• A 58 year old white male presents with history of upper back pain for 2 months.  He had a history of lymphoma which was treated with surgical biopsy followed by chemotherapy and radiation therapy (25 sittings "neck to stomach"). A mass in the right hemithorax was discovered. This lesion was biopsied with results being equivocal, but was treated with a repeat round of chemotherapy without improvement in back pain.

    Past Medical History:

    • Non-smoker; + chewing tobacco
    • Lymphoma treated per HPI
    • Diabetes Mellitus
    • Tylenol #3 for pain

    Exam

    • Partial Right Horner’s syndrome (miosis)
    • UE: full strength bilaterally
    • LE: 4/5 proximally, 4/5 ant tib/gastroc bilaterally, 4-/5 R EHL, 4/5 L EHL
    • Sensory: diminished L T1 (digits 4,5), R forearm
    • Reflexes symmetric

    Figure 3. (Below) These images demonstrate a transdural mass with the intradural extramedullary portion extending from C7 through T2. In addition, this appears to be contiguous with a right pulmonary mass/superior sulcus lesion with extension of abnormal signal from the right cervicothoracic junction into the spinal canal 

    Figure 1. CT scan demonstrates a right sided apical pleural based mass

    Figure 2.

    Figure 3.

    1. What is the etiology of the patientÂ’s miosis?

     

     2. Further workup should include all of the following except:

    3. What characteristic is NOT a poor prognostic factor for this pathology?

    4. Further investigation reveals no evidence of metastatic disease. Surgical treatment is advocated. What approach do you recommend?

     5. Which of the following describes you?

    6. I practice in one of the following locations.

    7. Please add any suggestions or comments regarding this case:

    • quite a challenging case
    • Neurosurgical management should aim at decompression of the cord. Since the vertebral bodies are largely uninvolved, stability is not a major issue, and laminectomy and decompression will achieve the aim. The tumor mass can be tackled separately by the Thoracic surgeon and Oncologist.
    • I would not advocate surgery until a diagnosis via biopsy is obtained. If this is recurrent lymphoma radiation/chemo and no surgery is the way to go. If its a radiation induced sarcoma or lung primary w extension into the spine then surgery should be considered
    • I touogth it is a kind of abcess in, which it coulb be too a neuroenteric cyst, the posibility to make a descompretion is high and the benefits too. A big surgery can make the things worse.
    • Tricky case
    • chemotherapy may be useful for management of thoracic lesion if biopsy is confirmed to be lymaphoma after excison of the spinal lesion and decomprsiion of spinal cord
    • thoracotomy with removal of thoracic mass and extension into spinal canal.post op biopsy and further treatment according to tissue diagnosis.
    • ýam a neurosurgeon in turkey.I performed surgery .
    • given the patient's history of lymphoma treatment by chemo/radiation, then this new mass lesion can be still be a recurrent lymphoma or a denovo malignant process induced by the radiation. Since the biopsy wasn't conclusive, it needs to be revised on a more extensive basis with also the aim of cord decompression to improve his objectively assessed neuro-deficit. I also think a posterior or a postero-lateral approach can achieve both goals, still with subtotal resection, since en bloc resection, in my belief, will carry considerable morbidity unwarranted in this patient...given his relatively fine neurological and general status
    • I would like to recommend only an intervention to have a biopsy sample of the lesion via image guided biopsy or posterior laminectomy decompression for biopsy or partial EXCISION OF THE LESION.

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