Journal of Surgical Oncology 23:173-174 (1983

)

Brain Metastasis From Prostatic Cancer
DEBA P. SARMA, MD, AND LINDA GODEAU, MD From the Department of Pathology, Louisiana State University Medical School, Veterans Administration Medical Center, New Orleans

Four cases of prostatic carcinoma with metastasis to brain are described. Two of those cases are diagnosed antemortem. Our experience from postmortem case studies and review of the literature point to the fact that metastasis to brain from a prostatic cancer remains a rare occurrence.
KEY WORDS: prostate

cancer, metastatic cancer, brain metastasis, metastatic brain

cancer INTRODUCTION

Carcinoma of the prostate very rarely metastasizes to the brain. In an extensive review of the literature only ten cases of prostate carcinoma were noted to have metastasized to brain among 1,202 patients with brain metastases from a variety of primary sites [1]. Frequency of brain metastasis in autopsy studies of prostatic carcinoma varies from 0% to 4% [1]. It appears that antemortem diagnosis of brain metastasis in a patient with prostatic carcinoma is quite uncommon. The purpose of this study is to describe our experience from autopsy cases as well as two cases where antemortem diagnosis of brain metastasis in prostatic carcinoma was made. MATERIALS, METHODS, AND RESULTS The records of all patients autopsied from January 1960 to December 1980 at New Orleans Veterans Administration Medical Center were reviewed. A total of 5,595 autopsies were done that included 2,032 patients with cancers of various organs. A total of 121 patients among those 2,032 cases were thought to have died of prostatic carcinoma. Three cases of metastatic prostatic carcinoma to the brain were found. Two of these cases were clinically advanced cancer. The third case was discovered as a prostatic carcinoma with metastasis to brain only at autopsy. Diagnosis of brain metastasis was made before death in one case (#2), and in two cases (#1, #3) it was noted only at autopsy. Recently we have encountered another patient with clinical brain metastasis (#4). Short clinical reports of those four cases are given below. CASE REPORTS Casel E.W., a 69-year-old white man, presented in 1960 with a one-week history of stroke. Complete left hemiplegia © 1983 Alan R. Liss, Inc.

was thought to be due to thrombosis of right middle cerebral artery. He had a long history of arteriosclerotic heart disease with mitral insufficiency. Rectal examination was negative for prostatic mass. The patient died in a coma two weeks after hospitalization. At autopsy, there was a moderately well differentiated adenocarcinoma of the prostate confined within the prostate with a 3.5-cm single metastasis to right cerebral hemisphere with marked hemorrhage and necrosis. Case 2 J.G., a 45-year-old black man, was admitted in 1961 with a clinical diagnosis of generalized neoplastic disease involving liver, bones, brain, and abdominal cavity. No primary site was known. The patient died ten days after admission. At autopsy, a transitional cell carcinoma of the prostate was found with extensive metastases to adrenals, liver retroperitoneal and mediastinal lymph nodes, lumbar vertebrae, and brain. Numerous metastatic foci were present in both cerebral and cerebellar hemispheres. No tumor was present in the kidneys, ureters, or urinary bladder. Case 3 W.W., a 65-year-old white man, was diagnosed to have prostatic adenocarcinoma in 1959. He was treated by transurethral resection and bilateral orchiectomy. He developed metastases to lumbar and pelvic spine in 1961. At admission, his serum acid phosphatase and alkaline phosphatase values were elevated. There were no neurologic abnormalities. Radiologic studies revealed progressive obstruction of both ureters with bilateral hydroAccepted for publication November 12, 1982. Address reprint requests to D.P. Sarma, MD, 1601 Perdido Street, New Orleans, LA 70146.

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nephrosis in addition to the bone metastasis. The patient received radiotherapy to the prostate and the pelvic and lumbar bones. Six weeks after admission he expired in uremia. At autopsy, metastatic prostatic carcinoma was noted in the periaortic lymph nodes, vertebrae, and ribs. Right parietal lobe of cerebrum contained a single 8-mm metastatic focus. Case 4 H.M., a 71-year-old white man, was diagnosed to have adenocarcinoma of prostate in 1978. He underwent radical prostatectomy (1978), bilateral pelvic lymphadenectomy (1979), and bilateral orchiectomy (1981). His final admission in the hospital was in February, 1982 for evaluation of seizure disorder of recent onset. Neurological examination was interpreted as being normal. A computed tomography (CT) scan of the brain showed a right temporal mass that on craniotomy and biopsy revealed metastatic prostatic carcinoma. Postoperatively, the patient developed right hemiparesis and continued deterioration until he expired two weeks later. An autopsy was not performed. DISCUSSION Prostatic carcinoma metastasizing to the brain is an unusual occurrence. In our study over a 20-year-period, 2.0% of 121 autopsied patients with clinical diagnosis of prostatic carcinoma were affected This compares similarly to a rate of 1.1% of 792 cases in eleven various series, but is lower than the 4.4% of 91 cases reported from the Roswell Park Memorial Institute [1]. Including the most recent case (#4) seen in 1982, the diagnosis of cerebral metastatic disease was made premortem in two of our cases. In one of these, the primary source was unknown prior to death. The other patient developed seizure disorder. Of the two unrecognized cases, one was asymptomatic; hemiplegia in the other was attributed to a cerebrovascular accident. The latter seemed probable in view of the patient's age, history of arteriosclerotic heart disease, and absence of prostatic mass. In regard to symptomatology in our series, seizure activity and motor deficit were commonly found in metastatic brain disease. In a study of 101 cases of metastatic

brain tumor at the National Cancer Center Hospital in Tokyo (none having prostatic carcinoma as the primary), hemiparesis was the second most common presenting symptom (25.8%), with headache being the most common (34%) [2]. Other primary symptoms, in decreasing order of frequency, included mental changes, monoparesis, nausea, vomiting, seizures, gait disturbance, and vertigo [2]. Two methods of cerebral metastases, both by the hematogenous route, have been suggested. The paravertebral venous plexus has been shown by Batson to be a direct route by which tumor cells reach the brain from the prostate [3]. Varkarakis et al have suggested a cascade or multistep process, where the lungs and skeletal system are first seeded, serving as the source for brain metastases at a later date [4]. In our series, both processes seemed to occur. Two cases involved only cerebral metastases, implicating Batson's direct route paravertebral venous pathway, while the other two cases involved other organ systems, implicating the cascade process. Of the four cases, three patients had a single focus of metastatic disease while one patient had multiple cerebral and cerebellar foci. It is of interest that the primary was a transitional cell carcinoma rather than the more common adenocarcinoma in the patient (#2) with cerebellar metastasis. The survival of patients with a clinical diagnosis of brain metastasis is very short, usually not more than a few weeks. ACKNOWLEDGMENTS The authors thank Dr. J. Lunseth for his assistance in preparing this manuscript. Ms. Karen Dunn provided the secretarial assistance.

REFERENCES
1. Catane R, Kaufman J, West C, Merrin C, Tsukada Y, Murphy GP: Brain metastasis from prostatic carcinoma. Cancer 38:25832587, 1976. 2. Kishi K, Nomura K, Miki Y, Shibui S, Takakura K: Metastatic brain tumor: A clinical and pathologic analysis of 101 cases with biopsy. Arch Pathol'Lab Med 106:133-135, 1982. 3. Batson OV: The function of the vertebral veins and their role in the spread of metastases. Ann Surg 112:138-149, 1940. 4. Varkarakis MJ, Winterberger AR, Gaeta J, Moore RH, Murphy GP: Lung metastases in prostatic carcinoma. Clinical significance. Urology 3:447-452, 1974.

Sarma DP, Godeau L (1983): Brain metastasis from prostatic cancer. J Surg Oncol 23:173-174. PMID:
6345936 [PubMed - indexed for MEDLINE]