Author(s): Abed Agbarya, Zaki el Zagzoug, Fadi Atrash , Prof. Dr. Bowirrat Abdalla

An otherwise healthy 44 - year-old female, was referred to the emergency department at the European Gaza Hospital in January 2009 for Dizziness, headache and Nausea. MRI was done and showed large left fronto-parietal cerebral space-occupying lesions with large lobulated cystic like lesion with ring enhanced wall and solid enhanced inter cystic component, measuring globally 5x6.5 x5 cm in the cranio-caudal, anteroposterior and transverse diameters respectively. Glioblastoma was highly suspected (Panel A, arrow). The patient underwent surgical resection and no post-operative radiotherapy was given due to shortage in equipment but a specimen was taken. The patient’s condition did not improve and right side hemeparesis and dysarthria was observed. Biopsy showed cellular Ependymoma composed of delicate network of small blood vessels and of closely packed polygonal cells having marked pleomorphism, irregular nuclei and moderate amount of eosinophilic cytoplasm, chromatin was diffusely basophilic, prominent nucleoli, there are no mitotic figures, the tumor cells arranged around and attached to the central blood vessels forming pseudorosettes and no vascular invasion were examined. In February 2009, the patient underwent second surgical resection, pathological examination showed cellular Ependymoma. On May 2009 the patient referred to Augusta Victoria Hospital (AVH), Jerusalem, where she received radiotherapy (the dose was above 45-50 Gy), she finished her radiotherapy on July 2009 and returned to Gaza with relatively good condition. On December 2012 the patient presented with fungating mass at left partial region, complete excision was done on January 2013, tissue was sent for pathology which showed Epandymoma grade- III (reported by Al-Shifa Hospital, Gaza on February 2013). On March 2013 the patient complained from dyspnea and CT scan was done and showed seeding Epenyemoma metastasis to the left cerebral hemisphere, left upper neck lymphoadenopathy and right lung nodules was observed (Panel B). On April 2013 the patient referred again to AVH for chemotherapy but she received radiotherapy 25 fractions to head and Left neck alone, she was presented with bleeding fungating mass about 4X4 cm, and left neck lymph nodes enlargement. On May 2013 biopsy was taken from the mass the blocks was sent to the Nazareth hospital’s lab and showed metastatic ependymoma (Panel C, D). On August 2013 the patient condition deteriorated sharply with severe dyspnea and she was confined to bed. She died on November 2013