Spinal glioblastoma with brain relapse in a child: clinical considerations

Primary and metastatic glioblastoma of the spine in the pediatric population: a systematic review

Pediatric glioblastoma multiforme (GBM) involving the spine is an aggressive tumor with a poor quality of life for patients. Despite this, there is only a limited number of reports describing the outcomes of pediatric spinal GBMs, both as primary spinal GBMs and metastases from an intracranial tumor. Here, we performed an individual patient meta-analysis to characterize factors affecting prognosis of pediatric spinal GBM. MEDLINE, Embase, and the Cochrane databases were searched for published studies on GBMs involving the spine in pediatric patients (age ≤ 21 years old). Factors associated with the survival were assessed with multi-factor ANOVAs, Cox hazard regression, and Kaplan-Meier analyses. We extracted data on 61 patients with spinal GBM from 40 studies that met inclusion criteria. Median survival was significantly longer in the primary spinal GBM compared that those with metastatic GBM (11 vs 3 months, p < 0.001). However, median survival of metastatic GBM patients was 10 months following diagnosis of their primary brain tumor, which was not different from that of primary spinal GBM patients (p = 0.457). Among primary spinal GBM patients, chemotherapy (hazard ratio (HR) = 0.255 [0.106-0.615], p = 0.013) and extent of resection (HR = 0.582 [0.374-0.905], p = 0.016) conferred a significant survival benefit. Younger age (less than 14 years) was associated with longer survival in patients treated with chemotherapy than those who did not undergo chemotherapy (β = - 1.12, 95% CI [- 2.20, - 0.03], p < 0.05). In conclusion, survival after presentation of metastases from intracranial GBM is poor in the pediatric population. In patients with metastatic GBM, chemotherapy may have provided the most benefit in young patients, and its efficacy might have an association with extent of surgical resection.

Intracranial Metastases Originating From Pediatric Primary Spinal Cord Glioblastoma Multiforme: A Case Report and Literature Review

Primary spinal cord glioblastoma multiforme (scGBM) is an uncommon entity in pediatrics, and intracranial metastasis originating in spinal cord gliomas is very rare. A 7-year-old female presented with weakness in the limbs, paralysis of the lower limbs and incontinence. The initial MRI of the spinal cord revealed expansion and abnormal signals from T2 to T5. She was initially diagnosed with Neuromyelitis optica spectrum disorders and treated with high-dose glucocorticoid and gamma globulin. Four months later, her symptoms worsened and follow-up imaging showed multiple intracranial mass lesions. We performed a subtotal resection of the right thalamic basal ganglia tumor and gross total resection of the right frontal lobe tumor under microscopic examination. Histopathology revealed scGBM with intracranial metastasis and the molecular pathology diagnosis suggested H3K27M mutant diffuse midline glioma WHO grade IV, which had previously been misdiagnosed as a Neuromyelitis optica spectrum disorders. We review the literature of intracranial metastases originating from pediatric primary spinal cord glioblastoma multiforme and summarize possible methods of differentiation, including changes in muscle strength or tone, intramedullary heterogeneously enhancing solitary mass lesions and cord expansion in MRI. Finally, we emphasize that in unexpected radiological changes or disadvantageous response to the treatment, a biopsy to achieve a pathological diagnosis is necessary to discard other diseases, especially neoplasms.

Primary bulbo-medullary glioblastoma in a child: case report

Glioblastoma (GBM) of the spinal cord represents a rare entity in children and account for less than 1% of all central nervous system (CNS) cancers. Their biology, localization, and controversial treatment options have been discussed in a few pediatric cases. Here, we report a case of primary spinal cord glioblastoma in a 5-year-old girl having the particularity to be extended to the brainstem. This tumor has been revealed by torticollis and bilateral brachial paresis. The patient underwent subtotal resection; unfortunately, she died in reanimation 1 week later by severe pneumopathy. To the best of our knowledge, this is the first case in the literature reporting this particular localization in a child. Beyond their dismal prognosis, we discuss the rarity of the disease and describe the peculiar characteristics, management, and prognosis of this rare tumor in pediatric oncology. This case appears to be unusual for both the histological type and the extension to brain stern.

Infantile Optic Pathway Glioblastoma

BACKGROUND

Optic pathway gliomas and glioblastomas remain a rare entity within the infant population.

CASE DESCRIPTION

We outline the case of a 6-month-old female who presented with failure to thrive, nystagmus and features of raised intracranial pressure. Subsequent magnetic resonance imaging demonstrated an infiltrating tumor radiating from the optic nerves bilaterally. She underwent emergent ventriculoperitoneal shunting and biopsy. Histology confirmed a World Health Organization grade IV glioblastoma.

CONCLUSIONS

The patient remained clinically and radiologically stable at 1 year. Optic pathway glioblastoma in this population is a previously undescribed entity that requires multidisciplinary input to guide ongoing therapy.

Glioblastoma Multiforme Involving Conus Medullaris in a Child

Primary spinal cord glioblastoma multiforme involving the conus medullaris is an uncommon entity with poor outcomes. An aggressive multimodality treatment approach has been used, but prognosis remains same. There are no guidelines for the treatment of patients with spinal glioblastoma multiforme (GBM). We highlight the case of a child diagnosed with conal GBM. He was treated with definitive surgery followed by adjuvant concurrent chemoradiation. After completion of treatment, he showed a temporary symptomatic improvement, but later on his condition deteriorated. We elaborate the stepwise treatment approach employed in this patient.

Cervical spinal glioblastoma multiforme in the elderly

Spinal glioblastoma multiforme (GBM) is uncommon, and its diagnosis may be challenging. This is especially true in the elderly population. Best management strategy remains to be defined. The purpose of this report is to document this rare condition, increase awareness (as a potential differential diagnosis) and propose treatment options in the elderly; a review of the relevant literature is included. A biopsy may be beneficial in given circumstances as cervical spinal GBM carries a better prognosis compared with intramedullary metastasis.

A systematic review of overall survival in pediatric primary glioblastoma multiforme of the spinal cord

OBJECTIVE The incidence of primary spinal cord glioblastoma multiforme (GBM) in the pediatric age group is very rare. Only a few case series and case reports have been published in the literature; therefore, overall survival (OS) outcome and the as-yet poorly defined management options are not discussed in detail. The authors performed a cumulative survival analysis of all reported cases of pediatric spinal cord GBM to identify the predictive factors related to final survival outcome. METHODS A comprehensive search for relevant articles was performed on PubMed's electronic database MEDLINE for the period from 1950 to 2015 using the search words "malignant spinal cord tumor" and "spinal glioblastoma multiforme." This study was limited to patients younger than 18 years of age. Survival rates for children with various tumor locations and treatments were collected from the published articles and analyzed. RESULTS After an extensive literature search, 29 articles met the study inclusion criteria. From the detailed information in these articles, the authors found 53 children eligible for the survival analysis. The majority (45%) of the children were more than 12 years old. Thirty-four percent of the cases were between 7 and 12 years of age, and 21% were younger than 7 years. In the Kaplan-Meier survival analysis, children younger than 7 years of age had better survival (13 months) than the children older than 7 years (7-12 years: 10 months, > 12 years: 9 months; p = 0.01, log-rank test). Fifty-five percent of the children were female and 45% were male. A cervical tumor location (32%) was the most common, followed by thoracic (28.3%). Cervicothoracic (18.9%) and conus (18.8%) tumor locations shared the same percentage of cases. Cervical tumors had a worse outcome than tumors in other locations (p = 0.003, log-rank test). The most common presenting symptom was limb weakness (53%), followed by sensory disturbances (25%). Median OS was 10 months. The addition of adjuvant therapy (radiotherapy [RT] and/or chemotherapy [CT]) after surgery significantly improved OS (p = 0.01, log-rank test). Children who underwent gross-total resection and RT had better outcomes than those who underwent subtotal resection and RT (p = 0.04, log-rank test). Cerebrospinal fluid spread, hydrocephalus, brain metastasis, and spinal metastasis were not correlated with OS in primary spinal GBM. CONCLUSIONS Adjuvant therapy after surgery had a beneficial effect on overall outcome of spinal GBM in the pediatric age group. Gross-total resection followed by RT produced a better outcome than subtotal resection with RT. Further large-scale prospective study is required to establish the genetic and molecular factors related to OS in primary GBM of the spinal cord in pediatric patients.

Dorsally exophytic cervicomedullary glioblastoma

Spinal glioblastoma multiforme is a rare entity comprising 1.5% of all spinal cord tumors. We report a 57-year-old man presenting with a 1.5 month history of left sided radiculopathy, lower cranial nerve weakness and difficulty in walking. MRI of the brain and spine showed an exophytic intramedullary lesion extending from the cervicomedullary junction to the lower margin of C4. To our knowledge, we report the first patient with dorsally exophytic cervicomedullary and cervical intramedullary glioblastoma multiforme.

Pediatric spinal glioblastoma multiforme: current treatment strategies and possible predictors of survival

PURPOSE

Pediatric spinal glioblastoma multiforme (GBM) is rare. Evidence-directed management relies on studies in which such cases are only a subset of a larger group. We reviewed cases of pediatric spinal GBM to assess outcomes and identify prognostic factors related to treatment.

METHODS

Clinical presentations, radiologic findings, surgical variables, radio- and chemotherapeutic management, and outcomes of eight pathologically proven cases of pediatric spinal GBM were reviewed.

RESULTS

Median age was 10 years. All patients presented with motor deficits. Four had sensory symptoms. Average McCormick score at presentation was II. There were three cervical, one cervicothoracic, and four thoracic tumors. Five had cysts. Patients underwent gross total resection (GTR) (n = 4), subtotal resection (STR) (n = 3), or biopsy (n = 1). Four patients improved neurologically after surgery. One patient was lost to follow-up. Seven received both chemo- and radiotherapy. Average overall survival was 15 months. Average survival after STR and GTR were 12.6 and 19.2 months, respectively. In the GTR subset, the 18-month-old patient survived 30 months, while the other two (>10 years) survived an average of 13.75 months. This difference based on age was not seen in the STR subset. Patients survived an average of 17.5 and 10.5 months, respectively, with and without tumoral cysts. Patients with cervical tumors survived an average of 12.5 months, 18.7 months with thoracic tumors, and 11.5 months with a cervicothoracic tumor.

CONCLUSIONS

Tumor location, presence of a cyst, gross total resection, and younger age are possible predictors of prolonged survival. Radiotherapy and chemotherapy remain widely used.

Spinal glioblastoma multiforme of the conus medullaris with holocordal and intracranial spread in a child: a case report and review of the literature

BACKGROUND CONTEXT

Spinal glioblastoma multiforme (GBM) is a rare clinical entity. According to our review of the literature, only 15 cases of spinal GBM originating from the conus medullaris (CM) have been reported. Furthermore, there has been no case of spinal GBM originating from the CM with holocordal and intracranial involvements, which were already present at the time of initial diagnosis. Despite a variety of treatments, the previous studies have uniformly reported poor results of this lethal condition.

PURPOSE

The present report illustrates a 10-year-old girl with spinal GBM with rare involvement pattern, that is, the tumor originating from the CM with the holocordal and intracranial involvements, undergoing a novel chemotherapy regimen.

STUDY DESIGN

A case report and review of literature.

METHODS

Magnetic resonance (MR) imaging with gadolinium enhancement clearly revealed holocordal and intracranial lesions, which were otherwise unidentifiable by plane MR imaging. Open biopsy was performed. After histologic diagnosis, novel chemotherapy regimen, that is, simultaneous high-dose chemotherapy (cyclophosphamide, cisplatin, vincristine, and etoposide) combined with autologous peripheral blood stem cell transplantation (auto-PBSCT), intrathecal injections of both methotrexate and dexamethasone, and radiotherapy, which respected the tolerance threshold of the spinal cord, were performed.

RESULTS

Novel chemotherapy regimen achieved marked tumor regression until the 12th month of treatment. The patient became ambulatory with T-shaped canes and has returned to the school life. Unfortunately, the patient died because of the relapse of the tumor 14 months after the initial diagnosis; however, this strategy has achieved longer survival than previously reported mean survival (12 months).

CONCLUSIONS

The authors advocate enhanced MR imaging of the whole central nervous system for the potential spreading of this disease. This is the first report of simultaneous high-dose chemotherapy combined with auto-PBSCT, intrathecal injections of antineoplastic agents, and radiotherapy for the treatment of spinal GBM, which achieved marked tumor regression. We believe that accumulated experiences in the treatment of this lethal condition might contribute well to improve its therapeutic outcome.

Irradiation of pediatric high-grade spinal cord tumors

PURPOSE

To report the outcome using radiation therapy (RT) for pediatric patients with high-grade spinal cord tumors.

METHODS AND MATERIALS

A retrospective chart review was conducted that included 17 children with high-grade spinal cord tumors treated with RT at St. Jude Children's Research Hospital between 1981 and 2007. Three patients had gross total resection, 11 had subtotal resection, and 3 underwent biopsy. The tumor diagnosis was glioblastoma multiforme (n = 7), anaplastic astrocytoma (n = 8), or anaplastic oligodendroglioma (n = 2). Seven patients received craniospinal irradiation (34.2-48.6 Gy). The median dose to the primary site was 52.2 Gy (range, 38-66 Gy).

RESULTS

The median progression-free and overall survivals were 10.8 and 13.8 months, respectively. Local tumor progression at 12 months (79% vs. 30%, p = 0.02) and median survival (13.1 vs. 27.2 months, p = 0.09) were worse for patients with glioblastoma multiforme compared with anaplastic astrocytoma or oligodendroglioma. The median overall survival was shorter for patients when failure included neuraxis dissemination (n = 8) compared with local failure alone (n = 5), 9.6 vs. 13.8 months, p = 0.08. Three long-term survivors with World Health Organization Grade III tumors were alive with follow-up, ranging from 88-239 months.

CONCLUSIONS

High-grade spinal cord primary tumors in children have a poor prognosis. The propensity for neuraxis metastases as a component of progression after RT suggests the need for more aggressive therapy.

Spinal glioblastoma multiforme: unusual cause of post-traumatic tetraparesis

BACKGROUND/OBJECTIVE

Glioblastoma multiforme (GBM) is the most common glial cell tumor of the adult brain. However, primary GBM of the spinal cord is a rare condition.

METHODS

Case report.

RESULTS

A young man presented with acute onset quadriparesis after a whiplash injury. A magnetic resonance scan showed the typical appearance of a high-grade intramedullary tumor with fusiform expansion of the entire cervical cord. Subtotal decompression and biopsy was done by posterior laminectomy, followed by external beam radiotherapy. Signs and symptoms improved after the completion of radiotherapy but did not resolve completely. Death caused by respiratory failure occurred 3 months later.

CONCLUSIONS

This presentation of GBM of the cervical cord is rare; an intramedullary tumor should be considered when minor cervical trauma results in disproportionate neurologic deficit. To the best of our knowledge, this is the first reported case of spinal GBM with extensive pan-cervical involvement.