Somatostatin receptor-2 negative meningioma: pathologic correlation and imaging implications

Meningiomas are the most common non-malignant primary intracranial tumors, accounting for nearly 40% of all primary brain tumors, usually expressing high levels of somatostatin receptors (SSTR), particularly SSTR2. Because 68Ga-DOTATATE targets SSTR2, it is increasingly used clinically for meningioma evaluation. While previous apparent lack of SSTR expression in meningiomas has been reported in isolated cases, these prior studies utilized Indium-111 (111In) Octreotide, which is of lesser diagnostic accuracy compared to 68Ga-DOTATATE, as well as Technetium-99m (99mTc)-DTPA scintigraphy, which necessitates an intact blood-tumor-permeability barrier. This paper presents a histopathologic proven atypical meningioma, WHO Grade II, with low level avidity on 68Ga-DOTATATE PET/MRI, subsequently proven to be SSTR2-negative by immunohistochemistry, with a review and discussion of the current literature and imaging implications. •Meningiomas express high levels of SSTR2 on their cell surface.•Meningiomas classically demonstrate intense avidity on 68Ga-DOTATATE PET.•Unusual case of an SSTR2-negative meningioma with low avidity on 68Ga-DOTATATE PET.•Discuss importance of this clinical entity with review of literature.