Uncharted Territory: A Case of Journey of a Mullerian Tumor to the Brain

Introduction: Ovarian cancer is one of the most common gynecological cancers in the United States. Common sites of distant metastasis from ovarian cancers and other cancers of Mullerian origin include the liver, pleura and lungs. However, metastasis to the brain remains exceptionally rare, ranging from 0.49 to 6.1%. Hence, the scarcity of such cases pose significant diagnostic and management challenges. Case Presentation: We present a case of an 80-year-old female who at the time of initial diagnosis presented with complaints of right leg pain, shortness of breath and cough. Imaging studies were remarkable for a pulmonary embolism, 2.5 cm mediastinal mass, pleural effusions, omental caking and an occlusive thrombus in the right greater saphenous vein. Malignancy was suspected in the setting of hypercoagulability. Biopsy of the omentum and pleural cytology revealed a high grade ovarian serous carcinoma. The patient received neoadjuvant chemotherapy followed by cytoreductive surgery and additional chemotherapy afterwards. She demonstrated good response to treatment with follow up PET without evidence of disease. Over the next four years, the patient was intermittently placed on chemotherapy when found to have elevated CA125 levels and PET scan showing small volume disease mostly in the pelvis. Six-years later, the patient presented to the oncology clinic with complaints of dizziness and imbalance for the past month. MRI brain showed a new left cerebellar mass with vasogenic edema and obstructive hydrocephalus. However, restaging CT chest, abdomen and pelvis showed minimal to no disease, with the only possible foci being a 1.2 cm paraaortic lymph node. The patient underwent left suboccipital craniotomy and cerebellar tumor resection with pathology showing metastatic carcinoma consistent with spread from a Mullerian primary. Conclusion: This case emphasizes the diagnostic complexity and evolving clinical course of Müllerian tumors. In a patient with a history of Mullerian tumor and new onset neurological symptoms, differential diagnosis should include metastasis to the brain, even with minimal to no active pelvic and systemic disease burden.