Distinct patterns of copy number alterations may predict poor outcome in central nervous system germ cell tumors.

We have previously reported that 12p gain may predict the presence of malignant components and poor prognosis for CNS germ cell tumor (GCT). Recently, 3p25.3 gain was identified as an independent predictor of poor prognosis for testicular GCT. Eighty-one CNS GCTs were analyzed. Copy number was calculated using methylation arrays. Five cases (6.2%) showed 3p25.3 gain, but only among the 40 non-germinomatous GCTs (NGGCTs) (5/40, 12.5%; p = 0.03). Among NGGCTs, those with a yolk sac tumor component showed a significantly higher frequency of 3p25.3 gain (18.2%) than those without (1.5%; p = 0.048). NGGCTs with gain showed significantly shorter progression-free survival (PFS) than those without (p = 0.047). The 3p25.3 gain and 12p gain were independent from each other. The combination of 3p25.3 gain and/or 12p gain was more frequent among NGGCTs with malignant components (69%) than among those without (29%; p = 0.02). Germinomas containing a higher number of copy number alterations showed shorter PFS than those with fewer (p = 0.03). Taken together, a finding of 3p25.3 gain may be a copy number alteration specific to NGGCTs and in combination with 12p gain could serve as a marker of negative prognosis or treatment resistance. Germinoma with frequent chromosomal instability may constitute an unfavorable subgroup.

Injury of the Internal Carotid Artery During Dissection of a Craniopharyngioma via the Pterional Approach: Case Report.

Among the various causes of intraoperative neurosurgical complications, a major arterial injury is one of the most devastating. Herein, the authors present a case of a 76-year-old patient who underwent removal of a craniopharyngioma via the pterional approach and experienced severe damage of her sclerotic left internal carotid artery because it was retracted excessively by a brain spatula, which resulted in complete sacrifice of the vessel. Despite stable parameters on intraoperative monitoring of motor evoked potentials and sufficient collateral blood flow, confirmed by Doppler flowmetry, a large infarct in the left cerebral hemisphere was noted after surgery. Although retraction of movable arteries, veins, and cranial nerves can often be done safely during neurosurgical procedures for effective exposure of the operative field, forced displacement of a sclerotic internal carotid artery in its paraclinoid portion anchored to the fixed distal dural ring should definitely be avoided because it poses a significant risk of major vessel damage.

Transcriptome and methylome analysis of CNS germ cell tumor finds its cell-of-origin in embryogenesis and reveals shared similarities with testicular counterparts.

BACKGROUND: CNS germ cell tumors (GCTs) predominantly develop in pediatric and young adult patients with variable responses to surgery, radiation, and chemotherapy. This study aimed to examine the complex and largely unknown pathogenesis of CNS GCTs. METHODS: We used a combined transcriptomic and methylomic approach in 84 cases and conducted an integrative analysis of the normal cells undergoing embryogenesis and testicular GCTs. RESULTS: Genome-wide transcriptome analysis in CNS GCTs indicated that germinoma had a transcriptomic profile representative of primitive cells during early embryogenesis with high meiosis/mitosis potentials, while nongerminomatous GCTs (NGGCTs) had differentiated phenotypes oriented toward tissue formation and organogenesis. Co-analysis with the transcriptome of human embryonic cells revealed that germinomas had expression profiles similar to those of primordial germ cells, while the expression profiles of NGGCTs were similar to those of embryonic stem cells. Some germinoma cases were characterized by extensive immune-cell infiltration and high expression of cancer-testis antigens. NGGCTs had significantly higher immune-cell infiltration, characterized by immune-suppression phenotype. CNS and testicular GCTs (TGCTs) had similar mutational profiles; TGCTs showed enhanced copy number alterations. Methylation analysis clustered germinoma/seminoma and nongerminoma/nonseminoma separately. Germinoma and seminoma were co-categorized based on the degree of the tumor microenvironment balance. CONCLUSIONS: These results suggested that the pathophysiology of GCTs was less dependent on their site of origin and more dependent on the state of differentiation as well as on the tumor microenvironment balance. This study revealed distinct biological properties of GCTs, which will hopefully lead to future treatment development.

12p gain is predominantly observed in non-germinomatous germ cell tumors and identifies an unfavorable subgroup of central nervous system germ cell tumors.

BACKGROUND: Central nervous system (CNS) germ cell tumors (GCTs) are neoplasms predominantly arising in pediatric and young adult populations. While germinomas generally respond to chemotherapy and radiation, non-germinomatous GCTs (NGGCTs) require more intensive treatment. This study aimed to determine whether 12p gain could predict the prognosis of CNS GCTs. METHODS: Eighty-two CNS GCTs were included in this study. The 12p gain was defined by an additional 12p in the background of potential polyploidy or polysomy. Cases were analyzed using an Illumina methylation 450K array for copy number investigations and validated by fluorescence in situ hybridization (FISH). RESULTS: A 12p gain was found in 25-out-of-82 cases (30%) and was more frequent in NGGCTs (12% of germinoma cases and 50% of NGGCT cases), particularly in cases with malignant components, such as immature teratoma, yolk sac tumor, choriocarcinoma, and embryonal carcinoma. 12p gain and KIT mutation were mutually exclusive events. The presence of 12p gain correlated with shorter progression-free (PFS) and overall survival (OS) (10-year OS: 59% vs. 94%, with and without 12p gain, respectively, P = 0.0002), even with histology and tumor markers incorporated in the multivariate analysis. Among NGGCTs, 12p gain still had prognostic significance for PFS and OS (10-year OS: 47% vs. 90%, respectively, P = 0.02). The 12p copy number status was shared among histological components in mixed GCTs. CONCLUSIONS: 12p gain may predict the presence of malignant components of NGGCTs, and poor prognosis of the patients. It may be associated with early tumorigenesis of CNS GCT.

Integrated clinical, histopathological, and molecular data analysis of 190 central nervous system germ cell tumors from the iGCT Consortium.

BACKGROUND: We integrated clinical, histopathological, and molecular data of central nervous system germ cell tumors to provide insights into their management. METHODS: Data from the Intracranial Germ Cell Tumor Genome Analysis (iGCT) Consortium were reviewed. A total of 190 cases were classified as primary germ cell tumors (GCTs) based on central pathological reviews. RESULTS: All but one of the cases that were bifocal (neurohypophysis and pineal glands) and cases with multiple lesions including neurohypophysis or pineal gland were germinomas (34 of 35). Age was significantly higher in patients with germinoma than other histologies. Comparison between tumor marker and histopathological diagnoses showed that 18.2% of histopathologically diagnosed germinomas were marker positive and 6.1% of non-germinomatous GCTs were marker negative, suggesting a limitation in the utility of markers or histopathology alone using small specimens for diagnosis. Comparison between local and central histopathological diagnoses revealed a discordance of 12.7%. Discordance was significantly less frequent in biopsy cases, implying difficulty in detecting all histopathological components of heterogeneous GCTs. Germinomas at the typical sites (neurohypophysis or pineal gland) showed a better progression-free survival than those at atypical sites (P = 0.03). A molecular clinical association study revealed frequent mitogen-activated protein kinase (MAPK) pathway mutations in males (51.4% vs 14.3%, P = 0.007), and phosphatidylinositol-3 kinase/mammalian target of rapamycin (PI3K/mTOR) pathway mutations in basal ganglia cases (P = 0.004). Basal ganglia cases also had frequent chromosomal losses. Some chromosomal aberrations (2q, 8q gain, 5q, 9p/q, 13q, 15q loss) showed potential prognostic significance. CONCLUSIONS: The in-depth findings of this study regarding clinical and molecular heterogeneity will increase our understanding of the pathogenesis of this enigmatic tumor.

[Chronic Subdural Hematoma with Middle Cranial Fossa Arachnoid Cyst Concomitant with Bilateral Papilledema:A Case Report].

Arachnoid cysts(AC)are benign cystic lesions often diagnosed in childhood. Although usually asymptomatic, AC can become symptomatic when the lesion size increases or coexists with a subdural hygroma or hematoma. AC patients with signs of increasing intracranial pressure(IICP)or neurological deficits may need surgical intervention; this usually results in a good prognosis. However, whether asymptomatic AC patients should undergo surgical treatment is controversial. Although trivial head trauma, such as that from contact sports, can cause subdural hematoma in AC patients, there are currently no definite criteria regarding sports participation for children with AC. CASE: A 12-year-old boy who belonged to a soccer club visited an ophthalmologist with the chief complaint of having had diplopia for two weeks. He was identified as having bilateral papilledema. Since he had been diagnosed with a right middle cranial fossa AC five years earlier, he was referred to our outpatient clinic. Cranial CT scans showed right chronic subdural hematoma alongside the AC. The patient subsequently underwent burr hole surgery and was discharged after one week. In this case, the patient did not present with the typical signs of IICP, such as headache or vomiting. This experience indicates that care must be taken when encountering patients with atypical symptoms, particularly children. In addition, it is important to carefully consider sports participation for children with AC.

Primary central nervous system malignant melanoma with leptomeningeal melanomatosis: a case report and review of the literature.

Leptomeningeal melanomatosis is an extremely rare variant of primary central nervous system (CNS) melanoma and has a poor prognosis and no standard treatment. Primary CNS melanoma is derived from the melanocytes of the leptomeninges. Here, we describe a case of a 37-year-old male who visited our hospital due to worsening headaches. Characteristic imaging findings of this tumor type include hyper-dense lesions that are enhanced by contrast medium on computed tomography and hyper-intensity on T1-weighted magnetic resonance images and iso- to hypo-intensity on T2-weighted magnetic resonance images. Imaging of the CNS in our patient showed several lesions of this type. Pathological diagnosis and exclusion of systemic melanoma are required to confirm primary CNS malignant melanoma. Partial resection of the mass in the left temporal lobe of this patient was performed, and histological analysis showed pigmentation, melanin black-45 positivity, and BRAF mutation. Because no lesions were found outside the CNS following a thorough whole-body search, he was diagnosed with primary CNS malignant melanoma with leptomeningeal melanomatosis. He was treated with whole-brain radiation and the BRAF kinase inhibitor vemurafenib. His condition worsened, and he was given the anti-programmed cell death-1 antibody nivolumab as second-line therapy. This was also unsuccessful, and he died 5 months after treatment initiation. Further studies are needed to improve treatment and prognosis of this rare but serious disease.

Genome-wide methylation profiles in primary intracranial germ cell tumors indicate a primordial germ cell origin for germinomas.

Intracranial germ cell tumors (iGCTs) are the second most common brain tumors among children under 14 in Japan. The World Health Organization classification recognizes several subtypes of iGCTs, which are conventionally subclassified into pure germinoma or non-germinomatous GCTs. Recent exhaustive genomic studies showed that mutations of the genes involved in the MAPK and/or PI3K pathways are common in iGCTs; however, the mechanisms of how different subtypes develop, often as a mixed-GCT, are unknown. To elucidate the pathogenesis of iGCTs, we investigated 61 GCTs of various subtypes by genome-wide DNA methylation profiling. We showed that pure germinomas are characterized by global low DNA methylation, a unique epigenetic feature making them distinct from all other iGCTs subtypes. The patterns of methylation strongly resemble that of primordial germ cells (PGC) at the migration phase, possibly indicating the cell of origin for these tumors. Unlike PGC, however, hypomethylation extends to long interspersed nuclear element retrotransposons. Histologically and epigenetically distinct microdissected components of mixed-GCTs shared identical somatic mutations in the MAPK or PI3K pathways, indicating that they developed from a common ancestral cell.

Recurrent neomorphic mutations of MTOR in central nervous system and testicular germ cell tumors may be targeted for therapy.

Germ cell tumors constitute a heterogeneous group that displays a broad spectrum of morphology. They often arise in testes; however, extragonadal occurrence, in particular brain, is not uncommon, and whether they share a common pathogenesis is unknown. We performed whole exome sequencing in 41 pairs of central nervous system germ cell tumors (CNS GCTs) of various histology and their matched normal tissues. We then performed targeted sequencing of 41 selected genes in a total of 124 CNS GCTs, 65 testicular germ cell tumors (tGCTs) and 8 metastatic GCTs to the CNS. The results showed that mutually exclusive mutations of genes involved in the MAPK pathway were most common (48.4 %), typically in KIT (27.4 %), followed by those in the PI3K pathway (12.9 %), particularly in MTOR (6.5 %), among the 124 CNS GCTs. Pure germinomas and non-germinomatous germ cell tumors (NGGCTs), as well as CNS and testicular GCTs, showed similar mutational profiles, suggesting that GCTs share a common molecular pathogenesis. Mutated MTOR identified in CNS GCTs upregulated phosphorylation of the AKT pathway proteins including AKT and 4EBP1 in nutrient-deprived conditions and enhanced soft-agar colony formation; both events were suppressed in a dose-dependent manner by addition of the MTOR inhibitor pp242. Our findings indicate that the dominant genetic drivers of GCTs regardless of the site of origin are activation of the MAPK and/or PI3K pathways by somatic point mutations. Mutated MTOR represents a potential target for novel targeted therapies for refractory GCTs.

Dendritic cell-based immunotherapy targeting Wilms' tumor 1 in patients with recurrent malignant glioma.

OBJECT: Dendritic cell (DC)-based vaccination is considered a potentially effective therapy against advanced cancer. The authors conducted a Phase I study to investigate the safety and immunomonitoring of Wilms' tumor 1 (WT1)-pulsed DC vaccination therapy for patients with relapsed malignant glioma. METHODS: WT1-pulsed and/or autologous tumor lysate-pulsed DC vaccination therapy was performed in patients with relapsed malignant gliomas. Approximately 1 × 10(7) to 2 × 10(7) pulsed DCs loaded with WT1 peptide antigen and/or tumor lysate were intradermally injected into the axillary areas with OK-432, a streptococcal preparation, at 2-week intervals for at least 5-7 sessions (1 course) during an individual chemotherapy regimen. RESULTS: Ten patients (3 men, 7 women; age range 24-64 years [median 39 years]) with the following tumors were enrolled: glioblastoma (6), anaplastic astrocytoma (2), anaplastic oligoastrocytoma (1), and anaplastic oligodendroglioma (1). Modified WT1 peptide-pulsed DC vaccine was administered to 7 patients, tumor lysate-pulsed DC vaccine to 2 patients, and both tumor lysate-pulsed and WT1-pulsed DC vaccine to 1 patient. The clinical response was stable disease in 5 patients with WT1-pulsed DC vaccination. In 2 of 5 patients with stable disease, neurological findings improved, and MR images showed tumor shrinkage. No serious adverse events occurred except Grade 1-2 erythema at the injection sites. WT1 tetramer analysis detected WT1-reactive cytotoxic T cells after vaccination in patients treated with WT1-pulsed therapy. Positivity for skin reaction at the injection sites was 80% (8 of 10 patients) after the first session, and positivity remained for these 8 patients after the final session. CONCLUSIONS: This study of WT1-pulsed DC vaccination therapy demonstrated safety, immunogenicity, and feasibility in the management of relapsed malignant gliomas.

Hematogenous extraneural metastasis of the germinomatous component of a pineal mixed germ cell tumor.

A 23-year-old man presented with a mass in the pineal region and obstructive hydrocephalus. A neuroendoscopicbiopsy for the lesion, ventriculoperitoneal (VP)shunting, and focal irradiation were conducted as initial treatment. Histological diagnosis of the biopsy specimen was germinoma. He underwent further irradiation and two tumor resections. Histological diagnosis was mature teratoma without a germinomatous component. After serial treatments, the intracranial lesion was controlled. However,14 months after presentation, extraneural lesions were confirmed in the posterior mediastinum and retroperitoneal space. The biopsy specimen of the retroperitoneal space lesion was histologically diagnosed as germinoma. Although chemotherapy with cisplatin and etoposide was undertaken,extraneural lesions ware uncontrollable and he died. At autopsy, extraneural lesions were confirmed in the posterior mediastinum, retroperitoneal space, and right lung. Histological diagnosis of extraneural lesions was germinoma.This case was considered to be a pineal mixed germ cell tumor mainly consisting of germinoma and mature teratoma,which caused hematogenous metastasis of the germinoma component. Systemic chemotherapy and irradiation for primary lesions as an initial treatment is important to cure the primary lesion and prevent extraneural metastasis.

Comparison of manual and digital microvascular density counting of RECK expression in glioma.

A microvascular density (MVD) counting method for reversion-inducing cysteine-rich protein with Kazal motifs (RECK) expression, using a digital image analysis tool, has advantages over manual counting by microscope. Thirty glioma cases with RECK staining were photographed at a magnification of 200× high power field and the photographs in RGB images were analyzed, and stained vessels were captured and were counted automatically. MVD with RECK expression using a digital image analysis tool showed comparable results to those of the manual method. RECK intensity expression could show linear correlation with grades of glioma by the digital method, which was superior compared to the manual method. The present method is recommended to researchers undertaking MVD study for glioma.

Expression of RECK in endothelial cells of glioma: comparison with CD34 and VEGF expressions.

Angiogenesis is thought to be involved in the progression of glioma grades, and reversion-inducing cysteine-rich protein with Kazal motifs (RECK) has been said to be involved in maturation of vessels. In this study, we aimed to determine whether high micro-vessel density (MVD) expressed by RECK in glioma tissue is correlated with grades of glioma. We also compared RECK expression with that of the formerly known vessel marker, CD34, and vascular endothelial growth factor (VEGF). RECK, CD34, and VEGF immuno-reactivities of 72 glioma tissues were studied. RECK was seen in microvessels of glioma tissues. CD34 showed a similar pattern to RECK, whereas VEGF showed positive staining in cytoplasm of tumor cells and endothelial cells. Average MVD with RECK was 107.6 microvessels (range 7-290). RECK was positively correlated with grades of glioma. RECK and CD34 also showed a strong correlation (P = 0.001). Higher frequency of VEGF staining was also correlated with higher grade of glioma. This is the first study describing expression of RECK in glioma, and its angiogenesis-related nature may provide a potential therapeutic target for glioma treatment in the future.

"Kissing" brainstem cavernous angiomas removed using a trans-fourth ventricular floor approach--case report.

A 39-year-old woman presented with a rare case of "kissing" brainstem cavernomas formed by separate lesions enlarging with simultaneous recurrent hemorrhages, which was successfully treated by staged resection using a trans-fourth ventricular floor approach. She had a familial history of cerebral cavernous angioma, and presented with a history of four episodes of sudden neurological deterioration. Magnetic resonance (MR) imaging obtained at each neurological event demonstrated two distinct brainstem cavernomas located in the pontine tegmentum and ventral part of the lower pons, both of which enlarged stepwise caused by simultaneous recurrent hemorrhages. Both cavernomas contacted and formed "kissing" lesions. She underwent midline suboccipital craniotomy in the prone position. The cavernoma in the pontine tegmentum was resected through a trans-fourth ventricular floor approach. Although "kissing" formation appeared on preoperative MR imaging, parenchyma was identified at the bottom of the removal cavity of the dorsal lesion, and resection was terminated. MR imaging following the first surgery revealed complete resection of the pontine tegmentum cavernoma and the ventral pontine cavernoma, which was located adjacent to the bottom of the removal cavity and aligned in same direction along the fourth ventricular floor approach. At 10 days after first surgery, she underwent the same procedure with the aid of neuronavigation to resect the ventral pontine cavernoma through the former removal cavity. This approach through the previous removal route, particularly for resection of "kissing" lesions which are difficult to access in the brainstem, is a technically feasible microsurgical procedure.

Gliosarcoma arising from a fibrillary astrocytoma.

We report a 67-year-old woman who was diagnosed with a gliosarcoma at a second operation after diagnosis of a fibrillary astrocytoma 5 months previously. Initially, she underwent a CT-guided stereotactic biopsy. Histological examination showed fibrillary astrocytoma (World Health Organization [WHO] grade II). Loss of heterozygosity (LOH) on 1p, 10q, and 19q was not detected. She received chemotherapy, but no radiotherapy. Five months after the biopsy, MRI revealed rapid tumor growth. Tissue obtained from partial removal of the tumor revealed gliosarcoma (WHO grade IV), and LOH on 10q and 19q was detected. The history, histopathology, and genetic alterations of this patient are discussed.

Pituitary abscess manifesting as meningitis and photophobia associated with Rathke's cleft cyst in a child. Case report.

A 12-year-old girl presented with complaints of headache, lethargy, photophobia, and fever. Cerebrospinal fluid examination revealed bacterial meningitis. Magnetic resonance (MR) imaging showed a cystic lesion with peripheral enhancement in the pituitary fossa. The patient underwent transnasal-transsphenoidal surgery (TSS). The diagnosis was pituitary abscess associated with Rathke's cleft cyst. Postoperatively, the patient recovered rapidly. However, recurrence of the pituitary abscess causing meningitis occurred four times and required repeated TSS. She had diabetes insipidus and received hormone replacement. This case requiring repeated emergency surgeries shows that follow-up examinations including MR imaging and pituitary endocrine evaluation are necessary because the rate of recurrence is high in patients with pituitary abscess associated with Rathke's cleft cyst.

Three-dimensional magnetic resonance imaging based on time-of-flight magnetic resonance angiography for superficial cerebral arteriovenous malformation--technical note.

Direct surgery remains important for the treatment of superficial cerebral arteriovenous malformation (AVM). Surgical planning on the basis of careful analysis from various neuroimaging modalities can aid in resection of superficial AVM with favorable outcome. Three-dimensional (3D) magnetic resonance (MR) imaging reconstructed from time-of-flight (TOF) MR angiography was developed as an adjunctive tool for surgical planning of superficial AVM. 3-T TOF MR imaging without contrast medium was performed preoperatively in patients with superficial AVM. The images were imported into OsiriX imaging software and the 3D reconstructed MR image was produced using the volume rendering method. This 3D MR image could clearly visualize the surface angioarchitecture of the AVM with the surrounding brain on a single image, and clarified feeding arteries including draining veins and the relationship with sulci or fissures surrounding the nidus. 3D MR image of the whole AVM angioarchitecture was also displayed by skeletonization of the surrounding brain. Preoperative 3D MR image corresponded to the intraoperative view. Feeders on the brain surface were easily confirmed and obliterated during surgery, with the aid of the 3D MR images. 3D MR imaging for surgical planning of superficial AVM is simple and noninvasive to perform, enhances intraoperative orientation, and is helpful for successful resection.

Spontaneous regression of multicentric pilocytic astrocytoma with CSF dissemination in an adult.

We present a case of spontaneous regression of multicentric pilocytic astrocytoma with cerebrospinal fluid (CSF) dissemination without neurofibromatosis type 1 (NF1) in an adult, the first such case reported. Magnetic resonance imaging (MRI) showed multiple low signal intensity lesions on T1-weighted images and high signal intensity areas on T2-weighted images in the bilateral thalamus, basal ganglia and midbrain. Contrast-enhanced MRI revealed that small, enhanced lesions were seen in the basal ganglia and the pineal region. Neuroendoscopic biopsy and third ventriculostomy were performed. Intraoperative findings demonstrated CSF dissemination. Histologically, the specimens showed pilocytic astrocytoma. Serial MRIs showed regression of the tumor without any additional treatment. The clinical features of spontaneous regression of pilocytic astrocytoma are discussed.

[Application of a polyethylene glycol hydrogel sealant system to prevent CSF leakage for lumbar intradural surgery: technical case report].

Postoperative cerebrospinal fluid (CSF) leakage is one of the most important surgical complications in spinal surgery. Particularly in intradural spinal cord tumor surgery, it is very important to prevent CSF leakage postoperatively, as it can lead to postoperative complications such as infection and pseudomeningocele formation. Compared to the intracranial region, as the operative field is narrower and the structure of the dura mater is more fragile in the spinal region, meticulous dural suturing is sometimes impossible after intradural procedures. To prevent CSF leakage, some surgical procedures and materials have been developed in the neurosurgical field, including the recently introduced polyethylene glycol-based hydrogel sealant system. The hydrogel sealant system consists of synthetic absorbable material, which eliminates the risk of viral transmission and reduces the risk of allergic reaction. It proved to have potential for reducing postoperative CSF leakage. We used this material in intradural lumbar lesion surgery, and postoperative CSF leakage did not occur with this surgical procedure. We report our experience with dural plasty using the hydrogel sealant system in the intradural lumbar spinal lesion surgery and discuss the usefulness of this material.

Solitary metastatic cauda equina tumor from breast cancer -case report-.

A 45-year-old woman presented with a rare case of metastatic cauda equina tumor from breast cancer without spinal column or brain metastasis. She had undergone resection of breast cancer 4 years previously. She presented with a 2-month history of severe low back pain. Magnetic resonance imaging showed a well-enhanced intradural extramedullary mass at the L1 level without other intradural lesions. At surgery, the tumor was partially removed to preserve the nerve root function under electrophysiological monitoring. The histological diagnosis was adenocarcinoma. The tumor was located in the subarachnoid space, suggesting hematogenous metastasis from the breast cancer. Postoperatively the pain subsided and no neurological deficit occurred. She underwent adjuvant therapy and rehabilitation. Cauda equina tumors may be relatively progressive regardless of imaging findings and clinical symptoms, so preoperative systemic investigation should be conducted, considering the possibility of metastatic tumor. A comprehensive therapeutic strategy involving adjuvant therapy after surgery is important to establish, considering the preservation of postoperative nerve function.