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CASE SERIES
Year : 2017  |  Volume : 32  |  Issue : 1  |  Page : 16-18  

Intracranial leptomeningeal carcinomatosis in three cases from breast cancer demonstrated on f-18 fluorodeoxyglucose positron emission tomography/computerized tomography


1 Department of Nuclear Medicine, School of Medicine, Bahcesehir University, Istanbul, Turkey
2 Department of Radiology, School of Medicine, Bahcesehir University, Istanbul, Turkey

Date of Web Publication17-Jan-2017

Correspondence Address:
Hulya Ortapamuk
Department of Nuclear Medicine, School of Medicine, Bahcesehir University, Goztepe Medical Park Hospital, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.198454

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   Abstract 

Leptomeningeal carcinomatosis (LC) is an uncommon late manifestation of non-central nervous system (CNS) solid tumors. With prolonged survival in solid tumors, an increased frequency of metastases is noted in these tumors too. The detection of tumor cells in the cerebrospinal fluid remains the gold standard. Noninvasively, magnetic resonance imaging is frequently used for the diagnosis of LC. Although its low sensitivity of F-18 fluorodeoxyglucose positron emission tomography/computerized tomography (F-18 FDG PET/CT) on demonstrating CNS lesions, it could be useful in identifying the possibility of LC of breast carcinoma by giving high attention to the meninges. We discuss here three cases all of them having intracranial LC; where 18F-FDG PET/CT study helped us in the diagnosis of LC. To our knowledge, this is the second report about intracranial LC from breast cancer demonstrating on 18F-FDG PET/CT.

Keywords: Breast cancer, F-18 fluorodeoxyglucose positron emission tomography/computerized tomography, leptomeningeal carcinomatosis


How to cite this article:
Ortapamuk H, Demir MK. Intracranial leptomeningeal carcinomatosis in three cases from breast cancer demonstrated on f-18 fluorodeoxyglucose positron emission tomography/computerized tomography. Indian J Nucl Med 2017;32:16-8

How to cite this URL:
Ortapamuk H, Demir MK. Intracranial leptomeningeal carcinomatosis in three cases from breast cancer demonstrated on f-18 fluorodeoxyglucose positron emission tomography/computerized tomography. Indian J Nucl Med [serial online] 2017 [cited 2019 Dec 15];32:16-8. Available from: http://www.ijnm.in/text.asp?2017/32/1/16/198454


   Introduction Top


Leptomeningeal carcinomatosis (LC) is characterized by invasion of leptomeninges and subarachnoid space by neoplastic cells and frequently with a poor prognosis. Although its treatment is palliative, the earlier diagnosis will lead to prolonged survival and improve functional outcome.[1],[2] It occurs in approximately 2–5% of patients with breast cancer and most of them have intraparenchymal brain metastases concurrent with LC.[3] The most common and definitive method for LC diagnosis is the detection of metastatic cells in cerebrospinal fluid (CSF); the first lumbar puncture reveals positive cytology in only up to 50% of patients, and the yield increases to 90% only after three lumbar punctures. Contrast-enhanced magnetic resonance imaging (MRI) is useful for diagnosis of LC.[1],[4] We present three cases of LC from breast cancer in which 18 F-fluorodeoxyglucose positron emission tomography (18 F-FDG PET) scan revealed abnormal FDG uptake on intracranial leptomeninges suggesting LC that were confirmed by MRI.


   Case Reports Top


Case 1

A 25-year-old woman with left breast cancer underwent a modified radical mastectomy with axillary dissection followed by six cycles of chemotherapy and local radiotherapy to the chest. She was admitted because of a headache 1 year later. The contrast-enhanced brain MRI was performed, and it revealed that abnormal hyperintense signal and nodular thickness on the surface of the bilateral cerebral and cerebellar hemispheres, suggestive of LC [Figure 1]a. She was referred for F-18 FDG PET/computerized tomography (CT) study to identify if there were any other metastases. PET/CT images showed increased abnormal FDG accumulations on both cerebellar and cerebral hemispheres surfaces with highly suspicious for LC [Figure 1]b and [Figure 1]c; multiple bone metastases involving vertebral column, sternum, iliac bones were also shown.
Figure 1: (a) MRI image shows focal nodular enhancement and thickening on cerebellar follia (arrows). Transaxial (b) and sagittal (c) images of PET, and transaxial PET/CT fusion images obtained 60 min after an intravenous injection of 370 MBq of 18F-FDG shows increased focal FDG accumulation on the surface of both cerebellar and cerebral hemispheres (arrows). F-18 FDG PET/CT: F-18 fluorodeoxyglucose positron emission tomography/computerized tomography, MRI: Magnetic resonance imaging

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Case 2

A 47-year-old woman with a history of left breast carcinoma had been underwent mastectomy, subsequent chemotherapy, and locoregional radiotherapy 2 years ago. She was complaining of generalize pain, fatigue for 1 month. F-18 FDG PET/CT performed to evaluate for recurrent disease if any. Whole body F-18 FDG PET showed bone metastases; additionally increased focal FDG accumulations on the right and left cerebral surface area which was highly suspicious for dural metastases [Figure 2]b. Contrast-enhanced MRI was requested, in which dural heterogen density and focal nodularity with increase contrast fixation suggestive of LC [Figure 2]a.
Figure 2: (a) Contrast axial images of MRI showing dural thickness and nodularities with contrast fixation of right and left cerebral leptomeninges (arrows). Transaxial (b) Transaxial images of 18F - FDG PET showing increases lepromeningeal FDG uptake on the right and left cerebral hemisphers (arrows)

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Case 3

A 46-year-old woman was admitted to our hospital due to a headache and ataxia for 2 weeks. Cranial MRI demonstrated contrast-enhancement on posterior fossa, bilaterally base of temporal lobes suggesting leptomeningeal metastases and 20 cm × 38 cm mass at left temporal lobe [Figure 3]a. Excisional biopsy of the left temporal mass showed metastatic cells and CSF aspiration showed malignant cells on the CSF. She was referred to F-18 FDG PET/CT for investigation of the primary tumor. PET/CT demonstrated increased FDG uptake on the surface of left temporal lobe, both cerebral hemispheres; also a hypermetabolic mass on lower quadrant of left breast [Figure 3]b and [Figure 3]c. Biopsy of the breast mass showed intraductal breast cancer.
Figure 3: (a) MRI showing leptomeningeal opacification on posterior cranial fossa, convexite, bilateral temporal lobes surface and intraparencyhmal mass on left frontobazal. Axial (b) slice of PET/CT and axial fusion image (c) demonstrating abnormal FDG uptake on the both surfaces of the cerebellar hemispheres, left temporal lobe, and intraparancymeal mass. F-18 FDG PET/CT: F-18 fluorodeoxyglucose positron emission tomography/computerized tomography, MRI: Magnetic resonance imaging

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   Discussion Top


Meningeal carcinomatosis is a fatal complication of breast cancer that affects 5–8% of patients. The incidences of meningeal metastases increase with prolonged lifespan resulting from treatment advances for primary breast cancer and their metastases.[5] Traditionally, LC occurs in late stages of the disease by hematogenous spread or invasion of brain metastases. It results severe neurological complications involving the cranial nerves, cerebrum, and spinal cord limiting life expectancy to <4 months. The clinical signs and symptoms are highly variable; diagnosis can be difficult. Treatment is currently palliative; in untreated patients expected median survival is <4 weeks.[6],[7] CSF cytological analysis is the gold standard for diagnosis. In symptomatic patients, contrast-enhanced MRI scan is the noninvasive diagnostic modality of choice. Enhancement of the metastatic lesion is dramatic as even small nodular metastases enhance strongly and are easily detected on postcontrast images.[1],[3]

Many patients who could potentially have spinal LC undergo 18 F-FDG PET/CT. Recent case reports have documented both intracranial and extracranial LC on 18 F-FDG PET/CT.[8],[9],[10],[11] FDG PET/CT can occasionally pick up LC if careful attention is paid to patterns of LM spread. Multiple factors may explain the observed low sensitivity of 18 F-FDG PET/CT for detecting LC. Small volumes of tumor may not accumulate sufficient FDG to generate a discernable signal, the spatial resolution of PET is intrinsically limited by the nature of positron annihilation events and PET instrumentation factors, and small metastatic foci adjacent to cerebral cortex may be inconspicuous because of high cortical FDG uptake. Chemotherapy and steroid therapy also have been shown to lower the efficacy of 18 F-FDG PET/CT in detecting malignancy and may lead to false-negative results.[12]

In literature, a few cases of F-18 FDG PET/CT detection of spinal LC from breast cancer and only one case was reported having intracranial LC from breast cancer detected with F-18 FDG PET/CT.[13],[14] In our all three cases, LC was demonstrated by F-18 FDG PET. In our knowledge, this is the second report of intracranial LC from breast cancer detected with F-18 FDG PET/CT in literature. The increase of cases with LC demonstrated on PET/CT; is not only by giving more pay attention to the leptomeningeal areas with increasing PET reader skills and also advances of PET/CT devices; there has been a considerable improvement in the sensitivity of the images may result detection of these type lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Wasserstrom WR, Glass JP, Posner JB. Diagnosis and treatment of leptomeningeal metastases from solid tumors: Experience with 90 patients. Cancer 1982;49:759-72.  Back to cited text no. 1
    
2.
Chamberlain MC. Leptomeningeal metastases: A review of evaluation and treatment. J Neurooncol 1998;37:271-84.  Back to cited text no. 2
    
3.
Boogerd W, Hart AA, van der Sande JJ, Engelsman E. Meningeal carcinomatosis in breast cancer. Prognostic factors and influence of treatment. Cancer 1991;67:1685-95.  Back to cited text no. 3
    
4.
Shah S, Rangarajan V, Purandare N, Luthra K, Medhi S. 18F-FDG uptakes in leptomeningeal metastases from carcinoma of the breast on a positron emission tomography/computerized tomography study. Indian J Cancer 2007;44:115-8.  Back to cited text no. 4
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5.
Mittica G, Senetta R, Richiardi L, Rudà R, Coda R, Castellano I, et al. Meningeal carcinomatosis underdiagnosis and overestimation: Incidence in a large consecutive and unselected population of breast cancer patients. BMC Cancer 2015;15:1021.  Back to cited text no. 5
    
6.
Chamberlain MC. Neoplastic meningitis. Neurologist 2006;12:179-87.  Back to cited text no. 6
    
7.
Mammoser AG, Groves MD. Biology and therapy of neoplastic meningitis. Curr Oncol Rep 2010;12:41-9.  Back to cited text no. 7
    
8.
Short RG, Bal S, German JP, Poelstra RJ, Kardan A. Potential of F-18 PET/CT in the detection of leptomeningeal metastasis. Neuroradiol J 2014;27:685-9.  Back to cited text no. 8
    
9.
Komori T, Delbeke D. Leptomeningeal carcinomatosis and intramedullary spinal cord metastases from lung cancer: Detection with FDG positron emission tomography. Clin Nucl Med 2001;26:905-7.  Back to cited text no. 9
    
10.
Rangarajan V, Purandare N, Luthra K, Medhi S. 18F-FDG uptakes in leptomeningeal metastases from carcinoma of the breast on a positron emission tomography/computerized tomography study. Indian J Cancer 2007;44:115-8.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Renard D, Dufour S, Collombier L, Labauge P. Cerebral FDG-PET hypermetabolism in carcinomatous meningitis. Eur Neurol 2011;66:332-3.  Back to cited text no. 11
    
12.
Papasozomenos H, Guha-Thakurta N, Mayer RR, Weinberg JS, Groves MD, Debnam JM, et al. Association between 18F-FDG PET/CT and MRI appearance of spinal leptomeningeal disease before and after treatment at a tertiary referral center. J Solid Tumors 2016;6:1-8.  Back to cited text no. 12
    
13.
Carra BJ, Clemenshaw MN. Intracranial leptomeningeal carcinomatosis from breast cancer detected on 18F-FDG PET. J Nucl Med Technol 2015;43:227-8.  Back to cited text no. 13
    
14.
Grande ML, Rayo JI, Serrano J, Infante JR, Garcia L, Duran C, et al. Leptomeningeal carcinomatosis as only pathological finding at FDG-PET/CT in case of tumor marker elevation in breast cancer. Indian J Nucl Med 2014;29:53-4.  Back to cited text no. 14
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