Atypical meningioma (WHO Grade II)

Case contributed by Dr Ernest Lekgabe

Presentation

Presented with headache. Background history of non-small-cell lung cancer.

Patient Data

Age: 70 years
Gender: Female
MRI

Pre-op MRI

Large right temporal enhancing mass appears extra-axial. Encasement of right MCA vessels with multifocal infarcts in the right MCA territory in keeping with compression of the vessels. No evidence of brain invasion on imaging. The hypointense T2 signal in the medial component of the tumour is suggestive of hard component of the tumour at surgery.Severe mass effect with uncal herniation and compression of the right cerebral peduncle.

MRI

3 weeks post op.

Partial resection of the right sphenoid wing extraaxial tumour has been performed. Residual tumour with persistent encasement of right MCA vessels. New regions of acute infarction in the right MCA territory involving the caudate head and body and lentiform nucleus. No MRA flow signal is identified within the right MCA vessels beyond the proximal M1 segment where the vessel is encased by the tumour.

Pathology

The tumour sections show a hypercellular meningioma with a meningothelial architecture. Tumour cells are arranged in whorls and diffuse sheets. Tumour cells demonstrate uniform nuclear features with occasional small nucleoli. There is focal tumour cell nuclear overlap and small cell change present. Scattered psammoma bodies are present. There are up to 5 mitoses/10hpf. Specimen 5 shows extensive areas of tumour necrosis. Focal brain invasion is identified. Dural attachment is noted. There is no evidence of malignancy.

Diagnosis: Atypical meningioma (WHO Grade II) with brain invasion.

Case Discussion

Meningiomas can be classified as benign (typical meningioma), atypical (grade II) and malignant (grade III).

Features of atypical meningioma include the clear cell and papillary subtypes, 4 or more mitoses/10hfp, high nuclear-cytoplasmic ratio, necrosis, and prominent nucleoli. Brain invasion is also now listed as a feature of atypical meningioma in the new WHO update.

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Case information

rID: 54742
Case created: 26th Jul 2017
Last edited: 31st Jul 2017
Inclusion in quiz mode: Included

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