Brain metastasis as initial presentation of non-small cell lung cancer

Case contributed by Dr Amr Farouk

Presentation

Headache, vomiting, and blurring of vision.

Patient Data

Age: 55 years
Gender: Female

Bilateral few (three in number) subcortical cystic SOLs are seen at the left frontal and bilateral parietal regions, the largest is seen at the left parietal lobe measuring about 3 x 2.6 cm along its maximal axial diameters. It elicits a low signal in T1 WI, a high signal in T2 and FLAIR Wis with central cystic signal and peripheral soft tissue enhanced component with peripheral restricted signal and central facilitation in DWIs.

Surrounding subcortical vasogenic edema is seen together exerting a secondary mass effect in the form of effacement of cortical sulci and attenuation of the frontal horns of the lateral ventricles more on the right side.​

MR spectroscopy showed:

  1. elevated choline peaks with increased choline:creatine ratio
  2. depression of the neuronal markers (N-acetylaspartate (NAA) peak)
  3. elevation of the lipid/lactate peak
  4. no myoinositol peak elevation

Right lower lung lobe anterior segment irregular speculated neoplastic mass lesion with surrounding spicules and parenchymal ground glass density reaching to the oblique fissure which shows nodular thickening. The mass is seen showing central cavitation as well. It measures 3.9 X 3.7 X 3.3 cm in its maximum axial and craniocaudal dimensions.

Pathologically enlarged right hilar, right paratracheal and subcarinal lymph nodes are seen showing heterogeneous enhancement, the largest is seen at the latter location measuring 2.5 x 1.4 cm in its maximum axial diameters.

Case Discussion

The differential diagnosis of a cerebral ring-enhancing lesion includes cerebral abscessmetastasisglioblastoma and tumefactive demyelinating lesion (incomplete ring of enhancement).

No single feature is pathognomonic. Many features of the lesion, as well as clinical presentation and patient demographics, are needed to reach a final diagnosis. Conventional MR features and MR spectroscopy are of malignant neoplasia with features in favor of metastases include multiplicity and significant surrounding edema.

Lack of thin and regular wall and lack of central restricted diffusion excludes a cerebral abscess. Lack of incomplete ring of enhancement toward the cortex makes tumefactive demyelinating lesion.

Metastatic brain disease was suggested and survey for primary origin was recommended. The patient had a CT exam of the chest showing a right lower lung lobe mass with ipsilateral hilar and mediastinal lymphadenopathy. The patient had a CT guided biopsy from the mass revealing bronchogenic cancer (NSCLC).

Most cases of NSCLC will present in advanced stages. Brain metastases are found in up to a quarter of patients at presentation and are known as a common site of disease recurrence after an initial treatment response.

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Case information

rID: 65122
Published: 27th Jun 2019
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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