METASTATIC ENDOCRINE CARCINOMA

Case Presentation:

A Syrian gentleman 58 years came to the clinic 05-11-2004 with complaining of right oculomotor plegia. He was referred as a case of meningioma and he was sent for more MRI and MRA investigations, which confirmed the diagnosis of right posterior clinoid meningioma. The patient start to complain of Diplopea for 2 days then the last 2 weeks progressed complete right oculomotor plegia. The patient was admitted to Al-Shmaisani hospital 09-11-2004 and was operated the same day: Wide right fronto-temporal approach with tranzygomatic route was achieved and the tumor was morphologically identical for meningioma with matrix and carpet of meningial involvement. It was engulfing the supraclinoid ICA and pushing the M1 and the solitary A1 upward. The tumor was radically removed with preservation of all even tiny anatomical structures, including the anterior choroidal artery, the right PcoA, the right ICA, right optic nerve and the compressed right oculomotor nerve. The Liliquist membrane was opened for 2 mm distance to ensure that the oculomotor nerve was in continuity. No attempt was intentionally direct to explore the basilar and PCAs, to avoid manipulations and slipping of blood to that region. The operation was straight forward without any unusual events and the preliminary frozen section was suspecting the non-meningioma histologic verification, which could not be believed at that time. Even with this consideration total resection of the lesion was achieved. The patient awakened from G.A. He was sent to ICU and he was drowsy. The breathing pattern was acceptable, but he was aphasic with left side hemiparesis. Considering the smooth operation, CT-scan done immediately after operation and the CT-findings were acceptable. The next day, the condition was the same, for what another CT-scan done and showed massive infarction in the territory of both PCAa more pronounced in the right side. The patient despite vigorous efforts to treat the seemingly infarcted area, progressed to deteriorate. Immunohistologic results were of highly malignant endocrine carcinoma. Considering that the patient was transferred from Syria , after putting him in ventilator in tracheostomy was performed 18-11-2004 to wean him off ventilator the next day. He was transferred to Syria 20-11-2004, and after some improvement, he was discharged to home to die 01-12-2004.

Comments:

Endocrine carcinoma is one of the most malignant tumors. It took here an aggressive course and the patient died within one month from the start of his illness. The strange point here to mention, that this tumor was unbelievable 100% grossly resembling a meningioma. The cascading catastrophic events also remain unexplained, since vasospasm was taken into account and precautionary measures were undertaken to prevent such event. The lesion was not related to the hypothalamus nor to the hypophysis. This interesting case is lacking more detailed investigations due to economic and geographic factors.

The supraclinoid part of right ICA is invaded by the tumor and M1 and A1 also. The mass compressing the right oculomotor nerve, but not invading it and the Liliquist membrane was intact.

Third postoperative day the infarction established and clexane 40 mg was given the next postoperative day to show some petechial haemorrhages, for what it was lowered to 20 mg. Notice radical resection of the tumor.

The fist operative day CT-scan showed no infarction, but the second operative day, the patient progressed massive right occipital lobe infarction, indicating that spasm of the right posterior cerebral artery took place.

Notice the left A1 is absent, which makes the surgery at the lesion more hazardous. The right ICA is elevated at the bifurcation and posterior communicating artery is shifted downward.

Brain MRI & MRA

done 2 days before surgery, showing posterior clinoid meningioma growing parasellar directions with involvement of the right ICA, M1 and M2. The right optic nerve was pushed antero-medially and the right posterior communicating artery was pushed inferior and the compressed oculomotor nerve inferiorly was not involved. Notice that the left A1 was missing, making the surgical task more challenging. The anterior parts of the tumor was invading the right ICA and adherent to its wall and the anterior choroidal artery was pushed medial. CT-scan done the same postoperative day was uneventful, but the second postoperative day it showed massive infarction of the right occipital lobe due to remote spasm of the right posterior cerebral artery. The patient was given clexane 40 mg once and the third postoperative CT-scan showed petechial haemorrhages, for what clexane was decreased to 20 mg daily.

The immuno-histologic study of the endocrine carcinoma with syntaptophysin stain

The endocrine metastatic carcinoma with H&E2 staining. The study performed by
Dr. Husam Farsakh

The immuno-histologic verification of the tumor with cytokeratin