The use of the flow-void sign on MRI: highly sensitive sign in detecting bone metastases from renal cell carcinoma

OBJECTIVE

To evaluate a range of pathologically proven malignant bone tumours, including primary bone sarcoma and metastatic bone lesions, referred to a tertiary referral centre for the presence of the flow-void sign on MR imaging.

MATERIALS AND METHODS

A retrospective search was performed using the radiology information system and oncology database in our institution to identify patients over the age of 40 years referred with a solitary bone lesion. Patients with a range of pathologically proven malignant bone tumours, including primary bone tumours and metastatic bone lesions, were included in the study. MRI images were reviewed for the presence of the flow-void sign. The presence and type of the flow-void sign were correlated with lesion size.

RESULTS

Two hundred and sixty-six cases were included in the study. Overall, the flow-void sign was identified in 40.9% of cases. The flow-void sign was most frequently seen in renal cell carcinoma metastasis (90.0%). The sign is highly sensitive (90%) for renal cell carcinoma metastases with a high negative predictive value (98.09%). When the flow-void sign is identified, the lesion is almost three times more likely to represent a renal cell carcinoma metastasis than any other malignant tumour in patients over the age of 40 years with a solitary bone lesion.

CONCLUSION

The flow-void sign is highly sensitive for renal cell carcinoma bone metastases and could negate the need for biopsy in patients with a known history of renal cell carcinoma or in whom an occult renal cell carcinoma is subsequently identified.

Skull Metastasis With Orbital Invasion as a Primary Manifestation of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a common worldwide cancer with a poor prognosis despite treatment advancements. Patients typically exhibit signs and symptoms pertaining to the liver. Extrahepatic metastasis of HCC is documented to be as low as 5% of cases. Bone metastasis ranks third following lungs and regional lymph nodes. The typical locations for bone metastasis include the vertebral column, pelvis, femora, and ribs, with skull metastasis, being reported in less than 1.6% of cases. Herein, we describe a case of HCC presenting with skull metastases and orbital invasion as the initial manifestation.

Spontaneous Acute Epidural Hematoma Associated With Metastatic Hepatocellular Carcinoma: A Case Report

Spontaneous acute epidural hematoma (AEDH) co-occurring with metastatic hepatocellular carcinoma (HCC) of the skull is rare, with only 7 documented cases in existing literature. This report describes the case of a 42-year-old man who presented with decreased consciousness following intermittent headaches following minor head trauma. Computed tomography imaging revealed an AEDH, prompting surgical intervention. Despite preliminary assumptions linking the causes of the trauma, surgical exploration revealed no evidence of traumatic injury. Instead, an infiltrative soft-tissue mass within the skull was identified. Histopathological examination confirmed that the mass was a metastatic HCC. Despite the successful hematoma evacuation, the patient's neurological status did not improve. This case underscores the importance of considering metastatic disease in the differential diagnosis of AEDH, particularly in patients with a history of malignant tumors, irrespective of prior indications of bone metastasis. Furthermore, it emphasizes the need to enhance diagnostic and therapeutic strategies for such complex cases.

Superior Sagittal Sinus Tumor Eroding through the Skull: An Unfamiliar Presentation of Hepatocellular Carcinoma and Literature Review

Background

Hepatocellular carcinoma (HCC) most commonly develops in patients with liver cirrhosis caused by hepatitis C and B virus. HCC is the most common cause of death in people with cirrhosis. The lungs, bone, and lymph nodes are frequent sites of metastasis of HCC.

Patients and Methods

We present a case of solitary skull metastasis as the first symptom of HCC. A literature review with regard to HCC skull metastasis was undertaken.

Results

This patient had HCC based on chronic hepatitis C. He presented with an erosive lesion masquerading as a scalp lipoma resulting in hepatocellular carcinoma with retrograde reflux and sinus metastases. The lesion was ultimately resected, but the patient died within one week from liver failure. Seventeen similar cases were found in the literature. Median age of the patients was 58 years with 95% being male and 35% having viral hepatitis. Surgery was the preferred treatment with chemotherapy and radiation being other options. Outcome was acceptable but baseline liver disease is a limiting factor.

Discussion

Cranial metastases of HCC are rare but should be considered in patients with chronic hepatitis C presenting with scalp skin lesions.

A case of monocular blindness as the initial presentation of hepatocellular carcinoma with skull metastasis

A 52-year-old man suffering from monocular blindness, with light perception only, was admitted to our hospital. The symptom had begun as low vision and developed rapidly within 3 weeks into monocular blindness in the right eye, with no other systemic manifestations. Imaging examinations revealed multiple hepatocellular carcinomas in the cirrhotic liver, and tumors at the skull base and vertebra. A pathological and immunochemical study of specimens obtained by endoscopic transnasal tumor biopsy and laminectomy revealed them to be metastatic hepatocellular carcinomas (HCCs). Although the patient underwent radiation therapy and chemotherapy, he died 5 months after admission to our hospital. The cranial HCC, involving only the optic canal, may have disturbed the optic nerve in preference to the other cranial nerves. This is the first report of a HCC patient with monocular blindness as the initial presentation of the disease.

Solitary skull metastasis as initial manifestation of hepatocellular carcinoma

Background

A solitary skull metastasis from hepatocellular carcinoma (HCC) prior to diagnosis of the primary tumor without liver dysfunction is a very rare event.

Case presentation

A 71-year-old male, without known liver disease, presented to our institution with a palpable occipital scalp mass. On brain magnetic resonance imaging (MRI), a highly enhanced and osteolytic skull tumor was observed. The histological diagnosis obtained from the percutaneous needle biopsy was a cranial metastasis from HCC. The metastatic tumor was removed via occipital craniectomy, and the two primary liver mass lesions were subsequently treated by transarterial chemoembolization.

Conclusion

An isolated skull metastasis may be the sole initial presentation of HCC. Early diagnosis is essential in order to treat the primary disease. A skull metastasis from HCC should be considered in the differential diagnosis in patients with subcutaneous scalp mass and osteolytic defects on X-ray.

The role of MR imaging in the diagnostic characterisation of appendicular bone tumours and tumour-like conditions

MRI has an established role in the local staging of primary bone tumours. However, as the majority of tumours have non-specific appearances on MRI, the diagnosis is usually established on the basis of clinical history, plain film findings and biopsy. This article reviews the value of MRI in the further characterisation of appendicular bone tumours and tumour-like lesions, with particular reference to peri-lesional oedema, fluid-fluid levels, flow voids, fat signal, cartilage signal and dedifferentiation. These features are a useful adjunct for distinguishing between benign and malignant disease, pointing towards a more specific diagnosis, and guiding biopsy.

Skull metastasis from hepatocellular carcinoma

Metastasis to the skull frequently occurs in patients with lung, breast and prostate cancer. However, skull metastases from hepatocellular carcinoma (HCC) have been rarely reported. We review the literature on skull metastasis from HCC and report a case of a 46-year-old male, who was diagnosed as HCC and was operated on by trans-arterial embolization and lobectomy in Oct. 2004. He complained of a painless mass over the left frontal region for two months. Radiograph of the skull revealed an osteolytic mass about 4-5 cm in size over the left frontal region. A cranial computerized tomography demonstrated a destructive lesion with soft tissue mass over the left frontal region. A left frontal craniectomy was performed and tumor was totally removed. The histological diagnosis was cranial metastasis from HCC. Postoperative recovery was uneventful without any neurological deficits. Because of improved and advancing treatment for HCC, survival time for HCC has been lengthened and distant metastases will thus be found to increase. Early diagnosis is essential to treat the primary disease. Skull metastases from HCC should be considered as a differential diagnosis in patients with scalp subcutaneous mass and osteolytic defect on X-ray skull films.

Brain metastases from hepatocellular carcinoma in US patients

Hepatocellular carcinoma (HCC) is a disease on the rise in the United States, due to the epidemic of hepatitis C-induced liver disease. Better chemotherapy options, aggressive surgery, and liver transplantation have led to improved patient survival and an increase in late-appearing, distant metastases from HCC. Brain metastases, although formerly thought of as rare manifestations of HCC, may be more likely to come to clinical and pathological attention than extrahepatic metastases in other sites since they often produce clinical symptoms that necessitate neurosurgical intervention and metastasis removal. In addition, brain metastases from HCC are frequently associated with mass-producing hemorrhage, further requiring evacuation. Hence, pathologists are relatively more likely to encounter brain metastases from HCC as surgical specimens than metastases from HCC to some other common sites of spread, such as bone, lymph nodes, or adrenal. Brain metastases from HCC are being increasingly documented in areas of the world with high endemic rates such as Asia, but thus far have only very rarely been reported in patients native to the United States. We describe our institution's experience with three Caucasian US males, two with hepatitis C as risk factors, who developed metastatic HCC to the brain. We expect clinicians and pathologists will encounter more patients with HCC and extrahepatic metastases, particularly those to brain, in the near future.

Cytologic diagnosis of brain metastasis from hepatocellular carcinoma by squash preparation

Hepatocellular carcinoma (HCC) metastasizes to the brain is rare instances. In published series and case reports of metastatic HCC, diagnosis of central nervous system metastases has been determined by histologic methods. We present a case of metastatic HCC of brain diagnosed by squash cytologic preparation. A 69-year-old male, HCV positive, suffering from post-hepatitic cirrhosis, initially diagnosed at age 68 with HCC presented with headaches of increasing frequency and severity. A computed tomography scan confirmed a 3-cm nodule in the right parietal lobe of the brain. Squash cytology was performed intraoperatively and preparations of a small tissue fragment resected from the mass showed medium-to-large-sized, well-cohesive clusters or sheets of uniform tumor cells. The tumor cells are highly cellular and contain solitary tumor cells in loose groupings as well as many fragments. They also appear somewhat bizarre and contain large, round, or ovoid nuclei with prominent nucleoli. Cytologic diagnosis of metastatic HCC was rendered reported and confirmed by a subsequent frozen section examination. To the best of our knowledge, this is the first reported case in which HCC was reported as brain metastasis, by using squash cytology. We suggest that intraoperative squash cytologic examination be viewed as a useful initial approach in the diagnosis of metastatic brain tumor.

Unusual case of skull metastasis from hepatocellular carcinoma

Hepatocellular carcinoma with a skull metastasis is a rare clinical entity especially in Western countries. The authors of the present article report a case of solitary skull metastasis from hepatocellular carcinoma in a 75-year-old lady who had no prior history of the primary disease or liver dysfunction. The clinicopathological and radiological features are reviewed and discussed.

Metastatic hepatocellular carcinoma presenting as epidural hematoma: case report

OBJECTIVE AND IMPORTANCE

A case of acutely symptomatic epidural hematoma caused by metastatic hepatocellular carcinoma (HCC) to the cranium is reported. This is a rare case of metastatic HCC without known primary presenting as an epidural hematoma.

CLINICAL PRESENTATION

The patient presented with an acute onset of headache, aphasia, and right hemiparesis 2 weeks after he experienced minor trauma to the cranium. An emergency computed tomographic scan of the head revealed the presence of a left parietal epidural hematoma.

INTERVENTION

An emergency evacuation of the epidural hematoma was performed, and metastatic HCC was diagnosed.

CONCLUSION

The patient's neurological deficits were reversed with surgical intervention, and he is now undergoing palliative chemotherapy. This was the first clinical manifestation of HCC in this patient. This case reaffirms the neurosurgeon's role in the complex, multidisciplinary care of patients with craniospinal metastasis.

Surgical resection of calvarial metastases overlying dural sinuses

OBJECTIVE

Few reports have addressed the surgical management of cranial metastases that overlie or invade the dural venous sinuses. To examine the role of surgery in the treatment of dural sinus calvarial metastases, we reviewed retrospectively 13 patients who were treated with surgery at the University of Texas M.D. Anderson Cancer Center between 1993 and 1999. We compared them with 14 patients who had calvarial metastases that did not involve a venous sinus.

METHODS

Clinical charts, radiological studies, pathological findings, and operative reports were analyzed retrospectively.

RESULTS

The median age of patients with dural sinus calvarial metastases was 54 years. Nine patients were men and four were women. Renal cell carcinoma and sarcoma were the most common primary tumors. Similar features were noted in the 14 patients with nonsinus calvarial metastases. Of the 13 dural sinus calvarial metastases, 11 involved the superior sagittal sinus, and 2 involved the transverse sinus. In nine patients, the involved sinus was resected, and in four patients, the sinus was reconstituted after tumor removal. Nine patients in the dural sinus calvarial metastases group received en bloc resection, and four received piecemeal resection. No operative deaths occurred. The overall median actuarial survival was 16.5 months. The survival times of the two groups were comparable. In the group with dural sinus calvarial metastases, transient postoperative neurological deficits occurred in two patients (15%), and a permanent deficit occurred in one patient (8%). No patients in the group with nonsinus calvarial metastases experienced deficits after resection. Compared with piecemeal resection, en bloc resection was associated with significantly less blood loss.

CONCLUSION

Complete extirpation of calvarial metastases that overlie or invade a dural sinus can be achieved with only slightly more morbidity than complete removal of calvarial metastases that are located away from the sinuses. En bloc resection is as safe as piecemeal resection and is more effective in limiting operative blood loss. The overall recurrence and survival rates of patients with dural sinus calvarial metastases are similar to those of patients with calvarial metastases that do not involve the sinuses. Therefore, involvement of a dural venous sinus should not discourage resection of calvarial metastases. In carefully selected cancer patients, surgery provides effective palliation of symptomatic calvarial metastases that overlie or invade the venous sinuses.