Postradiation gliosarcoma with osteosarcomatous components

TGF-β and BMP signaling are associated with the transformation of glioblastoma to gliosarcoma and then osteosarcoma

Background

Gliosarcoma, an isocitrate dehydrogenase wildtype (IDH-WT) variant of glioblastoma, is defined by clonal biphasic differentiation into gliomatous and sarcomatous components. While the transformation from a glioblastoma to gliosarcoma is uncommon, the subsequent transformation to osteosarcoma is rare but may provide additional insights into the biology of these typically distinct cancers. We observed a patient initially diagnosed with glioblastoma, that differentiated into gliosarcoma at recurrence, and further evolved to osteosarcoma at the second relapse. Our objective was to characterize the molecular mechanisms of tumor progression associated with this phenotypic transformation.

Methods

Tumor samples were collected at all 3 stages of disease and RNA sequencing was performed to capture their transcriptomic profiles. Sequential clonal evolution was confirmed by the maintenance of an identical PTEN mutation throughout the tumor differentiation using the TSO500 gene panel. Publicly available datasets and the Nanostring nCounter technology were used to validate the results.

Results

The glioblastoma tumor from this patient possessed mixed features of all 3 TCGA-defined transcriptomic subtypes of an IDH-WT glioblastoma and a proportion of osteosarcoma signatures were upregulated in the original tumor. Analysis showed that enhanced transforming growth factor-β (TGF-β) and bone morphogenic protein signaling was associated with tumor transformation. Regulatory network analysis revealed that TGF-β family signaling committed the lineage tumor to osteogenesis by stimulating the expression of runt-related transcription factor 2 (RUNX2), a master regulator of bone formation.

Conclusions

This unusual clinical case provided an opportunity to explore the modulators of longitudinal sarcomatous transformation, potentially uncovering markers indicating predisposition to this change and identification of novel therapeutic targets.

[Primary cerebral gliosarcoma: about two cases and review of the literature]

Gliosarcoma is a very rare brain tumor accounting for 1.8 -8% of all glial tumors. It has been classified by the World Health Organization as a variant of glioblastoma. It is a tumor with double glial and sarcomatous component. Patient's clinical picture is polymorphic, imaging data are evocative, diagnosis is based on histology. Treatment is always surgical. Prognosis is closely linked to the quality of resection. We here report two clinical cases with the aim of assessing the diagnostic, therapeutic and prognostic features of this rare entity.

Primary Cerebellar Gliosarcoma with Extracranial Metastases: An Orphan Differential Diagnosis

BACKGROUND

Gliosarcomas are rare, malignant primary brain tumors, most commonly located in the temporal lobe, that contain both glial and mesenchymal elements. Gliosarcomas located within the cerebellum are exceedingly rare. The previously unreported finding of a cerebellar gliosarcoma concurrently with an extracranial metastasis to the lungs is discussed here.

CASE DESCRIPTION

A 57-year-old man presented with a 3-month history of chest pain, weight loss, headaches, and vomiting. Physical examination revealed a left cerebellar dysfunction, and the radiological work-up revealed a 6 × 6-cm right apical pulmonary tumor and a 4 × 3.5 × 3.8-cm peripherally enhancing left cerebellar mass. On the basis of a smoking history in the setting of a lung lesion and cerebellar mass, the presumptive diagnosis was primary lung cancer with metastasis to the cerebellum. Gross total resection of a firm pseudo-encapsulated cerebellar mass was performed. The microscopic features and the immunohistochemical profile confirmed the diagnosis of Gliosarcoma. The thoracic lesion was removed subsequently, and pathology confirmed it as an extracranial metastasis from the cerebellar gliosarcoma. Adjuvant radiation and chemotherapy were then administered. No clinical or radiographic evidence of recurrence was observed during one year of follow-up monitoring.

CONCLUSIONS

To the best of our knowledge, a primary infratentorial gliosarcoma with extracranial metastases has not been previously described.

A biphasic tumor consisting of pilocytic astrocytoma with an anaplastic solitary fibrous tumor component in the pineal region: a case report and literature review

Here we report a case of a biphasic tumor consisting of pilocytic astrocytoma with anaplastic solitary fibrous tumor component in the pineal region. The majority of the tumor showed typical histologic features of pilocytic astrocytoma. A minor part of the tumor showed marked proliferation of short spindle cells around vessels. These spindle cells showed CD34 and CD99 immunoreactivity. From a review of the literature, we found that only one similar case has been reported. Contrary to the reported case, our case showed anaplastic features of solitary fibrous tumor histology.

Secondary gliosarcoma with extra-cranial metastases: a report and review of the literature

OBJECTIVE

To describe a unique case of secondary gliosarcoma (SGS) with widespread extra-cranial metastases that developed more than 5 years after the initial diagnosis of glioblastoma multiforme (GBM). This interval is the longest among the cases reported to date.

METHODS

A PUBMED search using the key words "secondary gliosarcoma" and "extra-cranial metastases" was performed followed by a review of cited literature.

RESULTS

Including our report, we found 44 cases of SGS, of which only 5 developed extra-cranial metastases.

CONCLUSION

SGS with extra-cranial metastases is extremely rare. Of previously reported cases, the longest survival was 2 months after the diagnosis of SGS. The present case had a survival of 6.5 months. Our case highlights the importance of screening for extra-cranial metastases in SGS. The optimal treatment of SGS is not known and strategies based on GBM and sarcoma treatments have been employed with limited success. A combination of treatment modalities may extend survival as in the present report; however the prognosis remains poor.

Radiological findings in gliosarcoma. A single institution experience

Gliosarcomas are rare tumors with a poor prognosis composed of intermingled malignant glial and sarcoma elements with an estimated incidence of 1.8-8.0% of all malignant astrocytic neoplasms. We aimed to review the imaging findings in eight patients with gliosarcoma who were treated in our center between 2002 and 2010. The diagnosis was confirmed by morphological and immunohistochemical stains. This study, to the best of our knowledge, is the largest describing the imaging manifestations of this tumor. Although our study revealed no unique radiological features for gliosarcoma, it is important to note that they all demonstrated either dural or ependymal involvement or both. Calcification, hemorrhage or cystic components are described with a tendency for a ring enhancement pattern. Interestingly pre-existing benign looking lesions and associated remotely located small meningiomas are also described.

[Secondary gliosarcoma: case report]

Gliosarcoma is a rare tumor of the central nervous system, consisting of gliomatous and sarcomatous elements. The glioblastoma can undergo a change in phenotype, transforming into a gliosarcoma, especially when the tumor has been treated with radiotherapy. Features unique to gliosarcoma compared to glioblastoma include their potential to appear similar to a meningioma at macroscopy, repeated reports of metastases and infrequency of EGFR mutations. We present a case of secondary gliosarcoma to emphasize on the specificities, essentially diagnostical of this rare entity.

Gliosarcoma of the cerebellar hemisphere: a case report and review of the literature

Gliosarcoma is a rare central nervous system tumor usually located in the supratentorial area. Here we report a rare case of a gliosarcoma that developed in the cerebellar hemisphere in a 70-year-old woman. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain revealed an infratentorial mass of which radiological features were similar to those of glioblastoma. The tumor was diagnosed by pathology as a gliosarcoma. Though rare, gliosarcoma should be considered in the differential diagnosis of infratentorial tumors with radiological features of glioblastoma or metastasis in elderly patients.

Secondary gliosarcoma after diagnosis of glioblastoma: clinical experience with 30 consecutive patients

OBJECT

Gliosarcoma can arise secondarily, after conventional adjuvant treatment of high-grade glioma. The current literature on the occurrence of secondary gliosarcoma (SGS) after glioblastoma multiforme (GBM) is limited, with only 12 reported cases. The authors present a large series of histologically confirmed SGSs, with follow-up to describe the clinical and radiological presentation, pathological diagnosis, and treatment outcomes.

METHODS

Gliosarcoma cases were identified using the University of California, San Francisco's Departments of Neurological Surgery and Neuropathology databases. Through a retrospective chart review, cases of gliosarcoma were considered SGS if the following inclusion criteria were met: 1) the patient had a previously diagnosed intracranial malignant glioma that did not have gliosarcoma components; and 2) the histopathological tissue diagnosis of the recurrence confirmed gliosarcoma according to the most current WHO criteria. Extensive review of clinical, surgical, and pathology notes was performed to gather clinical and pathological data on these cases.

RESULTS

Thirty consecutive patients in whom SGS had been diagnosed between 1996 and 2008 were included in the analysis. All patients had previously received a diagnosis of malignant glioma. For the initial malignant glioma, all patients underwent resection, and 25 patients received both external-beam radiation and chemotherapy. Three patients received radiotherapy alone, 1 patient was treated with chemotherapy alone, and 1 patient's tumor rapidly recurred as gliosarcoma, requiring surgical intervention prior to initiation of adjuvant therapy. The median time from diagnosis of the initial tumor to diagnosis of gliosarcoma was 8.5 months (range 0.5-25 months). All but 1 patient (who only had a biopsy) underwent a second operation for gliosarcoma; 8 patients went on to receive radiotherapy (4 had brachytherapy, 3 had external-beam radiation, and 1 had Gamma Knife surgery); and 14 patients received additional chemotherapy. The median length of survival from the time of gliosarcoma diagnosis was 4.4 months (range 0.7-46 months). The median survival from the time of the original GBM diagnosis was 12.6 months (range 5.7-47.4 months). Patients who had received concurrent and adjuvant temozolomide for GBM had worse outcomes than those who had not (4.3 and 10.5 months, respectively; p = 0.045). There was no difference in time to diagnosis of gliosarcoma in these 2 groups (8 and 8.5 months; p = 0.387). Two patients who had not received radiation therapy for GBM had an anecdotally very prolonged survival (20.9 and 46.4 months).

CONCLUSIONS

The data underscore the difficulty associated with management of this disease. The strikingly poor survival of patients with SGS who had previously received combined radiation and temozolomide chemotherapy for GBM may reflect a unique molecular profile of GBM that eventually recurs as SGS. Further work will be required, controlling for multiple prognostic factors with larger numbers of patients.

Gliosarcoma stem cells undergo glial and mesenchymal differentiation in vivo

Cancer stem cells (CSCs) are characterized by their self-renewing potential and by their ability to differentiate and phenocopy the original tumor in orthotopic xenografts. Long-term propagation of glioblastoma (GBM) cells in serum-containing medium results in loss of the CSCs and outgrowth of cells genetically and biologically divergent from the parental tumors. In contrast, the use of a neurosphere assay, a serum-free culture for selection, and propagation of central nervous system-derived stem cells allows the selection of a subpopulation containing CSCs. Gliosarcoma (GS), a morphological variant comprising approximately 2% of GBMs, present a biphasic growth pattern, composed of glial and metaplastic mesenchymal components. To assess whether the neurosphere assay would allow the amplification of a subpopulation of cells with "gliosarcoma stem cell" properties, capable of propagating both components of this malignancy, we have generated neurospheres and serum cultures from primary GS and GBM surgical specimens. Neurosphere cultures from GBM and GS samples expressed neural stem cell markers Sox2, Musashi1, and Nestin. In contrast to the GBM neurosphere lines, the GS neurospheres were negative for the stem cell marker CD133. All neurosphere lines generated high-grade invasive orthotopic tumor xenografts, with histological features strikingly similar to the parental tumors, demonstrating that these cultures indeed are enriched in CSCs. Remarkably, low-passage GS serum cultures retained the expression of stem cell markers, the ability to form neurospheres, and tumorigenicity. The GS experimental tumors phenocopied the parental tumor, exhibiting biphasic glial and mesenchymal components, constituting a clinically relevant model to investigate mesenchymal differentiation in GBMs.

Transformation of intracranial anaplastic astrocytoma associated with neurofibromatosis type I into gliosarcoma: case report

Gliosarcoma is an uncommon malignant brain tumor composed of distinct sarcomatous and malignant glial cell elements. These tumors are defined as a variant of glioblastoma, and it can be developed by progression of the malignant glial cell tumors or primary tumors. We report a rare case with gliosarcomatous recurrence of anaplastic astrocytoma with neurofibromatosis type 1 (NF-1) followed by chemoradiation therapy. A 26-year-old male patient was presented with headache. Five years before admission, he had been diagnosed with NF-1. Magnetic resonance imaging (MRI) showed a well-demarcated, enhanced lesion in the right frontal lobe and multiple enhanced lesions in the scalp, lower cervical, thoracic, and upper lumbar regions. He underwent an osteoplastic craniotomy with total tumor resection. Histopathology of the tumor showed findings corresponding with anaplastic astrocytoma. He was followed by radiotherapy and chemotherapy postoperatively. A month later, his spinal lesion was also resected and confirmed pathologically as plexiform neurofibroma. The subsequent follow-up period of 27 months was uneventful until he developed a generalized tonic-clonic seizure. MRI showed tumor recurrence in the original site of the tumor. Re-exploration was carried out. Pathological examination displayed a biphasic pattern of the glial and sarcomatous components suggesting gliosarcoma.

Secondary gliosarcoma: a review of clinical features and pathological diagnosis

OBJECT

Although secondary gliosarcoma after treatment of primary glioblastoma multiforme has been described, little is known of these rare tumors. In this article the authors review the literature on secondary gliosarcoma, with attention to clinical course and pathological features.

METHODS

A PubMed search of the key word intracranial "gliosarcoma" with and without "radiation" or "radiotherapy" in humans was performed. The 204 citations yielded were screened for relevancy to gliosarcomas that occur after treatment of previous intracranial neoplasms.

RESULTS

A search of the literature yielded 24 relevant articles, combined for a total of only 12 cases of secondary gliosarcoma and 12 cases of radiation-induced gliosarcoma. Of the 12 cases of secondary gliosarcoma, all were previously treated with surgery and radiotherapy (mean dose 50.7 Gy), with a mean survival of 13 months since time of gliosarcoma diagnosis (range 6.9-19.4 months). In the cases of radiation-induced gliosarcoma, the mean dose of previous radiotherapy was 51.3 Gy (median 54 Gy, range 24-60 Gy), and the mean survival since gliosarcoma diagnosis was 6.7 months (median 6 months, range 2-10 months).

CONCLUSIONS

Secondary gliosarcoma and radiation-induced gliosarcoma are exceedingly rare. The literature on secondary gliosarcoma illustrates a more favorable survival than for primary gliosarcoma but remains limited regarding clinical and radiographic presentation, response to treatment, and pathogenesis. The results of the present review also support the notion that secondary gliosarcomas and radiation-induced gliosarcomas are distinct entities, with longer survival and shorter latency of gliosarcoma induction seen in the former. Efforts to elucidate the role of radiotherapy in the induction of gliosarcomas may yield new insights into therapeutic risks of cranial radiation and CNS tumor pathogenesis.

Primary gliosarcoma: key clinical and pathologic distinctions from glioblastoma with implications as a unique oncologic entity

This report presents the historical experience, clinical presentation, treatment, prognosis, and pathogenesis of gliosarcoma described to date in the English literature. PubMed query of term “gliosarcoma” was performed, followed by a rigorous review of cited literature. Articles selected for analysis included: (1) case reports of gliosarcoma, (2) review articles of gliosarcoma, and (3) studies of the pathogenesis or genetics of gliosarcoma in humans. Our review identified 219 cases of gliosarcoma in 34 reports and eight articles addressing the pathogenesis. Survival in larger series ranged 4–11.5 months. Features unique to gliosarcoma compared to glioblastoma (GBM) include their temporal lobe predilection, potential to appear similar to a meningioma at surgery, repeated reports of extracranial metastases, and infrequency of EGFR mutations. Published experience is limited to small case series, and the pathogenesis remains unclear. Clinical and pathologic characteristics distinct from GBM suggest that they may warrant specific treatment, separate from conventional GBM therapy.

Gliosarcoma with osteosarcomatous features: a short illustrated review

INTRODUCTION

Gliosarcoma is a rare, malignant, biphasic brain tumor formed by both glioblastoma and sarcomatous components. Various lines of differentiation are described in the latter component, but most commonly fibrosarcomatous and pleomorphic sarcoma are present. Osteosarcomatous features are exceedingly rare.

OBJECTIVE

We report a case of gliosarcoma with osteosarcomatous features in a 33-year-old woman.

METHODS

Histologically, the sarcomatous portion displayed a typical pattern of fibrosarcoma associated with areas of osteoid formation.

RESULTS AND CONCLUSION

Immunohistochemical glial fibrillary acid protein (GFAP) expression was seen only in the glioblastoma portion. Clinicopathological characteristics and radiological data of this rare condition were reviewed. Possible differential diagnoses and potential histogenesis were also discussed.

Giant infantile gliosarcoma: magnetic resonance imaging findings

Gliosarcoma is an uncommon variant of glioblastoma multiforme, which is composed of gliomatous and sarcomatous elements. The tumor is rarely encountered in childhood. This case report presents the magnetic resonance imaging characteristics of a giant gliosarcoma in a 3-year-old girl. Size and location of the tumor are described.

Gliosarcoma with multiple extracranial metastases: case report and review of the literature

Gliosarcoma is a rare malignant neoplasm of the central nervous system with a propensity for metastasis. There are fewer than 20 reported cases of extracranial metastases of gliosarcoma with the majority of cases reflecting a tendency for hematogenous dissemination. Here we describe the case of a 47-year-old man who developed pervasive extracranial metastases from a temporal gliosarcoma following radio- and chemotherapy for a primary glioblastoma. The patient initially presented with progressively worsening headaches, left-sided weakness and numbness associated with right temporo-parietal mass for which he underwent craniotomy with stereotactic gross-total excision. Two months postoperatively, interstitial brachytherapy and external beam radiotherapy were initiated. The patient initially declined chemotherapy. The tumor recurred twice and the patient underwent re-operation and multiple courses of chemotherapy; histopathological diagnosis remained glioblastoma multiforme. Nineteen months following initial resection the patient's clinical status deteriorated and CT scan demonstrated multiple intrathoracic, hepatic and splenic lesions. Postmortem examination revealed widespread, infiltrating gliosarcoma with intravascular gliomatosis and extensive visceral metastases. This is the first report of pervasive extracranial metastases to numerous sites, several of which have not been previously reported. The histogenesis and the potential role of therapeutic irradiation in the development of gliosarcoma are briefly reviewed.

Gliosarcoma With Features of Osteoblastic Osteosarcoma: A Review

Context.—Gliosarcoma is a rare tumor of the central nervous system characterized by a biphasic histologic pattern, consisting of a gliomatous and a sarcomatous component, respectively. In most instances the sarcomatous component is represented by a fibrosarcoma, but other stromal malignancies have also been described. Osteosarcomatous differentiation in gliosarcoma has been rarely reported.

Objective.—To review characteristic radiologic and histopathologic features of this rare neoplasm, to debate about possible differential diagnoses that should be taken into consideration, and to provide an overview of the potential histopathogenesis of gliosarcomas.

Data Sources.—Relevant articles indexed in PubMed (National Library of Medicine) and reference medical texts.

Conclusions.—Recent molecular studies suggest that sarcomatous and gliomatous components of gliosarcoma might be derived from a single precursor cell clone, progressing in 2 subclones with distinct morphologic features during tumor evolution. Nonetheless, events determining splitting of the original clone into 2 histologic populations remain to be investigated.

Gliosarcoma with liposarcomatous differentiation: the new member of the lipid-containing brain tumors family

Gliosarcoma is a rare malignant, biphasic brain tumor composed of glioblastoma multiforme and sarcomatous components. Various types of sarcomatous differentiation are described in this tumor: fibrosarcomatous, malignant fibrous histiocytoma-like, chondrosarcomatous and osteosarcomatous types. We report an extremely unusual variant of liposarcomatous differentiation in gliosarcoma in 72-year-old woman. Fat cells were presented by atypical multivacuolar and monovacuolar lipoblasts, stained positive for S100. p53 that was positive in both glial and mesenchymal cells of the tumor were negative in the lipoblasts. To the best of our knowledge, this is the first report in the literature of liposarcomatous differentiation in gliosarcoma.

Preferential Recurrence of a Sarcomatous Component of a Gliosarcoma after Boron Neutron Capture Therapy: Case Report

Gliosarcoma, a rare pathological entity composed of 2-8% malignant gliomas, is characterized by a biphasic tissue pattern with alternating areas displaying glial and mesenchymal differentiation. Here we report the preferential recurrence of a sarcomatous component in gliosarcoma after boron neutron capture therapy (BNCT), while a gliomatous component disappeared as a result of the treatment. A 56-year-old woman with a left frontal tumor was introduced to our clinic. After stereotactic biopsy, craniotomy was applied and 90% of the mass was resected. The histological diagnosis was glioblastoma with small amounts of sarcomatous component, that is, gliosarcoma. BNCT was applied 30 days after craniotomy. Two weeks after BNCT, almost all of the contrast-enhanced mass had disappeared on magnetic resonance images; however, a half year later, the mass recurred just below the original site and extended posteriorly. Irrespective of repetitive salvage surgeries, the patient died of the recurrent tumor. At autopsy, tumor cells of the frontal lobe were absent. A well-circumscribed mass of the parietal and occipital lobes was composed of sarcomatous material, with very little glial fibrillary acid protein-positive glial material. We found in this patient the preferential recurrence of the sarcomatous component of a gliosarcoma after potent radiotherapeutics in the form of BNCT.

Multi-Focal Gliosarcoma: A Case Report and Review of the Literature

Gliosarcoma (GS) is an uncommon malignant brain tumor with biphasic tissue pattern consisted of both glial and sarcomatous components. It usually occurs in adult population of middle age. We report a rare case of multi-focal GS that was initially interpreted as metastases of extra-cranial tumor. The histological examination revealed the biphasic pattern of a GS. The patient was treated with postoperative external radiation therapy and had poor prognosis. To our knowledge this is the second published case of GS with multi-focal presentation. In this study we also review the literature on clinicopathological aspects of GS.

Gamma knife radiosurgery and its possible relationship to malignancy: a review

✓ The question has been raised recently whether gamma knife radiosurgery (GKS) can induce secondary neoplasia. Because there is little or no detailed knowledge about this potential complication, background information culled from the radiotherapy literature is reviewed as a guide to the clinical situations in which radiotherapy may induce secondary neoplastic change. Available case reports are then reviewed and discussed against the background of the current knowledge. On the basis of the review, the following suggestions are proposed on how to limiting the extent of this complication, document its frequency, and inform patients. It should be remembered that: the benefits of GKS are great; its alternatives also have risks; there often are no alternatives to GKS; follow-up documentation should be pursued more actively so that, if possible, no patient falls through the net; practitioners should be proactive in defining the problem, and genetic analysis of tumor biopsy specimens obtained in patients who will undergo or have undergone GKS should become routine; the extent of secondary neoplasia is not known; and patient information should be guided by what is known rather than by what is feared.