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Nucleus of the Tractus Solitarius Metastasis: Relationship to Respiratory Arrest?

Published online by Cambridge University Press:  02 December 2014

Roy H. Rhodes  and
H. Robert Wightman
Roy H. Rhodes
Affiliation:
Department of Pathology, University of Manitoba, Winnipeg, MB Canada
H. Robert Wightman
Affiliation:
Department of Pathology, Grace General Hospital, Winnipeg, MB Canada
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Abstract

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Background:

A 52-year-old woman with metastases in brain and bone had clinical and radiological response to therapy but died about 10 weeks after diagnosis. General autopsy failed to identify a primary neoplasm or an anatomic cause of death. Investigation of sudden respiratory cessation was a consideration when undertaking an anatomic study of the brain.

Methods:

Review of patient records and careful examination of the brain following autopsy were carried out.

Results:

The patient had terminal episodes of hypersomnia but episodes of sleep apnea were not observed. She received no respiratory support and no respiratory difficulties were recorded until she was pronounced dead at 7 a.m. Autopsy revealed metastatic adenocarcinoma in a pattern suggestive of a primary pulmonary neoplasm, including multiple cerebral metastases, although no significant pulmonary lesions of any type were found. A 0.2 cm metastatic adenocarcinoma was found in the nucleus of the tractus solitarius (NTS). No other tumor was present in the brain stem.

Conclusion:

Unilateral destruction of the NTS in the medulla would have severely disturbed the most critical point of convergence of autonomic and voluntary respiratory control and of cardiocirculatory reflexes in the central autonomic network. It is postulated that this caused respiratory arrest during a state transition from sleeping to waking. Few metastases to the medulla are reported, most are relatively large, and several have caused respiratory symptoms before death. The very small metastasis in our patient could be the direct anatomic cause of death, and as such it is an unusual complication of metastatic disease of which clinicians should be aware. It is speculated that dysfunction of direct NTS connections to the pons or of connections passing close to the metastatic deposit resulted in terminal hypersomnia.

Résumé:

RÉSUMÉ:Introduction:

Une femme âgée de 52 ans porteuse de métastases cérébrales et osseuses a eu une réponse clinique et radiologique au traitement mais elle est décédée environ 10 semaines après le diagnostic. Une autopsie n'a pas pu identifier un cancer primaire ou une cause anatomique de décès. À l'examen anatomopathologique du cerveau, on a recherché la cause de l'arrêt respiratoire subit.

Méthodes:

Il s'agit d'une revue de dossiers de patients et d'examens anatomopathologiques de cerveaux.

Résultats:

La patiente a eu des épisodes d'hypersomnie en phase terminale mais aucun épisode d'apnée du sommeil n'a été observé. Elle n'a pas reçu d'assistance respiratoire et aucune difficulté respiratoire n'a été notée jusqu'à ce que son décès ne soit constaté à 7 am. Une autopsie a révélé un adénocarcinome métastatique dont l'aspect était suggestif d'une néoplasie pulmonaire primaire, dont de multiples métastases cérébrales, bien qu'on n'a retrouvé aucune lésion pulmonaire significative de quelque type que ce soit. Un adénocarcinome métastatique de 0.2 cm a été retrouvé dans le noyau du faisceau solitaire (NFS). Il n'y avait aucune autre tumeur dans le tronc cérébral.

Conclusions:

Une destruction unilatérale du NFS dans le bulbe aurait sévèrement perturbé le point de convergence le plus critique du contrôle respiratoire autonome et volontaire et des réflexes cardiocirculatoires dans le réseau autonome central. Nous postulons qu'il s'agit là de la cause de l'arrêt respiratoire pendant un état de transition entre le sommeil et l'éveil. Peu de métastases bulbaires ont été rapportées, la plupart étant relativement grosses et plusieurs ayant causé des symptômes avant le décès. La petite métastase chez notre patiente pourrait être la cause anatomique directe de son décès et comme tel il s'agit d'une complication inusitée de la maladie métastatique que les cliniciens devraient connaÀtre. Nous émettons l'hypothèse qu'une dysfonction des connections directes entre le NFS et le pont ou des connections passant près du dépôt métastatique a causé l'hypersomnie terminale.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 27 , Issue 4 , November 2000 , pp. 328 - 332
Copyright
Copyright © The Canadian Journal of Neurological Sciences Inc. 2000

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