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Case Reports

Abstract

A 55-year-old male presented with a 6 cm, exophytic scalp tumor that had been growing for 4 years and concerning for cutaneous malignancy. Punch biopsy was performed.  Shortly afterwards, the patient presented to the ED with acute neurologic changes.  He reported a past medical history of multiple craniotomies, embolization procedures, and radiation at outside institutions to address CNS meningiomas.  Imaging at this presentation demonstrated growth of previously seen intracranial meningiomas.

The biopsy consisted mostly of inflamed scar. On some levels, there were rare nests of bland epithelioid cells. Immunohistochemistry demonstrated focal expression of epithelial membrane antigen (EMA) and patchy expression of AE1/3 and D2-40; S100, SOX-10, and progesterone receptor (PR) were negative. The findings were compatible with meningioma in a surgical scar.

The patient underwent embolization followed by excision. The final pathology demonstrated a 5.4 x 4.9 x 3.1 cm meningioma with diffuse expression of SSTR2a and p16 and no expression of PR. Despite the aggressive presentation, rare mitoses were seen, and it was most consistent with a CNS WHO grade 1 meningioma. The prior CNS specimens were not available.

Cutaneous meningioma is a rare entity divided into 3 categories: congenital (type 1), heterotopic (type 2), or direct extension from intracranial meningioma (type 3). Histological diagnosis can be challenging due to its overlap with other dermal neoplasms. We present this extraordinary example to emphasize the importance of clinical history, sampling, and levels to prevent its misdiagnosis.