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A unique case of intracranial metastasis from lung carcinoma
Clinical Nadvg~ 0
und Nrwosurgery,
95
257
(I 993) 257-260
1993 Elsevier Science Publishers B.V. All rights reserved 0303-8467/93/$06.00
CLINEU 00292
Case report
A unique case of intracranial metastasis from lung carcinoma S.Y. El Sharouni”, M.W. Berfelob, P.H.M.H. Theunissenc, J.J. Jager” and J.M.A. de Jong” “Radiotherapy Institute Limhurg, He&en,
The Netherlands, Departments of ‘Neurosurgery and ‘Pathology, De Wever Ziekenhuis. Heerlen. The Netherlunds (Received 4 June, 1992) (Revised, received 2 June, 1993) (Accepted 7 June. 1993)
Key words:
Meningioma: Small-cell lung carcinoma; Intracranial
metastasis
Summary We describe a case of an intracranial metastasis from a lung carcinoma in the same location from which an intracranial meningioma had been completely removed surgically eleven months earlier. It is demonstrated that the metastasis originated in the scar of the first operation.
Case report Metastatic intracranial carcinoma accounts for 1525% of all intracranial tumours [l]. In 1902 Berent [2] was the first to report a malignant tumour metastasising into another malignant one. In our case, the metastasis occurred in the scar left after the removal of the meningioma. There are reports on metastases in the original scar of the operation for the primary tumour [12], in a sternotomy scar after coronary artery bypass [13], episiotomy scar [15], or post-traumatic [l 11, and on primary malignancies complicating burn wounds [10,14]. There are no reports on metastasis of an extracranial carcinoma in a previously operated intracranial area. Only 28 cases of a metastatic carcinoma within a meningioma have been reported in the literature. The origin of the primary malignant tumour that may metastasize to an intracranial meningioma can be lung, breast, prostate, kidney, uterine cervix, uterine body in a number of instances, or the origin is unknown [3,5-91. C~~~~~.s~~~~~~~~e to: Dr. S.Y. El Sharouni, Radiotherapy Institute Limburg. HewI Dunantstraat 5,64i9 PC, Heerlen, The Netherlands.
A 64-year-old woman with focal epilepsy was admitted to the Neurosurgical Department in November 1990; she had no significant medical history and was not taking any medicines. General physical examination showed no abnormalities and neurological examination did not reveal any deficit. Fundoscopy was normal. Computerized tomography (CT) of the brain (Fig. 1) revealed a hypodense area in the right parietal lobe which became hyperdense after intravenous contrast injection. A parieto-temporal craniotomy was carried out. The dura was adherent to the bone and a mushroom-shaped subdural tumour was seen. The head of the tumour lay subdurally and was very soft whereas the firm stalk was embedded in the cortex. The tumour was removed completely. Histological examination showed a meningioma with no evidence of malignancy (Fig. 2). The postoperative course was uneventful and there were no neurological deficits. Extensive histological reexamination of the meningioma showed no micrometastasis of a carcinoma. Five months after the operation, the patient developed
Fig. 1. CT scan performed in October 1990 showing the meningioma.
pain in the left arm and in the region of the left scapula. Haemoptysis was noticed and therefore she was referred to the chest physician. General physical examination revealed no abnormal signs and, in particular, there were no abnormal findings in the chest. The chest X-ray disclosed a mass in the left hilus. CT scan of the lungs showed multiple pathologically enlarged lymph nodes in
the mediastinum and below the medial end of the left clavicle. Bronchoscopy identified a tumour in the leti lower bronchial segment. A biopsy was performed and the histological examination showed a small-cell carcinoma of the lung. The patient received polychemotherapy. A CT scan of the thorax after completion of the treatment revealed partial response. Palliative radiotherapy was given to the tumour region and to all pathological lymph nodes. In September 1991, the patient complained of attacks of muscle weakness in the left half of the face and in the left arm although physical examination showed no abnormal signs. CT of the brain (Fig. 3) showed a mass at the same location from which the meningioma had been removed in November 1990. In October 199 1, 11 months after the first. craniotomy, the patient was operated on again and another tumour was removed from the same location. Histological examination showed a metastasis from a small-cell carcinoma of the lung without any remnants of the meningioma (Fig. 4). Post-operatively radiotherapy was initiated.
Discussion
This patient suffered from an intracranial meningioma which was completely removed surgically. Histological
Fig. 2. Histological specimen showing the meningioma which was removed in November 1990.
259 same place was removed nation
of a small-cell meningioma
carcinoma
of the lung.
that metastases
surgical
removal
There are also reports
No
traces
of
scopy, burn wounds, or episiotomy
may arise in scar tissue left
of extracranial on primary
ing in scar tissue resulting bypass
exami-
proved it to be a metastasis
could be found.
It is known after
. Histological
surgically
of this second tumour
tumours
malignancies
from diagnostic
trauma,
sternotomy
[12].
originatmediastino-
after coronary
[lo-141. There is no clear explana-
tion for this phenomenon. This is the first report nial carcinoma a previous
operation.
ses about malignant mata. A tumour immunological Fig. 3. CT scan performed in September 1991 showing the solitary metastasis.
examination
showed
a completely
without signs of malignancy; carcinoma were found. Eleven
months
later
another
encapsulated
tumour
no micrometastases tumour
in exactly
of a the
of a metastasis
in an intracranial
of an extracra-
area at the exact site of
There have been different metastases
in intracranial
hypothemeningio-
within a tumour may represent a state of incompetence of tissues harbouring a
carcinoma [4]. The rich vascularity of a meningioma may provide fertile ground for seeds of a metastatic carcinoma [7,8]. Other biological factors, enzymatic or hormonal, either facilitate or inhibit implantation and growth of a metastasis in the host tumour. The slow growth of a vascular benign tumour may expose it to a higher risk of receiving a metastasis for a far longer period than a fast growing
malignant
Fig. 4. Histological specimen showing the solitary metastasis which was removed in October
tumour
1991.
[7]. The fact
that no remnants of meningioma were seen in the histologicat examination of the ~eurosurgica~ specimen of the metastasis excluded the possibiIity that the metastasis
7 Lordini, S. and Savoiardo,
might have originated
8
in the meningioma.
survey of the literature did not provide an answer to the question of whether there is a higher risk of metastati~ carcinoma at the site of a previous intracranial operation.
10
References
11
An extensive
Rubinste~n, L.J. (1972) Secondary tumors of the central nervous system. In: Tumors of the Central Nervous System, Fast. 6, 2nd series, Armed Forces Institute of Pathology. Washington, DC, pp* 3 13-332. Berent, W. (1902) Seltene Metastasenbiidung. Cbl. Allg. Pa-
thol. Re. Pathol. Anat., 13: 406-410. Weems, T.D. and Garcia, J.H. (1977) Intracranial meningioma containing metastatic foci. South. Med. J., 70: 5033.505. Hope, T.D. and Symon, L. (1978) Metastasis of carcinoma to meningioma. Acta Neurochir., 40: 307-3 13. Chambers, P.W., Davis, R.L. and Buck, F.S. (1980) Metastasis to primary intra~anial mening~omas and neur~lemmomas. Arch. Pathol. Lab. Med., 104: 350-354. Nunnery, E., Kahn, L.B. and Rudnick, S.A. (1980) Breast carcinoma metastatic to meningioma. Arch. Pathol. Lab. Med.. 104: 392,
9
12
13
14
15
M. (198I) Metastases of carcinoma to int~cranial meningioma: report of two cases and review of the literature. Cancer, 48: 266% 2673. Bernstein, R.A., Crumet, K.A. and Wetzel. NE. ( 1983) Metastases of prostatic carcinoma to intracranial meningioma. J. Neurosurg., 58: 774-777. Khang-Loon, Ho. (19801 Metastasis of carcinoma to meningioma. Arch. Pathol. Lab. Med., 104: 394. Abbas, J.S. and Beecham, J.E. (1988) Burn wound carcinoma: case report and review of the literature. Burns Incl. Therm. lnj., 14: 222-224. Lifeso, R.M., Rooney, R.J. and El-Shaker M. (1990) Posttraumatic squamous-cell carcinoma. J. Bone Joint Surg. Am., 72: 12-18. Edoute, Y.. Malberger, E., Lachter, J. and Toledano, 0. (199 1) Fine-needle aspiration cytology of abdominal wall scar lesions for diagnosing recurrent colorectal cancer. J. Clin. Gastroenterol., 13: 463-464. Korula. R. and Hughes, C.F. (1991) Squamous cell carcinoma arising in a sternotomy scar. Ann. Thorac. Surg., 5 i: 667-669. Lee. J.Y., Kapadia, S.B., Musgrave. R.H. and Futrell, W.J. (1992) Neurotropic malignant melanoma occurring in a stable burn scar. J. Cutan. Pathol., 19: 145-150, Van Dam, P.A., Irvine, L., Lowe, D.G., Fisher, C,, Barton, D.P. and Sheperd, J.H. (1992) Car~noma in episiotomy scars. Gynecol. Oncol., 44: 99-100.
und Nrwosurgery,
95
257
(I 993) 257-260
1993 Elsevier Science Publishers B.V. All rights reserved 0303-8467/93/$06.00
CLINEU 00292
Case report
A unique case of intracranial metastasis from lung carcinoma S.Y. El Sharouni”, M.W. Berfelob, P.H.M.H. Theunissenc, J.J. Jager” and J.M.A. de Jong” “Radiotherapy Institute Limhurg, He&en,
The Netherlands, Departments of ‘Neurosurgery and ‘Pathology, De Wever Ziekenhuis. Heerlen. The Netherlunds (Received 4 June, 1992) (Revised, received 2 June, 1993) (Accepted 7 June. 1993)
Key words:
Meningioma: Small-cell lung carcinoma; Intracranial
metastasis
Summary We describe a case of an intracranial metastasis from a lung carcinoma in the same location from which an intracranial meningioma had been completely removed surgically eleven months earlier. It is demonstrated that the metastasis originated in the scar of the first operation.
Case report Metastatic intracranial carcinoma accounts for 1525% of all intracranial tumours [l]. In 1902 Berent [2] was the first to report a malignant tumour metastasising into another malignant one. In our case, the metastasis occurred in the scar left after the removal of the meningioma. There are reports on metastases in the original scar of the operation for the primary tumour [12], in a sternotomy scar after coronary artery bypass [13], episiotomy scar [15], or post-traumatic [l 11, and on primary malignancies complicating burn wounds [10,14]. There are no reports on metastasis of an extracranial carcinoma in a previously operated intracranial area. Only 28 cases of a metastatic carcinoma within a meningioma have been reported in the literature. The origin of the primary malignant tumour that may metastasize to an intracranial meningioma can be lung, breast, prostate, kidney, uterine cervix, uterine body in a number of instances, or the origin is unknown [3,5-91. C~~~~~.s~~~~~~~~e to: Dr. S.Y. El Sharouni, Radiotherapy Institute Limburg. HewI Dunantstraat 5,64i9 PC, Heerlen, The Netherlands.
A 64-year-old woman with focal epilepsy was admitted to the Neurosurgical Department in November 1990; she had no significant medical history and was not taking any medicines. General physical examination showed no abnormalities and neurological examination did not reveal any deficit. Fundoscopy was normal. Computerized tomography (CT) of the brain (Fig. 1) revealed a hypodense area in the right parietal lobe which became hyperdense after intravenous contrast injection. A parieto-temporal craniotomy was carried out. The dura was adherent to the bone and a mushroom-shaped subdural tumour was seen. The head of the tumour lay subdurally and was very soft whereas the firm stalk was embedded in the cortex. The tumour was removed completely. Histological examination showed a meningioma with no evidence of malignancy (Fig. 2). The postoperative course was uneventful and there were no neurological deficits. Extensive histological reexamination of the meningioma showed no micrometastasis of a carcinoma. Five months after the operation, the patient developed
Fig. 1. CT scan performed in October 1990 showing the meningioma.
pain in the left arm and in the region of the left scapula. Haemoptysis was noticed and therefore she was referred to the chest physician. General physical examination revealed no abnormal signs and, in particular, there were no abnormal findings in the chest. The chest X-ray disclosed a mass in the left hilus. CT scan of the lungs showed multiple pathologically enlarged lymph nodes in
the mediastinum and below the medial end of the left clavicle. Bronchoscopy identified a tumour in the leti lower bronchial segment. A biopsy was performed and the histological examination showed a small-cell carcinoma of the lung. The patient received polychemotherapy. A CT scan of the thorax after completion of the treatment revealed partial response. Palliative radiotherapy was given to the tumour region and to all pathological lymph nodes. In September 1991, the patient complained of attacks of muscle weakness in the left half of the face and in the left arm although physical examination showed no abnormal signs. CT of the brain (Fig. 3) showed a mass at the same location from which the meningioma had been removed in November 1990. In October 199 1, 11 months after the first. craniotomy, the patient was operated on again and another tumour was removed from the same location. Histological examination showed a metastasis from a small-cell carcinoma of the lung without any remnants of the meningioma (Fig. 4). Post-operatively radiotherapy was initiated.
Discussion
This patient suffered from an intracranial meningioma which was completely removed surgically. Histological
Fig. 2. Histological specimen showing the meningioma which was removed in November 1990.
259 same place was removed nation
of a small-cell meningioma
carcinoma
of the lung.
that metastases
surgical
removal
There are also reports
No
traces
of
scopy, burn wounds, or episiotomy
may arise in scar tissue left
of extracranial on primary
ing in scar tissue resulting bypass
exami-
proved it to be a metastasis
could be found.
It is known after
. Histological
surgically
of this second tumour
tumours
malignancies
from diagnostic
trauma,
sternotomy
[12].
originatmediastino-
after coronary
[lo-141. There is no clear explana-
tion for this phenomenon. This is the first report nial carcinoma a previous
operation.
ses about malignant mata. A tumour immunological Fig. 3. CT scan performed in September 1991 showing the solitary metastasis.
examination
showed
a completely
without signs of malignancy; carcinoma were found. Eleven
months
later
another
encapsulated
tumour
no micrometastases tumour
in exactly
of a the
of a metastasis
in an intracranial
of an extracra-
area at the exact site of
There have been different metastases
in intracranial
hypothemeningio-
within a tumour may represent a state of incompetence of tissues harbouring a
carcinoma [4]. The rich vascularity of a meningioma may provide fertile ground for seeds of a metastatic carcinoma [7,8]. Other biological factors, enzymatic or hormonal, either facilitate or inhibit implantation and growth of a metastasis in the host tumour. The slow growth of a vascular benign tumour may expose it to a higher risk of receiving a metastasis for a far longer period than a fast growing
malignant
Fig. 4. Histological specimen showing the solitary metastasis which was removed in October
tumour
1991.
[7]. The fact
that no remnants of meningioma were seen in the histologicat examination of the ~eurosurgica~ specimen of the metastasis excluded the possibiIity that the metastasis
7 Lordini, S. and Savoiardo,
might have originated
8
in the meningioma.
survey of the literature did not provide an answer to the question of whether there is a higher risk of metastati~ carcinoma at the site of a previous intracranial operation.
10
References
11
An extensive
Rubinste~n, L.J. (1972) Secondary tumors of the central nervous system. In: Tumors of the Central Nervous System, Fast. 6, 2nd series, Armed Forces Institute of Pathology. Washington, DC, pp* 3 13-332. Berent, W. (1902) Seltene Metastasenbiidung. Cbl. Allg. Pa-
thol. Re. Pathol. Anat., 13: 406-410. Weems, T.D. and Garcia, J.H. (1977) Intracranial meningioma containing metastatic foci. South. Med. J., 70: 5033.505. Hope, T.D. and Symon, L. (1978) Metastasis of carcinoma to meningioma. Acta Neurochir., 40: 307-3 13. Chambers, P.W., Davis, R.L. and Buck, F.S. (1980) Metastasis to primary intra~anial mening~omas and neur~lemmomas. Arch. Pathol. Lab. Med., 104: 350-354. Nunnery, E., Kahn, L.B. and Rudnick, S.A. (1980) Breast carcinoma metastatic to meningioma. Arch. Pathol. Lab. Med.. 104: 392,
9
12
13
14
15
M. (198I) Metastases of carcinoma to int~cranial meningioma: report of two cases and review of the literature. Cancer, 48: 266% 2673. Bernstein, R.A., Crumet, K.A. and Wetzel. NE. ( 1983) Metastases of prostatic carcinoma to intracranial meningioma. J. Neurosurg., 58: 774-777. Khang-Loon, Ho. (19801 Metastasis of carcinoma to meningioma. Arch. Pathol. Lab. Med., 104: 394. Abbas, J.S. and Beecham, J.E. (1988) Burn wound carcinoma: case report and review of the literature. Burns Incl. Therm. lnj., 14: 222-224. Lifeso, R.M., Rooney, R.J. and El-Shaker M. (1990) Posttraumatic squamous-cell carcinoma. J. Bone Joint Surg. Am., 72: 12-18. Edoute, Y.. Malberger, E., Lachter, J. and Toledano, 0. (199 1) Fine-needle aspiration cytology of abdominal wall scar lesions for diagnosing recurrent colorectal cancer. J. Clin. Gastroenterol., 13: 463-464. Korula. R. and Hughes, C.F. (1991) Squamous cell carcinoma arising in a sternotomy scar. Ann. Thorac. Surg., 5 i: 667-669. Lee. J.Y., Kapadia, S.B., Musgrave. R.H. and Futrell, W.J. (1992) Neurotropic malignant melanoma occurring in a stable burn scar. J. Cutan. Pathol., 19: 145-150, Van Dam, P.A., Irvine, L., Lowe, D.G., Fisher, C,, Barton, D.P. and Sheperd, J.H. (1992) Car~noma in episiotomy scars. Gynecol. Oncol., 44: 99-100.