Cystic brain metastasis

Case contributed by Dr Ammar Ashraf

Presentation

Headache & vertigo for one week and vomiting for one day. Past history of ductal carcinoma left breast.

Patient Data

Age: 45 years
Gender: Female
CT

FINDINGS: There is a well-defined (~4 x 5 cm) cystic mass in left temporal lobe extending into adjacent deep parietal lobe along the sylvian fissure and associated with surrounding vasogenic edema, mass effect over the adjacent brain parenchyma, ipsilateral lateral ventricle, uncal herniation and subfalcine herniation of 9 mm. Pressure over third ventricle with entrapment & dilatation of the contralateral lateral ventricle is also noted. No other discrete concomitant lesion is noted in other cerebral hemisphere or below the tentorium. CONCLUSION: Well-defined cystic lesion in left temporo-parietal lobes associated with mass effect over the adjacent brain, raising the suspicion of metastasis.

MRI

FINDINGS: There is re-demonstration of a large cystic space-occupying lesion (~ 4 x 5 cm) in the left temporal lobe. Mass effect over the adjacent brain, as described in the CT brain. It is of high signal intensity on T2 and low signal intensity on T1 weighted images. Mild peripheral enhancement is seen on the post-contrast study. An enhancing peripheral solid component is also seen at the posterolateral aspect of the lesion. No other focal brain lesion is seen. IMPRESSION: Large left temporal lobe space-occupying lesion (mainly cystic, with a small peripheral solid component) associated with mass effect over the adjacent brain; regarding the history of CA breast, possibility of cystic metastases should be considered. Another less likely possible differential can be a primary malignant glial tumor.

MRI

MRI brain one week after biopsy

Status post left parietal craniotomy with removal of left temporal space-occupying lesion, leaving behind a small residual component.  Mild reduction is seen in the midline shift; however, no significant change is seen in the degree of perilesional edema when compared with the previous MRI. 

MRI

MRI brain three weeks after biopsy

There is interval re-growth of a peripherally enhancing lobulated cystic lesion, in the left temporal lobe, associated with an interval increase in the mass effect on the surrounding brain and contralateral midline shift,  Increased meningeal enhancement is seen in left parietal and temporal lobes. A large extra-calvarial subgaleal collection with an air-fluid level is seen in the left parietal region. Overall imaging features are suggestive of progressive disease. 

Case Discussion

Histopathology of the cerebral lesion showed metastatic carcinoma consistent with primary high-grade ductal carcinoma breast. Extensive necrosis was seen in the tumor. The tumor was negative for estrogen receptors (ER-negative), and progesterone receptors (PR-negative) but strongly positive for HER-2 neu with a score of 3.

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Case information

rID: 78902
Published: 17th Jun 2020
Last edited: 18th Jun 2020
Inclusion in quiz mode: Included
Institution: King Abdulaziz Hospital Al Ahsa (MNGHA)

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