Gliosarcoma with osteosarcomatous differentiation: review of radiological and pathological features

TGF-β and BMP signaling are associated with the transformation of glioblastoma to gliosarcoma and then osteosarcoma

Background

Gliosarcoma, an isocitrate dehydrogenase wildtype (IDH-WT) variant of glioblastoma, is defined by clonal biphasic differentiation into gliomatous and sarcomatous components. While the transformation from a glioblastoma to gliosarcoma is uncommon, the subsequent transformation to osteosarcoma is rare but may provide additional insights into the biology of these typically distinct cancers. We observed a patient initially diagnosed with glioblastoma, that differentiated into gliosarcoma at recurrence, and further evolved to osteosarcoma at the second relapse. Our objective was to characterize the molecular mechanisms of tumor progression associated with this phenotypic transformation.

Methods

Tumor samples were collected at all 3 stages of disease and RNA sequencing was performed to capture their transcriptomic profiles. Sequential clonal evolution was confirmed by the maintenance of an identical PTEN mutation throughout the tumor differentiation using the TSO500 gene panel. Publicly available datasets and the Nanostring nCounter technology were used to validate the results.

Results

The glioblastoma tumor from this patient possessed mixed features of all 3 TCGA-defined transcriptomic subtypes of an IDH-WT glioblastoma and a proportion of osteosarcoma signatures were upregulated in the original tumor. Analysis showed that enhanced transforming growth factor-β (TGF-β) and bone morphogenic protein signaling was associated with tumor transformation. Regulatory network analysis revealed that TGF-β family signaling committed the lineage tumor to osteogenesis by stimulating the expression of runt-related transcription factor 2 (RUNX2), a master regulator of bone formation.

Conclusions

This unusual clinical case provided an opportunity to explore the modulators of longitudinal sarcomatous transformation, potentially uncovering markers indicating predisposition to this change and identification of novel therapeutic targets.

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.

Clinical Characteristics and Surgical Features of Intracranial Fibrosarcoma

BACKGROUND

Intracranial fibrosarcoma is an extremely rare neoplasm in the central nervous system. Insofar there were only sporadic case reports describing its features. The purpose of this study is to review the clinical and surgical features of cases who were treated in our department.

METHOD

The authors retrospectively reviewed and detailed the clinical and surgical data obtained from 5 patients with fibrosarcoma who underwent treatment at our institute between January 2009 and January 2019.

RESULTS

There were 3 males and 2 females including 2 juvenile and 3 senior patients. The most frequent sign was intermittent pain and vomiting. The location of the tumor included middle fossa, thalamus and midbrain, sellar and suprasellar region and right parietal-occipital lobe. Surgical observation demonstrated the consistency of the tumor was tenacious with abundant blood supply. Gross total resection was achieved in 2 cases. Pathological analysis showed spindle cells in a herringbone form with positive Vimentin staining in all 5 cases, with the absence of GFAP or S-100. All 5 patients were deceased eventually after a varied period of time after the first surgery.

CONCLUSION

Intracranial fibrosarcoma was a highly malignant entity presented in the central nervous system. Surgery still remains the first-line treatment followed by radiotherapy, however, the prognostic outcome was very poor. Future studies should be more focused on accumulation of the relevant information on this disease thus hopefully in assisting to developing more optimized treatment.

Clinical Characteristics of Gliosarcoma and Outcomes From Standardized Treatment Relative to Conventional Glioblastoma

Background: Gliosarcoma (GS) is a rare histopathologic variant of glioblastoma (GBM) characterized by a biphasic growth pattern consisting of both glial and sarcomatous components. Reports regarding its relative prognosis compared to conventional GBM are conflicting and although GS is treated as conventional GBM, supporting evidence is lacking. The aim of this study was to characterize demographic trends, clinical outcomes and prognostic variables of GS patients receiving standardized therapy and compare these to conventional GBM. Methods: Six hundred and eighty GBM patients, treated with maximal safe resection followed by radiotherapy with concomitant and adjuvant temozolomide at a single institution, were retrospectively reevaluated by reviewing histopathological records and tumor tissue for identification of GS patients. Clinico-pathological- and tumor growth characteristics were obtained via assessment of medical records and imaging analysis. Kaplan-Meier survival estimates were compared with log-rank testing, while Cox-regression modeling was tested for prognostic factors in GS patients. Results: The cohort included 26 primary gliosarcoma (PGS) patients (3.8%) and 7 secondary gliosarcoma (SGS) patients (1.0%). Compared to conventional GBM tumors, PGS tumors were significantly more often MGMT-unmethylated (73.9%) and located in the temporal lobe (57.7%). GS tumors often presented dural contact, while extracranial metastasis was only found in 1 patient. No significant differences were found between PGS and conventional GBM in progression-free-survival (6.8 and 7.6 months, respectively, p = 0.105) and in overall survival (13.4 and 15.7 months, respectively, p = 0.201). Survival following recurrence was not significantly different between PGS, SGS, and GBM. Temporal tumor location and MGMT status were found associated with PGS survival (p = 0.036 and p = 0.022, respectively). Conclusion: Despite histopathological and location difference between GS and GBM tumors, the patients present similar survival outcome from standardized treatment. These findings support continued practice of radiation and temozolomide for GS patients.

Based on arterial spin labeling helps to differentiate high-grade gliomas from brain solitary metastasis: A systematic review and meta-analysis

BACKGROUND

We first introduced this meta-analysis was to assess the accuracy of arterial spin labeling (ASL) in the differentiating high-grade gliomas (HGG) from brain solitary metastases (BSM).

METHODS

The PubMed, Web of Knowledge, and Cochrane Libraries and China National Knowledge Infrastructure databases were searched up to August 31, 2018. The pooled weighted sensitivity and specificity, summary receiver operating characteristic curve (SROC), sensitivity analysis, and threshold effect analysis were performed on Stata version 12.0 and Meta-Disc version 1.4. Deeks' funnel plot asymmetry test was performed to assess publication bias.

RESULTS

Of 5 eligible articles, of the 346 lesions from 346 patients, 274 were HGG, and 72 were BSM. The forest pooled sensitivity of 0.88 (95% confidence interval [CI]: 0.65, 0.96) and specificity of 0.85 (95% CI: 0.74, 0.92) of ASL were reported in this meta-analysis. The pooled area under the curve of SROC was 0.92 (95% CI: 0.89, 0.94). Sensitivity analysis demonstrated that the pooled estimates were reliable. No evident publication bias was obtained (P = .38).

CONCLUSION

The parameters derived from ASL with high accuracy in differentiating HGG from BSM. However, results must be interpreted with caution due to the small sample size considered. Large sample prospective studies were necessary to assess and confirm its clinical value.

Brachium Pontis Gliosarcoma With Well-Differentiated Cartilaginous Tissue: A Case Report

Gliosarcoma (GS) belongs to World Health Organization grade IV neoplasm and displaying glial and mesenchymal differentiation. Only rare cases of GS have been reported in the brachium pontis and 4th ventricle region. Here, we report a rare case of GS located on brachium pontis region and extending into the 4th ventricle with well-differentiated cartilaginous metaplasia. A 28-year-old male patient experienced intermittent headache, vomiting, and gait disorders for 3 months. Magnetic resonance imaging (MRI) showed a heterogeneous ring-enhancement lesion with weak central enhancement in left brachium pontis and 4th ventricle region. Histology revealed the GS was constituted with glial and sarcomatous elements. After immunohistochemical analysis, a diagnosis of GS with cartilaginous differentiation was then made.Symptoms of GS, including headache, aphasia, hemiparesis, cognitive decline, and seizures, mainly determined by the location. The clinical manifestation and radiologic characteristic is not significantly different from that of glioblastoma. The grade of resection is the significant factor related to prognosis of GS, and the clinical effect of adjuvant radiotherapy and chemotherapy need further study. Reporting additional cases would be of great help in better understanding of this location and pathologic type of GS.

Cerebral gliosarcoma: Analysis of 16 patients and review of literature

BACKGROUND

Gliosarcoma (GS), a subtype of glioblastoma (GBM), is a rare primary neoplasm of the central nervous system. Certain features like temporal lobe affinity, tendency for extraneural metastasis and poorer outcome compared to GBM indicate that GS may indeed be a separate clinicopathologic entity. This led us to revisit this entity in our settings.

MATERIALS AND METHODS

Between 2009 and 2014, 16 cases of histologically proven GSs (14 primary, two secondary) were treated. Patient data were retrieved retrospectively. Statistical analysis was performed with? Statistical Package for Social Sciences, version 17.0. (Chicago, Illinois, USA). Survival was analyzed by Kaplan-Meier method.

RESULTS

GS predominantly affected males in their fifth decade of life. Raised intracranial pressure was the most common mode of clinical presentation. Temporal lobe was the most commonly affected part of the brain and majority of primary and all of secondary GBM were located peripherally. In 7 (43.8%) patients, tumor was radiologically well-demarcated and enhanced strongly and homogenously on contrast as compared to 9 (56.2%) patients where the tumor was ill-defined and showed heterogenous patchy or ring enhancement. Extent of excision was total in seven patients (43.8%), near total in 4 (25%) and subtotal in five patients (31.2%). Median survival was 6 months. Patients with well-demarcated, enhancing mass on imaging intraoperatively had firm tumors with a good plane of cleavage and had a better survival (8 months) compared to those in whom the tumor radiologically and intraoperatively mimicked GBM (2 months).

CONCLUSION

GS is associated with poor survival (median survival 6 months). Radiological and intraoperative findings help categorize these tumors into GBM like GS and meningioma like GS. While the former histologically mimics GBM and has very poor survival (2 months), GS with meningioma like feature tends to have better survival (8 months).

Intraspinal dural-based primary osteoblastoma with aneurysmal bone cyst-like change

Osteoblastoma is a benign bone-forming neoplasm that occurs commonly in the posterior elements of the spine and the sacrum. However, so far there has been no report of intradural osteoblastoma described in the literature. We present a unique case of intraspinal dural-based osteoblastoma with aneurysmal bone cyst-like change without evidence of vertebral involvement. An 11-year-old Chinese girl presented with a 3-month history of gradually progressive back pain and a weakness of both lower limbs. Thoracic MRI revealed a well-demarcated subdural mass at the T5 level with heterogeneous enhancement. Histologically, the tumor was found to be attached to the dura and composed of numerous osteoid spicules and trabecular bone with diffusely scattered osteoclast-type, multinucleated giant cells. Ectactic blood vessels and blood-filled cystic spaces were also observed. A diagnosis of primary intraspinal dural-based osteoblastoma with aneurysmal bone cyst-like change was made. To our best knowledge, this is possibly the first case of primary osteoblastoma arising from meninges. Meningeal osteocartilaginous tumors are rare, with obscure histogenesis. The differential diagnosis of osteoblastoma in unusual locations is difficult and the confirmation of diagnosis should be cautiously made. Awareness of dural-based osteoblastoma and its histological features is important to avoid a diagnostic pitfall caused by histological similarities to other intra-craniospinal lesions with osteoid differentiation or bone formation.

Analysis of a synchronous gliosarcoma and meningioma with long survival: A case report and review of the literature

Background:

The simultaneous occurrence of multiple intracranial neoplasms has been reported, especially in genetic familial syndromes and after cranial irradiation. In the absence of these etiologic factors, some reports showed simultaneous occurrence of glioblastoma and meningioma but the association between gliosarcoma and meningioma is unknown.

Case Description:

We report a case of a 51-year-old woman with synchronous gliosarcoma and meningioma in whom extensive immunohistochemical characterization and molecular profile was performed. The gliosarcoma recurred 21 months after the first resection, reaching 3 years of overall survival. A molecular characterization of all three lesions was performed. None of the lesions showed the presence of mutations in TP53 and BRAF genes. MGMT analysis showed the presence of loss of expression associated with promoter hypermethylation in both gliosarcoma lesions. EGFR overexpression and gene amplification was found only in the recurrent gliosarcoma.

Conclusion:

The immunohistochemistry and molecular data of this unique case, suggest the distinct clonal origin of meningioma and gliosarcoma lesions, and the association of MGMT methylation with the presumable favorable prognosis observed.

Secondary gliosarcoma after the treatment of primary glioblastoma multiforme

Context:

Gliosarcoma is a rare variant of glioblastoma multiforme containing distinct gliomatous and sarcomatous components. Gliosarcoma comprise 1.8–8% of glioblastoma multiforme and are clinically similar to them, affecting adults in the fourth and sixth decades of life, with a higher proportion found in males. The survival for patients with Gliosarcoma is equally poor as for those with glioblastoma multiforme, and there is a greater propensity for extracranial metastasis in Gliosarcoma. Clinical treatment-related experience reported in the literature is limited, and Gliosarcoma are currently treated in a similar fashion to glioblastoma multiforme, with modalities including tumor resection, postoperative radiation therapy, and chemotherapy. Gliosarcoma can arise secondarily, after conventional adjuvant treatment of high-grade glioma. The current literature on the occurrence of secondary gliosarcoma after glioblastoma multiforme is limited, with only 54 reported cases.

Case Report:

The authors present a 48-year-old Caucasian male who had previously received postoperative combined radiation and temozolomide chemotherapy for glioblastoma multiforme. After a free disease period of 9 months the disease recurs as Gliosarcoma. The patient underwent a Total surgical excision and received chemotherapy with a basis of bevacizumab and irinotecan. The patient died from tumor progression 5 months after gliosarcoma diagnosis.

Conclusion:

The poor survival of patients with secondary gliosarcoma who had previously received combined radiation and temozolomide chemotherapy for glioblastoma multiforme may reflect a unique molecular profile of glioblastoma multiforme that eventually recurs as secondary gliosarcoma. We have to keep in mind the possibility of gliosarcomatous change in the recurrence of malignant glioma. Awareness of this pathological entity will allow more rapid diagnosis and treatment.

Radiological findings in gliosarcoma. A single institution experience

Gliosarcomas are rare tumors with a poor prognosis composed of intermingled malignant glial and sarcoma elements with an estimated incidence of 1.8-8.0% of all malignant astrocytic neoplasms. We aimed to review the imaging findings in eight patients with gliosarcoma who were treated in our center between 2002 and 2010. The diagnosis was confirmed by morphological and immunohistochemical stains. This study, to the best of our knowledge, is the largest describing the imaging manifestations of this tumor. Although our study revealed no unique radiological features for gliosarcoma, it is important to note that they all demonstrated either dural or ependymal involvement or both. Calcification, hemorrhage or cystic components are described with a tendency for a ring enhancement pattern. Interestingly pre-existing benign looking lesions and associated remotely located small meningiomas are also described.

Molecular cytogenetic analysis of a gliosarcoma with osseous metaplasia

Gliosarcoma, a rare glioblastoma variant, is composed of a glial and a mesenchymal component. Though the mesenchymal portion most commonly resembles a fibrosarcoma, other differentiation patterns have been observed. We present the first genomic characterisation (karyotyping followed by FISH and array comparative genomic hybridisation analysis) of a gliosarcoma with osseous metaplasia. In addition to chromosomal changes often found in gliomas (+7, -10, -13, and -22), the tumour cells also harboured a hitherto unknown t(3;21)(q13∼21;q21∼22).

Gliosarcoma of the cerebellar hemisphere: a case report and review of the literature

Gliosarcoma is a rare central nervous system tumor usually located in the supratentorial area. Here we report a rare case of a gliosarcoma that developed in the cerebellar hemisphere in a 70-year-old woman. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain revealed an infratentorial mass of which radiological features were similar to those of glioblastoma. The tumor was diagnosed by pathology as a gliosarcoma. Though rare, gliosarcoma should be considered in the differential diagnosis of infratentorial tumors with radiological features of glioblastoma or metastasis in elderly patients.

Gliosarcoma with osteosarcomatous features: a short illustrated review

INTRODUCTION

Gliosarcoma is a rare, malignant, biphasic brain tumor formed by both glioblastoma and sarcomatous components. Various lines of differentiation are described in the latter component, but most commonly fibrosarcomatous and pleomorphic sarcoma are present. Osteosarcomatous features are exceedingly rare.

OBJECTIVE

We report a case of gliosarcoma with osteosarcomatous features in a 33-year-old woman.

METHODS

Histologically, the sarcomatous portion displayed a typical pattern of fibrosarcoma associated with areas of osteoid formation.

RESULTS AND CONCLUSION

Immunohistochemical glial fibrillary acid protein (GFAP) expression was seen only in the glioblastoma portion. Clinicopathological characteristics and radiological data of this rare condition were reviewed. Possible differential diagnoses and potential histogenesis were also discussed.

Gliosarcoma: an unusual cause of cerebral mass lesion in a patient with AIDS. A case report and review of the literature

Malignant glioma is the most common primary brain neoplasm. Generally, gliomas are not included in the differential diagnosis of enhancing lesions of the central nervous system in patients infected by the human immunodeficiency virus. We report a case of gliosarcoma in a patient with AIDS presenting as a single cerebral lesion. Stereotactic brain biopsy was obtained and definitive histopathological diagnosis of gliosarcoma was made. A decline in the incidence of opportunistic infections associated with highly active antiretroviral therapy suggest the importance of early stereotactic biopsy to confirm the diagnosis of these neoplasms.

Giant infantile gliosarcoma: magnetic resonance imaging findings

Gliosarcoma is an uncommon variant of glioblastoma multiforme, which is composed of gliomatous and sarcomatous elements. The tumor is rarely encountered in childhood. This case report presents the magnetic resonance imaging characteristics of a giant gliosarcoma in a 3-year-old girl. Size and location of the tumor are described.

Immunohistochemistry of gliosarcoma with liposarcomatous differentiation

A case of gliosarcoma composed of glioblastoma and liposarcoma is presented. A 70-year-old Japanese man was admitted to hospital because of dysarthria and aphasia. Magnetic resonance imaging indicated a brain tumor located in the temporal-parietal area of the left hemisphere. He rejected any therapy and died of respiratory failure. At autopsy the tumor was well-demarcated with firm consistency and myxoid appearance, accompanied by necrosis and hemorrhage. Microscopically the tumor consisted of both glial and sarcomatous components, compatible with a gliosarcoma. Lipoblast-like tumor cells were identified in the sarcomatous area. Glial component was observed in the periphery and was diffusely positive for CD56 and S100 protein and focally for glial fibrillary acidic protein. Only a small number of tumor cells in the sarcomatous area expressed neurogenic markers. Lipoblast-like tumor cells were positive for S100 protein but negative for any other neurogenic markers. A significant number of tumor cells were positive for retinoblastoma protein (pRB) in the glial area, whereas only a few of them were positive in the sarcomatous area, indicating alteration of pRB in sarcomatous component. The present tumor is a rare gliosarcoma with liposarcomatous differentiation; alteration of pRB may play a role in sarcomatous transformation of glial component.

Gliosarcoma with liposarcomatous differentiation: the new member of the lipid-containing brain tumors family

Gliosarcoma is a rare malignant, biphasic brain tumor composed of glioblastoma multiforme and sarcomatous components. Various types of sarcomatous differentiation are described in this tumor: fibrosarcomatous, malignant fibrous histiocytoma-like, chondrosarcomatous and osteosarcomatous types. We report an extremely unusual variant of liposarcomatous differentiation in gliosarcoma in 72-year-old woman. Fat cells were presented by atypical multivacuolar and monovacuolar lipoblasts, stained positive for S100. p53 that was positive in both glial and mesenchymal cells of the tumor were negative in the lipoblasts. To the best of our knowledge, this is the first report in the literature of liposarcomatous differentiation in gliosarcoma.