Acta Neurochir (Wien) (I996) 138:1172-1178 Acta Neurochirurgica

9 Springer-Verlag1996
Printed in Austria

Metastasis in Meningioma

S. Ather Enam 1, S. Abdulrauf 1, B. Mehta 2, G. M. Malik 1, and A. Mahmood 1

Departments of 1Neurosurgery and 2Diagnostic Radiology, Henry Ford Hospital, Detroit, Michigan, USA

Summary [29]. Overall, meningioma forms 13-19% of primary

Meningioma is a neoplastic growth originating from the lepto- intracranial neoplasms [5, 8, 10, 17].
meninges. Although meningiomas are usually benign, malignant Usually associated with a benign clinical course,
meningiomas with distant metastases occur infrequently. There is these slow-growing tumours occasionally display
little precise information in the literature regarding the frequency
malignant behaviour. Malignant attributes of any neo-
of metastases in meningiomas; their incidence has been vaguely
reported to be less than 1 per 1,000. Furthermore, most of the pre- plasm are judged by its histological characteristics,
vious studies have also included haemangiopericytomaswhich most propensity to recur, and most of all, the ability to
recent authorities do not consider meningiomas. In our experience metastasize. The histological characteristics and the
with the management of 396 meningiomas over the past 18 years, 7 rate of recurrence in malignant meningioma have
meningiomas were classified as malignant by defined histological
been well described [19, 21, 42]. The histological
criteria. After initially presenting as solitary intracranial neo-
plasms, three of the malignant meningiomas metastasized to extra- characteristics associated with the malignant behavi-
cranial tissues. Collectively, the metastases involved the vertebral our of meningioma are increased mitotic figures,
bodies, liver, pelvis, long bones, and the spinal cord. This confers atypical mitosis, hypercellularity, focal necrosis, pap-
an incidence of metastasis of 0.76% when considering all the illary transformation, and local invasion into adjacent
meningiomas, and an incidence of approximately 43% when con-
brain parenchyma. A large proportion of malignant
sidering only malignant meningioma; both percentages are signifi-
cantly higher than reported previously. This high incidence of meningioma recur (50% within 5 years after complete
metastasis in the malignant meningioma indicates a worse progno- resection). Regarding metastasis, this feature of
sis than formerly assessed and also characterizes the malignant malignant meningioma has not been addressed satis-
meningioma as a primary central nervous system neoplasm with factorily heretofore. The reported incidence of metas-
one of the highest rates of metastasis. In addition, when malignant
tasis in meningioma overall has been quite low: less
meningioma is classified by following strict criteria, the risk of
metastasis in the ensuing clinical course can be predicted with a than 1 in 1,000 meningiomas [9, 31, 34, 36].
higher reliability. Our experience with meningioma, from 1976 to
Keywords: Meningioma; metastasis; malignant. 1993, involves the management of 396 cases. We
have previously reported on the distribution of histo-
pathological subtypes of meningiomas and on an
analysis of recurrence of meningiomas after resection
Introduction [20, 21]. The purpose of the present study is to docu-
Meningioma originates from the arachnoid cap ment that the meningioma has a higher incidence of
cells which are usually present near arachnoid villi. In metastases than previously reported and that the
addition to leptomeninges, these cells can be found at malignant meningioma is one of the most frequently
other locations such as the choroid plexus and extra- metastasizing primary intracranial neoplasm. In addi-
cranial tissues, thus giving rise to unusual sites of tion, we propose that the risk of future metastases in a
meningioma [9]. The incidence of meningioma in the patient with solitary intracranial meningioma can
general population, based on a study of a community now be estimated with greater confidence when uti-
in Canada, has been estimated as 2.3 per 100,000 lizing appropriate histological grading.
S. Ather Enam et al.: Metastasis in Meningioma 1173

Patients and Methods Case 2

From 1976 to 1993, 396 patients were operated on at Henry A 50-year-old black male, with an old left hemiparesis due to a
Ford Hospital for meningioma. The histopathological specimens of subarachnoid haemorrhage in 1978, presented in March 1990 with
these cases were reviewed and classified according to the criteria worsening of the hemiparesis consequent upon a large right fronto-
defined by the World Health Organization (WHO) classification of parieto-occipital meningioma (Fig. 2 a). Histopathology of the re-
tumours mad its modifications [19, 20, 42]. The meningiomas were sected turnout showed hypercellularity, nuclear atypia, numerous
classified as benign, atypical, or malignant based on hypercellular- mitotic figures, areas of tumour necrosis, and invasion into adja-
ity, loss of architecture, nuclear pteomorphism, mitotic index, cent brain parenchyma. Postoperatively the patient received radio-
tumour necrosis, and brain invasion. Follow-up data were obtained therapy. During the course of rehabilitation, he developed an infec-
from medical records. Metastases were confirmed by histopatholo- gion of the craniotomy wound; the infected bone flap was removed
gy and/or radiography (computed tomography [CT], magnetic reso- in May 1990. In July 1991 the patient returned with progressive left
nance [MR] imaging, myelography, bone scans, and plain x-rays). hemiparesis due to a recurrence of the meningioma, which was
excised by a repeat craniotomy. Histopathology showed it to be
identical to the first mmour. Five weeks postoperatively he devel-
Case l oped an acute spinal cord compression. Myelogram demonstrated
drop metastases at several levels in the cervical, thoracic, and upper
A 73-year-old white female presented with focal seizures in
lumbar regions, without involving the vertebrae (Fig. 2 b, c). Only
June 1992. CT and MR imaging showed a midline frontoparietal
palliative measures were provided according to the wishes of the
mass, extending from the dura into the scalp, and locally destroying
patient's family; he died after two weeks.
the calvarium (Fig. 1 a). The tumour was removed en bloc, and was
found to be a syncytial (meningothelial) meningioma with malig-
nant features such as local invasion of the cerebral cortex, focal ar- Case 3
eas of necrosis, nuclear pleomorphism, and a high mitotic rate. A 52-year-old white female presented in October 1986 with
Ultrastructural examination revealed interdigitating plasma mem- headaches and left hemiparesis. CT revealed a large right sphenoi-
branes, numerous desmosomes, and intermediate filaments. In Jan- dal wing meningioma (Fig. 3 a), which was removed surgically and
uary 1993 the patient returned with progressive paraparesis due to followed by radiation therapy. Microscopic features of malignancy
an intracranial recurrence, which was subsequently removed by a (hypercellularity, pleomorphism, nuclear atypia, and areas of focal
craniotomy and followed by radiotherapy. Another recurrence, necrosis) were found in the meningioma. The tumour recurred at
observed in follow-up MR imaging in March 1993, was managed the original site as well as in the parietal bone and was resected in
by radiosurgery. Three months later she developed abdominal pain December 1987. The patient received Adriamycin chemotherapy
and a Brown-Sequard syndrome. CT and MR imaging showed an postoperatively. Histologically, the recun'ent meningioma was simi-
8 cm mass in the right lobe of the liver and a large vertebral mass lar to the original. Electron microscopy demonstrated interdigitat-
compressing the spinal cord at T t 0 level (Fig. 1 b, c). The spinal ing processes and desmosome-like junctions. In April 1988, the
cord was decompressed surgically and the spine and the abdomen patient developed intense low back pain. Plain x-rays, bone scan,
were irradiated. The liver mass nonetheless demonstrated rapid and myelogram with CT revealed metastases to the left proximal
growth, contributing to the patient's demise. Specimens from the femur and the lumbar spine with a compression fracture of the L2
recurrent intracranial meningioma as well as from spinal and liver vertebral body (Fig. 3 b). L1 and L2 corpectomy with methyl-
(needle biopsy) metastases showed similar histological and elec- methacrylate fusion was followed by radiotherapy to the spine and
tron microscopic features. the femur. Histological appearance of the specimen obtained from

Fig. 1. Case t: CT scan shows midline frontal mass locally destroying the calvarium (a). MR imaging of vertebral column (b, sagittal T1
image) and CT of abdomen (c, post-contrast axial scan) after development of Brown-Sequard syndrome show a vertebral mass at T10 com-
pressing the spinal cord (b) and a hepatic mass (c)
1174 S. Ather Enam et al.: Metastasis in Meningioma

Fig. 2. Case 2: CT scan on initial presentation, with large right frontoparietal extra-axial lesion (a). Postmyelogram axial CT scans of tho-
racic (b, soft tissue window) and lumbar spine (c, bone window) show drop metastases after recurrence of cranial lesion

Fig. 3. Case 3 presented with right sphenoid wing meningioma (a, contrast enhanced CT scan of head), which later metastasized to lumbar
vertebrae (b, post-myelogram CT scan of L2)

the lumbar vertebra was similar to that of the original tumour. In seen in h i s t o l o g i c a l l y a t y p i c a l or b e n i g n m e n i n g i o -
June 1988, the patient developed metastases to the pelvis. CT scan mas. Thus, the p r o p o r t i o n o f m a l i g n a n t m e n i n g i o m a s
of the head disclosed a recurrence of the meningioma more than
that m e t a s t a s i z e d in our series was 42.8%. W h e n c o n -
5 cm in size. The patient soon succumbed to the terminal disease at
a nursing home. s i d e r i n g all the m e n i n g i o m a s r e g a r d l e s s o f s u b t y p e ,
the ratio o f m e t a s t a s e s w a s 0.76%.
A n a n a l y s i s o f the t h r e e c a s e s d i s c u s s e d is p r e -
Results s e n t e d in Table 1. T h e a v e r a g e l e n g t h o f t i m e f r o m
O f the 396 m e n i n g i o m a s r e v i e w e d , 366 (92.4%) initial p r e s e n t a t i o n to a p p e a r a n c e o f m e t a s t a s e s was
w e r e b e n i g n , 23 (5.8%) w e r e a t y p i c a l , and 7 (1.8%) 1.45 years. A l l the m e t a s t a s e s o c c u r r e d after m u l t i p l e
w e r e m a l i g n a n t . T h r e e o f the m a l i g n a n t m e n i n g i o m a s o p e r a t i o n s at the p r i m a r y site for r e c u r r e n c e o f m e n i n -
later p r e s e n t e d w i t h m e t a s t a s e s . N o m e t a s t a s i s was gioma.
S. Ather Enam et al.: Metastasis in Meningioma 1175

Table 1. Summary of Case Histories of Metastatic Meningioma

Age (yr), Time from initial Histologic Sites Recurrence of Timefrom

race, g e n d e r presentationto detection type of metastases intracranial initial presentation
of metastases meningioma to metastases

Case 1 73, white, female 12 months malignant thoracic present 1 yr

vertebrae, liver
Case 2 50, black, male 17 months malignant spinal cord present 1.5 yr

Case 3 52, white, female 17 months malignant lumbar vertebrae, present 1.4 yr
femur, pelvic bone

Discussion teria were further defined and expanded on by our

group [20]. Each criterion was given a score of 0 to 3
Meningioma traditionally has been considered a on specific histological appearance; the partial scores
tumour that rarely metastasizes [9, 30-34, 40]. A were then added to obtain a cumulative score. A
review of the literature disclosed that at least 91 cases meningioma was categorized as benign if the total
of metastasizing meningioma (excluding haemangio- score ranged from 0 to 4, as atypical if the score was
pericytomas) have been reported to date. The inci- 5 to 11, and as malignant if the score was more than
dence of metastasis quoted in most of these accounts 11.
and in reviews is less than 0.1%. To our knowledge, In addition to light microscopy and immunohistol-
there has not been any large published series review- ogy, electron microscopy was used whenever feasible
ing the incidence of metastasis in meningioma since (cases 1 and 3) to study the pathological specimen of
the report by Strang et al. in 1964 [36]. We have the meningioma. The ultrastructural characteristics,
found a higher incidence of metastasis (approximate- however, were not included in categorizing the malig-
ly 1%) in meningioma in our series at the Henry Ford nant meningioma. It has been suggested that a loss of
Hospital. Since all the patients with metastatic menin- desmosomes and interdigitating cytoplasmic pro-
gioma presented initially with solitary intracranial cesses correlates with the malignant characteristics
lesions, a referral bias is excluded as a basis for this seen on light microscopy [11]. We failed to observe
high rate of metastasis. any loss of interdigitating cytoplasmic processes or
It is hard to predict with reliability the risk of desmosomes in the malignant meningiomas. The cor-
metastases on initial presentation and thus the final relation of the malignant nature of meningioma and
outcome of the meningioma. However, if strict histo- loss of the aforementioned ultrastructural features
pathological criteria are employed to categorize thus needs to be further evaluated. Unless the ultra-
meningioma into benign, atypical, and malignant, it structural features of the malignant meningioma are
becomes apparent that metastases are largely restrict- unanimously confirmed, the histological grading sys-
ed to the malignant subtype. An analysis of our tem based on haematoxylin-eosin staining described
records disclosed the incidence of malignant menin- earlier [20] should suffice to diagnose malignant
gioma to be approximately 2% [20]. All the menin- meningioma and assess the risk of future metastases.
giomas that metastasized had malignant features on All three patients discussed in this report received
initial presentation. The relative incidence of metasta- radiotherapy, without any obvious benefit. The role of
sis in malignant meningioma in our series was 43%. radiotherapy in meningiomas has not been well
Thus, upon finding a malignant histology in the defined. A few series have evaluated the efficacy of
meningioma [20] on initial presentation, one can pre-. radiotherapy but report conflicting results. Wara et al.
dict the risk of metastasis with considerable reliabili- [38] showed that radiotherapy can retard tumour
ty. growth in recurrent meningiomas, whereas a subse-
The criteria for histological grading of meningio- quent study by Yamashita et al. [41] on the role of
mas outlined by WHO are hypercellularity, loss of radiotherapy in the clinical outcome of recurrent
architecture, nuclear polymorphism, high mitotic benign meningiomas did not yield any significant
index, tumour necrosis, and brain invasion. These cri- result. Although radiotherapy has been recommended
1176 s. Ather Enam et al.: Metastasis in Meningioma

for all malignant, recurrent, and subtotally removed has been reported to be as frequent as that in malig-
benign meningiomas [2], a large controlled trial nant meningiomas [1, 14, 37]. Of our three cases, ver-
addressing this issue is needed. tebral bodies were involved in two cases, the liver in
Compared to an average rate of metastasis of 3.8% one case, and involvement of the spinal cord through
in all the primary intracranial neoplasms [25], the rate cerebrospinal fluid dissemination occurred in one
of metastasis in malignant meningioma (43%), accord- case. Although hepatic metastasis from haemangio-
ing to our calculation, is very high. In fact, in Naka- pericytoma has been reported frequently, only 4 cases
mura e t a I . ' s retrospective analysis of autopsy cases of hepatic metastasis from true meningiomas have
in Japan, malignant meningioma was listed along been reported over the past 30 years [12, 23, 27, 28].
with medulloblastoma, glioblastoma, and ependymo- Thus metastasis of an intracranial meningioma to the
ma as the primary intracranial neoplasms that metas- liver, as reported in this study, is a rare occurrence.
tasized most frequently [25]. Our report on metastatic Metastasis to the lungs, reported as the most common
meningioma does not include haemangiopericytomas. site of metastases by meningioma [16], was not ob-
Generally, most now agree that haemangiopericyto- served in our series. The number of cases in this study
mas should be classified as a'separate entity because is too small, however, to comment on the relative
they are not true meningiomas. Immunocytochemical incidence of metastatic sites.
and ultrastructural evidence supports the thesis that We have found that the meningioma metastasizes
meningioma and haemangiopericytoma are distinct at a rate higher than previously reported, and when
[13, 15, 24, 39]. It is well known that haemangioperi- meningiomas are classified strictly according to our
cytomas are malignant and metastasize frequently modifications of the WHO criteria, the risk of metas-
(23% [7]); interestingly, we found malignant menin- tasis can be predicted with greater reliability on initial
gioma to metastasize even more commonly than haem- presentation.
angiopericytomas. Considering that meningiomas
arise from cells that do not belong to the central ner- Acknowledgement
vous system and are present at the anatomical limits We thank Dario V. Caccamo, M.D., Departmentof Pathology,
of the blood-brain barrier, it should not be surprising Henry Ford Hospital, for reviewing and classifying the histology
slides of meningiomas.
that malignant meningiomas metastasize more fre-
quently than most of the neuro-epithelial tumours.
References
Although all of the metastatic meningiomas re-
1. Akimura T, Orita T, Hayashida O, Nishizaki T, Fudaba H
ported in this study were malignant, these are not the
(1992) Malignant meningioma metastasizing through the cere-
only kind of meningioma that metastasize. Metastases brospinal pathway. Acta Neurol Scand 85:368-371
arising from benign and atypical meningiomas have 2. Carella RJ, Ransohoff J, Newall J (1982) Role of radiation
been reported [3, 4, 22, 26, 35]. Whether these secon- therapy in the management of meningioma. Neurosurgery 10:
dary growths in cases of benign meningiomas repre- 332-339
3. Celli P, Palma L, DomenicucciM, Scarpinati M (1992) Histo-
sent true metastases or de novo growth of meningio-
logically benign recurrent meningioma metastasizing to the
mas from cell rests occurring elsewhere in the body parotid gland: case report and review of the literature. Neuro-
has yet to be decided. Nevertheless, the reports of surgery 31:1113-1116
metastases from malignant meningioma far outnum- 4. Couldwell WT, Fankhause H, de Tribolet N (1992) Osseous
ber the accounts of metastases from benign meningio- metastases from a benign intraventricular meningioma. Acta
Neurochir (Wien) 117:195-199
ma. We did not find any metastases in the benign or
5. Cushing H, Eisenhardt L (1938) Meningiomas: their classifi-
atypical meningiomas. cation, regional behavior, life history, and surgical end results.
A review of the literature which considered menin- Thomas, Springfield,IL
giomas and haemangiopericytomas collectively sug- 6. deVries J, WakhlooAK (1993) Repeatedmultifocalrecurrence
gests that the most common site of metastasis is the of grade I, grade II, and grade III meningiomas: regional mul-
ticentricity (primary new growth) or metastases? Surg Neurol
lung (60%), followed by abdominal viscera (34%);
41 : 299-305
only 11% of metastases end up in vertebrae [16]. 7. GoellnerJR, Laws ER Jr, Souel EH, Okazaki H (1978) Heman-
Metastasis through the cerebrospinal fluid has been giopericytomaof the meninges: Mayo clinic experience.Am J
reported, with an incidence of drop metastases as high Clin Patho! 70:375-380
as 5% in "non-benign" varieties [1, 6, 18]. Metastasis 8. Grant FC (1947) Intracranial meningiomas, surgical results.
of benign meningiomas through cerebrospinal fluid Surg Gynecol Obstet 85: 419431
9. Guthrie BL, Ebersold MJ, ScheithauerBW (1990) Neoplasms
S. Ather Enam et al.: Metastasis in Meningioma 1177

of the intracranial meninges. In: Youmans JR (ed) Neurologi- 28. Repola D, Weatherbee L (1976) Meningioma with sarcoma-
cal surgery. A comprehensive reference guide to the diagnosis tous change and hepatic metastasis. Arch Pathol Lab Med 100:
and management of neurosurgical problems. Saunders, Phila- 667-669
delphia, pp 3250-3315 29. Rohringer M, Sutherland GR, Louw DF, Sima AAF (1989)
10. Hoessly GF, Olivercrona H (1955) Report on 280 cases of veri- Incidence and clinicopathological features of meningioma. J
fied parasagittal meningiomas. J Neurosurg 12:614-626 Neurosurg 71 : 665-672
11. Inoue H, Tamura M, Koizumi H, Nakamura M, Naganuma H, 30. Russell T, Moss T (1986) Metastasizing meningioma. Neuro-
Ohye CH (1984) Clinical pathology of malignant meningio- surgery 19:1028-1030
mas. Acta Neurochir (Wien) 73:179-191 31. Salcman M (1991) Malignant meningiomas. In: A1-Mefty O
12. Ishibashi Y, Okada H, Mori T, Suzuki J (1983) Meningioma (ed) Meningiomas. Raven, New York, pp 75-85
with extracranial multiple metastases - a case report (Japa- 32. Shuangshoti S, Hongsaprabhas C, Netsky MG (1970) Metasta-
nese). No Shinkei Geka - Neurol Surg 11 : 203-208 sizing meningioma. Cancer 26:832-841
13. Iwaki T, Fukui M, Takeshita I, Tsuneyashi M, Tateishi J 33. Slavin ML (1989) Metastatic malignant meningioma. J Clin
(1988) Hemangiopericytoma of the meninges: a clinicopatho- Neuroophthalmol 9:55-59
logic and immunocytochemical study. Clin Neuropathol 7: 34. Sore PM, Sacher M, Strenger SW, Billet HF, Malis LI (1987)
93-99 "Benign" metastasizing meningiomas. Am J Neuroradiol 8:
14. Iwaki T, Takeshita I, Fukui M, Kitamura K (1987) Cell kinet- 127-130
ics of the malignant evolution of meningothelial meningioma. 35. Stoller JK, Kavuru M, Mehta AC, Weinstein CE, Estes ML,
Acta Neuropathol (Berl) 74:243-247 Gephardt GN (1987) Intracranial meningioma metastatic to the
15. Kabus D, Sidhu GS, Wieczorek RL, Choi H-SH (1993) Meta- lung. Cleve Clin J Med 54:521-527
static meningioma. Hemangiopericytoma or angioblastic 36. Strang RR, Tovi D, Nordenstam H (1964) Meningioma with
meningioma? Am J Surg Pathol 17:1144-1150 intracerebral, cerebellar, and visceral metastases, J Neurosurg
16. Karasick JL, Mullan SF (1974) A sm-vey of metastatic menin- 21:1098-1102
giomas. J Neurosurg 39:206-212 37. Tognetti F, Donati R, Bollini C (1987) Metastatic spread of
17. Katsura S, Suzuki J, Wada I (1959) A statistical study of brain benign intracranial meningioma. J Neurosurg Sci 31:23-27
tumors in the neurosurgical clinics in Japan. J Neurosurg 16: 38. Wara WM, Shelline GE, Newman H, Townsend JJ, et al
570-579 (1975) Radiation therapy of meningiomas. Am J Roentgenol
18. Kepes JJ (1982) Meningiomas. Biology, pathology, and differ- 123:453-458
ential diagnosis. Masson, New York, pp 190-200 39. Winek RR, Scheithauer BW, Wick MR (1989) Meningioma,
19. Kepes JJ (1990) Review of the WHO's new proposed classifi- meningeal hemangiopericytoma (angioblastic meningioma),
cation of brain tumors. Proceedings of the XIth International peripheral hemangiopericytoma, and acoustic schwannoma. A
Congress of Neuropathology, Kyoto, Japan, pp 87-97 comparative immunohistochemical study. Am J Surg Pathol
20. Mahmood A, Caccamo DV, Tomecek FJ, Malik GM (1993) 13:251-261
Atypical malignant meningiomas: a clinicopathological 40. Wu JK, Kasdon DL, Whitmore EL (1985) Metastatic menin-
review. Neurosurgery 33:955-963 gioma to cervical vertebra: case report. Neurosurg 17:75-79
21. Mahmood A, Qureshi N, Malik GM (1994) Intracranial menin- 41. Yamashita J, Handa H, Iwaki K, Abe M (1990) Recurrence of
giomas: analysis of recurrence after surgical treatment. Acta intracranial meningiomas, with special reference to radiothera-
Neurochir (Wien) 126:53-58 py. Surg Neurol 14:33-40
42. Zulch KJ (ed) (1979) Histologic typing of tumors of the central
22. Miller DC, Ojemann RG, Proppe KH, McGinnis BD, Grillo
nervous system. Geneva, World Health Organization
HC (1985) Benign metastasizing meningioma. J Neurosurg 62:
763-766
23. Mori H. Sugiyama Y, Terabayashi T, Niida H, Yamamoto K,
Kitazawa T, Wakaki K (1988) Recurrent meningioma with Comments
malignant change and extracranial multiple metastases (Japa- This work is a report of 3 cases of meningiomas with extracra-
nese). No Shinkei Geka - Neurol Surg 16:899 902 nial metastases. This eventuality, even if remaining relatively rare,
24. Moss TH (1987) Immunohistochemical characteristics of hem- is important to know, especially in the case of malignant tumours
angiopericytic meningiomas: comparison with typical menin- (as defined by the grading of WHO classification). The authors
giomas, hemangioblastomas, and hemangiopericytomas from have not considered the cases of haemangiopericytomas which
extracranial sites. Neuropathol Appl Neurobiol 13:467-480 constitutes now, with general agreement, a special entity. The
25. Nakamura K, Hawkin S, Aizawa M, Maekubo H, Kobayashi mechanism by which extracranial spreading occurs in the menin-
N, Ozasa T, Kunieda Y, Hokari I, Matsushima T, Miyazaki T giomas is not discussed in this article. If dissemination through the
(I986) Extracranial metastases of brain tumors - a case report circulation seems likely in extracranial tumours, CSF pathway is
and survey of patients with extracranial metastasis sampled also possible as noted by Iwaki [1]. It is also noteworthy that metas-
from a report on pathological autopsy cases in Japan. Gan No tases occur generally after primary surgery on the intracranial
Rinsho - Jpn J Cancer Clinics 32:281-286 lesion suggesting the dispartition of a barrier to metastases which is
26. Ng THK, Wong MP, Chan KW (1990) Benign metastasizing destroyed by surgery. This study underlines the importance of fol-
meningioma. Clin Neurol Neurosurg 92:152-154 lowing carefully meningiomas grade III and IV. In the presence of
27. Orlowska J, Jedrzewska-Iwanowska A, Rozycki M (1976) local recurrence, re-operation should be performed rapidly with a
Malignant meningioma with extracraniat metastases (Polish). large resection of all the invaded structures followed by regional
Neurol Neurochir Polska 10:595-597 irradiation.
1178 S. Ather Enam et al.: Metastasis in Meningioma

1. Iwaki T, Takeshita I, Fukui M, Kitamura K. (1987) Cell kinetics reported previously and I have no reason to doubt this number. As
of the malignant evolution of meningothelial meningioma. Acta a higher than supposed number of metastases are found in a definite
Neuropathol (Berl) 74:243-247 material, the results are worth reporting.
J. Philippon S. Valtonen

In a retrospective analysis of 396 meningiomas, the authors

have found seven malignant cases (according to WHO classifica- Correspondence: Neurosurgery Editorial Office, c/o S. White-
tion) and give a report on the three of them, which metastasized. house, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI
According to the authors, 91 meningioma metastases have been 48202, U.S.A.