Ovarian Carcinoma With Isolated Spinal Cord Metastasis (case report/review)

 

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Ovarian cancer metastasis to the spinal cord is quite rare, and few case reports have been published previously. Herein, we present a case of a patient who was treated for ovarian cancer and was thought to be disease free for 17 months, then presented with lower limb weakness. She was found to have a T11-T12 metastatic intramedullary spinal cord lesion. On pathology, the diagnosis of metastatic ovarian adenocarcinoma was made. This report highlights the importance of maintaining a low threshold for ovarian cancer metastases to the spinal cord when patients present with neurologic sequelae, even in the setting of normal laboratory values, as early detection can prevent permanent neurological consequences.

Discussion

Intramedullary spinal cord metastasis is quite rare, with a reported prevalence of up to 2.1% in an autopsy series of patients with cancer.³ Patients most commonly present with sensory deficits (40% to 90%) and pain (83% to 95%), with weakness (60% to 85%) and autonomic dysfunction (40% to 57%) being less common.²

The mechanism of metastatic spread for ovarian cancer may explain this phenomenon. Ovarian cancer does not exhibit the classic hematogenous spread found in most other cancers. Studies suggest that serous ovarian carcinomas grow very efficiently within the peritoneal cavity, but rarely metastasize outside of the area. When metastasis does occur, the hypothesized process states that as tumor cells detach singularly or in clusters from the primary tumor, they then travel by peritoneal fluid into the peritoneum and omentum.⁴

Distant metastases have been reported to the liver, brain, and other sites. Clinical predictors for distant metastasis remain unclear. Possible correlations are P53 mutations, genomic instability, and vascularization of the tumor. One of the few studies regarding distant metastasis in ovarian cancer studied 130 patients with ovarian cancer. Twenty-two percent were found to have distant metastasis either on initial presentation or during the course of the treatment. Multiple variables were considered as possible predictors of distant metastasis, including p53 null mutation; high-stage, high-grade, nodal metastasis; and presence of ascites. P53 null mutation was the most significant of these, followed by stage.^5....

  It is likely because the rarity of this condition may have contributed to the initial referral for physical therapy rather than establishing workup and proceeding with imaging studies. On her current presentation, the normal CA 125 level was misleading as well, and likely lead to increased time spent on exclusion of other diagnoses and performance of unnecessary tests such as lumbar puncture. Other published cases also reported normal Ca 125 levels, and no diagnostic value of lumbar puncture.¹

Specialized attention to patients with history of ovarian cancer and neurologic sequelae, including a detailed neurological exam or spinal MRI, may be employed in the future as screening measures for the benefit of patients with this uncommon condition.