Cranial intraosseous meningioma: spectrum of neuroimaging findings with respect to histopathological grades in 65 patients

Coexistence of meningioma and craniofacial fibrous dysplasia: a case series of clinicopathological study and literature review

BACKGROUND

The co-existence of meningioma and craniofacial fibrous dysplasia (CFD) is rare. Due to the similar radiological characteristics, it is challenging to differentiate such co-existence from solitary hyperostotic meningioma resulting in a dilemma of prompt diagnosis and appropriate intervention.

METHOD

We conducted a retrospective review of the data from 21 patients with concomitant meningioma and CFD who were treated at Beijing Tiantan Hospital from 2003 to 2021. We summarized their clinicopathological features and performed a comprehensive literature review. Additionally, we tested the characteristic pathogenic variants in exon 8 and 9 of GNAS gene and the expression of corresponding α-subunit of the stimulatory G protein (Gαs) related to CFD to explore the potential interactions between these two diseases.

RESULTS

The cohort comprised 4 men and 17 women (mean age, 45.14 years). CFD most commonly involved the sphenoid bone (n = 10) and meningiomas were predominantly located at the skull base (n = 12). Surgical treatment was performed in 4 CFD lesions and 14 meningiomas. Simpson grade I-II resection was achieved in 12 out of the 14 resected meningiomas and almost all of them were classified as WHO I grade (n = 13). The mean follow-up duration was 56.89 months and recurrence was noticed in 2 cases. Genetic study was conducted in 7 tumor specimens and immunohistochemistry was accomplished in 8 samples showing that though GNAS variant was not detected, Gαs protein were positively expressed in different degrees.

CONCLUSIONS

We presented an uncommon case series of co-diagnosed meningioma and CFD and provided a detailed description of its clinicopathological features, treatment strategy and prognosis. Although a definite causative relationship had not been established, possible genetic or environmental interplay between these two diseases could not be excluded. It was challenging to initiate prompt diagnosis and appropriate treatment for concomitant meningioma and CFD because of its similar radiological manifestations to meningioma with reactive hyperostosis. Personalized and multi-disciplinary management strategies should be adopted for the co-existence of meningioma and CFD.

Imaging Features of Primary Intraosseous Meningiomas

OBJECTIVE

To describe the imaging features of primary intraosseous meningiomas (PIMs) to aid an accurate diagnosis.

METHODS

Clinical materials and radiological data for 9 patients with pathologically confirmed PIMs were reviewed comprehensively.

RESULTS

Most lesions involved inner and outer plates of the calvaria and all were relatively well circumscribed. Upon computed tomography, portions of the solid neoplasm were hyperattenuated or isoattenuated. Hyperostosis was found in many lesions, but calcification was seen rarely. On magnetic resonance imaging, most neoplasms were hypointense on T1-weighted images, hyperintense on T2-weighted images, and heterogeneous on fluid-attenuated inversion recovery images. In most cases, the soft tissue of neoplasms showed hyperintense on diffusion-weighted imaging and hypointense on apparent diffusion coefficient. All lesions were obviously enhanced after gadolinium administration. Each patient accepted surgical treatment and recurrence was not observed during follow-up.

CONCLUSIONS

Primary intraosseous meningiomas are very rare tumors that occur usually in later life. They are well-defined and tend to involve the inner and outer plates of the calvaria, with a classic appearance of hyperostosis on computed tomography. Primary intraosseous meningiomas display hypointense on T1-weighted images, hyperintense on T2-weighted images, and hyperattenuated or isoattenuated on computed tomography. Hyperintense on diffusion-weighted imaging, hypointense on apparent diffusion coefficient can also be found. Obvious enhancement supplied additional information for an accurate diagnosis. A neoplasm with these features should raise the suspicion of a PIM.

A Primary Intraosseous Meningioma: A Rare Case of Malignancy with High Proliferative Ability

Primary intraosseous meningioma (PIM) is a rare tumor that arises in the skull. Histopathologically, it is generally described as a slow-growing, benign lesion. However, on rare occasions, PIM presents as a malignancy with high proliferative ability, which requires maximal resection, adjuvant radiotherapy, and subsequent careful follow-up. Because of the rarity of such cases, they present a diagnostic challenge with unusual pathological findings. Herein, we report a case of a primary intraosseous anaplastic meningioma with extensive invasion inside and outside the skull, along with the results of whole-genome analysis. Histopathological diagnosis was a World Health Organization grade 3 anaplastic meningioma. In the literature, only two cases of anaplastic PIM have been reported, so its characteristics and treatment are poorly understood. Our patient was successfully treated with tumor resection, followed by intensity-modulated radiation therapy. Follow-up imaging studies revealed no recurrence or distant metastasis, including to lung, liver, and bone, at 8 months after the surgery.

Primary intraosseous meningioma with subcutaneous and dural invasion: A case report and literature review

Primary intraosseous meningiomas (PIOMs) are a rare subset of meningiomas, comprising fewer than 1% of all such tumors. Furthermore, PIOMs presenting as osteogenic lesions that invade both the dura and subcutaneous tissue are extremely rare. Unlike intracranial meningiomas, diagnosing and treating PIOMs are challenges due to their insidious clinical behavior and a lack of clear radiological diagnostic criteria. We report the case of a 60-year-old female with headache and a slightly outward protrusion of the parietal region of the skull. CT showed an osteogenic lesion in the right parietal bone. MR imaging indicated mild to moderate homogeneous enhancement with an intense dural reaction. The suggested clinical diagnosis was lymphoma, so we performed a skull biopsy, which revealed an intraosseous benign meningioma. A precise resection strategy was planned with a neuronavigation system accompanied by a one-step customized titanium mesh cranioplasty. The lesion was completely removed, and pathological analysis confirmed a meningothelial meningioma (WHO Grade I) of intraosseous layer origin invading the dura mater and subcutaneous tissue. This case highlights the need for an initial biopsy when the lesion is difficult to diagnose on imaging. Complete resection should be attempted to minimize the risk of recurrence.

Bone Invasive Meningioma: Recent Advances and Therapeutic Perspectives

Meningioma is the most common primary neoplasm of the central nervous system (CNS). Generally, these tumors are benign and have a good prognosis. However, treatment can be challenging in cases with aggressive variants and poor prognoses. Among various prognostic factors that have been clinically investigated, bone invasion remains controversial owing to a limited number of assessments. Recent study reported that bone invasion was not associated with WHO grades, progression, or recurrence. Whereas, patients with longer-recurrence tended to have a higher incidence of bone invasion. Furthermore, bone invasion may be a primary preoperative predictor of the extent of surgical resection. Increasing such evidence highlights the potential of translational studies to understand bone invasion as a prognostic factor of meningiomas. Therefore, this mini-review summarizes recent advances in pathophysiology and diagnostic modalities and discusses future research directions and therapeutic strategies for meningiomas with bone invasion.

Benign purely intraosseous meningioma of the skull: Diagnosis and surgical outcomes

Primary intraosseous meningioma (PIM) is a rare subtype of extradural meningiomas that originates within bone. We aimed to characterize the clinical, radiographic, and pathologic features of PIM and the resulting outcomes following resection. Herein we examined a retrospective case series of all patients with a pathologically confirmed WHO grade I PIM that were managed at one of three tertiary care centers. Patients with tumors that demonstrated extraosseous extension or involvement of the dura mater were excluded. The main outcomes included surgical safety and duration of local tumor control. Nine patients were identified with benign PIMs, presenting with headaches or painless enlarging subcutaneous masses if involving the calvarium or with neurologic deficits if involving the skull base, or otherwise incidentally identified. Surgery was pursued for symptomatic relief and/or tissue diagnosis. Lesions were evaluated by radiographic imaging - including sensitive detection by plain X-ray films - and definitive diagnosis ascertained by histopathological examination. Maximal resection of both calvarial and skull base lesions was safely tolerated. PIM represents a rare benign skull lesion, whose identification depends on the integration of radiographic findings with intraoperative findings and histopathological confirmation; it should be considered in the differential for slow-growing expansile intraosseous lesions of the skull.

Intraoperative frozen cytology of intraosseous cystic meningioma in the sphenoid bone

Meningiomas in bone are rarely subjected to fine-needle aspiration diagnosis, and those arising in the skull bone with a cystic presentation are rare. A 24-year-old woman presented with subdural hemorrhage, and subsequent radiology depicted an osteolytic mass-like lesion in the sphenoid bone. Intraoperatively, a solid and cystic hemorrhagic lesion mimicking an aneurysmal bone cyst was observed in the sphenoid bone with dural tearing. Frozen cytology showed singly scattered or epithelioid clusters of round to elongated cells intermixed with many neutrophils. Tumor cells had bland-looking round nuclei with rare prominent nucleoli and nuclear inclusions and eosinophilic granular to globoid cytoplasm in capillary-rich fragments. Histology revealed intraosseous meningothelial and microcystic meningioma (World Health Organization grade 1) in right lesser wing of the sphenoid bone. Considering its unusual location and cytologic findings, differential diagnoses included chordoma, chondroma, chondrosarcoma, and aneurysmal bone cyst. The present case posed a diagnostic challenge due to possible confusion with these entities.

Modern day imaging of meningiomas

Meningiomas are the most common primary tumors of the central nervous system and as such they are often encountered at neuroimaging. Fortunately, meningiomas are readily diagnosed with anatomic computed tomography and magnetic resonance imaging. While conventional imaging is the mainstay for initial diagnosis and delineating tumor for treatment planning and posttreatment follow-up, the last couple of decades have given rise to advanced physiologic and metabolic imaging techniques that serve as powerful tools in the management of meningioma. These modern approaches are allowing imaging to expand its utility to include extraction of biologic and potentially prognostic information that will ultimately improve care for meningioma patients.

Removal of giant intraosseous meningioma followed by cranioplasty using a custom-made bioceramic implant: case report

Intraosseous meningioma of the chordoid type is a rare clinical entity. Radical surgical removal and subsequent cranioplasty is the treatment of choice. Here, the authors report a severe case involving more than 70% of the calvarial surface area, which was removed and repaired using a prefabricated custom-made, titanium-reinforced, bioceramic implant and bone-cutting guides. Tumor removal and good esthetic outcome were achieved, along with a 17.1% increase of intracranial volume. Bioceramic implants have shown promising initial results and may represent an important new tool in the surgeon’s armamentarium.

Primary intraosseous meningioma: clinical, histological, and differential diagnostic aspects

OBJECTIVE

Primary intraosseous meningioma (PIM) is a rare manifestation of meningioma, a benign, neoplastic lesion of the meninges. Its characteristic appearance is hyperostosis, while no or only minimal dural changes can be observed. This study aims to characterize this rare entity from both a clinical and histopathological point of view in order to improve clinical management.

METHODS

In the years 2009-2017, 26 cases of PIM were diagnosed using MRI and CT scans. In 16 cases the indication for resection was given, and specimens were further examined using a multilevel approach, including histological and immunohistochemical analyses. Additionally, the local database was searched for all cases of meningiomas, as well as osteosclerotic differential diagnoses-i.e., fibrous dysplasia, Paget's disease of bone, and other benign osteosclerotic lesions.

RESULTS

In this study, PIM represented 2.4% of all meningiomas with a predominant occurrence in females (85%). Regarding the initial manifestation, PIMs show a slightly earlier onset than meningiomas. While most PIMs are located in the sphenoid bone, associated calcifications were visible in 58% of the cases on CT scans. Most of the cases were classified as WHO grade I (93%) and meningotheliomatous meningiomas (91%). Tumor growth was associated with an increased bone resorption followed by massive osteoid deposition and consecutive sclerosis. The frequently observed frayed appearance results from multiple bony canals, which contain blood vessels for the blood supply of the highly vascularized tumor tissue.

CONCLUSIONS

PIM is a rare but important differential diagnosis for osteosclerotic lesions of the skull, especially in women. Tumor-induced, cellular-mediated bone resorption and formation may play a central role in the underlying pathogenesis.

Frontal intradiploic meningioma with progressive intracranial invasion: A rare case report

RATIONALE

Intradiploic meningiomas are a subset of extradural meningiomas that arise in the skull. They are mostly localized in the frontoparietal and orbital regions, and they are often mistaken for primary bone tumors.

PATIENT CONCERNS

The patient was a 48-year-old man with headache and a 12-year history of frontal cranium occupation, which was first discovered in 2005 and enlarged in 2009. The patient had a history of fracture in his frontal cranium 12 years ago. The computed tomography and magnetic resonance imaging revealed an occupation and intracranial invasion in frontal cranium. And the angiography showed an occlusion at the anterior part of sagittal sinus.

INTERVENTIONS

Bilateral frontal craniotomy, intracranial tumor resection, and cranioplasty were performed.

DIAGNOSIS

Histologic examination confirmed an intradiploic ectopic meningioma (World Health Organization Grade I).

OUTCOMES

He was discharged with no neurological deficits 3 days after surgery. At the 6-month clinical follow-up, there was no tumor recurrence or other complaints.

LESSONS

In this study, we present the case of a frontal intradiploic meningioma with progressive intracranial invasion and review the radiographic and clinical findings of patients with primary intraosseous meningioma.

Role of diffusion-weighted imaging in skull base lesions: A pictorial review

Skull base lesions can be related to wide number of pathologies including infections, benign and malignant tumors. Accurate diagnosis and differentiation between these entities is important for prompt and appropriate treatment. However, computed tomography and routine magnetic resonance imaging techniques only provide information on the extent of the lesions, with limited ability to differentiate between benign and malignant lesions. Diffusion-weighted imaging can help in many such situations by providing additional information, including help in differentiating benign from malignant lesions, so that appropriate treatment can be initiated. In this review article, we illustrate the imaging findings of the spectrum of skull base lesions, emphasizing the role of diffusion-weighted imaging in this domain.

Primary intraosseous meningioma: an osteosclerotic bone tumour mimicking malignancy

BACKGROUND

Sclerotic tumours of the calvarial bones are rare and may be due to primary and secondary bone tumours as well as extradural tumours of meningeal origin.

CASE PRESENTATION

We report a case of primary intraosseous meningioma (PIM) which arose in the frontal bone of a 63 year old woman who complained of progressive pain and thickening of the right skull. Radiology showed a large osteosclerotic lesion in the right frontal bone. Histology showed an intraosseous lesion containing dense fibrous tissue in which there were scattered cells that expressed epithelial membrane antigen and progesterone receptor. The tumour was partially resected and 3 years after operation has not recurred.

CONCLUSIONS

PIM is a rare tumour which needs to be distinguished from primary/secondary osteosclerotic calvarial bone tumours.

Primary intraosseous meningioma in the calvaria: morphological feature changes on magnetic resonance images over several years

Primary intraosseous meningiomas (PIMs) are rare, and their pathogenesis remains unclear. We report the case of a sizable PIM in the calvaria that progressively enlarged over several years and presented temporal changes in the morphological features on magnetic resonance images. Along with discussing the case, we further emphasize the potential pitfalls of diagnosing a PIM in the calvaria.

Microcystic meningioma of the calvarium: a series of 9 cases and review of the literature

Meningiomas are one of the most common tumors that arise within the central nervous system; they represent up to 30% of all primary intracranial tumors. Extradural meningiomas are rare (<2% of all meningiomas), and most arise within the calvarium. Intraosseous calvarial meningiomas are usually easy to diagnose histologically if they are of the meningothelial type; however, they may cause diagnostic challenges when they manifest as unusual morphologic variants, such as the microcystic type. To address this issue we present a series of 9 cases of calvarial microcystic meningiomas arising in 7 female and 2 male patients; all patients were adults. The tumors had heterogenous findings on imaging studies and ranged in size from 1.1 to 4.3 cm in greatest dimension. The neoplasms were composed predominantly of stellate and spindle cells with long, thin interconnecting cytoplasmic processes arranged in a complex network. The resulting cellular architecture was "sieve-like" in appearance because of the formation of numerous small "cyst-like" spaces interposed between the cytoplasmic processes of the tumor cells. All of the neoplasms expressed the characteristic immunophenotype of meningiomas (EMA, PR positive). Most tumors were resected, and none of these have recurred during a follow-up period of 1 to 83 months (average 17 mo). The morphology of the tumors and their anatomic location generated problems in diagnosis, especially in 6 patients with a history of malignancy and for whom metastatic disease was suspected clinically. Intraosseous microcystic meningioma is uncommon, and this series, the largest reported to date, describes their clinicopathologic findings, biological behavior, and features that facilitate their accurate diagnosis.