Treatment for posterior fossa dissemination of primary supratentorial glioma

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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).


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).


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:

© AANS, except where prohibited by US copyright law.



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    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.

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    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.


  • 1

    Arita NTaneda MHayakawa T: Leptomeningeal dissemination of malignant gliomas. Incidence, diagnosis and outcome. Acta Neurochir (Wien) 126:84921994

  • 2

    Awad IBay JWRogers L: Leptomeningeal metastasis from supratentorial malignant gliomas. Neurosurgery 19:2472511986

  • 3

    Brew BJGarrick R: Gliomas presenting outside the central nervous system. Clin Exp Neurol 23:1111171987

  • 4

    Bryan P: CSF seeding of intra-cranial tumors: a study of 96 cases. Clin Radiol 25:3553601974

  • 5

    Burton ECPrados MD: Malignant gliomas. Curr Treat Options Oncol 1:4594682000

  • 6

    Cairns HRussell DS: Intracranial and spinal metastases in glioma of the brain. Brain 54:3774201931

  • 7

    Chang SMParney IFHuang WAnderson FA JrAsher ALBernstein M: Patterns of care for adults with newly diagnosed malignant glioma. JAMA 293:5575642005

  • 8

    Cohen ZRHassenbusch SJMaor MHPfeffer RMRam Z: Intractable vomiting from glioblastoma metastatic to the fourth ventricle: three case studies. Neurooncol 4:1291332002

  • 9

    Davila GDuyckaerts CLazareth JPPoisson MDelattre JY: Diffuse primary leptomeningeal gliomatosis. J Neurooncol 15:45491993

  • 10

    Fujimura MKumabe TJokura HShirane RYoshimoto TTominaga T: Intractable vomiting as an early clinical symptom of cerebrospinal fluid seeding to the fourth ventricle in patients with high-grade astrocytoma. J Neurooncol 66:2092162004

  • 11

    Grabb PAAlbright ALPang D: Dissemination of supratentorial malignant gliomas via the cerebrospinal fluid in children. Neurosurgery 30:64711992

  • 12

    Hamilton MGTranmer BIHagen NA: Supratentorial glioblastoma with spinal cord intramedullary metastasis. Can J Neurol Sci 20:65681993

  • 13

    Herman CKupsky WJRogers LDuman RMoore P: Leptomeningeal dissemination of malignant glioma simulating cerebral vasculitis. Case report with angiographic and pathological studies. Stroke 26:236623701995

  • 14

    Kaplan EMeier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:4574811958

  • 15

    Kato HFujimura MKumabe TIshioka CKanamaru RYoshimoto T: PTEN gene mutation and high MIB-1 labeling index may contribute to dissemination in patients with glioblastoma. J Clin Neurosci 11:37412004

  • 16

    Kleihues PLouis DNScheithauer BWRorke LBReifenberger GBurger PC: The WHO classification of tumors of the nervous system. J Neuropathol Exp Neurol 61:2152292002

  • 17

    Koch D: Spinal metastases of cerebral glioma. Case report. Neurosurg Rev 19:2012031996

  • 18

    Kocher MTreuer HVoges JHoevels MSturm VMuller RP: Computer simulation of cytotoxic and vascular effects of radio-surgery in solid and necrotic brain metastases. Radiother Oncol 54:1491562000

  • 19

    Kyritsis APLevin VAYung WKLeeds NE: Imaging patterns of multifocal gliomas. Eur J Radiol 16:1631701993

  • 20

    Lamborn KRChang SMPrados MD: Prognostic factors for survival of patients with glioblastoma: recursive partitioning analysis. Neurooncol 6:2272352004

  • 21

    Laperriere NZuraw LCairncross G: Radiotherapy for newly diagnosed malignant glioma in adults: a systematic review. Radiother Oncol 64:2592732002

  • 22

    Laws ERParney IFHuang WAnderson FMorris AMAsher A: Survival following surgery and prognostic factors for recently diagnosed malignant glioma: data from the Glioma Outcomes Project. J Neurosurg 99:4674732003

  • 23

    Leith JTCook SChougule PCalabresi PWahlberg LLindquist C: Intrinsic and extrinsic characteristics of human tumors relevant to radiosurgery: comparative cellular radiosensitivity and hypoxic percentages. Acta Neurochir Suppl62:18271994

  • 24

    Louis DN: A molecular genetic model of astrocytoma histopathology. Brain Pathol 7:7557641997

  • 25

    Maria BLCafferty LLSinger HSEpstein JICarson BS: Diffuse leptomeningeal seeding from a malignant spinal cord astrocytoma in a child with neurofibromatosis. J Neurooncol 4:1591631986

  • 26

    Moonis MSmith TW: Meningeal gliomatosis presenting as multiple cerebral infarcts: a case report. Neurology 46:176017621996

  • 27

    Moore MTEisinger G: Extra primary seeding of glioblastoma multiforme in the subarachnoid space and ependyma. Neurology 13:8558651963

  • 28

    Okunieff PHoeckel MDunphy EPSchlenger KKnoop CVaupel P: Oxygen tension distributions are sufficient to explain the local response of human breast tumors treated with radiation alone. Int J Radiat Oncol Biol Phys 26:6316361993

  • 29

    Onda KTanaka RTakahashi HTakeda NIkuta F: Cerebral glioblastoma with cerebrospinal fluid dissemination: a clinico-pathological study of 14 cases examined by complete autopsy. Neurosurgery 25:5335401989

  • 30

    Onda KTanaka RTakahashi HTakeda NIkuta F: Symptomatic cerebrospinal fluid dissemination of cerebral glioblastoma. Computed tomographic findings in 11 cases. Neuroradiology 32:1461501990

  • 31

    Pang DAshmead JW: Extraneural metastasis of cerebellar glioblastoma multiforme. Neurosurgery 10:2522571982

  • 32

    Parsa ATWachhorst SLamborn KRPrados MDMcDermott MWBerger MS: Prognostic significance of intracranial dissemination of glioblastoma multiforme in adults. J Neurosurg 102:6226282005

  • 33

    Pasquier BPasquier DN'Golet APanh MHCouderc P: Extra-neural metastases of astrocytomas and glioblastomas: clinico-pathological study of two cases and review of literature. Cancer 45:1121251980

  • 34

    Perry AJenkins RBO'Fallon JRSchaefer PLKimmel DWMahoney MR: Clinicopathologic study of 85 similarly treated patients with anaplastic astrocytic tumors. An analysis of DNA content (ploidy), cellular proliferation, and p53 expression. Cancer 86:6726831999

  • 35

    Polmeteer FEKernohan JW: Meningeal gliomatosis: a study of 42 cases. Arch Neurol Psychiatry 57:5936161947

  • 36

    Sadik ARPort RGarfinkel BBravo J: Extracranial metastasis of cerebral glioblastoma multiforme: case report. Neurosurgery 15:5495511984

  • 37

    Saito RKumabe TJokura HShirane RYoshimoto T: Symptomatic spinal dissemination of malignant astrocytoma. J Neurooncol 61:2272352003

  • 38

    Simmons MLLamborn KRTakahashi MChen PIsrael MABerger MS: Analysis of complex relationships between age, p53, epidermal growth factor receptor, and survival in glioblastoma patients. Cancer Res 61:112211282001

  • 39

    Smith JSJenkins RB: Genetic alterations in adult diffuse glioma: occurrence, significance, and prognostic implications. Front Biosci 5:D213D2312000

  • 40

    Smith JSTachibana IPasse SMHuntley BKBorell TJIturria N: PTEN mutation, EGFR amplification, and outcome in patients with anaplastic astrocytoma and glioblastoma multiforme. J Natl Cancer Inst 93:124612562001

  • 41

    Sneed PKGutin PHLarson DAMalec MKPhillips TLPrados MD: Patterns of recurrence of glioblastoma multiforme after external irradiation followed by implant boost. Int J Radiat Oncol Biol Phys 29:7197271994

  • 42

    Stupp RMason WPvan den Bent MJWeller MFisher BTaphoorn MJ: Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:9879962005

  • 43

    Vertosick FT JrSelker RG: Brain stem and spinal metastases of supratentorial glioblastoma multiforme: a clinical series. Neurosurgery 27:5165221990

  • 44

    Wallace CJForsyth PAEdwards DR: Lymph node metastases from glioblastoma multiforme. AJNR Am J Neuroradiol 17:192919311996

  • 45

    Watanabe KTachibana OSata KYonekawa YKleihues POhgaki H: Overexpression of the EGF receptor and p53 mutations are mutually exclusive in the evolution of primary and secondary glioblastomas. Brain Pathol 6:2172241996




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