case_images: PMC7538966_01
case_images: Axial computed tomography abdomen and pelvis demonstrating L4 vertebral body destructive metastases (*) with extraosseous extension into the spinal canal, spinous process, and left paraspinal musculature measuring 7.8 x 7.1 cm (a) and L3 posterior vertebral body metastasis (arrow head) with intraosseous extension into the spinal canal measuring 2.1 x 2.0 cm (b).
case_images: SNI-11-279-g001.jpg
case_images: PMC7538966_01_SNI-11-279-g001.jpg
case_images: F1
case_images: On the MR/CT studies, there was accompanying L4 extraosseous extension into the spinal canal, spinous process, and left paraspinal musculature (7.8 x 7.1 cm), and another L3 posterior vertebral body lesion also with extension into the spinal canal (2.1 x 2.0 cm) [Figure 1].
case_images: Sagittal magnetic resonance imaging of the lumbar spine demonstrating near-complete marrow replacement of the L4 vertebral body (*) with expansile, locally destructive soft tissue with extension into the left posterior elements and spinous process (a). Associated extra cortical extension of disease with circumferential encasement of the epidural space resulting in extremely severe spinal canal stenosis with compression of the cauda equina nerve roots. There is also replacement of the posterior aspect of the L3 vertebral body (arrow head) and associated 20 percent posterior pathological compression fracture deformity (b). Frank extra cortical disease extension at this level results in moderate spinal canal narrowing with asymmetric effacement of the left lateral recess and compression of the traversing left L4 nerve roots.
case_images: SNI-11-279-g002.jpg
case_images: PMC7538966_01_SNI-11-279-g002.jpg
case_images: F2
case_images: Of note, the CT scan and bone scan also demonstrated other foci of metastatic disease to other organs (e.g., liver, lymph nodes, skull, and lumbar spine) [Figure 2].
case_images: Nuclear medicine bone scan demonstrating a focal rim of activity is seen in the right parietal-occipital skull, intense uptake in the L3-4 level, and mild irregular uptake in the left sacroiliac joint.
case_images: SNI-11-279-g003.jpg
case_images: PMC7538966_01_SNI-11-279-g003.jpg
case_images: F3
case_images: These findings conferred a Spinal Instability Neoplastic Score [SINS] of 13 [Figure 3].
case_images: Top row: Source AP fluoroscopy of left L3 radicular superselective angiography (left), digital subtraction angiography of preembolization tumor supply (middle), postembolization irrigation with obliteration of flow (right). Bottom row: similar representation of the left L4 superselective angiography with near total obliteration of supply.
case_images: SNI-11-279-g004.jpg
case_images: PMC7538966_01_SNI-11-279-g004.jpg
case_images: F4
case_images: Before spinal surgery, the patient had an endovascular embolization of the tumor- targeting, the L3 and L4 radicular arteries [Figure 4].
case_images: Lateral (a) and anterosuperior (b) X-rays of the lumbar spine demonstrating placement of a L4 corpectomy with placement of a cage and quad rod, pedicle screw instrumentation at L1, L2 and L3, L5, S1, and across the sacroiliac joints with an interlock at the L4 level.
case_images: SNI-11-279-g005.jpg
case_images: PMC7538966_01_SNI-11-279-g005.jpg
case_images: F5
case_images: The next day, through a posterolateral approach, corpectomies of both L3 and L4 with interbody arthrodesis were performed along with laminectomies at L1-L5 and L1-S2 alar-iliac (S2-AI) screw placement (e.g., placement of iliac bolts and a 4-rod construct [Figure 5].
case_images: Computed tomography head demonstrating a large expansile transcalvarial lesion centered at the right occipital convexity measuring approximately 7.1 x 2.3 cm transaxially (a) with resultant sulcal effacement of the subject temporal, parietal, and occipital lobes and expansion into the adjacent scalp soft tissues. Magnetic resonance imaging of the mass is also demonstrated (b).
case_images: SNI-11-279-g006.jpg
case_images: PMC7538966_01_SNI-11-279-g006.jpg
case_images: F6
case_images: A multidisciplinary tumor board recommended neoadjuvant chemoradiation on the basis of the mild cosmetic deformity without neurologic symptoms for the skull lesion, and the potential for immune therapy targeted toward the tumor's genetic profile [Figure 6].