Long-term surgical outcomes for myxopapillary ependymomas of the cauda equina

Extraneural metastasis of ependymoma in the cauda equina

We report a rare case of extraneural metastasis of spinal ependymoma that developed over a very long period. A 28-year-old man underwent surgery for ependymoma in the cauda equina. After he experienced three local recurrences and had undergone five operations, a lung metastasis occurred 46 years after the first operation. Although the tumor did not show the typical morphological malignancy, the maximum standard uptake value obtained by positron-emission tomography and the antigen Ki-67 labeling index demonstrated the tumor's active proliferative ability. One year after the last operation, the patient died of respiratory failure due to progressing lung metastases. The malignant behavior of spinal ependymomas is demonstrated in a case with long-term follow-up.

Craniospinal dissemination of filum myxopapillary ependymoma following spinal trauma: case report and literature review

BACKGROUND

Myxopapillary ependymoma is a rare benign variant of ependymoma, occurring most commonly in the cauda equina/filum terminale of the spinal cord. It is rare in pediatric patients. Dissemination of the myxopapillary ependymoma along the neuraxis is uncommon both in adults and pediatric patients.

METHODS

We report a 16-year-old boy with dissemination of the myxopapillary ependymoma along the neuraxis following spinal trauma. The possible mechanisms of tumor dissemination are discussed with a review of the literature.

Ependymomas of the filum terminale: The role of surgery and radiotherapy

Background:

Ependymomas of the filum terminale (EFT) form a specific and relatively uncommon subtype of spinal cord ependymomas. Most series in the literature are small, spanning a large time period. Up to date no consensus has been reached about the optimal treatment of these lesions. Some authors promote postoperative radiotherapy for all cases, others advocate postoperative radiotherapy only when a subtotal resection is performed or when metastasis are apparent.

Methods:

We performed a retrospective analysis of 22 patients with an EFT (mean age at diagnosis of 35.6 years).

Results:

In all patients (9/22) with lesions smaller than 4.5 cm no metastases were present and a complete resection could be obtained. No adjuvant radiotherapy was performed and at latest follow they had an excellent outcome. In our series, these initial tumor characteristics were more important regarding prognosis than either histology or treatment-related factors. For the larger tumors, total resection was obtained less frequently, more dissemination was diagnosed and a worse outcome was scored. Radiotherapy if indicated did lead to an acceptable disease control.

Conclusion:

In every case of EFT, an individual treatment protocol has to be outlined, but if an EFT is relatively small and can be resected completely, we would advocate to withhold radiotherapy.

Complications associated with the treatment for spinal ependymomas

Spinal cord ependymomas are rare neoplasms, comprising approximately 5% of all CNS tumors and 15% of all spinal cord tumors. Although surgery was once reserved for diagnosis alone, the evolution of surgical practices has elevated resection to the treatment of choice for these lesions. While technological advances continue to improve the capacity for gross-total resections and thus decrease the risk of recurrence, ependymoma spinal surgery still contains a variety of potential complications. The presence of neurological deficits and deterioration are not uncommonly associated with spinal cord ependymoma surgery, including sensory loss, dorsal column dysfunction, dysesthetic syndrome, and bowel and bladder dysfunction, particularly in the immediate postoperative period. Surgical treatment may also lead to wound complications and CSF leaks, with increased risk when radiotherapy has been involved. Radiation therapy may also predispose patients to radiation myelopathy and ultimately result in neurological damage. Additionally, resections of spinal ependymomas have been associated with postoperative spinal instability and deformities, particularly in the pediatric population. Despite the advances in microsurgical techniques and intraoperative cord monitoring modalities, there remain a number of serious complications related to the treatment of spinal ependymoma tumors. Identification and acknowledgment of these potential problems may assist in their prevention, early detection, and increased quality of life for patients afflicted with this disease.

Surgical treatment of rare cauda equina tumours

BACKGROUND

Cauda equina tumours (CET) are rare and usually benign. Treatment of schwannomas and benign ependymomas, which are the most frequent histopathological types of CET, is now well established. However, management of other presumed histopathological types of CET is still a matter of debate. The aim of this study was to assess the incidence and the surgical treatment of rare CET.

METHOD

A retrospective study was carried out on 176 adult patients surgically treated for CET in our two departments from 1994 to 2010. We reviewed pre- and postoperative symptoms, magnetic resonance imaging aspects, surgical findings, outcome including operative neurological morbidity, local recurrence rate and operative mortality, and incidence of rare CET.

FINDINGS

Seventeen percent (30 patients) of CETs operated on were neither schwannomas nor benign ependymomas. Half of these cases were benign tumours, with paragangliomas being the most common. Two patients were in poorer clinical condition after surgery, one patient experienced a local recurrence, and one died following surgery, from the progress of his disease (Von Hippel-Lindau disease). The other half were malignant tumours, with metastases being the most common. One third of the patients were worsened by surgery, and the mortality rate was 1/3 at 8 months (1-27 months).

CONCLUSIONS

Roughly one in six CET were neither schwannomas nor benign ependymomas. This study demonstrated the efficiency of surgery for rare benign CET with a low local recurrence rate. Surgical treatment of rare malignant CET led to a high rate of increased postoperative neurological deficit in patients with a reduced life expectancy.

Ependymomas in adults

Ependymomas are rare primary central nervous system tumors in adults. They occur most commonly in the spinal cord, where histopathologic evaluation is critical to differentiate the grade I myxopapillary ependymoma from the grade II ependymoma or grade III anaplastic ependymoma. Brain ependymomas are either grade II or III. Treatment for all grades and types includes maximum surgical resection. For myxopapillary ependymoma, complete removal while maintaining capsule integrity may be curative. Some grade II ependymomas may be observed carefully after imaging confirms complete resection, but grade III tumors require adjuvant radiation treatment. Radiation commonly is given to the region of tumor, except in cases in which there is imaging or cerebrospinal fluid evidence of tumor dissemination. Chemotherapy has not been studied extensively, although most reports suggest only modest benefit. Ongoing laboratory studies have uncovered important signal transduction pathways that may be better therapeutic targets, leading to the development of clinical trials using targeted agents.