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Boop S, Bonda D, Randle S, Leary S, Vitanza N, Crotty E, Novotny E, Friedman S, Ellenbogen RG, Durfy S, Goldstein H, Ojemann JG, Hauptman JS. A Comparison of Clinical Outcomes for Subependymal Giant Cell Astrocytomas Treated with Laser Interstitial Thermal Therapy, Open Surgical Resection, and mTOR Inhibitors. Pediatr Neurosurg 2023; 58:150-159. [PMID: 37232001 DOI: 10.1159/000531210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Subependymal giant cell astrocytoma (SEGA) is the most common CNS tumor in patients with tuberous sclerosis complex (TSC). Although these are benign, their proximity to the foramen of Monroe frequently causes obstructive hydrocephalus, a potentially fatal complication. Open surgical resection has been the mainstay of treatment; however, this can cause significant morbidity. The development of mTOR inhibitors has changed the treatment landscape, but there are limitations to their use. Laser interstitial thermal therapy (LITT) is an emerging treatment modality that has shown promise in treatment of a variety of intracranial lesions, including SEGAs. We present a single institution, retrospective study of patients treated for SEGAs with LITT, open resection, mTOR inhibitors, or a combination of these modalities. The primary study outcome was tumor volume at most recent follow-up compared with volume at treatment initiation. The secondary outcome was clinical complications associated with treatment modality. METHODS Retrospective chart review was performed to identify patients with SEGAs treated at our institution from 2010 to 2021. Demographics, treatment information, and complications were collected from the medical record. Tumor volumes were calculated from imaging obtained at initiation of treatment and at most recent follow-up. Kruskal-Wallis nonparametric testing was used to assess differences in tumor volume and follow-up duration between groups. RESULTS Four patients underwent LITT (3 with LITT only), three underwent open surgical resection, and four were treated with mTOR inhibitors only. Mean percent tumor volume reduction for each group was 48.6 ± 13.8, 90.7 ± 39.8, and 67.1 ± 17.2%, respectively. No statistically significant difference was identified comparing percent tumor volume reduction between the three groups (p = 0.0513). Additionally, there was no statistically significant difference in follow-up duration between groups (p = 0.223). Only 1 patient in our series required permanent CSF diversion and 4 discontinued or decreased the dose of mTOR inhibitor due to either cost or side effects. CONCLUSIONS Our study suggests that LITT could be considered as a treatment option for SEGAs as it was effective in reducing tumor volume with very few complications. This modality is less invasive than open resection and may be an alternative for patients who are not candidates for mTOR inhibitors. We recommend an updated paradigm for SEGA treatment which includes LITT in select cases after consideration of patient-specific factors.
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Affiliation(s)
- Scott Boop
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - David Bonda
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Stephanie Randle
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Sarah Leary
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Nicholas Vitanza
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Seattle Children's, University of Washington, Fred Hutch Cancer Research Center, Seattle, Washington, USA
| | - Erin Crotty
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Edward Novotny
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Seth Friedman
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sharon Durfy
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Hannah Goldstein
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jeffrey G Ojemann
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jason S Hauptman
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
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Grossen A, Gavula T, Chrusciel D, Evans A, McNall-Knapp R, Taylor A, Fossey B, Brakefield M, Carter C, Schwartz N, Gross N, Jea A, Desai V. Multidisciplinary neurocutaneous syndrome clinics: a systematic review and institutional experience. Neurosurg Focus 2022; 52:E2. [DOI: 10.3171/2022.2.focus21776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 02/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Neurocutaneous syndromes have variable multisystem involvement. The multiorgan involvement, potential pathologies, and various treatment options necessitate collaboration and open discussion to ensure optimal treatment in any given patient. These disorders provide quintessential examples of chronic medical conditions that require a lifelong, multidisciplinary approach. The objectives of this study were to 1) perform a systematic review, thoroughly assessing different multidisciplinary clinic layouts utilized in centers worldwide; and 2) characterize an institutional experience with the management of these conditions, focusing on the patient demographics, clinical presentation, complications, and therapeutic strategies seen in a patient population.
METHODS
A systematic review of studies involving multidisciplinary clinics and their reported structure was performed according to PRISMA guidelines using the PubMed database. Then a retrospective chart review of patients enrolled in the Oklahoma Children’s Hospital Neurocutaneous Syndromes Clinic was conducted.
RESULTS
A search of the PubMed database yielded 251 unique results. Of these, 15 papers were included in the analysis, which identified 16 clinics that treated more than 2000 patients worldwide. The majority of these clinics treated patients with neurofibromatosis (13/16). The remaining clinics treated patients with von Hippel–Lindau syndrome (n = 1), tuberous sclerosis complex (n = 1), and multiple neurocutaneous syndromes (n = 1). The most commonly represented subspecialties in these clinics were genetics (15/16) and neurology (13/16). Five clinics (31%) solely saw pediatric patients, 10 clinics saw a combination of children and adults, and the final clinic had separate pediatric and adult clinics. The retrospective chart review of the Neurocutaneous Syndromes Clinic demonstrated that 164 patients were enrolled and seen in the clinic from April 2013 to December 2021. Diagnoses were made based on clinical findings or results of genetic testing; 115 (70%) had neurofibromatosis type 1, 9 (5.5%) had neurofibromatosis type 2, 35 (21%) had tuberous sclerosis complex, 2 (1%) had von Hippel–Lindau syndrome, 2 (1%) had Gorlin syndrome, and the remaining patient (0.6%) had Aarskog-Scott syndrome. Patient demographics, clinical presentation, complications, and therapeutic strategies are also discussed.
CONCLUSIONS
To the best of the authors’ knowledge, this is the first detailed description of a comprehensive pediatric neurocutaneous clinic in the US that serves patients with multiple syndromes. There is currently heterogeneity between described multidisciplinary clinic structures and practices. More detailed accounts of clinic compositions and practices along with patient data and outcomes are needed in order to establish the most comprehensive and efficient multidisciplinary approach for neurocutaneous syndromes.
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Affiliation(s)
- Audrey Grossen
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Theresa Gavula
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Deepti Chrusciel
- Department of Pediatric Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Alexander Evans
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Rene McNall-Knapp
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ashley Taylor
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Benay Fossey
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Margaret Brakefield
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Carrick Carter
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Nadine Schwartz
- Department of Pediatric Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Naina Gross
- Department of Pediatric Neurosurgery, Saint Francis Hospital, Tulsa, Oklahoma
| | - Andrew Jea
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Virendra Desai
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
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Mo F, Pellerino A, Rudà R. Subependymal Giant Cell Astrocytomas (SEGAs): a Model of Targeting Tumor Growth and Epilepsy. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00673-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Tomoto K, Fujimoto A, Inenaga C, Okanishi T, Imai S, Ogai M, Fukunaga A, Nakamura H, Sato K, Obana A, Masui T, Arai Y, Enoki H. Experience using mTOR inhibitors for subependymal giant cell astrocytoma in tuberous sclerosis complex at a single facility. BMC Neurol 2021; 21:139. [PMID: 33784976 PMCID: PMC8011204 DOI: 10.1186/s12883-021-02160-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Subependymal giant cell astrocytoma (SEGA) is occasionally seen in tuberous sclerosis complex (TSC). Two main options are currently available for treating SEGA: surgical resection or pharmacotherapy using mammalian target of rapamycin inhibitors (mTORi). We hypothesized that opportunities for surgical resection of SEGA would have reduced with the advent of mTORi. METHODS We retrospectively reviewed the charts of patients treated between August 1979 and July 2020, divided into a pre-mTORi era group (Pre-group) of patients treated before November 2012, and a post-mTORi era group (Post-group) comprising patients treated from November 2012, when mTORi became available in Japan for SEGA. We compared groups in terms of treatment with surgery or mTORi. We also reviewed SEGA size, rate of acute hydrocephalus, recurrence of SEGA, malignant transformation and adverse effects of mTORi. RESULTS In total, 120 patients with TSC visited our facility, including 24 patients with SEGA. Surgical resection was significantly more frequent in the Pre-group (6 of 7 patients, 86 %) than in the Post-group (2 of 17 patients, 12 %; p = 0.001). Acute hydrocephalus was seen in 1 patient (4 %), and no patients showed malignant transformation of SEGA. The group treated using mTORi showed significantly smaller SEGA compared with the group treated under a wait-and-see policy (p = 0.012). Adverse effects of pharmacotherapy were identified in seven (64 %; 6 oral ulcers, 1 irregular menstruation) of the 11 patients receiving mTORi. CONCLUSIONS The Post-group underwent surgery significantly less often than the Pre-group. Since the treatment option to use mTORi in the treatment of SEGA in TSC became available, opportunities for surgical resection have decreased in our facility.
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Affiliation(s)
- Kyoichi Tomoto
- Department of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Ayataka Fujimoto
- Department of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan.
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan.
| | - Chikanori Inenaga
- Department of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Tohru Okanishi
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Shin Imai
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Masaaki Ogai
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Akiko Fukunaga
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Hidenori Nakamura
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Keishiro Sato
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Akira Obana
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Takayuki Masui
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Yoshifumi Arai
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Hideo Enoki
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
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Doddamani RS, Meena R, Sawarkar D, Singh PK, Chandra PS. Stereotactic guided ablation for subependymal giant cell astrocytomas: does it change the surgical indications? Childs Nerv Syst 2021; 37:735-736. [PMID: 32728931 DOI: 10.1007/s00381-020-04837-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | - Rajesh Meena
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Dattaraj Sawarkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Pankaj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, 110029, India
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Doddamani RS, Meena R, Samala R, Agrawal M, Tripathi M, Chandra PS. Expanding the Horizons of mTOR Inhibitors for Treating Subependymal Giant Cell Astrocytomas with Obstructive Hydrocephalus. Pediatr Neurosurg 2021; 56:102-104. [PMID: 33508851 DOI: 10.1159/000512720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/30/2020] [Indexed: 11/19/2022]
Affiliation(s)
| | - Rajesh Meena
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raghu Samala
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Tabori U, Das A, Hawkins C. Germline predisposition to glial neoplasms in children and young adults: A narrative review. GLIOMA 2021. [DOI: 10.4103/glioma.glioma_12_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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