Clinical and epidemiological characteristics of pediatric gliosarcomas

Pediatric gliosarcoma, a rare central nervous system tumor in children: Case report and literature review

Gliosarcoma is a rare and highly malignant central nervous system tumor that accounts for 1%-8% of glioblastomas; it usually occurs in middle-aged and older adults between 40 and 60 years of age and is rare in children. We report an 11-year-old boy with right frontal lobe gliosarcoma who underwent aggressive gross total resection and postoperative radiotherapy, experienced recurrence and subsequently underwent a second operation. To better understand the disease and explore treatment options, we briefly report this case and review the relevant literature.

Gliosarcoma With Glioneuronal and Rhabdomyosarcoma Components

Gliosarcoma is a rare subtype of glioblastoma, isocitrate dehydrogenase (IDH) wildtype. This biphasic tumor has two components. The first one is glial and usually represented by glioblastoma. The second is a sarcomatous component usually represented by nonspecific spindle cell sarcoma. Rarely, different glial tumors could represent the non-sarcomatous component, including oligodendroglioma and ependymoma. There were only two reported cases in the literature with glioneuronal components (both were anaplastic ganglioglioma) as the non-sarcomatous component. This work reports a gliosarcoma in the right frontal lobe of a 13-year-old female with a glioneuronal tumor representing the non-sarcomatous component and a rhabdomyosarcoma representing the sarcomatous component. The child lived for only six months after the resection of the tumor. The short survival attests to the dismal prognosis of gliosarcoma regardless of the nature of the non-sarcomatous component.

Pediatric Gliosarcoma With and Without Neurofibromatosis Type 1: A Whole-exome Comparison of 2 Patients

Gliosarcoma is rare among pediatric patients and among individuals with Neurofibromatosis Type 1 (NF1). Here we compare 2 pediatric gliosarcoma patients, one of whom has NF1. We performed whole-exome sequencing, methylation, and copy number analysis on tumor and blood for both patients. Whole-exome sequencing showed higher mutational burden in the tumor of the patient without NF1. Copy number analysis showed differences in chromosomal losses/gains between the tumors. Neither tumor showed O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation. The NF1 patient survived without progression while the other expired. This is the first reported case of gliosarcoma in a child with NF1.

Gliosarcoma in patients under 20 years of age. A clinicopathologic study of 11 cases and detailed review of the literature

BACKGROUND

Gliosarcoma is a rare variant of IDH- wild type glioblastoma with both glial and mesenchymal differentiation. It accounts for approximately 2% of glioblastomas and has a poor prognosis similar to that of classic glioblastoma. It is seen mostly between 40 and 60 years of age with a mean age over 50 years. Pediatric gliosarcoma is even rarer than gliosarcoma in adults. We describe the clinicopathological features of gliosarcoma in patients under 20 years of age and determine whether there are significant differences from gliosarcoma in adults. We also present detailed review of published literature on pediatric gliosarcoma.

METHODS

Slides of gliosarcomas in patients under 20 years of age were reviewed. Clinicopathological features were noted in detail and follow up was obtained.

RESULTS

Eleven cases of gliosarcoma were reported in patients under 20 years of age. Ages ranged from three to 19 years (mean age 13 years). Frontal, parietal and temporal lobes were the commonest locations. Mean and median tumor size was six and five cm respectively. All 11 cases demonstrated the classic biphasic pattern. In 10 cases, glial component was astrocytic and was highlighted on GFAP. Sarcomatous component in most cases resembled fibrosarcoma and was high grade in 72.7%. Glial areas were reticulin poor while sarcomatous areas were reticulin rich. In over 45% cases, bizarre tumor giant cells were seen in the sarcomatous areas. In 1 case, sarcomatous areas showed extensive bone and cartilage formation. Other histologic features included hyalinized blood vessels, hemorrhage, infarction, gemistocytic cells, rhabdoid cells etc. Follow up was available in nine patients, five received chemoradiation post resection while three received radiotherapy only. Prognosis was dismal and eight patients died within one to 14 months following resection.

CONCLUSIONS

Gliosarcomas in patients under 20 comprised 13% of all gliosarcomas reported during the study period. Frequency and mean age were higher compared to other published reports. Pathological features were similar to those described in literature. Clinicopathological features and prognosis of pediatric gliosarcomas were similar to adult gliosarcomas.

Retrobulbar chlorpromazine injection in a child with gliosarcoma invasion into the orbits

This paper has two main purposes: (1) to report a rare case of paediatric gliosarcoma that invaded the surrounding orbit and (2) to demonstrate chlorpromazine injection as a potential treatment option for blind, painful eye caused by tumour invasion. A 12-year-old man who presented with headaches was found to have glioblastoma multiforme and it was excised and treated with radiation and chemotherapy. Seven months later, the tumour recurred as gliosarcoma, a rare variant of glioblastoma multiforme containing distinct gliomatous and sarcomatous components. In spite of treatment, the tumour progressed and eventually invaded into the right orbit. He subsequently developed a proptotic, blind, painful eye and was treated with retrobulbar chlorpromazine injection, which provided immediate symptomatic relief.

Primary pediatric cerebellar gliosarcoma

Background:

Primary gliosarcomas of the central nervous are rare and very few have been reported in the infratentorial compartment. Here, we describe such a lesion in a 12-year-old male.

Case Description:

A 12-year-old male presented with headache, ataxia, and vomiting. When Magnetic resonance studies documented a posterior fossa lesion, he underwent placement of a right ventriculoperitoneal shunt followed by a suboccipital craniectomy. The lesion proved to be a primary gliosarcoma. Unfortunately, it recurred 2 years later and required repeated resection.

Conclusion:

Here, we reviewed the rare case of a 12-year-old male requiring shunt placement and suboccipital craniectomy for a primary gliosarcoma that recurred 2 years later.

Evaluating Surgical Resection Extent and Adjuvant Therapy in the Management of Gliosarcoma

Introduction: Gliosarcomas are clinically aggressive tumors, histologically distinct from glioblastoma. Data regarding the impact of extent of resection and post-operative adjuvant therapy on gliosarcoma outcomes are limited.

Methods: Patients with histologically confirmed gliosarcoma diagnosed between 1999 and 2019 were identified. Clinical, molecular, and radiographic data were assembled based on historical records. Comparisons of categorical variables used Pearson's Chi-square and Fisher's exact test while continuous values were compared using the Wilcoxon signed-rank test. Survival comparisons were assessed using Kaplan-Meier statistics and Cox regressions.

Results: Seventy-one gliosarcoma patients were identified. Secondary gliosarcoma was not associated with worse survival when compared to recurrent primary gliosarcoma (median survival 9.8 [3.8 to 21.0] months vs. 7.6 [1.0 to 35.7], p = 0.7493). On multivariable analysis, receipt of temozolomide (HR = 0.02, 95% CI 0.001–0.21) and achievement of gross total resection (GTR; HR = 0.13, 95% CI 0.02–0.77) were independently prognostic for improved progression-free survival (PFS) while only receipt of temozolomide was independently associated with extended overall survival (OS) (HR = 0.03, 95% CI 0.001–0.89). In patients receiving surgical resection followed by radiotherapy and concomitant temozolomide, achievement of GTR was significantly associated with improved PFS (median 32.97 [7.1–79.6] months vs. 5.45 [1.8–26.3], p = 0.0092) and OS (median 56.73 months [7.8–104.5] vs. 14.83 [3.8 to 29.1], p = 0.0252).

Conclusion: Multimodal therapy is associated with improved survival in gliosarcoma. Even in patients receiving aggressive post-operative multimodal management, total surgical removal of macroscopic disease remains important for optimal outcomes.

Pediatric gliosarcoma treated with adjuvant radiotherapy and temozolomide

PURPOSE

Primary pediatric gliosarcoma (pPGS) is an extremely rare entity with only 25 cases reported in the English literature. The value of concurrent and adjuvant temozolomide is not known in this group of patient.

METHODS

Five patients of pPGS treated from 2006 to 2011 were included in this retrospective analysis. All patients underwent maximal safe surgical resection. Adjuvant therapy included conformal radiation 60 Gy in 30 fractions (2 Gy daily for 5 days in a week) with concurrent temozolomide 75 mg/m(2) daily followed by six cycles of maintenance temozolomide 150-200 mg/m(2) (day 1 to day 5) every 4 weeks. We combined the survival data of 25 patients (already published) and five of our patients and analyzed them in terms of progression free survival (PFS) and overall survival (OS) using Kaplan-Meier method.

RESULTS

Male to female ratio was 1:4 and median age was 12 years (range, 7-19 years). All but one patient underwent gross total resection and four patients completed adjuvant radiotherapy as well as concurrent and adjuvant temozolomide. At a median follow up of 22.6 months (range, 0 to 45.3 months), two patients were dead and two were alive without disease while one was lost to follow up. For the pooled data, estimated median PFS and OS of all 30 patients reported in literature were 12 and 43 months, respectively. Two years PFS and OS rate for all patients was 44.2 and 62.9%, respectively.

CONCLUSION

Adjuvant radiotherapy and temozolomide is well tolerated and show an encouraging survival in pPGS.

Therapeutic management of gliosarcoma in the temozolomide era

Gliosarcoma (GS) is a malignant, uncommon variant of high-grade glioma comprised of infiltrative glial and atypical sarcomatous cells, identified in adult and pediatric populations. GS has been subcategorized into primary (de novo) and secondary tumors, with the latter typically arising in the setting of prior glioblastoma. Due to its rarity, the pathogenesis, epidemiology and optimal therapy of GS have been based on small retrospective cohort studies, with treatment presently utilizing regimens established for other high-grade gliomas, including combination of resection, radiotherapy and temozolomide-based chemotherapy. As more information is gathered about GS molecular profiles, novel treatment strategies may be developed to improve outcomes of GS patients. Here we summarize results of GS management with focus on the temozolomide era.

Malignant pediatric gliosarcoma defies general survival data

Gliosarcoma, a variant of glioblastoma multiforme, is a dimorphic tumor known for its intra-axial occurrence and poor survival of less than a year. Here is an 11-year-old boy with gliosarcoma. He had a near total excision and postoperative chemoradiotherapy. He has lived through the disease for over 34 months with a residual disease.This case report is to report an unusual long survival of gliosarcoma in a teenager (Ravisankar et al., 2012).

Long-term survival (>13 years) in a child with recurrent diffuse pontine gliosarcoma: a case report

Pediatric gliosarcoma (GS) is a rare variant of glioblastoma multiforme. The authors describe the case of an unusual pontine location of GS in a 9-year-old boy who was initially diagnosed with low-grade astrocytoma (LGA) that was successfully controlled for 4 years. Subsequently, his brain tumor transformed into a GS. Prior treatment of his LGA included subtotal tumor resection 3 times, standard radiation therapy, and Gamma Knife procedure twice. His LGA was also treated with a standard chemotherapy regimen of carboplatin and vincristine, and his GS with subtotal resection, high-dose cyclophosphamide, and thiotepa with stem cell rescue and temozolomide. Unfortunately, he developed disseminated disease with multiple lesions and leptomeningeal involvement including a tumor occupying 80% of the pons. Upon presentation at our clinic, he had rapidly progressing disease. He received treatment with antineoplastons (ANP) A10 and AS2-1 for 6 years and 10 months under special exception to our phase II protocol BT-22. During his treatment with ANP his tumor stabilized, then decreased, and, ultimately, did not show any metabolic activity. The patient's response was evaluated by magnetic resonance imaging and positron emission tomography scans. His pathology diagnosis was confirmed by external neuropathologists, and his response to the treatment was determined by central radiology review. He experienced the following treatment-related, reversible toxicities with ANP: fatigue, xerostomia and urinary frequency (grade 1), diarrhea, incontinence and urine color change (grade 2), and grade 4 hypernatremia. His condition continued to improve after treatment with ANP and, currently, he complains only of residual neurological deficit from his previous surgery. He achieved a complete response, and his overall and progression-free survival is in excess of 13 years. This report indicates that it is possible to obtain long-term survival of a child with a highly aggressive recurrent GS with diffuse pontine involvement with a currently available investigational treatment.

Pediatric glioblastoma: clinico-radiological profile and factors affecting the outcome

BACKGROUND AND PURPOSE

Glioblastoma in the pediatric age group is relatively rare. As a result, it has been difficult to deduce any consistent clinico-radiological and pathological profiles on these patients. Also, the prognostic factors affecting the survival in pediatric glioblastoma are not as well defined as in adults.

PATIENTS AND METHODS

In this retrospective series, 65 pediatric patients (age ≤ 18 years) from January 1995 to December 2011 with histopathologically proven diagnosis of intracranial glioblastoma were studied. Clinico-radiological, pathological, treatment, and follow-up data were collected. Progression-free and overall survivals were assessed using the Kaplan-Meier method.

RESULTS

The male-to-female ratio was 2.6:1 with a mean age of 13.29 ± 4.53 years (range 2-18 years). Headache with or without vomiting (n = 51, 78 %), followed by seizures (n = 42, 65 %), and focal deficits (n = 31, 47 %) were the leading symptoms. Forty-nine (75 %) patients had tumors located superficially, whereas there were 16 patients with deeply located glioblastomas (25 %). Gross total tumor excision was achieved in 43 (66 %) patients, while the remaining patients had incomplete excision (n = 22, 34 %). Mean follow-up was 17.7 months (range 1.5-119 months). The median progression-free and overall survivals were 10 and 20 months, respectively. Extent of resection was found to be the independent predictor of survival (p value = 0.002).

CONCLUSION

Pediatric glioblastomas are associated with longer progression-free as well as overall survivals. Extent of tumor resection is the strongest predictor of survival in pediatric glioblastoma. Hence, an aggressive surgical resection may fetch a better outcome in children with glioblastoma.

Clinical and molecular characteristics of congenital glioblastoma

Congenital glioblastoma (cGBM) is an uncommon tumor of infancy with a reported variable but often poor cure rate, even with intensive therapy. Five patients with cGBMs, arising de novo and not in familial tumor predisposition kindreds, were studied for histological and biological features, using Affymetrix microarray. Tumors were large, often associated with hemorrhage, extended into the thalamus, and often bulged into the ventricles. One patient died acutely from bleeding at the time of operation. The 4 surviving patients underwent surgery (1 gross total resection, 3 subtotal resections or biopsies) and moderate intensity chemotherapy without radiation, and remain progression-free at a median time of 36 months (range, 30-110 months). Affymetrix microarrays measured gene expression on the 3 cGBMs from which frozen tissue was available. Unsupervised hierarchical clustering of cGBMs versus 168 other central nervous system tumors demonstrated that cGBMs clustered most closely with other high-grade gliomas. Gene expression profiles of cGBMs were compared with non-congenital pediatric and adult GBMs. cGBMs demonstrated marked similarity to both pediatric and adult GBMs, with only 31 differentially expressed genes identified (false discovery rate, <0.05). Unique molecular features of cGBMs included over-expression of multiple genes involved in glucose metabolism and tissue hypoxia. cGBMs show histological and biological overlap with pediatric and adult GBMs but appear to have a more favorable outcome, with good response to moderate intensity chemotherapy with only subtotal resection or biopsy. Further study may determine whether identified gene expression differences contribute to the improved survival seen in these tumors.

Primary gliosarcoma--clinical experience from a regional cancer centre in north India

AIMS

We intended to assess the clinicopathological features and treatment outcome in patients of primary gliosarcoma, a rare malignant brain tumour.

MATERIALS AND METHODS

Medical records were reviewed and data collected on primary gliosarcoma over an 8-year period (2002-2009) from the departmental archives. Overall survival (OS) was analysed by Kaplan-Meier method.

RESULTS

Seventeen patients met the study criterion (male:female = 9:8). Median age and performance status at presentation were 50 years and Karnofsky performance scale (KPS) 70, respectively. Symptoms of raised intracranial tension (in 100%) and motor impairment (in 64.7%) were commonly observed. Tumour location was frontal in four patients, temporal in three, parietal in three, thalamic in one, multilobed in five and multicentric in one. All patients underwent maximal safe surgery (total excision-10, near-total excision-2, subtotal excision and decompression-5). On histopathology, all tumours showed biphasic pattern, glial component positive for glial fibrillary acidic protein (GFAP) and mesenchymal component positive for vimentin and reticulin. Atypia, mitoses, necrosis and endothelial proliferation were identified in the glial component. Post-operative radiotherapy (median dose--60 Gy/30#/6 weeks) was used in 15 patients (88.2%). Concurrent and adjuvant chemotherapy with temozolomide (TMZ) were used in two patients depending upon affordability. After the completion of treatment, 35.3% patients were asymptomatic, 23.5% had symptomatic improvement, while 41.2% deteriorated. Salvage therapy for local recurrence was used in three patients (temporal lobectomy-1; total excision-1; TMZ+bevacizumab-1). At last follow-up (FU), eight patients were alive, seven patients dead and two patients lost to FU with symptom. Median overall survival in the evaluable patients (N = 15) was noted to be 8.27 months (6 month survival 60.76%).

CONCLUSIONS

Primary gliosarcoma, a variant of glioblastoma poses clinical challenge because of rarity, poor prognosis and limited experience. In our centre, principle of therapy is akin to that of glioblastoma--surgery followed by radiation along with concurrent and adjuvant TMZ. However, chemotherapy is often cost-prohibitive in our setting as mirrored by limited use (17.6%). Median survival of only 8.27 months in our series is in concert with the existing survival result of primary gliosarcoma in world literature (6.25-11.5 months).

[Clinical factors in glioblastoma and neuroradiology]

Glioblastoma is found preferentially in men (1.5/1), nearing age 60, but all ages can be concerned. Clinical symptoms are intracranial mass without specificity, intracranial hypertension and localization signs. From the clinical history, the essential prognosis factors are: age, Karnofsky score and cognitive dysfunction. Conventional MRI sequences, including T1-FSE with and without contrast injection and T2-FSE or Flair-weighted sequences, provide the diagnosis in most cases, showing an intraparenchymal mass with a heterogeneous, irregularly enhanced signal. Other sequences define the tumor more precisely. Diffusion sequences provide the differential diagnosis with an abscess or a highly cellular tumor such as lymphoma. Perfusion sequences allow appreciation of tumor microvascularization outlining the tumor's most active areas. Magnetic resonance spectroscopy (SRM) sequences allow noninvasive exploration of tumor metabolism. Beyond its diagnostic role, imagery assists the surgical procedure itself, particularly with functional MRI, allowing a precise preoperative mapping of functional cortical areas. Biopsy can also be guided toward the most active areas of the tumor. In the postoperative period, MRI completes the surgeon's impression on whether or not there is residual tumor. Finally, this exam has become essential in follow-up to diagnose recurrence, radionecrosis, or pseudoprogression.