J Neurooncol (2010) 97:123–126 DOI 10.1007/s11060-009-9988-z
CASE REPORT
Solitary intra-ventricular brain metastasis from a breast carcinoma Alessandro Della Puppa Æ Sandro Dal Pos Æ Stefania Zovato Æ Enrico Orvieto Æ Pietro Ciccarino Æ Renzo Manara Æ Fable Zustovich Æ Franco Berti Æ Marina Paola Gardiman Æ Renato Scienza
Received: 30 March 2009 / Accepted: 9 August 2009 / Published online: 2 September 2009 Ó Springer Science+Business Media, LLC. 2009
Abstract Prevalence of symptomatic central nervous system (CNS) metastases among patients with breast cancer ranges from 5% to 16%, although autoptic studies have reported prevalence rates of up to 30%. Solid brain tumours are the most common presentation in the CNS (85–95%), and they tend to arise at the grey–white matter junction with a distribution that is proportional to the regional cerebral blood flow. Descriptions of solitary intra-ventricular metastasis are very rare; to date no cases from breast cancer have been reported in the literature. We present the unusual case of a breast cancer patient who developed a solitary choroid plexus metastasis in the left lateral ventricle. Keywords Breast cancer Solitary brain metastasis Intra-ventricular metastasis Choroid plexus metastasis
A. Della Puppa (&) P. Ciccarino R. Scienza Department of Neurosurgery, Padua University Hospital, Via Giustiniani 2, Azienda Ospedaliera di Padova, 35128 Padua, Italy e-mail:
[email protected] S. Dal Pos R. Manara Department of Neuro-Radiology, Padua University Hospital, Padua, Italy S. Zovato F. Zustovich Department of Oncology, IOV IRCCS of Padua, Padua, Italy E. Orvieto M. P. Gardiman Department of Pathology, Padua University Hospital, Padua, Italy F. Berti Department of Radiotherapy, IOV IRCCS of Padua, Padua, Italy
Case A 66-year-old female patient was brought to our attention because of progressive cognitive impairment, aphasia and right hemianopsia. We learned that she was operated on 2 years before for breast cancer. Histologically, the primary breast tumour was a poorly differentiated multifocal invasive ductal carcinoma with metastases in two axillary lymph nodes. It showed high expression of oestrogen receptors (80% positive cells) and very low expression of progesterone receptors (\2% immuno-reactive cells). The proliferative index was high (40% of cells positive for MIB1) while the tumour did not show over-expression for human epidermal growth factor receptor 2 (HER2) antigen (score 1?; Herceptest Dako). The patient underwent chemotherapy with six cycles of epyrubicin associated with docetaxel, and subsequently aromatase inhibitors were prescribed. Radiotherapy was found not to be necessary because of radical removal of the cancer (mastectomy). At follow-up, radiological investigations and blood markers were negative, while performance status (PS) remained unchanged. After about 18 months from the end of chemotherapy the patient complained of growing asthenia, headaches and vertigo. For these reasons she underwent a cerebral magnetic resonance imaging (MRI) (Fig. 1) that showed a well-delineated large tumour in the atrium and the temporal horn of the left lateral ventricle (Fig. 2). The tumour presented a mixed structure composed of a solid portion that was non-homogeneously contrast enhancing and some large cysts. It was surrounded by a moderate peritumoural oedema. No hydrocephalus was observed. Cerebral computed tomography (CT) scan did not detect intra-tumoural calcifications (Fig. 1c). Digital subtracted angiography (Fig. 1d) revealed a vascular blush in the left ventricular cavity, supplied by a prominent choroidal
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artery. This supported the hypothesis of an intra-ventricular tumour. With the patient’s history of breast cancer, the diagnosis of metastasis was considered as well, even though whole-body CT excluded other systemic malignancies. The patient was operated on by a left parietal craniotomy and gross total removal of the tumour was achieved. At surgery the mass appeared completely located within the ventricle and encasing the choroid plexus. Postoperative course was uneventful with the exception of a temporary worsening of aphasia. The histopathological report was of localization of a poorly differentiated carcinoma (Fig. 3). Morphologically the tumour showed marked anaplasia and bizarre neoplastic cells with abundant necrosis and brisk mitotic activity. Immune reaction for cytocheratin 7 and the absence of expression of cytocheratin 20 confirmed that the origin was from breast cancer. In the metastatic site the tumour showed the same phenotype as the primary localization, with high expression of oestrogen receptors and low expression of progesterone receptors. The metastasis showed low immunoreactivity for oncogene HER2 (score 1?; Herceptest Dako). This
Fig. 1 Imaging of the intraventricular tumour. MRI revealed a non-homogeneously enhancing tumour (a: axial T1weighted contrast-enhanced image), the presence of some large cysts and surrounding oedema (b: axial T2-weighted image). No calcifications were evidenced in the lesion by CT (c); small calcifications in the image are related to choroid plexus that is displaced by the tumour. Digital subtraction angiography d showed a large anterior choroidal artery (bold arrow) and a blush in the trigonal region (small arrows)
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information was confirmed by fluorescence in situ hybridisation (FISH) that resulted not amplified (PathVysionTM HER2 DNA probe kit). Few cases of intra-ventricular metastasis have been reported in the literature, above all from renal cell carcinoma [1–7]. Single reports from pulmonary [8], colon [9], bladder [10] and oesophagus [11] cancer have been described, but none surely referring to breast neoplasm. The more frequently described tumours located within cerebral ventricles are ependymoma, sub-ependymoma, choroid plexus papilloma, choroid plexus carcinoma, lymphoma, glioma and meningioma. Unfortunately, radiological diagnosis of a ventricular mass is difficult because the reported types of tumours can show the same characteristics on standard imaging (MRI and CT scan). Therefore, most authors suggest that the part of the ventricle involved and the age of the patient are pivotal in order to define the nature of the tumour [12]. In the presented case tumour arose in the trigonal part of the ventricle. In childhood, tumours that are usually reported in the trigone are choroid plexus papilloma, choroid plexus
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Fig. 2 Magnetic resonance T1weighted contrast-enhanced images in coronal a and sagittal b multi-planar reconstructed (MPR) planes clearly showed the intra-ventricular location of the tumour
homogenously contrast-enhancing tumour, frequently calcified, which occasionally presents cyst-like regions. Conversely, on MRI our case showed the typical radiological features of an aggressive neoplasm. In fact, these findings are rarely detected among intra-ventricular tumours. The radiological non-homogeneous aspect of the lesion and data about previous breast cancer suggested the diagnosis of metastasis despite the unusual intra-ventricular site. In our case, history of previous tumour was undoubtedly helpful for the radiological diagnosis. Nevertheless, metastasis should be considered even when a solitary intra-ventricular tumour is detected, as suggested by some authors [1, 3, 4]. The described case adds breast cancer to the possible origins of an intra-ventricular cerebral metastasis. This is particularly interesting if we consider that approximately 20% of breast cancer patients can develop brain metastasis as a synchronous disease.
References
Fig. 3 Primary a and secondary b breast cancer [haematoxylin and eosin (H&E) stain, 9400]
carcinoma and ependymoma. Radiologically they are heterogeneous and frequently calcified. In the elderly the most frequent trigonal tumour is meningioma, which is a quite
1. Tomiyama A, Nakayama H, Aoki K, Ueda M (2008) Solitary metastasis of renal cell carcinoma to the third ventricular choroid plexus with rapid clinical manifestation by intratumoral hemorrhage. Neurol India 56(2):179–181 2. Lauretti L, Fernandez E, Pallini R, Massimi L, Albanese A, Denaro L, Maira G (2005) Long survival in an untreated solitary choroid plexus metastasis from renal cell carcinoma: case report and review of the literature. J Neurooncol 71(2):157–160 (Review) 3. Leach JC, Garrott H, King JA, Kaye AH (2004) Solitary metastasis to the choroid plexus of the third ventricle mimicking a colloid cyst: a report of two cases. J Clin Neurosci 11(5):521–523 4. Al-Anazi A, Shannon P, Guha A (2000) Solitary metastasis to the choroids plexus. Case illustration. J Neurosurg 92(3):506 5. 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(4):359–363 (Japanese)
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126 6. Raila FA, Bottoms WT Jr, Fratkin JD (1998) Solitary choroid plexus metastasis from a renal cell carcinoma. South Med J 91(12):1159–1162 (Review) 7. Matsumura H, Yoshimine T, Yamamoto S, Maruno M, Hayakawa T, Ono Y, Kondoh N, Namiki M (1997) Single solitary metastasis of the slowly progressive type of renal cell carcinoma to the choroid plexus—case report. Neurol Med Chir (Tokyo) 37(12):916–919 (Review) 8. Kohno M, Matsutani M, Sasaki T, Takakura K (1996) Solitary metastasis to the choroid plexus of the lateral ventricle report of three cases and a review of the literature. J Neurooncol 27(1):47– 52 (Review) 9. Kitajima K, Morita M, Morikawa M, Sugimura K (2003) Choroid plexus metastasis of colon cancer. Magn Reson Med Sci 2(3):155–158
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J Neurooncol (2010) 97:123–126 10. Qasho R, Tommaso V, Rocchi G, Simi U, Delfini R (1999) Choroid plexus metastasis from carcinoma of the bladder: case report and review of the literature. J Neurooncol 45(3):237–240 (Review) 11. Sung WS, Dubey A, Erasmus A, Hunn A (2008) Solitary choroid plexus metastasis from carcinoma of the oesophagus. J Clin Neurosci 15(5):594–597 (Review) 12. Park P, Choksi VR, Gala VC, Kaza AR, Murphy HS, Ramnath S (2005) Well-circumscribed, minimally enhancing glioblastoma multiforme of the trigone: a case report and review of the literature. Am J Neuroradiol 26(6):1475–1478
