Dural-based Lesions Research Articles

Case of the season: Metastatic pituitary carcinoma mimicking meningioma

56-year-old man presented six years ago with a left temporal hemianopsia, gynecomastia, and serum prolactin of 1140 ng/mL. Trans-sphenoidal surgical resection confirmed a prolactin-producing pituitary adenoma and the patient was treated with hormonal therapy and radiotherapy. Five years later, serum prolactin was normal and a magnetic resonance imaging (MRI) study showed no tumor. One year later, he once again complained of breast tenderness and swelling and serum prolactin was 419 ng/mL. MRI showed four separate, enhancing dural-based lesions (Fig. 1). The largest lesion measured 2.3 cm and was located in the left parietal convexity. These extra-axial dural-based lesions were within the previous radiation field. Although the imaging appearance the dural-based lesions had the resemblance of meningioma, the associated rise of serum prolactin suggested the diagnosis of metastatic prolactinoma. The patient underwent a craniotomy with resection of the largest dural-based lesion. Histological examination of the specimen revealed prolactin-secreting adenoma with conspicuous mitotic figures that prompted the diagnosis of prolactin-secreting carcinoma. The patient experienced declining mental status and a continued rise in serum prolactin. He was treated with a prolactin-secretion inhibitor but a new MRI study showed progressive increasing size of the dural lesions. After an episode of aspiration, the patient was admitted to the intensive care unit where ventilator support was withdrawn a few days later. An autopsy limited to the brain showed no residual tumor in the sella turcica. On microscopic examination, all dural lesions were confirmed to be prolactin-secreting pituitary carcinoma.

Rosai–Dorfman disease associated with neurosensorial hearing loss in two siblings

Rosai–Dorfman disease (RDD) is an uncommon pathologic condition of unknown ethiology with an idiopathic proliferation of the hystiocytes. It is generally presented with massive bilateral hypertrophy of the cervical lymph nodes. But other lymph nodes may also be involved. Approximately, 30% of these patients have extra nodal mass or lesion with different signs or symptoms depending on localization. We present two male siblings with Rosai–Dorfman disease who have classical cervical lymphadenopathy associated with progressive neurosensorial hearing loss and dural-based intracranial lesions.

Intracranial Primary Mesenchymal Chondrosarcoma: A Case Report

We report a case of dural-based intracranial primary mesenchymal chondrosarcoma, initially thought to be a meningioma. This rare tumor should be included in the differential diagnosis of an aggresive dural-based lesion occurring in a young adult. A 27-year-old man presented with headache, nausea and vomiting, first experienced months earlier. Pre-enhanced CT revealed the presence of a well-marginated isodense mass with dense calcifications in the frontoparietal convexity, while MR images depicted a lobulated extra-axial mass with peritumoral edema. At T1-weighted imaging, the signal intensity of the mass was slightly low or than that of gray matter, while T2-weighted imaging demonstrated heterogeneous high signal intensity. Some portions of the tumor showed low signal intesnity at all sequences, suggesting the presence of calcification. After the injection of contrast medium, heterogeneous enhancement was observed. We report the radiologic findings of an intracranial primary mesenchymal chondrosarcoma, confirmed pathologically.

Association between intracranial plasmacytoma and multiple myeloma: clinicopathological outcome study.

Intracranial plasmacytomas are rare lesions that can arise from the calvarium, dura, or cranial base and exhibit a benign course unless associated with myeloma. Attention has recently been focused on the role of the cell adhesion molecules CD56 and CD31 in the pathogenesis of myeloma. No such information is available for intracranial plasmacytomas and myeloma-associated lesions. We investigated the relationship between CD56 and CD31 expression, intracranial location, and progression to myeloma for a series of nine intracranial plasmacytomas (three dural, one calvarial, and five cranial base lesions). These parameters were also correlated with proliferation indices, as assessed by MIB-1 immunostaining of the histological sections. A single pathologist (AO) performed immunohistochemical analyses and reviewed all slides. Intracranial plasmacytomas presented more commonly in female patients (89%). The three dural lesions were CD56- and CD31-negative and exhibited MIB-1 staining of less than 10%; no patient developed myeloma or recurrence. Of the five cranial base lesions, three were CD56-positive, none was CD31-positive, and two exhibited MIB-1 labeling of more than 45%, with plasmablastic morphological features. Compared with other intracranial plasmacytomas, five of five patients with cranial base lesions developed bone marrow biopsy-proven myeloma (P < 0.05) within 8 months. The calvarial lesion was CD56- and CD31-positive, and the patient developed myeloma soon after diagnosis. Both of the two highly proliferative plasmablastic lesions recurred, one after gross total resection without radiotherapy and the other after a biopsy and 2000-cGy radiotherapy. Among intracranial plasmacytomas, cranial base location was the strongest predictor of the development of multiple myeloma. Expression of the cell adhesion molecules CD31 and CD56 was not predictive of outcome. Extramedullary dural-based lesions were CD56-negative and were not associated with myeloma. A high proliferation index and plasmablastic morphological features were predictive of a short time to recurrence and aggressive behavior. We recommend 4050- to 5040-cGy fractionated radiotherapy for all intracranial plasma cell neoplasms and gross total resection for non-cranial base lesions.

Solitary sarcoid granuloma of the cerebellopontine angle: A case report

BACKGROUND Sarcoidosis involves the nervous system about 5% of the time and usually manifests as a granulomatous inflammation of the basal meninges and hypothalmus. Cases which are strictly isolated to the central nervous system occur infrequently; rarely, they may present as an intracranial mass. METHODS We present the case of a solitary sarcoid granuloma at the cerebellopontine angle in a 42-year-old female who presented with headache, facial numbness, and hearing loss. RESULTS A suboccipital craniectomy was performed and the lesion was noted to be grossly adherent to the lower cranial nerves and skull base. The lesion was misdiagnosed as a meningioma with preoperative magnetic resonance imaging and intraoperative histology, and perhaps additional morbidity resulted. CONCLUSION We present this case in order to demonstrate the importance of differentiating these dural-based lesions and propose that cases of neurosarcoidosis presenting as a solitary granuloma be treated with surgical debulking and immunosuppression.

Meningiomas

This article reviews the recent literature on the pathogenesis and pathology of meningiomas, contemporary techniques of surgical resection, and new nonsurgical treatments, including radiation and hormone therapy. Factors predisposing to meningioma formation include female sex, previous ionizing radiation, and Type 2 neurofibromatosis. The first factor may act through the expression of sex hormone receptors, especially the progesterone receptor, in these tumors; the other two probably act by causing a deletion on Chromosome 22. The pathological classifications of meningiomas include the traditional division into histological subtypes and the World Health Organization classification that selects characteristics that may lead to recurrence. There is an increasing emphasis on proliferative indices and other characteristics that may predict aggressive behavior in these tumors. On computed tomography, meningiomas are enhancing, well-marginated, dural-based lesions that may have considerable surrounding edema; the cause of the edema is uncertain but may result from secretory products of the tumor. Magnetic resonance imaging with enhancement will demonstrate these lesions accurately and can be used for three-dimensional reconstruction as well. Computed tomography and magnetic resonance imaging have largely replaced angiography in the preoperative diagnosis of meningiomas, but angiographic embolization may be a useful operative adjunct. Although meningioma surgery is sometimes thought of as benign and curative, the reported surgical mortality rate is as high as 14.3% and the reported 10-year survival rate after surgery varies from 43 to 77%. Surgery has advanced most in the management of suprasellar, cavernous sinus, clivus, tentorial, and posterior fossa meningiomas, because new approaches and a better understanding of anatomy have allowed more radical resection. There is still substantial morbidity associated with surgery in these regions, however, and the long-term recurrence rates are still unknown for these new radical techniques. For convexity, parasagittal, lateral sphenoid wing, and olfactory groove meningiomas, complete resection should be the goal and operative morbidity appears to be low. There is a high recurrence rate after surgery. With apparent total removal, the recurrence rate varies from 9 to 20% at 10 years, with subtotal resection varying from 18.4 to 50%. The degree of resection appears to be most important in recurrence, but histopathological features are also important. Recently, radiation therapy has been recognized as a useful adjunct to surgery, and with radiosurgical techniques may become more important in the future. Antiprogesterone therapy appears to have had some success as well, and it or other hormonal therapy may be another future option for residual or recurrent meningiomas.