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Cerebral metastasis - cholangiocarcinoma

Case contributed by Frank Gaillard
Diagnosis certain

Presentation

Headache.

Patient Data

Age: 60 years
Gender: Male

Hyperdense right temporal lobe mass is centrally hypodense and has avid peripheral post-contrast enhancement. There is pronounced vasogenic edema and midline shift. No hydrocephalus. There is normal venous sinus enhancement. No leptomeningeal enhancement. The bones appear normal

Conclusion:

Large right middle cranial fossa mass favors a malignancy, most likely a large solitary metastasis or a glioblastoma. 

Right temporal lobe lesion with midline shift. It contacts the superior surface of the tentorium and has a thick enhancing rind with corresponding diffusion restriction of the solid component, and thin peripheral and internal speckled susceptibility. This lesion is displacing the ventricular choroid superiorly. Extensive surrounding vasogenic edema that extends into the right occipital lobe, parietal lobe, insula and corona radiata. 

Conclusion:

Findings are most suspicious for a hemorrhagic cerebral metastasis.

Case Discussion

This patient had a known history of cholangiocarcinoma with partial hepatectomy. They went on to have a resection. 

Histology

Sections show a tumor composed of sheets of epithelioid to spindled cells with pale to vacuolated cytoplasm, markedly atypical nuclei, vesicular chromatin and prominent nucleoli. There are abundant geographic areas of necrosis and innumerable mitoses. A small amount of brain tissue is seen which is infiltrated by tumor.

By immunohistochemistry, tumor cells are positive for Cam 5.2, AE1/3 and CK 7 with minimal staining of SATB2, while negative for CK20, CDX2, TTF-1, GATA3, PAX8, NKX 3.1, SSTR 2, PR, STAT6, CD34, ERG and SOX10.

FINAL DIAGNOSIS: cerebral metastasis; poorly differentiated carcinoma.

The tumor morphology and immunophenotype is non-specific, however, would be compatible with the known history of cholangiocarcinoma.

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