Spinal and extracranial metastatic dissemination of malignant glioma

A Retrospective Study on Spinal Dissemination of Supratentorial Glioma

Objective

Metastatic spinal dissemination (MSD) of supratentorial glioma is very rare and there is no established standard of care. The current study investigates the clinical characteristics and course of spinal dissemination of supratentorial glioma.

Methods

A retrospective analysis of adult patients with MSD of supratentorial glioma treated in the Department of Oncology in Beijing Shijitan Hospital, Capital Medical University from June 2012 until August 2021 was performed. The time to event was estimated using Kaplan–Meier analysis. Univariate analyses were performed using log-rank test and multivariate analysis was performed using the Cox proportional hazards model.

Results

Thirty-four adult patients with MSD of supratentorial glioma were enrolled in this retrospective study. The median time to MSD (TTMSD) and overall survival (OS) were 5 months (range: 0–78 months) and 15 months (range: 0.7–85 months), respectively, in the entire cohort. Univariate analysis demonstrated that the patients who had received TMZ therapy had a longer TTMSD than those who did not (mTTMSD: 15 vs. 3 months, log-rank P = 0.0004). Furthermore, a protracted duration of salvage chemotherapy of >6 months after MSD was associated with longer OS of the patients with MSD of supratentorial glioma (mOS: 13 vs. 5 months, log-rank P = 0.0163) and reduced the death risk by 64.3% (hazard ratio: 0.357, 95% CI: 0.141–0.901, P = 0.029) compared with a duration ≤6 months.

Conclusion

Patients with MSD of supratentorial glioma experienced poor prognosis and adjuvant chemotherapy may delay the occurrence of MSD. The protracted duration of systemic salvage chemotherapy may favor survival after spinal dissemination.

Spinal Drop Metastasis of Glioblastoma-Two Case Reports, Clinicopathologic Features, Current Modalities of Evaluation, and Treatment with a Review of the Literature

BACKGROUND

Glioblastomas (World Health Organization grade IV) are aggressive primary neoplasms of the central nervous system. Spinal metastasis occurs supposedly in 2%-5% of patients. This percentage may be only the tip of iceberg because most succumb to the disease before clinical detection and few documented cases are reported.

CASE DESCRIPTIONS

A 45-year-old man presented with history of diplopia and gait disturbance. Magnetic resonance imaging showed a left cerebellar space-occupying lesion. The histopathology was consistent with glioblastoma. The patient underwent adjuvant chemoradiation. A year later, he presented with seizures, worsening headache, neck stiffness, and low back pain. Imaging showed metastasis to the S1/S2 region of the spinal canal. A 29-year-old man presented with episodic headaches associated with nausea, vomiting, neck stiffness, and imbalance while walking. Computed tomography of the brain showed a hypodense lesion involving the left midbrain, pons, and left middle cerebellar peduncle, causing fourth ventricular pressure with obstructive hydrocephalus. A navigation-guided biopsy of the brainstem lesion confirmed the diagnosis of glioblastoma World Health Organization grade IV, isocitrate dehydrogenase 1 (R132 H) and H3K27M negative. Isocitrate dehydrogenase gene sequencing was suggested. The patient was referred for chemoradiation. During treatment, he worsened neurologically and developed axial neck and back pain. Neuraxis screening showed disseminated leptomeningeal spread, which was confirmed on dural biopsy.

CONCLUSIONS

Spinal and dural metastasis should always be suspected in patients with glioblastoma with signs and symptoms not explained by primary lesion. A regular protocol with postcontrast magnetic resonance imaging before and after initial surgery is mandatory to detect spinal metastasis before it becomes clinically apparent, thereby improving the prognosis and quality of life in patients.

Unique Case Report of a Meningeal Sarcoma Arising during Ongoing Treatment for Progressing Intraparenchymal Glioma

Radiation-induced sarcomas in the brain are extremely rare, usually occur with an average latency of 9 years, and are associated with poor outcomes. Latency periods shorter than 1 year may indicate a genetic predisposition such as Li-Fraumeni syndrome. A 34-year-old man underwent initial tumor resection and radiation therapy for a World Health Organization (WHO) Grade II Astrocytoma. Within 6 months, the tumor recurred as WHO Grade III and was treated with temozolomide and then bevacizumab. Despite the patient's apparent improving condition, MRI revealed new dural-based lesions 10 months after radiation therapy and identified as high-grade sarcoma. The patient resumed bevacizumab, began NovoTTF treatment for progressing glioma, and ifosfamide/doxorubicin for the sarcoma. Genetic testing revealed no pathogenic mutation in the TP53 gene. Ultimately, treatment was unsuccessful and the patient succumbed to glioma and sarcoma within 2 years of initial diagnosis. This case was unique due to the rapidly progressing glioma and sudden appearance of a high-grade sarcoma. It is unusual to have two separate intracranial primary cancers with each requiring a different chemotherapy regimen. We discuss the difficulty of simultaneously treating with separate chemotherapy regimens. It remains unclear whether the sarcoma was induced by the radiation treatment or a genetic predisposition.

The Effect of Gabapentin and Tramadol in Cancer Pain Induced by Glioma Cell in Rat Femur

Preclinical Research The presence of pain as part of the cancer process is variable. Glioblastoma multiform (GBM) can produce bone metastasis, a condition that involves other pathological phenotypes including neuropathic and inflammatory pain. Tramadol and gabapentin are drugs used in the treatment of neuropathic pain. However, there are no studies evaluating their analgesic effects in bone metastasis. We produced a pain model induced by the inoculation of glioma cells (10⁵ ) into the rat femur, by perforating the intercodiloid fossa. Painful behavior was evaluated by measuring mechanical allodynia using the Von Frey test while thermal hyperalgesia was assessed in the plantar test. Histopathological features were evaluated and antinociceptive responses were compared using tramadol and gabapentin. The inoculation of cells inside the right femur produced nociceptive behaviors. Tramadol and gabapentin produced an anti-allodynic effect in this condition, but tramadol did not produce an anti-hyperalgesic response. The development of this model will allow us to perform tests to elucidate the pathology of bone metastasis, cancer pain, and in particular the pain produced by glioma. Drug Dev Res 78 : 173-183, 2017. © 2017 Wiley Periodicals, Inc.

Pattern of recurrence and factors associated with cerebrospinal fluid dissemination of glioblastoma in Chinese patients

Background:

Pattern of recurrence of glioblastoma (GBM) seems to have undergone some shifts from distant metastasis as a rarity to a higher proportion, including disease disseminated via cerebrospinal fluid (CSF) pathway. There is still no report on the pattern of recurrence for Chinese population. Here, we evaluated the pattern of recurrence of GBM in Chinese patients along with factors that could affect the distribution of recurrence.

Methods:

Medical records of GBM patients with definite recurrence were reviewed. Local recurrence was defined as tumor regrowth within the preoperative abnormal signals on magnetic resonance imaging (MRI) T2 sequence. New recurrence was a new lesion away from the preoperative T2 abnormalities. New recurrence in contact with CSF pathways was registered as new CSF dissemination. Progress-free survival (PFS) and survival after progress were compared using the Kaplan–Meier survival curves. Potential risk factors for new CSF dissemination were assessed using univariate models followed by multivariate analysis.

Results:

Thirty-six patients were proven to have recurrence; 22 local and 14 new recurrences. Among the 14 patients, 11 had new CSF dissemination. Median PFS for local, new parenchymal recurrence, and new CSF dissemination were 5.5 months, 9.9 months, and 12.1 months, whereas survival after progress were 6.1 months, 5.7 months, and 16.9 months, respectively. The ventricular entry during surgery and the completion of concomitant chemoradiotherapy were risk factors for new CSF dissemination. O⁶-methylguanine-DNA methyltransferase methylation was associated with the development of CSF dissemination.

Conclusion:

The majority of recurrence remained local (22/36, 61%). However, CSF dissemination was up to 30% (11/36). PFS for patients with CSF dissemination was the longest, and paradoxically survival after progress was the shortest. Ventricular entry should be avoided. Whole craniospinal MRI surveillance should be included for these patients.

Non-invasive real-time biopsy of intracranial lesions using short time expanded circulating tumor cells on glass slide: report of two cases

Background

Circulating Tumor Cells (CTCs) are promising biomarkers for monitoring solid cancer and were used to monitor brain tumors. Here we report two cases in which, for the first time, CTCs were used in cytological diagnostic evaluation to discriminate a space-occupying lesion of the brain.

Case presentation

Two cases of focal intracranial lesions, unclassified for diagnosis, untreated and apparently symptomatic, were examined after high-contrast resolution Magnetic Resonance Imaging and/or Computed Tomography scans. CTCs were seeded on chamber slides and short-time expanded under the optimized conditions as we previously reported. The first case was a focal lesion localized in the parietal-occipital area in a 67-year-old woman. The second case was a 31-year-old man with an expansive intracerebral lesion localized in the left peri-trigonal area. Both patients underwent excisional biopsy. Histopathological evaluation of the biopsy confirmed the previous cytological diagnoses, and the analysis of the clinical outcomes retrospectively validated both diagnoses.

Conclusions

The cases here reported illustrate the potential for using expanded CTCs as non-invasive, real-time biopsy. Moreover, non-invasive real-time biopsy can represent an alternative diagnostic tool to be used when a functional area of the brain is at risk of injury from excisional biopsy procedures.

A case of symptomatic synchronous cervical and cerebellar metastasis after resection of thoracal metastasis from temporal glioblastoma multiforme without any local recurrence

Glioblastoma multiforme (GBM) is the most common and the most malignant primary intracranial tumor in adults and it is usually occurs between the age of 40 and 60 years. It is local invasive and recurrent tumor and hence that has a poor prognosis. However, recent advances in tumor surgery, irradiation and chemotherapeutic agent permit long survival and metastasis which is symptomatic. Previously studies reported spinal metastasis, but we report a first case of synchronous symptomatic cerebellar and cervical spinal metastasis after resection of symptomatic thoracic spinal metastasis from temporal GBM without any recurrence of excision areas.

[Exceptional metastasis of glioblastoma]

Les métastases extracrâniennes découlant de glioblastome sont rares et le mécanisme de leur diffusion n'est pas bien connu. Nous rapportons le cas d'un homme suivi pour un glioblastome traité par chirurgie suivie d'une radiothérapie encéphalique avec Temozolamide en concomitant, et qui a présenté une métastase des parties molles.

Glioblastoma Circulating Cells: Reality, Trap or Illusion?

Metastases are the hallmark of cancer. This event is in direct relationship with the ability of cancer cells to leave the tumor mass and travel long distances within the bloodstream and/or lymphatic vessels. Glioblastoma multiforme (GBM), the most frequent primary brain neoplasm, is mainly characterized by a dismal prognosis. The usual fatal issue for GBM patients is a consequence of local recurrence that is observed most of the time without any distant metastases. However, it has recently been documented that GBM cells could be isolated from the bloodstream in several studies. This observation raises the question of the possible involvement of glioblastoma-circulating cells in GBM deadly recurrence by a “homing metastasis” process. Therefore, we think it is important to review the already known molecular mechanisms underlying circulating tumor cells (CTC) specific properties, emphasizing their epithelial to mesenchymal transition (EMT) abilities and their possible involvement in tumor initiation. The idea is here to review these mechanisms and speculate on how relevant they could be applied in the forthcoming battles against GBM.

Leptomeningeal and intramedullary metastases of glioblastoma multiforme in a patient reoperated during adjuvant radiochemotherapy

Despite huge advances in medicine, glioblastoma multiforme (GBM) remains a highly lethal, fast-growing tumour that cannot be cured by currently available therapies. However, extracranial and extraneural dissemination of GBM is extremely rare, but is being recognised in different imaging studies. To date, the cause of the GBM metastatic spread still remains under discussion. It probably develops at the time of intracranial progression following a surgical procedure. According to other hypothesis, the metastases are a consequence of spontaneous tumour transdural extension or haematogenous dissemination. We present a case of a 59-year-old woman with symptomatic leptomeningeal and intramedullary metastases of GBM who has been previously surgically treated with primary subtotal resection and underwent a repeated surgery during adjuvant radiotherapy and chemotherapy with temozolomide. Today, the main goal of surgery and chemoradiotherapy is to prevent neurologic deterioration and improve health-related quality of life. With this paper, we want to present this rare entity and emphasise the importance of a multidisciplinary approach, a key function in the management of brain tumour patients. The prognosis is still very poor although prolongation of survival can be obtained. Finally, although rare, our case strongly suggests that clinicians should be familiar with the possibility of the extracranial spread of GBM because as treatment improvements provide better control of the primary tumour and improving survival, metastatic disease will be increasingly encountered.

On the origin of cancer metastasis

Metastasis involves the spread of cancer cells from the primary tumor to surrounding tissues and to distant organs and is the primary cause of cancer morbidity and mortality. In order to complete the metastatic cascade, cancer cells must detach from the primary tumor, intravasate into the circulatory and lymphatic systems, evade immune attack, extravasate at distant capillary beds, and invade and proliferate in distant organs. Currently, several hypotheses have been advanced to explain the origin of cancer metastasis. These involve an epithelial mesenchymal transition, an accumulation of mutations in stem cells, a macrophage facilitation process, and a macrophage origin involving either transformation or fusion hybridization with neoplastic cells. Many of the properties of metastatic cancer cells are also seen in normal macrophages. A macrophage origin of metastasis can also explain the long-standing "seed and soil" hypothesis and the absence of metastasis in plant cancers. The view of metastasis as a macrophage metabolic disease can provide novel insight for therapeutic management.

A single institution experience of the incidence of extracranial metastasis in glioma

Glioblastoma multiforme (GBM) is the most common and aggressive subtype of all gliomas. The prognosis is poor but despite the aggressiveness of the tumour, extracranial metastasis of glioma is rare. Most documented cases of extracranial metastases of GBM involve leptomeningeal spread to the spine. In this clinical study we aim to review the incidence and location of extracranial metastasis of glioma from the Brain Tumor Database of the National Neuroscience Institute of Singapore, between September 2004 to October 2009. Four of 148 patients (2.7%) were identified, one of whom had pleomorphic xanthoastrocytoma (PXA) with scalp and spinal metastasis, suggestive of haematogenous rather than cerebrospinal fluid spread that has been described elsewhere. To our knowledge, there has been no published report of PXA with scalp metastasis or vertebral metastasis.

Hypothesis: are neoplastic macrophages/microglia present in glioblastoma multiforme?

Most malignant brain tumours contain various numbers of cells with characteristics of activated or dysmorphic macrophages/microglia. These cells are generally considered part of the tumour stroma and are often described as TAM (tumour-associated macrophages). These types of cells are thought to either enhance or inhibit brain tumour progression. Recent evidence indicates that neoplastic cells with macrophage characteristics are found in numerous metastatic cancers of non-CNS (central nervous system) origin. Evidence is presented here suggesting that subpopulations of cells within human gliomas, specifically GBM (glioblastoma multiforme), are neoplastic macrophages/microglia. These cells are thought to arise following mitochondrial damage in fusion hybrids between neoplastic stem cells and macrophages/microglia.

Metzincin proteases and their inhibitors: foes or friends in nervous system physiology?

Members of the metzincin family of metalloproteinases have long been considered merely degradative enzymes for extracellular matrix molecules. Recently, however, there has been growing appreciation for these proteinases and their endogenous inhibitors, tissue inhibitors of metalloproteinases (TIMPs), as fine modulators of nervous system physiology and pathology. Present all along the phylogenetic tree, in all neural cell types, from the nucleus to the synapse and in the extracellular space, metalloproteinases exhibit a complex spatiotemporal profile of expression in the nervous parenchyma and at the neurovascular interface. The irreversibility of their proteolytic activity on numerous biofactors (e.g., growth factors, cytokines, receptors, DNA repair enzymes, matrix proteins) is ideally suited to sustain structural changes that are involved in physiological or postlesion remodeling of neural networks, learning consolidation or impairment, neurodegenerative and neuroinflammatory processes, or progression of malignant gliomas. The present review provides a state of the art overview of the involvement of the metzincin/TIMP system in these processes and the prospects of new therapeutic strategies based on the control of metalloproteinase activity.

Perspectives on the mesenchymal origin of metastatic cancer

Emerging evidence suggests that many metastatic cancers arise from cells of the myeloid/macrophage lineage regardless of the primary tissue of origin. A myeloid origin of metastatic cancer stands apart from origins involving clonal evolution or epithelial-mesenchymal transitions. Evidence is reviewed demonstrating that numerous human cancers express multiple properties of macrophages including phagocytosis, fusogenicity, and gene/protein expression. It is unlikely that the macrophage properties expressed in metastatic cancers arise from sporadic random mutations in epithelial cells, but rather from damage to an already existing mesenchymal cell, e.g., a myeloid/macrophage-type cell. Such cells would naturally embody the capacity to express the multiple behaviors of metastatic cells. The view of metastasis as a myeloid/macrophage disease will impact future cancer research and anti-metastatic therapies.

Glutamine targeting inhibits systemic metastasis in the VM-M3 murine tumor model

Metastatic cancer is a major cause of morbidity and mortality. Current therapeutic options consist of chemotherapy, radiation or targeted therapies. However, these therapies are often toxic, effective over a small range of cancer types or result in drug resistance. Therefore, a more global, less toxic strategy for the management of metastatic cancer is required. Although most cancers display increased glucose metabolism, glutamine is also a major energy substrate for many cancers. We evaluated the antimetastatic potential of 6-diazo-5-oxo-L-norleucine (DON), a glutamine analog, using the new VM mouse model of systemic metastasis. We found that primary tumor growth was ∼20-fold less in DON-treated mice than in untreated control mice. We also found that DON treatment inhibited metastasis to liver, lung and kidney as detected by bioluminescence imaging and histology. Our findings provide proof of concept that metabolic therapies targeting glutamine metabolism can manage systemic metastatic cancer.

Spinal metastasis of glioblastoma multiforme: an uncommon suspect?

STUDY DESIGN

Case report.

OBJECTIVE

To report a case and review the literature on glioblastoma multiforme (GBM) with drop-like metastasis to the spine.

SUMMARY OF BACKGROUND DATA

GBM constitutes the most common adult malignant brain tumor with poor prognosis. Spinal metastases of this malignancy are quite rare and dissemination usually occurs late in the course of the disease. However, recent advances in cancer treatment prolongate survival and provide adequate time for these metastases to give clinical symptoms.

METHODS

We hereby present a case of a 57-year-old woman with a history of pineal GBM treated by stereotactic biopsy, chemotherapy, and radiotherapy, readmitted 38 months later due to gait disturbance, spastic paraparesis, edema of lower limbs, bilateral positive Babinski response, and loss of bladder control. A contrast-enhanced magnetic resonance imaging demonstrated an intramedullary lesion extending from C7 to T3 level. A T1 and T2 laminectomy was undertaken followed by extensive biopsy.

RESULTS

Histologic examination was consistent with GBM. No further treatment was given, and the patient died 2 months after the diagnosis of the spinal metastasis.

CONCLUSION

Spinal metastases should be commonly suspected in patients with a history of intracranial GBM who complain about symptoms not explained by the primary lesion.Glioblastoma multiforme (GBM) was first described by Rudolph Virchow in 1863 and represents the most common and most malignant tumor of the cerebral hemispheres, usually arising between the ages of 40 and 60 years. The incidence in Europe and North America is 2 to 3 cases/100,000 per year, and 75% of the patients die within 18 months after diagnosis. It is an infiltrating malignancy that recurs locally and it may spread along compact fiber pathways such as corpus callosum, optic irradiation, anterior commisure, and fornix or via cerebrospinal fluid (CSF) pathways. However, when GBM is under apparent control, spinal metastases are clinically rarely detected. Although involvement of the spinal cord (SC) has been noted with increasing frequency in recent years, literature provides only a few well documented cases.

A novel pre-clinical in vivo mouse model for malignant brain tumor growth and invasion

Glioblastoma multiforme (GBM) is a rapidly progressive disease of morbidity and mortality and is the most common form of primary brain cancer in adults. Lack of appropriate in vivo models has been a major roadblock to developing effective therapies for GBM. A new highly invasive in vivo GBM model is described that was derived from a spontaneous brain tumor (VM-M3) in the VM mouse strain. Highly invasive tumor cells could be identified histologically on the hemisphere contralateral to the hemisphere implanted with tumor cells or tissue. Tumor cells were highly expressive for the chemokine receptor CXCR4 and the proliferation marker Ki-67 and could be identified invading through the pia mater, the vascular system, the ventricular system, around neurons, and over white matter tracts including the corpus callosum. In addition, the brain tumor cells were labeled with the firefly luciferase gene, allowing for non-invasive detection and quantitation through bioluminescent imaging. The VM-M3 tumor has a short incubation time with mortality occurring in 100% of the animals within approximately 15 days. The VM-M3 brain tumor model therefore can be used in a pre-clinical setting for the rapid evaluation of novel anti-invasive therapies.