Stereotactic Radiosurgery for Carcinoid Brain Metastasis: A Case Report

Case report: Efficacy of lutetium-177 oxodotreotide for neuroendocrine tumor with central nervous system metastases

Neuroendocrine tumors (NETs) rarely metastasize to the brain. However, when they occur, NET brain metastases are associated with a poor prognosis. Due to their low incidence, NET brain metastases are poorly studied, with few data to guide a consensus for management. Prior reports have documented treatment with chemotherapy, resection, whole brain radiation therapy, and stereotactic radiosurgery, all with low rates of survival. We present a case of a patient with type 3 well-differentiated gastric NET with widespread metastatic disease, including central nervous system lesions in the pineal gland and left cerebellopontine angle (CPA), which were avid on 68Ga-dotatate positron emission tomography. The patient received four doses of 200 mCi (7.4 GBq) lutetium-177 oxodotreotide (177Lu-dotatate) administered every 8 weeks over the course of 6 months. The treatments provided local control of the pineal and CPA lesions for 23 months until the development of diffuse leptomeningeal progression that necessitated further therapies. 177Lu-dotatate may be a viable treatment for local control of NET brain metastases. More studies are needed to validate its efficacy in this clinical scenario.

Case Report: Metastatic Bronchopulmonary Carcinoid Tumor to the Pineal Region

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.