Glioblastoma multiforme occurring in a patient treated with gamma knife surgery

Case report and review of the literature

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✓ Stereotactic radiosurgery is being increasingly advocated as the primary modality for treatment of vestibular schwannomas (VS). This modality has been shown to arrest tumor growth, with few associated short-term morbidities, and with possibly better hearing and facial nerve preservation rates than microsurgery. Radiation-induced oncogenesis has long been recognized, although stereotactic radiosurgery de novo induction of a secondary tumor has never been clearly described. The authors report on a patient with a VS who did not have neurofibromatosis Type 2 and who underwent gamma knife surgery (GKS). This patient required microsurgical removal of the VS within 8 months because of development of a tumor cyst with associated brainstem compression and progressive hydrocephalus. The operation resulted in clinical stabilization and freedom from tumor recurrence.

Seven and a half years after undergoing GKS, the patient presented with symptoms of raised intracranial pressure. Magnetic resonance imaging demonstrated a new ring-enhancing lesion in the inferior temporal lobe adjacent to the area of radiosurgery, which on craniotomy was confirmed to be a glioblastoma multiforme (GBM). Despite additional conventional external-beam radiation to the temporal lobe, the GBM has progressed. Whereas this first reported case of a GBM within the scatter field of GKS does not conclusively prove a direct causal link, it does fulfill all of Cahan's criteria for radiation-induced neoplasia, and demands increased vigilance for the potential long-term complications of stereotactic radiosurgery, and reporting of any similar cases.

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Address reprint requests to: Abhijit Guha, M.D., F.R.C.S.(C), 2–415 McLaughlin Pavilion, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, Ontario, Canada M5T-2S8. email: ab.guha@utoronto.ca.

© AANS, except where prohibited by US copyright law.

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Figures

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    Upper: Stereotactic CT scans obtained using the double window technique (enhanced soft tissue and bone window settings integrated by the CT software). The isodose diagrams corresponding to the midlevel of the acoustic neuroma through the internal auditory canal (upper left) and the top portion of the neuroma 14 mm above (upper right) are shown. The 10, 20, 30, 40, 50, 70, and 90% isodose curves are displayed. The 40% isodose was the prescribed isodose level, conformal with the periphery of the acoustic neuroma, corresponding to a prescribed dose of 11 Gy. The center of the solid enhancing mural nodule of the subsequent GBM depicted in Fig. 3 received approximately 4 Gy, corresponding to the 14% isodose level (upper right). Lower Left: Axial T1-weighted nonenhanced MR image obtained 8 months after GKS. A posteromedial cystic component (arrowhead) to the tumor resulted in increased brainstem distortion and ventricular enlargement, in keeping with a worsening clinical status. Lower Right: Photomicrograph of S-100—stained tumor tissue demonstrating typical pathological features of an acoustic neuroma. Necrosis within the acoustic neuroma was not visualized. Original magnification × 100.

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    Axial T1- and T2-weighted MR images obtained 7 years after translabyrinthine and middle fossa resection of an acoustic neuroma, demonstrating a stable and asymptomatic pseudomeningocele and T2-weighted postoperative signal changes in the inferomesiotemporal lobe, with no evidence of VS recurrence or development of a new neoplasm in the adjacent region.

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    Axial CT contrast scans obtained a few months after the MR image in Fig. 2, demonstrating an enhancing cystic lesion in the right temporal lobe, with an enhancing mural nodule, mass effect, and midline shift. The enhancing nodule, which was confirmed to be a GBM at surgery, received 4 Gy of radiation (corresponding to the 14% isodose curve) from GKS, as shown in Fig. 1 upper left. After emergency debulking of this GBM nodule and subsequent external-beam radiation, the tumor recurred within 3 weeks, as seen on the gadolinium-enhanced MR image (lower right).

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    A and B: Paraffin sections (6 µm) stained with H & E (A) demonstrating increased numbers of oval-shaped pleomorphic glial fibrillary acidic protein—positive astrocytoma cells (B) obtained in the right temporal astrocytoma (shown in Fig. 3). C: Staining of the astrocytoma with Ki-67 demonstrating a labeling index of 10 to 15%. D: Staining with terminal deoxynucleotidyl transferase—mediated deoxyuridine triphosphate nick-end labeling, demonstrating apoptotic cells (arrowheads) around large areas of nearby necrosis (N) in the GBM specimen. E and F: Factor VIII positivity of the endothelium (E), and increased vascular endothelial growth factor expression by the astrocytoma cells (arrowheads), associated with increased tumor angiogenesis of the GBM specimen. Original magnification × 200.

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