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Case Report

Pulmonary metastases of malignant meningioma

[version 1; peer review: 3 approved with reservations, 1 not approved]
PUBLISHED 21 Oct 2013
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Abstract

Meningioma accounts for approximately one-third of primary central nervous system tumors. Most meningiomas are benign, although up to one third are classified as atypical or malignant. We describe a 63-year Caucasian male presenting with pleural metastases from an intracranial meningioma. Distant metastases from meningiomas are infrequently found in clinical practice and mostly are associated with atypical or malignant meningiomas. There is no standard treatment; however surgical resection of both the primary and metastatic lesions is the safest therapy. The overall prognosis of atypical meningiomas is poor. Our patient died one week after discharge from our hospital.

Case report

A 63-year-old Caucasian man was referred to our hospital for further analysis of slowly progressing pleural effusion with a history of cough and dyspnea. The patient had a long history of epilepsy and meningioma. He was working as head in a department of administration. He was married and had two healthy kids. As a medication he took Pantoprazol, Tegretol and Dorsolamide and had stopped smoking a long time ago.

Our patient was diagnosed with progression of a previous operated and irradiated (60 GY) atypical left parieto-occipital meningioma (WHO grade-II). Re-resection of the tumor was performed and histopathology showed a malignant meningioma (WHO grade-III). After reoperation, re-irradiation (60GY + additional 70GY) was given. One year later an asymptomatic re-recurrence was diagnosed (Figure 1A and B), for which conservative follow-up was performed without further surgical intervention.

a3c3aafe-22fd-4c70-afa5-e9d710505ad6_figure1.gif

Figure 1. MRI and CT scanning of the original meninigioma intra-cerebral and at distance metastasis intra-pleural.

A: T1 weighted image after administration of Gadolinium based contrast fluid shows a large extra-axial enhancing lesion in the left parieto-occipital region with local mass effect. Note that the sagittal sinus seems to be invaded. B: Contrast enhanced T1 weighted image after administration of Gadolinium based contrast fluid showing a large resection cavity after the second operation and recurrent disease at the most upper margin of the resection plane with enhancing areas surrounding the sagittal sinus. C: Midthoracal CT slice in the transverse plane. Scan performed after i.v. administration of iodine contrast. The lesion is easily distinguished at the left ventral thoracal intrapleural space, slightly enhanced suggesting solid tissue. Some pleural fluid is also present.

A few months later the patient was hospitalized with dyspnea, fatigue, productive cough and anorexia. Multiple pleural masses were detected at a chest computer-tomography (CT) scan. Histopathology was consistent with malignant meningioma (WHO grade-III, Figure 2A), there was a high expression in the EMA staining, also in the AE1/AE3 staining (Figure 2B). The CD 45 and CD 68 were positive and MIB-1 showed high proliferation. Palliative chemotherapy was offered but refused by the patient. The patient is died one week after discharge from the hospital as a result of voluntary euthanasia as was the will of the patient (valid written declaration).

a3c3aafe-22fd-4c70-afa5-e9d710505ad6_figure2.gif

Figure 2. Histology staining of a biopsy of the solid intrathoracal lesion showing the same morphology as the intracranial meningioma.

A: A specimen (HE-stained, 40x) showing histological resemblance between the intrathoracal lesion and the intracranial meningioma. B: Specimen (focal plus and focal weak) showed high expression in the EMA-staining and also in the AE1/AE3-staining.

Discussion

Pulmonary and pleural metastases from an intracranial meningioma are very rare. Distant metastases from meningiomas are infrequently found in clinical practice and mostly associated with atypical or malignant meningiomas. Meningiomas mainly recur loco-regional or adjacent to the radiation treatment fields1,2. There are only isolated case reports regarding pulmonary metastases from meningioma. Most lung metastases were incidentally detected by chest radiography or by CT-scans, because metastatic lesions are usually asymptomatic. The presence of pulmonary metastases appears to negatively affect survival in patients with recurrent meningioma3,4.

Regarding the relationship between the intracranial location and invasion of the sagittal sinus of the tumor and the pleural metastases the route of dissemination is most probably the central venous route to heart and lungs5. In previous case reports the lung was the most common extracranial metastatic site for intracranial meningioma6.

In this case, histopathologic findings of the primary tumor revealed hypercellularity, wide necrosis, and brain invasion into the normal brain parenchyma. Pathology of the lesion from the left thoracic wall was consistent with malignant meningioma.

Other case studies described that treatment of pulmonary metastasis of malignant meningioma consisted of surgical resection for both the primary or metastatic lesions1,5,7.

Postoperative conventional radiation therapy has been recommended for prevention of local recurrence, especially when resection is subtotal.

Informed consent

Written informed consent for publication of clinical details and clinical images was obtained from the next of kin.

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VERSION 2 PUBLISHED 21 Oct 2013
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Basunaid S, Franssen FME, Accord R et al. Pulmonary metastases of malignant meningioma [version 1; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2013, 2:222 (https://doi.org/10.12688/f1000research.2-222.v1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 21 Oct 2013
Views
29
Cite
Reviewer Report 21 Aug 2014
Antonio Santacroce, Department of Neurosurgery, Heinrich Heine University, Dusseldorf, Germany 
Approved with Reservations
VIEWS 29
Basunaid et al. report on a patient harboring a recurrent meningioma who developed pleural metastases. The primary tumour is reported to be an atypical meningioma WHO Gr II, which upon recurrence shows a malignant histology WHO Gr. III.

I share the ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Santacroce A. Reviewer Report For: Pulmonary metastases of malignant meningioma [version 1; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2013, 2:222 (https://doi.org/10.5256/f1000research.2443.r5747)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
26
Cite
Reviewer Report 27 Jun 2014
Christine Marosi, Department of Oncology, Medical University of Vienna, Vienna, Austria 
Approved with Reservations
VIEWS 26
I fully agree with the reviewer from Bonn, Matthias Simon. Meningiomas grade III are fortunately rare and they do metastasize through vascular pathways. Of course a register of such cases would be a valuable tool to get an idea of ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Marosi C. Reviewer Report For: Pulmonary metastases of malignant meningioma [version 1; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2013, 2:222 (https://doi.org/10.5256/f1000research.2443.r5253)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 27 Jun 2014
    Suhail Basunaid, Mayo University Hospital,, Ireland
    27 Jun 2014
    Author Response
    I would like to thank Dr. Marosi for her time spent on reviewing this case report, and the valuable comments given. I would like to leave my current version as ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 27 Jun 2014
    Suhail Basunaid, Mayo University Hospital,, Ireland
    27 Jun 2014
    Author Response
    I would like to thank Dr. Marosi for her time spent on reviewing this case report, and the valuable comments given. I would like to leave my current version as ... Continue reading
Views
30
Cite
Reviewer Report 16 Jan 2014
Matthias Simon, Department of Neurology, University of Bonn, Bonn, Germany 
Approved with Reservations
VIEWS 30
Basunaid et al. describe a patient with a recurrent meningioma who ultimately developed pleural metastases. The primary tumor was assigned to WHO grade II, and the recurrent tumor to grade III. While this paper by itself does not provide truly novel information, ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Simon M. Reviewer Report For: Pulmonary metastases of malignant meningioma [version 1; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2013, 2:222 (https://doi.org/10.5256/f1000research.2443.r2861)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 27 Jun 2014
    Suhail Basunaid, Mayo University Hospital,, Ireland
    27 Jun 2014
    Author Response
    I would like to thank Dr. Simon for his time and valuable comment. I wish to leave my current version as it is.
    Competing Interests: No competing interests were disclosed.
COMMENTS ON THIS REPORT
  • Author Response 27 Jun 2014
    Suhail Basunaid, Mayo University Hospital,, Ireland
    27 Jun 2014
    Author Response
    I would like to thank Dr. Simon for his time and valuable comment. I wish to leave my current version as it is.
    Competing Interests: No competing interests were disclosed.
Views
41
Cite
Reviewer Report 29 Oct 2013
Daniel Vorobiof, Department of Medical Oncology, Sandton Oncology Centre, Johannesburg, South Africa 
Not Approved
VIEWS 41
This case report documents an unusual spread of a malignant meningioma. It doesn't add any further ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Vorobiof D. Reviewer Report For: Pulmonary metastases of malignant meningioma [version 1; peer review: 3 approved with reservations, 1 not approved]. F1000Research 2013, 2:222 (https://doi.org/10.5256/f1000research.2443.r2143)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Reader Comment 06 Jun 2014
    Suhail Basunaid, Mayo University Hospital,, Ireland
    06 Jun 2014
    Reader Comment
    Dear Sir,

    I am not sure if you consider this an unusual spread of malignant meningioma. There were at least 3 years between the time of discovering it (by accident after a ... Continue reading
COMMENTS ON THIS REPORT
  • Reader Comment 06 Jun 2014
    Suhail Basunaid, Mayo University Hospital,, Ireland
    06 Jun 2014
    Reader Comment
    Dear Sir,

    I am not sure if you consider this an unusual spread of malignant meningioma. There were at least 3 years between the time of discovering it (by accident after a ... Continue reading

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 21 Oct 2013
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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