Cerebral intraventricular lung metastases

Case contributed by A.Prof Frank Gaillard

Presentation

2 weeks of lethargy and weight loss.

Patient Data

Age: 70 years
Gender: Male
CT

CT brain

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MRI

MRI brain

There are multiple predominantly periventricular subependymal foci which are mainly iso-intense on T1 and on T2 to grey matter. The largest subependymal lesion adjacent to the body of the left lateral ventricle is more hypointense on T2, but is not definitely hemorrhagic. Multiple lesions are seen in the septum pellucidum. On post-contrast imaging there are multiple subependymal nodular lesions demonstrating heterogeneous enhancement. An enhancing parenchymal lesion is identified at the left temporal pole measuring 9 mm. Periventricular FLAIR hyperintensity. 

Review of the diffusion weighted imaging shows most of the enhancing foci foci to be diffusion restricting. The largest mainly T2 hypointense lesion adjacent to the body of the left lateral ventricle shows mild peripheral diffusion restriction. The MR perfusion images demonstrate increased rCBV in most of these lesions. MRS shows mild elevated choline, moderate to marked reduced NAA and a moderate lipid/lactate peak.

The remainder of the brain parenchyma demonstrates FLAIR signal abnormality within the deep white matter of the hemispheres and the brainstem consistent with microvascular disease. Mild prominence of the sulci for age. 

Conclusion

Multiple heterogeneously enhancing predominantly periventricular subependymal lesions and a separate left temporal pole lesion. The precontrast CT hyperdensity and MRI findings would be in keeping with CNS lymphoma, but the heterogeneous enhancement is atypical for an immunocompetant patient and is more typical for an immunosuppressed patient. Is the patient immunosuppressed? Particularly if the patient is not immunosuppressed, then differentials include high grade glioma with subependymal spread and a temporal satellite lesion, or highly cellular +/- hemorrhagic subependymal metastasis. 

CT

CT chest

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Case Discussion

MACROSCOPIC DESCRIPTION: Multiple portions of red haemorrhagic tissue with focal cream areas measuring up to 2mm each.  

MICROSCOPIC DESCRIPTION: The sections show features of a cellular malignant tumour. It forms cohesive nests. The tumour cells have high N/C ratio with enlarged hyperchromatic nuclei, nuclear moulding, granular chromatin, inconspicuous nucleoli and scanty cytoplasm. Scattered mitoses, apoptotid debris and areas of necrosis are identified. The tumour cells are CK7, TTF-1, synaptophysin and CD56 positive. They are GFAP, CD3 and CD20 negative. The features are those of metastatic small cell carcinoma, consistent with lung primary.

DIAGNOSIS: Metastatic small cell carcinoma, consistent with lung primary.

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Case information

rID: 14502
Case created: 1st Aug 2011
Last edited: 10th Nov 2015
Inclusion in quiz mode: Included

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