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array:23 [ "pii" => "S2529849622000570" "issn" => "25298496" "doi" => "10.1016/j.neucie.2021.03.005" "estado" => "S300" "fechaPublicacion" => "2022-11-01" "aid" => "498" "copyright" => "Sociedad Española de Neurocirugía" "copyrightAnyo" => "2021" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Neurocirugia. 2022;33:334-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S2529849622000582" "issn" => "25298496" "doi" => "10.1016/j.neucie.2021.04.009" "estado" => "S300" "fechaPublicacion" => "2022-11-01" "aid" => "499" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Neurocirugia. 2022;33:340-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Spontaneous acute bleeding within subdural effusion from dural metastasis of gastric cancer: A case report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "340" "paginaFinal" => "344" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sangrado subdural agudo en el seno de una efusión subdural causada por una metástasis de cáncer gástrico: un caso clínico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 502 "Ancho" => 1500 "Tamanyo" => 105748 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Enhanced axial CT showing right frontal subdural effusion (yellow symbol in A) and dural metastases (red arrows in A and B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alejandro Augusto Ortega Rodriguez, Carlos Miguel Cohn Reinoso, Gemma Mateu Esquerda, Jordi de Manuel-Rimbau Muñoz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Alejandro Augusto" "apellidos" => "Ortega Rodriguez" ] 1 => array:2 [ "nombre" => "Carlos Miguel" "apellidos" => "Cohn Reinoso" ] 2 => array:2 [ "nombre" => "Gemma" "apellidos" => "Mateu Esquerda" ] 3 => array:2 [ "nombre" => "Jordi" "apellidos" => "de Manuel-Rimbau Muñoz" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849622000582?idApp=UINPBA00004B" "url" => "/25298496/0000003300000006/v3_202212060641/S2529849622000582/v3_202212060641/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2529849621000411" "issn" => "25298496" "doi" => "10.1016/j.neucie.2021.07.001" "estado" => "S300" "fechaPublicacion" => "2022-11-01" "aid" => "521" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Neurocirugia. 2022;33:328-33" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "A new, readily accessed and low-cost, device for treating depressed ping pong fractures non-surgically: Technical note" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "328" "paginaFinal" => "333" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Un nuevo dispositivo, de fácil acceso y bajo costo para el tratamiento no quirúrgico de fracturas deprimidas en «ping pong»: Nota técnica" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1036 "Ancho" => 1250 "Tamanyo" => 88378 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The MARS consists of: a) a paediatric anaesthesia mask; b) macro-drip set; c) a portion of that set to be used in the system; d) a three-way stopcock; and e) two 60-ml syringes.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Federico E. Minghinelli, Rodolfo Recalde, Mariano Socolovsky, Alfredo Houssay" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Federico E." "apellidos" => "Minghinelli" ] 1 => array:2 [ "nombre" => "Rodolfo" "apellidos" => "Recalde" ] 2 => array:2 [ "nombre" => "Mariano" "apellidos" => "Socolovsky" ] 3 => array:2 [ "nombre" => "Alfredo" "apellidos" => "Houssay" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1130147321000944" "doi" => "10.1016/j.neucir.2021.07.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147321000944?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849621000411?idApp=UINPBA00004B" "url" => "/25298496/0000003300000006/v3_202212060641/S2529849621000411/v3_202212060641/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Intramedullary pancreatic adenocarcinoma metastasis: The first case in literature" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "334" "paginaFinal" => "339" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Alican Tahta, Ahmet Cetinkal, Elif Calis, Cem Dinc" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Alican" "apellidos" => "Tahta" "email" => array:1 [ 0 => "atahta@medipol.edu.tr" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ahmet" "apellidos" => "Cetinkal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Elif" "apellidos" => "Calis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Cem" "apellidos" => "Dinc" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Istanbul Medipol University, Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Istanbul Medipol University, Faculty of Medicine, Department of Pathology, Istanbul, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metástasis de adenocarcinoma de páncreas intramedular: primer caso en la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 754 "Ancho" => 1500 "Tamanyo" => 78027 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Intramedullary area filled with a well-defined, sharp-contoured mass which has craniocaudal diameter of 33<span class="elsevierStyleHsp" style=""></span>mm with hypointensity in center and peripheric contrast enhancement on T1-weighted with contrast images at T4–T5 level. Radiological preliminary diagnosis of the mass was ependymoma or metastasis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pancreatic cancer is a progressive and fatal disease. There is an increase in incidence of pancreatic cancer along with the increase of the average life expectancy. Although the prognosis is poor, survival of patients is prolonged with surgical and adjuvant (chemotherapy, radiotherapy) treatments. In the follow-up of these patients, there is need for screening of metastases to prevent poor quality of life and apply early treatment.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The frequent sites of spinal metastases are vertebrae and epidural space. Intramedullary involvement is very rare. In large autopsy series of cancer patients, the incidence of intramedullary spinal cord metastasis (ISCM) was found between 0.9% and 3.5%.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2–4</span></a> Recently, studies indicate that the first choice of treatment modality should be early resection for suitable patients.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">5–7</span></a> In addition, steroids and radiotherapy are advised for patients with poor general condition and advanced neurological deficits. Although ISCM originating from various other primary tumors has also been reported, to the best of our knowledge, no reports have discussed ISCM originating from pancreatic adenocarcinoma. Here, we describe the first case of ISCM of pancreatic adenocarcinoma.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case presentation</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 36-year-old woman presented with back pain, difficulty in urinating, and weakness in the lower extremities. She had a history of Whipple operation 1 year ago. She was histopathologically diagnosed as pancreatic adenocarcinoma after this operation. She had a history of folfirinox, Irinitekan, Oxaliplatin, 5-fluorouracil, folinic acid treatment. Albumin-bound paclitaxel and Gemcitabine therapy were applied as the patient had progression in the follow-up. Primary tumor was stable after these chemotherapy regimens. After the patient had started to complain about pain and numbness in the lower extremities for 2 weeks, an intramedullary mass was detected at T4–T5 level on MR images (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). She was paraparetic (2/5) and bilateraly hypoesthetic.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was discussed in the neurooncology tumor board. Surgical intervention was planned for intramedullary tumor. Although the primary disease was expected to have a faster course and worse prognosis, her stable condition after Whipple operation with adjuvant chemotherapy, the absence of any distant metastasis in PET-CT at the time of diagnosis of intramedullary tumor, and the progressive neurological deterioration were factors for decision period. In addition, the patient preferred surgical treatment because she did not have a sign/symptom related to primary disease and she was unable to walk in a short time due to progressive neurological deficit.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient underwent T4–T5 total laminectomy, and the dural sac was exposed. The dural sac, which was expanded and stretched, was hung on the sides by making a liner incision in the midline. The spinal cord was swollen and non-pulsatile. Tumor tissue was reached by deepening through the medullary incision from the midline. The lesion's color was dirty pink. It was soft and had increased vascularity. A sample was taken for frozen examination (the result was adenocarcinoma metastasis). En bloc removal was done. Spillage of tumor fragments into subarachonid space was prevented by placing cottonoids below and above of the surgical area. Somatosensory and motor evoked potentials were monitored during surgery, and there was no change during surgery. The pathological result of the mass was reported as adenocarcinoma metastasis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Postoperative motor score of the patient was examined as left lower limb global muscle strength 1/5, right lower limb proximal 2/5, distal 1/5. No mass was observed on postoperative T1-weighted images with contrast (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Physical therapy and rehabilitation program was started after surgery and she recovered mostly in 3 months with the help of rehabilitation (She was −4/5 paraparetic, and was able to walk with support in last follow-up). She survived for 6 months after surgery despite postoperative craniocervical palliative radiotherapy for leptomeningeal metastases. The patient died because of distant disease.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Intramedullary primary spinal cord tumors mostly consist of gliomas and constitute 60–80% of ependymomas.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">8,9</span></a> Metastases constitute 1–3% of these tumors. The prevalence of ISCM in cancer patients range from 0.9% to 2.1% in autopsy series.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2,3</span></a> Lung cancer is the most common source of ISCM, and constitutes 50% of ISCMs. Breast carcinoma is the second with 16% incidence. Prostate, melanoma, and renal cell carcinoma are among the less frequently reported sources.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2,10,11</span></a> The incidence of ISCM increases with improved survival in most cancer types due to advanced treatments and neuroimaging techniques.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a> The number of published cases has increased in recent years. According to a review conducted by Payer et al. in 2015, almost 60% of all ISCM treated in last 3 years of a 22-year period,<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a> and the trend is still increasing.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Pancreatic cancer is found in approximately 27,000 people each year in United States, and about 338,000 people in the world (2% of all cancer diagnosis).<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">14–16</span></a> Patients with pancreatic cancer have one of the worst prognosis among patients with other types of cancer. The overall median survival from diagnosis is 4.6 months, and median survival is 2.8–5.7 months despite all chemotherapy regimens.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">17,18</span></a> Park et al. found that the incidence of central nervous system metastasis in patients with pancreatic cancer was 0.57%, and 3 of 1229 patients had spinal metastases.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a> None of them was intramedullary. However, Kim et al. reported a case of ISCM from a pancreatic neuroendocrine tumor which was a different pathology from our patient's.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">19</span></a> To our best knowledge, this is the first published case report of ISCM originated from pancreatic adenocarcinoma.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Hematogeneous spread, leptomeningeal seeding via cerebrospinal fluid, parenchymal penetration through the veins penetrating the Virchow-Robin cavities, direct extension from dura mater or nerve roots, and spread through Batson's plexus are possible routes of tumor extension.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">20–23</span></a> Hematogeneous spread is suggested mechanism of ISCM occurrence.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a> Park et al. found three out of four patients with cerebral metastasis also had lung metastasis in their study including 1,229 patients with pancreatic cancer. However, only one of three patients with spinal metastasis had lung involvement. Also, spinal metastasis and pancreatic cancer were simultaneously diagnosed in these three patients. So, they stated that cerebral metastasis may occur hematogenously, and spinal metastasis may be mediated by local spread through Batson's plexus.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a> We think that, most favorable route for pancreatic cancer dissemination is local spread through venous plexus due to the proximity of primary tumor.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The prognosis of intramedullary metastasis has been repeatedly reported as extremely poor. Several studies found a median survival of less than 12 months.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10,24</span></a> There is no full consensus on ISCM treatment and the treatment schemes to be followed are still being discussed. Previous studies are retrospective case series and do not give clear results. Since ISCM is rare, the amount of data to clarify treatment modalities is also insufficient. Therefore, the treatment scheme is arranged individually according to each case. Resection for ISCM is an option in patients who have rapid neurological deterioration, good preoperative The Karnofsky Performance Score (KPS) score, radioresistant tumor or ISCM with unknown primary malignancy that requires histopathological diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">13,25–28</span></a> Kalayci et al. analyzed 32 patients, that have been published in different studies.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a> They showed that there were no new postoperative neurological deficits. They also found improvement in clinical conditions of patients and increase in survival (from 5 months to 9.4 months). Gasser et al.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a> and Wilson et al.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a> reported that surgical treatment should be considered as a priority in choice. Our patient survived for 6 months after surgery because of aggressive nature of pancreatic adenocarcinoma. However, surgery was our choice of treatment due to rapid neurological deterioration and good general condition of patient, and stable primary tumor.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Strickland et al. noted transient deterioration in neurological function postoperatively in 6 of 13 patients. However, 4 of them improved in 2 months.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a> Our patient also had a decline in neurological function postoperatively. Fortunately, she recovered in 3 months with the help of rehabilitation.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with no neurological deficits, multiple metastases or low KPS scores are not good candidates for surgery.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10,30,31</span></a> If patients with ISCM are followed without treatment, rapid neurological deterioration is observed due to local compression, cord edema, and infarction.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">24,32,33</span></a> Although steroid and radiotherapy are the primary non-surgical treatments, they are more effective when the neurological examination is intact and the tumor shows radiosensitivity.<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">32,34,35</span></a> Radiotherapy is preferable because it is not invasive, slows tumor progression and provides neurological improvement, nonetheless its effect is limited in radioresistant tumors like in our patient.<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">36,37</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In a study of 5 cases, Shin et al. reported clinical improvement in 4 patients after single fraction radiosurgery. Median survival time has been reported as 5.2 months (2.2–19.4 months).<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">38</span></a> In a study of 18 cases treated with fractionated radiotherapy, Hashii et al. reported clinical improvement in 10 of the patients. Median survival was 4 months.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">39</span></a> Two studies; involving 11 cases<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a> and 6 cases<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a> reported that following a short recovery period, a rapid neurological deterioration observed within days after radiotherapy and steroid treatment.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Radiotherapy, surgery or combined approaches will probably never be compared in a randomized trial due to the insufficient number of cases and data. So, it is necessary to evaluate each patient individually and propose the best treatment modality. Also, multidisciplinary approach (neurosurgery, radiation oncology, and medical oncology) should be taken into consideration to achieve better prognosis, and quality of life for patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">To date, there have been no reports of ISCM from pancreatic adenocarcinoma, so no studies have discussed the optimal treatment for such cases. Moreover, a majority of pancreatic cancer patients do not respond to radiotherapy.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a> Surgical treatment should be regarded as a significant therapeutic option, such as in our case. Although ISCM is a rare situation, it is important to include it among the possibilities in differential diagnosis of patients suffering rapid and severe neurological deficits.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0075" class="elsevierStylePara elsevierViewall">To date, there are no previous reports of ISCM from pancreatic adenocarcinoma. We report the first case of ISCM originated from pancreatic adenocarcinoma that was removed successfully by microsurgical procedure. Since it is known to be radioresistant, the first treatment option for pancreatic adenocarcinomas should be surgery. In patients with pancreatic adenocarcinoma and progressively developing neurological deficits, ISCM should also be kept in mind in the differential diagnosis. Survival and quality of life can be increased by early diagnosis and treatment in these patients.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0080" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1814917" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Case description" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1584559" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1814916" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Descripción del caso" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1584560" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case presentation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-01-06" "fechaAceptado" => "2021-03-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1584559" "palabras" => array:4 [ 0 => "Pancreatic adenocarcinoma" 1 => "Intramedullary" 2 => "Metastasis" 3 => "Surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1584560" "palabras" => array:4 [ 0 => "Adenocarcinoma de páncreas" 1 => "Intramedular" 2 => "Metástasis" 3 => "Cirugía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pancreatic cancer is a common gastrointestinal malignancy, and is often associated with a poor prognosis. Although liver is generally seen as a distant metastasis point, it has been shown that it can metastasize to any organ, especially the gastrointestinal tract, and approximately 0.3% of metastases are observed in spinal cord.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case description</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report a 36-year-old woman with a prior history of pancreatic adenocarcinoma who presented to us with a thoracic intramedullary lesion and recent onset of neurological deficits. She underwent surgery with histological confirmation of a diagnosis of metastatic adenocarcinoma.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">To our knowledge there is no prior report of pure intramedullary spinal cord metastasis from a pancreatic adenocarcinoma in the literature. We report the present patient in view of the rarity of intramedullary spinal cord metastasis and its clinical significance. Although intramedullary metastases are rare, they should be investigated in every patient with malignancy and progressive neurological deficit. While its general prognosis is poor regardless of the type of treatment, early diagnosis and treatment is important in terms of quality of life and survival.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Case description" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Antecedentes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El cáncer de páncreas es una neoplasia maligna gastrointestinal común y, a menudo, se asocia con un mal pronóstico. Aunque el hígado generalmente se ve como un punto de metástasis distante, se ha demostrado que puede hacer metástasis a cualquier órgano, especialmente al tracto gastrointestinal, y aproximadamente el 0,3% de las metástasis se observan en la médula espinal.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Descripción del caso</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos una mujer de 36 años con antecedentes de adenocarcinoma de páncreas que se presentó con una lesión intramedular torácica y de reciente aparición de déficits neurológicos. Fue intervenida quirúrgicamente con confirmación histológica de diagnóstico de adenocarcinoma metastásico.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusión</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hasta donde sabemos, no existe en la literatura ningún informe previo de metástasis intramedular pura de la médula espinal de un adenocarcinoma pancreático. Presentamos el presente paciente en vista de la rareza de la metástasis intramedular de la médula espinal y su importancia clínica. Aunque las metástasis intramedulares son raras, deben investigarse en todo paciente con neoplasia maligna y déficit neurológico progresivo. Si bien su pronóstico general es malo independientemente del tipo de tratamiento, el diagnóstico y el tratamiento precoces son importantes en términos de calidad de vida y supervivencia.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Descripción del caso" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 754 "Ancho" => 1500 "Tamanyo" => 78027 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Intramedullary area filled with a well-defined, sharp-contoured mass which has craniocaudal diameter of 33<span class="elsevierStyleHsp" style=""></span>mm with hypointensity in center and peripheric contrast enhancement on T1-weighted with contrast images at T4–T5 level. Radiological preliminary diagnosis of the mass was ependymoma or metastasis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1127 "Ancho" => 1500 "Tamanyo" => 374739 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(A) Hematoxylin–eosin staining of a section from the intramedullary mass (H&E, 40×); (B) High magnification (H&E, 100×) view of the tumor with large pleomorphic epithelial cells and extensive necrosis; (C) tumor cells shows focal nuclear positivity with CDX2 stain (IHC, 100×); (D) Tumor cells positive for cytokeratin (IHC, 100×).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 649 "Ancho" => 1500 "Tamanyo" => 72189 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">No mass is observed on postoperative T1-weighted with contrast examinations.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0215" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nervous system involvement by pancreatic cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K.-S. 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