A rare case of a large spinal meningioma with mediastinal extension and malignant behavior classified histologically as benign.
OBJECTIVE
To report a rare case of a spinal WHO grade I meningioma extending through intervertebral foramina C7 to D4 with an extensive mediastinal mass and infiltration of the vertebrae, and to discuss the malignant behavior of a tumor classified as benign.


METHODS
(Clinical Presentation, Histology, and Imaging): A 54-year-old man suffered from increasing lower back pain with gait difficulties, weakness and numbness of the lower extremities, as well as urge incontinence. CT scan of the thorax and MRI scan of the spine revealed a large prevertebral tumor, which extended to the spinal canal and caused compression of the spinal cord at the levels of C7 to D4 leading to myelopathy with hyperintense signal alteration on T2-weighted MRI images. The signal constellation (T1 with and without contrast, T2, TIR) was highly suspicious for infiltration of vertebrae C7 to D5. Somatostatin receptor SPECT/CT with (111)In-DTPA-D: -Phe-1-octreotide detected a somatostatin receptor-positive mediastinal tumor with infiltration of multiple vertebrae, dura, and intervertebral foramina C7-D4, partially with Krenning score >2. Percutaneous biopsies of the mediastinal mass led to histopathological findings of WHO grade I meningioma of meningothelial subtype.


RESULTS
(Therapy): C7 to D4 laminoplasty was performed, and the intraspinal, extradural part of the tumor was microsurgically removed. Postoperative stereotactic radiation therapy was done using the volumetric modulated arc therapy (VMAT) technique (RapidArc). No PRRNT with (90)Y-DOTA-TOC was done.


CONCLUSIONS
Due to the rare incidence and complex presentation of this disease not amenable to complete surgical resection, an individualized treatment approach should be worked out interdisciplinarily. The treatment approach should be based not only on histology but also on clinical and imaging findings. Close clinical and radiological follow-up may be mandatory even for benign tumors.
Department of Internal Medicine, University of Bern, Bern, Switzerland.
S
S
Dahdal
R H
RH
Andres
E
E
Hewer
J C
JC
Reubi
B
B
Klaeser
A
A
Raabe
N
N
Cihoric
R
R
Schmid
K
K
Tänzler
T
T
Krause
D M
DM
Aebersold
M
M
Schmuecking
D003131:Combined Modality Therapy; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008482:Mediastinum / Q000473:pathology*; D008577:Meningeal Neoplasms / Q000473:pathology* / Q000628:therapy; D008579:Meningioma / Q000473:pathology* / Q000628:therapy; D008875:Middle Aged