Ring enhancing cerebral metastasis

Case contributed by Assoc Prof Frank Gaillard

Presentation

History of scleroderma

Patient Data

Age: Adult

Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.

Ring-enhancing mass in the left posterior frontal lobe with a small amount of surrounding vasogenic edema. Some peripheral (but not central) diffusion restriction. 

Histopathology

Final Diagnosis: Left frontal brain tumor, resection: Metastatic carcinoma.

Microscopic Description:

Sections show brain parenchymal fragments heavily involved by metastatic tumor. The tumor cells form cohesive clusters and sheets of highly malignant cells with frequent mitoses and areas of necrosis. The tumor border is relatively well circumscribed. In the adjacent gliotic brain parenchyma, capillary-sized blood vessels appear markedly thickened with hyalinized walls and sometimes a perivascular lymphocytic infiltrate. Tumor cells are strongly immunoreactive for CK7. Immunohistochemistry for CK20, GCDFP, progesterone and estrogen receptors, CDX2 and TTF-1 are negative. This immunoprofile may still represent a primary from lungs and upper gastrointestinal tract.

Interestingly, the above mentioned thick capillaries are surrounded and infiltrated by many CD4+ cells and some CD8+ reactive T-cells. Also, HLA-DR expression is increased especially in microglia and endothelial cells. These changes are consistent with the patient's history of scleroderma.

Case Discussion

'Perfect' ring enhancing lesion which is not a cerebral abscess (lack of central diffusion restriction on DWI and relative paucity of edema). MAGIC DR is a useful mnemonic for this appearance. 

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