Clinical Radiology (1992) 45, 139-140
Case Report: Calcified Brain Metastases From an Osteogenic Sarcoma W. K I N C A I D
Department of Radiology, Western Infirmary, Glasgow The computed tomographic (CT) appearances of a case of calcified brain metastases from a primary osteogenic sarcoma are described and the literature is reviewed. Kincaid, W. (1992).
Clinical Radiology 45, 1 3 9 - 1 4 0 . C a s e R e p o r t : C a l c i f i e d B r a i n M e t a s t a s e s
From
an
Osteogenic Sarcoma
lntracranial metastases from osteogenic sarcoma are uncommon. The appearances on computed tomography (CT) h a v e b e e n d e s c r i b e d p r e v i o u s l y ( D a n z i g e r et al., 1979; B a r a m et al., 1988). I n o n l y t w o c a s e s h a s C T demonstrated ossification or dense calcification within the m e t a s t a s e s . C a l c i f i e d b r a i n m e t a s t a s e s d e m o n s t r a t e d by C T h a v e a l s o b e e n d e s c r i b e d in p r i m a r y t u m o u r s o f colon, l u n g , b r e a s t a n d o e s o p h a g u s ( A n a n d a n d P o t t s , 1982). A f u r t h e r c a s e o f calcified c e r e b r a l m e t a s t a s e s a r i s i n g f r o m a p r i m a r y o s t e o g e n i c s a r c o m a is n o w described.
CASE REPORT A 19-year-old male presented in March 1987 with an osteogenic sarcoma of the left humerus. Investigation revealed metastases in the
Fig. 2 Follow-up CT made 2 months later after further treatment showing increased calcification in the right occipital lobe lesion. An adjacent CT section showed increased calcification in the left occipital lobe lesion as well. lungs, mediastinal and hilar lymph nodes, liver, left pelvic nodes and in the gluteal region. A brain CT at presentation was normal. Treatment with ifosfamide and doxorubicin HC1 produced improvement in his clinical condition and a radiological reduction in the size of the pulmonary, hepatic and pelvic metastases. Eight months later the patient returned with sacral pain, persistent frontal headache, nausea and vomiting. An isotope bone scan revealed multiple areas of increased uptake throughout the skeleton in keeping with metastases. A repeat brain CT now showed a heavily calcified lesion with surrounding oedema in each occipital lobe (Fig. 1). The appearances were consistent with metastatic disease. In addition, relapse of the pulmonary metastases was noted. Two months later after further treatment, the size and extent of calcification in the brain lesions had increased but the surrounding oedema had diminished (Fig. 2). Fig. 1 Brain CT made upon relapse, showing a partially calcified mass in the right occipital lobe with surrounding oedema. A partially calcified lesion is present in the left occipital lobe.
DISCUSSION
Correspondence to: W. Kincaid, Department of Radiology, Western Infirmary, Glasgow.
O s t e o g e n i c s a r c o m a is t h e s e c o n d m o s t c o m m o n primary malignant tumour of bone after multiple mye-
140
CLINICAL RADIOLOGY
loma. The p e a k incidence is between 10 a n d 25 years. T h e c o m m o n p r i m a r y sites are distal femur, p r o x i m a l tibia, p r o x i m a l fibula, h u m e r u s a n d pelvis. M e t a s t a t i c spread is h a e m a t o g e n o u s , m o s t c o m m o n l y to the 1.ungs a n d skeleton ( D a h l i n and C o n v e n t r y , t967; Jeffree et al., 1975). These m e t a s t a t i c deposits are frequently ossified (Vanel et al., 1984). T h e success o f c o m b i n a t i o n c h e m o t h e r a p y has altered the p a t t e r n o f s p r e a d a n d e x t r a p u l m o n a r y m e t a stases are n o w f o u n d m o r e c o m m o n l y , because o f the increased survival rate (Mills, 1978; G u i l i a n o et al., 1984). T h e r e are very few reports o f b r a i n metastases from' osteogenic sarcoma. D a h l i n et al. (1967) r e p o r t e d three cases o f brain metastases f r o m osteogenic s a r c o m a in an a u t o p s y series o f 150 cases. D a n z i g e r et al. (1979) presented a n o t h e r three patients with cerebral metastases. In two o f these cases, the cerebral metastases were osteoblastic, d i a g n o s e d by plain r a d i o g r a p h y in one a n d C T in the other. G u i l i a n o et al. (1984) described two patients with brain metastases in 111 cases o f osteogenic s a r c o m a but no further details were given. M o r e recently, B a r a m et al. (1988) described five cases o f b r a i n metastases in 87 patients with osteogenic s a r c o m a . All these 13 p a t i e n t s had evidence o f p u l m o n a r y deposits. O u r p a t i e n t also exhibited recurrent p u l m o n a r y metastases. The C T scan showed areas o f a m o r p h o u s calcification within two lesions with s u r r o u n d i n g o e d e m a (Fig. 1). A t b o n e settings, these lesions were shown to be separate from the skull vault, which was intact. T h e Hounsfield n u m b e r was 86. A repeat C T 2 m o n t h s after t r e a t m e n t showed an increase in size o f the lesions and the extent o f calcification but with r e d u c t i o n in the s u r r o u n d i n g o e d e m a (Fig. 2). T w o o f the three cases described by D a n z i g e r et al. (1979) showed osteoblastic features. A l t h o u g h no histological p r o o f was o b t a i n e d in our case, it is t h o u g h t justifiable to assume that the brain lesions
described are metastases from o s t e o s a r c o m a because of the wide d i s s e m i n a t i o n Of the process a n d the progressive g r o w t h o f the lesions. T h e a t t e n u a t i o n values o f calcified b r a i n metastases are r e p o r t e d to v a r y between 50 a n d 105 Hounsfield units ( H U ) ( A n a n d and Potts, 1982). The a t t e n u a t i o n o f fresh b l o o d is lower at 35-55 H U (Deck et al., 1976), a n d tends to reduce after 10 14 d a y s as the h a e m a t o m a resolves. The b r a i n m e t a s t a s e s o f p r i m a r y t u m o u r s o f the colon, lung, breast a n d o e s o p h a g u s m a y also c o n t a i n radiologically visible calcium deposits ( A n a n d and Potts, 1982).
REFERENCES
Anand, AK & Potts, DG (1982). Calcified brain metastases: demonstration by computed tomography. American Journal~?fNeuroradiology, 3, 527-529. Baram, TZ, Van Tassel, P & Jaffe, NA (1988). Brain metastases in osteogenic sarcoma: incidence, clinical and neuroradiological findings and management options. Journal of Neuro-Oncology, 6, 47-52. Dahlin, YDC & Conventry, MB (1967). Osteogenic sarcoma: a study of six hundred cases. Journal of Bone and Joint Surgery, 49, 101 110. Danziger, J, Wallace, S, Handel, S & De Santos, LA (1979). Metastatic osteosarcoma to the brain. Cancer, 43, 707 710. Deck, MDF, Messina, AV & Sackett, JF (1976). Computed tomography in metastatic disease of the brain. Radiology, 119, 115 120. Guiliano, AE, Feig, S & Ezlber, FR (1984). Changing metastatic pattern of osteosarcoma. Cancer, 54, 2160-2164. Jeffree, GM, Price, CHG & Sissons, HA (1975). The metastatic patterns of osteosarcoma. British Journal of Cancer, 32, 87 106. Mills, EED (1978)~ Osteosarcoma the winds of change. South A[?ican Medical Journal, 53, 695-698. Vanel, D, Henry-Amar, M, Lumbrosa, J, Lemalet, E, Couanet, D, Piekarski, JD et al. (1984). Pulmonary evaluation of patients with osteosarcoma: roles of standard radiography, tomography, CT, scintigraphy and tomoscintigraphy. American Journal of Roentgenology, 143, 519 523.
Case Report: Calcified Brain Metastases From an Osteogenic Sarcoma W. K I N C A I D
Department of Radiology, Western Infirmary, Glasgow The computed tomographic (CT) appearances of a case of calcified brain metastases from a primary osteogenic sarcoma are described and the literature is reviewed. Kincaid, W. (1992).
Clinical Radiology 45, 1 3 9 - 1 4 0 . C a s e R e p o r t : C a l c i f i e d B r a i n M e t a s t a s e s
From
an
Osteogenic Sarcoma
lntracranial metastases from osteogenic sarcoma are uncommon. The appearances on computed tomography (CT) h a v e b e e n d e s c r i b e d p r e v i o u s l y ( D a n z i g e r et al., 1979; B a r a m et al., 1988). I n o n l y t w o c a s e s h a s C T demonstrated ossification or dense calcification within the m e t a s t a s e s . C a l c i f i e d b r a i n m e t a s t a s e s d e m o n s t r a t e d by C T h a v e a l s o b e e n d e s c r i b e d in p r i m a r y t u m o u r s o f colon, l u n g , b r e a s t a n d o e s o p h a g u s ( A n a n d a n d P o t t s , 1982). A f u r t h e r c a s e o f calcified c e r e b r a l m e t a s t a s e s a r i s i n g f r o m a p r i m a r y o s t e o g e n i c s a r c o m a is n o w described.
CASE REPORT A 19-year-old male presented in March 1987 with an osteogenic sarcoma of the left humerus. Investigation revealed metastases in the
Fig. 2 Follow-up CT made 2 months later after further treatment showing increased calcification in the right occipital lobe lesion. An adjacent CT section showed increased calcification in the left occipital lobe lesion as well. lungs, mediastinal and hilar lymph nodes, liver, left pelvic nodes and in the gluteal region. A brain CT at presentation was normal. Treatment with ifosfamide and doxorubicin HC1 produced improvement in his clinical condition and a radiological reduction in the size of the pulmonary, hepatic and pelvic metastases. Eight months later the patient returned with sacral pain, persistent frontal headache, nausea and vomiting. An isotope bone scan revealed multiple areas of increased uptake throughout the skeleton in keeping with metastases. A repeat brain CT now showed a heavily calcified lesion with surrounding oedema in each occipital lobe (Fig. 1). The appearances were consistent with metastatic disease. In addition, relapse of the pulmonary metastases was noted. Two months later after further treatment, the size and extent of calcification in the brain lesions had increased but the surrounding oedema had diminished (Fig. 2). Fig. 1 Brain CT made upon relapse, showing a partially calcified mass in the right occipital lobe with surrounding oedema. A partially calcified lesion is present in the left occipital lobe.
DISCUSSION
Correspondence to: W. Kincaid, Department of Radiology, Western Infirmary, Glasgow.
O s t e o g e n i c s a r c o m a is t h e s e c o n d m o s t c o m m o n primary malignant tumour of bone after multiple mye-
140
CLINICAL RADIOLOGY
loma. The p e a k incidence is between 10 a n d 25 years. T h e c o m m o n p r i m a r y sites are distal femur, p r o x i m a l tibia, p r o x i m a l fibula, h u m e r u s a n d pelvis. M e t a s t a t i c spread is h a e m a t o g e n o u s , m o s t c o m m o n l y to the 1.ungs a n d skeleton ( D a h l i n and C o n v e n t r y , t967; Jeffree et al., 1975). These m e t a s t a t i c deposits are frequently ossified (Vanel et al., 1984). T h e success o f c o m b i n a t i o n c h e m o t h e r a p y has altered the p a t t e r n o f s p r e a d a n d e x t r a p u l m o n a r y m e t a stases are n o w f o u n d m o r e c o m m o n l y , because o f the increased survival rate (Mills, 1978; G u i l i a n o et al., 1984). T h e r e are very few reports o f b r a i n metastases from' osteogenic sarcoma. D a h l i n et al. (1967) r e p o r t e d three cases o f brain metastases f r o m osteogenic s a r c o m a in an a u t o p s y series o f 150 cases. D a n z i g e r et al. (1979) presented a n o t h e r three patients with cerebral metastases. In two o f these cases, the cerebral metastases were osteoblastic, d i a g n o s e d by plain r a d i o g r a p h y in one a n d C T in the other. G u i l i a n o et al. (1984) described two patients with brain metastases in 111 cases o f osteogenic s a r c o m a but no further details were given. M o r e recently, B a r a m et al. (1988) described five cases o f b r a i n metastases in 87 patients with osteogenic s a r c o m a . All these 13 p a t i e n t s had evidence o f p u l m o n a r y deposits. O u r p a t i e n t also exhibited recurrent p u l m o n a r y metastases. The C T scan showed areas o f a m o r p h o u s calcification within two lesions with s u r r o u n d i n g o e d e m a (Fig. 1). A t b o n e settings, these lesions were shown to be separate from the skull vault, which was intact. T h e Hounsfield n u m b e r was 86. A repeat C T 2 m o n t h s after t r e a t m e n t showed an increase in size o f the lesions and the extent o f calcification but with r e d u c t i o n in the s u r r o u n d i n g o e d e m a (Fig. 2). T w o o f the three cases described by D a n z i g e r et al. (1979) showed osteoblastic features. A l t h o u g h no histological p r o o f was o b t a i n e d in our case, it is t h o u g h t justifiable to assume that the brain lesions
described are metastases from o s t e o s a r c o m a because of the wide d i s s e m i n a t i o n Of the process a n d the progressive g r o w t h o f the lesions. T h e a t t e n u a t i o n values o f calcified b r a i n metastases are r e p o r t e d to v a r y between 50 a n d 105 Hounsfield units ( H U ) ( A n a n d and Potts, 1982). The a t t e n u a t i o n o f fresh b l o o d is lower at 35-55 H U (Deck et al., 1976), a n d tends to reduce after 10 14 d a y s as the h a e m a t o m a resolves. The b r a i n m e t a s t a s e s o f p r i m a r y t u m o u r s o f the colon, lung, breast a n d o e s o p h a g u s m a y also c o n t a i n radiologically visible calcium deposits ( A n a n d and Potts, 1982).
REFERENCES
Anand, AK & Potts, DG (1982). Calcified brain metastases: demonstration by computed tomography. American Journal~?fNeuroradiology, 3, 527-529. Baram, TZ, Van Tassel, P & Jaffe, NA (1988). Brain metastases in osteogenic sarcoma: incidence, clinical and neuroradiological findings and management options. Journal of Neuro-Oncology, 6, 47-52. Dahlin, YDC & Conventry, MB (1967). Osteogenic sarcoma: a study of six hundred cases. Journal of Bone and Joint Surgery, 49, 101 110. Danziger, J, Wallace, S, Handel, S & De Santos, LA (1979). Metastatic osteosarcoma to the brain. Cancer, 43, 707 710. Deck, MDF, Messina, AV & Sackett, JF (1976). Computed tomography in metastatic disease of the brain. Radiology, 119, 115 120. Guiliano, AE, Feig, S & Ezlber, FR (1984). Changing metastatic pattern of osteosarcoma. Cancer, 54, 2160-2164. Jeffree, GM, Price, CHG & Sissons, HA (1975). The metastatic patterns of osteosarcoma. British Journal of Cancer, 32, 87 106. Mills, EED (1978)~ Osteosarcoma the winds of change. South A[?ican Medical Journal, 53, 695-698. Vanel, D, Henry-Amar, M, Lumbrosa, J, Lemalet, E, Couanet, D, Piekarski, JD et al. (1984). Pulmonary evaluation of patients with osteosarcoma: roles of standard radiography, tomography, CT, scintigraphy and tomoscintigraphy. American Journal of Roentgenology, 143, 519 523.
