Non-dura based intaspinal clear cell meningioma

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.

Pituitary Adenoma Coexistent with Sellar Clear Cell Meningioma Unattached to the Dura: Case Report and Treatment Considerations

Collision tumors involving the sella are rare. Intrasellar collision tumors are most commonly composed of a combination of pituitary adenomas and pituitary neuroendocrine tumors; however, collision tumors consisting of a pituitary adenoma and intrasellar meningioma are exceedingly rare. The authors present the case of a 47-year-old man who presented with progressive right eye vision loss. Magnetic resonance imaging showed a large, heterogeneously enhancing sellar mass with suprasellar extension. Using a transcranial approach with a right subfrontal craniotomy, near-total resection of the mass was achieved. Histologic analysis confirmed a diagnosis of a gonadotroph adenoma with concomitant clear cell meningioma (CCM). This patient was discharged with improvement in visual acuity and no signs of diabetes insipidus. Given the indistinguishable radiographic characteristics of pituitary adenoma and CCM, a preoperative diagnosis of a collision tumor was difficult. This case was uniquely challenging since the CCM component lacked the classic dural attachment that is associated with meningiomas on neuroimaging. CCMs are classified as central nervous system (CNS) World Health Organization (WHO) grade 2 tumors and tend to behave more aggressively, therefore warranting close surveillance for signs of tumor recurrence. This is the first case to report a collision tumor consisting of pituitary adenoma and CCM.

Mother and daughter with a SMARCE1 mutation resulting in a cervical clear cell meningioma at an identical location: illustrative cases

BACKGROUND

A rare meningioma subtype is a clear cell (CC) meningioma, which can be associated with a SMARCE1 gene mutation. Manifestation of a CC meningioma in the cervical spine is unusual. In the current case, both mother and daughter present with a CC meningioma at an identical cervical location.

OBSERVATIONS

A 67-year-old patient with an intradural extramedullary mass at the level of C5 presented with progressive myelopathy. The mass was resected through a ventral approach by a two-level corpectomy with an expandable cage and instrumentation. The daughter of this patient appeared to have had an intradural extramedullary mass at C5 at the age of 20, which was resected through a posterior approach. Pathological investigation of both tumors revealed CC meningioma. Genetic testing of the daughter revealed a SMARCE1 mutation.

LESSONS

It is of major importance to consider a SMARCE1 mutation in elderly presenting with a CC meningioma, which is still uncommon in current practice. This could lead to timely diagnostics in the succeeding generation. Complete resection of a CC meningioma is important because of the high recurrence rate. Routine follow-up should therefore be performed in the postoperative period. An anterior approach should be considered for a ventral cervical CC meningioma.

Atypical meningioma originating from the spinal accessory nerve

Background

Atypical meningiomas rarely originate from the spinal accessory nerve at the C1-C2 level.

Case Description

A 57-year-old female presented with a 1-month history of headache. The cervical MR revealed a well-demarcated intradural/extramedullary tumor compressing the spinal cord at the C1-C2 level that measured 12 mm × 10 mm × 25 mm. She underwent microsurgical tumor resection. Intraoperatively, the tumor was adherent to the spinal accessory nerve, rather than the dura mater. Gross total tumor resection was performed, and the pathology was consistent with an atypical meningioma.

Conclusion

Atypical meningiomas rarely originate from the spinal accessory nerve. Gross total resection is the procedures of choice to mitigate the risk of tumor recurrence.

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.

Intraspinal clear cell meningioma without dural attachment: A case report and literature review

RATIONALE

Clear cell meningioma (CCM) is one of the rarest but most aggressive forms of meningioma, with a tendency to occur at a high recurrence rate. Intraspinal CCM, especially the nondura-based type, is even rarer than the intracranial CCM.

PATIENT CONCERNS

We report a case of a 45-year-old woman who presented with a 1-month history of episodic pain in the lower back and in both thighs in the front side. Femoral nerve stretch tests were positive on both sides. Magnetic resonance imaging (MRI) demonstrated an intradural tumor at the L3 level, which was isointense on T1- and T2-weighted images (WI) and homogeneously enhanced on gadolinium-contrast T1 WI.

DIAGNOSES

The space-occupying lesion was pathologically confirmed as CCM.

INTERVENTIONS

During surgery, we found that the tumor adhered to a nerve root, without dural attachment. The nerve root was partially removed to achieve complete resection.

OUTCOMES

The pain disappeared after the operation. The 1 year follow-up MRI revealed no evidence of tumor recurrence or metastasis.

LESSONS

Nondura-based intraspinal CCM is easier to completely remove, and such complete removal should be achieved during the first operation. Although the recurrence rate of this particular type of meningioma appears to be lower than that of other types, close clinical and radiological follow-up is necessary.

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.

Hereditary clear cell meningiomas in a single family: three-cases report

Clear cell meningiomas (CCMs) are rare subtypes of meningiomas and usually treated by maximum safely achievable tumor resection. We here present three hereditary cases with CCMs which were confirmed by Sanger sequencing of lymphocyte DNA. Gross total resection was achieved in a 5-year-old son with a spinal CCM and a 34-year-old father with a CCM in the cerebellopontine angle (CPA). For a 14-year-old daughter with CCM in the CPA, total resection was not achieved due to its large size. Early detection by screening high-risk family with CCM is strongly recommended.

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.

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.

Spinal cord compression due to undiagnosed thoracic meningioma following lumbar surgery in an elderly patient: a case report

As spinal surgery in elderly patients is becoming increasingly frequent, comorbidities likely to be decompensated after such procedures must be kept in mind. We report here the case of an 82-year-old woman who presented rapidly progressive spinal cord compression following lumbar surgery for radiculopathy. Investigations showed a thoracic intradural extramedullary compressive lesion, which after removal turned out to be a meningioma. We suggest that radiculopathy and non-specific degenerative modifications partially masked this lesion, and that lumbar surgery caused this acute neurological deterioration. Therefore, we advice caution in older patients among whom such ambiguous clinical presentation is frequent.

Benign spinal meningioma without dural attachment presenting delayed CSF dissemination and malignant transformation

Benign spinal meningiomas have good prognoses, with low rates of recurrence and no cerebrospinal fluid (CSF) dissemination. However, we experienced an extremely rare case of initially benign non-dura-based spinal meningioma that showed multiple CSF disseminated lesions, which progressed for 14 years. A 29-year-old woman without neurofibromatosis presented with progressing dysesthesia in her lower limbs, low back pain, and intermittent claudication. Magnetic resonance imaging (MRI) showed an intradural extramedullary mass lesion at the Th10/11 level. The patient underwent a tumor resection. Intraoperative findings indicated that the tumor had no dural attachment. Histopathological diagnosis after gross total removal was microcystic meningioma (grade I, WHO 2007). Seven years after the first operation, other lesions appeared at the levels of Th11/12, L1, and L2/3 in MRI. These tumors were slow growing and became symptomatic; thus, a second surgery was performed 14 years after the first operation. The histopathological diagnosis was atypical meningioma (grade II, WHO 2007). Benign spinal meningiomas show CSF dissemination extremely rarely, although some authors have reported non-dura-based intraspinal clear-cell meningiomas showing CSF dissemination. However, even in cases of WHO grade I, neurosurgeons should pay attention to late CSF dissemination and malignant transformation after surgical removal of non-dura-based intraspinal meningiomas.