An 80-year-old female patient presented to the emergency department with worsening right upper extremity (RUE) and lower extremity (RLE) weakness, difficulty with fine motor tasks, but intact comprehension and speech. Neurological exam revealed intact sensation, but weakness in the RUE and RLE: 4/5 right grip, 3/5 biceps/triceps, 1/5 right deltoid, 3/5 dorsi- and plantar flexors and 2/5 in hip flexion. The patient had known stage IIB (T3, N1, M0) PAC with liver metastasis, which was diagnosed in 2016. A Whipple procedure was performed at that time, followed by adjuvant chemotherapy and radiotherapy (Fig. 1) with excellent response. Brain computed tomography and magnetic resonance imaging (MRI) studies revealed a right (18 x 18 mm) and left (31 x 30 mm) frontal lesions with peripheral enhancement and central necrosis with mild adjacent brain edema without midline shift, but slight mass effect on the motor strip (Fig. 2a).
Operation
The patient was admitted to the hospital and underwent staging which revealed no additional primary or metastatic lesions. The patient was taken to the operating room and underwent bifrontal craniotomy with gross total resection of both tumors. Postoperative MRI scan (Fig. 2b) showed gross total resections of both lesions without residual enhancement. Pathologic analysis of the specimens demonstrated malignant cells consistent with metastatic adenocarcinoma of pancreatic primary exhibiting moderately to well-differentiated glandular structures with associated mucin and calcification. Immunostaining was positive for cytokeratin 7, epithelial membrane antigen, CDX2 (patchy) and CK20 (focal) without expression of thyroid transcription factor – 1.
Postoperative Course
Three weeks postoperatively, the patient had complete resolution of her right-sided weakness and no other neurological deficits.
The patient underwent postoperative stereotactic radiosurgery (SRS) to both tumor bed cavities. The total target dose of 2,700 cGy was prescribed, 900 cGy in 3 fractions. Unfortunately, the patient developed generalized tonic-clonic seizures, was diagnosed with leptomeningeal carcinomatosis, and died 5.5 months after tumor resection.