|Year : 2021 | Volume
| Issue : 1 | Page : 39-41
Isolated dural metastasis in breast cancer after 22 years and approach to its management
Sakina Mankada, Maitrik Mehta, Amit Kichloo, Akash Pandya, Chinmay Prajapati, Ubrangala Suryanarayana
Department of Radiation Oncology, BJMC and GCRI, Ahmedabad, Gujarat, India
|Date of Submission||26-Sep-2020|
|Date of Decision||09-Oct-2020|
|Date of Acceptance||19-Oct-2020|
|Date of Web Publication||14-Apr-2021|
A2 Amardeep Apartments, Civil Hospital Road, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Breast cancers are the second most common cause of intracranial metastasis, after lung cancer, mostly occurring in brain parenchyma. However, dural metastasis (DM) is a rare site representing only < 1% of all metastasis in breast cancers. Median age of occurrence of DM is after 2–3 years of primary diagnosis. DM is usually associated with other skeletal metastasis and isolated DM in a treated case of breast carcinoma is rarer. We report a case of DM in a 67-year-old female patient previously treated for breast cancer 22 years back. The patient underwent surgical excision for DM followed by whole brain radiation and is on palliative chemotherapy.
Keywords: Breast cancer, isolated dural metastasis, management
|How to cite this article:|
Mankada S, Mehta M, Kichloo A, Pandya A, Prajapati C, Suryanarayana U. Isolated dural metastasis in breast cancer after 22 years and approach to its management. Oncol J India 2021;5:39-41
|How to cite this URL:|
Mankada S, Mehta M, Kichloo A, Pandya A, Prajapati C, Suryanarayana U. Isolated dural metastasis in breast cancer after 22 years and approach to its management. Oncol J India [serial online] 2021 [cited 2021 Oct 22];5:39-41. Available from: https://www.ojionline.org/text.asp?2021/5/1/39/313668
| Introduction|| |
Dural metastasis (DM) is rarely reported in breast cancer patients and accounts for <1% of intracranial metastases. Breast cancer is the most common primary for DM. Magnetic resonance imaging (MRI) of brain is the investigation of choice for any intracranial metastasis. Due to paucity of literature regarding treatment of DM alone without brain and leptomeningeal metastasis (LM), we describe a case of DM treated in our institute having a past history of breast cancer diagnosed and treated 22 years back.
| Case Report|| |
A 67-year-old postmenopausal female, with a known hypertensive, presented in the outpatient department at our institute with chief complaints of dizziness and vertigo and on and off left-sided headache for 15–20 days. There was no associated complaint of fever, seizures, or loss of consciousness. On taking detailed history, she was a known case of carcinoma of the right breast diagnosed and treated 22 years before. She had undergone modified radical mastectomy, followed by adjuvant chemotherapy treatment for the same but not at our institute. The patient was started tablet tamoxifen after that as per local physician advice and continued the same till attaining our institute.
Her physical examination was normal. On local examination, the mastectomy scar was noted on the right chest wall and right axillary region. There was no clinically palpable lump on the left breast or lymphadenopathy. There was no clinically palpable axillary or supr clavicular lymphadenopathy. There was no associated spinal tenderness. Per abdomen and per vaginal examination was normal. No focal neurological deficit was present. As the patient received tablet tamoxifen for such a long period of 22-years, ultrasound of pelvis was done but showing only mild endometrial thickness.
Chest X-ray and routine blood investigations were normal. MRI of the brain was suggestive of 3 cm × 2.5 cm × 2.6 cm size extra-axial T 1 isointense to gray matter involving part of inner and midtable of left frontal bone and adjacent extradural space [Figure 1]. Lesion caused mild displacement and compressed over underlying superior and middle frontal cortex with mild white matter edema. Postcontrast study revealed inhomogeneous enhancement of the lesion. Few small hyperintense lesions in bilateral frontal and peritrigonal white matter were also noted which suggested age-related chronic small vessel ischemic changes. There was no evidence of any acute infarct on diffusion weighted images.
|Figure 1: Magnetic resonance imaging brain showing extra-axial lesion in left frontal region|
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After multidisciplinary discussion, an excisional biopsy was performed. Histopathological examination showed infiltration of cohesive groups of malignant cells with eosinophilic cytoplasm and large hyperchromatic nuclei arranged in ductal pattern. Dural and bony tissues were infiltrated with neoplastic cells arranged in ductal pattern of high-grade metastatic carcinoma [Figure 2]a. Immunohistochemistry of excised specimen was positive for estrogen receptor, progesterone receptor [Table 1], and CK7 [Figure 2]b but negative for HER 2 neu.
|Figure 2: Microsection on H and E stain showing ductal-like growth of neoplastic cells (a), and immunohistochemistry showing CK 7 positive (b)|
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|Table 1: Estrogen receptor and progesterone receptor results on immunohistochemistry study|
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Positron emission tomography (PET) scan postoperatively did not show any evidence of hypermetabolic lesion at the scar site over right anterior chest wall region [Figure 3] with only postoperative status involving left frontal region of brain and no evidence of focal hypermetabolic lesion involving brain parenchyma. No evidence of metabolic active disease was seen elsewhere in the body. Hence, with all the investigation including PET scan findings suggested isolated DM in the treated breast cancer patient.
|Figure 3: Positron emission tomography computed tomography finding showing no evidence of active disease elsewhere in the body|
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The patient was started on oral chemotherapy and hormonal treatment with a dose schedule of tablet capecitabine (1000 mg/m2) per oral twice daily for day 1–14 cycled every 21 days and tablet letrozole 2.5 mg once daily and was referred to the department of radiation oncology for palliative whole brain radiation therapy (WBRT). The patient was treated with palliative WBRT of a dose schedule of 3000 cGy in 10 fractions at 3 Gy per fraction 5 fractions per week for 2 weeks through two parallel opposed fields. The patient was advised not to discontinue chemotherapy and hormonal therapy during radiotherapy. The Pptient is on regular follow-up for eight cycles of oral capecitabine with daily letrozole and is asymptomatic for DM.
| Discussion|| |
DM is relatively rare, but DM without concomitant brain and LM is rarer. A study by Nayak et al. on intracranial DM of 122 patients shows that the most common primary tumor for DM was breast cancer (34%), followed by prostate (17%), lung (13%), and others. DM usually occurs as a direct extension of skull bone metastasis or through hematogenous spread. Intracranial metastasis must be evaluated to determine whether they are inside blood and brain barrier (BBB) and blood and cerebrospinal fluid barrier (BCSFB), which suppresses transfer of chemotherapy agents into the brain parenchyma. DM exists outside of these barriers and it is more easily exposed to chemotherapy than intracranial metastasis., MRI of the brain is the investigation of choice for DM. On MRI, DM may appear as a localized thickening of the dura matter or may be nodular, diffuse dural enhancement or diffuse involvement with nodular areas. Nodular involvement classically lenticular or biconvex may resemble a meningioma. Moreover, gadolinium-enhanced MRI of the brain helps to rule out the concurrent presence of leptomeningeal or brain parenchyma metastases, which is important for therapeutic and prognostic implications. Unlike LM,) dural enhancement and thickening do not continue along gyri and sulci. For an isolated dural lesion, meningioma could be an important differential diagnosis of DM, particularly in women with breast cancer, who have an increased incidence of meningiomas. The overlying skull metastases and bony erosion can aid the diagnosis of DM. In the absence of these features, surgical resection of the dural lesion for pathological confirmation of diagnosis. In our case, excision of the dural lesion confirms the diagnosis of DM in a treated case of breast cancer in the absence of any other skeletal metastatic findings.
The most common symptoms in patients with DM only are headache, followed by cranial neuropathy. Headache may be due to traction of the dura, invasion of the venous sinuses, or increased intracranial pressure alone or combined with subdural hemorrhage.,,
The median survival of breast cancer patients with DM alone is 12 months, whereas DM along with concurrent brain metastasis (BM)/LM had a median survival of 7 months. In patients with BM/LM, WBRT is an important treatment because the BBB reduces the efficacy of systemic chemotherapy by reducing the exposure of cytotoxic drugs. Systemic chemotherapy is indicated for DM patients because the metastatic cells are located from the diagnosis of breast outside the BBB and BCSFB. Choosing whether to give WBRT to DM only patients is complicated by the absence of BM and side effects of the WBRT. Focal radiotherapy after surgery can be tried, but it will hinder with effect of WBRT once there is brain metastasis. Sakaguchi et al. reported that WBRT can be considered for patients with DM alone for symptom improvement and for prevention of DM-related death. Although the precise efficacy of the WBRT in alone DM is not clear, WBRT does have an impact on the symptom relief.
| Conclusion|| |
Isolated DM can occur in a treated case of breast cancer and should be diagnosed pathologically in the absence of other skeletal metastases. Surgical resection of isolated dural metastatic lesion, followed by whole brain radiation may be offered in palliative setting for symptom relief.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]