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|Year : 2020 | Volume
| Issue : 5 | Page : 1188-1191
Recurrence of Intraventricular Meningioma along the Surgical Track
Abhidha Shah1, Saswat Dandpat1, Ravikiran Vutha1, Atul Goel2
1 Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, Maharashtra, India
2 Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel; Consultant Neurosurgeon, Lilavati Hospital and Research Centre, Bandra (E), Mumbai, Maharashtra, India
|Date of Web Publication||27-Oct-2020|
Prof. Atul Goel
Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
This is a report of three cases of intraventricular meningiomas treated in our department wherein the tumors recurred along the surgical tract. The meningioma in each case was histologically “benign” at the time of first surgery and even at the time of recurrence. Although reported earlier, such cases of recurrence of meningiomas along the surgical tract are relatively rare.
Keywords: Intraventricular meningioma, transcortical surgery, tumor metastasis
Key Message: This is a report of three cases of “benign” intraventricular meningiomas that recurred along the surgical track. Histology examination of the recurrence also showed benign nature of the meningioma. Such recurrence along the surgical tract is rare.
|How to cite this article:|
Shah A, Dandpat S, Vutha R, Goel A. Recurrence of Intraventricular Meningioma along the Surgical Track. Neurol India 2020;68:1188-91
Location in depth, frequently encountered large tumor size, need to traverse through the cerebral parenchyma and location of vascular feeding channels away from the line of surgical exposure makes intraventricular tumors a formidable surgical challenge. Despite the surgical difficulties, radical resection has been frequently associated with “cure” from the disease. The relative aggressiveness of intraventricular meningiomas and their propensity for recurrence is difficult to compare with convexity and skull base meningiomas. Recurrence of meningiomas along the surgical tract has been recorded earlier. We wish to put on record our departmental experience of 3 intraventricular meningiomas that recurred along the line of surgical trajectory. The relative rarity of such cases makes formulation of a common treatment protocol impossible. One of the three cases has been reported earlier. The other two cases are summarized.
| » Case 1|| |
A 15-year-old boy presented with complaints of headache and intermittent vomiting for a period of 6 months. For about four months, he had left sided limb weakness. Neurological examination showed left-sided hemiparesis with power of grade 4/5. Fundoscopy revealed bilateral papilledema. Gadolinium enhanced MRI of brain showed a large lobulated homogenously contrast enhancing lesion in the body of the right lateral ventricle that extended into the left lateral ventricle and third ventricle. [Figure 1] Patient was operated through a right frontal transcortical approach. Complete excision of tumor was done. Post operatively patient was fine and improved in his left sided limb weakness. Histological examination of the tumor showed a benign fibroblastic meningioma (WHO grade I). Follow up imaging after two years of surgery showed no evidence of tumor recurrence. The patient presented after five years of surgery with history of two episodes of seizure. Neurological examination was normal. Gadolinium enhanced MRI showed a recurrent right lateral ventricular tumor with multiple smaller tumors along the surgical tract. [Figure 1] Patient was reoperated through the previously used surgical route and a complete excision of all the components of the tumor was done. Postoperative course was uneventful. Histology showed the tumor to be fibroblastic meningioma.
|Figure 1: Images of a 15-year-old male patient. (Case 1). (a) T2 weighted axial image showing a large intraventricular meningioma in the body and frontal horn of the lateral ventricle at the time of initial presentation. (b) T1 weighted contrast coronal image showing the tumor. (c) T1 weighted contrast sagittal image showing the large tumor. (d) T1 weighted contrast axial image 5 years after the initial surgery showing a recurrent intraventricular tumor with daughter nodules along the previous surgical trajectory. (e) Coronal image showing the recurrence of meningioma along the surgical trajectory. (f) Post-operative image after the second surgery showing excision of the tumor|
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| » Case 2|| |
A 42-year female presented with complaint of moderately severe headache for a period of about six months. Examination revealed bilateral fulminant papilloedema. There was no other focal neurological deficit. Magnetic Resonance imaging (MRI) revealed a large homogenously enhancing tumor (5.8 × 4.9 × 4.8 cm) in the trigone of the left lateral ventricle [Figure 2]. Using the standard surgical techniques, the tumor was resected by a superior parietal lobule transcortical approach. The tumor was of characteristic consistency and of moderate vascularity. It was completely resected. The postoperative course was uneventful. Histological examination revealed that the tumor was a fibroblastic meningioma (Grade I). There was no evidence of tumor recurrence at a 2-year follow up imaging. A relatively small recurrent lesion in the left trigonal area was identified on imaging that was done as a routine follow-up after about 4-years of surgery. Additionally, multiple small enhancing nodules were seen along the previously operated surgical strategy. The patient did not prefer any surgical or adjuvant treatment. The patient presented after about seven years of initial surgery with complaints of headache and multiple episodes of vomiting. Repeat MRI at this time showed an increase in the size of all the previously observed lesions and additionally there was a large tumor component that was attached to the convexity dura and extended underneath the scalp [Figure 2]. She was operated through the previously taken incision and a radical resection of all the components of the tumor was done. The convexity meningioma appeared to be distinct from the other tumors. The trigonal component was connected to all the nodules along the surgical tract and they were all excised en masse. The patient fared well after the surgical procedure. Histology of all the components of the meningioma showed the same benign histology of Grade I fibroblastic meningioma.
|Figure 2: Images of a 42-year-old female patient. (Case 2). (a) T1 weighted axial image showing a large trigonal meningioma. (b) Coronal contrast image showing the tumor. (c) Post-operative axial contrast image after the first surgery showing excision of the tumor. (d) Post-operative coronal image showing the tumor excision. (e) T1 weighted axial contrast MRI 7 years after the initial surgery showing the recurrence of the tumor along the surgical tract and extending to the convexity dura underneath the scalp incision. (f) Coronal contrast image showing the recurrent meningioma. (g) Sagittal contrast image showing the large recurrence|
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| » Discussion|| |
Meningiomas are known to arise from arachnoid cap cells of the arachnoid villi. The exact site of origin of intraventricular meningiomas is unclear, but various authors have suggested that these tumors probably arise from the meningeal cells that are transported together with the choroid plexus as the ventricular system invaginates during embryogenesis. This understanding is supported by the fact that the vascular supply of most of these tumors is from the choroidal vessels. Patients with intraventricular meningiomas usually present with subtle symptoms and the tumors are of fairly large size at presentation due to their slow growth and the large accommodative capacity of the pliant ventricles. Lateral ventricular meningiomas present a surgical challenge because of the deep location, large size, firm consistency, and the frequently observed intense vascularity. A small cortical incision can sometimes suffice as the exposure is constantly widened as the tumor mass is debulked. A successful removal of an intraventricular meningioma has sometimes been associated with “surgical cure” as the meningioma is “completely” removed along with its site of origin of choroid plexus. Such radical resection of the tumor and the probable site of origin are difficult to achieve in skull base or convexity meningiomas. Despite this and the relatively benign histology of these tumors, distant metastasis to the lung, and spine has been reported., The metastasis can occur through a hematogenous or lymphatic route and also CSF dissemination is known.,,,,,,,, “Iatrogenic” metastasis of meningioma in the periosteum at the site of craniotomy and even in the thigh from where fascia lata is procured during surgery have been reported and incriminated to accidental implantation of meningioma cells during the surgical procedure. Ramkrishnamurty et al. presented a case of intraventricular meningioma (histology- transitional meningioma) with recurrence through CSF pathway along the surgical path up to the dura.
Intraventricular meningiomas generally have a favorable prognosis with good long-term outcomes. Recurrences of intraventricular meningiomas after “total” surgical resection are relatively rare. Chen et al. in a series of 89 cases of intraventricular meningioma achieved total excision in 75 cases and subtotal resection in 14 patients. Adjuvant Gamma knife was administered to 8 patients. During long-term follow up, 6 patients had recurrences that were successfully treated surgically. Nanda et al. in their series of 18 patients achieved complete microsurgical excision in 17 patients. However, four patients had recurrences and required reoperation. Our surgical series is of 93 intraventricular meningiomas treated during the period 1990 to 2019. Radical “total” tumor resection was achieved in all cases. Recurrence of tumor that merited reoperation was in only the three cases reported in the present series.
The recurrence of meningioma with metastasis occurred in the entire transcortical trajectory from the dura to the ventricle in both our current patients. In all the three cases, histology showed a benign morphology (WHO- grade I). There were no features fulfilling any criteria as laid down by WHO 2016 classification of CNS tumors to indicate a higher-grade tumor. We speculate that this occurrence of tumors can be explained by multiple mechanisms. The metastasis could have occurred through CSF dissemination as the entire surgical path was bathed with CSF following the tumor resection. A second mechanism that could possibly come into play is the implantation of viable tumor cells along the surgical tract. This seems to be the most likely mechanism to explain the occurrence of the convexity meningioma beneath the craniotomy site. Johnson et al. reported in their study that CSF stimulates leptomeningeal and meningioma cell proliferation. It appears that in both our current patients and in the previously reported patient all the three mechanisms could have played a role to cause metastasis and growth of the tumor along the surgical trajectory. It is unclear if liberally irrigating the field with saline during surgery after completion of tumor resection can help prevent recurrence. It is possible that a relatively small cortical incision over the thinnest part of the cortex will allow the remaining brain to fall over and cover the cortical incision once the tumor has been removed and the brain has become lax and prevent tumor spread beyond the limits of brain parenchyma. Use of sealants or glues to “cap” the resection cavity to prevent dissemination or spread of CSF, blood or tumor cells after tumor resection have not been described. Long-term follow up imaging is recommended even in Grade I meningiomas to detect recurrences. Adjuvant upfront treatment may be considered in case of recurrent “benign” and metastasizing meningiomas.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]