Temozolomide for recurrent low-grade spinal cord gliomas in adults

The Role of Radiotherapy, Chemotherapy, and Targeted Therapies in Adult Intramedullary Spinal Cord Tumors

Intramedullary primary spinal cord tumors are rare in adults and their classification has recently evolved. Their treatment most frequently relies on maximal safe surgical resection. Herein, we review, in light of the WHO 2021 classification of central nervous system tumors, the knowledge regarding the role of radiotherapy and systemic treatments in spinal ependymomas, spinal astrocytomas (pilocytic astrocytoma, diffuse astrocytoma, spinal glioblastoma IDH wildtype, diffuse midline glioma H3-K27M altered, and high-grade astrocytoma with piloid features), neuro-glial tumors (ganglioglioma and diffuse leptomeningeal glioneuronal tumor), and hemangioblastomas. In spinal ependymomas, radiotherapy is recommended for incompletely resected grade 2 tumors, grade 3 tumors, and recurrent tumors not amenable to re-surgery. Chemotherapy is used in recurrent cases. In spinal astrocytomas, radiotherapy is recommended for incompletely resected grade 2 astrocytomas and grade 3 or 4 tumors as well as recurrent tumors. Chemotherapy is indicated for newly diagnosed high-grade astrocytomas and recurrent cases. In hemangioblastomas not amenable to surgery, radiotherapy is an effective alternative option. Targeted therapies are playing an increasingly important role in the management of some intramedullary primary spinal cord tumor subtypes. BRAF and/or MEK inhibitors have demonstrated efficacy in pilocytic astrocytomas and glioneuronal tumors, belzutifan in von Hippel-Lindau-related hemangioblastomas, and promising results have been reported with ONC201 in diffuse midline glioma H3-K27M altered.

State-of-the-Art and New Treatment Approaches for Spinal Cord Tumors

Spinal cord tumors, though rare, present formidable challenges in clinical management due to their intricate nature. Traditional treatment modalities like surgery, radiation therapy, and chemotherapy have been the mainstay for managing these tumors. However, despite significant advancements, challenges persist, including the limitations of surgical resection and the potential side effects associated with radiation therapy. In response to these limitations, a wave of innovative approaches is reshaping the treatment landscape for spinal cord tumors. Advancements in gene therapy, immunotherapy, and targeted therapy are offering groundbreaking possibilities. Gene therapy holds the potential to modify the genes responsible for tumor growth, while immunotherapy harnesses the body's own immune system to fight cancer cells. Targeted therapy aims to strike a specific vulnerability within the tumor cells, offering a more precise and potentially less toxic approach. Additionally, novel surgical adjuncts are being explored to improve visualization and minimize damage to surrounding healthy tissue during tumor removal. These developments pave the way for a future of personalized medicine for spinal cord tumors. By delving deeper into the molecular makeup of individual tumors, doctors can tailor treatment strategies to target specific mutations and vulnerabilities. This personalized approach offers the potential for more effective interventions with fewer side effects, ultimately leading to improved patient outcomes and a better quality of life. This evolving landscape of spinal cord tumor management signifies the crucial integration of established and innovative strategies to create a brighter future for patients battling this complex condition.

Advances in Molecular Pathology, Diagnosis and Treatment of Spinal Cord Astrocytomas

Spinal cord astrocytoma (SCA) is a rare subtype of astrocytoma, posing challenges in diagnosis and treatment. Low-grade SCA can achieve long-term survival solely through surgery, while high-grade has a disappointing prognosis even with comprehensive treatment. Diagnostic criteria and standard treatment of intracranial astrocytoma have shown obvious limitations in SCA. Research on the molecular mechanism in SCA is lagging far behind that on intracranial astrocytoma. In recent years, huge breakthroughs have been made in molecular pathology of astrocytoma, and novel techniques have emerged, including DNA methylation analysis and radiomics. These advances are now making it possible to provide a precise diagnosis and develop corresponding treatment strategies in SCA. Our aim is to review the current status of diagnosis and treatment of SCA, and summarize the latest research advancement, including tumor subtype, molecular characteristics, diagnostic technology, and potential therapy strategies, thus deepening our understanding of this uncommon tumor type and providing guidance for accurate diagnosis and treatment.

Associations between urbanicity and spinal cord astrocytoma management and outcomes

BACKGROUND

The management of spinal cord astrocytomas (SCAs) remains controversial and may include any combination of surgery, radiation, and chemotherapy. Factors such as urbanicity (metropolitan versus non-metropolitan residence) are shown to be associated with patterns of treatment and clinical outcomes in a variety of cancers, but the role urbanicity plays in SCA treatment remains unknown.

METHODS

The Central Brain Tumor Registry of the United States (CBTRUS) analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results Programs, was used to identify individuals with SCAs between 2004 and 2019. Individuals' county of residence was classified as metropolitan or non-metropolitan. Multivariable logistic regression models were used to evaluate associations between urbanicity and SCA. Cox proportional hazard models were constructed to assess the effect of urbanicity on survival using the NPCR survival dataset (2004-2018).

RESULTS

1697 metropolitan and 268 non-metropolitan SCA cases were identified. The cohorts did not differ in age or gender composition. The populations had different racial/ethnic compositions, with a higher White non-Hispanic population in the non-metropolitan cohort (86 % vs 66 %, p < 0.001) and a greater Black non-Hispanic population in the metropolitan cohort (14 % vs 9.9 %, p < 0.001). There were no significant differences in likelihood of receiving comprehensive treatment (OR=0.99, 95 % CI [0.56, 1.65], p = >0.9), or survival (hazard ratio [HR]=0.92, p = 0.4) when non-metropolitan and metropolitan cases were compared. In the metropolitan cohort, there were statistically significant differences in SCA treatment patterns when stratified by race/ethnicity (p = 0.002).

CONCLUSIONS

Urbanicity does not significantly impact SCA management or survival. Race/ethnicity may be associated with likelihood of receiving certain SCA treatments in metropolitan communities.

Impact of extent of resection and adjuvant therapy in diffuse gliomas of the spine

BACKGROUND CONTENT

Diffuse gliomas of the spine (DGS)-consisting of intradural intramedullary glioblastoma, astrocytoma, and oligodendroglioma-are exceedingly rare tumors that account for about 2% of primary spinal cord tumors. Much is unknown about their optimal treatment regimen due to a relative lack of clinical outcome data.

PURPOSE

To provide an updated analysis on treatment and outcomes in DGS.

STUDY DESIGN/SETTING

Observational cohort study using The National Cancer Database (NCDB), a multicenter prospectively collected oncology outcomes database. A systematic literature review was also performed to compare the resulting data to previous series.

PATIENT SAMPLE

Patients with histologically confirmed DGS from 2004 to 2018.

OUTCOME MEASURES

Long-term overall survival and short-term 30/90-day postsurgical mortality, 30-day readmission, and prolonged hospital length of stay.

METHODS

Impact of extent of resection and adjuvant therapy on overall survival was evaluated using Kaplan-Meier estimates and multivariable Cox proportional hazards regression. Univariate and multivariate logistic regression was used to analyze covariables and their prognostic impact on short-term surgical outcomes.

RESULTS

Of the 747 cases that met inclusion criteria, there were 439 astrocytomas, 14 oligodendrogliomas, and 208 glioblastomas. Sixty percent (n=442) of patients received radiation, and 45% (n=324) received chemotherapy. Tumor histology significantly impacted survival; glioblastoma had the poorest survival (median survival time [MS]: 12.3 months), followed by astrocytoma (MS: 70.8 months) and oligodendroglioma (MS: 71.6 months) (p<.001). Gross total resection (GTR) independently conferred a survival benefit in patients with glioblastoma (hazard ratio [HR]: 0.194, p<0.001) and other WHO grade four tumors (HR: 0.223, p=.003). Adjuvant chemotherapy also improved survival in patients with glioblastoma (HR: 0.244, p=.007) and WHO grade four tumors (HR: 0.252, p<.001). Systematic literature review identified 14 prior studies with a combined DGS mortality rate of 1.3%, which is lower than the 4% real-world outcomes calculated from the NCDB. This difference may be explained by selection biases in previously published literature in which only centers with favorable outcomes publish their results.

CONCLUSIONS

There remains a paucity of data regarding treatment paradigms and outcomes for DGS. Our analysis, the largest to date, demonstrates that GTR and adjuvant therapy independently improve survival for certain high-grade subgroups of DGS. This best-available data informs optimal management for such patients.

Primary Spinal Cord Astrocytomas: Two-Center Clinical Experience of Low- and High-Grade Lesions

OBJECTIVE

Primary spinal cord astrocytomas are rare, fatal, and poorly studied.

METHODS

This study included a 2-center, retrospective analysis of primary spinal cord astrocytoma patients from 1997 to 2020. Patients with drop metastases or without at least one follow-up were excluded.

RESULTS

Seven World Health Organization grade I, 6 grade II, 7 grade III, and 4 grade IV astrocytoma patients were included. Older patients had higher grades (median 20 years in grade I vs. 36.5 in grade IV). The median follow-up was 15 months. Thirteen patients were discharged to rehabilitation. Eight patients demonstrated radiographic progression. Adjuvant therapy was utilized more in higher grades (5 of 13 grades III vs. all 11 grades IIIIV). Six patients died (1 death in grades III vs. 5 in grades IIIIV). Ten patients had worsened symptoms at the last follow-up. The median progression-free survival in grade I, II, III, and IV tumors was 116, 36, 8, and 8.5 months, respectively. The median overall survival in grade I, II, III, and IV tumors was 142, 69, 19, and 12 months, respectively. Thrombotic complications occurred in 2 patients, one with isocitrate dehydrogenasewild type glioblastoma.

CONCLUSIONS

Outcomes worsen with higher grades and lead to difficult postoperative periods. Clinicians should be vigilant for thromboembolic complications. Further research is needed to understand these rare tumors.

Epidemiology of primary malignant non-osseous spinal tumors in the United States

BACKGROUND CONTEXT

Primary malignant non-osseous spinal tumors are relatively rare and this has led to a paucity of studies specifically examining the epidemiology of malignant spinal tumors.

PURPOSE

To provide an updated and more comprehensive study examining the epidemiology and relative survival of these rare tumors.

STUDY DESIGN/SETTING

Data was retrospectively acquired from the Central Brain Tumor Registry of the United States (CBTRUS).

PATIENT SAMPLE

Primary malignant non-osseous spinal tumor cases diagnosed between 2000 and 2017 in the United States.

OUTCOME MEASURES

Incidence rates (IRs), relative survival rates, and hazard ratios (HR) were measured.

METHODS

IRs were calculated only for histologically-confirmed cases between 2000 and 2017. Relative survival estimates were calculated from survival information on malignant spinal tumors between 2001 and 2016 for death from any cause. Multivariable Cox proportional hazards regression models were constructed to control for age, sex, race, and ethnicity.

RESULTS

From 2000 to 2017, approximately 587 new cases of malignant non-osseous spinal tumors were diagnosed every year in the United States. The overall IR was 0.178 per 100,000 persons. Ependymomas were the most commonly diagnosed tumor in all age groups. The 10-year relative survival rates were 94.1%, 62.1%, 62.0%, and 13.3% for ependymomas, lymphomas, diffuse astrocytomas, and high-grade astrocytomas, respectively. Females have a significantly lower risk of death as compared with males for ependymomas (HR: 0.74, p<.001) and diffuse astrocytomas (HR: 0.70, p=.005). African-Americans have a significantly higher risk of death compared with Caucasians when diagnosed with ependymomas (HR: 1.52, p=.009) or lymphomas (HR: 1.55, p=.009).

CONCLUSION

Primary malignant non-osseous spinal tumors are primarily diagnosed in adulthood or late adulthood. Ependymal tumors are the most commonly diagnosed primary malignant non-osseous spinal tumors and have the highest 10-year relative survival rates. High-grade astrocytomas are rare and portend the worst prognosis.

Predictors of survival and time to progression following operative management of intramedullary spinal cord astrocytomas

PURPOSE

Surgical resection is considered standard of care for primary intramedullary astrocytomas, but the infiltrative nature of these lesions often precludes complete resection without causing new post-operative neurologic deficits. Radiotherapy and chemotherapy serve as potential adjuvants, but high-quality data evaluating their efficacy are limited. Here we analyze the experience at a single comprehensive cancer center to identify independent predictors of postoperative overall and progression-free survival.

METHODS

Data was collected on patient demographics, tumor characteristics, pre-operative presentation, resection extent, long-term survival, and tumor progression/recurrence. Kaplan-Meier curves modeled overall and progression-free survival. Univariable and multivariable accelerated failure time regressions were used to compute time ratios (TR) to determine predictors of survival.

RESULTS

94 patients were included, of which 58 (62%) were alive at last follow-up. On multivariable analysis, older age (TR = 0.98; p = 0.03), higher tumor grade (TR = 0.12; p < 0.01), preoperative back pain (TR = 0.45; p < 0.01), biopsy [vs GTR] (TR = 0.18; p = 0.02), and chemotherapy (TR = 0.34; p = 0.02) were significantly associated with poorer survival. Higher tumor grade (TR = 0.34; p = 0.02) and preoperative bowel dysfunction (TR = 0.31; p = 0.02) were significant predictors of shorter time to detection of tumor growth.

CONCLUSION

Tumor grade and chemotherapy were associated with poorer survival and progression-free survival. Chemotherapy regimens were highly heterogeneous, and randomized trials are needed to determine if any optimal regimens exist. Additionally, GTR was associated with improved survival, and patients should be counseled about the benefits and risks of resection extent.

Clinical outcomes and a therapeutic indication of intramedullary spinal cord astrocytoma

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Although intramedullary astrocytoma is associated with a high mortality rate, the optimal treatment has not reached a consensus. This study aimed at evaluating neurologic function and overall survival rate (OSR) in the treatment of this tumor.

SETTING

The single institution in Japan.

METHODS

This study enrolled 67 subjects who underwent surgical treatment for intramedullary astrocytoma. Demographic, imaging, and surgical information were collected from each participant. Tumors were histologically categorized using the World Health Organization classification, and subjects were divided into low-grade (I and II; n = 40) and high-grade (III and IV; n = 27) groups. Neurologic status was evaluated using the modified McCormick scale (MMS). OSR was assessed using Kaplan-Meier methods.

RESULTS

The OSR decreased when the pathological grade increased (p < 0.01). Regarding the therapeutic efficacy for low-grade astrocytomas, subjects who underwent gross total resection (GTR) showed a higher OSR than those who did not (p = 0.02). GTR prevented worsening of MMS score, while non-GTR increased the MMS score (p < 0.01). In the high-grade group, 19 and 10 underwent radiation therapy and chemotherapy, respectively. However, both treatments did not improve OSR. Cordotomy was performed for subjects whose lesional area was at the thoracic level, but the OSR did not significantly increase.

CONCLUSIONS

The most beneficial therapeutic strategy for low-grade astrocytomas was GTR, whereas that for the high-grade tumors was unclear. Further studies with a larger sample size are warranted to validate the effective treatment for malignant astrocytomas.

Prognostic Factors Independently Associated With Improved Progression-Free Survival After Surgical Resection in Patients With Spinal Cord Astrocytomas: An Institutional Case Series

BACKGROUND

Spinal astrocytomas are rare tumors in which the extent of resection and adjuvant therapy remain controversial. A number of new molecular markers are used, but their utility in spinal cord tumors remains unclear.

OBJECTIVE

To determine prognostic indicators of progression-free survival (PFS) in patients with spinal astrocytomas.

METHODS

A retrospective chart review identified all patients managed at a single institution for spinal cord astrocytomas between 1999 and 2019. Data collected included baseline demographics, presenting signs and symptoms, tumor size, operative outcomes, and adjuvant treatment. Pathological data including histopathological grade, proliferative index, and molecular profile were collected. Duration of follow-up, presence of tumor progression, and status at last follow-up were documented. Univariate and multivariate analyses were performed to determine predictors of PFS.

RESULTS

Seventy-five patients were included in our study with an average age of 42 ± 17 yr. The thoracic spine was the most commonly involved spinal segment (50 patients), and most patients had grade I or grade II tumors (50 patients). On univariate analysis, gross total resection (GTR), lower tumor grade, and low Ki-67 index were associated with lower tumor progression (P-values .01, .04, and .00013, respectively). On multivariate Cox regression analysis, GTR, adjuvant chemotherapy and radiation, and low Ki-67 index were independent predictors of PFS (P-values .009, .011, and .031, respectively).

CONCLUSION

In spinal astrocytomas, GTR, adjuvant therapy, and low Ki-67 are independently associated with improved PFS. These data may help guide management of these tumors and provide important prognosticating information.

A Prospective Clinical Study on MGMT Protein Expression and the Effect of Gene Promoter Methylation on Sensitivity to Chemotherapeutics in Spinal Glioma

Objective

The present study discusses the O6-methylguanine-DNA methyltransferase (MGMT) protein expression of spinal glioma cells and the correlation between the sensitivity of promoter methylation of the MGMT gene to chemotherapy drugs, establishes a prediction method for the sensitivity of chemotherapy drugs on spinal gliomas, providing a theoretical basis for determining the best chemotherapy regimens for clinical patients after a spinal glioma operation.

Methods

A total of 67 patients, who received microsurgical resection for spinal glioma from October 2010 to June 2016, were selected for the present study. Immunohistochemistry and methylation were performed after the operation. Among these patients, 47 patients with postoperative chemotherapy were assigned as the experimental group, while 20 patients without chemotherapy were designated as the control group.

Results

Among the 47 patients in the experimental group, 39 patients had no tumor recurrence after two years, while tumors increased and symptoms were aggravated in eight patients. The progression-free survival rate of chemotherapy was 82.9%, and the two-year survival rate was 100%. The adverse reactions of patients during chemotherapy were slight. Among the 20 patients in the control group, seven patients had no tumor recurrence, while 13 patients had increased tumor size, and the progression-free survival rate was 35.0%.

Conclusion

Under the guidance of MGMT immunohistochemical detection and MGMT gene promoter methylation detection after surgery, chemotherapy can effectively delay tumor recurrence, prevent a reoperation, and have good safety and tolerability. This chemotherapy regimen has good prospects.

Challenges in diagnosis and management of adult spinal cord gliomas

Intramedullary spinal cord gliomas have very low incidence rates. They are associated with difficulties in diagnosis and treatment, and cause significant morbidity. Their clinical presentation and their appearance at magnetic resonance imaging are not specific. They can mimic inflammatory, infectious, vascular disorders or other neoplastic lesions. Primary treatment is surgery. Surgical resection can often be total for ependymomas, but difficult for infiltrating astrocytomas. Radiotherapy is indicated for malignant tumors, but remains controversial in some indications. Chemotherapy is reserved for recurrence, but small retrospective series are available. Genetic studies have revealed genetic alterations which could have a potential impact on treatment in the near future.

Surgical and Radiologic Prognostic Factors in Intramedullary Spinal Cord Lesions

OBJECTIVE

The present study aimed to perform a comprehensive data analysis of 47 consecutive patients treated in 8 years and to observe how clinical, radiologic, and surgical factors affect early and long-term outcomes, recurrence rate, and survival.

METHODS

Clinical, radiologic, and surgical data were collected retrospectively from the review of a prospectively collected database. The neurologic disability was evaluated according to the modified Rankin Scale (mRS). Radiologic data were obtained by direct measurement performed on magnetic resonance imaging (MRI). Univariate and multivariate statistical analysis was performed.

RESULTS

From 2008 to 2016, 47 consecutive patients underwent microsurgical resection of intramedullary lesions (28 males and 19 females; mean age, 41.2 years). Ependymoma (53.2%), astrocytoma (14.9%), hemangioblastoma (14.9%), and cavernous angioma (6.4%) were the most frequent tumor histology. The mean follow-up duration was 69.3 months. Gross total tumor resection was performed in 80.8% of cases. Forty-two patients (89.4%) were alive at last follow-up. Five-year overall survival and recurrence-free survival were 92% and 82%, respectively.

CONCLUSIONS

Among the examined variables, age seemed to strongly correlate with outcomes; better chances of recovery and a good postoperative outcome were observed in younger patients. Surfacing lesions had a better early functional outcome than did intramedullary located lesions. Patients' preoperative neurologic and functional status (mRS score ≤2) had a significant impact on late neurologic outcome. Progression-free survival correlated with the extent of tumor resection. Surgery should probably be performed before patients' neurologic decline, aiming to achieve maximal resection without compromising patients' quality of life.

Chemotherapy for adult patients with spinal cord gliomas

Background

The incidence of spinal cord gliomas, particularly in adults is low, and the role of chemotherapy has remained unclear.

Methods

We performed a multicenter, retrospective study of 21 patients diagnosed with spinal cord glioma who received chemotherapy at any time during the disease course. Benefit from chemotherapy was estimated by magnetic resonance imaging. Data on radiotherapy were taken into consideration.

Results

Thirteen patients were diagnosed with astrocytic gliomas World Health Organization (WHO) grades 1-4, the remaining eight patients with ependymomas WHO grades 1 or 3. Most patients had more than one neurosurgical intervention. Median age at time of first chemotherapy was 33 years (range 21-67 years). Seven patients had chemotherapy combined with radiotherapy as first-line treatment. Two patients had chemoradiotherapy at recurrence, without prior tumor-specific treatment beyond surgery. One patient received chemotherapy alone as first-line treatment and 2 patients had chemotherapy alone at recurrence, without prior treatment. Nine patients had received radiation therapy at an earlier time and chemotherapy was given at time of further recurrences. Best responses in astrocytomas were as follows: chemotherapy alone-2 stable disease (SD) and 3 progressive disease (PD); chemoradiotherapy-1 complete response, 3 SD, and 4 PD. Best responses in ependymomas were as follows: chemotherapy alone-1 partial response, 5 SD, and 1 PD; chemoradiotherapy-1 SD.

Conclusions

Spinal cord gliomas represent a heterogeneous group of tumors. Survival outcomes in response to chemotherapy in adult spinal cord glioma patients vary substantially, but individual patients appear to derive benefit from chemotherapy.

Surgical treatment and neurological outcome of infiltrating intramedullary astrocytoma WHO II-IV: a multicenter retrospective case series

Introduction

Primary malignant spinal astrocytomas present rare oncological entities with limited median survival and rapid neurological deterioration. Evidence on surgical therapy, adjuvant treatment, and neurological outcome is sparse. We aim to describe the treatment algorithm and clinical features on patients with infiltrating intramedullary astrocytomas graded WHO II–IV.

Methods

The following is a multicentered retrospective study of patients treated for spinal malignant glioma WHO II–IV in five high-volume neurosurgical departments from 2008 to 2019. Pilocytic astrocytomas were excluded. We assessed data on surgical technique, perioperative neurological status, adjuvant oncological therapy, and clinical outcome.

Results

40 patients were included (diffuse astrocytoma WHO II n = 11, anaplastic astrocytoma WHO III n = 12, WHO IV n = 17). Only 40% were functionally independent before surgery, most patients presented with moderate disability (47.5%). Most patients underwent a biopsy (n = 18, 45%) or subtotal tumor resection (n = 15, 37.5%), and 49% of the patients deteriorated after surgery. Patients with WHO III and IV tumors were treated with combined radiochemotherapy. Median overall survival (OS) was 46.5 months in WHO II, 25.7 months in WHO III, and 7.4 months in WHO IV astrocytomas. Preoperative clinical status and WHO significantly influenced the OS, and the extent of resection did not.

Conclusion

Infiltrating intramedullary astrocytomas WHO II–IV present rare entities with dismal prognosis. Due to the high incidence of surgery-related neurological impairment, the aim of the surgical approach should be limited to obtaining the histological tissue via a biopsy or, tumor debulking in cases with rapidly progressive severe preoperative deficits.

Predictors of mortality in patients with primary spinal cord glioblastoma

PURPOSE

Primary spinal cord glioblastoma (GBM) is a rare and devastating disease. Little attention was ever paid to this rare disease. As a result, the standard treatment protocol and prognostic factors of primary spinal cord GBM were not well established. The aim of this study was to determine the predictors associated with survival in patients with primary spinal cord GBM.

METHODS

A total of 122 patients with primary spinal cord GBM from Surveillance, Epidemiology, and End Results database and our institution were included in this retrospective analysis. Information about age, sex, race, tumor invasion, extent of resection, radiation, chemotherapy and year of diagnosis was collected. Univariate and multivariate accelerated failure time (AFT) regression model was performed to identify prognostic factors.

RESULTS

Of the 122 patients, 102 (83.6%) expired at the time of data collection. Overall survival at 1 year, 2 years, 3 years and 5 years was 48.4%, 22.8%, 17.1% and 8.4%, respectively, and median survival time was 12 months. Only radiation was found to be associated with survival in the AFT regression model (time ratio 1.94, 95% CI 1.01-3.72, p < 0.05). Radiotherapy could improve survival slightly; patients who received RT survived approximately two times as long as patients who did not receive RT, but the advantage was short term.

CONCLUSION

The survival of primary spinal cord GBM is poor in the current treatment strategy. Radiotherapy was associated with better survival, but the advantage was short term.

Rare Primary Central Nervous System Tumors in Adults: An Overview

Overall, tumors of primary central nervous system (CNS) are quite common in adults with an incidence rate close to 30 new cases/100,000 inhabitants per year. Significant clinical and biological advances have been accomplished in the most common adult primary CNS tumors (i.e., diffuse gliomas). However, most CNS tumor subtypes are rare with an incidence rate below the threshold defining rare disease of 6.0 new cases/100,000 inhabitants per year. Close to 150 entities of primary CNS tumors have now been identified by the novel integrated histomolecular classification published by the World Health Organization (WHO) and its updates by the c-IMPACT NOW consortium (the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy). While these entities can be better classified into smaller groups either by their histomolecular features and/or by their location, assessing their treatment by clinical trials and improving the survival of patients remain challenging. Despite these tumors are rare, research, and advances remain slower compared to diffuse gliomas for instance. In some cases (i.e., ependymoma, medulloblastoma) the understanding is high because single or few driver mutations have been defined. The European Union has launched European Reference Networks (ERNs) dedicated to support advances on the clinical side of rare diseases including rare cancers. The ERN for rare solid adult tumors is termed EURACAN. Within EURACAN, Domain 10 brings together the European patient advocacy groups (ePAGs) and physicians dedicated to improving outcomes in rare primary CNS tumors and also aims at supporting research, care and teaching in the field. In this review, we discuss the relevant biological and clinical characteristics, clinical management of patients, and research directions for the following types of rare primary CNS tumors: medulloblastoma, pineal region tumors, glioneuronal and rare glial tumors, ependymal tumors, grade III meningioma and mesenchymal tumors, primary central nervous system lymphoma, germ cell tumors, spinal cord tumors and rare pituitary tumors.

Surgical Management of Intramedullary Spinal Cord Tumors

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.

Surgical management of spinal intramedullary tumors: Ten-year experience in a single institution

Despite their rare occurrence, intramedullary spinal cord tumors can cause considerable morbidity and mortality without treatment. Timing of surgery, extent of resection and selection of favorable treatment option are important considerations for a good surgical outcome. In this clinical study, we report our patient series and convey our treatment strategy. We retrospectively reviewed 91 patients with primary intramedullary spinal cord tumors who underwent microsurgical resection at our institution between 2008 and 2018. Data were collected consisting of age, sex, location and histology of tumor, extent of resection, presenting symptoms and neurological outcomes. Modified McCormick Scale was used to assess neurological status of patients. 47 female and 44 male patients were followed-up for a mean period of 35.7 months. The most frequent pathological diagnosis was ependymoma in 56 patients, followed by astrocytoma in 21 and hemangioblastoma in 5 patients. The rest of the tumors consisted of 3 cavernomas, 3 mature cystic teratomas, 2 PNET, one epidermoid tumor. Gross total resection was achieved in 67 patients, while subtotal resection and biopsy was performed in 15 and 9 respectively. The most commonly involved localization was cervical (n = 39), followed by thoracic region (n = 24). Despite immediate postoperative worsening of neurological status, a great number of patients improved at the last follow-up. Gross total resection remains the primary goal of treatment while adjuvant radiation and/or chemotherapy may be alternative options for high grade tumors. Preoperative neurological status was the most important and the strongest predictor of functional outcome.

Primary Spinal Astrocytomas: A Literature Review

Primary spinal astrocytoma is a subtype of glioma, the most common spinal cord tumor found in the intradural intramedullary compartment. Spinal astrocytomas account for 6-8% of all spinal cord tumors and are primarily low grade (World Health Organization grade I (WHO I) or WHO II). They are seen in both the adult and pediatric population with the most common presenting symptoms being back pain, sensory dysfunction, or motor dysfunction. Magnetic Resonance Imaging (MRI) with and without gadolinium is the imaging of choice, which usually reveals a hypointense T1 weighted and hyperintense T2 weighted lesion with a heterogeneous pattern of contrast enhancement. Further imaging which may aid in surgical planning includes computerized tomography, diffusion tensor imaging, and tractography. Median survival in spinal cord astrocytomas ranges widely. The factors most significantly associated with poor prognosis and shorter median survival are older age at initial diagnosis, higher grade lesion based on histology, and extent of resection. The mainstay of treatment for primary spinal cord astrocytomas is surgical resection, with the goal of preservation of neurologic function, guided by intraoperative neuromonitoring. Adjunctive radiation has been shown beneficial and may increase overall survival. The role of adjunctive chemotherapy is employed, however, its benefit has not been clearly defined. Primary spinal cord astrocytomas are rare and challenging to treat. The gold standard treatment is surgical resection. Second-line treatments include radiation and chemotherapy, although, the optimal regimen for adjunctive therapy has not yet been clearly defined.

Molecular foundations of primary spinal tumors-implications for surgical management

Primary spinal tumors are rare lesions that require careful clinical management due to their intimate relationship with critical neurovascular structures and the significant associated risk of morbidity. While the advent of molecular and genomic profiling is beginning to impact the management of the cranial counterparts, translation for spinal tumors has lagged behind. Maximal safe surgical resection remains the mainstay of patients with primary spinal tumors, with extent of resection and histology the only consistently identified independent predictors of survival. Adjuvant therapy has had limited impact. To develop targeted neoadjuvant and adjuvant therapies, improve prognostication, and enhance patient selection in spinal oncology, a thorough understanding of the current molecular and genomic landscape of spinal tumors is required. In this review, we detail the epidemiology, current standard-of-care, and molecular features of the most commonly encountered intramedullary spinal cord tumors (IMSCT), intradural extramedullary (IDEM) tumors, and primary spinal column malignancies (PSCM). We further discuss current efforts and future opportunities for integrating molecular advances in spinal oncology with clinical management.

A systematic review of outcome in intramedullary ependymoma and astrocytoma

The objective was to determine the impact of surgical resection and adjuvant therapies on survival in intramedullary ependymoma and astrocytoma. Secondary goals were to determine predictors of survival in surgical patients including histological grading, age and gender. Searching of Medline, Embase and Clinicaltrials.gov databases were performed. Multivariate analyses were performed for overall survival (OS) and progression-free survival (PFS) through Monte Carlo methods and Maximum Likelihood Estimation. 57 articles detail results for 3022 patients. Meta-analysis revealed the following factors to have a statistically significant effect on OS. Patients undergoing gross-total resection (GTR) are 5.37 times more likely to survive than patients with lesser volumes of tumor resected (HR for OS 1.68, p < 0.01). High-grade tumors were associated with a 14 times risk of death over low-grade tumors (HR for OS 2.64, p < 0.01). Radiation increased the risk of mortality in low-grade tumors (HR for OS 5.20, p < 0.01), but decreased mortality in high-grade lesions (HR for OS 2.46, p < 0.01). Adult patients were more likely to die from disease compared with pediatric patients by a factor of 1.6 (HR for OS 0.47, p < 0.01). In PFS, radiotherapy was associated with a reduced time to recurrence (HR for PFS 1.90, p < 0.01). There was a male predominance of 58%. Gender did not influence survival. 79% of patients demonstrated stable or improved functional neurological outcomes six months post-operatively. Our data indicates GTR improves OS in all tumor grades. Radiation improves OS only in the presence of high-grade histology. Advancing age and high-grade histology are negative prognostic indicators.

Recent advances in intradural spinal tumors

Intradural spinal tumors are rare tumors of the central nervous system. Due to the eloquence of the spinal cord and its tracts, the compact architecture of the cord and nerves, and the infiltrative nature of some of these tumors, surgical resection is difficult to achieve without causing neurological deficits. Likewise, chemotherapy and radiotherapy are utilized more cautiously in the treatment of intradural spinal tumors than their cranial counterparts. Targeted therapies aimed at the genetic alterations and molecular biology tailored to these tumors would be helpful but are lacking.Here, we review the major types of intradural spinal tumors, with an emphasis on genetic alterations, molecular biology, and experimental therapies for these difficult to treat neoplasms.

Spinal cord astrocytomas: progresses in experimental and clinical investigations for developing recovery neurobiology-based novel therapies

Spinal cord astrocytomas (SCAs) have discernibly unique signatures in regards to epidemiology, clinical oncological features, genetic markers, pathophysiology, and research and therapeutic challenges. Overall, there are presently very limited clinical management options for high grade SCAs despite progresses made in validating key molecular markers and standardizing tumor classification. The endeavors were aimed to improve diagnosis, therapy design and prognosis assessment, as well as to define more effective oncolytic targets. Efficacious treatment for high grade SCAs still remains an unmet medical demand. This review is therefore focused on research state updates that have been made upon analyzing clinical characteristics, diagnostic classification, genetic and molecular features, tumor initiation cell biology, and current management options for SCAs. Particular emphasis was given to basic and translational research endeavors targeting SCAs, including establishment of experimental models, exploration of unique profiles of SCA stem cell-like tumor survival cells, characterization of special requirements for effective therapeutic delivery into the spinal cord, and development of donor stem cell-based gene-directed enzyme prodrug therapy. We concluded that precise understanding of molecular oncology, tumor survival mechanisms (e.g., drug resistance, metastasis, and cancer stem cells/tumor survival cells), and principles of Recovery Neurobiology can help to create clinically meaningful experimental models of SCAs. Establishment of such systems will expedite the discovery of efficacious therapies that not only kill tumor cells but simultaneously preserve and improve residual neural function.

Remarkable efficacy of temozolomide for relapsed spinal myxopapillary ependymoma with multiple recurrence and cerebrospinal dissemination: a case report and literature review

PURPOSE

Myxopapillary ependymomas are intradural tumors which grow from the terminal filum of the spinal cord. Although they are classified as WHO grade I, they sometimes cause cerebrospinal fluid dissemination or local recurrence. In this report, we describe a case in that temozolomide (TMZ) showed remarkable efficacy on a recurrent spinal myxopapillary ependymoma.

CASE REPORT

A 26-year-old female underwent resection of an intradural myxopapillary ependymoma at L5 initially. Although an en bloc total resection, including the capsule, could be achieved, she needed two additional tumor resection surgeries with postoperative radiotherapy at L4 and at L3 (2 and 6 years after the initial surgery, respectively). Moreover, 4 years after the initial surgery, a disseminated metastatic tumor occurred at T11/12 and local radiotherapy was not effective. After the third surgery, an aggressive adjuvant therapy was necessary because there was a high risk of another recurrence. Therefore, TMZ was administered for 1 year. After 6 months of TMZ treatment, remarkably, the disseminated metastatic tumor at T11/12 had disappeared completely. Presently, 6 years after finishing the TMZ treatment, the follow-up MRI has shown no recurrence in the brain and whole spine.

CONCLUSIONS

TMZ is usually used in the treatment of glioblastoma and, recently, it has been reported to be effective for the lower grade spinal gliomas including spinal intramedullary ependymomas. However, for myxopapillary ependymomas, there has been no report that TMZ is effective. According to our results, TMZ could be one of the possible candidates for adjuvant therapy in multiple recurrent myxopapillary ependymomas.

[Contribution of temozolomide chemotherapy for intramedullary grade II spinal cord astrocytomas in adults: Our experience]

INTRODUCTION

Grade II intramedullary astrocytomas are rare tumors. Despite a well-defined role of adjuvant temozolomide chemotherapy for brain gliomas, the contribution of this therapy for intramedullary gliomas is not yet clearly defined.

METHOD

We retrospectively analyzed the data of 5 adult patients treated with temozolomide between 2008 and 2015 for a grade II intramedullary astrocytoma with progression after surgery.

RESULTS

Five patients from 19 to 70 years of age (median, 37years) underwent a second surgery for the progression of a grade II intramedullary astrocytoma (median progression-free survival 26months [8-90]). All tumors remained grade II. Due to a second clinical or/and radiological tumor progression, the patients were treated with temozolomide after a 37months median progression-free survival (5-66). All patients received at minimum 12 cycles (mean 14 ± 5; range 12-24) of temozolomide (150-200mg/m²/day, 5days/28days). All patients were alive after a 10-year median follow-up after diagnosis (6-13). All patients were able to walk except one, who was previously in McCormick autonomy grade IV before chemotherapy. The McCormick autonomy rating after temozolomide was stable for 4 patients and improved for 1 patient. The treatment was delayed once for hematological toxicity.

CONCLUSION

Temozolomide stabilized all 5 patients without any major toxicity. Based on this experience that needs to be confirmed, we consider that temozolomide should be envisaged within the therapeutic arsenal for progressive intramedullary grade II astrocytomas.

Intramedullary spinal cord tumors: a review of current and future treatment strategies

Intramedullary spinal cord tumors have low incidence rates but are associated with difficult treatment options. The majority of patients with these tumors can be initially treated with an attempted resection. Unfortunately, those patients who cannot undergo gross-total resection or have subtotal resection are left with few treatment options, such as radiotherapy and chemotherapy. These adjuvant treatments, however, are associated with the potential for significant adverse side effects and still leave patients with a poor prognosis. To successfully manage these patients and improve both their quality of life and prognosis, novel treatment options must be developed to supplement subtotal resection. New research is underway investigating alternative therapeutic approaches for these patients, including directed, localized drug delivery and nanomedicine techniques. These and other future investigations will hopefully lead to promising new therapies for these devastating diseases.

Primary Spinal Oligoastrocytoma

Astrocytomas are the most common intramedullary spinal cord tumors in pediatric and adolescent patients and the incidence decreases with age. Spinal oligoastrocytoma, which is a mixed glioma with distinct astrocytic and oligodendroglial components, is an extremely rare pathology of the spinal cord. To authors' best of knowledge, there are only 7 spinal oligoastrocytomas reported in the English literature. Here, the authors report a patient of a pathologically confirmed spinal oligoastrocytoma, who presented with severe left leg pain and numbness. This patient reminds us of the rarity of spinal oligoastrocytoma, and the treatment and prognosis were also investigated and reviewed.

Intramedullary Spinal Cord Tumors: Part II-Management Options and Outcomes

Study Design Broad narrative review. Objectives Intramedullary spinal cord tumors (IMSCT) are uncommon lesions that can affect any age group or sex. However, numerous IMSCT exist and the clinical course of each tumor varies. The following article addresses the various management options and outcomes in patients with IMSCT. Methods An extensive review of the peer-reviewed literature was performed, addressing management options and clinical outcomes of patients with IMSCT. Results Early diagnosis and intervention are essential to obtain optimal functional outcome. Each IMSCT have specific imaging characteristics, which help in the clinical decision-making and prognostication. A comprehension of the tumor pathology and the clinical course associated with each tumor can allow for the proper surgical and nonsurgical management of these tumors, and reduce any associated morbidity and mortality. Recent advances in the operative management of such lesions have increased the success rate of tumor removal while minimizing iatrogenic-related trauma to the patient and, in tandem, improving patient outcomes. Conclusions Awareness and understanding of IMSCT is imperative to design proper management and obtain optimal patient outcomes. Meticulous operative technique and the use of surgical adjuncts are essential to accomplish proper tumor removal, diminish the risk of recurrence, and preserve neurologic function. Operative management of IMSCT should be individualized and based on tumor type, location, and dimensional extensions. To assist with preoperative and intraoperative decision-making, a general algorithm is provided.

Radiotherapy of spinal cord gliomas : A retrospective mono-institutional analysis

BACKGROUND

Due to the rarity of spinal cord gliomas, no consensus has been reached regarding the optimal treatment strategy. The aim of the present retrospective study was to identify patient and tumor characteristics and to evaluate the effectiveness of radiotherapy within this setting.

PATIENTS AND METHODS

Patients diagnosed with spinal cord gliomas between 2003 and 2013 and treated at the Department of Radiation Oncology, University of Munich, were retrospectively analyzed. Overall survival was estimated with the Kaplan-Meier method and univariate analysis was performed by log-rank testing.

RESULTS

A total of 16 patients were identified. The cohort consisted of seven primary spinal cord gliomas and eight cases of metastases of cerebral gliomas. Median follow-up was 42 months and median total radiation dose was 45.0 Gy. In all, 62.5 % of patients received a simultaneous chemotherapy with temozolomide. The median overall survival was 6 months (95% CI: 0-27.5 months). Surgical resection of the tumor was a significant predictor of improved survival, compared with radiotherapy alone (p = 0.001). Patients with the diagnosis of a primary spinal cord glioma survived significantly longer than those presenting with a metastatic deposit from a cerebral glioma (p < 0.001). A statistically significant dose-response relationship at dose levels of ≥ 45 Gy vs. < 45 Gy could be derived (p < 0.001). Simultaneous chemotherapy did not influence survival outcome.

CONCLUSION

Despite the aggressive treatment in the present study, the prognosis for spinal cord gliomas was still poor, with a median overall survival of 6 months. To the best of our knowledge, this is the largest study reporting the results of simultaneous chemoradiation in spinal cord gliomas. A combined chemoradiation treatment seems feasible and can be considered as a new treatment option in the management of spinal cord gliomas.

Spinal cord tumours: advances in genetics and their implications for treatment

Tumours of the spinal cord, although rare, are associated with high morbidity. Surgical resection remains the primary treatment for patients with this disease, and offers the best chance for cure. Such surgical procedures, however, carry substantial risks such as worsening of neurological deficit, paralysis and death. New therapeutic avenues for spinal cord tumours are needed, but genetic studies of the molecular mechanisms governing tumourigenesis in the spinal cord are limited by the scarcity of high-quality human tumour samples. Many spinal cord tumours have intracranial counterparts that have been extensively studied, but emerging data show that the tumours are genetically and biologically distinct. The differences between brain and spine tumours make extrapolation of data from one to the other difficult. In this Review, we describe the demographics, genetics and current treatment approaches for the most commonly encountered spinal cord tumours--namely, ependymomas, astrocytomas, haemangioblastomas and meningiomas. We highlight advances in understanding of the biological basis of these lesions, and explain how the latest progress in genetics and beyond are being translated to improve patient care.

Temozolomide or bevacizumab for spinal cord high-grade gliomas

High-grade gliomas of the spinal cord are rare tumors, traditionally managed with surgery and radiotherapy. Once patients fail standard treatment, many receive some chemotherapy, although the data supporting such is limited. We reviewed our experience treating high-grade gliomas of the spinal cord with standard intracranial regimens including temozolomide and bevacizumab. Outcomes investigated include radiographic response, clinical response, progression-free survival, and overall survival. We identified eight patients who were treated with temozolomide and six who were treated with bevacizumab. Temozolomide was administered to three patients at initial diagnosis and five patients at recurrence after failing prior radiotherapy. For the recurrent patients, the median time-to-progression was 6.6 months (range 1-40 months) and the median overall survival from initiation of temozolomide was 16.6 months (range 1.2-64.5 months). We identified six patients who received bevacizumab at the time of recurrence. MRI demonstrated a partial response in five patients which also correlated with clinical improvement. The median time to progression was 20.7 months (range 3.3-29.9 months) and median overall survival was 22.8 months (range 3.3-31.8 months). This retrospective review suggests that temozolomide and bevacizumab may be beneficial in spinal cord high-grade gliomas. The compact architecture of the spinal cord makes bevacizumab a particularly appealing agent due to the drug's effect on peritumoral edema and mass effect.

Adult primary intradural spinal cord tumors: a review

Primary spinal cord tumors constitute 2% to 4% of all central nervous system neoplasms and are characterized based on their location as intramedullary, intradural extramedullary, and extradural. A contemporary literature review of primary intradural spinal cord tumors was performed. Among intramedullary tumors, ependymomas are more common and often can be surgically resected. However, astrocytomas infiltrate the spinal cord and complete resection is rare. Intradural extramedullary tumors include schwannomas, neurofibromas, and meningiomas and are usually amenable to surgical resection. Radiotherapy is reserved for malignant variants and recurrent gliomas, whereas chemotherapy is administered for recurrent primary spinal cord tumors without surgical or radiotherapy options. Early recognition of the signs and symptoms related to primary spinal cord tumors facilitates timely discovery, treatment, potentially minimizes neurologic morbidity, and may improve outcome. Treatment consists of surgical resection, and predictors of outcome include preoperative functional status, histologic grade of tumor, and extent of surgical resection.

Spinal cord astrocytoma: multidisciplinary experience

BACKGROUND

Astrocytomas of the spinal cord have rarely been reported. We examined our experience, treatment and outcome of patients treated during the last four years.

MATERIAL AND METHODS

We reviewed the charts from patients treated for this neoplasm in a multidisciplinary team of Granada, Spain. The information was retrospectively obtained from the patients' hospital records. The patients were evaluated with clinical history, physical exam, spinal magnetic resonance (MR), surgery, location and histology, treatment, and follow-up.

RESULTS

In the last four years, we have treated 37 astrocytomas, of which only 3 were intramedullary. All patients underwent surgery, radiotherapy and chemotherapy. Two patients died, but one is alive and practically asymptomatic.

CONCLUSION

The optimal treatment remains controversial. Radiotherapy should be considered for tumors with high-grade histopathology, clinically progressive and when a substantial resection cannot be achieved. New therapeutic strategies need to be studied to improve survival.

Treatment of spinal cord tumors

Tumors associated with the spinal cord can have devastating effects on patient function and quality of life. Most of these tumors are from metastatic disease, usually to the epidural space. Less frequently, the tumors are intrinsic to the spinal cord itself (ie, primary tumor). Regardless of the etiology, spinal cord tumors often present first with progressive local or radicular pain, or both. Other symptoms include weakness, sensory changes, or sphincter dysfunction. The timeliness of diagnosis of spinal cord tumors and promptness of treatment are important, as they directly affect outcome. Dexamethasone, a corticosteroid, is used as a temporizing measure to improve or stabilize neurologic function until definitive treatment. For nonambulatory patients with epidural metastatic tumors, surgery followed by radiation therapy maximizes neurologic function and modestly lengthens survival. However, palliative radiotherapy alone is recommended for those with neurologic deficits lasting longer than 48 hours, survival prognosis less than 3 months, inability to tolerate surgery, multiple areas of compression, or radiosensitive tumors. An ambulatory patient with a stable spine should be considered for radiation treatment only. The role of chemotherapy for epidural metastatic tumors is not well established. For intramedullary metastases, the role of surgery and chemotherapy remains controversial and radiation is the mainstay. For low-grade or benign primary spinal cord tumors, resective surgery is of benefit and can be curative. For high-grade tumors, the benefit of resection is less clear, and radiotherapy and/or chemotherapy may be helpful. The use of chemotherapy for primary spinal cord tumors has rarely been assessed. Agents reported in the literature for treatment of spinal cord gliomas include temozolomide, irinotecan, cisplatin, and carboplatin. A multidisciplinary approach is often required to maximize the therapeutic and functional outcome of patients with metastatic and primary spinal cord tumors.

Recurrent spinal cord glioblastoma: salvage therapy with bevacizumab

Primary spinal cord tumors constitute 2-4% of all primary central nervous system malignancies in adults of which less than 5% are glioblastoma. A retrospective evaluation to determine toxicity and response to bevacizumab in patients with recurrent spinal cord glioblastoma. Six patients (4 males; 2 females: median age 34 years) with recurrent spinal cord glioblastoma were treated with bevacizumab (10 mg/kg given once every 2 weeks wherein 2 treatments constituted a cycle of therapy). All patients had failed surgery and temozolomide-based chemoradiotherapy and post-radiotherapy temozolomide. Blood counts, chemistry panel, urine protein to creatinine ratio and neurologic examination were obtained bi-weekly. Contrast-enhanced spine MRI was performed after one cycle of therapy and thereafter following every two cycles of bevacizumab. Treatment-related complications included fatigue in six patients, constipation in 4, hypertension in 2, venous thrombosis in 2, and infection without neutropenia in 2. There were three grade 3 toxicities (1 each fatigue, leukopenia and venous thrombosis). There were no treatment-related deaths. After one cycle of bevacizumab, one patient (17%) demonstrated progressive disease, 2 (34%) partial responses and three (51%) stable disease. Overall median response or stable disease duration (disease free progression) was 7 months (range 3-11 months). Overall median survival was 9 months (range of 5-13 months). Bevacizumab is well tolerated, has tolerable toxicity and apparent activity in this small cohort of adults with recurrent spinal cord glioblastoma.

Management of intramedullary cystic pilocytic astrocytoma with rhenium-186 intracavitary irradiation: case report

OBJECTIVE

We report a case of cystic spinal cord pilocytic astrocytoma treated with surgical resection and 2 intracavitary injections of rhenium.

CLINICAL PRESENTATION

A 22-year-old man presented with low-back pain, saddle dysesthesia, and sphincter and sexual dysfunction. Spinal cord magnetic resonance showed a large, cystic, intramedullary tumor extending from T9 to T12.

TREATMENT

Two surgical approaches and 1 computed tomography (CT)-scan guided tapping allowed shrinkage of the cystic component but each time the cyst enlarged and neurological symptoms worsened. Pathological examination allowed the diagnosis of pilocytic astrocytoma. The patient underwent 2 intracystic CT-scan guided injections of rhenium that achieved good control of cystic component.

CONCLUSION

Interstitial intracavitary rhenium brachytherapy of recurrent spinal cord cystic astrocytomas achieved excellent stabilization of the cyst with minor side-effects and dramatic improvement of neurological deficits.

Adult primary spinal cord tumors

Primary spinal cord tumors represent 2-4% of all neoplasms of the CNS. Primary spinal cord tumors are anatomically separable into two broad categories: intradural intramedullary and intradural extramedullary. Intramedullary tumors are comprised predominantly of gliomas (infiltrative astrocytomas and ependymomas). Resective surgery can usually be accomplished with spinal ependymomas owing to separation of tumor from spinal cord and, when complete, require no further therapy. By contrast, spinal cord gliomas infiltrate the myelon and, consequently, surgery is nearly always incomplete. Involved-field radiotherapy is most often administered after partial resection. Intradural extramedullary tumors are either peripheral nerve sheath tumors (neurofibromas or schwanommas) or meningiomas. In either instance, complete resection may be accomplished and is often curative. Radiotherapy is reserved for rare malignant variants and for patients in whom surgery is contraindicated. Chemotherapy is administered for recurrent primary spinal cord tumors without other options, that is, reoperation or re-irradiation. Problematic, however, is the lack of clinical trials in general for these CNS tumors and for spinal cord tumors in particular. Consequently, treatment is similar to that for intracranial tumors with a similar histology. Early recognition of the signs and symptoms of primary spinal cord tumors allows for early treatment, potentially minimizes neurologic morbidity and improves outcome. Primary treatment is surgery in essentially all spinal cord tumors, and predictors of outcome include preoperative functional status, histological grade of tumor and extent of surgical resection.

Primary intramedullary tumors of the spinal cord

STUDY DESIGN

Clinically based systematic review.

OBJECTIVE

To define optimal clinical care for primary intramedullary spinal cord tumors using a systematic review with expert opinion.

METHODS

Focused questions on the treatment of primary intramedullary spinal cord tumors were refined by a panel of spine oncology surgeons, medical and radiation oncologist. Keyword were searched through Medline database and pertinent abstracts and manuscripts obtained. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence based review system the proposed questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise.

RESULTS

The literature searches revealed low and very low quality evidence with no prospective or randomized studies. The MEDLINE search engine returned 9000 articles which was restricted to articles about human subjects and written in the English language. The subsequent search resulted in a return of: "spinal cord tumor" (5053), "ependymoma" (580), "astrocytoma" (420), and "glioma" (235) articles. Seventeen articles referenced timing of surgical intervention and symptomatology for intramedullary spinal cord tumors. One hundred fifty-eight chemotherapy and 183 radiation therapy articles for intramedullary spinal cord tumors were reviewed.

CONCLUSION

The most important factor in determining the IMSCT patient's long-term neurologic and functional outcome after surgery is the patient's preoperative neurologic status. However, this must be taken in the context of the underlying tumor histology. Therefore, resection is reserved for progressive neurologic decline and serial monitoring for asymptomatic individuals. Adjuvant therapy is an option for high grade astrocytomas (WHO grades 3-4).