Metastatic tonsillar squamous cell carcinoma. Evaluate for progression of brain metastasis.Additional clinical history from electronic medical records: 60 y/o female with a history of stage IV tonsil SCCa (HPV-) s/p CRT completed in 2/2012, salvage R neck dissection in 7/2012, with biopsy-proven lung oligometastasis in 6/2014, s/p RT to a LUL nodule (40 Gy/10 fxs) and two left perihilar lesions (50 Gy/10 fxs) completed in 8/2014. She was found to have brain metastases in 2015 and underwent resection followed by post-op SRS for a L temporal lesion in 3/2015. She recently presented with progressive intracranial and extracranial disease. She also received palliative whole brain radiotherapy in April 2016. Multiple cortically-based and intra-sulcal, contrast-enhancing lesions involving both cerebral hemispheres have become more prominent and slightly larger. The largest lesion which involves the left occipital lobe measures maximally in the axial plane 16 mm, compared to 13 mm previously. The lesion seems to involve the adjacent leptomeningeal disease and is associated with mild but increased perilesional edema. The second largest lesion, which is located more superiorly at the junction between the left parietal and occipital lobes, measures maximally 8 mm compared to 7 mm previously and is also now associated with mild surrounding edema. A third lesion involving the right precentral gyrus measures up to 8 mm in the axial plane, compared to 7 mm previously. There are also a few tiny new contrast-enhancing lesions with associated focal diffusion restriction in the left frontal and anterior left parietal lobes. There is slightly increased contrast enhancement at the site of previous metastectomy from the lateral left temporal lobe but this area is partially obscured and affected by susceptibility artefact from the overlying craniotomy. There is no significant mass-effect. The ventricles and other CSF-containing spaces are slightly larger than before, reflecting mild underlying volume loss. There is no acute territorial infarct or intracranial hemorrhage. Foci of diffusion restriction involving the left supramarginal gyrus and left cerebellar hemisphere are resolved/evolved. There is no midline shift or herniation. The major vascular flow voids are preserved.There are multiple contrast-enhancing skull lesions, the largest of which involves the left occipitotemporal region and measures up to 9 mm in the axial plane, compared to 5 mm previously. Minimal fluid intensity in the left mastoid air cells is unchanged. The orbits are grossly unremarkable.
1.Since March 2016, there has been an increase in the number and, to a lesser extent, the size of multiple small cortical and intra-sulcal contrast-enhancing lesions, concerning for progression of metastatic disease. The larger lesions are now associated with mild surrounding edema. There is no significant mass-effect or brain herniation. There is no acute intracranial hemorrhage.2.Increased contrast enhancement at the site of previous surgery in the left temporal lobe is less specific and may reflect progression of residual/recurrent metastasis but may also reflect posttreatment change.3.New/enlarging skull lesions are compatible with osseous metastasis.