Metastases of glioblastoma multiforme to cervical lymph nodes. Report of two cases

Cervical Lymph Node Metastases from Central Nervous System Tumors: A Systematic Review

Introduction

Lymph node metastasis (LNM) from primary tumors of the central nervous system (CNS) is an infrequent condition, and classically it was thought that CNS tumors could not spread via the lymphatic route. Recent discoveries about this route of dissemination make its knowledge necessary for surgeons and pathologists to avoid delays in diagnosis and unnecessary treatments. The aim of this paper is to review the literature and to discuss the relevant pathogenetic mechanism and the cytologic features along with recommendations for surgical treatment of these cervical LNM.

Materials and Methods

Using PRISMA guidelines, we conducted a systematic review of the literature published from 1944 to 2021, updating the comprehensive review published in 2010 by our group.

Results

Our review includes data of 143 articles obtaining 174 patients with LNM from a primary CNS tumor. The mean age of the patients was 31.9 years (range, 0.1–87) and there were 61 females (35.1%) and 103 males (59.2%), and in 10 cases (5.7%) the gender was not specified. The more frequent sites of distant metastasis were bones (23%), lungs (11.5%) and non-cervical lymph nodes (11%).

Conclusion

Cervical LNM from CNS tumors is infrequent. Pathologic diagnosis can be obtained by fine-needle aspiration cytology in most cases, giving surgeons the option to plan the appropriate surgical treatment. Given the poor prognosis of these cases, the most conservative possible cervical dissection is usually the treatment of choice.

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

Background

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

Methods

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

Results

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

Conclusions

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

Cytomorphology of glioblastoma metastic to a cervical lymph node diagnosed by fine needle aspiration (FNA): A case report and review of literature

Glioblastoma is an aggressive primary central nervous system tumor with a dismal prognosis. However, extracranial metastases are extremely rare. Very few cases have been reported in the literature. We present a case of a 64-year-old male with glioblastoma metastatic to a cervical lymph node in which the diagnosis was made on fine needle aspiration cytology (FNAC). The cytomorphologic features of glioblastoma are distinct, with pleomorphic cells in loosely cohesive clusters with prominent nucleoli, coarsely clumped chromatin and cellular processes. We suggest that FNAC, along with clinical history, is a cost effective, safe, and diagnostically accurate method of diagnosing glioblastoma metastases. Cell block is also helpful in establishing the diagnosis.

Vital Functions Contribute to the Spread of Extracellular Fluids in the Brain: Comparison Between Life and Death

Vascular pulsations, contractions of vascular smooth muscle cells and breathing have been reported to foster movement and clearance of interstitial and cerebrospinal fluids from the brain. The aim of this study was to estimate the contribution of these vital functions. We compared the spread of an injected hydrophilic tracer (Fluoro-Emerald, a 10 kDa fluorescein-coupled dextran amine) in the brains of live anesthetized and sacrificed rats at 30 and 90 min after injection. To determine the overall pattern of distribution of tracers, we created 3D-reconstructions of the horizontal transections of the whole brain. Immunofluorescence staining with laminin and collagen IV was performed to determine the pattern of distribution of tracer in relation to the cerebrovascular basement membranes. We found that diffusion was widely restricted to the periventricular region in sacrificed rats with no spread to the contralateral hemisphere, while the bulk flow occurred along the vasculature and reached the surface and the contralateral hemisphere as soon as 30 min after injection in live anesthetized animals. The tracer appeared to be localized along the vascular basement membranes and along fiber tracts as reported previously. Thus, our data indicate that vital functions are essential for the remote movement of extracellular fluids within the cerebral parenchyma.

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.

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

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

The natural history of extracranial metastasis from glioblastoma multiforme

Extracranial metastasis is a unique but rare manifestation of glioblastoma multiforme. It is thought to arise from glioblastoma cells disseminated into the blood stream. We undertook a comprehensive analysis of 88 cases of extracranial glioblastoma (5 were gliosarcomas) published between 1928 and 2009. Cases included in the analysis were primary or secondary glioblastomas that subsequently invaded organs outside the brain or spinal cord. The median age was 38 years and the median overall survival time was 10.5 months (range 0.0-60.0 months). The median time from symptom onset to diagnosis of primary glioblastoma was 2.5 months, from diagnosis to detection of extracranial metastasis was 8.5 months, and from metastasis to death was 1.5 months. From 1940 to 2009, there has been progressive lengthening of the interval from detection of extracranial metastasis to death, at a rate of 0.7 months per decade (95% confidence interval 0.5-1.0 month). Use of magnetic resonance imaging correlates with an increase in overall survival but not age, gender, or site of primary glioblastoma. Patients treated with surgery + radiation + chemotherapy + cerebrospinal fluid shunting had the longest average survival interval from metastasis to death when compared to those treated with surgery alone, radiation alone, surgery + radiation, and surgery + radiation + chemotherapy. Lung metastasis is a prognostic factor of extremely poor outcomes. We conclude that patients with glioblastoma extracranial metastasis have poor prognosis, but there has been a progressive lengthening of survival in each successive decade from 1940 to 2000.

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

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

A survey of metastatic central nervous system tumors to cervical lymph nodes

In the realm of head and neck diseases, one particularly common clinical presentation is that of the patient with a cervical mass. In children, neck masses often prove to be developmental cysts; in adults, the recent onset of a neck mass can signal a metastasis from a head and neck squamous carcinoma. Less often, both adults and children may present with cervical masses caused by either non-Hodgkin's lymphoma or Hodgkin's disease. There are, of course, less frequently encountered differential diagnostic possibilities; one of the most uncommon of all is the possibility of metastasis from an intracranial tumor. Intracranial tumors rarely give rise to cervical node metastases. The present review examines the published experience with 128 tumors that gave rise to cervical node metastases in both adult and in pediatric patients. While it is presumed that the blood-brain barrier blocks the spread of most tumors beyond the intracranial locale, this is speculative. Although many of the cervical node metastases reported here arose after craniotomy (and, presumably, after breaching of the blood-brain barrier), some arose in the absence of any preceding surgical procedure. Cervical node metastases may arise from glial tumors (including glioblastoma multiforme, in both adult and pediatric patients) and non-glial tumors (such as medulloblastoma in pediatric patients). The history of a previous intracranial lesion is often the key to correct diagnosis, since, without prompting, neither the pathologist nor the radiologist is likely to think of a cervical node metastasis from a brain tumor when assessing a cervical mass of unknown etiology.

Extra-cranial metastasis of glioblastoma multiforme presenting as acute parotitis

We present an unusual case of extracranial metastasis of glioblastoma multiforme (GBM) to the parotid gland and cervical lymph nodes. The patient had previously undergone two craniotomies to debulk a left frontal GBM, followed by radiotherapy. After the second craniotomy, while waiting for chemotherapy, the patient was re-admitted with a short history of a painful swelling of his left parotid gland. The initial diagnosis was infective parotitis; however, as there was no improvement with broad-spectrum antibiotics, CT was undertaken, which revealed a mass in the parotid gland with a necrotic centre and enlarged cervical lymph nodes. Parotid gland biopsy revealed a parotid GBM metastasis. This case illustrates how GBM behaves in an aggressive manner even outside the CNS. A brief review of the literature and of the theories, which might explain the extra-neural metastasis of this tumour is also presented.

[Magnetic resonance imaging in 67 cases of glioblastoma multiforme and occurrence of metastases]

PURPOSE

The purpose of this paper is to demonstrate the main MRI characteristics of glioblastoma multiforme (GBM), the most common CNS primary tumor, emphasizing its location and the occurrence of metastases.

METHOD

The MR imaging of 67 pathologically proven cases of glioblastoma multiforme were retrospectively reviewed. The exams were realized in the period between 1995 and 2003, in one of three 1.5 Signa GE units (Milwaukee, WI).

RESULTS

The ages of the patients ranged from 4 years to 86 years, mean 60 years, and the occurrence of the tumor was preponderant among men, with 39 cases (58%). The most common location was in the frontal lobes (47%) followed by the temporal lobes (18%) and the parietal lobes (16%). In 19% of the cases there were involvement of more than one site and long distance metastases were seen in 22% of the patients.

CONCLUSION

According to the literature, the most common location of GBM was in the frontal lobe of older than 50 years old men. Metastases occurred in 22% of our cases.

Cutaneous metastasis from an intracranial glioblastoma multiforme

A 34-year-old white man with a history of an intracranial glioblastoma multiforme was treated with surgical excision and radiotherapy. Five months later, the patient had a rapidly growing scalp mass develop. This lesion was excised, and the histology revealed a tumor that was similar to the originally resected intracranial glioblastoma. Immunohistochemistry for general neuroepithelial derivation (S-100 protein) and for glial fibrillary acidic protein (GFAP) was positive, whereas mesenchymal, epithelial, and neuronal markers were negative. This immunohistochemistry pattern was identical to the original tumor. Although metastasis of this tumor is not uncommon, metastasis to the skin has never been reported. To our knowledge, this is the first reported case of cutaneous metastasis from glioblastoma in the world literature.

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.

Lack of evidence of osteo-medullary metastases at diagnosis in patients with high grade gliomas

High grade gliomas usually show a transient response to standard therapy by radiation. A local evolution leads to patient death in most of the cases. Necropsic series suggest that metastatic evolution is rather frequent in lungs, lymph nodes, bones or bone marrow. Are these metastatic deposits present initially? The authors retrospectively reviewed the bone marrow smears performed in 20 patients and the bone scans in 10 patients with high grade gliomas at time of diagnosis. None of these investigations showed metastatic deposits. It is thus suggested that metastatic deposits are probably a late event in the natural history of high grade gliomas. However, if local treatment could reach local control, metastases would probably become a major problem. Thus definitive cure of high grade glioma may require multidisciplinary approach.

Bone metastases from secondary glioblastoma multiforme: a case report

Extraneural metastases of glioblastoma multiforme (GBM) are a relatively rare occurrence which usually manifest after de novo GBM. We report a case of a patient with an oligodendroastrocytoma who developed over a period of 12 years malignant progression to glioblastoma followed by multiple cytologically confirmed bone metastases. No 1p deletions were detected in the original tumour. GBM cells disclosed the EGFr(+) and p53(-) immunophenotype more characteristic of a primary GBM.

Extracranial metastasis of glioblastoma multiforme diagnosed by fine-needle aspiration: a report of two cases and a review of the literature

Extracranial metastasis of cerebral glioblastoma is rarely seen. Craniotomy and diversionary shunt are widely accepted causes of dissemination. Prognosis is poor but new therapeutic modalities may improve the survival and lessen the patient's symptoms. It is also important to diagnose extracranial metastasis because of possible response to treatment and fine-needle aspiration cytology can then be helpful. Two cases of extracranial metastases of glioblastoma multiforme diagnosed by fine-needle aspiration cytology are reported and a review of the literature is presented.

Glioblastoma cells do not intravasate into blood vessels

Glioblastoma is very rarely found outside the central nervous system. The ability of rat C6 glioblastoma cells to intravasate into central nervous system and pial blood vessels is tested using a rat homografting model and two in vitro models. In vivo, scanning electron microscopy demonstrates that upon grafting C6 cells into implantation pockets in rat cortex, blood vessels can be spared in large digestion cysts formed in host brain parenchyma. Immunocytochemistry of the grafted rat cortex reveals that the glioblastoma cells are upon the blood vessel basement membrane, surrounded by the extracellular matrix material, fibronectin. The endothelial cells of the blood vessel are inside the laminin and fibronectin, and there were areas of endothelial cell hyperplasia. C6 cells are not observed inside blood vessels. In vitro, C6 cell cultures seeded with blood vessels from fresh rat pia exhibit the same relationship of the C6 glioblastoma cells to the blood vessel as those in the other models. The C6 cells migrate upon the pial blood vessel basement membrane but do not intravasate into the blood vessel. To ascertain whether structure and components of the blood vessel basement membrane are important factors in glioblastoma cell exclusion from blood vessels, C6 cells are seeded upon artificial basement membrane hydrated gel wafers. C6 cells migrate into the artificial basement membrane gel wafer by 1 day after seeding. These data indicate that glioblastoma cells are confined to the central nervous system by an inability to pass through vital basement membrane.

The nasal route of cerebrospinal fluid drainage in man. A light-microscope study

The drainage routes from the subarachnoid space to the nasal mucosa were investigated in autopsy material. Indian ink, applied post-mortem to the olfactory groove, promptly filled the perineurial spaces around the olfactory nerve branches in the dura, the lamina cribrosa and the submucosal tissue in the nose. In a case of recent subarachnoid haemorrhage, the perineurial spaces even around the most distal olfactory nerve branches were congested with blood and there was an abundant accumulation of red corpuscles in the apical part of the nasal mucosa. Iron-containing pigment was found in the perineurial spaces of proximal and distal olfactory nerve branches as well as in the nasal mucosal stroma in cases with older haemorrhagic lesions. The findings show that the perineurial spaces provide an efficient drainage route from the subarachnoid space to the nasal mucosa in cases with haemorrhagic cerebral lesions. A complementary drainage route for the cerebrospinal fluid was indicated by the presence of indian ink, red corpuscles and iron pigment in arachnoid villi, which penetrated the lamina cribrosa and ended in the nasal submucosal tissue. Iron in the deep cervical lymph nodes should not be taken as evidence of transport from the CNS, since iron pigment was also found in cases without intracranial haemorrhage.

The risks of metastases from shunting in children with primary central nervous system tumors

The authors reviewed the hospital charts of 415 pediatric patients treated for benign or malignant primary brain tumors over the past 20 years at the Children's Hospital Medical Center, Seattle. Patients' ages ranged from the neonatal period to 18 years. A shunt was placed in 152 patients (37%), 45 before and 94 after surgery. Confirmation of extraneural metastases was based on clinical and diagnostic examination. Factors analyzed as possibly influencing the occurrence of extraneural metastases were: 1) the shunt: type, valve, location, filter, and revisions; 2) extent of resection; 3) pathology; and 4) treatment regimen. Eight of the 415 patients developed extraneural metastases during life. All eight patients had a medulloblastoma (cerebellar primitive neuroectodermal tumor). These eight patients were separated into Group A (without a shunt) and Group B (with a shunt). In Group A (five patients), the mean interval from primary diagnosis to metastasis was 15 months. Two children had gross total resection of the tumor. The predominant location of metastases in Group A was: bone (two cases); cervical lymph nodes (one); lung/bone (one); and retroperitoneal pelvic mass (one). Three Group A patients had a simultaneous central nervous system (CNS) recurrence. Of the three Group B patients, two had a ventriculoperitoneal (VP) shunt and one a ventriculoatrial (VA) shunt; all were placed postoperatively. One Group B patient had a simultaneous CNS recurrence. No shunt revisions were performed in these three patients. The mean time from primary diagnosis to metastasis was 25 months. One patient had a total tumor resection. The predominant location of metastases was bone (one case), retroperitoneal pelvic mass (one), and abdominal cavity with ascites (one case). Only one patient in the entire series had a filter placed; this resulted in shunt obstruction and was removed 1 month following placement. It is concluded that cerebrospinal fluid shunts, regardless of type, location, revision rate, or filter insertion, do not predispose pediatric patients with brain tumors to develop extraneural metastases. A diagnosis of shunt-related metastases should be based on the development of intra-abdominal (VP shunt) or pulmonary (VA shunt) dissemination primarily with or without additional sites. The diagnosis of medulloblastoma is an important factor related to metastasis occurrence while the extent of resection and postoperative therapy are not influential.

Intracranial astrocytoma with diffuse bone marrow metastasis: a case report and review of the literature

A 41 year old male presented with headache, lethargy, and ataxia and found to have a left temporal lobe mass and a leukoerythroblastic peripheral blood smear. The latter prompted an iliac crest bone marrow biopsy on which a diagnosis of metastatic glioma was made and verified by immunohistologic characterization. The patient was treated with cranial irradiation and simultaneous systemic BCNU (bis-dichloroethylnitrosurea) with complete response. This case with diffuse bone marrow involvement demonstrates that a glioblastoma is capable of extracranial metastases without previous intervention. From a review of reported cases of gliomas of extraneural metastasis, it is concluded that untreated gliomas are capable of vascular spread although less frequently than previously manipulated tumors.

Extraneural metastases of central nervous system tumors

In the past, extraneural metastasis of central nervous system tumors was considered to be a rare event. However, more recently, a considerable body of literature has accumulated so that to date some 282 patients with extraneural metastases have been reported. Of these reported cases, 40.4% have occurred in children. Although central nervous system tumors can spread spontaneously beyond the confines of the central nervous system, most instances of extraneural metastasis occur after craniotomy or diversionary cerebrospinal fluid shunting. Extraneural metastases are universally fatal. Although it is not curative, chemotherapeutic treatment of metastases may greatly decrease the patient's discomfort and improve the quality and duration of survival. Every effort should be made to prevent this complication by avoiding diversionary cerebrospinal fluid shunting procedures or by incorporating a filtering device if a shunt becomes necessary.

Correlations between cytologic composition and biologic behavior in the glioblastoma multiforme. A postmortem study of 50 cases

The brains of 50 adults with supratentorial glioblastoma multiforme were studied post mortem. The cytologic compositions of the neoplasms were examined in each of three sites: (1) in and around the original tumor bed; (2) zones of infiltration of contiguous structures; and (3) implants in the subarachnoid and/or ventricular spaces. For this purpose, six different cell types were defined: small anaplastic cells (SAC), small fibrillated cells (SFC), fibrillated astrocytes (FA), pleomorphic astrocytes (PA), gemistocytic astrocytes (GA), and large bizarre cells (LBC). In 16 cases with marked mass effect in the original tumor bed entirely due to the neoplasm, the cytologic composition of the neoplasm was predominantly SAC (14 cases) and SFC (2 cases). The prevalence of these two cellular types was evident in the infiltrated regions in 36 of 42 cases, and in the metastatic foci of 11 of 13 cases. In 10 of 11 cases in which there was mild or no mass effect, only limited infiltration in the ipsilateral hemisphere, and no metastases, the neoplasms were composed of a combination of FA, PA, GA, and LBC. The observations suggest that, in spite of the glioblastoma's cytologic heterogeneity, the pathologic substrate of aggressiveness in this malignant glioma is related largely to the proliferation of a population of small anaplastic cells. On the basis of this observation, as well as the consideration of certain clinical and therapeutic variables, an outline is presented summarizing the history of the glioblastoma multiforme from treatment until the time of death.

Glioblastoma multiforme metastatic to the neck

Glioblastoma multiforme, a rapidly growing intracranial neoplasm, rarely metastasizes unless operated upon, and even after surgical exposure metastasis is uncommon unless the patient is a long-term survivor. The most likely site of metastasis is the cervical lymph nodes. A patient developed a rapidly expanding cervical metastasis a year after surgery and irradiation for the primary. The 6-cm neck mass responded dramatically to radiation therapy and lomustine. The patient is clinically without evidence of progression of disease 20 months after the initial diagnosis, and there is no palpable recurrence in the neck. It is recommended that the patient who has a cervical mass and a history of surgically treated glioblastoma multiforme undergo a careful otolaryngologic examination prior to open biopsy. In general, such a patient can be spared an extensive "unknown primary" evaluation before biopsy.

Malignant gliomas - glioblastoma multiforme and astrocytoma III-IV with extracranial metastases. Report of two cases

The authors describe two rate cases of extraneural metastases of glioblastoma multiforme and of astrocytoma III-IV, but with different distribution routes. In the first case - astrocytoma III-IV - via the lymphatic system, with metastases in the cervical lymph nodes; in the second case-glioblastoma-via the blood system, with metastases in the sternum and vertebrae. Survival times were 18 months in the astrocytoma case (operation plus irradiation), and 6 months in the glioblastoma case (operation, irradiation, and chemotherapy). The discussion deals with the possible paths of the metastases, the connection between metastatic spread and survival time (in the longer surviving patient the metastases were discovered together with the recurrence), and problems in deciding the individual therapy.

Extraneural metastases of astrocytomas and glioblastomas: clinicopathological study of two cases and review of literature

Two cases of intracranial gliomas with extraneural metastases are described. Case 1, studied with biopsy material only, was a left malignant astrocytoma from the area of the rolandic fissure with right cervical lymph nodes metastases in a 43-year-old man. Case 2 was a left temporal malignant astrocytoma in a 21-year-old woman. Fifteen days after craniotomy, a left submandibular lymph node metastasis appeared. Forty days after surgery, a ventriculoperitoneal shunt was performed. Fifty-four days after surgery, the patient died. Autopsy revealed three liver metastases. Our review of the literature consists of 72 autopsy cases with extraneural deposits. Thos metastases occurred mainly in adults (63/72) and among men (46/72). The primary glioma was supratentorial in 67 cases. Metastases were mainly pulmonary and pleural. The majority of patients (82.8%) died within 2 years after onset of symptoms. In 8 of the cases, metastasis developed without any craniotomy and in 8 other cases, through a shunt.

Extracerebrospinal metastases in glioblastoma. Case report and review of the literature

A malignant glioblastoma adherent to the dura mater was removed from the parieto-occipital lobe in a 12-year-old boy. The site of the tumor was subsequently irridiated by 4000 rads of Cobalt-60. Five months later the boy was readmitted complaining of pains in the pelvis an in both thighs. X-ray examination of the pelvis demonstrated multiple metastases. Investigation of bone marrow revealed replacement of normal haematopoiesis by a tumor cell population histologically identical to that of the brain tumor. Reviewing the literature 58 reports on glioblastomas with extracerebrospinal metastases could be found. Metastases were preferably localized in cervical or mediastinal lymph nodes, lungs, bones, liver, dura mater, and operative flap. It is suggested that extracerebrospinal metastases occur most frequently after the tumor has infiltrated the cranium and extracranial soft tissues. In the case reported here it is speculated that the tumor spread to extraneural tissues after invading the dural veins. The possible occurrence of extracerebrospinal metastases in glioblastoma emphasizes the necessity of additional chemotherapy.

Extracranial metastases of anaplastic cerebral gliomas

Seven cases are reported of anaplastic cerebral gliomas with metastases outside the neuraxis, seen among about 1500 gliomas. There were two children with anaplastic ependymomas, one adult with oligodendroglioma, and four young to middle-aged adults with astrocytomas grade III and IV. All patients had one or more craniotomies, and four had radiotherapy prior to the appearance of distant tumour deposits. The survival times ranged from 7 to 31 months in cases with gliomas grade II, and from 8 to 18 months with high grade astrocytomas. All seven tumours showed invasion of the meninges, ventricular walls, or both, and in four cases they transgressed the dura and surrounding bone or soft tissues. In six autopsy cases there was widespread dissemination of gliomas through the CSF pathways. Distant metastases involved regional or distant lymph nodes in six patients, the lungs in two, and the vertebrae, pleura, liver, or mediastinum in one patient each. The possible pathways for distant spread or intracranial gliomas and the factors which are considered responsible are briefly discussed.

Glioblastoma multiforme with extraneural metastases in the absence of previous surgery

A 63-year-old man was found to have an intracerebral glioblastoma multiforme and preoperative roentgenographic evidence of a mass in the middle lobe of the right lung. Because of the rarity of extraneural metastases from glioblastoma, especially in the absence of prior surgery, the lesions were considered to be separate neoplasms until death. The histologic appearance of the lung tumor obtained at autopsy was identical to the cerebral tumor. Additional metastases were found to bronchial lymph nodes and a lumbar vertebra. This case demonstrates that a glioblastoma can spontaneously metastasize extraneurally. Invasion of the glioblastoma into the lumen of a blood vessel was demonstrated within the primary tumor. Embolization of cells to the lung and beyond is the suspected mode of spread.