Case Study 2

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Case Study 2

• Harry Kellermier

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Question 1

• The following smear is from an intraoperative
  consultation for an 81-year-old female who
  presents with progressive loss of vision in her
  left eye and a large mass in the temporal region
  of her scalp.  Imaging is not available. 
  Intraoperatively, the surgeon informs you that
  the tumor involves the dural aspect of the skull
  as well as the skin surface.  Describe the
  following smear taken during this procedure.
• Click here to view slide.

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Answer

• a.  Cellular lesion?b.  Pseudosyncytial
  pattern?c.  Whorl-like structures?d.  Cells
  show?     i.  Pulled taffy cytoplasm?    ii. 
  Intranuclear pseudoinclusions?   iii.  Some show
  prominent nucleoli?e.  Mitoses are easily found

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Question 2

• What would the intraoperative consultation be
  based on the previous smear? (A Category such as
  Defer, Reactive, or Neoplastic B More specific
  diagnosis, C additional information)

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Answer

• a.  A Neoplastic?b.  B Meningioma?c.  C A high
  grade lesion cannot be excluded

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Question 3

• Describe the microscopic findings on the
  permanent section from the intraoperative
  specimen.
• Click here to view slide.

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Answer

• a.  Hypercellular neoplasm composed of atypical
  cellsb.  Pseudosyncytial appearancec.  The
  tumor invades soft tissued.  Whorls and
  Whorl-like arease.  Vaguely fascicular
  architecturef.  Areas of sheetingg.  Cells with
  prominent nucleolih.  Greater than 20 mitoses
  per 10 high power fields 

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Question 4

• What is the differential diagnosis based on the
  HE slide?

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Answer

1. Spindle cell carcinoma
2. Anaplastic meningioma
3. Leiomyosarcoma
4. Melanoma
5. Atypical fibrous xanthoma/malignant fibrous
   histiocytoma
6. Hemangiopericytoma with atypical features
7. Solitary fibrous tumor with atypical features

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Question 5

• What immunohistochemical stain would you order to
  narrow your differential diagnosis?

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Answer

1. EMA (Positive in meningioma)
2. Ki-67 (Assess proliferative ability of tumor)
3. S100 (Positive in melanoma)
4. SMA (Positive in leiomyosarcoma)
5. CD34 (Positive in solitary fibrous tumor and
   hemangiopericytoma)
6. BCL-2 (Positive in solitary fibrous tumor
7. Cytokeratins (Positive in carcinomas)
8. Vimentin (Positive in meningiomas and other
   tumors)

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Question 6

• What is the proliferation index of this tumor?
• Click here to view slide.

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Answer

• 20-30

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Question 7

• The EMA and vimentin come back positive.  What is
  your diagnosis?
• Click here to view slide.

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Answer

• Anaplastic meningioma

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Question 8

• What is the characteristic appearance of a
  meningioma on MRI?

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Answer

1. Enhancing
2. Dural tail

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Question 9

• Name the subtypes of meningiomas

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Answer

• Anaplastic Rhabdoid Papillary Atypical
  Chordoid Clear cell Meningothelial Fibrous
  Transitional Microcystic Psammomatous
  Angiomatous (Don't use the term angioblastic
  meningioma.  That's an old term for a
  hemangiopericytoma) Metaplastic Secretory
  Lymphoplasmacyte-rich

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Question 10

• What WHO grade are most meningiomas?

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Answer

• WHO grade 1

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Question 11

• What subtypes are considered WHO grade 2?

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Answer

• a.  Atypical
• b.  Chordoid
• c.  Clear cell

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Question 12

• What histologic characteristics are needed to
  make a diagnosis of atypical meningioma?

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Answer

• a.  4 mitoses per 10 hpfb.  3 out of the
  following 5 criteria       i. 
  hypercellularity      ii.  necrosis     iii. 
  macronucleoli      iv.  small cell change     
  v.  sheeting

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Question 13

• What subtypes of meningioma are considered to
  beWHO grade 3?

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Answer

• a.  Anaplastic
• b.  Rhabdoid
• c.  Papillary

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Question 14

• What histologic characteristic is needed to make
  adiagnosis of anaplastic meningioma?

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Answer

• 20 mitoses per 10 hpf