PMC5546056_01
(a) Preoperative axial CT scan of the brain (bone window) showing osteolytic changes with associated soft tissue swelling. (b) Preoperative unenhanced parasagittal T1-weighted MRI image showing hyperintense epidural cystic mass compressing the cortex underlying. (c) Preoperative axial T2-weighted MRI image showing mildly hyperintense mass on the right parietal region. (d) Preoperative FLAIR coronal MRI showing hyperintense mass that traverses the skull.
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Investigations also included CT brain, which demonstrated a lytic bony lesion with classic sunburst periosteal reaction measuring 4.3 x 3.1 x 5.4 cm (Figure 1(a)). T2-weighted image sequences which involved full skull thickness and has an epidural extension. The lesion demonstrates significant heterogenous enhancement after gadolinium administration, with adjunct focal dural enhancement. The gradient echo sequences demonstrate some areas of susceptibility artifacts within the lesion representing calcification (Figures 1(b), 1(c), and 1(d)).
(a) Axial and (b) coronal contrast-enhanced chest CT scan showing malignant looking pleural-based lobulated left upper lobe soft tissue.
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Further screening with CT scan of the chest and abdomen did not reveal any lesions aside from the lung nodule, which was malignant, looking like pleural-based lobulated left upper lobe soft tissue mass, with central necrosis measuring 4.1 x 5.3 cm (Figures 2(a) and 2(b)).
Intraoperative photographs showing (a) the cystic destructive skull lesion, (b) inner side of the lesion after reflection of bone flap, (c) outer side of lesion after excision, and (d) inner side of the lesion after excision. Duraplasty and the application of titanium mesh (e) followed by the application of cement (f).
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The skull flap was reflected, and the lesion was identified without scalp involvement (Figure 3(a)). The entire lesion was excised; it was brown in color, slippery, and with high viscosity (Figures 3(b), 3(c), and 3(d)). Titanium mesh was fixed, and cement was applied to fill the bony defect resulting from the craniotomy (Figures 3(e) and 3(f)).
Both lung (a) and (b) skull bone and dura specimens demonstrating infiltrative glandular epithelium with intracytoplasmic mucin and hyperchromatic nuclei, some showing prominent nucleoli (hematoxylin & eosin, magnification x200).
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The nuclei are hyperchromatic and mildly pleomorphic with some showing prominent nucleoli (Figure 4).
Tumor cells are positive for Napsin A staining in (a) lung and (b) skull bone and dura specimens (immunohistochemistry, magnification x200).
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It is also positive for cytokeratins CK7 and CK19 but negative for CK20, caudal type homeobox 2 (CDX2), and thyroid transcription factor-1 (TTF1) (Figure 5).
Postoperative nonenhanced (a) bone window and (b) brain window axial CT showing a metallic mesh over the site of bony resection, with no associated intracranial hemorrhage or residual bony lesion.
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The follow-up CT scan (Figure 6) revealed good reconstruction, and MRI scan revealed no recurrence at one-year follow-up.