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Case 344

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Female patient, 48 years old, with progressive intermittent holocranial headache, bradipsiquism, spatial disorientation, slow walking, nausea and vomiting. Past medical history: Primary cancer of the right breast (T2N1, HER2+) diagnosed at the age of 42 and treated with mastectomy and adjuvant chemotherapy. Progression with recurrence in the left breast, lymph nodes and lung metastases, and liver nodules after two years of the underlying disease diagnosis. Requested magnetic resonance imaging (MRI) of the brain.

After data analysis, the medical team raised the hypothesis of breast cancer brain metastases, opting for resection of one of the lesions. What complication presented in the images explains the conduct?

a) Encephalitis

25%

b) Enlargement of the ventricular system

25%

c) Subarachnoid hemorrhage

25%

d) Midline shift

25%
   

Image analysis

 

Image 01: Magnetic resonance imaging (MRI) of the brain, T1-weighted, sagittal view at the level of the interhemispheric fissure, without contrast. Increased cerebellar dimensions due to presence of expansive injury (yellow star). Compression of the fourth ventricle, cerebral aqueduct (of Sylvius) and brainstem (blue arrows), and tonsillar herniation (red arrow).

Image 02: MRI of the brain, T1-weighted, with contrast. From the left to the right, axial reconstructions at the level of the bridge, the lateral ventricles and cranially to the lateral ventricles, respectively. Multiple intra-axial expansive injuries, distributed in the cerebral and cerebellar hemispheres, enhanced with contrast associated to enlargement of the supratentorial ventricular system (blue star).

Image 03: MRI of the brain, T2-weighted, without contrast. From the left to the right, axial reconstructions at the level of the bridge, the lateral ventricles (two central images) and cranially to the lateral ventricles, respectively. Multiple expansive injuries, characterized by heterogeneous signal tending to hypersignal (yellow arrows), distributed in the cerebral and cerebellar hemispheres. Enlargement of the ventricular system (blue star) and hypersignal of the periventricular white matter, probably related to the cerebrospinal fluid permeation (red arrow).

Highlights

- Metastases represent 14% to 22% of the intracranial tumor injury in adults;

- The tumors that most commonly metastasize to the brain are: bronchopulmonary and breast carcinomas, melanoma and kidney and colon carcinomas;

- MRI with contrast is considered the first line exam to evaluate the cerebral metastases;

- In the MRI, metastases are typically presented as multiple peripheral, spherical and gadolinium ring enhanced injuries;

- In general, cerebral metastases treatment consists in supportive care and radiotherapy, though surgical resection can be therapeutic and palliative;

- Obstructive hydrocephalus can indicate surgical resection of brain metastases injuries;

- Patients with cerebral metastases have a reserved prognosis, with short life-expectancy;

References

- Instituto Nacional de Câncer José Alencar Gomes da Silva [internet]. Tipos de câncer: Mama [access in July, 2018]. Available in: www2.inca.gov.br/wps/wcm/connect/tiposdecancer/site/home+/mama/cancer_mama.

- Filho GB. Bogliolo: Patologia. 9th Ed. Rio de Janeiro: Guanabara Koogan, 2016.

- DynaMed [internet]. Brain metastases [updated in July, 2018, access in July, 2018]. Available in: http://search.ebscohost.com/login.aspx?direct=true&db=dnh&AN=920581&site=dynamed-live&scope=site.

- Darby MJ, Barron D, Hyland RE. Oxford Handbook of Medical Imaging. Oxford: Oxford University Press, 2012.

Author

Vinícius Rezende Avelar, 4th year medical student at Universidade Federal de Minas Gerais (UFMG).

E-mail: vireavelar[at]gmail.com

Supervisors

Doctor Marayra Inês França Coury, specialist in Internal Medicine and Geriatrics and coordinator of the specialization in Internal Medicine of the Socor Hospital by the Brazilian Society of Internal Medicine.

E-mail: marayra[at]ufmg.br

 

Doctor Carlos Magno, neurosurgeon and neuroradiologist at Hospital das Clínicas of UFMG.

E-mail: carlosbresil[at]hotmail.com

Reviewers

Guilherme Carvalho, Lucas Bruno, Professor José Nelson Mendes Vieira; Professor Viviane Santuari Parisotto Marino.

Translator

Gabriella Yuka Shiomatsu, 4th year medical student at UFMG.

E-mail: gabriellashiomatsu[at]gmail.com

Test question

(UNIVERSIDADE FEDERAL DO PARANÁ – 2009) In relation to brain metastases, it is correct to affirm that:

a) Surgery and radiotherapy present better results in cerebral metastases treatment than chemotherapy

25%

b) They are relatively malignant tumors and less common than the gliomas

25%

c) Computed tomography is a more sensitive exam than the magnetic resonance imaging for diagnosing small injuries

25%

d) The lung is the most common primary site, and the median survival of the patient with cerebral metastases is approximately 3 years

25%

e) Cerebral metastases must be only biopsied and treated with whole brain radiotherapy

25%
   

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