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Zeng Y, Zhang J, Jian W, Zhang Y, Yang Y, Li R, Fu Q. Rhabdoid meningioma with a history of Budd-Chiari syndrome: a case report and review of the literature. Front Oncol 2023; 13:1209244. [PMID: 37503325 PMCID: PMC10370419 DOI: 10.3389/fonc.2023.1209244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/21/2023] [Indexed: 07/29/2023] Open
Abstract
Background Rhabdoid meningioma and Budd-Chiari syndrome are both extremely rare, and there is no report describing the two diseases occurring in the same patient thus far. Herein, we showed an unusual case of rhabdoid meningioma with a history of Budd-Chiari syndrome. Case presentation The man was found to have abnormal liver function during physical examination in 2016 at 36 and was not paid attention to it. In 2019, he went to Beijing YouAn Hospital Affiliated to Capital Medical University for the decompensation of cirrhosis and was diagnosed with Budd-Chiari syndrome, subsequent angiography of the inferior vena cava combined with balloon dilatation were performed, the anticoagulation and hepatoprotective therapy were performed for a long time. When he turned 40 who had magnetic resonance imaging (MRI) that showed a left frontotemporal lobe space-occupying lesion, and postoperative pathological examination confirmed rhabdoid meningioma. He underwent surgery and postoperative adjuvant radiotherapy, but then he developed severe psychiatric symptoms and eventually succumbed to a lung infection two months after treatment. Conclusions Budd-Chiari syndrome and Rhabdoid meningiomas are both extremely rare diseases. To the best of our knowledge, there is no report that the two rare diseases occurred in the same patient, and this is the first case. However, whether there is any link between the two diseases is unclear, more researches are needed to confirm it in the future.
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Affiliation(s)
- Ying Zeng
- Department of Radiation Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jing Zhang
- Department of Radiation Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Wei Jian
- Department of Radiation Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yong Zhang
- Department of Radiation Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ying Yang
- Department of Pathology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Rongqing Li
- Department of Radiation Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qiaofen Fu
- Department of Radiation Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, China
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2
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Garrido Ruiz PA, González-Tablas M, Pasco Peña A, Zelaya Huerta MV, Ortiz J, Otero Á, Corchete LA, Ludeña MD, Caballero Martínez MC, Córdoba Iturriagagoitia A, Fernández IC, González-Carreró Fojón J, Hernández Laín A, Orfao A, Tabernero MD. Clinical, Histopathologic and Genetic Features of Rhabdoid Meningiomas. Int J Mol Sci 2023; 24:ijms24021116. [PMID: 36674634 PMCID: PMC9865044 DOI: 10.3390/ijms24021116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/29/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
Rhabdoid meningiomas (RM) shows heterogeneous histological findings, and a wide variety of chromosomal copy number alterations (CNA) are associated with an unpredictable course of the disease. In this study, we analyzed a series of 305 RM samples from patients previously reported in the literature and 33 samples from 23 patients studied in our laboratory. Monosomy 22-involving the minimal but most common recurrent region loss of the 22q11.23 chromosomal region was the most observed chromosomal alteration, followed by losses of chromosomes 14, 1, 6, and 19, polysomies of chromosomes 17, 1q, and 20, and gains of 13q14.2, 10p13, and 21q21.2 chromosomal regions. Based on their CNA profile, RM could be classified into two genetic subgroups with distinct clinicopathologic features characterized by the presence of (1) chromosomal losses only and (2) combined losses and gains of several chromosomes. The latter displays a higher frequency of WHO grade 3 tumors and poorer clinical outcomes.
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Affiliation(s)
- Patricia Alejandra Garrido Ruiz
- Neurosurgery Service of the University Hospital of Salamanca, Surgery Department, University of Salamancaca (USAL), Paseo de la Transición Española, 37007 Salamanca, Spain
- Institute for Biomedical Research of Salamanca, IBSAL University Hospital of Salamanca, Paseo de San Vicente, 58-182, 10ªPlanta, 37007 Salamanca, Spain
| | - María González-Tablas
- Institute for Biomedical Research of Salamanca, IBSAL University Hospital of Salamanca, Paseo de San Vicente, 58-182, 10ªPlanta, 37007 Salamanca, Spain
- Centre for Cancer Research (CIC-IBMCC; CSIC/USAL; IBSAL) and Department of Medicine, Campus Miguel de Unamuno, University of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Networking Centre on Cancer—CIBERONC (CB16/12/00400), Institute of Health Carlos III, C. Sinesio Delgado, 4, 28029 Madrid, Spain
| | - Alejandro Pasco Peña
- Pathology Service of the University Hospital of Pamplona, Universidad Pública de Navarra, C. de Irunlarrea, 3, 31008 Navarra, Spain
| | - María Victoria Zelaya Huerta
- Pathology Service of the University Hospital of Pamplona, Universidad Pública de Navarra, C. de Irunlarrea, 3, 31008 Navarra, Spain
| | - Javier Ortiz
- Pathology Service of the University Hospital of Salamanca, Cell Biology and Pathology Department, Paseo de la Transición Española, 37007 Salamanca, Spain
| | - Álvaro Otero
- Neurosurgery Service of the University Hospital of Salamanca, Surgery Department, University of Salamancaca (USAL), Paseo de la Transición Española, 37007 Salamanca, Spain
- Institute for Biomedical Research of Salamanca, IBSAL University Hospital of Salamanca, Paseo de San Vicente, 58-182, 10ªPlanta, 37007 Salamanca, Spain
| | - Luis Antonio Corchete
- Institute for Biomedical Research of Salamanca, IBSAL University Hospital of Salamanca, Paseo de San Vicente, 58-182, 10ªPlanta, 37007 Salamanca, Spain
| | - María Dolores Ludeña
- Institute for Biomedical Research of Salamanca, IBSAL University Hospital of Salamanca, Paseo de San Vicente, 58-182, 10ªPlanta, 37007 Salamanca, Spain
- Pathology Service of the University Hospital of Salamanca, Cell Biology and Pathology Department, Paseo de la Transición Española, 37007 Salamanca, Spain
| | | | - Alicia Córdoba Iturriagagoitia
- Pathology Service of the University Hospital of Pamplona, Universidad Pública de Navarra, C. de Irunlarrea, 3, 31008 Navarra, Spain
| | | | | | - Aurelio Hernández Laín
- Pathology Service of the University Hospital 12 Octubre, Universidad Complutense, Av. de Córdoba, s/n, 28041 Madrid, Spain
| | - Alberto Orfao
- Institute for Biomedical Research of Salamanca, IBSAL University Hospital of Salamanca, Paseo de San Vicente, 58-182, 10ªPlanta, 37007 Salamanca, Spain
- Centre for Cancer Research (CIC-IBMCC; CSIC/USAL; IBSAL) and Department of Medicine, Campus Miguel de Unamuno, University of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Networking Centre on Cancer—CIBERONC (CB16/12/00400), Institute of Health Carlos III, C. Sinesio Delgado, 4, 28029 Madrid, Spain
| | - María Dolores Tabernero
- Institute for Biomedical Research of Salamanca, IBSAL University Hospital of Salamanca, Paseo de San Vicente, 58-182, 10ªPlanta, 37007 Salamanca, Spain
- Centre for Cancer Research (CIC-IBMCC; CSIC/USAL; IBSAL) and Department of Medicine, Campus Miguel de Unamuno, University of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Networking Centre on Cancer—CIBERONC (CB16/12/00400), Institute of Health Carlos III, C. Sinesio Delgado, 4, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-923-29-48-11; Fax: +34-923-29-46-24
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3
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Prasad RN, Gardner UG, Yaney A, Prevedello DM, Koboldt DC, Thomas DL, Mardis ER, Palmer JD. Germline BAP1 Mutation in a Family With Multi-Generational Meningioma With Rhabdoid Features: A Case Series and Literature Review. Front Oncol 2021; 11:721712. [PMID: 34504799 PMCID: PMC8421801 DOI: 10.3389/fonc.2021.721712] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/05/2021] [Indexed: 12/15/2022] Open
Abstract
Meningioma is the most common primary brain tumor, and recurrence risk increases with increasing WHO Grade from I to III. Rhabdoid meningiomas are a subset of WHO Grade III tumors with rhabdoid cells, a high proliferation index, and other malignant features that follow an aggressive clinical course. Some meningiomas with rhabdoid features either only focally or without other malignant features are classified as lower grade yet still recur early. Recently, inactivating mutations in the tumor suppressor gene BAP1 have been associated with poorer prognosis in rhabdoid meningioma and meningioma with rhabdoid features, and germline mutations have been linked to a hereditary tumor predisposition syndrome (TPDS) predisposing patients primarily to melanoma and mesothelioma. We present the first report of a familial BAP1 inactivating mutation identified after multiple generations of a family presented with meningiomas with rhabdoid features instead of with previously described BAP1 loss-associated malignancies. A 24-year-old female presented with a Grade II meningioma with rhabdoid and papillary features treated with subtotal resection, adjuvant external beam radiation therapy, and salvage gamma knife radiosurgery six years later. Around that time, her mother presented with a meningioma with rhabdoid and papillary features managed with resection and adjuvant radiation therapy. Germline testing was positive for a pathogenic BAP1 mutation in both patients. Sequencing of both tumors demonstrated biallelic BAP1 inactivation via the combination of germline BAP1 mutation and either loss of heterozygosity or somatic mutation. No additional mutations implicated in oncogenesis were noted from either patient's germline or tumor sequencing, suggesting that the inactivation of BAP1 was responsible for pathogenesis. These cases demonstrate the importance of routine BAP1 tumor testing in meningioma with rhabdoid features regardless of grade, germline testing for patients with BAP1 inactivated tumors, and tailored cancer screening in this population.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
| | - Ulysses G Gardner
- Boonshoft School of Medicine, Wright State University, Dayton, OH, United States
| | - Alexander Yaney
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
| | - Daniel C Koboldt
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Diana L Thomas
- Department of Pathology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
| | - Elaine R Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
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4
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Nguyen DV, Duong NV, Tran TT. Rhabdoid Meningioma Metastases Cervical Lymph Nodes: A Rare Clinical Case Report and Treatment Outcome. J Investig Med High Impact Case Rep 2021; 9:23247096211029789. [PMID: 34229471 PMCID: PMC8267018 DOI: 10.1177/23247096211029789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Meningioma is the most common central nervous system tumor that usually behaves benignly and has a good prognosis after treatment with tumor gross resection and with or without adjuvant therapy. Malignancy in meningioma is very rare and extracranial metastasis to cervical lymph nodes is even rarer. We report a case of a 40-year-old woman diagnosed with metastatic rhabdoid meningioma. She had recurrent primary disease and metastasis to bilateral cervical lymph nodes. She previously had intracranial tumor twice resected. We also review relevant, previously published cases in the literature. I hope you find these suggestions helpful.
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Affiliation(s)
- Dang Van Nguyen
- Hanoi Medical University, Hanoi, Vietnam.,Vietnam National Cancer Hospital, Hanoi, Vietnam
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5
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Du HG, Phuoc VX, Hoang ND, Tan LD, Van Trung N. Triad of meningothelial meningioma, rhabdoid meningioma and ependymoma: successful management of an extremely rare case. J Surg Case Rep 2020; 2020:rjaa267. [PMID: 32855801 PMCID: PMC7444614 DOI: 10.1093/jscr/rjaa267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/16/2020] [Accepted: 06/30/2020] [Indexed: 11/12/2022] Open
Abstract
An 8-year-old girl was admitted with four limb weakness for 2 months. Hyperactive reflexes were observed in all four limbs, and positive Hoffmann's signs were revealed. An MRI spine with the coronal slide detected two tumors, first in the intradural and intramedullary space at the C2-C4 level and the second in the intradural and extramedullary space at the C5-C7 level. Axial T1W contrast MRI brain showed a tumor in the left parietal region. The patient underwent spine surgery first and following by brain surgery. No invasive lesions were remarked during surgery. Histological findings showed meningothelial meningioma and ependymoma from the spine and rhabdoid meningioma from the brain. Two months after the second surgery, the patient recovered fully with no symptoms and was able to participate in all regular activities in life. This work is the first report of a mixed tumor with distinct spinal meningioma and ependymoma components occurring in the cervical spinal cord at the C2-C7 level and coexisting with cranial meningioma. The remarkable result was that the patient fully recovered without any symptoms after receiving two surgeries.
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Affiliation(s)
- Hoang Gia Du
- Department of Orthopedic and Spine Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Vu Xuan Phuoc
- Department of Orthopedic and Spine Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Nguyen Duc Hoang
- Department of Orthopedic and Spine Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Le Dang Tan
- Department of Orthopedic and Spine Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Nguyen Van Trung
- Department of Orthopedic and Spine Surgery, Bach Mai Hospital, Hanoi, Vietnam
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6
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Alzoubi H, Gianno F, Giangaspero F, Bartolini D, Riccioni L, Miele E, Antonelli M. Dural-based atypical teratoid/rhabdoid tumor in an adult: DNA methylation profiling as a tool for the diagnosis. CNS Oncol 2020; 9:CNS54. [PMID: 32602741 PMCID: PMC7341157 DOI: 10.2217/cns-2020-0006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Atypical teratoid/rhabdoid tumor (ATRT) is a malignant CNS embryonal tumor that mostly occurs in childhood, adult cases are rare. We report a case of a 23-year-old male with an extra-axial dura-based lesion in the left frontal area, previously diagnosed as gliosarcoma. After 6 years, the patient had a recurrence and the previous slides were reviewed. Tumor was positive for vimentin and negative for INI1. The differential diagnosis for this extra-axial tumor with long survival was rhabdoid meningioma with INI1 loss or ATRT. DNA methylation profiling was performed to reach the final and the most definitive diagnosis; the result was ATRT. Our case suggests the usefulness of DNA methylation profiling for diagnosing challenging CNS tumors.
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Affiliation(s)
- Hiba Alzoubi
- Department of Basic Medical Sciences, Faculty of medicine, Yarmouk University, Irbid, Jordan.,Department of Radiological, Oncological & Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesca Gianno
- Department of Radiological, Oncological & Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Felice Giangaspero
- Department of Radiological, Oncological & Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed-Mediterranean Neurological Institute, Pozzilli, Italy
| | | | - Luca Riccioni
- Department of Pathology, Bufalini Hospital, Cesena, Italy
| | - Evelina Miele
- Department of Paediatric Haematology/Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Manila Antonelli
- Department of Radiological, Oncological & Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
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Abstract
In August 2016, an 11-year-old boy presented to the authors' institution with a right orbital tumor that was located superotemporally (superolaterally) and adherent to the sclera. The patient's past medical history revealed that he had undergone 2 previous craniotomies elsewhere in June 2008 and July 2010 for a superomedially located orbital lesion that had been histopathologically diagnosed as a neurothekeoma. After the second craniotomy, the patient underwent adjuvant intensity modulated radiotherapy (IMRT) to the right medial orbit. At the authors' institution, total excision of the orbital tumor was performed via an anterior conjunctival orbitotomy. Histopathological examination revealed a rhabdoid meningioma. Review of the histopathology obtained at the time of previous tumor excisions showed that the lesion was misdiagnosed as neurothekeoma and instead represented a meningioma from the beginning. The patient was started on a regimen of oral sunitinib and remained free of recurrence at 1.5 years of follow-up. Ectopic meningioma of the orbit is a rare entity. Rhabdoid meningioma is a rarely seen subtype of meningioma, accounting for 1%-3% of all intracranial meningiomas. To the best of the authors' knowledge, this is the first case of an ectopic orbital rhabdoid meningioma reported in the literature. They suspect that tumor seeding during the previous surgeries might have played a role in the occurrence of the tumor in an orbital location not targeted by IMRT.
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Affiliation(s)
| | | | - Aylin Okçu Heper
- 2Pathology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Esra Erden
- 2Pathology, Ankara University Faculty of Medicine, Ankara, Turkey
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Mondal S, Pradhan R, Pal S, Chatterjee S, Bandyapadhyay A, Bhattacharyya D. Rhabdoid Meningioma of Brain - A Rare Aggressive Tumor. Indian J Med Paediatr Oncol 2017; 38:218-219. [PMID: 28900335 PMCID: PMC5582564 DOI: 10.4103/ijmpo.ijmpo_87_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Rhabdoid meningioma is a rare aggressive variant of meningioma, regarded as WHO Grade III type. Histologically and cytologically, it is distinctive type having abundant eosinophilic cytoplasm, cytoplasmic inclusion with eccentrically placed vesicular nuclei and prominent nucleoli. High recurrence rate and poor outcome are important features. Here, we are presenting a rare case of rhabdoid meningioma found in a recurrent meningioma of the posterior fossa in a middle-aged female. We emphasized the squash cytology and histology finding of the rare neoplasm.
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Affiliation(s)
- Sajeeb Mondal
- Department of Pathology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| | - Rajashree Pradhan
- Department of Pathology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| | - Subrata Pal
- Department of Pathology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
| | - Sharmistha Chatterjee
- Department of Oncopathology, Calcutta Medical College and Hospital, Kolkata, West Bengal, India
| | - Arindam Bandyapadhyay
- Department of Pediatrics, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
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Abolfotoh M, Tavanaiepour D, Hong C, Dunn IF, Lidov H, Al-Mefty O. Primary calcified rhabdoid meningioma of the cranio-cervical junction: A case report and review of literature. J Craniovertebr Junction Spine 2013; 3:32-7. [PMID: 23741128 PMCID: PMC3669473 DOI: 10.4103/0974-8237.110127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rhabdoid meningioma (RM) is a relatively new, rare, and aggressive subtype of meningioma, classified as Grade III malignancy in 2000, 2007 versions of WHO classification of the central nervous system. We reviewed the data available from all published cases of RMs. To the best of our knowledge, there are more than 100 published cases of RMs; none have documented extensive calcification or origin from the cranio cervical junction. We report the first case of a totally calcified (stony mass), primary RM, at the cranio cervical junction. Also, we highlighted the role of the transcondylar approach to achieve microscopic total removal of such a challenging lesion. A 37 year old female, allergic to erythromycin, presented with 5 years of progressive right upper extremity numbness and weakness, right facial numbness, and occipital pain. Imaging demonstrated a large calcified mass at the right posterior–lateral margin of the cranio cervical junction, encasing the right vertebral artery and right PICA loop. Patient underwent microscopic total resection of the lesion. Pathological diagnosis was confirmed as RM with atypical features. Subsequently, the patient received postoperative intensity modulated radiotherapy (IMRT) on the tumor bed, and close follow up imaging showed no recurrence 2 years after surgery. We report the first case of a primary RM originating from the cranial cervical junction; also, it is the first case to present with extensive calcification in this morphological subtype. We also conclude that RM has now become a feature of newly diagnosed cases and not only a disease of recurrent cases as it was thought in the past. Since RMs are typically considered aggressive, total surgical resection with close follow up and postoperative adjuvant radiation should be considered. However, the adjuvant therapy of each separate case of RM should be tailored according to its particular histopathologic profile.
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Affiliation(s)
- Mohammad Abolfotoh
- Department of Neurosurgery, Brigham and Women's Hospital, and children's hospital, Harvard Medical School, Boston MA, USA ; Department of Neurosurgery, Ain Shams University, Cairo, Egypt
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