Treatment of Premedullary Mass
The treatment of a premedullary mass requires urgent referral to a specialized center for multidisciplinary management, with specific treatment depending on the underlying pathology, neurological status, and spinal stability.
Initial Evaluation and Diagnosis
- MRI of the complete spine is the first-line imaging modality for diagnosing premedullary masses, as it provides superior visualization of the spinal cord, neural structures, and surrounding tissues 1
- Urgent MRI should be performed within 12 hours if there is clinical suspicion of metastatic epidural spinal cord compression (MESCC) to enable prompt treatment 1
- CT scans may be helpful when MRI is contraindicated or to better visualize bone destruction, periosteal bone formation, and cortical destruction 1
- Plain X-rays in two planes should be obtained initially but cannot exclude spinal metastases 1
Treatment Approach Based on Pathology
For Metastatic Disease (Most Common)
- Treatment selection depends on three key factors: estimated survival, spinal stability, and expected treatment outcome 1
- The Spinal Instability Neoplastic Score (SINS) should be used to assess stability risk, with scores ≥13 indicating instability requiring surgical intervention 1
- For metastatic epidural spinal cord compression:
- Surgery is indicated for spinal instability, neurological deterioration during radiotherapy, or recurrence/progression after radiotherapy 1
- Radiotherapy is the first-line treatment for stable spines with symptomatic metastases 1
- Stereotactic body radiotherapy (SBRT) shows superior pain response compared to conventional radiotherapy 1
- Treatment should begin within 24 hours of diagnosis to prevent irreversible neurological damage 1, 2
For Primary Spinal Cord Tumors
Ependymomas (most common intramedullary tumor in adults):
- Gross total resection is the primary goal of surgery 1
- For WHO grade II ependymomas with complete resection, observation is recommended 1
- For incompletely resected WHO grade II ependymomas, postoperative local radiotherapy with doses of 45-54 Gy is recommended 1
- For WHO grade III (anaplastic) ependymomas, postoperative radiotherapy is recommended regardless of resection extent 1
Astrocytomas (common in children):
- Surgical resection is the primary treatment, though complete resection is often more challenging than with ependymomas 3
For Other Premedullary Masses
- Extramedullary hematopoiesis: Treatment includes blood transfusion, corticosteroids, and radiotherapy 4
- Extramedullary intradural masses (meningiomas, schwannomas): Surgical resection is typically the treatment of choice 5
Multidisciplinary Approach
- All patients with suspected premedullary masses should be discussed in a multidisciplinary tumor board including at minimum a radiation oncologist and spinal surgeon 1
- For urgent cases with progressive neurological deficits, an ad hoc consultation with the responsible physician, radiation oncologist, and spinal surgeon is required 1
- Systemic treatment should be considered as primary therapy for highly responsive tumors (e.g., multiple myeloma, lymphoma) 1
Follow-up and Monitoring
- Postoperative MRI should be performed to evaluate the extent of resection 1
- Disease staging with craniospinal MRI and CSF cytology is recommended following surgery (not earlier than 2-3 weeks) due to the risk of CSF dissemination 1
- Long-term follow-up with enhanced MRI is necessary due to the risk of asymptomatic and/or late relapses 1
Common Pitfalls to Avoid
- Delaying diagnosis and treatment, as early intervention is critical to prevent irreversible neurological damage 1, 2
- Performing biopsies before referral to a specialized center, as poorly performed biopsies can compromise treatment 1
- Failing to assess spinal stability, which is crucial for determining appropriate treatment 1
- Overlooking the possibility of metastatic disease in patients over 40 years, where metastatic carcinoma in bone is more likely 1