Primary Ependymoma in the Posterior Mediastinum

Pediatric Extraspinal Subcutaneous Sacrococcygeal Myxopapillary Ependymoma: Case Report and Minireview

ABSTRACT

A 9-year-old girl presented with a slow-growing and painless mass for 7 months in the soft tissue of the sacrococcygeal region. Magnetic resonance imaging revealed a well-circumscribed solid mass located in the subcutaneous soft tissue of the sacrococcygeal area, but not affecting bone structures. The mass was completely removed, and the disorder was diagnosed as myxopapillary ependymoma. In addition, the MYCN gene amplification status of the tumor was evaluated. Extra-axial ependymomas are very rare tumors with a tendency to metastasis, but they are usually regarded as low-grade ependymomas. Long-time surveillance and follow-up are necessary even after complete excision. Besides, we also discuss the diagnosis of primary soft tissue myxopapillary ependymoma.

Primary uterine broad ligament ependymoma with CHEK2 p.H371Y germline mutation: A CARE-compliant case report uterine broad ligament ependymoma

Ependymomas arise from ependymal cells lining the ventricles and central canal of the spinal cord and can occur throughout the whole neuraxis. The lesion rarely occurs in extracranial or extraspinal regions, particularly in the uterine broad ligament. Thus, for the pathogenesis of nonsacral extra‐central nervous system (CNS) ependymomas remains elusive. Here, we describe a rare case of primary uterine broad ligament. ependymoma with cell‐cycle‐checkpoint kinase 2 (CHEK2) p.H371Y germline mutation. A 45‐year‐old woman presented with a uterine mass. The transvaginal sonographic examination confirmed a 4.4 cm × 3.7 cm, cystic and solid, mass located on the right side uterine wall near isthmus. First, laparoscopy with the neoplasm resection was carried out. Based on morphological and immunohistochemical characteristics of tumor cells that expressed glial fibrillary acidic protein (GFAP), S‐100, and vimentin, the tumor was diagnosed as an ependymoma. After that, she underwent a laparotomic total hysterectomy, bilateral salpingo‐oophorectomy, and lymphadenectomy. Furthermore, we performed next‐generation sequencing (NGS) of the patient's resected tumor tissue and peripheral blood and identified a novel CHEK2 p.H371Y germline mutation. Following surgery, the patient received oral tamoxifen (10 mg 2/day) and followed by letrozole (2.5 mg/day) for 6 months. The patient remained disease‐free after 4 years of follow‐up. Conceivably, CHEK2 p.H371Y is a driving gene for the development of extra‐CNS ependymoma.

Extra-axial sacral soft tissue giant cell ependymoma affecting a child: Case report and review of the literature

An otherwise healthy eight-year-old girl presented with a mass in the soft tissue of the sacral region. The lesion was diagnosed as a vascular malformation on imaging studies, for which percutaneous sclerotherapy was attempted. The mass continued to grow and a complete resection was performed after four years. The pathological diagnosis was giant cell ependymoma (GCE). GCE is a term used to describe a rare histologic variant of ependymoma characterized by malignancy-like morphologic phenotype and indolent behavior. To the best of our knowledge, this is the first case of extra-axial soft tissue sacral GCE reported in a child.

Mediastinal Anaplastic Ependymoma

Ependymomas arise from ependymal cells and can grow at any site in the central nervous system (CNS), as well as in some locations outside of the CNS. The latter is rare, contributing to the frequent misdiagnoses of such cases. Herein, we present the case of a 54-year-old man with a history of lower limb weakness and numbness. Magnetic resonance imaging revealed an extradural, heterogeneously enhanced solid lesion with a regular and well-defined border in the posterior mediastinum. A post-resection histopathological examination revealed tumor-forming perivascular pseudo-rosettes that showed immunoreactivity against glial fibrillary acidic protein, epithelial membrane antigen, and vimentin, as well as a high Ki-67 labeling index. Based on pathological features, a diagnosis of anaplastic ependymoma was established.

Ependymoma of the broad ligament mimicking an ovarian surface epithelial tumor

We report a case of ependymoma of the broad ligament occurring in a 21-year-old woman. CT and MRI findings showed a 40-mm-diameter, well-demarcated cystic mass with a lobulated solid component in the right pelvis. The solid component showed heterogeneous intermediate signal intensity on T2-weighted image and prolonged mild contrast enhancement. The tumor was resected and confirmed as ependymoma based on the histologic findings along with its immunohistochemical profile. To our knowledge, this is the first report of an adnexal ependymoma describing the precise radiological characteristics that resembled those of borderline or malignant epithelial ovarian tumors.

Ovarian ependymoma presenting in pregnancy: a case report and literature review

Background

Ovarian ependymoma is a rare malignancy. Because of the extreme rarity, certain features of the neoplasm, including its clinical behaviour and optimal therapy, are incompletely characterized.

Case presentation

A 32-year-old pregnant woman at term presented with a left ovarian neoplasm that occurred in the early stage of pregnancy. She underwent left adnexectomy during the caesarean section, and the neoplasm was histologically and immunohistochemically identified to be ovarian ependymoma. Immunohistochemical staining with oestrogen receptors and progesterone receptors showed strong positive staining. According to reports in the literature, the pathological type of ovarian ependymoma in our patient was the extra-axial type. Interestingly, the foetus was also found to have bilateral ependymal cysts during pregnancy. The patient received no further surgical treatment or adjuvant therapy. She and her 14-month-old baby both have no evidence of disease at present. The follow-up of both mother and child is still continuing.

Conclusions

The case presented here illustrates high levels of oestrogen during pregnancy may stimulate viable malignant ependymal cells to proliferate. Hence, young women with extra-axial-type ependymomas may not be suitable for fertility preservation. Moreover, hormone-based therapies can be a potentially effective treatment for women with extra-axial ependymomas.

Primary ependymoma of the retropubic space in a male patient

We report a case of primary intraabdominal ependymoma arising in the retropubic space of a male patient. An incidental intraabdominal mass was discovered in a 51-year-old man. Radiological studies revealed a 10 cm, solid and cystic tumor located in the Retzius fossa. Microscopically, the lesion was characterized by multiple cellular nodules composed of bland small cells forming true and pseudorosettes. No nuclear atypia, necrosis or increased mitotic activity was present. Neoplastic cells positive for AE1/3 and Cam5.2, and expressed patchy GFAP, and paranuclear dot-like to microvesicular EMA and D2-40, while S100, synaptophysin, PAX8, TLE1, WT1, inhibin, calretinin, Melan-A, and HMB45 were negative. Electron microscopy findings supported the diagnosis: 1) Frequent intracytoplasmic vacuoles with short and redundant microvilli and few cilia 2) lung intercellular junctions. The patient is alive with no evidence of disease for 4 years. Pathologists should be aware that rare extraneural ependymomas may occur in the Retzius space, even in a male patient. This entity should be kept in mind especially when the differential diagnosis is metastatic carcinoma with an unusual morphology and immune profile.

A case of bi-focal mediastinal ependymoma

Ependymomas are tumors located in the central nervous system, mostly in the brain and spinal cord. This tumor is rarely seen as a primary mediastinal location. The aim of this study is to discuss this rare pathology in the clinical course of an unusual case. A 47-year-old female patient was referred to our clinic with the complaint of back and shoulder pain, via VATS posterior mediastinum located paravertebral mass excision was performed. The pathology reported as ependymoma. Two years later, CT scans of the routine control showed the well-defined mass in anterior mediastinum. The SUVmax of the lesion was measured as 9.3 at PET-CT. The lesion in the anterior mediastinum was excised by partial sternotomy. The pathology result was the same as the prior operation: Ependymoma. As our case, in these kinds of tumors meticulous follow-up of the patients is important for the detection and treatment of recurrent localization and distant metastases.

Primary mediastinal ependymoma: A case report and literature review

RATIONALE

Ependymomas are neuroepithelial tumors that typically occur in the central nervous system. Ependymomas arising in the mediastinum are exceedingly rare, with only approximately 9 isolated cases reported in the literature to date.

PATIENT CONCERNS

A 35-year-old woman was referred to our hospital with complaints of progressive back pain for 3 months. Physical examination revealed decreased breathing sounds and tenderness. Contrast-enhanced computed tomography showed a soft tissue mass with heterogeneous enhancement in the right posterior mediastinum.

DIAGNOSES

The diagnosis of primary mediastinal ependymomas (PMEs) was confirmed by postoperative histopathologic examination.

INTERVENTIONS AND OUTCOMES

The patient underwent surgical resection of the tumor and experienced local recurrence with neck metastasis 2 years postoperatively. She underwent reoperation for the recurrent tumors and received postoperative radiotherapy and adjuvant chemotherapy. Two years later, the patient is doing well, with no evidence of tumor progression or recurrence.

LESSONS

Since PMEs are exceedingly rare, treatment options are limited. Surgical resection seems to be the mainstay of treatment. Further evidence-based studies are required to prove the benefit of radiotherapy and chemotherapy in the treatment of PMEs.

Pituitary Ependymoma: A Case Report and Review of the Literature

BACKGROUND

Pituitary ependymoma is exceptionally rare. Its etiology, clinical presentation, radiologic feature, and treatment strategy are still a matter of debate. Only 7 human cases with limited data were reported in the English literature, and now we described another case of pituitary ependymoma. We also systematically reviewed previously reported cases and described its potential etiology, clinical presentation, radiologic features, pathology, immunohistochemical analysis, and ultrastructural examinations.

CASE DESCRIPTION

A lesion in pituitary fossa was discovered in a 40-year-old man after suffering a progressive deterioration of vision in his right eye for >1 year with intermittent headache. The lesion was microsurgically resected and proved to be ependymoma upon pathologic and histologic examination. The patient made a fully recovery after surgery.

CONCLUSIONS

To our knowledge, only 7 patients with ependymoma in the sellar region have been described in the English literature. We reported 1 more case of pituitary ependymoma and discussed the potential etiology, clinical presentation, radiologic features, pathology, immunohistochemical analysis, ultrastructural examinations, treatment, surgery, radiotherapy, chemotherapy, and prognosis of pituitary ependymoma. The case report may serve as a helpful reference for clinicians and radiologists.

Ependymomas arising outside of the central nervous system: A case series and literature review

BACKGROUND

Extracranial and extraspinal ependymomas are extremely rare tumors mostly published in the literature as case reports.

METHODS

MD Anderson Cancer Center institutional database was screened for patients with extra CNS ependymomas over a 25 year period.

RESULTS

Eight patients with extra CNS ependymoma were identified. Five cases originated in the sacrum or subcutaneous sacral area, and the other 3 cases originating in the breast, lung and adnexa of the uterus. By histology, most cases were myxopapillary ependymomas (5 cases), 2 cases were grade II ependymoma and 1 case was an anaplastic ependymoma. Metastases occurred in 6 cases and 3 patients died due to progressive disease. Most cases required surgery, radiation and chemotherapy.

CONCLUSION

Extra CNS ependymomas are very rare tumors that tend to metastasize, even though most cases are histologically classified as low grade ependymomas.

Recent Advances in the Classification and Treatment of Ependymomas

OPINION STATEMENT

Ependymomas are a subgroup of ependymal glia-derived neoplasms that affect children as well as adults. Arising within any CNS compartment, symptoms at presentation can range from acute onset due to increased intracranial pressure to insidious myelopathy. The overall survival (OS) outcomes in adult patients across the subgroups is heterogeneous with subependymoma having an excellent prognosis often even in the absence of any treatment, whereas supratentorial ependymomas tend to be higher grade in nature and may have an OS of 5 years despite gross total resection and adjuvant radiation. The rarity of ependymal tumors, together still only representing 1.8% of all primary CNS tumors, has been a long-standing challenge in defining optimal treatment guidelines via prospective randomized trials. Retrospective studies have supported maximal safe resection, ideally gross total resection, as the optimal treatment with adjuvant radiation therapy proffering additional tumor control. The evidence for efficacy of chemotherapy and targeted agents in adult ependymomas is minimal. Recent investigations of the molecular, genetic, and DNA methylation profiles of ependymal tumors across all age groups and CNS compartments have identified distinct oncogenic gene products as well as nine molecular subgroups correlating with similar outcomes. The 2016 World Health Organization of Tumors of the Central Nervous System update addresses some of these findings, although their clinical significance has not yet been fully validated. There are inconsistent survival outcomes in retrospective studies for ependymomas graded as II versus III, bringing into question the validity of histologic grading which is subject to high interobserver variability in part due to inconsistent application of mitotic count parameters.

Pelvic Ependymoma With Clinical Response to GnRH Analog Therapy: A Case Report With an Overview of Primary Extraneural Ependymomas

Extraneural ependymomas are rare tumors that occur in sacrococcygeal, pelvic and extra pelvic regions. While sacrococcygeal extraneural ependymomas are equally distributed among males and females, pelvic and extra pelvic ependymomas have been exclusively reported in women, mainly of child bearing age. We present a case of extraneural, pelvic ependymoma that showed clinical response to GnRH therapy with its immunohistochemical and electron microscopic analysis, and an overview of primary extraneural ependymomas based on a review of all such cases published in English literature.

Genomics and epigenetics: A study of ependymomas in pediatric patients

OBJECTIVE

We identify chromosomal alterations, the methylation pattern and gene expression changes in pediatric ependymomas.

METHODS

CGH microarray, methylation and gene expression were performed through the Agilent platform. The results were analyzed with the software MatLab, MapViewer, DAVID, GeneCards and Hippie.

RESULTS

Amplification was found in 14q32.33, 2p22.3 and 8p22, and deletion was found in 8p11.23-p11.22 and 1q21.3. We observed 42.387 CpG islands with changes in their methylation pattern, in which we found 272 genes involved in signaling pathways related to carcinogenesis. We found 481 genes with altered expression. The genes IMMT, JHDMD1D, ASAH1, ZWINT, IPO7, GNAO1 and CISD3 were found to be altered among the three levels.

CONCLUSION

The 2p22.3, 8p11.23-p11.22 and 14q32.33 regions were identified as the most important; the changes in the methylation pattern related to cell cycle and cancer genes occurred in MIB2, FGF18 and ITIH5. The IPO7, GNAO1 and ASAH1 genes may play a major role in ependymoma development.

Extramedullary Conus Ependymoma Involving a Lumbar Nerve Root with Filum Terminale Attachment

PURPOSE

In the current report, we describe a case of an extramedullary ependymoma involving a lumbar nerve root near conus medullaris. Spinal ependymomas commonly present as intramedullary tumors in the cervical or thoracic cord or as tumors arising from the conus medullaris or the filum terminale. In this case, we showed an extramedullary conus ependymoma involving a lumbar nerve root with filum terminale attachment.

CASE PRESENTATION

A 69-year-old woman presented with lower back pain, but without sensory disturbance or motor weakness in her lower extremities.

CLINICAL ASSESSMENT

Magnetic resonance imaging revealed an intradural mass at T12-L1 at the conus medullaris, which was totally resected. Histopathology revealed a non-myxopapillary ependymoma (WHO grade 2). Postoperatively, the patient did well and displayed no neurological deficits. Moreover, no radiotherapy was required.

CONCLUSIONS

This report documented a rare case of intradural extramedullary ependymoma located at the conus medullaris, involving the lumbar nerve root, and attached to the filum terminale. Although extramedullary ependymomas at this region are more frequently classified as myxopapillary, histopathological examination revealed this tumor as a non-myxopapillary ependymoma.