İsmail İSTEMEN, Ali ARSLAN, Semih Kıvanç OLGUNER, Yurdal GEZERCAN, Ali İhsan ÖKTEN, Kemal Alper AFŞER, Emre BİLGİN

Miksopapiller ependimomda cerrahi sonuçlar: kapsül bütünlüğünün önemi

Özet:Giriş: Primer intramedüller tümörler nadir görülen, yetişkinlerde ağırlıklı olarak astrositomlar ve ependimomlardan oluşan tümörlerdir. Ependimomlar servikal ve servikotorasik bölgede sık görülürken, miksopapiller ependimomlar hemen her zaman konus medüllaris, kauda ekuina ve filum terminale düzeyinde ortaya çıkarlar. Miksopapiller ependimomlar düşük evreli (evre 1) ve mitotik aktivitesi düşük olan tümörlerdir ancak rekürrens sık bildirilmiştir. Tedavisi total cerrahi rezeksiyondur ve total çıkarılan tümörlerde tekrarlama ihtimali oldukça düşüktür. Kapsülasyonu zayıf olan vakalarda total rezeksiyon mümkün değildir, bu olgularda rekürrens, seeding metastaz ve uzak metastaz riski artmaktadır. Total çıkarılamayan olgularda radyoterapi eklenmesi önerilir. Çalışmamızda kliniğimizde 2014-2016 yılları arasında total çıkarım yapılan ve patoloji sonucu miksopapiller ependimom olarak gelen 9 olgu retrospektif olarak incelenmiş ve klinik sonuçları literatür verileri ile birlikte değerlendirilmiştir.Gereç ve Yöntem: 2014-2016 yılları arasında, Adana Şehir Eğitim ve Araştırma Hastanesi Beyin Cerrahi Bölümü’nde spinal kitle nedeni ile opere edilen, kapsülü ile birlikte bütün olarak çıkartılan ve patoloji sonucu miksopapiller ependimom olarak bildirilen olgular retrospektif olarak incelenmiştir. Hastalar, operasyon öncesi ve sonrası klinik ve radyolojik bulguları ile değerlendirilmiştir. Radyolojik tanı yöntemi olarak manyetik rezonans görüntüleme kullanılmıştır. Cerrahi yöntem olarak lezyon seviyesinde total laminektomi ile total kitle eksizyonu uygulanmıştır.Bulgular: 7 kadın 2 erkek hasta takibe alınmıştır. Yaş aralığı 9-57 olup ortalama yaş 33’tü. 3 hastada kitle L2 seviyesinde, 2 hastada L3 seviyesinde, 1 hastada L4 seviyesinde ve 3 hastada L4-L5 vertebralar boyunca yerleşmekteydi. Tüm hastaların ortak şikayeti bel ağrısı olup; dört hastada paraparezi ve bir hastada da gaita idrar inkontinansı ilave şikayetlerdendi. Operasyon sonrasında ağrı şikayeti tüm hastalarda geçti. Paraparezisi olan 4 hastadan 3’ünde erken dönemde önemli oranda düzelme saptandı. 1 hastada ise 2. ay kontrolünde düzelme olduğu görüldü. İnkontinans gelişmiş hastada ise düzelme olmadı. Hastanede kalış süresi ortalama 5,1 gün olarak hesaplandı. Hastaların 2 yıllık radyolojik takiplerinde hiçbir hastada nüks saptanmadı. Sonuç: Kapsül bütünlüğü bozulmadan total olarak kitle çıkarılması rekürensi ve seeding metastazları önlemede önemlidir. Bu hastalar radyoterapi verilmeksizin takip edilebilirler. Ancak uzun dönem takipler ve daha fazla sayıda hasta gruplarının olduğu çalışmalar gereklidir. Anahtar Sözcükler: İntramedüller Tümör, Miksopapiller Ependimom, Spinal Tümör, Total Cerrahi Çıkarım

Anahtar Kelimeler:

İntramedüller tümör, miksopapiller ependimom, total cerrahi çıkarım

Surgıcal results of myxopapıllary ependymoma: the ımportance of capsule ıntegrıty.

Abstract: Introduction: Primary intramedullary tumors are rare tumors and mainly astrocytomas and ependymomas in adults. While ependymomas are common in the cervical and cervicothoracic region, myxopapillary ependymomas often occur at the level of conus medullaris, cauda ekuina and filum terminale. Myxopapillary ependymomas are low stage (stage 1) tumors with low mitotic activity but recurrence has been reported frequently. The treatment is total surgical resection and the probability of recurrence with total removed tumors is very low. Total resection is not possible in cases with thin and weak capsula, which increases the risk of recurrence, seeding metastasis and distant metastasis. It is recommended to add radiotherapy for patients who cannot be totally removed. The aim of this study to asses the clinical outcomes of the patients who underwent surgery with myxopapillary ependymoma and to share our clinical experience Material and methods: In the present study, 9 cases with the diagnosis of myxopapillary ependymoma underwent total excision between 2014-2016 in Adana City Treaning and Research Hospital at the Department of Neurosurgery were evaluated retrospectively. The patients were evaluated with radiological images and clinical parameters preoperatively and postoperatively. Patients were treated with laminectomy and tumour excision. Results: 7 male and 2 female patients were taken to routine follow-up. The age range is 9-57 and the average age is 33. The mass was located at L2 level in 3 patients, at L3 in 2 patients, at L4 in 1 pateient and at L4 and L5 in 3 patients. All patients had back pain, additionally 4 had paraparesia and 1 had urine-anal incontinence. Following surgery all patiens recovered from back pain. Significant improvement in muscle strength was detected in 3 patients in the early postoperative period and 2 months after following surgery in 1 patient. no improvement was observed in sphincter function. The mean length of stay in hospital was 5.1 days. No recurrence was detected in the postoperative 2 years radiologically. Conclusion: Total removal of mass without deterioration of capsule integrity is imperative in preventing recurrence and seeding metastases. These patients can be followed without radiotherapy. However, long-term follow-up studies and more patient groups are required.

Keywords:

Intramedullary tumor, myxopapillary ependymoma, total surgical removal,

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