The genetic basis of intradural spinal tumors and its impact on clinical treatment

An adult with recurrent atypical teratoid rhabdoid tumor of the spine

Atypical teratoid rhabdoid tumors (AT/RT) are rare and highly malignant CNS neoplasms primarily affecting children. Adult cases are extremely uncommon, with only approximately 92 reported. Spinal AT/RT in adults is particularly rare. Here, we present the case of a 50-year-old patient diagnosed with AT/RT of the spine. Initially, they were diagnosed and treated for a spinal ependymoma. However, after 10 years, a recurrence was detected through magnetic resonance imaging (MRI) and the tumor was reclassified as AT/RT. We discuss the significance of SMARCB1 gene mutations in diagnosing AT/RT and describe our unique treatment approach involving surgery, radiation and anti-PD1 therapy in this patient.

Primary intradural extramedullary lesions: a longitudinal study of 212 patients and analysis of predictors of functional outcome

BACKGROUND

Primary intradural extramedullary (IDEM) lesions are rare, with an incidence of about 1/100,000 person-years. The aim of this study was to investigate their demographic, clinical, imaging, management, histopathological and outcome parameters. Another objective was to evaluate the various predicting factors leading to long-term favorable outcomes, thereby answering the controversial question: when to operate?

METHODS

This study observed 212 patients of primary IDEM lesions and followed-up for a mean of 53.80 months. The patient's outcome using McCormick grade at follow-up was correlated with age, sex, duration of symptoms, preoperative McCormick grade, tumor location and extent, extradural spread, extent of excision, vascularity, WHO grade and histopathological tumor type.

RESULTS

Benign nerve sheath tumors were the commonest lesions (47.17% schwannoma, 4.72% Neurofibroma), followed in incidence by meningioma (19.34%). There was predominance of males (57.08%), except in meningiomas (male: female ratio 1:2.15). Pain was the commonest initial symptom (51.88%). Limb weakness was the most common presenting complaint (88.68%). Gross total excision was achieved in 81.60% of cases and 70.75% of patients improved following surgery. The significant factors predicting favorable outcome included preoperative McCormick grade (P=0.001), the vertical extent of the tumor (P=0.027), histopathological tumor type (P=0.023) and WHO grading (P=0.015); and extent of excision had an odds ratio of 1: 2.5.

CONCLUSIONS

Significant predictors of functional outcome following surgery in IDEM lesions included preoperative McCormick grade, extent of the tumor, tumor type, WHO grading and extent of resection. The authors recommend surgery with the intent of complete tumor excision, before the onset of substantial symptoms, for better outcome.

Pediatric Spine Tumors and Dysontogenetic Masses

The pediatric spine undergoes complex stages of development and growth, resulting in highly age-dependent physiology and variable susceptibility to certain pathologies. Optimal radiologic evaluation requires image acquisition tailored to the clinical history and an interpretive approach that accounts for demographic variations. In this article, the author discusses the diagnostic approach to pediatric spine masses, beginning with a discussion of normal anatomy and variants, clinical evaluation, and imaging techniques and protocols. The author then covers the major etiologies, imaging appearances, and mimics of pediatric spine masses in the following categories: congenital malformations, genetic syndromes, intramedullary, intradural, epidural, bone, and paraspinal lesions.

The Role of Cellular Immunity and Adaptive Immunity in Pathophysiology of Brain and Spinal Cord Tumors

Major advances have been made in our understanding of CNS tumors, especially glioma, however, the survival of patients with malignant glioma remains poor. While radiation and chemotherapy have increased overall survival, glioblastoma multiforme (GBM) still has one of the worst 5-year survival rates of all human cancers. Here, in this chapter, the authors review the abrogation of the immune system in the tumor setting, revealing many plausible targets for therapy and the current immunotherapy treatment strategies employed. Notably, glioma has also been characterized as a subset of primary spinal cord tumor and current treatment recommendations are outlined here.

Current Knowledge on Spinal Meningiomas Epidemiology, Tumor Characteristics and Non-Surgical Treatment Options: A Systematic Review and Pooled Analysis (Part 1)

BACKGROUND

Spinal meningiomas are the most common primary intradural spinal tumors. Although they are a separate entity, a large portion of the knowledge on spinal meningiomas is based on findings in intracranial meningiomas. Therefore, a comprehensive review of all the literature on spinal meningiomas was performed.

METHODS

Electronic databases were searched for all studies on spinal meningiomas dating from 2000 and onward. Findings of matching studies were pooled to strengthen the current body of evidence.

RESULTS

A total of 104 studies were included. The majority of patients were female (72.83%), elderly (peak decade: seventh), and had a world health organization (WHO) grade 1 tumor (95.7%). Interestingly, the minority of pediatric patients had a male overrepresentation (62.0% vs. 27.17%) and higher-grade tumors (33.3% vs. 4.3%). Sensory and motor dysfunction and pain were the most common presenting symptoms. Despite a handful of studies reporting promising findings associated with the use of non-surgical treatment options, the literature still suffers from contradictory results and limitations of study designs.

CONCLUSIONS

Elderly females with WHO grade 1 tumors constituted the stereotypical type of patient. Compared to surgical alternatives, the evidence for the use of non-surgical treatments is still relatively weak.

Characterization and Treatment of Spinal Tumors

The prevalence of spinal tumors is rare in comparison to brain tumors which encompass most central nervous system tumors. Tumors of the spine can be divided into primary and metastatic tumors with the latter being the most common presentation. Primary tumors are subdivided based on their location on the spinal column and in the spinal cord into intramedullary, intradural extramedullary, and primary bone tumors. Back pain is a common presentation in spine cancer patients; however, other radicular pain may be present. Magnetic resonance imaging (MRI) is the imaging modality of choice for intradural extramedullary and intramedullary tumors. Plain radiographs are used in the initial diagnosis of primary bone tumors while Computed tomography (CT) and MRI may often be necessary for further characterization. Complete surgical resection is the treatment of choice for spinal tumors and may be curative for well circumscribed lesions. However, intralesional resection along with adjuvant radiation and chemotherapy can be indicated for patients that would experience increased morbidity from damage to nearby neurological structures caused by resection with wide margins. Even with the current treatment options, the prognosis for aggressive spinal cancer remains poor. Advances in novel treatments including molecular targeting, immunotherapy and stem cell therapy provide the potential for greater control of malignant and metastatic tumors of the spine.

Current knowledge on spinal meningiomas: a systematic review protocol

INTRODUCTION

Meningiomas are primary central nervous system tumours that arise from both cranial and spinal meninges. Spinal meningiomas occur less frequently than their cranial counterparts and are consequently given less attention in the literature. Therefore, systematic studies are needed to summarise the current knowledge on spinal meningiomas, providing a solid evidence base for treatment strategies. This systematic review of the literature will therefore assess studies describing spinal meningiomas, their epidemiology, diagnostics, treatment and outcomes.

METHODS AND ANALYSIS

Electronic databases, including PubMed, Web of Science and Embase, will be searched using the keywords "spinal" and "meningioma". The search will be set to provide only English studies published after 2000 to avoid any conflicts regarding terminology and classification, as well as to reflect the current status. Case reports, editorials, letters and reviews will also be excluded. Reference lists of relevant records will also be searched. Identified studies will be screened for inclusion, by one reviewer in a first step and then three in the next step to decrease the risk of bias. The results will be categorised to allow for a structured summary of the outcomes and their evidence grade conforming to the Grading of Recommendations, Assessment, Development and Evaluation approach. Categories may include: epidemiology, histopathology, radiological diagnostics, surgery, complications, non-surgical or adjuvant treatments, disease outcomes and predictors, and lastly recurrence. This review will summarise the current knowledge on spinal meningiomas to allow for a better understanding of the disease and contribute to improve its management. For clinicians, the systematic collection and grading of available evidence may aid in decision making and for those seeking to further the scientific field, this review may help to identify areas where knowledge is currently lacking.

ETHICS AND DISSEMINATION

Ethics approval was not required for our systematic review as it is based on existing publications. The results will be disseminated via submission for publication in a peer-reviewed journal.

Recent Molecular and Genetic Findings in Intramedullary Spinal Cord Tumors

The study of genetic alterations and molecular biology in central nervous system (CNS) tumors has improved the accuracy of estimations of patient prognosis and tumor categorization. Therefore, the updated 2021 World Health Organization (WHO) classification includes various diagnostic genes, molecules, and pathways for diagnosis, as well as histological findings. These findings are expected both to have diagnostic applications and to facilitate new targeted therapies that target tumor-specific genetic changes and molecular biology. Intramedullary spinal cord tumors (IMSCTs) are rare CNS tumors that are difficult to treat because they occur in eloquent areas. Although the genetic underpinnings of IMSCTs remain unclear compared to their intracranial counterparts, the genetic characteristics of these tumors are gradually being revealed. Here, we describe the major changes in the new 2021 WHO classification and review the major types of IMSCTs, with an emphasis on their clinical features and genetic alterations.

Prognostic Factors Independently Associated With Improved Progression-Free Survival After Surgical Resection in Patients With Spinal Cord Astrocytomas: An Institutional Case Series

BACKGROUND

Spinal astrocytomas are rare tumors in which the extent of resection and adjuvant therapy remain controversial. A number of new molecular markers are used, but their utility in spinal cord tumors remains unclear.

OBJECTIVE

To determine prognostic indicators of progression-free survival (PFS) in patients with spinal astrocytomas.

METHODS

A retrospective chart review identified all patients managed at a single institution for spinal cord astrocytomas between 1999 and 2019. Data collected included baseline demographics, presenting signs and symptoms, tumor size, operative outcomes, and adjuvant treatment. Pathological data including histopathological grade, proliferative index, and molecular profile were collected. Duration of follow-up, presence of tumor progression, and status at last follow-up were documented. Univariate and multivariate analyses were performed to determine predictors of PFS.

RESULTS

Seventy-five patients were included in our study with an average age of 42 ± 17 yr. The thoracic spine was the most commonly involved spinal segment (50 patients), and most patients had grade I or grade II tumors (50 patients). On univariate analysis, gross total resection (GTR), lower tumor grade, and low Ki-67 index were associated with lower tumor progression (P-values .01, .04, and .00013, respectively). On multivariate Cox regression analysis, GTR, adjuvant chemotherapy and radiation, and low Ki-67 index were independent predictors of PFS (P-values .009, .011, and .031, respectively).

CONCLUSION

In spinal astrocytomas, GTR, adjuvant therapy, and low Ki-67 are independently associated with improved PFS. These data may help guide management of these tumors and provide important prognosticating information.

A Case Series of Surgically Treated Spinal Dumbbell Tumors of Critical Parent Nerve Roots: To Cut or Not to Cut?

BACKGROUND

Dumbbell tumors present challenging cases, with either an incomplete tumor resection or a need to sacrifice nerve roots. Published literature suggests encouraging neurological outcomes after nerve root amputation.

OBJECTIVE

To determine the incidence of postoperative neurological deficits after amputating the parent nerve root.

METHODS

A retrospective consecutive analysis of all patients treated for dumbbell nerve sheet tumors with a reported amputation of the functional relevant parent nerve roots C5-Th1 and L3-S1.

RESULTS

Among 21 evaluated patients, minor postoperative neurological motor function deterioration occurred in 4 patients (19%). Most patients recovered to the preoperative level at the follow-up examination, and only one patient retained a new Medical Research Council (MRC) scale of 4/5 for deltoid weakness. The majority of tumors were resected at the lumbar level (nerve root L3: 28.6%, L5: 19%). Gross total resection was achieved in 90.5% of patients. Neuropathic pain was reported in one third of the patients during the long-term follow-up.

CONCLUSION

Amputating critical parent nerve roots during the dumbbell tumor resections seems to result in a low incidence of postoperative motor deficits and may offer an acceptable sacrifice in otherwise only incompletely resectable dumbbell tumors. The cross-innervation of neighboring nerve roots and its, probably, per-se-reduced functionality may be a possible mechanism for maintaining motor function.

Intramedullary metastasis in medulloblastoma: a case report and literature review

BACKGROUND

Cerebellar medulloblastomas are the most common malignant tumors of the posterior fossa in childhood that frequently metastasize. Leptomeningeal dissemination and distant metastasis have been associated with medulloblastomas; however, intramedullary metastases are rare with very few case reports in the literature available.

METHODS

We present a case of a 3-year-old girl with a medulloblastoma who underwent surgical resection of spinal intramedullary metastases. Histopathology revealed the tumor to be an anaplastic medulloblastoma similar to the intracranial lesions. The patient subsequently underwent postoperative chemotherapy followed by radiotherapy.

RESULTS

Following the surgery and subsequent follow-up, the patient showed a good recovery without any new neurological dysfunction.

CONCLUSIONS

Intramedullary metastasis of medulloblastoma remains a rare disease. Surgical resection could play a possible role in the management in addition to radiation and chemotherapy.

The role of gene therapy as a valuable treatment modality for multiple spinal pathologies

The world of biomedical research has led to several breakthroughs in the treatment of various spinal pathologies. As we investigate chronic pathologies of the spine, we start to unravel the underlying molecular mechanisms through a careful analysis of mutated genetic sequences. Investigations have led to gene therapy being explored for its potential as a treatment modality. Despite only about 2% of current gene therapy trials being centered for spinal pathologies, spinal diseases are valuable targets in gene therapy administration. Through a comprehensive literature review, our objective is to discuss the molecular mechanisms behind gene therapy for spinal pathologies, the genetic targets, along with the outcomes, success, and possible pitfalls in gene therapy research and administration. The emerging development of robotic technologies and intelligent carriers are recognized as a promising innovative technique for increasing the efficiency of gene therapy and potentially resolving spinal pathologies.

Spinal intramedullary hemangioblastoma and schwannoma collision tumor: illustrative case

BACKGROUND

Intramedullary spinal cord tumors represent a minority of intradural tumors. Among intramedullary spinal cord tumors, hemangioblastomas are uncommon, and schwannomas are extremely rare. Collision tumors are histologically distinct tumors that are intermingled and growing together.

OBSERVATIONS

In this report, the authors describe a patient with a cervical intramedullary collision tumor involving a hemangioblastoma and schwannoma. To the authors’ knowledge, no prior spinal intramedullary collision tumor involving multiple neoplasms has been described. The patient’s presentation and management are described.

LESSONS

Clinicians should consider the possibility of collision tumors when evaluating intramedullary spinal cord tumors, especially when patient presentation and radiographic findings are atypical. When tumors with similar radiographic characteristics form collision tumors, distinction using preoperative imaging can be extremely challenging. In addition, surgical management of intramedullary collision tumors, like that for all intramedullary spinal cord tumors, should involve meticulous perioperative care and a methodical surgical technique. Maximal safe resection will depend upon histopathological diagnosis, anatomical location of the tumor, presence of distinct dissection planes, and stability of neuromonitoring. Finally, ongoing research on the genetics of intramedullary spinal cord tumors may identify underlying genetic links for intramedullary hemangioblastomas and schwannomas.

Drug delivery to optimize angiogenesis imbalance in keloid: A review

The wound healing process involves three continuous stages. Where, any imbalance can lead to the formation of unwanted keloids, hypertrophic scar, or tumors. Keloids are any unpleasant, non-compliant comorbidity affecting a major section of people around the globe who acquire it either genetically or by pathological means as a result of a skin injury. Angiogenesis is unavoidable in the healing process after an injury or disruption of skin to promote tissue regeneration. Uncontrolled angiogenesis during the healing process can initiate the unwanted response in the wound that facilitate keloid. Angiogenic therapy is adapted to accelerate healing after an injury. Else ways, there exists a risk of keloid formation due to excessive angiogenesis during the wound healing process. There are numerous strategies to treat keloid. Anti-angiogenic factors are provided to patients post-surgery to prevent the keloid formation; however, they come into the picture after the formation of keloid. The available strategies to treat keloids are steroidal injections, surgical excision of the keloid, radiotherapy, pressure therapy, the use of cryosurgery, and many more. The available treatments are not promising in reducing the recurrent rate of keloids as there are chances of high re-occurrences with similar/larger lesions on the removed keloid site. In this review, we are discussing the importance of controlled angiogenesis with the help of controlled drug delivery strategies enabling the wound healing process without the induction of keloid.

The Search for Molecular Markers in a Gene-Orphan Case Study of a Pediatric Spinal Cord Pilocytic Astrocytoma

BACKGROUND/AIM

We herein presented a case of pediatric spinal cord pilocytic astrocytoma diagnosed on the basis of histopathological and clinical findings.

MATERIALS AND METHODS

Given the paucity of data on genetic features for this tumor, we performed exome, array CGH and RNA sequencing analysis from nucleic acids isolated from a unique and not repeatable very small amount of a formalin-fixed, paraffin-embedded (FFPE) specimen.

RESULTS

DNA mutation analysis, comparing tumor and normal lymphocyte peripheral DNA, evidenced few tumor-specific single nucleotide variants in DEFB119, MUC5B, NUDT1, LTBP3 and CPSF3L genes. Differently, tumor DNA was not characterized by for the main pilocytic astrocytoma gene variations, including BRAFV600E. An inframe trinucleotides insertion involving DLX6 or lnc DLX6-AS1 genes was scored in 44.9% of sequenced reads; the temporal profile of this variation on the expression of DLX-AS1 was investigated in patient's urine-derived exosomes, reporting no significant variation in the one-year molecular follow-up. Array CGH identified a tumor microdeletion at the 6q25.3 chromosomal region, spanning 1,01 Mb and comprising ZDHHC14, SNX9, TULP4 and SYTL3 genes. The expression of these genes did not change in urine-derived exosomes during the one-year investigation period. Finally, RNAseq did not reveal any of the common pilocytic BRAF-KIAA1549 genes fusion events.

CONCLUSION

To our knowledge, the present report is one of the first described gene-orphan case studies of a pediatric spinal cord pilocytic astrocytoma.

Stereotactic Radiation for Treating Primary and Metastatic Neoplasms of the Spinal Cord

Stereotactic radiation treatment can be used to treat spinal cord neoplasms in patients with either unresectable lesions or residual disease after surgical resection. While treatment guidelines have been suggested for epidural lesions, the utility of stereotactic radiation for intradural and intramedullary malignancies is still debated. Prior reports have suggested that stereotactic radiation approaches can be used for effective tumor control and symptom management. Treatment-related toxicity has been documented in rare subsets of patients, though the incidences of injury are not directly correlated with higher radiation doses. Further studies are needed to assess the factors that influence the risk of radiation-induced myelopathy when treating spinal cord neoplasms with stereotactic radiation, which can include, but may not be limited to, maximum dose, dose-fractionation, irradiated volume, tumor location, histology and treatment history. This review will discuss evidence for current treatment approaches.

Surgical Management of Intramedullary Spinal Cord Tumors

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.

Genomic Landscape of Intramedullary Spinal Cord Gliomas

Intramedullary spinal cord tumors (IMSCTs) are rare neoplasms that have limited treatment options and are associated with high rates of morbidity and mortality. To better understand the genetic basis of these tumors we performed whole exome sequencing on 45 tumors and matched germline DNA, including twenty-nine spinal cord ependymomas and sixteen astrocytomas. Though recurrent somatic mutations in IMSCTs were rare, we identified NF2 mutations in 15.7% of tumors (ependymoma, N = 7; astrocytoma, N = 1), RP1 mutations in 5.9% of tumors (ependymoma, N = 3), and ESX1 mutations in 5.9% of tumors (ependymoma, N = 3). We further identified copy number amplifications in CTU1 in 25% of myxopapillary ependymomas. Given the paucity of somatic driver mutations, we further performed whole-genome sequencing of 12 tumors (ependymoma, N = 9; astrocytoma, N = 3). Overall, we observed that IMSCTs with intracranial histologic counterparts (e.g. glioblastoma) did not harbor the canonical mutations associated with their intracranial counterparts. Our findings suggest that the origin of IMSCTs may be distinct from tumors arising within other compartments of the central nervous system and provides the framework to begin more biologically based therapeutic strategies.

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.

miR‑489 promotes apoptosis and inhibits invasiveness of glioma cells by targeting PAK5/RAF1 signaling pathways

Glioma patients receiving therapy are at a high risk of relapse and rapid progression and, thus, more effective treatments are required. The aim of the present study was to determine the suppressive role of miR-489 as an alternative therapeutic target for preventing glioma progression. The results of the present study demonstrated that patients with relatively lower levels of expression of miR-489 had more favorable clinical outcomes. Furthermore, miR-489 expression was inversely correlated with p21-activated kinase 5 (PAK5) mRNA expression levels in glioma specimens. A dual luciferase reporter assay revealed that miR-489 suppressed PAK5 expression by directly targeting the PAK5 3′-untranslated region. The effects of miR-489 on cell viability were measured using MTT and Cell Counting Kit-8 assays. The results demonstrated that ectopic expression of miR-489 mimic decreased cell viability by interfering with cyclin D1 and c-Myc signaling. Additionally, the effect of miR-489 on apoptosis was determined using Hoechst 33258 staining and flow cytometry. The results demonstrated that miR-489 decreased the activity of RAF1, reduced Bcl-2 and promoted Bax expression, resulting in increased cell apoptosis. Furthermore, the effect of miR-489 mimic on cellular motility was assessed using migration and invasion assays. miR-489 was shown to abolish the PAK5/RAF1/MMP2 pathway, resulting in decreased cell invasion ability. These results indicated that miR-489 may be involved in PAK5-mediated regulation of glioma progression, demonstrating the potential therapeutic benefits of targeting miR-489 in glioma.

Primary Spinal Astrocytomas: A Literature Review

Primary spinal astrocytoma is a subtype of glioma, the most common spinal cord tumor found in the intradural intramedullary compartment. Spinal astrocytomas account for 6-8% of all spinal cord tumors and are primarily low grade (World Health Organization grade I (WHO I) or WHO II). They are seen in both the adult and pediatric population with the most common presenting symptoms being back pain, sensory dysfunction, or motor dysfunction. Magnetic Resonance Imaging (MRI) with and without gadolinium is the imaging of choice, which usually reveals a hypointense T1 weighted and hyperintense T2 weighted lesion with a heterogeneous pattern of contrast enhancement. Further imaging which may aid in surgical planning includes computerized tomography, diffusion tensor imaging, and tractography. Median survival in spinal cord astrocytomas ranges widely. The factors most significantly associated with poor prognosis and shorter median survival are older age at initial diagnosis, higher grade lesion based on histology, and extent of resection. The mainstay of treatment for primary spinal cord astrocytomas is surgical resection, with the goal of preservation of neurologic function, guided by intraoperative neuromonitoring. Adjunctive radiation has been shown beneficial and may increase overall survival. The role of adjunctive chemotherapy is employed, however, its benefit has not been clearly defined. Primary spinal cord astrocytomas are rare and challenging to treat. The gold standard treatment is surgical resection. Second-line treatments include radiation and chemotherapy, although, the optimal regimen for adjunctive therapy has not yet been clearly defined.

Metastasis manners and the underlying mechanisms of ALK and ROS1 rearrangement lung cancer and current possible therapeutic strategies

The rearrangements of anaplastic lymphoma kinase (ALK) and the c-ros oncogene 1 (ROS1) have both been important driving factors in non-small-cell lung cancer (NSCLC). They have already been defined in 3-5% of NSCLC patients. ALK and ROS1 rearrangements are associated with unique clinical and pathological features, especially patients are usually younger, with milder or never smoking history, and adenocarcinoma histology. Also, they have both been found to contribute to the metastasis of NSCLC by cell migration and invasion. It has recently been recognized that the brain can be considered as a primary site for metastasis in cancers with ALK or ROS1 rearrangements. The present review summarizes the current status of NSCLC metastasis and possible mechanisms based on available evidence, and then we list possible therapeutic strategies so that an increase in control of ALK and ROS1 rearrangement of NSCLC metastases by combination therapy can be translated in an increase in overall survival and prognosis.

Intradural extramedullary metastasis: a review of literature and case report

Introduction

Intradural extramedullary (IDEM) metastatic disease is infrequently encountered by spine surgeons and consequently poorly understood. Discovery often corresponds with the onset of neurologic symptoms and no consensus exists regarding the importance of complete resection or anticipated postoperative outcome. We aim to elucidate treatment methodologies that exist in the literature.

Case presentation

We present a unique case of a 57-year-old male with a known history of esophageal adenocarcinoma, including brain and visceral metastases, who presented with cauda equina syndrome. An IDEM metastatic esophageal adenocarcinoma lesion was identified on advanced imaging and biopsy. This was treated operatively without return of neurologic function.

Discussion

We reviewed and summarized the existing literature. Trends are highlighted to further guide surgeons treating this unusual metastatic phenomenon.

Conclusion

Intradural metastasis is a harbinger of advanced disease with a poor prognosis regardless of the etiology of the primary lesion. There are a number of proposed mechanisms for metastatic spread with little available literature for surgeon guidance. Most authors are advocates of a palliative, decompressive approach.

Spontaneous Arrest of Sporadic Spinal Hemangioblastoma Growth after Postoperative Nodular Recurrence: Case Report

Hemangioblastomas are rare, slow-growing, highly vascularized tumors of the central nervous system which often occur in the spinal cord. When presenting as sporadic, isolated tumors without Von-Hippel Lindau disease, they are curable through surgery with a low rate of recurrence. Tumor recurrence in these cases is usually associated with prior subtotal resection. However, to the best of our knowledge, cases of recurrent, sporadic spinal hemangioblastoma have not been reported to spontaneously arrest without intervention or symptoms. We report a patient who underwent an initial complete resection of a cervical spinal hemangioblastoma, a subtotal resection of tumor recurrence four and a half years later, and nine years of neurologic and radiographic stability with no additional interventions.

Spinal cord astrocytomas: progresses in experimental and clinical investigations for developing recovery neurobiology-based novel therapies

Spinal cord astrocytomas (SCAs) have discernibly unique signatures in regards to epidemiology, clinical oncological features, genetic markers, pathophysiology, and research and therapeutic challenges. Overall, there are presently very limited clinical management options for high grade SCAs despite progresses made in validating key molecular markers and standardizing tumor classification. The endeavors were aimed to improve diagnosis, therapy design and prognosis assessment, as well as to define more effective oncolytic targets. Efficacious treatment for high grade SCAs still remains an unmet medical demand. This review is therefore focused on research state updates that have been made upon analyzing clinical characteristics, diagnostic classification, genetic and molecular features, tumor initiation cell biology, and current management options for SCAs. Particular emphasis was given to basic and translational research endeavors targeting SCAs, including establishment of experimental models, exploration of unique profiles of SCA stem cell-like tumor survival cells, characterization of special requirements for effective therapeutic delivery into the spinal cord, and development of donor stem cell-based gene-directed enzyme prodrug therapy. We concluded that precise understanding of molecular oncology, tumor survival mechanisms (e.g., drug resistance, metastasis, and cancer stem cells/tumor survival cells), and principles of Recovery Neurobiology can help to create clinically meaningful experimental models of SCAs. Establishment of such systems will expedite the discovery of efficacious therapies that not only kill tumor cells but simultaneously preserve and improve residual neural function.

Knockdown of collagen α-1(III) inhibits glioma cell proliferation and migration and is regulated by miR128-3p

As a member of the collagen family, collagen α-1(III) (COL3A1) is an important protein in the development and progression of several tumors. However, the role of COL3A1 in glioma is not yet clear. The present study examined the expression and function of COL3A1 in glioma cell behavior and identified microRNA (miRNA) regulators. It was demonstrated that COL3A1 expression was upregulated in glioma and directly correlated with the tumor grade. Analysis of the GSE4290 and GSE7696 profiles acquired from the Gene Expression Omnibus database also revealed an increased COL3A1 expression in malignant gliomas compared with the lower grade gliomas and non-tumor brain tissue, which was directly correlated with glioma grade. To explore the functional role of COL3A1 in glioma cell growth, small interfering RNA interference was applied to inhibit COL3A1 expression in Hs683 and U251 cells. The relative COL3A1 mRNA and protein expression levels were significantly reduced in the knockdown cells as determined by western blot analysis. In addition, decreased COL3A1 expression in Hs683 and U251 glioma cells resulted in a delay in cell growth and colony disruption as determined by MTS and colony formation assays. Wound healing analysis indicated that cells with suppressed expression of COL3A1 had a reduced ability to migrate. COL3A1 mRNA levels were inversely correlated with the miR128-3p level in glioma, suggesting that miR128-3p expression is associated with COL3A1 inhibition as verified by reverse transcription-quantified polymerase chain reaction. These results suggest that COL3A1 may be a novel regulator of glioblastoma cell behavior and may represent a novel target for gene therapies against glioma.

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.

Thoracic Spinal Cord Glioblastoma Mimicking Epidural Abscess: Case Report and Literature Review

Spinal cord glioblastoma (SG) accounts for 1.5% of all spinal tumors and has a poor prognosis with survival ranging from 2 to 26 months from presentation.

A 57-year-old male presented with one week of paraparesis and contrasted magnetic resonance imaging (MRI) findings of an epidural enhancing thoracic mass suspicious for an epidural abscess. Intraoperative and pathologic findings revealed SG.

Spinal cord tumors can mimic epidural abscess on MRI. When planning to address extradural spinal pathologies, one should be cognizant of the potential for either isolated or concurrent intradural pathologies. When the epidural findings do not correlate with preoperative imaging, intraoperative ultrasound imaging can identify intradural pathologies without violating the dura.

Primary spinal intradural extramedullary lymphoma: A novel management strategy

Primary spinal intradural extramedullary lymphoma remains a very rare entity in spinal oncology. In this case report, we present the first treatment of a PSIEL diagnosed by cytopathologic analysis alone followed by urgent radio- and chemotherapy in the literature. At 18-month follow-up, our patient was ambulatory with near total imaging resolution of the lesion. In conclusion, surgical excision or biopsy may not be necessary when suspicion for PSIEL exists, and may delay prompt medical and radiation treatment due to necessity for wound healing. Further research into the management of extramedullary lymphoma treatment strategies is warranted.

Thoracic exophytic ependymoma masquerading as a benign extra-axial tumor

Spinal tumors are conventionally differentiated based on location in relation to the spinal cord. Benign spinal tumors such as schwannomas and meningiomas are typically extra-axial (intradural extramedullary) lesions, whereas more aggressive primary spinal tumors such as ependymomas are typically intramedullary masses. Rarely, ependymomas can have both intramedullary and extramedullary components (typically referred to as exophytic ependymomas). We report a case of a spinal exophytic ependymoma that radiographically masqueraded as a benign intradural extramedullary lesion causing cord compression and neurologic deficit in a 47-year-old man. The diagnosis of exophytic ependymoma was made intra-operatively, with resultant gross total resection of the extramedullary portion and subtotal resection of the intramedullary portion. Histopathological examination confirmed ependymoma with World Health Organization grade II/IV. Pre-operative suspicion of an exophytic ependymoma influences operative planning and clinical management. We review the literature and discuss clinical management strategies for these interesting spinal tumors.

Management of Spinal Meningiomas

Spinal meningiomas are the most common spinal tumors encountered in adults, and account for 6.5% of all craniospinal tumors. The treatment for these lesions is primarily surgical, but emerging modalities may include chemotherapy and radiosurgery. In this article, the current management of spinal meningiomas and the body of literature surrounding conventional treatment is reviewed and discussed.