Intramedullary clear cell meningioma

Spinal Intramedullary Meningiomas: A Systematic Review with a Case Illustration

BACKGROUND

Intramedullary meningiomas are an exceptionally rare subtype of spinal tumors, accounting for only 5% of primary spinal neoplasms. Given their scarcity and unique characteristics, understanding optimal management approaches is crucial for improved clinical decision-making. This systematic review aims to consolidate existing literature and present a detailed case illustration to enhance understanding of this uncommon spinal tumor entity.

METHODS

A systematic search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Eligible studies included case reports, case series, cohort studies, reviews, and meta-analyses. Data extraction and synthesis focused on demographic characteristics, tumor location, clinical presentation, imaging findings, surgical interventions, histopathological features, and outcomes.

RESULTS

A total of 15 high-quality scientific articles were included in the systematic review, providing insights into various aspects of intramedullary meningiomas. Demographic analysis revealed a broad age distribution with an equal gender distribution among affected patients. Common clinical presentations included difficulty walking, sensory disturbances, spastic paraparesis, and urinary incontinence. Neuroimaging findings demonstrated heterogeneous signal intensity variations on T1- and T2-weighted images, with variable enhancement patterns on gadolinium-enhanced images. Surgical interventions, predominantly total resection, resulted in favorable postoperative outcomes in most cases.

CONCLUSIONS

Intramedullary meningiomas pose diagnostic and therapeutic challenges due to their rarity and unique characteristics. Tailored surgical approaches, incorporating techniques such as intraoperative neurophysiological monitoring and fluorescence-aided resection, are crucial for minimizing neurological deficits and optimizing patient outcomes. Despite their infrequency, recognizing intramedullary meningiomas in the differential diagnosis of spinal tumors is essential for prompt diagnosis and timely intervention, ultimately improving patient prognosis.

Central nervous system clear cell meningioma: a systematic literature review

Clear cell meningiomas are a rare histological subtype of World Health Organization (WHO) grade II meningioma. Despite its relatively low frequency, clear cell meningioma has attracted considerable attention because of its unique pathological characteristics, clinical behavior, and challenging management considerations. The purpose of our systematic review is to provide clinicians with a better understanding of this rare disease. PubMed was searched for articles in the English language published from 1988 to 2023 June. The keywords were as follows: "clear cell meningioma," "clear cell" and "meningioma." We analyzed clinical manifestations, radiological manifestations, pathological features, comprehensive treatment strategies, and prognosis to determine the factors influencing recurrence-free survival (RFS). Recurrence-free survival curves of related factors were calculated by the Kaplan‒Meier method. The log-rank test and Cox univariate analysis were adopted to assess the intergroup differences and seek significant factors influencing prognosis and recurrence. Fifty-seven papers met the eligibility criteria, including 207 cases of clear cell meningioma (CCM), which were confirmed by postoperative pathology. The fifty-seven articles involved 84 (40.6%) males and 123 (59.4%) females. The average age at diagnosis was 27.9 years (range, 14 months to 84 years). Among the symptoms observed, headache, neurologic deficit, and hearing loss were the most commonly reported clinical manifestations. Most tumors (47.8%) were located in the skull base region. Most tumors showed significant enhancement, and homogeneous enhancement was more common. A total of 152 (74.1%) patients underwent gross total resection (GTR), and 53 (25.9%) patients underwent subtotal resection (STR). During the follow-up, the tumor recurred in 80 (39.4%) patients. The log-rank test and the Cox univariate analysis revealed that tumor resection range (GTR vs. STR) and adjuvant treatment (YES vs. NO) were significant predictors of recurrence-free survival (RFS). Clear cell meningioma is a rare type of meningioma with challenging diagnosis and therapy. The prognosis of this disease is different from that of regular meningiomas. Recurrence remains a possibility even after total tumor resection. We found that the surgical resection range and adjuvant treatment affected the recurrence period. This finding provides significant guidance for the treatment of clear cell meningioma.

Spinal clear cell meningioma without dural attachment: a case report and literature review

Clear cell meningiomas (CCM) are a very rare histologic subtype of meningioma usually affecting younger patients. The reported data on spinal CCM are extremely rare. Until today, only 89 cases have been reported. Furthermore, CCM without dural attachment is even rarer since only 19 cases have been reported in English literature. In this article, we present the twentieth case of a spinal CCM without dural attachment. Our patient was a 58-year-old female who was presented with pain in her lower back and bilateral sciatica for 6 months. Magnetic resonance imaging showed an intra-dural well-demarcated lesion at L3. Via a posterior approach, total resection was possible due to the lack of dural adhesion of the tumor. Histologic diagnosis was clear cell meningioma.

A Giant Nondural-Based Lumbosacral Clear Cell Meningioma Mimicking Schwannoma: A Case Report and Review of the Literature

Spinal clear cell meningiomas (CCMs) are rare and dural-based lesion usually affecting the younger population. We report the rare case of giant nondural-based spinal CCM mimicking schwannoma and review the literature. A literature search was performed at PubMed and Embase until January 1, 2020. A total of 19 cases of nondural-based spinal CCM was reported. The following relevant data were extracted: authors, publication year, patient and tumor characteristics, treatment, and outcome. The mean age of the presentation was 20.58 years. Twelve (63.16%) were female and seven patients (36.84%) were male. The most common location was lumbosacral region 15 (79%). Fifteen (79%) tumors had cranio-caudal dimension ≤2 vertebral level, and only four (21%) tumors had dimension ≥2 vertebral level. Gross total resection (GTR) was performed in 18 (95%) patients and subtotal resection (STR) in 1 patient. Recurrences were reported in five (26.14%) patients. Four of them showed recurrences within 6 months; earliest at 2.3 months in the patient had undergone STR. Our patient is 19-year-old male diagnosed with a lumbosacral intradural lesion. Craniocaudal dimension is ≥2 vertebral level shows the foraminal extension and vertebral scalloping. GTR is performed. Intraoperatively, the tumor has foraminal extension and shows attachment with right S1S2 nerve root. No dural attachment is found. Six-month follow-up magnetic resonance image shows no evidence of disease. Nondural-based spinal CCMs are extremely rare and should be kept as a differential diagnosis in young patients with giant intradural tumor, and whose radiological features suggesting of schwannoma. It affects young patients and usually involves more than one vertebral level. The chances of recurrences and metastasis are always high even after GTR; hence, close follow-up of the entire neuraxis is warranted.

Spinal Clear Cell Meningiomas: Clinical Features and Factors Predicting Recurrence

OBJECTIVE

As a World Health Organization grade II tumor of the nervous system, clear cell meningioma (CCM) is an uncommon histologic variant of meningioma. Spinal CCMs are even rarer, with <100 spinal CCMs reported in the English literature. We present this study to characterize clinical manifestations of spinal CCMs and determine the factors predicting recurrence.

METHODS

A literature search was performed for relevant case reports and series in PubMed and Embase until September 1, 2019. These articles were reviewed to identify clinical features, treatment modalities, and prognosis of patients with spinal CCMs.

RESULTS

Eighty-four spinal CCMs were analyzed. Of these patients, 36 (42.9%) were young (age ≤18 years), and the mean age at resection was 24 years. Fifty-three patients (63.1%) were female and 31 (36.9%) were male. Most of the tumors (56/84, 66.7%) were located in the lumbar region. In 31 patients (36.9%) >2 segments in the craniocaudal direction were involved (number of involved segments ≥3 levels). Gross tumor resection was performed in 77 patients (91.7%). Twenty patients (23.8%) showed radiographic evidence of recurrence during follow-up. Recurrence-free survival at 1, 5, and 10 years after resection of spinal CCM was 87%, 71%, and 47%, respectively. Multivariate analysis showed that age ≤18 years (hazard ratio [HR], 3.64; P = 0.024), subtotal resection (HR, 3.43; P = 0.031), and segments involving ≥3 levels (HR, 5.66; P = 0.002) were associated with increased recurrence.

CONCLUSIONS

Spinal CCMs have their own unique clinical features compared with conventional spinal meningiomas and intracranial CCMs. Spinal CCMs have a predilection to affect younger patients, are prone to appear in the lumbar region, and have a high recurrence rate. Age ≤18 years, subtotal resection, and involvement of long segments (≥3 levels) are positive predictors of recurrence.

Intramedullary Thoracic Meningioma: A Rare Case Report and Review of the Literature

BACKGROUND

Quite a few cases of intramedullary meningioma have been described in previously reported studies. We have presented a rare case of intramedullary thoracic meningioma, which was quite different from subdural extramedullary meningioma, and the preliminary diagnosis was mistakenly given as hemangioblastoma.

CASE DESCRIPTION

A 46-year-old man with complaints of gait problems and pain in the right lower extremity was admitted to our hospital. The neurological examination revealed 3 of 5 motor strength, spastic paraparesis, hyperreflexia, increased tone, and sensory deficits in the right lower extremity. Contrast-enhanced images showed a T6-T7 intramedullary lesion and an evident and homogeneously enhanced lesion with clearly defined borders on the sagittal, coronal, and axial views. The preliminary diagnosis was hemangioblastoma. However, he underwent tumor resection, and the histopathological examination findings confirmed the diagnosis of intramedullary meningioma.

CONCLUSION

Intramedullary thoracic meningiomas are extremely rare and differ from the common subdural extramedullary meningiomas. Clinicians should be aware of this when diagnosing intramedullary tumors. Gross total resection using a microsurgical technique will be the best treatment strategy.

Spinal Clear Cell Meningioma: Clinical Study with Long-Term Follow-Up in 12 Patients

BACKGROUND

Clear cell meningioma (CCM) is a rare histologic subtype of meningioma. The features of CCMs have commonly been based on intracranial cases. However, CCMs in the spinal cord are even rarer, and their natural history, management, and prognosis remain ill-defined.

METHODS

From January 2006 to January 2018, 12 patients with spinal CCM were treated in our hospital. The clinical features, radiologic findings, diagnosis, treatment, and outcome of these patients were analyzed retrospectively. Additionally, we performed a review of the reported data on spinal CCMs.

RESULTS

CCMs accounted for 2.8% of all the spinal meningiomas treated in our hospital. The most common localization of this disease was the lumbar region (7 of 12). The mean age at diagnosis was significantly younger than that of patients with spinal meningiomas (28.8 ± 13.4 years vs. 54.0 ± 14.4 years). During the follow-up period, 5 patients (41.7%) experienced tumor recurrence. Kaplan-Meier analysis showed that younger patients had a significantly shorter progression-free survival time than older patients. The review of the reported data showed that 55 cases of spinal CCMs had been reported. Nineteen patients (38.0%) had developed local recurrence, with a 5-year progression-free survival rate of 33.3%.

CONCLUSIONS

Spinal CCMs are extremely rare tumors with a predilection to affect younger patients and have a high recurrence rate. Although gross total resection is considered to be the optimal treatment, radiotherapy could be considered for patients who had undergone subtotal resection or for younger patients, regardless of the extent of removal. Close follow-up of the entire neuraxis for years is crucial.

Rhabdoid type intramedullary meningioma. A case report and review of the literature

Meningiomas are the most frequent tumors located at the spinal level together with neurinomas and metastases. These tumors tend to be intradural and extramedullar. There are few cases described in the literature with a purely intramedullary location (less than 10 cases) and they are frequently observed in the union craneal-cervical. In the presence of an intramedullary tumor we perform differential diagnoses with ependymomas, astrocytomas... In this article we present the first case described in the literature of a patient with a rabdoid-type meningioma exclusively intramedullary at the level of the medullary cone.

Loss of SMARCE1 expression is a specific diagnostic marker of clear cell meningioma: a comprehensive immunophenotypical and molecular analysis

Clear cell meningioma (CCM) is a rare grade II histopathological subtype that usually occurs in young patients and displays high recurrence rate. Germline SMARCE1 mutations have been described in hereditary forms of this disease and more recently in small syndromic and sporadic CCM series. The diagnostic value of SMARCE1 in distinguishing between CCM and other meningioma variants has not been yet established. The aim of our study was to investigate the status of SMARCE1 in a series of CCMs and its morphological mimickers. We compared the performance of an anti-SMARCE1 antibody and the molecular analysis of the SMARCE1 gene in a retrospective multicenter series of CCMs. All CCMs lossed SMARCE1 immunoexpression. Bi-allelic inactivating events were found by NGS-based sequencing in all of these cases, except for one, which was incompletely explored, but had a wild-type sequence. We then validated the anti-SMARCE1 antibody specificity by analyzing additional 305 pediatric and adult meningiomas of various subtypes and 15 non-meningioma clear cell tumors by SMARCE1 immunohistochemistry. A nuclear immunostaining was preserved in all other meningioma variants, as well as non-meningioma clear cell tumors. In conclusion, our series showed, for the first time, that SMARCE1 immunostaining is a highly sensitive biomarker for CCM, useful as a routine diagnostic biomarker.

Intramedullary Recurrence of a Thoracic Meningioma-Presentation of an Unusual Case and Review of the Literature

BACKGROUND

Spinal meningiomas are typically extra-axial, slow-growing, benign tumors that arise from the arachnoid cap cells. Intramedullary spinal meningiomas are exceedingly rare with few cases reported in the literature.

CASE DESCRIPTION

A 64-year-old man with a history of grade I thoracic meningioma at the T4 level resected initially in 1989 and who required reoperation in 2013 for intradural, extramedullary recurrence of tumor presented again in 2015 with gait difficulty. Magnetic resonance imaging revealed a soft tissue mass at the T3 to T4 levels on the left side of the canal that was mildly enhancing on T1 contrasted sequences. The patient was taken to the operating room, where a purely intramedullary recurrence was discovered without extramedullary extension or a dural-based attachment. The intramedullary tumor was completely resected, and postoperatively the patient recovered well and was at his neurologic baseline. The patient ultimately underwent proton beam radiotherapy because this tumor, although benign, had recurred twice.

CONCLUSIONS

Intramedullary spinal meningiomas, particularly intramedullary low-grade recurrence of a previously extramedullary tumor, are rare phenomena. Although the pathogenic mechanisms are not well understood, intramedullary recurrence as described in this patient may reflect extrinsic factors related to prior surgical resections in addition to histologic progression. When operating on recurrent extramedullary lesions, aggressive arachnoid dissection may predispose patients to unusual patterns of recurrence.

A rare case of intramedullary 'whorling-sclerosing' variant meningioma

A 52-year-old man with a seven-year history of progressive weakness, gait problems, and pain in his extremities presented with subacute worsening of his symptoms. Examination revealed weakness in all four extremities, increased tone, hyperreflexia, and sensory deficits. MRI of the cervical spine showed an area of signal abnormality and abnormal enhancement within the cervical cord at the C5–C6 level. The patient initially underwent biopsy followed a few days later by a debulking surgery. Postoperatively, the patient showed improvement in strength as well as ambulation. Intraoperatively, the lesion was confirmed to be intramedullary without any dural attachments. Histopathological examination revealed an extensively hyalinized tumor with sparse collections of cells that were immunopositive for both cytokeratin and GFAP, and immunonegative for EMA and progesterone receptor. This is an unusual pattern of expression, with cytokeratin immunopositivity suggesting a meningioma and GFAP immunopositivity suggesting a glioma. Considering the combination of extensive hyalinization with cytokeratin positivity the tumor was thought to be most consistent with a hyalinized meningioma with GFAP positivity. GFAP-positive meningiomas are rare, and these include the recently described ‘whorling-sclerosing’ variant. Only three cases of this tumor have been previously reported, all of which were intracranial. This is the first reported case of an intramedullary whorling-sclerosing meningioma.

Non-dural-based spinal meningioma : the first case report of a fibrous subtype and a review of the literature

Spinal meningiomas typically adhere to the dura matter. Non-dural based spinal meningiomas are rare and most are clear cell meningiomas. We report here the first case of a fibrous meningioma with non-dural attachment. The patient was a 49-year-old female, who complained of numbness in the legs and a gait disturbance. Magnetic resonance imaging revealed a 1.7×1.4-cm mass in the C7-T1 intra-dural extramedullary space, showing peripheral gadolinium enhancement without a "dural tail sign". A complete microsurgical resection was performed. The mass was covered with a white membrane but was not adhered to the dura, and its appearance was consistent with a neurilemmoma. The histopathological diagnosis was fibrous-type meningioma. The recovery of the patient was uneventful. No surgical complications and no recurrence of the tumor had occurred at the 6-month follow-up.

Intracranial clear cell meningioma: a clinicopathologic study of 15 cases

OBJECT

Clear cell meningioma (CCM) is a rare histological variant of meningioma. CCM has a high recurrence rate and aggressiveness. In this study, we reviewed our experience in the treatment of the lesion.

METHODS

Here we present a series of 15 patients with intracranial CCM. The clinical data were retrieved from the records of our Neurosurgery Department and the patients' prognoses were attained by clinic service and telephone. Immunohistochemistry for epithelial membrane antigen (EMA), vimentin, glial fibrillary acidic protein (GFAP), CD10, and S-100 was done, and the MIB-1 labeling index was calculated in all cases.

RESULTS

The 15 patients included eight males and seven females; the mean age was 34.8 years. The most frequent initial symptoms were headache and hearing loss. The most common location was the cerebellopontine angle (CPA) zone. Eleven patients had total removal and four patients underwent subtotal removal. Histological features of atypia were present in different proportions, from 6.7% to 100%, and six cases accorded with atypia. Three tumors showed brain invasion. EMA and vimentin were 100% positive, and CD10 was 100% negative. GFAP was 87% negative and S-100 was 93% negative. The mean follow-up period was 36.7 months. Three patients with brain invasion all recurred and five cases with atypia recurred. In 11 patients with total removal, six patients recurred. In four patients with subtotal removal, three patients recurred. Kaplan-Maier analysis showed that incomplete surgical resection was significantly associated with recurrence (p = 0.001). The MIB-1 labeling index for recurrence was 5.7 ± 2.7% versus 2.8 ± 1.5% for no recurrence (p = 0.036).

CONCLUSIONS

CCM is a rare subtype of meningioma, with a tendency to present in younger patients and a propensity to recur. Immunohistochemistry plays a vital role in differentiating CCM from other tumors. Brain invasion, atypia and MIB-1 labeling index are likely to predict the recurrence. The extent of resection might be connected with the prognosis.

Non-dura based intaspinal clear cell meningioma

A 34-year-old female patient was presented with leg and hip pain for 6 months as well as voiding difficulty for 1 year. Magnetic resonance imaging revealed a well-demarcated mass lesion at L2-3. The mass was hypo-intense on T1- and T2-weighted images with homogeneous gadolinium enhancement. Surgery was performed with the presumptive diagnosis of intradural extramedullary meningioma. Complete tumor removal was possible due to lack of dural adhesion of the tumor. Histologic diagnosis was clear cell meningioma, a rare and newly included World Health Organization classification of meningioma usually affecting younger patients. During postoperative 2 years, the patient has shown no evidence of recurrence. We report a rare case of cauda equina clear cell meningioma without any dural attachment.

An unusual case of cervical clear-cell meningioma in pediatric age

INTRODUCTION AND BACKGROUND

A 4-year-old girl was admitted with complaints of diplegia, right lower limb monoplegia, and left lower limb monoparesia. Cervical magnetic resonance imaging revealed an intradural-extramedullary tumor at the level of C1-C2. The tumor was resected totally. Histopathologic diagnosis revealed clear-cell meningioma.

DISCUSSION

Intraspinal clear-cell meningioma (ICCM) is a rare aggressive variant of meningioma. There are only 25 cases reported to date, and only 13 of them are in pediatric age group. Of these 25 ICCM cases, only two are at cervical region. This report is the first ICCM case at upper cervical region (C1-C2) in both adult and pediatric age populations.