How to interpret the findings of molecular testing reports of a resected tumor?

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As you did not describe the location, imaging, and patient history, it is very difficult for a clinician like me to give you a quality consult.

Nevertheless, the NF2 mutation that you mentioned in your note is the famous mutation that is seen in neurofibromatosis type 2. It is a genetic disorder that causes multi-benign tumors around nerves and nerve sheets in the brain, spinal cord, and peripheral nerves. For example, it can cause acoustic neuroma around the vestibular nerve and cause hearing problems or even palsy of one-half of the face. You also mentioned the BRIP mutation that is related to ovarian and breast cancer susceptibility. I cannot relate these two separate mutations to one condition.

You should request a consult from a geneticist.

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Now, I have a better image of the situation. I saw your attached documents (attachments removed to protect the privacy of the patient). The good news is that your brother's brain tumor is yet benign (non-cancerous and not malignant) because it is a grade 2 meningioma. Nevertheless, there is another side that is not good; the grade 2 atypical meningioma with NF2 and BRIP1 mutations means that the tumor has a high ability of recurrence, and it means that he may need multiple surgeries and the chance of changing to grade 3 (transformation to malignancy) would be notable in the future.

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Please note that the grading of meningioma is mainly based on its behavior under a microscope. The pathology report (under a microscope) defined the type grade 2 (non-cancerous). Fortunately, the molecular testing of malignant (grade 3) type meningioma (TERT or CDKN) was not seen in the samples. The NF2 mutation is not a definite grade 3 tumor, but as I said previously, it tells us that your brother's tumor has the ability of multiple recurrences, and in each recurrence, it has the ability to change its manner and transform into a grade 3 (malignant). Moreover, the existence of NF2 mutation tells us the tumor is not grade 1. The BRIP mutation is not related to grade 3 as well. In summary, regarding the NF2 and the pathology report of cells' features under the microscope, the grade of your brother's tumor is grade 2 (non-malignant).

All the above would be true if the pathologist's diagnosis of the tumor were true. If you are suspicious about the pathology report, request a second opinion from another pathologist or pathology center. In your brother's case, if the pathology says possibly that the grade is 3, with the same molecular report, it would be a grade 3. I mean that the pathology report is the cornerstone of grading the tumor. I hope that my explanation has clarified the whole grading process for you.

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I hope so. The answer to your first question is: according to WHO (world health organization) classification, NF2-positive tumors may be grade 2 or grade 3 (the pathology report is crucial to determine which grade it is). In your brother's case, the report says it is a grade 2 (atypical meningioma). The answer to 2nd question is; I am a neurologist, not a pathologist. I just rely on the final diagnosis in the pathology report. It is the reason that I recommended you request a second pathologist's opinion if you do not trust that hospital report. In such cases, the second pathologist gives the opinion usually by seeing the histological samples by themselves, not just by reading the report.