141: Cancer Pain Red Flag: Paraparesis from Spinal Cord Metastasis of GI Cancer�Case Report

Topic: Basic Science
Subtopic: Pain category (ICD-11), Chronic cancer related pain, , , , , , , Assessment and Measurement of Pain/Nociception, ,

Background and Aims: Cancer-related pain may precede neurological deficits in malignant spinal cord compression (MSCC) and should be recognized as a critical diagnostic red flag. In young patients, intrathoracic masses often raise suspicion for primary mediastinal tumors, potentially leading to diagnostic bias and delayed identification of metastatic disease

Methods: A 29-year-old woman presented with a one-year history of progressive, treatment-refractory low back pain, followed by a three-month progression to lower limb weakness and ascending paresthesia. Neurological examination revealed upper motor neuron paraparesis, a thoracic sensory level, and autonomic dysfunction consistent with MSCC. Imaging demonstrated a large heterogeneous intrathoracic mass extending into the spinal canal at T10–T11. Initial differential diagnoses included germ cell tumor (suspected immature teratoma), neurogenic tumor, and infectious etiologies. Most tumor markers were within normal limits, with only mildly elevated CA-125, and the diagnosis remained inconclusive despite multidisciplinary evaluation.

Results: Histopathological examination following surgical intervention revealed signet-ring cell carcinoma with secondary infection, indicating advanced metastatic malignancy of gastrointestinal origin. Spinal involvement represented the initial manifestation of an occult primary cancer.

Conclusions: Progressive, treatment-refractory cancer pain must be considered a critical red flag for MSCC, even in the absence of known malignancy. This case highlights the risk of diagnostic anchoring when encountering intrathoracic masses in young patients and demonstrates that gastrointestinal cancers, including signet-ring cell carcinoma, may rarely present as paraparesis due to spinal metastasis, mimicking primary mediastinal tumors. Histopathology remains the diagnostic gold standard. Early recognition of cancer pain as an early neurological warning signal is essential to expedite diagnosis and prevent irreversible neurological deficits.

References: 1. Vavourakis M, Sakellariou E, Galanis A, Karampinas P, Zachariou D, Tsalimas G, et al. Comprehensive Insights into Metastasis-Associated Spinal Cord Compression: Pathophysiology, Diagnosis, Treatment, and Prognosis: A State-of-the-Art Systematic Review. Journal of Clinical Medicine. Multidisciplinary Digital Publishing Institute (MDPI); 2024. doi:10.3390/jcm13123590
2. Mulvey MR, Paley CA, Schuberth A, King N, Page A, Neoh K. Neuropathic Pain in Cancer: What Are the Current Guidelines? Curr Treat Options Oncol. 2024 Sep 1;25(9):1193–202. doi:10.1007/s11864-024-01248-7 PubMed PMID: 39102168.
3. Rispoli R, Giorgiutti F, Veltri C, Copetti E, Imbruce’ P, Iacopino G, et al. The Efficacy of a Multidisciplinary Approach and Diagnostic–Therapeutic Algorithm for Vertebral Metastases with Spinal Cord Compression. Medicina (Lithuania). 2024 Jul 1;60(7). doi:10.3390/medicina60071020 PubMed PMID: 39064449.
4. Ozgun G, Nappi L. Primary Mediastinal Germ Cell Tumors: A Thorough Literature Review. Biomedicines. MDPI; 2023. doi:10.3390/biomedicines11020487
5. Fichtner A, Marx A, Ströbel P, Bremmer F. Primary germ cell tumours of the mediastinum: A review with emphasis on diagnostic challenges. Histopathology. John Wiley and Sons Inc; 2024. p. 216–37. doi:10.1111/his.15090 PubMed PMID: 37994540.
6. Mura R, Pochepnia S, Kifjak D, Khenkina N, Prosch H. A diagnostic approach to mediastinal masses in clinical practice. BJR Open. Oxford University Press; 2025. doi:10.1093/bjro/tzaf009
7. American Medical Association. Clinical Guidelines Chest Imaging Guidelines [Internet]. 2025 Jan. Available from: www.EviCore.com
8. Montecino RMB, Sukhorosl M, Francis MA, Kancherla N, Akuma O, Nwangene NL, et al. A Rare Case of Primary Gastric Signet Ring Cell Carcinoma: a Review of Guidelines for the Management of Gastric Cancer. Indian J Surg Oncol. 2024 Mar 1;15(1):153–9. doi:10.1007/s13193-023-01852-3
9. Zhao W, Jia Y, Sun G, Yang H, Liu L, Qu X, et al. Single-cell analysis of gastric signet ring cell carcinoma reveals cytological and immune microenvironment features. Nat Commun. 2023 Dec 1;14(1). doi:10.1038/s41467-023-38426-4 PubMed PMID: 37225691.
10. Machlowska J, Pucułek M, Sitarz M, Terlecki P, Maciejewski R, Sitarz R. State of the art for gastric signet ring cell carcinoma: From classification, prognosis, and genomic characteristics to specified treatments. Cancer Management and Research. Dove Medical Press Ltd; 2019. p. 2151–61. doi:10.2147/CMAR.S188622
11. Notarangelo G, Margelli M, Giovannico G, Bruno F, Milella C, Feller D, et al. Diagnostic Utility of Red flags for Detecting Spinal Malignancies in Patients with Low Back Pain: A Scoping Review. Journal of Clinical Medicine. Multidisciplinary Digital Publishing Institute (MDPI); 2025. doi:10.3390/jcm14207174
12. Occhetto B, Ballesio M, Mourad F, Trucco M, Maselli F, Chiarotto A, et al. Red flags to screen for tumours in patients with neck pain: A scoping review. Physiotherapy. 2026 Jun;131:101869. doi:10.1016/j.physio.2025.101869 PubMed PMID: 41529318.
13. Fallon MT, Colvin L. Neuropathic pain in cancer. Br J Anaesth. 2013 Jul 1;111(1):105–11. doi:10.1093/bja/aet208 PubMed PMID: 25841479.
14. Fichtner A, Nettersheim D, Bremmer F. Pathogenesis and pathobiology of testicular germ cell tumours: a view from a developmental biological perspective with guidelines for pathological diagnostics. Histopathology. John Wiley and Sons Inc; 2024. p. 701–15. doi:10.1111/his.15249 PubMed PMID: 38922953.
15. Vega Moreno DA, Reyes Soto G, Lopez-Valdes JC, Arellano-Mata A, Galicia Palacios H, Amador Hernandez MA, et al. Comprehensive guide to the diagnosis, management, and treatment of metastatic spinal cord compression syndrome. Surgical Oncology. Elsevier Ltd; 2026. doi:10.1016/j.suronc.2025.102341
16. Lara AP, Arana E, Bello Báez A, De D, Martins-Romeo A. Radiological diagnosis of malignant spinal cord compression syndrome: Consensus document from SENR, SERAU, SERME, SERAM 2025. Available from: www.elsevier.es/rx
17. Aida, Soeroso NN, Riandini HM. Diagnostic challenges in differentiating mediastinal tuberculosis from mediastinal tumors: A case report. Respir Med Case Rep. 2025 Jan 1;53. doi:10.1016/j.rmcr.2024.102152
18. Şelaru Ş, Eva L, Sava A, Dumitrescu GF, Dabija MG, Poroch V, et al. Evaluation of epidemiological and pathological features of symptomatic spinal metastases in Romania – what could we learn from a retrospective study? Romanian Journal of Morphology and Embryology. 2024 Jul 1;65(3):481–92. doi:10.47162/RJME.65.3.10 PubMed PMID: 39529341.
19. Wei X, Dai W, Deng P. Bone marrow metastasis from gastric cancer: A case report. Oncol Lett. 2026 May 1;31(5). doi:10.3892/ol.2026.15528

Presenting Author: Shella Trisiana
Submitting Author: Shella Trisiana

Senior Author: Endang Mutiawati

IASP 2026 Global Year theme of Neuropathic Pain: Yes