Cutaneous metastasis from glioblastoma

Cutaneous Seeding of Glioblastoma: A Case Report and Literature Review

ABSTRACT

We present the case of a 61-year-old male patient with a history of intracranial IDH-wildtype glioblastoma with an isolated cutaneous metastasis within the previous surgical site scar. The cytomorphology of the cutaneous deposits was reminiscent of metastatic melanoma, which is a differential diagnostic pitfall. The tumor molecular characteristics are described, as these have become essential diagnostic criteria for many central nervous system tumors, along with a discussion of the role of immunohistochemical markers and potential pitfalls in the differential diagnosis of melanoma and poorly differentiated carcinoma. We discuss the biology of metastatic glioblastoma and provide a focused literature review of previous glioblastomas with tumor cell seeding within prior surgical scars.

Rapid progression of subcutaneous glioblastoma: A case report and literature review

Extra-neural spread of glioblastoma (GBM) is extremely rare. We report a case of postoperative intracranial GBM spreading to the subcutaneous tissue via the channel of craniotomy defect in a 73-year-old woman. Radiological images and histopathology indicate that the tumor microenvironment of the subcutaneous tumor is clearly different from the intracranial tumor. We also model the invasion of GBM cells through the dura-skull defect in mouse. The retrospective analysis of GBM with scalp metastases suggests that craniectomy is a direct cause of subcutaneous metastasis in patients with GBM. Imaging examinations of other sites for systemic screening is also recommended to look for metastases outside the brain when GBM invades the scalp or metastasizes to it.

Glioblastoma multiforme metastasizing to the skin, a case report and literature review

Glioblastoma Multiforme (GBM) is the most common primary central nervous system (CNS) malignancy in adults. It is very aggressive and is notorious for its fast and local invasion of nearby brain parenchyma. Consequently, the overall survival (OS) of patients with GBM is short despite resection, radiotherapy and chemotherapy regimens. The most common sites of metastasis of GBM are the lungs and pleura, cervical lymph nodes, and bone. Metastasis to the skin is a rare event and to our knowledge, there are less than 30 cases of GBM metastasizing to cutaneous or subcutaneous tissue described in the literature. None of these cases were diagnosed and/or treated in the Middle East region; and the majority of the metastases found were adjacent to the site of surgery undergone to remove the primary malignancy. We present the case of a 53-year-old male diagnosed with GBM and later showing signs of metastases at the anterio-auricular side of his face near-distant from the site of previous surgery done to remove the primary tumor.

A case series of extraneural metastatic glioblastoma at Memorial Sloan Kettering Cancer Center

Background

Extraneural metastasis of glioma is a rare event, often occurring in patients with advanced disease. Genomic alterations associated with extraneural glioma metastasis remain incompletely understood.

Methods

Ten patients at Memorial Sloan Kettering Cancer Center diagnosed with extraneural metastases of glioblastoma (9 patients) and gliosarcoma (1 patient) from 2003 to 2018 were included in our analysis. Patient characteristics, clinical course, and genomic alterations were evaluated.

Results

Patient age at diagnosis ranged from 14 to 73, with 7 men and 3 women in this group. The median overall survival from initial diagnosis and from diagnosis of extraneural metastasis was 19.6 months (range 11.2 to 57.5 months) and 5 months (range 1 to 16.1 months), respectively. The most common site of extraneural metastasis was bone, with other sites being lymph nodes, dura, liver, lung, and soft tissues. All patients received surgical resection and radiation, and 9 patients received temozolomide, with subsequent chemotherapy appropriate for individual cases. 1 patient had an Ommaya and then ventriculoperitoneal shunt placed, and 1 patient underwent craniectomy for cerebral edema associated with a brain abscess at the initial site of resection. Genomic analysis of primary tumors and metastatic sites revealed shared and private mutations with a preponderance of tumor suppressor gene alterations, illustrating clonal evolution in extraneural metastases.

Conclusions

Several risk factors emerged for extraneural metastasis of glioblastoma and gliosarcoma, including sarcomatous dedifferentiation, disruption of normal anatomic barriers during surgical resection, and tumor suppressor gene alterations. Next steps with this work include validation of these genomic markers of glioblastoma metastases in larger patient populations and the development of preclinical models. This work will lead to a better understanding of the molecular mechanisms of metastasis to develop targeted treatments for these patients.

Early Wound Site Seeding in a Patient with Central Nervous System High-Grade Neuroepithelial Tumor with BCOR Alteration

BACKGROUND

Advances in molecular profiling have facilitated the emergence of newly defined entities of central nervous system (CNS) tumor, including CNS high-grade neuroepithelial tumor with BCOR alteration (CNS HGNET-BCOR). Relatively little is known about the clinical behavior of these newly characterized tumors.

CASE DESCRIPTION

We describe a pediatric male patient with CNS HGNET-BCOR, who developed seeding of the tumor into the site of the surgical wound within months of surgery and who underwent resection of a residual posterior fossa tumor.

CONCLUSIONS

This case emphasizes 3 important points. First, CNS HGNET-BCOR can be aggressive tumors that necessitate close clinical and radiologic surveillance. Second, surveillance imaging in such cases should incorporate the surgical incision site into the field of view, and this should be closely scrutinized to ensure the timely detection of wound site seeding. Third, wound site seeding may still occur despite the use of meticulous surgical techniques.

GBM skin metastasis: a case report and review of the literature

Glioblastoma (GBM) is the most common type of malignant tumor found in the brain, and acts very aggressively by quickly and diffusely infiltrating the surrounding brain parenchyma. Despite its aggressive nature, GBM is rarely found to spread extracranially and develop distant metastases. The most common sites of these rare metastases are the lungs, pleura and cervical lymph nodes. There are also a few case reports of skin metastasis. We present the clinical, imaging and pathologic features of a case of a GBM with metastasis to the soft tissue scar and skin near the original craniotomy site. In addition, we discuss the details of this case in the context of the previously reported literature.

Concurrence of chromosome 6 chromothripsis and glioblastoma metastasis

The authors report an unusual case of a widely metastatic glioblastoma. DNA copy number microarray profile of the resected specimen revealed complex rearrangements found throughout chromosome 6, a phenomenon known as chromothripsis. Such chromothripsis pattern was not observed in 50 nonmetastatic glioblastoma specimens analyzed. Analysis of the 1000+ gliomas profiled by The Cancer Genome Atlas (TCGA) data set revealed one case of chromosome 6 chromothripsis resembling the case described here. This TCGA patient died within 6 months of undergoing tumor resection. Implications of these findings are reviewed in the context of the current literature.

Extraneural metastases in glioblastoma patients: two cases with YKL-40-positive glioblastomas and a meta-analysis of the literature

Glioblastoma (GBM) are high-grade gliomas that severely impact on overall survival (OS). GBM cell motility and the breakdown of the blood-brain barrier could favor GBM cell communication with the systemic circulation. In spite of this, extracranial GBM metastases are rare. Here, we describe two YKL-40-positive GBM patients with extra-CNS (central nervous system) metastases, and we present a meta-analysis of 94 cases. The analysis concluded that extra-CNS metastases occurred 8.5 months after first GBM diagnosis and OS was 12 months; surgical GBM excision was associated at a longer interval to extra-CNS metastasis than biopsy only, and even longer if followed by radiotherapy and chemotherapy. Both our case reports were adult males who developed extra-CNS, YKL-40-positive metastases at lymph nodes, lung and subcutaneous sites, after 86 and 24 months from initial diagnosis of GBM. At first GBM local recurrence, they were treated with bevacizumab (BV), an anti-vascular endothelial growth factor antibody. They died after 4 and 1 month from the occurrence of metastases. Both cases expressed YKL-40 and lacked EGFR amplification, suggesting a mesenchymal phenotype, and maintained such profile at extra-CNS recurrence; they did not show MGMT promoter methylation, IDH1/2 mutations, or c-Met upregulation. Our two cases and the meta-analysis support the idea that prolonged survival of GBM patients increases the probability of GBM cells shedding to lymphatic and hematic system. Interestingly, the present two cases showed the features of mesenchymal profile, usually related with worst prognosis that was maintained in extracranial metastases.

Glioblastoma multiforme with subcutaneous metastases, case report and literature review

Glioblastoma multiforme (GBM) is the most common primary brain tumor and the most malignant astrocytoma in adults, with rare extra-cranial metastases, especially for subcutaneous metastases. It could be easily misdiagnosed as primary subcutaneous tumor. In this report, we describe a patient with pontine GBM who developed a subcutaneous swelling at the ipsilateral posterior cervical region 8 months after operation, and the pathological and immunocytochemical examination carry the same characteristics as the primary intracranial GBM cells, which defined it as subcutaneous metastasis. GBM with subcutaneous metastasis is extremely rare, and knowledge of a prior intracranial GBM, pathological examinations and immunocytochemical tests with markers typically expressed by GBM are of vital importance for the diagnosis of GBM metastasis. Surgical resection of subcutaneous swelling, followed by chemotherapy and radiotherapy, could be the best strategy of treatment for the patients with GBM subcutaneous metastasis.

Skin spread from an intracranial glioblastoma: case report and review of the literature

Extracranial metastases secondary to intracranial neoplasm are extremely rare. The incidence of extraneural metastases of brain tumours is estimated to be less than 0.4%. The authors report a case of postoperative intracranial glioblastoma spreading to the skin in an adult patient. In this case, the radiological images and surgical findings suggest that the potential dissemination mechanism is as a result of infiltration through the surgical wound site. The primary tumour-upon coming into contact with the dura and the skin-mimicked the characteristics of both tissues. This case supports the theory of risk of spread through the durotomy site, although this phenomenon is extremely rare. Both the specific pathogenic mechanisms as well as the ideal and effective management have not been established yet and require further investigation.

Water jet dissection in neurosurgery: an update after 208 procedures with special reference to surgical technique and complications

BACKGROUND

Water jet dissection represents a promising technique for precise brain tissue dissection with preservation of blood vessels. In the past, the water jet dissector has been used for various pathologies. A detailed report of the surgical technique is lacking.

OBJECTIVE

The authors present their results after 208 procedures with a special focus on surgical technique, intraoperative suitability, advantages, and disadvantages.

METHODS

Between March 1997 and April 2009, 208 patients with various intracranial neurosurgical pathologies were operated on with the water jet dissector. Handling of the device and its usefulness and extent of application were assessed. The pressures encountered, potential risks, and complications were documented. The patients were followed 1 to 24 months postoperatively.

RESULTS

A detailed presentation of the surgical technique is given. Differences and limitations of the water jet dissection device in the various pathologies were evaluated. The water jet dissector was intensively used in 127 procedures (61.1%), intermittently used in 56 procedures (26.9%), and scarcely used in 25 procedures (12%). The device was considered to be very helpful in 166 procedures (79.8%) and helpful to some extent in 33 procedures (15.9%). In 8 (3.8%) procedures, it was not helpful, and in 1 procedure (0.5%), the usefulness was not documented by the surgeon.

CONCLUSION

The water jet dissector can be applied easily and very safely. Precise tissue dissection with preservation of blood vessels and no greater risk of complications are possible. However, the clinical consequences of the described qualities need to be demonstrated in a randomized clinical trial.

Extra-neural metastases of malignant gliomas: myth or reality?

Malignant gliomas account for approximately 60% of all primary brain tumors in adults. Prognosis for these patients has not significantly changed in recent years-despite debulking surgery, radiotherapy and cytotoxic chemotherapy-with a median survival of 9-12 months. Virtually no patients are cured of their illness. Malignant gliomas are usually locally invasive tumors, though extra-neural metastases can sometimes occur late in the course of the disease (median of two years). They generally appear after craniotomy although spontaneous metastases have also been reported. The incidence of these metastases from primary intra-cranial malignant gliomas is low; it is estimated at less than 2% of all cases. Extra-neural metastases from gliomas frequently occur late in the course of the disease (median of two years), and generally appear after craniotomy, but spontaneous metastases have also been reported. Malignant glioma metastases usually involve the regional lymph nodes, lungs and pleural cavity, and occasionally the bone and liver. In this review, we present three cases of extra-neural metastasis of malignant gliomas from our department, summarize the main reported cases in literature, and try to understand the mechanisms underlying these systemic metastases.

Extraventricular anaplastic ependymoma with metastasis to scalp and neck

We report a case of anaplastic ependymoma with extracranial metastases in a 22-year-old female. The patient originally presented with headaches and dysarthria. Neuroimaging revealed a large solid and cystic right fronto-temporal lesion. It was located completely extraventricularly and a glioblastoma was suspected based on the neuroimaging findings. A gross total resection was achieved. Histopathologic examination revealed an anaplastic ependymoma. The patient was treated with radiotherapy. Approximately 1 year after the initial surgery, the patient presented with metastatic disease to the scalp. At 2 years, an intraparotid metastasis was detected. Subsequent neck dissection revealed positive lymph nodes at several levels. It was followed by radiotherapy to the neck. 5 years after the initial surgery, the patient has residual metastatic disease. The case is discussed and the literature on extraventricular ependymal neoplasms is reviewed.

A case of soft tissue metastasis from glioblastoma and review of the literature

Despite recent advances, glioblastoma (GBM) remains incurable but is typically characterized by local tumor recurrence in the brain. Soft tissue metastases from GBM are extremely rare, with only eight reported cases in the literature. It has been postulated that this type of metastases rarely occurs due to inability of tumor cells to survive outside the brain milieu, physical barriers preventing tumor spread, and/or early patient death from this aggressive tumor. Here we present another case of soft tissue metastases that occurred in a young woman with GBM and review the previous literature.

Glioblastoma multiforme in skin: a report of 2 cases and review of the literature

Despite an aggressive clinical course, glioblastoma multiforme (GBM) rarely develops extracranial metastasis, with only 6 cases of skin involvement reported in the literature. We report 2 cases of GBM that spread to the scalp. Both patients presented with a firm nodule adjacent to their original craniotomy site. Histologic examination revealed highly anaplastic tumor cells invading the subcutaneous tissues. Immunohistochemistry was positive for vimentin, S-100, and glial fibrillary acidic protein in the malignant cells. Although it is possible that these cases represent true metastatic GBM, the close proximity of the nodules to suture lines suggests extension of GBM to the skin through surgical sites or seeding of tumor cells. It is important to have an accurate clinical history when evaluating scalp nodules in patients with GBM, so that a diagnosis of GBM is not overlooked.