Management of primary spinal cord tumors

Primary spinal glioma in children: Results from a referral pediatric institution in Shanghai

PURPOSE

Primary spinal cord glioma is a rare entity especially in children; accounting for less than 10% of all central nervous system tumors. Low grade is the most reported subtype. Treatment modalities have largely evolved; large improvements have been made in the surgical field but also in both of radiotherapy and chemotherapy. Nevertheless, the optimal treatment is yet to be defined.

MATERIAL AND METHODS

A chart review of 11 pediatric patients with a diagnosis of low grade spinal cord glioma at Xhinhua hospital in Shanghai was conducted. A statistical package for Social Sciences Package (SPSS) was used for analysis. Means and standard deviations were calculated. The Kaplan-Meier method was used to analyze overall survival and progression-free survival.

RESULTS

The mean age was 6.7 years (range: 6 months-14.3 years). Revealing symptoms were variable and slowly progressive. The mean duration of symptoms prior to diagnosis was of 7±3.2 months. Astrocytoma was the most commonly reported histological type (seven cases, 63.6%), ependymomas were reported in three cases (27.3%). Surgery was performed in all patients. Subtotal resection concerned the majority of patients (nine patients, 81.8%). Adjuvant radiotherapy was indicated in all cases. A total dose of 39.6Gy was delivered to the whole group. Three patients received adjuvant chemotherapy, of whom two patients had grade III glioma and one patient had a tumor recurrence. Temozolomide-based regimen was the main protocol used for all our patients. The 3 years overall survival rate was 100%, whereas the progression free survival rate was 87.5%. One case relapsed during the next year following completion of treatment.

CONCLUSION

Our preliminary results are consistent with that of other similar published reports, however longer follow up is needed. So are specific recommendations that are still lacking in this setting.

Neurological outcome after surgical treatment of intramedullary spinal cord tumors

Objective

Recently, surgical outcomes of patients with intramedullary spinal cord tumors (IMSCT) have been improved due to advances of medicine. The purposes of our study were to evaluate the recent neurological outcomes after surgical treatment of IMSCTs.

Methods

We retrospectively reviewed 69 patients who underwent surgical treatment for IMSCT in our hospital between 1998 and 2013. Patient's age, sex, histological origin and grade, tumor location, tumor extension, preoperative neurological state, initial presenting symptom, and extend of tumor resection were analyzed to evaluate predictive factors that affect postoperative functional outcome.

Results

The neurological states at last follow-up were improved in 16 patients (23.2%), unchanged in 47 (68.1%), aggravated in 6 (8.7%). In all patients, the functional outcomes were good in 52 patients (75.4%), fair in 10 (14.5%), poor in 7 (10.1%). Preoperative good neurological state was the strongest positive predictor of good functional outcome (p<0.05). In tumor location, functional outcomes of thoracic tumors were poor than those in cervical and conus medullaris region (p=0.011). High-grade tumor shows poor outcome compare to low-grade tumor (p=0.03).

Conclusion

The most reliable predicting factor of surgical outcome was the preoperative neurological state. In addition, IMSCTs in thoracic region and high-grade tumor showed relatively bad outcome and had a risk of postoperative morbidity.

Predictors of ambulatory function after surgical resection of intramedullary spinal cord tumors

BACKGROUND

Contemporary treatment of intramedullary spinal cord tumors (IMSCTs) involves radical or subtotal tumor resection with adjuvant radiation and/or chemotherapy, depending on the tumor's histological type and grade as well as the extent of resection. Despite advances in surgical therapy, this approach continues to have significant morbidity. Although previous research is limited, identifying reliable predictors of functional status after tumor resection would be clinically useful for perioperative modification strategies.

METHODS

All patients who underwent surgery for IMSCTs at an academic tertiary care institution between 1995 and 2004 were retrospectively reviewed, and predictors of postoperative neurological functional status were assessed by multivariate logistical regression analysis. Neurological status was gauged by the ability to walk without assistance at the time of the last follow-up visit.

RESULTS

Seventy-eight IMSCT resections were performed during the study period. Preoperative (on the day of or the day before surgery) serum glucose greater than 170 mg/dl (relative risk, 0.03; 95% confidence interval, 0.00-0.27; P = 0.001) and preoperative radiation therapy (relative risk, 0.02; 95% confidence interval, 0.00-0.39, P = 0.012) were independently associated with poor functional status postoperatively. The ability to walk unassisted before surgery (relative risk, 17.1; 95% confidence interval, 1.89-154.5, P = 0.012), on other hand, was the only positive predictor of the ability to walk unassisted at the time of the last follow-up visit.

CONCLUSION

This study suggests that early surgical intervention after the onset of symptoms for patients with IMSCT may help preserve ambulatory function. Deferral of preoperative radiation therapy for less radiosensitive tumors and strict perioperative glucose control may also help maximize a patient's subsequent ambulatory status.

Outcomes in treatment for intradural spinal cord ependymomas

PURPOSE

Spinal cord ependymomas are rare tumors, accounting for <2% of all primary central nervous system tumors. This study assessed the treatment outcomes for patients diagnosed with spinal cord ependymomas within the Southern California Kaiser Permanente system.

METHODS AND MATERIALS

We studied 23 patients treated with surgery with or without external beam radiotherapy (EBRT). The local and distant control rates and overall survival rates were determined.

RESULTS

The overall local control, overall recurrence, and 9-year overall survival rate was 96%, 17.4%, and 63.9%, respectively.

CONCLUSIONS

The results of our study indicate that en bloc gross total resection should be the initial treatment, with radiotherapy reserved primarily for postoperative cases with unfavorable characteristics such as residual tumor, anaplastic histologic features, or piecemeal resection. Excellent local control and overall survival rates can be achieved using modern microsurgical techniques, with or without local radiotherapy.

Spinal cord gliomas: A multi-institutional retrospective analysis

PURPOSE

To determine the impact of postoperative radiation therapy (POXRT) on outcome in spinal cord gliomas.

PATIENTS AND METHODS

Data from 242 patients were collected retrospectively from six institutions using a standardized data sheet. Pathology specimens, when available, were centrally reviewed.

RESULTS

A total of 183 patients were analyzed: 82 received surgery alone as initial treatment, whereas 101 had surgery and POXRT. Demographic, diagnostic, and treatment factors were analyzed for impact on progression-free (PFS) and overall survival (OS). PFS in ependymoma patients was 74%, 60%, and 35% at 5, 10, 15 years, respectively, and was significantly influenced by treatment type, race, age, tumor grade, and type of surgery on univariate analysis, with age being the only significant factor on multivariate analysis (MVA) (p = 0.01). OS of ependymoma patients was 91%, 84%, and 75% at 5, 10, and 15 years, respectively, and was significantly influenced by both complete resection (p = 0.04) and age (p = 0.03) on MVA. In astrocytomas, PFS was 42%, 29%, and 15% at 5, 10, and 15 years, and was significantly influenced by POXRT in low- and intermediate-grade tumors on MVA (p = 0.02). OS at 5, 10, and 15 years was 59%, 53%, and 32%, respectively, and was significantly influenced by grade on MVA (p < 0.01).

CONCLUSION

Postoperative radiation therapy reduced disease progression in low- and moderate-grade astrocytomas. In ependymomas, complete resection significantly influenced OS.

Intramedullary spinal cord tumors in patients older than 50 years of age: management and outcome analysis

OBJECT

Intramedullary spinal cord tumors (IMSCTs) in the older-age adult population pose complex management issues regarding the extent of resection and functional outcome, especially in terms of quality of life. Historically, IMSCTs in the older adult population were treated with irradiation alone because it was assumed that functional recovery would be poor. The authors examined their IMSCT database and report the first large series of IMSCTs in patients older than 50 years of age.

METHODS

In this retrospective clinical and chart review there were 30 cases meeting inclusion criteria drawn from databases at three different institutions. A modified McCormick Scale was used to assess functional levels in all 30 patients pre- and postoperatively. The mean age of patients in this cohort was 59.8 years (range 50-78 years), and the mean follow-up period was 10.6 years (range 2-16 years). Ependymoma was the most common tumor (83%), and 55% were located in the thoracic spine. The most common presenting symptom was sensory dysesthesia, with rare motor loss. The prodromal period to treatment was 19.4 months. Based on the McCormick Scale score at last follow-up examination 67% of patients were clinically functionally the same, 9% were worse, and 24% were improved after surgery. There were two deaths due tumor progression (both malignant tumors) and one recurrence (anaplastic astrocytoma). All three patients in whom malignant astrocytomas were diagnosed underwent postoperative radiation therapy.

CONCLUSIONS

In the population of patients older than age 50 years, thoracic ependymomas are the most common IMSCTs that present characteristically with sensory symptoms. The longer prodromal period in the older adult population may reflect the fact that their diagnosis and workup is inadequate. There was no significant increase in the length of stay in the neurosurgical ward. The authors recommend motor evoked potential-guided aggressive microsurgical resection, because the long-term outcome of benign lesions is excellent (good functional recovery and no tumor recurrence).

A retrospective analysis of 52 cases of spinal cord glioma managed with radiation therapy

PURPOSE

To describe the outcome of primary spinal cord glioma treated with radiation therapy after surgery and to identify variables predictive of outcome.

METHODS AND MATERIALS

A chart review of 52 patients with a diagnosis of spinal cord non-ependymoma glioma at the Princess Margaret Hospital was conducted. Thirty-two patients (62%) were male and 20 (38%) were female. Median age was 32 years (2-76 years). Median follow-up was 3.7 years (2 months to 27 years). Initial surgical management consisted of biopsy alone in 27 (52%) cases, subtotal resection in 20 (38%) cases, and gross total resection in 5 (10%) cases. All patients received postoperative radiation therapy; median total dose was 50 Gy, given in 25 daily fractions (20-60 Gy). Actuarial survival rates were calculated and the influence of patient-, tumor-, and treatment-related variables on outcome was determined.

RESULTS

Five-year overall, cause-specific, and progression-free survivals were 54%, 62%, and 58%, respectively. Ten-year survivals were 45%, 50%, and 43%, respectively. A total of 29 (56%) patients died during the period of review. For 23 (79%) of these patients, death was cancer specific. Progression of tumor was documented in 28 of 52 (54%) patients. The following factors predicted for improved outcome on univariate analysis: age < 18 years, low-grade histology, and length of symptoms prior to diagnosis > 6 months.

CONCLUSION

The outcome of patients in this series is consistent with that of other similar published reports. Specific recommendations are made for the management of this tumor.

Prognostic factors and survival in patients with spinal cord gliomas after radiation therapy

The purpose of this study was to determine the impact of various prognostic factors on survival in spinal cord gliomas treated with radiation. Fifty-three patients with spinal cord gliomas irradiated at three major institutions were studied. Fifty-one patients were classified as having ependymoma, astrocytoma, or both. Two patients were classified as having gliomas (otherwise unspecified). Eleven patients had complete resection of their tumor. Biopsy or partial resection was done in the remaining patients. All patients received external beam radiation. Information on these patients was placed in a central database file and analyzed for the effect of several prognostic factors on survival. Overall survival of the entire group was 76.9% and 61.5% at 5 and 10 years, respectively. Pathologic status significantly affected survival (p = 0.03). Patients with ependymomas had a 5-year survival of 93.8% and a 10-year survival of 67.5%. Patients with astrocytoma had a 5-year survival of 64.2% and a 10-year survival of 54%. Univariate analysis showed pathology and the presence of cysts (p = 0.038) to significantly affect survival. Age, sex, location of the primary, extent of surgery radiation dose, and number of involved segments did not affect survival. On multivariate analysis, astrocytic pathology, involvement of more than five segments, male sex, and the absence of cysts (in or adjacent to the tumor) were associated with a significantly inferior survival. This study confirms the importance of pathology and number of segments involved in determining outcome or survival. The presence of cysts adjacent to or within the tumor was found to be associated with an improvement in survival.

Treatment of spinal cord tumors in children

BACKGROUND

A retrospective review was carried out of nine children under 17 years of age with a diagnosis of intramedullary tumor seen during the period 1989-1995. Six had astrocytomas; one each had an ependymoma, a PNET, and a choroid plexus papilloma. Five patients had back pain, 3 others had mild pareses and the ninth had incapacitating defects. Seven of the 9 were treated by subtotal extirpation of the lesion, and biopsy alone was performed in the other two. All tumors were low grade (grade I or II) and therefore radiation therapy (RT) was performed as the only postoperative treatment in 8 of the 9 children.

RESULTS

In February 1996, seven (77.8%) children were alive and two (22.2%) died of recurrent tumor (7 months and 5 years after diagnosis, respectively). Median follow-up was 3 years 4 months (range: 1 year 6 months to 7 years 3 months).

CONCLUSION

Surgical removal of intraspinal tumors provides the best hope of control, but spinal column deformity after laminectomy and irradiation is a serious long-term problem in children. Orthopedic supervision for the prevention of these deformities; e.g., by external immobilization, is mandatory.

Conservative surgery and radiotherapy in the treatment of spinal cord astrocytoma

Spinal cord astrocytomas are rare neoplasms, and optimal treatment guidelines are undefined, 23 patients with spinal cord astrocytomas were treated between 1984 and 1993 with conservative surgery and postoperative radiotherapy. The mean age was 31 years. Twelve patients were male and eleven female. All patients presented with neurologic deficit. Cervical cord was involved in five patients, cervicothoracic in four, thoracic in eight and thoracolumbar in six. Five patients had intramedullary cysts. Fifteen patients had low grade tumors and six high grade. Surgery was near total excision in three patients, partial excision in ten and biopsy in ten patients. All patients received postoperative radiotherapy to a median dose of 45 Gy in 25 fractions over 5 weeks. The median followup was 51 months (range 7-143 months). At 6 months post radiotherapy, twelve patients had improvement of neurologic status, nine had stable status, and two deteriorated. The actuarial overall survival was 55% at 5 years and 39% at 10 years. The actuarial progression free survival probability was 75% at 5 years and 55% at 10 years. Five patients had local failure and two failed at distant sites. Twelve patients died, six due to progressive disease, five due to complications of paraplegia and one patient of unrelated causes. Tumor grade was a significant prognostic factor for overall survival. 5 year overall survival was 79% for low grade tumors. No patient with high grade tumor survived more than 2 years and the median survival was 10 months. Low grade, female sex and presence of intramedullary cysts were associated with significantly improved progression free survival. Conservative surgery followed by radiotherapy appears to have a role in achieving tumor control and neurologic recovery in patients with low grade astrocytomas of the spinal cord. Treatment results of high grade tumors remain poor and new therapeutic strategies need to be studied.

Spinal cord astrocytoma: pathological and treatment considerations

Seventy-nine patients underwent surgery, with or without radiation therapy, for astrocytoma of the spinal cord. There were 43 tumors (54%) classified as pilocytic astrocytoma and 25 (32%) as diffuse fibrillary astrocytoma. Eleven tumors (14%) could not be classified other than as astrocytoma, "type not otherwise specified." The 10-year overall survival rate for all 79 patients was 50% but significantly differed by histological type: 81% for patients with pilocytic astrocytoma compared to 15% for those with diffuse fibrillary astrocytoma. Tumor grade by the Kernohan, et al., or St. Anne-Mayo methods was also a significant predictor of survival in patients with diffuse fibrillary astrocytoma. The extent of surgical resection (biopsy vs. subtotal resection vs. gross total resection) did not significantly impact survival among patients with pilocytic or nonpilocytic astrocytomas of the spinal cord, although there was a trend toward poorer survival in patients undergoing some degree of resection as opposed to biopsy. Postoperative radiation therapy improved survival but did so more for diffuse fibrillary astrocytoma than pilocytic astrocytoma. In this series, histological type was the most significant predictor of survival in patients with astrocytoma of the spinal cord. The survival rate was highest in patients who underwent biopsy followed by postoperative radiation therapy.

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.

Management of intramedullary tumours in children

Clinical presentation, diagnosis, surgical technique and results of 25 cases of intramedullary tumours in patients under 16 years of age are analyzed. Pre-operative spinal deformity was present in 9 patients. Surgery was performed in all. After multilaminectomy with preservation of the intervertebral joints, total removal of the lesion was achieved in 11 patients and subtotal removal in 14 others. After surgery, external immobilization lasting an average period of 5 years was instituted in all patients. Postoperative radiation therapy was performed in 11 cases (5 "high grade" astrocytomas, 5 ependymomas, 1 glioblastoma). There were 11 recurrences: 4 of which (2 ependymomas and 2 "low grade" astrocytomas) were treated surgically, 7 (5 "high grade" astrocytomas, 1 glioblastoma, 1 oligodendroglioma) with palliative radiation treatment. Six patients eventually developed postlaminectomy spinal deformities as diagnosed roentgenographically 6 to 50 months postoperatively. Of the 16 patients still alive, 7 did not present relevant neurological deficit, 1 presented a monoparesis, while the other 8 presented invalidating deficits. Surgical treatment did not differ from that employed in the intramedullary tumours in the adult: radical resection is indeed the optimal therapeutic origin. The risk of radiation therapy are greater in children: it is crucial to limit radiation therapy to only some histotypes. The incidence of spinal column deformity after multilevel laminectomy is greater in young patients. It is advisable to implement prevention of spinal deformities by postoperative external immobilization and constant follow-up so as to detect early changes of spinal stability.

Management of spinal astrocytoma with conservative surgery and radiotherapy

Twenty-seven patients with histologically verified spinal astrocytoma were treated at the Royal Marsden Hospital with postoperative radiotherapy. All patients had previous surgery; 10 had partial resection and 17 biopsy alone. All patients received involved field radiotherapy to a median dose of 50 Gy in 33 fractions. Overall 5- and 10-year survival was 59 and 52%, and progression free survival was 38 and 26% at 5 and 10 years, respectively, at a median follow-up of 6.5 years. Following radiotherapy, eight patients showed functional improvement, 15 were unchanged and two deteriorated. Sixteen patients relapsed, eleven at the primary site and five elsewhere in the CNS. Low grade histology, female gender and the presence of intramedullary cysts were favourable prognostic factors for survival on univariate analysis. The extent of surgery was not a significant predictor of survival. It is not possible to define the precise role of radiotherapy. However, all patients had residual tumour prior to irradiation, and 53% of low grade and 33% of high grade gliomas remained controlled locally at 3 years with stabilization or improvement in neurological function in all but two patients. This suggests that radiotherapy may result in temporary disease control analogous to cerebral gliomas.

Postoperative radiotherapy in the management of spinal cord ependymoma

Fifty-eight patients with histologically verified spinal cord ependymomas were treated at the Royal Marsden Hospital and Atkinson Morley's Hospital between 1950 and 1987. The median age in this series was 40 years (range 1 to 79 years) and the male:female ratio was 1.8:1. Ten patients had tumors in the cervical cord and 10 in the thoracic cord; 14 tumors involved the conus medullaris and 24 the cauda equina. Forty ependymomas were grade I and 13 were grades II to IV (in five patients there was insufficient material for grading). Eleven patients underwent biopsy only, 33 had partial or subtotal resection, and 14 had complete resection. Forty-three patients received postoperative radiotherapy. The median follow-up period was 70 months (range 3 to 408 months). Cause-specific survival rates were 74% and 68% at 5 and 10 years, respectively. On univariate analysis, age, histological grade, postoperative neurological function, and era of treatment were significant prognostic factors for survival. The histological grade was the only significant independent prognostic factor. The relative risk of death from ependymoma was 9.0 for patients with tumor grades II to IV compared to grade I (p less than 0.005, 95% confidence interval 2.7 to 30). The survival rates of patients following complete excision were significantly better compared to those after incomplete surgery (p less than 0.025). The majority of completely resected neoplasms were low-grade cauda equina tumors. Despite incomplete surgery, 5- and 10-year progression-free survival rates following radical radiotherapy were both 59%, and cause-specific survival rates were 69% at 5 years and 62% at 10 years. This suggests that radiotherapy may achieve long-term tumor control in over half of those patients with residual spinal ependymoma.

The role of radiation therapy in the management of ependymomas of the spinal cord

Twenty patients with biopsy-proven ependymomas of the spinal cord were treated between 1960 and 1984-7 with surgery only, 3 with radiation therapy only, and 10 with surgery and postoperative radiation therapy. Of these, 2 patients developed recurrent tumor at the primary site, 3 developed a recurrent tumor in the thecal sac, and 1 developed distant metastasis. The absolute 5- and 10-year survival rates were 95% (19/20) and 86% (12/14), respectively. None of 13 patients who were treated with radiation therapy only or combined surgery and postoperative radiation therapy developed recurrent tumor at the primary site, and none of 7 patients who received thecal sac irradiation developed thecal sac recurrences. In contrast, 2 of 7 patients (29%) treated with surgery alone developed recurrent tumor at the primary site, and 3 of 13 patients (23%) who received no thecal sac irradiation developed a recurrent tumor in the thecal sac. The failure rates following surgery were greatest in patients who had tumor removed in a piecemeal fashion (43%, 6/14). The results show that radiation therapy is probably not necessary if the tumor has been removed completely in an en bloc fashion. However, radiation therapy is needed if the tumor has been incompletely removed or removed in a piecemeal fashion. If the tumor has been removed in a piecemeal fashion, the radiation portals should be extended to include the thecal sac. Histologic subtypes influenced the pattern of recurrence. Myxopapillary ependymomas and high grade cellular ependymomas appear to be more likely to recur in the thecal sac. However, no big difference could be detected in local recurrence.

External beam radiotherapy for primary spinal cord tumors

Of 34 evaluated patients with primary spinal cord tumors, 32 were irradiated at our institutions between 1969 and 1983. The results are reported of 32 patients, 16 with ependymoma and 16 with astrocytoma, who were treated with postoperative external beam radiotherapy following biopsy or subtotal resection. Twenty-nine patients received 45-55 Gy megavoltage beam irradiation in five to six weeks, and the remaining three patients received less than 40 Gy. The minimum follow-up was five years. Five- and ten-year actuarial survival rates for the entire group of patients were 73% (22/30) and 50% (8/16), respectively, including three patients who were salvaged by surgery after radiotherapy failures. Corresponding five- and ten-year relapse-free survival rates were 60% (18/30) and 32% (6/19), respectively. Of the 29 patients who received more than 45 Gy, relapse-free survival at five years was 63% (17/27). Treatment failed in 13 patients, and all of those failures were within the irradiated portals. Patients with ependymomas have significantly better relapse free survival than those with astrocytomas, 80% vs. 40% (p less than 0.05). There was a significant difference in survival between patients with tumors involving the cervical spine and those with tumors in the other locations, 45% vs. 89% (p less than 0.05). There was no significant difference in survival between patients with cauda equina tumors and those with tumors of the spinal cord, 100% vs. 68% (p less than 0.05). No radiotherapy-related neurological deficit was noted with a maximum 20 year follow-up. This study confirms that external beam radiotherapy is a safe and effective treatment modality for primary spinal cord tumors.

Intramedullary ependymoma of the spinal cord

A consecutive series of 23 patients underwent operative removal of an intramedullary spinal cord ependymoma between January, 1976, and September, 1988. Thirteen women and 10 men between the age of 19 and 70 years experienced symptoms for a mean of 34 months preceding initial diagnosis. Eight patients had undergone treatment prior to tumor recurrence and referral. Mild neurological deficits were present in 22 patients on initial examination. The location of the tumors was predominantly cervical or cervicothoracic. Radiological evaluation revealed a wide spinal cord in all cases. Magnetic resonance (MR) imaging was the single most important radiological procedure. At operation, a complete removal was achieved in all patients. No patient received postoperative radiation therapy. Histological examination revealed a benign ependymoma in all cases. The follow-up period ranged from 6 to 159 months (mean 62 months) with seven patients followed for a minimum of 10 years after surgery. Fourteen patients underwent postoperative MR imaging at intervals ranging from 8 months to 10 years postoperatively. No patient has been lost to follow-up review and there were no deaths. No patient showed definite clinical or radiological evidence of tumor recurrence during the follow-up period. Recent neurological evaluation revealed functional improvement from initial preoperative clinical status in eight patients, no significant change in 12 patients, and deterioration in three patients. The data support the belief that long-term disease-free control of intramedullary spinal ependymomas with acceptable morbidity may be achieved utilizing microsurgical removal alone.

Postoperative radiotherapy of primary spinal cord tumors

During the 30 year period from 1957 to 1986, 42 patients with primary tumors arising from the spinal cord or cauda equina received postoperative irradiation at the University of California, San Francisco. Twenty-one patients had ependymomas: 18 were localized to one site, and 3 diffusely involved the cord. There were 12 patients with low grade astrocytomas and 3 with highly anaplastic astrocytoma or glioblastoma multiforme. All astrocytomas were localized at presentation. In 6 cases tissue was insufficient to permit a histologic diagnosis. Thirty-nine patients (93%) received total radiation doses ranging between 45.0-54.7 Gy using standard fractionation. The 10-year actuarial disease-specific survival rate for patients with localized ependymoma was 93%; 33% of these tumors recurred locally. The corresponding rate for diffuse ependymomas was 50%; the spinal disease was controlled in all 3 patients, but one developed a cerebral metastasis despite prophylactic cranial irradiation. Low-grade astrocytoma patients had a 10-year actuarial disease-specific survival rate of 91%, with 33% of these tumors recurring locally. No patient with highly anaplastic astrocytoma or glioblastoma multiforme survived longer than 8 months; all of these tumors recurred locally, and two of the three also developed diffuse craniospinal axis metastases. Local recurrence for ependymoma was delayed as long as 12 years following treatment, while all but one astrocytoma failure occurred within 3 years of treatment. No significant dose-response relationship with respect to local control was noted for either localized ependymomas or low grade astrocytomas. One patient developed radiation myelitis after receiving 50.4 Gy with standard fractionation. These results indicate that patients who undergo postoperative irradiation for low grade spinal astrocytomas and localized spinal ependymomas achieve excellent survival. However, despite treatment with total radiation doses taken to the practical limit of spinal cord tolerance, local failure remains common.

Postoperative management of primary spinal cord ependymomas

Treatment and final outcome of 11 patients with primary spinal cord ependymomas admitted between 1967 and 1983 have been reviewed. All patients had undergone surgery once or twice before radiation treatment. Six of them are alive and disease-free 78 months to more than 180 months after radiation therapy. A short analysis of the recent literature is presented with special emphasis on the most frequent treatment techniques, extension of radiation fields and doses. The value of postoperative radiation therapy and the complications of both surgery and radiotherapy are analyzed. Some guidelines for treatment are finally discussed and proposed.

Radiotherapeutic management of adult intraspinal ependymomas

Twenty-two adults with ependymomas of the spinal cord were treated with surgery and postoperative radiation between January 1963 and December 1983. The median age was 47 years. Nineteen patients had grade 1 lesions, two had grade 2 and one grade 3. Ten patients had the myxopapillary histologic subtype (all grade 1) and 12 had the cellular variant. There were 15 distal cord lesions originating from the conus medullaris, filum terminale and/or cauda equina. The remaining seven lesions arose more proximally. Fourteen patients had localized lesions involving one to three vertebral segments, while the remaining eight had extensive ependymomas spanning six to thirteen vertebral segments. The median time from onset of symptoms to diagnosis was 3 years. Surgical treatment consisted of biopsy only in three patients, subtotal removal in eleven patients and total removal in eight patients. Radiation was given to the spine only in all cases. Five patients received whole spine radiation; seventeen received partial spine treatment, appropriate for the length of the primary lesion. The median dose was 5000 cGy (range 3600-5700 cGy). The disease free survival at 5 and 10 years was 81 and 71%, respectively. Overall survival at 5 and 10 years was 95%. Seven of twenty-two (32%) patients failed. Factors analyzed for prognostic significance included age, sex, histology, extent of primary, location of primary within the cord, extent of surgical resection and dose. Too few grade 2 and 3 patients precluded meaningful statistical analysis of grade as a prognostic factor. Neither age, sex, histology, extent of primary, location of primary, nor extent of surgical removal significantly affected disease free or overall survival (p greater than 0.05). Four of nineteen (21%) patients with grade 1 lesions failed, while all three patients with grade 2 and 3 lesions did so. Half of the eight patients with extensive ependymomas failed compared to three of fourteen (21%) with limited ones. Six of seventeen (35%) patients failed at doses less than or equal to 5000 cGy while only one of five (20%) failed at doses greater than 5000 cGy. Patterns of failure were analyzed for the seven patients who failed. Six of the seven failures (86% of the failure group, 27% of the overall group) were local, that is, within the initial radiation field at the site of the original tumor. A single patient (grade 2) failed in the posterior fossa while remaining NED in the spinal cord (a head CT scan at initial work-up was negative).(ABSTRACT TRUNCATED AT 400 WORDS)

Astrocytomas of the spinal cord in children and adolescents

The authors review 32 cases of spinal cord astrocytoma in patients under 20 years of age who were treated at the Mayo Clinic between 1955 and 1980. There was a 1.3:1 male to female ratio. Twenty patients were between 6 and 15 years of age at the time of diagnosis. The duration of symptoms prior to definitive diagnosis varied from 5 days to 9 years, with an average of 24 months. The most common symptoms were pain (62.5%), gait disturbance (43.7%), numbness (18.8%), and sphincteric dysfunction (18.8%). The most common neurological findings were a Babinski response (50.0%), posterior column sensory dysfunction (40.6%), and paraparesis (37.5%). A median follow-up period of 8.6 years (range 0.8 to 25.5 years) revealed that the survival time diminished with increased histological grade of the astrocytoma (p less than 0.001). The development of postlaminectomy spinal deformities represented a serious postoperative complication. This occurred in 13 patients and was first recognized between 8 and 90 months postoperatively. Six deformities occurred following cervical laminectomy, and eight patients required at least one orthopedic procedure. It is crucial to follow these patients for an extended period of time to watch for postoperative spinal deformities.

Primary spinal cord tumors treated with surgery and postoperative irradiation

Between 1954 and 1979, 37 patients with a primary spinal cord tumor received postoperative irradiation after laminectomy. There were 26 intramedullary and 11 tumors of the conus/cauda equina. The 26 intramedullary tumors were divided as follows: 14 astrocytomas, eight ependymomas, three unbiopsied tumors, and one diffuse histiocytic lymphoma. Of the cauda equina tumors, 10 were ependymomas and one was an astrocytoma. Patients were followed until death or for a minimum of 4 years. The 5- and 10-year actuarial survivals for the entire group were 70 and 58%, respectively. Anatomic location of the tumor was the most important predictor of both survival and neurologic function. Patients with tumors of the cauda equina had superior neurologic function and a significantly better survival than those with tumors at other sites. Recurrent tumor was the cause of death in 82% of the patients dead at the time of analysis. Of the patients alive at the conclusion of the study, 10 were completely normal or had only mild neurologic deficit; the remaining 10 patients were severely disabled. Increasing radiation dose correlated with an increase in tumor control and survival. Of those receiving less than 40 Gy, 77% died of recurrent tumor, while 83% of those who received greater than 40 Gy are alive 4.1 to 28.9 years after treatment.

Ependymomas of the spinal cord

Many patients with spinal cord ependymomas (SCE) undoubtedly benefit from post-operative radiation therapy; however, because of the wide variability in the total doses given, the optimal post-operative dose for SCE remains unclear. Several recent papers recommend total doses of 4000 rad to 5000 rad in 4 1/2 to 6 weeks. Unfortunately, only a small number of patients reported in the literature have been consistently treated to these high dose recommendations. Nine consecutive adult patients with SCE have been treated in a consistent way at Yale-New Haven Hospital with total doses of approximately 4500 rad to 5000 rad at 180 rad to 200 rad per day. The acute and chronic morbidity from such treatment has been minimal and no patient has had a local recurrence at 8 months to 8 years following treatment.