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Year : 2020  |  Volume : 57  |  Issue : 2  |  Page : 209--211

Unusual cause of seizure in a child: Intracranial calcified metastasis of osteosarcoma

Venkatesh Hosur Ananthashayana1, Manisha Jana1, Sumeet S Malapure2, Arun K Gupta1,  
1 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
2 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Venkatesh Hosur Ananthashayana
Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi
India

Abstract

Intracranial parenchymal calcification has both benign and malignant etiologies. Calcifications by malignant etiologies are comparatively rare. Malignant calcification has numerous causes. Calcified brain metastasis from osteosarcoma is one such cause. We present histopathologically confirmed intracranial calcified metastasis in a 10 year old girl. This girl had received treatment for primary osteosarcoma of the left femur with pulmonary metastases. Radiological imaging with Positron emission tomography–computed tomography revealed an intracranial calcified lesion in the frontal lobe and she was successfully operated for the same. The malignant causes of intracranial calcifications are reviewed and radiological differential diagnoses of malignant intracranial calcifications are discussed in this case report. Prior history, strong clinical suspicion, and radiological imaging are needed to arrive at the diagnosis of intracranial calcified metastasis from primary osteosarcoma of the appendicular skeleton.



How to cite this article:
Ananthashayana VH, Jana M, Malapure SS, Gupta AK. Unusual cause of seizure in a child: Intracranial calcified metastasis of osteosarcoma.Indian J Cancer 2020;57:209-211


How to cite this URL:
Ananthashayana VH, Jana M, Malapure SS, Gupta AK. Unusual cause of seizure in a child: Intracranial calcified metastasis of osteosarcoma. Indian J Cancer [serial online] 2020 [cited 2020 Sep 25 ];57:209-211
Available from: http://www.indianjcancer.com/text.asp?2020/57/2/209/283527


Full Text



 Introduction



Osteosarcoma is the most common primary tumor of the bone in thefirst two decades of life.[1] Lung is the most common site of metastasis. Second most common site is metastasis to another noncontiguous bone. Metastasis to brain is uncommon, and calcified brain metastases are rare, with only few cases being reported.[1] Here, we report a patient with osteosarcoma of long bone with calcified metastasis to the brain.

 Case Report



A 10 year old girl was reported to the pediatric casualty with an episode of seizure. The patient had been diagnosed with osteosarcoma of the left femur at 6 years of age and had undergone above-knee amputation. Review of previous investigations, 99mTc-MDP skeletal scintigraphy [Figure 1], showed single large mass involving the distal end of the left femur with increased radiotracer uptake, consistent with primary osteosarcoma. The patient had undergone chemotherapy (high-dose methotrexate) for six months after the surgery. Two years after the surgery, the patient reported to have one calcified metastasis in the right lung and two calcified metastases in the left lung [Figure 2]c, for which she underwent metastasectomy and repeat chemotherapy (high-dose methotrexate, doxorubicin, cisplatin) for 12 months. After that, the patient was on regular follow-up and had no significant disease-related issues.{Figure 1}{Figure 2}

She underwent noncontrast CT of head to evaluate the cause of seizure episode. Noncontrast CT showed a well-defined single (6 × 5.5 cm) intra-axial calcified parenchymal lesion in the left frontal lobe with mild perilesional edema [Figure 2]a and b]. PET-CT scan showed increased tracer uptake in the same lesion. Underlying bone was normal in both noncontrast CT and PET-CT. History and imaging findings suggested a possibility of calcified brain metastasis from osteosarcoma of the femur. Surgical resection of brain metastasis was done with no major complications during the intraoperative and postoperative period. Subsequent histopathological examination confirmed the metastasis of osteogenic origin. The patient was discharged and kept on follow-up for 3 months without any significant complaints. She was followed up with fluorodeoxyglucose (FDG)-PET-CT after 3 months, which showed a coin-shaped calcified lesion with FDG uptake suggestive of the recurrent or residual tumor [Figure 2]d. The patient was asymptomatic after 6 months of follow-up, after which she did not turn up for follow-up or further treatment.

 Discussion



Metastases with calcification are seen in lung carcinoma, breast carcinoma, osteosarcoma, ovarian tumors, squamous cell carcinoma of uterus and cervix, and adenocarcinoma.[2],[3] Cranial metastases from osteosarcoma are uncommon and calcified brain metastases are rare.[1] Till now, approximately 80 cases of intracranial metastases from osteosarcoma have been reported in English literature and less than one-third of these metastases were calcified.[1] Usually, brain metastases occur in an individual with prior pulmonary metastases as seen in our case, the hypothesis being the dissemination of tumor embolus from lung to brain. Most common location of the metastases is frontal lobe, which is seen in our case also.[2] In our patient, the interval between pulmonary metastases and initial diagnosis of the primary tumor was about 2 years, and the interval between pulmonary and brain metastases was almost 2 years. Standard care of treatment for solitary metastasis to brain is surgical excision, with radiotherapy and chemotherapy reserved as the palliative measures. Prognosis of the patient with brain metastases ranges from several months to years. Several studies also recommend periodical brain imaging in patients with active pulmonary metastases.[1]

The imaging differential diagnoses for this pattern of the calcified parenchymal lesion are calcified granuloma, calcified hematoma, and primary intra-axial tumors with calcification. Completely calcified granuloma and calcified hematoma do not show perilesional edema, and FDG uptake is unlikely. Large size of the lesion and lack of history of trauma further exclude this diagnosis. The primary intra-axial supratentorial tumors, which show calcification, are oligodendroglioma and neuronal–glial tumors. However, complete calcification of tumor is uncommon and they show variable solid component. Prior history of metastatic osteosarcoma and radiological findings supports the diagnosis of calcified intracranial metastasis of osteosarcoma.

 Conclusion



Even though intracranial calcified metastasis from osteosarcoma is rare, strong clinical suspicion, prior history, and radiological examination are needed to arrive at the diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Shweikeh F, Bukavina L, Saeed K, Sarkis R, Suneja A, Sweiss F, et al. Brain metastasis in bone and soft tissue cancers: A review of incidence, interventions, and outcomes. Sarcoma 2014;2014:475175.
2Teksam M, Cevik B, Coskun M. Calcified brain metastasis of osteosarcoma: CT findings. Eur J Radiol Extra 2004;52:47-9.
3Umezu H, Sano T, Aiba T, Unakami M. Calcified intracranial metastatic tumor mimicking meningioma--case report. Neurol Med Chir (Tokyo) 1994;34:108-10.