gms | German Medical Science

Objective: Cerebral metastasis originating from tissues outside the brain are the most common tumours of the central nervous system. Among woman the most common primary source is breast cancer. While surgical resection of a solitary lesion is consentinent policy, the indication for surgery in the management of multiple or recurrent metastases is discussed controversial to date. Owing to an estimation as far advanced disease stage the diagnosis of a recurrent cerebral metastatic spreaded breast cancer implies significant therapeutical consequences.

Method: We report a case of a 66-year old female patient with diagnosis of a recurrent cerebral metastatic spreaded breast cancer by radiological and nuclear medical imaging and try to illuminate the cardinal differential diagnosis following surgical resection and radiation, radiation necrosis, vital for management decision making.

Results: This 66-year old female patient presented in our hospital with the primary diagnosis of a solitary cerebral metastatic spreaded breast cancer 2 years earlier. Following microsurgical extirpation and radiation therapy the cerebral lesion disappeared. Though in the meantime regular staging diagnostics revealed hepatic metastases, a palliative treatment regime was conducted. While the peripheral lesions vanished, a routine MRI-scan then exposed slightly contrast enhancement in the region of the former metastasis, radiological well suitable for a recurrent disease. After confirming the imaging result by one of the recent imaging modalities - O-(2-[18F]-fluoroethyl)-L-tyrosine positron emission tomography (FET-PET), we decided for a “wait and see” strategy based on the good clinical state of the woman and the far advanced disease state. Expeditious an obvious clinical impact of the newly diagnosed cerebral lesion in terms of behavioral changes and affected alertness occurred. An extraordinary fast growing contrast enhancing lesion, space occupying with median line shift was exposed by a refreshed MRI-scan. The initiated steroid therapy showed an excellent clinical improvement. We performed surgery under the presumption to resect a recurrent life threatening brain metastasis. Indeed the pathological examination verified a radiation necrosis.

Conclusion: We show that in a case of recurrent brain lesion after radiation therapy treatment decision making based on radiological and nuclear medical imaging may mislead and indication for surgery should be discussed and provided generous. Otherwise vital consequences are threatened. Furthermore, we highlight the absent specificity and sensitivity of one of the more recently implemented milestones in nuclear medicine, positron emission tomography used with different tracers, for assessing metastases as well as primary tumors and for monitoring their disease extension during therapy respectively their early detection in case of recurrence.