HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): William L. Holman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Murrah, C. P. Articles by Holman, W. L. Search for Related Content PubMed PubMed Citation Articles by Murrah, C. P. Articles by Holman, W. L.

Ann Thorac Surg 1996;61:1823-1824
© 1996 The Society of Thoracic Surgeons

---

Case Report

Resection of Multiple Pulmonary Metastases From a Recurrent Intracranial Meningioma

Divisions of Cardiothoracic Surgery, Neurosurgery, and Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama

Accepted for publication December 22, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Surgical resection of multiple pulmonary metastases from a recurrent intracranial meningioma in a 53-year-old woman is presented. The primary tumor was diagnosed in 1984 and partially excised in early 1985. The tumor recurred and was re-excised in 1989 and 1992. A fourth intracranial recurrence was noted in 1993, accompanied by multiple bilateral pulmonary metastases. The metastases were excised using staged thoracotomies in July and September 1994. The patient is surviving with cranial tumor residual.

	Introduction

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Meningiomas are usually benign intracranial tumors that only rarely metastasize. In 1987, Stoller and associates [1] found 113 extracranial metastatic cases. Sixty-one percent of these cases had lung metastasis. The lung was the only site of extracranial metastasis in 32%. Only 13% had greater than three metastases. This case illustrates surgical management of a patient with nine bilateral pulmonary metastases from a recurrent intracranial meningioma.

The patient is a 53-year-old woman who was found to have a mass in the left frontal hemispheric convexity in 1984. The mass was excised in early 1985, and was diagnosed as a meningioma. The meningioma recurred and was re-excised twice, in 1989 and 1992. A fourth recurrence was noted in late 1993, this time accompanied by multiple nodules observed on chest radiographs. The patient was without pulmonary symptoms. The meningioma was again excised in early 1994.

Thoracic computed tomography was performed in June 1994 and revealed nine pulmonary masses. Three each were located in the right upper and right lower lobes of the lung. Two were located in the left upper lobe, and one large mass was located in the left lower lobe. Fine-needle aspiration biopsy was done. This showed metastatic meningioma. A trial with the investigational drug RU486 was attempted at an outside hospital and failed.

Workup revealed no metastases to other organs. The patient had adequate pulmonary function and was deemed an acceptable operative risk. Due to the large left lower lobe mass, staged thoracotomies were done rather than a median sternotomy.

Left thoracotomy was done in July 1994. A firm 4.5 x 3 x 2-cm mass was found in the left lower lobe. There were two nodules measuring 2 x 1.5 x 1 cm each in the periphery of the left upper lobe. These were excised using electrocautery. The surgical beds were cauterized using the argon beam coagulator to secure hemostasis. This was followed by left lower lobectomy and removal of nine left hilar and mediastinal lymph nodes.

Right thoracotomy was done in September 1994. A total of six nodules measuring 1 to 3 cm in greatest dimension were found in the right lung. Three each were located in the right upper and lower lobes. All of the nodules were excised using electrocautery and the argon beam coagulator. Eight right hilar and mediastinal lymph nodes were also removed. The patient tolerated each of the operations well.

On gross examination, compression and extension of the tumor into the bronchial and arterial walls was noted. All of the lesions excised were found by light and electron microscopy as well as immunohistochemistry to be consistent with the primary tumor. The tumor approached but did not invade the visceral pleura. Immunoperoxidase stains were positive for vimentin, locally positive for neuron-specific enolase, and negative for epithelial membrane antigen. Tumor was identified in one of the 17 hilar and mediastinal lymph nodes.

	Comment

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Minimum criteria for resection of pulmonary metastases were described by Ehrenhaft and associates in 1958 [2]. These criteria have undergone little change since that time. There is almost universal agreement on the following criteria: (1) control of the primary neoplasm, (2) absence of metastasis to other organs, and (3) ability to resect all pulmonary metastases with acceptable operative risk and adequate residual pulmonary function [3]. This case represents an interesting application, but the principles remain the same. Other factors such as the number of metastases, disease-free interval, histologic type, and tumor doubling time, although not individually excluding a patient from resection, come into play when determining the operability of borderline cases.

The number of pulmonary metastases resected does not appear to significantly affect survival [4–6]. The upper limit of resectable metastases has not been defined, but is limited by the ability to meet the primary criteria of removing all metastatic lesions and leaving adequate pulmonary function [3]. Resection of all nine lesions was carried out without compromising these criteria.

The disease-free interval has been found to have a variable effect on prognosis [3]. This may be due to different distributions of histologic types between studies. Other case studies suggest that metastatic meningioma is an indolent disease. Twenty-two patients reviewed by Stoller and associates [1] had a mean time (± standard deviation) from detection of the primary tumor to detection of the first metastasis of 77 months (6.4 years) ± 66 months, and the longest disease-free interval was 20 years. Our patient had a disease-free interval of 122 months (10.2 years).

The histologic type of the primary tumor has an important influence on survival after resection for pulmonary metastases. Renal cell carcinomas and sarcomas tend to metastasize to the lungs before metastasizing to other organs. Patients with these histologic types tend to benefit from metastatic pulmonary resection. Melanomas typify the other extreme of tumors that have already spread to other organs by the time they are detected in the lung. Results for pulmonary resection of melanoma metastases have not been as encouraging as those for less aggressive tumors. Stoller and associates [1] reported that 61% of 113 cases of metastatic meningioma had pulmonary metastases (with or without other sites of metastases). The lung was the only site of metastasis in 32%. It was nearly as common (31%) for metastases to spare the lung but involve other extracranial organs. Due to the rarity of the disease, there is little information available on the results of metastatic pulmonary resection, although they would be expected to fall in the intermediate range.

The tumor doubling time, defined as the number of days necessary for a tumor to double in size, can be assessed by measuring tumor diameter on sequential chest radiographs. Most studies have shown a direct relationship between tumor doubling time and survival, regardless of histologic type. Published data suggest that metastatic meningioma is usually an indolent disease, as it was in this patient [1].

The surgical technique used in this patient was staged lateral thoracotomies. Median sternotomy normally is the preferred exposure for resection of bilateral pulmonary metastases; however, the size of the left lower lobe lesion precluded this approach. Regional excision using electrocautery was done to spare as much pulmonary parenchyma as possible. Disadvantages of staged thoracotomies for metastatic pulmonary resection are that time is allowed for growth of the tumor in the contralateral lung before the second thoracotomy, and that metastases may occur from the nonresected tumor during this interval. Staged thoracotomies could also delay the beginning of adjuvant therapy. These disadvantages are relatively unimportant for an indolent disease like metastatic meningioma.

	Acknowledgments

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
This work was performed during the tenure of Dr Holman as an Established Investigator of the American Heart Association.

	Footnotes

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Address reprint requests to Dr Holman, Department of Surgery, University of Alabama at Birmingham, University Station, Birmingham, AL 35294.

	References

Top Footnotes Abstract Introduction Comment Acknowledgments References

 

1. Stoller JK, Kavuru M, Mehta AC, Weinstein CE, Estes ML, Gephardt GN. Intracranial meningioma metastatic to the lung. Cleve Clin J Med 1987;54:521–7.[Medline]
2. Ehrenhaft JL, Lawrence MS, Sensenig DM. Pulmonary resections for metastatic lesions. Arch Surg 1958;77:606–12.
3. Baue AE, Geha AS, Hammond GL, Laks H, Naunheim KS, eds. Glenn's cardiovascular and thoracic surgery. 5th ed. Englewood Cliffs, NJ: Prentice-Hall, 1991:429–39.
4. Morrow CE, Vassilopoulos PP, Grage TB. Surgical resection for metastatic neoplasms of the lung: experience at the University of Minnesota Hospitals. Cancer 1980;45:2981–5.[Medline]
5. McCormack PM, Bains MS, Beattie EJ Jr, Martini N. Pulmonary resection in metastatic carcinoma. Chest 1978;73:163–6.[Abstract/Free Full Text]
6. Mountain CF, McMurtrey MJ, Hermes KE. Surgery for pulmonary metastasis: a 20-year experience. Ann Thorac Surg 1984;38:323–30.[Abstract]

This article has been cited by other articles:

				M. D'Aiuto, G. Veronesi, G. Pelosi, P. F. Presicci, G. M. Ferraroli, R. Gasparri, and L. Spaggiari Two-Year Survival After Multiple Bilateral Lung Metastasectomies for Cranial Meningioma Ann. Thorac. Surg., September 1, 2005; 80(3): 1129 - 1130. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): William L. Holman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Murrah, C. P. Articles by Holman, W. L. Search for Related Content PubMed PubMed Citation Articles by Murrah, C. P. Articles by Holman, W. L.