Skull Metastasis Research Articles

Excellent RAI therapeutic response on a patient presenting skull metastasis of follicular thyroid cancer after 15 years.

Bone is the second most common site of metastasis for differentiated thyroid carcinoma (DTC). Bone metastasis (BMs) occur in about 10% of patients with DTC and is observed more often in follicular thyroid carcinoma (FTC) (7-28%) than papillary thyroid carcinoma (PTC) (1-7%). Bone metastasis is associated with unfavorable clinical outcomes mainly including skeletal-related events (SREs), such as pathologic fractures, bone pain, spinal cord compressions, and hypercalcemia, which negatively impact the quality of life of patients and reduce their life expectancy. Patients with BMs from DTC require comprehensive and multimodal treatment approaches, including radioiodine (RAI) therapy, palliative care, surgery, external beam radiotherapy, and targeted drug therapy. RAI therapy is the first-line treatment, despite being rather ineffective, especially in large BMs. The response to RAI therapy, either alone or in combination with BM focal treatment depends on iodine avidity. This study reports a rare case of metachronous skull bone metastasis from FTC in a 72-year-old female patient 15 years after initial treatment. The patient had an excellent response to RAI therapy, which resulted in the abnormal uptake disappearing. Following treatment, the patient has been disease-free for six years. This case confirms that a complete response to RAI treatment for BM depends on the degree of dedifferentiation of cancer cells, which highlights the need for long-term follow-up, especially for FTC patients.

Solitary skull metastasis as initial presentation of hepatocellular carcinoma

Solitary skull metastasis as initial presentation of hepatocellular carcinoma

Large Skull Metastasis in Follicular Thyroid Carcinoma: A Comprehensive Case Presentation and Systematic Review.

Skull metastases from follicular thyroid carcinoma (FTC) are infrequent but clinically significant, often presenting with localized pain, neurologic deficits, and cranial nerve dysfunction. Early detection and accurate diagnosis pose challenges due to their asymptomatic nature in some cases. A systematic literature review, conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identified and analyzed 15 relevant studies focusing on large skull metastases in FTC. Data extraction and synthesis included clinical presentation, diagnostic methods, treatment strategies, and patient outcomes. The systematic review encompassed 20 patients with secondary skull metastases from FTC, offering insights into the clinical diversity of this rare condition. Clinical presentations varied, with localized pain (70% of cases) and headaches being predominant symptoms. Imaging techniques, including computed tomography (CT) and magnetic resonance imaging (MRI), played a pivotal role in diagnosis. Surgical resection was considered in select cases, achieving complete or near-complete tumor removal in 30 to 50% of patients. Radiotherapy, including external beam radiation therapy (EBRT) and stereotactic radiosurgery (SRS), provided local control and symptom relief in 70 to 80% of cases. Systemic therapies, such as tyrosine kinase inhibitors (TKIs), showed promise in disease stabilization or regression (45% of patients). Prognosis remained poor, with a median overall survival of 6 to 12 months, reflecting an advanced and aggressive disease state. Managing secondary skull metastases from FTC requires a comprehensive approach, including surgical intervention, radiotherapy, and potential systemic therapies. The rarity of these metastases underscores the need for further research to establish standardized treatment guidelines, explore molecular profiling, and investigate immunotherapy and combination therapies, offering hope for improved outcomes in this challenging clinical scenario.

Mammary Angiosarcoma in an Adolescent : A Case Report

Mammary angiosarcoma is an extremely rare and highly aggressive malignant tumour of vascular origin. It can be divided into 2 types; primary angiosarcoma which develops de-novo and secondary angiosarcoma which occurs as a complication of post-radiotherapy or chronic lymphoedema. We present a case of a 19-year-old adolescent with a large right breast mass for the duration of 9 months. The core biopsy was reported as an angiosarcoma. She did not haveany previous breast pathology. She underwent a right mastectomy, followed by adjuvant radiotherapy. She developed scalp and skull metastases 5 months postsurgery and was currently undergoing palliative chemotherapy. There is a lack of international consensus on the management of mammary angiosarcoma due to its rarity. The main modality of management is surgery, preferably mastectomy. Radiotherapy and chemotherapy are sometimes given in an attempt to prevent or treat local recurrence and metastasis.

Dural Metastasis in Breast Cancer: MRI-Based Morphological Subtypes and Their Clinical Implications.

This study aimed to investigate the clinical factors associated with breast cancer (BRCA) dural metastases (DMs), their impact on prognosis compared to brain parenchymal metastases (BPMs) alone, and differences between DM subtypes, aiming to inform clinical decisions. We retrospectively analyzed 119 patients with BRCA with brain metastasis, including 91 patients with BPM alone and 28 patients with DM. Univariate and multivariate analyses were performed to compare the clinical characteristics between the two groups and within subtypes of DM. Overall survival after DM (OSDM) and the interval from DM to leptomeningeal carcinomatosis (LMC) were compared using Kaplan-Meier analysis. DM was notably linked with extracranial metastasis, luminal-like BRCA subtype (p=0.033), and skull metastases (p < 0.001). Multiple logistic regression revealed a strong association of DM with extracranial and skull metastases, but not with subtype or hormone receptor status. Patients with DM did not show survival differences compared with patients with BPM alone. In the subgroup analysis, nodular-type DM correlated with human epidermal growth factor receptor 2 status (p=0.044), whereas diffuse-type DM was significantly associated with a higher prevalence of the luminal-like subtype (p=0.048) and the presence of skull metastasis (p=0.002). Patients with diffuse DM did not exhibit a significant difference in OSDM but had a notably shorter interval from DM to LMC compared to those with nodular DM (p=0.049). While the impact of DM on the overall prognosis of patients with BRCA is minimal, our findings underscore distinct characteristics and prognostic outcomes within DM subgroups.

Ischemic Stroke due to Intracerebral Steal from Calvarial Metastasis: a Case Report (P2-5.001)

<h3>Objective:</h3> NA <h3>Background:</h3> Malignancy is an important risk factor for ischemic stroke. Various mechanisms may explain the association between cancer and ischemic stroke, including hypercoagulation, accelerated atherosclerosis, and toxic effects of chemotherapy and radiation. Here, we report a rare case in which a patient with known occlusive radiation vasculopathy (ORV) presented with ischemic strokes caused by an “intracerebral steal” phenomenon from new metastatic calvarial lesions. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 64-year-old woman with remote history of left neck squamous cell carcinoma and prior left frontal stroke from left common carotid artery (CCA) occlusion secondary to ORV presented to the emergency department with acute-onset right hemiparesis. Brain magnetic resonance imaging revealed scattered infarcts in the convexity of the left hemisphere as well as adjacent calvarial destruction. On functional and structural MRI, the calvarial lesion demonstrated increased vascularity and diffusion restriction. CT angiography redemonstrated complete occlusion of the left CCA and strong right-to-left collateral circulation across the anterior communicating artery. The remainder of the stroke workup, including echocardiogram, laboratory analyses, venous dopplers, and carotid ultrasound was unrevealing. CT scans of the chest, abdomen and pelvis revealed only lytic lesions in the T11 vertebra, left ilium and right sacrum, and biopsy of the latter revealed adenocarcinoma. <h3>Conclusions:</h3> In this patient, neck radiation therapy had resulted in a chronic occlusion of the left CCA. Years later, a hypervascular skull metastasis drew from this limited blood supply, causing ischemic strokes in the parenchyma adjacent to the hypermetabolic calvarial metastasis. This case of an “intracerebral steal” phenomenon demonstrates how hypervascular extradural lesions may also lead to ischemia, particularly in cases of ipsilateral poor hemodynamic reserve. <b>Disclosure:</b> Miss Murthy has nothing to disclose. Dr. Kumar has nothing to disclose. Dr. Testai has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Swanson Martin &amp; Bell, LLP. Dr. Testai has received publishing royalties from a publication relating to health care. Edward Michals has stock in Off Color Brewing. Edward Michals has received personal compensation in the range of $100,000-$499,999 for serving as a Staff Physician with University of Illinois.

Scalp Swelling a Rare Presentation of Disseminated Lung Carcinoma

Subcutaneous metastatic nodules are uncommon presentation of underlying malignancy. Cutaneous metastasis is seen in less than 4% cases of all malignancies and is usually seen following initial diagnosis. Lung carcinoma has higher predisposition for bony metastasis compared to other malignancies, however skull metastasis is rare. Cutaneous metastasis is seen in less than 15% cases of lung cancer. These lesions are mostly detected late after the diagnosis of primary tumour in later course of disease. However, an asymptomatic patient presenting with scalp swelling as initial presentation of underlying advances lung malignancy is rare, less than 20 such cases reported in literature till date. Our case is highlighting not only the rarity of such cases but also consider detail evaluation of any scalp swelling.

Skull metastasis from follicular thyroid cancer

Differentiated thyroid cancers have indolent clinical course and good prognosis with an approximate 85–90% 10-year survival rate. Distant metastases from follicular thyroid cancer are uncommon but are one of the main causes of cancer-specific mortatily. Mainly involve the lung, bone, and brain. Bone metastasis most commonly occurs in the vertebrae, costas and hip bones. Metastasis of a follicular thyroid carcinoma to the skull is very rare and only a small number of reports are found in the literature. We present a case of solitary lytic skull metastasis of a follicular thyroid cancer in a 79-year-old woman. The patient presented with a painless mass on the right side of the head. Physical examination showed a large, palpable, immobile and hard tumor. CT scan showed thyroid enlargement along with neck lympadenopathy and a lesion with an osteolytic component in the right parietal area. The patient was euthyroid and we performed an initial biopsy excision. The histopathological examination revealed a well-differentiated follicular thyroid cancer metastasis. After that a total thyroidectomy was subsequently performed. The patient refused the craniectomy and was given thyroid-stimulating hormone (TSH) suppression therapy followed by whole body iodine-131 (I131) internal radiation. She gave up on therapy and died 20 months after the initial surgery. Management of metastatic thyroid cancer, requires a multidisciplinary approach and multimodality treatment. Distant metastases should be surgically removed whenever possible, providing the best chance to prolong patient survival. Radiotherapy should be reserved for inoperable and residual tumor cases.

Skull metastasis is a poor prognostic factor for prostate cancer patients with bone metastasis: a retrospective study based on a Chinese population

BackgroundSkull is a relatively rare metastasis site for prostate cancer (PCa). There is no evidence regarding the prognostic indication of skull metastasis (SM) in PCa patients. In this study, we analyzed the prognostic value of SM for metastatic PCa patients receiving androgen deprivation therapy (ADT).Methods107 consecutive patients were included from September 2008 to August 2021. All patients were administered with standard ADT. Abiraterone plus glucocorticoid and/or docetaxel chemotherapy were given after failure to castration-resistant prostate cancer. Clinical parameters and follow-up prognostic data were retrospectively analyzed. The association of clinical and pathological parameters with SM were analyzed. The progression-free survival (PFS) and overall survival (OS) were assessed using Kaplan–Meier analysis and Cox regression analyses.ResultsPatients with SM (n = 26) had significantly higher biopsy Gleason scores, higher clinical T stage, higher prostate-specific antigen level at diagnosis, and were more likely to have high-burden metastasis and lymph node metastasis, compared with those without SM (n = 81). They also showed significantly lower level of hemoglobin, albumin and serum calcium, along with higher level of alkaline phosphatase. SM was significantly associated with shorter medium PFS (9.4 vs. 18.3 months, p < 0.001) and OS (22.2 vs. 58.2 months, p < 0.001). Cox analysis demonstrated that SM was an independent risk factor for shorter PFS (hazard ratio 2.327 [1.429–3.789], p = 0.001) and shorter OS (hazard ratio 2.810 [1.615–4.899], p < 0.001).ConclusionIn this study, we found that SM was significantly correlated with more aggressive disease and indicated poor prognosis in PCa patients with bone metastasis. Our study may provide useful reference for the risk stratification of PCa patients.

Time to Pain Relapse After Palliative Radiotherapy for Bone Metastasis: A Prospective Multi-institutional Study.

Low risk asymptomatic bone metastasis (LRABM) without gross osteolytic changes tends to be out of indication for radiotherapy. The aim of this study was to evaluate the time between the end of palliative radiotherapy of bone metastasis (BM) until the start of new pain, in patients with painful BM. Patients with BM were prospectively assessed for location and strength of pain every month for one year after radiotherapy. The correlation of pain relapse at irradiated site, and pain onset outside the irradiated site was evaluated with sex, age, primary tumor, pathology of tumor, visceral metastases, baseline scores for Eastern Cooperative Oncology Group performance status (PS), and baseline verbal rating scale (VRS). A hundred and thirty-two patients were included (79 males and 53 females). Median age was 66 years. Primary sites were lung (n=60), breast (n=17), colon (n=12), prostate (n=11), and others (n=33) (one patient had two primary sites). Median follow-up was 185 days. Pain relief was observed in 92 patients (86.0%). Out of them, pain progression was observed in 69.6%. Median time to pain progression was 75.5 days. Pain onset outside the irradiated site was observed in 57 patients (43.2%). Median time to pain onset was 109 days. Out of the 57 patients, 13 (22.8%) had LRABM which existed before the start of radiotherapy. There were 54 patients with LRABM in this study and because many patients had more than one LRABM, the total LRABM sites were 123. Out of them, pain onset was observed within one year after irradiation in 44 (36%) lesions. Median time to pain onset was 67 days, which was the shortest of the three: irradiated site, out of the irradiated site, and LRABM site. Risk factors for high probability of pain onset within one year in LRABM lesions were female sex (showing a trend in univariate analysis), and pelvic, skull and spine metastasis (significant in multivariate analysis). Time to pain onsets in LRABM are relatively short, especially in female patients with pelvic, skull and spine metastasis. In these patients, prophylactic radiotherapy could be an option to consider.

An atypical imaging characteristic of calvarial metastasis of neuroblastoma as multiple multi-loculated cystic masses with internal blood-fluid levels: a case report

As the third most common malignancy of childhood, Neuroblastoma has a great propensity to metastasize to multiple organs. The most common site of metastasis is the bone and bone marrow. Concerning the central nervous system, neuroblastoma usually involves the calvarium and the external dural surface. The skull metastases may show different appearances, including: multiple lytic bone lesions, bone thickening, hair-on-end periosteal reaction, irregular suture widening and/or plaque like epidural deposits. Here we present a case of metastatic neuroblastoma, appearing as multiple multi-loculated cystic epidural masses with internal blood-fluid levels as a rare imaging manifestation of calvarial metastasis. An 8-year-old boy with known history of autism, presented to the emergency department with a 3-month history of intermittent fever, malaise and myalgia and headache along with significant weight loss. Laboratory examination revealed elevated ESR and CRP and anemia. On Abdomino-Pelvic imaging a well-defined, 45*30*24mm, solid-cystic mass was observed, replacing the normal left adrenal gland. On brain MRI, multiple multi-loculated cystic, lentiform masses were observed on the external surface of cerebral hemispheric dura. Multiple fluid-fluid levels were noted in the locules in some of which the dependent fluid was hyperintense on T1w and FLAIR and hypointense on T2w sequences, compatible with blood, representing blood-fluid level. The wall and septa of the masses, enhanced after contrast administration. Associated abnormal marrow signal and aggressive type periosteal reactions were identified in the overlying bone. All of the lesions had increased uptake in MIBG scan. Bone marrow biopsy revealed small round cells, diagnostic for neuroblastoma. The patient underwent chemotherapy treatment. All calvarial/epidural metastatic lesions resolved after chemotherapy and residual adrenal tumor was resected. Cystic epidural lesions, especially when associated with adjacent abnormal bone marrow signal, or periosteal reaction and containing blood-fluid level should raise the suspicion of a calvarial metastasis.

Skull Metastasis as a Primary Manifestation in Cervical Carcinoma

Skull Metastasis as a Primary Manifestation in Cervical Carcinoma

S3163 Skull Metastasis in a Patient With HCC

Introduction: Hepatocellular carcinoma (HCC) rarely metastasizes to the skull. The prevalence of skull metastasis in HCC has been described to be 6.1%. Cranial nerve deficits are seen in more than a third of patients presenting with skull metastasis. We present a patient with a diagnosis of HCC with a concomitant soft tissue mass at the clivus concerning metastatic HCC. Case Description/Methods: A 62-year-old male with a medical history of cirrhosis secondary to hepatitis C, arterial hypertension and type 2 diabetes mellitus who arrived to our institution due to 5-day history of progressive abdominal swelling and distension. In addition, he referred to having intense left-sided headache and visual disturbances, described as "double vision," three months before arrival. The physical exam showed an uncomfortable, acutely ill, with a temporal wasting patient. HEENT exam revealed the inability to abduct his left eye—suggestive of cranial nerve VI palsy—and tongue deviation to the right side. Also, the abdominal exam showed a soft and depressible abdomen, with flank dullness and mild abdominal tenderness to palpation. Imaging workup included a brain MRI which showed a soft tissue mass at the clivus extending superiorly to the suprasellar region invading the sphenoid sinuses. Additional abdominopelvic CT scan revealed a cirrhotic liver with associated portal hypertension, a large infiltrative right liver lobe LT-TIV observation due to hepatocellular carcinoma (HCC), and celiac lymph node findings concerning for metastatic disease. Management strategies include performing a diagnostic and therapeutic paracentesis which yielded results concerning portal hypertension. Neurosurgery service evaluated the patient and recommended radiotherapy without further neurosurgery management. The patient was eventually discharged home with multidisciplinary follow-up. Discussion: Skull metastasis from HCC is uncommon; but it is notorious for affecting the patient's prognosis and quality of life. Therefore, it is important to make an early diagnosis and properly manage skull metastasis from HCC. This case exhibits the importance of considering the skull and brain metastases of a hepatocellular when evaluating a patient with HCC with neurological symptoms.

Skull metastases from extramammary Paget's disease emerging 8 years after initial treatment with no local progression: illustrative case.

BACKGROUNDThe foci of distant metastasis from extramammary Paget’s disease (EMPD) are the lung, liver, truncal bones, vertebrae, and brain. However, skull metastases have not been reported.OBSERVATIONSThe authors treated a patient with calvarial and skull base metastases from EMPD who had undergone wide local resection of EMPD 8 years before, and they report his clinical course.LESSONSBecause EMPD with distant metastasis is fatal, it should be recognized that EMPD can metastasize to the skull even when it seemed to be in remission for several years.

Isolated Skull Metastasis as first presentation of possible primary from Lung

Skull or scalp metastasis is commonly seen in carcinoma of breast, prostate, kidneys and lungs. Here we report a case of 80-year-old male who presented with scalp swelling for treatment. High resonance ultrasonography (HRUS) and contrast-enhanced computed tomography (CECT) of brain showed large soft tissue lesion on right occipito-parietal region with erosion of underlying bone, suggestive of neoplastic etiology. Subsequently, on further workup, his CT thorax showed lesion in right hilar and lower lobe of right lung with mediastinal lymph nodes. Patient underwent excision of the right occipito-parietal lesion which on histopathology was reported as epithelial malignancy, favoring metastatic moderately differentiated squamous cell carcinoma. This case is reported here to emphasize the importance of good clinical workup to rule out metastatic lesions which might be the initial presentation of an unknown primary at other site.

Skull metastases and osseous venous malformations: The role of diffusion-weighted and dynamic contrast-enhanced MRI.

Skull metastasis (SM) is a common secondary malignancy. We evaluated the diagnostic performance of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (MRI) in differentiating SM from osseous venous malformations and SM of various origins. This study included 31 patients with SM (median age, 64years; range, 41-87years; 29 women; 24 and 7 patients with breast and non-small cell lung cancer, respectively) and 16 with osseous venous malformations (median age, 68years; range, 20-81years; 10 women) who underwent both DWI and dynamic contrast-enhanced MRI between January 2015 and October 2021. Normalized mean apparent diffusion coefficients (ADCs) and dynamic contrast-enhanced MRI parameters were compared between SM and osseous venous malformations, and between breast cancer and non-small cell lung cancer. Multivariate stepwise logistic regression analyses were performed to identify statistically significant parameters. Plasma volume and time-to-maximum enhancement were the most statistically significant parameters for differentiating SM from osseous venous malformations, with an area under the receiver operating characteristic curve of 0.962. The normalized mean ADC and peak enhancement values were the most statistically significant parameters for differentiating breast cancer from non-small cell lung cancer, with an area under the curve of 0.924. Our results highlight the efficacious diagnostic performance of DWI and dynamic contrast-enhanced MRI in distinguishing SM from osseous venous malformations and differentiating SM of various origins.

Correlation of findings of CT and MRI in skull lesions

Introduction: Skull vault lesions are often asymptomatic and are usually discovered incidentally during computed tomography or magnetic resonance imaging of the brain. Calvarial lesions can be benign or malignant. Calvarial lesions may arise from skull bones or can be secondary to invasion of skull vault from brain or scalp based lesions. Objectives: The aim of this study is to study the role of CT and MRI in evaluating skull vault lesions. Material and methods: 50 patients with skull vault lesions were considered in our study.The patients underwent CT and MRI scans of head. Results: Among 50 patients, most common skull vault lesions were Skull metastases, osteoma and epidermoid cyst. Chordoma, osseous hemangioma and intraosseous meningioma were the least encountered lesions. Conclusion: This article has demonstrated that CT and MRI have complementary roles in determining the nature of skull lesions. CT is the most accurate method for evaluating bone destruction of the inner and outer tables while MRI is best to assess marrow involvement, soft tissue component and invasion of adjacent tissues.

Development of Two Diagnostic Prediction Models for Leptomeningeal Metastasis in Patients With Solid Tumors.

ObjectivesFor accurate diagnosis of leptomeningeal metastasis (LM) and to avoid unnecessary examinations or lumber puncture (LP), we develop two diagnostic prediction models for patients with solid tumors.Study Design, Setting, and ParticipantsThis is a retrospective cohort study launched at the Second Affiliated Hospital of Dalian Medical University. In total, 206 patients who had been admitted between January 2005 and December 2021 with a solid tumor and clinical suspicion of LM were enrolled to develop model A. In total, 152 patients of them who underwent LPs for cytology and biochemistry were enrolled to develop model B.Model DevelopmentDiagnostic factors included skull metastasis, active brain metastasis, progressed extracranial disease, number of extracranial organs involved, number of symptoms, cerebrospinal fluid (CSF) protein, and CSF glucose. The outcome predictor was defined as the clinical diagnosis of LM. Logistic least absolute shrinkage and selection operator (LASSO) regression was used to identify relevant variables and fit the prediction model. A calibration curve and the concordance index (c-index) were used to evaluate calibration and discrimination ability. The n-fold cross-validation method was used to internally validate the models. The decision curve analysis (DCA) and the interventions avoided analysis (IAA) were used to evaluate the clinical application.ResultsThe area under the curve (AUC) values of models A and B were 0.812 (95% CI: 0.751–0.874) and 0.901 (95% CI: 0.852–0.949). Respectively, compared to the first magnetic resonance imaging (MRI) and first LP, models A and B showed a higher AUC (model A vs. first MRI: 0.812 vs. 0.743, p = 0.087; model B vs. first LP: 0.901 vs. 0.800, p = 0.010). The validated c-indexes were 0.810 (95% CI: 0.670–0.952) and 0.899 (95% CI: 0.823–0.977). The calibration curves show a good calibrated ability. The evaluation of clinical application revealed a net clinical benefit and a reduction of unnecessary interventions using the models.ConclusionsThe models can help improve diagnostic accuracy when used alone or in combination with conventional work-up. They also exhibit a net clinical benefit in medical decisions and in avoiding unnecessary interventions for patients with LM. Studies focused on external validation of our models are necessary in the future.

Papillary Thyroid Cancer Presenting as Skull Metastasis

A 73-year-old man with a history of non-Hodgkin lymphoma in remission and well-controlled hypertension presented to his primary care physician’s office with a slow growing lump on his head. He denied any headaches and visual or auditory symptoms. The lump was initially thought to be a lipoma, and he was advised to follow up. Due to the COVID-19 pandemic, the patient did not follow up. He presented 6 months later with a progressive increase in the size of the lump. Physical examination was notable for an approximately 5 × 3-cm nontender mass with smooth surface, elastic consistency at the left parietal region without any associated skin changes.

Scalp Angiosarcoma with Skull Roof Infiltration and Metastasis to the Lung.

Scalp Angiosarcoma with Skull Roof Infiltration and Metastasis to the Lung.