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Primary ectopic meningioma in the right ethmoid sinus: a case report
Auris Nasus Larynx 24 (1997) 321 – 324
Case report
Primary ectopic meningioma in the right ethmoid sinus: a case report Makoto Hanada *, Kazutomo Kitajima Department of Otolaryngology, Head and Neck Surgery, Shiga Uni6ersity of Medical Science, Seta, Otsu, Shiga Pref., 520 – 21, Japan Received 22 April 1996; received in revised form 15 October 1996; accepted 18 November 1996
Abstract A 29-year-old female with primary ectopic meningioma in the right ethmoid sinus was reported. She was treated by a right lateral rhinotomy with total removal of the tumor and the subsequent clinical course was good. Contrast enhanced magnetic resonance image (MRI) was most informative to define the tumor and decide the surgical procedure, in which it was demonstrated as well circumscribed mass lesion with considerable homogeneous contrast enhancement. © 1997 Elsevier Science Ireland Ltd. Keywords: Ectopic meningioma; ethmoid sinus
1. Introduction Meningiomas originate from meningocytes and constitute about 15% of all intracranial and 12% of intraspinal neoplasmas [1,2]. But extracranial and also extraspinal meningiomas (primary ectopic meningiomas) are rare, which are estimated to be less than 1% of all meningiomas [3,4]. Therefore, there hasn’t been so many reports ac* Corresponding author. Tel.: + 81 775 482261; fax: + 81 775 457489.
cording to diagnosis of this disease, especially to radiologic features. In this paper, we present a case of primary ectopic meningioma arising from the right ethmoid sinus and describe its radiologic features.
2. Case report A 29-year-old female presented at our clinic in November 1990, complaining of pain of the right frontal region and ophthalmalgia of 5 years’ dura-
0385-8146/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 8 5 - 8 1 4 6 ( 9 6 ) 0 0 0 3 2 - 6
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M. Hanada, K. Kitajima / Auris Nasus Larynx 24 (1997) 321–324
tion. She never complained of nasal obstruction, lack of smelling or visual disturbance. Endoscopic examination revealed a reddish smooth mass in the right nasal cavity (Fig. 1). Plain computed tomography (CT) scan demonstrated an expansive mass lesion without bone destruction or calcification in the right ethmoid sinus (Fig. 2). It was demonstrated by magnetic resonance image (MRI) as low intensity in T1 weighted and isointensity in T2 weighted image, which was well enhanced with Gd-DTPA (Figs. 3 and 4). This mass was suspected of ‘neurinoma’ by the result of preoperative biopsy. The patient underwent a right lateral rhinotomy with total removal of the tumor. This tumor expanded medially to the nasal septum, laterally to the lamina papyracea, anteriorly to the inferior nasal turbinate, posteriorly to the anterior wall of sphenoid sinus and superiorly to the tegmen plate of posterior ethmoid sinus, whereas the tumor never extended into the cranium. The surgical specimen revealed a greyish-white encapsulated solid mass weighing 15 g. Microscopically the tumor was consisted of many fibrous cells occasionally arranging in pallisading or whorls, which were surrounded by a lot of argyrophilic fibers (Figs. 5 and 6). Immunohistochemical studies proved negative for both S-100 protein and neuron-specific enolase (NSE). Finally, histological diagnosis was ‘extracranial fibroblastic meningioma’.
Fig. 1. Endoscopic appearance of the right nasal cavity at the first medical examination. (T, tumor; NS, nasal septum; MT, middlle nasal turbinate)
Fig. 2. Plain CT demonstrating an expansive mass lesion (1), which was confirmed to be in the right ethmoid sinus by surgical findings.
After the treatment, she never noticed the symptoms and there has been no sign of recurrence for 5 years.
3. Discussion Primary ectopic meningiomas are found most often in the orbit, the skin, the skull, and very rarely in the paranasal sinuses [1,5–7]. Possible mechanisms of their origins have been suggested as follows: (1) originating from heterotopic meningocytes dislocated upon the closure of the midline structures during fetal life [8,9], (2) originating from meningocytes found around the skull or intervertebral foramina or along perineural sheaths of cranial nerves [10,11], (3) differentia-
Fig. 3. The tumor is demonstrated as low intensity in T1 weighted (left) and isointensity in T2 weighted image by MRI. The sphenoiditis is also identified;
M. Hanada, K. Kitajima / Auris Nasus Larynx 24 (1997) 321–324
323
Fig. 4. Gd-DTPA-enhanced MRI demonstrating well enhanced circumscribed mass lesion which never extends into the cranium.
Fig. 6. Microphotograph showing many fibrous cells surrounded by a lot of argyrophilic fibers. (Silver impregnation, ×400)
tion of Schwann cells into meningocytes [12], (4) originating from multipotential mesenchymal cells [5,11]. In our case, the origin was supposed to be (3) or (4), because the tumor was located only in the ethmoid sinus and the nasal cavity which was never associated with cranial nerves or skull foramina and histologically resembled Schwannoma. In diagnosis of meningiomas, radiographic findings (especially CT and MRI) have been informative. Most indicative findings are ‘calcification’ and ‘contrast enhancement’. Schubeus et al. reported that calcification had been found in 13 cases (26%) in CT and 2 cases (4%) in MRI of 50 meningiomas [13]. Scho¨rner et al. reported
that CT and MRI had represented a similar enhancement effect on the imaging of meningiomas but enhanced MRI had been considered to be of a higher diagnostic value than enhanced CT [14]. On the other hand, Geoffray et al. advocated that CT was the most accurate and informative method to define the tumor with homogeneous contrast enhancement in extracranial and extraspinal meningiomas [2]. But in our case, there was no finding of calcification in CT as in most cases and the tumor was much more enhanced in MRI than in CT. Therefore, enhanced MRI is most useful method to diagnose the tumor and estimate the extent of its development, especially its intracranial involvement, and primary ectopic meningioma must be kept in mind when there is well circumscribed mass lesion with considerable homogeneous contrast enhancement in the paranasal sinuses.
4. Summary
Fig. 5. Microphotograph of fibroblastic men ingioma with fibrous cells occasionally arranging in pallisading and whorls. (HE stain, ×100)
A 29-year-old female with primary ectopic meningioma in the right ethmoid sinus was presented. She was treated by the operation (lateral rhinotomy) and the subsequent clinical course was good. Enhanced MRI was the most accurate and informative method to define the tumor and decide the surgical procedure.
M. Hanada, K. Kitajima / Auris Nasus Larynx 24 (1997) 321–324
324
References [1] Michel RG, Woodard BH. Extracranial meningioma. Ann Otol 1979;88:407–412. [2] Geoffray A, Lee YY, Jing BS, Wallace S. Extracranial meningiomas of the head and neck. AJNR 1984;5:599– 604. [3] Farr HW, Gray GF, Vrana M, Panio M. Extracranial meningioma. J Surg Oncol 1973:412–420. [4] Whicker JH, Devine KD, MacCarty CS. Diagnostic and therapeutic problems in extracranial meningiomas. Am J Surg 1973;126:452 – 457. [5] Shuangshoti S, Panyathanya R. Ectopic meningiomas. Arch Otolaryngol 1973;98:102–105. [6] Schmid C, Bosisio MB, Schiaffino E, Servida E, Zibordi F. Extra and intracranial meningiomas. Tumori 1980;66:661 – 667. [7] Kershisnik M, Callender DL, Batsakis JG. Extracranial, extraspinal meningiomas of the head and neck. Ann Otol Rhinol Laryngol 1993;102:967–971.
.
[8] McGavran MH, Biller HF, Ogura JH. Primary intranasal meningioma. Arch Otolaryngol 1971;93:95 – 97. [9] Ho KL. Primary meningioma of the nasal cavity and paranasal sinuses. Cancer 1980;46:1442 – 1447. [10] New GB, Devine KD. Neurogenic tumors of nose and throat. Arch Otolaryngol 1947;46:163 – 179. [11] Papavasiliou A, Sawyer R, Lund V. Effects of meningiomas on the facial skeleton. Arch Otolaryngol 1982;108:255 – 257. [12] Atherino CCT, Garcia R, Lopes LJ. Ectopic meningioma of the nose and paranasal sinuses (Report of a case). J Laryngol Otol 1985;99:1161 – 1166. [13] Schubeus P, Scho¨rner W, Rottacker C, Sander B. Intracranial meningiomas: How frequent are indicative findings in CT and MRI? Neuroradiology 1990;32:467 – 473. [14] Scho¨rner W, Schubeus P, Henkes H, Rottacker C, Hamm B, et al. Intracranial meningiomas: Comparison of plain and contrast-enhanced examinations in CT and MRI. Neuroradiology 1990;32:12 – 18.
Case report
Primary ectopic meningioma in the right ethmoid sinus: a case report Makoto Hanada *, Kazutomo Kitajima Department of Otolaryngology, Head and Neck Surgery, Shiga Uni6ersity of Medical Science, Seta, Otsu, Shiga Pref., 520 – 21, Japan Received 22 April 1996; received in revised form 15 October 1996; accepted 18 November 1996
Abstract A 29-year-old female with primary ectopic meningioma in the right ethmoid sinus was reported. She was treated by a right lateral rhinotomy with total removal of the tumor and the subsequent clinical course was good. Contrast enhanced magnetic resonance image (MRI) was most informative to define the tumor and decide the surgical procedure, in which it was demonstrated as well circumscribed mass lesion with considerable homogeneous contrast enhancement. © 1997 Elsevier Science Ireland Ltd. Keywords: Ectopic meningioma; ethmoid sinus
1. Introduction Meningiomas originate from meningocytes and constitute about 15% of all intracranial and 12% of intraspinal neoplasmas [1,2]. But extracranial and also extraspinal meningiomas (primary ectopic meningiomas) are rare, which are estimated to be less than 1% of all meningiomas [3,4]. Therefore, there hasn’t been so many reports ac* Corresponding author. Tel.: + 81 775 482261; fax: + 81 775 457489.
cording to diagnosis of this disease, especially to radiologic features. In this paper, we present a case of primary ectopic meningioma arising from the right ethmoid sinus and describe its radiologic features.
2. Case report A 29-year-old female presented at our clinic in November 1990, complaining of pain of the right frontal region and ophthalmalgia of 5 years’ dura-
0385-8146/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 8 5 - 8 1 4 6 ( 9 6 ) 0 0 0 3 2 - 6
322
M. Hanada, K. Kitajima / Auris Nasus Larynx 24 (1997) 321–324
tion. She never complained of nasal obstruction, lack of smelling or visual disturbance. Endoscopic examination revealed a reddish smooth mass in the right nasal cavity (Fig. 1). Plain computed tomography (CT) scan demonstrated an expansive mass lesion without bone destruction or calcification in the right ethmoid sinus (Fig. 2). It was demonstrated by magnetic resonance image (MRI) as low intensity in T1 weighted and isointensity in T2 weighted image, which was well enhanced with Gd-DTPA (Figs. 3 and 4). This mass was suspected of ‘neurinoma’ by the result of preoperative biopsy. The patient underwent a right lateral rhinotomy with total removal of the tumor. This tumor expanded medially to the nasal septum, laterally to the lamina papyracea, anteriorly to the inferior nasal turbinate, posteriorly to the anterior wall of sphenoid sinus and superiorly to the tegmen plate of posterior ethmoid sinus, whereas the tumor never extended into the cranium. The surgical specimen revealed a greyish-white encapsulated solid mass weighing 15 g. Microscopically the tumor was consisted of many fibrous cells occasionally arranging in pallisading or whorls, which were surrounded by a lot of argyrophilic fibers (Figs. 5 and 6). Immunohistochemical studies proved negative for both S-100 protein and neuron-specific enolase (NSE). Finally, histological diagnosis was ‘extracranial fibroblastic meningioma’.
Fig. 1. Endoscopic appearance of the right nasal cavity at the first medical examination. (T, tumor; NS, nasal septum; MT, middlle nasal turbinate)
Fig. 2. Plain CT demonstrating an expansive mass lesion (1), which was confirmed to be in the right ethmoid sinus by surgical findings.
After the treatment, she never noticed the symptoms and there has been no sign of recurrence for 5 years.
3. Discussion Primary ectopic meningiomas are found most often in the orbit, the skin, the skull, and very rarely in the paranasal sinuses [1,5–7]. Possible mechanisms of their origins have been suggested as follows: (1) originating from heterotopic meningocytes dislocated upon the closure of the midline structures during fetal life [8,9], (2) originating from meningocytes found around the skull or intervertebral foramina or along perineural sheaths of cranial nerves [10,11], (3) differentia-
Fig. 3. The tumor is demonstrated as low intensity in T1 weighted (left) and isointensity in T2 weighted image by MRI. The sphenoiditis is also identified;
M. Hanada, K. Kitajima / Auris Nasus Larynx 24 (1997) 321–324
323
Fig. 4. Gd-DTPA-enhanced MRI demonstrating well enhanced circumscribed mass lesion which never extends into the cranium.
Fig. 6. Microphotograph showing many fibrous cells surrounded by a lot of argyrophilic fibers. (Silver impregnation, ×400)
tion of Schwann cells into meningocytes [12], (4) originating from multipotential mesenchymal cells [5,11]. In our case, the origin was supposed to be (3) or (4), because the tumor was located only in the ethmoid sinus and the nasal cavity which was never associated with cranial nerves or skull foramina and histologically resembled Schwannoma. In diagnosis of meningiomas, radiographic findings (especially CT and MRI) have been informative. Most indicative findings are ‘calcification’ and ‘contrast enhancement’. Schubeus et al. reported that calcification had been found in 13 cases (26%) in CT and 2 cases (4%) in MRI of 50 meningiomas [13]. Scho¨rner et al. reported
that CT and MRI had represented a similar enhancement effect on the imaging of meningiomas but enhanced MRI had been considered to be of a higher diagnostic value than enhanced CT [14]. On the other hand, Geoffray et al. advocated that CT was the most accurate and informative method to define the tumor with homogeneous contrast enhancement in extracranial and extraspinal meningiomas [2]. But in our case, there was no finding of calcification in CT as in most cases and the tumor was much more enhanced in MRI than in CT. Therefore, enhanced MRI is most useful method to diagnose the tumor and estimate the extent of its development, especially its intracranial involvement, and primary ectopic meningioma must be kept in mind when there is well circumscribed mass lesion with considerable homogeneous contrast enhancement in the paranasal sinuses.
4. Summary
Fig. 5. Microphotograph of fibroblastic men ingioma with fibrous cells occasionally arranging in pallisading and whorls. (HE stain, ×100)
A 29-year-old female with primary ectopic meningioma in the right ethmoid sinus was presented. She was treated by the operation (lateral rhinotomy) and the subsequent clinical course was good. Enhanced MRI was the most accurate and informative method to define the tumor and decide the surgical procedure.
M. Hanada, K. Kitajima / Auris Nasus Larynx 24 (1997) 321–324
324
References [1] Michel RG, Woodard BH. Extracranial meningioma. Ann Otol 1979;88:407–412. [2] Geoffray A, Lee YY, Jing BS, Wallace S. Extracranial meningiomas of the head and neck. AJNR 1984;5:599– 604. [3] Farr HW, Gray GF, Vrana M, Panio M. Extracranial meningioma. J Surg Oncol 1973:412–420. [4] Whicker JH, Devine KD, MacCarty CS. Diagnostic and therapeutic problems in extracranial meningiomas. Am J Surg 1973;126:452 – 457. [5] Shuangshoti S, Panyathanya R. Ectopic meningiomas. Arch Otolaryngol 1973;98:102–105. [6] Schmid C, Bosisio MB, Schiaffino E, Servida E, Zibordi F. Extra and intracranial meningiomas. Tumori 1980;66:661 – 667. [7] Kershisnik M, Callender DL, Batsakis JG. Extracranial, extraspinal meningiomas of the head and neck. Ann Otol Rhinol Laryngol 1993;102:967–971.
.
[8] McGavran MH, Biller HF, Ogura JH. Primary intranasal meningioma. Arch Otolaryngol 1971;93:95 – 97. [9] Ho KL. Primary meningioma of the nasal cavity and paranasal sinuses. Cancer 1980;46:1442 – 1447. [10] New GB, Devine KD. Neurogenic tumors of nose and throat. Arch Otolaryngol 1947;46:163 – 179. [11] Papavasiliou A, Sawyer R, Lund V. Effects of meningiomas on the facial skeleton. Arch Otolaryngol 1982;108:255 – 257. [12] Atherino CCT, Garcia R, Lopes LJ. Ectopic meningioma of the nose and paranasal sinuses (Report of a case). J Laryngol Otol 1985;99:1161 – 1166. [13] Schubeus P, Scho¨rner W, Rottacker C, Sander B. Intracranial meningiomas: How frequent are indicative findings in CT and MRI? Neuroradiology 1990;32:467 – 473. [14] Scho¨rner W, Schubeus P, Henkes H, Rottacker C, Hamm B, et al. Intracranial meningiomas: Comparison of plain and contrast-enhanced examinations in CT and MRI. Neuroradiology 1990;32:12 – 18.