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Lung Carcinoma Metastasis Presenting As a Pineal Region Tumor

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Lung Carcinoma Metastasis Presenting As a Pineal Region Tumor Neurocirugía 2011; 22: 579-582 Lung carcinoma metastasis presenting as a pineal region tumor Y. Samanci; C. Iplikcioglu; E. Ozek; D. Ozcan* and B. Marangozoglu** Neurosurgery and Pathology* Departments. Ministry of Health Okmeydani Education and Research Hospital. Istanbul Turkey. Department of Neurology**. Istanbul University. Istanbul Faculty of Medicine. Istanbul. Turkey. Summary %1 of all intracranial tumors27,30,32. Pineal region metas- tasis is even rarer and accounted for only 1.8% to 4% in The pineal region is an unusual site for brain metas- literature3,8,22,29. In approximately half of reported cases, tasis and most metastatic pineal lesions are asymptoma- the pineal gland was the only site of intracranial metastasis tic. A 53 year-old man presented with severe headache, with variable sizes1,2,16,17,25,28,33,35. The most common site of limitation of upward gaze and diplopia. The patient’s primary origin is lung carcinoma, followed by breast carci- neurological examination was unremarkable. Magnetic noma and malignant melanoma33. The mechanism of pineal resonance imaging (MRI) scans of the brain demonstrated metastasis seems most probable via the bloodstream. a 1,5 x 2 cm well demarcated solitary mass in the pineal Here we report a patient with a pineal region metastasis region with hydrocephalus. Surgery was performed and proven to be from adenocarcinoma of the lung mimicking a adenocarcinoma was diagnosed. A systemic investigation primary pineal region tumor. revealed adenocarcinoma of the lung as primary lesion. Although rare, metastatic tumor should be considered in Case report the differential diagnosis of pineal region tumors. A 53-year-old man suffered sudden onset severe KEY WORDS. Pineal region. Metastasis. Lung carcinoma. headache and diplopia. He had developed progressively MRI. Pineal tumor. worsening visual and consciousness disturbance. He had no history of any systemic disease. The patient’s neurolo- Metástasis del carcinoma de pulmón que se presenta gical examination was unremarkable, except limitation of como tumor de la región pineal upward gaze and bilateral Babinski sign. Standard blood work-up was normal. A computed tomography (CT) scan Resumen showed hydrocephalus and a hyperdense space-occupying lesion located in the pineal region with perifocal edema. La región pineal es un sitio inusual para el depósito MRI revealed a 1,5 x 2 cm well demarcated solitary mass de metástasis y la mayoría de las metástasis pineales son in the pineal region. MRI demonstrated the tumor to be asintomáticas. Un hombre de 53 años debutó con una hyperintense on both T1 and T2-weighted images and to cefalea intensa, limitación en la supraversión y diplopia. enhance heterogeneously after administration of contrast. La exploración neurológica fue irrelevante. La resonancia (Figure 1a,1b). The patient underwent a supracerebellar magnética (RM) cerebral demostró una lesión solitaria de infratentorial approach with total microsurgical resection 1,5 x 2 cm bien delimitada, en la región pineal con hidroce- of the pineal region mass following a ventriculoperitoneal falia. Fue intervenido quirúrgicamente siendo el diagnóstico shunt operation. Histological examination of the tumor anatomopatológico de adenocarcinoma. Un estudio sistémico specimen taken from the central part of the tumor revea- descubrió un adenocarcinoma de pulmón como tumor prima- led atypical epithelial cells arranged in papillary patterns rio. Aunque muy raramente, las metástasis deben considerarse with coagulation necrosis. (Figure 2a, 2b) Based on the en el diagnóstico diferencial de tumores de la región pineal. histological characteristics of the tumor cells, the mass was diagnosed as lung carcinoma metastatic to the pineal Introduction body. The patient suffered pulmonary complications and died. Pineal region neoplasms are rare and compose only Recibido: 14-02-10. Aceptado: 3-06-11. 579 Neurocirugía Neurocirugía Samanci et al 2011; 22: 579-582 2011; 22: Figure 2a. Photomicrograph of pineal glandular tissue and tumoral tissue (hematoxylin & eosin staining, magnifica- tion x100). Figure 1a,1b. T1-weighted (a) and T2-weighted (b) images in the transaxial plane showing solitary mass in the pineal Figure 2b. Photomicrograph of sheets of highly pleomor- region. phic malignant cells with epithelial characteristics. Note glandular formation. (hematoxylin & eosin staining, mag- Discussion nification x200). Metastasis to the pineal region is a rare manifestation plasma cell leukemia12,31, lymphoma, multiple myeloma, of malignancy and was first reported in a patient with melanoma6,22,33, melanocytoma4 and frontal sinus malig- carcinoma of the lung7. Pineal metastasis used to be found nancy constituted a solitary tumor mass in the pineal at autopsy3,10,14,16,22 in older cases but more recently due to region. Although Ortega et. al suggested hematogeneous better diagnostic imaging, CT and/or MRI has detected spread to the pineal body through the posterior choroidal such lesions1,14-17,19,25,28,33,35 which would previously have arteries22, the mechanism of metastasis is still unclear. been subclinical. A literature review suggested that lung The differential diagnosis of a pineal region mass in carcinoma was the most frequent primary lesion responsi- elderly patients would include the various histological ble1,2,10,16,17,22,23,33,35. In these cases, histologically small cell types of primary pineal tumors11, however, metastasis carcinoma1,16,17,23,35 and undifferentiated carcinoma10,22,33 are should also be considered, especially in patients with a his- frequently seen, although other histological types inclu- tory of malignancy. In these patients approximately 90% of ding squamous cell carcinoma10 and adenocarcinoma14,22 all supratentorial lesions represent metastasis34. have also been reported. Carcinomas in other organs, such There are more than 17 different pathological tumor as breast22, stomach13-15,36, esophagus19,22, rectum19,25 and types in the pineal region5 and therapeutic approach differs kidney19,23 have been reported as primaries. Occasionally for each21. The correct histopathological diagnosis of a 580 581 Neurocirugía Neurocirugía 2011; 22: Lung carcinoma metastasis presenting as a pineal region tumor 2011; 22: 579-582 neoplasm arising in the pineal region often cannot be deter- melonoma of central nervous system. Pineal involvement in mined on the basis of imaging characteristics or cerebros- a patient with nevus of ota and multiple pigmented skin nevi. pinal fluid sampling30. So the primary objective of surgical Arch Pathol 1973; 95: 392-395 management of pineal region tumors is the establishment 7. Förster. Ein fall von markschwamm mit ungewohnlich of an accurate histological diagnosis by examination of vielfacher metastatischer verbreitung. Arch Path Anat 1858; the tissue obtained by surgical intervention. Stereotactic 13: 271-274. biopsy rather than open surgery may be adequate investi- 8. France,, L.H.: Contribution to the study of 150 cases of gation of a pineal region mass18,24,26 in patients with poor cerebral metastases. J Neurosurg Sci 1975; 4: 189-210. medical condition. 9. Freilich, R.J., Thompson, S.J., Walker, R.W., Rosen- The present tumor represented adenocarcinoma, and blum, M.K.: Adenocarcinomatous transformation of intracra- that seems to be a rare histological type observed in nial germ cell tumors. Am J Surg Pathol 1995; 19: 537-544. cases with lung cancer metastatic to the pineal body. It 10. Halpert, B., Erickson, E.E., Fields, W.S.: Intracranial is well known that germ cell tumors of the pineal gland involvement from carcinoma of the lung. AMA Arch Pathol can undergo malignant transformation into enteric type 1960; 69: 93-103. adenocarcinoma9,20. In such cases, glandular epithelium of 11. Hirato, J., Nakazato, Y.: Pathology of pineal region enteric character may retain αFP expression9. In the present tumors. J Neurooncol 2001; 54: 239-249. case no germ cell tumor elements or no α-FP-positive cells 12. Holness, R.O., Sangalang, V.E.: Myelomatous metas- were found in mass. tases to the pineal body. Surg Neurol 1976; 5: 97-100. 13. Joyner, J.E.: Metastatic gastric adenocarcinoma to the Conclusion pineal body. A case report. Acta Neuropathol 1962; 1: 416- 419. Although rare, solitary metastasis to the pineal gland 14. Kakita, A., Kobayashi, K., Aoki, N., Eguchi, I., Morita, is one of the possible diagnosis when dealing with a mass T., Takahashi, H.: Lung carcinoma metastasis presenting as a in this region. Careful examination for systemic malig- pineal region tumor. Neuropathology 2003; 23: 57-60. nant disease will be needed. For an accurate histological 15. Kanai, H., Yamada, K., Aihara, N., Watanabe, K.: diagnosis, sample tissue should be obtained by surgical Pineal region metastasis appearing as hypointensity on T2- intervention from the mass. Stereotactic biopsy rather than weighted magnetic resonance imaging. Neurol Med Chir open surgery may be adequate only for establishing the (Tokyo) 2000; 40: 283-286. histological diagnosis of pineal tumors18,26,33. Therapeutic 16. Kashiwagi, S., Hatano, M., Yokoyama, T.: Metastatic approach can be determined based on histopathological small cell carcinoma to the pineal body: Case report. Neuro- diagnosis. Selection of open surgery, stereotactic biopsy, or surgery 1989; 25: 810-813. radiotherapy for the treatment of pineal tumors should give 17. Keyaki, A., Makita, Y., Nabeshima, S. et al.: Pineal full consideration to the patient’s medical history and the metastatic tumor from lung
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