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EPIDEMIOLOGÍA Y CLASIFICACIÓN DE LOS TUMORES DEL SISTEMA

NERVIOSO CENTRAL

XI CURSO NACIONAL DE NEURORRADIOLOGÍA Barcelona, 19 de febrero de 2015

Neurorradiología en la patología tumoral cerebral

Elena Martínez Sáez Servicio de Anatomía Patológica

Hospital Universitario Vall d’Hebron, Barcelona


2000

2007

months to 1 year, respectively. Thus, this loose definition accom-modated histologically benign and malignant tumors as well aslesions resulting in localized pressure upon vital centers, cere-brospinal fluid obstruction with secondary hydrocephalus, brainherniation and infiltrative growth with or without metastasis.Although these mechanisms of death were not closely correlatedwith histologic grade, the concept of clinical malignancy contin-ues to affect our notions of WHO grade.

This dual clinical/histologic malignancy approach continued tobe incorporated into subsequent editions of the WHO Classifica-tion of Tumours of the Central Nervous System. A three- orfour-tier numerical (WHO grades I–IV) scheme of histologicmalignancy often paralleled verbal designations. This was mostapparent in gliomas, particularly the spectrum of astrocytic, oli-godendroglial and ependymal tumors, but was also applied toother tumor categories, such as meningiomas in which clear mor-phologic criteria of atypia (grade II) and malignancy (grade III)(12) eventually came to be formulated, albeit not without livelydiscussion. Prognosis, including recurrence and survival data,

were thus played off against histology and its time-proven param-eters, including cellularity, atypia, mitoses, vascular proliferationand necrosis. Tumor staging according to the tumor–nodes–metastasis (TNM) approach was initially formulated by the UICCbut was later abandoned because of its lack of relevance to CNSneoplasms. Tumor coding, as articulated in the Manual of TumorNomenclature and Coding by the American Cancer Society (1),subsequently became the International Classification of Diseasesfor Oncology (ICD-O) published by the WHO (14).

SUBSEQUENT “BLUE BOOKS”Understandably, given the popularity and international acceptanceof the first WHO Classification, subsequent editions followed andwere enthusiastically received. These were all under the auspices ofthe WHO (6) and some under the International Agency forResearch on Cancer (IARC) as well (10, 13). In association withthe International Society of Neuropathology a similar work wasproduced in 1997, one which, although not strictly a “blue book,”

A B

Figure 7. The first edition (1979) of the World Health Organization Classification of Tumours of the Central Nervous System. The distinctive color ofthis series (A) lent the designation “blue books” to the entire series, a term still loosely applied to subsequent editions. (B) Title page.

History of WHO Classification of CNS Tumors Bernd

558 Brain Pathology 19 (2009) 551–564

© 2008 The Author; Journal Compilation © 2008 International Society of Neuropathology

1979

1993

M I S C E L L A N E O U S

International Society of Neuropathology-Haarlem ConsensusGuidelines for Nervous System Tumor Classificationand GradingDavid N. Louis1; Arie Perry2; Peter Burger3; David W. Ellison4; Guido Reifenberger5,6;Andreas von Deimling6,7; Kenneth Aldape8; Daniel Brat9; V. Peter Collins10; Charles Eberhart3;Dominique Figarella-Branger11; Gregory N. Fuller12; Felice Giangaspero13,14; Caterina Giannini15;Cynthia Hawkins16; Paul Kleihues17; Andrey Korshunov6,18; Johan M. Kros19; M. Beatriz Lopes20;Ho-Keung Ng21; Hiroko Ohgaki22; Werner Paulus23; Torsten Pietsch24; Marc Rosenblum25;Elisabeth Rushing26; Figen Soylemezoglu27; Otmar Wiestler28; Pieter Wesseling29,30

1 Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA2 Department of Pathology, University of California San Francisco, San Francisco CA, USA3 Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore MD, USA4 Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA5 Department of Neuropathology, Heinrich Heine University, Duesseldorf, Germany6 Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany7 Department of Neuropathology, Institute of Pathology, Ruprecht-Karls-University, Heidelberg, Germany8 Department of Pathology, Princess Margaret Hospital, Toronto, Canada9 Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta GA, USA10 Department of Pathology, University of Cambridge, Cambridge, UK11 Department of Pathology and Neuropathology, La Timone Hospital, Aix Marseille University, Marseille, France12 Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston TX, USA13 Department of Radiological, Oncological and Anatomo-Pathological Sciences, University La Sapienza, Rome, and14 IRCCS Neuromed, Pozzilli, Italy15 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester MN, USA16 Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada17 Medical Faculty, University of Zurich, Switzerland18 Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany19 Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands20 Department of Pathology, University of Virginia School of Medicine, Charlottesville VA, USA21 Department of Anatomical Pathology and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong22 International Agency for Research on Cancer (IARC), Lyon, France23 Institute of Neuropathology, University Hospital Münster, Münster, Germany24 Institute of Neuropathology, Brain Tumor Reference Center, University of Bonn, Bonn, Germany25 Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York NY, USA26 Institute for Neuropathology, University Hospital of Zurich, Zurich, Switzerland27 Department of Pathology, Hacettepe University, Ankara, Turkey28 German Cancer Research Center (DKFZ), Heidelberg, Germany29 Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands30 Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands

Corresponding authors:David N. Louis, MD, Pathology Service, Massachusetts General Hospital, WRN225, 55 Fruit Street, Boston, MA 02114(E-mail: [email protected])

Arie Perry, MD, Department of Pathology, Division of Neuropathology, University of California San Francisco (UCSF), 505 Parnassus Avenue,#M551, Box# 0102, San Francisco, CA 94143 (E-mail: [email protected])

Pieter Wesseling, MD, PhD, Department of Pathology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands(E-mail: [email protected])

Published Online Article Accepted 3 July 2014

doi:10.1111/bpa.12171

Brain Pathology ISSN 1015-6305

429Brain Pathology 24 (2014) 429–435

© 2014 The Authors. Brain Pathology published by John Wiley & Sons Ltd on behalf of International Society of Neuropathology.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided theoriginal work is properly cited.

Julio 2014








doi:10.1111/bpa.12171


429Brain Pathology 24 (2014) 429–435


International Society of Neuropathology-Haarlem ConsensusGuidelines for Nervous System Tumor ClassificationGuidelines for Nervous System Tumor Classificationand Grading


TUMOURS OF NEUROEPITHELIAL TISSUE WHO classification, 2007

TUMORES ASTROCITARIOS

TUMORES OLIGODENDROGLIALES

TUMORES OLIGO-

ASTROCITARIOS

TUMORES EPENDIMARIOS

TUMORES DE PLEXOS

COROIDEOS

OTROS TUMORES NEUROEPITELIALES

TUMORES NEURONALES Y

MIXTOS NEUROGLIALES

TUMORES DE LA REGIÓN PINEAL TUMORES

EMBRIONARIOS


TUMORES ASTROCITARIOS

TUMORES OLIGODENDROGLIALES

TUMORES OLIGO-

ASTROCITARIOS

Astrocitoma Difuso (gr. II)

Astrocitoma anaplásico

(gr. III) Glioblastoma

Multiforme (gr. IV)

Tumores difusamente infiltrantes

Astrocitoma Pilocítico (gr. I/III)

XAP (gr. II)

SEGA (gr. I)

A.! Pmx (gr. II)

Tumores bien delimitados

OA (gr. II)

OAA (gr. III)

O (gr. II)

O Anapl (gr. III)


!!Astrocitomas difusos- grado II - 10-15% de los astrocitomas - 4ª década - 6-8 años de supervivencia media !!Astrocitoma anaplásico- grado III - 45 años - 2 años de supervivencia media !!Glioblastoma- grado IV -! Más frecuente: 12-15% tumores intracraneales, 60-75% de astrocitomas. -! 61 años -! 12 meses de supervivencia media

ASTROCITOMAS INFILTRANTES DIFUSOS


ASTROCITOMA DIFUSO-gr II-HIPERCELULARIDAD


ASTROCITOMA ANAPLÁSICO-gr. III- MITOSIS


GLIOBLASTOMA MULTIFORME-gr. IV NECROSIS

Y/O PROLIFERACIÓN VASCULAR


PROLIFERACIÓN MICROVASCULAR

HIPERPLASIA ENDOTELIAL

¡¡DOS FORMAS DE PROLIFERACIÓN VASCULAR!!


TÉCNICAS INMUNOHISTOQUÍMICAS

Proteína glial fibrilar acídica

(GFAP)


GFAP

Ki67

Índice de proliferación celular



GFAP

Ki67

p53

Gen supresor tumoral. Papel en apoptosis y control del ciclo celular. GBM secundarios



Astrocito o célula precursora

GLIOBLASTOMA PRIMARIO LOH 10q (70%) Amplificación EGFR (36%) Deleción p16 (31%) Mutación TP53 (28%) Mutación PTEN (25%) Grado IV OMS

ASTROCITOMA DE BAJO GRADO Mutación TP53 (59%) Sobreexpresión PDGFR Grado II OMS

ASTROCITOMA ANAPLÁSICO Mutación TP53 (53%) Sobreexpresión PDGFR Grado III OMS

GLIOBLASTOMA SECUNDARIO LOH 10q (63%) Amplificación EGFR (8%) Deleción p16 (19%) Mutación TP53 (65%) Mutación PTEN (4%) Grado IV OMS

Ohgaki H and Kleihues P. Genetic Pathways to Primary and Secondary Glioblastoma. Am J Pathol 2007, 150:1445-1453.

ALTERACIONES MOLECULARES EN ASTROCITOMAS


Astrocytomas typically develop in cells with IDH1/2mutations that subsequently acquire TP53 mutations.Recent studies have also described mutations in the ATRX(a-thalassemia/mental-retardation-syndrome-X-linked)gene that are often copresent with IDH1/2 mutations andTP53 mutations in diffuse astrocytomas WHO grades II/IIIand secondary glioblastomas (36, 37). Our current conceptof the genetic pathways leading to astrocytic and oligoden-droglial gliomas is summarized in Figure 1.

Only 7% of WHO grade II diffuse gliomas had none ofthese genetic alterations (i.e., IDH1/2 mutations, TP53mutations, and 1p/19q loss) and were termed "triple neg-ative" (33). These cases are still poorly understood; aminorfraction shows loss of cell-cycle control regulated by the RB1pathway (38). The possibility cannot be excluded that theyare derived from a different precursor cell population.

IDH1 mutations in gliomas associated with theLi-Fraumeni syndrome

As indicated earlier, IDH1mutations precede TP53muta-tions in sporadic astrocytic tumors. Patients with Li-Frau-meni syndrome (LFS) carry a germline TP53 mutation thatis present in every somatic cell. Thus, by definition TP53mutations would be the first event in LFS-associated glio-mas, which account for 12% to 13%of all tumors occurringin LFS families (39, 40). Inpatients from3 familieswith LFS,we identified IDH1 mutations in 5 astrocytic gliomas thatdeveloped in carriers of a TP53 germlinemutation.Withoutexception, all contained the R132C (CGT-->TGT)mutation(41), which in sporadic astrocytic tumors amounts to less

than 5% of all IDH1 mutations (10–12). This remarkablyselective occurrence suggests a preference for R132C muta-tions in neural precursor cells that already carry a germlineTP53 mutation.

Biologic Consequences of IDH MutationsThemechanisms bywhich IDH1mutations contribute to

the development and malignant progression of astrocyticand oligodendroglial tumors are still not fully understood.Conditional IDH1 (R132H) knockin mice with expressionin all hematopoietic cells or cells of the myeloid lineagecaused an increased number of early hematopoietic pro-genitors with splenomegaly, anemia, and extramedullaryhematopoiesis (42), whereas brain-specific IDH1 (R132H)-conditional knockin mice exhibited hemorrhage and peri-natal lethality (43). Like EGFR amplification in primaryglioblastomas, IDH1mutations in secondary glioblastomasare typically lost during culture in vitro (44). This is enig-matic, since selective suppression of endogenous mutantIDH1 expression in a fibrosarcoma cell line with a nativeIDH1R132C heterozygous mutation significantly inhibitscell proliferation (45). Only recently, using a neurosphereculture method, it has been possible to establish a braintumor stem cell line from an IDH1-mutant anaplasticoligoastrocytoma with an endogenous IDH1mutation anddetectable production of 2-hydroxyglutarate (2HG; ref. 46).This may suggest that IDH1-mutant glioma cells have stemcell–like features that confer a growth advantage underneurosphere culture conditions. Alternatively, there maybe intratumoral heterogeneity of IDH1 mutations, and

EGFR�� !� � ! � � �� $ ��TP53��"! � ! � � �� $ ��PTEN��"! � ! � � �� $ �� $ �� $ ��

�%�� ! � �#

�� $ � ��

�� ! � ��

�� ! � �� ! �� #! � ��

Secondaryglioblastoma

-�� "�� ! �� ! � � �� !� �� #� � �� ! �#� � ! � � �� ! #� �

IV

III

II

WHOgrade

$ ��#

$ �#

�� *� //" � �� ! �� #! � ��

�� ' � � � � � � ��CIC� � " ! � ! � � � � � $ (��FUBP1� � " ! � ! � � � � � $ ��

TP53�� " ! � ! � � � � � $ ��ATRX��"! � ! � � �� $ ��

, � "�� &�� &�� #�� &� �� "�� ! �� ! � � �� !� �

Primaryglioblastoma

+ � � � � �� ! � ��

) � �� "� � �� 0� ! �� IDH1/2��"! � ! � � �

+ � � � � �� ! � ��

1 � �� ! � � � � /� � � ) � � � � � � .� � � � � �

Figure 1. Genetic pathways toprimary and secondaryglioblastomas. Note that onlysecondary glioblastomas sharecommon origin of cells witholigodendrogliomas.

Ohgaki and Kleihues

Clin Cancer Res; 19(4) February 15, 2013 Clinical Cancer Research766

on October 29, 2014. © 2013 American Association for Cancer Research. clincancerres.aacrjournals.org Downloaded from

Published OnlineFirst December 3, 2012; DOI: 10.1158/1078-0432.CCR-12-3002

Ohgaki H and Kleihues P. The definition of Primary and Secondary Glioblastomas. Clin Can Res 2013, 19(4).

GLIOBLASTOMAS PRIMARIOS VS SECUNDARIOS

�� ! � ��

��

�� ' � � � � � � ��CIC� � " ! � ! � � � � � $ (��FUBP1� � " ! � ! � � � � � $ ��

Amplificación EGFR

Mutación IDH

Mutación p53

Mutación ATRX


Epidermal Growth Factor Receptor (EGFR)

Amplificado en el 35% de GBMs primarios.

Ayuda en el diagnóstico

diferencial.


Isocitrato DesHidrogenasa 1&2

-!Parsons DW et al, 2008: 12% IDH mutado (An integrated genomic analysis of human glioblastoma multiforme. Science 321:1807-1812). - Balss et al, 2008 (Analysis of the IDH1 codon 132 mutation in brain tumours. Acta Neuropathol 116:597-602): 685 tumores neurogliales,

-! 68% astrocitomas difusos -! 69% oligodendrogliomas -! 78% oligoastroctomas -! 88% GBM secundarios

mutado (An integrated genomic analysis of

Mejor pronóstico en GBM


IDH R132H


Metilación del promotor de MGMT

O6-MethylGuanine-DNAMethylTransferase Proteína reparadora de DNA que protege a las células del GBM de agentes alquilantes (TMZ). Metilación del promotor >silenciación epigenética de MGMT >predictivo de mayor supervivencia tras TMZ+RT. Excesiva variabilidad intra e interlaboratorios en el método de detección >pirosecuenciación.


ATRX (Alpha-Thalassemia/Mental Retardation syndrome X-linked)

2011: mutaciones en 30-40% GBM pediátricos. 2012: mutaciones en 25,6% de 363 gliomas:

-! 67% astrocitomas grado II -! 73% astrocitomas grado III -! 57% GBMs secundarios -! 68% oligoastrocitomas mixtos -! 14% oligodendrogliomas puros -! 4% GBMs primarios

La mutación de ATRX y la codeleción de 1p/19q son casi excluyentes.


Clinical Neuropathology, Vol. 33 – No. 2/2014 (108-111)

ATRX (Alpha-Thalassemia/Mental Retardation syndrome X-linked)


!! Gliomas infiltrantes

!! Mejor pronóstico que los astrocitomas infiltrantes: supervivencia media de 11a.

!! 40-45 años.

!! Grados II (oligodendroglioma) y III (oligodendroglioma anaplásico)

!!Codeleción 1p/19q: factor diagnóstico y pronóstico

OLIGODENDROGLIOMAS


Oligodendroglioma, gr. II: Núcleos redondos, halo perinuclear

Capilares finos ramificados


Oligodendroglioma anaplásico, gr. III: Hipercelularidad, atipia, abundantes mitosis, proliferación microvascular y necrosis


Astrocytomas typically develop in cells with IDH1/2mutations that subsequently acquire TP53 mutations.Recent studies have also described mutations in the ATRX(a-thalassemia/mental-retardation-syndrome-X-linked)gene that are often copresent with IDH1/2 mutations andTP53 mutations in diffuse astrocytomas WHO grades II/IIIand secondary glioblastomas (36, 37). Our current conceptof the genetic pathways leading to astrocytic and oligoden-droglial gliomas is summarized in Figure 1.

Only 7% of WHO grade II diffuse gliomas had none ofthese genetic alterations (i.e., IDH1/2 mutations, TP53mutations, and 1p/19q loss) and were termed "triple neg-ative" (33). These cases are still poorly understood; aminorfraction shows loss of cell-cycle control regulated by the RB1pathway (38). The possibility cannot be excluded that theyare derived from a different precursor cell population.

IDH1 mutations in gliomas associated with theLi-Fraumeni syndrome

As indicated earlier, IDH1mutations precede TP53muta-tions in sporadic astrocytic tumors. Patients with Li-Frau-meni syndrome (LFS) carry a germline TP53 mutation thatis present in every somatic cell. Thus, by definition TP53mutations would be the first event in LFS-associated glio-mas, which account for 12% to 13%of all tumors occurringin LFS families (39, 40). Inpatients from3 familieswith LFS,we identified IDH1 mutations in 5 astrocytic gliomas thatdeveloped in carriers of a TP53 germlinemutation.Withoutexception, all contained the R132C (CGT-->TGT)mutation(41), which in sporadic astrocytic tumors amounts to less

than 5% of all IDH1 mutations (10–12). This remarkablyselective occurrence suggests a preference for R132C muta-tions in neural precursor cells that already carry a germlineTP53 mutation.

Biologic Consequences of IDH MutationsThemechanisms bywhich IDH1mutations contribute to

the development and malignant progression of astrocyticand oligodendroglial tumors are still not fully understood.Conditional IDH1 (R132H) knockin mice with expressionin all hematopoietic cells or cells of the myeloid lineagecaused an increased number of early hematopoietic pro-genitors with splenomegaly, anemia, and extramedullaryhematopoiesis (42), whereas brain-specific IDH1 (R132H)-conditional knockin mice exhibited hemorrhage and peri-natal lethality (43). Like EGFR amplification in primaryglioblastomas, IDH1mutations in secondary glioblastomasare typically lost during culture in vitro (44). This is enig-matic, since selective suppression of endogenous mutantIDH1 expression in a fibrosarcoma cell line with a nativeIDH1R132C heterozygous mutation significantly inhibitscell proliferation (45). Only recently, using a neurosphereculture method, it has been possible to establish a braintumor stem cell line from an IDH1-mutant anaplasticoligoastrocytoma with an endogenous IDH1mutation anddetectable production of 2-hydroxyglutarate (2HG; ref. 46).This may suggest that IDH1-mutant glioma cells have stemcell–like features that confer a growth advantage underneurosphere culture conditions. Alternatively, there maybe intratumoral heterogeneity of IDH1 mutations, and

EGFR�� !� � ! � � �� $ ��TP53��"! � ! � � �� $ ��PTEN��"! � ! � � �� $ �� $ �� $ ��

�%�� ! � �#

�� $ � ��

�� ! � ��

�� ! � �� ! �� #! � ��

Secondaryglioblastoma

-�� "�� ! �� ! � � �� !� �� #� � �� ! �#� � ! � � �� ! #� �

IV

III

II

WHOgrade

$ ��#

$ �#

�� *� //" � �� ! �� #! � ��

�� ' � � � � � � ��CIC� � " ! � ! � � � � � $ (��FUBP1� � " ! � ! � � � � � $ ��

TP53�� " ! � ! � � � � � $ ��ATRX��"! � ! � � �� $ ��

, � "�� &�� &�� #�� &� �� "�� ! �� ! � � �� !� �

Primaryglioblastoma

+ � � � � �� ! � ��

) � �� "� � �� 0� ! �� IDH1/2��"! � ! � � �

+ � � � � �� ! � ��

1 � �� ! � � � � /� � � ) � � � � � � .� � � � � �

Figure 1. Genetic pathways toprimary and secondaryglioblastomas. Note that onlysecondary glioblastomas sharecommon origin of cells witholigodendrogliomas.

Ohgaki and Kleihues

Clin Cancer Res; 19(4) February 15, 2013 Clinical Cancer Research766

on October 29, 2014. © 2013 American Association for Cancer Research. clincancerres.aacrjournals.org Downloaded from

Published OnlineFirst December 3, 2012; DOI: 10.1158/1078-0432.CCR-12-3002

Ohgaki H and Kleihues P. The definition of Primary and Secondary Glioblastomas. Clin Can Res 2013, 19(4).

Mutación IDH

Codeleción 1p/19q


Codeleción 1p/19q

Woehrer, Sander, Haberler et al. Clinical Neuropathology, Vol. 30 – No. 2/2011 (47-55)

•! Mejor pronóstico. •! Mejor respuesta a

tratamiento.









doi:10.1111/bpa.12171


429Brain Pathology 24 (2014) 429–435


Julio 2014








doi:10.1111/bpa.12171


429Brain Pathology 24 (2014) 429–435


International Society of Neuropathology-Haarlem ConsensusGuidelines for Nervous System Tumor ClassificationGuidelines for Nervous System Tumor Classificationand Grading

molecular testing is performed. (See example of adultdiffuse gliomas, below. Note that this is an example onlyand that the eventual definitions will result from the WHOclassification updating process.)(iii) To do the above, the definitions of some diseaseentities need to be refined, while others need to be added.

(b) For some diagnostic entities, histology alone will remainthe basis for definition and diagnosis.

(3) A key concept was that diagnoses should be “layered” in orderto provide a format for displaying multiple types of information(Tables 2–5). The analogy is to modern map technology, in whichmultiple layers can be readily superimposed on top of one anotherfor easy viewing; such an approach has been advocated for diseasetaxonomy in general (2). A layered approach also facilitates stand-ardization of diagnosis, which will be necessary to use such diag-nostic information in computational systems. The suggestedformat is summarized in Table 2.

(a) The “integrated diagnosis” will be the top line in order toemphasize its primacy over the other lines even though it willbe the last portion of the diagnostic format completed, as it isdependent on all diagnostic information being present. It isanticipated therefore that the integrated diagnosis will be“pending” for a period of time between histological examina-tion and the availability of molecular information.(b) The “histological classification” is the standard micro-scopic diagnosis that is based on hematoxylin and eosinstaining and additional histological techniques such as histo-chemistry, immunohistochemistry and electron microscopy.(c) The “WHO grade” is the standard histological grade. Asin the past, WHO grade reflects natural history after surgeryalone, rather than expected patient prognosis following currentadjuvant therapies. For example, despite substantiallyimproved control rates with current therapy, a medulloblas-toma is still considered WHO grade IV as, if left withoutadequate postoperative treatment, it will follow a rapidly pro-gressive, typically fatal course. Thus, the question arose as to

whether a separate, additional grade reflecting expectedbehavior following therapy should be considered. However,because both current therapies and responses are subject tochanges and having two different grades on a single report isconfusing, the group opined that only a WHO grade based onnatural history should be reported. This discussion raised theadditional challenge that in some tumor types (eg, IDH-mutantglioblastoma or WNT-subgroup medulloblastoma in a child),stressing the WHO grade in the diagnosis may be more con-fusing than helpful, and that such situations may require acomment stating that the prognosis is better in such a molecu-lar subtype than suggested by the grade.(d) The “molecular information” is a synoptic account of theresults of the molecular tests recommended for that particulartumor entity. Notably, the specific molecular tests recom-mended vary among tumor entities and will likely change overtime. Moreover, the reporting of such molecular informationshould follow a set of guidelines, which are outlined in thefollowing section.

(4) Regarding molecular testing and reporting:(a) Whether particular tests are required or recommended fordiagnosis will depend on the biological properties of indi-vidual tumor types and whether the reported biomarkers arediagnostic, prognostic and/or predictive.

Table 2. Report format.

Layer 1: Integrated diagnosis (incorporating all tissue-basedinformation)

Layer 2: Histological classificationLayer 3: WHO grade (reflecting natural history)Layer 4: Molecular information

Table 3. Diagnosis example: atypical teratoid/rhabdoid tumor.

A B

Integrated diagnosis Atypical teratoid/rhabdoid tumor, WHO grade IV Embryonal tumor with rhabdoid features, WHO grade IVHistological classification Embryonal tumor with rhabdoid features Embryonal tumor with rhabdoid featuresWHO grade IV IVMolecular information INI1 loss of protein expression/mutation or BRG1

loss of protein expression/mutationINI1 and BRG1 protein expression retained/not mutated

or molecular/immunohistochemical testing not performed

In this example, using the layered diagnosis format, the integrated diagnosis of atypical teratoid/rhabdoid tumor is only possible in the setting ofeither INI1 or BRG1 loss of protein expression or mutation (column A); without these findings, only a descriptive diagnosis is possible (column B).(Note that this is an example only and that the eventual definition will result from the WHO classification updating process.)

Table 4. Reporting format example: medulloblastoma.

Integrateddiagnosis

Medulloblastoma histological subtype and molecularsubgroup (eg, Wnt, SHH, non-WNT/non-SHH*),WHO grade IV

Histologicalclassification

Classic, anaplastic, large cell, desmoplastic/nodular,medulloblastoma with extensive nodularity

WHO grade IVMolecular

informationMYC amp, NMYC amp, TP53 status, CTNNB1

status, SMO status, PTCH status, i17q,monosomy 6**

Medulloblastoma diagnosis would incorporate the histological subtype,the WHO grade and the molecular subgroup.*This is just an example of an approach to biological subgrouping anddecisions on recommended subgrouping would await further delibera-tion by the WHO working group.**This list of potentially detectable molecular alterations (presence vs.absence) is illustrative only and decisions on recommended tests wouldawait further deliberation by the WHO working group.Abbreviations: Amp = gene amplification; i17q = isochromosome orisodicentric chromosome 17q.

ISN-Haarlem Brain Tumor Classification Guidelines Louis et al

432 Brain Pathology 24 (2014) 429–435

© 2014 The Authors. Brain Pathology published by John Wiley & Sons Ltd on behalf of International Society of Neuropathology


(b) Future decisions to incorporate such testing into diagnos-tic definitions will be based on conclusive published evidencefrom multiple independent studies.(c) For some genetic tests, some general methodologicalapproaches may be recommended over others (eg, detectingwhole-arm loss in oligodendrogliomas). In some situations,second-level tests should follow first-level tests (eg, IDH1/2sequencing to exclude rare mutations if IDH1 R132Himmunohistochemistry is negative).(d) In settings in which molecular testing is required or rec-ommended, a report should state if it was not done(“unknown”) or if ordered (“pending”), along with a reason ifnot performed (eg, “tissue insufficient for molecular testingfor MGMT promoter methylation status”).(e) The methodological and results parameters of the assaysperformed should be included in reports in order to providetesting details and interpretive significance. This was feltimportant as, in some institutions, molecular reports are sepa-rate from surgical pathology reports and the results of molecu-lar testing are either left out of the pathology report entirely oronly abstracted in addenda. The group felt that by incorporat-ing the pertinent details into the original surgical pathologyreport, this would facilitate comparability of data and multi-institutional patient care, given that the pathology report aloneis often forwarded to outside centers.(f) Molecular testing must be based on histologically repre-sentative tissue. While this practice is routine in most aca-demic centers, it remains possible that fragments of tissue aresent directly by neurosurgeons to molecular testing laborato-ries without histological confirmation; this practice risks false-negative results and must be avoided.

(5) The grading of adult type diffuse gliomas will followstandard, current WHO criteria for astrocytomas andoligodendrogliomas with the caveat that in some circumstances,assigning a precise grade is not possible. The latter is most rel-evant for the category of diffuse glioma that is not clearly of pureastrocytic or pure oligodendroglial subtype, either in the settingof a small biopsy in which selective sampling may be a concernor because of lack of molecular studies being performed, a dis-cordance between morphology and molecular studies (eg, ahistologically classic oligodendroglioma that lacks 1p/19qco-deletion or shows ATRX loss), or a molecular pattern that doesnot fit neatly into a single tumor type. In such circumstances, theWHO grade may either be left off altogether (preferably with anexplanatory comment) or may appear as “high grade” or “at leastWHO grade . . .”. For example, a phenotypically ambiguousdiffuse glioma with atypia, mitoses, microvascular proliferation,and necrosis could initially be diagnosed as being “at least WHOgrade III” given that it would qualify as grade III ifoligodendroglial (ie, anaplastic oligodendroglioma) or grade IVif astrocytic (ie, glioblastoma). In compliance with WHO termi-nology, the term “anaplastic” will precede any astrocytic oroligodendroglial tumor qualifying for a grade III designation. Theterm glioblastoma will be utilized for astrocytic neoplasms quali-fying as grade IV.(6) Some pediatric tumor types will require separation fromtheir adult histological “look-alikes.” Separating these pediatricentities becomes critical now that there is clear evidence that theunderlying molecular basis is different (eg, histone H3.3 K27Mmutations in diffuse pediatric high-grade gliomas/intrinsic pon-tine gliomas and a rarity of 1p/19q co-deletion in pediatricoligodendrogliomas).

Table 5. Example: integrated diagnoses for WHO grade II adult diffuse gliomas.#

Histologic classification

Diffuse astrocytoma Oligodendroglioma “Oligoastrocytoma” orambiguous histology

Mol

ecul

arin

form

atio

n

IDH-mut, 1p/19q-nondel,ATRX loss

Diffuse astrocytoma, ATRX loss ofexpression

Diffuse glioma* (oligodendrogliomaphenotype), 1p/19q non-deleted,ATRX loss of expression

Diffuse astrocytoma, ATRXloss of expression

IDH-mut, 1p/19q-codel,ATRX intact

Diffuse glioma (astrocytomaphenotype), 1p/19q-codeleted

Oligodendroglioma, 1p/19q-codeleted Oligodendroglioma, 1p/19q-codeleted

IDH wild type Diffuse astrocytoma, IDH wild type* Diffuse glioma* (oligodendrogliomaphenotype), IDH wild type*

Diffuse astrocytoma, IDHwild type*

Testing not performed Diffuse astrocytoma, NOS Oligodendroglioma, NOS “Diffuse glioma, NOS”

This example shows how the integrated diagnostic terms for adult WHO grade II diffuse gliomas (names in italics in boxes) could involve acombination of histological and molecular data, although an NOS (not otherwise specified) diagnosis would be made in the absence of molecularinformation (bottom row). Highlighted in light gray are the common, narrowly histologically and molecularly defined, “classic” diffuse astrocytoma andoligodendroglioma. Note that in this suggested scheme, the term “oligoastrocytoma” does not appear in a diagnostic box, with the last columnshowing the alternative diagnoses for what has been inconsistently termed “oligoastrocytoma.”#A similar classification scheme would apply for WHO grade III, anaplastic gliomas.*This tumor type may include gliomas that carry genetic alterations similar to primary glioblastoma (eg, +7/!10, EGFR gene amplification) and areassociated with poor prognosis, in particular in the setting of anaplastic (WHO grade III) histology. (Note that this table is an example only; the eventualdefinitions would result from the WHO classification updating process.)Abbreviations: 1p/19q-codel = whole-arm 1p and 19q co-deletion; ATRX intact = retained nuclear expression by immunohistochemistry; ATRXloss = loss of nuclear expression in tumor cells (with retained expression in non-neoplastic cells as positive control); Mut = mutant form.

Louis et al ISN-Haarlem Brain Tumor Classification Guidelines

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doi:10.1111/bpa.12171


429Brain Pathology 24 (2014) 429–435



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Acta Neuropathol (2015) 129:133–146DOI 10.1007/s00401-014-1370-3

ORIGINAL PAPER

ATRX and IDH1-R132H immunohistochemistry with subsequent copy number analysis and IDH sequencing as a basis for an “integrated” diagnostic approach for adult astrocytoma, oligodendroglioma and glioblastoma

David E. Reuss · Felix Sahm · Daniel Schrimpf · Benedikt Wiestler · David Capper · Christian Koelsche · Leonille Schweizer · Andrey Korshunov · David T. W. Jones · Volker Hovestadt · Michel Mittelbronn · Jens Schittenhelm · Christel Herold-Mende · Andreas Unterberg · Michael Platten · Michael Weller · Wolfgang Wick · Stefan M. Pfister · Andreas von Deimling

Received: 17 October 2014 / Revised: 17 November 2014 / Accepted: 19 November 2014 / Published online: 27 November 2014 © Springer-Verlag Berlin Heidelberg 2014

1p/19q codeletion in a series of 405 adult patients. Among the WHO 2007 classified tumors were 152 astrocytomas, 61 oligodendrogliomas, 63 oligoastrocytomas and 129 glioblas-tomas. Following the concepts of the “ISN-Haarlem”, we rediagnosed the series to obtain “integrated” diagnoses with 155 tumors being astrocytomas, 100 oligodendrogliomas and 150 glioblastomas. In a subset of 100 diffuse gliomas from the NOA-04 trial with long-term follow-up data available, the “integrated” diagnosis had a significantly greater prognostic power for overall and progression-free survival compared to WHO 2007. Based on the “integrated” diagnoses, loss of ATRX expression was close to being mutually exclusive to 1p/19q codeletion, with only 2 of 167 ATRX-negative tumors

Abstract Diffuse gliomas are represented in the 2007 WHO classification as astrocytomas, oligoastrocytomas and oligodendrogliomas of grades II and III and glioblasto-mas WHO grade IV. Molecular data on these tumors have a major impact on prognosis and therapy of the patients. Con-sequently, the inclusion of molecular parameters in the WHO definition of brain tumors is being planned and has been forwarded as the “ISN-Haarlem” consensus. We, here, ana-lyze markers of special interest including ATRX, IDH and

Electronic supplementary material The online version of this article (doi:10.1007/s00401-014-1370-3) contains supplementary material, which is available to authorized users.

D. E. Reuss · F. Sahm · D. Schrimpf · D. Capper · C. Koelsche · L. Schweizer · A. Korshunov · A. von Deimling (� ) German Cancer Consortium (DKTK), CCU Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germanye-mail: [email protected]

D. E. Reuss · F. Sahm · D. Schrimpf · D. Capper · C. Koelsche · L. Schweizer · A. Korshunov · A. von Deimling Department Neuropathology, Institute of Pathology, University of Heidelberg, Heidelberg, Germany

B. Wiestler · M. Platten · W. Wick Neurology Clinic, Heidelberg University Hospital, Heidelberg, Germany

B. Wiestler · W. Wick Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany

D. T. W. Jones · S. M. Pfister Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany

V. Hovestadt Division of Molecular Genetics, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany

M. Mittelbronn Institute of Neurology (Edinger Institute), Goethe University, Frankfurt, Germany

M. Mittelbronn German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany

J. Schittenhelm Department of Neuropathology, Institute of Pathology and Neuropathology, University Tuebingen, Tuebingen, Germany

C. Herold-Mende · A. Unterberg Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany

139Acta Neuropathol (2015) 129:133–146

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with a typical pattern—all tumor cell nuclei are completely unstained while nuclear positivity is seen in vessels, micro-glia, reactive astrocytes and entrapped neurons. ATRX immunohistochemistry is significantly affected by the quality of material—tumor portions not sufficiently fixed or thermally altered do not provide satisfactory results. In our experience, however, most tissue blocks contain areas with tumor tissue of sufficient quality for evaluation. In regard to tumor cell content in a sample for ATRX evalu-ation: We did not systematically assess ATRX loss in the infiltration zone of astrocytoma, however, we advise to perform such analysis preferably in solid tumor tissue. We consider this method not suitable for the analysis of single cells. We detected only one single case with focal ATRX loss that could not be attributed to suboptimal quality of the material. Thus, we assume focal loss of ATRX expression to be diagnostic if internal controls in these regions such as endothelia or microglia demonstrate nuclear staining. In our series, 38/42 (90 %) of WHO II and 101/113 (89 %) of WHO III astrocytomas presented with loss of ATRX expression. In contrast, 0/28 (0 %) oligodendrogliomas and 2/72 (3 %) anaplastic oligodendrogliomas showed loss of ATRX. This difference is significant (p � 1.70 ! 10"50; Fisher’s exact test). Further, 25/136 (18 %) of glioblasto-mas and 1/14 (7 %) gliosarcomas displayed loss of ATRX. Loss of ATRX and mutation of the TERT promoter were almost mutually exclusive in this series (p � 9.88 ! 10"47; Fisher’s exact test). Typical examples for ATRX staining are given in Fig. 3.

ATRX association with tumor entity depends on diagnostic approach

Diffuse astrocytoma grade II (AII) diagnosed by WHO 2007 exhibited nuclear ATRX loss in 34/47 (72 %) and anaplastic astrocytoma (AIII) in 72/105 (69 %) of the cases. Applying the “integrated” approach, 36/37 (97 %) AII-IDHmut and 100/103 (97 %) AIII-IDHmut exhibited nuclear ATRX loss. In contrast, only 2/5 of the rare AII-IDHwt and 4/10 (40 %) AIII-IDHwt exhibited nuclear ATRX loss. Oli-godendroglioma grade II (OII) diagnosed by WHO 2007 exhibited nuclear ATRX loss in 3/25 (12 %) and ana-plastic oligodendroglioma (OIII) in 5/36 (14 %) of the cases. Applying the “integrated” approach, 0/28 OII and 2/72 (3 %) OIII exhibited nuclear ATRX loss. OAII diag-nosed by WHO 2007 exhibited nuclear ATRX loss in 5/9 and OAIII in 20/54 (37 %) of the cases. Our “integrated” approach does not recognize the diagnosis of oligoastrocy-toma anymore. This distribution clearly shows the poten-tial of ATRX status to differentiate astrocytoma from oli-godendroglioma in IDH-mutated tumors and demonstrates the mixed composition of the WHO 2007 oligoastrocytoma groups. Independently of the diagnostic approach, the dif-ferences in ATRX association with a tumor entity were remarkably stable across tumor grades. This in fact, holds true also for 1p/19qcodel and IDH mutations.

Association of ATRX expression with 1p/19q and IDH status

Inclusion of an additional molecular basis for the genera-tion of an integrated diagnosis in our set of 405 tumors resulted in 6 groups. Within these groups, there is strik-ingly little overlap of the genetic lesions. AII and AIII typically carry IDH mutations and exhibit loss of nuclear ATRX expression. OII and OIII carry 1p/19q codel and IDH mutations and only two of these tumors exhibited loss of nuclear ATRX expression. Interestingly, both of these cases had a wild-type TERT promoter and this is typical for astrocytoma, whereas the vast majority of oligodendroglio-mas carry a TERT promoter mutation [25, 26]. GBM and GS typically exhibit the combination of 7p gain and 10q loss accompanied by absence of IDH mutations and main-tenance of nuclear ATRX expression. A set of 23 GBM demonstrated nuclear ATRX loss and among these 11 car-ried an IDH mutation. Interestingly, H3F3A mutations (4 cases with K27M and 4 cases with G34R) in glioblastoma were only seen in combination with nuclear ATRX loss and without IDH mutation—providing evidence for a GBM subset in adult patients with molecular similarities to pedi-atric GBM [44]. In each of the groups, a few cases did not match the expected pattern: One AII and 6 AIII with IDH mutation did not exhibit ATRX loss. These observations

O61 63 152 93 12 7 3 14

O100 119 14 3 14

A sMBGAO GBM GBMo gcGBM GS

A-IDHwt GBM-IDHmutGBM gcGBM GSA-IDHmut

139 16

ini!al diagnosis

integrated diagnosis

Fig. 2 Changes from initial to integrated diagnosis in 405 adult patients with supratentorial glioma. Width of bars indicates relative proportions of the initial tumor groups. A astrocytoma, OA oligoastro-cytoma, O oligodendroglioma, GBM glioblastoma, GBMo glioblas-toma with oligodendroglial component, GBMs secondary glioblas-toma, gcGBM giant cell glioblastoma, GS gliosarcoma

405 casos


142 Acta Neuropathol (2015) 129:133–146

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loss the typical molecular fingerprint of diffuse astrocy-toma including its manifestation having progressed towards glioblastoma. Likewise, the combination of IDH mutation and ATRX loss virtually excludes the presence of complete 1p/19q loss and thus the diagnosis of oligodendroglioma in its narrower ISN-Haarlem boundaries. The combination of IDH mutation and ATRX loss is, therefore, expected to reduce the need for 1p/19q analysis by a significant fraction of tumors.

Oligoastrocytoma

Oligoastrocytoma is a well-established diagnosis in WHO 2007. Diagnosing tumors on the basis of IDH, ATRX and

1p/19q analysis according to the present suggestion groups these tumors either to astrocytoma or oligodendroglioma. The demonstration of 1p/19q status being of much more relevance to prognosis and treatment response than the morphological differentiation between astrocytoma, oli-goastrocytoma and oligodendroglioma clearly warrants such an approach. Further, we recently demonstrated on a series of IDH1-R132H mutated oligoastrocytomas diag-nosed at different institutions that these cases could be reli-ably allotted either to astrocytoma or oligodendroglioma based on molecular data [40], and an epigenome-wide anal-ysis of a large cohort of anaplastic glioma further substanti-ated that there is no biological basis for the diagnosis of an oligoastrocytoma [53].

Glioblastoma with oligodendroglial differentiation

Four of 12 tumors with initial diagnosis of GBMo exhibited 1p/19q codel, and were therefore classified as anaplastic oli-godendroglioma. The remaining 8 tumors were reclassified as GBM, one of which carried an IDH mutation. Separation of these tumors is further supported by the observation that GBMo appears to have a more favorable prognosis, that gliomas with 1p/19q codel nearly inevitably carry an IDH mutation and that IDH mutations are the single most prog-nostic marker in GBM [49]. Our approach aims at classifi-cation, however, it does not solve grading problems. Inter-estingly, the presence of necrosis appears to be no predictor for poorer overall survival in anaplastic oligodendroglioma [32]. Whether the GBMo reclassified as anaplastic oligo-dendroglioma should be allotted a WHO grade higher than III needs to be addressed in further studies.

An “integrated” diagnostic approach alters the frequency of astrocytoma and oligodendroglioma diagnoses

Up to WHO 2007, the frequency with which astrocytoma, oligoastrocytoma and oligodendroglioma were diagnosed

AO OA

A-IDHmut -IDHwt

41 8

O A GBM

ini!al diagnosis

integrated diagnosis

16 37 47

37 14

Fig. 5 Changes from initial to integrated diagnosis in 100 patients with anaplastic astrocytomas, oligoastrocytomas and oligodendro-gliomas diagnosed according to WHO 2007 from the NOA04 study. Width of bars indicates relative proportions of the initial tumor groups. A astrocytoma, OA oligoastrocytoma, O oligodendroglioma, GBM glioblastoma

Table 2 Comparison of WHO 2007 and “integrated” diagnostic approaches with clinical outcome in 100 NOA-04 patients

(def) This parameter is employed for definition of the “integrated” diagnosis

n/r not reached

Diagnosis WHO 2007 “Integrated” diagnosis

A OA O A-IDHmut O A-IDHwt GBM-IDHwt

Number 47 37 16 41 37 8 14

1p/19-codel 3 23 11 0 (def) 37 (def) 0 (def) 0 (def)

IDH-mut 30 34 14 41 (def) 37 0 (def) 0

7p-gain 13 4 2 4 2 2 11

10q-loss 19 4 2 7 2 2 14

7p-gain/10q-loss 10 1 0 0 0 0 (def) 11 (def)

EGFR-amp 7 1 0 0 0 0 (def) 8 (def)

ATRX loss 27 12 3 36 2 4 0

Mean OS 1,536 2,182 n/r 2,182 n/r 1,883 706

Mean TTF 1,175 1,840 1,684 1,691 n/r 1,325 374


1 3

demonstrated a great inter-institutional variation. Most of this variation was accounted for by the use of the diagno-sis oligoastrocytoma. Linking the definition of astrocytoma

and oligodendroglioma more strongly to biological param-eters and omitting the use of the diagnosis oligoastrocy-toma will reduce this inter-institutional variation. In our

Time (days)

Anaplastic oligodendroglioma (WHO grade III)Anaplastic oligoastrocytoma (WHO grade III)Anaplastic astrocytoma (WHO grade III)

Time (days)

Anaplastic oligodendroglioma (WHO grade III)Anaplastic astrocytoma (WHO grade III) IDH mutatedAnaplastic astrocytoma (WHO grade III)Glioblastoma (WHO grade IV)

Prediction Error for TTFPrediction Error for OS

OS for 2007 reference histology TTF for 2007 reference histology

OS for „integrated“ diagnosis

Time (days)


TTF for „integrated“ diagnosis

Time (days)


Time (days)

NullModelWHO2007Integrated

Time (days)

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Fig. 6 OS (panels on left) and TTF (panels on right) of 100 NOA-04 patients with anaplastic astrocytomas, oligoastrocytomas and oli-godendrogliomas diagnosed according to WHO 2007 (upper panels) and receiving an “integrated” diagnosis (middle panels). Lower pan-els show prediction error curves for OS (left) and TTF (right), depict-

ing the Brier score over time. A higher prediction error indicates a greater difference between observed (known) survival status of patients and the survival probabilities calculated from the respective Cox model, i.e., less prediction accuracy. OS overall survival, TTF time to treatment failure


1 3

demonstrated a great inter-institutional variation. Most of this variation was accounted for by the use of the diagno-sis oligoastrocytoma. Linking the definition of astrocytoma

and oligodendroglioma more strongly to biological param-eters and omitting the use of the diagnosis oligoastrocy-toma will reduce this inter-institutional variation. In our

Time (days)


Time (days)


Prediction Error for TTFPrediction Error for OS

OS for „integrated“ diagnosis

Time (days)


TTF for „integrated“ diagnosis

Time (days)


NullModelWHO2007Integrated

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Fig. 6 OS (panels on left) and TTF (panels on right) of 100 NOA-04 patients with anaplastic astrocytomas, oligoastrocytomas and oli-godendrogliomas diagnosed according to WHO 2007 (upper panels) and receiving an “integrated” diagnosis (middle panels). Lower pan-els show prediction error curves for OS (left) and TTF (right), depict-

ing the Brier score over time. A higher prediction error indicates a greater difference between observed (known) survival status of patients and the survival probabilities calculated from the respective Cox model, i.e., less prediction accuracy. OS overall survival, TTF time to treatment failure

-! Mejor correlación con supervivencia -! Menor variabilidad intra e interobservador


Nature Reviews Cancer 4, 718-727

Raf quinasas: A-Raf, B-Raf, C-Raf

Vía de señalización celular Ras, Raf, MAPK

Proliferación celular


BRAF

MUTACIÓN V600E

FUSIÓN BRAF-KIAA

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Muestra WT Muestra Mutada (V600E)

GTG>GAG Valina>glutamato

ESTUDIO DE MUTACIÓN DE BRAF V600E

Muestra WT Muestra Mutada (V600E)


ORIGINAL PAPER

Analysis of BRAF V600E mutation in 1,320 nervous system tumorsreveals high mutation frequencies in pleomorphic xanthoastrocytoma,ganglioglioma and extra-cerebellar pilocytic astrocytoma

Genevieve Schindler � David Capper � Jochen Meyer � Wibke Janzarik � Heymut Omran �

Christel Herold-Mende � Kirsten Schmieder � Pieter Wesseling � Christian Mawrin � Martin Hasselblatt �

David N. Louis � Andrey Korshunov � Stefan Pfister � Christian Hartmann � Werner Paulus �

Guido Reifenberger � Andreas von Deimling

Received: 11 January 2011 / Revised: 18 January 2011 /Accepted: 18 January 2011 / Published online: 29 January 2011! Springer-Verlag 2011

Abstract Missense mutations of the V600E type consti-tute the vast majority of tumor-associated somatic

alterations in the v-RAF murine sarcoma viral oncogene

homolog B1 (BRAF) gene. Initially described in melanoma,colon and papillary thyroid carcinoma, these alterations

have also been observed in primary nervous system tumors

albeit at a low frequency. We analyzed exon 15 of BRAFspanning the V600 locus by direct sequencing in 1,320

adult and pediatric tumors of the nervous system including

various types of glial, embryonal, neuronal and glioneuro-nal, meningeal, adenohypophyseal/sellar, and peripheral

nervous system tumors. A total of 96 BRAF mutations weredetected; 93 of the V600E type and 3 cases with a three base

pair insertion between codons 599 and 600. The highest

frequencies of BRAFV600E mutations were found in WHOgrade II pleomorphic xanthoastrocytomas (42/64; 66%) and

pleomorphic xanthoastrocytomas with anaplasia (15/23;

65%), as well as WHO grade I gangliogliomas (14/77;18%), WHO grade III anaplastic gangliogliomas (3/6) and

pilocytic astrocytomas (9/97; 9%). In pilocytic astrocyto-

mas BRAFV600E mutation was strongly associated withextra-cerebellar location (p = 0.009) and was most fre-

quent in diencephalic tumors (4/12; 33%). Glioblastomas

and other gliomas were characterized by a low frequency orG. Schindler and D. Capper contributed equally to this work.

D. Capper ! C. Hartmann ! A. von Deimling ( � )Department of Neuropathology, Institute of Pathology,Ruprecht-Karls-University Heidelberg, Im Neuenheimer Feld220/221, 69120 Heidelberg, Germanye-mail: [email protected]

D. Capper ! J. Meyer ! A. Korshunov ! C. Hartmann !A. von DeimlingClinical Cooperation Unit Neuropathology G380,German Cancer Research Center, Heidelberg, Germany

G. Schindler ! K. SchmiederDepartment of Neurosurgery, Medical Facultyof the Ruprecht-Karls-University Heidelberg,Mannheim, Germany

C. Herold-MendeDivision of Neurosurgical Research,Department of Neurosurgery,Ruprecht-Karls-University Heidelberg,Heidelberg, Germany

P. WesselingDepartment of Pathology, Nijmegen Center for Molecular LifeSciences (NCMLS), Radboud University Nijmegen MedicalCentre, Nijmegen, The Netherlands

C. MawrinDepartment of Neuropathology,Otto-von-Guericke-University Magdeburg,Magdeburg, Germany

M. Hasselblatt ! W. PaulusInstitute of Neuropathology,University Hospital Munster, Munster, Germany

D. N. LouisDepartment of Pathology,Massachusetts General Hospital and Harvard Medical School,Boston, MA, USA

S. PfisterDivision Molecular Genetics,German Cancer Research Center, Heidelberg, Germany

S. PfisterPediatric Hematology and Oncology,Heidelberg University Hospital, Heidelberg, Germany

G. ReifenbergerDepartment of Neuropathology,Heinrich Heine University, Dusseldorf, Germany

123

Acta Neuropathol (2011) 121:397–405

DOI 10.1007/s00401-011-0802-6

Mutación BRAF V600E descrita en: -! Melanoma -! Carcinoma de colon -! Carcinoma papilar de tiroides

!! Xantoastrocitomas pleomórficos: 66% !! XAP con rasgos anaplásicos: 65%

!! Gangliogliomas: 18% !! Gangliogliomas anaplásicos (3/6)

Astrocitomas pilocíticos: 9% !! DIENCEFÁLICOS !! EXTRA-CEREBELOSOS


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XANTOASTROCITOMA PLEOMÓRFICO Con MUTACIÓN BRAF V600E:

-! Localización TEMPORAL -! Mayor trama de reticulina -! Mayor expresión de CD34

R E S E A R C H A R T I C L E

BRAF-Mutated Pleomorphic Xanthoastrocytoma isAssociated with Temporal Location, Reticulin FiberDeposition and CD34 ExpressionChristian Koelsche1,2; Felix Sahm1,2; Adelheid Wöhrer3; Astrid Jeibmann4; Jens Schittenhelm5;Patricia Kohlhof6; Matthias Preusser7,8; Bernd Romeike9; Hildegard Dohmen-Scheufler10;Christian Hartmann11; Michel Mittelbronn12,13,14; Albert Becker15; Andreas von Deimling1,2;David Capper1,2

1 Department of Neuropathology, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany.2 German Cancer Consortium (DKTK), CCU Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany.3 Institute of Neurology, Medical University of Vienna, Vienna, Austria.4 Institute of Neuropathology, University Hospital Münster, Münster, Germany.5 Department of Neuropathology, Institute for Pathology and Neuropathology, University of Tübingen, Tübingen, Germany.6 Department of Pathology, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany.7 Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.8 Department of Medicine I, Medical University of Vienna, Vienna, Austria.9 Institute of Pathology, Department of Neuropathology, Jena University Hospital, Friedrich Schiller University, Jena, Germany.10 Institute of Neuropathology, Medical School, Justus Liebig University, Giessen, Germany.11 Department for Neuropathology, Hannover Medical School, Hanover, Germany.12 Neurological Institute (Edinger-Institut), Goethe University, Frankfurt am Main, Germany.13 German Cancer Consortium (DKTK), Heidelberg, Germany.14 German Cancer Research Center (DKFZ), Heidelberg, Germany.15 Department of Neuropathology, University of Bonn, Bonn, Germany.

Keywordsbrain tumor, BRAF V600E, CDKN2A, CD34,immunohistochemistry, pleomorphicxanthoastrocytoma, p16, VE1.

Corresponding author:David Capper, MD, Department ofNeuropathology, Ruprecht-Karls-UniversitätHeidelberg, Im Neuenheimer Feld 224,D-69120 Heidelberg, Germany (E-mail:[email protected])

Received 10 September 2013Accepted 20 November 2013Published Online Article Accepted 18December 2013

Conflict of interest: David Capper andAndreas von Deimling have applied for apatent on the diagnostic use of BRAF V600Emutant-specific antibody VE1. All terms arebeing managed by the German CancerResearch Center in accordance with itsconflict of interest policies. The other authorsdo not have any conflicts of interest todisclose.

doi:10.1111/bpa.12111

AbstractBRAF V600E mutation and homozygous deletion of CDKN2A (p16) are frequent molecu-lar alterations in pleomorphic xanthoastrocytomas (PXAs). We investigated 49 PXAsfor clinical, histological and immunohistochemical characteristics related to BRAFmutation status. BRAF mutation was detected by immunohistochemical assay and DNAsequencing in 38/49 (78%) tumors. All but one PXA located in the temporal lobeharbored a BRAF V600E mutation (23/24; 96%) compared with 10/19 nontemporalPXAs (53%; P = 0.0009). Histological and immunohistochemical analysis demonstratedincreased reticulin deposition (76% vs. 27%; P = 0.003) and a more frequent expression ofCD34 in BRAF-mutant PXAs (76% vs. 27%; P = 0.003).

We further investigated the utility of combined BRAF V600E (VE1) and p16 analysis byimmunohistochemistry to distinguish PXAs from relevant histological mimics like giant-cell glioblastoma. Among PXAs, 38/49 (78%) were VE1-positive, and 30/49 (61%) had aloss of p16 expression. The combined features (VE1 positivity/p16 loss) were observed in25/49 PXAs (51%) but were not observed in giant-cell glioblastoma (VE1 0/28, p16 loss14/28). We demonstrate that temporal location, reticulin deposition and CD34 expressionare associated with BRAF mutation in PXA. Combined VE1 positivity and p16 lossrepresents a frequent immunoprofile of PXA and may therefore constitute an additionaldiagnostic tool for its differential diagnosis.


221Brain Pathology 24 (2014) 221–229

© 2013 International Society of Neuropathology

R E S E A R C H A R T I C L E

BRAF-Mutated Pleomorphic Xanthoastrocytoma isAssociated with Temporal Location, Reticulin FiberDeposition and CD34 ExpressionChristian Koelsche1,2; Felix Sahm1,2; Adelheid Wöhrer3; Astrid Jeibmann4; Jens Schittenhelm5;Patricia Kohlhof6; Matthias Preusser7,8; Bernd Romeike9; Hildegard Dohmen-Scheufler10;Christian Hartmann11; Michel Mittelbronn12,13,14; Albert Becker15; Andreas von Deimling1,2;David Capper1,2

1 Department of Neuropathology, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany.2 German Cancer Consortium (DKTK), CCU Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany.3 Institute of Neurology, Medical University of Vienna, Vienna, Austria.4 Institute of Neuropathology, University Hospital Münster, Münster, Germany.5 Department of Neuropathology, Institute for Pathology and Neuropathology, University of Tübingen, Tübingen, Germany.6 Department of Pathology, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany.7 Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.8 Department of Medicine I, Medical University of Vienna, Vienna, Austria.9 Institute of Pathology, Department of Neuropathology, Jena University Hospital, Friedrich Schiller University, Jena, Germany.10 Institute of Neuropathology, Medical School, Justus Liebig University, Giessen, Germany.11 Department for Neuropathology, Hannover Medical School, Hanover, Germany.12 Neurological Institute (Edinger-Institut), Goethe University, Frankfurt am Main, Germany.13 German Cancer Consortium (DKTK), Heidelberg, Germany.14 German Cancer Research Center (DKFZ), Heidelberg, Germany.15 Department of Neuropathology, University of Bonn, Bonn, Germany.

Keywordsbrain tumor, BRAF V600E, CDKN2A, CD34,immunohistochemistry, pleomorphicxanthoastrocytoma, p16, VE1.

Corresponding author:David Capper, MD, Department ofNeuropathology, Ruprecht-Karls-UniversitätHeidelberg, Im Neuenheimer Feld 224,D-69120 Heidelberg, Germany (E-mail:[email protected])

Received 10 September 2013Accepted 20 November 2013Published Online Article Accepted 18December 2013

Conflict of interest: David Capper andAndreas von Deimling have applied for apatent on the diagnostic use of BRAF V600Emutant-specific antibody VE1. All terms arebeing managed by the German CancerResearch Center in accordance with itsconflict of interest policies. The other authorsdo not have any conflicts of interest todisclose.

doi:10.1111/bpa.12111

AbstractBRAF V600E mutation and homozygous deletion of CDKN2A (p16) are frequent molecu-lar alterations in pleomorphic xanthoastrocytomas (PXAs). We investigated 49 PXAsfor clinical, histological and immunohistochemical characteristics related to BRAFmutation status. BRAF mutation was detected by immunohistochemical assay and DNAsequencing in 38/49 (78%) tumors. All but one PXA located in the temporal lobeharbored a BRAF V600E mutation (23/24; 96%) compared with 10/19 nontemporalPXAs (53%; P = 0.0009). Histological and immunohistochemical analysis demonstratedincreased reticulin deposition (76% vs. 27%; P = 0.003) and a more frequent expression ofCD34 in BRAF-mutant PXAs (76% vs. 27%; P = 0.003).

We further investigated the utility of combined BRAF V600E (VE1) and p16 analysis byimmunohistochemistry to distinguish PXAs from relevant histological mimics like giant-cell glioblastoma. Among PXAs, 38/49 (78%) were VE1-positive, and 30/49 (61%) had aloss of p16 expression. The combined features (VE1 positivity/p16 loss) were observed in25/49 PXAs (51%) but were not observed in giant-cell glioblastoma (VE1 0/28, p16 loss14/28). We demonstrate that temporal location, reticulin deposition and CD34 expressionare associated with BRAF mutation in PXA. Combined VE1 positivity and p16 lossrepresents a frequent immunoprofile of PXA and may therefore constitute an additionaldiagnostic tool for its differential diagnosis.


221Brain Pathology 24 (2014) 221–229

© 2013 International Society of Neuropathology

-! Mayor supervivencia global

Pleomorphic XanthoastrocytomaWhat Do We Really Know about It?

Caterina Giannini, M.D., Ph.D.1

Bernd W. Scheithauer, M.D.1

Peter C. Burger, M.D.2

Daniel J. Brat, M.D., Ph.D.2

Peter C. Wollan, Ph.D.3

Bolek Lach, M.D.4

Brian P. O’Neill, M.D.5

1 Department of Pathology, Mayo Clinic, Roches-ter, Minnesota.

2 Department of Pathology, Johns Hopkins Hospi-tal, Baltimore, Maryland.

3 Department of Biostatistics, Mayo Clinic, Roch-ester, Minnesota.

4 Department of Pathology, Ottawa Civic Hospital,Ottawa, Canada.

5 Department of Neurology, Mayo Clinic, Roches-ter, Minnesota.

Presented in part at the 73rd annual meeting of theAmerican Association of Neuropathologists, Pitts-burgh, Pennsylvania, June 11–16, 1997.

Address for reprints: Bernd W. Scheithauer, M.D.,Department of Pathology and Laboratory Medicine,Mayo Clinic, 200 1st Street S.W., Rochester, MN55905.

Received July 30, 1998; revision received Decem-ber 3, 1998; accepted December 23, 1998.

BACKGROUND. Pleomorphic xanthoastrocytomas (PXA) may recur and demon-strate aggressive clinical behavior with a mortality rate between 15% and 20%. Tothe authors’ knowledge, no histopathologic features currently are known to reliablypredict recurrence or tumor progression.METHODS. The study was based on 71 cases with available information regardingclinical and therapeutic data and follow-up. Diagnostic features included cellularpleomorphism, giant and/or xanthic cells, eosinophilic granular bodies, desmo-plasia, and leptomeningeal involvement. The mitotic index (MI), the presence ofnecrosis, and endothelial proliferation were recorded in all primary resectionspecimens.RESULTS. The study included 35 females and 36 males, age 26 ! 16 years (mean !

standard deviation). Approximately 98% of tumors were supratentorial, with 49%in the temporal lobe. Seizures were the presenting symptoms in 71% of patients.Extent of tumor removal was macroscopic total resection in 68% of cases andsubtotal resection (STR) in 32% of cases. Postoperative radiotherapy, alone or withchemotherapy, was administered in 29% and 12.5% of cases, respectively. Therecurrence free survival rates (RFS) were 72% at 5 years and 61% at 10 years,whereas overall survivals rates (OS) were 81% at 5 years and 70% at 10 years. Inunivariate analysis, the extent of resection was the single factor associated moststrongly with RFS (P " 0.003), followed by MI (P " 0.007) and atypical mitoses (P "

0.04). Necrosis was not found to be significant. The extent of resection and MI wereconfirmed as independent predictors of RFS by multivariate analysis. MI (P "

0.001), atypical mitoses (P " 0.02), and necrosis (P " 0.04) were associated with OSby univariate analysis. In multivariate analysis, only MI was an independentpredictor of survival. Information regarding MIB-1 labeling index and the use ofadjuvant therapy was too limited to explore their prognostic significance confi-dently.CONCLUSIONS. The study confirms that PXA is an astrocytic tumor with a relativelyfavorable prognosis. MI and extent of resection appear to be the main predictorsof RFS and OS. Given the slow growth of the tumor, more studied cases and longerperiods of follow-up will be essential to confirm our findings regarding prognosticfactors affecting this unusual tumor. Cancer 1999;85:2033– 45.© 1999 American Cancer Society.

KEYWORDS: glioma, pleomorphic xanthoastrocytoma, natural history, pathology,prognostic factors, neurooncology.

P leomorphic xanthoastrocytoma (PXA), a new addition to the re-cent 1993 World Health Organization (WHO) classification of tu-

mors of the central nervous system, was first described by Kepes andcoauthors in 1979.1,2 This morphologically distinctive cerebral gliomaoccurred primarily in young subjects, showed a predilection to su-

2033

© 1999 American Cancer Society

perficial growth, and had a relatively favorable prog-nosis. Prior to that time, such tumors were often clas-sified among giant cell glioblastomas given theirominous histologic features, which include markedcellular pleomorphism, nuclear atypia, and the pres-ence of bizarre, multinucleate giant cells. Due to therich reticulin network that characterizes superficialportions of PXA, some had initially been consideredmesenchymal tumors and were designated fibrousxanthomas or xanthosarcomas by the same author.3

Finally, some had been included in the now defunctcategory of “monstrocellular sarcoma.” Unlike giantcell glioblastomas and sarcomas, however, PXAs areassociated with much longer recurrence free and over-all survivals.

Since its initial description, over 100 PXAs havebeen reported, most as single cases or small series.4 – 67

Consequently, data regarding its natural history andprognostic factors are fragmentary. Nonetheless stud-ies generally confirm the clinical and pathologic ob-servations of the original series. It is of note that PXAmay recur and that 15–20% undergo progressive ana-plastic transformation. Such tumors are less pleomor-phic and are more diffusely infiltrative.62,68 The 1993WHO classification of brain tumors recognizes theoccurrence of Grade 3 (anaplastic) transformation inPXAs but does not provide minimal criteria permittingtheir identification.1 Indeed, a careful review of pub-lished cases leaves the reader without a definitionpermitting prospective identification of “anaplasticPXA,” an aggressive variant prone to recurrenceand/or a fatal outcome. Furthermore, although thereis agreement that surgical resection is the treatment ofchoice, the role of adjuvant therapies is presently un-clear.3

Herein, we studied a large series of patients withPXA in order to better define its clinicopathologic fea-tures and natural history. Our findings were comparedwith an analysis of previously reported, adequatelydocumented cases. Having evaluated clinical data atinitial presentation and the various pathologic fea-tures generally thought to signify aggressive behavior,we found that mitotic index IMI) was the main histo-logic predictor of recurrence and survival. Use of theterm “PXA with anaplastic features” is recommended,followed by a clear statement of just which features,such as increased mitotic activity, necrosis, or otherindicate correlating with potentially more aggressiveclinical behavior were found. We purposely chose notto use the term “anaplastic (Grade 3I) PXA,” becausethat designation may provoke inappropriately aggres-sive treatment. Our results, although based upon thelargest series of patients presently available, might still

not prove to be definitive. More cases and longerfollow-up will be necessary to confirm or refute thesefindings.

MATERIALS AND METHODSPatient IdentificationThe 71 cases studied were derived from the databaseof the Mayo Clinic tissue registry and from the con-sultation files of two of the authors (B.W.S., P.C.B.).Their inclusion was based on availability of originalhematoxylin and eosin (H&E)-stained sections and/orrepresentative paraffin embedded tissue obtained atprimary surgery. Histologic features upon which thediagnosis of PXA was made included the original cri-teria of Kepes et al. as well as those of the 1993 WHOclassification of tumors of the nervous system.1,2 Thus,PXA is a moderately cellular astrocytoma composed ofcells of varying size and shape, giant and lipidizedexamples being characteristic. Often superficial in lo-cation and partly occupying the leptomeninges, PXAinvariably shows some infiltration of underlying brainparenchyma and exhibits a tendency to perivascular(Virchow-Robin) space involvement. Reticulin stainsdemonstrate a meshwork surrounding individual orclusters of tumor cells, especially in superficial andleptomeningeal portions of the tumor. Small numbersof lymphocytes and plasma cells are usually present.Glial fibrillary acidic protein (GFAP) immunoreactivityis seen within the cytoplasm of greatly varying num-bers of tumor cells. Although it was not stressed in theoriginal description of PXA or in the WHO monograph,granular bodies of varying size, texture, and eosino-philia are a regular feature of this tumor.69

Clinical FeaturesData recorded included patient age and gender, pre-senting symptoms e.g., seizure or increased intracra-nial pressure duration of symptoms, tumor location,neuroimaging appearance (e.g., presence of a cyst),and mode of treatment, including type and extent ofsurgery as well as adjuvant radiotherapy and/or che-motherapy.

Pathologic StudiesIn all cases, routinely processed tissues included orig-inal and/or newly prepared 5 !m, H&E-stained sec-tions. All were separately examined by two neuropa-thologists (C.G., B.W.S.), the diagnosis of PXA beingconfirmed independently. Specifically recorded werethe presence of: cellular pleomorphism with multinu-cleate giant cells, spindle cells, small cells, and vacu-olated (xanthic) cells; granular bodies, whether coarseand intensely eosinophilic or delicate and pale;

2034 CANCER May 1, 1999 / Volume 85 / Number 9

Pleomorphic Xanthoastrocytoma: Natural History and Long-term Follow-up. Brain Pathol. 2014 Oct 16. doi: 10.1111/bpa.12217.

CLINICAL STUDY

Salvage therapy with BRAF inhibitors for recurrent pleomorphicxanthoastrocytoma: a retrospective case series

Marc C. Chamberlain

Received: 9 April 2013 / Accepted: 2 June 2013 / Published online: 12 June 2013! Springer Science+Business Media New York 2013

Abstract Pleomorphic xanthoastrocytoma (PXA) is aWorld Health Organization Grade 2 glioma that is

uncommon (\1 % all adult gliomas) and seen primarily in

children and young adults. PXA has been demonstrated tomanifest the V600E BRAF mutation in nearly 70 % of

all tumors, a mutation that constitutively activates the

BRAF/MEK signaling pathway. Assess response and tox-icity of a BRAF inhibitor, vemurafenib, in recurrent PXA

manifesting the V600E mutation. Four adults [2 males; 2

female: median age 45 years (range 34–53)] with surgery,radiation and alkylator refractory recurrent PXA demon-

strating the BRAF mutation (V600E) were treated with

vemurafenib. A cycle of vemurafenib was defined as4 weeks of continuous therapy. All toxicities seen were

grade 2 and included arthralgia, photosensitivity, fatigue

and nausea (1 patient each). The median number of cyclesof therapy was 5 (range 2–10). Radiographic response was

progressive disease in 1, stable disease in 2 and partial

response in 1. Median progression free survival was5 months (range 2–10 months). Median overall survival

was 8 months (range 4–14 months). In this small retro-spective series of select patients with recurrent PXA

manifesting the BRAF V600E activating mutation, vemu-

rafenib appears to have single agent activity with man-ageable toxicity. Confirmation in a larger series of similar

patients is required.

Keywords BRAF inhibitor ! Vemurafenib !Recurrent pleomorphic xanthoastrocytoma (PXA) !Alkylator-refractory

Introduction

Pleomorphic xanthoastrocytoma (PXA) is a World HealthOrganization (WHO) Grade 2 glioma that is uncommon

(\1 % all adult gliomas) and seen primarily in children and

young adults [1–5]. The majority of PXA are supratentorialand nearly one half are located in the temporal lobe. Most

PXA are associated with partial seizures (the commonest

presentation) and have a good prognosis not dissimilar tothat seen in other more common WHO Grade 2 low-grade

gliomas (LGG) in adults. A subset of PXA (*15 %) is

notable for the presence of anaplasia but this pathologicaldifferentiation has no impact on WHO grade. Similar to

other adult LGG, maximum safe resection is the treatment

of first choice and radiotherapy (RT) is reserved forrecurrent disease or in some centers PXA manifesting

anaplasia (the latter category however is not evidenced-

based). Due to the rarity of PXA there is no consensusregarding treatment aside from that espoused for adult

LGG of surgery and RT for patients with high-risk features

as articulated by Pignatti [6]. Temozolomide (TMZ) orother alkylator-based chemotherapies such as BCNU

(carmustine), CCNU (lomustine) or PCV (procarbazine,

CCNU and vincristine) is reserved for patients withrecurrent disease as is customary for other LGG.

Recently, PXA has been demonstrated to manifest the

V600E BRAF mutation in nearly 70 % of all tumors, amutation that constitutively activates the RAS/RAF/MEK/

ERK signaling pathway [7–12]. BRAF is a serine/threonine

kinase downstream from RAS in the mitogen-activated

M. C. ChamberlainDepartment of Neurology and Neurological Surgery,University of Washington, Seattle, WA, USA

M. C. Chamberlain ( � )Division of Neuro-Oncology, Fred Hutchinson Cancer Center,Seattle Cancer Care Alliance, 825 Eastlake Ave E, MS: G4-940,Seattle, WA 98109, USAe-mail: [email protected]

123

J Neurooncol (2013) 114:237–240

DOI 10.1007/s11060-013-1176-5CLINICAL STUDY


Marc C. Chamberlain




















Introduction






















123

J Neurooncol (2013) 114:237–240

DOI 10.1007/s11060-013-1176-5

CLINICAL STUDY


Marc C. Chamberlain




















Introduction






















123

J Neurooncol (2013) 114:237–240

DOI 10.1007/s11060-013-1176-5

Successful Treatment of a ProgressiveBRAF V600E–Mutated Anaplastic

Pleomorphic Xanthoastrocytoma WithVemurafenib Monotherapy

IntroductionPleomorphic xanthoastrocytoma (PXA) is a rare brain tumor

that most commonly affects children and young adults. PXA under-goes anaplastic transformation in 15% to 20% of patients.1 Althoughthe prognosis is relatively favorable for patients with a WHO grade 2PXA, data suggest that the prognosis for anaplastic PXA is significantlyworse.1,2 Maximal resection is generally recommended, but the role ofradiation or chemotherapy in the management of these tumors re-mains unclear.

Alterations in the BRAF gene have been described in severalpediatric low-grade gliomas.3-6 Approximately 70% of pilocytic astro-cytomas contain BRAF fusions, resulting from a tandem duplicationand rearrangement on 7q34 between BRAF and a gene centromeric toBRAF. This is in contrast with PXA, in which the described BRAFalteration is instead a BRAF mutation that results from an amino acidsubstitution replacing valine (V) with glutamic acid (E) at position600. This BRAF V600E mutation is found in approximately 60% to65% of WHO grade 2 and 3 PXAs,7,8 and is the same mutation that isfound in approximately 50% of melanomas.9

Vemurafenib is a BRAF inhibitor that is approved for thetreatment of BRAF-mutated metastatic melanoma in the UnitedStates and the European Union.10 There are several case reports ofCNS melanoma metastases that were responsive to vemu-rafenib,11,12 and preliminary results from an open-label pilot studyof vemurafenib for patients with melanoma and brain metastasessuggest some activity.13 This evidence indicates that vemurafenibmay penetrate CNS tumors. In addition, BRAF inhibition repressesthe growth of intracranial BRAF V600E pediatric malignant astro-cytoma xenografts in mouse models.14 Hence, vemurafenib mayhave a role in the treatment of intracranial neoplasms with BRAFmutations. In support of this, we now present a case of a progres-sive BRAF V600E–mutated anaplastic PXA that was successfullytreated with vemurafenib monotherapy.

Case ReportA 41-year-old, right-handed man with an anaplastic PXA with a

BRAF V600E mutation developed radiographic progression despitesurgery, radiation, and treatment with temozolomide. His neurologichistory dates to his early twenties, when he presented with seizures.This was not further investigated until 2009, when he also developedheadaches. Magnetic resonance imaging (MRI) of the brain revealed aright frontotemporal mass with solid and cystic components and focalareas of intense enhancement within the solid portion. The patientunderwent a near gross total resection with pathology demonstratinga PXA (WHO grade 2). BRAF mutational status was assessed by

polymerase chain reaction–based amplification of exon 15, followedby pyrosequencing of polymerase chain reaction products using acommercial assay (Qiagen, Valencia, CA). This demonstrated a BRAFV600E (c.1799T!A) mutation. The patient was observed with serialimaging until 2011, when MRIs demonstrated increased surroundingenhancement. He was treated with temozolomide but developed ra-diographic progression after two cycles.

The patient underwent another resection in February 2012. Re-view of the pathology showed an anaplastic PXA (WHO grade 3). Thehistology had markedly changed since his 2009 resection and showedincreased cellularity, mitoses, and a Ki-67 labeling index of 20%. Hereceived involved field radiation to a total dose of 59.40 Gy in 47fractions of 1.8 Gy, as well as concurrent temozolomide as a radiationsensitizer. He completed radiation and concurrent temozolomide inMay 2012; thereafter, observation with serial imaging was planned.The initial postradiation brain MRI demonstrated some improve-ment radiographically with decreased enhancement, but then the le-sion began to develop increasing nodular enhancement, as noted onsubsequent scans. Because of the possibility of so-called pseudopro-gression, the patient continued to undergo observation with closemonitoring for 6 months. However, the abnormality continued toexpand, with an increase in nodular enhancement (Fig 1A) and sur-rounding edema (Fig 1B) that was concerning for progressive dis-ease. Despite these radiographic changes, the patient remainedclinically asymptomatic, neurologically intact, and seizure free,without corticosteroids. We addressed management options, in-cluding repeat surgery for pathology to confirm progression.However, given the patient’s comorbid nonischemic dilated car-diomyopathy and his preference to avoid surgery, no further bi-opsy or resection was performed.

Because the patient’s tumor was known to harbor a BRAF V600Emutation, we appealed to his health insurer, who agreed to cover thecost of vemurafenib. The patient began receiving treatment with ve-murafenib at a dose of 720 mg twice per day in early February 2013. Hedeveloped a grade 2 diffuse morbilliform eruption with xerosis andfollicular prominence 10 to 14 days after starting treatment. A punchbiopsy was obtained from his thigh and revealed a superficial and deepperivascular lymphocytic infiltrate with rare eosinophils that was sug-gestive of a hypersensitivity reaction. He had a concomitant grade 1transaminitis without other evidence of systemic hypersensitivity. Hewas managed with liberal topical corticosteroids and antihistamines,with eventual improvement in his skin eruption and transaminitis.Other adverse events that may have been related to vemurafenibincluded grade 1 alopecia and grade 1 diarrhea. He remained neuro-logically intact and without systemic corticosteroids. A restaging brainMRI with contrast after approximately 3 weeks of vemurafenib treat-ment demonstrated an interval decrease in the amount of nodularenhancement. This was confirmed by another brain MRI with con-trast after approximately 12 weeks of vemurafenib, which showedminimal residual enhancement (Fig 1C) and improvement in edema(Fig 1D) that was consistent with a nearly complete response.

JOURNAL OF CLINICAL ONCOLOGY D I A G N O S I S I N O N C O L O G Y

© 2014 by American Society of Clinical Oncology 1Journal of Clinical Oncology, Vol 32, 2014

http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2013.51.1766The latest version is at Published Ahead of Print on August 4, 2014 as 10.1200/JCO.2013.51.1766

Copyright 2014 by American Society of Clinical OncologyDownloaded from jco.ascopubs.org on October 30, 2014. For personal use only. No other uses without permission.

Copyright © 2014 American Society of Clinical Oncology. All rights reserved.

-! Futuros tratamientos con inhibidores de BRAF: Vemurafenib

Successful Treatment of a ProgressiveBRAF V600E–Mutated Anaplastic

Pleomorphic Xanthoastrocytoma WithVemurafenib Monotherapy

IntroductionPleomorphic xanthoastrocytoma (PXA) is a rare brain tumor

that most commonly affects children and young adults. PXA under-goes anaplastic transformation in 15% to 20% of patients.1 Althoughthe prognosis is relatively favorable for patients with a WHO grade 2PXA, data suggest that the prognosis for anaplastic PXA is significantlyworse.1,2 Maximal resection is generally recommended, but the role ofradiation or chemotherapy in the management of these tumors re-mains unclear.

Alterations in the BRAF gene have been described in severalpediatric low-grade gliomas.3-6 Approximately 70% of pilocytic astro-cytomas contain BRAF fusions, resulting from a tandem duplicationand rearrangement on 7q34 between BRAF and a gene centromeric toBRAF. This is in contrast with PXA, in which the described BRAFalteration is instead a BRAF mutation that results from an amino acidsubstitution replacing valine (V) with glutamic acid (E) at position600. This BRAF V600E mutation is found in approximately 60% to65% of WHO grade 2 and 3 PXAs,7,8 and is the same mutation that isfound in approximately 50% of melanomas.9

Vemurafenib is a BRAF inhibitor that is approved for thetreatment of BRAF-mutated metastatic melanoma in the UnitedStates and the European Union.10 There are several case reports ofCNS melanoma metastases that were responsive to vemu-rafenib,11,12 and preliminary results from an open-label pilot studyof vemurafenib for patients with melanoma and brain metastasessuggest some activity.13 This evidence indicates that vemurafenibmay penetrate CNS tumors. In addition, BRAF inhibition repressesthe growth of intracranial BRAF V600E pediatric malignant astro-cytoma xenografts in mouse models.14 Hence, vemurafenib mayhave a role in the treatment of intracranial neoplasms with BRAFmutations. In support of this, we now present a case of a progres-sive BRAF V600E–mutated anaplastic PXA that was successfullytreated with vemurafenib monotherapy.

Case ReportA 41-year-old, right-handed man with an anaplastic PXA with a

BRAF V600E mutation developed radiographic progression despitesurgery, radiation, and treatment with temozolomide. His neurologichistory dates to his early twenties, when he presented with seizures.This was not further investigated until 2009, when he also developedheadaches. Magnetic resonance imaging (MRI) of the brain revealed aright frontotemporal mass with solid and cystic components and focalareas of intense enhancement within the solid portion. The patientunderwent a near gross total resection with pathology demonstratinga PXA (WHO grade 2). BRAF mutational status was assessed by

polymerase chain reaction–based amplification of exon 15, followedby pyrosequencing of polymerase chain reaction products using acommercial assay (Qiagen, Valencia, CA). This demonstrated a BRAFV600E (c.1799T!A) mutation. The patient was observed with serialimaging until 2011, when MRIs demonstrated increased surroundingenhancement. He was treated with temozolomide but developed ra-diographic progression after two cycles.

The patient underwent another resection in February 2012. Re-view of the pathology showed an anaplastic PXA (WHO grade 3). Thehistology had markedly changed since his 2009 resection and showedincreased cellularity, mitoses, and a Ki-67 labeling index of 20%. Hereceived involved field radiation to a total dose of 59.40 Gy in 47fractions of 1.8 Gy, as well as concurrent temozolomide as a radiationsensitizer. He completed radiation and concurrent temozolomide inMay 2012; thereafter, observation with serial imaging was planned.The initial postradiation brain MRI demonstrated some improve-ment radiographically with decreased enhancement, but then the le-sion began to develop increasing nodular enhancement, as noted onsubsequent scans. Because of the possibility of so-called pseudopro-gression, the patient continued to undergo observation with closemonitoring for 6 months. However, the abnormality continued toexpand, with an increase in nodular enhancement (Fig 1A) and sur-rounding edema (Fig 1B) that was concerning for progressive dis-ease. Despite these radiographic changes, the patient remainedclinically asymptomatic, neurologically intact, and seizure free,without corticosteroids. We addressed management options, in-cluding repeat surgery for pathology to confirm progression.However, given the patient’s comorbid nonischemic dilated car-diomyopathy and his preference to avoid surgery, no further bi-opsy or resection was performed.

Because the patient’s tumor was known to harbor a BRAF V600Emutation, we appealed to his health insurer, who agreed to cover thecost of vemurafenib. The patient began receiving treatment with ve-murafenib at a dose of 720 mg twice per day in early February 2013. Hedeveloped a grade 2 diffuse morbilliform eruption with xerosis andfollicular prominence 10 to 14 days after starting treatment. A punchbiopsy was obtained from his thigh and revealed a superficial and deepperivascular lymphocytic infiltrate with rare eosinophils that was sug-gestive of a hypersensitivity reaction. He had a concomitant grade 1transaminitis without other evidence of systemic hypersensitivity. Hewas managed with liberal topical corticosteroids and antihistamines,with eventual improvement in his skin eruption and transaminitis.Other adverse events that may have been related to vemurafenibincluded grade 1 alopecia and grade 1 diarrhea. He remained neuro-logically intact and without systemic corticosteroids. A restaging brainMRI with contrast after approximately 3 weeks of vemurafenib treat-ment demonstrated an interval decrease in the amount of nodularenhancement. This was confirmed by another brain MRI with con-trast after approximately 12 weeks of vemurafenib, which showedminimal residual enhancement (Fig 1C) and improvement in edema(Fig 1D) that was consistent with a nearly complete response.

JOURNAL OF CLINICAL ONCOLOGY D I A G N O S I S I N O N C O L O G Y

© 2014 by American Society of Clinical Oncology 1Journal of Clinical Oncology, Vol 32, 2014

http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2013.51.1766The latest version is at Published Ahead of Print on August 4, 2014 as 10.1200/JCO.2013.51.1766

Copyright 2014 by American Society of Clinical OncologyDownloaded from jco.ascopubs.org on October 30, 2014. For personal use only. No other uses without permission.

Copyright © 2014 American Society of Clinical Oncology. All rights reserved.


ASTROCITOMA PILOCÍTICO FUSIÓN BRAF-KIAA 1549

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$ 0/ 45* 565* 7& -: " $ 5* 7& 7" -* / & � 50� ( -65" . " 5& � � � � � � 10* / 5 . 65" �5* 0/ � 8 ) * $ ) " $ 5* 7" 5& 4 � � � 8 * 5) 065 < 345 / & & %* / ( 61453& " .� " 4 1) 041) 03: -" 5* 0/ � � � � " ' � � � � & 9* 454 * / %* 7& 34& 56. 034�* / $ -6%* / ( . & -" / 0$ : 5* $ / & 7* � . & -" / 0. " � $ 0-0/ $ " / $ & 3� " / %1" 1�* --" 3: 5) : 30* %$ " / $ & 3� � 5* 4 13& 4& / 5* / � � 50 � 0' ( 3" %& � � 50� %* ' ' 64& -: * / < -53" 5* 7& 1& %* " 53* $ " 4530$ : 50. " 4 � � Y � � � # 65 * /-& 44 5) " / � 0' $ 0. 1" 3" # -& " %6-5( -* 0. " 4 � � � � � Y � � � � � / # 05)

$ ) * -%3& / " / %" %6-54� -& 44 5) " / � � 0' " -- � � 4 ) " 7& 5) & . 65" �5* 0/ � " / %* 5* 4 13& 4& / 5* / 0/ -: � 0' $ & 3& # & --" 3 � � 4 � � � � � � � � � � � � � � � " 3& -: � 5) & . 65" 5* 0/ $ " / 0$ $ 63 * / $ 0/ + 6/ $ 5* 0/ 8 * 5)" � � � ' 64* 0/ * / 5) & 4" . & 56. 03 � � � � � � / " %6-54� & * 5) & 3 � � � � 03 � � � ' 64* 0/ 4 & 7& / 0$ $ " 4* 0/ " --: $ 0& 9* 458 * 5) � � � � � �. 65" 5* 0/ 4 � � � � � � -5) 06( ) 40. & 5* . & 4 13& 4& / 5* / 56. 0348 * 5) � � �-* , & . 031) 0-0( : � � � � � * 4 . 03& " 440$ * " 5& %8 * 5) 05) & 356. 034 * /5) & %* ' ' & 3& / 5* " -� * / $ -6%* / ( � � 50 � 0' 1& %* " 53* $ " / % " %6-5( " / ( -* 0( -* 0. " 4 " / % � � � 50 � � � 0' 1-& 0. 031) * $ 9" / 5) 0" 4�530$ : 50. " 4 * / # 05) " ( & ( 30614 � � � � � � � � � � � � � � � ) 64� * / 5) &1& %* " 53* $ 1016-" 5* 0/ � " � � � � 3& 46-5 * 4 / 0526* 5& " 4 ) & -1' 6- " 4 � � � ' 64* 0/ * / %* ' ' & 3& / 5* " 5* / ( / 0/ * / < -53" 5* 7& ' 30. * / < -53" 5* 7&( -* 0. " 4� 1" 35* $ 6-" 3-: * ' 5) & %* ' ' & 3& / 5* " - * 4 # & 58 & & / " ( " / ( -* 0�( -* 0. " " / %" %* ' ' 64& ( -* 0. " 07& 35" , * / ( ( 3" : . " 55& 3�

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ASTROCITOMA PILOCÍTICO FUSIÓN BRAF-KIAA 1549

Centrómero cr 7 Gen de BRAF Porción kinasa


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# . ; 9� ' 2: . 5; - . : . + * /' - 459: /) ' 4* 685- 459: /) /3 62/) ' �: /549 5, � � � � , ; 9/54 ' 8+ 45: ? + : ) 53 62+ : + 2? ) 2+ ' 8 /4 ' 22 9/: �; ' : /549� /4 3 59: ) ' 9+ 9 � 3 ' ? ( + ' 22� � ' , ; 9/54 + 7; ' : + 9 : 5 ' �58 � � � ' 4* ' : : . + < + 8? 2+ ' 9: � /: /9 45: ' 4 ; 4, ' < 58' ( 2+ 685- �459: /) 3 ' 81+ 8� � 549/* + 8/4- : . ' : � � � � , ; 9/549 /4 - 2/53 ' 9 = + 8+A89: 8+ 658: + * 542? ? + ' 89 ' - 5� 685- 8+ 99 . ' 9 ( + + 4 8+ 3 ' 81' ( 2+ �� 4 : . + 5: . + 8 . ' 4* � : . + 8+ /9 45: ? + : ' )549+ 49; 9 54 : . + ( + 9:= ' ? � 9� 5, * + : + ) : /4- : . + 9+ , ; 9/549� # . /9 /9)53 62/) ' : + * ( ? : . + , ' ) :: . ' : � � � � � � � � � � � , ; 9/549 5)) ; 8 ' : 3 ; 2: /62+ 9/: + 9 54 ( 5: .- + 4+ 9� # . + 3 59: )53 3 54 /9 + > 54 � 5, � � � � � � � 05/4+ * : 5+ > 54 � 5, � � � � � � Y � � /4 3 58+ : . ' 4 � � 5, , ; 9/549� ,5225= + *( ? � Y � /4 4+ ' 82? � � � 5, ) ' 9+ 9 ' 4* � Y /4 � : 5 � � 5,) ' 9+ 9 � � /- � � � � � � � � � � � � � ! ' 8+ 8 , ; 9/5495)) ; 8( + : = + + 4 � Y � � Y � � � Y � � Y � ' 4* � Y � ' 9 = + 22' 9 : . + ' ,58+ 3 + 4: /54+ *� � � � � � � � � � � ' 4* � � � � � � � � � � , ; 9/549 � � � �

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( 25)1/4- * 8; - 9� 56: /3 ' 2 ' 99' ? 9 = /224+ + * : 5 * + : + ) : ' 9 3 ' 4?< ' 8/' : /549 ' 9 6599/( 2+ � � 58 = /* + 968+ ' * ; 9+ � 9; ) . 3 + : . 5* 9 3 ; 9:' 295 ( + * 5' ( 2+ /4 ,583 ' 2/4� A> + * � 6' 8' ,A4� + 3 ( + * * + * � � � � �: /99; + 9� � /- . � 8+ 952; : /54 )56? 4; 3 ( + 8 ' 99' ? 9 2/1+ 52/- 5 ' 88' ?) 53 6' 8' : /< + - + 453 /) . ? ( 8/* /@ ' : /54 ) ' 4 * + : + ) : : . + + > : 8' , ; �9/54 - + 4+ 54 � 7� � � � � � ( ; : 8+ 7; /8+ . /- . � 7; ' 2/: ? 94' 6� ,85@ + 4: /99; + 9 ' 4* 8; 4 : . + 8/91 5, & & * /2; : /54� � ( ? + > ) + 99/< + ' * 3 /> + *454� 4+ 562' 9: /) � � � � � 45< + 28+ ) + 4: 2? 6; ( 2/9. + * ' 6685' ) ./9 : 5 3 + ' 9; 8+ : . + ) 56? 4; 3 ( + 8 8' : /5 5, � � � � = /: . ' � � � � � �69+ ; * 5- + 4+ 54 ). 853 5953 + % < /' 6? 859+ 7; + 4) /4- � # . /9 3 + : . 5*- + 4+ 8' : + * 9/3 /2' 88+ 9; 2: 9 /4 ,85@ + 4 ' 4* � � � : /99; + 9 � � � � �

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Niños> adultos Infratentorial>supratentorial

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