Kikkawa Yuichiro, Nakamizo Akira, Suzuki Satoshi O, Tanaka Shunya, Tsuchimochi Ryosuke, Amano Toshiyuki, Yoshimoto Koji, Mizoguchi Masahiro, Iwaki Toru, Sasaki Tomio
Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
Surg Neurol Int. 2012;3:78. doi: 10.4103/2152-7806.98518. Epub 2012 Jul 14.
Surgical treatment of endodermal cysts requires total removal of the cyst wall during the first operation to prevent recurrence. Therefore, intraoperative pathological diagnosis plays an important role in determining the optimal surgical strategy. We present a rare case of a spinal endodermal cyst and discuss its diagnostic difficulty during the intraoperative pathological examination.
An 18-year-old male presented with progressive paraparesis and precordial oppression. Magnetic resonance (MR) imaging revealed an intradural extramedullary cystic mass having the same signal intensity as cerebrospinal fluid (CSF) without gadolinium enhancement at the T1-T2 level. The preoperative diagnosis was an endodermal or arachnoid cyst. The patient underwent surgery. An intraoperative frozen section showed a cyst wall consisting of loose, thin, fibrous tissue intermittently covered by flattened epithelium. The diagnosis was an arachnoid cyst. Accordingly, partial resection of the cyst wall was performed to create CSF communication between the cyst and subarachnoid space. However, the postoperative pathological diagnosis from permanent sections was an endodermal cyst, which was lined with ciliated columnar epithelium that was immunopositive for cytokeratin and epithelial membrane antigen. Subsequent paraffin embedding and immunostaining of the intraoperative frozen sample also confirmed patchy cytokeratin expression by all flattened epithelial cells. The patient's cyst had refilled 10 months after surgery, and he subsequently underwent fenestration of the cyst wall and placement of a cyst-subarachnoid shunt.
Examination of multiple samples from multiple sites or intraoperative immunostaining of frozen sections is recommended for accurate intraoperative diagnosis of endodermal cysts.
内胚层囊肿的手术治疗需要在首次手术时完全切除囊肿壁以防止复发。因此，术中病理诊断在确定最佳手术策略中起着重要作用。我们报告一例罕见的脊柱内胚层囊肿病例，并讨论其在术中病理检查时的诊断困难。
一名18岁男性，出现进行性双下肢轻瘫和心前区压迫感。磁共振成像显示在T1 - T2水平有一个硬膜内髓外囊性肿块，其信号强度与脑脊液相同，钆增强扫描无强化。术前诊断为内胚层或蛛网膜囊肿。患者接受了手术。术中冰冻切片显示囊肿壁由疏松、薄的纤维组织构成，其间断被扁平上皮覆盖。诊断为蛛网膜囊肿。因此，对囊肿壁进行了部分切除，以使囊肿与蛛网膜下腔建立脑脊液交通。然而，永久切片的术后病理诊断为内胚层囊肿，内衬纤毛柱状上皮，细胞角蛋白和上皮膜抗原免疫阳性。随后对术中冰冻样本进行石蜡包埋和免疫染色也证实所有扁平上皮细胞均有散在的细胞角蛋白表达。患者的囊肿在术后10个月复发，随后他接受了囊肿壁开窗术并置入囊肿 - 蛛网膜下腔分流管。
对于内胚层囊肿的准确术中诊断，建议从多个部位取多个样本进行检查或对冰冻切片进行术中免疫染色。
