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Fabbrocini L, Zin F, Keyvani K, Ebner FH. Cauda equina neuroendocrine tumor: a report of three cases and review of the literature with focus on differential diagnosis and postoperative management. Neurosurg Rev 2024; 47:166. [PMID: 38632184 DOI: 10.1007/s10143-024-02405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/21/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Cauda equina neuroendocrine tumors (CENETs), previously described as cauda equina paragangliomas (PGLs) are rare and well-vascularized benign entities which can be often misdiagnosed with other intradural tumors more common in this anatomical site, such as ependymomas and neurinomas. We describe three cases of CENETs observed at our institution with particular focus on differential diagnosis and postoperative management. Since the lack of guidelines, we performed a literature review to identify factors that can predict recurrence and influence postoperative decision making. CASE REPORT AND LITERATURE REVIEW We report on three patients, two of them presenting with a clinical history of lower back pain and sciatica. In all cases magnetic resonance imaging (MRI) of the lumbosacral spine with and without Gd-DTPA revealed an intradural lesion with strong contrast enhancement, first described as atypical ependymoma or schwannoma. A complete tumor resection was achieved in all cases, the histopathological diagnosis classified the tumors as CENETs. In our literature review, a total of 688 articles were screened and 162 patients were included. Patients demographic data, clinical symptoms, resection and recurrence were recorded. DISCUSSION Differential diagnosis between CENETs and other more common tumors affecting cauda equina region, such as ependymomas or schwannomas (neurinomas), is still very challenging. Due to the lack of specific clinical or radiological characteristics, a correct preoperative diagnosis is almost impossible. With this paper we want to point out that CENETs must be considered in the differential diagnosis, most of all in case of entities with atypical radiological features. According to the literature, tumor recurrence after gross total resection is unlikely, while a long-term follow-up is recommended in case of subtotal resection or local aggressive behavior.
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Affiliation(s)
- L Fabbrocini
- Department of Neurosurgery, Alfried Krupp Hospital, Alfried Krupp Str. 21, 45131, Essen, Germany.
| | - F Zin
- Institute of Neuropathology, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - K Keyvani
- Institute of Neuropathology, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - F H Ebner
- Department of Neurosurgery, Alfried Krupp Hospital, Alfried Krupp Str. 21, 45131, Essen, Germany
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Ajmera P, Agarwal AK, Mehta PM, Benson JC, Madhavan AA, Diehn FE, Soni N, Bathla G. Cauda equina neuroendocrine tumors: A single institutional imaging review of cases over two decades. Neuroradiol J 2024; 37:84-91. [PMID: 37933451 PMCID: PMC10863566 DOI: 10.1177/19714009231212359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
Cauda Equina Neuroendocrine Tumors (CE-NET), previously referred to as paragangliomas are a rare subset of spinal tumors, with limited data on imaging. Herein, we present a retrospective review of clinical and imaging findings of CE-NETs in ten patients who were evaluated at our institution over the past two decades. All patients had well-defined intradural lesions in the lumbar spine which demonstrated slow growth. A review of imaging findings revealed the presence of an eccentric vascular pedicle along the dorsal aspect of the tumor in 8 of the 10 patients (eccentric vessel sign), a distinctive finding that has not previously been reported with this tumor and may help improve the accuracy of imaging-based diagnosis. In all cases, a gross-total resection was performed, with resolution of symptoms in most of the cases.
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Affiliation(s)
- Pranav Ajmera
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Amit K Agarwal
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Parv M Mehta
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Neetu Soni
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Girish Bathla
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Stonnington HO, Olson VA, Kalani MA, Krishna C, Patel NP, Bendok BR. Commentary: En Bloc Resection of a Cauda Equina Paraganglioma and Associated Intradural Hematoma After Diagnosis of Renal Clear Cell Carcinoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e144-e145. [PMID: 36637329 DOI: 10.1227/ons.0000000000000550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Henry O Stonnington
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, USA.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Vita A Olson
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Maziyar A Kalani
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Chandan Krishna
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Naresh P Patel
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA.,Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
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Nagaraj A, Jumah F, Raju B, Nanda A. Microsurgical Resection of a Paraganglioma of the Cauda Equina-A Technical Note: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e63. [PMID: 35591779 DOI: 10.1227/ons.0000000000000210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Anmol Nagaraj
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
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Munim MA, Butler AJ, Miller IJ, Colman MW. Paraganglioma of the Spine: Review of Six Cases in 20 Years at a Single Institution. World Neurosurg 2022; 163:e539-e548. [DOI: 10.1016/j.wneu.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
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Primary Paraganglioma of the Spine: A Systematic Review of Clinical Features and Surgical Management in Cauda Equina vs Non-Cauda Equina Lesions. World Neurosurg 2022; 161:190-197.e20. [PMID: 35123022 DOI: 10.1016/j.wneu.2022.01.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Primary spine paragangliomas are rare tumors. Surgical resection plays a role, but aggressive lesions are challenging. We reviewed the literature on primary spine paragangliomas. METHODS PubMed, Scopus, Web of Science, and Cochrane were searched upon the PRISMA guidelines to include studies on primary spine paragangliomas. Clinical-radiological features, treatments, and outcomes were analyzed and compared between cauda-equina vs non-cauda-equina tumors. RESULTS We included 143 studies comprising 334 patients. Median age was 46 years (range, 6-85). The most frequent symptoms were lower-back (64.1%) and radicular (53.9%) pain, and sympathetic in 18 patients (5.4%). Cauda-equina paragangliomas (84.1%) had frequently lumbar (49.1%) or lumbosacral (29%) locations. Non-cauda-equina tumors were mostly in the thoracic (11.4%), thoracolumbar (5.1%), and cervical (3.6%) spine. Median tumor diameter was 2.5cm (range, 0.5-13.0). Surgical resection (98.5%) was preferred over biopsy (1.5%). Decompressive laminectomy (53%) and spine fusion (6.9%) were also performed. Adjuvant radiotherapy was delivered in 39 patients (11.7%) with aggressive tumors. Post-treatment symptomatic improvement was described in 86.2% cases. Median follow-up was 19.5 months (range, 0.1-468.0), and 23 patients (3.9%) had tumor recurrences. No significant differences were found between cauda-equina vs non-cauda-equina tumors. CONCLUSION Surgical resection is effective and safe in treating primary spine paragangliomas; however, adjuvant treatments may be needed for aggressive lesions.
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Shtaya A, Iorga R, Hettige S, Bridges LR, Stapleton S, Johnston FG. Paraganglioma of the cauda equina: a tertiary centre experience and scoping review of the current literature. Neurosurg Rev 2021; 45:103-118. [PMID: 34021421 PMCID: PMC8827161 DOI: 10.1007/s10143-021-01565-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
Cauda equina paragangliomas are rare benign extra-adrenal neuroendocrine tumours arising from the neural crest cells associated with autonomic ganglia. These tumours are often mistaken preoperatively for ependymomas or schwannomas. Patients present with axial or radicular pain with or without neurological deficits. Recurrence, secretory features and length of follow-up are controversial. We conducted a retrospective cohort study of paraganglioma through searching a prospectively maintained histopathology database. Patient demographics, presentation, surgery, complications, recurrence, follow-up and outcome between 2004 and 2016 were studied. The primary aim was to collate and describe the current evidence base for recurrence and secretory features of the tumour. The secondary objective was to report outcome and follow-up strategy. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Ten patients were diagnosed (M:F 7:3) with a mean age of 53.6 ± 5.1 (range 34–71 years). MRI scans revealed intradural lumbar enhancing lesions. All patients had complete microsurgical excisions without adjuvant therapy with no recurrence with a mean follow-up of 5.1 ± 1.4 years. Tumours were attached to the filum terminale. Electron microscopic images demonstrated abundant neurosecretory granules with no evidence of catecholamine production. A total of 620 articles were screened and 65 papers (including ours) combining 121 patients (mean age 48.8 and M:F 71:50) were included. The mean follow-up was 3.48 ± 0.46 (range 0.15–23 years). Back pain was the most common symptom (94%). Cure following surgery was achieved in 93% of the patients whilst 7% had recurrence. Total resection likely results in cure without the need for adjuvant therapy or prolonged follow-up. However, in certain situations, the length of follow-up should be determined by the treating surgeon.
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Affiliation(s)
- Anan Shtaya
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK. .,Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK. .,Wessex Spinal Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Robert Iorga
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Samantha Hettige
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Leslie R Bridges
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.,Department of Cellular Pathology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Simon Stapleton
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Francis G Johnston
- Atkinson Morley Neurosurgery Centre, St George's University Hospitals NHS Foundation Trust, London, UK
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Rahimizadeh A, Ahmadi SA, Koshki AM, Rahimizadeh A, Karimi M. Paraganglioma of the filum terminal: Case report and review of the literature. Int J Surg Case Rep 2021; 78:103-109. [PMID: 33360629 PMCID: PMC7773680 DOI: 10.1016/j.ijscr.2020.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 12/03/2022] Open
Abstract
Paraganglioma of the filum terminal/cauda equina is a rare slow growing tumor which originates from the ectopic sympathetic neurons. Surgically, total excision may be difficult for this well demarcated tumor surrounded by couple of rootlets but is usually possible in nearly all cases. Actually, final diagnosis cannot be determined intraoperatively, but is possible only after an immunohistochemical staining. Herein, the authors present a middle age woman whose initial symptoms were lower back pain and radiculopathy. Her MRI was found to be compatible with a cauda equina tumor. During her excisional surgery a hard and relatively vascular tumor was fully removed. The Immunohistochemical results were compatible with paraganglioma of the filum terminale. In addition to case presentation, thorough review of the literature is also done.
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Affiliation(s)
- Abolfazl Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Seyed Ali Ahmadi
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Abdolreza Mohammadi Koshki
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Ava Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Mona Karimi
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
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Ramani B, Gupta R, Wu J, Barreto J, Bollen AW, Tihan T, Mummaneni PV, Ames C, Clark A, Oberheim Bush NA, Butowski N, Phillips D, King BE, Bator SM, Treynor EC, Zherebitskiy V, Quinn PS, Walker JB, Pekmezci M, Sullivan DV, Hofmann JW, Sloan EA, M Chang S, Berger MS, Solomon DA, Perry A. The immunohistochemical, DNA methylation, and chromosomal copy number profile of cauda equina paraganglioma is distinct from extra-spinal paraganglioma. Acta Neuropathol 2020; 140:907-917. [PMID: 32892244 PMCID: PMC7682537 DOI: 10.1007/s00401-020-02221-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/28/2020] [Accepted: 08/29/2020] [Indexed: 10/23/2022]
Abstract
Paragangliomas are neuroendocrine tumors of the autonomic nervous system that are variably clinically functional and have a potential for metastasis. Up to 40% occur in the setting of a hereditary syndrome, most commonly due to germline mutations in succinate dehydrogenase (SDHx) genes. Immunohistochemically, paragangliomas are characteristically GATA3-positive and cytokeratin-negative, with loss of SDHB expression in most hereditary cases. In contrast, the rare paragangliomas arising in the cauda equina (CEP) or filum terminale region have been shown to be hormonally silent, clinically indolent, and have variable keratin expression, suggesting these tumors may represent a separate pathologic entity. We retrospectively evaluated 17 CEPs from 11 male and 6 female patients with a median age of 38 years (range 21-82), none with a family history of neuroendocrine neoplasia. Six of the 17 tumors demonstrated prominent gangliocytic or ganglioneuromatous differentiation. By immunohistochemistry, none of the CEPs showed GATA3 positivity or loss of SDHB staining; all 17 CEPs were cytokeratin positive. Genome-wide DNA methylation profiling was performed on 12 of the tumors and compared with publicly available genome-wide DNA methylation data. Clustering analysis showed that CEPs form a distinct epigenetic group, separate from paragangliomas of extraspinal sites, pheochromocytomas, and other neuroendocrine neoplasms. Copy number analysis revealed diploid genomes in the vast majority of CEPs, whereas extraspinal paragangliomas were mostly aneuploid with recurrent trisomy 1q and monosomies of 1p, 3, and 11, none of which were present in the cohort of CEP. Together, these findings indicate that CEPs likely represent a distinct entity. Future genomic studies are needed to further elucidate the molecular pathogenesis of these tumors.
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Affiliation(s)
- Biswarathan Ramani
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Rohit Gupta
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Jasper Wu
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Jairo Barreto
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Andrew W Bollen
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Tarik Tihan
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Aaron Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Nancy Ann Oberheim Bush
- Division of Neuro-Oncology, Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Nicholas Butowski
- Division of Neuro-Oncology, Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Bruce E King
- Department of Pathology and Laboratory Medicine, Penn Medicine Lancaster General Hospital, Lancaster, PA, USA
| | - Susan M Bator
- Department of Pathology and Laboratory Medicine, Penn Medicine Lancaster General Hospital, Lancaster, PA, USA
| | | | - Viktor Zherebitskiy
- Department of Pathology and Laboratory Medicine, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | | | | | - Melike Pekmezci
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Daniel V Sullivan
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Jeffrey W Hofmann
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Emily A Sloan
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Susan M Chang
- Division of Neuro-Oncology, Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - David A Solomon
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Arie Perry
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA.
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