Intraventricular metastases demonstrated by cranial computed tomography

Metastasis of the choroid plexuses: A systematic review of the literature and case illustration

BACKGROUND

Choroid plexus (CP) metastases are an extremely rare condition accounting for less than 1% of brain metastases. Due to its scarcity, little is known about this pathology and its management. Herein, we propose a review of the current literature to help its diagnosis and management.

METHODS

Through a literature review based on PubMed/MEDLINE database, we reviewed 94 cases of intraventricular metastasis of solid cancer in 28 full-text articles in English from 1980 to 2010. We have reported epidemiological, clinical, radiological, histological data, as well as management strategies and outcomes. A case report of fourth ventricular pulmonary metastasis illustrates this review.

RESULTS

Intraventricular metastases are most often reported in patients in their 6th decade. The clinical presentation is marked by acute hydrocephalus, more rarely lesional bleeding. Three-quarters of intraventricular metastases develop in lateral ventricle, then respectively in the fourth and third ventricles. Kidney cancer accounts for 45% of the cases. The treatment modalities are surgical removal in case of a single lesion and adjuvant radiotherapy and chemotherapy depending on the primary cancer. The prognosis remains poor due to dissemination via the cerebrospinal fluid.

CONCLUSION

Multiple choroid plexus metastasis is a rare diagnosis, affecting patients with a specific clinical presentation and a misleading radiological appearance. There is no standard of care for the management of these lesions and surgical approach can be challenging.

Radiologic and Clinical Outcomes of Stereotactic Radiosurgery for Intraventricular Metastases

OBJECTIVE

The optimal management of intraventricular metastases remains debatable. The aim of this study is to define the safety and efficacy of Gamma-Knife radiosurgery in the treatment of intraventricular metastases.

METHODS

This retrospective, single-center study involved patients that were treated with stereotactic radiosurgery (SRS) for intraventricular metastases. The study end points included SRS-related toxicity, local and distal intracranial tumor control, as well as the incidence of post-treatment hydrocephalus and leptomeningeal dissemination. Factors associated with radiologic and clinical outcomes were also analyzed.

RESULTS

The cohort included 17 consecutive patients who underwent stereotactic radiosurgery for treatment of 41 intracranial metastases, of which 23 were primary intraventricular (intraventricular metastasis). Median overall survival from primary tumor diagnosis and from SRS treatment were 28 and 5 months, respectively. With a median radiological follow-up of 3 (interquartile range 3) months, 7 patients (41.18%) experienced overall intracranial disease progression, whereas 7 (27.27%) intraventricular metastases progressed radiologically. Four (23.53%) and 3 (17.65%) patients developed hydrocephalus and leptomeningeal dissemination post-SRS, respectively. Four patients (23.53%) died due to intracranial disease progression.

CONCLUSIONS

SRS offers a reasonable chance of local tumor control for patients with intraventricular brain metastasis. However, the risk of hydrocephalus and leptomeningeal spread of disease is not inconsequential and merits close follow-up for patients with brain metastasis involving the ventricular system.

Stereotactic radiosurgery for intraventricular brain metastases

Object

The authors' institution previously reported a 69% rate of crude local control for surgical management of lateral ventricle metastases at the University of Texas MD Anderson Cancer Center. For comparison, the authors here report their institutional experience with use of stereotactic radiosurgery (SRS) to treat intraventricular metastases.

Methods

To identify patients with intraventricular metastases for this retrospective review, the authors queried an institutional SRS database containing the medical records of 1962 patients with 5800 brain metastases who consecutively underwent SRS from June 2009 through October 2013. End points assessed were local control (crude and locoregional), distant failure–free survival, progression-free survival, and overall survival.

Results

Of the 1962 records examined, those for 25 (1.3%) patients with 30 (0.52%) intraventricular metastases were identified. Median patient age at SRS was 55.8 years. The most common primary malignancy was renal cell carcinoma (n = 13), followed by melanoma (n = 7) and breast adenocarcinoma (n = 5). Median tumor volume was 0.75 cm3 (range 0.01–5.6 cm3). Most lesions were located in the lateral ventricles (n = 25, 83.3%) and were treated to a median dose of 20 Gy (range 14–20 Gy). A total of 12 (48%) patients received whole-brain radiation therapy, most (n = 10) before SRS. With a median follow-up of 11.4 months (range 1.6–39.2 months), the rate of crude local control was 93.3%, and the rates of 6-month and 1-year actuarial locoregional control were 85.2% and 56.2%, respectively. The median overall survival time after SRS was 11.6 months (range 1.3–38.9 months), and the 6-month and 1-year actuarial rates were 87.1% and 46.7%, respectively. Disease dissemination developed in 7 (28%) patients as a second intraventricular metastatic lesion (n = 3, 12%), leptomeningeal disease (n = 3, 12%), or both (n = 1, 4%). Radiographic changes developed in 5 (20%) patients and included necrosis (n = 2, 8%) and hemorrhage (n = 3, 12%). A primary diagnosis of renal cell carcinoma was associated with an improved rate of distant failure–free survival (p = 0.05) and progression-free survival (p = 0.08).

Conclusions

SRS provides excellent local control for intraventricular metastases, with acceptable treatment-related toxicity, thereby supporting nonsurgical treatment for these lesions. The propensity for intraventricular dissemination among intraventricular metastases seems to be histologically dependent.

Intraventricular metastases from small cell carcinoma of the lung

Small cell lung carcinoma (SCLC) represents 15-20% of all lung cancers. It is characterised by rapid growth and early metastatic dissemination. Generally, the prognosis of these patients is poor. When brain metastases develop, the prognosis is even poorer. Most of these cases present parenchymal metastases; however, intraventricular dissemination may also occur although it is very uncommon. To our knowledge the case reported here is the first showing multiple synchronic intraventricular dissemination from SCLC.

Choroid Plexus Metastasis From Papillary Thyroid Carcinoma Presenting With Intraventricular Hemorrhage

OBJECTIVE

Metastases to the choroid plexus from extracranial tumors are rare. Kidney, lung, and colon are the common primary origins of choroid plexus metastases. Choroid plexus metastases from thyroid carcinoma are very rare, with only 2 cases reported thus far. We report the third case of choroid plexus metastasis from thyroid carcinoma.

CLINICAL PRESENTATION

A 75-year-old man presented with severe headache, nausea, and vomiting. He had a history of thyroid carcinoma, which had metastasized to the lymph nodes and lung. Computed tomography, magnetic resonance imaging, and magnetic resonance angiography revealed right intraventricular hemorrhage with mild hydrocephalus, without evidence of a bleeding source. The bleeding source was assumed to be the choroid plexus metastasis in the trigone of the right lateral ventricle (following second admission).

INTERVENTION

Surgery was performed using a navigation-assisted system. The tumor was entirely removed, including some choroid plexus tissue. A ventriculoperitoneal shunt was also performed to treat the hydrocephalus. Histopathological examination revealed brain metastasis from papillary thyroid carcinoma. Postoperatively, the patient showed good recovery, with nausea and vomiting improved, and gait disturbance diminished. The patient was discharged from the hospital one month later.

CONCLUSION

Choroid plexus metastasis from papillary thyroid carcinoma is very rare, and this is the first case of intraventricular hemorrhage reported.

Surgical management of lateral-ventricle metastases: report of 29 cases in a single-institution experience

OBJECT

The aim of this study was to review the outcome of patients undergoing surgery for treatment of lateral-ventricle metastases.

METHODS

Imaging information and chart reviews of operative reports were used to conduct a retrospective analysis in 29 patients who underwent resection of lateral-ventricle metastases at the authors' institution between 1993 and 2007. Clinical and neurosurgical outcomes and recurrence rates were studied.

RESULTS

The mean patient age was 56 years (range 20-69 years); 66% of patients were male. Single intraventricular metastases occurred in 69% of patients, and 55% of them had systemic metastases. The 30-day postoperative mortality rate was 7%. There was intracerebral tumor recurrence in 41% of patients, with 1 patient undergoing a second operation for this. The median postoperative survival duration for 28 patients (excluding 1 patient with preoperative leptomeningeal disease) was 11.7 months; the 3- and 5-year survival rates were 17 and 11%, respectively. Univariate analysis identified factors significantly influencing survival, including the preoperative Karnofsky Performance Scale (KPS) score (p = 0.02), the number of cerebral metastases (p = 0.02), the presence of primary renal cell carcinoma (RCC) (p = 0.02), and the resection method (en bloc vs piecemeal; p = 0.05). The presence of extracranial metastases did not significantly influence survival. Multivariate analysis showed that the preoperative KPS score (p = 0.002), the presence of primary RCC (p = 0.039), and the resection method (en bloc vs piecemeal; p = 0.008) correlated significantly with survival time.

CONCLUSIONS

Surgery is an important component in the management of intraventricular metastases. To the authors' knowledge, this is the first study focusing totally on resection of lateral-ventricle metastases. The authors found that patients with primary RCC, those with a favorable preoperative KPS score, and those who underwent en bloc resection had a better outcome than others.

Long survival in an untreated solitary choroid plexus metastasis from renal cell carcinoma: case report and review of the literature

Brain metastases from renal cell carcinoma (RCC) are rare. Among them, the metastases localized only in the choroid plexus are exceptional and only six cases are reported in the literature. Here we report on a patient with a single choroid plexus metastasis from RCC which presented an unusual biological behaviour. For several years, such metastasis was interpreted as a benign intraventricular tumor and was not treated. Four years after the initial neuroradiological evidence, because of the appearance of symptoms, the brain metastasis was excised. We think that this unusual biological behaviour of the tumor determined the late inset of the neurological symptoms, despite the location at the choroid plexus that usually leads to an early obstructive hydrocephalus. To our knowledge, this 46 months survival is the longest survival of a patient affected by a single choroid plexus metastasis from RCC.

Renal cell carcinoma metastatic to the choroid mimicking intraventricular meningioma

BACKGROUND

Metastatic renal cell carcinoma to the choroid plexus is a rare condition and can be easily confused with meningioma.

METHODS

A 61-year-old female presented with progressive neurologic deterioration and MRI findings of obstructive hydrocephalus and a homogeneously contrast enhancing 3 cm oval mass in the trigone of the left lateral ventricle.

RESULTS

Despite radiologic, intraoperative gross features, and frozen pathology all consistent with meningioma, the final pathology revealed metastatic renal cell carcinoma.

CONCLUSION

Renal cell carcinoma metastatic to the choroid plexus can mimic intraventricular meningioma. We present a review of the literature and comparison of the radiological features of meningiomas and metastatic renal cell carcinoma. We also discuss the use of an under-utilized technique, the contralateral transcallosal approach, in the surgical treatment of this intraventricular lesion.

Surgical resection of metastatic intraventricular tumors

The ventricle is a rare site of brain metastases. Renal cell carcinoma has a higher propensity to metastasize to the ventricle compared with more common metastatic tumors (e.g., lung cancer). The trigone is the predominant location for intraventricular metastases, presumably because of the high concentration of choroid plexus in this region. Surgical resection is an important component of the management of these lesions, particularly if there is only a single intraventricular lesion. Despite the deep location of these tumors within the ventricle, survival in patients undergoing surgery for them is comparable to that in patients receiving surgery for intraparenchymal metastases.

Solitary metastasis to the choroid plexus of the lateral ventricle. Report of three cases and a review of the literature

Three cases of cancer metastasis to the choroid plexus of the lateral ventricle are reported. The metastases were from sigmoid colon cancer, renal cell carcinoma and pulmonary cancer, and were located in the trigone in two cases and the right inferior horn in one. Total removal was accomplished in all cases without any complications. In addition, eight reported cases of single brain metastasis to the choroid plexus of the lateral ventricle, including clinical and radiological features, are discussed. Peritumoral edema on computed tomographic (CT) scan or magnetic resonance (MR) imagining was found to be an important feature of metastasis developing at this site.

Review article: computed tomography and magnetic resonance in the diagnosis of intraventricular cerebral masses

We describe a series of 60 cases of patients with masses arising within the cerebral ventricles. The site and relative frequency is noted for each histological type. The differential diagnosis depends on patient age and sex, site, morphology and number of masses, presence and type of hydrocephalus and the characteristics of the mass on computed tomography (CT) and magnetic resonance (MR) images. A review of the literature has been performed and this information collated with our own experience to give detailed descriptions of the typical features of each intraventricular mass. Attention is drawn to intraventricular neurocytoma, a recently described tumour that may be mistaken histologically for intraventricular oligodendroglioma or ependymoma. A comparison is made of the value of CT and MR in the diagnosis of intraventricular masses.

Primary carcinoma of the choroid plexus in the lateral ventricle

Primary carcinomas of the choroid plexus are rare and occur more frequently in children than in adults. They have been posing a problem in their differential diagnosis from benign papilloma of the choroid plexus, ependymoma, and metastatic tumors of extracranial origin. A case of a 31-year-old woman with primary carcinoma of the choroid plexus in the trigone is reported. Electron microscopic and immunohistochemical studies are helpful, but not decisive yet, to reach the diagnosis. The literature is reviewed.

Diffuse subependymal periventricular metastases. Report of three cases

Three clinicopathologic cases with a remarkable pattern of extensive diffuse subependymal periventricular spread of cerebral metastases from solid systemic cancer are reported. Two patients had a small cell carcinoma of the lung. In the third case, the histologic features of the brain metastases were consistent with a neuron-specific enolase-positive, small cell anaplastic carcinoma. Involvement of the choroid plexus and leptomeninges was moderate or absent. Intraparenchymatous nodular metastases were not found except in one case in which rare nodular superficial cortical metastases were present. The clinical data were nonspecific except for orthostatic hypotension, in one patient, which was probably due to the infiltration of the floor of the third and fourth ventricles. Results of the cerebrospinal fluid examination, available in two cases, were normal. The only diagnostic investigation was contrast-enhanced computed tomography scanning.