Detection of multiple extracranial metastases from glioblastoma multiforme by means of whole-body [18F]FDG-PET

Metastatic glioblastoma to the lungs: a case report and literature review

Glioblastoma is the most common malignant primary brain tumor. Despite its infiltrative nature, extra-cranial glioblastoma metastases are rare. We present a case of a 63-year-old woman with metastatic glioblastoma in the lungs. Sarcomatous histology, a reported risk factor for disseminated disease, was found. Genomic alterations of TP53 mutation, TERT mutation, PTEN mutation, and +7/-10 were also uncovered. Early evidence suggests these molecular aberrations are common in metastatic glioblastoma. Treatment with third-line lenvatinib resulted in a mixed response. This case contributes to the growing body of evidence for the role of genomic alterations in predictive risk in metastatic glioblastoma. There remains an unmet need for treatment of metastatic glioblastoma.

Whole-body 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Demonstrating Multiple Rare Extracranial Metastases in a Treated Case of Glioblastoma

Glioblastoma (GBM) is the most aggressive primary brain tumor in adults that accounts for nearly 20% of all primary malignant brain tumors. While GBM is notable for local recurrence and invasion, extracranial metastases (ECMs) are exceedingly rare, occurring in <2% of patients. However, the report of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging in evaluating ECM is limited, and the importance of whole-body FDG PET/CT imaging in GBM has not been well elucidated. We present here a case of GBM, post excision 12 years before, whole-body 18F-FDG PET/CT showing no recurrence in the brain and ECM to multiple bones, right kidney, and pancreas.

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.

Identification of Distant Metastases From Recurrent Gliosarcoma Using Whole-Body 18F-FDG PET/CT

A 51-year-old man presented with recurrent gliosarcoma and increasing cough over the last months. On F-FDG PET/CT, solid lung masses with high F-FDG uptake were present. A biopsy taken from a lung lesion indicated distant metastases from gliosarcoma. Gliosarcoma, a rare malignant central nervous system tumor, presents with extracranial metastases in only less than 10%. As highlighted by this case, F-FDG PET/CT can be used for whole-body staging in patients with metastatic brain tumor. Vice versa, highly F-FDG-avid lung lesions in patients with brain tumors should lead to distant metastases as differential diagnosis despite their rare occurrence.

Extracranial Metastases of a Cerebral Glioblastoma: A Case Report and Review of the Literature

The glioblastoma, a malignant human brain tumor, is known for its devastating intracranial progress and its dismal prognosis. Whereas treatment and research are most prominently focused on the primary tumor lesion, in recent years evidence has accumulated that points to the rare occurrence of extracranial glioblastoma metastases. We here present a case of a female patient with a known glioblastoma who was detected to harbor multiple metastases in the bones, lung, pleura, liver, mesentery, and the subcutaneous soft tissue. Pathogenetically, these metastatic lesions developed most probably after a local progression of the left temporal glioblastoma through the skull base, thus getting access to the systemic lymphatics. Similar cases of extensive glioblastoma metastization, their putative underlying mechanisms, and implications for clinical care are discussed.

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.

Glioblastoma multiforme metastastic to the bone: diagnosis by (18)F-NaF PET/CT

Extracranial metastases from glioblastoma multiforme (GBM) are rare. We report a case of osseous metastases from GBM diagnosed by F-NaF PET/CT. A 30-year-old man with a history of GBM presented with bone pain and underwent F-NaF PET/CT for further evaluation. On PET/CT, intense uptake in 2 bone lesions was noted. Histopathologic evaluation revealed osseous metastases from GBM. Although rare, bone metastases have to be considered in patients with axial tumors and atraumatic bone pain. F-NaF PET/CT is a highly sensitive and valuable tool for detection of osseous metastases.

Extracranial glioblastoma with synchronous metastases in the lung, pulmonary lymph nodes, vertebrae, cervical muscles and epidural space in a young patient - case report and review of literature

Background

Extraneural and extracranial metastases of glioblastoma (GB) are very rarely reported in the literature. They occur in only 0.2% of all GB patients.

Case presentation

We present a 40 year old caucasian male with secondary GB and first diagnosis of an astrocytoma world health organisation (WHO) grade II through stereotactic biopsy in 2006. He presented a new hemiparesis and a progress of the known mass lesion in 2008. Subtotal tumor resection was performed and the histological examination verified a GB. After combined radio- and chemotherapy the adjuvant temozolomide therapy was not started because of non-compliance.

In 2011 a second local relapse was resected and 4 month later the patient presented a fast progressing tetraparesis. Cervical CT and MRI scan showed a mass lesion infiltrating the fifth and sixth vertebra with infiltration of the spinal canal and large paravertebral tumor masses. Emergency surgery was performed. By additional screening further metastases were detected in the thoracal and lumbal spine and surprisingly also in the lung and pulmonary lymphnodes. Palliative radio- and chemotherapy of the pulmonal lesions was completed, further antitumor therapy was rejected. The patient died 10 months after diagnosis of the extraneural metastases.

Conclusion

Especially young “long-term-survivors” seem to have a higher risk of extraneural metastasis from a GB and appropriate staging should be performed in these cases.

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.