Brain stem gliomas: Patterns of Care in Victoria from 1998–2000

Adult brainstem glioma presenting with isolated persistent hemifacial spasm or facial nerve palsy

OBJECT

Adult brainstem gliomas are a rare group of heterogeneous brain tumors. Classical clinical presentation includes progressive impairment of cranial nerves associated with long tract signs. The prognosis and response to treatment are poor; nevertheless, some patients do have a long survival. The objective of this study was to describe a series of patients with an isolated persistent hemifacial spasm and/or facial nerve palsy as the presenting symptom of a brainstem glioma.

METHODS

Fourteen patients from 3 French hospitals (Paris, Caen, Lille) were included. Clinical and radiological features and overall survival were retrospectively analyzed. A review of the literature of similar cases was performed.

RESULTS

Mean age at diagnosis was 35 years (range 19-57 years). Mean duration of facial nerve involvement before diagnosis was 17 months (range 1-48 months). Tumors were characterized on MRI by a lateralized location in the pons, a T1-weighted hyposignal, a T2-weighted hypersignal and no contrast enhancement after Gadolinium injection except for 2 cases. Biopsies were performed in 10 cases and showed 8 low-grade and 2 high-grade gliomas. All the patients were initially treated with radiotherapy and 6 patients with chemotherapy after progression. Eleven patients died from tumor progression. Median survival time was 90 months.

CONCLUSIONS

Adult brainstem gliomas revealed by a progressive isolated involvement of the facial nerve seem to have particular clinico-radiological features of slow progressive tumors and may be associated with long patient survival.

Surgical Application of the Suboccipital Subtonsillar Approach to Reach the Inferior Half of Medulla Oblongata Tumors in Adult Patients

Medulla oblongata (MO) tumors are uncommon in adults. Controversies about their treatment arise regarding the need for histological diagnosis in this eloquent area of the brain, weighing benefits of a reliable diagnosis, and the potential disadvantages of invasive procedures. As a broader variety of pathological findings could be found in this localization, the accurate histopathological definition could not only allow an adequate therapy but also can prevent the disastrous consequences of empiric treatments. There are few publications about their surgical management and all belongs to small retrospective cohorts. In this scenario, we are reporting two patients with exophytic or focal lesions in the inferior half of the medulla, who underwent surgery by suboccipital midline subtonsillar approach. This approach was not specifically described to reach MO before, and we found that the lesions produced a mild elevation of the tonsils providing a wide surgical view from the medulla to the foramen of Luchska laterally, and up to the middle cerebellar peduncle, offering a wide and safe access.

Recurrent glioblastoma: Current patterns of care in an Australian population

This retrospective population-based survey examined current patterns of care for patients with recurrent glioblastoma (rGBM) who had previously undergone surgery and post-operative therapy at original diagnosis. The patients were identified from the Victorian Cancer Registry (VCR) from 2006 to 2008. Patient demographics, tumour characteristics and oncological management were extracted using a standardised survey by the treating clinicians/VCR staff and results analysed by the VCR. Kaplan-Meier estimates of overall survival (OS) at diagnosis and progression were calculated. A total of 95 patients (48%) received treatment for first recurrence; craniotomy and post-operative treatment (38), craniotomy only (34) and non-surgical treatment (23). Patients receiving treatment at first progression had a higher median OS than those who did not (7 versus 3 months, p<0.0001). All patients progressed after treatment for first progression with 43 patients (45%) receiving treatment at second progression. To our knowledge this is the first population-based pattern of care survey of treatment for rGBM in an era where post-operative "Stupp" chemo-radiation is standard. First and second line therapy for rGBM is common and associated with significant benefit. Treatment generally includes re-resection and/or systemic therapy.

Management of glioblastoma in Victoria, Australia (2006-2008)

We describe the management of patients with newly diagnosed glioblastoma multiforme (GBM) in a population-based cohort and compare this to a previously studied cohort. We performed a retrospective cohort study of patients diagnosed with GBM from 2006-2008 in Victoria, Australia. Patients were identified from the population-based Victorian Cancer Registry and their treating doctors surveyed by questionnaire. Outcomes were then compared to a study of GBM patients who were diagnosed between 1998 and 2000 using an identical methodology. We reviewed 351 eligible patients. There were slightly more males (62%) and a minority had multifocal disease (13%). Total macroscopic resection, partial resection or biopsy only was performed in 32%, 37% and 24% of patients, respectively. The majority of patients were referred to a radiation oncologist and medical oncologist postoperatively. A total of 56% of patients were treated with postoperative radiotherapy with concurrent and sequential temozolomide and had a median survival of 14.4 months. This was significantly better than patients treated with postoperative radiotherapy alone in the current or earlier cohorts (2006-2008: median survival 6.2 months, p<0.0001 versus 1998-2000: 8.9 months, p<0.0001). This study demonstrates that postoperative chemoradiation has become the standard of care in this Victorian population with an associated improvement in median survival.

Survival prediction model of children with diffuse intrinsic pontine glioma based on clinical and radiological criteria

BACKGROUND

Although diffuse intrinsic pontine glioma (DIPG) carries the worst prognosis of all pediatric brain tumors, studies on prognostic factors in DIPG are sparse. To control for confounding variables in DIPG studies, which generally include relatively small patient numbers, a survival prediction tool is needed.

METHODS

A multicenter retrospective cohort study was performed in the Netherlands, the UK, and Germany with central review of clinical data and MRI scans of children with DIPG. Cox proportional hazards with backward regression was used to select prognostic variables (P < .05) to predict the accumulated 12-month risk of death. These predictors were transformed into a practical risk score. The model's performance was validated by bootstrapping techniques.

RESULTS

A total of 316 patients were included. The median overall survival was 10 months. Multivariate Cox analysis yielded 5 prognostic variables of which the coefficients were included in the risk score. Age ≤3 years, longer symptom duration at diagnosis, and use of oral and intravenous chemotherapy were favorable predictors, while ring enhancement on MRI at diagnosis was an unfavorable predictor. With increasing risk score categories, overall survival decreased significantly. The model can distinguish between patients with very short, average, and increased overall survival (medians of 7.0, 9.7, and 13.7 mo, respectively). The area under the receiver operating characteristic curve was 0.68.

CONCLUSIONS

We developed a DIPG survival prediction tool that can be used to predict the outcome of patients and for stratification in trials. Validation of the model is needed in a prospective cohort.

Clinical management and outcome of histologically verified adult brainstem gliomas in Switzerland: a retrospective analysis of 21 patients

Because of low incidence, mixed study populations and paucity of clinical and histological data, the management of adult brainstem gliomas (BSGs) remains non-standardized. We here describe characteristics, treatment and outcome of patients with exclusively histologically confirmed adult BSGs. A retrospective chart review of adults (age >18 years) was conducted. BSG was defined as a glial tumor located in the midbrain, pons or medulla. Characteristics, management and outcome were analyzed. Twenty one patients (17 males; median age 41 years) were diagnosed between 2004 and 2012 by biopsy (n = 15), partial (n = 4) or complete resection (n = 2). Diagnoses were glioblastoma (WHO grade IV, n = 6), anaplastic astrocytoma (WHO grade III, n = 7), diffuse astrocytoma (WHO grade II, n = 6) and pilocytic astrocytoma (WHO grade I, n = 2). Diffuse gliomas were mainly located in the pons and frequently showed MRI contrast enhancement. Endophytic growth was common (16 vs. 5). Postoperative therapy in low-grade (WHO grade I/II) and high-grade gliomas (WHO grade III/IV) consisted of radiotherapy alone (three in each group), radiochemotherapy (2 vs. 6), chemotherapy alone (0 vs. 2) or no postoperative therapy (3 vs. 1). Median PFS (24.1 vs. 5.8 months; log-rank, p = 0.009) and mOS (30.5 vs. 11.5 months; log-rank, p = 0.028) was significantly better in WHO grade II than in WHO grade III/IV tumors. Second-line therapy considerably varied. Histologically verification of adult BSGs is feasible and has an impact on postoperative treatment. Low-grade gliomas can simple be followed or treated with radiotherapy alone. Radiochemotherapy with temozolomide can safely be prescribed for high-grade gliomas without additional CNS toxicities.

The expressions of Wnt/β-catenin pathway-related components in brainstem gliomas

BACKGROUND

The overall prognosis of brainstem gliomas is very poor, and the current treatment cannot significantly prolong the overall survival of these patients; therefore, studying the molecular biological mechanisms of the occurrence and development of brainstem gliomas has important significance for their treatment. The Wnt/β-catenin signaling pathway is closely associated with the occurrence and development of tumors, but its relationship with brainstem gliomas remains unclear.

METHODS

This study used Western blot and immunohistochemistry methods to detect the expressions of Wnt/β-catenin signaling pathway-related components such as Wnt-1, Wnt-2, β-catenin and C-myc in six cases of normal brain tissues and 24 cases of brainstem gliomas and analyzed the relationship between their expressions and clinicopathological characteristics.

RESULTS

Wnt-1 had no obvious expression in normal brain tissues and did not show any significant difference between high- and low-grade brainstem gliomas; the expressions of Wnt-2, β-catenin and C-myc in high-grade brainstem gliomas were significantly higher than that in low-grade brainstem gliomas and normal brain tissues and were positively correlated with the expression of Ki-67. Moreover, the expressions of Wnt-2 and C-myc were significantly associated with the prognosis of brainstem glioma patients; additionally, there was a trend toward increased β-catenin expression with shorter survival, but there was no statistical difference.

CONCLUSIONS

Wnt/β-catenin signaling pathway might be abnormally activated and plays an important role in the occurrence and development of brainstem gliomas. Wnt-2, β-catenin and C-myc may be potential targets for brainstem glioma treatment.

Expression of β-catenin and E- and N-cadherin in human brainstem gliomas and clinicopathological correlations

Brainstem gliomas are usually associated with serious dysfunction and poor prognosis especially for diffuse intrinsic brainstem gliomas; however, the reasons are still unclear. Some clinical studies have suggested that the invasive ability may be different among brainstem gliomas, and the dysfunction of β-catenin and E- and N-cadherin appears to be connected with tumor invasion and progression. In this study, the expression of β-catenin and E- and N-cadherin was detected in 40 brainstem glioma samples using immunochemistry and was further analyzed in 18 samples using reverse transcription-polymerase chain reaction. The clinicopathological characteristics were also analyzed. The results show that there was no obvious staining for E-cadherin, but weak expression at the messenger RNA (mRNA) level could be seen in a few samples. The protein and mRNA expression levels of β-catenin and N-cadherin were significantly associated with the pathological grades of brainstem gliomas. No significant differences in the expression levels of β-catenin and N-cadherin were observed for age, sex, location or diffuse growing pattern. The overall survival of patients with low β-catenin expression was longer than that with high β-catenin expression, and there was a trend toward increased expression of N-cadherin with shorter survival; however, both of them had no statistical differences. These results demonstrate that expression of β-catenin and N-cadherin is associated with the malignant progression of brainstem gliomas but not correlated with the diffuse and invasive growing pattern. β-catenin and N-cadherin are potential therapeutic targets and prognostic markers for brainstem glioma, which need to be validated in a larger patient cohort.

Characterization and outcomes of infratentorial malignant glioma: a population-based study using the Surveillance Epidemiology and End-Results database

PURPOSE

Using a population-based database, we sought to characterize brainstem gliomas and to evaluate the prognosis of various subgroups.

MATERIALS AND METHODS

Using the Surveillance Epidemiology and End-Results (SEER) database we identified patients diagnosed with malignant infratentorial gliomas between 1988 and 2003 who underwent a surgical procedure and/or received radiation therapy (RT).

RESULTS

A total of 455 patients were identified with a median age at diagnosis of 13 years (range 0-87). The overwhelming majority, 95.6%, received RT. Median survival (MS) was 11 months. Those not undergoing RT had a MS of 3 months. MS varied significantly by age, p<0.001. MS for patients aged 0-18 years was 11 months; 19-29 years was 35 months; 30-49 years was 17 months; 50-69 years was 6 months; and 70 years or older was 3 months. The small group with grades I and II tumors had improved MS of 58 and 37 months, respectively. There was no difference in survival by the year of diagnosis (1999 versus 2000 or later) with MS of 10 versus 11 months, respectively, p=0.949.

CONCLUSION

Brainstem glioma is primarily a childhood malignancy with a generally poor prognosis. A minority of patients has favorable features and can achieve long-term survival.