Treatment for posterior fossa dissemination of primary supratentorial glioma

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Object

This study was designed to assess the presentation, management, and outcome of cases involving patients who had a supratentorial glioma that subsequently progressed in the posterior fossa (PF).

Methods

The authors performed a retrospective chart review of adult patients treated between 1997 and 2005 for supratentorial gliomas that progressed in the PF. The 29 patients with PF progression in this study were relatively young (median age of 34 years at original presentation). Twenty of these patients presented with symptoms. The symptoms were typically nonspecific to this population, at times leading to delays in diagnosis. Overall, these symptoms resolved in eight patients (40%) and progressed or remained unchanged in 12 (60%). Patients treated with more than 5000 cGy of radiation administered to the PF were more likely to have symptom resolution than those who received any other form of treatment, including reduced doses of radiation (p = 0.004). The patients treated with higher doses also survived significantly longer after PF progression (univariate analysis, p = 0.01, and after adjusting for tumor grade, p = 0.04).

Conclusions

Patients with PF progression of supratentorial infiltrative gliomas may benefit from treatment, and the authors recommend more than 5000 cGy of radiation to the PF if prior radiotherapy ports and doses allow.

Abbreviations used in this paper:CI = confidence interval; CSF = cerebrospinal fluid; EBRT = external-beam radiation therapy; GBM = glioblastoma multiforme; KPS = Karnofsky Performance Scale; MR = magnetic resonance; PF = posterior fossa; UCSF = University of California, San Francisco.

Article Information

Address reprint requests to: Susan M. Chang, M.D., Neuro-Oncology Service, Department of Neurological Surgery, University of California, San Francisco, 400 Parnassus Avenue, A-808, San Francisco, California 94143-0350. email: changs@neurosurg.ucsf.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Neuroimages obtained in two patients with supratentorial infiltrative gliomas who subsequently demonstrated PF dissemination. A: Gadolinium-enhanced axial T1-weighted MR image (left) obtained in a 43-year-old man with a left frontotemporal GBM. The lesion was treated with subtotal resection, EBRT, chemotherapy, and radiosurgery. Axial (center) and coronal (right) fluid attenuated inversion recovery images obtained 7 months after the initial diagnosis showing tumor progression in the left superior cerebellar peduncle, left cerebellar hemisphere, and vermis. Progression of the primary lesion is also demonstrated on the coronal image. B: Gadolinium-enhanced axial T1-weighted MR image (left) obtained in a 35-year-old woman with a left occipital anaplastic mixed oligoastrocytoma (Grade III). The lesion was treated with gross-total resection and subsequent EBRT, chemotherapy, and radiosurgery. Axial (center) and coronal (right) fluid attenuated inversion recovery images obtained almost 6 years after the initial diagnosis demonstrate tumor progression in the PF, surrounding the fourth ventricle. Stable appearance of the primary lesion is also demonstrated on the coronal image.

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    Bar graph showing symptom status at follow up in patients with PF progression according to treatment group. Values on the y axis indicate percentages of patients. Light bars indicate symptom progression; dark bars indicate symptom resolution or stabilization. The overall group (20 patients) includes all patients in this study for whom follow-up data were available for the period after PF progression, except for patients who were asymptomatic at the time of PF progression diagnosis and patients with less than 16 weeks' follow up whose symptoms were stable at the last follow up. The no-EBRT group (seven patients) includes all patients who did not receive fractionated radiation treatment to the PF. The EBRT group (13 patients) includes all patients who received fractionated radiation therapy to the PF. The EBRT < 5000 (five patients) and EBRT > 5000 (five patients) groups include the patients who received fractionated radiation treatment to the PF (either < 5000 cGy or > 5000 cGy, respectively) for whom the dose of radiation could be determined from clinical records.

  • View in gallery

    Kaplan–Meier plot showing cumulative survival for patients who did (solid line) and did not (dotted line) receive EBRT > 5000 cGy for treatment of PF dissemination (p = 0.01, log-rank test). Note that two patients were censored at 50 weeks in the EBRT > 5000 cGy group.

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