A 32-year-old gentleman was referred for left frontal brain lesion for further management. He presented with headache, giddiness, and blurring of vision at left eye for the past 2 months. All symptoms progressively worsened over time. He has no other known medical illnesses nor complained of anything else. There is no significant family history of tuberculosis (TB) exposure or malignancy. History of smoker about 15 pack years, not alcoholic and denies other social issues. He has neither drug allergies nor drug adverse effects during his stay in the ward.
On examination, his Glasgow Coma Scale (GCS) was full. He is orientated to time, place, and person. Vital signs were stable throughout admission. No palpable lymph nodes were observed. There were unremarkable cardiovascular, respiratory, neurological, and gastrointestinal system findings. Fundoscopy reveals left eye papilloedema. Karnofsky performance status (KPS) is 80% in which patient is able to perform normal activity with some difficulty due to symptoms such as headache, giddiness, and blurring of vision.
Metastasis was made as one of the differential diagnosis from the computed tomography (CT) brain findings. Screening was done by means of CT thorax-abdomen-pelvis for distant metastases and lung lesions were found. Bronchoscopy revealed abnormal lower tracheal mucosa and right hilar-carina region appears widened. Biopsy result was not suggestive as there is no diagnostic material received. He also later complained of left sided upper thigh pain radiating to the front and we noted left gluteal mass from which biopsy was taken and the result is mesenchymal tumor suggestive of alveolar soft part sarcoma.
Patient was operated due to a good life expectancy as the left frontal brain lesion was solitary. Craniotomy with complete excision of tumor was done in December 2011. Intra-operative findings were vascularized tumor with a mix of solid-cystic-friable lesion and total excision was done.
Results of diagnostic imaging are as below:
Noted multiple hypodense lesions (cannon ball lesions) and huge radio opaque lesion at mediastinum [Figure 1].
Left frontal lobe mass with significant mass effect and small lesion at occipital lobe [Figure 2].
Right lower lobe lung mass (7.5 x 8 cm) extending to mediastinum, multiple lung metastases, normal CT abdomen and pelvis. Left gluteus mass is probably metastasis. T4 N2 M1, Stage IV Carcinoma. Conclusion made as advanced carcinoma of the right lower lobe with multiple lung metastases and left gluteal metastasis [Figure 3].
Results of histopathological examination are as below:
No diagnostic material or inadequate for interpretation.
Mesenchymal tumor suggestive of alveolar soft part sarcoma [Figure 4].
Features are compatible with metastatic tumor, request to correlate with gluteus mass biopsy result [Figure 5].
He is asymptomatic at his next review but repeated scan shows multiple new brain lesions in just 2 months post operative period. He is planned for palliative chemotherapy due to high recurrence rate and multi-systemic involvement.
Left frontal lesion, right occipital lesion, right parietal lesion, and midline intraventricular lesion. Features show local spread to the surrounding brain tissue [Figure 6].