Chordoid glioma: ten years of a low-grade tumor with high morbidity

[Chordoid gliomas of the third ventricle]

BACKGROUND

Chordoid glioma is a rare slow-growing tumor of the central nervous system. Available world experience includes no more than 200 cases (lesion of the third ventricle in absolute majority of cases). Recognition and treatment of chordoid glioma are currently difficult problems due to small incidence of this disease.

OBJECTIVE

To describe clinical manifestations and surgical treatment of chordoid glioma of the third ventricle considering literature data and own experience.

MATERIAL AND METHODS

There were 12 patients (6 men and 6 women) with chordoid glioma between 2004 and 2023 (10 patients with lesion of the third ventricle, 1 - lateral ventricle, 1 - pineal region). Only patients with tumors of the third ventricle were analyzed.

RESULTS

Total and subtotal resection was performed in 1 and 3 cases, respectively. Five patients underwent partial resection, 1 patient underwent biopsy. The follow-up data were available in 7 out of 10 patients (mean 25 months). Radiotherapy was performed in 4 patients (continued tumor growth in 2 cases). One patient died.

CONCLUSION

Chordoid glioma is a benign tumor predominantly localized in the third ventricle. Preoperative MRI and CT in some cases make it possible to suspect chordoid glioma and differentiate this tumor from craniopharyngioma, meningioma and pituitary adenoma by such signs as isointense signal in T1WI, hyper- or isointense signal in T2WI, homogeneous contrast enhancement and edema of basal ganglia in T2 FLAIR images. The only effective treatment for chordoid glioma is surgery. Total resection is often impossible or extremely dangerous due to location of tumor, large size and invasion of the third ventricle. Postoperative mental disorders and diabetes insipidus, including severe hypernatremia, are common that requires mandatory monitoring of water and electrolyte balance.

Benign Glioma

Benign glioma broadly refers to a heterogeneous group of slow-growing glial tumors with low proliferative rates and a more indolent clinical course. These tumors may also be described as "low-grade" glioma (LGG) and are classified as WHO grade I or II lesions according to the Classification of Tumors of the Central Nervous System (CNS) (Louis et al. in Acta Neuropathol 114:97-109, 2007). Advances in molecular genetics have improved understanding of glioma tumorigenesis, leading to the identification of common mutation profiles with significant treatment and prognostic implications. The most recent WHO 2016 classification system has introduced several notable changes in the way that gliomas are diagnosed, with a new emphasis on molecular features as key factors in differentiation (Wesseling and Capper in Neuropathol Appl Neurobiol 44:139-150, 2018). Benign gliomas have a predilection for younger patients and are among the most frequently diagnosed tumors in children and young adults (Ostrom et al. in Neuro Oncol 22:iv1-iv96, 2020). These tumors can be separated into two clinically distinct subgroups. The first group is of focal, well-circumscribed lesions that notably are not associated with an increased risk of malignant transformation. Primarily diagnosed in pediatric patients, these WHO grade I tumors may be cured with surgical resection alone (Sturm et al. in J Clin Oncol 35:2370-2377, 2017). Recurrence rates are low, and the prognosis for these patients is excellent (Ostrom et al. in Neuro Oncol 22:iv1-iv96, 2020). Diffuse gliomas are WHO grade II lesions with a more infiltrative pattern of growth and high propensity for recurrence. These tumors are primarily diagnosed in young adult patients, and classically present with seizures (Pallud et al. Brain 137:449-462, 2014). The term "benign" is a misnomer in many cases, as the natural history of these tumors is with malignant transformation and recurrence as grade III or grade IV tumors (Jooma et al. in J Neurosurg 14:356-363, 2019). For all LGG, surgery with maximal safe resection is the treatment of choice for both primary and recurrent tumors. The goal of surgery should be for gross total resection (GTR), as complete tumor removal is associated with higher rates of tumor control and seizure freedom. Chemotherapy and radiation therapy (RT), while not typically a component of first-line treatment in most cases, may be employed as adjunctive therapy in high-risk or recurrent tumors and in some select cases. The prognosis of benign gliomas varies widely; non-infiltrative tumor subtypes generally have an excellent prognosis, while diffusely infiltrative tumors, although slow-growing, are eventually fatal (Sturm et al. in J Clin Oncol 35:2370-2377, 2017). This chapter reviews the shared and unique individual features of the benign glioma including diffuse glioma, pilocytic astrocytoma and pilomyxoid astrocytoma (PMA), subependymal giant cell astrocytoma (SEGA), pleomorphic xanthoastrocytoma (PXA), subependymoma (SE), angiocentric glioma (AG), and chordoid glioma (CG). Also discussed is ganglioglioma (GG), a mixed neuronal-glial tumor that represents a notable diagnosis in the differential for other LGG (Wesseling and Capper 2018). Ependymomas of the brain and spinal cord, including major histologic subtypes, are discussed in other chapters.

Magnetic resonance imaging of a third ventricular chordoid glioma

Chordoid gliomas are uncommon neoplasms located within the anterior portion of the third ventricle. In this article, we aimed to describe the clinical presentation, magnetic resonance imaging characteristics, histological findings, and surgical treatment applied to a case of chordoid glioma. Chordoid gliomas are typically observed as solid masses within the anterior segment of the third ventricle, characterized by homogenous and vivid enhancement. Despite being classified as a low-grade neoplasm, the outcome of choroid glioma is often uncertain.

Chordoid glioma: a rare old foe but a new pathological and radiological presentation

Chordoid glioma (CG) is a rare WHO Grade II neoplasm of the anterior third ventricle. We report two cases of CG with new presentation in terms of histopathology and location: a case of CG with osseous metaplasia evident on imaging, and another CG, unusually located in the posterior portion of the third ventricle.

Update on Circumscribed Gliomas and Glioneuronal Tumors

Well-circumscribed intra-axial CNS tumors encompass a wide variety of gliomas and glioneuronal tumors, usually corresponding to WHO grades I and II. Nonetheless, sometimes high-grade 'diffuse' gliomas such as gliosarcoma and giant cell glioblastoma can be relatively circumscribed but are often found to have foci of diffuse infiltration on careful examination, harboring distinct molecular alterations. These tumors are excluded from the discussion in this chapter with the current review emphasizing on lower-grade entities to include a brief description of their histology and associated molecular findings. Like elsewhere in brain biopsy evaluation, imaging is crucial and acts as a surrogate to gross examination. Given the circumscribed nature of these tumors, surgery alone is the mainstay treatment in most entities.

Intracranial chordoid glioma: A clinical, radiological and pathological study of 14 cases

BACKGROUND

Chordoid gliomas (CGs) are rare neuroepithelial tumors, which commonly arise from the anterior part of the third ventricle. Most studies on CGs included only one or two cases. To better understand the disease, we report 14 patients with pathologically confirmed CGs.

METHOD

The clinical characteristics, including radiological and histological examination, operative records, and prognoses were analyzed and reviewed.

RESULT

The case series included six male and eight female patients with an average age of 44.4 years. The most common preoperative symptom was headache (64.3%) and visual deterioration (57.1%). Radiological results showed that the third ventricle (12/14) was the most common site of the brain involved, and the lesions presented with solid (n = 9, 64.3%) or cystic-solid (n = 5, 35.7%) appearance. All patients were misdiagnosed as non-CG tumors. The operation approach was mainly determined by tumor location, thus trans-callosal approach (9/14) and trans-laminar terminalis approach were commonly used. Gross total resection (GTR) was achieved in all cases and none of them received any adjuvant therapy postoperatively. The most frequent postoperative complications were diabetes insipidus, electrolyte disturbance, hypopituitarism, cognitive dysfunction, and obstructive hydrocephalus. During an average follow-up period of 40.1 months, 2 cases (14.3%) were died of refractory hypopituitarism and pulmonary embolism, respectively. The preoperative symptoms and postoperative complications were all significantly improved in other 12 patients, and MRI showed no tumor recurrence.

CONCLUSION

According to our experience, we recommend GTR as the primary goal, which is associated with improved rates of tumor control and without increasing rates of postoperative complications.

A Rare Instance of Chordoid Glioma With Large Calcification Mimicking Craniopharyngioma

Chordoid glioma (CG) is a world health organization classified grade II tumor whose typical localization is in the anterior part of the third ventricle. It's clinical, neuroimaging, and pathologic features may vary and furthermore mimic other types of benign lesions usually associated with a better outcome, thus representing a potential radiological and diagnostic pitfall. In this article, the authors present a novel case of a 51-year-old male who underwent gross total removal of the tumor of the third ventricle with high calcification. The imaging studies and the intraoperative examination led at first to a hypothesis of craniopharyngioma. In this case, the patient underwent successful operative management and has remained well throughout follow-up.

Chordoid Glioma Infiltrating Optic Structures

Chordoid glioma of the third ventricle (CGTV) is a rare, slow-growing, World Health Organization Grade II glial tumor, with stereotyped localization in the anterior third ventricle. Despite being considered a noninvasive tumor, CGTV is usually associated with a poor clinical outcome due to its close proximity to important cerebral structures, such as the hypothalamus and visual pathways. Our patient with CGTV experienced visual involvement, but after subtotal surgical resection showed no evidence of progression at 5-year follow-up.

Uncommon low-grade brain tumors

The 2016 World Health Organization (WHO) classification of primary central nervous system (CNS) tumors includes numerous uncommon (representing ≤1% of tumors) low-grade (grades I-II) brain neoplasms with varying clinical behaviors and outcomes. Generally, gross tumor or maximal safe resection is the primary treatment. Adjuvant treatments, though their exact role is unknown, may be considered individually based on pathological subtypes and a proper assessment of risks and benefits. Targetable mutations such as BRAF (proto-oncogene B-Raf), TRAIL (tumor necrosis factor apoptosis inducing ligand), and PDGFR (platelet derived growth factor receptor) have promising roles in future management.

Chordoid Glioma of the Third Ventricle: A Case Report and a Treatment Strategy to This Rare Tumor

Chordoid glioma (CG) of the third ventricle is a rare type of brain tumor. Here, we present a case, review of the literature and proposed a treatment strategy for this rare tumor. Here, A 33-years-old woman presented with the menstrual disorder and progressive obesity. Magnetic resonance imaging showed a large irregularly circular tumor in the third ventricle. The tumor was subtotally resected by microsurgery via the right modified port approach. Immunohistochemical staining was positive for glial fibrillary acidic protein (GFAP), Vimentin and transcription termination factor-1 (TTF-1), and the Ki-67 proliferation index was low (5%), which indicating CG. Residual tumor decreased after treated by Gamma Knife radiosurgery (GKRS) with a dose of 15 Gy. During 30 months of follow-up, the tumor did not recur, and the patient suffered no complications. The diagnosis of CG requires a combination of clinical presentation, neuroimaging, and pathology. The ideal therapy is gross total resection (GTR) of the tumor. However, GTR is usually difficult and carries a high risk of postoperative complications because of the tumor location. This case indicates that planed subtotal resection followed by GKRS with a proper marginal dose could be a good treatment strategy for CG.

Chordoid Glioma as a Differential Diagnosis of Anterior Third Ventricle Tumours: A Rare Case Report and Five-Year Follow-Up

Chordoid glioma is a rare and relatively recently defined tumour entity. Worldwide there have only been around 90 cases described until now. A chordoid glioma comprises a low-grade suprasellar neuroepithelial neoplasm originating in the anterior part of the third ventricle, with consistent radiological features on MRI. This lesion should be considered as a differential of third ventricle tumours. The patient described in this paper is quite unique in the sense that despite only partial tumour resection was obtained, the residual tumour was not progressive during several years of follow-up. Preoperative recognition of this disease entity is crucial to modify the treatment approach and improve patient outcome.

Chordoid glioma: an entity occurring not exclusively in the third ventricle

Chordoid gliomas are extremely rare entities, which are generally considered occurring exclusively in the third ventricle. Despite the low-grade histological grade, aggressive behaviors have been reported in literatures. Due to the low morbidity, the origins, clinical, and radiological features, management and prognosis are still yet to be well elucidated. We retrospectively reviewed the clinical profiles from a series of 6 patients with chordoid gliomas. All patients underwent surgical treatment, and the diagnoses were based on histopathological examinations. Magnetic resonance imaging (MRI) was performed perioperatively. Follow-up outcomes were presented. This case series consisted of three male and three female patients (age range 27-67 years; mean age 43.3 years). MRI results showed tumors in the third ventricle (4/6), temporal-parietal-occipital lobe involving the lateral ventricle (1/6), and cerebellar hemisphere (1/6). Three tumors were solid, and the others were cystic-solid. Hydrocephalus was present in one patient. The T1-weighted imaging showed hypo- to isointensity, and T2-weighted imaging showed iso- to hyperintensity; enhancement was homogeneous (4/6) or heterogeneous (2/6). Diffusion-weighted imaging showed no evidence of restricted diffusion. Magnetic resonance spectrum showed an elevated choline value and reduced N-acetylaspartate value. Gross total resection was achieved in all patients, and during an average follow-up period of 35.8 months, no recurrence was noted. Chordoid gliomas can occur outside the third ventricle with a great diagnostic challenge. The MRI characteristics suggest a low-grade tumor, and the accurate diagnosis depends on pathological criteria. Complete surgical resection is associated with a favorable outcome.

Suprasellar chordoid glioma: a report of two cases

Chordoid glioma (CG) is considered a slow growing glial neoplasm. We report two new cases with endocrinological presentation, management and outcome. Case reports: 1) An 18 year-old female patient was admitted due to headaches, nausea and vomiting and visual abnormalities. She was in amenorrhea. A brain magnetic resonance imaging (MRI) demonstrated a 35 mm-diameter sellar and suprasellar mass. An emergency ventricular peritoneal valve was placed due to obstructive hydrocephalus. Transcraneal surgery was performed. The patient developed central hypothyroidism, adrenal insufficiency and transient diabetes insipidus; she never recovered spontaneous menstrual cycles. Histopathologic study showed cells in cords, inside a mucinous stroma, positive for glial fibrillary acidic protein (GFAP). Due to residual tumor gamma knife radiosurgery was performed. Three years after surgery, the patient is lucid, with hypopituitarism under replacement. 2) A 46 year-old woman complained about a three year-history of amenorrhea, galactorrhea and headache. An MRI showed a solid-cystic sellar mass 40 mm-diameter that extended to the suprasellar cistern. She had hypogonatropic hypogonadism and mild hyperprolactinemia. The tumor mass was removed via nasal endoscopic approach. Histopathological study reported cellular proliferation of glial lineage positive for GFAP. The patient evolved with central hypothyroidism and diabetes insipidus. She was re-operated for fistula and again under the diagnosis of extradural abscess. She evolved with cardiorespiratory descompensation and death, suspected to be due to a thromboembolism. In conclusion, the first case confirms that best treatment for CG is surgery considering radiotherapy as an adjuvant therapy. The other case, on the contrary, illustrates the potentially fatal evolution due to surgical complications.

Usefulness of neuroimaging and immunohistochemical study for accurate diagnosis of chordoid glioma of the third ventricle: A case report and review of the literature

Background:

Chordoid glioma of the third ventricle is a rare neuroepithelial tumor characterized by a unique histomorphology within the third ventricular region, but with radiological and histopathological features mimicking benign lesions such as meningioma. We report a case of chordoid glioma of the third ventricle and suggest a useful indicator for accurate diagnosis.

Case Description:

A previously healthy 46-year-old woman was admitted to our hospital with mild headache. Neuroimaging revealed a large tumor measuring approximately 18 mm in the suprasellar region, and perifocal edema in the optic tract and internal capsule on magnetic resonance imaging. Laboratory findings revealed no pituitary dysfunction including diabetes insipidus. Gross total resection of the tumor was performed by the interhemispheric translamina terminalis approach. Histological findings revealed nests of regular epithelioid cells with large nuclei and abundant eosinophilic cytoplasm within myxoid stroma. Immunohistochemical studies demonstrated diffuse cytoplasmic expression of glial fibrillary acidic protein (GFAP) and CD34, and strong nuclear staining for thyroid transcription factor 1 (TTF-1). We, therefore, histologically classified the tumor as chordoid glioma of the third ventricle. Headache improved immediately postoperatively, and follow-up neuroimaging after 12 months showed no signs of recurrence.

Conclusions:

Chordoid glioma of the third ventricle is a very rare tumor that is difficult to diagnose on routine neuroimaging. Accurate diagnosis requires detailed analysis of neuroimaging and immunohistochemical studies using CD34 and TTF-1 staining.

Chordoid glioma of the third ventricle: a patient presenting with SIADH and a review of this rare tumor

INTRODUCTION

Chordoid glioma of the third ventricle is a rare and recently described tumor characterized by a unique histomorphology and exclusive association with the suprasellar/third ventricular compartment. Its clinical, radiological and histological features may vary. Despite the fact that chordoid glioma is a low-grade tumor, its prognosis has been relatively poor because of its insidious presentation and the difficulty in obtaining complete surgical resection.

MATERIALS AND METHODS

Here, we report on a new case of chordoid glioma occurring in a 48-year-old woman, presented with hyponatremia, and on the initial work-up with a diagnosis of hyponatremia due at least in part to SIADH. We review the current literature on this rare pathology, discuss the radiological and histopathologic findings, and discuss the optimal management of chordoid glioma in general.

CONCLUSION

Based on this new case and the previous literature reports, we suggest that chordoid glioma should be included in the differential diagnosis of uncommon masses of the third ventricle, especially in middle-aged women, and we emphasize current management guidelines.

Chordoid Glioma with Intraventricular Dissemination: A Case Report with Perfusion MR Imaging Features

Chordoid glioma is a rare low grade tumor typically located in the third ventricle. Although a chordoid glioma can arise from ventricle with tumor cells having features of ependymal differentiation, intraventricular dissemination has not been reported. Here we report a case of a patient with third ventricular chordoid glioma and intraventricular dissemination in the lateral and fourth ventricles. We described the perfusion MR imaging features of our case different from a previous report.

Rare glial tumors

This chapter describes the epidemiology, pathology, molecular characteristics, clinical and neuroimaging features, treatment, outcome, and prognostic factors of the rare glial tumors. This category includes subependymal giant cell astrocytoma, pleomorphic xanthoastrocytoma, astroblastoma, chordoid glioma of the third ventricle, angiocentric glioma, ganglioglioma, desmoplastic infantile astrocytoma and ganglioma, dysembryoplastic neuroepithelial tumor, papillary glioneuronal tumor, and rosette-forming glioneuronal tumor of the fourth ventricle. Many of these tumors, in particular glioneuronal tumors, prevail in children and young adults, are characterized by pharmacoresistant seizures, and have an indolent course, and long survival following surgical resection. Radiotherapy and chemotherapy are reserved for recurrent and/or aggressive forms. New molecular alterations are increasingly recognized.

Prognostic factors for recurrence and complications in the surgical management of primary chordoid gliomas: A systematic review of literature

OBJECTIVE

Chordoid gliomas (CG) are rare neoplasms which frequently arise within the third ventricle. Surgery remains the mainstay treatment for CG. The present study comprehensively reviews all reported cases of CG within the literature in order to identify risk factors for surgical complications and tumor recurrence.

METHODS

A comprehensive search on MEDLINE (OVID and PubMed), Scopus, Embase, and Web of Science was conducted following PRISMA guidelines to identify all reported cases of CG.

RESULTS

A total of 81 patients met the study criteria which comprised of 33 males and 48 females. Median age at diagnosis was 48 years with a range from 5 to 72 years, and mean tumor size was 3.1cm. Biopsy, subtotal resection (STR), and gross total resection (GTR) were achieved in 8, 34, and 33 patients, respectively, with six cases not reporting extent of resection (EOR). Thirteen patients underwent adjuvant radiotherapy. Postoperative complications were noted in 30 cases (37%), with new onset diabetes insipidus being the most common. Postoperative morbidity was not associated with age, tumor size, or extent of resection. A trans-lamina terminalis approach demonstrated a strong trend towards decreased overall rates of postoperative morbidity compared to other approaches (p=0.051). GTR was associated with improved progression-free survival (PFS; p=0.028), while adjuvant radiotherapy, age, tumor size and proliferative index were not predictive of patient outcomes.

CONCLUSION

GTR should be the primary goal for the management of CG, as it is associated with improved rates of tumor control without an increased rate of postoperative complications. Surgical approach was a stronger predictor of complication rates than extent of resection. Morbidity remains high, and future studies to further elaborate on factors predictive of postoperative complications are critical.

Chordoid glioma: a rare radiologically, histologically, and clinically mystifying lesion

Chordoid glioma (CG) is a rare central nervous system neoplasm (WHO grade II) of uncertain origin whose typical localization is in the anterior part of the third ventricle. Its clinical, radiological, and histological features may vary and furthermore mimic other kind of benign lesions usually associated with a better outcome. We report a case of a 43-year-old female who underwent gross total removal of a lesion of the third ventricle causing hydrocephalus. The imaging studies and the intraoperative examination led at first to a hypothesis of meningioma. Early surgical and neurological outcomes were good. The patient underwent multiple complications related to hypothalamic dysfunctions and thrombohemorragic issues and eventually died because of systemic infections. Definitive examination was of chordoid glioma of the third ventricle. Reviewing literature, we evaluated possible pitfalls in radiological and histological diagnosis as well as in surgical and medical treatment of CGs. Despite their benign presentation, a high incidence of multiple possible severe complications is reported. Early alertness and combined treatment strategies could improve overall CGs treatment strategies.

Chordoid glioma: Case report and review of the literature

•

We reported the 80th case of chordoid glioma and reviewed the literature.

•

Clinical outcomes reported have been poor.

•

If possible, efficient treatment depends upon radical surgical resection, however partial resection with adjuvant radiosurgery can be the most recommend due to local tumor and morbid-mortality relation.

•

No chemotherapeutic regimen has been shown to be effective for CG.

Introduction

Chordoid glioma is a rare low-grade brain tumor originating from the anterior wall of the third ventricle.

Case presentation

A 13-year-old female with progressive intermittent holocranial headaches and a diagnosis of chordoid glioma underwent tumor resection in our neuro-oncology unit.

Discussion

We review all 79 cases of chordoid glioma reported in the literature so far, focusing on the diagnostic criteria, treatment options and prognosis.

Conclusion

Efficient treatment of chordoid glioma depends upon radical surgical resection. Based on the reviewed data, which showed high morbi-mortality rates for this kind of tumor, we recommend a more conservative treatment approach.

From the radiologic pathology archives: intraventricular neoplasms: radiologic-pathologic correlation

A variety of neoplasms may arise in the ventricular system. Intraventricular neoplasms may be discovered as an incidental finding at cross-sectional imaging or may manifest with varied symptoms depending on their location, including symptoms of increased intracranial pressure. These lesions may arise from various ventricular structures, including the ependymal lining (eg, ependymoma), subependymal layer (eg, subependymoma), or choroid plexus (eg, choroid plexus neoplasms), or they may have a cell of origin that has yet to be determined (eg, chordoid glioma). Other neoplasms involving the ventricular system include central neurocytoma, subependymal giant cell tumor, meningioma, rosette-forming glioneuronal tumor, and metastases. The differential diagnosis for intraventricular neoplasms can be broad, and many of them have similar patterns of signal intensity and contrast enhancement at imaging. However, the location of the lesion in the ventricular system-along with knowledge of the patient's age, gender, and underlying conditions-will help narrow the differential diagnosis.

Glioma cordoide do terceiro ventrículo: descrição de um novo caso

O glioma cordoide é um tumor cerebral raro, recentemente descrito, localizado na região do terceiro ventrículo e com características histológicas, imuno-histoquímicas e ultraestruturais peculiares. Este estudo ilustra um caso de glioma cordoide do terceiro ventrículo em uma paciente de 59 anos de idade.