The clinical experience of recurrent central nervous system hemangioblastomas

Novel Clinical Insights into Spinal Hemangioblastoma in Adults: A Systematic Review

BACKGROUND

Hemangioblastomas (HBs) are well-vascularized, benign central nervous system tumors and the third most common primary spinal cord tumor after astrocytoma/ependymoma, occurring sporadically or as a part of autosomal dominant von Hippel-Lindau disease, in which tumors are often multiple and prone to relapse. Spinal HBs are commonly located in the cervical cord and associated with a syrinx formation. Owing to location and growth trends, they may cause significant neurological deficit, impairing quality of life. We conducted a systematic review to understand better clinical insights into spinal HB in adults and compare spinal HB versus posterior cranial fossa HB.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews, we reviewed the English-language literature on adult spinal HB in the MEDLINE/PubMed database over the last 40 years.

RESULTS

We reviewed 237 articles on adult spinal HB and analyzed national and continental distribution, clinical symptoms, tumor location and presence of syringomyelia, treatment strategies and postoperative complications, histology and immunochemistry, and treatment outcomes. We compared individual characteristics in sporadic and von Hippel-Lindau disease spinal HBs. Finally, we compared features of posterior cranial fossa and spinal HBs.

CONCLUSIONS

Spinal cord HBs most commonly have a dorsal intramedullary location. Total surgical tumor resection is the first treatment option; preoperative embolization may be performed to reduce intraoperative bleeding and surgical time. HBs located in the spine have decreased mortality and rate of infection, but increased rates of cardiopulmonary complications compared with HBs in the posterior cranial fossa.

Solid Component Volume as a Proxy to Identify Distinct Hemangioblastoma Populations

BACKGROUND

Posterior fossa hemangioblastomas usually consist of a small solid nodule with a large cyst, while more rarely they present as a large solid mass with a small or absent cyst, which can be surgically challenging. We sought to investigate the potential existence of multiple distinct hemangioblastoma populations using tumor volumetric data as an indicator.

METHODS

We conducted a retrospective review of surgically treated hemangioblastomas between 2005 and 2019 in our unit, including clinical notes, preoperative magnetic resonance imaging volumetric analysis of the solid component of the tumor, and pathology. Finite Gaussian mixture modeling was applied on the solid component volume dataset to identify potential underlying Gaussian distributions with their associated characteristics. Nonparametric Mann-Whitney U tests were used to investigate significance of differences (P < 0.05) in solid component volume and different variables (Von Hippel-Lindau disease, extent of resection, outcome).

RESULTS

A total of 68 consecutive patients were included. Solid component volumes followed a multimodal distribution (median = 1287 mm³, interquartile range of 3428 mm³). The best-fit finite Gaussian mixture modeling model identified 3 statistically significant different (P = 0.001) potential mixture components: X₁ (219 ± 187 mm³)_, X₂ (2686 ± 1299 mm³), and X₃ (10,800 ± 5514 mm³). The second-best model detected 2 significantly different (P = 9.99e^-08) mixture components Y₁ (222 ± 189 mm³) and Y₂ (5391 ± 5094 mm³). A significant difference in solid component volume was found between patients with favorable and unfavorable outcome (P = 0.002).

CONCLUSIONS

This study has shown preliminary evidence that large solid hemangioblastomas may constitute a completely distinct population, rather than a variant of one large group of hemangioblastomas.

Central nervous system hemangioblastomas: An age-stratified analysis

BACKGROUND

Hemangioblastomas (HBs) are rare and understudied. The impact of age on clinical features, optimal treatment, and postoperative outcome in HBs has not been systemically studied.

MATERIALS AND METHODS

We performed an institutional study in the West China Hospital, including patients diagnosed with hemangioblastomas between October 2011 and October 2016. Clinical data and surgical outcomes were compared among three different age groups (0-20, 21-59, and ≥ 60 years). We also studied surgical prognostic factors.

RESULTS

187 patients (102 males and 85 females) were identified. HBs in spinal locations were more prevalent in children and adolescents, while the most common site in young and old-age adults was the cerebellum (P = 0.023). Risk of Von Hippel-Lindau syndrome (VHL) was negatively correlated with patient age (P = 0.003). 47.6 % of patients aged 0-20, 23 % of patients aged 21-59, and 6.45 % of patients aged ≥60 years were diagnosed with VHL. Older aged patients had a significantly lower risk of VHL and had a lower tumor recurrence rate. Surgical resection was an adequate and sufficient procedure in all age groups with a favorable surgical outcome (P = 0.823). Solid tumor, VHL disease, and localization in the brainstem were associated with poor outcome in patients with hemangioblastomas.

CONCLUSIONS

Our study showed that HBs in elderly patients were mostly included in the cerebellum and had a solid configuration and large size, while HBs in children were mainly localized in the spinal cord. VHL disease was more common in children and adolescents but rare in patients older than 60 years. The present study found no excess surgical mortality and risks for HBs in elderly patients or children than in younger adults.

Sporadic Solid/Cystic Hemangioblastomas in the Cerebellum: Retrospective Study of More Than Ten Years of Experience in a Single Center

BACKGROUND

Solid/cystic hemangioblastomas are rare, and they lack a systematic description. We clarify the epidemiology, clinical features, imaging characteristics, and surgical outcomes of sporadic solid/cystic hemangioblastomas in the cerebellum.

METHODS

A total of 75 patients with sporadic hemangioblastomas from 2006 to 2018 were enrolled in this retrospective study and divided into solid (26/75), cystic (40/75), and solid/cystic (9/75) groups according to the imaging findings. All patients underwent microsurgical resection and had a definite 31 pathologic diagnosis.

RESULTS

The age at diagnosis in the solid/cystic group was the highest among the 3 groups (P < 0.05). The solid/cystic group showed the shortest symptom duration (P < 0.05), which was related to obvious peritumoral brain edema (P < 0.05). The combination of computed tomography angiography and magnetic resonance imaging helped with the differential diagnosis. The solid/cystic group showed the lowest rate of gross total resection (P < 0.05) as a result of the obscure brain-tumor interface, and the guidance of intraoperative ultrasonography helped with the microsurgical procedures to a certain extent. Patients in the solid/cystic group showed greater intraoperative blood loss (P < 0.05), a lower ratio of symptom improvement (P < 0.05), and a longer mean hospital stay (P < 0.05) than did patients in the cystic group.

CONCLUSIONS

Cerebellar sporadic solid/cystic hemangioblastomas are rare and usually affect elderly people. The combination of computed tomography angiography and magnetic resonance imaging may improve the preoperative diagnosis. Solid/cystic hemangioblastomas showed the lowest rate of gross total resection as a result of the obscure brain-tumor interface.

Cystic-solid hemangioblastoma at the cerebellopontine angle: A case report

RATIONALE

Hemangioblastomas (HMGs) originating from the cerebellopontine angle (CPA) are extremely uncommon. Nevertheless, the cystic-solid form of this lesion at the above location is even rarer.

PATIENT CONCERNS

We present a 31-years old male with a right ear hearing loss of 3 months duration. He did not experience earache or discharge before the hearing loss. He; however, experienced visual acuity and dizziness. General physical examination did not yield much.

DIAGNOSES

Computed tomography and magnetic resonance imaging revealed a cystic-solid mass at right CPA. We initial misdiagnosed the lesion as an acoustic neuroma with cystic changes. Immunohistochemistry studies revealed HMG.

INTERVENTIONS

The lesion was total surgical resection via the retro-sigmoid approach.

OUTCOMES

The patient's symptomatology resolved after the surgery. Two years follow-up show no recurrence of the lesion and the patient is well.

LESIONS

Identification of feeding arteries and electro-coagulating them during the operation minimized intraoperative bleeding. The tumor should usually be dissected out whole and not piece meal fashion. Pre-operative CTA is very useful in outlining the vasculature of the tumor.

Central nervous system hemangioblastomas in the elderly (over 65 years): Clinical characteristics and outcome analysis

OBJECTIVES

Hemangioblastomas (HBs) in the elderly are very uncommon and have rarely been studied. This retrospective study aimed to identify clinical features, optimal treatment, surgical outcomes and long-term prognostic factors in these rare lesions.

PATIENTS AND METHODS

We performed a retrospective analysis of HBs patients over 65 years old who underwent surgery from 2008 to 2018 at our department. Clinical data was retrospectively reviewed and statistically analyzed.

RESULTS

Thirty-three elderly patients with a mean age of 68.76 years were included in this study. Cerebellum, brainstem, and spinal cord locations accounted for 72.7 %, 18.2 % and 9.1 %. Two patients (6.1 %) were diagnosed as von Hippel-Lindau (VHL) syndrome. After mean follow-up of 37.95 ± 22.12 months, clinical symptoms improved in 22 patients (67 %), unchanged in seven patients (21 %) and aggravated in 4 patients (12 %). Only 1(3 %) patient experienced local recurrence during follow-up. Univariate analysis showed tumor size (P = 0.044) and tumor characteristic (cystic or solid) (P = 0.034) were significantly related to long-term outcomes, while multiple logistic regression analysis depicted tumor characteristics were exclusively correlated with outcomes (P = 0.04).

CONCLUSIONS

Our study suggests elderly hemangioblastomas may be different from their younger counterparts in that they often display solid configuration with large size and include more cerebellar tumors. HBs should be included in the differential diagnosis of elderly patients presenting with cerebellar mass. Despite many challenges involved, surgical removal of HBs in this age group is a safe procedure with acceptable risks. They may do not require as frequent follow-up as younger counterparts due to the low associations with VHL disease and tumor recurrence rate.

Stereotactic radiosurgery for central nervous system hemangioblastoma: systematic review and meta-analysis

Hemangioblastomas are rare, benign, vascular tumors of the central nervous system (CNS), often associated with von-hippel lindau (VHL) disease. Current therapeutic options include microsurgical resection or stereotactic radiosurgery (SRS). With no randomized controlled studies and minimal data beyond single-institution reviews, the optimal management approach for patients with CNS hemangioblastomas is unclear. We completed a Pubmed/SCOPUS literature search from January 1990 to January 2017 for eligible studies on SRS for CNS hemangioblastomas. Relevant articles were identified and reviewed in accordance to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. 26 studies met eligibility criteria for qualitative synthesis, representing 596 subjects and 1535 tumors. The Gamma Knife was the most published SRS method for CNS hemangioblastomas. After critical study appraisal for intra-study bias, 14 studies were used for quantitative meta-analysis of 5-year progression free survival (PFS). The pooled 5-year PFS across all eligible studies was 88.4%. No difference was observed between spine versus intracranial studies. Individual patient data (IPD) was extracted from 14 studies, representing 322 tumors. Univariate analysis of IPD revealed that VHL patients were younger, and had smaller tumors compared to those with sporadic disease. Adverse events were associated with increasing marginal dose, independent of tumor volume. VHL status, sex, radiosurgical method, tumor location, and tumor volume were not found to be significantly associated with tumor progression. Multiple studies show excellent tumor control at 5-year follow up, however, the long-term efficacy of SRS for CNS hemangioblastomas still needs to be investigated, and the studies exploring the role of SRS for early treatment of asymptomatic lesions is wanting.

Pediatric central nervous system hemangioblastomas: different from adult forms? A retrospective series of 25 cases

BACKGROUND

Pediatric hemangioblastomas are rare, and the clinical features, timing of surgical intervention, optimal treatment, and clinical outcomes are still unclear.

METHODS

We performed a retrospective study of all patients with CNS hemangioblastomas who were treated at West China Hospital from January 2003 to March 2015. Patients under the age of 16 years were included in the study. The medical records of these patients were reviewed and statistically analyzed.

RESULTS

Twenty-five children (15 females and ten males, [mean age 12.6 ± 4.7 years, range 1-16 years]) presented with hemangioblastomas. Tumors were detected in the cerebellum, brainstem, and spinal cord in 40, 28, and 32% of patients, respectively. Sixteen children (64%) had VHL syndrome. The most frequent symptoms were those related to increased intracranial pressure. The mean duration of symptoms was 1.5 ± 2.1 months. Preoperative hydrocephalus was noted in 11 children (44%). Gross total resection was achieved in all children. Clinical symptoms improved in 19 children (76%), unchanged in four children (16%), and aggravated in two children (8%), respectively. The mean follow-up was 44.5 ± 32.3 months. Five patients (20%) experienced disease progression. Using univariate analysis, both tumor-associated cysts (P = 0.027) and VHL disease (P = 0.032) were significantly related to postoperative outcomes.

CONCLUSIONS

Pediatric hemangioblastomas have many different clinical features compared with adult cases. A high degree of suspicion for VHL disease should be raised in pediatric hemangioblastomas. Despite many challenges involved, surgical outcomes for pediatric hemangioblastomas are favorable. Lifelong follow-up is mandatory to detect the disease progression.

Recurrent or symptomatic residual posterior fossa hemangioblastomas: how are they different from their primary counterparts?

BACKGROUND

Posterior fossa hemangioblastomas are WHO grade I benign lesions with a surprisingly high recurrence rate. This study determines the factors responsible for recurrence and the clinico-radiological and histopathological differences between primary (group A; n = 60) and recurrent/symptomatic residual (group B; n = 24) tumors.

METHODS

Radiologically, tumors were differentiated into cystic, cystic with a mural nodule, solid-cystic/microcystic and solid. Surgery was undertaken via a midline or lateral suboccipital approach. Histopathology differentiated them into reticular, cellular or mixed subtypes.

RESULTS

Truncal-appendicular ataxia in group A and von Hippel-Lindau (VHL) disease and raised intracranial pressure in group B were the predominant presentations. VHL patients in group B had a longer duration of symptoms (median 72 months) than those with non-VHL recurrences (median: 36 months). Multicentric mural nodules (n = 9/24, 37.50%, P = 0.0001) and bilateral cerebellar hemispheric involvement (n = 6/24, 25%, P = 0.0003) were exclusively seen in the preoperative radiology of group B tumors. Brainstem involvement was seen in the tumors of ten (16.67%) patients in group A and six (25.00%) patients in group B. One subset of patients required several resurgeries for repeated recurrences. Abnormal vascular proliferation and papillary projections into adjacent brain, and highly cellular stroma were unique histological features at recurrence. Total resection was achieved in 45 group A and 19 group B patients. The outcome based on the Karnofsky performance scale (KPS) was assessed at follow-up at 6 weeks (A: n = 60, B: n = 24): KPS0: A = 4, B = 1; KPS10-40 (dependent): A: 4, B = 5; KPS50-70 (independent for daily needs): A = 36, B = 16; KPS80-100 (fully independent): A = 16; B = 2.

CONCLUSIONS

In recurrent/residual tumors, the radiological as well as histopathological features showed a distinctive change toward a more aggressive nature. Higher incidences of multiple mural nodules, bilateral spread, remote recurrence and VHL disease at preoperative radiology; as well as proliferative angioarchitecture, an irregular brain tumor interface and highly cellular stroma at histology were found in these patients compared to their primary counterparts.

Surgical treatment of cerebellar hemangioblastomas

BACKGROUND

Hemangioblastomas (HBL) are uncommon tumors of the central nervous system (CNS), corresponding to 1-2.5% of all intracranial tumors. They can present sporadically or in patients with von Hippel-Lindau (VHL) disease and are most often located in the cerebellum, brainstem, and spinal cord. VHL disease is a multiple neoplasia syndrome inherited in an autosomal dominant fashion and caused by a VHL suppressor gene deletion. We present our experience in the management of patients with cerebellar HBL.

METHODS

Thirty consecutive patients with cerebellar HBL were included in this study. Hospital charts, radiological images, and operative records were reviewed. Modified Rankin scores were used to evaluate the clinical course.

RESULTS

Thirty patients diagnosed with cerebellar HBL were operated. Complete total resection was achieved in 93% of the cases. Postoperatively, 83% of the patients showed good functional recovery.

CONCLUSIONS

HBL of the cerebellum should be resected when symptomatic or when the tumor (or a tumor-associated cyst) shows signs of enlargement. Surgical intent should seek en bloc resection to minimize intraoperative bleeding. Patients with HBLs must be tested for VHL gene mutations, and in confirmed cases, relatives should be offered genetic counseling.

Clinical Features and Surgical Outcomes in Patients with Cerebellopontine Angle Hemangioblastomas: Retrospective Series of 23 Cases

OBJECTIVES

Hemangioblastomas in the cerebellopontine angle (CPA) are uncommon and have rarely been reported. They may be easily misdiagnosed because of the atypical location and clinical and imaging features. The present study aimed to characterize clinical and radiologic features, treatment strategies, and outcomes in these rare lesions and to investigate various factors that may affect postoperative outcomes.

METHODS

The medical records of patients with CPA hemangioblastomas who underwent surgery from 2003-2016 at the West China Hospital were reviewed retrospectively and statistically analyzed.

RESULTS

Twenty-three patients (14 males and 9 females) presented with CPA hemangioblastomas. Eight patients (34.8%) had von Hippel-Lindau (VHL) syndrome. Gross total resection was achieved in 22 patients (95.6%). The mean follow-up was 45.1 ± 36.2 months (range 3-144 months). After surgery, the symptoms improved in 18 cases (78.3%), remained unchanged in 3 cases (13%), and were aggravated in 2 cases (8.7%). Four patients showed local recurrence during follow-up (17.4%). Patients with cystic hemangioblastomas had a better neurologic improvement (P = 0.041) compared with patients with solid tumors. Furthermore, patients with maximal diameter of tumors >3 cm (P = 0.035) or solid tumors (P = 0.018) showed a higher incidence of postoperative complications. The local recurrence was correlated with VHL disease (P = 0.027).

CONCLUSIONS

Although hemangioblastomas of the CPA are challenging lesions to treat surgically, they can be removed safely when these lesions are appropriately diagnosed and treated. Patients with VHL disease are more likely to have a local recurrence. A regular follow-up is recommended to detect the local and distant recurrence, even if the clinical course is benign and the tumor is totally resected.

Solid hemangioblastoma in the cerebellopontine angle: Importance of external carotid blood supply with regard to the probable site of origin and preoperative embolization

BACKGROUND

Hemangioblastoma (HBL) is rare in the cerebellopontine angle (CPA) with questionable origin and limited access for circumferential dissection and "en-bloc" excision. We report a case of surgical removal of large solid CPA-HBL and discuss the pattern of blood supply suggesting its origin and indicating preoperative embolization.

CASE DESCRIPTION

The solid and highly vascular CPA-HBL had feeders mainly from neuromeningeal division of ascending pharyngeal branch of external carotid artery, suggesting true extra-axial origin. We could achieve "en-bloc" excision without significant blood loss or morbidity using preoperative embolization.

CONCLUSION

Large solid HBL is rare in CPA necessitating arduous "en-bloc" excision. The pattern of blood supply probably indicates the site of origin and safety of preoperative embolization.

Neurosurgical Management of Brainstem Hemangioblastomas: A Single-Institution Experience with 116 Patients

OBJECTIVE

Brainstem hemangioblastomas (HBs) are considered one of the most challenging lesions in surgical procedures. We present our institutional experience with 116 patients over a period of 20 years in the treatment of HBs.

METHODS

We evaluated the results of microsurgical treatment and highlighted the management strategies. There were 60 male and 56 female patients including 13 cases with clinical evidence of von Hippel-Lindau disease. Tumors were solid in 99 cases and cystic in 17 cases. Tumors were small (≤2 cm) in 43 cases, large (2-4 cm) in 45 cases, and giant (≥4 cm) in 28 cases.

RESULTS

Radical removal was achieved in 111 patients (95.7%), and incomplete removal was achieved in 5 cases (4.3%). The immediate postoperative mortality and morbidity were 7.8% and 17.2%, respectively. Detailed analyses of outcomes showed that surgical complications were related to some tumor characteristics. Follow-up study was available in 83 patients by Karnofsky performance scale scores. Most patients maintained their preoperative neurologic status. There were 17 patients with surgical disability who demonstrated a clear improvement with rehabilitation treatment. Worsening of neurologic deficits occurred in 2 patients. Ectopic recurrent lesions developed in 2 patients.

CONCLUSIONS

Based on our experience, microsurgery is safe and effective, and excellent outcomes can be obtained for cystic or small tumors. We advocate early surgical intervention for sporadic HBs; giant solid HBs remain a challenge, and meticulous microsurgical technique and perioperative management are vital. Long-term monitoring also is recommended.