Spinal cord schwannomas mimicking drop metastases in a patient with intramedullary ependymoma and neurofibromatosis 2

Spinal Intradural Intramedullary Dissemination in the Absence of Intracranial Relapse of a Previously Radically Treated Temporal Lobe Glioblastoma Multiforme

Intracranial glioblastoma multiforme (GBM) constitutes the most frequent and unfortunately aggressive primary central nervous system malignancy. Despite the high tendency of these tumors to show local relapse within the brain after primary therapy, dissemination into the spinal axis is an infrequent event. If spinal metastases occur they are leptomeningeal in the vast majority of cases and always in the context of intracranial progressive disease. Spinal intramedullary metastases of intracranial GBM have rarely been described to date. We report the unique case of a young woman with subacute progressive paraparesis due to spinal intramedullary metastases of a temporal lobe GBM despite the remarkable absence of intracranial tumor relapse. The patient had undergone gross total resection of a left temporal GBM in contact with the ventricles and cisternal space followed by radio- and chemotherapy 13 months before. At the moment of diagnosis of spinal intramedullary metastases, there were no signs of intracranial tumor recurrence as revealed by MRI scans. Since a high level of suspicion may be needed to detect this rare evolution of intracranial GBM and other differential diagnoses must be ruled out at presentation, we discuss the important features of this case regarding clinical manifestation, diagnosis, surgery, and management. Furthermore, we mention possible factors that may have contributed to the development of these metastases in the context of intracranial remission.

Intramedullary schwannoma of the upper cervical spinal cord: a case study of identification in pathologic autopsy

Intramedullary schwannoma of the upper cervical spinal cord is rarely reported in forensic medicine. We herein report a case involving a patient who died of compression from an intramedullary schwannoma in the upper cervical spinal cord. A 30-year-old man initially presented with a five-day history of pain in the left chest that progressed to weakening in the left arm. Although the patient was treated with analgesic poultices, he developed inspiratory dyspnoea and died while working the next day without having undergone any medical imaging examination or surgical treatment. Anatomical and histopathological examinations revealed an intramedullary schwannoma in the left cervical spinal cord (C₃-C₅) underneath the spinal nerve root. The cause of death might have been asphyxia secondary to the tumour, which interfered with the nerve function in the respiratory muscles. This finding suggests that an autopsy is essential for pathologists and medicolegists to comprehensively undertake their due obligation to obtain "the first evidence", especially when there is a lack of directly related evidence. As part of the central nervous system, the spinal cord could be systematically included in a routine pathological autopsy in some cases.

Neurofibromatosis-2 and spinal cord ependymomas: Report of two cases and review of the literature

OBJECT

The incidence of ependymoma in patients with neurofibromatosis-2 (NF-2) is low and information regarding treatment and prognosis is lacking. We present two cases of cervicomedullary tumors in patients with NF-2 from our institution, and we provide a review of the literature in order to summarize the known clinical information about this rare occurrence.

PATIENTS AND METHODS

Patient #1 had histological confirmation of ependymoma and was treated with subtotal resection followed by observation and has had no evidence of progression for 11 months. Patient #2 has been observed for 4 1/2 years without treatment for a cervicomedullary tumor, which appears to be an ependymoma by imaging. Although it has increased in size very slowly, there have been no clinical symptoms. Among the additional 21 cases of NF-2 and ependymoma from the literature, the most common location is the cervical spine (70%), and the median age at diagnosis is 15 years. Surgical resection was performed in 85% of the cases and subtotal resection in 64% of cases. Fifteen patients (75%) were reported alive at the time of the published reports, with survival ranging from 0.1 to 10 years, and the 8-year survival estimated as 51%. Survival was related to the location of the tumor.

CONCLUSIONS

We conclude from our two cases and review of the existing literature that NF-2 associated spinal ependymomas have an indolent course and typically can be observed or treated by surgical excision alone.

Successful treatment of intracranial ependymoma with leptomeningeal spread with systemic chemotherapy and intrathecal liposomal cytarabine in a two-year-old child

Ependymoma is the third most common CNS tumor in children. Neuraxis dissemination at the time of diagnosis is rare and occurs in fewer than 10% of patients. Recent advances in neuroimaging, neurosurgery, and radiation therapy have improved disease control and functional outcomes for children with ependymoma. However, children under the age of 3 years with ependymoma and leptomeningeal spread historically have had worse outcomes. It is not clear if age alone, or a combination of risk factors such us unfavorable location, which may prevent gross total resection, and withholding radiation therapy may have contributed to poor outcomes in younger age groups. The reason for attempting GTR is based on results from retrospective and prospective studies, where the most important prognostic factor is extent of resection. These patients are not candidates for craniospinal irradiation. Therefore, new therapeutic approaches must be attempted. This is a case report of a posterior fossa ependymoma with leptomeningeal dissemination in a two-year-old child, successfully treated with dose intensive chemotherapy and intrathecal liposomal cytarabine.