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Metastatic Adenocarcinoma in the Brain: Magnetic Resonance Imaging with Pathological Correlations to Mucin Content

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Metastatic Adenocarcinoma in the Brain: Magnetic Resonance Imaging with Pathological Correlations to Mucin Content ANTICANCER RESEARCH 28: 407-414 (2008) Metastatic Adenocarcinoma in the Brain: Magnetic Resonance Imaging with Pathological Correlations to Mucin Content SHINYA OSHIRO, HITOSHI TSUGU, FUMINARI KOMATSU, HIROSHI ABE, TADAHIRO OHMURA, SEISABUROU SAKAMOTO and TAKEO FUKUSHIMA Department of Neurosurgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan Abstract. Background: Hypointense signal appearance of may manifest as various signal intensities on routine metastatic adenocarcinoma on T2-weighted imaging (T2-WI) conventional MRI (2, 3). T2-weighted imaging (T2-WI) has been infrequently documented. The purpose of this report commonly shows a cerebral metastasis as a hyperintense was to evaluate the degree to which mucin content affects signal mass (4), representing a non-specific finding. The finding of manifestations on conventional MR imaging. Patients and hypointensity is unusual for metastases, but may be more Methods: This series of 24 cases with intracerebral metastatic specific for metastatic adenocarcinoma originating from the adenocarcinoma was assessed retrospectively, focusing on the gastrointestinal (GI) tract (2, 5). This hypointense association between hypointense appearance on T2-WI and appearance on T2-WI could be explained by the mucin intratumoral mucin content. Results: Among the 24 metastatic content found in specimens of metastatic adenocarcinoma adenocarcinomas, intratumoral mucin was histopathologically (3, 6). The purpose of this report was to clarify whether a confirmed in 8 lesions. Of these, 4 masses were demonstrated as characteristic signal appearance is identifiable according to hyperintense signal on T2-WI. The other 4 masses were depicted differences in primary cancer and to evaluate the degree to as isointensity. No cases were identified with hypointense signals which mucin content affects signal manifestations on in mucin-containing metastatic adenocarcinoma. Conversely, conventional MR imaging. only 2 metastatic tumors originating from the stomach exhibited hypointense signal lesions on T2-WI. No histological or Patients and Methods magnetic resonance imaging evidence of blood products or other forms of iron were identified as causes of the hypointense Patient selection. We reviewed the medical records of patients with appearance on T2-WI. Conclusion: This hypointense signal intracerebral metastatic adenocarcinoma who had undergone may simply reflect the relatively shorter T2 relaxation time of surgery at our Institution between January 2002 and December the primary tissue from which metastases arose. Intratumoral 2006. The patient population comprised 24 patients (17 men, 7 women) with a mean age of 56.5 years (range, 38-73 years). mucin itself may be considered to demonstrate the masses as Patients with the following conditions were excluded: previous hyper- or isointense signals in the brain. chemo- or radiotherapy, or biopsy for brain lesions before data acquisition. All study protocols were approved by the institutional Although metastatic brain tumors can usually be diagnosed review board and written informed consent was obtained for MR based on clinical information and imaging studies, some examination. metastatic lesions cannot easily be differentiated from high- grade glioma, malignant lymphoma or brain abscess on Conventional MRI. All MRI was performed using an Intera Achieva 1.5-T system (Philips Medical Systems, Amsterdam, The conventional magnetic resonance imaging (MRI) (1). The Netherlands). The conventional MRI study included precontrast histology of metastatic brain tumors may affect signal axial T1-WI (repetition time: TR, 600 ms; echo time: TE, 11 ms; intensities. In addition, intratumoral components such as field-of-view, 24x24 cm; matrix, 256 ◊ 224; number of excitation solid tumor, degeneration, hemorrhage or cystic formation pulses, 2; bandwidth, 12.5 kHz; slice thickness, 6 mm; interslice gap, 1 mm; total number of scan slices, 16) and T2-WI (TR, 3500 ms; TE, 85 ms; other parameters were identical to those used in T1-WI) and fluid-attenuated inversion recovery (FLAIR) sequences (TR, Correspondence to: Shinya Oshiro, MD, Department of 9000 ms; TE, 120 ms; time of inversion, 2200 ms; matrix, 256x192; Neurosurgery, Faculty of Medicine, Fukuoka University, 7-45-1 number of excitation pulses, 1; other parameters identical to those Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan. Tel: +81 92 801 used in T1-WI), and contrast-enhanced T1-WI (0.1 mmol/kg of 1011, Fax: +81 92 865 9901, e-mail: [email protected] contrast agent) and FLAIR sequences (double-dose contrast technique) (7). Tumor intensities were classified as hypo-, iso- or Key Words: Adenocarcinoma, metastatic brain tumor, MRI, mucin. hyperintense to white matter on conventional MRI, and the 0250-7005/2008 $2.00+.40 407 ANTICANCER RESEARCH 28: 407-414 (2008) Table I. Summary of 24 cases with metastatic adenocarcinoma. Case Age/Gender Primary site Lesions Cyst T1-WI T2-WI FLAIR Gd pattern Mucin 1 46/M stomach single – hypo hyper hypo heterogeneous + 2 66/M stomach multiple – iso hypo hypo heterogeneous – 3 71/M stomach multiple – iso hypo hypo homogeneous – 4 53/M stomach multiple + hypo iso iso nodule – 5 47/M duodenum single – hypo hyper iso heterogeneous + 6 55/F colon single – iso iso hypo heterogeneous – 7 72/M colon single – hypo iso hypo homogeneous – 8 49/M colon single – hypo hyper iso heterogeneous – 9 51/F colon single – hypo iso hypo homogeneous – 10 67/F breast single – iso iso iso homogeneous – 11 55/M lung multiple + iso iso iso nodule – 12 61/M lung multiple – hypo hyper iso heterogeneous – 13 46/M lung single – hypo iso iso homogeneous + 14 63/M lung multiple – hypo hyper iso heterogeneous – 15 68/M lung multiple – hypo iso iso heterogeneous – 16 52/F lung multiple + hyper iso hyper ringed + 17 63/M lung single + iso hyper iso ringed + 18 55/M lung single + iso hyper iso nodule – 19 73/F lung multiple – hypo iso hypo heterogeneous – 20 58/M lung single + iso iso iso nodule + 21 43/M lung multiple – hypo iso iso homogeneous – 22 49/M lung single – hypo iso iso heterogeneus – 23 38/F lung multiple + hypo iso iso heterogeneus + 24 54/F lung multiple + hypo hyper hyper nodule + hypo: hypointensity, hyper: hyperintensity, iso: isointensity; Gd pattern: the enhancing portions of tumors are categorized into four contrast enhancement patterns: homogeneous, heterogeneous, nodular and ringed. enhancing portion of the tumor was analyzed using 4 types of Table II. Correlation between radiological and pathological findings. contrast enhancement pattern: homogeneous (n=6); heterogeneous (n=11); nodular (n=5); and ringed (n=2). Original T1-WI T2-WI FLAIR Pathology lesion Histopathological examination. All 24 surgically obtained specimens Mucin Necrosis Hemorrhage were fixed in 10% formalin and embedded in paraffin. These specimens were stained using hematoxylin and eosin (HE) and Stomach hypo hyper hypo 1+ 1+ 1+ pathological diagnoses were achieved. For the confirmation of Duodenum hypo hyper iso 2+ – – Lung hypo iso iso 1+ – – mucin content, Alcian-blue staining was performed and the Lung hyper iso hyper 1+ 1+ 1+ presence of necrosis or hemosiderin/hemorrhage was carefully Lung iso hyper iso 1+ – – analyzed. Mucin content was evaluated as mild (1+) or moderate Lung iso iso iso 1+ – 1+ (2+), as were the degree of necrosis and hemosiderin/hemorrhage. Lung hypo iso iso 1+ 1+ 2+ Lung hypo hyper hyper 2+ 2+ 1+ Results Mucin content is evaluated as mild (1+) or moderate (2+). Degree of Clinical characteristics. Characteristics of the 24 patients necrosis or hemorrhage/hemosiderin is also graded as mild (1+) or moderate (2+). are included in Table I. Of these, 14 patients had metastatic adenocarcinomas from lung cancer. Nine patients displayed metastases from GI tract cancer (colorectal cancer, n=4; stomach, n=4; duodenal, n=1) Radiological findings. Characteristics of these patients based and 1 patient showed metastasis from breast cancer on conventional MR findings are also summarized in Table (4.1%). Single metastatic lesions were present in 12 I. On T2-WI, 14 of 24 masses displayed isointense signal patients, with multiple metastases in the other 12 patients. appearance and 8 masses were displayed as hyperintense Sixteen patients exhibited solid component appearance, signals. Only 2 masses originating from stomach cancer while the other 8 patients had masses combined with a displayed a purely hypointense signal appearance (Figure cystic component. 1). On T1-WI, all lesions except for 1 hyperintense signal 408 Oshiro et al: MRI of Intracerebral Metastatic Adenocarcinoma Figure 1. Case 2. A 66-year-old man with multiple metastases from stomach cancer. Magnetic resonance imaging revealed the heterogeneously enhancing cerebellar mass lesion on contrast-enhanced T1-weighted imaging (A), depicted as signal hypointensity on both T2-weighted (B) and FLAIR imaging (C). A photomicrograph of the tumor specimen (hematoxylin and eosin; original magnification, x100) demonstrated findings compatible with metastatic adenocarcinoma (D). lesion (Case 16) were demonstrated as hypo- or isointense heterogeneous enhancement patterns, associated with signals. In a post-contrast enhancement study, lesions single metastasis (Figure 2). Conversely, in metastases from demonstrated various enhanced patterns (heterogeneous, lung cancer, 7 out of 14 patients showed a cystic component n=11; homogeneous, n=6; nodule, n=5; ring, n=2). In with nodular or ring enhancement, while 9 patients metastatic lesions originating from colorectal cancer,
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