PMC6212508_01
Initial imaging showing multiple menigniomas. Preoperative contrasted T1 and T2 MRI scans reveal multiple meningiomas. The left calcified parafalcine lobulated mass (2 x 2.2 x 3.3 cm, AP, TV, CC) was associated with vasogenic edema (red arrows in A,B, D-E). In the left frontal temporal convexity, there was a 4.5 x 2.9 x 4.1 cm (AP, TV, CC) mass with another 2.3 x 2.0 x 1.9 cm (AP, TV, CC) mass located superior to it (black arrows in B-F). In the occipital lobe, the mass was measured to be 2.6 x 2.9 x 3.9 cm (AP, TV, CC) (white arrows in A,B,E). There was an 8 mm rightward midline shift. The images seemed to suggest neurofibromatosis type 2.
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F1
An MRI scan was ordered that showed multiple masses some of which harbored hemorrhagic components: a left frontal parafalcine, calcified 2.0 x 2.2 x 3.3 cm [anteroposterior (AP), transverse (TV), craniocaudal (CC)] mass with associated vasogenic edema, a 4.5 x 2.9 x 4.1 cm (AP, TV, CC) mass in the left frontotemporal convexity with another mass measuring approximately 2.3 x 2.0 x 1.9 cm (AP, TV, CC) located just superiorly, and a 2.6 x 2.9 x 3.9 cm (AP, TV, CC) mass in the left occipital lobe (Figure 1). Additionally, there was an 8 mm left to right midline shift (Figure 1). The first surgical stage involved a left-sided craniotomy for resection of the frontal-parietal-temporal meningiomas; pathology reported WHO Grade I meningiomas with a low/moderate proliferation index (percentages of positive Ki-67 tumor nuclei: left occipital mass: 2-3%; midline frontal mass: 3-4%; and left frontal mass: 1-2%; Figure 1).
Resection of the frontal/parietal/temporal mass. Post-operative MRI contrasted T1 and T2 scans showed resection of the meningiomas in the left frontal/parietal/temporal convexity with expected post-operative changes (red arrows in A,C, not shown in B). The occipital lobe mass was visible from the sagittal view (white arrow in A).
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F2
Post-operative MRIs showed resection of the meningiomas in the left frontal/parietal/temporal convexity (Figure 2).
Resection of the occipital mass. Preoperative MRI showed a 2.6 x 2.9 x 3.9 cm (AP, TV, CC) mass in the left occipital convexity (white arrows in A-C). Immediate post-operative MRI showed removal of the mass (white arrows in D-F).
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F3
Seven months after her first-stage surgery, she underwent the second surgical stage: left occipital craniotomy for resection of a 2.9 x 2.7 x 4.2 cm (AP, TV, CC) mass (Figure 3).
Pathologic findings of meningothelial meningioma. Macroscopic view at low power magnification (10X) shows meningothelial cells that are packed together in fascicles and whorls in a syncytial pattern. The nuclei are round and uniform, and occasional psammoma bodies are noted (A). Approximately 2-3% of tumor cells nuclei are immunoreactive for Ki- 67 (Immunostainx100) (B). Some of the tumor cells are immunoreactive for PR (Immunostainx100) (C).
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F4
A specimen from the left occipital mass was sent to pathology which classified it as meningioma, WHO Grade I with a Ki-67 of 2-3% (Figure 4).
Latest imaging. Her most recent MRIs (16 months after her last surgery) show multiple enhancing extra-axial masses, stable compared to her immediate post-operative MRIs. Here is a stable 1.8 cm (superior-inferior) meningioma arising from the left posterior falx, adjacent to the prior resection cavity (red arrows in A-C). No recurrence observed.
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F5
Her most recent post-operative MRI scans at 16 months of follow up show multiple stable enhancing extra-axial masses compared to her immediate post-operative ones with no new lesions observed (Figure 5).
Imaging of her right palm mass. MRI scans showed an approximately 11 x 10 x 20 mm mass in her right palm. Plastic surgery excised the mass and pathology confirmed a benign nerve sheath tumor, consistent with Schwannoma (A,B).
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F6
MRI scans showed the mass to be approximately 11 x 10 x 20 mm (Figure 6) with unclear pathology, and the patient was referred to plastic surgery.