Brain metastases as a cause of malignant cerebrospinal fluid ascites: case report and review of the literature

Peritoneal carcinomatosis after lumboperitoneal shunt in a patient with a cancer of unknown primary site: Case report and review of the literature

Cancer of unknown primary site (CUP) often presents with atypical clinical behaviours that make identifying the primary tumour challenging. In this paper, we discuss the case of a patient with brain metastases from a CUP, which was ultimately diagnosed as pleomorphic carcinoma of the lung following autopsy. Clinically, the development of peritoneal carcinomatosis had reduced suspicion of a primary lung neoplasm, despite imaging tests initially suggesting this. However, the patient had previously undergone lumboperitoneal (LP) shunt insertion. The sequence of clinical events and autopsy findings strongly indicated that the LP shunt facilitated the metastatic spread. In addition to this case report, we provide a systematic review of the literature on the role of ventriculoperitoneal (VP) and LP shunts in the metastatic dissemination of tumours. Although the spread of primary brain tumours via VP or LP shunts is rare, albeit well-documented, this phenomenon has been reported only twice for secondary tumours.

Stereotactic radiosurgery for fourth ventricle brain metastases: tumor control outcomes and the need for CSF diversion. Patient series

BACKGROUND

Stereotactic radiosurgery is a favorable alternative to surgery for intracranial cerebral metastases. Fourth ventricle (V4) metastases are challenging because of the location and surrounding structures, with a high risk for obstructive hydrocephalus and brainstem compression. Here, the authors evaluate the effectiveness in terms of safety, tumor control rates, and permanent cerebrospinal fluid (CSF) diversion of primary Gamma Knife radiosurgery (GKRS) in treating V4 metastases.

OBSERVATIONS

Eleven of 1060 patients had V4 brain metastases. No patients had pre-GKRS hydrocephalus. The mean tumor volume was 3.3 cm3, treatment dose was 18 Gy to the 50.5% isodose line (average 14 shots), conformity index was 1.4, and volume of brainstem receiving greater than 12 Gy was 0.2 cm3. Eight patients had radiographic and clinical follow-ups. The average time to initial follow-up was 3.1 months. Karnofsy Performance Status did not change from the initial consultation to the post-GKRS follow-up. No patients developed hydrocephalus or required permanent CSF diversion. One patient required transient external ventricular drain placement; however, neurological symptoms resolved with steroid therapy. Seven patients received steroid therapy post-GKRS. Seven patients had radiographic disease control at the 6-month follow-up. One patient had tumor progression at 6 months and underwent surgery.

LESSONS

Primary GKRS for V4 metastases with a close follow-up is safe and optimizes quality of life for patients with significant cancer burden. https://thejns.org/doi/10.3171/CASE24293.

The effect of Gamma Knife radiosurgery on large posterior fossa metastases and the associated mass effect from peritumoral edema

OBJECTIVE

Gamma Knife radiosurgery (GKRS) as monotherapy is an option for the treatment of large (≥ 2 cm) posterior fossa brain metastases (LPFMs). However, there is concern regarding possible posttreatment increase in peritumoral edema (PTE) and associated compression of the fourth ventricle. This study evaluated the effects and safety of GKRS on tumor and PTE control in LPFM.

METHODS

The authors performed a single-center retrospective review of 49 patients with 51 LPFMs treated with GKRS. Patients with at least 1 clinical and radiological follow-up visit were included. Tumor, PTE, and fourth ventricle volumetric measurements were used to assess efficacy and safety. Overall survival was a secondary outcome.

RESULTS

Fifty-one lesions in 49 consecutive patients were identified; 57.1% of patients were male. At the time of GKRS, the median age was 61.5 years, and the median Karnofsky Performance Status score was 90. The median number of LPFMs and overall brain metastases were 1 and 2, respectively. The median overall tumor, PTE, and fourth ventricle volumes at diagnosis were 4.96 cm3 (range 1.4-21.1 cm3), 14.98 cm3 (range 0.6-71.8 cm3), and 1.23 cm3 (range 0.3-3.2 cm3), respectively, and the median lesion diameter was 2.6 cm (range 2.0-5.07 cm). The median follow-up time was 7.3 months (range 1.6-57.2 months). At the first follow-up, 2 months posttreatment, the median tumor volume decreased by 58.66% (range -96.95% to +48.69%, p < 0.001), median PTE decreased by 78.10% (range -99.92% to +198.35%, p < 0.001), and the fourth ventricle increased by 24.97% (range -37.96% to +545.6%, p < 0.001). The local control rate at first follow-up was 98.1%. The median OS was 8.36 months. No patient required surgical intervention, external ventricular drainage, or shunting between treatment and first follow-up. However, 1 patient required a ventriculoperitoneal shunt at 23 months from treatment. Posttreatment, 65.30% received our general steroid taper, 6.12% received no steroids, and 28.58% required prolonged steroid treatment.

CONCLUSIONS

In this retrospective analysis, patients with LPFMs treated with GKRS had a statistically significant posttreatment reduction in tumor size and PTE and marked opening of the fourth ventricle (all p < 0.001). This study demonstrates that GKRS is well tolerated and can be considered in the management of select cases of LPFMs, especially in patients who are poor surgical candidates.

Removal of pineal region teratomas using occipital transtentorial approach (OTA) technique: Case report and literature review

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Pathological tumors originating purely from the pineal gland are very rare, which mainly found in children and adolescents.

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Clinical manifestations of pineal tumor mosty: visual impairment, headaches, and a decrease of cognitive and consciousness.

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It is recommended to install VP-shunt several days before definitive tumor surgery for ventricular decompression.

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The choice of technique is determined by the tumor location, pathological findings, and risk of complications.

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The OTA technique allows excellent views of pineal region, and access to the midline, superior vermis, and ventricle III.

Introduction

The development of improved micro-surgery techniques and neuroanesthesia has become increasingly sophisticated makes open-microsurgery tumor resection a choice for the management of the pineal region.

Case presentation

An 11-year-old male with a pineal body tumor post ventriculo-peritoneal (VP) shunt, underwent tumor resection. Patients complain of headaches, relieve with medication but often recurrent, and often experience a decrease in consciousness. One month before the procedure, the patient experienced blurred vision, staggering, nausea, vomiting, and decrease of consciousness. The operation is performed with an occipital transtentorial approach (OTA) technique. During surgery, hemodynamics was relatively stable. Postoperatively, the patient underwent controlled ventilation in the intensive care room, and recover significantly within one week.

Discussion

Various surgical approaches have been proposed for pineal region tumors. We review the available literature (PubMed) with 11 reported cases of pineal tumor therapy with the occipital transtentorial approach and evaluate general symptoms in clinical manifestations, histopathological features, radiological findings, and survival times to demonstrate therapeutic effectiveness. Several cases of the pineal tumor were also reported using tumor extraction by occipital transtentorial approach.

Conclusion

The choice of approach is influenced by the location of the tumor, pathology findings, the neurosurgeon’s comfort and consideration of the risk of complications.