INTRACEREBRAL METASTASIS: A CASE REPORT Patsy R. Prussia, MB, BS, DM(Path), Hadley A. Clarke, MB, BS, FRCS(Ed), FRCS(lre), FRCS(C), George Mansoor, MB, BS, MRCP (UK), Stewart Garriques, MB, BS, and Bavani Maheswaran, MB, BS Barbados, West Indies

A case of a 36-year-old woman with a past history of uterine leiomyosarcoma and an intracerebral metastasis is reported. The patient presented with a 24-hour history of severe headache with coma, and the CT findings were consistent with a metastatic lesion. Pathological examination of the operative specimen showed features of a leiomyosarcoma. Uterine leiomyosarcoma is an uncommon tumor and metastasis to the brain is rare. (J Nati Med Assoc. 1992;84:368-370.) Key words * leiomyosarcoma * cerebral metastasesuterine tumor

parietal mass, most likely a metastatic or primary brain tumor (Figure 1). She was treated with dexamethasone for several days prior to surgery. A review of her hospital records revealed previous hysterectomy and right salpingo-oophorectomy for uterine leiomyosarcoma in November 1983 and laparotomy for intraabdominal recurrence in August 1984. She underwent a right temporoparietal craniotomy and excision of a well-defined fleshy tumor. This mass was firm and relatively vascular at surgery. Following surgery, she made an uneventful recovery and was discharged from the hospital on the seventh postoperative day.

PATHOLOGY REPORT Leiomyosarcoma is a malignant tumor of smooth muscle and arises in areas such as the uterus, the gastrointestinal tract, the kidney, and blood vessels. Spread of these tumors occurs via the bloodstream principally to lung, liver, and peritoneal cavity.14 Other tissues where metastasis may be found are bone, spleen, and soft tissues. Rare sites, including cutaneous and muscular areas, have been reported in uterine leiomyosarcoma.5

CASE REPORT A 36-year-old woman presented with a 24-hour history of sudden headache and coma. An emergency computed tomography (CT) scan showed a large deep From the Faculty of Medical Sciences, University of the West Indies, Queen Elizabeth Hospital, Barbados, West Indies. Requests for reprints should be addressed to Dr R Prussia, Faculty of Medical Sciences, University of the West Indies, Queen Elizabeth Hospital, Barbados, West Indies. 368

The uterus excised in 1983 was symmetrically enlarged, weighed 750 g, and measured 15 cm X 14 cm X 7 cm. A partly necrotic submucous neoplasm 16 cm X 5 cm arising in the fundus filled the uterine cavity and extended into the endocervical canal with resultant shortening and dilatation of the cervix uteri. Nonnecrotic tumor had a whorled white appearance and was partly firm, partly soft fish-flesh consistency. The histologic appearance on hematoxylin-eosin stained sections was that of a moderately differentiated leiomyosarcoma (Figure 2) composed of spindly cells with 13 to 15 mitoses/10 high-power field. The tumor was extensively infiltrating the myometrium but did not extend through the serosa. The brain specimen was received in two parts. It was partly white and reddish brown, and measured 6 cm X 4 cm X 1.5 cm and 4 cm X 3 cm X 1 cm. The histologic appearance was that of a leiomyosarcoma but less differentiated than the previous two specimens. The cells were slightly spindly to epithelioid and mitoses JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 4

UTERINE LEIOMYOSARCOMA

1.. Figure 2. Uterine tumor: moderately differenti. ated leiomyosarcoma (hematoxylin eosin stain, magnification x 132).

Figure 1. Intravenous contrast CT scan showing a large deep parietal mass.

were numerous and abnormal (Figure 3). There was also extensive tumor necrosis giving a jigsaw puzzle appearance.

DISCUSSION Leiomyosarcoma is an uncommon malignant tumor of smooth muscle and is a rare source of cerebral metastasis. In an indepth review, Willis6 was unable to document any case of cerebral metastasis. However, Sato and colleagues7 and Adachi et a18 reported separate cases of metastatic leiomyosarcoma to the cerebrum. In another report, Haykai et a19 reported two cases and stressed the nonspecific CT findings of uniform enhancing lesions resembling findings seen in meningiomas. In this case, the lesion appeared as a ring enhancing lesion with a hypodense center-findings consistent with metastatic lesions. The 5-year survival rate for patients with confirmed uterine leiomyosarcoma ranges from O%1o to 68%.I A poor prognosis in cases of leiomyosarcoma is associated with a spread to other organs and increased mitoses.12 Other reports indicate that increased mitosis and cellular pleomorphism are related to prognosis.'3 Necrosis and hemorrhage are also important prognostic features. 14 The patient reported here has been alive for 6 years since being diagnosed, despite the presence of tumor necrosis and high mitotic activity initially and an abdominal recurrence in 1984. Finally, this case illusJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 4

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Figure 3. Cerebral tumor metastases: less differentiated leiomyosarcoma composed of epithelioid cells. Note the mitoses in the center of the field. trates that with prolonged survival, metastatic lesions will appear at unusual sites and must be considered in the differential diagnosis in brain lesions in patients with a known primary uterine leiomyosarcoma. Acknowledgments The authors thank Miss Pamela Fingall for typing the manuscript. Literature Cited 1. Ranchod M, Kempson RL. Smooth muscle tumors of the gastrointestinal tract and retroperitoneum. Cancer. 1 977;39:255-262. 2. Akwari OE, Dozois RR, Weiland LH, Beahrs OH. Leiomyosarcoma of the small and large bowel. Cancer 1978;42:1375-1384. 369

UTERINE LEIOMYOSARCOMA

3. Bennington JL, Beckwith JB. Tumors of the Kidney, Renal Pelvis and Ureter Atlas of Tumor Pathology. 2nd series, fascicle 12. Washington, DC: Armed Forces Institute of Pathology; 1975:213. 4. Lazarus JA, Freidman F. Leiomyosarcoma of the kidney. Am J Surg. 1954;87:251-258. 5. McIntosh GS, Li AKC, Hobb KER Late cutaneous and muscular metastases of a uterine leiomyosarcoma after an initial presentation with an adenocarcinoma. Ann Chir Gynaecol. 1983;72:229-231. 6. Willis RA. Pathology of Tumors. 4th ed. London, England: Butterworths Publishers; 1976:749-751. 7. Sato S, Kambra H, Hotta J. A case of fatal leiomyosarcoma with cerebral metastasis. Orthopaedics Surgery. 1 972;23:381 -384. 8. Adachi M, Wellmann KF, Garcia R. Metastatic leiomyo-

sarcoma in the brain and heart. J Pathol. 1969;98:294-296. 9. Haykai H, Wang AM, Zamani A. Leiomyosarcoma, metastasis to the brain: CT features and review. American Joumal of Neuroradiology. 1 987;8:91 1-912. 10. Bartsich EG, Bowe ET, Moore JG. Leiomyosarcoma of the uterus. A 50 year review of 42 cases. Obstet Gynecol. 1968;32:101-106. 11. Novak E, Anderson DF. Sarcoma of the uterus. Am J

Obstet Gynecol. 1937;34:740-761. 12. Gallup DG, Cordray DR. Leiomyosarcoma of the uterus, case reports and a review. Obstet Gynecol Surv. 1979;34:300312. 13. Vardi JR, Tovell HMM. Leiomyosarcoma of the uterus clinico-pathologic study. Obstet Gynecol. 1980;56:428-434. 14. Christophersen WH, Williamson EE, Gray LA. Leiomyosarcoma of the uterus. Cancer 1972;29:1512-1517.

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 4

Uterine leiomyosarcoma with intracerebral metastasis: a case report.

A case of a 36-year-old woman with a past history of uterine leiomyosarcoma and an intracerebral metastasis is reported. The patient presented with a ...
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