Case Report

A 57-year-old-male, former smoker, an established case of adenocarcinoma of the right lung and stage IV NSCLC with multiple brain metastases, was treated with palliative external beam radiation therapy (EBRT) to the whole brain (WBRT, to a dose of 3000 centigray (cGy) in 10 fractions over 2 weeks) at an outside facility (outside USA). Liquid biopsy was negative for epidermal growth factor receptor (EGFR) exon 19 deletion, wild type. Four months later, he presented to the emergency room to our facility in USA with bilateral lower extremity weakness, numbness, tingling, difficulty walking, speech problems, back pain with progressive bowel and bladder incontinence. No systemic therapy was administered in the interim. Serum sodium was low, 131 mol/L. An MRI of the thoracic, lumbar spine regions demonstrated a 1·5 × 0·6 cm lesion within spinal cord at T2/T3 and a 2·4 × 0·7 cm lesion at T12 involving the conus, IMSC location (Figure 1A–D). Three enhancing lesions with surrounding vasogenic oedema and carcinomatous meningitis were seen on MRI of the brain. CT scan of the chest, abdomen and pelvis revealed a 7·2 × 6 × 5·5 cm right upper lobe mass with bulky mediastinal, bilateral hilar lymph node metastases and multiple lung nodules bilaterally. A Foley catheter was placed, and a bolus dose of intravenous dexamethasone, 10 mg, was administered followed by round the clock steroids, Keppra for seizure prophylaxis. Multidisciplinary team of neurosurgeon, neurologist, medical oncologist and radiation oncologist assessed the patient, and in view of disseminated stage IV malignancy, surgery was deferred and repeat biopsy of the lung lesion done was positive for poorly differentiated adenocarcinoma. Immunohistochemistry studies done showed tumour cells to be positive for pancytokeratin, CK7, Vimentin and TTF-1 and negative for CK20, p63, synaptophysin, chromogranin and CEA. EGFR, KRAS wild type, HER2 negative and PD-L1 were 80% positive. An urgent palliative radiation therapy to both the IMSC lesions was done to T1–T4 and T11-L1 cord levels to a dose of 3000 cGy in 10 fractions using 300 cGy per fraction over 13 days duration utilising 3-dimensional conformal radiation therapy technique. Daily image guidance with cone beam CT was done prior to treatments for treatment verification accuracy and precision, image-guided radiation therapy. Syndrome of inappropriate antidiuretic hormone secretion was managed conservatively. He tolerated treatments very well and steroid taper was done after completion of RT. Patient refused systemic treatment (chemo-immunotherapy) and was on symptomatic/supportive measures. He died 3 months later while on home hospice.

Figure 1.

(A–D) MRI of thoracic spine (with contrast, axial sagittal T1 and T2 weighted images) showing an enhancing mass within the spinal canal at T2/T3 (as in 1C–D), intramedullary location, 1·5 × 0·6 cm, and the second enhancing mass seen distally at the level of T12 involving conus, intramedullary, 2·4 × 0·7 cm (as in 1A–B), central canal is dilated.