Dr. Ali Chahlavi joins XenRounds to review a fascinating case

Added: 2026-05-28

[00:00:00]There are moments in medicine where the images stop you cold. Not because they're dramatic, not because they're bloody, because they make no sense.

[00:00:08]Congenital lesion present since birth.

[00:00:12]Quite for 56 years, then suddenly pain, weakness, neurological decline, and inside the seemingly dominant spinal defect, a cancer no one had ever seen before. An angio saroma inside a mining seal. This shouldn't happen. And yet it did. I'm Dr. Ali Shalavi, neurosurgeon and director of neuroscience at Ascension San Vincent in Jacksonville, Florida. And this is Zen Rounds by Zenko Medical.

[00:00:43]The story presented by Wang Kang and Chan begins with a 56-year-old man carrying a congenital lumbosacral mass for essentially his entire life. Imagine that for a moment. Not a tumor, not an infection, a defect, a developmental mistake made only weeks after conception. And yet for decades, the patient adapted. Humans are extraordinarily good at adapting. We normalize discomfort. We normalize asymmetry. We normalize survival. But according to the authors, over the course of a single year, the patient began developing progressive low back pain, weakness, numbness, and sensory changes in the left leg. And if you're a spine surgeon listening to this, your instincts immediately begin to sharpen because congenital lesions are usually stable.

[00:01:41]When they change rapidly, biology has changed.

[00:01:46]To understand what happens here, we need to rewind all the way back to embryology, which honestly is where some of the strangest stories in neurosurgery began. As Wang and colleague explained, the patient suffered from a spinal drafism involving a congenital menosil. A meno seal occurs when the meninges the protective covering surrounding the spinal cord herniate outward toward a defect in the spine forming a fluid fil sack. Usually these are repaired early in life. This one wasn't. In over 56 years, the lesion became something almost geological, layered, chronically stressed, inflamed, mechanically irritated, a biological time capsule. Then came the imaging and this is where the case described by Wang Kang and Chan starts to feel almost cinematic. The X-rays revealed scoliosis twisting through the thoracic and lumbar spine, congenital vertebral fusion, and a dense protrusion in the lumbar sacral region. Already unusual, but the CT scan revealed something even more extraordinary.

[00:03:13]Diasta meta myelia a split spinal cord which sounds almost fictional but it's real imagine the spinal cord divided longitudinally by a bony septum one cord becoming two embryology gone off script now add to that a tether cord congenital fusion spinal drafism and a meningosil extending ing posteriorly through the skin. The patient's spine wasn't just abnormal. It was a living map of interrupted embryological development.

[00:03:54]And then the MRI, every radiologist knows this feeling. You look at an image and then your brain says something about this isn't benign. According to the report, the lesion demonstrated heterogeneous signal intensity, irregular enhancement, and a mixed tissue characteristics.

[00:04:14]Not smooth, not quiet, not stable. It looked biologically active. And here is one of the fascinating truths about medicine. Your eyes often knows before your words do, before pathology, before diagnosis.

[00:04:30]Sometimes your subconscious recognizes danger first.

[00:04:35]The biopsy changed everything. As Wang and colleagues described, hisystologology demonstrated sheets of atypical epithelial cells with hyperchromatic nuclei, mitoic figures and irregular vascular channels.

[00:04:51]Iohischemistry showed positivity for CD31 and flee 1.

[00:04:57]The diagnosis epithelioid angio saroma. Not if you're not.

[00:05:04]Now, if you're not in oncology or neurosurgery, let me translate what that means. This is a rare malignant tumor arising from endothelial cells, the cells lining blood vessels. And biologically, it is vicious, fast growing, aggressive, highly invasive, the kind of tumor that seems to operate with urgency.

[00:05:30]And here is where the case becomes historically important. The authors performed a literature review and identified only 15 previously reported malignancies arising from meningo seals or milo meningoils.

[00:05:47]15 across decades of global neurosurgical and oncological literature most were squamus cell carcinomaomas.

[00:05:57]one adino carcinoma, one liomyio saroma.

[00:06:01]But according to Wang, Kang and Chen, this was the first documented case of epithelioid angiocaroma arising from a congenital lumbocral mining seal. Which means somewhere in the medical history, this happened for the first time or at least the first time anyone recognized it and described it. And this raises the central mystery of the case. How does congenital anatomy transform into malignant biology? The authors propose chronic inflammation and persistent irritation of a possible mechanism.

[00:06:37]And fascinatingly, that theory connects this rare case of some of the deeper principles in cancer biology because cancer often emerges where tissue is chronically injured.

[00:06:52]Think about it. Chronic hepatitis leading to liver cancer. Barrett's esophagus leading to esophageal adocarcinoma.

[00:07:02]Ulcerative colitis leading to colon cancer. Persistent inflammation changes tissue behavior. DNA damage accumulates.

[00:07:12]Repair mechanisms destabilize.

[00:07:15]Cells adapt until adapt adaptation becomes mutation. Now imagine 56 years of mechanical pressure, chronic irritation, altered vascularity, and congenital structural instability. That lesion was not dormant. It was evolving slowly, silently for decades. And perhaps the most unsettling detail highlighting by Wang and colleagues is this. The overlying skin remained intact. No ulceration, no draining sinus, no obvious external wound.

[00:07:50]Historically, malignant transformation in these lesions was often associated with chronic ulceration or infection, but not here. This suggests that profound inflammatory and oncoenic process can occur beneath apparently preserved tissue. Invisible pathology, invisible evolution, invisible danger until symptoms finally forces the body to reveal the truth. The surgical team performed the excision of the menango seal, tethered cord release and dural repair. Now technically this is extraordinarily complex surgery.

[00:08:29]Congenital anatomy distorts normal tissue planes. Neural structures may not exist where you expect them to. Scar tissue accumulates over decades and angio saroma introduces another challenge entirely bleeding. These tumors are vascular, fragile, infiltrative.

[00:08:50]The operations become part oncological.

[00:08:56]Sorry, repeat. The operation becomes part of oncologic surgery and part reconstructive embryology. But despite surgery, the biology itself is declared quickly. Repeat, the biology declared itself quickly. 3 months later, the tumor recurred. MRI demonstrated recurrent enhancing tissue within the spinal canal and parispinal region.

[00:09:24]According to the report, the patient subsequently underwent VMAT radiotherapy along with a targeted therapy using an low tinip chemotherapy and interestingly follow-up imaging demonstrating regression of the lesion.

[00:09:45]For a moment, the medicine appeared to work and this is one of the emotional realities of oncology. Sometimes imaging improves long before prognosis does.

[00:09:58]Despite treatment, the patient ultimately died approximately one year after surgery. And there is something heartbreaking about that timeline. He survived with a congenital defect for six for 56 years, but after malignant transformation only one.

[00:10:18]What makes this publication by Wang Kang and Chen so important is that it expands medicine's imagination.

[00:10:26]It reminds us that congenital disease is not static, that chronic inflammation can create entirely new biological behavior and that rare cases are often where science learns the most. The authors ultimately emphasize vigilance and early recognition, rapid growth, pain, neurological decline, injuration. These changes demand biopsy, demand urgency because sometimes the rarest diagnosis is the correct one. I think what fascinates me most about this story is that it blurs boundaries between congenital disease and cancer, between embryology and oncology, between adaptation and uh catastrophe.

[00:11:14]For 56 years, this lesion was simply part of the patient's anatomy. Then one day, it became a predator. And somewhere inside that transformation lies a biological process. We still do not fully understand that what keeps medicine endlessly humbling. No matter how advanced our imaging becomes, the human body still holds mysteries. I'm Dr. Ali Shalabi and this has been Zen Rounds by Zenko Medical. Where grand rounds meets storytelling, where science becomes human and where their rarest cases reveal the deepest truth. Thank you.