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

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
Inroduction S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH:

Severaldiseasescan present with multi-cystic brain lesions:

  • True cysts

  • Abscess formations

  • Cysticercosis

  • Fungal infections

  • Cerebral tumors

  • Metastases…


Radiologist S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAHrole?

1- Positive diagnosis

easy!

2- Approach of etiologicdiagnosis:

the main question!


Case report
Case report: S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

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


  • S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

  • 49 yearsold

  • No medical histories

  • Smoking patient

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


Neurological examination: S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

  • cerebellar syndrome

  • no other focal signs

    Biology:

  • Lymphocytes:  ↓

  • Alkaline phosphatase: ↑

  • Other laboratory studies: normal

    CT brain Scan was indicated


C S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAHT 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 S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAHand allowed to objectify:

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


a1 a2 a3 S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

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 S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

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 S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

b1 b2 b3

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

Multiples nodularlesionshyperintense in diffusion with a low ADC.


In total: S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)

    ????


In total: S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)

    ???


In total: S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)

    ??


In total: S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)

    ?


Lung cancer
Lung cancer? S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

In total:

  • 49 yearsold

  • No medical histories

  • Smoking patient

  • Lc ↓ , PAL ↑

  • multi-cystic brain lesions (CT – MRI)


  • a CT-chest-scan revealed a S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAHlungular small nodule not exceeding 12mm of main line with no other secondary locations

  • Stereotaxic brain biopsy confirmed a well-differentiated lung adenocarcinoma


Discussion
Discussion: S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH

  • 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: carcinomas of :

-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
Conclusion: carcinomas of :

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
References carcinomas of ::

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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