Unusual cause of neuropathy: extensive dural spread of primary cervical osteosarcoma
The patient was a 62-year-old woman brought in to the hospital by her daughter who said that the patient had complained of several swellings in her neck region over a period of 4 months.\nAll the swellings had progressively increased in size and the patient indicated that she had pain upon flexion, extension, and rotation of the neck. The pain was associated with hoarseness and a lowering in pitch of the voice. She had significant weight loss (approximately 30% reduction) over the past 4 months. The patient also complained of some weakness of the right upper limb and numbness of the right hand.\nUpon examination, the patient was cachexic with significant muscle wasting especially in the supraclavicular fossae. Examination of the neck revealed three swellings as follows: swelling 1: Posterior neck: swelling measured 7 × 8 cm, round, well-defined margins, firm, rubbery, not attached to the superficial fascia but fixed to the muscle, not mobile, and mildly tender to palpation; swelling 2: Right level V(B) lymph node measuring 3 × 2 cm, well-defined borders, firm, rubbery, not mobile, not fixed to the superficial fascia, and mildly tender to palpation; and swelling 3: Left level III lymph node measuring 2 × 2 cm, well-defined borders, firm, rubbery, not attached to the superficial fascia, not mobile, and mildly tender to palpation.\nThe following investigations were carried out:\nAn excision biopsy of the right neck level V (B) lymph node showed a high grade sarcoma, consistent with osteosarcoma. The histopathological examination showed cells having osteoid deposition (osteoblastic variant of osteosarcoma) (Fig. ) and staining positively with vimentin and smooth muscle actin but not with S100 protein; Magnetic resonance imaging (MRI) of the neck showed a 5 × 4 cm posterior neck tumor, centered around the spinous processes of C2–C4, with bony destruction. The tumor also enveloped the posterior elements and wrapped around them. Anteriorly, the tumor extended up to the spinal canal, compressing the spinal cord but without any abnormal cord signal. There was enhancement of the posterior dura and body of C2 and C3 suggesting dural and bony involvement. There were also multiple enhancing neck nodes; Computed tomography (CT) of the chest and abdomen showed pleural and lung nodules most likely metastasis, in view of the history; Contrast-enhanced CT (CECT) of the neck, thorax, and abdomen after the patient had received three cycles of chemotherapy with IV Doxorubin 20 mg/m2 and IV Cisplatin 25 mg/m2 showed tumor progression with worsening of lung metastases and cervical lymph node involvement; extensive intradural involvement from C2 to C4 (Figs. and ) was seen as well.\nDue to these findings a decision was made to stop chemotherapy and start radiotherapy. The patient underwent one session of radiotherapy and was to continue with this treatment when she suddenly became paraplegic. The patient refused any further treatment.