Myxopapillary Ependymoma¶

Definition¶

Myxopapillary ependymoma is a slow-growing, WHO grade II variant of ependymoma that arises almost exclusively from the filum terminale at the conus medullaris. It is the most common tumor of the filum terminale and cauda equina region. Despite its low-grade histology, it can disseminate through the CSF (drop metastases).

Imaging Findings¶

MRI¶

Location — Intradural extramedullary mass at the conus medullaris and filum terminale, centered in the lumbar or lumbosacral thecal sac
T1-weighted — Isointense to hyperintense (may be bright due to mucin or hemorrhage)
T2-weighted — Hyperintense, well-defined, lobulated mass
Enhancement — Intense, homogeneous enhancement
Hemorrhage — Hemosiderin staining or hemorrhage may produce heterogeneous signal
Scalloping — May cause posterior vertebral body scalloping from chronic pressure
CSF dissemination — Evaluate the entire spine for drop metastases (enhancing nodules on cord or roots)

CT Myelography¶

Intradural mass creating a filling defect in the contrast column at the conus/cauda level

Clinical Pearl

A well-defined, avidly enhancing mass at the conus medullaris/filum terminale in a young adult is myxopapillary ependymoma until proven otherwise. Despite being classified as "low grade," it has a significant propensity for CSF dissemination — whole-spine MRI with contrast should be performed for staging.

Demographics¶

Peak incidence in young adults (age 20–40)
Slight male predominance
Most common tumor of the cauda equina/filum terminale

Management¶

En bloc surgical resection is the treatment of choice
Piecemeal resection has a higher recurrence rate and risk of CSF dissemination
Radiation therapy for recurrence or incomplete resection
Long-term follow-up with whole-spine MRI is essential

Key Points¶

Most common tumor of the filum terminale/cauda equina
Located at the conus medullaris in young adults
Intensely enhancing, well-defined intradural mass
Can disseminate via CSF despite low-grade histology — whole-spine staging MRI is essential
En bloc resection reduces recurrence risk compared to piecemeal removal

References¶

Gaillard F, Murphy A, et al. Myxopapillary ependymoma. Radiopaedia.org. Available from: https://radiopaedia.org/articles/myxopapillary-ependymoma-1
Limaiem F, Das JM. Myxopapillary Ependymoma. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559172/
Kresbach C, Neyazi S, Schüller U. Updates in the classification of ependymal neoplasms: the 2021 WHO Classification and beyond. Brain Pathol. 2022;32(4):e13068.
Wippold FJ 2nd, Smirniotopoulos JG, Moran CJ, Suojanen JN, Vollmer DG. MR imaging of myxopapillary ependymoma: findings and value to determine extent of tumor and its relation to intraspinal structures. AJR Am J Roentgenol. 1995;165(5):1263-7.
Soto CJ, Novick SD, Poojita ANL, Khan S, Khan MW, Holder SS. Spinal myxopapillary ependymoma: a rare case and review of management strategies. Cureus. 2023;15(5):e39381.