Multiple radiation-induced intracranial lesions after treatment for pituitary adenoma. Case report

De novo meningiomas and cavernous malformations developing after coil embolization for dural arteriovenous fistula

A 25-year-old woman presented with exophthalmos. With the diagnosis of dural arteriovenous fistula of the transverse sinus, the patient underwent coil embolization. Fifteen years later, she sustained visual disturbance due to de novo tuberculum sellae meningioma that was resected. Surveillance magnetic resonance imaging (MRI) performed at the age of 42 years detected tumor recurrence and small, apparent meningioma in the cerebral convexity. The patient underwent the second tumor resection at the age of 46 years. The histological appearance was consistent with meningothelial meningioma. In addition, surveillance MRI at the age of 43 years detected de novo cerebral and cerebellar cavernous malformations (CMs). These CMs showed repeat hemorrhages on MRI but remained asymptomatic during the next 38 months. De novo meningiomas and CMs may develop in association with radiation exposure during endovascular therapy. Sufficiently long-term follow-up is recommended after endovascular therapy for monitoring secondary pathologies.

Secondary Intracranial Tumors Following Radiotherapy for Pituitary Adenomas: A Systematic Review

Pituitary adenomas are often treated with radiotherapy for the management of tumor progression or recurrence. Despite the improvement in cure rates, patients treated by radiotherapy are at risk of development of secondary malignancies. We conducted a comprehensive literature review of the secondary intracranial tumors that occurred following radiotherapy to pituitary adenomas to obtain clinicopathological characteristics. The analysis included 48 neuroepithelial tumors, 37 meningiomas, and 52 sarcomas which were published between 1959–2017, although data is missing regarding overall survival and type of irradiation in a significant proportion of the reports. The average onset age for the pituitary adenoma was 37.2 ± 14.4 years and the average latency period before the diagnosis of the secondary tumor was 15.2 ± 8.7 years. Radiotherapy was administered in pituitary adenomas at an average dose of 52.0 ± 19.5 Gy. The distribution of pituitary adenomas according to their function was prolactinoma in 10 (7.2%) cases, acromegaly in 37 (27.0%) cases, Cushing disease in 4 (2.9%) cases, PRL+GH in 1 (0.7%) case, non-functioning adenoma in 57 (41.6%) cases. Irradiation technique delivered was lateral opposing field in 23 (16.7%) cases, 3 or 4 field technique in 27 (19.6%) cases, rotation technique in 10 (7.2%) cases, radio surgery in 6 (4.3%) cases. Most of the glioma or sarcoma had been generated after lateral opposing field or 3/4 field technique. Fibrosarcomas were predominant before 1979 (p < 0.0001). The median overall survival time for all neuroepithelial tumors was 11 months (95% confidence intervals (CI), 3–14). Patients with gliomas treated with radiotherapy exhibited a non-significant positive trend with longer overall survival. The median overall survival time for sarcoma cases was 6 months (95% CI, 1.5–9). The median survival time in patients with radiation and/or chemotherapy for sarcomas exhibited a non-significant positive trend with longer overall survival. In patients treated with radiotherapy for pituitary adenomas, the risk of secondary tumor incidence warrants a longer follow up period. Moreover, radiation and/or chemotherapy should be considered in cases of secondary glioma or sarcoma following radiotherapy to the pituitary adenomas.

Neural Axis Metastasis from Metachronous Pulmonary Basaloid Carcinoma Developed after Chemotherapy & Radiation Therapy of Uterine Cervical Carcinoma

Multiple primary or secondary malignancies after anticancer therapy were recently reported to be increasing in frequency. The authors describe a case of metachronous metastatic pulmonary basaloid carcinoma to the central nervous system that was discovered after chemotherapy and radiation therapy for cervical uterine carcinoma. Two different types of cancer developed within some interval. There's the possibility that a secondary pulmonary neoplasm developed after the chemotherapy and radiotherapy conducted as cervical cancer treatment.

A case of multiple radiation-induced gliomas 24 years after radiation therapy against pituitary adenoma

We treated a case in which multiple astrocytomas of varying grades developed in the irradiation field 24 years after radiation therapy. Differentiation from radiation necrosis based on presurgical diagnostic imaging was difficult; therefore, we feel it is essential to aggressively pursue histological diagnoses to select the optimal treatment method.

World Health Organization Grade II Oligodendroglioma Occurring after Successful Treatment for Childhood Acute Lymphoblastic Leukemia

When treating childhood acute lymphoblastic leukemia (ALL), secondary neoplasms are a significant long term problem. Radiation is generally accepted to be a major cause of the development of secondary neoplasms. Following treatment for ALL, a variety of secondary tumors, including brain tumors, hematologic malignancies, sarcomas, thyroid cancers, and skin cancers have been reported. However, oligodendroglioma as a secondary neoplasm is extremely rare. Herein we present a case of secondary oligodendroglioma occurring 13 years after the end of ALL treatment.

Radiation-induced anaplastic ependymoma mimicking a skull base meningioma: A case report

The present study describes the case of a 63-year-old woman presenting with headache, dizziness and vomiting due to a an ovoid mass in the left pre-bulbar cistern, apparently arising from the lower clivus and the foramen magnum. The clinical history revealed the subtotal removal of a right cerebellar low-grade glioma 15 years previously and subsequent conventional 60-Gy radiotherapy. Notably, following gross total resection, histopathological examination showed microscopic features that resulted in a diagnosis of anaplastic ependymoma. The patient underwent surgery to remove the mass and post-operative chemotherapy with temozolomide. A progressive improvement of neurological signs and symptoms was observed during the postoperative course. At the 6-month follow-up, the patient was free from clinical and radiological recurrence. The unusual features of this rare secondary brain tumor were the extrassial location in the posterior fossa, the unusual age-associated location of the histological subtype and the fact that it closely mimicked a skull-base meningioma.

Prolactinoma associated with an ependymoma in the fourth ventricle: A case report and review of the literature

Pituitary adenoma associated with ependymoma in the fourth ventricle is a rare condition. In the present study, a 46-year-old man diagnosed with prolactinoma, who previously underwent two surgical procedures (one for the removal of a primary tumor and a second following its recurrence) developed a complication of ependymoma in the fourth ventricle. The presence of the ependymoma was confirmed by pathological analysis and the patient recovered well following two-phase surgical resection of the two tumors. The present study compared the probable cause of concurrent pituitary adenoma and ependymoma within the fourth ventricle with previous relevant studies. These comparisons were used to propose possible genomic and endocrine contributions for the development of the ependymoma from the pituitary adenoma.

Rates and characteristics of radiographically detected intracerebral cavernous malformations after cranial radiation therapy in pediatric cancer patients

Rates and characteristics of intracerebral cavernous malformations after cranial radiation therapy remain poorly understood. Herein we report on intracerebral cavernous malformations detected on follow-up imaging in pediatric cancer patients who received cranial radiation therapy at age ≤18 years from 1980 to 2009. Through chart reviews (n = 362) and phone interviews (n = 104) of a retrospective cohort, we identified 10 patients with intracerebral cavernous malformations. The median latency time for detection of intracerebral cavernous malformations after cranial radiation therapy was 12 years (range 1-24 years) at a median age of 21.4 years (interquartile range = 15-28). The cumulative incidence was 3% (95% confidence interval 1%-8%) at 10 years post cranial radiation therapy and 14% (95% confidence interval 7%-26%) at 15 years. Three patients underwent surgical resection. Two surgical specimens were pathologically similar to sporadically occurring intracerebral cavernous malformations; one was consistent with capillary telangiectasia. Intracerebral cavernous malformations are common after cranial radiation therapy and can show a spectrum of histologic features.

The postirradiation incidence of cavernous angioma is higher in patients with childhood pineoblastoma or primitive neuroectodermal tumors than medulloblastoma

PURPOSE

The purpose of this study is to investigate the incidence of cavernous angioma (CVA) in long-term survivors of childhood embryonal tumors treated by cranial irradiation.

MATERIALS AND METHODS

Between 1990 and 2012, we treated 25 patients (13 males, 12 females) with embryonal tumors (17 medulloblastomas, 5 primitive neuroectodermal tumors (PNET), 3 pineoblastomas) with craniospinal irradiation. Follow-up ranged from 15.5 to 289.9 months, the irradiation dose to the whole neural axis from 18 to 36 Gy, and the total local dose from 49.6 to 60 Gy. All patients underwent follow-up magnetic resonance imaging (MRI) studies at least once a year, and the diagnosis of posttreatment CVA was based solely on MRI findings.

RESULTS

At the time of this writing, 18 were alive and free of the recurrence of the original disease or the development of secondary neoplasms other than CVA; another 2 were alive with medulloblastoma or diffuse astrocytoma. Posttreatment, 14 patients developed CVAs in the course of a median of 56.7 months; 13 of these presented with multiple CVAs. Patients who underwent radiation therapy (RT) at an age younger than 6 years developed multiple CVAs significantly earlier than those treated at a later age (p = 0.0110). Patients with PNET or pineoblastoma developed Zabramski type 1 and 2 CVA significantly earlier than did medulloblastoma patients (p = 0.0042).

CONCLUSION

We attribute the high rate of post-RT CVA in our long-term follow-up study of pediatric patients to the delivery of cranial irradiation for embryonal tumors, especially PNET and pineoblastoma, and recommend the regular, long-term follow-up of patients whose embryonal tumors were treated by cranial irradiation.

Characterization of radiation-induced cavernous malformations and comparison with a nonradiation cavernous malformation cohort

OBJECT

The objective of this study was to characterize the clinical features of radiation-induced cavernous malformations (RICMs).

METHODS

The authors retrospectively reviewed the clinical and radiological characteristics of patients with RICMs. The features of these RICMs were then compared with features of nonradiation cavernous malformations (CMs) in 270 patients.

RESULTS

Thirty-two patients with RICMs were identified (56.2% men), with a median age of 31.1 years at RICM diagnosis. The median latency from radiation treatment to RICM diagnosis was 12.0 years (interquartile range 5.0-19.6 years). RICMs were always within the previous radiation port. RICMs were symptomatic at diagnosis in 46.9%, and were associated with symptomatic intracranial hemorrhage at any time in 43.8%. Older age at the time of radiation treatment and higher radiation dose were associated with shorter latency. RICMs tended to be diagnosed at a younger age than nonradiation CMs (median 31.1 vs 42.4 years, respectively; p = 0.054) but were significantly less likely to be symptomatic at the time of diagnosis (46.9% vs 65.8%, respectively; p = 0.036). RICMs were more likely to be multiple CMs than nonradiation CMs (p = 0.0002). Prospectively, the risk of symptomatic hemorrhage was 4.2% for RICMs and 2.3% for nonradiation CMs per person-year (p = 0.556). In the absence of symptoms at presentation, the risk of hemorrhage for RICMs was higher than for nonradiation CMs (4.2% vs 0.35%, respectively; p = 0.118).

CONCLUSIONS

In this patient population, RICMs occurred within the radiation port approximately 12 years after radiation treatment. Compared with nonradiation CMs, RICMs were more likely to occur as multiple CMs, to present at a younger age, and were at least as likely to cause symptomatic hemorrhage.

Natural history of cavernous malformations in children with brain tumors treated with radiotherapy and chemotherapy

Cavernous malformations (CM) are cerebral irradiation-related late complications. Little is known about their natural history and the pathogenetic role of concomitant chemotherapy. We present a retrospective, single-institution study of 108 children affected with medulloblastoma, ependymoma, or germinoma treated with radio- and chemotherapy. The frequency, clinical and radiological presentations, and outcomes were analyzed to investigate the relationship among radiation dose, associated chemotherapy, age, latency and localization of radiation-induced CM. 100 out of 108 children were treated with radiotherapy for primary brain tumor; 34 (27 with medulloblastoma and 7 with other histologies) out of 100 patients developed CM. No significant relationship was found between CM and gender (p = 0.70), age (p = 0.90), use of specific chemotherapy (standard versus high-dose, p = 0.38), methotrexate (p = 0.49), and radiation dose (p = 0.45). However, CM developed more frequently and earlier when radiotherapy was associated with methotrexate (70 % of cases). Radiation-induced CM prevailingly occurred in the cerebral hemispheres (p = 0.0001). Only 3 patients (9 %) were symptomatic with headache. Three patients underwent surgery for intra- or extra-lesional hemorrhage. CM was confirmed by histopathology for all 3 patients. The vast majority of radiation-induced CM is asymptomatic, and macro-hemorrhagic events occur rarely. Concomitant therapy with methotrexate seems to favor their development. We recommend observation for asymptomatic lesions, while surgery should be reserved to symptomatic growth or hemorrhage.

Cavernous malformations of the brain after treatment for acute lymphocytic leukemia: presentation and long-term follow-up

OBJECT

The authors undertook this study to determine the clinical course and long-term outcomes in pediatric patients who developed cavernous malformations of the brain following treatment for acute lymphocytic leukemia (ALL).

METHODS

They reviewed the senior author's database of surgically treated cavernous malformations of the brain to identify those patients whose cavernous malformations developed after cranial radiation during treatment for ALL. The medical records of these patients were reviewed to determine their clinical presentation, radiological findings, and outcome at long-term follow-up.

RESULTS

Five patients fulfilled the specified criteria over a 23-year period. At the time of ALL diagnosis, they were all 4-5 years old. The cerebral cavernous malformations developed 2-8 years after cranial radiation, and 4 of the 5 patients presented with neurological symptoms, which ranged from focal deficits to seizures. Two patients required a second craniotomy, one from lesion recurrence possibly due to incomplete resection, and another for a second cavernous malformation, which developed at another site 6 years after the initial malformation was excised. Long-term follow-up of 2, 10, 11, 11, and 17 years has revealed no additional lesion development or recurrence.

CONCLUSIONS

Symptomatic cavernous malformations of the brain may develop several years after chemotherapy and cranial radiation treatment for ALL, and the clinical course of these cavernous malformations may be more aggressive than that of the typical post-radiation lesions seen in other conditions. Long-term clinical and imaging monitoring is recommended for children who have undergone treatment for ALL. Craniotomy for excision of the malformations appears to convey long-term protection from repeat hemorrhage and accumulating neurological deficits.

Intracranial malignancies occurring more than 20 years after radiation therapy for pituitary adenoma

A 37-year-old woman developed a left third cranial nerve palsy 28 years after radiation for a nonsecreting pituitary adenoma. Imaging disclosed a left parasellar mass and a midbrain/pontine signal abnormality. Biopsy of the parasellar mass revealed a malignant sarcoma. The brainstem abnormality was presumptively diagnosed as a malignant glioma. A 63-year-old man developed a malignant astrocytoma of the left optic nerve and chiasm 23 years after partial excision and radiation of a nonsecreting pituitary adenoma. Both patients died of their malignancies. Although secondary malignancies have been described in this setting, such long latencies have not been reported.

Endovascular Treatment Increases but Gamma Knife Radiosurgery Decreases Angiogenic Activity of Arteriovenous Malformations

OBJECTIVE

To compare the angiogenic potentials of embolized, gamma knife–treated or untreated cerebral arteriovenous malformations (AVMs), using a rat cornea angiogenesis model.

METHODS

Tissue samples from cerebral AVM patients who were either untreated or had previously been treated with embolization or gamma knife radiosurgery and who had undergone operations for hemorrhage at the Neurosurgery Department or the Neurological Sciences Institute of Marmara University were used. For the macroscopic evaluation of angiogenesis, tissue samples were inoculated in a micropocket created on the rat eye, and the level of angiogenic activity was graded macroscopically for 15 days, with glioblastoma multiforme and normal brain artery tissues serving as positive and negative controls, respectively. For the other part of the experiment, eyes of another set of rats were inoculated with the study samples only using the same cornea angiogenesis model, in which microvessel count and vascular endothelial growth factor assessment was done at days 3, 7, 11, and 15.

RESULTS

Based on our macroscopic findings in the cornea angiogenesis model, embolized AVMs exhibited the highest angiogenic activity, followed by untreated AVMs and gamma knife–treated AVMs. Evaluations of vascular endothelial growth factor expression and microvessel counts showed a similar relation among the 3 tissue groups with regard to the level of angiogenic activity, supporting the results of macroscopic examinations.

CONCLUSION

This study, for the first time, provides experimental semiquantitative data to compare the angiogenic potentials of embolized and gamma knife–treated AVM tissues. Embolization may increase angiogenic activity, and gamma knife radiosurgery may decrease it when compared with activity in previously untreated AVMs. These data can be useful to understand why recurrence of AVMs after angiographically demonstrated endovascular occlusion is common but after gamma knife occlusion is rare.

Radiation-induced cavernous hemangiomas: case report and literature review

The case of a 51-year-old man diagnosed with two acquired cavernous hemangiomas 17 years after cranial irradiation for a cerebellar astrocytoma is reported. A review of 84 cases of radiation-induced cavernous hemangiomas found in the literature is presented. In this series the mean age at the time of irradiation (+/- SD) was 10.4 +/- 2.0 years (median = 8 years), while the mean time to cavernous hemangioma diagnosis (+/- SD) was 10.3 +/- 1.9 years (median = 8 years). Time to cavernous hemangioma diagnosis was found to be inversely related to radiation dose. Hemorrhage from radiation-induced cavernous hemangiomas was found in 40.0% of patients, with an incidence of 3.9% per patient year. An inverse trend was identified between radiation dose and symptomatic presentation, cavernous hemangioma hemorrhage or surgical resection. This review of radiation-induced cavernous hemangiomas confirms that both younger patients and those who received a larger dose of radiation are at increased risk of radiation-induced cavernous hemangiomas. Our results suggest that, based on an assessment of CT or MR images, there may be an increased risk of hemorrhage when comparing radiation-induced to congenital cavernous hemangiomas. Increasing radiation doses appear to stabilize these lesions, decreasing the risk of a symptomatic presentation, cavernous hemangioma hemorrhage and surgical intervention.

Olfactory neuroblastoma following treatment for pituitary adenoma

Olfactory neuroblastoma is extremely rare as a second neoplasm. We report an unusual case of olfactory neuroblastoma in a 59-year-old woman who had undergone two operations and received 54 Gy of irradiation for pituitary adenoma 20 years ago. At the time of admission, the patient presented with nasal obstruction and frequent epistaxis. Imaging studies showed a large mass in the nasal cavities and ethmoid sinus, extending to the intracranial area, with no evidence of any recurrence of the previous pituitary adenoma. The tumor was completely excised via a trans-cranial and trans-nasal approach. A diagnosis of olfactory neuroblastoma was established, and the patient was given postoperative chemotherapy. Although relatively uncommon, second neoplasms are an important consideration in the differential diagnosis of patients with new or recurring symptoms after treatment for pituitary adenoma. Furthermore, it is likely that radiation played a critical role in the development of olfactory neuroblastoma in our patient.

Two metachronous tumors induced by radiation therapy: case report and review of the literature

Various radiation-induced tumors, including meningioma, glioma, and sarcoma, have been reported; however, metachronous intracranial double tumors induced by radiation therapy are extremely rare. A 1-year-old boy had undergone tumor removal and craniospinal radiation therapy (30 Gy) for cerebellar medulloblastoma. At 24 years old, parasagittal meningioma developed in the left parietal region and was totally removed. Six years later, an infiltrative tumor was newly found in the right fronto-temporal white matter. The patient underwent stereotactic biopsy, and the tumor was found to be an anaplastic astrocytoma. Chromosomal analysis by fluorescence in situ hybridization (FISH) revealed loss of heterozygosity (LOH) of 1p. As the patient had previously had craniospinal irradiation, no additional radiation therapy was delivered. He underwent chemotherapy with temozolomide and the disease is now stable. Since both secondary tumors were located within the area of previous radiation and the patient did not have any genetic disease predisposing him to tumors, radiation therapy was considered to be responsible for their tumorigenesis. To our knowledge, this case is the fourth case of radiation-induced double CNS tumors arising after radiotherapy to be described in the literature. Whenever radiation is administered to children or young adults, careful serial screening studies are needed.

[Radiation-induced cavernoma of the central nervous system]

Central nervous system radiation-induced cavernoma (RIC) is a rare entity. We report one case with a review of the literature. This case illustrates the following features: mean age of 11.7 years at time of radiation and mean latency period of nine years for these RIC, which are often numerous (38%), and located in the field of the craniospinal radiation therapy. This nosological entity belongs to the spectrum of radiation-induced lesions, and requires a long-term MRI follow up in patients who underwent cranial radiation therapy.

Radiosurgery of growth hormone-producing pituitary adenomas: factors associated with biochemical remission

OBJECT

The authors reviewed outcomes after stereotactic radiosurgery for patients with acromegaly and analyzed factors associated with biochemical remission.

METHODS

Retrospective analysis was performed for 46 consecutive cases of growth hormone (GH)-producing pituitary adenomas treated by radiosurgery between 1991 and 2004. Biochemical remission was defined as a fasting GH less than 2 ng/ml and a normal age- and sex-adjusted insulin-like growth factor-I (IGF-I) level while patients were not receiving any pituitary suppressive medications. The median follow up after radiosurgery was 63 months (range 22-168 months). Twenty-three patients (50%) had biochemical remission documented at a median of 36 months (range 6-63 months) after one radiosurgical procedure. The actuarial rates of biochemical remission at 2 and 5 years after radiosurgery were 11 and 60%, respectively. Multivariate analysis showed that IGF-I levels less than 2.25 times the upper limit of normal (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.2-6.9, p = 0.02) and the absence of pituitary suppressive medications at the time of radiosurgery (HR 4.2, 95% CI 1.4-13.2, p = 0.01) correlated with biochemical remission. The incidence of new anterior pituitary deficits was 10% at 2 years and 33% at 5 years.

CONCLUSIONS

Discontinuation of pituitary suppressive medications at least 1 month before radiosurgery significantly improved endocrine outcomes for patients with acromegaly. Patients with GH-producing pituitary adenomas should not undergo further radiation therapy or surgery for at least 5 years after radiosurgery because GH and IGF-I levels continue to normalize over that interval.

Targeting cerebral arteriovenous malformations for minimally invasive therapy

OBJECTIVE

Cerebral arteriovenous malformation (AVM) embolization has been performed for nearly 40 years to reduce the risk of hemorrhage, to reduce symptomatic arteriovenous shunting, and to pretreat patients for surgical excision or radiosurgery. In some cases, embolization alone may be able to angiographically cure an AVM, although this is a small percentage of all AVMs.

METHODS

This report reviews the current limitations of embolic therapy of cerebral AVMs from the standpoint of AVM angioarchitecture and the physical limitations of current embolic materials. In addition, it seeks to identify the areas in which embolization therapy may make advancements both as a pretreatment and as a sole therapy.

RESULTS

Currently, liquid embolic agents, ethylene vinyl alcohol, and n-butylcyanoacrylate seem to provide the greatest resistance to recanalization in AVM embolization. These agents, however, elicit only a weak, nonspecific, bioactive inflammatory response by histopathology.

CONCLUSION

The further evaluation and understanding of the vascular biology of AVM vessels and the endothelium cell wall biology will help us devise more bioactive material solutions to AVM nidus obliteration. Targeting specific receptors in AVMs with the embolic material delivered may additionally enhance the effects of radiosurgery in these patients.

Gamma knife radiosurgery for medically and surgically refractory prolactinomas

OBJECTIVE

Experience with gamma knife radiosurgery (GKRS) for prolactinomas is limited because of the efficacy of medical and surgical intervention. Patients who are refractory to medical and/or surgical therapy may be treated with GKRS. We characterize the efficacy of GKRS for medically and surgically refractory prolactinomas.

METHODS

We reviewed our series of patients with prolactinomas who were treated with GKRS after failing medical and surgical intervention who had at least 1 year of follow-up.

RESULTS

Twenty-three patients were included in analysis of endocrine outcomes (median and average follow-up of 55 and 58 mo, respectively) and 28 patients were included in analysis of imaging outcomes (median and average follow-up of 48 and 52 mo, respectively). Twenty-six percent of patients achieved a normal serum prolactin (remission) with an average time of 24.5 months. Remission was significantly associated with being off of a dopamine agonist at the time of GKRS and a tumor volume less than 3.0 cm3 (P < 0.05 for both). Long-term image-based volumetric control was achieved in 89% of patients. Complications included new pituitary hormone deficiencies in 28% of patients and cranial nerve palsy in two patients (7%).

CONCLUSION

Clinical remission in 26% of treated patients is a modest result. However, because the GKRS treated tumors were refractory to other therapies and because complication rates were low, GKRS should be part of the armamentarium for treating refractory prolactinomas. Patients with tumors smaller than 3.0 cm3 and who are not receiving dopamine agonist at the time of treatment will likely benefit most.

Meningeoma pós-radioterapia

Os meningeomas são neoplasias derivadas das células aracnóideas, sendo sua origem ligada a alterações genéticas idiopáticas (deleção do braço longo do cromossomo 22), doenças predisponentes à sua formação e indução por radioterapia. Relata-se o caso de um homem de 50 anos com meningeoma pós-radioterapia diagnosticado 20 anos após o tratamento de um oligodendroglioma. Os critérios que suportam o diagnóstico de meningeoma induzido por radioterapia são discutidos, assim como é revisada a literatura pertinente ao assunto.

Metachronous secondary atypical meningioma and anaplastic astrocytoma after postoperative craniospinal irradiation for medulloblastoma

INTRODUCTION

Malignant brain tumors have been reported to occur after childhood irradiation more frequently than in the nonirradiated population.

DISCUSSION

In this study, we report the case of a 15-year-old boy treated for medulloblastoma with surgery and craniospinal radiotherapy, who developed a meningioma 18 years after initial treatment and subsequently an anaplastic astrocytoma 23 years after primary treatment. The meningioma was resected without complications. The patient is currently alive but with recurrent astrocytoma after a complete remission on temozolomide monotherapy. Second malignancies are a rare, potentially devastating risk in cancer survivors, with risk continuing lifelong.

Late development of intraventricular papillary pituitary carcinoma after irradiation of prolactinoma

BACKGROUND

Intracranial dissemination of pituitary adenomas is a rare event that does not equate malignancy. Most of the cases have been reported as metastases from pituitary carcinoma. A case of papillary pituitary carcinoma developed 12 years after radiotherapy for prolactin-secreting hormone pituitary adenoma is presented.

CASE DESCRIPTION

A 37-year-old woman was admitted for the second time with neurologic disturbance and hypertension. A gadolinium-enhanced magnetic resonance scan of the brain demonstrated a 50-mm enhanced mass (absent on previous studies) on the lateral ventricle, involving the left temporal lobe. The patient underwent a craniotomy and biopsy of the lesion that was consistent with pituitary carcinoma; it was immunoreactive to follicle-stimulating hormone, adrenocorticotropic hormone, pituitary tumor-transforming gene, and epithelial cell adhesion molecule. Transmission electron microscopy analysis confirmed the secretory pituitary tumor diagnosis.

CONCLUSIONS

The tumor was considered a primary pituitary papillary carcinoma. The clinical course indicated that this tumor was the seedling of a pituitary tumor, although it could be interpreted as metastases from a pituitary carcinoma.

Review of the literature on de novo formation of cavernous malformations of the central nervous system after radiation therapy

✓In this paper the authors review the literature concerning de novo cavernoma formation after radiation treatment. PubMed and MEDLINE database searches were performed. Data were compiled on all patients in whom de novo cavernomas formed after radiation treatment and whose cases were reported in the literature. The authors found reports in the literature of 76 patients in whom cavernomas formed de novo after radiation treatment. The mean age of the patients was 11.7 years, and the majority of these lesions occurred in males. The patients received a mean radiation dose of 60.45 Gy. The mean latency period before detection of the cavernoma was 8.9 years, and most of these lesions were detected incidentally. In symptomatic patients, the most common presenting symptoms were seizures. Thirty-seven of the patients had evidence of hemorrhage, and 54% of these required surgical intervention.

De novo formation of cavernomas after radiation treatment is a relatively rare phenomenon. Patients in whom these cavernomas develop need to be followed closely because there is a propensity for the lesions to hemorrhage. Surgical intervention to treat symptomatic lesions has a favorable outcome.

Growth Retardation and Bilateral Cataracts Followed by Anaplastic Meningioma 23 Years after High-Dose Cranial and Whole-Body Irradiation for Acute Lymphoblastic Leukemia: Case Report and Review of the Literature

We report a case of meningioma diagnosed 23 years after high-dose cranial and whole-body irradiation for the treatment of acute lymphocytic leukemia (ALL). Radiotherapy in this case also caused early radiation injury to the lenses and the pituitary gland, with growth retardation and mineralizing angiopathy. Radiation-induced meningiomas are more commonly malignant, more commonly multiple, and more likely to recur after resection than non-radiation-induced meningiomas. Survivors of childhood ALL treated with high-dose cranial irradiation are at risk both for early radiation injury in radiosensitive organs, such as the lens and pituitary gland, and for the later development of a radiation-induced meningioma.

Cerebral Cavernous Malformations Associated with Venous Anomalies: Surgical Considerations

OBJECTIVE:

Once thought to be rare entities, mixed cerebrovascular malformations with pathological features of more than one type of malformation within the same lesion are now being recognized with increasing frequency. Their identification generates several hypotheses about common pathogenesis or causation-evolution among different types of lesions and leads to controversial discussion on therapeutic strategies.

METHODS:

Fifteen patients drawn from a consecutive series of 58 patients harboring cavernous malformations (25.9%) were found to have an associated venous malformation (VM). Three (33.3%) of the first 9 patients, in whom the large draining vein of the VM had been left untouched at previous interventions, developed recurrent and/or de novo lesions.

RESULTS:

Histopathological analysis, interestingly, revealed that the new lesions were different in nature (three arteriovenous angiomas in two patients, a capillary telangiectasia in one patient). During extirpation of the new malformation, the draining vein of the VM in these three patients could be coagulated without any adverse events. Coagulation and dissection of the draining vein of the associated VM was performed in six more patients of our series, and this has prevented development of new lesions up to now.

CONCLUSION:

Our results are in favor of the hypothesis that the draining vein of a VM is the actual underlying abnormality of mixed vascular malformations. Causing flow disturbances and having the potential for hemorrhages, the VM seems to promote the development of new adjacent malformations. Thus, permanent cure of associated malformations might depend on the surgical treatment of the VM. We present a preliminary personal series and a thorough review of the literature.

De novo presentation of an arteriovenous malformation. Case report and review of the literature

The authors report the case of a patient with a de novo arteriovenous malformation (AVM), indicating that the origin of these lesions may not always be congenital. A 3-year-old girl who was struck by a car suffered a mild head injury and experienced posttraumatic epilepsy. The initial magnetic resonance (MR) image obtained in this child revealed only a small contusion in the left frontal lobe. Intractable epilepsy subsequently developed. A second MR image obtained almost 4 years after the injury demonstrated an AVM in the right posterior temporal lobe that was verified using angiography. The lesion was classified as a Spetzler-Martin Grade III AVM. The patient underwent embolization of the feeding vessels followed by gamma knife surgery. Fourteen months after treatment she was asymptomatic. Follow-up MR images demonstrate no evidence of an AVM and no changes in the white matter. This case presents a de novo AVM that developed within approximately 4 years. The findings indicate that AVMs may not always be congenital and reinforce the concept that the natural history of AVMs is dynamic. Lesions may appear de novo, grow, and thrombose spontaneously.

Multiple Spinal Cavernous Malformations with Atypical Phenotype after Prior Irradiation: Case Report

OBJECTIVE AND IMPORTANCE:

This is the first reported case of histologically proven multiple spinal cavernous malformations (CMs) associated with previous irradiation. There are only two cases reported in the literature of solitary spinal CM after irradiation. In addition, the lesions in our patient had an atypical magnetic resonance imaging appearance mimicking intraspinal drop metastasis.

CLINICAL PRESENTATION:

A 33-year-old man had an incidental finding of multiple enhancing intraspinal lesions as revealed by magnetic resonance imaging during staging tests for hepatocellular carcinoma. He had a history of Wilms' tumor at a young age with irradiation to the abdomen and pelvis. His family history included a paternal cousin with multiple cerebral CMs. The diagnosis of spinal drop metastasis was made, and further intervention was undertaken for confirmation.

INTERVENTION:

The patient underwent a lumbar laminectomy with durotomy and excision of two of the lesions. Macroscopic analysis revealed mulberry-like appearance with nerve root involvement, and pathological analysis confirmed the diagnosis of CM. Genetic testing of the patient and his affected cousin was negative for the CCM1 gene.

CONCLUSION:

The occurrence of multiple spinal lesions in the context of known neoplasia indicates a diagnosis of metastasis. Spinal CMs were not suspected preoperatively because of the atypical appearance revealed by magnetic resonance imaging scans, with uniform contrast enhancement and absence of hemosiderin rim. This case report is discussed relative to previous literature regarding radiation-induced CMs and other known causes of the disease.

Radiation-induced intracranial meningiomas: review of six operated cases

It is well known that radiation can induce meningiomas. These tumors usually arise in patients with a history of low-dose radiation to the scalp for treatment of tinea capitis or high-dose radiation for a previous brain tumor. Radiation-associated meningiomas (RAMs) morphologically resemble their spontaneously arising counterparts. However, RAMs frequently present a more malignant phenotype and, as such, are diagnosed as "atypical" or "aggressive" meningiomas and occur predominantly in younger patients. This paper describes six cases of radiation-associated intracranial meningiomas in patients previously treated with low-dose radiation to the scalp for tinea capitis.

Radiation-induced meningiomas: clinical, pathological, cytokinetic, and cytogenetic characteristics

Object. Radiation-induced meningiomas are known to occur after high- and low-dose cranial radiation therapy. The goal of this study was to discern the distinguishing findings and characteristics of radiation-induced meningiomas.

Methods. The records of 16 patients (seven men and nine women) who fulfilled the criteria for radiation-induced meningiomas were retrospectively reviewed. Clinical, histopathological, cytokinetic, and cytogenetic findings as well as the patients' outcome were analyzed.

The mean age of the patients was 38.8 years and the mean tumor latency was 26.5 years. Five patients had multiple meningiomas in the irradiated field. The recurrence rate was 100% after the initial resection; 62% of patients had a second recurrence and 17% had a third recurrence. Thirty-eight percent of patients had atypical or malignant histopathological findings. The presence of progesterone receptors and low proliferation indices in these patients did not correlate with benign tumor behavior. Cytogenetic analysis showed multiple clonal aberrations in all tumors studied. The most frequent aberrations were found on chromosomes 1p, 6q, and 22. Derivative, lost, or additional chromosome 1p was found in 89% of cases and loss or deletion on chromosome 6 was found in 67%.

Conclusions. The age of patients at presentation with meningioma and the latency period of radiation-induced meningiomas are dose related. These tumors are more aggressive and are certain to recur, have a higher histopathological grade, and are associated with complex cytogenetic aberrations particularly involving 1p and 6q.

Rare Presentations of Delayed Radiation Injury: A Lobar Hematoma and a Cystic Space-occupying Lesion Appearing More Than 15 Years after Cranial Radiotherapy: Report of Two Cases

OBJECTIVE AND IMPORTANCE

Radiation vasculopathy and radionecrosis, constituting delayed radiation injury, are rare but recognized complications of radiation therapy occurring at a peak incidence of 3 years after treatment. Little information is available about these complications occurring more than 15 years after radiotherapy and presenting as other than solid intracranial masses.

CLINICAL PRESENTATION

We describe two patients who presented with space-occupying cerebral lesions. Patient 1 presented as an emergency with a sudden loss of consciousness. Computed tomography revealed a large left intracerebral hemorrhage; cerebral angiography disclosed nothing abnormal, and a primary spontaneous hemorrhage was presumed. Twenty-seven years earlier, this patient had received adjuvant whole-brain and spine radiotherapy and concomitant chemotherapy after excision of a vermis medulloblastoma. Patient 2 presented with a left frontal cystic lesion (presumed malignant glioma) as the cause of personality and behavioral changes for some months. She had previously received external beam radiation for a basal cell epithelioma, which had been excised from her left forehead 19 years earlier.

INTERVENTION

Both patients recovered well after undergoing craniotomies and removal of their lesions; they were discharged home with no neurological deficit.

CONCLUSION

Even after long intervals after radiotherapy, it is important to consider radiation vasculopathy and radionecrosis as differential diagnoses of more common conditions. Histological confirmation of a delayed radiation injury in the absence of any evidence of neoplasia or vascular abnormality has allowed appropriate prognosis and management to be formulated with confidence in each of these patients.

Stereotactic Radiosurgery as an Alternative to Fractionated Radiotherapy for Patients with Recurrent or Residual Nonfunctioning Pituitary Adenomas

OBJECTIVE

To evaluate tumor control rates and complications after stereotactic radiosurgery for patients with nonfunctioning pituitary adenomas.

METHODS

Between 1992 and 2000, 33 patients underwent radiosurgery for treatment of nonfunctioning pituitary adenomas. Thirty-two patients (97%) had undergone one or more previous tumor resections. Twenty-two patients (67%) had enlarging tumors before radiosurgery. The median tumor margin dose was 16 Gy (range, 12–20 Gy). The median follow-up period after radiosurgery was 43 months (range, 16–106 mo).

RESULTS

Tumor size decreased for 16 patients, remained unchanged for 16 patients, and increased for 1 patient. The actuarial tumor growth control rates at 2 and 5 years after radiosurgery were 97%. No patient demonstrated any decline in visual function. Five of 18 patients (28%) with anterior pituitary function before radiosurgery developed new deficits, at a median of 24 months after radiosurgery. The actuarial risks of developing new anterior pituitary deficits were 18 and 41% at 2 and 5 years, respectively. No patient developed diabetes insipidus.

CONCLUSION

Stereotactic radiosurgery safely provides a high tumor control rate for patients with recurrent or residual nonfunctioning pituitary adenomas. However, despite encouraging early results, more long-term information is needed to determine whether radiosurgery is associated with lower risks of new endocrine deficits and radiation-induced neoplasms, compared with fractionated radiotherapy.

Results of stereotactic radiosurgery in patients with hormone-producing pituitary adenomas: factors associated with endocrine normalization

OBJECT

The goal of this study was to determine factors associated with endocrine normalization after radiosurgery is performed in patients with hormone-producing pituitary adenomas.

METHODS

Between 1990 and 1999, 43 patients with hormone-producing pituitary adenomas underwent radiosurgery: 26 patients with growth hormone (GH)-producing tumors, nine with adrenocorticotrophic hormone-producing tumors, seven with tumors that produced prolactin (PRL) alone, and one with a tumor that secreted both GH and PRL. The median patient age was 42 years. Thirty-seven patients (86%) had undergone surgery earlier and in 30 (70%) there was tumor extension into the cavernous sinus. The product-limit method was used to calculate endocrine normalization while patients were not receiving any hormone-suppressive medication. The median follow-up period after radiosurgery was 36 months (range 12-108 months). In 20 patients (47%) there was normalization of hormone secretion at a median of 14 months (range 2-44 months) after radiosurgery; no correlation was found between tumor type and cure. Actuarial cure rates were 20, 32, and 61% at 1, 2, and 4 years posttreatment. Multivariate analysis demonstrated that the absence of hormone-suppressive medications at the time of radiosurgery (relative risk 8.9, 95% confidence interval [CI] 1.2-68.7, p = 0.04) and maximum radiation doses greater than 40 Gy (relative risk 3.9, 95% CI 1.3-11.7, p = 0.02) correlated with an endocrine cure. A new anterior pituitary deficiency developed in seven patients (16%), temporal lobe necrosis was identified in two patients, an asymptomatic internal carotid artery stenosis was detected in two patients, and unilateral blindness occurred in one patient.

CONCLUSIONS

Radiosurgery provides an endocrine cure for many patients with persistent or recurrent hormone-producing pituitary adenomas. Further study is needed to determine whether pituitary hormone-suppressive medications have a radioprotective effect.

Radiation-induced cavernous hemangiomas of the brain: a late effect predominantly in children

INTRODUCTION

The induction of cavernomas as a consequence of brain irradiation was first suspected in 1994 and has been controversial since that time.

METHODS

Between 1986 and 2000, 189 cerebral cavernomas were diagnosed in the Neurosurgical Department of the University of Heidelberg; of those patients, 5 had received prior radiation therapy. The ages of these 5 patients were compared with those of the 184 others with naturally occuring cavernomas. In an examination of 40 patients with cavernomas occurring after radiation (the 5 mentioned above, plus 35 from the literature) the age distribution was investigated, and a possible relationship between radiation dosage and latency interval to diagnosis of cavernoma was examined.

RESULTS

Almost one in four of the patients under 15 years of age diagnosed with a cerebral cavernoma in the Neurosurgical Department of the University of Heidelberg had received prior radiation. In 40 patients with cavernomas and prior radiation (5 from Heidelberg, 35 from the literature), there was a clear accumulation in the age group of 10-19 years (50%). Most of those patients had received radiation in the first 10 years of life. The accumulation of cavernomas after radiation in childhood could not be explained by a greater frequency of radiation exposure in children compared to adults. In children up to 10 years of age at the time of radiation therapy, a dose of 3000 cGy and higher was followed by a shorter latency interval to incidence of cavernoma (P = 0.0018). In patients older than 10 years at the time of radiation, postradiation cavernomas only occurred when dosage was 3000 cGy or greater.

CONCLUSION

These results indicate a correlation between radiation and cavernoma, particularly in children under 10 years of age at the time of radiation therapy. In adults, cavernomas after radiation rarely occur, and then only after higher radiation dosages (3000 cGy or more).

De novo cerebral arteriovenous malformation: case report

OBJECTIVE AND IMPORTANCE

Arteriovenous malformations (AVMs) are generally thought to have a congenital cause. This is the first report of an angiographically proven de novo cerebral AVM in an adult patient without previous vascular abnormality.

CLINICAL PRESENTATION

A 26-year-old African-American woman developed multiple cranial nerve deficits and ataxia over the course of a few days after a streptococcal throat infection. T2-weighted magnetic resonance imaging scans revealed a hyperintense signal in the midbrain with extension into the diencephalon. A cerebral angiogram performed at that time to exclude vasculitis revealed normal cerebral vasculature. The patient was treated with corticosteroids, and symptoms resolved. Subsequently, at the age of 32, this patient presented with a severe headache and emesis, but with no focal neurological deficit.

INTERVENTION

The patient's cranial computed tomographic and magnetic resonance imaging scans revealed a right posterior temporal intraparenchymal hemorrhage, and cerebral angiography revealed a new 3- by 2-cm AVM. The patient underwent microsurgical resection of the AVM and associated hematoma. Postoperative angiography revealed no evidence of residual AVM.

CONCLUSION

This study details the case of a woman who developed a de novo cerebral AVM during a 6-year period. This report challenges the conventional belief that all AVMs have a congenital cause.

Surgical decision-making on cerebral cavernous malformations

This study is an attempt to clarify surgical decision-making on cerebral cavernous malformations based on the data available in the literature. Using a mathematical model, we calculated the morbidity-free survival curves of the patients harboring cerebral cavernous malformations. Using these survival curves, we calculated the morbidity-free life expectancies of the patients at certain age undergoing either natural course or surgery. For superficially located lesions, permissible surgical risks were very small ranging from 0.4 to 2.8 percent of combined morbidity and mortality. The surgical gain of morbidity free life expectancy was also very small (0.0-1.1 years) irrespective of patient's age or eloquence of the location. For deep lesions, the permissible risk of surgery was very large, ranging from 64.1% for a 20-year-old and 31.4% for a 60-year-old patient. The gain of morbidity-free life expectancy was also large for younger patients (17-25 years for 20-year-old patients), but this gain rapidly decreased as the patient's age grew older, becoming 1.1 to 3.1 years for 60-year-old patients. Surgery seems to be justified for younger patients with deep lesions. There seems to be little indication for surgery of superficial lesions as far as the risk of bleeding is concerned.

Secondary intracranial meningiomas after high-dose cranial irradiation: report of five cases and review of the literature

PURPOSE

To review cases of secondary intracranial meningiomas following high-dose cranial irradiation (>/= 10 Gy) identified in Slovenia between 1968 and 1998, to determine their histological profile and to review the literature on this topic.

METHODS AND MATERIALS

Personal files of patients treated for secondary intracranial meningioma during a 31-year period were reviewed. In cases which met the criteria for radiation-induced tumors, steroid hormone receptor and Ki-67 status were analyzed. For the literature review, computerized database systems and reference lists from respective publications were used.

RESULTS

Five patients (2 females, 3 males), 3-11 years old at the time of cranial irradiation, developed secondary meningioma after a latency period of 9.5-31.5 years. Three patients had multiple tumors and 2 developed recurrent disease. Of 9 histologically examined tumors, 5 were graded as benign and 4 as atypical meningiomas, with Ki-67 proliferative index 3.2 +/- 3.6 and 10 +/- 6, respectively. The ratio between positive and negative meningiomas regarding immunostaining for progesterone and estrogen receptors was eight-to-one and six-to-three, respectively. Cumulative actuarial risk of secondary meningioma in a cohort of 445 children 16 years or younger treated with high-dose cranial irradiation between 1968 and 1990 in Slovenia at 10, 20, and 25 years was 0.53%, 1.2%, and 8.18%, respectively. Out of 126 cases of radiation-induced meningiomas reported, 57% were females and 43% were males, with mean age at presentation 33 +/- 17.3 years. The majority (68%) of patients was irradiated during childhood. The latency period was significantly shorter in those who aged 5 years or less at the time of cranial irradiation (p = 0.04), and in those with atypical/anaplastic tumor (p = 0.01). Correlation between radiation dose and latency period could not be found.

CONCLUSION

Secondary meningiomas following high-dose cranial irradiation are characterized by younger age at presentation, by higher male-to-female ratio and by biologically more aggressive variants compared to primary spontaneous meningiomas. Latency period correlated with the age at the time of cranial irradiation and with tumor grade but not with irradiation dose. Ki-67 immunoreactivity correlated with histological grade. The progesterone and estrogen receptor immunoreactivity was high. The risk for development of secondary meningioma after high-dose cranial irradiation was increasing with the time of follow-up.

Sarcomatous transformation of a prolactinoma associated with development of a fatal internal carotid artery pseudoaneurysm--case report

A 21-year-old female with a 5-year history of prolactinoma was referred to our hospital because of cerebrospinal fluid leakage and meningitis immediately following a third transsphenoidal operation for a rapidly growing tumor. Histological examination of the tumor removed at the second transsphenoidal operation found atypical epithelial and sarcomatous components. Administration of bromocriptine, radiotherapy, and chemotherapy were initiated. Emergent craniotomy was required for rapid regrowth of the tumor. Histological examination found predominant sarcomatous components. Tumor growth was difficult to control. The patient died of subarachnoid hemorrhage due to rupture of a pseudoaneurysm involving the C1 portion of the right internal carotid artery. Pituitary adenoma rarely shows malignant transformation. In this case, prolactinoma underwent malignant change to sarcoma. Development of the pseudoaneurysm may have resulted from surgical manipulation, radiotherapy, or tumor invasion.

De novo development of a cavernous malformation of the spinal cord following spinal axis radiation. Case report

Analysis of recent reports has suggested that cavernous malformations (CMs) of the brain may have an acquired pathogenesis and a dynamic pathophysiological composition, with documented appearance of new lesions in familial cases and following radiotherapy. The authors report the first case of demonstrated de novo formation of an intramedullary CM following spinal radiation therapy. A 17 year-old boy presented with diabetes insipidus and delayed puberty. Evaluation of endocrine levels revealed hypopituitarism, and magnetic resonance (MR) imaging demonstrated an infundibular mass. The patient underwent a pterional craniotomy and removal of an infundibular germinoma. The MR image of the spine demonstrated normal results. The patient received craniospinal radiation therapy and did well. He presented 5 years later with acute onset of back pain, lower-extremity weakness and numbness, and difficulty with urination. An MR image obtained of the spine revealed an intramedullary T-7 lesion; its signal characteristics were consistent with a CM. The patient was initially managed conservatively but developed progressive myelopathy and partial Brown-Séquard syndrome. Although he received high-dose steroids and bed rest, his symptoms worsened. He underwent a costotransversectomy and excision of a hemorrhagic vascular lesion via an anterolateral myelotomy. Pathological examination confirmed features of a CM. The patient has done well and was walking without assistance within 4 weeks of surgery. De novo genesis of CMs may be associated with prior radiation therapy to the spinal cord.