- Department of Neurosurgery, National Brain Aneurysm and Tumor Center, United Hospital, Minneapolis, Minnesota, United States,
- Department of Interventional Neuroradiology, Midwest Radiology, Saint Paul, Minnesota, United States,
- Department of Pathology, Regions Hospital, Saint Paul, Minnesota, United States,
- Superior Medical Experts, Saint Paul, Minnesota, United States.
Eric S. Nussbaum
Superior Medical Experts, Saint Paul, Minnesota, United States.
DOI:10.25259/SNI_74_2021Copyright: © 2021 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, tweak, 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: Eric S. Nussbaum1, Collin M. Torok2, Zena M. Khalil3, John M. Pederson4. Neoplastic cerebral aneurysm from triple-negative breast cancer: A case report. 03-May-2021;12:204
How to cite this URL: Eric S. Nussbaum1, Collin M. Torok2, Zena M. Khalil3, John M. Pederson4. Neoplastic cerebral aneurysm from triple-negative breast cancer: A case report. 03-May-2021;12:204. Available from: https://surgicalneurologyint.com/surgicalint-articles/10780/
Background: We present a rare case of a ruptured neoplastic aneurysms (NCA) caused by metastatic spread of triple-negative breast cancer (TNBC) in a female patient in her 60s. The patient had a medical history of TNBC and presented to the emergency department after experiencing 3 days of persistent headache.
Case Description: Head computed tomography (CT) revealed a small volume subarachnoid hemorrhage and digital subtraction angiography revealed a 3.9 x 3.5 x 4.2 mm aneurysm or pseudoaneurysm involving the left middle cerebral artery. The aneurysm was successfully clipped and resected, and histopathological examination confirmed triple-negative invasive ductal breast carcinoma within the aneurysm. Six weeks after surgery, she underwent stereotactic radiosurgery and began treatment with chemotherapy. Four months later, the patient presented once again with acute severe headache, and magnetic resonance imaging revealed multiple small lesions within the brain parenchyma, compatible with new metastatic deposits. The patient was subsequently treated with whole-brain radiation therapy and chemotherapy. Over the ensuing 4 months, CT revealed progression of malignancy in the chest, abdomen, and pelvis. Chemotherapy and radiation therapy were terminated, and the patient unfortunately succumbed to her disease 6 months later.
Conclusion: In patients with NCA with poor prognosis due to aggressive brain metastases, treatments that improve quality of life and survival time should be favored.
Keywords: Choriocarcinoma, Metastasis, Neoplastic aneurysm, Subarachnoid hemorrhage, Triple-negative breast cancer
Neoplastic cerebral aneurysms (NCAs) are exceptionally rare lesions caused by tumor cell invasion of the arterial wall, leading to loss of structural integrity and aneurysm formation. The most common cause of NCAs are myxomas of cardiac origin, which are well-characterized in the clinical literature and typically have a good clinical outcome.[
Here, we report the course of therapy of a patient with a peripheral NCA of the left middle cerebral artery (MCA). The aneurysm was successfully clipped and resected, which was followed by radiosurgery and chemotherapy; however, she developed multiple additional tumors that were treated with chemotherapy and radiation therapy, tolerating the therapies well and living for another 6 months. In patients with NCA and a poor prognosis due to aggressive brain metastases, preference should be given to treatments that improve quality of life and survival time.
History and examination
A 60-year-old female experienced an acute onset headache that was temporarily relieved with ibuprofen but presented to the emergency department 3 days later due to headache persistence. It was noted that she had a medical history of triple-negative breast cancer (TNBC) and ST-segment elevation myocardial infarction, as well as a family history of lung cancer and thyroid cancer. Head computed tomography (CT) revealed a small volume subarachnoid hemorrhage within the sulci overlying the posterior left cerebral convexity [
Preoperative, intraoperative, and postoperative imaging. (a) Head computed tomography (CT) at presentation indicating subarachnoid hemorrhage, (b) preoperative angiogram (anteroposterior view), (c) preoperative angiogram (oblique view), (d) preoperative 3D angiography of the neoplastic aneurysm, (e) intraoperative angiogram, (f) postoperative head CT.
Embolization through distal navigation was attempted with a Headway® DUO microcatheter over a Synchro2® Soft microwire. However, due to the distal location, navigation was ultimately unsuccessful. Surgical clipping with intraoperative DSA guidance was then performed. The aneurysm was successfully clipped and resected, and the sample was sent for histopathology [
Pathology images. (a) Hematoxylin and eosin staining demonstrating a vessel with tumor cells within the lumen and wall, (b) immunohistochemical stain for cytokeratin AE1/AE3, demonstrating positivity in the tumor cells, (c) immunohistochemical stain showing positivity for Sox10, characteristic of triple-negative breast cancer.
Four months later, the patient presented once again with acute severe headache. Magnetic resonance imaging revealed multiple small lesions within the brain parenchyma, compatible with new metastatic deposits. Catheter angiography showed bilateral cerebral aneurysms, including a new mixed fusiform and saccular pseudoaneurysm arising from a distal M3 posterior division branch of the right MCA. In addition, there was a mixed fusiform and saccular pseudoaneurysm arising from a distal branch of the left callosomarginal artery with a saccular component measuring up to 2 mm in maximum dimension [
Follow-up radiographic imaging. (a) Digital subtraction angiography (DSA) of a new pseudoaneurysm arising from a distal branch of the left callosomarginal artery (red arrow), (b) 3D DSA of the aneurysm (red arrow), (c) DSA of small pseudoaneurysm arising from a distal M2 anterior division branch of the right middle cerebral artery (red arrow).
Given the patient’s medical condition, these aneurysms were not felt to be amenable to open surgical repair, and endovascular therapy would have required parent artery sacrifice with associated risk of stroke. The patient was seen by an oncologist and radiation oncologist, and it was suggested by the team that there was a chance the aneurysms would be responsive to radiation therapy. The patient was subsequently treated with whole-brain radiation therapy and chemotherapy with capecitabine (Xeloda®). Radiation was well-tolerated other than headaches and fatigue, although the patient was capable of limited self-care and confined to a bed or chair >50% of waking hours. A short-term follow-up DSA was recommended to be sure that there was no unexpected, dramatic enlargement or change in configuration of the lesions. Although a nonsurgical course had been chosen, given the paucity of data regarding these unusual aneurysms, we felt that it was important to be able to modify our recommendations to the family if a significant change had occurred, potentially indicating a very high risk of imminent bleeding. Follow-up cerebral angiography 6 days after initiation of radiation therapy demonstrated interval decreased size of the right MCA posterior division distal M3 segment aneurysm.
Over the ensuing 4 months, CT revealed progression of malignancy in the chest, abdomen, and pelvis. Termination of chemotherapy and radiation therapy was decided, and the patient was offered palliative care. She was placed on a tapering schedule of dexamethasone (Decadron®) to control inflammation and the anticonvulsant medication levetiracetam (Keppra®). The patient died 6 months later while receiving palliative treatment.
The present case involved a rare example of a ruptured NCA caused by metastatic spread of TNBC, which is the only case to our knowledge of multiple metachronous NCAs developing in this setting. Only one other case of NCA caused by breast cancer has been published, which was recently reported by Koga et al.[
Although treatment of our patient’s first aneurysm was “successful,” at the time of representation with multiple aneurysms and new brain metastases, the patient’s poor prognosis precluded additional surgical therapy. Our patient also demonstrated rapid progression of disease with diffuse metastatic deposits at 4-month follow-up, making it difficult to justify aggressive surgical intervention. Whole-brain radiation therapy and chemotherapy were well-tolerated with minimal side effects, but her treatment was terminated due to her poor prognosis. It is interesting to note that the largest of her aneurysms demonstrated rapid decrease in size after the initiation of radiation therapy, but this could have been related to local spasm or thrombosis. Nevertheless, the true natural history of these lesions is poorly defined, and it is possible that conservative management, possibly including radiation therapy, might provide adequate control for these lesions. It is worth noting that our patient did not rebleed from her aneurysm during the limited follow-up period.
Although NCAs from breast cancer are exceptionally rare, breast cancer is considered the second most common cause of brain metastasis after lung cancer[
We report the second case of an NCA caused by metastatic breast cancer and the only case of multiple metachronous aneurysms developing in this setting. While NCAs are most commonly caused by myxomas and typically have good outcomes, those caused by systemic malignancy such as TNBC have a very poor prognosis. In NCA patients with aggressive brain metastases, surgical resection may not be justified and treatments that improve quality of life and survival time are encouraged. Radiation and chemotherapy without resection can be safely provided in NCA patients with poor prognosis, avoiding the adverse sequelae related to surgical intervention.
Patient’s consent not required as patients identity is not disclosed or compromised.
This study was funded by the United Hospital Foundation.
JP is employed by and has ownership interest in Superior Medical Experts. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
The authors acknowledge Superior Medical Experts for research and drafting assistance.
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