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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 71  |  Issue : 1  |  Page : 77-79

Calcified brain metastasis from ovarian cancer: A case report and literature review


1 Department of Medical Oncology, Lishui Municipal Central Hospital, Lishui, China
2 Department of Oncology, Sunshine Union Hospital, Weifang, China
3 Department of Pathology, Fujian Cancer Hospital, Fuzhou, China

Date of Submission18-Dec-2019
Date of Acceptance25-Jul-2021
Date of Web Publication17-Mar-2022

Correspondence Address:
Dr. Yan-Ru Xie
Department of Medical Oncology, Lishui Municipal Central Hospital, 289 Kucang Road, Lishui 323 000, Zhejiang
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JASI.JASI_241_19

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  Abstract 


The overall incidence of ovarian cancer with calcified brain metastasis is low. However, in the absence of edema, it is difficult to distinguish metastasis from isolated brain calcifications. Metastasis should be considered in any cancer patient who presents with brain calcification(s) and symptomatology of the nervous system. The authors report a case of advanced ovarian cancer with multiple calcifications in the brain and edema after multiline treatment, in which metastatic cystadenocarcinoma was confirmed by biopsy.

Keywords: Brain metastasis, ovarian cancer, pathology


How to cite this article:
Huang JH, Ma JZ, Xu CW, Liu XN, Lou J, Xie YR. Calcified brain metastasis from ovarian cancer: A case report and literature review. J Anat Soc India 2022;71:77-9

How to cite this URL:
Huang JH, Ma JZ, Xu CW, Liu XN, Lou J, Xie YR. Calcified brain metastasis from ovarian cancer: A case report and literature review. J Anat Soc India [serial online] 2022 [cited 2022 May 24];71:77-9. Available from: https://www.jasi.org.in/text.asp?2022/71/1/77/339879




  Introduction Top


Although ovarian cancer is the second most common cancer of the female reproductive system, brain metastasis from ovarian cancer is relatively rare. According to a literature review, the incidence of brain metastasis of ovarian cancer is approximately 0.29% to 12%.[1] The incidence of calcified brain metastasis is low, which has been confirmed in 1% of surgeries and 6% of autopsies.[2] This report describes a rare case involving a patient exhibiting calcified brain metastasis from ovarian cancer. All protocols used in the present study were approved by the Human Clinical and Research Ethics Committees of the Lishui Municipal Central Hospital (Zhejiang, China) and the Sunshine Union Hospital (Shandong, China). The patient provided written informed consent for treatment and publication of anonymized case details.


  Case Report Top


A 56-year-old woman was diagnosed with ovarian cancer. She had been operated on >9 years previously, and metastasis occurred 3 years ago. Physical examination revealed a performance status score of 1 and a numerical rating scale score of 0. Her consciousness was clear, with no enlargement of the superficial (i.e. bilateral supraclavicular and axillary) lymph nodes. Breath sounds in both lungs were clear; dry and wet rales were not heard. Her heart rate was 100 beats/min with normal rhythm, her abdomen was flat and soft, and the operation scar healed well. The entire abdomen was free of tenderness and rebound pain, the liver and spleen were palpable in the subcostal region, and mobility voiced sounds were negative, with no edema in both lower extremities. Pathological signs were not elicited. The patient was diagnosed with an ovarian tumor in the authors' hospital in July 2010. Subsequently, an ovarian tumor staging operation was performed under general anesthesia. Postoperative pathology revealed bilateral borderline serous cystadenocarcinoma of the ovary [Figure 1]. She was treated with a 3-cycle regimen of paclitaxel + cisplatin (i.e., “TP”). After regular reexamination, stable disease was confirmed. Positron emission tomography-computed tomography (CT) performed in June 2016 revealed postoperative changes in the ovarian tumor and anterior mediastinal metastatic tumors, metastasis of the right side of the anterior mediastinum, subcutaneous metastasis of the right side of the right quarter, metastasis of the left iliopsoas muscle, peritoneal metastasis around the liver, metastasis of the two lungs, and metastasis of the mediastinal lymph nodes. She underwent paclitaxel + carboplatin (i. e., “TC”) therapy plus a 6-cycle regimen of recombinant human endostatin from September 2016 to January 2017. CT revealed a reduction in the lung lesions, and the patient achieved partial response. Subsequently, she was treated with 12 cycles of paclitaxel combined with endostatin maintenance therapy from February 2017 to January 2018. Reexamination with abdominal CT revealed enlargement of abdominal wall nodules and chest CT revealed enlarged lesions in the lungs. The patient then underwent implantation of radioactive particles in the right abdominal wall metastasis in January 2018 and was treated with local radiotherapy for sternal metastasis in February 2018. From March 2018 to February 2019, the patient was treated with 13 cycles of gemcitabine combined with endostatin. Abdominal CT revealed small nodules on the left side of the pelvic cavity that were enlarged. The patient underwent 7 cycles of irinotecan chemotherapy from March to July 2019. One week previously, the patient experienced weakness in the right upper limb accompanied by unstable gait. Cranial CT revealed multiple calcifications with edema in both cerebral hemispheres, the left cerebellar hemisphere, and vermis [Figure 2]. Brain magnetic resonance imaging (MRI) revealed multiple calcifications with edema [Figure 3]. To clarify the nature of the brain calcification, CT-guided biopsy of the metastatic brain tumor was performed in August 2019, which revealed metastatic cystadenocarcinoma [Figure 4]. The patient underwent whole-brain palliative radiotherapy (DT: 3000cGy/10f/300cGy) combined with simultaneous targeted bevacizumab (400 mg) therapy. The patient exhibited movement of the right upper limb, which recovered after radiotherapy and targeted therapy; however, head MRI examination was not performed. The patient was still undergoing bevacizumab therapy as of this writing.
Figure 1: (a) Postoperative specimens of ovarian tumor. (b) Postoperative pathology of ovarian serous cystadenocarcinoma. (×400)

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Figure 2: Computed tomography scan revealing multiple calcification metastases with edema (a and b)

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Figure 3: Cranial magnetic resonance imaging revealing multiple calcification metastases with edema (a and b)

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Figure 4: Postoperative pathology of calcified brain metastasis: Metastatic cystadenocarcinoma. (×1000)

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  Discussion Top


Primary tumors with a high incidence of brain metastasis of malignant tumors mainly include lung and breast cancers, melanoma, and gastrointestinal tumors,[1] of which brain metastasis of lung cancer accounts for 60% of all brain metastases. Brain metastasis of female reproductive system tumor(s) is rare; the incidence of brain metastasis of ovarian cancer reported in the literature is 1.19%.[3] With recent advances in imaging modalities and targeted drug therapies, the incidence of brain metastasis of ovarian cancer has demonstrated an upward trend.[4] Although the incidence of brain metastasis of ovarian cancer is higher, the incidence of calcified brain metastasis remains very low. Calcified brain metastasis can easily be misdiagnosed as a benign tumor or brain calcification, and calcification may be a sign of long survival of a metastatic tumor.[5] In the present case, multiple metastases were diagnosed and limb symptoms appeared 9 years after surgery and 3 years of treatment. Multiple craniocerebral calcifications were found using transcranial CT and MRI, and craniocerebral calcification metastasis was confirmed using puncture biopsy.

Although the pathogenesis of intracranial calcified metastasis currently remains unclear, it may be related to the destruction of the blood–brain barrier, abundant tumor cells, and calcium deposition in the tumor area. Tumor blood vessels are necessary to maintain the biological characteristics of the tumor including rapid growth, invasion, and metastasis. It is characterized by neovascularization and incomplete basement membrane of capillaries. This provides favorable conditions for the outward progression, migration, and metastasis of tumor cells and facilitates the deposition of calcium in the blood in tumor cells through blood vessels, which is the basis for the formation of calcification and metastasis. Craniocerebral calcified metastasis is easily misdiagnosed without peritumoral edema and contrast enhancement and can negatively impact patient treatment.[6] Most intracranial calcified metastases are located in the cerebral cortex or the junction of the cerebral cortex and medulla. They are characterized by mild peripheral edema, weak enhancement, and benign lesions.[7]

The treatment of calcified brain metastasis is basically the same as that of ordinary brain metastasis. For patients with multiple brain metastases, whole-brain radiotherapy combined with whole-body therapy can be selected. For patients with single brain metastasis, surgical resection of the metastatic lesions and other targeted radiotherapy may also be helpful in prolonging patient survival. In recent years, targeted drugs and immunological inhibitors have become more widely used. It has been reported that antiangiogenic therapy can be used as a part of a comprehensive treatment strategy for calcified brain metastasis without an increased risk for cerebral hemorrhage.[8]

In conclusion, the occurrence of brain metastasis of ovarian cancer is relatively rare, and the probability of calcification metastasis is even lower. Patients experiencing limb symptoms should be examined using craniocerebral CT/MRI to determine the occurrence/presence of brain metastasis. When obvious calcification is found on CT/MRI, it cannot be considered a benign lesion, and further investigation should be conducted to rule out the possibility of tumor metastasis. The probability of long (er) survival in patients with brain metastasis of ovarian cancer has significantly increased; as such, craniocerebral imaging should be considered in the routine follow-up of those in high-risk groups. The treatment of brain calcification metastasis can be combined with whole-body therapy on the basis of whole-brain radiotherapy, including antiangiogenic drugs, targeted drugs, and immunological inhibitors aimed at prolonging patient survival.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barnholtz-Sloan JS, Sloan AE, Davis FG, Vigneau FD, Lai P, Sawaya RE. Incidence proportions of brain metastases in patients diagnosed (1973 to 2001) in the Metropolitan Detroit Cancer Surveillance System. J Clin Oncol 2004;22:2865-72.  Back to cited text no. 1
    
2.
Tashiro Y, Kondo A, Aoyama I, Nin K, Shimotake K, Tashiro H, et al. Calcified metastatic brain tumor. Neurosurgery 1990;26:1065-70.  Back to cited text no. 2
    
3.
Cohen ZR, Suki D, Weinberg JS, Marmor E, Lang FF, Gershenson DM, et al. Brain metastases in patients with ovarian carcinoma: Prognostic factors and outcome. J Neurooncol 2004;66:313-25.  Back to cited text no. 3
    
4.
Fakour F, Hajizadeh Fallah H, Khajeh Jahromi S, Porteghali P. Central nervous system metastasis in epithelial ovarian carcinoma: A case report and literature review. J Family Reprod Health 2015;9:41-4.  Back to cited text no. 4
    
5.
Kawamura D, Tanaka T, Fuga M, Yanagisawa T, Tochigi S, Irie K, et al. Slow progression of calcified cerebellar metastasis from ovarian cancer: A case report and review of the literature. Neurol Med Chir (Tokyo) 2013;53:722-6.  Back to cited text no. 5
    
6.
Ricke J, Baum K, Hosten N. Calcified brain metastases from ovarian carcinoma. Neuroradiology 1996;38:460-1.  Back to cited text no. 6
    
7.
Zhu XH. CT diagnosis of intracranial calcifying metastases. Southwest Mil Med J 2009;11:454.  Back to cited text no. 7
    
8.
Lin X, DeAngelis LM. Treatment of Brain Metastases. J Clin Oncol 2015;33:3475-84.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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