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Cite this article: Al-Harthy H, Al-Mahrouqi T, Al-Obaidani A, et al. (06 Aug 2020) Solitary fibrous tumor revealed by worsening clinical depression: a case report from Oman. Article 12, paragraph 8: e9584. doi: 10.7759/.9584
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Brain tumors are serious pathologies that can cause significant morbidity and mortality, and early recognition and diagnosis can lead to good patient outcomes. We present a case of a 27-year-old man who was referred to the Department of Behavioral Medicine, Sultan Qaboos University Hospital (SQUH), Oman, in 2019 because of worsening depressive symptoms. Depression was the only initial symptom of the patient’s solitary fibrous tumor, and surgical removal of the tumor followed by radiation therapy resulted in complete resolution of her psychiatric symptoms.
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Patients with brain tumors may present with a variety of signs and symptoms, with common clinical manifestations such as headache, cognitive dysfunction, and seizures [ 1 ]. However, in rare cases, brain tumors may present exclusively with psychiatric symptoms, in which patients may experience mood and anxiety symptoms, psychosis, and behavioral and personality changes [2]. Such a presentation can complicate the clinical presentation and lead to delayed diagnosis or misdiagnosis as a mental illness [3]. Some primary brain tumors have a poor prognosis and can be life-threatening, so early screening and recognition are essential, as diagnostic delays have a detrimental effect on the survival and quality of life of patients and their families [4].
A 27-year-old man was referred to the Department of Behavioral Medicine at Sultan Qaboos University Hospital (SQUH), Muscat, Oman in 2019 after worsening of pre-existing depressive symptoms. The patient had had low mood, social isolation, abulia and apathy for seven months. These symptoms initially appeared as a result of social stress, as the lady he wanted to marry rejected his proposal and married someone else. At the same time, the patient’s initial symptoms appeared, as he mostly stayed in his room, did nothing, had minimal social contact with his family and did not go to the mosque to pray. And although he expressed that he was very interested in his work, he lacked motivation or drive to come to work, progressive absenteeism and eventually stopped going to work; as a result, his salary was suspended. You’ve lost interest in many pastimes you used to enjoy, such as going out with friends or going to the gym. The patient had difficulty sleeping, nocturnal sleep disturbances, early morning awakenings, and inability to return to sleep. She reported low energy, tired easily, and failed to meet her basic needs such as personal hygiene, proper clothing, and nutrition. He had to take a shower and manage to keep himself clean. She was in a bad mood, but showed no signs of self-harm or suicide. He had no associated symptoms of anxiety, mania, or psychosis. He denied drug use or alcohol consumption and had no fever or head injury. As the disease progressed, the appetite worsened, with significant weight loss. The patient had occasional headaches, which became more severe with time; no aura, nausea or vomiting. The patient had no history of mental disorders and this was her first contact with mental health services. In terms of his personal history, he achieved normal developmental milestones and obtained a General High School Diploma.
He was evaluated as an outpatient and started on an antidepressant and cognitive behavioral therapy, but due to poor response to treatment and the severity of his symptoms, he was referred to SQUH for inpatient treatment. On examination, he presented as a depressed and unkempt man who appeared apathetic, with minimal responses and no psychotic symptoms. Neurologically, she had right-sided tremors and exaggerated reflexes with normal tone and strength and no neurological focal deficits. He was fully conscious and informed, and the rest of the systemic examination was unremarkable.
The patient underwent a pre- and post-contrast brain CT scan (Figure 1). CT scan showed a large medial axial lobular mass in the basifrontal region, traversing the brainstem. Masses approximately 7.0 cm x 7.1 cm x 7.0 cm in antero-frontal, transverse, and craniocaudal dimensions. It showed enthusiastic heterogeneous signal reduction and enhancement on post-contrast images with suboptimal foci indicating necrosis. Together, there was perilesional edema and a marked mass effect in the anterior branches of the lateral ventricles, which displaced the masses posteriorly. Bone window images showed erosion of the inner table of the left frontal bone. Magnetic resonance imaging (MRI) of the brain before and after administration of gadolinium-based contrast showed a mass with heterogeneous signal and low signal mainly on T1-weighted images (T1 WI) and T2 WI images and necrotic/cystic areas. (Figure 2). Large anechoic vessels were seen in the mass, suggestive of a vascular tumor. Diffusion limitation was not observed, nor was significant artifactual bloom suggestive of hemorrhage observed. The crowd showed enthusiastic heterogeneous enhancement on post-contrast images. Different diagnoses of this mass include atypical aggressive meningioma and hemangiopericytoma (HPC).
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(a) Precontrast axial image shows a large heterogeneous mass involving the midline basifrontal region. The mass is excessively attenuated relative to the adjacent gray matter. (b) Post-contrast image shows a strongly enhancing mass with non-enhancing necrotic foci. (c) Bone window image shows erosion of the inner plate of the left frontal bone.
(a) Axial T2WI image shows heterogeneous signal intensity of the mass, which is isointense and slightly hypointense compared to the gray matter, indicating cystic foci and vessels with multiple signal gaps. There is mild perilesional edema with significant mass effect and a rightward deviation of the midline. A CSF fissure sign (red arrow) is seen, indicating an extra-axial origin of the mass. (b) Post-contrast T1 image shows enthusiastic enhancement of the mass.
The patient underwent first-stage bifrontal craniotomy and biopsy. However, due to significant blood loss, the procedure was stopped considering patient safety and complete resection of the tumor in the second stage. Histologically, the tumor cells had a “cell” appearance with round or oval nuclei and prominent nucleoli. Scattered mitotic activity reached 3/10 high-power fields (HPFs) with evidence of bone invasion. Immunohistochemically, the tumor cells were positive for vimentin, B-cell lymphoma 2 (BCL-2), cluster of differentiation 34 (CD34), CD99, CAM5.2 and AE1/AE3. Nuclear expression of signal transducer and activator of transcription 6 (STAT6) was not viable by immunohistochemistry, and NAB2-STAT6 fusion protein could not be verified because the reagent kit is not available at our center. The first biopsy was suboptimal due to marked cautery artifact, and definitive grading as defined by the World Health Organization (WHO) is best deferred to the final resection specimen; excision of the second-stage tumor was performed abroad and the sent histopathology report was consistent with hemangiopericytoma; however, no further details were available regarding the WHO classification (Figures 3–9). On postoperative evaluation, the patient was conscious and alert with normal reflexes and neurologic motor evaluation. Two weeks after surgery, the patient developed severe headache and complex partial seizures. He then underwent a second bifrontal craniotomy for the residual tumor, which was successful. Postoperative MRI contrast examination showed no enhancement indicating residual disease (Figure 10). Two months after the operation, he underwent five sessions of radiation therapy, and six months later, an MRI scan showed no clear evidence of residual tumor. Her condition improved, she recovered well, with a normal neurological examination, no more seizures, and no depressive symptoms during follow-up examinations. He continued to work and returned to his pre-illness level of functioning.
Figure 3: Hematoxylin and eosin (H&E)-stained section of hemangiopericytoma showing oval vesicular, slightly pleomorphic nuclei, prominent nucleoli, and tightly packed cells with eosinophilic cytoplasm.
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Post-contrast T1 fat-saturation images in (a) and coronal (b) planes show edema in the operating bed with no residual enhancement-enhancing tumor.
Mood symptoms are common clinical symptoms in brain tumor patients [5]. In this case report, we discuss the presentation of worsening clinical depression in a patient diagnosed with hemangiopericytoma (HPC). Cranial HPCs are rare tumors with aggressive behavior, including local recurrence and distant metastasis [ 6 ]. In our case, contrast-enhanced positron emission tomography-computed tomography (PET/CT) was performed to determine the stage, which did not show distal metastases. Brain tumors may present with purely psychiatric symptoms, with or without neurologic manifestations, but there are no established guidelines for brain imaging indications in patients with psychiatric symptoms. A systematic review and meta-analysis by Huang et al. showed that the overall prevalence of depressive symptoms was 21.7% in cranial tumor patients [7]. However, there is no consensus regarding the indication for brain imaging in patients with depressive symptoms; however, it is recommended for late-onset depression, treatment-resistant cases, and altered patients.
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