Recurrent (Nonfamilial) Hemangioblastomas Involving Spinal Nerve Roots: Case Report

Aggressive dissemination of central nervous system hemangioblastoma without association with von Hippel–Lindau disease: A case report and literature review

Background:

Hemangioblastomas (HBs) typically present with benign behavior and are most commonly found in the posterior fossa. Multiple central nervous system (CNS) HBs are usually associated with von Hippel–Lindau disease, and leptomeningeal dissemination of sporadic HBs is extremely rare. A review of the literature identified 30 cases of leptomeningeal dissemination of sporadic HBs previously published in the literature.

Case Description:

We report the case of a patient who was diagnosed with multiple CNS HBs with aggressive progression 6 years after resection of a posterior fossa HB. He underwent multiple surgeries and died 4 years after the diagnosis of the first spinal dissemination.

Conclusion:

Dissemination of sporadic HBs is rare and aggressive disease evolution is usually observed. Further studies are necessary to determine the optimal therapeutic options.

Novel Clinical Insights into Spinal Hemangioblastoma in Adults: A Systematic Review

BACKGROUND

Hemangioblastomas (HBs) are well-vascularized, benign central nervous system tumors and the third most common primary spinal cord tumor after astrocytoma/ependymoma, occurring sporadically or as a part of autosomal dominant von Hippel-Lindau disease, in which tumors are often multiple and prone to relapse. Spinal HBs are commonly located in the cervical cord and associated with a syrinx formation. Owing to location and growth trends, they may cause significant neurological deficit, impairing quality of life. We conducted a systematic review to understand better clinical insights into spinal HB in adults and compare spinal HB versus posterior cranial fossa HB.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews, we reviewed the English-language literature on adult spinal HB in the MEDLINE/PubMed database over the last 40 years.

RESULTS

We reviewed 237 articles on adult spinal HB and analyzed national and continental distribution, clinical symptoms, tumor location and presence of syringomyelia, treatment strategies and postoperative complications, histology and immunochemistry, and treatment outcomes. We compared individual characteristics in sporadic and von Hippel-Lindau disease spinal HBs. Finally, we compared features of posterior cranial fossa and spinal HBs.

CONCLUSIONS

Spinal cord HBs most commonly have a dorsal intramedullary location. Total surgical tumor resection is the first treatment option; preoperative embolization may be performed to reduce intraoperative bleeding and surgical time. HBs located in the spine have decreased mortality and rate of infection, but increased rates of cardiopulmonary complications compared with HBs in the posterior cranial fossa.

Disseminated central nervous system hemangioblastoma in a patient with no clinical or genetic evidence of von Hippel-Lindau disease-a case report and literature review

BACKGROUND

Hemangioblastomas (HB) are benign tumors of the central nervous system (CNS) that can appear sporadic or as part of von Hippel-Lindau (VHL) disease. It is often curable with surgical resection, but upon relapse, the disease exhibits a treatment-refractory course.

CASE REPORT

A patient treated for sporadic cerebellar HB relapsed 12 years post-surgery. She developed disseminated disease throughout the CNS, including leptomeningeal manifestations. Repeat surgery and craniospinal radiation therapy were unsuccessful.

CONCLUSION

This case is in line with previous publications on disseminated non-VHL HB. Available treatment options are inefficient, emphasizing the need for improved understanding of HB biology to identify therapeutic targets.

Extraneuraxial hemangioblastoma: A clinicopathologic study of 10 cases with molecular analysis of the VHL gene

Less than 250 extraneuraxial hemangioblastomas occurring in paraneuraxial or peripheral sites have been reported to date, sporadically or in the setting of von Hippel-Lindau disease. Seventeen such cases underwent molecular genetic analysis, using either the patient's peripheral blood in 9 cases or paraffin embedded tumor tissue in the rest. VHL gene mutations were documented in 3/9 cases in which DNA from peripheral blood lymphocytes was used, all with clinically manifest von Hippel-Lindau disease; instead, no VHL gene alterations were found in all of the 8 cases with sporadic extraneuraxial hemangioblastoma in which DNA from tumor tissue was analyzed. Our aim is to investigate the molecular genetic profile of the VHL gene in extraneuraxial hemangioblastoma using paraffin embedded tumor tissues. The clinical features, histopathology, and molecular investigations of 10 extraneuraxial hemangioblastomas (7 females, 3 males; median age: 47 years) are presented herein. The histopathologic diagnosis was supported by immunohistochemistry (10/10) and electron microscopy (4/10). Molecular genetic analysis was conducted (10/10) for VHL gene mutations, LOH, and gene promoter methylation. Two of the present cases were already published with only limited or no molecular investigations. Four tumors of the present series were paraneuraxial, and 6 peripheral (2 involved soft tissues, and 4 the kidney). One tumor was von Hippel-Lindau disease-associated, 1 was classified as "hemangioblastoma-only VHLD", 7 were sporadic, and one was unknown. All were histopathologically analogous to their counterpart located inside the central nervous system. Immunophenotypically, all tumors expressed vimentin, S-100, NSE, and alpha-inhibin (10/10). Ultrastructurally, unbound lipid droplets filled the cytoplasms of the stromal cells. Molecular analysis revealed 3 inactivating mutations (1 germline, two somatic) in the coding sequence of the VHL gene in 2 different extraneuraxial hemangioblastomas, and LOH in 4 (two as a double hit), all non-renal extraneuraxial hemangioblastomas. Methylation analysis failed to disclose promoter methylation in any case. In conclusion, we report eight new cases from the wide category of extraneuraxial hemangioblastomas (4 paraneuraxial, and 4 renal), one of which was von Hippel-Lindau disease-associated and 7 sporadic. VHL gene alterations were found not only in the von Hippel-Lindau disease-associated tumor, but - for the first time - also in 3 sporadic ones, two of which with novel mutations.

Extraneuraxial Hemangioblastoma: Clinicopathologic Features and Review of the Literature

Extraneuraxial hemangioblastoma occurs in nervous paraneuraxial structures, somatic tissues, and visceral organs, as part of von Hippel-Lindau disease (VHLD) or in sporadic cases. The VHL gene plausibly plays a key role in the initiation and tumorigenesis of both central nervous system and extraneuraxial hemangioblastoma, therefore, the underlying molecular and genetic mechanisms of the tumor growth are initially reviewed. The clinical criteria for the diagnosis of VHLD are summarized, with emphasis on the distinction of sporadic hemangioblastoma from the form fruste of VHLD (eg, hemangioblastoma-only VHLD). The world literature on the topic of extraneuraxial hemangioblastomas has been comprehensively reviewed with ∼200 cases reported to date: up to 140 paraneuraxial, mostly of proximal spinal nerve roots, and 65 peripheral, 15 of soft tissue, 6 peripheral nerve, 5 bone, and 39 of internal viscera, including 26 renal and 13 nonrenal. A handful of possible yet uncertain cases from older literature are not included in this review. The clinicopathologic features of extraneuraxial hemangioblastoma are selectively presented by anatomic site of origin, and the differential diagnosis is emphasized in these subsets. Reference is made also to 10 of the authors' personal cases of extraneuraxial hemangioblastomas, which include 4 paraneuraxial and 6 peripheral (2 soft tissue hemangioblastoma and 4 renal).

[Hemangioblastoma of the right L4 nerve root with radicular extraforaminal involvement]

Hemangioblastomas are benign hypervascular tumours, which are frequently located at the posterior fossa or the spinal cord. Nerve root hemangioblastomas account for less than 2% of total cases. Sometimes the initial diagnosis can be inaccurate and the final diagnosis is not reached until the surgical procedure is performed. Given the high vascularisation of this particular kind of tumour, preoperative embolisation of the tumour is recommended to reduce surgical bleeding and minimise the risk of injuries to motor nerve roots. In this particular case, the patient presented with radicular pain in the right L4 nerve root territory originated by a radicular extraforaminal hemangioblastoma. After tumour devascularization and under neurophysiological control, total excision of lesion was achieved without posterior neurological deficit.

Typical magnetic resonance features of a haemangioblastoma, an uncommon nerve root lesion: case report and literature review

Haemangioblastomas are uncommon tumours of the central nervous system. Nerve root haemangioblastomas with both intradural and extradural components are extremely rare. We present a case of a C2 nerve root haemangioblastoma in a 64-year-old man where the preoperative diagnosis was a spinal meningioma. An unexpectedly vascular tumour was found at initial procedure. Urgent catheter angiography was performed and the tumour was embolized prior to complete excision at a subsequent procedure.

Multiple filum terminale hemangioblastomas symptomatic during pregnancy

✓Hemangioblastomas are low-grade, highly vascular tumors commonly associated with von Hippel–Lindau (VHL) syndrome and most often appearing in the cerebellum. They very rarely occur in the spinal nerve roots, and an origin in the filum terminale is exceptional with no instances of multiple hemangioblastomas of the filum terminale reported in the literature. Because of their vascular nature, these lesions can enlarge and become symptomatic in the context of the changes that take place during pregnancy, as has been noted with cerebellar hemangioblastomas. In any case, the evolution of spinal hemangioblastomas during pregnancy is not well known given its rarity. The conjunction of both processes—that is, multiple hemangioblastomas arising in the filum terminale and pregnancy—is unique. The authors describe the case of a 41-year-old woman with multiple hemangioblastomas of the filum terminale and no other evidence of VHL syndrome, in whom pregnancy precipitated symptoms. The interruption of gestation led to a remission of the symptoms. The literature concerning filum terminale hemangioblastomas and pregnancy is also reviewed.

Imaging of a thoracic spinal nerve haemangioblastoma by three-dimensional digital angiography

Haemangioblastomas occur sporadically or in association with Von Hippel-Lindau (VHL) disease. Occasionally, they are associated with intrathecal cauda equina nerve roots and rarely with spinal nerve roots. The occurrence of a completely extrathecal, thoracic spinal nerve haemangioblastoma is exceptional, with only one case previously described in the English-language literature. We report an extradural thoracic spinal nerve haemangioblastoma in a patient with VHL disease causing a progressive thoracic radiculopathy. The advantages of three-dimensional digital angiography will be discussed. Three-dimensional reconstruction of the images acquired by rotational digital subtraction angiography is one of the most promising developments to improve surgical planning for complex vascular lesions.

Hemangioblastoma of the filum terminale

A 52-year-old man presented with low backache, paraesthesiae and spasticity of both lower limbs. He had urinary retention and constipation. Investigations revealed a vascular intradural cauda equina-conus tumor. MRI scan demonstrated an enhancing mass at the second and third lumbar vertebral levels. There were multiple dilated and tortuous veins draining from both poles of the tumor. Digital subtraction spinal angiogram showed the tumor to be supplied mainly by the radiculo-medullary artery from first lumbar artery and dural branches of the second and third lumbar arteries. At surgery, after pre-operative embolization, a well-defined tumor with an orange hue and fleshy consistency was encountered arising from the filum terminale. The tumor was excised en bloc. A sporadic hemangioblastoma arising from the filum terminale should be considered as a rare cause of back pain and sciatica. Total excision of the tumor offers cure.

Cervical Dumbbell Intra-extradural Hemangioblastoma: Total Removal through the Lateral Approach: Technical Case Report

OBJECTIVE AND IMPORTANCE:

Extradural hemangioblastomas account for 8 to 12% of all spinal hemangioblastomas. Among them, intra-extradural forms with a dumbbell extension are extremely rare. We report a case of intra-extradural hemangioblastoma involving the C6 cervical nerve root.

CLINICAL PRESENTATION:

The patient was a 31-year-old woman presenting with signs of myelopathy and C6 radiculopathy on the right side. A computed tomographic scan and magnetic resonance imaging demonstrated a dumbbell tumor that had developed through the C5–C6 intervertebral foramen. Angiography revealed a well-circumscribed mass with feeders from the vertebral artery and the deep cervical artery.

INTERVENTION:

The tumor was totally removed through the lateral approach, with control of the vertebral artery and sacrifice of the C6 cervical nerve root. Limited bone drilling to enlarge the foramen permitted us to reach and resect the intradural component. Histopathological examination confirmed the diagnosis of hemangioblastoma. Follow-up was uneventful.

CONCLUSION:

This is the sixth reported case of a cervical dumbbell hemangioblastoma investigated by computed tomographic scanning and MRI but the first one resected via the lateral approach. The lateral approach seems appropriate for surgical resection because it provides primary control of the vascular feeders and access to the extradural and intradural components.

Characterization of Hemangioblastomas of Spinal Nerves

OBJECTIVE:

Hemangioblastoma is classified as a benign tumor of the central nervous system. Peripheral nervous system hemangioblastomas to date have been described only in a few case reports. Experience in treating patients with these rare lesions, which harbor diagnostic and therapeutic pitfalls, is limited.

METHODS:

To characterize these lesions better, we reviewed our hemangioblastoma database for patients who underwent surgery for extradural hemangioblastoma of the spinal nerve.

RESULTS:

Between 1983 and 2003, six patients underwent surgery for spinal nerve hemangioblastomas at our institution. These tumors occurred in 2% of all patients with hemangioblastomas of the central nervous system, or 6% of all patients with spinal hemangioblastomas. The occurrence did not differ in von Hippel-Lindau disease cases versus sporadic cases. Radiographically, the tumors easily could be mistaken for schwannomas or metastases; however, they did have some typical features. If a hemangioblastoma was not suspected primarily, profuse bleeding could complicate surgery. Most of the tumors arose from the dorsal sensory fascicles. The vascular supply was from extradural circulation. In general, the surgical outcome of these lesions was good, and permanent neurological deficit was rare. However, local recurrence was observed in three of six patients.

CONCLUSION:

These tumors harbor diagnostic and therapeutic pitfalls. In general, the tumors are surgically more challenging, and clinically significant bleeding as well as local tumor recurrence is more common than in intradural hemangioblastomas, mostly because of the frequency of incorrect initial radiographic diagnosis. We suggest that because of the surgical consequences, hemangioblastoma should always be considered to be an important radiological differential diagnosis for nerve sheath tumors. Angiography can bring clarification to ambiguous cases.

Proximal nerve root spinal hemangioblastomas: presentation of three cases, MR appearance, and literature review

BACKGROUND

Hemangioblastomas (HBLs) are relatively uncommon tumors of uncertain histogenesis usually located in the cerebellum or spinal cord. Much less frequently they are identified in extramedullary locations including the filum terminale, proximal nerve roots, or even distal nerves of the peripheral nervous system (PNS). PNS cases not only present diagnostic challenges but also raise interesting questions regarding the common cell of origin for these CNS and PNS neoplasms. Few studies have detailed the neuroimaging characteristics of the rare extramedullary variants.

METHODS

Neuroimaging and intraoperative findings of three recent cases of proximal nerve root HBLs are described. The English language literature on extramedullary HBLs is reviewed and discussed, particularly in regards to magnetic resonance (MR) findings and association with von Hippel-Lindau Syndrome (VHL).

RESULTS

All 3 of our cases had prominent vessels present within the subarachnoid space on MR scans and all lesions enhanced. All were of intermediate or mildly decreased signal intensity on the T1-weighted images before contrast and were either iso- or hyperintense to spinal cord on the T2-weighted images. Two had probable cystic areas on MR, and all had cystic areas on histologic evaluation.

CONCLUSION

These neuroimaging characteristics can serve to distinguish HBLs from the more common benign nerve sheath tumors with which they are most frequently confused. Less than half of all extramedullary HBLs are diagnosed in patients with known VHL. It is important to consider HBLs in the differential diagnosis, as they are vascular and have the propensity for causing significant blood loss at surgery.