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Malignant transformation of a conservatively managed incidental childhood cerebral mass lesion: controversy regarding management paradigm

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Abstract

Background

Incidental findings on neuroimaging in the pediatric population are an emerging treatment challenge. Treatment options for these incidental childhood brain mass lesions, which radiologically may be assumed to be low-grade gliomas (LGG), vary, ranging from careful conservative “wait and scan” treatment to surgical biopsy, gross total resection, and upfront radiation and/or chemotherapy. As malignant transformation of LGG in children is extremely rare, some series advocate careful conservative management of these lesions; however, universal treatment protocols are not totally agreed upon.

Illustrative case

We present the case of a 10-year-old boy with a fronto-basal incidental cerebral mass lesion, suspected to be a low-grade glial neoplasm. Initially, magnetic resonance imaging (MRI) was done to rule out a pathology causing his growth to be delayed. A treatment with growth hormone was initiated. After close clinical and radiological follow-up of this asymptomatic lesion for 6 years, a minimal growth of the lesion was seen, which we decided to continue following. After 7 years, a clear growth with new contrast enhancement was seen on routine MRI. At this point, the lesion was surgically resected. The diagnosis was, surprisingly, glioblastoma multiforme (WHO grade IV, BRAF V-600E mutation).

Discussion

Malignant transformation of LGGs in children is a very rare phenomenon. This is to our knowledge the first well-documented case describing malignant transformation of a suspected benign pediatric cerebral mass lesion, which did not undergo radiation, in a patient without a cancer predisposition syndrome (e.g., neurofibromatosis), with the transformation occurring after such a long follow-up period. The management of these lesions is still controversial. Unfortunately, radiological risk factors for malignant transformation of such lesions in the pediatric age group are lacking.

Conclusion

Conservative treatment of incidental cerebral mass lesions in children seems a valid option. These lesions should probably be followed indefinitely, while carefully watching for changes in imaging characteristics.

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References

  1. Graf WD, Kayyali HR, Alexander JJ, Simon SD, Morriss MC (2008) Neuroimaging-use trends in nonacute pediatric headache before and after clinical practice parameters. Pediatrics 122:e1001–e1005

    Article  PubMed  Google Scholar 

  2. Perret C, Boltshauser E, Scheer I, Kellenberger CJ, Grotzer MA (2011) Incidental findings of mass lesions on neuroimages in children. Neurosurg Focus 31:E20

    Article  PubMed  Google Scholar 

  3. Graf WD, Kayyali HR, Abdelmoity AT, Womelduff GL, Williams AR, Morriss MC (2010) Incidental neuroimaging findings in nonacute headache. J Child Neurol 25:1182–1187

    Article  PubMed  Google Scholar 

  4. Ali ZS, Lang SS, Sutton LN (2014) Conservative management of presumed low-grade gliomas in the asymptomatic pediatric population. World neurosurg 81:368–373

    Article  PubMed  Google Scholar 

  5. Brown PD, Wald JT, McDermott MW, Baumann GS, Cloughesy TF, Oncodiagnosis panel RSA (2003) Oncodiagnosis panel: 2002. Patient’s symptoms not related to the lesion seen in the MR images. Radiographics Rev Publ Radiol Soc North Am Inc 23:1591–1611

    Google Scholar 

  6. Bredlau AL, Constine LS, Silberstein HJ, Milano MT, Korones DN (2012) Incidental brain lesions in children: to treat or not to treat? J Neuro-Oncol 106:589–594

    Article  Google Scholar 

  7. Roth J, Keating RF, Myseros JS, Yaun AL, Magge SN, Constantini S (2012) Pediatric incidental brain tumors: a growing treatment dilemma. J Neurosurg Pediatr 10:168–174

    Article  PubMed  Google Scholar 

  8. Berger MS, Deliganis AV, Dobbins J, Keles GE (1994) The effect of extent of resection on recurrence in patients with low grade cerebral hemisphere gliomas. Cancer 74:1784–1791

    Article  CAS  PubMed  Google Scholar 

  9. Jakola AS, Myrmel KS, Kloster R, Torp SH, Lindal S, Unsgard G et al (2012) Comparison of a strategy favoring early surgical resection vs a strategy favoring watchful waiting in low-grade gliomas. JAMA 308:1881–1888

    Article  CAS  PubMed  Google Scholar 

  10. Janny P, Cure H, Mohr M, Heldt N, Kwiatkowski F, Lemaire JJ et al (1994) Low grade supratentorial astrocytomas. Management and prognostic factors. Cancer 73:1937–1945

    Article  CAS  PubMed  Google Scholar 

  11. Keles GE, Lamborn KR, Berger MS (2001) Low-grade hemispheric gliomas in adults: a critical review of extent of resection as a factor influencing outcome. J Neurosurg 95:735–745

    Article  CAS  PubMed  Google Scholar 

  12. Smith JS, Chang EF, Lamborn KR, Chang SM, Prados MD, Cha S et al (2008) Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas. J Clin Oncol Off J Am Soc Clin Oncol 26:1338–1345

    Article  Google Scholar 

  13. Mistry M, Zhukova N, Merico D, Rakopoulos P, Krishnatry R, Shago M et al (2015) BRAF mutation and CDKN2A deletion define a clinically distinct subgroup of childhood secondary high-grade glioma. J Clin Oncol Off J Am Soc Clin Oncol 33:1015–1022

    Article  CAS  Google Scholar 

  14. Winograd E, Pencovich N, Yalon M, Soffer D, Beni-Adani L, Constantini S (2012) Malignant transformation in pediatric spinal intramedullary tumors: case-based update. Child's Nerv Syst : ChNS : Off J Int Soc Pediatr Neurosurg 28:1679–1686

    Article  CAS  Google Scholar 

  15. Shay V, Fattal-Valevski A, Beni-Adani L, Constantini S (2012) Diagnostic delay of pediatric brain tumors in Israel: a retrospective risk factor analysis. Child's Nerv Syst : ChNS : Off J Int Soc Pediatr Neurosurg 28:93–100

    Article  Google Scholar 

  16. Ellis JA, Waziri A, Balmaceda C, Canoll P, Bruce JN, Sisti MB (2009) Rapid recurrence and malignant transformation of pilocytic astrocytoma in adult patients. J Neuro-Oncol 95:377–382

    Article  Google Scholar 

  17. Stuer C, Vilz B, Majores M, Becker A, Schramm J, Simon M (2007) Frequent recurrence and progression in pilocytic astrocytoma in adults. Cancer 110:2799–2808

    Article  PubMed  Google Scholar 

  18. Pignatti F, van den Bent M, Curran D, Debruyne C, Sylvester R, Therasse P et al (2002) Prognostic factors for survival in adult patients with cerebral low-grade glioma. J Clin Oncol Off J Am Soc Clin Oncol 20:2076–2084

    Article  Google Scholar 

  19. Aghi MK, Nahed BV, Sloan AE, Ryken TC, Kalkanis SN, Olson JJ (2015) The role of surgery in the management of patients with diffuse low grade glioma: a systematic review and evidence-based clinical practice guideline. J Neuro-Oncol 125:503–530

    Article  Google Scholar 

  20. Soffietti R, Baumert BG, Bello L, von Deimling A, Duffau H, Frenay M et al (2010) Guidelines on management of low-grade gliomas: report of an EFNS-EANO Task Force. Eur J Neurol 17:1124–1133

    Article  CAS  PubMed  Google Scholar 

  21. Broniscer A (2015) Malignant transformation of low-grade gliomas in children: lessons learned from rare medical events. J Clin Oncol Off J Am Soc Clin Oncol 33:978–979

    Article  CAS  Google Scholar 

  22. Unal E, Koksal Y, Cimen O, Paksoy Y, Tavli L (2008) Malignant glioblastomatous transformation of a low-grade glioma in a child. Child's Nerv Syst : ChNS : Off J Int Soc Pediatr Neurosurg 24:1385–1389

    Article  Google Scholar 

  23. Pollack IF (2014) Management of low-grade gliomas in childhood. World Neurosurg 81:265–267

    Article  PubMed  Google Scholar 

  24. Ishibashi K, Inoue T, Fukushima H, Watanabe Y, Iwai Y, Sakamoto H et al (2016) Pediatric thalamic glioma with H3F3A K27M mutation, which was detected before and after malignant transformation: a case report. Child's Nerv Syst : ChNS : Off J Int Soc Pediatr Neurosurg 32:2433–2438

    Article  Google Scholar 

  25. Patterson BC, Chen Y, Sklar CA, Neglia J, Yasui Y, Mertens A et al (2014) Growth hormone exposure as a risk factor for the development of subsequent neoplasms of the central nervous system: a report from the childhood cancer survivor study. J Clin Endocrinol Metab 99:2030–2037

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Shen L, Sun CM, Li XT, Liu CJ, Zhou YX (2015) Growth hormone therapy and risk of recurrence/progression in intracranial tumors: a meta-analysis. Neurol Sci Off J Ital Neurol Soc Ital Soc Clin Neurophysiol 36:1859–1867

    Google Scholar 

  27. Pirotte BJ, Lubansu A, Massager N, Wikler D, Van Bogaert P, Levivier M et al (2010) Clinical interest of integrating positron emission tomography imaging in the workup of 55 children with incidentally diagnosed brain lesions. J Neurosurg Pediatr 5:479–485

    Article  PubMed  Google Scholar 

  28. Wisoff JH, Sanford RA, Heier LA, Sposto R, Burger PC, Yates AJ et al (2011) Primary neurosurgery for pediatric low-grade gliomas: a prospective multi-institutional study from the Children’s Oncology Group. Neurosurgery 68:1548–1554 discussion 54-5

    Article  PubMed  Google Scholar 

  29. Kruer MC, Kaplan AM, Etzl MM Jr, Carpentieri DF, Dickman PS, Chen K et al (2009) The value of positron emission tomography and proliferation index in predicting progression in low-grade astrocytomas of childhood. J Neuro-Oncol 95:239–245

    Article  Google Scholar 

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Acknowledgments

We would like to thank Mrs. Adina Sherer for the medical editing of this manuscript.

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Authors and Affiliations

  1. Departments of Neurosurgery and Pediatric Neurosurgery, Tel Aviv Medical Center & Dana Children’s Hospital, 6 Weizmann Street, Tel Aviv, Israel

    Jehuda Soleman, Jonathan Roth, Zvi Ram & Shlomi Constantini

  2. Tel-Aviv University, Tel Aviv, Israel

    Jonathan Roth, Zvi Ram, Michal Yalon & Shlomi Constantini

  3. Department of Pediatric Hemato-Oncology, Edmond and Lilly Safra Children’s Hospital and Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel

    Michal Yalon

Authors
  1. Jehuda Soleman
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  2. Jonathan Roth
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Correspondence to Shlomi Constantini.

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Soleman, J., Roth, J., Ram, Z. et al. Malignant transformation of a conservatively managed incidental childhood cerebral mass lesion: controversy regarding management paradigm. Childs Nerv Syst 33, 2169–2175 (2017). https://doi.org/10.1007/s00381-017-3566-z

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  • DOI: https://doi.org/10.1007/s00381-017-3566-z

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