Mobile Spinal Schwannoma with a Completely Cystic Appearance

Abstract

BACKGROUND Spinal schwannomas are benign tumors arising from Schwann cells. Although they have been well described, tumor movement in the spinal canal is an extremely rare finding, and entirely cystic spinal schwannomas have rarely been reported. This is the first report of a spinal schwannoma that simultaneously exhibited both these unusual features. CASE REPORT A 48-year-old female presented with dysuria and right leg pain. Initial magnetic resonance imaging (MRI) revealed a well-delineated intradural cystic lesion at the level of L4-S1 vertebrae that was isointense with cerebrospinal fluid on both T1- and T2-weighted images. A follow-up MRI 6 months later showed that the tumor had moved to the level of L2-L4; it also revealed tortuous configuration of nerve roots of the cauda equina. The tumor was resected, and a diagnosis of schwannoma with extensive cystic degeneration was pathologically confirmed. CONCLUSIONS Various possible mechanisms have been suggested for the mobility of extramedullary tumors. In the present case, MRI findings indicated the cause of the tumor movement might be attributed to the laxity of nerve roots. Besides, it is highly atypical for a schwannoma to present an entirely cystic appearance, and the combination of the 2 extraordinary features made preoperative diagnosis difficult. However, 16 out of 22 (73%) of previously reported mobile spinal tumors were schwannomas, so the differential diagnosis for a mobile spinal tumor should include schwannoma, even when the lesion seems entirely cystic on MRI. To minimize the risk of complications and additional surgical dissection, physicians should acknowledge that spinal tumors can migrate.

Figure 1.

Initial MR imaging. The initial sagittal T1-weighted (A), sagittal T2-weighted (B), and axial T2-weighted (C) images showed an intradural extramedullary cystic mass at the level of the L4–S1 vertebrae with homogeneous intensity identical to that of cerebrospinal fluid. The cystic mass had a smooth margin, and no solid component was observed.

Figure 2.

Follow-up MRI at 6 months after the initial scan. The sagittal T2-weighted image (A) revealed that the tumor had moved to the level of L2–L4 (arrow) and showed the wrinkled appearance of nerve roots (circle). The sagittal diffusion-weighted image (B) showed no abnormal signal intensity. The thin-section coronal constructive interference in steady state image (C) demonstrated no solid component.

Figure 3.

Hematoxylin and eosin (H&E) staining of the resected specimen. (A) A low-power field (H&E stain, 20×) showed a large cystic space within the tumor. (B) A high-power field (H&E stain, 400×) revealed the proliferation of spindle cells with elongated nuclei, which exhibited a nuclear palisade arrangement.