Intraparenchymal hemorrhage from dural metastasis of breast cancer mimicking meningioma

Abstract

Intraparenchymal hemorrhage from dural metastasis of breast cancer is rare. A 54-year-old woman without a significant medical history showed altered consciousness and left hemiparesis. Radiological examination revealed an extra-axial mass in the right middle fossa with intraparenchymal hemorrhage and another mass invading the skull in the right parietal region. The pre-operative diagnosis was a sphenoid ridge meningioma presenting with intraparenchymal hemorrhage and another meningioma in the convexity. The tumors and hematoma were removed. Pathological findings of the tumors were compatible with adenocarcinoma. Systemic examination revealed breast cancer with metastasis to the spine. Although the radiological findings were similar to those of meningioma, a differential diagnosis of metastatic brain tumor with intraparenchymal hemorrhage should be taken into consideration.

Introduction

Intracranial hemorrhage from a brain tumor is well known but not so common. The incidence of hemorrhage from intracranial tumors is around 5%.¹ About 20–40% of breast cancer patients develop intracranial metastasis during their disease course.² On the other hand, dural metastasis is rarely reported, and represents less than 1% of intracranial metastases.³ At autopsy, dural metastases are found in 9% of patients with systemic cancer.² There have been some reports describing dural metastasis of breast cancer.^3–7 According to Nayak et al.,² breast cancer was the most common primary tumor associated with dural metastasis. However, reports of patients with intracranial hemorrhage from dural metastasis of breast cancer are rare.^8–12 Most of them were patients with subdural hematoma. In this report, we describe a patient with dural metastasis of breast cancer presenting with intraparenchymal hemorrhage. We discuss the radiological findings, clinical course, and management of this rare condition mimicking meningioma.

Case presentation

A 54-year-old woman developed sudden-onset altered consciousness and left hemiparesis. Computed tomography (CT) on admission revealed an extra-axial mass adjacent to the right sphenoid ridge and intraparenchymal hemorrhage (Figure 1(a) and (b)). The main lesion showed a slightly high density on CT suggesting hypercellularity. CT also demonstrated perifocal edema and midline shift. Magnetic resonance imaging (MRI) demonstrated an enhanced extra-axial mass in the right middle fossa and intraparenchymal hemorrhage (Figure 2(a) and (b)). The size of the main lesion was about 41 × 35 × 30 mm. There was another extra-axial lesion in the right parietal bone, and the skull adjacent to the tumor was eroded (Figure 1(c) and (d)). MRI also demonstrated another enhanced lesion in the left parietal bone with dural enhancement (Figure 2 (c) and (d)). The radiological findings indicated that there were two different lesions. Emergency craniotomy was performed. The main lesion in the middle fossa was soft and well-demarcated. No adhesion between the tumor and brain was observed. The tumor and hematoma were totally removed. The hematoma was localized between the tumor and temporal lobe, and further extended to the intraparenchymal region. The main tumor was attached to the dural membrane at the middle fossa. The attachment was extensively coagulated by a bipolar coagulator. The parietal lesion was found to invade the skull and subcutaneous tissue. The dural lesion was resected including the eroded bone.

Figure 1.

(a, b) Axial CT without contrast enhancement on admission showing an extra-axial mass in the right middle fossa and intracerebral hemorrhage. Axial (c) and coronal (d) CT without contrast enhancement also demonstrates bone erosion in the right parietal region (arrow). Left panels in (c) and (d): bone density images.

Figure 2.

T2- (a) and T1-weighted images (WI) with contrast enhancement (CE) (b–d) of MRI. MRI demonstrating an enhanced mass in the right middle cranial fossa with hemorrhage and another small lesion invading the right parietal bone, suggesting osseous metastasis with dural invasion (arrow). (a–c): axial, (d): coronal images.

Pathological examination of the main lesion revealed that the tumor cells with nuclear polymorphism showed papillotubular formation. The tumor cells were positive for cytokeratin (AE1/AE3), EMA, e-cadherin, and estrogen receptor, but negative for vimentin (Figure 4). The same pathological findings were observed in the parietal lesion. Tumor cell invasion to the dural membrane and skull was evident in the parietal lesion. The pathological findings were consistent with adenocarcinoma.

Figure 4.

Microphotographs of the specimen demonstrating tumor cells consistent with adenocarcinoma of the breast. The tumor cells were positive for cytokeratin (AE1/AE3), EMA, e-cadherin, and estrogen receptor, but not vimentin. Original magnification ×100.

Examination of the whole body revealed breast cancer with metastasis to the thoracic spine. MRI on post-operative day 10 showed a new extra-axial lesion in the contralateral parietal region, which had not been seen on pre-operative MRI (Figure 3). CT demonstrated bone erosion in the left parietal bone. The new lesion was diagnosed as an osseous metastasis with dural invasion based on the radiological findings. Hemiparesis improved and her post-operative course was uneventful. She was transferred to another hospital for irradiation of the brain and spine on post-operative day 19. After irradiation, chemotherapy was performed.

Figure 3.

CE-T1-WI of MRI (left panel: axial, right: coronal images). MRI obtained 10 days after the operation demonstrating a new lesion in the left parietal bone and dural enhancement adjacent to the affected bone (arrow).

Discussion

Intracranial hemorrhage from a brain tumor is well-known. We encountered a patient with dural metastasis of breast cancer presenting with intraparenchymal hemorrhage. Most reported cases of dural metastasis with hemorrhage showed subdural hematoma due to the location of the tumor in the subdural space.^8–12 Our patient is the first reported case of dural metastasis of breast cancer presenting with intraparenchymal hemorrhage. In our case, the hemorrhage from the tumor might have occurred in the portion adjacent to the brain and spread to the space between the tumor and temporal lobe, and further into the cerebrum. In addition, perifocal edema was evident in our case. Therefore, there is a possibility that the hemorrhage was induced by venous infarction due to the compression of surrounding veins or venous sinus thrombosis.

Based on radiological findings, the pre-operative diagnosis of the present case was meningioma with intraparenchymal hemorrhage. There have been some reports describing cases of meningioma with intracranial hemorrhage.¹³ The radiological findings in our case seemed to be consistent with meningioma. Although pre-operative CT demonstrated invasion of the tumor into the skull, these findings are also seen in meningioma. Kremer et al. reported MRI findings to distinguish between dural metastasis and meningioma.⁵ According to them, dural metastasis is sometimes indistinguishable from meningioma using conventional MRI. Also, the relative cerebral blood volume (rCBV) mapping of dynamic contrast MRI can provide additional information to distinguish between the two conditions in detail. The rCBV of metastasis of lung, breast, and rectal carcinoma and lymphoma was significantly lower than that of meningiomas. In our case, a new lesion was found 10 days after surgery, indicating malignant features. For our emergent patient, there was not enough time to perform adequate radiological examinations. However, for a case of extra-axial tumor with intraparenchymal hemorrhage, dural metastasis of cancer should be taken into consideration as a differential diagnosis.

Conclusion

Although intraparenchymal hemorrhage from dural metastasis of breast cancer is rare, it should be taken into consideration as a differential diagnosis.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.