Chemotherapy for progressive pilocytic astrocytomas in the chiasmo-hypothalamic regions

Management of Optic Pathway Glioma: A Systematic Review and Meta-Analysis

Background: OPG accounts for 3−5% of childhood central nervous system (CNS) tumors and about 2% of pediatric glial lesions. Methods: Article selection was performed by searching PubMed, Web of Science, and Cochrane databases. Results: The pooled mortality rate was 0.12 (95%CI 0.09−0.14). Due to the unrepresentative data, improved and not changed outcomes were classified as favorable outcomes and worsened as unfavorable. Meta-analyses were performed to determine the rate of clinical and radiological favorable outcomes. In terms of visual assessment, the pooled rate of a favorable outcome in chemotherapy, radiotherapy, and surgery was 0.74, 0.81, and 0.65, respectively, and the overall pooled rate of the favorable outcome was 0.75 (95%CI 0.70−0.80). In terms of radiological assessment, the rate of a favorable outcome following chemotherapy, radiotherapy, and surgery was 0.71, 0.74, and 0.67, respectively, and the overall pooled rate of the favorable outcome is 0.71 (95%CI 0.65−0.77). The subgroup analysis revealed no significant difference in the rate of clinical and radiological favorable outcomes between the different treatment modalities (p > 0.05). Conclusion: Our analyses showed that each therapeutic modality represents viable treatment options to achieve remission for these patients.

Recurrent adult pilocytic astrocytoma presenting with intraventricular and leptomeningeal spread

Background

Infratentorial pilocytic astrocytomas are uncommon tumors in adulthood but are thought to be prognostically similar to their pediatric counterparts with excellent overall survival following gross total resection. However, given the relative rarity of these tumors, no management guidelines exist for recurrent adult pilocytic astrocytomas (APAs). This lack of consensus is especially problematic for inoperable recurrences or those with aggressive features concerning for malignant transformation.

Case Description

In 2017, a 26-year-old female presented with headaches, nausea, vomiting, and blurry vision. A brain magnetic resonance imaging (MRI) demonstrated a large, well-circumscribed mass within the fourth ventricle causing obstructive hydrocephalus. She underwent near-total resection through a midline suboccipital transtonsillar approach. Pathology demonstrated a World Health Organization Grade 1 pilocytic astrocytoma. Despite initial improvement in her symptoms, she developed worsening headaches and lethargy 10 months after surgery and repeat MRI demonstrated recurrent tumor within the entire ventricular system and the subarachnoid spaces of the left cerebellopontine angle suggesting leptomeningeal spread. Due to the unresectable nature of the recurrence, the patient declined any further intervention and succumbed to her disease 6 months later.

Conclusion

We present the first case of a recurrent APA presenting with intraventricular and leptomeningeal spread. Although thought to be a benign neoplasm, close interval follow-up with serial imaging is of essential, especially in those patients with known residual tumor, to prevent aggressive recurrences such as this.

Rare infundibular tumors: clinical presentation, imaging findings, and the role of endoscopic endonasal surgery in their management

Background The spectrum of infundibular lesions is broad and distinct from sellar pathologies. In many cases, histology is needed to establish the correct diagnosis and determine the treatment approach. Methods Medical files of eight patients with distinct infundibular tumors were reviewed. Histopathologically confirmed diagnosis included three pituicytomas, three granular cell tumors, and two pilocytic astrocytomas. Results Patients shared similar imaging findings and clinical symptoms, including visual impairment (n = 5), hypopituitarism (n = 4), and headache (n = 4); one patient presented with disseminated disease and symptoms from spinal metastases. All the pituicytomas, two granular cell tumors, and one infundibular pilocytic astrocytoma case underwent endoscopic endonasal surgery; gross total resection was achieved in five patients, three developed postoperative diabetes insipidus, and two developed hypopituitarism. No recurrences were observed. One granular cell tumor patient was treated with gamma-knife radiosurgery after stereotactic biopsy; the tumor remained stable in size for over 9 years. The infundibular pilocytic astrocytoma patient who presented with spinal metastases received radiotherapy and systemic chemotherapy. The overall mean follow-up period was 25.1 months. Conclusion Infundibular tumors are rare entities that represent a diagnostic challenge. Histopathological examination is essential for definitive diagnosis. Surgery, radiation therapy, and chemotherapy all have a role in the management of these tumors.

Medulloblastoma in childhood: revisiting intrathecal therapy in infants and children

INTRODUCTION

Intrathecal chemotherapy is being explored in medulloblastoma in pre-school children as part of brain-sparing strategies and as an alternative to unacceptably neurotoxic cranio-spinal radiotherapy. The range of drugs suitable for this route of administration is restricted by the lack of research evidence of pharmacological suitability and efficacy of other drugs in medulloblastoma.

METHODS

Ideal clinical, biological, physicochemical and pharmaceutical properties for intrathecal administration were defined through literature review of pharmaceutical texts, Medline, Embase and consulting the manufacturers. A total of 126 chemotherapy agents were assessed against these criteria by searching the academic domain of pharmaceutical texts, computer databases and consultation with manufacturers.

RESULTS

Of the 126 candidate drugs, 99 were rejected because of documentation of their irritant nature, neurotoxicity and requirement for hepatic activation in standard pharmaceutical texts. Fifty were rejected for a single identifiable reason including, neurotoxicity (n = 24), irritant (n = 15), needs enzyme activation (n = 5), clinical evidence of intrathecal neurotoxicity (n = 4) and no evidence of tumour-specific efficacy (n = 2). Where two reasons were cited the justifications were: neurotoxic and irritant (n = 3) and needs activation and systemic administration results in equivalent concentration (n = 1). Twenty-seven drugs remained of which 12 were selected as eligible for further clinical investigation, and 15 were selected for further pre-clinical investigation.

CONCLUSIONS

The pre-determined criteria were not applicable, in their entirety, in the majority of drugs, due to lack of information in the academic domain, emphasising the importance of a more open approach for sharing basic drug information. The prioritised list of 12 candidate drugs for clinical trial and 15 for pre-clinical investigation justify that a concerted research effort in this area of practice is made.

Management of optic-hypothalamic gliomas in children: still a challenging problem

Optic pathway-hypothalamic gliomas (OPHGs) are rare, often unresectable tumors that mostly occur in childhood. Their biological behavior is unpredictable, although they tend to follow an aggressive clinical course in infants and a benign course in children with neurofibromatosis type 1. Optimal management is still controversial. Nonprogressing OPHGs are usually followed by surveillance alone. Surgery is advocated for progressing tumors to decompress the optic pathways, obtain a quick relief from intracranial hypertension and allow histologic examination (when needed). The current trend is in favor of conservative surgical behavior, except for resectable tumors. Chemotherapy is increasingly used in the management of OPHGs, especially in infants, to delay radiotherapy. Carboplatin and vincristine are the most frequently used drugs, although several chemotherapeutic agents in different combinations are currently employed with good results. Radiotherapy is utilized in children over 5 years of age as an adjuvant or as an alternative to surgery. The prognosis of OPHGs is quite good, with regard to the overall survival rate (70-100% at 5 years), but less favorable in terms of late morbidity.

Les astrocytomes pilocytiques du diencéphale de l’enfant

BACKGROUND AND PURPOSE

Pilocytic astrocytoma (PA) is a WHO grade I tumor of the central nervous system mostly arising in children and young adults. Management of diencephalic PA is a difficult challenge. Surgical treatment has to cope with both the difficulties of deep location and eloquent area tumors.

MATERIALS AND METHODS

We retrospectively reviewed seven pediatric cases (female: 4, male: 3) of diencephalic PA. Opto-chiasmatic tumors were excluded from the series. Mean age at diagnosis was 108 months (9 years) (range: 4 month-18 years), median age was 111 months. Median follow-up for the series was 125 months. Tumor locations were as followed: right thalamus: 2, both thalami: 1, hypothalamus: 3, and right basal ganglia: 1. At the onset, the first symptom was mostly raised intracranial pressure. The delay in diagnosis ranged from 48 hours up to 6 years.

TREATMENT

a shunting procedure was performed in 3 patients, a direct surgical approach in 5 patients (gross total removal: 2; partial removal: 3) and one patient had only a biopsy. Three children were re-operated. Three patients were treated by radiationtherapy (RT) after surgery. Chemotherapy was delivered for 4 children.

RESULTS

The overall survival rate was 71.4 months (almost 6 years) (range: 3-184 months). Median survival rate was 42 months (3.5 years). Three children died, two by tumor progression and one death related to late side-effects of RT. Four patients have a good quality of life with GOS I (n = 3) or II (n = 1). We observed tumor regression in two patients at 1 and 17 years after the beginning of treatment. Correct diagnosis was only made for two cases at the initial pathological examination.

CONCLUSION

The course of diencephalic PA is still unpredictable. The tumor can be controlled by a partial surgical removal, and a residual tumor can sometimes decrease in size after surgery. Gross total removal of these tumors, although difficult, may be performed. With cranial navigation systems, the risk is low. Pathological diagnosis is sometimes difficult to assess.

Spinal seeding of a pilocytic astrocytoma following multiple subtotal resections

We report the case of a 4-year-old girl presenting with spinal and leptomeningeal dissemination following several subtotal resections of cerebellar pilocytic astrocytomas.

Management of pilocytic astrocytoma with diffuse leptomeningeal spread: two cases and review of the literature

INTRODUCTION

Leptomeningeal dissemination of juvenile pilocytic astrocytoma (JPA) is a rare event. We report two children with disseminated JPAs treated with a chemotherapeutic agent, temozolomide, after progression of the disease despite surgery, traditional chemotherapy, and/or radiation therapy.

CASE REPORTS

Patient 1 presented with hydrocephalus and progressive lower extremity weakness, and was found to have a suprasellar mass as well as extensive spinal disease. Ventriculoperitoneal shunting, decompressive laminectomy with spinal tumor debulking, and chemotherapy with carboplatin and vincristine were initially employed. However, disease progressed and craniospinal irradiation and temozolomide were used. Patient 1 remains in a fair condition today, 2 years later. Patient 2 presented at 8 months of age with failure to thrive. Imaging revealed a cystic lesion in the hypothalamic region with extensive subarachnoid metastatic disease to the spine. Biopsy was performed followed by chemotherapy with vincristine, cyclohexylchloroethylnitrosourea (CCNU), 6-TG, and procarbazine. Due to the continued progression of the disease, cytoreductive surgery was performed and her chemotherapeutic regimen was switched to temozolomide. Two years after initial presentation patient 2 is clinically much improved with stable residual disease.

DISCUSSION

We review the literature and discuss treatment strategies for this challenging disease.

Successful high-dose chemotherapy for widespread neuroaxis dissemination of an optico-hypothalamic juvenile pilocytic astrocytoma in an infant: a case report

We report a 13-month-old boy with diencephalic syndrome (DS) due to an optico-hypothalamic juvenile pilocytic astrocytoma (JPA). Massive neuroaxis dissemination was identified at diagnosis. He received 6 courses of combined conventional-dose chemotherapy consisting of carboplatin (CBDCA), etoposide (VP-16), and cyclophosphamide (CPA) followed by high-dose chemotherapy with CBDCA, CPA, and ranimustine (MCNU) and peripheral blood stem cell transplantation (PBSCT). This treatment produced tumor regression in both intracranial and spinal lesions and remarkable improvement of DS. The rare combination of DS and symptomatic neuroaxis dissemination of JPA at diagnosis suggests that the behavior of some of these tumors is more aggressive and resistant to conventional-dose chemotherapy than is that of JPA without DS manifestation and dissemination.

Visual improvement despite radiologically stable disease after treatment with carboplatin in children with progressive low-grade optic/thalamic gliomas

BACKGROUND

The purpose of this study was to examine the clinical and radiologic response to carboplatin by children with progressive optic/thalamic gliomas.

PATIENTS AND METHODS

Between July 1997 and July 1999, 12 consecutive children were treated with monthly carboplatin for progressive optic/thalamic gliomas.

RESULTS

Five children have completed 12 cycles of carboplatin and five children are currently receiving treatment. Two children had progressive disease noted both clinically and radiologically. Nine children have stable radiologic disease and one child has had a partial radiologic response to chemotherapy. Eight children have had regular visual assessments. Four children (three with stable radiology and one with a partial radiologic response) have had improvement in their vision. Three children with radiologically stable disease have had no change in vision. One child has had deterioration in vision despite radiologically stable disease.

CONCLUSIONS

The results suggest that the clinical response of optic/thalamic gliomas to carboplatin, as measured by visual acuity and visual fields, may be better than predicted by radiologic assessment. These data suggest that a prospective clinical study is warranted of the role of carboplatin in children with progressive optic/thalamic gliomas and visual impairment.

Chemotherapy of low-grade gliomas

Histologic subtypes of low-grade gliomas include pilocytic astrocytomas (World Health Organization [WHO] grade I), diffuse infiltrating astrocytomas, oligodendrogliomas, and mixed oligo-astrocytomas (WHO grade II). Although extended survival is typical with these tumors, most patients eventually succumb to recurrent or progressive disease despite receiving either adjuvant radiation therapy or radiation at the time of recurrence. Not surprisingly, chemotherapy for low-grade gliomas has primarily been evaluated in the salvage setting of postradiotherapy progression in both adults and children. Unfortunately, the published body of literature describing chemotherapy for these tumors is small and subject to a number of confounding methodologic limitations. Nonetheless, some guidelines for the use of chemotherapy in these patients can be inferred from the published experience. The data reviewed clearly identifies a potential benefit for PCV chemotherapy (procarbazine, CCNU, and vincristine) in at least a subset of patients with low-grade oligodendroglial tumors. Nitrosoureas and platinum agents appear to have modest efficacy in recurrent oligodendroglial tumors and in some patients with newly diagnosed or progressive low-grade astrocytomas; however, surgery and radiation remain the primary treatment modalities for this group of malignancies. Until new data becomes available, chemotherapy still should be used only as a salvage option in previously irradiated patients with recurrent or progressive low-grade gliomas.

Cisplatin/vincristine chemotherapy for hypothalamic/visual pathway astrocytomas in young children

Hypothalamic/visual pathway astrocytomas in children are usually quiescent, but certain cases contain aggressive neoplasms that cause progressive neurological and visual deterioration. Radiotherapy is not recommended in young children because of its adverse effects later in life. This report describes the efficacy of a chemotherapeutic regimen. Four young children with hypothalamic/visual pathway astrocytoma, with a mean of 18 months of age at diagnosis, were treated with chemotherapy. Three patients had diencephalic syndrome at the disease's onset. Three patients with pilocytic astrocytoma were histologically verified, and another infant was clinically diagnosed. A combination chemotherapy using cisplatin and vincristine was administered in a total of 8 cycles in 3 children and 4 in one child. One patient who demonstrated renal insufficiency after 4 cycles of this regimen was treated with additional 4 cycles using carboplatin instead of cisplatin. The acute and subacute hematologic and otologic toxicities were mild, and a transient renal insufficiency in a child during chemotherapy improved. After chemotherapy, tumor regression was documented in 3 patients, and the disease was observed to be stable in one patient with an evidence of intratumoral necrosis on MRI. Three patients showed neurological and endocrinological improvements. These results suggest that this regimen is feasible in young children and may be useful as a first-line treatment for hypothalamic/visual pathway astrocytomas, which in turn may allow potentially deleterious irradiation on the maturing brain to be deferred until the disease progresses.