Pigmented astrocytoma with suprasellar location: case report and literature review

Demography, Pattern of Care, and Survival in Patients with Xanthoastrocytoma: A Systematic Review and Individual Patient Data Analysis of 325 Cases

Objectives Xanthoastrocytoma (XA) is a low-grade glial tumor seen in young adults and there is lack of robust data on treatment of this rare tumor. In this systematic review and individual patient's data analysis, we aimed to look into the demography, pattern of care, survival outcomes, and prognostic factors in patients with both Grade II and III XA. Methods A comprehensive search was conducted with the Medical Subject Heading terms: "Xanthoastrocytoma; Pleomorphic Xanthoastrocytoma; Anaplastic Xanthoastrocytoma; Xanthoastrocytoma AND treatment; and Anaplastic Xanthoastrocytoma AND survival" to find all possible publications. Results A total of 325 individual patients from a total of 138 publications pertaining to XA were retrieved. Median age of the entire cohort was 19 years. About 56.1% of the patients underwent a gross total resection (GTR) and 31.4% underwent a subtotal resection. Nearly, 76.6% of the patients had a Grade II tumor and adjuvant radiation was delivered in 27.4% of the patients. Estimated 2- and 5-year progression-free survival (PFS) were 68.5 and 51.2%, respectively. Age, grade, and extent of surgery were significant factors affecting PFS. Estimated 2- and 5-year overall survival (OS) was 88.8 and 78%, respectively. The median OS for Grade II and Grade III tumors were 209 and 49 months, respectively. Age and extent of surgery were significant factors affecting OS. Conclusion XA is a disease of young adults with favorable prognosis. Younger patients (<20 years), patients who undergo a GTR, and patients with a lower grade tumor have a better treatment outcome.

Suprasellar pleomorphic xanthoastrocytoma: A case report

Background:

Pleomorphic xanthoastrocytoma (PXA) is a rare form of astrocytic neoplasm most commonly found in children and young adults. This neoplasm, which is classified as a Grade II tumor by the World Health Organization classification of tumors of the central nervous system, carries a relatively favorable outcome. It is usually found supratentorially in cortical regions of the cerebral hemispheres, and as such, presenting symptoms are similar to other supratentorial cortical neoplasms; with seizures being a common initial symptom. Due to the rarity of this type of neoplasm, PXA arising elsewhere in the brain is often not included in the initial differential diagnosis.

Case Description:

This report presents an extremely rare patient with PXA arising in the suprasellar region who presented with progressive peripheral vision loss. Magnetic resonance imaging of the brain demonstrated a heterogeneous suprasellar mass with cystic and enhancing components initially; the most likely differential diagnosis was craniopharyngioma. The patient underwent endoscopic endonasal resection of the tumor. Microscopically, the tumor was consistent with a glial neoplasm with variable morphology. Based on these findings along with further immunohistochemical workup, the patient was diagnosed with a PXA arising in the suprasellar region. At the 1-year follow-up, the patient remained free of recurrence. Although rare PXA originating in other uncommon locations, such as the spinal cord, cerebellum, the ventricular system, and the pineal region have been previously described.

Conclusion:

Although rare, PXA should be included in the differential diagnosis for solid-cystic tumors arising in the suprasellar region in young adults.

Neurosurgical treatment of pediatric pleomorphic xanthoastrocytomas: long-term follow-up of a single-institution, consecutive series of 12 patients

OBJECTIVE

The authors conducted a study to delineate the long-term results of the surgical treatment of pediatric pleomorphic xanthoastrocytomas (PXAs).

METHODS

All consecutive children and adolescents (0-20 years) who underwent primary tumor resection for a PXA during the years 1972-2015 were included in this retrospective study on surgical morbidity, mortality rate, academic achievement, and/or work participation. Gross motor function and activities of daily living were scored according to the Barthel Index.

RESULTS

Of the 12 patients, 8 patients were in the 1st decade of life and 4 in the 2nd. The male/female ratio was 6:6. No patient was lost to follow-up. One patient presented with severe progressive tumor disease and died within 3 months after repeated resection. Another child died 3 days following a second surgical procedure involving gross-total resection (GTR) 8 years after the initial operation. The other 10 patients were alive at the latest follow-up when they reached the median age of 34 years (range 11-60 years). The median follow-up duration was 22 years (range 2-41 years). Barthel Index score was 100 in all 10 survivors. A total 18 tumor resections were performed. Five patients underwent a second tumor resection after MRI/CT confirmed recurrent tumor disease, from 6 months up to 17 years after the initial operation. Only one of our patients received adjuvant therapy: a 19-year-old male who underwent resection (GTR) for a right-sided temporal tumor in 1976. This particular tumor was originally classified as astrocytoma WHO grade IV, and postoperative radiotherapy (54 Gy) was given. The histology was reclassified to that of a PXA. Seven of 8 children whose primary tumor resection was performed more than 20 years ago are alive as of this writing-i.e., 88% observed 20-year survival. These are long-term survivors with good clinical function and all are in full- or part-time work.

CONCLUSIONS

Pediatric patients with PXA can be treated with resection alone with rewarding results. Recurrences are not uncommon, but repeated surgery is well tolerated and should be considered in low-grade cases before adjuvant therapy is implemented. Follow-up including repeated MRI is important during the first postoperative years, since individual patients may have a more aggressive tumor course.

Grade II Pleomorphic Xanthoastrocytoma; a meta-analysis of data from previously reported 167 cases

Pleomorphic Xanthoastrocytoma [PXA] is a rare low grade glial tumor commonly affecting young adults. We did this systematic review and meta-analysis to identify prognostic factors and optimal treatment in these patients. A thorough search of the PubMed, Google scholar was made to find all possible publications related to grade II PXA. A total of 167 patients from 89 articles were included in the analysis. Median age of the entire cohort was 20 years. Headache was the most common presentation in 49.1% of the patients followed by seizure in 27.9%. Temporal lobe was the most common location of the tumor. 63% patents underwent a gross total resection [GTR] and 26.7% underwent a sub total excision [STR]. Adjuvant radiation was given to 17.6% of patients. Median follow-up for the entire cohort was 33 months. Estimated median overall survival [OS] for the entire cohort was 209.0 months [96% CI: 149.7-268.3]. Estimated median progression free survival [PFS] was 48 months [95% CI: 31.9-64.0]. In univariate and multivariate analysis younger patients and patients who underwent a GTR had a significantly better survival outcome. Use of adjuvant therapy was not found to be a significant factor affecting PFS or OS. Radiotherapy was used in salvage treatment in 76.1% of the patients. Younger patients and patients who undergo a GTR, have better survival outcomes. There is inadequate evidence to recommend routine adjuvant radiation or chemotherapy in all patients with grade II PXA.

Melanosomal melanin pigment in pleomorphic xanthoastrocytoma, evidence for neuronal-glial origin: A case report with review of the literature

We describe a unique case of pleomorphic xanthoastrocytoma (PXA) in a 19-year-old male presenting with the chief complaint of seizures. On radiology, the tumor was located in the temporal lobe. It was cortically based and solid cystic in nature. Light microscopy showed pleomorphic large polygonal cells with inclusions, nuclear clustering, lipidization, and foamy cytoplasm intermingled with spindle cells arranged in sweeping pattern and focally containing cytoplasmic brownish black pigment. The pigment stained black with Fontana-Masson stain and bleached with potassium permanganate. Gomori silver stain showed reticulin fibers surrounding individual tumor cells as well as groups of cells. On immunohistochemistry, tumor cells were positive for GFAP, S-100 and focally for synaptophysin and CD34 but negative for HMB-45. CD34 revealed a specific membranous pattern around individual cells as well as groups of cells along the fibers replicating a reticulin pattern. The ultrastructural examination showed supporting melanosomes, thus confirming the melanin pigment. Sequencing for BRAF V600E showed a heterozygous mutation. To our knowledge only five cases of PXA with melanin pigment have been reported and none of which described BRAF V600E mutation analysis. This case provides further insight into the origin and pathogenesis of pigmented astrocytic tumor, additionally highlighting the characteristic CD34 staining pattern.

Pleomorphic xanthoastrocytoma arising from the suprasellar region: A report of two cases

Pleomorphic xanthoastrocytoma (PXA) is a rare astrocytic neoplasm that usually arises in children and young adults. Typically, lesions of PXA are superficially located in the cerebral hemispheres. Herein, we report two extremely rare patients with PXA arising from suprasellar regions. One of the patients is a 29-year-old man admitted to our hospital with a history of progressive headache for 1month. The patient's brain MRI revealed a large tumor arising from the suprasellar cistern of the third ventricle. The second patient, a 52-year-old woman, presented with progressive dizziness and visual disturbance that had developed over the course of 1year. The MRI revealed a well-enhanced suprasellar solid mass measuring 1.4×1.2×1.4cm. Both patients underwent surgical removal of their tumors, and both patients showed similar microscopic structures and immunohistochemical phenotypes: the tumor cells were pleomorphic with mixtures of spindle-shaped, and multinuclear giant cells. In addition, eosinophilic granular bodies and xanthomatous cells were seen on section. Immunohistochemistry was positive for GFAP, S-100, and CD34, and was negative for IDH 1, CK, and Syn. The Ki-67 proliferation index was less than 1%. Silver impregnation revealed reticulin fibers surrounding the individual tumor cells, and small cell groups. Based on these findings, the two patients were diagnosed with PXA in the suprasellar region. To date, only five such patients have been reported in the literature. PXA should be included in the differential diagnosis for tumors arising in the sellar region.

23-year-old man with a superficial cortical brain tumor

A 23-year-old male presented with a tonic-clonic generalized seizure. Neuroradiological examination revealed a superficial cystic mass with a mural nodule in the right fronto-parietal lobe. Histological and immunohistochemical examination were consistent with a pigmented (melanin producing) desmoplastic ganglioglioma.These tumors have been first described in childhood, one of them displaying melanin deposits. Only twenty cases of non-infantile desmoplastic gangliogliomas have been reported in the literature, none of them pigmented. According to the clinical and histomorphology (including the desmoplastic component) features, the differential diagnosis should include the ganglioglioma, the xanthoastrocytoma pleomorphic (both tumors also with pigmented forms) and the superficial desmoplastic infantile astrocytoma.

Pigmented pleomorphic xanthoastrocytoma: a rare variant and literature review

A 16-year-old male teenager presented with seizure and loss of consciousness for 20 min. Magnetic resonance imaging demonstrated a mass occupying the right medial temporal lobe. Histological examination revealed a non-pigmented area with spindle-shaped and large xanthomatous pleomorphic cells and a pigmented region with pigmented neoplastic cells with fascicular arrangement. Immunohistochemical studies showed the tumor was positive for GFAP and low index of Ki-67. Considering the patient's history, clinical data and pathological findings, we rendered a rare variant named pigmented pleomorphic xanthoastrocytoma.

Non-melanocytic mimics of melanocytic neoplasms

On histopathologic examination, many non-neoplastic conditions mimic benign or malignant neoplasms. Alternatively, some benign and malignant neoplasms can also mimic non-neoplastic lesions. This is true of all organ systemsskin is no exception. Examples of these mimickers can be found in skin lesions of almost all tissue types, including those that are melanocytic, lymphoid, epithelial, neural, vascular, neuroendocrine, and fibrohistiocytic. Melanocytic neoplasms are particularly important as it's challenging to differentiate them as being benign or malignant, and it's difficult to tell them apart from non-melanocytic neoplasms. This review illustrates examples of non-melanocytic lesions that disguise themselves as melanocytic.

A case of melanotic desmoplastic ganglioglioma

We describe a case of desmoplastic infantile ganglioglioma (DIG) in a 9-month-old boy located in the temporal lobe. Grossly the tumor was brown and superficially located. Histologically the tumor contained pigment in numerous neoplastic cells, shown to be melanosomal melanin by ultrastructural examination. Pigmented neoplasms have been reported at various sites in the central and peripheral nervous system. Previous reports on pigmented neuroepithelial tumors include neoplasms containing melanin, while others have contained neuromelanin and or lipofuscin. This case represents the first description of pigmented neoplastic cells in DIG, enlarging the spectrum of pigmented primary CNS tumors.

A 15 year old boy with a posterior fossa tumor

A 15 year old male presented with hydrocephalus from a tectal mass obstructing the cerebral aqueduct and upper fourth ventricle. The solid-cystic partly enhancing mass proved to be a pigmented pleomorphic xanthoastrocytoma, the third such example reported. The lesion revealed typical features of a PXA with the unusual addition of intracytoplasmic melanin in select lesional cells. Melanin pigment production is uncommon in glial tumors and of uncertain significance. The present case is recurrence-free one year post-operatively.

Gliosarcoma with melanocytic differentiation

We present an unusual case of gliosarcoma containing numerous islands of well-differentiated melanocytes in a 65 year-old man. Melanocytic differentiation of medulloblastomas is well described, and it has also rarely been reported in low-grade glial neoplasms. Histologic features and immunophenotyping are helpful in differentiating divergent differentiation in a gliosarcoma from melanoma. To our knowledge, this is the first description of a gliosarcoma with melanocytic differentiation. Awareness of the phenomenon of melanocytic differentiation within primary neuroepithelial and glial neoplasms is important to prevent the misdiagnosis of these tumors such as metastatic melanoma or primary melanocytic neoplasms of the CNS.

Malignant progression in pleomorphic xanthoastrocytoma: Personal experience and review of the literature

Pleomorphic xanthoastrocytoma (PXA) is a rare primary low-grade astrocytic tumor, recently classified as a neuroglial tumor. It generally occurs in children and young adults and shows benign behaviour (WHO II), although an anaplastic variant and malignant potential have been described. Pleomorphic xanthoastrocytomas with malignant transformation have been reported in three out of eight patients operated on for this type of tumor in our department in the last 15 years. The three patients were two adult women and a child, the primary tumors were located in the cortex of the right temporal lobe, and treatment consisted of complete surgical resection. Histological examination revealed simple PXA in two patients and a PXA with anaplastic foci in the other. Mean recurrence time was 5.7 years, with the original xanthoastrocytoma evolving to glioblastoma in two cases and anaplastic astrocytoma in the third. All three patients underwent a second operation, followed by adjuvant therapies. Two died from tumor progression and one from brain edema after intracerebral haemorrhage. A review of the available PXA literature dating back to 1979 revealed 16 cases of primary anaplastic astrocytoma and 21 cases of PXA with malignant transformation. Our experience adds three more cases of malignant transformations, outlining once again the potential malignancy of pleomorphic xanthoastrocytomas and the fact that prognosis in these cases is the same as for primary anaplastic astrocytoma and glioblastoma. Analysis of glioneuronal markers, Ki67 and p53 in all pleomorphic xanthoastrocytomas did not prove to be a discriminating factor to identify a subgroup of xanthoastrocytomas prone to malignancy. Accordingly, these tumors demand close long-term clinical and radiological follow-up.