Clinical Characteristics of High-Grade Glioma with Primary Leptomeningeal Seeding at Initial Diagnosis in a Single Center Study

Long-Term Outcomes of Radiation Therapy for Pediatric Brain Tumors: A Single-Center Study

Brain tumors are the leading cause of mortality among pediatric patients. Recent advancements in genetic analysis have facilitated the development of new therapeutic agents, and high-precision radiotherapy techniques have improved survival rates for certain pediatric brain tumors. However, owing to the rarity of these tumors and the diversity of histological types, most treatment results are reported in clinical trials, and real-world data on the long-term treatment effects of radiotherapy in Japan are scarce. This study investigated the long-term outcomes of pediatric brain tumor treatment at a single institution. A total of 54 pediatric brain tumor patients aged ≤14 years who had undergone radiotherapy between 2007 and 2021 were included. Irradiation was performed using three-dimensional conformal or intensity-modulated radiation therapy. The distribution of each tumor type was as follows: eight diffuse intrinsic pontine gliomas, six malignant gliomas, 12 medulloblastomas, eight ependymomas, 15 germ cell tumors, and five other tumors (malignant peripheral nerve sheath tumor, pinealoblastoma, atypical teratoma/rhabdoid tumor, primitive neuroectoderm tumor, and malignant astroblastoma). The median follow-up duration for all patients and survivors was 48.4 months and 110 months, respectively. The one-, five-, and 10-year overall survival rates according to tumor type were as follows: diffuse intrinsic pontine glioma - 12.5%, 0%, and 0%; malignant glioma - 50%, 0%, and 0%; medulloblastoma - 91.7%, 83.3%, and 58.3%; ependymoma - 100%, 50%, and 37.5%; germ cell tumors - 93.3%, 93.3%, and 93.3%; and others - 80%, 80%, and 40%, respectively. The one-, five-, and 10-year progression-free survival rates according to the tumor type were 0% for both diffuse intrinsic pontine gliomas and malignant gliomas; 75%, 50%, and 50% for medulloblastoma; 62.5%, 25%, and not available for ependymoma; 86.7%, 80%, and 80% for germ cell tumor; and 60%, 40%, and not available for other tumors, respectively. Adverse events of grade 3 or higher (based on common terminology criteria for adverse events version 5.0) were observed in three patients as follows: two with hearing impairment and one with secondary cancer. Our findings revealed that the prognosis and recurrence patterns such as local and disseminated recurrence substantially differ depending on the tumor type. This confirms that each tumor type requires a unique approach. In recent years, significant progress has been made in the stratification and optimization of treatment through genetic analysis. However, to achieve improved tumor control and minimize late effects, the accumulation of long-term clinical data is essential.

Improved Survival and Symptom Relief Following Palliative Cerebrospinal Fluid Diversion for Leptomeningeal Disease from Brain Cancers: A Case Series and Systematic Review

BACKGROUND

Leptomeningeal disease (LMD) from cancer indicates advanced cancer and can lead to obstructive hydrocephalus, for which palliative cerebrospinal fluid (CSF) diversion may be indicated to alleviate symptoms. We investigated surgical outcomes for hydrocephalus for adult patients with LMD and conducted a systematic review on pediatric and adult cases.

METHODS

We analyzed outcomes from a 10-year period of patients with neoplastic LMD, obstructive hydrocephalus, and documented date of death. We also searched databases from inception until 20 August 2022, using search terms including 'cancer', 'hydrocephalus', and 'shunt'. Preferred reporting items for systematic reviews and meta-analyses guidelines were followed.

RESULTS

Among 50 patients, 30 (60%) underwent CSF diversion after LMD diagnosis with comparable median age in both the surgery (58.4 ± 14.4 years) and non-surgery (57.8 ± 14.5 years) groups. Twenty-three patients (76.7%) achieved symptom relief. The surgery group lived longer after LMD diagnosis than the non-surgery group (6.6 ± 6.0 vs. 1.3 ± 4.3 months, p < 0.001) and had a higher likelihood of survival (hazard ratio 2.49, 95% confidence interval 1.37-4.52, p = 0.002). Median survival after surgery was 2.8 ± 3.8 months. From 23 articles, 995 patients (34.3%) presented with LMD. Complication rates were 0-37.7% with no extraneural metastases. Symptom relief rates were 50-100%. Three studies reported median survival after surgery (2-3.3 months).

CONCLUSIONS

A rare entity with dismal prognosis, LMD can present as symptomatic hydrocephalus in patients with cancer. Symptom relief and improved survival can be achieved with palliative CSF diversion with low complication rates. Prospective studies are needed to assess the outcomes and needs of these patients.

Leptomeningeal Spread at the Diagnosis of Glioblastoma Multiforme: A Case Report and Literature Review

Approximately two-thirds of glioblastoma (GBM) patients progress to leptomeningeal spread (LMS) within two years. While 90% of LMS cases are diagnosed during the progression and/or recurrence of GBM (defined as secondary LMS), LMS presentation at the time of GBM diagnosis (defined as primary LMS) is very rare. ¹⁸F-fluorodeoxy glucose positron emission tomography computed tomography (¹⁸F-FDG PET/CT) study helps to diagnose the multifocal spread of the malignant primary brain tumor. Our patient was a 31-year-old man with a tumorous lesion located in the right temporal lobe, a wide area of the leptomeninges, and spinal cord (thoracic 5/6, and lumbar 1 level) involvement as a concurrent manifestation. After the removal of the right temporal tumor, the clinical status progressed rapidly, showing signs of increased intracranial pressure and hydrocephalus caused by LMS. He underwent a ventriculoperitoneal shunt a week after craniotomy. During management, progression of cord compression, paraplegia, bone marrow suppression related to radiochemotherapy, intercurrent infections, and persistent ascites due to peritoneal metastasis of the LMS through the shunt system was observed. The patient finally succumbed to the disease nine months after the diagnosis of simultaneous GBM and LMS. The overall survival of primary LMS with GBM in our case was nine months, which is shorter than that of secondary LMS with GBM. The survival period after the diagnosis of LMS did not seem to be significantly different between primary and secondary LMS. To determine the prognostic effect and difference between primary and secondary LMS, further cooperative studies with large-volume data analysis are warranted.

Leptomeningeal disease in glioblastoma: endgame or opportunity?

INTRODUCTION

Glioblastoma is an aggressive cancer with a notoriously poor prognosis. Recent advances in treatment have increased overall survival, though this may be accompanied by an increased incidence of leptomeningeal disease (LMD). LMD carries a particularly severe prognosis and remains a late stage manifestation of glioblastoma without satisfactory treatment. The objective of this review is to survey the literature on treatment of LMD in glioblastoma and to more fully characterize the current therapeutic strategies.

METHODS

The authors performed a systematic review following PRISMA criteria on PubMed and OVID databases. Articles that included adult patients with LMD from glioblastoma were retrieved and reviewed.

RESULTS

LMD in glioblastoma patients is increasing in incidence, with reports of up to 21%. The overall survival without treatment is alarmingly brief, with patients surviving between 1.6-3.8 months. All studies showed that treatment does improve overall survival significantly, increasing to 11.7 months in one study. However, no one adjuvant or surgical therapy has been shown to improve survival in LMD significantly over another. Direct treatment methods include chemotherapy (standard, anti-angiogenic, intrathecal, immunotherapy), and radiation. Hydrocephalus is a complication in LMD that can be treated with ventriculoperitoneal shunt placement, however treating hydrocephalus and delivering intrathecal chemotherapy is a challenge.

CONCLUSION

Though evidence remains lacking and there is no consensus, treatments show a trend towards improving survival and should be considered on a case-by-case basis. Further studies are necessary in the pursuit of a standard of care.