Cerebral edema associated with meningiomas: the role of peritumoral brain tissue

We undertook a morphological study of small pieces of peritumoral brain tissue removed from seven patients with meningiomas submitted to surgery. All patients had cerebral edema, as shown by preoperative C.T. and N.M.R.. Control specimens were obtained from five patients undergoing ventriculo-peritoneal shunt. The tissue fragments were fixed in glutaraldehyde-osmium and embedded in Epon. In semi-thin sections observed under light microscopy peritumoral endothelial cells exhibited voluminous cytoplasm and nucleus. Morphometrical evaluation confirmed that these endothelial cell nuclei were significantly larger than controls. Under the electron microscope those cells showed nuclei rich in euchromatin and cytoplasm rich in pinocytotic vesicles. The morphological changes observed suggest a process of dedifferentiation of brain peritumoral capillary cells and are compatible with an increase in permeability. Both events, which may be due to diffusion of a tumoral vascular permeability factor, favour the hypothesis that peritumoral brain tissue contributes to edema fluid that accumulates around meningiomas.

Neural interaction in the human spiral ganglion: a TEM study

A TEM study was performed on freshly fixed human spiral ganglions (HSG) collected during skull base surgery. This technique gives well preserved tissue for ultrastructural analysis. Unlike spiral ganglion cells in mature animals so far studied, most HSG cells lack a myelin coat, but are surrounded by a thin rim of Schwann cell (SC) cytoplasm. In the region of maximal innervation density (upper basal and middle turn), HSG cells were frequently ensheathed by the same Schwann cell, forming a "unit-like" structure. In this region the cells often showed signs of physical interaction where the SCs were frequently incompletely developed ("gaps") so that the cell membranes of adjacent ganglion cells (sometimes as many as four in one section plane) were in direct apposition. In one thin section as many as 20 of 100 ganglion cells were found to face the cell membrane, at any point, of an adjacent cell. At these "gaps" in the SC, complexes of cell membrane specializations occurred between individual HSG cells. The same nerve junctions were also found between unmyelinated nerve fibres and the body of large ganglion cells. Our findings may challenge the view that afferent information in the acoustic nerve is conveyed uninterrupted to the CNS at the level of the spiral ganglion.

Establishment and characterization of cell lines derived from a transplantable rat malignant meningioma: morphological heterogeneity and production of nerve growth factor

A cell line (KMY-J) was established from a transplantable tumor (MM-KMY) derived from a spontaneous malignant meningioma arising in an aged F344 rat, and three cloned cell lines (KMY-1, KMY-2 and KMY-3) were induced from the parent KMY-J. Morphologically, KMY-J and tumors induced in syngeneic rats by KMY-J showed cell pleomorphism. All neoplastic cells in KMY-J and its tumors were immunoreactive to vimentin; occasional cells reacted to ED1 (rat macrophage/histiocyte-specific antibody) and alpha-smooth muscle actin (alpha-SMA), indicating expression of histiocytic or myofibroblastic immunophenotypes of meningioma cells. In contrast, KMY-1, KMY-2 and KMY-3 consisted of a uniform cell population differing from each other. KMY-1-induced tumors were similar histologically to meningeal fibrosarcomas. Dendritic cells seen in KMY-2 cultures gave an appearance of arachnoid trabecular cells. In KMY-3 and its tumors, large round cells and multinucleated giant cells were predominant. Cells of these cloned cell lines also reacted to vimentin, but were negative for ED1 and alpha-SMA. By the bioassay using PC12 cells and reverse transcription-polymerase chain reaction for nerve growth factor (NGF) mRNA, production of NGF was demonstrated in the parent and cloned cell lines. The present cell lines may prove useful for studying the histological features of meningeal tumors and the bioactive factors produced by meningeal cells.

Oncocytic meningioma

Six cases of meningioma showing oncocytic changes are described. The lesions were composed mostly of sheets, nests, and cords of large polygonal cells with finely granular eosinophilic cytoplasm rich in mitochondria. Neoplastic cells showed nuclear pleomorphism with prominent nucleoli. Necrosis and high mitotic rate were present in the majority of cases. Oncocytic differentiation was demonstrated by conventional histology, immunocytochemistry, electron microscopy, and Western-blot analysis. Oncocytic meningiomas showed an aggressive behavior; recurrences were observed in three cases, and invasion of brain cortex was evident in other two cases.

Solitary fibrous tumor of the spinal cord

We report a case of primary solitary fibrous tumor occurring in the intramedullary thoracic spinal cord in a 47-year-old man. The tumor predominately consisted of spindle cells separated by abundant collagen; a few areas of hemangiopericytomatous morphology were also present. The diagnosis was confirmed by immunohistochemistry and electron microscopy. The tumor was reactive to vimentin and CD34 but was negative for glial fibrillary acid protein (GFAP), S-100, smooth muscle actin, epithelial membrane antigen, HMB-45, myelin basic protein, and keratin; ultrastructural examination showed fairly undifferentiated cells within a collagenous matrix, few tight junctions, and sparse extravascular basement membrane. The occurrence of this tumor within the spinal cord parenchyma and in other extraserosal sites emphasizes the current belief that solitary fibrous tumors arise from mesenchymal tissues and are not restricted to the pleura and other serosal surfaces. Furthermore, solitary fibrous tumor is an entity that must be considered in the differential diagnosis of spindle cell central nervous system neoplasms.

Intracytoplasmic chromophobe inclusion bodies in an anaplastic meningioma

Intracytoplasmic inclusion bodies are rarely found in meningiomas. A 74-year-old woman had an anaplastic meningioma with intracytoplasmic chromophobe inclusion bodies (CIB) histologically. These CIB were various shapes, e.g. round, teardrop-like, fusiform, horse-shoe-like, crescentic and perinuclear. The size of CIB ranged from 7 to 14 microns and the nuclei of the tumor cells with CIB were often eccentric. Most CIB were immunopositive only for vimentin, staining more intensely than surrounding cytoplasm in a comparative study using adjacent sections stained with hematoxylin-eosin and vimentin. CIB showed loosely textured filamentous structures which were in parallel and entangled arrangements ultrastructurally. The diameter of the filaments was 13-14 nm and they were thicker than normal intermediate filaments. Moreover, these filaments appeared to be studded with granular and fuzzy substances. These findings suggest that CIB are mainly composed of abnormally synthesized and arranged vimentin filaments.

Prostaglandin D synthase (beta-trace) in human arachnoid and meningioma cells: roles as a cell marker or in cerebrospinal fluid absorption, tumorigenesis, and calcification process

Glutathione-independent prostaglandin D synthase (PGDS) is an enzyme responsible for biosynthesis of prostaglandin D2 in the CNS and is identical to a major cerebrospinal fluid protein, beta-trace. Although PGDS has been identified recently in rat leptomeninges, little information is available about human meninges or meningiomas. Here, we report PGDS to be expressed consistently in 10 human arachnoid and arachnoid villi and in 21 meningiomas by immunohistochemistry, Western blot, and reverse transcription (RT)-PCR analyses. In arachnoid, PGDS immunoreactivity was seen in arachnoid barrier cells but was negligible in arachnoid trabecula and pia mater. In contrast, in arachnoid villi, PGDS was seen in core arachnoid cells rather than in the cap cell cluster or arachnoid cell layer. Meningioma cells also showed intense immunoreactivity in the perinuclear region, and it was often concentrated within meningocytic whorls and around calcifying psammoma bodies. Immunoelectron microscopic data, when compared with the ultrastructure, showed that PGDS was localized at rough endoplasmatic reticulum of arachnoid and meningioma cells. Western blot showed a 29 kDa immunoreactive band indicating PGDS, but the extent of expression was variable from case to case, which was compatible with immunohistochemical data. RT-PCR revealed PGDS gene expression in all meningiomas studied, regardless of histological subtypes, and also in human arachnoid villi. Because human arachnoid and meningioma cells exclusively express PGDS, it can be considered their specific cell marker. These results show functional differences in various types of meningeal cells attributable to differences in PGDS expression.

Morphological and ultrastructural study of the histogenesis of meningeal granular cell tumors in rats

To clarify the cell of origin of granular cell tumors in the rat brain, light and/or electron microscopic examinations were performed on 40 cases of spontaneous meningeal tumors in Wistar (Jcl: Wistar) rats. The meningeal tumors were histologically subclassified into 3 types: meningothelial meningiomas (MMs), 3 cases; granular cell tumors (GCTs), 28 cases; and mixed forms (MIXs) of GCTs and MMs, 9 cases. Of these tumors, 2 MMs, 2 GCTs, and 3 MIXs were examined by transmission electron microscopy. Tumor cells of MMs were characterized by cytoplasmic intermediate filaments and prominent interdigitating cell processes often connected with cellular junctions without surrounding basal laminae. GCTs were composed of 2 cell types: granular cells with many dense bodies and filamentous cells with fine intermediate filaments. MIXs consisted of granular cells, filamentous cells, and intermediate cells. The tumor cells in GCTs and MIXs were apposed to each other and connected with cellular junctions. MIXs displayed a spectrum of cellular differentiation in that 2 MIXs had a close morphological resemblance to GCTs and the other one to MMs. These findings indicate there might be a histogenetic sequence among MMs, GCTs, and MIXs. The present study supports the suggestion that GCTs and MIXs may be variants of MMs from the meningeal arachnoid cell.

In vitro chemotherapy of steroid receptor positive human meningioma low-passage primary cultures with nitrosourea-methionine-steroid conjugates

The antiproliferative activity of two nitrosourea-methionine-steroid conjugates, N-[N'-(2-chloroethyl)-N'-nitrosocarbamoyl] (CNC)-L-methionine-testosterone-17-ester and CNC-L-methionine-dihydrotestosterone-17-ester, was investigated in two meningioma low-passage primary cultures that had been derived from human meningiomas and characterized with regard to proliferation pattern and progesterone receptor content. Treatment was given over 4 days. Cytotoxicity (concentrations investigated: 50, 100, and 200 microM) was compared with the effects of the equimolar mixtures of CNC-Met plus steroid. The steroid-linked nitrosoureas were superior to their unlinked components. CNC-Met itself displayed no or marginal activity, whereas the steroid component displayed significant activity.

Filamentous aggregates in a meningioma

The light microscopic and ultrastructural appearances of unusual filamentous aggregates in a right parietal meningioma in a 14-year-old boy are described. The tumor showed prominent meningothelial as well as fibroblastic components and was graded as an atypical meningioma. By light microscopy, eosinophilic, PAS-positive, granular, irregularly shaped Rosenthal fiber-like structures were widespread within the tumor, in both an intra- and an extracellular location. By immunohistochemical staining, similar location of positivity was obtained for vimentin, laminin, and collagen type IV. The inclusions were nonreactive for keratin, lysozyme, alpha-1-antitrypsin, and ubiquitin. Ultrastructurally, these aggregates were composed of an irregular tangle of filaments with electron dense condensations, sometimes with a lattice pattern. The intracellular aggregates were membrane-bound, and some were found within dilated rough endoplasmic reticulum, while extracellularly, they filled up spaces between adjacent tumor cells. Less prominently, flocculent osmiophilic nonfilamentous material was also seen within the inclusions. These observations suggest that these novel inclusions in a meningioma are composed of intermediate filaments (vimentin) and extracellular matrix proteins, with active synthesis in the rough endoplasmic reticulum and subsequent extrusion from the tumor cells into the extracellular spaces.

Optic nerve glioma mimicking an optic nerve meningioma

The case is described of an optic nerve glioma, mimicking an optic nerve meningioma in a man aged 41 years. CT, MRI and DSA revealed an enhancing tumor surrounding the optic nerve. Histopathologic examination of the removed optic nerve revealed a centrally located glioma surrounded by normal optic nerve fibres.

Considerations on the tendency for calcification in meningiomas

Calcifications in meningotheliomatous and fibromatous meningiomas were demonstrated after maceration under the scanning electron microscope and by pluck preparation. In five predominantly meningotheliomatous and five fibromatous meningiomas vascular features were studied after injection of Indian ink. The influx of calcium into the tumor parenchyma is thought to be related to long vessel loops and parallel coursing vessels which act as a countercurrent multiplication system similar to the loops of Henle in the kidney. Abruptly changing of diameter of vessels reduces the flow rate and enhances the transport of ions across vessels walls. Furthermore, the fine structure of endothelium favors the escape of ions into vessel walls and into parenchyma. Possible consequences of an intratumoral Ca overload are briefly discussed.

Clear cell meningioma: a case report

A case of clear cell meningioma in a 12-year-old male is reported. The tumor was located at the left side cerebellopontine angle, and characterized by sheets of patternless clear cells rich in cytoplasmic glycogen. Vague whorl formation and focal small clusters of typical meningothelial cells were the most important diagnostic features. The tumor cells showed positive immunoreactivity for vimentin, epithelial membrane antigen (EMA), and S100 protein. Cytokeratin and glial fibrillary acidic protein (GFAP) were negative. Ultrastructural features exhibited were abundant cytoplasmic glycogen particles, desmosome-like junctions and tangles of intermediate filaments, while cell membrane interdigitations were few. Clear cell meningioma is rare and is potentially aggressive in that it may recur, spread locally, and even metastasize, despite its bland histologic appearance. There is probably a predilection for younger age group. It is histologically unique but should be differentiated from other mimicking clear cell tumors of the central nervous system, including metastatic renal cell carcinoma, hemangioblastoma, oligodendroglioma, and clear cell ependymoma.

Observation of psammoma bodies in cultured meningiomas: analysis of three-dimensional structure using scanning and transmission electron microscopy

In contrast to the inner structure, three-dimensional structure of psammona bodies in meningiomas is not well defined. This study examined three cultured meningiomas, in which surface observation of psammoma bodies might be easier than in the tumor tissues since influence of interposing connective tissue is minimized in tissue culture. Early culture revealed that psammoma bodies with frank calcification were suspended in the tissue culture medium, and so were they collected, centrifuged, and then processed for electron microscopy. Ultrastructurally, psammoma bodies were mostly spherical in shape and composed of a core of dense calcification and surrounding collagen fiber bundles. Apart from psammoma bodies, round bodies with concentric lamination like a transversely cut onion were frequently noted by light microscopy. These bodies were composed mainly of tangles of collagen fibers emerged from surrounding tumor cell processes. The results suggest that psammoma bodies in meningiomas arise in part from meningothelial whorls due to collagen production by tumor cells followed by obliteration and disappearance of tumor cell processes, although some of the alternative pathways for psammoma body formation proposed by other investigators cannot be ruled out by this study.

Retroperitoneal malignant meningioma. A light microscopic, immunohistochemical, and ultrastructural study

Malignant meningiomas are uncommon and rarely occur outside the central nervous system. We describe herein a morphologically unusual malignant neoplasm that arose in the retroperitoneum of a 25-year-old woman. The tumor was composed of sheets of epithelioid cells that were frequently arranged in prominent whorls. By electron microscopy, the neoplastic cells had long, tapering cell processes that formed numerous interdigitations; many junctions including desmosomes; and abundant intermediate filaments. Immunohistochemistry showed that the tumor cells expressed vimentin, keratin, and epithelial membrane antigen. Based on these findings, the neoplasm was classified as a malignant meningioma. According to our review of the literature, this is the first reported occurrence of a primary retroperitoneal meningothelial neoplasm and the second reported case of an ectopic meningioma that was malignant.

Clear cell meningioma: report of a spinal case

A sacrococcygeal case of clear cell meningioma in a 38-year-old man is reported. Compared to the seven spinal clear cell meningiomas described so far, this case demonstrated the highest recurrency rate. Multiple recurrences were most likely due to the extensive infiltrative growth pattern of the tumor hindering complete microscopic surgical resection. Histologic parameters were not relevant to predict recurrences, since cellular anaplasia was lacking and growth fraction was low in the first operation and all subsequent recurrences. In view of what is now known of clear cell meningiomas, the tumor showed all histologic and immunohistochemical features which are typical for this tumor entity. However, the tumor was first diagnosed by capable pathologists and neuropathologists as fibroma-like mesenchymal tumor, metastatic renal carcinoma, chordoma, chondroma untypical osteosarcoma, and microcystic meningioma. Correct diagnosis was made by electron microscopy which has revealed comparable findings to those of other rare electron microscopical cases reported so far; high content of cytoplasmic glycogen diffusely distributed throughout the cytoplasm or aggregated within vacuoles, intermediate filaments, desmosomes, interdigitation of cell membranes and large amounts of collagen fibers, some of which were of the giant amianthoid type. Since meningiomatous features of clear cell meningiomas are not obvious light microscopically and the tumors may be confused with nonmeningiomatous neoplasms, electron microscopical investigation is highly recommended in each case of suspected clear cell meningioma.

Subcellular distribution and photocytotoxicity of aluminium phthalocyanines and haematoporphyrin derivative in cultured human meningioma cells

The photocytotoxicity characteristics of aluminium phthalocyanine chloride (AIPc), aluminium phthalocyanine disulphonate (AlS2Pc), aluminium phthalocyanine tetrasulphonate (AlS4PC) and haematoporphyrin derivative (HpD) were compared using primary cultures of human meningioma cells. Cells were preincubated with the photosensitising agent for 16 h, then illuminated for 15 min with broad band red light (5 OW/cm2). The resultant cytotoxicity was assessed by tetrazolium (MTT) reduction 24 h later. AlPc was found to be 400, 10,000 and 250 times more potent that AlS2Pc, AlS4Pc and HpD, respectively, as an in vitro photosensitizing agent for meningioma cells. The subcellular localisation of AlPc, AlS2Pc, AlS4Pc and HpD in meningioma cells was determined by confocal laser scanning microscopy. None of the agents localized to the nucleus. The distribution of ALPc was quite diffuse through the cytoplasm. In contrast, AlS2Pc and AlS4Pc were localized vesicles suggestive of lysosomes, and HpD in membranous organelles distinct from mitochondria. AlPc and HpD were tested with five different meningioma samples and provided a range of IC50 values from 0.009 to 0.022 OM and from 3.5 to 6.5 OM, respectively. When the MTT assay with AlPc was performed 0, 24, 48 and 72 h after illumination, the mean IC50 values were 0.25, 0.037, 0.019 and 0.012 OM, respectively, indicating that the cytotoxic effect continued to increase up to 72 h. Cells were incubated with AlPc and HpD for different times up to 24 h before exposure to light. AlPc cytotoxicity was half-maximal with an incubation time of 8 h, whereas HpD cytotoxicity was half-maximal with an incubation time of 2 h, implying slower uptake kinetics for AlPc than for HpD. These data indicate unique features of AlPc which suggests its application as a potent, non-toxic photosensitizer in the photodynamic therapy of human meningiomas.

Malignant meningioma of the parapharyngeal space: a case report

A case of a malignant meningioma arising in the left parapharyngeal space in a 29-year-old woman is reported. Electron microscopic examination of the tumor was critical in establishing the diagnosis. Meningiomas of the parapharyngeal space are extremely rare. This constitutes the first malignant case documented in this location.

Giant desmosomes in tumors

The lengths of desmosomal profiles were measured in sections of tumor tissue from cases of mesothelioma, adenocarcinoma, squamous cell carcinoma, thymoma, and meningioma. Giant desmosomes (length of profile 1 micron or greater than 1 micron) were found in all the above-mentioned tumors except adenocarcinomas. The largest desmosomal profile in adenocarcinoma was approximately 0.8 micron long; the largest in mesothelioma was approximately 2 microns long. Our observations suggest that one of the ways in which giant desmosomes arise is by growth and fusion of adjacent desmosomes. Giant desmosomes may at times help in distinguishing mesothelioma from adenocarcinoma, but this is a rather rare phenomenon. In this study giant desmosomes were found in only 2 out of 10 cases of mesothelioma.

Lipoblastic meningioma: a light and electron microscopic study

A patient with intracranial lipoblastic meningioma in the right frontal lobe is reported. The tumor was entirely made up of vacuolated cells. The nature of this rare neoplasm has been verified by light and electron microscopic studies.

Clear cell meningioma. A clinicopathologic study of a potentially aggressive variant of meningioma

Since clear cell meningioma has only recently been recognized as a morphologic entity, its pathobiology has not been studied. Fourteen examples occurring in seven females and six males, ages 9 to 82 years (mean 29 years), were examined; one was associated with type 2 neurofibromatosis. Of these cases, seven (50%) were spinal-intradural (six lumbar, one thoracic), three (21%) arose in the posterior fossa (cerebellopontine angle), three (21%) were supratentorial, and one (7%) was centered upon the foramen magnum. In one case (8%), two tumors were considered to be independent primaries. One tumor (8%) appeared to show no dural attachment. Thirteen tumors were subject to complete study. All were composed of sheets of clear, glycogen-rich, polygonal cells forming only a few vague whorls. Hyalinization, both stromal and perivascular, was often extensive. Mitoses were rare in primary tumors. Immunohistochemistry showed vimentin and epithelial membrane antigen staining to be reactive in 100%. Stains for S-100 protein and CAM 5.2 were negative. Progesterone and estrogen receptor staining was observed in 77% and 0%, respectively. Ultrastructural study showed abundant cytoplasmic glycogen, a few cytoplasmic lumina, intermediate filaments, interdigitation of cell membranes, and desmosomal junctions. The means, medians, and ranges of proliferating cell nuclear antigen (PCNA) and MIB-1 antigen labeling indices for nonrecurring and recurring tumors were 10.4%, 8.8%, 0.8-23.4% and 11%, 1.4%, 0.1-50.3%, as compared with 7.4%, 6.7%, 2.9-17.2% and 13.3%, 13.4%, 3.3-25.7%, respectively. Twelve successful DNA ploidy studies showed that 11 tumors (85%) were diploid and one was tetraploid; percentage S-phase determinations varied from 4 to 9% (mean 6.0%). Recurrence was noted in eight patients (61%) (five of whom had multiple recurrences); there was local discontinuous spread in two cases (15%) and widespread cranial to spinal metastasis in one case (8%). Three patients (23%) are dead of disease. In summary, clear cell meningiomas are morphologically unique, show no sex predilection, affect primarily the lumbar region and cerebellopontine angle, and despite their benign appearance, may be inordinately aggressive, particularly intracranial examples. No close association was noted between recurrence or clinical outcome and such factors as mitotic activity, PCNA proliferation indices, percent S-phase determination, or DNA ploidy status. In contrast, MIB-1 proliferation indices were appreciably higher among recurring tumors.

Clear cell (glycogen-rich) meningioma with special reference to spherical collagen deposits

A detailed immunohistochemical and electron microscopic study of a case of clear cell (glycogen-rich) meningioma is presented. The neoplasm recurred three times and the patient died of the disease. The specimens obtained at all three operations showed similar basic histologic patterns. The tumor was comprised mainly of a syncytial, sheet-like proliferation of polygonal cells with clear cytoplasm containing abundant glycogen. The immunohistochemical features included epithelial membrane antigen- and vimentin-positive cytoplasm. The ultrastructural examination revealed distinctive meningocytic cells which contained large amounts of glycogen granules. In addition, the presence of numerous blocky, collagen conglomerations were a conspicuous feature of this tumor. The collagen deposits exhibited intensive immunopositivity for types I, III, IV and VI collagen, and their fine structure suggested the production of the extracellular matrix substance from the contiguous meningothelial cells with well developed Golgi complexes and frequent vesicles near the cell membrane. Proliferating cell nuclear antigen cell kinetics study revealed high labeling index of this neoplasm. The findings for this clear cell (glycogen-rich) meningioma may be useful in the differential diagnosis and treatment of this distinctive subtype of meningioma.

Detachment of desmosomes in a microcystic meningioma

This report demonstrates the detachment of desmosomes in the microcystic area of a frontal convexity meningioma removed from a 69-year-old woman. Well-developed interdigitations of the tumor cell processes with numerous desmosomes and with narrow extracellular spaces were characteristic features of the solid area of the meningioma. By contrast, the microcystic area of the tumor had markedly distended extracellular spaces. Various stages in the separation of desmosomal attachments were seen in this area. The observed configurations ranged from the widening of opposing junctions to the formation of large cavities where hemidesmosome-like structures were evident. The latter lacked basal lamina, and are considered to represent a transition leading to the loss of desmosome, and thus involved in the enlargement of the extracellular space in microcystic meningiomas.

Primary cutaneous meningioma associated with von Recklinghausen's disease

Cutaneous meningeal tumors are rare and can pose a diagnostic problem. We present a case of a 12-year-old girl with a family history of von Recklinghausen's disease. The patient was asymptomatic until the age of 11, when she developed two lesions on the head, both diagnosed as plexiform neurofibroma. Subsequently, she presented with a subcutaneous nodule on the left posterior occipital scalp which was excised. On histology, the tumor was composed of spindle-shaped cells with diffuse and nested patterns. A whorled configuration of the cells, with occasional giant cells and psammoma bodies, was present. There was no evidence of connection between the tumor and the underlying tissues. Immunohistochemical studies were positive for epithelial membrane antigen, vimentin, and weakly for neuron-specific enolase. Cytokeratin, S-100 protein, and muscle markers were negative. Based on these features, the diagnosis of cutaneous meningioma was made. An MRI examination failed to detect any communication between the tumor site and the meninges; however, asymptomatic bilateral acoustic neuromas were identified. This case, besides being of interest as a primary cutaneous meningioma, also documents a unique combination of findings, i.e., plexiform neurofibroma, meningioma, and cerebellopontine acoustic neuromas, which should alert the clinician to a forme fruste presentation of von Recklinghausen's disease.