Cerebral metastasis of non-small cell lung cancer

Case contribution: Dr Radhiana Hassan

Clinical:

  • A 47 years old man with underlying lung carcinoma
  • Non-operable non-small cell ca Stage III on immunotherapy
  • Presented with headache since past one month
  • No fever, no history of trauma
  • No vomiting, no blurred vision
MRI brain in axial plane T1 weighted images post contrast
MRI of brain in axial plane; (A) T1WI, (B) T2WI, (C) FLAIR, (D) T1+Gado, (E) Hemo and (F) DWI.
MRI of brain in axial plane; (A) T1WI, (B) T2WI, (C) FLAIR, (D) T1+Gado, (E) Hemo and (F) DWI.

MRI findings:

  • There are multiple lesions within the brain parenchyma
  • Some the lesions are hypo on T1, hyper on T1 with homogenous enhancement post contrast (white arrows)
  • Some of the lesions are hypo on T1, hyper on T2 and not enhanced post contrast.
  • A lesion at left temporal region (yellow arrow) shows blooming artifact on hemo sequence suggestive of hemorrhagic component
  • Another lesion at left frontal lobe shows restricted diffusion of its wall (red arrow) and no obvious enhancement on post contrast image.

Diagnosis: Cerebral metastasis from lung cancer (presumed diagnosis, no biopsy done)

Discussion:

  • Brain is one of the common sites of distant metastasis as well as initial recurrence in patients with lung cancer with an incidence of 20% at diagnosis and up to more than 50% at autopsy.
  • Non-small cell lung cancer does not have a set of clinical pattern of┬ámetastasis and it may exist in neurologically asymptomatic patients.
  • No single feature is pathognomonic. Due to great variation in imaging appearance, diagnosis may be a diagnostic challenge.
  • 80% of metastasis localize to cerebral hemisphere, 15% localized to cerebellum and 3% localized to the basal ganglia.
  • Although multiplicity favours metastasis, about 50% of metastasis are solitary at diagnosis. Grey white matter junction and watershed areas are common location of cerebral metastasis.
  • In this case the lesions show mixed feature, some are solid enhancing nodules, a hemorrhagic lesion and another lesion shows restricted diffusion at wall of lesion.
  • Metastasis that haemorrhage include melanoma, renal cell carcinoma, choriocarcinoma, thyroid cancer, lung and breast cancers.
Author: radhianahassan