Presentation
Increasing headaches and left sided weakness.
Patient Data
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Large enhancing right frontal mass contains a rounded relatively T2 hypointense component with peripheral susceptibility artefact in keeping with intralesional hemorrhage. Small areas of diffusion restriction and ADC reduction within the lesion are compatible
hypercellularity. The enhancing mass extends to the cortical margin abutting juror although without convincing nodular dural enhancement. Marked surrounding vasogenic edema throughout the right frontal lobe extends posteriorly into the right parietal white matter and inferiorly along internal, external and extreme capsules.
The lesion causes 12 mm of subfalcine herniation to the left with distortion of the mid brain, effacement of the suprasellar cistern and mild uncal herniation but no tonsillar herniation. Mild enlargement of the left temporal horn and signal change surrounding the left lateral ventricle suggests hydrocephalus with mild transependymal edema.
Sulcal FLAIR hyperintensity at the vertex and right parieto-occipital region does not correlate with precontrast T1 hyperintensity or susceptibility artefact to suggest blood product, and there is no convincing sulcal enhancement to suggest leptomeningeal disease.
Vividly T1 and T2 hyperintense structure which wraps around the splenium of the corpus callosum with a thin tail extending anteriorly along the upper surface of corpus callosum. The rostrum is normally formed.
Widening the windows demonstrates the fatty pericallosal mass, confirming the diagnosis.
Left lung upper zone mass measuring 34 x 33 mm present. No pleural effusion. Heart size is normal. No evidence of lymphadenopathy.
4.4 by 2.8 cm left upper lobe posterior segment mass which abuts major fissure and extends inferomedially to abut the main and left upper lobe pulmonary arteries.
A prominent left lower paratracheal lymph node measures 10 mm in short axis diameter; no other lymphadenopathy. No other focal pulmonary parenchymal or pleural abnormality
A craniotomy was performed.
Histology
Paraffin sections show a densely hypercellular tumor. This consists of markedly pleomorphic cells with large round and oval vesicular nuclei many with conspicuous nucleoli and a large amount of pale and foamy cytoplasm. These are arranged in diffuse sheets and regionally in lobules delimited by capillaries. Frequent mitotic figures are identified and there are several foci of tumor necrosis. Immunohistochemistry shows strong nuclear staining in the majority of tumor cells for TTF-1 as well as moderate cytoplasmic staining for cytokeratin CK7. There is patchy weaker cytoplasmic staining for cytokeratin CK5&6. No staining for carcinoembryonic antigen (CEA), tyrosinase, estrogen receptor (ER) or cytokeratins CK20 or BerEp4 is seen in tumor cells. The features are of metastatic undifferentiated large cell carcinoma arising from lung.
Case Discussion
This case has a number of findings and highlights the need to window CT brains widely and to obtain chest x-rays as a pre-operative investigation (although resecting this symptomatic cranial metastasis was still performed)
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