To present a rare case of metastatic meningioma to supraclavicular lymph node with concomitant CD5+ B-cell Lymphoma upon commencing bevacizumab therapy after multiple failed resections and radiation therapy.

Meningiomas account for approximately 15% of all primary CNS tumors and are the most common extra-axial tumors. Distant metastases of meningiomas are rare with less than 1% occurrence, but have been described to lung, bone, liver and rarely to lymph nodes.

88-year-old Cuban male after incidentally being diagnosed with a right parietal meningioma in April 2014, underwent initial craniotomy with placement of a mesh. Subsequently he had recurrence with progression showing nodular dural enhancement of the right parietal region. He then underwent re-resection showing atypical meningioma with initiation of radiation therapy to the right parietal region of 59.4 Gy with volumetric arc radiation therapy (33 fractions) and IGRT from 11/17 to 12/17. In January 2020, he was found out to have re-recurrence in the right parieto-occipital region and underwent re-resection showing anaplastic meningioma. Bevacizumab therapy was started in 03/2020 but discontinued when he suffered from pulmonary embolism in 02/22. Later he was found out to have re-recurrence involving the mastoid with thrombosis of distal right transverse sinus which was treated with SRT radiation (5.0 Gy/5 fractions, total dose: 25.0 Gy) from 10/22 to 11/22. Most recently in 07/23, patient presented with an asymptomatic enlarging fixed right supraclavicular neck mass and its biopsy revealed metastatic malignant meningioma grade III similar to the prior tumors with flow cytometry demonstrating CD5+ B-cell lymphoma. Palliative radiation therapy to the right supraclavicular mass was started but he progressed on treatment and was placed on hospice.

Physicians must remain aware of the possibility of distant, often isolated spread in patients with a long history of recurrent atypical meningiomas presenting with lymphatic adenopathy.