Management and outcome of high-grade multicentric gliomas: a contemporary single-institution series and review of the literature

Two Patterns of White Matter Connection in Multiple Gliomas: Evidence from Probabilistic Fiber Tracking

Background: Multiple lesions are uncommon in brain gliomas, and their pathophysiology is poorly understood. Invasive growth along white matter tracts is an important clinicopathological characteristic of gliomas, and a major factor in a poor therapeutic outcome. Here, we used probabilistic fiber tracking and cluster analysis to investigate the inter-focal connectivity relationships of multiple gliomas, in order to seek inferential evidence of common origin. Methods: MRI scans of 46 patients with multiple gliomas were retrospectively analyzed. Before surgery, all patients underwent multimodal functional MR imaging, including diffusion tensor imaging, enhanced 3D T1-weighted imaging, diffusion-weighted imaging, 1H MR spectroscopy, and dynamic susceptibility contrast perfusion-weighted imaging. Probabilistic fiber tracking was used to quantify white matter connectivity between neoplastic foci. Hierarchical cluster analysis was performed to identify patterns of white matter connection. Results: Cluster analysis reveals two patterns of connectivity, one with smaller, and one with greater, connectivity (2675 ± 1098 versus 30432 ± 22707, p < 0.0001). The two subgroups show significant differences in relative cerebral blood volume (2.31 ± 0.95 versus 1.73 ± 0.48, p = 0.002) and lipid/creatine ratio (0.32 ± 0.22 versus 0.060 ± 0.051, p = 0.006). Conclusion: Two distinct patterns of white matter connection exist in multiple gliomas. Those with lower connectivity tend to have independent origins, and can be termed true multicentric glioma, whereas those with greater connectivity tend to share common origin, and spread along white matter tracts. True multicentric gliomas have higher vascularity and more intratumoral necrosis. These findings may help to develop personalized therapeutic strategies for multiple gliomas.

Multicentric Glioma: An Ideal Model to Reveal the Mechanism of Glioma

As a special type of glioma, multicentric glioma provides an ideal pathological model for glioma research. According to the stem-cell-origin theory, multiple lesions of multicentric glioma share the same neuro-oncological origin, both in gene level and in cell level. Although the number of studies focusing on genetic evolution in gliomas with the model of multicentric gliomas were limited, some mutations, including IDH1 mutations, TERTp mutations and PTEN deletions, are found to be at an early stage in the process of genetic aberrance during glioma evolution based on the results of these studies. This article reviews the clinical reports and genetic studies of multicentric glioma, and intends to explain the various clinical phenomena of multicentric glioma from the perspective of genetic aberrance accumulation and tumor cell evolution. The malignant degree of a glioma is determined by both the tumorigenicity of early mutant genes, and the stemness of early suffered cells.

Decreased CD8+ Lymphocytic Infiltration in Multifocal and Multicentric Glioblastomas

Purpose

Multifocal and multicentric glioblastomas (mGBMs) are associated with a poorer prognosis compared to unifocal glioblastoma (uGBM). The presence of CD8⁺ tumor-infiltrating lymphocytes (TILs) is predictive of clinical outcomes in human malignancies. Here, we examined the CD8⁺ lymphocytic infiltration in mGBMs.

Methods

The clinical data of 57 consecutive IDH wildtype primary mGBM patients with histopathological diagnoses were retrospectively reviewed. CD8⁺ TILs were quantitatively evaluated by immunohistochemical staining. The survival function of CD8⁺ TILs was assessed by Kaplan–Meier analysis and Cox proportional hazard models.

Results

No significant difference in the concentration of CD8⁺ TILs was observed among foci from the same patient (P>0.150). The presence of CD8⁺ TILs was similar between multifocal and multicentric GBMs (P=0.885). The concentration of CD8⁺ TILs was significantly lower in mGBMs than in uGBMs (P=0.002). In mGBM patients, the CD8⁺ TIL level was associated with preoperative KPS (P=0.018). The median overall survival (OS) of the 57 mGBMs was 9 months. A low CD8⁺ TIL level (multivariate HR 4.404, 95% CI 1.954-9.926, P=0.0004) was an independent predictor of poor OS, while postoperative temozolomide chemotherapy (multivariate HR 6.076, 95% CI 2.330-15.842, P=0.0002) was independently associated with prolonged OS in mGBMs.

Conclusions

Decreased CD8⁺ TIL levels potentially correlate with unfavorable clinical outcome in mGBMs, suggesting an influence of the local immuno-microenvironment on the progression of mGBMs.

On the Prognosis of Multifocal Glioblastoma: An Evaluation Incorporating Volumetric MRI

Primary glioblastoma (GBM), IDH-wildtype, especially with multifocal appearance/growth (mGBM), is associated with very poor prognosis. Several clinical parameters have been identified to provide prognostic value in both unifocal GBM (uGBM) and mGBM, but information about the influence of radiological parameters on survival for mGBM cohorts is scarce. This study evaluated the prognostic value of several volumetric parameters derived from magnetic resonance imaging (MRI). Data from the Department of Neurosurgery, Leipzig University Hospital, were retrospectively analyzed. Patients treated between 2014 and 2019, aged older than 18 years and with adequate peri-operative MRI were included. Volumetric assessment was performed manually. One hundred and eighty-three patients were included. Survival of patients with mGBM was significantly shorter (p < 0.0001). Univariate analysis revealed extent of resection, adjuvant therapy regimen, residual tumor volume, tumor necrosis volume and ratio of tumor necrosis to initial volume as statistically significant for overall survival. In multivariate Cox regression, however, only EOR (for uGBM and the entire cohort) and adjuvant therapy were independently significant for survival. Decreased ratio of tumor necrosis to initial tumor volume and extent of resection were associated with prolonged survival in mGBM but failed to achieve statistical significance in multivariate analysis.

An Integrative Survival Analysis for Multicentric Low-Grade Glioma

OBJECTIVE

This study aimed to perform a survival analysis of patients with multicentric low-grade gliomas (MLGGs) and to assess the influence of various prognostic factors on progression-free survival (PFS) and overall survival.

METHODS

A literature search on Web of Science and PubMed was performed for literature in English published from 1963 to September 2018. Detailed information including demographics, clinical characteristics, treatments, critical events, and time to events for survival analysis were extracted from the included articles.

RESULTS

A total of 36 cases from published articles were selected for analysis. Univariate analysis showed that age (<31 years or ≥31 years), grade (pure low grade/low and high grade) and glioma type (astrocytoma/oligodendroglioma) had a significant relationship with PFS. Cox regression analysis showed that tumor grade was an independent prognostic factor for PFS. No factors correlated with overall survival.

CONCLUSIONS

This integrative analysis of MLGGs patients revealed that age younger than 31 years, pure MLGG, and oligodendroglioma were significantly associated with improved PFS, and pure MLGGs was an independent prognostic factors for PFS.

Clinical implications of multiple glioblastomas: An analysis of prognostic factors and survival to distinguish from their single counterparts

PURPOSE

Glioblastoma (GBM) has the highest fatality rate among primary malignant brain tumors. GBMs with synchronous multiple foci (multiple GBMs) is rarely diagnosed in the clinical scenario. This study aims to compare the clinical characteristics between multiple and single GBMs and to identify factors associated with the survival of GBM and evaluate their effects.

METHODS

We retrospectively reviewed the medical records of patients with primary GBM in a referral medical center in Taiwan who were diagnosed between 2005 and 2016. They were identified from the cancer registry database of the center and followed from the date of diagnosis to october 2018. The primary endpoint of this study was overall survival (OS), and the independent factors for survival were identified through Cox regressions.

RESULTS

A total of 48 patients were identified, of whom 44 GBM (92%) and 4 gliosarcoma (GSM) (8%). Preoperative images showed five (10%) patients had multiple brain lesions. GSM showed a high ratio of multiple lesions (50%) than patients with GBM (5%) (p = 0.05). Those with multiple lesions had significantly worse median OS of 8.2 months compared to patients with a single lesion (16 months, p = 0.03). We found that multiple GBMs was a predictor of worse survival (hazard ratio [HR] = 3.57, 95% confidence interval [95%CI]: 1.26-10.13) after adjusting for other significant predictor of radiotherapy (HR = 0.47, 95%CI: 0.23-0.96).

CONCLUSION

Patients with multiple GBMs had worse survival compared to those with single GBM. GBM patients without post-operative radiotherapy were also a predictor of worse survival.

Simultaneous multiple craniotomies in the management of multifocal malignant brain lesions: case reports

The appropriate strategy for treating multiple malignant brain tumors has not been well established. We discuss the indications and surgical considerations of multiple craniotomies in the same surgical session, and present three such cases. A 41-year-old woman (case 1) and a 65-year-old man (case 2), both presented with two metastatic brain lesions, one in each hemisphere. The third case was a 65-year-old woman with multiple recurrent atypical meningiomas, who underwent surgical removal in two stages. In the first surgery, only the superior sagittal sinus lesion was excised. Then in the second surgery, multiple disseminated bilateral convexity tumors were excised through a craniotomy on each side. All cases had a remarkable neurological improvement immediately after surgery. We suggest that the indications for surgical removal of multiple brain tumors with two or more craniotomies in the same surgical session are: 1) progressing neurological symptoms, 2) tumors with a maximum diameter more than 2 cm, 3) resistance to radiation and/or chemotherapy, 4) ability to tolerate the scheduled surgical time, 5) vital prognosis anticipated to be more than 3 months, 6) expectation of significant neurological improvement, and 7) single-session surgery not carrying more risk than multiple surgeries.

Clinical value of magnetic resonance imaging in identifying multiple cerebral gliomas from primary central nervous system lymphoma

Clinical value of magnetic resonance imaging (MRI) in identifying and diagnosing multiple cerebral glioma (MCG) from primary central nervous system lymphoma (PCNSL) was evaluated. A total of 21 patients with MCG diagnosed clinically and pathologically in Zhangzhou Municipal Hospital from March 2016 to April 2017 were selected as group A, and 30 patients with PCNSL diagnosed in Zhangzhou Affiliated Hospital of Fujian Medical University during the same period as group B. Plain MRI, enhanced MRI and diffusion weighted imaging (DWI) were performed in all patients, the apparent diffusion coefficient (ADC) value of lesions was measured, and the diagnostic efficacy of ADC for MCG and PCNSL was evaluated by receiver operating characteristic (ROC) curve. The incidence of hippocampus lesions, patchy and cystic lesions, and the heterogeneous signal of plain scan in group A was significantly higher than that in group B (P<0.05), and the incidence of basal ganglia lesions was significantly lower than that in group B (P<0.05). Mass lesions in group A were significantly less than those in group B (P<0.05). The ADC value of lesions in group A was significantly higher than that in contralateral normal white matter (P<0.05), the ADC value in group B was significantly lower than that in normal contralateral white matter (P<0.05), so the ADC value in group A was significantly higher than that in group B (P<0.05). The location, lesion shape and signal characteristic of MCG and PCNSL have their own specificity; there are significant differences in DWI signal and ADC color map signal intensity of the lesions; ADC has certain diagnostic value for MCG and PCNSL; the differential diagnosis of MCG from PCNSL by MRI is of great significance.

Integrative radiogenomic analysis for multicentric radiophenotype in glioblastoma

We postulated that multicentric glioblastoma (GBM) represents more invasiveness form than solitary GBM and has their own genomic characteristics. From May 2004 to June 2010 we retrospectively identified 51 treatment-naïve GBM patients with available clinical information from the Samsung Medical Center data registry. Multicentricity of the tumor was defined as the presence of multiple foci on the T1 contrast enhancement of MR images or having high signal for multiple lesions without contiguity of each other on the FLAIR image. Kaplan-Meier survival analysis demonstrated that multicentric GBM had worse prognosis than solitary GBM (median, 16.03 vs. 20.57 months, p < 0.05). Copy number variation (CNV) analysis revealed there was an increase in 11 regions, and a decrease in 17 regions, in the multicentric GBM. Gene expression profiling identified 738 genes to be increased and 623 genes to be decreased in the multicentric radiophenotype (p < 0.001). Integration of the CNV and expression datasets identified twelve representative genes: CPM, LANCL2, LAMP1, GAS6, DCUN1D2, CDK4, AGAP2, TSPAN33, PDLIM1, CLDN12, and GTPBP10 having high correlation across CNV, gene expression and patient outcome. Network and enrichment analyses showed that the multicentric tumor had elevated fibrotic signaling pathways compared with a more proliferative and mitogenic signal in the solitary tumors. Noninvasive radiological imaging together with integrative radiogenomic analysis can provide an important tool in helping to advance personalized therapy for the more clinically aggressive subset of GBM.

Multiple high-grade gliomas: epidemiology, management, and outcome. A systematic review and meta-analysis

Multiple high-grade gliomas (M-HGGs) are well--separated tumors, differentiated as multifocal (MF) and multicentric (MC) by their MRI features. The authors performed a systematic review and meta-analysis of literature examining epidemiology, clinical and radiological characteristics, management, and the overall survival from M-HGGs. According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and January 2017 was carried out. The authors identified studies that examined the prevalence rate, clinical and radiological characteristics, treatment, and overall survival from M-HGGs in patients with HGG. Data were analyzed using a random-effects meta-analysis model. Finally, we systematically reviewed demographic characteristics, lesion location, and surgical and adjuvant treatments. Twenty-three studies were included in this systematic review. The M-HGGs prevalence rate was 19% (95% CI 13-26%) and the hazard ratio of death from M-HGGs in the HGGs population was 1.71 (95% CI 1.49-1.95, p < 0.0001). The MC prevalence rate was 6% (CI 95% 4-10%), whereas MF prevalence rate was 11% (CI 95% 6-20%) (p < 0.0001). There were no statistically significant differences between MF and MC HGGs in gender, lesion location, histological type, and surgical treatment. Survival analysis of MC tumors showed that surgical resection (gross total resection or subtotal resection) is an independent predictor of improved outcome (HR 7.61 for biopsy subgroup, 95% CI 1.94-29.78, p = 0.004). The prevalence of M-HGGs is approximately 20% of HGGs. The clinical relevance of separating M-HGGs in MF and MC tumors remains questionable and its prognostic significance is unclear. When patient status and lesion characteristics make it safe and feasible, cytoreduction should be attempted in patients with M-HGGs because it improves overall survival.

Case-Based Review: newly diagnosed glioblastoma

Glioblastoma (WHO grade IV astrocytoma) is the most common and most aggressive primary brain tumor in adults. Optimal treatment of a patient with glioblastoma requires collaborative care across numerous specialties. The diagnosis of glioblastoma may be suggested by the symptomatic presentation and imaging, but it must be pathologically confirmed via surgery, which can have dual diagnostic and therapeutic roles. Standard of care postsurgical treatment for newly diagnosed patients involves radiation therapy and oral temozolomide chemotherapy. Despite numerous recent trials of novel therapeutic approaches, this standard of care has not changed in over a decade. Treatment options under active investigation include molecularly targeted therapies, immunotherapeutic approaches, and the use of alternating electrical field to disrupt tumor cell division. These trials may be aided by new insights into glioblastoma heterogeneity, allowing for focused evaluation of new treatments in the patient subpopulations most likely to benefit from them. Because glioblastoma is incurable by current therapies, frequent clinical and radiographic assessment is needed after initial treatment to allow for early intervention upon progressive tumor when it occurs.