WITHDRAWN: Primary CNS lymphoma and high-grade glioma: differentiation using perfusion and proton spectroscopic MR imaging

Abstract INTRODUCTION Tumors arising from the spinal cord are uncommon, especially high-grade tumors in pediatric patients. We report a case of high-grade glioma in the spinal cord harboring NTRK1 gene fusion, who received effective entrectinib therapy. CASE REPORT: A 5-year-old boy presented right hemiparesis and MR imaging revealed an intramedullary enhancing mass at the vertebral body level between C3 and Th1. He underwent microsurgical partial resection and the histological diagnosis was low-grade astrocytoma. After the first-line chemotherapy with vincristine and carboplatin, his right hemiparesis deteriorated and recurrent MR imaging showed growth of the tumor. He underwent microsurgical partial resection again and the histological examination was high-grade glioma with endothelial proliferation and necrosis. The chemoradiotherapy with temozolomide and focal irradiation of 50.4 Gy were given, and his neurological symptom slightly improved. One month later, he presented respiratory disturbance and required assisted ventilation with tracheostomy. MR imaging showed tumor progression invading upward to medulla oblongata. NTRK1 gene fusion was detected in the previous surgical specimen by a gene panel testing, and he received entrectinib, a potent inhibitor of tropomyosin receptor kinase (TRK). Since then, no tumor progression has been demonstrated for several months by MRI and he has been stable neurologically. CONCLUSION High-grade spinal cord tumors are rare and effective treatment strategies have not been addressed. Although the frequency of the gene fusion is very low in pediatric gliomas, identification of the driver gene aberration like in this case by a gene panel can provide potential targeted therapies for selected patients.

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Lymphomatous meningitis in primary central nervous system lymphoma

Neurosurgical FOCUS ◽

10.3171/foc.2006.21.5.7 ◽

2006 ◽

Vol 21 (5) ◽

pp. 1-7 ◽

Cited By ~ 9

Author(s):

Marc C. Chamberlain

Keyword(s):

Central Nervous System ◽

Nervous System ◽

Drug Therapy ◽

Mr Imaging ◽

Primary Cns Lymphoma ◽

Chemotherapeutic Agents ◽

Cranial Computed Tomography ◽

Cns Lymphoma ◽

High Dose ◽

Lymphomatous Meningitis

✓Lymphomatous meningitis (LM) due to primary central nervous system (CNS) lymphoma is an uncommon problem in neurooncology and can occur at time of diagnosis or recurrence. Notwithstanding frequent focal signs and symptoms, LM is a disease affecting the entire neuraxis, and therefore staging and treatment need to encompass all cere-brospinal fluid (CSF) compartments. Central nervous system staging of LM includes contrast agent–enhanced cranial computed tomography (CT) or Gd-enhanced magnetic resonance (MR) imaging, Gd-enhanced spinal MR imaging, CT myelography, and radionuclide CSF flow study. Treatment of LM includes involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy can benefit patients with LM and can obviate the need for intra-CSF chemotherapy. At present, intra-CSF drug therapy is confined to three chemotherapeutic agents (methotrexate, cytosine arabinoside, and thiotepa) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Although treatment of LM is palliative and the expected median survival of patients is 4 to 6 months, it often provides stabilization and protection from further neurological deterioration. In patients with primary CNS lymphoma, CNS prophylaxis has been recommended (using a combination of high-dose systemic chemotherapy and intra-CSF chemotherapy), but the strategy remains controversial because high-dose systemic methotrexate is commonly used as an adjuvant therapy. Patients with primary CNS lymphoma at high risk as defined by positive CSF cytology or neuroradiography consistent with LM may benefit from the inclusion of intra-CSF chemotherapy.

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PATH-60. PRIMARY CNS LYMPHOMA PRECEDED BY ACUTE DEMYELINATION

Neuro-Oncology ◽

10.1093/neuonc/noz175.655 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi156-vi157

Author(s):

Justin Low ◽

Anne Buckley ◽

Dina Randazzo

Keyword(s):

Oral Prednisone ◽

Primary Cns Lymphoma ◽

Brain Biopsy ◽

B Cell Lymphoma ◽

High Grade Glioma ◽

Acute Disseminated Encephalomyelitis ◽

Cns Lymphoma ◽

Central Demyelination ◽

Initial Biopsy ◽

Radiographic Improvement

Abstract Primary CNS lymphoma commonly presents with nonspecific encephalopathy or focal neurologic deficits. Magnetic resonance imaging typically shows a homogeneously enhancing mass with surrounding edema. The imaging differential diagnosis is broad, and includes high grade glioma and neuroinflammatory conditions. Definitive diagnosis therefore requires biopsy. Here we present a case of primary CNS lymphoma that was diagnosed as an acute demyelinating process on initial biopsy. A 68 year old female presented with gait instability and vertigo. MRI showed right cerebellar and right trigonal enhancing lesions. Biopsy revealed an acute demyelinating inflammatory process and she was diagnosed with acute disseminated encephalomyelitis. She was treated with intravenous methylprednisolone followed by oral prednisone with resulting clinical and radiographic improvement. She was re-admitted to hospital 4 months later with encephalopathy. Imaging showed a new enhancing mass in the pericallosal frontal lobes. Repeat brain biopsy showed diffuse large B-cell lymphoma. This case illustrates a highly unusual situation of biopsy-proven central demyelination preceding a primary CNS lymphoma diagnosis. It raises a number of etiopathological questions concerning the coexistence and potential causal relationships between demyelination and lymphoma. Additionally, it highlights the need for repeat biopsy if clinical and radiographic suspicion for lymphoma persists despite an alternative initial biopsy result.

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Correlations between Perfusion MR Imaging Cerebral Blood Volume, Microvessel Quantification, and Clinical Outcome Using Stereotactic Analysis in Recurrent High-Grade Glioma

American Journal of Neuroradiology ◽

10.3174/ajnr.a2743 ◽

2011 ◽

Vol 33 (1) ◽

pp. 69-76 ◽

Cited By ~ 75

Author(s):

L.S. Hu ◽

J.M. Eschbacher ◽

A.C. Dueck ◽

J.E. Heiserman ◽

S. Liu ◽

...

Keyword(s):

Clinical Outcome ◽

Mr Imaging ◽

Blood Volume ◽

Cerebral Blood Volume ◽

High Grade Glioma ◽

High Grade ◽

Perfusion Mr ◽

Perfusion Mr Imaging

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Assessing Biological Response to Bevacizumab Using 18F-Fluoromisonidazole PET/MR Imaging in a Patient with Recurrent Anaplastic Astrocytoma

Case Reports in Radiology ◽

10.1155/2015/731361 ◽

2015 ◽

Vol 2015 ◽

pp. 1-4 ◽

Cited By ~ 3

Author(s):

Ramon F. Barajas ◽

Miguel H. Pampaloni ◽

Jennifer L. Clarke ◽

Youngho Seo ◽

Dragana Savic ◽

...

Keyword(s):

Mr Imaging ◽

Anaplastic Astrocytoma ◽

Biological Effects ◽

Biological Response ◽

High Grade Glioma ◽

Index Patient ◽

High Grade ◽

Initial Experience ◽

Vascular Normalization ◽

Single Modality

We present our initial experience in using single modality fluoromisonidazole (FMISO) PET/MR imaging to noninvasively evaluate the biological effects induced by bevacizumab therapy in a patient treated for recurrent high grade glioma. In this index patient, bevacizumab therapy resulted in the development of nonenhancing tumor characterized by reduced diffusion and markedly decreased FMISO uptake in the setting of maintained CBF and CBV. These observations suggest that the dynamic biological interplay between tissue hypoxia and vascular normalization occurring within treated recurrent high grade glioma can be captured utilizing FMISO PET/MR imaging.

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Use of CT and MR imaging to distinguish intracranial lesions and to define the need for biopsy in AIDS patients

Journal of Neurosurgery ◽

10.3171/jns.1990.73.5.0720 ◽

1990 ◽

Vol 73 (5) ◽

pp. 720-724 ◽

Cited By ~ 130

Author(s):

Samuel F. Ciricillo ◽

Mark L. Rosenblum

Keyword(s):

Mr Imaging ◽

Primary Cns Lymphoma ◽

Signs And Symptoms ◽

Cns Lymphoma ◽

Mr Images ◽

Aids Patients ◽

Content Type ◽

Immunodeficiency Syndrome ◽

Mass Lesions ◽

Cns Lesions

✓ To explore the potential usefulness of imaging studies in the diagnosis of focal central nervous system (CNS) lesions associated with acquired immunodeficiency syndrome (AIDS), the authors retrospectively examined the radiographic studies of 149 AIDS patients who presented with signs and symptoms of the three most common focal CNS lesions. Of these patients, 74 (50%) had Toxoplasma abscesses, 45 (30%) had primary CNS lymphoma, and 30 patients (20%) had progressive multifocal leukoencephalopathy (PML). Magnetic resonance (MR) imaging was more sensitive than computerized tomography (CT) in detecting lesions, especially in cases of PML. Whereas CT was unable to distinguish mass lesions caused by toxoplasmosis from those caused by lymphoma, 71% of the solitary lesions seen on MR images were lymphomas. These results indicate that empirical treatment for toxoplasmosis, the most common initial treatment for AIDS patients with neurological symptoms stemming from mass lesions, is not likely to be successful for patients with solitary lesions on MR images. Rather, early biopsy is advisable. If the presence of lymphoma is confirmed, the rapid initiation of treatment can allow prolonged high-quality survival.

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INNV-28. TEMOZOLOMIDE IN RENAL DYSFUNCTION

Neuro-Oncology ◽

10.1093/neuonc/noaa215.511 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii122-ii122

Author(s):

Kayla Garzio ◽

Kelly McElroy ◽

Stuart Grossman ◽

Matthias Holdhoff ◽

Byram Ozer ◽

...

Keyword(s):

Renal Function ◽

Medical Records ◽

Alkylating Agent ◽

Primary Cns Lymphoma ◽

Cns Lymphoma ◽

High Grade ◽

Secondary Endpoints ◽

Grade 3 ◽

Number Of Cycles ◽

Experienced Grade

Abstract BACKGROUND Temozolomide (TMZ) is a cytotoxic DNA alkylating agent. It is the only chemotherapy known to improve survival in patients with high grade astrocytomas. The active alkylating species, methylhydrazine, is not recovered in the urine and thus renal function is not expected to affect clearance of this agent. It has never been formally evaluated in adults with eGFR < 36 mL/min/1.73 m2, and it is often recommended to administer with caution, dose reduce, or withhold therapy. However, lacking other effective therapies, we have elected to administer TMZ at full dose to these patients. This IRB approved retrospective study was conducted to evaluate the safety of this practice. METHODS The primary endpoint was to characterize the incidence and severity of thrombocytopenia in patients with renal impairment defined as eGFR < 60 mL/min/1.73 m2 who received TMZ for the treatment of their high grade gliomas (HGG) or primary CNS lymphoma (PCNSL). Secondary endpoints included incidence and severity of neutropenia, lymphocytopenia, hepatotoxicity, and number of cycles administered. Medical records were reviewed for adult patients with HGG or PCNSL treated with TMZ from October 1, 2016-September 30, 2019. RESULTS Thirty-four patients met criteria for inclusion. Of the 7 patients with eGFR < 36 mL/min/1.73m2, 33/34 cycles (97%) were completed successfully without grade 3–4 thrombocytopenia. No patients experienced grade 3–4 neutropenia, and grade 3–4 lymphocytopenia occurred in 5 cycles (15%). One patient required discontinuation of TMZ 7 days prior to completion of radiation due to thrombocytopenia. CONCLUSION The side effect profile from TMZ administered to patients with eGFR < 36 mL/min/1.73 m2 appears to be similar to that of patients with normal renal function. This is not an unanticipated finding given what is known about the metabolism of the drug.

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RTHP-14. PSEUDOPROGRESSION IN HIGH GRADE GLIOMA PATIENTS AFTER PROTON OR PHOTON THERAPY

Neuro-Oncology ◽

10.1093/neuonc/noz175.887 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi213-vi213

Author(s):

Vonetta Williams ◽

Lia Halasz ◽

Jason Rockhill ◽

James Fink

Keyword(s):

Mr Imaging ◽

High Grade Glioma ◽

Extent Of Resection ◽

High Dose ◽

High Grade ◽

Proton Group ◽

Kaplan Meier ◽

Dose Volume ◽

Biological Effectiveness ◽

Grade Iii

Abstract Pseudoprogression is defined as the appearance of false progression on MR imaging following radiation therapy. Proton therapy is thought to have increased relative biological effectiveness-the ratio of the doses required by two types of radiation to cause the same level of effect-near the edges of the high dose volume. This could lead to different rates of pseudoprogression for protons compared to photons. In our IRB approved study, a board-certified neuroradiologist reviewed serial imaging of 74 patients (photons: n=37, protons: n=37) treated from 2013–2018 with either proton or photon radiotherapy to 59.4–60 Gy in 30–33 fractions and temozolomide for high grade glioma. MR imaging was performed 1 month after completion of treatment and then every 3 months. True progression was scored based on updated RANO criteria. Pseudoprogression was determined if imaging improved without change in therapy. Cumulative incidences of these outcomes and survival were calculated utilizing Kaplan-Meier analyses. Patient and treatment factors were analyzed for their association with incidence of pseudoprogression. Median follow-up for alive patients in the proton and photon groups were 15 and 29 months, respectively. Median age was 49 years in the proton group and 54 years in the photon group (p=0.17). Among proton patients, 14 had grade III glioma and 23 had grade IV glioblastoma. Among photon patients, 1 had grade III glioma. Median survival was 23 and 35 months for the proton and photon groups, respectively (p=0.57). The cumulative incidence of pseudoprogression was 14.4% and 10.4% at 12 months for the proton and photon groups, respectively (p=0.53). Grade, extent of resection, age, and IDH status, were not significantly associated with development of pseudoprogression. MGMT methylated tumors showed a trend toward association with pseudoprogression compared to unmethylated tumors (p=0.058). We concluded that the incidence of pseudoprogression is similar regardless of whether proton or photon therapy was utilized.

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