Arq Neuropsiquiatr 2006;64(2-A):300-302
D e p a rtment of Neuro s u rg e ry, Hospital Nossa Senhora das Graças, Curitiba PR, Brazil: 1Resident in Neuro s u rg e ry; 2N e u ro s u rg e o n ; 3Neurosurgeon, Federal University of Sergipe (Aracaju SE, Brasil); 4Neurosurgeon Director of the Residency Program.
Received 7 June 2005, received in final form 16 January 2006. Accepted 23 January 2006.
D r. Joacir Graciolli Cord e i ro - Rua Alcides Munhoz 433 - Neuro c i ru rgia - 80810-040 Curitiba PR - Brasil. E-mail: joacirg c @ h o t m a i l . c o m
CEREBRAL META S TASIS OF CERVICAL UTERINE CANCER
Report of three cases
Joacir Graciolli Cordeiro
1, Daniel Monte-Serrat Prevedello
2,
Léo Fernando da Silva Ditzel
2, Carlos Umberto Pereira
3, João Cândido Araújo
4ABSTRACT - Cervical uterine cancer (CUC) spreads locally (pelvis and paraortic lymphnodes) or distantly (lungs, liver and bones). Metastasis to central nervous system (CNS) are rare. There are about 80 cases re p o rted in the literature. Outcome is poor and survival varies from 3 to 6 months. Three cases of CNS metastasis from CUC are reported, one infratentorial and two supratentorials in location. In one patient, the initial manifestation was due to the cerebral lesion, a feature re p o rted for the first time. All cases were t reated by surg e ry, radiotherapy and/or chemotherapy. Clinical findings and treatment options of these rare lesions are reviewed.
KEY WORDS: cerebral metastasis, cervical uterine cancer.
Metástases cerebrais de câncer de colo de útero: relato de três casos
RESUMO - Tumores do cólo uterino se disseminam por contigüidade ou via hematogênica (pulmão, fíga-do e ossos). Metástases para sistema nervoso central são incomuns. Apenas cerca de 80 casos são citafíga-dos na literatura. Manifestações clínicas são devidas à hipertensão intracraniana e a déficits focais. A sobrevi-da varia de 3 a 6 meses. Três casos são relatados sendo um infratentorial e dois supratentoriais. No primeiro , o diagnóstico da metástase antecedeu o da lesão uterina. No segundo, houve 5 anos sem recidiva após a c i ru rgia, fato este inédito. O tratamento foi ciru rgia, radioterapia e/ou quimioterapia. A discussão enfati-za manejo multidisciplinar destas raras lesões.
PALAVRAS-CHAVE: metástase cerebral, câncer de colo uterino.
C e rvical uterine cancer (CUC) is responsible for 15% of deaths due to cancer in women older than 15 years of age in Brazil1. It most often invades local
s t ru c t u res, reaching pelvis and paraortic lymphnodes. Distant organs are reached by haematogenous dis-s e m i n a t i o n1 - 4. The frequency of distant organs
metas-tasis varies from 38 to 85%5 - 7. Haematogenous spre a d
is responsible for a more aggressive behaviour. Most commonly affected distant organs are lungs, liver and bones6. Brain involvement is extremely rare1 - 2 4.
T h e re are re p o rts of cervical cancer metastasis to pitu-i t a ry gland, pancreas, ure t h e r, kpitu-idney, adrenal gland, ovaries, uterine tube, gallbladder, spine cord and to a convexity brain meningioma5,10,18,21,24.
The objective of this article is to re p o rt three cas-es of cerebral metastasis from cervical uterine can-cer and to discuss their clinical features and tre a t-ment options.
This study was perf o rmed with the approval of the Ethics Committee of the hospitals where these t h ree patients were treated. Informed consent was obtained from either the patient or a relative in all cases.
CASES
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Case 2 – A 31-year-old woman was admitted with headache and visual deficit since 2 weeks before admis-sion. She had been submitted to lung metastasis re s e c t i o n from CUC 10 months before admission in another service. She received adjuvant chemotherapy and local radiother-a p y. On physicradiother-al exradiother-aminradiother-ation she presented right homony-mous hemianopsia. Cranial MRI revealed a 3 cm diameter left occipital lesion with ring enhancement, perilesional edema and central hypointensity in T1 and hyperintensity in T2-weighted images (Fig 1). The lesion was completely removed by craniotomy and pathological diagnosis was that of low diff e rentiated carcinom a similar to her cerv i-cal uterine cancer. She received adjuvant whole brain radio-t h e r a p y. Posradio-toperaradio-tive period was unremarkable and she presented no other deficits. She had no recurrence of the
lesion and no other neurological manifestation in 5 years of follow-up (Fig 2).
Case 3 – A 31-year-old woman was admitted with hea-dache, drowsiness, vomiting, visual impairment and diplop-ia since 2 months before admission. Two years earlier she had been submitted to pan-hysterectomy for mucinous cer-vical uterine adenocarcinoma. She received adjuvant brachy-therapy and telebrachy-therapy. On physical examination she pre-sented with disorientation, right dismetria ant gait ataxia. CT scan revealed a right hemispheric cerebellar heteroge-neous lesion and supratentorial hydrocephalus. MRI showed a 5 cm diameter lesion isointense in T1-weighted images and irregular contrast enhancement. She was submitted to ventricular drainage and lesion removal through a suboc-cipital craniectomy. Specimen was compatible with low dif-f e rentiated adenocarcinoma similar to her cervical uterine c a n c e r. She received adjuvant whole brain radiotherapy. Post-operatively she developed pneumonia and urinary tract infection. Abdominal ultrasound revealed local invasi-ve re c u rrence. She died one month latter due to complica-tions of urinary tract infection.
DISCUSSION
C e rebral metastasis from cervical uterine cancer w e re re p o rted initially by Henriksen in 1949. They appear late in the clinical course of this disease1 0.
Their occurrence is very uncommon. There are about 80 cases re p o rted in literature, with brain involve-ment usually occurring late in the course of the dis-ease, usually preceeded by local pelvic invasion1-24.
Haematogenous spread depends on histological type of the tumor. Cerebral metastasis are more fre-quent in poorly diff e rentiated tumors. Histological subtypes in decreasing frequency are squamous cells c a rcinoma, adenocarcinoma, carcinoid tumor and adenosquamous carc i n o m a3 , 4 , 1 6. Cases in present
re-p o rt comre-prise one squamous cell carcinoma and two adenocarcinomas.
A c c o rdding to Kishi, most common clinical p re s-entation include headache (34%), hemiparesis (25.8%), confusion (22.7%), monoparesis (14.4%) and nausea ( 9 . 2 % )1 7. In Robinson’s re v i e w, most common initial
symptoms were hemiparesis, headache, facial palsy and seizures. Ikeda related a medium interval bet-ween initial diagnosis and brain metastasis of 28 m o n t h s1 6. Case 1 had no previous neurological or
sys-temic manifestations and re p resents the only re p o rt-ed case in which diagnosis was initially made out of a metastatic brain and scalp lesion1 - 2 4. Case 2 is fre e
f rom the disease 5 years after diagnosis and surg e ry. To our knowledge this is the first re p o rted case with such a long survival in literature1-24.
Fig 1. Case 2. Pre-operative MRI coronal image weighted in T1 showing a left occipital 3 cm diameter lesion. The lesion is ro u n d ed, well limited, with hypointense central core, ring enhance -ment and perilesional edema.
302 Arq Neuropsiquiatr 2006;64(2-A)
CUC brain metastasis are solitary in one third of the patients and frontal lobe is the most common a ffected site3 , 9 , 1 1 , 1 3 , 1 4 , 1 8 , 2 2. In Ikeda´s re v i e w, 50% were
s o l i t a ry lesions and all of them were supratentori-a l .1 6. Cormio re p o rted 6 single lesions, 8 multiple, 10
supratentorial, 2 cerebellar and 2 with infra and su-pratentorial involvement2 , 1 2. As opposed to the
liter-a t u re, our 3 cliter-ases were solitliter-ary lesions liter-and none in frontal lobe.
CUC brain metastasis are usually treated by sur-g e ry, chemotherapy and radiotherapy. Sursur-gical re m o-val is a consensus in the literature for solitary le-s i o n le-s4 , 1 9 , 2 0. Surg e ry may also be considered in case of
two or more lesions surgically removable in the same c r a n i o t o m y2 3. Other surgical indications are lack of
diagnosis, life threatening situations (hemorrh a g e , h y d rocephalus or infection), symptomatic relief after ineffective clinical treatment and insertion of intra-thecal chemotherapy devices23.
Radiotherapy may play an adjuvant role to surg i-cal resection or remains as the only loi-cal treatment, associated or not to chemotherapy. Patchell re v e a l e d that patients treated with surg e ry plus radiotherapy had longer survival, better neurological condition and lower re c u rrence of the disease in the nerv o u s system, when compared to those who received radio-therapy alone1 9. Most of the authors consider surg
e-ry followed by adjuvant radiotherapy the best option for solitary CUC brain metastasis5,6,10,12,16,18,21.
S t e reotaxic radiosurg e ry is as effective as conven-tional surgery for local brain metastasis control and may also be used in inaccessible lesions8. There are
no data in literature about radiosurg e ry effects in CUC brain metastasis. The decision between conven-tional craniotomy plus adjuvant radiotherapy and r a d i o s u rg e ry must be made on an individual basis, considering size, number and location of the lesion, clinical condition and available technology4 , 5 , 6 , 8 , 1 6 , 2 0 , 2 3.
Chemotherapy plays an important role in clinical t reatment of CUC and cisplatin is the most fre q u e n t-ly used drug. Chemotherapy may determine regres-sion of CUC brain metastasis and also has systemic e ffect. Its final influence in the outcome of CUC cere-bral metastasis is still unknown2 , 3 , 6 , 1 2. In cases with
multiple lesions, chemotherapy may be the first choice of tre a t m e n t5 , 6 , 1 0 , 1 2 , 1 6 , 1 8 , 2 1. Cases 2 and 3
devel-oped brain metastasis despite adjuvant chemother-apy for uterine disease.
Other therapeutic suggested strategies in study for clinical treatment of unresecable metastasis in-clude selective intra-arterial chemotherapy, use of
reversible haemato-encephalic barrier modifiers and h o rmonal therapy (melatonin) without, however, w o rthwhile eff e c t2. Outcome of patients with CUC
brain metastasis depends on age, neurological sta-tus, length of clinical history, histological subtypes, number of lesions and clinical comorbidities. The p rognosis is poor despite any treatment option, with s u rvival of 3 to 6 months after diagnosis of brain metastasis10.
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