Third Ventricular Epidermoid Tumor in a Pediatric Case

Epidermoid tumors, which constitute 0.2 to 1.8% of primary intracranial neoplasms, occur in the third and fifth weeks of fetal development. Epidermoid tumors, which are known to occur most frequently in the cerebellopontine angle, are rarely located intraventricularly. A third ventricular location can be seen in 0.7% of cases. Epidermoid tumors are more common between the ages of 19 and 69, and are very rare in the pediatric period. In this report, we present a third ventricular epidermoid tumor in an 11 years old pediatric patient.

Epidemiology and Clinicopathologic Study of Nonneoplastic Cystic Lesions of the Central Nervous System at a Tertiary Care Center

Background Nonneoplastic cysts of brain are a diverse group of benign lesions with variable etiopathogenesis. Due to different site and histogenesis, these lesions have wide clinicopathologic spectrum.

Objective The study was performed to evaluate epidemiology and clinicopathologic spectrum of nonneoplastic central nervous system (CNS) cysts highlighting the role of histopathology in the diagnosis as well as to compare the data with other institution’s data available in literature.

Materials and Methods All nonneoplastic CNS cysts reported from January 2013 to June 2020 in the Department of Pathology of Sawai Man Singh Medical College, Jaipur, were retrieved and reviewed. The data were evaluated for age, site, cyst wall lining, nature of cyst contents, and location (intracranial and spinal), using SPSS software version 20.0.

Results A total of 255 cases were reviewed with an incidence of 4.96% and an age range of 2 to 74 years with slight male preponderance. Among them there were 157, 34, 26, 24, and 2 cases of epidermoid, arachnoid, dermoid, colloid, and glioependymal cysts, respectively, and 1 case of perineural cyst. Infective cysts were much less common than noninfective cysts, accounting for two cases of neurocysticercosis and hydatid cysts each. All cyst types mainly presented with signs and symptoms of a mass lesion.

Conclusion Nonneoplastic cyst mainly presented like a CNS mass lesion with overlapping clinical features, and image finding revealing the key role of histopathological analysis. Epidermoids were the most common type of these cysts in the present series followed by the arachnoid cysts.

Radiotherapy for recurrent intracranial epidermoid cysts without malignant transformation: a single-institution case series

INTRODUCTION

Recurrent intracranial epidermoid cysts may be difficult to address surgically given their proximity to critical neurovascular structures of the skull base. There are emerging reports of using radiotherapy (RT) for the treatment of recurrent epidermoid cysts. Here, we report a case series of adjuvant fractionated external beam RT for recurrent intracranial epidermoid cysts.

METHODS

A single-institution review of all recurrent epidermoid cysts treated with adjuvant therapy between 2000 and 2017 was performed.

RESULTS

Eight patients with recurrent epidermoid cysts who underwent adjuvant external beam RT were identified. Average age at initial diagnosis was 42.2 years, and median clinical follow-up after initial diagnosis and RT was 16.4 and 2.9 years, respectively. The median number of surgical resections prior to RT was 3 (range 2-5). Rationale for RT included multiple recurrent disease, rapid recurrence following prior resection, increased risk of further surgical morbidity, and patient preference. Median dose was 50.4 delivered in 1.8 Gy fractions (median 28 fractions). By the date of last follow-up, no patient has demonstrated progression, and there have been no cases of malignant degeneration.

CONCLUSION

Adjuvant RT should be considered in the context of recurrent epidermoid cysts to decrease the likelihood of further recurrences.

Review of xanthomatous lesions of the sella

Xanthomatous lesions of the sellar region have traditionally been divided into two separate categories, xanthomatous hypophysitis (XH) and xanthogranuloma (XG) of the sellar region. The seminal article on XH, a condition typified by foamy histiocytes and lymphoplasmacytic infiltrates in the pituitary gland/sellar region, but usually little or no hemosiderin pigment, detailed three patients. However, most reports since that time have been single cases, making understanding of the entity difficult. In contrast, the seminal report on XG, characterized by sellar region cholesterol clefts, lymphoplasmacytic infiltrates, marked hemosiderin deposits, fibrosis, multinucleated giant cells around cholesterol clefts, eosinophilic granular necrotic debris, and accumulation of macrophages, included 37 patients, allowing more insights into etiology. Few examples could be linked to adamantinomatous craniopharyngioma, and although ciliated epithelium similar to that of Rathke cleft cyst (RCC) was identified up to 35% of the 37 cases, it could not be proven that XG was related to hemorrhage into RCC. Case reports since that time, however, occasionally linked XG to RCC when an etiology could be identified at all, and a few recognized that a spectrum exists in xanthomatous lesions of the sella. They review literature, adding 23 cases from our own experience, to confirm that overlap occurs between XH and XG, and that the majority-but not all-can be linked to RCC leakage/rupture/hemorrhage. It was suggested that progressive accumulation of hemosiderin pigment in the lesion, possibly caused by the multiple episodes of bleeding, could account for the transition of at least some cases of XH to XG.

Ultrastructure of Pericystic or Intracystic Blood Vessels in Epidermoid Cysts-A Transmission Electron Microscopy Study: Laboratory Investigation

OBJECTIVES

Recently, we reported a tendency toward spontaneous hemorrhage in both the preoperative and postoperative periods in patients with intracranial epidermoid cyst (EC). According to our experience, this tendency for spontaneous hemorrhage was partly caused by the pathologic blood vessels adjacent to the EC. This study was designed to testify this hypothesis.

METHODS

Twenty-three removable pericystic or intracystic blood vessels from 17 patients with EC were collected during surgery and were then examined by transmission electron microscopy. The microvascular structure in gliomas was chosen as the control.

RESULTS

Under electron microscopy, variant pathologic changes of vessels were found in all patients with EC. In the tunicae intima, we found vacuolization, apoptosis, necrosis, and intralumenal protrusion of endothelial cells, as well as swollen basement and highly flexed and discontinued elastic plate. In the tunicae media, vacuolization and swollen mitochondria were found in muscular cells. In the tunicae adventitia, extravascular erythrocytes, edema or apoptosis of pericytes, collagen predominance, and inflammatory cell infiltration and destruction were found. Neuron denature and necrosis were found in the peripheral brain tissue. In the microvascular structure of 5 glioma specimens, we found enlargement and hyperplasia of endothelial cells, swollen basement membrane, swollen pericytes, and astrocytic hyperplasia and neuron denature in adjacent brain tissues.

CONCLUSIONS

Our findings provide strong evidence for the hypothesis that intracystic or pericystic vascular degeneration or destruction accounts for the spontaneous hemorrhage tendency before and after surgical resection of ECs.

Complete endoscopic resection of a pituitary stalk epidermoid cyst using a combined infrasellar interpituitary and suprasellar endonasal approach: case report

Intracranial epidermoid cysts are benign lesions of epithelial origin that most frequently present with symptoms of mass effect. Although they are often associated with a high rate of residual tumor and recurrence, maximal safe resection usually leads to good outcomes. The authors report a complete resection of an uncommon pituitary stalk epidermoid cyst with intrasellar extension using a combined suprasellar and infrasellar interpituitary, endoscopic endonasal transsphenoidal approach. The patient, a 54-year-old woman, presented with headache, visual disturbance, and diabetes insipidus. Postoperatively, she reported improvement in her visual symptoms and well-controlled diabetes insipidus using 0.1 mg of desmopressin at bedtime and normal anterior pituitary gland function. One year later, she continues to receive the same dosage of desmopressin and is also taking 50 mcg of levothyroxine daily after developing primary hypothyroidism unrelated to the surgical procedure. A combined infrasellar interpituitary and suprasellar approach to this rare location for an epidermoid cyst can lead to a safe and complete resection with good clinical outcomes.

Primary Intracranial Epidermoid Carcinoma with Diffuse Leptomeningeal Carcinomatosis: Report of Two Cases

BACKGROUND

Malignant degeneration of epidermoid cyst (EC) with accompanying leptomeningeal carcinomatosis (LC) at presentation is extremely rare. We add two cases to the literature, including the first case of primary brainstem involvement with simultaneous diffuse LC, and discuss clinical and radiological cues to differentiate benign and malignant epidermoid tumors for early diagnosis.

CASE DESCRIPTION

The first patient in this report was a 54-year-old woman with recurrent aseptic meningitis and hydrocephalus. Imaging revealed a prepontine and parapontine extra-axial EC with an intra-axial brainstem ring-enhancing cystic lesion, diffuse leptomeningeal enhancement, and intradural extramedullary nodular deposits throughout the spine. Surgical decompression of the cysts confirmed the diagnosis of invasive primary squamous cell carcinoma of the brainstem and benign epidermoid tumor of the cerebellopontine cistern. The second patient was a 37-year-old woman with extensive left-sided cranial neuropathies. Imaging revealed prepontine and parapontine enhancing and nonenhancing deposits along multiple cranial nerves and diffuse leptomeningeal nodular enhancement in the thoracolumbar spine. A biopsy confirmed the diagnosis of infiltrative, poorly differentiated carcinoma adjacent to a benign EC. Both patients underwent systemic screening to rule out metastatic disease.

CONCLUSIONS

These cases illustrate that a high index of clinical suspicion is necessary for early diagnosis of disseminated disease in cases of recurrent episodes of aseptic meningitis. In cases of primary benign EC, aggressive resection should be attempted to reduce the risk of malignant degeneration. A separate biopsy specimen from the enhancing portion of the tumor is used to rule out an underlying coexisting malignancy. Multimodal management carries the best prognosis for primary intracranial squamous cell carcinoma with LC.

Intracranial cysts: an imagery diagnostic challenge

Intracerebral cysts and cystic appearing intracerebral masses are common findings at routine cerebral imaging examination. We discuss here the most interesting aspects of some intracerebral cysts encountered in medical practice in terms of imaging, clinical and pathological description, and problems of differential diagnosis. On an almost routine basis, the neurologists have to deal with such differentials. Therefore, we aim to mention here some of the frequently encountered diagnosis problems when a patient presents with a cystic cerebral mass.

Hemorrhagic epidermoid cyst in a patient with generalized tonic clonic seizure

Epidermoid cysts account for approximately 1% of all intracranial tumors. Hemorrhage into an epidermoid cyst is extremely rare, and has only been reported a few times. To our knowledge, there are no reports of a hemorrhagic epidermoid cyst presenting with a first generalized tonic clonic seizure. We present a 68-year old female with an epidermoid cyst with intracystic hemorrhage who presented with a first time generalized tonic clonic seizure. When complicated with hemorrhage, the diagnosis of an epidermoid cyst is challenging and there is a potential for misdiagnosis.

An analysis of intracranial epidermoid tumors with malignant transformation: treatment and outcomes

OBJECTIVE

While typically benign, epidermoid tumors upon rare occasion can undergo malignant transformation, which carries a poor prognosis. Here, we reviewed treatment strategies and analyzed outcomes for every case of malignant epidermoid tumor reported since its original description in 1912.

METHODS

A comprehensive literature review identified all reported cases of malignant transformation of intracranial epidermoid tumor. Treatments were categorized as follows: palliative management, stereotactic radiosurgery (SRS), chemotherapy, and surgery plus multiple (2+) adjuvant therapies. Survival data of these groups were compared to treatment outcomes for patients receiving only surgical resection, as reported in our previous study.

RESULTS

We identified 58 cases of intracranial epidermoid tumor with malignant degeneration. Average survival regardless of therapy was 11.8 months. Mean survival outcomes for groups treated with palliative management, chemotherapy, SRS, and multiple postoperative adjuvant therapies were 5.3 months, 25.7 months, 29.2 months, and 36.3 months, respectively. Outcomes for the groups including SRS, chemotherapy, and multiple post-operative adjuvant therapies were statistically significant compared to surgical resection alone.

CONCLUSION

While there remains a lack of consensus regarding the best approach to the management of patients with malignant epidermoid tumors, our systematic analysis characterizes and confirms the added benefit of SRS, chemotherapy, and multimodal adjuvant therapies.

Survival outcomes for radiotherapy treatment of epidermoid tumors with malignant transformation

Epidermoid tumors are intracranial lesions that may occasionally undergo malignant transformation. Although surgical resection is the first-line treatment for malignant epidermoids, postoperative radiotherapy has been intermittently reported with favorable findings. Our analysis identified all previously reported patients with malignant epidermoids treated with surgical resection alone or surgery plus radiotherapy to examine the potential role for this adjuvant therapy. Whereas patients treated with surgery only had an overall survival of 6.6 months, those treated with postoperative radiotherapy demonstrated a statistically significant increase in survival to 12.7 months (log-rank test, p<0.003). Furthermore, the mean dosage of radiation given to this patient population was 52.2 Gy, with no appreciable survival benefit for the utilization of levels of radiation greater than 50 Gy. When determining the management for malignant transformation of epidermoid tumors, the combination of surgical resection and radiotherapy may be associated with improved short-term survival.

Clinical characteristics and diagnostic imaging of epidermoid tumors

Epidermoid tumors are rare, benign congenital lesions which typically present between the third and fifth decades of life. They are thought to originate from ectodermal cells misplaced during neural tube formation and separation. While epidermoids may present anywhere in the cranial vault, they are characteristically located intradurally and in a paramedian position within the cerebellopontine angle and parasellar regions. Although imaging results may vary depending upon cystic content, CT scanning generally reveals a well-circumscribed, nonenhancing, lobulated, hypodense mass. They are hypointense on T1-weighted MRI, and hyperintense on T2-weighted MRI, diffusion-weighted imaging and fluid-attenuated inversion recovery sequences. The use of appropriate neuroimaging should be utilized to differentiate epidermoids from other intracranial lesions. While gross total resection of these tumors is the definitive treatment to prevent recurrence and aseptic meningitis, a subtotal resection may be necessary to preserve neurological function.