Pineal metastasis as first clinical manifestation of colorectal adenocarcinoma: case report

Metástase pineal como primeira manifestação clinica de adenocarcinoma colorretal: relato de caso

PINEAL METASTASIS AS FIRST CLINICAL MANIFESTATION OF COLORECTAL ADENOCARCINOMA

CASE REPORT

RICARDO RAMINA^*, MAURÍCIO COELHO NETO^**, WAGNER M. MARIUSHI^**, WALTER O. ARRUDA^***

ABSTRACT- Cerebral metastases from colorectal adenocarcinomas occur in 8% of the cases. Diagnosis is usually made when primary disease and widespread metastases are already known. We report the case of a patient with single metastases in the pineal region as the first clinical manifestation of a colorectal adenocarcinoma. A 48-year-old female with Parinaud's syndrome for 15 days prior her admission was evaluated in our clinic. She had no symptoms or signs of colorectal disease. MRI examination revealed an heterogeneous lesion with peritumoral gadolinium enhancement, located in the pineal region. The tumor was radically resected through an infratentorial/supracerebellar approach. Histology showed metastatic carcinoma and immunohistochemical examination showed gastrointestinal tract adenocarcinoma. Metastases to the pineal region are extremely rare and should be considered in the differential diagnosis of tumors of this region.

KEY WORDS: pineal tumors, cerebral metastases, colorectal adenocarcinoma.

Metástase pineal como primeira manifestação clinica de adenocarcinoma colorretal: relato de caso

RESUMO - Metástases cerebrais derivadas de adenocarcinomas colorretais ocorrem em 8% dos casos. Geralmente a doença primária e as metástases em outros órgãos já são conhecidas quando do momento das manifestações neurológicas. Descrevemos um caso de metástase única na região pineal que promoveu a primeira manifestação clínica de adenocarcinoma colorretal. Uma mulher de 48 anos de idade apresentava há quinze dias de sua admissão ao nosso serviço diplopia e síndrome de Parinaud . O exame de ressonância magnética revelou lesão heterogênea localizada na região pineal. O tumor foi completamente retirado por acesso infratentorial/supracerebelar. O exame histológico revelou tumor metastático indiferenciado e o exame imuno-histoquímico demostrou adenocarcinoma do trato gastrointestinal moderadamente diferenciado. Metástases para a região pineal são extremamente raras e devem ser consideradas no diagnóstico diferencial de tumores nesta região.

PALAVRAS-CHAVE: tumores da pineal, metástases cerebrais, adenocarcinoma colorretal.

Colorectal adenocarcinomas are the fourth cause of central nervous system metastases in frequency. In most cases, the primary disease is already diagnosed when the brain is affected.

We present a case where the first manifestation of a colorectal adenocarcinoma was a solitary pineal metastasis.

CASE REPORT

A 48-year-old woman, with no previous disease, presented to the Neurosurgical Department of Curitiba Skull Base Foundation with Parinaud's syndrome and nauseas. There was no other clinical evidence of neurologic or systemic disease. MRI examination revealed a single heterogeneous hyperintense lesion in T1 sequences with peritumoral gadolinium enhancement (Fig. 1). The patient was operated on using an infratentorial/supracerebellar approach and radical resection was possible. The intraoperative histopathologic diagnosis suggested a metastatic carcinomatous lesion (Fig.2). Immunohistochemical study showed a moderately differentiated adenocarcinoma. Abdominal ultrasound detected multiple hypo and hyperecoic metastatic nodules in the liver. Adjutant treatment with 5-fluouracil and radiotherapy was started.

On 32nd day of the postoperative course, the patient presented acute abdomen syndrome. Emergency laparotomy showed suppurative appendicitis and a tumor with no inflammatory aspect in the cecum region. Pathological examination of this lesion revealed moderately differentiated adenocarcinoma. The patient died 90 days after resection of the pineal metastasis with other lesions in brain stem and recurrence.

DISCUSSION

Ninety five per cent of colorectal tumors are adenocarcinomas. Lesions in the cecum and ascending colon may be asymptomatic for a long period of time, what increases the possibility of its first manifestation as metastatic disease.

About 8% of patients with colorectal adenocarcinoma present brain metastases during the late course of the disease, when the primary disease is already diagnosed^1,2. Solitary brain metastases is a rare condition and corresponds to 1% of all cerebral metastases³. There are 25 cases of colorectal adenocarcinoma with cerebral metastases (including this case) as first sign of the disease reported in the literature^4-8.

Metastatic tumors in the pineal region represents 1.8 to 4% of all forms of disseminated cancer⁹. The first case was described by Forster in 1858; it is cited by Vaquero et al.⁴ in his recent rewiew. Vaquero et al.⁴ reviewed 75 cases of pineal region metastases, and approximately half of them were solitary^4,10-14. The diagnosis of solitary metastatic lesions in the pineal region prior to the identification of the primary disease is an uncommon situation especially when the primary site is a colorectal adenocarcinoma^4,5.

The literature reports solitary brain metastases from intestinal cancer occurring in 0,5 to 1% of all cerebral metastases^7,8,15. The neuroradiological findings, including MRI, are not specific for these lesions.

The pineal region is devoided of blood-brain barrier, and thus more proned to hematogenous implantation from distant tumors^16-18.

Indication for surgery is controversial when the primary lesion is known. According to Sato et al.¹⁹, surgery would be indicated for improvement of life quality. Vaquero et al.⁴ comment that because of metastatic disease, life expectancy of these patients is extremely poor and less aggressive procedures (e.g. biopsies) should be eventually performed. Some authors recommend only radiotherapy for colorectal metastases, for no change in survival rates has been observed in operated patients^1,6. Patients with extracranial primary disease in progress should receive radiotherapy. In our case, surgical treatment was indicated because no primary disease was known at the time of the neurological manifestations.

In conclusion, pineal region metastases, especially single, are extremely rare. The neuroradiological findings are not typical but, this entity should be considered in the differential diagnosis of tumors of this region. Surgical removal of single pineal metastases confirms diagnosis, decompresses neighbor structures, raises life quality of the patients and indicates adjutant therapy. When primary disease is already known, only radiotherapy is carried out, as the disease is usually already widespread.

Acknowledgment - We thank Dr. Luiz Fernando Bleggi-Torres, M.D., Ph.D. by the histological studies.

Curitiba Skull Base Foundation - Hospital das Nações, Curitiba - Brazil:

Dr. Ricardo Ramina - Rua Gonçalves Dias 713 - 80240-340 Curitiba PR - Brasil. Fax [phone].

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*

Neurosurgeon;

**

Resident in Neurosurgery;

***

Neurologist. Aceite: 25-outubro-1998.

Publication Dates

• Publication in this collection
  14 Oct 2002
• Date of issue
  Mar 1999

History

• Accepted
  25 Oct 1998