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Amine KM, Bouzoubaa Y, Oukessou Y, Rouadi S, Abada RL, Mahtar M. A primary sphenoclival skull base neuroendocrin tumor: A rare case report and literature review. Int J Surg Case Rep 2024; 121:109750. [PMID: 38943936 PMCID: PMC11261418 DOI: 10.1016/j.ijscr.2024.109750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 07/01/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Primary intracranial neuroendocrine tumors (NETs) are exceedingly rare, often posing diagnostic challenges, particularly in non-secreting variants. These tumors may initially present with nonspecific symptoms, leading to delayed diagnosis and potential neurological complications. CASE REPORT We present the case of a 33-year-old male admitted with a one-year history of progressively worsening headache accompanied by acute left ptosis and diplopia. Initial examination revealed left eye ptosis and hypotropia, indicative of third and fourth cranial nerve paralysis. Cavoscopy revealed a mild anterior wall bulge of the sphenoid with normal mucosa. MRI imaging unveiled an expansive clival process extending towards the sellar region and left cavernous sinus, completely occupying the sphenoid sinus and exerting mass effect on the pituitary stalk. Hormonal assays were within reference ranges, ruling out a hormonally-active tumor. Endoscopic endonasal surgery for biopsy revealed a low-grade neuroendocrine tumor positive for cytokeratin AE1/AE2, chromogranin A, synaptophysin, and beta-catenin, with a Ki-67-labeling index <2 %. Somatostatin receptor scintigraphy confirmed intense hyper fixation of the tracer in the sphenoidal tumor, supporting its neuroendocrine origin. The patient declined surgical intervention after informed consent, opting for C1 somatostatin analogs prior to radiotherapy. One-year follow-up demonstrated symptom stability with no tumor progression. CLINICAL DISCUSSION To this day, no consensus among reports concerning the optimal management of these cases. Imaging assessment is crucial to validate the primary nature of the tumor and to exclude any distant localization. Various therapeutic modalities, such as surgery, radiotherapy, and somatostatin analogs, should be considered based on the specific characteristics and extent of the tumor. CONCLUSION Our case is a clear reminder that neuroendocrine tumors should be considered as a differential diagnosis for skull base neoplasms.
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Affiliation(s)
- Karmouch Mohamed Amine
- ENT Department, Face and Neck Surgery, Hospital August, 20'1953, University Hospital Center IBN ROCHD, Casablanca, Morocco.
| | - Youssef Bouzoubaa
- ENT Department, Face and Neck Surgery, Hospital August, 20'1953, University Hospital Center IBN ROCHD, Casablanca, Morocco
| | - Youssef Oukessou
- ENT Department, Face and Neck Surgery, Hospital August, 20'1953, University Hospital Center IBN ROCHD, Casablanca, Morocco
| | - Sami Rouadi
- ENT Department, Face and Neck Surgery, Hospital August, 20'1953, University Hospital Center IBN ROCHD, Casablanca, Morocco
| | - Redallah Larbi Abada
- ENT Department, Face and Neck Surgery, Hospital August, 20'1953, University Hospital Center IBN ROCHD, Casablanca, Morocco
| | - Mohammed Mahtar
- ENT Department, Face and Neck Surgery, Hospital August, 20'1953, University Hospital Center IBN ROCHD, Casablanca, Morocco
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Parghane RV, Basu S. Triple Tumors (Neuroendocrine Tumor, Schwannoma, and Papillary Thyroid Carcinoma) With Brain Lesions in a Single Patient Demonstrating Avidity on 68 Ga-DOTATATE PET/CT and Their Characterization With FDG-PET/CT and Brain MRI. Clin Nucl Med 2024; 49:e329-e330. [PMID: 38778465 DOI: 10.1097/rlu.0000000000005273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
ABSTRACT Neuroendocrine tumor (NET) typically spreads to the liver, lymph nodes, lungs, and skeleton. Brain metastasis in NET is uncommon. Therefore, each case of detected brain metastases in NET is crucial for the development of treatment guidelines for these types of tumors. We present a unique case of triple tumors (NET, papillary thyroid carcinoma, and schwannoma) in a single patient who presented with neurological symptoms and somatostatin receptor-avid T2 hyperintense multiple metastatic brain lesions from NET on 68 Ga-DOTATATE-PET/CT scan and brain MRI. Despite the rarity of brain metastases in NET, we conclude that the presence of neurological sign or symptoms and/or the detection of somatostatin receptor-avid brain lesions in patients with NET should raise suspicion of brain metastases.
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Singh P, Khan AA, Kolte S, Singh M. Cytomorphology of a brain lesion and its pitfall. Cytojournal 2023; 20:38. [PMID: 37942304 PMCID: PMC10629278 DOI: 10.25259/cytojournal_24_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/08/2023] [Indexed: 11/10/2023] Open
Affiliation(s)
- Priyanka Singh
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Adil Aziz Khan
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sachin Kolte
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Mukul Singh
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Aziz Khan A, Ahuja S, Zaheer S. A rare case of primary neuroendocrine carcinoma of the central nervous system. Neuropathology 2023; 43:421-424. [PMID: 37013337 DOI: 10.1111/neup.12904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 04/05/2023]
Abstract
Primary neuroendocrine carcinoma (NEC) of the brain is an extremely rare presentation, with only a few previous case reports. We describe a primary NEC arising from the left parieto-occipital lobe. The 55-year-old patient presented with complaints of headache and dizziness for the preceding 7 months. Magnetic resonance imaging revealed a large ill-defined mass in the left parieto-occipital lobe, with possible differential diagnosis of meningioma. A craniotomy was performed, and a firm vascular tumor was removed. Histopathological examination revealed a large cell NEC. Immunohistochemistry was performed to exclude the possibility of an extracranial primary. Based on the immunohistochemical expression and absence of any extracranial tumor on positron emission tomography, the diagnosis of primary NEC of the brain was made. It is important to differentiate between primary and metastatic neuroendocrine tumors because they show a significant difference in prognosis and treatment.
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Affiliation(s)
- Adil Aziz Khan
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sana Ahuja
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sufian Zaheer
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Swied MY, Turk YA, Jegadeesan R. A Poorly Differentiated Esophageal Neuroendocrine Carcinoma With Brain Metastasis. ACG Case Rep J 2023; 10:e01156. [PMID: 37753106 PMCID: PMC10519462 DOI: 10.14309/crj.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Esophageal neuroendocrine carcinomas (NECs) are a rare type of esophageal neoplasm that can initially present with vague signs and symptoms. Gastrointestinal manifestations, such as dysphagia and abdominal discomfort, are the most common symptoms of neuroendocrine neoplasms. Although there is a potential for distant metastases because of esophageal NEC, few cases of brain metastasis have been reported. We report a rare case of an esophageal NEC metastasizing to the brain region.
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Affiliation(s)
| | - Yahia Al Turk
- Southern Illinois University School of Medicine, Springfield, IL
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Primary Neuroendocrine Carcinoma of Pineal Gland With Extensive Meningeal Metastasis Detected by 18F-NOTATATE PET/CT. Clin Nucl Med 2022; 47:1105-1107. [PMID: 36342798 DOI: 10.1097/rlu.0000000000004368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
ABSTRACT Primary neuroendocrine tumor of the pineal gland is a rare disease. A 44-year-old woman with right cerebellopontine angle metastatic small cell neuroendocrine carcinoma underwent 18F-FDG and 18F-NOTATATE PET/CT scans. 18F-NOTATATE PET/CT showed intense uptake in the pineal gland lesions and multiple foci of intense focus of uptake in the intracranial leptomeningeal and whole spinal canal. However, the lesions are less impressive on 18F-FDG PET/CT.
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Caro-Osorio E, Perez-Ruano LA, Martinez HR, Rodriguez-Armendariz AG, Lopez-Sotomayor DM. Primary Neuroendocrine Carcinoma of the Cerebellopontine Angle: A Case Report and Literature Review. Cureus 2022; 14:e27564. [PMID: 36059346 PMCID: PMC9431898 DOI: 10.7759/cureus.27564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 11/25/2022] Open
Abstract
Primary intracranial neuroendocrine tumors are extremely rare malignancies with very few cases reported in the world literature. We describe a primary neuroendocrine carcinoma arising from the right cerebellopontine angle, the second case that has been described in this location. The possible origin in this place and treatment are described. A 29-year-old male patient, diagnosed with schwannoma of the right cerebellopontine angle, and treated with radiosurgery at another institution, came to our hospital six months later, The patient presented with a history of rapid progression of numbness on the right side of the face, diplopia, dizziness, vomiting, and facial palsy. On examination, the right cranial nerves V, VI, VII, VIII, and IX were affected. The MRI showed tumor growth occupying the right cerebellopontine angle, with compression of the brain stem and cerebellum. A right retromastoid craniectomy removed the tumor partially and the histopathological examination revealed a high-grade neuroendocrine carcinoma. We describe a primary neuroendocrine tumor of the brain that, despite its rarity, must be considered in the differential diagnosis. There are currently no guidelines for the management of these tumors. According to previously reported cases, surgery is the first line of treatment, followed by radiotherapy or chemotherapy. We consider that such a rare case is needed to be reported for a better understanding of the disease and its neurobiology.
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Stepien N, Haberler C, Theurer S, Schmook MT, Lütgendorf-Caucig C, Müllauer L, Gojo J, Azizi AA, Czech T, Slavc I, Peyrl A. Unique Finding of a Primary Central Nervous System Neuroendocrine Carcinoma in a 5-Year-Old Child: A Case Report. Front Neurosci 2022; 16:810645. [PMID: 35401087 PMCID: PMC8984181 DOI: 10.3389/fnins.2022.810645] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Neuroendocrine tumors (NETs) are rare neoplasms predominantly arising in the gastrointestinal-tract or the lungs of adults. To date, only ten cases of primary central nervous system (CNS) NETs have been reported, with just three of them describing a neuroendocrine carcinoma (NECA) and none occurring in a child. We report on a previously healthy 5-year-old boy, who presented with headaches, nausea and vomiting, and was diagnosed with a left cerebellar solid mass with a cystic component. After gross-total resection, histology revealed a neuroendocrine carcinoma. Molecular analysis of the tumor tissue showed a KRAS-splice-site mutation (c451-3C > T). The KRAS-mutation was discovered to be a maternal germline mutation, previously described as likely benign. After extensive search for an extracranial primary tumor, including Ga-68 DOTANOC-PET-CT, the diagnosis of a primary CNS NECA was established, and proton irradiation was performed. Unfortunately, the patient developed an in-field recurrence just 5 weeks after the end of radiotherapy. The tumor was re-resected with vital tumor tissue. Six cycles of chemotherapy were initiated, consisting of cisplatin, carboplatin, etoposide and ifosfamide. The patient remains disease free 22 months after the end of treatment, supporting the beneficial effect of platinum- and etoposide-based chemotherapy for this tumor entity.
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Affiliation(s)
- Natalia Stepien
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Christine Haberler
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Christine Haberler,
| | - Sarah Theurer
- Institute of Pathology, University of Duisburg-Essen, Essen, Germany
| | - Maria-Theresa Schmook
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Leonhard Müllauer
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Johannes Gojo
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Amedeo A. Azizi
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Thomas Czech
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Irene Slavc
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andreas Peyrl
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
- *Correspondence: Andreas Peyrl, , orcid.org/0000-0002-5736-8231
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Cheng A, Barron J, Holmes O, Bartlett P, Jenkins G, Seal M. Primary neuroendocrine tumor of the pineal gland: a case report. BMC Neurol 2021; 21:323. [PMID: 34416869 PMCID: PMC8377818 DOI: 10.1186/s12883-021-02351-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/12/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Primary intracranial neuroendocrine tumors are exceedingly rare, with few cases in the literature. We present a case of a primary neuroendocrine carcinoma of the pineal gland, which is the second that has ever been reported. CASE PRESENTATION A 53-year-old male patient presented with vomiting, weakness, and headaches. Imaging revealed a lesion in the pineal region, which was surgically resected. This mass was characterized by histology as a neuroendocrine carcinoma, given the presence of neuroendocrine markers and cytokeratin markers with absence of a primary lesion elsewhere on imaging. CONCLUSIONS There are currently no guidelines on the management of primary intracranial neuroendocrine tumors. In this case, the patient underwent surgical resection and craniospinal radiotherapy. He subsequently received one cycle of chemotherapy with temozolomide, an alkylating agent, but he unfortunately did not tolerate treatment. A multidisciplinary decision was made along with the patient and his family to focus on palliative care. Eighteen months after the initial presentation, disease recurred in the patient's neck. The patient underwent resection to control the metastases, with a plan to follow with radiotherapy and chemotherapy. Unfortunately, the patient became unwell and died at 21 months after initial diagnosis. This demonstrates a need for continued research and reporting on this uncommon disease entity.
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Affiliation(s)
- Angela Cheng
- Faculty of Medicine, Memorial University, 105-78 Thorburn Road, St. John's, NL, A1B3T4, Canada.
| | - Jane Barron
- Discipline of Laboratory Medicine (Neuropathology), Memorial University Faculty of Medicine, St. John's, Canada
| | - Oliver Holmes
- Discipline of Oncology (Radiation Oncology), Memorial University Faculty of Medicine, St. John's, Canada
| | - Peter Bartlett
- Department of Radiology, Memorial University Faculty of Medicine, St. John's, Canada
| | - Gregory Jenkins
- Department of Surgery (Neurosurgery), Memorial University Faculty of Medicine, St. John's, Canada
| | - Melanie Seal
- Discipline of Oncology (Medical Oncology), Memorial University Faculty of Medicine, St. John's, Canada
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KAMBE A, NAKAJIMA S, FUKUSHIMA K, MIZUSHIMA M, SAKAMOTO M, HORIE Y, KUROSAKI M. Primary Intracranial Neuroendocrine Tumor of the Skull Base Complicated with Tension Pneumocephalus after Radiotherapy. NMC Case Rep J 2021; 8:609-615. [PMID: 35079524 PMCID: PMC8769468 DOI: 10.2176/nmccrj.cr.2020-0367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 05/06/2021] [Indexed: 11/20/2022] Open
Abstract
Neuroendocrine tumors (NETs) are neoplasms that originate from cells of the endocrine and nervous systems, and are commonly found in the gastrointestinal and respiratory tracts. Primary intracranial NETs are extremely rare and have been the focus of only a few studies thus far. Herein, we report the case of a primary intracranial NET of the skull base complicated with tension pneumocephalus after radiotherapy. An 84-year-old woman visited a local hospital for a head injury, and CT revealed a skull base tumor. MRI showed that the tumor was located mainly on the clivus and extended into the paranasal sinuses and nasal cavity. We biopsied the tumor via the nasal cavity, and the pathological diagnosis was NET, WHO grade 2. We subsequently administered focal intensity-modulated radiation therapy, but the patient developed tension pneumocephalus 1 year after radiotherapy. We therefore performed endoscopic transnasal cerebrospinal fluid leak closure with a nasoseptal flap. The postoperative course was successful, and the patient returned home but died of an unknown cause 2 years after discharge. The optimal postoperative management of primary intracranial NETs remains controversial. Tension pneumocephalus related to radiotherapy is a rare complication. Assessing skull bone erosion before radiotherapy and performing regular radiological follow-up examinations are essential to prevent this rare complication.
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Affiliation(s)
- Atsushi KAMBE
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Sadao NAKAJIMA
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Kei FUKUSHIMA
- Department of Otolaryngology/Head and Neck Surgery, Fukuyama Medical Center, Fukuyama, Hiroshima, Japan
| | - Minoru MIZUSHIMA
- Department of Neurosurgery, Matsue Seikyo General Hospital, Matsue, Shimane, Japan
| | - Makoto SAKAMOTO
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Yasushi HORIE
- Division of Molecular Pathology, Department of Pathology, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Masamichi KUROSAKI
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
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Cuoco JA, Kortz MW, McCray E, Guilliams EL, Busch CM, Rogers CM, Jarrett RW, Mittal S. Case Report: Metastatic Bronchopulmonary Carcinoid Tumor to the Pineal Region. Front Endocrinol (Lausanne) 2021; 12:623756. [PMID: 33868166 PMCID: PMC8044440 DOI: 10.3389/fendo.2021.623756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/08/2021] [Indexed: 12/02/2022] Open
Abstract
Intracranial spread of a systemic malignancy is common in advanced staged cancers; however, metastasis specifically to the pineal gland is a relatively rare occurrence. A number of primary lesions have been reported to metastasize to the pineal gland, the most common of which is lung. However, metastasis of a bronchial neuroendocrine tumor to the pineal gland is a seldom-reported entity. Here, we present a 53-year-old female who presented with worsening headaches and drowsiness. MRI brain revealed a heterogeneously enhancing partially cystic mass in the pineal region. The patient had an extensive oncologic history consisting of remote stage IIA invasive breast ductal carcinoma as well as a more recently diagnosed atypical bronchopulmonary neuroendocrine tumor with lymph node metastases. She underwent microsurgical volumetric resection of the large pineal mass and a gross total removal of the tumor was achieved. Histopathology confirmed a metastatic tumor of neuroendocrine origin and the immunohistochemical profile was identical to the primary bronchopulmonary carcinoid tumor. Eight weeks after surgery, she underwent stereotactic radiosurgical treatment to the resection cavity. At 1-year follow-up, the patient remains clinically stable without any new focal neurological deficits and without any evidence of residual or recurrent disease on postoperative MRI. Metastatic neuroendocrine tumors should be considered in the differential diagnosis of pineal region tumors and aggressive surgical resection should be considered in selected patients. Gross total tumor resection may afford excellent local disease control. We discuss the relevant literature on neuroendocrine tumors and current treatment strategies for intracranial metastases of neuroendocrine origin.
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Affiliation(s)
- Joshua A. Cuoco
- Department of Neurosurgery, Carilion Clinic Neurosurgery, Roanoke, VA, United States
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- School of Neuroscience, Virginia Tech, Blacksburg, VA, United States
| | - Michael W. Kortz
- Department of Neurosurgery, University of Colorado, Aurora, CO, United States
- College of Osteopathic Medicine, Kansas City University, Kansas City, MO, United States
| | - Edwin McCray
- Department of Neurosurgery, Duke University, Durham, NC, United States
| | - Evin L. Guilliams
- Department of Neurosurgery, Carilion Clinic Neurosurgery, Roanoke, VA, United States
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- School of Neuroscience, Virginia Tech, Blacksburg, VA, United States
| | - Christopher M. Busch
- Department of Neurosurgery, Carilion Clinic Neurosurgery, Roanoke, VA, United States
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- School of Neuroscience, Virginia Tech, Blacksburg, VA, United States
| | - Cara M. Rogers
- Department of Neurosurgery, Carilion Clinic Neurosurgery, Roanoke, VA, United States
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- School of Neuroscience, Virginia Tech, Blacksburg, VA, United States
| | - Robert W. Jarrett
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- Carilion Clinic Pathology and Dominion Pathology Associates, Roanoke, VA, United States
| | - Sandeep Mittal
- Department of Neurosurgery, Carilion Clinic Neurosurgery, Roanoke, VA, United States
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- School of Neuroscience, Virginia Tech, Blacksburg, VA, United States
- Fralin Biomedical Research Institute, Roanoke, VA, United States
- *Correspondence: Sandeep Mittal,
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