Cerebellar Sarcoma with Bone Metastases

Invasion of adjoining structures and/or metastasis to other organs of the body are cardinal features of a malignant growth. In brain tumors involvement of surrounding tissue is a common surgical finding but metastases are rare. Distant metastasis from intracranial neoplasms was first reported by Klebs (7) in 1889, as cited by Jurow (6), who reports an additional case of his own. Jurow also cites a case reported by Lindner (8) in 1902. All 3 tumors were classified as endothelioma. In 2 of the cases there were metastases to the lung, and in 1 to the bladder. The case of Cushing and Eisenhardt (2), coming to autopsy after seventeen operations for recurrent meningioma, showed a solitary metastasis in the right upper lung. A report from the Records of the Massachusetts General Hospital (9) in 1938 describes a tumor found at necropsy to be a fibrosarcoma of the dura with generalized metastases to the bones, lungs, and adrenals. Other reported cases have revealed metastatic lesions in the spinal cord (1), regional lymph nodes (4, 5) lumbar spine and pelvis (10, 11), mediastinum (12), liver, and abdominal lymph nodes (11). In all, there are but 10 cases reported in the literature of extradural metastases in adults from proved intracranial neoplasms, and only 3 with metastasis to bone. Case Report L. P., a 28-year-old white male, was admitted to the Veterans Hospital, Aspinwall, June 3, 1948. Occipital headaches of three months duration, with vomiting, weakness, and staggering gait, were the predominating symptoms. Examination disclosed nystagmus, unequal pupils, and blurring of the optic disk margins. Neurologic findings were a positive Romberg sign and astereognosis of the left hand. Roentgenograms of the skull and chest were negative. Spinal fluid studies showed a pressure of 300 mm., manometrically, and 62 mg. protein per 100 c.c. Following admission, the patient became stuporous, with a rapid fall of pulse and respiratory rates. Ventricular drainage with a Frazier T-cannula inserted through a burr hole in the right occipitoparietal region afforded temporary relief. A ventriculogram revealed moderate dilatation of the lateral and third ventricles. Two cubic centimeters of phenolsulfonphthalein injected into the ventricular system failed to appear in the spinal fluid in forty-five minutes. It was decided that the patient had an obstructive hydrocephalus caused by a lesion in the posterior fossa. A suboccipital craniotomy was performed eight days after admission, and extensive exploration of the posterior fossa failed to reveal evidence of tumor. The cerebellar tonsils herniated into the foramen magnum, and a decompression was carried out on the presumption of a tumor, surgically inaccessible, located high in the left cerebellar hemisphere. A tentative diagnosis of medulloblastoma was agreed upon, and it was decided that a course of roentgen therapy should be given.