Recurrent calcified spinal meningioma detected by plain radiograph

Calcified spinal meningiomas: a systematic review of clinical characteristics, treatment strategies, and outcomes

BACKGROUND

Calcified meningiomas involving the spine are rare but can pose significant surgical challenges. We systematically reviewed the literature on calcified spinal meningiomas.

METHODS

PubMed, EMBASE, Web-of-Science, and Scopus databases were searched to include studies reporting clinical data of patients with calcified spinal meningioma. Included articles were analyzed for symptoms, imaging, spine level of the tumor, tumor location relative to the spinal cord, calcification status, treatment regimen, recurrence, progression-free survival, and outcomes.

RESULTS

A total of 35 articles encompassing 94 patients were included. Most patients were female (90.4%), presenting with lower extremity weakness (44%) and/or lower extremity paresthesia (38.1%). Most calcified spinal meningiomas occurred in the thoracic spine (82%) and on the dorsal (33.3%) or ventral (27.2%) side relative to the spinal cord. Most tumors were intradural (87.2%). Histologically, most calcified spinal meningiomas were WHO grade I (97.4%) and psammomatous (50.7%). Most tumors demonstrated macroscopic calcification (48.9%). Most patients underwent gross total resection (91.5%) through a posterior approach (100%). Two patients (2.1%) received adjunctive radiotherapy. The most common treatment related complication was CSF leakage. Post-operatively, most patients demonstrated symptomatic improvement (75.5%) and 2 (2.1%) had local tumor recurrence.

CONCLUSIONS

Calcified spinal meningiomas are uncommon but benign entities. These neoplasms tend to adhere to surrounding tissues and nerves and, thus, can be surgically challenging to remove. In most patients, safe gross total resection remains the standard of care, but accurate surgical planning is necessary to reduce the risks of postoperative complications.

Spinal meningiomas, from biology to management - A literature review

Meningiomas arise from arachnoidal cap cells of the meninges, constituting the most common type of central nervous system tumors, and are considered benign tumors in most cases. Their incidence increases with age, and they mainly affect females, constituting 25-46% of primary spinal tumors. Spinal meningiomas could be detected incidentally or be unraveled by various neurological symptoms (e.g., back pain, sphincter dysfunction, sensorimotor deficits). The gold standard diagnostic modality for spinal meningiomas is Magnetic resonance imaging (MRI) which permits their classification into four categories based on their radiological appearance. According to the World Health Organization (WHO) classification, the majority of spinal meningiomas are grade 1. Nevertheless, they can be of higher grade (grades 2 and 3) with atypical or malignant histology and a more aggressive course. To date, surgery is the best treatment where the big majority of meningiomas can be cured. Advances in surgical techniques (ultrasonic dissection, microsurgery, intraoperative monitoring) increase the complete resection rate. Operated patients have a satisfactory prognosis, even in those with poor preoperative neurological status. Adjuvant therapy has a growing role in treating spinal meningiomas, mainly in the case of subtotal resection and tumor recurrence. The current paper reviews the fundamental epidemiological and clinical aspects of spinal meningiomas, their histological and genetic characteristics, and their management, including the various surgical novelties and techniques.

Spinal Meningiomas

Spinal meningiomas are relatively rare, but account for a significant proportion of primary spinal tumors in adults. These meningiomas can be found anywhere along the spinal column and their diagnosis is often delayed due to their slow growth and the lack of significant neurological symptoms until they reach a critical size, at which point signs of spinal cord or nerve root compression generally manifest and progress. If left untreated, spinal meningiomas can cause severe neurological deficits including rendering patients paraplegic or tetraplegic. In this chapter we will review the clinical features of spinal meningiomas, their surgical management, and detail molecular features that differentiate them from intracranial meningiomas.

Multiple ossified spinal meningiomas in the thoracic spine: A case report and literature review

Background

Ossified spinal meningioma (OSM) is a rare form of a spinal tumor. The surgical strategies and pathologic findings related to OSM have been investigated in recent years. However, multiple OSMs are rarely reported. Here, we intend to present a rare case of multiple OSMs and review the relevant published literature.

Case Presentation

A 76-year-old woman experienced a progressive sensorimotor disturbance in her bilateral lower limbs for the past 2 years. She complained of inability to walk, urinary incontinence, and chronic constipation when referred to our hospital. A neurological examination revealed a diminished sensation below the bilateral T7, and her neurological status was Nurick Grade 6. Magnetic resonance imaging (MRI) revealed multiple intradural-extramedullary neoplasms at the T7-T11 level. Computed tomography (CT) scans showed five high-density masses of varying sizes in the spinal canal at the T7-T12 level. The patient underwent tumor resection through T7-T11 laminectomy. A histopathological examination revealed multiple OSMs.

Conclusion

We reported a rare case of multiple OSMs in an elderly patient. After one-stage complete resection, the patient recovered with satisfactory curative effect. Although elderly patients will face various postoperative complications due to their poor physical condition, we still recommend one-stage complete resection of multiple OSMs to reduce recurrence.

MAC-spinal meningioma score: A proposal for a quick-to-use scoring sheet of the MIB-1 index in sporadic spinal meningiomas

Objective

MIB-1 index is an important predictor of meningioma progression. However, MIB-1 index is not available in the preoperative tailored medical decision-making process. A preoperative scoring sheet independently estimating MIB-1 indices in spinal meningioma (SM) patients has not been investigated so far.

Methods

Between 2000 and 2020, 128 patients with clinical data, tumor imaging data, inflammatory laboratory (plasma fibrinogen, serum C-reactive protein) data, and neuropathological reports (MIB-1, mitotic count, CD68 staining) underwent surgery for spinal WHO grade 1 and 2 meningioma.

Results

An optimal MIB-1 index cut-off value (≥5/<5) predicting recurrence was calculated by ROC curve analysis (AUC: 0.83; 95%CI: 0.71-0.96). An increased MIB-1 index (≥5%) was observed in 55 patients (43.0%) and multivariable analysis revealed significant associations with baseline Modified McCormick Scale ≥2, age ≥65, and absence of calcification. A four-point scoring sheet (MAC-Spinal Meningioma) based on Modified McCormick, Age, and Calcification facilitates prediction of the MIB-1 index (sensitivity 71.1%, specificity 60.0%). Among those patients with a preoperative MAC-Meningioma Score ≥3, the probability of a MIB-1 index ≥5% was 81.3%.

Conclusion

This novel score (MAC-Spinal Meningioma) supports the preoperative estimation of an increased MIB-1 index, which might support preoperative patient-surgeon consultation, surgical decision making and enable a tailored follow-up schedule or an individual watch-and-wait strategy.

The surgical challenge of ossified ventrolateral spinal meningiomas: tricks and pearls for managing large ossified meningiomas of the thoracic spine

The authors present an illustrative technical note on microsurgical resection of ventrolateral completely ossified spinal meningiomas (OSMs) and a literature review of the surgical management of calcified spinal meningiomas or OSMs. These tumors are surgically demanding due to their solid consistency, especially when in a ventrolateral location with dislocation of the spinal cord. A challenging case with significant thoracic cord compression and displacement is described. Due to the firm consistency and the ventrolateral localization of the meningioma, a piecemeal resection was necessary. This could have resulted in a free-floating tumor remnant adherent to the spinal cord, impeding safe tumor resection. To avoid such a remnant, an anchoring burr hole was drilled at the border between the spinal cord and the adamantine tumor mass. Then, a microdissector was placed within the anchoring burr hole and the tumor was gently pulled laterally while drilling away the medial parts of the ossified tumor. This procedure was repeated until separation of the tumor from the spinal cord was possible and a gross-total resection (Simpson grade II) was manageable. Throughout the procedure, continuous intraoperative neurophysiological monitoring was performed.

Primary Spinal Intradural Extramedullary Mesenchymal Chondrosarcoma

BACKGROUND

Among chondrosarcomas arising from bones and soft tissues, mesenchymal chondrosarcoma (MCS), especially primary spinal intradural extramedullary MCS, is extremely rare, and only 18 cases have been reported to date. We report an adult case of this rare condition mimicking meningioma.

CASE DESCRIPTION

A 42-year-old woman presented with paraplegia and sensory disturbance associated with right-sided Brown-Séquard syndrome following back pain. Magnetic resonance imaging showed an intradural mass in the right dorsal spinal canal with homogeneous enhancement and dural tail sign at the T8 level. Computed tomography demonstrated a calcified portion in the mass. Following T7-8 laminectomies, an intradural extramedullary tumor was completely removed after detaching the tumor from the dura mater. The histopathologic diagnosis was MCS, and positron emission tomography showed no metastatic lesions at other sites. The patient did not receive adjuvant therapy, and magnetic resonance imaging revealed no evidence of recurrence during 2-year follow-up.

CONCLUSIONS

Primary spinal intradural extramedullary MCS has been reported to have a better prognosis than MCS occurring in other regions. In a case with early complete surgical resection, adjuvant therapy should be considered at the time of recurrence.

Ossified Spinal Meningioma: A Case Report and a Review of the Literature

Ossified spinal meningiomas are a rare form of spinal tumors. These tumors increase surgical morbidities due to their hard consistency and strong adhesion to the neural tissue and relatively narrow surgical space. Here, the authors describe the clinical findings, surgical strategies, and histological findings of a patient with an ossified meningioma. Preoperative diagnosis of these tumors can prevent surgical morbidities. Total resection can be curative with the application of meticulous microsurgical techniques.

Ossified Metaplastic Spinal Meningioma Without Psammomatous Calcification: A Case Report

Meningiomas constitute approximately 25% of primary spinal cord tumors, and 1% to 5% are calcified. Ossification is a rare event and the etiology of ossification in meningiomas is not well known. We present the case of a 29-year-old female with a rare case of ossified thoracic spinal metaplastic meningioma. The tumor was successfully resected, and pathology confirmed ossified metaplastic meningioma. On histopathological examination, only mature bone tissue and tumor cells were present in the region containing no psammoma bodies, suggesting that the tumor cells had transitioned to mature osteocytes.

Magnetic resonance imaging spectrum of spinal meningioma

PURPOSE

To evaluate magnetic resonance (MR) imaging findings of spinal meningioma and to determine the radiological subtypes based on the MR imaging findings and their respective clinical features.

MATERIAL AND METHODS

Data for 105 patients with surgically treated and histopathologically diagnosed spinal meningiomas at our hospital between May 1, 2003 and May 1, 2017 were evaluated in this study. Two radiologists reviewed the characteristics of spinal meningiomas on MR images and categorized the spinal meningiomas into subtypes based on MR imaging findings.

RESULTS

Most spinal meningiomas showed higher signal intensity than that of the spinal cord but lower than that of the subcutaneous fat on T2-weighted images (WI). 56 cases (54%) showed adjacent spinal cord signal changes. Meningiomas could be categorized according to MR imaging findings into type A: dural-based tumors with a homogeneous signal intensity and intense contrast enhancement (81 cases, 77%); type B: round or oval-shaped tumors with an internal hypointense portion on T2-weighted images (18 cases, 17%); type C: en plaque tumors (three cases, 3%); and type D: tumors with unusual findings and a heterogeneous appearance (three cases, 3%). All type C patients showed spinal cord signal changes.

CONCLUSIONS

Spinal meningioma showed slightly high signal intensity rather than high signal intensity on T2-weighted images. Spinal cord signal changes were present in more than half of the cases. Clinical differences were observed among the different MR imaging types.

Ossified spinal meningiomas: Clinical and surgical features

OBJECT

Meningiomas constitute 25% of primary spinal tumors and predominantly involve the thoracic spinal cord. Although calcifications are commonly seen in intracranial meningiomas, gross calcifications are observed in only 1-5% of all spinal meningiomas. We report the clinical findings, surgical strategy and histological features of 9 patients with ossified spinal meningiomas (OSMs).

PATIENTS AND METHODS

Clinical and surgical features of 9 patients with ossified spinal meningiomas were retrospectively reviewed.

RESULTS

There were 8 women and 1 man with a mean age of 59 years. In 7 patients, the lesions were localized in the thoracic segment of the spine while in 2 patients in the lower cervical segment. All patients presented with weakness of the lower limbs and hypoesthesia below the site level of the lesion. Only 2 patients presented with urinary incontinence. Gross-total resection of the tumor was achieved in 6 patients while in 3 a subtotal removal of the meningioma was obtained. In all patients the postoperative course was uneventful. Six patients presented with a significant neurological improvement while in 3 patients a mild improvement was observed. Microscopically, all tumors showed typical histological pattern of ossified meningioma.

CONCLUSIONS

OSMs are amenable to surgery if the complete removal can be achieved. Because of their hard-rock consistency complete resection can be challenging. In difficult cases, subtotal removal can be advised and follow-up imaging is mandatory. Overall, the risk of long-term recurrence of the lesions is low, and a good clinical outcome after total or subtotal removal can be expected.

Totally ossified metaplastic spinal meningioma

A 61-year-old woman with a very rare case of totally ossified large thoracic spinal metaplastic meningioma, showing progressing myelopathy is presented. Computed tomographic images showed a large totally ossfied intradural round mass occupying the spinal canal on T9-10 level. Magnetic resonance imaging revealed a large T9-10 intradural extramedullary mass that was hypointense to spinal cord on T1- and T2-weighted sequences, partial enhancement was apparent after Gadolinium administration. The spinal cord was severely compressed and displaced toward the right at the level of T9-10. Surgical removal of the tumor was successfully accomplished via the posterior midline approach and the histological diagnosis verified an ossified metaplastic meningioma. The clinical neurological symptoms of patient were improved postoperatively. In this article we discuss the surgical and pathological aspects of rare case of spinal totally ossified metaplastic meningioma.

Myelopathy due to calcified meningiomas of the thoracic spine: minimum 3-year follow-up after surgical treatment

Object

Calcified meningiomas are an uncommon type of meningioma. This study details the clinical features, treatment, and follow-up of 11 calcified meningiomas treated from 2002 to 2009, for the purpose of providing general information, describing the skill required for the surgery, and detailing the imaging study of these tumors.

Methods

Between 2002 and 2009, 11 patients underwent surgery for the treatment of calcified meningiomas. All were treated by the same group of doctors at the same institution, including surgery and rehabilitation after surgery. The minimum 3-year (> 36 months) follow-up data from the 11 patients were detailed. Neurological function was evaluated twice, based on the Frankel scale and Japanese Orthopaedic Association scoring system. The first evaluation occurred before surgery and the second 3 years after surgery.

Results

In 3 cases, the Frankel score decreased by 1 level. In a comparison of the duration of preoperative symptoms, age, degree of canal stenosis, and intraoperative blood loss, it was found that the greater the degree of canal stenosis, the poorer the outcome of the patient. Calcified meningiomas were more likely to adhere to the nerves and dura, a finding that might explain the high incidence of neurological dysfunction and CSF leakage after surgery.

Conclusions

Calcified meningiomas are the most rare of all meningiomas. It appears that a greater degree of canal stenosis can lead to a poorer outcome. Computed tomography scans and MRI with contrast enhancement are recommended for intraspinal tumors before surgery to exclude the possibility of calcification. For calcified meningiomas, precise tumor resection, dura repair during surgery, and medical care after surgery are important for achieving an acceptable outcome.

Recurrent spinal meningioma: a case report

Meningiomas are the second most common intradural spinal tumors accounting for 25% of all spinal tumors. Being a slow growing and invariably benign tumor, it responds favorably to surgical excision. In addition, spinal meningioma has low recurrence rates. However, we experienced a case of intradural extramedullary spinal meningioma which recurred 16 years after the initial surgery on a 64-year-old woman. She presented with progressive neurological symptoms and had a surgical history of removal of thoracic spinal meningioma 16 years ago due to bilateral low leg weakness. She underwent a second operation at the same site and a pale yellowish tumor was excised, which was histopathologically confirmed as meningothelial meningioma, compared with previously transitional type. she showed neurological recovery after the operation. We, therefore, report the good results of this recurrent intradural spinal meningioma case developed after 16 years with literature review.

CT and MRI findings of calcified spinal meningiomas: correlation with pathological findings

OBJECTIVE

This study was designed to present characteristic CT and MR findings of calcified spinal meningiomas that correlate with pathological findings and to assess the efficacy of CT for the detection of calcifications within a mass in comparison to MRI.

MATERIALS AND METHODS

Between 1998 and 2009, 10 out of 11 patients who had pathologically confirmed psammomatous meningiomas showed gross calcifications on CT images and were included in this study. On CT scans of the 10 patients, the distribution pattern, morphology and number of calcifications within masses were evaluated. MRI was performed in seven patients and signal intensities of masses were assessed. The pathological results analyzed semi-quantitatively were compared with the density or the size of calcifications within a mass as seen on a CT scan.

RESULTS

Seven of 10 masses were located at the thoracic spine level. Eight masses had intradural locations. The other two masses had extradural locations. Four masses were completely calcified based on standard radiographs and CT. Symptoms duration, the size of the mass and size or number of calcifications within a mass had no correlation. The location, size, and distribution pattern of calcifications within masses were variable. On MR images, signal intensity of calcified tumor varied on all imaging sequences. All the masses enhanced after injection of intravenous contrast material.

CONCLUSION

A calcified meningioma should be first suggested when extradural or intradural masses located in the spine contain calcifications regardless of the size or pattern as depicted on CT, especially in the presence of enhancement as seen on MR images.

Spinal meningioma containing bone: a case report and review of literature

Meningiomas constitute about 25% of primary spinal tumours and 1% to 5% of them are calcified. Ossification is a rare event and is rarely reported. Here, the case of a 40-year-old woman who had dorsal spinal cord meningioma (globular variety) at the T(6) vertebral level is reported; the meningioma showed a nidus of T2 weighting hypointensity on MRI as well as a bony chip inside the tumour intraoperatively. The tumour was successfully resected. Though the aetiology of ossification in the meningioma is not well known, metaplasia of arachnoid cells/dystrophic calcification may be the cause. Ossified meningiomas are more difficult to resect than the usual variety. Hypointensity inside tumour in T2-weighted images of MRI should make the surgeon suspicious of this condition, which may in some cases complicate tumour resection.

The cytogenetic relationship between primary and recurrent meningiomas points to the need for new treatment strategies in cases at high risk of relapse

PURPOSE

Recurrence is the major factor influencing the clinical outcome of meningioma patients although the exact relationship between primary and recurrent tumors still needs to be clarified. The aim of the present study is to analyze the cytogenetic relationship between primary and subsequent recurrent meningiomas developed within the same individual.

EXPERIMENTAL DESIGN

Multicolor interphase fluorescence in situ hybridization was done for the identification of numerical abnormalities of 12 chromosomes in single-cell suspensions from 59 tumor samples corresponding to 25 recurrent meningioma patients. In 47 of these tumors, the distribution of different tumor cell clones was also analyzed in paraffin-embedded tissue sections. In parallel, 132 nonrecurrent cases were also studied.

RESULTS

Most recurrent meningiomas showed complex cytogenetic aberrations associated with two or more tumor cell clones in the first tumor analyzed. Interestingly, in most individuals (74%), exactly the same tumor cell clones identified in the initial lesion were also detected in the subsequent recurrent tumor samples. In the recurrent tumor samples of the remaining cases (26%), we observed tumor cell clones related to those detected in the initial lesion but which had acquired one or more additional chromosome aberrations associated with either the emergence of new clones with more complex karyotypes or the disappearance of the most representative clones from the primary lesions. Multivariate analysis of prognostic factors showed that the Maillo et al. prognostic score, based on age of patient, tumor grade, and monosomy 14, together with tumor size was the best combination of independent variables for predicting tumor recurrence at diagnosis.

CONCLUSION

Overall, our results indicate that the development of recurrent meningiomas after complete tumor resection is usually due to regrowth of the primary tumor and rarely to the emergence of an unrelated meningioma, underlining the need for alternative treatment strategies in cases at high risk of relapse, particularly those with a high Maillo et al. prognostic score and larger tumors.

Thoracic ossified meningioma and osteoporotic burst fracture: treatment with combined vertebroplasty and laminectomy without instrumentation

✓ Although spinal meningioma is a common benign neoplasm, the ossified variant is rare. No more than 20 sporadic cases were reported in the literature between 1977 and January 2005. Recently, the authors treated a patient with a symptomatic ossified meningioma located in the posterior aspect of T-11 and an associated osteoporotic T-11 burst fracture. The tumor was completely removed by T10–11 laminectomy and transpedicular vertebroplasty was performed. The kyphotic deformity of the T-11 burst fracture was partially reduced and maintained for at least 2 months after vertebroplasty and laminectomy. The clinical presentation and management of this case are reported.

Recurrent spinal meningioma: a case report with review of the literature

Spinal meningioma generally responds favourably to surgical excision and has a low rate of recurrence. However, follow-up data on patients under 50 years of age are limited. We report a recurrence of intraspinal meningioma 18 years after the initial surgery in a 45-year-old woman. She presented with weakness in both lower limbs that had gradually progressed over the previous 8 months, and difficulty in walking for the last 2 months. She had no history of sensory loss or visceral involvement, but had undergone a major surgical intervention of the upper spine for a similar episode of weakness in both lower limbs 18 years earlier. She underwent a second surgery at the same site, and a greyish-white tumour was excised, which was histopathologically confirmed as recurrent psammomatous meningioma. The patient demonstrated complete neurological recovery in 8 months.

Metaplastic bone formation in a low grade conus glioma: case report and review of the literature

Calcifications associated with both benign and neoplastic intra-axial lesions of the central nervous system (CNS) are well recognized. Bony metaplasia in the CNS, where there is formation of mature trabecular bone, is a much more rare entity and has not been reported in the spinal cord. We present a case of bony metaplasia in the conus medullaris associated with a low grade astrocytoma. Radiological, pathological and clinical features of this unique case are discussed.