Leptomeningeal metastasis from supratentorial malignant gliomas

Primary glioblastoma multiforme of the oculomotor nerve. Case report

Tumors of the oculomotor nerve are rare and most instances reported have been schwannomas. The authors present clinical, neuroradiological, and neuropathological findings in a 70-year-old woman with a glioblastoma multiforme (GBM) growing primarily in the proximal part of the left oculomotor nerve. The patient presented with a 1-month history of transient diplopia. Neurological examination revealed an incomplete left-sided oculomotor nerve palsy with no further signs of neurological dysfunction. Cranial computerized tomography and magnetic resonance imaging showed a tumor of the left oculomotor nerve without any obvious signs of penetration into the midbrain or upper pons. Following subtotal removal of the tumor, neuropathological examination of the operative specimen revealed a GBM that had grown diffusely within peripheral nerve tissue. Six weeks after surgery, the patient suddenly died of pulmonary thromboembolism. Postmortem examination of the brain confirmed a large leptomeningeal GBM at the left pontomesencephalic junction with complete destruction of the left oculomotor nerve. To the authors' knowledge, this represents the first case of a GBM of the oculomotor nerve, probably originating from glial cells within the most proximal part of the nerve or the adjacent leptomeninges.

Spinal metastases of cerebral glioma. Case report

We report a case of multiple spinal leptomeningeal metastases from an intracerebral glioblastoma and the original tumor having been an oligoastrocytoma (WHO II). Three time resection of this right frontal tumor with opening of the lateral ventricle preceded intraventricular spread. Diagnosis of spinal dissemination was based on the previous history and Gadolineum-DTPA enhanced MR.

A review of leptomeningeal metastases in pediatrics

Leptomeningeal metastasis is an uncommon problem in pediatric neurology and oncology. It occurs primarily in children with acute lymphoblastic leukemia and primary brain tumors. Although leptomeningeal metastasis may present with focal neurologic signs and symptoms, leptomeningeal metastasis is a disease affecting the entire neuraxis and necessitating an extent-of-disease evaluation of both the brain and spinal cord. Neuroradiographic staging of leptomeningeal metastases includes contrast-enhanced cranial computed tomography, magnetic resonance imaging, contrast-enhanced spine magnetic resonance imaging or computed tomographic myelography, and radionuclide cerebrospinal fluid flow studies. As a consequence of global neuraxis involvement, the treatment of leptomeningeal metastases requires therapy directed at all cerebrospinal fluid compartments. The treatment of leptomeningeal metastases usually includes both radiotherapy and intra-cerebrospinal fluid drug therapy. Radiotherapy is directed to regions of bulky or symptomatic central nervous system disease. Intra-cerebrospinal fluid drug therapy, using one of three available chemotherapeutic agents (methotrexate, cytarabine, or triethylene thiophosphoramide), is administered by a variety of schedules and either by intralumbar or intraventricular drug delivery. Notwithstanding that the treatment of leptomeningeal metastases is palliative, with an expected patient survival of 6 months, it often affords stabilization and protection from further neurologic deterioration in children with leptomeningeal metastases in whom death is usually a consequence of progressive systemic or parenchymal brain disease.

Leptomeningeal dissemination of malignant gliomas. Incidence, diagnosis and outcome

To understand the clinicopathology features of leptomeningeal dissemination of malignant gliomas, a total of 157 consecutive patients treated between 1978 and 1989 were analysed. Twenty-two patients (14%) were judged to have dissemination. In 20 patients, the dissemination was diagnosed antemortem. Eleven patients had neurological deficits due to dissemination, whereas the other 9 without these had CT or myelographic evidence of dissemination. The peak incidence of dissemination was seen in the first and second decades of life. The mean age of 22 patients with dissemination was 31 years, significantly lower than that (44.5 years) of patients without dissemination. Fifteen patients developed dissemination within one year after diagnosis (early dissemination), 60% of them were less than 30 years of age. All patients with late dissemination (more than one year after diagnosis) underwent a second craniotomy for tumour removal before dissemination, while none of the 15 patients with early dissemination did. Survival after diagnosis in patients with dissemination was shorter, although statistically not significant, than that of patients without dissemination. Survival after dissemination was limited in all patients (mean 19 weeks, range 2-39 weeks). Immunohistochemical study revealed that the disseminated tumour expressed less glial fibrillary acidic protein than the primary tumour. Our results suggest that dissemination does not seem to result from extended survival of the patients, but may occur at any time in malignant gliomas. Some malignant gliomas, especially in younger patients, have a capability to acquire biological characteristics suitable for dissemination in the earlier stage of the disease.

Ventricular entry during resection of malignant gliomas: effect on intracranial cerebrospinal fluid tumor dissemination

The ventricular system is not infrequently entered during the course of maximum cytoreductive surgery for high-grade supratentorial gliomas. It is unclear if ventricular entry during surgery and/or proximity of the tumor to the ventricular system affects cerebrospinal fluid (CSF) tumor dissemination or the patients' overall survival rate. The authors retrospectively reviewed hospital records and neuroradiological studies of 51 patients operated on at the University of Washington between 1987 and 1991. Inclusion in this study necessitated a pathological diagnosis of malignant glioma and the availability of preoperative and postoperative computerized tomography scans or magnetic resonance images. Patients were excluded from the study if they had radiographic evidence of ventricular entry or CSF tumor dissemination prior to referral to the authors' institution. The index operation was defined as the first operation at the University of Washington or (in those patients with ventricular entry) the operation in which the ventricle was entered. Patients were followed until time of death or, in the case of survivors, until February, 1992. The effect of both ventricular entry and the proximity of the tumor to the ventricular system on CSF tumor dissemination and survival rate was assessed using statistical survival methodology. There was no significant difference in time from diagnosis to the index operation between groups compared (Mann-Whitney U-test, p > 0.40). Cerebrospinal fluid dissemination was radiographically documented in 18 patients (35%) following the index operation. This occurrence was not significantly influenced by either ventricular entry during surgery (Mantel-Cox test, p = 0.13), the proximity of the tumor to the ventricular system (p = 0.63), or these two variables combined (p = 0.28). Survival rate following the index operation was not significantly affected by ventricular entry (p = 0.66), proximity of the tumor to the ventricular system (p = 0.61), or these two variable considered in combination (p = 0.44). However, survival rate was significantly decreased once CSF tumor dissemination had occurred (Cox model, p = 0.03).

A case of cerebral glioblastoma with extensive cerebrospinal fluid dissemination: diagnostic value of immunohistochemical examination and MR imaging

A 9-year, 6-month-old boy presented with peripheral-type multiple cranial nerve palsy due to extensive cerebrospinal fluid (CSF) dissemination of intracranial glioblastoma multiforme. Tissue obtained from biopsy did not stain for glial fibrillary acidic protein (GFAP). The relationship between GFAP-negative tumor cells and extensive CSF dissemination agreed with recent reports. Magnetic resonance imaging with gadolinium-DPTA enhancement clearly depicted not only the cranial meningeal dissemination but also spinal metastasis. Magnetic resonance imaging showed undoubted usefulness in demonstrating disseminated glioblastoma.

Neoplastic meningitis as the presentation of occult primitive neuroectodermal tumors

Seven children and young adults initially presented with subacute meningitis and/or increased intracranial pressure. The diagnosis of neoplastic meningitis secondary to a primitive neuroectodermal neoplasm was delayed by the absence of an obvious primary tumor. The neuroradiologic appearance was that of a basimeningeal infiltrative process, complicated by communicating hydrocephalus or "pseudotumor cerebri." Myelography was important in the diagnosis of disseminated meningeal malignancy in four cases. Cerebrospinal fluid cytologic diagnosis was insensitive but ultimately confirmed in five cases. All seven patients experienced progressive disease despite neuraxis radiotherapy and intensive chemotherapy; six have died. Systemic dissemination to bone and/or peritoneum occurred in three patients while on therapy. In two, a primary parenchymal brain or spinal cord tumor could not be identified at postmortem examination. The presentation of a primitive neuroectodermal tumor as subacute meningitis without an evident primary tumor heralds an aggressive and refractory neoplasm.

Primary diffuse leptomeningeal gliomatosis (PDLG): a neoplastic cause of chronic meningitis

Cancerous 'chronic meningitis' may be related to subarachnoid space involvement by solid tumors, hematologic malignancies or rarely intraparenchymatous gliomas. Primary leptomeningeal gliomatosis is a rare condition that is attributed to malignant transformation of heterotopic neuroglial tissue. We discuss the clinical and biological features of a patient who died with the diffuse form of primary leptomeningeal gliomatosis (PDLG). A literature search shows that a one to two months long non-specific prodromal phase followed by a fluctuating neurologic downhill course is suggestive of this disease. Cerebro-spinal fluid (CSF) cytology has been diagnostic in only 1 of 8 reported cases. Recent technical progress, including the use of GFAP (glial fibrillary acidic protein) directed antibody, may enhance the sensitivity of CSF cytologies. Diagnosis may require repeated cerebral biopsies, because the hemispheric lesions are often separated by normal tissue. PDLG must be added to the large differential diagnosis of 'chronic meningitis'.

Supratentorial glioblastoma with spinal cord intramedullary metastasis

A patient presented with myelopathy due to intramedullary thoracic spinal cord glioblastoma 10 months after treatment for a supratentorial glioblastoma. There was no supratentorial recurrence, and no evidence of gross leptomeningeal dissemination documented by CSF cytology, complete myelography, and MRI imaging. Gross examination of the spinal cord and arachnoid at the time of exploratory thoracic spinal surgery was normal. However, histological review of thoracic arachnoid demonstrated microscopic deposits of glial fibrillary acidic protein (GFAP) positive tumour consistent with malignant astrocytoma. Intramedullary spinal cord metastasis of cerebral glioblastoma rarely occurs, but may develop in association with leptomeningeal tumour dissemination. As local control of primary tumours improves, distant metastasis is likely to become a more common clinical problem. Leptomeningeal gliomatosis may be very difficult to document, even when clinically suspected and GFAP staining of a biopsy of arachnoid tissue can play an important role in confirming the diagnosis. This information can be critical to establish prognosis and develop an appropriate treatment strategy.

Diffuse primary leptomeningeal gliomatosis

A 38 year old patient developed multiple cranial nerve palsy, seizures and progressive alteration in consciousness. CSF examination revealed tumor cells and a tentative diagnosis of leptomeningeal carcinomatosis from an unknown primary tumor was made. Treatment with intrathecal methotrexate and cranial radiation therapy was started without effect. At autopsy widespread leptomeningeal gliomatosis originating from a previously unknown astrocytoma of the hippocampus was found.

Leptomeningeal dissemination of cerebellar pilocytic astrocytoma. Case report

A case of surgically treated pilocytic astrocytoma in the cerebellar vermis is reported in a patient who subsequently demonstrated multiple subarachnoid nodular masses in the cerebrum and spinal cord 6 years after the initial surgery. The nodular tumors did not indicate a growth tendency on computerized tomography or magnetic resonance imaging over a 2-year observation period. The histology of the nodular masses in the cerebrum and spinal cord was similar to that of the original tumor. The bromodeoxyuridine labeling index indicated low proliferative activity (0.5%). The peculiar pattern of dissemination of the pilocytic astrocytoma is described.

Dissemination of supratentorial malignant gliomas via the cerebrospinal fluid in children

Of 100 children with supratentorial gliomas (excluding gliomas of the anterior visual pathways) treated at the Children's Hospital of Pittsburgh from 1980 to 1990, 34 had malignant gliomas. Follow-up was adequate in 33 of these patients, and an antemortem diagnosis of dissemination of the malignant glioma via the cerebrospinal fluid (CSF) was made in 11. Of these 11, 8 were boys and 3 were girls; they ranged in age from 17 months to 16 years at the time of diagnosis of the primary glioma. The distribution of histological types was as follows: glioblastoma multiforme, 4; malignant oligodendroglioma, 3; anaplastic astrocytoma, 2; malignant mixed glioma, 1; and malignant ependymoma, 1. The interval between diagnosis and CSF dissemination ranged from 1 week to 59 months (median, 8 months). Survival after dissemination ranged from 3 weeks to 11 months (median, 4 months). Two patients were alive 5 and 3 months after diagnosis of dissemination, respectively. These 11 patients were compared with the other 22 patients who did not have CSF dissemination. The risk factors for dissemination suggested by our data were male sex, ventricular operative entry, multiple resections, and malignant oligodendroglioma. Because of the high incidence (33%) of CSF dissemination, postoperative evaluation of the craniospinal axis with gadolinium-enhanced magnetic resonance imaging should be performed on all children with supratentorial malignant gliomas. Moreover, since the mortality is extremely high once dissemination has occurred, craniospinal irradiation should be considered in children with one or more of the above risk factors, even before symptoms or definite radiological evidence of CSF dissemination emerge.

Patterns of recurrence of malignant astrocytoma following stereotactic interstitial brachytherapy with iodine-125 implants

The pattern of tumor recurrence was studied in a series of 68 patients who were treated with interstitial brachytherapy for malignant astrocytoma. Thirty-six patients had newly diagnosed tumors and were treated following surgery and external beam therapy, while 32 were treated for recurrent tumors. Recurrence pattern was determined using computed tomography at the time of clinical deterioration. Thirty-eight percent of tumor recurrence occurred within the original tumor margin and 50% occurred at the original site but extended beyond the initial margin. In all, 88.0% recurred at the initial tumor site, 71.4% being confined to within 2 cm of the pretreatment tumor borders while 6.0% recurred intracranially outside of the initial tumor margin. One patient recurred with spinal metastasis while two patients developed systemic metastases. The significance of these findings is discussed.

Intratumor administration of beta-interferon in recurrent malignant gliomas. A phase I clinical and laboratory study

We administered doses of 5 to 180 x 10(6) IU of beta-serine-interferon (IFN-beta ser17) twice weekly to 20 patients with recurrent malignant gliomas in a Phase I study. Interferon was given through an Ommaya reservoir connected by a catheter to the tumor cavity. Side effects of interferon therapy occurred in only one patient and consisted of nausea, vomiting, fever, and chills after each treatment, presumably due to rapid diffusion of interferon into ventricular cerebrospinal fluid (CSF). Problems with the Ommaya reservoir (obstruction in two patients and infection in four patients) led to six patients being terminated from the study, and represent the major difficulty with this form of therapy. Although this was primarily a study of interferon toxicity, of 12 evaluable patients, 3 had stable disease for 148, 192, and 539 days; 9 had progressive disease. In addition, we tested the effect of IFN-beta ser17 on the growth of early passage in vitro cultures of malignant gliomas established from patients. Growth inhibition varied from 0% to more than 50%. In all cultures evaluated, the combination of recombinant gamma-interferon plus IFN-beta ser17 enhanced growth inhibition. Further clinical and laboratory study is necessary to better define the therapeutic efficacy of IFN-beta ser17 and the role of combinations of interferons in the treatment of malignant gliomas.

Symptomatic cerebrospinal fluid dissemination of cerebral glioblastoma. Computed tomographic findings in 11 cases

Computed tomography (CT) findings in eleven patients with symptomatic cerebrospinal fluid (CSF) dissemination from cerebral glioblastoma were analyzed and, in seven cases subsequently autopsied, they were compared with histological observations. Each patient had multiple CT abnormalities including periventricular enhancement (5/11), subarachnoid enhancement (10/11) and progressive hydrocephalus (7/9) by cranial CT, and small filling defects with or without block (5/5) by CT myelography. The areas that showed periventricular or subarachnoid enhancement on CT were confirmed to have macroscopically detectable seeding at autopsy. On the other hand, microscopic deposits were more widely distributed than the enhancement suggested, and were hardly visualized on CT. In association with subarachnoid seeding, we found low-density lesions on CT which had resulted from ischemia or reinvasion of adjacent structures by disseminated glioblastoma and resulting parenchymal edema. By cranial CT, subarachnoid enhancement seems to be a very reliable sign of CSF seeding, whereas periventricular enhancement due to CSF metastases should be carefully distinguished from that due to periventricular tumor infiltration. CT myelography is capable of revealing minute metastatic spinal deposits and may be helpful for ruling out spinal seeding as well as its precise evaluation.

Periventricular enhancement: a non-pathognomonic sign of intracerebral tumours

Four cases of periventricular contrast enhancement on computed tomography due to different tumours are reported, emphasizing that periventricular contrast enhancement is a non-specific radiological sign.

Leptomeningeal gliomatosis with spinal cord or cauda equina compression: a complication of supratentorial gliomas in adults

Seven patients with supratentorial gliomas developed leptomeningeal gliomatosis (LMG) without symptomatic recurrence at the primary tumor site. In all, severe back and radicular pain, often simulating disc disease, preceded the development of spinal cord or cauda equina dysfunction. In 4 instances, intracranial hypertension due to hydrocephalus developed prior to spinal involvement. Cytological examination of the CSF revealed malignant cells in only 2/7 but a myelogram was diagnostic in all 7. All patients received spinal irradiation (RT) and 5 received chemotherapy. Two patients with low-grade gliomas improved transiently; 5 with malignant gliomas responded poorly, became paraplegic over 4 months and eventually died of LMG. When fatal LMG occurs in young adults suffering from supratentorial glioma, the primary tumor is often quiescent. Hydrocephalus is often the first manifestation of LMG and, when it is detected, a myelogram and CSF cytology study should be performed in the hope that diagnosis and treatment of spinal cord lesion at a very early stage will prove beneficial. Irradiation of the entire spinal canal is probably required as there is a high risk of rapid development of new lesions in non irradiated segments of the spinal canal.