French brain tumor database: 5-year histological results on 25 756 cases

Long-term autonomy, professional activities, cognition, and overall survival after awake functional-based surgery in patients with IDH-mutant grade 2 gliomas: a retrospective cohort study

Background

In isocitrate dehydrogenase (IDH)-mutant low-grade gliomas (LGGs), awake functional-based resection (i.e., resection based on intraoperative functional responses rather than anatomical margins) has emerged as an efficient method to reduce tumour volume (TV) while minimizing postoperative deficits. Here, our goal was to assess the long-term onco-functional outcomes after awake functional-based resection in IDH-mutant LGGs, in conjunction with clinico-radiological and molecular factors.

Methods

We retrospectively studied a consecutive cohort (June 1997-January 2023) of 949 patients. Six hundred patients with IDH-mutant LGGs benefited from an awake functional-based resection with a median follow-up of 7.8 years (95% Confidence interval [CI]: 7.1-8.4 years). The main outcomes were the overall survival (OS), the OS with Karnofsky performance status ≥80% (OSKPS ≥ 80%), cognition measures, and professional activities at 12 months post-surgery.

Findings

600 patients were included in the cohort (274 female [46.0%], median age: 36 years [Interquartile range, IQR: 30-44 years]). The rate of return to work was 93.7%. The impact of surgery on cognition was of limited magnitude. The median postsurgical TV of 2.5 mL (IQR: 0-8.0 mL). The median OS was over 20 years (median: NA, 95% CI: 17.0-NA years). The median OSKPS ≥ 80% was 14.7 years (95% CI: 13.2-17.2 years). Factors associated with longer OS and OSKPS ≥ P80% were 1p19q codeletion (Hazard ratio [HR]OS: 0.27, 95% CI: 0.16-0.43, HRKPS ≥ 80%:0.25, 95% CI: 0.17-0.36), supratotal resection (HROS: 0.08, 95% CI: 0.005-0.40, HRKPS ≥ 80%:0.12, 95% CI: 0.03-0.34) and total resection (HROS: 0.31, 95% CI: 0.16-0.59, HRKPS ≥ 80%:0.21, 95% CI: 0.12-0.36). Recursive partitioning analyses established three OS and OSKPS ≥ 80% prognostic groups, highlighting the contributions of histomolecular status, extent of resection, postsurgical and presurgical TV. Further propensity-matching analyses confirmed the oncological benefits of supratotal resections.

Interpretation

Awake functional-based resection surgery in newly diagnosed IDH-mutant grade 2 LGG, was an effective strategy associated with long survival (median OS over 20 years) and long-term preservation of autonomy. More complete tumor resections favored better onco-functional outcomes across all molecularly-defined subtypes. Short-term effects were of limited magnitude regarding postoperative cognitive and professional outcomes. Supratotal functional-based resections offered additional survival benefits.

Funding

None.

Glioblastoma in the real-world setting: patterns of care and outcome in the Austrian population

PURPOSE

We present results of a retrospective population-based investigation of patterns of care and outcome of glioblastoma patients in Austria.

PATIENTS AND METHODS

In this nation-wide cooperative project, all Austrian glioblastoma patients newly diagnosed between 2014 and 2018 and registered in the ABTR-SANOnet database were included. Histological typing used criteria of the WHO classification of CNS tumors, 4th edition 2016. Patterns of care were assessed, and all patients were followed until the end of 2019.

RESULTS

1,420 adult glioblastoma cases were identified. 813 (57.3%) patients were male and 607 (42.7%) female. Median age at diagnosis was 64 years (range: 18-88). Median overall survival (OS) was 11.6 months in the total cohort and 10.9 months in patients with proven IDH-wildtype. Median OS in the patient group ≤ 65 years receiving postoperative standard of care therapy was 16.1 months. In the patient group > 65 years with postoperative therapy, median OS was 11.2 months. Follow-up ≥ 5 years identified 13/264 (4.9%) long-term survivors. Brain tumor surgery frequently was assisted by 5-aminolevulinic acid (5-ALA) fluorescence (up to 55%). Postoperative treatment was initiated around one month after surgery (median: 31 days) following standardized protocols in 1,041/1,420 (73.3%) cases. In 830 patients (58.5%), concomitant radiochemotherapy was started according to the established standard of care. Treatment in case of progressive disease was considerably variable. 170/1,420 patients (12.0%) underwent a second surgical procedure, 467 (33.0%) received systemic treatment after progression, and 173 (12.2%) were re-irradiated.

CONCLUSION

Our data illustrate and confirm nation-wide translation of effective standard of care to Austrian glioblastoma patients in the recent past. In the case of progressive disease, highly variable therapeutic approaches were used, most frequently accompanied by anti-angiogenic therapy. Long-term survival was observed in a minor proportion of mostly younger patients who typically had gross total tumor resection, a favorable postoperative ECOG score, and standard of care therapy.

Descriptive epidemiology of 399 histologically confirmed newly diagnosed meningeal solitary fibrous tumours and haemangiopericytomas in France: 2006-2015

PURPOSE

Meningeal solitary fibrous tumour (SFT) and haemangiopericytoma (HPC) are uncommon tumours that have been merged into a single entity in the last 2021 WHO Classification of Tumors of the Central Nervous System. To describe the epidemiology of SFT/HPC operated in France and, to assess their incidence.

METHODS

We processed the French Brain Tumour Database (FBTDB) to conduct a nationwide population-based study of all histopathologically confirmed SFT/HPC between 2006 and 2015.

RESULTS

Our study included 399 SFT/HPC patients, operated in France between 2006 and 2015, in one of the 46 participating neurosurgical centres. The incidence reached 0.062, 95%CI[0.056-0.068] for 100,000 person-years. SFT accounted for 35.8% and, HPC for 64.2%. The ratio of SFT/HPC over meningioma operated during the same period was 0.013. SFT/HPC are about equally distributed in women and men (55.9% vs. 44.1%). For the whole population, mean age at surgery was 53.9 (SD ± 15.8) years. The incidence of SFT/HPC surgery increases with the age and, is maximal for the 50-55 years category. Benign SFT/HPC accounted for 65.16%, SFT/HPC of uncertain behaviour for 11.53% and malignant ones for 23.31%. The number of resection progresses as the histopathological behaviour became more aggressive. 6.7% of the patients with a benign SFT/HPC had a second surgery vs.16.6% in case of uncertain behaviour and, 28.4% for malignant SFT/HPC patients.

CONCLUSION

Meningeal SFT and HPC are rare CNS mesenchymal tumours which both share common epidemiological characteristics, asserting their merging under a common entity. SFT/HPC incidence is less that one case for 1 billion per year and, for around 100 meningiomas-like tumours removed, one SFT/HPC may be diagnosed. SFT/HPC are equally distributed in women and men and, are mainly diagnosed around 50-55 years. The more aggressive the tumour, the higher the probability of recurrence.

Radiotherapy for central neurocytoma: A multicentric retrospective study in France

PURPOSE

Neurocytomas represent 0.25 to 0.5% of primary brain tumours and are mainly found in young adults. These tumours have neuronal differentiation. The cornerstone treatment is neurosurgery. The efficacy of other therapies, including radiotherapy, is still unclear. The objective of this study was to evaluate the management of central neurocytomas and the role of radiotherapy.

MATERIALS AND METHODS

All adult patients (age 18 years or older) newly diagnosed with a histologically confirmed neurocytoma between 2006 and 2015 in France were included.

RESULTS

One hundred and sixteen patients were diagnosed with a central neurocytoma during the study period. All patients underwent surgical resection, and six received adjuvant radiotherapy. Eleven patients received radiotherapy due to progression. After a median follow-up of 68.7 months, local failure occurred in 29 patients. The 5-year local control rate was 73.4%. According to univariate analysis, marker of proliferation Ki67 index greater than 2% (hazard ratio [HR]: 1.48; confidence interval [CI]: 1.40-1.57; P=0.027) and subtotal resection (HR: 8.48; CI: 8.01-8.99; P<0.001) were associated with an increase in local failure. Gross total resection was associated with a higher risk of sequelae epilepsy (HR: 3.62; CI: 3.42-3.83; P<0.01) and memory disorders (HR: 1.35; CI: 1.07-1.20; P<0.01). Ten patients (8.6%) died during the follow-up. The 10-year overall survival rate was 89.0%. No prognostic factors for overall survival were found.

CONCLUSION

The analysis showed that patients who underwent subtotal surgical resection, particularly when the tumour had a Ki67 index greater than 2%, had an increased risk of local recurrence. These patients could benefit from adjuvant radiotherapy.

Descriptive epidemiology of 30,223 histopathologically confirmed meningiomas in France: 2006-2015

BACKGROUND AND OBJECTIVES

Meningioma is one of the most common neoplasm of the central nervous system. To describe the epidemiology of meningioma operated in France and, to assess grading and histopathological variability among the different neurosurgical centres.

METHODS

We processed the French Brain Tumour Database (FBTDB) to conduct a nationwide population-based study of all histopathologically confirmed meningiomas between 2006 and 2015.

RESULTS

30,223 meningiomas cases were operated on 28,424 patients, in 61 centres. The average number of meningioma operated per year in France was 3,022 (SD ± 122). Meningioma was 3 times more common in women (74.1% vs. 25.9%). The incidence of meningioma increased with age and, mean age at surgery was 58.5 ± 13.9 years. Grade 1, 2, and 3 meningiomas accounted for 83.9%, 13.91% and, 2.19% respectively. There was a significant variability of meningioma grading by institutions, especially for grade 2 which spanned from 5.1% up to 22.4% (p < 0.001). Moreover, the proportion of grade 2 significantly grew over the study period (p < 0.001). There was also a significant variation in grade 1 subtypes diagnosis among the institutions (p < 0.001). 89.05% of the patients had solely one meningioma surgery, 8.52% two and, 2.43% three or more. The number of surgeries was associated to the grade of malignancy (p < 0.001).

CONCLUSION

The incidence of meningioma surgery increased with age and, peaked at 58.5 years. They were predominantly benign with meningothelial subtype being the most common. However, there was a significant variation of grade 1 subtypes diagnosis among the centres involved. The proportion of grade 2 meningioma significantly grew over the study time, on contrary to malignant meningioma proportion, which remained rare and, stable over time around 2%. Likewise, there was a significant variability of grade 2 meningioma rate among the institutions.

Use of fluorescein sodium to obtain histological diagnosis of primary Central nervous system lymphoma ghost tumour despite disappearance on intraoperative magnetic resonance imaging: technical note and review of the literature

BACKGROUND AND IMPORTANCE

Corticosteroid pre-treatment in patients with primary central nervous system lymphoma (PCNSL) can lead to the phenomenon of ghost tumours (GhT). This affects the diagnostic yield of biopsies and potentially causes misdiagnosis of the condition. The usual strategy of neuronavigation using preoperative magnetic resonance imaging (MRI) or localisation using intraoperative MRI (iMRI) can be rendered ineffective in this situation.

CLINICAL PRESENTATION

A middle-aged Chinese male with newly diagnosed human immunodeficiency virus infection was found to have an intracranial lesion suggestive of PCNSL. Preoperatively corticosteroid led to an attenuation of the contrast enhancing lesion on iMRI. However, intraoperative use of FS allowed the successful identification, biopsy and diagnosis of the condition.

CONCLUSION

FS is useful in the biopsy of PCNSL GhT even when the lesion is not seen in subsequent MRI imaging.

Occurrence of non-central nervous system cancers during postoperative follow-up of patients who underwent surgery for a WHO grade II glioma: implications for therapeutic management

PURPOSE

Survival is currently prolonged in WHO grade II glioma (GIIG). Although exceptionally described, long-term survivors may develop second primary cancers outside the central nervous system (CNS). Here, a consecutive series explored the association between non-CNS cancers (nCNSc) and GIIG in patients who underwent glioma resection.

METHODS

Inclusion criteria were adult patients operated for a GIIG who experienced nCNSc following cerebral surgery.

RESULTS

Nineteen patients developed nCNSc after GIIG removal (median time 7.3 years, range 0.6-17.3 years), including breast cancers (n = 6), hematological cancers (n = 2), liposarcomas (n = 2), lung cancers (n = 2), kidney cancers (n = 2), cardia cancers (n = 2), bladder cancer (n = 1), prostate cancer (n = 1) and melanoma (n = 1). The mean extent of GIIG resection was 91.68 ± 6.39%, with no permanent neurological deficit. Fifteen oligodendrogliomas and 4 IDH-mutated astrocytomas were diagnosed. Adjuvant treatment was administrated in 12 patients before nCNSc onset. Moreover, 5 patients underwent reoperation. The median follow-up from initial GIIG surgery was 9.4 years (range 2.3-19.9 years). Nine patients (47%) died in this period. The 7 patients who deceased from the second tumor were significantly older at nCNSc diagnosis than the 2 patients who died from the glioma (p = 0.022), with a longer time between GIIG surgery and the occurrence of nCNSc (p = 0.046).

CONCLUSION

This is the first study investigating the combination between GIIG and nCNSc. Because GIIG patients are living longer, the risk to experience second neoplasm and to die from it is increasing, especially in older patients. Such data may be helpful for tailoring the therapeutic strategy in neurooncological patients developing several cancers.

Characteristics and management of hydrocephalus in adult patients with cerebellar glioblastoma: lessons from a French nationwide series of 118 cases

The characteristics of hydrocephalus associated with cerebellar glioblastoma (cGB) remain poorly known. The objectives were to describe the occurence of hydrocephalus in a French nationwide series of adult patients with cGB, to identify the characteristics associated with hydrocephalus and to analyze the outcomes associated with the different surgical strategies, in order to propose practical guidelines. Consecutive cases of adult cGB patients prospectively recorded into the French Brain Tumor Database between 2003 and 2017 were screened. Diagnosis was confirmed by a centralized neuropathological review. Among 118 patients with cGB (mean age 55.9 years), 49 patients (41.5%) presented with pre-operative hydrocephalus. Thirteen patients (11.0%) developed acute (n=7) or delayed (n=6) hydrocephalus postoperatively. Compared to patients without hydrocephalus at admission, patients with hydrocephalus were younger (52.0 years vs 58.6 years, p=0.03) and underwent more frequently tumor resection (93.9% vs 73.9%, p=0.006). A total of 40 cerebrospinal-fluid diversion procedures were performed, including 18 endoscopic third ventriculostomies, 12 ventriculoperitoneal shunts and 10 external ventricular drains. The different cerebrospinal-fluid diversion options had comparable functional results and complication rates. Among the 89 patients surgically managed for cGB without prior cerebrospinal-fluid diversion, 7 (7.9%) were long-term shunt-dependant. Hydrocephalus is frequent in patients with cGB and has to be carefully managed in order not to interfere with adjuvant oncological treatments. In case of symptomatic hydrocephalus, a cerebrospinal-fluid diversion is mandatory, especially if surgical resection is not feasible. In case of asymptomatic hydrocephalus, a cerebrospinal-fluid diversion has to be discussed only if surgical resection is not feasible.

[Histomolecular diagnosis of glial and glioneuronal tumours]

While rare compared to extra-cranial neoplasms, glial and glioneuronal tumors are responsible of high morbidity and mortality. In 2016, the World Health Organization introduced histo-molecular ("integrated") diagnostics for central nervous system tumors based on morphology, immunohistochemistry and the presence of key genetic alterations. This combined phenotypic-genotypic classification allows for a more objective diagnostic of brain tumors. The implementation of such a classification in daily practice requires immunohistochemical surrogates to detect common genetic alterations and sometimes expensive and not widely available molecular biology techniques. The first step in brain tumor diagnostics is to inquire about the clinical picture and the imaging findings. When dealing with a glial tumor, the pathologist needs to assess its nature, infiltrative or circumscribed. If the tumor is infiltrative, IDH1/2 genes (prognostic marker) and chromosomes 1p/19q (diagnosis of oligodendroglioma) need to be assessed. If the tumor appears circumscribed, the pathologist should look for a neuronal component associated with the glial component (glioneuronal tumor). A limited immunohistochemistry panel will help distinguish between diffuse glioma (IDH1-R132H, ATRX, p53) and circumscribed glial/glioneuronal tumor (CD34, neuronal markers, BRAF-V600E), and some antibodies may reliably detect genetic alterations (IDH1-R132H, BRAF-V600E and H3-K27M mutations). Chromosomal imbalances (1p/19q codeletion in oligodendroglioma; chromosome 7 gain/chromosome 10 loss and EGFR amplification in glioblastoma) and gene rearrangements (BRAF fusion, FGFR1 fusion) will be identified by molecular biology techniques. The up-coming edition of the WHO classification of the central nervous system tumors will rely more heavily on molecular alterations to accurately diagnose and treat brain tumors.

The Impact of Surgery on the Survival of Patients with Recurrent Glioblastoma

Objective:

The purpose of this study was to investigate the possible benefit of repeat surgery on overall survival for patients with recurrent glioblastoma multiforme (GBM).

Methods:

We performed a retrospective analysis of data from patients who presented with recurrent GBM over a 5-year period (n = 157), comparing baseline characteristics and survival for patients who had at least 1 new tumor resection followed by chemotherapy (reoperation group, n = 59) and those who received medical treatment only (no-reoperation group, n = 98) for recurrence.

Results:

The baseline characteristics of the two groups differed in terms of WHO performance status (better in the reoperation group), mean age (60 years in the reoperation group vs. 65 years in the no-reoperation group), mean interval to recurrence (3 months later in the reoperation group than in the no-reoperation group) and more gross total resections in the reoperation group. Nevertheless, the patients in the reoperation group had a higher rate [32.8%] of sensorimotor deficits than those of the no-reoperation group [14.2]. There was no significant difference in sex; tumor localization, side, or extent; MGMT status; MIB-1 labeling index; or Karnofsky Performance Status [KPS] score. After adjustment for age, the WHO performance status, interval of recurrence, and extent of resection at the first operation, multivariate analysis showed that median survival was significantly better in the reoperation group than in the no-reoperation group (22.9 vs. 14.61 months, P < 0.05). After a total of 69 repeat operations in 59 patients (10 had 2 repeat surgeries), we noted 13 temporary and 20 permanent adverse postoperative events, yielding a permanent complication rate of 28.99% (20/69). There was also a statistically significant (P = 0.029, Student's t-test) decrease in the mean KPS score after reoperation (mean preoperative KPS score of 89.34 vs. mean postoperative score of 84.91).

Conclusion:

Our retrospective study suggests that repeat surgery may be beneficial for patients with GBM recurrence who have good functional status (WHO performance status 0 and 1), although the potential benefits must be weighed against the risk of permanent complications, which occurred in almost 30% of the patients who underwent repeat resection in this series.

Changing Incidence and Survival of Primary Central Nervous System Lymphoma in Australia: A 33-Year National Population-Based Study

Simple Summary

In Australia, all cancers are recorded in the Australian Cancer Database. We used pathological and anatomical classification codes to identify cases of brain lymphoma—termed primary central nervous system lymphoma or PCNSL—that had occurred in Australia during the past four decades. This allowed us to calculate the incidence of PCNSL, as well as the overall survival after diagnosis with this lymphoma. PCNSL is rare, recently affecting approximately 4 per one million adult Australians per year. However, the number of people diagnosed with this cancer is increasing. Survival of people diagnosed with PCNSL has been improving, but is still low, with only 33% of people alive at 5 years after receiving this diagnosis. As the first survey of the incidence of PCSNL in Australia and the survival of Australians diagnosed with this rare cancer, our research supports current efforts to understand risk factors and improve outcomes.

Abstract

Primary central nervous system lymphoma (PCNSL) is a rare brain cancer that remains challenging to study. Epidemiology of PCNSL in the Australian population, which is racially and ethnically diverse, has not been examined previously. Using ICD-O-3.1 Morphology and Topography Codes to identify cases, we analyzed complete datasets from the comprehensive Australian Cancer Database (1982–2014, adults aged ≥ 20 years) to establish incidence rates and trends of PCNSL, and to define survival outcomes of individuals diagnosed with PCNSL, including the predominant diffuse large B-cell lymphoma (DLBCL) type. Age-standardized incidence of PCNSL increased by an average annual 6.8% percent over the study period, with current incidence of 0.43 (95% confidence interval, 0.41–0.46) per 100,000 person-years, in comparison to 21.89 (21.41–22.38) per 100,000 person-years for non-CNS lymphoma. Increase in incidence was characterized by an acute rise between 1996 and 1999, was more pronounced with increasing age, and was driven by increasing incidence of DLBCL. Overall survival for persons diagnosed with PCNSL improved significantly across the study period, with 5-year survival probability increasing from 0.21 (95% confidence interval, 0.16–0.26) to 0.33 (0.30–0.36), and median survival increasing from 318 to 600 days, between 1982–1999 and 2000–2014. Increase in survival was significantly higher for persons with DLBCL versus non-DLBCL PCNSL, but substantially lower than that for persons with non-CNS lymphoma, who had a 5-year survival probability of 0.62 (0.62–0.62) and a median survival of 3388 days in 2000–2014. This study links increasing incidence of PCNSL in Australia to increasing incidence of DLCBL, including in younger adults, and highlights the improving, but low, survival outcome of this cancer.

Primary Pituitary Lymphoma As Rare Cause Of A Pituitary Mass And Hypopituitarism In Adulthood

OBJECTIVE

Differential diagnosis of nonadenomatous sellar masses causing hypopituitarism is still a challenge. Among these masses, growing evidence has demonstrated that primary pituitary lymphoma is a specific and emerging entity. The aim of our study was to describe our experience with a case of primary pituitary lymphoma and to perform a review of the available literature.

METHODS

We searched relevant databases up to March 2020, identifying 36 suitable articles basing on inclusion criteria (primary pituitary lymphoma in adult immunocompetent subjects). Overall, 43 cases were included in the review, adding a new case diagnosed and treated in our hospital. Epidemiologic data, clinical presentation, hormonal status, radiologic findings, pathology, treatment, and outcome were extracted.

RESULTS

Mean age at diagnosis was 58.9 years, without gender difference. Symptoms related to mass were common (52.3%), in particular cranial nerve palsy (70.5%), headache (56.8%), and alteration in visual field (40.9%). Impaired hormonal status was detected in 89.7% of patients; of them, 58.9% presented with anterior pituitary failure (partial or total), while 25.6% presented with panhypopituitarism. Overall, diabetes insipidus was present in 30.8% and hyperprolactinemia in 41.0% of patients. The majority of patients presented a radiologically invasive mass in the suprasellar region and cavernous sinus (65.9% and 40.9%, respectively) and histologic diagnosis of diffuse B-cell lymphoma (54.5%).

CONCLUSION

The differential diagnosis of sellar and parasellar masses causing hypopituitarism should include primary pituitary lymphoma, even in absence of systemic symptoms or posterior pituitary dysfunction. The disease has a heterogeneous pattern, so a collaboration between endocrinologists, neuroradiologists, neurosurgeons, and hematologists is desirable.

Management, functional outcomes and survival in a French multicentric series of 118 adult patients with cerebellar glioblastoma

PURPOSE

To analyze the outcomes and predictors in a large series of cerebellar glioblastomas in order to guide patient management.

METHODS

The French brain tumor database and the Club de Neuro-Oncologie of the Société Française de Neurochirurgie retrospectively identified adult patients with cerebellar glioblastoma diagnosed between 2003 and 2017. Diagnosis was confirmed by a centralized neuropathological review.

RESULTS

Data from 118 cerebellar glioblastoma patients were analyzed (mean age 55.9 years, 55.1% males). The clinical presentation associated raised intracranial pressure (50.8%), static cerebellar syndrome (68.6%), kinetic cerebellar syndrome (49.2%) and/or cranial nerve disorders (17.8%). Glioblastomas were hemispheric (55.9%), vermian (14.4%) or both (29.7%). Hydrocephalus was present in 49 patients (41.5%). Histologically, tumors corresponded either to IDH-wild-type or to K27-mutant glioblastomas. Surgery consisted of total (12.7%), subtotal (35.6%), partial resection (33.9%) or biopsy (17.8%). The postoperative Karnofsky performance status was improved, stable and worsened in 22.4%, 43.9% and 33.7% of patients, respectively. Progression-free and overall survivals reached 5.1 months and 9.1 months, respectively. Compared to other surgical strategies, total or subtotal resection improved the Karnofsky performance status (33.3% vs 12.5%, p < 0.001), prolonged progression-free and overall survivals (6.5 vs 4.3 months, p = 0.015 and 16.7 vs 6.2 months, p < 0.001, respectively) and had a comparable complication rate (40.4% vs 31.1%, p = 0.29). After total or subtotal resection, the functional outcomes were correlated with age (p = 0.004) and cerebellar hemispheric tumor location (p < 0.001) but not brainstem infiltration (p = 0.16).

CONCLUSION

In selected patients, maximal resection of cerebellar glioblastoma is associated with improved onco-functional outcomes, compared with less invasive procedures.

Correlations between genomic subgroup and clinical features in a cohort of more than 3000 meningiomas

OBJECTIVE

Recent large-cohort sequencing studies have investigated the genomic landscape of meningiomas, identifying somatic coding alterations in NF2, SMARCB1, SMARCE1, TRAF7, KLF4, POLR2A, BAP1, and members of the PI3K and Hedgehog signaling pathways. Initial associations between clinical features and genomic subgroups have been described, including location, grade, and histology. However, further investigation using an expanded collection of samples is needed to confirm previous findings, as well as elucidate relationships not evident in smaller discovery cohorts.

METHODS

Targeted sequencing of established meningioma driver genes was performed on a multiinstitution cohort of 3016 meningiomas for classification into mutually exclusive subgroups. Relevant clinical information was collected for all available cases and correlated with genomic subgroup. Nominal variables were analyzed using Fisher's exact tests, while ordinal and continuous variables were assessed using Kruskal-Wallis and 1-way ANOVA tests, respectively. Machine-learning approaches were used to predict genomic subgroup based on noninvasive clinical features.

RESULTS

Genomic subgroups were strongly associated with tumor locations, including correlation of HH tumors with midline location, and non-NF2 tumors in anterior skull base regions. NF2 meningiomas were significantly enriched in male patients, while KLF4 and POLR2A mutations were associated with female sex. Among histologies, the results confirmed previously identified relationships, and observed enrichment of microcystic features among "mutation unknown" samples. Additionally, KLF4-mutant meningiomas were associated with larger peritumoral brain edema, while SMARCB1 cases exhibited elevated Ki-67 index. Machine-learning methods revealed that observable, noninvasive patient features were largely predictive of each tumor's underlying driver mutation.

CONCLUSIONS

Using a rigorous and comprehensive approach, this study expands previously described correlations between genomic drivers and clinical features, enhancing our understanding of meningioma pathogenesis, and laying further groundwork for the use of targeted therapies. Importantly, the authors found that noninvasive patient variables exhibited a moderate predictive value of underlying genomic subgroup, which could improve with additional training data. With continued development, this framework may enable selection of appropriate precision medications without the need for invasive sampling procedures.

Machine Learning in Meningioma MRI: Past to Present. A Narrative Review

Meningioma is one of the most frequent primary central nervous system tumors. While magnetic resonance imaging (MRI), is the standard radiologic technique for provisional diagnosis and surveillance of meningioma, it nevertheless lacks the prima facie capacity in determining meningioma biological aggressiveness, growth, and recurrence potential. An increasing body of evidence highlights the potential of machine learning and radiomics in improving the consistency and productivity and in providing novel diagnostic, treatment, and prognostic modalities in neuroncology imaging. The aim of the present article is to review the evolution and progress of approaches utilizing machine learning in meningioma MRI-based sementation, diagnosis, grading, and prognosis. We provide a historical perspective on original research on meningioma spanning over two decades and highlight recent studies indicating the feasibility of pertinent approaches, including deep learning in addressing several clinically challenging aspects. We indicate the limitations of previous research designs and resources and propose future directions by highlighting areas of research that remain largely unexplored. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 2.

An epidemiology report for primary central nervous system tumors in adolescents and young adults: a nationwide population-based study in France, 2008-2013

BACKGROUND

Primary central nervous system tumors (PCNST) among adolescents and young adults (AYA, 15-39 y) have rarely been reported. We present a nationwide report of PCNST histologically confirmed in the French AYA population between 2008 and 2013.

METHODS

Patients were identified through the French Brain Tumor Database (FBTDB), a national dataset that includes prospectively all histologically confirmed cases of PCNST in France. Patients aged 15 to 39 years with histologically confirmed PCNST diagnosed between 2008 and 2013 were included. For each of the 143 histological subtypes of PCNST, crude rates, sex, surgery, and age distribution were provided. To enable international comparisons, age-standardized incidence rates were adjusted to the world-standard, European, and USA populations.

RESULTS

For 6 years, 9661 PCNST (males/females: 4701/4960) were histologically confirmed in the French AYA population. The overall crude rate was 8.15 per 100 000 person-years. Overall, age-standardized incidence rates were (per 100 000 person-years, population of reference: world/Europe/USA): 7.64/8.07/8.21, respectively. Among patients aged 15-24 years, the crude rate was 5.13 per 100 000. Among patients aged 25-39 years, the crude rate was 10.10 per 100 000. Age-standardized incidence rates were reported for each of the 143 histological subtypes. Moreover, for each histological subtype, data were detailed by sex, age, type of surgery (surgical resection or biopsy), and cryopreserved samples.

CONCLUSION

These data represent an exhaustive report of all histologically confirmed cases of PCNST with their frequency and distribution in the French AYA population in 2008-2013. For the first time in this age group, complete histological subtypes and rare tumor identification are detailed.

A diagnostic challenge of primary Central nervous system lymphoma: from the eyes to the brain

Background: Being a subtype of primary central nervous system lymphoma (PCNSL), primary vitreoretinal lymphoma (PVRL) is a rare and fatal intraocular malignancy manifesting as blurred vision and floaters, and is usually combined with, or eventually progresses to, central nervous system lesions. The diagnosis of PVRL/PCNSL remains challenging because of the nonspecific clinical features and diagnostic dependency on biopsy.Case presentation: In this paper, we present the clinical, imaging, laboratory, brain biopsy, and vitreous biopsy findings of a 56-year-old immunocompetent woman who presented with blurred vision of the left eye, but which rapidly evolved into lesions of the central nervous system. The dramatic changes on brain imaging and the undiagnostic brain and vitreous biopsy results presented great challenges for the diagnosis. PCNSL was eventually presumed according to comprehensive consideration of the disease progression pattern, the characteristic neuroimaging, and molecular hints.Conclusions: PCNSL is a highly invasive tumor, and timely diagnosis is the key point in clinical practice. However, the requirement for biopsy and the existence of sentinel lesions impedes the diagnosis. Therefore, follow-up and repeated biopsy is always necessary for a definitive diagnosis. This case indicates that a complete evaluation of neuroimaging, ophthalmic testing, cytologic examination of the cerebrospinal fluid, diagnostic vitrectomy, and brain biopsy are essential for diagnosis of PCNSL. Moreover, molecular and cytokine analyses are useful adjuncts to the diagnostic cytology. Of note, the analysis of cytokine levels (IL-10/IL-6) is an important auxiliary diagnostic strategy in the diagnosis of diffuse large B-cell lymphoma.

Italian consensus and recommendations on diagnosis and treatment of low-grade gliomas. An intersociety (SINch/AINO/SIN) document

In 2018, the SINch (Italian Society of Neurosurgery) Neuro-Oncology Section, AINO (Italian Association of Neuro-Oncology) and SIN (Italian Association of Neurology) Neuro-Oncology Section formed a collaborative Task Force to look at the diagnosis and treatment of low-grade gliomas (LGGs). The Task Force included neurologists, neurosurgeons, neuro-oncologists, pathologists, radiologists, radiation oncologists, medical oncologists, a neuropsychologist and a methodologist. For operational purposes, the Task Force was divided into five Working Groups: diagnosis, surgical treatment, adjuvant treatments, supportive therapies, and follow-up. The resulting guidance document is based on the available evidence and provides recommendations on diagnosis and treatment of LGG patients, considering all aspects of patient care along their disease trajectory.

De novo and secondary anaplastic meningiomas: a study of clinical and histomolecular prognostic factors

Background

Following recent studies underlining the differences between de novo and secondary anaplastic meningiomas and the prognostic value of telomerase reverse transcriptase (TERT) promoter mutation, we decided to conduct a multicenter retrospective study to address these questions and determine specific prognostic factors in each of these 2 anaplastic meningioma subgroups.

Methods

Among the 68 meningioma cases initially selected, only 57 were confirmed as anaplastic meningiomas after centralized pathological review. TERT promoter mutation analysis was performed in all cases.

Results

Median overall survival was 2.6 years and 5-year survival rate was 10%. This study confirmed the better prognosis of de novo anaplastic meningiomas (28 tumors) compared with secondary anaplastic meningiomas (29 tumors) (P = 0.02). In the "de novo" group, meningiomas diagnosed on histological anaplasia alone had a better prognosis than those in patients with a high number of mitoses with or without anaplasia (P = 0.01). In the "secondary" group, tumors demonstrate very heterogeneous clinical courses leading to malignant transformation, and time to first relapse as a low-grade tumor was a strong predictor of overall survival (P = 0.0007). TERT promoter mutation in anaplastic meningiomas was rare (14%) and did not influence overall survival but was associated with a shorter recurrence-free survival in the secondary anaplastic meningioma subgroup (P = 0.02). The absence of TERT promoter methylation, although rare (3/33 cases), may be associated with prolonged overall survival (P = 0.02).

Conclusion

This study highlights the different prognoses of de novo and secondary anaplastic meningiomas with specific prognostic factors in each subgroup. The analysis of TERT mutation and methylation could provide additional prognostic insights.

Astrocytic Tumors in Mexico: An Overview of Characteristics and Prognosis in an Open Reference Center for Low-Income Population

Objective:

The authors aimed to analyze the current epidemiology of high- and low-grade gliomas, follow-up strategies, and prognosis in a national reference center of a developing country.

Materials and Methods:

Medical records of patients diagnosed with intracranial gliomas from January 2012 to January 2016 were reviewed. Data were classified by age, symptoms, Karnofsky functional scale (KFS), tumor location, extent of resection (EOR), histopathology, hospital stay, Glasgow outcome scale (GOS), adjuvant treatments, overall survival (OS), and mortality.

Results:

Astrocytomas accounted for 28.2% of the intracranial tumors and 53.5% were male. Headache was the most common symptom, while sensory disturbance was the least frequent. The right cerebral hemisphere was involved in 56.5% of cases and frontal lobe in 31.3%. Gross total resection (GTR) was achieved in 18.1% cases, 35.3% subtotal resection, and 46.4% biopsy. Regarding the astrocytomas, 43.3% were low grade and 56.4% high grade. Low-grade tumors had the highest frequency in the fourth decade of life, while Grade III and IV in the fifth and seventh decades of life, respectively. In high-grade lesions, there was a slight male predominance (~1.4:1). The initial KFS was regularly 80 for low-grade gliomas and 60 for high-grade. By 1-month postdischarge, the score decreased by 10 points. About half of the patients (47.5%) received adjuvant therapy after surgery. From the Glasgow Outcome Scale (GOS), the majority had a form of disability and 30-month OS was above 88% for Grade I-II and 0% for Grade III and IV.

Conclusions:

Astrocytic tumors were the most frequently noted intra-axial tumors. Age, histological grade, and EOR are important prognostic factors. These results are similar to other reports; however, increased variability was noted when treatment-related factors were considered. Additional studies are necessary to identify the factors related to these treatment results.

Highlights:

There are no data describing the basic epidemiology and prognosis of high-grade and low-grade gliomas in Mexico.

Intracranial astrocytomas account for 28.2% tumors in our institution.

Age, histological grade, and EOR are important prognostic factors.

Poor overall survival was achieved in our target population.

Association of patterns of care, prognostic factors, and use of radiotherapy-temozolomide therapy with survival in patients with newly diagnosed glioblastoma: a French national population-based study

Background

Glioblastoma is the most frequent primary malignant brain tumor. In daily practice and at whole country level, oncological care management for glioblastoma patients is not completely known.

Objectives

To describe oncological patterns of care, prognostic factors, and survival for all patients in France with newly-diagnosed and histologically confirmed glioblastoma, and evaluate the impact of extended temozolomide use at the population level.

Methods

Nationwide population-based cohort study including all patients with newly-diagnosed and histologically confirmed glioblastoma in France in 2008 and followed until 2015.

Results

Data from 2053 glioblastoma patients were analyzed (male/female ratio 1.5, median age 64 years). Median overall survival (OS) was 11.2 [95% confidence interval (CI) 10.7–11.9] months. The first-line therapy and corresponding median survival (MS, in months) were: 13% did not receive any oncological treatment (biopsy only) (MS = 1.8, 95% CI 1.6–2.1), 27% received treatment without the combination of radiotherapy (RT)–temozolomide (MS = 5.9, 95% CI 5.5–6.6), 60% received treatment including the initiation of the concomitant phase of RT–temozolomide (MS = 16.4, 95% CI 15.2–17.4) whom 44% of patients initiated the temozolomide adjuvant phase (MS = 18.9, 95% CI 18.0–19.8). Only 22% patients received 6 cycles or more of adjuvant temozolomide (MS = 25.5, 95% CI 24.0–28.3). The multivariate analysis showed that the risk of mortality was significantly higher for the non-progressive patients who stopped at 6 cycles (standard protocol) than those who continued the treatment, hazard ratio = 1.5 (95% CI 1.2–1.9).

Conclusion

In non-progressive patients, prolonging the adjuvant temozolomide beyond 6 cycles may improve OS.

Electronic supplementary material

The online version of this article (10.1007/s11060-018-03065-z) contains supplementary material, which is available to authorized users.

The 2016 World Health Organization classification of tumours of the central nervous system

The 2016 WHO classification of tumours of the central nervous system represents the new paradigm among the specialists in the brain tumours and proposes a new approach combining histopathological and molecular features into diagnosis named 'integrated diagnosis'. The aim of this challenge is to overstep the interobserver variability of diagnosis based on previous classifications in order to ensure homogenous biological entities with a more accurate clinical significance. Over the last two decades, several molecular aberrations into gliomagenesis were highlighted and then confirmed as emerging biomarkers through prognostic stratification. In particular, IDH1/IDH2 genes mutations, 1p/19q codeletion and mutations in genes encoding histone H3 variants drastically changed the knowledge about diffuse gliomas inducing the WHO working group to consider the phenotype-genotype approach. In the present review, the historical development of the diagnosis of brain tumours from the 3D spatial configuration to the integration of multidisciplinary data up to recent molecular alterations is discussed. At the national level, the RENOCLIP network (supported by the National Cancer Institute) contributes to improve the standardization of histological diagnosis and the facilitation of access to molecular biology platforms for the detection of genetic aberrations necessary for integrated diagnosis. Importantly, the French POLA cohort allowed to test the clinical impact of the new criteria introduced by 2016 WHO classification of CNS tumours confirming the high accuracy in predicting clinical behaviour for diffuse gliomas.

Paradoxes of evidence-based medicine in lower-grade glioma: To treat the tumor or the patient?

Brain lower-grade gliomas (LGG) usually occur in young adults who enjoy an active life. This tumor has a high risk of malignant transformation resulting in neurologic deterioration and finally death. Early and multistage therapeutic management can increase survival over 10 years. Preservation of functional neural networks and quality of life is crucial. In the era of evidence-based medicine, the issues discussed are those associated with the design, analysis, and clinical application of randomized controlled trials (RCTs) for LGG. RCTs should take account of the following: considerable variability in the natural course of LGG; limited prognostic value of molecular biology at the individual level; large variability of brain organization across patients; technical and conceptual progress of therapies over years; combination or repetition of iterative treatments, taken as a whole and not only in isolation; and long-term consequences on oncologic and functional outcomes. As it is difficult to translate the results of an RCT into benefits for a unique patient with LGG, personalized decisions must be made by considering the tumor behavior, individual pattern of neuroplasticity, and patient needs, and not by administrating a standardized protocol exclusively based on an RCT.

Prognostic Value of the Metabolic and Volumetric Parameters of 11C-Methionine Positron-Emission Tomography for Gliomas: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have demonstrated that ¹¹C-methionine positron-emission tomography provides information on prognosis.

PURPOSE

We performed a systematic review and meta-analysis of the prognostic value of the metabolic and volumetric parameters of ¹¹C-methionine-PET for gliomas.

DATA SOURCES

A systematic search was performed using the following combination of keywords: "methionine," "PET," "glioma," and "prognosis."

STUDY SELECTION

The inclusion criteria were the use of ¹¹C-methionine-PET as an imaging tool, studies limited to gliomas, studies including metabolic parameters (tumor-to-normal ratio) and/or volumetric parameters (metabolic tumor volume), and studies reporting survival data. The electronic search first identified 181 records, and 14 studies were selected.

DATA ANALYSIS

Event-free survival and overall survival were the outcome measures of interest. The effect of the tumor-to-normal ratio and metabolic tumor volume on survival was determined by the effect size of the hazard ratio. Hazard ratios were extracted directly from each study when provided or determined by analyzing the Kaplan-Meier curves.

DATA SYNTHESIS

The combined hazard ratios of the tumor-to-normal ratio for event-free survival was 1.74 with no significance and that of the tumor-to-normal ratio for overall survival was 2.02 with significance. The combined hazard ratio of the metabolic tumor volume for event-free survival was 2.72 with significance and that of the metabolic tumor volume for overall survival was 3.50 with significance.

LIMITATIONS

The studies selected were all retrospective, and there were only 4 studies involving the metabolic tumor volume.

CONCLUSIONS

The present meta-analysis of ¹¹C-methionine-PET suggests that the tumor-to-normal ratio for overall survival and the metabolic tumor volume for event-free survival and overall survival are significant prognostic factors for patients with gliomas.

Treatment and survival of glioblastoma patients in Denmark: The Danish Neuro-Oncology Registry 2009-2014

BACKGROUND

As many glioblastoma patients are in a poor condition they are unable to undergo the full treatment documented in clinical trials. We aimed to examine the survival and its relationship to clinical characteristics and treatment in a nationwide population of glioblastoma patients in Denmark.

METHODS

We included prospectively recorded clinical data from 1364 adult patients with histologically verified glioblastoma from the Danish Neuro-Oncology Registry, 2009-2014.

RESULTS

The age standardized incidence rate was 6.3/100,000 person-years for males and 3.9 for females and the median age was 66 years. The median overall survival was 11.2 months. There was an independently significant prognostic effect of age, performance status, cognitive symptoms, tumor diameter, multifocality, crossing midline, and contrast enhancement. For partial and total resection compared to biopsy only, the adjusted risk of dying was reduced by 43% (HR [CI] 0.57 [0.48-0.68]) and 51% (0.49 [0.40-0.60]), respectively. For patients receiving a partial and full radiochemotherapy regimen compared to no postsurgical treatment, the risk reduction was 56% (HR [CI] 0.44 [0.37-0.53]) and 70% (0.30 [0.25-0.35]), respectively. The full radiochemotherapy regimen was only allocated to 50% of the patients, 29% among the oldest (70+ years) and 60% among the younger (18-69 years).

CONCLUSIONS

Glioblastoma patients had a poor overall survival but with several specific independent prognostic factors. Extensive cancer treatment was associated with an increasing survival in all age groups, but only half of the patients were sufficiently fit for a full regimen of postoperative combined radiochemotherapy.

Improving surgical outcome for gliomas with intraoperative mapping

INTRODUCTION

Radical glioma resection improves overall survival, both in low-grade and high-grade glial tumors. However, preservation of the quality of life is also crucial. Areas covered: Due to the diffuse feature of gliomas, which invade the central nervous system, and due to considerable variations of brain organization among patients, an individual cerebral mapping is mandatory to solve the classical dilemma between the oncological and functional issues. Because functional neuroimaging is not reliable enough, intraoperative electrical stimulation, especially in awake patients benefiting from a real-time cognitive monitoring, is the best way to increase the extent of resection while sparing eloquent neural networks. Expert commentary: Here, we propose a paradigmatic shift from image-guided resection to functional mapping-guided resection, based on the study of the dynamic distribution of delocalized cortico-subcortical circuits at the individual level, i.e., the investigation of brain connectomics and neuroplastic potential. This surgical philosophy results in an improvement of both oncological outcomes and quality of life. This highlights the need to reinforce the link between glioma surgery and cognitive neurosciences.

Natural course and prognosis of anaplastic gangliogliomas: a multicenter retrospective study of 43 cases from the French Brain Tumor Database

Background

Anaplastic gangliogliomas (GGGs) are rare tumors whose natural history is poorly documented. We aimed to define their clinical and imaging features and to identify prognostic factors.

Methods

Consecutive cases of anaplastic GGGs in adults prospectively entered into the French Brain Tumor Database between March 2004 and April 2014 were screened. After diagnosis was confirmed by pathological review, clinical, imaging, therapeutic, and outcome data were collected retrospectively.

Results

Forty-three patients with anaplastic GGG (median age, 49.4 y) from 18 centers were included. Presenting symptoms were neurological deficit (37.2%), epileptic seizure (37.2%), or increased intracranial pressure (25.6%). Typical imaging findings were unifocal location (94.7%), contrast enhancement (88.1%), central necrosis (43.2%), and mass effect (47.6%). Therapeutic strategy included surgical resection (95.3%), adjuvant radiochemotherapy (48.8%), or radiotherapy alone (27.9%). Median progression-free survival (PFS) and overall survival (OS) were 8.0 and 24.7 months, respectively. Three- and 5-year tumor recurrence rates were 69% and 100%, respectively. The 5-year survival rate was 24.9%. Considering unadjusted significant prognostic factors, tumor midline crossing and frontal location were associated with shorter OS. Temporal and parietal locations were associated with longer and shorter PFS, respectively. None of these factors remained statistically significant in multivariate analysis.

Conclusions

We report a large series providing clinical, imaging, therapeutic, and prognostic features of adult patients treated for an intracerebral anaplastic GGG. Our results show that pathological diagnosis is difficult, that survivals are only slightly better than for glioblastomas, and that complete surgical resection followed with adjuvant chemoradiotherapy offers longer survival.

RNA-seq transcriptome analysis of formalin fixed, paraffin-embedded canine meningioma

Meningiomas are the most commonly reported primary intracranial tumor in dogs and humans and between the two species there are similarities in histology and biologic behavior. Due to these similarities, dogs have been proposed as models for meningioma pathobiology. However, little is known about specific pathways and individual genes that are involved in the development and progression of canine meningioma. In addition, studies are lacking that utilize RNAseq to characterize gene expression in clinical cases of canine meningioma. The primary objective of this study was to develop a technique for which high quality RNA can be extracted from formalin-fixed, paraffin embedded tissue and then used for transcriptome analysis to determine patterns of gene expression. RNA was extracted from thirteen canine meningiomas-eleven from formalin fixed and two flash-frozen. These represented six grade I and seven grade II meningiomas based on the World Health Organization classification system for human meningioma. RNA was also extracted from fresh frozen leptomeninges from three control dogs for comparison. RNAseq libraries made from formalin fixed tissue were of sufficient quality to successfully identify 125 significantly differentially expressed genes, the majority of which were related to oncogenic processes. Twelve genes (AQP1, BMPER, FBLN2, FRZB, MEDAG, MYC, PAMR1, PDGFRL, PDPN, PECAM1, PERP, ZC2HC1C) were validated using qPCR. Among the differentially expressed genes were oncogenes, tumor suppressors, transcription factors, VEGF-related genes, and members of the WNT pathway. Our work demonstrates that RNA of sufficient quality can be extracted from FFPE canine meningioma samples to provide biologically relevant transcriptome analyses using a next-generation sequencing technique, such as RNA-seq.

Recurrent glioblastomas in the elderly after maximal first-line treatment: does preserved overall condition warrant a maximal second-line treatment?

A growing literature supports maximal safe resection followed by standard combined chemoradiotherapy (i.e. maximal first-line therapy) for selected elderly glioblastoma patients. To assess the prognostic factors from recurrence in elderly glioblastoma patients treated by maximal safe resection followed by standard combined chemoradiotherapy as first-line therapy. Multicentric retrospective analysis comparing the prognosis and optimal oncological management of recurrent glioblastomas between 660 adult patients aged of < 70 years (standard group) and 117 patients aged of ≥70 years (elderly group) harboring a supratentorial glioblastoma treated by maximal first-line therapy. From recurrence, both groups did not significantly differ regarding Karnofsky performance status (KPS) (p = 0.482). Oncological treatments from recurrence significantly differed: patients of the elderly group received less frequently oncological treatment from recurrence (p < 0.001), including surgical resection (p < 0.001), Bevacizumab therapy (p < 0.001), and second line chemotherapy other than Temozolomide (p < 0.001). In multivariate analysis, Age ≥70 years was not an independent predictor of overall survival from recurrence (p = 0.602), RTOG-RPA classes 5-6 (p = 0.050) and KPS at recurrence <70 (p < 0.001), available in all cases, were independent significant predictors of shorter overall survival from recurrence. Initial removal of ≥ 90% of enhancing tumor (p = 0.004), initial completion of the standard combined chemoradiotherapy (p = 0.007), oncological treatment from recurrence (p < 0.001), and particularly surgical resection (p < 0.001), Temozolomide (p = 0.046), and Bevacizumab therapy (p = 0.041) were all significant independent predictors of longer overall survival from recurrence. Elderly patients had substandard care from recurrence whereas age did not impact overall survival from recurrence contrary to KPS at recurrence <70. Treatment options from recurrence should include repeat surgery, second line chemotherapy and anti-angiogenic agents.

EGFR Amplification and IDH Mutations in Glioblastoma Patients of the Northeast of Morocco

Glioblastomas are the most frequent and aggressive primary brain tumors which are expressing various evolutions, aggressiveness, and prognosis. Thus, the 2007 World Health Organization classification based solely on the histological criteria is no longer sufficient. It should be complemented by molecular analysis for a true histomolecular classification. The new 2016 WHO classification of tumors of the central nervous system uses molecular parameters in addition to histology to reclassify these tumors and reduce the interobserver variability. The aim of this study is to determine the prevalence of IDH mutations and EGFR amplifications in the population of the northeast region of Morocco and then to compare the results with other studies. Methods. IDH1 codon 132 and IDH2 codon 172 were directly sequenced and the amplification of exon 20 of EGFR gene was investigated by qPCR in 65 glioblastoma tumors diagnosed at the University Hospital of Fez between 2010 and 2014. Results. The R132H IDH1 mutation was observed in 8 of 65 tumor samples (12.31%). No mutation of IDH2 was detected. EGFR amplification was identified in 17 cases (26.15%). Conclusion. A systematic search of both histological and molecular markers should be requisite for a good diagnosis and a better management of glioblastomas.

[Recommendations for the organ donation from patients with brain or medullary primitive tumors on behalf of the Association of the Neuro-oncologists of French Expression (ANOCEF) and the Club of Neuro-oncology of the French Society of Neurosurgery]

Requests of organs to be transplanted increase. As a matter of urgency, it is not always easy to decide if a patient carrier of a brain tumor can be candidate in the donation. After a review of the literature, the members of the Association of the Neuro-oncologists of French Expression (ANOCEF) and the Club of Neuro-oncology of the French Society of Neurosurgery propose consensual recommendations in case of donor carrier of primitive tumor intra-cranial or intra-medullary. A contact with the neuro-oncologist/neurosurgeon will allow to discuss the indication in case of glioma of grade I/II/III, according to the grade, the current status (absence of progressive disease), the number of surgeries and of lines of treatment. The taking is disadvised in case of glioma of grade IV (glioblastoma), of lymphoma or meningioma of grade III. No contraindication for the meningiomas of grade I, and individual discussion for the meningiomas of grade II. It is advisable to remain careful in case of hemangiopericytoma and of meningeal solitary fibrous tumor. The patients in first complete remission of a medulloblastoma or intra-cranial primitive germinoma seem good candidates for the taking of organ if the follow-up is of at least 10 years (3 years for non germinomas). In every case, a multidisciplinary discussion is desirable when it is materially possible.

Genetic aberrations and molecular biology of skull base chordoma and chondrosarcoma

Chordomas and chondrosarcomas are two major malignant bone neoplasms located at the skull base. These tumors are rarely metastatic, but can be locally invasive and resistant to conventional chemotherapies and radiotherapies. Accordingly, therapeutic approaches for the treatment of these tumors can be difficult. Additionally, their location at the skull base makes them problematic. Although accurate diagnosis of these tumors is important because of their distinct prognoses, distinguishing between these tumor types is difficult due to overlapping radiological and histopathological findings. However, recent accumulation of molecular and genetic studies, including extracranial location analysis, has provided us clues for accurate diagnosis. In this report, we review the genetic aberrations and molecular biology of these two tumor types. Among the abundant genetic features of these tumors, brachyury immunohistochemistry and direct sequencing of IDH1/2 are simple and useful techniques that can be used to distinguish between these tumors. Although it is still unclear why these tumors, which have such distinct genetic backgrounds, show similar histopathological findings, comparison of their genetic backgrounds could provide essential information.

The etiopathogenesis of diffuse low-grade gliomas

The origins of diffuse low-grade gliomas (DLGG) are unknown. Beyond some limited data on their temporal and cellular origins, the mechanisms and risk factors involved are poorly known. First, based on strong relationships between DLGG development and the eloquence of brain regions frequently invaded by these tumors, we propose a "functional theory" to explain the origin of DLGG. Second, the biological pathways involved in DLGG genesis may differ according to tumor location (anatomo-molecular correlations). The cellular and molecular mechanisms of such "molecular theory" will be reviewed. Third, the geographical distribution of diffuse WHO grade II-III gliomas within populations is heterogeneous, suggesting possible environmental risk factors. We will discuss this "environmental theory". Finally, we will summarize the current knowledge on genetic susceptibility in gliomas ("genetic predisposition theory"). These crucial issues illustrate the close relationships between the pathophysiology of gliomagenesis, the anatomo-functional organization of the brain, and personalized management of DLGG patients.

Epidemiology for primary brain tumors: a nationwide population-based study

Primary central nervous system tumors (PCNST) are rare tumors responsible for high mortality and morbidity. Their epidemiology is poorly known, and clinical data are scarcely analyzed at a national level. In this study, we aimed at providing descriptive epidemiological data and incidence rates for all histological subtypes of PCNST according to the WHO classification. We conducted a nationwide population-based study of all newly diagnosed and histologically confirmed PCNST in France, between 2006 and 2011. A total of 57,816 patients were included: male 46.4%, median age at diagnosis 56 years old (range 0-99). For all newly diagnosed PCNST with histological confirmation the crude incidence rate was 15.5/10⁵ per 100,000 person-years. To enable international comparisons, standardized rates were calculated: 14.1/10⁵ (population of reference: USA), 14.5/10⁵ (population of reference: Europe), and 12.0/10⁵ (population of reference: world). 23.4% of samples were cryopreserved. Resection was performed in 79.1% of cases. Results are detailed (incidence rate, sex ratio, median age at diagnosis, number of cryopreserved samples, and type of surgery) for each of the 143 histological subtypes of PCNST, including all rare tumors. For example, incidence rates (population of reference: USA) were 0.018/10⁵ for anaplastic gangliogliomas, 0.054/10⁵ for malignant meningiomas, and 0.036/10⁵ for hemangiopericytomas. Our study is the first to describe incidence rates and epidemiological data for all histological subtypes of PCNST, including rare tumors, at a national level. Its methodology ensures the exhaustiveness of the data collection for histologically-proven cases. Histological population-based studies have many perspectives in the field of clinical epidemiology and research.

[Prevalence of central nervous system tumours and histological identification in the operated patient: 20 years of experience]

BACKGROUND

Central nervous system tumours comprise a heterogeneous group of neoplasms with great histological diversity. Despite the rising prevalence of these tumours in developing countries, some places like Mexico and Latin America have no representative studies that show the real impact of these tumours in our population.

OBJECTIVE

To describe the characteristics of the primary and secondary tumours of the central nervous system in the last 20 years in a Mexican institution.

MATERIAL AND METHODS

Patients with histopathological diagnosis from 1993 to 2013 in our institution, grouping them according to WHO classification 2007, characterising them by age group, gender, and anatomical location.

RESULTS

There were a total of 511 tumours of the central nervous system. Of those, 292 were women and 219 men, with a ratio 1.3: 1, and a mean age of 49.3 years. Tumours with higher prevalence were: Meningeal tumours, 171 (33%), followed by neuroepithelial, 121 (24%). Astrocytoma had the highest prevalence in paediatric patients, whereas in those older than 20 years it was the meningioma. The supratentorial location was the most involved.

CONCLUSION

This is the first study of a series of cases in Mexico that is performed by taking into account benign and malignant tumours of the central nervous system, with patients of all age groups with a range of 20 years. While this work only represents a retrospective analysis of an institution, it can be a strong indication of the epidemiology of these tumours in our environment.

Diagnosis Disclosure Process in Patients With Malignant Brain Tumors

BACKGROUND

The way to disclose a cancer diagnosis has evolved, and psycho-oncology has developed a more prominent place in cancer care. The diagnosis disclosure process was established to improve the overall quality of patient care and the communication about a cancer diagnosis.

OBJECTIVES

The aim of this study was to assess the implementation of the disclosure process in a neurosurgical unit.

METHODS

This study was conducted prospectively during a one-year period. All patients were diagnosed with malignant brain tumors and received their diagnosis using the disclosure process. The communication between the provider and the patient during diagnosis disclosure was recorded for analysis, and patients completed a satisfaction survey.

FINDINGS

Ninety-one patients with a brain tumor diagnosis participated in the study. Twenty-six were unable to complete the satisfaction survey because they were either deceased or close to the end of their lives. In total, 65 questionnaires were sent to patients and their families, and 43 responded. Patients were satisfied with the quality of the disclosure process regarding information given, psychological support, and communication with all healthcare providers. This assessment allowed the authors to better characterize the impact of the disclosure process on the overall care of patients and to measure the effect of the components of the disclosure process on patient satisfaction.

Primary CNS lymphoma at first relapse/progression: characteristics, management, and outcome of 256 patients from the French LOC network

BACKGROUND

Treatment of relapsed/refractory (R/R) primary CNS lymphoma (PCNSL) is poorly defined, because randomized trials and large studies are lacking. The aim of this study was to analyze the characteristics, management, and outcome of R/R PCNSL patients after first-line therapy in a nationwide cohort.

METHODS

We analyzed R/R PCNSL patients following first-line treatment who had been prospectively registered in the database of the French network for oculocerebral lymphoma (LOC) between 2011 and 2014.

RESULTS

Among 563 PCNSL patients treated with first-line therapy, we identified 256 with relapsed (n = 93, 16.5%) or refractory (n = 163, 29.0%) disease. Patients who were asymptomatic at relapse/progression (25.5%), mostly diagnosed on routine follow-up neuroimaging, tended to have a better outcome. Patients who received salvage therapy followed by consolidation (mostly intensive chemotherapy plus autologous hematopoietic stem cell transplantation [ICT + AHSCT]) experienced prolonged survival compared with those who did not receive salvage or consolidation therapy. Independent prognostic factors at first relapse/progression were: KPS ≥ 70 vs KPS < 70), sensitivity to first-line therapy (relapsed vs refractory disease), duration of first remission (progression-free survival [PFS] ≥1 y vs <1 y), and management at relapse/progression (palliative care vs salvage therapy). Patients who relapsed early after first-line therapy (ie, PFS < 1 y) had a poor outcome, comparable to that of refractory patients. Conversely, patients experiencing late relapses (PFS ≥ 1 y) and/or undergoing consolidation with ICT + AHSCT experienced prolonged survival.

CONCLUSIONS

About a third of PCNSL patients are primary refractory to first line treatment. We identified several independent prognostic factors that can guide the management of R/R PCNSL patients.

Correlation of SUV-Derived Indices With Tumoral Aggressiveness of Gliomas in Static 18F-FDOPA PET: Use in Clinical Practice

PURPOSE

Glioma grading is necessary for prognostic evaluation and optimal treatment decisions. The aims of this study were to establish whether a correlation between F-FDOPA uptake with tumor grade was observed and to determine which of the SUV-derived indices was the best correlated.

PATIENTS AND METHODS

Thirty-one patients were retrospectively included (mean [SD] age, 36.8 [12.1] years) including 21 proven low-grade tumors due to histology, imaging, and clinical follow-up and 10 histologically proven high-grade tumors. Static PET acquisitions were postreconstructed between the 10th and 30th minute after injection of F-FDOPA. Regions of interest of 20 mm were applied to tumors, and isocontoured volumes were defined at levels of 50% and 80% of the peak intensity voxel. Background was quantified with 30-mm-diameter regions of interest on contralateral striatum and centrum semioval. Tumoral uptake was evaluated with the following SUV-derived indices: SUVmax, SUVmean, SUVmax, and SUVmean of isocontoured volume, tumor/striatum ratio (T/S), and tumor/normal brain ratio (T/N).

RESULTS

All the SUV-derived indices tested were significantly correlated with tumor grade, considering low-grade and high-grade groups (P < 0.05), except for the SUVmean 50%. The 2 best-correlated indices were SUVmean T/N and SUVmean T/S, with correlation coefficients of 0.561 and 0.522, respectively. Receiver operating characteristic analysis defined optimal thresholds of 1.33 and 1 for sensitivity and specificity of 71% and 100% and 67% and 100%, respectively.

CONCLUSIONS

F-FDOPA PET SUV-derived indices are routinely available information that enables accurate discrimination of low-grade and high-grade gliomas. The best-correlated indices were SUVmean T/N and SUVmean T/S with thresholds of 1.33 and 1.

Valproic acid, compared to other antiepileptic drugs, is associated with improved overall and progression-free survival in glioblastoma but worse outcome in grade II/III gliomas treated with temozolomide

Valproic acid (VPA) is an anti-epileptic drug with properties of a histone deacetylase inhibitor (HDACi). HDACi play a key role in epigenetic regulation of gene expression and have been increasingly used as anticancer agents. Recent studies suggest that VPA is associated with improved survival in high-grade gliomas. However, effects on lower grade gliomas have not been examined. This study investigates whether use of VPA correlates with tumor grade, histological progression, progression-free and overall survival (OS) in grade II, III, and IV glioma patients. Data from 359 glioma patients (WHO II-IV) treated with temozolomide plus an antiepileptic drug (VPA or another antiepileptic drug) between January 1997 and June 2013 at the Massachusetts General Hospital was analyzed retrospectively. After confounder adjustment, VPA was associated with a 28 % decrease in hazard of death (p = 0.031) and a 28 % decrease in the hazard of progression or death (p = 0.015) in glioblastoma. Additionally, VPA dose correlated with reduced hazard of death by 7 % (p = 0.002) and reduced hazard of progression or death by 5 % (p < 0.001) with each 100 g increase in total dose. Conversely, in grade II and III gliomas VPA was associated with a 118 % increased risk of tumor progression or death (p = 0.014), and every additional 100 g of VPA raised the hazard of progression or death by 4 %, although not statistically significant (p = 0.064). Moreover, grade II and III glioma patients taking VPA had 2.17 times the risk of histological progression (p = 0.020), although this effect was no longer significant after confounder adjustment. In conclusion, VPA was associated with improved survival in glioblastoma in a dose-dependent manner. However, in grade II and III gliomas, VPA was linked to histological progression and decrease in progression-free survival. Prospective evaluation of VPA treatment for glioma patients is warranted to confirm these findings.

A Probabilistic Atlas of Diffuse WHO Grade II Glioma Locations in the Brain

Diffuse WHO grade II gliomas are diffusively infiltrative brain tumors characterized by an unavoidable anaplastic transformation. Their management is strongly dependent on their location in the brain due to interactions with functional regions and potential differences in molecular biology. In this paper, we present the construction of a probabilistic atlas mapping the preferential locations of diffuse WHO grade II gliomas in the brain. This is carried out through a sparse graph whose nodes correspond to clusters of tumors clustered together based on their spatial proximity. The interest of such an atlas is illustrated via two applications. The first one correlates tumor location with the patient's age via a statistical analysis, highlighting the interest of the atlas for studying the origins and behavior of the tumors. The second exploits the fact that the tumors have preferential locations for automatic segmentation. Through a coupled decomposed Markov Random Field model, the atlas guides the segmentation process, and characterizes which preferential location the tumor belongs to and consequently which behavior it could be associated to. Leave-one-out cross validation experiments on a large database highlight the robustness of the graph, and yield promising segmentation results.

Correlation of (18)F-fluoroethyl tyrosine positron-emission tomography uptake values and histomorphological findings by stereotactic serial biopsy in newly diagnosed brain tumors using a refined software tool

Background

Magnetic resonance imaging (MRI) is the standard neuroimaging method to diagnose neoplastic brain lesions, as well as to perform stereotactic biopsy surgical planning. MRI has the advantage of providing structural anatomical details with high sensitivity, though histological specificity is limited. Although combining MRI with other imaging modalities, such as positron-emission tomography (PET), has proven to increment specificity, exact correlation between PET threshold uptake ratios (URs) and histological diagnosis and grading has not yet been described.

Objectives

The aim of this study was to correlate exactly the histopathological criteria of the biopsy site to its PET uptake value with high spatial resolution (mm³), and to analyze the diagnostic value of PET using the amino acid O-(2-[¹⁸F]fluoroethyl)-l-tyrosine (¹⁸F-FET) PET in patients with newly diagnosed brain lesions in comparison to histological findings obtained from stereotactic serial biopsy.

Patients and methods

A total of 23 adult patients with newly diagnosed brain tumors on MRI were enrolled in this study. Subsequently to diagnoses, all patients underwent a ¹⁸F-FET PET-guided stereotactic biopsy, using an original newly developed software module, which is presented here. Conventional MRI, stereotactic computed tomography series, and ¹⁸F-FET PET images were semiautomatically fused, and hot-spot detection was performed for target planning. UR was determined using the uptake value from the biopsy sites in relation to the contralateral frontal white matter. UR values ≥1.6 were considered positive for glioma. High-grade glioma (HGG) was suspected with URs ≥3.0, while low-grade glioma (LGG) was suspected with URs between 1.6 and 3.0. Stereotactic serial biopsies along the trajectory at multiple sites were performed in millimeter steps, and the FET URs for each site were correlated exactly with a panel of 27 different histopathological markers. Comparisons between FET URs along the biopsy trajectories and the histological diagnoses were made with Pearson product-moment correlation coefficients. Analysis of variance was performed to test for significant differences in maximum UR between different tumor grades.

Results

A total of 363 biopsy specimens were taken from 23 patients by stereotactic serial biopsies. Histological examination revealed eight patients (35%) with an LGG: one with a World Health Organization (WHO)-I lesion and seven with a WHO-II lesion. Thirteen (57%) patients revealed an HGG (two with a WHO-III and three with a WHO-IV tumor), and two patients (9%) showed a process that was neither HGG nor LGG (group X or no-grade group). The correlation matrix between histological findings and the UR revealed five strong correlations. Low cell density in tissue samples was found to have a significant negative correlation with the measured cortical uptake rate (r=−0.43, P=0.02), as well as moderate cell density (r=−0.48, P=0.02). Pathological patterns of proliferation (r=0.37, P=0.04), GFAP (r=0.37, P=0.04), and Olig2 (r=0.36, P=0.05) showed a significant positive correlation with cortical URs. Analysis of variance tests showed a significant difference between the LGG and the HGG groups (F=8.27, P<0.002), but no significant differences when differentiating between the X group and the HGG (P=0.2)/LGG (P=0.8) groups, nor between the no-grade group and the WHO-I group.

Conclusion

¹⁸F-FET PET is a valuable tool, as it allows the differentiation of HGGs from LGGs. Its use is not limited to preoperative evaluation; it may also refine biopsy targeting and improve tumor delimitation for radiotherapy. Histology is still necessary, and remains the gold standard for definitive diagnosis of brain lesions.

Effect of 10 different polymorphisms on preoperative volumetric characteristics of glioblastoma multiforme

There is a distinct diversity between the appearance of every glioblastoma multiforme (GBM) on pretreatment magnetic resonance imaging (MRI) with a potential impact on clinical outcome and survival of the patients. The object of this study was to determine the impact of 10 different single nucleotide polymorphisms (SNPs) on various volumetric parameters in patients harboring a GBM. We prospectively analyzed 20 steroid-naïve adult patients who had been treated for newly diagnosed GBM. The volumetry was performed using MRI with the help of a semiautomated quantitative software measuring contrast enhancing tumor volume including necrosis, central necrosis alone and peritumoral edema (PTE). We calculated ratios between the tumor volume and edema (ETR), respectively necrosis (NTR). SNP analysis was done using genomic DNA extracted from peripheral blood genotyped via PCR and sequencing. There was a strong correlation between tumor volume and PTE (p < 0.001), necrosis (p < 0.001) and NTR (p = 0.003). Age and sex had no influence on volumetric data. The Aquaporin 4-31G > A SNP had a significant influence on the ETR (p = 0.042) by decreasing the measured edema compared with the tumor volume. The Interleukin 8-251A > T SNP was significantly correlated with an increased tumor (p = 0.048), PTE (p = 0.033) and necrosis volume (p = 0.028). We found two SNPs with a distinct impact on pretreatment tumor characteristics, presenting a potential explanation for the individual diversity of GBM appearance on MRI and influence on survival.

Guidelines, "minimal requirements" and standard of care in glioblastoma around the Mediterranean Area: A report from the AROME (Association of Radiotherapy and Oncology of the Mediterranean arEa) Neuro-Oncology working party

Glioblastoma is the most common and the most lethal primary brain tumor in adults. Although studies are ongoing, the epidemiology of glioblastoma in North Africa (i.e. Morocco, Algeria and Tunisia) remains imperfectly settled and needs to be specified for a better optimization of the neuro-oncology healthcare across the Mediterranean area and in North Africa countries. Over the last years significant therapeutic advances have been accomplished improving survival and quality of life of glioblastoma patients. Indeed, concurrent temozolomide-radiotherapy (temoradiation) and adjuvant temozolomide has been established as the standard of care associated with a survival benefit and a better outcome. Therefore, considering this validated strategy and regarding the means and some other North Africa countries specificities, we decided, under the auspices of AROME (association of radiotherapy and oncology of the Mediterranean area; www.aromecancer.org), a non-profit organization, to organize a dedicated meeting to discuss the standards and elaborate a consensus on the "minimal requirements" adapted to the local resources. Thus, panels of physicians involved in daily multidisciplinary brain tumors management in the two borders of the Mediterranean area have been invited to the AROME neuro-oncology working party. We report here the consensus, established for minimal human and material resources for glioblastoma diagnosis and treatment faced to the standard of care, which should be reached. If the minimal requirements are not reached, the patients should be referred to the closest specialized medical center where at least minimal requirements, or, ideally, the standard of care should be guaranteed to the patients.

Genetic characterization of skull base chondrosarcomas

OBJECT

Although chondrosarcomas rarely arise in the skull base, chondrosarcomas and chordomas are the 2 major malignant bone neoplasms occurring at this location. The distinction of these 2 tumors is important, but this distinction is occasionally problematic because of radiological and histological overlap. Unlike chordoma and extracranial chondrosarcoma, no case series presenting a whole-genome analysis of skull base chondrosarcomas (SBCSs) has been reported. The goal of this study is to clarify the genetic characteristics of SBCSs and contrast them with those of chordomas.

METHODS

The authors analyzed 7 SBCS specimens for chromosomal copy number alterations (CNAs) using comparative genomic hybridization (CGH). They also examined IDH1 and IDH2 mutations and brachyury expression.

RESULTS

In CGH analyses, the authors detected CNAs in 6 of the 7 cases, including chromosomal gains of 8q21.1, 19, 2q22-q32, 5qcen-q14, 8q21-q22, and 15qcen-q14. Mutation of IDH1 was found with a high frequency (5 of 7 cases, 71.4%), of which R132S was most frequently mutated. No IDH2 mutations were found, and immunohistochemical staining for brachyury was negative in all cases.

CONCLUSIONS

To the best of the authors' knowledge, this is the first whole-genome study of an SBSC case series. Their findings suggest that these tumors are molecularly consistent with a subset of conventional central chondrosarcomas and different from skull base chordomas.