122 Malignant gliomas anaplastic astrocytoma gb gliosarcoma
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Youmans Neurological Surgery
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122 Malignant gliomas anaplastic astrocytoma gb gliosarcoma
- 1. Chapter 122 Malignant Gliomas : Anaplastic Astrocytoma Glioblastoma Multiforme Gliosarcoma Youmans,Neurological surgery 15/12/2015
- 2. Outline • Epidemiology • Clinical manifestation • Histopathology • Neuroimaging studies • Management
- 3. Epidemiology : Anaplastic Astrocytoma (WHO grade III) Glioblastoma Multiforme(WHO grade IV) • Most common primary brain tumor in adults • Median age : AAs 40 yrs, GBM 53 yrs • GBM is more common in men, with a male-to- female ratio of 1.5:1
- 4. Epidemiology : Gliosarcoma • 2% and 8% of cases of GBM (WHO grade IV) • Clinical findings and prognosis are similar in gliosarcoma and GBM • Mean age of 53 Yrs(40-60 Years) • Male-to-female ratio of 1.8 : 1 • May also occur in children
- 5. Clinical manifestation : Anaplastic Astrocytoma Glioblastoma Multiforme • Cerebral hemispheres • Can arise from low-grade astrocytoma (WHO grade II) • AAs can progress to GBM and recur locally,often at the margins of the tumor resection • Symptoms and signs are nonspecific in patients with GBM – raised intracranial pressure – extraocular palsies, objective papilledema, pupil abnormalities, or decreased level of consciousness
- 6. Clinical manifestation : Anaplastic Astrocytoma Glioblastoma Multiforme • Prominent in the morning and improve over the course of the day • Progressive headaches are a hallmark of the symptomatology of these tumors • Seizure
- 7. Clinical manifestation : Gliosarcoma • Most common : Temporal lobe, also occur in parietal, frontal, occipital lobes • Multifocal display of cerebral and cerebellar gliosarcomas • Can spread into the cerebrospinal fluid pathways and invade the ventricles, cranial nerves, leptomeninges, and spinal cord • Tendency toward peripheral brain localization and dural attachment
- 8. Clinical manifestation : Gliosarcoma • Metastasis much more frequently than glioblastoma • Most common symptoms : headache, hemiparesis, nausea, seizures, and personality change • Most common signs : focal weakness, visual field defects, papilledema, and dysphasia
- 10. Histopathology : Anaplastic Astrocytoma Glioblastoma Multiforme • Morphology is the “gold standard” – Pilocytic astrocytoma (WHO grade I) – Low-grade astrocytoma (WHO grade II) • nuclear atypia, no mitosis – Anaplastic Astrocytoma (WHO grade III) • mitotic activity and nuclear atypia – Glioblastoma Multiforme (WHO grade IV) • nuclear atypia, mitoses, and endothelial proliferation or necrosis
- 13. Histopathology : Anaplastic Astrocytoma Glioblastoma Multiforme • MIB-1 /Ki-67 labeling index increases proportionally with tumor grade – AA (WHO grade III) : 5-10% – GBM (WHO grade IV) : 10-20%
- 14. Primary glioblastomas Secondary glioblastomas > 50 years younger patients as low-grade astrocytoma or AA and then transform over a period of several years into glioblastoma Mutation or amplification of EGFR overexpression of platelet-derived growth factor receptor (PDGFR) loss of heterozygosity of chromosome 10q loss of heterozygosity of chromosome 10q deletion of the phosphatase and tensin homologue on chromosome 10 (PTEN) mutations in the TP53 tumor suppressor gene deletion of chromosome p16. abnormalities in the p16 mutation of isocitrate dehydrogenase 1 (IDH1) Molecular biology
- 15. Histopathology : Gliosarcomas • Characterized by a biphasic tissue pattern with glial and mesenchymal component • Glial portion : astrocytes with nuclear atypia and mitotic figures • Sarcomatous region : neoplastic mesenchymal cells with associated reticulin formation • Glial fibrillary acidic protein (GFAP) immunostaining : distinguishing between gliosarcoma and other tumors such as glioblastoma or pure sarcoma
- 16. Histopathology : Gliosarcomas • Vimentin : marker for mesenchymal cells, occurs mostly in sarcomatous areas with scarce staining in glial regions • Gross – tough, well-circumscribed lobular mass often attached to the dura and at surgery may resemble a meningioma – contain areas of necrosis – The sarcomatous component of these tumors is firm and well circumscribed
- 17. Neuroimaging studies : Anaplastic Astrocytoma Glioblastoma Multiforme • MRI – T1 : irregular hyposignal with various degrees of contrast enhancement – Ring-like enhancement surrounding irregularly shaped areas : suggests glioblastoma – However, AAs can appear as nonenhancing tumors, and even glioblastomas may initially be manifested as a nonenhancing lesions, especially in older patients
- 18. Neuroimaging studies : Anaplastic Astrocytoma Glioblastoma Multiforme • fMRI – locations of functionally eloquent cortex, such as the motor cortex, Broca’s area, Wernicke’s area, and the visual cortex • Pseudoprogression : increased enhancement reflects a transient increase in vessel permeability that is a result of radiotherapy • Magnetic resonance spectroscopy(MRS) : differentiate tumors from stroke, old trauma, radionecrosis, infection, and multiple sclerosis
- 19. Neuroimaging studies : Anaplastic Astrocytoma Glioblastoma Multiforme • Fluorodeoxyglucose positron emission tomography (FDG-PET) – effective in demonstrating hypermetabolism in high- grade tumors – distinguishing tumor or tumor recurrence from radionecrosis
- 20. Neuroimaging studies : Gliosarcomas • MRI – T1 : well demarcated hyperdense mass with heterogeneous or irregular ring enhancement – T2 : isosignal with surrounding edema – Intraaxial superficial with a dural base – Vasogenic edema – Central hypodensity, as a result of necrosis, is less common in gliosarcomas
- 21. Management : General Medical Management • Seizure – Selecting antiepileptic drugs to prevent drug interactions(phenytoin,carbamazepine) – Prefer levetiracetam – AAN : advises against the routine use of antiepileptic drugs in patients who have never had a seizure • Venous thromboembolism – anticoagulation therapy – LMWH may be more effective and safer than warfarin
- 22. Management : General Medical Management • Peritumoral edema – Corticosteroid(dexamethasone) – Side effect : Cushing’s syndrome, corticosteroid myopathy, Pneumocystis jiroveci pneumonitis – New therapy : corticotropin releasing factor, bevacizumab (VEGF monoclonal antibody), VEGF receptor inhibitors • Fatigue – Methylphenidate for abulia – Donepezil and memantine may reduce memory loss
- 23. Management : Surgery • Goal – obtain a tissue diagnosis – decrease the mass effect – reduce the tumor burden
- 25. Management Radiation Therapy Chemotherapy • Carmustine-loaded biodegradable polymers • RCT • Improve survival : 23 weeks to 31 weeks after revision resection • Surgery time to death : 58 weeks vs 39 weeks placebo • Median survival time : 13.8 months vs 11.6 months placebo
- 26. Management Radiation Therapy Chemotherapy • Most effective treatment • Resection • Carmustine-loaded biodegradable wafers • Temodar • Radiation therapy • 20 Months
- 27. Management Radiation Therapy Chemotherapy • O6-Methylguanine-DNA methyltransferase (MGMT) • Repair enzyme that contributes to resistance of tumors to alkylating agents such as carmustine or Temodar
- 28. Management : Gliosarcoma • Surgery – firm, well demarcated, and vascular – can be excised to achieve gross macroscopic clearance • Chemotherapy • Radiotherapy • All patient • Increase survival 8-15 wks
- 29. Patient outcome and survival • Median survival is less than 2 years • Anaplastic glioma : 2-5 years • Age and KPS score are the most significant prognostic factors • Gliosarcoma : 6 - 14.8 months
Editor's Notes
- Atypia การติด สีเข้ม รูปร่างหยักไปมา ไม่กลมรีตามปกติ pleomorphism
- -epidermal growth factor (EGF) receptror ถ้ามากขึ้น ไม่ดี -TP53 เนื่องจากยีนนี้ท าหน้าที่สร้าง โปรตีน P53 ที่มีหน้าที่ 2 ประการ คือ 1) ตรวจเช็ค ความเสียหายของดีเอ็นเอ เมื่อตรวจพบจะสั่ง หยุดวัฎจักรเซลล์ และส่งสัญญาณให้มีการซ่อมแซม ดีเอ็นเอจนกว่าซ่อมเสร็จ จึงจะส่งสัญญาณให้วัฎจักร ของเซลล์ด าเนินต่อ 2) ชักน าการเกิดการฆ่าตัวตาย ของเซลล์ ในกรณีที่ดีเอ็นเอเสียหายมากจนไม่ สามารถซ่อมแซมได้ ซึ่งหน้าที่ทั้ง 2 นี้เป็นหน้าที่ที่มี ความส าคัญต่อการต้านการเกิดมะเร็ง -LOH มีการขาดหายไปของ allel หรือมี กลไล ทำให้ ยีนเปลี่ยนจาก สภาวะ heterozygosity
- American academy of neurology
- Donepezil Rx Alzheimer disase Methylphendinate : stimulate sympathetic system Abulia lack of will power
- Retrospective study
- Tenodar Temozolamide