case_images: PMC10811062_01
case_images: Magnetic resonance imaging (MRI) and intraoperative findings. (A) Preoperative and postoperative MRI at initial presentation, showing a partially contrast-enhancing lesion in the left frontal lobe with a cyst, which was completely removed by surgery. (B) Preoperative and postoperative MRI at the time of recurrence and correspondence with intraoperative findings. (a) Multiple small, enhanced lesions adhering to the dura, and (b) the largest heterogeneously enhanced lesion.
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case_images: Magnetic resonance imaging (MRI) of the head showed a neoplastic lesion with a cyst in the left frontal lobe ( Figure 1A ), and he underwent craniotomy. The tumor in the left convexity dura was extensively resected and was replaced with Durawave  ( Figure 1B ). Surgical findings showed that small lesions undetectable on MRI were also attached to the dura mater ( Figure 1Ba ).
case_images: Histopathological findings of the tumor and dura. (A) Hematoxylin and eosin (HE) staining of the tumor at initial presentation is shown. Cells with hyperchromatic large nuclei formed a perivascular pseudorosette and proliferated (scale bar, 100 mum). (B) HE staining of excised dura at the time of tumor recurrence (scale bar, 5000 mum) and immunostaining for D2-40 and CD34 in serial sections (scale bar, 500 mum) are shown. The dura mater, which appeared normal macroscopically, showed tumor cells attached to the dura mater when observed microscopically after staining. In addition to D2-40+ tumor cells, many D2-40+/CD34+ lumens were observed in the dura at the tumor attachment site. (C) Fluorescence immunostaining of the dura at the tumor attachment site (scale bar, 50 mum). D2-40+/CD34+ lymphatic vessels proliferated in the dura mater of the tumor-adherent area (white arrow). Blood vessels showed D2-40-/CD34+ (yellow arrow). (D) The number of the lymphatic vessels at the tumor attachment site was significantly higher than that in the normal dura mater (19 vs 0, p<0.05, Mann-Whitney U test). There was no significant difference in the number of blood vessels between the tumor attachment site and normal dura mater (14 vs 15.6, p=0.66, Mann-Whitney U test). Each square (a, b, c) shown in the HE staining on the left corresponds to the respective immunostain on the right.
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case_images: f2
case_images: The findings are consistent with anaplastic ependymoma ( Figure 2A ). The dura mater, which appeared normal macroscopically, also had multiple tumor lesions upon microscopic examination, showing similar histopathological features ( Figure 2B ).  INC., Tokyo, Japan) as a marker of vascular endothelial cells ( Figure 2B ). In addition to luminal structures that appeared to be lymphatic vessels, the tumor was also positive for D2-40. Immunofluorescence staining for D2-40 and CD34 was also performed ( Figure 2C ), which showed proliferation of the D2-40+/CD34+ lymphatic vessels in the dura mater in the tumor-adherent area. The dura mater at the tumor attachment site was measured in 5 areas, and 5 areas of normal dura mater were also measured and compared ( Figure 2D ).
case_images: Molecular examination of the tumor. (A) Detection of ZFTA-RELA translocation in DNA extracted from specimens. (a) Electrophoresis showed a band at the position of the fusion of ZFTA exon 2 and RELA exon 2. (b) Sequence analysis also showed the ZFTA-RELA fusion. (B) Comparison of epithelial-to-mesenchymal transition factors (SNAI1, SNAI2, ZEB1, and TWIST1) in this case and another ependymoma. ZEB1 was elevated compared with in ependymoma without dural lesions. Data represent the mean +- SEM.
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case_images: ZFTA fusion-positive, CNS WHO grade 3 (without dural lesions) at our hospital ( Figure 3B ). ZEB1 was elevated in this case compared with ependymoma without dural lesions (P<0.001).