Leptomeningeal Enhancement and Cortical Hypodensity in a Patient with Metastatic Endometrial Cancer: Metastasis or Stroke?

Case Presentation

Ann Hematol Oncol. 2018; 5(6): 1215.

Leptomeningeal Enhancement and Cortical Hypodensity in a Patient with Metastatic Endometrial Cancer: Metastasis or Stroke?

Rachumalla PR¹, Faour A², Harrison M¹ and Moylan E¹*

¹Department of Medical Oncology, Liverpool Hospital, Australia

²Department of Cardiology, Liverpool Hospital, Australia

*Corresponding author: Moylan E, Department of Medical Oncology, Liverpool Hospital, Elizabeth St, Liverpool, Sydney, NSW 2170, Australia

Received: September 04, 2018; Accepted: September 25, 2018; Published: October 02, 2018


We report a 46-year-old woman with advanced endometrial cancer who presented to the emergency department with confusion, worsening ascites and symptoms of a lower respiratory tract infection. She was thought to have brain metastases based on a CT brain but was later identified to have multiple cerebral infarcts on an MRI of the brain secondary to Non-Bacterial Thrombotic Endocarditis (NBTE). Her anticoagulation was optimized to Enoxaparin 1mg/ kg twice a day. She passed away within 3 months with a recurrent ischemic stroke despite optimal anticoagulation. This case highlights the importance of accurate diagnosis of brain lesions in cancer patients and the need for proactive investigations to look for source of arterial emboli in patients with advanced malignancy. The case also demonstrates high risk of recurrent embolization and poor overall survival associated with NBTE.

Keywords: Non-Bacterial Thrombotic Endocarditis (NBTE); Marantic Endocarditis; Cancer; Metastases; Hypercoagulability


CAP: Chest Abdomen and Pelvis; CT: Computed Tomography; CVA: Cerebral Vascular Accident; DVT: Deep Vein Thrombus; ECHO: Echocardiogram; MRI: Magnetic Resonance Imaging; NBTE: Nonbacterial Thrombotic Endocarditis; PE: Pulmonary Embolism; USA: United States of America; USS: Ultrasound Scans

Case Presentation

A 46-year-old woman was diagnosed with an advanced endometrial cancer and bilateral pulmonary emboli 5 months prior to this presentation. Histopathology on a pipelle biopsy of the endometrium was reported to show a grade 1, ER >60% positive, PR > 60% positive endometriosis adenocarcinoma. The tumour was reported to demonstrate compact glands showing focal squamous differentiation and extensive mucinous differentiation with copious extracellular mucin. The tumour stroma contained abundant foamy macrophages. The patient received 3 cycles of Carboplatin and Paclitaxel from April to June 2017 with a significant clinical response, but she had discontinued treatment prematurely following initial improvement. She presented to the emergency department in September 2017 with recent-onset confusion, worsening ascites and lower respiratory tract symptoms. She had no significant comorbidities. She was on enoxaparin 1.5mg/kg per day for pulmonary emboli although adherence to prescribed therapy was unable to be confirmed. She was a non-smoker and had no significant medical family history. She was commenced on empirical antibiotic therapy for presumed respiratory tract infection with little improvement in her symptoms. Her CA 125 was increasing compared to previous readings. The CA125 level at the end of chemotherapy was 780 kU/L (normal range: 0-35 kU/L) and was 2693 kU/L at the time of presentation to emergency department. She had a re-staging CT CAP and cerebral CT. CT CAP showed recurrent pulmonary emboli (Figures 1A & 1B) progression of cancer (Figure 2) with increase in the size of pelvic mass, omental caking, large volume ascites, extensive abdominal lymphadenopathy and new lung base/diaphragmatic pleural metastases. There was also a wedge shaped splenic infarct (Figure 3). A contrast-enhanced CT brain was reported to show leptomeningeal enhancement (Figure 4) associated with a wedge shaped area of hypodensity involving the left parietal cortex and subcortical white matter. This raised the possibility of multiple brain metastases. Further evaluation with MRI of the brain (Figures 5 & 6) showed multifocal acute and subacute infarcts in both cerebrum and cerebellum. These findings led to further investigations in order to identify the source of emboli, suspecting either the presence of a patent foramen ovale with paradoxical systemic emboli or marantic endocarditis. A transoesophageal echocardiogram was reported to show a mobile right ventricular density (Figure 7) and a mobile anterior mitral leaflet density (Figure 8). Three peripheral sets of blood cultures were negative for organisms and therefore, a diagnosis of marantic endocarditis was made. The anticoagulation was changed from Enoxaparin 1.5mg/kg daily to 1mg/kg twice a day. The patient was also recommenced on Carboplatin/Paclitaxel chemotherapy for her underlying malignancy. Her symptoms slightly improved but she passed away 10 weeks later following another ischemic stroke.