PMC4706409_01
Preoperative MRI before the first operation. Sagittal T1-sequence without (A) and with contrast (B) of the thoracic and lumbar spine showing the number of the vertebrae marked, as well as the initial thecal sac compression at the level of T7 and the other bone metastasis at T12 and L4. (C) Axial T2-sequence at the level T7. A nearly complete compression of the thecal sac can be seen.
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MRI after the first radiation cycle. Sagittal T2-sequence (A) and T1-sequence without contrast (B) showing a stable disease at the operated level T7 and the suspicion of progressive disease at T12 and L4 levels.
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T7-L5, where he also had lytic lesions within the bodies and laminae of several vertebrae, with a dose prescription of 2 Gy five times a week until 40 Gy was achieved. The initial follow-up showed a stable spine disease at the operated level. (Fig. 2) The patient recovered well, except for a slightly left-sided paresis of the L2-3 dermatome muscles.
Preoperative MRI before the second operation. Sagittal T1-sequence (A) without contrast and T2-sequence (B) of the thoracic and lumbar spine showing the recurrent growth of the metastasis with the corresponding thecal sac compression at the level of T7 and the other bone metastasis at T12, L1, and L4. (C) Axial T2-sequence at the level T7. An almost identical imaging to the initial MRI, where a nearly complete compression of the thecal sac can be observed.
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Histology - second surgery. (A) Hematoxylin- and eosin-stained tissue sections demonstrated a highly cellular, epithelial tumor consisting of cells with medium-sized, round nuclei and pale, eosinophilic cytoplasm. The tumor grew in small to large nests with an occasional follicular histological pattern. Not only was the tumor strongly immunopositive for cytokeratin 18 (B), but it also exhibited positive immunostaining for calcitonin in the majority of the tumor cells (C).
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The immunohistochemical work-up of the specimen showed a strong positive reaction for calcitonin, cytokeratin 8 and 18, and thyroid transcription factor-1, so that the findings corresponded again with a metastasis of the MTC. (Fig. 4) The patient recovered well from the operation and was then referred to radiation therapy applied at the same location as 2 years before and with the same prescription dose.
MRI after the second radiation cycle. Sagittal T1-sequence (A) without contrast and T2-sequence (B) showing a stable disease at the reoperated level T7 and a stable disease at T12 and L4 levels.
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The spinal MRI at 6 months following radiation therapy again showed a stable spine disease. (Fig. 5) Calcitonin, CEA, and calcium levels also remained unaltered.