A high-dose busulfan-thiotepa combination followed by autologous bone marrow transplantation in childhood recurrent ependymoma. A phase-II study

Sixteen children with refractory or relapsed ependymoma were entered in a phase-II study of high-dose chemotherapy followed by autologous bone marrow transplantation (ABMT). The conditioning regimen consisted of busulfan 150 mg/m2/day for 4 days and thiotepa 300 mg/m2/day for the 3 following days. All patients had previously been treated by surgery and conventional chemotherapy. Eight of them had also received irradiation at doses ranging from 45 to 55 Gy at the tumor site. At the time of transplantation, 9 patients were in first relapse, 5 in second relapse and 2 in third relapse or more; all had measurable disease; 15 patients were evaluable for response. No radiologic response > 50% was observed. Stable disease and progressive disease were documented in 10 and 5 cases, respectively. The duration of response to this treatment, which lasted for a median time of 7 months (range: 5-8 months), was only evaluable in 5 patients who did not receive further treatment after ABMT. To date, there are 3 disease-free survivors at 15, 25 and 27 months all of whom were treated with second complete surgical resection and local radiotherapy (55 Gy). Toxicity was severe, mainly digestive and cutaneous, and 1 toxicity-related death occurred. Unlike medulloblastomas, ependymomas do not appear to be sensitive to this combination therapy. New therapeutic approaches are warranted.

Adjuvant chemotherapy of childhood posterior fossa ependymoma: cranio-spinal irradiation with or without adjuvant CCNU, vincristine, and prednisone: a Childrens Cancer Group study

In 1975, members of The Children's Cancer Group (CCG) initiated a trial for patients with infratentorial medulloblastomas and ependymomas. Patients, all of whom received post-operative cranio-spinal irradiation (CSI), were randomized to receive or not receive adjuvant chemotherapy (CT) with lomustine (CCNU), vincristine, and prednisone for 1 year. Thirty-six of the 42 patients with ependymoma entered on study were suitable for analysis; 22 received combined modality therapy and 14 irradiation (RT) alone. The failure-free survival (FFS) for the entire sample at 10 years is 36% and overall survival (OS) 39%, with no difference in outcomes between the two regimens. Survival was better for females (73%) than males (21%) and for those older than 10 years (51% vs. 31%). There were two toxic deaths in the group receiving CT. We conclude from this study with long-term follow-up that the CT used was not effective in improving the outcome in children with ependymoma.

Hyperperfusion and hypermetabolism in brain radiation necrosis with epileptic activity

We report a case of high uptake of 11C-methionine (MET), 18F-FDG (FDG) and 201Tl-Cl (Tl) in brain radiation necrosis. Twenty-one years previously, the patient had undergone surgery and radiation therapy consisting of 60-Gy for ependymoma in the anterior horn of the right lateral ventricle. The clinical features consisting of frequent seizures of the left face and arm suddenly appeared 2 wk before admission. MRI depicted a Tl and T2-prolonged lesion in the right frontal lobe. Abnormally high uptake in this area demonstrated by MET-PET, FDG-PET, Tl-SPECT or HMPAO-SPECT suggested the presence of a recurrent tumor. A craniotomy was then performed and an intraoperative electrocorticogram showed continuous epileptic spikes in the lesion. The epileptic foci were resected and the histological features of the lesion were consistent with radiation necrosis. After surgery, the seizures disappeared and the postoperative examinations with MET-PET, FDG-PET, Tl-SPECT and HM-PAO-SPECT no longer showed abnormally high uptake. Hypermetabolism and hyperperfusion related to epileptic fits are therefore thought to result in high uptake of MET, FDG and Tl in radiation necrosis.

Posterior fossa lateral ependymoma in childhood

Over a period extending from 1984 to 1993, 16 children ranging in ages from 2 months to 12 years with posterior fossa ependymoma were treated. Four of these tumors were classified as lateral ependymomas because of their configuration and suspected site of origin. These 4 patients' ages ranged from 2 months to 5 years. Signs and symptoms of increased intracranial pressure and cranial nerve dysfunction were the hallmark of their presentation. Their imaging evaluation included a preoperative and postoperative CT san and/or MRI. A gross total surgical resection' was completed in the 4 children. At least a 1-year follow-up was available for all the patients. Intraoperative brain stem evoked potentials and facial and glossopharyngeal nerve monitoring were used in all the surgeries. Three children required a ventriculoperitoneal shunt postoperatively. Chemotherapy was used postoperatively in 3 children. The 4th child did not receive chemotherapy due to parental refusal and succumbed to a recurrence 1 years postoperatively. Radiation therapy was given to 2 children. Tumor recurrences developed in all children at 12 months, 18 months, 3 years and 4 years postoperatively in proximity to the original tumor site. Histologic sections in 3 patients, including those at the time of recurrence, were consistent with a low mitotic index. Only 1 child's histologic diagnosis was consistent with a high-grade ependymoma. The lower cranial nerve dysfunction transiently worsened in all the patients and was permanent in 2. The child's age, tumor histology and extent of resection play an important role in the prognosis of posterior fossa ependymoma. The lateral posterior fossa ependymoma has a particularly poor prognosis due to its location and its significant postoperative morbidity. The authors propose a combined midline and lateral suboccipital approach in order to expose the fourth ventricular floor, upper cervical spine, lateral recess, cerebellomedullary fissure, cerebellopontine and the cerebellomedullary cistern in an attempt at a "total' resection with a focus on the site of origin. The usage of neurophysiological monitoring appears to be useful in limiting and predicting the extent of postoperative complications. However, prolonged morbidity is likely and is commonly related to lower cranial nerve deficits. The author proposes a proactive approach in order to limit the sequelae of these complications.

Ondansetron in radiation therapy of brain tumor in children

Ten children receiving 5 to 6 week courses of radiotherapy after brain tumor surgery were given ondansetron treatment for persistent nausea and emesis. All patients continued the ondansetron treatment until the end of their radiotherapy course. Nausea, emesis, appetite, and adverse events were scored throughout the ondansetron treatment period. Ondansetron was well tolerated by all patients and was effective at reducing symptoms in 60% of the children.

[Chemotherapy of primary malignant brain tumors in adults]

Chemotherapy of primary malignant brain tumors (PMBT) is palliative, except for germinomas. It is used as adjuvant therapy or alone at recurrence. The chemosensitivity of PMBT differs among tumors of different histological types. The role of chemotherapy in the treatment strategy will be reviewed by tumor type (malignant astrocytic gliomas, anaplastic oligodendrogliomas and mixed gliomas, anaplastic ependymomas, medulloblastomas, germinomas, primary malignant cerebral lymphoma).

Intracranial ependymomas: analysis of prognostic factors in a population-based series

A retrospective study of 31 children presenting in the period 1976-1993 with intracranial ependymomas in the south-west region of the UK was performed. The diagnosis was confirmed by histological review and several histological variables recorded, including pleomorphism, cellularity, numbers of mitotic figures and extent of necrosis. Histological features, presentation and treatment were correlated with outcome. Eleven patients had supratentorial primaries and 20 infratentorial primaries. Seven patients had macroscopically complete resections of which 5 had supratentorial primaries. Eight patients had no other therapy apart from surgery. Six patients received craniospinal irradiation, 11 had involved-field irradiation and 14 did not have radical radiotherapy. Twelve patients received chemotherapy. Eleven patients are relapse-free at a median of 43 months. Of the 20 relapses, 19 were local and only 1 metastatic. The grade of the tumor assigned at presentation had no correlation with outcome. On histological review, the only feature that had a significant correlation (p = 0.05) with survival was tumor cellularity. There was a survival advantage for a supratentorial primary site (p = 0.04). The event-free survival was significantly longer for patients diagnosed after 1986 than before (p = 0.006). Survival was not significantly affected by radiotherapy or chemotherapy. Children who had had a macroscopically complete excision of the tumor had a 5-year survival of 69% as opposed to 47% for those who had incomplete surgery, but this difference is not significant (p = 0.13). The data suggest that: (1) the event-free survival rate has improved significantly with time; (2) there is little correlation between a variety of pathological features and outcome, and (3) failure at the primary site is the major obstacle to improved cure rates. The role of complete resection, including second-look surgery, needs further evaluation.

The role of radiotherapy in the management of spinal cord glioma

PURPOSE

To determine the role of radiotherapy in the management of spinal cord gliomas.

METHODS AND MATERIALS

Thirty-six patients with spinal cord glioma treated between 1979 and 1993 were examined. The patients had 13 astrocytic tumors (7 astrocytomas, 4 anaplastic astrocytomas, 2 glioblastomas), 22 ependymal tumors (18 ependymomas, 4 myxopapillary ependymomas), and 1 unclassified glioma. Fifteen of the patients were treated by surgery alone, but the remaining 21 patients also received postoperative radiotherapy. Total resection was performed on 1 astrocytoma and 13 ependymomas. In general, 40-50 Gy/16-20 fractions/4-5 weeks were given after parital resection, but no radiotherapy was given after total resection.

RESULTS

Actuarial survival was significantly better for patients with ependymal tumors than for those with astrocytic tumors (p = 0007), 5-year actuarial survival rates being 96% and 50% for patients with ependymal tumors and astrocytic tumors, respectively. For patients with ependymal tumors, there was no difference in motor function and survival between those with total resection and those with partial resection followed by radiotherapy. Actuarial 3-year survival was 80% for patients with astrocytomas and 40% for those with anaplastic astrocytomas plus glioblastomas. The difference in the degree of motor function between the patients treated with radiotherapy and those without radiotherapy was not statistically significant. One anaplastic astrocytoma and one glioblastoma patient have lived longer than 4 years after radical treatment including radiocordectomy, or irradiation using doses larger than the tolerance threshold of the spinal cord.

CONCLUSION

Postoperative conventional radiotherapy is indicated after less than total resection of low-grade ependymal tumors and astrocytomas but not after total resection of ependymomas. Radiocordectomy may be an option for certain cases with high-grade astrocytic tumors.

Non-metastatic childhood ependymomas

PURPOSE

Intracranial ependymomas of childhood are relatively infrequent. There are significant disagreements concerning optimal postoperative treatment as well as the patterns of relapse following treatment. The purpose of this retrospective study was the analysis of the recurrence pattern and therefore the implication on the extent of the radiotherapy fields. Data from 37 patients referred within 19 years were used for this study.

PATIENTS AND METHODS

From April 1975 to July 1993, 37 children aged 1-14 years were referred for postoperative treatment of an intracranial ependymoma. Twenty-eight children received postoperative radiation therapy and 26 patients received chemotherapy. The median follow-up is 6 years (range 2 months to 19 years).

RESULTS

Overall survival and event free survival at 5 and 10 years were 40%. Eighteen children relapsed. Relapses occurred from 1.5 months to 3.6 years post treatment. Relapses were distant in four cases and local in 14. Age, sex, extent of primary resection, chemotherapy and type of radiation therapy did not influence the outcome. Children with poorly differentiated tumors who did not receive postoperative radiation therapy had a higher relapse rate but this difference is not statistically significant.

CONCLUSIONS

Despite doses of radiation > or = 50 Gy the majority of recurrences were local. Our results, despite the small number of patients are in accordance to those previously published, suggest that prophylactic craniospinal irradiation is superfluous. Better means of achieved local control are required, such as three-dimensional conformal radiation therapy with dose-escalation study or hyperfractionation regimen.

Neurobehavioral and neurologic outcome in long-term survivors of posterior fossa brain tumors: role of age and perioperative factors

We evaluated the neuropsychological and neurologic outcome of 15 long-term survivors of posterior fossa tumors who were treated between 1970 and 1984 with cranial irradiation (n = 15) and surgery (n = 14). The interval between diagnosis and evaluation ranged from 4 to 20 years (median = 10 years). Earlier age at diagnosis (< 6 years) was associated with an increased incidence of severe neurologic and neuropsychological sequelae. Hydrocephalus, obtundation, and tumor extension outside the vermis also were more prevalent in the younger group. Poor neurobehavioral outcomes in young children with posterior fossa tumors may be related to more aggressive tumor growth or complications of the initial therapy and not solely due to toxicity from craniospinal irradiation.

[Intraoperative radiotherapy (IORT) in malignant brain tumors]

PURPOSE

Feasibility and morbidity of IORT for malignant brain tumors as well as value of innovative imaging for diagnosis of rest tumors and recurrences were examined.

METHODS AND MATERIALS

Between May 1992 and November 1993, 23 patients with malignant brain tumors were treated in Münster with IORT. The patient collective was heterogeneous and negatively selected, i.e. beside of primary treatments, also patients with extensive previous treatment, recurrent tumors or metastases were included. Therapy consisted of radical surgical resection and intraoperative electron radiotherapy using total doses from 15 Gy to 25 Gy relative to the 90% isodose. Afterwards, patients without prior treatment underwent percutaneous irradiation with a maximum dose of 60 Gy, related to the small volume of the tumor area plus a safety margin of 2 cm.

RESULTS

No increase of peri-operative morbidity or subacute sequelae was observed. Overall 1-year survival was 67% for grade III gliomas (WHO), and 56% for glioblastoma multiforme. When the Matsutani selection criteria (primary therapy of a supratentorial, peripheral astrocytoma grade III or glioblastoma smaller than 5 cm in diameter with a Karnofsky performance index of more than 60% and possible wide resection) were applied, 1-year survival increased to 75%. Nuclear medical diagnostics using 123I-alpha-methyltyrosin SPECT proved a valuable method for imaging of non-resectable tumor tissue and diagnosis of recurrences.

CONCLUSIONS

The results of this study indicate that IORT can contribute to successful tumor treatment while neither increasing peri-operative morbidity nor subacute sequelae.

Intradural tumors of the cauda equina: a single institution review of clinical characteristics

A retrospective review of 106 cases of intradural tumors of the cauda equina are presented, subdivided into 5 groups according to their histological characteristics. For each group the clinical course and long-term postoperative results were analyzed: it emerged that differential diagnosis between neurinomas, meningiomas or non-tumoral lesions is not possible based on clinical findings alone and that neuroradiological diagnosis is more accurate when MRI is employed. Long-term prognosis was always favorable with the exception of the group of ependymomas. Nevertheless, early diagnosis in the latter group of tumors gives excellent results because prognosis is apparently directly correlated to the length of preoperative clinical history.

Intracranial ependymomas: treatment results and prognostic factors

Forty-nine intracranial ependymoma patients were postoperatively irradiated with craniospinal, cranial, or wide local fields. Thirty-two patients received an adjuvant chemotherapy regimen of vincristine and CCNU with or without procarbazine. The 10-year actuarial overall and progression-free survival rates were 57% and 57%, respectively. Age was the only significant prognostic factor in favor of adults (p = 0.01).

Cranial irradiation and early puberty

Low doses of cranial irradiation (18-24 gray) employed in the management of acute lymphoblastic leukemia may cause early or precocious puberty, predominantly in girls. To determine whether this sexual dichotomy exists at higher irradiation doses (25-47 gray), the onset of puberty was identified in 46 GH-deficient children (30 males) previously irradiated for a brain tumor not involving the hypothalamic-pituitary axis and compared with the normal pubertal standards of Marshall and Tanner. Age at irradiation was at least 2 SD below the mean age of pubertal onset in normal children. There was a significant linear association between age at irradiation and age at onset of puberty. The onset of puberty occurred at an early age in both sexes (mean, 8.51 yr in girls and 9.21 yr in boys plus 0.29 yr for every year of age at irradiation). For example, the estimated age at onset of puberty in a boy irradiated at 2 yr of age would be 9.79 yr, and that for a boy irradiated at 9 yr of age would be 11.82 yr. In the context of GH deficiency, which is usually associated with a delay in the onset of puberty, this is abnormal. At each age of irradiation, the estimated age at the onset of puberty was approximately 0.7 yr earlier in girls than boys. A similar trend was seen for bone age, which was abnormally early at the time of pubertal onset (mean, 7.39 yr in girls and 8.66 yr in boys plus 0.25 yr for every year of age at the time of irradiation). At the doses of irradiation employed in the treatment of brain tumors, radiation-induced early puberty is not restricted to girls. The clinical consequence of early puberty in the management of poor growth associated with radiation-induced GH deficiency is to foreshorten the time available for treatment with GH.

Pediatric leptomeningeal metastasis: 111In-DTPA cerebrospinal fluid flow studies

Nine children (five girls and four boys) ranging in age from 1 to 18 years (median age, 12 years) with leptomeningeal metastasis were evaluated for cerebrospinal fluid compartmentalization with cerebrospinal fluid flow studies using ventricular diethylenetriaminepentaacetic acid labeled with indium 111 (111In-DTPA). Histologic diagnosis included medulloblastoma (two), primitive neuroectodermal tumor (two), acute lymphoblastic leukemia (two), pineoblastoma (one), ependymoma (one), and anaplastic astrocytoma (one). Sixteen 111In-DTPA cerebrospinal fluid flow studies were performed, of which nine demonstrated normal anterograde cerebrospinal fluid flow of radionuclide, with the following cerebrospinal fluid compartment median times to appearance, with ranges in parentheses: ventricles, 1 minute (0 to 3 minutes); cisterna magna/basal cisterns, 5 minutes (3 to 5 minutes); cervical subarachnoid space, 8 minutes (5 to 10 minutes); thoracic subarachnoid space, 15 minutes (10 to 30 minutes); lumbar subarachnoid space, 35 minutes (20 to 45 minutes); and sylvian cistern, 80 minutes (60 to 90 minutes). Blockage of normal anterograde cerebrospinal fluid flow was seen in seven 111In-DTPA cerebrospinal fluid flow studies in the following cerebrospinal fluid compartments: cervical subarachnoid space (four), lumbar subarachnoid space (two), and cisterna magna/basal cisterns (one). Five 111In-DTPA cerebrospinal fluid flow studies were performed after demonstration of cerebrospinal fluid compartmentalization and treatment with limited-field radiation therapy to involved regions; cerebrospinal fluid flow blocks resolved in three. In conclusion, cerebrospinal fluid compartmentalization, as shown by radionuclide ventriculography, is a common occurrence in pediatric leptomeningeal metastasis (four of nine patients, or 44%) and may be palliated by involved-field radiotherapy.

Fourth ventricle ependymomas. A study of 20 cases with survival analysis

Twenty patients with fourth ventricle ependymoma were treated surgically at our Neurosurgery Division between January 1976 and December 1990. Ependymoblastomas and mixed gliomas operated on in the same period have not been considered. A statistical analysis of our cases and a review of the largest published series show that favourable prognostic factors are: age over 16, post-operative radiotherapy to the posterior cranial fossa and a good Karnofsky performance status (KPS) after operation. The 5-year survival rate of patients under 16 was 20%, in comparison with 60% of adults (p = 0.013). Post-operative radiotherapy to the posterior cranial fossa improved the survival markedly (5-year survival rate 68%, versus 18% without treatment; p = 0.011). The differences of survival are also significant according to a multivariate analysis (p = 0.038). Patients with a post-operative KPS over 70 had a 5-year survival rate of 61% as against 17% of the group with a worse clinical condition (p = 0.032); the multivariate analysis confirmed also that this difference was significant (p = 0.046). Pre-operative symptoms and signs, and KPS, histological grade and extent of surgical removal seem to influence the prognosis, even if the differences of survival are not statistically significant. The statistical relevance of postoperative residual tumour on CT or MRI was brought out on multivariate analysis (p = 0.044).

Ependymomas of the third ventricle

Third ventricular ependymomas are rare tumors that have not been specifically examined. Four cases of these tumors are reported. The presenting symptoms included headache, ataxia, vertigo, and Parinaud's syndrome. All the patients underwent computed tomographic scanning and cerebral angiography, followed by craniotomy and microsurgical resection of the tumor. In addition, all patients had or developed symptomatic obstructive hydrocephalus requiring shunting procedures. Three of the patients are alive with a follow-up of 4 to 12 years. It is remarkable that these tumors are so rare, given that the ependymal surface area of the third ventricle is greater than that of the fourth. The management of these tumors should include aggressive surgical resection, radiation therapy, and cerebrospinal fluid diversion.

Treatment of intracranial ependymomas of children: review of a 15-year experience

PURPOSE

There are still major controversies in the optimal management of children with intracranial ependymomas. To assess the impact of tumor site, histology, and treatment, the outcome of children treated at the Institut Gustave Roussy was reviewed retrospectively.

METHODS AND MATERIALS

Between 1975 and 1989, 80 children aged 4 months to 15.8 years were seen at the Institut Gustave Roussy for postoperative management of an intracranial ependymoma. Location of tumor was infratentorial in 63 cases and supratentorial in 17. Surgical treatment consisted of complete resection in 38, incomplete resection in 38 and biopsy only in 4. Postoperative irradiation was done in 65 patients and chemotherapy in 33. Surviving patients have been followed from 12-197 months with a median of 54 months.

RESULTS

The 5-year actuarial survival and event-free survival are 56% and 38%, respectively. Thirty-four patients relapsed from 3-72 months after diagnosis (median 25 months). In 20 patients, the only site of failure was the original tumor site. Three patients failed locally and at distance, while 10 others failed only at distance. Survival at 5 years was significantly better for patients who had complete resection of the tumor (75% vs. 41%, p = 0.001) and for those who received radiation therapy (63% vs. 23%, p = 0.003). Event-free survival at 5 years was superior in patients with complete resection of the tumor (51% vs. 26%, p = 0.002) and in patients who received radiation therapy (45% vs. 0%, p < 0.001). Sex and tumor site had no impact on survival or event-free survival. There was no difference in survival, event-free survival, or pattern of failure between patients treated with local field, whole brain or craniospinal irradiation, while severe longterm sequelae were noted predominantly in the latter two groups.

CONCLUSION

Considering that failures were predominantly local and that there was no apparent benefit from prophylactic irradiation, we recommend local field irradiation with doses above 50.0 Gy for all children with intracranial ependymomas, without meningeal dissemination at diagnosis. Special considerations are necessary for children < 3 years of age.

Psychosocial adjustment in long-term survivors of childhood medulloblastoma and ependymoma treated with craniospinal irradiation

Improved prognosis for pediatric brain tumors has stimulated research into the quality of life of survivors. To assess cognitive function and psychosocial and family adjustment among this population, 18 long-term survivors of childhood medulloblastoma or posterior fossa ependymoma treated with surgical resection and craniospinal irradiation were interviewed and administered achievement tests and psychosocial questionnaires. A majority of parents reported significant difficulty caring for their child with a brain tumor, but no significant adverse effects upon the family. Academic achievement was significantly impaired in 12/18 subjects. Psychosocial adjustment was normal in 10/18 subjects. Although specific treatment variables (radiation dosage, chemotherapy, etc.) were not significantly related to these two outcome measures, impaired academic achievement was correlated with young age at diagnosis (p < 0.05) and impaired psychosocial adjustment was correlated with greater time since diagnosis (p < 0.05). Overall quality of life reported by these individuals appears to be acceptable but neuropsychological and psychosocial examination is clearly indicated as part of the follow-up program.

Late sequelae in children treated for brain tumors and leukemia

Forty-two survivors treated at an age of 2-16 years for brain tumors or leukemia were, 4-21 years after treatment, subjected to an extensive follow-up investigation, including physical examination and interview; 35 of them also had endocrinological and 33 psychological evaluation. Hormonal deficiencies were found in about two-thirds of patients and were most common in those treated for brain tumors. The great majority had verbal intelligence quotient (VIQ) within normal range. Also, the performance intelligence quotients (PIQ) were normal in most patients. However, the results suggested that the primary intellectual capacity in children treated for cancer was not being fully utilized, their PIQ being on the average higher than their VIQ; this tendency was especially pronounced in the leukemia patients.

Treatment results in primary intraspinal gliomas

During the period 1970-1990, 50 patients with primary intraspinal gliomas were treated with either surgery alone or combined surgery and postoperative irradiation. Thirty-four patients had an ependymoma. In this group, 17 patients had a macroscopically total tumor resection; 14 of these patients did not receive further additional treatment. The other 17 patients underwent a partial resection or biopsy; 11 of these patients received postoperative radiation therapy. There were 13 patients with astrocytoma and none of these tumors was radically resected. Twelve patients with astrocytoma received postoperative radiation therapy. Average total dose was 49 Gy for both histological types. The 10-year survival rate in the whole group of patients with ependymomas was 91%. Patients with ependymoma treated with partial tumor resection followed by radiotherapy had a similar survival rate as patients with total resected tumors without postoperative irradiation. The local recurrence rate of ependymomas was 25%, without differences between both treatment modalities. There were 3 major complications due to surgery and no late complications related to radiotherapy. The 10-year survival rate in the group of patients with astrocytoma was 43% and tumor progression was the most important cause of death. Three patients had a spongioblastoma and were treated with radiotherapy following biopsy or partial resection. These patients are alive 6, 11 and 15 years after treatment without evidence of disease. On the basis of our retrospective data and those in the literature we would recommend postoperative radiation therapy in all the intraspinal gliomas where total tumor resection is not possible. The recommended total dose is 50 Gy in 5-6 weeks.

Progression of hearing loss following the completion of chemotherapy and radiation therapy: case report

There have been scattered accounts reported in the oncology literature of progressive hearing loss following the conclusion of chemotherapy. In this case study, we report the audiologic findings of such a case. These data underscore the need for post-therapy monitoring in cases where threshold shifts are discovered during the course of drug administration.

Spinal cord ependymomas: a retrospective analysis of 59 cases

PURPOSE

To determine the outcome of patients with primary spinal ependymoma treated with postoperative radiotherapy and to identify clinical and treatment variables predictive of outcome.

METHODS AND MATERIALS

A retrospective chart review was undertaken of 59 spinal ependymoma patients referred to the Princess Margaret Hospital between 1958 and 1987. All patients were treated with radiation therapy to either the site of the primary tumor or the craniospinal axis. There were 23 female and 36 male patients with a median age of 37 years (range: 8-66 years). Median follow-up was 130 months (range: 1-371 months). Clinical variables including age, sex, length of symptoms, functional status, tumor location, and grade as well as treatment variables including extent of surgery, radiation dose and treatment volume were analyzed for influence on outcome.

RESULTS

Treatment was well-tolerated with no cases of radiation myelopathy identified. Overall actuarial survival at 5 and 10 years was 83% and 75%, respectively. Eleven patients had recurrent tumor with the 9/11 having a component of their recurrence within the treatment field. Median time to recurrence was 2 years with 9 of the 11 recurrences within the first 3 years. Tumor grade was the only independent variable identified as predictive of outcome. Patients with well differentiated tumors had a 5-year cause-specific survival of 97% compared to 71% for those with intermediate or poorly differentiated tumors (p = 0.005).

CONCLUSION

We conclude that postoperative irradiation for patients with spinal ependymomas is associated with a favorable outcome and that tumor grade is a major prognostic factor. Based on results of this series and a review of the literature, specific management recommendations are made for this rare tumor.