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东港安泰医院 病理科梁燕青主任
表一 脑膜瘤的组织分级(Histological grading)
| Histological |
Grade
|
|||
| Feature |
0
|
1
|
2
|
3
|
| Hypercellularity | 10whorls/HPF | Same except increasedcellularity in perivascularareas | Less defined small,more closely packedwhorls(up to 30 per HPF) | Densely crowed over-lapping nuclei with loss of whorls |
| Nuclearpleomorphisms | Uniform, blandnuclei,no nucleoi,"pepper and salt"chromatin | Occasional larger nuclei,2 or 3times larger withirregular contours | Many cells with large pale unclei, small nonprominent nucleoli | Most cells with large,vesicular nuclei,variable size,prominent nucleoli |
| Mitosis | None | 1-2 per 10 HPFs | 3-4 per 10 HPFs | >5 per10HPFs |
| Necrosis | None | Rare, each involvingless than 1/2 of HPF | Frequent foci involvingmore than but less than 1/2 but more than 1HPF | Large, confluent areas of necrosis more than1HPF |
| Loss of architecture | None | Incipient loss | Involving 1-2 adjacentHPF | Involving more than 2 adjacent HPFs |
| Brain invasion | Absent | Tumor pushing the brain without intervening meninges | Cords infiltrating the brain | |
HPF, high-power field
Neurosurgery, vol. 33, NO6, December 1993
依此标准，本病例第一次手术主要部分的检体的可得0~1分，分级属于"良性"的分类，而次要部分的检体，可得5~7分，分级属于"异常"。但第二次检体 之组织级数高达13分，分级属于恶性。
综合以上，我们认为第一次手术时的肿瘤诊断应为脑膜瘤合并部分细胞异常(meningioma with focal cellular atypism)或异常的脑膜瘤(atypical meningioma)，如此似更能理解复发时所发现的恶性转变。所以一个明确客观的诊断标准对正确的诊断及预后判断是有正面意义。在临床表现上，我们的病人为41岁女性，其发生年龄较一般脑膜瘤好发年龄稍早，而复发时间也比一般接受肿瘤全切除的病患短4，可知此肿瘤有相当的恶性潜力(malignant biological potential)。其位在脑室虽属罕见，但恶性脑膜瘤并没有明显的好发位置。另外在CT及MRI的表现，复发前后均表现出明显的周边脑水肿及局部钙化。但这在诊断潜在恶性上并无明显的贡献。其他研究也都倾向此看法。复发前后的症状虽有不同，但都属于非特异的表现。
◎结语
恶性脑膜瘤为一罕见的肿瘤，而组织学上分歧的诊断标准更增加其诊断的困难度，也常造成组织学上的判断和临床表现不相符合。所以我们认为一明确、客观而广为大部分人所接受的标准是十分重要的。
◎参考文献
1. Mahmood A. Caccamo DV et al:Atypica (and malignant menigioma - a clinicopathological review. Nenrosurg 1993；33 : 955 ~63)
2. Repola D, weatherlee L : Meningioma with sarcomatons change and hepatic metastasis Arch pathol Lab. Med 1976 ; 100 : 667-9
3. Russel Ds , Rubistein LT : Pathology of tumor of the Nervous Sysytem. London, Edward Arnold, 1988, ed 5, p449-532
4. Simpson D : The recurrence of intracranial meningiomas after surgical treatment . J. Neural Neurosurgery psychiatry20: 22 ~ 39, 1957
5. Ferracimi R,Poggi S,Frank G,etal: Meningeal sarcomawith Rabdomyo-bbastic differnti- ation:case Report. Neuroswzgery 1992; 30: 782-5
6. Vagner-capodano AM et al : Corrwlation between cyto- genltic and histopatho- logical finding in 75 human reningiomas. Neuroswzgery 1993;32: 892 ~900
7.Wong MP,Cham KW:Benign meta- stasiging meningioma. Clin Neurol Neurosurgery 1990; 92: 152~4
8.Mirimanoff RO et al : Meningioma- analysis of recurrence and Progression following neurosurgical resection . J Neurosung1985; 62: 18-24