- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
- Department of Radiology, Rush University Medical Center, Chicago, IL, USA
Ryan B. Kochanski
Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
DOI:10.4103/2152-7806.176674Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kochanski RB, Byrne N, Arvanitis L, Bhabad S, Byrne RW. A rare intracranial tumor consisting of malignant anaplastic and papillary meningioma subtypes. Surg Neurol Int 17-Feb-2016;7:21
How to cite this URL: Kochanski RB, Byrne N, Arvanitis L, Bhabad S, Byrne RW. A rare intracranial tumor consisting of malignant anaplastic and papillary meningioma subtypes. Surg Neurol Int 17-Feb-2016;7:21. Available from: http://surgicalneurologyint.com/surgicalint_articles/a-rare-intracranial-tumor-consisting-of-malignant-anaplastic-and-papillary-meningioma-subtypes/
Background:Intracranial tumors with heterogeneous histopathology are a well-described pathologic entity. Pathologically, distinct tumors in direct contact with one another, also known as collision tumors are exceptionally rare, and collision between meningioma subtypes has not been previously described in the literature.
Case Description:A 79-year-old female with a history of breast carcinoma presenting with visual and motor deficits and imaging/intraoperative findings consistent with separate, distinct lesions. Histopathologic findings provided evidence for a collision between World Health Organization Grade III anaplastic and papillary meningioma.
Conclusion:We report a possible collision tumor between two separate meningioma subtypes based on the unique radiologic, intraoperative, and histopathologic findings. Submission of multiple pathologic specimens during surgical resection is key for accurate histopathologic diagnosis.
Keywords: Anaplastic, collision tumor, meningioma, papillary
Solitary intracranial tumors with intratumoral heterogeneity consisting of varying meningioma subtypes are a known reported pathologic entity.[
A 79-year-old right-handed female with a history of recently diagnosed Stage III, Grade II invasive ductal breast carcinoma presented with a 2-week history of progressive left-sided weakness, visual loss, gait imbalance, and headache. Her neurological examination was remarkable for a left homonymous hemianopia as well as mild left-sided hemiparesis.
Contrast-enhanced head computed tomography scan and subsequent brain magnetic resonance imaging with gadolinium demonstrated a large, multilobulated, contrast enhancing, dural-based, and predominantly extra-axial mass in the right parietooccipital region with apparent invasion of the underlying right parietal brain parenchyma [
Axial contrast-enhanced computed tomography (a), T1-weighted noncontrast (b) and T1-weighted contrasted (c) magnetic resonance imaging showing contrast-enhancing predominantly extra-axial dural-based lesion with invasion into underlying brain parenchyma. Two radiologic distinct components are delineated by the red arrow in the T1-weighted contrast-enhanced coronal and sagittal images (d and e)
The patient was taken to the operating room where a right parasagittal craniotomy was performed for gross total resection of the lesion. Intraoperative frozen section was consistent with meningioma. This diagnosis was consistent with the initially encountered vascular dural-based lesion. The deeper portion of the tumor was noticeably less vascular, lobular, and largely intraventricular. This portion was adherent to the choroid plexus of the atrium. Because of concerns of the differing appearance of this portion of the tumor, a second permanent pathology specimen was submitted.
The patient had an uneventful postoperative course with no new deficits. She was discharged to a skilled nursing facility.
Histologic examination revealed two distinct malignant neoplasms, which intermingled in areas. The sections that were submitted from the superficial dural-based lesion showed a predominantly solid growth pattern forming focal papillary structures [
Anaplastic meningioma (H and E ×40). This tumor was characterized by sheet-like growth pattern (a) high mitotic activity with more than 20 mitotic figures per 10 high-power fields (arrows) (b) better-differentiated area showed morphologic features of a transitional meningioma with psammoma bodies (c) and identifiable whorl formations (d)
By immunohistochemistry, both tumors showed an immunophenotype consistent with meningioma with strong positivity for epithelial membrane antigen [
Collision between the anaplastic (above) and papillary (below) meningiomas (a) H and E, ×4. Cytokeratin AE1/AE3 is positive in the papillary meningioma and completely negative in the anaplastic meningioma; clearly delineating the two tumors (b) CK AE1/AE3 IHC ×4, higher power ×10 of the same area (inset)
Review of the patient's breast and axillary lymph node biopsy results showed histopathology consistent with Grade II invasive ductal breast carcinoma. Immunohistochemical analysis showed strong estrogen receptor (ER), CK7, mammaglobin, and gross cystic disease fluid protein 15 (GCDFP-15) positivity. Immunohistochemistry was negative for progesterone receptor and human epidermal growth factor receptor 2-neu.
Here, we present a unique case of an intracranial tumor consisting of two differing meningioma subtypes in a patient with recently diagnosed invasive ductal breast carcinoma. In terms of entertaining the diagnosis of collision tumor, meningioma is the second most common intracranial tumor to collide with another, but all other reported cases have been in conjunction with an entirely different tumor (astrocytoma, metastatic tumor).[
Interestingly, our patient had been recently diagnosed with Stage III, Grade II invasive ductal breast carcinoma. Cases of intracranial collision tumor between metastatic carcinoma/sarcoma and meningioma have been previously described.[
Intracranial meningiomas with intratumoral heterogeneity (adenocarcinoma-like metaplasia) have also been reported in the literature.[
Despite imaging findings suggestive of two separate compartments, the provisional diagnosis preoperatively in our case was that of one tumor type; however, a demarcation between the two differing meningioma subtypes during gross resection as evidenced by the differing consistency and vascularity of the intraventricular lesion led to our suspicion of two distinct tumors and the submission of multiple specimens. The submission of multiple specimens is imperative when concern for multiple distinct lesions arises during surgical resection. Without this suspicion, this unique histopathologic diagnosis would not be reported.
We report a rare case of two distinct intracranial lesions with unique radiologic, histopathologic, and gross appearing characteristics. These characteristics provide evidence for a possible collision tumor between meningioma subtypes. During surgical resection, multiple pathologic specimens should be submitted if there is a concern for differing pathologic diagnoses or subtypes.
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Conflicts of interest
There are no conflicts of interest.
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