PMC10408638_01
Preoperative (a and b) and postoperative (c and d) gadolinium-enhanced T1-weighted magnetic resonance imaging of the first surgery (in 2016) in our institution. (a and b) Voluminous polylobulated expansive brain tumor with skull base compromise, orbital and nasal invasion. (c and d) Imaging control of gross total resection of the tumor.
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F1
He underwent surgery in a different center before reaching our institution in 2016, with a recurrent meningioma with intranasal and right orbit invasion [Figures 1a and b]. Complete exeresis was performed by double surgical approach: transcranial and endoscopic transnasal [Figures 1c and d].
Anatomical pathology images of the first surgery in 2016 (a-c). (a) Focal positivity for progesterone receptor (Immunohistochemistry, x40). (b) Increase in cellular kinetics (Ki 67 immunohistochemistry. x40). (c) Cells with syncytium formation and conspicuous nucleoli. Mitosis figures are observed (Hematoxylin and eosin stain, x40).
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F2
The histopathologic analysis revealed an atypical meningioma [Figures 2a-c].
Gadolinium-enhanced T1-weighted magnetic resonance imaging of the tumor recurrence and the neck metastasis in 2018. (a and b) A more extensive component of the expansive nasoethmoidal and orbital wall lesion can be observed. The lesion compromises the subcutaneous tissue of the nose. (c and d) Right laterocervical adenopathy compatible with metastasis (white arrow).
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F3
One year later, the patient presented with anterior skull base tumor recurrence and nasal skin infiltration, as well as pial and brain parenchyma infiltration, associated to right level II cervical lymphadenopathy [Figures 3a-d].
Brain computed tomography of anterior skull base and paranasal sinus with thin cuts where bone erosion of the tumor can be seen. Yellow lines show measures of the tumor (45.36 x 47.21 mm).
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F4
Chest and abdomen contrast tomography was performed to exclude any other metastasis; brain computed tomography showed typical bone erosion [Figure 4].
Anatomical pathology images of the second surgery in 2018 (a-e). (a) Syncytial arrangement, moderate nuclear pleomorphism (H&E, x40). (b) Nuclear pleomorphism, evident nucleoli and marked vascularization (H&E, x40). (c) Areas of tumor necrosis and nuclear pleomorphism with some pyknotic nuclei (H&E, x40). (d) Increase of cellular kinetics with "hot spots" of 12% with Ki67 (Immunohistochemistry, x40). (e) Neoplastic infiltration in lymph node. Note the presence of intranuclear vacuoles in the center of the field (H&E, x40).
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F5
The histopathologic analysis confirmed the recurrence of an atypical meningioma [Figures 5a-e].
Preoperative (a and b) and postoperative (c and d) picture of the patient in 2018. (a and b) There is a more exophytic component of the expansive nasoethmoidal and orbital lesion. (c and d) Reconstruction with free microvascular pediculated flap of anterior rectus abdominis muscle.
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F6
In this way, the pedicle was extended to 10 cm to reach the neck, where vascular anastomosis with the facial artery and the thyrolinguofacial trunk was performed without resorting to a vein graft [Figures 6a-d].
Intraoperative image, where metastatic right laterocervical adenopathy is observed.
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F7
Later, selective resection of the right cervical level II was performed [Figure 7].