Spinal intramedullary spread of medulloblastoma. Case report

Intramedullary metastasis in medulloblastoma: a case report and literature review

BACKGROUND

Cerebellar medulloblastomas are the most common malignant tumors of the posterior fossa in childhood that frequently metastasize. Leptomeningeal dissemination and distant metastasis have been associated with medulloblastomas; however, intramedullary metastases are rare with very few case reports in the literature available.

METHODS

We present a case of a 3-year-old girl with a medulloblastoma who underwent surgical resection of spinal intramedullary metastases. Histopathology revealed the tumor to be an anaplastic medulloblastoma similar to the intracranial lesions. The patient subsequently underwent postoperative chemotherapy followed by radiotherapy.

RESULTS

Following the surgery and subsequent follow-up, the patient showed a good recovery without any new neurological dysfunction.

CONCLUSIONS

Intramedullary metastasis of medulloblastoma remains a rare disease. Surgical resection could play a possible role in the management in addition to radiation and chemotherapy.

EGF as a New Therapeutic Target for Medulloblastoma Metastasis

Medulloblastoma (MB) is a malignant pediatric brain tumor known for its aggressive metastatic potential. Despite the well-documented migration of MB cells to other parts of the brain and spinal column, MB chemotaxis is poorly understood. Herein, we examined the in vitro migratory and cellular responses of MB-derived cells to external signaling of Epidermal Growth Factor (EGF), hepatocyte growth factor (HGF), platelet-derived growth factor (PDGF-BB), and the stromal cell-derived factors 1-alpha (SDF-1). Experiments utilized transwell assays and immunocytochemistry to identify receptor activation in MB migration, and used a microfluidic platform to examine directionality, trajectory, and gradient-dependence of motile cells. Data illustrates that MB-derived cells respond strongly to EGF in a dosage and gradient-dependent manner with increased EGF-R activation, and show that high EGF gradient fields cause an increased number of cells to migrate longer directed distances. Our results provide evidence that EGF and its receptor play an important role than previously documented in MB chemotactic migration than previously documented and should be considered for developing migration-target therapies against MB metastasis.

A rare case of medulloblastoma coexisting with multiple spinal intramedullary tumors

Medulloblastoma is the most common primary central nervous system tumor of childhood. Medulloblastoma can metastasize along the neuraxis and to extraneural locations, but multiple intramedullary spinal metastases are very rare. The usual presenting clinical features are related to posterior fossa syndrome and/or hydrocephalus. We describe a unique case of medulloblastoma with multiple intramedullary lesions at the D-7 and D-12 levels.

Cauda equina syndrome as the initial presenting clinical feature of medulloblastoma: a case report

INTRODUCTION

Medulloblastoma is one of the most common pediatric brain malignancies. The usual presenting clinical features are related to posterior fossa syndrome or/and hydrocephalus. Cauda equina syndrome is a very rare presentation for this disease.

CASE PRESENTATION

We describe the case of a three-year-old boy with cauda equina syndrome as the initial presenting clinical feature for medulloblastoma. He was initially diagnosed as having a spinal tumor by magnetic resonance imaging scan. Subsequently, a cranial magnetic resonance imaging scan revealed a posterior fossa tumor with features of dissemination. He had substantial improvement after treatment. This case report is complemented by a literature review related to this unusual presentation.

CONCLUSIONS

Medulloblastoma primarily presenting with cauda equina syndrome is very rare. However, spinal drop metastasis should be considered in the pediatric age group to avoid suboptimal management.

Spinal intramedullary metastasis of medulloblastoma at initial diagnosis

CASE REPORT

Spinal magnetic resonance imaging of a 4-year-old boy with medulloblastoma at the initial presentation showed intramedullary lesion without enhancement effect and slight cord swelling from C-5 to T-1. After complete response to the initial therapy, this lesion recurred and slowly expanded. Cervical 11C-methionine-positron emission tomography could establish the diagnosis of intramedullary metastasis.

CONCLUSION

Spinal intramedullary metastasis of medulloblastoma at initial diagnosis is extremely rare, but must be considered.

Neoplasms of the spinal cord and filum terminale: radiologic-pathologic correlation

Intramedullary spinal cord neoplasms are rare, accounting for about 4%10% of all central nervous system tumors. Despite their rarity, these lesions are important to the radiologist because magnetic resonance (MR) imaging is the preoperative study of choice to narrow the differential diagnosis and guide surgical resection. On contrast materialenhanced MR images, intramedullary spinal tumors almost always manifest as expansion of the spinal cord and show enhancement. Syringohydromyelia and cystic lesions are frequently associated with intramedullary tumors. Nontumoral cysts tend to be located at the poles of the tumors and do not enhance on contrast-enhanced MR images, whereas cysts within the substance of the tumor are considered tumoral cysts and typically demonstrate peripheral enhancement. Spinal cord ependymomas are the most common type in adults, and cord astrocytomas are most common in children. Both entities constitute up to 70% of all intramedullary neoplasms. A central location within the spinal cord, presence of a cleavage plane, and intense homogeneous enhancement are imaging features that favor an ependymoma. Intramedullary astrocytomas are usually eccentrically located within the cord, are ill defined, and have patchy enhancement after intravenous contrast material administration. Even with these characteristics, it may not be possible to differentiate these two entities on the basis of imaging features alone. Cord hemangioblastomas are the third most common type of intramedullary spinal tumor. Gangliogliomas commonly extend over more than eight vertebral segments. Paragangliomas and primitive neuroectodermal tumors have an affinity for the filum terminale and cauda equina. Other spinal cord tumors include metastatic disease, which is characterized by prominent cord edema for the size of the enhancing portion, and primary lymphoma.

Secondary manifestation of medulloblastoma: metastases and local recurrences in 66 patients

Although primary treatment of medulloblastoma is now successful in a high percentage of patients, its secondary manifestations still bear a poor prognosis. Thorough studies of secondary manifestations are therefore pivotal to plan therapeutic approaches for the long-term management of medulloblastoma. Here we describe the incidence of secondary tumour manifestations in 66 patients of a single centre who underwent surgery for medulloblastoma between 1975 and 1990. No patient was excluded due to a poor postoperative course. Thirty-five patients showed evidence of secondary tumour growth. Of these, 17 suffered from local recurrence, and 27 developed metastastatic disease. The median latencies for secondary manifestations were 25 months for local recurrence (n = 17), 11 months for spinal metastases (n = 10), 15 months for supratentorial metastases (n = 8), 8 months for subleptomeningeal dissemination (n = 6), and 23 months for systemic metastases (n = 8). Two patients developed primary metastatic spread to the posterior fossa. Of 8 patients with supratentorial metastases, 6 developed fronto-basal lesions. In our patients, 89% of secondary lesions occurred within less than 3 years after primary diagnosis. 85% of patients with extra-axial tumour spread had been treated with a permanent shunt. Radical tumour resection and radiotherapy with 30 Gy to the neuraxis and 20 Gy boost to the posterior fossa was an important prognostic factor in this series. Patients with additional chemotherapy did not benefit significantly from this treatment. We conclude that optimal management of the primary lesions should aim at (i) total resection, (ii) avoid permanent shunting, and (iii) completion of the radiotherapy with inclusion of the medial frontobasal cisterns in the radiotherapeutic regimen. Our analysis suggests that adequate postoperative screening programmes should consist of 3-monthly scans of the neuraxis in the first three postoperative years and 6-monthly scans thereafter.

Extracranial metastases of medulloblastoma in adults: literature review

A consecutive series of 30 cases of extracranial medulloblastoma metastases in adults is analysed. The majority of the patients were males with a 3:1 male/female ratio. Bone was the most frequent site of metastases in adults (77%) and children (78%), followed by lymph nodes (33%) in both children and adults. Lung metastases were more common in adults (17%), but liver metastases occurred more frequently in children (15%). Possible routes of spread and development of metastases are discussed, with special emphasis on the role of shunts in tumour seeding. Distant extracranial metastatic spread of medulloblastoma occurs at the rate of 7.1%. Mean interval between operation of the primary tumour and the discovery of metastases was shorter in children (20 months) than in adults (36 months). Survival after the discovery of metastases was also shorter in children (5 months) than in adults (9.5 months). Shunts were associated with an earlier appearance of metastases and with a poorer prognosis. A detailed review of the literature of 119 cases of medulloblastoma with extracranial metastases is provided.

Adult cerebellar medulloblastomas: the pathological, radiographic, and clinical disease spectrum

The records of 34 patients over 16 years of age with cerebellar medulloblastoma were retrospectively reviewed. All patients were treated by surgery, and all surviving patients were given radiation therapy. The imaging characteristics of this rare entity were evaluated with regard to the tumor location in the cerebellum, and the prognostic effects of histological characteristics such as neuronal or glial differentiation and the presence of desmoplasia were investigated. Neither histological parameters nor tumor location (median, paramedian, or lateral cerebellar) affected patient survival. The desmoplastic variant was encountered in 38% of these adult medulloblastomas and occurred in all three cerebellar locations. The degree of surgical resection did not have a major effect on long-term survival; long-term survival was possible even in patients who had received only a biopsy. The extent of initial radiation therapy was positively correlated with recurrence-free survival; full neuraxis irradiation was associated with a 13% incidence of delayed spinal metastases, whereas 75% of patients treated with irradiation of only the posterior fossa and/or the whole brain developed spinal deposits. A similar local recurrence rate (12.5%) was noted in both irradiation groups. Chemotherapy resulted in palliation in some patients with metastatic disease.

Isolated metastasis to optic nerve from medulloblastoma

Isolated involvement of the optic nerve with metastatic tumor is uncommon. A 19-year-old man had a midline cerebellar medulloblastoma; a gross total removal was performed. He received postoperative radiation therapy to the whole brain, posterior fossa, and craniospinal axis. A progressive optic neuropathy developed 28 months later with radiologic evidence of an enlarged optic nerve. There was no evidence of metastatic disease elsewhere. An optic nerve biopsy showed metastatic medulloblastoma. An intramedullary metastasis developed 48 months after the primary diagnosis, and the patient died 5 months later.

Recurrent intramedullary enterogenous cyst of the cervical spinal cord

Intramedullary enterogenous cysts of the cervical spinal cord are rare. We report a case of symptomatic recurrence of this type of cyst 8 years following its original surgical treatment.

Medulloblastomas: a review of 11 cases

The authors review 11 cases of medulloblastomas, 9 of which were diagnosed and treated in the last 6 years. All were uniformly treated by surgery, radiotherapy and chemotherapy, according to the SIOP protocol. Complications and results are described.