Progressive Paraparesis and Spinal Glioblastoma in a Young Female

Glioblastoma, a primary brain tumor known for its adverse prognosis and aggressive nature, presents a significant challenge when occurring in the spinal cord. We report a case of a 20-year-old female with no prior medical history who developed progressive paraparesis and urinary retention, symptoms indicative of an intramedullary glioblastoma in the spinal cord. This case study delves into the clinical presentation, diagnostic process, and therapeutic interventions, highlighting the complexities encountered during the patient's treatment course. Despite the typically poor prognosis associated with glioblastoma, with an average survival rate of approximately 15 months post-diagnosis, our patient's initial response to adjuvant chemotherapy and radiotherapy extended her survival to 34 months. However, tumor recurrence ultimately led to a decision against aggressive treatment, reflecting the challenges in managing this devastating condition. This case emphasizes the importance of a multidisciplinary approach in the care of spinal glioblastoma patients, ranging from neurosurgery, anesthesiology and intensive care, radiology, oncology, anatomic pathology and nuclear medicine, underscoring the complexity of the disease, while highlighting the urgent need for ongoing research and innovation in neuro-oncology to improve treatment outcomes. The use of modern treatment techniques, including the potential role of nanomaterials for drug delivery, suggests avenues for future research. This case report contributes to the scarce literature on spinal glioblastoma, advocating for detailed documentation of cases to enhance understanding and treatment strategies for this formidable disease.

New Breakthroughs in the Diagnosis of Leptomeningeal Carcinomatosis: A Review of Liquid Biopsies of Cerebrospinal Fluid

Leptomeningeal carcinomatosis represents a terminal stage and is a devastating complication of cancer. Despite its high incidence, current diagnostic methods fail to accurately detect this condition in a timely manner. This failure to diagnose leads to the refusal of treatment and the absence of clinical trials, hampering the development of new therapy strategies. The use of liquid biopsy is revolutionizing the field of diagnostic oncology. The dynamic and non-invasive detection of tumor markers has enormous potential in cancer diagnostics and treatment. Leptomeningeal carcinomatosis is a condition where invasive tissue biopsy is not part of the routine diagnostic analysis, making liquid biopsy an essential diagnostic tool. Several elements in cerebrospinal fluid (CSF) have been investigated as potential targets of liquid biopsy, including free circulating tumor cells, free circulating nucleic acids, proteins, exosomes, and even non-tumor cells as part of the dynamic tumor microenvironment. This review aims to summarize current breakthroughs in the research on liquid biopsy, including the latest breakthroughs in the identification of tumor cells and nucleic acids, and give an overview of future directions in the diagnosis of leptomeningeal carcinomatosis.

Selected-Lesion Stereotactic Radiosurgery (SL-SRS) as a Novel Strategy in the Treatment of Patients With Multiple Brain Metastases

INTRODUCTION

With the diminishing use of whole-brain radiotherapy (WBRT), there is increasing debate regarding the maximum number of brain metastases that should be treated with stereotactic radiosurgery (SRS). In patients with >10-15 lesions, some groups are proposing a new approach - selected-lesion SRS (SL-SRS) - where only a subset of intracranial lesions are chosen for irradiation. This study is an initial look into this practice.

METHODS

This is a cross-sectional exploratory survey study. A survey of 19 questions was created by the International Radiosurgery Research Foundation (IRRF) using open-ended and multiple-choice style questions on SL-SRS practices and indications with the goal of qualitatively understanding how SL-SRS is being implemented worldwide. The survey was distributed to physicians in the United States (US) and internationally who are members of the IRRF and who perform SRS frequently. Ten out of 50 IRRF institutions provided responses reflecting the practices of 16 physicians.

RESULTS

SL-SRS is being performed at 8/10 institutions. The most common reasons for using SL-SRS included patients with prior WBRT, patients with progressing systemic disease with central nervous system (CNS)-penetrating or immunotherapies available, specific requests from medical oncology, and cooperative studies using this approach. Lesion size was cited as the most important factor when choosing to irradiate any single lesion. The majority of respondents reported 30 mm and 40 mm as size cutoffs (by largest dimension) for treatment of a lesion in eloquent and non-eloquent locations, respectively. Eloquence of lesion location and attributable symptoms were also considered important. Progression of untreated lesions was the most common reason reported for bringing patients back for additional treatment.

CONCLUSION

The responses to this survey show that SL-SRS is being used, allowing for small/asymptomatic brain metastases to be left safely unirradiated. It is currently used in patients who have >10-15 lesions with prior WBRT, those with progression of extracranial disease but with acceptable systemic treatment options, and those with poor functional status. The incorporation of this new approach into clinical trials should be considered for the safe study of the efficacy of new CNS-penetrating systemic therapies.

Difluoromethylornithine (DFMO) and Neuroblastoma: A Review

Neuroblastoma is a type of cancer that affects the sympathetic nervous system and is the most common extracranial solid tumor in children. Difluoromethylornithine (DFMO) is a drug that has shown promise as a treatment option for high-risk neuroblastoma. This review aims to provide an overview of the current research on the use of DFMO in neuroblastoma treatment. The review includes a discussion of the mechanisms of action of DFMO, as well as its potential for use in combination with other treatments such as chemotherapy and immunotherapy. The review also examines the current clinical trials involving DFMO in high-risk neuroblastoma patients and provides insights into the challenges and future directions for the use of DFMO in neuroblastoma treatment. Overall, the review highlights the potential of DFMO as a promising therapy for neuroblastoma and highlights the need for further research to fully understand its potential benefits and limitations.

Primary Intramedullary Spinal Melanoma: A Rare Disease of the Spinal Cord

Primary malignant melanoma of the intramedullary region of the spinal cord has rarely been reported in the literature. These tumors can have variable appearance on magnetic resonance imaging (MRI) due to different extents of melanin and hemorrhage. Histopathologic confirmation and a comprehensive workup to rule out extra-spinal melanoma are required to make definitive diagnosis. We present a case of a patient diagnosed with primary intramedullary spinal melanoma in his lower thoracic spinal cord who was effectively treated with surgical resection, adjuvant radiation, and adjuvant immunotherapy. Gross total resection (GTR) is most vital in the management of this spinal tumor. Although several studies have established the efficacy of immunotherapy agents in advanced malignant melanoma, the use of these agents has not been studied in primary central nervous system melanomas. This case provides insight into the diagnostic approach and treatment options for this unique malignancy.

Meningeal Hemangiopericytoma Presenting as Pure Gerstmann Syndrome: A Double Rarity

Gerstmann syndrome is a neurobehavioral syndrome characterized by four cardinal symptoms: acalculia, agraphia, finger-toe agnosia, and dysgraphia. The syndrome is caused primarily by lesions at the confluence of parietal, temporal, and occipital lobes, but also can involve the middle frontal lobe of the dominant hemisphere. Documented inciting lesions include stroke, tumor, hemorrhage, arteriovenous malformations, and seizures. A meningeal solitary fibrous tumor (SFT)/hemangiopericytoma (HPC) is a diagnostic challenge due to its resemblance to more common brain tumors like meningioma, with histopathology being the definitive diagnostic test. A 37-year-old male presented to our tertiary center with blurred vision, “not being himself,” and “acting funny” for three weeks. On exam, he was found to have a right inferior quadrantanopia, grade II papilledema and demonstrated all four symptoms of Gerstmann syndrome - inability to perform simple calculations (acalculia), or identify his fingers (finger agnosia), could not distinguish his left side from the right (left-right disorientation), nor write out his name (agraphia). Brain imaging showed an extra-axial, highly vascularized 7.6-cm mass compressing the left parietal lobe. He underwent a complete resection of the mass. Postoperatively, he had gradual improvement with complete resolution of agraphia, acalculia, finger agnosia, and left-right disorientation within a week status post-resection. Tumor pathology indicated hemangiopericytoma/solitary fibrous tumor. This case enunciates the enigmatic tetrad of Gerstmann syndrome. Though classically described as a sequela of stroke, the mass effect of the tumor on the parietal lobe may produce the symptoms, which can resolve following resection.

Pleomorphic Xanthoastrocytoma of the Frontal Lobe in a Child: A Rare Entity

Pleomorphic xanthoastrocytoma (PXA) is an infrequent neoplasm that affects children less commonly than adults. In this case report, a four-year-old boy presented with focal seizures has diagnosed with this tumor in the frontal lobe. Complete surgical resection was achieved, and histopathological features of PXA grade II were observed. During follow-up, the patient showed improvement of the focal seizures. In spite of the pleomorphic features, the PXA had a favorable prognosis.

Multicentric Spinal Pilocytic Astrocytoma Presenting with Syringomyelia

Pilocytic spinal cord astrocytomas make up 21% of intramedullary tumors. Only 20% of those tumors are associated with syringomyelia. To our knowledge, this is the first report of an adult presenting with multiple spinal pilocytic astrocytomas associated with syringomyelia. We report a case of a 27-year-old woman who had neck and arm pain for months. She underwent cervical magnetic resonance imaging (MRI) that demonstrated a syrinx from C2 and extending to C6. A coronal view of the MRI showed multiple mural nodules. Total excision of multicentric nodules within a cyst was performed with an uneventful intraoperative and postoperative period and the patient was discharged home with moderate right-hand numbness.

An Open-Source Tool for Anisotropic Radiation Therapy Planning in Neuro-oncology Using DW-MRI Tractography

There is evidence from histopathological studies that glioma tumor cells migrate preferentially along large white matter bundles. If the peritumoral white matter structures can be used to predict the likely trajectory of migrating tumor cells outside of the surgical margin, then this information could be used to inform the delineation of radiation therapy (RT) targets. In theory, an anisotropic expansion that takes large white matter bundle anatomy into account may maximize the chances of treating migrating cancer cells and minimize the amount of brain tissue exposed to high doses of ionizing radiation. Diffusion-weighted MRI (DW-MRI) can be used in combination with fiber tracking algorithms to model the trajectory of large white matter pathways using the direction and magnitude of water movement in tissue. The method presented here is a tool for translating a DW-MRI fiber tracking (tractography) dataset into a white matter path length (WMPL) map that assigns each voxel the shortest distance along a streamline back to a specified region of interest (ROI). We present an open-source WMPL tool, implemented in the package Diffusion Imaging in Python (DIPY), and code to convert the resulting WMPL map to anisotropic contours for RT in a commercial treatment planning system. This proof-of-concept lays the groundwork for future studies to evaluate the clinical value of incorporating tractography modeling into treatment planning.