Surgıcal results of myxopapıllary ependymoma: the ımportance of capsule ıntegrıty.

Yıl 2020, , 27 - 31, 21.01.2020

İsmail İştemen , Ali Arslan , Semih Kıvanç Olguner , Yurdal Gezercan , Ali İhsan Ökten , Kemal Alper Afşer Emre Bilgin

https://doi.org/10.31362/patd.551122

Öz

Abstract:

Introduction: Primary intramedullary tumors are rare
tumors and  mainly astrocytomas and
ependymomas in adults. While ependymomas are common in the cervical and
cervicothoracic region, myxopapillary ependymomas often occur at the level of
conus medullaris, cauda ekuina and filum terminale. Myxopapillary ependymomas
are low stage (stage 1) tumors with low mitotic activity but recurrence has
been reported frequently. The treatment is total surgical resection and the
probability of recurrence with total removed tumors is very low. Total
resection is not possible in cases with thin and weak capsula, which increases
the risk of recurrence, seeding metastasis and distant metastasis. It is recommended
to add radiotherapy for patients who cannot be totally removed. The aim of this
study to asses the clinical outcomes of the patients who underwent surgery with
myxopapillary ependymoma and to share our clinical experience

Material and methods:

In the present
study, 9 cases with the diagnosis of myxopapillary ependymoma underwent total excision
between 2014-2016 in Adana City Treaning and Research Hospital at the
Department of Neurosurgery were evaluated retrospectively. The patients were
evaluated with radiological images and clinical parameters preoperatively and
postoperatively. Patients were treated with laminectomy and tumour excision.

Results: 7 male and 2 female patients were
taken to routine follow-up. The age range is 9-57 and the average age is 33.
The mass was located at L2 level in 3 patients, at L3 in 2 patients, at L4 in 1
pateient and at L4 and L5 in 3 patients. All patients had back pain,
additionally 4 had paraparesia and 1 had urine-anal incontinence. Following
surgery all patiens recovered from back pain. Significant improvement in muscle
strength was detected in 3 patients in the early postoperative period and 2
months after following surgery in 1 patient. no improvement was observed in sphincter
function. The mean length of stay in hospital  was 5.1 days. No recurrence was detected in
the postoperative 2 years radiologically.

Conclusion: Total removal of mass without
deterioration of capsule integrity is imperative in preventing recurrence and
seeding metastases. These patients can be followed without radiotherapy. However,
long-term follow-up studies and more patient groups are required.

Anahtar Kelimeler

Intramedullary tumor, myxopapillary ependymoma, total surgical removal

Miksopapiller ependimomda cerrahi sonuçlar: kapsül bütünlüğünün önemi

Öz

Özet:

Giriş:
Primer
intramedüller tümörler nadir görülen, yetişkinlerde ağırlıklı olarak
astrositomlar ve ependimomlardan oluşan tümörlerdir. Ependimomlar servikal ve
servikotorasik bölgede sık görülürken, miksopapiller ependimomlar hemen her
zaman konus medüllaris, kauda ekuina ve filum terminale düzeyinde ortaya
çıkarlar. Miksopapiller ependimomlar düşük evreli (evre 1) ve mitotik
aktivitesi düşük olan tümörlerdir ancak rekürrens sık bildirilmiştir. Tedavisi
total cerrahi rezeksiyondur ve total çıkarılan tümörlerde tekrarlama ihtimali
oldukça düşüktür. Kapsülasyonu zayıf olan vakalarda total rezeksiyon mümkün
değildir, bu olgularda rekürrens, seeding metastaz ve uzak metastaz riski
artmaktadır. Total çıkarılamayan olgularda radyoterapi eklenmesi önerilir.
Çalışmamızda kliniğimizde 2014-2016 yılları arasında total çıkarım yapılan ve
patoloji sonucu miksopapiller ependimom olarak gelen 9 olgu retrospektif olarak
incelenmiş ve klinik sonuçları literatür verileri ile birlikte
değerlendirilmiştir.

Gereç
ve  Yöntem: 2014-2016 yılları
arasında, Adana Şehir Eğitim ve Araştırma Hastanesi Beyin Cerrahi Bölümü’nde
spinal kitle nedeni ile opere edilen, kapsülü ile birlikte bütün olarak
çıkartılan ve patoloji sonucu miksopapiller ependimom olarak bildirilen olgular
retrospektif olarak incelenmiştir. Hastalar, operasyon öncesi ve sonrası klinik
ve radyolojik bulguları ile değerlendirilmiştir. Radyolojik tanı yöntemi olarak
manyetik rezonans görüntüleme kullanılmıştır. Cerrahi yöntem olarak lezyon
seviyesinde total laminektomi ile total kitle eksizyonu uygulanmıştır.

Bulgular: 7 kadın 2 erkek
hasta takibe alınmıştır. Yaş aralığı 9-57 olup ortalama yaş 33’tü. 3 hastada kitle
L2 seviyesinde, 2 hastada L3 seviyesinde, 1 hastada L4 seviyesinde ve 3 hastada
L4-L5 vertebralar boyunca yerleşmekteydi. Tüm hastaların ortak şikayeti bel
ağrısı olup; dört hastada paraparezi ve bir hastada da gaita idrar inkontinansı
ilave şikayetlerdendi. Operasyon sonrasında ağrı şikayeti tüm hastalarda geçti.
Paraparezisi olan 4 hastadan 3’ünde erken dönemde önemli oranda düzelme
saptandı. 1 hastada ise 2. ay kontrolünde düzelme olduğu görüldü. İnkontinans
gelişmiş hastada ise düzelme olmadı. Hastanede kalış süresi ortalama 5,1 gün
olarak hesaplandı. Hastaların 2 yıllık radyolojik takiplerinde hiçbir hastada
nüks saptanmadı.

Sonuç: Kapsül bütünlüğü
bozulmadan total olarak kitle çıkarılması rekürensi ve seeding metastazları
önlemede önemlidir. Bu hastalar radyoterapi verilmeksizin takip edilebilirler.
Ancak uzun dönem takipler ve daha fazla sayıda hasta gruplarının olduğu
çalışmalar gereklidir.

Anahtar
Sözcükler: İntramedüller Tümör, Miksopapiller Ependimom, Spinal Tümör, Total Cerrahi Çıkarım

Anahtar Kelimeler

İntramedüller tümör, miksopapiller ependimom, total cerrahi çıkarım

Kaynakça

• Referans1 Helseth A, Mork SJ. Primary intraspinal neoplasms in Norway, 1955–1986, a population-based survey of 467 patients. J Neurosurg. 1989;71:842–845.
• Referans2 Choi JY, Chang KH, Yu IK, et al. Intracranial and spinal ependymomas: Review of MR images in 61 patients. Korean J Radiol. 2002;3:219-228.
• Referans3 Ferrante L, Mastronardi L, Celli P, Lunardi P, Acqui M, Fortuna A. Intramedullary spinal cord ependymomas: a study of 45 cases with longterm follow-up. Acta Neurochir. 1992;119:74–9.
• Referans4 Sakai Y, Matsuyama Y, Katayama Y, et al. Spinal myxopapillary ependymoma: Neurological deterioration in patients treated with surgery. Spine. 2009;34:1619-1624.
• Referans5 Barone BM, Elridge AR. Ependymoma, a clinical survey. J Neurosurgery 1970;33:428-438.
• Referans6 Johnson DL, Schwarz S. Intracranial metastases from malignant spinal cord astrocytoma. J Neurosurgery 1987;66: 621-625.
• Referans7 Sonneland PR, Scheithauer BW, Onofrio BM. Myxopapiller ependymoma, a clinicopathologic and immunocythochemical study of 77 cases. Cancer 1985;56: 883-893.
• Referans8 Bagley CA, Kothbauer KF, Wilson S, Bookland MJ, Epstein FJ and Jallo GI: Resection of myxopapillary ependymomas in children. J Neurosurg 2007;106 (4 Suppl): 261 267.
• Referans9 Celli P, Cervoni L, Morselli E, Ferrante L: Spinal ependymomas and papilledema: Report of 4 cases and review of literature. J Neurosurg Sci 1993;37(2): 97-102.
• Referans10 Hoshimaru M, Koyama T, Hashimoto N, Kikuchi H. Results of microsurgical treatment for intramedullary spinal cord ependymomas: analysis of 36 cases. Neurosurgery. 1999;44:264–269.
• Referans11 Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the spinal cord and filum terminale: radiologic-pathologic correlation. Radiographics. 2000;20:1721–1749.
• Referans12 Nakamura M, Ishii K, Watanabe K, et al: Long term surgical outcomes for myxopapillary ependymomas of the cauda equina. Spine (Phila Pa 1976) 2009;34: 756 760.
• Referans13 Schweitzer JS, Batzdorf U: Ependymoma of the cauda equina region: diagnosi, treatment, and outcome in 15 patients. Neurosurgery 1992;30(2): 202-207.
• Referans14 McLendon R, Rosenblum M, Schiffer D, et al. Myxopapillary ependymoma. In: Louis D, Ohgaki H, Wiestler O, Cavenee W, eds. WHO Classification. Lyon: WHO 2007;72–73.
• Referans15 Keleş E, Aydın S, Mandel NM, Selek U: Düşük dereceli glial tümörler. Temel Nöroşirürji Cilt 1, Türk Nöroşirürji Derneği Yayınları No:10 Ankara 2010;1019-1037.
• Referans16 Kucia EJ, Bambakidis NC, Chang SW, Spetzler RF. Surgical technique and outcomes in the treatment of spinal cord ependymomas, part 1: intramedullary ependymomas. Neurosurgery. 2011;68:57–63.
• Referans17 Nakamura M, Ishii K, Watanabe K: Surgical treatment of intramedullary spinal cord tumors: prognosis and complications. Spinal Cord 2008;46 (4): 282-286.
• Referans18 Goh KY, Velasquez L, Epstein FJ. Pediatric intramedullary spinal cord tumors: is surgery alone enough? Pediatr neurosurgery, 1977;27: 34-39.
• Referans19 Whitaker SJ, Bessel EM, Ashly SE. Postoperative radiotherapy in the in the manegement of the spinal cord ependymoma. J Neurosurgeri 1991;74(5): 720-728.
• Referans20 Bavbek M, Altinors MN, Caner HH, Bilezikci B, Agildere M. Lumbar myxopapillary ependymoma mimicking neurofibroma. Spinal Cord. 2001;39:449-452.
• Referans21 Wippold FJ, Smirniotopoulos JG, Moran CJ, Suojanen JN, Vollmer DG. MR imaging of myxopapillary ependymoma: Findings and value to determine extent of tumour and its relation to intraspinal structures. Am J Radiol. 1995; 165:1263-1267.
• Referans22 Sun B, Wang C, Wang J, Liu A. MRI features of intramedullary spinal cord ependymomas. J Neuroimaging. 2003;13:346-351.
• Referans23 Volpp PB, Han K, Kagan AR, Tome M. Outcomes in treatment for intradural spinal cord ependymomas. Int J Radiation Oncology Biol Phys. 2007;69:1199-1204.
• Referans24 Asazuma T, Toyama Y, Suzuki N, et al. Ependymomas of the spinal cord and cauda equine: An analysis of 26 cases and a review of the literature. Spinal Cord. 1999; 37:753-59.
• Referans25 Bagley CA, Wilson S, Kothbauer KF, Bookland MJ, Epstein F, Jallo GI. Long term outcomes following surgical resection of myxopapillary ependymomas. Neurosurg Rev. 2009; 32:321-334.
• Referans26 Bandopadhayay P, Silvera VM, Ciarlini PD, Malkin H, Bi WL, Bergthold G, et al: Myxopapillary ependymomas in children: imaging, treatment and outcomes. J Neurooncol 2015;126(1):165-174.
• Referans27 Klekamp J: Spinal ependymomas. Part 2: Ependymomas of the filum terminale. Neurosurg Focus 2015;39:7.
• Referans28 Damien C. Weber, Yucai Wang, Robert Miller, Salvador Villa` , Renata Zaucha, Alessia Pica, Philip Poortmans, Yavuz Anacak, Gokhan Ozygit, Birgitta Baumert, Guy Haller, Matthias Preusser, and Jing Li. Long-term outcome of patients with spinal myxopapillary ependymoma: treatment results from the MD Anderson Cancer Center and institutions from the Rare Cancer Network. Neuro-Oncology 2015;17(4), 588–595.
• Referans29 Agbahiwe HC, Wharam M, Batra S, et al. Management of pediatric myxopapillary ependymoma: the role of adjuvant radiation. Int J Radiat Oncol Biol Phys. 2013;85(2):421–427.
• Referans30 Taylor RE. Review of radiotherapy dose and volume for intracranial ependymoma. Pediatr Blood Cancer. 2004;42(5):457–460.