Presentation
Seizure.
Patient Data
mmm
Confluent left frontoparietal white matter FLAIR signal abnormality with mass effect and multifocal enhancement within. The high T2 signal change spares the cortex with no evidence of non-enhancing tumor. The largest enhancing lesion measures, demonstrates central non-enhancing cystic components and extends to the corticomedullary junction. No intrinsic T1 hyperintensity. At least five further small foci of nodular enhancement are present through the area of signal abnormality.
Conclusion
The differential is between a multifocal glioblastoma and a cluster of cerebral metastases. If non-enhancing tumor were present, the diagnosis of a glioma could be made with confidence. Its absence, however, is not as helpful.
Case Discussion
The patient went on to have a resection.
Histology
MICROSCOPIC DESCRIPTION:
Sections of brain show a circumscribed deposit of metastatic carcinoma. The biphasic tumor is composed of solid nests of large basaloid cells and focal areas of squamous differentiation. Central tumor necrosis is present. Basaloid tumor cells demonstrate enlarged, oval nuclei with coarsely granular chromatin and small inconspicuous nucleoli. Frequent mitoses and apoptoses are present. Squamoid tumor cells contain abundant densely eosinophilic cytoplasm and prominent intercellualr bridges. No definite keratin or gland formation is seen.
Immunohistochemical results show tumor cells stain:
Squamous component: CKAE1/3: positive, CAM5.2: positive, CK7: positive, CK20: positive, p63: positive, p40: positive, CK17: positive, CK5/6: positive, CK14: negative.
Neuroendocrine component: CD56: positive, Chromogranin: negative, Synaptophysin: negative.
Both components: TTF1: positive (focal), NapsinA: negative, S100: negative, MelanA: negative, SOX10: negative, p16: positive, EBER-ISH: negative.
FINAL DIAGNOSIS: Metastatic poorly differentiated carcinoma with mixed squamous and large cell neuroendocrine differentiation.
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