Brain Miliary Dissemination Pattern by Lung Adenocarcinoma: Case Report

Transcription

1 Brin Miliry Dissemintion Pttern y Lung Adenocrcinom: Cse Report Ptrón de diseminción milir cererl por denocrcinom pulmonr: Presentción de cso Cmilo Andrés Lr Rodríguez 1 Ntli Rued-Ruiz 2 Key words (MeSH) Brin neoplsms Lung neoplsm Adenocrcinom Mgnetic resonnce imging Tuerculosis, miliry Summry The cse of mle ptient of 56 yers who consulted for long-stnding respirtory symptoms initilly focused s pulmonry sttionry tuerculosis, with sttionry evolution nd neurologicl deteriortion nd histopthologic dignosis of lung denocrcinom s well s scnogrphic findings comptile with rin metsttic lesions in miliry pttern. In ddition to the clinicl nd imging cse, review of the literture is done with mgnetic resonnce imging findings for differentil dignosis of miliry rin tuerculosis given the similrities in the imging findings. Plrs clve (DeCS) Neoplsis encefálics Neoplsis pulmonres Adenocrcinom Imgen por resonnci mgnétic Resumen Se trt de un pciente de 56 ños de edd quien consultó por síntoms respirtorios de lrg evolución inicilmente enfocdos como tuerculosis pulmonr, con evolución estcionri, deterioro neurológico y dignóstico histoptológico de denocrcinom pulmonr, sí como hllzgos rdiológicos comptiles con lesiones metstásics cererles en ptrón milir. Además de l descripción clínic e imginológic del cso se efectú un revisión de l litertur con los hllzgos por resonnci mgnétic, pr relizr el dignóstico diferencil con tuerculosis milir cererl en rzón de ls semejnzs imginológics. Tuerculosis milir 1 Doctor, Rdiology specilist, Universidd del Rosrio. Hospitl Universitrio de Bucrmng Los Comuneros. Bucrmng, Colomi. 2 Rdiology nd dignostic imging resident. Hospitl Universitrio Snt Fe de Bogot. Bogot, Colomi. Introduction Metsttic cererl dissemintion occurs in 25-35% of cncer ptients. Primry tumors with centrl nervous system (CNS) dissemintion include the lung, rest, skin (melnom), kidney, nd gstrointestinl trct, the ltter two of which develop rin metstses more frequently (40% nd 28% respectively ) (1). The est dignostic study for rin metstses is mgnetic resonnce imging (MRI) where they re seen s sphericl lesions, with perilesionl edem loclized t sucorticl corticl junction. Miliry pttern rin metstses re, in most cses, secondry to primry lung neoplsm with susequent impirment of neurologic sttus ssocited with dementi, disorienttion, nd rrely com progression, nd, unlike non-miliry metstses, my not enhnce with the contrst medium (2). Clinicl cse A 56-yer-old mle ptient from n urn re with history of smoking 20 pcks / yer) suspended in the lst 2 yers, with no other history of importnce, with clinicl history of 3 months of evolution consisting of occsionl dry cough ssocited with nocturnl diphoresis, stheni, dynmi nd weight loss. In the lst 15 dys prior to the visit he developed progressive dyspne until rest nd persistent wet cough, in ddition the reltives indicte episodes spordic ltertions in the stte of consciousness with spontneous recovery, without other ssocited symptoms. At dmission to the emergency deprtment, pulmonry usculttion is reduced vesiculr murmur without other findings relevnt to physicl exmintion, norml serum lortories for ge, chest X-ry entry (Figure 1) on the sis of which is suspected of infectious process type pulmonry tuerculosis miliry vs. pulmonry mycosis. Extension studies included 6 negtive smer Rev. Colom. Rdiol. 2017; 28(3):

2 microscopes for cid-fst cilli, serology, nd HIV-negtive ELISA. Trnsthorcic echocrdiogrphy records severe circumferentil pericrdil effusion with systolic collpse of the right cvities. Pericrdiocentesis ws performed with dringe of 700 cm3 of lood fluid. He hd ilterl pleurl effusion. Cultures nd cytologies of the pericrdil nd pleurl fluid were negtive; norml fieroptic ronchoscopy ws with negtive ronchiololveolr lvge cultures. Bronchil mucos iopsy showed typicl ronchil lesion; it ws suspected grnulomtous infectious process (pulmonry pericrdil tuerculosis), neoplstic process ws not ruled out. The clinicl evolution ws sttionry. Thorcic computed tomogrphy (CT) ws performed (Figure 2) with which it ws decided to perform dignostic pulmonry thorcoscopic loectomy nd representtive smples for histopthologicl study (Figure 3). Susequently, the ptient presented deteriortion of the neurologicl stte, considered s process not ssocited with delirium, for which rin mgnetic resonnce (MRI) study ws performed (Figures 4 nd 5). The results of the lung iopsy were: modertely differentited denocrcinom, with res of comedocrcinom with vsculr invsion, lymphtic nd viscerl pleur, negtive for grnulomtous disese. The ptient progresses moridly with deteriortion of the neurologicl nd respirtory stte nd dies. out 1.9 million people re infected ech yer with Mycocterium tuerculosis nd pproximtely 1% of cses develop dissemintion to the CNS, with worse prognosis thn in other dissemintion sites (5). Cererl tuerculosis typiclly presents with hedche, low-grde fever nd neurologicl trgeting; some ptients my experience epileptic seizures nd meningel syndromes, nd even in ptients with initil respirtory symptoms nd exposure to the cillus, this entity should e included nd studied within differentil dignoses (5). Discusion Tuerculosis continues to e one of the most importnt pthologies. It is the second leding cuse of deth in the world due to infectious disese fter the humn immunodeficiency virus nd predomintes in immunocompromised ptients. It hs high risk of mortlity nd neurologicl sequele. According to WHO glol reports on tuerculosis , 8.6 million new cses were reported in 2012 (3), with decline in incidence rtes y 2015 of 1.5% per yer (4); in generl, c Figure 1. Portle chest X-ry, nteroposterior projection with multiple micronodulr opcities nd right prhilir locliztion mss tht erses the right contour of the medistinum. Figure 2. Chest CT in the pulmonry window: ) xil cuts, ) coronl nd c) sgittl reconstructions: mss of right prhilr loction nd spiculted contours ssocited with multiple micronodulr opcities nd miliry distriution in oth lung prenchym. In the xil section, in ddition, right pneumothorx chmer is identified Brin Miliry Dissemintion Pttern y Lung Adenocrcinom: Cse Report. Lr C., Rued N.

3 c Figure 3. nd ). Imges tken during the loectomy in pulmonry wedge y videothorcoscopy. At the level of the minor fissure: elow the middle loe of the nodulr surfce, ove the upper loe with rod scrring region nd diffuse nthrcosis. c) Surgicl prt in wedge of the right lower loe, nodulr lung prenchym nd res of congestion. c Figure 4. MRI sequence with T1 informtion with contrst medium: nd ) xil sections nd c) coronl reconstruction, showing smll foci of sucorticl nodulr enhncement supr nd infrtentoril, without white mtter edem or meningel enhncement. Figure 5. MRI sequences with T2 informtion: ) xil plne nd ) coronl: High sucorticl signl of micronodulr ppernce corresponding to the res of enhncement in sequences with T1 informtion is identified. Meningel tuerculosis is the most common form, ut it lso presents s diffuse cererl tuerculosis, such s exudtive sl meningitis or loclized forms, such s tuerculoms, scesses, or cereritis. In children it is usully infrtentoril, wheres in dults predomintes the suprtentoril loction. CT nd MRI findings differ ccording to presenttion in the CNS, compromise of meninges, ssocited cererl infrcts or tuerculoms my e Rev. Colom. Rdiol. 2017; 28(3): found. In generl, rin MRI is superior to CT to define lesions in sl gngli, rin stem or to ssess spinl cord involvement (6). CT scn of the skull with contrst medium should e performed initilly in the evlution of ll ptients with suspected tuerculosis in the CNS, with sensitivity of 99% nd specificity of 85.7% for cererl tuerculom, reported up to 10-30% of the cses (6, 7). 4749

4 Miliry tuerculosis is rre extrpulmonry disese, more frequent in immunosuppressed ptients, nd is usully the result of hemtogenous dissemintion of lung infection nd in the mjority of cses due to Mycocterium tuerculosis infection (8). There re few descriptions of cses of cererl miliry tuerculosis with cererl CT studies within limits of normlity, ut with MRI findings of diffuse nodulr lesions nd predominnce in the posterior foss, suggesting smll tuerculoms. These tuerculoms generlly mesure less thn 2 millimeters in dimeter, re usully not identified in sequences with simple T1 informtion, so tht only smll high signl foci re oserved in sequences with T2 informtion tht present punctte enhncement with prmgnetic contrst in sequences with informtion T1 with contrst medium (9). Cererl metstsis More thn 50% of rin tumors correspond to metstses. This is one of the most serious complictions of cncer due to its incpcitting neurologicl symptoms; in the United Sttes the reltionship etween rin metstses nd primry rin neoplsm is 10: 1 nd the proility of developing rin metstses from primry is 48% for melnom, 32% for lung, 21% rest, 11% renl cell tumor nd 6% gstrointestinl. In the first two cses re usully multiple lesions nd in the others, single lesions; differentil dignoses include primry rin tumors, scesses, neurosrcoidosis, CNS ngiitis nd demyelintion, without overlooking opportunistic infections of the CNS (1, 2). The incidence of this type of metstsis hs een incresing given the mjor erly extension studies in which MRI is included. Locliztion frequencies re descried in the cererl hemispheres in out 80% of the cses, 15% in the cereellum nd 5% in the cererl stem nd sl gngli (1,10); solitry metsttic lesions re present in 50% of the cses nd, to lesser extent, s multiple lesions, up to 30% re found with three or more metsttic nodules (11). Cererl metstses in the cererl CT re seen s lesions of medium or low signl, locted in the cortico-sucorticl union, with perilesionl edem in vrile degree, ssocited in some cses with intrcrnil (spontneous) hemorrhge; in studies with contrst medium there is intense, nodulr enhncement, which cn est e oserved in lrger lesions nd studies with lte phses t 5 nd 10 minutes; however, smll or loclized lesions in the rin stem or posterior foss my not e clerly seen (11). MRI findings with contrst medi re more specific nd sensitive, oth for dignosis nd for evlution of response to tretment, nd include: lesions with ring enhncement surrounded y vsogenic edem of preference in corticl-sucorticl junction, which in T1-enhnced sequences re medium or low signl (melnoms re oserved with high signl); in FLAIR sequences, moderte-high lesions with hlo with striking high signl, nd diffusion sequences usully without evidence of restriction re oserved. Some imging findings my suggest tht the lesions do not hve metsttic origin, for exmple, enhncement in demyelinting pthology is usully presented s C rther thn complete ring, even in cses of tumor recurrence. postrdition cererl necrosis my e indistinguishle in CT nd MRI, in which cse complementry studies re suggested y metolic techniques, such s positron emission tomogrphy (PET). In this cse, in the first cse, there is n increse in the cellulr enhncement of glucose nd in the second, hypometolic imges (2). Crcinomtous encephlitis Cererl metstses with miliry pttern re rre presenttion of rin metstses nd re chrcterized y perivsculr nodules of diffuse miliry distriution, lso descried s crcinomtous encephlitis, first reported in 1951 (12). They re shown s multiple lesions, smll nd of high intensity in the cererl cortex nd in the sl gngli tht enhnce with the contrst medium (Gd-DPTA). Perivsculr miliry metstses (crcinomtous encephlitis) my not enhnce nd e confused with inflmmtory or infectious processes, such s vsculitis or tuerculosis, within differentil dignoses (2). The literture descries cses of ptients with clinicl symptoms tht initilly show respirtory symptoms with dignosis of pulmonry neoplsi nd susequent deteriortion of the neurologicl stte (comptile with rin metstses) with clinicl nd imging improvement fter oncologicl tretment (3). Conclusions Cererl miliry lesions detected nd chrcterized y MRI re n infrequent, very chrcteristic, ut not pthognomonic, finding of n infectious disese cused y Mycocterium tuerculosis, common in our country. However, we must not forget the metsttic crcinom of the lung primry encephlitis, which is indistinguishle from n imginry point of view. We recommend to lwys consider the dt of clinicl history tht cn orient towrds one pthology or nother, eing very importnt the interction etween the different groups of specilists nd the multidisciplinry mngement. CT, even with multidetector equipment, is very low sensitivity study for the detection of cererl compromise in this pthology; however, we recommend its use for the complementry evlution of the thorx, which is of vitl importnce in the differentil dignosis. Finlly, it is essentil to use the contrst medium during the MRI study, since it is the contrsted phse tht est delimits nd chrcterizes the miliry lesions. Acknowledgements The uthors thnk Dr. Crlos E. Grvito, chest surgeon, for providing the corresponding imges to the intropertive pulmonry smple. References 1. Nvs-Vluen C, Alvis-Mirnd H, Moscote-Slzr LR. Metástsis cererles: Fisioptologí, dignóstico y trtmiento. Neuroci Colom. 2013;20(4): Lssmn AB, Dengelis LM. Brin metstses. Neurol Clin N Am. 2003;(21): Whoint. Informe mundil sore l tuerculosis [internet] [citdo: 2016 jun. 1]. Disponile en: WHO_HTM_TB_ _sp.pdf. 4. Whoint 1. Informe mundil sore l tuerculosis [internet] [citdo: 2016 jun. 1]. Disponile en: gtr2015_execsummry_es.pdf?u= Brin Miliry Dissemintion Pttern y Lung Adenocrcinom: Cse Report. Lr C., Rued N.

5 5. Alghtni HA, Aldrmhi AA, Alghtni YA, Al-Ri MW, Smkri AM. Tumour-like presenttion of centrl nervous system tuerculosis: A retrospective study in Kingdom of Sudi Ari. J Tih Univ Med Sci. 2014;9(2): Leonrd J. Centrl Nervous System Tuerculosis [internet] [citdo 2016 r. 15]. Disponile en: 7. Bernrdo J. Clinicl mnisfesttions, dignosis nd tretment of extrpulmonry nd miliry tuerculosis [internet] [citdo: 2016 jun. 15]. Disponile en: 8. Fontn-Cmpos M, Alrcón-Frutos S, González-Trrio Polo L, López-Guchr Rmírez P. Tuerculosis en pciente inmunocompetente. A propósito de un cso. Semergen-Medicin de fmili. 2008;l34(10). 9. Gupt RK, Kumr S. Centrl nervous system tuerculosis. Neuroimg Clin N Am. 2011; 21(4): Löffler J. Overview of the clinicl mnifesttions, dignosis, nd mngement of ptients with rin metstses [internet] [citdo 2016 r. 15]. Disponile en: htm?30/31/31216?source=see_link. 11. Osorn AG, Slzmn KL, Jhveri MD, Brkovich AJ. Dignostic imging rin. Cndá: AMIRSYS; Mochizuki S, Nishimur N, Inoue A, Murkmi K, Nukiw T, Chohnyshi N. Miliry rin metstses in 2 cses with dvnced non-smll cell lung cncer hroring EGFR muttion during gefitini tretment. Respir Investig. 2012;3(50): Correspondence Cmilo Andrés Lr Rodríguez Clle 36 # 22A-108, cs 42, Conjunto Vlterr Floridlnc-Sntnder, Colomi cmilolr74@gmil.com Received for evlution: June 20, 2016 Accepted for puliction: Ferury 21,2017 Rev. Colom. Rdiol. 2017; 28(3):