Intracranial Metastases from Prostate Carcinoma: Classification, Management, and Prognostication

The Clinical, Diagnostic, Therapeutic, and Prognostic Characteristics of Brain Metastases in Prostate Cancer: A Systematic Review

AIM

Prostate cancer (PCa) is the second most common nonskin malignancy and the second most common cause of cancer-related deaths in men. The most common site of metastasis in PCa is the axial skeleton which may lead to back pain or pathological fractures. Hematogenous spread to the brain and involvement of the central nervous system (CNS) are a rare occurrence. However, failed androgen deprivation therapy (ADT) may facilitate such a spread resulting in an advanced metastatic stage of PCa, which carries a poor prognosis.

METHODS

In this systematic review, we searched the PubMed, Scopus, and Web of Science online databases based on the PRISMA guideline and used all the medical subject headings (MeSH) in terms of the following search line: ("Brain Neoplasms" OR "Central Nervous System Neoplasms") and ("Prostatic Neoplasms" OR "Prostate"). Related studies were identified and reviewed.

RESULTS

A total of 59 eligible studies (902 patients) were included in this systematic review. In order to gain a deeper understanding, we extracted and presented the data from included articles based on clinical manifestations, diagnostic methods, therapeutic approaches, and prognostic status of PCa patients having BMs.

CONCLUSION

We have demonstrated the current knowledge regarding the mechanism, clinical manifestations, diagnostic methods, therapeutic approaches, and prognosis of BMs in PCa. These data shed more light on the way to help clinicians and physicians to understand, diagnose, and manage BMs in PCa patients better.

Dural metastasis from prostate carcinoma mimicking tuberculum sellae meningioma: A case report

Background:

Prostate carcinoma rarely metastasizes to the central nervous system. However, when it does, a dural lesion is a common and possible misdiagnosis of meningioma. Here, we describe a case of a 77-year-old man with dural metastasis from prostate carcinoma of the tuberculum sellae.

Case Description:

The patient was diagnosed with prostate carcinoma 7 years previously and was well-controlled by hormone therapy. He was incidentally found to have a suprasellar tumor and underwent endoscopic endonasal transsphenoidal surgery because of rapid tumor growth and worsening visual impairment. Since his serum prostate-specific antigen (PSA) level was within the normal range, malignant meningioma was suspected based on the magnetic resonance imaging (MRI) and the course. However, the pathological findings revealed dural metastasis from prostate carcinoma. He received radiation therapy, and the tumor disappeared on MRI. His visual impairment improved without recurrence. This case report highlights that dural metastasis of the tuberculum sellae arose despite the patient’s PSA level being within the normal range, and a single metastasis to the dura was found.

Conclusion:

In patients with a history of prostate carcinoma or older men, careful follow-up considering the possibility of metastasis is required when a dural lesion is found.

Case report: Cavernous hemangioma in the right frontoparietal junction

Background

Primary intraosseous cavernous hemangioma is a benign tumor with slow growth and is rarely seen in clinics. The clinical manifestations of most patients are progressive enlargement of the head mass.

Case presentation

We report a 30-year-old female patient with cavernous hemangioma at the frontoparietal junction. Upon admission, the right frontal lobe mass was progressively enlarged for 3 years and underwent lesion resection and stage I skull reconstruction. The postoperative outcome was good, with no recurrence at 1-year follow-up.

Conclusion

Primary intraosseous cavernous hemangioma is a relatively rare clinical tumor, the pathogenesis of which is still unclear, and most of them have no specific clinical manifestations. Characteristic imaging findings are highly suspicious of this disease, but the definitive diagnosis still depends on histopathological examination. Currently, total surgical resection of the tumor is a relatively effective and preferred treatment.

Prostate Cancer Brain Metastasis: Review of a Rare Complication with Limited Treatment Options and Poor Prognosis

Brain metastases (BM) are perceived as a rare complication of prostate cancer associated with poor outcome. Due to limited published data, we conducted a literature review regarding incidence, clinical characteristics, treatment options, and outcomes of patients with prostate cancer BM. A literature analysis of the PubMed, MEDLINE, and EMBASE databases was performed for full-text published articles on patients diagnosed with BM from prostate cancer. Eligible studies included four or more patients. Twenty-seven publications were selected and analyzed. The sources of published patient cohorts were retrospective chart reviews, administrative healthcare databases, autopsy records, and case series. BM are rare, with an incidence of 1.14% across publications that mainly focus on intraparenchymal metastases. Synchronous visceral metastasis and rare histological prostate cancer subtypes are associated with an increased rate of BM. Many patients do not receive brain metastasis-directed local therapy and the median survival after BM diagnosis is poor, notably in patients with multiple BM, dural-based metastases, or leptomeningeal dissemination. Overall, prostate cancer BM are rare and associated with poor prognosis. Future research is needed to study the impact of novel prostate cancer therapeutics on BM incidence, to identify patients at risk of BM, and to characterize molecular treatment targets.

Intra-Parenchymal Cerebellar Metastasis—A Rare Presentation of Castration-Resistant Prostate Cancer

Intracranial metastases from prostate carcinoma are uncommon and usually manifest as dural secondaries in the supratentorial compartment. We present an unusual case of intra-parenchymal posterior fossa prostatic metastasis in a 61-year-old gentleman and discuss the diagnostic and management challenges involved. A 61-year-old hypertensive, diabetic man presented with gait unsteadiness for 1-month duration and no other neurological deficits. He had previously undergone bilateral orchiectomy for prostate carcinoma with multiple osseous metastases. Magnetic resonance imaging showed a well-defined lobulated, intraventricular, peripherally enhancing lesion in the fourth ventricle with obstructive hydrocephalus. He underwent sub-occipital craniectomy and decompression, and histological examination was consistent with metastatic prostate adenocarcinoma. Although cerebellar secondaries are atypical, a suspicion of metastasis should be upheld in all patients with the history of prostate carcinoma, regardless of their location and radiological characteristics of the intracranial lesion.

Aggressive primary scalp lymphoma mimicking an acute epidural hematoma: Case report and Review of the literature

BACKGROUND

Cutaneous Central Follicular Lymphoma (CCFL) is a Type B cutaneous lymphoma with a usually indolent course. Scalp localization of CCFL is extremely rare, we report a new case mimicking an epidural hematoma, and showing a rapid progression with aggressive infiltration of skin, calvaria, dura and brain parenchyma.

CASE REPORT

A 58-year-old patient with an unlabeled polymalformative syndrome was admitted to the Emergency department following a head injury secondary to a self-resolving tonic-clonic epileptic seizure. The initial CT scan was interpreted as a minor subcutaneous and epidural hematoma initially deemed for conservative management. Within 4 days the patient showed a progressive neurological deterioration culminating into a stuporous status which prompted a constrast-enhanced brain MRI. The scan revealed a multilayered solid lesion, extending from the subgaleal compartment to the subdural space, threatening the integrity of overlying skin and causing infiltration of the brain parenchyma. Following emergency neurosurgical excision a definitive histology diagnosis of central follicular lymphoma was made. A focused chemotherapy with high-dose Methotrexate with R-CHOP protocol led to disease control until the latest follow up at 2 years.

CONCLUSION

To our knowledge, this case represents the first CCFL invading the brain parenchyma and the second extending to the dura. Although such tumor is usually indolent the aggressive behavior herein reported extend the differential diagnosis to high-grade meningiomas, sarcomas, and metastases. Prognostication and appropriate adjuvant treatment require prompt surgical excision and histological confirmation.

Incidence of dural metastases in castrate-resistant prostate cancer

Purpose:

The natural history and clinical manifestations of dural metastases (DM) in castrate-resistant prostate cancer (CRPC) will change with advances in new hormonal therapy. Here, we characterised the incidence, clinical presentation, and outcomes of patients with DM in a contemporary patient cohort with CRPC.

Methods:

We retrospectively reviewed our CRPC database from 2012 to 2020. The primary outcome was the diagnosis of DM, defined as metastasis to the dura mater in the brain or spine. We describe the presenting symptoms, biochemistry, radiologic findings, and therapy sequence for all DM patients. Multivariable logistic regression was performed to identify predictors of DM.

Results:

Six of the 275 patients (2.2%) with CRPC developed DM. The average age of CRPC diagnosis for patients with DM was 65.6 years. Mean patient survival was 4.5 months after the diagnosis of DM. At the time of CRPC diagnosis, patients who developed DM were significantly younger, had lower baseline haemoglobin, higher lactate dehydrogenase (LDH), and elevated alkaline phosphatase (ALP) compared to those without DM. On multivariable analysis, younger age of CRPC diagnosis was found to be a predictor for DM.

Conclusion:

The presence of neurological symptoms in the context of younger age, anaemia, and elevated baseline LDH and ALP are associated with DM in CRPC.

Level of Evidence:

4

Case Report: Creeping Growth in Lymphoplasmacyte-Rich Meningioma-A Radiologic Variant

Lymphoplasmacyte-rich meningioma (LRM) is a rare histologic subtype of meningioma. Creeping-growth pattern is uncommon in meningioma, and the mechanism is unclear. Here, we report a 44-year-old man presented with extremities weakness for 2 months and incontinence for 2 weeks. Head and neck MRI revealed diffuse creeping-growth nodular meningeal masses with skull base, tentorium, sella area, and C1-6 vertebral plane involvement. An operation was carried out, cervical and lower clivus part of the lesion was resected, but gross total resection could not be achieved due to the widespread lesions. Pathologic examination revealed the diagnosis of LRM. The patient is free from progression clinically 3 months postoperatively. We also conducted a systematic literature review about LRM with creeping-growth pattern. A total of only nine cases (including the present case) of creeping-growth LRMs were included and analyzed in terms of clinical manifestations, radiological features, treatment, and outcome. LRMs show a higher rate (7.5%) of creeping-growth pattern than other types of meningiomas. The average creeping length of all creeping-growth LRMs was 11.4 ± 10.9 cm (range, 3–30 cm). Most cases (66.7%) had obvious peritumoral edema. Total removal rate is low (33.3%), and two of them (22.2%) received biopsy, followed by steroids treatment (or further immunosuppressive drugs therapy) and radiotherapy. The recurrence rate is higher than conventional LRMs (22.2 vs. 11.3%), and one patient (11.1%) died 11 months after treatment. Creeping-growth pattern in LRM may be considered as a general radiologic variant. The recurrence rate is higher compared with LRM with round/swelling pattern. We speculated that the pathogenesis of creeping growth in LRM may be associated with damage of lymphatic systems of the central nervous system.

A solitary hypothalamic metastasis from prostatic cancer mimicking a giant thrombotic aneurysm and presenting with intraventricular hemorrhage and acute hydrocephalus: a case report

Background

Despite the high prevalence of prostate cancer, its brain parenchymal metastasis is not common and intracranial hemorrhage due to such a metastasis is even less common. This report presents a challenging case of solitary brain metastasis secondary to prostate cancer that gave rise to intraventricular hemorrhage and acute hydrocephalus mimicking a giant aneurysm.

Case presentation

A 77-year-old man with a history of prostate cancer, hypertension, and morbid obesity presented to the emergency room with a severe headache. He was afebrile with a blood pressure of 144/79 mmHg, alert, without any sign of sensory or motor deficit. Shortly after admission, he became unresponsive and was immediately intubated. His blood tests revealed hypernatremia at 154 mmol/L; otherwise, the lab data including the COVID-19 screening proved normal. The cerebral CT and MR images, with and without contrast, were interpreted as a giant thrombotic aneurysm extending to the suprasellar region by the emergency radiologist. Also, moderate intraventricular hemorrhage, acute hydrocephalus, and sub-ependymal interstitial edema were observed. Upon further evaluation of the images, the lesion was determined to be an exophytic hemorrhagic hypothalamic mass, and the subsequent biopsy was consistent with prostate cancer metastasis.

Conclusions

The exophytic hemorrhagic hypothalamic metastasis can mimic a ruptured aneurysm on imaging. Given the improved survival of patients with prostate cancer, radiologists may encounter such unusual cerebral metastases from prostate cancers more frequently in the future.

[What is the place of surgery in the management of brain metastases in 2020?]

Brain metastases are the most common intracranial tumors and are associated with a dismal prognosis. The management of patients with brain metastases has become more important because of the increased incidence of these tumours, the better treatment of the systemic disease and the improvement of surgical techniques. The treatment requires multidisciplinary approaches and become complex because of new emerging systemic therapy and advancements in neurosurgery and radiation oncology. The surgical treatment has an indispensable role to obtain a tissue diagnosis, in relieving intracranial effect mass and improving neurological status by improving induced encephalopathy. An understanding of the role and indications of the surgery in patients with metastatic brain lesions is essential for the effective management of this growing population.

Dural Metastases of Advanced Prostate Cancer Detected by 18F-Fluorocholine

Prostate cancer with extensive dural metastases is very rare, with only few cases described in the literature. We report one such case of a 74-year-old man with advanced prostate cancer, and in relatively good clinical condition. The patient returned with complaints of headache and diplopia. Fluorocholine (¹⁸F) chloride (¹⁸F-FCH) is an analog of choline in which a hydrogen atom has been replaced by fluorine (¹⁸F). After crossing the cell membrane by a carrier-mediated mechanism, choline is phosphorylated by choline kinase to produce phosphorylcholine. ¹⁸F-FCH positron emission tomography–computed tomography (PET/CT) is widely used to stage and restage patients affected by prostate cancer with good sensitivity. ¹⁸F-FCH PET/CT showed disease progression with the onset of multiple skull lesions. Numerous suspicious dural hypermetabolic lesions indicating neoplastic involvement were detected along the fronto-parietal convexities, in the left fronto-orbital region and right lateral wall of the orbit, concerning for metastases in these regions. A contrast-enhanced computed tomography (CECT) scan was performed which showed corresponding enhancing tissue which correlated with the PET findings. The final imaging diagnosis was osteo-dural metastases from prostate cancer associated with poor outcome. Awareness of this pattern of metastases may be of clinical relevance in order to avoid unnecessary invasive diagnostic procedures in groups of patients with a dismal prognosis.