Brain metastases from renal cell carcinoma

Case contributed by Dr Mostafa El-Feky

Presentation

Known patient with neglected left renal malignancy who refused surgery six months ago currently presents with persistent headaches and attacks of convulsions.

Patient Data

Age: 60 years
Gender: Male
MRI

MRI brain

Multiple brain lesions are noted involving both cerebral hemispheres, notably the left frontal and right temporal lobes as well as the left cerebellar hemisphere. They show enhancing soft tissue and cystic components. The largest lesion is noted at the right temporal lobe. Mild peri-lesional edema is noted. No midline shift.

CT

CT abdomen (multiphase kidney protocol)

An exophytic renal soft tissue mass lesion is noted at the lower pole of the left kidney with stranding of the surrounding fat planes and abutting the left psoas muscle with no line of cleavage.

This is associated with smaller cortical lesions at the left kidney (about three) with the same enhancing pattern. Other rather cortical lesions are noted at the upper and middle zones of the right kidney (about four) with the same enhancing pattern suggestive of smaller lesions of the same nature.

A heterogeneously enhancing soft tissue lesion is noted at the right suprarenal gland measuring 2 x 1.3 cm with attenuation density more than 15 HU on the non-contrast study suspicious for right adrenal metastasis.

Case Discussion

Cerebral metastasis is common and is suspected in patients with primary malignancies with neurological manifestations. Renal cell carcinoma is one of the commonest primaries of brain metastasis.

Cerebral metastases are usually solid, however, it can show cystic changes as tumor-associated cysts or due to necrosis, also it can be predominately cystic with a marginal enhancing solid component as in this case. Brain metastasis can show hemorrhagic changes, especially at their cystic component. Other common primaries for brain metastasis include lung cancer, breast cancer, colorectal carcinoma and melanoma.

About half of brain metastasis are solitary, and history of primary malignancy aids in suggesting metastasis rather than the primary tumor, especially if associated with other sites of metastasis as solitary metastasis can entirely appear in MRI like a primary intra-cranial tumor and it needs different management.

MRI is more sensitive than CT in detecting brain metastasis, especially in contrast-enhanced T1 WI.

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Case information

rID: 42222
Published: 26th Feb 2016
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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