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Presented by Peter Illei, M.D. and prepared by Danielle Wehle, M.D.
Case 3: The patient is a 79 year-old male who presented with a history of prostate carcinoma and Hodgkin’s Lymphoma.
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1. Question
Week 284: Case 3
The patient is a 79 year-old male who presented with a history of prostate carcinoma and Hodgkin’s Lymphoma. He presented to the neurology service complaining of pressure behind the left thigh as well as headaches on the left side. There were occasional hot flashes as well. The symptoms began a year ago and he also experienced some weakness on the left side while walking. An MRI scan was obtained and revealed a left sided meningeal mass./images/pbi925064a.jpg
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/images/pbi925064d.jpgCorrect
Answer: Meningioma, WHO grade II
Histology: Clinically and on imaging the lesion was felt to be most likely a meningioma, however, the possibility of metastatic carcinoma or involvement by lymphoma could not be excluded. Histologically, the tumor is a hypercellular meningioma with solid growth pattern and focally prominent nuclear atypia. The mitotic rate is variable and is ranging from areas where it’s less than 1 mitosis per 10 HPF to areas with 2-3 mitosis per 10 HPF. Immunostains for Ki67 shows increased activity with approximately15% of the cells positive.
Discussion: Based on these findings this tumor is best characterized as an atypical meningioma (WHO grade 2). Atypical meningiomas are tumors that show increased mitotic activity (4 or more mitosis per 10 HPF) or tumors that have 3 or more of the following features: increased cellularity, small cells with high N/C ratio, prominent nucleoli, sheet-like growth pattern, and necrosis. The current case exhibits sheet-like patternless growth, hypercellularity, focal atypia and increased proliferative activity. Meminigiomas are most common in middle-aged and elderly patients. Overall there is an increased incidence of meningioma in females, whereas atypical and anaplastic meningiomas are more common in males. Tumor grades (WHO 1-3) correlate well with rate of recurrence. Approximately17-20% benign (WHO grade1) meningiomas recur, whereas approximately 29-40% of atypical meningiomas will recur. The recurrence rate for anaplastic meningiomas (WHO grade 3) is 60-80%. While it’s not possible to establish universal values for determining recurrence, Ki67 labeling indices above 5-10% have increased risk for recurrence and therefore should be diagnosed as atypical meningiomas.
Incorrect
Answer: Meningioma, WHO grade II
Histology: Clinically and on imaging the lesion was felt to be most likely a meningioma, however, the possibility of metastatic carcinoma or involvement by lymphoma could not be excluded. Histologically, the tumor is a hypercellular meningioma with solid growth pattern and focally prominent nuclear atypia. The mitotic rate is variable and is ranging from areas where it’s less than 1 mitosis per 10 HPF to areas with 2-3 mitosis per 10 HPF. Immunostains for Ki67 shows increased activity with approximately15% of the cells positive.
Discussion: Based on these findings this tumor is best characterized as an atypical meningioma (WHO grade 2). Atypical meningiomas are tumors that show increased mitotic activity (4 or more mitosis per 10 HPF) or tumors that have 3 or more of the following features: increased cellularity, small cells with high N/C ratio, prominent nucleoli, sheet-like growth pattern, and necrosis. The current case exhibits sheet-like patternless growth, hypercellularity, focal atypia and increased proliferative activity. Meminigiomas are most common in middle-aged and elderly patients. Overall there is an increased incidence of meningioma in females, whereas atypical and anaplastic meningiomas are more common in males. Tumor grades (WHO 1-3) correlate well with rate of recurrence. Approximately17-20% benign (WHO grade1) meningiomas recur, whereas approximately 29-40% of atypical meningiomas will recur. The recurrence rate for anaplastic meningiomas (WHO grade 3) is 60-80%. While it’s not possible to establish universal values for determining recurrence, Ki67 labeling indices above 5-10% have increased risk for recurrence and therefore should be diagnosed as atypical meningiomas.
