Bilateral thalamic gliomas (BTGs) are rare brain tumors. In general, the prognosis is poor because of the involvement of bilateral thalami and limitations of surgical excision. Consequently, patients with symptoms of personality changes and memory impairment must be differentiated from others. Magnetic resonance imaging (MRI) is essential for the diagnosis of BTGs and reveals a hypo-intense lesion on T1-weighted images and a hyper-intense lesion on T2 images. We report a case of a 17-year-old female patient suffering from progressive cognitive dysfunction and personality changes and subsequent rehabilitation treatment. Brain MRI showed an enlarged bilateral thalamus, with hyperintensity on T2-weighted images and iso-intensity on T1-weighted images. A biopsy was performed, and the pathology revealed a high-grade glioma. The patient was referred for radiotherapy and chemotherapy. She also underwent rehabilitation treatment for 5 weeks and showed improvement in standing balance, endurance, and speech fluency. The patient's Modified Barthel Index scores also improved. Cancer rehabilitation is important in brain tumor patients because they have a higher incidence of neurological sequelae than others. Rehabilitation of patients with a malignant brain tumor is also important for improving health-related quality of life by maintaining the general condition and preventing complications during and after cancer treatment.
Adolescent ; Biopsy ; Brain ; Brain Neoplasms ; Diagnosis ; Drug Therapy ; Female ; Glioma ; Humans ; Incidence ; Magnetic Resonance Imaging ; Memory ; Memory Disorders ; Neurobehavioral Manifestations ; Pathology ; Prognosis ; Quality of Life ; Radiotherapy ; Rehabilitation ; Thalamus

Choroid plexus tumors are uncommon brain tumors that primarily occur in children. Most of these tumors originate from the intraventricular area, and the most common clinicalpresentation is increased intracranial pressure. Dissemination through the cerebrospinal fluid space is the inevitable natural course of the disease. Here, we present 2 rare cases of adult choroid plexus carcinoma (CPC), each with distinct clinical presentation and progression. The first case was a 40-year-old male who presented with multiple intraventricular masses. After surgical biopsy, radiation and intrathecal chemotherapy failed to elicit any response. The patient progressed with spinal cord dissemination and expired 1 year later. The second case presented with visual disturbance, and brain MRI revealed a large ovoid juxtaventricular mass with peritumoral edema. This 49-year-old female patient underwent craniotomy for what was thought to be a high-grade glioma; however, the mass was connected to the choroid plexus at the operative field. Her pathology specimen was diagnosed as CPC, and adjuvant systemic chemotherapy was administered. She has now been free of recurrence for 10 months. The description of the presentation and progression of these rare adult-onset CPC provides insight for the diagnosis and treatment of other rare instances of choroid plexus tumors.
Adult ; Biopsy ; Brain ; Brain Neoplasms ; Cerebrospinal Fluid ; Child ; Choroid Plexus Neoplasms ; Choroid Plexus ; Choroid ; Craniotomy ; Diagnosis ; Drug Therapy ; Edema ; Female ; Fourth Ventricle ; Glioma ; Humans ; Intracranial Pressure ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Pathology ; Recurrence ; Spinal Cord

BACKGROUND: Mixed gliomas, such as oligoastrocytomas (OA), anaplastic oligoastrocytomas, and glioblastomas (GBMs) with an oligodendroglial component (GBMO) are defined as tumors composed of a mixture of two distinct neoplastic cell types, astrocytic and oligodendroglial. Recently, mutations ATRX and TP53, and codeletion of 1p/19q are shown to be genetic hallmarks of astrocytic and oligodendroglial tumors, respectively. Subsequent molecular analyses of mixed gliomas preferred the reclassification to either oligodendroglioma or astrocytoma. This study was designed to apply genetically integrated diagnostic criteria to mixed gliomas and determine usefulness and prognostic value of new classification in Korean patients. METHODS: Fifty-eight cases of mixed OAs and GBMOs were retrieved from the pathology archives of Seoul National University Hospital from 2004 to 2015. Reclassification was performed according to genetic and immunohistochemical properties. Clinicopathological characteristics of each subgroup were evaluated. Overall survival was assessed and compared between subgroups. RESULTS: We could reclassify all mixed OAs and GBMOs into either astrocytic or oligodendroglial tumors. Notably, 29 GBMOs could be reclassified into 11 cases of GBM, IDH-mutant, 16 cases of GBM, IDH-wildtype, and two cases of anaplastic oligodendroglioma, IDH mutant. Overall survival was significantly different among these new groups (p<.001). Overall survival and progression-free survival were statistically better in gliomas with IDH mutation, ATRX mutation, no microscopic necrosis, and young patient age (cut off, 45 years old). CONCLUSIONS: Our results strongly suggest that a genetically integrated diagnosis of glioma better reflects prognosis than former morphology-based methods.
Astrocytoma ; Classification ; Diagnosis ; Disease-Free Survival ; Genetics ; Glioblastoma ; Glioma ; Humans ; Necrosis ; Oligodendroglioma ; Pathology ; Prognosis ; Seoul

In the field of computational histopathology, computer-assisted diagnosis systems are important in obtaining patient-specific diagnosis for various diseases and help precision medicine. Therefore, many studies on automatic analysis methods for digital pathology images have been reported. In this work, we discuss an automatic feature extraction and disease stage classification method for glioblastoma multiforme (GBM) histopathological images. In this paper, we use deep convolutional neural networks (Deep CNNs) to acquire feature descriptors and a classification scheme simultaneously. Further, comparisons with other popular CNNs objectively as well as quantitatively in this challenging classification problem is undertaken. The experiments using Glioma images from The Cancer Genome Atlas shows that we obtain 96:5% average classification accuracy for our network and for higher cross validation folds other networks perform similarly with a higher accuracy of 98:0%. Deep CNNs could extract significant features from the GBM histopathology images with high accuracy. Overall, the disease stage classification of GBM from histopathological images with deep CNNs is very promising and with the availability of large scale histopathological image data the deep CNNs are well suited in tackling this challenging problem.
Classification* ; Diagnosis ; Diagnosis, Computer-Assisted ; Genome ; Glioblastoma* ; Glioma ; Methods ; Pathology ; Precision Medicine ; Subject Headings

Tuberous sclerosis complex (TSC) is an uncommon multiorgan disorder that may present many and different manifestations on imaging. Radiology plays an important role in diagnosis and management, and can substantially improve the clinical outcome of TSC. Therefore, a comprehensive understanding of this disease is essential for the radiologist. The manifestations of TSC on computer tomography (CT) and magnetic resonance (MR) images were analyzed. Eleven patients with a clinical diagnosis of TSC were retrospectively reviewed. Central nervous system lesions included subependymal nodules (SENs) (11/11), subependymal giant cell astrocytomas (SEGAs) (2/11), cortical and subcortical tuber lesions (5/11), and white matter lesions (4/11). Of the 6 patients with abdominal scans, there were 6 cases of renal angiomyolipomas (AMLs), and one case of hepatic AMLs. Of the 4 patients undergoing chest CT, lung lymhangioleiomyomatosis (LAM) (2/4), and multiple small sclerotic bone lesions (2/4) were observed. Different modalities show different sensitivity to the lesion. Analysis of images should be integrated with patients' history in order to diagnose TSC.
Adolescent ; Adult ; Brain ; diagnostic imaging ; pathology ; Child ; Child, Preschool ; Female ; Glioma, Subependymal ; diagnosis ; diagnostic imaging ; pathology ; Humans ; Lung ; diagnostic imaging ; pathology ; Magnetic Resonance Imaging ; methods ; Male ; Middle Aged ; Nervous System Diseases ; diagnosis ; diagnostic imaging ; pathology ; Tuberous Sclerosis ; classification ; diagnosis ; diagnostic imaging ; pathology

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.
Adult ; Cerebral Ventricle Neoplasms/diagnosis/pathology/*secondary ; Fourth Ventricle/*pathology ; Glioma/diagnosis/*pathology ; Humans ; Lateral Ventricles/*pathology ; Magnetic Resonance Imaging/methods ; Male ; Third Ventricle/*pathology

The current standards in radiotherapy of high-grade gliomas (HGG) are based on anatomic imaging techniques, usually computed tomography (CT) scanning and magnetic resonance imaging (MRI). The guidelines vary depending on whether the HGG is a histological grade 3 anaplastic glioma (AG) or a grade 4 glioblastoma multiforme (GBM). For AG, T2-weighted MRI sequences plus the region of contrast enhancement in T1 are considered for the delineation of the gross tumor volume (GTV), and an isotropic expansion of 15 to 20 mm is recommended for the clinical target volume (CTV). For GBM, the Radiation Therapy Oncology Group favors a two-step technique, with an initial phase (CTV1) including any T2 hyperintensity area (edema) plus a 20 mm margin treated with up to 46 Gy in 23 fractions, followed by a reduction in CTV2 to the contrast enhancement region in T1 with an additional 25 mm margin. The European Organisation of Research and Treatment of Cancer recommends a single-phase technique with a unique GTV, which comprises the T1 contrast enhancement region plus a margin of 20 to 30 mm. A total dose of 60 Gy in 30 fractions is usually delivered for GBM, and a dose of 59.4 Gy in 33 fractions is typically given for AG. As more than 85% of HGGs recur in field, dose-escalation studies have shown that 70 to 75 Gy can be delivered in 6 weeks with relevant toxicities developing in <10% of the patients. However, the only randomized dose-escalation trial, in which the boost dose was guided by conventional MRI, did not show any survival advantage of this treatment over the reference arm. HGGs are amongst the most infiltrative and heterogeneous tumors, and it was hypothesized that the most highly aggressive areas were missed; thus, better visualization of these high-risk regions for radiation boost could decrease the recurrence rate. Innovations in imaging and linear accelerators (LINAC) could help deliver the right doses of radiation to the right subvolumes according to the dose-painting concept. Advanced imaging techniques provide functional information on cellular density (diffusion MRI), angiogenesis (perfusion MRI), metabolic activity and cellular proliferation [positron emission tomography (PET) and magnetic resonance spectroscopy (MRS)]. All of these non-invasive techniques demonstrated good association between the images and histology, with up to 40% of HGGs functionally presenting a high activity within the non-contrast-enhanced areas in T1. New LINAC technologies, such as intensity-modulated and stereotactic radiotherapy, help to deliver a simultaneous integrated boost (SIB) > 60 Gy. Trials delivering a SIB into a biological GTV showed the feasibility of this treatment, but the final results, in terms of clinical benefits for HGG patients, are still pending. Many issues have been identified: the variety of MRI and PET machines (and amino-acid tracers), the heterogeneity of the protocols used for image acquisition and post-treatment, the geometric distortion and the unreliable algorithms for co-registration of brain anatomy with functional maps, and the semi-quiescent but highly invasive HGG cells. These issues could be solved by the homogenization of the protocols and software applications, the simultaneous acquisition of anatomic and functional images (PET-MRI machines), the combination of complementary imaging tools (perfusion and diffusion MRI), and the concomitant addition of some ad hoc targeted drugs against angiogenesis and invasiveness to chemoradiotherapy. The integration of these hybrid data will construct new synthetic metrics for fully individualized treatments.
Antineoplastic Agents, Alkylating ; therapeutic use ; Brain Neoplasms ; diagnosis ; pathology ; radiotherapy ; Dacarbazine ; analogs & derivatives ; therapeutic use ; Diffusion Tensor Imaging ; Glioblastoma ; diagnosis ; drug therapy ; pathology ; radiotherapy ; Glioma ; diagnosis ; pathology ; radiotherapy ; Humans ; Magnetic Resonance Imaging ; Magnetic Resonance Spectroscopy ; Neoplasm Grading ; Particle Accelerators ; Positron-Emission Tomography ; Radiotherapy Dosage ; Radiotherapy, Intensity-Modulated ; methods

Glioma-related edema (GRE) is a significant contributor to morbidity and mortality from glioma. GRE is a complicated process involving not only peritumoral edema but also the water content of the tumor body. In terms of etiology, this condition derives from both GRE in the untreated state and GRE secondary to clinical intervention, and different cell types contribute to distinct components of GRE. Peritumoral edema was previously believed to loosen glioma tissue, facilitating tumor-cell invasion; however, the nutrition hypothesis of the tumor microecosystem suggests that tumor cells invade for the sake of nutrition. Edema is the pathologic consequence of the reconstructed trophic linkage within the tumor microecosystem. Glioma cells induce peritumoral brain edema via an active process that supplies a suitable niche for peritumoral invasive cells, suggesting that glioma-related peritumoral brain edema is determined by the invasive property of tumor cells. There are differences between pivotal molecular events and reactive molecular events in the development of GRE. Molecular therapy should target the former, as targeting reactive molecular events will produce undesired or even adverse results. At present, brain glioma angiogenesis models have not been translated into a new understanding of the features of brain images. The effect of these models on peritumoral brain edema is unclear. Clinical approaches should be transformed on the basis of new knowledge of the molecular mechanism underlying GRE. Exploring clinical assessment methods, optimizing the existing control strategy of GRE, and simultaneously developing new treatments are essential.
Brain Edema ; diagnosis ; drug therapy ; metabolism ; pathology ; Brain Neoplasms ; diagnosis ; drug therapy ; metabolism ; pathology ; Glioma ; diagnosis ; drug therapy ; metabolism ; pathology ; Humans ; Magnetic Resonance Imaging ; Molecular Targeted Therapy ; Vascular Endothelial Growth Factor A ; metabolism

OBJECTIVETo study the correlation between apparent diffusion coefficient (ADC) and Ki-67, a marker of tumor activity, in the diagnosis of gliomas.

METHODSConventional magnetic resonance imaging (MRI), enhanced scanning, and diffusion-weighted imaging were performed in 76 patients with pathologically confirmed gliomas. The ADC values were measured at tumor parenchyma and the corresponding contralateral normal brain. The relatively ADC (rADC) values of the tumor parenchyma were calculated. The correlation of the ADC values with tumor grades was analyzed. The expression of Ki-67 was detected by immunohistochemical staining. The correlation between ADC value and Ki-67 in the diagnosis of gliomas was analyzed.

RESULTSThe ADC values and rADC values of high-grade gliomas were significantly lower than those of low-grade gliomas. The ADC values of tumor parenchyma were inversely associated with the degree of malignancy of the gliomas (r=-0.898, r=-0.868; P<0.01). The expression of Ki-67 was significantly higher in high-grade gliomas than that in low-grade gliomas. The Ki-67 labeling index in grade 3 and 4 gliomas were (29.48 ± 19.78)% and (31.21 ± 17.50)%, respectively. Both of them were significantly higher than Ki-67 labeling index in low-grade (grade 1 and 2) gliomas [(2.33 ± 2.20)%] (P<0.01). Nevertheless, the Ki-67 labeling index showed no significant difference between grade 3 and 4 gliomas (P>0.05). The expression of Ki-67 was negatively correlated with the ADC values and rADC values in tumor parenchyma (r=-0.627, r=-0.607; P<0.01).

CONCLUSIONThe ADC and rADC values of tumor parenchyma can indirectly reflect the proliferation and malignancy of gliomas and therefore can be useful for the grading of glioma.

Adolescent ; Adult ; Brain Neoplasms ; diagnosis ; metabolism ; pathology ; Child ; Child, Preschool ; Diffusion Magnetic Resonance Imaging ; methods ; Female ; Glioma ; diagnosis ; metabolism ; pathology ; Humans ; Ki-67 Antigen ; metabolism ; Male ; Middle Aged ; Young Adult

OBJECTIVETo evaluate application value of apparent diffusion coefficient (ADC) in differentiating brain radiation-injuries and glioma recurrence.

METHODSTotally 23 patients [18 men and 5 women aged 32 to 67 years (mean: 47 years)] with previously resected and irradiated glioma were examined by using a 3.0T MR Scanner, including conventional and diffusion weighted image (DWI) sequences. All the cases were proved by pathology or clinical follow-up. Postprocessing of ADC maps was performed by using Functool software (AW 4.3, GE Healthcare), and the regions of interest (ROIs) were manually drawn on ADC maps in the area corresponding to the contrast-enhancing area on post-contrast axial T1-weighted images, avoiding the hemorrhage or necrosis. The ADC values were calculated automatically. ADC values were measured 10 times in order to reduce errors, and mean ADC value, maximum ADC value, and minimum ADC value were acquired.

RESULTSBoth recurrent glioma and irradiated necrosis tended to have hemorrhage, necrosis, and edema. The mean ADC value and maximum ADC value were lower in the recurrent tumor group than in the radiation-injuries group, but no statistical difference was achieved. However, the minimum ADC value was significantly lower in the recurrent tumor group than in the radiation-injuries group (P=0.016).

CONCLUSIONThe minimum ADC value can be used as an useful tool in differentiating tumor recurrence from radiation-injuries.

Adult ; Aged ; Brain Injuries ; diagnosis ; Brain Neoplasms ; diagnosis ; pathology ; Diagnosis, Differential ; Diffusion Magnetic Resonance Imaging ; Female ; Glioma ; diagnosis ; pathology ; Humans ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; diagnosis ; Radiation Injuries ; diagnosis