Gliomatosis cerebri: findings with computed tomography and magnetic resonance imaging

Pediatric gliomatosis cerebri mimicking tubercular encephalitis

Gliomatosis cerebri (GC) is a diffuse infiltrating glial neoplasm of astrocytic origin. GC in children is rare and difficult to diagnose, often presenting with a variety of signs and symptoms that may mimic myriad conditions. We discuss here the presentation and diagnosis of GC in a child who was initially treated on lines of tubercular encephalitis, with transient clinical relief and disappearance of enhancing component of the disease on magnetic resonance imaging. In this report, we highlight the limitations of clinical presentation and neuroimaging as well as the essential role of histological evaluation for the diagnosis of GC in children. Also is highlighted a more benign and protracted clinical course following radiotherapy in a subset of patients, with Ki index <10%, thereby stressing earliest possible diagnosis. A new prognostic classification can also be proposed for pediatric GC based on various parameters. Since these are rare cases, a combined effort is required for this.

Pediatric Gliomatosis Cerebri: A Review of 15 Years

Gliomatosis cerebri is a rare glial tumor that carries a poor prognosis. Seen in both adults and children, gliomatosis cerebri appears to differ in these populations as with adult versus pediatric glioblastoma. We present 10 children who either presented to the Weill Cornell Medical College or enrolled in the institution's Gliomatosis Cerebri International Registry alongside a cohort of 89 pediatric patients reported in the literature between 2000 and 2014. Age ranged from 4 months to 21 years, with a male to female ratio of 1.71. Median overall survival for patients in the registry cohort was 17 months (n = 10) and for the historic cohort was 13 months (n = 52). Overall survival was analyzed for the combined cohort and was significantly longer when presenting at age ≥ 10 (20 vs 10 months), for boys (18 vs 11 months), and with low-grade pathology (26.5 vs 12 months) but did not vary significantly by treatment approach.

Procarbazine, CCNU, and Vincristine Chemotherapy in Gliomatosis Cerebri

A 49-year-old female patient was admitted due to memory disturbances. Magnetic resonance (MR) imaging suggested gliomatosis cerebri (GC), which had spread to both insular lobes, both frontal and basal ganglia and the brain stem. A stereotactic biopsy was performed at the high signal intensity area of the T2-weighted MR image, and the revealed a diffuse astrocytoma. Radiation therapy was judged not to be an appropriate treatment for the patient because of her cognitive impairment. A combinatorial chemotherapy regiment consisting of Procarbazine, CCNU, and Vincristine (PCV) was agreed upon after discussion. The patient underwent six cycles of PCV chemotherapy (a full dose was applied until the 3rd cycle, and dose then was reduced to 75% for the remaining cycles). Although the patient exhibited side effects such as bone marrow suppression and gastrointestinal symptoms, these were managed by medication. Over the 28 months following initiation of treatment, the high signal area in the right frontal and temporal lobes in the T2-weighted MR image decreased, and the patient's cognitive function [global deterioration scale (GDS) 4 points, mini-mental state examination (MMSE) 25 point] also improved (GDS 1 points, MMSE 29 points). PCV chemotherapy can therefore be an alternative therapeutic option for patients with GC who cannot be treated with radiation therapy or other chemotherapies.

Bilateral Telencephalic Gliomatosis Cerebri in a Dog

An 8-year-old intact male Lagotto Romagnolo was presented with forebrain signs. Neuroanatomic localization was diffuse prosencephalon. MRI revealed diffuse, bilateral, and symmetric T2 and FLAIR hyperintensities in the parieto-occipital white matter and corpus callosum. No mass effect or contrast enhancement was noted. Analysis of cerebrospinal fluid revealed normal protein content and mild mononuclear pleocytosis. Atypical cells were not identified. 15 days later because of the worsening of clinical condition the patient was euthanized upon owner’s request. Neuropathological investigations were consistent with gliomatosis cerebri (GC). Such an unusual imaging pattern appeared similar to some cases of human GC and to a previous reported case in a dog, suggesting a possible repeatable imaging findings for this rare brain neoplasm. GC should be included in the MRI differentials for diffuse bilateral white matter signal changes and specific MRI findings described in this report may help in reaching a presumptive diagnosis of this tumor.

MRI features of gliomatosis cerebri in a dog

The features of gliomatosis cerebri involving the brainstem and cerebellum in a 3-year-old dog are described. In magnetic resonance (MR) images, there was diffuse loss of the cerebellar folia and cerebellar gray and white matter contrast. Multiple illdefined T2-hyperintensities were present in the cerebellar parenchyma. A poorly defined, T2-hyperintense mass effect was present ventral to the pons and rostral medulla. No contrast enhancement was noted. Cerebrospinal fluid (CSF) was normal. Postmortem examination was consistent with gliomatosis cerebri, based on compatible histopathology and immunohistochemical findings. Although rare, gliomatosis cerebri should be included as a differential for diffuse infiltrative central nervous system (CNS) lesions.

Gliomatosis Cerebri in Two Dogs

A 3.5 yr old Saint Bernard was evaluated for nonambulatory tetraparesis and cranial nerve dysfunction, and a 7 yr old rottweiler was evaluated for progressive paraparesis. Clinical signs of left-sided vestibular and general proprioceptive ataxia and cranial nerve VII dysfunction in the Saint Bernard suggested a lesion affecting the brain stem. Signs in the rottweiler consisted of general proprioceptive/upper motor neuron paraparesis, suggesting a lesion involving the third thoracic (T3) to third lumbar (L3) spinal cord segments. MRI was normal in the Saint Bernard, but an intra-axial lesion involving the T13–L2 spinal cord segments was observed in the rottweiler. In both dogs, the central nervous system (CNS) contained neoplastic cells with features consistent with gliomatosis cerebri (GC). In the Saint Bernard, neoplastic cells were present in the medulla oblongata and cranial cervical spinal cord. In the rottweiler, neoplastic cells were only present in the spinal cord. Immunohistochemistry disclosed two distinct patterns of CD18, nestin, and vimentin staining. GC is a rarely reported tumor of the CNS. Although GC typically involves the cerebrum, clinical signs in these two dogs reflected caudal brainstem and spinal cord involvement.

Gliomatosis cerebri: report of 3 cases

Gliomatosis cerebri is an uncommon glial neoplasm that is exceedingly rare in children and difficult to diagnose. The authors describe the presentation and diagnosis of GC in 3 children ages 12, 14, and 16 years. These children exhibited signs and symptoms of increased intracranial pressure as well as other vague or site specific neurological signs. Because clinical presentation, CSF analysis, and neuroimaging were nonspecific, a stereotactic biopsy to obtain tissue for pathological review was ultimately necessary to confirm the diagnosis. These pediatric cases underscore the limitations of relying solely on clinical presentation and neuroimaging and call to attention the essential role of neurosurgical intervention. The authors emphasize the need to maintain gliomatosis cerebri in the differential diagnosis of children presenting with diffuse neurological signs and MR imaging evidence of widespread, infiltrative lesions.

Pediatric gliomatosis cerebri mimicking acute disseminated encephalomyelitis

Gliomatosis cerebri (GC) is a diffuse infiltrating glial neoplasm of astrocytic origin. GC in children is rare and difficult to diagnose, often presenting with a variety of signs and symptoms that may mimic encephalitis. We discuss here the presentation and diagnosis of GC in 2 children who were initially suspected to have acute disseminating encephalomyelitis. In this report we underscore the limitations of relying on clinical presentation and neuroimaging as well as the essential role of pathologic evaluation for the diagnosis of GC in children.

Value of diagnosis and differential diagnosis of MRI and MR spectroscopy in gliomatosis cerebri

PURPOSE

The purpose of this study was to characterize gliomatosis cerebri on magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS), and to analyze the value of these two techniques in diagnosis and differential diagnosis of gliomatosis cerebri.

MATERIALS AND METHODS

MR images of 14 patients with gliomatosis cerebri were reviewed retrospectively; seven of the patients also underwent MRS (single-voxel point-resolved spectroscopy, and chemical-shift imaging point-resolved spectroscopy). Tumorous were confirmed by surgery and biopsy. The distribution, extension and signal features of lesions were assessed, and the MR spectroscopy results were analyzed.

RESULTS

Tumors involved at least two lobes of the brain in all patients. Widespread invasion with isointensity or hypointensity on T1-weighted MR images and hyperintensity on T2-weighted images were found while no prominent necrosis, hemorrhage or contrast enhancement was found. All patients who underwent MRS showed elevated Cho/Cr and Cho/NAA levels as well as decreased NAA/Cr ratios in the abnormal areas on T2-weighted images, three of which showed a lactate doublet. Anaplastic lesions had higher Cho/NAA levels in three cases. Abnormality of metabolism was also seen in the margin of the lesion that was normal on T2-weighted images.

CONCLUSION

MRI and MRS are valuable techniques for diagnosis and differential diagnosis of gliomatosis cerebri. Combining clinical information and MRI findings, as well as MRS, is crucial for making a definitive diagnosis.

Gliomatosis cerebri: 20 years of experience at the Children's Hospital of Philadelphia

BACKGROUND

Gliomatosis cerebri (GC) is a rare and typically fatal glial neoplasm of the central nervous system. In this report, the authors describe the largest cohort of children to date with GC and explore relations between potential prognostic factors, treatment, and survival.

METHODS

Imaging, pathologic, and outcome data were reviewed from 13 patients who were diagnosed with GC and were treated at the Children's Hospital of Philadelphia (CHOP) between 1982 and 2005. All patients had GC confirmed by biopsy. Twelve patients received cranial irradiation, and 8 of those patients received adjuvant chemotherapy. A single patient age 1 year received chemotherapy alone. A review of the literature identified 51 pediatric patients with GC.

RESULTS

The progression-free survival rate in this study was 13% (range, 1.5-43 months), and the overall survival (OS) rate was 64% (range, 6.5-67 months) at 2 years. OS was significantly shorter for patients who presented in the first decade of life (P = .04). The time to progression was prolonged significantly for patients who had no evidence of tumor enhancement on imaging studies (P = .03). When survival data from patients reported in the literature were combined with the CHOP cohort, treatment prolonged OS significantly (P = .003).

CONCLUSIONS

The outcome of pediatric patients with GC was extremely poor; however, the current results indicated that treatment may prolong OS. Age < 10 years and contrast enhancement on magnetic resonance imaging studies at diagnosis may be risk factors for shorter survival in pediatric patients with GC.

Gliomatosis cerebri: quantitative proof of vessel recruitment by cooptation instead of angiogenesis

Object. Gliomas are the most common primary brain tumors, many of which (especially astrocytic and oligodendroglial neoplasms) are characterized by diffuse infiltrative growth in the preexisting brain tissue. Gliomatosis cerebri is a rare glial tumor and represents an extreme example of such diffuse infiltrative growth. This growth pattern not only hampers curative treatment but also allows for vessel cooptation rather than tumor angiogenesis as a way of vessel recruitment by the tumor tissue. The goal of this study was to establish the extent to which tumor angiogenesis occurs in gliomatosis cerebri.

Methods. Computerized image analysis was performed to assess quantitatively two microvascular parameters (vessel density and diameter) in different areas of a brain harboring a gliomatosis cerebri. These regions were the cerebral white and gray matter in which there was a diffuse infiltrative tumor, cerebral white and gray matter in which there was a more compact growth pattern of tumor cells, and normal cerebral white and gray matter. In addition, the authors performed immunohistochemical stainings for blood—brain barrier (BBB) characteristics (Glut-1 and PgP) on samples obtained in these different areas.

The results of the quantitative analysis strongly indicated that in gliomatosis cerebri tumor, angiogenesis was completely absent, a finding that is corroborated by the fact that the microvasculature in gliomatosis cerebri persists in exhibiting immunohistochemical characteristics of the BBB.

Conclusions. The results of this study may help resolve the difficulties in radiological detection and delineation of the diffuse infiltrative part of glial brain tumors and put the expectations for antiangiogenic treatment of such tumors into perspective.

Gliomatosis cerebri: a review of 22 cases

OBJECTIVE

Gliomatosis cerebri is an enigmatic diffuse brain neoplasm whose prognosis is grim. We reviewed data for patients with gliomatosis who were treated at the University of California, San Francisco, during a 10-year period. Our focus was on presentation, radiological and pathological features, and outcomes.

METHODS

We reviewed hospital and clinic records and magnetic resonance imaging scans for 22 patients with gliomatosis. The diagnosis was based on magnetic resonance imaging findings and tissue confirmation for all patients. Seven patients also underwent magnetic resonance spectroscopy. Eleven patients were male (50%), and the median age at presentation was 49 years (range, 7-79 yr).

RESULTS

Kaplan-Meier analysis demonstrated median lengths of survival as follows: no treatment, 1 month (n = 4); radiotherapy alone, 28 months (95% confidence interval, 5-51 mo; n = 13); radiotherapy followed by chemotherapy, two patients, alive at 28 and 104 months; radiotherapy and chemotherapy simultaneously, three patients, one alive at 18 months and the others dead at 7 and 9 months. There was no significant difference between radiotherapy alone and radiotherapy combined with chemotherapy (P = 0.69). Karnofsky Performance Scale scores of >/=70 and grade were both significantly related to length of survival in univariate analyses (P < 0.05); these correlations were confirmed in the multivariate analysis, although the small numbers of patients and deaths precluded reliable interpretation.

CONCLUSION

Although the small number of patients in our study and its retrospective nature preclude definitive conclusions regarding the utility of treatment, our findings suggest that biopsies are useful not only for diagnosis but also for prediction of the length of survival.

Vascular endothelial growth factor-A determines detectability of experimental melanoma brain metastasis in GD-DTPA-enhanced MRI

We have previously shown that the dense vascular network in mouse brain allows for growth of human melanoma xenografts (Mel57) by co-option of preexisting vessels. Overexpression of recombinant vascular endothelial growth factor-A (VEGF-A) by such xenografts induced functional and morphologic alterations of preexisting vessels. We now describe the effects of VEGF-A expression on visualization of these brain tumors in mice by magnetic resonance imaging (MRI), using gadolinium diethylenetriaminepenta-acetic acid (Gd-DTPA) and ultra small paramagnetic iron oxide particles (USPIO) as contrast agents. Brain lesions derived from (mock-transfected) Mel57 cells were undetectable in MRI after Gd-DTPA injection. However, the majority of such lesions became visible after injection of USPIO, due to the lower vascular density in the lesions as compared to the surrounding parenchyma. In contrast, VEGF-A-expressing lesions were visualized using Gd-DTPA-enhanced MRI by a rapid circumferential enhancement, due to leaky peritumoral vasculature. USPIO-enhanced MRI of these tumors corroborated the immunohistochemic finding that peritumorally located, highly irregular and dilated vessels were present, while intratumoral vessel density was low. Our study shows that VEGF-A is a key factor in imaging of brain neoplasms. Our data also demonstrate that, at least in brain, blood-pool agent-enhanced MRI may be a valuable diagnostic tool to detect malignancies that are not visible on Gd-DTPA-enhanced MRI. Furthermore, the involvement of VEGF-A in MRI visibility suggests that care must be taken with MRI-based evaluation of antiangiogenic therapy, as anti-VEGF treatment might revert a tumor to a co-opting phenotype, resulting in loss of contrast enhancement in MRI.

Histological and MR correlations in Gliomatosis cerebri

The diagnosis of Gliomatosis cerebri (GC) is known to be difficult and is still a matter of debate. In order to better define this entity, we studied clinical, neuroradiological, pathological and follow-up data of 9 patients affected with GC. MRI were done with T1 before and after gadolinium injection, and with T2-weighted images and Flair in 3 cases. Histological confirmation of glial proliferation was obtained in all patients by craniotomy or stereotactic biopsies. Patients were treated and followed-up in our center. The histological analyses highlighted a heterogeneous glial proliferation with various degrees of anaplasia in all the cases including 2 cases of oligodendroglioma, 1 case of anaplastic oligodendroglioma, 2 cases of anaplastic mixed oligoastrocytoma, 1 case of anaplastic astrocytoma, 2 cases of glioblastoma and 1 case of astrocytic proliferation typical of GC. The topography of the tumoral infiltration was characteristic involving mainly the white matter, basal ganglia and thalamus, brainstem and less often hypothalamus. More than two cerebral lobes were involved. Contrast enhancement, mass effect and necrosis were minimal compared to the extent of tumoral infiltration. Patients were treated with various schemes of treatment all including nitrosourea. Survival from diagnosis was under one year except for 2 patients (17 and 14 months). This study shows that the diagnosis of GC needs to be based not on pathological data alone, but on pathological, clinical and, above all, on radiological criteria. Response to therapy could not clearly be observed in GC, despite oligodendroglial component in 6/9 cases. Prognosis of GC was constantly poor.

Posterior fossa decompression for life-threatening tonsillar herniation in patients with gliomatosis cerebri: report of three cases

OBJECTIVE AND IMPORTANCE

Gliomatosis cerebri (GC) is a rare type of primary brain tumor that diffusely infiltrates more than two lobes of the brain while the normal cerebral architecture is maintained. To the best of our knowledge, the association between an acquired tonsillar herniation and GC has never been reported. In this article, we describe three patients with progressive gliomatosis of the cerebellar hemispheres who subsequently showed signs and symptoms secondary to tonsillar herniation. Early recognition of this potentially life-threatening complication allowed us to recommend prompt surgical intervention.

CLINICAL PRESENTATION

One patient with primary, or Type I, GC presented with suboccipital headaches, and two patients with secondary, or Type II, GC presented with the signs and symptoms of progressive myelopathy. Serial imaging studies demonstrated progressive involvement of the cerebellum, descent of the cerebellar tonsils through the foramen magnum, and cervicomedullary spinal cord compression.

INTERVENTION

Once the tonsillar herniation was recognized, all three patients underwent posterior fossa decompression, a cervical laminectomy to the lowest level of the tonsillar herniation, and duraplasty. All three patients experienced immediate improvement in their conditions.

CONCLUSION

Early recognition of tonsillar herniation, a possibly overlooked cause of death in patients with GC, allows for early surgical intervention as a potentially lifesaving procedure and significant improvement in the patient's condition.

Intracranial perineural extension of invasive mycosis: a novel mechanism of disease propagation by Aspergillus fumigatus

We describe an immunocompetent woman who had refractory, invasive sphenoid sinus Aspergillus fumigatus infection for which there was radiologic evidence of intracranial perineural spread. The patient responded to a combination of antifungal and adjuvant recombinant cytokine therapy.

Histological and genetic diagnosis of gliomatosis cerebri: case report

Gliomatosis cerebri is considered grade III astrocytoma because of the short survival period of patients with this tumor, while the tumor histologically consists of widespread low grade astrocytoma cells. The authors tried to clarify this discrepancy by applying genetic analysis of the tumor. A 29-year-old man originally presented with mild headache and showed diffuse high intensity areas in both hemispheres and in the cerebellum by T2-weighted magnetic resonance imaging (MRI) without gadolinium-dimeglumine (Gd)-enhancement in T1-weighted imaging. Histological diagnosis was gliomatosis cerebri with diffuse grade II astrocytoma. Seven months after temporary improvement following irradiation and chemotherapy, he developed progressive mental deterioration, and died in one year after the surgery. At this time T1-weighted imaging showed Gd-enhanced lesions with enlargement only of the cerebellar tumor. Genetic analysis demonstrated positive FGFR 1 and less FGFR 2 mRNA in the tumor tissue, and FGFR 1 mRNA was beta type dominant. These results indicated that the genetic features of this tumor are similar to those of glioblastoma multiforme concerning FGFR expression. The authors conclude that genetic investigation of the tumor tissue is required to predict the prognosis of gliomatosis cerebri patients, in addition to imaging and histological examinations.