Pleomorphic xanthoastrocytoma

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sujit Routray, M.D. [2]

Synonyms and keywords: Pleomorphic xanthoastrocytomas; PXA

Overview

Pleomorphic xanthoastrocytoma is a type of rare, low-grade astrocytoma (WHO Grade II) found in young patients who typically present with temporal lobe epilepsy.

Pathophysiology

Pathogenesis

• Pleomorphic xanthoastrocytoma is formed through the abnormal mitosis of the astrocytes.

Gross Pathology

• On gross pathology, polymorphic xanthoastrocytoma is characterized by a well circumscribed mass, often with a cystic component and a superficially situated mural nodule.
• Polymorphic xanthoastrocytomas are almost invariably (98%) located supratentorially, typically involving the cortex and overlying leptomeninges. Approximately half are located in the temporal lobe.
• They are found commonly in the area of the temporal lobe, frontal lobe, or superior to the parietal lobe. In about 20% of cases, more than one lobe is involved.

Microscopic Pathology

• On microscopic histopathological analysis, polymorphic xanthoastrocytoma is characterized by:

• Ill-defined margins
• Spindle cells, polygonal cells, multi-nucleated cells, and lipid laden xanthomatous astrocytes
• Pleomorphic nuclei
• No endothelial proliferation or necrosis

Immunohistochemistry

• On immunohistochemistry, polymorphic xanthoastrocytoma is characterized by a positive GFAP tumor marker.

Differentiating Pleomorphic Xanthoastrocytoma from other Diseases

Pleomorphic xanthoastrocytoma must be differentiated from:

• Desmoplastic infantile ganglioglioma
• Neuroblastoma
• Extraventricular neurocytoma
• Dysembryoplastic neuroepithelial tumor (DNET)​
• Ganglioglioma
• Oligodendroglioma

Epidemiology and Demographics

Prevalence

• Pleomorphic xanthoastrocytoma constitutes approximately 1% of all primary brain tumors.

Age

• Pleomorphic xanthoastrocytoma is a rare disease that tends to affect children and young adults.
• The median age at diagnosis is 26 years.

Natural History, Complications and Prognosis

Natural History

If left untreated, patients with pleomorphic xanthoastrocytoma may progress to develop seizures, focal neurological deficits, and maliganant transformation to either WHO grade III lesion or glioblastoma multiforme.

Complication

Common complications of pleomorphic xanthoastrocytoma include:

• Local recurrence
• Malignant transformation (WHO grade III astrocytoma or glioblastoma multiforme)

Prognosis

Prognosis is generally good, and the 5-year survival rate of patients with pleomorphic xanthoastrocytoma is approximately 70-80%.

Symptoms

Symptoms of fibrillary astrocytoma include:

• Elevated intracranial pressure

• Headaches
• Nausea
• Vomiting

• Temporal lobe epilepsy

• Seizures with or without aura
• Amnesia
• Loss of consciousness
• Auditory sensations (sound or tune)
• Gustatory senasation (taste)
• Olfactory sensation (smell that is not truly present)
• Dysphoria or euphoria
• Motionless staring, automatic movements of the hands or mouth, inability to respond to others, unusual speech, or unusual behavior

• Neurological symptoms

• Hemiparesis
• Changes in behavior

CT

Head CT scan is helpful in the diagnosis of pleomorphic xanthoastrocytoma. On CT scan, pleomorphic xanthoastrocytoma is characterized by:

• Iso- or hypoattenuating mass
• Calcification
• Vivid enhancement on contrast administration

MRI

Brain MRI is helpful in the diagnosis of pleomorphic xanthoastrocytoma. On MRI, pleomorphic xanthoastrocytoma is characterized by:

MRI Component	Findings
T1 weighted image	Solid component: iso- to hypointense compared to the gray matter Cystic component: hypointense Leptomeningeal involvement
T2 weighted image	Solid component: iso- to hyperintense compared to the gray matter Cystic component: hyperintense Mild surrounding vasogenic edema
T1 weighted image with contrast	Solid component: vivid enhancement

Biopsy

Biopsy of pleomorphic xanthastrocytoma tumor mass, taken through a needle during a simple surgical procedure, helps to confirm the diagnosis.

Other Diagnostic Studies

Electroencephalogram

• Electroencephalogram (EEG) is performed among patients of pleomorphic xanthoastrocytoma to record any abnormal electrical activities (seizures).

Digital Subtraction Angiography

• Digital subtraction angiography (DSA): Despite vivid enhancement, pleomorphic xanthoastrocytomas are usually avascular on angiography.

Positron Emission Tomography

• F-18 FDG PET images of pleomorphic xanthoastrocytoma demonstrates markedly decreased accumulation of [18F]-fluorodeoxyglucose (glucose hypometabolism).

Treatment

• The predominant therapy for pleomorphic xanthoastrocytoma is surgical resection. Adjunctive radiation may be indicated in cases of incompletely resected or recurrent tumors.
• Complete surgical resection is often possible. However, the best choice of treatment will depend on many individual factors including:

• Patient's medical history and overall health condition
• Type, location, and size of the tumor
• Patient's age
• Aggressiveness of the tumor

• If surgery is performed and the tumor is completely resected, further treatment may not be required.