DOI:10.2214/AJR.04.1931
AJR 2006; 186:1314-1316
© American Roentgen Ray Society
Extraforaminal Meningioma with Extrapleural Space Extension
Carlos S. Restrepo1,
Diego A. Herrera2 and
Julio A. Lemos3
1 Department of Radiology, University of Texas Health Science Center at San
Antonio, 7703 Floyd Curl Dr., Bldg. HSC-MED, Rm. 625E-4, San Antonio, TX
78229-3900.
2 Department of Radiology, Universidad de Antioquia, Medellín,
Colombia.
3 Department of Radiology, Louisiana State University Health Sciences Center,
New Orleans, LA 70112-4800.
Received December 20, 2004;
accepted after revision March 2, 2005.
Address correspondence to C. S. Restrepo.
Keywords: chest • MRI • oncologic imaging • pleura
Introduction
Thoracic involvement by meningioma is uncommon. Most reported cases are
secondary to metastatic disease. Brachial plexus invasion by extraforaminal
meningioma has been reported in the literature. This case illustrates another
form of thoracic involvement by meningioma: extension to the chest wall. To
our knowledge, the imaging findings of extrapleural space involvement by
meningioma have not been described previously in the radiologic literature. We
therefore present the MRI findings and pathologic correlation in the case of a
patient with this unusual presentation of meningioma.
Case Report
A 57-year-old woman had a history of leg pain. Physical examination
revealed hyperreflexia with decreased muscle strength in both lower
extremities, a Babinski sign, and decreased sensation of the abdominal wall
suggesting a spinal cord abnormality. The findings on MRI of the cervical and
thoracic spine confirmed the presence of abnormal soft tissue from an
infiltrative process at the C7-T2 area involving the epidural space,
predominantly on the right side, compressing the cord, and showing homogeneous
enhancement after gadolinium injection (Figs.
1A,
1B, and
1C). This abnormal soft tissue
expanded and involved the neuroforamina at the C7-T1 level on the right side
with a dumbbell configuration protruding into the paraspinal region and the
extrapleural space. The imaging appearance suggested a neurogenic tumor such
as neurofibroma. The patient underwent multilevel laminectomy and tumor
resection. Tumor with an infiltrative appearance was found at the lateral
aspect of the T1-T2 foramen and extending out into the apical extrapleural
space. A clear plane was identified between the parietal pleura and the tumor
on the lung side and between bone and tumor on the canal side. The tumor was
circumferentially dissected away from surrounding structures and then removed
in a piecemeal manner. Pathologic examination revealed an infiltrative
epithelioid neoplasm containing focal whorls and several psammomatous
calcifications (Figs. 1D and
1E). Because extension of the
lesion into the superior aspect of the pleural cavity was suspected, adjuvant
radiation therapy was given. Eight-month follow-up evaluation showed no
evidence of recurrence.
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Fig. 1B —57-year-old woman with meningioma involving extrapleural space.
Axial T1-weighted MR image obtained after gadolinium injection shows
homogeneous enhancement, cord compression, tumor (long arrow), and
extension (short arrows) to and involving extrapleural space.
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Fig. 1C —57-year-old woman with meningioma involving extrapleural space.
Coronal section of axial T1-weighted MR image shows infiltrative process
(arrow) extending into apical extrapleural space. Clear fat plane is
evident between parietal pleura and tumor.
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Fig. 1D —57-year-old woman with meningioma involving extrapleural space.
Photomicrographs show infiltrative epithelioid neoplasm containing focal
whorls, several psammomatous calcifications (arrow, D), and
meningothelial cells. (D, H and E x20; E, H and E
x40)
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Fig. 1E —57-year-old woman with meningioma involving extrapleural space.
Photomicrographs show infiltrative epithelioid neoplasm containing focal
whorls, several psammomatous calcifications (arrow, D), and
meningothelial cells. (D, H and E x20; E, H and E
x40)
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Discussion
The extrapleural space is represented in healthy persons by a potential
line of cleavage in the loose connective tissue that constitutes the
endothoracic fascia, which lines the entire thoracic cavity
[1]. The space is between the
parietal pleura and the thoracic cage. The endothoracic fascia appears as a
distinct layer only over the upper parts of the pleura (the cupulae) as they
project above the first rib into the base of the neck. There the endothoracic
fascia is thickened and is called the suprapleural membrane
[2]. The structures within and
adjacent to this region include connective tissue, nerves, vessels, muscles,
and ribs [1].
In the differential diagnosis of extrapleural lesions, it is important to
consider infectious processes such as tuberculosis, mycosis, and actinomycosis
arising in a rib or in the soft tissues; extrapleural lipoma; fat pads;
myeloma; lymphoma; and primary neoplasm, especially superior sulcus tumor,
lymphadenopathy, and neurogenic tumors, such as schwannomas and neurofibromas.
A less common condition that should be considered in the differential
diagnosis of brachial plexus and chest wall tumors is aggressive fibromatosis
(desmoid tumor), which is benign proliferation of fibroblasts involving the
deep soft tissues [2]. Other
less common tumors, such as extraforaminal and ectopic invasive meningioma,
also occur at this level and involve the brachial plexus
[3].
Meningiomas are benign neoplasms that arise from the intracranial and
spinal meninges or their dural extensions. These tumors constitute 14-19% of
all central nervous system neoplasms. They are considered benign neoplasms
because they generally do not metastasize, are not invasive, and are usually
cured by surgical resection
[4].
Most extracranial and extraspinal meningiomas (extraaxial meningiomas)
occur secondarily, either by direct extension or by metastasis. They occur
less commonly as ectopic primary meningiomas
[3]. Ectopic meningiomas are
rare. The following 4 mechanisms have been suggested in their occurrence: (1)
direct extension from an intracranial lesion, (2) distant metastasis from an
intracranial meningioma, (3) origin from arachnoid cells within the sheaths of
cranial nerves, and (4) origin from embryonic meningothelial cell rests.
Cushing noted that arachnoid cell clusters (meningothelial cells) are common
at the spinal nerve root exit zones
[5,
6].
Various signs and symptoms of meningioma involving the chest have been
described. Most of the lesions are due to metastasis
[4], which occurs in fewer than
1 in 1000 cases of intracranial tumor
[7]. Brachial plexus invasion
also has been reported [3].
Primary intrapulmonary meningioma has been reported only sporadically
[8]. This case illustrates
another form of thoracic involvement by meningioma: extension into the chest
wall and extrapleural space.
References
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Neuroradiol 1997; 18:1335
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Introduction
Case Report
