Surgical Neurology 66 (2006) 324 – 327 www.surgicalneurology-online.com
Breast carcinoma metastasis and meningioma. A case report Hakan Seckin, MDa, Kazim Yigitkanli, MDa,4, Ozgur Ilhan, MDb, Unsal Han, MDb, Murad Bavbek, MDa a
Neurosurgery Department, and bPathology Department, Ministry of Health, Diskapi Educational and Research Hospital, Ankara, Turkey Received 29 November 2005; accepted 30 November 2005
Background: The simultaneous occurrence of meningioma and breast cancer with or without brain metastasis is an unusual but well-known event. However, contiguous occurrence of meningioma and brain cancer metastasis is a less rare evidence and we are aware of only one previously published case in the literature. Case Description: A 72-year-old woman presented with headache, nausea and vomiting, and diminished mentation and memory. Seven years ago, she had had simple mastectomy at another hospital. Histopathologic examination had been reported as breast carcinoma. The patient had not gone to the controls and was unaware of the diagnosis. Cranial MRI examination of the patient showed two extraaxial masses. Histopathologic examination of the lesion at the frontal convexity, which was reported as en plaque meningioma radiologically, revealed meningioma but the other tumor at the sylvian fossa resembling the other meningioma was reported as breast carcinoma metastasis at histopathologic examination. Conclusions: Although meningiomas have well-known radiological features, the other pathologies like breast metastasis may simulate them. A possible hormonal relationship between breast cancer and meningioma has not been clarified. We are not sure that this has played a role in dissociation of both tumor cells in our case. D 2006 Elsevier Inc. All rights reserved.
Breast cancer; Meningioma; Metastasis; Estrogen; Progesteron
2. Case report
The simultaneous occurrence of meningioma and breast cancer with or without brain metastasis is an unusual but well-known event [8,9]. Breast cancers have also rarely been reported to metastasize into meningiomas (tumor-totumor phenomenon) [1,3,4,14,15]. However, contiguous occurrence of meningioma and breast cancer metastasis is a less rare evidence and we are aware of only one previously published case in the literature . In this article, the authors report a rare case of breast cancer metastasis closely neighboring an intracranial meningioma.
2.1. Clinical course
Abbreviations: CT, computed tomography; MRI, magnetic resonance image. 4 Corresponding author. SB, DVYkapV YVldVrVm BeyazVt Eg˘itim ve AraYtVrma Hastanesi, Ankara, Turkey. Fax: +90 312 517 31 44. E-mail address: [email protected]
(K. Yigitkanli). 0090-3019/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2005.11.056
A 71-year-old woman presented with headache, nausea and vomiting, and diminished mentation. Seven years ago, she had had simple mastectomy for a breast carcinoma at another institute. Pathological diagnosis was an infiltrative ductal breast carcinoma. The patient refused further radiotherapy and chemotherapy. A right mastectomy incision scar was observed on her physical examination. On neurological examination, she had disorientation for time and place. Neuro-ophthalmological examination revealed bilateral papilledema. Other neurological and physical findings were normal. Cranial CT without contrast enhancement reported bifrontal and right sylvian mass lesions compressing the frontal lobes causing massive edema. Contrast-enhanced cranial CT showed homogenous enhancement of the tumors. The sylvian part was more markedly enhanced (Fig. 1A).
H. Seckin et al. / Surgical Neurology 66 (2006) 324 – 327
Cranial MRI of the patient showed two different extraaxial mass patterns (Fig. 1B). The first lesion was located at the bifrontal convexities and the primary diagnosis was an en plaque meningioma. The tumor at the left sylvian fissure was also thought to be a meningioma primarily, but metastatic carcinoma was also included in the differential diagnosis. The two tumors seemed to be connected with a dural extension. There were no other enhancing leptomeningeal or parenchymal lesions. Cerebral angiography did not show any vascularization unlike expected in meningiomas. There was posterior displacement of the distal branches of the anterior cerebral artery (Fig. 2A-B). The patient underwent bifrontal and right peritoneal craniotomy. The tumor at the sylvian fissure was hemorrhagic and soft, whereas those in the bifrontal localization were
Fig. 2. Right lateral (A) and left lateral internal carotid artery injections (B). Note slight posterior displacement of the distal branches of both anterior cerebral arteries.
grayish and firm. During surgery, both tumors were found to be connected to each other along their dural extensions and with a thick arachnoidal band (Fig. 3). Anterior part of the superior sagittal sinus was invaded and occluded by the tumor invasion, which was ligated and removed. Perioperative diagnosis was meningioma and gross total removal of both tumors was done. Postoperative course was uneventful. 3. Histological examination
Fig. 1. A: Contrast-enhanced CT image demonstrating bilateral frontal mass and left sylvian mass with surrounding edema. B: Contrast-enhanced T1 magnetic resonance axial image reported as en plaque frontal meningioma and left sylvian meningioma connected with dural tail.
Pathology report included two different histopathologic diagnoses. The tumor at the sylvian fissure was reported as breast carcinoma metastasis and the bifrontal tumor as meningothelial meningioma. The breast carcinoma metastasis was composed of tubular, cribriform, and papillary structures, made up of epithelial cells in a sclerotic and fibrotic stroma (Fig. 4). This tumor was strongly stained with pancytokeratin (Nova, LP34), GCDFP-15 (Neo, 23A3), estrogen (Nova 6F11) and progesterone (Nova 1A6) receptors, E-cadherin (Dako, NCH38), and c-erb B2 (Dako).
H. Seckin et al. / Surgical Neurology 66 (2006) 324 – 327
Fig. 3. Intraoperative photograph of the left sylvian necrotic mass connected to the bifrontal tumor with arachnoid thickening.
Fig. 5. The histological appearance of meningioma shows meningothelial cells with interlacing bundles of cells and whorl formation (H&E, 200).
The meningioma was composed of meningothelial cells with oval-round, focally clear nucleus. The cells were forming whorls and sheets containing many psammoma bodies (Fig. 5). The same immunohistochemical panel was applied to the meningioma and only epithelial membrane antigen positivity was observed. Whole block of meningioma was sectioned for searching breast cancer metastasis but the result was negative. E-cadherin (Doko, NCH-38) expression was also negative in meningioma cells.
include the frequent occurrence of both tumors in women in the fifth to seventh decades of life, the acceleration of clinical course during pregnancy, and the frequent positivity of estrogen and progesterone receptors [8,9]. The overexpression of the c-myc oncogene in both tumors has also been suggested to induce the development of both tumors . In women with a history of breast cancer and presenting with an intracranial mass, the differential diagnosis of the brain tumor gains diagnostic and prognostic importance because the latter has a chance to be a potentially curable meningioma [6,11,12]. Almost all primary carcinomas have been reported to metastasize to the brain of patients with meningioma [2-5, 8-10,13]. Three different intracranial localizations of the metastatic lesion have been found in patients with meningioma. The brain metastasis may harbor within the meningioma, in the surrounding brain parenchyma or elsewhere in the brain. However, the mechanisms causing these different localizations of metastatic tumors are yet to be identified. Regarding the tumor-in-tumor phenomenon, the rich vascular network of meningiomas was thought to act as a tumor filter . In the present case, the vascularization of meningioma was very poor. Unlike the usual angiographic tumor blush that is seen in meningiomas, there was only posterior dislocation of the distal branches of the bilateral anterior cerebral artery complex. This might be the main reason that the breast cancer cells have not infiltrated the meningioma in the present case. E-cadherin expression was also proposed to promote the adhesion of metastatic cells if it is also expressed by the recipient cells . In our case, E-cadherin expression was positive in breast cancer cells but negative in meningioma cells. Although not proven, it may be speculated that the negativity of E-cadherin expression in the recipient tumor— in our case a meningioma—played a role in preventing meningioma harboring the metastatic breast cancer cells.
4. Discussion The possible association of breast cancer and meningioma in women has been explained by many factors . These
Fig. 4. The histological appearance of metastatic tumor shows nest and ductal differentiation of pleomorphic cells (H&E, 200).
H. Seckin et al. / Surgical Neurology 66 (2006) 324 – 327
In the previous reports describing the cases of tumor-totumor metastasis, we could not find information about the status of estrogen and progesterone receptors. The effect of progesterone and estrogen receptors, if there is any, on the cerebral behavior of breast cancer metastasis has not been mentioned before. It might as well be one of the hormonal reasons playing a role on the route the metastatic cells follow once they enter the bloodstream. In our case, breast cancer cells were strongly positive for estrogen and progesterone receptors, whereas meningioma cells were negative for both.
  
5. Conclusions The preoperative diagnosis of intracranial masses in a woman previously diagnosed as having a breast cancer is important. In these cases, the diagnostic studies must be directed to evaluate the possibility of the brain tumor being a primary benign or malignant cerebral tumor. It is also impor tant to differentiate the types of tumors that are radiologically contiguous and may be interpreted as a single type. The knowledge about the reasons causing different behaviors of the metastatic cells and determining their ultimate localization may help in accurate preoperative diagnosis. References  Baratelli GM, Ciccaglioni B, Dainese E, Arnaboldi L. Metastasis of breast carcinoma to intracranial meningioma. J Neurosurg Sci 2004;48:71 - 3.  Blankenstein MA, Verheijen FM, Jacobs JM, Donker TH, Duijnhoven MWF, Thijssen JHH. Occurrence, regulation, and significance of progesterone receptors in human meningioma. Steroids 2000;65: 795 - 800.  Bucciero A, Del Basso De Caro M, Vizioli L, Carraturo S, Cerillo A, Tedeschi G. Metastasis of breast carcinoma to intracranial meningioma. J Neurosurg Sci 1992;36:169 - 72.  ElmacV L, Ekinci G, Kurtkaya O, Sav A, Pamir MN. Tumor in tumor: metastasis of breast carcinoma to intracranial meningioma. Tumori 2001;87:423 - 7.  Honma K, Hara K, Sawai T. Tumour-to tumour metastasis. A report of two unusual autopsy cases. Virchows Archiv A Pathol Anat 1989;416: 153 - 7.  Kremer S, Grand S, Remy C, Pasquier B, Benabid AL, Bracard S, Le Bas JF. Contribution of dynamic contrast MR imaging to the
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Commentary This paper reminds me of a paper I read years ago about a physician whose wife had known breast cancer. She developed an intracranial mass that he assumed was a metastases form the breast cancer. No additional therapy was given and his wife died. At autopsy, the intracranial lesion was found to be a meningioma. This experience and this paper lead us to the humbling conclusion that we must have a tissue diagnosis before a treatment decision is made. In this time of advanced technology, how many lesions are we misdiagnosing? What can be done to prevent that catastrophe? What would you want done if the patient were your wife or spouse? James I. Ausman, MD, PhD Editor