An Official publication of The Asian Congress of Neurological Surgeons (AsianCNS)

Search Article
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Advertise Subscribe Contacts Login  Facebook Tweeter
  Users Online: 1298 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  

   Table of Contents      
CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 1  |  Page : 140-143

Unique case of atypical central neurocytoma with craniospinal metastases and pituitary adenoma


1 Department of Neurology, University of South Alabama, Mobile, Alabama, USA
2 Baptist Medical Center South, Montgomery, Alabama, USA

Date of Submission23-Oct-2019
Date of Acceptance10-Jan-2020
Date of Web Publication25-Feb-2020

Correspondence Address:
Dr. Peter Soh
Department of Neurology, University of South Alabama, Mobile, Alabama
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajns.AJNS_316_19

Rights and Permissions
  Abstract 


Atypical central neurocytoma with extracranial metastases is a rare variant of benign central neurocytoma (CN). No definitive course of treatment exists for atypical CN. We report a unique case of atypical CN with concomitant pituitary macroadenoma and subsequent metastases to the spine. The patient received craniospinal radiation therapy. Close-follow up post tumor-resection may be advised to monitor for drop metastases. To the best of our knowledge, this is the only case reported of atypical CN with drop metastases to the spine concomitant with pathological-proven pituitary macroadenoma.

Keywords: Drop, intraventricular, MIB, radiation, suprasellar


How to cite this article:
Soh P, Manning B, Doan N. Unique case of atypical central neurocytoma with craniospinal metastases and pituitary adenoma. Asian J Neurosurg 2020;15:140-3

How to cite this URL:
Soh P, Manning B, Doan N. Unique case of atypical central neurocytoma with craniospinal metastases and pituitary adenoma. Asian J Neurosurg [serial online] 2020 [cited 2020 Mar 28];15:140-3. Available from: http://www.asianjns.org/text.asp?2020/15/1/140/279037




  Introduction Top


Central neurocytomas (CN) are benign lesions that typically develop from the nuclei of the septum pellucidum and present as intraventricular tumors. CN is generally a benign tumor classified as Grade II by the World Health Organization and associated mainly with a favorable outcome.[1] Atypical CN can have aggressive nature of metastasizing to other areas of the brain and to extracranial areas, including the spine. Immunohistochemistry stain cell proliferation index (MIB-1) can help to differentiate atypical CN from benign CN. Here, we report a case of atypical CN that metastasized to the cervical, thoracic, and lumbar spine, with concomitant pituitary macroadenoma found on imaging. We believe this is the only case reported of this kind.


  Case Report Top


A 48-year-old male presented with 11-month history of syncopal episodes and questionable seizures. The patient was seen at an outside hospital and referred to our institution for neurosurgical care after computed tomography (CT) and magnetic resonance imaging (MRI) brain showed a mass centered in the trigone of the left lateral ventricle as well as pineal gland extending into the third ventricle and fourth ventricle with local mass effect and possible infiltration of the left and right cerebral peduncles, left thalamus, and splenium of the corpus callosum [Figure 1]a. A suprasellar mass consistent with pituitary macroadenoma compressing optic chiasm was also noted [Figure 1]b. Enlargement of the lateral and third ventricles was consistent with obstructive hydrocephalus [Figure 1]c. Periventricular white matter signal changes with increased signal intensity on T2-weighted images were consistent with subependymal cerebrospinal fluid (CSF) migration [Figure 1]c. On presentation, he had normal vision and no papilledema with an unremarkable neurological examination. The working diagnosis preoperatively was pituitary tumor and hydrocephalus due to obstructive tumor in the left thalamopeduncular area.
Figure 1: (a) Magnetic resonance imaging brain axial T1 postcontrast. Central neurocytoma on the left lateral ventricle. (b) Magnetic resonance imaging brain sagittal T1 contrast three-dimensional. Pituitary macroadenoma. (c) Magnetic resonance imaging brain coronal T2 fluid-attenuated inversion recovery (left) and axial T2 (right). (d) High-power H and E of tumor. Neuroendocrine appearance with perivascular orientation

Click here to view


The patient underwent an endoscopic biopsy and subtotal resection (STR) of the intraventricular tumor and ventriculostomy with a subsequent VP shunt. Intraoperatively, approximately 50% of the tumor, 6 cm, was removed from the left ventricle. Grossly, the tumor was hemorrhagic and had reddish consistency. Histologically, the tumor had a cellular neuroendocrine appearance with perivascular orientation and occasional pyknotic nuclei [Figure 1]d. Synaptophysin immunostain was diffusely positive, whereas glial fibrillary acidic protein (GFAP) stain was negative. MIB-1 proliferation rate was 5%–15%. These findings were consistent with the diagnosis of atypical CN. Pituitary mass was not operated on because of the lack of vision change, and therefore, was monitored until the patient developed vision changes.

The patient began radiation therapy targeting the pineal gland tumor. Due to concern for malignancy with the pineal gland tumor, MRI of the spine was taken 2 months after biopsy which showed no significant mass on the cervical spine but a focal enhancing lesion in the spinous process of T10 and curvilinear enhancement adjacent to the filum terminale at the S2 level. Repeat MRI of the thoracic and lumbar spine 3 months after the biopsy did not show significant changes. MRI brain 1-year postresection demonstrated no new evidence of recurrence of pineal tumor [Figure 2]. The patient was then lost to follow-up to oncology for about 1 year due to multiple missed appointments from hospitalizations. His headaches and syncopal episodes had resolved, however, he was having recurrent seizures and anomia.
Figure 2: Magnetic resonance imaging brain axial T2 fluid-attenuated inversion recovery

Click here to view


The patient presented to oncology approximately 2 years later with peripheral visual changes complaining of darkness over the right peripheral vision. On physical examination, the patient had decreased vision in the peripheral fields. CT brain showed an increase in the size of suprasellar mass that was compressing optic chiasm. Transsphenoidal pituitary tumor resection was performed; however, the fibrous nature of the tumor precluded complete resection. The surgical pathology report confirmed the morphologic and immunohistochemistry findings of the pituitary adenoma.

Repeat MRI brain 1 month after transsphenoidal pituitary tumor resection reported new enhancing lesions in the left cerebellum, medulla, and spinal cord, with an increase in the size of the pituitary macroadenoma [Figure 3]. The cranial approach was performed subsequently to resect more tumor. The postoperative CT brain showed unchanged right posterior parietal ventriculostomy shunt terminating at the septum pellucidum [Figure 4].
Figure 3: Magnetic resonance imaging brain coronal T2 fluid-attenuated inversion recovery fat suppression

Click here to view
Figure 4: Computed tomography brain axial

Click here to view


The radiologist recommended MRI spine to monitor for drop metastasis, because surveillance MRI brain showed a mass on the upper part of the cervical spine. MRI of the spine revealed extensive subarachnoid seeding throughout the cervical, thoracic, and lumbar spine [Figure 5]. The patient complained of leg weakness and had bilateral hemiparesis (3/5 strength). He was subsequently treated with craniospinal radiation therapy, temozolomide, and dexamethasone. He continued to have seizures despite anti-epileptic therapy and progressive worsening of gait instability. He was transitioned to hospice care.
Figure 5: Magnetic resonance imaging C-spine sagittal short tau inversion recovery (left). Magnetic resonance imaging T-spine sagittal short tau inversion recovery (middle). Magnetic resonance imaging L-spine sagittal T1 fat suppression (right)

Click here to view



  Discussion Top


CN was first described by Hassoun et al., in 1982 as a rare intraventricular brain tumors, comprising only 0.25%–0.5% of all brain tumors.[2],[3] Both sexes are equally affected by this tumor, with a median age at the time of diagnosis was 34 years.[4] The typical clinical presentation of CN includes headache, memory or vision problems, seizures, vomiting, nausea, and increased intracranial pressure, which can lead to hydrocephalus. Most neurocytomas develop from the nuclei of the septum pellucidum.[5] Radiological imaging and pathological finding from a biopsy confirmed the diagnosis. Immunohistochemistry is performed for the diagnosis of CN because of its histological similarities to brain tumors such as ependymomas and oligodendrogliomas. Positive staining for synaptophysin is a major indicator of the presence of CN. The absence of other markers, including GFAP, neurofilament, Vimentin, and neuron-specific enolase, aids in confirming the diagnosis of CN.[6],[7]

Gross total resection (GTR) of the tumor is stated as the best course of treatment and favors survival rates without recurrence.[8] While CN is generally associated with a favorable prognosis, more aggressive clinical cases are known. Such cases are termed atypical CN and can be characterized by recurrence and atypical histological features such as increased mitotic activity or vascular proliferation.[9],[10] Atypical CN with malignant behavior has shown an increased tendency to disseminate through the CSF causing spinal metastasis.[11],[12],[13],[14] MIB-1 labeling index is a key marker in determining the prognosis of CN. An MIB-1 labeling index of ≥2% or ≥3% is a defining feature of atypical CN and portends a poorer survival rate and a higher risk of relapse.[15],[16] In general, when GTR is not an option, STR of the tumor is performed. STR has a 3.8 times higher risk of adverse outcomes than GTR.[8] Adjuvant radiotherapy or chemotherapy has been stated as additional courses of treatment for patients presenting with atypical CN. Since no definitive course of treatment exists for atypical CN, case reports provide anecdotal experience in treating this rare metastatic lesion.


  Conclusion Top


Our patient was a unique case of atypical CN with drop metastases to the spine because he had a pathological-proven pituitary macroadenoma concomitant with the unrelated atypical CN. The patient had lost follow-up to oncology for almost 1½ years during which the patient developed drop metastases to the spine causing bilateral lower leg weakness and neck pain. Close follow-up, therefore, is prudent for patients with atypical CN to detect earlier further metastases. In our patient, it was the worsening vision due to the pituitary macroadenoma that led to prompt brain imaging, which then revealed spinal metastases to the upper cervical cord.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, et al. The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 2007;114:97-109.  Back to cited text no. 1
    
2.
Hassoun J, Gambarelli D, Grisoli F, Pellet W, Salamon G, Pellissier JF, et al. Central neurocytoma. An electron-microscopic study of two cases. Acta Neuropathol 1982;56:151-6.  Back to cited text no. 2
    
3.
Chuang MT, Lin WC, Tsai HY, Liu GC, Hu SW, Chiang IC. 3-T proton magnetic resonance spectroscopy of central neurocytoma: 3 case reports and review of the literature. J Comput Assist Tomogr 2005;29:683-8.  Back to cited text no. 3
    
4.
Li Y, Ye XF, Qian G, Yin Y, Pan QG. Pathologic features and clinical outcome of central neurocytoma: Analysis of 15 cases. Chin J Cancer Res 2012;24:284-90.  Back to cited text no. 4
    
5.
Chen CL, Shen CC, Wang J, Lu CH, Lee HT. Central neurocytoma: A clinical, radiological and pathological study of nine cases. Clin Neurol Neurosurg 2008;110:129-36.  Back to cited text no. 5
    
6.
von Deimling A, Janzer R, Kleihues P, Wiestler OD. Patterns of differentiation in central neurocytoma. An immunohistochemical study of eleven biopsies. Acta Neuropathol 1990;79:473-9.  Back to cited text no. 6
    
7.
Kubota T, Hayashi M, Kawano H, Kabuto M, Sato K, Ishise J, et al. Central neurocytoma: Immunohistochemical and ultrastructural study. Acta Neuropathol 1991;81:418-27.  Back to cited text no. 7
    
8.
Vasiljevic A, François P, Loundou A, Fèvre-Montange M, Jouvet A, Roche PH, et al. Prognostic factors in central neurocytomas: A multicenter study of 71 cases. Am J Surg Pathol 2012;36:220-7.  Back to cited text no. 8
    
9.
Rades D, Fehlauer F, Schild SE. Treatment of atypical neurocytomas. Cancer 2004;100:814-7.  Back to cited text no. 9
    
10.
Vajrala G, Jain PK, Surana S, Madigubba S, Immaneni SR, Panigrahi MK. Atypical neurocytoma: Dilemma in diagnosis and management. Surg Neurol Int 2014;5:183.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Tatter SB, Borges LF, Louis DN. Central neurocytomas of the cervical spinal cord. Report of two cases. J Neurosurg 1994;81:288-93.  Back to cited text no. 11
    
12.
Stapleton SR, David KM, Harkness WF, Harding BN. Central neurocytoma of the cervical spinal cord. J Neurol Neurosurg Psychiatry 1997;63:119.  Back to cited text no. 12
    
13.
Li Z, Gao J, Wang T, Kong X, Guan J, Li Y. Intramedullary central neurocytoma of the thoracic spinal cord: A case report and literature review. Mol Clin Oncol 2018;8:544-8.  Back to cited text no. 13
    
14.
Stephan CL, Kepes JJ, Arnold P, Green KD, Chamberlin F. Neurocytoma of the cauda equina. Case report. J Neurosurg 1999;90:247-51.  Back to cited text no. 14
    
15.
Söylemezoglu F, Scheithauer BW, Esteve J, Kleihues P. Atypical central neurocytoma. J Neuropathol Exp Neurol 1997;56:551-6.  Back to cited text no. 15
    
16.
Rades D, Schild SE, Fehlauer F. Prognostic value of the MIB-1 labeling index for central neurocytomas. Neurology 2004;62:987-9.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
 
  Search
 
<
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed99    
    Printed1    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal