1
|
Trezza A, de Laurentis C, Biassoni V, Carrabba GG, Schiavello E, Canonico F, Remida P, Moretto A, Massimino M, Giussani C. Cervicomedullary Gliomas in Pediatric Age: A Systematic Review of the Literature and Tertiary Care Center Experience. Pediatr Neurosurg 2022; 57:149-160. [PMID: 35306489 DOI: 10.1159/000524165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/14/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cervicomedullary gliomas (CMGs) are usually low-grade tumors often found in the pediatric age. Histological findings, treatments, and classification have been much the same for 40 years, although histological and molecular classifications have largely been developed for other pediatric CNS tumors. The management and treatment of pediatric CMG are still conducted by many authors according to their anatomical location and characteristics, independently from histology. METHODS We conducted a literature review in PubMed (Medline) to identify relevant contributions about pediatric CMG published until December 31, 2021. We also analyzed a series of 10 patients with CMG treated from 2006 to 2021 at IRCCS Istituto Nazionale dei Tumori. The aim of the present review was to see whether and how the diagnosis, treatment, and classification of CMGs in children have developed over time, especially in the context of molecular advancements, and to analyze our single-center experience in the last 15 years. RESULTS Thirty articles have been included in the review. Articles have been divided into two historical periods (1981-2000 and 2001-2021) and data from different series were analyzed to see how much the management and treatment of pediatric CMG have changed during years. Analysis of our series of 10 patients affected by CMG was also performed to compare it with the literature. DISCUSSION Management and classification of CMG in children have not dramatically changed during years. However, new insight from molecular diagnostics and target therapies and the development of radiological, neurophysiological, and radiotherapy techniques have updated treatment modalities in the last 20 years. Treatment modalities and their innovations have been reviewed and discussed. Further studies are needed to standardize and customize treatment protocols for these tumors.
Collapse
Affiliation(s)
| | - Camilla de Laurentis
- Neurosurgery, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Veronica Biassoni
- Pediatrics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giorgio G Carrabba
- Neurosurgery, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | | | | | - Paolo Remida
- Neuroradiology, San Gerardo Hospital, Monza, Italy
| | - Alessandra Moretto
- Pediatric Anesthesia, Department of Perioperative Medicine and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Maura Massimino
- Pediatrics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Carlo Giussani
- Neurosurgery, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| |
Collapse
|
2
|
Repeat Bleeding 18 Years After Hemorrhagic Pilocytic Astrocytoma: Prognostic Implications of Conservative Management-Case Report and Literature Review. World Neurosurg 2018; 123:328-338. [PMID: 30579034 DOI: 10.1016/j.wneu.2018.12.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute hemorrhagic occurrence of pilocytic astrocytomas is extremely rare but has become increasingly recognized and often presents in clinically emergent situations. The precise significance of hemorrhage in these tumors and its pathogenetic mechanisms have not yet been defined. Nothing is known about the natural history of bleeding pilocytic astrocytomas. CASE DESCRIPTION A 21-year-old man presented with acute biventricular hydrocephalus for repeat bleeding of a midbrain lesion that had been diagnosed 18 years earlier after a similar acute hemorrhagic episode. The patient had been initially treated conservatively, considering the high risk of surgery. He underwent urgent biventricular external shunt surgery and, subsequently, total removal of the lesion. Histopathological analysis revealed pilocytic astrocytoma. Including the present case, 59 cases were analyzed and reviewed, including 5 cases with a pilomyxoid variant. Different pathogenetic mechanisms have been proposed, including histological characteristics, rupture of the bridging veins torn by the neoplastic mass, and vascular instability determined by overexpression of vascular endothelial growth factor. CONCLUSIONS To the best of our knowledge, the presented case is completely unique owing to the long-term observational follow-up data available. The hemorrhagic potential did not decrease over time, representing a specific feature of this tumor. The occurrence of bleeding might not reflect either malignancy or aggressiveness. However, the worse prognosis is related to the clinical behavior, with life-threatening complications often associated. Surgery remains the standard treatment and will influence the final prognosis.
Collapse
|
3
|
Hemorrhagic presentation of intracranial pilocytic astrocytomas: literature review. Neurosurg Rev 2017; 42:97-106. [PMID: 28980149 DOI: 10.1007/s10143-017-0915-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/13/2017] [Accepted: 09/26/2017] [Indexed: 10/24/2022]
Abstract
Pilocytic astrocytomas (PAs) are seemingly innocuous and benign tumors. However, in recent times, many case series have documented high rates of hemorrhage in these neoplasms. We hereby provide a detailed analysis on hemorrhagic pilocytic astrocytomas (HPA) in adults and report one such case managed at our institute. In addition, salient differences between adult and pediatric hemorrhagic PA have been briefed. Hospital records were retrieved for our case. Literature review was conducted by searching online databases for the following keywords-pilocytic astrocytoma, hemorrhage, cranial, pediatric, and adults. A 22-year-old male with neurofibromatosis-1 presented with sudden onset headache and vomiting of 3-day duration. Imaging revealed a lobulated suprasellar lesion with obstructive hydrocephalus. Pterional transsylvian approach and subtotal resection were performed. Histopathology showed features of PA with bleed. Including current report, a total of 26 cases have been reported. Mean age was 37 years (21-75 years) and they are mostly found in the third decade. The male:female ratio was 2.1:1. Sudden headache with vomiting was the most common symptoms. Tumors were mostly located in cerebral hemispheres (n = 9/34.6%), hypothalamus/suprasellar region (n = 7/27%), and cerebellum (n = 6/23%). Two-thirds underwent gross total excision. There were two deaths and except one case, no recurrences were reported in those with available follow-ups. Hemorrhagic presentation of a PA is rare, although more commonly seen in adults and most commonly located in cerebral hemispheres. Maximal safe resection is the standard treatment and recurrences are rare.
Collapse
|
4
|
Hemorrhagic onset of cerebellar pilocytic astrocytoma in an adult: a case report and review of the literature implying a possible relation of degenerative vascular changes to the massive intratumoral hemorrhage. Brain Tumor Pathol 2011; 29:96-102. [DOI: 10.1007/s10014-011-0068-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 09/20/2011] [Indexed: 10/16/2022]
|
5
|
Kim MS, Kim SW, Chang CH, Kim OL. Cerebellar pilocytic astrocytomas with spontaneous intratumoral hemorrhage in adult. J Korean Neurosurg Soc 2011; 49:363-6. [PMID: 21887396 DOI: 10.3340/jkns.2011.49.6.363] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 12/22/2010] [Accepted: 05/30/2011] [Indexed: 12/20/2022] Open
Abstract
Cerebellar pilocytic astrocytomas (PAs) are benign gliomas predominantly found in the pediatric population. Intracranial hemorrhages are extremely rare in initial presentations of cerebellar PAs. There are no reports in the medical literature of adult cerebellar PA cases presenting with intratumoral hemorrhage. We report 2 cases of adult cerebellar pilocytic astrocytomas with intratumoral hemorrhage. The first case is a 37-year-old woman presenting with severe headache, nausea, and vomitting. Computed tomography demonstrated an acute hemorrhage adjacent to the right cerebellar hemisphere and hydrocephalus. Magnetic resonance imaging (MRI) revealed a cerebellar vermian tumor with the hemorrhage as a mixed isointense area in the T2-weighted image, and as a mixed hyperintense area in the contrast-enhanced T1-weighted image. The second case is a 53-year-old man presenting with headache for 3 weeks. MRI revealed a cerebellar hemispheric tumor with the hemorrhage as a mixed hyperintense area. It had a cystic mass with a heterogeneous enhanced mural nodule in the gadolinium-enhanced T1-weighted image and a fluid-fluid level within the cyst in the T2-weighted image. Both of them underwent radical resections of their respective lesions. Histological examination of the specimens revealed typical astrocytoma, including a hemorrhagic portion. Both patients recovered postoperatively and continue to do well at present. The medical literature on hemorrhagic cerebellar PAs is also reviewed.
Collapse
Affiliation(s)
- Min-Su Kim
- Department of Neurosurgery, Yeungnam University College of Medicine, Daegu, Korea
| | | | | | | |
Collapse
|
6
|
YOSHIKAWA G, KAWAMOTO S, YAKOU K, TSUTSUMI K. Massive Intracranial Hemorrhage Associated With Pleomorphic Xanthoastrocytoma -Case Report-. Neurol Med Chir (Tokyo) 2010; 50:220-3. [DOI: 10.2176/nmc.50.220] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Kyoko YAKOU
- Department of Neurosurgery, Showa General Hospital
| | | |
Collapse
|
7
|
Linscott LL, Osborn AG, Blaser S, Castillo M, Hewlett RH, Wieselthaler N, Chin SS, Krakenes J, Hedlund GL, Sutton CL. Pilomyxoid astrocytoma: expanding the imaging spectrum. AJNR Am J Neuroradiol 2008; 29:1861-6. [PMID: 18701580 DOI: 10.3174/ajnr.a1233] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Pilomyxoid astrocytoma (PMA) is a recently described variant of pilocytic astrocytoma (PA) with unique clinical and histopathologic characteristics. Because the histopathology of PMA is distinct from that of PA, we hypothesized that PMAs would display distinctive imaging characteristics. We retrospectively reviewed the imaging findings in a large number of patients with PMA to identify these characteristics. MATERIALS AND METHODS CT and MR images, pathology reports, and clinical information from 21 patients with pathology-confirmed PMA from 7 institutions were retrospectively reviewed. CT and MR imaging findings, including location, size, signal intensity, hemorrhage, and enhancement pattern, were tabulated. RESULTS Patients ranged in age from 9 months to 46 years at initial diagnosis. Sex ratio was 12:9 (M/F). Twelve of 21 (57%) tumors were located in the hypothalamic/chiasmatic/third ventricular region. Nine (43%) occurred in other locations, including the parietal lobe (2/21), temporal lobe (2/21), cerebellum (2/21), basal ganglia (2/21), and fourth ventricle (1/21). Ten (48%) tumors showed heterogeneous rim enhancement, 9 (43%) showed uniform enhancement, and 2 (9%) showed no enhancement. Five (24%) masses demonstrated intratumoral hemorrhage. CONCLUSION This series expands the clinical and imaging spectrum of PMA and identifies characteristics that should suggest consideration of this uncommon diagnosis. One third of patients were older children and adults. Almost half of all tumors were located outside the typical hypothalamic/chiasmatic region. Intratumoral hemorrhage occurred in one quarter of patients. PMA remains a histologic diagnosis without definitive imaging findings that distinguish it from PA.
Collapse
Affiliation(s)
- L L Linscott
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
White JB, Piepgras DG, Scheithauer BW, Parisi JE. Rate of spontaneous hemorrhage in histologically proven cases of pilocytic astrocytoma. J Neurosurg 2008; 108:223-6. [PMID: 18240915 DOI: 10.3171/jns/2008/108/2/0223] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Spontaneous intracerebral hemorrhage is an uncommon but recognized initial presenting sign of both primary and metastatic brain tumors. The rate of tumor-related intracranial hemorrhage is variably reported from <1 to 14.6%. Hemorrhage in primary gliomas occurs in 3.7-7.2% of gliomas, mainly in glioblastoma muliforme and oligodendroglioma with low-grade astrocytomas accounting for <1%. Hemorrhage associated with pilocytic astrocytomas (PAs) is only sporadically reported. The authors report on a series of patients in whom PAs presenting as hemorrhages prompted them to examine the incidence of bleeding in these tumors. METHODS Cases involving a confirmed tissue diagnosis of PA from 1994-2005 were reviewed retrospectively. The authors included only patients with evidence of hemorrhage on computed tomography and/or magnetic resonance imaging seen prior to biopsy or resection and in the absence of trauma or other vascular pathological entities. RESULTS In 138 patients with histologically proven PAs, the mean age at diagnosis was 23 years. In 11 patients (8%; 5 male and 6 female) there was evidence of hemorrhage at presentation. There were no locations more susceptible to hemorrhage than any other, although no bleeding occurred within the cerebellum. All but 1 patient was treated with a gross-total resection. CONCLUSIONS Hemorrhage in association with PAs likely results from the frequently observed abnormal vasculature in these tumors, occurs with a greater frequency than previously thought, and should be considered in the differential diagnosis of spontaneous intracerebral hemorrhage.
Collapse
Affiliation(s)
- J Bradley White
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
| | | | | | | |
Collapse
|
9
|
Della Puppa A, Zustovich F, Gardiman M, Manara R, Cecchin D, Scienza R. Haemorrhagic presentation of low-grade glioma in adults. Acta Neurochir (Wien) 2007; 149:1151-5; discussion 1155. [PMID: 17676407 DOI: 10.1007/s00701-007-1263-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 07/10/2007] [Indexed: 10/23/2022]
Abstract
Intracranial bleeding is rare in patients with low-grade gliomas, above all in adult population. We reviewed the literature of such cases and reported another case of a haemorrhagic low-grade glioma in a 54-year-old woman presenting with a left hemiparesis. Computer tomography (CT) images showed a right basal ganglia haemorrhage with no mass effect. Vascular malformations were ruled out by angiography. Eighteen fluoro-fluoro deossiglucosio (18F-FDG) positron emission tomography (PET/CT) showed a large hypometabolic area corresponding to the lesion. We waited for patient's improvement. Late magnetic resonance images revealed a low-grade glioma at the bleeding site. Tumour was removed and histopathologic examination revealed a WHO grade II mixed glioma. The authors emphasize that this evidence has to be kept in mind since it has important therapeutic implications.
Collapse
Affiliation(s)
- A Della Puppa
- Department of Neurosurgery, Padua Hospital, Padua, Italy.
| | | | | | | | | | | |
Collapse
|
10
|
Shingu T, Akiyama Y, Daisu M, Maruyama N, Matsumoto Y, Miyazaki T, Nagai H, Yamamoto Y, Yamasaki T, Yoshida M, Maruyama R, Moritake K. Symptomatic hemorrhage associated with recurrent pilocytic astrocytoma with granulation tissue--case report. Neurol Med Chir (Tokyo) 2007; 47:222-8. [PMID: 17527050 DOI: 10.2176/nmc.47.222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 51-year-old woman had been followed up for 10 years for recurrence of pilocytic astrocytoma 5 years after the initial treatment consisting of subtotal resection, chemotherapy, and radiation therapy. The patient presented with sudden onset of headache and vomiting. Computed tomography and T(2)*-weighted magnetic resonance imaging revealed hemorrhage in the tumor located in the right basal ganglia, thalamus, and hypothalamus. She underwent gross total resection of the lesion. Histological examination confirmed recurrent pilocytic astrocytoma with organizing hematoma and granulation tissue. Although neither symptomatic hemorrhage nor late benign recurrence is common, careful long-term follow up is necessary for patients with pilocytic astrocytoma.
Collapse
Affiliation(s)
- Takashi Shingu
- Department of Neurosurgery, Shimane University School of Medicine, Izumo, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Oka F, Yamashita Y, Kumabe T, Tominaga T. Total Resection of a Hemorrhagic Tectal Pilocytic Astrocytoma-Case Report-. Neurol Med Chir (Tokyo) 2007; 47:219-21. [PMID: 17527049 DOI: 10.2176/nmc.47.219] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 21-year-old man presented with a hemorrhagic pilocytic astrocytoma of the tectal plate manifesting as sudden onset of severe headache, vertigo, nausea, and vomiting. Computed tomography demonstrated acute hydrocephalus and hemorrhage within the brain stem and fourth ventricle. Magnetic resonance (MR) imaging revealed a dorsally exophytic tectal tumor as hypointense on the T(1)-weighted image and hyperintense on the T(2)-weighted image with contrast enhancement. Radical resection of the tumor was selected because of the unusual aggressive clinical course with hemorrhage and suspicion of malignant components. The tumor was totally resected via an occipital transtentorial approach using a neuronavigation system without surgical complications. The histological diagnosis was pilocytic astrocytoma. The patient was discharged home without neurological deficits on the 9th postoperative day. Twenty-three months after the surgery, follow-up MR imaging demonstrated no recurrence. Tectal plate pilocytic astrocytoma is rarely associated with hemorrhage but should be considered in the differential diagnosis of intracranial hemorrhage with acute presentation. Such exceptional tectal tumors should be resected radically and undergo histological examination to decide on further appropriate treatment.
Collapse
Affiliation(s)
- Fumiaki Oka
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | | | | | | |
Collapse
|
12
|
Lyons MK. Pilocytic astrocytoma with spontaneous intracranial hemorrhages in an elderly adult. Clin Neurol Neurosurg 2007; 109:76-80. [PMID: 16621238 DOI: 10.1016/j.clineuro.2006.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Revised: 02/28/2006] [Accepted: 03/03/2006] [Indexed: 11/18/2022]
Abstract
Pilocytic astrocytomas are relatively uncommon tumors found predominantly in the pediatric population. Reports of these tumors are extremely rare in the elderly. This is a report of a 75-year-old man presenting with two spontaneous intracranial hemorrhages and subsequent resection of a pilocytic astrocytoma. The history, evaluation, radiographic features, histopathology, rationale for surgery and potential mechanism of hemorrhage are discussed. A review of the literature summarizes the current field of knowledge of adult pilocytic astrocytomas in the setting of intracranial hemorrhage.
Collapse
Affiliation(s)
- Mark K Lyons
- Department of Neurological Surgery, Mayo Clinic Arizona, Mayo Clinic College of Medicine, 13600 East Shea Boulevard, Scottsdale, AZ 85259, USA.
| |
Collapse
|
13
|
Lee G, Zacest AC, Reilly PL. Recurrent haemorrhage from a malignant brain stem glioma: a review of the mechanisms of tumoural haemorrhage. J Clin Neurosci 2003; 10:632-4. [PMID: 12948477 DOI: 10.1016/s0967-5868(03)00134-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The authors report a 23-year-old man who was diagnosed with a brain stem malignant glioma following his first episode of generalised seizure. This was subsequently complicated by three separate documented episodes of intracranial haemorrhage. The literature is reviewed and the pathophysiological mechanisms of tumoural haemorrhage are discussed. It is speculated that significant intratumoural arteriovenous shunting may lead to recurrent haemorrhages.
Collapse
Affiliation(s)
- G Lee
- Department of Neurosurgery, Royal Adelaide Hospital, North Terrace, 5000, Adelaide, Australia
| | | | | |
Collapse
|
14
|
Gottfried ON, Fults DW, Townsend JJ, Couldwell WT. Spontaneous hemorrhage associated with a pilomyxoid astrocytoma. Case report. J Neurosurg 2003; 99:416-20. [PMID: 12924720 DOI: 10.3171/jns.2003.99.2.0416] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pilomyxoid astrocytomas have been identified as a more aggressive variant of pilocytic astrocytomas that occur in infants and in young children. These tumors are characterized by a perivascular arrangement of pilocytic cells that has a monomorphous architecture with uniform, elongated bipolar cells loosely ranged within a prominent myxoid background. The authors present the case of a 24-year-old man with a pilomyxoid astrocytoma of the temporal lobe, who presented with a hemorrhage. The patient underwent gross-total tumor resection, and no evidence of residual or recurrent tumor was found on magnetic resonance images at the 6-month follow-up examination. The occurrence of a pilomyxoid astrocytoma in an adult suggests that this tumor is not limited to children. The tumor described in this report is unique because of its presentation with a hemorrhage, which has not been previously described in cases of pilomyxoid astrocytomas and is rarely found in those of pilocytic astrocytomas. Although this tumor predominantly exhibited the pattern of a pilomyxoid astrocytoma, there was a small focus of pilocytic astrocytoma, indicating that there is a spectrum of histological components found in these tumors and that certain elements may be associated with a more aggressive phenotype. In this paper the authors review the literature on pilomyxoid astrocytomas and discuss the unique aspects of this particular tumor presentation.
Collapse
Affiliation(s)
- Oren N Gottfried
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah 84132, USA
| | | | | | | |
Collapse
|