Occult tumors presenting with negative imaging: analysis of the literature

A review

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Object

Some patients presenting with neurological symptoms and normal findings on imaging studies may harbor occult brain tumors that are undetectable on initial imaging. The purpose of this study was to analyze the cases of occult brain tumors reported in the literature and to determine their modes of presentation and time to diagnosis on imaging studies.

Methods

A review of the literature was performed using PubMed. The authors found 15 articles reporting on a total of 60 patients with occult tumors (including the authors' illustrative case).

Results

Seizures were the mode of initial presentation in a majority (61.7%) of patients. The initial imaging was CT scanning in 55% and MRI in 45%. The mean time to diagnosis for occult brain tumors was 10.3 months (median 4 months). The time to diagnosis (mean 7.5 months, median 3.2 months) was shorter (p = 0.046) among patients with seizures. Glioblastoma multiforme (GBM) was found more frequently among patients with seizures (67.6% vs 34.8%, p = 0.013). The average time to diagnosis of GBM was shorter than the time to diagnosis of other tumors; the median time to diagnosis was 3.2 months for GBM and 6 months for other tumors (p = 0.04). There was no predilection for side or location of occult tumors. In adult patients, seizures may be predictive of left-sided tumors (p = 0.04).

Conclusions

Based on the results of this study, the authors found that in patients with occult brain tumors, the time to diagnosis is shorter among patients with seizures and also among those with GBM.

Abbreviation used in this paper:GBM = glioblastoma multiforme.

Article Information

Address correspondence to: Anil Nanda, M.D., Department of Neurosurgery, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, Louisiana 71130-3932. email: ananda@lsuhsc.edu.

Please include this information when citing this paper: published online April 13, 2012; DOI: 10.3171/2012.3.JNS112098.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Axial CT head scan obtained without contrast revealing a hyperdensity in the left frontal region. There were no abnormalities noted in the images.

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    Axial MRI studies of the brain with and without Gd contrast agent revealing the presence of a nonenhancing left frontal lesion. The lesion appeared hypointense on T1-weighted images obtained with Gd contrast (left), and it appeared hypointense on T2-weighted images as well (right). A diagnosis of unruptured cavernous malformation was made based on the typical MRI findings.

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    The patient presented next with altered mental status and headaches. At this time, a head CT scan performed without contrast agents in the emergency department revealed a hyperdense lesion (left) and a large amount of edema (right) in the left frontal region.

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    Axial MRI studies of the brain revealing a large border-enhancing lesion in the left frontal region (left), with evidence of severe edema in the left frontal region (right).

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    An MRI study of the brain obtained at the time of diagnosis revealed that the originally discovered left frontal cavernous malformation had been displaced posteriorly due to neoplastic expansion. Axial Gd-enhanced T1- (A) and T2-weighted (B) images reveal the cavernous malformation. A sagittal Gd-enhanced T1-weighted image (C) reveals the new location of the displaced incidental cavernous malformation.

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    Low-power photomicrograph demonstrating the presence of a markedly cellular glial neoplasm with microvascular proliferation and pseudopalisading necrosis. H & E, original magnification × 200.

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    High-power photomicrograph showing the astrocytic character of mildly to moderately pleomorphic neoplastic glial cells. Abundant typical and atypical mitotic figures are present. H & E, original magnification × 400.

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    A graphic representation of the growth rate of occult tumors. The x axis represents days, with initial clinical presentation at Day 0. The imaging characteristics (median duration) identified in this study are represented above the x axis. Below the x axis are the potential investigative and therapeutic intervention points along the timeline. Above the x axis, the potential change in size of these tumors is depicted. A deeper understanding of growth rates of occult tumors from large studies will assist in making these points clear and based on evidence.

References

1

ACEP Clinical Policies Committee Clinical Policies Subcommittee on Seizures: Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 43:6056252004

2

Baehring JMBi WLBannykh SPiepmeier JMFulbright RK: Diffusion MRI in the early diagnosis of malignant glioma. J Neurooncol 82:2212252007

3

Bolender NFCromwell LDGraves VMargolis MTKerber CWWendling L: Interval appearance of glioblastomas not evident in previous CT examinations. J Comput Assist Tomogr 7:5996031983

4

Chaichana KLChaichana KKOlivi AWeingart JDBennett RBrem H: Surgical outcomes for older patients with glioblastoma multiforme: preoperative factors associated with decreased survival. Clinical article. J Neurosurg 114:5875942011

5

Confavreux CVighetto ABoisson DAimard GDevic M: [Isolated late epilepsy disclosing glioblastoma and false negatives on the scanner.]. Nouv Presse Med 10:25161981. (Fr) (Letter)

6

De Vile CJSufraz RLask BDStanhope R: Occult intracranial tumours masquerading as early onset anorexia nervosa. BMJ 311:135913601995

7

Gömöri EHalbauer JDKasza GVarga DHorvath ZKomoly S: Glioblastoma multiforme with an unusual location and clinical course. Clin Neuropathol 28:1651672009

8

Gupta KLDuvall ERVitek JJStanley RJFaught RE: Occult gliomas demonstrated by serial CT scans in new onset of seizures. Ala J Med Sci 25:1591631988

9

Hylton PDReichman OH: Clinical manifestation of glioma before computed tomographic appearance: the dilemma of a negative scan. Neurosurgery 21:27321987

10

Jung TYJung S: Early neuroimaging findings of glioblastoma mimicking non-neoplastic cerebral lesion. Neurol Med Chir (Tokyo) 47:4244272007

11

Krumholz AWiebe SGronseth GShinnar SLevisohn PTing T: Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 69:199620072007

12

Landy HJLee TTPotter PFeun LMarkoe A: Early MRI findings in high grade glioma. J Neurooncol 47:65722000

13

Laws ERParney IFHuang WAnderson FMorris AMAsher A: Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the Glioma Outcomes Project. J Neurosurg 99:4674732003

14

Lesoin FSalomez JLClarisse JJomin M: [Isolated late epilepsy as manifestation of glioblastoma. True negative tests with the scanner.]. Nouv Presse Med 11:38591982. (Fr) (Letter)

15

Listernick RCharrow JGreenwald M: Emergence of optic pathway gliomas in children with neurofibromatosis type 1 after normal neuroimaging results. J Pediatr 121:5845871992

16

Massry GGMorgan CFChung SM: Evidence of optic pathway gliomas after previously negative neuroimaging. Ophthalmology 104:9309351997

17

Nishi NKawai SYonezawa TFujimoto KMasui K: Early appearance of high grade glioma on magnetic resonance imaging. Neurol Med Chir (Tokyo) 49:8122009

18

Okamoto KIto JTakahashi NIshikawa KFurusawa TTokiguchi S: MRI of high-grade astrocytic tumors: early appearance and evolution. Neuroradiology 44:3954022002

19

Tentler RLPalacios E: False-negative computerized tomography in brain tumor. JAMA 238:3393401977

20

Walker RLieberman ANPinto RGeorge ARansohoff JTrubek M: Transient neurologic disturbances, brain tumors, and normal computed tomography scans. Cancer 52:150215061983

21

Westra IDrummond GT: Occult pontine glioma in a patient with hemifacial spasm. Can J Ophthalmol 26:1481511991

22

Wulff JDProffitt PQPanszi JGZiegler DK: False-negative CTs in astrocytomas: the value of repeat scanning. Neurology 32:7667691982

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