- Divisions of Pathology, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Pathology, Swedish Hospital, Seattle, WA, USA
- Department of Medical Oncology, Swedish Hospital, Seattle, USA
- Division of Neurosurgery, Swedish Medical Center, Seattle, USA
Divisions of Pathology, St. Michael's Hospital, Toronto, Ontario, Canada
DOI:10.4103/2152-7806.112824Copyright: © 2013 Nassiri F 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: Nassiri F, Scheithauer BW, Corwin DJ, Kaplan HG, Mayberg M, Cusimano MD, Rotondo F, Kovacs K. Invasive thymoma metastatic to the cavernous sinus. Surg Neurol Int 01-Jun-2013;4:74
How to cite this URL: Nassiri F, Scheithauer BW, Corwin DJ, Kaplan HG, Mayberg M, Cusimano MD, Rotondo F, Kovacs K. Invasive thymoma metastatic to the cavernous sinus. Surg Neurol Int 01-Jun-2013;4:74. Available from: http://sni.wpengine.com/surgicalint_articles/invasive-thymoma-metastatic-to-the-cavernous-sinus/
Background:Thymomas are typically benign tumors of thymic epithelium. Metastases to distal sites, particularly intracranial locations, are extremely rare. Herein, we present the third case of thymoma and the second invasive thymoma to metastasize to the cavernous sinus, adjacent to the pituitary.
Case Description:A 41-year-old female patient presented with headaches, stuffy nose, and drooping of the right face. A magnetic resonance imaging scan revealed a complex, multilobulated mass centered upon the right cavernous sinus. The mass was removed via transsphenoidal surgery, and histopathological investigation confirmed the diagnosis of metastatic thymoma. A positron emission tomography-computed tomography scan demonstrated a large anterior mediastinal mass. A biopsy confirmed the diagnosis of invasive thymoma morphologically identical to the World Health Organization type B2 sellar region metastasis.
Conclusion:Although rare, thymomas can metastasize to the central nervous system. Our case is the second invasive thymoma to metastasize to the cavernous sinus, adjacent to the pituitary.
Keywords: Cancer, immunohistochemistry, metastatic tumor, pathology, sellar metastases, thymoma
Thymomas are typically benign tumors of thymic epithelium. They are classified as malignant when invasive beyond the thymic capsule. Defined as such, up to 36% of thymomas are malignant. Most show only local invasion. Metastases to distant sites are infrequent, occurring in less than 3% of malignant thymomas.[
In February 2010, a 41-year-old female presented with a 6-week history of headaches, nasal congestion, epistaxis, difficulty opening her mouth and ptosis of the right eyelid. A magnetic resonance imaging (MRI) scan revealed a complex multilobulated mass centered within the right cavernous sinus, the cavernous internal carotid artery being encased [Figures
Transsphenoidal surgery was undertaken to obtain a tissue diagnosis and to debulk the mass. Postoperative adjuvant chemotherapy was administered (Cytoxan, Adriamycin). The patient is considering adjuvant radiation therapy.
The formalin-fixed, routinely processed specimen was cut at 5 μm and stained with hematoxylin and eosin (H and E), the Gomori reticulin method, and the periodic acid-Schiff method with and without diastase digestion. Immunohistochemistry (streptavidin-biotin peroxidase complex method) utilized antisera directed against epithelial membrane antigen (EMA; Dako, Carpinteria, CA; 1:20, E29) keratin (AE1-AE3; Zymed, South San Francisco, CA; 1:200), vimentin (Dako; 1:500, 3B4), chromogranin (Roche, Indianapolis, IN; 1:1000, LK2H10), S-100 protein (Dako; 1:800, polyclonal), p53 protein (Dako; 1:200, DO-7), and Ki-67 (MIB-1; Dako; 1:800).
Histologically, sections revealed a lympho-epithelial tumor [
Flow cytometric evaluation with gating of lymphocytes showed cell viability to be low (18%). Almost all intact cells recovered (97%) were lymphocytes. As with the immunohistochemical stains [Figure
A positron emission tomography-computed tomography (PET-CT) scan of the mediastinum demonstrated a large (9.8 × 6.9 × 4.4 cm) anterior mediastinal mass [
Thymoma and lymphoma are the most frequently occurring thymic tumors. The former are defined as tumors of thymic epithelium. Their classification is a controversial topic[
Symptomatic metastases to the pituitary region are uncommon. Most frequent primary sites in women include mammary carcinoma followed by the lung and gastric carcinoma. In men, the most frequent primary tumors include carcinoma of the lung followed by prostate cancer.[
Metastases to the sellar region occur via several routes. These include direct hematogenous spread to the pituitary, spread from juxtasellar masses, spread through the suprasellar cisterns, and via the portal vessels.[
Only 7% of metastases to the pituitary are symptomatic,[
Patients with invasive thymoma and single metastases to the CNS have a mean survival of only 8.5 months. This further decreases with increasing numbers of metastases.[
The authors thank the Jarislowsky Foundation and the Lloyd-Carr Harris Foundation and the Canadian Italian Business Professional's Association-Ladie's Auxiliary for their continued generous support. The authors thank Janice Yau for her help with formatting the images. The authors also acknowledge the secretarial skills of Mrs. Denise Chase of Mayo Clinic.
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