| History |
A 63-year-old female patient of Chinese ethnicity was referred for unexplained visual loss in her right eye, discovered incidentally 1 month before presentation. Her past medical history revealed quiescent asthma and a benign cyst in the left lung, excised 27 years earlier. The patient had no vascular risk factors and was not smoking. On examination, best-corrected vision was counting fingers in the right eye and 6/7.5 in the left eye, associated with severe color vision loss in the right eye. There was a dense right relative afferent pupillary defect, but the remainder of the neuro-ophthalmic examination was normal, including fundoscopy, ocular motility and other cranial nerves functions. There was a dense visual field defect in the right eye and a Cirrus OCT disclosed normal retinal nerve fiber layer thickness in both eyes. The presumptive diagnosis was unexplained right retrobulbar optic neuropathy. A brain MRI disclosed an enhancing mass involving the anterior right clivus and apex, infiltrating the ipsilateral cavernous sinus, highly suggestive of meningioma. Excision of the tumor was decided by the neuro-surgical team, and pathology confirmed a WHO Grade III parapapillary chordoid meningioma. Post- operatively, the patient had an ispilateral iatrogenic pupil-involving 3rd nerve palsy, an ipsilateral 4th nerve palsy and developed a right soleal vein thrombosis, treated symptomatically. However, the patient's main post-operative complaint was persistent coughing. |
| OCR Text |
Show "Just the Two of Us" Dan Milea1, Pratik Chougule2, Ming Lee3 Singapore National Eye Centre, Singapore, Singapore, 2Singapore Eye Research Institute, Singapore, Singapore, 3Department of Anatomical Pathology, Singapore, Singapore 1 History & Exam A 63-year-old female patient of Chinese ethnicity was referred for unexplained visual loss in her right eye, discovered incidentally 1 month before presentation. Her past medical history revealed quiescent asthma and a benign cyst in the left lung, excised 27 years earlier. The patient had no vascular risk factors and was not smoking. On examination, best-corrected vision was counting fingers in the right eye and 6/7.5 in the left eye, associated with severe color vision loss in the right eye. There was a dense right relative afferent pupillary defect, but the remainder of the neuro-ophthalmic examination was normal, including fundoscopy, ocular motility and other cranial nerves functions. There was a dense visual field defect in the right eye and a Cirrus OCT disclosed normal retinal nerve fiber layer thickness in both eyes. The presumptive diagnosis was unexplained right retrobulbar optic neuropathy. A brain MRI disclosed an enhancing mass involving the anterior right clivus and apex, infiltrating the ipsilateral cavernous sinus, highly suggestive of meningioma. Excision of the tumor was decided by the neurosurgical team, and pathology confirmed a WHO Grade III parapapillary chordoid meningioma. Postoperatively, the patient had an ispilateral iatrogenic pupil-involving 3rd nerve palsy, an ipsilateral 4th nerve palsy and developed a right soleal vein thrombosis, treated symptomatically. However, the patient's main post-operative complaint was persistent coughing. Financial Disclosures: The authors had no disclosures. Grant Support: None. 2019 Annual Meeting Syllabus | 47 "Just the Two of Us" Answer Final Diagnosis Intra-meningioma tumor-to-tumor metastasis of previously undiagnosed lung adenocarcinoma. Summary of Case The persistent coughing prompted re-evaluation of the pre-operative chest X ray, which disclosed nonspecific nodules. A chest CT-scan showed multiple pulmonary nodules and confluent mediastinal lymphadenopathies consistent with a metastatic process. A whole body PET scan confirmed hypermetabolic enlarged bilateral hilar and mediastinal lymphadenopathy and FDG-avid right supraclavicular lymph nodes. Bronchoscopy with broncho-alveolar lavage was performed, completed by trans bronchial needle aspiration, revealing a tumour with cribriform and papillary architecture, positive for TTF1 and CK7, confirming the diagnosis of lung adenocarcinoma. The initial meningioma diagnosis was challenged and reviewed, confirming presence of meningothelial cells, but also showing evidence of additional intrameningeal metastatic adenocarcinoma, suggesting a final diagnosis or tumour-to-tumour metastasis. The papillary/glandular portion of the meningeal tumor was indeed identical (positive CK7, TTF-1 and Napsin) with the sample analyzed in the lung biopsy. The patient declined chemotherapy, but underwent adjuvant brain radiotherapy (60Gy, 30 fractions). Five months post-operatively, the patient recovered 6/12 vision in the previously blind eye and visual fields improved significantly. Sequential follow-up brain MRIs over 6 months showed no recurrence of the tumor. Struggle/Dilemma of the Clinical Presentation Description The patient was initially diagnosed incorrectly (or rather incompletely) with meningioma, due to the radiological MRI appearance of the lesion and to the imperfect pathology evaluation. Subsequently, the patient was also diagnosed with metastatic lung carcinoma, which was not coincidental. Re-evaluation of the pathology from the two biopsy sites confirmed tumor-to-tumor metastasis into the meningioma. The adenocarcinoma metastasis was locally more invasive than the meningeal component of the tumour, requiring specific treatment. Keywords: Tumor, Optic Neuropathy, metastatic carcinoma, optic nerve, Compressive optic neuropathy References 1/ Sohail S, Karambizi DI, Baker A, Groh DM, Toms SA. A Comparative Report on Intracranial Tumor-toTumor Metastasis and Collision Tumors. World Neurosurgery 2018;116:454-463 2/ Caroli E, Salvati M, Giangaspero F, Ferrante L, Santoro A. Intrameningioma metastasis as first clinical manifestation of occult primary breast carcinoma. Neurosurg Rev 2006;29:49-54. 48 | North American Neuro-Ophthalmology Society |
