Cerebral and cerebellar metastases

Case contributed by Gabriel Alonso Callupe Huamán

Presentation

Headache of several months duration, nausea and vomiting. Heavy smoker in her youth.

Patient Data

Age: 80 years
Gender: Female

CT brain

ct

A nodular lesion, located in the right occipital lobe shows defined and thin walls, with hypodense content (30 HU) and peripheral enhancement.

A second mass in the left cerebellar hemisphere, also with defined walls but with nodular aspect that enhances with contrast, heterogeneous hypodense content with areas of liquid density.

The diagnosis is: neoformative lesions of cystic appearance, an extension of the study with Magnetic Resonance Imaging is requested.

Chest x-ray

x_ray

A chest X-ray is obtained as part of the basic studies, which shows a right hilar mass, with a "hidden hilum" sign, suggesting an expansive process at the level of the hilum.

MRI brain

mri

The multilobulated cystic lesion in the left cerebellar hemisphere shows high internal T2 signal that is partially suppressed on FLAIR and has thin nodular borders that enhance with contrast; also on VEN BOLD sequence, it shows peripheral areas with absence of signal.

There is a small lesion of similar characteristics in the right occipital lobe. In DWI sequences small foci of diffusion restriction are appreciated at the posterior fossa level located within the border that enhances at the margins of the lesion; the lesion is associated with surrounding vasogenic edema.

Cystic lesions with peripheral nodular annular enhancement, in addition to peripheral hematic debris and proteinaceous/necrotic content, associated with chest x-ray images, are compatible with metastases.

CT chest

ct

A heterogeneous nodule at the level of the right hilum, attached to lobar branches of the right upper lobe, with heterogeneous enhancement to contrast, which associates multilobulated and irregular borders.

A filling defect in the left pulmonary arterial branches with distal consolidation. 

Bilateral effusion with subsequent passive atelectasis.

Conclusion: 

  • The right hilar nodule most likely represents a squamous cell carcinoma.
  • Acute pulmonary thromboembolism is associated with parenchymal infarction areas on the left side. A thrombus is also visible at the level of the superior vena cava.
  • Bilateral effusion and passive atelectasis.

Case Discussion

Cystic masses in the posterior fossa represent a diverse group of entities: on the one hand, benign cystic lesions (which are usually incidental findings without associated symptomatology) such as an arachnoid cyst.

Pathologies that one should consider should take into account age (for example, pilocytic astrocytoma and medulloblastomas are typical in children), epidemiology (such as living in endemic areas for cysticercosis), oncological history (metastases can behave as cystic masses with all the associated symptoms of mass effect, as in this case).

The patient underwent craniotomy with removal of a left posterior fossa mass which was confirmed to be compatible with metastatic non-small cell lung cancer (NSCLC on histology. 

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