- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
DOI:10.4103/2152-7806.82250Copyright: © 2011 Tsugu A This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Tsugu A, Yoshiyama M, Matsumae M. Brain metastasis from large cell neuroendocrine carcinoma of the urinary bladder. Surg Neurol Int 21-Jun-2011;2:84
How to cite this URL: Tsugu A, Yoshiyama M, Matsumae M. Brain metastasis from large cell neuroendocrine carcinoma of the urinary bladder. Surg Neurol Int 21-Jun-2011;2:84. Available from: http://sni.wpengine.com/surgicalint_articles/brain-metastasis-from-large-cell-neuroendocrine-carcinoma-of-the-urinary-bladder/
BackgroundIn patients with urinary bladder cancer, brain metastases are quite rare and occur in only 1–7% of these patients. Of the urinary bladder cancers, large cell neuroendocrine carcinoma (LCNEC) is extremely rare; only 16 cases have been reported to date. In this report, a case of brain metastasis from LCNEC of the urinary bladder is described.
Case DescriptionA 74-year-old man was admitted with confusion and left-sided hemiparesis. Head magnetic resonance imaging demonstrated a ring-enhancing lesion in the right frontal lobe. Whole body computed tomography revealed a suspicious lesion in the urinary bladder. These findings were considered consistent with metastatic brain tumor. Craniotomy and tumor removal were performed. After craniotomy, the patient underwent cystoscopy and the bladder mass was biopsied. Histological and immunohistochemical examination of both the brain tumor and bladder mass revealed LCNEC. According to these findings, the patient was diagnosed with a brain metastasis from LCNEC of the urinary bladder.
ConclusionTo our knowledge, this is the first report of a patient with a brain metastasis from LCNEC of the urinary bladder.
Keywords: Brain metastasis, large cell neuroendocrine carcinoma, thyroid transcription factor-1, urinary bladder
Brain metastases are quite rare in patients with urinary bladder cancer, and various case series in the literature have reported a 1–7% incidence of brain metastases in these patients.[
The patient was a 74-year-old man who presented to our institution with a 2-week history of confusion and memory disturbance. On neurological examination, the patient was found to have disorientation and mild left-sided hemiparesis. Magnetic resonance imaging (MRI) of the head demonstrated a mass lesion, 4 cm in diameter, in the right frontal lobe with surrounding edema; the ring-enhancing lesion was strongly enhanced by gadolinium contrast on T1-weighted imaging [
Histological examination of the brain specimen revealed metastatic LCNEC characterized by diffuse proliferation of large atypical cells with coarse nuclear chromatin and frequent nucleoli [Figure
Microscopic findings of metastatic brain large cell neuroendocrine carcinoma. Neoplastic cells showing a sheet-like growth with trabecular and rosette-like patterns (a, b). Tumor cells demonstrating abundant cytoplasm, frequent salt-and-pepper like nuclear chromatin and numerous mitotic figures (H and E: a, ×100; b, ×200). Tumor cell expression of CD56 (c), chromogranin A (d), synaptophysin (e) and TTF-1 (f) (×200)
A urology consultation was requested. The patient underwent cystoscopy and the bladder mass was biopsied. Histological and immunohistochemical examination revealed LCNEC, the same findings as the brain specimen [
Microscopic findings of primary urinary large cell neuroendocrine carcinoma. Large tumor cells have abundant cytoplasm with large nuclei, vesicular nuclear chromatin, and prominent nucleoli (a) (H and E, ×200). Tumor cell expression of chromogranin A (b), synaptophysin (c) and TTF-1 (d) (×200)
Aggressive chemotherapy was initiated with carboplatin and etoposide. The patient also received whole brain radiotherapy. Head MRI done 4 months after surgical treatment showed complete removal of the brain metastasis and no evidence of recurrence or new lesions. However, the patient suddenly died of pulmonary embolism 5 months after surgical treatment.
Neuroendocrine tumors of the urinary bladder are relatively rare and include carcinoids, LCNEC, and SCC, the latter being by far the most common. Travis et al. first described LCNEC in the lungs[
Furthermore, LCNEC of the urinary bladder is extremely rare, with only 16 reported cases in the English language literature, to our knowledge.[
The low frequency of brain metastases in patients with bladder cancer may indicate a lack of metastatic potential for the brain. Moreover, the liver and lung act as filters to the right side of the heart, and this filtering before systemic circulation is probably partly responsible for the low incidence of metastasis to the brain. Review of the literature reveals that most patients with brain metastasis were identified after urinary bladder cancer was diagnosed. However, in the present case, there was no clinical evidence of urinary bladder cancer before the brain lesion was diagnosed. This observation is also quite rare and unusual. To date, routine neuroimaging screening is not performed on patients with a past history of urinary bladder cancer. Neuroimaging is undertaken generally only when symptoms such as headache, seizures, or focal deficits are present. This may have led to a lower frequency of brain metastases being detected. Patients′ complaints should be carefully noted, and detailed neuroimaging should be carried out promptly if such patients have symptoms including headache, seizures, altered consciousness or focal deficits.
Once metastasis to the brain occurs, prognosis is very poor, with most patients surviving less than 6 months. Surgical resection of a brain metastasis does not influence the underlying disease and may not increase long-term survival. On the other hand, surgical resection may enhance the quality of life, as occurred in the present patient with resolution of his paresis. Early detection and early treatment are desirable for improvement of outcomes in patients with brain metastases.
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