Other Sites of Metastasis

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The liver is an unusual site of metastasis but is a more common site in NSGCT cases than in seminoma cases. In patients with NSGCTs, metastases can be mistaken for simple cysts because these metastases may be low-density (cystic) lesions (see Figure 6-13). If doubt exists regarding the presence or character of a lesion, then ultrasonography or MRI may provide useful additional information. Ultrasonography is also useful for guiding biopsies of focal lesions in the liver that are suspected of representing metastases.

Although MRI is the preferred technique for investigating brain metastases, CT is an excellent alternative. Patients who are at high risk (with

Brain Metastasis Stage

Figure 6-12. Postsurgical change. This patient underwent retroperitoneal nodal dissection following chemotherapy for stage II nonseminomatous germ cell tumor. Early postsurgical computed tomography showed a 2 cm well-defined cystic lesion within the right retroperitoneum (arrow), in keeping with a lymphocele. Note the surgical clip adjacent to the left psoas muscle.

Figure 6-12. Postsurgical change. This patient underwent retroperitoneal nodal dissection following chemotherapy for stage II nonseminomatous germ cell tumor. Early postsurgical computed tomography showed a 2 cm well-defined cystic lesion within the right retroperitoneum (arrow), in keeping with a lymphocele. Note the surgical clip adjacent to the left psoas muscle.

embryonal carcinoma elements, or with vascular invasion and lymphatic invasion) may harbor occult brain metastases. Such metastases are usually hem-orrhagic and therefore have characteristic appearances on both MRI and CT.31 They have very high

Liver Tumor Metastasis From Lung
Figure 6-13. Lung and liver metastases in a 45-year-old man with nonseminomatous germ cell tumor. A, Computed tomography (CT) demonstrated multiple rounded metastases within the lung bases. B, CT also showed several low-density metastases within the liver.

signal intensity on T1-weighted unenhanced MRI (Figure 6-14) and frequently have a low-signal-intensity peripheral rim representing hemosiderin and other degradation products from the hemorrhage. On unenhanced CT, these metastases have a very high density due to hemorrhage. On contrast-enhanced imaging with CT and MRI, these metastases enhance, and, similarly to other brain metastases, the lesions are usually surrounded by edema on both unenhanced and enhanced CT and MRI.

Metastases to bone are relatively rare and are usually suspected on the basis of clinical features. Radionuclide bone scanning, plain-film radiography, CT, and MRI all have a place in diagnosis and will demonstrate the characteristic features of bone metastases. There are no imaging findings that distinguish testicular tumor bone metastases from other primary sites of disease. Bone deposits are usually destructive lesions, and CT or MRI may show an associated soft-tissue mass.

Although rare at the time of staging, metastases may develop in any site, and scans should be carefully scrutinized to cover all areas. It is also important to recognize incidental disease that may mimic metastases, such as an incidental renal carcinoma or

Seminoma Metastasis Brain
Figure 6-14. Hemorrhagic brain metastasis. Unenhanced axial T1-weighted magnetic resonance imaging through the brain revealed a high-signal lesion surrounded by a rim of relatively low-signal edema within the right parietal lobe, typical of a hemorrhagic metastasis.

a nonfunctioning adrenal tumor.32

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