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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 55-59

Diffuse midline glioma, H3-K27M mutant: Awareness leads to identification

1 Department of Pathology, Institute of Human Behaviour and Allied Sciences, Delhi, India
2 Department of Neurosurgery, Guru Teg Bahadur Hospital, Delhi, India

Date of Web Publication1-Apr-2019

Correspondence Address:
Dr. Sadhana Tiwari
Department of Pathology, Institute of Human Behaviour and Allied Sciences, Dilshad Garden, Delhi - 110 095
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/glioma.glioma_1_19

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Midline astrocytic neoplasms have distinct molecular characteristics, quite different from astrocytic neoplasms with similar morphology but not located in the midline. It is imperative that neuropathologists should be aware of the existence of these tumors, so they can be correctly diagnosed. Here, we discuss the case of a 14-year-old boy who presented with acute onset of vomiting followed by loss of consciousness. Subsequent magnetic resonance imaging revealed an ill-defined exophytic lesion arising from the brainstem and extending into the left cerebellopontine angle, with areas of hemorrhage and patchy restricted diffusion. The tumor was resected. Microscopy revealed medium-sized tumor cells in diffuse sheets, having round nuclei, granular chromatin, and scant cytoplasm. Microvascular and endothelial cell proliferation in small necrotic areas were seen. Mitosis was 0–1 per high-power field. By routine histopathological analysis, all features were consistent with the diagnosis of glioblastoma. Tumor cells were immunopositive for glial fibrillary acidic protein and isocitrate dehydrogenase-1 mutation (R132H), immunonegative for p53, and retained alpha thalassemia/mental retardation syndrome X-linked. It also showed a strong immunopositivity for H3-K27M mutation. A diagnosis of a diffuse midline glioma with H3-K27M mutation corresponding to the World Health Organization Grade IV was made. This case highlights the importance of exploring signature mutations in well-defined tumor categories such as H3-K27M-mutant diffuse midline glioma.

Keywords: Diffuse intrinsic pontine glioma, H3-K27M-mutant, histone H3 gene sequencing, histone H3.1, histone H3.3, isocitrate dehydrogenase wildtype, midline glioma, pediatric brain tumor

How to cite this article:
Tiwari S, Pant I, Chaturvedi S, Singh G. Diffuse midline glioma, H3-K27M mutant: Awareness leads to identification. Glioma 2019;2:55-9

How to cite this URL:
Tiwari S, Pant I, Chaturvedi S, Singh G. Diffuse midline glioma, H3-K27M mutant: Awareness leads to identification. Glioma [serial online] 2019 [cited 2023 Oct 2];2:55-9. Available from: http://www.jglioma.com/text.asp?2019/2/1/55/255149

  Introduction Top

Based on genetic alterations in addition to histopathologic features, the term “diffuse midline glioma,” a high-grade infiltrative astrocytoma arising from midline structures of the brain, is an added entity in the World Health Organization (WHO) Classification of Tumors of the Central Nervous System, 4th edition. Although it mainly occurs in children, adults can also develop the same disorder. This term includes a formerly referred entity, the diffuse intrinsic pontine glioma (DIPG). The H3K27 missense mutation occurs in two genes (H3F3A and HIST1H3B) encoding histone H3 variants, H3.3, and H3.1, respectively. The substitution of lysine for methionine at codon 27 (K27M) occurs in these two histone variants.[1] These aggressive tumors are classified as Grade IV regardless of histological features and exhibit poor prognosis. Herein, we emphasize the importance of correct subtyping of high-grade glioma for its appropriate prognostic and clinical significance and describe a case report of a pediatric diffuse midline glioma.

  Case Report Top

A 14-year-old boy presented with an acute onset of a single episode of vomiting followed by loss of consciousness. On examination, the patient had diplopia, nystagmus, and motor weakness. Subsequent magnetic resonance imaging (MRI) revealed an ill-defined exophytic lesion arising from pons and medulla and extending into the left cerebellopontine angle with areas of hemorrhage and patchy restricted diffusion [Figure 1]. The patient's father signed the written informed consent.
Figure 1: Coronal T2-weighted magnetic resonance imaging (A and B) showing an exophytic mass in the brainstem extending into the left cerebellopontine angle, and with areas of hemorrhage (arrows)

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Based on the clinicoradiologic findings, a provisional diagnosis of brainstem glioma was made. The patient underwent retromastoid craniotomy and tumor resection. The tumor was soft to firm in consistency, grayish-white in color, with mild-to-moderate vascularity.

Postoperatively, a very tiny specimen was sent for histopathological examination and was subjected to squash smears preparation that showed features of low-grade glioma. Afterward, the specimen received in formalin for paraffin sections was stained with hematoxylin and eosin, which revealed a cellular tumor composed of medium-sized cells in diffuse sheets, having round nuclei, granular chromatin, conspicuous nucleoli, and scant cytoplasm [Figure 2]. At places, perinuclear clearing along with microvascular and endothelial cell proliferation and small areas of necrosis was seen. Mitosis was 0–1/high-power field [Figure 2]. On routine histopathology, all features were consistent with the diagnosis of glioblastoma.
Figure 2: Histopathological and immunohistochemical examinations. (A) Histopathology showing medium-sized cells with round nucleus, perinuclear clearing (hematoxylin-eosin staining, ×400; arrow); (B) Areas of necrosis (hematoxylin-eosin staining, ×200; arrow); (C) Microvascular and endothelial proliferation (hematoxylin-eosin staining, ×200; arrow); (D) Strong immunostaining for glial fibrillary acidic protein; (E) Immunohistochemistry and H3- K27M mutant showing nuclear positivity (×200; arrow). (F) Retained alpha thalassemia/mental retardation syndrome X-linked immunostain

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Since WHO 2016 classification,[2] clearly defines a separate entity of diffuse midline glioma, we evaluated the tumor for the presence of the H3K27M-mutation. Immunohistochemical staining showed that the tumor cells were positive for glial fibrillary acidic protein, retained alpha thalassemia/mental retardation syndrome X-linked, and showed immunopositivity for isocitrate dehydrogenase-1 (IDH-1) mutation and immunonegativity for p53. More importantly, there was a strong immunopositivity for H3-K27M mutation [Figure 2]. The diagnosis of a diffuse midline glioma with H3-K27M mutation was made in accordance with the WHO Classification of Tumors of the Central Nervous System, 4th edition. In spite of the best postoperative care, the patient died 2 weeks postoperatively.

  Discussion Top

In the pediatric population, diffuse midline glioma arises from the pons (about 50%), thalamus (13%), cerebellum (5%), and spinal cord (3%).[3] According to the WHO Classification of Tumors of the Central Nervous System, 4th edition,[2] the median age of presentation of diffuse midline glioma is 5–11 years with the pontine tumors developing earlier (7 years) than the thalamic tumors (11 years). There is no sex difference.

Solomon et al.[1] and Aboian et al.[4] analyzed the data of 47 and 24 cases in their studies of diffuse midline glioma for histone H3-K27M-mutation, respectively. Solomon et al. found that the age at diagnosis ranged from 2 to 65 years (median 14 years) and concluded pontine tumors (median age 7 years) develop at an earlier age than thalamic (24 years) and spinal cord (25 years) tumors. The incidence with respect to location and age of these tumors is summarized in [Table 1] and [Figure 3].[1]
Table 1: Location wise incidence of diffuse midline glioma H3-K27M-mutated

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Figure 3: Localization of diffuse midline glioma with H3- K27M-mutation in relationship to age. These tumors are more common in younger age group (0–20 years) and pons being the most common site. In older age groups, its incidence decreases and tumors of the spinal cord predominate

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The clinical presentation depends mainly on the location of the tumor, but the classic clinical presentation is the triad of multiple cranial neuropathies, long tract signs, and ataxia. The history is usually short and includes nausea, vomiting, drowsiness, up-beating nystagmus, or facial numbness. On MRI, these tumors are usually T1 hypointense and T2 hyperintense. These tumors can show contrast enhancement, necrosis, and/or hemorrhage. In 2017, Aboian et al.[4] reviewed imaging characteristics of these tumors in pediatric patients [Table 2]. They also tried to compare the imaging characteristics of H3-K27M mutant to wild-type tumor. For posterior fossa tumors, they found no significant difference and for thalamus location due to a lesser number of cases, the comparison was limited.
Table 2: Imaging characteristics of diffuse midline glioma H3-K27M mutanted in pediatric patients

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Tumors harboring H3-K27M mutation show wide morphological variations including small monomorphic cells, giant cells, epithelioid cells, primitive neuroectodermal tumor-like tumor foci, and prominent pilomyxoid features.[4]

For pediatric DIPG and nonbrainstem glioblastoma, two separate studies conducted in 2012, identified the somatic mutations of histone genes, H3F3A (75%) and HIST1H3B (20%–25%) encoding histone H3 variants H3.3 and H3.1, respectively. H3.3 and H3.1 mutations occur in a mutually exclusive manner.[5] Majority of DIPGs and thalamic glioblastoma showed recurrent lysine to methionine substitution at codon 27 (K27M) in one of the two histone H3 variants.[6] A recurrent glycine to arginine/valine substitution at codon 34 was identified in pediatric nonmidline glioblastomas arising from the cerebral hemispheres.[6] The presence of this distinct H3-K27M mutation imparts clinically aggressive behavior and worse prognosis regardless of the histological grade of the tumor and gives reason to keep it as Grade IV tumor by 2016 WHO. Almost ~30% of DIPGs show activating missense somatic mutations in ACVR1 G328 that are concurrent with HIST1H3B K27M mutation.[7] Some important mutation associations of these tumors[2],[8] are summarized in [Table 3] and [Table 4].
Table 3: Important mutations in the development of diffuse intrinsic pontine glioma

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Table 4: Other mutations in midline glioma H3-K27M-mutant

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Multivariate analysis by Castel et al.[9] showed various prognostic factors such as ACVR1 mutation, histone H3 wildtype/K27M status, clinicoradiological risk score, metastasis, and MRI contrast enhancement, but the strongest predictor of survival was mutated histone H3.

These tumors can neither be completely removed surgically due to their location nor be treated effectively with radiotherapy or chemotherapy. In 2017, Piunti et al.[10] found significant suppression of tumor growth in DIPG patients treated with the epigenetic modifier, JQ1, a bromodomain, and terminal family protein inhibitor. Other new epigenetic strategies have been developed targeting chromatin-modifying enzymes. In addition, in some cases, nanotechnology has proven effective.[11] The recognition of this morphologically and molecularly defined tumors accounts for specific therapy against these mutations and their prognosis [Figure 4].[8]
Figure 4: Schematic view of molecular testing of isocitrate dehydrogenase-wildtype midline glioma. H3-K27M-mutation and isocitrate dehydrogenase-1 mutations are mutually exclusive. Midline tumors, which are isocitrate dehydrogenase wildtype, should be tested for H3-K27M-mutation status. H3-K27M wildtype has a better prognosis compared to the mutated form. Cases positive for the H3-K27M mutation should have histone H3 gene sequencing. Alpha thalassemia/mental retardation syndrome X-linked

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  Conclusion Top

The case highlights the importance of exploring for signature mutations in well-defined tumor categories like H3-K27M-mutant diffuse midline gliomas. Phenotypically similar tumors may be genetically heterogeneous and, therefore, have different biological behavior entities.

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Institutional review board statement

We have only diagnosed this case. It does not involve any kind of research activity or clinical trial. So it is exempted.

Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained the appropriate patient consent form. In the form, the patient's father has given his consent for the patient's images and other clinical information to be reported in the journal. The patient's father understands that the patient's name and initial will not be published and due efforts will be made to conceal his identity.

  References Top

Solomon DA, Wood MD, Tihan T, Bollen AW, Gupta N, Phillips JJ, et al. Diffuse midline gliomas with histone H3-K27M mutation: A series of 47 cases assessing the spectrum of morphologic variation and associated genetic alterations. Brain Pathol 2016;26:569-80.  Back to cited text no. 1
Hawkins C, Ellision DW, Sturm D. Diffuse midline glioma, H3 K27M-mutant. In: Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Ellison DW, Figarella-Branger D, et al., editors. WHO Classification of Tumours of the Central Nervous System. Revised. 4th ed. Lyon: IARC; 2016. p. 57-9.  Back to cited text no. 2
Jones C, Baker SJ. Unique genetic and epigenetic mechanisms driving paediatric diffuse high-grade glioma. Nat Rev Cancer 2014;14:651-61.  Back to cited text no. 3
Aboian MS, Solomon DA, Felton E, Mabray MC, Villanueva-Meyer JE, Mueller S, et al. Imaging characteristics of pediatric diffuse midline gliomas with histone H3 K27M mutation. AJNR Am J Neuroradiol 2017;38:795-800.  Back to cited text no. 4
Buczkowicz P, Hoeman C, Rakopoulos P, Pajovic S, Letourneau L, Dzamba M, et al. Genomic analysis of diffuse intrinsic pontine gliomas identifies three molecular subgroups and recurrent activating ACVR1 mutations. Nat Genet 2014;46:451-6.  Back to cited text no. 5
Schwartzentruber J, Korshunov A, Liu XY, Jones DT, Pfaff E, Jacob K, et al. Driver mutations in histone H3.3 and chromatin remodelling genes in paediatric glioblastoma. Nature 2012;482:226-31.  Back to cited text no. 6
Taylor KR, Mackay A, Truffaux N, Butterfield Y, Morozova O, Philippe C, et al. Recurrent activating ACVR1 mutations in diffuse intrinsic pontine glioma. Nat Genet 2014;46:457-61.  Back to cited text no. 7
Lapin DH, Tsoli M, Ziegler DS. Genomic insights into diffuse intrinsic pontine glioma. Front Oncol 2017;7:57.  Back to cited text no. 8
Castel D, Philippe C, Calmon R, Le Dret L, Truffaux N, Boddaert N, et al. Histone H3F3A and HIST1H3B K27M mutations define two subgroups of diffuse intrinsic pontine gliomas with different prognosis and phenotypes. Acta Neuropathol 2015;130:815-27.  Back to cited text no. 9
Piunti A, Hashizume R, Morgan MA, Bartom ET, Horbinski CM, Marshall SA, et al. Therapeutic targeting of polycomb and BET bromodomain proteins in diffuse intrinsic pontine gliomas. Nat Med 2017;23:493-500.  Back to cited text no. 10
Long W, Yi Y, Chen S, Cao Q, Zhao W, Liu Q, et al. Potential new therapies for pediatric diffuse intrinsic pontine glioma. Front Pharmacol 2017;8:495.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]

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