Images below require Macromedia's Flash Player to view

Neuroradiology Case of the Week

Case 142

Tanya Tivorsak, Loris Cedeno, MD, Jeevak Almast, MD,
and PL Westesson MD, DDS, PhD

Clinical Presentation: Patient is a 47-year-old female with ovarian carcinoma and neurological changes.

Radiological Findings: MR images show multiple enhancing nodular lesions in both the supra- and infratentorial compartment (Figs. 1-2). There is associated vasogenic edema surrounding the lesions, notably in the left middle cerebellar peduncle (Fig. 3) and in the right frontal lobe (Fig. 4).

Discussion: The patterns of spread of ovarian cancer are (1) peritoneal seeding and lymphatic spread within the pelvis, and (2) hematogenous spread to lung, liver, brain, etc. Brain metastases in ovarian cancer are rare. A review of the literature shows that the incidence is < 2.0%, however, there is evidence that the incidence may be increasing. Serous cyst adenocarcinoma is reported to be the most common histology associated with brain metastases. Almost all cases involve the parenchyma; very few involve the leptomeninges. Previous reviews of the literature have reported less than 20 cases of leptomeningeal metastases in ovarian carcinoma. Common symptoms are neurological deficits, headaches, and seizures; symptoms are more widespread in leptomeningeal carcinomatosis, including spinal and cranial nerve palsies. The interval between the initial diagnosis of ovarian cancer and the diagnosis of brain metastases is between a few months to 3 years, but as survival duration improves, metastases can occur beyond this time due to chemosensitive relapses. Studies show that brain metastases are a part of disseminated recurrent disease in 40-60% of the cases, with the remaining cases showing the brain to be the only metastatic site. Most women with ovarian cancer metastatic to the brain will have extra- or intraperitoneal disease at the time of diagnosis.
     MR with gadolinium-based contrast medium is the most sensitive technique for the detection of brain metastases. The typical appearance is multiple lesions with marked vasogenic edema located at the gray-white matter junction. Mucinous adenocarcinoma metastases can be hypointense on T2WI and hyperintense on T1WI. Contrast-enhanced head CT can be used to exclude CNS metastases in women with ovarian cancer but is often negative in leptomeningeal metastases, in which case MRI should be done.
     Surgical resection, stereotactic radiosurgery, whole brain radiation therapy (WBRT), and chemotherapy are the current treatment options. Surgical resection is considered the best therapeutic approach and can be done alone or in combination with chemotherapy and radiotherapy based on the condition of the patient and the location and number of metastases. Surgical resection with WBRT has been shown to be superior to resection alone or WBRT alone. Overall survival after diagnosis of CNS recurrence in ovarian carcinoma ranges from 1-24 months, with a median of 3-6 months, depending on the treatment.

References:

1. Cohen ZR, Suki D, Weinberg JS, Marmor E, Lang FF, Gershenson DM, Sawaya R . Brain metastases in patients with ovarian carcinoma: prognostic factors and outcome. J Neurooncol 2004; 66(3):313-25. [Medline]
2. Kolomainen DF, Larkin JM, Badran M, A'Hern RP, King DM, Fisher C, Bridges JE, Blake PR, Barton DP, Shepherd JH, Kaye SB, Gore ME. Epithelial ovarian cancer metastasizing to the brain: a late manifestation of the disease with an increasing incidence. J Clin Oncol. 2002; 20(4):982-6. [Medline]
3. Rodriguez GC, Soper JT, Berchuck A, Oleson J, Dodge R, Montana G, Clarke-Pearson DL. Improved palliation of cerebral metastases in epithelial ovarian cancer using a combined modality approach including radiation therapy, chemotherapy, and surgery. J Clin Oncol 1992; 10:1553–1560. [Medline]
4. Dauplat J, Nieberg RK, Hacker NF. Central nervous system metastases in epithelial ovarian carcinoma. Cancer 1987; 60: 2559–2562. [Medline]
5. Geisler JP, Geisler HE. Brain metastases in epithelial ovarian carcinoma. Gynecol Oncol 1995; 57:246-249. [Medline]
6. Yuh WT, Engelken JD, Muhonen MG, Mayr NA, Fisher DJ, Ehrhardt JC. Experience with high-dose gadolinium MR imaging in the evaluation of brain metastases. Am J Neuroradiol. 1992; 13(1):335-45. [Medline]
7. Anupol N, Ghamande S, Odunsi K, Driscoll D, Lele S. Evaluation of prognostic factors and treatment modalities in ovarian cancer patients with brain metastases. Gynecol Oncol. 2002; Jun;85(3):487-92. [Medline]
8. Sanderson A, Bonington SC, Carrington BM, Alison DL, Spencer JA. Cerebral metastasis and other cerebral events in women with ovarian cancer. Clin Radiol. 2002; 57(9):815-9. [Medline]