Article Navigation
Article Contents
-
Abstract
-
Introduction
-
Case report
-
Discussion
-
Compliance with ethical standards
-
Conflict of interest statement
-
Funding
-
References
- < Previous
- Next >
Journal Article
, Damir Tomac Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic Ivan Konstantinović Neurosurgery Division, University Hospital Centre Split , 21000 Split , Croatia Corresponding author. Neurosurgery Division, University Hospital Centre Split, Spinčićeva 1, 21000 Split, Croatia. E-mail: ivan.konstan@gmail.com Search for other works by this author on: Oxford Academic Čedna Tomasović-Lončarić Department of Pathology and Cytology, Dubrava University Hospital , 10000 Zagreb , Croatia School of Medicine, Catholic University of Croatia , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic Jurica Maraković Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic Anđelo Kaštelančić Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic Darko Orešković Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic Dominik Romić Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic Petar Marčinković Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic Marina Raguž Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia School of Medicine, Catholic University of Croatia , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic Darko Chudy Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia School of Medicine, University of Zagreb , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic
Tonko Marinović Department of Neurosurgery, University Hospital Dubrava , 10000 Zagreb , Croatia Medicine of Sports and Exercise Chair , Faculty of Kinesiology, University of Zagreb , 10000 Zagreb , Croatia Search for other works by this author on: Oxford Academic
Journal of Surgical Case Reports, Volume 2024, Issue 6, June 2024, rjae413, https://doi.org/10.1093/jscr/rjae413
Published:
19 June 2024
Article history
Received:
03 April 2024
Accepted:
27 May 2024
Published:
19 June 2024
- Split View
- Views
- Article contents
- Figures & tables
- Video
- Audio
- Supplementary Data
-
Cite
Cite
Damir Tomac, Ivan Konstantinović, Čedna Tomasović-Lončarić, Jurica Maraković, Anđelo Kaštelančić, Darko Orešković, Dominik Romić, Petar Marčinković, Marina Raguž, Darko Chudy, Tonko Marinović, Brain metastases of the mucoepidermoid lung carcinoma: a case report, Journal of Surgical Case Reports, Volume 2024, Issue 6, June 2024, rjae413, https://doi.org/10.1093/jscr/rjae413
Close
Search
Close
Search
Advanced Search
Search Menu
Abstract
Mucoepidermoid carcinoma, a salivary gland tumor, rarely occurs in bronchial mucous glands. Brain metastases are rarely seen which makes for a challenging diagnosis and treatment approach. A 40-year-old woman presented with confusion, and ataxia, accompanied by a declining Glasgow Coma Score. Brain computerized tomography revealed two hyperdense, postcontrast-enhanced infra- and supratentorial lesions with perifocal edema. First causing obstructive hydrocephalus. The initial surgery involved external ventricular drainage system placement leading to the patient’s clinical improvement. After radiological diagnostics, both lesions were resected without complications. Histopathological analysis revealed solid clusters of atypical, polygonal epithelial cells exhibiting mucin production, classified as a poorly differentiated mucoepidermoid carcinoma metastasis which originated from the upper lobe’s apicoposterior segment and left lung. The correct treatment approach remains elusive due to the infrequent occurrence and challenging diagnosis. While new oncological and radiosurgery options promise improved overall survival rates, radical resection remains the preferred initial option.
brain, metastases, mucoepidermoid, lung, carcinoma, tumor
Introduction
Mucoepidermoid carcinoma (MEC) prevails as the most common malignant neoplasm in salivary glands, accounting for 10%–15% of such cases, notably observed more in females (51.5%) [1]. Its typical locations include the parotid glands (56.8%) or the hard palate (18%) [2]. Although MEC is relatively common in salivary glands, its occurrence in bronchial mucous glands is infrequent [3, 4]. Classified as a subtype of non-small cell lung cancer (NSCLC), lung-associated MEC represents a minute fraction (0.1%–0.2%) of primary lung cancers, comprising mucus-secreting, squamous, and intermediate cells, historically linked to prognostic indicators based on tumor staging and grading. The MEC is classified into 2 subtypes based on histological features: low-grade and high-grade, depending on the ratio between mucinous and epidermoid cells [5]. While a favorable prognosis is associated with low-grade MEC resulting in a promising 5-year survival rate, for high-grade MEC, the prognosis is poor, potentially comparable to that of other types of NSCLC [6]. Surgical resection is a treatment of choice. Evidence supporting the efficacy of chemotherapy or radiotherapy is scarce. The results suggested the benefit of adjunctive chemotherapy for high-grade malignancies but did not advocate its use for low-grade malignancies due to their favorable prognosis [6, 7]. The effectiveness of radiotherapy remains uncertain; previous reports have indicated its ineffectiveness for mucoepidermoid carcinoma of the lung. Brain metastases (BM) occur in 14% of NSCLC patients [8, 9]. Herein, we report a rare case of supratentorial and infratentorial lung MEC brain metastases with compression to the fourth ventricle and subsequent obstructive hydrocephalus.
Case report
A 40-year-old female presented with confusion, ataxia, and an unsteady gait with a deteriorating Glasgow coma score (GCS). Neuro-radiological evaluation via brain computerized tomography (CT) revealed a hyperdense, postcontrast-enhanced lesion in the right posterior fossa, surrounded by perifocal edema, compressing the fourth ventricle. Another lesion with similar characteristics was noted frontally on the right side, likely secondary. After the fourth ventricle’s compression, the lateral and third ventricles dilated, leading to hydrocephalus. The initial surgical intervention involved right frontal bone trepanation and external ventricular drainage system implantation. After the initial operation, the patient was clinically stable, with GCS 15. She was referred to the brain MRI confirming intracranial secondary changes, revealing lesions in the right cerebellar hemisphere and right frontal cortex, with contrast enhancement on T1W, perifocal edema on T2W, and diffusion restriction on ADC sequence (Fig. 1). Following the MRI scan, further scanning and disease staging investigations were necessary. The CT scan of the thorax, abdomen, and pelvis unveiled an irregularly shaped structure suggestive of a suspicious tumor in the upper lobe’s apicoposterior segment and left lung. The 24 × 18 × 25 mm lesion, inseparable from the pleura over a 10-mm length, exhibited necrotic regions and a solid postcontrast enhancing component. Additionally, enlarged lymph nodes (22 × 18mm) were noticed in the left lower paratracheal mediastinal group, accompanied by notable centrilobular and paraseptal emphysema.
Figure 1
T1W with gadolinium contrast (a,b), T2W (c,d), ADC (e,f): the frontal lesion measures 1.8 × 2.1cm (transverse plane) and 1.9 × 1.4cm (coronal plane), while the lesion in the right cerebellar hemisphere measures 3.5 × 2.8cm (coronal plane) and 3.9 × 3.6cm (transverse plane), and both lesions show heterogeneous signal intensity, are surrounded by a zone of perifocal edema, and do not demonstrate that central or marginal enhancement with contrast agent in postcontrast imaging, possible necrosis, and ADC sequence shows restricted diffusion.
Open in new tabDownload slide
Gross total surgical resection has been carried out with the intention of cure, a posterior fossa lesion was removed, followed by a subsequent right frontal craniotomy and removal of the second one. The surgery went without any complications. The patient recovered uneventfully. Tissue samples acquired during the surgical procedure underwent pathophysiological analysis.
The histopathological findings correspond to fragments of tumor tissue composed of solid clusters of atypical, polygonal epithelial cells displaying visible mucin production in some cells [periodic acid-schiff staining (PAS)-Alcian +]. Immunohistochemically, the tumor cells show positivity for CKAE1/AE3, CK 7, and Gata3 with weak intensity, partially p63 positive, while negative for ER, PR, HER2, TTF-1, CK5/6, p40, CK20, Pax8, Napsin A, CD10, AR, mammaglobin, and CKHMW (Fig. 2).
Figure 2
(a–c) HE, hematoxylin–eosin, PAS Alcian is a histochemical method used to demonstrate mucin production in the tumor; (d, e) CK7 and CKAE1/AE3 are antibodies for cytokeratins-intermediate filaments, parts of the cytoskeleton of epithelial cells, and (f) Gata 3 is usually positive in breast carcinomas but also in salivary gland carcinomas.
Open in new tabDownload slide
According to the WHO classification, tumor tissue corresponded to a poorly differentiated mucoepidermoid carcinoma metastasis, potentially originating from the lungs (a variant of salivary gland-type tumors). Subsequently, the patient was referred to further PET-CT diagnostics and oncological treatment.
Discussion
Lung MEC with BM presents challenges to physicians due to the rarity of the disease and the complexity of the treatment. While it is a common salivary gland carcinoma, it is not often seen as a pulmonary disease, especially with brain metastases [10]. Predilection sites include predominately (53%) parotid, sublingual, and submandibular glands and rarely lung [11]. Macroscopically, they mostly present as fixed, firm, often cystic, and painless tumors with a mucosae overlayer. Histopathologically, it is characterized by mucinous and squamous (epidermoid), and intermediate-type cells. They are usually multicystic with solid components. The low-grade type is characterized by >50% mucinous cells, while the high-grade type is characterized by a predominance of epidermoid cells with <10% [5, 11, 12]. Since it was first described by Smetana etal. [2], not many reports can be found describing radiological characteristics or treatment options. Previous reports expressed difficulties in radiological differentiation from the abscess of the brain [2, 13]. Our MRI brain scan verified infratentorial and supratentorial predilection sites, heterogeneous signal intensity, and the presence of perifocal edema. The difference between the two lesions is in the presence of necrosis, which is found in infratentorial lesions, which corresponds to the previous radiological description of high-grade lung MEC [4, 5, 14]. The low value in the central portion of the infratentorial lesion on the ADC scan confirms the previous report by Saito etal. [13].
Furthermore, the histopathological report confirmed the poorly differentiated mucoepidermoid carcinoma nature of the brain metastases, consistent with a variant of salivary gland-type tumors originating in the lungs with a high squamous epithelial cell which is a prerogative of high-grade MEC [4, 5]. Immunohistochemical analysis further supported the diagnosis, emphasizing the importance of utilizing specific markers such as CKAE1/AE3, CK 7, and Gata3 to distinguish MEC from other malignancies [3]. The negative staining for hormone receptors (ER, PR, and HER2), thyroid transcription factor-1 (TTF-1), and other markers ruled out alternative primary sources [9]. While HER2 expression was reported in high-grade MEC, here we found it to be negative [15] (Fig. 2).
The first option treatment is still complete surgical excision which results in a better long-term survival rate [6]. Previous reports emphasize margin-free resection of the MEC, especially for the low-grade MEC, following posttreatment PET-CT and MR investigations [7]. High-grade MEC is treated with chemo- and radiotherapy after the resection [8, 14, 16–18]. For the BM, after the resection, whole-brain radiation therapy is usually performed, but in recent years, stereotactic radiosurgery/fractionated stereotactic radiotherapy emerged as a more prominent choice for patients with multiple BM and extended life expectancy [19]. Gene mutation-targeting drugs have a good effect on BM in NSCLC with corresponding gene mutation; however, there are no particularly effective drugs for BM in primary lung MEC [8, 17].
The presented case of lung MEC with BM offers a unique insight, exposing the challenges associated with its diagnosis, management, and treatment. While MEC is commonly encountered in salivary glands, its manifestation in the bronchial mucous glands was unusual in this case, resulting in difficulties in the accurate diagnosis, since there were no initial pulmonary symptoms. This report stresses the necessity for a multidisciplinary approach involving pulmonary, neurosurgical intervention, radiological, and oncological evaluation, with specialized imaging techniques such as MR, and PET-CT for a comprehensive understanding and management of MEC with BM. Further research is warranted to elucidate optimal treatment strategies and targeted therapies for this rare variant of lung cancer with distinct histopathological features. Improved insights into the molecular and genetic aspects of primary lung MEC may pave the way for more tailored therapeutic interventions in the future.
Compliance with ethical standards
The patient has given an informed consent for participation in this paper.
Conflict of interest statement
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Funding
None declared.
References
1.
Limaiem F Sharma S
Mucoepidermoid Lung Tumor
. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2024
. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537277/.
OpenURL Placeholder Text
2.
Smetana HF Iverson L Swan LL
Bronchogenic carcinoma; an analysis of 100 autopsy cases.
Mil Surg.
1952
;
111
:
335
–
51
.
OpenURL Placeholder Text
3.
Wolf KM Mehta D Claypool WD
Mucoepidermoid carcinoma of the lung with intracranial metastases
.
Chest
1988
;
94
:
435
–
8
4.
Peraza A Gómez R Beltran J
An update and review of the literature
.
J Stomatol Oral Maxillofac Surg
2020
;
121
:
713
–
20
5.
Qian X Sun Z Pan W
Childhood bronchial mucoepidermoid tumors: a case report and literature review
.
Oncol Lett
2013
;
6
:
1409
–
12
6.
Leonardi HK Jung-Legg Y Legg MA
Tracheobronchial mucoepidermoid carcinoma. Clinicopathological features and results of treatment
.
J Thorac Cardiovasc Surg
1978
;
76
:
431
–
8
7.
Shen C Che G
Clinicopathological analysis of pulmonary mucoepidermoid carcinoma
.
World J Surg Oncol
2014
;
12
:
33
.
8.
Yamamoto T Nakajima T Suzuki H
Surgical treatment of mucoepidermoid carcinoma of the lung: 20 years’ experience
.
Asian Cardiovasc Thorac Ann
2016
;
24
:
257
–
61
9.
Bishnoi S Puri HV Asaf BB
Lung preservation in mucoepidermoid carcinoma of tracheobronchial tree: a case series
.
Lung India Off Organ Indian Chest Soc
2021
;
38
:
18
–
22
. https://doi.org/10.4103/lungindia.lungindia_511_20.
OpenURL Placeholder Text
10.
Xi Zhang SQ
Stereotactic radiosurgery (SRS) alone versus whole brain radiotherapy plus SRS in patients with 1 to 4 brain metastases from non-small cell lung cancer stratified by the graded prognostic assessment
.
Med Baltim
2018
;
97
:
E11777
.
OpenURL Placeholder Text
11.
Halasz LM Weeks JC Neville BA
Use of stereotactic radiosurgery of brain metastases from non-small cell lung cancer in the United States
.
Int J Radiat Oncol Biol Phys
85
:
e109
–
16
12.
Yamamoto T Yoshino I
Surgical treatment of mucoepidermoid carcinoma of the lung: 20 years’ experience
.
Asian Cardiovasc Thorac Ann
2016
;
24
:
257
–
61
.
13.
Dossani RH Akbarian-Tefa*ghi H Lemonnier L
Mucoepidermoid carcinoma of palatal minor salivary glands with intracranial extension: a case report and literature review
.
J Neurol Surg Rep
2016
;
77
:
e156
–
9
14.
Saito T Ujiie H Kadoyama S
Brain metastasis from a lung mucoepidermoid carcinoma mimicking a brain abscess.
Surg Neurol Int.
2015
;
6
:
S300
–
3
15.
Ishizumi T Tateishi U Watanabe SI
F-18 FDG PET/CT imaging of low-grade mucoepidermoid carcinoma of the bronchus
.
Ann Nucl Med
2007
;
21
:
299
–
302
16.
Chen Y Zhang F Chen X
Rapid metastasis of stage IA primary pulmonary high-grade mucoepidermoid carcinoma with a cystic airspace: a case report and reflection
.
J Int Med Res
2021
;
49
:
030006052110381
17.
Bou Zerdan M Kumar PA Zaccarini D
Molecular targets in salivary gland cancers: a comprehensive genomic analysis of 118 mucoepidermoid carcinoma Tumors
.
Biomedicine
2023
;
11
:
519
. https://doi.org/10.3390/biomedicines11020519.
OpenURL Placeholder Text
18.
Sonobe S Inoue K Tachibana S
A case of pulmonary mucoepidermoid carcinoma responding to carboplatin and pacl*taxel
.
Jpn J Clin Oncol
2014
;
44
:
493
–
6
19.
Xiyou Liu HY
Apatinib and fractionated stereotactic radiotherapy for the treatment of limited brain metastases from primary lung mucoepidermoid carcinoma
.
Med Baltim
2020
;
23
:
E22925
.
OpenURL Placeholder Text
Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2024.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Subject
Neurosurgery
Issue Section:
Case Report
Download all slides
Advertisem*nt
Citations
Views
149
Altmetric
More metrics information
Metrics
Total Views 149
129 Pageviews
20 PDF Downloads
Since 6/1/2024
Month: | Total Views: |
---|---|
June 2024 | 149 |
Citations
Powered by Dimensions
Altmetrics
Email alerts
Article activity alert
Advance article alerts
New issue alert
In progress issue alert
Subject alert
Receive exclusive offers and updates from Oxford Academic
Citing articles via
Google Scholar
-
Latest
-
Most Read
-
Most Cited
Advertisem*nt