Ann Thorac Surg 2005;80:1129-1130
© 2005 The Society of Thoracic Surgeons
Case report
Two-Year Survival After Multiple Bilateral Lung Metastasectomies for Cranial Meningioma
Massimiliano D’Aiuto, MD,
Giulia Veronesi, MD,
Giuseppe Pelosi, MD,
Pietro Fabio Presicci, MD,
Giorgio Maria Ferraroli, MD,
Robero Gasparri, MD,
Lorenzo Spaggiari, MD, PhD
*
Divisions of Thoracic Surgery and Pathology, European Institute of Oncology, Milan, Italy
Accepted for publication February 17, 2004.
* Address reprint requests to Dr Spaggiari, Division of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, Milan I-20141, Italy; (Email: lorenzo.spaggiari{at}ieo.it).
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Abstract
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The lung represents a common site of metastases from extrathoracic malignancies, and several studies have strengthened the evidence that complete resection of pulmonary metastases is a useful therapeutic treatment for prolonged survival in selected patients. However, fewer data are available in the literature regarding the role of lung metastasectomy in rare malignancy. We present a case of extensive bilateral lung metastases due to recurrent cranial meningioma, which was successfully treated by aggressive, staged metastasectomies.
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Introduction
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Cranial meningioma is considered a slow-growing tumor arising from arachnoid cells in the meninges with good prognosis if radically resected. However, on occasion (in less than 0.1% of cases), metastases can develop. Although the lung is the most frequent site of metastatic spread, it is extremely rare to find more than three pulmonary deposits. We report the case of a patient with extensive bilateral pulmonary metastatic meningiomas resected by staged thoracotomy and followed-up for 2 years without evidence of relapse.
A 71-year-old man was referred to our institution with multiple pulmonary bilateral nodules. He had undergone a resection of a cranial meningioma of the right temporo-occipital region 13 years prior. At that time the pathologic examination showed a radically resected typical meningioma with syncytial features (grade I according to the World Health Organization classification). The patient had been followed-up for 5 years with periodic neurologic evaluations with no signs of relapse. A chest roentgenogram was performed 7 years later for unknown reasons, which had revealed the presence of bilateral lung lesions that were neither subsequently investigated nor taken into account. He came to our attention after a neurologic consultation, which he had requested for persistent headaches and vomiting. Workup included a total body computed tomographic scan that identified four brain lesions of the right temporo-occipital region measuring 2.5 cm, 1.5 cm, 2 cm, and 4 cm, which showed the presence of multiple bilateral pulmonary nodules (ie, 9 at the right level and 12 at the left level; range, 1 to 5 cm in diameter) (Fig 1). An 18-F-2-fluoro-deoxy-D-glucose-positron-emission tomographic scan was positive for both lungs, although only the nodules larger then 2 cm presented abnormal uptake. A fine needle aspiration of one lung lesion led to a diagnosis of metastatic psammomatous meningioma. Craniotomy was first performed by the same previous surgical access, and the lesions were completely resected. Pathologic examination showed an atypical meningioma with syncytial features and high mitotic activity (5 to 6 mitoses/10 high power fields, grade II according to the World Health Organization classification) in all cases. No adjuvant cranial radiotherapy was performed. Three months bilateral-staged lateral muscle-sparing thoracotomies were scheduled for multiple lung metastasectomies. Preoperative functional evaluation included routine blood tests, electrocardiogram, spirometry, and perfusion lung scan without evidence of concomitant cardiac and pulmonary disease. At the time of the first thoracotomy, the spirometry showed a forced expiratory volume in 1 second of 2.3 L (98.2% of the predicted) and a predicted carbon monoxide diffusion lung capacity of 128.1%, with a left lung scan perfusion of 44.6%. At the time of the second thoracotomy the forced expiratory volume in 1 second was 1.4 L (60% of the predicted), with a predicted carbon monoxide diffusion lung capacity of 98.7%.
We started from the left side due to the presence of the major number and the greater size of pulmonary metastases. The interval between the two thoracotomies was 40 days.
Twenty-one right and 16 left lung metastases were resected. To spare as much pulmonary parenchyma as possible, almost all the lesions were cut out with the precision tumorectomy technique, using the electrocautery excision with at least 5 mm margin of normal lung tissue around the nodule. Only three lesions were removed by mechanical staplers because of their larger size. Mediastinal lymph node sampling was also performed.
Pathologic examination of all the lung lesions showed the same pathologic characteristics as the cranial meningioma previously resected (Fig 2). Lesion sizes ranged from 0.4 cm to 6 cm without evidence of margin infiltration. All 11 lymph nodes resected resulted negative. No postoperative complications occurred. The patient was followed-up with 6-month interval chest and head computed tomographic scan. The patient is alive with no evidence of pulmonary relapse after 2 years of follow-up, with a satisfactory residual respiratory function.
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Comment
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Meningioma with distant extracranial metastasis is an extremely rare event occurring in less than 1 in 1,000 cases (0.1%) [1–5]. Most cases are usually found several years after a craniotomy [2] in conjunction with a local recurrence of the lesion. However, generally, even when lung deposits are present, meningioma maintains its slow-growing attribute.
For this reason, radical surgical resection of the pulmonary metastases from the meningioma is considered the treatment of choice. However, due to the rarity of this disease, there is little information available in the literature regarding its long-term results. The traditional criteria for selecting patients who may benefit from pulmonary metastasectomies include control of the primary tumor, absence of metastases to other organs, and the ability to resect all pulmonary metastases with acceptable operative risk and adequate residual pulmonary function [5]. The present case demonstrated all of these traditional criteria, and despite the high number of pulmonary metastases, we were strongly encouraged to perform surgical resection due to their estimated complete respectability with adequate residual pulmonary function. In fact, what makes this case peculiar are the high number of resected lesions (37), followed by the 2-year disease-free follow-up of the patient (>24 months).
We believe that this is the first case of extensive bilateral pulmonary metastatic meningiomas with this type of diffusion that has been operated on. This finding strengthens the evidence for select cases, even when bilateral, multiple pulmonary metastatic meningiomas are present, and complete surgical excision may lead to mean control of the metastatic disease. Two years of disease-free survival may be considered a satisfying result, although a longer follow-up time is needed to confirm this outcome because of the slow-growing attribute of this malignancy. Therefore we encourage an aggressive surgical attitude toward these select patients who present with radically respectable, multiple pulmonary met astases with acceptable operative risk and adequate residual pulmonary function.
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References
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- Adlakha A, Rao K, Adlakha H, et al. Meningioma metastatic to the lung Mayo Clin Proc 1999;74(11):1129-1133.[Abstract]
- Ayerbe J, Lobato RD, de la Cruz J, et al. Risk factors predicting recurrence in patients operated on for intracranial meningiomaa multivariate analysis. Acta Neurochir (Wien) 1999;141(9):921-932.[Medline]
- Kodama K, Doi O, Higashiyama M, et al. Primary and metastatic pulmonary meningioma Cancer 1991;67:1412-1417.[Medline]
- Kaminski JM, Movsas B, King E, et al. Metastatic meningioma to the lung with multiple pleural metastases Am J Clin Oncol 2001;24(6):579-582.[Medline]
- Murrah CP, Ferguson ER, Jennelle RL, et al. Resection of multiple pulmonary metastases from a recurrent intracranial meningioma Ann Thorac Surg 1996;61:1823-1824.[Abstract/Free Full Text]
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Abstract
Introduction
