Favorable Long-Term Outcomes of Chordoid Meningioma Compared With the Other WHO Grade 2 Meningioma Subtypes

BACKGROUND

WHO grade 2 meningiomas, including atypical, chordoid, and clear cell subtypes, form a heterogenous group of meningiomas with varying aggressiveness and clinical behavior.

OBJECTIVE

To demonstrate the differences of clinical-histopathological characteristics and long-term outcomes among these 3 subtypes.

METHODS

A total of 609 consecutive patients diagnosed with WHO grade 2 meningiomas (543 atypical meningiomas [AMs], 36 chordoid meningiomas [CMs], and 30 clear cell meningiomas [CCMs]) from 2010 to 2018 were enrolled in this study. We compared the clinical-histopathological characteristics and long-term outcomes in these 3 subtypes and assessed survival differences among the subtypes. Targeted panel sequencing of meningioma-relevant genes was performed in the cases of CM.

RESULTS

The patients with CCM were significantly younger than those with AM ( P < .001) and CM ( P = .016). CMs were more likely to receive gross total resection than AMs and CCMs ( P = .033). The Ki-67 index was lower ( P < .001) while the progesterone receptors-positive rate was higher ( P = .034) in CM than in AM and CCM. Importantly, survival analysis demonstrated that CM had better progression-free survival ( P = .022) and overall survival ( P = .0056) than non-CM tumors. However, the PFS of CM was still worse than WHO grade 1 meningiomas ( P < .001). Alterations in NF2 (20.6%) and KMT2C (26.5%) were associated with poorer PFS in CM ( P = .013 for NF2 ; P = .021 for KMT2C ).

CONCLUSION

Patients with CM had better long-term postoperative outcomes than the other WHO grade 2 subtypes. A lower Ki-67 index, higher PR status, higher extent of resection, and lower frequency of NF2 alteration might contribute to favorable clinical outcomes of CM.

Rare case of extracranial chordoid meningioma adjacent to the carotid sheath: illustrative case

BACKGROUND

Chordoid meningioma is a rare World Health Organization (WHO) grade 2 variant of meningioma with histological features resembling those of a chordoma. This tumor type is known for having an aggressive clinical course with a propensity for local recurrence. Most cases occur within the cranium, more specifically around the cerebral convexities. Although extracranial meningiomas of various subtypes have been documented, extracranial meningioma with a chordoid subtype is an extremely rare entity.

OBSERVATIONS

The authors herein report the case of a 51-year-old female who presented with a chief complaint of dysphagia and was found to have a neck mass abutting the carotid sheath. The patient underwent resection and final pathology results revealed a WHO grade 2 chordoid meningioma.

LESSONS

This case report demonstrates an atypical case of an extracranial chordoid meningioma adjacent to the carotid sheath. To the authors' knowledge, this is the first reported case of a chordoid meningioma occurring within the soft tissue of the neck.

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.

Chordoid Meningioma. Case Report and Review of the Literature

Chordoid meningioma is an uncommon histopathological type of meningioma, frequently associated with Castleman's syndrome. Histologically, chordoid meningiomas are similar to chordomas. Because of their high proliferative index, they present aggressive biological behavior and high risk of postoperative recurrence. We report a case of chordoid meningioma in an adult patient without Castleman's syndrome manifestation. As its chordoid feature is related with a rapid recurrence after incomplete removal, meticulous histopathological examination is crucial for the adequate postoperative treatment plan.

A Case of Tuberculum Sellae Chordoid Meningioma Treated via Extended Endoscopic Endonasal Trans-sphenoidal Surgery

A 68-year-old female was admitted to our hospital with right-sided hemianopsia. Magnetic resonance imaging (MRI) demonstrated a well-enhanced tuberculum sellae region tumor. The patient underwent surgical tumor resection via an extended endoscopic endonasal trans-sphenoidal approach and the tumor was totally removed. The mass was extremely soft and there was no clear attachment between it and the dura mater. Furthermore, the histopathological findings obtained for the tumor during intra-operative rapid diagnosis were divergent from typical meningioma. We therefore diagnosed the tumor intra-operatively as a pituitary adenoma. However, the post-operative pathological diagnosis for the tumor was chordoid meningioma (CM). CM is a rare subtype of meningioma, and most of such tumors arise in the convexity. In the preoperative MRI in the present case, meningioma was suspected; however, since we did not consider CM for differential diagnosis, we failed to reach an accurate diagnosis during the operation. Tuberculum sellae CM is very rare, and only a few cases have been reported previously. The surgical strategy will differ greatly depending on whether the tumor is a meningioma or a pituitary adenoma, especially when treatment involves the dura mater. The pre and/or intra-operative diagnosis is thus very important for developing an accurate treatment strategy. We report here the details of our rare case and describe the intra-operative features of tuberculum sellae CM.

Mutation Status and Epithelial Differentiation Stratify Recurrence Risk in Chordoid Meningioma-A Multicenter Study with High Prognostic Relevance

Chordoid meningioma is a rare WHO grade II histologic variant. Its molecular alterations or their impact on patient risk stratification have not been fully explored. We performed a multicenter, clinical, histological, and genomic analysis of chordoid meningiomas from 30 patients (34 tumors), representing the largest integrated study to date. By NHERF1 microlumen immunohistochemical detection, three epithelial differentiation (ED) groups emerged: #1/fibroblastic-like, #2/epithelial-poorly-differentiated and #3/epithelial-well-differentiated. These ED groups correlated with tumor location and genetic profiling, with NF2 and chromatin remodeling gene mutations clustering in ED group #2, and TRAF7 mutations segregating in ED group #3. Mutations in LRP1B were found in the largest number of cases (36%) across ED groups #2 and #3. Pathogenic ATM and VHL germline mutations occurred in ED group #3 patients, conferring an aggressive or benign course, respectively. The recurrence rate significantly correlated with mutations in NF2, as single gene, and with mutations in chromatin remodeling and DNA damage response genes, as groups. The recurrence rate was very high in ED group #2, moderate in ED group #3, and absent in ED group #1. This study proposes guidelines for tumor recurrence risk stratification and practical considerations for patient management.

Epithelial differentiation with microlumen formation in meningioma: diagnostic utility of NHERF1/EBP50 immunohistochemistry

Meningioma is a primary brain tumor arising from the neoplastic transformation of meningothelial cells. Several histological variants of meningioma have been described. Here we show that NHERF1/EBP50, an adaptor protein required for structuring specialized polarized epithelia, can distinguish meningioma variants with epithelial differentiation. NHERF1 decorates the membrane of intracytoplasmic lumens and microlumens in the secretory variant, consistent with a previously described epithelial differentiation of this subtype. NHERF1 also labels microlumens in chordoid meningioma, an epithelial variant not previously known to harbor these structures, and ultrastructural analysis confirmed the presence of microlumens in this variant. NHERF1 associates with the ezrin-radixin-moesin (ERM)-NF2 cytoskeletal proteins, and moesin but not NF2 was detectable in the microlumens. In a meningioma series from 83 patients, NHERF1 revealed microlumens in 87.5% of the chordoid meningioma (n = 25) and meningioma with chordoid component (n = 7) cases, and in 100% of the secretory meningioma cases (n = 12). The most common WHO grade I meningioma variants lacked microlumens. Interestingly, 20% and 66.6% of WHO grades II (n = 20) and III (n = 3) meningiomas, respectively, showed microlumen-like NHERF1 staining of ultrastructural tight microvillar interdigitations, mainly in rhabdoid, papillary-like or sheeting areas, revealing a new subset of high grade meningiomas with epithelial differentiation. NHERF1 failed to detect microlumens in 12 additional cases of chordoid glioma of the 3rd ventricle, chordoma and chondrosarcoma, neoplasms that may mimic the histological appearance of chordoid meningioma. This study uncovers features of epithelial differentiation in meningioma and proposes NHERF1 immunohistochemistry as a method of discriminating chordoid meningioma from neoplasms with similar appearance.

Innate immunity may play a role in growth and relapse of chordoid meningioma

Chordoid meningioma (CM) is a rare subtype of meningioma, which represents only 0.5% of all meningiomas. It is classified as Grade II according to the World Health Organization classification because of its tendency to relapse. Pathological and clinical characteristics have been studied in order to forecast the future evolution of the lesions. However, information about infiltration of macrophagic elements and mast cells is very scarce. The authors analyzed the immunohistochemical patterns of three cases and a relapse of CM, in order to verify whether infiltrating macrophages are in a polarized state and what would be the proportion between such elements and mastocytes. Results suggest that macrophages in CMs are mainly in a non-polarized or M2 state and their abundance might be associated with a major potential of relapse; additionally, there is an inverse correlation between the number of mast cells and macrophages. Further studies are requested in order to confirm these intriguing data.

Spinal chordoid meningioma in a child: A case report and review of the literature

As an uncommon subtype of meningioma, chordoid meningioma (CM) of the spinal canal is extremely rare. There have been only two reported cases of intraspinal CM in the literature, and this lesion has not been previously reported in the pediatric age group. To the best of our knowledge, the present study reports the first case of spinal chordoid meningioma in a pediatric patient. A 12-year-old female presented with a 3-month history of progressive numbness and weakness in the right-side limbs, and intermittent pain in the neck and right shoulder. Spinal magnetic resonance imaging (MRI) revealed an intraspinal lesion at the C2-3 level with irregularly heterogeneous enhancement. The patient underwent a C2-3 laminotomy. Due to adhesion to the dura and proximity to the vertebral artery, the tumor was partially removed intraoperatively. The post-operative course was uneventful and the symptoms were apparently relieved. The patient experienced recurrence 5 years subsequent to surgery. MRI revealed an extradural regrown tumor at the C2-5 level. Partial removal combined with radiotherapy was performed. However, the patient experienced progression of tetraplegia and succumbed to severe pneumonia and respiratory failure 5 months subsequent to the second surgery. In the present study, the clinicoradiological findings and treatment outcome of this rare entity are discussed, in addition to a review of the relevant literature. Spinal CMs should be included in the differential diagnosis of intraspinal tumors of the pediatric spine. Multidisciplinary treatment, consisting of total surgical removal and adjuvant radiotherapy, should be considered due to the aggressive nature of this abnormality and the risk of long-term recurrence.