Vertebral collapse with quadraparesis due to metastatic gliobla multiforme: case report and review of the literature

Mesenchymal-Type Genetic Mutations Are Likely Prerequisite for Glioblastoma Multiforme to Metastasize Outside the Central Nervous System: An Original Case Series and Systematic Review of the Literature

BACKGROUND

Glioblastoma multiforme (GBM) is the most aggressive and prevalent type of malignant brain tumor, yet it metastasizes outside the central nervous system (CNS) in only 0.4% of cases. Little is known about what enables this subset of GBMs to take root outside the CNS, but genetic mutations likely play a role.

METHODS

We conducted a PRISMA-compliant systematic review of metastatic GBM wherein we reviewed 3579 search results and 1080 abstracts, analyzing data from 139 studies and 211 unique patients. In addition, we describe 4 cases of patients with pathologically confirmed GBM metastases outside the CNS treated at our institution.

RESULTS

We found that metastases were discovered near previous surgical sites in at least 36.9% of cases. Other sites of metastasis included bone (47.9%), lung (25.6%), lymph nodes (25.1%), scalp (19.2%), and liver (14.2%). On average, metastases were diagnosed 12.1 months after the most recent resection, and the mean survival from discovery was 5.7 months. In our patients, primary GBM lesions showed mutations in NF1, TERT, TP53, CDK4, and RB1/PTEN genes. Unique to the metastatic lesions were amplifications in genes such as p53 and PDGFRA/KIT, as well as increased vimentin and Ki-67 expression.

CONCLUSIONS

There is strong evidence that GBMs acquire novel mutations to survive outside the CNS. In some cases, tumor cells likely mutate after seeding scalp tissue during surgery, and in others, they mutate and spread without surgery. Future studies and genetic profiling of primary and metastatic lesions may help uncover the mechanisms of spread.

Recurrent glioblastoma metastatic to the lumbar vertebra: A case report and literature review: Surgical oncology

Background

Glioblastoma is a malignant tumor, and its prognosis is as poor as 1.5 to 2 years. Most cases recur within one year even under the standard treatment. The majority of recurrences are local, and in rare cases, metastasize mostly within the centra nervous system. Extradural metastasis of glioma is exceedingly rare. Here, we present a case of vertebral metastasis of glioblastoma.

Case presentation

We present a 21-year-old man post total resection of the right parietal glioblastoma, diagnosed with lumbar metastasis. He originally presented with impaired consciousness and left hemiplegia and underwent gross total resection of the tumor. Given the diagnosis of glioblastoma, he was treated with radiotherapy combined with concurrent and adjuvant temozolomide. Six months after tumor resection, the patient presented with severe back pain, and was diagnosed as metastatic glioblastoma on the first lumbar vertebrae. Posterior decompression with fixation and postoperative radiotherapy were conducted. He went on to receive temozolomide and bevacizumab. However, at 3 months after the diagnosis of lumbar metastasis, further disease progression was noted, and his care was transitioned to best supportive care. Comparison on copy number status between primary and metastatic lesions on methylation array analysis revealed more enhanced chromosomal instability including 7p loss, 7q gain and 8 gain in the metastatic lesion.

Conclusion

Based upon the literature review and our case, younger age of initial presentation, multiple surgical interventions, and long overall survival seem to be the risk factors of vertebral metastasis. As the prognosis of glioblastoma improves over time, its vertebral metastasis is seemingly more common. Therefore, extradural metastasis should be kept in mind in the treatment of glioblastoma. Further, detailed genomic analysis on multiple paired specimens is mandated to elucidate the molecular mechanisms of vertebral metastasis.

Bone metastasis from glioblastoma: a systematic review

INTRODUCTION

Glioblastoma (GBM) is a devastating disease with poor overall survival. Despite the common occurrence of GBM among primary brain tumors, metastatic disease is rare. Our goal was to perform a systematic literature review on GBM with osseous metastases and understand the rate of metastasis to the vertebral column as compared to the remainder of the skeleton, and how this histology would fit into our current paradigm of treatment for bone metastases.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant literature search was performed using the PubMed database from 1952 to 2021. Search terms included "GBM", "glioblastoma", "high-grade glioma", "bone metastasis", and "bone metastases".

RESULTS

Of 659 studies initially identified, 67 articles were included in the current review. From these 67 articles, a total of 92 distinct patient case presentations of metastatic glioblastoma to bone were identified. Of these cases, 58 (63%) involved the vertebral column while the remainder involved lesions within the skull, sternum, rib cage, and appendicular skeleton.

CONCLUSION

Metastatic dissemination of GBM to bone occurs. While the true incidence is unknown, workup for metastatic disease, especially involving the spinal column, is warranted in symptomatic patients. Lastly, management of patients with GBM vertebral column metastases can follow the International Spine Oncology Consortium two-step multidisciplinary algorithm for the management of spinal metastases.

Diffuse vertebral metastases from glioblastoma with vertebroepidural diffusion: A case report and review of the literature

Background:

The occurrence of extraneural metastasis in patients diagnosed with glioblastoma (GBM) is rare with an estimated incidence ranging from 0.4% to 2.0%. Short clinical history is believed to be a possible explanation of the paucity of such cases. Furthermore, to date, only few papers describe cases of vertebral metastases from GBM without evidence of synchronous visceral involvement.

Case Description:

The authors report on the case of a 46-year-old woman presenting with a history of surgically treated GBM who developed multiple metastases located in the posterior laminae and vertebral bodies with a single dural metastasis at D6-D8 level 5 years after the initial diagnosis. Total-body computed tomography did not show signs of either intracranial recurrence or visceral involvement. Postoperative pathological examination confirmed the diagnosis of the World Health Organization-2016 Grade IV GBM metastases.

Conclusion:

From a clinical point of view, the awareness of the possibility of spinal and vertebral metastasis from intracranial GBM is crucial. The present case demonstrates that distant dissemination from the primary tumor is possible despite the absence of intracranial recurrence.

A case series of extraneural metastatic glioblastoma at Memorial Sloan Kettering Cancer Center

Background

Extraneural metastasis of glioma is a rare event, often occurring in patients with advanced disease. Genomic alterations associated with extraneural glioma metastasis remain incompletely understood.

Methods

Ten patients at Memorial Sloan Kettering Cancer Center diagnosed with extraneural metastases of glioblastoma (9 patients) and gliosarcoma (1 patient) from 2003 to 2018 were included in our analysis. Patient characteristics, clinical course, and genomic alterations were evaluated.

Results

Patient age at diagnosis ranged from 14 to 73, with 7 men and 3 women in this group. The median overall survival from initial diagnosis and from diagnosis of extraneural metastasis was 19.6 months (range 11.2 to 57.5 months) and 5 months (range 1 to 16.1 months), respectively. The most common site of extraneural metastasis was bone, with other sites being lymph nodes, dura, liver, lung, and soft tissues. All patients received surgical resection and radiation, and 9 patients received temozolomide, with subsequent chemotherapy appropriate for individual cases. 1 patient had an Ommaya and then ventriculoperitoneal shunt placed, and 1 patient underwent craniectomy for cerebral edema associated with a brain abscess at the initial site of resection. Genomic analysis of primary tumors and metastatic sites revealed shared and private mutations with a preponderance of tumor suppressor gene alterations, illustrating clonal evolution in extraneural metastases.

Conclusions

Several risk factors emerged for extraneural metastasis of glioblastoma and gliosarcoma, including sarcomatous dedifferentiation, disruption of normal anatomic barriers during surgical resection, and tumor suppressor gene alterations. Next steps with this work include validation of these genomic markers of glioblastoma metastases in larger patient populations and the development of preclinical models. This work will lead to a better understanding of the molecular mechanisms of metastasis to develop targeted treatments for these patients.

Spinal Drop Metastasis of Glioblastoma-Two Case Reports, Clinicopathologic Features, Current Modalities of Evaluation, and Treatment with a Review of the Literature

BACKGROUND

Glioblastomas (World Health Organization grade IV) are aggressive primary neoplasms of the central nervous system. Spinal metastasis occurs supposedly in 2%-5% of patients. This percentage may be only the tip of iceberg because most succumb to the disease before clinical detection and few documented cases are reported.

CASE DESCRIPTIONS

A 45-year-old man presented with history of diplopia and gait disturbance. Magnetic resonance imaging showed a left cerebellar space-occupying lesion. The histopathology was consistent with glioblastoma. The patient underwent adjuvant chemoradiation. A year later, he presented with seizures, worsening headache, neck stiffness, and low back pain. Imaging showed metastasis to the S1/S2 region of the spinal canal. A 29-year-old man presented with episodic headaches associated with nausea, vomiting, neck stiffness, and imbalance while walking. Computed tomography of the brain showed a hypodense lesion involving the left midbrain, pons, and left middle cerebellar peduncle, causing fourth ventricular pressure with obstructive hydrocephalus. A navigation-guided biopsy of the brainstem lesion confirmed the diagnosis of glioblastoma World Health Organization grade IV, isocitrate dehydrogenase 1 (R132 H) and H3K27M negative. Isocitrate dehydrogenase gene sequencing was suggested. The patient was referred for chemoradiation. During treatment, he worsened neurologically and developed axial neck and back pain. Neuraxis screening showed disseminated leptomeningeal spread, which was confirmed on dural biopsy.

CONCLUSIONS

Spinal and dural metastasis should always be suspected in patients with glioblastoma with signs and symptoms not explained by primary lesion. A regular protocol with postcontrast magnetic resonance imaging before and after initial surgery is mandatory to detect spinal metastasis before it becomes clinically apparent, thereby improving the prognosis and quality of life in patients.

Multiple Bone Metastases from Glioblastoma Multiforme without Local Brain Relapse: A Case Report and Review of the Literature

Extracranial metastases from glioblastoma multiforme (GBM) are a very rare event, even if an increasing incidence has been documented. We report the case of a young woman with primary GBM who developed bone metastases without local brain relapse. Because of persistent headache and visual disturbances, in March 2011 the patient underwent magnetic resonance imaging (MRI) evidencing a temporoparietal mass, which was surgically resected. Histology revealed GBM. She was given concomitant chemoradiotherapy according to the Stupp regimen. After a 4-week break, the patient received 6 cycles of adjuvant temozolomide according to the standard 5-day schedule every 28 days. In December 2011 she complained of progressive low back pain, and MRI showed multiple bone metastases from primary GBM, confirmed by histology. Cases of metastatic GBM in concurrence with a primary brain tumor or local relapse are more common in the literature; only a few cases have been reported where extracranial metastases from GBM occurred without any relapse in the brain. Here we report our experience.

Extra Central Nervous System Metastases from Cerebral Glioblastoma Multiforme in Elderly Patients. Clinico-Pathological Remarks on our Series of Seven Cases and Critical Review of the Literature

Aims and background

The aim of the study was to evaluate the treatment of the extracranial metastases from glioblastoma multiforme in the elderly, discussing their uncommon occurrence and their pathogenesis.

Methods

The authors report seven cases of elderly patients (mean age, 69 years), with an initial diagnosis of cerebral glioblastoma multiforme, treated by a grossly total surgical removal and followed by adjuvant radiotherapy (64 Gy in 6 weeks, using Linac) and adjuvant chemotherapy (temozolomide both concomitant and sequential to radiotherapy).

Results

All patients presented a postoperative course characterized by good functional and clinical conditions (Karnofsky performance scale ≥70), which remained unchanged for a mean period of about 21 months (range, 16–23), with no neuroradiological signs of lesion regrowth. After this interval, new clinical signs occurred, and their clinical and radiological investigation showed metastatic repetitions in different sites: lung, liver, humerus and lymph nodes. All the metastases were surgically treated, but regrowth of the brain tumor and progression to deep important neural structures caused the patients’ exitus after a mean interval of about 10 months (range, 8–12) from the diagnosis of metastasis.

Conclusions

We found 128 cases of extra CNS metastases in the English literature. The main features of the patients of the previous reports and of those of the present series were analyzed. The main modalities of glioblastoma multiforme spread, the few theories about the rarity of metastasis, and the probable biological, histological and immunogenetic mechanisms involved in the pathogenesis are described. Although several studies have reported a poor outcome in elderly patients, they affirm that the treatment of those with a Karnofsky performance status >60 should be just as aggressive as in younger patients. This allows them to obtain a longer survival time and to also treat metastases, which are uncommon particularly in the elderly.

Extraneural Glioblastoma Multiforme Vertebral Metastasis

Glioblastoma multiforme (GBM) is the most common malignant central nervous system tumor; however, extraneural metastasis is uncommon. Of those that metastasize extraneurally, metastases to the vertebral bodies represent a significant proportion. We present a review of 28 cases from the published literature of GBM metastasis to the vertebra. The mean age at presentation was 38.4 years with an average overall survival of 26 months. Patients were either asymptomatic with metastasis discovered at autopsy or presented with varying degrees of pain, weakness of the extremities, or other neurologic deficits. Of the cases that included the time to spinal metastasis, the average time was 26.4 months with a reported survival of 10 months after diagnosis of vertebral metastasis. A significant number of patients had no treatments for their spinal metastasis, although the intracranial lesions were treated extensively with surgery and/or adjuvant therapy. With increasing incremental gains in the survival of patients with GBM, clinicians will encounter patients with extracranial metastasis. As such, this review presents timely information concerning the presentation and outcomes of patients with vertebral metastasis.

Metastatic glioblastoma: case presentations and a review of the literature

Extracranial metastases from glioblastoma (GBM) are uncommon with an estimated incidence of less than 2%. We report two cases of metastatic GBM seen within an 8-week period followed by a literature review. We attempted to identify common factors or a causative mechanism. Factors that predominated among the reviewed cases included male gender, tumor location, and younger age. Causative mechanisms were not apparent. While metastatic disease remains rare, it might be occurring with increasing frequency. This trend might be due to increased diagnosis, better imaging, a more extensive physician workup, or an increase in survival. Metastatic GBM can present and progress quite rapidly, and repeat evaluations of persistent or worsening complaints among GBM patients are warranted. Early diagnosis of metastatic disease spread can help to expedite alleviation of patients' discomfort, in an already aggressive disease process.

Extra-neural metastases of malignant gliomas: myth or reality?

Malignant gliomas account for approximately 60% of all primary brain tumors in adults. Prognosis for these patients has not significantly changed in recent years-despite debulking surgery, radiotherapy and cytotoxic chemotherapy-with a median survival of 9-12 months. Virtually no patients are cured of their illness. Malignant gliomas are usually locally invasive tumors, though extra-neural metastases can sometimes occur late in the course of the disease (median of two years). They generally appear after craniotomy although spontaneous metastases have also been reported. The incidence of these metastases from primary intra-cranial malignant gliomas is low; it is estimated at less than 2% of all cases. Extra-neural metastases from gliomas frequently occur late in the course of the disease (median of two years), and generally appear after craniotomy, but spontaneous metastases have also been reported. Malignant glioma metastases usually involve the regional lymph nodes, lungs and pleural cavity, and occasionally the bone and liver. In this review, we present three cases of extra-neural metastasis of malignant gliomas from our department, summarize the main reported cases in literature, and try to understand the mechanisms underlying these systemic metastases.

Spinal and extracranial metastatic dissemination of malignant glioma

Metastatic dissemination of malignant glioma is rare. Metastatic disease usually occurs within the neuraxis but extracranial spread to the liver, spleen, lung, peritoneum and lymph nodes can also occur. In most cases of metastatic disease, the patient has previously undergone a craniotomy. The prognosis is uniformly poor. The vast majority of patients do not survive beyond six months from diagnosis of metastatic spread of a primary intracranial tumour. The pathophysiology and natural history of this condition is still not fully understood, hence well-designed prospective studies are needed.

Fine needle aspiration diagnosis of extracranial glioblastoma multiforme: Case report and review of the literature

Background

Hitherto uncommon, the incidence of extracranial metastases of primary brain malignancies may increase, with improved treatment methods and longer patient survival. Fine needle aspiration biopsy is a simple, safe and reliable method to diagnose metastatic malignancy. It has definite advantages over tissue biopsy, which is more invasive and is of higher risk to the patient. Ours is a case of glioblastoma multiforme, which metastasized to the scalp and was diagnosed on fine needle aspiration biopsy. Only a few articles document the cytological features of extracranial glioblastoma multiforme, diagnosed by fine needle aspiration biopsy.

Case presentation

We report the case of an elderly female who presented with focal neurological symptoms. She was diagnosed radiologically with an intracranial lesion in the left temporal region, which was subsequently resected. Histology revealed a glioblastoma multiforme confirmed by immunohistochemistry. The tumor recurred subsequently and the patient was treated with chemotherapy, intraoperatively. At a later stage, she presented with a scalp mass on which fine needle aspiration biopsy was performed. The cytomorphological features aided by immunohistochemistry supported a diagnosis of metastatic glioblastoma multiforme. The mass was later resected and histology confirmed the fine needle aspiration diagnosis of glioblastoma multiforme.

Conclusion

Reports of extracranial metastases of primary brain tumors are few. When they do occur, the primary cause is implantation during surgery or biopsy. However, spontaneous metastases to other organs do occur rarely. We believe fine needle aspiration biopsy to be very useful in the diagnosis of metastatic glioblastoma multiforme. The ability to use a cellblock for immunohistochemical studies is greatly advantageous and helpful in differentiating this tumor, from other malignancies that can occur in the scalp. A detailed discussion of the material obtained from fine needle aspiration biopsy of metastatic glioblastoma multiforme is presented, as well as a review of previous accounts in the literature.

Symptomatic spinal dissemination of malignant astrocytoma

OBJECT

Symptomatic spinal dissemination of malignant astrocytoma is rarely found except at autopsy. This study evaluated the clinical incidence and characteristics of spinal dissemination and the effect on outcome.

PATIENTS AND METHODS

Patients treated for primary malignant astrocytoma, including 33 with anaplastic astrocytoma and 35 with glioblastoma, at our department between 1997 and 1999 were followed up until April 30, 2001. Head magnetic resonance (MR) imaging of all patients was obtained every 2-3 months. Signs and symptoms of leptomeningeal spread were checked at monthly outpatient examinations. Spinal MR imaging was performed if any symptoms indicating spinal dissemination were found.

RESULTS

Median survival times of patients with anaplastic astrocytoma and glioblastoma were 40.5 and 16.0 months, respectively. Seventeen patients (25%) developed intracranial dissemination and 15 of these died. Six patients (8.8%), one with anaplastic astrocytoma and five with glioblastoma, developed spinal dissemination. All patients with spinal dissemination also had intracranial dissemination. Five of the six patients died, despite systemic radiochemotherapy in four patients. All patients died of extensive whole brain and spinal dissemination or nodular mass enlargement at the upper cervical cord, not of local massive tumor progression.

CONCLUSIONS

Symptomatic spinal dissemination of malignant astrocytoma is not so rare, and is the cause of death. The relatively high incidence of symptomatic leptomeningeal dissemination must be considered in the treatment of malignant astrocytomas.

Lack of evidence of osteo-medullary metastases at diagnosis in patients with high grade gliomas

High grade gliomas usually show a transient response to standard therapy by radiation. A local evolution leads to patient death in most of the cases. Necropsic series suggest that metastatic evolution is rather frequent in lungs, lymph nodes, bones or bone marrow. Are these metastatic deposits present initially? The authors retrospectively reviewed the bone marrow smears performed in 20 patients and the bone scans in 10 patients with high grade gliomas at time of diagnosis. None of these investigations showed metastatic deposits. It is thus suggested that metastatic deposits are probably a late event in the natural history of high grade gliomas. However, if local treatment could reach local control, metastases would probably become a major problem. Thus definitive cure of high grade glioma may require multidisciplinary approach.

Bone metastases from secondary glioblastoma multiforme: a case report

Extraneural metastases of glioblastoma multiforme (GBM) are a relatively rare occurrence which usually manifest after de novo GBM. We report a case of a patient with an oligodendroastrocytoma who developed over a period of 12 years malignant progression to glioblastoma followed by multiple cytologically confirmed bone metastases. No 1p deletions were detected in the original tumour. GBM cells disclosed the EGFr(+) and p53(-) immunophenotype more characteristic of a primary GBM.

Extraneural metastatic glioblastoma after interstitial brachytherapy

PURPOSE

This is a report of 3 cases of extraneural metastasis of glioblastoma after interstitial radiation and assessment of pertinent literature addressing concern over an increased risk of these events with this therapy.

METHODS AND MATERIALS

In a series of 82 patients treated with (125)I brachytherapy for primary malignant brain tumors over a 7-year interval, 3 cases of extraneural glioblastoma were identified. The multicatheter technique for delivery of (125)I sources was utilized in all. Extraneural metastases were documented by imaging studies or biopsy. Over the same period, 310 patients with primary malignant brain tumors were treated without brachytherapy.

RESULTS

Biopsy-proven scalp and skull metastases occurred in 2 patients, at 3 and 8 months following brachytherapy. Each developed radiographic evidence of systemic metastases at 7 and 14 months postbrachytherapy, respectively. The third patient developed biopsy-proven cervical node involvement 4 months after brachytherapy. No patients with malignant gliomas undergoing craniotomy or stereotactic biopsy, but not brachytherapy, during the same time period developed extraneural metastases. Incidence in previously reported series commenting on this otherwise rare process range from 0% to 4.3%. The incidence of extraneural metastases in this series is 3.7% (3/82) and is comparable to those reports.

CONCLUSIONS

Percutaneous catheter-delivered brachytherapy may be associated with an increased incidence of extraneural metastatic glioma.

Verification of 50- to 100-mer DNA and RNA sequences with high-resolution mass spectrometry

Electrospray ionization with Fourier-transform mass spectrometry achieves accurate (< 50-ppm) determination of molecular weights of nucleotides, verifying structures of biological RNA and synthetic single-stranded DNA. High (1o(5)) resolving power makes possible detection of subpicomole impurities and adducts that confuse lower-resolution measurements. Molecular ions in a spectrum of 76-mer tRNA(Phe) had 34-55 Na adducts; when desalted, these show a molecular mass of 24,950.5 Da (expected, 24,950.3 Da) and minor variants at approximately -15 and +15 Da. A 50-mer DNA is characterized with < 10-ppm mass error, with detection of both N + 1 and N - 1 failure sequences. Special electrospray ionization conditions are necessary for a 72-mer to minimize fragmentation in the ion source. Despite the chemical noise from this, as well as failed sequences from automated synthesis, the spectrum of a 100-mer single-stranded DNA yielded a molecular mass of 30,702.4 +/- 1 Da, in good agreement with the expected value, 30,702.1 Da.