The abscopal effect is a term that has been used to describe the phenomenon in which localized radiation therapy treatment of a tumor lesion triggers a spontaneous regression of metastatic lesion(s) at a non-irradiated distant site(s). Radiation therapy induced abscopal effects are believed to be mediated by activation and stimulation of the immune system. However, due to the brain’s distinctive immune microenvironment, extracranial abscopal responses following cranial radiation therapy have rarely been reported. In this report, we describe the case of 42-year-old female patient with metastatic melanoma who experienced an abscopal response following her cranial radiation therapy for her brain metastasis. The patient initially presented with a stage III melanoma of the right upper skin of her back. Approximately 5 years after her diagnosis, the patient developed a large metastatic lesion in her upper right pectoral region of her chest wall and axilla. Since the patient’s tumor was positive for BRAF and MEK, targeted therapy with dabrafenib and trametinib was initiated. However, the patient experienced central nervous system (CNS) symptoms such as headache and disequilibrium and developed brain metastases prior to the start of targeted therapy. The patient received radiation therapy to a dose of 30 Gy delivered in 15 fractions to her brain lesions while the patient was on dabrafenib and trametinib therapy. The patient’s CNS metastases improved significantly within weeks of her therapy. The patient’s non-irradiated large extracranial chest mass and axilla mass also shrank substantially demonstrating the abscopal effect during her CNS radiation therapy. Following radiation therapy of her residual chest lesions, the patient was disease free clinically and her CNS lesions had regressed. However, when the radiation therapy ended and the patient continued her targeted therapy alone, recurrence outside of her previously treated fields was noted. The disease recurrence could be due to the possibility of developing BRAF resistance clones to the BRAF targeted therapy. The patient died eventually due to wide spread systemic disease recurrence despite targeted therapy.
Adult ; Axilla ; Brain ; Central Nervous System ; Clone Cells ; Diagnosis ; Female ; Headache ; Humans ; Immune System ; Immunization ; Melanoma ; Molecular Targeted Therapy ; Neoplasm Metastasis ; Radiation, Ionizing ; Recurrence ; Skin ; Skin Neoplasms ; Thoracic Wall ; Thorax

An atypical teratoid/rhabdoid tumor (AT/RT) is a rare malignancy occurring in the first few years of life. This tumor shows rapid growth, a poor response to treatment, and poor prognosis. Cutaneous metastases presents as hamartomatous lesions mimicking skin tags. Immunohistochemical examination shows varied patterns of expression based on the sites of the body affected. Integrase interactor-1 (INI-1) gene sequencing and loss of expression of INI-1 observed with immunostaining can confirm AT/RT. In our patient, the skin lesion was identified at birth. Histopathological examination of the skin lesion could not establish an accurate diagnosis. Two months later, the patient presented with a brain tumor. Immunohistochemical examination of the brain lesion revealed complete loss of INI-1 expression in tumor cells, and the lesion was diagnosed as AT/RT. After that, we can detect the loss of INI-1 expression in the skin on the back. We report a rare case of AT/RT affecting the brain with cutaneous metastasis diagnosed with immunohistochemical staining.
Brain ; Brain Neoplasms ; Diagnosis ; Humans ; Integrases ; Neoplasm Metastasis ; Parturition ; Prognosis ; Skin

Angiosarcomas are rare, but aggressive malignancies. Reports of brain metastasis are uncommon. In this report, we describe the clinical features of a 62 year-old man who presented with hemoptysis and right-sided weakness. Chest computed tomography showed multiple ill-defined part solid nodules in both lungs and brain magnetic resonance imaging showed multiple hemorrhagic bran masses. The patient underwent whole body proton emission tomography to identify biopsy site and showed multiple bone lesions. A right acetabulum biopsy in confirmed the diagnosis of angiosarcoma.
Acetabulum ; Biopsy ; Brain ; Diagnosis ; Hemangiosarcoma ; Hemoptysis ; Humans ; Lung ; Magnetic Resonance Imaging ; Neoplasm Metastasis ; Protons ; Thorax

BACKGROUND: As patients with brain metastasis (BM) of non-small cell lung cancer (NSCLC) have dismal prognosis, some of them decide to discontinue further treatment for BM. The objective of this study was to determine factors for renouncing further active therapy in patients with BM of NSCLC, focusing on their demographic and socioeconomic status. METHODS: Medical records of 105 patients with radiological diagnosis of BM of NSCLC for the recent 11 years at authors' institution were retrospectively reviewed. Clinical features as well as demographic and socioeconomic characteristics such as marriage status, cohabiting family members, religious affiliations, educational background, and economic responsibility were reviewed. RESULTS: Median overall survival (OS) was 13.84 (95% CI: 10.26–17.42) years in 67 patients (group A) who underwent active treatment (radiotherapy and/or chemotherapy) and 4.76 (95% CI: 3.12–6.41) years in 38 patients (group B) who renounced active treatment. Less patients were unmarried (p=0.046), more cohabitating family members (p=0.008), and economically independent (p=0.014) in group A than those in group B. Similarly, the unmarried, and none cohabitating family members had short OS (5.17 and 7.38 years, respectively). In multivariate analysis for predisposing factors of OS in these patients, the following demographic and socioeconomic factors had independent significance: marriage status and cohabitating family members. CONCLUSION: This study suggests that demographic and socioeconomic status as well as clinical factors could influence the decision of further active treatment and prognosis of patients with BM of NSCLC.
Brain ; Carcinoma, Non-Small-Cell Lung ; Causality ; Demography ; Diagnosis ; Humans ; Marriage ; Medical Records ; Multivariate Analysis ; Neoplasm Metastasis ; Palliative Care ; Prognosis ; Retrospective Studies ; Single Person ; Social Class ; Socioeconomic Factors

PURPOSE: We aimed to investigate organ-specific recurrence or the metastatic pattern of breast cancer according to biological subtypes and clinical characteristics. METHODS: We retrospectively analyzed the medical records of 168 patients with recurrent breast cancer who were diagnosed between January 1, 2000 and April 30, 2017. Four biological subtypes were classified according to estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and Ki-67 expression: luminal A, luminal B, HER2-enriched, and triple negative breast cancer (TNBC). To analyze recurrence patterns according to biological subtypes, we accessed clinical variables including age at diagnosis, TNM stage, type of surgery in the breast and axilla, histologic grade, nuclear grade, lymphatic, vascular, and neural invasion, Ki-67 expression and recurrence to distant organs. RESULTS: The biological subtypes of recurrent breast cancer comprised the following luminal A (n=33, 19.6%), luminal B (n=95, 56.5%), HER2 enriched (n=19, 11.3%), and TNBC (n=21, 12.5%). Luminal A (7.7%) and B (6.5%) subtypes were associated with the increased rate of local recurrence compared to HER2-enriched (2.4%) and TNBC subtypes (1.8%) (p=0.005). The bone (53.6%) was the most common metastatic organ, followed by the lung (34.5%), liver (29.8%), brain (17.9%), and other visceral organ (7.7%). Bone metastasis was commonly observed in individuals with luminal B (63.2%), HER2-enriched (57.9%), and luminal A (42.4%) subtypes (p=0.005). Most liver metastases occur in individuals with luminal B (40.0%) and HER2-enriched subtypes (31.6%) (p=0.002). CONCLUSION: Luminal B subtype was commonly observed in individuals with recurrent breast cancer, and the bone is the most common target organ for breast cancer metastasis, followed by the lungs and liver.
Axilla ; Brain ; Breast Neoplasms ; Breast ; Diagnosis ; Estrogens ; Humans ; Liver ; Lung ; Medical Records ; Neoplasm Metastasis ; Organ Specificity ; Phenobarbital ; Receptor, Epidermal Growth Factor ; Receptors, Progesterone ; Recurrence ; Retrospective Studies ; Triple Negative Breast Neoplasms

BACKGROUND: Malignant melanoma is a cutaneous malignancy with a high mortality rate and high potential for metastases. Detailed information on the clinicopathologic characteristics and prognostic factors of cutaneous melanoma is currently limited in Korea. This study aimed to identify the epidemiological and clinicopathologic characteristics of primary cutaneous melanoma in Korean patients, and to assess which prognostic variables could influence both the development of metastases in primary cutaneous melanoma and overall survival (OS). METHODS: A total of 261 patients diagnosed with primary cutaneous melanoma in seven medical centers between 1997 and 2017 were retrospectively investigated with regard to clinical presentation, localization of the tumor, histopathologic subtype, and survival time. RESULTS: The nodular histologic subtype, ulceration, and Breslow thickness were significantly associated with the development of metastasis; and overweight and obesity (body mass index > 23) were significantly associated with increased Breslow thickness. The location of the metastases appeared to influence OS: brain metastases were associated with the highest risk of death, followed by gastrointestinal, lung, and extra-regional lymph node metastases. CONCLUSION: In this study, tumor thickness, nodular histologic subtype, and ulceration predicted metastatic spread of primary cutaneous melanoma. In addition, OS was associated with the location of metastases. Obesity was related to the prognosis of primary cutaneous melanoma. Clinicians should bear these findings in mind when forming a diagnosis because of the risk of a poor prognosis.
Brain ; Diagnosis ; Humans ; Korea ; Lung ; Lymph Nodes ; Melanoma ; Mortality ; Neoplasm Metastasis ; Obesity ; Overweight ; Prognosis ; Retrospective Studies ; Skin Neoplasms ; Ulcer

We present the case of a 71-year-old man who was diagnosed with amoebic encephalitis caused by Balamuthia mandrillaris. He had rheumatic arthritis for 30 years and had undergone continuous treatment with immunosuppressants. First, he complained of partial spasm from the left thigh to the left upper limb. Magnetic resonance imaging revealed multifocal enhancing nodules in the cortical and subcortical area of both cerebral hemispheres, which were suggestive of brain metastases. However, the patient developed fever with stuporous mentality and an open biopsy was performed immediately. Microscopically, numerous amoebic trophozoites, measuring 20 to 25 µm in size, with nuclei containing one to four nucleoli and some scattered cysts having a double-layered wall were noted in the background of hemorrhagic necrosis. Based on the microscopic findings, amoebic encephalitis caused by Balamuthia mandrillaris was diagnosed. The patient died on the 10th day after being admitted at the hospital. The diagnosis of amoebic encephalitis in the early stage is difficult for clinicians. Moreover, most cases undergo rapid deterioration, resulting in fatal consequences. In this report, we present the first case of B. mandrillaris amoebic encephalitis with fatal progression in a Korean patient.
Aged ; Balamuthia mandrillaris ; Biopsy ; Brain ; Cerebrum ; Diagnosis ; Encephalitis ; Fever ; Humans ; Immunosuppressive Agents ; Magnetic Resonance Imaging ; Necrosis ; Neoplasm Metastasis ; Rheumatic Fever ; Spasm ; Stupor ; Thigh ; Trophozoites ; Upper Extremity

We report a case of a 69-year-old man with metastatic cutaneous duodenal gastrointestinal stromal tumor, which led to find multiple metastases on orbital muscle and scalp. The patient presented with a rapidly growing chest nodule with mild tenderness. He underwent surgical resection for duodenal gastrointestinal stromal tumor and had been treated with imatinib for three years. Histopathological examination of the chest nodule was consistent with gastrointestinal stromal tumor. A brain magnetic resonance imaging of follow work-up revealed multiple metastases at the left superior rectus muscle and occipital scalp. Under the diagnosis with imatinib-resistant duodenal gastrointestinal stromal tumors, a second-line therapy with sunitinib was tried. After six weeks, his skin lesion was completely improved and other metastatic cancers showed a response of stable disease. This is the first reported case of a cutaneous metastasis from duodenal GIST. This report emphasizes the importance of a full-skin examination in patients with a medical history of gastrointestinal stromal tumor which leads to find multiple metastases.
Aged ; Brain ; Diagnosis ; Duodenum ; Gastrointestinal Stromal Tumors* ; Humans ; Imatinib Mesylate ; Magnetic Resonance Imaging ; Neoplasm Metastasis* ; Orbit ; Scalp ; Skin ; Thorax

Germinoma is the most common type of intracranial germ cell tumors (GCTs). Pineal gland and suprasellar region are the most frequent sites of central nervous system (CNS) involvement. Intracranial masses caused by Langerhans cell histiocytosis (LCH) mimics features of CNS GCTs. LCH frequently involve spine and is the most common cause of vertebra plana in children. A 15-year-old boy presented with progressing symptoms of polydipsia, polyuria, general headache, nausea and severe back pain. Brain MRI showed brain tumor with simultaneous involvement of suprasellar region and pineal gland. An excisional biopsy of suprasellar mass was done. The pathologic assessment confirmed the diagnosis of germinoma. Patient's treatment continued accordingly. A spine MRI, done due to persistent backache, showed a vertebra plana. We reevaluated the primary diagnosis suspecting LCH. Germinoma of CNS was confirmed and a biopsy of vertebral lesion resulted in hemangioma. Thus we report a case of CNS germinoma with co-occurrence of vertebra plana. We emphasized the importance of histopathologic diagnosis of pineal/suprasellar masses and primary investigation of other CNS regions including spine for possible metastasis or comorbidities.
Adolescent ; Back Pain ; Biopsy ; Brain ; Brain Neoplasms ; Central Nervous System ; Child ; Comorbidity ; Diagnosis ; Germinoma* ; Headache ; Hemangioma ; Histiocytosis, Langerhans-Cell ; Humans ; Magnetic Resonance Imaging ; Male ; Nausea ; Neoplasm Metastasis ; Neoplasms, Germ Cell and Embryonal ; Pineal Gland ; Polydipsia ; Polyuria ; Spine*

BACKGROUND: Leptomeningeal metastasis (LM) is an uncommon, but devastating complication of advanced cancer and has no standard treatment. Herein, we analyzed the clinical characteristics and outcomes of patients with solid tumors who were diagnosed with LM. METHODS: Between January 2007 and December 2017, we retrospectively analyzed the medical records of patients with solid tumors who were diagnosed with LM. RESULTS: A total of 58 patients were enrolled in this study. The median age of patients was 51 years (range, 27–72 years), and 62.1% had a poor Eastern Cooperative Oncology Group (ECOG) performance status (PS) (>2). The common types of primary tumor were breast cancer (39.7%), gastric cancer (25.9%), and non-small cell lung cancer (20.7%). Forty-two patients (72.4%) were diagnosed with LM by MRI of the brain and/or spine and cerebrospinal fluid (CSF) analysis, 14 were diagnosed by CSF analysis alone, and 2 were diagnosed by MRI alone. Treatments for LM were performed in 53 patients (91.4%), and best supportive care was provided for 5 patients (8.6%). Intrathecal chemotherapy, radiotherapy, and systemic chemotherapy were administered in 43 (74.1%), 17 (29.3%), and 24 (41.4%) patients, respectively. The median overall survival of the entire cohort was 2.4 months (95% confidence interval, 1.0–3.7). In the analysis of prognostic factors for survival, a good ECOG PS (≤2), administration of systemic chemotherapy after LM diagnosis, and a prior history of brain radiation were associated with prolonged survival. CONCLUSION: Although the prognosis of LM in patients with solid tumors is poor, systemic chemotherapy might improve survival in selected patients with a good PS.
Brain ; Breast Neoplasms ; Carcinoma, Non-Small-Cell Lung ; Cerebrospinal Fluid ; Cohort Studies ; Diagnosis ; Drug Therapy ; Humans ; Magnetic Resonance Imaging ; Medical Records ; Meningeal Carcinomatosis ; Neoplasm Metastasis* ; Prognosis ; Radiotherapy ; Retrospective Studies* ; Spine ; Stomach Neoplasms