Ependymoma

Single-cell RNA sequencing of anaplastic ependymoma and H3K27M-mutant diffuse midline glioma

BACKGROUND

Anaplastic ependymoma and H3K27M-mutant diffuse midline glioma are two common subtypes of brain tumors with poor long-term prognosis. The present study analyzed and compared the differences in cell types between two tumors by single-cell RNA sequencing (scRNA-seq) technology.

METHODS

ScRNA-seq was performed to profile cells from cancer tissue from anaplastic ependymoma patient and H3K27M-mutant diffuse midline glioma patient. Cell clustering, marker gene identification, cell type annotation, copy number variation analysis and function analysis of differentially expressed genes were then performed.

RESULTS

A total of 11,219 cells were obtained from anaplastic ependymoma and H3K27M mutant diffuse midline glioma, and these cells categorized into 12 distinct clusters. Each cell cluster could be characterized with specific cell markers to indicate cellular heterogeneity. Five cell types were annotated in each sample, including astrocyte, oligodendrocytes, microglial cell, neural progenitor cell and immune cell. The cluster types and proportion of cell types were not consistent between the two brain tumors. Functional analyses suggest that these cell clusters are involved in tumor-associated pathways, with slight differences in the cells of origin between the two tumors. In addition, cell communication analysis showed that the NRG3-ERBB4 pair is a key Ligand-receptor pair for anaplastic ependymoma, while in H3K27M-mutant diffuse midline glioma it is the PTN-PTPRZ1 pair that establishes contact with other cells.

CONCLUSION

There was intratumor heterogeneity in anaplastic ependymoma and H3K27M mutant diffuse midline glioma, and that the subtype differences may be due to differences in the origin of the cells.

Posterior fossa ependymoma with preoperative cerebrospinal metastases: a case report with literature review

BACKGROUND

Adult posterior fossa ependymomas (PF-EPN) with preoperative cerebrospinal metastases are extremely rare. Only 3 cases have been reported in previous literature.

CASE PRESENTATION

A case of a 32-year-old male patient complained of headaches for three months. Pure tone audiometry showed a slight decrease in bilateral hearing. Auditory evoked potential indicated that the hearing on the left was slightly weaker than that on the right. Magnetic resonance imaging (MRI) revealed a primary tumor arising within the fourth ventricle and metastasizing to bilateral cerebellopontine angle (CPA), the third ventricle, the left lateral ventricle, T1, L1-2 and L5. A gross total resection (GTR) was performed on the lesion located in the left CPA. The histological examination showed a papillary ependymoma (WHO grade II). Immunohistochemical staining for H3K27me3 showed that nuclear positivity in more than 80% of cells. No NF2 mutation was observed. No progression was found during a 24-month follow-up.

CONCLUSIONS

Our data indicate that preoperative multiple metastases in adult PF-EPN are extremely rare. This kind of disease usually has a low WHO grade and a favorable prognosis. GTR should be achieved when feasible and patients need a long-term follow-up with MRI.

Characterizing the tumor immune microenvironment of ependymomas using targeted gene expression profiles and RNA sequencing

BACKGROUND

Defining the tumor immune microenvironment (TIME) of patients using transcriptome analysis is gaining more popularity. Here, we examined and discussed the pros and cons of using RNA sequencing for fresh frozen samples and targeted gene expression immune profiles (NanoString) for formalin-fixed, paraffin-embedded (FFPE) samples to characterize the TIME of ependymoma samples.

RESULTS

Our results showed a stable expression of the 40 housekeeping genes throughout all samples. The Pearson correlation of the endogenous genes was high. To define the TIME, we first checked the expression of the PTPRC gene, known as CD45, and found it was above the detection limit in all samples by both techniques. T cells were identified consistently using the two types of data. In addition, both techniques showed that the immune landscape was heterogeneous in the 6 ependymoma samples used for this study.

CONCLUSIONS

The low-abundant genes were detected in higher quantities using the NanoString technique, even when FFPE samples were used. RNA sequencing is better suited for biomarker discovery, fusion gene detection, and getting a broader overview of the TIME. The technique that was used to measure the samples had a considerable effect on the type of immune cells that were identified. The limited number of tumor-infiltrating immune cells compared to the high density of tumor cells in ependymoma can limit the sensitivity of RNA expression techniques regarding the identification of the infiltrating immune cells.

A, Gota V, Goda JS. Insight into lipid-based nanoplatform-mediated drug and gene delivery in neuro-oncology and their clinical prospects

Tumors of the Central nervous System (CNS) are a spectrum of neoplasms that range from benign lesions to highly malignant and aggressive lesions. Despite aggressive multimodal treatment approaches, the morbidity and mortality are high with dismal survival outcomes in these malignant tumors. Moreover, the non-specificity of conventional treatments substantiates the rationale for precise therapeutic strategies that selectively target infiltrating tumor cells within the brain, and minimize systemic and collateral damage. With the recent advancement of nanoplatforms for biomaterials applications, lipid-based nanoparticulate systems present an attractive and breakthrough impact on CNS tumor management. Lipid nanoparticles centered immunotherapeutic agents treating malignant CNS tumors could convene the clear need for precise treatment strategies. Immunotherapeutic agents can selectively induce specific immune responses by active or innate immune responses at the local site within the brain. In this review, we discuss the therapeutic applications of lipid-based nanoplatforms for CNS tumors with an emphasis on revolutionary approaches in brain targeting, imaging, and drug and gene delivery with immunotherapy. Lipid-based nanoparticle platforms represent one of the most promising colloidal carriers for chemotherapeutic, and immunotherapeutic drugs. Their current application in oncology especially in brain tumors has brought about a paradigm shift in cancer treatment by improving the antitumor activity of several agents that could be used to selectively target brain tumors. Subsequently, the lab-to-clinic transformation and challenges towards translational feasibility of lipid-based nanoplatforms for drug and gene/immunotherapy delivery in the context of CNS tumor management is addressed.

Linear energy transfer-inclusive models of brainstem necrosis following proton therapy of paediatric ependymoma

Background and Purpose

Radiation-induced brainstem necrosis after proton therapy is a severe toxicity with potential association to uncertainties in the proton relative biological effectiveness (RBE). A constant RBE of 1.1 is assumed clinically, but the RBE is known to vary with linear energy transfer (LET). LET-inclusive predictive models of toxicity may therefore be beneficial during proton treatment planning. Hence, we aimed to construct models describing the association between brainstem necrosis and LET in the brainstem.

Materials and methods

A matched case-control cohort (n = 28, 1:3 case-control ratio) of symptomatic brainstem necrosis was selected from 954 paediatric ependymoma brain tumour patients treated with passively scattered proton therapy. Dose-averaged LET (LET_d) parameters in restricted volumes (L_50%, L_10% and L_0.1cm³, the cumulative LET_d) within high-dose thresholds were included in linear- and logistic regression normal tissue complication probability (NTCP) models.

Results

A 1 keV/µm increase in L_10% to the brainstem volume receiving dose over 54 Gy(RBE) led to an increased brainstem necrosis risk [95% confidence interval] of 2.5 [0.0, 7.8] percentage points. The corresponding logistic regression model had area under the receiver operating characteristic curve (AUC) of 0.76, increasing to 0.84 with the anterior pons substructure as a second parameter. 19 [7, 350] patients with toxicity were required to associate the L_10% (D > 54 Gy(RBE)) and brainstem necrosis with 80% statistical power.

Conclusion

The established models of brainstem necrosis illustrate a potential impact of high LET regions in patients receiving high doses to the brainstem, and thereby support LET mitigation during clinical treatment planning.

Clinical Characteristics and Treatment Outcomes of Long-Level Intramedullary Spinal Cord Tumors: A Consecutive Series of 43 Cases

Objective: Long-level intramedullary spinal cord tumors (LIMSCTs) cause complex treatment issues. However, LIMSCTs have rarely been analyzed separately. The authors reported a large case series of LIMSCTs and analyzed the clinical characteristics and treatment outcomes.Methods: The medical data of patients with LIMSCTs at our institution between January 2015 and December 2019 were retrospectively reviewed. Demographics, tumor size and location, pathology, extent of resection, and neurological functional status were collected.Results: A total of 43 consecutive cases were included. Twenty-three cases (53.5%) of LIMSCTs were ependymal tumors. All patients with ependymal tumors achieved gross total resection (GTR). In ependymal tumor cases, 3 cases (13%) of ependymal tumors experienced postoperative neurological deterioration, and 66% of them showed an improvement at follow-up; 25.6% were low-grade astrocytic tumors. The rates of GTR, subtotal resection (STR) and partial resection (PR) were 63.6%, 27.3%, and 9.1%, respectively. Twenty-seven percent cases showed postoperative neurological worsening, and 33% of them had an improvement at follow-up; 20.9% were high-grade astrocytic tumors. The excision rates were 44.4% for GTR, 44.4% for STR, and 11% for PR, respectively. Fifty-five percent cases showed postoperative neurological worsening, and none of them had an improvement at follow-up.Conclusion: In this series, all LIMSCTs were gliomas. Aggressive tumor resection did not increase the risk of long-term functional deterioration in ependymal tumors and low-grade astrocytic tumors, but in high-grade astrocytic tumors, patients had a higher risk of neurological deterioration and difficulty in recovery. In ependymal tumors and low-grade astrocytic tumors, patients can achieve long-time survival after performing aggressive tumor resection.

PARP inhibition utilized in combination therapy with Olaparib-Temozolomide to achieve disease stabilization in a rare case of BRCA1-mutant, metastatic myxopapillary ependymoma

Myxopapillary ependymoma (MPE) is a primary tumor of the central nervous system (CNS), characteristically an indolent malignancy involving the spinal conus medullaris, Filum terminale or cauda equina. We present a rare case of MPE, recurrent in the pelvic soft tissue with eventual pleural and intra-pulmonary metastasis. Refractory to repeated gross resection, adjuvant radiotherapy, platinum-based chemotherapy and temozolomide exploitation of mutant somatic BRCA1 status with the addition of a poly (ADP-ribose); polymerase inhibitor (PARPi) in a novel combination regimen with olaparib-temozolomide (OT) has achieved stable radiological disease after 10 cycles.

Brain and Spinal Cord Tumors Among the Life-Threatening Health Problems: An Introduction

As one of the global concerns, cancers, including brain and spinal cord tumors, are responsible for mortalities and irreversible morbidities in the affected patients. Although advancements in molecular pathology and imaging of tumors may have influenced the incidence rate due to higher diagnosis in early stages, exposure to environmental risk factors could be another explanation for increased incidence of these tumors over the past decades. Similar to many other tumors, the CNS tumors begin in cellular dimension with activation of different molecular pathways. Several genetic, epigenetic, and immunologic pathways and processes are already discovered to play roles in pathophysiology of these tumors, which mostly will eventually become symptomatic. Each of these tumors may exhibit imaging characteristics, making it possible to list a series of differential diagnosis before histopathologic examination. Advances in molecular pathology have resulted in better understanding and categorization of CNS tumors, leading to better decision-making on the most appropriate therapeutic approach for each category, as well as proposing new therapeutic modalities to treat these tumors. As an introduction to the 2-volume book, this chapter addressed different types of human brain and spinal cord tumors based on the fifth version of WHO classification of CNS tumors.

Vision transformer-based weakly supervised histopathological image analysis of primary brain tumors

Diagnosis of primary brain tumors relies heavily on histopathology. Although various computational pathology methods have been developed for automated diagnosis of primary brain tumors, they usually require neuropathologists' annotation of region of interests or selection of image patches on whole-slide images (WSI). We developed an end-to-end Vision Transformer (ViT) - based deep learning architecture for brain tumor WSI analysis, yielding a highly interpretable deep-learning model, ViT-WSI. Based on the principle of weakly supervised machine learning, ViT-WSI accomplishes the task of major primary brain tumor type and subtype classification. Using a systematic gradient-based attribution analysis procedure, ViT-WSI can discover diagnostic histopathological features for primary brain tumors. Furthermore, we demonstrated that ViT-WSI has high predictive power of inferring the status of three diagnostic glioma molecular markers, IDH1 mutation, p53 mutation, and MGMT methylation, directly from H&E-stained histopathological images, with patient level AUC scores of 0.960, 0.874, and 0.845, respectively.

Immunotherapy for Pediatric Brain and Spine Tumors: Current State and Future Directions

BACKGROUND

Brain tumors are the most common solid tumors and the leading cause of cancer-related deaths in children. Incidence in the USA has been on the rise for the last 2 decades. While therapeutic advances in diagnosis and treatment have improved survival and quality of life in many children, prognosis remains poor and current treatments have significant long-term sequelae.

SUMMARY

There is a substantial need for the development of new therapeutic approaches, and since the introduction of immunotherapy by immune checkpoint inhibitors, there has been an exponential increase in clinical trials to adopt these and other immunotherapy approaches in children with brain tumors. In this review, we summarize the current immunotherapy landscape for various pediatric brain tumor types including choroid plexus tumors, embryonal tumors (medulloblastoma, AT/RT, PNETs), ependymoma, germ cell tumors, gliomas, glioneuronal and neuronal tumors, and mesenchymal tumors. We discuss the latest clinical trials and noteworthy preclinical studies to treat these pediatric brain tumors using checkpoint inhibitors, cellular therapies (CAR-T, NK, T cell), oncolytic virotherapy, radioimmunotherapy, tumor vaccines, immunomodulators, and other targeted therapies.

KEY MESSAGES

The current landscape for immunotherapy in pediatric brain tumors is still emerging, but results in certain tumors have been promising. In the age of targeted therapy, genetic tumor profiling, and many ongoing clinical trials, immunotherapy will likely become an increasingly effective tool in the neuro-oncologist armamentarium.

Ensemble learning based functional independence ability estimator for pediatric brain tumor survivors

A history of brain tumor strongly affects children’s cognitive abilities, performance of daily activities, quality of life, and functional outcomes. In light of the difficulties in cognition, communication, physical skills, and behavior that these patients may encounter, occupational therapists should perform a comprehensive needs-led assessment of their global functioning after recovery. Such an assessment would ensure that the patients receive adequate support and services at school, at home, and in the community. By predicting the functional activity performance of children with a history of brain tumor, clinical workers can determine the progress of their ability recovery and the optimal treatment plan. We selected several features for testing and employed common machine learning models to predict Functional Independence Measure (WeeFIM) scores. The ensemble learning models exhibited stronger predictive performance than did the individual machine learning models. The ensemble learning models effectively predicted WeeFIM scores. Machine learning models can help clinical workers predict the functional assessment scores of patients with childhood brain tumors. This study used machine learning models to predict the WeeFIM scores of patients with childhood brain tumors and to demonstrate that ensemble machine learning models are more suitable for this task than are individual machine learning models.

Case report: Primary ependymoma of the trigeminal nerve presenting as trigeminal neuralgia

Background:

Ependymomas are usually found in the posterior fossa originating from the fourth ventricle. Primary ependymomas arising from cranial nerves are rare with only a handful of reported cases. Trigeminal neuralgia (TN) is rarely due to space occupying lesions.

Case Description:

A 20-year-old female presented with TN with a rare presentation of a pure extra-axial ependymoma involving the right trigeminal nerve in the cerebellopontine angle.

Conclusion:

It is essential to explore the possibility of a mass arising from the trigeminal nerve when investigating the cause of TN.

Multifocal lumbar myxopapillary ependymoma presenting with drop metastasis: a case report and review of the literature

INTRODUCTION

Spinal myxopapillary ependymomas (SME) are rare WHO grade II neoplasms of the spinal cord. Despite their good prognosis, they have a high propensity for metastasis and recurrence, although the presentation of SME as multifocal is uncommon.

CASE PRESENTATION

Here we describe a rare case of a 34-year-old man who presented with painful bilateral radiculopathy with sexual dysfunction and altered sensation with defecation. The patient also reported worsening weakness of bilateral lower extremities when climbing stairs. Biopsy results revealed multifocal SME in the lumbar and sacral spine that was treated with staged surgical resection and post-operative focal radiation therapy.

DISCUSSION

We discuss and evaluate surgical resection and the role of postoperative radiotherapy for SME. We also review the literature surrounding multifocal SME presenting in adults.

Radiomics Can Distinguish Pediatric Supratentorial Embryonal Tumors, High-Grade Gliomas, and Ependymomas

BACKGROUND AND PURPOSE

Pediatric supratentorial tumors such as embryonal tumors, high-grade gliomas, and ependymomas are difficult to distinguish by histopathology and imaging because of overlapping features. We applied machine learning to uncover MR imaging-based radiomics phenotypes that can differentiate these tumor types.

MATERIALS AND METHODS

Our retrospective cohort of 231 patients from 7 participating institutions had 50 embryonal tumors, 127 high-grade gliomas, and 54 ependymomas. For each tumor volume, we extracted 900 Image Biomarker Standardization Initiative-based PyRadiomics features from T2-weighted and gadolinium-enhanced T1-weighted images. A reduced feature set was obtained by sparse regression analysis and was used as input for 6 candidate classifier models. Training and test sets were randomly allocated from the total cohort in a 75:25 ratio.

RESULTS

The final classifier model for embryonal tumor-versus-high-grade gliomas identified 23 features with an area under the curve of 0.98; the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 0.85, 0.91, 0.79, 0.94, and 0.89, respectively. The classifier for embryonal tumor-versus-ependymomas identified 4 features with an area under the curve of 0.82; the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 0.93, 0.69, 0.76, 0.90, and 0.81, respectively. The classifier for high-grade gliomas-versus-ependymomas identified 35 features with an area under the curve of 0.96; the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 0.82, 0.94, 0.82, 0.94, and 0.91, respectively.

CONCLUSIONS

In this multi-institutional study, we identified distinct radiomic phenotypes that distinguish pediatric supratentorial tumors, high-grade gliomas, and ependymomas with high accuracy. Incorporation of this technique in diagnostic algorithms can improve diagnosis, risk stratification, and treatment planning.

Do We Need Radiotherapy in Grade II Ependymoma?

Purpose/Objectives

The debate on whether radiotherapy (RT) is an essential part of primary treatment in patients with grade II ependymoma (G2E) is still ongoing, and this study aimed to evaluate its role.

Materials/Methods

A retrospective analysis of all the consecutive patients treated due to G2E in years 1985–2019 was performed. The group consisted of 116 patients with a small predominance of woman (55% vs. 45%) and the location of the tumor in the brain (58% vs. 42%). All had surgery as the primary treatment with 47% R0 resection. Radical RT was applied in 81 patients. In majority of cases (91%), patients received local irradiation.

Results

Median follow-up was 65 months, and during that time, 17 patients died. Five- and 10-year overall survival (OS) of the whole group was 87% and 83%. Radical surgery (R0 vs. R1/2) improved OS (p = 0.004), but the difference was observed only in patients with brain lesions (p = 0.01). Five- and 10-year progression-free survival (PFS) was 68% and 51%, respectively. Looking at the treatment of recurrence, those who received RT as a part of the treatment of the recurrent tumor had better OS (p = 0.048)—5- and 10-year OS of 85% and 78% vs. 66% and 57%. In the multivariate analysis, radical surgery (R0 vs. R1/2) and the use of RT in the primary treatment improved PFS (p = 0.006 and 0.007). Based on the location of the tumor, the positive influence of RT on PFS was observed only in the case of patients with brain tumors (p = 0.01). Also, comparing R1/2 surgery with R0 resection—the benefit of RT was only observed in R1/2 group (0.02).

Conclusions

RT in the case of patients with G2E is a valuable treatment of the recurrent disease. Patients with brain lesions after nonradical surgery might benefit from the local irradiation in terms of PFS.

Orbital Ependymoma

Orbital ependymomas are rare in the orbit and usually occur secondary to extracerebral extension of an intraventricular ependymoma. The authors present a rare case of orbital ependymoma in a 74-year-old female. The patient was initially diagnosed with intraventricular ependymoma at the age of 13 years that required multiple repeat craniotomies for tumor recurrence. She then developed progressive tumor growth with extension into the bilateral frontal lobes and orbit. The orbital involvement produced binocular diplopia, epiphora, and globe distortion with compressive optic neuropathy. To the authors knowledge, this is the first such report in the English language ophthalmic literature.

Molecular Classification and Therapeutic Targets in Ependymoma

Ependymoma is a biologically diverse tumor wherein molecular classification has superseded traditional histological grading based on its superior ability to characterize behavior, prognosis, and possible targeted therapies. The current, updated molecular classification of ependymoma consists of ten distinct subgroups spread evenly among the spinal, infratentorial, and supratentorial compartments, each with its own distinct clinical and molecular characteristics. In this review, the history, histopathology, standard of care, prognosis, oncogenic drivers, and hypothesized molecular targets for all subgroups of ependymoma are explored. This review emphasizes that despite the varied behavior of the ependymoma subgroups, it remains clear that research must be performed to further elucidate molecular targets for these tumors. Although not all ependymoma subgroups are oncologically aggressive, development of targeted therapies is essential, particularly for cases where surgical resection is not an option without causing significant morbidity. The development of molecular therapies must rely on building upon our current understanding of ependymoma oncogenesis, as well as cultivating transfer of knowledge based on malignancies with similar genomic alterations.

Development and validation of prognostic nomogram in ependymoma: A retrospective analysis of the SEER database

Background

The prognostic factors for survival in patients with ependymoma (EPN) remain controversial. The aim of this study was to establish a prognostic model for 5‐ and 10‐year survival probability nomograms for patients with EPN.

Methods

Clinical data from the Surveillance, Epidemiology, and End Results (SEER) database were used for patients diagnosed with ependymoma between 2000 and 2018 and were randomized 7:3 into a development set and a validation set. Factors significantly associated with prognosis were screened out using the least absolute shrinkage and selection operator (LASSO) regression. The calibration chart and consistency index (C‐index) are used to evaluate the discrimination and consistency of the prediction model. Decision curve analysis (DCA) was used to further evaluate the established model. Finally, prognostic factors selected by LASSO regression were evaluated using Kaplan–Meier (KM) survival curves.

Results

A total of 3820 patients were included in the prognostic model. Seven survival predictors were obtained by LASSO regression screening, including age, gender, morphology, location, size, laterality, and resection. The prognostic model of the nomogram showed moderate discriminative ability in the development group and the validation group, with a C‐index of 0.642 and 0.615, respectively. In the development set and validation set survival curves, the prognosis index of high risk was less effective than low risk (p < 0.001).

Conclusions

Our nomograms may play an important role in predicting 5 and 10‐year outcomes for patients with ependymoma. This will help assist clinicians in personalized medicine.

Supratentorial Extraventricular Ependymomas: Imaging Features and the Added Value of Apparent Diffusion Coefficient

OBJECTIVE

To improve the understanding and the diagnosis of intracranial ependymal tumors.

METHODS

The clinical, radiological and prognostic features of 48 supratentorial extraventricular ependymomas and 74 intraventricular ependymomas were summarized and compared.

RESULTS

Supratentorial extraventricular ependymomas, most often located in the frontal lobe (33.3%) and classified as grade III (75.0%), had relatively large eccentric cysts (3.07 ± 2.03 cm), significant enhancement (84.8%), low apparent diffusion coefficient (ADC) values, and associated with higher mortality (41.3%). The majority of intraventricular lesions occurred in the fourth ventricle (86.5%) and classified as grade II (78.4%), had relatively small and multiple cystic changes (1.04 ± 0.87 cm), slight or moderate enhancement (76.9%), high ADC values and associated with lower mortality (20.7%). There were few significant differences between grade II and grade III tumors in these 2 groups, respectively. Young age, high grade and low ADC values are worse prognostic indicators for patients with supratentorial extraventricular ependymomas, but not for those with intraventricular ependymomas.

CONCLUSIONS

Conventional radiological features, combined with clinical manifestations and quantitative information provided by diffusion-weighted imaging, may not only enhance the diagnosis and assist in determining prognosis but also provide a better pathophysiological understanding of intracranial ependymal tumors.

Developing a Radiomics Signature for Supratentorial Extra-Ventricular Ependymoma Using Multimodal MR Imaging

Rationale and Objectives: To build a machine learning-based diagnostic model that can accurately distinguish adult supratentorial extraventricular ependymoma (STEE) from similarly appearing high-grade gliomas (HGG) using quantitative radiomic signatures from a multi-parametric MRI framework.

Materials and Methods: We computed radiomic features on the preprocessed and segmented tumor masks from a pre-operative multimodal MRI dataset [contrast-enhanced T1 (T1ce), T2, fluid-attenuated inversion recovery (FLAIR), apparent diffusion coefficient (ADC)] from STEE (n = 15), HGG-Grade IV (HGG-G4) (n = 24), and HGG-Grade III (HGG-G3) (n = 36) patients, followed by an optimum two-stage feature selection and multiclass classification. Performance of multiple classifiers were evaluated on both unimodal and multimodal feature sets and most discriminative radiomic features involved in classification of STEE from HGG subtypes were obtained.

Results: Multimodal features demonstrated higher classification performance over unimodal feature set in discriminating STEE and HGG subtypes with an accuracy of 68% on test data and above 80% on cross validation, along with an overall above 90% specificity. Among unimodal feature sets, those extracted from FLAIR demonstrated high classification performance in delineating all three tumor groups. Texture-based radiomic features particularly from FLAIR were most important in discriminating STEE from HGG-G4, whereas first-order features from T2 and ADC consistently ranked higher in differentiating multiple tumor groups.

Conclusions: This study illustrates the utility of radiomics-based multimodal MRI framework in accurately discriminating similarly appearing adult STEE from HGG subtypes. Radiomic features from multiple MRI modalities could capture intricate and complementary information for a robust and highly accurate multiclass tumor classification.

An Insight into Pathophysiological Features and Therapeutic Advances on Ependymoma

Simple Summary

Although biological information and the molecular classification of ependymoma have been studied, the treatment systems for ependymoma are still insufficient. In addition, because the disease occurs infrequently, it is difficult to obtain sufficient data to conduct large-scale or randomized clinical trials. Therefore, this study is intended to emphasize the importance of understanding its pathological characteristics and prognosis as well as developing treatments for ependymoma through multilateral studies.

Abstract

Glial cells comprise the non-sensory parts of the central nervous system as well as the peripheral nervous system. Glial cells, also known as neuroglia, constitute a significant portion of the mammalian nervous system and can be viewed simply as a matrix of neural cells. Despite being the “Nervenkitt” or “glue of the nerves”, they aptly serve multiple roles, including neuron repair, myelin sheath formation, and cerebrospinal fluid circulation. Ependymal cells are one of four kinds of glial cells that exert distinct functions. Tumorigenesis of a glial cell is termed a glioma, and in the case of an ependymal cell, it is called an ependymoma. Among the various gliomas, an ependymoma in children is one of the more challenging brain tumors to cure. Children are afflicted more severely by ependymal tumors than adults. It has appeared from several surveys that ependymoma comprises approximately six to ten percent of all tumors in children. Presently, the surgical removal of the tumor is considered a standard treatment for ependymomas. It has been conspicuously evident that a combination of irradiation therapy and surgery is much more efficacious in treating ependymomas. The main purpose of this review is to present the importance of both a deep understanding and ongoing research into histopathological features and prognoses of ependymomas to ensure that effective diagnostic methods and treatments can be developed.

Brain Ependymoma in an African Grey Parrot (Psittacus erithacus erithacus)

A 14-year-old unsexed African grey parrot (Psittacus erithacus erithacus) was presented with a 12-hour history of neurological signs and vomiting. The external physical examination of the patient revealed lethargy, moderate hypothermia, a head tilt, and horizontal nystagmus. Whole-body radiographic imaging and blood biochemistry parameters were unremarkable, and a serological test to detect bornavirus was negative. A computed tomography scan of the bird revealed a large cystic lesion located on the fourth ventricle of the brain. In spite of treatment (nonsteroidal anti-inflammatory drugs and antibiotic and antiparasitic therapy), the parrot's health continued to decline, and it was euthanatized 12 days after presentation. A complete postmortem examination was performed on the patient's brain. Histopathological interpretation of tissues submitted described a large neoformation composed of cells arranged in perivascular pseudorosettes. Hyperchromatic nuclei and marked anisokaryosis were suggestive of a malignant tumor. The tissue mass was associated with significant dilation of the fourth ventricle and a severe peripheral gliosis. The histopathological diagnosis of the neoformation was an ependymoma. Ependymomas are glial tumors of the ependymal cells that line the central canal and the ventricles of the brain and are rarely described in mammals. In birds, ependymomas were only described in budgerigars (Melopsittacus undulatus). In human medicine, the recommended treatment is surgical removal of the tumor when possible, followed by radiotherapy.

The Emerging Role of Microbiota and Microbiome in Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignant tumors due to the absence of biomarkers for early-stage detection and poor response to therapy. Since mounting evidence supports the role of microbiota composition in tumorigenesis and cancer treatment, the link between microbiome and PDAC has been described. In this review, we summarize the current knowledge regarding the impact of the gut and oral microbiome on the risk of PDAC development. Microenvironment-driven therapy and immune system interactions are also discussed. More importantly, we provide an overview of the clinical trials evaluating the microbiota role in the risk, prognosis, and treatment of patients suffering from PDAC and solid tumors. According to the research findings, immune tolerance might result from the microbiota-derived remodeling of pancreatic tumor microenvironment. Thus, microbiome profiling and targeting represent the potential trend to enhance antitumor immunity and improve the efficacy of PDAC treatment.

Conventional and Advanced Magnetic Resonance Imaging Features of Supratentorial Extraventricular Ependymomas

OBJECTIVE

To describe the magnetic resonance imaging characteristics of supratentorial ependymomas.

METHODS

The magnetic resonance imaging and computed tomography imaging characteristics of 49 cases of supratentorial ependymomas were analyzed retrospectively. The location, size, degree of perilesional edema, gross appearance, computed tomography attenuation characteristics, T1 and T2 signal intensity characteristics, degree of diffusion restriction, presence of calcification, and hemorrhage were documented for each lesion. The intratumoral susceptibility scores (ITSS), apparent diffusion coefficient (ADC) values, relative cerebral blood volume, and choline/N-acetyl aspartate ratios were documented where available.

RESULTS

The frontal lobe was the most common location with a mean size of 6.37 × 4.8 cm. Severe perilesional edema was evident in 30%. Heterogenous, solid-cystic appearance was present in 96% lesions, with 95% of extraventricular lesions extending from pial surface to the ventricular margin. Calcification was seen in 55% of cases. The ITSS was 3 in 85.7% of lesions. The mean ADC value calculated was 600 × 10 mm/s. The mean relative cerebral blood volume on dynamic susceptibility contrast perfusion was 4.83. The mean choline/N-acetyl aspartate ratio was 5.87. Leptomeningeal dissemination was demonstrable in 5 lesions. Four lesions were abutting the dura with frank dural invasion in one. One patient presented with disseminated disease without evidence of a primary lesion.

CONCLUSIONS

A large lesion with relatively well-defined margins, heterogeneous solid cystic appearance, extending from the pial surface to the ventricular margin, presence of calcification, and ADC values approaching those of white matter should raise a suspicion of supratentorial ependymoma. High ITSS, MR perfusion parameters, and magnetic resonance spectroscopy characteristics are similar to those of other high-grade gliomas.

MRI Features of Intracranial Anaplastic Ependymomas: A Comparison of Supratentorial and Infratentorial Lesions

Background: Several previous reports of anaplastic ependymomas have described their imaging features, and most of these studies were case reports. However, no studies have compared the magnetic resonance imaging (MRI) features between the infratentorial and supratentorial anaplastic ependymomas.

Objective: The goal of this study was to explore MRI characteristics for intracranial anaplastic ependymomas.

Material and Methods: We retrospectively reviewed the demographics of 165 patients and MRI findings of 60 patients with supratentorial (SAEs) and infratentorial anaplastic ependymomas (IAEs) before surgery. The demographics and MRI features for SAEs and IAEs were compared and evaluated.

Results: Among the 60 patients, most SAEs (91.7%) were extraventricular, whereas most IAEs (91.7%) were intraventricular. Of sixty intracranial anaplastic ependymomas, most lesions were well-defined (n = 45) and round-like (n = 36). On T1-weighted imaging, compared with the gray matter, the SAEs exhibited heterogeneous signal intensity, whereas IAEs exhibited iso-hypointense signals. T2 signals exhibited greater associations with hyperintense signals in IAEs; however, SAEs showed hyperintense or hypointense–hyperintense. On diffusion-weighted imaging (DWI), almost all solid tissues of SAEs appeared as hyperintense, whereas IAEs exhibited iso-hypointense signals. Peritumoral edema and intratumoral hemorrhage occurred more frequently in SAEs. Almost all anaplastic ependymomas exhibited heterogeneous enhancement. Cysts or necrosis was associated with 56 anaplastic ependymomas; however, large cysts were more prevalent in SAEs. On magnetic resonance spectroscopy (MRS), the mean choline/creatine (Cho/Cr) and choline/N-acetyl-aspartate (Cho/NAA) ratio of anaplastic ependymomas were (6.58 ± 4.26) and (8.84 ± 6.34), respectively, representing typical high-grade tumors.

Conclusion: We demonstrate the conventional and functional MRI features of intracranial anaplastic ependymomas, including DWI and MRS. MRI characteristics, such as location, cyst, diffusion restriction, and peritumoral edema, differed between supratentorial and infratentorial locations. Cho/Cr and Cho/ NAA ratios of anaplastic ependymomas are increased.

Poor Prognostic Factors for Surgical Treatment of Spinal Intramedullary Ependymoma (World Health Organization Grade II)

Study Design

Single-center retrospective study.

Purpose

We aimed to explore the postoperative prognostic factors for spinal intramedullary ependymoma.

Overview of Literature

Ependymoma (World Health Organization grade II) is the most frequent intramedullary spinal tumor and is treated by total resection. However, postoperative deterioration of motor function occasionally occurs.

Methods

Eighty patients who underwent surgical resection at Keio University and Fujita Health University in Tokyo, Japan between 2003 and 2015 with more than 2 years of follow-up were enrolled. A good surgical result was defined as an improvement in the modified McCormick Scale score by one grade or more or having the same clinical grade as was observed preoperatively. Meanwhile, a poor result was defined as a reduction in the McCormick Scale score of one grade or more or remaining in grade IV or V at final follow-up. Univariate and multivariate logistic regression analyses of the following factors were performed in the two groups: sex, age, preoperative Visual Analog Scale (VAS), tumor location, the extent of tumor resection, hemosiderin caps, cavity length, and tumor length on magnetic resonance imaging.

Results

At final follow-up, 15 patients were included in the poor results group and 65 in the good results group. In the univariate analysis, the factors related to poor results were as follows: higher age, preoperative McCormick Scale score severity, higher preoperative VAS, thoracic location, hemosiderin capped, and non-gross total resection (GTR). A multiple logistic regression analysis was conducted and showed that age, worse preoperative McCormick Scale score, and non-GTR were significant factors for poor prognosis.

Conclusions

The independent risk factors for motor deterioration after ependymoma resection were age, worse preoperative McCormick Scale score, and non-GTR. Early surgery for patients with even mild neurological disorders could facilitate functional outcomes. These results may contribute to determining the optimal timing of surgery for spinal intramedullary ependymoma.

Craniospinal irradiation as part of re-irradiation for children with recurrent intracranial ependymoma

BACKGROUND

The goal of this study was to evaluate outcomes in children with relapsed, molecularly characterized intracranial ependymoma treated with or without craniospinal irradiation (CSI) as part of a course of repeat radiation therapy (re-RT).

METHODS

This was a retrospective cohort study of 31 children. Patients with distant relapse received CSI as part of re-RT. For patients with locally recurrent ependymoma, those treated before 2012 were re-irradiated with focal re-RT. In 2012, institutional practice changed to offer CSI, followed by boost re-RT to the site of resected or gross disease.

RESULTS

Median follow-up was 5.5 years. Of 9 patients with distant relapse after initial RT, 2-year freedom from progression (FFP) and overall survival (OS) were 12.5% and 62.5%, respectively. There were 22 patients with local failure after initial RT. In these patients, use of CSI during re-RT was associated with improvement in 5-year FFP (83.3% with CSI vs 15.2% with focal re-RT only, P = 0.030). In the subgroup of patients with infratentorial primary disease, CSI during re-RT also improved 5-year FFP (100% with CSI, 10.0% with focal re-RT only, P = 0.036). Twenty-three patients had known molecular status; all had posterior fossa group A tumors (n = 17) or tumors with a RELA (v-rel avian reticuloendotheliosis viral oncogene homolog A) fusion (n = 6). No patient developed radiation necrosis after fractionated re-RT, though almost all survivors required assistance throughout formal schooling. Five out of 10 long-term survivors have not developed neuroendocrine deficits.

CONCLUSIONS

Re-irradiation with CSI is a safe and effective treatment for children with locally recurrent ependymoma and improves disease control compared with focal re-irradiation, with the benefit most apparent for those with infratentorial primary tumors.

Novel prognostication of patients with spinal and pelvic chondrosarcoma using deep survival neural networks

BACKGROUND

We used the Surveillance, Epidemiology, and End Results (SEER) database to develop and validate deep survival neural network machine learning (ML) algorithms to predict survival following a spino-pelvic chondrosarcoma diagnosis.

METHODS

The SEER 18 registries were used to apply the Risk Estimate Distance Survival Neural Network (RED_SNN) in the model. Our model was evaluated at each time window with receiver operating characteristic curves and areas under the curves (AUCs), as was the concordance index (c-index).

RESULTS

The subjects (n = 1088) were separated into training (80%, n = 870) and test sets (20%, n = 218). The training data were randomly sorted into training and validation sets using 5-fold cross validation. The median c-index of the five validation sets was 0.84 (95% confidence interval 0.79-0.87). The median AUC of the five validation subsets was 0.84. This model was evaluated with the previously separated test set. The c-index was 0.82 and the mean AUC of the 30 different time windows was 0.85 (standard deviation 0.02). According to the estimated survival probability (by 62 months), we divided the test group into five subgroups. The survival curves of the subgroups showed statistically significant separation (p < 0.001).

CONCLUSIONS

This study is the first to analyze population-level data using artificial neural network ML algorithms for the role and outcomes of surgical resection and radiation therapy in spino-pelvic chondrosarcoma.

Personalizing age-specific survival prediction and risk stratification in intracranial grade II/III ependymoma

BACKGROUND

Models for estimation of survival rates of patients with intracranial grade II/III ependymoma (EPN) are scarce. Considering the heterogeneity in prognostic factors between pediatric and adult patients, we aimed to develop age-specific nomograms for predicting 3-, 5-, and 8-year survival for these patients.

METHODS

A total of 1390 cases (667 children; 723 adults) of intracranial grade II/III EPNs diagnosed between 1988 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database for our study. Univariable and multivariable Cox analyses were employed to identify independent prognostic predictors. Age-specific nomograms were developed based on the results of multivariate Cox analyses. We also evaluated the performance of these predictive models by concordance index, calibration curves, time-dependent receiver operating characteristic curves, and decision curve analyses.

RESULTS

Considerable heterogeneity in prognostic factors was highlighted between pediatric and adult patients. Age, sex, tumor grade, surgery treatment and radiotherapy were identified as significant predictors of overall survival for children, and age, tumor grade, tumor size, surgery treatment, and marital status for adult. Based on these factors, age-specific nomogram models were established and internally validated. These models exhibited favorable discrimination and calibration characteristics. Nomogram-based risk classification systems were also constructed to facilitate risk stratification in EPNs for optimization of clinical management.

CONCLUSIONS

We developed the first nomograms and corresponding risk classification systems for predicting survival in patients with intracranial grade II/III EPN. These easily used tools can assist oncologists in making accurate survival evaluation.

Predictors of Functional Outcome after Spinal Ependymoma Resection

Aim:

Spinal ependymomas are among the most common intramedullary neoplasms in both adults and children. While surgical resection is the golden treatment standard, the role chemotherapy and radiotherapy have in patients with spinal ependymomas remains unclear. The aim of this study is to determine the predictors of functional outcome following spinal ependymoma resection to single out patients that may require adjuvant therapy.

Methods:

We conducted a retrospective study on patients that underwent spinal ependymoma resection in our institution in a 10-year period. Magnetic resonance imaging of the spine was used to set the diagnosis of an intradural/intramedullary neoplasm. All patients underwent either gross tumor resection or tumor mass reduction. Histological diagnosis and histopathological grading of spinal ependymoma were done for all collected samples. Patients’ general and neurological examination were performed early after the surgery (within the 1^st week) and in a 6-month follow-up.

Results:

A total of 51 intradural and intramedullary ependymoma resection surgeries on 43 patients were performed. There were slightly more male patients (57%) and the average patient age was 41 years. About 76.5% of patients presented with a tumor affecting one vertebrae level, while 23.5% presented with tumors expanding over two or more spinal regions. Gross tumor resection was achieved in 80% of cases, while 25% of procedures were performed on a recurring ependymomas. Most of the tumors (57%) were classified as G2 histological grade, while 8% were anaplastic ependymomas. In 80% of cases, early postoperative patient status was either better or equivalent to the preoperative one, while in a 6-month follow-up, up to 60% of cases showed a significant improvement over the preoperative status. Different demographic and clinical parameters were not proven to be predictors of postsurgical patient outcome including age, gender, and initial neurological presentation. Interestingly, most tumor characteristics were also not associated with postoperative functional outcome (histological grade, number of vertebrae levels affected, whether it is a primary or recurrent tumor). Even the scope of surgical procedure did not affect the functional outcome. The spinal region affected by the tumor was proven to be a predictor of early postoperative outcome (ρ= 0.346, P = 0.033), with lumbar spine being associated with the best outcomes. As expected, the scope of the surgery and whether gross tumor resection or tumor mass reduction was performed were the only significant predictors of tumor recurrence (ρ= 0.391, P = 0.005).

Conclusions:

Spinal ependymoma resection is an efficient procedure that improves the patient outcomes. Spinal region affected by the tumor is likely to be the most important predictor of functional outcome, while the procedure scope seems to be the most important predictor of tumor recurrence.

Cerebellopontine angle neoplasms in four cases: intra-axial or extra-axial?

Supplemental Digital Content is available in the text

A rare case of an intramedullary metastasis of a myxopapillary ependymoma

Background:

Myxopapillary ependimoma (MPE) is a benign slow-growing tumor, and it has been designated histologically as a Grade I neoplasm according to the 2016 World Health Organization classification. Despite the benign character, dissemination and metastasis have occasionally been reported. The retrograde dissemination to other levels of the neuraxis is extremely rare, being more frequent to the intracranial compartment.

Case Description:

We hereby present a case of medullary metastasis of cauda equina MPE, with a history of having undergone a subtotal resection and postoperative adjuvant radiotherapy. The patient presents complaints of night dorsal pain attributable to intradural metastasis twenty-one years after the first surgical intervention.

Conclusion:

The case reported highlights the importance of long follow-up in patients with MPE, since the possibility of secondary seeding to distant craniospinal sites or local spinal sites after surgery, and radiotherapy should be considered in metastatic disease.

Predicting Survival of Patients with Spinal Ependymoma Using Machine Learning Algorithms with the SEER Database

OBJECTIVE

This study was conducted to understand the clinical and demographic factors influencing the overall survival (OS) of patients with spinal ependymoma and to predict the OS with machine learning (ML) algorithms.

METHODS

We compiled spinal ependymoma cases diagnosed between 1973 and 2014 from the Surveillance, Epidemiology, and End Results (SEER) registry. To identify the factors influencing survival, statistical analyses were performed using the Kaplan-Meier method and Cox proportional hazards regression model. In addition, we implemented ML algorithms to predict the OS of patients with spinal ependymoma.

RESULTS

In the multivariate analysis model, age ≥65 years, histologic subtype, extraneural metastasis, multiple lesions, surgery, radiation therapy, and gross total resection (GTR) were found to be independent predictors for OS. Our ML model achieved an area under the receiver operating characteristic curve (AUC) of 0.74 (95% confidence interval [CI], 0.72-0.75) for predicting a 5-year OS of spinal ependymoma and an AUC of 0.81 (95% CI, 0.80-0.83) for predicting a 10-year OS. The stepwise logistic regression model showed poorer performance by an AUC of 0.71 (95% CI, 0.70-0.72) for predicting a 5-year OS and an AUC of 0.75 (95% CI, 0.73-0.77) for predicting a 10-year OS.

CONCLUSIONS

With SEER data, we reaffirmed that therapeutic factors, such as surgery and GTR, were associated with improved OS. Compared with statistical methods, ML techniques showed satisfactory results in predicting OS; however, the dataset was heterogeneous and complex with numerous missing values.

Differentiation of spinal myxopapillary ependymomas from schwannomas by contrast-enhanced MRI

BACKGROUND

Spinal myxopapillary ependymomas (MPEs) and schwannomas (SCHs) are both frequently located at the conus and caudal regions. The differentiation between MPEs and SCHs before surgery is crucial. Signal patterns of MPEs and SCHs on T2-weighted (T2W) magnetic resonance imaging (MRI) are diverse. Gadolinium (Gd+)-enhanced areas in MRI scans areas are areas where tumor cells are abundant. Therefore, investigating these enhanced areas should facilitate the differentiation. This study aimed to evaluate Gd+ areas in MRI scans in spinal MPEs and SCHs. Furthermore, the relation between MRI pattern and pathological features was investigated.

METHODS

In total, 41 patients with spinal MPEs (n = 7) or SCHs (n = 34) around the conus medullaris were included. SCHs were classified per the Gd+ area of the tumor on T1-weighted (T1W) contrast images, into Gd+ areas with T2W hyperintensity (Gd+/T2high) (n = 4, 11.8%) or Gd+ areas with T2W isointensity (Gd+/T2iso) (n = 30, 88.2%). Four patients with Gd+/T2iso were selected randomly for comparison. In three patient groups, T2 values at the Gd+ area and tumor cell density as measured by HE stains (cell density) were compared.

RESULTS

T2 values at the Gd+ area was higher in patients with MPE than in those with SCH with Gd+/T2high, and significantly higher than that in patients with SCH with Gd+/T2iso. Cell density was significantly lower in patients with MPEs than for those with SCHs with Gd+/T2high, and those with SCHs with Gd+/T2iso.

CONCLUSION

The evaluation of the Gd+ area proved useful because it excludes cysts or necrotic portions. If the Gd+ area is hyperintense on T2WI, MPEs can be suspected. If the Gd+ area is isointense on T2WI, SCHs can be suspected. There were several exceptional cases of SCH with a Gd+ area that was hyperintense on T2WI. This could be explained by pathological findings showing low cell density, as is typical for MPEs.

Surgical outcomes of spinal cord and cauda equina ependymoma: Postoperative motor status and recurrence for each WHO grade in a multicenter study

BACKGROUND

The goals of the study are to analyze postoperative outcomes and recurrence in cases of spinal cord and cauda equina ependymoma in each World Health Organization (WHO) Grade, and to examine the influence of extent of surgical removal on prognosis. Spinal ependymoma has a relatively high frequency among intramedullary spinal cord tumors. The tumor is classified in WHO guidelines as grades I, II, and III, but few studies have examined postoperative prognosis based on these grades.

METHODS

The records of 80 patients undergoing surgery for spinal cord and cauda equina ependymoma were examined in a multicenter study using a retrospective database. Neurological motor status, pathological type, extent of resection, and tumor recurrence were evaluated.

RESULTS

The histopathological types were grade I in 23 cases (myxopapillary: 21, subependymoma: 2), grade II in 52 cases, and grade III in 5 cases (including all anaplastic cases). Total resection was performed in 60 cases (83%), and eight cases had recurrence, including 2 in WHO grade I, 2 in grade II, and 4 in grade III. The 5-year recurrence-free survival rates were 90%, 91%, and 20% in grades I, II and III, respectively. Adjuvant radiotherapy for the local site was performed in 8 cases, including 3 in grade I and 5 in grade III; however, 4 of the 5 grade III cases (80%) had recurrence after radiotherapy. Among 59 patients with normal ambulation or independence without external assistance (McCormick Grade I or II), 53 (90%) maintained the same mobility after surgery. In cases that underwent total resection, the recurrence rate was significantly lower (p < 0.01). A good preoperative motor status also resulted in significantly better postoperative recovery of motor status (p < 0.05).

CONCLUSIONS

Total resection of spinal cord and cauda equina ependymoma leads to postoperative motor recovery and may reduce tumor recurrence. Therefore, early surgery for this tumor is recommended before aggravation of paralysis.

Adult Spinal Ependymomas: An Epidemiologic Study

OBJECTIVE

In adults, spinal ependymomas constitute only 3% to 6% of central nervous system tumors. Because of their rarity and poor prognosis, large population-based studies are needed to assess the epidemiology and survival risk factors associated with these tumors in the hope of improving outcome. The authors undertook this retrospective study to explore factors that may influence survival in adult patients with spinal ependymomas.

METHODS

Using the Surveillance, Epidemiology, and End Results database, a prospective cancer registry, the authors retrospectively assessed survival in histologically confirmed spinal ependymomas in patients 18 years of age and older. Survival was described with Kaplan-Meier curves, and a multivariate regression analysis was used to assess the association of several variables with survival while controlling for confounding variables.

RESULTS

Overall survival at 1 year, 3 years, and 5 years after diagnosis was 97.0%, 94.3%, and 93.3%, respectively. Patient age at diagnosis (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.04-1.07, P < 0.001), tumor grade IV (HR 11.11, 95% CI 1.27-97.02, P = 0.032), and the use of radiation therapy during the course of treatment (HR 4.42, 95% CI 1.69-11.57, P = 0.003) were each associated with decreased survival. Gross total resection (HR 0.42, 95% CI 0.20-1.10, P = 0.026) was associated with improved overall survival. Gender, tumor size, and tumor extension were not found to impact survival.

CONCLUSIONS

High-grade ependymomas occurring in the spine have a much worse prognosis than do those with lower grades. Early diagnosis and surgery appear to be associated with improved survival and outcomes, whereas radiation therapy has an unclear role.

Clinical association analysis of ependymomas and pilocytic astrocytomas reveals elevated FGFR3 and FGFR1 expression in aggressive ependymomas

BACKGROUND

Fibroblast growth factor receptors (FGFRs) are well-known proto-oncogenes in several human malignancies and are currently therapeutically targeted in clinical trials. Among glioma subtypes, activating FGFR1 alterations have been observed in a subpopulation of pilocytic astrocytomas while FGFR3 fusions occur in IDH wild-type diffuse gliomas, resulting in high FGFR3 protein expression. The purpose of this study was to associate FGFR1 and FGFR3 protein levels with clinical features and genetic alterations in ependymoma and pilocytic astrocytoma.

METHODS

FGFR1 and FGFR3 expression levels were detected in ependymoma and pilocytic astrocytoma tissues using immunohistochemistry. Selected cases were further analyzed using targeted sequencing.

RESULTS

Expression of both FGFR1 and FGFR3 varied within all tumor types. In ependymomas, increased FGFR3 or FGFR1 expression was associated with high tumor grade, cerebral location, young patient age, and poor prognosis. Moderate-to-strong expression of FGFR1 and/or FGFR3 was observed in 76% of cerebral ependymomas. Cases with moderate-to-strong expression of both proteins had poor clinical prognosis. In pilocytic astrocytomas, moderate-to-strong FGFR3 expression was detected predominantly in non-pediatric patients. Targeted sequencing of 12 tumors found no protein-altering mutations or fusions in FGFR1 or FGFR3.

CONCLUSIONS

Elevated FGFR3 and FGFR1 protein expression is common in aggressive ependymomas but likely not driven by genetic alterations. Further studies are warranted to evaluate whether ependymoma patients with high FGFR3 and/or FGFR1 expression could benefit from treatment with FGFR inhibitor based therapeutic approaches currently under evaluation in clinical trials.

Hormonal based treatment of ovarian anaplastic ependymoma with anastrozole

Objective

Ovarian anaplastic ependymoma is a rare gynecologic malignancy that poses diagnostic and treatment challenges. Treatment of sub-optimally debulked disease usually portends poor prognosis. Molecular testing of tumor specimen can identify more specific targets for additional therapy such as estrogen and progesterone receptors (ER/PR).

Case

A 29-year-old woman presented with incidental finding of large bilateral adnexal masses and elevated CA 125. Biopsy proved anaplastic ovarian ependymoma with high ER/PR expression. She underwent sub-optimal surgical debulking followed by adjuvant chemotherapy with bleomycin, etoposide and cisplatin (BEP) which resulted in a partial response. Due to extensive residual disease she has been maintained on anastrozole for over fifteen months without increased tumor burden. Targeted somatic mutation testing was negative for all high risk clinically useful variants.

Conclusion

Aromatase inhibitors may be considered in patients with extra-axial anaplastic ependymoma and can produce prolonged stable disease.

•

Ovarian anaplastic ependymoma is a rare gynecologic malignancy.

•

Histology shows perivascular rosettes, hypercellularity, and nuclear atypia.

•

Standard therapy includes surgical debulking followed by chemotherapy with BEP.

•

Molecular diagnostics can identify estrogen and progesterone receptor expression.

•

ER/PR expression can help direct treatment with aromatase inhibitors.

Clinical presentation and outcomes for adult ependymoma patients

BACKGROUND

Outcomes projects can be a catalyst for determining disease- and treatment-related consequences for patients with rare tumors. The Adult Ependymoma Outcomes (AEO) survey uses self-reported experience to evaluate how this tumor affects patient groups throughout the illness trajectory.

METHODS

Patients completed the AEO survey via a Web-based portal. The survey included questions on treatment, tumor recurrence, and current health status; the MD Anderson Symptom Inventory Brain Tumor and Spine Tumor modules; and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36).

RESULTS

The sample included 264 participants (57% female) with a median age of 46 years (range, 18-77 years). Radiation treatment was commonly used for patients who had brain involvement (χ² (1) = 20.7; P < .001), underwent a partial resection (43%; χ² (3) = 15.4; P < .001), or had a grade 3 tumor (41%; χ² (2) = 18.8; P < .001). Recurrence occurred in a small group (29%), with grade 1 tumor patients 2.6 times more likely and grade 3 tumor patients 2.5 times more likely to experience recurrence than those with grade 2 tumors. Spine tumor patients had a higher symptom burden (mean, 2.8; scale, 0-10) than brain tumor patients (t(247) = -4.0), and they reported more moderate to severe symptoms (rating ≥ 5; 29%) than their counterparts (18%). Within the physical health portion of the SF-36, spine tumor patients reported worse health with respect to bodily pain (t(249) = 6.8; P < .001), physical functioning (t(252) = 4.1; P < .001), and vitality (t(202.2) = 3.0; P < .003).

CONCLUSIONS

These results demonstrate the feasibility of implementing outcomes projects that report on the clinical and demographic characteristics of a rare patient population, and they underscore the importance of outcomes data in understanding disease-related issues. Cancer 2017;123:494-501. © 2016 American Cancer Society.

Spinal myxopapillary ependymoma with interval drop metastasis presenting as cauda equina syndrome: case report and review of literature

Myxopapillary ependymoma is a benign slow-growing tumour, arising predominantly in the region of the filum terminale. It has been designated histologically as grade I neoplasm according to the 2007 WHO classification. Despite this benign character dissemination and metastasis along the cerebrospinal axis and metastasis to distant sites have occasionally been reported. There have been previously reported cases of drop metastasis from MPE, however in three of these cases the drop metastasis was diagnosed with concurrent primary spinal MPE. There has been only one previously published case of interval drop metastasis in a case of operated spinal MPE in literature. We hereby present the second case of interval drop metastasis in a case of conus MPE, with history of having undergone a subtotal resection and post operative adjuvant radiotherapy prior to second surgery. The patient presented months after the primary surgery with symptoms of cauda equina syndrome attributable to the drop metastasis.

Magnetic resonance imaging findings of extraventricular anaplastic ependymoma: A report of 11 cases

Anaplastic ependymomas are rare malignant tumors of the central nervous system. Few studies are available regarding their neuroradiological characteristics. The present study aimed to retrospectively review a series of patients with extraventricular anaplastic ependymoma and to analyze the magnetic resonance imaging (MRI) characteristics to distinguish anaplastic ependymoma from other intracranial tumors. The clinical and pathological images of 11 patients who presented with histologically proven anaplastic ependymoma at Nanfang Hospital (Southern Medical University, Guangzhou, Guangdong, China) between September 2004 and March 2015 were retrospectively reviewed. MRI scans were obtained in all 11 cases. Computed tomography scans were obtained in only 3 cases. In total, 8 tumors were located at the supratentorial parenchyma, and 3 tumors were derived from the cerebellar hemisphere. Images displayed quasi-circular (4/11), irregularly-lobulated (7/11) variable-intensity masses. The masses presented with cysts or necrosis (8/11), hemorrhage (7/11), marked (9/11) or mild (2/11) enhancement, and moderate (4/11), mild (3/11) or absent (4/11) peritumoral edema. The tumors were also frequently closely associated with the lateral ventricle (6/11). Tumors appeared isointense to hypointense on T1-weighted imaging (T1WI) and heterogeneously hyperintense or hypointense on T2WI, demonstrating wreath-like and ring-like characteristics, with intratumoral nodules (3/11) or marked flake-like inhomogeneous (6/11) enhancement on post-contrast MRI. Only 2 solid lesions showed mild enhancement (2/11). Although the MRI features of the extraventricular anaplastic ependymomas varied and were non-specific, these characteristic MRI findings, combined with the locations of the lesions, the age of onset and the short disease course, could be useful in differentiating anaplastic ependymomas from other intracranial neoplasms in the future.

Myxopapillary ependymoma: a SEER analysis of epidemiology and outcomes

Myxopapillary ependymoma (MPE) is an exceedingly rare tumor histology. While surgery is clearly the treatment of choice, controversy exists regarding the role of adjuvant radiotherapy (RT). Using the Surveillence, epidemiology, and end results (SEER) database, we aimed to determine the epidemiology, prognostic factors, and treatment-related outcomes for MPE. A total of 773 cases were found in the SEER database. The incidence in the American population was found to be 1.00 per million person-years. On multivariate analysis, receipt of surgery (HR = 0.14, CI = 0.06-0.35, p < 0.001), receipt of RT (HR = 4.06, CI = 1.87-8.81, p < 0.001), age less than 30 (HR = 0.24, CI = 0.08-0.72, p = 0.01), and Caucasian race (HR = 0.37, CI = 0.13-0.996, p = 0.049) were statistically significant prognostic factors. The mean tumor size among those receiving RT (4.6 cm) was significantly larger than among those not receiving RT (3.2 cm, p = 0.0002). Those who lived in metropolitan areas were more likely to receive RT than those who did not. Given multiple previous studies show that RT improves PFS and the discrepancy in tumor size, selection bias is likely a significant contributor to the apparent negative impact of RT on OS. Regardless, surgery remains the most crucial aspect in the care of patients with MPE.