Intra and extradural thoracic meningioma

Case contributed by Dr Mark Rodrigues

Presentation

Enlarging right axillary lump. ? lymphoma

Patient Data

Age: 50 years
Gender: Female

Small fat attenuation mass in the right lateral chest wall musculature in keeping with a simple lipoma. No abnormal thoracic lymph nodes.

Extramedullary mass within the lower thoracic vertebral canal with extension through the right neural foramen. The spinal cord is displaced to the left and partially compressed. The mass has areas of high attenuation in keeping with calcification. There is mild scalloping of the posterior wall of the vertebral body. There is no significant widening of the right neural foramen. 

Transitional vertebral anatomy. Counting inferiorly from the skull base, the last mobile vertebral body is the S1 vertebra.

Right-sided vertebral canal mass extending from the level of the T10/T11 disc to the mid T12 level. It is isointense to spinal cord on T1w and mildly hyperintense on T2w and shows homogeneous enhancement. There are no cystic components. The mass causes minor bony remodeling, smoothly scalloping the T11 posterior vertebral body on the right side and extends through the right T11/12 neural foramen, which appears slightly expanded, into the paraspinal fat deep to the pleura of the right lung base. 

The mass appears largely extradural, displacing and compressing the thecal sac and spinal cord to the left. There are areas where the right side of the dura appears discontinuous, with enhancing tissue extending intradurally to surround the right side of the spinal cord. A small amount of linear dural enhancement is present anteriorly. There is effacement of CSF at the level of the mass and a small amount of high T2w cord signal. No syrinx. 

The patient had slowly progressive symptoms of balance impairment and reduced sensation in her feet and therefore underwent surgical resection

Histopathology:

Microscopy

Microscopy reveals a moderately cellular tumor composed of meningothelial cells with round to eleongated nuclei, occasional intracytoplasmic inclusions and indistinct cell borders.  Nuclear atypia is mild.  Abundant psammoma bodies are noted and there are many well-defined cellular whorls.  There are no areas of necrosis and mitotic activity is inconspicuous (1 mitotic figure per 10 high power fields).  Brain tissue is not identified.

 The overall features are of a psammomatous meningioma WHO grade 1.

Case Discussion

Largely extradural mass in the thoracic spine, displacing and compressing the thecal sac and spinal cord, with some myelopathic signal change. The right side of the dura appears breached in a couple of places, with a small amount of enhancing tumor extending intradurally. There is thin linear dural enhancement and some calcification on CT. These appearance are more in keeping with a meningioma.

 

Key points:

  • location of spinal masses (intramedullary, extramedullary intradural or extradural) is important to help narrow the differential diagnosis
  • masses may involve more than one location, as in this case
  • other imaging features, such as homogeneity of enhancement, presence of calcification or cystic change and degree of bony remodeling are also helpful
  • it is important to identify transitional vertebral anatomy and clearly describe the vertebral numbering used in the report to ensure the correct level is operated on

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