Leptomeningeal metastasis from supratentorial malignant gliomas

Comparative Analysis of Subventricular Zone Glioblastoma Contact and Ventricular Entry During Resection in Predicting Dissemination, Hydrocephalus, and Survival

BACKGROUND

Ventricular entry during glioblastoma resection and tumor contact with the subventricular zone (SVZ) have both been shown to associate with development of hydrocephalus, leptomeningeal dissemination, distant parenchymal recurrence, and decreased survival. However, prior studies did not analyze these variables together in a single-patient population; therefore, it is unknown which is an independent predictor of these outcomes.

OBJECTIVE

To conduct a comparative outcome analysis of surgical ventricular entry and SVZ contact by glioblastoma in a retrospective cohort of 232 patients.

METHODS

Outcomes studied included hydrocephalus, leptomeningeal dissemination, distant tumor recurrences, and progression-free (PFS) and overall (OS) survival. The Cox proportional regression analyses were adjusted for age at diagnosis, preoperative Karnofsky performance status score, extent of resection, temozolomide and radiation treatments, and tumor molecular status (specifically, IDH1/2 mutation and MGMT promoter methylation).

RESULTS

Surgical ventricular entry, SVZ-contacting glioblastoma, hydrocephalus, leptomeningeal dissemination, and distant recurrences were observed in 85 (36.6%), 114 (49.1%), 19 (8.2%), 78 (33.6%), and 59 (25.4%) patients, respectively. Multivariate, adjusted analysis revealed SVZ tumor contact-but not ventricular entry-associated with hydrocephalus (hazard ratio, HR, 4.20 [1.13-15.7], P = .03), leptomeningeal dissemination (HR 1.93 [1.14-3.28], P = .01), PFS (HR 2.10 [1.53-2.88], P < .001), and OS (HR 1.90 [1.35-2.67], P < .001). Distant recurrences were not associated with either. No interaction between the 2 variables was statistically noted.

CONCLUSION

SVZ contact by glioblastoma was independently associated with the development of hydrocephalus, leptomeningeal dissemination, and decreased survival. SVZ tumor contact was associated with ventricular entry during surgical resections, which did not independently correlate with these outcomes.

Combining therapy with recombinant human endostatin and cytotoxic agents for recurrent disseminated glioblastoma: a retrospective study

BACKGROUND

The optimal chemotherapeutics of recurrent disseminated glioblastoma has yet to be determined. We analyzed the efficacy and safety of recombinant human endostatin (rh-ES) combined with temozolomide and irinotecan in patients with recurrent disseminated glioblastoma.

METHODS

We retrospectively reviewed 30 adult patients with recurrent disseminated glioblastoma treated with this combination chemotherapy at Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University of China from November 2009 to August 2018. Temozolomide was given orally at 200 mg/m² daily for 5 days and rh-ES was administrated 15 mg/d daily for 14 days of each 28-day treatment cycle. Irinotecan was given intravenously every 2 weeks on a 28-day cycle at 340 mg/m² or 125 mg/m² depending on antiepileptic drugs. Primary endpoint was progression-free survival (PFS) at 6 months (6 m-PFS).

RESULTS

The 6 m-PFS was 23.3%. The median PFS was 3.2 months. The overall survival rate (OS) at 12 months was 28.6%. The median OS was 6.9 months. Six out of 30 (20%) patients demonstrated partial radiographic response and 11 (36.7%) remained stable. The PFS of the 6 patients who got partial response was 5.8, 6.3, 6.9, 13.6, 15.8 and 16.6 months, respectively, and the median time interval of first response was 4 (range, 2.0-6.6) months. The most common adverse events were hematologic toxicities and gastrointestinal effects. The Grade ≥ 3 adverse event was hematologic toxicities. The adverse events were manageable.

CONCLUSIONS

Rh-ES, in combination with cytotoxic drugs, was an alternative effective regimen with manageable toxicities in treatment of recurrent disseminated glioblastoma.

Cancer Dissemination, Hydrocephalus, and Survival After Cerebral Ventricular Entry During High-Grade Glioma Surgery: A Meta-Analysis

BACKGROUND

The consequences of ventricular entry during resection of high-grade gliomas (HGG) are uncertain and often not detectable clinically.

OBJECTIVE

To reveal odds of tumor dissemination, hydrocephalus, and mortality in adult patients who had ventricular entry during surgical resection of HGG.

METHODS

Titles and abstracts of published journals in the NCBI/NLM PubMed and OVID EMBASE databases were searched without language restriction and systematically screened. Outcomes extracted included the odds of leptomeningeal dissemination and hydrocephalus in patients with ventricular entry during HGG resection compared to without. They were analyzed using a random-effects model to calculate summary odds ratios (sORs). Overall survival data were also compared between patients with and without ventricular entry.

RESULTS

Twenty final studies with 2251 total patients were included from the 6910 retrieved. Patients with ventricular entry during HGG resection demonstrated higher odds of leptomeningeal dissemination (sOR: 3.91 [95% confidence interval (CI): 1.89-8.10]; P = .0002; 86/410 vs 57/847 patients in 9 studies) and hydrocephalus (sOR: 7.78 [95% CI: 3.77-16.05]; P < .00001; 58/431 vs 11/565 patients in 11 studies). They also had decreased survival (median survival: 16.8 vs 19.1 mo; 413 vs 322 patients in 10 studies; hazard ratio: 1.25 [95% CI: 1.05-1.48], P = .01).

CONCLUSION

The association between ventricular entry during HGG resection and tumor dissemination, hydrocephalus, and decreased survival invites investigations to understand this link. Neurosurgeons and neuro-oncologists must be aware of the consequences of ventricular entry during surgery for HGG.

hsa-miR-9 controls the mobility behavior of glioblastoma cells via regulation of MAPK14 signaling elements

Background

Glioblastoma Multiforme (GBM) is the most common and lethal primary tumor of the brain. GBM is associated with one of the worst 5-year survival rates among all human cancers, despite much effort in different modes of treatment.

Results

Here, we demonstrate specific GBM cancer phenotypes that are governed by modifications to the MAPAKAP network. We then demonstrate a novel regulation mode by which a set of five key factors of the MAPKAP pathway are regulated by the same microRNA, hsa-miR-9.

We demonstrate that hsa-miR-9 overexpression leads to MAPKAP signaling inhibition, partially by interfering with the MAPK14/MAPKAP3 complex. Further, hsa-miR-9 overexpression initiates re-arrangement of actin filaments, which leads us to hypothesize a mechanism for the observed phenotypic shift.

Conclusion

The work presented here exposes novel microRNA features and situates hsa-miR-9 as a therapeutic target, which governs metastasis and thus determines prognosis in GBM through MAPKAP signaling.

Symptomatic Leptomeningeal and Intramedullary Metastases from Intracranial Glioblastoma Multiforme: A Case Report

Background

Glioblastoma multiforme infrequently metastasizes to the leptomeninges and even more rarely to the spinal cord. Moreover, very few patients with intracranial glioblastoma develop symptoms from spinal dissemination, with most patients not surviving long enough for spinal disease to become clinically evident.

Case Report

We present a rare case of symptomatic diffuse spinal leptomeningeal metastases simultaneously to an intramedullary lesion from an intracranial glioblastoma multiforme. After the diagnosis of spinal metastases the patient was treated with limited-field spinal radiotherapy (30 Gy in 3-Gy fractions).

Results

Radiotherapy on the main spinal lesions provided either relief from pain or mild improvement of neurological deficits. The patient died due to intracranial progression 4 months after diagnosis of spinal seeding and 17 months after diagnosis of the primary disease. We analyzed leptomeningeal and spinal metastases from glioblastoma multiforme with reference to the literature.

Conclusions

Radiotherapy for spinal disease may provide important symptom relief but the prognosis of these patients remains dramatically poor. As the local control of primary glioblastoma multiforme has improved with recent therapeutic advances, distant metastasis from high-grade gliomas is likely to become a more common clinical problem and such patients need to be included in clinical trials to evaluate new therapeutic approaches.

Cerebrospinal Fluid Dissemination and Neoplastic Meningitis in Primary Brain Tumors

BACKGROUND

Neoplastic meningitis, also known as leptomeningeal disease, affects the entire neuraxis. The clinical manifestations of the disease may affect the cranial nerves, cerebral hemispheres, or the spine. Because of the extent of disease involvement, treatment options and disease staging should involve all compartments of the cerebrospinal fluid (CSF) and subarachnoid space. Few studies of patients with primary brain tumors have specifically addressed treatment for the secondary complication of neoplastic meningitis. Therapy for neoplastic meningitis is palliative in nature and, rarely, may have a curative intent.

METHODS

A review of the medical literature pertinent to neoplastic meningitis in primary brain tumors was performed. The complication of neoplastic meningitis is described in detail for the various types of primary brain tumors.

RESULTS

Treatment of neoplastic meningitis is complicated because determining who should receive aggressive, central nervous system (CNS)-directed therapy is difficult. In general, the therapeutic response of neoplastic meningitis is a function of CSF cytology and, secondarily, of the clinical improvement in neurological manifestations related to the disease. CSF cytology may manifest a rostrocaudal disassociation; thus, consecutive, negative findings require that both lumbar and ventricular cytological testing are performed to confirm the complete response. Based on data from several prospective, randomized trials extrapolated to primary brain tumors, the median rate of survival for neoplastic meningitis is several months. Oftentimes, therapy directed at palliation may improve quality of life by protecting patients from experiencing continued neurological deterioration.

CONCLUSIONS

Neoplastic meningitis is a complicated disease in which response to therapy varies by histology. Thus, survival rates after CNS-directed therapy will differ by the underlying primary tumor. Optimal therapy of neoplastic meningitis is poorly defined, and few guidelines exist to guide clinicians on the most appropriate choice of therapy.

Significant antitumor response of disseminated glioblastoma to bevacizumab resulting in long-term clinical remission in a patient with encephalocraniocutaneous lipomatosis: A case report

The prognosis of recurrent and disseminated glioblastoma is very poor. Bevacizumab is an effective established therapy for recurrent glioblastoma following treatment with radiotherapy plus temozolomide. However, the efficacy of bevacizumab is limited to prolonging progression-free survival, without significant prolongation of the overall survival. We herein report a case of glioblastoma in a 32-year-old female patient with encephalocraniocutaneous lipomatosis (ECCL) that had disseminated following surgical resection and subsequent treatment with temozolomide and radiation therapy. The disseminated tumors disappeared completely after five courses of bevacizumab therapy. Surprisingly, the patient has remained in clinical remission for >2.5 years after dissemination by continuing this therapy. To the best of our knowledge, this is the first case of long-time clinical remission following glioblastoma dissemination and treatment with bevacizumab. In the present case, bevacizumab exerted an atypically strong antitumor effect against disseminated glioblastoma after multidisciplinary treatments had already been applied. Moreover, this is the first report of ECCL associated with a malignant brain tumor.

Is a modification of the radiotherapeutic target volume necessary after resection of glioblastomas with opening of the ventricles?

Extensive surgical resection of centrally localized, newly diagnosed glioblastoma can lead to opening ventricles and therefore carries a potential risk of spreading tumor cells into the cebrospinal fluid. However, whether ventricle opening consequently implies a greater frequency of distant tumor recurrence after radiation therapy-and, therefore, reduced survival-remains unknown. Therefore, is an adaption of target volumes in radiation therapy necessary to account for a potential tumor cell spread into the ventricle system? The present study assessed the resection statuses of 311 primary-glioblastoma patients who underwent radiation therapy. Overall, in 78 cases (25.1 %) the ventricle system was opened during surgical resection. This study assessed the connection between ventricle opening and progression-free survival, overall survival, and distant and multifocal recurrence. OS rates of patients that underwent gross total resection were superior to patients with subtotal resection (p = 0.002). PFS (p = 0.53) and OS (p = 0.18) did not differ due to ventricle opening during surgical resection. However, in a subsample of STR cases increased survival was observed when the ventricle system was opened (16.8 vs. 14.3 months; p = 0.03). The occurrence of distant (p = 0.75) and contralateral recurrence (p = 0.87) was not influenced by ventricle opening. Newly diagnosed glioblastoma patients whose ventricle systems were opened during microsurgical resection did not experience decreased survival or show increased likelihoods of distant and contralateral progressions following radiation therapy. In short, patients profit from surgical resections that are as extensive as reasonably possible, even if this entails ventricle opening. Thus, additional inclusion of the ventricles in the radiation therapy target volume after ventricle opening does not seem to be indicated.

Glioblastoma

Glioblastoma is the most common and aggressive primary brain tumor in adults. Defining histopathologic features are necrosis and endothelial proliferation, resulting in the assignment of grade IV, the highest grade in the World Health Organization (WHO) classification of brain tumors. The classic clinical term "secondary glioblastoma" refers to a minority of glioblastomas that evolve from previously diagnosed WHO grade II or grade III gliomas. Specific point mutations of the genes encoding isocitrate dehydrogenase (IDH) 1 or 2 appear to define molecularly these tumors that are associated with younger age and more favorable outcome; the vast majority of glioblastomas are IDH wild-type. Typical molecular changes in glioblastoma include mutations in genes regulating receptor tyrosine kinase (RTK)/rat sarcoma (RAS)/phosphoinositide 3-kinase (PI3K), p53, and retinoblastoma protein (RB) signaling. Standard treatment of glioblastoma includes surgery, radiotherapy, and alkylating chemotherapy. Promoter methylation of the gene encoding the DNA repair protein, O(6)-methylguanyl DNA methyltransferase (MGMT), predicts benefit from alkylating chemotherapy with temozolomide and guides choice of first-line treatment in elderly patients. Current developments focus on targeting the molecular characteristics that drive the malignant phenotype, including altered signal transduction and angiogenesis, and more recently, various approaches of immunotherapy.

Surgical Ventricular Entry is a Key Risk Factor for Leptomeningeal Metastasis of High Grade Gliomas

Leptomeningeal metastasis (LM) of high grade gliomas (HGG) can lead to devastating disease courses. Understanding of risk factors for LM is important to identify patients at risk. We reviewed patient records and magnetic resonance imaging (MRI) of all patients with a first diagnosis of HGG who underwent surgery in our institution between 2008 and 2012. To assess the influence of potential risk factors for LM and the impact of LM on survival multivariate statistics were performed. 239 patients with a diagnosis of HGG and at least 6 months of MRI and clinical follow-up were included. LM occurred in 27 (11%) patients and was symptomatic in 17 (65%). A strong correlation of surgical entry to the ventricle and LM was found (HR: 8.1). Ventricular entry was documented in 137 patients (57%) and LM ensued in 25 (18%) of these. Only two (2%) of 102 patients without ventricular entry developed LM. Median overall survival of patients after diagnosis of LM (239 days) was significantly shorter compared to patients without LM (626 days). LM is a frequent complication in the course of disease of HGG and is associated with poor survival. Surgical entry to the ventricle is a key risk factor for LM.

Efficacy of temozolomide and bevacizumab for the treatment of leptomeningeal dissemination of recurrent glioblastoma: A case report

The prognosis of leptomeningeal dissemination of recurrent glioblastoma is poor, and chemotherapy results in minimal palliative efficacy. Temozolomide (TMZ) is an established therapy for patients with malignant glioma and the standard of care in parenchymal gliomas; however, few reports have been published with regard to its use for the treatment of leptomeningeal dissemination. Only one report has indicated the radiographic response of leptomeningeal dissemination to a TMZ rechallenge, suggesting a potential causative effect. While bevacizumab is an effective therapy for recurrent glioblastoma, its effect on leptomeningeal dissemination of recurrent glioblastoma remains unclear. The present study reports a case of leptomeningeal dissemination of recurrent glioblastoma in which transient neurological and radiological improvement was observed following chemotherapy with TMZ and bevacizumab. However, five months after the diagnosis of leptomeningeal dissemination the patient succumbed to the disease.

Pediatric supratentorial high-grade glioma: multicenter retrospective observational study of the Korean Society for Pediatric Neuro-Oncology

We analyzed the prognostic factors of Korean pediatric patients with supratentorial high-grade glioma (HGG). Between 1997 and 2011, 62 patients with 34 glioblastomas and 28 anaplastic gliomas were surgically operated at nine institutions. The male-to-female ratio was 33 to 29 and the median age was 12 years (range 1-18). The prognostic significance of tumor location, extent of removal, pathologic grade, treatment method, and pattern of recurrence was analyzed. The median progression-free survival (PFS) and overall survival (OS) were 9.3 (± 0.8) and 17.8 (± 1.9) months, respectively. Glioblastoma and anaplastic glioma showed OSs of 15.9 (± 1.3) and 19.6 (± 2.4) months, respectively. Based on the univariate analysis, gross total removal (GTR) and initial combined chemoradiotherapy improved PFS (p = 0.012 and p = 0.003) and OS (p = 0.030 and p = 0.013), respectively. Cerebrospinal fluid (CSF) dissemination showed poor OS (p = 0.001). Based on the multivariate analysis, GTR and initial combined chemoradiotherapy resulted in an improved PFS [(hazard ratio 0.360; 95 % CI 0.177-0.733; p = 0.005) and (hazard ratio 0.458; 95 % CI 0.230-0.911; p = 0.026), respectively]. GTR, initial combined chemoradiotherapy, and no CSF seeding resulted in an improved OS [(hazard ratio 0.417; 95 % CI 0.201-0.861; p = 0.018), (hazard ratio 0.406; 95 % CI 0.206-0.800; p = 0.009), and (hazard ratio 0.288; 95 % CI 0.148-0.563; p = 0.000), respectively]. No significant difference in PFS and OS was observed between glioblastoma and anaplastic glioma. CSF dissemination was observed in 22 patients (35.5 %) during total follow-up. Pediatric anaplastic glioma showed poor survival, similarly to glioblastoma. GTR and initial combined chemoradiotherapy were associated with improved survival.

Meningeal seeding from glioblastoma multiforme treated with radiotherapy and temozolomide

Extracranial and meningeal seeding of glioblastoma multiforme is rare. We report herein a case of glioblastoma in a 41-year-old man who underwent surgical resection, concomitant chemoradiotherapy (CCRT) and seven courses of adjuvant chemotherapy with temozolomide. The patient then complained of intermittent severe lower back pain and gait disturbance. Imaging studies demonstrated that although the intracranial residual tumors were well-controlled by the treatment, meningeal seeding involving the brainstem and spinal cord was present. The patient died 2 months after the diagnosis of spinal seeding. This case illustrates the need for consideration of extracranial metastasis if a patient is symptomatic, even if the intracranial tumor appears responsive to treatment. We suggested that the prophylactic craniospinal irradiation may be considered in patients at high risk of meningeal seeding immediately after surgery.

Successful treatment of leptomeningeal gliomatosis of pilomyxoid astrocytoma after failed frontline chemotherapy

INTRODUCTION

Pilomyxoid astrocytoma (PMA) is a rare variant of pilocytic astrocytoma. Compared with pilocytic astrocytoma, PMA is more aggressive, has a higher rate of local recurrence, and often disseminates to the leptomeninges. Leptomeningeal gliomatosis is another rare but often intractable neoplasm. PMA presenting as leptomeningeal gliomatosis can be a therapeutic challenge, particularly in young children for whom many pediatric oncologists consider radiation therapy only as a back-up treatment. However, chemotherapy, usually considered a frontline treatment for low-grade tumors such as PMA, has little impact on leptomeningeal gliomatosis.

CASE REPORT

We report on a 5-year-old boy with an approximately 2-month history of progressively worsening loss of vision. Radiographic studies with contrast revealed an enhanced mass within the optic nerve, an enhanced lesion in the leptomeninges, and diffusely scattered nonenhanced white matter lesions in the craniospinal axis. The patient was treated with a 10-week carboplatin and vincristine regimen without a biopsy. After completing induction and 1 maintenance cycle, however, the patient developed coma caused by hydrocephalus. External ventricular drainage was performed and a biopsy was taken through ventriculoscopy, revealing PMA. The patient was then treated with craniospinal irradiation and concomitant temozolomide, a regimen to which he had a complete response. Two years after initial presentation the patient was free of disease.

CONCLUSIONS

This report documents a rare, intractable tumor and provides evidence that radiation therapy, given as craniospinal irradiation, can be effective for leptomeningeal gliomatosis.

Epithelial growth factor receptor tyrosine kinase inhibitor prevents infiltration and cerebrospinal fluid dissemination in malignant glioma: an experimental study

BAC1KGROUND: AG1478 is an epithelial growth factor receptor tyrosine kinase inhibitor. Epithelial growth factor receptor regulates the expression of cadherin in cells via its action on β-catenin, and N-cadherin downregulation promotes infiltration and cerebrospinal fluid (CSF) dissemination of glioma cells.

OBJECTIVE

To confirm whether AG1478 might have indirect effects on N-cadherin upregulation and whether, in addition to exhibiting an antitumor effect, AG1478 might also exert protective effects against infiltration and CSF dissemination.

METHODS

Green fluorescent protein (GFP) was introduced into C6 cells to obtain C6-GFP, and N-cadherin was introduced into C6-GFP to obtain C6-GFP-NCH. To confirm N-cadherin upregulation and the anti-infiltrative effect of AG1478 in vitro, we conducted Western blotting, aggregation assays, and Matrigel infiltration experiments. To confirm whether AG1478 exerted preventive effects against infiltration and CSF dissemination in vivo, in addition to exerting an antitumor effect, AG1478 was administered via various routes to rat C6-GFP inoculation models.

RESULTS

In vitro experiments demonstrated that AG1478 could indirectly upregulate N-cadherin in C6-GFP and reduced infiltration to the level of C6-GFP-NCH. In in vivo experiments, intrathecal administration of AG1478 inhibited CSF dissemination but did not prevent infiltration. Direct administration into the tumor mass demonstrated antitumor and anti-infiltration effects and inhibited CSF dissemination in each cistern, except at the convexity. Direct and intrathecal administration was the best treatment, resulting in significantly reduced numbers of disseminated cells in the CSF smear test.

CONCLUSION

AG1478 was highly effective both when administered intrathecally and when inoculated directly into the tumor mass.

Implication of 5-aminolevulinic acid fluorescence of the ventricular wall for postoperative communicating hydrocephalus associated with cerebrospinal fluid dissemination in patients with glioblastoma multiforme: a report of 7 cases

OBJECT

Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) has been broadly recognized as a beneficial tool for the resection of glioblastoma multiforme (GBM). Fluorescence in the ventricular walls, which were apparently free of macroscopic tumor or MR imaging enhancement indicative of CSF dissemination, was detected during surgery for GBM. To evaluate the clinical significance of the 5-ALA fluorescence, the authors resected ventricle wall tissue together with the adjacent tumors for pathological examination and then followed up the clinical courses of the patients.

METHODS

Seven consecutive GBMs located near the lateral ventricle were surgically treated using a fluorescence-guided technique with 5-ALA at the authors' hospital since acquiring instrumentation for the detection of 5-ALA fluorescence in 2007. All of the procedures were performed using a ventricular entry, and 5-ALA fluorescence of the ventricular wall was detected despite the absence of macroscopic tumor invasion of the wall.

RESULTS

A pathological examination of the resected ventricular wall tissues revealed tumor cells in 6 of the 7 cases and disruption of the ependymal cell layer in all 7 cases. Delayed communicating hydrocephalus followed surgery in all 7 patients, and ventricular wall enhancements on MR imaging were demonstrated after hydrocephalus in 2 of the patients.

CONCLUSIONS

Data in this study suggest that 5-ALA fluorescence of the ventricular wall may be predictive of postoperative hydrocephalus associated with CSF dissemination even in cases without evidence of CSF dissemination on MR imaging studies before surgery. The authors also speculate that postoperative radiotherapy covering the whole ventricular system may be a better therapeutic option for these patients.

Spinal metastasis of glioblastoma multiforme: an uncommon suspect?

STUDY DESIGN

Case report.

OBJECTIVE

To report a case and review the literature on glioblastoma multiforme (GBM) with drop-like metastasis to the spine.

SUMMARY OF BACKGROUND DATA

GBM constitutes the most common adult malignant brain tumor with poor prognosis. Spinal metastases of this malignancy are quite rare and dissemination usually occurs late in the course of the disease. However, recent advances in cancer treatment prolongate survival and provide adequate time for these metastases to give clinical symptoms.

METHODS

We hereby present a case of a 57-year-old woman with a history of pineal GBM treated by stereotactic biopsy, chemotherapy, and radiotherapy, readmitted 38 months later due to gait disturbance, spastic paraparesis, edema of lower limbs, bilateral positive Babinski response, and loss of bladder control. A contrast-enhanced magnetic resonance imaging demonstrated an intramedullary lesion extending from C7 to T3 level. A T1 and T2 laminectomy was undertaken followed by extensive biopsy.

RESULTS

Histologic examination was consistent with GBM. No further treatment was given, and the patient died 2 months after the diagnosis of the spinal metastasis.

CONCLUSION

Spinal metastases should be commonly suspected in patients with a history of intracranial GBM who complain about symptoms not explained by the primary lesion.Glioblastoma multiforme (GBM) was first described by Rudolph Virchow in 1863 and represents the most common and most malignant tumor of the cerebral hemispheres, usually arising between the ages of 40 and 60 years. The incidence in Europe and North America is 2 to 3 cases/100,000 per year, and 75% of the patients die within 18 months after diagnosis. It is an infiltrating malignancy that recurs locally and it may spread along compact fiber pathways such as corpus callosum, optic irradiation, anterior commisure, and fornix or via cerebrospinal fluid (CSF) pathways. However, when GBM is under apparent control, spinal metastases are clinically rarely detected. Although involvement of the spinal cord (SC) has been noted with increasing frequency in recent years, literature provides only a few well documented cases.

Association of stem cell marker CD133 expression with dissemination of glioblastomas

Dissemination of glioblastoma was once considered rare but is now increasingly encountered with longer survival of glioblastoma patients. Despite the potential negative impact of dissemination on clinical outcome, however, molecular markers useful for prediction of dissemination risk still remains ill defined. We tested in this study for an association between the expression of stem cell marker CD133 and the risk of dissemination in 26 cases of glioblastoma (16 with dissemination and 10 without dissemination). The protein expression of CD133 was examined by western blot analysis of tumor specimens, and the CD133 expression levels were quantified by densitometry and normalized to beta-actin. The results indicated that CD133 expression levels are significantly higher in glioblastomas with dissemination (mean 10.3, range 0.20-27.8) than in those without (mean 1.18, range 0.07-3.58). The results suggest that CD133 could be a molecular predictor of glioblastoma dissemination, and also give rise to an intriguing idea that CD133-positive cancer stem cells may be implicated in the initiation of disseminated lesions.

High-grade primary diffuse leptomeningeal gliomatosis in a child with neurofibromatosis Type 1

The authors report on a child with known neurofibromatosis Type 1 who developed high-grade diffuse leptomeningeal gliomatosis, without a known primary glioma. To the authors' knowledge, this is the first report of the coexistence of these conditions in a child.

Pattern of recurrence in paediatric malignant glioma: an institutional experience

BACKGROUND

The purpose of this retrospective study was to investigate the pattern of recurrence in paediatric malignant gliomas.

MATERIAL AND METHODS

We reviewed the notes, diagnostic imaging and treatment charts of 30 consecutive paediatric patients (age less than 18 years at diagnosis, range 0.5-17 years) presenting with a malignant glioma presenting to the paediatric oncology unit at the Royal Marsden Hospital over a 10-year period. The imaging at the time of first relapse was compared with the initial diagnostic scans to define a relapse as local, marginal or distant.

RESULTS

Median follow-up was 13 months (range 1-99 months). Twenty-four of 30 patients (80%) showed evidence of progression with a median time to progression of 8.5 months (range 3-64 months). Thirteen out of 24 patients developed local or marginal recurrences while 11/24 patients recurred at distant sites as site of first relapse (46%).

CONCLUSION

Our series suggests that the pattern of relapses in paediatric malignant gliomas could be different from that reported in adult studies as we observed a significant incidence of distant relapses. Larger prospective series need to be conducted to investigate the clinico-biological characteristics of the population at high risk for leptomeningeal dissemination.

Treatment for posterior fossa dissemination of primary supratentorial glioma

OBJECT

This study was designed to assess the presentation, management, and outcome of cases involving patients who had a supratentorial glioma that subsequently progressed in the posterior fossa (PF).

METHODS

The authors performed a retrospective chart review of adult patients treated between 1997 and 2005 for supratentorial gliomas that progressed in the PF. The 29 patients with PF progression in this study were relatively young (median age of 34 years at original presentation). Twenty of these patients presented with symptoms. The symptoms were typically nonspecific to this population, at times leading to delays in diagnosis. Overall, these symptoms resolved in eight patients (40%) and progressed or remained unchanged in 12 (60%). Patients treated with more than 5000 cGy of radiation administered to the PF were more likely to have symptom resolution than those who received any other form of treatment, including reduced doses of radiation (p = 0.004). The patients treated with higher doses also survived significantly longer after PF progression (univariate analysis, p = 0.01, and after adjusting for tumor grade, p = 0.04).

CONCLUSIONS

Patients with PF progression of supratentorial infiltrative gliomas may benefit from treatment, and the authors recommend more than 5000 cGy of radiation to the PF if prior radiotherapy ports and doses allow.

Secondary dissemination in children with high-grade malignant gliomas and diffuse intrinsic pontine gliomas

In children, treatment regimen for high-grade gliomas (HGG) and diffuse intrinsic pontine gliomas (DIPG) are generally not stratified according to disease stage. The hypothesis was that secondary disseminating disease (SDD) in children with HGG is related to an even worse outcome. Description of SDD pattern was performed. In total, 270 children with newly diagnosed HGG or DIPG were eligible for retrospective analysis of SDD. Medical and computer records of these patients were reviewed for demographic characteristics, sites of dissemination, prognostic variables. Forty-six (17%) of the 270 patients had developed SDD. The median time to SDD was 8.2 months. The median overall survival (OS) after dissemination was 3.2 months. The SDD was located parenchymal in the supratentorial (34.8%), infratentorial (6.5%), supratentorial and infratentorial (19.6%), spinal (10.9%), spinal and cerebral (6.5%) regions of the CNS, or leptomeningeal (21.7%). For HGG patients, the median OS was shorter among patients with SDD than among patients without SDD (1.02 vs 1.41 years, P=0.0495). In the group of patients with SDD, patients with cerebrospinal fluid dissemination had a worse outcome compared with patients with parenchymal metastases. Summarising, SDD is a negative prognostic factor for patients with HGG outside the pons. Treatment stratification should be considered.

Spinal and extracranial metastatic dissemination of malignant glioma

Metastatic dissemination of malignant glioma is rare. Metastatic disease usually occurs within the neuraxis but extracranial spread to the liver, spleen, lung, peritoneum and lymph nodes can also occur. In most cases of metastatic disease, the patient has previously undergone a craniotomy. The prognosis is uniformly poor. The vast majority of patients do not survive beyond six months from diagnosis of metastatic spread of a primary intracranial tumour. The pathophysiology and natural history of this condition is still not fully understood, hence well-designed prospective studies are needed.

Primary dissemination of high-grade gliomas in children: experiences from four studies of the Pediatric Oncology and Hematology Society of the German Language Group (GPOH)

PURPOSE

Clinical data on central nervous system (CNS) dissemination of high-grade gliomas (HGG) at initial presentation in children are rare.

PATIENTS AND METHODS

We conducted a retrospective data analysis of all patients enrolled into four consecutive HGG protocols of the Pediatric Oncology and Hematology Society of the German Language Group (GPOH) to determine the incidence of primary CNS dissemination of HGG and to describe clinical characteristics and outcome of children with HGG who were diagnosed with CNS dissemination at initial presentation. 546 patients with newly diagnosed HGG (n=348) or diffuse intrinsic pontine gliomas (n=198) were enrolled in these four studies. Data concerning tumor dissemination are available from 324 patients.

RESULTS

A total of 10 patients (3.1%) (anaplastic astrocytoma: n=3, glioblastoma multiforme: n=6, diffuse intrinsic pontine glioma: n=1) had primary tumor dissemination. Median age at diagnosis was 9.3 years (range: 0.3-21.3 years). The most frequent primary tumor sites were the cortex (n=4), followed by the ventricles (n=2), cerebellum (n=1), spinal cord (n=1), and pons (n=1). One patient had diffuse gliomatosis cerebri. Following surgery eight patients received local radiotherapy and eight additional chemotherapy. At a median follow-up of 10 months (range: 0.05-3 years) four patients are alive. None is disease-free. Median progression-free and overall survival was 0.8 years (95% CI 0.2-1.4) and 1.5 years (95% CI 0.67-2.29) for patients with primary tumor dissemination, respectively, with no statistically significant differences between the group with and the group without primary tumor dissemination.

CONCLUSIONS

Initial diagnostic evaluation should include complete CNS imaging as well as cerebrospinal fluid examination in all patients with HGG. As prognosis of children with HGG and primary CNS dissemination was not inferior to patients without dissemination in our population, these patients should be treated in the same way as patients without primary CNS dissemination.

Leptomeningeal metastasis of primary central nervous system (CNS) neoplasms

Leptomeningeal dissemination of primary CNS tumors varies widely by histologic subtype. In certain tumors including medulloblastoma, ependymoma, germ cell tumors, and primary CNS lymphoma, seeding of the cerebrospinal fluid space is a critical factor in determining stage, prognosis and appropriate therapy. Other tumor types, such as glioma, may have radiographic evidence of leptomeningeal metastases without clear impact on prognosis or therapy.

PTEN gene mutation and high MIB-1 labeling index may contribute to dissemination in patients with glioblastoma

Dissemination of glioblastomas is often observed, but the underlying mechanism is not well clarified especially from the genetic viewpoints. The present study examined whether PTEN gene mutations and MIB-1 labeling index (LI) correlate with the dissemination in 39 consecutive patients with glioblastomas. Dissemination was defined as leptomenigeal enhancement by magnetic resonance imaging performed in all patients every 2-3 months. We examined PTEN mutations in 26 patients using cDNA-based direct sequencing and MIB-1 LI in 38 patients. Median survival time of the 39 patients was 16.2 months. Dissemination was found in 17 of 39 patients (43.6%). PTEN mutation was significantly associated with dissemination (P=0.0140), and higher MIB-1 LI (> or =35%) resulted in earlier dissemination (P=0.0156). Kaplan-Meier survival plots showed a significantly poorer survival for patients with PTEN mutation (P=0.0012). The results indicate that the evaluation of PTEN mutation and MIB-1 LI are useful to predict dissemination and prognosis of glioblastomas.

Leptomeningeal dissemination of cerebellar malignant astrocytomas

Primary malignant astrocytomas of the cerebellum are extremely rare, and the dissemination patterns and effectiveness of postoperative radiation therapy are unclear. Five consecutive cases of histologically proven cerebellar malignant astrocytoma, two anaplastic astrocytomas, one anaplastic pilocytic astrocytoma, and two glioblastomas, were treated between 1997 and 2001. Four patients underwent surgical removal, local irradiation, and chemotherapy, and one patient with anaplastic pilocytic astrocytoma received subtotal removal followed by gamma knife radiosurgery for the residual tumor. Two patients had no recurrence at the primary site. All patients developed leptomeningeal dissemination. Four patients had supratentorial dissemination and two patients had spinal metastases. The time interval between the diagnosis of the primary cerebellar tumor and the diagnosis of leptomeningeal dissemination was 5-29 months (mean 14.6 +/- 10.4 months). All patients died at 10-38 months (mean survival 22.2 +/- 13.6 months). Intensive treatment including chemotherapy and radiotherapy may be required in cerebellar malignant astrocytomas, considering the high incidence of symptomatic leptomeningeal dissemination.

Cost of migration: invasion of malignant gliomas and implications for treatment

Tumors of glial origin consist of a core mass and a penumbra of invasive, single cells, decreasing in numbers towards the periphery and still detectable several centimeters away from the core lesion. Several decades ago, the diffuse nature of malignant gliomas was recognized by neurosurgeons when super-radical resections using hemispherectomies failed to eradicate these tumors. Local invasiveness eventually leads to regrowth of a recurrent tumor predominantly adjacent to the resection cavity, which is not significantly altered by radiation or chemotherapy. This raises the question of whether invasive glioma cells activate cellular programs that render these cells resistant to conventional treatments. Clinical and experimental data demonstrate that glioma invasion is determined by several independent mechanisms that facilitate the spread of these tumors along different anatomic and molecular structures. A common denominator of this cellular behavior may be cell motility. Gene-expression profiling showed upregulation of genes related to motility, and functional studies demonstrated that cell motility contributes to the invasive phenotype of malignant gliomas. There is accumulating evidence that invasive glioma cells show a decreased proliferation rate and a relative resistance to apoptosis, which may contribute to chemotherapy and radiation resistance. Interestingly, interference with cell motility by different strategies results in increased susceptibility to apoptosis, indicating that this dynamic relationship can potentially be exploited as an anti-invasive treatment paradigm. In this review, we discuss mechanisms of glioma invasion, characteristics of the invasive cell, and consequences of this cellular phenotype for surgical resection, oncologic treatments, and future perspectives for anti-invasive strategies.

Combined-modality treatment of leptomeningeal gliomatosis

OBJECTIVE

Leptomeningeal gliomatosis (LG) is a clinically uncommon metastatic complication of high-grade gliomas (HGGs), for which there is no consensus regarding treatment. The goal of this study was to determine the toxicity and response rate of combined-modality therapy for the treatment of patients with HGGs and LG.

METHODS

Eighteen patients (10 men and 8 women), ranging in age from 28 to 70 years (median, 38 yr), with clinically, neuroradiologically, and cytologically documented LG received intraventricular chemotherapy. Tumor histological types included anaplastic astrocytoma (10 patients) and glioblastoma multiforme (8 patients). Concurrent radiotherapy (11 patients) or systemic chemotherapy (13 patients) was administered as clinically indicated. Methotrexate was administered initially, and treatment was continued for patients in stable or improved condition. For patients who experienced progression, cytosine arabinoside was administered as second-line therapy, followed by N,N',N"-triethylenethiophosphoramide as third-line therapy. Patients underwent bimonthly evaluations with cerebrospinal fluid cytological assessments and neurological examinations.

RESULTS

Four to 13 cycles (median, 5 cycles) of intraventricular chemotherapy were administered. Toxicity included aseptic meningitis (12 patients), radiation-induced enteritis (2 patients), and myelosuppression of Grade II or less (4 patients). No patient required hospitalization or transfusions, and no treatment-related deaths occurred. Partial responses were observed for 6 patients, and 12 patients demonstrated progressive disease. The median duration of response was 3 months (range, 2-4 mo). Survival times after the initiation of intraventricular chemotherapy ranged from 2 to 8 months (median, 3.5 mo). The cause of death was progressive LG (14 patients), combined LG and HGG (3 patients), and HGG (1 patient).

CONCLUSION

For this small cohort of patients, combined-modality therapy had modest toxicity but minimal palliative efficacy. For the majority of patients with LG, supportive care should be considered.

Symptomatic spinal dissemination of malignant astrocytoma

OBJECT

Symptomatic spinal dissemination of malignant astrocytoma is rarely found except at autopsy. This study evaluated the clinical incidence and characteristics of spinal dissemination and the effect on outcome.

PATIENTS AND METHODS

Patients treated for primary malignant astrocytoma, including 33 with anaplastic astrocytoma and 35 with glioblastoma, at our department between 1997 and 1999 were followed up until April 30, 2001. Head magnetic resonance (MR) imaging of all patients was obtained every 2-3 months. Signs and symptoms of leptomeningeal spread were checked at monthly outpatient examinations. Spinal MR imaging was performed if any symptoms indicating spinal dissemination were found.

RESULTS

Median survival times of patients with anaplastic astrocytoma and glioblastoma were 40.5 and 16.0 months, respectively. Seventeen patients (25%) developed intracranial dissemination and 15 of these died. Six patients (8.8%), one with anaplastic astrocytoma and five with glioblastoma, developed spinal dissemination. All patients with spinal dissemination also had intracranial dissemination. Five of the six patients died, despite systemic radiochemotherapy in four patients. All patients died of extensive whole brain and spinal dissemination or nodular mass enlargement at the upper cervical cord, not of local massive tumor progression.

CONCLUSIONS

Symptomatic spinal dissemination of malignant astrocytoma is not so rare, and is the cause of death. The relatively high incidence of symptomatic leptomeningeal dissemination must be considered in the treatment of malignant astrocytomas.

Glioma invasion--pattern of dissemination by mechanisms of invasion and surgical intervention, pattern of gene expression and its regulatory control by tumorsuppressor p53 and proto-oncogene ETS-1

The capacity of glioma cells to invade normal brain leads to far reaching dissemination of these tumors limiting surgical resection and the prospect of local treatment strategies. The analysis of the dissemination pattern, the molecular substrates and mechanisms involved suggest that glioma invasion most likely represents independent cellular behaviors leading to distinct pattern of spread. The search for common denominators of the invasive phenotype has demonstrated that invasive cells show gene expression profiles indicating elevated expression of motility associated genes and genes involved in resistance to apoptosis whereas proliferation and apoptosis related gene expression is repressed. Confirming these findings, invasive cells in vitro show elevated motility and resistance to drug induced apoptosis. Obviously invasiveness is an early event in the progression of glial tumors. Therefore, the loss of control over invasion genes must involve key elements of molecular tumor progression. We have recently demonstrated that deregulation of invasion gene expression occurs as a consequence of functional impairment of tumor suppressor p53 leading to unrestrained activation of proto-oncogene Ets-1 dependent invasion-associated genes. In this article the prospect of limiting the dissemination of glial tumors by anti-invasive strategies and targets for modulation of the invasive phenotype to reconstitute chemo- and radiation sensitivity are discussed.

Standard and novel radiotherapeutic approaches to neoplastic meningitis

Neoplastic meningitis usually occurs late in the natural history of cancer. Adequate staging and assessment of the patient's overall reserves and prognosis are crucial in determining whether aggressive treatment is justified. Although radiotherapy remains the single most effective treatment, it is considered palliative for epithelial cancers and is generally directed to sites of bulky disease that obstruct the flow of cerebrospinal fluid or cause neurologic dysfunction. Such diseases as leukemia, medulloblastoma, and germinoma are exceptions that can be treated definitively with craniospinal irradiation. Innovations in conformal therapy may help to reduce the significant amount of myelosuppression associated with spinal irradiation. The main long-term toxicity associated with whole-brain irradiation (WBI) is dementia resulting from leukoencephalopathy, which may be exacerbated when WBI is given in combination with chemotherapy. A case report highlighting the use of radiotherapy for palliation in a patient with neoplastic meningitis is presented at the end of this article.

Spinal leptomeningeal metastases following glioblastoma multiforme treated with radiotherapy

A case of glioblastoma with leptomeningeal spread after control of the primary lesion by radiation therapy. A discussion is made regarding leptomeningeal metastatic disease with reference to the literature.

Leptomeningeal dissemination of pilocytic astrocytoma via hematoma in a child

A case of recurrent pilocytic astrocytoma with leptomeningeal dissemination (LMD) is described. A cerebellar tumor was diagnosed in a 3-year-old boy, in whom resection was performed. When the boy was 6 years of age, recurrence was treated with surgery and local radiotherapy. At age 13 years, scoliosis was present, but the patient was asymptomatic. Twelve years after initial surgery LMD was demonstrated in the lumbar spinal region without recurrence of the original tumor. This tumor also was subtotally removed. During the procedure, a hematoma was observed adjacent to the tumor, but the border was clear. Histological examination of the spinal cord tumor showed features similar to those of the original tumor. There were no tumor cells in the hematoma. The MIB-1 labeling index indicated no malignant change compared with the previous samples. Radiotherapy was performed after the surgery. The importance of early diagnosis and management of scoliosis is emphasized, and the peculiar pattern of dissemination of the pilo-cytic astrocytoma and its treatment are reviewed.

Radiation-induced glioma presenting as diffuse leptomeningeal gliomatosis: a case report

BACKGROUND

Leptomeningeal gliomatosis is a rare and fatal disease.

METHODS

Case report.

RESULTS

We report the case of a man who was presented with severe intractable headaches, lymphocytic CSF pleocytosis, and spinal leptomeningeal enhancement on contrast MRI. Meningeal biopsy demonstrated diffuse infiltration by malignant glial cells, and symptom alleviation was achieved by CSF diversion. He later developed an enhancing thalamic tumor arising within the treatment field of a remotely irradiated pituitary adenoma. Subsequent management included chemotherapy and further radiotherapy with transient response, before death from leptomeningeal and parenchymal tumor progression 16 months after diagnosis.

CONCLUSION

We report a unique case embodying two rare conditions: radiation induced glioma and leptomeningeal gliomatosis. Our patient's course is novel in that symptomatic relief was achieved with CSF diversion and a combination of chemotherapy and focal radiation allowed prolonged survival.

Contrast-enhanced fluid-attenuated inversion recovery MRI is useful to detect the CSF dissemination of glioblastoma

We present three cases of glioblastoma with CSF dissemination that contrast-enhanced fluid-attenuated inversion recovery MRI was sensitive enough to detect compared with contrast-enhanced T1-weighted MRI. An autopsy was performed on one patient, and its histologic findings proved the existence of CSF dissemination.

Extraneural metastases of primary brain tumors

Extraneural metastasis (ENM) of primary brain tumors is arare occurence. Based on acritical analysis of the literature the present review focuses on illustrating special common features of these tumors with regard to immunological, cytokinetical and tumorbiological issues. In this respect much can be learned from the specific conditions following organ transplantation which is extensively discussed.

Neoplastic meningitis: a guide to diagnosis and treatment

Neoplastic meningitis is a disease of the entire neuraxis and is pleomorphic in its clinical presentation. Diagnosis is achieved by recognition of the clinical manifestations of neoplastic meningitis followed by neuroradiography of the brain and spinal cord and examination of the cerebrospinal fluid. Treatment, if clinically warranted, includes irradiation of symptomatic or bulky disease and intracerebrospinal fluid chemotherapy following an assessment of the extent of metastatic disease treatment is based on the results of four randomized intracerebrospinal fluid chemotherapy trials.

[Multiple gliomas. Illustrative cases of 4 different presentations]

Multiple gliomas are uncommon and may be classified according to: a) the time of presentation in early (at diagnosis) or late (during treatment); b) the characteristics of computed tomography or magnetic resonance imaging (CT/MRI) in multifocal (with evidence of spread) and multicentric (without evidence of spread). From 212 patients with histopathologic diagnosis of glioma evaluated from March/90 to September/99, 15 (7%) had multiple lesions. We describe 4 patients: early multicentric, late multicentric, early multifocal and late multifocal, with emphasis on characteristics of CT/MRI and possible differential diagnosis. The differential diagnosis of multiple lesions in the central nervous system includes mainly infectious/inflammatory diseases and metastasis, however multiple gliomas should always be considered, even in patients with known systemic cancer, as described by others. Considering that CT/MRI features are not definite, the diagnosis should always be confirmed by histopathologic examination.

Survival of patients with high grade glioma treated with intrathecal thiotriethylenephosphoramide for ependymal or leptomeningeal gliomatosis

BACKGROUND

The diagnosis of leptomeningeal dissemination of malignant glioma (meningeal gliomatosis) is associated with poor survival. Intrathecal (IT) chemotherapeutic agents used to achieve tumor control and improve survival include methotrexate, cytosine arabinoside (ara-C), thiotriethylenephosphoramide (thio-TEPA), neocarzinostatin, and 3-[(4-amino-2-methyl-5-pyrimidinyl)methyl]-1-(2-chloroethyl)-1-nitros ourea hydrochloride (ACNU). Little information exists about survival following administration of IT chemotherapy. The authors report survival data from a series of patients with supratentorial anaplastic astrocytoma (AA) or glioblastoma multiforme (GBM) treated for ependymal or leptomeningeal gliomatosis with IT thio-TEPA.

METHODS

The authors reviewed the records of 14 patients treated between 1991 and 1997 (GBM: n = 9; AA: n = 5). All patients were diagnosed with ependymal (n = 8) or leptomeningeal (n = 6) dissemination of tumor on the basis of clinical signs and symptoms, ependymal or leptomeningeal contrast enhancement on magnetic resonance imaging (MRI), and/or cerebrospinal fluid analysis. All 14 patients underwent placement of a ventricular reservoir system and subsequent instillation of IT thio-TEPA on a weekly basis for 6-12 weeks. Response to treatment was evaluated clinically and by MRI at intervals of 1-3 months and 3-6 months from the initiation of IT thio-TEPA. Data on survival from the time of diagnosis of dissemination was assessed.

RESULTS

The median survival, from the time of diagnosis of ependymal or leptomeningeal dissemination, of patients who received IT thio-TEPA was 10 months (AA = 19 months; GBM = 10 months). Five of 14 patients had a radiographic response to treatment within 6 months. The median survival of patients with a radiographic response was 15.5 months, compared with 10 months for nonresponders. No significant neurotoxicity or myelopathy was observed.

CONCLUSIONS

Early treatment with IT thio-TEPA may result in improved survival with minimal morbidity. Radiographic response may predict prolonged survival.

Treatment of meningeal gliomatosis

To evaluate whether vigorous treatment is beneficial for patients with meningeal gliomatosis (MG) we reviewed the case records of 20 consecutive patients treated for a symptomatic MG in our center. All received systemic or intrathecal chemotherapy and six received additional cranial or spinal radiotherapy. Six patients (30%) achieved a partial response (one low-grade astrocytoma, two anaplastic astrocytomas, one anaplastic oligodendroglioma and two glioblastomas). In these cases, clinical improvement was associated with radiological improvement on CT scan or MRI in five and with a major cerebrospinal fluid improvement in three. Three patients (15%) were stable for 3 months or more and 11 (55%) had progressive disease. Median survival was longer for the responding patients (10 months) than for the other patients (2 months). This study suggests that some patients with MG may benefit from a treatment combining radiotherapy to symptomatic areas and chemotherapy with agents that cross the blood-brain barrier or are delivered directly into the CSF.

Isolated oculomotor nerve palsy: an unusual presentation of glioblastoma multiforme. Case report and review of the literature

The authors present a case of a very unusual clinical presentation of an intra-axial supratentorial glioblastoma multiforme (GBM) in a 63 year old diabetic female patient presenting with a three week history of left progressive complete oculomotor nerve palsy. CT scan and magnetic resonance imaging of the head revealed a left intra-axial mesial temporal glioblastoma multiforme. Operative resection and microscopic examination of a tissue specimen confirmed the diagnosis. The nature of the tumor, the pattern of spread and the postulated mechanisms of such a presentation are discussed. The authors suggest including the diagnosis of GBM in the differential diagnosis of patients with isolated complete oculomotor nerve palsy at the appropriate age group.

Diffuse leptomeningeal gliomatosis associated with multifocal CNS infarcts

BACKGROUND

Widespread dissemination of astrocytoma throughout the cerebrospinal fluid is unusual, especially as the initial presentation in a patient, and association with cerebral infarcts is rare. CASE DESCRIPTION A 47-year-old man subacutely developed progressive headache and backache, vomiting, altered consciousness, and numbness in both arms. Brain computerized axial tomography showed calcification in the fourth ventricle and magnetic resonance imaging demonstrated diffuse meningeal enhancement, a lesion in the canal of Magendie, and T2-weighted hyperintense lesions in several locations. Angiography showed vasospasm/vasculopathy involving multiple cerebral vessels. Biopsy of the fourth ventricular mass revealed a subependymoma with an overlying leptomeningeal anaplastic astrocytoma with numerous Rosenthal fibers. The patient was treated with three doses of intrathecal methotrexate via lumbar puncture but suddenly became unresponsive and died 6 days later, 8 weeks after initial symptoms. Autopsy demonstrated the subependymoma and a widespread leptomeningeal anaplastic astrocytoma, which showed no clear-cut origin from the subependymoma, but microscopically infiltrated the left medial temporal lobe. Multiple subacute and acute infarcts of the brain, brain stem, and upper spinal cord were seen only in areas with leptomeningeal tumor. CONCLUSION Glioma cells surrounding and focally permeating central nervous system vessels without lumenal occlusion can lead to vasospasm and widespread infarcts.

Imaging techniques in neoplastic meningiosis

Since the introduction of CT and MRI as diagnostic aids, it has been possible to obtain direct images of neoplastic meningiosis. After more than ten years experience, the combination of MRI with the administration of a paramagnetic contrast medium is now accepted as the method of choice for the sensitive detection of meningeal diseases and for monitoring their treatment. The almost uniform character of leptomeningeal or pachymeningeal enhancement in the presence of infective, inflammatory, neoplastic, vascular or reactive changes is the reason for the restricted specificity of MRI, so that with the imaging process alone only very limited information about the etiology is available. Clinical data, laboratory findings, examination of the CSF and histopathological examination are therefore essential for interpreting the meningeal changes and making a differential diagnosis. Various pathophysiological processes can lead to a single meningeal enhancement visualizable with MRI: 1. a genuine disturbance of the blood-brain barrier is found in the presence of infection or inflammation, 2. leptomeningeal structures can be directly infiltrated by sheets or nodules of tumors, the blood vessels of which possess no intact blood-brain barrier, 3. physical or chemical irritants may produce of local inflammatory reaction with vascular proliferation and its corresponding enhancement, a 4. a pseudoenhancement may follow reactive dilatation of the vessels. In the present article the various appearances of neoplastic invasion of the meninges in MRI and their differential diagnosis will be described.

Leptomeningeal metastases: a review of evaluation and treatment

Leptomeningeal metastases (LM) is a common problem in neuro-oncology occurring in approximately 5% of all patients with cancer. Notwithstanding frequent focal signs and symptoms in LM, LM is a disease affecting the entire neuraxis and therefore staging and treatment need encompass all cerebrospinal fluid (CSF) compartments. Central nervous system (CNS) staging of LM includes contrast enhanced cranial computerized tomography (CE-CT) or magnetic resonance imaging (MR-Gd), contrast enhanced spine magnetic resonance imaging (MR-S) or computerized tomographic myelography (CT-M) and radionuclide CSF flow study (FS). Treatment of LM involves involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy may benefit patients with LM and may obviate the need for intra-CSF chemotherapy. At present, intra CSF drug therapy is confined to three chemotherapeutic agents (i.e. methotrexate, cytosine arabinoside and thio-TEPA) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Although treatment of LM is palliative with an expected median patient survival of 6 months, it often affords stabilization and protection from further neurologic deterioration in patients with LM.

Expression and role of cadherins in astrocytic tumors

Cadherins are Ca(2+)-dependent cell adhesion molecules that play an important role in tissue formation and morphogenesis in multicellular organisms. In recent years, there have been reports of cadherin involvement in tumor invasion and metastasis. Twenty-two surgical specimens and some cultured cells were studied by immunohistochemical staining. No significant difference was observed in the patients with anaplastic astrocytoma, whereas decreased expression of N-cadherin was detected at the time of recurrence in those with glioblastoma. In these groups, cerebrospinal fluid dissemination was found, and contralateral cerebral metastases and extracranial metastases were observed. We conclude that decreased N-cadherin expression at the immunohistochemically demonstrated time of recurrence correlates with tumor invasion and dissemination of cerebrospinal fluid.

Adeno-associated viral vector gene transfer into leptomeningeal xenografts

Leptomeningeal carcinomatosis is a painful and debilitating complication of cancer. Indwelling reservoirs provide continuous assess to the subarachnoid space, making leptomeningeal cancer potentially amenable to gene therapy. Adeno-associated virus (AAV) is a defective virus not associated with any human disease. We used an AAV vector to transduce medulloblastoma (DAOY) cells in a nude rat model of leptomeningeal disease. After intraventricular injection of vector carrying the bacterial lacZ gene, beta-galactosidase positive cells were found in the implanted tumor and in ependymal and subependymal cells but not in underlying normal brain parenchyma. No evidence of virally-mediated toxicity was noted in the animals. The results of this pilot study demonstrate that AAV vectors may be used to transfer and express foreign genes in established leptomeningeal tumors.