Clinical
Presentation: A 53-year-old male presented with a palpable defect in the posterior aspect of the head.
Imaging Findings: Head CT and MRI were performed which revealed a large lytic lesion with a soft-tissue component in the right parietal bone. There wasa no evidence of dural or parenchymal invasion or involvement. PET/CT demonstrated increased metabolic activity in the mid-esophagus. Multiple osseous metastases were also evident.
Figures 1A & B: Axial sections from head CT, in bone and soft tissue windows, show a destructive lytic lesion measuring up to 5.6 cm in length involving the right parietal bone. The brain parenchyma appears spared.
Figures 2A-C: Axial T1 with and without contrast administration and T2-weighted MR images reveal a large defect involving the right parietal bone with loss of the calvarium at this level. The heterogeneous tissue which replaces the calvarium demonstrates contrast enhancement.
c
Figure3: Coronal MIP from PET/CT demonstrates a thick-walled esophagus overall with SUV ranging up to 13.8. Also seen are multiple hypermetabolic metastatic lytic lesions destruction involving several bones, including the posterior right skull.
Diagnosis: Metastatic esophageal adenocarcinoma
Discussion: Esophageal adenocarcinoma comprises about half of all forms of esophageal cancers. Over 90% of esophageal adenocarcinomas arise from Barrett's esophagus. Early cancers measuring less than 3.5 cm and are best evaluated via double-contrast esophagraphy, endoscopic gastroduodenoscopy, and endoscopic ultrasonography. Classic imaging features include immobile, irregular narrowing by a flap or polypoid mass in the lower- to mid-third of the esophagus. CT and/or PET are mainly used for staging advanced cases and metastatic disease. PET is more sensitive for distant metastases than CT alone (69% versus 46%) [1].
Metastases are detected in 18% of patients with newly diagnosed esophageal adenocarcinoma [2]. The most common sites for metastasis include lymph nodes, liver, and lung. Bone metastases are found in 9% of patients, while brain metastases occur in 2% of cases [2]. Metastatic esophageal adenocarcinoma lesions involving the cranium are unusual [3, 4]. Involvement of the temporal bone may lead to facial nerve paralysis [4].
References:
Luketich JD, Friedman DM, Weigel TL, Meehan MA, Keenan RJ, Townsend DW, Meltzer CC. Evaluation of distant metastases in esophageal cancer: 100 consecutive positron emission tomography scans. Ann Thorac Surg. 1999 Oct;68(4):1133-6; discussion 1136-7. PMID: 10543468 [PubMed]
Quint LE, Hepburn LM, Francis IR, Whyte RI, Orringer MB. Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma. Cancer. 1995 Oct 1;76(7):1120-5. PMID: 8630886 [PubMed]
Tideman H, Arvier JF, Bosanquet AG, Wilson DF. Esophageal adenocarcinoma metastatic to the maxilla. Oral Surg Oral Med Oral Pathol. 1986 Nov;62(5):564-8. PMID: 3466129 [PubMed]
Weiss MD, Kattah JC, Jones R, Manz HJ. Isolated facial nerve palsy from metastasis to the temporal bone: report of two cases and a review of the literature. Am J Clin Oncol. 1997 Feb;20(1):19-23. PMID: 9020282. [PubMed]
