A rare case of solitary, isolated dural metastasis from hepatocellular carcinoma mimicking a meningioma
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States
- Department of Neurosurgery, The Queen’s Medical Center, Honolulu, Hawaii, United States
- Department of Pathology, The Queen’s Medical Center, Honolulu, Hawaii, United States
- Department of Neurointerventional Surgery, The Queen’s Medical Center, Honolulu, Hawaii, United States
- Department of Neuroscience Institute, The Queen’s Medical Center, Honolulu, Hawaii, United States.
Joo Won Choi, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States.
DOI:10.25259/SNI_733_2023Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Joo Won Choi1, Richard Ho1, Yi Jonathan Zhang2, Wichit Sae-Ow3, Ferdinand K. Hui4, Stacy C. Brown5, Samuel Tsappidi4. A rare case of solitary, isolated dural metastasis from hepatocellular carcinoma mimicking a meningioma. 10-Nov-2023;14:398
How to cite this URL: Joo Won Choi1, Richard Ho1, Yi Jonathan Zhang2, Wichit Sae-Ow3, Ferdinand K. Hui4, Stacy C. Brown5, Samuel Tsappidi4. A rare case of solitary, isolated dural metastasis from hepatocellular carcinoma mimicking a meningioma. 10-Nov-2023;14:398. Available from: https://surgicalneurologyint.com/surgicalint-articles/12628/
Background: Distinguishing an isolated metastatic dural tumor from a meningioma on imaging is challenging and may lead to a delay in treatment. Here, we present the first known case of isolated, solitary dural metastasis from hepatocellular carcinoma (HCC) mimicking a meningioma.
Case Description: A 64-year-old male with a history of liver cirrhosis presented with a 5.8 cm enhancing left parafalcine hemorrhagic dural-based mass extending across the midline. Cerebral angiography revealed a distal left anterior pseudoaneurysm, and tumor contrast blush with feeders from the left ophthalmic and right middle meningeal artery. The pseudoaneurysm was successfully embolized to stop the bleeding, followed by an uneventful bi-coronal frontal craniotomy for falcine tumor resection to relieve brain compression. Histopathological analysis of the dural-based tumor showed poorly differentiated carcinoma with positive albumin in situ hybridization and cytokeratin tumor markers, consistent with dural metastases from HCC.
Conclusion: When encountering a solitary, highly vascular mass bearing resemblance to a meningioma, it may be prudent to consider the possibility of a dural-based metastatic carcinoma.
Keywords: Dural metastasis, Hepatocellular carcinoma, Meningioma
With advancements in systemic treatments that have prolonged survival times in patients with late-stage malignancies, there has been a growing body of literature demonstrating cancer metastases to previously uncommon sites. Among them include metastases to the brain dura mater, which are rare, late manifestations of solid tumors that often portend poor prognoses.[
To date, reported cases of isolated dural metastasis have been limited to patients with primary malignancies of the lung, breast, or prostate; dural extension from hepatocellular carcinoma (HCC) has yet to be described.[
A 64-year-old male presented to the emergency department from his care home with 12 days of dysarthria and right hemiparesis and three days of progressively worsening altered mental status. His medical history was significant for homelessness, chronic hepatitis C, liver cirrhosis, polysubstance use disorder, and schizoaffective disorder. Of note, an incidental abdominal and pelvic computed tomography (CT) scan for a urinary tract infection obtained one year before admission was negative for any liver masses.
The patient’s initial examination was notable for the left gaze preference, global aphasia, and right hemiparesis, with head CT showing a large hypervascular 5.7 cm tumor with surrounding edema [
(a) Initial head CT showing a 5.7 cm left frontal hypervascular tumor with significant edema. (b) Pre- and (c) post-contrast T1-weighted MRI showing a 5.8 cm enhancing extra-axial left parafalcine hemorrhagic mass crossing midline. (d) T2-FLAIR MRI shows extensive surrounding vasogenic edema. CT: Computed tomography, MRI: Magnetic resonance imaging, FLAIR: Fluid-attenuated inversion recovery.
Cerebral angiography showing (a) left ACA pseudoaneurysm, and tumor contrast blush with additional supply from the (b) left meningeal branch of the left ophthalmic artery (red arrows) and the (c) right middle meningeal artery (blue arrows). (d) Post-embolization of the ACA pseudoaneurysm. ACA: Anterior cerebral artery.
The patient’s postoperative course was complicated by persistent neurologic disability, Klebsiella pneumoniae and Methicillin-sensitive Staphylococcus aureus pneumonia, and prolonged ventilator dependence. Given his advanced disease, the patient was transitioned to comfort measures following a discussion with the family and expired on day 18 of hospitalization. Histopathological findings of the dural-based tumor returned following the patient’s passing, revealing a poorly differentiated carcinoma with positive epithelial markers and in situ hybridization staining for albumin [
Prepared slides of the dural-based tumor stained with hematoxylin and eosin showing (a) viable tumor (left) and necrotic tumor (right), (b) cohesive nests of tumor cells with a fair amount of eosinophilic cytoplasm, and (c) atypical tumor cells with brisk mitotic activity, nuclear pleomorphism, and prominent nucleoli. Immunohistochemical examination showing (d) markedly elevated ki-67 index of 25%, supporting the malignant nature of the tumor. (e) The tumor was diffusely positive for epithelial markers (cytokeratin AE1/AE3) and negative for hepatocellular markers (HepPar1, glypican 3), though albumin in situ hybridization was positive in a large subset of tumor cells. These findings in a patient with a history of liver cirrhosis were consistent with metastatic hepatocellular carcinoma.
Intra- and extra-axial brain metastasis are very rare manifestations of HCC, with an estimated incidence of 0.3–2.2%.[
Several hypothesized mechanisms detail how tumor seeding of the dura mater may occur. One such route involves direct extension from existing calvarial metastases to the dura, most commonly in breast and prostate cancer.[
Diagnosis of dural metastatic carcinoma is challenging as they are both clinically and radiographically difficult to distinguish from meningiomas.[
Solitary, isolated metastasis to the dura mater is a rare manifestation of HCC that is seldom the initial clinical presentation and is imperative to distinguish from a meningioma. When faced with an isolated, hypervascular mass resembling a meningioma, a metastatic tumor should remain on the differential.
Patient’s consent not required as patient’s identity is not disclosed or compromised.
There are no conflicts of interest.
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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