Brain Tumor Pathol (2011) 28:65–70 DOI 10.1007/s10014-010-0010-4
CASE REPORT
Rhabdoid glioblastoma in a child: case report and literature review Hiroyuki Momota • Kenichiro Iwami • Masazumi Fujii Kazuya Motomura • Atsushi Natsume • Jiro Ogino • Tadashi Hasegawa • Toshihiko Wakabayashi
•
Received: 7 September 2010 / Accepted: 18 October 2010 / Published online: 7 January 2011 Ó The Japan Society of Brain Tumor Pathology 2010
Abstract Rhabdoid glioblastoma is a rare type of glioblastoma characterized by cells resembling rhabdomyoblasts. Several reports have identified its aggressive clinical course and the pathological differences from other primary brain tumors. We report a case of rhabdoid glioblastoma in a 12-year-old boy who presented with headache and harbored a 70-mm solid tumor in the left temporal lobe. The tumor was surgically excised, but early tumor recurrence and leptomeningeal spread developed, and the patient died of the disease 4.9 months after surgery. Histologically, the tumor contained two distinct patterns of glioblastoma and rhabdoid cells with necrosis and hemorrhage. Immunohistochemical analysis revealed that both cells were positive for glial fibrillary acid protein, vimentin, and INI1, which is consistent with the reported diagnosis of rhabdoid glioblastoma. Genetic studies confirmed no loss of the INI1 gene and identified hemizygous deletion of the CDKN2A gene. We review reported cases of rhabdoid glioblastoma and summarize the clinical, radiological, and histological features.
Keywords
Rhabdoid glioblastoma INI1 Child
Introduction Primary central nervous system (CNS) tumors with rhabdoid features have been identified. Astrocytomas, meningiomas, and CNS embryonal tumors, including atypical teratoid/rhabdoid tumors (AT/RTs) are well known to show diverse differentiation and rhabdoid phenotype [1]. Among these tumors, rhabdoid glioblastoma (GBM) is a recently recognized and rare astrocytic tumor in which GBM has a rhabdoid component [2–6]. Whereas AT/RTs show loss of INI1 protein in all cases because of he INI1 deletions or mutations [7, 8], rhabdoid GBM retains INI1 despite low expression level or focal expression loss [5, 6]. Rhabdoid GBM tends to occur in younger patients and has been reported as being a highly aggressive tumors type with early recurrence and leptomeningeal spread [2–6]. Here we report a case of supratentorial rhabdoid GBM in a child and present a literature review of this rare tumor type.
Materials and methods H. Momota (&) K. Iwami M. Fujii K. Motomura A. Natsume T. Wakabayashi Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan e-mail:
[email protected] J. Ogino T. Hasegawa Department of Surgical Pathology, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo 060-8543, Japan
Tumor sample and DNA extraction Collection and use of human tissues were performed after obtaining written consent from the patient at the time of second surgical resection. The tumor tissue sample was frozen and stored at -80°C until the extraction of genomic DNA. DNA was prepared using the QIAmpÒ DNA Mini kit (Qiagen, Hilden, Germany) according to the manufacturer’s instructions. Placental DNA was used as the normal control.
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Multiplex ligation-dependent probe amplification Multiplex ligation-dependent probe amplification (MLPA) was used to determine gene allelic losses and gains in the tumor samples. The analysis was performed using the SALSAÒ MLPAÒ KIT P088-B1 and P105-C1 (MRC Holland, Amsterdam, The Netherlands) according to the manufacturer’s protocol. Information regarding probe sequences and ligation sites can be found at http://www.mlpa.com. Amplification products were separated on an ABIÒ 3130 9 I Genetic Analyzer (Applied Biosystems, Foster City, CA, USA) and quantified with Genemapper 4.0 software (Applied Biosystems). Duplicate experiments and data analysis were performed, as described previously [9]. Pyrosequencing Tumor DNA was modified with bisulfate using the EpiTect bisulfite kit (Qiagen). PyrosequencingTM technology was used to determine methylation status of the CpG island region of O6-methylguanine-DNA methyltransferase (MGMT), as described previously [9]. Briefly, polymerase chain reaction (PCR) was performed using the MGMT forward primer, 50 -TTGGTAAATTAAGGTATAGAGTT TT-30 , and the MGMT biotinylated reverse primer, 50 -AAA CAATCTACGCATCCT-30 . The biotinylated PCR product was purified using Streptavidin Sepharose HP (Amersham Biosciences, Uppsala, Sweden), and pyrosequencing was performed using the PSQ HS 96 Pyrosequencing System (Pyrosequencing, Inc., Westborough, MA, USA) using the pyrosequencing primer 50 -GGAAGTTGGGAAGG-30 . Methylation quantification was performed using the provided software. TP53, IDH1/IDH2, and INI1 sequencing Direct sequencing of the TP53 (exons 5–8), isocitrate dehydrogenase 1 and 2 (IDH1/2) (catalytic domains of IDH1 including codon 132 and IDH2 including codon 172), and INI1 (exons 3–9) was performed using the indicated primer sets and conditions, as described previously [10–12] PCR was done by TP600 TaKaRa PCR Thermal Cycler DiceÒ Gradient (Takara, Otsu, Japan). After purification of the PCR products by QIAquick PCR Purification Kit (Qiagen), DNA sequencing was done by CEQ 8000TM Genetic Analysis System (Beckman Coulter, Fullerton, CA, USA) or ABIÒ 3100 Genetic Analyzer (Applied Biosystems) using the same primers. Fluorescence in situ hybridization Fluorescence in situ hybridization (FISH) study was performed using formalin-fixed paraffin-embedded specimens
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sectioned into 4-lm-thick tissue sections, as described previously [13]. Probes for chromosome 22 centromeric (SpectrumGreen-labeled, 444 kb) and INI1 on 22q11 (SpectrumOrange-labeled, 148 kb) were used. The slides were observed using a fluorescence microscope with appropriate filters, and the resulting images were captured using a charge-coupled-device camera. Immunohistochemistry Immunohistochemical analysis was performed using a streptavidin–biotin–peroxidase method (Histofine; Nichirei, Tokyo, Japan). The following antibodies were used according to the manufacturers’ protocols: Ki-67 (MIB-1, Dako, Glostrup, Denmark), p53 (DO7, BioGenex, San Roman, USA), glial fibrillary acid protein (GFAP) (6F2, Dako), neurofilament (2F11, Dako), neuron-specific enolase (NSE) (BBS/NC/VI-H14, Dako), S-100 (polyclonal, Dako), olig2 (18953, IBL), vimentin (V9, Dako), epithelial membrane antigen (EMA) (E29, Dako), smooth-muscle actin (SMA) (1A4, Dako), cytokeratin (AE1/AE3, Dako), INI1 (25, BD Transduction Laboratories, San Diego, CA, USA), CD30 (Ber-H2, Dako), Granzyme B (GrB-7, Dako), and activin receptor-like kinase-1 (ALK1, Dako). MIB-1and p53-positive cells were counted in one of the most strongly staining fields per section (500–1,500 cells/field). Immunoreactivities were judged according to the staining intensity and pattern as follows: ? weak to moderate; ?? strong; ?/- occasional or focal.
Case report A 12-year-old boy presented to the nearby clinic with gradually worsening headache. He had no other past medical history or familial medical history. Computed tomography (CT) disclosed a relatively demarcated isodense tumor in the left temporooccipital lobe, and he was hospitalized without any neurological deficit. The lesion was 70 mm in diameter, enhanced heterogeneously on magnetic resonance imaging (MRI) with gadolinium-based contrast agents, and intratumoral hemorrhage and calcification was suspected (Fig. 1a–f). He underwent partial resection of the mass. Macroscopically, the tumor was soft, reddish, hypervascular, and relatively well circumscribed. The histological examination revealed that the tumor contained hemorrhage and necrosis and that tumor cells were composed of epithelioid GBM cells and rhabdoid tumor cells (Fig. 2a–d). The pathological diagnosis of GBM with rhabdoid component was made. The residual tumor grew rapidly within a month, and he was referred to our hospital. On admission, he had nausea and headache, papilledema, gait disturbance, and right homonymous
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Fig. 1 Preoperative cranial computed tomography (CT) scan and magnetic resonance imaging (MRI). a CT scan showing hyperdense mass with calcification in the left temporal lobe. b Axial T1-weighted image with gadolinium contrast showing a well-circumscribed solid tumor with heterogeneous enhancement. c Coronal T1-weighted image with gadolinium contrast revealing dural attachment of the tumor on the basement of the left middle fossa. d Fluid-attenuated
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inversion recovery (FLAIR) image demonstrating the isointense tumor with minimal peritumoral edema. e T2*-weighted image showing massive low-intensity signals within the tumor, indicating abnormal vessels and hemorrhage. f Diffusion-weighted image showing isointense to low-intensity signals suggesting necrosis and hemorrhage in the tumor
Fig. 2 Histopathological features of rhabdoid glioblastoma (GBM). a Hematoxylin and eosin (H&E) staining of the tumor at low magnification showing hemorrhage and necrosis within. b High-magnification image of GBM component showing epithelioid-like cells with oval nuclei with relatively abundant eosinophilic cytoplasm. c Transitional area of GBM cells to rhabdoid cells. d H&E staining of rhabdoid component demonstrating plump cell with large, eccentric nuclei, prominent nucleoli, and cytoplasmic ball-like inclusion. a 9100, b–d 9400
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Fig. 3 Cranial and spinal magnetic resonance imaging (MRI) after a first and b, c second operation. a Axial T1-weighted image with gadolinium contrast showing rapid tumor regrowth in the postoperative tumor cavity. b Coronal T1-weighted image with gadolinium
contrast obtained in the terminal stage showing leptomeningeal metastases along dura mater (red arrows). c Contrast-enhancing T1weighted image of the upper spinal cord demonstrating leptomeningeal spread of the tumor
hemianopia. MRI revealed rapid regrowth of the tumor (Fig. 3a), and he underwent gross total removal 34 days after the first surgery. He started to receive focal brain radiotherapy (61.2 Gy/36 fractions, 5 days/week for 6 weeks) and concomitant chemotherapy with oral temozolomide (75 mg/m2/day, 7 days/week for 6 weeks) and intravenously administered interferon (IFN)-b (3,000,000 IU, 3 days/week for 6 weeks) 3 weeks after the second operation. However, he subsequently developed severe headache and marked neck stiffness. The cytology of his cerebrospinal fluid revealed positive tumor cells, and MRI demonstrated leptomeningeal enhancement and hydrocephalus. He underwent ventriculoperitoneal shunting, but his condition worsened, with leptomeningeal spread along the surface of brain and spinal cord (Fig. 3b, c). The patient died of tumor 4.9 months after diagnosis. To investigate this clinically aggressive and morphologically rare brain tumor, we performed more detailed histological and cytogenetic analyses. Microscopically, the rhabdoid cells were characterized by large, eccentric nuclei with prominent nucleoli and abundant eosinophilic cytoplasm (Fig. 2d). Immunohistochemistry revealed that rhabdoid cells were focally immunopositive for GFAP, neurofilament, olig2, and EMA, whereas almost all rhabdoid cells were strongly positive for vimentin and NSE (Fig. 4a, b). To exclude AT/RT, we performed immunohistochemistry for INI1 protein. Nuclear INI1 expression was observed in both GBM and rhabdoid cells, but the staining intensity was weaker in rhabdoid cells than in GBM cells, and INI1-negative rhabdoid cells were seen (Fig. 4c). FISH analysis revealed no deletion of the INI1 gene region (Fig. 4d). We conducted further immunohistochemical analyses for the differential diagnosis of anaplastic large-cell lymphoma with CD30, Granzyme B, and ALK antibodies, and none of them were immunopositive in tumor cells. The results of immunohistochemistry were
consistent with prior reports of rhabdoid GBMs (Table 1). Genetic study revealed hemizygous deletion of the CDKN2A gene, whereas any of the following were not detected: loss or amplification of PTEN, TP53, ERBB2, EGFR or chromosome 1p and/or 19q, promoter methylation of MGMT, and mutation of IDH1/2, TP53, or INI1 (data not shown).
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Discussion Epithelial differentiation is occasionally found in a variety of astrocytic tumors, and epithelioid GBM has been reported as a rare entity of GBM, with some morphologic overlap with rhabdoid GBM [6, 14, 15]. Rhabdoid GBM is a recently recognized CNS tumor with rhabdoid component. The rhabdoid cells consist of oval cells with large eccentric nuclei, prominent nucleoli, and cytoplasmic balllike inclusion and are characterized by positivity for GFAP and vimentin and focal loss of INI1 in immunohistochemistry [6]. To our knowledge, only four cases of rhabdoid GBM have been published in the English literature (Table 2) [2–6]. The clinical features of rhabdoid GBM are similar to other tumors with rhabdoid features and show preferential occurrence in children and young adults, with an extremely poor prognosis [2–6]. Tumor size at diagnosis is relatively large (20–70 mm), and tumors are enhanced heterogeneously with gadolinium on MRI, suggesting necrosis. Tumors are located in frontal or temporal lobe and attached to the brain surface or dura mater in most cases. Prognosis is extremely poor, with 4.1 months of mean survival time from diagnosis. Leptomeningeal dissemination and early recurrence are frequently observed. The extent of tumor removal may be the most important factor for better survival prognosis.
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Fig. 4 Histopathological and cytogenetic features of rhabdoid component. a Immunohistochemistry for vimentin showing strong cytoplasmic positivity in tumor cells. b Focally immunopositive area for glial fibrillary acid protein (GFAP) indicating differentiation from astrocytic lineage. c Immunohistochemistry for INI1, revealing INI1positive cells in the rhabdoid component. Note part of the cells show
weak or absent INI1 expression (red arrows) compared with positive tumor cells (black arrow). d Fluorescence in situ hybridization (FISH) analysis demonstrating retained INI1 gene loci in rhabdoid cells. Both markers in green and red are located on chromosome 22 (centromere in green, INI1 in red). a–c 9400, d 91,000
Table 1 Immunohistochemical expression profile in rhabdoid and glioblastoma (GBM) cells MIB-1 (%)
p53 (%)
GFAP
NF
NSE
S-100
Olig2
VIM
EMA
SMA
AE1/3
INI1
Rhabdoid cells
41
45
?/-
?/-
??
?
?/-
??
?/-
-
-
?/-
Glioblastoma cells
39
33
??
-
?
??
?/-
?
?/-
-
-
?
GFAP glial fibrillary acid protein, NF neurofilament, NSE neuron-specific enolase, VIM vimentin, EMA epithelial membrane antigen, SMA smooth-muscle actin, AE1/3 AE1/AE3 (pan cytokeratin), - negative, ?/- occasional or focally positive, ? positive, ?? strongly positive
Table 2 Reported cases of rhabdoid glioblastoma Reference
[2, 5]d [3]
Age/sex
18/M 16/F
Location
Size (mm)
Nec
R frontal R frontotemporal
70 20
? ?
DA
LM
? N/A
? ?
OSa (months)
3.7 3.2
Rhabdoid component MIB-1b
GFAPb
VIMb
INI1c
26% N/A
Focal ?
? ?
Focal N/A ?
[4]
66/M
R temporal
40
?
N/A
N/A
Short
N/A
?
?
[6]
67/F
R parietooccipital
64
?
?
?
8.3
18%
?
?
Focal
Our case
12/M
L temporal
70
?
?
?
4.9
41%
Focal
?
Focal
Nec necrosis, DA dural attachment at first presentation, LM leptomeningeal metastasis, OS overall survival, GFAP glial fibrillary acid protein, VIM vimentin, R right, L left, N/A not available a
Survival after the first resection of rhabdoid glioblastoma
b
Positivity or staining result of immunohistochemistry
c
Expression status confirmed by immunohistochemistry or fluorescent in situ hybridization analysis Secondary rhabdoid glioblastoma
d
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Histologically, rhabdoid components usually contain necrosis and show high MIB-1 staining indices ranging from 18% to 41%. Rhabdoid cells show strong positivity for vimentin and reactivity for GFAP in all cases. Immunopositivity for p53 protein has been reported, including in our cases [5, 6]. Most importantly, INI1 protein expression is retained in all cases reported, whereas focal loss of INI1 protein is seen in a subset of rhabdoid cells [5, 6]. Of note, there is a report of the infrequent INI1 gene alteration but frequent loss of INI1 protein expression in epithelioid sarcoma [12]. Dysfunction of INI1 protein may be the mechanism of the rhabdoid phenotype development. We investigated whether INI1 mutation but not deletion was attributed to INI1 protein dysfunction in our patient, but no mutation was found. In fact, complete inactivation of INI1 protein has been only identified in AT/RTs among the primary CNS tumors, including rhabdoid meningiomas [16]. Genetic alterations of rhabdoid GBM seem scarce. Polysomy 22q [4], monosomy 22 [2, 6], positive, or negative EGFR amplification [6] and PTEN loss [6] have been reported so far, but none of them are common. Our results revealed hemizygous deletion of CDKN2A, but no PTEN or INI1 loss or EGFR amplification, suggesting no specific abnormality in this tumor type. However, some mechanisms leading to a rhabdoid phenotype might be present either genetically or nongenetically. Several tumors with rhabdoid features have been reported to arise from preexisting glial tumors, such as low-grade astrocytoma, GBM, and ganglioglioma [2, 17, 18]. This indicates that rhabdoid cells are transformed or differentiated from primary neoplastic cells. As in the cases of primary rhabdoid GBMs, rhabdoid phenotype in secondary neoplasms correlates with short survival despite the aggressive treatment. Although clinical and histopathological evidence of rhabdoid GBM is accumulating, more studies are needed to dissect the pathogenesis of this rare brain tumor. Acknowledgments We thank Takashi Yamanouchi (Department of Neurosurgery, Nagoya University, Japan) for clinical information and Masafumi Ito (Department of Pathology, Japanese Red Cross Nagoya Daiichi Hospital, Japan) and Seiichi Kato (Department of Pathology, Nagoya University, Japan) for pathology expertise.
References 1. Louis DN, Ohgaki H, Wiestler OD et al (eds) Tumours of the central nervous system. World Health Organization classification of tumours. IARC, Lyon, pp 25–49, 132–149, 164–172
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Brain Tumor Pathol (2011) 28:65–70 2. Wyatt-Ashmead J, Kleinschmidt-DeMasters BK, Hill DA et al (2001) Rhabdoid glioblastoma. Clin Neuropathol 20:248–255 3. Lath R, Unosson D, Blumbergs P et al (2003) Rhabdoid glioblastoma: a case report. J Clin Neurosci 10:325–328 4. Fung KM, Perry A, Payner TD et al (2004) Rhabdoid glioblastoma in an adult. Pathology 36:585–587 5. Kleinschmidt-DeMasters BK, Meltesen L, McGavran L et al (2006) Characterization of glioblastomas in young adults. Brain Pathol 16:273–286 6. Kleinschmidt-DeMasters BK, Alassiri AH, Birks DK et al (2010) Epithelioid versus rhabdoid glioblastomas are distinguished by monosomy 22 and immunohistochemical expression of INI-1 but not claudin 6. Am J Surg Pathol 34:341–354 7. Judkins AR, Mauger J, Ht A et al (2004) Immunohistochemical analysis of hSNF5/INI1 in pediatric CNS neoplasms. Am J Surg Pathol 28:644–650 8. Momota H, Holland EC (2009) Mouse models of CNS embryonal tumors. Brain Tumor Pathol 26:43–50 9. Motomura K, Natsume A, Kishida Y et al (2010) Benefits of interferon-b and temozolomide combination therapy for newly diagnosed primary glioblastoma with the unmethylated MGMT promoter: a multicenter study. Cancer. doi:10.1002/cncr.25637 10. Fults D, Brockmeyer D, Tullous MW et al (1992) p53 mutation and loss of heterozygosity on chromosomes 17 and 10 during human astrocytoma progression. Cancer Res 52:674–679 11. Hartmann C, Meyer J, Balss J et al (2009) Type and frequency of IDH1 and IDH2 mutations are related to astrocytic and oligodendroglial differentiation and age: a study of 1,010 diffuse gliomas. Acta Neuropathol 118:469–474 12. Kohashi K, Izumi T, Oda Y et al (2009) Infrequent SMARCB1/ INI1 gene alteration in epithelioid sarcoma: a useful tool in distinguishing epithelioid sarcoma from malignant rhabdoid tumor. Hum Pathol 40:349–355 13. Matsumura T, Yamaguchi T, Seki K et al (2008) Advantage of FISH analysis using FKHR probes for an adjunct to diagnosis of rhabdomyosarcomas. Virchows Arch 452:251–258 14. Rosenblum MK, Erlandson RA, Budzilovich GN (1991) The lipid-rich epithelioid glioblastoma. Am J Surg Pathol 15:925–934 15. Rodriguez FJ, Scheithauer BW, Giannini C et al (2008) Epithelial and pseudoepithelial differentiation in glioblastoma and gliosarcoma: a comparative morphologic and molecular genetic study. Cancer 113:2779–2789 16. Perry A, Fuller CE, Judkins AR et al (2005) INI1 expression is retained in composite rhabdoid tumors, including rhabdoid meningiomas. Mod Pathol 18:951–958 17. Pimentel J, Silva R, Pimentel T (2003) Primary malignant rhabdoid tumors of the central nervous system: considerations about two cases of adulthood presentation. J Neurooncol 61:121–126 18. Bannykh SI, Perry A, Powell HC et al (2002) Malignant rhabdoid meningioma arising in the setting of preexisting ganglioglioma: a diagnosis supported by fluorescence in situ hybridization. Case report. J Neurosurg 97:1450–1455
