- Email: [email protected]
Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma
Journal of Clinical Neuroscience xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Review
Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma Sahejmeet S. Guraya a, Richard A. Prayson b,⇑ a b
Case Western Reserve University, School of Medicine, Cleveland, OH, USA Department of Anatomic Pathology (L25), The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195-5138, USA
a r t i c l e
i n f o
Article history: Received 4 May 2016 Accepted 5 June 2016 Available online xxxx Keywords: Brain tumor Meningioma Metastasis Prostatic adenocarcinoma Tumor-to-tumor metastasis
a b s t r a c t The diagnosis of a tumor-to-tumor metastasis in the central nervous system most commonly involves metastasis to a meningioma. These combined lesions are often radiographically unsuspected and mimic a meningioma. Most commonly, the source of metastatic disease are carcinomas from the lung and breast. To our knowledge, fewer than a half dozen cases of metastatic prostatic adenocarcinoma to a meningioma have been documented in the literature. This report documents a 67-year-old man who presented with worsening confusion and altered mental status, accompanied by symptoms of increased urinary frequency, incontinence, and difficulty urinating. Imaging revealed a mass at the base of the bladder and an intracranial lesion, surrounded by edema, which was initially suspicious for intracranial metastasis of prostate cancer. Due to worsening neurological symptoms, the patient underwent craniotomy to remove the intracranial mass. The mass was comprised of a meningothelial meningioma, World Health Organization Grade I, accompanied by atypical epithelioid cells which demonstrated immunoreactivity to prostate specific antigen, chromogranin and neuron specific enolase antibodies, consistent with a metastatic prostatic adenocarcinoma with neuroendocrine differentiation. The patient suffered severe neurological complications post-operatively, developed multiple metastases and expired 12 months later. The report reviews current theories as to why meningiomas are the most common host tumor for tumor-to-tumor metastases in the brain and reviews the literature on previously reported cases involving metastatic prostatic adenocarcinoma. Ó 2016 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Tumor-to-tumor metastasis of systemic cancer to a meningioma is an unusual occurrence with only approximately 100 patients with this phenomenon reported in the literature, to our knowledge. The majority of patient reports involve metastases from lung and breast cancers; these patients are typically older, female and as expected, are often associated with poor outcomes [1,2]. Only rare instances of tumor-to-tumor metastasis to a meningioma have been associated with prostatic adenocarcinoma [2–4]. Radiological imaging of these lesions is unable to detect the coexistence of the two lesions and can sometimes be confused with intracranial metastatic prostate disease [3]. Most occurrences are discovered incidentally upon post-operative histological examination of the lesion after rapid onset of neurological symptoms due to a presumed metastasis [1,2].
A 67-year-old man with a history of alcohol abuse presented with progressively worsening confusion and altered mental status over a 3.5-month period. On review of symptoms, the patient also complained of increased urinary frequency, occasional incontinence, and difficulty urinating. Since the onset of these symptoms, the patient had undergone a funduscopic evaluation positive for papilledema as well as abdominal CT, which revealed a 5.9 cm mass indenting the base of the bladder. Concurrent blood tests also found elevated prostate specific antigen (PSA). Subsequent head CT scan and brain MRI revealed a 5.3 cm olfactory groove meningioma with significant vasogenic edema, which was closely associated with the planum sphenoidale and anterior falx. This lesion was found to have a significant mass effect on the frontal lobes bilaterally, as well as evidence of effacement of the frontal horn of both lateral ventricles. Initial medical treatment including regimens of dexamethasone, steroid injection, and levetiracetam failed to control the patient’s neurological symptomology. A craniotomy was performed to excise the tumor.
⇑ Corresponding author. Tel.: +1 216 444 8805; fax: +1 216 445 6967. E-mail address: [email protected] (R.A. Prayson). http://dx.doi.org/10.1016/j.jocn.2016.06.004 0967-5868/Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Guraya SS, Prayson RA. Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.06.004
2
S.S. Guraya, R.A. Prayson / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
Table 1 Summary of clinicopathologic features of metastatic prostate cancer to meningioma reported in the loterature Patient
Age (years)
Sex
Presentation
Meningioma Morphology
Prostate Cancer Type
Outcome
References
1
70
Male
Left facial droop, left-sided weakness and slurred speech
Meningothelial
Adenocarcinoma
[3]
History of falls, multiple hematomas
Endotheliomatous (Meningothelial)
Adenocarcinoma
Progressive lower body weakness Left-sided weakness primary of lower body, intermittent dull headache of right frontal area for past 3–4 years with recent nausea Fever, various psychiatric diagnoses Conscious collapse, seizure
Meningothelial Endotheliomatous (Meningothelial)
Carcinoma Adenocarcinoma
Unknown
Adenocarcinoma
Subtotal resection with adjuvant chemotherapy (goserelin and prednisone daily) and local radiotherapy. Patient alive 17 months after presentation Patient expired 10 hours after admission from brainstem compression from mass effect of the lesion Unknown Total resection with adjuvant whole-brain radiotherapy. Patient regained ability to walk over next 6 months, expired from pulmonary collapse at an unknown time post-procedure Lesion found at autopsy
2
75
Male
3 4
78 55
Male Male
5
67
Male
6
72
Male
Atypical
Adenocarcinoma
[8]
Meningothelial
Adenocarcinoma
Total resection with adjuvant chemotherapy and radiotherapy. Unknown follow-up. Subtotal resection with palliative radiotherapy. Patient expired 12 months after presentation
Current
67
Male
Worsening confusion, altered mental status, increased urinary frequency, occasional incontinence, and difficulty urinating
Fig. 1. Histological examination of the surgical specimen. Larger, atypical cells representing the prostate adenocarcinoma metastasis are seen juxtaposed to a meningothelial meningioma (hematoxylin and eosin, original magnification 200).
[4]
[5] [6]
[7]
N/A
Fig. 2. Immunohistochemical examination of the surgical specimen. Prostate specific antigen antibody positivity was present in the metastasis, consistent with prostatic adenocarcinoma (original magnification 200).
3. Discussion Upon histologic examination, the mass was found to have a biphasic appearance (Fig. 1). Some areas contained oval meningothelial cells without prominent nucleoli and an occasional intermixed psammoma body, consistent with a World Health Organization Grade I meningioma. Juxtaposed with the meningioma, were nests and cords of larger, atypical epithelioid cells which stained positively for PSA (1:2400 dilution; Dako, Carpentaria, CA, USA), chromogranin (1:100 dilution; DAKO), neuron specific enolase (1:50 dilution; DAKO) consistent with a metastatic prostatic adenocarcinoma with neuroendocrine differentiation (Fig. 2). Post-operatively, the patient reported chronic fatigue, weakness, gait imbalance, multiple falls and both long and short term memory loss. He developed multiple metastases to other organ systems including liver and bone (vertebral column) leading to a regimen of radiation therapy and palliative care to manage symptoms. The patient expired 12 months later.
Meningiomas represent the most common host for a tumor-totumor metastasis within the central nervous system [1]. The reason for this is not well understood. Theories posited by various authors include: the low metabolic rate of meningioma acting as a non-competitive environment for tumor growth; the collagen and lipid rich content of meningioma providing an energy rich environment for growth; the extensive vascularity of meningiomas increases the likelihood of a hematogenously disseminated metastasis; and complementary interactions between cell adhesion molecules of both lesions [1]. Of the 114 cases of tumor-to-tumor metastasis to meningiomas reviewed by Erdogan et al., only two such phenomena were attributed to prostatic adenocarcinoma [2], and only six such cases are found within the literature [3–8] (Table 1). Differentiating between these tumors and intracranial prostatic metastases is complicated by the latter neoplasm’s ability to present as
Please cite this article in press as: Guraya SS, Prayson RA. Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.06.004
S.S. Guraya, R.A. Prayson / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
a dural based mass which can simulate a meningioma [8], as was seen in this patient. It is of no surprise then, that all patients with this occurrence have been diagnosed after histological examination post-operatively. As was seen in this patient, resection of the lesion can alleviate the neurological symptoms involved, and should be complemented with radiation therapy and adjuvant chemotherapy to manage the underlying cancer of the prostate [3,8].
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.
3
References [1] Lanotte M, Benech F, Panciani PP, et al. Systemic cancer metastasis in a meningioma: Report of two cases and review of the literature. Clin Neurol Neurosurg 2009;111:87–93. [2] Erdogan H, Aydin MV, Tasdemiroglu E. Tumor-to-tumor metastasis of the central nervous system. Turk Neurosurg 2014;24:151–62. [3] Pugsley D, Bailly G, Gupta R, et al. A case of metastatic adenocarcinoma of the prostate arising in a meningioma. Can Urol Assoc J 2009;3:E4–6. [4] Döring L. Metastasis of carcinoma of prostate to meningioma. Virchows Arch A 1975;366:87–91. [5] Cluroe AD. Metastasis to meningioma: clues and investigation. Pathology 2006;38:76–8. [6] Bernstein RA, Grmet KA, Wetzel N. Metastasis of prostatic carcinoma to intracranial meningioma. J Neurosurg 1983;58:774–7. [7] Chambers PW, Davis RL, Blanding JD, et al. Metastases to primary intracranial meningiomas and neurilemomas. Arch Pathol Lab Med 1980;104:350–4. [8] Mitchell RA, Dimou J, Tsui A, et al. Metastatic prostate adenocarcinoma invading an atypical meningioma. J Clin Neurosci 2011;18:1723–5.
Please cite this article in press as: Guraya SS, Prayson RA. Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.06.004
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Review
Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma Sahejmeet S. Guraya a, Richard A. Prayson b,⇑ a b
Case Western Reserve University, School of Medicine, Cleveland, OH, USA Department of Anatomic Pathology (L25), The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195-5138, USA
a r t i c l e
i n f o
Article history: Received 4 May 2016 Accepted 5 June 2016 Available online xxxx Keywords: Brain tumor Meningioma Metastasis Prostatic adenocarcinoma Tumor-to-tumor metastasis
a b s t r a c t The diagnosis of a tumor-to-tumor metastasis in the central nervous system most commonly involves metastasis to a meningioma. These combined lesions are often radiographically unsuspected and mimic a meningioma. Most commonly, the source of metastatic disease are carcinomas from the lung and breast. To our knowledge, fewer than a half dozen cases of metastatic prostatic adenocarcinoma to a meningioma have been documented in the literature. This report documents a 67-year-old man who presented with worsening confusion and altered mental status, accompanied by symptoms of increased urinary frequency, incontinence, and difficulty urinating. Imaging revealed a mass at the base of the bladder and an intracranial lesion, surrounded by edema, which was initially suspicious for intracranial metastasis of prostate cancer. Due to worsening neurological symptoms, the patient underwent craniotomy to remove the intracranial mass. The mass was comprised of a meningothelial meningioma, World Health Organization Grade I, accompanied by atypical epithelioid cells which demonstrated immunoreactivity to prostate specific antigen, chromogranin and neuron specific enolase antibodies, consistent with a metastatic prostatic adenocarcinoma with neuroendocrine differentiation. The patient suffered severe neurological complications post-operatively, developed multiple metastases and expired 12 months later. The report reviews current theories as to why meningiomas are the most common host tumor for tumor-to-tumor metastases in the brain and reviews the literature on previously reported cases involving metastatic prostatic adenocarcinoma. Ó 2016 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Tumor-to-tumor metastasis of systemic cancer to a meningioma is an unusual occurrence with only approximately 100 patients with this phenomenon reported in the literature, to our knowledge. The majority of patient reports involve metastases from lung and breast cancers; these patients are typically older, female and as expected, are often associated with poor outcomes [1,2]. Only rare instances of tumor-to-tumor metastasis to a meningioma have been associated with prostatic adenocarcinoma [2–4]. Radiological imaging of these lesions is unable to detect the coexistence of the two lesions and can sometimes be confused with intracranial metastatic prostate disease [3]. Most occurrences are discovered incidentally upon post-operative histological examination of the lesion after rapid onset of neurological symptoms due to a presumed metastasis [1,2].
A 67-year-old man with a history of alcohol abuse presented with progressively worsening confusion and altered mental status over a 3.5-month period. On review of symptoms, the patient also complained of increased urinary frequency, occasional incontinence, and difficulty urinating. Since the onset of these symptoms, the patient had undergone a funduscopic evaluation positive for papilledema as well as abdominal CT, which revealed a 5.9 cm mass indenting the base of the bladder. Concurrent blood tests also found elevated prostate specific antigen (PSA). Subsequent head CT scan and brain MRI revealed a 5.3 cm olfactory groove meningioma with significant vasogenic edema, which was closely associated with the planum sphenoidale and anterior falx. This lesion was found to have a significant mass effect on the frontal lobes bilaterally, as well as evidence of effacement of the frontal horn of both lateral ventricles. Initial medical treatment including regimens of dexamethasone, steroid injection, and levetiracetam failed to control the patient’s neurological symptomology. A craniotomy was performed to excise the tumor.
⇑ Corresponding author. Tel.: +1 216 444 8805; fax: +1 216 445 6967. E-mail address: [email protected] (R.A. Prayson). http://dx.doi.org/10.1016/j.jocn.2016.06.004 0967-5868/Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Guraya SS, Prayson RA. Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.06.004
2
S.S. Guraya, R.A. Prayson / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
Table 1 Summary of clinicopathologic features of metastatic prostate cancer to meningioma reported in the loterature Patient
Age (years)
Sex
Presentation
Meningioma Morphology
Prostate Cancer Type
Outcome
References
1
70
Male
Left facial droop, left-sided weakness and slurred speech
Meningothelial
Adenocarcinoma
[3]
History of falls, multiple hematomas
Endotheliomatous (Meningothelial)
Adenocarcinoma
Progressive lower body weakness Left-sided weakness primary of lower body, intermittent dull headache of right frontal area for past 3–4 years with recent nausea Fever, various psychiatric diagnoses Conscious collapse, seizure
Meningothelial Endotheliomatous (Meningothelial)
Carcinoma Adenocarcinoma
Unknown
Adenocarcinoma
Subtotal resection with adjuvant chemotherapy (goserelin and prednisone daily) and local radiotherapy. Patient alive 17 months after presentation Patient expired 10 hours after admission from brainstem compression from mass effect of the lesion Unknown Total resection with adjuvant whole-brain radiotherapy. Patient regained ability to walk over next 6 months, expired from pulmonary collapse at an unknown time post-procedure Lesion found at autopsy
2
75
Male
3 4
78 55
Male Male
5
67
Male
6
72
Male
Atypical
Adenocarcinoma
[8]
Meningothelial
Adenocarcinoma
Total resection with adjuvant chemotherapy and radiotherapy. Unknown follow-up. Subtotal resection with palliative radiotherapy. Patient expired 12 months after presentation
Current
67
Male
Worsening confusion, altered mental status, increased urinary frequency, occasional incontinence, and difficulty urinating
Fig. 1. Histological examination of the surgical specimen. Larger, atypical cells representing the prostate adenocarcinoma metastasis are seen juxtaposed to a meningothelial meningioma (hematoxylin and eosin, original magnification 200).
[4]
[5] [6]
[7]
N/A
Fig. 2. Immunohistochemical examination of the surgical specimen. Prostate specific antigen antibody positivity was present in the metastasis, consistent with prostatic adenocarcinoma (original magnification 200).
3. Discussion Upon histologic examination, the mass was found to have a biphasic appearance (Fig. 1). Some areas contained oval meningothelial cells without prominent nucleoli and an occasional intermixed psammoma body, consistent with a World Health Organization Grade I meningioma. Juxtaposed with the meningioma, were nests and cords of larger, atypical epithelioid cells which stained positively for PSA (1:2400 dilution; Dako, Carpentaria, CA, USA), chromogranin (1:100 dilution; DAKO), neuron specific enolase (1:50 dilution; DAKO) consistent with a metastatic prostatic adenocarcinoma with neuroendocrine differentiation (Fig. 2). Post-operatively, the patient reported chronic fatigue, weakness, gait imbalance, multiple falls and both long and short term memory loss. He developed multiple metastases to other organ systems including liver and bone (vertebral column) leading to a regimen of radiation therapy and palliative care to manage symptoms. The patient expired 12 months later.
Meningiomas represent the most common host for a tumor-totumor metastasis within the central nervous system [1]. The reason for this is not well understood. Theories posited by various authors include: the low metabolic rate of meningioma acting as a non-competitive environment for tumor growth; the collagen and lipid rich content of meningioma providing an energy rich environment for growth; the extensive vascularity of meningiomas increases the likelihood of a hematogenously disseminated metastasis; and complementary interactions between cell adhesion molecules of both lesions [1]. Of the 114 cases of tumor-to-tumor metastasis to meningiomas reviewed by Erdogan et al., only two such phenomena were attributed to prostatic adenocarcinoma [2], and only six such cases are found within the literature [3–8] (Table 1). Differentiating between these tumors and intracranial prostatic metastases is complicated by the latter neoplasm’s ability to present as
Please cite this article in press as: Guraya SS, Prayson RA. Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.06.004
S.S. Guraya, R.A. Prayson / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
a dural based mass which can simulate a meningioma [8], as was seen in this patient. It is of no surprise then, that all patients with this occurrence have been diagnosed after histological examination post-operatively. As was seen in this patient, resection of the lesion can alleviate the neurological symptoms involved, and should be complemented with radiation therapy and adjuvant chemotherapy to manage the underlying cancer of the prostate [3,8].
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.
3
References [1] Lanotte M, Benech F, Panciani PP, et al. Systemic cancer metastasis in a meningioma: Report of two cases and review of the literature. Clin Neurol Neurosurg 2009;111:87–93. [2] Erdogan H, Aydin MV, Tasdemiroglu E. Tumor-to-tumor metastasis of the central nervous system. Turk Neurosurg 2014;24:151–62. [3] Pugsley D, Bailly G, Gupta R, et al. A case of metastatic adenocarcinoma of the prostate arising in a meningioma. Can Urol Assoc J 2009;3:E4–6. [4] Döring L. Metastasis of carcinoma of prostate to meningioma. Virchows Arch A 1975;366:87–91. [5] Cluroe AD. Metastasis to meningioma: clues and investigation. Pathology 2006;38:76–8. [6] Bernstein RA, Grmet KA, Wetzel N. Metastasis of prostatic carcinoma to intracranial meningioma. J Neurosurg 1983;58:774–7. [7] Chambers PW, Davis RL, Blanding JD, et al. Metastases to primary intracranial meningiomas and neurilemomas. Arch Pathol Lab Med 1980;104:350–4. [8] Mitchell RA, Dimou J, Tsui A, et al. Metastatic prostate adenocarcinoma invading an atypical meningioma. J Clin Neurosci 2011;18:1723–5.
Please cite this article in press as: Guraya SS, Prayson RA. Metastatic prostatic adenocarcinoma with neuroendocrine differentiation to meningioma. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2016.06.004