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CASE REPORT  
Year : 2022  |  Volume : 65  |  Issue : 3  |  Page : 719-721
Intraventricular metastasis from carcinoma breast masquerading as choroid plexus neoplasm: A case report


Department of Pathology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India

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Date of Submission26-Jan-2021
Date of Decision23-Feb-2022
Date of Acceptance24-Feb-2022
Date of Web Publication21-Jul-2022
 

   Abstract 


Metastatic tumors in the brain represent the most common type of intracranial neoplasm, comprising 8–10% of all brain tumors. 30% of such tumors are primarily of breast origin in females. Brain parenchymal metastasis is the more common presentation. Intraventricular spread is rare, seen in less than 5% of cases in a metastatic scenario. Here, we report a case of 41-year-old female presenting with intraventricular brain metastasis in a follow-up case of carcinoma breast. Five years post-surgery, the patient presented with complaints of headache. On evaluation, magnetic resonance imaging (MRI) brain showed an intraventricular lesion in the fourth ventricle. She was operated on for the same and the biopsy revealed a tumor with a complex papillary pattern resembling choroid plexus papilloma. On immunohistochemistry (IHC), the tumor cells were positive for cytokeratin 7 (CK7), Epithelial membrane antigen (EMA), GATA3, and mammaglobin favoring a metastasis from breast origin. Hence, a possibility of brain metastasis should be kept in mind in patients presenting with solitary ventricular masses due to the lack of definite radiological characteristics in such locations and histological overlap. Also, organ-specific IHC is a must in today's evidence-based era as is reflected in our case.

Keywords: Brain metastasis, breast, GATA-3, IHC, intraventricular

How to cite this article:
Dhamecha M, Sharma A, Kamboj M, Pahwa S, Pasricha S. Intraventricular metastasis from carcinoma breast masquerading as choroid plexus neoplasm: A case report. Indian J Pathol Microbiol 2022;65:719-21

How to cite this URL:
Dhamecha M, Sharma A, Kamboj M, Pahwa S, Pasricha S. Intraventricular metastasis from carcinoma breast masquerading as choroid plexus neoplasm: A case report. Indian J Pathol Microbiol [serial online] 2022 [cited 2022 Aug 15];65:719-21. Available from: https://www.ijpmonline.org/text.asp?2022/65/3/719/351625





   Introduction Top


Metastatic tumors in the brain represent the most common type of intracranial neoplasm, comprising 8–10% of all brain tumors.[1] Metastasis to the brain is seen in 10–20% of patients with breast cancer, making it the second most common source of brain metastasis.[2],[3] Incidence of central nervous system (CNS) metastasis in breast cancer is more commonly seen in patients who had chemotherapy.[4] In females, 30% of brain metastatic tumors are primarily of breast origin.[5] Among these tumors, brain parenchymal metastasis is more frequently seen. Intraventricular spread is quite rare and is seen in less than 5% of metastatic tumors.[6] Here, we report a rare case of intraventricular brain metastasis in a follow-up case of carcinoma breast post multiple lines of treatment, which initially resembled a primary choroid plexus neoplasm.


   Case History Top


A 41-year-old female with a previous history of carcinoma right breast was diagnosed as invasive breast carcinoma, grade 2 (pT2NxMx), in 2012. The hormonal status was positive for estrogen receptor (ER) (90%) and progesterone receptor (PR) (60%) while human epidermal growth factor receptor-2 (HER-2) was negative (score 0) on IHC. She was given adjuvant chemotherapy regime PACS-01 (six cycles) from December 2012 until May 2013, following which adjuvant radiotherapy was given for 2 months. Subsequently, she received adjuvant hormonal therapy (tamoxifen) until September 2015.

At 3 years follow-up, while on hormonal therapy she presented with bilateral pulmonary metastasis with mediastinal lymphadenopathy (3 years post-surgery), which was confirmed on histopathology. The ER, PR, and HER2 status remained unchanged. In view of metastatic disease, three cycles of TEC (Docetaxel + Epirubicin + Cyclophosphamide) were administered until December 2016.

Follow-up positron emission tomography-computed tomography (PET–CT) scan revealed progressive disease in lungs and thus was put on palliative chemotherapy (Carboplatin/Taxotere) [Figure 1]a. Post the third cycle of chemotherapy, PET–CT (November 2016) showed partial response in the form of regression of pulmonary nodules as well as nodal disease.

After 1 year of disease-free survival, she presented with complaints of headache and vomiting. On evaluation, MRI and PET–CT brain showed an intraventricular lesion in the fourth ventricle [Figure 1]b, for which she underwent midline occipital craniectomy and decompression. The tissue on histopathology showed a tumor with complex papillary and glandular architecture resembling a choroid plexus tumor [Figure 2]a. The tumor cells were cuboidal to columnar with hyperchromatic nuclei, inconspicuous nucleoli, and moderate cytoplasm. Significant mitotic activity was seen [Figure 2]b. On IHC, the tumor cells were positive for CK7, EMA, GATA3, and mammaglobin while it was negative for CK20 and S-100 [Figure 3]. Ki67 index was high. IHC for KIR 7.1 for choroid plexus papilloma was done which was negative. Overall findings were diagnostic of metastatic breast carcinoma. The ER (100%), PR (30%), and HER2 (negative) status were unaltered. Further follow-up in January 2019 showed persistent fluorodeoxyglucose (FDG)-avid bilateral lung nodules on whole-body PET–CT. MRI brain revealed smoothly marginated cystic lesion with a rim of the hemorrhagic component in right parietal lobe which was non-FDG-avid on PET–CT. No abnormality or FDG uptake was seen in the fourth ventricle. During this period, she was given inj. fulvestrant 250 ml for 5 months, following which patient was lost to follow-up.
Figure 1: (a) PET–CT showing bilateral multiple metabolically active lung parenchymal and subpleural nodular infiltrates, largest along right diaphragmatic pleura (blue arrow) (axial, sagittal, coronal). (b) PET–CT (after 1 year DFS) showing an intraventricular lesion in the fourth ventricle, in the midline (white arrow), with heterogeneous tracer uptake and minimal perilesional edema (axial, sagittal, coronal)

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Figure 2: (a) Photomicrograph shows a tumor resembling a choroid plexus papillary tumor (upper left). [part of normal cerebellum (lower right)] (H and E, 100×). (b) Photomicrograph shows neoplastic cells with moderate cytoplasm, round to oval nuclei with granular euchromatin, and inconspicuous nucleoli. Mitotic activity is evident (H and E, 400×)

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Figure 3: (a) Strong and diffuse staining of tumor cells with a) CK7, (b) EMA, (c) GATA3, (d) Ki-67 index done was 10%, (e) The tumor cells were focally positive for mammaglobin f) Negative immunostaining of tumor cells with CK20, S100, KIR 7.1

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   Discussion Top


Solid brain tumors are the most common presentation (85–95%) in the CNS, and they tend to arise at the gray–white matter junction with a distribution that is proportional to the regional cerebral blood flow. Metastatic brain lesions are uncommon and account for only 10% of all neoplasms.[5] Parenchymal metastases from breast cancer are more frequent, but the intraventricular spread is rare, seen in less than 5% of breast cancer patients.[2] Most intraventricular lesions are primary tumors arising from epithelial and mesenchymal elements of the choroid plexus.[7] The tumors of the lateral ventricle arise from the walls of the ventricle or tissues within and around the ventricles notably the choroid plexus, septum pellucidum, and thalamus. Most of these tumors are low-grade and slow-growing, which include astrocytoma, oligodendroglioma, choroid plexus papilloma, and meningioma. Few of them are malignant, like malignant ependymoma and choroid plexus carcinoma.

Metastasis accounts for a rare differential diagnosis of an intraventricular mass. True intraventricular metastases arise within the ventricle, while parenchymal metastases may protrude into the ventricle as nodular deposits (seen in meningeal carcinomatosis) and these should not be classified as intraventricular metastasis.[8],[9] The most common site of intraventricular metastasis is the trigone of lateral ventricles due to the high vascularity of the choroid plexus. The next most common site is the fourth and third ventricle, respectively.[8],[10]

Primary carcinomas of renal, breast, or lung origin, squamous cell carcinoma of the uterine cervix, colon carcinoma, and melanoma can metastasize to the ventricles.[8] Description of solitary intraventricular metastasis is very rare. Hence, the clinicians must be aware to look for CNS involvement by performing a CT/MRI scan in cancer patients presenting with altered mental status on follow-up. Radical surgical resection seems to be the most relevant option for patients with intraventricular metastases.[8]


   Conclusion Top


Metastasis is a rare differential of an intraventricular mass and should be a consideration even in a solitary presentation in a known case. Organ-specific IHC is a must in today's evidence-based era, as observed in our case.

Abbreviations

MRI = Magnetic resonance imaging

IHC = Immunohistochemistry

PET–CT = Positron emission tomography–computed tomography

CNS = Central nervous system.

Informed consent

A general informed consent was taken from the patient regarding sharing of clinical data for research purpose. All the patients information in the manuscript is anonymised and only de-identified data is used.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yildirim IO, Buyukkutlu AR, Aydogdu K. MRI findings of Brain metastases in Lung cancers. Med-Science 2014;3:1092-102.  Back to cited text no. 1
    
2.
Sajko T, Rotim K, Kudelić N, Krpina H, Miletić L. Intraventricular location of metastatic breast carcinoma: A case report. Acta Clin Croat 2009;48:55-8.  Back to cited text no. 2
    
3.
DiStefano A, Yong Yap Y, Hortobagyi GN, Blumenschein GR. The natural history of breast cancer patients with brain metastasis. Cancer 1979;44:1913-8.  Back to cited text no. 3
    
4.
Lee YN. Breast carcinoma: Pattern of metastasis at autopsy. J Surg Oncol 1983;23:175-80.  Back to cited text no. 4
    
5.
Della Puppa A, Dal Pos S, Zovato S, Orvieto E, Ciccarino P, Manara R, et al. Solitary intra-ventricular brain metastasis from a breast carcinoma. J Neurooncol 2010;97:123-6.  Back to cited text no. 5
    
6.
Hassaneen W, Suki D, Salaskar AL, Wildrick DM, Lang FF, Fuller GN, et al. Surgical management of lateral-ventricle metastases: Report of 29 cases in a single-institution experience. J Neurosurg 2010;112:1046-55.  Back to cited text no. 6
    
7.
Raila FA, Bottoms WT Jr, Fratkin JD. Solitary choroid plexus metastasis from a renal cell carcinoma. South Med J 1998;91:1159-62.  Back to cited text no. 7
    
8.
Ravikanth R, Kamalasekar K. Unusual presentation of intraventricular metastases from small-cell carcinoma of the lung. Chrismed J Health Res 2019;6:194.  Back to cited text no. 8
  [Full text]  
9.
Healy JF, Rosenkrantz H. Intraventricular metastases demonstrated by cranial computed tomography. Radiology 1980;136:124.  Back to cited text no. 9
    
10.
Lekic M, Kovac V, Triller N, Knez L, Sadikov A, Cufer T, et al. Outcome of small cell lung cancer (SCLC) patients with brain metastases in a routine clinical setting. Radiol Oncol 2012;46:54-9.  Back to cited text no. 10
    

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Correspondence Address:
Saloni Pahwa
Department of Pathology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpm.ijpm_92_21

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  [Figure 1], [Figure 2], [Figure 3]



 

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