Difference between revisions of "Astrocytoma"

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An '''astrocytoma''' is a neoplasm derived from an [[neurohistology|astrocyte]].  Diffuse astrocytomas are common glial tumours and grouped together with [[Oligodendroglioma]] in the current WHO brain tumor classficiation.  Some (often circumscribed) astrocytic tumors are biologically different from diffuse astrocytomas An overview of CNS tumours is found in the ''[[CNS tumours]]'' article.
An '''astrocytoma''' is a neoplasm thought to be derived from an [[neurohistology|astrocyte]].  Astrocytomas/Glioblastomas are most common type of glial tumours and grouped together with [[Oligodendroglioma]] and glioneuronal tumours in the current WHO brain tumor classficiation.  Some (often circumscribed) astrocytic tumors and pediatric tumours are biologically different from adult-onset diffuse astrocytomas. An overview of other CNS tumours is found in the ''[[CNS tumours]]'' article.
 
=Categorization=
Astrocytomas can be categorized in serveral ways.
* Common vs. uncommon tumours.
* Adult vs. pediatric tumours.
* Circumscribed vs. diffusely growing astrocytomas.
 
Until 2016 WHO classification, roman numerals I-IV were used for grading. The current 2021 WHO classification uses arabic numbering 1-4 for CNS WHO grading instead.


=Overview=
=Overview=
These astrocytic tumors are frequently diagnosed in neuropathology practice:
{| class="wikitable sortable"  
{| class="wikitable sortable"  
! Name
! Name
! Type
! Type
! Variants / Patterns
! Age
! Variants / Patterns / Other designations
! Image
! Image
|-
|-
| Diffuse Astrocytoma, WHO II
| Astrocytoma, IDH mutant WHO CNS grade 2
| diffuse
| diffuse
| protoplasmatic, fibrillar, gemistocytic
| adults
| Diffuse, protoplasmatic, fibrillar or gemistocytic astrocytoma.
| [[File:Astrocytoma whoII HE.jpg|thumb|center|150px]]
| [[File:Astrocytoma whoII HE.jpg|thumb|center|150px]]
|-
|-
| Anaplastic Astrocytoma, WHO III
| Astrocytoma, IDH mutant WHO CNS grade 3
| diffuse
| diffuse
| gliomatosis cerebri
| adults
| Anaplastic astrocytoma, gliomatosis cerebri
| [[File:Anaplastic_astrocytoma_-_very_high_mag.jpg|thumb|center|150px]]
| [[File:Anaplastic_astrocytoma_-_very_high_mag.jpg|thumb|center|150px]]
|-
|-
| Glioblastoma, WHO IV
| Astrocytoma, IDH mutant WHO CNS grade 4
| diffuse
| diffuse
| adults
|
| [[File:IDH1_GBM_20x.jpg|thumb|center|150px]]
|-
| Glioblastoma, WHO CNS grade 4
| diffuse
| adults
| small cell, epitheloid/rhabdoid, with PNET componet, with granular cell component, giant cell, gliosarcoma
| small cell, epitheloid/rhabdoid, with PNET componet, with granular cell component, giant cell, gliosarcoma
| [[File:Glioblastoma_(1).jpg|thumb|center|150px]]
| [[File:Glioblastoma_(1).jpg|thumb|center|150px]]
|-
|-
| Diffuse midline glioma, H3 K27M-mutant, WHO IV
| Diffuse midline glioma, H3 K27M-mutant, WHO CNS grade 4
| diffuse
| diffuse
| children
|  
|  
| [[File:K27M mutant diffuse glioma of the midline.jpg|thumb|center|150px]]
| [[File:K27M mutant diffuse glioma of the midline.jpg|thumb|center|150px]]
|-
|-
|-
|-
| Pilocytic astrocytoma, WHO I
| Pilocytic astrocytoma, WHO CNS grade 1
| circumscribed
| circumscribed
| children
| pilomyxoid astrocytoma, anaplastic pilocytic astrocytoma
| pilomyxoid astrocytoma, anaplastic pilocytic astrocytoma
| [[File:Rosenthal_HE_40x.jpg|thumb|center|150px]]
| [[File:Rosenthal_HE_40x.jpg|thumb|center|150px]]
|-
|-
| Pleomorphic xanthoastrocytoma, WHO II (PXA)
| Pleomorphic xanthoastrocytoma, WHO CNS grade 2 (PXA)
| circumscribed
| circumscribed
| young adults
|  
|  
| [[File:PXA_HE_x20.jpg|thumb|center|150px]]
| [[File:PXA_HE_x20.jpg|thumb|center|150px]]
|-
|-
| Anaplastic pleomorphic xanthoastrocytoma, WHO III (PXA)
| Pleomorphic xanthoastrocytoma, WHO CNS grade 3 (PXA)
| circumscribed
| circumscribed
|  
| young adults
|  
| Anaplastic PXA.
| [[File:Anaplastic_pxa_histology.jpg|thumb|center|150px]]
|-
|-
| Subependymal giant cell astrocytoma, WHO I (SEGA)
| Subependymal giant cell astrocytoma, WHO CNS grade 1 (SEGA)
| circumscribed
| circumscribed
| young adults
| SEGA in tuberous sclerosis
| SEGA in tuberous sclerosis
| [[File:SEGA_HE.jpg|thumb|center|150px]]
| [[File:SEGA_HE.jpg|thumb|center|150px]]
|}
|}
=Common=
 
=Adult-type astrocytomas=
*[[Astrocytoma, IDH-mutant]].
*[[Glioblastoma]], IDH wildtype.
*[[High-grade astrocytoma with piloid features]].
*[[Pleomorphic xanthroastrocytoma]].
*[[Subependymal giant cell astrocytoma]].
*Chordoid glioma.
 
=Pediatric-type astrocytomas=
*[[Pilocytic astrocytoma]].
*[[Pediatric-type diffuse high-grade glioma]].
*[[Pediatric-type diffuse low-grade glioma]].
*[[Astroblastoma]], MN1-altered.
 
=Diffuse growing astrocytomas=
*[[Astrocytoma, IDH-mutant]].
*[[Glioblastoma]], IDH wildtype.
*[[Diffuse midline glioma, H3 K27-altered]].
*[[Diffuse hemispheric glioma, H3 G34-mutant]].
*[[Diffuse astrocytoma, MYB- or MYBL-altered]].
*Diffuse pediatric-type high-grade glioma, H3-wildtype and IDH-wildtype.
*Angiocentric glioma.
*Diffuse low-grade glioma, MAPK pathway-altered.
 
=Circumscribed astrocytomas=
*[[Pilocytic astrocytoma]].
*[[High-grade astrocytoma with piloid features]].
*[[Pleomorphic xanthroastrocytoma]].
*[[Subependymal giant cell astrocytoma]].
*[[Chordoid glioma]].
*[[Astroblastoma]], MN1-altered.
 
=Common Astrocytomas=
==Pilocytic astrocytoma==
==Pilocytic astrocytoma==
* Benign, cystic, infratentorial.
* Benign, cystic, infratentorial.
* Classic childhood tumor, surgically resectable.
* Classic childhood tumor, surgically resectable.
* Circumscribed astrocytic glioma
* Variant: [[Pilomyxoid astrocytoma]]
* Variant: [[Pilomyxoid astrocytoma]]
{{Main|Pilocytic astrocytoma}}
{{Main|Pilocytic astrocytoma}}


==Diffuse astrocytoma==
==Astrocytoma, IDH mutant==
* Grade II astrocytic tumors typically seen in adults.
* Astrocytoma, IDH mutant are less common than glioblastoma.
* Usually show progression to glioblastoma.
* Grade 2-4 depends on histological and molecular criteria:
{{Main|Diffuse astrocytoma}}
{{Main|Astrocytoma, IDH-mutant}}


==Anaplastic astrocytoma==
=== Astrocytoma, IDH mutant grade 2===
* Grade III astrocytic tumors typically seen in adults.
* Formerly designated as Diffuse astrocytoma Grade II.
* Typically seen in adults.
* Usually shows progression to astrocytoma IDH mutant, grade 4.
 
===Astrocytoma, IDH mutant grade 3===
* Formerly designated Anaplastic astrocytoma Grade III.
* Typically seen in adults.
* Increased cellularity, cell atypia and mitotic activity.
* Lacks endothelial proliferations and necrosis of glioblastoma.
* Lacks endothelial proliferations and necrosis of glioblastoma.
{{Main|Anaplastic astrocytoma}}
 
===Astrocytoma, IDH mutant grade 4===
* Formerly called Glioblastoma, IDH mutant.
* Endothelial proliferations and necrosis  indistinguishable from glioblastoma.
* Homozygous CDKN2A deletion qualifies grade 2 and grade 3 astrocytomas as grade 4 tumor.


==Glioblastoma==
==Glioblastoma==
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{{Main|Glioblastoma}}
{{Main|Glioblastoma}}


=Uncommon=
=Uncommon Astrocytomas=
==Diffuse astrocytoma, MYB- or MYBL-altered==
* Pediatric-type diffuse low-grade glioma.
* Associated with epileptic seizures.
* Excellent prognosis.
{{Main|Diffuse astrocytoma, MYB- or MYBL-altered}}
 
==Subependymal giant cell astrocytoma==
==Subependymal giant cell astrocytoma==
* Intraventricular benign tumor of adolescents.
* Intraventricular benign tumor of adolescents.
* Assoicated with [[Tuberous sclerosis]].
* Associated with [[Tuberous sclerosis]].
{{Main|Subependymal giant cell astrocytoma}}
{{Main|Subependymal giant cell astrocytoma}}


Line 83: Line 158:
* Large lipidized cells mimicking a malignant tumor  
* Large lipidized cells mimicking a malignant tumor  
{{Main|Pleomorphic xanthoastrocytoma}}
{{Main|Pleomorphic xanthoastrocytoma}}
==Diffuse midline glioma, H3 K27-altered==
* High-grade astrocytic neoplasm associated with midline structures (thalamus, brain stem, spinal cord).
* Mostly in children and adolescents.
* Includes diffuse intrinsic pontine gliomas (DPIG).
{{Main|Diffuse midline glioma, H3 K27-altered}}
==Diffuse hemispheric glioma, H3 G34-mutant==
* Infiltrative hemispheric glioma of young adults.
* Glioblastoma-like appearance (CNS WHO grade 4 tumor).
* Newly defined entity in WHO 2021 classification.
* H3F3A missense mutation G34R or G34V.
{{Main|Diffuse hemispheric glioma, H3 G34-mutant}}
==High-grade astrocytoma with piloid features==
* Frequent in posterior fossa (75%).
* 1-3% of all brain tumors.
* Histology may resemble Glionblastoma or Pleomorphic xanthoastrocytoma.
* Tumor is enriched for piloid cell processes.
* ATRX nuclear loss is frequent.
* Usu. MAPK-pathway alterations + CDKN2A homozygous deletion.
* Distinct methylation profile.
{{Main|High-grade astrocytoma with piloid features}}


==Gliomatosis cerebri==
==Gliomatosis cerebri==
Line 95: Line 194:
** GC type 2: with a solid portion, mostly IDH1 mutant.
** GC type 2: with a solid portion, mostly IDH1 mutant.
* Genetic studies indicate strong overlap with diffuse astrocytic gliomas, oligodendrogliomas and glioblastoma.
* Genetic studies indicate strong overlap with diffuse astrocytic gliomas, oligodendrogliomas and glioblastoma.
==Diffuse midline glioma, H3 K27M mutant==
* High-grade astrocytic neoplasm associated with midline structures (thalamus, brain stem, spinal cord).
* Mostly in children and adolescents.
* Includes diffuse intrinsic pontine gliomas (DPIG).
* Newly defined entity since WHO 2016 classification.<ref>{{Cite journal  | last1 = Louis | first1 = DN. | last2 = Perry | first2 = A. | last3 = Reifenberger | first3 = G. | last4 = von Deimling | first4 = A. | last5 = Figarella-Branger | first5 = D. | last6 = Cavenee | first6 = WK. | last7 = Ohgaki | first7 = H. | last8 = Wiestler | first8 = OD. | last9 = Kleihues | first9 = P. | title = The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. | journal = Acta Neuropathol | volume = 131 | issue = 6 | pages = 803-20 | month = Jun | year = 2016 | doi = 10.1007/s00401-016-1545-1 | PMID = 27157931 }}</ref>
* Distinct biological and clinical group with poor prognosis.<ref>{{Cite journal  | last1 = Khuong-Quang | first1 = DA. | last2 = Buczkowicz | first2 = P. | last3 = Rakopoulos | first3 = P. | last4 = Liu | first4 = XY. | last5 = Fontebasso | first5 = AM. | last6 = Bouffet | first6 = E. | last7 = Bartels | first7 = U. | last8 = Albrecht | first8 = S. | last9 = Schwartzentruber | first9 = J. | title = K27M mutation in histone H3.3 defines clinically and biologically distinct subgroups of pediatric diffuse intrinsic pontine gliomas. | journal = Acta Neuropathol | volume = 124 | issue = 3 | pages = 439-47 | month = Sep | year = 2012 | doi = 10.1007/s00401-012-0998-0 | PMID = 22661320 }}</ref>
** EGFR amplification is usu. absent.<ref>{{Cite journal  | last1 = Meyronet | first1 = D. | last2 = Esteban-Mader | first2 = M. | last3 = Bonnet | first3 = C. | last4 = Joly | first4 = MO. | last5 = Uro-Coste | first5 = E. | last6 = Amiel-Benouaich | first6 = A. | last7 = Forest | first7 = F. | last8 = Rousselot-Denis | first8 = C. | last9 = Burel-Vandenbos | first9 = F. | title = Characteristics of H3 K27M-mutant gliomas in adults. | journal = Neuro Oncol | volume = 19 | issue = 8 | pages = 1127-1134 | month = Aug | year = 2017 | doi = 10.1093/neuonc/now274 | PMID = 28201752 }}</ref>
** Tumors usu. have unmethylated MGMT promotor.<ref>{{Cite journal  | last1 = Banan | first1 = R. | last2 = Christians | first2 = A. | last3 = Bartels | first3 = S. | last4 = Lehmann | first4 = U. | last5 = Hartmann | first5 = C. | title = Absence of MGMT promoter methylation in diffuse midline glioma, H3 K27M-mutant. | journal = Acta Neuropathol Commun | volume = 5 | issue = 1 | pages = 98 | month = 12 | year = 2017 | doi = 10.1186/s40478-017-0500-2 | PMID = 29246238 }}</ref>
* MRI: May be or be not enhancing.
*Histologic spectrum ranges from minimal hypercellularity to full-blown glioblastoma.
Note: Cases may also appear outside midline structures and in adult patients.<ref>{{Cite journal  | last1 = Nakata | first1 = S. | last2 = Nobusawa | first2 = S. | last3 = Yamazaki | first3 = T. | last4 = Osawa | first4 = T. | last5 = Horiguchi | first5 = K. | last6 = Hashiba | first6 = Y. | last7 = Yaoita | first7 = H. | last8 = Matsumura | first8 = N. | last9 = Ikota | first9 = H. | title = Histone H3 K27M mutations in adult cerebellar high-grade gliomas. | journal = Brain Tumor Pathol | volume = 34 | issue = 3 | pages = 113-119 | month = Jul | year = 2017 | doi = 10.1007/s10014-017-0288-6 | PMID = 28547652 }}</ref>
<gallery>
File:K27M mutant diffuse glioma of the midline.jpg|Nuclear [[H3F3A]] K27M immunostaining in a diffuse glioma of the midline. (WC/jensflorian)
</gallery>


==Gliosarcoma==
==Gliosarcoma==

Latest revision as of 13:48, 17 October 2022

An astrocytoma is a neoplasm thought to be derived from an astrocyte. Astrocytomas/Glioblastomas are most common type of glial tumours and grouped together with Oligodendroglioma and glioneuronal tumours in the current WHO brain tumor classficiation. Some (often circumscribed) astrocytic tumors and pediatric tumours are biologically different from adult-onset diffuse astrocytomas. An overview of other CNS tumours is found in the CNS tumours article.

Categorization

Astrocytomas can be categorized in serveral ways.

  • Common vs. uncommon tumours.
  • Adult vs. pediatric tumours.
  • Circumscribed vs. diffusely growing astrocytomas.

Until 2016 WHO classification, roman numerals I-IV were used for grading. The current 2021 WHO classification uses arabic numbering 1-4 for CNS WHO grading instead.

Overview

These astrocytic tumors are frequently diagnosed in neuropathology practice:

Name Type Age Variants / Patterns / Other designations Image
Astrocytoma, IDH mutant WHO CNS grade 2 diffuse adults Diffuse, protoplasmatic, fibrillar or gemistocytic astrocytoma.
Astrocytoma whoII HE.jpg
Astrocytoma, IDH mutant WHO CNS grade 3 diffuse adults Anaplastic astrocytoma, gliomatosis cerebri
Anaplastic astrocytoma - very high mag.jpg
Astrocytoma, IDH mutant WHO CNS grade 4 diffuse adults
IDH1 GBM 20x.jpg
Glioblastoma, WHO CNS grade 4 diffuse adults small cell, epitheloid/rhabdoid, with PNET componet, with granular cell component, giant cell, gliosarcoma
Glioblastoma (1).jpg
Diffuse midline glioma, H3 K27M-mutant, WHO CNS grade 4 diffuse children
K27M mutant diffuse glioma of the midline.jpg
Pilocytic astrocytoma, WHO CNS grade 1 circumscribed children pilomyxoid astrocytoma, anaplastic pilocytic astrocytoma
Rosenthal HE 40x.jpg
Pleomorphic xanthoastrocytoma, WHO CNS grade 2 (PXA) circumscribed young adults
PXA HE x20.jpg
Pleomorphic xanthoastrocytoma, WHO CNS grade 3 (PXA) circumscribed young adults Anaplastic PXA.
Anaplastic pxa histology.jpg
Subependymal giant cell astrocytoma, WHO CNS grade 1 (SEGA) circumscribed young adults SEGA in tuberous sclerosis
SEGA HE.jpg

Adult-type astrocytomas

Pediatric-type astrocytomas

Diffuse growing astrocytomas

Circumscribed astrocytomas

Common Astrocytomas

Pilocytic astrocytoma

  • Benign, cystic, infratentorial.
  • Classic childhood tumor, surgically resectable.
  • Circumscribed astrocytic glioma
  • Variant: Pilomyxoid astrocytoma
Main article: Pilocytic astrocytoma

Astrocytoma, IDH mutant

  • Astrocytoma, IDH mutant are less common than glioblastoma.
  • Grade 2-4 depends on histological and molecular criteria:
Main article: Astrocytoma, IDH-mutant

Astrocytoma, IDH mutant grade 2

  • Formerly designated as Diffuse astrocytoma Grade II.
  • Typically seen in adults.
  • Usually shows progression to astrocytoma IDH mutant, grade 4.

Astrocytoma, IDH mutant grade 3

  • Formerly designated Anaplastic astrocytoma Grade III.
  • Typically seen in adults.
  • Increased cellularity, cell atypia and mitotic activity.
  • Lacks endothelial proliferations and necrosis of glioblastoma.

Astrocytoma, IDH mutant grade 4

  • Formerly called Glioblastoma, IDH mutant.
  • Endothelial proliferations and necrosis indistinguishable from glioblastoma.
  • Homozygous CDKN2A deletion qualifies grade 2 and grade 3 astrocytomas as grade 4 tumor.

Glioblastoma

Main article: Glioblastoma

Uncommon Astrocytomas

Diffuse astrocytoma, MYB- or MYBL-altered

  • Pediatric-type diffuse low-grade glioma.
  • Associated with epileptic seizures.
  • Excellent prognosis.
Main article: Diffuse astrocytoma, MYB- or MYBL-altered

Subependymal giant cell astrocytoma

Main article: Subependymal giant cell astrocytoma

Pleomorphic xanthroastrocytoma (PXA)

  • Kids & young adults usually with good prognosis.
  • Large lipidized cells mimicking a malignant tumor
Main article: Pleomorphic xanthoastrocytoma

Diffuse midline glioma, H3 K27-altered

  • High-grade astrocytic neoplasm associated with midline structures (thalamus, brain stem, spinal cord).
  • Mostly in children and adolescents.
  • Includes diffuse intrinsic pontine gliomas (DPIG).
Main article: Diffuse midline glioma, H3 K27-altered

Diffuse hemispheric glioma, H3 G34-mutant

  • Infiltrative hemispheric glioma of young adults.
  • Glioblastoma-like appearance (CNS WHO grade 4 tumor).
  • Newly defined entity in WHO 2021 classification.
  • H3F3A missense mutation G34R or G34V.
Main article: Diffuse hemispheric glioma, H3 G34-mutant

High-grade astrocytoma with piloid features

  • Frequent in posterior fossa (75%).
  • 1-3% of all brain tumors.
  • Histology may resemble Glionblastoma or Pleomorphic xanthoastrocytoma.
  • Tumor is enriched for piloid cell processes.
  • ATRX nuclear loss is frequent.
  • Usu. MAPK-pathway alterations + CDKN2A homozygous deletion.
  • Distinct methylation profile.
Main article: High-grade astrocytoma with piloid features

Gliomatosis cerebri

  • Depreceated entity.
  • Was used for extensively diffusely growing astrocytic neoplasms.
    • Introduced in 1938 as a post-mortem diagnosis.[1]
    • Since 2016 it is no longer considered a distinct entity.[2][3]
  • More than 3 lobes have to be involved, us. bilateral (radiology required).
  • biologic behaviour corresponds to WHO III (ICD-O: 9381/3)
  • Based on presence / absence of a solid component authors propose two types:[4]
    • GC type 1: classic diffuse growth, without IDH1/2 mutation.
    • GC type 2: with a solid portion, mostly IDH1 mutant.
  • Genetic studies indicate strong overlap with diffuse astrocytic gliomas, oligodendrogliomas and glioblastoma.

Gliosarcoma

General

  • Considered to be a variant of glioblastoma by WHO.[5]
  • Rare ~ 200 cases reported in the literature.[5]
  • Definition: gliosarcoma = glioblastoma + sarcomatous component.[6]
  • Usual location (like glioblastoma): temporal lobe.
  • Prognosis is similiar to glioblastoma.[7]
    • Age below 65 years is prognostic.

Microscopic

Features:

  • Glioblastoma.
  • Sarcomatous component (one of the following):[5][6]
    • Fibroblastic.
    • Cartilaginous.
    • Osseous.
    • Smooth muscle.
    • Striated muscle.
    • Adipocyte.

Images

  • Gliosarcoma - elastica van Giesson. (WC)

www:

IHC

  • GFAP +ve -- astrocytic component.[8]
    • Spindle cell component -ve.[9]

Gliosarcoma with smooth muscle component (gliomyosarcoma):[10]

  • SMA +ve.
  • Factor VIII +ve.

Gliofibroma

  • Very rare indolent tumor in children [11]
  • Usually not dura-based (DD: Desmoplastic infantile astrocytoma)
  • Glial tumor with non-neoplastic fibromatous component.

See also

References

  1. ↑ SAMUEL NEVIN - GLIOMATOSIS CEREBRI, DOI: http://dx.doi.org/10.1093/brain/61.2.170 170-191 First published online: 1 June 1938
  2. ↑ Johnson, DR.; Guerin, JB.; Giannini, C.; Morris, JM.; Eckel, LJ.; Kaufmann, TJ.. "2016 Updates to the WHO Brain Tumor Classification System: What the Radiologist Needs to Know.". Radiographics 37 (7): 2164-2180. doi:10.1148/rg.2017170037. PMID 29028423.
  3. ↑ Herrlinger, U.; Jones, DT.; Glas, M.; Hattingen, E.; Gramatzki, D.; Stuplich, M.; Felsberg, J.; Bähr, O. et al. (Oct 2015). "Gliomatosis cerebri: no evidence for a separate brain tumor entity.". Acta Neuropathol. doi:10.1007/s00401-015-1495-z. PMID 26493382.
  4. ↑ Seiz, M.; Tuettenberg, J.; Meyer, J.; Essig, M.; Schmieder, K.; Mawrin, C.; von Deimling, A.; Hartmann, C. (Aug 2010). "Detection of IDH1 mutations in gliomatosis cerebri, but only in tumors with additional solid component: evidence for molecular subtypes.". Acta Neuropathol 120 (2): 261-7. doi:10.1007/s00401-010-0701-2. PMID 20514489.
  5. ↑ 5.0 5.1 5.2 Han SJ, Yang I, Tihan T, Prados MD, Parsa AT (February 2010). "Primary gliosarcoma: key clinical and pathologic distinctions from glioblastoma with implications as a unique oncologic entity". J. Neurooncol. 96 (3): 313–20. doi:10.1007/s11060-009-9973-6. PMC 2808523. PMID 19618114. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2808523/.
  6. ↑ 6.0 6.1 Ayadi L, Charfi S, Khabir A, et al. (March 2010). "[Cerebral gliosarcoma: clinico-pathologic study of 8 cases]" (in French). Tunis Med 88 (3): 142–6. PMID 20415184.
  7. ↑ Frandsen, J.; Orton, A.; Jensen, R.; Colman, H.; Cohen, AL.; Tward, J.; Shrieve, DC.; Suneja, G. (Jun 2017). "Patterns of care and outcomes in gliosarcoma: an analysis of the National Cancer Database.". J Neurosurg: 1-6. doi:10.3171/2016.12.JNS162291. PMID 28621623.
  8. ↑ Horiguchi, H.; Hirose, T.; Kannuki, S.; Nagahiro, S.; Sano, T. (Aug 1998). "Gliosarcoma: an immunohistochemical, ultrastructural and fluorescence in situ hybridization study.". Pathol Int 48 (8): 595-602. PMID 9736406.
  9. ↑ URL: http://path.upmc.edu/cases/case361.html. Accessed on: 15 January 2012.
  10. ↑ Khanna, M.; Siraj, F.; Chopra, P.; Bhalla, S.; Roy, S.. "Gliosarcoma with prominent smooth muscle component (gliomyosarcoma): a report of 10 cases.". Indian J Pathol Microbiol 54 (1): 51-4. doi:10.4103/0377-4929.77324. PMID 21393877.
  11. ↑ Deb, P.; Sarkar, C.; Garg, A.; Singh, VP.; Kale, SS.; Sharma, MC. (Feb 2006). "Intracranial gliofibroma mimicking a meningioma: a case report and review of literature.". Clin Neurol Neurosurg 108 (2): 178-86. doi:10.1016/j.clineuro.2004.11.021. PMID 16412839.
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