Presentation
Presents to ED with confusion and word finding difficulties. External CT - left MCA infarct with edema.
Patient Data
Extensive vasogenic edema 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 ischemia. 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 edema.
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 hemorrhage. Diffuse vasogenic edema 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 ischemia.
Histopathology:
MACROSCOPIC DESCRIPTION: "Parietal lobe tumor": The specimen consists of a pale tan hemorrhagic nodule 16x10x9mm. The cut surface is heterogeneous with yellow and cream color. A1.
MICROSCOPIC DESCRIPTION: The sections show features of metastatic poorly differentiated adenocarcinoma. The tumor forms solid nests, some containing occasional glandular lumina. The tumor cells have enlarged pleomorphic nuclei, prominent nucleoli and moderate amounts of pale cytoplasm. No evidence of lymphovascular invasion is seen. The tumor 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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