Question:

Confusion in differentiating between meningiomas and metastatic disease may because of the following reasons EXCEPT:
1. The high attentuation values on CT imaging
2. Tumor location
3. The "dural tail sign"
4. No additional differentiation techniques besides CT, MRI, and angiography
5. Calcifications





Answer:

The correct answer for the question "Confusion in differentiating between meningiomas and metastatic disease may because of the following reasons EXCEPT:" is:

4. No additional differentiation techniques besides CT, MRI, and angiography



Explanation

1. A diagnostic dilemma between meningioma and metastatic disease may occur because of high attenuation values on CT, tumor location, the "dural tail sign," the non-specific, asymptomatic general condition of patients, and calcifications. As of 2007, 29 cases of dural metastases imitating a meningioma have been reported. As of 2008, the number of cases currently is less than 40. Concerning the topic of high attenuation values on CT, the enhancement pattern on CT scanning for metastatic colon adenocarcinoma is similar to that of intracranial meningiomas (15). 2. Concerning location, cerebral metastases are typically located in the brain or cerebellum and infrequently in the meninges; moreover, they can be isolated or diffuse lesions (11). When they are located in the meninges (an intra-cranial, extra-axial location) and appear as an isolated form on radiological appearance, this may suggest a primary tumor such as a meningioma and confusion pertaining to definitive diagnosis is evident, particularly when the macroscopic form with its lobular growth pattern also demonstrates findings suggestive of a meningioma because they are indistinguishable (11, 15, 16). 3. 3. Concerning the enhancing "dural tail sign," the enhancement of the meninges adjacent to the meningiomas was once considered specific and characteristic for meningiomas; however, it has now been designated as being nonspecific on CT/MRI and can be associated with multiple etiologies of dural-based lesions, including meningeal metastases (5, 15, 16, 17). 4. There are multiple additional differentiation techniques outside of CT, MRI, and angiography which include functional MRI, MR spectroscopy, cytologic study of cerebrospinal fluid and serologic study, and dynamic perfusion MRI. 5. Additionally, findings that are rare in metastatic brain tumors but common in benign meningiomas, like calcifications, may complicate the diagnosis. Typically, the presence of calcification within an intracranial mass lesion is an indicator of slow growth or benign nature (6). Intracranial lesions with calcifications include meningiomas, gliomas, aneurysms, angiomas, and granulomatous lesions (6). A diagnostic dilemma surfaces when a high-density area on CT cranial scans is visualized because even though calcification may be a possibility, other possibilities include intratumoral hemorrhage or mucoid degeneration, thus expanding our differential diagnosis even though metastatic brain tumors uncommonly demonstrate calcification on CT scans (6). Multiple case reports demonstrate that what was originally identified as a high density mass on precontrast CT scans and correlated with meningioma, actually was later diagnosed as a microhemorrhage within a metastatic dural-based tumor (16). Typically, the homogeneously hyperdense appearance of meningiomas on CT is secondary to calcification; contrastingly, the homogeneously hyperdense appearance of adenocarcinoma is secondary to the aforementioned hemorrhages, mucoid degeneration, calcification, or dense cell structure (16). Moreover, through the year 1994 there were only 25 cases of calcified intracranial metastatic carcinoma in the literature with the most common primary sites being breast (7 cases), lung (5 cases) and colon (4 cases) (6).



From the manuscript:
Dural Based Mass: Malignant or Benign
Radiology Case. 2009 Nov; 3(11):1-12


This article belongs to the Neuro section.




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From the manuscript

Dural Based Mass: Malignant or Benign

Free full text article: Dural Based Mass: Malignant or Benign

Abstract
In March 2007, a 68 year old female was diagnosed with colonic adenocarcinoma metastatic to the lungs and a frontoparietal parafalcine lesion suspected to be a meningioma was also noted. She denied neurologic symptoms and resection of the parafalcine lesion did not occur. For 14 months, she received chemotherapy with poor response. In June 2008, she developed multiple focal neurologic deficits. Enlargement of the parafalcine brain lesion was noted on head computerized tomography and magnetic resonance imaging. Cerebral angiogram demonstrated a parafalcine mass supplied by the middle meningeal artery. All 3 modality findings confirmed a meningioma. Embolization of the middle meningeal artery with craniotomy for excision of the suspected meningioma was performed. Pathology indicated metastatic adenocarcinoma with colonic primary without evidence of meningioma. Meningiomas are the most common dural based lesions; however, a variety of dural lesions mimic meningiomas. Dural metastatic tumors mimicking meningiomas is an uncommon phenomenon, particularly when the primary location is the colon. This paper additionally discusses the differentiation of benign dural based tumors like meningiomas from malignant findings. Multiple adjunct studies can differentiate meningiomas from metastatic tumor. The definitive diagnosis is based on histopathology.






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