Metastasis to and from the central nervous system--the 'relatively protected site'

A rare case of esophageal cancer (T2N0) with a solitary cerebellar metastasis

A 72-year-old man with a history of distal gastrectomy was diagnosed with esophageal cancer (EC). A subtotal esophagectomy and the residual total gastrectomy were performed via a right-sided thoracotomy and laparotomy with D2 lymph node dissection followed by reconstruction with a retrosternal right colonic interposition. The pathological diagnosis was Mt, 65 mm, moderately differentiated squamous cell carcinoma, pT2, ly0, v2, pN0, sM0, pStage II. The patient suddenly developed neurological symptoms 10 days after the operation, and brain magnetic resonance imaging detected a single solid left cerebellar tumor. This tumor was completely excised, and pathological diagnosis confirmed the tumor as an EC metastasis. He received adjuvant chemotherapy with cisplatin + 5-fluorouracil. Seven months later, he developed multiple brain metastases; however, no evidence of local recurrence or other metastatic sites was found. He died 8 months after the surgery. Solitary cerebellar metastasis from EC in which the primary tumor is T2N0 is rare, and the mechanism of this metastatic pattern is of particular interest. Our case study suggests that even if the primary tumor is in the limited stage and other metastatic sites are not identified at presentation, it seems reasonable to perform preoperative imaging of the brain for all patients with EC.

Multifocal oligodendroglioma in three dogs

This report describes the clinical, histopathologic, and imaging findings of multifocal oligodendrogliomas from three canine patients. Clinical history varied but included seizure activity and behavior changes. Neurologic examination abnormalities included ataxia, proprioceptive deficits, cranial nerve deficits, and changes in mentation. MRI in one patient revealed multifocal brain lesions; however, the MRI was normal in another one of the patients. Histopathologic evaluation identified multifocal neoplastic infiltrates in all three patients involving the cerebral cortex, brainstem, and spinal cord, with leptomeningeal extension in two of the three patients. All three patients were euthanized due to progression of their neurologic condition and/or complications due to aspiration pneumonia. Oligodendrogliomas should be considered a differential diagnosis for patients with multifocal brain disease.

Extra-neural metastases of malignant gliomas: myth or reality?

Malignant gliomas account for approximately 60% of all primary brain tumors in adults. Prognosis for these patients has not significantly changed in recent years-despite debulking surgery, radiotherapy and cytotoxic chemotherapy-with a median survival of 9-12 months. Virtually no patients are cured of their illness. Malignant gliomas are usually locally invasive tumors, though extra-neural metastases can sometimes occur late in the course of the disease (median of two years). They generally appear after craniotomy although spontaneous metastases have also been reported. The incidence of these metastases from primary intra-cranial malignant gliomas is low; it is estimated at less than 2% of all cases. Extra-neural metastases from gliomas frequently occur late in the course of the disease (median of two years), and generally appear after craniotomy, but spontaneous metastases have also been reported. Malignant glioma metastases usually involve the regional lymph nodes, lungs and pleural cavity, and occasionally the bone and liver. In this review, we present three cases of extra-neural metastasis of malignant gliomas from our department, summarize the main reported cases in literature, and try to understand the mechanisms underlying these systemic metastases.

Anaplastic ependymoma with sclerotic bone metastases

Ependymomas are glial central nervous system (CNS) tumors that arise from the ependymal layer of brain and spinal cord. These are heterogeneous group of tumors with varied histopathological features and prognosis. They frequently relapse at the primary site and may disseminate to other CNS sites. Extraneural metastases are, however, extremely rare. We present a case of ependymoma in a child with widespread metastasis to her bones, a previously unreported event.

Radiosurgery for brain metastases from unknown primary cancers

PURPOSE

We evaluated the role of Gamma Knife stereotactic radiosurgery in the multidisciplinary management of brain metastases from an undiagnosed primary cancer.

METHODS AND MATERIALS

Twenty-nine patients who had solitary or multiple brain metastases without a detectable primary site underwent stereotactic radiosurgery between January 1990 and March 2007 at the University of Pittsburgh. The median patient age was 61.7 years (range, 37.9-78.7 years). The median target volume was 1.0 cc (range, 0.02-23.6 cc), and the median margin radiosurgical dose was 16 Gy (range, 20-70 Gy).

RESULTS

After radiosurgery, the local tumor control rate was 88.5%. Twenty four patients died and 5 patients were living at the time of this analysis. The overall median survival was 12 months. Actuarial survival rates from stereotactic radiosurgery at 1 and 2 years were 57.2% and 36.8%, respectively. Factors associated with poor progression-free survival included large tumor volume (3 cc or more) and brainstem tumor location.

CONCLUSIONS

Radiosurgery is an effective and safe minimally invasive option for patients with brain metastases from an unknown primary site.

Fibulin-3 is uniquely upregulated in malignant gliomas and promotes tumor cell motility and invasion

Malignant gliomas are highly invasive tumors with an almost invariably rapid and lethal outcome. Surgery and chemoradiotherapy fail to remove resistant tumor cells that disperse within normal tissue, which are a major cause for disease progression and therapy failure. Infiltration of the neural parenchyma is a distinctive property of malignant gliomas compared with other solid tumors. Thus, glioma cells are thought to produce unique molecular changes that remodel the neural extracellular matrix and form a microenvironment permissive for their motility. Here, we describe the unique expression and proinvasive role of fibulin-3, a mesenchymal matrix protein specifically upregulated in gliomas. Fibulin-3 is downregulated in peripheral tumors and is thought to inhibit tumor growth. However, we found fibulin-3 highly upregulated in gliomas and cultured glioma cells, although the protein was undetectable in normal brain or cultured astrocytes. Overexpression and knockdown experiments revealed that fibulin-3 did not seem to affect glioma cell morphology or proliferation, but enhanced substrate-specific cell adhesion and promoted cell motility and dispersion in organotypic cultures. Moreover, orthotopic implantation of fibulin-3-overexpressing glioma cells resulted in diffuse tumors with increased volume and rostrocaudal extension compared with controls. Tumors and cultured cells overexpressing fibulin-3 also showed elevated expression and activity of matrix metalloproteases, such as MMP-2/MMP-9 and ADAMTS-5. Taken together, our results suggest that fibulin-3 has a unique expression and protumoral role in gliomas, and could be a potential target against tumor progression. Strategies against this glioma-specific matrix component could disrupt invasive mechanisms and restrict the dissemination of these tumors.

Lymph node metastasis of medulloblastoma in a young adult

Medulloblastoma is the commonest primary central nervous system malignancy in childhood, but is rare in adults. Rarer still is metastasis of such a tumour to a lymph node. This report describes such a case, and briefly discusses relevant pathophysiology and epidemiology.

Vessel microport technique for applications in cerebrovascular research

Cerebrovascular research suffers from a lack of reliable methods with which to deliver exogenous substances effectively into the central nervous system (CNS) of small experimental animals. Here we describe a novel vessel microport surgical technique for a variety of cerebrovascular applications that is reproducible and well tolerated in mice. The procedure is based on the insertion of a vessel microport into the external carotid artery for substance delivery into the CNS via the internal carotid artery. The method results in selective substance delivery into the ipsilateral hemisphere. Other novel aspects of this surgical technique include the ability to perform multiple injections, study of conscious mice well removed from surgery, and lack of occlusion of the common or internal carotid artery that allows carotid flow to be maintained. The feasibility of this technique has been validated by infusion of HIV Tat protein to induce permeability of the blood-brain barrier and by implantation of tumor cells to establish a brain metastasis model. Thus, the described vessel microport technique can be employed in a variety of cerebrovascular research applications.

Extraneural metastases of anaplastic oligodendroglial tumors

Extraneural metastases of malignant gliomas are rare. According to the literature, they tend to appear in glioblastoma patients, but are exceptionally rare in anaplastic oligodendroglioma. We report on an anaplastic oligodendroglioma and an anaplastic oligoastrocytoma that metastasized to cervical lymph nodes and bones. Both patients were women aged 54 and 30 years, and the metastases appeared following craniotomy. In the first patient, metastases to cervical lymph nodes developed one year after surgery, and, despite adjuvant therapy, recurred in the same location several times. Fine needle aspiration biopsy (FNAB) of the cervical lymph node prior to neck dissection suggested a possible metastatic primitive neuroepithelial tumor. In the second case, metastases to the sacrum and femur developed after surgery for a recurrent anaplastic oligoastrocytoma. Our two cases reconfirm a rare but definite ability not only of glioblastoma but also of anaplastic oligodendroglioma, namely to metastasize to extraneural sites. It is important to bear this in mind, particularly in cases when the history of primary brain tumor is unavailable. In such instances, the correct diagnosis of the metastatic lesion may be extremely difficult if not impossible.

The expression of three genes in primary non-small cell lung cancer is associated with metastatic spread to the brain

PURPOSE

Brain metastases affect 25% of patients with non-small cell lung cancer (NSCLC). We hypothesized that the expression of genes in primary NSCLC tumors could predict brain metastasis and be used for identification of high-risk patients, who may benefit from prophylactic therapy.

EXPERIMENTAL DESIGN

The expression of 12 genes was measured by real-time quantitative reverse transcriptase PCR in 142 frozen NSCLC tissue samples. Univariate and multivariate Cox regression analysis was used to analyze the correlation between gene expression and the occurrence of brain metastasis. Immunohistochemistry on independent samples was used to verify the findings.

RESULTS

A score based on the expression levels of three genes, CDH2 (N-cadherin), KIFC1, and FALZ, was highly predictive of brain metastasis in early and advanced lung cancer. The probability of remaining brain metastasis-free at 2 years after diagnosis was 90.0+/-9.5% for patients with stage I/stage II tumors and low score compared with 62.7+/-12% for patients with high score (P<0.01). In patients with more advanced lung cancer, the brain metastasis-free survival at 24 months was 89% for patients with low score compared with only 37% in patients with high score (P<0.02). These results were confirmed by immunohistochemical detection of N-cadherin in independent cohort of primary NSCLC.

CONCLUSIONS

The expression levels of three genes in primary NSCLC tumors may be used to identify patients at high risk for brain metastasis who may benefit from prophylactic therapy to the central nervous system.

Glioblastoma multiforme in skin: a report of 2 cases and review of the literature

Despite an aggressive clinical course, glioblastoma multiforme (GBM) rarely develops extracranial metastasis, with only 6 cases of skin involvement reported in the literature. We report 2 cases of GBM that spread to the scalp. Both patients presented with a firm nodule adjacent to their original craniotomy site. Histologic examination revealed highly anaplastic tumor cells invading the subcutaneous tissues. Immunohistochemistry was positive for vimentin, S-100, and glial fibrillary acidic protein in the malignant cells. Although it is possible that these cases represent true metastatic GBM, the close proximity of the nodules to suture lines suggests extension of GBM to the skin through surgical sites or seeding of tumor cells. It is important to have an accurate clinical history when evaluating scalp nodules in patients with GBM, so that a diagnosis of GBM is not overlooked.

The proteoglycan brevican binds to fibronectin after proteolytic cleavage and promotes glioma cell motility

The adult neural parenchyma contains a distinctive extracellular matrix that acts as a barrier to cell and neurite motility. Nonneural tumors that metastasize to the central nervous system almost never infiltrate it and instead displace the neural tissue as they grow. In contrast, invasive gliomas disrupt the extracellular matrix and disperse within the neural tissue. A major inhibitory component of the neural matrix is the lectican family of chondroitin sulfate proteoglycans, of which brevican is the most abundant member in the adult brain. Interestingly, brevican is also highly up-regulated in gliomas and promotes glioma dispersion by unknown mechanisms. Here we show that brevican secreted by glioma cells enhances cell adhesion and motility only after proteolytic cleavage. At the molecular level, brevican promotes epidermal growth factor receptor activation, increases the expression of cell adhesion molecules, and promotes the secretion of fibronectin and accumulation of fibronectin microfibrils on the cell surface. Moreover, the N-terminal cleavage product of brevican, but not the full-length protein, associates with fibronectin in cultured cells and in surgical samples of glioma. Taken together, our results provide the first evidence of the cellular and molecular mechanisms that may underlie the motility-promoting role of brevican in primary brain tumors. In addition, these results underscore the important functional implications of brevican processing in glioma progression.

BEHAB/brevican requires ADAMTS-mediated proteolytic cleavage to promote glioma invasion

Malignant gliomas are the most common and deadly primary brain tumors, due to their infiltrative invasion of the normal neural tissue that makes them virtually impossible to completely eliminate. We have previously identified and characterized the proteoglycan BEHAB/brevican in gliomas and have demonstrated that upregulation and cleavage of this CNS-specific molecule promote glioma invasion. Here, we have further investigated if the proteolytic processing of BEHAB/brevican by metalloproteases of the ADAMTS family is a necessary step in mediating its pro-invasive effect in glioma. By generating a site-specific ((396)SRG(398) --> NVY) mutant form resistant to ADAMTS cleavage, we have shown that the predominant proteolytic processing of BEHAB/brevican by glioma cells occurs only at this site. More importantly, "uncleavable" BEHAB/brevican is unable to enhance glioma cell invasion in vitro and tumor progression in vivo. In addition, our results suggest that the full-length protein and its cleavage products may act independently because the mutant form does not exert a dominant negative effect on normal BEHAB/brevican expression or cleavage. These results illustrate how the regulated processing of major components of the neural extracellular matrix has important functional implications in glioma progression. In addition, our findings underscore the relevance of the ADAMTS family of metalloproteases as attractive targets for novel pharmacological approaches in glioma therapy.

Extraneural spread of glioblastoma--report of two cases

BACKGROUND

Glioblastoma, a highly aggressive tumor, accounts for the majority of all primary brain tumors in adults. Despite a destructive local growth pattern, extraneural spread of these tumors is extremely rare. CASE 1: We describe the case of a 58-year-old man with glioblastoma, in whom an epidural mass was diagnosed 5 months after initial local therapy of the brain. A positron emission tomography (PET) scan revealed multiple metastases in the lungs, in the retroperitoneum, and in the left trochanter minor region. A soft tissue swelling of the right thigh was histologically proven to be metastatic tissue from the primary glioblastoma. The patient died 11 months after initial diagnosis. CASE 2: A 47-year-old woman with recurrent glioblastoma had a long lasting complete response to chemotherapy. 2 years after initial diagnosis she presented with a pleural mass which was a metastasis of the formerly diagnosed glioblastoma.

CONCLUSION

Although systemic metastases in glioblastoma are rare, different organs can be involved.

Extraneural metastases of anaplastic oligodendroglioma

Extraneural metastases from primary central nervous system (CNS) tumors are unusual, and glioblastomas and medulloblastomas constitute the majority of these. That oligodendroglioma frequently seeds within the CNS is well known. However, extraneural metastases of anaplastic oligodendroglioma are rare. We report a 50-year-old woman who developed multiple lung and liver metastases 28 months after resection of a temporal lobe anaplastic oligodendroglioma.

Metastatic ependymoma: a multi-institutional retrospective analysis of prognostic factors

PURPOSE

Metastatic ependymoma is exceedingly rare at diagnosis with variable prognosis reported in the literature. The purpose of this study was to identify prognostic factors in children with metastatic ependymoma.

PROCEDURE

Data regarding diagnosis, treatment and follow-up for 40 patients from eight institutional cohorts were collected.

RESULTS

Twenty-nine (72%) patients were less than 36 months of age at the time of diagnosis, 28% were females, and 90% of the patients had posterior fossa tumors. Gross total resection (GTR) of the primary tumor was achieved in 16 patients (40%). Adjuvant therapy was variable and included craniospinal irradiation (CSRT), chemotherapy, and chemotherapy with focal irradiation. The 5-year event free survival (EFS) and overall survival (OS) from the time of diagnosis were 29% (+/-7%) and 43% (+/-8%), respectively. Age at diagnosis was associated significantly with both EFS and OS (P < 0.001 for EFS, and P = 0.01 for OS). Patients who were 24-35 months of age at diagnosis had a 5-year EFS of 66% and a 5-year OS of 73%; both survival rates were superior to those of patients younger than 24 months of age or older than 36 months. Patients with GTR achieved a 5-year EFS of 35% and OS of 59%, compared to a 5-year EFS of 25% and OS of 32% for patients who did not achieve GTR (P = 0.12 for EFS, P = 0.03 for OS).

CONCLUSIONS

GTR should be attempted in patients with metastatic ependymoma. A subgroup of patients between 24 and 35 months might have a favorable outcome.

Diffuse glioma growth: a guerilla war

In contrast to almost all other brain tumors, diffuse gliomas infiltrate extensively in the neuropil. This growth pattern is a major factor in therapeutic failure. Diffuse infiltrative glioma cells show some similarities with guerilla warriors. Histopathologically, the tumor cells tend to invade individually or in small groups in between the dense network of neuronal and glial cell processes. Meanwhile, in large areas of diffuse gliomas the tumor cells abuse pre-existent "supply lines" for oxygen and nutrients rather than constructing their own. Radiological visualization of the invasive front of diffuse gliomas is difficult. Although the knowledge about migration of (tumor)cells is rapidly increasing, the exact molecular mechanisms underlying infiltration of glioma cells in the neuropil have not yet been elucidated. As the efficacy of conventional methods to fight diffuse infiltrative glioma cells is limited, a more targeted ("search & destroy") tactic may be needed for these tumors. Hopefully, the study of original human glioma tissue and of genotypically and phenotypically relevant glioma models will soon provide information about the Achilles heel of diffuse infiltrative glioma cells that can be used for more effective therapeutic strategies.

Intracranial dissemination of primary spinal cord anaplastic oligodendroglioma

We report the first case of a 22-year-old man, with a previously neurosurgically treated intramedullary anaplastic oligodendroglioma (World Health Organization grade III), who developed 19 months later two histologically proven intracranial metastases. We support a hypothesis whereby the anaplastic parts of tumors have spread along the spinal cord and brainstem via the cerebrospinal fluid pathways, a process that could be promoted by surgical manipulation, although the relative contribution of the two factors remains speculative.

Enhanced chemotherapy delivery by intraarterial infusion and blood-brain barrier disruption in the treatment of cerebral metastasis

BACKGROUND

Cerebral metastases are clinically significant in 10% to 30% of patients with neoplasia. Multiple cerebral metastases are typically treated with palliative radiotherapy. There is no consensus on the role of enhanced chemotherapy delivery as an adjuvant treatment modality in this disease. In this report, the authors detailed their experience with intraarterial (IA) chemotherapy infusion with and without blood-brain barrier disruption (BBBD) in patients with multiple cerebral metastases.

METHODS

From November 1999 to May 2005, 38 patients with multiple cerebral metastases were enrolled in a prospective study. Patients were treated with IA carboplatin, except for those with cerebral metastases of systemic lymphoma, who were administered IA methotrexate. Osmotic BBBD was offered to patients without the presence of a significant mass effect. These regimens were coupled with intravenous etoposide and cyclophosphamide. Cycles were repeated every 4 weeks.

RESULTS

Survival was calculated from study entry and radiologic response was based on MacDonald criteria. Kaplan-Meier estimates were generated for all subgroups. Mean and median survival obtained was as follows: 34 and 29.6 months for the whole group; 33.6 and 42.3 months for ovarian carcinoma; 15.3 and 13.5 months for lung adenocarcinomas; 8.3 and 8.8 months for small cell lung carcinoma; 8.9 and 8.1 months for breast carcinoma; and 24.8 and 16.3 months, respectively, for cerebral metastasis from systemic lymphoma.

CONCLUSIONS

Even with a small number of patients in each subgroup, the results obtained seem promising for multiple brain metastasis of ovarian carcinoma, adenocarcinoma of lung, small cell lung carcinoma, and systemic lymphoma.

Primary and secondary tumours occurring simultaneously in the brain of a dog

Primary brain tumours of a single histological type and metastatic brain tumours are well described in dogs in the current veterinary literature. However, the concurrent presence of a primary and secondary tumour in the brain of a dog has never, to the authors' knowledge, been previously reported. The clinical and pathological features of a nine-year-old, female boxer with an oligodendroglioma and metastases from a mammary gland adenocarcinoma occurring simultaneously in the brain are described in this case report. Information in the veterinary literature on multiple malignancies affecting the central nervous system is very limited; therefore, a discussion about comparative situations in human medicine has been included.

[Medulloblastoma with extracentral nervous system metastases: clinical presentation and risk factors]

PURPOSE

Extra-central nervous system (extra-CNS) metastases are relatively unknown failure patterns in medulloblastoma. The aim of this study was to analyse epidemiological, clinical and aetiopathological aspects of these extra-CNS localisations.

PATIENTS AND METHODS

Extra-CNS metastases were retrospectively identified in patients treated in the department of radiation therapy at Salah-Azaïz institute (ISA) for medulloblastoma. These metastases were diagnosed as extra-CNS for all secondary localisations not related to other tumour aetiology. Aetiopathological aspects are discussed with a literature review.

RESULTS

Among 103 patients treated and followed-up in the department of radiation therapy of ISA from 1970 to 1992, 8 developed extra-CNS metastases (7.7%). Age at diagnosis of primitive tumour varied from 3 to 23 years. Sex ratio was 1. Primitive tumour treatment was: complete surgical resection in 4 patients with preoperative cerebrospinal fluid shunting in two, cerebrospinal axis irradiation in 7 patients and a cerebral-limited irradiation in 1. Two patients received chemotherapy for their initial treatment (systemic in one case and intrathecal in the other). The mean free-interval from diagnosis of primitive tumour to extra-CNS metastases was 23 months, varying from 8 to 53 months. These metastases were located in the liver (1 case), cervical lymph nodes (2 cases), bone marrow (1 case) and bone (2 cases). Two patients had multiple metastases: bone and bone marrow (in one), lung, pleura, cervical lymph node and bone localisations (in one). Treatment of these metastases was: chemotherapy in 5 cases, chemotherapy and radiation in one, radiation therapy in one and 2 patients were given only supportive care treatment. All patients died or are in progressive disease in less than one year from the diagnosis of extra-CNS metastases.

CONCLUSION

Extra-CNS metastases are not rare and have a poor prognosis. The most commonly involved sites are bone, cervical lymph nodes and bone marrow. A complete work-up at initial diagnosis is recommended to screen early metastases. Literature review showed that histopathologic grading might help to identify groups at risk.

Intraneural metastasis of a synovial sarcoma to a peripheral nerve

We describe a case of intraneural metastasis of a synovial sarcoma, the first published case of a metastasis of a soft-tissue sarcoma to a peripheral nerve.

Novel tumor-specific isoforms of BEHAB/brevican identified in human malignant gliomas

Malignant gliomas are deadly brain tumors characterized by diffuse invasion into the surrounding brain tissue. Understanding the mechanisms involved in glioma invasion could lead to new therapeutic strategies. We have previously shown that BEHAB/brevican, an extracellular matrix protein in the central nervous system, plays a role in the invasive ability of gliomas. The mechanisms that underlie BEHAB/brevican function are not yet understood, due in part to the existence of several isoforms that may have different functions. Here we describe for the first time the expression of BEHAB/brevican in human brain and characterize two novel glioma-specific isoforms, B/b(sia) and B/b(Deltag), which are generated by differential glycosylation and are absent from normal adult brain and other neuropathologies. B/b(sia) is an oversialylated isoform expressed by about half the high- and low-grade gliomas analyzed. B/b(Deltag) lacks most of the carbohydrates typically present on BEHAB/brevican and is the major up-regulated isoform of this protein in high-grade gliomas but is absent in a specific subset of low-grade, indolent oligodendrogliomas. B/b(Deltag) is detected on the extracellular surface, where it binds to the membrane by a mechanism distinct from the other BEHAB/brevican isoforms. The glioma-specific expression of B/b(Deltag), its restricted membrane localization, and its expression in all high-grade gliomas tested to date suggest that it may play a significant role in glioma progression and make it an important new potential therapeutic target. In addition, its absence from benign gliomas prompts its use as a diagnostic marker to distinguish primary brain tumors of similar histology but different pathologic course.

S100beta as a predictor of brain metastases: brain versus cerebrovascular damage

BACKGROUND

The identification of brain metastases in patients with malignant disease has important implications for determining their treatment and prognosis. Asymptomatic metastatic brain tumors may be detected by surveillance imaging techniques, but longitudinal follow-up of patients who are at risk is sporadic primarily due to cost. Because the development of brain metastases is accompanied and detected by extravasation of contrast agents across the blood-brain barrier (BBB), the authors hypothesized that peripheral analysis of the BBB indicator S100beta may be useful as a screening tool for brain metastases in patients who have no neurologic symptoms.

METHODS

Thirty-eight patients were enrolled for the current study. All patients had newly diagnosed lung carcinoma and had no neurologic symptoms or known history of brain metastasis. Patients underwent an initial magnetic resonance imaging (MRI) scans and S100beta blood tests. S100beta tests were repeated in a subset of patients at the time of routine follow-up MRI scans.

RESULTS

Based on imaging studies and on serum S100beta analyses, the patients were divided in 3 categories: 1) patients with normal S100beta levels (0.08 +/- 0.02 microg/L; n = 22 patients) and normal MRI scans; 2) patients with elevated S100beta levels (0.5 +/- 0.28 microg/L; n = 8 patients) and pronounced microvascular changes on MRI scans but with no metastases; and 3) patients with elevated S100beta levels (0.28 +/- 0.19 microg/L; n = 7 patients) and metastatic brain tumor(s) on MRI scans.

CONCLUSIONS

Because of the significant overlap in S100beta levels between patients with cerebral microvascular diseases and patients with brain metastases, the authors concluded that the serum S100beta level may be used as a surveillance tool to predict or detect brain metastases if appropriate prescreening radiologic tests are obtained and if patients who are candidates for false-positive results are identified and excluded.

Brain metastasis in pediatric extracranial solid tumors: survey and literature review

OBJECTIVES

Brain is a rare site of metastasis in most extracranial pediatric solid tumors. The aim of this study is to investigate the incidence, treatment, prognosis of brain metastasis in extracranial pediatric malignant tumors in a single institution and to review the literature.

METHODS

From September 1989 to December 2002, 1100 children <or=16 years of age with extracranial solid tumors including lymphomas were diagnosed and treated in the Division of Pediatric Oncology, Oncology Institute, Istanbul University. Patients with parenchymal metastases in the brain were assessed.

RESULTS

Sixteen (10 female, 6 male) of 1100 patients (1.45%) with extracranial solid tumors developed brain metastases. The median age of the patients was 10.5 (1-16) years. The diagnosis was sarcomas in 12 patients: 5 osteosarcomas, 4 Ewing's sarcoma family tumors, 1 rhabdomyosarcoma, 1 clear cell sarcoma of the soft tissue, 1 alveolar soft part sarcoma. Two patients had Wilms' tumor and two had germ cell tumors. Four patients (25%) had brain metastasis at diagnosis. Twelve (75%) developed brain metastasis during therapy or relapse at a median duration of 16 (1-70) months from initial diagnosis. All patients had metastases to various sites, mostly lung, at the time the brain metastases were detected. Treatment included surgery, followed by postoperative radiotherapy (RT) and chemotherapy (CT) in 1, S and RT in 1, S in 1, RT and CT in 6, RT in 1, CT in 1 and no treatment in 5. Only one patient with alveolar soft part sarcoma is alive with disease 20 months from diagnosis of brain metastasis. All other patients died at a median time of 2 months (2 days-6 months) from the time of brain metastasis.

CONCLUSIONS

Children with metastatic cancer who develop headaches or any other neurologic symptom should be investigated for possible brain metastasis. Although, the outcome for these patients is dismal in this series and in the literature; reports of long term survival in a few cases with Wilms' tumor, osteosarcoma and alveolar soft part sarcoma who had isolated brain metastasis, suggest that a subset of patients may benefit from therapy.

Brain metastasis of unknown primary: A diagnostic and therapeutic dilemma

The diagnosis of a brain metastasis is usually made during the routine follow up examinations of patients with known cancer, who are under the care of oncology departments. The involvement of the neurosurgeon depends on the philosophy and referral patterns of each oncology group. Patients with brain metastases of unknown primary (BMUP) are much more likely to seek the help of a neurosurgeon or a neurologist before contacting an oncologist, because the presenting clinical features originate from the brain. BMUPs are almost equal in numbers to brain primaries and differ from regular cerebral metastases regarding their site of origin, which will remain unknown in about 50% despite vigorous investigation. The clinical picture is similar to that of primary brain tumours but they seem to show different areas of predilection in the brain parenchyma. By reviewing the literature we are presenting the epidemiology, clinical presentation, diagnostic workup and treatment plan for this group of patients.

ADAM23 methylation and expression analysis in brain tumors

The ADAMs comprises a family of cell surface proteins with putative roles in cell-cell and/or cell-matrix interactions and in protease activities. In this work, we have examined the expression level and the methylation status of the 5' upstream region of the adhesion molecule ADAM23 in two brain tumor cell lines (A172 and T98G) as well as in three primary brain tumors (one grade II astrocytoma and two meningiomas) and 15 glioblastoma xenografts. Using bisulfite sequencing we verified that the percentage of methylated dinucleotides is higher in T98G when compared to A172 and that methylation significantly correlates with ADAM23 mRNA and protein expression. However, we were unable to detect methylation and down-regulation of the ADAM23 gene in brain tumors. Together, these results indicate that ADAM23 down-regulation by methylation in brain tumors is a rare event and it may help explain why brain tumor metastases are rarely found elsewhere in the body.

The pathogenesis and treatment of brain metastases: a comprehensive review

Brain metastases are the most common intracranial tumors and their incidence is increasing. Untreated brain metastases are associated with a poor prognosis and a poor performance status. The role of surgery in the management of multiple brain metastases is still controversial. As more than 70% of patients have multiple metastases at the time of diagnosis, whole brain radiotherapy is the treatment of choice in most cases. Brain metastases are an ideal target for stereotactic radiosurgery, as they are better circumscribed than primary brain tumors. Currently, chemotherapy has a limited role in the treatment of most brain metastases. Several new therapies, with a good penetration through the blood brain barrier, such as temozolomide, have been used in brain metastases with different results depending on the histology of the primary tumor. A better understanding of the complex processes underlying the development of brain metastasis will enable us to develop more satisfactory targeted treatments.

Molecular diagnosis of metastasizing oligodendroglioma: a case report

We report the case of a suspicious parotid mass in which molecular determination of loss of heterozygosity (LOH) of chromosome arms 1p and 19q in combination with cytologic and immunohistochemical analysis defined the tumor to be metastatic oligodendroglioma. The patient was a 41-year-old woman who developed a World Health Organization grade II oligodendroglioma in her right frontal lobe at age 32, for which no adjuvant chemo- or radiotherapy was administered. Five years following this diagnosis, radiological assessment revealed a 10-centimeter mass in the tumor bed, suspicious for a recurrence. Resection of this lesion revealed an anaplastic oligodendroglioma (grade III) and adjuvant radiotherapy was given. Eleven months after this surgery the patient presented with a 5.5-cm subcutaneous, non-mobile, non-tender mass in the region of the right parotid gland. Fine needle aspiration (FNA) yielded highly cellular material, morphologically and immunohistochemically suspicious for oligodendroglioma. Molecular analysis of microsatellite loci residing on chromosome arms 1p and 19q was performed using DNA extracted from the patient's recurrent brain oligodendroglioma and the FNA specimen. This analysis revealed evidence of LOH at all eight of the microsatellite loci tested. The combination of cytologic and molecular findings defined the extracranial tumor to be metastatic oligodendroglioma.

Clinical presentation, treatment and outcome of patients with cerebral metastases: the University of São Paulo series

INTRODUCTION: Secondary neoplasias are the most common tumors affecting the central nervous system and several clinical aspects of this disease are still controversial. METHOD: Forty-seven consecutive patients with the diagnosis of cerebral metastases (CM) were retrospectively studied at the Clinical Hospital of São Paulo University Medical School. Mean age was 53.9 years and 25 patients were female. RESULTS: The most frequent primary sites were breast, lung and skin. Symptoms were related to increased intracranial pressure (ICP) in 48.9%, focal neurological events in 27.7% and both in 17.0%. Single brain metastases were found in 57.4% of those cases, the frontal lobe being most frequently affected. Surgical treatment was performed in 68.1%, radiotherapy in 40.4% and chemotherapy in 17.0%. CONCLUSION: After statistical analysis, there was a trend towards prolonged survival of female patients, patients with ICP symptoms and the surgical group. Data from different centers are essential to establish the best management of CM.

Epidemiology, Diagnosis, and Treatment of Patients With Metastatic Cancer and High-grade Gliomas of the Central Nervous System

Cancer is the hyperactive state of cell growth in which the multiplication and division of cells occur abnormally. Malignant cancer to the brain frequently begins and ends with the loss of self or quality of life. Cancer of the central nervous system can be in the form of a primary or secondary brain tumor commonly known as metastatic cancer. Primary brain tumors can be benign or malignant on the basis of the cell type or location within the brain. Metastatic cancer has a primary source of origin, from which it has traveled to the brain by direct extension (tumors arising from the skull or vertebral column), or most commonly by hematogenous spread (through the blood supply, lymphatic system, or cerebral spinal fluid). As the cancer grows, the individual can experience headache, seizures, or focal neurologic deficits, all impinging on quality of life. This article addresses malignant central nervous system cancer including metastatic cancer and malignant gliomas (anaplastic astrocytoma, grade III, and glioblastoma multiforme, grade IV). Epidemiology, diagnostic workup, treatment, and outcome also are reviewed.