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Pleomorphic xanthoastrocytoma with invasion of the tentorium and falx
ELSEVIER
PLEOMORPHIC XANTHOASTROCYTOMA WITH INVASION OF THE TENTORIUM AND FALX Orlando
De Jesfis, M.D., and Nathan Rifkinson, M.D.
Section of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
De
Jest% 0, Rifkinson N. Pleomorphic xanthoastrocytoma with invasion of the tentorium and falx. Surg Neural 1995;43:77-9.
A case of a 21-year-old patient with a recurrent pleomorphic xanthoastrocytoma with invasion of the tentorium and falx cerebri is reported. Dural attachment has been reported in some cases. Invasion of the dura of the falx cerebri and complete infiltration of the left tentorium by the tumor were found intraoperatively. This is the first case in the literature which shows invasion of the dura in a pleomorphic xanthoastrocytoma. KEY WORDS
Brain tumor, dura, leptomeninges, trocytoma.
P
pleomorphic
xanthoas-
leomorphic xanthoastrocytoma, which was originally described by Kepes et al in 1979, has
been considered a tumor with a favorable biological behavior [2]. Recurrences have been noted, but most of the patients have a favorable prognosis. Some cases have shown that the tumor can be attached to the dura, but no cases have shown invasion of the dura.
CASE REPORT A 21-year-old female was admitted to our University Hospital in November 1992 with recent onset of headaches. At the age of 18, she had presented with complex-partial seizures for which she was started on carbamazepine. Magnetic resonance imaging (MRl) showed a cystic tumor superficially located at the left occipital lobe over the tentorium with an enhancing nodule. The patient underwent a left occipital craniotomy with total tumor removal. Review of the pathological specimen at the Armed Forces Institute of Pathology was compatible with Address
reprint
requests to: Orlando De Jestis, M.D., University of of Neurosurgery, G.P.O. Box 5067, San Juan, Puerto
Puerto Rico, Section
Rico 00936. Received May 17, 1994; accepted
July 8, 1994.
0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY
10010
pleomorphic xanthoastrocytoma. She was given postoperative whole-brain radiotherapy, but she decided not to continue treatment after a dose of 4,000 rads. On March 12, 1991, in Florida, she had reoperation for a solid recurrence (Figure 1). When this patient was seen at our hospital, her physical examination was unremarkable except for a right upper quadrantanopsia. MRl showed a solid superficial tumor in the left occipital area invading the tentorium and extending infratentorially, and also invading parts of the falx cerebri (Figure 2). On November 20, 1992, the patient was taken to the operating room; through the previous occipital craniotomy, a yellowish fibrous-rubbery tumor with complete invasion of the left tentorium was found. The supratentorial component was removed first, then the infratentorial component, without being able to recognize the tentorium except at its very lateral attachment to the petrous bone. The tumor was also invading the falx cerebri above the straight sinus. The tumor was attached to the leptomeninges covering the occipital lobe and the cerebellar hemisphere, without invading the nervous tissue. A subtotal removal was accomplished with residual tumor remaining at the dura forming the junction of the major venous sinuses involved. HlSTOPATHOLOGY Light microscopy showed a moderately cellular tumor composed of spindle-shaped cells with elongated nuclei arranged in fascicles, round tumor cells with ground-glass-like cytoplasm, and some multinucleated giant cells (Figure 3). Clusters of lymphocyte infiltrates were seen. The superficial cortex was not invaded. Reticulin fibers were only seen surrounding blood vessels. Glial fibrillary acid protein (GFAP) was demonstrated in some of the spindle cells. The S-100 was present in the tumoral cells. 0090-3019/95/$9.50 SSDI0090_3019(94)0010LL5
Surg Neurol
De Jesus and Rifkinson
1995;43:77-9
0
Gadoliniumenhanced sagittal MRI before the second surgery showing a solid recurrence at the same
site of the previous
surgery.
DISCUSSION Pleomorphic xanthoastrocytoma is a tumor that was classified 14 years ago with less than 100 cases reported in the world. The preferred location of this tumor is the temporal lobe, but it may occur in the parietal and occipital lobes. Pleomorphic xanthoastrocytoma is normally con-
Gadoliniumenhanced coronal MRI before the third surgery showing a solid tumor in the left occipital area invading the tentorium and extending infratentorially, and also invading parts of the falx cerebri.
fined to the leptomeninges and the superficial cortex, but it may infiltrate by growth within the perivascular spaces or by direct invasion. Although previous reports have shown that it does not invade or attach to the dura, Whittle et al. [4] reported three cases in which the tumor was found at surgery to be attached to the dura. Yoshino and Lucia [5] reported two cases. Despite the original description of pleomorphic xanthoastrocytoma as one of benign biological behavior, some reports of dedifferentiation to malignant glioma have been published [ 1, 31. In this report a case of pleomorphic xanthoastrocytoma is presented. Initially, the tumor was located superficially with involvement of the leptomeninges. Three years later, it showed invasion of the dura forming the tentorium and falx cerebri. This occurred without malignant transformation of the tumor. The small amount of reticulin fibers and cells stained with GFAP was compatible with a recurrent pleomorphic xanthoastrocytoma as previously described by Kepes et al [3]. This is the first case reported in the literature which documents invasion of the dura in a pleomorphic xanthoastrocytoma. Extensive or complete surgical excision seems to be the best form of treatment for this tumor, with reoperation for residual or recurrent tumor. Radiotherapy has not changed the outcome of patients. Chemotherapy has not been considered as a form of primary treatment. Based on the findings in this case, we conclude that pleomorphic xanthoastrocytomas may involve
Pleomorphic
Xanthoastrocytoma
with Invasion
of the Tentorium
and Falx
Surg Neurol 1995;43: 77-9
79
Photomicrograph showing q the surgical specimen. (Hematoxylin-eosin, 150.) X
the dura, but this should not be considered a criterion for malignancy. When anatomical structures permit, surgical excision of all the involved dura should be performed. REFERENCES Allegranza A, Ferraresi S, Bruzzone M, Giombini S. Cerebromeningeal pleomorphic xanthoastrocytoma. Report on four cases: clinical, radiological and pathological features. (Including a case with malignant eve lution). Neurosurg Rev 1991;14:43-9. Kepes JJ, Rubinstein LJ, Eng LF. Pleomorphic xan-
thoastrocytoma: a distinctive meningocerebral glioma of young subjects with relatively favorable prognosis. 3 A study of 12 cases. Cancer 1979;44:1839-52. Kepes JJ, Rubinstein LJ, Ansbacher L, Schreiber DJ. Histopathological features of recurrent pleomorphic xanthoastrocytomas: further corroboration of the glial nature of this neoplasm. A study of three cases. Acta Neuropathol 1989;78:585-93. 4. Whittle IR, Gordon A, Misra BK, Shaw JF, Steers JW. Pleomorphic xanthoastrocytoma. Report of four cases. J Neurosurg 1989;70:463-8. 5. Yoshino MT, Lucia R. Pleomorphic xanthoastrocytoma. Am J Neuroradiol 1992;13:1330-2.
UNDAMENTALLY, THERE ARE ONLY TWO WAYS OF COORDINATING THE ECONOMIC ACTIVITIES OF MILLIONS. ONE IS CENTRAL DIRECTION INVOLVING THE USE OF COERCION-THE TECHNIQUE OF THE ARMY AND OF THE MODERN TOTALITARIAN STATE. THE OTHER IS VOLUNTARY COOPERATION OF INDIVIDUALS-THE TECHNIQUE OF THE MARKETPLACE.
F
MILTON FRIEDMAN (19 12-j CAPITALISM AND FREEDOM, 1962
PLEOMORPHIC XANTHOASTROCYTOMA WITH INVASION OF THE TENTORIUM AND FALX Orlando
De Jesfis, M.D., and Nathan Rifkinson, M.D.
Section of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
De
Jest% 0, Rifkinson N. Pleomorphic xanthoastrocytoma with invasion of the tentorium and falx. Surg Neural 1995;43:77-9.
A case of a 21-year-old patient with a recurrent pleomorphic xanthoastrocytoma with invasion of the tentorium and falx cerebri is reported. Dural attachment has been reported in some cases. Invasion of the dura of the falx cerebri and complete infiltration of the left tentorium by the tumor were found intraoperatively. This is the first case in the literature which shows invasion of the dura in a pleomorphic xanthoastrocytoma. KEY WORDS
Brain tumor, dura, leptomeninges, trocytoma.
P
pleomorphic
xanthoas-
leomorphic xanthoastrocytoma, which was originally described by Kepes et al in 1979, has
been considered a tumor with a favorable biological behavior [2]. Recurrences have been noted, but most of the patients have a favorable prognosis. Some cases have shown that the tumor can be attached to the dura, but no cases have shown invasion of the dura.
CASE REPORT A 21-year-old female was admitted to our University Hospital in November 1992 with recent onset of headaches. At the age of 18, she had presented with complex-partial seizures for which she was started on carbamazepine. Magnetic resonance imaging (MRl) showed a cystic tumor superficially located at the left occipital lobe over the tentorium with an enhancing nodule. The patient underwent a left occipital craniotomy with total tumor removal. Review of the pathological specimen at the Armed Forces Institute of Pathology was compatible with Address
reprint
requests to: Orlando De Jestis, M.D., University of of Neurosurgery, G.P.O. Box 5067, San Juan, Puerto
Puerto Rico, Section
Rico 00936. Received May 17, 1994; accepted
July 8, 1994.
0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY
10010
pleomorphic xanthoastrocytoma. She was given postoperative whole-brain radiotherapy, but she decided not to continue treatment after a dose of 4,000 rads. On March 12, 1991, in Florida, she had reoperation for a solid recurrence (Figure 1). When this patient was seen at our hospital, her physical examination was unremarkable except for a right upper quadrantanopsia. MRl showed a solid superficial tumor in the left occipital area invading the tentorium and extending infratentorially, and also invading parts of the falx cerebri (Figure 2). On November 20, 1992, the patient was taken to the operating room; through the previous occipital craniotomy, a yellowish fibrous-rubbery tumor with complete invasion of the left tentorium was found. The supratentorial component was removed first, then the infratentorial component, without being able to recognize the tentorium except at its very lateral attachment to the petrous bone. The tumor was also invading the falx cerebri above the straight sinus. The tumor was attached to the leptomeninges covering the occipital lobe and the cerebellar hemisphere, without invading the nervous tissue. A subtotal removal was accomplished with residual tumor remaining at the dura forming the junction of the major venous sinuses involved. HlSTOPATHOLOGY Light microscopy showed a moderately cellular tumor composed of spindle-shaped cells with elongated nuclei arranged in fascicles, round tumor cells with ground-glass-like cytoplasm, and some multinucleated giant cells (Figure 3). Clusters of lymphocyte infiltrates were seen. The superficial cortex was not invaded. Reticulin fibers were only seen surrounding blood vessels. Glial fibrillary acid protein (GFAP) was demonstrated in some of the spindle cells. The S-100 was present in the tumoral cells. 0090-3019/95/$9.50 SSDI0090_3019(94)0010LL5
Surg Neurol
De Jesus and Rifkinson
1995;43:77-9
0
Gadoliniumenhanced sagittal MRI before the second surgery showing a solid recurrence at the same
site of the previous
surgery.
DISCUSSION Pleomorphic xanthoastrocytoma is a tumor that was classified 14 years ago with less than 100 cases reported in the world. The preferred location of this tumor is the temporal lobe, but it may occur in the parietal and occipital lobes. Pleomorphic xanthoastrocytoma is normally con-
Gadoliniumenhanced coronal MRI before the third surgery showing a solid tumor in the left occipital area invading the tentorium and extending infratentorially, and also invading parts of the falx cerebri.
fined to the leptomeninges and the superficial cortex, but it may infiltrate by growth within the perivascular spaces or by direct invasion. Although previous reports have shown that it does not invade or attach to the dura, Whittle et al. [4] reported three cases in which the tumor was found at surgery to be attached to the dura. Yoshino and Lucia [5] reported two cases. Despite the original description of pleomorphic xanthoastrocytoma as one of benign biological behavior, some reports of dedifferentiation to malignant glioma have been published [ 1, 31. In this report a case of pleomorphic xanthoastrocytoma is presented. Initially, the tumor was located superficially with involvement of the leptomeninges. Three years later, it showed invasion of the dura forming the tentorium and falx cerebri. This occurred without malignant transformation of the tumor. The small amount of reticulin fibers and cells stained with GFAP was compatible with a recurrent pleomorphic xanthoastrocytoma as previously described by Kepes et al [3]. This is the first case reported in the literature which documents invasion of the dura in a pleomorphic xanthoastrocytoma. Extensive or complete surgical excision seems to be the best form of treatment for this tumor, with reoperation for residual or recurrent tumor. Radiotherapy has not changed the outcome of patients. Chemotherapy has not been considered as a form of primary treatment. Based on the findings in this case, we conclude that pleomorphic xanthoastrocytomas may involve
Pleomorphic
Xanthoastrocytoma
with Invasion
of the Tentorium
and Falx
Surg Neurol 1995;43: 77-9
79
Photomicrograph showing q the surgical specimen. (Hematoxylin-eosin, 150.) X
the dura, but this should not be considered a criterion for malignancy. When anatomical structures permit, surgical excision of all the involved dura should be performed. REFERENCES Allegranza A, Ferraresi S, Bruzzone M, Giombini S. Cerebromeningeal pleomorphic xanthoastrocytoma. Report on four cases: clinical, radiological and pathological features. (Including a case with malignant eve lution). Neurosurg Rev 1991;14:43-9. Kepes JJ, Rubinstein LJ, Eng LF. Pleomorphic xan-
thoastrocytoma: a distinctive meningocerebral glioma of young subjects with relatively favorable prognosis. 3 A study of 12 cases. Cancer 1979;44:1839-52. Kepes JJ, Rubinstein LJ, Ansbacher L, Schreiber DJ. Histopathological features of recurrent pleomorphic xanthoastrocytomas: further corroboration of the glial nature of this neoplasm. A study of three cases. Acta Neuropathol 1989;78:585-93. 4. Whittle IR, Gordon A, Misra BK, Shaw JF, Steers JW. Pleomorphic xanthoastrocytoma. Report of four cases. J Neurosurg 1989;70:463-8. 5. Yoshino MT, Lucia R. Pleomorphic xanthoastrocytoma. Am J Neuroradiol 1992;13:1330-2.
UNDAMENTALLY, THERE ARE ONLY TWO WAYS OF COORDINATING THE ECONOMIC ACTIVITIES OF MILLIONS. ONE IS CENTRAL DIRECTION INVOLVING THE USE OF COERCION-THE TECHNIQUE OF THE ARMY AND OF THE MODERN TOTALITARIAN STATE. THE OTHER IS VOLUNTARY COOPERATION OF INDIVIDUALS-THE TECHNIQUE OF THE MARKETPLACE.
F
MILTON FRIEDMAN (19 12-j CAPITALISM AND FREEDOM, 1962