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Multiple, Primary Brain Tumors with Diverse Origins Published online: 2019-09-02 Case Series Multiple, Primary Brain Tumors with Diverse Origins and Different Localizations: Case Series and Review of the Literature Thara Tunthanathip, Kanet Kanjanapradit1, Sanguansin Ratanalert, Nakornchai Phuenpathom, Thakul Oearsakul, Anukoon Kaewborisutsakul Department of Surgery, Background: Multiple, primary brain tumors with different histological types Neurosurgical Unit, Faculty occurring in the same patient are extremely rare. Several hypotheses have been of Medicine, Prince of Songkla University, proposed, and the pathophysiology of coexisting tumors has long been debated; 1Department of Pathology, however, due to low incidence, standard practices for this scenario are still Abstract Faculty of Medicine, Prince inconclusive. Case Description: The authors describe 6 cases of coexisting of Songkla University, tumors. By conducting a literature research focused on the computed tomography Hat Yai, Songkhla, 90110, (CT) era and patients without prior radiation or phakomatosis. Sixty‑five such Thailand reported cases were identified. In addition, the authors summarize their experience in 6 patients including histopathological features, chronological presentations, outcomes, mortality, and management from their series as well as from previous cases from the reported literature. Conclusion: The coexistence of multiple, primary brain tumors is an interesting condition. Surgical management remains the major treatment; malignant histology has a poor prognostic factor. Keywords: Coexistence of brain tumor, diffuse astrocytoma, glioblastoma, meningioma, multiple primary brain tumor Introduction gender‑specific distribution, the incidence rate of tumor he association of multiple, primary brain tumors of the meninges is higher in females (10.51/100,000) T with different histology occurring simultaneously rather than in males (4.85/100,000), while the in the same patient is an extremely rare condition. It has incidence rate of the tumor of the neuroepithelial been frequently associated with previous radiotherapy tissue is higher in males (7.77/100,000) rather than in [4] or phakomatosis[1,2] but is still exceptionally rare as females (5.61/100,000). Moreover, the incidental, a primary observation. Before the era of computed primary brain tumor can be found in general population. tomographies (CTs), Cushing and Eisenhardt reported, Asymptomatic meningiomas were the most frequent in 1938, a patient who harbored both a glioblastoma and in 0.9%–1% while pituitary adenomas were 0.3% a meningioma.[3] Only a few cases of this scenario have within the population.[5,6] However, the condition where since been reported. The authors present their experience coexisting, primary brain tumors occur in the same gained from a series of such primary brain tumors patient is truly scarce. with different histopathology types and in different We reviewed these from the relevant literature in intracranial localizations. They discuss these cases in the MEDLINE, EMBASE, and Scopus. The selection context of the currently available literature. criteria included those in the English language and The most frequently reported primary brain tumor in the Central Brain Tumor Registry of the United States Address for correspondence: Dr. Thara Tunthanathip, is nonmalignant meningioma (36.1%), followed by Department of Surgery, Neurosurgical Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand. glioblastoma (15.4%). In addition, the nonmalignant E‑mail: [email protected] pituitary adenoma and nerve sheath tumors account for 15.1% and 8% of all tumors, respectively. In This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is Access this article online given and the new creations are licensed under the identical terms. Quick Response Code: Website: For reprints contact: [email protected] www.ruralneuropractice.com How to cite this article: Tunthanathip T, Kanjanapradit K, Ratanalert S, DOI: Phuenpathom N, Oearsakul T, Kaewborisutsakul A. Multiple, primary brain 10.4103/jnrp.jnrp_82_18 tumors with diverse origins and different localizations: Case series and review of the literature. J Neurosci Rural Pract 2018;9:593-607. © 2018 Journal of Neurosciences in Rural Practice | Published by Wolters Kluwer - Medknow 593 Tunthanathip, et al.: Multiple primary brain tumor illustrated neuroimaging such as CT or magnetic proliferation and necrosis. Furthermore, the specimen resonance imaging (MRI) brain scans. The authors stained positive for glial fibrillary acidic protein (GFAP), also do not consider these tumors to be associated which indicated a glial cell tumor. Due to the lack of with previous radiotherapy (Cahan’s criteria) or diagnostic molecular testing, a final diagnosis of tumor phakomatosis.[7] According to the criteria, 65 cases was designated as those not otherwise specified diffuse were reported in the literature and the authors added astrocytoma (WHO II) according to the 2016 WHO 6 cases in Appendix 1.[8‑39] classification [Figure 1 e and f]. After surgery, this patient again made an uneventful recovery without Case Series any new neurological impairment. At follow‑up, she Patient 1: Meningioma and diffuse astrocytoma maintained independent daily activities. A 68‑year‑old, right‑handed women suffering from Chromosome analysis dementia on the right arm coupled with suffering leg Chromosomal analysis from peripheral blood cells weakness in October 2013. A clinical examination of the patient was performed for screening germline showed right hemiparesis and right facial nerve mutation. The karyotype was 44, XX and an absence of palsy with upper motor neuron type. She had neither chromosome 17p deletions. café‑au‑lait spots nor Lisch nodules, which are found in neurofibromatosis Type 1 (NF1). There was also an Patient 2: Glioblastoma multiforme with pituitary absence of first‑degree relatives of NF1. adenoma A 63‑year‑old male patient was referred to our hospital MRI of the brain showed a homogeneously enhancing due to an alteration in his consciousness. Two weeks mass with dural tail sign located in the left frontal lobe prior, he had suffered from a change in mentation and as seen on T1‑weighted (T1W) gadolinium‑enhanced left hemiparesis, so the patient had been admitted to images. Furthermore, another lesion was observed at a provincial hospital. CT head scans demonstrated the right insular lobe that showed an ill‑defined area of two sites with intracranial tumors: an irregular mixed hypo‑ and hyperintense but nonenhancing lesion rim‑enhancing mass at the right frontoparietal lobe and a on T1W, fluid‑attenuated inversion recovery, and T1W sellar tumor. During hospitalization, the patient showed gadolinium‑enhanced images, respectively [Figure 1a]. In progressive neurological deterioration. Therefore, addition, the T1‑weight inversion recovery MRI showed the patient underwent a decompressive craniectomy hyperintensity of the right insular lesion [Figure 1b]. and was transferred to our hospital. At the tertiary A left craniotomy for tumor removal was performed to hospital, he was fully oriented but had hemiplegia on address the frontal lesion first. The tumor was found the left side. Cranial T1W MRI with intravenous (I/V) attached to the dura mater and measuring 4.5 cm in gadolinium revealed an irregular, heterogeneously diameter by 4.5 cm. Both tumor and attached dura contrast‑enhancing mass at the right frontoparietal lobe mater were completely removed. After surgery, this measuring 52 mm × 68 mm × 54 mm with central patient made an uneventful recovery without any new hypointensity indicative of necrosis [Figure 2a]. neurological impairment. The pathology of the frontal In addition, another tumor was noted in the sellar lesion was fibrous meningioma (WHO II) [Figure 1d]. region with suprasellar extension, measuring One year after the first surgery, the patient suffered a 20 mm × 21 mm × 29 mm [Figure 2d and e]. Pituitary generalized tonic–clonic seizure. A follow‑up MRI brain hormones were found to be within normal values. An scan showed no evidence of recurrence of the left frontal extended right frontoparietal craniotomy was performed meningioma, and there was a stable size of the right insular to approach both tumors. However, the patients’ position lesion. In addition, no decreased N‑acetylaspartate (NAA) was suboptimal to access the sellar region limiting the and no choline peak were noted in magnetic resonance resection to a partial one at this site. spectroscopy [Figure 1c]. Taking the clinical seizure as Histopathology of the right frontoparietal lesion revealed a a sign of progression, we had the indications that an glioblastoma multiforme [Figure 2b and c] while the sellar operation was required to obtain a diagnosis. A right‑sided tumor was identified as pituitary adenoma [Figure 2f]. craniotomy for a transsylvian approach was performed. Since his hormonal profiles were normal, nonfunctioning Discoloration of the insular cortex was encountered, and pituitary adenoma was designated. The postoperative the extent of resection was 90% in the complex location. period was uneventful, and the patient was sent for Thus, surgical specimens were sent for analysis. adjuvant therapy. Unfortunately, the patient refused Pathological examination of the specimens found adjuvant therapy and
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