Unraveling morphology, methylation profiling, and diagnostic challenges in BRAF-Mutant pediatric glial and glioneuronal tumors.

OBJECTIVES: To elucidate the relationship between DNA methylation profiling (DMP) and pathological diagnosis (PD) in pediatric glial and glioneuronal tumors with B-Raf proto-oncogene, serine/threonine kinase (BRAF) mutations, addressing their diagnostic challenges. METHODS: This retrospective study, conducted in Saudi Arabia, analyzed 47 cases from the Children's Brain Tumor Network online database using scanned images, next-generation sequencing data, and methylation profiles processed using the Heidelberg methylation brain tumor classifiers v12.5 and v12.8. The data was last access on 10 November 2023. RESULTS: The highest prevalence of BRAF mutations was observed in pilocytic astrocytoma and ganglioglioma. The DMP was consistent with PD in 23 cases, but discrepancies emerged in others, including diagnostic changes in diffuse leptomeningeal glioneuronal tumor and polymorphous low-grade neuroepithelial tumor of the young. A key inconsistency appeared between a pilocytic astrocytoma MC and a glioneuronal tumor PD. Two high-grade astrocytomas were misclassified as pleomorphic xanthoastrocytomas. Additionally, low variant allelic frequency in gangliogliomas likely contributed to misclassifications as control in 5 cases. CONCLUSION: This study emphasized the importance of integrating DMP with PD in diagnosing pediatric glial and glioneuronal tumors with BRAF mutations. Although DMP offers significant diagnostic insights, its limitations, particularly in cases with low tumor content, necessitate cautious interpretation, as well as its use as a complementary diagnostic tool, rather than a definitive method.

Imaging manifestations of papillary glioneuronal tumors.

To analyse the imaging findings of papillary glioneuronal tumors (PGNTs), in order to improve the accuracy of preoperative diagnosis of this tumor. The clinical and imaging manifestations of 36 cases of PGNT confirmed by pathology were analyzed retrospectively. A total of 17 males and 19 females, averaging 22.47 (± 11.23) years. Initial symptoms included epilepsy in ten, headache in seven, and others in 19 cases. 97.2% (35/36) of the lesions were located in the supratentorial area, and 80.5% (29/36) in the intraventricular or deep white matter adjacent to the lateral ventricles. Twenty-four of the lesions (66.7%) were mixed cystic and solid, four (11.1%) were cystic with mural nodules, four (11.1%) were cystic, and four (11.1%) were solid. Four cases of PGNT of cystic imaging showed a "T2-FLAIR mismatch" sign. 69.4% (25/36) had septations. Nine lesions (25%) were accompanied by edema, and 9 (25%) of the mixed cystic and solid lesions were accompanied by hemorrhage. Among the 18 patients who underwent computed tomography (CT) or susceptibility-weighted imaging (SWI), nine had lesions with calcification. PGNTs mostly manifest as cystic mass with mural nodules or mixed cystic and solid mass in the white matter around the supratentorial ventricle, and the cystic part of the lesion is mostly accompanied by septations. Pure cystic lesions may exhibit the sign of "T2-FLAIR mismatch". PGNT is rarely accompanied by edema but sometimes by calcification and hemorrhage. Patients often present with seizures, headaches, and mass effect symptoms.

Middle temporal gyrus approach to mesial temporal lobe tumours in children.

AIM OF THE STUDY: To assess whether the middle temporal gyrus (MTG) approach to mesial temporal lobe (MTL) tumours is an effective procedure for the treatment of epilepsy in children. CLINICAL RATIONALE FOR THE STUDY: MTL tumours are a common cause of drug-resistant epilepsy in children. There is as yet no consensus regarding their treatment. One possibility is resection via a MTG approach. MATERIAL AND METHODS: We assessed the medical records of patients treated at the Department of Neurosurgery, Children's Memorial Health Institute,Warsaw, Poland between 2002 and 2020. A prospectively maintained database including clinical, laboratory, and radiographic presentation, as well as pre- and post-operative course, was analysed. Patients with at least a one- -year follow-up were included. RESULTS: There were 14 patients aged 4-18 years who underwent a MTG approach for a MTL tumour. All presented with epileptic seizure, and none had neurological deficit on admission to hospital. Median follow-up was 2.5 years. Neuronavigation was used to adjust the approach, localise the temporal horn, and achieve radical resection of the tumour and the hippocampus. Gross total resection was performed in all cases. In most patients, histopathological examination revealed ganglioglioma. One patient had transient aphasia. Two patients developed hemiparesis after surgery, which later improved. One of them also experienced visual disturbances. Acute complications were more frequent in younger patients (p = 0.024). In all cases, MRI confirmed complete resection and there was no tumour recurrence during the follow-up period. 13/14 patients remained seizure-free (Engel class I). CONCLUSIONS AND CLINICAL IMPLICATIONS: The MTG approach to MTL tumours is an effective procedure for the treatment of epilepsy in children. It avoids removal of the lateral temporal lobe and poses only a minor risk of permanent neurological complications.

Nomograms Based on MRI Radiomics for Differential Diagnosis and Predicting BRAFV600E Expression in Pleomorphic Xanthoastrocytoma and Ganglioglioma.

RATIONALE AND OBJECTIVES: This study was designed to investigate the value of nomograms based on MRI radiomics and clinical semantic features in identifying pleomorphic xanthoastrocytoma (PXA) and ganglioglioma (GG) as well as predicting BRAFV600E expression. MATERIALS AND METHODS: This study included 265 patients histologically diagnosed with PXA (n = 113) and GG (n = 152). T1WI, T2WI, and CET1 sequences were utilized to extract radiomics features. Univariate analysis, Spearman correlation analysis, and the least absolute shrinkage and selection operator were used for dimensionality reduction and feature selection. Following this, logistic regression was utilized to establish the radiomics model. Univariate and multivariate analyses of clinical semantic features were applied, and clinical models were constructed. The nomograms were established by merging radiomics and clinical features. Furthermore, ROC curve analysis was used for examining the model performance, whereas the decision curve analysis (DCA) examined the clinical utility of the nomograms. RESULTS: Nomograms achieved the best predictive efficacy compared to clinical and radiomics models alone. Concerning the differentiation between PXA and GG, the area under the curve (AUC) values of the nomogram were 0.879 (0.828-0.930) and 0.887 (0.805-0.969) for the training and testing cohorts, respectively. For predicting BRAFV600E expression, the AUC values of the nomogram were 0.873 (0.811-0.936) and 0.851 (0.740-0.963) for the training and testing cohorts, respectively. DCA confirmed the clinical utility of the nomograms. CONCLUSION: Nomograms based on radiomics and clinical semantic features were noninvasive tools for differential diagnosis of PXA and GG and predicting BRAFV600E expression, which may be helpful for assessing patient prognosis and developing individualized treatment strategies.

MRI characteristics predict BRAF V600E status in gangliogliomas and pleomorphic xanthoastrocytomas and provide survival prognostication.

BACKGROUND: BRAF V600E mutation is a common genomic alteration in gangliogliomas (GGs) and pleomorphic xanthoastrocytomas (PXAs) with prognostic and therapeutic implications. PURPOSE: To investigate the ability of magnetic resonance imaging (MRI) features to predict BRAF V600E status in GGs and PXAs and their prognostic values. MATERIAL AND METHODS: A cohort of 44 patients with histologically confirmed GGs and PXAs was reviewed retrospectively. BRAF V600E status was determined by immunohistochemistry (IHC) staining and fluorescence quantitative polymerase chain reaction (PCR). Demographics and MRI characteristics of the two groups were evaluated and compared. Univariate and multivariate Cox regression analyses were performed to identify MRI features that were prognostic for progression-free survival (PFS). RESULTS: T1/FLAIR ratio, enhancing margin, and mean relative apparent diffusion coefficient (rADCmea) value showed significant differences between the BRAF V600E-mutant and BRAF V600E-wild groups (all P < 0.05). Binary logistic regression analysis revealed only rADCmea value was the independent predictive factor for BRAF V600E status (P = 0.027). Univariate Cox regression analysis showed age at diagnosis (P = 0.032), WHO grade (P = 0.020), enhancing margin (P = 0.029), and rADCmea value (P = 0.005) were significant prognostic factors for PFS. In multivariate Cox regression analysis, increasing age (P = 0.040, hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 1.002-1.079) and lower rADCmea values (P = 0.021, HR = 0.036, 95% CI = 0.002-0.602) were associated with poor PFS in GGs and PXAs. CONCLUSION: Imaging features are potentially predictive of BRAF V600E status in GGs and PXAs. Furthermore, rADCmea value is a valuable prognostic factor for patients with GGs or PXAs.

Unusual Locations of Gangliogliomas: Intraventricular and Posterior Fossa.

AIM: To report a series of patients diagnosed with gangliogliomas (GG) in unusual locations; and to review the clinical and imaging features as well as surgical treatment and outcomes. MATERIAL AND METHODS: A series of consecutive patients who underwent surgery for GGs at unusual locations, such as intraventricular region and posterior fossa, from 2010 to 2022 were included in the study. RESULTS: Nine patients with GGs located in unusual areas, one in the intraventricular region and 8 in the posterior fossa, were included. There were 5 males and 4 females, with a mean age 31±8.5 years. We performed GTR in 6 cases and STR in 3 cases. Seven tumors were grade I WHO while the remaining two were anaplastic. Five patients also had preoperative hydrocephalus. We found a positive correlation between midline GG of the posterior fossa and solid aspect of the tumor (p=0.05). Univariate analysis found no other statistically significant associations, but this was due to the small patient sample. Recurrence was seen in 2 cases with STR, after 1 and 10 years, respectively. CONCLUSION: GG should be considered in the differential diagnosis of patients with tumors in the intraventricular region or posterior fossa. Maximal tumor resection and restoration of CSF flow pathways ensure a good outcome. Growth patterns correlate with resection and can help choose the best candidates for surgery. However, further studies on large patient samples are needed.

A rare tumor in the sellar region: ganglioglioma, a case report and a general overview.

BACKGROUND: Gangliogliomas are rare mixed neuronal-glial tumors of the central nervous system, accounting for less than 2% of intracranial tumors. CASE DESCRIPTION: This report presents a rare case of ganglioglioma in the sellar region of a 3-year-old and 5-month-old pediatric patient. The patient underwent surgical intervention initially through a transnasal transsphenoidal approach and subsequently through a transcranial pterional craniotomy approach. Subsequently, radiotherapy and chemotherapy were administered for residual tumor tissue. The purpose of this report is to highlight the presence of ganglioglioma as a distinct diagnosis in sellar region tumors, discuss the surgical, radiotherapy, and/or chemotherapy treatment options for sellar region gangliogliomas based on the literature, and contribute the patient's follow-up and treatment outcomes to the existing literature. CONCLUSION: Complete tumor resection may not be feasible in sellar region gangliogliomas, especially in pediatric cases, due to endocrinological and vision-related complications. In cases where complete resection is not possible, radiotherapy and/or chemotherapy may be considered. However, the optimal treatment approach has not yet been established, and further research is needed.

Vestibular seizures and spontaneous downbeat nystagmus of ganglioglioma origin: a case report.

BACKGROUND: Low-grade gangliogliomas (GGs) are typically epileptogenic intracranial neoplasms. Yet, the presentation of simplex vertiginous experience and spontaneous downbeat nystagmus (DBN) has not been reported to date. CASE PRESENTATION: We present the case of a 26-year-old male with focal onset impaired awareness seizures, characterized by vertigo due to right temporal lobe epilepsy caused by ganglioglioma. As rare presentations, a spontaneous, consistent DBN in the absence of vertiginous experience was noticed. MRI suggested lesion in the right temporal pole. Twenty-four-hour continuous electroencephalogram (EEG) monitoring recorded periodic sharp and slow waves, originating from the right temporal lobe. The patient was completely relieved of the symptoms after surgical removal of the tumor, which was histologically confirmed as Grade I Ganglioglioma. CONCLUSIONS: Asides from the cortical pathogenesis of epileptic vertigo, this case also provides insight into the DBN secondary to tumor of the temporal lobe. Moreover, the 24-h EEG is advantageous to recognize vestibular seizures and localize the ictal onset areas.

A unique case of intracranial collision tumor composed of ganglioglioma WHO gr I and supratentorial ependymoma WHO gr III: case-based literature review.

PURPOSE: Intracranial collision tumor is a rare entity that represents the coexistence of two histopathological different tumor types in the same area without histological admixture or an intermediate cell population zone. So far, several cases of collision tumors with ganglioglioma as its component have been reported in the literature, while supratentorial ependymoma has never been reported as a collision tumor component. We are presenting a unique case of collision tumor in patient without previous history of head trauma, neurological surgery, radiotherapy, or phakomatosis. METHODS AND RESULTS: A 17-year-old male with no previous history of head trauma, neurological surgery, radiotherapy, or phakomatosis was presented to our clinic with grand mal seizure. Brain magnetic resonance imaging with gadolinium contrast was done revealing a contrast-enhancing lesion of right frontal lobe closely related to dura, surrounded by perifocal edema. The patient underwent a gross total tumor resection. Histological examination revealed collision tumor with two distinct components: ganglioglioma and supratentorial ependymoma. CONCLUSION: To our best knowledge, no previous reports of collision tumor composed of ganglioglioma and supratentorial ependymoma in a single patient have been reported. We believe that this report could significantly contribute to further surgical practice as well as to treatment decision for these types of collision tumors.

Genomic and epigenomic re-categorization of congenital glioblastoma and desmoplastic infantile ganglioglioma.

INTRODUCTION: The recently updated World Health Organization classification of central nervous system (CNS) tumors, 5th edition, (CNS5) reclassifies pediatric tumors according to their distinct molecular drivers, recognizing a new entity-infant-type hemispheric glioma (IHG). Defined by its unique epigenetic signature, and/or genomic fusions in ALK, ROS1, NTRK, or MET gene, IHG subsumes many cases previously classified as congenital glioblastoma (cGBM). Histologic features of IHG are still poorly defined with known overlap with a clinic radiologically similar entity-desmoplastic infantile ganglioglioma/astrocytoma (DIG). METHODS: We revisited our cohort of cGBMs and DIGs, now reclassifying them according to CNS5 and compared the clinical, radiologic, molecular and histologic features between the two. RESULTS: 3/6 cases of cGBM that underwent targeted NGS fusion mutation panel were positive for ALK fusions (involving MAP4, MZT2Bex2, and EML4 genes as fusion partners), and 1/6 showed GOPC:ROS1 fusion. Interestingly, GOPC:ROS1 fusion was also shared by 1/5 cases of histologically defined DIG. DNA methylation profiling using the Heidelberg classifier (v12.3) recategorized 2/5 DIG cases as IHG (including the case with ROS1 alteration). CONCLUSION: In conclusion, histology alone is insufficient to distinguish IHG from DIG, necessitating epigenomic and genomic testing for the diagnosis of early-life gliomas.

Spinal anaplastic ganglioglioma.

Anaplastic gangliogliomas of the spinal cord are extremely rare with only four cases reported in the literature. Here we present the case of a 22-year-old female who presented acutely with quadraparesis and urinary retention. Radiographic imaging demonstrated an intramedullary lesion within the cervical spine. She underwent a cervical laminectomy and resection of the lesion under neurophysiological monitoring. Post-operatively, she regained some function, but remained paraparetic. Histopathology demonstrated an anaplastic ganglioglioma (WHO Grade 3). She subsequently underwent radiotherapy. Following surgery, she remained stable and had MRC Grade 3 Power in all four limbs. Herein, we describe a previously undescribed case of cervical anaplastic ganglioglioma and review the existing literature.

Suprasellar Ganglioglioma Arising from the Third Ventricle Floor: A Case Report and Review of the Literature.

Gangliogliomas are uncommon intracranial tumors that include neoplastic and abnormal ganglion cells, and show positive immunohistochemical staining for GFAP and syn. This type of lesion occurs more frequently in the temporal lobe than in other areas; they are extremely rare in the suprasellar region. To the best of our knowledge, including our case, 19 cases of GGs have been found in the suprasellar region. Among them, five tumors invaded the optic nerve, nine tumors invaded the optic chiasm, one tumor invaded the optic tract, and two tumors invaded the entire optic chiasmal hypothalamic pathway. In the present study, we describe the first case of suprasellar GGs arising from the third ventricle floor that was removed through the endoscopic endonasal approach. In addition, we summarize the clinical characteristics of GGs, such as age of onset, gender distribution, MRI signs, main clinical symptoms, and treatment methods for GG cases.

Uncommon Glioneuronal Tumors: A Radiologic and Pathologic Synopsis.

Glioneuronal tumors are characterized exclusively by neurocytic elements (neuronal tumors) or a combination of neuronal and glial features (mixed neuronal-glial tumors). Most of these tumors occur in young patients and are related to epilepsy. While ganglioglioma, dysembryoplastic neuroepithelial tumor, and desmoplastic infantile tumor are common glioneuronal tumors, anaplastic ganglioglioma, papillary glioneuronal tumor, rosette-forming glioneuronal tumor, gangliocytoma, and central neurocytoma are less frequent. Advances in immunohistochemical and molecular diagnostics have improved the characterization of these tumors and favored the description of variants and new subtypes, some not yet classified by the World Health Organization. Not infrequently, the histologic findings of biopsies of glioneuronal tumors simulate low-grade glial neoplasms; however, some imaging findings favor the correct diagnosis, making neuroimaging essential for proper management. Therefore, the aim of this review was to present key imaging, histopathology, immunohistochemistry, and molecular findings of glioneuronal tumors and their variants.

Peritoneal metastasis of a brainstem anaplastic ganglioglioma in a 2-year-old boy: case report and literature review.

Anaplastic gangliogliomas (AGG) are rare tumors of the central nervous system (CNS) that commonly affect children and young adults, with an unusual infratentorial presentation, which is related to hydrocephalus and a worse prognosis. We report a case of a brainstem AGG in a 2-year-old boy who underwent a ventriculoperitoneal shunting (VPS) and later presented peritoneal metastasis. We also reviewed the related literature. Even though rare, disease dissemination through VPS should be sought in patients with CNS tumors and VPS who develop new abdominal symptoms. The early diagnosis and intervention may minimize morbidity and improve quality of life of such patients.

Gamma Knife radiosurgery as salvage therapy for gangliogliomas after initial microsurgical resection.

INTRODUCTION: Gangliogliomas (GG) are considered WHO grade I rare tumors. While they commonly manifest as temporal lobe epilepsy, they can be located anywhere in the brain. Primary treatment is complete microsurgical resection. Remnant or recurrent GG can benefit from radiation therapy. Here, we present a series of GG who received Gamma Knife radiosurgery (GKR) after initial microsurgery. METHODS: Between October 2009 and February 2020, four patients benefitted from such approach. The median age at surgery was 16 years (mean 17, 11-25) and at the time of GKR was 22.5 years (mean 23, 19-28). Initial clinical symptom was epilepsy in 3 cases and incidental in one. Biopsy was firstly performed in one case. One patient had stereotactic electroencephalography. The respective anatomical locations were right parieto-occipital, sylvian, left paraventricular and left inferior parietal. RESULTS: Gamma Knife radiosurgery was performed after a median time of 3.5 years after initial gross total microsurgical resection (GTR). The median follow-up after GKR was 54 months (mean 58.5, 6-120). The median marginal dose was 18 Gy (mean 17.5, 16-18). The median target volume was 0.5 mL (mean 0.904, 0.228-2.3). The median prescription isodose volume was 0.6 mL (mean 0.9, 0.3-2.4). At last follow-up, GG majorly decreased in 3 patients, remained stable in one. CONCLUSION: Gamma Knife radiosurgery is safe and effective for remnant GG after GTR. Primary treatment remains microsurgical resection, especially in cases with symptomatic mass effect or with epilepsy. Single fraction GKR can be a valuable option for remnant or recurrent tumors after initial resection.

Ganglioglioma espinal intramedular: caso clínico y revisión comparativa de la literatura / Intramedullary spinal cord ganglioglioma: Case report and comparative literature review

Introducción Los gangliogliomas espinales intramedulares (GGEI) representan el 35-40% de todos los tumores intramedulares en niños. Estos tumores presentan un algoritmo terapéutico y pronóstico diferente con respecto a otros tumores medulares, tales como los astrocitomas o los ependimomas espinales. El objetivo del estudio es revisar la literatura para esclarecer una vía diagnóstica y terapéutica de dicho tumor en base a un caso clínico de GGEI diagnosticado en nuestro centro. Método Se ha realizado una revisión literaria exhaustiva de los GGEI publicados desde 1911 hasta 2018 a través de la plataforma PubMed-NCBI, adjuntando de cada paciente, las características epidemiológicas, la localización, la clínica, el diagnóstico radiológico y el tratamiento. Resultados Se encontraron un total de 167 casos de GGEI, incluyendo nuestro caso. En nuestra muestra, el 52% de los pacientes pertenece al sexo femenino, siendo la década de edad más afectada la que va de los 0 a los 9 años (35% de los pacientes). El déficit motor se establece como síntoma principal en pacientes adultos en mayor proporción que en pacientes pediátricos. Radiológicamente, este tumor se presenta con mayor hiperintensidad y captación de contraste que los astrocitomas y los ependimomas, así como un mayor porcentaje de quistes intratumorales. La mutación BRAFV600E es menos frecuente en los gangliogliomas espinales que en los supratentoriales. La cirugía con resección total es el tratamiento de elección. Solamente el 19% de los pacientes de la muestra recibieron radioterapia y solo el 9% quimioterapia como única vía de tratamiento. Conclusiones Los GGEI son frecuentes en la población pediátrica y requieren de un alto nivel de sospecha para su correcto diagnóstico y tratamiento, ya que tienen 3 veces más riesgo de recurrencia que sus homólogos supratentoriales (AU)

Introduction Intramedullary spinal cord gangliogliomas (ISCGGs) account for 35-40% of all intramedullary tumors in children. These tumors have a different algorithm for treatment and prognosis than other medullary tumors, such as astrocytomas and spinal ependymomas. The objective of the study was to review the literature and examine an approach to diagnosing and treating this tumor based on a case report of ISCGG diagnosed at our center. Method An exhaustive review of cases of ISCGG published via the PubMed-NCBI platform between 1911 and 2018 was performed, and each patient's epidemiological characteristics, tumor location, symptoms, radiological diagnosis and treatment were appended. Results A total of 167 cases of ISCGG were found, including our own. In our sample, 52% of patients were female and the most commonly affected age group was 0-9 years of age (35% of patients). Motor deficit has been found to be the main symptom in a larger proportion of adults patients versus pediatric patients. On X-ray, this tumor shows greater hyperintensity and contrast uptake than astrocytomas and ependymomas, as well as a higher percentage of intratumoral cysts. The BRAFV600E mutation is less common in spinal as opposed to supratentorial gangliogliomas. Surgery with complete resection is the treatment of choice. Only 19% of the patients in the sample received radiotherapy, and only 9% received chemotherapy as their only line of treatment. Conclusions ISCGGs are common in the pediatric population and require strong suspicion for proper diagnosis and treatment, as the risk of recurrence of ISCGGs is 3 times greater than that of supratentorial gangliogliomas (AU)