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TITLE: Angiomatous, Predominantly Cystic Meningiomas: A Case Report and Literature Review of a Unique Group of Meningiomas |
LICENSE: This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. |
ABSTRACT: AbstractMeningiomas are the most common intracranial benign tumors. Among them, cystic angiomatous meningiomas are very rare entities, making preoperative differentiation with other tumors challenging. We present a case of parasagittal angiomatous meningioma with a large associated cyst that mimicked a hemang... |
## Introduction |
Angiomatous meningiomas represent an uncommon subtype among meningiomas, which are the most common intracranial benign tumors [1]. Angiomatous meningiomas account for only about 2.1% of all cases [2-5], and their most distinctive characteristics are that the tumor is rich in vasculature [2] and often shows considerable... |
Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data. |
## Case presentation |
Case description |
The patient was an 80-year-old male who experienced a bout of nausea, which resulted in a fall with a short loss of consciousness, followed by altered mental status. Subsequently, shortly after a coronavirus disease 2019 (COVID-19) infection, the patient noticed a deterioration of his handwriting, which led to a neurol... |
Following referral to our outpatient clinic, we initially suspected a supratentorial hemangioblastoma and recommended microsurgical resection. As for comorbidities, the patient suffered from arterial hypertension, type 2 diabetes, hypercholesterolemia, atherosclerosis of the left internal carotid artery, and osteoarthr... |
Microsurgical resection was performed in a modified supine position. The patient was slightly turned to the right side, and a cushion was placed under his left shoulder and thorax, allowing for a 90-degree head turn and slight elevation. Neuronavigation was adopted to tailor the craniotomy just above the contrast-enhan... |
The patient recovered well, and a postoperative CT scan ruled out any complications. In the later course, the patient described a short episode with rhythmic twitching of his right hand, which was interpreted as a focal seizure. He was subsequently started on levetiracetam. The rest of the postoperative course was unev... |
Histopathological assessment |
To our surprise, the histopathological assessment revealed an angiomatous meningioma (CNS WHO Grade 1), and not a hemangioblastoma as preoperatively suspected. The well-vascularized, capillary-rich tumor displayed epithelial membrane antigen (EMA)-positive interspersed meningothelial cells with low mitotic activity. Ad... |
## Discussion |
A closer look at angiomatous cystic meningiomas |
Meningioma is the most common intracranial benign tumor [1], arising from the arachnoid cap cells of the meninges. Among these, angiomatous meningiomas represent an uncommon subtype [2-4], whose most distinctive characteristic is their richness in vasculature [2] and the frequent presence of considerable peritumoral ed... |
The age at presentation of angiomatous and cystic meningiomas varies, usually between the fourth to sixth decades of life [6-9], compared to the median age at diagnosis of 67 for meningiomas in general [1]. The age at diagnosis of cystic angiomatous meningiomas ranges from 42 years [1-27] to 80 years (our patient was 8... |
Radiologically, angiomatous meningiomas are usually hypo/iso-intense in T1W sequences and hyperintense on T2W images, with a homogeneous post-contrast enhancement, except in the cases with cystic degeneration where contrast-enhancement can be heterogeneous (Table 1) [5,6,10]. |
[TABLE] Clinical and radiological features of 11 documented patients with a brain cystic angiomatous meningiomaNS: not specified |
Study | Year | Number of patients | Patient sex | Age at diagnosis | Location | Symptoms | Enhancement | Dural tail sign | Peritumoral brain edema | Extent of excision |
Liu et al. [3] | 2013 | 4 | NS | NS | NS | NS | Yes (heterogeneous) | NS | NS | NS |
Hua et al. [6] | 2017 | 48 | NS | NS | NS | NS | NS | NS | NS | NS |
Xia et al. [7] | 2023 | 1 | M | 61 | Supratentorial (left frontal) | Right limb weakness | Yes | NS | NS | NS |
Boukobza et al. [8] | 2016 | 1 | NS | NS | NS | NS | NS | NS | Yes | NS |
Go et al. [9] | 2018 | 2 | NS | NS | NS | NS | NS | NS | NS | NS |
Wang et al. [12] | 2016 | 1 | M | 57 | Supratentorial (right frontal) | Left hemiparesis | Yes | NS | Yes | Total |
Guan et al. [14] | 2013 | 1 | F | 30 | Infratentorial | Headache, vomiting | Yes | No | No | Total |
Deb et al. [15] | 2010 | 1 | M | 58 | Infratentorial (cerebellopontine angle) | Vomiting, cerebellar symptoms | Yes | NA | Yes | Total |
Pawan et al. [19] | 2021 | 5 | NS | NS | NS | Headache, seizures | NS | NS | Yes | NS |
Bansal et al. [20] | 2016 | 1 | F | 42 | Supratentorial (right frontal) | Left hemiparesis | Yes | No | No | Total |
Present case | 2024 | 1 | M | 80 | Supratentorial (left frontoparietal) | Deterioration of handwriting | Yes | No | Yes | Total |
Cystic meningiomas are classified into four different morphologic types according to the Nauta classification [11]: type I: central cyst surrounded by macroscopic tumor; type II: peripheral cyst surrounded by a rim of microscopic tumor tissue; type III: peripheral cyst, outside the tumor and contained within the brain ... |
Intracranial lesions mimicking hemangioblastoma |
The preoperative differentiation between cystic meningiomas and other tumors can be difficult, and the final histopathological examination can lead to surprises [13]. The radiological features of a large cyst with contrast-enhancing mural nodule can mimic the appearance of a hemangioblastoma, as in our case, although t... |
The histopathological diagnosis of hemangioblastoma may lead to a suspicion of Von Hippel-Lindau disease [16,18], which makes further diagnostic workup necessary. Other lesions also need to be differentiated from hemangioblastomas, with which they share cystic features, such as pilocytic astrocytomas [25], pleomorphic ... |
## Conclusions |
Among meningiomas, angiomatous cystic types represent a unique entity, and they are rarely described in the literature; therefore, a differential diagnosis with other intracranial lesions is critical. Our report illustrated how a cystic angiomatous meningioma can mimic an intra-axial lesion like hemangioblastoma. This ... |
## Disclosures |
## Author Contributions |
## References |
39898bdd3fc558d82429a1429398d6a11bd126c92bb5f3731989143892c126d3 pmc12233036.txt |
This is an open-access article distributed under the terms of the Creative Commons Attribution- 4.0 International License ( https://creativecommons.org/licenses/by/4.0/ ) which permits Share, copy and redistribution of the material in any medium or format or adapt, remix, transform, and build upon the material for any ... |
2e5fc1c4653d1dc651eeafdc844a124240c219cd36a9f980573d2c6cd36733e4 pmc12308192-licence-evidence.txt |
PMCID: PMC12308192 |
TITLE: Evaluation of TTF-1, Napsin A, p40, and p63 in the Subtyping of Non–Small Cell Lung Carcinoma: A Cross-Sectional Study from India |
LICENSE: This is an open-access article distributed under the terms of the Creative Commons Attribution- 4.0 International License (https://creativecommons.org/licenses/by/4.0/) which permits Share, copy and redistribution of the material in any medium or format or adapt, remix, transform, and build upon the material f... |
ABSTRACT: AbstractBackground & Objective:Subtyping non–small cell lung carcinoma (NSCLC) into adenocarcinoma (ADC) and squamous cell carcinoma (SCC) is crucial for selecting appropriate molecular tests, as driver mutations are often subtype-specific. This study aimed to evaluate the utility of TTF-1, Napsin A, p40, and... |
## Introduction |
Lung carcinoma (LC) is one of the most lethal malignancies and remains the leading cause of cancer-related mortality worldwide. In India, it accounts for approximately 5.9% of all cancers, with tobacco smoking being the predominant risk factor in nearly 80% of cases (1). Nevertheless, a substantial proportion of lung c... |
Lung cancer is broadly classified into small cell lung carcinoma (SCLC) and non–small cell lung carcinoma (NSCLC) based on histopathological characteristics. NSCLC accounts for nearly 85% of all cases and includes adenocarcinoma (ADC), squamous cell carcinoma (SCC), large cell carcinoma (LCC), adenosquamous carcinoma (... |
ADC is the most common subtype in India (1) and demonstrates histologic heterogeneity, often expressing pneumocyte- or mucin-related markers. SCC, an epithelial malignancy, is characterized by keratinization, intercellular bridges, or poorly differentiated morphology, with immunohistochemical confirmation through p40 o... |
Because approximately 60% of lung cancer cases are diagnosed at advanced stages (III or IV), when surgical resection is typically not feasible, diagnosis often relies on small tissue samples, including core biopsies, fine-needle aspiration (FNA), and cell blocks (4). A multidisciplinary diagnostic approach incorporatin... |
The primary immunomarkers used to differentiate NSCLC subtypes include TTF-1 and Napsin A for adenocarcinoma, and CK5/6, p40, and p63 for squamous cell carcinoma (7–9). TTF-1, encoded by the NKX2-1 gene, is a homeodomain-containing transcription factor expressed in pulmonary adenocarcinomas and thyroid neoplasms (7). N... |
p40, an isoform of p63 (ΔNp63), is a highly specific marker for squamous differentiation, while p63, a member of the p53 transcription factor family located on chromosome 3q, is also expressed in normal respiratory epithelium (9). This study was conducted to assess the diagnostic utility of TTF-1, Napsin A, p40, and p6... |
## Materials and Methods |
### Ethics and Setting |
In this timebound study, lung biopsies obtained from January 2014 to December 2020 from patients with clinically suspected primary lung cancer were included. These samples were received in the Department of Pathology, Kasturba Medical College, Mangalore, and consisted of bronchoscopic biopsies, computed tomography (CT)... |
### Biopsy Review |
Following morphological evaluation of hematoxylin and eosin (H&E), stained slides, all cases of non, small cell lung carcinoma (NSCLC) were confirmed and subtyped into adenocarcinoma, squamous cell carcinoma, and NSCLC-not otherwise specified (NOS) based on morphological criteria outlined by the World Health Organizati... |
### Immunohistochemistry |
IHC was performed on formalin-fixed, paraffin-embedded (FFPE) tissue that had been previously evaluated morphologically. Thin sections were cut from representative blocks onto adhesive-coated slides at the same time as H&E sections to minimize tissue loss. IHC staining was carried out using the following antibodies: TT... |
Immunohistochemical evaluation for TTF-1, p40, and p63 was based on nuclear staining, while cytoplasmic staining was considered for Napsin A. Particular attention was given to excluding entrapped pneumocytes and macrophages, which may show background positivity for TTF-1 and Napsin A, to ensure accurate interpretation ... |
### Statistical Analysis |
Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25.0. Descriptive statistics such as mean, proportion, and standard deviation were used to summarize the findings. Clinical and demographic variables in this study were categorical. Age groups were divided into four categories with ... |
## Results |
During the study period, a total of 560 cases of lung carcinoma were diagnosed on biopsy. Of these, 70 cases were diagnosed as small cell carcinoma, and 490 were classified as non–small cell lung carcinoma (NSCLC). Among these, 95 consecutive NSCLC cases that met the inclusion and exclusion criteria were included in th... |
The majority of patients in the study were between 61 and 70 years of age, accounting for 37% of the total cases. A significant male predominance was noted, with a male-to-female ratio of 4.5:1. A history of current or previous tobacco smoking was present in 70% of the patients. |
Based on morphology alone, the frequency of each subtype is shown in Table 2. |
[TABLE] Frequency of distribution of subtype of Non‑Small Cell Lung Carcinoma (NSCLC) based on morphology. |
Histologic description | Cases |
Adenocarcinoma | 35 |
Squamous cell carcinoma | 57 |
NSCLC with adenosquamous morphology | 1 |
NSCLC – not otherwise specified | 2 |
Total | 95 |
Adenocarcinoma |
Morphologically, most adenocarcinoma cases exhibited a combination of acinar (77.1%) and solid (85.7%) arrangements in varying proportions. The tumor cells displayed vacuolated to eosinophilic cytoplasm in 51.4% of cases, vesicular nuclei in 51.4%, and prominent nucleoli in 82.9%, all of which were statistically signif... |
[TABLE] Clinicopathological characteristics of Adenocarcinoma and Squamous cell carcinoma |
Category | | ADC (Count) | ADC (%) | SCC (Count) | SCC (%) |
Age (in years) | 50 and below | 10 | 28.6% | 10 | 17.85% |
51-60 | 8 | 22.9% | 14 | 25% |
61-70 | 11 | 31.4% | 20 | 35.7% |
Above 70 | 6 | 17.1% | 12 | 21.42% |
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