Best cases from the AFIP: myxopapillary ependymoma of the sacrum

Pediatric presacral tumors with intraspinal extension: a rare entity with diagnostic challenges

The presacral space is a potential space located between the rectum and the lumbosacral spine. It contains various primitive germ cell types that serve as the origin for a range of tumors. Imaging is crucial in characterizing, assessing the extent of and evaluating the treatment response to these tumors. We report a series of six cases of pediatric presacral tumors with intraspinal extension, including an immature sacrococcygeal teratoma (Altman type II), a malignant sacrococcygeal teratoma (Altman type IV), a neuroblastoma, a rhabdomyosarcoma, a clear cell sarcoma and an Ewing's sarcoma of the ilium. These tumors can be broadly categorized as tumors of germ cell, neuroblastic, mesenchymal and osteogenic origin. Despite overlapping imaging features, a review of the existing literature and careful retrospective observation revealed several distinctive features that aid in the optimal characterization of tumors. These include the tumor's epicenter, the pattern and degree of bone involvement, the status of sacral foramina and neural elements, and internal tumor characteristics such as the presence of fat, calcification, hemorrhage and necrosis.

Rare sacral extradural grade II ependymoma: a comprehensive review of literature

Sacral spinal cord ependymoma is an uncommon pathology. Most of the reported cases are consistent with a myxopapillary ependymoma histopathologic subtype. Non-myxopapillary ependymomas rarely occur in the sacral region. Most lesions are intradural; however, rare extradural cases can occur. We present the case of a 46-year-old female patient diagnosed with a grade II sacral extradural ependymoma, emphasising the importance of an interdepartmental case approach for diagnosis and management. Even though grade II ependymomas are considered low grade, the potential for recurrence and metastatic disease has been reported. There are no treatment guidelines for these rare tumours besides gross total resection.

Anaplastic myxopapillary ependymoma of the sacrum: A case report

Background

Myxopapillary ependymoma (MPE) with anaplastic features is extremely rare. There are very few such case reports in the medical literature.

Case Description

A 23-year-old female presented with lower back pain, and both urinary and fecal dysfunction. The patient underwent gross total surgical excision of the MR documented expansile intrasacral tumor. The histology was compatible with a MPE containing anaplastic features.

Conclusion

The medical literature contains a few comparable cases of subcutaneous sacrococcygeal MPE with anaplastic components. Here, however, we have a young female with an anaplastic intrasacral MPE treated with gross total surgical excision.

Incidental Discovery of a Presacral Extradural Myxopapillary Ependymoma

Ependymoma is a malignant central nervous system tumor arising from the lining of the ventricles or central canal of the spinal cord. Extradural spinal ependymomas arise from heterotopic ependymal cells or the coccygeal medullary vestige and are extremely infrequent. We present a rare case of presacral extradural ependymoma. Extradural ependymomas typically demonstrate an extraneural spread and, thus, surveillance of the entire central nervous system is not typically recommended. A radiograph of the chest, liver profile, and attention to palpable lymphadenopathy (especially inguinal) on physical examination are vital for surveillance. Obtaining an R0 resection is the most important prognostic factor in survival and local recurrence.

Giant Iliac Artery Pseudoaneurysm Mimicking Postoperative Fluid Collection and Diskitis

BACKGROUND

In this report, we describe an extremely rare case of a giant pseudoaneurysm of the internal iliac artery causing marked destructive changes at a disk space and mimicking diskitis-osteomyelitis. Only 2 other cases of pseudoaneurysms extending into the disk space have been reported, and those arose from the aorta and were relatively straightforward to diagnose.

CASE DESCRIPTION

Our case is unique because the pseudoaneurysm arose from the internal iliac artery, an artery that is not usually included in the field of view of lumbar magnetic resonance imaging or computed tomography. However, the pseudoaneurysm was so large that it extended to the lumbosacral junction, where it eroded a disk space and caused findings of diskitis-osteomyelitis.

CONCLUSIONS

Complex paraspinal fluid collections causing osseous erosions should raise the possibility of an aneurysm/pseudoaneurysm. Computed tomography or conventional angiography should be considered if the question of a vascular mass/collection cannot be answered on conventional cross-sectional imaging, as inadvertent biopsy of a pseudoaneurysm can cause catastrophic bleeding.

Recurrent Extradural Myxopapillary Ependymoma With Oligometastatic Spread

Myxopapillary ependymomas are a slow-growing, grade I type glial tumor in the lumbosacral region. More rarely, they can present as extradural, subcutaneous sacrococcygeal, or perisacral masses, and it is under these circumstances that they are more likely to spread. Here, we report the presentation of a sacrococcygeal mass in patient that was initially resected confirming extradural myxopapillary ependymoma. At initial resection, multiple small pulmonary nodules were detected. This mass recurred 2 years later at the resection site with an interval increase in the previously imaged pulmonary nodules. Resection of both the post-sacral mass and largest lung metastasis confirmed recurrent myxopapillary ependymoma with oligometastatic spread. Because these tumors are rare, with extradural presentation being even more infrequent, to this date there are no definitive therapeutic guidelines for initial treatment and continued surveillance. For myxopapillary ependymoma, current standard of care is first-line maximal surgical resection with or without postoperative radiotherapy depending on the extent of disease and extent of resection. However, there remains insufficient evidence on the role of radiotherapy to oligometastatic foci in providing any further survival benefit or extending time to recurrence. Thus, prospective studies assessing the role of upfront treatment of oligometastases with local resection and adjuvant radiotherapy are needed for improved understanding of extradural myxopapillary ependymoma.

Invasive myxopapillary ependymoma of the lumbar spine: A case report

BACKGROUND

Myxopapillary ependymomas are rare spinal tumours. Although histologically benign, they have a tendency for local recurrence.

CASE SUMMARY

We describe a patient suffering from extra- and intradural myxopapillary ependymoma with perisacral spreading. He was treated with subtotal resection and postoperative radiation therapy. After treatment, he experienced slight sphincter disorders and lumboischialgic pain with no motor or sensory disturbances. Eight months later, a tumour regression was documented. The patient is still followed-up regularly.

CONCLUSION

Lumbar myxopapillary ependymomas may present with lumbar or radicular pain, similar to more trivial lesions. Magnetic resonance imaging (MRI) is the primary modality for diagnosis. The treatment aim is to minimize both tumour and therapy-related morbidity and to involve different treatment modalities.

Primary spinal primitive neuroectodermal tumor on MR imaging

Neoplasms in the region of filum terminale are not uncommon. Myxopapillary ependymoma is the commonest tumor at this location. The differentials reported for this entity are nerve sheath tumor, meningioma, paraganglioma, intradural metastases, lymphoma, other varieties of ependymoma, subependymoma, astrocytoma, ganglioglioma, hemangioblastoma, and primitive neuroectodermal tumor (PNET). PNET may very rarely present as an intradural thoracolumbar mass. We present pre- and post-therapy magnetic resonance imaging (MRI) features of a patient with proven primary spinal primitive neuroectodermal tumor (PSPNET) of peripheral subtype.

[Chordoma]

PURPOSES

To review in the literature, all the epidemiological, clinical, radiological, histological and therapeutic data regarding chordomas as well as various notochordal entities: ecchordosis physaliphora, intradural and intraparenchymatous chordomas, benign notochordal cell tumors, parachordomas and extra-axial chordomas. To identify different types of chordomas, including familial forms, associations with tuberous sclerosis, Ollier's disease and Maffucci's syndrome, forms with metastasis and seeding. To assess the recent data regarding molecular biology and progress in targeted therapy. To compare the different types of radiotherapy, especially protontherapy and their therapeutic effects. To review the largest series of chordomas in their different localizations (skull base, sacrum and mobile spine) from the literature.

MATERIALS

The series of 136 chordomas treated and followed up over 20 years (1972-2012) in the department of neurosurgery at Lariboisière hospital is reviewed. It includes: 58 chordomas of the skull base, 47 of the craniocervical junction, 23 of the cervical spine and 8 from the lombosacral region. Similarly, 31 chordomas in children (less than 18 years of age), observed in the departments of neurosurgery of les Enfants-Malades and Lariboisière hospitals, are presented. They were observed between 1976 and 2010 and were located intracranially (n=22 including 13 with cervical extension), 4 at the craniocervical junction level and 5 in the cervical spine.

METHODS

In the entire Lariboisière series and in the different groups of localization, different parameters were analyzed: the delay of diagnosis, of follow-up, of occurrence of metastasis, recurrence and death, the number of primary patients and patients referred to us after progression or recurrence and the number of deaths, recurrences and metastases. The influence of the quality of resection (total, subtotal and partial) on the prognosis is also presented. Kaplan-Meier actuarial curves of overall survival and disease free survival were performed in the entire series, including the different groups of localization based on the following 4 parameters: age, primary and secondary patients, quality of resection and protontherapy. In the pediatric series, a similar analysis was carried-out but was limited by the small number of patients in the subgroups.

RESULTS

In the Lariboisière series, the mean delay of diagnosis is 10 months and the mean follow-up is 80 months in each group. The delay before recurrence, metastasis and death is always better for the skull base chordomas and worse for those of the craniocervical junction, which have similar results to those of the cervical spine. Similar figures were observed as regards the number of deaths, metastases and recurrences. Quality of resection is the major factor of prognosis with 20.5 % of deaths and 28 % of recurrences after total resection as compared to 52.5 % and 47.5 % after subtotal resection. This is still more obvious in the group of skull base chordomas. Adding protontherapy to a total resection can still improve the results but there is no change after subtotal resection. The actuarial curve of overall survival shows a clear cut in the slope with some chordomas having a fast evolution towards recurrence and death in less than 4 years and others having a long survival of sometimes more than 20 years. Also, age has no influence on the prognosis. In primary patients, disease free survival is better than in secondary patients but not in overall survival. Protontherapy only improves the overall survival in the entire series and in the skull base group. Total resection improves both the overall and disease free survival in each group. Finally, the adjunct of protontherapy after total resection is clearly demonstrated. In the pediatric series, the median follow-up is 5.7 years. Overall survival and disease free survival are respectively 63 % and 54.3 %. Factors of prognosis are the histological type (atypical forms), localization (worse for the cervical spine and better for the clivus) and again it will depend on the quality of resection.

CONCLUSIONS

Many different pathologies derived from the notochord can be observed: some are remnants, some may be precursors of chordomas and some have similar features but are probably not genuine chordomas. To-day, immuno-histological studies should permit to differentiate them from real chordomas. Improving knowledge of molecular biology raises hopes for complementary treatments but to date the quality of surgical resection is still the main factor of prognosis. Complementary protontherapy seems useful, especially in skull base chordomas, which have better overall results than those of the craniocervical junction and of the cervical spine. However, we are still lacking an intrinsic marker of evolution to differentiate the slow growing chordomas with an indolent evolution from aggressive types leading rapidly to recurrence and death on which more aggressive treatments should be applied.

Myxopapillary ependymoma masquerading as subcutaneous sacrococcygeal non-healing ulcer: case report

Ependymomas outside the confines of the cranium and spinal cord are rare. The occurrence of these tumors in an extradural, sacrococcygeal, or subcutaneous location may prove challenging, particularly in the absence of any obvious central nervous system connection. The origin of these tumors from sub.cutaneous sacrococcygeal ependymal rests is postulated on the basis of earlier reports. We describe 1 such rare extradural case of myxopapillary ependymoma in a 30-year-old female, which presented as a non-healing ulcer in the left gluteal area. It was initially diagnosed and was being treated as an infected epidermoid cyst. Clinical and histopathological features are described, and a brief review of published reports is presented.

Imaging of sacral masses: self-assessment module

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of sacral masses and the key imaging characteristics of various sacral masses.

Giant destructive myxopapillary ependymomas of the sacrum

Myxopapillary ependymomas rarely present as a primary intrasacral lesion, and extensive sacral osteolysis is unusual. The authors report a case series of 6 patients with these complex tumors causing extensive sacral destruction, who underwent resection, lumbopelvic reconstruction, and fusion. The operative procedure, complications, and outcome are summarized after a mean follow-up of 3.55 years (range 18–80 months).