Sex: female
Age: 70 years
History
Surgery for breast cancer 24 years ago and lymphoedema right arm 10 years after surgery. No tumour recurrence since the surgical treatment.
Laboratory data
Normal.
Physical findings
Paresis and sensory disturbance right leg.
Case text
The patient presented with complaints of vertigo as well as sensory and motor disturbances in the right leg. She was referred to radiology for to exclude a cerebral mass lesion.
Image 1-5
CT Scan of the brain.
1 through 5- Axial, 5mm thick, contrast-enhanced (single and double contrast doses) sections.
Image 6-10
MRI of the brain.
6- Axial, T2- weighted (3103/120) image.
7 through 10- Axial, contrast-enhanced, T1- weighted (570/ 12) images.
Image 11-15
MRI of the brain.
11 through 14- Axial, contrast-enhanced, T1- weighted (570/ 12) images.
15- Coronal, contrast-enhanced (triple dose), T1- weighted (547/ 12) image.
Image 1-5
1. What is the abnormality present on the post-contrast brain CT Scan ?
An inhomogeneously contrast-enhancing mass lesion with surrounding edema in the left fronto-parietal region.
2. Are other abnormalities present ?
No.
3. What is your diagnosis?
Single metastasis.
4. What is the differential diagnosis ?
Malignant glioma.
5. What is your next diagnostic step ?
MRI.
Image 6-10
6. What is the abnormality present on the MRI of the brain ?
A contrast enhancing mass lesion in the left fronto-panietal region with surrounding oedema. The lesion is slightly hypointense on T2.
7. Did MRI reveal ather abnormalities ?
No.
8. What is your diagnosis ?
Single metastasis.
9. What is the differential diagnosis ?
Malignant glioma.
10. What is the next step ?
MRI with triple dose contrast medium to pick up possible further metastases.
Image 11-15
11. Did triple dose contrast-enhanced MRI provide any further information ?
Yes. Another small cortical, contrast enhancing lesion is found in the left frontal
12. What is your diagnosis?
Multiple metastases.
13. Is this new information of any importance ?
Yes, because the treatment usually differs between patients with single versus multiple metastases
Final diagnosis
Metastasis from adenocarcinoma.
Differential diagnosis
None. However, the metastasis could either originate from the resected breast
cancer or from a new primary tumour of unknown origin.
Discussion
Metastases account for about one third of all brain tumours in adults. The most common sites of origin for hematogeneously spread metastases to the brain are the lung, breast and malignant melanoma. The majority of brain metastases occur at the junction between gray and white matter but involvement of deeper structures is also common. Metastases usually present as rounded solid or partially cystic mass lesions with extensive perifocal oedema. Most of them enhance to a moderate or marked degree in solid or ringlike patterns, following contrast agent administration.
Clinically it is of great importance to increase the diagnostic sensitivity of imaging in the evaluation of patients with brain metastases. Surgical resection of a single brain metastasis has been shown to increase the length of survival. Patients with one to four metastases are also accepted for stereotactic irradiation. The magnetization transfer (MT) technique has been shown to increase the number of lesions detected compared to a routine T1WI SE-sequence. However, in this case neither MT or delayed imaging showed more than one metastasis, while triple dose contrast medium revealed two lesions. Recently, the use of high dose contrast medium MRI has been shown to be more efficient than a standard dose in the detection of brain metastases and also gave a higher degree of certainty in the diagnosis. In a review, it was recommended to use high dose contrast medium MRI when the standard dose examination was negative, equivocal or showed only a solitary metastasis. A high dose contrast medium MRI was also indicated when radiosurgical treatment of a limited number of brain metastases was considered.