WHO Grade II and III supratentorial hemispheric ependymomas in adults: case series and review of treatment options

Supratentorial extra-axial anaplastic ependymoma: a rare case report

Introduction and importance

Ependymomas are central nervous system tumors arising from the ependymal lining of the ventricle and spinal cord. Supratentorial extra-axial ependymomas are very rare, most commonly affecting the pediatric population and rarely in adults.

Case presentation

The authors report a case of a 71-year-old female with a headache and blurred vision. An MRI scan revealed a lesion at the parafalcine region of the occipital lobe. A parieto-occipital craniotomy was performed. When the dura was opened during the operation, the extra-axially located, well-circumscribed, dirty yellow-white tumor dissected from the surrounding tissue was excised entirely by microdissection. Histopathological examination revealed supratentorial extra-axial anaplastic ependymoma. The patient received postoperative radiation therapy (54 Gray over 30 fractions). No recurrence of the tumor was observed during the 4-year follow-up.

Discussion

Supratentorial ependymomas at the extra-axial region are uncommon; extra-axial anaplastic ependymoma and meningiomas have similar radiological findings, such as a dural tail, subarachnoid plane, and diffuse enhancement after contrast injection. This close similarity might cause misdiagnoses. Total surgical resection was followed by adjuvant radiotherapy and close follow-up in the gold standard of the treatment.

Conclusion

The authors report a rare case of anaplastic ependymomas located at the extra-axial region. Anaplastic tumors are prone to recurrence despite total resection and radiation therapy; hence, a close follow-up is warranted.

A rare presentation of extra-axial supratentorial ependymoma with subdural hematoma mimicking a parasagittal meningioma

Introduction

Primary extra-axial ependymomas, though rare, the majority of such lesions are identified as WHO grade III ependymomas. These ependymomas may mimick a meningioma on radiological investigations which can be confirmed by histopathology.

Research Question

We show in this case report a rare presentation of extra-axial supratentorial ependymoma with concomitant subdural hematoma mimicking a parasagittal meningioma.

Material and Methods

A 59 years lady with no known comorbidities presented with weakness of right half of body and decreased speech for 2 days. She was aphasic. Contrast MRI brain revealed an extra-axial dural-based homogenously enhancing lesion in the left anterior 1/3^rd parasagittal area with left frontotemporoparietal chronic subdural hematoma. With a provisional diagnosis of meningioma, the patient was subjected to bifrontal open-book craniotomy with gross total excision of lesion with periosteal graft duraplasty and acrylic cranioplasty. Left sided frontotemporal subacute SDH with thin greenish yellow membrane was present. In post operative period, patient quickly became E4V5M6 with power of 4/5 in the right half of body which was same as compared to the preoperative period.

Results

The biopsy of the mass, however, revealed features suggestive of extra-axial supratentorial ependymoma (WHO Grade III). Immunohistochemistry supported the diagnosis of supratentorial ependymoma, NOS. The patient was then referred for further chemoradiation.

Discussion and Conclusion

We report the first case of extra-axial supratentorial ependymoma mimicking a parasagittal meningioma occurring with adjacent subdural hematoma. Clinical and imaging background along with a complete pathological examination with immunohistochemical study is essential to confirm the diagnosis of rare brain tumours.

Supratentorial cortical ependymoma: A systematic literature review and case illustration

Cortical ependymomas are currently not considered a subgroup of supratentorial ependymomas; however, there is a growing body of literature investigating the natural history of these lesions compared to supratentorial ependymomas. We performed a systematic literature review of cortical ependymomas with a focus on the natural history, clinical characteristics, and clinical outcomes of these lesions as compared to supratentorial ependymomas. Our search revealed 153 unique cases of cortical ependymomas. The mean age on presentation was 21.2 years. Males and females comprised 58.8% (90/153) and 41.2% (63/153) of cases, respectively. The most common presenting symptom was seizure activity occurring in 44.4% of the cohort (68/153). The recently recognized C11orf95-RELA fusion was identified in 13.7% of the cohort (21/153) and 95.5% of cases (21/22) reporting molecular characterization. World Health Organization grades 2 and 3 were reported in 52.3% (79/151) and 47.7% (72/151) of cases, respectively. The frontal lobe was involved in the majority of cases (54.9%, 84/153). Gross total resection was achieved in 80.4% of cases (123/153). Tumor recurrence was identified in 27.7% of cases (39/141). Mean clinical follow-up was 41.3 months. Mean overall survival of patients who expired was 27.4 months whereas mean progression-free survival was 15.0 months. Comparatively, cortical ependymomas with C11orf95-RELA fusions and supratentorial ependymomas with C11orf95 RELA fusions exhibited differing clinical outcomes. Further studies with larger sample sizes are necessary to investigate the significance of RELA fusions on survival in cortical ependymomas and to determine whether cortical ependymomas with C11orf95-RELA fusions should be classified as a distinct entity.

Differentiation between supratentorial pilocytic astrocytoma and extraventricular ependymoma using multiparametric MRI

BACKGROUND

The differentiation of supratentorial pilocytic astrocytomas (STPAs) and supratentorial extraventricular ependymomas (STEEs) is clinically pivotal because of distinct therapeutic management and prognosis, which is sometimes challenging to both neuroradiologists and pathologists.

PURPOSE

To explore and compare the conventional and advanced magnetic resonance imaging (MRI) features between STPA and STEE.

MATERIAL AND METHODS

A total of 23 patients with STPAs and 23 patients with STEEs were reviewed in this study. All patients performed conventional MRI, susceptibility-weighted imaging (SWI), and diffusion-weighted imaging (DWI), and 34 patients (17 with STPAs and 17 with STEEs) examined dynamic susceptibility contrast-enhanced perfusion-weighted imaging (DSC-PWI) in addition. Clinical data, conventional MRI features, minimum relative apparent diffusion coefficient ratio (rADC_min), and maximum relative cerebral blood volume ratio (rCBV_max) were compared between the two groups and subgroups. The optimal cutoff values of rADC_min and rCBV_max with sensitivity and specificity were calculated.

RESULTS

STPA manifested similar to STEE as a solid-cystic mass but more frequently presented with a marked enhancing deep nodule (P = 0.02), no peritumoral edema (P = 0.036), higher rADC_min value (2.0 ± 0.5 vs. 0.9 ± 0.2; P < 0.001), and lower rCBV_max value (2.1 ± 0.4 vs. 14.4 ± 5.5; P < 0.001). The cutoff value of >1.39 for rADC_min and ≤ 2.81 for rCBV_max produced a high sensitivity of 95.65% and 100.0%, respectively, and all produced a specificity of 100.0% in differentiating STPAs from STEEs.

CONCLUSION

Multiparametric MRI techniques including conventional MRI, DWI, and DSC-PWI contribute to the differential diagnosis of STPA and STEE.

Cortically based cystic supratentorial RELA fusion-positive ependymoma: a case report with unusual presentation and appearance and review of literature

Ependymomas are rare central nervous system tumors that can arise anywhere in the neuroaxis. Supratentorial and posterior fossa ependymomas were identified as distinct diseases after extensive molecular analysis. The 2016 World Health Organization update further introduced RELA fusion-positive ependymoma as a novel entity as a subset of supratentorial ependymomas indicating the presence of C11orf95-RELA fusion genes. RELA fusion-positive ependymomas are commonly intraventricular, though they may rarely manifest as extraventricular, cortically-based tumors. They are commonly large solid, mixed solid/cystic tumors or rarely cystic. In this paper, we report a case of RELA fusion positive cortically based-cystic ependymoma and review the existing literature. Our patient is a 9-year-old boy who presented with an unusual presentation of right facial droop. He underwent gross total resection of the ependymoma, following resection, his facial droop resolved and there was no neurologic deficit.

The Survival and Prognostic Factors of Supratentorial Cortical Ependymomas: A Retrospective Cohort Study and Literature-Based Analysis

Aim

Survival rates and prognostic factors of cortical ependymomas (CEs) remain elusive. This study aimed to perform a comprehensive analysis of prognostic factors, treatment, and outcomes for patients with CEs based on institutional and literature case series.

Materials and Methods

Thirty patients with CEs from our department were included in this study. Furthermore, a systemic review of the literature yielded an additional 106 patients with CEs. Clinical data including patient age, sex, symptoms, tumor location, World Health Organization (WHO) grade, extent of surgery, radiation, recurrence, and survival were recorded and statistically analyzed.

Results

From January 2009 to October 2019, 30 (4.2%) cases were diagnosed as CEs in our department. These series consisted of 19 males and 11 females, 10 continuous patients after 2017 screened for C11orf95-RELA fusion, and 9 patients (90%) were RELA fusion positive. During the follow-up period, nine (30%) patients depicted tumor recurrence or progression; four (13.3%) patients died of tumor progression. The literature review yielded 106 CE cases, with additional 30 cases of our own collected for further analysis. Of these 136 cases, the frontal lobe (40%) was the most common location, and the average age was 22.6 ± 17.6 years. Anaplastic histology/WHO grade III tumors were identified in 68 (50%) patients. Statistically analysis demonstrated that extent of surgery and WHO tumor grade were significant prognostic factors in Kaplan–Meier log-rank testing and Cox proportional hazards models. Gross total resection (GTR) predicted longer progression-free survival (PFS) [P = 0.013, hazard ratio (HR) = 3.012, 95% confidence interval (CI) = 1.257–7.213] and overall survival (OS) (P = 0.003, HR = 5.322, 95% CI = 1.751–16.178). WHO grade III tumors had worse PFS (P = 0.002, HR = 5.17, 95% CI = 1.804–14.816) and OS (P = 0.025, HR = 5.640, 95% CI = 1.248–25.495).

Conclusion

CEs accounted for only 3.5 to 5.7% of ependymomas, with seizures the most common symptom and the frontal lobe the most frequent location. CEs may have higher rate of RELA fusions, but generally favorable prognosis. The extent of surgery and WHO tumor grade were significant prognostic factors for PFS and OS in multivariate analysis. GTTR or WHO grade II tumors had better overall outcome in patients with CEs.

Comparison of Conventional, Diffusion, and Perfusion MRI Between Low-Grade and Anaplastic Extraventricular Ependymoma

OBJECTIVE. The purpose of this study was to investigate and compare conventional MRI, DWI, and dynamic susceptibility contrast-enhanced perfusion-weighted imaging (DSC-PWI) characteristics between low-grade and anaplastic extraventricular ependymomas. MATERIALS AND METHODS. Twenty-six patients with extraventricular ependymomas (19 anaplastic and seven low-grade) who underwent preoperative MRI were enrolled in this retrospective study. Conventional MRI and DWI were performed in all patients; DSCPWI was performed in 15 patients (11 with anaplastic ependymoma and four with low-grade ependymoma). Demographics, conventional MRI features, minimum relative apparent diffusion coefficient (rADC_min), and maximum relative cerebral blood volume (rCBV_max) of the low-grade and anaplastic ependymomas were compared. Diagnostic performance with optimal cutoff values was determined. RESULTS. Anaplastic extraventricular ependymomas were more likely to be located in the superficial supratentorial cerebral hemisphere (p = 0.026) and to present with pial and cortical involvement (p = 0.028 and 0.013, respectively) and necrotic degeneration (p = 0.014). The mean rADC_min ± SD of anaplastic ependymoma was significantly lower than that of low-grade ependymoma (0.8 ± 0.2 vs 1.2 ± 0.3, p = 0.002). The mean rCBV_max of anaplastic ependymoma was significantly higher than that of low-grade ependymoma (15.7 ± 5.3 vs 9.0 ± 4.4, p = 0.042). The cutoff values in grading extraventricular ependymoma were 1.02 for rADC_min and 10.43 for rCBV_max. Combining conventional MRI, DWI, and DSC-PWI allowed the best differentiation of low-grade and anaplastic ependymoma (AUC = 1.00). CONCLUSION. Conventional MRI, DWI, and DSC-PWI techniques may aid in assessing and grading extraventricular ependymomas.

MRI Features of Intracranial Anaplastic Ependymomas: A Comparison of Supratentorial and Infratentorial Lesions

Background: Several previous reports of anaplastic ependymomas have described their imaging features, and most of these studies were case reports. However, no studies have compared the magnetic resonance imaging (MRI) features between the infratentorial and supratentorial anaplastic ependymomas.

Objective: The goal of this study was to explore MRI characteristics for intracranial anaplastic ependymomas.

Material and Methods: We retrospectively reviewed the demographics of 165 patients and MRI findings of 60 patients with supratentorial (SAEs) and infratentorial anaplastic ependymomas (IAEs) before surgery. The demographics and MRI features for SAEs and IAEs were compared and evaluated.

Results: Among the 60 patients, most SAEs (91.7%) were extraventricular, whereas most IAEs (91.7%) were intraventricular. Of sixty intracranial anaplastic ependymomas, most lesions were well-defined (n = 45) and round-like (n = 36). On T1-weighted imaging, compared with the gray matter, the SAEs exhibited heterogeneous signal intensity, whereas IAEs exhibited iso-hypointense signals. T2 signals exhibited greater associations with hyperintense signals in IAEs; however, SAEs showed hyperintense or hypointense–hyperintense. On diffusion-weighted imaging (DWI), almost all solid tissues of SAEs appeared as hyperintense, whereas IAEs exhibited iso-hypointense signals. Peritumoral edema and intratumoral hemorrhage occurred more frequently in SAEs. Almost all anaplastic ependymomas exhibited heterogeneous enhancement. Cysts or necrosis was associated with 56 anaplastic ependymomas; however, large cysts were more prevalent in SAEs. On magnetic resonance spectroscopy (MRS), the mean choline/creatine (Cho/Cr) and choline/N-acetyl-aspartate (Cho/NAA) ratio of anaplastic ependymomas were (6.58 ± 4.26) and (8.84 ± 6.34), respectively, representing typical high-grade tumors.

Conclusion: We demonstrate the conventional and functional MRI features of intracranial anaplastic ependymomas, including DWI and MRS. MRI characteristics, such as location, cyst, diffusion restriction, and peritumoral edema, differed between supratentorial and infratentorial locations. Cho/Cr and Cho/ NAA ratios of anaplastic ependymomas are increased.

World Health Organization Grade III Supratentorial Extraventricular Ependymomas in Adults: Case Series and Review of Treatment Modalities

Context:

Supratentorial ependymomas and their anaplastic variants are relatively uncommon central nervous system neoplasms that afflict both adults and children.

Aims:

Discuss the clinical and pathological features of patients with anaplastic ependymomas involving an extraventricular supratentorial location and review modalities and options of treatment for those rare tumors.

Settings and Design:

Whereas the treatment algorithm in the pediatric population is well established, however, treatment in the adult population is less defined. Treatment options are exposed through the author's cases and review of the literature.

Subjects and Methods:

In our case series of two adult patients with supratentorial ependymomas World Health Organization (WHO) Grade III (anaplastic variant), patients presented in both cases in the emergency room after having a generalized tonic–clonic seizure at home the first case, and mild hemiparesis the second case.

Results:

Patients underwent surgical treatment, and a gross total resection was achieved in both cases. The histopathological examination revealed a diagnosis of anaplastic ependymoma (WHO Grade III). Both patients had additional radiotherapy, and in the first case, adjuvant platinum-based chemotherapy was administered due to leptomeningeal gliomatosis.

Conclusion:

In our experience, gross total resection was achieved in all patients with supratentorial extraventricular ependymomas WHO Grade III with additional radiotherapy and platinum-based chemotherapy. Patients require initial close serial imaging follow-up. The role of chemotherapy is still uncertain but may be necessary in younger patients and in tumors that behave more like the pediatric ependymomas.

Supratentorial Pure Cortical Ependymoma: An Unusual Lesion Causing Focal Motor Aware Seizure

Ependymomas usually arise from the ependymal lining cells of the ventricular system and central canal of the spinal cord. Supratentorial ependymoma is a rare entity with the variable clinical course. In a small number of cases, ependymoma arises from supratentorial parenchyma. Only a few cases are reported in the literature. We report a case of 3-year-old girl with left frontal mass. Total removal of the mass lesion was performed without any neurological deficit. Pathological examination of the excised tumor was consistent with anaplastic ependymoma. We have discussed management strategy of this rare entity.

Clinicopathological and Genetic Features of Supratentorial Cortical Ependymomas

OBJECTIVE

Supratentorial cortical ependymomas (CEs) are rare. These lesions, selectively occurring in the superficial cortex, have not been fully characterized. We analyzed the clinicopathological and genetic features of CEs.

METHODS

Eight patients with CEs from our institution and 84 other reported CE cases were included in the present study. We retrospectively reviewed their clinical characteristics, imaging findings, treatment methods, pathological features, molecular status, and clinical outcomes.

RESULTS

The median age at diagnosis of our 8 patients was 7.5 years. The mean tumor diameter was 70 mm. All the tumors had a cystic appearance, and calcification was observed in 6. Gross total resection was achieved in 6 patients and subtotal resection in 2 patients. Of the 8 tumors, 7 were World Health Organization grade III and 1 was World Health Organization grade II. Six tumors were immunopositive for L1 cell adhesion molecule (L1CAM). We investigated the presence of C11orf95-RELA fusion in 5 patients, all of whom exhibited it. Postoperative radiotherapy was performed for all patients with grade III tumors, except for children aged <3 years. Although 4 patients developed recurrence, all were alive throughout the follow-up period. Compared with previously reported CEs, our patients were younger and had larger tumors; however, the clinical outcomes did not differ significantly.

CONCLUSIONS

Although most CEs in our group were immunopositive for L1CAM and showed C11orf95-RELA fusion, which have been associated with a poor prognosis in supratentorial ependymomas, all our patients had good outcomes. Gross total resection and adjuvant radiotherapy contributed to the relatively favorable prognosis of CEs compared with other supratentorial ependymomas.

Updates in the Neuoroimaging and WHO Classification of Primary CNS Gliomas: A Review of Current Terminology, Diagnosis, and Clinical Relevance From a Radiologic Prospective

As new advances in the genomics and imaging of CNS tumors continues to evolve, a standardized system for classification is increasingly essential to diagnosis and management. The molecular markers introduced in the 2016 WHO classification of CNS tumors bring both practical and conceptual advances to the characterization of gliomas, strengthening the prognostic and predictive value of terminology while shedding light on the underlying mechanisms that drive biologic behavior. The purpose of this article is to provide a succinct overview of primary intracranial gliomas from a neuroradiologic prospective and according to the 5th edition WHO classification that was revised in 2016. An update of the molecular markers pertinent to defining the major lineages of brain gliomas will be provided, followed by discussion of the terminology, grading and imaging features associated with individual entities. Neuroradiologists should be aware of the key genomic and radiomic features of common brain gliomas, and familiar with an integrated approach to their diagnosis and grading.

Supratentorial Cortical Ependymomas: A Retrospective Series of 13 Cases at a Single Center

OBJECTIVE

Cortical ependymomas (CEs), supratentorial ependymomas that selectively involve the cerebral cortex, are relatively rare neoplasms that have not been extensively described. The purpose of our study was to identify the clinical features, radiologic characteristics, and treatment of a series of such tumors.

METHODS

Thirteen patients with CEs from our hospital were included in this study. Epidemiologic characteristics, clinical features, imaging findings, treatment methods, and clinical outcomes were reviewed retrospectively.

RESULTS

The patients consisted of 7 men and 6 women with mean age of 31.1 ± 23.2 years (range, 4-74 years). The most common clinical manifestation was seizure (n = 11; 85%), followed by headache (n = 2; 15%). None of the tumors were incidentally detected. Eight CEs were located in the right hemisphere and 5 in the left side. The 2 most common tumor locations were the frontal (n = 5; 38%) and parietal lobe (n = 5; 38%). All patients underwent surgical resection. Gross total resection was achieved in 12 patients (92%), and subtotal resection was performed in 1 patient (8%). Ten of the 11 patients who presented with seizure are seizure-free after surgery (91% seizure-free rate). According to the World Health Organization classification system, 9 tumors (69%) were Grade II (ependymoma) and 4 (31%) were Grade III (anaplastic ependymoma). The mean follow-up was 52 months (range, 20-88 months). No recurrence was observed in patients with Grade II CEs. Of 4 patients with Grade III CEs, 2 (50%) suffered from tumor recurrence after initial treatment.

CONCLUSIONS

CEs are a rare subset of supratentorial ependymomas that selectively involve the cerebral cortex. Most CEs are low grade and present with seizures. Anaplastic CEs show a greater recurrence rate and a relatively poor prognosis. Gross total resection with or without adjuvant radiotherapy is currently the optimal treatment for CEs. CEs seem to have a more favorable prognosis than other supratentorial ependymomas.

Adult Supratentorial Extraventricular Anaplastic Ependymoma: Therapeutic Approach and Clinical Review

We report a 69-year-old patient with left paresthesia and hemiparesis. Magnetic resonance imaging revealed a right frontoparietal cystic tumor. A subtotal surgical resection was performed, and an Ommaya reservoir was left in place. The pathological diagnosis was supratentorial extraventricular anaplastic ependymoma. Radiation therapy was administered, and Ommaya reservoir drainages were performed. Four months after, her clinical status deteriorated after a reservoir drainage and image revealed an acute hemorrhage. An additional resection was carried out, and chemotherapy was undergone. One month later the tumor relapsed and the patient died 18 months after initial diagnosis. Some poor prognostic factors have been suggested in the literature: Young age, incomplete tumor resection – eloquent area location, histological anaplasia, supratentorial, and extraventricular locations. Ommaya reservoirs may be used in cystic lesions as a temporary measure only. Surgery is the mainstay of therapy with adjuvant radiotherapy and/or chemotherapy.

Pituitary Ependymoma, 10-Year Follow-Up after Partial Resection and Radiation Therapy

Ependymoma usually arises within the ventricles and central canal of the spinal cord. These tumors, found in the sellar region, are extremely rare. We report a case of pituitary ependymoma followed up over 10 years. A 59-year-old male patient presented with fatigue, general weakness, erectile dysfunction, and loss of body hair, including pubic hair. Brain magnetic resonance imaging (MRI) revealed a 3.3×3.5×2.3-cm sellar and suprasellar snowman-shaped enhancing mass. The tumor was partially resected via the trans-sphenoidal approach followed by postoperative radiation therapy. The pathologic confirmation was pituitary ependymoma. At the 10-year follow up, MRI revealed no evidence of tumor progression. With lack of knowledge about pituitary ependymoma, our case is the only case in which the disease has been well controlled over a long period of time without tumor progression.

Clinical, radiological, and histological features and treatment outcomes of supratentorial extraventricular ependymoma: 14 cases from a single center

OBJECTIVE Reports on supratentorial extraventricular ependymoma (STE) are relatively rare. The object of this study was to analyze the clinical, radiological, and histological features and treatment outcomes of 14 patients with STE. METHODS Overall, 227 patients with ependymoma underwent surgical treatment in the authors' department between January 2010 and June 2015; 14 of these patients had STE. Data on clinical presentation, radiological studies, histopathological findings, surgical strategies, and treatment outcomes in these 14 cases were retrospectively analyzed. RESULTS The patients consisted of 6 women and 8 men (sex ratio 0.75). Mean age at diagnosis was 24.5 ± 13.5 years (range 3-48 years). Tumors were predominantly located in the frontal and temporal lobes (5 and 4 cases, respectively). Typical radiological features were mild to moderate heterogeneous tumor enhancements on contrast-enhanced MRI. Other radiological features included well-circumscribed, "popcorn" enhancement and no distinct adjoining brain edema. Gross-total resection was achieved in 12 patients, while subtotal removal was performed in 2. Radiotherapy was administered in 7 patients after surgery. Seven tumors were classified as WHO Grade II and the other 7 were verified as WHO Grade III. The mean follow-up period was 22.6 months (range 8-39 months). There were 3 patients with recurrence, and 2 of these patients died. CONCLUSIONS Supratentorial extraventricular ependymoma has atypical clinical presentations, various radiological features, and heterogeneous histological forms; therefore, definitive diagnosis can be difficult. Anaplastic STE shows malignant biological behavior, a higher recurrence rate, and a relatively poor prognosis. Gross-total resection with or without postoperative radiotherapy is currently the optimal treatment for STE.

Magnetic resonance imaging findings of extraventricular anaplastic ependymoma: A report of 11 cases

Anaplastic ependymomas are rare malignant tumors of the central nervous system. Few studies are available regarding their neuroradiological characteristics. The present study aimed to retrospectively review a series of patients with extraventricular anaplastic ependymoma and to analyze the magnetic resonance imaging (MRI) characteristics to distinguish anaplastic ependymoma from other intracranial tumors. The clinical and pathological images of 11 patients who presented with histologically proven anaplastic ependymoma at Nanfang Hospital (Southern Medical University, Guangzhou, Guangdong, China) between September 2004 and March 2015 were retrospectively reviewed. MRI scans were obtained in all 11 cases. Computed tomography scans were obtained in only 3 cases. In total, 8 tumors were located at the supratentorial parenchyma, and 3 tumors were derived from the cerebellar hemisphere. Images displayed quasi-circular (4/11), irregularly-lobulated (7/11) variable-intensity masses. The masses presented with cysts or necrosis (8/11), hemorrhage (7/11), marked (9/11) or mild (2/11) enhancement, and moderate (4/11), mild (3/11) or absent (4/11) peritumoral edema. The tumors were also frequently closely associated with the lateral ventricle (6/11). Tumors appeared isointense to hypointense on T1-weighted imaging (T1WI) and heterogeneously hyperintense or hypointense on T2WI, demonstrating wreath-like and ring-like characteristics, with intratumoral nodules (3/11) or marked flake-like inhomogeneous (6/11) enhancement on post-contrast MRI. Only 2 solid lesions showed mild enhancement (2/11). Although the MRI features of the extraventricular anaplastic ependymomas varied and were non-specific, these characteristic MRI findings, combined with the locations of the lesions, the age of onset and the short disease course, could be useful in differentiating anaplastic ependymomas from other intracranial neoplasms in the future.

Primary Intracranial Extra-Axial Anaplastic Ependymomas

BACKGROUND

Ependymomas are usually located in the ventricular system or in the central canal of the spinal cord; intracranial extra-axial ependymomas (IEAEs) are rare. To date, only 17 cases of IEAEs have been reported.

CASE DESCRIPTION

We report 2 cases with 3 IEAEs (anaplastic) that were initially misdiagnosed. In Case 1 (47-year-old male), the para-falcine lesion was initially refractory to radiosurgery and gross total resection (GTR) was required due to relentless growth. The lesion had adhered to the falx and was well demarcated from the surrounding cortex. It was then correctly diagnosed as an anaplastic ependymoma on the basis of histopathology, and the patient received radiotherapy. No recurrence was observed after the 53-month follow-up. In Case 2 (30-year-old male), 2 IEAEs underwent staged surgeries and were identified as extra-axial lesions without connection to the ventricular system. Near total resection (NTR) and GTR were achieved in the right temporal and right occipital lesions, respectively, but the patient declined radiotherapy. The residual tumor after NTR regrew rapidly, and aggressive resection was performed followed by radiotherapy. No further recurrence was observed after 28 months. The previous 17 cases were male predominant (76.5%) without correct preoperative diagnoses; no recurrence was observed after total resection in the 9 patients reported in the literature.

CONCLUSIONS

IEAEs are rare and have a wide spectrum of clinical and radiological phenotypes. Preoperative diagnosis is difficult. Favorable outcomes for IEAEs can be achieved by GTR plus radiotherapy. Multiple IEAEs benefit from tailored staged surgical resection plus radiotherapy.

Supratentorial hemispheric ependymomas: an analysis of 109 adults for survival and prognostic factors

OBJECTIVE Survival rates and prognostic factors for supratentorial hemispheric ependymomas have not been determined. The authors therefore designed a retrospective study to determine progression-free survival (PFS), overall survival (OS), and prognostic factors for hemispheric ependymomas. METHODS The study population consisted of 8 patients from our institution and 101 patients from the literature with disaggregated survival information (n = 109). Patient age, sex, tumor side, tumor location, extent of resection (EOR), tumor grade, postoperative chemotherapy, radiation, time to recurrence, and survival were recorded. Kaplan-Meier survival analyses and Cox proportional hazard models were completed to determine survival rates and prognostic factors. RESULTS Anaplastic histology/WHO Grade III tumors were identified in 62% of cases and correlated with older age. Three-, 5-, and 10-year PFS rates were 57%, 51%, and 42%, respectively. Three-, 5-, and 10-year OS rates were 77%, 71%, and 58%, respectively. EOR and tumor grade were identified on both Kaplan-Meier log-rank testing and univariate Cox proportional hazard models as prognostic for PFS and OS. Both EOR and tumor grade remained prognostic on multivariate analysis. Subtotal resection (STR) predicted a worse PFS (hazard ratio [HR] 4.764, p = 0.001) and OS (HR 4.216, p = 0.008). Subgroup survival analysis of patients with STR demonstrated a 5- and 10-year OS of 28% and 0%, respectively. WHO Grade III tumors also had worse PFS (HR 10.2, p = 0.004) and OS (HR 9.1, p = 0.035). Patients with WHO Grade III tumors demonstrated 5- and 10-year OS of 61% and 46%, respectively. Postoperative radiation was not prognostic for PFS or OS. CONCLUSIONS A high incidence of anaplastic histology was found in hemispheric ependymomas and was associated with older age. EOR and tumor grade were prognostic factors for PFS and OS on multivariate analysis. STR or WHO Grade III pathology, or both, predicted worse overall prognosis in patients with hemispheric ependymoma.

Supratentorial cortical ependymoma: An unusual presentation of a rare tumor

Ependymomas are glial tumors derived from ependymal cells lining the ventricles and the central canal of the spinal cord. Two thirds of ependymomas arise in the infratentorial or intraventricles, whereas one-third are located in supratentorial space. But supratentorial "cortical" ependymomas are very rare. We report a case of a cortical ependymoma in a 17-year-old boy. The patient presented with transient recurrent right weakness and diplopia. This tumor was located in the left parieto-occipital region and he had gross total excision. Microscopy and immunohistochemistry showed grade III differentiation ependymoma.

Prognosis by tumor location in adults with intracranial ependymomas

Intracranial ependymomas are rare tumors in adults. Thus, factors affecting prognosis are poorly understood. We performed a study to investigate whether tumor location is an important prognostic factor in adults who undergo surgery for intracranial ependymomas. PubMed was searched to identify studies that reported clinical outcomes in adult patients with intracranial ependymoma. Data were extracted for patient and tumor characteristics, extent of resection, progression-free survival (PFS), and overall survival (OS). Tumors were categorized as supratentorial or infratentorial and extraventricular or intraventricular. Presenting clinical features and tumor characteristics were tabulated. Kaplan-Meier and multivariate Cox regression survival analyses were performed to determine PFS and OS by tumor location. Extent of resection was also analyzed by tumor location. A total of 183 patients were included in the meta-analysis. Patients presented at a mean of 8.2months with a myriad of clinical features. The mean tumor size was 3.38 cm, and 19.3% of tumors were cystic. Supratentorial tumors were most commonly located in the frontal and parietal lobes, and infratentorial tumors in the fourth ventricle. Supratentorial tumors demonstrated significantly poorer PFS (p<0.001) and OS (p=0.003) than infratentorial tumors, despite a higher rate of gross total resection (GTR) for the supratentorial tumors (72.6% versus 42.1%). Extraventricular ependymomas displayed significantly poorer PFS than intraventricular ependymomas (p=0.009). In summary, supratentorial ependymomas have significantly poorer PFS and OS than their infratentorial counterparts, despite being more conducive to GTR, suggesting increased clinical aggressiveness. Extraventricular location is also associated with significantly poorer PFS than intraventricular location.

Ectopic cortical anaplastic ependymoma: an unusual case report and literature review

Ependymona occasionally occurs outside the ventricular structures, which is called ectopic ependymona (EE), while pure cortex location is uncommon. However, cortical anaplastic ependymoma (CE) is rare, especially in children. There were only four primary CEs, which is located in the superficial cortex, were reported the age of the patient under 12 years old. The present case is a 20-month-old boy presenting with simple partial seizure was treated in our department. Cranial magnetic resonance imaging (MRI) revealed a fronto-parietal lobe mass of more than 50mm in diameter with mixed signal intensity. Total removal of the mass lesion was performed without any neurological deficit. Pathological examination of the excised tumor were consistent with anaplastic ependymoma (AE). The patient had a good recovery after his surgical resection. Radiotherapy and chemotherapy were not taken into account in view of his age, the favorable site and the complete resection. The management of this unusual tumor is summarized in this paper.

Cortical anaplastic ependymoma with significant desmoplasia: a case report and literature review

Ectopic brain anaplastic ependymomas with no connection to the ventricles are rare. We present a rare case of a 25-year-old male who presented with generalized convulsions. Computed tomography (CT), Magnetic Resonance Imaging (MRI), and magnetic resonance spectroscopy (MRS) showed characters of an intra- and extra-axial lesion. Intraoperatively, the lesion was a cortical solid mass that had no connections to the dura or to the ventricle. The histological diagnosis showed an anaplastic ependymoma with WHO grade III with distinctive desmoplasia. A literature review of ectopic anaplastic ependymomas regarding their clinical presentations, management, and prognostic factors was performed. There is a need to establish a clinically based histopathological grading system for anaplastic ependymomas. Ectopic anaplastic ependymomas should be included in the preoperative differential diagnosis.

Natural history and role of radiation in patients with supratentorial and infratentorial WHO grade II ependymomas: results from a population-based study

Patients with World Health Organization (WHO) grade II supratentorial ependymomas are commonly observed after gross total resection (GTR), although supporting data are limited. We sought to characterize the natural history of such tumors. We used the Surveillance, Epidemiology, and End Results program to identify 112 patients ages 0-77 diagnosed with WHO grade II ependymomas between 1988 and 2007, of whom 63 (56 %) and 49 (44 %) had supratentorial and infratentorial primaries, respectively. Inclusion criteria were strict to ensure patient homogeneity. Of 33 patients with supratentorial tumors after GTR, 18 (55 %) received adjuvant radiation therapy and 15 (45 %) did not. Ependymoma-specific mortality (ESM) was the primary endpoint. With a median follow up of 4.5 years, only 1 of 33 patients with supratentorial ependymoma died of their disease after GTR; the 5-year estimate of ESM in this population was 3.3 % (95 % CI 0.2-14.8 %). Among patients with infratentorial ependymomas after GTR, the 5-year estimate of ESM was 8.7 % (95 % CI 1.4-24.6 %). In patients with subtotally resected tumors, 5-year estimates of ESM in patients with supratentorial and infratentorial primaries were 20.1 % (95 % CI 8.0-36.2 %) and 12.3 % (95 % CI 2.9-28.8 %), respectively. Among the whole cohort, on both univariable and multivariable regression, extent of resection was predictive of ESM, while tumor location and use of radiation were not. After GTR, patients with WHO grade II supratentorial ependymomas have a very favorable natural history with low associated cancer-specific mortality. Observation, with radiation reserved as a salvage option, may be a reasonable postoperative strategy in this population.

A systematic review of treatment outcomes in pediatric patients with intracranial ependymomas

OBJECT

Ependymoma is the third most common primary brain tumor in children. Tumors are classified according to the WHO pathological grading system. Prior studies have shown high levels of variability in patient outcomes within and across pathological grades. The authors reviewed the results from the published literature on intracranial ependymomas in children to describe clinical outcomes as they relate to treatment modality, associated mortality, and associated progression-free survival (PFS).

METHODS

A search of English language peer-reviewed articles describing patients 18 years of age or younger with intracranial ependymomas yielded data on 182 patients. These patients had undergone treatment for ependymoma with 1 of 5 modalities: 1) gross-total resection (GTR), 2) GTR as well as external beam radiation therapy (EBRT), 3) subtotal resection (STR), 4) STR as well as EBRT, or 5) radiosurgery. Mortality and outcome data were analyzed for time to tumor progression in patients treated with 1 of these 5 treatment modalities.

RESULTS

Of these 182 patients, 69% had supratentorial ependymomas and 31% presented with infratentorial lesions. Regardless of tumor location or pathological grade, STR was associated with the highest rates of mortality. In contrast, GTR was associated with the lowest rates of mortality, the best overall survival, and the longest PFS. Children with WHO Grade II ependymomas had lower mortality rates when treated more aggressively with GTR. However, patients with WHO Grade III tumors had slightly better survival outcomes after a less aggressive surgical debulking (STR+EBRT) when compared with GTR.

CONCLUSIONS

Mortality, PFS, and overall survival vary in pediatric patients with intracranial ependymomas. Pathological classification, tumor location, and method of treatment play a role in outcomes. In this study, GTR was associated with the best overall and PFS rates. Patients with WHO Grade II tumors had better overall survival after GTR+EBRT and better PFS after GTR alone. Patients with WHO Grade III tumors had better overall survival after STR+EBRT. Patients with infratentorial tumors had improved overall survival compared with those with supratentorial tumors. Progression-free survival was best in those patients with infratentorial tumors following STR+EBRT. Consideration of all of these factors is important when counseling families on treatment options.

Supratentorial extraventricular anaplastic ependymoma in an adult with repeated intratumoral hemorrhage

We report the case of a 61-year-old man with supratentorial extraventricular anaplastic ependymoma who presented with repeated intratumoral hemorrhage. The patient was admitted with headache. Computed tomography and magnetic resonance imaging showed an enhancing mass with intratumoral hemorrhage in the right temporal lobe. Gross total resection was performed. The tumor was well demarcated from the brain tissue, and showed no continuity with the ventricular system. Histopathological examination revealed the features of anaplastic ependymoma. Therefore, additional radiation therapy and adjuvant chemotherapy were administered. Ten months later, the tumor recurred with hemorrhage in the spinal canal. This case showed rapid malignant progression and repeated intratumoral hemorrhage within a short period of time, both of which are characteristics of anaplastic ependymomas. Close observation of the central nervous system and adjuvant radiotherapy are mandatory, even if the ependymoma presents with repeated intratumoral hemorrhage.

Anaplastic supratentorial cortical ependymoma presenting as a butterfly lesion

BACKGROUND

Anaplastic cortical ependymomas are rare lesions with few cases reported in the literature.

CASE DESCRIPTION

We present a unique case of an anaplastic cortical ependymoma in a 51-year-old female presenting as a butterfly lesion with involvement of both frontal lobes. The patient underwent gross total resection of her tumor with further adjuvant treatment. We present the findings in our case and review the literature surrounding supratentorial ependymomas and their treatment outcomes.

CONCLUSION

Rarely, cortical ependymoma can present as a butterfly lesion and should be considered in the differential diagnosis of such lesions in adults.

The complete surgical resection without the radiotherapy for a recurred anaplastic ependymoma at the cervicomedullary junction

The intramedullary anaplastic ependymoma rarely occurs in the cervicomedullary junction. A 45-year-old woman had a history of right arm pain for several months. Magnetic resonance imaging (MRI) of the cervical spine demonstrated an intramedullary tumor with syrinx at the cervicomedullary junction. The patient underwent a partial resection at another institute. Neurologic deficit worsened after the first surgery. The follow up MRI showed that the enlarged enhancing tumor and syrinx still existed with the same size and configuration. Complete surgical resection was achieved in the revision surgery. Final histologic examination confirmed the diagnosis of an anaplastic ependymoma, and since complete surgical resection was achieved the patient did not receive adjuvant radiation or chemotherapy. The patient was followed-up periodically at the outpatient department, and at the 7 months follow-up the muscle tone of the right hand was normal but with mild sensory deficit, and the MRI demonstrated no evidence of recurrent disease. Intramedullary anaplastic ependymoma that occur in the cervicomedullary junction which are completely resected may be followed-up without adjuvant radiation or chemotherapy to attain good clinical outcome.

Role of neurosurgery and radiation therapy in the management of brain tumors

In the United States, approximately 65,000 people are diagnosed with primary brain tumors each year, with an incidence of 19.3 cases per 100,000 person-years. These numbers represent a wide spectrum of disease, from benign to malignant, and prognosis varies widely based on disease. Treatment of primary brain tumors most often uses a combination of surgery and radiation. However, over the past several generations, technological advancements have significantly altered the treatment paradigm. This article reviews the current role of neurosurgery and radiation therapy in the management of primary brain tumors.

Supratentorial clear cell ependymoma mimicking oligodendroglioma : case report and review of the literature

Clear cell ependymomas (CCEs) are rare variants of ependymomas. Tumors show anaplastic histological features and behave as an aggressive manner. CCEs have a predilection for extraneural metastases and early recurrence, and they demonstrate characteristic radiographic features. These tumors should be radiologically and pathologically differentiated from oligodendrogliomas. On microscopic examination, CCEs are composed of sheets of cells and resemble oligodendroglioma. However, upon closer examination, the nature of CCEs can be detected earlier, resulting in prompt treatment of the tumor. Although we report only one case, we emphasize the importance of early diagnosis and treatment. Future description of more cases of these rare cancers is necessary to aid in their diagnosis and treatment.

Supratentorial cortical ependymoma in a 21-month-old boy

Two-thirds of ependymomas arise in the infratentorial or intraventricles, whereas one-third are located supratentorially. But supratentorial "cortical" ependymomas are very rare. We report a case of a cortical ependymoma in a 21-month-old boy. The patient presented with simple partial seizures. This tumor was located in the postcentral gyrus and he had gross total excision. Microscopy and immunohistochemistry showed grade II differentiation ependymoma.

Extraventricular anaplastic ependymoma with metastasis to scalp and neck

We report a case of anaplastic ependymoma with extracranial metastases in a 22-year-old female. The patient originally presented with headaches and dysarthria. Neuroimaging revealed a large solid and cystic right fronto-temporal lesion. It was located completely extraventricularly and a glioblastoma was suspected based on the neuroimaging findings. A gross total resection was achieved. Histopathologic examination revealed an anaplastic ependymoma. The patient was treated with radiotherapy. Approximately 1 year after the initial surgery, the patient presented with metastatic disease to the scalp. At 2 years, an intraparotid metastasis was detected. Subsequent neck dissection revealed positive lymph nodes at several levels. It was followed by radiotherapy to the neck. 5 years after the initial surgery, the patient has residual metastatic disease. The case is discussed and the literature on extraventricular ependymal neoplasms is reviewed.