Treatment of spinal cord tumors

Paediatric spinal cord low-grade gliomas-evaluation and management of post-surgical residual disease

PURPOSE

To assess the evaluation and management of post-surgical residual disease for low-grade intramedullary spinal cord tumours (IMSCT) in childhood.

METHODS

A single-centre retrospective review of low-grade IMSCTs treated between 2000 and 2019. All surgeries were performed with intent of safe maximal resection guided by intra-operative neurophysiological monitoring (IONM). Pre- and post-operative MRIs were reviewed to assess the extent of resection (EOR), recorded as follows: gross total resection (GTR), near total resection (NTR), sub-total resection (STR) and partial resection (PR). Outcome measures were time to recurrence, need for and modality of additional therapy and ambulatory status at last follow-up.

RESULTS

Thirty patients underwent surgery for IMSCT (median age 6.9 years). EOR was GTR = 8, NTR = 4, STR = 9, PR = 9. All patients were alive at last follow-up (median follow-up 73 months [IQR 93 months]). Eighteen patients (60%) remained radiologically stable. Twelve patients (40%) developed recurrence during surveillance. Progression free survival was significantly better in cases with GTR + NTR in comparison to either STR or PR (p = 0.039). 10/30 (33%) patients were treated with additional therapy. At last follow-up, 26/30 patients were independently mobile.

CONCLUSION

Survival rates for low-grade IMSCT are excellent. Radical micro-surgical resection, guided by IONM provides effective means of balancing the objectives of maximal safe resection, functional outcome and tumour control. Whilst evidence of 'residual disease' was identified in over 2/3 of immediate post-operative MRI scans, additional treatment was required in only 1/3 of cases. Critical appraisal of post-operative imaging findings is required to better define 'residual disease'. Small volume residual disease (< 5%) does not compromise progression-free survival.

[Histological profile and progression of intraspinal tumors after surgery]

Les tumeurs intrarachidiennes sont peu fréquentes. Leur diagnostic positif est basé sur l´imagerie médicale surtout l´IRM. L´anatomopathologie apporte la certitude du diagnostic. La chirurgie est le traitement de choix pour la plupart d´entre elles. Le pronostic est fonction de la nature histologique et de l´état clinique initial du patient. Nous rapportons le profil histologique et l´évolution des tumeurs intra rachidiennes opérées dans notre service. Il s´agissait d´une étude rétrospective sur une période 10 ans. Ont été inclus les cas opérés confirmés à l´histologie (23 cas). Quatre dossiers non exploitables ont été exclus. Les patients ont consulté en moyenne 79 jours après les premiers symptômes pour un syndrome de compression médullaire lente dans 11 cas. Sept TDM et 14 IRM permettaient d´objectiver 4 tumeurs intramédullaires, 9 intradurales, 1 extra durale et 5 localisations non précises. L´histologie concluait à un méningiome dans 11 cas, un neurinome dans 3 cas. Elle a conclu au même diagnostic que l´imagerie médicale dans 7 cas (4 TDM et 3 IRM). L´exérèse était macroscopiquement complète dans 14 cas, partielle dans 5 cas. Après un recul de 6 mois, 6 patients avaient récupéré totalement, 9 partiellement. Le diagnostic était tardif. L´IRM décrivait mieux la lésion, mais était limitée dans l´approche histologique. Les méningiomes dominaient. L´exérèse était le plus souvent complète. Les suites opératoires étaient favorables.

Combination Therapy by Tissue-Specific Suicide Gene and Bevacizumab in Intramedullary Spinal Cord Tumor

PURPOSE

Malignant gliomas are aggressive spinal cord tumors. In this study, we hypothesized that combination therapy using an anti-angiogenic agent, bevacizumab, and hypoxia-inducible glioblastoma-specific suicide gene could reduce tumor growth.

MATERIALS AND METHODS

In the present study, we evaluated the effect of combination therapy using bevacizumab and pEpo-NI2-SV-TK in reducing the proliferation of C6 cells and tumor growth in the spinal cord. Spinal cord tumor was generated by the injection of C6 cells into the T5 level of the spinal cord. Complexes of branched polyethylenimine (bPEI)/pEpo-NI2-SV-TK were injected into the spinal cord tumor. Bevacizumab was then administered by an intraperitoneal injection at a dose of 7 mg/kg. The anti-cancer effects of combination therapy were analyzed by histological analyses and magnetic resonance imaging (MRI). The Basso, Beattie and Bresnahan scale scores for all of the treatment groups were recorded every other day for 15 days to assess the rat hind-limb strength.

RESULTS

The complexes of bPEI/pEpo-NI2-SV-TK inhibited the viability of C6 cells in the hypoxia condition at 5 days after treatment with ganciclovir. Bevacizumab was decreased in the cell viability of human umbilical vein endothelial cells. Combination therapy reduced the tumor size by histological analyses and MRI. The combination therapy group showed improved hind-limb function compared to the other groups that were administered pEpo-NI2-SV-TK alone or bevacizumab alone.

CONCLUSION

This study suggests that combination therapy using bevacizumab with the pEpo-NI2-SV-TK therapeutic gene could be useful for increasing its therapeutic benefits for intramedullary spinal cord tumors.

[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.

Corticosteroid Treatment for Metastatic Spinal Cord Compression: A Review

STUDY DESIGN

Narrative review.

OBJECTIVE

Metastatic spinal cord compression (MSCC) is a very frequent complication among cancer patients. Presenting commonly as nocturnal back pain, MSCC typically progresses to lower extremity paresis, loss of ambulatory capabilities, and paraplegia. In addition to standard treatment modalities, corticosteroid administration has been utilized in preclinical and clinical settings as adjunctive therapy to reduce local spinal cord edema and improve clinical symptoms. This article serves as a review of existing literature regarding corticosteroid management of MSCC and seeks to provide potential avenues of research on the topic.

METHODS

A literature search was performed using PubMed in order to consolidate existing information regarding dexamethasone treatment of MSCC. Of all search results, 7 articles are reviewed, establishing the current understanding of metastatic spine disease and dexamethasone treatment in both animal models and in clinical trials.

RESULTS

Treatment with high-dose corticosteroids is associated with an increased rate of potentially serious systemic side effects. For this reason, definitive guidelines for the use of dexamethasone in the management of MSCC are unavailable.

CONCLUSIONS

It is still unclear what role dexamethasone plays in the treatment of MSCC. It is evident that new, more localizable therapies may provide more acceptable treatment strategies using corticosteroids. Looking forward, the potential for more targeted, localized application of the steroid through the use of nanotechnology would decrease the incidence of adverse effects while maintaining the drug's efficacy.

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

RATIONALE

Primary spinal glioblastoma multiforme (GBM) is a rare clinical entity with an aggressive course and an invariably dismal prognosis. Its clinical characteristics, radiologic and pathologic findings, and treatment protocols have been discussed in a few cases.

PATIENT CONCERNS

A 15-year-old female was admitted to the neurology department with a chief complaint of progressive numbness and weakness in her left upper extremity for 3 months and neck pain for 1 month.

DIAGNOSES

Spinal magnetic resonance imaging showed an intramedullary expansile mass localized between C4 and C7. The diagnosis of GBM was determined on the basis of the histopathological findings after operation.

INTERVENTIONS

Laminotomy and laminoplasty between C4 and C7 were performed, and the tumor was partially resected. The patient was administered focal adjuvant radiotherapy concomitantly with oral chemotherapy following the surgery.

OUTCOMES

With severe neurologic deficits at 13 months after the diagnosis, the patient expired.

LESSONS

Although therapeutic options have been improving, the prognosis of the primary spinal GBM remains poor. The treatment of primary spinal GBM entered into a central registry and multiple-center cooperation is important in establishing future therapeutic strategies.

Review of the History of Non-traumatic Spinal Cord Dysfunction

Background: The incidence of non-traumatic spinal cord dysfunction (SCDys) is reported to be higher than traumatic spinal cord injury (SCI) in many countries. No formal review of the history of SCDys has been published. Objective: This article aims to identify key highlights in the history of SCDys. Method: An electronic literature search was conducted (January 2017) using MEDLINE (1946-2016) and Embase (1974-2016) databases for publications regarding the history of SCDys. Publications on the history of SCI and a selection of neurology textbooks and books on the history of neurology were reviewed for potentially relevant references. The focus of the literature search was on identifying publications that detail key highlights regarding the history of the diagnosis and management of the most common SCDys conditions, as well as those of historical significance. Results: The electronic search of MEDLINE and Embase identified 11 relevant publications. The majority of publications included were identified from the authors' libraries and a selection of books on neurology and the history of neurology. Conclusions: This review outlines the history of SCDys, taking a broader historical perspective and covering the increasing awareness of the role of the spinal cord and knowledge of neuroanatomy. Key milestones in the history of the diagnosis and management of the most common SCDys conditions are presented. An appreciation of the history of SCDys increases our understanding of the large number of people who contributed to our current knowledge of these conditions and in some situations helps guide efforts regarding prevention of SCDys.