Metastatic meningiomas: an unusual clinical and pathological diagnosis with highly variable outcome

Metastasis of WHO Grade II Meningioma With Subsequent Pathological T12 Fracture: A Case Report

CASE

A 64-year-old woman with a history of World Health Organization Grade II (Ki-67 20%) atypical meningioma presented with T12 vertebral body burst fracture as a complication of metastatic meningioma (SSTR2+). Following disease progression, decompression surgery and stabilization through T10-L2 posterior thoracolumbar instrumented fusion was performed.

CONCLUSION

This is one of few documented cases of spinal metastatic meningioma causing pathological fracture and the first to detail surgical management and longitudinal follow-up. Applying the neurologic, oncologic, mechanical, and systemic decision framework to this rare presentation, the patient was indicated for the selected surgical approach, yielding short-term improvement of patient outcome and neurologic deficit.

A systematic review of extraneural meningioma metastasis: timing, evolution and outlook

PURPOSE

Extraneural meningioma metastasis is a rare occurrence and may pose a clinical challenge due to its unclear prognosis. In this systematic review, we analyze patient demographics, clinical characteristics, management strategies, and outcomes.

METHODS

PubMed, EMBASE, Scopus, Cochrane, and Web of Science databases were searched from inception to February 23, 2024 for cases of metastatic meningioma according to PRISMA guidelines. Descriptive statistics, Mann-Whitney U test, Fisher's exact tests, Kaplan-Meier curves, and log-rank tests were used for selected analyses.

RESULTS

A total of 288 patients (52% male) were included with an average age of 49 years at meningioma diagnosis. Tumors were distributed across WHO grade 1 (38%), 2 (36%), and 3 (26%). Most patients experienced intracranial recurrence (79%) and mean time to first metastasis was approximately 8 years. No change in WHO grade between primary and metastasis was observed for most cases (65%). Treatment of the initial metastasis was most often with surgery (43%), chemotherapy (20%), or no treatment (14%). Half of the patients were alive (50%) with an average follow-up of 3 years following metastasis. Overall median survival was 36 months for the entire cohort. This differed significantly between WHO grade 1 versus 2/3 meningioma primaries (168 vs. 15 months, p < 0.005).

CONCLUSION

Metastatic meningioma appears to be associated with more positive prognosis than other brain tumor types with extra-neural metastasis or metastasis in general. This is particularly true for cases arising from a WHO grade 1 meningioma.

Evolution of a Meningothelial Meningioma: From WHO Grade 1 to Anaplastic Grade 3 with Extracranial Metastasis Including Extensive Liver Metastasis

A 61-year-old patient was diagnosed with a left-sided falx meningioma. Histopathological analysis following extirpation showed a meningothelial meningioma ZNS WHO grade 1 with sparse mitoses. Over the course of 12 years, the patient received irradiation (54.0 Gy), peptide radio-receptor therapy (177Lu-DOMITATE) and targeted therapy (mTOR inhibitor). Follow-up imaging revealed an increased size of the residual tumor. Due to increased liver function parameters, imaging of the liver was performed, showing widespread space-occupying lesions with atypical appearance. Biopsy revealed metastasis of the meningioma, now with 2.7 mitoses/mm2, necrosis and homozygous CDKN2A/B deletion, corresponding to an anaplastic CNS meningioma WHO grade 3. A second small meningioma on the left petroclival side has been consistent in size over 12 years. Metastatic meningiomas pose a pertinent clinical challenge due to poor prognosis. The lung, bone, liver and cervical lymph nodes are the most common sites of extracranial metastasis. According to the World Health Organization criteria, the most important predictive factor for recurrence and metastasis is the tumor grade.

Multiparametric 18F-FDG and 68GA-DOTATOC PET Imaging in Bone Metastatic Meningioma Before Radionuclide Therapy: Assessment of Tumor Heterogeneity

ABSTRACT

This report presents the case of a 61-year-old woman with assessment of fronto-temporo-sphenoidal refractory meningioma before radionuclide therapy with pretherapeutic 68Ga-DOTATOC PET/CT. Given the discovery of osteolytic lesions, 18F-FDG PET/CT is planned to search for the primitive origin. Meningioma bone metastasis is confirmed with spine biopsies. The presence of dedifferentiated meningioma lesions indicating that high somatostatin receptor expression does not necessarily coincide with areas of increased glucose metabolism. 18F-FDG and 68Ga-DOTATOC PET/CT allows optimal characterization of tumor heterogeneity and guide targeted therapeutic management before PPRT.

Surgical management of de novo metastatic meningioma of the spine: An underestimated issue for WHO grade II/III meningiomas

OBJECTIVES

Meningioma is a slow-growing neoplasm derived from meningothelial cells. Extradural metastasis of WHO grade II/III meningiomas is relatively rare, and spinal metastatic meningiomas (SMM) have only been described in individual case reports. The aim of the present study is to discuss the clinical features and treatments of SMM patients.

METHODS

Fourteen SMM patients who received surgery in our center between 2010 and 2020 were reviewed retrospectively. Possible prognostic factors affecting local progression-free survival (LPFS) and overall survival (OS) were analyzed by log-rank analysis.

RESULTS

Our series comprised nine men and five women, with a median age of 49 years. The interval from the primary treatment to SMM varied from 1 to 11 years. Lesions were mainly located in the lumbar-sacral region (7/14, 50.0%), followed by the thoracic spine (5/14, 35.7%) and cervical (2/14, 14.3%) spine. The median follow-up period was 42.7 months, during which six patients (42.9%) passed away. Local tumor progression was detected in four patients (28.6%). Log-rank analysis indicated that circumferential surgery was associated with good LPFS, whereas WHO grade III and visceral metastasis were factors adversely affecting OS.

CONCLUSIONS

SMM is a challenging clinical entity, usually occurring in the fourth to fifth decades of life. Circumferential surgery is associated with good LPFS. WHO grade III and visceral metastasis are factors adversely affecting OS of patients with SMM. Long-term follow-up is recommended for patients who have received surgical treatment for primary meningiomas (Simpson Grade III/IV), especially for WHO III lesions.

The Myth of Prometheus in metastatic meningioma to the liver: from craniotomy to hepatectomy

Metastases from intracranial meningiomas are rare, and among them, meningiomas with hepatic dissemination are extremely rare. Therefore, there are currently no guidelines for staging and treatment of metastatic disease in meningioma, a disease that is a challenge for both the clinician and the pathologist. Our literature review revealed 24 cases of liver metastases originating from intracranial meningiomas. We used them to analyze the pathological patterns of dissemination and to assess the different management strategies available, the most efficient and beneficial being surgery and chemotherapy, especially in the case of meningiomas with hepatic and∕or systemic dissemination.

Meningioma sampling: how much is enough for the accurate grading of atypical meningiomas?

Meningioma grading relies on several pathological criteria (brain invasion, mitotic count, sheeting, small cell foci, necrosis, macronucleoli and hypercellularity) and histopathological subtypes. Regardless of histopathological subtype, the presence of these pathological parameters can be focally present and not present on each slide of a meningioma. We performed (1) a retrospective work comparing the frequency of parameters used for meningioma grading between two periods with different sampling techniques, and (2) we calculated the probability of presence of each criterion on resected meningiomas entirely processed included and examined. First, we compared two time periods: between 2002-2008 where meningiomas were not all entirely sampled, and between 2012-2018 where all meningiomas were entirely sampled. The frequency of tumour grades was not significantly different between the two periods (p=0.17). Mitosis ≥4/1.6mm², small cell foci, macronucleoli and hypercellularity were more frequently found when meningiomas were entirely sampled (p<0.05). Second, we focused on 59 grade 2 meningiomas entirely sampled to highlight the distribution of histopathological parameters used for meningioma grading. We have shown that a correct grading of more than 95% of meningiomas can be achieved when at least six slides are examined. Our work suggests that meningioma sampling might be an issue and the sampling system must be specified in research works on grading.

DNA methylation profiling demonstrates superior diagnostic classification to RNA-sequencing in a case of metastatic meningioma

Meningiomas are the most common primary intracranial tumors, but meningioma metastases are rare. Accordingly, the clinical workup, diagnostic testing, and molecular classification of metastatic meningioma is incompletely understood. Here, we present a case report of multiply recurrent meningioma complicated by liver metastasis. We discuss the patient presentation, imaging findings, and conventional histopathologic characterization of both the intracranial lesion and the metastatic focus. Further, we perform multiplatform molecular profiling, comprised of DNA methylation arrays and RNA-sequencing, of six stereotactically-guided samples from the intracranial meningioma and a single ultrasound-guided liver metastasis biopsy. Our results show that DNA methylation clusters distinguish the liver metastasis from the intracranial meningioma samples, and identify a small focus of hepatocyte contamination with the liver biopsy. Nonetheless, DNA methylation-based classification accurately identifies the liver metastasis as a meningioma with high confidence. We also find that clustering of RNA-sequencing results distinguishes the liver metastasis from the intracranial meningiomas samples, but that differential gene expression classification is confounded by hepatocyte-specific gene expression programs in the liver metastasis. In sum, this case report sheds light on the comparative biology of intracranial and metastatic meningioma. Furthermore, our results support methylation-based classification as a robust method of diagnosing metastatic lesions, underscore the broad utility of DNA methylation array profiling in diagnostic pathology, and caution against the routine use of bulk RNA-sequencing for identifying tumor signatures in heterogeneous metastatic lesions.

Meningioma metastases: incidence and proposed screening paradigm

OBJECTIVE

Extracranial meningioma metastases are uncommon, occurring in less than 1% of patients diagnosed with meningioma. Due to the rarity of meningioma metastases, patients are not routinely screened for distant disease. In this series, we report their experience with meningioma metastases and results of screening for metastases in select patients with recurrent meningiomas.

METHODS

All patients undergoing resection or stereotactic radiosurgery for primary or recurrent meningioma from 2009 to 2017 at a single center were retrospectively reviewed to identify patients who were diagnosed with or underwent imaging to evaluate for systemic metastases. Imaging to evaluate for metastases was performed with CT scanning of the chest, abdomen, and pelvis or whole-body PET/CT using either FDG or 68Ga-DOTA-octreotate (DOTATATE) tracers in 28 patients. Indications for imaging were symptomatic lesions concerning for metastasis or asymptomatic screening in patients with greater than 2 recurrences being evaluated for additional treatment.

RESULTS

Of 1193 patients treated for meningioma, 922 (77.3%) patients had confirmed or presumed WHO grade I tumors, 236 (19.8%) had grade II tumors, and 35 (2.9%) had grade III tumors. Mean follow-up was 4.3 years. A total of 207 patients experienced recurrences (17.4%), with a mean of 1.8 recurrences. Imaging for metastases was performed in 28 patients; 1 metastasis was grade I (3.6%), 16 were grade II (57.1%), and 11 were grade III (39.3%). Five patients (17.9%) underwent imaging because of symptomatic lesions. Of the 28 patients screened, 27 patients had prior recurrent meningioma (96.4%), with a median of 3 recurrences. On imaging, 10 patients had extracranial lesions suspicious for metastasis (35.7%). At biopsy, 8 were meningioma metastases, 1 was a nonmeningioma malignancy, and 1 patient was lost to follow-up prior to biopsy. Biopsy-confirmed metastases occurred in the liver (5), lung (3), mediastinum (1), and bone (1). The observed incidence of metastases was 0.67% (n = 8). Incidence increased to 2% of WHO grade II and 8.6% of grade III meningiomas. Using the proposed indications for screening, the number needed to screen to identify one patient with biopsy-confirmed malignancy was 3.83.

CONCLUSIONS

Systemic imaging of patients with multiply recurrent meningioma or symptoms concerning for metastasis may identify extracranial metastases in a significant proportion of patients and can inform decision making for additional treatments.

Subcutaneous Metastasis of Atypical Meningioma: Case Report and Literature Review

BACKGROUND

Meningioma, a neoplasm of the meninges, is usually a benign localized tumor. Extraneural metastasis is an extremely rare complication of meningiomas, and only a few cases have been reported to date. The present study reports a case of scalp metastasis of an atypical meningioma and discusses the types of atypical meningiomas and their management options.

CASE DESCRIPTION

A 69-year-old man presented with scalp metastasis of an atypical meningioma. Six years after the right frontoparietal meningioma lesion was completely resected, an isolated subcutaneous metastasis developed at the right frontal region of the scalp, originating at the scar left by the first surgery. Postoperative histologic examination of the subcutaneous tumor revealed the features of an atypical meningioma.

CONCLUSIONS

This study highlights that resection of meningiomas is still associated with a risk of iatrogenic metastasis. Surgeons should carefully wash out the operative field and change surgical tools frequently to avoid the potential risk of metastasis.

Infiltration of Benign Meningioma into Sagittal Sinus and Subsequent Metastasis to Lung: Case Report and Literature Review

BACKGROUND

Meningioma is an intracranial tumor frequently encountered in the neurosurgical setting. Extracranial disease is a rare occurrence, with a reported incidence in 0.1% of cases. Metastasis is associated with previous craniotomy, venous sinus invasion, local recurrence, and World Health Organization (WHO) grade III tumor. Metastasis of a benign, grade I meningioma is extraordinarily rare.

CASE DESCRIPTION

We report a case of a 41-year-old with a WHO grade I intracranial meningioma that had invaded and occluded the superior sagittal sinus. Chest computed tomography (CT) scan revealed pulmonary nodules, which were biopsied and confirmed benign meningioma. The metastatic meningiomas were found before resection of the primary tumor, suggesting direct seeding through the venous system versus iatrogenic seeding. Thirteen years later, an additional lung mass was found incidentally on abdominal CT scan for workup of a sarcoidosis. Biopsy and subsequent resection confirmed benign meningioma. A retrospective review of earlier chest CT scans revealed a small lesion that corresponded to the larger lesion found 13 years later.

CONCLUSIONS

This a rare case of a WHO grade I meningioma involving the sagittal sinus with direct seeding of the pulmonary vascular bed leading to multiple meningioma metastases. The report highlights an increased risk of distant metastases for a benign meningioma with invasion of dural sinuses.

WHO Grade I Meningioma Metastasis to the Lung 26 Years after Initial Surgery: A Case Report and Literature Review

Metastases from meningioma grade I are especially rare. We describe a case of a 65-year-old male with meningioma WHO grade I with a history of local recurrence and distant metastasis to the lung 26 years after the initial surgery. The original tumor was localized at the occipital low convex and invaded into the venous sinus and posterior cranial fossa; it was resected. About 15 years later, the tumor recurred in the posterior cranial fossa and γ-knife radiosurgery was performed. About 4 years later, the recurred tumor was resected at our hospital. Another 7 years later, the tumor recurred in the same area and right middle cranial fossa. All tumors except that inside the venous sinus were excised. All specimens obtained were classified as meningioma WHO grade I. Preoperative examination of the third operation revealed a nodule in the lower lobe of the right lung. The nodule grew gradually. Four months after the third surgery, partial resection of the right lung was performed. Histology indicated meningioma WHO grade I. The two lesions in the cranium and lung lesions were subjected to fluorescence in situ hybridization of the NF2 gene, and the three specimens had similar findings, genetically confirming them to be metastases of the intracranial meningioma. A literature review of past cases of meningioma progression revealed that the mean duration to metastasis is 12.5, 6.8, 3.7 years for grades I, II, and III, respectively. The current case therefore has an extended time frame.

Extensive Pulmonary Metastases 13 Years after Initial Resection of Intracranial Meningioma

Background

Extracranial metastasis from intracranial meningioma is a very rare condition. A current literature review reveals that only few cases are documented with extensive pulmonary involvement >10 years after initial intracranial meningioma resection. Diagnosis of pulmonary meningioma is often confirmed by computed tomography chest-guided core biopsies. The prognosis of extensive metastatic pulmonary meningioma, however, is unknown and there is no gold standard treatment option.

Case Description

We present a case of multiple pulmonary meningioma metastases developing 13 years after initial resection of left occipital parafalcine World Health Organization Grade I intracranial meningioma.

Conclusion

There are no established guidelines for the optimal management or surveillance of extensive pulmonary metastatic meningioma. In patients with high-grade meningioma and multiple cannonball pulmonary lesions, metastatic meningioma should be considered as part of the differential diagnosis. Metastatic meningioma may occur even a decade after initial tumour resection.

Incidental Metastatic Meningioma Presenting as a Large Liver Mass

Meningiomas are slow growing neoplasms of the central nervous system (CNS). Most of the tumors are benign and distant metastasis from a benign meningioma is rare. Metastasis to the liver, although rare, usually presents with hypoglycemia or occurs in conjunction with a clinical history of an intracranial meningioma or following the resection of a prior CNS meningioma, thus making clinical diagnosis relatively easy. Here we present an unusual case of metastatic meningioma to the liver in a 54-year-old female who presented with an incidental liver mass by ultrasound. Her clinical history and physical examination were unremarkable. A partial hepatectomy revealed a meningioma on histology. Further investigation by imaging studies showed a frontal parasagittal dural mass which was confirmed to be a World Health Organization (WHO) grade 1 meningioma. To our knowledge, this is the first report of a clinically silent metastatic meningioma to the liver without either a concurrent or a previous history of meningioma. Precise diagnosis of this challenging case requires high clinical suspicion, histopathology, and immunohistochemistry.

Pulmonary and pleural metastasis of intracranial anaplastic meningioma in a 3-year-old boy: A case report

In adults, meningiomas occasionally display aggressive behavior and may occasionally metastasize. By contrast, pediatric meningiomas are rare, and there is limited information regarding their clinical characteristics, treatment and prognosis. We herein report the case of a 3-year-old boy with anaplastic meningioma with a history of local recurrence and late pulmonary metastasis. At diagnosis, a 70-mm mass lesion in was identified in the right frontal lobe, with intratumoral hemorrhage. The tumor was attached to the falx cerebri and was completely resected. The histological diagnosis was anaplastic meningioma, World Health Organization grade III. Two months after the surgery, the meningioma recurred at the same site. Although the patient received radiotherapy after a second operation, the tumor metastasized to the lung and pleura 8 months after the initial operation. The metastasis was resistant to treatment, even after gross total resection, and the effectiveness of further radiotherapy was limited. The patient succumbed to the disease 1 year and 4 months after the initial diagnosis. The findings of the present case and a review of the relevant literature suggest that recurrence and metastasis of meningiomas are difficult to predict. Therefore, such patients should be carefully monitored throughout the follow-up period.

Rhabdoid Meningioma Arising Concurrent in Pulmonary and Intracranial with a Rare Malignant Clinical Progression: Case Report and Literature Review

BACKGROUND

Rhabdoid meningioma (RM) is an unusual variant of meningioma, classified as World Health Organization grade III. Although its recurrence is common, extracranial metastasis is rare and usually misdiagnosed. The transfer mechanism and pathway are ambiguous; once the metastasis occurs, the prognosis is poor, and there is no effective management. The present case is the first report of concurrent intracranial and pulmonary RM with rapid and widespread metastasis. We hope this report can serve as a helpful reference for clinicians and radiologists.

CASE DESCRIPTION

A 39-year-old woman presented to our hospital complaining of headache and memory disturbances. Magnetic resonance imaging (MRI) of the brain revealed a well-defined, inhomogeneous signal tumor with intense enhancement and severe peritumoral edema. Postoperatively, RM (grade III) was confirmed by histopathology. A chest CT performed 2 weeks later revealed an isolated lung mass, which was confirmed as RM on subsequent surgery. Three months after the first radiotherapy, the cancer had progressed uncommonly rapidly with widespread metastasis to the cerebellum, lung, kidney, and thigh. Gamma knife radiosurgery, chemotherapy, and molecular-targeted therapy were performed; however, the patient's condition continued to worsen, and she died 1 year after the initial operation.

CONCLUSIONS

Intracranial RM is a relatively rare tumor with the potential for wide intracranial and extracranial transfer. Cystic components and necrosis can be seen in this type of meningioma. Metastatic meningioma should be kept in mind when dealing with isolated lung lesions. This case report may serve as a helpful reference for clinicians and radiologists.

[Recommendations for the organ donation from patients with brain or medullary primitive tumors on behalf of the Association of the Neuro-oncologists of French Expression (ANOCEF) and the Club of Neuro-oncology of the French Society of Neurosurgery]

Requests of organs to be transplanted increase. As a matter of urgency, it is not always easy to decide if a patient carrier of a brain tumor can be candidate in the donation. After a review of the literature, the members of the Association of the Neuro-oncologists of French Expression (ANOCEF) and the Club of Neuro-oncology of the French Society of Neurosurgery propose consensual recommendations in case of donor carrier of primitive tumor intra-cranial or intra-medullary. A contact with the neuro-oncologist/neurosurgeon will allow to discuss the indication in case of glioma of grade I/II/III, according to the grade, the current status (absence of progressive disease), the number of surgeries and of lines of treatment. The taking is disadvised in case of glioma of grade IV (glioblastoma), of lymphoma or meningioma of grade III. No contraindication for the meningiomas of grade I, and individual discussion for the meningiomas of grade II. It is advisable to remain careful in case of hemangiopericytoma and of meningeal solitary fibrous tumor. The patients in first complete remission of a medulloblastoma or intra-cranial primitive germinoma seem good candidates for the taking of organ if the follow-up is of at least 10 years (3 years for non germinomas). In every case, a multidisciplinary discussion is desirable when it is materially possible.

Metastatic meningioma presenting as a malignant soft tissue tumour

Background

Extracranial metastasis of malignant meningioma to soft tissues is extremely rare and its clinical, radiological and pathological features are not well-characterised.

Case presentation

We report a case of a 58 year old man who presented with a mobile mass within the left trapezius muscle. The patient had previously undergone surgery for a right frontal lobe high grade anaplastic meningioma. Histology of the soft tissue lesion showed metastatic anaplastic meningioma with clumps of pleomorphic tumour cells which expressed epithelial membrane antigen, cytokeratin and P63 but were negative for other epithelial and mesenchymal markers. A PET-CT scan revealed additional metastatic lesions in the left pleura, liver and iliac bone.

Conclusions

Metastatic malignant meningioma can very rarely present as a high grade pleomorphic malignant soft tissue tumour and needs to be distinguished from soft tissue sarcomas and metastatic carcinomas that express epithelial antigens.