Ependymoma


Article Author:
Edgar Zamora


Article Editor:
Fahad Alkherayf


Editors In Chief:
Donald Kushner
Annabelle Dookie


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
3/13/2019 6:03:46 PM

Introduction

Ependymomas are glial cell tumors that commonly arise in the lining cells of the ventricular system, and less commonly outside the central nervous system (CNS), or within the brain parenchyma. They are comprised of genetically distinct subgroups of tumors and affect children more commonly than adults.[1]

Etiology

While ependymomas that arise from different regions of the CNS are histologically similar, their clinical course often varies. Histological classification alone has not provided consistent and reliable survival outcomes in retrospective studies, meaning that ependymomas with similar histological grade may follow a substantially different clinical course. Recent studies suggest that these tumors may be categorized based on different populations of progenitor cells, which would explain different clinical courses in tumors with the same histological grade.[2] Several genetic abnormalities have been found to correlate with ependymoma and comprise large genomic regions.[3] Some of these studies have demonstrated that ependymomas correlate with distinct oncogenic products and molecular subgroups which may correlate more accurately with clinical outcomes compared with than histologic classification alone.[4]

Epidemiology

Ependymomas affect all age groups, with a higher frequency in children.[1] It is the third most common brain tumor in pediatric patients.[3]

As per the Central Brain Tumor Registry of the United States (CBTRUS) Statistical Report for CNS tumors from the years 2011 to 2015, ependymal tumors represent 1.7% of all brain and CNS tumors, with a median age of 44 years.[5]

In childhood, brain tumors are the primary cause of death associated with solid tumors. The most common pediatric brain tumors being medulloblastoma, pilocytic astrocytoma, brainstem glioma, and ependymoma.[6]

Histopathology

As with other CNS tumors, the TNM system of classification does not apply to ependymomas as they rarely spread outside of the CNS, and the WHO classification for CNS tumors is the current standard used to classify these ependymomas[1][7]:

  • Grade I, slow-growing tumors which are often considered benign, including subependymomas and myxopapillary ependymomas:
    • Subependymomas typically arise in the ventricular walls, most commonly in the fourth or lateral ventricles - they are histologically characterized by a hypocellular tissue presenting clusters of cells with a bland nucleus surrounded by glial matrix.
    • Myxopapillary ependymomas most commonly arise in the cauda equina, filum terminale or conus medullaris, and present histologically as pseudopapillary structures with mucin-rich microcysts, the cells are cuboidal and radially arranged surrounding a myxoid stroma.
  • Grade II are ependymomas presenting with high cellularity and papillary structures. Cells are arranged regularly and present a clear cytoplasm.
  • Grade III, are anaplastic ependymomas, presenting with abundant mitotic cells with pseudopalisading necrosis.

History and Physical

As ependymomas arise within different CNS compartments, their clinical presentation may vary from acute onset increased intracranial pressure causing nausea and vomiting, to a more chronic and insidious clinical course.[4]

Ependymoma is a histological diagnosis, and it most commonly presents in three major anatomical sites: supratentorial, spinal cord and infratentorial.[8]

Ependymoma is commonly suspected in adult patients suffering prolonged clinical courses, who present a non-enhancing and well-demarcated intraventricular lesion on brain imaging, isodense in computed tomography, and isointense on T1 images on MRI.[9]

Evaluation

Traditionally, ependymomas are classified using the World Health Organization (WHO) system to classify tumors of the nervous system. This histological grading commonly aids in predicting the clinical and biological behavior of central nervous tumors. In ependymoma, however, the molecular and genomic profile may provide more accurate information than only using histological grade.[10]

Tumor grading using the WHO classification system for nervous system tumors is based on different histological grades, this classification by itself would often not provide a reliable estimate of clinical course in patients with ependymoma. With increasing information about molecular pathogenetic mechanisms in ependymomas, the 2016 classification for nervous system tumors from WHO now includes in their classification the presence or absence of specific genetic alterations, RELA fusion-positive or negative, for ependymomas.[10][11]

There are nine molecular subgroups described in ependymomas, which correlate with different anatomical locations, genetics, and demographic characteristics. These new findings offer the opportunity of potentially improving the classification, management and prognostic information for ependymomas based on their molecular subgroup.[8]

No current molecular or immunohistochemical markers are in routine use in the diagnostic workup for patients with ependymoma.[8]

Treatment / Management

Ependymal tumors are rare, constituting 1.7% of all brain tumors, as reported in the most recent CBTRUS statistical report; this poses a challenge in defining the optimal management for these entities. Retrospective studies have described improved survival in patients undergoing resection with adjuvant radiation therapy. There is minimal and limited evidence supporting chemotherapy for adult ependymomas.[4]

No established guidelines use the molecular subgroups to guide treatment of ependymoma. The current consensus, however, recommends that patients with PF-EPN-A positive ependymoma, who are older than 12 months of age, undergo maximal safe micro-neurosurgical removal in addition to local radiotherapy.[8]

For intracranial ependymomas, surgery is typically the mainstay treatment. Complete resection without residual disease has presented better clinical outcomes and overall survival than partial resection. As discussed previously, there is insufficient evidence to support the use of chemotherapy.[8]

Differential Diagnosis

Differential diagnosis for tumors in the posterior fossa includes, astrocytoma, medulloblastoma, choroid plexus tumors. For supratentorial tumors, differential includes glial tumors, choroid plexus carcinoma or papilloma, and embryonal tumors.[10]

Prognosis

The extent of surgical resection for intracranial ependymomas has been the most reliable and consistent independent prognostic factor. Intracranial ependymomas show a low metastatic potential and predominantly present a locally invasive histological pattern. Ependymomas that fall within the histological grade III from the WHO classification have correlated with a worse outcome than grade II.[12][13]

Patients who undergo complete resection without signs of residual disease have presented a better outcome and overall survival compared to patients who undergo partial resection. For this reason, treatment typically consists of aggressive surgical excision.[8]

Across the different subgroups, infratentorial ependymomas generally have an excellent prognosis, even without treatment. Supratentorial ependymomas, however, often present a higher histological grade and have a lower survival rate despite treatment with resection and adjuvant radiation.[4]

Prognosis varies for pediatric patients and will be subject to location, type of treatment and pathological classification. A previous study showed that gross total resection had the best overall and progression-free survival. Patients with WHO classification grade II had improved overall survival after gross total resection in addition to external beam radiation therapy, and improved progression-free survival after gross total resection alone. Patients with WHO classification grade III had improved overall survival after subtotal resection in addition to external beam radiation therapy. While progression-free survival was better in patients with infratentorial tumors following subtotal resection in addition to external beam radiation therapy.[14][15][16][17]

Complications

Patients who are long term survivals from CNS tumors may present a wide diversity of complications, including neurological deficits, cognitive limitations, sensorineural hearing loss, endocrine and growth abnormalities, and secondary malignancies. Adult patients may present long term complications, most commonly fatigue, numbness and tingling, pain, and disturbed sleep.[15][16][18][19]

Deterrence and Patient Education

Patients should receive counseling regarding their prognosis. Those with CNS tumors at end-of-life benefit from palliative care. Family members and patients will benefit from early and anticipatory counseling, in addition to comfort measures. Palliative care should be interdisciplinary to cover for the wide spectrum of needs that these patients will face.[20][21]

Enhancing Healthcare Team Outcomes

The mainstay of treatment for ependymoma includes a multidisciplinary approach that may include surgery, radiation therapy, and chemotherapy. For confirmation of the tumor through tissue biopsy or tumor resection therapy, referral to neurosurgery is necessary. Palliative care may be necessary for patients at end-of-life.[20][21] Those who undergo surgery may also develop a number of neurological deficits. These individuals may require physical therapy, speech therapy, and occupational therapy. In many cases, the neurological deficits are permanent.


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Ependymoma - Questions

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A 64-year-old is found to have an ependymoma in the posterior fossa after having headaches and episodic dizziness. Which of the following is the most likely complication if not treated?



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A 32-year-old female presents with a few month history of worsening intermittent headaches associated with dizziness. Exam between headaches is normal. MRI shows a probable ependymoma at the posterior fossa. What is the most serious complication?



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What segment are cord ependymomas are most commonly found?



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A 43-year-old woman complaining of worsening visual disturbance and headaches for the past few months is found to have a spinal infiltrative mass diagnosed as ependymoma. Which of the following is true regarding these tumors?



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A 52-year-old male evaluated by new-onset seizures and focal neurological deficits is found to have imaging findings consistent with a brain mass, which of the following imaging findings is most suggestive of ependymoma?



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A 42-year-old patient presents with increasing sporadic episodes of vomiting, on physical examination he presents papilledema. Neuroimaging reveals a tumor arising from the ventricular lining of the fourth ventricle; histology reveals papillary structures. Which of the following is the most common treatment for the most likely tumor in this patient?



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Ependymoma - References

References

Wu J,Armstrong TS,Gilbert MR, Biology and management of ependymomas. Neuro-oncology. 2016 Jul;     [PubMed]
Taylor MD,Poppleton H,Fuller C,Su X,Liu Y,Jensen P,Magdaleno S,Dalton J,Calabrese C,Board J,Macdonald T,Rutka J,Guha A,Gajjar A,Curran T,Gilbertson RJ, Radial glia cells are candidate stem cells of ependymoma. Cancer cell. 2005 Oct;     [PubMed]
Mack SC,Taylor MD, The genetic and epigenetic basis of ependymoma. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2009 Oct;     [PubMed]
Leeper H,Felicella MM,Walbert T, Recent Advances in the Classification and Treatment of Ependymomas. Current treatment options in oncology. 2017 Aug 10;     [PubMed]
Ostrom QT,Gittleman H,Truitt G,Boscia A,Kruchko C,Barnholtz-Sloan JS, CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2011-2015. Neuro-oncology. 2018 Oct 1;     [PubMed]
Brandão LA,Young Poussaint T, Posterior Fossa Tumors. Neuroimaging clinics of North America. 2017 Feb;     [PubMed]
Vitanza NA,Partap S, Pediatric Ependymoma. Journal of child neurology. 2016 Oct;     [PubMed]
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Maiuri F,Gangemi M,Iaconetta G,Signorelli F,Del Basso De Caro M, Symptomatic subependymomas of the lateral ventricles. Report of eight cases. Clinical neurology and neurosurgery. 1997 Feb;     [PubMed]
Chhabda S,Carney O,D'Arco F,Jacques TS,Mankad K, The 2016 World Health Organization Classification of tumours of the Central Nervous System: what the paediatric neuroradiologist needs to know. Quantitative imaging in medicine and surgery. 2016 Oct;     [PubMed]
Louis DN,Perry A,Reifenberger G,von Deimling A,Figarella-Branger D,Cavenee WK,Ohgaki H,Wiestler OD,Kleihues P,Ellison DW, The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta neuropathologica. 2016 Jun;     [PubMed]
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Cage TA,Clark AJ,Aranda D,Gupta N,Sun PP,Parsa AT,Auguste KI, A systematic review of treatment outcomes in pediatric patients with intracranial ependymomas. Journal of neurosurgery. Pediatrics. 2013 Jun;     [PubMed]
Broniscer A,Ke W,Fuller CE,Wu J,Gajjar A,Kun LE, Second neoplasms in pediatric patients with primary central nervous system tumors: the St. Jude Children's Research Hospital experience. Cancer. 2004 May 15;     [PubMed]
Spiegler BJ,Bouffet E,Greenberg ML,Rutka JT,Mabbott DJ, Change in neurocognitive functioning after treatment with cranial radiation in childhood. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2004 Feb 15;     [PubMed]
Duffner PK,Krischer JP,Horowitz ME,Cohen ME,Burger PC,Friedman HS,Kun LE, Second malignancies in young children with primary brain tumors following treatment with prolonged postoperative chemotherapy and delayed irradiation: a Pediatric Oncology Group study. Annals of neurology. 1998 Sep;     [PubMed]
Stavrou T,Bromley CM,Nicholson HS,Byrne J,Packer RJ,Goldstein AM,Reaman GH, Prognostic factors and secondary malignancies in childhood medulloblastoma. Journal of pediatric hematology/oncology. 2001 Oct;     [PubMed]
Cohen A,Rovelli A,Merlo DF,van Lint MT,Lanino E,Bresters D,Ceppi M,Bocchini V,Tichelli A,Socié G, Risk for secondary thyroid carcinoma after hematopoietic stem-cell transplantation: an EBMT Late Effects Working Party Study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2007 Jun 10;     [PubMed]
Armstrong TS,Vera-Bolanos E,Gilbert MR, Clinical course of adult patients with ependymoma: results of the Adult Ependymoma Outcomes Project. Cancer. 2011 Nov 15;     [PubMed]
Himelstein BP,Hilden JM,Boldt AM,Weissman D, Pediatric palliative care. The New England journal of medicine. 2004 Apr 22;     [PubMed]
Gade G,Venohr I,Conner D,McGrady K,Beane J,Richardson RH,Williams MP,Liberson M,Blum M,Della Penna R, Impact of an inpatient palliative care team: a randomized control trial. Journal of palliative medicine. 2008 Mar;     [PubMed]

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