Presentation
Gradual upper limb weakness.
Patient Data
An enhancing mass is present within the substance of the cervical cord centered at the C5 level. It is of intermediate signal intensity on T1 and T2 weighted sequences and demonstrates contrast enhancement. It is surrounded at either end by dilated cystic spaces which are not surrounded by enhancing tissue and may represent a tumor syrinx rather than part of the mass itself. There is faint signal drop on on T2 weighted images which may represent peripheral blood product, although it is not pronounced.
A mass ( * ) located centrally within the cord (note displaced 'normal' cord around the lesion (green arrows)) is of high T2 signal and demonstrates moderate contrast enhancement. At either end multiple cystic regions are demonstrated (blue arrows) most of which do not have any solid enhancing component and thus probably represent tumor syrinx rather than intra-tumoral cysts. Best seen inferiorly is a region of signal drop out (yellow arrow) which probably represents blood product (a poorly formed hemosiderin cap).
The patient went on to have surgery and a biopsy.
Histology
MICROSCOPIC DESCRIPTION: The specimens show multiple fragments of tumor tissue, together with a small amount of gliotic spinal cord tissue. The tumor is moderately cellular, with prominent perivascular pseudo rosetting as well as areas resembling ependyma lined channels. The tumor cells range from polygonal to columnar to elongate, the latter component with well-developed unipolar processes. The tumor cell nuclei are rounded and mildly pleomorphic. Nucleoplasm is coarsely granular and sometimes vesicular, with nucleoli often fairly prominent. An occasional mitotic figure is seen. There is no tumor necrosis and microvascular proliferation is not found.
FINAL DIAGNOSIS: Ependymoma, WHO grade 2.
Case Discussion
This case demonstrates fairly typical appearances of a spinal ependymoma, although hemosiderin capping is often better defined.
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