Highly anaplastic extraventricular ependymoma arising in an adult, mimicking metastatic adenocarcinoma with heavy stromal inflammation and emperiporesis

A case of myxopapillary ependymoma with predominant giant cell morphology: A rare entity with comprehensive genomic profiling and review of literature

In the evolving landscape of ependymoma classification, which integrates histological, molecular, and anatomical context, we detail a rare case divergent from the usual histopathological spectrum. We present the case of a 37-year-old man with symptomatic spinal cord compression at the L3-L4 level. Neuroradiological evaluation revealed an intradural, encapsulated mass. Histologically, the tumor displayed atypical features: bizarre pleomorphic giant cells, intranuclear inclusions, mitotic activity, and a profusion of eosinophilic cytoplasm with hyalinized vessels, deviating from the characteristic perivascular pseudorosettes or myxopapillary patterns. Immunohistochemical staining bolstered this divergence, marking the tumor cells positive for glial fibrillary acidic protein and epithelial membrane antigen with a characteristic ring-like pattern, and CD99 but negative for Olig-2. These markers, alongside methylation profiling, facilitated its classification as a myxopapillary ependymoma (MPE), despite the atypical histologic features. This profile underscores the necessity of a multifaceted diagnostic process, especially when histological presentation is uncommon, confirming the critical role of immunohistochemistry and molecular diagnostics in classifying morphologically ambiguous ependymomas and exemplifying the histological diversity within MPEs.

Giant-Cell Ependymoma of the Cervical Spinal Cord With Syringomyelia and Pathological Presentation: A Case Report and Review of the Literature

Ependymomas are unusual neuroepithelial tumors of the central nervous system that arise from clusters of ependymal cells. In adults, ependymomas are the most common primary spinal cord tumors. Nevertheless, only a few cases of large-cell ependymoma have been documented; these cases often involve the brain. Here, we report the case of a 43-year-old man who had a cervical spinal cord ependymoma with syringomyelia. The giant-cell ependymoma (GCE) in the spinal cord discussed in this case emphasizes the characteristics of GCE and the discrepancy between the pathological appearance, the surgical results, and the clinically good prognosis.

Giant Cell Ependymoma of Cervicomedullary Junction: A Case Report of a Long-Term Survivor and Literature Review

BACKGROUND

Ependymoma accounts for 3%-9% of all neuroepithelial tumors. Giant cell ependymoma (GCE) is a rare and distinct variant, with only 22 cases described in the literature. The 2007 World Health Organization classification first acknowledged this rare subtype. The cytologic features of GCE include the presence of pleomorphic giant cells with several cellular atypias, which at intraoperative frozen diagnosis may appear to be high-grade glial lesions. Despite its apparently malignant histology, GCE seems to be a neoplasm with a relatively good prognosis. Extended tumor removal is the gold standard without adjuvant treatment.

CASE DESCRIPTION

We describe the first case, to our knowledge, of GCE situated at the cervicomedullary junction in a 62-year-old patient. Surgery was performed with combined intraoperative monitoring of motor evoked potentials and somatosensory evoked potentials. Intraoperative frozen diagnosis revealed a high-grade glial neoplasm; however, gross total resection was achieved. The definitive diagnosis was GCE. At follow-up evaluation 11 years after surgery, the patient did not present with any tumor recurrence.

CONCLUSIONS

As the intraoperative diagnosis can be misleading, whenever a cleavage plane is recognized, it is essential to perform a gross total resection with the aid of intraoperative neurophysiologic monitoring, to improve prognosis and neurologic outcome. Data reported in the literature show that prognosis is mainly influenced by grade of resection.

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.

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 extraventricular anaplastic ependymoma presenting with repeated intratumoral hemorrhage

Supratentorial extraventricular anaplastic ependymomas are extremely rare. We report the case of a 23-year-old male with a supratentorial extraventricular anaplastic ependymoma that presented with repeated intratumoral hemorrhage. The patient was diagnosed with an intracerebral hematoma in the left occipital lobe and underwent operation. The hematoma did not reveal tumor cells, but a new tumor grew in the same location 5 years later. Magnetic resonance imaging showed a tumor with intratumoral hemorrhage. The patient underwent the tumor resection. Intraoperative findings showed that the tumor had no continuity with the ventricle. Histopathological examinations confirmed an anaplastic ependymoma. The spinal evaluation was unremarkable, and radiotherapy was administered to the left occipital lobe. Four years later, the tumor recurred at the cervicomedullary junction and T8-T9 levels. This case demonstrates that anaplastic ependymomas should be included in the differential diagnoses of supratentorial extraventricular tumors presenting with repeated intratumoral hemorrhage.

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.

Ventricular and Extraventricular Ependymal Tumors in 18 Cats

Ependymal tumors are reported rarely in domestic animals. The aims of this study were to examine the clinical and pathologic features of ventricular and extraventricular ependymomas and subependymomas in 18 domestic cats examined between 1978 and 2011. Parameters examined included age, sex, breed, clinical signs, and macroscopic and histopathologic features. The mean age of affected cats was 9 years, 4 months; median age, 8.5 years. There were 8 female and 4 male cats, and 6 cats for which sex was not recorded. Breeds included 10 domestic shorthaired, 2 domestic longhaired, 1 Persian, and 1 Siamese. Clinical signs included altered mentation or behavior, seizures, circling, propulsive gait, generalized discomfort, and loss of condition. The tumors often formed intraventricular masses and usually arose from the lining of the lateral or third ventricles, followed by the fourth ventricle, mesencephalic aqueduct, and spinal cord central canal. Three tumors were extraventricular, forming masses within the cerebrum and adjacent subarachnoid space. Histologically, 15 tumors were classified as variants of ependymomas (classic, papillary, tanycytic, or clear cell) and 3 as subependymomas. Tumors were generally well demarcated; however, 6 ependymomas focally or extensively infiltrated the adjacent neural parenchyma. Characteristic perivascular pseudorosettes were observed in all ependymomas; true rosettes were less common. Some tumors had areas of necrosis, mineralization, cholesterol clefts, and/or hemorrhage. This cohort study of feline ependymal tumors includes subependymoma and primary extraventricular ependymoma, variants not previously described in the veterinary literature but well recognized in humans.

Anaplastic ependymoma simulating glioblastoma in the cerebrum of an adult

A case of anaplastic ependymoma of the cerebral hemisphere in which the histopathological features closely simulated those of glioblastoma is reported. The patient was a 72-year-old woman with a large, well-demarcated tumor in the left temporal lobe. The tumor was totally extirpated, but recurred 18 months later, and the patient died after 4 months. The extirpated tumor was well circumscribed from the surrounding brain tissue and consisted of a sheet-like, dense proliferation of atypical, short spindle or polygonal cells. Extensive geographic necrosis with nuclear pseudopalisading was seen. Although perivascular pseudorosettes were observed in many areas, true ependymal rosettes were absent. Immunohistochemistry for glial fibrillary acidic protein and epithelial membrane antigen and ultrastructural study confirmed the ependymal nature of tumor cells. The histopathological spectrum of anaplastic ependymoma is very wide and reflects the basically dual characteristics of ependymal cells: epithelial and glial phenotypes. The present case indicates that some anaplastic ependymomas strongly express the glial phenotype and also show remarkable anaplastic cytological features, thus closely simulating glioblastoma. The diagnostic criteria for anaplastic ependymoma, and the nosological position of highly anaplastic ependymoma and its possible clinical implications, are briefly discussed.

Multiple chromosomal monosomies are characteristic of giant cell ependymoma

Giant cell ependymoma, a rare ependymoma subtype, was recently recognized as a separate diagnostic entity with variations both in malignant potential and course of disease. We analyzed the first supratentorial giant cell ependymoma using G-band karyotyping, DNA ploidy analysis, and array comparative genomic hybridization. The tumor was hypodiploid, and the karyotype showed multiple monosomies. This novel cytogenetic pattern seems specific for giant cell ependymoma as the only previous cytogenetic analysis of a giant cell ependymoma found similar monosomies. We were also able to analyze cytogenetically the subsequent recurrent tumor, phenotypically an anaplastic ependymoma, allowing a first insight into the genetic events involved in disease progression.

Tanycytic ependymoma of the spinal cord with anaplastic cytological features

In a 43-year-old man, an intramedullary spinal cord tumor spreading from the level of the T2 to T5 vertebrae was subtotally resected. The tumor predominantly consisted of a fascicular proliferation of spindle cells having bland nuclei and bipolar, long cytoplasmic processes, and a few perivascular pseudo-rosettes were found. Although there were no true ependymal rosettes, intracytoplasmic dot-like immunoreactivity for epithelial membrane antigen (EMA) was found in a few cells. In some areas, a dense and diffuse proliferation of anaplastic, short-spindled cells having hyperchromatic nuclei and scant cytoplasm was noted, and the Ki-67 labeling index was remarkably higher (18.2%) in these areas. Neither microvascular proliferation nor necrosis was observed. In the boundary region, these two areas showed gradual transition from one to the other. The patient has remained free from recurrence for 10 months postoperatively. This is the first documentation of tanycytic ependymoma in which tumor cells showed anaplastic cytological features.

Giant cell ependymoma of the thoracic spine: pathology case report

INTRODUCTION AND IMPORTANCE: Spinal ependymomas are slow-growing lesions that comprise the majority of primary spinal cord neoplasms. When surgery is indicated, the extent of tumor removal is most prognostic for long-term survival. Unusual histological subtypes can make intraoperative diagnosis spurious, possibly altering the surgical approach from gross total resection for ependymomas to debulking for high-grade astrocytomas.

CLINICAL PRESENTATION

We describe a 67-year-old woman with a thoracic spine intramedullary giant cell ependymoma. She presented with decreased lower extremity sensation leading to unsteadiness and an eventual fall. A physical examination revealed lower extremity hyperreflexia and ankle clonus, but no clear sensory level. Magnetic resonance imaging demonstrated an intramedullary T1 and T2 hypointense, homogenously enhancing lesion at T8 with extensive cephalad and caudal edema.

INTERVENTION AND TECHNIQUE

A laminectomy at T8 to T9 afforded gross total resection of the lesion that had a clear cleavage plane with normal spinal cord. Intraoperative pathology suggested a high-grade glioblastoma, but final section showed sporadic giant cells with marked pleomorphism, uniform immunofluorescence staining with both glial fibrillary acidic protein and cluster of differentiation 99, and high MIB-1 index. Electron microscopy showed "zipper-like" junctions. There were no detected genomic abnormalities consistent with glioblastoma.

CONCLUSION

We present this first reported case of thoracic spine giant cell ependymoma alongside scant literature yielding 1 case in the cervical spine and 2 cases at the filum terminale. Those cases had benign courses, whereas ours demonstrates a high degree of proliferation, making the malignant potential difficult to assess.

Giant cell ependymoma of the cervical spinal cord: case report and review of the literature

Ependymomas account for 2-6% of all central nervous system neoplasms. They develop from the ependymal cells that line the ventricular cavities of the brain and the central canal of the spinal cord, as well as from ependymal clusters in the filum terminale. Giant cell ependymoma (GCE) is a rare subtype, with few cases reported, mostly in the brain. We describe the case of a cervical spinal cord ependymoma with pleomorphic giant cells and focal calcifications occurring in a 25-year-old woman. Magnetic resonance imaging revealed a large multicystic and partially enhancing intramedullary tumour extending from C2 to C5. Intraoperative analysis of frozen section tissue fragments suggested a malignant tumour; however, an obvious cleavage plane was present around most of the mass, and a macroscopically complete tumour removal could be achieved. Subsequently, paraffin sections and immunohistochemical investigations revealed unequivocal evidence of a GCE with focal calcifications. This case, the second giant-cell ependymoma to be described in the spinal cord and the first with focal calcifications, highlights the features of GCE and the discrepancy between the worrisome histological appearance, the surgical findings and the clinical relatively good prognosis.

Suprasellar giant cell ependymoma: a rare neoplasm in a unique location

Ependymomas are glial tumors that usually present in the posterior fossa in children and in the spinal cord in adults. Giant cell ependymoma, a rare ependymal subtype only recently recognized as a diagnostic entity in the last decade, demonstrates pleomorphic giant cells admixed with features of typical ependymoma. Although only 8 giant cell ependymomas have been reported to date, none have been reported in the suprasellar space. Moreover, as these neoplasms demonstrate a high incidence of anaplastic grade, recognition of this ependymal subtype is paramount. We describe the presentation and pertinent radiologic, histologic, immunologic, and ultrastructural findings in conjunction with relevant clinical implications of the first reported case of a suprasellar giant cell ependymoma occurring in a 34-year-old female 7 years after an initial diagnosis of a medullary ependymoma with rare atypical giant cells, a potential tumor seeding culprit.

Giant cell ependymoma: a case report

Ependymomas account for 3-9% of all neuroepithelial tumors. A peculiar variant of ependymoma known as "giant cell ependymoma" ("GCE") is especially rarely reported, it may pose some difficulties for the diagnosing neuropathologist. Here we present a case of a giant cell ependymoma occuring in a 17-year-old patient with the history of 2-year recurrent headaches and a 1-month history of vision impairment. CT scanning demonstrated a mass in the left occipital lobe, arising from the occipital horn of the lateral ventricle. Histological, immunohistochemical and electron microscopic findings were consistent with high-grade ependymoma. Especially striking was the presence of bizzare pleomorphic giant cells which predominated in the tumor tissue. As a result the diagnosis of GCE was established. This type of neoplasm necessitates, at least in theory, differentiation with anaplastic oligodendroglioma, clear cell ependymoma, pleomorphic xanthoastrocytoma, giant cell glioblastoma, and subependymal giant cell astrocytoma. To date giant cell ependymomas (GCEs) were reported in seven cases in the literature. To the best of our knowledge this is the 8th case in the literature. In spite of apparently "worrisome" histology GCE seems to be a neoplasm with a relatively good prognosis.

Highly cystic brain tumor: rare histological features in an ependymoma

Ependymoma is a slowly growing tumor appearing mostly in children and young adults. Several histological patterns are described. We report a case with unusual microscopic features, composed mostly of multiple cysts. Ultrastructural and immunohistochemical examination confirmed the diagnosis. Neuropathologists should be aware of this particular change which can generate some diagnostic difficulties.

Rare giant cell ependymoma in an octogenarian. Case report and review of the literature

Ependymomas are glial tumors that occur most often in children. In adults, ependymomas most often appear in the spinal cord. The World Health Organization recognizes several rare ependymoma subtypes, including the giant cell ependymoma of the terminal filum. The authors describe an unusual case of a posterior fossa giant cell ependymoma in an 89-year-old man presenting with vertigo and disequilibrium. Only seven cases of this tumor have been reported in the literature to date. The authors discuss the clinical presentation, radiological findings, pathological considerations, and surgical intervention in this patient and review the relevant literature.

Infratentorial giant cell ependymoma: a rare variant of ependymoma

We describe a giant cell ependymoma occurring in a 50-year-old man. The mass was located in the posterior aspect of the foramen magnum, extending from the cerebellar tonsil to the upper cervical spine. The tumor was a highly cellular neoplasm showing biphasic histology. Diffuse sheets of non-cohesive atypical giant cells, having eccentrically located single or multiple nuclei and plump eosinophilic cytoplasm, partly infiltrated the desmoplastic inflammatory stroma. Parts of perivascular pseudorosette-forming or pseudopapillary areas were composed of atypically elongated cells, which looked like conventional anaplastic ependymoma. There was a transitional area between two patterns. Numerous mitoses and focal necrosis were observed. Immunohistochemically, the tumor cells were immunoreactive for glial fibrillary acidic protein, vimentin, S-100 protein, and CD99. None of the tumor cells showed immunoreactivity for epithelial membrane antigen except for the intracytoplasmic lumen of a few vacuolated cells. Ultrastructurally, tumor cells were ependymal in nature; we noted cytoplasmic intermediate filaments and intercellular microrosettes with microvilli, cilia, and long zonula adherens. The features of this tumor, e.g. its superficial location, mixed giant cells, perivascular pseudorosettes or papillaries, complicated its differentiation from rhabdoid/papillary meningioma. However, immunohistochemistry and electron microscopy confirmed the diagnosis of ependymoma. The giant cell variant should be included in the subclassification of the ependymoma.