Keywords
tumor-to-tumor - meningioma - adenocarcinoma - prostate
Palavras-chave
tumor a tumor - meningioma - adenocarcinoma - próstata
Introduction
Metastasis is the most frequent tumors of the central nervous system. Prostatic adenocarcinoma
is the most common cancer in men and frequently metastasizes, mainly to bones and
lymph nodes. Few cases of metastasis of prostatic adenocarcinoma in the intracranial
compartment are reported in the literature. Meningiomas are the most common primary
brain tumors. Brain metastasis and meningiomas are common. However, metastases implanted
in meningiomas ('tumor-to-tumor') are extremely rare. This article aims to present
a case of a 65-year-old male patient with a radiological diagnosis of an expansive
extra-axial frontal lesion on the left, who presented with mental confusion. The anatomopathological
and immunohistochemical findings showed prostatic adenocarcinoma metastases in a transitional
meningioma. Therefore, the patient was investigated and the presence of multimetastatic
prostate neoplasm was defined.
Case Report
A 65-year-old male patient, previously with arterial hypertension, began to experience
progressive confusion two weeks before admission. On physical examination, the patient
appeared in good general condition, alert, confused (disoriented in time and space),
and without language impairment. Strength and sensitivity are preserved. No meningeal
signs. The investigation began with a non-contrast computed tomography (CT) scan of
the brain, which showed an expansile left frontal lesion that was isodense to the
parenchyma, with adjacent vasogenic edema, causing a 10 mm shift of the midline to
the right and v encephalomalacia on the right, suggestive of a previous ischemic lesion
([Fig. 1]).
Fig. 1 Non-contrast cranial CT in axial sections showing expansile frontal lesion on the
left with perilesional vasogenic edema resulting in midline shift to the right and
temporoparietal gliotic area on the right.
The investigation continued with magnetic resonance imaging (MRI) of the brain, which
showed a large expansile extra-axial frontal lesion on the left, measuring 5.1 × 5.4 × 5.3 cm,
with intense gadolinium enhancement and extensive adjacent vasogenic edema. On T2
and FLAIR, the lesion presents predominantly with hypersignal, with areas of hyposignal
within. The lesion results in compression of the frontal horn of the left lateral
ventricle. The MRI findings suggest convexity meningioma ([Fig. 2]).
Fig. 2 Figur: MRI, axial sections, A-C, flair-weighted, showing expansive lesion in the
left frontal pole, heterogeneous, with adjacent vasogenic edema. Temporoparietal gliosis
on the right (previous ischemic stroke). D-F, T2-weighted, showing cerebrospinal fluid
rim adjacent to the expansive frontal lesion, defining an extra-axial lesion. G-I,
T1-weighted with contrast, showing intense gadolinium enhancement.
Neurosurgery was indicated, and total macroscopic resection of the lesion was performed
with meningeal resection adjacent to the lesion (Simpson I). The patient progressed
satisfactorily in the postoperative period, with no new deficits and improved mental
confusion. A postoperative control CT scan of the skull was performed, with no evidence
of neurosurgical complications ([Fig. 3]).
Fig. 3 Postoperative CT of the skull and axial sections, showing complete resection of the
expansile lesion. No evidence of neurosurgical complications.
The anatomopathological examination revealed whitish and infiltrative areas in a grayish-white,
shiny lesion, sometimes lobulated, sometimes fasciculated. These findings suggest
adenocarcinoma metastasis in transitional meningioma. Immunohistochemistry confirmed
the findings, defining prostatic adenocarcinoma in transitional meningioma ([Fig. 4]).
Fig. 4 A: Meningioma without atypia with fascicular architectural pattern. B: Meningioma
without atypia and meningothelial pattern. C: Acinar pattern adenocarcinoma involving
meningioma. (Hematoxylin-eosin, 100x). D: Adenocarcinoma revealing positive immunoexpression
for NKX3. E: Adenocarcinoma revealing positive immunoexpression for CK7. F: Meningioma
revealing positive immunoexpression for EMA. (100X).
Considering the anatomopathological results, the investigation continued with oncological
screening and staging exams. CT scans of the chest, abdomen, and pelvis showed that
bone structures were extensively affected by small bone lesions with a predominantly
osteoblastic appearance ([Fig. 5]). Presence of lymph node enlargement in bilateral iliac chains, more exuberant in
external iliac chains measuring up to 3.6 × 3.4 cm on the left and 2.6 × 2.4 cm on
the right. Prominent lymph nodes in the lumbar retroperitoneum, measuring up to 1.4 × 1.0 cm
in the para-aortic chain. Prostate antigens corroborated the immunohistochemistry
findings: Free PSA: 47.7 ng/ml and total PSA: 1333 ng/ml. Thus, the diagnosis of metastatic
prostatic adenocarcinoma was confirmed.
Fig. 5 CT scan of the chest, abdomen, and pelvis, sagittal section, bone window, showing
multiple diffuse osteoblastic lesions in the spine and sternum (arrows).
Patients with adequate post-operative neurological rehabilitation followed up for
oncological treatment.
Discussion
Metastases are the most common tumors in the central nervous system and can be found
in different compartments, including brain parenchyma, meninges, cranial vault, and
ventricular system. The most common primary symptoms are lung, breast, skin (melanoma),
and kidney cancers. Prostatic adenocarcinoma is the most common cancer in men and
frequently metastasizes, mainly to the bones and lymph nodes. The spread of metastasis
of prostatic adenocarcinoma to the intracranial compartment is rare and varies from
0.2 to 0.63% in published series.[1]
[2]
[3]
[4]
[5]
Meningiomas are the most common primary brain tumors. They originate in the arachnoid
and may be either extraaxial or, less frequently, intraventricular. The most found
topographies are parasagittal, convexity, falx cerebri, and olfactory groove.
Brain metastases and meningiomas are common. However, metastases implanted in meningiomas
are extremely rare, with approximately 149 cases currently described in the literature.[1] Documented cases of metastases in meningiomas include the most common primary cancer
topography: breast, lung, skin (melanoma), kidney, gastrointestinal, and prostate,
with the first two being the most frequent. The literature shows 10 cases of prostatic
adenocarcinoma metastases in meningioma ([Table 1]).[3]
[4]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
Table 1
Published cases of patients with prostate cancer metastases in meningiomas
|
Patient
|
Age
|
Meningioma topography
|
Meningioma histology
|
Reference
|
|
1
|
70
|
Right parietal convexity
|
Meningothelial
|
[3]
|
|
2
|
75
|
Left cerebellopontine angle
|
Meningothelial
|
[6]
|
|
3
|
78
|
Falcine
|
Meningothelial
|
[7]
|
|
4
|
55
|
Parasagittal
|
Meningothelial
|
[4]
|
|
5
|
67
|
No data
|
No data
|
[8]
|
|
6
|
72
|
Falcine
|
Atypical
|
[9]
|
|
7
|
67
|
Olfactory groove
|
Meningothelial
|
[10]
|
|
8
|
58
|
Right frontal convexity
|
No data
|
[11]
|
|
9
|
57
|
Parasagittal
|
No data
|
[11]
|
|
10
|
68
|
Left sphenoid wing
|
Transitional
|
[12]
|
|
Current
|
65
|
Left frontal convexity
|
Transitional
|
Current
|
Several factors make meningiomas the most common intracranial tumors that receive
metastases, including more incident primary intracranial tumors, slow growth rate,
hypervascularity, and high collagen and lipid content. Furthermore, it is believed
that cell adhesion molecules and specific receptors in meningiomas may facilitate
the colonization of metastatic cells.[1]
[12]
The incidence of tumor metastasis is not well defined. However, it is probably underdiagnosed.
Clinical studies and published case reports highlight the importance of considering
this hypothesis in patients with meningiomas, with anatomopathological analysis of
the entire lesion being essential.[1]
Conclusion
Tumor-to-tumor metastases in intracranial neoplasms are rare. Still, they indicate
the occurrence of coexisting systemic cancer, often not yet diagnosed. Therefore,
it is essential to conduct a thorough histopathological study. Given the low incidence
of this condition, there is a lack of data in the literature that would help to better
elucidate the conditions of presentation, diagnosis, and management of these diseases.
Despite these facts, it is important to continue with the already-known treatment
of meningioma and the usual oncological management of metastatic cancer.
