule is often used for high grade ependymomas plus or minus CSF spread?
Craniospinal irradiation to 36 Gy, boost to 50.4-54 Gy gross disease
What anatomic region needs to be covered with radiation in caudal ependymomas?
The thecal sac down to S2-3 needs to be covered.
What are the typical superior and inferior radiation margins for spinal cord tumors?
The typical superior and inferior margin required for spinal cord tumors is 3-5 cm.
What is the l'hermitte sign? When does it occur and to what is it due?
The l'hermitte sign is shocklike sensations in extremities upon neck flexion. It occurs within 2-6 months of radiation of radiation from demyelination of nerve tracks.
When does radiation myelopathy occur and what is the temporal sequence of onset of neurologic deficits?
Radiation myelopathy occurs 13-29 months after radiation with paresthesia, weakness, pain/temperature loss, loss of bowel and bladder function.
Within what time frame do spinal cord astrocytoma patients usually relapse?
Relapse in spinal cord astrocytoma patients usually occurs within 2 years, most in field.
How long of a follow-up is required after spinal cord ependymoma resection?
Greater than 10 years follow-up is required, as late recurrence greater than 12 years in 5-10% of patients.
What region of the spinal cord has traditionally been thought to be most sensitive to radiation? Least sensitive?
The lumbar spinal cord is thought to be most sensitive to radiation, while the cervical cord is thought to be least sensitive.
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