Pathological crying and emotional vasovagal syncope as symptoms of a dorsally exophytic medullary tumor

A 3-year-old boy with a dorsally exophytic tumor arising from the rostral medulla presented with a chief complaint of a change in his emotional behavior, most notably anxiety and paroxysmal crying often followed by syncope. Magnetic resonance imaging revealed that the tumor pushed on the dorsal surface of the medulla and displaced the medulla anteriorly, and also displaced the cerebellar vermis upward and slightly posteriorly. Tissue from a partial resection was diagnosed as a pilocytic astrocytoma. The symptoms did not improved after surgery, but did improve clinically after chemotherapy with vincristine and carboplatin, at which time MR showed a reduction in tumor size. We diagnosed the paroxysmal crying as 'pathological crying' and the syncope with increased anxiety as 'emotional vasovagal syncope'. This case stresses the importance of recognition of this rare presentation as an indication of a medullary tumor.

[Our Experience of Providing Home End-of-Life Care for a Child with a Brain Tumor - Overview of Issues Including Environmental Adjustment and Family Care]

INTRODUCTION

We provided home end-of-life care to a child with a brain tumor. As cases of children with malignancies who receive such care have rarely been described in Japan, we report our experience with this patient.

CASE REPORT

An 11-year-old previously healthy boy was found to have a brainstem glioma in December X. The tumor was reduced by radiotherapy and chemotherapy, but relapse was noted in August X plus 1. Best supportive care alone was selected for this patient. Before the initiation of home care, we consulted a designated hospital for pediatric cancer treatment in the area and requested a case- worker from the child/home section in his resident area. As the patient was too young for long-term care insurance, we immediately applied for a physical disability certificate to augment welfare support. After the initiation of home care, swallowing function diminished markedly, but we provided guidance on dietary contents and suction, allowing continued oral ingestion by prioritizing his and his family's wishes. In January X plus 2 of the following year, his respiratory condition worsened after the development of aspiration pneumonitis, and he died at home.

SUMMARY

We advocate the establishment of a regional network so that children with brain tumors can receive end-of-life care at home.

Diffuse intrinsic pontine gliomas: treatments and controversies

Diffuse intrinsic pontine gliomas (DIPGs) are a fairly common pediatric brain tumor, and children with these tumors have a dismal prognosis. They generally are diagnosed within the first decade of life, and due to their location within the pons, these tumors are not surgically resectable. The median survival for children with DIPGs is less than 1 year, in spite of decades of clinical trial development of unique approaches to radiation therapy and chemotherapy. Novel therapies are under investigation for these deadly tumors. As clinicians and researchers make a concerted effort to obtain tumor tissue, the molecular signals of these tumors are being investigated in an attempt to uncover targetable therapies for DIPGs. In addition, direct application of chemotherapies into the tumor (convection-enhanced delivery) is being investigated as a novel delivery system for treatment of DIPGs. Overall, DIPGs require creative thinking and a disciplined approach for development of a therapy that can improve the prognosis for these unfortunate children.

[Diffusely growing brainstem tumors in children and adolescents: has alternating treatment policy changed results?]

The authors analyze the MEDLINE publications in the past 20 years on the treatment of diffusely growing brainstem tumors in children and adolescents. Radiation and chemoradiation are main treatments for these diseases. The use of different radiation dose fractionation modes and different combinations of cytotoxic drugs has caused no significant changes in long-term results. Whatever the used treatment option is, most patients die within the next 1-2 years after tumor progression. Prognosis mainly depends on the biological properties of a tumor and patients with low-grade glioma generally survive longer. The late effects of radiotherapy make quality of life worse in long-term survivors after treatment. Hopes to enhance therapeutic effectiveness are placed on the development of targeted therapy options based on molecular biological markers.

Clinical management and outcome of histologically verified adult brainstem gliomas in Switzerland: a retrospective analysis of 21 patients

Because of low incidence, mixed study populations and paucity of clinical and histological data, the management of adult brainstem gliomas (BSGs) remains non-standardized. We here describe characteristics, treatment and outcome of patients with exclusively histologically confirmed adult BSGs. A retrospective chart review of adults (age >18 years) was conducted. BSG was defined as a glial tumor located in the midbrain, pons or medulla. Characteristics, management and outcome were analyzed. Twenty one patients (17 males; median age 41 years) were diagnosed between 2004 and 2012 by biopsy (n = 15), partial (n = 4) or complete resection (n = 2). Diagnoses were glioblastoma (WHO grade IV, n = 6), anaplastic astrocytoma (WHO grade III, n = 7), diffuse astrocytoma (WHO grade II, n = 6) and pilocytic astrocytoma (WHO grade I, n = 2). Diffuse gliomas were mainly located in the pons and frequently showed MRI contrast enhancement. Endophytic growth was common (16 vs. 5). Postoperative therapy in low-grade (WHO grade I/II) and high-grade gliomas (WHO grade III/IV) consisted of radiotherapy alone (three in each group), radiochemotherapy (2 vs. 6), chemotherapy alone (0 vs. 2) or no postoperative therapy (3 vs. 1). Median PFS (24.1 vs. 5.8 months; log-rank, p = 0.009) and mOS (30.5 vs. 11.5 months; log-rank, p = 0.028) was significantly better in WHO grade II than in WHO grade III/IV tumors. Second-line therapy considerably varied. Histologically verification of adult BSGs is feasible and has an impact on postoperative treatment. Low-grade gliomas can simple be followed or treated with radiotherapy alone. Radiochemotherapy with temozolomide can safely be prescribed for high-grade gliomas without additional CNS toxicities.

Diffuse intrinsic pontine glioma treated with prolonged temozolomide and radiotherapy--results of a United Kingdom phase II trial (CNS 2007 04)

Diffuse intrinsic pontine glioma (DIPG) has a dismal prognosis with no chemotherapy regimen so far resulting in any significant improvement over standard radiotherapy. In this trial, a prolonged regimen (21/28d) of temozolomide was studied with the aim of overcoming O(6)-methylguanine methyltransferase (MGMT) mediated resistance. Forty-three patients with a defined clinico-radiological diagnosis of DIPG received radiotherapy and concomitant temozolomide (75 mg/m(2)) after which up to 12 courses of 21d of adjuvant temozolomide (75-100mg/m(2)) were given 4 weekly. The trial used a 2-stage design and passed interim analysis. At diagnosis median age was 8 years (2-20 years), 81% had cranial nerve abnormalities, 76% ataxia and 57% long tract signs. Median Karnofsky/Lansky score was 80 (10-100). Patients received a median of three courses of adjuvant temozolomide, five received all 12 courses and seven did not start adjuvant treatment. Three patients were withdrawn from study treatment due to haematological toxicity and 10 had a dose reduction. No other significant toxicity related to temozolomide was noted. Overall survival (OS) (95% confidence interval (CI)) was 56% (40%, 69%) at 9 months, 35% (21%, 49%) at 1 year and 17% (7%, 30%) at 2 years. Median survival was 9.5 months (range 7.5-11.4 months). There were five 2-year survivors with a median age of 13.6 years at diagnosis. This trial demonstrated no survival benefit of the addition of dose dense temozolomide, to standard radiotherapy in children with classical DIPG. However, a subgroup of adolescent DIPG patients did have a prolonged survival, which needs further exploration.

PD-0332991, a CDK4/6 inhibitor, significantly prolongs survival in a genetically engineered mouse model of brainstem glioma

Diffuse intrinsic pontine glioma (DIPG) is an incurable tumor that arises in the brainstem of children. To date there is not a single approved drug to effectively treat these tumors and thus novel therapies are desperately needed. Recent studies suggest that a significant fraction of these tumors contain alterations in cell cycle regulatory genes including amplification of the D-type cyclins and CDK4/6, and less commonly, loss of Ink4a-ARF leading to aberrant cell proliferation. In this study, we evaluated the therapeutic approach of targeting the cyclin-CDK-Retinoblastoma (Rb) pathway in a genetically engineered PDGF-B-driven brainstem glioma (BSG) mouse model. We found that PD-0332991 (PD), a CDK4/6 inhibitor, induces cell-cycle arrest in our PDGF-B; Ink4a-ARF deficient model both in vitro and in vivo. By contrast, the PDGF-B; p53 deficient model was mostly resistant to treatment with PD. We noted that a 7-day treatment course with PD significantly prolonged survival by 12% in the PDGF-B; Ink4a-ARF deficient BSG model. Furthermore, a single dose of 10 Gy radiation therapy (RT) followed by 7 days of treatment with PD increased the survival by 19% in comparison to RT alone. These findings provide the rationale for evaluating PD in children with Ink4a-ARF deficient gliomas.

Morphologic characteristics and immunohistochemical profile of diffuse intrinsic pontine gliomas

Tumors of the central nervous system are the second most common malignancy in children. In particular, diffuse intrinsic pontine gliomas (DIPGs) are aggressive tumors with poor prognosis and account for 10% to 25% of pediatric brain tumors. The majority of DIPGs are astrocytic, infiltrative, and localized to the pons. Studies have shown median survival times of less than a year, with 90% of children dying within 2 years. We built multitissue arrays with 24 postmortem DIPG samples and analyzed the morphology and expression of several proteins (p53, EGFR, GFAP, MIB1, BMI1, β-catenin, p16, Nanog, Nestin, OCT4, OLIG2, SOX2) with the goal of identifying potential treatment targets and improving our understanding of the biology of these tumors. The majority of DIPGs were high-grade gliomas (22), with 18 cases having features of glioblastoma (World Health Organization [WHO] grade IV) and 4 cases with high-grade features consistent with anaplastic astrocytoma (WHO grade III). One case was low grade (WHO grade II), and 1 case showed intermediate features between a grade II and grade III glioma (low mitotic rate but increased cellularity and cell atypia), being difficult to grade precisely. The majority of the tumors were positive for GFAP (24/24), MIB1 (23/24), OLIG2 (22/24), p16 (20/24), p53 (20/24), SOX2 (19/24), EGFR (16/24), and BMI1 (9/24). Our results suggest that dysregulation of EGFR and p53 may play an important role in the development of DIPGs. The majority of DIPGs express stem cell markers such as SOX2 and OLIG2, consistent with a role for tumor stem cells in the origin and maintenance of these tumors. Targeted therapies against these proteins could be beneficial in treatment.

A phase I trial of arsenic trioxide chemoradiotherapy for infiltrating astrocytomas of childhood

BACKGROUND

Arsenic trioxide (ATO) has demonstrated preclinical evidence of activity in the treatment of infiltrating astrocytomas.

METHODS

We conducted a phase I trial of ATO given concomitantly with radiation therapy in children with newly diagnosed anaplastic astrocytoma, glioblastoma, or diffuse intrinsic pontine glioma. Eligible patients received a fixed daily dose of 0.15 mg/kg of ATO once a week, with each subsequent cohort of patients receiving an additional dose per week up to a planned frequency of ATO administration 5 days per week as tolerated. Twenty-four children were enrolled and 21 children were evaluable.

RESULTS

ATO was well tolerated throughout the entire dose escalation, resulting in confirmation of safety when administered 5 days per week during irradiation.

CONCLUSIONS

The recommended dose of ATO during conventional irradiation is 0.15 mg/kg given on a daily basis with each fraction of radiation therapy administered.

Rapid eye movement sleep behavior disorder in a patient with brainstem lymphoma

Rapid eye movement (REM) sleep behavior disorder (RBD) is common in patients with neurodegenerative diseases. RBD occurring in a patient with brainstem lymphoma has not yet been reported. A 30-year-old man had an eleven-month history of violent motor and vocal behavior during sleep. Brain magnetic resonance imaging disclosed hypointensity T1 and hyperintensity T2 signals in the pontomesencephalic junction and at the upper/mid pons level. A stereotactic biopsy demonstrated the presence of diffuse large B-cell lymphoma. On polysomnography, there was enhanced submental and limb electromyographic tone and increased muscular activity during REM sleep. Chemotherapy diminished the dream-enacting behaviors. This case provides evidence that treatment aimed at the primary disease can partially improve the frequency of RBD.

Critical oncogenic mutations in newly diagnosed pediatric diffuse intrinsic pontine glioma

Diffuse intrinsic pontine gliomas (DIPG) can not be cured with current treatment modalities. Targeted therapy in this disease would benefit from advanced technologies detecting relevant drugable mutations. Twenty patients with classic newly diagnosed DIPG underwent stereotactic biopsies and were analyzed for the presence of 983 different mutations in 115 oncogenes and tumor-suppressor genes using OncoMap, a mass spectrometric method of allele detection. Our results identified oncogenic mutations in TP53 (40%), PI3KCA (15%), and ATM/MPL (5%) while none were identified in a large number of other genes commonly mutated in malignant gliomas. The identification of oncogenic mutations in the PI3K pathway offers the potential of a therapeutic target at initial diagnosis in this devastating disease.

Adult brainstem gliomas

Brainstem gliomas are uncommon in adults and account for only 1%-2% of intracranial gliomas. They represent a heterogeneous group of tumors that differ from those found in their pediatric counterparts. In adults, a low-grade phenotype predominates, which is a feature that likely explains their better prognosis compared to that in children. Because biopsies are rarely performed, classifications based on the radiological aspect of magnetic resonance imaging results have been proposed to establish treatment strategies and to determine outcomes: (a) diffuse intrinsic low-grade, (b) enhancing malignant glioma, (c) focal tectal gliomas, and (d) exophytic gliomas. Despite significant advances in neuroradiology techniques, a purely radiological classification remains imperfect in the absence of a histological diagnosis. Whereas a biopsy may often be reasonably avoided in the diffuse nonenhancing forms, obtaining histological proof seems necessary in many contrast-enhanced brainstem lesions because of the wide variety of differential diagnoses in adults. Conventional radiotherapy is the standard treatment for diffuse intrinsic low-grade brainstem gliomas in adults (the median survival is 5 years). In malignant brainstem gliomas, radiotherapy is the standard treatment. However, the possible benefit of combined radiotherapy and chemotherapy (temozolomide or other agents) has not been thoroughly evaluated in adults. The role of anti-angiogenic therapies in brainstem gliomas remains to be defined. A better understanding of the biology of these tumors is of primary importance for identifying homogeneous subgroups and for improving therapy options and outcomes.

[Safety and efficacy of three-dimensional conformal radiotherapy combined with temozolomide in treatment of diffuse brainstem gliomas]

OBJECTIVE

To study the safety and efficacy of three-dimensional conformal radiotherapy in combination with temozolomide in treatment of patients with diffuse brainstem glioma.

METHODS

Twelve patients with MRI-confirmed diffuse brainstem glioma received 54 Gy three-dimensional conformal radiotherapy for 6 weeks with 1.8 Gy per fraction, 5 times per week. All of the patients were given daily oral temozolomide 75 mg/m(2) during radiotherapy. Four weeks after radiotherapy, all of the patients received 6 cycles of temozolomide, each cycle lasted 5 days with 28 days interval between each two cycles. 150 mg/m(2) of temozolomide was given for the first cycle for five days, followed by 200 mg/m(2) of the drug for the rest of the cycles if no significant drug-related toxicities were observed. Magnetic resonance imaging and laboratory tests were performed to evaluate the efficacy and adverse reactions.

RESULTS

In the 12 patients, CR was 1 case (8.3%), PR 6 cases (50.0%), SD 2 cases (16.7%), and PD 3 cases (25.0%). The overall clinical benefit rate was 75.0%. Progression-free survival rate was 75.0% (9/12) at 6 months and 50.0% (6/12) at 1 year. The one-year overall survival rate was 75.0%. There were no severe temozolomide-related toxicities.

CONCLUSIONS

Concurrent temozolomide with three-dimensional conformal radiotherapy and followed by 6 cycles of temozolomide chemotherapy for diffuse brainstem gliomas have a better clinical efficacy, good tolerance and with no severe toxicities.

Treatment of recurrent diffuse intrinsic pontine glioma: the MD Anderson Cancer Center experience

Recurrent diffuse intrinsic pontine gliomas (DIPG) are traditionally treated with palliative care since no effective treatments have been described for these tumors. Recently, clinical studies have been emerging, and individualized treatment is attempted more frequently. However, an informative way to compare the treatment outcomes has not been established, and historical control data are missing for recurrent disease. We conducted a retrospective chart review of patients with recurrent DIPG treated between 1998 and 2010. Response progression-free survival and possible influencing factors were evaluated. Thirty-one patients were identified who were treated in 61 treatment attempts using 26 treatment elements in 31 different regimens. The most frequently used drugs were etoposide (14), bevacizumab (13), irinotecan (13), nimotuzumab (13), and valproic acid (13). Seven patients had repeat radiation therapy to the primary tumor. Response was recorded after 58 treatment attempts and was comprised of 0 treatment attempts with complete responses, 7 with partial responses, 20 with stable diseases, and 31 with progressive diseases The median progression-free survival after treatment start was 0.16 years (2 months) and was found to be correlated to the prior time to progression but not to the number of previous treatment attempts. Repeat radiation resulted in the highest response rates (4/7), and the longest progression-free survival. These data provide a basis to plan future clinical trials for recurrent DIPG. Repeat radiation therapy should be tested in a prospective clinical study.

6-year-old girl with hydrocephalus

With rare exceptions, pediatric tectal gliomas have been generally reported as low-grade tumors with relatively good prognosis. The patients are usually treated conservatively to manage the signs and symptoms of obstructive hydrocephalus. We report a case of a tectal glioma in a 6-years-old girl with histological features of anaplastic mixed oligoastrocytoma that continues to progress despite chemotherapy and radiation therapy.

Primary midbrain germinoma

Intracranial germinomas arising primarily in the midbrain are extremely rare and only one case has been reported in the literature. A 15-year-old boy presented with headache, diplopia, unsteadiness and personality changes. Brain MRI showed a heterogeneous lesion in the midbrain. The pineal body region was free. The preoperative diagnosis included brain-stem glioma, metastasis and lymphoma. Stereotactic biopsy was permitted in order to take a specimen and the diagnosis of germinoma was established. The patient responded well to chemotherapy and radiotherapy. Germinoma should be included in the differential diagnosis of midbrain lesions. Preoperative diagnosis is difficult and biopsy is still needed for such lesions.

Preradiation chemotherapy may improve survival in pediatric diffuse intrinsic brainstem gliomas: final results of BSG 98 prospective trial

Radiation therapy remains the only treatment that provides clinical benefit to children with diffuse brainstem tumors. Their median survival, however, rarely exceeds 9 months. The authors report a prospective trial of frontline chemotherapy aimed at delaying radiation until time of clinical progression. The aim was to investigate the possibility that radiotherapy would maintain its activity in children whose disease progressed after chemotherapy. Twenty-three patients took part in this protocol, the BSG 98 protocol, which consisted of frontline chemotherapy alternating hematotoxic and nonhematotoxic schedules. Each cycle included three courses delivered monthly; the first course was 1,3-bis(2-chloroethyl)-1-nitrosoureacisplatin, and the second and third were high-dose methotrexate. Three patients underwent one cycle; 5 patients each, two and three cycles; and 10 patients, four cycles. Twenty of the 23 patients eventually received local radiation therapy. A historical cohort of 14 patients who received at least local radiation therapy served as controls. Four patients experienced severe iatrogenic infections, and 11 patients required platelet transfusions. Median survival increased significantly in patients participating in the protocol compared to that in the historical controls (17 months, 95% confidence interval [CI], 10-23 months, vs. 9 months, 95% CI, 8-10 months; p = 0.022), though hospitalization was prolonged (57 vs. 25 days, p = 0.001). Although frontline chemotherapy alternating hematotoxic and nonhematotoxic schedules significantly increases overall median survival, its cost from infection and hospitalization deserves honest discussion with the children and their parents.

Prediction of tumour regrowth of pontine glioma using a two-term model

BACKGROUND

Modelling tumour regrowth kinetics and determining tumour burden is critically important in making accurate patient prognoses.

PATIENTS AND METHODS

Our two-term model, which describes tumour regrowth after chemotherapy was tested by analyzing tumour sizes in patients with pontine gliomas treated at a major cancer centre during the past 40 years. Tumour measurements at four early time points were used to fit the model, which was then used to predict later tumour sizes. The predictions were compared with observed measurements from clinical charts and this model's performance was compared to that of a quadratic model.

RESULTS

The mean of relative errors using the two-term model was 0.186; standard deviation, 0.176. For the quadratic model, the mean of relative errors was 0.412; standard deviation, 0.521.

CONCLUSION

The two-term model fits the tumour regrowth data reasonably well and is more accurate than a competing quadratic model used in the same way (p < 0.05).

[Efficiency of radiation or chemoradiation therapy for diffusely growing brainstem tumors in children]

Radiation or chemoradiation therapy was performed in 97 children with diffusely growing brainstem tumors. A reduction in the severity of neurological disorders was achieved in 92 (94.8%) patients. The course of the disease was traced in 79 patients. Control studies recorded no complete tumor regression. Following 4-8 months, there was growth resumption of a tumor with its lysis and cyst formation in most children. The principal cause of death was local tumor progression. Six-month survivors were 64 (81%) patients; one-, two-, and three-survivors were 21 (26.5%), 8 (10.1%), and 3 (7.65) patients, respectively; one (2.8%) patient survived 5 years. A combination of radiotherapy and monochemotherapy with temodal, vincristine, oncofer, and theraloc failed to improve immediate and long-term results

Primary germinoma arising from the midbrain

A 29-year-old man presented with diplopia, dysarthria, anisocoria, oculomotor nerve paralysis, abducens nerve paralysis, right facial palsy, and spastic hemiparetic gait. Magnetic resonance imaging (MRI) showed a homogenously enhanced mass in the midbrain. MRI-guided stereotactic biopsy was performed, and the histologic diagnosis was pure germinoma. The tumor disappeared after chemotherapy and radiotherapy. Germinoma should be included in the differential diagnosis of midbrain lesions in young adults. MRI-guided stereotactic biopsy provided a helpful diagnostic clue in a patient with a midbrain lesion.

Secondary dissemination in children with high-grade malignant gliomas and diffuse intrinsic pontine gliomas

In children, treatment regimen for high-grade gliomas (HGG) and diffuse intrinsic pontine gliomas (DIPG) are generally not stratified according to disease stage. The hypothesis was that secondary disseminating disease (SDD) in children with HGG is related to an even worse outcome. Description of SDD pattern was performed. In total, 270 children with newly diagnosed HGG or DIPG were eligible for retrospective analysis of SDD. Medical and computer records of these patients were reviewed for demographic characteristics, sites of dissemination, prognostic variables. Forty-six (17%) of the 270 patients had developed SDD. The median time to SDD was 8.2 months. The median overall survival (OS) after dissemination was 3.2 months. The SDD was located parenchymal in the supratentorial (34.8%), infratentorial (6.5%), supratentorial and infratentorial (19.6%), spinal (10.9%), spinal and cerebral (6.5%) regions of the CNS, or leptomeningeal (21.7%). For HGG patients, the median OS was shorter among patients with SDD than among patients without SDD (1.02 vs 1.41 years, P=0.0495). In the group of patients with SDD, patients with cerebrospinal fluid dissemination had a worse outcome compared with patients with parenchymal metastases. Summarising, SDD is a negative prognostic factor for patients with HGG outside the pons. Treatment stratification should be considered.

[Treatment results of children and adolescents with brain stem tumours. Own experiences]

INTRODUCTION

Despite progress in neuro-oncology, treatment results of children and adolescents with brain stem tumours remain poor. There are also controversies concerning the role of chemotherapy in the treatment of these tumours. THE AIM of our study was to analyze treatment results of patients with brain stem tumours treated with radiotherapy alone and with the addition of chemotherapy and to assess which chemotherapy protocol is the most efficient.

MATERIAL, METHODS

Between 1981-2004, 126 patients were treated in our department. The patients were divided into 2 groups according to treatment methods applied. The first group consisted of 49 patients treated with radiotherapy alone. In the second group 77 patients were irradiated and received chemotherapy. Overall survival (OS) at 1 and 5 years was analyzed in both groups. The efficacy of treatment of patients from the second group was assessed by evaluating reaction to radiotherapy, to different chemotherapy protocols and duration of tumour regression. Additionally OS was assessed separately for patients with low grade gliomas treated in the second group.

RESULTS

Seven out of 49 patients from the first group are alive with a follow up from 8 years 9 months to 24 years, median 6 years 7 months. In the second group, 25 out of 77 patients are alive with the follow up from 7 months to 8 years 2 months, median--l year 7 months. OS at l and 5 years for patients treated with radiotherapy alone is 48 and 14% and for those receiving additionally irradiation 59 and 18% respectively (statistically insignificant). Best tumour response was achieved in 42% of patients with radiotherapy but in 75% of cases regression lasted from 2 weeks to l year 3 months, median 4 months. Addition of chemotherapy consisting of cisplatinum and temozolamide resulted in tumour regression in 27% of patients lasting from 4 weeks to 4 years 5 months, median 4 months. OS for patients with LGG was 34.6% at 5 years.

CONCLUSIONS

1. Radiotherapy in brain stem tumours allows to achieve tumour regression but short duration of remission and poor final outcome forces to search for other, effective treatment. 2. Patients with brain stem tumours may benefit from chemotherapy in terms of prolonging survival. 3. Chemotherapy consisting of temozolamide and cisplatinum seems to be promising and might add to improvement of treatment results, but further clinical studies are needed. 4. Patients with low grade gliomas of the brain stem constitute a separate group with a better prognosis.

Treatment options in childhood pontine gliomas

BACKGROUND

Pontine gliomas are the subgroup of brainstem gliomas with the worst prognosis. Controversial treatment approaches are discussed.

PATIENTS AND METHODS

Data of children with pontine gliomas treated in different prospective multi-center studies who were registered in the HIT-GBM database were pooled and analyzed addressing prognostic factors and the relevance of intensive treatment using contingency tables, Kaplan-Meier curves and Cox regression analyses.

RESULTS

From 1983 to 2001, 153 patients (74 males, 79 females, mean age: 8.1 years) with pontine gliomas were registered. Twenty-one tumors were low-grade and 60 were high-grade gliomas (72 undefined histology: 67 no surgery, 5 incomplete data). Sixteen tumors were partially resected, and 125 were irradiated. Ninety children received chemotherapy according to the "HIT-GBM" protocols ("Hirntumor-Glioblastoma multiforme"). The one-year overall survival rate (1YOS) of all patients with pontine glioma was 39.9+/-4.3%. None of the surviving patients had an observation time longer than 3.9 years. Favorable prognostic factors seemed to be age younger than 4 years, low-grade histology and smaller tumor. All three major treatment modalities including resection, irradiation and chemotherapy had prognostic relevance in univariable analysis. Chemotherapy remained beneficial, even if the analysis was restricted to the subgroup of irradiated tumors (1YOS 45.8+/-5.4% vs. 34.4+/-13.5%, P=0.030).

CONCLUSION

Irradiation is an effective element for the treatment of pontine gliomas. Intensive chemotherapy seems to be important in achieving a better OS.

Acute hemolytic transfusion reaction in a pediatric patient following transfusion of apheresis platelets

The practice of transfusing ABO-incompatible platelets, driven primarily by concerns about inventory management, has been considered generally safe because the accompanying plasma is usually diluted in the recipient's total blood volume. However, if the platelet product contains a large volume of plasma or a high concentration of incompatible isoagglutinin, there may be hemolysis of the recipient's red cells. Patients with a small blood volume, such as babies and children, are considered to be at particular risk for such a complication. We describe the case of a baby who suffered massive hemolysis of her group A red cells after transfusion of group O Apheresis Platelets containing a high-titered anti-A isoagglutinin. We also offer a review of the literature on this subject and recommendations to avoid acute hemolytic reactions as a result of platelet transfusion.