Long-term survival enhanced by cordectomy in a patient with a spinal glioblastoma multiforme and paraplegia. Case report

Primary Spinal Glioblastoma Mimicking Neuroschistosomiasis: A Case Report

Primary glioblastoma of the spinal cord (sGB) is a rare and challenging diagnosis. In the diagnostic algorithm, reversible causes should be considered while the diagnosis of sGB is under evaluation. We present a case of cervical sGB mimicking neuroschistosomiasis. A 21-year-old Somali man presented with neck pain, sensory disturbances, and spastic tetraplegia. Cervical spine magnetic resonance imaging with contrast showed a heterogeneously enhancing intramedullary mass spanning from the level of the C1 to T3 vertebrae. Cerebrospinal fluid analysis showed a lymphocytic predominance and elevated protein. Due to the patient's history of poorly treated schistosomiasis, praziquantel and dexamethasone were initiated while the diagnostic work-up was completed. Three days after the patient was discharged to a rehabilitation facility where he experienced worsened motor function with radiographic progression of the lesion and increased cord edema. The patient underwent a surgical biopsy which confirmed a diagnosis of primary sGB. sGB is an unusual diagnosis that can masquerade as a non-neoplastic lesion. However, the diagnosis of sGB should be considered in patients with an intramedullary spinal cord lesion who exhibit rapid radiographic and clinical progression.

Clinical outcomes and a therapeutic indication of intramedullary spinal cord astrocytoma

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Although intramedullary astrocytoma is associated with a high mortality rate, the optimal treatment has not reached a consensus. This study aimed at evaluating neurologic function and overall survival rate (OSR) in the treatment of this tumor.

SETTING

The single institution in Japan.

METHODS

This study enrolled 67 subjects who underwent surgical treatment for intramedullary astrocytoma. Demographic, imaging, and surgical information were collected from each participant. Tumors were histologically categorized using the World Health Organization classification, and subjects were divided into low-grade (I and II; n = 40) and high-grade (III and IV; n = 27) groups. Neurologic status was evaluated using the modified McCormick scale (MMS). OSR was assessed using Kaplan-Meier methods.

RESULTS

The OSR decreased when the pathological grade increased (p < 0.01). Regarding the therapeutic efficacy for low-grade astrocytomas, subjects who underwent gross total resection (GTR) showed a higher OSR than those who did not (p = 0.02). GTR prevented worsening of MMS score, while non-GTR increased the MMS score (p < 0.01). In the high-grade group, 19 and 10 underwent radiation therapy and chemotherapy, respectively. However, both treatments did not improve OSR. Cordotomy was performed for subjects whose lesional area was at the thoracic level, but the OSR did not significantly increase.

CONCLUSIONS

The most beneficial therapeutic strategy for low-grade astrocytomas was GTR, whereas that for the high-grade tumors was unclear. Further studies with a larger sample size are warranted to validate the effective treatment for malignant astrocytomas.

Management, outcomes, and prognostic factors of adult primary spinal cord gliomas

PURPOSE

Primary spinal cord tumors are rare, particularly in the adult population, and national guidelines remain ambiguous with regard to management approaches. To address this knowledge gap, we evaluated management, outcomes, and prognostic factors of these neoplasms.

METHODS

The National Cancer Database was queried (2004-2016) for newly-diagnosed, histologically-confirmed WHO grades I-III astrocytomas and glioblastoma. Statistics included Kaplan-Meier overall survival (OS) analysis, along with Cox proportional hazards modeling.

RESULTS

Of 1,033 subjects, 196 (19%) were pilocytic astrocytomas (PAs), 539 (52%) were grade II/III astrocytomas, and 298 (29%) were glioblastomas (GBMs). Respectively, 11%, 30%, and 27% did not undergo resection (biopsy only). RT was delivered to 27%, 54%, and 73%; chemotherapy was given to 5%, 21%, and 37%, respectively. The median OS was not reached for PAs, but was 101.2 months for grade II/III astrocytomas, and 23.9 months for GBMs (p < 0.001). Neither chemotherapy nor RT (or dose thereof) was associated with increased OS for grade II/III astrocytomas (p > 0.05 for all), though there was a trend toward improved OS with the use of chemotherapy for patients with GBM. Surgical resection was associated with improved OS for grade II/III astrocytomas and GBM (p < 0.05). Independent prognostic factors for survival in this cohort included histologic classification and resection (compared to biopsy only) (p < 0.05 for both).

CONCLUSIONS

This study sheds light onto the management of these rare tumors; surgery was associated with OS benefit for patients with GBM and Grade II/III astrocytomas. Neither RT nor chemotherapy were associated with OS benefit. Although not implying causation, these data can be used to guide patient counseling and therapeutic approaches.

Spinal cordectomy for the management of thoracic malignant intraspinal tumors in paraplegic or irreversibly, severely paraparetic patients: A technical remark

BACKGROUND

Malignant Intramedullary Spinal Cord Tumor are a relatively uncommon entity affecting patients whose prognosis is quickly and relentlessly dismal. Since the '50s Spinal Cordectomy' has been advocated for the surgical management of these conditions, but to date, no standard operative protocol has been reported yet.

OBJECTIVE

Although apparently "easy", burdened by virtually no further risk for the neurological function in paraplegic or severely paraparetic patients, SCt conceals notable pitfalls and surgical problems that are to date not yet completely discussed. The objective of the present paper is therefore to report a detailed stepwise description of the surgical technique.

METHODS AND RESULTS

SCt addresses the problem of reaching a surgical radicality in patients whom neurological preoperative conditions have already irreversibly declined to a deep nonfunctional motor impairment and whose preoperative Brain MRI scan rules out intracranial seeding. The dural sac along with the radicular pouches must be considered as possible seeding and recurrence locations therefore such structure should be "en-bloc" removed. The cranial medullary end of the resection should be identified on the ground of the preoperative MRI and intraoperatively confirmed with fresh histological examinations ruling out the presence of tumor cells above the cordectomy. Due to the topographic and functional medullary arterial anatomy, no SCt should be performed above T3. The risk of postoperative sagittal imbalance is high and therefore a concurrent posterior vertebral stabilization is required.

CONCLUSION

Spinal Cordectomy is a safe and feasible "last chance" treatment to prolong survival in paraplegic or severely paraparetic patients.

Glioblastoma Multiforme of the Conus Medullaris—Management Strategies and Complications

Primary spinal glioblastoma multiforme (GBM) of the conus medullaris is a rare and devastating pathologic entity. The presenting symptoms commonly include progressive neurologic deficits in the lower extremities, bowel and bladder dysfunction, and low back pain. Histologically, these tumors have high-grade features similar to their intracranial counterparts. However, recent advancements in the field of molecular oncology have been beginning to elucidate a unique molecular blueprint for these spinal gliomas. Given the lack of standardized treatment strategies, we have presented our institutional experience in treating a small series of patients with conus medullaris GBM and have reviewed the reported data on the relevant molecular markers, management strategies, and complication avoidance for this malignant pathologic entity.

H3K27M-Positive Primary Spinal Glioblastoma Presenting with Hemorrhage-A Rare Clinical Entity

BACKGROUND

Primary spinal glioblastoma multiforme is a rare and aggressive spinal tumor with dismal outcomes CASE DESCRIPTION: We have presented an unusual case-the first, to the best of our knowledge, to be reported-with intratumoral hemorrhage and sudden-onset quadriplegia in a patients with primary spinal glioblastoma multiforme. The patient underwent emergency surgical decompression. The patient died after a prolonged intensive care unit stay.

CONCLUSION

The tumor was positive for histone molecular alteration, H3K27M.

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.

Primary spinal glioblastoma multiforme: A case report and review of the literature

RATIONALE

Primary spinal glioblastoma multiforme (GBM) is a rare clinical entity with an aggressive course and an invariably dismal prognosis. Its clinical characteristics, radiologic and pathologic findings, and treatment protocols have been discussed in a few cases.

PATIENT CONCERNS

A 15-year-old female was admitted to the neurology department with a chief complaint of progressive numbness and weakness in her left upper extremity for 3 months and neck pain for 1 month.

DIAGNOSES

Spinal magnetic resonance imaging showed an intramedullary expansile mass localized between C4 and C7. The diagnosis of GBM was determined on the basis of the histopathological findings after operation.

INTERVENTIONS

Laminotomy and laminoplasty between C4 and C7 were performed, and the tumor was partially resected. The patient was administered focal adjuvant radiotherapy concomitantly with oral chemotherapy following the surgery.

OUTCOMES

With severe neurologic deficits at 13 months after the diagnosis, the patient expired.

LESSONS

Although therapeutic options have been improving, the prognosis of the primary spinal GBM remains poor. The treatment of primary spinal GBM entered into a central registry and multiple-center cooperation is important in establishing future therapeutic strategies.

Rapid Neurological Recovery Following Partial Surgical Resection of Spinal Glioblastoma Multiforme in a Pediatric Patient Presenting With Complete Paraplegia

Pediatric spinal cord glioblastoma multiforme is a rare entity with a poor prognosis often presenting with lower extremity weakness or paralysis. Previous literature suggests that aggressive surgical resection may provide overall survival benefit; however, there is limited concurrent analysis demonstrating neurological recovery following surgical resection. We report the case of a 9-year-old boy who presented with complete paraplegia and regained the ability to ambulate independently following subtotal surgical resection, radiation, and chemotherapy. The case demonstrates the balance between meaningful neurological recovery and overall survival when deciding on the extent of resection in cases of pediatric spinal glioblastoma multiforme.

A Systematic Review on the Characteristics, Treatments and Outcomes of the Patients with Primary Spinal Glioblastomas or Gliosarcomas Reported in Literature until March 2015

Our aim was to determine the characteristics, treatments and outcomes of patients with primary spinal glioblastomas (GB) or gliosarcomas (GS) reported in literature until March 2015. PubMed and Web of Science were searched for peer-reviewed articles pertaining to cases of glioblastomas / gliosarcomas with primary spinal origin, using predefined search terms. Furthermore we performed hand searches tracking the references from the selected papers. Eighty-two articles published between 1938 and March 2015 were eligible. They reported on 157 patients. Median age at diagnosis was 22 years. The proportion of patients who received adjuvant chemo- or radiotherapy clearly increased from the time before 1980 until present. Median overall survival from diagnosis was 8.0 ± 0.9 months. On univariate analysis age influenced overall survival, whereas tumor location, gender and the extent of initial resection did not. Outcomes did not differ between children (< 18 years) and adults. However, the patients who were treated after 1980 achieved longer survival times than the patients treated before. On multivariable analysis only age (< 60 years) and the time period of treatment (≥ 1980) were confirmed as positive independent prognostic factors. In conclusion, primary spinal GB / GS mainly affect younger patients and are associated with a dismal prognosis. However, most likely due to the increasing use of adjuvant treatment, modest therapeutic progress has been achieved over recent decades. The characteristics and treatments of primary spinal glioblastomas should be entered into a central registry in order to gain more information about the ideal treatment approach in the future.

Long-term cure of high-grade spinal cord glioma in a pediatric patient who underwent cordectomy

High-grade spinal cord gliomas are rare and carry a poor prognosis. A number of treatment modalities exist for spinal cord gliomas, but no consensus exists regarding their management. Cordectomy represents a possible option for treating these lesions; however, few cases have been reported in adults, and none have been reported in the pediatric population. The authors describe the use of cordectomy for the treatment of a high-grade spinal glioma in a 9-year-old boy who remains cancer free 14 years following his initial presentation.

Cordectomy for intramedullary spinal cord glioblastoma with a 12-year survival

Background:

Prognosis of patients with spinal cord glioblastoma is poor, with an average survival of 18 months. There are reports in the literature describing cordectomy as a treatment option for patients with spinal cord tumors.

Case Description:

This is a case report of a patient with spinal cord glioblastoma who, in addition to radiation and chemotherapy, was treated with cordectomy. Outcome of treatment resulted in 12-year survival.

Conclusion:

Cordectomy in spinal cord glioblastoma can result in prolonged and meaningful survival.

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.

Histopathologic and immunohistochemical profile of spinal glioblastoma: a study of six cases

Spinal intramedullary glioblastomas are uncommon tumors and are known to have a very poor prognosis. Only a few studies in the literature have described their histopathological characteristics. We describe the detailed histopathological and immunohistochemical profiles of six cases of spinal glioblastoma. Most of the tumors were located in the cervical or cervicothoracic region. The majority of the patients were young adults (mean age 34.8 years), presenting with a short duration of symptoms of 2 months or less. Their histopathological features were similar to cerebral glioblastoma. Diverse vascular changes like microvascular proliferation, sprouting angiogenesis, sclerosed and thrombosed vessels, along with field necrosis were prominent findings. All tumors were positive for GFAP and negative for EMA. The MIB-1 labeling index was very high (mean 16.7 ± 3.2%). Five out of six tumors were immunoreactive for p53 protein, and only two showed over-expression of EGFR protein. The predominant expression of p53 in these young patients suggests that spinal glioblastomas are similar to secondary glioblastoma in the cerebral hemispheres, despite the short duration of symptoms in them and vascular changes that are similar to those noted in primary glioblastoma. These observations support the fact that spinal glioblastomas are heterogeneous tumors underlined by complex molecular pathways. Nevertheless, inactivation of the p53 tumor suppressor pathway could play a major role in the genesis of these neoplasms.

Glioblastoma multiforme in the adult conus medullaris

De novo glioblastoma multiforme (GBM) of the spine is rare. We present a patient with a unique GBM arising within the conus and radiographically mimicking a filum terminale ependymoma. During surgery the lesion was notable for its highly vascular and diffuse infiltration of the surrounding spinal cord parenchyma. The operative goals were altered to account for the unexpected pathology. The treatment and prognosis of spinal GBM are briefly reviewed and the importance of considering an aggressive pathology when formulating a surgical plan for benign appearing lesions is emphasized.

Cordotomy for patients with thoracic malignant astrocytoma

Object

The optimal management of malignant astrocytomas remains controversial, and the prognosis of these lesions has been dismal regardless of the administered treatment. In this study the authors investigated the surgical outcomes of cordotomy in patients with thoracic malignant astrocytomas to determine the effectiveness of this procedure.

Methods

Cordotomy was performed in 5 patients with glioblastoma multiforme (GBM) and 2 with anaplastic astrocytoma (AA). A Kaplan-Meier survival analysis was performed, and the associations of the resection level with survival and postoperative complications were retrospectively examined.

Results

Cordotomy was performed in a single stage in 2 patients with GBM and in 2 stages in 3 patients with GBM and 2 patients with AA. In the 2 patients with GBM, cordotomy was performed 2 and 3 weeks after a partial tumor resection. In the 2 patients with AA, the initial treatment consisted of partial tumor resection and subtotal resection combined with radiotherapy, and rostral tumor growth and progressive paralysis necessitated cordotomy 2 and 28 months later. One patient with a secondary GBM underwent cordotomy; the GBM developed 1 year after subtotal resection and radiotherapy for a WHO Grade II astrocytoma. Four patients died 4, 5, 24, and 42 months after the initial operation due to CSF dissemination, and 3 patients (2 with GBM and 1 with AA) remain alive (16, 39, and 71 months). No metastasis to any other organs was noted.

Conclusions

One-stage cordotomy should be indicated for patients with thoracic GBM or AA presenting with complete paraplegia preoperatively. In patients with thoracic GBM, even if paralysis is incomplete, cordotomy should be performed before the tumor disseminates through the CSF. Radical resection should be attempted in patients with AA and incomplete paralysis. If the tumor persists, radiotherapy and chemotherapy are indicated, and cordotomy should be reserved for lesions growing progressively after such second-line treatments.

Cordectomy as final treatment option for diffuse intramedullary malignant glioma using 5-ALA fluorescence-guided resection

BACKGROUND

We present a case of an anaplastic astrocytoma (WHO-grade III, AA III) in a 27-year-old woman treated by spinal cordectomy. The patient was pretreated by surgery, radiation therapy and temozolomide chemotherapy and repeat surgery at recurrence. Later on, she developed paraplegia and a diffuse severe pain syndrome. MRI demonstrated intramedullar invasion from T12 to T9. To assess tumor invasion intraoperatively, we used tumor fluorescence derived from 5-aminolevulinic acid (5-ALA).

PATIENTS COURSE

The spinal cord was amputated caudally to the root entry zones of the T10 sensory roots. Additional cordectomy was performed because of tumor infiltration at the cut end to T9 as identified by intraoperative tumor fluorescence, and as verified histologically. The final transected level was between T8 and T9, and the cut end did not reveal any tumor invasion intraoperatively by tumor fluorescence and postoperatively by MRI and with regard to the pathological result. After surgery, the patient was unchanged concerning spasticity, motor and sensory function, and showed complete relief of pain. She refused additional adjuvant therapy. The patient is free of recurrence 15 months after surgery.

CONCLUSION

Our observation suggests 5-ALA fluorescence-guided resections to be useful in the context of malignant spinal cord gliomas. Furthermore, our particular case indicates that palliative spinal cordectomy with a wide margin and intraoperative resection using fluorescence guidance may be a final option for patients with recurrent spinal malignant glioma presenting with complete deficit below the lesion.

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.