Brain metastasis (extensive vasogenic edema)
Previous history of breast cancer. First seizure episode.
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Technique: Pre and post contrast images have been obtained through the brain.
Findings: There is a left frontal paramedian cortical tumor that shows mild peripheral hyperattenuation and heterogeneous contrast enhancement. The lesion has a broad contact with the cerebral falx without disrupting it or dural tail sign. A prominent vasogenic edema is observed along the left frontal lobe associated with mass effect that promotes lateral ventricle compression and subfalcine herniation with mild midline shift. The remainder brain is unremarkable.
Conclusion: Left frontal mass with a prominent vasogenic edema and mass effect most likely represents a metastasis.
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Technique: Multiplanar multisequence imaging including pre- and post-contrast T1, T2, FLAIR, DWI/ADC and stereotaxis.
Findings: There is a superficially located mass in the left superior frontal gyrus anteriorly measuring 22 x 13 x 20 mm (AP x LR x SI). This has developed in the region of subcortical FLAIR hyperintensity present on the previous MRI. The mass is centered on the grey-white matter junction involving both cortex and subcortical white matter and has a broad dural abutment. The mass demonstrates subtle intrinsic T1 hyperintensity and blooming consistent with blood product and heterogeneous solid contrast enhancement. The lesion is of heterogeneous T2 signal with mixed hyperintense and hypointense components. No central restricted diffusion in the mass. Extensive surrounding vasogenic edema in the left frontal and parietal lobes. There is associated mass effect on the left lateral ventricle and sulci and rightward midline shift of 7 mm. No other intracranial mass. No hydrocephalus.
Conclusion: Left superior frontal gyrus mass associated with extensive vasogenic edema and mass effect most likely represents a metastasis.
MICROSCOPIC DESCRIPTION: 1&2. Paraffin sections show a densely hypercellular tumour within brain parenchyma. Tumour cells have pleomorphic round and oval nuclei with an open chromatin pattern and a small amount of pale cytoplasm. These are arranged in irregularly shaped solid islands within an intensely vascular stroma. There is prominent palisading of tumour cells at the periphery of some of the islands. Frequent mitotic figures are identified and there are several foci of tumour necrosis.Tumour is sharply demarcated from adjacent gliotic and oedematous brain parenchyma.
Immunohistochemistry shows strong membrane staining in tumour cells for E-cadherin and strong cytoplasmic staining for EGFR, pancytokeratin AE1/AE3 and cytokeratin CK5&6. There is patchy moderate staining for CD56. No staining for synaptophysin is seen in tumour cells.
The features are of metastatic undifferentiated carcinoma consistent with an origin from breast.
DIAGNOSIS: 1&2. Left frontal brain tumour: Metastatic undifferentiated carcinoma consistent with an origin from breast.
- Oestrogen receptor negative (no staining)
- Progesterone receptor negative (no staining)
- HER-2 negative (+ cytoplasmic staining <10%)
- EGFR positive
- Ki-67 approximately 60%
SUPPLEMENTARY RREPORT: Further immunohistochemistry shows tumour cells are TTF-1 -ve, CEA -ve, Napsin A -ve, cytokeratin CK7+ and BerEp4+. This profile is inconsistent with an origin of tumour from lung and an origin from breast remains highly likely.
This case illustrates a cortical-subcortical left superior frontal gyrus mass that has a prominent and disproportional vasogenic edema and mass effect for its size. The hemorrhagic component and the location (cortico-subcortical), in the context of the previous history of breast cancer, are strongly suggestive o a brain metastasis, which was further confirmed by histology.