Treatments of gliosarcoma of the brain: a systematic review and meta-analysis

A case of right fronto-parietal gliosarcoma

Gliosarcoma (GS) is a rare subtype of glioblastoma multiforme, characterized by a shorter clinical course and poorer prognosis compared to glioblastoma. Here, we report the case of a 50-year-old male patient who presented with episodic loss of consciousness and left-sided limb weakness for one month. MRI revealed a complex neoplastic lesion in the right fronto-parietal region. Postoperative pathology confirmed GS, and the patient underwent adjuvant radiotherapy and chemotherapy. This case highlights the characteristic features of GS through a combination of imaging and pathological findings, providing valuable insights for radiologists.

Gliosarcoma: A Multi-Institutional Analysis on Clinical Outcomes and Prognostic Factors

PURPOSE

This study describes oncological outcomes and investigates prognostic factors for patients with gliosarcomas (GSM).

METHODS

Histopathologically confirmed GSM patients who underwent treatment at five European institutions were retrospectively analyzed.

RESULTS

We analyzed 170 patients with a median clinical follow-up time of 9.2 months. The majority received surgery (94.1%), postoperative radiotherapy (pRT, 81.8%), and temozolomide (TMZ)-based postoperative chemotherapy (66.5%). The median overall survival (OS) and progression-free survival (PFS) were 12.3 and 6.6 months, respectively. In the multivariable Cox regression analysis (MVA), the following factors were significantly associated with OS: age per year (hazard ratio (HR): 1.03, p < 0.001), subtotal resection (STR) versus biopsy only (HR: 0.15, p = 0.018), gross total resection (GTR) versus biopsy only (HR: 0.13, p = 0.011), pRT versus no pRT (HR: 0.20, p < 0.001), postoperative TMZ-based chemotherapy versus no postoperative chemotherapy (HR: 0.44, p = 0.003), MGMT promoter non-methylated versus methylated (HR: 1.79, p = 0.05), and tumor diameter per cm (HR: 1.15, p = 0.046). For PFS, the following factors were significantly associated in the MVA: GTR versus biopsy only (HR: 0.19, p = 0.026), pRT versus no pRT (HR: 0.36, p = 0.006), postoperative TMZ-based chemotherapy vs. no postoperative chemotherapy (HR: 0.39, p < 0.001), MGMT promoter status unknown versus methylated (HR: 1.69, p = 0.034), and tumor diameter per cm (HR: 1.18, p = 0.016). Sex, primary or secondary GSM, and TP53 mutational status were not significantly associated with OS or PFS.

CONCLUSIONS

Trimodal therapy comprising surgical resection, pRT and TMZ-based chemotherapy appears to have the most beneficial effect on survival in GSM patients. Smaller tumor size, younger age and methylated MGMT promoters are associated with improved survival. To our knowledge, this is the largest multi-institutional cohort study investigating outcomes and prognostic factors for GSM.

Primary Gliosarcoma: A 15-Year Experience at a Tertiary Care Center

INTRODUCTION

Gliosarcomas (GSM) are rare intracranial tumors composed of both glial and mesenchymal components. Given the rarity of the condition, there is limited literature on their clinical, radiological, pathological features, and treatment modalities.

METHODS

Histopathologically confirmed cases of gliosarcomas were retrospectively analyzed. Based on the intraoperative macroscopic descriptions, patients were subdivided into two groups: tumors resembling meningioma and tumors resembling glioblastoma. Clinicoradiological presentations, characteristic pathological features, therapeutic modalities, and the survival of patients with gliosarcoma were analyzed.

RESULTS

Twenty-five patients (17 males and 8 females) were retrospectively analyzed in this study. The mean age of presentation was 45.8 + 11.7 years, while the mean duration of symptoms was 2 months. The most common site of the tumor was frontal lobe. All the patients underwent maximal safe resections. Postoperative radiotherapy was received by all 25 patients. Sixteen patients received concurrent and adjuvant chemotherapy with temozolomide.The median survival was 11 months (range: 4-42 months). Patients with tumors mimicking a meningioma (intraoperatively) had better survival than patients with glioblastoma-like features (P < 0.01).

CONCLUSION

Our study supports the presence of two distinct types of GSM: one which is similar to glioblastoma multiforme and another which resembles more of meningioma. Good surgical excision is a favorable prognostic factor for the outcome of GSM. Gliosarcoma which resembles meningioma has got better survival outcome compared to the one that resembles glioblastoma.

Conditional survival and changing risk profile in patients with gliosarcoma

Background

Conditional survival (CS) considers the duration since the initial diagnosis and can provide supplementary informative insights. Our objective was to evaluate CS among gliosarcoma (GSM) patients and develop a CS-incorporated nomogram to predict the conditional probability of survival.

Methods

This retrospective study using the Surveillance, Epidemiology, and End Results (SEER) database included patients with GSM between 2000 and 2017. The CS was defined as the probability of surviving additional y years after already surviving for x years. The formula utilized for CS was: CS(y|x) = S(y + x)/S(x), where S(x) denotes the overall survival at x years. Univariate Cox regression, best subset regression (BSR) and the least absolute shrinkage and selection operator (LASSO) were used for significant prognostic factors screening. Following this, backward stepwise multivariable Cox regression was utilized to refine predictor selection. Finally, a novel CS-integrated nomogram model was developed and we also employed diverse evaluation methods to assess its performance.

Results

This study included a total of 1,015 GSM patients, comprising 710 patients in training cohort and 305 patients in validation cohort. CS analysis indicated a gradual increase in the probability of achieving a 5-year survival, ascending from 5% at diagnosis to 13, 31, 56, and 74% with each subsequent year survived after 1, 2, 3, and 4 years post-diagnosis, respectively. Following variable screening through univariate Cox regression, BSR, and LASSO analysis, five factors-age, tumor stage, tumor size, radiotherapy, and chemotherapy-were ultimately identified for constructing the CS-nomogram model. The performance of the nomogram model was validated through discrimination and calibration assessments in both the training and validation cohorts. Furthermore, we confirmed that the effectiveness of the CS-nomogram in stratifying GSM patient risk status.

Conclusion

This nationwide study delineated the CS of patients diagnosed with GSM. Utilizing national data, a CS-nomogram could provide valuable guidance for patient counseling during follow-up and risk stratification.

Prognostic Factors for Patients with Primary Gliosarcoma: A Single-Center Retrospective Study

BACKGROUND

Primary gliosarcoma is a rare form of malignant central nervous system tumor, with limited understanding regarding its prognostic determinants and effective therapeutic interventions.

METHODS

The medical records of patients diagnosed with gliosarcoma at Tangdu Hospital between March 2011 and June 2023 were retrospectively analyzed in this study. Patients with a prior history of glioma or those who received preoperative chemoradiotherapy were excluded. Survival analyses were conducted using Kaplan-Meier and Cox regression analysis.

RESULTS

A total of 77 patients were included in the final analysis, with a median age of 57 years (range: 13-83). The predominant symptom leading to diagnosis was headache, and the temporal lobe was the most frequently affected site. Univariate analysis revealed that age ≤65 years, complete resection, Ki67 ≤ 25%, postoperative Karnofsky Performance Status ≥ 70, adherence to the Stupp protocol, and additional active therapy upon relapse were associated with enhanced survival. Furthermore, multivariate analysis identified complete resection, age ≤65 years, Stupp protocol treatment, and active therapy following relapse were independent predictors of overall survival. Notably, 1 patient experienced subcutaneous metastasis during treatment.

CONCLUSIONS

The present study's findings suggest that optimal management of primary gliosarcoma entails maximal safe resection, combined with adjuvant radiotherapy and chemotherapy with temozolomide, followed by salvage therapy in case of recurrence. However, the risk of metastases should be carefully monitored during the treatment course.

Primary Intracranial Gliosarcoma: Is It Really a Variant of Glioblastoma? An Update of the Clinical, Radiological, and Biomolecular Characteristics

Gliosarcomas (GS) are sporadic malignant tumors classified as a Glioblastoma (GBM) variant with IDH-wild type phenotype. It appears as a well-circumscribed lesion with a biphasic, glial, and metaplastic mesenchymal component. The current knowledge about GS comes from the limited literature. Furthermore, recent studies describe peculiar characteristics of GS, such as hypothesizing that it could be a clinical-pathological entity different from GBM. Here, we review radiological, biomolecular, and clinical data to describe the peculiar characteristics of PGS, treatment options, and outcomes in light of the most recent literature. A comprehensive literature review of PubMed and Web of Science databases was conducted for articles written in English focused on gliosarcoma until 2023. We include relevant data from a few case series and only a single meta-analysis. Recent evidence describes peculiar characteristics of PGS, suggesting that it might be a specific clinical-pathological entity different from GBM. This review facilitates our understanding of this rare malignant brain tumor. However, in the future we recommend multi-center studies and large-scale metanalyses to clarify the biomolecular pathways of PGS to develop new specific therapeutic protocols, different from conventional GBM therapy in light of the new therapeutic opportunities.

Clinicopathological and Neuroimaging Features of Primary Gliosarcoma: A Case Series and Review of Literature

BACKGROUND

Gliosarcoma (GS) is a rare primary high-grade brain neoplasm with a poor prognosis and challenging surgical resection. Although it is now considered a morphologic variant of IDH-wildtype glioblastoma (World Health Organization Classification of Tumours 2021), GS may display peculiarities that hamper both surgical and oncological management.

METHODS

In this retrospective study, we searched our registry for histologically confirmed GS patients between 2006 and 2020. Cases were reviewed for clinical information, pathologic characteristics, imaging findings, management, and outcome.

RESULTS

21 patients with histologically confirmed GS were identified with a median age of 62 years. Twelve were men and 9 women. The temporal lobe was the most common location (9 patients, 42.9%). Nineteen patients underwent surgical resection, and only 4 (19%) demonstrated gross total resection on postsurgical MRI, with an overall median survival of 7 months (range, 0.5-37). Diagnostic MRI demonstrated heterogenous lesions with necrotic-cystic areas and a ring-enhancement pattern. Only 1 case of extracranial extension was seen in our sample, and no patient showed distant metastases.

CONCLUSIONS

The rarity of primary GS and the absence of specific therapeutic guidelines represent a significant clinical challenge. Our study provides a comprehensive analysis of clinical and neuroimaging characteristics in a real-world patient cohort and compares our findings with the available literature.

Prognostic Factors of Gliosarcoma in the Real World: A Retrospective Cohort Study

Purpose

Gliosarcoma is a histopathological variant of glioblastoma, which is characterized by a biphasic growth pattern consisting of glial and sarcoma components. Owing to its scarcity, data regarding the impact of available treatments on the clinical outcomes of gliosarcoma are inadequate. The purpose of this retrospective cohort study was to analyze the prognostic factors of gliosarcoma.

Methods

By screening the clinical database of neurosurgical cases at a single center, patients with gliosarcoma diagnosed histologically from 2013 to 2021 were identified. Clinical, pathological, and molecular data were gathered founded on medical records and follow-up interviews. Prognostic factors were derived using the Cox proportional hazards model with backward stepwise regression analysis.

Results

Forty-five GSM patients were included. Median overall survival was 25.6 months (95% CI 8.0-43.1), and median relapse-free survival was 15.2 months (95% CI 9.7-20.8). In multivariable analysis, total resection (p = 0.023, HR = 0.192, 95% CI 0.046-0.797) indicated an improved prognosis. And low expression of Ki-67 (p = 0.059, HR = 2.803, 95% CI 0.963-8.162) would be likely to show statistical significance. However, there might be no statistically significant survival benefit from radiotherapy with concurrent temozolomide (n = 33, 73.3%, log-rank p = 0.99) or adjuvant temozolomide (n = 32, 71.1%, log-rank p = 0.74).

Conclusion

This single-center retrospective study with a limited cohort size has demonstrated the treatment of gross total resection and low expression of Ki-67 which are beneficial for patients with GSM, while radiotherapy or temozolomide is not.

Survival outcomes associated with MGMT promoter methylation and temozolomide in gliosarcoma patients

PURPOSE

Gliosarcoma is an uncommon glioblastoma subtype, for which MGMT promoter methylation's relationship with response to temozolomide chemotherapy is unclear. We therefore examined this question using a national cohort.

METHODS

 The National Cancer Database was queried for patients histopathologically diagnosed with gliosarcoma between 2010 and 2019. The associations between MGMT promoter methylation, first-line single-agent chemotherapy-presumed to be temozolomide herein-and overall survival (OS) were examined using log-rank tests and Cox regression, with correction for multiple testing (p < 0.01 was significant).

RESULTS

580 newly-diagnosed gliosarcoma patients with MGMT status were available, among whom 33.6% were MGMT promoter methylated. Median OS for gliosarcoma patients that received standard-of-care temozolomide and radiotherapy was 12.1 months (99% confidence interval [CI] 10.8-15.1) for MGMT promoter unmethylated and 21.4 months (99% CI 15.4-26.2) for MGMT promoter methylated gliosarcomas (p = 0.003). In multivariable analysis of gliosarcoma patients-which included the potential confounders of age, sex, maximal tumor size, extent of resection, and radiotherapy-receipt of temozolomide was associated with improved OS in both MGMT promoter methylated (hazard ratio [HR] 0.23 vs. no temozolomide, 99% CI 0.11-0.47, p < 0.001) and unmethylated (HR 0.50 vs. no temozolomide, 99% CI 0.29-0.89, p = 0.002) gliosarcomas. MGMT promoter methylation was associated with improved OS among temozolomide-treated gliosarcoma patients (p < 0.001), but not in patients who did not receive chemotherapy (p = 0.35).

CONCLUSION

In a national analysis of gliosarcoma patients, temozolomide was associated with prolonged OS irrespective of MGMT status. These results provide support for the current practice of trimodal therapy for gliosarcoma.