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Hurthle cell carcinoma presenting as a single choroid plexus metastasis
Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Report
Hurthle cell carcinoma presenting as a single choroid plexus metastasis Andrew T. Healy a,⇑, Balint Otvos b, Jason Schroeder c, Amir H. Hamrahian d, Lilyana Angelov a, Kambiz Kamian a a
Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA Case Western Reserve University, Lerner College of Medicine, Cleveland, OH, USA c Department of Neurosurgery, University of Toledo, Toledo, OH, USA d Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA b
a r t i c l e
i n f o
Article history: Received 19 December 2013 Accepted 24 December 2013 Available online xxxx Keywords: Central nervous system metastases Choroid plexus Hurthle cell carcinoma Intraventricular mass
a b s t r a c t Choroid plexus masses represent approximately 0.3–0.8% of intracranial tumors. Herein we present, to our knowledge, the first reported patient with an isolated Hurthle cell papillary thyroid carcinoma metastasis to the choroid plexus of the lateral ventricle. Unresponsive to iodine ablation and refusing surgery, the patient underwent Gamma Knife radiosurgery (Elekta AB, Stockholm, Sweden), receiving 15 Gy to the 50% isodose line. The lesion regressed until 5 years later at which time it was unresponsive to 18 Gy and required surgical resection. Although extraneural metastatic cancers are recognized as potential sources for the single choroid plexus mass, we must consider even the unusual culprit in patients with a history of cancer. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Choroid plexus (CP) tumors are rare, representing approximately 0.3–0.8% of intracranial tumors [1,2] and only 6–7% of intraventricular mass lesions [3]. Excluding extension of primary parenchymal lesions into the CP, the remainder of masses arising from the CP are most often CP papillomas, outnumbering CP carcinomas five-to-one [1]. Although rare, extraneural metastases to the CP have been increasingly recognized [3–8]. Two existing case reports involve thyroid carcinoma metastasizing to the CP with either papillary [4] or follicular histologies [7]. However, to our knowledge, no reports exist of Hurthle cell papillary thyroid carcinoma (HCPTC) metastasizing to the CP.
2. Case report 2.1. History and examination A 70-year-old woman presented with an enlarging cervical mass in January of 2005. She was diagnosed with Stage II T3N0M0 HCPTC and underwent complete thyroidectomy and adjuvant radioactiveiodine ablation. In October 2005, positron emission tomography ⇑ Corresponding author. Tel.: +1 216 444 2200. E-mail address: [email protected] (A.T. Healy).
revealed an incidental 3.4 cubic centimeter (cc) left temporal lesion. MRI revealed a heterogeneously enhancing, well circumscribed intraventricular mass with elevated cerebral blood volume. On subsequent imaging in January 2006, there was an increase in the size of the lesion 5.3 cc (Fig. 1A). Surgery was recommended, however the patient chose to continue with observation. An octreotide scan demonstrated uptake within mass, as well as the neck, suggesting metastatic disease or intraventricular meningioma (Fig. 1B). Due to her refusal of surgery, the lesion was treated with Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden).
2.2. Treatment course The patient underwent GKRS in June 2006 with 15 Gy to the 50% isodose line covering 100% of the target. The lesion regressed to 0.9 cc in October 2011 (Fig. 2A) until asymptomatic enlargement prompted re-treatment (18 Gy at the 50% isodose line). Initially stable, she began to develop cognitive impairment and speech difficulty. MRI at that time revealed post-radiation changes in addition to tumor enlargement (Fig. 2B) leading to the surgical resection of the mass in June 2012. Pathology demonstrated metastatic HCPTC. Post-operative MRI confirmed gross total resection (Fig. 3). The patient recovered well and was without evidence of tumor recurrence at the time of writing.
http://dx.doi.org/10.1016/j.jocn.2013.12.012 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Healy AT et al. Hurthle cell carcinoma presenting as a single choroid plexus metastasis. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2013.12.012
2
Case Report / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Fig. 1. Pre-treatment imaging depicting axial (A) T1-weighted MRI with gadolinium contrast administration (January 2006) and (B) an octreotide scan (May 2006) with uptake noted within the left lateral ventricular lesion.
Fig. 2. Axial T1-weighted MRI with gadolinium administration post-radiosurgery showing (A) the greatest reduction in tumor dimensions (October 2011), following 15 Gy to the 50% isodose line and (B) lesion recurrence following 18 Gy to the 50% isodose line, with lesional, as well as local subependymal enhancement (May 2012).
3. Discussion Distant metastases from thyroid cancers occur in up to 8.7% of diagnosed cases, with metastasis to the brain occurring in just 0.9–1.5% of patients [4,7,9,10]. Once brain metastasis occurs, prognosis is considered poor, as it is felt to represent the final stages of otherwise widely metastatic disease [10,11]. HCPTC is a variant of differentiated thyroid carcinoma, comprising 1–11% of cases [11– 15]. While HCPTC tends to be more aggressive, radio-resistant and chemo-resistant; [9,11–14] spread is thought to be initially via lymphatics and seeding of the CP in the absence of other metastases is surprising [14]. The limited systemic treatment options substantiate the importance of surgical intervention [10]. Surgery has been demonstrated as having a positive survival benefit in the management of metastatic thyroid carcinomas to the brain [15], however, adjuvant therapies for cerebral HCPTC metastases have not been established. Prior reports have not demonstrated a significant benefit of stereotactic radiosurgery for the management of brain metastases from Hurthle cell cancers [11,16]. We achieved partial regression of the lesion with reduction
in volume from 5.3 cc in May 2005 to 0.9 cc in May 2011 after treatment with 15 Gy to the 50% isodose line. The overall survival time of the patient presented in this case report is atypical, and might be used as an anecdote of multimodal treatment for this type of tumor. 4. Conclusions We present to our knowledge the first report of HCPTC metastasizing to the CP, existing as an isolated intracranial metastasis. In this patient GKRS (15 Gy) to the lesion provided regression of the mass with recurrence over 5 years later. Although some extraneural metastatic cancers are recognized as potential sources for the single CP mass, even this unusual culprit must be considered. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
Please cite this article in press as: Healy AT et al. Hurthle cell carcinoma presenting as a single choroid plexus metastasis. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2013.12.012
Case Report / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Fig. 3. Axial T1-weighted MRI with gadolinium administration following left temporal craniotomy demonstrating gross total resection (June 2012).
3
[2] Wolff JE, Sajedi M, Brant R, et al. Choroid plexus tumors. Br J Cancer 2002;87:1086–91. [3] Kadrian D, Tan L. Single choroid plexus metastasis 16 years after nephrectomy for renal cell carcinoma: case report and review of the literature. J Clin Neurosci 2004;11:88–91. [4] Wasita B, Sakamoto M, Mizushima M, et al. Choroid plexus metastasis from papillary thyroid carcinoma presenting with intraventricular hemorrhage: case report. Neurosurgery 2010;66:E1213–4. [5] Leach JC, Garrott H, King JA, et al. Solitary metastasis to the choroid plexus of the third ventricle mimicking a colloid cyst: a report of two cases. J Clin Neurosci 2004;11:521–3. [6] Sung WS, Dubey A, Erasmus A, et al. Solitary choroid plexus metastasis from carcinoma of the oesophagus. J Clin Neurosci 2008;15:594–7. [7] Zhang YA, Kavar B, Drummond KJ. Thyroid carcinoma metastasis to the choroid plexus of the lateral ventricle. J Clin Neurosci 2009;16:118–21. [8] Toms SA, Suh JH, Weil RJ. Choroid plexus metastasis. Urology 2007;70:370–1. [9] Benbassat CA, Mechlis-Frish S, Hirsch D. Clinicopathological characteristics and long-term outcome in patients with distant metastases from differentiated thyroid cancer. World J Surg 2006;30:1088–95. [10] Salvati M, Frati A, Rocchi G, et al. Single brain metastasis from thyroid cancer: report of twelve cases and review of the literature. J Neurooncol 2001;51:33–40. [11] Bernad DM, Sperduto PW, Souhami L, et al. Stereotactic radiosurgery in the management of brain metastases from primary thyroid cancers. J Neurooncol 2010;98:249–52. [12] Besic N, Hocevar M, Zgajnar J, et al. Aggressiveness of therapy and prognosis of patients with Hürthle cell papillary thyroid carcinoma. Thyroid 2006;16:67–72. [13] Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Am J Surg 1996;172:692–4. [14] Cannon J. The significance of Hurthle cells in thyroid disease. Oncologist 2011;16:1380–7. [15] McWilliams RR, Giannini C, Hay ID, et al. Management of brain metastases from thyroid carcinoma: a study of 16 pathologically confirmed cases over 25 years. Cancer 2003;98:356–62. [16] Heery CR, Engelhard HH, Slavin KV, et al. Unusual CNS presentation of thyroid cancer. Clin Neurol Neurosurg 2012;114:1107–9.
References [1] Safaee M, Oh MC, Bloch O, et al. Choroid plexus papillomas: advances in molecular biology and understanding of tumorigenesis. J Neurooncol 2013;15:255–67.
Please cite this article in press as: Healy AT et al. Hurthle cell carcinoma presenting as a single choroid plexus metastasis. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2013.12.012
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Report
Hurthle cell carcinoma presenting as a single choroid plexus metastasis Andrew T. Healy a,⇑, Balint Otvos b, Jason Schroeder c, Amir H. Hamrahian d, Lilyana Angelov a, Kambiz Kamian a a
Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA Case Western Reserve University, Lerner College of Medicine, Cleveland, OH, USA c Department of Neurosurgery, University of Toledo, Toledo, OH, USA d Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA b
a r t i c l e
i n f o
Article history: Received 19 December 2013 Accepted 24 December 2013 Available online xxxx Keywords: Central nervous system metastases Choroid plexus Hurthle cell carcinoma Intraventricular mass
a b s t r a c t Choroid plexus masses represent approximately 0.3–0.8% of intracranial tumors. Herein we present, to our knowledge, the first reported patient with an isolated Hurthle cell papillary thyroid carcinoma metastasis to the choroid plexus of the lateral ventricle. Unresponsive to iodine ablation and refusing surgery, the patient underwent Gamma Knife radiosurgery (Elekta AB, Stockholm, Sweden), receiving 15 Gy to the 50% isodose line. The lesion regressed until 5 years later at which time it was unresponsive to 18 Gy and required surgical resection. Although extraneural metastatic cancers are recognized as potential sources for the single choroid plexus mass, we must consider even the unusual culprit in patients with a history of cancer. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Choroid plexus (CP) tumors are rare, representing approximately 0.3–0.8% of intracranial tumors [1,2] and only 6–7% of intraventricular mass lesions [3]. Excluding extension of primary parenchymal lesions into the CP, the remainder of masses arising from the CP are most often CP papillomas, outnumbering CP carcinomas five-to-one [1]. Although rare, extraneural metastases to the CP have been increasingly recognized [3–8]. Two existing case reports involve thyroid carcinoma metastasizing to the CP with either papillary [4] or follicular histologies [7]. However, to our knowledge, no reports exist of Hurthle cell papillary thyroid carcinoma (HCPTC) metastasizing to the CP.
2. Case report 2.1. History and examination A 70-year-old woman presented with an enlarging cervical mass in January of 2005. She was diagnosed with Stage II T3N0M0 HCPTC and underwent complete thyroidectomy and adjuvant radioactiveiodine ablation. In October 2005, positron emission tomography ⇑ Corresponding author. Tel.: +1 216 444 2200. E-mail address: [email protected] (A.T. Healy).
revealed an incidental 3.4 cubic centimeter (cc) left temporal lesion. MRI revealed a heterogeneously enhancing, well circumscribed intraventricular mass with elevated cerebral blood volume. On subsequent imaging in January 2006, there was an increase in the size of the lesion 5.3 cc (Fig. 1A). Surgery was recommended, however the patient chose to continue with observation. An octreotide scan demonstrated uptake within mass, as well as the neck, suggesting metastatic disease or intraventricular meningioma (Fig. 1B). Due to her refusal of surgery, the lesion was treated with Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden).
2.2. Treatment course The patient underwent GKRS in June 2006 with 15 Gy to the 50% isodose line covering 100% of the target. The lesion regressed to 0.9 cc in October 2011 (Fig. 2A) until asymptomatic enlargement prompted re-treatment (18 Gy at the 50% isodose line). Initially stable, she began to develop cognitive impairment and speech difficulty. MRI at that time revealed post-radiation changes in addition to tumor enlargement (Fig. 2B) leading to the surgical resection of the mass in June 2012. Pathology demonstrated metastatic HCPTC. Post-operative MRI confirmed gross total resection (Fig. 3). The patient recovered well and was without evidence of tumor recurrence at the time of writing.
http://dx.doi.org/10.1016/j.jocn.2013.12.012 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Healy AT et al. Hurthle cell carcinoma presenting as a single choroid plexus metastasis. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2013.12.012
2
Case Report / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Fig. 1. Pre-treatment imaging depicting axial (A) T1-weighted MRI with gadolinium contrast administration (January 2006) and (B) an octreotide scan (May 2006) with uptake noted within the left lateral ventricular lesion.
Fig. 2. Axial T1-weighted MRI with gadolinium administration post-radiosurgery showing (A) the greatest reduction in tumor dimensions (October 2011), following 15 Gy to the 50% isodose line and (B) lesion recurrence following 18 Gy to the 50% isodose line, with lesional, as well as local subependymal enhancement (May 2012).
3. Discussion Distant metastases from thyroid cancers occur in up to 8.7% of diagnosed cases, with metastasis to the brain occurring in just 0.9–1.5% of patients [4,7,9,10]. Once brain metastasis occurs, prognosis is considered poor, as it is felt to represent the final stages of otherwise widely metastatic disease [10,11]. HCPTC is a variant of differentiated thyroid carcinoma, comprising 1–11% of cases [11– 15]. While HCPTC tends to be more aggressive, radio-resistant and chemo-resistant; [9,11–14] spread is thought to be initially via lymphatics and seeding of the CP in the absence of other metastases is surprising [14]. The limited systemic treatment options substantiate the importance of surgical intervention [10]. Surgery has been demonstrated as having a positive survival benefit in the management of metastatic thyroid carcinomas to the brain [15], however, adjuvant therapies for cerebral HCPTC metastases have not been established. Prior reports have not demonstrated a significant benefit of stereotactic radiosurgery for the management of brain metastases from Hurthle cell cancers [11,16]. We achieved partial regression of the lesion with reduction
in volume from 5.3 cc in May 2005 to 0.9 cc in May 2011 after treatment with 15 Gy to the 50% isodose line. The overall survival time of the patient presented in this case report is atypical, and might be used as an anecdote of multimodal treatment for this type of tumor. 4. Conclusions We present to our knowledge the first report of HCPTC metastasizing to the CP, existing as an isolated intracranial metastasis. In this patient GKRS (15 Gy) to the lesion provided regression of the mass with recurrence over 5 years later. Although some extraneural metastatic cancers are recognized as potential sources for the single CP mass, even this unusual culprit must be considered. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
Please cite this article in press as: Healy AT et al. Hurthle cell carcinoma presenting as a single choroid plexus metastasis. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2013.12.012
Case Report / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Fig. 3. Axial T1-weighted MRI with gadolinium administration following left temporal craniotomy demonstrating gross total resection (June 2012).
3
[2] Wolff JE, Sajedi M, Brant R, et al. Choroid plexus tumors. Br J Cancer 2002;87:1086–91. [3] Kadrian D, Tan L. Single choroid plexus metastasis 16 years after nephrectomy for renal cell carcinoma: case report and review of the literature. J Clin Neurosci 2004;11:88–91. [4] Wasita B, Sakamoto M, Mizushima M, et al. Choroid plexus metastasis from papillary thyroid carcinoma presenting with intraventricular hemorrhage: case report. Neurosurgery 2010;66:E1213–4. [5] Leach JC, Garrott H, King JA, et al. Solitary metastasis to the choroid plexus of the third ventricle mimicking a colloid cyst: a report of two cases. J Clin Neurosci 2004;11:521–3. [6] Sung WS, Dubey A, Erasmus A, et al. Solitary choroid plexus metastasis from carcinoma of the oesophagus. J Clin Neurosci 2008;15:594–7. [7] Zhang YA, Kavar B, Drummond KJ. Thyroid carcinoma metastasis to the choroid plexus of the lateral ventricle. J Clin Neurosci 2009;16:118–21. [8] Toms SA, Suh JH, Weil RJ. Choroid plexus metastasis. Urology 2007;70:370–1. [9] Benbassat CA, Mechlis-Frish S, Hirsch D. Clinicopathological characteristics and long-term outcome in patients with distant metastases from differentiated thyroid cancer. World J Surg 2006;30:1088–95. [10] Salvati M, Frati A, Rocchi G, et al. Single brain metastasis from thyroid cancer: report of twelve cases and review of the literature. J Neurooncol 2001;51:33–40. [11] Bernad DM, Sperduto PW, Souhami L, et al. Stereotactic radiosurgery in the management of brain metastases from primary thyroid cancers. J Neurooncol 2010;98:249–52. [12] Besic N, Hocevar M, Zgajnar J, et al. Aggressiveness of therapy and prognosis of patients with Hürthle cell papillary thyroid carcinoma. Thyroid 2006;16:67–72. [13] Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Am J Surg 1996;172:692–4. [14] Cannon J. The significance of Hurthle cells in thyroid disease. Oncologist 2011;16:1380–7. [15] McWilliams RR, Giannini C, Hay ID, et al. Management of brain metastases from thyroid carcinoma: a study of 16 pathologically confirmed cases over 25 years. Cancer 2003;98:356–62. [16] Heery CR, Engelhard HH, Slavin KV, et al. Unusual CNS presentation of thyroid cancer. Clin Neurol Neurosurg 2012;114:1107–9.
References [1] Safaee M, Oh MC, Bloch O, et al. Choroid plexus papillomas: advances in molecular biology and understanding of tumorigenesis. J Neurooncol 2013;15:255–67.
Please cite this article in press as: Healy AT et al. Hurthle cell carcinoma presenting as a single choroid plexus metastasis. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2013.12.012