Intracranial Cystic Metastases from Breast Cancer

A 37-year-old woman presented to the emergency department complaining of seizures for 2 days. She also complained of a lump in her right breast of 6 months duration for which she had received no treatment. On general examination, a hard, fixed left supraclavicular lymph node was palpable, and local examination was consistent with carcinoma of the breast with hard, fixed right axillary lymph nodes. Fine needle aspiration cytology (FNAC) of the breast lump confirmed the diagnosis of breast carcinoma. She was further investigated following a clinical diagnosis of metastatic breast cancer. A bone scan showed multiple lytic areas in the ribs, and a computed tomography (CT) scan of head revealed parenchymal cystic areas in the brain (Figure), suggesting that brain metastasis were responsible for her seizures. The patient was advised to undergo palliative chemoradiation, which she did not receive for financial reasons. Brain metastases are the most common form of intracranial neoplasms and occur in about 25% of all cancer patients. The most common histologies are lung, breast, melanoma and renal cell cancer. Breast cancer is the second most common cause of brain metastases (after lung cancer); it occurs in 10–15% of breast cancer patients, although autopsy studies suggest that the actual incidence is twice this figure [1]. Distant breast cancer metastases are more common in the lungs, bones and liver. The incidence of brain metastases is thought to be increasing because of the introduction of more sensitive and accurate diagnostic methods, the development of improved adjuvant and palliative therapy regimens that lead to improved survival and the more frequent use of screening studies. Metastases to the brain parenchyma are thought to be hematogenous in origin. Parenchymal brain metastases most commonly have an insidious onset characterized by headache (24–48%) and neurological deficits consisting of focal motor weakness (16–40%)and altered mental status and cognitive dysfunction (24–34%) [2]. Seizures, ataxia or nausea-vomiting can also be the presenting symptoms. Gadolinium-enhanced magnetic resonance imaging (MRI) is more sensitive than contrast-enhanced CT for identifying both parenchymal and leptomeningeal disease and is therefore the preferred noninvasive diagnostic test [1]. A stereotactic brain biopsy must be considered whenever the diagnosis of metastasis remains in doubt. The optimum therapy for brain metastases is still evolving. Corticosteroids, radiotherapy, surgical therapy and radiosurgery all have an established place in their management. In addition, chemotherapy is useful in some patients.