Case of primary diffuse leptomeningeal gliomatosis

Leptomeningeal Spread at the Diagnosis of Glioblastoma Multiforme: A Case Report and Literature Review

Approximately two-thirds of glioblastoma (GBM) patients progress to leptomeningeal spread (LMS) within two years. While 90% of LMS cases are diagnosed during the progression and/or recurrence of GBM (defined as secondary LMS), LMS presentation at the time of GBM diagnosis (defined as primary LMS) is very rare. ¹⁸F-fluorodeoxy glucose positron emission tomography computed tomography (¹⁸F-FDG PET/CT) study helps to diagnose the multifocal spread of the malignant primary brain tumor. Our patient was a 31-year-old man with a tumorous lesion located in the right temporal lobe, a wide area of the leptomeninges, and spinal cord (thoracic 5/6, and lumbar 1 level) involvement as a concurrent manifestation. After the removal of the right temporal tumor, the clinical status progressed rapidly, showing signs of increased intracranial pressure and hydrocephalus caused by LMS. He underwent a ventriculoperitoneal shunt a week after craniotomy. During management, progression of cord compression, paraplegia, bone marrow suppression related to radiochemotherapy, intercurrent infections, and persistent ascites due to peritoneal metastasis of the LMS through the shunt system was observed. The patient finally succumbed to the disease nine months after the diagnosis of simultaneous GBM and LMS. The overall survival of primary LMS with GBM in our case was nine months, which is shorter than that of secondary LMS with GBM. The survival period after the diagnosis of LMS did not seem to be significantly different between primary and secondary LMS. To determine the prognostic effect and difference between primary and secondary LMS, further cooperative studies with large-volume data analysis are warranted.

[Primary leptomeningeal gliomatosis treated with temozolomide: a case report]

A 35-year-old man was admitted to our department for loss of consciousness. CT and MRI revealed diffuse enhancement of the subarachnoid space surrounding the brainstem and the cerebellar sulci, without any parenchymal lesions in the brain or the spinal cord. Furthermore, gadolinium-enhanced MRI revealed a nodular lesion with heterogeneous enhancement in the right prepontine cistern, at the site from which a biopsy was obtained via right lateral suboccipital craniotomy on the day following admission. Histopathological examination of the resected specimen revealed glioblastoma multiforme. Based on the radiological and histopathological findings, the patient was diagnosed with primary leptomeningeal gliomatosis (PLG). The patient received temozolomide chemotherapy with concurrent radiotherapy and showed radiological remission, 12 months after diagnosis. However, he developed local recurrence 6 months later and died 23 months after diagnosis. Autopsy findings showed tumor cell infiltration of the leptomeninges, as well as the brain and spinal parenchyma. PLG should be considered in the differential diagnosis in patients with diffuse leptomeningeal enhancement even without parenchymal lesions on radiological imaging. A surgical biopsy is recommended for prompt and accurate diagnosis in such cases.

Primary diffuse leptomeningeal oligodendrogliomatosis with an isolated 1p deletion

We report a case of primary diffuse leptomeningeal oligodendrogliomatosis with an isolated 1p deletion confirmed by fluorescent in situ hybridization (FISH) analysis in 52 year-old man. The MRI scan in a patient presenting with progressive headache, nausea and diplopia revealed diffuse leptomeningeal thickening and enhancement without definitive evidence of an intraparenchymal lesion. Biopsy of thickened, enhancing meninges within the left sylvian fissure revealed subarachnoid proliferation of oligodendroglial cells with varying degrees of de-differentiation and sparing of the underlying cortex. An isolated 1p deletion was confirmed by FISH analysis. This is the first reported adult case of a 1p deletion in primary diffuse leptomeningeal oligodendrogliomatosis.

Parenchymal Infiltration in Primary Diffuse Leptomeningeal Gliomatosis: Dynamic Changes in Brain MRI

Primary diffuse leptomeningeal gliomatosis (PDLG) is a rare and fatal disease with no special clinical manifestations. Here, we report the dynamic brain magnetic resonance imaging (MRI) changes in a 30-year-old female PDLG patient over a 10-month period. MRI showed aggressive dilation of the subarachnoid space and the ventricular system, numerous encapsulated cysts in the subarachnoid space and the dilated cerebral sulci, diffuse reticulated or focal nodular enhancement in the subarachnoid space, as well as overall enhancement in the cystic walls. In addition to the aforementioned PDLG pathological findings, MRI also revealed non-contrasted solid lesions and a contrasted cyst-like lesion in the paraventricular areas. The dynamic and multiform neuroradiological changes help us to understand the pathological process of PDLG. Of particular interest is the discovery that parenchymal infiltration can occur in PDLG.

Craniospinal irradiation with concomitant and adjuvant temozolomide--a feasibility assessment of toxicity in patients with glioblastoma with a PNET component

There is no standard treatment for glioblastoma with elements of PNET (GBM-PNET). Conventional treatment for glioblastoma is surgery followed by focal radiotherapy with concurrent temozolomide. Given the increased propensity for neuroaxial metastases seen with GBM-PNETs, craniospinal irradiation (CSI) with temozolomide (TMZ) could be a feasible treatment option but little is known regarding its toxicity. The clinical records of all patients treated at two UK neuro-oncology centres with concurrent CSI and TMZ were examined for details of surgery, radiotherapy, chemotherapy and toxicities related to the CSI-TMZ component of their treatment. Eight patients were treated with CSI-TMZ, the majority (6/8) for GBM-PNET. All patients completed radiotherapy to the craniospinal axis 35-40 Gy in 20-24 daily fractions with a focal boost to the tumour of 14-23.4 Gy in 8-13 daily fractions. Concurrent TMZ was administered at 75 mg/m(2) for seven of the cohort, with the other patient receiving 50 mg/m(2). The most commonly observed non-haematological toxicities were nausea and vomiting, with all patients experiencing at least grade 2 symptoms of either or both. All patients had at least grade 3 lymphopaenia. Two patients experience grade 4 neutropaenia and grade 3 thrombocytopaenia. Three of the eight patients required omission of TMZ for part of their chemoradiotherapy and 3/8 required hospital admission at some point during chemoradiotherapy. The addition of TMZ to CSI did not interrupt radiotherapy. Principal toxicities were neutropaenia, lymphopaenia, thrombocytopaenia, nausea and vomiting. Treatment with CSI-TMZ merits further investigation and may be suitable for patients with tumours at high-risk of metastatic spread throughout the CNS who have TMZ-sensitive pathologies.

Primary diffuse leptomeningeal gliomatosis as a rare cause of pain in cervical spine

Background

Primary diffuse leptomeningeal gliomatosis (PDLG) is a very rare neuro-oncological disease, with only 90 cases of PDLG described in medical literature so far.

Case presentation

We present a case report of a 56-years-old female patient, who was originally hospitalized due to cervical spine pain lasting several months. Despite complex diagnostics and treatment, the neurological state of the patient progressively deteriorated. Patient died 10 months after the first reported symptom. Postmortem pathological findings resulted in the diagnosis of PDLG.

Conclusions

Affection of the cervical spine in early stages of PDLG is rare and has been described in only six patients so far. PDLG is a fatal neuro-oncological disease and it must be kept in mind in the differential diagnosis of persistent back pain syndromes.

Primary Leptomeningeal Gliomatosis in Children and Adults: A Morphological and Molecular Comparative Study With Literature Review

BACKGROUND:

Primary leptomeningeal gliomatosis (PLG) is a poorly recognized tumor of the central nervous system.

OBJECTIVE:

To describe the histopathological, immunohistochemical, and molecular features of PLG.

METHODS:

Results of our multicentric retrospective study of 6 PLG cases (3 pediatric and 3 adult) were compared with literature data.

RESULTS:

The mean age was 54.7 years for adults and 8.7 years for children, with 3 males and 3 females. Clinical symptoms were nonspecific. Cerebrospinal fluid analyses showed a high protein level often associated with pleocytosis but without neoplastic cells. On neuroimaging, diffuse leptomeningeal enhancement and hydrocephalus were observed, except in 1 case. PLG was mostly misinterpreted as infectious or tumoral meningitis. The first biopsy was negative in 50% of cases. Histopathologically, PLG cases corresponded to 1 oligodendroglioma without 1p19q codeletion and 5 astrocytomas without expression of p53. No immunostaining for IDH1R132H and no mutations of IDH1/2 and H3F3A genes were found. Overall survival was highly variable (2-82 months) but seems to be increased in children treated with chemotherapy.

CONCLUSION:

This study shows the difficulties of PLG diagnosis. The challenge is to achieve an early biopsy to establish a diagnosis and to begin a treatment, but the prognosis remains poor. PLG seems to have a different molecular and immunohistochemical pattern compared with intraparenchymal malignant gliomas.

Primary diffuse leptomeningeal gliosarcomatosis

Primary diffuse leptomeningeal gliomatosis (PDLG) is a rare condition with a fatal outcome, characterized by diffuse infiltration of the leptomeninges by neoplastic glial cells without evidence of primary tumor in the brain or spinal cord parenchyma. In particular, PDLG histologically diagnosed as gliosarcoma is extremely rare, with only 2 cases reported to date. We report a case of primary diffuse leptomeningeal gliosarcomatosis. A 68-year-old man presented with fever, chilling, headache, and a brief episode of mental deterioration. Initial T1-weighted post-contrast brain magnetic resonance imaging (MRI) showed diffuse leptomeningeal enhancement without a definite intraparenchymal lesion. Based on clinical and imaging findings, antiviral treatment was initiated. Despite the treatment, the patient's neurologic symptoms and mental status progressively deteriorated and follow-up MRI showed rapid progression of the disease. A meningeal biopsy revealed gliosarcoma and was conclusive for the diagnosis of primary diffuse leptomeningeal gliosarcomatosis. We suggest the inclusion of PDLG in the potential differential diagnosis of patients who present with nonspecific neurologic symptoms in the presence of leptomeningeal involvement on MRI.

Diffuse leptomeningeal gliomatosis initially presenting with intraventricular hemorrhage: a case report and literature review

Background

Primary diffuse leptomeningeal gliomatosis (PDLG) is a lethal neoplasm that is characterized by glioma cells exclusively infiltrating into cerebral and spinal meninges. Intraventricular hemorrhage as an initial symptom in PDLG patient has not been reported in the literatures.

Case presentation

A 39-year-old man initially presented with intraventricular hemorrhage. The patient had an improved outcome at the early stage of hemorrhagic course; however, the clinical condition began to a sudden turn for deterioration with intracranial hypertension and cerebral hernia on day 15 after admission. Cerebral CT and MRI showed diffuse patchy signals with enhancement in bilateral cerebellopontine angle cistern, suprasellar cistern, ambient cistern, quadrigeminal cistern, bilateral cerebellum, cerebral hemisphere, and upper cervical cord surface. Pathological examination revealed that numerous spindled cells were scant of cytoplasm with hyperchromatic nuclei and various mitotic figures. Immunohistochemistry showed that the cells were positive to glial fibrillary acidic protein (GFAP) with about 5 % Ki-67 positive labeling. The pathological findings were consistent with the diagnostic criteria of anaplastic astrocytoma (WHO grade III).

Conclusion

We reported an interesting case that PDLG initially presented with intraventricular hemorrhage that might be caused by astrocytoma rupturing into pial vessels.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0341-1) contains supplementary material, which is available to authorized users.