Transtentorial dissemination of optic nerve glioblastoma: case report

Primary glioblastoma multiform (GBM) of the optic nerve and chiasma: A case report and systematic review of the literature

Key Clinical Message

Primary GBM of the optic nerve and chiasma should be included in the differential diagnosis of progressive lesions despite initial treatment; clinicians should avoid delay in confirming the histology to initiate proper treatment and improve prognosis.

Abstract

Primary GBM of the optic nerve or chiasma is very rare. The characteristics of this condition have not been well-described, which poses difficulties in establishing the correct diagnosis, affecting the treatment and the prognosis. We present a case of GBM of the optic chiasma diagnosed through an open biopsy at our centre. Following the PRISMA statement, we also conducted a systematic review after protocol registration in PROSPERO (CRD42021285855). We searched Medline and Embase through Ovid from inception until December 31, 2021. Two reviewers independently screened the studies. Studies were eligible for inclusion if they reported cases of primary GBM confined to the optic nerve or chiasma as the initial radiological diagnosis. A 77-year-old female was referred for progressive visual loss lasting 8 weeks. MRI revealed a suspected lesion in the left chiasma. The patient's vision deteriorated further despite initially diagnosing an inflammatory process and empirical treatment with corticosteroids. Subsequently, the patient underwent an open biopsy and surgical debulking. Histology, including epigenetic analysis, confirmed GBM grade IV. Radiochemotherapy was administered. The patient died 19 months after surgery. We identified 45 similar cases (22 female) reported in 35 studies between 1949 and 2020. The mean age of the cases was 61 (SD = 14.6). Most cases were misdiagnosed and mistreated accordingly, so there was a median delay of 8 weeks (IQR: 5-14 weeks) in obtaining histological confirmation of the diagnosis, delaying the initiation of appropriate treatment. Five cases became no treatment since the patients died shortly after the delayed histologic diagnosis. The Kaplan-Meier estimate indicated that most patients died within 20 months of presentation, with a 1-year survival rate of 50%, and untreated cases had very low survival rates compared to treated cases. Primary GBM of the optic nerve and chiasma is a rare condition primarily affecting adults. The rarity of this condition contributes to initial misdiagnosis, mistreatment, and delays in confirming the histology and initiating appropriate treatment. The prognosis remains poor, but treatment, including surgery and radiochemotherapy, improves survival.

Glioblastoma in the optic chiasm: A case report

Malignant optic gliomas are an uncommon pathology, with around 67 cases reported worldwide in the literature. We present the case of a 77-year-old-male with a two-month history of progressive vision loss, ultimately leading to bilateral blindness. The initial clinical suspicion was a non-inflammatory ischemic optic neuropathy. Stereotactic biopsy was performed on the optic chiasm, and the histopathological diagnosis was confirmed as Glioblastoma.

Transtentorial spread of glioblastoma multiforme to cerebellopontine angle - A rare case report

BACKGROUND

Glioblastoma multiforme (GBM) is the most common central nervous system malignant tumor in adults with 48.3% of cases. Despite it, the presence of transtentorial spread is uncommon, with few patients reported in the literature. In this study, the authors report a case of GBM transtentorial spread to cerebellopontine angle after resection and adjuvant treatment.

CASE DESCRIPTION

A 55-year-old male patient with GBM, previously submitted to surgical resection and adjuvant treatment with radiotherapy and quemotherapy. Fourteen months after the first surgery, he developed headaches associated with dysphagia and dysphonia. Magnetic resonance imaging showed a recurrence of the left parietal lesion and a new mass in the right cerebellopontine angle. The patient underwent successful surgical resection of both lesions. Chemotherapy was maintained after the surgery.

CONCLUSION

To the best of our knowledge, there are few cases of GBM metastasis to the cerebellopontine angle reported in the literature. Surgical management should be considered in cases of intracranial hypertension and patients with good performance status.

Malignant optic nerve glioma in a young woman with 7 year follow up without recurrence

Purpose

To report diagnostic and management challenges of a case of WHO Grade III glioma of the optic nerve occurring in an unusually young patient with more than 7 years of survival without recurrence.

Observations

An 18-year-old woman reported rapidly progressive vision loss in the right eye in the setting of a right optic nerve lesion, central retinal artery occlusion, central retinal vein occlusion, and neovascularization of the optic disc. An orbital MRI with contrast demonstrated enhancement of the intraocular, intraorbital, and intracanalicular portion of the right optic nerve. Biopsy of a portion of the intraorbital optic nerve was negative, however, biopsy of the intracranial optic nerve confirmed WHO Grade III glioma (anaplastic astrocytoma). Although the tumor was excised, there remained positive margins at the optic chiasm. The patient was then managed with a combination of radiation and temozolomide. Postoperatively, the initial neovascularization of the optic nerve that had resolved, re-emerged with gliosis. In this setting a concern for intraorbital tumor arose and the globe was enucleated, definitively ruling out neoplasm. The patient has remained tumor free seven years after resection.

Conclusions and importance

Malignant optic pathway glioma is rare and carries a high 5-year mortality rate. Diagnosis can be elusive given orbital MRI with contrast often appears to be non-specific. Inflammatory changes can be confounding such that a biopsy in the respective area will yield a negative pathologic result. Repeat biopsy is recommended if clinical suspicion is high. Combination treatment of optic nerve tumor resection, temozolomide and radiation has been effective in treating this patient who continues to be followed closely and has had no clinical or radiographic evidence of recurrence in over 7 years. The re-emergence of neovascularization with gliosis/fibrosis of the optic nerve, was driven by ischemia and further precipitated by radiation. To our knowledge this patient represents the youngest reported case of malignant optic nerve glioma with the longest reported survival in the literature to date (over seven years).