A rare case of multiple cystic metastases in the brain from adenocarcinoma of the lung
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A. HRICHI, S. KOUKI, M. LANDOULSI ,R. AOUINI,  I. GANZOUI, S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH Radiology service, Main Military hospital of Instruction of Tunis, Tunisia. A RARE CASE OF MULTIPLE CYSTIC METASTASES IN THE BRAIN FROM ADENOCARCINOMA OF THE LUNG . CH7. Inroduction :.

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A RARE CASE OF MULTIPLE CYSTIC METASTASES IN THE BRAIN FROM ADENOCARCINOMA OF THE LUNG

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A. HRICHI, S. KOUKI, M. LANDOULSI ,R. AOUINI,  I. GANZOUI, S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

Radiology service, Main Military hospital of Instruction of Tunis, Tunisia

A RARE CASE OF MULTIPLE CYSTIC METASTASES IN THE BRAIN FROM ADENOCARCINOMA OF THE LUNG

CH7


Inroduction:

Severaldiseasescan present with multi-cystic brain lesions:

  • True cysts

  • Abscess formations

  • Cysticercosis

  • Fungal infections

  • Cerebral tumors

  • Metastases…


Radiologistrole?

1- Positive diagnosis

easy!

2- Approach of etiologicdiagnosis:

the main question!


Case report:

A rare case of cystic intracerebral metastases from adenocarcinoma of the lung


  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Presented with progressive dizziness and equilibrium disorders that had developed for 5 days.


Neurological examination:

  • cerebellar syndrome

  • no other focal signs

    Biology:

  • Lymphocytes:  ↓

  • Alkaline phosphatase: ↑

  • Other laboratory studies: normal

    CT brain Scan was indicated


CT brain scan without(a) and with(b) injection of iodinated contrast: multifocal hypodense lesions(a) with partial peripheral contrast enhancement(b) but without significant perifocaloedema.

Imaging findings:

a1 b1

a2 b2


Further brain MRI was performed and allowed to objectify:

multifocal cystic lesions with partial peripheral contrast enhancement but without significant perifocaloedema.


a1 a2 a3

b1 b2 b3

Axial T1-weighted with (a1, a2, a3) and without gadolinium (b1, b2, b3):nodularhypointense multiple extra-axial lesions, with partial peripheral contrast enhancement.


a1 a2 a3

b1 b2 b3

Axial T2-weighted (a1, a2, a3) and FLAIR (b1, b2, b3): Multiple hyper-T2 hypo-FLAIR extra-axial lesions (cysticlesions).


a1 a2 a3

b1 b2 b3

axial diffusion (a1, a2, a3) and ADC (b1, b2, b3):

Multiples nodularlesionshyperintense in diffusion with a low ADC.


In total:

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)

    ????


In total:

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)

    ???


In total:

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)

    ??


In total:

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)

    ?


Lung cancer?

In total:

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)


  • a CT-chest-scan revealed a lungular small nodule not exceeding 12mm of main line with no other secondary locations

  • Stereotaxic brain biopsy confirmed a well-differentiated lung adenocarcinoma


Discussion:

  • Brain lesions in patients with known malignancies are suspicious for metastases;

    → usually: as well-circumscribed densely enhancing masses with surrounding vasogenic edema.

  • Cystic brain lesions are unusual;

    → can be misdiagnosed as: brain abscesses, primary cerebral tumors, or parasitic infections, especially in patients without a history of malignancy.


Cystic cerebral metastases have been described in carcinomas of :

  • Thymus

  • Breast

  • Prostate

  • Pancreas


However, and in reviewing the literature:

-We have only found 2 similar cases reports of lung adenocarcinoma with cystic cerebral metastases.

-In both of them, the patients were already followed for bronchial adenocarcinoma.

- while in our case, cystic cerebral metastases revealed the disease.


Conclusion:

This case demonstrates an unusual pattern of cerebral metastases of a bronchial adenocarcinoma. This constellation should be considered in the differential diagnosis of cerebral cystic lesions even in patients without a history of malignancy, and wich is necessary to evoke at every smoking adult's of about forty. The exact nature of which might be difficult to assess without biopsy.


References:

1-Monabati A, Kumar PV, Kamkarpour A. Intraoperativecystodiagnosis of metastatic brain tumors confused clinically with brain abscess (A report of three cases). ActaCytol. 2000;44:437–441

2-Nieder C, Grosu AL, Grzadziel A, et al. Brain metastases in renal cell cancer: diagnostic and therapeutic aspects. Am J Clin Oncol. 2004;27:632–634

3-White AC, Dakik H, Diaz P. Asymptomatic neurocysticercosis in a patient with AIDS and criptococcal meningitis. Am J Med. 1995;99:101–102

4-Cosgrove SE. Cases from the Osler Medical Service at Johns Hopkins University. Am J Med. 2002;113:158–160

5-Ersahin M, Kilic K, Gögüsgeren MA, et al. Multiple brainmetastasesfrommalignantthymoma. J Clin Neurosci. 2007;14:1116–1120

6-Tsai V, Kim S, Clatterbuck RE, et al. Cystic prostate metastases to the brain parenchyma: report of two cases and review of the literature. J Neurooncol. 2001;51:167–173

7-De Shields MS, Ruether J. Lung carcinoma presenting as multiple cystic lesions in the brain. Del Med J. 1998;70:77–80

8-A.Surov, M Hainz, M Kornhuber . Multiple cystic metastases in the brain from adenocarcinoma of the lung.The American Journal of Medicine. 2009;122:3-4


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