Malignant astrocytoma following radiotherapy for craniopharyngioma

1985, The British Journal of Radiology, 58, 480-482 Case reports TREUNER, J., FEURE, U., NIETHAMMER, D., MULLER- SCHAUMBERG, W., MEINKE, J., ElBACH, E., DOPFER, R., KLINGEBUL, TH. & GRUMBECH, ST., 1984. Scintigraphic imaging of neuroblastoma with 131 I iodo-benzyl-guanidine. Lancet, i, 333-334. WIELAND, D. ML, Wu, J-L., BROWN, L. E., MANGNER, T. J., SWANSON, D. P. & BEIERWALTES, W. H., 1980. Radiolabelled adrenergic neurone-blocking agents: adrenomedullary imaging with 131 I-iodobenzyl-guanidine. Journal of Nuclear Medicine, 21, 349-353. Malignant astrocytoma following radiotherapy for craniopharyngioma By *M. L C. Maat-Schieman, M.D., tG. T. A. M. Bots, M.D., §R. T. W. M. Thomeer, M.D. and tG. J. Vielvoye, M.D. Departments of 'Neurology, tPathology, §Neurosurgery and iNeuroradiology, Leiden University Hospital, The Netherlands (Received July 1984 and in revised form November 1984) Although the human adult brain is considered to be 10 times less sensitive to cancer induction by radiation than the bone marrow (ICRP, 1969) a relationship between X-ray therapy and subsequent intracranial sarcoma (Martin et al, 1980; Shin et al, 1980; Gerlach & Janisch, 1979; Schratz & Araoz, 1972; Noetzli & Malamud, 1962) and meningioma (Gomori & Shaked, 1982; Spallone, 1982; Iacono et al, 1981) has often been suggested in the literature. Few reports concern the possible association of human glioma and previous radiotherapy. The following case report describes a boy with a malignant astrocytoma in the mid-line of the cerebellum 14 years after X-ray therapy for craniopharyngioma. In our hospital this is the first case of a suspected radiation-induced brain tumour in 66 patients treated for cranial lesions by radiotherapy between 1969 and 1979 who have survived more than 5 years. CASE REPORT In March, 1969, this 5-year-old boy presented with left oculomotor nerve paresis and a history of headache and occasional vomiting for the past year. X-ray examination revealed a calcined suprasellar mass, most likely a craniopharyngioma. As the tumour was considered to be inoperable at that time, he was treated by 60 Co irradiation (60 Gy in 7 weeks in a 7 x 9.5 cm lateral field and in 5 x 6 cm postero- anterior and antero-posterior fields). He did well until March 1983, when he started to complain of headache, dizziness and difficulty in walking. CT scanning showed an enlarged sella turcica and intra- and suprasellar calcifications compatible with craniopharyngioma, but also in the roof of the fourth ventricle a tumour mass with a ring enhancement after IV contrast-administration, suggesting the possibility of a high- grade glioma. At the end of April, 1983, a cystic tumour presenting subcortically in the superior part of the vermis cerebelli was partially resected. Histopathological examination showed a very cellular tumour, infiltrating the cerebellar tissue. Tumour cells had scanty and ill-defined cytoplasm, their nuclei showed considerable pleiomorphism and variable hyperchromasia. Mitoses were abundant. Blood-vessel proliferation and scattered foci of necrosis surrounded by palisading tumour cells were conspicuous. With anti-GFAP serum many positive cells were demonstrated in the tumour; we could not however exclude the possibility that these were all reactive astrocytes. After initial improvement the patient's condition deteriorated and he died in June 1983. Postmortem examination revealed no significant findings outside the cranial cavity. The brain showed a cystic suprasellar lesion reaching the floor of the third ventricle. The cyst wall was smooth and white and surrounded by partly granular, partly whitish opaque tissue. On section the cerebellum showed a poorly demarcated tumour mass, both haemorrhagic and necrotic, located centrally in the region of the vermis and extending into both hemispheres (Fig. 1). Histological examination of the suprasellar lesion showed loose fibrous tissue with scattered calcifications and ghosts of squamous cells, altogether compatible with the diagnosis of craniopharyngioma. The cerebellar tumour showed the same features as the surgical specimen (Figs. 2 and 3). The histological diagnosis was astrocytoma grade 4. The brainstem showed neither tumour nor changes that might have been caused by radiation. FIG. 1. Sagittal section of brain showing the craniopharyngioma in the suprasellar region as well as the haemorrhagic cerebellar tumour. The brainstem is free of tumour or changes caused by irradiation. 480

Malignant astrocytoma following radiotherapy for craniopharyngioma

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