Metastatic meningioma presenting as a malignant soft tissue tumour

Deciphering extracranial metastasis in high-grade meningiomas: insights from a case study and literature review

Introduction and importance

These high-grade meningiomas have higher recurrence rates and poorer survival outcomes compared to benign variants. This study presents a case of metastasis in a high-grade meningioma and a comprehensive analysis of the literature published between 2000 and 2023, including only original studies focused on extracranial metastasis.

Case presentation

We report the case of a 45-year-old female who presented with progressive left-sided weakness and partial seizures. Imaging revealed a large, lobulated extra-axial mass in the right parietal parasagittal region, which was surgically resected and diagnosed as an anaplastic meningioma (WHO grade III). Despite an initial recovery, the patient experienced tumor recurrence with local invasion, multiple metastases to the contralateral brain, liver, lung, spine, and long bone. Various treatments, including radiotherapy, chemotherapy, and surgery, were employed, but the disease progressed, leaving the patient bed-bound at 8 years follow up.

Clinical discussion

In our literature review, encompassing 247 patients with extracranial metastasis of meningiomas from seven studies, the lungs and bones were the most common metastatic sites. Patients with grade III meningiomas had poorer survival outcomes than those with grade II. Gross total resection (GTR) was associated with improved progression-free survival, while recurrence markedly reduced overall survival, underscoring the aggressive nature of metastatic meningiomas and the importance of early, comprehensive treatment strategies.

Conclusion

Extracranial metastasis in high-grade meningiomas poses significant diagnostic and therapeutic challenges. Our analysis underscores the complexity of managing these cases and highlights the critical need for early identification of high-risk patients and tailored treatment protocols to improve long-term outcomes.

Metastatic meningioma: a case series and systematic review

BACKGROUND

Meningiomas are the most common primary intracranial tumor. While the majority of meningiomas are benign, rarely they can metastasize extracranially. There is a need for a more comprehensive review of these patients to improve our understanding of this rare phenomenon and its prevalence globally. Here we describe our institution's experience of patients presenting with metastatic meningiomas. We further perform a systematic review of the existing literature to explore common features of this rare manifestation of meningioma and review the efficacy of current treatments.

METHODS

We performed a retrospective clinical review of all adult patients with metastatic meningioma managed at our institution over the past 20 years, identifying 6 patients. We then performed a systematic review of cases of metastatic meningioma in the literature ranging from the years 1886 to 2022. A descriptive analysis was then conducted on the available data from 1979 onward, focusing on the grade and location of the primary tumor as well as the latency period to, and location of, the metastasis.

RESULTS

In total, we analyzed 155 cases. Fifty-four percent of patients initially presented with a primary meningioma located in the convexity. The most common site of metastasis was the lung. Risk factors associated with a shorter time to metastasis were male sex and a high initial grade of the tumor. Regarding treatment, the addition of chemotherapy was the most common adjunct to the standard management of surgery and radiotherapy. Despite an exhaustive review we were unable to identify effective treatments. The majority of published cases came from centers situated in high-income countries (84%) while only 16% came from lower- and middle-income countries.

CONCLUSIONS

Metastatic meningiomas pose a pertinent, and likely underestimated, clinical challenge within modern neurosurgery. To optimize management, timely identification of these patients is important. More research is needed to explore the mechanisms underlying these tumors to better guide the development of effective screening and management protocols. However, screening of each meningioma patient is not feasible, and at the heart of this challenge is the inability to control the primary disease. Ultimately, a consensus is needed as to how to correctly screen for and manage these patients; genomic and epigenomic approaches could hold the answer to finding druggable targets.

Surgical management of a giant hepatic metastasis from a cranial meningioma 10 years after resection

Meningiomas are the most common type of primary brain tumor; they have a low risk for extracranial metastases, which are primarily associated with increased tumor grade. Hepatic metastases from cranial meningiomas are extremely rare, with only a paucity of cases reported in the literature and no standardized approach to management. Herein, we report a case of an incidentally discovered giant (>20 cm) metastatic meningioma to the liver treated with surgical resection 10 years following resection of a low-grade cranial meningioma. This report also highlights the use of (68Ga) DOTATATE PET/CT as the diagnostic imaging modality of choice when evaluating for meningioma metastases. To our knowledge, this report describes the largest hepatic metastasis from a cranial meningioma to undergo surgical resection in the literature.

Extraaxial Cerebellopontine Angle Medulloblastoma with Multiple Intracranial Metastases in Adult: A Rare Case Report with a Review of Literature

Medulloblastoma (MB) is very rare malignant primary brain tumor in adults and its location at cerebellopontine angle (CPA) is even rarer. There are only few case reports of CPA MBs in literature. Most of them are reported in pediatric age groups which are mostly intraaxial. Only 11 cases of extra-axial CPA MBs have been reported so far. The author is reporting a very rare case of adult extra-axial CPA MBs with multiple intracranial metastases. We are also reviewing clinical and radiological features and unusual way of its presentation along with surgical management. Keeping MBs as one of the differential diagnosis for extra-axial CPA tumors is going to increase our spectrum of diagnosis which can lead to alteration in management.

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.