American Journal of Neuroradiology 25:1223-1224, August 2004
© 2004 American Society of Neuroradiology
Case Report
BRAIN
Leptomeningeal Metastasis from Malignant Pleural Mesothelioma
Boris D. Petrovica,
Dusko B. Kozica,
Robert R. Semnica,
Mladen Prvulovica,
Dragana Djilas-Ivanovica,
R. Nuri Senerc and
Istvan Klemb
a Department of Diagnostic Imaging, Institute of Oncology, Sremska Kamenica, Serbia and Montenegro
b Department of Pathology, Institute for Lung Diseases, Sremska Kamenica, Serbia and Montenegro
c Department of Radiology, Ege University Hospital, Bornova, Izmir, Turkey
Address correspondence to Professor R. Nuri Sener, Department of Radiology, Ege University Hospital, Bornova, Izmir, Turkey
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Abstract
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Summary: Leptomeningeal metastasis from malignant mesothelioma
is very rare; to our knowledge, only one imaging report exists
in the literature. We present the case of widespread leptomeningeal
lesions secondary to a malignant mesothelioma in a 61-year-old
woman.
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Introduction
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CNS involvement due to metastatic mesothelioma is very rare.
The metastatic intracranial lesion may present as a solitary
mass or as leptomeningeal infiltration (
1–
7). Leptomeningeal
metastasis is extremely rare, and to our knowledge, only one
report of the MR imaging findings of this condition exists in
the literature (
1). Herein, we believe we report the imaging
findings in the second such reported case of this condition.
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Case Report
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Malignant mesothelioma of the right pleura in a 61-year-old
woman was confirmed by pleurolysis and biopsy (
Fig 1A and B).
Although she responded well to chemotherapy, 1 year later she
was admitted to the hospital because of vomiting, for which
she received symptomatic therapy. A year thereafter, she was
admitted again with confusion and ataxia, at which time T2-weighted
images revealed an impression of widened cerebellar sulci (
Fig 2A).
On postcontrast T1-weighted images, widespread leptomeningeal
infiltrations were evident in the cerebellar and cerebral sulci.
The lesions were more prominent in the cerebellar sulci compared
with in the cerebral sulci. The third and lateral ventricles
were dilated, which suggested development of acute hydrocephalus
(
Fig 2B and C). At that stage, findings of a chest radiograph
and an abdominal sonogram were noted to be normal. Lumbar puncture
revealed findings consistent with those of neoplastic infiltration.
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FIG 1. Mesothelioma.
A, Conventional radiograph of the chest, revealing the mesothelioma in the right pleura.
B, Positive Calretinin reaction of the mesothelioma (tumor biopsy obtained by pleuroscopy; x250 magnification).
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FIG 2. Leptomeningeal metastasis.
A, T2-weighted image, revealing widening of vermian sulci.
B, Postcontrast T1-weighted image, revealing enhancement of the vermian sulci corresponding to leptomeningeal infiltration. Note dilatation of temporal horns.
C, Postcontrast T1-weighted image, revealing leptomeningeal enhancement in the frontal sulci. Lateral ventricular dilatation is noted.
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The patient died 30 days after the MR imaging examination. At autopsy, mesothelioma with infiltration of the lower lobe of the right lung was evident. Metastases to the mediastenial lymph nodes and micrometastases to the liver were noted. Leptomeningeal infiltration was confirmed by histologic analysis revealing presence of sarcomatous cells (Fig 3).
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Discussion
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It has been reported that hematogenous metastases of malignant
mesothelioma usually involves the liver, adrenal glands, kidneys,
and the contralateral lung. Metastatic spread to the CNS is
rare. Most of these had been encountered as masses in the brain
parenchyma (
2–
6), and one case was noted with orbital
metastasis (
7). Falconieri et al (
2) reported three autopsy
cases of malignant pleural mesothelioma with brain metastases
and provided a review of 15 similar previously published reports.
They noted that in two patients, the brain metastases were discovered
incidentally at autopsy. In one patient, the brain metastasis
was discovered ante mortem, when a CT scan suggested a primary
tumor of the brain. With respect to the histopathologic findings,
the tumors had spindle-shaped malignant cells, pseudopalisading,
necrosis, and vascular buds suggestive of glioblastoma multiforme
(
2). Other authors also had the impression that the metastatic
tumors of malignant mesothelioma in the brain mimicked the pattern
of glioblastoma multiforme both histologically and radiologically
(
2–
6). On the other hand, leptomeningeal involvement is
very rare. The only imaging report is by Oksuzoglu et al (
1),
who used MR imaging. Their patient was a 44-year-old woman who
presented clinically with convulsions, and the diagnosis of
malignant mesothelioma was confirmed by biopsies of lymph nodes
(
1).
It is known that the causes of leptomeningeal metastasis include adenocarcinomas originating from the lung, stomach, breast, ovary, malignant melanoma, leukemia, lymphoma, and primary CNS malignancies. Clinically, these usually present as a low-grade meningitis syndrome. Our patient also presented with such a syndrome in that she had confusion and ataxia, which was an indication for a cranial MR imaging examination. This revealed leptomeningeal metastases with contrast enhancement, more prominent in the cerebellar sulci, and changes consistent with acute hydrocephalus, which likely accounted for ataxia and confusion.
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Conclusion
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This patient reveals that, although very rare, leptomeningeal
metastases can be associated with malignant mesothelioma of
the pleura. In the event that these patients present clinically
with a low-grade meningitis syndrome, brain MR imaging should
be performed with administration of intravenous paramagnetic
contrast medium to uncover lesions in the leptomeninges.
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References
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- Oksuzoglu B, Yalcin S, Erman M, Dagdelen S. Leptomeningeal infiltration of malignant mesothelioma. Med Oncol 2002;19:167–169[Medline]
- Falconieri G, Grandi G, DiBonito L, et al. Intracranial metastases from malignant pleural mesothelioma: report of three autopsy cases and review of the literature. Arch Pathol Lab Med 1991;115:591–595[Medline]
- Kitai R, Kabuto M, Kawano H, et al. Brain metastasis from malignant mesothelioma: case report. Neurol Med Chir (Tokyo) 1995;35:172–174[Medline]
- Kawai A, Nagasaka Y, Muraki M, et al. Brain metastasis in malignant pleural mesothelioma. Intern Med 1997;36:591–594[Medline]
- Schwechheimer K, Butzengeiger M. Brain metastases in malignant fibrous mesothelioma: case report and review of the literature. Acta Neuropathol (Berl) 1983;60:301–304[Medline]
- Kobayashi S, Ida M, Matsui O, et al. Lipomatous change in a brain metastasis from malignant pleural mesothelioma. Neuroradiology 2001;43:159–161[Medline]
- Kubota K, Furuse K, Kawahara M, et al. A case of malignant pleural mesothelioma with metastasis to the orbit. Jpn J Clin Oncol 1996;26:469–471[Abstract/Free Full Text]
Received November 6, 2003;
accepted after revision November 20, 2003.
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Abstract
Introduction