Intramedullary spinal gliomas: long-term results of surgical treatments

MR imaging findings in primary spinal cord glioblastoma

Spinal cord glioblastoma is a rare disease, with an aggressive course and a poor prognosis. We describe magnetic resonance imaging (MRI) findings, in 3 adult cases of biopsy-confirmed glioblastoma.

Conventional MRI findings were unclear with regard to the differential diagnosis between this rare tumor and other more common spinal cord lesions, including less aggressive tumors such as ependymoma or pilocytic astrocytoma, abscesses or tumefactive demyelinating lesions. After reasonable exclusion of infectious/inflammatory conditions, a final diagnosis of glioblastoma was established based on histopathological analysis. The cases reported reflect the difficulty of early radiological diagnosis of spinal cord glioblastoma, and indicate the need to perform a biopsy once inflammatory-infectious conditions are excluded with appropriate laboratory tests.

Variation in management of spinal gliobastoma multiforme: results from a national cancer registry

PURPOSE

Primary glioblastoma of the spinal cord (spinal GBM) is a rare central nervous system tumor, relative to its cranial counterpart (cranial GBM). Our current knowledge of spinal GBM epidemiology, tumor characteristics and treatment are insufficient and mostly based on single-institution case series.

METHODS

All patients diagnosed with grade-4 GBM from 2004 to 2014 were queried from the National Cancer Database. Chi square analysis was used to compare presenting characteristics while Kaplan-Meier and Cox regression analyses were employed for survival analyses.

RESULTS

Total 103,496 patients with cranial GBM and 190 patients with spinal GBM were analyzed. Median survival for spinal GBM was found to be higher compared to cranial GBM (p = 0.07). Spinal GBM patients had significant better survival in 18 to 65 years age group than < 18 years and > 65 years age group (p = 0.003). Overall survival time for 95 spinal GBM patients with available treatment data was not statistically different among the four treatment modalities (radiation with or without chemotherapy, surgery alone, surgery with adjuvant therapy, and palliative therapy; p = 0.28).On multivariable analysis, < 18 years age group was associated with improved survival (HR 0.50, 95% CI 0.23-1.00, p = 0.046), while tumor extension was associated with poor survival (HR 2.71, 95% CI 1.04-6.22, p = 0.041). Interestingly surgery with adjuvant therapy was unable to show increase survival compared to other treatment modalities.

CONCLUSIONS

Our study adds to the growing literature on spinal GBM with a focus on comparative trends with cranial GBM and outcomes with different treatment modalities.

A very rare spinal cord tumor primary spinal oligodendroglioma: A review of sixty cases in the literature

LITERATURE REVIEW

In this study, we evaluated a case of primary spinal oligodendroglioma (PSO) with a rare localization between L3 and S2, and also examined sixty cases in the literature in terms of demographic characteristics, clinical, radiological, and histopathological characteristics, and treatment planning. A case of PSO has been presented, and the relevant literature between 1931 and 2016 was reviewed. A total of 57 papers regarding PSO were found and utilized in this review. The main treatment options include radical surgical excision with neuromonitoring, followed by radiotherapy. Despite these treatment protocols, the relapse rate is high, and treatment does not significantly prolong survival. Oligodendrogliomas are rare among the primary spinal cord tumors. Oligodendrogliomas are predominantly found in the cervical spinal cord, thoracic spinal cord, or junctions during childhood and adulthood. Extension to the sacral region, inferior to the Conus, is very rare. Furthermore, of the sixty cases in the literature, the case we present here is the first to be reported in this particular age group. These localizations usually occur in the pediatric age group and after relapses. While for a limited number of cases the oligodendroglioma initiates in the thoracic region and reaches as far as L2, we encountered a case of an oligodendroglioma within the range of L3 to S2. Clinical findings are observed in accordance with location, and magnetic resonance imaging is the gold standard for diagnosis.

Primary Spinal Glioblastoma Multiforme with Secondary Manifestation as a Cerebral "Angioglioma." Literature Review and Case Report

Primary intramedullary spinal glioblastoma multiforme (sGBM) with a secondary cerebral manifestation is a very rare entity with a poor outcome. Case studies show a mean average of survival of 10 months after diagnosis. These tumors tend to develop at a young age. A combination with an arteriovenous malformation in the same location has never been published before. Vascular malformations in association with cerebral glioblastomas have only been reported in five cases so far. Proangiogenic factors are assumed to be involved in the appearance of both entities. We present a case study and a review of the literature.

Cordectomy for intramedullary spinal cord glioblastoma with a 12-year survival

Background:

Prognosis of patients with spinal cord glioblastoma is poor, with an average survival of 18 months. There are reports in the literature describing cordectomy as a treatment option for patients with spinal cord tumors.

Case Description:

This is a case report of a patient with spinal cord glioblastoma who, in addition to radiation and chemotherapy, was treated with cordectomy. Outcome of treatment resulted in 12-year survival.

Conclusion:

Cordectomy in spinal cord glioblastoma can result in prolonged and meaningful survival.

Prognosis by tumor location in adults with spinal ependymomas

OBJECT

Ependymomas are primary central nervous system tumors that occur more frequently in the spines of adults than they do there in children. Previous studies consist mainly of retrospective single-institutional experiences or case studies. In this study, a comprehensive literature review was performed on reported cases of spinal ependymoma treated with resection to determine whether tumor location along the spinal axis conveys important prognostic information.

METHODS

A PubMed search was performed to identify all papers that included data on patients with spinal ependymoma. Only cases involving adult patients who underwent ependymoma resection with a clearly reported tumor location were included for analysis. Tumor locations were separated into 6 groups: cervicomedullary, cervical, cervicothoracic, thoracic, thoracolumbar, and conus + cauda equina. Kaplan-Meier survival and Cox regression analyses were performed to determine the effect of tumor location on progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 447 patients who underwent resection of spinal ependymomas with clearly indicated location of tumor were identified. The most common locations of spinal ependymomas were the cervical (32.0%) and conus + cauda equina (26.8%) regions. The thoracolumbar and cervicomedullary regions had the fewest tumors (accounting for, respectively, 5.1% and 3.4% of the total number of cases). The conus + cauda equina and thoracolumbar regions had the highest percentage of WHO Grade I tumors, while tumors located above these regions consisted of mostly WHO Grade II tumors. Despite the tendency for benign grades in the lower spinal regions, PFS for patients with spinal ependymomas in the lower 3 regions (thoracic, thoracolumbar, conus + cauda equina) was significantly shorter (p < 0.001) than for those with tumors in the upper regions (cervicomedullary, cervical, cervicothoracic), but the difference in OS did not achieve statistical significance (p = 0.131).

CONCLUSIONS

Spinal ependymomas along different regions of spinal axis have different characteristics and clinical behaviors. Tumor grade, extent of resection, and PFS varied by tumor location (upper vs lower spinal regions), while OS did not. Recurrence rates were higher for the lower spinal cord tumors, despite a greater prevalence of lower WHO grade lesions, compared with upper spinal cord tumors, suggesting that tumor location along the spinal axis is an important prognostic factor.

The impact of fluorescence guidance on spinal intradural tumour surgery

PURPOSE

5-Aminolevulinic acid (5-ALA)-based fluorescence-guided surgery was shown to be beneficial for cerebral malignant gliomas. Extension of this technique for resection of meningiomas and cerebral metastasis has been recently evaluated. Aim of the present study is to evaluate the impact of fluorescence-guided surgery in spinal tumor surgery.

METHODS

Twenty-six patients with intradural spinal tumors were included in the study. 5-ALA was administered orally prior to the induction of anesthesia. Intraoperative, 440 nm fluorescence was applied after exploration of the tumor and, if positive, periodically during and at the end of resection to detect tumor-infiltrated sites.

RESULTS

Tumors of WHO grade III and IV were found in five patients. In detail intra- or perimedullary metastasis of malignant cerebral gliomas was found including glioblastoma WHO grade IV (n = 2), anaplastic astrocytoma WHO grade III (n = 1), anaplastic oligoastrocytoma WHO grade III (n = 1). In addition, one patient suffered from a spinal drop metastasis of a cerebellar medulloblastoma WHO grade IV. Tumors of WHO grade I were diagnosed in 18 patients: Eight cases of meningioma (two recurrences), six cases of neurinoma, one neurofibroma, two ependymoma and one plexus papilloma. At least, benign pathologies were histologically proven in three patients. All four spinal metastasis of malignant glioma (100 %), seven of eight meningiomas (87.5 %) and one of two ependymoma (50 %) were found to be ALA-positive.

CONCLUSION

The present study demonstrates that spinal intramedullary gliomas and the majority of spinal intradural meningiomas are 5-ALA positive. As a surgical consequence, especially in intramedullary gliomas, the use of 5-ALA fluorescence seems to be beneficial.

Primary spinal glioblastoma: A case report and review of the literature

Primary spinal glioblastoma (GBM) is a rare disease, with an aggressive course and a poor prognosis. We report a case of a 19-year-old male with a 4-week history of progressive weakness in both lower limbs, which progressed to paraparesis with a left predominance and difficulty in initiating urination over a week. Spine magnetic resonance imaging (MRI) showed an intramedullary expansile mass localised between T6 and T11. We performed a laminotomy and laminoplasty between T6 and T11 and the tumour was partially removed. Histopathological study was compatible with GBM. The patient was administered focal spine radiotherapy with chemotherapy with temozolamide. Serial MRI performed after the initial surgery demonstrated enlargement of the enhancing mass from T3 to T12 and subarachnoid metastatic deposits in C2 and C4, the pituitary stalk, inter-peduncular cistern, left superior cerebellar peduncle and hydrocephalus. We review the literature with regard to the disease and treatment options, and report the unique features of this case. Primary spinal GBM is an extremely rare entity with a poor prognosis and a short survival time. An aggressive management of the different complications as they arise and improvement of current modes of treatment and new treatment options are required to improve survival and ensure better quality of life.

Adjuvant radiotherapy delays recurrence following subtotal resection of spinal cord ependymomas

BACKGROUND

Ependymoma is the most common glial tumor of the adult spinal cord. Current consensus recommends surgical resection with gross total resection (GTR) whenever possible. We performed a comprehensive review of the literature to evaluate whether adjuvant radiotherapy after subtotal resection (STR) has any benefit.

METHODS

A PubMed search was performed to identify adult patients with spinal cord ependymoma who underwent surgical resection. Only patients who had clearly defined extent of resection with or without adjuvant radiotherapy were included for analysis. Kaplan-Meier and multivariate Cox regression survival analyses were performed to determine the effects of adjuvant radiotherapy on progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 348 patients underwent surgical resection of spinal cord ependymomas, where GTR was obtained in 77.0% (268/348) of patients. Among those who received STR, 58.8% (47/80) received adjuvant radiotherapy. PFS was significantly prolonged among those who received adjuvant radiotherapy after STR (log rank; P < .001). This prolonged PFS with adjuvant radiotherapy remained significant in multivariate Cox regression analysis (STR versus STR + RT group; hazard ratio (HR) = 2.26, P = .047). By contrast, improved OS was only associated with GTR (GTR versus STR + RT group; HR = 0.07, P = .001) and benign ependymomas (HR = 0.16, P = .001).

CONCLUSIONS

Surgery remains the mainstay treatment for spinal cord ependymomas, where GTR provides optimal outcomes with longest PFS and OS. Adjuvant radiotherapy prolongs PFS after STR significantly, and OS is improved by GTR and benign tumor grade only.

Glioblastoma multiforme in the adult conus medullaris

De novo glioblastoma multiforme (GBM) of the spine is rare. We present a patient with a unique GBM arising within the conus and radiographically mimicking a filum terminale ependymoma. During surgery the lesion was notable for its highly vascular and diffuse infiltration of the surrounding spinal cord parenchyma. The operative goals were altered to account for the unexpected pathology. The treatment and prognosis of spinal GBM are briefly reviewed and the importance of considering an aggressive pathology when formulating a surgical plan for benign appearing lesions is emphasized.

Spinal cord anaplastic oligodendroglioma with 1p deletion: report of a relapsing case treated with temozolomide

Primary spinal cord oligodendroglial tumor is very rare, and in only one patient with spinal cord oligodendroglioma has a deletion of chromosome 1p/19q been reported. We present the case of an 18-year-old girl, who had one-year lower back pain and one-month lower limb weakness. Magnetic resonance images of the spinal cord showed an intramedullary mass from level T8 to T10, which was then radically removed. Histology revealed an anaplastic oligodendroglioma. The patient was treated with radiotherapy postoperatively. Eight months after the treatment, follow-up magnetic resonance images disclosed an enhancing intramedullary mass at level T4-T8; recurrence of the tumor was therefore diagnosed. Maximum surgical removal of the recurrent tumor was performed, diagnosis of anaplastic oligodendroglioma was made, and a chromosome 1p deletion was determined by FISH. After treatment with temozolomide for six months, the patient had a remarkable improvement of her lower limb symptoms, and complete imaging regression of the residual tumor showed no evidence of recurrence at any other sites. The most recent MRI of brain and spinal cord showed postoperative changes without evidence of tumor recurrence of the spine and oligodendrogliomatosis along the cerebral-spinal axis. To our knowledge, this is the first report of a recurrent anaplastic oligodendroglioma with 1p deletion occurring in the spinal cord. It is also the first case of the patient with recurrent intramedullary anaplastic oligodendroglioma who had a significant clinical improvement and complete imaging remission after subtotal resection then treatment with temozolomide chemotherapy.

Cordectomy as final treatment option for diffuse intramedullary malignant glioma using 5-ALA fluorescence-guided resection

BACKGROUND

We present a case of an anaplastic astrocytoma (WHO-grade III, AA III) in a 27-year-old woman treated by spinal cordectomy. The patient was pretreated by surgery, radiation therapy and temozolomide chemotherapy and repeat surgery at recurrence. Later on, she developed paraplegia and a diffuse severe pain syndrome. MRI demonstrated intramedullar invasion from T12 to T9. To assess tumor invasion intraoperatively, we used tumor fluorescence derived from 5-aminolevulinic acid (5-ALA).

PATIENTS COURSE

The spinal cord was amputated caudally to the root entry zones of the T10 sensory roots. Additional cordectomy was performed because of tumor infiltration at the cut end to T9 as identified by intraoperative tumor fluorescence, and as verified histologically. The final transected level was between T8 and T9, and the cut end did not reveal any tumor invasion intraoperatively by tumor fluorescence and postoperatively by MRI and with regard to the pathological result. After surgery, the patient was unchanged concerning spasticity, motor and sensory function, and showed complete relief of pain. She refused additional adjuvant therapy. The patient is free of recurrence 15 months after surgery.

CONCLUSION

Our observation suggests 5-ALA fluorescence-guided resections to be useful in the context of malignant spinal cord gliomas. Furthermore, our particular case indicates that palliative spinal cordectomy with a wide margin and intraoperative resection using fluorescence guidance may be a final option for patients with recurrent spinal malignant glioma presenting with complete deficit below the lesion.

Spinal cord oligodendroglioma with 1p and 19q deletions presenting with cerebral oligodendrogliomatosis

Oligodendroglioma of the spinal cord is a rare tumor that most often presents with spinal cord symptoms. The authors present a case of spinal cord oligodendroglioma that was associated with cerebral rather than spinal cord symptoms. A 30-year-old woman developed nausea, vomiting, and severe headaches. Magnetic resonance imaging of the brain showed meningeal enhancement. The patient underwent a craniotomy with biopsies of the meninges and brain. The biopsy findings revealed an abnormal arachnoid thickening without tumor cells. The patient later developed hydrocephalus and underwent shunt placement. Cerebrospinal fluid cytological findings were negative for tumor cells or infection. She was found to have a cervical cord lesion at C3–4 that was initially nonenhancing but later enhanced after Gd administration. Biopsy of the cord lesion with partial resection showed a WHO Grade II oligodendroglioma with 1p and 19q deletions determined by fluorescence in situ hybridization. Neurooncological treatment with tumor radiation and temozolomide (Temodor) resulted in improvement in radiographic findings, symptoms, and long-term survival. This paper presents an extensive review of the literature, which revealed only 2 other reported cases of cerebral symptoms in adults that preceded spinal cord symptoms in a patient with oligodendroglioma of the spinal cord. It is also the first reported case of oligodendrogliomatosis due to a cervical spinal cord oligodendroglioma with 1p and 19q deletions.

Long-term survival enhanced by cordectomy in a patient with a spinal glioblastoma multiforme and paraplegia. Case report

Spinal glioblastomas multiforme (GBMs) are rare lesions of the central nervous system with a prognosis as poor as that of their intracranial counterpart. The authors present a case of a 50-year-old man with a GBM of the spinal cord treated with surgical removal of the mass and cordectomy after the onset of paraplegia. Six years later, the patient developed hepatitis C and received interferon therapy. Six months after the start of interferon therapy, magnetic resonance imaging revealed a right cerebellar mass pathologically consistent with a GBM. Despite aggressive treatment, the patient died 1 month later. Although intracranial dissemination of spinal GBMs has been reported, this case illustrates the longest reported interval between the occurrence of a spinal GBM and its intracranial dissemination. Thus, cordectomy should be considered as a reasonable alternative in patients with complete loss of neurological function at and below the level where they harbor a malignant spinal cord astrocytoma.

Spinal glioblastoma with brain relapse in a child: clinical considerations

STUDY DESIGN

Case report.

OBJECTIVES

To describe a child with intramedullary glioblastoma at T9-T10-T11, and to discuss the clinical features of this rare pathology.

SETTING

Department of Neurological Sciences, Italy.

CASE REPORT

Spinal cord glioblastoma in children has only rarely been reported. It most frequently involves the thoracic region with a predilection for the second and third decades of life. This report describes one case of thoracic glioblastoma multiforme in a 6-year-old child and reviews other cases reported in the literature.

RESULTS

Laminectomy and excision of the tumour were performed. Postoperative radiotherapy and chemotherapy were given, but 4 months later the patient presented with a brain relapse of the tumour. At 9 months after diagnosis the patient died from cerebral tumour regrowth.

CONCLUSIONS

Full neuraxis MRI is always recommended in order to detect possible metastases. The prognosis after multimodality therapy (surgery, radiotherapy, chemotherapy) remains poor. From the literature, only four cases of paediatric patients with long-term survival have been reported.

Primary spinal cord oligodendroglioma: case report and review of the literature

OBJECTS

The objectives were to present a case of pediatric spinal oligodendroglioma and review the existing literature written in English on the subject of human spinal oligodendrogliomas. A comparison of the clinical, radiologic, and pathologic characteristics, as they relate to those already described in similar cases, was also attempted.

METHODS

Thorough evaluation of the patient's clinical course was undertaken. Presenting symptoms and signs are reported. The perioperative radiologic features of the case are presented and the intraoperative details as well as the pathologoanatomic findings and follow-up history are provided. We subsequently performed a thorough search in the literature focusing on the number, characteristics, treatment modalities, and prognosis of patients with spinal cord oligodendrogliomas.

CONCLUSIONS

Spinal oligodendrogliomas are a distinctly rare type of nervous system tumor, especially in the pediatric population. An international registry addressing all of their clinical and pathobiological characteristics would be of great benefit to patients harboring these rare tumors.

Surgical experience with resection en bloc of intramedullary astrocytomas and ependymomas in the cervical and cervicothoracic region

We performed 8 operations on 7 patients with benign intramedullary astrocytomas and ependymomas in the cervical and cervicothoracic region. All patients initially underwent gross total tumor resection en bloc. One patient with an astrocytoma showed tumor recurrence postoperatively, and underwent a second operation resulting in subtotal removal. The follow-up after the initial surgery ranged from 2.7 to 19.7 years (mean 8.5 years). Symptomatic improvement was observed in 6 patients after the initial operation. Two patients showed postoperative neurological deterioration, one with an ependymoma and the other after the second operation. No operative complications or deaths, nor postoperative respiratory dysfunction occurred. Benign intramedullary astrocytomas and ependymomas of the cervical and cervicothoracic spinal cord can be treated by radical resection en bloc with a low morbidity and recurrence, as well as acceptable outcomes. We describe here the surgical technique for en bloc tumor removal.

Rarer causes of radiculopathy: spinal tumors, infections, and other unusual causes

For the physiatrist practicing musculoskeletal medicine, patients with radiculopathy are a challenging and rewarding population for whom to provide care. Despite the rarity of diseases discussed in this article, at some time in his or her career every musculoskeletal physiatrist will see patients with these diagnoses as the cause of radiculopathy or back pain. A high index of suspicion is necessary to identify these rare disease processes accurately and promptly. The patient's history, examination, and plain-film radiographic evaluations remain the best tools with which to establish a differential and working diagnosis. The most important services that the physiatrist can provide to these patients are an astute application of the differential diagnosis to identify the specific etiology and the leadership required to organize a multi-disciplinary team of specialists to address all of the patient's needs.

Hemangioblastomas and other uncommon intramedullary tumors

Astrocytoma and ependymoma make up 90% of intramedullary tumors between them. However, a host of less common tumors form the remaining 10%: these include hemangioblastomas, subependymomas, gangliogliomas and other neuronal variants, metastases from extraneural cancers, and a host of other lesions that typically occur intracranially but which present on rare occasions in the intramedullary location. Most neurosurgeons will encounter the unusual tumors of the spinal cord described in this review only a few times during their professional careers, but it is nevertheless important to recognize the distinct radiological and intraoperative features of those for which significant series of patients have been accumulated. Metastases and germinomas aside, the other neoplasms described here are relatively benign in their clinical and histological behavior, and can be meaningfully resected by careful microsurgical technique.

Spinal cord gliomas: management and outcome with reference to adjuvant therapy

The authors review their experience with 19 consecutive cases with either astrocytic tumour (glioblastoma multiforme one, anaplastic astrocytoma one, astrocytoma 4, pilocytic astrocytoma 4) or ependymoma (10 tumours in 9 patients) of the spinal cord who were treated during the period from 1982 to 1996. The patients included 10 male and 9 female patients with a median age of 38 years. The main tumour locations included the cervicomedullary region 5 the cervical cord (8), the thoracic cord (5) and one each in the thoracolumbar region and conus medullaris. While a total removal of the tumour was achieved in 8 out of 10 ependymomas, the initial treatment for astrocytic tumours was a partial resection in 5, and biopsy in the remaining 5. As adjuvant treatment, 8 patients received radiation therapy and 2 received chemotherapy. Two patients with an astrocytic tumour received chemotherapy only, while the remaining 9 received neither radiation therapy nor chemotherapy initially. After these treatments, 6 out of the 8 patients with low grade astrocytoma have remained alive for 1.3-12.6 years, while 2 patients with high grade astrocytic tumours died within 15 months following surgery. Eight out of 9 patients with an ependymoma have remained alive for 3.0-12.3 years, while one committed suicide 2 years after surgery. As a result, 14 patients are still alive; half of them are accompanied by a mild neurological dysfunction, while the remaining one has a moderate deficit. The postoperative results and the rationale for surgery is discussed, and an approach for utilising adjuvant therapy for high grade tumours is also suggested.

Surgical results of 100 intramedullary tumors in relation to accompanying syringomyelia

During the period from 1977 to August 1992, 100 intramedullary tumors in 94 patients were operated on in the Department of Neurosurgery at the Nordstadt Hospital in Hannover, Germany. Of these, 45% presented with associated syringes. A syrinx was more likely to be found above (49%) than below (11%) the tumor level. In 40%, a syrinx could be identified above and below the tumor level. Ependymomas and hemangioblastomas were the most common tumor types to be associated with syringes. Astrocytomas tended to demonstrate syringes less often. Regardless of histology, the higher the spinal level, the more likely a syrinx was encountered. In general, the presence of an associated syrinx favored the resectability of the tumor, because it indicated a displacing rather than an infiltrating tumor. Patients with syringomyelia tended to recover from surgery sooner. However, surgical results and long-term prognosis were not influenced significantly by an associated syrinx. The most important factor determining long-term outcome was the preoperative level of neurological function. We propose that factors independent of the tumor, disturbances of cerebrospinal fluid and extracellular fluid flow in particular, have major roles in the pathogenesis of syrinx formation associated with intramedullary tumors.

Spinal cord tumors in children: long-term results of combined surgical and radiation treatment

The authors report a series of 31 children under 17 years of age with primary spinal cord tumors who underwent radiation treatment following decompression laminectomy with or without tumor resection between 1959 and 1990. The tumors consisted of 15 astrocytomas, 11 ependymomas, one mixed glioma, one gangliolioma, and three of unknown histology. Ten- and 20-year survival rates and 10- and 20-year relapse-free survival rates for the 28 patients with known histology were 80% and 53%, and 73% and 67%, respectively. Eleven patients (35%) had no resection, 14 (45%) had a partial resection, and six (19%) had a grossly complete resection. Eight patients (26%) are dead: five due to recurrent tumor, two due to a second malignant tumor, and one due to intercurrent disease. primary tumor relapse or progression occurred in nine patients (29%), four of whom were salvaged. A second malignant tumor developed in four patients (13%), two of whom died. Local control of the tumor was finally achieved in 26 cases (84%), despite either grossly incomplete or no resection in 25 of these cases (81%). These statistics suggest that radiation treatment without resection may achieve long-term control in children with astrocytoma or ependymoma of the spinal cord.

Increased intracranial pressure in a case of spinal cervical glioblastoma multiforme. Analysis of these two rare conditions

The authors describe a rare case of increased intracranial hypertension consequent to a spinal cervical glioblastoma multiforme in a young patient. They analyse the physiopathology of intracranial hypertension in spinal tumors and the rarity of such kind of tumor in this location, and its clinico-pathological aspects.

Intramedullary spinal cord ependymomas--a study of 45 cases with long-term follow-up

Of the 62 patients with intramedullary spinal cord ependymoma treated surgically at our Neurosurgery Division between January 1951 and December 1990 45 had a follow-up of at least 3 years and the longest 30 years. The 28 conus-cauda equina-filum ependymomas operated during the same period are not considered in this study. An analysis of our cases and of the larger published series shows that favourable prognostic factors, apart of course from total tumour removal, which is now usually possible, are a site below the high cervical segments and a mild pre-operative symptom pattern. Patient age at diagnosis, tumour size and "low dose" (< 40 Gy) radiotherapy seem to have no influence on the prognosis. Aggressive surgical removal is the treatment of choice and also for long-term recurrence.

Intramedullary "holocord" oligodendroglioma: case report

Primary spinal cord oligodendrogliomas are rare tumours. Only 3 holocord cases have been reported in the literature. We present a primary intramedullary "holocord" oligodendroglioma in a 13 year-old male. Scoliosis was the initial symptom. Neurological deterioration prompted MRI, which demonstrated the lesion. Total removal was achieved. This case shows that meticulous surgery may obtain an optimal result in holocord oligodendrogliomas. 2 years after surgery, the young patient has made an excellent recovery.

Surgical treatment of intramedullary tumors (spinal cord and medulla oblongata). Analysis of 16 cases

From February 1987 to July 1988, 16 patients of our clinic with intramedullary tumors (seven astrocytomas, six ependymomas, two angiomas with intramedullary hematomyelia, and one angioblastoma of the medulla oblongata) underwent surgery. Radical excision was possible in six cases with tumors in the cervical and/or thoracic region as well as in two cases with tumors in the medulla oblongata. In the group of patients with cervical and/or thoracic tumors, seven showed improvement, up to complete remission of the neurological symptoms. From eight patients with tumors of the medulla oblongata, one patient showed an invasive tumor of the medulla oblongata and pons with corresponding extensive neurological deficits, and died six weeks after surgery. The neurologic symptoms of the other seven patients improved after a postoperative interval of at least six weeks. The surgical approach to tumors of the medulla oblongata or spinal cord was performed by midline incision. Occasionally, a dorsal root entry zone (DREZ) incision was used when the tumor showed strictly unilateral localization. Tumors of the rhomboid fossa were approached by a lateral incision to avoid damage to nuclear structures. The more rostral the tumor localization (medulla oblongata, pons), the less complete was the surgery: only one ependymoma of the medulla oblongata was accessible to total extirpation. The tumor dignity worsened with ascending level of tumor localization. As described generally in the literature, neurological deficits of those patients with tumors in the medulla oblongata increased in the first few postoperative weeks before they began to improve. Chemotherapy, radiation therapy or decompressive laminectomy by themselves only lead to an improvement and are, therefore, not recommended.