Spinal drop of atypical choroid plexus papilloma in an adult patient: A case report and literature review

Abstract

Background: Choroid plexus papillomas (CPPs) are benign extra-axial tumors that originate from the choroid plexus; these tumors rarely have metastases, being at the spinal level the location with few reported cases.

Case description: We report the case of a 48-year-old man with a history of atypical fourth ventricular CPP and gross total resection (GTR) in 2008. In 2015, he presented with radicular pain, decreased strength, and paresthesia in the left leg. Magnetic resonance imaging revealed a well-defined intradural ovoid lesion in the vertebral canal at the level of the L3-L4 intersomatic space. Subtotal resection of the tumor was performed. The patient recovered well, with relief of pain and no neurological deficit. A literature research few cases of CPP metastasis in adults. We describe here a fifth-decade male patient with a lumbar neoplasm, which according to the histopathologic characteristics and location is the first case of an atypical papilloma implant of the choroid plexus at this spinal level.

Conclusion: GTR of primary lesions and associated implants remains the gold standard for surgical treatment of CPP. Radiotherapy, stereotactic radiosurgery, and chemotherapy are adjuvant therapies for CPP but there is no definitive protocol for the management of implants. Proper follow-up of these patients is essential since spinal drop can appear many years after the initial presentation of CPP.

Keywords: Choroid plexus papilloma; Metastasis; Spinal drop.

Figure 1:

Brain magnetic resonance imaging. Axial brain contrast material-enhanced T1-weighted image. Within the fourth ventricle, there is a well-defined lesion, homogenous enhancement, and causing partial obliteration of the fourth ventricle.

Figure 2:

Spinal magnetic resonance imaging. (a) Sagittal T2-weighted image (b) sagittal lumbar spine contrast material-enhanced T1-weighted image (c) coronal T2-weighted image (d) axial lumbar spine contrast material-enhanced T1-weighted image. In the vertebral canal at the level of the intersomatic space, L3L4 presents a well-defined ovoid lesion, isointense on T2 sequence, with a length of 1.7 × 1.2 cm, and intradural-extramedullary behavior that involves the spinal canal with homogeneous enhancement.

Figure 3:

Surgical view. Soft yellow-colored lesion, firmly adhered to the nerve root of L4, with a length of 1.6 × 0.6 cm.

Figure 4:

Photomicrographs of the spinal implant resected in 2017. A neoplasm with papillary architecture is observed, similar to that of 2008 (a and b) with solid areas (c) that present mitosis figures (c and d) of which four mitoses were counted in ten high-rise fields.

Figure 5:

Immunohistochemical reactions of the spinal implant showing positivity for cytokeratin seven, positivity for S100 protein, synaptophysin, and with a proliferation index (Ki67) of <1%.

Figure 6:

Photomicrographs of atypical fourth ventricle tumor resected in 2008. A neoplasm with papillary architecture is observed with several layers of epithelial cells in some portions, they are ovoid and uniform (a) with a small amount of mitosis (b).