Brain metastases in children with solid tumors

An Evaluation of Risk Factors for Intracranial Metastases of Sarcomas: A Systematic Review and Meta-Analysis

INTRODUCTION

Sarcomas, a group of neoplasms comprising both tissue and bone soft tissue tumors, has an increasing prevalence in recent years. Prognosis significantly hinges on early detection, and if not detected early, may consequently metastasize. This review will be the first systematic review and meta-analysis characterizing the presentation and progression of brain metastases from bone and soft tissue cancers.

METHODS

The PubMed, Scopus, and Web of Science databases were queried to identify studies reporting the incidence of intracranial brain metastases from primary sarcoma to the present. Abstract and full-text screening of 1822 initial articles returned by preliminary search yielded 28 studies for inclusion and data extraction. Qualitative assessment of the studies was conducted in accordance with the Newcastle-Ottawa Scale criteria. Meta-analyses were applied to assess risk factors on outcomes.

RESULTS

The average age within the cohort was 27.9 years with a male and female prevalence of 59.1% and 40.9%, respectively. The odds ratio for living status (dead/alive) was calculated for several risk factors - male/female [OR 1.14, 95% CI 0.62, 2.07], single/multiple metastases [OR 0.67, 95% CI 0.35, 1.28], lung metastases/not [OR 1.63, 95% CI 0.85, 3.13], surgery/no surgery [OR 0.49, 95% CI 0.20, 1.21]. The standardized mean differences for duration from diagnoses to metastases were likewise analyzed - male/female [SMD 0.13, 95% CI -0.15, 0.42], single/multiple metastases [SMD 0.11, 95% CI -0.20, 0.42], lung metastases/not [SMD -0.03, 95% CI -0.38, 0.32], surgery/no surgery [SMD 0.45, 95% CI -0.18, 1.09]. The standardized mean differences for duration from metastases to death were analyzed - lung metastases/not [SMD 0.43, 95% CI -0.08, 0.95].

CONCLUSIONS

Our study observed no statistically significant differences in mortality rate among several patient risk factors. Consequentially, there lacks a clear answer as to whether or not an association between mortality rates exists with these patient factors. As such, it is important to continue research in brain-metastasizing sarcomas despite their relative rarity.

Survival outcomes of patients with brain metastasis of osteosarcoma can be improved by aggressive multi-disciplinary interventions including chemotherapy

BACKGROUND/OBJECTIVE

Brain metastasis in osteosarcoma (BMO) is rare and its clinical characteristics are often buried among studies on brain metastasis of bone and soft tissue sarcomas. The aim of the present study was to summarize the incidence, clinical characteristics, treatment and outcomes of patients with BMO.

METHODS

This retrospective study included 7 patients with BMO who received treatment in our center between 2005 and 2019. The clinical medical records of the 7 patients, together with data of 70 BMO patients published in 33 articles and retrieved by means of PubMed and Medline, were analyzed, retrospectively.

RESULTS

Data analysis of the 97 BMO patients showed a high correlation between the interval from the primary diagnosis to BMO occurrence and the interval from the primary diagnosis to prior metastases. Multivariate analysis showed that chemotherapy, radiotherapy and surgery were three main factors affecting the overall survival of BMO patients (HR = 0.427; HR = 0.372; HR = 0.296). Surgery combined with chemotherapy or radiotherapy offered a better overall survival than surgery alone.

CONCLUSION

Patients with BMO may obtain survival benefits from regular neuroimaging and early aggressive multi-disciplinary interventions including surgical resection, postoperative radiotherapy and chemotherapy.

SYNOPSIS

This is a retrospective study describing the characteristics of metastasic intervals, locations, clinical features and prognosis in 97 patients with brain metastasis of osteosarcoma (BMO). Multivariate analysis showed that chemotherapy was effective as surgery and radiotherapy for the treatment of BMO. Our findings emphasize the importance of regular neuroimaging and early aggressive multi-disciplinary interventions including surgical resection, postoperative radiotherapy and chemotherapy.

Characterization of pediatric non-hematopoietic tumor metastases to the central nervous system: A single institution review

Central nervous system (CNS) metastases represent a small portion of pediatric CNS neoplasms and data surrounding this condition with high morbidity is scarce. Single institutional archival institutional pathology records between 1999 and 2022 were searched for patients over 21 years old and younger with CNS, dura, cranial nerve, CSF, or leptomeningeal metastases; 41 cases were identified. We documented primary tumor types and locations, metastasis locations, types of invasion (direct extension vs distant metastasis), times from imaging or pathologic diagnosis to CNS involvement, and outcomes. Distant metastasis was the most common mechanism of metastasis (n = 32, 78%). Interval times to CNS metastasis varied by both tumor type and primary tumor location. In this cohort, osteosarcoma portended the shortest survival following CNS metastasis. This study highlights the diverse mechanisms and locations of CNS involvement in pediatric CNS metastases and illuminates a need for varied monitoring strategies when considering primary tumor type and anatomic location.

Central Nervous System Metastases in Pediatric Patients With Ewing Sarcoma

Metastatic central nervous system (CNS) involvement is rare in pediatric primary extracranial Ewing sarcoma (ES). We describe the incidence and course of 6 patients with extracranial ES who developed metastatic CNS lesions treated at a single institution. The median time to CNS disease detection was 16.3 months (10.0-28.3 months). Event-free and overall survival after CNS disease detection were 1.9 months (0.4 to 10.3 months) and 4.6 months (1.1 to 50.9 months), respectively. One patient was alive at the time of analysis. Clinical status and ability to obtain disease control should be considered when making decisions regarding aggressive interventions in these patients with poor prognosis.

Brain metastases of sarcoma: a rare phenomenon in rare tumours

The usual site for distant metastases of sarcoma is lungs, while brain metastasis (BM) occurs much less frequently and usually late in the disease progression. Despite the advancement in cancer treatment, the outcome for patients with brain metastasis is poor, and their lifespan is short. The frequency of BM in sarcoma seems to be affected by the location and histology of the primary tumour. Sarcoma subtypes with a high propensity for brain metastasis are ASPS, leiomyosarcoma and osteosarcoma. There are no clear guidelines for the treatment of sarcoma brain metastasis. However, therapeutic options include surgery, radiotherapy and chemotherapy, and are often combined. Targeted therapies are a promising treatment option for sarcoma but require investigation in patients with BM. The following review presents the data on sarcoma brain metastasis incidence, treatment and prognosis.

The Epidemiology of Brain and Spinal Cord Tumors

CNS tumors are a diverse group of neoplasms that emerge from a variety of different CNS cell types. These tumors may be benign, malignant, or borderline in nature. The majority of high grade glial tumors are fatal, with the exception of pilocytic astrocytoma. Primary malignant CNS tumors occur at a global annual rate of 2.1 to 5.8 per 100,000 persons. Males are more likely to develop malignant brain tumors than females, whereas benign meningiomas are more common in adult females. Additionally, gender inequalities in non-malignant tumors peak between the ages of 25 and 29 years. Only a small number of genetic variants have been associated with survival and prognosis. Notably, central nervous system (CNS) tumors exhibit significant age, gender, and race variation. Race is another factor that affects the incidence of brain and spinal cord tumors. Different races exhibit variation in terms of the prevalence of brain and CNS malignancies. This chapter discusses ongoing research on brain and spinal cord tumor epidemiology, as well as the associated risks and accompanied disorders.

Is it necessary for patients with potentially resectable esophageal squamous cell cancer to receive routine preoperative brain MRI/CT?

BACKGROUND

This study aimed to investigate the value and efficiency of routine brain MRI or CT in the preoperative workup for patients with potentially resectable (cT_1-4a N_0-3 ) thoracic esophageal squamous cell cancer (ESCC).

METHODS

This was a prospective cross-sectional clinical trial (ChiCTR1800020304). A total of 385 patients with potentially resectable (cT_1-4a N_0-3 ) thoracic ESCC diagnosed from October 2018 to August 2020 were included. Plain brain MRI or CT was performed preoperatively to detect brain metastases (BrM). The primary endpoint was BrM detected by imaging.

RESULTS

Of all 385 patients, the rate of positive brain MRI/CT findings was 1% (n = 4). BrM Patients received chemoradiotherapy, and the median OS was 6 months (95% CI: 4.303-7.697). All 381 remaining patients with initial negative brain MRI/CT diagnosis revealed no brain-associated symptoms within 6 months. The median follow-up for patients without BrM was 20 months (range, from 6 to 32). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of plain MRI or CT to detect BrM were all 100%.

CONCLUSIONS

Preoperative plain MRI or CT is an effective method to detect BrM for potentially resectable (cT_1-4a N_0-3 ) thoracic ESCC. However, due to the low incidence, the value of brain MRI/CT as a routinely preoperational examination in potentially resectable esophageal squamous cell cancer is rather limited. Therefore, preoperative brain MRI/CT should not be recommended as a routine preoperative examination for ESCC.

Pathological Features of Brain Metastases

Metastases are the most common intracranial tumors in adults. Lung cancer, melanoma, renal cell carcinoma, and breast cancer are the most common primary tumors that metastasize to the brain. Improved detection of small metastases by MRI, and improved systemic therapy for primary tumors, resulted in increased incidence of brain metastasis. Advances in neuroanesthesia and neurosurgery have significantly improved the safety of surgical resection of brain metastases. Surgical approach and active management have become applicable for many patients. Subsequently, brain metastases diagnosis no longer equals palliative treatment. Moreover, the demand for diagnosing brain masses has increased with its associated challenges.

Palliative radiation therapy for children with cancer

Radiation therapy (RT) is often used as a palliative treatment for children with recurrent malignant disease to ameliorate or prevent symptoms. However, no guidelines exist regarding the clinical indications or dose fractionation for palliative RT. The goal of this report is to provide guidelines for the use of palliative RT in children with cancer. In this guideline, appropriate indications for palliative RT, recommended dose-fractionation schedules, relevant toxicities, and avenues for future research are explored. RT is an effective palliative treatment for bone, brain, liver, lung, abdominopelvic and head-and-neck metastases, spinal cord compression, superior vena cava syndrome, and bleeding. Single-fraction regimens (8 Gy in one fraction) for children with short life expectancy are recommended for simple, uncomplicated bone metastases and can be considered for some patients with lung or liver metastases. A short, hypofractionated regimen (20 Gy in five fractions) may be used for other indications to minimize overall burden of therapy. There are little data supporting use of more prolonged fractionation regimens, though they may be considered for patients with very good performance status. Future research should focus on response and outcomes data collection, and to rigorously evaluate the role of stereotactic body RT in well-designed, prospective studies.

Site-Specific Metastasis and Survival in Papillary Thyroid Cancer: The Importance of Brain and Multi-Organ Disease

Introduction-heterogeneity in clinical outcomes and survival was observed in patients with papillary thyroid cancer (PTC) and distant metastases. Here, we investigated the effect of distant metastases sites on survival in PTC patients. Methods-patients with a diagnosis of PTC and known metastases were identified using the Surveillance, Epidemiology, and End Results database (1975-2016). Univariate and multivariate Cox regression analyses were performed to analyze the effect of distant metastases sites on thyroid cancer-specific survival (TCSS) and overall survival (OS). Results-from 89,694 PTC patients, 1819 (2%) developed distant metastasis at the initial diagnosis, of whom 26.3% presented with the multiple-organ disease. The most common metastatic sites were lung (53.4%), followed by bone (28.1%), liver (8.3%), and brain (4.7%). In metastatic patients, thyroid cancer-specific death accounted for 73.2%. Kaplan-Meier curves showed decreased OS in patients with metastases to the brain (median OS = 5 months) and liver (median OS = 6 months) compared to lung (median OS = 10 months) and bone (median OS = 23 months). Moreover, multiple organ metastasis had a higher mortality rate (67.4%) compared to single organ metastasis (51.2%, p < 0.001). Using multivariate analysis, risk factors that significantly influence TCSS and OS were male gender (HR = 1.86, 95% CI = 1.17-2.94, p < 0.001, and HR = 1.90, 95% CI = 1.40-2.57, p = 0.009), higher tumor grade (HR = 7.31, 95% CI = 2.13-25.0, p < 0.001 and HR = 4.76, 95% CI = 3.93-5.76, p < 0.001), multiple organ involvement (HR = 6.52, 95% CI = 1.50-28.39, p = 0.026 and HR = 5.08, 95% CI = 1.21-21.30, p = 0.013), and brain metastasis (HR = 1.82, 95% CI = 1.15-2.89, p < 0.001 and HR = 4.21, 95% CI = 2.20-8.07, p = 0.010). Conclusion-the pattern of distant metastatic organ involvement was associated with variability in OS in PTC. Multi-organ metastasis and brain involvement are associated with lower survival rates in PTC. Knowledge of the patterns of distant metastasis is crucial to personalize the treatment and follow-up strategies.

Secondary brain metastases of Ewing's sarcoma presenting with collapse after 6 years of complete remission

Routine brain imaging with MRI and long-term follow-up of Ewing's sarcoma could be the way to move forward by increasing our understanding in this area, as well as improving treatment and long-term outcome for patients.

Epidemiology of synchronous brain metastases

Background

The objectives of this study were to characterize (1) epidemiology of brain metastases at the time of primary cancer diagnosis, (2) incidence and trends of synchronous brain metastases from 2010 to 2015, and (3) overall survival (OS) of patients with synchronous brain metastases.

Methods

A total of 42 047 patients with synchronous brain metastases from 2010 to 2015 were identified from the Surveillance, Epidemiology, and End Results database. Descriptive analysis was utilized to analyze demographics and incidence. The Kaplan-Meier method and a Cox proportional hazards model were utilized to evaluate potential prognostic factors for OS.

Results

The majority of patients were diagnosed from age older than 50 (91.9%). Common primary sites included lung (80%), melanoma (3.8%), breast (3.7%), and kidney/renal pelvis (3.0%). Among pediatric patients, common primaries included kidney/renal pelvis and melanomas. The incidence was roughly 7.3 persons/100 000. Synchronous brain metastases were associated with significantly poorer OS compared to extracranial metastases alone (hazard ratio [HR] =1.56; 95% CI: 1.54-1.58; P < .001). Among patients with brain metastases, male gender (HR = 1.60 vs 1.52), age older than 65 years (HR = 1.60 vs 1.46), synchronous liver, bone, or lung metastases (HR = 1.61 vs 1.49), and earlier year of diagnosis (HR = 0.98 for each year following 2010) were associated with significantly poorer OS.

Conclusions

The vast majority of brain metastases are from lung primaries. Synchronous brain metastases are associated with poorer OS compared to extracranial metastases alone.

Clinical characteristics, treatment and prognosis of paediatric patients with metastatic neuroblastoma to the brain

OBJECTIVE

Neuroblastoma (NB) is the most common extracranial solid malignancy in children. Metastatic involvement of brain is rare in NB. This study was established to evaluate the clinical characteristics, treatment and prognosis of NB patients with brain metastases.

PATIENTS AND METHODS

From September 2005 to December 2016, the clinical data of 15 cases with brain metastases among 264 NB patients admitted to Beijing Tongren Hospital, Capital Medical University were collected and retrospectively analysed. The clinical features of the 15 patients were summarised, and the patients were grouped according to different treatment methods and followed up for a median time of 41 months. The survival curves were plotted, and the Log-rank test was performed to compare the effect of different treatment methods on the prognosis.

RESULTS

The proportion of brain metastases in NB patients in our hospital is 5.68% (15/264). For the prognosis of 15 NB cases, the survival time of combined radiotherapy and/or autologous peripheral blood stem cell transplantation group was longer than that of simple operation and chemotherapy group (61.79 ± 9.59 vs. 30.00 ± 5.99 months, P = 0.03). Among the 15 patients, 4 cases underwent intracranial tumor resection, 4 cases received craniospinal irradiation, and the rest received maintenance chemotherapy. The 2-year survival rate was 82.2%, and the 5-year survival rate was 19.9%. The survival time of combined intracranial surgery and/or radiotherapy group was significantly longer than that of the chemotherapy group (46.67 ± 6.69 vs. 16.42 ± 1.42 months, P = 0.003).

CONCLUSIONS

The incidence of brain metastases NB in children is relatively small, but the prognosis is very poor. Active chemotherapy, radiotherapy and surgery-based comprehensive treatment can prolong the survival time.

Surgery versus stereotactic radiotherapy for people with single or solitary brain metastasis

BACKGROUND

Brain metastases occur when cancer cells spread from their original site to the brain and are a frequent cause of morbidity and death in people with cancer. They occur in 20% to 40% of people during the course of their disease. Brain metastases are also the most frequent type of brain malignancy. Single and solitary brain metastasis is infrequent and choosing the most appropriate treatment is a clinical challenge. Surgery and stereotactic radiotherapy are two options. For surgery, tumour resection is performed using microsurgical techniques, while in stereotactic radiotherapy, external ionising radiation beams are precisely focused on the brain metastasis. Stereotactic radiotherapy may be given as a single dose, also known as single dose radiosurgery, or in a number of fractions, also known as fractionated stereotactic radiotherapy. There is uncertainty regarding which treatment (surgery or stereotactic radiotherapy) is more effective for people with single or solitary brain metastasis.

OBJECTIVES

To assess the effectiveness and safety of surgery versus stereotactic radiotherapy for people with single or solitary brain metastasis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, March 2018), MEDLINE and Embase up to 25 March 2018 for relevant studies. We also searched trials databases, grey literature and handsearched relevant literature.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing surgery versus stereotactic radiotherapy, either a single fraction (stereotactic radiosurgery) or multiple fractions (fractionated stereotactic radiotherapy) for treatment of single or solitary brain metastasis.

DATA COLLECTION AND ANALYSIS

Two review authors screened all references, evaluated the quality of the included studies using the Cochrane tool for assessing risk of bias, and performed data extraction. The primary outcomes were overall survival and adverse events. Secondary outcomes included progression-free survival and quality of life . We analysed overall survival and progression-free survival as hazard ratios (HRs) with 95% confidence intervals (CIs), and analysed adverse events as risk ratios (RRs). For quality of life we used mean difference (MD).

MAIN RESULTS

Two RCTs including 85 participants met our inclusion criteria. One study included people with single untreated brain metastasis (n = 64), and the other included people with solitary brain metastasis (22 consented to randomisation and 21 were analysed). We identified a third trial reported as completed and pending results this may be included in future updates of this review. The two included studies were prematurely closed due to poor participant accrual. One study compared surgery plus whole brain radiotherapy (WBRT) versus stereotactic radiosurgery alone, and the second study compared surgery plus WBRT versus stereotactic radiosurgery plus WBRT. Meta-analysis was not possible due to clinical heterogeneity between trial interventions. The overall certainty of evidence was low or very low for all outcomes due to high risk of bias and imprecision.We found no difference in overall survival in either of the two comparisons. For the comparison of surgery plus WBRT versus stereotactic radiosurgery alone: HR 0.92, 95% CI 0.48 to 1.77; 64 participants, very low-certainty evidence. We downgraded the certainty of the evidence to very low due to risk of bias and imprecision. For the comparison of surgery plus WBRT versus stereotactic radiosurgery plus WBRT: HR 0.53, 95% CI 0.20 to 1.42; 21 participants, low-certainty evidence. We downgraded the certainty of the evidence to low due to imprecision. Adverse events were reported in both trial groups in the two studies, showing no differences for surgery plus WBRT versus stereotactic radiosurgery alone (RR 0.31, 95% CI 0.07 to 1.44; 64 participants) and for surgery plus WBRT versus stereotactic radiosurgery plus WBRT (RR 0.37, 95% CI 0.05 to 2.98; 21 participants). Most of the adverse events were related to radiation toxicities. We considered the certainty of the evidence from the two comparisons to be very low due to risk of bias and imprecision.There was no difference in progression-free survival in the study comparing surgery plus WBRT versus stereotactic radiosurgery plus WBRT (HR 0.55, 95% CI 0.22 to 1.38; 21 participants, low-certainty evidence). We downgraded the evidence to low certainty due to imprecision. This outcome was not clearly reported for the other comparison. In general, there were no differences in quality of life between the two studies. The study comparing surgery plus WBRT versus stereotactic radiosurgery plus WBRT found no differences after two months using the QLQ-C30 global scale (MD -10.80, 95% CI -44.67 to 23.07; 14 participants, very low-certainty evidence). We downgraded the certainty of evidence to very low due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

Currently, there is no definitive evidence regarding the effectiveness and safety of surgery versus stereotactic radiotherapy on overall survival, adverse events, progression-free survival and quality of life in people with single or solitary brain metastasis, and benefits must be decided on a case-by-case basis until well powered and designed trials are available. Given the difficulties in participant accrual, an international multicentred approach should be considered for future studies.

Detection of residual metastatic tumor in the brain following Gamma Knife radiosurgery using a single or a series of magnetic resonance imaging scans: An autopsy study

The aim of the present study was to investigate the usefulness of magnetic resonance image (MRI) for the detection of residual tumors following Gamma Knife radiosurgery (GKR) for brain metastases based on autopsy cases. The study investigated two hypotheses: i) Whether a single MRI may detect the existence of a tumor; and ii) whether a series of MRIs may detect the existence of a tumor. The study is a retrospective case series in a single institution. A total of 11 brain metastases in 6 patients were treated with GKR between 2002 and 2011. Histopathological specimens from autopsy were compared with reconstructed follow-up MRIs. The maximum diameters of the lesions on MRI series were measured, and the size changes classified. The primary sites in the patients were the kidneys (n=2), lung (n=1), breast (n=1) and colon (n=1), as well as 1 adenocarcinoma of unknown origin. The median prescribed dose for radiosurgery was 20 Gy (range, 18-20 Gy), and median time interval between GKR and autopsy was 10 months (range, 1.6-20 months). The pathological outcomes included 7 remissions and 4 failures. Enhanced areas on gadolinium-enhanced MRI contained various components: Viable tumor cells, tumor necrosis, hemorrhage, inflammation and vessels. Regarding the first hypothesis, it was impossible to distinguish pathological failure from remission with a single MRI scan due to the presence of various components. Conversely, in treatment response (remission or failure), on time-volume curves of MRI scans were in agreement with pathological findings, with the exception of progressive disease in the acute phase (0-3 months). Thus, regarding the second hypothesis, time-volume curves were useful for predicting treatment responses. In conclusion, it was difficult to predict treatment response using a single MRI, and a series of MRI scans were required to detect the existence of a tumor.

Outcome of patients with intracranial relapse enrolled on national Wilms Tumor Study Group clinical trials

BACKGROUND

The occurrence of brain metastases (at diagnosis or at relapse) in patients with Wilms tumor is very rare.

METHODS

We retrospectively reviewed the clinical characteristics of patients with Wilms tumor and relapse to the brain enrolled on the National Wilms Tumor Studies (NWTSs) 1-5.

RESULTS

Intracranial relapse was documented in 47 patients (0.5%). Of the 45 patients with adequate data, 26 (58%) patients were male. Thirty-eight (84%) patients had favorable histology Wilms tumor. In 30 patients (67%), the appearance of intracranial disease was preceded by relapse at another site. Ten patients did not have any disease-directed therapy. Surgical resection was attempted in 15 patients; gross total resection was achieved in 11 patients. Twenty-nine patients received brain irradiation; the median dose was 3,000 cGy (range 1,080-4,000 cGy). Twenty-seven patients received chemotherapy. The 5-year overall survival from the time of intracranial relapse was 28.7% (95% confidence interval: 14.4-43.1%). Nine patients (all favorable histology Wilms tumor) were alive with a median follow-up from brain relapse of 140 months (range 35-381 months). All nine survivors received radiation therapy, eight received chemotherapy, and four underwent surgery (two gross total resection, two partial resection). The overall survival after brain metastases of the NWTS-5 patients was significantly higher than the overall survival of the NWTS 1-4 patients (P value = 0.029, log-rank test).

CONCLUSIONS

Patients with Wilms tumor recurrence involving the brain may have durable survival, particularly those treated in recent years. Multimodality therapy including radiation and chemotherapy should be considered for these patients.

Brain metastases in patients diagnosed with a solid primary cancer during childhood: experience from a single referral cancer center

OBJECT

Metastasis to the brain is frequent in adult cancer patients but rare among children. Advances in primary tumor treatment and the associated prolonged survival are said to have increased the frequency of brain metastasis in children. The authors present a series of cases of brain metastases in children diagnosed with a solid primary cancer, evaluate brain metastasis trends, and describe tumor type, patterns of occurrence, and prognosis.

METHODS

Patients with brain metastases whose primary cancer was diagnosed during childhood were identified in the 1990-2012 Tumor Registry at The University of Texas M.D. Anderson Cancer Center. A review of their hospital records provided demographic data, history, and clinical data, including primary cancer sites, number and location of brain metastases, sites of extracranial metastases, treatments, and outcomes.

RESULTS

Fifty-four pediatric patients (1.4%) had a brain metastasis from a solid primary tumor. Sarcomas were the most common (54%), followed by melanoma (15%). The patients' median ages at diagnosis of the primary cancer and the brain metastasis were 11.37 years and 15.03 years, respectively. The primary cancer was localized at diagnosis in 48% of patients and disseminated regionally in only 14%. The primary tumor and brain metastasis presented synchronously in 15% of patients, and other extracranial metastases were present when the primary cancer was diagnosed. The remaining patients were diagnosed with brain metastasis after initiation of primary cancer treatment, with a median presentation interval of 17 months after primary cancer diagnosis (range 2-77 months). At the time of diagnosis, the brain metastasis was the first site of systemic metastasis in only 4 (8%) of the 51 patients for whom data were available. Up to 70% of patients had lung metastases when brain metastases were found. Symptoms led to the brain metastasis diagnosis in 65% of cases. Brain metastases were single in 60% of cases and multiple in 35%; 6% had only leptomeningeal disease. The median Kaplan-Meier estimates of survival after diagnoses of primary cancer and brain metastasis were 29 months (95% CI 24-34 months) and 9 months (95% CI 6-11 months), respectively. Untreated patients survived for a median of 0.9 months after brain metastasis diagnosis (95% CI 0.3-1.5 months). Those receiving treatment survived for a median of 8 months after initiation of therapy (95% CI 6-11 months).

CONCLUSIONS

The results of this study challenge the current notion of an increased incidence of brain metastases among children with a solid primary cancer. The earlier diagnosis of the primary cancer, prior to its dissemination to distant sites (especially the brain), and initiation of presumably more effective treatments may support such an observation. However, although the actual number of cases may not be increasing, the prognosis after the diagnosis of a brain metastasis remains poor regardless of the management strategy.

The pathological spectrum of solid CNS metastases in the pediatric population

OBJECT

Collectively, metastatic tumors are the most common malignancy encountered in the adult central nervous system (CNS), arising most often from lung, breast, skin, and gastrointestinal tract carcinomas. Limited information is available in the literature regarding solid nonhematopoietic CNS metastases in children. The authors carried out a retrospective study of pediatric metastatic neoplasms to the CNS treated in a 30-year period to characterize their frequency, common histological subtypes, and sites of origin.

METHODS

The archival pathology files were searched (1981-2011) for metastatic tumors to the CNS in patients 21 years of age and younger. Pathology material was reviewed, tumors were classified by site of origin and histological subtype, and survival was evaluated.

RESULTS

The authors identified 26 patients with solid nonhematopoietic CNS metastases out of 1135 pediatric CNS tumors diagnosed from 1981 to 2011. Patients ranged in age from 1.5 to 20.3 years and were equally divided between sexes. Most CNS metastases were supratentorial (85%) and solitary (65%). The mean interval from primary malignant diagnosis to CNS metastasis was 27 months. Sites of origin included kidney/adrenal, bone/soft tissue, gonads, head and neck, lung, and liver. Mean survival after CNS involvement was 36.6 months. Overall 1-year and 5-year survival rates were 52% and 16%, respectively.

CONCLUSIONS

In neuropathology practice, nonhematopoietic pediatric CNS metastases are far less common than are nonhematopoietic adult CNS metastases, accounting for approximately 2% of all pediatric CNS tumors. The most common tumors to exhibit CNS metastasis are of kidney/adrenal origin, followed by those from bone/soft tissue. As expected, prognosis is dismal, despite aggressive therapy.

Rare incidence of a diffuse brain metastatic carcinoma: A case report

Brain metastases generally present in the parenchyma of the brain. In the current report, a very rare case of brain metastasis, which simultaneously invaded the subgaleal region, the skull, and the dural and cavernous sinuses is presented. The patient, a 54-year-old female, complained of a progressive headache and exhibited the symptoms of intracranial hypertension. Coronal contrast-enhanced T1-weighted magnetic resonance imaging (MRI) showed high intensity signals in the subgaleal tissue of the left frontoparietal area, as well as in the dural and the cavernous sinuses. The patient was initially diagnosed with an intracranial infection, however, the administered treatment was ineffective. The patient subsequently underwent a biopsy and the pathological diagnosis was determined as a metastatic adenocarcinoma; a primary tumor was not identified during the examinations. Surgical removal of certain metastases and a decompressive craniectomy were performed to relieve the intracranial hypertension. However, the prognosis was unsatisfactory. The patient’s neurological condition progressively worsened and an axial computed tomography scan with a bone window demonstrated a bulging growth in the brain tissue. The patient succumbed after one month due to the widespread metastasis. Thus, this case presents the unusual clinical development of this type of metastatic adenocarcinoma. In addition, due to the intracranial hypertension, the unusual sites of the high intensity signals in the MRI and the lack of a primary tumor, the patient was misdiagnosed with an intracranial infection. Furthermore, this case highlights the necessity for conducting a biopsy as soon as possible and demonstrates the poor prognosis associated with this type of patient.

Brain metastasis in bone and soft tissue cancers: a review of incidence, interventions, and outcomes

Bone and soft tissue malignancies account for a small portion of brain metastases. In this review, we characterize their incidence, treatments, and prognosis. Most of the data in the literature is based on case reports and small case series. Less than 5% of brain metastases are from bone and soft tissue sarcomas, occurring most commonly in Ewing's sarcoma, malignant fibrous tumors, and osteosarcoma. Mean interval from initial cancer diagnosis to brain metastasis is in the range of 20-30 months, with most being detected before 24 months (osteosarcoma, Ewing sarcoma, chordoma, angiosarcoma, and rhabdomyosarcoma), some at 24-36 months (malignant fibrous tumors, malignant peripheral nerve sheath tumors, and alveolar soft part sarcoma), and a few after 36 months (chondrosarcoma and liposarcoma). Overall mean survival ranges between 7 and 16 months, with the majority surviving < 12 months (Ewing's sarcoma, liposarcoma, malignant fibrous tumors, malignant peripheral nerve sheath tumors, angiosarcoma and chordomas). Management is heterogeneous involving surgery, radiosurgery, radiotherapy, and chemotherapy. While a survival advantage may exist for those given aggressive treatment involving surgical resection, such patients tended to have a favorable preoperative performance status and minimal systemic disease.

Epidemiology of brain metastases

Brain metastases are one of the most common neurologic complications of cancer. The incidence is 9%-17% based on various studies, although the exact incidence is thought to be higher. The incidence is increasing with the availability of improved imaging techniques which aid early diagnosis, and effective systemic treatment regimens which prolong life, thus allowing cancer to disseminate to the brain. Lung cancer, breast cancer, and melanoma are the most frequent to develop brain metastases, and account for 67%-80% of all cancers. Most patients with brain metastases have synchronous extracerebral metastases. Some patients present with no known primary cancer diagnosis. In children, brain metastases are rare; germ cell tumors, sarcomas, and neuroblastoma are the common offenders.

Neuroimaging of pediatric posterior fossa tumors including review of the literature

Conventional, anatomical MRI is an essential tool for diagnosis and evaluation of location, quality, and extent of posterior fossa tumors, but offers limited information regarding tumor grade and type. Advanced MRI techniques such as diffusion weighted imaging (DWI) and diffusion tensor imaging (DTI) may improve the specific diagnosis of brain tumors in the posterior fossa in children. In this review the conventional neuroimaging findings, as well as the DWI, and DTI characteristics of common pediatric posterior fossa tumors are discussed and summarized.

Brain metastasis of Wilms tumor with diffuse anaplasia and complex cytogenetic phenotype in a child with neurofibromatosis Type 1

The authors report the first case of a Wilms tumor (WT) with diffuse anaplasia metastatic to the brain in a 13-year-old girl with a history of neurofibromatosis Type 1. At presentation, the metastatic tumor had radiological features that suggested a meningioma. Histologically it was characterized by striking anaplasia and features similar to the patient's previously resected WT with diffuse anaplasia.

Imaging tumors of the pediatric central nervous system

Primary tumors of the central nervous system (CNS) are the second most common neoplasms in children and the leading cause of death in this patient population. The primary objective of this article is to describe the most common pediatric brain tumors and to offer an overview of their respective imaging features, primarily on magnetic resonance imaging. Precise anatomic characterization is essential for developing an appropriate differential diagnosis. Once equipped with this critical information, physicians should be better able to make firm diagnoses, leading to improved disease management and patient outcomes in the setting of CNS tumors of childhood.

Whole neuraxis irradiation to address central nervous system relapse in high-risk neuroblastoma

BACKGROUND

As systemic control of high-risk neuroblastoma (NB) has improved, relapse in the central nervous system (CNS) is an increasingly recognized entity that carries a grim prognosis. This study describes the use of craniospinal irradiation (CSI) for CNS relapse and compares outcomes to patients who received focal radiotherapy (RT).

METHODS

A retrospective query identified 29 children with NB treated at Memorial Sloan-Kettering Cancer Center since 1987 who received RT for CNS relapse. At CNS relapse, 16 patients received CSI (median dose, 2160cGy), and 13 received focal RT. Of those who underwent CSI, 14 (88%) received intra-Ommaya (IO) radioimmunotherapy (RIT); one patient in the non-CSI cohort received IO-RIT.

RESULTS

Patient characteristics were similar between the groups. Time to CNS relapse was 20 and 17 months for the CSI and non-CSI cohorts, respectively. At a median follow-up of 28 months, 12 patients (75%) in the CSI group are alive without CNS disease, including two patients with isolated skeletal relapse. Another patient is alive without disease after a brain relapse was retreated with RT. Three patients died-one with no NB at autopsy, one of CNS disease, and one of systemic disease. The two patients who died of NB did not receive IO-RIT. All 13 patients in the non-CSI cohort died at a median of 8.8 months.

CONCLUSIONS

Low-dose CSI together with IO-RIT provides durable CNS remissions and improved survival compared with focal RT and conventional therapies. Further evaluation of long-term NB survivors after CSI is warranted to determine the treatment consequences for this cohort.

The role of magnetic resonance imaging in children with hematogenous brain metastases from primary solid tumors

Within a 10-year period, 4 out of 429 children with solid tumors treated at the pediatric oncology department developed brain metastases. Lesions secondary to direct extension from the skull or dura were excluded. The tumors causing brain metastases were non-small cell lung carcinoma, Wilms' tumor, osteosarcoma, und hepatoblastoma. All patients had single brain metastasis. All tumors were subcortical/cortical based and isointense on T1-images and, in 2 cases, mildly hyperintense on T2-images. Two patients showed diffusion abnormalities. Three showed enhancement. In the patient with osteosarcoma, metastasis was calcified. Central nervous system (CNS) metastasis may not in itself be a terminal event; metastasis in patients with Wilms' tumor might behave differently. Neuroimaging should be considered in children with pediatric solid tumors with neurological symptoms on follow up.

Neuroblastoma involvement of the falx cerebri

Involvement of the falx cerebri in infants with stage 4 neuroblastoma is thought to be rare. The falx is derived from the neural crest and thus may be a location for primary neuroblastoma. Its propensity for metastasis is unknown. Management of neuroblastoma in this location is potentially challenging. We describe two children less than 18 months of age who were successfully managed with chemotherapy alone (without radiation or surgery) for falx involvement with neuroblastoma.

Brain metastases in HER2-positive breast cancer: the evolving role of lapatinib

Due to improvements in diagnosis and systemic therapy, brain metastases are an increasingly common cause of morbidity and mortality for patients with advanced breast cancer. The incidence of symptomatic brain metastases among women with metastatic breast cancer ranges from 10% to 16%. The HER2 receptor, which is overexpressed in approximately 25% of all breast cancers, is an important risk factor for the development of central nervous system metastases. Surgery and radiation therapy are the primary approaches to the treatment of brain metastases but new chemotherapy and biological agents promise to play an important role in the future management of central nervous system disease. This article reviews the epidemiology, current treatment options and recent advances in the field, with a focus on HER2-positive disease and the emerging role of lapatinib for the treatment and prevention of brain metastases.

Thirteen-year-old child with a malignant chest tumor: clinicopathologic conference

A case of pleuropulmonary blastoma in a 13-year-old child, exposed to the Chernobyl disaster while in-utero, is presented and discussed by both clinician and pathologist, in this traditional clinical-pathologic conference. The discussion includes the differential diagnoses of chest mass in children.

Cerebral metastasis and other central nervous system complications of pleuropulmonary blastoma

BACKGROUND

Pleuropulmonary blastoma (PPB) is a rare tumor of pleura and lung in young children. Central nervous system (CNS) complications, particularly cerebral parenchymal metastases, occur in aggressive forms of PPB: Types II and III PPB. This article evaluates cerebral and meningeal metastases, cerebrovascular events (CVA) caused by tumor emboli, spinal cord complications, and intracranial second malignancies in PPB.

PROCEDURE

International PPB Registry and literature cases were evaluated for CNS events. Cerebral metastasis patients were evaluated for gender, side of origin of PPB, PPB Type, interval from diagnosis to metastasis, status of chest disease, treatment, and outcome. Standard statistical methods were used to calculate the cumulative probability of cerebral metastasis and survival following metastasis.

RESULTS

Thirty-nine cases of cerebral metastasis were identified in 5/53 Registry Type II cases, 15/44 Registry Type III cases, and 19/143 literature Type II/III cases. Metastases occurred 1-60, median 11.5 months after diagnosis. Chest disease was controlled in 50% of children at time of metastasis. The cumulative probability of cerebral metastasis by 5 years from diagnosis was 11% for Type II patients (95%CI (confidence interval): 2-20%) and 54% for Type III patients (95%CI: 31-76%). Seven children survive cerebral metastasis. Other CNS complications were post-operative CVA (five cases), spinal cord invasion or compression (six), leptomeningeal disease (three), and second intracranial malignancies (two).

CONCLUSIONS

Cerebral metastasis is more frequent in PPB than in other childhood sarcomas. Clinicians should screen for this complication. Diverse other CNS complications are less common and require careful diagnosis.

Brain metastases: epidemiology and pathophysiology

Metastases are the most common tumors of the central nervous system (CNS), but cancer databases are often incomplete leading to underestimation of the incidence of even symptomatic brain metastases. Brain imaging studies are not routinely performed on neurologically asymptomatic cancer patients and autopsy studies are outdated. Furthermore, while incidence rates for cancers are stable and mortality is decreasing due to earlier detection and better therapy, the incidence of brain metastases appears to be increasing. The pathophysiology of brain metastases is a complex multistage process, mediated by molecular mechanisms; from the primary organ, cancer cells must transform, grow and be transported to the CNS where they can lay dormant for various lengths of time before invading and growing further. Understanding the pathophysiology of brain metastases is of great importance, because it may lead to the development of more efficient therapies to combat brain tumor growth or to possibly make the CNS an undesirable environment for tumor progression.

Brain metastasis in pediatric extracranial solid tumors: survey and literature review

OBJECTIVES

Brain is a rare site of metastasis in most extracranial pediatric solid tumors. The aim of this study is to investigate the incidence, treatment, prognosis of brain metastasis in extracranial pediatric malignant tumors in a single institution and to review the literature.

METHODS

From September 1989 to December 2002, 1100 children <or=16 years of age with extracranial solid tumors including lymphomas were diagnosed and treated in the Division of Pediatric Oncology, Oncology Institute, Istanbul University. Patients with parenchymal metastases in the brain were assessed.

RESULTS

Sixteen (10 female, 6 male) of 1100 patients (1.45%) with extracranial solid tumors developed brain metastases. The median age of the patients was 10.5 (1-16) years. The diagnosis was sarcomas in 12 patients: 5 osteosarcomas, 4 Ewing's sarcoma family tumors, 1 rhabdomyosarcoma, 1 clear cell sarcoma of the soft tissue, 1 alveolar soft part sarcoma. Two patients had Wilms' tumor and two had germ cell tumors. Four patients (25%) had brain metastasis at diagnosis. Twelve (75%) developed brain metastasis during therapy or relapse at a median duration of 16 (1-70) months from initial diagnosis. All patients had metastases to various sites, mostly lung, at the time the brain metastases were detected. Treatment included surgery, followed by postoperative radiotherapy (RT) and chemotherapy (CT) in 1, S and RT in 1, S in 1, RT and CT in 6, RT in 1, CT in 1 and no treatment in 5. Only one patient with alveolar soft part sarcoma is alive with disease 20 months from diagnosis of brain metastasis. All other patients died at a median time of 2 months (2 days-6 months) from the time of brain metastasis.

CONCLUSIONS

Children with metastatic cancer who develop headaches or any other neurologic symptom should be investigated for possible brain metastasis. Although, the outcome for these patients is dismal in this series and in the literature; reports of long term survival in a few cases with Wilms' tumor, osteosarcoma and alveolar soft part sarcoma who had isolated brain metastasis, suggest that a subset of patients may benefit from therapy.

Incidence and survival of central nervous system involvement in childhood malignancies: Hungarian experience

Direct extension and hematogenous metastasis of primary non-CNS malignant tumors to the CNS are rare complications in children. The authors analyzed the incidence and outcome of these complications in Hungary. During a 14-year period between 1989 and 2002, 406 patients younger than 18 years were studied at Semmelweis University, Second Department of Pediatrics, in Budapest. Among the 406 patients with non-CNS solid tumors, nine hematogenous metastases and five direct tumor extensions to the CNS occurred. Primary tumors included rhabdomyosarcoma, neuroblastoma, tumors of the Ewing sarcoma family, non-Hodgkin lymphoma, and malignant chordoma. Mean interval between the initial diagnosis and the diagnosis of CNS involvement was 11.4 months. Despite intensive treatment, the mean survival after detection of CNS involvement was 10.4 months. The frequency of CNS involvement in non-CNS tumors is low, with a very poor survival.

Intracranial relapse in Wilms tumor patients

BACKGROUND

In children with nephroblastoma, recurrence with metastases in the central nervous system is rare. Recently, previous reports (NWTSG and UKCCSG) reported brain metastases with an incidence of respectively 0.5% and 0.6% in Wilms tumor (WT) patients (respectively n = 30/5,852 and n = 7/1,249).

PROCEDURE

We retrospectively investigated the incidence and survival of patients with central nervous system relapse in WT patients, treated according to the consecutive SIOP protocols 1, 2, 5, 6, 9, and 93-01. All children with WT from 1971 until 2000 were enrolled in the study (3,040 eligible patients). Specimens at diagnosis and if possible at relapse were centrally reviewed. Patients with renal neoplasms other than WT were excluded.

RESULTS

CNS relapse was documented in 14 patients (0.5%). Median time to CNS relapse was 16 months (3-69). The occurrence of relapse was not associated with specific histological subtypes. In seven patients intracranial metastases occurred at first relapse, of which two were isolated relapses. In five patients no treatment was started because of the poor condition of the patient, the other nine cases were treated with (a combination of) chemotherapy (n = 6), surgery (n = 4), and radiotherapy (n = 6).

CONCLUSIONS

CNS relapse in WNT is rare. In contrast to reports of other Wilms tumor study groups, although four patients reached (local) CR, the SIOP registry showed that eventually none of the documented WT patients survived.

Management of brain metastases

Solid tumour brain metastases are a frequent clinical dilemma for oncologists and general physicians. The sound management of brain metastases requires a multidisciplinary approach. In this review we discuss the diagnosis and management of brain metastases including the role of surgery, radiotherapy, and chemotherapy. The standard approaches of surgical excision and primary radiotherapy have evolved from randomised studies. However, controversies remain regarding post-surgery irradiation in the setting of a solitary metastasis and the role of palliative chemotherapy.

Central nervous system involvement in children with sarcoma

OBJECTIVES

To summarize and analyze the experience in CNS involvement (CNSI) in children with sarcomas treated in the above-mentioned institutions.

PATIENTS AND METHODS

From 1990 to 2001, all medical charts were retrospectively reviewed: 19 sarcoma patients (12 boys and 7 girls) were diagnosed with CNSI (4 osteogenic sarcomas, 11 Ewing sarcomas, 2 rhabdomyosarcomas, 1 alveolar soft part sarcoma and 1 mesenchymal chondrosarcoma). Mean age of all patients at the time of initial diagnosis was 14.9 years (range: 4-24 years), mean age at the time when CNSI was diagnosed was 16.9 years (range: 5.5-27 years).

RESULTS

The frequency of CNSI among our patients was 6.17%. The following symptoms and signs (sometimes combined) presented: headache (10 patients), nausea and vomiting (6 patients), seizures (11 patients) and focal neurological signs (9 patients). The mean duration of time elapsed since diagnosis of CNSI till death or last follow-up was 5.2 months (SD: +/-5.7 months). Four patients received chemotherapy (CT) alone, 8 CT and radiotherapy (RT), 2 RT alone, 3 supportive treatment only, 1 CT and surgery and 1 surgery alone. Sixteen patients died; there was no significant difference in the duration of survival between those who were treated with RT or surgery (mean +/- SD: 6.77 +/- 6.56 months) and those who received only CT or supportive treatment (mean +/- SD: 2.60 +/- 2.94 months) (p = 0.07). Brain disease was the main cause of death in all but 1 patient who died 4 days after autologous bone marrow transplantation from uncontrolled sepsis. In 16 patients, CNSI was part of a metastatic disease.

CONCLUSIONS

Among children with sarcoma, CNSI is encountered in 6.17% of cases. More effective therapy has to be developed in order to improve their outcome.

Brain metastasis in children with sarcoma, neuroblastoma, and Wilms' tumor

PURPOSE

To determine the incidence and prognosis of children who develop brain metastasis.

MATERIALS AND METHODS

The medical and tumor registry records of 611 children treated at the University of Iowa Hospitals and Clinics between 1965 and 2000 for a sarcoma, neuroblastoma, or Wilms' tumor were reviewed.

RESULTS

Thirty children (4.9%) were found to have brain metastasis. Brain metastasis occurred in 9 of 113 (8%) neuroblastoma, 7 of 104 (6.7%) rhabdomyosarcoma, 6 of 105 (5.7%) Ewing's sarcoma, 5 of 106 (4.7%) osteosarcoma, 2 of 83 (2.4%) nonrhabdomyosarcoma soft-tissue sarcoma, and 1 of 100 (1%) Wilms' tumor patients. There were 22 male and 8 female patients, with a median age of 14 years at the time of diagnosis of brain metastasis (range 8 months-20 years). Four patients were diagnosed at autopsy, whereas five had brain metastasis at initial diagnosis. For the 25 children who did not have brain metastasis at initial presentation, the median interval from initial diagnosis to development of brain metastasis was 5 months (range 1-43 months). Twenty-nine (97%) had concurrent or prior history of distant metastasis. Eighteen (60%) had solitary brain metastasis. Treatment for the 26 non-autopsy-diagnosed children included surgery (S), followed by postoperative radiotherapy (RT) and chemotherapy (CT) in 2, S and postoperative RT in 1, RT and CT in 16, S alone in 2, CT alone in 2, RT alone in 1, and no treatment in 2. Median survival was 4 months after diagnosis of brain metastasis, with a 1-year survival rate of 11.5%. On multivariate analysis, only the use of RT was found to positively influence freedom from neurologic progression (p = 0.005).

CONCLUSION

Brain metastasis is uncommon in children with a diagnosis of sarcoma, neuroblastoma, or Wilms' tumor and is often accompanied by concurrent distant disease. Children treated with RT for brain metastasis had a better freedom from neurologic progression rate than those who did not receive radiotherapy.

Central nervous system metastases in neuroblastoma: radiologic, clinical, and biologic features in 23 patients

BACKGROUND

Central nervous system (CNS) metastases rarely occur in patients with neuroblastoma, although recent reports suggest an increase in the rate. CNS recurrence may represent a different mechanism of spread than bone and bone marrow metastases and may be associated with unique genetic determinants. Further definition of the radiologic, clinical, and biologic features may provide clues to the predisposing factors and mechanisms of CNS dissemination.

METHODS

A retrospective analysis of all children ages 0-21 years with Stage IV neuroblastoma who were diagnosed at the Institut Curie and the Institut Gustave-Roussy between 1985 and 2000 was performed with direct review of medical records and magnetic resonance images, computed tomography scans, and iodine-123 or iodine-131 metaiodobenzylguanidine scintiscans (MIBG scans). When tumor tissue was available, genetic analysis was performed using comparative genomic hybridization (CGH).

RESULTS

Of 434 patients with Stage 4 disease, 23 children had the CNS as their site of first recurrence. The estimated risk of CNS recurrence was 8.0% at 3 years, with no significant change in risk over the 15-year period. Eleven patients had isolated CNS recurrences, and the remaining patients developed recurrences concomitantly in other sites. The sites of recurrences were parenchymal (n = 8 patients), parenchymal with meningeal (n = 7 patients), and meningeal alone (n = 8 patients). MIBG scans detected CNS lesions in only 43% of patients. Significant risk factors for CNS recurrence included lumbar puncture at diagnosis, ages 2-3 years, and MYCN gene amplification. Abnormalities that were identified using CGH, in addition to 2p24 amplification in 5/7, included gains of 17q and 18q and losses of 1p, 3p, 10q25-26, and 11q.

CONCLUSIONS

The risk of CNS recurrence in patients with neuroblastoma is 8% at 3 years after diagnosis and has not increased in the last 15 years. Because the CNS often is the sole site of recurrence, either it may be a sanctuary site, or the biologic determinants of CNS metastasis may be unique. Elucidation of risk factors and pathogenesis may allow prevention of this fatal event. Cancer 2003;98:155-65.

Brain neoplasms: epidemiology, diagnosis, and prospects for cost-effective imaging

Currently, the literature lacks a solid body of research on decision and cost-effectiveness analysis of imaging strategies for adults and children suspected of having a brain neoplasm. This article describes the epidemiology and clinical presentation of brain neoplasms, reviews current diagnostic strategies, highlights gaps in the literature on decision and cost-effectiveness analysis, and suggests directions for future research.