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Uncommon Presentations of Malignancies

CASE 3. BRAIN METASTASIS FROM OVARIAN CANCER

Institut Gustave-Roussy, Villejuif, France

A 52-year-old woman presented to the emergency department with a seizure. Four years earlier she had undergone a bilateral salpingo-oophorectomy with total omentectomy and pelvic and para-aortic lymph node dissection for an International Federation of Gynecology and Obstetrics stage IB ovarian mucinous adenocarcinoma. Adjuvant chemotherapy with six cycles of cisplatin and cyclophosphamide followed by a year of maintainance therapy with melphalan had been administered. The patient had a close follow-up and had remained in good health until the current presentation.

A brain CT scan showed a left temporal-occipital mass (Fig 1). The CA125, which had been 65 IU/mL at the initial diagnosis and had been normalized since the adjuvant cisplatin/cyclophosphamide treatment, was now 117 IU/mL. A brain stereotactic-guided biopsy showed the presence of a mucinous cystadenocarcinoma consistent with an ovarian origin (Fig 2 and 3). A CT scan of the abdomen and pelvis was normal with no pancreatic lesions and no ascites. Upper endoscopy and colonoscopy were normal.

View larger version (125K): [in this window] [in a new window]   Fig 1. Brain CT scan showing a left temporal-occipital mass.

View larger version (181K): [in this window] [in a new window]   Fig 2. Brain stereotactic-guided biopsy showing the presence of a mucinous cystadenocarcinoma consistent with an ovarian origin.

View larger version (136K): [in this window] [in a new window]   Fig 3. Brain stereotactic-guided biopsy showing the presence of a mucinous cystadenocarcinoma consistent with an ovarian origin.

Although brain metastases of ovarian origin are not frequent, many cases have been reported in the literature.^1–5 Three points illustrated in the current case deserve to be discussed. Brain metastases from stage I ovarian adenocarcinoma are rare, but this is because of the fact that the prevalence of early-stage disease is lower than advanced disease. In fact, no correlation between stage and occurrence of brain metastases has been found.⁶ In addition, no other prognostic factors of ovarian cancer such as primary tumor grade, residual disease after debulking surgery and chemotherapy response, has been associated with an increased incidence of CNS involvement.⁶

The interval between the initial diagnosis of ovarian cancer and the diagnosis of brain metastases is, in the great majority of cases, between a few months and 3 years, but brain metastases can occur beyond this time, as evidenced in the current case as survival duration improves. Cases of brain metastases occurring more than 5 years after diagnosis of the primary tumor have been reported.^4,6–9

In about two thirds of the cases, brain metastases are part of disseminated recurrent disease, but in the remaining third the brain is the only metastatic site. Chemotherapy and radiation therapy are only moderately effective for the treatment of CNS metastases. Surgical resection remains the best therapeutic approach and should be considered alone or in combination with chemotherapy and radiotherapy if the general condition of the patient as well as the location and number of metastases allows it, in order to prolong survival and improve quality of life.^9,10 Stereotactic radiosurgery or use of the gamma knife may also be of value in selected cases.

REFERENCES

1. Bruzzone M, Campora E, Chiara S, et al: Cerebral metastases secondary to ovarian cancer: still an unusual event. Gynecol Oncol 49:37–40, 1993[CrossRef][Medline]

2. Cormio G, Maneo A, Parma G, et al: Central nervous system metastases in patients with ovarian carcinoma: a report of 23 cases and a literature review. Ann Oncol 6:571–574, 1995[Abstract/Free Full Text]

3. Geisler JP, Geisler HE: Brain metastases in epithelial ovarian carcinoma. Gynecol Oncol 57:246–249, 1995[CrossRef][Medline]

4. Kolomainen DF, Larkin JM, Badran M, et al: Epithelial ovarian cancer metastasizing to the brain: a late manifestation of the disease with an increasing incidence. J Clin Oncol 20:982–986, 2002[Abstract/Free Full Text]

5. Stein M, Steiner M, Klein B, et al: Involvement of the central nervous system by ovarian carcinoma. Cancer 58:2066–2069, 1986[CrossRef][Medline]

6. Kaminsky-Forrett MC, Weber B, Conroy T, Spaeth D: Brain metastases from epithelial ovarian carcinoma. Int. J Gynecol Cancer 10:366–371, 2000[CrossRef][Medline]

7. Dauplat J, Nieberg RK, and Hacker NF: Central nervous system metastases in epithelial ovarian carcinoma. Cancer 60:2559–2562, 1987[CrossRef][Medline]

8. LeRoux PD, Berger MS, Elliott JP, Tamimi HK: Cerebral metastases from ovarian carcinoma. Cancer 67:2194–2199, 1991[CrossRef][Medline]

9. Rodriguez GC, Soper JT, Berchuck A, et al: Improved palliation of cerebral metastases in epithelial ovarian cancer using a combined modality approach including radiation therapy, chemotherapy, and surgery. J Clin Oncol 10:1553–1560, 1992[Abstract/Free Full Text]

10. Mayer RJ, Berkowitz RS, Griffiths CT, et al: Central nervous system involvement by ovarian carcinoma: a complication of prolonged survival with metastatic disease. Cancer 41:776–83, 1978[CrossRef][Medline]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Atallah, D. Articles by Voutsadakis, I. A. Search for Related Content PubMed PubMed Citation Articles by Atallah, D. Articles by Voutsadakis, I. A. Social Bookmarking                            What's this?