Presentation
Presents to ED with confusion and word finding difficulties. External CT - left MCA infarct with oedema.
Patient Data
Extensive vasogenic oedema with partial effacement of the left lateral ventricle but no midline shift or cerebral parenchymal herniation. Elsewhere, there is periventricular and deep white matter hypoattenuation, most in keeping with chronic small vessel ischaemia. No hydrocephalus. Grey-white differentiation is preserved. No hyperdense vessel.
In the left parieto-occipital region is a homogeneously and vividly enhancing mass. It has slightly lobulated contours and is isodense to gray matter on the non-contrast images. Extensive surrounding vasogenic oedema.
Left parietal intra-axial mass involving the cortex and adjacent white matter with isointense signal to the cortex on both T1 and T2, moderate diffusion restriction, and vivid contrast enhancement. No evidence of haemorrhage. Diffuse vasogenic oedema with mild effacement of the posterior aspect of the left lateral ventricle.
Multiple high T2/FLAIR signal foci scattered through the supratentorial white matter are nonspecific, most likely represents chronic small vessel ischaemia.
Histopathology:
MACROSCOPIC DESCRIPTION: "Parietal lobe tumour": The specimen consists of a pale tan haemorrhagic nodule 16x10x9mm. The cut surface is heterogeneous with yellow and cream colour. A1.
MICROSCOPIC DESCRIPTION: The sections show features of metastatic poorly differentiated adenocarcinoma. The tumour forms solid nests, some containing occasional glandular lumina. The tumour cells have enlarged pleomorphic nuclei, prominent nucleoli and moderate amounts of pale cytoplasm. No evidence of lymphovascular invasion is seen. The tumour cells are CK7, TTF-1 and Napsin-A positive, in keeping with lung primary.
DIAGNOSIS: Metastatic poorly differentiated adenocarcinoma, in keeping with lung primary.
Case Discussion
CT demonstrates a large lung mass, and lung cancer is one of the most common causes of cerebral metastases. Approximately 50% of cerebral metastasis present as a solitary mass, and this diagnosis should always be thought of in patients with cerebral masses, especially in older patients.
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