We present the case of a 59-year-old man who consulted for intellectual deficit, convulsions, bradypsychia, disorientation and stupor in the previous days. CT scan without contrast showed a peripheral left frontal lesion of 3.5 cm in diameter, with a broad base and mass effect, accompanied by trans-subzyphoidal herniation, collapse of the third ventricle and dilatation of the lateral ventricles. These findings were interpreted as the presence of a left frontal lobe menigioma and a resection was performed in December 2000. The pathological anatomy was reported as meningeal osteosarcoma (Macroscopy: 5.2x4.5 cm partially calcified mass. Microscopy: Well demarcated osteogenic tumour, without parenchymal infiltration. Irregular bone trabeculae containing atypical areas, well-differentiated areas with osteoclastic cells, necrosis and haemorrhage).
The 99mTecnetium scan was positive in the surgical field, laboratory tests were normal and the body CT scan showed paralysis of the left hemidiaphragm and hydrothorax.
Referred to our unit and having ruled out metastatic involvement, the patient started an adjuvant QT programme, but after a first cycle of cisplatin and adriamycin, the MRI showed the persistence of a frontal meningeal neoplasm surrounded by a collection of blood, with mass effect and ventricular collapse.
A second resection with wide margins was performed and the pathologist reported in the specimen the persistence of an osteosarcoma of the dural meninx, with infiltration of brain tissue and bone. An adjuvant QT regimen was scheduled with cyclophosphamide 600 mg/m2, bleomycin 15 mg/m2 and actinomycin-D 0.6 mg/m2 (day 1/21 days) and weekly methotrexate, which the patient discontinued of his own volition after the first cycle. For this reason, adjuvant RT was administered from March to May 2000, 50 + 14 Gy (5x2 Gy/weekly) of 60Cobalt.
The patient continued to undergo check-ups until May 2003, when a local relapse was discovered by MRI, and he was sent to the neurosurgery department of the Carlos Haya Hospital in Malaga. On 11-05-2003, referring intellectual deficit and urinary incontinence, he underwent a new CMRI which showed an expansive frontoparietal process, extending to the right frontal lobe and corpus callosum, and a thoracic CT scan which showed multiple metastatic nodules in both lungs. Treatment with surgery, QT and RT was ruled out, and high-dose corticosteroids were administered, achieving an initial improvement.
However, on August 30, 2003, the patient came to the emergency room of our centre, presenting severe deterioration of consciousness, with a Karnoffsky index of 30%, dyspnoea and thrombosis of the left femoral system, with multiple pulmonary metastases seen in the chest X-ray.
Once stabilisation was achieved, active oncological treatment was ruled out and the patient was referred to our Palliative Care Unit.