J Cerebrovasc Endovasc Neurosurg.  2024 Sep;26(3):331-337. 10.7461/jcen.2024.E2023.04.005.

Preoperative embolization and en bloc resection of a metastatic pheochromocytoma of the cervical spine

• Singh A
• Santangelo G
• Ellens N
• Kohli G
• Pranaat R
• Bender MT

• KMID: 2559445
• DOI: http://doi.org/10.7461/jcen.2024.E2023.04.005

Abstract

This is a unique case of metastatic pheochromocytoma of the cervical spine treated with preoperative embolization and subsequent en bloc resection. A 65-year-old man with metastatic pheochromocytoma presented with two weeks of worsening neck pain, left arm and leg weakness and paresthesia, and urinary incontinence. Magnetic resonance imaging showed a metastatic osseous lesion at C6 with severe stenosis and spinal cord compression. The patient underwent successful preoperative angiographic embolization with a liquid embolic agent followed by C5-C7 laminectomy, en bloc tumor resection, and C3-T2 posterior spinal fusion. Six weeks postoperatively, the patient reported improving strength and resolving neck pain and paresthesias. While there is no standard paradigm for the treatment of metastatic pheochromocytomas of the cervical spine, preoperative embolization may minimize intraoperative blood loss and hemodynamic instability during subsequent surgical resection.

Keyword

Pheochromocytoma; Therapeutic embolization; Cervical spine; En bloc; Preoperative embolization

Figure

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  Fig. 1. (A) Sagittal MRI of extradural metastatic cervical pheochromocytoma at the C6 level with epidural extension (B) Axial MRI at the C6 level demonstrating severe cord compression. (C) Sagittal contrasted MRI demonstrating a diffusely enhancing lesion extending from the posterior elements into the epidural space.

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  Fig. 2. (A) Pre-embolization digital subtraction angiography of the deep cervical branch of the left costocervical trunk, demonstrating multiple pedicles contributing to a robust tumor blush. A Headway Duo microcatheter was navigated over an 0.014 inch microwire into a pedicle arising from the deep cervical artery and directly supporting the tumor (arrow). Onyx 18 was used to embolize the tumor from this position. (B) Digital subtraction angiography demonstrating infiltration of Onyx cast throughout the previously visualized tumor blood supply. (C) Digital subtraction angiography of the left subclavian artery demonstrating substantial reduction in tumor blush following Onyx embolization.

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  Fig. 3. (A) The lamina of C4-6 has been detached from the right side and the extradural lesion (white arrow) can be visualized beneath the lamina. The grey color of the lesion due to pre-operative onyx embolization and the demarcated capsule of the lesion from the dura can be appreciated. (B) En bloc resection of the C4-6 lamina with the lesion attached to the undersurface.

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  Fig. 4. (A) Sagittal MRI post-operatively with complete resection of the lesion and decompression of the cord. (B) Axial MRI at the C6 level showing laminectomies and complete resection.

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