Presentation
This patient presented to the emergency room with complaints of lumbar pain and lower extremity paresthesias, with progressive difficulty ambulating, lasting two months.
Patient Data
MRI of the lumbar spine revealed an extensive longitudinal, intradural, centrally located solid expansile mass at the lumbosacral spine. The tumor extends from the tip of conus medullaris at the L1 level, along the cauda equina/filum terminale, to the S1 level. This mass has circumscribed margins, and it is iso-intensity in T1-weighted image and T2WI slightly high signal intensity compared with the spinal cord, with intense contrast enhancement. The tumor measures 1,4 x 1,7 x 15 cm.
The patient underwent surgical excision of the tumor with subsequent histopathologic examination.
Microscopic views of the stained tissue specimens (hematoxylin-eosin stain) depict a hypercellular tumor with mitotic activity, hyperchromatic nuclei, and compact perivascular pseudorosettes.
The final histopathologic diagnosis confirmed an anaplastic ependymoma, grade III - WHO 2016.
Note by the editorial board: The recent WHO 2021 classification has dropped the term "anaplastic" in favor of grading only. Also, grading should be written using arabic numerals. Thus according, to the WHO 2021 system the diagnosis would be ependymoma, grade 3.
Case Discussion
Spinal ependymomas derive from ependymal cells lining the surface of the central canal of the spinal cord 1,2,3. Spinal ependymomas present as intramedullary tumors in the cervical or thoracic cord, or occasionally they arise at the conus medullaris, cauda equina, and filum terminale 2,3. Spinal anaplastic ependymomas are grade 3 – WHO 2016/2021. They are rare and constitute the most malignant type of ependymoma 1,2,4. Radiologists can contribute to the management of this tumor, either by informing the most likely differential diagnoses or helping the neurosurgeon choose the best strategy for resection or biopsy 1,4.
This case demonstrates imaging features of a lumbar spine anaplastic ependymoma, grade III, with pathologic confirmation.
Case courtesy of:
- Maria Eduarda Zamorano, MD - PGY-3, radiology resident, Department of Radiology
- Fernanda Lima Didjurgeit, MD – pathologist, Department of Pathology
- Ana Lúcia A Brito, MD – pathologist, Department of Pathology
- Antonio Rodrigues de Aguiar Neto, MD - radiologist, Department of Radiology
Hospital da Restauração – Recife, PE – Brazil