Anaplastic ependymoma with holocordal and intracranial meningeal carcinomatosis and holospinal bone metastases

Crucial differential diagnosis of rapidly progressive dementia: A case of leptomeningeal metastasis

Background

Dementia that advances subacutely without accompanying neurological symptoms can often be misdiagnosed as a psychiatric condition. Leptomeningeal metastasis (LM), caused by the spread of malignant cells to the leptomeninges and the subarachnoid space, is a relatively unfamiliar condition to psychiatrists in this context. The diagnosis of LM remains challenging due to the scarcity of diagnostic tools possessing high sensitivity and specificity.

Case Presentation

We present the clinical presentation of a male in his seventies with LM secondary to gastric ring cell carcinoma. The patient exhibited an acute confusional state, visual hallucinations, irritability, and cognitive impairments over a 3-week period. Initially, the patient was misdiagnosed with several conditions, including alcohol withdrawal syndrome, psychosis, and delirium associated with dementia, as there were no noteworthy findings on neurological examination or the head magnetic resonance imaging (MRI). Given the rapidly progressive cognitive decline, we maintained vigilance for potential neurological conditions, and a repeat investigation using head MRI and cerebrospinal fluid analysis led to the diagnosis of LM.

Conclusion

This critical case report underscores the rarity of psychiatric-onset LM originating from gastric cancer and highlights the importance of comprehensive neurological evaluations.

Giant Ependymoma Removal via a Skipped Myelotomy Technique

Intramedullary ependymomas should be treated with surgical resection. Different surgical techniques are described for these tumors, such as skipped and long-segment myelotomies. A 31-year-old male patient with a giant thoracic spinal cord ependymoma extending from the level of T5 to T10 was operated on with a skipped myelotomy technique. Although the patient had urinary incontinence and muscle weakness in both legs, the patient's complaints were nearly completely resolved in the fourth postoperative month. Operating with the smallest possible myelotomy has given us preferable results; however, more studies are needed to hypothesize the superiority of this technique over conventional myelotomy.

Primary spinal anaplastic ependymoma: A single-institute retrospective cohort and systematic review

Objective

Primary spinal anaplastic ependymoma (PSAE) is an extremely rare disease. We aim to report the largest PSAE cohort, evaluate the treatments, and investigate the prognostic factors for progression-free survival (PFS).

Methods

Clinical data collected from the authors' institute and literature articles were pooled and described. Survival analysis and multivariable Cox regression analysis were performed to evaluate therapies and investigate prognostic factors for PFS.

Results

Our cohort included 22 females and 16 males, with a median age of 33 years. PSAE developed mostly on cervical and cervicothoracic levels. The median length measured 3 segments. Half of PSAE were intramedullary. Pain was the most common symptom. The median duration of symptoms was 6 months. Neurological statuses were improved in 76% following treatments, whereas clinical tumor progression occurred in 41.7%. The estimated median progression-free survival was 132 months, and the estimated median survival was 192 months. The median Ki-67 index was 15%. Patients aged less than or equal to 25 experienced worse neurological statuses and more repeated progression. Age less than or equal to 25 (HR 10.312, 95%CI 1.535-69.260, p=0.016), gross total resection (HR 0.116, 95%CI 0.020-0.688, p=0.018), and radiotherapy (HR 0.084, 95%CI 0.009-0.804, p=0.032) are three prognostic factors for tumor progression.

Conclusion

Tumor progression remains a big concern in the clinical course of PSAE. Being aged above 25, undergoing GTR, and accepting adjuvant radiotherapy put patients at lower risk for tumor progression. Younger patients might have worse neurological statuses compared with those aged over 25.

Intradural Extramedullary Nonconus Nonfilum Spinal Ependymomas: Report of a Rare Variant and Newer Insights into Their Histogenesis with Proposal of a Classification Scheme and a Management Algorithm Based on a Review of Literature

BACKGROUND

Ependymomas are common intramedullary spinal tumors but there are scattered reports of this tumor presenting with exophytic growth patterns masquerading as intradural extramedullary (IDEM) tumors. Such IDEM ependymomas are seldom suspected preoperatively and it is only during surgery that their existence is revealed. Little is known of such rare growth patterns of an otherwise common intramedullary spinal cord tumor, their characteristics, and their management considerations.

METHODS

We present a case of an exophytic dorsal ependymoma with a stalk like attachment to the spinal cord and the surgical management in a 24-year old woman. An extensive literature search was carried out on all prominent databases to find out similar cases reported earlier. We excluded filum/conus ependymoma, purely extradural spinal ependymoma as well as the extraspinal ependymomas. Details of each case reported before were obtained and tabulated.

RESULTS

IDEM ependymomas have been reported in 54 patients so far, including the present case. Four patterns of growth emerged from the literature review: intramedullary ependymoma with exophytic component (group I, n = 9), exophytic IDEM ependymoma without intramedullary component (group II, n = 6), IDEM ependymoma arising from nerve roots (group III, n = 7), and pure IDEM ependymoma (group IV, n = 32). Except in group I, IDEM ependymoma affects females more frequently, without any specific age predilection. Thoracic spinal cord/canal is the most common location across all groups. Multifocal disease, craniospinal dissemination, and recurrences tend to be maximum in group IV.

CONCLUSIONS

IDEM ependymomas are more common in thoracic segment of the cord and broadly divisible into 4 subgroups. We suggest a subpial origin of group II IDEM ependymomas. We also advocate proliferation index estimation in grade II ependymomas to enable formulation of an optimal management plan.

Giant intradural extramedullary spinal ependymoma, a rare arachnoiditis-mimicking condition: case report and literature review

Background and importance: Ependymomas are tumours arising from the ependymal cells lining the ventricles and the central canal of the spinal cord. They represent the most common intramedullary spinal cord tumour in adults and are very rarely encountered in an extramedullary location. Only 40 cases of intradural extramedullary (IDEM) ependymomas have been reported, all of which were diagnosed pre-operatively as IDEM ependymomas on contrast-enhanced MRI. Clinical presentation: We report a 23-year old male presenting with rapidly worsening signs and symptoms of spinal cord disease. A spinal MRI demonstrated a posterior multi-cystic dilatation extended between T1 and T12. Post-contrast sequences showed peri-medullar leptomeningeal enhancement and the diagnosis of spinal arachnoiditis was made. The patient underwent surgery and the spinal cord appeared circumferentially wrapped by an irregular soft tissue. The tissue was sub-totally removed and the pathological diagnosis was ependymoma WHO grade II. The patient experienced an excellent neurological recovery and no further treatments were administered. A small residue is now stable at 2.5 years follow-up. Conclusions: Giant IDEM ependymomas are rare entities and pre-operative diagnosis can be challenging in some cases. Surgery represents the main treatment option being resolutive in most cases.

An integrative analysis of treatment, outcomes and prognostic factors for primary spinal anaplastic ependymomas

The aim of this study was to elucidate the role of treatment modalities in primary spinal anaplastic ependymomas (PSAE) and identify promising prognostic factors. PSAE are rare tumors of the central nervous system with poorly understood clinical characteristics and treatment outcomes. We reviewed the literature in PubMed, Web of Science and Scopus databases to identify patients with PSAE. Multivariate Cox proportional hazards analysis and univariate Kaplan-Meier analysis were performed on the PSAE patients and overall survival (OS) and progression-free survival (PFS) were assessed to evaluate the clinical outcomes. Of the 40 patients with PSAE, the tumors were mostly intramedullary (n=19; 47.5%) and frequently involved the thoracic cord (n=25; 62.5%). Eighteen patients suffered recurrence during the follow-up with a median PFS of 24 months. The 1, 2, and 5year OS rates of the PSAE patients were 91.5%, 82.1%, and 63.1%, respectively. Gross total resection (GTR) was independently associated with prolonged PFS (hazard ratio [HR] 0.11; p=0.004) and OS (HR 0.11; p=0.003) in the multivariate analysis. Adjuvant radiotherapy also conferred improved PFS (HR 0.15; p=0.008) and OS (HR 0.16; p=0.022). Age, sex, tumor location and chemotherapy did not influence the outcomes in this group. The results of our study suggest that GTR and adjuvant radiotherapy are strong prognostic indicators in patients with PSAE and the role of chemotherapy is yet to be defined.