- Department of Neurosurgery, Hospital Universitario de la Ribera, Cátedra de Neurociencias - Fundación Vithas – CEU, Spain.
- Department of Pathology, Hospital Universitario de la Ribera, Carretera de Corbera, Alzira, Valencia, Spain.
- Department of Radiology, Hospital Universitario de la Ribera, Carretera de Corbera, Alzira, Valencia, Spain.
Department of Radiology, Hospital Universitario de la Ribera, Carretera de Corbera, Alzira, Valencia, Spain.
DOI:10.25259/SNI_698_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ruben Rodríguez-Mena1, José Piquer-Belloch1, Jose Luis Llácer-Ortega1, Pedro Riesgo-Suárez1, Vicente Rovira-Lillo1, Alain Flor-Goikoetxea-Gamo1, Antonio Cremades-Mira2, Raúl Mut-Pons3. Cervical intramedullary solitary fibrous tumor: Case report and review of the literature. 29-Dec-2020;11:468
How to cite this URL: Ruben Rodríguez-Mena1, José Piquer-Belloch1, Jose Luis Llácer-Ortega1, Pedro Riesgo-Suárez1, Vicente Rovira-Lillo1, Alain Flor-Goikoetxea-Gamo1, Antonio Cremades-Mira2, Raúl Mut-Pons3. Cervical intramedullary solitary fibrous tumor: Case report and review of the literature. 29-Dec-2020;11:468. Available from: https://surgicalneurologyint.com/surgicalint-articles/10500/
Background: Solitary fibrous tumors (SFTs) are benign tumors derived from mesenchymal tissues that predominantly occur in the pleura. Establishing the diagnosis of these very rare intramedullary spinal lesions, with no clear-cut pathognomonic radiographic characteristics, is particularly challenging.
Case Description: Two males, 30 and 41 years of age, presented with progressive cervical myelopathies attributed to a cervical intramedullary exophytic tumor with associated spinal cord edema. One patient showed that the lesion was highly vascularized. Both patients underwent surgical excision of firm, solid, focal, and, particularly in one of them, very vascular/hemorrhagic tumors; at surgery, there was some adherence between the tumors and the cord tissue, but gross-total resections were achieved in both cases, demonstrated on postoperative MR scans. Histological and immunohistochemical findings confirmed the diagnosis of SFT (WHO Grade I). After a 6-month postoperative period, both patients neurologically improved and had no MR evidence of tumor recurrence.
Conclusion: Intramedullary cervical exophytic SFTs are extremely rare. Although these solid tumors may present with hemorrhagic features and at surgery demonstrate significant adherence to the pial/cord surface, complete surgical resections are feasible resulting in good outcomes.
Keywords: Cervical, Intramedullary, Solitary fibrous tumor, Surgery, Vascularized
Intramedullary cervical solitary fibrous tumors (SFTs) are extremely rare. Their low rate of presentation within the spinal cord itself makes the preoperative radiologic diagnosis and surgical planning, particularly challenging.[
CASE REPORT # 1
A 30-year-old male presented a 3-month history of neck pain and a progressive cervical myelopathy. The MR showed an intramedullary exophytic well-circumscribed C2-C3 mass with associated spinal cord edema inferior to the lesion. The tumor was isointense on T1-weighted image (T1WI), hyperintense on T2-weighted image (T2WI), and showed homogeneous gadolinium contrast enhancement. Digital subtraction angiogram (DSA) showed rich tumor vascularization with feeding branches from both of the vertebral arteries, including a right lateral spinal artery descending from the right posteroinferior cerebellar artery (PICA) [
Sagittal (a) and axial (b) T1-weighted magnetic resonance image (T1WI) showing an intramedullary exophytic C2-C3 tumor with homogeneous gadolinium enhancement. (c) T2-weighted images showing a hyperintense mass with associated spinal cord edema inferior to the lesion with signal void images in the upper cervical spine representing prominent vessels within the cerebrospinal fluid. (d and e) Feeding branches from both vertebral arteries were visualized on digital subtraction angiogram (black arrows in d), including a right lateral spinal artery (black arrow on e) descending from the right posteroinferior cerebellar artery (black arrow on e). Sagittal (f) and axial (g) contrast T1WI confirming complete tumor resection.
The histological examination confirmed the diagnosis of a SFT. It revealed uniform spindle cells surrounded by moderate fibrous stroma with intermingled collagenous fibers and a few well-demarcated branched blood vessels (“staghorn” vasculature). The overall cell population barely had discrete cytological atypia and mitotic activity, and there was no evidence of necrosis. On immunohistochemistry, the neoplasm was diffusely and strongly positive for BcL-2, CD34, and CD99 and negative for S-100, glial fibrillary acidic protein (GFAP), and epithelial membrane antigen (EMA). The Ki-67 proliferation index was 1%, and the conclusive diagnosis of a SFT with no malignant features (WHO Grade I) was made.
CASE REPORT # 2
A 41-year-old male presented with a 2-month history of a slowly progressive cervical myelopathy. The MR demonstrated an intramedullary exophytic tumor at C5-C7. The lesion was isointense on T1WI, heterogeneous on T2WI (predominantly hypointense with alternating smaller hyperintense areas), and homogeneously enhanced with contrast [
Sagittal (a) and axial (b) T1-weighted magnetic resonance image (T1WI) showing an intramedullary exophytic C5-C7 tumor with homogeneous gadolinium enhancement. (c) Slight heterogeneous aspect on T2-weighted images (predominantly hypointense with alternating smaller hyperintense areas). Sagittal (d) and axial (e) T1WI indicating complete removal of the tumor.
The pathological analysis was consistent with an SFT. It showed uniform small, basophilic, ovoid to spindled cells with oval nuclei, and ill-defined cytoplasm, with numerous thin-walled ramifying blood vessels in certain areas. Necrosis and mitosis were not evident. Immunohistochemical staining indicated strong positivity for CD34 and Bcl-2 (C). The Ki-67 proliferation index was less than 1%. The final diagnosis of a SFT with no malignant features (WHO Grade I) was then established [
Inside the CNS, spinal cord occurrence of SFT is exceedingly uncommon; there have been 22 cases reported [
SFT occurs predominantly in middle-aged patients, with a modest male preponderance.[
On MR, SFTs can be seen as a single, oval or irregular heterogeneous mass, sometimes having well-circumscribed margins, and tend to appear isointense on T1WI and hypointense on T2WI.[
Histopathologically, SFT cells are encircled by dense collagen networks in fascicular, storiform, herringbone, or patternless arrangements on hematoxylin and eosin staining.[
Gross-total removal is the recommended treatment of spinal SFT (under intraoperative neurophysiological monitoring) [
Here, we described two cases of intramedullary cervical exophytic SFTs that were completely excised and have not yet recurred, 2 and 3 years postoperatively.
Declaration of patient consent
Patient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Albert GW, Gokden M. Solitary fibrous tumors of the spine: A pediatric case report with a comprehensive review of the literature. J Neurosurg Pediatr. 2017. 19: 339-48
2. Bisceglia M, Dimitri L, Giannatempo G, Carotenuto V, Bianco M, Monte V. Solitary fibrous tumor of the central nervous system: Report of an additional 5 cases with comprehensive literature review. Int J Surg Pathol. 2011. 19: 476-86
3. Bohinski RJ, Mendel E, Aldape KD, Rhines LD. Intramedullary and extramedullary solitary fibrous tumor of the cervical spine. J Neurosurg Spine. 2004. 100: 358-63
4. Bruder M, Tews D, Mittelbronn M, Capper D, Seifert V, Marquardt G. Intramedullary solitary fibrous tumor--a benign form of hemangiopericytoma? Case report and review of the literature. World Neurosurg. 2015. 84: 189.e7-12
5. Ciappetta P, D’Urso PI, Cimmino A, Ingravallo G, Rossi R, Colamaria A. Intramedullary solitary fibrous tumor of dorsal spinal cord. Neuropathology. 2009. 30: 273-8
6. Glauser G, Sharma N, Kritikos M, Malhotra NR, Choudhri O. Cervical, intradural extramedullary solitary fibrous tumor of the spinal cord: A case report and review of the literature. Asian J Neurosurg. 2020. 15: 204-9
7. Jallo GI, Roonprapunt C, Kothbauer K, Freed D, Allen J, Epstein F. Spinal solitary fibrous tumors: A series of four patients: Case report. Neurosurgery. 2005. 57: E195
8. Tihan T, Viglione M, Rosenblum MK, Olivi A, Burger PC. Solitary fibrous tumors in the central nervous system. A clinicopathologic review of 18 cases and comparison to meningeal hemangiopericytomas. Arch Pathol Lab Med. 2003. 127: 432-9
9. Wang J, Zhao K, Han L, Jiao L, Liu W, Xu Y. Solitary fibrous tumor/hemangiopericytoma of spinal cord: A retrospective single-center study of 16 cases. World Neurosurg. 2019. 123: e629-38
10. Yi X, Xiao D, He Y, Yin H, Gong G, Long X. Spinal solitary fibrous tumor/hemangiopericytoma: A clinicopathologic and radiologic analysis of eleven cases. World Neurosurg. 2017. 104: 318-29