INTRACRANIAL TUMORS WITH EXTRACRANIAL METASTASES. CASE REPORT AND REVIEW OF THE LITERATURE

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.

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.

Extra-Neural Metastases From Primary Intracranial Ependymomas: A Systematic Review

Background

Primary intracranial ependymomas (IE) are rare brain tumors rarely metastasizing outside the central nervous system. We systematically reviewed the literature on extra-neural metastases from primary IEs.

Methods

PubMed, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of extra-neural metastases from primary IEs. Clinical features, management strategies, and survival were analyzed.

Results

We collected 48 patients from 43 studies. Median age was 13 years (range, 2-65). Primary IEs were frequently located in the parietal (22.9%) and frontal (16.7%) lobes, and mostly treated with resection (95.8%) and/or radiotherapy (62.5%). Most IEs were of grade-III (79.1%), and few of grade-I (6.3%) or grade-II (14.6%). 45 patients experienced intracranial recurrences, mostly treated with resection (86.7%), radiotherapy (60%), and/or chemotherapy (24.4%). Median time-interval from primary IEs was 28 months (range, 0-140). Most extra-neural metastases were diagnosed at imaging (37.5%) or autopsy (35.4%). Extra-neural metastases were multifocal in 38 patients (79.1%), mostly involving cervical or hilar lymph-nodes (66.7%), lung/pleura (47.9%), and/or scalp (29.1%). Surgical resection (31.3%), chemotherapy (31.3%) and locoregional radiotherapy (18.8%) were the most common treatments for extra-neural metastases, but 28 (58.3%) patients were not treated. At last follow-up, 37 patients died with median overall-survivals from primary IEs of 36 months (range, 1-239), and from extra-neural metastases of 3 months (range, 0.1-36). Overall-survival was significantly longer in patients with grade-I and II IEs (P=0.040).

Conclusion

Extra-neural metastases from primary IEs are rare, but mostly occur at later disease stages. Multidisciplinary management strategies should be intended mostly for palliation.

TP53 Mutation and Extraneural Metastasis of Glioblastoma: Insights From an Institutional Experience and Comprehensive Literature Review

Extraneural metastases of glioblastoma (GBM), although rare, are becoming an increasingly recognized occurrence. Currently, the biological mechanism underlying this rare occurrence is not understood. To explore the potential genomic drivers of extraneural metastasis in GBM, we present the molecular features of 4 extraneural metastatic GBMs, along with a comprehensive review and analysis of previously reported cases that had available molecular characterization. In addition to our 4 cases, 42 patients from 35 publications are reviewed. To compare the molecular profiles between GBM cases with extraneural metastasis and the general GBM population, genomic data from GBM samples in The Cancer Genome Atlas (TCGA) database were also analyzed. We found that 64.5% (20/31) of the cases with extraneural metastasis that were tested for TP53 changes had at least 1 TP53 pathogenic variant detected in either 1 or both primary and metastatic tumors. In contrast, TP53 mutation was significantly less frequent in the unselected GBM from TCGA (22.6%, 56/248) (P=0.000). In addition, O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation was more common in unselected TCGA GBM cases (48.6%, 170/350) than in cases with extraneural metastasis (31.8%, 7/22), although not statistically significant. Although isocitrate dehydrogenase (IDH) mutation is a rare occurrence in high-grade astrocytomas, IDH-mutant grade 4 astrocytomas are at least as likely to metastasize as IDH wild-type GBMs; 3 metastatic cases definitively harbored an IDH1 (p.R132H) mutation in our analysis. Our findings not only provide potential biomarkers for earlier screening of extraneural metastasis, but could also suggest clues to understanding biological mechanisms underlying GBM metastasis, and for the development of therapeutic modalities.

Extraneural metastatic anaplastic ependymoma: a systematic review and a report of metastases to bilateral parotid glands

Background

Anaplastic ependymoma with extraneural metastases is associated with a poor clinical outcome. Metastatic spread to the parotid gland is a rare clinical entity that requires multidisciplinary intervention. Herein, we present a systematic review of anaplastic ependymoma with extraneural metastases and report on a case with metastases to both parotid glands.

Methods

Electronic databases were searched from their inception to February 2019. Inclusion criteria included reports of anaplastic ependymoma with extraneural metastasis. Studies were excluded if the tumor grade was not reported. A case illustration is provided.

Results

The search yielded 15 cases of anaplastic ependymoma with extraneural metastases, including the present case. Mean age at diagnosis was 15 years. The initial tumor location was predominantly supratentorial (93.3%). All cases demonstrated leptomeningeal seeding before extraneural metastasis. Mean survival from initial diagnosis was 4.5 years. Metastasis to the parotid gland occurred in 2 cases, including the present case. We present a 17-year-old female patient who underwent gross total resection of a supratentorial, paraventricular anaplastic ependymoma followed by adjuvant external beam radiation therapy. The patient developed recurrent leptomeningeal seeding, treated with Gamma Knife radiosurgery over a 5-year period. She returned with a parotid mass and cervical lymphadenopathy and underwent parotidectomy and modified radical neck dissection. She continued to experience recurrences, including the left parotid gland, and was ultimately placed in hospice care.

Conclusions

Anaplastic ependymoma with extraneural metastasis is rare. A combination of repeated surgical resection, radiation therapy, and chemotherapy can be used to manage recurrent and metastatic disease, but outcomes remain poor.

Early Glial Tumor Metastases through a Ventriculo-Atrial Shunt

A girl of 12 with a pontine polymorphous astrocytoma diffusely metastasizing to the spinal cord leptomeninges suddenly died 20 hours after the insertion of a right ventriculo–atrial shunt. Many severely damaged glial neoplastic cells were found in the blood vessels of the lung and liver.

Primary Intracranial Malignant Melanoma with Extracranial Metastasis

We report a case of primary intracranial malignant melanoma (PIMM) with extracranial metastases. The patient was an 82-year-old woman diagnosed with PIMM under the left cerebellar tentorium. We performed a tumor resection followed by gamma knife surgery. An magnetic resonance imaging at 11 months after surgery showed a local intracranial recurrence. At 12 months, vertebral metastasis was suspected, and 2-[fluorine-18]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT) showed multiple extracranial metastases. She died at 13 months after surgery. Although extracranial metastases of PIMM are extremely rare, we should carefully follow up extracranial metastases together with intracranial ones, especially by FDG-PET/CT, even at an early asymptomatic stage.

Post-radiation reactive changes in a single vertebral body mimicking metastatic pineoblastoma

This 18-year-old woman presented with headache and diplopia over several months and was found to have an enhancing pineal tumor with resultant obstructive hydrocephalus. Following standard preoperative diagnostic tests, including spinal axis imaging, the patient was taken to the operating room for an endoscopic third ventriculostomy to relieve hydrocephalus and then subsequently underwent a craniotomy for gross-total resection of the pineal mass. The patient was discharged after an uneventful hospital course and received standard adjuvant cranial-spinal radiation and chemotherapy as an outpatient. Follow-up imaging 1 year after surgery demonstrated a metabolically active, lytic lesion in the C-3 vertebral body and new lung lesions suggesting a metastatic pineoblastoma. The patient underwent a C-3 anterior corpectomy and reconstruction without complication as aggressive therapy for presumed metastatic disease. Final pathological results from the vertebral lesion were consistent with radiation-induced reactive changes, not metastatic pineoblastoma as originally suspected. The patient recovered well and remains symptom free. To the authors' knowledge this is the first reported case of reactive changes mimicking metastasis in a single vertebral body following standard therapy for resected primary pineoblastoma.

Extracranial metastases of glioblastoma in a child: case report and review of the literature

Glioblastoma (GBM) is the most common adult malignant brain tumor but is notably less common in children. Primary brain tumors rarely metastasize outside the central nervous system and when metastases occur, it is often in patients with diversionary shunting of the cerebrospinal fluid. This report details the case of a 13(1/2)-year-old boy who was diagnosed with GBM. He survived 10 months after diagnosis. At autopsy, the tumor was found to extensively infiltrate the leptomeninges as well as the cranial skin and soft tissue. Further examination disclosed multiple liver and lung metastatic GBM nodules. This pattern of spread is very uncharacteristic of gliomas and emphasizes the importance of adequate metastatic evaluation.

Extra-cranial metastasis of glioblastoma multiforme presenting as acute parotitis

We present an unusual case of extracranial metastasis of glioblastoma multiforme (GBM) to the parotid gland and cervical lymph nodes. The patient had previously undergone two craniotomies to debulk a left frontal GBM, followed by radiotherapy. After the second craniotomy, while waiting for chemotherapy, the patient was re-admitted with a short history of a painful swelling of his left parotid gland. The initial diagnosis was infective parotitis; however, as there was no improvement with broad-spectrum antibiotics, CT was undertaken, which revealed a mass in the parotid gland with a necrotic centre and enlarged cervical lymph nodes. Parotid gland biopsy revealed a parotid GBM metastasis. This case illustrates how GBM behaves in an aggressive manner even outside the CNS. A brief review of the literature and of the theories, which might explain the extra-neural metastasis of this tumour is also presented.

Extraneural metastases of paediatric brain tumours

A survey of published cases of extraneural metastases of primary brain tumours in children under the age of 18 years revealed 245 cases; 60.7% occurred in boys and 27.3% were directly related to the placing of a shunt. The most common entities leading to extraneural metastases were medulloblastomas (56.3%), germinomas (9.8%), glioblastomas (6.9%), ependymomas (3.7%) and pilocytic astrocytomas (2.9%). While medulloblastomas were frequent among non-shunt-related metastases (69.4%), germ cell tumours were most common among shunt-related metastases (33.3%). Metastases were encountered equally often in bone (56.3%) and visceral organs (55.5%) but were markedly rarer in lymph nodes (25.3%). Medulloblastomas showed a preference for bones (88.3% of cases), germinomas for bones (77.8%) and visceral organs (66.7%), whereas ependymomas and ependymoblastomas were more frequently found in lymph nodes and visceral organs (71.5-100%). The most frequent sites of bone metastases were the pelvis (59.3% of cases with osseous lesions), femur (54%) and vertebrae (46%). Medulloblastomas preferentially spread into pelvis, femur and vertebrae, whereas germ cell tumours mainly involved pelvis, femur and ribs and glioblastomas vertebrae and pelvis. Most frequent sites of lymph node metastases were cervical (45.8% of cases with nodular lesions) and thoracic (31.3%) with 54% of children suffering from medulloblastomas and 7.9% from germ cell tumours. The most frequent organ involved in non-shunt-related metastases were the lungs (56.5% of children with visceral lesions) followed by muscle/soft tissue (26.9%), pleura (16.4%), skin (14.9%) and liver (13.4%). Among shunt-related cases, the peritoneum was the most frequent site (86.6% of children). The mean interval between primary brain tumour and occurrence of metastasis was 22.1 months with particularly grave outcomes among medulloblastomas, non-germinomatous germ cell tumours and glioblastomas (85.5-100% deceased children), whereas 60% of children suffering from germinomas were still alive at the time of reporting.

Metastatic infiltration of the dental pulp by medulloblastoma

Medulloblastoma is an infratentorial primitive neuroectodermal tumour. It is the most commonly occurring brain tumour of childhood, accounting for 15-20% of all paediatric tumours. Extracranial metastasis is rare, but may involve the skeleton. Jaw lesions, however, have never been described. A case is reported of metastases of a medulloblastoma to the jaw including the dental pulp.

Cutaneous metastasis from an intracranial glioblastoma multiforme

A 34-year-old white man with a history of an intracranial glioblastoma multiforme was treated with surgical excision and radiotherapy. Five months later, the patient had a rapidly growing scalp mass develop. This lesion was excised, and the histology revealed a tumor that was similar to the originally resected intracranial glioblastoma. Immunohistochemistry for general neuroepithelial derivation (S-100 protein) and for glial fibrillary acidic protein (GFAP) was positive, whereas mesenchymal, epithelial, and neuronal markers were negative. This immunohistochemistry pattern was identical to the original tumor. Although metastasis of this tumor is not uncommon, metastasis to the skin has never been reported. To our knowledge, this is the first reported case of cutaneous metastasis from glioblastoma in the world literature.

Extraneural metastases of primary brain tumors

Extraneural metastasis (ENM) of primary brain tumors is arare occurence. Based on acritical analysis of the literature the present review focuses on illustrating special common features of these tumors with regard to immunological, cytokinetical and tumorbiological issues. In this respect much can be learned from the specific conditions following organ transplantation which is extensively discussed.

Extraneural metastatic glioblastoma after interstitial brachytherapy

PURPOSE

This is a report of 3 cases of extraneural metastasis of glioblastoma after interstitial radiation and assessment of pertinent literature addressing concern over an increased risk of these events with this therapy.

METHODS AND MATERIALS

In a series of 82 patients treated with (125)I brachytherapy for primary malignant brain tumors over a 7-year interval, 3 cases of extraneural glioblastoma were identified. The multicatheter technique for delivery of (125)I sources was utilized in all. Extraneural metastases were documented by imaging studies or biopsy. Over the same period, 310 patients with primary malignant brain tumors were treated without brachytherapy.

RESULTS

Biopsy-proven scalp and skull metastases occurred in 2 patients, at 3 and 8 months following brachytherapy. Each developed radiographic evidence of systemic metastases at 7 and 14 months postbrachytherapy, respectively. The third patient developed biopsy-proven cervical node involvement 4 months after brachytherapy. No patients with malignant gliomas undergoing craniotomy or stereotactic biopsy, but not brachytherapy, during the same time period developed extraneural metastases. Incidence in previously reported series commenting on this otherwise rare process range from 0% to 4.3%. The incidence of extraneural metastases in this series is 3.7% (3/82) and is comparable to those reports.

CONCLUSIONS

Percutaneous catheter-delivered brachytherapy may be associated with an increased incidence of extraneural metastatic glioma.

Metastatic atypical meningioma: case report and review of the literature

Extracranial metastasis of an intracranial meningioma is rare. We discuss the clinical, radiological and histopathological presentation of an elderly man with pulmonary metastases from a recurrent meningioma of atypical histology, and review the literature pertaining to this phenomenon.

High levels of gelatinase-B and active gelatinase-A in metastatic glioblastoma

PURPOSE

Extra-neural metastases from glioblastoma multiforme (GBM) are rare. Because gelatinases-A and -B have been implicated in tumor invasion/metastasis in non-neural tumors, we compared the expression of gelatinase-A and -B in 2 patients (both had a prior craniotomy performed) with extraneural metastases from GBM to expression levels in 24 other gliomas; 15 non-metastatic GBMs, 9 other lower grade gliomas, and 7 normal brain tissues.

METHODS

The intracerebral tumor from both patients, patient # 1's extraneural metastases, 24 other gliomas, 1 sample of reactive astrocytes and 7 normal brain tissues were studied using gelatin zymography. The active form of gelatinases was confirmed by co-migration after activation with APMA.

RESULTS

Expression of the latent form of gelatinase-A correlated with glioma grade (r = 0.486; p = 0.0053). Active gelatinase-A was found only in the 2 GBMs with extraneural metastases and patient # 1's cervical metastases. In contrast, latent gelatinase-B levels correlated more strongly with histologic grade (r = 0.577; p = 0.0009) (higher levels with higher grades). Very high levels of gelatinase-B were seen in both GBMs with extraneural metastases, a cervical extraneural metastases, and 2 GBMs without metastases.

CONCLUSIONS

We observed that gelatinases-A and -B are present in most gliomas but we found active gelatinase-A only in the GBMs with extraneural metastases suggesting that the active form of this enzyme may determine the metastatic potential of GBMs. We propose that high levels of gelatinolytic activities are associated with intracerebral invasion and rarely, metastases of GBMs.

Pleuropulmonary metastasis from an intracranial glioblastoma

We present an unusual case of glioblastoma with intrathoracic and liver metastasis. The clinical diagnosis was confirmed by a percutaneous core needle biopsy from a metastatic lung lesion. The pathogenetic and diagnostic aspects of the case are discussed.

High levels of gelatinase-B and active gelatinase-A in metastatic glioblastoma

PURPOSE

Extra-neural metastases from glioblastoma multiforme (GBM) are rare. Because gelatinases-A and -B have been implicated in tumor invasion/metastasis in non-neural tumors, we compared the expression of gelatinase-A and -B in 2 patients (both had a prior craniotomy performed) with extraneural metastases from GBM to expression levels in 24 other gliomas; 15 non-metastatic GBMs, 9 other lower grade gliomas, and 7 normal brain tissues.

METHODS

The intracerebral tumor from both patients, patient # 1's extraneural metastases, 24 other gliomas, 1 sample of reactive astrocytes and 7 normal brain tissues were studied using gelatin zymography. The active form of gelatinases was confirmed by co-migration after activation with APMA.

RESULTS

Expression of the latent form of gelatinase-A correlated with glioma grade (r = 0.486; p = 0.0053). Active gelatinase-A was found only in the 2 GBMs with extraneural metastases and patient # 1's cervical metastases. In contrast, latent gelatinase-B levels correlated more strongly with histologic grade (r = 0.577; p = 0.0009) (higher levels with higher grades). Very high levels of gelatinase-B were seen in both GBMs with extraneural metastases, a cervical extraneural metastases, and 2 GBMs without metastases.

CONCLUSIONS

We observed that gelatinases-A and -B are present in most gliomas but we found active gelatinase-A only in the GBMs with extraneural metastases suggesting that the active form of this enzyme may determine the metastatic potential of GBMs. We propose that high levels of gelatinolytic activities are associated with intracerebral invasion and rarely, metastases of GBMs.

Cutaneous metastatic disease

The relative frequencies of cutaneous metastases are similar to those of the primary cancers; breast, colon, and melanoma are the most frequent in women and lung, colon, and melanoma are the most common in men. Cutaneous metastases represent an opportunity to detect a potentially treatable cancer before other evidence of it is present, to modify therapy as appropriate to the tumor stage, or possibly to use the cutaneous lesion as a source of easily accessible tumor cells for specific therapy. Cutaneous metastatic disease as the first sign of internal cancer is most commonly seen with cancer of the lung, kidney, and ovary.

MIB1 staining index and scoring of histologic features in meningioma. Indicators for the prediction of biologic potential and postoperative management

BACKGROUND

The biology of brain tumors, including cell kinetics, has been studied. Recently, monoclonal antibody to Ki67 (MIB1), a nuclear protein related to cell proliferation, has been analyzed immunohistochemically using tissue prepared from paraffin embedded sections.

METHODS

The authors assessed the prognostic usefulness of various histologic indicators of the biologic potential of meningiomas in patients who underwent total resection (Simpson's Grade I and II) by evaluating the time to recurrence as an end point. Forty-three patients with a total of 36 meningiomas and 7 hemangiopericytomas were investigated by immunohistochemical analysis using MIB1.

RESULTS

MIB1 staining index (SI) and histologic score were well correlated with the recurrence-free interval (r = -0.6749, P = 0.002 and r = -0.4939, P = 0.027, respectively) and with each other (r = 0.7909, P < 0.001). The MIB1 SI and histologic score in the nonrecurrence group were significantly lower than those in the recurrence/metastasis group (P < 0.001 and P = 0.001, respectively). The values of these indicators showed that as the value increased, so did the recurrence rate.

CONCLUSIONS

Evaluation using the MIB1 SI and total histologic score of meningioma is useful in assessing the prognosis as well as postoperative management of these patients.

The nasal route of cerebrospinal fluid drainage in man. A light-microscope study

The drainage routes from the subarachnoid space to the nasal mucosa were investigated in autopsy material. Indian ink, applied post-mortem to the olfactory groove, promptly filled the perineurial spaces around the olfactory nerve branches in the dura, the lamina cribrosa and the submucosal tissue in the nose. In a case of recent subarachnoid haemorrhage, the perineurial spaces even around the most distal olfactory nerve branches were congested with blood and there was an abundant accumulation of red corpuscles in the apical part of the nasal mucosa. Iron-containing pigment was found in the perineurial spaces of proximal and distal olfactory nerve branches as well as in the nasal mucosal stroma in cases with older haemorrhagic lesions. The findings show that the perineurial spaces provide an efficient drainage route from the subarachnoid space to the nasal mucosa in cases with haemorrhagic cerebral lesions. A complementary drainage route for the cerebrospinal fluid was indicated by the presence of indian ink, red corpuscles and iron pigment in arachnoid villi, which penetrated the lamina cribrosa and ended in the nasal submucosal tissue. Iron in the deep cervical lymph nodes should not be taken as evidence of transport from the CNS, since iron pigment was also found in cases without intracranial haemorrhage.

Histologically benign recurrent meningioma metastasizing to the parotid gland: case report and review of the literature

This report presents a very rare case of metastatic meningioma of the parotid gland from a recurring intracranial lesion. The primary tumor, intracranial residues, and parotid metastasis were histologically benign. Meningiomas rarely metastasize; even rarer are cases in which both the primary and the secondary tumors have benign histological characteristics. The 11 cases reported in the literature have been critically reviewed. The case we present is noteworthy also for the exceptional localization of the metastasis in the parotid gland.

Extraneural metastases of infratentorial glioblastoma multiforme to the peritoneal cavity

This report describes two autopsy-proven cases of a rare complication of infratentorial glioblastoma multiforme (GBM): metastatic seeding of the peritoneal cavity through ventriculoperitoneal (VP) shunts. Patient 1 was a 13-year-old boy with a pontine GBM, and Patient 2 was a 9-year-old girl with a thoracolumbar spinal cord GBM. Autopsy of both patients demonstrated leptomeningeal gliomatosis encasing the spinal cord and basal structures of the brain, in addition to peritoneal and omental metastases. The pattern of abdominal metastasis seen in these patients is typical of tumors that directly seed the peritoneal cavity and implicates the VP shunt as the vehicle of extraneural spread. Although a rare occurrence, extraneural metastases should be sought in patients with glioma with VP shunts who demonstrate increased abdominal girth, unexplained weight gain, or persistent abdominal pain.

Metastatic cutaneous lesions in children and adolescents with a case report of metastatic neuroblastoma

A child with neuroblastoma metastatic to the skin is reported. A review of the literature revealed that neuroblastoma and leukemia are the neoplasms most frequently associated with cutaneous metastases in children and adolescents. The low incidence of these lesions and their high malignant potential are two important factors that emphasize the pivotal role the dermatologist plays in prompt diagnosis and early referral.

The risks of metastases from shunting in children with primary central nervous system tumors

The authors reviewed the hospital charts of 415 pediatric patients treated for benign or malignant primary brain tumors over the past 20 years at the Children's Hospital Medical Center, Seattle. Patients' ages ranged from the neonatal period to 18 years. A shunt was placed in 152 patients (37%), 45 before and 94 after surgery. Confirmation of extraneural metastases was based on clinical and diagnostic examination. Factors analyzed as possibly influencing the occurrence of extraneural metastases were: 1) the shunt: type, valve, location, filter, and revisions; 2) extent of resection; 3) pathology; and 4) treatment regimen. Eight of the 415 patients developed extraneural metastases during life. All eight patients had a medulloblastoma (cerebellar primitive neuroectodermal tumor). These eight patients were separated into Group A (without a shunt) and Group B (with a shunt). In Group A (five patients), the mean interval from primary diagnosis to metastasis was 15 months. Two children had gross total resection of the tumor. The predominant location of metastases in Group A was: bone (two cases); cervical lymph nodes (one); lung/bone (one); and retroperitoneal pelvic mass (one). Three Group A patients had a simultaneous central nervous system (CNS) recurrence. Of the three Group B patients, two had a ventriculoperitoneal (VP) shunt and one a ventriculoatrial (VA) shunt; all were placed postoperatively. One Group B patient had a simultaneous CNS recurrence. No shunt revisions were performed in these three patients. The mean time from primary diagnosis to metastasis was 25 months. One patient had a total tumor resection. The predominant location of metastases was bone (one case), retroperitoneal pelvic mass (one), and abdominal cavity with ascites (one case). Only one patient in the entire series had a filter placed; this resulted in shunt obstruction and was removed 1 month following placement. It is concluded that cerebrospinal fluid shunts, regardless of type, location, revision rate, or filter insertion, do not predispose pediatric patients with brain tumors to develop extraneural metastases. A diagnosis of shunt-related metastases should be based on the development of intra-abdominal (VP shunt) or pulmonary (VA shunt) dissemination primarily with or without additional sites. The diagnosis of medulloblastoma is an important factor related to metastasis occurrence while the extent of resection and postoperative therapy are not influential.

Extracranial metastasis of an astrocytoma detected by fine-needle aspiration: a case report

Extracranial metastasis of gliomas is rare, and the documented cases of extracranial metastasis are based on histological material. A case of metastatic astrocytoma to the soft tissue of the neck and back detected by fine-needle aspiration is reported. Demonstration of glial fibrillary acidic protein by immunoperoxidase technique on aspirated material helped to confirm the diagnosis.

Bone metastasis associated with shunt-related peritoneal deposits from a pineal germinoma. Case report and review of the literature

The case of a 15-year-old boy with a pineal germinoma is reported. The patient first underwent a ventriculoperitoneal (VP) shunt followed by a stereotactic biopsy, then, because of the rapidly deteriorating neurological status, an emergency craniotomy with subtotal removal of the tumour was performed. Two months after surgery, a left femoral metastasis and extensive peritoneal lesions became evident; they were regarded as due to haematogenous and VP shunt spread of the germinoma. At that time, extremely high serum levels of placental alkaline phosphatase were detected. The patient died 6 months after the initial diagnosis. The occurrence of extraneural metastases as well as of shunt related peritoneal deposits from primary intracranial germinoma is discussed. As far as we know this is the first reported case of a combination of haematogenous as well as VP shunt spread of a pineal germinoma.

Extracranial metastases of medulloblastoma in adults: literature review

A consecutive series of 30 cases of extracranial medulloblastoma metastases in adults is analysed. The majority of the patients were males with a 3:1 male/female ratio. Bone was the most frequent site of metastases in adults (77%) and children (78%), followed by lymph nodes (33%) in both children and adults. Lung metastases were more common in adults (17%), but liver metastases occurred more frequently in children (15%). Possible routes of spread and development of metastases are discussed, with special emphasis on the role of shunts in tumour seeding. Distant extracranial metastatic spread of medulloblastoma occurs at the rate of 7.1%. Mean interval between operation of the primary tumour and the discovery of metastases was shorter in children (20 months) than in adults (36 months). Survival after the discovery of metastases was also shorter in children (5 months) than in adults (9.5 months). Shunts were associated with an earlier appearance of metastases and with a poorer prognosis. A detailed review of the literature of 119 cases of medulloblastoma with extracranial metastases is provided.

Osteoblastic metastases from astrocytomas: a report of two cases

The spread of primary central nervous system (CNS) neoplasms beyond the confines of the neuraxis is a relatively uncommon observation. Extraneural metastases involving bone are quite rare, and have been observed almost exclusively in cases of medulloblastoma, high-grade (III-IV) astrocytoma, and glioblastoma multiforme. To date there has been only one case reported of bone metastasis from a "well-differentiated" astrocytoma. We now report two cases of astrocytoma in children with diffuse osteoblastic metastases and a fulminant clinical course. These cases demonstrate that due to the potential morphologic heterogeneity of these neoplasms, an initial biopsy diagnosis of low-grade astrocytoma does not always imply a benign clinical course.

Diffuse bony metastases at presentation in a child with glioblastoma multiforme. A case report

At initial diagnosis, an 11-year-old girl with glioblastoma multiforme (GBM) presented with diffuse osteoblastic metastases. Primary brain tumors rarely metastasize outside of the central nervous system (CNS) without prior neurosurgery. Extracranial spread at diagnosis has been previously documented in just two adults. Extracranial metastasis of a childhood glioma without prior neurosurgery at any time during the course of the disease is exceedingly rare. Spread to bone by gliomas is also infrequent, and when they occur, bony metastases are usually isolated to one or two sites in any given patient. The widespread osseous metastases in our patient have been reported in three prior cases of high-grade gliomas. This child's GBM likely reflects a highly aggressive variant with the potential to spread outside the CNS and with a predilection for bone. Oncologists should be aware that GBM may present in this fashion during childhood.

Metastases to bone in medulloblastoma. A report of five cases

Medulloblastoma is a relatively common intracranial neoplasm in childhood. Its extraneural spread was, until recently, thought to be a rare occurrence. Metastases are most commonly to bone. Five patients with medulloblastoma metastatic to bone are presented, and findings are compared to those of previous reports. Two of the five cases showed patchy extensive osteosclerosis of the pelvis and/or proximal femora. One case had concurrent lymph node involvement. In patients with past or present medulloblastoma and bone pain, metastases to bone should be excluded. Medulloblastoma metastatic to bone is a rare cause of extensive osteosclerosis.

Intracranial astrocytoma with diffuse bone marrow metastasis: a case report and review of the literature

A 41 year old male presented with headache, lethargy, and ataxia and found to have a left temporal lobe mass and a leukoerythroblastic peripheral blood smear. The latter prompted an iliac crest bone marrow biopsy on which a diagnosis of metastatic glioma was made and verified by immunohistologic characterization. The patient was treated with cranial irradiation and simultaneous systemic BCNU (bis-dichloroethylnitrosurea) with complete response. This case with diffuse bone marrow involvement demonstrates that a glioblastoma is capable of extracranial metastases without previous intervention. From a review of reported cases of gliomas of extraneural metastasis, it is concluded that untreated gliomas are capable of vascular spread although less frequently than previously manipulated tumors.

Metastatic malignant glioma with resultant extradural compression of a sacral nerve root

A patient with a malignant cerebral mixed oligodendroglioma-astrocytoma presented with a severe, painful S-1 radiculopathy. Neuroradiological examinations revealed an extradural soft-tissue mass compressing the first sacral nerve root. Spinal fluid examination and myelography gave no evidence of intradural disease. Surgery confirmed the presence of metastatic glioma compressing the S-1 nerve root. The tumor was entirely epidural in location. Mechanisms of dissemination are discussed.

Papillary meningioma. Clinicopathologic study of seven cases and review of the literature

Seven cases of papillary meningioma are reported. The patients, 3 females and 4 males, were aged between 21 and 69 years. Five tumors were supratentorial, 1 was located in the left temporal bone, and 1 in the thoracic spinal canal. Five patients had local recurrences and died within 1.4 to 9 years of the original operation. In Case 2, one small pulmonary metastatic nodule was found at autopsy. Microscopically, these meningiomas showed foci of necrosis, numerous mitotic figures and local invasiveness. Psammoma bodies were occasional or absent. Forty-six papillary meningiomas have been identified in the literature. Certain histologic features (necrosis, high mitotic index, rich peripapillary reticulin network) and evolutive events (high rate of local recurrence, development of distant metastases) suggest that this aggressive variant of meningioma could form a histologic link between syncytial, fibroblastic, and hemangiopericytic meningiomas.

Primary leptomeningeal ependymoblastoma. Case report

Ependymoblastoma is considered to be a primitive malignant glioma with ependymal differentiation. This rare tumor occurs in very early life and shows rapid growth and a diffuse infiltration through the leptomeningeal space. The tumor cells are highly immature, with numerous mitoses and multilayered ependymal rosettes. The ependymoblastoma described in this report was found in a 17-year-old girl. In spite of detailed clinical and postmortem examinations, no definite primary site was identified in the neuraxis. The lesion spread predominantly throughout the leptomeningeal space. Histological analysis strongly suggested that this tumor originated from a heterotopic glial nest in the subarachnoid space. The absence of immunohistochemical neural tissue markers, glial fibrillary acidic protein, S-100 protein, neuron-specific enolase, and neurofilaments ruled out neuronal or glial differentiation. The authors were unable to find any previous report of primary leptomeningeal ependymoblastoma.

Metastatic meningioma of the lung

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Extraneural metastases of central nervous system tumors

In the past, extraneural metastasis of central nervous system tumors was considered to be a rare event. However, more recently, a considerable body of literature has accumulated so that to date some 282 patients with extraneural metastases have been reported. Of these reported cases, 40.4% have occurred in children. Although central nervous system tumors can spread spontaneously beyond the confines of the central nervous system, most instances of extraneural metastasis occur after craniotomy or diversionary cerebrospinal fluid shunting. Extraneural metastases are universally fatal. Although it is not curative, chemotherapeutic treatment of metastases may greatly decrease the patient's discomfort and improve the quality and duration of survival. Every effort should be made to prevent this complication by avoiding diversionary cerebrospinal fluid shunting procedures or by incorporating a filtering device if a shunt becomes necessary.

Pineal germinoma with widespread extracranial metastases

A case of primary pineal germinoma with widespread extracranial metastasis in a 36-year-old man is presented. A clinical work-up revealed bilateral pleural effusions, ascites, and metastatic lesions involving the lung. Cytology and electron microscopic study of the pleural and ascitic fluid and of the fine needle aspiration material revealed metastatic germinoma. Although the cytologic features were not distinct from those of anaplastic carcinoma, they were distinguishable from those of glial neoplasms, lymphoma, and sarcoma. The computed tomography findings, elevated human chorionic gonadotropin level, and electron microscopic features contributed significantly to the diagnosis of extracranial metastasis of the pineal germinoma. Metastatic spread most likely occurred via the ventriculoperitoneal shunt.

Ependymoblastoma. A reappraisal of a rare embryonal tumor

This article reviews the clinicopathologic features of 12 ependymoblastomas, including those of 7 previously unreported cases. The histologic characteristics included a high density of small to medium-sized neuroepithelial cells with a uniform cytologic appearance, frequent mitotic figures, and numerous diagnostic ependymal rosettes and tubules. Differentiation was restricted to glial precursor cells and to cells with the differentiating features of ependymal cells. Cytogenetically, the tumor cells with the differentiating hallmarks of ependymal cells but which have retained their mitotic activity were considered to be ependymoblasts. Many of the rosettes in the tumors were of the ependymoblastic type, but ependymal rosettes were also present. The absence of pleomorphism, giant cells, multinucleation and pseudopalisades, and the scanty proliferation of vascular endothelial cells are additional features that delineate this tumor from an anaplastic (malignant) ependymoma. The median age of the patients was 2 years. After surgical treatment the median survival time was 12 months. Because of the frequency of leptomeningeal involvement, whole neuraxis radiation should be considered.

Selective peripancreatic sarcoma metastases from primary gliosarcoma. Case report

Two phenomena associated with malignant gliomas are: 1) the ability to metastasize systemically, and 2) the capacity to induce sarcomatous transformation within the supportive mesenchyma. An unusual case is presented of selective metastases of the sarcomatous elements of a mixed gliosarcoma. Immunohistochemical cell staining with glial fibrillary acidic protein was used to confirm the presence of abnormal glial elements in the primary brain tumor as well as the absence of such glial elements in the abdominal metastases.

Spinal metastases. A rare mode of presentation of brain tumors

An analysis of more than 18,000 primary central nervous system (CNS) tumors revealed only 18 cases (0.01%) in which dropped spinal metastases had caused the presenting symptoms. This group included 11 males and 7 females in whom there was no history of surgical intervention or irradiation. Primitive neuroectodermal tumors ( PNET , medulloblastoma), comprised the largest group (11 patients) followed by high-grade astrocytomas (anaplastic and glioblastoma) (5 patients). One case each of germinoma and ependymoma were also identified. The clinicopathologic data of these cases, and a brief review of the literature are presented.

Extracranial metastases in childhood primary intracranial tumors. A report of 21 cases and review of the literature

A clinical and pathologic review of primary intracranial tumors (917 cases in a 62-year period) at The Hospital for Sick Children, Toronto, identified 21 cases with systemic metastases (2.3%). This included 15 cases of medulloblastoma and 1 case each of astrocytoma, meningeal sarcoma, malignant melanoma, ependymoblastoma, teratoma, and endodermal sinus tumor, adding to the pediatric literature of 94 previously reported cases (72 medulloblastoma and 22 cases of other brain tumors). Like adults, children with medulloblastoma tend to develop bone and bone marrow metastases, while those with other brain tumors frequently invade adjacent tissues, and then spread to regional lymph nodes and the lungs. The prognosis is almost uniformly fatal, although prolonged palliation could be achieved with radiation and/or chemotherapy. The pathogenesis of systemic metastases is related to breakage of the blood-brain barrier, whether at surgery, or with tumor invasion into vascular channels, and especially with preoperative systemic-cerebrospinal fluid shunting. Thirteen of 16 patients who developed systemic metastases, including 5 with peritoneal involvement, had ineffective or no millipore filters within their shunts, suggesting their possible prophylactic role against tumor dissemination. A greater understanding of the pathogenesis of systemic metastases may aid the design of future effective preventive measures.

Four primary tumors in one child

A child is described who, following surgery and irradiation for malignant choroid plexus papilloma at the age of 11 months, developed three further tumors: A benign myxofibroma of the cranium at the age of 3 1/2 years, an undifferentiated anaplastic tumor of his clavicle at 7 1/2 years, and a chondroblastic osteogenic sarcoma of his pelvis at the age of 12 years. There was no apparent genetic predispositions to malignancy. The latter three neoplasms may have originated either in, or at the edge of, the original radiotherapy field, suggesting that the child has a particular susceptibility to the oncogenic potential of radiotherapy.

Diffuse bone marrow metastasis by glioblastoma: premortem diagnosis by peroxidase-antiperoxidase staining for glial fibrillary acidic protein

Extraneural metastases from malignant glioma and glioblastoma are believed to be rare. The most common sites of metastases are lung, lymph nodes, bone, and liver. We recently encountered two patients with glioblastoma multiforme who presented with pain and thrombocytopenia caused by diffuse metastasis to bone marrow. A premortem diagnosis was established in the first patient with the aid of peroxidase-antiperoxidase staining of the bone marrow biopsy specimen for glial fibrillary acidic protein, a glial-specific marker. In the second patient glial fibrillary acidic protein staining confirmed the glial nature of the primary brain tumor as well as the metastatic tumor in bone marrow. The first patient also had metastatic nodules on the pleural surface and on the fifth rib. All three metastatic foci had similar cellular morphology, suggesting selection of a population of tumor cells with extraneural metastatic potential.

Glioblastoma multiforme metastatic to the neck

Glioblastoma multiforme, a rapidly growing intracranial neoplasm, rarely metastasizes unless operated upon, and even after surgical exposure metastasis is uncommon unless the patient is a long-term survivor. The most likely site of metastasis is the cervical lymph nodes. A patient developed a rapidly expanding cervical metastasis a year after surgery and irradiation for the primary. The 6-cm neck mass responded dramatically to radiation therapy and lomustine. The patient is clinically without evidence of progression of disease 20 months after the initial diagnosis, and there is no palpable recurrence in the neck. It is recommended that the patient who has a cervical mass and a history of surgically treated glioblastoma multiforme undergo a careful otolaryngologic examination prior to open biopsy. In general, such a patient can be spared an extensive "unknown primary" evaluation before biopsy.