Multiple intradural-extramedullary ependymomas: proven dissemination by genetic analysis

Multifocal intradural extramedullary ependymoma, MYCN amplified: illustrative case

BACKGROUND

Ependymomas are the most frequent tumors of the adult spinal cord, representing 1.9% of all central nervous system tumors and 60% of spinal cord tumors. Spinal ependymomas are usually solitary, intramedullary lesions. While intradural extramedullary (IDEM) ependymomas are infrequent, multifocal IDEM ependymomas are exceptionally rare.

OBSERVATIONS

The authors reported the first case in the literature of a patient diagnosed with multifocal IDEM ependymomas who was treated with tumor resection and brain and spinal radiotherapy. The patient presented with a 10-day history of bilateral leg numbness extending to the umbilicus and gait instability. Magnetic resonance imaging (MRI) studies revealed multiple enhancing nodular nodules throughout the entire spinal canal. Brain MRI revealed no abnormal lesions. A World Health Organization grade II ependymoma was confirmed histologically. At 31 months postoperatively, the patient remained clinically asymptomatic. Although cervical and thoracic MRI revealed stable intradural nodules and several areas of leptomeningeal enhancement, no malignant cells were seen in the cerebrospinal fluid (CSF). He underwent genetic testing to determine the appropriate chemotherapeutic agent if activation of the tumor should arise.

LESSONS

Because complete resection of multifocal IDEM ependymomas is not feasible, continued monitoring with brain and spine MRI is warranted to detect potential tumor dissemination in the CSF.

A Case of Spinal Ependymoma Developed in the Extramedullary Location: A Case Report and Literature Review

Intradural extramedullary (IDEM) ependymoma except for tumors originated from the filum terminale or conus medullaris is rare. The present study showed a case of IDEM ependymoma. A 16-year-old boy was referred to our hospital with a complaint of right hypochondriac pain and motor weakness in his right leg. MRI revealed a solitary intradural tumor at Th5–8 level with syringomyelia at Th2–4 level. Microscopic total tumor resection was performed with right hemi-laminectomy of Th4–9. Histological diagnosis was ependymoma (WHO grade 2). Although his leg weakness was worsened transiently, he showed improvement in leg weakness being able to go up and down the stairs 1 month after the surgery. There was no tumor recurrence until now, 7 years after the surgery, without any adjunctive therapies. A total of 44 cases of IDEM ependymoma had been reported in the past literatures. They are thought to arise from ependymal cells which remained during the process of neural tube closure. Like intramedullary ependymomas, most of the IDEM ependymomas have clear border to surrounding tissue and often removed completely. However, a small number of recurrences and malignant transformations had been reported after complete resections despite benign histological features tumors. In the case of totally resected low grade IDEM ependymoma, it is thought to be reasonable to perform long-term periodical radiographic follow-up without postoperative adjunctive therapy.

Ependymoma of the spinal cord with multiple intradural extramedullary ependymomas: The first case report and literature review

Ependymomas are the most prevalent intramedullary neoplasms in adults. Few cases have been reported on exophytic intramedullary ependymoma or multiple non-conus, and non-filum intradural extramedullary (IDEM) ependymomas. Here, we reported a 30-years old female with exophytic ependymoma in T10-11 and multiple IDEM ependymomas in T3-S2 and who's condition ultimately improved. This is the first case of exophytic ependymoma of the spinal cord with multiple IDEM ependymomas.

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.

Multifocal intradural extramedullary anaplastic ependymoma of the spine

Ependymomas are neuroectodermal tumours arising from the ependymal lining of the ventricles and central canal of the spinal cord. Intradural extramedullary (IDEM) ependymomas which are multifocal, and/or anaplastic (WHO grade III) at presentation are exceedingly rare. We present the second case of multifocal anaplastic IDEM ependymoma in the literature. A 47-year old female presented with left gluteal and thigh pain radiating to the groin associated with paraesthesiae. She had a normal neurological examination. Magnetic resonance imaging of the lumbar spine and subsequent magnetic resonance imaging (MRI) of the remaining neuroaxis demonstrated >10 lesions throughout cervical, thoracic and lumbosacral levels. There were no intracranial lesions. The patient initially underwent surgery for removal of three symptomatic lesions at S2. She recovered well. One year later she had further surgery for three progressing lesions at T5. Four of six lesions were WHO grade III. Two smaller nodules at T5 were WHO grade II. The patient had mild sensory disturbance over the right side of the trunk which resolved postoperatively. There were no long-term sequelae. The patient subsequently underwent full craniospinal irradiation using proton beam therapy. Due to their rarity, there are no guidelines for the management of multifocal IDEM ependymoma. The only previously published case of multifocal anaplastic IDEM ependymoma by Schuurmans et al. involved surgical resection and 20 cycles of whole-spine radiotherapy. Schuurmans patient unfortunately died two years post-diagnosis with progressive cranial metastases and post-radiation myelopathy. In our case, all remaining lesions are stable and she is neurologically intact at 48-month follow up.

Intradural Extramedullary Ependymoma with Leptomeningeal Dissemination: The First Case Report in a Child and Literature Review

BACKGROUND

Primary intradural extramedullary ependymomas are very rare tumors and have never been described in children.

CASE DESCRIPTION

We report on an 11-year-old girl presenting with a 1-month history of neck pain, left arm weakness, paresthesia in the fingers of the left hand and gait disturbances. Magnetic resonance imaging on admission revealed an intradural extramedullary cystic lesion at the cervical level with craniospinal leptomeningeal nodules causing mild hydrocephalus. The multicystic lesion was surgically removed and neuropathologic examination revealed a World Health Organization grade II ependymoma. The patient underwent adjuvant radiotherapy with progressive reduction of the metastatic nodules. At her 2-year follow-up, the patient was symptom free with no evidence of recurrence on magnetic resonance imaging.

CONCLUSIONS

Although a rare entity, intradural extramedullary ependymomas should be included in the differential diagnosis of intradural extramedullary lesions in children. Surgical treatment seems to play a pivotal role in the prognosis of these rare tumors, with a possible role for adjunctive radiotherapy in the case of recurrence, anaplastic transformation, and metastasis.

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

BACKGROUND AND IMPORTANCE

Ependymomas are the most frequent intramedullary neoplasms in adult patients. Anaplastic histology, extramedullary location, meningeal dissemination at initial diagnosis, and extraneural metastases are rare findings. We describe a case of extramedullary anaplastic ependymoma that presented with holocordal and intracranial leptomeningeal carcinomatosis and bone metastases in all the vertebral bodies and the sternum. Such an aggressive dissemination at initial diagnosis has not been previously reported.

CLINICAL PRESENTATION

A 36-year-old woman presented with headache, multiple cranial nerve palsies, visual hallucinations, confusion, hemiparesis, hemihipoestesia, episodes of disconnection, and toxic syndrome. Magnetic resonance imaging and positron emission tomography scan revealed leptomeningeal carcinomatosis in the brainstem, the cerebellum, and along the whole spinal cord. Various nodular, intradural extramedullary lesions were present at multiple dorsal and lumbar levels. Metastatic bone disease affected all the vertebral bodies and various extraspinal bones. An intradural and bone biopsy was performed at L4, providing the diagnosis of anaplastic ependymoma (World Health Organization grade III) with focal neuronal differentiation. Despite chemotherapy, the patient's symptoms quickly progressed, and she died 7 weeks after diagnosis.

CONCLUSION

To our knowledge, there are no previous descriptions of ependymomas with this extensive leptomeningeal, spinal, intracranial, and extraneural dissemination at clinical onset. Bone metastases in spinal ependymoma have not been previously reported.

Metachronous, multicentric glioma of pilocytic astrocytoma with oligodendroglioma-like component and oligodendroglioma through distinct genetic aberrations

This patient presented with a rare case of metachronous, multicentric gliomas first manifesting as headache and nausea in 1983 when he was an 8-year-old boy. Computed tomography revealed a cerebellar tumor and the tumor was subtotally resected. The histological diagnosis was pilocytic astrocytoma, and radiation therapy to the posterior fossa and chemotherapy consisting of nimustine hydrochloride and fluorouracil were performed. In 1989, at age 14 years, the patient presented with local recurrence. He underwent gross-total resection of the tumor, and histological examination revealed that the tumor consisted of classic pilocytic astrocytoma with a biphasic pattern and a small oligodendroglioma-like component. In 2011, at age 36 years, he presented with seizure. Magnetic resonance imaging revealed a mass lesion in the right middle frontal gyrus. Gross-total resection of the tumor was performed, and the histological diagnosis was oligodendroglioma. Genetic analyses revealed amplification of the BRAF gene in both the primary cerebellar pilocytic astrocytoma and the recurrent tumor with biphasic features, as well as a BRAF V600E missense mutation in the oligodendroglioma-like component. On the other hand, the IDH1 R132H mutation, instead of aberrations of the BRAF gene, was identified in the oligodendroglioma arising in the right frontal lobe. Different types of aberrations of the BRAF gene in the classic and oligodendroglioma-like component in the recurrent pilocytic astrocytoma suggest that they had different cell origins or that amplification of BRAF was negatively selected under the de novo BRAF V600E mutation. In addition, the aberration profiles of IDH1 and BRAF suggest that the oligodendroglioma arose independent of cerebellar pilocytic astrocytoma.

Intradural extramedullary ependymoma with spinal root attachment: a case report

A 36-year-old female patient presented with shoulder pain experienced over a period of one year and progressive weakness in both legs for one month. A magnetic resonance imaging scan revealed an intradural extramedullary (IDEM) fusiform mass about 9.8 cm in length, heterogeneously enhanced at the level of C6-T4 with spinal cord compression. At the time of surgery, the surgeon found an encapsulated IDEM tumor with spinal root attachment. The tumor was completely resected and the histologic diagnosis revealed ependymoma. The patient showed a favorable outcome with no recurrence at the 6-month follow-up. This paper reports a rare case of intradural extramedullary ependymoma with spinal root attachment.

Acute neurological deterioration as a result of two synchronous hemorrhagic spinal ependymomas

Background:

Ependymomas are the most common intramedullary tumors in adults and are the most common in mid-adult years. The presence of synchronous ependymomas in different sites of the spine is not common and it is even more infrequent to find hemorrhage from a spinal ependymoma as a cause of neurological deterioration.

Case Description:

A 32-year-old man presented with back pain and progressive paraparesia. Magnetic resonance (MR) showed two intradural extramedullary lesions on spinal canal with signs of acute hemorrhage. The patient underwent emergent surgical decompression and resection. Pathology revealed myxopapillary ependymomas.

Conclusion:

To our knowledge, we report the first case of a patient with acute neurological deterioration as a consequence of synchronous bleeding of two spinal ependymomas located at different levels in the spinal cord. This study illustrates the importance of recognizing the rare, but known occurrence of acute neurological deterioration after spontaneous hemorrhage in spinal ependymomas.