Lymphoplasmacyte-rich meningioma in a child. Case report

Lymphoplasmacyte-Rich Meningioma or IgG4-Related Disease: Walking the Thin Line

Lymphoplasmacyte-rich meningioma (LP meningioma) is a rare form of grade 1 meningioma. It shows dense lymphoplasmacytic infiltrate, mimicking an inflammatory lesion. We present a case of Lymphoplasmacyte-rich (LP) meningioma in the left parasagittal region in a 47-year-old female. On histological examination, it showed dense lymphoplasmacytic infiltrate masking the meningothelial component. There was dense fibrosis and numerous IgG4-positive plasma cells (100-120/hpf), admixed with lymphocytes and few histiocytes. The meningothelial component was highlighted by epithelial membrane antigen (EMA) immunostain. The patient had normal serum IgG4 level. This case highlights the morphological overlap between LP meningioma and IgG4-related disease. The presence of fibrosis and increased IgG4-positive plasma cells as a major inflammatory component in LP meningioma, as demonstrated in the present case and some other previous studies raise suspicion of its association with IgG4-related disease. However, this hypothesis requires further detailed studies for confirmation.

Clinical features, radiological findings, and prognostic factors for primary intracranial chordoid meningioma

OBJECTIVES

Chordoid meningioma (CM) is an infrequent histologic subtype of meningiomas. Owing to its low occurrence, this subtype has been rarely described. Our subject was to explore the clinical features, radiological characteristics, and prognostic factors of primary intracranial chordoid meningioma.

METHODS

We reviewed the medical records and collected follow-up information of 34 cases who had been surgically treated and histologically diagnosed with CM at the Department of Neurosurgery, West-China Hospital of Sichuan University, from January 2009 to December 2021.

RESULTS

Among all 7,950 meningioma cases, the proportion of primary intracranial CM was 0.43% (34/7,950). The median diagnosis age was 47 (ranging from 12 to 74) and the gender ratio (male to female) was 2.1:1. For radiological features, heterogeneous enhancement, skull base, and ventricular localization, cystic degeneration and dural tail sign were common in CM cases. In treatment, gross total resection (GTR) was achieved in 22/34 cases (64.7%) and subtotal resection (STR) was achieved in 12/34 cases (35.3%). Further, 11/34 patients (32.4%) had received postoperative adjuvant radiotherapy (RT). The follow-up duration ranged from 4 to 157 months after operation. The progression rate was 20.7% (6/29) and the median of PFS was 38 months. By survival analysis, accepting adjuvant radiotherapy and achieving GTR were correlated with longer progression-free survival for prognosis.

CONCLUSION

CM is a rare subtype of meningiomas. In our series, it mainly involved adults and did not show a predilection for women compared with meningiomas in general. For a better prognosis, gross total resection and postoperative adjuvant radiotherapy are recommended. Nevertheless, due to the restriction of the series sample, patients lost for follow-up and inherent biases of a retrospective study, more cases and a shorter follow-up duration are needed for better management of chordoid meningioma.

Lymphoplasmacyte-rich meningioma in the central nervous system: An unusual case report

RATIONALE

Lymphoplasmacyte-rich meningioma (LPRM) is a rare meningioma characterized by significant infiltration of plasma cells and lymphocytes, and changes in the ratio of meningeal epithelial components. According to the World Health Organization, tumors of the central nervous system are classified as grade I tumors.

PATIENT CONCERNS

A 44-year-old man presented to our department with complaints of limb weakness accompanied by hand numbness. Half a month before admission, the patient's limb weakness worsened and he could not walk and raise his hands, with limb sensory disturbance and incontinence.

DIAGNOSIS

Magnetic resonance imaging of the head and cervical spinal cord showed a diffuse extramedullary mass creeping on the tentorium and skull base meninges along the clivus down to the sixth cervical spinal meninges. The cervical spinal cord was enveloped and pressed (Fig. 1A-C). Postoperative histopathological examination showed meningothelial areas admixed with lymphocytes and plasma cells (Fig. 2D-H), indicating that the mass was a LPRM.

INTERVENTION

Suboccipital craniotomy, C1 laminectomy, and C2-C6 laminoplasty were performed for this patient, and postsurgical pathology showed that the tumor was a LPRM with large amounts of lymphocytes and plasma cells.

OUTCOME

After 2 weeks of active treatment, the patient died of worsening pneumonia.

LESSONS

LPRM is a rare variant of meningioma, and it is more unusual that the lesions involve the intracranial dura mater and the entire cervical spinal meninges. So far, surgical resection has been the main treatment for LPRM, but according to its own characteristics of lymphoplasmacyte-rich, immunotherapy may become a new treatment option.

Lymphoplasmacyte-rich meningioma: a convexity mass with regional enhancement in the adjacent brain parenchyma

Lymphoplasmacyte-rich meningioma (LPM) is a rare, benign variant of meningioma, characterized by massive inflammatory cell infiltration and a variable proportion of meningothelial tumorous elements. Here we report the clinicopathological features of an LPM located at the right frontal convexity in a 37-year-old woman. The patient had suffered an initial generalized tonic-clonic seizure when she was 32 weeks pregnant. The lesion exhibited low intensity on T1-weighted MRI and high intensity on T2-weighted images, with surrounding parenchymal edema. The mass exhibited gadolinium enhancement with dural tail signs. Moreover, multiple foci of linear enhancement spreading through the sulci and into the nearby brain parenchyma were evident. At 1 month after parturition, en bloc removal of the mass, the attached dura mater and adjacent brain tissue was performed. Histologically, the mass located in the subdural space was composed of a mixture of B- and T-lymphocytes and plasma cells. Within the mass, multiple small lobules of meningothelial cells showing immunoreactivity for epithelial membrane antigen and vimentin were observed. The inflammatory cells had also infiltrated the subarachnoid and Virchow-Robin spaces, and the dura mater. The cerebral cortex showed ischemic changes, but no tumor cell invasion. On the basis of these histological features, the lesion appeared to be LPM with an inconspicuous meningothelial component and extensive inflammatory infiltration. This case appears to provide useful information on the pathogenesis of this variant.

Clear cell meningioma causing Castleman syndrome in a child

This 11-year-old boy presented with a rare case of Castleman syndrome caused by a clear cell meningioma manifesting as persistent fever of unknown origin, 2 years after glomerulonephritis. Laboratory investigation of the patient showed an increased inflammatory reaction, as well as elevated polyclonal gamma globulin titer and serum level of C-reactive protein. Magnetic resonance imaging revealed a tumor at the cerebellopontine angle. Neurosurgical intervention was performed under the presumptive diagnosis of Castleman syndrome caused by intracranial tumor. Histological examination of the tumor verified that it was clear cell meningioma with infiltration of lymphoplasma cells, and surgical removal resulted in complete resolution of the patient's symptoms and biochemical abnormalities. The present case of clear cell meningioma manifesting as Castleman syndrome shows that the possibility of a brain tumor should be considered in patients presenting with fever of unknown origin, anemia, hypergammaglobulinemia, or other systemic illness.

Lymphoplasmacyte-Rich Meningioma Mimicking Idiopathic Hypertrophic Pachymeningitis

A 24-year-old man presented with long-term headache and progressive visual loss. Neuro-ophthalmic manifestations included finger counting acuity in both eyes, weakly reactive pupils, pale optic discs, and increased deep tendon reflexes. Brain MRI showed meningeal thickening that involved the optic nerves and chiasm and enveloped and displaced the brainstem as far caudally as the foramen magnum. The diffuse extensive nature of the lesion suggested an inflammatory process such as idiopathic hypertrophic pachymeningitis (IHP), but anterior temporal brain biopsy disclosed a relatively high proportion of meningothelial cells with islands of polyclonal inflammatory reaction consistent with a diagnosis of lymphoplasmacyte-rich meningioma (LRM), a rare variant. Among the 19 reported cases of LRM, none has shown as extensive a mass as seen in our patient. Distinguishing between LRM and IHP is important because these entities are treated differently.

Lymphoplasmacyte-rich meningioma with atypical invasive nature

A 12-year-old boy presented with a lymphoplasmacyte-rich (LPR) meningioma in the posterior fossa. The tumor was subtotally removed. Histological examination showed the tumor had invaded the normal brain tissue despite its benign grade in the World Health Organization classification. The Ki-67 staining index using MIB-1 monoclonal antibody was relatively high. (18)F-2-fluoro-2-deoxy-D-glucose positron emission tomography revealed high uptake in the tumor. These findings indicate the atypical nature of LPR meningioma.

Intracranial Rosai-Dorfman disease in a child mimicking bilateral giant petroclival meningiomas: a case report and review of literature

OBJECTIVES AND IMPORTANCE: Rosai-Dorfman disease (RDD) is a rare but distinctive entity of unknown etiology; isolated intracranial RDD is uncommon. Of 37 reported intracranial RDD cases, only three were reported in children.

CLINICAL PRESENTATION

We report an unusual case of a 15-year-old boy presenting with 4 months history of raised intracranial pressure with visual deterioration. Computed tomography and magnetic resonance imaging revealed bilateral petroclival enhancing lesions with cavernous sinus extension mimicking meningioma. However, histological examination was diagnostic of RDD.

INTERVENTION

The patient underwent extended right-sided middle fossa approach and near-total tumor removal from petroclival region and cavernous sinus on both sides in two stages 6 weeks apart.

CONCLUSION

Ours is the first case of pediatric isolated intracranial RDD presenting with giant bilateral petroclival masses successfully managed with bilateral extended middle fossa approach in two stages. An optimal treatment for RDD is not established, but complete surgical resection alone seems effective.

Sphenoid ridge lymphoplasmacyte-rich meningioma

There are numerous histologic variants of meningioma. Among the more uncommon are intracranial masses composed of meningiomatous and plasma cell-lymphocytic elements. We report a 22-year-old woman with lymphoplasmacyte-rich meningioma who initially presented with dizziness and progressive headache. Neuroradiologic images revealed typical meningiomas of the sphenoid ridge with extensive perifocal edema. Complete macroscopic removal of the tumor was performed. Histologic examination revealed a meningioma with massive infiltrates of plasma cells and lymphocytes. Brain computed tomography on the 6th postoperative day revealed total removal of the tumor with marked reduction of brain edema. Complete resolution of symptoms occurred with no evidence of tumor recurrence during 2 years of follow-up.

Intracranial plasma cell granuloma

Plasma cell granulomas (PCGs) are benign, inflammatory masses of unknown etiology composed of polyclonal mature plasma and lymphoid cells. The lung is their most common location, and occurrence within the cranial cavity is extremely rare. We report the case of an 11-year-old girl who presented with seizures and was diagnosed as having a dural-based right frontal tumor that extended toward the sagittal sinus and the falx. The lesion was totally excised, together with the abnormal dura. A limited cortical excision was also performed using electrocorticographic guidance. Histopathologic diagnosis of intracranial plasma cell granuloma was reached after extensive immunohistochemical tests and electron microscopy. This is the third case of PCG with description of changes in the neighboring cerebral tissue. Although PCGs are well-circumscribed lesions, lymphoplasmocytic inflammation, neuronal loss, and reactive gliosis occur within the adjacent cortex. Disturbed cortical lamination, as we have observed, appears to be a histological finding that has not been described previously.

Chordoid meningioma: a clinicopathologic study of 42 cases

The term chordoid meningiomas was first used by Kepes et al. in 1987 to describe a meningeal tumor in young patients associated with microcytic anemia and/of dysgammaglobulinemia. Such tumors were composed of spindle or epithelioid cells disposed in chordoma-like clusters and cords in a myxoid matrix and often featured a prominent lymphoplasmacellular infiltrate. Our study includes 42 chordoid meningiomas that represented 0.5% of all meningiomas operated at Mayo Clinic during the interval 1975 to 1997. The male to female ratio was 1:1 and the age range was 12 to 77 years (mean, 47.4 yrs). Only two (5.2%) occurred in children. The majority (88%) were large and supratentorial. No manifestation of systemic disease was noted. Chordoid elements comprised 10% to 100% of the tumors: 34 (81%) were more than 50% chordoid. Thirty-seven tumors (88%) were classified as typical and five as atypical. Lymphoplasmacytic infiltrates varied, being moderate in 10 cases (23.8%), mild in 15 (35.7%), and absent in 17 (40.5%). In 14 (42%) of the 33 cases with available follow up, one or more recurrences were noted. All but one recurrent tumor had been subtotally resected. In 86% of recurrent tumors, the primary lesion was more than 50% chordoid in pattern and contained little or no inflammatory infiltrate. In our experience, chordoid meningiomas are primarily tumors of adults, lack sex predilection, are unassociated with systemic manifestations, and uniformly recur when subtotally excised.

Chordoid meningioma in a child. Case report

A case of chordoid meningioma occurring in a 15-year-old girl is presented. The patient manifested seizures as the initial symptom and subsequently exhibited subclinical microcytic hypochromic anemia. The tumor, located in the falcotentorial region and associated with diffuse edema, was totally resected. On histological examination of the surgical specimen, the clustering pattern of partly vacuolated cells in the mucoid stroma mimicked chordoma; however, positive staining of individual cells for vimentin and epithelial membrane antigen led to a diagnosis of meningioma. Interestingly, the tumor cells were surrounded by a periodic acid-Schiff- and type IV collagen-positive substance. Electron microscopy demonstrated a strikingly dense and thick basal lamina. The patient's microcytic hypochromic anemia disappeared after the tumor was removed. Both the clinical and pathological features of this case resemble those of chordoid meningioma, a rare meningioma variant.

Lymphoplasmacyte-rich meningioma with clinical resemblance to inflammatory pseudotumor. Report of two cases

Two cases of lymphoplasmacyte-rich meningioma manifesting clinical and radiological characteristics unusual for a meningioma are reported. The patient in Case 1 was a 22-year-old man with a 9-year history of bilateral visual disturbances and recent dyspnea. An en plaque skull base mass, which was partially resected, was found at surgery to extend down from the planum sphenoidale into the spinal canal to C-5. Seven years later most of the residual mass in the spinal canal had disappeared, although a localized round tumor recurred at C2-3. The patient in Case 2 was a 24-year-old woman with an original diagnosis of clival meningioma, which recurred as multiple skull base lesions that spontaneously regressed in 10 months. These two cases and others reported in the literature indicate that lymphoplasmacyte-rich meningiomas may manifest peculiar biological behavior more typical of intracranial granulomas than of meningiomas.