Other / General Medicine
Brandon M. Mazal, DO
Resident Physician
SUNY Upstate Physical Medicine and Rehabilitation
Syracuse, New York, United States
Kathryn Gibbs, DO
Attending Physician
SUNY Upstate Physical Medicine and Rehabilitation
Syracuse, New York, United States
Brandon M. Mazal, DO
SUNY Upstate Physical Medicine and Rehabilitation
Syracuse, New York, United States
Leptomeningeal carcinomatosis (LC) secondary to metastatic renal cell carcinoma (RCC) in patient with prior spinal metastasis.
Case Description:
87-year-old male with recurrent RCC metastasis to the spinal cord resulting in paraplegia, was admitted to acute rehabilitation after surgical resection of an intradural extramedullary mass at T12-L1, neurologically classified as L1 AIS C. Two weeks of radiation therapy (RT) was initiated shortly after the rehabilitation admission. Patient’s tolerance to therapy declined significantly throughout and continued post-RT. Shortly after RT completion, he developed a Bell’s Palsy, and subsequently developed additional palsies of cranial nerves three and six as well as decreased motor strength, now AIS B at best. Differential included LC vs. Paraneoplastic syndrome. LC was confirmed after further work-up. Prognosis and options for treatment were discussed, and patient opted for comfort care.
Discussions:
This illustrates an atypical progression of metastatic RCC with delayed development of LC, a rare complication. The patient initially had localized spinal symptoms, complicated by post-RT development of multiple cranial neuropathies and worsening paraparesis. Brain MRI findings were inconclusive for leptomeningeal spread, highlighting the diagnostic challenge of early leptomeningeal disease, which may not demonstrate enhancement on imaging. This underscores the importance of combining serial clinical evaluations with advanced diagnostics, including CSF analysis, particularly in oncologic patients with evolving neurologic signs. The distinction between leptomeningeal disease and potentially treatable paraneoplastic syndromes can direct timely therapeutic decisions. This also highlights the challenge of differentiating decompensation from cancer treatment vs. disease progression.
Conclusions:
LC should be suspected in cancer patients with multifocal neurologic symptoms, even in the absence of early MRI findings. Cranial neuropathies may precede radiographic changes and warrant thorough evaluation. Serial strength assessments are critical postoperatively to differentiate between disuse, surgical complications, or disease progression. Prompt workup can facilitate diagnosis and guide goals-of-care discussions. Multidisciplinary coordination of care should be initiated by physiatrists.
