Pilomyxoid astrocytoma presenting as diencephalic syndrome

We report the case of a child who presented with diencephalic syndrome. During diagnostic work- up, he was found to have a supra-sellar hypothalamic tumour. Histopathological examination of the tumour revealed it to be pilomyxoid astrocytoma, which is a WHO grade-II tumour, previously considered to be part of the spectrum of WHO grade-I pilocytic astrocytomas. However, because of its characteristic histopathology and behaviour, it was later segregated from pilocytic astrocytomas. In this case report, we discuss the cytological and histopathological features of this tumor with the aim of increasing awareness of this tumour amongst general histopathologists, to highlight the importance of its differentiation from pilocytic astrocytomas in view of its different behaviour, treatment and prognosis and that it should be included in the differential diagnosis of diencephalic syndrome.

Ecthyma gangrenosum caused by Pseudomonas aeruginosa in a patient with astrocytoma treated with chemotherapy

Ecthyma gangrenosum, presenting as embolic lesions caused by Pseudomonas aeruginosa infection, has distinct pathognomonic features and a high mortality rate in patients with bacteremia, but when recognized early is easily treated. In this case report we describe this disseminated infection in an adult patient treated with chemotherapy for an astrocytoma.

Rare cases of reflex epilepsy in patients with gliomas of the left hemisphere

We present the cases of symptomatic reflex epilepsy in patients with left hemisphere tumors. The first case: a 23-year-old man has had tonic-clonic seizures of the tongue with rare secondary localization over the past several months. The seizures were caused by intense tongue movements, in particular rightward and leftward (when having chewing gum or a candy in his mouth), but not during speech production or eating. MRI scanning detected a small tumor in the lower segments of the central gyrus. It was found during the surgery under electrophysiological control that the tumor (Gr II astrocytoma) resided in the zone corresponding to the right half of the tongue and included this zone. The tumor was partially resected. The second patient, a 52-year-old man, has been suffering from generalized seizures since 1998. The seizures were caused by intense verbal load, in the beginning of spontaneous speech and subsequently when the patient was listening to others' speech or was writing. Spontaneous seizures emerged when the patient stopped taking his anti-seizure medications unilaterally. MRI showed glioma in the posterior segments of the left temporal lobe. The patient underwent radiation and chemotherapy. In 2013, the patient's condition worsened (right-sided hemiparesis and severe speech impairment emerged); the tumor was partially resected and an extensive cyst was opened. The third patient, a 38-year-old man with Gr III astrocytoma in the left insula with past medical history of spontaneous vegetative seizures, had only a seizure anticipation caused by strong smells. All the patients were prescribed chemo-, radiation, and anti-seizure therapy.

Protein-protein interaction network analysis and gene set enrichment analysis in epilepsy patients with brain cancer

Many patients with brain cancer experience seizures or epilepsy and tumor-associated epilepsy (TAE) significantly decreases their quality of life. This study aimed to achieve a better understanding of the mechanisms of TAE. The differentially expressed genes (DEG) between epilepsy patients with or without brain tumor were firstly screened using the Linear Models for Microarray Data package using GSE4290 datasets from the USA National Center for Biotechnology Information Gene Expression Omnibus database. Then the protein-protein interaction (PPI) network, using data from the Human Protein Reference Database and the Biological General Repository for Interaction Datasets, was constructed. For further analysis, the PPI network structure and clusters in this PPI network were identified by ClusterOne. Meanwhile, gene set enrichment analysis was performed to illuminate the biological pathways and processes which generally affect patients with TAE. A total of 5113 DEG were identified and a PPI network, which contained 114 DEG and 21 normal genes, was established. Proteins, which mainly belonged to the mini chromosome maintenance and collagen families, were discovered to be enriched in the three identified clusters in the PPI network. Finally, several biological pathways (including cell cycle, DNA replication and transforming growth factor β1 signaling pathways) and processes (such as nucleocytoplasmic transport, nuclear transport and regulation of phosphorylation) were identified. Proteins in these three clusters may become new targets for TAE treatment. Our results provide some potential underlying biomarkers for understanding the pathogenesis of epilepsy in patients with brain tumor.

[Management of obstructive hydrocephalus before posterior fossa tumor resection in children]

OBJECTIVE

To explore the management of obstructive hydrocephalus caused by posterior fossa tumors before tumor resection in children.

METHODS

The clinical data were reviewed of 162 pediatric patients of posterior fossa tumors with obstructive hydrocephalus undergoing surgical tumor removal between January 2008 and June 2012. Ninety children received preoperative Ommaya external drainage (group A) and 72 underwent preoperative ventriculo-peritoneal shunting (V-Ps) (group B). The therapeutic effects were evaluated and compared between the two groups.

RESULTS

Postoperative complications found in a total of 67 cases including infection (27), shunt blockage (19), subdural hematoma or effusion (16), ventricle fissure syndrome (5), and tumor hernia (4). Significant differences were found in the incidences of shunt blockage (P=0.047) and subdural hematoma or effusion (P=0.039) but not in the incidences of intracranial infection (P=0.478) or tumor hernia (P=0.462) between the two groups.

CONCLUSION

Ommaya reservoir can produce good results through simple surgical procedures for treatment of acute hydrocephalus in children with posterior fossa tumors and is associated less trauma and complications.

Split laminotomy and complementary spacer insertion for opening and enlargement of the thoracic spinal canal at infiltrative intramedullary tumor removal

OBJECTIVE

The author main objective was to improve the previously developed technique of split laminotomy and moderate enlargement of the spinal canal with preservation of the majority of posterior structures, and to avoid the complications of the classic autologous bone grafting procedure.

METHODS

A multilevel spinous process splitting and distracting laminotomy technique with complementary spacer insertion between the laminar parts was developed. We used Poly-Ether-Ether-Ketone (PEEK) cages. This improved method was used in five patients to remove malignant intramedullary tumors at the thoracic level.

RESULTS

Adequate surgery of the tumors located intramedullary, and permanent decompression of the spinal canal was achieved in all patients using our new modified procedure. The results have been postoperatively confirmed with MRI and CT. The affected spine was the thoracic in all cases. The numbers of split laminae were three to five. Histological results were as follows: four intramedullary astrocytomas, one ependymoma. The ependymoma was completely, while the astrocytomas were only subtotally removed. In all cases heterologous grafts were inserted between the sides of the distracted laminas, to achieve the enlargement of the spinal canal. The mean duration of the whole surgical procedure was 118 minutes (range 91 to 145 minutes). The average follow-up was 11.2 months, with the range from five to 16 months. Upon postoperative neurological follow-up, no complications were revealed related to the newly developed procedure. The postoperative followup CT scans demonstrated bony healing, with a cage between the osteotomized faces. No compression or dislocation of the spacer was seen. Instability was not detected in any of the patients by flexion or extension lateral radiographs.

CONCLUSION

This modification of the split laminotomy and heterologous grafting method fulfills the requirements of other laminotomy techniques. The split laminotomy is suitable for removing intramedullary tumors, and the posterior stabilizing structures of the spine, as the vertebral laminae and the longitudinal musculature are completely prevented. Due to use of allograft the complications of the classic hip bone grafting procedures are avoided. The spacers, inserted between the osteotomized faces, provided permanent decompression of the spinal canal, and bony healing--throughout the spacer--of the splitted vertebral laminae, without iliac graft complications.

[Control of epilepsy in adult patients with tuberous sclerosis]

INTRODUCTION

Tuberous sclerosis is a genetic disease, the main manifestations of which are the formation of neuroectodermal tumours, which are very often associated to secondary epilepsy.

AIM

To describe the epileptic profile, control, frequency of seizures and effectiveness of treatment in adult patients with tuberous sclerosis.

PATIENTS AND METHODS

The study was descriptive and included adult patients (over 14 years of age) with a confirmed diagnosis of tuberous sclerosis. Both the frequency and type of seizures were analysed. A study was conducted to analyse and record the number of different antiepileptic drugs in each patient and the frequency of use of each active ingredient, and the control of seizures and the type of therapy were also included in another comparative study.

RESULTS

Of a total of 19 adults who were studied, 16 of them (84%) had epileptic seizures. Results showed that 44%, 25% and 31% of them presented full control of seizures, sporadic seizures and frequent seizures, respectively. A certain frequency of focal, general and both types of seizures existed in 38%, 6% and 25%, respectively. Likewise, 38%, 44% and 19% of them were under treatment with antiepileptic drugs in monotherapy, bitherapy and tritherapy, respectively. Overall, the most commonly consumed drug was levetiracetam, followed by carbamazepine and valproic acid. In monotherapy the most common was carbamazepine, with a higher proportion of full control.

CONCLUSIONS

Epilepsy in tuberous sclerosis is relatively benign and an acceptable degree of control is achieved in most cases with a number of the antiepileptic drugs recommended in the treatment guidelines. In our series, we observed stability of involvement and there was no progression to a malignant status. The small number of individuals in the sample limits the study, but the proportions of treatment effectiveness are seen to be similar to those observed in another series published in the literature.

Deaths among adult patients with hypopituitarism: hypocortisolism during acute stress, and de novo malignant brain tumors contribute to an increased mortality

CONTEXT

Patients with hypopituitarism have an increased standardized mortality rate. The basis for this has not been fully clarified.

OBJECTIVE

To investigate in detail the cause of death in a large cohort of patients with hypopituitarism subjected to long-term follow-up.

DESIGN AND METHODS

All-cause and cause-specific mortality in 1286 Swedish patients with hypopituitarism prospectively monitored in KIMS (Pfizer International Metabolic Database) 1995-2009 were compared to general population data in the Swedish National Cause of Death Registry. In addition, events reported in KIMS, medical records, and postmortem reports were reviewed.

MAIN OUTCOME MEASURES

Standardized mortality ratios (SMR) were calculated, with stratification for gender, attained age, and calendar year during follow-up.

RESULTS

An excess mortality was found, 120 deaths vs 84.3 expected, SMR 1.42 (95% confidence interval: 1.18-1.70). Infections, brain cancer, and sudden death were associated with significantly increased SMRs (6.32, 9.40, and 4.10, respectively). Fifteen patients, all ACTH-deficient, died from infections. Eight of these patients were considered to be in a state of adrenal crisis in connection with death (medical reports and post-mortem examinations). Another 8 patients died from de novo malignant brain tumors, 6 of which had had a benign pituitary lesion at baseline. Six of these 8 subjects had received prior radiation therapy.

CONCLUSION

Two important causes of excess mortality were identified: first, adrenal crisis in response to acute stress and intercurrent illness; second, increased risk of a late appearance of de novo malignant brain tumors in patients who previously received radiotherapy. Both of these causes may be in part preventable by changes in the management of pituitary disease.

Short lasting activity-related headaches with sudden onset in children: a case-based reasoning on classification and diagnosis

BACKGROUND

Short lasting headaches related to activity or cough are rare, particularly in childhood, and can be difficult to diagnose, especially in young children who are not able to describe their symptoms. In the literature there are few data on this topic in adults and the paediatric cases reported are even more rare.

FINDINGS

We present the clinical history of a 7-year-old child and a 3-year-old child both diagnosed as having activity-related headaches, characterized by sudden onset of short lasting (few seconds) attacks, that were triggered by cough or exercise. There were no accompanying symptoms and the neurological examination was normal in both cases. Brain magnetic resonance imaging showed, in the first case, a cerebellar pilocytic astrocytoma and, in the second case, a Chiari 1 malformation. Both cases received an early diagnosis, were surgically treated and had a good prognosis at follow-up.

CONCLUSIONS

When headache has a recent onset, it presents suddenly, and it is triggered by strain, even with normal neurological examination, neuroimaging is mandatory in order to exclude secondary headaches, especially in children.

Efficacy and safety of everolimus for subependymal giant cell astrocytomas associated with tuberous sclerosis complex (EXIST-1): a multicentre, randomised, placebo-controlled phase 3 trial

BACKGROUND

Tuberous sclerosis complex is a genetic disorder leading to constitutive activation of mammalian target of rapamycin (mTOR) and growth of benign tumours in several organs. In the brain, growth of subependymal giant cell astrocytomas can cause life-threatening symptoms--eg, hydrocephalus, requiring surgery. In an open-label, phase 1/2 study, the mTOR inhibitor everolimus substantially and significantly reduced the volume of subependymal giant cell astrocytomas. We assessed the efficacy and safety of everolimus in patients with subependymal giant cell astrocytomas associated with tuberous sclerosis complex.

METHODS

In this double-blind, placebo-controlled, phase 3 trial, patients (aged 0-65 years) in 24 centres in Australia, Belgium, Canada, Germany, the UK, Italy, the Netherlands, Poland, Russian Federation, and the USA were randomly assigned, with an interactive internet-response system, in a 2:1 ratio to oral everolimus 4·5 mg/m(2) per day (titrated to achieve blood trough concentrations of 5-15 ng/mL) or placebo. Eligible patients had a definite diagnosis of tuberous sclerosis complex and at least one lesion with a diameter of 1 cm or greater, and either serial growth of a subependymal giant cell astrocytoma, a new lesion of 1 cm or greater, or new or worsening hydrocephalus. The primary endpoint was the proportion of patients with confirmed response--ie, reduction in target volume of 50% or greater relative to baseline in subependymal giant cell astrocytomas. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00789828.

FINDINGS

117 patients were randomly assigned to everolimus (n=78) or placebo (n=39). 27 (35%) patients in the everolimus group had at least 50% reduction in the volume of subependymal giant cell astrocytomas versus none in the placebo group (difference 35%, 95% CI 15-52; one-sided exact Cochran-Mantel-Haenszel test, p<0·0001). Adverse events were mostly grade 1 or 2; no patients discontinued treatment because of adverse events. The most common adverse events were mouth ulceration (25 [32%] in the everolimus group vs two [5%] in the placebo group), stomatitis (24 [31%] vs eight [21%]), convulsion (18 [23%] vs ten [26%]), and pyrexia (17 [22%] vs six [15%]).

INTERPRETATION

These results support the use of everolimus for subependymal giant cell astrocytomas associated with tuberous sclerosis. Additionally, everolimus might represent a disease-modifying treatment for other aspects of tuberous sclerosis.

FUNDING

Novartis Pharmaceuticals.

Neurofibromatosis type 1 (NF1) associated with tumor of the corpus callosum

INTRODUCTION

Neurofibromatosis type 1 (NF1), one of the most common neurocutaneous disorders, is a multisystemic disease associated with tumors in any organ of the body, especially in the central nervous system and also the peripheral nervous system. Pilocytic astrocytomas have been described in almost all intracranial regions in patients with NF1. However, only a few patients with NF1 and tumor of the corpus callosum have been reported to date.

MATERIAL AND METHODS

An 11-year-old white Spanish boy was evaluated due to a family history of NF1 and low performance test scores in school. He was studied from the neurological and intellectual level points of view.

RESULTS

Magnetic resonance (MR) study revealed a tumor in the anterior-middle portion of the corpus callosum and a Wechsler Intelligence Scale for Children-Revised showed verbal IQ of 92, a performance IQ of 108, and a total IQ of 100. In addition, he showed attention deficit and hyperactivity disorder.

CONCLUSIONS

Tumors of corpus callosum in patients with NF1 are very uncommon. The patient presented in this paper consulted due to family history of NF1, progressive hyperactivity, and below average school performance. The MR study showed tumor in the corpus callosum. Tumor histology was not investigated.

Echography in the diagnosis and follow-up of retinal astrocytoma: case report

The purpose is to show echographic presentation of retinal astrocytoma in Bourneville's disease and the possibilities of clinical and echographic diagnosis and follow-up. In our patient, partial and generalized seizures were the first sign of the disease at the age of 3.5 years. Computed tomography showed hyperdense cerebral lesions and Sabryl medication was efficient in controlling the seizures. At the age of 7, typical retinal mulberry lesions were seen on the fundus bilaterally. Echography revealed solid epiretinal masses of high surface and internal echogenicity casting a shadow on distal structures. There were two parapapillary lesions and one lesion in the periphery on the left eye. Due to permanent Sabryl therapy, perimetry and visual evoked potentials were monitored to show reduced retinal sensitivity in the periphery of both eyes. Facial angiofibrosis developed at the age of 8 years. Regular yearly controls up to the age of 12 were without significant changes in clinical and echographic characteristics. In conclusion, typical echographic presentation of retinal astrocytoma is of great help in differential diagnosis to other intrabulbar massive lesions in childhood, such as retinoblastoma.

Primary spinal cord desmoplastic astrocytoma in an adolescent: a rare tumour at rare site and rare age

We report a case of a non-infantile primary intramedullary spinal cord desmoplastic astrocytoma in an 18-year-old girl who presented with spastic paraparesis. The patient had been unable to run for 1 year. Magnetic resonance imaging of her spine showed an intramedullary solid and cystic heterogeneously enhancing lesion located at T7-T8 level. Partial excision was performed. Histology revealed a desmoplastic astrocytoma. To the best of our knowledge, there is no report on primary desmoplastic astrocytoma of the spinal cord in literature. Nor has such a symptomatic tumour manifesting at the age of 18 years been documented.

[Before you diagnose a patient with a conversion disorder, perform a thorough general medical and neurological examination. Case study]

INTRODUCTION

Dissociative and conversion disorders are classified together according to ICD-10 as states that are not confirmed by the presence of somatic diseases, which they suggest. According to the DSM-IV, both disorders are classified separately. Conversion disorders are a group of psychiatric disorders whose symptoms mimic the presence of malfunction or loss of motor or sensory function, whereas the nature and dynamics of the observed symptoms is not fully explained by the results of objective assessments and consultations, nor is the direct effect of a psychoactive substance. Impaired mental integration of different functions which normally interact simultaneously in the perception of reality and inner experience of the individual is found in dissociative disorders.

AIM

The article describes the case of 25-year old man, in whom after initial suspicion of myasthenia gravis and its exclusion, a diagnosis of conversion disorder was made on the basis of the clinical picture and treatment with an SSRI antidepressant and individual psychotherapy were recommended. No improvement in mental and neurological status after six month therapy resulted in an in-depth diagnostics in a clinical setting and diagnosis of brain stem tumor (aastrocytoma fibrillare).

CONCLUSIONS

(a) Neuroimaging is a source of important clinical data and in many cases should constitute an inherent element of a psychiatric diagnosis. (b) Diagnosis of conversion (dissociative) disorders requires a precise differential diagnosis, excluding the somatic causes of observed neurological ailments. (c) A late diagnosis of neurological or somatic causes of symptoms which arouse a suspicion of conversion (dissociative) disorders may make a radical treatment impossible or may considerably aggravate the remote prognosis and quality of the patients' life.

Pleomorphic xanthoastrocytoma: an atypical astrocytoma

Pleomorphic xanthoastrocytoma (PXA) is rare primary neoplasm of brain. Despite its pleomorphic appearance, it has a relatively good prognosis. We report a case of biopsy proven pleomorphic xanthoastrocytoma in a young male who presented with visual and sensory symptoms, classical neuroimaging findings and showed remarkable recovery, post surgery. We have also reviewed recent literature focusing on neuroimaging, histopathology and prognostic markers of the tumour.

Are patients with encephalocraniocutaneous lipomatosis at increased risk of developing low-grade gliomas?

INTRODUCTION

Cancer-prone genetic disorders are responsible for brain tumors in a considerable proportion of children. Additionally, rare genetic syndromes associated to cancer development may potentially disclose genetic mechanisms related to oncogenesis.

METHOD

We describe two pediatric patients with encephalocraniocutaneous lipomatosis (ECCL), a very rare genetic syndrome with around 60 reported cases, which developed low-grade astrocytoma at 3 and 12 years of age.

RESULTS

Patients with ECCL seem to be at risk of benign forms of osseous tumors such as ossifying fibromas, odontomas, and osteomas.

CONCLUSION

The association between brain tumor and ECCL was previously reported only once, in a pediatric case of a mixed neuronal-glial histology. Whether ECCL may be a genetic condition of predisposing brain tumor in children strongly needs to be addressed.