Glioblastoma of the cerebellum. Computed tomographic and pathologic considerations

Primary glioblastoma of cerebellopontine angle: The diagnostic dilemma of this rare case

Supratentorial glioblastoma is a common primary intracranial tumor in adults. High-grade glioma in cerebellopontine angle (CPA) is rare. We describe a case of adult-type diffuse high-grade glioma of CPA in a 49-year-old female that was managed surgically at our institute. Glioblastoma is an infiltrating type of glioma (WHO grade 4). MRI helped in characterizing the lesion; however, diagnosis was confirmed on histopathology. This report aims at the imaging pattern of primary adult-type diffuse high-grade glioma (WHO grade 4) at cerebellopontine angle.

Unexpected Prolonged Survival in a Case of Cerebellar GBM: An Interesting Case with Literature Review

Glioblastoma multiforme (GBM) of cerebellar hemisphere is a rare entity and constitutes less than 1% of all the GBMs. The rarity of occurrence leads to significant challenge in differentiating morphologically from other subtypes of glioma in the posterior fossa. Previous studies have suggested that cerebellar GBM occurs in the younger age group as compared with the supratentorial counterpart.

Here, we report a case of cerebellar GBM in a young adult and discuss the pathogenesis including radiological and pathological aspects involved in the treatment of cerebellar GBM.

Cerebellar anaplastic astrocytoma in adult patients: 15 consecutive cases from a single institution and literature review

Adult cerebellar anaplastic astrocytomas (cAA) are rare entities and their clinical and genetic appearances are still ill defined. Previously, malignant gliomas of the cerebellum were combined and reviewed together (cAA and cerebellar glioblastomas (cGB), that could have possibly affected overall survival (OS) and progression-free survival (PFS). We present characteristics of 15 adult patients with cAA and compared them to a series of 45 patients with a supratentorial AA (sAA) in order to elicit the effect of tumor location on OS and PFS. The mean age at cAA diagnosis was 39.3 years (range 19-72). A history of neurofibromatosis type I was noted in 1 patient (6.7%). An IDH-1 mutation was identified in 6/15 cases and a methylated MGMT promoter in 5/15 cases. Patients in study and control groups were matched in age, sex and IDH-1 mutation status. Patients in a study group tended to present with longer overall survival (50 vs. 36.5 months), but the difference did not reach statistical significance. In both cAA and supratentorial AA groups presence of the IDH-1 mutation remains a positive predictor for the prolonged survival. The present study suggests that adult cAA constitute a group of gliomas with relatively higher rate of IDH-1 mutations and prognosis similar to supratentorial AA. The present study is the first to systematically compare cAA and supratentorial AA with respect to their genetic characteristics and suggests that both groups show a similar survival prognosis.

A Rare Case of Cerebellar Glioblastoma Mimicking Acute Stroke in an Elderly Patient

Patient: Female, 82-year-old

Final Diagnosis: Cerebellar glioblastoma

Symptoms: Dizziness

Medication: —

Clinical Procedure: —

Specialty: Neurology

Glioblastoma Multiforme of the Cerebellum in an Elderly Man. A Case Report

Glioblastoma multiforme of the cerebellum is rare and comprises a small fraction of all glioblastomas. Eighty-five cases have been reported in the literature to date. A 75 year old man is reported with a left cerebellar glioblastoma multiforme. The pathogenesis, course, treatment and prognosis are reviewed.

Insular Gliomas with Exophytic Extension to the Sylvian Cistern: A Glioma Growth Pattern That Has Gone Previously Unnoticed

BACKGROUND

An exophytic tumor is defined as a tumor that has its epicenter in the nervous tissue but grows outside the anatomical superficial boundaries of the brain within an adjacent space. Exophytic extension of hemispheric gliomas is extremely rare. The object of this study is to describe the exophytic growth pattern of insular gliomas.

METHODS

A series of 28 insular gliomas operated on consecutively were analyzed. The definition of exophytic glioma included these 2 criteria: 1) preoperative magnetic resonance imaging with evidence of exophytic local tumor extension outside the anatomical superficial boundaries of the brain; and 2) surgical identification of piamater and arachnoid invasion, with tumor growth to the adjacent cisterns.

RESULTS

A series of 6 exophytic gliomas (21.4%) are reported, among a series of 28 consecutive insular gliomas operated. The exophytic component originated from the posterior portion of the basal frontal lobe, with extension to the sphenoidal compartment of the sylvian cistern, reaching the temporal pole. All exophytic tumors were type 5A in Yasargil classification. The histologic diagnosis was World Health Organization grade II glioma in 3 cases and anaplastic glioma in 3 cases. All patients underwent surgery, and the exophytic component was removed completely.

CONCLUSIONS

Radiologic features that define the exophytic growth pattern in insular gliomas are the posterior displacement of the middle cerebral artery and a sharp subarachnoid margin that separates the exophytic tumor from the temporal pole. Contrary to the tumor that infiltrates the anterior perforating substance, the exophytic tumor is amenable for safe and complete resection.

Cerebellar glioblastoma multiforme presenting as hypertensive cerebellar hemorrhage: case report

Background Cerebellar glioblastoma multiforme (GBM) is rare and presents with increased intracranial pressure and cerebellar signs. The recommended treatment is radical resection, if possible, with radiation and chemotherapy.

Clinical Presentation A 53-year-old man presented with hypertensive cerebellar bleeding and a 2-day history of severe headaches, nausea, vomiting, gait instability, and elevated blood pressure. Computed tomography (CT) showed a left cerebellar hematoma with no obstruction of cerebrospinal fluid and no hydrocephalus. CT angiography showed no signs of pathologic blood vessels in the posterior cranial fossa. The patient was observed in the hospital and discharged. Subsequent CT showed complete hematoma resorption. Two weeks later, he developed headaches, nausea, and worsening cerebellar symptoms. Magnetic resonance imaging (MRI) showed a 4-cm diameter tumor in the left cerebellar hemisphere where the hemorrhage was located. The tumor was radically resected and diagnosed as GBM. The patient underwent radiation and chemotherapy. At a follow-up of 1.5 years, MRIs showed no tumor recurrence.

Conclusion Hypertensive cerebellar hemorrhage may be the first presentation of underlying tumor, specifically GBM. Patients undergoing surgery for cerebellar hemorrhage should have clot specimens sent for histologic examination and have pre- and postcontrast MRIs. Patients not undergoing surgery should have MRIs done after hematoma resolution to rule out underlying tumor.

Exophytic cerebellar glioblastoma in the cerebellopontine angle: case report and review of the literature

We report the unique case of a 69-year-old man with a cerebellar glioblastoma showing an exophytic growth pattern. Magnetic resonance imaging revealed a heterogeneously gadolinium-enhancing tumor in the right cerebellopontine angle. The preoperative differential diagnoses included an intraaxial tumor, such as high-grade glioma, and an extraaxial tumor, such as a meningioma or neurinoma. The tumor with a clear boundary was subtotally removed, except for the adhesion site to the petrosal vein, and the histologic diagnosis was glioblastoma. Immunohistochemical analyses demonstrated that the tumor cells were immunopositive for epidermal growth factor receptor and immunonegative for p53 mutation and IDH1 R132H, indicating that it had different genetic features from a typical cerebellar glioblastoma. Conventional radiotherapy with 60 Gy concurrent with temozolomide was performed, and the condition of the patient has remained stable for 24 months since the operation. Exophytic cerebellar glioblastoma should be considered in the differential diagnosis of cerebellopontine angle tumor.

Outcome and prognostic factors in adult cerebellar glioblastoma

Cerebellar glioblastoma multiforme (GBM) occurs rarely in adults, accounting for 0.4-3.4% of all GBM. Current studies have all involved small patient numbers, limiting the clear identification of prognostic factors. Additionally, while few studies have compared cerebellar GBM to their supratentorial counterparts, there is conflicting data regarding their relative prognosis. To better characterize outcome and identify patient and treatment factors which affect survival, the authors analyzed cases of adult cerebellar GBM from the Surveillance, Epidemiology, and End Results database. A total of 247 adult patients with cerebellar GBM were identified, accounting for 0.67% of all adult GBM. Patients with cerebellar GBM were significantly younger than those with supratentorial tumors (56.6 versus 61.8 years, p < 0.0001), but a larger percentage of patients with supratentorial GBM were Caucasian (91.7% versus 85.0%, p < 0.0001). Overall median survival did not differ between those with cerebellar and supratentorial GBM (7 versus 8 months, p = 0.24), with similar rates of long-term (greater than 2 years) survival (13.4% versus 10.6%, p = 0.21). Multivariate analysis revealed age greater than 40 years (hazard ratio [HR]: 2.20; 95% confidence interval [CI]: 1.47-3.28; p = 0.0001) to be associated with worse patient survival, while the use of radiotherapy (HR: 0.33; 95% CI: 0.24-0.47; p < 0.0001) and surgical resection (HR: 0.66; 95% CI: 0.45-0.96; p = 0.028) were seen to be independent favorable prognostic factors. In conclusion, patients with cerebellar GBM have an overall poor prognosis, with radiotherapy and surgical resection significantly improving survival. As with supratentorial GBM, older age is a poor prognostic factor. The lack of differences between supratentorial and cerebellar GBM with respect to overall survival and prognostic factors suggests these tumors to be biologically similar.

Adult cerebellar glioblastoma cases have different characteristics from supratentorial glioblastoma

This study is a histological and clinical investigation of four cases of cerebellar glioblastoma, a rare tumor. The cases included three males and one female, from 33 to 67 years in age (mean 49 years). Tumor resection, postoperative irradiation and chemotherapy were performed in all cases. Two patients died of local tumor recurrence after 14 and 27 months. Another patient relapsed after 10 months; however, after additional tumor resection and second line chemotherapy, she remains disease-free 41 months after the initial treatment. The fourth patient has not relapsed in the 6 months since initial treatment. The histopathology of all cases was glioblastoma with pseudopalisading necrosis. However, low-grade glioma histopathology was found in three patients. All glioblastomas were immunopositive for p53 and immunonegative for epidermal growth factor receptor (EGFR) and isocitrate dehydrogenase 1 (IDH1). These adult cerebellar glioblastoma cases had similar clinical and pathological characteristics, and had different characteristics compared with supratentorial glioblastomas.

Cerebellar glioblastomas: pathophysiology, clinical presentation and management

Glioblastoma multiforme usually affects the cerebral hemispheres with the peak age of onset in the sixth or seventh decade, while cerebellar glioblastoma multiforme is a rare tumour especially in younger patients. Most result from de-differentiation from low grade astrocytoma (secondary glioblastoma) or can develop de novo (primary glioblastoma). Primary glioblastomas develop in older patients while secondary glioblastomas develop in younger patients and contain TP53 mutations as the earliest detectable change. We report a 28 year old patient with primary multi-focal cerebellar glioblastoma multiforme and review the pathophysiology, clinical presentation, diagnosis and treatment of cerebellar glioblastomas.

Cerebellar glioblastoma multiforme in an adult

Primary cerebellar glioblastoma multiforme (GBM) is a rare tumor in adults that accounts for just 1% of all cases of GBM. Due to their rarity, cerebellar GBMs are not yet completely understood about the pathogenesis and the prognosis. Here, we present a case of GBM in a 69-year-old man. Neurologic examination revealed the presence of cerebellar signs. Magnetic resonance imaging (MRI) showed a 4.5 x 3.6 cm-sized, ill-defined, heterogeneously enhancing mass in the left cerebellum and two patchy hyperintense lesions in the right cerebellum with minimal enhancement. After operation, glioblastoma was histologically confirmed. Postoperative radiotherapy with concomitant and adjuvant temozolomide chemotherapy was subsequently followed. Here, a case of unusual GBM in the cerebellum is reported with review of literature regarding the pathogenesis, the differential diagnosis and prognosis. There was no evidence of recurrence during postoperative one year. This patient showed a good prognosis in spite of the multiple lesions.

Leptomeningeal dissemination of cerebellar malignant astrocytomas

Primary malignant astrocytomas of the cerebellum are extremely rare, and the dissemination patterns and effectiveness of postoperative radiation therapy are unclear. Five consecutive cases of histologically proven cerebellar malignant astrocytoma, two anaplastic astrocytomas, one anaplastic pilocytic astrocytoma, and two glioblastomas, were treated between 1997 and 2001. Four patients underwent surgical removal, local irradiation, and chemotherapy, and one patient with anaplastic pilocytic astrocytoma received subtotal removal followed by gamma knife radiosurgery for the residual tumor. Two patients had no recurrence at the primary site. All patients developed leptomeningeal dissemination. Four patients had supratentorial dissemination and two patients had spinal metastases. The time interval between the diagnosis of the primary cerebellar tumor and the diagnosis of leptomeningeal dissemination was 5-29 months (mean 14.6 +/- 10.4 months). All patients died at 10-38 months (mean survival 22.2 +/- 13.6 months). Intensive treatment including chemotherapy and radiotherapy may be required in cerebellar malignant astrocytomas, considering the high incidence of symptomatic leptomeningeal dissemination.

Malignant gliomas of the cerebellum: an analytic review

Using an analytical review, the demographic data on malignant cerebellar gliomas such as length of survival, and those factors associated with prolonged survival were examined. Seventy-one cases of malignant cerebellar glioma reported since 1975 were combined and reviewed with the seven cases treated at our institution since that time. Thirty-seven patients (47%) had grade III tumors and 41 (53%) had grade IV tumors. Fifty-nine percent of the tumors were located in the hemispheres and 41% were found in the vermis. Median survival for patients with grade III anaplastic astrocytomas was 32 months compared to 11 months for those with grade IV glioblastomas multiforme (P = 0.0257). For the entire cohort, patients with grade III tumors, those who had a surgical resection, and those that had received radiation therapy for treatment of their tumor had prolonged survival on multivariable analysis. Radiation therapy was associated with extended survival for patients with grade III tumors by uni- and multivariate analysis. For grade IV tumors, univariate analysis revealed prolonged survival for those patients who had surgical resection compared to those who had biopsy alone (P = 0.0036) and for those who received external beam radiation therapy (P = 0.0001). Patients with malignant gliomas of the cerebellum had length of survival comparable to their supratentorial counterparts. Prompt diagnosis and treatment may explain the similarity in survival found between supra- and infratentorial malignant gliomas despite an expected shorter survival because of treatment limitations. Surgical resection followed by radiation therapy is recommended for patients with malignant gliomas of the cerebellum.

A rare case of cerebellar glioblastoma multiforme in childhood: MR imaging

Glioblastoma multiforme is a highly malignant brain neoplasm that is very rarely discovered in childhood but accounts for approximately 17% of intracranial tumors in the adult. Only approximately 25 children with glioblastoma multiforme in the cerebellum have been described in the literature. We report on a 4 1/2-year-old girl with this tumor in the cerebellar hemisphere and discuss the magnetic resonance imaging findings.

Poorly differentiated gliomas of the cerebellum. A study of 18 patients

Eighteen patients with poorly differentiated gliomas of the cerebellum were treated by the University of California San Francisco Neuro-Oncology Service between January 1977 and January 1987. Within this group pathologic diagnosis included five glioblastoma multiforme (28%), nine anaplastic astrocytomas (50%), and four mixed malignant gliomas (22%). The group included 13 male and five female patients with a median age at diagnosis of 23 years (range, 4-46 years). All patients underwent surgical resection, 16 of 18 received radiation therapy (12 limited-field irradiation and four whole-brain with or without a posterior fossa boost), and 16 of 18 received chemotherapy. Overall median survival was 31.5 months (range, 5-366 months). Ten patients (55%) died of recurrent disease with a median survival of 32 months (range, 5-128 months), two of whom manifested metastatic disease within the central nervous system (one parietal lobe and one cervical cord). Of the two extracerebellar metastatic recurrences, one patient failed at the junction of whole-brain irradiation and the cervical cord and one patient failed after inadequate posterior fossa irradiation. Eight patients (45%) are alive with a median follow-up of 27.5 months (range, 14-366 months). In this series recurrences of primary cerebellar anaplastic gliomas were locoregional failures. As a consequence, the authors suggest high-dose limited-field irradiation directed at the primary tumor as in their current strategy utilized for supratentorial gliomas.

Malignant cerebellar astrocytic tumours in children

The authors reviewed 5 cases of histopathologically verified malignant cerebellar astrocytic tumours (2 anaplastic astrocytomas and 3 glioblastomas) in children admitted to our department. All cases exhibited symptoms and signs of increased intracranial pressure and of a cerebellar lesion. Brain stem symptoms were present in 4 cases. All of the tumours were located in or near the midline of the cerebellum with no large cyst. Surgical removal (70 to 90% removal) of the tumour was performed in 4 cases. In one case only a biopsy was done. Even with subsequent follow-up treatment including radiotherapy, chemotherapy, and/or immunotherapy, the course of the disease could not be reversed, and all of the children died 3 to 13 months (mean 7 months) after admission due to tumour re-growth or recurrence. Tumour dissemination along the walls of the ventricular system was seen in 2 cases, and was considered to be a peculiar, fatal form of tumour recurrence in patients with this type of tumour. Malignant cerebellar astrocytic tumours in children have an extremely poor prognosis. Until, improved therapy is available to counteract this tragic consequence, it will remain so.

Primary cerebellar glioblastoma multiforme

Glioblastoma multiforme in adults arising in the cerebellum is a rare tumor, well documented in only 13 cases in the literature. We report a fourteenth case, an 80-year-old female, and reassess the clinical and CT aspects of this tumor based on review of the world's literature. The median age of patients is 53 years with a median survival of three months, which is less than adult cerebral hemisphere malignant gliomas.

Evolution and outcome in malignant astroglial neoplasms of the cerebellum

Malignant astroglial neoplasms of the cerebellum are rare and the clinical behavior of these tumors is unpredictable. The authors describe the histological characteristics and clinical outcome in 10 patients; eight had malignant cerebellar astrocytomas, and one each had an astroblastoma and a true polar spongioblastoma. Malignant glial tumors involving the cerebellum usually behave very aggressively. Cerebellar astroblastomas and polar spongioblastomas are too rare to predict their natural history. Some hypotheses are proposed concerning the evolution and interrelationship of malignant glial tumors of the cerebellum.