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Neuroradiology Case of the Week

Case 202

Devang Butani, MD

Clinical Presentation: Patient is a 62-year-old with breast cancer and known intra-axial metastatic disease presenting with nausea and vomiting.

Radiological Findings: Multiple predominantly erosive lesions with sclerotic components are seen in the bony calvarium and skull base. There are no associated intra or extra-axial abnormalities on the shown images. There is no overlying soft tissue laceration or swelling. There is no dystrophic calcification or ossification. The brain parenchyma is otherwise unremarkable.

Diagnosis: Skull metastatic disease

Discussion: Primary diagnostic concern is bony metastatic disease. Less likely differential diagnoses include chronic osteomyelitis (however, no other associated signs), status post bone grafting (however, no evidence of surgery), osteomalacia, or primary bone lymphoma. Given patient’s known history of breast cancer, this is metastatic disease.
     Case reports and other literature describes skull base and calvarial lesions in association with virtually cancers of almost every origin. Adjacent bony metastatic disease from intra-axial malignancy is also known to occur. In patients with a known primary carcinoma, the development of clinical bone pain is considered to be highly suggestive of bone metastases. Occasionally, patients with bone metastases may present with a pathologic fracture.
      A bone scan is the most cost-effective whole-body screening test for the assessment of bone metastases. Combined analysis and reporting of findings on radiographs and 99mTc bone scintiscans improve the diagnostic accuracy in detecting bone metastases and assessing the response to therapy.
      CT and MRI are useful in evaluating suspicious bone scan findings that appear equivocal on radiographs. MRI can also help in detecting metastatic lesions before bone metabolism make the lesions detectable on bone scans. CT is useful in guiding needle biopsy if needed. MRI is helpful in determining the extent of local disease in planning surgery or radiation therapy.

References:

1. Grossman RI, Yousem DM. Neuroradiology. The Requisites. Mosby, 1994.
2. Osborn AG. Diagnostic Neuroradiology. CV Mosby, 1994.
3. Osborn AG, et al. Diagnostic Imaging: Brain. Amirsys 2004.
4. www.learningradiology.com - Case of the Week 166- Neuroradiology: Leptomeningeal Cyst