Treatment of ovarian anaplastic ependymoma by an aromatase inhibitor

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.

A Rare Case of Metastatic Primary Peritoneal Ependymoma: A Case Report and Literature Review

Background

Primary peritoneal ependymoma is an exceedingly rare tumour with only four cases reported in the literature. It typically follows an indolent disease course. We describe a rare case of metastatic primary peritoneal ependymoma which was treated with chemotherapy and radiotherapy resulting in prolonged survival to date for 10 years. Case Presentation. The patient was a 23-year-old female on presentation. She presented with right upper quadrant pain associated with an abdominal mass. Computed tomography demonstrated a large mass displacing the liver. Debulking surgery was done revealing a tumour arising from the peritoneum as well as multiple metastatic pleural and peritoneal nodules. Pathology was consistent with primary peritoneal ependymoma. The patient was then treated with multiple lines of chemotherapy containing etoposide as the backbone. She also received palliative radiotherapy to the thoracic metastases with good and durable response.

Conclusion

We reported a rare case of metastatic primary peritoneal ependymoma. Etoposide containing the chemotherapy regimen is effective in the treatment of peritoneal ependymoma. Radiotherapy is also effective for palliation of local symptoms with durable response.

Individualized treatment for a case of recurrent ovarian ependymoma

Ovarian anaplastic ependymoma is a rare gynecologic malignancy. Owing to its rarity, treatment is challenging. Unilateral ovarian ependymoma was found during laparoscopy in a 19-year-old woman. After cytoreductive surgery, three cycles of bleomycin, etoposide, and cisplatin were administered. Four years after chemotherapy, the patient experienced relapse. After the secondary cytoreductive surgery, no further treatment was performed. She is in good condition, ~19 months after secondary cytoreductive surgery using hormone-replacement therapy without chemotherapy. Some cases of ovarian ependymoma can be treated with surgery alone without chemotherapy and the outcome has been satisfying. Choosing treatment based on malignant ovarian germ cell tumors may be not optimal. Therefore, we suggest individualized treatment for ovarian ependymoma.

Primary Glial and Neuronal Tumors of the Ovary or Peritoneum: A Clinicopathologic Study of 11 Cases

Primary glial and neuronal tumors of the ovary or peritoneum are rare neuroectodermal-type tumors similar to their counterparts in the central nervous system. We retrospectively reviewed 11 cases. These cases included 4 ependymomas, 6 astrocytic tumors, and 1 neurocytoma. Patients' age ranged from 9 to 50 years (mean, 26 y; median, 24 y). All ependymal tumors with detailed clinical history (n=3) were not associated with any other ovarian neoplasm. In contrast, all astrocytic tumors were associated with immature teratoma (n=4), mature cystic teratoma (n=1), or mixed germ cell tumor (n=1). The neurocytoma arose in association with mature teratomatous components in a patient with a history of treated mixed germ cell tumor. Immunohistochemical staining showed that 7 of 7 ependymal and astrocytic tumors (100%) were positive for glial fibrillary acidic protein, and 2 of 2 ependymomas (100%) were positive for both estrogen and progesterone receptors. The neurocytoma was positive for synaptophysin and negative for S100 protein, glial fibrillary acidic protein, and SALL4. No IDH1-R132H mutation was detected in 2 of 2 (0%) astrocytomas by immunohistochemistry. Next-generation sequencing was performed on additional 2 ependymomas and 2 astrocytomas but detected no mutations in a panel of 50 genes that included IDH1, IDH2, TP53, PIK3CA, EGFR, BRAF, and PTEN. Follow-up information was available for 8 patients, with the follow-up period ranging from 4 to 59 months (mean, 15 mo; median, 8.5 mo), of which 3 had no evidence of disease and 5 were alive with disease. In conclusion, primary glial and neuronal tumors of the ovary can arise independently or in association with other ovarian germ cell tumor components. Pathologists should be aware of these rare tumors and differentiate them from other ovarian neoplasms. Even though an IDH1 or IDH2 mutation is found in the majority of WHO grade II and III astrocytomas, and in secondary glioblastomas arising from them, such mutations were not identified in our series, suggesting that these tumors are molecularly different from their central nervous system counterparts despite their morphologic and immunophenotypic similarities.

Complete response to paclitaxel, ifosfamide, and cisplatin therapy in a case of ovarian ependymoma

There are many reports on paclitaxel, ifosfamide, and cisplatin (TIP) therapy, following standard bleomycin, etoposide, and cisplatin (BEP) therapy, for salvage treatment of testicular malignant germ cell tumors, but there are no reports on its use for ovarian malignant tumors. We report here that a patient with primary ependymoma of the ovary, who was resistant to BEP therapy, achieved a complete response to a combined therapy, including TIP therapy as the second-line chemotherapy and surgery. This important case, combined with published studies, suggests that TIP therapy is effective for both testicular and ovarian malignant tumors and indicates that TIP therapy can be used as an effective second-line therapy for malignant tumors resistant to BEP therapy.

Hormonal based treatment of ovarian anaplastic ependymoma with anastrozole

Objective

Ovarian anaplastic ependymoma is a rare gynecologic malignancy that poses diagnostic and treatment challenges. Treatment of sub-optimally debulked disease usually portends poor prognosis. Molecular testing of tumor specimen can identify more specific targets for additional therapy such as estrogen and progesterone receptors (ER/PR).

Case

A 29-year-old woman presented with incidental finding of large bilateral adnexal masses and elevated CA 125. Biopsy proved anaplastic ovarian ependymoma with high ER/PR expression. She underwent sub-optimal surgical debulking followed by adjuvant chemotherapy with bleomycin, etoposide and cisplatin (BEP) which resulted in a partial response. Due to extensive residual disease she has been maintained on anastrozole for over fifteen months without increased tumor burden. Targeted somatic mutation testing was negative for all high risk clinically useful variants.

Conclusion

Aromatase inhibitors may be considered in patients with extra-axial anaplastic ependymoma and can produce prolonged stable disease.

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Ovarian anaplastic ependymoma is a rare gynecologic malignancy.

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Histology shows perivascular rosettes, hypercellularity, and nuclear atypia.

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Standard therapy includes surgical debulking followed by chemotherapy with BEP.

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Molecular diagnostics can identify estrogen and progesterone receptor expression.

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ER/PR expression can help direct treatment with aromatase inhibitors.

A case of ependymoma arising from the peritoneum

Ependymoma arising from the peritoneum is extremely rare. We present the case of a 23-year-old woman who underwent urgent laparoscopic surgery because of a pelvic mass and intraperitoneal bleeding. Although peritoneal carcinoma was suspected, pathological re-examination revealed ependymoma with a perivascular pseudorosette and positive for glial fibrillary acidic protein. Residual tumor extraction indicated that the ependymoma had developed from the peritoneum. This case highlights the need to consider ependymoma as a potential diagnosis in young women with suspected ovarian or peritoneal cancer.

Evidence for involvement of steroid receptors and coactivators in neuroepithelial and meningothelial tumors

Steroid receptors such as androgen receptor (AR) and estrogen receptors (ER) ER-α and ER-β, and their receptor coactivators (steroid receptor coactivator, SRC) are widely localized in the brain. Although previous studies have investigated the expression of steroid receptors in brain tumors like astrocytoma, the studies on the expression of steroid receptors and SRCs in other brain tumors are lacking. Here, we investigated the expression of AR, ERs, and SRCs in neuroepithelial (medulloblastoma, ependymoma, oligodendroglioma) and meningothelial meningioma using tissue microarray immunohistochemistry. Compared to normal brain tissue, we found that the expression of SRC-1, SRC-3, and ER-α significantly decreased in meningothelial tumor and neuroepithelial tumor, suggesting that the SRC-1/SRC-3 levels may be regulated by ER-α. Moreover, the levels of AR strongly correlated to the levels of ER-β. Furthermore, correlation was also detected between SRC-3 and AR in neuroepithelial tumor, and between ER-α and ER-β in meningothelial tumor. In addition, the decreased ratio of SRC-1/SRC-3 was associated with an increase of ER-β in neuroepithelial tumor. These results indicate that expressions of different steroid receptors and activators may be tumor type dependent. While AR, ER-α, and ER-β may be involved in the pathogenesis of meningothelial tumor, SRCs/ER-β axis and SRC-3/AR axis may play a role in the pathogenesis of neuroepithelial tumor.

Paraneoplastic internal jugular vein thrombosis leading to diagnosis of bilateral ovarian ependymoma

Ovarian ependymomas are extremely rare tumors of the ovary. We present a case of a 67-year-old lady presented to us with swelling in the right side of neck for 2 months followed by pelvic pain, lower abdominal distention, and weight loss for 1 month. Her coagulation profile, blood chemistry, lipid profile, and tumor markers were within normal limits. Neck Doppler ultrasonography revealed thrombus in the right internal jugular vein and CT scan of the abdomen showed bilateral ovarian masses. Patient was subjected to debulking surgery for suspected ovarian cancer and microscopy revealed a highly cellular tumor composed of small cells with hyperchromatic, round-to-oval nuclei with scanty cytoplasm, and perivascular pseudorosettes. Diagnosis was confirmed by immunophenotype showing strong positivity to glial fibrillary acidic protein, estrogen receptors, and progesterone receptors. Patient was successfully managed with anticoagulants, adjuvant chemotherapy with BEP regimen, and letrozole. After ruling out other common conditions for thrombosis in this age group, this seems to be a paraneoplastic presentation of ovarian malignancy that preceded the diagnosis of ependymoma by 2 months. To the best of our knowledge this is the first case report in the world literature as "paraneoplastic internal jugular vein thrombosis leading to diagnosis of bilateral ovarian ependymoma."

Papillary ependymoma of the endometrium

AIMS

To report an exceptional case of papillary ependymoma occurring in the endometrium.

METHODS AND RESULTS

A clinicopathological study was performed regarding a case of papillary ependymoma occurring in the endometrial cavity of a 61-year-old patient who had presented with a solid-type, stage III anaplastic ependymoma of the ovary, treated with cytoreductive surgery that included total abdominal hysterectomy. The uterus was enlarged and showed a dilated cavity, with broadly implanted papillary excrescences without myometrial invasion that were covered by tall, cylindrical cells. These cells had glial fibrillary acidic protein-expressing cytoplasm that was also positive for cytokeratins 7, 8, 18, and 34β-E12, epithelial membrane antigen, S100 protein, vimentin, and oestrogen and progesterone receptors.

CONCLUSIONS

Pathogenetically, the presence of this uterine ependymoma could represent either an example of multicentricity or a phenomenon of transtubal implantation of the ovarian tumour. Exceptionally, papillary ependymoma can occur in the endometrium, and may prompt differential diagnoses with other papillary endometrial tumours. Pathologists should consider this rare possibility in the differential diagnosis of papillary ovarian and endometrial lesions.