Acta Neurochir (Wien) (2005) 147: 1003–1004 DOI 10.1007/s00701-005-0591-6
Brief Report of Special Case Intraventricular haemorrhage from a renal cell carcinoma pituitary metastasis J. Pallud, F. Nataf, T. Roujeau, and F.-X. Roux Department of Neurosurgery Sainte-Anne Hospital, Paris, France Received January 27, 2005; accepted June 8, 2005; published online July 25, 2005 # Springer-Verlag 2005
Summary Symptomatic pituitary metastasis and intraventricular haemorrhage from a cerebral metastasis are exceptional events in the natural history of a renal cell carcinoma. We report the first case of a metastatic renal cell carcinoma to the pituitary gland presenting with intraventricular haemorrhage. The origin of intraventricular haemorrhage and its association with renal cell carcinoma pituitary metastasis are discussed. Keywords: Hydrocephalus; intraventricular haemorrhage; metastasis; neoplasm; pituitary gland; renal cell carcinoma; trans-sphenoidal surgery.
Introduction Renal cell carcinoma (RCC) symptomatic pituitary metastases are uncommon [5]. Intraventricular haemorrhage (IVH) arising from a RCC metastasis is exceptional [3] and a pituitary origin has never been reported. Case report A 70-year-old man with a history of nephrectomy for RCC 6 years earlier presented with retro-orbital headaches and bitemporal hemianopsia. MRI demonstrated an enhanced sellar and suprasellar mass eroding the sellar base. A partial resection was performed using a trans-sphenoidal approach. The diaphragma sellae was intact. Histological examination concluded a metastatic localization of the RCC. No air or blood was found within the ventricular system on postoperative CT-scan. Local radiotherapy was given postoperatively. Ten months after surgery, the patient complained of slowness of thought and examination revealed gait disturbance, incontinence but no history of headaches. CT-scan and MRI demonstrated a global hydrocephalus and a moderate IVH (Fig. 1). No other metastases or vascular malformations were found. Two subtractive lumbar taps showed a xanthochromic fluid. Symptomatic hydrocephalus due to IVH was considered as a diagnosis and a ventriculoperitoneal shunt was inserted. Peroperative studies showed a xanthochromic fluid
with rare tumour cells. The patient was discharged free of neurological symptoms. No other metastases was found on 6-month postoperative MRI. The patient is still alive 14 months after shunt placement.
Discussion The occurence of RCC metastases to any cerebral sites being associated with intracranial haemorrhage is predictable from the hypervascular nature of such a tumour. However, IVH from a RCC metastasis has only been reported in 3 cases where metastases were intraventricular [3]. In our case, RCC pituitary metastasis and IVH were concomitant. Pituitary metastasis was defined as the origin of IVH because tumour cells were found in the xanthochromic cerebrospinal fluid and because it was the only metastatic lesion found in both preoperative and postoperative MRI. Moreover, no other possible aetiology was identified. IVH originating from a pituitary apoplexy, a known cause of subarachnoid haemorrhage, or a pituitary urinary bladder carcinoma metastasis have been reported [1, 2, 4]. The large suprasellar extension and the close relationship to the third ventricle floor were defined as the 2 main factors facilitating IVH. Diagnosis was made at the acute stage because massive IVH and=or pituitary apoplexy were symptomatic. Our case differs in some points. MRI did not show evident involvement of the diaphragma sellae or the third ventricle floor. Tumour haemorrhage was asymptomatic and diagnosis was made when hydrocephalus appeared, which may explain the absence of tumour changes on MRI. During surgery, the diaphragma sellae was intact. On the postoperative
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J. Pallud et al.: Intraventricular haemorrhage from a renal cell carcinoma pituitary metastasis
Fig. 1. T1-weighted coronal MRI with contrast enhancement (A) showing an enhanced sellar mass with a suprasellar extension reaching the optic chiasma but without cavernous sinus involvement. Computed tomography (B) showing a spontaneous hyperdense deposit in the occipital horns of lateral ventricles
CT-scan, there was neither blood nor air in the ventricular system, which allowed peroperative opening of the diaphragma sellae to be eliminated. Moreover, hydrocephalus, symptomatic of IVH, appeared 10 months after surgery, indicating that disruption occurred secondarily. This case illustrates that IVH from a pituitary metastasis is possible and does not always have an acute symptomatology. A third ventricle floor involvement may be present even if there are no radiological signs. Metastasis should always be considered in the differential diagnosis in patients with IVH and a sellar mass. References 1. Challa VR, Richards F 2nd, Davis CH Jr (1981) Intraventricular hemorrhage from pituitary apoplexy. Surg Neurol 16(5): 360–361 2. Furuta S, Hatakeyama T, Zenke K, Fukumoto S (1999) Pituitary metastasis from carcinoma of the urinary bladder mimicking pituitary apoplexy-case report. Neurol Med Chir (Tokyo) 39: 165–168 3. Iwatsuki K, Sato M, Taguchi J, Fukui T, Kiyohara H, Yoshimine T, Hayakawa T (1999) [Choroid plexus metastasis of renal cell carcinoma causing intraventricular hemorrhage: a case report]. No Shinkei Geka 27: 359–363 4. Patel DV, Shields MC (1979) Intraventricular hemorrhage in pituitary apoplexy. J Comput Assist Tomogr 3(6): 829–831 5. Weber J, Gassel AM, Hoch A, Spring A (2003) Concomitant renal cell carcinoma with pituitary adenoma. Acta Neurochir (Wien) 145: 227–231
Comments Renal clear cell carcinoma (RCC) is a quite hemorrhagic tumor and intracerebral haematoma from RCC metastasis is rather common, but the intraventricular hemorrhage from RCC pituitary metastasis such as reported in this paper is quite rare. In patients with intraventricular hemorrhage and a sellar mass lesion, metastasis must be considered as part of the differential diagnosis. K. Takakura Tokyo Pallud et al. present the case of a patient with a metastasis to the pituitary of a renal cell carcinoma. The patient was subjected to transsphenoidal surgery of the tumor, followed by radiotherapy. 10 months later the patient developed hydrocephalus due to intraventricular haemorrhage and was treated by placement of a ventriculoperitoneal shunt. The evidence is circumstantial that residual tumor and intraventricular hemorrhage are linked. Nevertheless, with two pathologies occurring with a modest interval, chances are high that they are, in fact, interrelated. It is well established that renal cell carcinoma metastasis to the brain can present with haemorrhage, and atypical haemorrhage would prompt a number of imaging studies, such as angiography or MR imaging, especially if the patient has a history of carcinoma. In this particular case however, intraventricular haemorrhage did not lead to detection of the pituitary metastasis but this occurred later. Walter Stummer Dusseldorf
Correspondence: Franc° ois Nataf, Service de Neurochirurgie, Centre R. Garcin, Centre Hospitalier Sainte-Anne, 1 rue Cabanis, 75674 Paris, France. e-mail:
[email protected]
