Presentation
Headache, bouts of vomiting and blurring of vision.
Patient Data
Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.
Selected MRI image at first presentation, after resection of craniopharyngioma and after onset of metastatic recurrence in right temporal fossa.
MRI shows a mass with a cystic component filled with proteinaceous fluid in the suprasellar region causing compression of optic chiasma.
This patient underwent right parietal craniotomy for suprasellar craniopharyngioma in 2008. The histology indicated an adamantinous craniopharyngioma.
It was believed to be completely resected surgically and the immediate post-operative MRI imaging one year after surgery confirmed complete resection without residual tumor (not shown). No radiotherapy was given. He was on hormone replacement therapy with cortisol and thyroxine.
3 years after the surgery, the child again developed visual symptoms and headache. MRI done after this second symptomatic presentation demonstrated a cystic lesion in the right temporoparietal region with an enhancing wall. There was no recurrence at the site of surgery. Since the symptoms were mild the patient was followed up for 18 months.
Therefore repeat right parietal craniotomy was performed to resect this lesion. The biopsy again confirmed a metastatic seedling of adamantinous craniopharyngioma.
The MRI after 2 years demonstrated further enlargement of this implant metastasis.
Case Discussion
Our patient had a recurrence along the surgical route in the right middle cranial fossa. The approximate time period between surgery and recurrence was two years. There were reported 17 cases in the available literature out of which 5 were under the age of 18 years. In most of the cases, metastases have occurred along the surgical route. There were two recurrences in the spinal cord and the rest were at ectopic sites not related to surgical route 10,11. In one case report a patient has presented with two metastases 4: one in the temporal fossa at 3 years and another in the frontal space at 10 years 7.
These patients are usually given hormonal replacement therapy 7. Our patient was treated with thyroxine, cortisol and DDAVP. He underwent repeat surgical resection of the metastasis in March 2013.
Two mechanisms have been postulated for these ectopic recurrences.
the first is metastasis often occurs along the surgical route, as in our case
spreading to distant locations via cerebrospinal fluid has been suggested 3. Therefore regular follow-up is necessary, even after supposedly total resection
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