Intramedullary spinal cord metastases from breast cancer detection mpMRI: One case report and literature review

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Regardless of the therapeutic options, its prognosis is mostly poor, as its presence often indicates end-stage malignancy. However, with early diagnosis and appropriate treatment, selected patients may have better neurological outcomes and quality of life. Advanced imaging techniques: mpMRI could lead to improved outcomes for patients by facilitating earlier diagnosis and tailored therapeutic approaches, helping clinicians to better determine treatment options, which is crucial for improving patient outcomes in cases of ISCM. Intramedullary spinal cord metastasis (ISCM) breast cancer magnetic resonance imaging (MRI) Multiparametric MRI Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 INTRODUCTION One of the rare major neurological complications with poor prognosis of malignancy is intramedullary spinal cord metastasis (ISCM) [ 1 ]. Early detection is of crucial importance, and timely treatment may alleviate neurologic deterioration [ 2 ]. Lung cancer is the major origin of ISCM, followed by breast cancer [ 3 ]. In cases of spinal cord tumors, the diagnostic imaging frequently starts with computed tomography (CT) and conventional MRI to assess osseous involvement and to localize abnormalities within the spinal canal and determine anatomic relationships to the spinal cord [ 4 , 5 ]. Fluorodeoxyglucose positron emission tomography (FDG-PET) can be helpful in determining the aggressiveness of a neoplasm [ 6 ]. Multi-parametric MR imaging (mpMR) is a technique that combines anatomic sequences (T1- and T2-weighted MR imaging) with functional and quantitative imaging sequences (diffusion-weighted imaging (DWI), dynamic contrast-enhanced MR imaging, and in-phase/opposed-phase imaging), demonstrating efficacy in detecting, localizing, and staging various neurological disorders, including spinal metastasis [ 7 , 8 ]. This article presents a rare case of a patient with ISCMs originating from breast cancer, as documented by the new mpMRI imaging. The use of mpMRI in this case not only facilitated the identification of the spinal metastases but also provided critical insights into the extent of disease progression. By integrating both anatomical and functional imaging techniques, clinicians can develop a more comprehensive treatment plan tailored to the patient's specific needs. CASE REPORT A 73-year-old lady underwent a left mastectomy in November 2013, followed by chemotherapy and radiotherapy for ductal breast cancer. However, in March 2023, the patient experienced attacks of confusion with generalized bony aches. A follow-up tumor marker test revealed an increase of the serum markers CEA and CA 15.3 (31.6 ng/ml, 32.2 U/ml, respectively). Subsequently, she underwent an F-18-FDG 6 mCi injected I.V. which revealed no metabolically active right breast local tumoral recurrence but identified metabolically active left cervical lymph nodes, several metabolically active mediastinal nodal metastatic deposits, pulmonary deposits, metabolically active hepatic focal lesions, and newly noted metabolically active sclerotic osseous lesions seen at D12 left inferior articular facet, L1 spinous process, L5 right pedicle, and left scapular neck. An MRI of the brain showed multiple supra- and infratentorial foci of low signal seen at both cerebral and cerebellar hemispheres as well as the brainstem, exhibiting blooming susceptibility effect on SWIs, which could be hemorrhagic metastatic deposits with deep cerebral white matter ischemia (Fazekas type 1). A US-guided tru-cut biopsy from the left deep cervical lymph node shows signs of metastatic adenocarcinoma that presumably originated from the breast. After whole-brain radiotherapy with 20 Gy and steroid administration, the symptoms showed amelioration. We then treated her with additional cycles of chemotherapy and started her on 20 mg/day of tamoxifen. In January 2025, she experienced sudden onset paraparesis and acute urinary retention with constipation for 1 day. The weakness was asymmetrical, more on the right side, associated with paresthesia in both lower extremities and diminished sensation up to the level of the umbilicus. A neurologic examination revealed brisk deep tendon reflexes in both lower limbs, along with a bilateral extensor plantar response, which indicated a long tract spinal cord involvement, as well as normal upper and lower abdominal reflexes, while superficial and deep sensory function was diminished up to D5. The MRI brain showed newly developed bilateral white matter confluent patches of high T2/FLAIR signal seen at both corona radiata and centrum semiovale, likely post-radiation changes, and there were no changes in the previously seen multiple supra- and infratentorial foci of low signal with a blooming susceptibility effect on SWI [Fig. 1]. An MRI of the dorsal spine revealed multiple focal marrow lesions of variable sizes, each exhibiting abnormally low signal on both T1 and T2 WIs. The out-of-phase T1 images showed a bright signal, which suggests that these lesions are metastatic deposits. The most pronounced of these is at the D12 body level, implicating most of the vertebrae and the neural arches; it is also followed by the lesions at L1 and L2, while smaller ones are higher up in the dorsal vertebral bodies. There is no vertebral collapse, no bony retropulsion, and no cord compression currently seen. The spinal cord itself harbors a small lesion at the D5 level about 0.5 cm that could be a cavernous angioma or a metastatic deposit to the cord with associated subtle cord edema above and below the lesion and surrounding it (Fig. 2). We performed an I.V. injection of F-18-FDG 6 mCi, which showed a newly metabolically active small intramedullary cord lesion. The mpMR of the dorsal spine was done, which included pre- and post-contrast MR and diffusion, T1 post-contrast perfusion, MR myelography, MR spectroscopy, MR tractography, and MR angiography. The pre- and post-contrast MR and diffusion revealed a heterogeneous pattern of post-contrast enhancement, accompanied by a slightly irregular inner margin, which is suggestive of a malignant entity. It has a small hemorrhagic part showing faint high signal on T1 precontrast and dark signal on T2 WIs. There is surrounding cord edema that extends cranially up to the D2-D3 disc level and caudally down to the D7-D8 disc level. The lesion and the edema are causing expansion of the cord. The lesion shows diffusion restriction due to the high cell packing and the presence of the neoplastic entity (Fig. 3). The MR myelography confirms the intramedullary location and rules out other comparable lesions or nerve root involvement (Fig. 4). MR spectroscopy showed a moderate to marked increase in choline, which indicates cell membrane turnover in metabolically active lesions, along with higher levels of lipid and lactate due to necrosis and hypoxia. There were also significant increases in the ratios of choline to creatine and choline to N-acetylaspartate (NAA) in the lesion. Additionally, there were moderate to marked abnormal elevations of choline to creatine and choline to NAA ratios in the lesion (Fig. 5). MR T1 perfusion data showed that the lesion is remarkably hyperperfused compared to normal cord parenchyma, and the dynamic time intensity curve indicates rapid uptake of contrast media followed by washout, so going with the malignant neoplastic pattern rather than other entities (Fig. 6). The MR tractography showed that the lesion is causing deviation of cord fibers around it and changes in color brightness and color hues, intensity, and integrity, while swelling of the fibers by the edema above and below it, and this would go with a metastatic deposit rather than an astrocytoma or ependymoma. The quantitative data showed abnormally reduced fractional anisotropy and abnormally elevated ADC for the lesion compared to normal cord parenchyma and a similar but to a lesser extent of the edema (Fig. 7). The intramedullary lesion opposite D5 carries multiparametric features that are strongly suggestive of a malignant neoplastic entity, especially considering the patient's history of breast cancer, raising the possibility of it being a spinal cord metastasis. These findings led to the diagnosis of ISCH. The patient started on dexamethasone and received local external beam radiation therapy (20 Gy) to the spinal cord. However, her general condition deteriorated due to metastatic progression, and she died 3 months after the onset of ISCM symptoms. Discussion In this report, we describe a 73-year-old female patient who presented with a sudden onset of paraparesis of the Brown-Sequard type with a sensory level of D5 and urinary retention. She was known to have right breast cancer, underwent surgery, received radiotherapy and chemotherapy, and developed metastatic brain, lung, liver, and bone deposits for which she received chemotherapy and radiotherapy. The spine MRI revealed a spot on the spinal cord at the D5 level, approximately 0.5 cm in size, which might be a metastatic deposit. This spot carries multiparametric MRI features that suggest a malignant neoplastic entity. Consequently, we diagnosed an ISCM of breast cancer. The patient received radiotherapy and steroid therapy. The patient’s condition deteriorated, and she died 3 months after the appearance of ISCM symptoms. The occurrence of ISCM is infrequent; however, advancements in therapy for malignancies have resulted in improved survival rates, leading to more publications on ISCM, including case reports and literature reviews [5]. Intramedullary metastatic disease occurs in 0.1%-0.4% of cancer patients and constitutes 1%-3% of all intramedullary spinal cord neoplasms [9]. ISCM clinically affects 4%-8.5% of cancer patients with central nervous system (CNS) metastases [3, 4, 10, 11]. The most common cancers associated with this type of lesion are lung small-cell carcinoma, making up about 50% of all ISCMs, followed by breast cancer, and less frequently, kidney cancer, melanoma, lymphoma, colorectal cancer, and ovarian adenocarcinomas [3, 4, 10, 11, 12]. Breast cancer is one of the most prevalent solid tumors that may metastasize to multiple sites but less commonly to intramedullary spinal cord metastases [13]. The most common site of ISCM is cervical, in 41% of cases, followed by lumbar and thoracic, in 32–38% and 26–34% of cases, respectively, mostly due to the larger size and rich blood supply of the cervical cord [3, 10]. ISCMs may involve multiple levels in some cases [12, 14, 15]. Simultaneous discovery of brain metastases occurs in 41–89% of ISCM cases [4, 16]. Therefore, to complete the ISCM work-up, clinicians should schedule a cerebral MRI to check for brain metastases. Several pathophysiologic mechanisms have been described for ISCH, including arterial spread through embolization of neoplastic cells that bypass the lung filter and spread through the secondary capillary network to the penetrating arteries that enter the spinal cord, or retrograde venous spread (via Batson venous plexus) by connection between the intraspinal epidural venous plexus and the azygos, hemiazygos, vertebral, and jugular veins, especially if there is flow inversion due to increases in intrathoracic or intra-abdominal pressure after Valsalva or obstruction caused by a neoplasm in the region [12, 17, 18, 19]. This can explain the coexistence of lung and brain metastases in most cases, like our case [17]. Additionally, in cases of CNS tumors elsewhere, spread to the spinal cord is by direct extension from nerve roots into the subarachnoid space or through cerebrospinal fluid with malignant cells in leptomeningeal carcinomatous, infiltrating the vascular Virchow-Robin gaps, entering the spinal cord, and invading the spinal cord parenchyma [3, 4, 20]. However, given the simultaneous occurrence of brain and spinal cord metastasis in our case, hematogenous spread could potentially be the mechanism. The clinical manifestations of metastatic intramedullary spinal cord tumors are typically paresthesia, paraparesis, and autonomic dysfunction, respectively, due to edema, distortion, and compression of the cord parenchyma [1, 3, 11, 21]. In certain instances, additional symptoms, including asymmetrical weakness, back pain, or root pain, are reported [3]. Back pain, motor dysfunction, and rapid deterioration of neurologic functions are features of both epidural compression and ISCM. However, the finding of asymmetric lower extremity motor deficit and sensory disturbances like Brown-Séquard syndrome often favors ISCM, similar to our case [12]. Epidural metastases typically cause a more symmetrical motor dysfunction and frequently show a sensory level distal to the spinal cord lesion. Furthermore, sudden onset and rapid progression of symptoms distinguish ISCM from primary intramedullary tumors, which typically have a gradual progressive course [11, 22]. The neurological condition rapidly deteriorates over the course of days to weeks, and the majority of patients eventually showed complete cord syndrome [23, 24]. When symptoms suggestive of ISCM occur, the diagnosis relies mainly on MRI, which remains the gold standard, as MRI detection is superior to CT scans [4, 5]. Before the introduction of MRI, autopsy was the primary method for identifying the majority of ISCM cases [20]. The MR imaging features of the ISCM showed solitary lesions in the spinal cord, eccentrically located within the cord, expanding the cord, extending ≥2 segments, T2-hyperintense, and T1-isointense with significant enhancement after the injection of Gadolinium [1, 21, 25]. Moreover, the metastatic lesions may be multifocal in 15% of cases [26]. 18F-FDG PET/CT is currently the primary imaging technique for whole-body screening for metastases; FDG PET/CT may be helpful for the detection and diagnosis of ISCM [12]. Flanagan et al. found that spinal cord FDG-PET hypermetabolism was detected in 17 of 21 [81%] patients with neoplastic myelopathy [27]. Furthermore, FDG PET/CT has the advantage of extramedullary disease status assessment [28]. However, FDG PET/CT is less sensitive than MRI; it might miss spinal metastases with low glucose metabolism or show false-positive findings in patients with inflammatory diseases. Furthermore, FDG PET/CT has the advantage of extramedullary disease status assessment [28]. Despite mpMRI being a non-invasive tool that can evaluate the structural, molecular, and functional aspects of various neurological disorders, its use in spinal cord diseases has been limited, in part because of the technical difficulties involved in imaging the spine and the cost [29]. EL-Morsy et al. reported that although conventional MRI is the imaging modality of choice in detecting and evaluating spinal bony metastatic lesions of 47 patients, mpMRI adds more accuracy in the differentiation and characterization of these malignant lesions [30]. mpMRI is a non-invasive, radiation-free, safe, and sensitive method that can help make the final diagnosis of ISCM in comparison to excisional biopsy. Managing ISCMs presents a challenging clinical scenario with no clear guidelines available, and the outcomes of current treatments vary [3, 10, 13, 24, 31, 32]. Treatment decisions are generally based on the doctor’s experience and the patient’s performance status [33]. Therapeutic options range from radiotherapy, surgery, chemotherapy, corticosteroids, rehabilitation, and palliative care when the general status of the patient is poor [1, 34, 35]. Tsai et al. reported that there were no differences between conservative treatment (non-treatment or radiotherapy) and aggressive intervention (surgery or surgery plus radiotherapy) in mortality and the trend of survival probability in their 19 analyzed ISCM cases [33]. Like with other metastases to the central nervous system, ISCM patients have poor prognosis and short survival. As with other CNS metastases, patients with ISCM have a short life expectancy, with a median survival of 3 to 4 months from the date of diagnosis [13, 18, 36]. Metastatic spinal cord compression is a devastating complication in cancer patients, and its incidence is expected to rise due to improving cancer treatments and survival [37]. Thorough history-taking, careful physical examination, and wise use of laboratory and imaging procedures are essential for accurate diagnosis and to prevent permanent neurological damage. Although the prognosis can be grim, early intervention may lead to improved outcomes and quality of life for patients. Treatments such as corticosteroids, radiation therapy, and surgical decompression can alleviate symptoms and potentially restore function if initiated promptly. MRI is the gold standard for ISCM imaging [35]. mpMRI may be of value in certain cases as a noninvasive, safe, sensitive technique for confirming the diagnosis, excluding other malignant entities, and selecting the appropriate management plans. Conclusions ISCM is a rare type of CNS involvement and represents a gloomy finding of systemic malignancy that requires early diagnosis and urgent referral to a specialist neurology/neurosurgery team for better management. In these situations, MRI is the most reliable diagnostic tool with thorough history taking and meticulous physical examination. Advanced neuroimaging mpMRI has brought MR DWI, perfusion, myelography, spectroscopy, tractography, and angiography to our toolkit that may allow for a combination of functional and anatomic information that holds enormous promise for further defining the diagnosis, allowing for a more precise treatment plan, and ultimately improving patient outcomes. As research continues to evolve, the integration of innovative imaging modalities will play a pivotal role in shaping future standards of care in oncology. Abbreviations CNS Central nervous system CT Computed Tomography DWI Diffusion weighted imaging FDG-PET Fluorodeoxyglucose positron emission tomography ISCM Intramedullary spinal cord metastasis mpMRI multi-parametric MRI MRI Magnetic resonance imaging NAA N-acetylaspartate SWI Susceptibility-weighted imaging Declarations Acknowledgements Not applicable. Author contributions TA, AA, RA: design and conceptualized manuscript, collecting the data, drafted the manuscript for intellectual content. ME, RA: designing, drafting and revision of manuscript. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript. Funding None. Availability of data and materials The data sets generated and analyzed during the current study are not publicly available due to institutional limitations, yet they are available from the corresponding author on reasonable request. Ethics approval and consent to participate. Patient provided informed written consent for publishing case-related data. Competing interests The authors declare that they have no competing interests. References Payer S, Mende KC, Westphal M, Eicker SO. Intramedullary spinal cord metastases: an increasingly common diagnosis. Neurosurg Focus. 2015 Aug;39(2):E15. doi: 10.3171/2015.5.FOCUS15149. PMID: 26235013. Vavourakis M, Sakellariou E, Galanis A, Karampinas P, Zachariou D, Tsalimas G, Marougklianis V, Argyropoulou E, Rozis M, Kaspiris A, Pneumatikos SG. Comprehensive Insights into Metastasis-Associated Spinal Cord Compression: Pathophysiology, Diagnosis, Treatment, and Prognosis: A State-of-the-Art Systematic Review. 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Cite Share Download PDF Status: Published Journal Publication published 19 Jan, 2026 Read the published version in The Egyptian Journal of Neurology, Psychiatry and Neurosurgery → Version 1 posted Editorial decision: Revision requested 14 Oct, 2025 Reviews received at journal 10 Oct, 2025 Reviewers agreed at journal 10 Oct, 2025 Reviews received at journal 06 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers agreed at journal 05 Oct, 2025 Reviewers invited by journal 25 Sep, 2025 Editor assigned by journal 20 Aug, 2025 Submission checks completed at journal 20 Aug, 2025 First submitted to journal 16 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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08:52:11","extension":"xml","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86297,"visible":true,"origin":"","legend":"","description":"","filename":"0745cb1a427c4e21afdc62d57b7357351structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/bd3f88710737ef849273fbd4.xml"},{"id":93021140,"identity":"08964c9c-a3ca-4f24-a97f-6a962f00b7e2","added_by":"auto","created_at":"2025-10-08 08:52:10","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95339,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/7af78ba3a022fb45d320444d.html"},{"id":93021133,"identity":"4cc748af-5267-4142-8c41-79c4e2eb0acd","added_by":"auto","created_at":"2025-10-08 08:52:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":149031,"visible":true,"origin":"","legend":"\u003cp\u003eAxial FLAIR (a) \u0026nbsp;\u0026amp; SWI (b) of brain showed bilateral white matter confluent patches of high FLAIR signal seen at both corona radiata and centrum semiovale, and multiple supra tentorial foci of low signal seen at both cerebral, with blooming susceptibility effect on SWI.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/ea3e55eb46b2f5378fdec3b7.png"},{"id":93022124,"identity":"c41d26b9-ab4a-49d3-b337-05f63bfa871c","added_by":"auto","created_at":"2025-10-08 09:00:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":96652,"visible":true,"origin":"","legend":"\u003cp\u003eAn MRI of the dorsal spine sagittal T1 (a) and T2WI (b) showed focal marrow lesions of different sizes and had abnormally low signal on both T1 and T2 WIs. The most pronounced of these is at the D 12 body level. There is a small lesion at the D5 level about 0.5 cm? Metastatic deposit to the cord with associated subtle cord edema above and below the lesion and surrounding it.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/0a1dfe91c57aaf4bf8a3ca3f.png"},{"id":93020768,"identity":"d10d46fa-5c45-4b4c-b24c-8ff6a37c813f","added_by":"auto","created_at":"2025-10-08 08:44:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":434437,"visible":true,"origin":"","legend":"\u003cp\u003epre-and post-contrast MR showed heterogeneous pattern of post contrast enhancement with slightly irregular inner margin. It has a small hemorrhagic part showing faint high signal on T1 precontrast.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/8f51c013fc66a47314f298b7.png"},{"id":93020782,"identity":"8675d48f-2b88-4275-a13e-c2b73f4bba03","added_by":"auto","created_at":"2025-10-08 08:44:10","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":165386,"visible":true,"origin":"","legend":"\u003cp\u003eThe MR myelography confirms the intramedullary location.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/d4df2ff67d9569c0a3f7e98b.png"},{"id":93020772,"identity":"e77ffea7-0a73-4a79-b792-ac639531123d","added_by":"auto","created_at":"2025-10-08 08:44:10","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":256561,"visible":true,"origin":"","legend":"\u003cp\u003eMultivoxel spectroscopy of the enhancing part of the lesion (orange tag), and of the normal cord parenchyma (green tag) shows moderate to marked abnormal elevation of choline to creatine and choline to NAA ratios in the lesion.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/006e643bf378ea05bd8aeb6c.png"},{"id":93021134,"identity":"d02a652e-59cf-47f3-b61b-29bf65e037d9","added_by":"auto","created_at":"2025-10-08 08:52:10","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":272278,"visible":true,"origin":"","legend":"\u003cp\u003eMR T1 perfusion data showed that the lesion is hyperperfused and the dynamic time intensity curve shows rapid uptake of contrast media followed by washout.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/9aadedc3323d203d2d79d6ec.png"},{"id":93021139,"identity":"6c550efc-3e2f-4d8c-904d-336dd78dc978","added_by":"auto","created_at":"2025-10-08 08:52:10","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":252775,"visible":true,"origin":"","legend":"\u003cp\u003eThe MR tractography (a) showed deviation of cord fibers and changes in color brightness and color hues, intensity, and integrity, by the lesion. The quantitative data (b) showed abnormally reduced fractional anisotropy and abnormally elevated ADC for the lesion compared to normal cord parenchyma and a similar but to a lesser extent of the edema.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/f31cb6c208a9a8dc01c57165.png"},{"id":101152944,"identity":"37dbacde-c6c0-4073-8028-d997fac01db9","added_by":"auto","created_at":"2026-01-26 16:13:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2246781,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7385300/v1/0557fb44-b3dc-4b73-b57f-98c8e3c6ee8b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eIntramedullary spinal cord metastases from breast cancer detection mpMRI: One case report and literature review\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOne of the rare major neurological complications with poor prognosis of malignancy is intramedullary spinal cord metastasis (ISCM) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Early detection is of crucial importance, and timely treatment may alleviate neurologic deterioration [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Lung cancer is the major origin of ISCM, followed by breast cancer [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In cases of spinal cord tumors, the diagnostic imaging frequently starts with computed tomography (CT) and conventional MRI to assess osseous involvement and to localize abnormalities within the spinal canal and determine anatomic relationships to the spinal cord [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Fluorodeoxyglucose positron emission tomography (FDG-PET) can be helpful in determining the aggressiveness of a neoplasm [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Multi-parametric MR imaging (mpMR) is a technique that combines anatomic sequences (T1- and T2-weighted MR imaging) with functional and quantitative imaging sequences (diffusion-weighted imaging (DWI), dynamic contrast-enhanced MR imaging, and in-phase/opposed-phase imaging), demonstrating efficacy in detecting, localizing, and staging various neurological disorders, including spinal metastasis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This article presents a rare case of a patient with ISCMs originating from breast cancer, as documented by the new mpMRI imaging. The use of mpMRI in this case not only facilitated the identification of the spinal metastases but also provided critical insights into the extent of disease progression. By integrating both anatomical and functional imaging techniques, clinicians can develop a more comprehensive treatment plan tailored to the patient's specific needs.\u003c/p\u003e"},{"header":"CASE REPORT","content":"\u003cp\u003eA 73-year-old lady underwent a left mastectomy in November 2013, followed by chemotherapy and radiotherapy for ductal breast cancer.\u003c/p\u003e\u003cp\u003eHowever, in March 2023, the patient experienced attacks of confusion with generalized bony aches. A follow-up tumor marker test revealed an increase of the serum markers CEA and CA 15.3 (31.6 ng/ml, 32.2 U/ml, respectively). Subsequently, she underwent an F-18-FDG 6 mCi injected I.V. which revealed no metabolically active right breast local tumoral recurrence but identified metabolically active left cervical lymph nodes, several metabolically active mediastinal nodal metastatic deposits, pulmonary deposits, metabolically active hepatic focal lesions, and newly noted metabolically active sclerotic osseous lesions seen at D12 left inferior articular facet, L1 spinous process, L5 right pedicle, and left scapular neck. An MRI of the brain showed multiple supra- and infratentorial foci of low signal seen at both cerebral and cerebellar hemispheres as well as the brainstem, exhibiting blooming susceptibility effect on SWIs, which could be hemorrhagic metastatic deposits with deep cerebral white matter ischemia (Fazekas type 1).\u003c/p\u003e\u003cp\u003eA US-guided tru-cut biopsy from the left deep cervical lymph node shows signs of metastatic adenocarcinoma that presumably originated from the breast. After whole-brain radiotherapy with 20 Gy and steroid administration, the symptoms showed amelioration. We then treated her with additional cycles of chemotherapy and started her on 20 mg/day of tamoxifen.\u003c/p\u003e\u003cp\u003eIn January 2025, she experienced sudden onset paraparesis and acute urinary retention with constipation for 1 day. The weakness was asymmetrical, more on the right side, associated with paresthesia in both lower extremities and diminished sensation up to the level of the umbilicus.\u003c/p\u003e\u003cp\u003eA neurologic examination revealed brisk deep tendon reflexes in both lower limbs, along with a bilateral extensor plantar response, which indicated a long tract spinal cord involvement, as well as normal upper and lower abdominal reflexes, while superficial and deep sensory function was diminished up to D5.\u003c/p\u003e\u003cp\u003eThe MRI brain showed newly developed bilateral white matter confluent patches of high T2/FLAIR signal seen at both corona radiata and centrum semiovale, likely post-radiation changes, and there were no changes in the previously seen multiple supra- and infratentorial foci of low signal with a blooming susceptibility effect on SWI [Fig.\u0026nbsp;1].\u003c/p\u003e\u003cp\u003eAn MRI of the dorsal spine revealed multiple focal marrow lesions of variable sizes, each exhibiting abnormally low signal on both T1 and T2 WIs. The out-of-phase T1 images showed a bright signal, which suggests that these lesions are metastatic deposits. The most pronounced of these is at the D12 body level, implicating most of the vertebrae and the neural arches; it is also followed by the lesions at L1 and L2, while smaller ones are higher up in the dorsal vertebral bodies. There is no vertebral collapse, no bony retropulsion, and no cord compression currently seen. The spinal cord itself harbors a small lesion at the D5 level about 0.5 cm that could be a cavernous angioma or a metastatic deposit to the cord with associated subtle cord edema above and below the lesion and surrounding it (Fig.\u0026nbsp;2). We performed an I.V. injection of F-18-FDG 6 mCi, which showed a newly metabolically active small intramedullary cord lesion.\u003c/p\u003e\u003cp\u003eThe mpMR of the dorsal spine was done, which included pre- and post-contrast MR and diffusion, T1 post-contrast perfusion, MR myelography, MR spectroscopy, MR tractography, and MR angiography. The pre- and post-contrast MR and diffusion revealed a heterogeneous pattern of post-contrast enhancement, accompanied by a slightly irregular inner margin, which is suggestive of a malignant entity. It has a small hemorrhagic part showing faint high signal on T1 precontrast and dark signal on T2 WIs. There is surrounding cord edema that extends cranially up to the D2-D3 disc level and caudally down to the D7-D8 disc level. The lesion and the edema are causing expansion of the cord. The lesion shows diffusion restriction due to the high cell packing and the presence of the neoplastic entity (Fig.\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eThe MR myelography confirms the intramedullary location and rules out other comparable lesions or nerve root involvement (Fig.\u0026nbsp;4).\u003c/p\u003e\u003cp\u003eMR spectroscopy showed a moderate to marked increase in choline, which indicates cell membrane turnover in metabolically active lesions, along with higher levels of lipid and lactate due to necrosis and hypoxia. There were also significant increases in the ratios of choline to creatine and choline to N-acetylaspartate (NAA) in the lesion. Additionally, there were moderate to marked abnormal elevations of choline to creatine and choline to NAA ratios in the lesion (Fig.\u0026nbsp;5).\u003c/p\u003e\u003cp\u003eMR T1 perfusion data showed that the lesion is remarkably hyperperfused compared to normal cord parenchyma, and the dynamic time intensity curve indicates rapid uptake of contrast media followed by washout, so going with the malignant neoplastic pattern rather than other entities (Fig.\u0026nbsp;6).\u003c/p\u003e\u003cp\u003eThe MR tractography showed that the lesion is causing deviation of cord fibers around it and changes in color brightness and color hues, intensity, and integrity, while swelling of the fibers by the edema above and below it, and this would go with a metastatic deposit rather than an astrocytoma or ependymoma. The quantitative data showed abnormally reduced fractional anisotropy and abnormally elevated ADC for the lesion compared to normal cord parenchyma and a similar but to a lesser extent of the edema (Fig.\u0026nbsp;7).\u003c/p\u003e\u003cp\u003eThe intramedullary lesion opposite D5 carries multiparametric features that are strongly suggestive of a malignant neoplastic entity, especially considering the patient's history of breast cancer, raising the possibility of it being a spinal cord metastasis.\u003c/p\u003e\u003cp\u003eThese findings led to the diagnosis of ISCH. The patient started on dexamethasone and received local external beam radiation therapy (20 Gy) to the spinal cord. However, her general condition deteriorated due to metastatic progression, and she died 3 months after the onset of ISCM symptoms.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this report, we describe a 73-year-old female patient who presented with a sudden onset of paraparesis of the Brown-Sequard type with a sensory level of D5 and urinary retention. She was known to have right breast cancer, underwent surgery, received radiotherapy and chemotherapy, and developed metastatic brain, lung, liver, and bone deposits for which she received chemotherapy and radiotherapy. The spine MRI revealed a spot on the spinal cord at the D5 level, approximately 0.5 cm in size, which might be a metastatic deposit. This spot carries multiparametric MRI features that suggest a malignant neoplastic entity. Consequently, we diagnosed an ISCM of breast cancer. The patient received radiotherapy and steroid therapy. The patient’s condition deteriorated, and she died 3 months after the appearance of ISCM symptoms.\u003c/p\u003e\n\u003cp\u003eThe occurrence of ISCM is infrequent; however, advancements in therapy for malignancies have resulted in improved survival rates, leading to more publications on ISCM, including case reports and literature reviews [5].\u003c/p\u003e\n\u003cp\u003eIntramedullary metastatic disease occurs in 0.1%-0.4% of cancer patients and constitutes 1%-3% of all intramedullary spinal cord neoplasms [9]. ISCM clinically affects 4%-8.5% of cancer patients with central nervous system (CNS) metastases [3, 4, 10, 11].\u003c/p\u003e\n\u003cp\u003eThe most common cancers associated with this type of lesion are lung small-cell carcinoma, making up about 50% of all ISCMs, followed by breast cancer, and less frequently, kidney cancer, melanoma, lymphoma, colorectal cancer, and ovarian adenocarcinomas [3, 4, 10, 11, 12]. Breast cancer is one of the most prevalent solid tumors that may metastasize to multiple sites but less commonly to intramedullary spinal cord metastases [13]. The most common site of ISCM is cervical, in 41% of cases, followed by lumbar and thoracic, in 32–38% and 26–34% of cases, respectively, mostly due to the larger size and rich blood supply of the cervical cord [3, 10]. ISCMs may involve multiple levels in some cases [12, 14, 15].\u003c/p\u003e\n\u003cp\u003eSimultaneous discovery of brain metastases occurs in 41–89% of ISCM cases [4, 16]. Therefore, to complete the ISCM work-up, clinicians should schedule a cerebral MRI to check for brain metastases.\u003c/p\u003e\n\u003cp\u003eSeveral pathophysiologic mechanisms have been described for ISCH, including arterial spread through embolization of neoplastic cells that bypass the lung filter and spread through the secondary capillary network to the penetrating arteries that enter the spinal cord, or retrograde venous spread (via Batson venous plexus) by connection between the intraspinal epidural venous plexus and the azygos, hemiazygos, vertebral, and jugular veins, especially if there is flow inversion due to increases in intrathoracic or intra-abdominal pressure after Valsalva or obstruction caused by a neoplasm in the region [12, 17, 18, 19]. This can explain the coexistence of lung and brain metastases in most cases, like our case [17]. Additionally, in cases of CNS tumors elsewhere, spread to the spinal cord is by direct extension from nerve roots into the subarachnoid space or through cerebrospinal fluid with malignant cells in leptomeningeal carcinomatous, infiltrating the vascular Virchow-Robin gaps, entering the spinal cord, and invading the spinal cord parenchyma [3, 4, 20]. However, given the simultaneous occurrence of brain and spinal cord metastasis in our case, hematogenous spread could potentially be the mechanism.\u003c/p\u003e\n\u003cp\u003eThe clinical manifestations of metastatic intramedullary spinal cord tumors are typically paresthesia, paraparesis, and autonomic dysfunction, respectively, due to edema, distortion, and compression of the cord parenchyma [1, 3, 11, 21]. In certain instances, additional symptoms, including asymmetrical weakness, back pain, or root pain, are reported [3]. Back pain, motor dysfunction, and rapid deterioration of neurologic functions are features of both epidural compression and ISCM. However, the finding of asymmetric lower extremity motor deficit and sensory disturbances like Brown-Séquard syndrome often favors ISCM, similar to our case [12]. Epidural metastases typically cause a more symmetrical motor dysfunction and frequently show a sensory level distal to the spinal cord lesion. Furthermore, sudden onset and rapid progression of symptoms distinguish ISCM from primary intramedullary tumors, which typically have a gradual progressive course [11, 22]. The neurological condition rapidly deteriorates over the course of days to weeks, and the majority of patients eventually showed complete cord syndrome [23, 24].\u003c/p\u003e\n\u003cp\u003eWhen symptoms suggestive of ISCM occur, the diagnosis relies mainly on MRI, which remains the gold standard, as MRI detection is superior to CT scans [4, 5]. Before the introduction of MRI, autopsy was the primary method for identifying the majority of ISCM cases [20]. The MR imaging features of the ISCM showed solitary lesions in the spinal cord, eccentrically located within the cord, expanding the cord, extending ≥2 segments, T2-hyperintense, and T1-isointense with significant enhancement after the injection of Gadolinium [1, 21, 25]. Moreover, the metastatic lesions may be multifocal in 15% of cases [26].\u003c/p\u003e\n\u003cp\u003e18F-FDG PET/CT is currently the primary imaging technique for whole-body screening for metastases; FDG PET/CT may be helpful for the detection and diagnosis of ISCM [12]. Flanagan et al. found that spinal cord FDG-PET hypermetabolism was detected in 17 of 21 [81%] patients with neoplastic myelopathy [27]. Furthermore, FDG PET/CT has the advantage of extramedullary disease status assessment [28]. However, FDG PET/CT is less sensitive than MRI; it might miss spinal metastases with low glucose metabolism or show false-positive findings in patients with inflammatory diseases. Furthermore, FDG PET/CT has the advantage of extramedullary disease status assessment [28].\u003c/p\u003e\n\u003cp\u003eDespite mpMRI being a non-invasive tool that can evaluate the structural, molecular, and functional aspects of various neurological disorders, its use in spinal cord diseases has been limited, in part because of the technical difficulties involved in imaging the spine and the cost [29]. EL-Morsy et al. reported that although conventional MRI is the imaging modality of choice in detecting and evaluating spinal bony metastatic lesions of 47 patients, mpMRI adds more accuracy in the differentiation and characterization of these malignant lesions [30]. mpMRI is a non-invasive, radiation-free, safe, and sensitive method that can help make the final diagnosis of ISCM in comparison to excisional biopsy.\u003c/p\u003e\n\u003cp\u003eManaging ISCMs presents a challenging clinical scenario with no clear guidelines available, and the outcomes of current treatments vary [3, 10, 13, 24, 31, 32]. Treatment decisions are generally based on the doctor’s experience and the patient’s performance status [33]. Therapeutic options range from radiotherapy, surgery, chemotherapy, corticosteroids, rehabilitation, and palliative care when the general status of the patient is poor [1, 34, 35]. Tsai et al. reported that there were no differences between conservative treatment (non-treatment or radiotherapy) and aggressive intervention (surgery or surgery plus radiotherapy) in mortality and the trend of survival probability in their 19 analyzed ISCM cases [33].\u003c/p\u003e\n\u003cp\u003eLike with other metastases to the central nervous system, ISCM patients have poor prognosis and short survival. As with other CNS metastases, patients with ISCM have a short life expectancy, with a median survival of 3 to 4 months from the date of diagnosis [13, 18, 36].\u003c/p\u003e\n\u003cp\u003eMetastatic spinal cord compression is a devastating complication in cancer patients, and its incidence is expected to rise due to improving cancer treatments and survival [37]. Thorough history-taking, careful physical examination, and wise use of laboratory and imaging procedures are essential for accurate diagnosis and to prevent permanent neurological damage. Although the prognosis can be grim, early intervention may lead to improved outcomes and quality of life for patients. Treatments such as corticosteroids, radiation therapy, and surgical decompression can alleviate symptoms and potentially restore function if initiated promptly. MRI is the gold standard for ISCM imaging [35]. mpMRI may be of value in certain cases as a noninvasive, safe, sensitive technique for confirming the diagnosis, excluding other malignant entities, and selecting the appropriate management plans.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eISCM is a rare type of CNS involvement and represents a gloomy finding of systemic malignancy that requires early diagnosis and urgent referral to a specialist neurology/neurosurgery team for better management. In these situations, MRI is the most reliable diagnostic tool with thorough history taking and meticulous physical examination. Advanced neuroimaging mpMRI has brought MR DWI, perfusion, myelography, spectroscopy, tractography, and angiography to our toolkit that may allow for a combination of functional and anatomic information that holds enormous promise for further defining the diagnosis, allowing for a more precise treatment plan, and ultimately improving patient outcomes. As research continues to evolve, the integration of innovative imaging modalities will play a pivotal role in shaping future standards of care in oncology.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentral nervous system\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDWI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiffusion weighted imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFDG-PET\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFluorodeoxyglucose positron emission tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eISCM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntramedullary spinal cord metastasis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003empMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emulti-parametric MRI\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNAA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eN-acetylaspartate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSWI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSusceptibility-weighted imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTA, AA, RA: design and conceptualized manuscript, collecting the data, drafted the manuscript for intellectual content. ME, RA: designing, drafting and revision of manuscript. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are\u003c/p\u003e\n\u003cp\u003eappropriately investigated and resolved. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets generated and analyzed during the current study are not publicly\u003c/p\u003e\n\u003cp\u003eavailable due to institutional limitations, yet they are available from the\u003c/p\u003e\n\u003cp\u003ecorresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate.\u003c/p\u003e\n\u003cp\u003ePatient provided informed written consent for publishing case-related data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePayer S, Mende KC, Westphal M, Eicker SO. 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Tumori. 2017; 103(Suppl. 1): e28\u0026ndash;e30, doi: 10.5301/tj.5000647, indexed in Pubmed: 28574131.\u003c/li\u003e\n \u003cli\u003eKuah T, Vellayappan BA, Makmur A, Nair S, Song J, Tan JH, Kumar N, Quek ST, Hallinan JTPD. State-of-the-Art Imaging Techniques in Metastatic Spinal Cord Compression. Cancers (Basel). 2022 Jul 5;14(13):3289. doi: 10.3390/cancers14133289. PMID: 35805059; PMCID: PMC9265325.\u003c/li\u003e\n \u003cli\u003eScalia G, Costanzo R, Viola A, et al. Intramedullary Spinal Cord Metastases from Breast Cancer: A Systematic Review. Anticancer Res. 2023; 43(2): 523\u0026ndash;535, doi: 10.21873/anticanres.16189, indexed in Pubmed: 36697093.\u003c/li\u003e\n \u003cli\u003eBarzilai O, Fisher CG, Bilsky MH. State of the Art Treatment of Spinal Metastatic Disease. Neurosurgery. 2018 Jun 1;82(6):757-769. doi: 10.1093/neuros/nyx567. PMID: 29481645.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-neurology-psychiatry-and-neurosurgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejnp","sideBox":"Learn more about [The Egyptian Journal of Neurology, Psychiatry and Neurosurgery](http://ejnpn.springeropen.com)","snPcode":"41983","submissionUrl":"https://submission.springernature.com/new-submission/41983/3","title":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Intramedullary spinal cord metastasis (ISCM), breast cancer, magnetic resonance imaging (MRI), Multiparametric MRI","lastPublishedDoi":"10.21203/rs.3.rs-7385300/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7385300/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAlthough intramedullary spinal cord metastasis (ISCM) is rare, it may be a fatal complication of malignancy. Regardless of the therapeutic options, its prognosis is mostly poor, as its presence often indicates end-stage malignancy. However, with early diagnosis and appropriate treatment, selected patients may have better neurological outcomes and quality of life. 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