PMC6159254_01
MRI with and without contrast of the brain, top row left to right sagittal T1, axial T2, fluid-attenuated inversion-recovery and bottom row left to right axial T1 precontrast, axial T2 postcontrast, coronal T1 postcontrast. MRI demonstrates recurrent multilobulated heterogeneous mass with associated oedema and avid enhancement. There is extension into the falx-tentorial region and likely involvement of the superior sagittal and straight sinuses. There is mass effect on the corpus callosum posteriorly.
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Subsequent CT revealed both pulmonary and pleural components, and MRI of the brain demonstrated recurrent brain mass in area of previous surgical resection (fFigure 1).
Positron emission tomography-CT obtained within 1 year of figure 1 demonstrates multiple foci of abnormal fludeoxyglucose uptake in both lungs and pleura, which correspond to conglomerate masses on concurrent CT. Maximum SUV = 11.1. Also noted is extensive involvement of hilar, mediastinal, retrocrural and upper abdomen lymph nodes as well as partially visualized T12 vertebral body involvement. Right iliac bone involvement is not seen on provided images. Left pleural biopsy resulted in spindle cell neoplasm with pathology similar to intracranial tumour resection specimen and previous intracranial tumour resection specimen (not included).
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SVU within nodules involving the lungs, pleura and epiphrenic/retrocrural lymph nodes (Figure 2). Subsequent left pleural biopsy revealed spindle cell neoplasm with pathology similar to findings from previous intracranial resection specimen.
Haematoxylin and eosin stained histologic slides of left pleural soft tissue nodule biopsy sample, with top row left to right 4x, 10x, and 40x magnification of resected intracranial mass demonstrating proliferation of spindled meningothelial cells with an excess of 35 mitoses per 10 HPF (high power field), compatible with anaplastic meningioma (WHO 3). Bottom row left to right 4x, 10x and 40x magnification of left pleural nodule biopsy consistent with low to intermediate grade malignant spindle cell neoplasm with similar morphological appearance to resected intracranial meningioma.
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Immunohistochemical staining results included focal dot-like positive epithelial membrane antigen (EMA) stain, high MIB-1 (Mindbomb E3 ubiquitin protein ligase 1) proliferation index up to 45% in more active areas, glial fibrillary acidic protein (GFAP) staining suggestive of multifocal areas of invasion of the brain, negative CD34 ruling out the possibility of solitary fibrous tumour and negative S-100 staining (Figures 3 and 4).
Immunohistochemical staining of left pleural nodule biopsy sample with epithelial membrane antigen (top left) demonstrates focal weak dot-like positive stain. Epithelial membrane antigen stain is a typical marker of meningioma, with decreased expression often seen with anaplastic meningioma and recurrent meningioma. Staining with S-100 (bottom right) is negative, consistent with meningioma.
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Immunohistochemical staining results included focal dot-like positive epithelial membrane antigen (EMA) stain, high MIB-1 (Mindbomb E3 ubiquitin protein ligase 1) proliferation index up to 45% in more active areas, glial fibrillary acidic protein (GFAP) staining suggestive of multifocal areas of invasion of the brain, negative CD34 ruling out the possibility of solitary fibrous tumour and negative S-100 staining (Figures 3 and 4).