Acta Neurochir (2015) 157:1179–1181 DOI 10.1007/s00701-015-2458-9
LETTER TO THE EDITOR - SPINE
Pilocytic astrocytoma of the lower thoracic spine in an adult patient Christopher R. Pasarikovski 1 & Pat A. Allevato 2 & Robert Hammond 3 & Abdurrahim A. Elashaal 4
Received: 30 March 2015 / Accepted: 20 May 2015 / Published online: 31 May 2015 # Springer-Verlag Wien 2015
Dear Editor, Although common in the pediatric population, pilocytic astrocytomas of the spinal cord become exceedingly rare with increasing age [5]. To our knowledge, only two case reports of adult patients diagnosed with pilocytic astrocytoma of the spinal cord have been described in the literature [3, 9]. We report on the first case of an adult patient with pathologically confirmed pilocytic astrocytoma of the lower thoracic spine (T4-8). A 49-year-old woman presented to the Emergency Department with a fall secondary to increasing weakness in the left leg. The patient had a 2-year history of progressive left leg numbness and tingling radiating into her first toe. She also had progressive weakness in her left hip, knee and ankle but was still able to ambulate with difficulty. There were also bladder symptoms over the last 5 months including a slow urinary stream and overactive bladder that included urinating every
* Christopher R. Pasarikovski [email protected] 1
Schulich School of Medicine and Dentistry, Western University, 1151 Richmond Street, London, Ontario, Canada N6A 5C1
2
Department of Pathology and Laboratory Medicine, Windsor Regional Hospital, Windsor, Ontario, Canada
3
Department of Pathology, London Health Sciences Center, Western University, London, Ontario, Canada
4
Department of Neurosurgery, Windsor Regional Hospital, Windsor, Ontario, Canada
30 min. There was no urinary or bowel incontinence. Examination showed no evidence of systemic disease. Neurological examination revealed bilateral leg weakness. Right hip, knee, and ankle strength were 4/5 respectively. Left hip, knee, and ankle strength were each 4-/5. Patellar and ankle reflexes were hyperactive bilaterally. There was a T4 sensory level just below the breast. Imaging findings included a magnetic resonance imaging (MRI) of the thoracic and lumbar spine (Fig. 1). There was a large, intramedullary and intradural mass extending from T4-T8, severely compressing the thoracic spinal cord at the T6-T7 level. The patient underwent laminectomy from T4 to T8 and partial laminectomy at T3 and T9. After completing the laminectomy, intraoperative ultrasound was used to locate and delineate the lesion. The dura was opened and the tumor was gradually and delicately dissected from the inferior spinal cord between the nerve roots. A small portion of the lesion was left in the spinal cord as clear margins could not be delineated under the microscope and to avoid damage to the cord. The cord decompressed well after the lesion was excised. The pathological diagnosis was pilocytic astrocytoma World Health Organization (WHO) grade 1 (Fig. 2). At the 8-week post-operative mark in the rehabilitation facility, the patient needed help standing from a seated position and could only walk a few steps with no assistance. The patient’s presentation of motor weakness was in line with the commonest initial presentation of astrocytoma of the spinal cord [2, 4]. Furthermore, MRI
1180
Fig. 1 MRI. a Sagittal T2, b sagittal T1, c sagittal T1 with contrast, and d transverse T1 with contrast. The lesion measured 9.3 cm in the superior/ inferior, 1.3 cm in the medial/lateral, and at its maximum transverse measuring 1.4 cm, almost compressing the entire spinal cord. The lesion demonstrated diffuse, but non-uniform T2 hyperintense signal, and a hypointense T1 signal
Fig. 2 Tumor photomicrographs: a moderate cellularity and microcystic change (H&E, bar50 µm); b areas with coarse fibrillarity (H&E, bar50 µm); c hyalined blood vessels (H&E, bar100 µm); d) areas of recent bland infarction (H&E, bar200 µm); e Rosenthal fibers (arrowheads), (H&E, bar25 µm); f glomeruloid vascular proliferation (H&E, bar50
Acta Neurochir (2015) 157:1179–1181
characteristics, which delineated a hypointense lesion relative to the spinal cord on T1-weighted imaging and hyperintense on T2-weighted image, are in keeping with the typical presentation of astrocytoma of the spinal cord [4, 8]. The ideal surgical candidates for the resection of intramedullary spinal cord tumors (IMSCTs) are those who can still ambulate and in which the progressive development of weakness and sensory changes can be stalled or stopped [4, 8]. Due to the nature of the IMSCT, the entire lesion could not be excised without greatly compromising neurological function. Previous studies have shown that there is no relationship between the size of resected lesion and recurrence rate, confirming that it is not necessary to proceed with total resection at the cost of neurological deficit [6, 7, 10]. The most important prognostic factors reported are age and preoperative neurological functioning [1, 6]. We have examined the rare case of a 49-year-old female patient with pathologically confirmed pilocytic astrocytoma of the lower thoracic spine. The patient presentation, imaging findings, and inability to fully resect the lesion are in agreement with those reported in the literature. To our knowledge, this is the first case report to highlight a pilocytic astrocytoma of the lower thoracic spine in an adult.
µm); g GFAP expression in tumor cells (anti-GFAP immunoperoxidase, bar25 µm); h beta-crystallin expression in Rosenthal fibers (arrowheads) and select tumor cells (arrow), (anti-beta-crystallin immunoperoxidase, bar25 µm)
Acta Neurochir (2015) 157:1179–1181
1181
Conflicts of interest None.
5.
Informed patient consent The patient has consented to the submission of the case report for submission to the journal.
6.
References 1.
2. 3. 4.
Cristante L, Herrmann HD (1994) Surgical management of intramedullary spinal cord tumors: functional outcome and sources of morbidity. Neurosurgery 35(1):69–74 Epstein FJ, Farmer JP, Freed D (1992) Adult intramedullary astrocytomas of the spinal cord. J Neurosurg 77(3):355–359 Harraher CD, Vogel H, Steinberg GK (2013) Spinal pilocytic astrocytoma in an elderly patient. World Neurosurg 79(5-6):797–799 Houten JK, Cooper PR (2000) Spinal cord astrocytomas: presentation, management and outcome. J Neuro-Oncol 47(3):219–224
7.
8.
9.
10.
Innocenzi G, Raco A, Cantore G, Raimondi AJ (1996) Intramedullary astrocytomas and ependymomas in the pediatric age group: a retrospective study. Childs Nerv Syst 12(12):776–780 Innocenzi G, Salvati M, Cervoni L, Delfini R, Cantore G (1997) Prognostic factors in intramedullary astrocytomas. Clin Neurol Neurosurg 99(1):1–5 Minehan KJ, Shaw EG, Scheithauer BW, Davis DL, Onofrio BM (1995) Spinal cord astrocytoma: pathological and treatment considerations. J Neurosurg 83(4):590–595 Roonprapunt C, Houten JK (2006) Spinal cord astrocytomas: presentation, management, and outcome. Neurosurg Clin N Am 17(1): 29–36 Saad A, Tuli S, Ali EN, Houtchens M, Delalle I, Kesari S (2008) Pilocytic astrocytoma of the spinal cord in an adult. J Neuro-Oncol 88(2):189–191 Samii M, Klekamp J (1994) Surgical results of 100 intramedullary tumors in relation to accompanying syringomyelia. Neurosurgery 35(5):865–873
LETTER TO THE EDITOR - SPINE
Pilocytic astrocytoma of the lower thoracic spine in an adult patient Christopher R. Pasarikovski 1 & Pat A. Allevato 2 & Robert Hammond 3 & Abdurrahim A. Elashaal 4
Received: 30 March 2015 / Accepted: 20 May 2015 / Published online: 31 May 2015 # Springer-Verlag Wien 2015
Dear Editor, Although common in the pediatric population, pilocytic astrocytomas of the spinal cord become exceedingly rare with increasing age [5]. To our knowledge, only two case reports of adult patients diagnosed with pilocytic astrocytoma of the spinal cord have been described in the literature [3, 9]. We report on the first case of an adult patient with pathologically confirmed pilocytic astrocytoma of the lower thoracic spine (T4-8). A 49-year-old woman presented to the Emergency Department with a fall secondary to increasing weakness in the left leg. The patient had a 2-year history of progressive left leg numbness and tingling radiating into her first toe. She also had progressive weakness in her left hip, knee and ankle but was still able to ambulate with difficulty. There were also bladder symptoms over the last 5 months including a slow urinary stream and overactive bladder that included urinating every
* Christopher R. Pasarikovski [email protected] 1
Schulich School of Medicine and Dentistry, Western University, 1151 Richmond Street, London, Ontario, Canada N6A 5C1
2
Department of Pathology and Laboratory Medicine, Windsor Regional Hospital, Windsor, Ontario, Canada
3
Department of Pathology, London Health Sciences Center, Western University, London, Ontario, Canada
4
Department of Neurosurgery, Windsor Regional Hospital, Windsor, Ontario, Canada
30 min. There was no urinary or bowel incontinence. Examination showed no evidence of systemic disease. Neurological examination revealed bilateral leg weakness. Right hip, knee, and ankle strength were 4/5 respectively. Left hip, knee, and ankle strength were each 4-/5. Patellar and ankle reflexes were hyperactive bilaterally. There was a T4 sensory level just below the breast. Imaging findings included a magnetic resonance imaging (MRI) of the thoracic and lumbar spine (Fig. 1). There was a large, intramedullary and intradural mass extending from T4-T8, severely compressing the thoracic spinal cord at the T6-T7 level. The patient underwent laminectomy from T4 to T8 and partial laminectomy at T3 and T9. After completing the laminectomy, intraoperative ultrasound was used to locate and delineate the lesion. The dura was opened and the tumor was gradually and delicately dissected from the inferior spinal cord between the nerve roots. A small portion of the lesion was left in the spinal cord as clear margins could not be delineated under the microscope and to avoid damage to the cord. The cord decompressed well after the lesion was excised. The pathological diagnosis was pilocytic astrocytoma World Health Organization (WHO) grade 1 (Fig. 2). At the 8-week post-operative mark in the rehabilitation facility, the patient needed help standing from a seated position and could only walk a few steps with no assistance. The patient’s presentation of motor weakness was in line with the commonest initial presentation of astrocytoma of the spinal cord [2, 4]. Furthermore, MRI
1180
Fig. 1 MRI. a Sagittal T2, b sagittal T1, c sagittal T1 with contrast, and d transverse T1 with contrast. The lesion measured 9.3 cm in the superior/ inferior, 1.3 cm in the medial/lateral, and at its maximum transverse measuring 1.4 cm, almost compressing the entire spinal cord. The lesion demonstrated diffuse, but non-uniform T2 hyperintense signal, and a hypointense T1 signal
Fig. 2 Tumor photomicrographs: a moderate cellularity and microcystic change (H&E, bar50 µm); b areas with coarse fibrillarity (H&E, bar50 µm); c hyalined blood vessels (H&E, bar100 µm); d) areas of recent bland infarction (H&E, bar200 µm); e Rosenthal fibers (arrowheads), (H&E, bar25 µm); f glomeruloid vascular proliferation (H&E, bar50
Acta Neurochir (2015) 157:1179–1181
characteristics, which delineated a hypointense lesion relative to the spinal cord on T1-weighted imaging and hyperintense on T2-weighted image, are in keeping with the typical presentation of astrocytoma of the spinal cord [4, 8]. The ideal surgical candidates for the resection of intramedullary spinal cord tumors (IMSCTs) are those who can still ambulate and in which the progressive development of weakness and sensory changes can be stalled or stopped [4, 8]. Due to the nature of the IMSCT, the entire lesion could not be excised without greatly compromising neurological function. Previous studies have shown that there is no relationship between the size of resected lesion and recurrence rate, confirming that it is not necessary to proceed with total resection at the cost of neurological deficit [6, 7, 10]. The most important prognostic factors reported are age and preoperative neurological functioning [1, 6]. We have examined the rare case of a 49-year-old female patient with pathologically confirmed pilocytic astrocytoma of the lower thoracic spine. The patient presentation, imaging findings, and inability to fully resect the lesion are in agreement with those reported in the literature. To our knowledge, this is the first case report to highlight a pilocytic astrocytoma of the lower thoracic spine in an adult.
µm); g GFAP expression in tumor cells (anti-GFAP immunoperoxidase, bar25 µm); h beta-crystallin expression in Rosenthal fibers (arrowheads) and select tumor cells (arrow), (anti-beta-crystallin immunoperoxidase, bar25 µm)
Acta Neurochir (2015) 157:1179–1181
1181
Conflicts of interest None.
5.
Informed patient consent The patient has consented to the submission of the case report for submission to the journal.
6.
References 1.
2. 3. 4.
Cristante L, Herrmann HD (1994) Surgical management of intramedullary spinal cord tumors: functional outcome and sources of morbidity. Neurosurgery 35(1):69–74 Epstein FJ, Farmer JP, Freed D (1992) Adult intramedullary astrocytomas of the spinal cord. J Neurosurg 77(3):355–359 Harraher CD, Vogel H, Steinberg GK (2013) Spinal pilocytic astrocytoma in an elderly patient. World Neurosurg 79(5-6):797–799 Houten JK, Cooper PR (2000) Spinal cord astrocytomas: presentation, management and outcome. J Neuro-Oncol 47(3):219–224
7.
8.
9.
10.
Innocenzi G, Raco A, Cantore G, Raimondi AJ (1996) Intramedullary astrocytomas and ependymomas in the pediatric age group: a retrospective study. Childs Nerv Syst 12(12):776–780 Innocenzi G, Salvati M, Cervoni L, Delfini R, Cantore G (1997) Prognostic factors in intramedullary astrocytomas. Clin Neurol Neurosurg 99(1):1–5 Minehan KJ, Shaw EG, Scheithauer BW, Davis DL, Onofrio BM (1995) Spinal cord astrocytoma: pathological and treatment considerations. J Neurosurg 83(4):590–595 Roonprapunt C, Houten JK (2006) Spinal cord astrocytomas: presentation, management, and outcome. Neurosurg Clin N Am 17(1): 29–36 Saad A, Tuli S, Ali EN, Houtchens M, Delalle I, Kesari S (2008) Pilocytic astrocytoma of the spinal cord in an adult. J Neuro-Oncol 88(2):189–191 Samii M, Klekamp J (1994) Surgical results of 100 intramedullary tumors in relation to accompanying syringomyelia. Neurosurgery 35(5):865–873
