Fourth ventricular solitary fibrous tumor: a case report and review of the literature

  • Congli Wang1Email author,

    Affiliated with

    • Varsha Manucha1,

      Affiliated with

      • Scott Faro2,

        Affiliated with

        • Michael Weaver3 and

          Affiliated with

          • Abir L Mukherjee1

            Affiliated with

            Journal of Medical Case Reports20126:205

            DOI: 10.1186/1752-1947-6-205

            Received: 14 November 2011

            Accepted: 9 May 2012

            Published: 17 July 2012

            Abstract

            Introduction

            Solitary fibrous tumors of the central nervous system usually present as dura-based masses and clinically resemble meningiomas. There are very few reported cases of intra-ventricular solitary fibrous tumors, particularly in the fourth ventricle.

            Case presentation

            Our patient was a 52-year-old African-American man, who presented to our facility with a two-month history of progressive weakness and numbness in all extremities. A computed tomography scan and brain magnetic resonance imaging scan revealed a homogeneous, avidly enhancing 4.5 × 3.7 × 2.7cm fourth ventricular mass, with compression of adjacent medulla and cerebellum and extension into the foramen of Luschka. Our patient underwent a suboccipital craniotomy and resection of the tumor. A histological examination showed a spindle cell neoplasm with prominent collagenized stroma. The neoplastic cells were strongly and diffusely positive for CD34, vimentin and Bcl-2, and negative for S-100, CD99 and epithelial membrane antigen. The molecular immunology Borstel-1 (MIB-1) proliferation index was low (1%). CD31 immunostain highlighted the endothelial cells but the spindle cells were negative. Reticulin stain demonstrated a moderate reticulin network but individual cells were not invested by reticulin fibers. The histological features and immunoprofile was consistent with a solitary fibrous tumor.

            Conclusions

            In the central nervous system, solitary fibrous tumors are usually indolent tumors, with only rare examples showing hypercellularity and increased mitotic activity; features that were absent in our patient’s case. We present an uncommon central nervous system neoplasm in a rare location. Although uncommon, solitary fibrous tumors should be included in the differential diagnosis of intra-ventricular tumors in adults.

            Keywords

            Fourth ventricle Intraventricular Solitary fibrous tumor

            Introduction

            Solitary fibrous tumors (SFTs) were originally described in pleura and subsequently in soft tissue and many other organs including the central nervous system. SFTs of the central nervous system are rare entities, usually presenting as dura-based masses predominantly in the posterior fossa and spinal region [1]. SFTs are composed of spindle cells in a collagenized stroma with characteristic immunohistochemical features: diffuse and strong reactivity to CD34, positive for vimentin, and often immunoreactive to CD99 and Bcl-2 [1]. Intra-ventricular SFTs are rare, and only six cases have been reported in the fourth ventricle [27].

            Case presentation

            Our patient was a 52-year-old African-American man who presented to our facility with a two-month history of progressive weakness and numbness in all extremities. A computed tomography (CT) scan and a brain magnetic resonance imaging (MRI) scan revealed a 4.5 × 3.7 × 2.7cm, homogeneous, avidly enhancing mass located in the fourth ventricle, compressing adjacent medulla and cerebellum and extending into the foramen of Luschka (Figure 1). Angiography demonstrated multiple dysplastic-appearing branches from the right posterior inferior cerebellar artery supplying the neoplasm.
            http://static-content.springer.com/image/art%3A10.1186%2F1752-1947-6-205/MediaObjects/13256_2011_2166_Fig1_HTML.jpg
            Figure 1

            Contrast-enhanced T1-weighted axial (A) and sagittal (B) magnetic resonance imaging scans showing a homogenous mass located in the fourth ventricle.

            Our patient underwent a suboccipital craniotomy and resection of the tumor. During the operation, a cavitron ultrasonic surgical aspirator as well as bipolar cautery and suction were used to debulk the tumor, followed by a combination of RHOTON™ dissectors as well as microscissors to separate the tumor. The entire tumor was successfully removed.

            Histological examination showed a spindle cell neoplasm with prominent collagenized stroma (Figure 2A). Mitotic figures were not readily found and the molecular immunology Borstel-1 (MIB-1) proliferation index was low (1%). Meningothelial whorls and psammoma bodies were absent. The neoplastic cells were strongly and diffusely positive for CD34 (Figure 2B), vimentin and Bcl-2 (Figure 3A); no immunoreactivity with S-100, CD99 and epithelial membrane antigen (EMA) was detected. A CD31 immunostain highlighted the endothelial cells but not the spindle tumor cells. A moderate reticulin network was demonstrated by reticulin staining, but individual cells were not invested by reticulin fibers (Figure 3B). The histological features and immunoprofile were consistent with SFT.
            http://static-content.springer.com/image/art%3A10.1186%2F1752-1947-6-205/MediaObjects/13256_2011_2166_Fig2_HTML.jpg
            Figure 2

            Photomicrographs (original magnification, 200×). (A) Bland spindle cell tumor with collagenized stroma. (B) Neoplastic cells are strongly immunoreactive to CD34.

            http://static-content.springer.com/image/art%3A10.1186%2F1752-1947-6-205/MediaObjects/13256_2011_2166_Fig3_HTML.jpg
            Figure 3

            Photomicrographs (original magnification, 200×). (A) The tumor cells are immunoreactive to Bcl-2. (B) Neoplastic cells have moderately rich reticulin network.

            Our patient experienced no neurological deficit after surgery, and there were no signs of recurrence at one-year follow-up.

            Discussion

            Intraventricular tumors can have a wide spectrum of differential diagnosis based on radiological and histopathological features. A bland spindle cell tumor with collagenized stroma and avid contrast enhancement initially suggested a diagnosis of fibroblastic meningioma. However the immunoprofile of the neoplastic cells was typical of a solitary fibrous tumor (negative for EMA, strongly positive for CD34, vimentin and Bcl-2). In contrast, meningiomas are EMA positive and CD34 negative. Hemangiopericytomas can have histological overlap with solitary fibrous tumor, but CD34 and Bcl-2 staining is weak and patchy [8].

            To the best of our knowledge, just 17 Intraventricular solitary fibrous tumors have been reported in the literature to date. Six of these tumors were located in the fourth ventricle [27], eight cases were in lateral ventricle location [1, 914], one tumor located in the third ventricle [15], one case occurred in the foramina of Monro [16] and one case was a recurrent SFT arising from the falx cerebri, extending to the bilateral lateral ventricles and the third ventricle [17]. The clinical and radiological features of these tumors are given in Table 1; the immunomorphological features are given in Table 2. The age of patients ranged from 11 to 75 years old, with the vast majority being over 40 years; there was no sex predominance. Based on the available data, all the tumors were less or equal to 5.0 cm in their greatest dimension. On MRI scans, the tumors are typically iso- to hypointense on T1-weighted images, and show intense and homogeneous enhancement after intravenous administration of gadolinium. Most of those SFTs had bland histological features except two tumors showed mild to marked pleomorphism [5, 11]. Intraventricular SFTs have an indolent clinical course and excellent prognosis after surgery; however, owing to the small number of cases and limited follow-up, more data is needed to better assess the biological behavior of these tumors and the long-term outcome after treatment.
            Table 1

            Summary of clinical and radiological features of intraventricular solitary fibrous tumors reported in the literature

            Reference

            Age/sex

            Location

            Size (greatest dimension)

            Imaging features

            Follow-up

            Clarençon et al. [2]

            32/F

            Fourth ventricle

            2.5cm

            MRI: hypointense T1; heterogeneous- hypointense T2; post-contrast enhancement

            NA

            Cummings et al. [3]

            52/M

            Fourth ventricle

            NA

            MRI: homogeneous post-contrast enhancement

            Autopsy

            Gessi et al. [4]

            63/F

            Fourth ventricle

            2cm

            MRI: isointense T1; partial post-contrast enhancement

            NA

            Kim et al. [5]

            49/F

            Fourth ventricle

            NA

            MRI: dense post-contrast enhancement

            No recurrence after one year

            Montano et al. [6]

            61/M

            Fourth ventricle

            NA

            MRI: hypointense T1; iso-hypointense T2; marked post-contrast enhancement

            No recurrence after two years

            Sawauchi et al. [7]

            57/M

            Fourth ventricle

            NA

            MRI: low intensity T1; homogeneous post-contrast enhancement

            NA

            Tihan et al. [1]*

            NA

            Lateral ventricle

            NA

            MRI: low density T1; post-contrast enhancement

            NA

            Clarençon et al. [9]

            44/F

            Right lateral ventricle

            4.0cm

            MRI: hypointense T1; hyperintense T2; thin peripheral enhancement of multiple confluent cysts post-contrast

            NA

            Liao et al. [10]

            NA

            Right lateral ventricle

            NA

            NA

            NA

            Mekni et al. [11]

            40/M

            Right lateral ventricle

            3.5cm

            NA

            No recurrence after three years

            Surendrababu et al. [12]

            55/F

            Left lateral ventricle

            5.0cm

            NA

            No recurrence after one year

            Vassal et al. [13]

            60/F

            Left lateral ventricle

            5.0cm

            MRI: lobulated mass; homogeneous post-contrast enhancement

            No recurrence after two years

            Wright et al. [14]

            11/F

            Right lateral ventricle

            NA

            NA

            NA

            Koçak et al. [15]

            63/M

            Third ventricle

            2.5cm

            MRI: isointense T1 and T2; significant post-contrast enhancement

            No recurrence after three and a half years

            Kinfe et al. [16]

            75/F

            Foramen of Monro

            2.5cm

            CT: Hypointense tumor at the foramina of Monro; homogeneous post-contrast enhancement

            No recurrence after one year

            Teranishi et al. [17]

            61/M

            Falx cerebri, extended to bilateral lateral ventricles and the third ventricle

            NA

            MRI: isointense T1; iso-hyperintense T2; heterogeneous post-contrast enhancement

            NA

            Present case

            52/M

            Fourth ventricle

            4.5cm

            Iso-hypointense T1; heterogeneous T2; homogeneous post-contrast enhancement

            No recurrence after one year

            *Two cases.

            NA = not available.

            MRI=magnetic resonance imaging.

            Table 2

            Summary of immunomorphological features of intraventricular solitary fibrous tumors reported in the literature

            Reference

            Histologic features

            Immunohistochemical features

            Pleomorphism

            Mitosis

            Necrosis

            CD 34

            Bcl-2

            Vimentin

            S-100

            EMA

            MIB-1

            Reticulin

            Clarençon et al. [2]

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            Cummings et al. [3]

            NA

            NA

            NA

            Strong, diffuse +

            Strong, diffuse +

            Strong, diffuse +

            -

            -

            NA

            NA

            Gessi et al. [4]

            NA

            Absent

            Absent

            Strong +

            Strong +

            Strong +

            -

            -

            <2%

            NA

            Kim et al. [5]

            Mild

            Rare

            NA

            Diffuse +

            NA

            NA

            -

            -

            <3%

            Outlining of individual cells -

            Montano et al. [6]

            NA

            NA

            NA

            +

            +

            +

            -

            -

            <1%

            NA

            Sawauchi et al. [7]

            NA

            NA

            NA

            +

            NA

            +

            NA

            NA

            NA

            NA

            Tihan et al. [1]*

            NA

            NA

            NA

            Strong +

            NA

            Strong +

            -

            -

            NA

            Overall highlighted only the coarse collagen background

            Clarençon et al. [9]

            NA

            NA

            NA

            Strong +

            NA

            NA

            NA

            NA

            NA

            NA

            Liao et al. [10]

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            Mekni et al. [11]

            Marked

            5/10 HPF

            Focal

            Strong +

            +

            Strong +

            NA

            NA

            <2%

            NA

            Surendrababu et al.[12]

            Absent

            NA

            NA

            +

            +

            +

            -

            -

            <2%

            NA

            Vassal et al. [13]

            Absent

            Absent

            Absent

            Diffuse +

            NA

            Diffuse +

            -

            -

            <2%

            NA

            Wright et al. [14]

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            NA

            Koçak et al. [15]

            NA

            NA

            NA

            Focal +

            Diffuse +

            NA

            -

            -

            1%

            Interlacing reticular fibers +

            Kinfe et al. [16]

            NA

            NA

            NA

            Strong +

            Strong +

            Strong +

            -

            -

            <1%

            Rich network of reticular fibers

            Teranishi et al. [17]

            NA

            NA

            NA

            Strong +

            NA

            +

            -

            -

            5%

            NA

            Present case

            Absent

            Absent

            Absent

            Strong, diffuse +

            Strong, diffuse +

            Strong, diffuse +

            -

            -

            1%

            Reticulin network moderate +; individual cells -

            *Two cases.

            HPF = high power field; NA = not available; + = positive; - = negative.

            Conclusions

            We report a rare case of SFT in an unusual location. Though rare, SFTs should be considered in the histological differential diagnosis of intra-ventricular tumors particularly, spindle cell tumors with collagenized stroma, along with meningioma and schwannoma.

            Consent

            Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

            Declarations

            Acknowledgements

            We acknowledge the cooperation of our patient, as well as our patient’s family. This paper was not funded by any external source.

            Authors’ Affiliations

            (1)
            Department of Pathology and Laboratory Medicine, Temple University Hospital
            (2)
            Department of Radiology, Temple University Hospital
            (3)
            Department of Neurosurgery, Temple University Hospital

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            © Wang et al.; licensee BioMed Central Ltd. 2012