Analyzing the role of adjuvant or salvage radiotherapy for spinal myxopapillary ependymomas

Spinal ependymal tumors

Spinal ependymomas are strictly to be subdivided into intramedullary lesions and extramedullary lesions as they are histologically and genetically distinct. Whereas the intramedullary lesions (SPE) are assigned to the WHO grade 2 and very rarely grade 3, the extramedullary lesions or myxopapilary tumors (MPE) are only as recently also assigned to WHO grade 2. The major difference is that in general, an intramedullary lesion of grade 2 remains confined to the local site of origin, even when rarely recurring after complete resection. In contrast, the MPEs have the capacity to spread throughout the cerebrospinal fluid compartment but can also be controlled by cautious complete resection. We here review the clinical features of spinal ependymomas, contrasting the entities, and describe the treatment found best from the literature to manage these lesions including interdisciplinary approaches.

Predictors of Progression-Free Survival in Patients With Spinal Intramedullary Ependymoma: A Multicenter Retrospective Study by the Neurospinal Society of Japan

BACKGROUND AND OBJECTIVES

Ependymoma is the most common spinal intramedullary tumor. Although clinical outcomes have been described in the literature, most of the reports were based on limited numbers of cases or been confined to institutional experience. The objective of this study was to analyze more detailed characteristics of spinal intramedullary ependymoma (SIE) and provide clinical factors associated with progression-free survival (PFS).

METHODS

This retrospective observational multicenter study included consecutive patients with SIE in the cervical or thoracic spine treated surgically at a total of 58 institutions between 2009 and 2020. The results of pathological diagnosis at each institute were confirmed, and patients with myxopapillary ependymoma, subependymoma, or unverified histopathology were strictly excluded from this study. Outcome measures included surgical data, surgery-related complications, postoperative systemic adverse events, postoperative adjuvant treatment, postoperative functional condition, and presence of recurrence.

RESULTS

This study included 324 cases of World Health Organization grade II (96.4%) and 12 cases of World Health Organization grade III (3.6%). Gross total resection (GTR) was achieved in 76.5% of cases. Radiation therapy (RT) was applied after surgery in 16 cases (4.8%), all of which received local RT and 5 of which underwent chemotherapy in combination. Functional outcomes were significantly affected by preoperative neurological symptoms, tumor location, extent of tumor resection, and recurrence. Multivariate regression analysis suggested that limited extent of tumor resection or recurrence resulted in poor functional outcomes. Multiple comparisons among the groups undergoing GTR, subtotal resection and biopsy, or partial resection of the tumor showed that the probability of PFS differed significantly between GTR and other extents of resection.

CONCLUSION

When GTR can be safely obtained in the surgery for SIE, functional maintenance and longer PFS can be expected.

Clinical management and prognosis of spinal myxopapillary ependymoma: a single-institution cohort of 72 patients

PURPOSE

Myxopapillary ependymoma (MPE) was classified as grade 2 tumor in the 2021 World Health Organization central nervous system classification because of its high recurrence probability. This study aimed to investigate predictive factors and management of tumor recurrence.

METHODS

Seventy-two patients with spinal MPE underwent initial surgical treatment at our hospital between 2011 and 2021. Kaplan-Meier curves and Cox regression were used to analyze the correlation between clinical variables and progression-free survival (PFS).

RESULTS

The median age at diagnosis was 33.5 years (range 8-60 years). Twenty-one patients (29.2%) had preoperative spinal drop metastases. Gross total resection (GTR) was performed in 37 patients (51.4%). The median follow-up was 7.2 years, and the follow-up rate was 88.9% (64 of 72 cases). Twelve of the 64 patients (18.9%) relapsed, and preoperative drop metastasis occurred in 7 patients (58.3%). The estimated 5-year and 10-year PFS rates were 82% and 77%, respectively. Univariate analysis showed that GTR was associated with improved PFS (hazard ratio [HR] 0.149, p = 0.014), while preoperative drop metastasis (HR 3.648, p = 0.027) and tumor involvement sacrococcygeal region (HR 7.563, p = 0.003) were associated with tumor recurrence. Adjuvant radiotherapy (RT) was significantly associated with improved PFS in patients with preoperative drop metastasis (p = 0.039).

CONCLUSION

Complete surgical resection under the premise of protecting neurological function is an important factor in reducing spinal MPE recurrence. Adjuvant RT is recommended when the tumor invades the capsule with preoperative drop metastasis or adhesion to the nerve and cannot reach GTR.

Multifocal lumbar myxopapillary ependymoma presenting with drop metastasis: a case report and review of the literature

INTRODUCTION

Spinal myxopapillary ependymomas (SME) are rare WHO grade II neoplasms of the spinal cord. Despite their good prognosis, they have a high propensity for metastasis and recurrence, although the presentation of SME as multifocal is uncommon.

CASE PRESENTATION

Here we describe a rare case of a 34-year-old man who presented with painful bilateral radiculopathy with sexual dysfunction and altered sensation with defecation. The patient also reported worsening weakness of bilateral lower extremities when climbing stairs. Biopsy results revealed multifocal SME in the lumbar and sacral spine that was treated with staged surgical resection and post-operative focal radiation therapy.

DISCUSSION

We discuss and evaluate surgical resection and the role of postoperative radiotherapy for SME. We also review the literature surrounding multifocal SME presenting in adults.

Myxopapillary ependymomas; proximity to the conus and its effect on presentation and outcomes

Background:

Myxopapillary ependymomas (MPE) are intradural spinal tumors with a predilection to the filum terminale. Damage to conus medullaris during surgery can result in sphincteric and sexual dysfunction. The purpose of this study is to determine how myxopapillary ependymoma proximity to the conus impacts patient presentation, extent of resection, and clinical outcomes.

Methods:

Fifty-one patients who underwent surgical resection of pathologically confirmed myxopapillary ependymoma with at least 1 year of follow-up were included in the study. We collected initial presenting symptoms, distance of the tumor from the conus, extent of resection, and postoperative clinical outcomes including bladder dysfunction.

Results:

Average age was 38 years (range 7–75 years) with a male to female ratio of 1.43:1. Patients most commonly presented with pain symptoms (88%), and 12 patients (23.5%) had urologic symptoms on presentation. The mean tumor distance from the tip of the conus was 1.60 cm (10 cm above to 21 cm below the tip of the conus). Patients with tumors in contact with the conus had a significantly higher rate of preoperative urinary symptoms and were more likely (32% vs. 14%) to suffer postoperative urinary sphincteric disturbances. Tumors with direct invasion of the conus medullaris were more likely to require intralesional resection and fail to achieve a gross total resection (GTR).

Conclusion:

Patients with MPE in close proximity to the conus were more likely to suffer from long-term morbidity related to urologic issues following surgical resection. Adjuvant radiotherapy may be a viable option for patients who fail to achieve GTR.