A 57-year-old female from a remote village in Biratnagar, Nepal was brought to our emergency with the chief complaints of progressive headache of 1 month duration followed by altered sensorium since last one day. The patient had been taking over the counter painkillers for her headache and did not seek any further medical advice for the same. There was no significant past medical or surgical illnesses. On examination, the patient was drowsy with left sided hemi-paresis. Urgent computerized tomography (CT) head revealed presence of right intra-parenchymal (parieto-temporal) focal edema with contrast enhancing subdural and scalp lesions on the right side (Fig. 1). There were also multiple osteolytic lesions in the skull as seen in the bone window (Fig. 2). These were collaboratively highly suggestive of metastatic deposits in the parenchyma, leptomeninges, skull and the scalp. Thorough physical examination revealed the presence of breast lump with multiple axillary lymph nodes on the right side.
Figure 1:
CT head images showing evidence of deposits in the brain parenchyma (white circle), sub-dural space (blue arrow) and the scalp (white arrow).
Figure 2:
CT head bone window showing osteolytic bony deposits.
CT head images showing evidence of deposits in the brain parenchyma (white circle), sub-dural space (blue arrow) and the scalp (white arrow).CT head bone window showing osteolytic bony deposits.The likely medical condition was explained to the patient party. The decision was taken to remove the subdural deposits for decompression as well as confirmatory histological diagnosis. However, there were multiple deposits seen in cobblestone fashion in the scalp. Biopsy was taken from the same. Fine needle aspiration cytology (FNAC) was also taken from the breast and the axillary swellings. Histology from the FNAC as well as the scalp deposits was highly suggestive of an infiltration by malignant ductal cell carcinoma from the breast (Figs 3 and 4). The patient party decided to take her home following thorough counseling regarding advanced stage of the tumor and its grave prognosis.
Figure 3:
Operative findings of cobblestone pattern deposits in the scalp and its histology showing cells with high nucleus to cytoplasmic ratio with coarse chromatin and prominent nucleoli (black arrows) amidst fibrous stroma similar to malignant cells seen in FNAC smears from the breast and the axillary lumps and thereby suggestive of metastatic deposits in the scalp.
Figure 4:
Breast (long black arrow) and axillary (long white arrow) lumps and their FNAC smears showing the presence of pleomorphic cells with high nucleus to cytoplasmic ratio and coarse chromatin with prominent nucleoli consistent with ductal carcinoma with metastatic deposits in the axillary lymph nodes (small white and black arrows, respectively).
Operative findings of cobblestone pattern deposits in the scalp and its histology showing cells with high nucleus to cytoplasmic ratio with coarse chromatin and prominent nucleoli (black arrows) amidst fibrous stroma similar to malignant cells seen in FNAC smears from the breast and the axillary lumps and thereby suggestive of metastatic deposits in the scalp.Breast (long black arrow) and axillary (long white arrow) lumps and their FNAC smears showing the presence of pleomorphic cells with high nucleus to cytoplasmic ratio and coarse chromatin with prominent nucleoli consistent with ductal carcinoma with metastatic deposits in the axillary lymph nodes (small white and black arrows, respectively).Herein, we report an extremely rare event of holo-cranial deposits to the brain (scalp, skull, leptomeninges as well as intra-parenchymal) in a patient from an advanced Ca breast lesion. Such metastasis has been described in isolated cases separately but not as constellations in one single case [1-4]. Prognosis in such advanced case is poor and management is only focused in symptomatic relief [5].
Figure 1:
Figure 2:
Figure 3:
Figure 4: