Cerebellar Metastasis Research Articles

The Louisiana State University Experience in the Management of Single Small Cerebellar Metastasis

Cerebellar metastasis is often believed to be a more immediately life-threatening complication than brain metastasis in other locations. It is considered a negative prognostic factor in patients with systemic cancers. Despite its clinical importance and technological advances, the survival outcomes of patients with single small cerebellar metastases are rarely studied. To retrospectively evaluate our experience in the management of patients with single small cerebellar metastasis and compare the treatment modalities. A total of 35 patients with single small cerebellar metastasis were included in this retrospective analysis. Of the 35 patients, 24 had surgery followed by whole-brain radiation therapy and 11 had Gamma Knife radiosurgery alone. The median survival for the whole cohort was 5.6 months after the intervention. No significant differences were noted in median survival between the surgery plus whole-brain radiation therapy and the Gamma Knife radiosurgery alone groups (6.3 months: 95% confidence interval [CI], 4.0-8.6; vs 5.0 months: 95% CI, 1.9-8.1; P=.9). There was no difference in the median time to local progression, distance progression, and overall progression between the 2 groups. Patients with hydrocephalus had a significantly lower survival rate (median, 3.3 months; 95% CI, 0.0-6.6) compared with those without hydrocephalus (median, 6.9 months; 95% CI, 4.4-9.8; P=.02). In the Cox regression model, the significant predictor of survival was hydrocephalus (P=.01; hazard ratio, 3.5; 95% CI, 1.3-9.1) after propensity score adjustment. Treatment with Gamma Knife radiosurgery alone and surgery plus whole-brain radiation therapy were both efficacious in patients with single small cerebellar metastasis. Overall survival was nearly identical in both treatment groups.

Restricted Diffusion in a Ring-Enhancing Mucoid Metastasis With Histological Confirmation

We present a case of restricted diffusion in a ring-enhancing cerebellar metastasis in a 58-year-old man. Diffusion imaging showed restriction with low apparent diffusion coefficient values within the cavity. Diagnosis of abscess was suggested based on radiological findings. A suspicious lung nodule was found in the systemic evaluation, and histological examination of the brain lesion confirmed metastatic adenocarcinoma with mucoid content confirmed by further specific pathological tests. We discuss the reason of diffusion findings and the importance of the correct interpretation of this technique in a clinical situation. Our case confirms previous hypothesis about restricted diffusion related to mucoid content in metastasis.

Cerebral High Grade Glioma with Crossed Cerebellar Metastases: A Report of Three Cases

We describe three patients with high grade supratentorial gliomas who were operated and later presented with cerebellar mass lesions on the opposite side. Supratentorial infarct with crossed cerebellar atrophy is a well-known entity called crossed cerebellar diaschisis. We hypothesize that supratentorial high grade tumours might also spread to the opposite cerebellum through crossed cerebrocerebellar fiber tracts similar to crossed cerebellar diaschisis.

Leptomeningeal carcinomatosis from renal cell cancer: treatment attempt with radiation and sunitinib (case report)

A case of leptomeningeal carcinomatosis in a patient with known brain and lung metastases from renal cell cancer without previous systemic therapy is presented. Neoplastic meningitis (NM) developed 31 months after first diagnosis of simultaneous extra- and intracranial recurrence of kidney cancer and surgical resection of a cerebellar metastasis. In spite of local radiotherapy to the macroscopic NM lesions in the cervical and lumbar spine followed by initiation of sunitinib, the patient succumbed to his disease 4 months after the diagnosis of NM. The untreated lung metastases progressed very slowly during almost 3 years of observation. This case illustrates important issues around both biological behaviour and treatment approaches in metastatic renal cell cancer.

Solitary Hemorrhagic Cerebellar Metastasis from Occult Papillary Thyroid Microcarcinoma

Cerebellar metastasis (CM) from papillary thyroid carcinoma (PTC) is exceptional with only 12 reported cases and usually carries a very poor prognosis. In the two previously reported patients in whom CM was detected before PTC, other distant or local metastases were already present by the time of PTC diagnosis. We report a patient found to have papillary thyroid microcarcinoma after surgical resection and histopathological study of a large solitary hemorrhagic CM, who showed no evidence of other metastatic sites and survived 7 years after initial diagnosis. A 65-year-old female patient with a history of surgical resection of a 7-cm cerebellar mass diagnosed with PTC metastasis, and adjuvant treatment with cranial external radiotherapy, was referred to us. The neck ultrasonography showed a solitary 4-mm right thyroid nodule. Histopathology after total thyroidectomy revealed a 2-mm papillary thyroid microcarcinoma, sclerosing variant, with capsule infiltration but no regional lymph node invasion. Although she received a total dose of 500 mCi of 131-I after surgery and the last two whole-body scans were normal, serum thyroglobulin levels progressively increased. The patient refused any further test or treatment other than basal blood sampling and suppressive therapy with levothyroxine and remained stable for 4 years until she started to complain about deviation of her walk. A computed tomography scan showed a regrowth of the metastasis. She suffered a sudden worsening of her neurological status because of a big intratumoral hemorrhage that required decompressive craniectomy and hematoma evacuation surviving 3 years more after this episode. To our knowledge, this is the first reported case of a solitary CM from an occult PTC, and also the first that developed an acute cerebellar hemorrhage years after cranial surgery, however, exhibiting the longest reported survival. This case highlights the importance of not only an appropriate initial treatment of the CM and primary PTC in these patients, but also a close follow-up, to avoid further complications and improve their prognosis.

Cavernous Sinus Metastasis of Non-Small Cell Lung Cancer

Progressive ptosis and headache developed in a 50-year-old woman with non-small cell lung cancer. Although brain magnetic resonance imaging showed improved cerebellar metastasis after prior radiotherapy without any other abnormality, the follow-up examination taken 6 months later revealed metastasis to the cavernous sinus. The diagnosis of metastasis to the cavernous sinus is often difficult because it is a very rare manifestation of lung cancer, and symptoms can occur prior to developing a radiologically detectable lesion. Therefore, when a strong clinical suspicion of cavernous sinus metastasis exists, thorough neurologic examination and serial brain imaging should be followed up to avoid overlooking the lesion.

Osteosarcoma presenting as hemorrhagic cerebellar metastasis

Osteosarcoma is the most common malignant bone tumor in children and adolescents. Brain metastasis from osteosarcoma was once uncommon; however, with the advent of chemotherapeutic agents and improved imaging modalities, it has become a more common and recognized finding. Brain metastases are, rarely, the initial presenting symptom, but instead are a late and preterminal event in the disease process. When osteosarcomas manifest in the central nervous system, they tend to occur in the gray-white junction in the anterior circulation akin to other metastatic lesions in the brain. The authors report a case of a 16-year-old boy who presented with acute neurological deterioration due to a posterior fossa hemorrhage and was subsequently found to have a primary site localizing to the metaphysis of the right femur with florid metastatic disease. This is the first case reported in the literature in which an osteosarcoma initially presented as cerebral metastasis in the form of a posterior fossa hemorrhage with a rapidly deteriorating course.

Cerebellar mass as a primary presentation of papillary thyroid carcinoma: case report and literature review

BackgroundPapillary carcinoma is the most common differentiated malignant thyroid neoplasm. The biological course of this cancer is typically indolent with a protracted clinical course. Metastases commonly occur in regional lymph nodes, and distant metastasis is a late and rare occurrence. We report a patient who presented with cerebellar metastasis prior to the diagnosis of papillary thyroid carcinoma and review the literature of brain metastasis from papillary thyroid carcinoma.ResultsA 75-year old female presented at the emergency room with progressive dizziness, headache and vomiting, where a brain CT and MRI showed a posterior cerebellar tumor. Surgical resection revealed papillary carcinoma consistent with thyroid origin. Subsequent ultrasound and CT-scan revealed a thyroid nodule, after which the patient underwent total thyroidectomy. Pathologic evaluation was consistent with papillary thyroid carcinoma.ConclusionBrain metastasis may rarely be the initial presentation of papillary thyroid carcinoma. Solitary brain metastasis can completely be resected with better prognosis.

Case 144: Dysplastic Cerebellar Gangliocytoma (Lhermitte-Duclos Disease)

A 28-year-old right-handed man presented with longstanding occipital headache, progressive ataxia, and blurred vision. He had begun vomiting 8-10 days earlier. He had no other important history. Neurologic examination revealed average intelligence and was remarkable for cerebellar ataxia. Papilledema was noted at fundoscopy. Magnetic resonance (MR) imaging of the brain was performed. No abnormality was noted on apparent diffusion coefficient maps or T2 * -weighted gradient-echo images (not shown).

Brainstem distortion from postoperative cerebellar herniation through a dural and bony defect

We report a patient with a cerebellar encephalocele following excision of a cerebellar metastasis. This is a life-threatening condition that may be prevented with adequate dural and bony closure.

Metastases to the cerebellum. Results and prognostic factors in a consecutive series of 44 operated patients

Recent reports on large number of patients with brain metastases report that Whole Brain Radiotherapy (WBRT) and Radiosurgery (RS) should be the treatments of choice, particularly in multiple lesions cases. Among the prognostic factors, the cerebellar location was never considered, although this results in hydrocephalus, brain stem compression, ataxia, intracranial hypertension. We evaluated 44 patients with cerebellar metastases operated over 6 years. Primary lesions were: Lung (15), Breast (12), Gastrointestinal (9), Gut (3), Ovary (2), Melanoma (1), Salivary gland carcinoma (1), Unknown (1). Lesions were <3 cm in 11 cases, > or =3 cm in 33. Average KPS scoring at admission was 69.9. Twenty nine scored > or =70, 15 < 70. Two patients died for surgical complications, 2 died within 1 months for other causes, 2 were lost to follow up. Eight had postoperative hematoma requiring reoperation, 1 had an occipital infarction. Average KPS scoring at discharge was 76.4, P < 0.002. Those patients that had complications scored less, the difference is significant (P < 0.008). Median survival was 8 months, 1 year survival rate 29.9%. Survival was correlated with either admission or discharge KPS (> or =70 vs. <70): P = 0.05 and P = 0.0001 respectively. None of the other parameters considered reached statistical significance. Open microneurosurgery is probably still the most effective therapy in improving survival and KPS in patients with large cerebellar metastases, given that the proper surgical technique is used and that complications do not occur. Specific data on cerebellar metastases as an independent subgroup are needed from radiosurgical series.

Cerebellar metastasis in squamous cell vulvar carcinoma

Brain metastasis is rarely seen in gynecologic cancers. It is more rarely encountered in vulvar carcinoma. A 56-year-old postmenopausal women referred our gynecologic oncology unit for the treatment of locally advanced vulvar carcinoma. Twenty-five days after the operation she developed vertigo and nystagmus. Cranial MRI investigation revealed that she had multiple cerebellar metastasis. Brain metastasis might be seen in patient with vulvar carcinoma. To the best of our knowledge, this is the first reported case of vulvar carcinoma which developed cerebellar metastasis.

Monosomy 7 mosaicism in metastatic choroidal melanoma

Uveal melanoma is the most common primary intraocular malignancy in adults. Several cytogenetic studies on uveal melanoma cells have revealed that the majority of these cells harbor alterations in chromosomes 3, 6, and 8. This report describes the results of cytogenetic analysis performed on a fresh choroidal melanoma tissue sample from a patient with cerebellar metastasis. Monosomy 7 mosaicism was observed. To our knowledge, monosomy 7 has not been reported in patients with uveal melanoma. We suggest that observation of monosomy 7 may be related to an aggressive clinical behavior and unusual cerebellar metastasis in uveal melanoma. Further data are necessary to define the exact role of monosomy 7 in the pathogenesis and evolution of uveal melanoma.

COMBINED X-RAY AND MAGNETIC RESONANCE IMAGING FACILITY

To assess the feasibility of a hybrid imaging setup combining x-ray and magnetic resonance imaging (MRI) in the setting of both stereotactic and functional neurosurgery. A combined x-ray and MRI scanning facility with a trolley system for a fast patient transfer between both modalities was installed in a neurosurgical setting. A registration algorithm for fusion of MRI scans and x-ray images was derived for augmentation of fluoroscopic x-ray projection images with MRI scan data, such as anatomic structures and planned probe trajectories. Phantom measurements were obtained between both modalities for estimation of registration accuracy. Practical application of our system in stereotactic and functional neurosurgery was tested in brachytherapy, deep brain stimulation, and motor cortex stimulation. Phantom measurements yielded a mean spatial deviation of 0.7 +/- 0.3 mm with a maximum deviation of 1.1 mm for MRI scans versus x-rays. Augmentation of x-ray images with MRI scan data allowed intraoperative verification of the planned trajectory and target in three types of neurosurgical procedures: positioning iodine seeds in brachytherapy in one case with cerebellar metastasis, placement of electrodes for deep brain stimulation in two cases of advanced Parkinson's disease, and placement of an epidural grid for motor cortex stimulation in two cases of intractable pain. Combined x-ray and MRI-guided stereotactic and functional neurosurgery is feasible. Augmentation of x-ray projection images with MRI scan data, such as planned probe trajectories and MRI scan segmented anatomic structures may be beneficial for probe guidance in stereotactic and functional neurosurgery.

Bilateral Choroidal Metastases from Mesothelioma

CASE REPORT A 69-year-old retired carpenter with previous asbestos exposure was diagnosed with pleural epithelioid mesothelioma in 2003. He was treated with a pleural decortication but subsequently relapsed in supraclavicular and axillary lymph nodes and in the peritoneum. He was treated with palliative radiotherapy to symptomatic sites and then with chemotherapy, including pemetrexed, carboplatin, and gemcitabine. After initial response, his disease progressed. In late 2005, he presented with rapidly progressive loss of vision. Ophthalmologic assessment revealed bilateral choroidal lesions consistent with metastatic deposits (Figures 1 and 2). Differential diagnoses included choroidal melanomas, especially amelanotic melanomas, and benign lesions such as hemangiomas, and inflammatory granulomas.1 The presence of multiple lesions in one eye and the involvement of both eyes in the setting of known metastatic mesothelioma established the diagnosis of choroidal metastases.1 Computed tomography scans of the brain, orbit, chest, abdomen, and pelvis were also performed showing overall progression of disease within the mediastinum, abdomen, peritoneum, and lungs and possible cerebellar metastasis (Figure 3). He was treated with dexamethasone and bilateral orbital irradiation to a dose of 30 Gy in 10 fractions using 6-MV photons. Following completion of radiotherapy, his vision stabilized, and 2 months after treatment, he is able to read, although with some difficulty. The patient is

Octreotide in the therapy of recurrent medulloblastomas

BACKGROUND: Recurrence of medulloblastoma appears after 30% to 40% of the surgeries. Different from primary medulloblastoma, in which five-year survival rate is 50%, the survival time of relapses much shorter and only 20% of the patients manage to survive a year. There is a logical need for additional methods of treatment of recurrent medulloblastomas. The aim of the study is to determine the effects of intracavitary and long-term subcutaneous application of Sandostatin (octreotide) on the recurrent medulloblastomas. METHODS: Fourteen children aged 4 to 9 years, in which, despite of craniospinal irradiation and chemotherapy came to a recurrence of medulloblastoma during the first 6 months after the surgery, were treated subcutaneously with Sandostatin (octreotide) in a longer period of time. Cerebellar medulloblastomas with a diameter bigger than 20 mm and spinal over 10 mm were removed operatively and octreotide with Beriplast was applied intracavitary. RESULTS: Magnetic resonance of cranioaxis shows that the application of octreotide has caused the disappearance of spinal drop metastases in all 7 patients and the cerebellar metastases smaller than 5 mm in all 4 patients. Subcutaneous application of octreotide combined with intracavitary expresses an antitumoral effect in 2/3 of the relapses. The application of octreotide results with a transformation of Chang's stage M0 into M1 in 71.43% of the patients. CONCLUSION: In the case of in loco or metastatic recurrence of medulloblastomas, intracavitarily and subcutaneously applied octreotide results with a regression of the tumor in a 3 year time within 2/3 of the treated patients.

Stereotactic interstitial radiosurgery for cerebral metastases

The Photon Radiosurgery System (PRS) is a miniature x-ray generator that can stereotactically irradiate intracranial tumors by using low-energy photons. Treatment with the PRS typically occurs in conjunction with stereotactic biopsy, thereby providing diagnosis and treatment in one procedure. The authors review the treatment of patients with brain metastases with the aid of the PRS and discuss the indications, advantages, and limitations of this technique. Clinical characteristics, treatment parameters, neuroimaging-confirmed outcome, and survival were reviewed in all patients with histologically verified brain metastases who were treated with the PRS at the Massachusetts General Hospital between December 1992 and November 2000. Local control of lesions was defined as either stabilization or diminution in the size of the treated tumor as confirmed by Gd-enhanced magnetic resonance imaging. Between December 1992 and November 2000, 72 intracranial metastatic lesions in 60 patients were treated with the PRS. Primary tumors included lung (33 patients), melanoma (15 patients), renal cell (five patients), breast (two patients), esophageal (two patients), colon (one patient), and Merkle cell (one patient) cancers, and malignant fibrous histiocytoma (one patient). Supratentorial metastases were distributed throughout the cerebrum, with only one cerebellar metastasis. The lesions ranged in diameter from 6 to 40 mm and were treated with a minimal peripheral dose of 16 Gy (range 10-20 Gy). At the last follow-up examination (median 6 months), local disease control had been achieved in 48 (81%) of 59 tumors. An actuarial analysis demonstrated that the survival rates at 6 and 12 months were 63 and 34%, respectively. Patients with a single brain metastasis survived a mean of 11 months. Complications included four patients with postoperative seizures, three with symptomatic cerebral edema, two with hemorrhagic events, and three with symptomatic radiation necrosis requiring surgery. Stereotactic interstitial radiosurgery performed using the PRS can obtain local control of cerebral metastases at rates that are comparable to those achieved through open resection and external stereotactic radiosurgery. The major advantage of using the PRS is that effective treatment can be accomplished at the time of stereotactic biopsy.

Cerebellar mutism in adults after posterior fossa surgery: a report of 2 cases

Background Mutism has been associated with injury to midline cerebellar structures secondary to degenerative disease, tumors, hemorrhage, or surgery. Typically, cerebellar mutism syndrome (CMS) has been seen in children and only rarely described in adults after surgery of the posterior fossa. This syndrome typically arises 48 hours after the initiating event and resolves approximately 7 to 8 weeks later. Characteristics of CMS include complete absence of speech without impaired consciousness, other cranial nerve deficits, or long tract signs. Case Description The authors report on 2 patients each of whom developed cerebellar mutism after tumor resection using a posterior fossa approach. The first patient underwent gross total resection of a pineal region tumor via a supracerebellar approach. The second patient underwent posterior fossa decompression for a left cerebellar hemispheric renal cell carcinoma metastasis with adjacent hemorrhage. One patient displayed a variant of cerebellar mutism with severe ataxic dysarthria without complete absence of speech, whereas the other demonstrated frank mutism. After neuroimaging studies confirmed the absence of a surgically treatable postoperative cause for the patients' symptoms, they were managed in a supportive fashion (eg, speech therapy) and improved within 3.5 months and 1 year, respectively. Conclusion It is paramount that neurosurgeons be aware of cerebellar mutism with regard to its very rare occurrence in adults, its time of onset, and typical self-limiting course.

Images in neuro-oncology: brain metastases and leptomeningeal dissemination of nonseminomatous germ cell tumor

A 39-year-old man with a right testicular mass and a 3month history of asthenia was admitted to hospital on June 6. Physical examination evidenced a large, hard right testicle and bilateral cervical nodes. Computerized tomography scanning revealed, in addition, retroperitoneal and lung metastases. Head CT scan was normal on admission. The patient’s a-fetoprotein level was 2414.7 lg/l b-human chorionic gonadotropin level was 2149.3 lg/l and LDH level was 1095 IU/l. On June 16, the right testicle was excised. Histological analysis revealed nonseminomatous germ cell tumor (NSGCT) with elements of embryonal cell carcinoma and endodermal sinus tumor (Figure 1). The patient underwent four courses of chemotherapy consisting of bleomycin, etoposide and cisplatin (BEP). By the end of this treatment, LDH, b-HCG and a-FP were normal, but residual retroperitoneal mass was still observed on CT scan. While waiting for surgery of this retroperitoneal mass, the patient developed partial motor seizures on the left arm. CT scan and cranial MRI were obtained showing bilateral parietal and left cerebellar metastases (Figure 2). Whole brain radiation therapy (10 · 300 cGy) was administered over 2 weeks, reducing the size of the lesions. We then decided to operate the largest metastases (>3 cm large in diameter) and treat with radiosurgery the other two lesions and the bed of the resected one. While waiting for radiosurgery, the patient complained of neck pain, gait difficulty and urinary incontinence. Cranial and spinal MRI were performed (Figure 3), showing massive regrowth of the right parietal metastases and cervical and thoracic leptomeningeal dissemination. Symptoms progressed very rapidly driving the patient lethargic, incontinent and bedridden. By that time, surgery was considered not indicated, and

Gefitinib (‘Iressa’, ZD1839) is active against brain metastases in a 77 year old patient

This report highlights the case of a symptomatic 77-year-old non-smoking female patient who was diagnosed with advanced non-small-cell lung cancer (NSCLC), metastatic to the liver and contralateral lung. After tumor progression in the liver and lung following polychemotherapy, multiple diffuse brain and cerebellar metastases were apparent. Oral treatment with the epidermal growth factor receptor tyrosine kinase inhibitor gefitinib ('Iressa') 250 mg/day resulted in progressive and durable symptom relief, and improvements in quality of life and performance status. Reductions in the size of the primary pulmonary tumor and brain, cerebellar, and liver metastases were observed. Furthermore, gefitinib was well tolerated with an absence of adverse events. These results provide evidence that oral gefitinib is active in patients with advanced NSCLC and central nervous system metastases.