Atypical Sites Of Metastasis-Two Cases

These are two atypical sites of secondaries in recent past in my practise, which we are sharing in our site.

The metastatic lesions of pancreas are extremely rare. Tumors metastasizing to the pancreas include lung carcinoma, gastrointestinal tract carcinoma, breast carcinoma, renal carcinoma, melanoma, lymphoma, and (osteo)sarcoma. This is a 15 year old girl known case of osteosarcoma, with suspected pancreatic secondaries.

Another atypical case, is a 67 year old male with past nephrectomy for hypernephroma and had shoulder pain. MRI done revealed altered marrow signal intensity involving the glenoid process of scapula along with involvement of the coracoid process. There is evidence of associated osseous destruction and soft tissue component. Similar cases of glenoid secondaries has been reported previously in the literature especially with hypernephroma. Reference-Daluga D, Quast M, Bach Bernard, Gilelis S. Shoulder neoplasms mimicking rotator cuff tears. Orthopaedics 1990 July; 13:765-767.

HEMORRHAGIC INTRACRANIAL SECONDARIES

The incidence of hemorrhage in metastatic neoplasms is highest in melanoma, hypernephroma, bronchogenic carcinoma, and choriocarcinoma. Other metastatic tumours that bleed are breast and thyroid metastasis. Of the primary intracranial neoplasms, hemorrhage occurs most frequently in relation to pituitary neoplasms. Other primary tumors that have been reported to bleed include glioblastoma multiforme, lower-grade gliomas, ependymomas, choroid plexus papillomas, sarcomas, and meningiomas.
Our patient is 55 yr old male and shows large ring enhancing, slightly hyperintense lesions in parietal and frontal region. Lesions are hyperintense on both T1 and T2 weighted images and show ring enhancement on contrast study. This appearance is very suggestive of secondaries from renal cell carcinoma.

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Spinal metastasis-MRI

This is MRI lumbar spine of a 70 yr old male who came to us with complaints of back pain and pain in both lower limbs. It shows evidence of osseous destruction along with marorw signal abnormality of multifocal vertebral bodies involving all lumbar vertebral bodies, sacral ala. There is epidural soft tissue component with involvement of the posterior elements, appearing heterogeneously hyperintense on STIR and hypointense on T1W along with compromise of neural sac.
Discussion:
Four MR patterns of vertebral metastatic disease are seen – focal lytic, focal sclerotic, diffuse inhomogenous, diffuse homogenous. The most common among them is focal lytic lesions characterized by low signal intensity on T1 and high on T2. Pedicle destruction is more in favour of metastatic etiology. Pathologic compression fractures are also seen and show comparatively low signal intensity on T1 and high signal on T2 as compared to benign osteoporotic fractures which are mostly isointense on all sequences.

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Spinal metastatic disease-MRI

Primary sources for spinal metastatic disease include the following: Lung (31%), Breast (24%), GI (9%), Prostate (8%), Lymphoma (6%), Melanoma (4%), Unknown (2%), Kidney (1%), Others including multiple myeloma (13%). Time relation between primary and spinal metastases vary according to the site and nature of the primary. Spread from primary tumors is mainly by the arterial route via nutrient artery. Retrograde spread through the Batson plexus during Valsalva maneuver has been postulated. Direct invasion through the intervertebral foramina also can occur.