Metastatic Meningioma Diagnosed By Endobronchial Biopsy

Introduction: Meningiomas make up 15-20% of primary intra-cranial and intra-spinal tumors. Although the majority of meningiomas are benign, there are rare cases of atypical meningiomas with varying degrees of malignant histologies. Only 0.1% of meningiomas metastasize to distant sites and predilection for metastasis correlates with the degree of histologic atypia. Here we report a case of a patient with a metastatic meningioma diagnosed by endobronchial biopsy. Case Report: CM is a 57 year-old woman with a history of recurrent atypical meningioma that had previously been resected on three separate occasions. Her last resection was two years prior to presentation with complete excision of the tumor followed by proton beam radiation treatment for local control. At that time there were no signs of metastatic disease. One month prior to presentation she exhibited neurologic symptoms that prompted repeat brain imaging. A fourth recurrence of her meningioma was diagnosed and she was scheduled for a repeat surgical excision. A pre-operative chest radiograph (figure 1) was obtained and prompted consultation with a pulmonologist. A chest radiograph taken two years prior was normal. At the time of consultation her only complaint was infrequent and intermittent dyspnea on exertion. She denied cough, fevers, chills or hemoptysis. Fiberoptic bronchoscopy was performed and endobronchial lesions (figure 2) were noted in the airways of the lower lobes bilaterally. Several endobronchial biopsies were taken and the pathology was consistent with her previously resected intra-cranial meningioma. (Figure presented) Discussion: Meningiomas are generally slow growing benign tumors that comprise 15% to 20% of intracranial and intra-spinal neoplasms. Patients within the ages of 40 to 60 have been found to have higher incidence of metastatic meningioma. The male to female ratio of metastasis is 3:2, despite the fact that meningiomas are 2 to 4 times more likely to occur in females. Approximately 60% of metastatic meningiomas have been found to be in the lung making it the most common site of metastasis. Sites such as the ocular fundus, adrenal glands, breast, bladder, thyroid and thymus are found to be the rarest sites for metastasis. This is a unique case in which a recurrent meningioma with incidental pulmonary metastasis was diagnosed with endobronchial biopsy. Although not usually high on the differential diagnosis list of pulmonary masses, patients with a known diagnosis of meningioma and coexisting pulmonary lesions should be evaluated for metastatic meningioma.