Presentation
Presented with headache. Background history of non-small-cell lung cancer.
Patient Data
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 tumor is suggestive of hard component of the tumor at surgery.Severe mass effect with uncal herniation and compression of the right cerebral peduncle.
Partial resection of the right sphenoid wing extraaxial tumor has been performed. Residual tumor 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 tumor.
The tumor sections show a hypercellular meningioma with a meningothelial architecture. Tumor cells are arranged in whorls and diffuse sheets. Tumor cells demonstrate uniform nuclear features with occasional small nucleoli. There is focal tumor 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 tumor 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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