Case Reports in Pathology

Case Reports in Pathology / 2020 / Article

Case Report | Open Access

Volume 2020 |Article ID 1528698 | 6 pages | https://doi.org/10.1155/2020/1528698

Chondro-Osseous Metaplasia in Ependymoma: A Rare Histopathological Finding

Academic Editor: Janina Kulka
Received28 Aug 2019
Revised19 Apr 2020
Accepted20 Apr 2020
Published05 May 2020

Abstract

Ependymoma is a circumscribed glioma composed of uniform glial cells with bland nuclei in a fibrillary matrix. It is characterized by the presence of perivascular pseudorosettes. Unusual histopathological findings have rarely been reported in ependymomas, 0.5% of all diagnosed cases. Such unusual and exceedingly rare histological findings include osseous or chondroid metaplasia. To the best of our knowledge, only 15 cases of osseocartilaginous ependymomas have been reported in English literature. We report a 3-year-old boy who presented with ataxia, vomiting, and headache for three months. Radiological imaging revealed a posterior fossa lesion. Histopathological examination of the lesion confirmed a posterior fossa ependymoma with chondro-osseous metaplasia. The present case outlines the clinical presentation, histopathological findings, and outcome of chondro-osseous metaplasia in ependymomas. To date, the etiology of chondro-osseous metaplasia in ependymomas remains uncertain. Further research exploring such phenomenon is of paramount importance to explain how these tumors develop.

1. Introduction

Ependymoma is a noninfiltrative glioma usually arising near the ventricular system or central canal. Half of all ependymomas, particularly those in the posterior fossa, occur in children, making them the second most frequent solid brain tumor in the pediatric population after medulloblastoma [1]. Ependymomas represent 5.7% of all diagnosed CNS tumors in children aged 1-14 years with an estimated annual incidence rate of 0.30 per 100,000 people [2]. The incidence of ependymoma is higher in males [1]. Ependymomas tend to have a variable clinical outcome, dependent upon the extent of surgical resection, adjuvant radiotherapy, and the molecular classification [3].

Traditionally, according to the WHO grading scheme, ependymomas are divided into three types. These include myxopapillary ependymoma (WHO grade I), conventional ependymoma (WHO grade II), and anaplastic ependymoma (WHO grade III). Unusual histopathological patterns such as pigmented (melanotic) ependymomas, giant-cell ependymomas, ependymomas with extensive tumor cell vacuolization, and chondro-osseous ependymomas have been reported in the literature. These rare patterns are noted in only 0.5% of all diagnosed ependymomas [4].

The presence of bony or cartilaginous differentiation in gliomas is extremely rare and has been recognized in fourth-ventricular ependymomas and midline astrocytomas [59]. A review of the English literature reveals 15 cases of chondro-osseous ependymomas. We report a case of ependymoma with chondro-osseous metaplasia by outlining the clinical presentation, histopathological features, and outcome.

2. Case Description

A 3-year-old boy presented with a 3-month history of ataxia, vomiting, and headache, quickly followed by signs of increased intracranial pressure (ICP). Investigations and radiological imaging in private hospitals identified a posterior fossa space-occupying lesion (Figure 1). Consequently, ventricular shunting and a subtotal resection (STR) were performed which were complicated by a moderate posterior fossa syndrome.

2.1. Histopathological Findings

The histopathological examination of the posterior fossa tumor showed mostly a moderately cellular glial tumor with perivascular pseudorosettes (Figure 2). There are foci of hypercellularity, pleomorphism, and increased mitotic activity (up to 10 mitoses per 10 HPF). The tumor cells are immunopositive for GFAP. EMA immunostain showed a perinuclear dot-like pattern (Figure 2(f)). The histopathology and the immunoprofile are classical for ependymoma with a focus of anaplasia (WHO III). In addition, there was a focus of chondro-osseous metaplasia within the well-differentiated part of the tumor. There is a rim of dystrophic calcification adjacent to this metaplasia as well.

2.2. Outcome and Follow-Up

After four months of the STR, the patient underwent gross total resection to remove the residual tumor. Afterwards, the patient completed radiation therapy. Routine follow-up after two years revealed that the boy’s speech was coherent with no oropharyngeal deficits. The VP shunt was compressible, filling promptly on 2.0 pressure, with no signs of malfunction. He was able to ambulate independently with minimal residual gait ataxia noted when running. The patient was otherwise grossly intact.

Subsequent radiological imaging revealed no evidence of residual tumor, recurrence, or drop metastasis. The cerebrospinal fluid and cytopathological analyses were negative for malignant cells. The patient is currently followed up in the pediatric neurosurgery clinic.

3. Discussion

Chondro-osseous metaplasia in ependymomas is exceedingly rare. An extensive review of the literature revealed 15 prior cases of chondro-osseous ependymomas (Table 1). We report an additional case encountered at our institution. Most of the reported cases (; 68.7%) were diagnosed in the pediatric age group (defined as less than or equal to 16 years). The youngest patient who was diagnosed with ependymoma with chondroid metaplasia was one year old (age range: 1–61 years).


No.1st Author (year)Age/sexLocalizationHistologyWHO gradeMetaplasiaOutcome

1Ghosal N [10], 201016/M4th ventricleEpendymomaIIChondroidLost to follow-up
2Coli A [11], 20145/M4th ventricleAnaplasticIIIChondroidDeath at 36 months
3Boukas A [7], 20135/M4th ventricleAnaplasticIIIChondroidDeath at 3 months
4Wang X [9], 20125/M4th ventricleEpendymomaIIChondro-osseousDeath at 18 months
5Jain A [8], 200921/M4th ventricleEpendymomaIIChondroidRecurrence at 5 years
6Mridha AR [12], 20079/MLt. CP angle cisternAnaplasticIIIChondro-osseousNA
7Siqueira EB [13], 196610/F4th ventricleEpendymomaIIChondroidDeath
8Kepes JJ [14], 19847/F4th ventricleEpendymomaIIChondroidDeath at 5th day post-operation
9Güzey FK [6], 200556/FRt. Temporo-occipital lobeEpendymomaIIChondroidNo complaints at 15 months
10Bannykh S [15], 200761/MLt. Frontal lobeAnaplasticIIIChondro-osseousDeath at 6 months
11Chakraborti S [16], 201250/F4th ventricleMyxopapillaryIChondroidNo recurrence at 3 years
12Gessi M [4], 20111/F4th ventricleAnaplasticIIIChondroidNA
13Gessi M [4], 20112/F4th ventricleAnaplasticIIIChondro-osseousNA
14Gessi M [4], 20113/F4th ventricleEpendymomaIIChondro-osseousNA
15Gessi M [4], 201153/F4th ventricleSubependymoma/EpendymomaIChondro-osseousNA
16Present Case, 20203/M4th ventricleAnaplasticIIIChondro-osseousNo recurrence at 2 years

Age is expressed in years. CP: Cerebellopontine; M: male; F: female; Rt: right; Lt: left; WHO: World Health Organization; NA: not available.

Of the fifteen reported cases, six depicted both chondroid and osseous metaplasia with no gender predilection. This makes the present case the seventh of its kind. The majority of the tumors were localized in the posterior fossa (; 87.5%) with the remaining tumors in the frontal lobe, temporo-occipital lobes, and cerebellopontine angle cistern.

Histologically, seven patients (43.7%) had conventional ependymoma (WHO II), six patients (40%) had anaplastic ependymoma (WHO III), one patient had subependymoma/ependymoma, and one had myxopapillary ependymoma. As far as the outcome is concerned, six patients (37.5%) passed away within three years of the diagnosis, one patient (6.2%) was lost to follow-up, and two patients (13.3%) had an uneventful outcome. The boy in the present case had no recurrence of the tumor after two years of the diagnosis.

According to Wang et al., the presence of chondro-osseous metaplasia in ependymomas is associated with a dismal prognosis despite aggressive therapy, concluding that such tumors may behave aggressively [9]. Boukas and his group reported the first case of ependymoma in which cartilaginous metaplasia has replaced the entire architecture of the tumor. They considered the presence of chondro-osseous metaplasia in ependymomas an obstacle to achieve gross total resection [7].

Several mechanisms have been postulated to explain chondro-osseous metaplasia in ependymoma [9]. Two of the most accepted theories state that such a phenomenon in gliomas may arise due to the metaplastic transformation of either the neoplastic glial cells or the mesenchymal tissue component of the tumor [16]. Güzey et al. reported a case of ependymoma with cartilage formation. They concluded that the cartilage formation might have developed from a transformation of the neuroepithelial cells to mesenchymal cells, as the cartilaginous tissue lacked a fibrous capsule and immunoreacted positively to glial fibrillary acidic protein (GFAP) antibody [6].

Gessi et al. identified four patients with cartilaginous ependymomas in his case series. They were not able to establish any relationship between the tumor grade and the presence of chondro-osseous metaplasia. In his case series, there were no high-grade features. They postulated that chondro-osseous metaplasia could have resulted from a simple transformation of mesenchymal stromal tissue within the tumor [4].

The capacity of neoplastic cells to produce cartilage in gliomas may be related to their ability to secrete and synthesize basement membrane material which, upon condensation, may become a chondroid substance [14]. However, considering the rarity of this histopathological feature, no single mechanism could explain the presence of osseocartilaginous metaplasia in ependymomas [6].

4. Conclusion

We report a case of posterior fossa ependymoma with chondro-osseous metaplasia. Although rare, such metaplastic changes can be identified in ependymomas and the prognostic significance is uncertain.

Ethical Approval

This case report was approved by the Institutional Review Board (IRB) at King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard - Health Affairs (NGHA), Riyadh, Saudi Arabia. The data and images were anonymized to maintain the patient’s privacy.

Conflicts of Interest

The authors declare that they have no conflict of interest.

Authors’ Contributions

Ali Alkhaibary acquired the histopathological and neuroradiological images, wrote the original draft, revised, and edited the manuscript. Fahd AlSufiani conceptualized, supervised, wrote the microscopic description, revised, and edited the manuscript. Ali H. Alassiri supervised, wrote the microscopic description, revised, and edited the manuscript. Makki Almuntashri wrote the radiological description, revised, and edited the manuscript. Salma Tarik Al Qutub wrote the radiological description. All authors have critically reviewed and approved the final version of the manuscript.

References

  1. C. S. McGuire, K. L. Sainani, and P. G. Fisher, “Incidence patterns for ependymoma: a surveillance, epidemiology, and end results study,” Journal of Neurosurgery, vol. 110, no. 4, pp. 725–729, 2009. View at: Publisher Site | Google Scholar
  2. Q. T. Ostrom, H. Gittleman, J. Fulop et al., “CBTRUS statistical report: primary brain and central nervous system tumors diagnosed in the United States in 2008-2012,” Neuro-Oncology, vol. 17, Supplement 4, pp. iv1–iv62, 2015. View at: Publisher Site | Google Scholar
  3. D. N. Louis, H. Ohgaki, O. D. Wiestler, and W. K. Cavenee, WHO classification of tumours of the central nervous system, WHO Press, International agency for research on cancer (IARC), France, 2016.
  4. M. Gessi, K. Kuchelmeister, L. Lauriola, and T. Pietsch, “Rare histological variants in ependymomas: histopathological analysis of 13 cases,” Virchows Archiv, vol. 459, no. 4, pp. 423–429, 2011. View at: Publisher Site | Google Scholar
  5. A. Maleci, M. T. Giordana, F. Bianco, and N. L. Di, “Intramedullary astrocytoma with cartilage formation. Case report,” Journal of Neurosurgical Sciences, vol. 40, no. 2, pp. 157–160, 1996. View at: Google Scholar
  6. F. K. Güzey, E. M. Erhan, Ç. BAYINDIR, N. S. BAŞ, S. E. Barış, and İ. Alataş, “Ependymoma with cartilage formation: a case report,” Turkish Neurosurgery, vol. 15, no. 1, pp. 12–17, 2005. View at: Google Scholar
  7. A. Boukas, A. Joshi, A. Jenkins, and D. Holliman, “Extensive cartilaginous metaplasia of recurrent posterior fossa ependymoma: case report and review of the literature,” Pediatric Neurosurgery, vol. 49, no. 2, pp. 93–98, 2013. View at: Publisher Site | Google Scholar
  8. A. Jain, A. Rishi, V. Suri et al., “Recurrent ependymoma with cartilaginous metaplasia in an adult: report of a rare case and review of literature,” Clinical Neuropathology, vol. 28, no. 2, pp. 101–104, 2009. View at: Publisher Site | Google Scholar
  9. X. Wang, S. Zhang, Y. Ye, Y. Chen, and X. Liu, “Ependymoma with cartilaginous metaplasia might have more aggressive behavior: a case report and literature review,” Brain Tumor Pathology, vol. 29, no. 3, pp. 172–176, 2012. View at: Publisher Site | Google Scholar
  10. N. Ghosal, G. Murthy, R. Dadlani, A. S. Hegde, and D. Singh, “Recurrent posterior fossa anaplastic ependymoma with prominent chondroid metaplasia: a case report and review of literature,” Indian Journal of Pathology & Microbiology, vol. 53, no. 4, pp. 787–789, 2010. View at: Publisher Site | Google Scholar
  11. A. Coli, M. Novello, L. Massimi, M. Caldarelli, V. Ranucci, and L. Lauriola, “Cartilage differentiation in ependymoma: histogenetic considerations on a new case,” Child's Nervous System, vol. 30, no. 7, pp. 1301–1305, 2014. View at: Publisher Site | Google Scholar
  12. A. R. Mridha, M. C. Sharma, C. Sarkar, A. Garg, M. M. Singh, and V. Suri, “Anaplastic ependymoma with cartilaginous and osseous metaplasia: report of a rare case and review of literature,” Journal of Neuro-Oncology, vol. 82, no. 1, pp. 75–80, 2007. View at: Publisher Site | Google Scholar
  13. E. B. Siqueira and P. C. Bucy, “Case report: chondroma arising within a mixed glioma,” Journal of Neuropathology and Experimental Neurology, vol. 25, no. 4, pp. 667–673, 1966. View at: Publisher Site | Google Scholar
  14. J. J. Kepes, L. J. Rubinstein, and H. Chiang, “The role of astrocytes in the formation of cartilage in gliomas. An immunohistochemical study of four cases,” The American Journal of Pathology, vol. 117, no. 3, pp. 471–483, 1984. View at: Google Scholar
  15. S. Bannykh and J. M. Baehring, “Images in neuro-oncology: rapid development of osseous and chondrous metaplasia in recurrent anaplastic ependymoma,” Journal of Neuro-Oncology, vol. 81, no. 3, pp. 257-258, 2007. View at: Publisher Site | Google Scholar
  16. S. Chakraborti, A. Govindan, J. P. Alapatt, M. Radhakrishnan, and V. Santosh, “Primary myxopapillary ependymoma of the fourth ventricle with cartilaginous metaplasia: a case report and review of the literature,” Brain Tumor Pathology, vol. 29, no. 1, pp. 25–30, 2012. View at: Publisher Site | Google Scholar

Copyright © 2020 Ali Alkhaibary et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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