Clinical case recurrence of anaplastic astroblastoma in an adolescent [Neurosurgery Wiki]

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====== Clinical case recurrence of anaplastic astroblastoma in an adolescent ======


Abstract:
We report the case of a female patient with a rare astroblastoma initially diagnosed in adolescence, who experienced histologically confirmed anaplastic recurrence several years later and a suspected second recurrence thereafter. This case illustrates the complex diagnostic, surgical, and therapeutic strategies required in long-term follow-up of astroblastoma, highlighting challenges in seizure control and neuropathic sequelae.

Patient Information:

Sex: Female

Current Age: Early 20s

Age at First Diagnosis: 12 years

Hospital: Tertiary academic center

Medical History:

No drug allergies

Normal psychomotor development

Vaccination schedule completed

No relevant family or systemic diseases

Initial generalized seizure episode in early adolescence

Clinical Course:

First Diagnosis:

Imaging identified a cystic lesion in the right frontoparietal region.

EEG confirmed epileptogenic activity in the same location.

Surgical resection was performed.

Histopathology: Astroblastoma (low proliferative index, no WHO grading available).

Postoperative seizure control achieved; antiepileptic therapy was eventually discontinued.

First Recurrence:

Several years after surgery, the patient developed new-onset partial seizures and sensory symptoms in the left upper limb.

MRI demonstrated a contrast-enhancing lesion at the previous surgical bed.

Re-resection was performed.

Histopathology confirmed anaplastic astroblastoma, with necrosis, mitotic activity, Ki-67 index 20%, IDH1 and BRAF wild-type, and p53 positive.

Second Recurrence (Suspected):

A new contrast-enhancing lesion with elevated rCBV was identified on MRI during routine follow-up.

The patient reported worsening focal seizures and neuropathic pain in the left limbs.

Anti-seizure treatment was escalated due to drug resistance and suboptimal response to previous regimens.

A third surgical resection was planned and performed.

Histopathological analysis is pending.

Genetic and Molecular Markers (from prior confirmed recurrence):

IDH1: Wild-type

ATRX: Expression retained

BRAF: Wild-type

p53: Positive

Ki-67: 20%

Seizure Management:

Seizure Type: Focal motor and sensory, with occasional postictal paresis

Frequency: 3–4 episodes/month

Current Treatment:

Brivaracetam

Eslicarbazepine

Tapering gabapentin

Introduction of cenobamate following structured titration protocol

Past Medications: Levetiracetam, topiramate, pregabalin, lacosamide (discontinued due to side effects or inefficacy)

Pain and Neurological Status:

Persistent neuropathic pain and dysesthesias in the left hand and leg

Fatigue with impact on daily functioning

No significant motor deficits on examination

Radiological Findings:

Postoperative MRI showed encephalomalacia and gliosis in the right frontal lobe.

New focal contrast enhancement and elevated perfusion in the surgical bed suggested recurrence.

No mass effect or midline shift.

Posterior fossa and brainstem structures preserved.

Multidisciplinary Plan:

Await final histopathology from most recent surgery

If recurrence confirmed, proceed with adjuvant radiotherapy

Monitor neurological status, optimize seizure control, and manage pain

Maintain close imaging surveillance

Second opinion obtained from national reference center confirmed surgical and RT plan

Discussion:
Astroblastoma is a rare tumor with unclear classification and behavior. Recurrences, including anaplastic transformation, are possible even years after initial resection. This case underscores the importance of long-term follow-up, individualized management of seizures and pain, and coordination among neurosurgery, neuro-oncology, and neurology teams.

Conclusion:
This case highlights the complexity of recurrent anaplastic astroblastoma in a young patient. The combination of advanced imaging, reintervention, evolving pharmacological strategies, and neuro-palliative care exemplifies a personalized approach to a rare and unpredictable neoplasm.

Key Points:

Astroblastomas may recur or transform after long latency

Histological progression can occur with molecularly negative markers

Refractory epilepsy and pain remain central to long-term management

Multidisciplinary and individualized care is critical