Brain Metastasis after Breast Cancer and Hysterectomy for a Benign Leiomyoma

This 51-year-old patient was admitted to the emergency department for convulsion and hemi-neglecting syndrome. Her medical history revealed 4 uneventful deliveries, a vaginal hysterectomy for symptomatic myomatosis in 2003 and a breast carcinoma in 2006. The pathological examination of the uterus displayed a 7 cm intramural mass diagnosed as an atypical leiomyoma with diffuse cellular atypias (group 2 according to Bell, Kempson and Andrikson) with approximately 34 mitosis per 10hpf and possible small foci of necrosis considered as presenting a moderate risk of recurrence. Fifteen blocks representative of the lesion were performed. The uterus was not morcellated at the time of the surgery. The patient was nevertheless followed-up by abdomino-pelvic CT scan every 6 months for a 3-year period. The breast tumour was located in the left lower quadrant. The patient underwent a partial mastectomy associated with the resection of sentinel nodes. This lobular carcinoma measured 11 mm. One out of the 3 sentinel lymph axillary nodes examined, displayed involvement by the tumour. The complementary axillary dissection revealed 9 uninvolved nodes. The tumour was therefore staged pT1cN1. The oestrogen receptors were considered positive (Clone : 6F11 Novocastra Laboratories, Newcastle, UK) 8/8 ; the progesterone receptors negative (Clone : 6F11 Novocastra Laboratories, Newcastle, UK) 0/8. The immunohistochemical analysis did not display over expression of c erb2 protein (Clone : 6F11 Novocastra Laboratories, Newcastle, UK). The proliferative index Ki 67 displayed 8% of positive cells (clone MIBI Dako cytomation, Glostrup, Denmark). An adjuvant treatment of chemotherapy (six courses FEC 100), radiotherapy and aromatase inhibitor (anastrazole) was prescribed and administered. The treatment was well supported. The evolution was uneventful till February 2009 when the patient was admitted to the emergency department because of a convulsion episode. Her recent history revealed a one-week holocranial headache, two recent episodes of fall from her seat and a 12-hour paresis of the right hemibody, and speech difficulties. A cerebral CT scan revealed a vast hypodense left parieto-occipital mass surrounded by oedema with no sign of engagement. An MRI confirmed this 26 36 mm well-limited mass (suggesting its metastatic origin) and an infracentimetric right parasagittal parietal mass. The radiological assessment was completed by a chest CT scan and a total body PET scan. These tests did not reveal any other malignant site. A breast cancer origin being the most probable, a complete restaging was performed that ruled out other metastatic localizations. A macroscopically complete surgical resection of this mass was performed, completed by panencephalic radiotherapy and by a gamma knife destruction of the small heterolateral lesion. No evidence of malignant mesen chymatous tumour was noticed in this area. The pathological examination describes a highly cellularised tumour with fusal-like cells. A huge number of mitosis were noticed (maximal mitotic index 4 mitoses by hpv field). This tumour was accompanied by a strong stromal reaction and some foci of necrosis. It displays a focal, but marked, antigenicity with antidesmine antibody (Dako D33 clone) and with anticaldesmone (Novacastra TD107 clone). The comparison with the myometrial tissue displays great similarity with a much better conserved differentiation in the uterine tumour. They nevertheless share the same immunohistochemical profile, including oestrogen and progesterone receptor status. The diagnosis of cerebral metastasis of a uterine leiomyosarcoma was thereby established. Three months later, the patient was readmitted to the emergency department suffering from seizures. A PET scan test indicated a high suspicion of tumoral recurrence in the area of the resected metastasis. Because of the degradation of the neurological examination, a new metastasectomy followed by gamma knife treatment of the resection limits was performed. Four months later, the patient presented with two new brain metastases measuring respectively 49 and 29 mm.