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Hindawi Case Reports in Oncological Medicine Volume 2019, Article ID 9207632, 4 pages https://doi.org/10.1155/2019/9207632 Case Report Histological Characteristics of Myxoid (Metaplastic) Meningioma in a 44-Year-Old Woman 1 1 2 1 Akiko Marutani , Ryou Nakano, Noriyuki Nishi, and Tomonori Yamada Department of Neurosurgery, National Hospital Organization, Osaka Minami Medical Center, Osaka, Japan Oshima Medical Association Hospital, Kagoshima, Japan Correspondence should be addressed to Akiko Marutani; email@example.com Received 3 June 2019; Revised 10 September 2019; Accepted 26 September 2019; Published 6 December 2019 Academic Editor: Raﬀaele Palmirotta Copyright © 2019 Akiko Marutani et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Myxoid (metaplastic) meningioma is the rarest WHO grade 1 meningioma, and its histological characteristics are useful in diagnostics. We present the case report of a myxoid (metaplastic) meningioma in a 44-year-old woman to highlight the important histological features and observations that are critical for making an accurate diagnosis. We report a rare myxoid meningioma using magnetic resonance imaging (MRI) images and its histopathological features. 1. Introduction Intraoperative ﬁndings showed that the tumor was hem- orrhagic, dark red, and relatively soft and was partially Meningiomas are tumors that develop from arachnoid cells; accompanied by ﬁbrous tissue (Figure 4(a)). After the approximately 15 histological subtypes with various charac- MMA was treated, internal decompression was performed teristics are known. Myxoid meningioma is an extremely rare with Sonopet (Stryker Japan KK) to achieve total resection subtype of WHO grade I benign meningioma; only eight of the tumor, including removal of the inﬁltrated dura cases have been reported . Here, we report a case of (Simpson grade I) (Figure 4(b)). myxoid (metaplastic) meningioma using MRI images and Histopathological analysis showed that ﬁbrous connec- its histopathological features. tive tissue containing numerous blood vessels was subfrac- tioned into leaﬂet-like portions (Figure 5(a)). The areas inside the leaﬂets were stained with Alcian blue and con- 2. Case Report tained a mucoid matrix (Figure 5(b)). Immunostaining revealed that the tumor was positive for vimentin and epithe- A 44-year-old woman presented with a headache and visual lial membrane antigen (EMA) and negative for glial ﬁbrillary impairment in August 2017 and visited a local doctor one acidic protein (GFAP). A small percentage (4.4%) of tumor month later. A head computed tomography (CT) scan cells were positive for Ki-67, and there was no ﬁnding of showed a 90 × 90 mm mass in the right frontal lobe malignancy. Based on the above ﬁndings, we diagnosed the (Figure 1), and she was referred to our hospital. Head MRI revealed a mass presenting homogeneous hypointense sig- tumor as myxoid meningioma. After surgery, the neurologic deﬁcits resolved and the nals on T1 images (Figure 2(a)) and hyperintense signals patient’s progress was favorable. The patient was discharged with a clear border on T2 images (Figure 2(b)) at the same two weeks after surgery and was able to walk independently site. Gadolinium- (Gd-) based contrast-enhanced MRI sig- upon discharge. Two years after surgery, recurrence had niﬁcantly enhanced the signals (Figure 3). On cerebral angi- ography, the mass had a sunburst appearance and reﬂuxed not been observed. Written informed consent was obtained from the patient from the middle meningeal artery (MMA). Based on these results, we diagnosed the mass a convexity meningioma for publication of this case report. A copy of the written con- sent is available for review upon request. and performed a craniotomy and tumorectomy. 2 Case Reports in Oncological Medicine Figure 1: A head computed tomography (CT) scan showed a 90 × 90 mm mass in the right frontal lobe. (a) (b) Figure 2: (a) Head magnetic resonance imaging (MRI) revealed a mass presenting homogeneous hypointense signals on T1 images. (b) At the same site, hyperintense signals with a clear border on T2 images. 3. Discussion ses are important for deﬁnitive diagnosis and discrimina- tion from other histological subtypes of meningioma and mucoid tumors (subtypes include osteosarcoma, chondro- Metaplastic meningioma is a subtype of tumor in which a metaplasia of cells into stromal cells occurs locally to form sarcoma, liposarcoma, chordoma, and xanthoma) . In bone, cartilage, lipids, and mucus. It includes osseous, carti- addition to whorl formation, psammoma body, and syncy- laginous, lipomatous, myxoid, xanthomatous, and melanin tial formation that are histopathological characteristics of meningiomas . Till now, most of reports of the metaplastic meningioma, myxoid meningioma is characterized by an abundant mucoid matrix in the cytoplasm and large amounts meningioma were osseous, lipomatous, xanthomatous, and smooth muscle meningiomas . of acidic mucopolysaccharides that stain with Alcian blue Myxoid meningioma is a rare type of metaplastic . Our case is stained with Alcian blue and contained a meningioma; pathological and immunohistological diagno- mucoid matrix. Case Reports in Oncological Medicine 3 Figure 3: Gadolinium- (Gd-) based contrast-enhanced MRI signiﬁcantly enhanced the signals. (a) (b) Figure 4: (a) Intraoperative ﬁndings showed that the tumor was hemorrhagic, dark red, and relatively soft and was partially accompanied by ﬁbrous tissue. (b) After the MMA was treated, internal decompression was performed with Sonopet (Stryker Japan KK) to achieve total resection of the tumor, including removal of the inﬁltrated dura (Simpson grade I). (a) (b) Figure 5: (a) Histopathological analysis showed that ﬁbrous connective tissue containing numerous blood vessels was subfractioned into leaﬂet-like portions. (b) The areas inside the leaﬂets were stained with Alcian blue and contained a mucoid matrix. 4 Case Reports in Oncological Medicine  O. Ozen, A. Sar, B. Atalay, N. Altinörs, and B. Demirhan, Grade II chordoid meningioma is an additional histolog- “Chordoid meningioma: rare variant of meningioma,” Neuro- ical subtype of meningioma that commonly requires discrim- pathology, vol. 24, no. 3, pp. 243–247, 2004. ination. Compared with myxoid meningioma, chordoid  J. Ortiz, M. D. Ludeña, J. Gonçalves, S. Del Carmen, Á. Maillo, meningioma shows a higher grade of dyskaryosis and causes and A. Bullon, “Myxoid meningioma: an example of a rare a reticular arrangement with less cytoplasmic vacuolation. brain Tumour of diﬃcult diagnosis,” Open Journal of Pathology, In addition, lymphocytes are not observed in myxoid vol. 03, no. 01, pp. 51–53, 2013. meningioma, while Castleman disease, which causes chordoid  Y.-H. Choi, C.-Y. Choi, C.-H. Lee, H.-W. Koo, and S.-H. Chang, meningioma, is characterized by abundant lymphocytes . “Metaplastic meningioma overspreading the cerebral convex- Myxoid meningioma shows positive immunohistological ity,” Brain Tumor Research and Treatment, vol. 6, no. 2, reactivity for vimentin and EMA and negative reactivity for pp. 97–100, 2018. cytokeratin, HMB45, S-100, actin, desmin, CD117, neuroﬁla-  C. F. Begg and R. Garret, “Hemangiopericytoma occurring in ments, and GFAP . A few metaplastic tumors showing the meninges: case report,” Cancer, vol. 7, no. 3, pp. 602–606, positive immunoreactivity for smooth muscle action (SMA) suggest muscular diﬀerentiation . We consider that the hemorrhagic, dark red characteris- tics are due to abundant vascularization. MRI showed signif- icantly hyperintense signals on T2 images. The contrast was successfully enhanced using a Gd-based contrast agent due to the histologically abundant mucoid matrix and vasculari- zation. Our histopathological analysis showed ﬁbrous con- nective tissue containing numerous blood vessels. In our case, MRI showed very hyperdense signals on T2 images and enhanced Gd-based contrast. Ki-67 (MIB-1) is used to examine tumor proliferative activity. After nuclear immunostaining, calculating the per- centage of cells positive for Ki-67 enables prediction of tumor malignancy, prognosis, and recurrence . In the present case, we were able to perform a total resection with no ﬁnding of malignancy. However, cases with a high recurrence, ﬁnd- ings of malignancy, and a high score of Ki-67 have been reported; therefore, careful follow-up is necessary. 4. Conclusion We report a rare case of myxoid (metaplastic) meningioma using MRI images and its histopathological features. How- ever, its biological behavior is poorly understood because of the limited number of reported cases. This is a matter that demands full investigation for diagnosis. Conflicts of Interest The authors declare that they have no conﬂicts of interest. References  K. M. Krisht, T. Altay, and W. T. Couldwell, “Myxoid meningioma: a rare metaplastic meningioma variant in a patient presenting with intratumoral hemorrhage,” Journal of Neurosurgery, vol. 116, no. 4, pp. 861–865, 2012.  D. D. Bigner, E. R. McLendon, and M. J. Bruner, “Tumors of the cranial, spinal and peripheral nerve sheaths,” in Pathology of Tumors of the Nervous System, S. D. Russell and J. L. Rubinstein, Eds., pp. 141–193, Edward Arnold, London, 6th edition, 1998.  H. Tang, H. Sun, H. Chen et al., “Clinicopathological analysis of metaplastic meningioma: report of 15 cases in Huashan Hospital,” Chinese Journal of Cancer Research, vol. 25, no. 1, pp. 112–118, 2013.  L. R. Begin, “Intriguing Case: Myxoid meningioma,” Ultrastruc- tural Pathology, vol. 14, no. 4, pp. 367–374, 1990. 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Published: Dec 6, 2019
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