Distinct imaging patterns of pseudoprogression in glioma patients following proton versus photon radiation therapy

Mapping Intimacies ◽

10.21203/rs.3.rs-197830/v1 ◽

2021 ◽

Author(s):

Reed Ritterbusch ◽

Lia M. Halasz ◽

Jerome J. Graber

Keyword(s):

Radiation Therapy ◽

Mr Imaging ◽

Tumor Progression ◽

Clinical Symptoms ◽

Molecular Subtype ◽

Tumor Grade ◽

Photon Radiation ◽

Low Grade ◽

Mean Time

Abstract Purpose Criteria by the Radiologic Assessment in Neuro-Oncology (RANO) group outline the diagnosis of pseudoprogression (Ps) after photon therapy for gliomas based on timing and location. We noted that patients receiving proton therapy manifested radiographic changes that appear different than Ps after photon therapy, which could be interpreted as tumor progression. In this study, we retrospectively reviewed MR imaging after proton or photon radiation for gliomas. We propose criteria to characterize proton pseudoprogression (ProPs) as distinct from Ps seen after photons. Methods Post-treatment MR imaging, clinical and pathological data of low grade glioma patients were reviewed. Overall, 57 patients receiving protons were reviewed for the presence of ProPs, and 43 patients receiving photons were reviewed for any equivalent imaging changes. Data collected included the location and timing of the new enhancement, tumor grade, molecular subtype, chemotherapy received, and clinical symptoms. Results Fourteen patients (24.6%) had new enhancement following radiation therapy that was unique to treatment with protons. The mean time to development of the ProPs was 15.4 months (7–27 months). We established the following criteria to characterize ProPs: located at the distal end of the proton beam; resolves without tumor-directed therapy; and subjectively multifocal, patchy, and small (< 1 cm). In the group receiving photons, none had changes that met our criteria for ProPs. Conclusion Patients who receive protons have unique imaging changes after radiation therapy. ProPs could be mistaken for tumor progression, but typically resolves on follow up. Further studies are needed to understand the radiobiology and pathophysiology underlying these imaging changes.

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Intrinsic tumors of the insula: a prospective surgical study of 30 patients

Journal of Neurosurgery ◽

10.3171/jns.1996.85.2.0263 ◽

1996 ◽

Vol 85 (2) ◽

pp. 263-271 ◽

Cited By ~ 90

Author(s):

Josef Zentner ◽

Bernhard Meyer ◽

Armin Stangl ◽

Johannes Schramm

Keyword(s):

Surgical Treatment ◽

Mr Imaging ◽

Karnofsky Performance Scale ◽

Low Grade ◽

Incomplete Resection ◽

Content Type ◽

Transsylvian Approach ◽

Preoperative Magnetic Resonance ◽

Mean Time

✓ Intrinsic insular tumors are frequently excluded from surgical treatment. The authors propose a more extensive approach to these lesions based on the results of this prospective series. From September 1993 to January 1995, 30 patients (18 males and 12 females; mean age 42 years) harboring benign (15 patients) or malignant (15 patients) tumors involving the insula underwent surgical treatment. The dominant and nondominant hemispheres were both affected in 15 cases. Two groups were defined on the basis of preoperative magnetic resonance (MR) imaging: 14 lesions were restricted to the insula and the corresponding opercula; the other 16 lesions also involved other mesocortical and/or allocortical areas. Most patients displayed only mild preoperative symptoms. The median score according to the Karnofsky performance scale was 90. Microsurgical removal was achieved via a transsylvian approach in nine cases and via a frontal and/or temporal approach in 21 cases. According to early postoperative MR imaging, complete tumor removal (100%) was seen in five patients, nearly complete (> 80%) in 21, and incomplete resection (50%–80%) in four patients. There was no operative mortality; 19 patients (63%) experienced immediate postoperative morbidity, including reduced performance. After a mean follow-up review of 8.5 months two of 21 patients suffered permanent deficits, accounting for an overall operative morbidity of 10%. At the mean time of review, three patients with Grade IV tumors had died of tumor recurrence. The authors conclude that low-grade intrinsic insular tumors, as well as Grade III tumors, can be removed with favorable results in the majority of patients. Surgery to excise glioblastomas should only be considered for patients with good preoperative performance and young age.

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HGG-12. A CASE OF PEDIATRIC SPINAL HIGH-GRADE GLIOMA WITH NTRK1 GENE FUSION

Neuro-Oncology ◽

10.1093/neuonc/noaa222.301 ◽

2020 ◽

Vol 22 (Supplement_3) ◽

pp. iii346-iii346

Author(s):

Tamaki Morisako ◽

Daisuke Umebayashi ◽

Kazuaki Kamata ◽

Hiroyuki Yamamoto ◽

Takumi Yamanaka ◽

...

Keyword(s):

Spinal Cord ◽

Mr Imaging ◽

Tumor Progression ◽

Gene Fusion ◽

High Grade Glioma ◽

Gene Panel ◽

Partial Resection ◽

Low Grade ◽

High Grade ◽

Surgical Specimen

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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Multiple Victims of Carbon Monoxide Poisoning in the Aftermath of a Wildfire: A Case Series

Acta Médica Portuguesa ◽

10.20344/amp.9811 ◽

2018 ◽

Vol 31 (3) ◽

pp. 146 ◽

Cited By ~ 3

Author(s):

Luís Ramos dos Santos ◽

Magna Alves-Correia ◽

Margarida Câmara ◽

Manuela Lélis ◽

Carmo Caldeira ◽

...

Keyword(s):

Carbon Monoxide ◽

Hyperbaric Oxygen ◽

Clinical Symptoms ◽

Carbon Monoxide Poisoning ◽

Case Series ◽

Neurological Syndrome ◽

High Flow Oxygen ◽

Lost To Follow Up ◽

Mean Time

Introduction: Carbon monoxide poisoning may occur in several contexts.Material and Methods: Retrospective of 37 carbon monoxide poisoning cases that underwent hyperbaric oxygen during wildfires in Funchal in August 2016.Results: The studied sample included 37 patients, mean age of 38 years, 78% males. Ten were firefighters, four children and two pregnant victims. Neurological symptoms were the most reported. Median carboxyhemoglobin level was 3.7% (IQR 2.7). All received high-flow oxygen from admission to delivery of hyperbaric oxygen. Persistence of symptoms was the main indication for hyperbaric oxygen. Median time to hyperbaric oxygen was 4.8 hours (IQR 9.5), at 2.5 ATA for 90 minutes, without major complications. Discharge in less than 24 hours occurred in 92% of the cases. Thirty days follow-up: five patients presented clinical symptoms of late neurological syndrome; twelve patients were lost to follow-up. Carboxyhemoglobin levels on admission and mean time to hyperbaric oxygen were no different between those who did and did not develop the syndrome at 30 days (p = 0.44 and p = 0.58, respectively).Discussion: Late neurological syndrome at 30 days occurred in 20% and no new cases were reported at 12 months.Conclusion: Use of hyperbaric oxygen appears to have reduced the incidence of the syndrome. This seems to be the first Portuguese series reporting use of hyperbaric oxygen in carbon monoxide poisoning due to wildfires. The authors intend to alert to the importance of referral of these patients because the indications and benefits of this treatment are well documented. This is especially important given the ever-growing issue of wildfires in Portugal.

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Intracranial Gliomas: Association between MRI Features and Tumor Grade

Bangladesh Journal of Neurosurgery ◽

10.3329/bjns.v8i2.42351 ◽

2019 ◽

Vol 8 (2) ◽

pp. 93-99

Author(s):

Md Rokibul Islam ◽

KM Tarikul Islam ◽

Moshiur Rahman ◽

Mohammad Hossain ◽

Raziul Haque ◽

...

Keyword(s):

Mr Imaging ◽

Contrast Enhancement ◽

Predictive Value ◽

Tumor Grade ◽

Mass Effect ◽

Low Grade ◽

Imaging Features ◽

Peritumoral Edema ◽

Cross Sectional ◽

Mri Features

Purpose: Intracranial gliomas are not uncommon in our country. The therapeutic management and prognosis in patients with gliomas depend on the reliable distinction between high and low-grade gliomas. The purpose of the present study was to determine whether any association exists between various individual MR imaging features and histopathologically determined tumor grade of intracranial gliomas. Our target was to explore whether MRI could enable correct determination the grading of gliomas which will help early diagnosis, staging, grade assessing, determining the appropriate treatment, preoperative planning for surgical resection and post operative management plan. Materials and Methods: It was a cross sectional type of observational study. This study was conducted on 44 cases of intracranial gliomas. Only patients having histopathologically proven intracranial gliomas who underwent surgery or stereotactic biopsy were considered as a study population. Results: The present study revealed that there is significant association between the MR imaging features and histopathological grading of intracranial gliomas. Contrast enhancement in MRI showed most significant (p<0.001). Other significant MR imaging features were peritumoral edema (p=0.001), tumor border definition (p=0.001), necrosis or cystic change of tumor (p=0.001) and mass effect (p=0.003). In this study preoperative MRI diagnosis was correct in 39 patients with accuracy of 88.6%. Sensitivity, specificity, positive predictive value and negative predictive value of MRI in detecting tumor grade were 86.4%, 90.9%, 90.5% and 87% respectively. Conclusion: MRI is sensitive, specific and accurate in assessing the grade of gliomas. Contrast enhancement is the most important predictor. Peritumoral edema, tumor border definition, mass effect and necrosis/cystic changes of tumor are also important indicators of tumor grade. Bang. J Neurosurgery 2019; 8(2): 93-99

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Focal brain-stem astrocytomas causing symptoms of involvement of the facial nerve nucleus: long-term survival in six pediatric cases

Journal of Neurosurgery ◽

10.3171/jns.1994.80.1.0020 ◽

1994 ◽

Vol 80 (1) ◽

pp. 20-25 ◽

Cited By ~ 24

Author(s):

Michael S. B. Edwards ◽

William M. Wara ◽

Samuel F. Ciricillo ◽

A. James Barkovich

Keyword(s):

Radiation Therapy ◽

Facial Nerve ◽

Brain Stem ◽

Pilocytic Astrocytoma ◽

Low Grade ◽

Brain Stem Glioma ◽

Term Survival ◽

Juvenile Pilocytic Astrocytoma ◽

Nerve Nucleus

✓ Six children with a history of isolated facial nerve dysfunction or dizziness and nausea were treated for brain-stem glioma between 1984 and 1992. Computerized tomography and/or magnetic resonance (MR) imaging showed a focal, uniformly enhancing mass involving the facial nerve nucleus of the pons. All patients underwent biopsy; the histological diagnosis was juvenile pilocytic astrocytoma in five cases. In the remaining case the biopsy was nondiagnostic, although the surgeon believed that the lesion was a glioma. Postoperatively, five patients underwent conventional focal megavoltage radiation therapy (180 to 200 cGy/day) over a period of 5½ weeks to a total dose of approximately 5400 cGy. One child's family refused radiation therapy; she remained well and stable for 4 years, despite persistent facial weakness, and was eventually lost to follow-up review. Four irradiation-treated patients had complete resolution of their tumors on MR images and have had no evidence of neuropsychological or neuroendocrinological deficits during 4½ to 8 years of follow-up evaluation. Patients whose neuroradiological studies show a lesion resembling those in this series should undergo biopsy and, if the histology of a low-grade tumor (in particular, a juvenile pilocytic astrocytoma) is confirmed, should then receive focal radiation therapy with conventional megavoltage dosages.

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Long-term outcome of 89 low-grade brain-stem gliomas after interstitial radiation therapy

Journal of Neurosurgery ◽

10.3171/jns.1991.75.5.0740 ◽

1991 ◽

Vol 75 (5) ◽

pp. 740-746 ◽

Cited By ~ 48

Author(s):

Fritz Mundinger ◽

Dieter F. Braus ◽

Joachim K. Krauss ◽

Walter Birg

Keyword(s):

Radiation Therapy ◽

Brain Stem ◽

Low Grade ◽

Content Type ◽

Long Term Follow Up ◽

Interstitial Radiation Therapy ◽

Brain Stem Gliomas ◽

Interstitial Radiation

✓ Between 1974 and 1985, 89 patients suffering from histologically confirmed, nonresectable low-grade astrocytomas located in the brain stem were entered into a retrospective study. Iodine-125 (125I) was implanted in 29 patients and iridium-192 (192Ir) in 26 patients. Computerized tomography revealed that 78% of the tumors in these patients were located chiefly in the mesencephalic region, 70% were circumscribed, and 78% were contrast-enhanced. Thirty-four patients underwent biopsy without prior aggressive tumor-specific therapy such as chemotherapy or external beam irradiation. Among these, 70% of the tumors were located predominantly in the pons, 74% were diffuse, and 59% were hypodense or isodense after contrast enhancement. Long-term follow-up investigations indicated that life expectancy after interstitial radiation therapy with 125I implanted directly by catheter either permanently or temporarily showed a more favorable trend than that after treatment with 192Ir. Interstitial radiation therapy with 125I appears to be an effective treatment for slowly proliferating, differentiated, well-delineated, nonresectable brain-stem gliomas. This technique makes it possible to achieve radio-surgical tumor control and, when carefully applied, represents the least traumatic treatment. Reduction of the tumor mass brings about improvement of the clinical symptoms. Further investigations on the biological behavior of brain-stem gliomas and prospective randomized long-term follow-up studies are necessary to evaluate the different kinds of treatment available for these patients.

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Radiotherapy of Intracranial Astrocytomas

Neurosurgery ◽

10.1227/00006123-197909000-00001 ◽

1979 ◽

Vol 5 (3) ◽

pp. 301-308 ◽

Cited By ~ 97

Author(s):

Paul W. Scanlon ◽

William F. Taylor

Keyword(s):

Radiation Therapy ◽

Postoperative Radiotherapy ◽

Tumor Grade ◽

Low Grade ◽

Unexpected Finding ◽

High Grade ◽

Death Rates ◽

Brain Irradiation ◽

Total Brain ◽

Better Than

Abstract In a review of 417 intracranial astrocytomas treated radiotherapeutically at the Mayo Clinic from 1960 through 1969, the well-known correlation of tumor grade with survival was verified. Totally unexpected was the finding that age was fully as important a discriminant as tumor grade. Another unexpected finding was that patients treated with biopsy only followed by radiation therapy did as well as or slightly better than those subjected to resection followed by postoperative radiotherapy. We could not verify the importance to survival of either large dose or large volume radiotherapy, which has been emphasized by some. Patients receiving less than 1400 rets did just as well as or slightly better than those receiving more than 1400 rets. With low grade astrocytomas, survival beyond 4 years was significantly worse (higher death rates) in the group receiving more than 1400 rets. This suggested the possibility of radiation damage with delayed manifestations. We also could not verify an increased effectiveness for the generally accepted use of total brain irradiation for high grade gliomas.

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Long-term outcomes for low-grade intracranial ganglioglioma: 30-year experience from the Mayo Clinic

Journal of Neurosurgery ◽

10.3171/2012.7.jns111260 ◽

2012 ◽

Vol 117 (5) ◽

pp. 825-830 ◽

Cited By ~ 50

Author(s):

Julia J. Compton ◽

Nadia N. Issa Laack ◽

Laurence J. Eckel ◽

David A. Schomas ◽

Caterina Giannini ◽

...

Keyword(s):

Overall Survival ◽

Radiation Therapy ◽

Mayo Clinic ◽

Progression Free Survival ◽

Low Grade ◽

Term Survival ◽

Free Survival

Object Gangliogliomas comprise less than 1% of all brain tumors and occur most often in children. Therefore, there are a limited number of patients and data involving the use or role of adjuvant therapy after subtotal resections (STRs) of gangliogliomas. The objective of this study was to examine and review the Mayo Clinic experience of 88 patients with gangliogliomas, their follow-up, risk of recurrence, and the role of radiation therapy after STR or only biopsy. Methods Eighty-eight patients with gangliogliomas diagnosed between 1970 and 2007 were reviewed. Data on clinical outcomes and therapy received were analyzed. The Kaplan-Meier method was used to estimate progression-free survival (PFS) and overall survival. Results The median age at diagnosis was 19 years. The median potential follow-up as of June 2008 was 142 months (range 9–416 months). Fifteen-year overall survival was 94%, median PFS was 5.6 years, with a 10-year PFS rate of 37%. Progression-free survival was dramatically affected by extent of initial resection (p < 0.0001). Conclusions This single-institution retrospective series of patients with gangliogliomas is unique given its large cohort size with a long follow-up duration, and confirms the excellent long-term survival rate in this group. The study also shows the importance of resection extent on likelihood of recurrence. Patients with gangliogliomas who undergo STR or biopsy alone have poor PFS. Radiation therapy may delay time to progression in patients with unresectable disease.

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Infiltrative brainstem and cerebellar neurocytoma

Journal of Neurosurgery Pediatrics ◽

10.3171/2012.8.peds08286 ◽

2012 ◽

Vol 10 (5) ◽

pp. 418-422 ◽

Cited By ~ 7

Author(s):

Faiz Ahmad ◽

Marc K. Rosenblum ◽

Gabriel Chamyan ◽

David I. Sandberg

Keyword(s):

Radiation Therapy ◽

Radiation Field ◽

Endoscopic Third Ventriculostomy ◽

Additional Treatment ◽

Third Ventriculostomy ◽

Low Grade ◽

Intraventricular Tumor ◽

Unique Case ◽

Biopsy Specimens

Neurocytomas are typically intraventricular in location, and extraventricular neurocytomas are uncommon. The authors report the unique case of a 15-year-old girl who was found to have a low-grade neurocytoma infiltrating the brainstem and cerebellum and spreading along the CSF pathways to the lateral and third ventricles. The patient underwent endoscopic third ventriculostomy to treat associated hydrocephalus, and biopsy specimens from intraventricular tumor nodules were obtained. Because of the low-grade pathology, the fact that the lesion was not amenable to resection, and the extensive radiation field required for radiation therapy, she has been treated conservatively with close follow-up. Over the course of almost 4 years since diagnosis, no additional treatment has been required. Neurocytoma with widespread infiltration of the brainstem and cerebellum has not been previously reported.

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