Multiple subtentorial metastasis in diffuse midline glioma receiving tumor treating fields: a case report and literature review

Abstract

Diffuse midline glioma (DMG) is one of fatal glioblastoma multiforme (GBM) with no proven medical therapies. Tumor treating fields (TTFields) is a new revolutionary therapy for GBM which prolongs the overall survival time obviously. However, we can observe more tumor growth phenomena (such as distant multiple metastases) than before. This report describes an adult patient who presented headache and dizziness, accompanied by left limb weakness, nausea, and vomiting following car accident trauma, following imaging examinations suggested thalamus GBM. He was treated with subtotal excision. Final pathology was diagnosed as DMG with H3F3A mutation, isocitrate dehydrogenase (IDH) wild type. Following concurrent chemoradiation therapy (CCRT) and adjuvant temozolomide (TMZ) chemotherapy + TTFields therapy were carried out. Supratentorial tumor has been exhibited a partial radiological response for nine months until TTFields was used irregularly or even discontinued in the later stage. Especially, subtentorial and spinal multiple metastasis occurred during this time. Both supratentorial and subtentorial tumors were treated with surgery, radiotherapy, chemotherapy, even targeted drugs, with the only difference being TTFields, but we could see different consequences for tumor growth. One conclusion might be drawn that TTFields can provide a longer survival time (14 vs. 8 months reported before) for DMG patients and improve survival benefits. However, we can observe that patients maybe die from subtentorial metastasis because TTFields could not cover the subtentorial tumors, which is the focal challenge at present. So further research on subtentorial tumors with TTFields is urgently needed.

Fulminant hemorrhagic course of a thalamic H3 K27-altered diffuse midline glioma in an adult patient: illustrative case

“… 25 , 26 However, pediatric and spinal H3 K27–mutant DMGs seem to exhibit more intratumoral hemorrhages. 27–29 In rare cases, H3 K27–altered DMGs are associated with gliomatosis cerebri growth pattern, 20 multifocal manifestations, 14 , 15 , 19 and metastases located outside the central nervous system. 13 …”

“…Of 89 identified publications, 19 met the inclusion criteria (Supplemental Table 1). 3,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] The study identification and selection process are outlined in the PRISMA flowchart (Supplemental Fig. 1).…”

“…25,26 However, pediatric and spinal H3 K27-mutant DMGs seem to exhibit more intratumoral hemorrhages. [27][28][29] In rare cases, H3 K27-altered DMGs are associated with gliomatosis cerebri growth pattern, 20 multifocal manifestations, 14,15,19 and metastases located outside the central nervous system. 13 Regarding the surgical management of adult H3 K27-altered DMGs, subtotal/partial tumor resection and biopsy were the most common procedures, which is not surprising, given the highly eloquent location of these tumors.…”

Regulation of cancer stem cells and immunotherapy of glioblastoma (Review)

“…The severity of the condition of the patient, a functional status <70 on the Karnofsky scale, or subtentorial, thalamic, multifocal or bihemispheric localization of the tumor often render it impossible to treat the condition surgically without a direct risk to the life of the patient, and make a strong case for the refusal of surgery in patients with newly diagnosed GB ( 16 , 17 ). Moreover, brain tissue infiltration by CCs, even with the use of the most modern surgical technologies, does not allow the radical removal of the tumor without causing severe and irreparable neurological damage to the patient ( 18 , 19 ).…”