Aggressive Diffuse Leptomeningeal Glioneuronal Tumor in a Pediatric Patient Presenting With Mismatch Repair Gene Mutations

Abstract

Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a rare primary central nervous system tumor. We present the case of a five-year-old male patient with a rapid progression of a thoracic DLGNT. Initial presentation and workup confirmed acute communicating hydrocephalus requiring a ventriculoperitoneal shunt. Cerebrospinal fluid analysis showed hyperproteinorrachia. Additional workup demonstrated an intramedullary mass at the conus medullaris associated with leptomeningeal enhancement. A T10-T12 laminoplasty with tumor resection was performed. Immunohistochemistry was positive for glial fibrillary acid protein and synaptophysin, with a negative epithelial membrane antigen. The tumor had a Ki67 proliferation index of 9%. Gene tumor analysis revealed the presence of the KIAA1549-BRAF gene fusion. The tumor expressed MSH6, MLH1, MSH2, and PMS2 mismatch repair gene mutations. Multiple subsequent shunt revisions were performed due to malfunction secondary to the hyperproteinorrachia. Follow-up studies showed extensive brain and spinal nodular cystic lesions associated with extensive leptomeningeal spread of disease. The patient received chemotherapy but died due to disease progression. This case report described a rapidly progressive and aggressive DLGNT in a pediatric patient presenting mismatch repair gene mutations. Due to hyperproteinorrachia, shunt revisions are frequently needed in these patients. Even though DLGNT pathology can depict a low-grade tissue, some tumors behave aggressively with minimal significant response to medical and surgical treatments. Mutations of mismatch repair genes MSH6, MLH1, MSH2, and PMS2 may be associated with more aggressive tumors.

Keywords: diffuse leptomeningeal glioneuronal tumor; genetics; hydrocephalus; hyperproteinorrachia; mismatch repair genes; mutations.