Brain metastasis - sarcoma

Case contributed by Dr Bruno Di Muzio

Presentation

Seizure.

Patient Data

Age: 57-year-old
Gender: Female

CT Brain

Modality: CT

Right frontal lobe circumscribed hyperdense mass showing vivid contrast enhancement and associated with surrounding vasogenic oedema. No midline shift or cerebral herniations. Ventricles and basal cisterns are unremarkable. No skull lesions. 

MRI Brain

Modality: MRI

Centred in the right posterosuperior frontal lobe there is a mass that has mildly heterogeneous signal intensity but is mainly isointense to grey matter on T1 and T2-weighted images. Peripherally there is some diffusion restriction, with heterogeneous enhancement. Surrounding this there is vasogenic oedema which does not have any significant mass effect with local sulcal effacement but no midline shift or cerebral parenchymal herniation. Cerebral blood volume (CBV) is increased around the periphery of the mass. Spectroscopy demonstrates depressed choline, creatine and NAA peaks with elevation of the lactate/lipid peaks within the mass (not shown above). In the surrounding vasogenic oedema the spectroscopy traces are relatively normal. No further lesion is identified. Remainder of the brain is unremarkable. 

Brain CT and MRI findings suggest a solitary hyperdense metastasis, further assessment was performed with CT Abdomen and Pelvis and CT Chest for a screening of primary malignancy. 

CT Abdomen and pelvis (selected images)

Modality: CT

Large mass in segment 2/3 and further multiple smaller hypodensities throughout the remainder of the liver, which are variable attenuation (between 20 HU and 60 HU). Right upper pole 1.4 cm indeterminate density mass. Left kidney, adrenal glands, spleen and pancreas are unremarkable. Focal narrowing at the hepatic flexure is non-specific. No pelvic mass. Pelvic surgical clips, probably tubal ligation. No abdominopelvic or inguinal lymphadenopathy. No destructive bone lesion.

Modality: Pathology

MICROSCOPIC DESCRIPTION: Sections show a well circumscribed malignant spindle cell tumour with areas of geographic necrosis. Tumour cells contain elongate, oval vesicular nuclei, prominent nucleoli and abundant eosinophilic cytoplasm. Frequent mitoses are observed (>20/10hpf). Tumour cells are set within a dense sclerotic stroma. Scattered thin and thick walled blood vessels are present. No heterologous elements are seen. Immunohistochemical results show tumour cells stain:

Positive: CD99, CKAE1/3, CAM5.2, EMA focal, CD31 focal, GATA3 focal, Calretinin focal

Negative: CD34, BCL2, SMA, Desmin, cKIT, DOG1, S100, SOX10, WT1, p40, CK7, CK20, CDX2, TTF1, Mesothelin, AFP, HepPar1

DIAGNOSIS: Brain tumour: Undifferentiated malignant spindle cell tumour of uncertain lineage - further immunohistochemical stains to follow.

Case Discussion

Large liver lesion is most likely a metastasis given the brain lesion. Further smaller liver lesions may represent further metastases, although some could be cysts. No definite primary malignancy identified. on CT Chest, Abdomen and Pelvis. 

Histology of the brain lesion confirmed a sarcoma metastasis

From all types of brain metastases, sarcomas are estimated to represent only 3% and only 1 to 8% of patients with any kind of sarcoma may develop brain metastases 1.  

PlayAdd to Share

Case Information

rID: 47576
Case created: 22nd Aug 2016
Last edited: 23rd Aug 2016
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.