Poor prognosis despite aggressive treatment in adults with intramedullary spinal cord glioblastoma

Predictive Factors of Long-Term Neurologic Outcome and Progression-Free Survival in Intramedullary Spinal Cord Tumors: A 10-year Single-Center Cohort Study and Review of the Literature

BACKGROUND

Intramedullary spinal cord tumors (IMSCTs) are a rare subgroup of neoplasms, encompassing both benign, slow-growing masses, and malignant lesions; radical surgical excision represents the cornerstone of treatment for such pathologies regardless of histopathology, which, on the other hand, is a known predictor of survival and neurologic outcome postsurgery. The present study aims to investigate the relevance of other factors in predicting survival and long-term functional outcomes.

METHODS

We conducted a review of current literature on functional outcomes of IMSCTs, as well as a 10-years prospective analysis of a wide cohort of patients with diagnosis of IMSCTs who underwent surgical resection at our institution.

RESULTS

Our series encompasses 60 patients with IMSCTS, among which 36 ependymomas, 6 cavernous angiomas, 5 hemangioblastomas, 6 WHO Grade I-IV astrocytomas, 3 intramedullary spinal metastases and 4 miscellaneous tumors. GTR was achieved in 76,67% of patients, with high preoperative McCormick grade, syringomyelia and changes at neurophysiologic monitoring being the strongest predictors at multivariate analysis (P = 0.0027, P = 0.0017 and P = 0.001 respectively).

CONCLUSIONS

Consistently with literature, preoperative neurologic function is the most important factor predicting long-term functional outcome (0.17, CI 0.069-0.57 with P = 0.0018), advocating for early surgery in the management of IMSCTs, whereas late complications such as myelopathy and neuropathic pain were present regardless of preoperative function.

Malignant Spinal Tumors

Malignant spinal tumors constitute around 22% of all primary spinal tumors. The most common location of metastases to the spinal region is the extradural compartment. The molecular and genetic characterization of these tumors was the basis for the updated WHO classification of CNS tumors in 2016, where many CNS tumors are now diagnosed according to their genetic profile rather than relying solely on the histopathological appearance. Magnetic resonance imaging (MRI) is the current gold standard for the initial evaluation and subsequent follow-up on intradural spinal cord tumors, and the imaging sequences must include T2-weighted images (WI), short time inversion recovery (STIR), and pre- and post-contrast T1-WI in the axial, sagittal, and coronal planes. The clinical presentation is highly variable and depends on the tumor size, growth rate, type, infiltrative, necrotic and hemorrhagic potential as well as the exact location within the spinal compartment. Surgical intervention remains the mainstay of management of symptomatic and radiographically enlarging spinal tumors, where the goal is to achieve maximal safe resection. Tumor recurrences are managed with repeat surgical resection (preferred whenever possible and safe), radiotherapy, chemotherapy, or any combination of these therapies.

Therapeutic Approaches in Adult Primary Spinal Cord Astrocytoma: A Systematic Review

Simple Summary

Adult primary spinal cord astrocytoma (SCA) is a very rare disease, with no standardized consensus about its therapy. We focus on treatment efficacy based on systematic review: only 18 papers were eligible for the analysis, including 285 patients. No clinical trials results were available. Not enough data were extracted to determine a univocal treatment plan for SCA. Given the rarity of these diseases, a collaboration among institutions is mandatory to establish a standard for study conduction (homogenous inclusion criteria and method of analysis), to perform homogenous studies and define future evidence-based recommendation. Contextually, multicentric clinical trials with molecular investigations are strongly advised to better manage SCA and unveil their biology.

Abstract

The issue: Gliomas are primary tumors arising from supporting cells of the central nervous system (CNS), usually in the brain. The 2021 World Health Organization (WHO) classifies gliomas as adult-type diffuse gliomas or circumscribed astrocytic gliomas depending on their histology and molecular features. Spinal astrocytic gliomas are very rare, and nowadays no standard of therapy is available. Treatment options are limited: surgery is often not radical, and adjuvant therapies include mostly radiotherapy (RT) or systemic chemotherapy (CHT). There is lack of knowledge about the efficacy and safety of therapies and their multidisciplinary approaches. The aim of the review: A systematic review of the literature from January 2000 to June 2021 was performed, including both clinical trials and observational studies on histological adult primary spinal cord astrocytomas (SCA), with a minimum follow-up of 6 months and reporting the overall survival, progression-free survival or clinical neurological outcome after any therapeutic approach (surgery, RT or CHT). What are the main findings? A total of 1197 citations were identified by the Medline search and additional records; based on our inclusion criteria, 18 studies were included with a total of 285 adult patients. We documented the lack of any clinical trial. What are the conclusions? The available literature data are limited to series/retrospective studies, including heterogeneous patients, i.e., astrocytoma as well as ependymoma or pediatric/adult age, with scanty data on the outcomes of interest. No clinical trials have been run. Due to the rarity of this disease, multicentric clinical trials with molecular investigations are mandatory to better manage such a rare disease.

Clinical outcomes and a therapeutic indication of intramedullary spinal cord astrocytoma

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Although intramedullary astrocytoma is associated with a high mortality rate, the optimal treatment has not reached a consensus. This study aimed at evaluating neurologic function and overall survival rate (OSR) in the treatment of this tumor.

SETTING

The single institution in Japan.

METHODS

This study enrolled 67 subjects who underwent surgical treatment for intramedullary astrocytoma. Demographic, imaging, and surgical information were collected from each participant. Tumors were histologically categorized using the World Health Organization classification, and subjects were divided into low-grade (I and II; n = 40) and high-grade (III and IV; n = 27) groups. Neurologic status was evaluated using the modified McCormick scale (MMS). OSR was assessed using Kaplan-Meier methods.

RESULTS

The OSR decreased when the pathological grade increased (p < 0.01). Regarding the therapeutic efficacy for low-grade astrocytomas, subjects who underwent gross total resection (GTR) showed a higher OSR than those who did not (p = 0.02). GTR prevented worsening of MMS score, while non-GTR increased the MMS score (p < 0.01). In the high-grade group, 19 and 10 underwent radiation therapy and chemotherapy, respectively. However, both treatments did not improve OSR. Cordotomy was performed for subjects whose lesional area was at the thoracic level, but the OSR did not significantly increase.

CONCLUSIONS

The most beneficial therapeutic strategy for low-grade astrocytomas was GTR, whereas that for the high-grade tumors was unclear. Further studies with a larger sample size are warranted to validate the effective treatment for malignant astrocytomas.

Radiation-induced glioblastoma of the conus medullaris from radiation treatment of cervical cancer

Radiation-induced spinal glioblastoma is an extremely rare disease with only four previously published reports in the literature. We report the fifth case, a 69-year-old woman who previously underwent treatment with brachytherapy for cervical cancer, and thereafter presented with neurologic deficits from a conus medullaris tumour. Biopsy and histopathology confirm glioblastoma, not otherwise specified. Treatment of spinal glioblastoma consists of surgery, either biopsy or excision and chemoradiation. However, results are still unsatisfactory and prognosis remains poor.

Spinal cord glioblastoma during pregnancy: Case report

Spinal Cord Glioblastoma Multiforme (SCGBM) is a very rare, debilitating and often fatal tumor. Cases of intracranial GBM during pregnancy have been reported, and as other tumor occurring in this setting, it harbors a great dilemma to attending physicians and families. We report the first case of a SCGBM diagnosed during pregnancy and discuss its management and treatment.

Clinical Features and Outcomes of Primary Spinal Cord Glioblastoma: A Single-Center Experience and Literature Review

OBJECTIVE

We aim to elucidate the clinical characteristics of patients with primary spinal cord glioblastoma (PSC GBM) and prognostic factors for their outcomes.

METHODS

A cohort of 11 patients with pathologically diagnosed PSC GBM from our center were retrospectively reviewed. The clinical, radiologic, operative, and molecular information were recorded, and univariate analysis was performed to identify prognostic factors.

RESULTS

The patient cohort included 5 males (45.5%) and 6 females (54.5%) with a median age of 26 years (range, 9-69 years). The median duration of the preoperative symptoms was 4.0 months (range, 0.5-120 months). Subtotal resection was achieved in 8 patients (72.7%) and partial resection in 3 (27.3%). Two patients (18.2%) underwent postoperative adjuvant chemoradiotherapy, 2 patients underwent (27.3%) chemotherapy only, and 6 patients (54.5%) neither. Two patients underwent additional therapy with bevacizumab. After a mean follow-up of 12.4 months (range, 1-33 months), Kaplan-Meier plot showed that the median progression-free survival and overall survival were 6.0 (range, 0.5-12.0) months and 12.0 (range, 1.0-33.0) months, respectively, and 1-year survival was 31.8%. Age at diagnosis and duration of the preoperative symptoms were confirmed as prognostic factors of progression-free survival and overall survival in univariate analysis (P < 0.05).

CONCLUSIONS

Despite aggressive treatment, PSC GBM still has a dismal prognosis and leads to severe neurologic deficit. Age at diagnosis and duration of the preoperative symptoms were confirmed as prognostic factors, yet the role of adjuvant radiochemotherapy and extent of resection are still unclear, necessitating further research.

Predictors of mortality in patients with primary spinal cord glioblastoma

PURPOSE

Primary spinal cord glioblastoma (GBM) is a rare and devastating disease. Little attention was ever paid to this rare disease. As a result, the standard treatment protocol and prognostic factors of primary spinal cord GBM were not well established. The aim of this study was to determine the predictors associated with survival in patients with primary spinal cord GBM.

METHODS

A total of 122 patients with primary spinal cord GBM from Surveillance, Epidemiology, and End Results database and our institution were included in this retrospective analysis. Information about age, sex, race, tumor invasion, extent of resection, radiation, chemotherapy and year of diagnosis was collected. Univariate and multivariate accelerated failure time (AFT) regression model was performed to identify prognostic factors.

RESULTS

Of the 122 patients, 102 (83.6%) expired at the time of data collection. Overall survival at 1 year, 2 years, 3 years and 5 years was 48.4%, 22.8%, 17.1% and 8.4%, respectively, and median survival time was 12 months. Only radiation was found to be associated with survival in the AFT regression model (time ratio 1.94, 95% CI 1.01-3.72, p < 0.05). Radiotherapy could improve survival slightly; patients who received RT survived approximately two times as long as patients who did not receive RT, but the advantage was short term.

CONCLUSION

The survival of primary spinal cord GBM is poor in the current treatment strategy. Radiotherapy was associated with better survival, but the advantage was short term.

Spinal cord anaplastic astrocytoma with BRAF V600E mutation: A case report and review of literature

A 17-year-old female complained of lower extremity pain that progressed to low back pain accompanied by paraparesis. Magnetic resonance imaging revealed a mass in the conus medullaris of the spinal cord at the thoracic spine 11-12 level. The patient underwent resection of the mass. The pathological diagnosis was anaplastic astrocytoma based on the densely proliferating astrocytic tumor cells without necrosis or microvascular proliferation. The patient received chemoradiotherapy with oral temozolomide and a total of 54 Gy of local irradiation, followed by 24 courses of temozolomide as maintenance chemotherapy. The patient survived for 8 years without tumor recurrence following the initial treatment. Genetic analysis of the tumor revealed a BRAF V600E mutation that has not yet been reported in spinal cord high-grade gliomas (HGGs). In recent years, the molecular therapy targeting the BRAF V600E mutation has been applied in clinical practice for several cancer types. Although the frequency in spinal cord HGGs is uncertain, it is necessary to investigate BRAF V600E mutation as a potential therapeutic target in the future.

Updates in the management of intradural spinal cord tumors: a radiation oncology focus

Primary spinal cord tumors represent a hetereogeneous group of central nervous system malignancies whose management is complex given the relatively uncommon nature of the disease and variety of tumor subtypes, functional neurologic deficits from the tumor, and potential morbidities associated with definitive treatment. Advances in neuroimaging; integration of diagnostic, prognostic, and predictive molecular testing into tumor classification; and developments in neurosurgical techniques have refined the current role of radiotherapy in the multimodal management of patients with primary spinal cord tumors, and corroborated the need for prospective, multidisciplinary discussion and treatment decision making. Radiotherapeutic technological advances have dramatically improved the entire continuum from treatment planning to treatment delivery, and the development of stereotactic radiosurgery and proton radiotherapy provides new radiotherapy options for patients treated in the definitive, adjuvant, or salvage setting. The objective of this comprehensive review is to provide a contemporary overview of the management of primary intradural spinal cord tumors, with a focus on radiotherapy.

Antimicrobial Peptide TP4 Induces ROS-Mediated Necrosis by Triggering Mitochondrial Dysfunction in Wild-Type and Mutant p53 Glioblastoma Cells

Antimicrobial peptide tilapia piscidin 4 (TP4) from Oreochromis niloticus exhibits potent bactericidal and anti-tumorigenic effects. In a variety of cancers, the mutation status of p53 is a decisive factor for therapeutic sensitivity. Therefore, we investigated the impact of p53 status on TP4-induced cytotoxicity in glioblastoma cell lines and the molecular mechanisms that govern cytotoxic effects. Both U87MG (wild-type/WT p53) and U251 (mutant p53) glioblastoma cell lines were sensitive to TP4-induced cytotoxicity. The necrosis inhibitors Necrostatin-1 and GSK’872 attenuated TP4-induced cytotoxicity, and TP4 treatment induced the release of cyclophilin A, a biomarker of necrosis. Moreover, TP4 induced mitochondrial hyperpolarization and dysfunction, which preceded the elevation of intracellular reactive oxygen species, DNA damage, and necrotic cell death in both U87MG and U251 glioblastoma cells. p38 was also activated by TP4, but did not contribute to cytotoxicity. SB202190, a specific p38 inhibitor, enhanced TP4-induced oxidative stress, mitochondrial dysfunction, and cytotoxicity, suggesting a protective role of p38. Furthermore, TP4-induced cytotoxicity, oxidative stress, phosphorylation of p38, and DNA damage were all attenuated by the mitochondrial-targeted reactive oxygen species (ROS) scavenger MitoTEMPO, or the reactive oxygen species scavenger N-acetyl-L-cysteine. Based on these data, we conclude that TP4 induces necrosis in both WT and mutant p53 glioblastoma cells through a mitochondrial ROS-dependent pathway.

Primary Spinal Cord Glioblastoma Multiforme: A Retrospective Study of Patients at a Single Institution

BACKGROUND AND OBJECTIVE

Primary spinal cord (PSC) glioblastoma multiforme (GBM) is extremely rare and accounts for only 1.5% of all spinal cord tumors. Therefore, its treatment is still ill defined. To elucidate prognostic factors, we performed a single-institutional retrospective review of the largest series to date of patients with PSC GBM who underwent surgical resection in West China Hospital between 2008 and 2014. A total of 14 patients with PSC GBM were reviewed.

METHODS

Demographic, operative, and postoperative factors were recorded. Overall survival (OS) and progression-free survival (PFS) were calculated and compared with the Kaplan-Meier method.

RESULTS

Eight males (57%) and 6 females (43%) were involved in the study. Their median age was 28 years (range, 14-56 years). Median Karnofsky Performance Status score was 60 (range, 20-90). Four patients (28.6%) received gross total resection, 5 (35.7%) partial resection, and the remaining 5 (35.7%) biopsy only. Nine patients (64.3%) received postoperative radiotherapy and chemotherapy, 3 (21.4%) chemotherapy only, and 2 (14.3%) neither. Median follow-up period was 15 months (range, 5-26 months). One-year and 2-year survival was 78.5% (11/14) and 7.1% (1/14), respectively. Median OS was 15 months, and median PFS 8 months. Univariate log-rank analysis showed that OS and PFS were significantly associated with patients' age (P = 0.007 and P = 0.04, respectively) and postoperative radiotherapy (P = 0.001 and P = 0.002, respectively). However, preoperative Karnofsky Performance Status score affected only OS and did not affect PFS (P = 0.033 and P = 0.106, respectively).

CONCLUSIONS

According to our study, the combination of postoperative radiotherapy and temozolomide chemotherapy can improve prognosis and may serve as a feasible postoperative adjuvant treatment of PSC GBM.