Case 11315 Intraventricular brain metastases from malignant melanoma Aruna S. Pallewatte, Uditha Wijesinghe Section: Neuroradiology Published: 2013, Oct. 24 Patient: 37 year(s), female
Authors' Institution Neuroimaging Unit, National Hospital of Sri Lanka; Sriyani, Oruthota 11000 Gampaha, Sri Lanka; Email:
[email protected]
Clinical History A 37-year-old female patient presented with an acute onset severe occipital headache of two weeks duration. She had a history of malignant melanoma of vaginal vault and had undergone hysterocolpectomy, salphyngo-oophorectomy, omentectomy and pelvic lymphadenectomy six weeks before. While awaiting chemotherapy the patient developed this occipital headache.
Imaging Findings The preliminary non contrast CT performed at admission demonstrated an Intraventricular Haemorrhage (IVH) in the right lateral ventricle with an associated intra-ventricular soft tissue density mass. (Fig. 1) The MRI revealed two well-defined lesions, one in the right lateral ventricle and the other in the third ventricle. The lesions were hyperintense to grey matter in T1 and hypointense to grey matter in T2. In FLAIR images they were slightly hyperintense to grey matter. There lesions showed
intense homogeneous enhancement with Gadolinium. There was evidence of a subacute intraventricular haemorrhage and a small ICH in relation to the lesion in the right lateral ventricle. There were no lesions in the brain parenchyma or in extra-axial location. (Fig. 2, 3, 4)
Discussion Brain metastases are common in malignant melanoma and carry a poor prognosis. [1, 2] In this patient metastases were only found in CNS. Contrast-enhanced magnetic resonance imaging (MRI) is the most sensitive imaging method to document CNS metastases and meningeal involvement. [3] Most CNS metastases classically appear as multiple areas of hypointensity on T1-weighted MRI and heterogeneous hyperintensity on T2-weighted MRI. In addition, as in this case, melanoma can be hyperintense on T1-weighted MRI and hypointense on T2-weighted MRI because of the melanin content of the tumour. However, the presence of haemorrhage may alter the MRI signal intensity and further complicate the radiologic diagnosis. [4] Secondary CNS melanoma most often results from haematogenous spread. These metastases most commonly involve the brain parenchyma and leptomeninges. Melanomas may occur at any location on the skin and seldom on the mucus membranes or other locations. However, only a few cases of vaginal melanomas have been reported. [5]Therefore this case falls into a very rare category. Intracranial metastases from malignant melanomas are known to occur in several locations such as brain parenchyma, leptomeninges, choroid plexus and within ventricles etc. Among these, intraventricular metastases, as in this case, are also considered to be a very rare occurrence [6} The main strategies in the management of melanoma brain metastases are microsurgical resection and stereo-tactic radiosurgery. However, the overall prognosis is known to be poor [7].
Final Diagnosis Intraventricular brain metastases from malignant melanoma associated with haemorrhage
Differential Diagnosis List Haemorrhagic metastases from another primary, Primary intraventricular tumours
Figures Figure 1 Non contrast axial CT
IVH in right lateral ventricle with associated mass © NSU-MRI
Area of Interest: Neuroradiology brain; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Acute; Figure 2 Gadolinium enhanced T1 weighted sagittal image
Intense enhancement of the tumour in the posterior horn of the right lateral ventricle. © NSU MRI
Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Diagnostic procedure;
Special Focus: Neoplasia; Figure 3 T2 weighted axial image
The tumour is hypointense to the gray matter and intraventricular haemorrhage is isointense to the grey matter. © NSU MRI
Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia; Figure 4 Coronal unenhanced FLAIR image
Slightly hyperintense tumour the right lateral ventricle and third ventricle. © NSU-MRI
Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Metastases;
References [1] Geoffrey Thomas Gibney, Peter A. Forsyth , Vernon K Sondak (2012) Melanoma in the brain: biology and therapeutic options Melanoma Research 22-3, 177-183 [2] Leo J. Schouten, Joost Rutten, Hans Huveneers, Albert Twijnstra (2002) Incidence of brain metastases in a cohort of patients with carcinoma of the breast, colon, kidney, and lung and melanoma Cancer 94-10;2698-2705 [3] Valérie Laurent, Grégory Trausch, Olivier Bruot, Pierre Olivier, Jacques Felblinger, Denis Régent (2010) Comparative study of two whole-body imaging techniques in the case of melanoma metastases: Advantages of multi-contrast MRI examination including a diffusion-weighted sequence in comparison with PET-CT European Journal of Radiology 75-3; 376-383, [4] Edward J. Escott (2001) A Variety of Appearances of Malignant Melanoma in the Head: A Review, Radiographics 21,625-639. [5] Kim H, Jung SE, Lee EH, Kang SW (2003) Case report: magnetic resonance imaging of vaginal malignant melanoma Jr Comput Assist Tomog. 27(3):357-60 [6] Kelly K. Koeller, Glenn D. Sandberg (2002) Archives of the AFIP: Cerebral Intraventricular Neoplasms: Radiologic-Pathologic Correlation Radiographics 22:6 1473-1505
[7] Dorothea Miller, Valeria Zappala, Nicolai El Hindy, Elisabeth Livingstone, Dirk Schadendorf, Ulrich Sure, Ibrahim Erol Sandalcioglu (2013) Intracerebral metastases of malignant melanoma and their recurrences-A clinical analysis. Clinical Neurology and Neurosurgery 115-9, 1721-1728
Citation Aruna S. Pallewatte, Uditha Wijesinghe (2013, Oct. 24) Intraventricular brain metastases from malignant melanoma {Online} URL: http://www.eurorad.org/case.php?id=11315
