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To date, there have been less than a 100 confirmed case reports of primary cardiac malignant fibrous histiocytomas, a rare form of sarcoma. In this report, we discuss the case of a 15-year-old girl who initially presented with a histiocytic cerebral sarcoma that was treated with aggressive resection and chemotherapy. Three years later, the same patient developed increasing shortness of breath and was found to have a high-grade pleomorphic undifferentiated cardiac sarcoma that likely represents the primary tumour from which the cerebral lesion metastasised. This represents an extremely unique case; in 2010, a research group in Germany claimed the very first description of a true cardiac sarcoma with brain metastasis [1]. However, even as far back as 1960, there were three case reports [2] and more extensive sarcoma studies recently have revealed further cases [3]. Nevertheless, there have probably been less than 10 cases in the literature up until this point.

BACKGROUND/AIM Patients with gynecological malignancies account for 2% of patients with cerebral metastases. Many patients receive whole-brain irradiation (WBI) alone. Local therapies (resection, stereotactic radiosurgery (SRS)) are becoming more popular. This study compared intracerebral control after local therapy to WBI alone in patients with gynecological malignancies. PATIENTS AND METHODS Of 56 patients, 45 received WBI alone, 6 SRS alone and 5 resection plus WBI. Treatment type, age, performance score, cancer site, number of cerebral lesions, metastases outside the brain, recursive partitioning analysis (RPA) class and period from gynecological cancer diagnosis to brain metastasis treatment were evaluated. RESULTS On univariate analyses, local therapy (p=0.003), single cerebral lesion (p

Journal of Neuroradiology - In Press.Proof corrected by the author Available online since mardi 22 decembre 2015

Resume Durant le dernier congres de la Societe francaise de radiotherapie oncologique (SFRO), un point a ete fait sur les differentes strategies therapeutiques proposees dans la prise en charge des metastases cerebrales. Les indications et les limites de la chirurgie, de la radiotherapie stereotaxique et de la radiotherapie panencephalique, ainsi que leurs benefices en termes de survie, de controle intracerebral et d’amelioration du statut fonctionnel et neurocognitif ont ete discutes. L’influence des differents phenotypes de cancer du sein sur la survenue de metastases cerebrales ainsi que leurs impacts sur le traitement des metastases cerebrales ont egalement ete evoques. Ainsi, la chirurgie ameliore la probabilite de survie globale des patients atteints d’une metastase cerebrale solitaire et est particulierement indiquee chez le patient symptomatique. La radiotherapie stereotaxique a une efficacite comparable a la chirurgie en termes de survie. Ces traitements sont principalement indiques pour les patients en bon etat general, atteints d’une a trois metastases cerebrales de diametre de moins de 3 cm d’une tumeur controlee en dehors du cerveau. La radiotherapie panencephalique apres traitement local des metastases cerebrales est controversee en raison de sa toxicite cognitive tardive. Des techniques permettant d’epargner la region hippocampique sont en cours d’investigation afin de diminuer cette toxicite. En ce qui concerne les metastases cerebrales d’origine mammaire, leur risque de survenue est augmente chez les patientes atteintes de tumeur « triple negative » et celles exprimant HER2. Le pronostic differe aussi selon le sous-groupe biologique, avec un allongement de la survie constate chez les patientes atteintes de tumeur exprimant HER2 traitees par des agents ciblant le recepteur HER2. Les associations optimales des traitements systemiques et locaux restent cependant a definir.

Squamous cell carcinoma of the anus is a relatively uncommon GI malignancy. When it does occur, it metastasizes in only a small minority of patients. Spread of anal squamous cell carcinoma to the brain is exceedingly rare, and has been previously reported only three times in the medical literature. We report the case of a 67 year old male who was diagnosed on presentation with a poorly differentiated anal squamous cell carcinoma that already had a solitary metastasis to the liver. While the tumors were initially responsive to chemoradiotherapy, the patient’s primary and liver lesions recurred. The patient then underwent synchronous abdominoperineal resection for the primary lesion and a liver lobectomy for the metastasis. Soon thereafter, the patient developed focal neurologic symptoms and was found to have an intracranial lesion that on biopsy demonstrated metastatic squamous cell carcinoma. This case highlights the fact that patients with a previous history of anal squamous cell carcinoma can occasionally develop cerebral metastasis. Furthermore, cerebral metastases from anal squamous cell carcinoma portend a dismal prognosis even in the face of aggressive medical and surgical therapy.

Resume Objectifs Le but de cette etude est de rapporter la tolerance et la reponse de l’association concomitante de radiotherapie a l’ensemble de l’encephale et de trastuzumab pour des metastases encephaliques de cancer du sein. Patientes et methodes Nous avons realise une etude retrospective de 31 patientes irradiees pour metastases cerebrales d’un cancer du sein avec surexpression Her2 et qui ont recu une irradiation cerebrale en association concomitante avec le trastuzumab. La dose delivree etait de 30 Gy en dix fractions dans la majorite des cas. Toutes les patientes ont beneficie d’un suivi hebdomadaire afin d’evaluer la tolerance. Toutes les patientes ont poursuivi le trastuzumab apres la radiotherapie. Resultats L’âge moyen au moment du diagnostic de la metastase cerebrale etait de 55 ans (38 a 73 ans) avec un etat general conserve ( performance status selon OMS : 0-2). Le delai median avant la progression etait de 10,5 mois. L’evolution clinique etait marquee par une reponse chez 27 patientes (87,1 %) avec, pour 23 d’entre elles, une disparition complete des symptomes (74,2 %). Une remission radiologique complete etait notee chez six patientes (19,4 %), et partielle chez 17 (54,8 %). Le traitement a ete bien tolere, seules sept patientes (23 %) ont presente des nausees grades 1 et 2, une asthenie ou des cephalees. Conclusion Nos resultats suggerent que la poursuite du trastuzumab pendant la radiotherapie des metastases cerebrales est bien toleree. Le taux de reponse est encourageant mais il est necessaire d’evaluer ces resultats par des etudes prospectives comparant la radiotherapie seule a l’association radiotherapie-trastuzumab.

Isolated asymptomatic brain metastasis in papillary carcinoma thyroid (PCT) is extremely rare. We here present such a case of a 48-year-old woman with PCT. SPECT/CT localized the 131I radiotracer concentration seen on whole-body scan in this patient to the right posterior parietal cortex, suggesting brain metastasis. Contrast-enhanced MRI and 18F-FDG PET/CT confirmed the diagnosis and the patient was taken for gamma-knife radiosurgery. 131I SPECT/CT in this case accurately restaged the patient by detecting asymptomatic isolated brain metastasis and correctly directed the management strategy.

Object Oligometastatic brain metastases may be treated with stereotactic radiosurgery (SRS) alone, but no consensus exists as to when SRS alone would be appropriate. A survey was conducted at 2 radiosurgery meetings to determine which factors SRS practitioners emphasize in recommending SRS alone, and what physician characteristics are associated with recommending SRS alone for ≥ 5 metastases. Methods All physicians attending the 8th Biennial Congress and Exhibition of the International Stereotactic Radiosurgery Society in June 2007 and the 18th Annual Meeting of the Japanese Society of Stereotactic Radiosurgery in July 2009 were asked to complete a questionnaire ranking 14 clinical factors on a 5-point Likert-type scale (ranging from 1 = not important to 5 = very important) to determine how much each factor might influence a decision to recommend SRS alone for brain metastases. Results were condensed into a single dichotomous outcome variable of “influential” (4–5) versus “not influential” (1–3). Respondents were also asked to complete the statement: “In general, a reasonable number of brain metastases treatable by SRS alone would be, at most, ___.” The characteristics of physicians willing to recommend SRS alone for ≥ 5 metastases were assessed. Chi-square was used for univariate analysis, and logistic regression for multivariate analysis. Results The final study sample included 95 Gamma Knife and LINAC-using respondents (54% Gamma Knife users) in San Francisco and 54 in Sendai (48% Gamma Knife users). More than 70% at each meeting had ≥ 5 years experience with SRS. Sixty-five percent in San Francisco and 83% in Sendai treated ≥ 30 cases annually with SRS. The highest number of metastases considered reasonable to treat with SRS alone in both surveys was 50. In San Francisco, the mean and median numbers of metastases considered reasonable to treat with SRS alone were 6.7 and 5, while in Sendai they were 11 and 10. In the San Francisco sample, the clinical factors identified to be most influential in decision making were Karnofsky Performance Scale score (78%), presence/absence of mass effect (76%), and systemic disease control (63%). In Sendai, the most influential factors were the size of the metastases (78%), the Karnofsky Performance Scale score (70%), and metastasis location (68%). In San Francisco, 55% of respondents considered treating ≥ 5 metastases and 22% considered treating ≥ 10 metastases “reasonable.” In Sendai, 83% of respondents considered treating ≥ 5 metastases and 57% considered treating ≥ 10 metastases “reasonable.” In both groups, private practitioners, neurosurgeons, and Gamma Knife users were statistically significantly more likely to treat ≥ 5 metastases with SRS alone. Conclusions Although there is no clear consensus for how many metastases are reasonable to treat with SRS alone, more than half of the radiosurgeons at 2 international meetings were willing to extend the use of SRS as an initial treatment for ≥ 5 brain metastases. Given the substantial variation in clinicians' approaches to SRS use, further research is required to identify patient characteristics associated with optimal SRS outcomes.

Resume L’evolution metastatique cerebrale est frequente dans les cancers bronchiques et la mediane de survie est alors limitee. Le traitement standard pour les patients ayant plusieurs metastases cerebrales est l’irradiation de l’encephale en totalite. Cependant, meme si dans la plupart des cas on observe une amelioration des signes neurologiques, le controle local reste faible (50%). Le but de la radiotherapie cerebrale en condition stereotaxique est d’augmenter de maniere tres localisee au niveau du volume-cible la dose d’irradiation, sans augmenter la dose aux organes avoisinant. Le but in fine est d’augmenter le controle local, possiblement la survie des patients sans augmenter la toxicite neurologique a long terme. Il existe 2 types de radiotherapie cerebrale en conditions stereotaxiques : la radiochirurgie et la radiotherapie stereotaxique hypofractionnee. Ces 2 techniques permettent une augmentation du controle local jusqu’a environ 85%.

Les metastases cerebrales sont frequentes dans l’evolution des cancers. L’irradiation encephalique en totalite est un traitement incontournable. Les ameliorations therapeutiques ont conduit a une augmentation de la survie globale des patients. Les consequences neuropsychiques de l’irradiation sont mal evaluees. Recemment, l’utilisation de tests multiples a permis de remettre en question le dogme de la toxicite cerebrale ineluctable de la radiotherapie. La premiere cause de deterioration neuropsychique est l’absence de controle cerebral de la maladie.

Les tumeurs intracrâniennes, tous types confondus, sont frequentes en neurologie. Leur incidence suit celle des accidents vasculaires cerebraux et des demences. Leur prise en charge implique un partenariat multidisciplinaire. Ainsi, a l’heure de la preservation de la qualite de vie en oncologie, la neuropsychologie prend une place croissante dans la preparation de la prise en charge des patients presentant ces tumeurs. En effet, tant dans son optique evaluative/diagnostique que du point de vue de la mise en place d’une reeducation cognitive ou d’une prise en charge comportementale, le neuropsychologue s’allie aux neuro-oncologue, neuroradiologue, anatomopathologiste, neurochirurgien, radiotherapeute… Cet article expose les grandes lignes de l’evaluation neuropsychologique, propose des pistes pour un « bilan type » base sur l’experience de l’auteur dans les tumeurs cerebrales primitives que sont les gliomes de bas grade et suggere une reduction de ce bilan au fur et a mesure de l’evolution et de l’aggravation de la pathologie pour preconiser en cas de metastases cerebrales un bilan minimaliste adapte.

Resume Objectif de l’etude Rechercher dans la litterature des arguments permettant de guider dans le choix entre radiochirurgie et radiotherapie stereotaxique hypofractionnee dans le traitement des metastases cerebrales. Patients et methodes Quatre cent quarante-huit patients ont ete traites dans huit series par irradiation stereotaxique hypofractionnee avec une contention non invasive, une marge de securite de 2 a 10 mm (mediane 3 mm) a une dose de 24 a 40 Gy delivree en trois a cinq seances sur cinq a huit jours dans six series et 15–16 jours dans deux autres series, completant une irradiation encephalique totale de modalites variables dans 30 % des cas. Deux mille cent cinquante-sept patients ont ete traites dans 12 series recentes par radiochirurgie avec une contention invasive, sans marge perilesionnelle, a une dose de 10 a 25 Gy en une seule seance, completant une irradiation encephalique totale, le plus souvent de 30 Gy en dix fractions et 12 jours, dans des 58 % des cas. Les comparaisons ont porte sur les volumes tumoraux macroscopiques medians, la duree mediane de survie, les taux de survie a un an, de controle local et de toxicite. Resultats Pour les series de radiotherapie stereotaxique hypofractionnee, le volume tumoral macroscopique median etait de 0,52–4,47 cm 3 (mediane : 2,8 cm 3 ), la duree mediane de survie de cinq a 16 mois (mediane : 8,7 mois), le taux de survie a un an de 68,2 a 93 % (mediane : 82,5 %) et le taux de necrose de 3,1 %. Pour les series de radiochirurgie, le volume tumoral macroscopique median etait de 1,3 a 5,5 cm 3 (mediane : 2 cm 3 ), la duree mediane de survie de 5,5–22 mois (mediane : 11 mois), le taux de survie a un an de 71 a 95 % (mediane : 85 %) et la taux de necrose de 0,5 a 6 % (mediane : 2,4 %). La toxicite de la radiochirurgie est documentee dans les metastases volumineuses mais elle n’est pas connue pour la radiotherapie stereotaxique hypofractionnee. La marge de tissus sains incluse dans le volume cible previsionnel majore les risques de toxicite. L’association variable a une radiotherapie stereotaxique fractionnee rend l’interpretation des resultats difficile. Il s’agit d’une premiere etude exploratoire dont la methodologie est discutable. Conclusion Les volumes tumoraux macroscopiques ≤ 500 mm 3 (diametre de moins de 10 mm) necessitent une contention invasive et donc la radiochirurgie. Pour ceux de plus de 4200 mm 3 (diametre de 20 mm), la radiotherapie stereotaxique hypofractionnee parait preferable. La radiochirurgie ou la radiotherapie stereotaxique hypofractionnee sont utilisables pour les metastases cerebrales dont le volume tumoral macroscopique est compris entre 500 et 4200 mm 3 . Le fractionnement et l’etalement optimaux restent cependant a determiner.

La radiochirurgie (RC) ou irradiation cerebrale par mini-faisceaux en conditions stereotaxiques occupe une place croissante dans le traitement des metastases cerebrales du fait de son caractere non invasif, de son acces a des lesions non accessibles chirurgicalement et de son rapport cout-efficacite remarquable. Ces lesions sont detruites principalement selon deux modalites techniques : l’accelerateur lineaire (LINAC) qui utilise des photons et le gamma-knife (GK) qui utilise des sources de cobalt.En l’absence d’un syndrome d’hypertension intracrânienne (HIC), la radiochirurgie est le plus souvent proposee comme traitement de premiere intention des metastases cerebrales, mais elle peut egalement etre indiquee comme traitement de rattrapage ou comme « boost » en association avec l’irradiation encephalique totale (IET). Son efficacite sur le controle local des lesions est au moins equivalente a celle de la chirurgie, les recidives in situ survenant dans moins de 5 % des cas. Dans la majorite des cas, cependant, la qualite du controle local n’ameliore pas la survie des patients car celle-ci est d’abord influencee par le controle de la maladie cancereuse. La toxicite immediate ou retardee est faible et reside dans le risque de survenue d’une radionecrose dans moins de 10 % des cas. Les developpements actuels tels que l’hypofractionnement de la dose, l’association a d’autres techniques chirurgicales ou a de nouvelles therapies devraient permettre d’etendre les indications a des lesions plus volumineuses et d’ameliorer les resultats.

Primary cardiac sarcomas are exceptionally rare tumours. A brain metastasis of a primary cardiac sarcoma has never been reported before. Although we know lots of primary malignomas spreading to the brain, we never observed cerebral metastases of an atrial spindle cell sarcoma. Cardiac sarcomas are more likely to haematogenously metastasize to the lung or the liver. Here, we describe the case of a young man, who suffered from a cerebral metastasis of a spindle cell sarcoma in the left heart atrium nine years ago. Postoperative whole brain irradiation with 30 Gy was performed. Later on, the patient experienced a local recurrence within the left atrium accompanied by cardiac arrhythmia and mitral valve insufficiency. This case is the very first description of a true cerebral metastasis from a primary heart sarcoma. Therefore, clear treatment paradigms are not established. Further case illustrations and the publication of larger patient series are mandatory, whenever possible.

La survenue d’une metastase cerebrale a partir d’un carcinome du col uterin est extremement rare et ne represente que 0,5 a 1,2 % dans les differentes series rapportees. Son pronostic reste pauvre. Nous rapportons l’observation clinique d’une jeune patiente de 45 ans, operee pour un carcinome epidermoide du col uterin et qui presente une annee plus tard une metastase cerebrale frontale droite. La symptomatologie clinique etait dominee par le syndrome d’hypertension intracrânienne. Notre patiente a beneficie d’une resection chirurgicale completee par une radiotherapie. L’evolution a ete marquee par le deces de la patiente apre`s une duree de six mois.

Background: Contrast-enhanced magnetic resonance (MR) imaging with gadolinium-based contrast agents is widely used for the detection of cerebral metastases with standard contrast agents. Newer developments in MR contrast agents have led to a higher relaxivity and/or concentration for these agents. Purpose: To assess the effectiveness of a standard dose of 1.0 M gadobutrol compared with a standard dose of gadopentetate dimeglumine for the MR detection of brain metastases. Material and Methods: 27 patients with at least one cerebral metastasis were examined twice with contrast-enhanced MR imaging, using gadobutrol at 0.1 ml/kg and gadopentetate dimeglumine at 0.2 ml/kg (i.e., identical gadolinium dosage of 0.1 mmol/kg bodyweight). The interval between examinations was 18 hours, and the order of injection was fully randomized. Images were acquired using a three-dimensional (3D) fast gradient echo sequence, and evaluated in blinded fashion by two experienced neuroradiologists in consensus in terms of the total number of lesions detected at each examination in each patient and qualitatively in terms of the lesion conspicuity observed. Results: A total of 67 lesions were detected after gadobutrol compared with 65 lesions detected after gadopentetate dimeglumine. In two patients, a lesion was seen only after gadobutrol. Qualitative comparison of images revealed improved lesion conspicuity after gadobutrol in 10/27 cases compared with 0/27 cases after gadopentetate dimeglumine, and equivalent conspicuity in 17/27 cases ( P=0.002, gadobutrol vs. gadopentetate dimeglumine). Conclusion:At equal gadolinium dosage, gadobutrol appears to offer significant advantages over gadopentetate dimeglumine for the visualization of brain metastases, with particular benefit for improving the conspicuity of detected lesions.

Resume Introduction La neurocysticercose est la parasitose la plus frequente du systeme nerveux central. C’est une maladie cosmopolite, endemique dans de nombreux pays en voie de developpement. Observation Nous rapportons le cas d’une femme guadeloupeenne, âgee de 70 ans, presentant des troubles de la marche, un ralentissement ideatoire et une paresie de l’hemicorps droit dans un contexte d’alteration de l’etat general. Le bilan biologique etait normal. Le scanner et l’IRM cerebraux objectivaient une hydrocephalie triventriculaire liee a une stenose de l’aqueduc de Sylvius, ainsi que de multiples lesions nodulaires sus- et sous-tentorielles rehaussees apres injection du produit de contraste et evoquant en priorite des lesions metastatiques. Dans ce contexte, une ventriculostomie et une biopsie frontale ont ete realisees. Le diagnostic de neurocysticercose a ete retenu sur l’aspect histologique de la lesion cerebrale et la detection d’anticorps specifiques de Taenia solium . Les symptomes ont regresse sous albendazole et corticoides. Conclusion Le diagnostic de neurocysticercose fait partie du diagnostic differentiel des metastases cerebrales.

Resume Les metastases cerebrales surviennent dans 15 a 20 % des cancers et leur incidence est en augmentation. Elles apparaissent habituellement a un stade avance de la maladie mais peuvent etre revelatrices du cancer. L’objectif des traitements, le plus souvent palliatifs, est de preserver les fonctions neurologiques du patient pour lui assurer la meilleure qualite de vie possible. Les traitements medicamenteux symptomatiques reposent sur les corticoides qui necessitent une surveillance et une adaptation reguliere des doses et sur les antiepileptiques qui ne devraient etre prescrits qu’apres une crise averee. En cas de metastases cerebrales multiples survenant a un stade avance de la maladie, l’irradiation de l’encephale en totalite permet de controler efficacement et rapidement les symptomes pour la plupart des patients mais ameliore modestement la survie globale, qui depend surtout de la maladie systemique disseminee. A l’oppose, la chirurgie a une indication privilegiee en cas de metastase unique, d’autant plus que le patient est jeune (inferieur a 65 ans), en bon etat general (index de Karnofsky superieur ou egal a 70), et que le cancer primitif est bien controle. Chez ces patients ayant de bons facteurs pronostiques, mais un petit nombre de metastases cerebrales (≤ 4), la radiochirurgie offre une alternative interessante. La chimiotherapie, longtemps delaissee car consideree comme peu efficace, prend une place plus importante chez les patients ayant des metastases multiples non menacantes de cancers chimiosensibles (sein, testicule…). La radiochirurgie et l’irradiation encephalique totale sont deux techniques complementaires. Leur utilisation respective dans la prise en charge des metastases multiples (≤ 4) doit encore faire l’objet d’etudes randomisees. Les options therapeutiques sont de plus en plus nombreuses pour ameliorer le pronostic fonctionnel des patients atteints de metastases cerebrales. Idealement, une evaluation pluridisciplinaire permet de proposer au patient un traitement « sur mesure », garant d’une prise en charge optimale.

L’incidence de recidives cerebrales est de l’ordre de 5 % dans les lymphomes. Elle peut atteindre plus de 30 % dans le traitement du cancer du sein par trastuzumab [7] ou apres la prescription de chimiotherapies ne passant pas la barriere hematomeningee comme dans l’association doxorubicine plus docetaxel [3]. Que l’incidence soit faible ou elevee, cette complication est grave et de mauvais pronostic avec une issue fatale dans la majorite des cas. La radiotherapie est le traitement de choix des metastases cerebrales des tumeurs solides. Dans les lymphomes, la mise en place d’une prophylaxie systematique chez tous les patients ne se justifie pas car l’incidence reste faible. L’identification de sous-groupes de patients pour lesquels une prophylaxie aurait un interet majeur reste donc interessante et l’index pronostique international ajuste a l’âge (aa-IPI) pourrait etre utile dans ce cadre. L’ifosfamide est un anticancereux largement utilise. La forme active moutarde isophosphoramide (IFM) a un effet alkylant sur l’ADN. L’ifosfamide est metabolise par voie hepatique par la chaine oxydative des cytochromes P450. Comme la majorite des agents anticancereux, l’ifosfamide a des effets toxiques dont une neurotoxicite connue et due au catabolite chloroacetaldehyde. L’incidence de la neurotoxicite est tres faible lorsque la molecule est administree en perfusion continue. L’ifosfamide (IFO) et son metabolite actif (IFM) possedent tous deux la capacite de traverser la barriere hematoencephalique: un traitement a base d’IFO est, donc, a priori efficace dans la prevention des rechutes cerebrales chez les patients souffrant de lymphomes a haut rique de rechute. Le rapport benefice/risque pour de tels patients merite d’etre evalue.

We present a patient with a solitary cerebral metastasis from a transitional cell carcinoma of the right renal pelvis in the right occipital lobe with intratumoral hemorrhage. Despite aggressive multimodality management the patient died within 3 months of presentation due to widespread systemic disease.

Brain metastases are the most common intracranial tumors in adults and source of the most common neurological complications of systemic cancer. The treatment approach to brain metastases differs essentially from treatment of systemic metastases due to the unique anatomical and physiological characteristics of the brain. Surgery and radiosurgery are important components in the complex treatment of brain metastases and can prolong survival and improve the quality of life (QOL). Aggressive intervention may be indicated for selected patients with well-controlled systemic cancer and good performance status in whom central nervous system (CNS) disease poses the greatest threat to functionality and survival. In this review the respective roles of surgery and radiosurgery, patient selection, general prognostic factors and tailoring of optimal surgical management strategies for cerebral metastases are discussed.

Resume Dix a 15 % des cancers du sein metastatiques developperont des metastases cerebrales symptomatiques. L'introduction du trastuzumab (Herceptin®) a ameliore les taux de reponse et la survie des patientes atteintes d'un cancer du sein metastatique surexprimant HER2+. Malgre la limite des etudes, retrospectives, d'effectif faible, de prise en charge differente, plusieurs auteurs soulignent une incidence de 30 % de metastases cerebrales chez les patientes avec un cancer du sein metastatique surexprimant HER2, traitees par trastuzumab alors que dans 70 a 80 % des cas la maladie est controlee en systemique. Dans le but d'un meilleur controle de la maladie au niveau central, un depistage en routine des metastases cerebrales chez des patientes a haut risque pourrait etre propose. L'apport du dosage des marqueurs tumoraux en tant qu'aide au diagnostic des metastases centrales pourrait etre interessant notamment quand la cytologie est negative, ce qui represente 30 % des cas, en raison d'une meilleure sensibilite de detection du processus tumoral par les dosages de marqueurs tumoraux.

Das maligne Melanom der Schleimhaute ist auch im Bereich der Nasen- und Nasennebenhohlen ein selten vorkommender Tumor, der sich durch eine Epistaxis oder durch die Zeichen einer nasalen Obstruktion zu erkennen gibt. Da die klinische Symptomatik in der Regel erst bei einem fortgeschrittenen Tumorwachstum beobachtet wird, muss die Prognose der nasalen Schleimhautmelanome als ungunstig angesehen werden. Das in der folgenden Kasuistik beschriebene Septum-Melanom entspricht in typischer Weise dem klinischen Verlauf nasaler Schleimhautmelanome. Die Diagnose war infolge anhaltender Nasenblutungen gestellt worden, wobei zu diesem Zeitpunkt bereits eine intrazerebrale Metastasierung nachgewiesen werden konnte. Malignant melanoma of the mucous membrane of the nose and the sinus is a rare tumour. Typical symptoms are nose bleeds and signs of nasal obstruction. Prognosis of these tumours is poor since clinical symptoms occur at an advanced stage. This case report presents a typical patient's history of a malignant melanoma of the nasal septum. When diagnosis was made the patient already had cerebral metastasis.

Resume L'irradiation prophylactique cerebrale est devenue un standard dans le traitement des cancers bronchiques a petites cellules en remission complete. Elle permet de diminuer le taux de dissemination cerebrale de moitie et d'ameliorer celui de survie globale de 5,4 % a trois ans. Si le pronostic des cancers pulmonaires non a petites cellules localement evolues s'est ameliore avec les associations de chimiotherapie et de radiotherapie, voire de chirurgie dans certains cas, l'evenement « rechute cerebrale » est devenu proportionnellement plus important. Ainsi, le taux de dissemination cerebrale varie entre 10 et 30 %, pouvant meme approcher 50 % dans certaines etudes, presque semblable au taux observe dans les carcinomes a petites cellules. La survie apres traitement de metastases cerebrales est limitee et leur impact sur la qualite de vie important. Suivant le meme rationnel que pour les cancers a petites cellules, quatre etudes randomisees d'irradiation prophylactique cerebrale ont ete menees dans les cancers non a petites cellules dans les annees 1970–1980. Trois d'entre elles ont montre une diminution significative de l'incidence des metastases cerebrales, mais aucun allongement de la survie. Au vu de ces seules donnees, il n'est pas possible de recommander l'irradiation prophylactique cerebrale en pratique courante dans la prise en charge des carcinomes bronchiques non a petites cellules, mais il y aurait place pour de nouveaux essais.

Background/Aims: To report a case of cutaneous malignant melanoma with cerebral metastasis found to have vitreoretinal metastasis upon referral for neovascular glaucoma. Methods: The clinical history and ocular examination findings, including histologic, cytologic, genetic, and immunohistochemical features of the vitreoretinal metastatic tumor, were reviewed. Additionally, the histologic and immunohistochemical features of the primary skin tumor and brain metastasis were also assessed. Results: A 62-year-old woman with cutaneous malignant melanoma metastatic to the right frontal lobe (BRAF V600E negative) was evaluated for blurred vision in the right eye. Neovascular glaucoma, iritis, and posterior synechiae with no view of the retina or vitreous were evident on examination. Vitreoretinal biopsy and enucleation specimen both showed widespread neoplastic involvement of the retina and residual vitreous strands after vitrectomy. Choroid, trabeculum, and other intraocular structures were devoid of tumor burden. Diagnosis of cutaneous malignant melanoma metastatic to the retina and vitreous was confirmed, and the patient expired shortly thereafter. Conclusion: Cutaneous malignant melanoma metastatic to the eye has a relatively greater preference for the retina and frequently presents with uveitis and glaucoma. Neovascular glaucoma in these cases may likely be attributable to unusually increased vascular endothelial growth factor production by the intraocular melanoma tumor cells.

Background: Malignant pleural mesothelioma (MPM) is an aggressive malignant neoplasm that was thought to be a localised disease with limited metastatic capability. However, recent post-mortem studies have identified metastases to the central nervous system (CNS) in about 3% of cases. Case Description: We present the case of a 65-year-old with a solitary supratentorial metastatic deposit of MPM treated with surgical resection and adjuvant whole brain radiotherapy. Despite a good surgical outcome with symptomatic recovery, the patient died of cardiopulmonary compromise five months postoperatively. Conclusions: Although rare, CNS metastasis of MPM is a condition that neurosurgeons should be aware of. CNS metastases may occur via three distinct mechanisms, namely perineural spread, leptomeningeal carcinomatosis and, most commonly, haematogenous spread leading to parenchymal deposits. Surgical resection of these deposits can lead to symptomatic improvement, and together with radiotherapy, to local disease control. However, the overall survival remains poor.

The purpose of this retrospective study was to determine the outcome of gamma knife radiosurgery in a variety of patients including relatively poor-risk patients with multiple or large brain metastases. Between April 2000 and January 2003, 206 patients with cerebral metastases from cancers of the lung, gastrointesinal tract,breast,and kidney were treated with gamma knife radiosurgery by the senior author at Aizawa Hospital. Of the 199 patients who were suitable for analysis,there were 132 patients with lung cancer, 37 with gastrointestinal cancer, 17 with breast cancer, and 13 with renal cell carcinoma. A total of 262 treatment sessions were required for salvage therapy by July 2003 (the average was 1.4 times in one individual). The median follow-up period was 8.5 months. When the number of metastases was less than 10, the median survival was 8 months in patients with lung cancer, 6 months with gastrointestinal cancer, 6 months with breast cancer, and 8.5 months with renal cell carcinoma. In a group of non-small cell lung cancer, the median survival was 9.5 months in patients with less than 5 metastases,7 months with 5 to 9 metastases, and 8 months with 10 or more metastases. There were 21 patients who had 10 or more metastases,and the median survival was 6 months. There were 16 patients in whom tumor control had failed 6 months after gamma knife radiosurgery or who experienced radiation-induced symptoms (8%).There were 26 patients with metastases 3 to 4 cm in diameter, and tumor control failed in 4 (15.4%). Gamma knife radiosurgery can be a useful tool even in the palliative management in poor-risk patients with multiple or large brain metastases., Article, 信州医学雑誌 51(6): 401-409(2004)

Colorectal carcinoma in childhood is rare in spite of the rising prevalence of the condition in the African population. Even rarer is the occurrence of multiple cranial nerve paralysis simulating Garcin's syndrome in this age group. This report discusses a case of an 11-year-old boy who presented to our unit with histologically confirmed adenocarcinoma of the rectum with cerebral metastasis and multiple cranial nerve paralysis suggestive of Garcin's syndrome. Challenges in management were highlighted, and we reviewed the literature on colorectal carcinoma in children.

This study aimed to identify clinical factors associated with survival and to develop a prognostic tool in patients receiving radiosurgery alone for very few cerebral metastases from melanoma. Ten characteristics of 69 patients treated with radiosurgery alone for 1-3 cerebral metastases from melanoma were retrospectively analyzed for survival. Serum lactate dehydrogenase levels before radiosurgery, Karnofsky performance score, maximum diameter of all irradiated cerebral lesions, and extracranial lesions were significantly associated with survival and included in the tool. Twelve-month survival rate (in %) divided by 10 was calculated for each of these four factors. The four scores were summed resulting in total scores ranging 9-22 points. Based on the 12-month survival rates, three groups were formed: less than 15 points (group I, n = 25); 15-20 points (group II, n = 34); and more than 20 points (group III, n = 10). Corresponding 12-month survival rates were 10 ± 6%, 51 ± 9% and 90 ± 9%, respectively (P

Background Diffusion-weighted MRI (DWI) has been used in neurosurgical practice mainly to distinguish cerebral metastases from abscess and glioma. There is evidence from other solid organ cancers and metastases that DWI may be used as a biomarker of prognosis and treatment response. We therefore investigated DWI characteristics of cerebral metastases and their peritumoral region recorded pre-operatively and related these to patient outcomes. Methods Retrospective analysis of 76 cases operated upon at a single institution with DWI performed pre-operatively at 1.5T. Maps of apparent diffusion coefficient (ADC) were generated using standard protocols. Readings were taken from the tumor, peritumoral region and across the brain-tumor interface. Patient outcomes were overall survival and time to local recurrence. Results A minimum ADC greater than 919.4 × 10-6 mm2/s within a metastasis predicted longer overall survival regardless of adjuvant therapies. This was not simply due to differences between the types of primary cancer because the effect was observed even in a subgroup of 36 patients with the same primary, non-small cell lung cancer. The change in diffusion across the tumor border and into peritumoral brain was measured by the “ADC transition coefficient” or ATC and this was more strongly predictive than ADC readings alone. Metastases with a sharp change in diffusion across their border (ATC >0.279) showed shorter overall survival compared to those with a more diffuse edge. The ATC was the only imaging measurement which independently predicted overall survival in multivariate analysis (hazard ratio 0.54, 95% CI 0.3 – 0.97, p = 0.04). Conclusions DWI demonstrates changes in the tumor, across the tumor edge and in the peritumoral region which may not be visible on conventional MRI and this may be useful in predicting patient outcomes for operated cerebral metastases.

Pulmonary blastoma is a very rare malignant tumor of the lungs. A biphasic pulmonary blastoma was histologically diagnosed by a characteristic finding as it was mainly constituted of immature tumor tissue that had both epithelial and mesenchymal components. We present a case of a 68-year-old man with biphasic pulmonary blastoma. The patient underwent cranial metastatectomy and left lung upper lobectomy. Although the tumor was resected, there was rapid metastasis to the cranial, liver, kidney and multiple bones. Although radiotherapy and chemotherapy were administrated, the patient died about 6 months postoperatively. Close follow-up and aggressive chemotherapy should be considered for such tumours. In the light of this case, the authors review the pathologic, clinical, radiological and therapeutic features of this very rare malignant lung tumor.

Background: Goal of this retrospective analysis was to evaluate the role of repeat whole brain radiotherapy in the palliative care of patients with brain metastases due to solid tumors. Methods: Data regarding demographic data, primary tumor, metastasis, radiotherapy and symptoms were compiled on 134 patients with cerebral metastases that received repeat whole brain radiotherapy (WBRT) in our clinic between 2002 and 2011. Results: The analyzed group consisted of 63 (47%) women and 71 (53%) men with a median age of 57 at the start of re-irradiation. Most frequent primary site was the lung (87%). Sixty patients with lung cancer received the first WBRT prophylactically. At the time of re-WBRT 81% of all patients suffered from additional extracerebral metastases. Time between first and second WBRT was a median of 13.4 months. Full dose for the first WBRT was 30 Gy in 2.0 Gy single dose, for the second 20 Gy in 2.0 Gy single dose. At the start of the Re-WBRT 81 patients (60.4%) had mild, 32 (23.9%) severe neurological symptoms, 21 patients (15.7%) were asymptomatic. The median Karnofsky performance status was 70%. Overall, re-WBRT was tolerated satisfactorily. Main side effects were fatigue, erythema and focal alopecia, 10% of patients discontinued treatment before reaching the planned dose. Median survival was 2.8 months since the end of the re-WBRT with good performance status at the start of the re-irradiation being a key indicator for longer survival. Fifty-two patients (39%) showed a clinical improvement of neurological symptoms after the therapy, 59 patients (44%) remained stable, 23 patients (17%) showed worse symptoms. Conclusions: From this large patient collective we were able to show that re-WBRT can be an important therapeutic option with low rate of acute side effects for patients in adequate general condition.

Resume La frequence des metastases cerebrales de tumeurs solides augmente parallelement a l’augmentation de la survie des patients cancereux, et parallelement les options therapeutiques s’enrichissent des avancees en matiere de radiotherapie, neurochirurgie et chimiotherapie. Bien que les metastases cerebrales soient frequemment considerees comme non chirurgicales, certaines etudes montrent que la chirurgie peut ameliorer la survie de certains patients et leur qualite de vie, pour peu que ces patients soient correctement selectionnes. Les patients jeunes, en bon etat general, dont la maladie cancereuse systemique est controlee, et ayant une metastase cerebrale unique, ou au maximum, trois metastases cerebrales, peuvent beneficier d’une resection neurochirurgicale et des avancees en matiere d’imagerie preoperatoire et de cartographie fonctionnelle peroperatoire (neuronavigation, electrophysiologie cerebrale peroperatoire), qui ont diminue la morbidite postoperatoire. La resection neurochirurgicale suivie de radiotherapie de l’encephale in toto, ou la radiochirurgie stereotaxique constituent deux techniques efficaces aux indications specifiques. Des etudes controlees sont en cours comparant la chirurgie suivie de radiotherapie encephalique in toto, a la chirurgie suivie de radiochirurgie des marges operatoires et a la radiochirurgie exclusive.

While haloperidol represents the first-line treatment of delirium, some studies have shown that atypical antipsychotics could be used as an efficacious treatment in delirium management. This article reports a case of a delirious patient, treated effectively and quickly with Quetiapine sustained release with negligible side effects.