Gliomatosis cerebri. Report of a case with isolated amnesic disorders

Gliomatosis cerebri: clinical characteristics, management, and outcomes

Gliomatosis cerebri is a rare diffusely infiltrating primary neoplastic glial process of the brain. Our objective is to review clinical presentation, management, and outcome in a large single institution series of gliomatosis cerebri patients. 54 consecutive gliomatosis cerebri cases presenting to Mayo Clinic Rochester between 1991 and 2008 were retrospectively reviewed. Inclusion criteria included involvement of at least three cerebral lobes, lack of a single discrete mass and pathological confirmation of diffuse glioma. Median overall survival (OS) was 18.5 months. Age, gender, presenting symptoms, and contrast enhancement did not correlate significantly with survival, though there was a trend toward decreased overall survival in patients above the median age of 46 years. Karnofsky performance score <70 was associated with poor OS (median 9.5 vs. 20.5 months, p = 0.02). Higher histologic grade was associated with poor progression-free survival (PFS; median for WHO grades II, III, and IV: 21.5, 6.5, and 4 months; p = 0.03) and OS (median 34, 15.5, and 8.5 months; p < 0.05). Radiation therapy was strongly associated with better prognosis (PFS 16.5 vs. 4.5 months, p < 0.01; OS 27.5 vs. 6.5, p < 0.01), but chemotherapy was not. Gliomatosis cerebri patients have a poor prognosis. Lower KPS upon presentation and higher histologic grade predict decreased survival. Surgery's role is limited beyond biopsy for diagnostic purposes. Radiotherapy appears beneficial, although selection bias could be present in this retrospective study. Chemotherapy's value is not as clear but this must be interpreted with caution given variable treatment regimens in this series.

Gliomatosis cerebri in children. Case report and clinical considerations

OBJECTIVE

Gliomatosis cerebri (GC) is an uncommon entity characterised by the diffuse overgrowth of large parts of the brain by glial cells. Reports in the literature often refer to adult patients, its occurrence in children being even more rare.

CASE REPORT

We report the case of an 8-year-old boy with GC and discuss the problem of intra vitam diagnosis.

CONCLUSIONS

Diagnosis of GC is very difficult; thus, cases diagnosed during life are rare.

Gliomatosis Cerebri: A Review of 296 Cases from the ANOCEF Database and the Literature

Gliomatosis cerebri (GC) is a rare disease, defined as a diffuse neoplastic glial cell infiltration of the brain. Diagnosis and management of GC are difficult. This study analyzed 296 individual cases (90 patients followed through the ANOCEF network, and 206 cases from the literature), aged 1 month to 85 years (median 42), sex ratio=1.31. Median survival was 14.5 months. It was higher for patients younger than 42 years (17 months vs. 13 months), with performance status>or=80 (27 months vs. 9 months), low grade gliomatosis (grade 2=20 months, grade 3=11.5 months, grade 4=8.5 months), oligodendroglial subtype (36 months compared to 14 months for mixed GC and 11 months for astrocytic GC). Male population was younger (median 39 years vs. 45), had a higher incidence of oligodendroglial GC (22% vs. 13%), which may explain their better prognosis (median survival 17 months vs. 11.5 months) than female population. Despite a high rate of stabilization, the impact on survival of whole brain radiotherapy, which carries the risk of severe toxicity, is still unclear. Up-front chemotherapy benefit to some patients and may be preferred to whole brain radiotherapy. However, the many bias of such retrospective heterogeneous data claim for multicentric clinical trials in this rare disease.

La gliomatose cérébrale

INTRODUCTION

Gliomatosis cerebri (GC) is defined as a diffuse neoplastic glial cell infiltration of the brain involving more than two cerebral lobes and, occasionally, the infratentorial structures or the spinal cord. The tumor may appear de novo (primary GC) or result from the spreading of a focal glioma (secondary GC). Diagnosis and management of GC are difficult. Because of the diffuse nature of gliomatosis cerebri (GC), surgery is not suitable and large field radiotherapy carries the risk of severe toxicity.

STATE OF ART

The analysis of current literature shows that the male population (58 percent) is younger, has a higher incidence of oligodendroglial GC and better prognosis than the female population. Survival (median=14.5 months) is also better for young patients, with high performance status, low-grade gliomatosis, and oligodendroglial subtype. Initial chemotherapy results in nearly 30 percent clinical or radiological improvement. In this setting, temozolomide is well tolerated and appears to be a valuable alternative to procarbazine-CCNU-vincristine, especially for slow-growing, low-grade GC.

PERSPECTIVE

Genotyping could be helpful to predict the response to chemotherapy in GC patients.

Three-dimensional anisotropy contrast imaging of gliomatosis cerebri: two case reports

BACKGROUND

Magnetic resonance imaging (MRI) can provide a preoperative diagnosis of gliomatosis cerebri, but the findings sometimes do not correspond with the clinical symptoms or histologic findings.

CASE DESCRIPTION

Three-dimensional anisotropy contrast (3DAC) imaging was used to assess damage to the neuronal fibers in two patients with gliomatosis cerebri who presented with only mental deterioration. Conventional MRI depicted markedly abnormal findings consisting of widespread areas of abnormally high signal intensity in the corpus callosum and in the bilateral white matter in both cases. In contrast, 3-D AC imaging showed no abnormality except for small dark areas in the corpus callosum or white matter.

CONCLUSION

3-D AC imaging provides more accurate information about damage to the neuronal fibers in cases of gliomatosis cerebri than other MRI techniques.

Speech rate as a sticky switch: a multiple lesion case analysis of mutism and hyperlalia

Though it has long been known on the basis of clinical associations and serendipitous observation that speech rate is related to mood and psychomotor baseline, it is less known that speech rate is also related to libido and to immune function. We make the case for a bipolar phenomenon of "psychic tonus," encompassing all these dimensions. The elated, agitated, libidinal, immunofacilitated, and talkative pole is an "approach" disposition primarily activated by the normal left hemisphere-especially, though not exclusively, its frontal lobe. The dejected, lethargic, delibidinized, immunosuppressed, and mute pole is an "avoidance" disposition primarily activated by the normal right hemisphere-especially, though not exclusively, its frontal lobe. In support of this proposed model, we present new evidence, via meta-analysis of previously published single lesion case reports, of a highly significant association between right hemisphere lesions and non-aphasic hyperlalia, and between left hemisphere lesions and non-aphasic mutism.

Gliomatosis cerebri: improved outcome with radiotherapy

PURPOSE

Gliomatosis cerebri is a rare, diffuse involvement of the central nervous system by a malignant glioma that permeates the brain extensively without destroying the neural architecture and involves more than two lobes. In this study, we sought to assess the role of radiotherapy (RT) and identify prognostic factors in gliomatosis cerebri.

METHODS AND MATERIALS

Thirty patients who received RT at a single institution and had radiographic follow-up were retrospectively reviewed with respect to outcome, radiation parameters, extent of surgery, and chemotherapy. All cases were analyzed histologically and documented. All pathology slides and radiology images were reviewed.

RESULTS

The median age at diagnosis was 38.6 years (range 16-68). The median follow-up was 12.8 months (range 3-110). The mean radiation dose was 54.9 Gy, given in a mean of 28 fractions. Radiographic improvement or disease stabilization was achieved in 87% of patients. Clinical improvement was observed in 70%. The median time to progression was 10 months, and it was significantly longer for patients <40 years old (p = 0.0007) and for patients having a tumor histologic subtype other than glioblastoma (p = 0.01). The median overall survival was 18 months and was also longer for patients <40 years (p = 0.0001) and for patients having nonglioblastoma histologic features (p = 0.007). Extensive surgery, administration of chemotherapy, or increased RT volume improved neither overall survival nor the time to disease progression.

CONCLUSION

RT is effective against gliomatosis cerebri. Patients who are young and have a nonglioblastoma tumor histologic subtype perform more favorably. In this analysis, no role for chemotherapy, extensive surgery, or whole-brain RT was found.

Gliomatosis cerebri with secondary glioblastoma formation: report of two cases

The clinicopathological features of two cases of gliomatosis cerebri associated with secondary glioblastoma formation are reported. In both cases, glial cells were diffusely distributed in the supra- and infratentorial regions and underlying brain structures were preserved from the onset. In spite of such diffuse distribution of neoplastic glial cells, similar to that observed in low-grade astrocytoma, in both cases the tumor underwent complete remission after radiotherapy. However, the tumor recurred as a localized glioblastoma in both cases, 37 months (case 1) and 7 months (case 2) after the radiotherapy. In both cases, recurrence was accompanied by prominent dissemination of CSF. The recurrent tumors were radiation resistant, and the patients' conditions deteriorated rapidly after recurrence. The present two cases demonstrated that gliomatosis cerebri, classified among brain tumors of unknown origin by the World Health Organization, may transform into highly proliferative circumscribed tumors, in spite of their good response to radiotherapy. Examination of pathological features and their correlation with MRI findings may allow us to better understand the response to radiotherapy and the process of recurrence.

Gliomatosis cerebri with good prognosis

A 52-year-old man was admitted to our clinic with severe headache and bilateral papilledema. Magnetic resonance (MR) images on admission demonstrated diffuse swelling of the cerebral cortex without formation of a tumor mass. Biopsy revealed diffuse infiltration with neoplastic glial cells. After radiation and chemotherapy, the MR images returned to normal. The morphological and neurological features of the present case met the criteria for gliomatosis cerebri. However, this patient showed an unusually good response to radiation and chemotherapy.

Rapidly progressive dementia: a clinicopathologic correlation

We evaluated a 66-year-old man with a rapidly progressive, akinetic-rigid dementia syndrome. Despite extensive testing, which included magnetic resonance imaging (MRI), we were unable to make the correct antemortem diagnosis. Autopsy demonstrated spontaneous progressive multifocal leukoencephalopathy. This report illustrates that even in the absence of characteristic MRI findings, this uncommon cause of dementia should be considered in the differential diagnosis of rapidly progressive, akinetic-rigid syndromes with dementia.