[Factor analysis of cerebrospinal fluid spread in glioblastoma].

Objective: To analyze the prognosis factors of cerebrospinal fluid (CSF) spread after surgery in glioblastoma (GBM) patients when tumors progressed and the effect factors on prognosis. Methods: A retrospective study was conducted on 124 patients who were pathologically diagnosed as glioblastoma after surgery, and found tumor progressed during regularly follow-up at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University between January 2009 and August 2017.There were 82 males and 42 females, aged 47.9 years(range: 19 to 75 years) .Patients were divided into local recurrence group(96 cases) and CSF spread group (28 cases) .Clinical data were recorded in detail and compared by independent sample t test or χ(2) test.Kaplan-Meier survival curves was used to demonstrated the distribution of progression free survival (PFS) overall survival (OS) and post progression survival (PPS), and differences between local recurrence and CSF spread groups were assessed by Log-rank test.Cox proportion hazard regression analysis was used to identify independent prognostic factors. Results: Logistics regression analysis showed ventricle entry was the only prognosis factor of CSF spread (OR=2.667, 95% CI: 1.128 to 6.304, P=0.025).No significant distinction was observed in PFS between CSF spread group and local recurrence group(7.0 months vs.9.3 months, P=0.066).However, OS and PPS were substantially shortened in CSF spread group (13.0 months vs.23.0 months, P=0.011; 6.0 months vs.11.0 months, P=0.022, respectively).Mutations of isocitrate dehydrogenase gene, distant spread, gross-total resection, Ki-67 index>30% were independent prognostic factors of GBM patients. Conclusions: Ventricle entry is a prognosis factor for CSF spread, after which the median OS and PPS are markedly diminished.However, ventricle entry is not independent prognosis factor shortening survival.

Transventricular Migration of Choroid Plexus Carcinoma Causing an Intraoperative Conundrum: A Case Report with a Review of the Literature.

Migrating intracranial tumors are extremely rare occurrences in the neurosurgery literature. Introduction of any factor causing disequilibrium in cerebrospinal fluid circulation and pressure can potentially precipitate transventricular migration of pedunculated intraventricular lesions. The identification of such factors, prior to excision of intraventricular pedunculated tumors, is imperative to avoid intraoperative mismanagement. We report an extremely rare case of transventricular migration of a choroid plexus carcinoma in an infant, possibly precipitated by a ventriculoperitoneal (VP) shunt on the opposite side. This resulted in intraoperative confusion and a subsequent re-exploration of the opposite side for excision of the tumor. The literature provided only two similar occurrences in the past; however, in both cases, the migration was within the same ventricle and was documented prior to definitive resection. We report the first instance of transventricular migration of a tumor to the opposite ventricle following VP shunt which resulted in a negative intraoperative finding requiring a subsequent re-intervention on the opposite side. We believe that for any pedunculated intraventricular lesion, where an emergency management of hydrocephalus takes priority, a repeat neuroimaging is a must prior to definitive resection.

Supratentorial high-grade astrocytoma with leptomeningeal spread to the fourth ventricle: a lethal dissemination with dismal prognosis.

PURPOSE: Leptomeningeal spread to the fourth ventricle (LSFV) from supratentorial high-grade astrocytoma (HGA) is rarely investigated. The incidence and prognostic merit of LSFV were analyzed in this study. METHODS: A consecutive cohort of 175 patients with pathologically diagnosed HGA according to the 2016 WHO classification of brain tumors was enrolled. LSFV was defined as radiological occupation in the fourth ventricle at the moment of initial progression. Clinical, radiological, and pathological data were analyzed to explore the difference between HGA patients with and without LSFV. RESULTS: There were 18 of 175 (10.3%) HGAs confirmed with LSFV. The difference of survival rate between patients with LSFV or not was significant in both overall survival (OS) (14.5 vs. 24 months, P = 0.0007) and post progression survival (PPS) (6.0 vs. 11.5 months, P = 0.0004), while no significant difference was observed in time to progression (TTP) (8.5 months vs. 9.5 months P = 0.6795). In the Cox multivariate analysis, LSFV was confirmed as an independent prognostic risk factor for OS (HR 2.06, P = 0.010). LSFV was correlated with younger age (P = 0.044), ventricle infringement of primary tumor (P < 0.001) and higher Ki-67 index (P = 0.013) in further analysis, and the latter two have been validated in the Logistic regression analysis (OR 18.16, P = 0.006; OR 4.04, P = 0.012, respectively). CONCLUSION: LSFV was indicative of end-stage for supratentorial HGA patients, which shortened patients' PPS and OS instead of TTP. It's never too cautious to alert this lethal event when tumor harbored ventricle infringement and higher Ki-67 index in routine clinical course.

A rare case of small cell carcinoma of lung with intraventricular metastasis.

Our case report involves a Chinese patient who was presented to our hospital with the chief complaint of dizziness and double vision for one week. He was diagnosed with small cell carcinoma of lung in the past. The patient undertook various test at our hospital. His MR scan revealed an intraventricular metastasis from small cell carcinoma of lung which is very rare. We have analyzed the clinical data of this patient and related literature. We report this case to increase the awareness of this rare metastasis of small cell carcinoma of lung.

Hypothalamic relapse of a cardiac large B-cell lymphoma presenting with memory loss, confabulation, alexia-agraphia, apathy, hypersomnia, appetite disturbances and diabetes insipidus.

A 37-year-old Hispanic man with a right atrial intracardiac mass diagnosed as diffuse large B-cell lymphoma (DLBCL) was successfully treated with surgery and chemotherapy. During 4 years, several total-body positron emission tomography and MRI scans showed no extracardiac lymphoma. On year 5 after the cardiac surgery, patient presented with sleepiness, hyperphagia, memory loss, confabulation, dementia and diabetes insipidus. Brain MRI showed a single hypothalamic recurrence of the original lymphoma that responded to high-dose methotrexate treatment. Correction of diabetes insipidus improved alertness but amnesia and cognitive deficits persisted, including incapacity to read and write. This case illustrates two unusual locations of DLBCL: primary cardiac lymphoma and hypothalamus. We emphasise the importance of third ventricle tumours as causing amnesia, confabulation, behavioural changes, alexia-agraphia, endocrine disorders and alterations of the circadian rhythm of wakefulness-sleep secondary to lesions of specific hypothalamic nuclei and disruption of hypothalamic-thalamic circuits.

Simultaneous meningioma and brain metastasis from renal cell carcinoma - a rare presentation. Case report.

CONTEXT:: Brain metastases are the most common tumors of the central nervous system. Because of their high frequency, they may be associated with rare situations. Among these are tumor-to-tumor metastasis and an even a rarer situation called simultaneous brain tumors, which are more related to primary tumors of the reproductive and endocrine systems. CASE REPORT:: A 56-year-old male patient with a history of renal cell carcinoma (which had previously been resected) presented with a ventricular lesion (suggestive of metastatic origin) and simultaneous olfactory groove lesion (probably a meningioma). First, only the ventricular lesion was dealt with, but after a year, the meningothelial lesion increased and an occipital lesion appeared. Therefore, both of these were resected in a single operation. All the procedures were performed by the same neurosurgeon. The patient evolved without neurological deficits during the postoperative period. After these two interventions, the patient remained well and was referred for adjuvant treatment. CONCLUSIONS:: This study provides the first description of an association between these two tumors. Brain metastases may be associated with several lesions, and rare presentations such as simultaneity with meningioma should alert neurosurgeons to provide the best oncological treatment.

Simultaneous meningioma and brain metastasis from renal cell carcinoma - a rare presentation. Case report / Meningioma e metástase cerebral de carcinoma de células renais simultâneos - uma apresentação rara. Relato de caso

ABSTRACT CONTEXT: Brain metastases are the most common tumors of the central nervous system. Because of their high frequency, they may be associated with rare situations. Among these are tumor-to-tumor metastasis and an even a rarer situation called simultaneous brain tumors, which are more related to primary tumors of the reproductive and endocrine systems. CASE REPORT: A 56-year-old male patient with a history of renal cell carcinoma (which had previously been resected) presented with a ventricular lesion (suggestive of metastatic origin) and simultaneous olfactory groove lesion (probably a meningioma). First, only the ventricular lesion was dealt with, but after a year, the meningothelial lesion increased and an occipital lesion appeared. Therefore, both of these were resected in a single operation. All the procedures were performed by the same neurosurgeon. The patient evolved without neurological deficits during the postoperative period. After these two interventions, the patient remained well and was referred for adjuvant treatment. CONCLUSIONS: This study provides the first description of an association between these two tumors. Brain metastases may be associated with several lesions, and rare presentations such as simultaneity with meningioma should alert neurosurgeons to provide the best oncological treatment.

RESUMO CONTEXTO: As metástases cerebrais são os tumores mais comuns do sistema nervoso central e, devido à sua elevada frequência, podem estar associadas a situações raras. Entre estas estão as "tumor to tumor metastasis" e uma situação ainda mais rara chamada de tumores cerebrais simultâneos, mais relacionados a tumores primários dos sistemas endocrinológico e reprodutivo. RELATO DE CASO: Um homem de 56 anos com histórico de câncer de células renais (extirpado previamente) apresentou-se com lesão ventricular (sugestiva de origem metastática) e simultaneamente com uma lesão em topografia de goteira olfatória (provavelmente meningioma). Primeiramente, apenas a lesão ventricular foi abordada, porém após um ano, a lesão meningotelial aumentou e uma lesão occipital apareceu e então ambas foram ressecadas em uma única cirurgia. Todos os procedimentos foram realizados pelo mesmo neurocirurgião. O paciente evoluiu sem déficits neurológicos no período pós-operatório. Após essas duas intervenções, o paciente permaneceu bem, sendo encaminhado para tratamento adjuvante. CONCLUSÕES: O presente trabalho é a primeira descrição da associação encontrada entre esses dois tumores. As metástases cerebrais podem associar-se a várias lesões, e manifestações raras, tais como apresentação simultânea com meningioma, devem alertar o neurocirurgião a fornecer o melhor tratamento oncológico.

Endoscopic Reconstruction of CSF Pathways in Ventricular Tumors.

Neuroendoscopy is now considered to be a minimally invasive surgical approach for expanding lesions bulging into the ventricle, and it is also considered to be a relevant tool for performing biopsy procedures, fenestration of cystic walls, or for performing tumor removal in selected cases. Furthermore, the use of neuroimaging and the accurate follow-up of brain tumor patients have allowed the documentation of tumoral and pseudotumoral cystic areas that cause the obstruction of cerebrospinal fluid (CSF) pathways. Neuroendoscopic procedures enable the fenestration of cystic lesions, in addition to enabling third ventriculostomy or septostomy to restore CSF pathways. We analyze our experience regarding 77 patients affected by brain tumors arising from the wall of the third or lateral ventricle. In all cases hydrocephalus or obstruction of CSF flow was present. With an endoscopic technique, septostomy, cystostomy, endoscopic third ventriculostomy (ETV), and tumor resection were performed to control intracranial hypertension.ETV was performed in 53 patients with noncommunicating hydrocephalus. In 4 patients with low-grade astrocytoma ETV was definitely the only surgical treatment. In 12 cystic tumors, cystostomy and marsupialization into the ventricle solved a relevant mass effect with clinical intracranial hypertension syndrome. In 10 patients, neuroendoscopic relief of CSF pathways was possible by performing septostomy with the implantation of an Ommaya reservoir or one-catheter shunt. In 5 colloid cysts and 2 cystic craniopharyngiomas, removal was possible by restoring CSF flow without other procedures. After intracranial hypertension control, in 13 malignant gliomas and 5 leptomeningeal metastases, the patients' quality of life improved sufficiently to provide for tumor adjuvant therapy.In this series, endoscopy, due to its minimally invasive characteristics and reduced complications, was found to be safe and effective, without any relevant postoperative morbidity, gained by avoiding major surgical approaches.Based on these results and on the increasing number of series described in the literature, we believe that endoscopic techniques should be considered a selected approach for treating CSF obstructions caused by para-intraventricular tumors. The result of using neuroendoscopy is the reconstruction of CSF pathways that bypass the tumor occlusion. This surgical procedure is not only limited to the relief of noncommunicating hydrocephalus, but it is also useful for tumor removal or biopsies and the evacuation of cystic lesions. In patients affected by malignant tumors, neuroendoscopy can be performed to control intracranial hypertension before the patients start adjuvant chemotherapy or radiotherapy.

Rosette-Forming Glioneuronal Tumor Originating From the Spinal Cord: Report of 2 Cases and Literature Review.

Rosette-forming glioneuronal tumor (RGNT) is a recently recognized and rarely encountered tumor occurring in the fourth ventricle. RGNT was first described as a new entity for the distinct clinicopathologic features by Komori et.al. in 2002. Histologically, it is composed of 2 distinct features: a glial component, resembling pilocytic astrocytoma, and a neurocytic component forming neurocytic rosettes and/or perivascular rosettes. We report 2 extremely rare cases of RGNT arising from the spinal cord, which were misdiagnosed as ependymoma and astrocytoma preoperatively. Symptoms included dissociated sensory disturbances and episodic pain and fatigue of 2 years' duration in case 1, as well as motor disturbance for 2 months' duration in case 2. Magnetic resonance imaging (MRI) revealed these masses in the thoracolumbar (T7-L1) and cervicothoracic (C3-C7) spinal cord. The solid component appeared hypointense in T1-weighted MRI sequences, hyperintense in the T2-weighted MRI sequences, and heterogeneous in MRI images enhanced with gadolinium contrast medium in both cases. Gross total resection was performed via a median laminectomy. Postoperative pathological examination confirmed the diagnosis of RGNT. In addition, extensive analysis of genetic mutations was performed to explore the relationship with glioma, including telomerase reverse transcriptase promoter, isocitrate dehydrogenase 1/2, BRAF-V600E, and O(6)-methylguanine-DNA methyltransferase promoter. No radiotherapy or chemotherapy were performed in these two cases. As of the latest follow-up, both patients had a good prognosis. Given the widely varying clinical characteristics of, prognosis of, and treatments for spinal tumors, differential diagnosis is of great importance before surgery. Consideration of the tumor location and the patient's age and sex, in combination with the imaging features, may be the best approach to narrowing the differential diagnosis. Surgery is the preferred treatment for RGNT. We do not recommend to implement adjuvant radiotherapy and chemotherapy in these patients except the invasive or recurrent tumors. Further examination and routine follow-up should be recommended to estimate the long-term prognosis.

Chordoid Glioma with Intraventricular Dissemination: A Case Report with Perfusion MR Imaging Features.

Chordoid glioma is a rare low grade tumor typically located in the third ventricle. Although a chordoid glioma can arise from ventricle with tumor cells having features of ependymal differentiation, intraventricular dissemination has not been reported. Here we report a case of a patient with third ventricular chordoid glioma and intraventricular dissemination in the lateral and fourth ventricles. We described the perfusion MR imaging features of our case different from a previous report.

Solitary Metastasis of Renal Cell Carcinoma to the Third Ventricle Mimicking a Colloid Cyst: Case Report.

Colloid cysts are the most common third ventricle lesions and metastasis to this area is rare. We presented a case of solitary metastasis from a renal cell carcinoma to the third ventricle choroid plexus mimicking a colloid cyst. A 53-year-old man, who had a history of renal cell carcinoma 12 years ago, was operated for single third ventricle lesion and hydrocephalus via a transcallosal approach. Total removal could not be performed due to intraoperative massive bleeding. Histological examination revealed a metastatic renal cell carcinoma. The patient died on the postoperative 13th day because of bleeding from the residual tumor. Stereotactic radiosurgery and ventriculoperitoneal shunting might be favorable in such cases in order to avoid serious complications.

Endoscopic diagnosis of an MRI-occult, low-grade glioma with ependymal dissemination.

A 21-year-old man presented with triventricular hydrocephalus due to a tectal mass. He underwent an endoscopic third ventriculostomy, and multiple nodules were identified at the floor of the third ventricle intraoperatively. Surgical pathology of one of these lesions demonstrated that the tissue represented a low-grade astrocytoma. The case highlights the existing potential of neuroendoscopy to reveal neuroimaging-occult lesions, in spite of the significant advances of MRI. Furthermore, the combination of the age of the patient, the nonenhancing MRI appearance, and the multifocality of the lesions constitutes a rare and interesting neoplastic presentation within the brain. The constellation of findings likely represents dissemination of a low-grade tectal glioma via the CSF compartment.

Stereotactic radiosurgery for intraventricular brain metastases.

OBJECT: The authors' institution previously reported a 69% rate of crude local control for surgical management of lateral ventricle metastases at the University of Texas MD Anderson Cancer Center. For comparison, the authors here report their institutional experience with use of stereotactic radiosurgery (SRS) to treat intraventricular metastases. METHODS: To identify patients with intraventricular metastases for this retrospective review, the authors queried an institutional SRS database containing the medical records of 1962 patients with 5800 brain metastases who consecutively underwent SRS from June 2009 through October 2013. End points assessed were local control (crude and locoregional), distant failure-free survival, progression-free survival, and overall survival. RESULTS: Of the 1962 records examined, those for 25 (1.3%) patients with 30 (0.52%) intraventricular metastases were identified. Median patient age at SRS was 55.8 years. The most common primary malignancy was renal cell carcinoma (n = 13), followed by melanoma (n = 7) and breast adenocarcinoma (n = 5). Median tumor volume was 0.75 cm(3) (range 0.01-5.6 cm(3)). Most lesions were located in the lateral ventricles (n = 25, 83.3%) and were treated to a median dose of 20 Gy (range 14-20 Gy). A total of 12 (48%) patients received whole-brain radiation therapy, most (n = 10) before SRS. With a median follow-up of 11.4 months (range 1.6-39.2 months), the rate of crude local control was 93.3%, and the rates of 6-month and 1-year actuarial locoregional control were 85.2% and 56.2%, respectively. The median overall survival time after SRS was 11.6 months (range 1.3-38.9 months), and the 6-month and 1-year actuarial rates were 87.1% and 46.7%, respectively. Disease dissemination developed in 7 (28%) patients as a second intraventricular metastatic lesion (n = 3, 12%), leptomeningeal disease (n = 3, 12%), or both (n = 1, 4%). Radiographic changes developed in 5 (20%) patients and included necrosis (n = 2, 8%) and hemorrhage (n = 3, 12%). A primary diagnosis of renal cell carcinoma was associated with an improved rate of distant failure-free survival (p = 0.05) and progression-free survival (p = 0.08). CONCLUSIONS: SRS provides excellent local control for intraventricular metastases, with acceptable treatment-related toxicity, thereby supporting nonsurgical treatment for these lesions. The propensity for intraventricular dissemination among intraventricular metastases seems to be histologically dependent.

Singular case of third ventricle metastasis of colorectal carcinoma--case report.

Third ventricle tumors are uncommon central nervous system lesions and unusual locations for metastatic colorectal cancer. We present a case of a 68 year old woman with a solitary 3rd ventricle lesion found on a computed tomography scan of the brain and the synchronous mass of the right colon. The aim in this case was local control of cerebral lesion with pathological diagnosis. Surgery was followed by a short-term good evolution but with sudden death.

Malignant intraventricular meningioma with craniospinal dissemination and concurrent pulmonary metastasis.

BACKGROUND: Malignant intraventricular meningiomas are quite rare and may spread along the craniospinal axis or extraneurally. However, simultaneous cerebrospinal dissemination and distal extraneural metastasis has seldom been reported. CASE PRESENTATION: A 51-year-old woman presented with recurrent anaplastic meningioma in the trigone of right lateral ventricle over a 1.5-year period. Suggested radiotherapy was refused after each operation. The patient showed a local relapse and dissemination around the previous tumoral cavity and along the spinal canal during the last recurrence. Left pulmonary metastasis was also found. She died despite multiple lesion resections. CONCLUSIONS: Malignant intraventricular meningiomas are an uncommon subset of intracranial meningiomas, and have a great potential for intraneural and extraneural metastasis. Systemic investigation for metastasis is required after surgery, especially for those without adjuvant therapies.

[A case of intraventricular dissemination arising from hepatocelullar carcinoma effectively treated with intrathecal administration of methotrexate].

A 78-year-old man with hepatocellular carcinoma was admitted to our hospital for vertigo after transcatheter arterial chemoembolization. Contrast-enhanced magnetic resonance imaging revealed metastasis in the cerebellar vermis. Although the cerebellar metastasis decreased in size after cyberknife radiotherapy, multiple enhancing nodules appeared in the cerebral ventricles. A diagnosis of intraventricular dissemination from the cerebellar metastatic lesion originating from the hepatocellular carcinoma was made. Six intrathecal administrations of 20 mg of methotrexate through lumbar puncture resulted in a dramatic decrease in the intraventricular dissemination. Although intraventricular dissemination recurred 4 months later, these lesions disappeared after an additional 8 administrations of intrathecal methotrexate. Intraventricular dissemination arising from hepatocellular carcinoma is rare. Here we report a case that was successfully treated by intrathecal chemotherapy with methotrexate.

The ventricular system and choroid plexus as a primary site for renal cell carcinoma metastasis.

BACKGROUND: Brain metastases (BM) are the most common intracranial tumours amongst adults. Ten to 40 % of patients with cancer will develop BM. In this study, we observed a high affinity of renal cell carcinoma (RCC) to the ventricular system, with close association to the choroid plexus. METHODS: This is a retrospective study evaluating data of our prospectively maintained brain tumour database, focusing on consecutive BM patients, who were treated at our center between March 2003 and December 2011. Data collected included primary pathologies, anatomical distribution of the brain metastasis according to neuroimaging, and treatment modalities. RESULTS: We identified 614 patients with BM, of whom 24 (3.9 %) were diagnosed with RCC, harboring 33 lesions. Nine of the 24 patients (37.5 %) presented with an intraventricular location (10 of 33 RCC BM lesions). Of the remaining 590 patients with non-RCC pathologies, five patients (0.8 %) were diagnosed with intraventricular lesions (p < 0.0001). CONCLUSION: In this unselected, consecutive treated BM patient cohort we observed a high affinity of RCC BM to the ventricular system with close association to the choroid plexus. The reason for this affinity is unknown. Surgical approaches for resection of these lesions should be planned to include early control on the vascular supply from the choroidal vessels.

Pituitary carcinoma with fourth ventricle metastasis: treatment by excision and Gamma-knife radiosurgery.

Pituitary carcinomas, which are rare, generally present with craniospinal and systemic metastases. Although several treatments exist, the prognoses of patients with pituitary carcinomas are extremely poor to date. In this report, the authors describe the case of a 23-year-old male who had undergone trans-sphenoidal surgery and radiotherapy for an invasive prolactinoma. Seven years later, he presented with a new 4th ventricle metastasis from the pituitary lesion, and it was diagnosed with a pituitary carcinoma. He underwent resection and Gamma-knife radiosurgery (GKRS). The tumor has been well controlled for over 3 years. To our knowledge, there have been no reports of the effects of GKRS in patients with pituitary carcinomas. GKRS might have considerable effects in the treatment of pituitary carcinomas.

Neuroblastoma with a solitary intraventricular brain metastasis visualized on I-123 MIBG scan.

BACKGROUND: Although metastatic skull lesions of neuroblastoma are not uncommon, brain involvement is infrequent and prompt diagnosis is of utmost importance in such cases. Previous studies have shown that Meta-Iodo-Benzyl-Guanidine (MIBG) scans were not always reliable in detecting central nervous system metastases, however most published reports referred to the Iodine-131 ((131)I)-MIBG scans. Herein, we report an intraventricular metastasis of neuroblastoma diagnosed using an Iodine-123 ((123)I)-MIBG scan, which is increasingly being used in clinical practice and reported as a more accurate method for detecting metastatic lesions. CASE DESCRIPTION: An unusual case of metastatic neuroblastoma to the left lateral ventricle of the brain is presented. Planar (123)I-MIBG scintigraphy showed faint tracer activity close to the midline without asymmetric extensions or abnormal activity in the skull bones. A subsequent brain MR scan revealed an enhancing mass within the left frontal horn consistent with a metastatic lesion. The patient underwent tumor resection with pathology showing neuroblastoma. CONCLUSIONS: Our case shows that (123) I-MIBG scintigraphy can be useful in detecting intraventricular brain metastases of neuroblastoma. Although the (123)I-MIBG scintigraphy has been reported to have a significantly superior sensitivity in monitoring asymptomatic patients with neuroblastoma compared with (131)I-MIBG scans, bone marrow histology, bone scan, CT, and urinary catecholamine levels, further studies may be necessary to evaluate its sensitivity in detecting brain lesions.