Supratentorial Pure Cortical Ependymoma: An Unusual Lesion Causing Focal Motor Aware Seizure

Anaplastic cortical ependymoma in 10 months girl: A case report

INTRODUCTION AND IMPORTANCE

Ependymomas arise from the ependymal cells that line the brain ventricles, and central canal. In children most of them are benign. However, cortical anaplastic ependymomas are very rare in pediatrics.

CASE PRESENTATION

A 10 months girl presented with vomits for one week, increased head circumference, psychomotor development delay, left facial nerve (VII) palsy, and left hemiparesis 3/5. Magnetic resonance imaging (MRI) of the brain demonstrated a large parenchymal lesion filling most of the right hemisphere. She underwent a total excision of the lesion. The tumor had no connection to the ventricular ependymal lining. No adjuvant chemotherapy or radiotherapy was considered. The final diagnosis is Anaplastic Ependymoma (WHO Grade III).

CLINICAL DISCUSSION

Cortical anaplastic ependymomas are extremely rare. In pediatrics they affect frontal, frontoparietal, and parietal lobes, Temporal and occipital lobes are uncommon. Migration disorders from the germinal matrix and the differentiation of primitive neuroectodermal tumors along the ependymal lineage are considered two hypotheses that explain the pathogenesis of ectopic ependymomas.

CONCLUSION

Ependymomas should be considered a differential diagnosis in children, as the successful total removal of ependymomas in that age saves the patient from the need of adjuvant therapy such as radio-therapy or chemotherapy.

Supratentorial cortical ependymoma: A systematic literature review and case illustration

Cortical ependymomas are currently not considered a subgroup of supratentorial ependymomas; however, there is a growing body of literature investigating the natural history of these lesions compared to supratentorial ependymomas. We performed a systematic literature review of cortical ependymomas with a focus on the natural history, clinical characteristics, and clinical outcomes of these lesions as compared to supratentorial ependymomas. Our search revealed 153 unique cases of cortical ependymomas. The mean age on presentation was 21.2 years. Males and females comprised 58.8% (90/153) and 41.2% (63/153) of cases, respectively. The most common presenting symptom was seizure activity occurring in 44.4% of the cohort (68/153). The recently recognized C11orf95-RELA fusion was identified in 13.7% of the cohort (21/153) and 95.5% of cases (21/22) reporting molecular characterization. World Health Organization grades 2 and 3 were reported in 52.3% (79/151) and 47.7% (72/151) of cases, respectively. The frontal lobe was involved in the majority of cases (54.9%, 84/153). Gross total resection was achieved in 80.4% of cases (123/153). Tumor recurrence was identified in 27.7% of cases (39/141). Mean clinical follow-up was 41.3 months. Mean overall survival of patients who expired was 27.4 months whereas mean progression-free survival was 15.0 months. Comparatively, cortical ependymomas with C11orf95-RELA fusions and supratentorial ependymomas with C11orf95 RELA fusions exhibited differing clinical outcomes. Further studies with larger sample sizes are necessary to investigate the significance of RELA fusions on survival in cortical ependymomas and to determine whether cortical ependymomas with C11orf95-RELA fusions should be classified as a distinct entity.

Cortically based cystic supratentorial RELA fusion-positive ependymoma: a case report with unusual presentation and appearance and review of literature

Ependymomas are rare central nervous system tumors that can arise anywhere in the neuroaxis. Supratentorial and posterior fossa ependymomas were identified as distinct diseases after extensive molecular analysis. The 2016 World Health Organization update further introduced RELA fusion-positive ependymoma as a novel entity as a subset of supratentorial ependymomas indicating the presence of C11orf95-RELA fusion genes. RELA fusion-positive ependymomas are commonly intraventricular, though they may rarely manifest as extraventricular, cortically-based tumors. They are commonly large solid, mixed solid/cystic tumors or rarely cystic. In this paper, we report a case of RELA fusion positive cortically based-cystic ependymoma and review the existing literature. Our patient is a 9-year-old boy who presented with an unusual presentation of right facial droop. He underwent gross total resection of the ependymoma, following resection, his facial droop resolved and there was no neurologic deficit.

The Survival and Prognostic Factors of Supratentorial Cortical Ependymomas: A Retrospective Cohort Study and Literature-Based Analysis

Aim

Survival rates and prognostic factors of cortical ependymomas (CEs) remain elusive. This study aimed to perform a comprehensive analysis of prognostic factors, treatment, and outcomes for patients with CEs based on institutional and literature case series.

Materials and Methods

Thirty patients with CEs from our department were included in this study. Furthermore, a systemic review of the literature yielded an additional 106 patients with CEs. Clinical data including patient age, sex, symptoms, tumor location, World Health Organization (WHO) grade, extent of surgery, radiation, recurrence, and survival were recorded and statistically analyzed.

Results

From January 2009 to October 2019, 30 (4.2%) cases were diagnosed as CEs in our department. These series consisted of 19 males and 11 females, 10 continuous patients after 2017 screened for C11orf95-RELA fusion, and 9 patients (90%) were RELA fusion positive. During the follow-up period, nine (30%) patients depicted tumor recurrence or progression; four (13.3%) patients died of tumor progression. The literature review yielded 106 CE cases, with additional 30 cases of our own collected for further analysis. Of these 136 cases, the frontal lobe (40%) was the most common location, and the average age was 22.6 ± 17.6 years. Anaplastic histology/WHO grade III tumors were identified in 68 (50%) patients. Statistically analysis demonstrated that extent of surgery and WHO tumor grade were significant prognostic factors in Kaplan–Meier log-rank testing and Cox proportional hazards models. Gross total resection (GTR) predicted longer progression-free survival (PFS) [P = 0.013, hazard ratio (HR) = 3.012, 95% confidence interval (CI) = 1.257–7.213] and overall survival (OS) (P = 0.003, HR = 5.322, 95% CI = 1.751–16.178). WHO grade III tumors had worse PFS (P = 0.002, HR = 5.17, 95% CI = 1.804–14.816) and OS (P = 0.025, HR = 5.640, 95% CI = 1.248–25.495).

Conclusion

CEs accounted for only 3.5 to 5.7% of ependymomas, with seizures the most common symptom and the frontal lobe the most frequent location. CEs may have higher rate of RELA fusions, but generally favorable prognosis. The extent of surgery and WHO tumor grade were significant prognostic factors for PFS and OS in multivariate analysis. GTTR or WHO grade II tumors had better overall outcome in patients with CEs.

Clinicopathological and Genetic Features of Supratentorial Cortical Ependymomas

OBJECTIVE

Supratentorial cortical ependymomas (CEs) are rare. These lesions, selectively occurring in the superficial cortex, have not been fully characterized. We analyzed the clinicopathological and genetic features of CEs.

METHODS

Eight patients with CEs from our institution and 84 other reported CE cases were included in the present study. We retrospectively reviewed their clinical characteristics, imaging findings, treatment methods, pathological features, molecular status, and clinical outcomes.

RESULTS

The median age at diagnosis of our 8 patients was 7.5 years. The mean tumor diameter was 70 mm. All the tumors had a cystic appearance, and calcification was observed in 6. Gross total resection was achieved in 6 patients and subtotal resection in 2 patients. Of the 8 tumors, 7 were World Health Organization grade III and 1 was World Health Organization grade II. Six tumors were immunopositive for L1 cell adhesion molecule (L1CAM). We investigated the presence of C11orf95-RELA fusion in 5 patients, all of whom exhibited it. Postoperative radiotherapy was performed for all patients with grade III tumors, except for children aged <3 years. Although 4 patients developed recurrence, all were alive throughout the follow-up period. Compared with previously reported CEs, our patients were younger and had larger tumors; however, the clinical outcomes did not differ significantly.

CONCLUSIONS

Although most CEs in our group were immunopositive for L1CAM and showed C11orf95-RELA fusion, which have been associated with a poor prognosis in supratentorial ependymomas, all our patients had good outcomes. Gross total resection and adjuvant radiotherapy contributed to the relatively favorable prognosis of CEs compared with other supratentorial ependymomas.