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Liu KX, Indelicato DJ, Paulino AC, Looi WS, Catalano PJ, Chintagumpala MM, Gallotto SL, Marcus KJ, Haas-Kogan DA, Tarbell NJ, MacDonald SM, Mahajan A, Yock TI. Multi-institutional Characterization of Outcomes for Pediatric and Young Adult Patients With High-Risk Myxopapillary Ependymoma After Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:1174-1180. [PMID: 37437812 DOI: 10.1016/j.ijrobp.2023.06.2293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Myxopapillary ependymoma (MPE) is a rare, typically slow-growing subtype of spinal ependymomas. There are no standard guidelines for radiotherapy and long-term outcomes after radiation, particularly patterns of relapse, for pediatric and young adult (YA) patients with MPE remain under-characterized. METHODS AND MATERIALS This is an Institutional Review Board-approved multi-institutional retrospective cohort study of 60 pediatric and YA patients diagnosed with MPE and received radiotherapy between 2000-2020. Clinical and treatment characteristics, and long-term outcomes were recorded. Site(s) of progression was compared to radiation fields. Survival outcomes were analyzed using Kaplan-Meier method. Cumulative incidence of local in-field progression (CILP) after initial radiotherapy was analyzed using Gray's method with out-of-field-only progression as a competing risk. Univariate analyses were performed using Cox proportional hazard's model. RESULTS The median age at radiation was 14.8 years (range: 7.1-26.5). At time of radiotherapy, 45 (75.0%) and 35 (58.3%) patients had gross residual and multifocal disease, respectively. Forty-eight (80.0%), seven (11.7%) and five (8.3%) patients received involved field radiotherapy, craniospinal irradiation, and whole spine radiation, respectively. Median follow-up from end of radiotherapy was 6.2 years (range: 0.6-21.0). Five-year overall survival, progression-free survival, and CILP were 100%, 60.8% and 4.1%, respectively. Both local recurrences were at sites of gross residual disease. Of the eighteen out-of-field first recurrences after radiotherapy, all were superior to the initial treatment field and nine had intracranial relapse. On univariate analyses, distant-only recurrence before radiation (HR: 4.00, 95% CI: 1.54-10.43, p = 0.005) was significantly associated with shorter time to progression. CONCLUSIONS While the risk of recurrence within the radiation field is low, pediatric and YA patients with high-risk MPE remain at risk for recurrences in the spine above the radiation field and intracranially after radiotherapy. Future prospective studies are needed to investigate the appropriate radiation field and dose based on the extent of metastases.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Wen S Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Paul J Catalano
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Murali M Chintagumpala
- Department of Pediatrics, Division of Hematology-Oncology, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Sara L Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karen J Marcus
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Inspire Exercise Medicine, Naples, Florida
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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2
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Zhang YW, Wang B, An SY, Liu WH, Wang C, Yan H, Xu YL, Wang YZ, Jia WQ. Clinical management and prognosis of spinal myxopapillary ependymoma: a single-institution cohort of 72 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2459-2467. [PMID: 37027035 DOI: 10.1007/s00586-023-07690-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/12/2023] [Accepted: 03/24/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE Myxopapillary ependymoma (MPE) was classified as grade 2 tumor in the 2021 World Health Organization central nervous system classification because of its high recurrence probability. This study aimed to investigate predictive factors and management of tumor recurrence. METHODS Seventy-two patients with spinal MPE underwent initial surgical treatment at our hospital between 2011 and 2021. Kaplan-Meier curves and Cox regression were used to analyze the correlation between clinical variables and progression-free survival (PFS). RESULTS The median age at diagnosis was 33.5 years (range 8-60 years). Twenty-one patients (29.2%) had preoperative spinal drop metastases. Gross total resection (GTR) was performed in 37 patients (51.4%). The median follow-up was 7.2 years, and the follow-up rate was 88.9% (64 of 72 cases). Twelve of the 64 patients (18.9%) relapsed, and preoperative drop metastasis occurred in 7 patients (58.3%). The estimated 5-year and 10-year PFS rates were 82% and 77%, respectively. Univariate analysis showed that GTR was associated with improved PFS (hazard ratio [HR] 0.149, p = 0.014), while preoperative drop metastasis (HR 3.648, p = 0.027) and tumor involvement sacrococcygeal region (HR 7.563, p = 0.003) were associated with tumor recurrence. Adjuvant radiotherapy (RT) was significantly associated with improved PFS in patients with preoperative drop metastasis (p = 0.039). CONCLUSION Complete surgical resection under the premise of protecting neurological function is an important factor in reducing spinal MPE recurrence. Adjuvant RT is recommended when the tumor invades the capsule with preoperative drop metastasis or adhesion to the nerve and cannot reach GTR.
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Affiliation(s)
- Yao-Wu Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Bo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Song-Yuan An
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Wei-Hao Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Chong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Hao Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yu-Lun Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yong-Zhi Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
| | - Wen-Qing Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
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3
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Sim D, Groswald M, Watters A. Myxopapillary Ependymoma in an 11-Year-Old Patient With Right-Sided Nocturnal Thigh Pain. Clin J Sport Med 2023; 33:00042752-990000000-00104. [PMID: 36877660 DOI: 10.1097/jsm.0000000000001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/31/2022] [Indexed: 03/07/2023]
Abstract
ABSTRACT This case report highlights a rare type of primary spinal cord tumor, myxopapillary ependymoma, in a pediatric patient who presented to clinic with worsening chronic unilateral thigh pain and neurologic deficits. He was appropriately treated with total gross resection of the tumor and adjuvant radiotherapy and was cleared for competitive sports without any restriction within 1 year of his diagnosis and treatment. Although most musculoskeletal complaints among pediatric patients are of benign etiology, as evidenced by our case, clinicians should have a low threshold to further investigate with advanced imaging modalities should the clinical history and examination be consistent with a more concerning pathologic process.
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Affiliation(s)
- Don Sim
- Department of Internal Medicine and Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael Groswald
- Department of Diagnostic Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Aaron Watters
- Indiana University (IU) Health Physicians Orthopedics and Sports Medicine, Carmel, Indiana
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4
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Abdallah A, Baloğlu G, Güler Abdallah B, Gündağ Papaker M. Factors Affecting Long-Term Surgical Outcomes of Spinal Extramedullary Ependymomas: A Retrospective Study. World Neurosurg 2022; 167:e877-e890. [PMID: 36049726 DOI: 10.1016/j.wneu.2022.08.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spinal intradural-extramedullary ependymomas (IEEs) most commonly affect the lumbosacral spine. Because of their neural axis dissemination and adherence to neural structures, managing IEEs is still a controversial neurosurgical challenge. The study aimed to investigate the potential prognostic factors that influence long-term surgical outcomes by evaluating consecutively operated patients with IEEs. METHODS During the study period, medical records of all diagnosed patients with spinal tumors were reviewed retrospectively. This study included all patients with consecutive IEEs who underwent surgical intervention in 3 neurosurgical institutions in different periods (February 2004 to December 2020). RESULTS In 3 neurosurgical institutions, 64 (28 women, 36 men) patients were operated upon for IEE. The mean age of the patients at diagnosis was 38.9 years. The mean preoperative symptom duration was 17.8 months. Radicular pain was the most common symptom, observed in 53 patients. Gross total resection was applied to 48 patients. 54 patients had good clinical outcomes at their last follow-up after 106.9 months on average. Myxopapillary ependymoma was the most common histopathological type (n = 43). The progression was observed in 5 patients. The presence of preoperative neurological deficits, IEEs extending >2 spinal levels, bone-eroded IEEs, surgical complication, capsule violation, and incomplete resection were associated with poor prognosis. CONCLUSIONS Several clinical and surgical factors can affect the functional outcomes of the surgical treatment of IEEs. Some radiological features can make neurosurgeons aware of the prognosis of IEEs. In such cases, the neurosurgeons should plan to remove tumors without violating their integrities (capsules) to obtain satisfactory functional outcomes.
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Affiliation(s)
- Anas Abdallah
- Department of Neurosurgery, Istanbul Training and Research Hospital, Samatya-Istanbul, Turkey.
| | - Gökhan Baloğlu
- Department of Neurosurgery, Osmaniye State Hospital, Merkez-Osmaniye, Turkey
| | - Betül Güler Abdallah
- Department of Psychiatry-AMATEM Unit, University of Health Sciences, Bakırköy Training and Research Hospital for Neurology Neurosurgery, and Psychiatry, Bakırköy-Istanbul, Turkey
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Extra-Neural Metastases of Late Recurrent Myxopapillary Ependymoma to Left Lumbar Paravertebral Muscles: Case Report and Review of the Literature. Brain Sci 2022; 12:brainsci12091227. [PMID: 36138961 PMCID: PMC9497216 DOI: 10.3390/brainsci12091227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 11/21/2022] Open
Abstract
Ependymomas are commonly classified as low-grade tumors, although they may harbor a malignant behavior characterized by distant neural dissemination and spinal drop metastasis. Extra-CNS ependymoma metastases are extremely rare and only few cases have been reported in the lung, lymph nodes, pleura, mediastinum, liver, bone, and diaphragmatic, abdominal, and pelvic muscles. A review of the literature yielded 14 other case reports metastasizing outside the central nervous system, but to our knowledge, no studies describe metastasis in the paravertebral muscles. Herein, we report the case of a 39-year-old patient with a paraspinal muscles metastasis from a myxopapillary ependymoma. The neoplasm was surgically excised and histologically and molecularly analyzed. Both the analyses were consistent with the diagnosis of muscle metastases of myxopapillary ependymoma. The here-presented case report is first case in the literature of a paraspinal muscles metastasis of myxopapillary ependymoma.
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Johnson RA, Cramer SW, Dusenbery K, Samadani U. Resection of disseminated recurrent myxopapillary ependymoma with more than 4-year follow-up: operative nuance for prolonged prone position. Illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE2235. [PMID: 36303501 PMCID: PMC9379707 DOI: 10.3171/case2235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/15/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Symptomatic disseminated myxopapillary ependymoma (MPE) in a young person presents a daunting challenge because the risks of prolonged prone positioning and spinal cord injury may outweigh the likelihood of attaining the benefit of gross total resection. OBSERVATIONS The authors reported the case of a 15-year-old girl with five discrete recurrent spinal cord ependymomas. The patient received a 25-hour surgical procedure for gross total resection of the tumors and fusion over an approximately 33-hour period. She experienced complete resolution of all preoperative neurological symptoms and subsequently received adjuvant radiation therapy. At 52 months after surgery, she was still experiencing neurologically intact, progression-free survival. This case illustrated one of the most extensive recurrent tumor resections for MPE with prolonged disease-free survival reported to date. It may also represent the longest prone position spinal case reported and was notable for a lack of any of the complications commonly associated with the prolonged prone position. LESSONS The authors discussed the complexity of surgical decision-making in a symptomatic patient with multiple disseminated metastases, technical considerations for resection of intradural and intramedullary spinal cord tumors, and considerations for avoiding complications during prolonged positioning necessary for spinal surgery.
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Affiliation(s)
- Reid A. Johnson
- University of Minnesota Medical School, Minneapolis, Minnesota
| | | | | | - Uzma Samadani
- Surgical Services, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Bioinformatics and Computational Biology, University of Minnesota, Minneapolis, Minnesota; and
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7
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Abstract
PURPOSE OF REVIEW To review state of art and relevant advances in the molecular genetics and management of ependymomas of children and adults. RECENT FINDINGS Ependymomas may occur either in the brain or in the spinal cord. Compared with intracranial ependymomas, spinal ependymomas are less frequent and exhibit a better prognosis. The new WHO classification of CNS tumors of 2021 has subdivided ependymomas into different histomolecular subgroups with different outcome. The majority of studies have shown a major impact of extent of resection; thus, a complete resection must be performed, whenever possible, at first surgery or at reoperation. Conformal radiotherapy is recommended for grade 3 or incompletely resected grade II tumors. Proton therapy is increasingly employed especially in children to reduce the risk of neurocognitive and endocrine sequelae. Craniospinal irradiation is reserved for metastatic disease. Chemotherapy is not useful as primary treatment and is commonly employed as salvage treatment for patients failing surgery and radiotherapy. Standard treatments are still the mainstay of treatment: the discovery of new druggable pathways will hopefully increase the therapeutic armamentarium in the near future.
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Affiliation(s)
- Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Francesco Bruno
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Via Cherasco 15, 10126 Turin, Italy
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8
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Jones B, Forsyth S, Daly D, Nash M, Crowe P. Massive myxopapillary ependymoma of the gluteal cleft. ANZ J Surg 2022; 92:2380-2381. [PMID: 35102662 PMCID: PMC9542744 DOI: 10.1111/ans.17492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/12/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Benjamin Jones
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Sarah Forsyth
- Department of Surgery, Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Daniel Daly
- Department of Surgery, Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mitchell Nash
- Department of Surgery, Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Philip Crowe
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Department of Surgery, Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Trybula SJ, Wadhwani NR, Mohammad LM, Lam SK, Lenzen AC, Alden TD. Pediatric spinal intramedullary anaplastic myxopapillary ependymoma: a case report. Childs Nerv Syst 2022; 38:223-227. [PMID: 34125264 DOI: 10.1007/s00381-021-05171-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
A 6-year-old girl presented with a 1-week history of progressive upper and lower extremity weakness and bilateral upper extremity dysesthesia. Imaging demonstrated a 4.7 × 1.2-cm enhancing intramedullary lesion in the cervical spine from level C2 to C5 with associated cystic components and syringomyelia. The patient underwent a C2-C5 laminoplasty, with gross total resection of the intramedullary lesion. Histological analysis showed small to medium-sized epithelioid cells, with predominantly a solid architecture focally infiltrating into the adjacent spinal cord tissue. Focal papillary differentiation was present along with peri-vascular pseudorosettes, mucin microcysts, and globules of dense collagen. Focal anaplasia was noted with mitosis (5/10 HPF), focal necrosis, and elevated Ki67 10-15%. These findings were consistent with a myxopapillary ependymoma with anaplastic features. CSF cytology was negative for tumor cells. MYCN amplification was not present. She was treated with targeted proton-beam radiation therapy. This is the fourth case of an intramedullary anaplastic myxopapillary ependymoma to date, and the first case in the cervical spine reported in the literature.
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Affiliation(s)
- S Joy Trybula
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children's Hospital, 225 E. Chicago Avenue, Chicago, IL, 60611, USA
| | - Nitin R Wadhwani
- Department of Pathology and Laboratory Medicine, Director of Pediatric Neuropathology, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Laila M Mohammad
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children's Hospital, 225 E. Chicago Avenue, Chicago, IL, 60611, USA
| | - Sandi K Lam
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children's Hospital, 225 E. Chicago Avenue, Chicago, IL, 60611, USA
| | - Alicia C Lenzen
- Department of Pediatrics, Division of Hematology, Oncology, Neuro-Oncology and Stem Cell Transplantation, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Tord D Alden
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children's Hospital, 225 E. Chicago Avenue, Chicago, IL, 60611, USA.
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10
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Kanno H, Kanetsuna Y, Shinonaga M. Anaplastic myxopapillary ependymoma: A case report and review of literature. World J Clin Oncol 2021; 12:1072-1082. [PMID: 34909401 PMCID: PMC8641005 DOI: 10.5306/wjco.v12.i11.1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/17/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Myxopapillary ependymoma (MPE) is a pathological grade I tumor that arises in the filum terminale. MPE with anaplastic features is extremely rare, and only 5 cases have shown malignancy at the time of recurrence.
CASE SUMMARY The patient (a 46-year-old woman) had undergone a MPE operation 30 years ago. After subtotal resection of the tumor located in L4-S1, it had a solid component that extended to the adjacent subcutaneous region. Histologically, the tumor consisted of a typical MPE with anaplastic features. The anaplastic areas of the tumor showed hypercellularity, a rapid mitotic rate, vascular proliferation, and connective tissue proliferation. Pleomorphic cells and atypical mitotic figures were occasionally observed. The MIB-1 index in this area was 12.3%. The immunohistochemical study showed immunoreactivity for vimentin, glial fibrillary acidic protein and S100. The morphological pattern and immunohistochemical profile were consistent with anaplastic MPE. The patient tolerated surgery well without new neurological deficits. She underwent local irradiation for the residual tumor and rehabilitation.
CONCLUSION Although extremely rare, anaplastic MPE occurs in both pediatric and adult patients, similar to other ependymomas. At a minimum, close monitoring is recommended, given concerns about aggressive biological potential. In the future, further study is needed to determine the WHO classification criteria and genetic indicators of tumor progression. The possibility of malignant transformation of MPE should be taken into account, and patients with MPE should be treated with care and follow-up.
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Affiliation(s)
- Hiroshi Kanno
- Department of Neurosurgery, International University of Health and Welfare Atami Hospital, Atami 413-0012, Shizuoka, Japan
| | - Yukiko Kanetsuna
- Department of Pathology, International University of Health and Welfare Atami Hospital, Atami 413-0012, Shizuoka, Japan
| | - Masamichi Shinonaga
- Department of Neurosurgery, International University of Health and Welfare Atami Hospital, Atami 413-0012, Shizuoka, Japan
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Eschbacher KL, Rao AN, Greipp PT, Gliem TJ, Daniels DJ, Warad D, Eckel LJ, Raghunathan A. Pediatric Myxopapillary Ependymomas: A Clinicopathologic Evaluation. J Pediatr Hematol Oncol 2021; 43:e1194-e1200. [PMID: 33395181 DOI: 10.1097/mph.0000000000002041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/12/2020] [Indexed: 11/26/2022]
Abstract
Myxopapillary ependymomas (MPEs) have an indolent clinical course, corresponding to World Health Organization Grade I. A total of 13 pediatric MPEs have been reported in the literature with "anaplastic features," including elevated proliferative activity (≥5 mitoses/10 high-power fields), necrosis, and microvascular proliferation. No consensus exists regarding the prognostic significance of such features. A retrospective clinicopathologic review of pediatric MPEs diagnosed between 1996 and 2018 at Mayo Clinic was performed. Totally, 8 pediatric MPEs (6 male; age: 7.52 to 16.88 y) were identified. Totally, 3 had disseminated disease at presentation. All patients underwent surgical resection (7 gross total; 1 subtotal). Totally, 5 cases harbored ≥5 mitoses/10 high-power fields (range: 5 to 9), 3 of which showed necrosis (2 with disseminated disease). Postsurgery, 2 patients received radiation; one with disseminated disease and another with increased mitotic activity/necrosis; neither has recurred (follow-up: 1.18 and 3.19 y). In all, 2 patients with disseminated disease, elevated mitotic activity, and necrosis had new metastatic disease/progression of nonresected metastatic foci (2.6 and 26.8 mo), received radiation therapy, and remain progression free (3.01 and 9.34 y). All patients are alive (median follow-up 1.31 y, range: 0.66 to 11.75). Among pediatric MPEs, the concurrent presence of elevated mitotic activity and necrosis may be associated with an aggressive clinical course, warranting closer surveillance and consideration of adjuvant therapies.
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Affiliation(s)
| | - Amulya Nageswara Rao
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | - Troy J Gliem
- Departments of Laboratory Medicine and Pathology
| | | | - Deepti Warad
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN
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12
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Looi WS, Indelicato DJ, Mailhot Vega RB, Morris CG, Sandler E, Aldana PR, Bradley JA. Outcomes following limited-volume proton therapy for multifocal spinal myxopapillary ependymoma. Pediatr Blood Cancer 2021; 68:e28820. [PMID: 33226179 DOI: 10.1002/pbc.28820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Spinal myxopapillary ependymoma (MPE) often presents with a multifocal distribution, complicating attempts at resection. There remains no standard approach to irradiating these patients. We report disease control and toxicity in pediatric patients with multifocal spinal MPE treated with limited-volume proton therapy. MATERIALS/METHODS Twelve patients (≤21 years old) with multifocal spinal MPE were treated between 2009 and 2018 with limited-volume brain-sparing proton therapy. Median age was 13.5 years (range, 7-21). Radiotherapy was given as adjuvant therapy after primary surgery in five patients (42%) and for recurrence in seven (58%). No patient received prior radiation. Eleven patients (92%) had evidence of gross disease at radiotherapy. Eleven patients received 54 GyRBE; one received 50.4 GyRBE. Treatment toxicity was graded per the CTCAEv4.0. We estimated disease control and survival using the Kaplan-Meier product-limit method. RESULTS The median follow-up was 3.6 years (range, 1.8-10.6). The five-year actuarial rates of local control, progression-free survival, and overall survival were 100%, 92%, and 100%, respectively. One patient experienced an out-of-field recurrence in the spine superior to the irradiated region. No patients developed in-field recurrences. Following surgery and irradiation, one patient developed grade three spinal kyphosis and one patient developed grade 2 unilateral L5 neuropathy. CONCLUSION 54 GyRBE to a limited volume appears effective for disseminated spinal MPE in both the primary and salvage settings, sparing children the toxicity of full craniospinal irradiation. Compared with historical reports, this approach using proton therapy improves the therapeutic ratio, resulting in minimal side effects and high rates of disease control.
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Affiliation(s)
- Wen Shen Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric Sandler
- Department of Pediatrics, Nemours Children's Specialty Clinic, Jacksonville, Florida
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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13
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Jahanbakhshi A, Najafi M, Jafari F, Moshtaghian M, Gomar M, Anbarlouei M, Naderi S. Adjunctive treatment of myxopapillary ependymoma. Oncol Rev 2021; 15:518. [PMID: 33824699 PMCID: PMC8018208 DOI: 10.4081/oncol.2021.518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/12/2020] [Indexed: 11/23/2022] Open
Abstract
Myxopapillary ependymoma are rare tumors and optimal therapeutic strategy is remained controversial. The main treatments for myxopapillary ependymoma tumors include surgery and radiotherapy. Hence, the present study aimed to review adjuvant treatment of myxopapillary ependymoma, focusing on spinal myxopapillary ependymoma. The information sources of all articles were the English authoritative databases including PubMed, Web of science, Scopus, Science direct and Google scholar. In this review study, the keywords including adjuvant, treatment, myxopapillary and ependymoma were selected from MeSH medical library. Related articles were published from 2000 to 2020. Given radiation tolerance in the spinal cord is 10-15% lower than that of the brain, it also should be noted that with increased dose and scope of therapeutic field, the corresponding risks are increased, as well. Also, chemotherapy has never been used as the primary treatment approach. Radiotherapy's value is considered while involving with sensitive areas where chemotherapy is also recommended. Gross total resection is the preferred primary treatment. But the role of adjuvant radiotherapy is debated in different tumor and patient scenarios and no standard treatment strategy had been defined yet. The bottom line is that as long as cellular and molecular methods or gene therapy can be used in the treatment of myxopapillary ependymoma, all the studies confirm that the best treatment method is still wide surgical resection as much as possible.
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Affiliation(s)
- Amin Jahanbakhshi
- Skull Base Research Center, Neurosurgery Department, Iran University of Medical Sciences, Tehran
| | - Masoumeh Najafi
- Skull Base Research Center, Neurosurgery Department, Iran University of Medical Sciences, Tehran
| | - Fatemeh Jafari
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran
- Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran
| | - Mahsa Moshtaghian
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran
- Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran
| | - Marzieh Gomar
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran
| | | | - Soheil Naderi
- Neurosurgery Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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14
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Albadr F, Albahkali SM, Alahmadi MS, Alsakkaf HM, Al-Habib A, Alkhalidi H, Basalamah AA. Atypical Imaging of Hemorrhagic Lumbosacral Myxopapillary Ependymoma with Histopathological Correlation: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925449. [PMID: 33082304 PMCID: PMC7588349 DOI: 10.12659/ajcr.925449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient: Male, 16-year-old Final Diagnosis: Hemorrhagic myxopapillary ependymoma • myxopapillary ependymoma Symptoms: Gait abnormality • pain in lumbar region Medication: — Clinical Procedure: Resection of intraspinal mass Specialty: Neurosurgery • Radiology
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Affiliation(s)
- Fahad Albadr
- Radiology Unit, King Saud University Medical City (KSUMC), College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Salha M Albahkali
- Department of Radiology, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Mohammad S Alahmadi
- Department of Radiology, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Hussein M Alsakkaf
- Radiology Unit, King Saud University Medical City (KSUMC), College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Amro Al-Habib
- Medical Imaging Administration, King Fahad Medical Medical City (KFMC), Riyadh, Saudi Arabia
| | - Hisham Alkhalidi
- Pathology Department, King Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Ali A Basalamah
- Neurosurgery Division, Surgery Department, King Saud University Medical City (KSUMC), College of Medicine, King Saud University, Riyadh, Saudi Arabia
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15
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Achey RL, Vo S, Cioffi G, Gittleman H, Schroer J, Khanna V, Buerki R, Kruchko C, Barnholtz-Sloan JS. Ependymoma, NOS and anaplastic ependymoma incidence and survival in the United States varies widely by patient and clinical characteristics, 2000-2016. Neurooncol Pract 2020; 7:549-558. [PMID: 33014396 DOI: 10.1093/nop/npaa023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Ependymoma is a rare CNS tumor arising from the ependymal lining of the ventricular system. General differences in incidence and survival have been noted but not examined on a comprehensive scale for all ages and by histology. Despite the rarity of ependymomas, morbidity/mortality associated with an ependymoma diagnosis justifies closer examination. METHODS Incidence data were obtained from the Central Brain Tumor Registry of the United States in collaboration with the Centers for Disease Control and Prevention and the National Cancer Institute, and survival data from Surveillance Epidemiology and End Results, from 2000 to 2016 for anaplastic ependymoma and ependymoma, not otherwise specified (NOS). Age-adjusted incidence rates (IRs) per 100 000 person-years were analyzed by age, sex, race, and location. Survival analysis was performed with Kaplan-Meier curves and multivariable Cox proportional hazards models. RESULTS Incidence of anaplastic ependymoma was highest in ages 0 to 4 years. African American populations had lower incidence but had a 78% increased risk of death compared to white populations (hazard ratio [HR]: 1.78 [95% CI, 1.30-2.44]). Incidence was highest for anaplastic ependymoma in the supratentorial region. Adults (age 40+ years) had almost twice the risk of death compared to children (ages 0-14 years) (HR: 1.97 [95% CI, 1.45-2.66]). For ependymoma, NOS, subtotal resection had a risk of mortality 1.86 times greater than gross total resection ([HR: 1.86 [95% CI, 1.32-2.63]). CONCLUSIONS African American populations experienced higher mortality rates despite lower incidence compared to white populations. Extent of resection is an important prognostic factor for survival. This highlights need for further evaluation of treatment patterns and racial disparities in the care of patients with ependymoma subtypes.
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Affiliation(s)
- Rebecca L Achey
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sierra Vo
- Department of Mathematics, Applied Mathematics, and Statistics, Case Western Reserve, Cleveland, Ohio
| | - Gino Cioffi
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Haley Gittleman
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Julia Schroer
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vishesh Khanna
- Department of Internal Medicine, Stanford University, Stanford, California
| | - Robin Buerki
- Department of Neurology, University Hospitals of Cleveland, Cleveland, Ohio
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois
| | - Jill S Barnholtz-Sloan
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Central Brain Tumor Registry of the United States, Hinsdale, Illinois
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16
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National trends in management of adult myxopapillary ependymomas. J Clin Neurosci 2020; 73:162-167. [PMID: 31987634 DOI: 10.1016/j.jocn.2019.12.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/20/2019] [Indexed: 01/13/2023]
Abstract
Myxopapillary ependymomas (MPE) are WHO Grade I ependymomas that annually occur in 0.05-0.08 per 100,000 people. Surgical resection is the recommended first line therapy. Due to the rarity of the disease, there is a relatively poor understanding of the use of radiotherapy (RT) in managing this disease. The National Cancer Database (NCDB) was analyzed for patterns of care foradult MPE diagnosed between 2002 and 2016. Of 753 qualifying cases, the majority of patients underwent resection (n = 617, 81.9%). A relatively small portion received RT (n = 103, 13.3%) with most receiving RT post-operatively (n = 98, 95.1%). The likelihood of patients to undergo resection and RT was associated with patient age at diagnosis (p = 0.002), tumor size (p < 0.001), and race (p = 0.017). Chemotherapy was not widely utilized (0.27% of patients). One limitation of our analysis is that there was no data on progression free survival (PFS), an important outcome given the high survival rate in this disease. Surgery remains the primary means to manage adult MPE. For spinal MPE, it is understood that gross total resection (GTR) should be attempted whenever possible as GTR has been associated with improved PFS in several studies. The impact of RT on overall survival (OS) is indeterminate given the 1.6% death rate in the cohort. Analyses of the impact of RT on PFS in a larger database would be beneficial for determining an algorithm for post-operative and definitive RT in this disease entity.
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17
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Abdallah A. Spinal Seeding Metastasis of Myxopapillary Ependymoma: Report of Three Pediatric Patients and a Brief Literature Review. Pediatr Neurosurg 2020; 55:127-140. [PMID: 32777780 DOI: 10.1159/000509061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 06/02/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Myxopapillary ependymomas (MPEs) in children are rarely reported low-grade glial tumors; however, MPEs sometimes possess malignant characteristics such as spinal seeding/drop metastasis (SSM). We aimed to present 3 pediatric MPE cases that experienced SSM at 2 neurosurgical centers. MATERIALS AND METHODS We retrospectively reviewed the medical records of 38 primary spinal MPE cases who underwent surgery at 2 neurosurgical centers spanning 16 years, from 2004 to 2019. All pediatric cases (patient age <18 years) who were diagnosed with MPE and re-presented with SSM were selected as the core sample for this study. Relevant literature was briefly reviewed. RESULTS Three pediatric MPE cases (2 females and 1 male) experienced SSM. The mean age at first presentation was 12.0 ± 1.0 years. The mean preoperative course was 2.9 ± 1.2 months. The predominant location was the lumbar spine in 2 tumors (both originated from terminal filum [TF]). Two tumors were located intradural intramedullary. Gross-total resection was achieved in 2 patients. No patient had neurofibromatosis type 2. No adjuvant treatment was given after the first surgery. The mean period between the first diagnosis and diagnosis of SSM was 44.0 ± 31.5 months. The location of SSM in all patients was the sacral spine (1 patient experienced distant metastasis in her brain besides her sacral metastasis). The mean follow-up was 68.3 ± 53.7 months. CONCLUSIONS We found a statistically significant relationship between SSM in pediatric MPEs and the intramedullary location, TF origin, and number of affected segments. Close clinical and radiological follow-up is essential for pediatric MPE patients.
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Affiliation(s)
- Anas Abdallah
- Department of Neurosurgery, Bezmialem Vakif University, Istanbul, Turkey,
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18
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Seidel C, Dietzsch S, Kortmann RD, Schackert G, Hau P. Radiation Therapy in Ependymal Tumors. Radiat Oncol 2020. [DOI: 10.1007/978-3-319-52619-5_4-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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19
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Abdallah A, Emel E, Gündüz HB, Sofuoğlu ÖE, Asiltürk M, Abdallah BG. Long-Term Surgical Resection Outcomes of Pediatric Myxopapillary Ependymoma: Experience of Two Centers and Brief Literature Review. World Neurosurg 2019; 136:e245-e261. [PMID: 31899399 DOI: 10.1016/j.wneu.2019.12.128] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 12/20/2019] [Accepted: 12/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Myxopapillary ependymoma (MPE) is a rarely reported lesion of the spinal cord in the pediatric population. Based on their low mitotic index and slow-growth, MPEs are classified as low-grade glial tumors. However, MPEs have malignant characteristics, such as distant neural axis and extraneural axis dissemination. We present the long-term surgical resection outcomes of 5 consecutive pediatric MPE cases and the results of a literature search for reported cases of pediatric spinal MPE. METHODS We retrospectively reviewed the medical records of 38 primary spinal MPE cases who underwent surgery at 2 neurosurgical centers over a 16-year period from January 2004 to January 2019. All pediatric cases (age <18 years; n = 5) who were diagnosed with MPE composed the core sample for this study. RESULTS This series comprised 5 patients (3 females and 2 males), with a mean age at first presentation of 13.6 ± 2.3 years. The mean preoperative course was 8.2 ± 9.3 months. The predominant location was the lumbar spine, for 4 tumors. Gross total resection (GTR) was achieved in 4 patients. All patients were diagnosed histopathologically as MPE, World Health Organization grade I. No adjuvant treatment was provided after the first surgery. Three patients experienced spinal drop metastasis. The mean interval between the first diagnosis and diagnosis of neural dissemination was 44.0 ± 31.5 months. The location of neural dissemination in all patients was the sacral spine; 1 patient experienced distant metastasis in the brain along with her sacral metastasis. The mean duration of follow-up was 75.0 ± 37.6 months. CONCLUSIONS Even with GTR, pediatric MPE has a high propensity for neural axis dissemination. We recommend close clinical and radiologic follow-up for pediatric patients with MPE.
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Affiliation(s)
- Anas Abdallah
- Department of Neurosurgery, Bezmialem Vakif University, Istanbul, Turkey.
| | - Erhan Emel
- Department of Neurosurgery, University of Health Sciences, Bakırköy Research and Training Hospital for Neurology, Neurosurgery, and Psychiatry, Istanbul, Turkey
| | - Hasan Burak Gündüz
- Department of Neurosurgery, University of Health Sciences, Bakırköy Research and Training Hospital for Neurology, Neurosurgery, and Psychiatry, Istanbul, Turkey
| | - Özden Erhan Sofuoğlu
- Department of Neurosurgery, University of Health Sciences, Bakırköy Research and Training Hospital for Neurology, Neurosurgery, and Psychiatry, Istanbul, Turkey
| | - Murad Asiltürk
- Department of Neurosurgery, University of Health Sciences, Bakırköy Research and Training Hospital for Neurology, Neurosurgery, and Psychiatry, Istanbul, Turkey
| | - Betül Güler Abdallah
- Department of Neurosurgery Intensive Care Unit, University of Health Sciences, Bakırköy Research and Training Hospital for Neurology, Neurosurgery, and Psychiatry, Istanbul, Turkey
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20
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Abstract
PURPOSE OF REVIEW This review discusses the evidence base behind current and emerging strategies of management of intracranial and spinal ependymomas in children, with a particular focus on aspects of surgical techniques, challenges and complications. RECENT FINDINGS The cornerstone of management remains maximal safe resective surgery, which has repeatedly been shown to correlate with improved survival. This is followed by focal conformal radiotherapy, although good results using proton beam therapy, with the potential for diminished side effects, are emerging. The role of chemotherapy remains largely unproven for paediatric ependymoma. Despite optimal management strategies, many children with ependymoma suffer from tumour recurrence. The standard of care for paediatric ependymoma comprises surgery and radiotherapy. Results of ongoing clinical trials will help shape its management in order to leverage our increasingly sophisticated understanding of the genetic drivers behind these tumours into survival benefit for this challenging group of patients.
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Affiliation(s)
- Sebastian M Toescu
- Developmental Imaging and Biophysics Section, UCL-GOS Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.,Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.
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21
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Abstract
Background The aim of this study was to assess the clinical and radiological outcomes of surgical treatment for primary spinal ependymoma in children. Material/Methods Medical records of 46 primary spinal ependymoma patients who underwent surgery in BRSHH hospital during a 12-year period from 2004 to 2015 were retrospectively reviewed. All pediatric patients (patient age <18 years) were selected as the core sample used for this study. Results This series included 1 female and 2 male patients between the ages of 9 and 17 years with mean age 13.3±3.9 years. The mean preoperative course was 9.1±10.5 months. The most common location was the lumbar spinal cord (n=2). The most common presenting symptoms was lower-limb weakness and numbness. Two tumors were located intradural-intramedullary and 1 was located intradural-extramedullary. Gross-total resection (GTR) was achieved in 2 patients, and a near-total resection was performed in 1 patient. No adjuvant treatment was received. The mean follow-up duration was 51.3±37.6 (17–98) months. No complications were recorded. Functional assessment of all patients by the latest follow-up evaluation showed good progress even though the patient is not fully recovered. At 6.3 years after the first operation, 1 patient presented with drop-seeding metastasis. No patients had neurofibromatosis type 2. Conclusions Laminoplasty and intraoperative neurophysiological monitorization are essential in surgical treatment of pediatric spinal ependymomas. GTR and recovery in pediatric spinal ependymoma are more likely than in adults. Despite the GTR, the risk of drop metastasis remains. Therefore, close clinical and radiological follow-up is recommended.
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Affiliation(s)
- Özden Erhan Sofuoğlu
- Department of Neurosurgery, Health Science University, Bakirköy Research and Training Hospital for Neurology Neurosurgery and Psychiatry, Istanbul, Turkey
| | - Anas Abdallah
- Department of Neurosurgery, Bezmialem Vakif University, Istanbul, Turkey
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22
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Rudà R, Reifenberger G, Frappaz D, Pfister SM, Laprie A, Santarius T, Roth P, Tonn JC, Soffietti R, Weller M, Moyal ECJ. EANO guidelines for the diagnosis and treatment of ependymal tumors. Neuro Oncol 2018; 20:445-456. [PMID: 29194500 PMCID: PMC5909649 DOI: 10.1093/neuonc/nox166] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Ependymal tumors are rare CNS tumors and may occur at any age, but their proportion among primary brain tumors is highest in children and young adults. Thus, the level of evidence of diagnostic and therapeutic interventions is higher in the pediatric compared with the adult patient population.The diagnosis and disease staging is performed by craniospinal MRI. Tumor classification is achieved by histological and molecular diagnostic assessment of tissue specimens according to the World Health Organization (WHO) classification 2016. Surgery is the crucial initial treatment in both children and adults. In pediatric patients with intracranial ependymomas of WHO grades II or III, surgery is followed by local radiotherapy regardless of residual tumor volume. In adults, radiotherapy is employed in patients with anaplastic ependymoma WHO grade III, and in case of incomplete resection of WHO grade II ependymoma. Chemotherapy alone is reserved for young children <12 months and for adults with recurrent disease when further surgery and irradiation are no longer feasible. A gross total resection is the mainstay of treatment in spinal ependymomas, and radiotherapy is reserved for incompletely resected tumors. Nine subgroups of ependymal tumors across different anatomical compartments (supratentorial, posterior fossa, spinal) and patient ages have been identified with distinct genetic and epigenetic alterations, and with distinct outcomes. These findings may lead to more precise diagnostic and prognostic assessments, molecular subgroup-adapted therapies, and eventually new recommendations pending validation in prospective studies.
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Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science University Hospital, Turin, Italy
| | - Guido Reifenberger
- Institute of Neuropathology, Medical Faculty, Heinrich Heine University Düsseldorf and German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, Düsseldorf, Germany
| | - Didier Frappaz
- Département de Neuro-Oncologie, Centre Léon-Bérard, Institut d’Hématologie et Oncologie Pédiatrique et Adulte, Lyon, France
| | - Stefan M Pfister
- Division of Pediatric Neuro-oncology, German Cancer Research Center, DKTK, Heidelberg, Germany and Department of Pediatric Oncology, Hematology and Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Anne Laprie
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | | | - Patrick Roth
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Joerg Christian Tonn
- Department of Neurosurgery Ludwig-Maximilians-Universität and DKTK partner site, University of Munich, Munich, Germany
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University of Turin and City of Health and Science University Hospital, Turin, Italy
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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23
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Rogers S, Jones DTW, Ireland A, Gottardo NG, Endersby R. Unusual paediatric spinal myxopapillary ependymomas: Unique molecular entities or pathological variations on a theme? J Clin Neurosci 2018; 50:144-148. [PMID: 29402569 DOI: 10.1016/j.jocn.2018.01.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 01/08/2018] [Indexed: 02/07/2023]
Abstract
Ependymomas are the commonest type of spinal glioma which represent a group of relatively benign tumours. Myxopapillary ependymoma (MPE) is a common variant found within the distal spinal cord around the conus. These two entities are clearly differentiated on the basis of their characteristic histological and molecular features. Rare variants of MPE's are described in the literature to have the propensity to metastasise and grow in extraspinal locations despite appearing histologically identical to their more benign relatives. Here, we describe two unusual cases of MPE and utilise DNA methylation analyses to compare their molecular signatures with known molecular subtypes of ependymoma in an attempt to distinguish whether these tumours represent a unique subset of disease.
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Affiliation(s)
- Sasha Rogers
- Telethon Kids Institute, Perth, WA, Australia; Centre for Child Health Research, University of Western Australia, Perth, WA, Australia; Department of Neurosurgery, Princess Margaret Hospital, Perth, WA, Australia.
| | - David T W Jones
- Division of Paediatric Neuro-oncology, German Cancer Research Centre (DKFZ), Heidelberg, Germany; Hopp-Children's Tumour Centre at the NCT Heidelberg, Heidelberg, Germany
| | - Amanda Ireland
- Department of Anatomical Pathology, PathWest Laboratory Medicine, QEII Medical Centre, Perth, WA, Australia
| | - Nick G Gottardo
- Telethon Kids Institute, Perth, WA, Australia; Centre for Child Health Research, University of Western Australia, Perth, WA, Australia; Department of Oncology, Princess Margaret Hospital, Perth, WA, Australia
| | - Raelene Endersby
- Telethon Kids Institute, Perth, WA, Australia; Centre for Child Health Research, University of Western Australia, Perth, WA, Australia
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24
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Bandopadhayay P, Silvera VM, Ciarlini PDSC, Malkin H, Bi WL, Bergthold G, Faisal AM, Ullrich NJ, Marcus K, Scott RM, Beroukhim R, Manley PE, Chi SN, Ligon KL, Goumnerova LC, Kieran MW. Myxopapillary ependymomas in children: imaging, treatment and outcomes. J Neurooncol 2016; 126:165-174. [PMID: 26468139 DOI: 10.1007/s11060-015-1955-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 10/05/2015] [Indexed: 02/07/2023]
Abstract
Myxopapillary ependymomas (MPEs) are rare spinal tumors in children. The natural history and clinical course of pediatric MPEs are largely unknown and the indication for adjuvant therapy remains to be clarified. We performed an IRB-approved, retrospective review of children with MPEs treated at the Dana-Farber/Boston Children's Cancer and Blood Disorder Center between 1982 and 2013. Eighteen children (age range 8-21 years, median age 14 years) met inclusion criteria. We reviewed the histopathology, magnetic resonance imaging, tumor location and stage, surgical management, adjuvant therapy, and clinical outcomes. The median follow-up duration was 9.4 years (range 1-30 years). Children most commonly presented with pain, scoliosis, and urinary symptoms. All primary tumors were located in the lower thoracic or lumbar spine. Nine children (50%) had leptomeningeal tumor seeding at presentation, most commonly located within the distal thecal sac. A gross-total resection was achieved in nine children (50%). Three children were treated with irradiation following initial surgery. No child received adjuvant chemotherapy at diagnosis. The 10-year event-free survival (EFS) was 26% ± 14.8. Children with disseminated disease trended towards inferior EFS compared to those with localized disease (10-year EFS 12.7% ± 12 vs. 57 ± 25%, p value 0.07). The 10-year overall survival was 100%. The efficacy of adjuvant irradiation could not be assessed due to the small sample size. Although children with MPEs frequently present with disseminated tumor and/or develop recurrent or progressive disease, their overall survival is excellent. Treatment should aim to minimize both tumor- and therapy-related morbidity.
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Affiliation(s)
- Pratiti Bandopadhayay
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA
| | - V Michelle Silvera
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02215, USA
| | - Pedro D S C Ciarlini
- Division of Neuropathology, Department of Pathology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02215, USA
| | - Hayley Malkin
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02215, USA
| | - Guillaume Bergthold
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA
| | - Ahmed M Faisal
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA
| | - Nicole J Ullrich
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA.,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Karen Marcus
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA
| | - R Michael Scott
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02215, USA
| | - Rameen Beroukhim
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Peter E Manley
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA
| | - Susan N Chi
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA
| | - Keith L Ligon
- Division of Neuropathology, Department of Pathology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02215, USA. .,Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.
| | - Liliana C Goumnerova
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA. .,Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02215, USA. .,Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Mark W Kieran
- Dana-Farber Cancer Institute and Boston Children's Hospital, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, 450 Brookline Ave, Boston, 02215, USA.
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Lucchesi KM, Grant R, Kahle KT, Marks AM, DiLuna ML. Primary spinal myxopapillary ependymoma in the pediatric population: a study from the Surveillance, Epidemiology, and End Results (SEER) database. J Neurooncol 2016; 130:133-140. [PMID: 27423644 DOI: 10.1007/s11060-016-2218-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 07/09/2016] [Indexed: 12/16/2022]
Abstract
Primary spinal myxopapillary ependymomas (MPE) in children are extremely rare. We examined the patient demographics, treatment modalities, and the associated outcomes of children with MPE using the Surveillance, Epidemiology, and End Results (SEER) national cancer database to gain a better understanding of these tumors. The SEER database (1973-2012) was used to analyze patients 21 years of age and younger with histologically confirmed MPE localized to the spinal cord or cauda equina. We analyzed patient demographics, extent of surgical resection, and radiation treatment. Overall survival was calculated using the Kaplan-Meier method. Statistical significance was defined as p < 0.05, with all data analyzed in IBM SPSS Statistics 21. 122 pediatric patients met inclusion criteria. The median age was 16 years (range 0-21) with 63 % male and 87 % Caucasian. The mean follow-up time was 4.5 years (95 % CI 3.93-5.07). Overall survival at 5 and 10 years was 97 and 95 %, respectively. We found 37 % underwent gross-total resection (GTR), 36 % subtotal resection (STR), and 27 % biopsy only. Patients who received GTR alone (n = 37) had a statistically significant increase in overall survival compared to those who received STR plus adjuvant radiation (n = 20) (Χ2 = 5.9, p < 0.05). To our knowledge, this is the largest survival analysis of pediatric patients with MPE. Overall survival is excellent at the 5 and 10-year time points; however, GTR should be the goal of treatment when possible. For patients with MPE, future studies should focus on longer follow-up, the role of radiation, and the therapeutic approach at tumor recurrence.
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Affiliation(s)
- Kelly M Lucchesi
- Frank H. Netter MD School of Medicine, Quinnipiac University, 370 Bassett Road, North Haven, CT, 06473, USA.
| | - Ryan Grant
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, USA
| | - Asher M Marks
- Department of Pediatrics and Hematology-Oncology, School of Medicine, Yale University, New Haven, CT, USA
| | - Michael L DiLuna
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, USA
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Abdulaziz M, Mallory GW, Bydon M, De la Garza Ramos R, Ellis JA, Laack NN, Marsh WR, Krauss WE, Jallo G, Gokaslan ZL, Clarke MJ. Outcomes following myxopapillary ependymoma resection: the importance of capsule integrity. Neurosurg Focus 2016; 39:E8. [PMID: 26235025 DOI: 10.3171/2015.5.focus15164] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECT While extent of resection has been shown to correlate with outcomes after myxopapillary ependymoma (MPE) resection, the effect of capsular violation has not been well studied. The role of adjuvant radiation also remains controversial. In this paper the authors' goals were to evaluate outcomes following resection of MPE based on intraoperative capsular violation and to explore the role of adjuvant radiotherapy in cases of capsular violation. METHODS A retrospective review of patients undergoing resection of MPE at 2 academic institutions between 1990 and 2013 was performed. Cases with dissemination at presentation, less than 12 months of follow-up, or incomplete records were excluded. Extent of resection was defined as en bloc if all visible tumor was removed without capsular violation, gross-total resection (GTR) if all visible tumor was removed, but with capsular violation, and subtotal resection (STR) if a known residual was left at the time of surgery. Postoperative MR images were reviewed to confirm the extent of resection. Primary outcomes were progression-free survival (PFS) and overall recurrence rates. The effects of extent of resection, capsular violation, and adjuvant radiotherapy on recurrence rates and PFS were analyzed using Kaplan-Meier statistics. Associations between recurrence and preoperative variables were evaluated using Fisher exact methods and t-tests where appropriate. RESULTS Of the 107 patients reviewed, 58 patients (53% were male) met inclusion criteria. The mean age at surgery was 40.8 years (range 7-68 years). The median follow-up was 51.5 months (range 12-243 months). Extent of resection was defined as en bloc in 46.5% (n = 27), GTR in 34.5% (n = 20), and STR in 18.9% (n = 11). No recurrences were noted in the en bloc group, compared with 15% (n = 3) and 45% (n = 5) in the GTR and STR groups. En bloc resection was achieved most frequently in tumors involving the conus. Twelve patients (20%) underwent adjuvant radiotherapy following either STR or GTR. The overall recurrence rate was 13.8% (n = 8), and the 5-year PFS was 81%. Capsular violation was associated with a higher recurrence rate (p = 0.005). Adjuvant radiotherapy showed a nonsignificant trend of lower recurrence rates (16.7% vs 31.6%, p = 0.43) and longer PFS at 5 years (83.3% vs 49.9%, p = 0.16) in cases of capsular violation. CONCLUSIONS A strong correlation between capsular violation and recurrence was found following removal of MPE and should be assessed when defining extent of resection in future studies. Although the use of adjuvant radiotherapy in cases of capsular violation showed a trend toward improved PFS, further investigation is needed to establish its role as salvage therapy also appears to be effective at halting disease progression.
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Affiliation(s)
| | | | - Mohamad Bydon
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
| | | | - Jason A Ellis
- Department of Neurosurgery, Columbia University, New York, New York
| | - Nadia N Laack
- Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - George Jallo
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
| | - Ziya L Gokaslan
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
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Bates JE, Choi G, Milano MT. Myxopapillary ependymoma: a SEER analysis of epidemiology and outcomes. J Neurooncol 2016; 129:251-8. [PMID: 27306443 DOI: 10.1007/s11060-016-2167-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/01/2016] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- James E Bates
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Ave, 647, Rochester, NY, 14642, USA
| | - Gyujae Choi
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Ave, 647, Rochester, NY, 14642, USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Ave, 647, Rochester, NY, 14642, USA.
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28
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Abstract
Great progress has been made in many areas of pediatric oncology. However, tumors of the central nervous system (CNS) remain a significant challenge. A recent explosion of data has led to an opportunity to understand better the molecular basis of these diseases and is already providing a foundation for the pursuit of rationally chosen therapeutics targeting relevant molecular pathways. The molecular biology of pediatric brain tumors is shifting from a singular focus on basic scientific discovery to a platform upon which insights are being translated into therapies.
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Chen X, Li C, Che X, Chen H, Liu Z. Spinal myxopapillary ependymomas: a retrospective clinical and immunohistochemical study. Acta Neurochir (Wien) 2016; 158:101-7. [PMID: 26577638 DOI: 10.1007/s00701-015-2637-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 11/05/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Myxopapillary ependymoma (MPE) is a rare subtype of ependymoma that develops almost exclusively within the spinal cord. Despite its benign biological nature, MPE has a propensity to recur locally or distantly. Although variables influencing the prognosis, such as age, the extent of surgery and radiotherapy, have been widely discussed, no definitive standard has been established. Compared to other spinal tumors, many fewer histological markers have been elucidated to assist the determination of the prognosis. METHODS Twenty-seven patients who underwent resection of MPE were enrolled. We determined their demographic features, imaging characteristics, clinical presentations and outcomes, surgical procedures and histological properties by chart review, telephone contact, reviewing of surgical notes, pre-/postoperative imaging and immunohistological staining. RESULTS GTR (gross total resection) was achieved in 18 patients (66.7 %) and STR (subtotal resection) in 9 (33.3 %). Although GTR rendered a better disease control rate, the difference was not significant. Pediatric patients suffered from a greater risk of recurrence as well as a shorter period to disease relapse. In the majority of cases, we observed the overexpression of platelet-derived growth factor receptor α (PDGFRα), matrix metalloproteinase-2 (MMP2) and matrix metalloproteinase-14 (MMP14). Epidermal growth factor receptor (EGFR) was observed in the tumors of 7 of 23 nonrecurrent patients, but not in any recurrent tumors. CONCLUSIONS The results of the present study indicate that the extent of resection and age are major factors related to tumor recurrence. Therefore, gross total resection is recommended whenever possible unless following neurological dysfunction is predictable. Moreover, pediatric patients need considerable attention after surgery, particularly in the early stages. PDGFRα, MMP2 and MMP14 may be new diagnostic and therapeutic targets and EGFR a potential predictor of improved prognosis for MPE.
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Affiliation(s)
- Xi Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Chao Li
- Department of Neuropathology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoming Che
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong Chen
- Department of Neuropathology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhengyan Liu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
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Abstract
OBJECT
Ependymomas of the filum terminale provide specific surgical challenges due to their often enormous size, contact with nerve roots of the cauda equina and conus, and potential for subarachnoid dissemination. This study presents treatment results for these tumors over a 30-year period.
METHODS
Among 1447 patients with tumors of the spinal canal treated between 1980 and 2014, 618 patients presented with extramedullary tumors. Of these, 42 patients (25 males, 17 females) demonstrated a myxopapillary ependymoma in the lumbosacral region. Thirty-four patients underwent 36 operations for 39 such tumors. The mean patient age was 38 ± 14 years (range 11−73 years), with an average clinical history of 37 ± 67 months. Patients were followed through outpatient visits and questionnaires, with a mean follow-up of 10 years (127 ± 100 months). Twenty-seven operations were performed to treat de novo tumors and the remainder were undertaken on recurrent tumors. Short-term results were determined for individual symptoms, and tumor recurrence rates were calculated with Kaplan-Meier statistical analyses.
RESULTS
Subarachnoid dissemination was observed in 11 patients and was related to previous surgery in 9 patients and associated with extensive tumors in 2 patients. Gross-total resections (GTR) were achieved in 28 operations (77.7%) and subtotal resections in the remainder. Subtotal resections were restricted to unencapsulated ependymomas (61.5%). Radiotherapy was employed after 6 operations on unencapsulated tumors, with 5 of these also demonstrating subarachnoid seeding. Permanent surgical morbidity affected 3 patients who experienced permanent worsening of bladder function, while 7 patients showed no postoperative changes, and the remaining 26 operations were followed by improvements. Long-term outcome depended on the amount of resection and the presence of a tumor capsule. Eight of 9 tumor recurrences affected unencapsulated tumors, of which 3 had undergone GTR. The overall recurrence rates were 6.6%, 19.0%, and 37.0% after 1, 10, and 20 years, respectively. For unencapsulated ependymomas, the corresponding rates were 15.6%, 32.5%, and 66.2% after 1, 10, and 20 years, respectively, with significantly lower rates of 9.1% after 10 and 20 years for encapsulated tumors. Postoperative radiotherapy tended to prolong the recurrence-free interval for patients with unencapsulated tumors. Five patient deaths occurred during follow-up, of which 2 deaths were tumor related and occurred at 216 and 287 months after surgery.
CONCLUSION
Extramedullary ependymomas are slow-growing tumors in the lumbosacral region, sometimes with an indolent course for long periods of time. Despite their delicate location and often enormous size, surgical morbidity in experienced hands is low, with good chances for postoperative clinical improvements and very low recurrence rates after GTR for encapsulated tumors. The role of postoperative radiotherapy remains controversial. Radiotherapy may be considered after incomplete resections of unencapsulated tumors and/or for patients with subarachnoid dissemination.
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Tsai CJ, Wang Y, Allen PK, Mahajan A, McCutcheon IE, Rao G, Rhines LD, Tatsui CE, Armstrong TS, Maor MH, Chang EL, Brown PD, Li J. Outcomes after surgery and radiotherapy for spinal myxopapillary ependymoma: update of the MD Anderson Cancer Center experience. Neurosurgery 2015; 75:205-14; discussion 213-4. [PMID: 24818785 DOI: 10.1227/neu.0000000000000408] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The role of radiotherapy after surgery for myxopapillary ependymoma (MPE) is unclear. OBJECTIVE To review long-term outcomes after surgery, with or without radiation, for spinal MPE. METHODS Fifty-one patients with spinal MPE treated from 1968 to 2007 were included. Associations between clinical variables and overall survival (OS), progression-free survival (PFS), and local control (LC) were tested with Cox regression analysis. RESULTS The median age at diagnosis was 35 years (range, 8-63 years). Twenty patients (39%) had surgery alone, 30 (59%) had surgery plus radiotherapy (RT), and 1 (2%) had RT only. At a median follow-up of 11 years (range, 0.2-37 years), 10-year OS, PFS, and LC for the entire group were 93%, 63%, and 67%, respectively. Nineteen patients (37%) had disease recurrence, and the recurrence was mostly local (79%). Twenty-eight of 50 patients who had surgery (56%) had gross total resection; 10-year LC was 56% after surgery vs 92% after surgery and RT (log-rank P = .14); the median time of LC was 10.5 years for patients receiving gross total resection plus RT, and 4.75 years for gross total resection only (P = .03). Among 16 patients with subtotal resection and follow-up data, 10-year LC was 0% after surgery vs 65% for surgery plus RT (log-rank P = .008). On multivariate analyses adjusting for resection type, age older that 35 years at diagnosis and receipt of adjuvant radiation were associated with improved PFS (hazard ratio [HR]: 0.14, P = .003 and HR: 0.45, P = .009) and LC (HR: 0.22, P = .02 and HR: 0.45, P = .009). CONCLUSION Postoperative radiotherapy after resection of MPE was associated with improved PFS and LC.
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Affiliation(s)
- Chiaojung Jillian Tsai
- Departments of ‡Radiation Oncology and ¶Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas; §Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey; ‖School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas; #Department of Radiation Oncology, University of Southern California, Los Angeles, California
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Weber DC, Wang Y, Miller R, Villà S, Zaucha R, Pica A, Poortmans P, Anacak Y, Ozygit G, Baumert B, Haller G, Preusser M, Li J. Long-term outcome of patients with spinal myxopapillary ependymoma: treatment results from the MD Anderson Cancer Center and institutions from the Rare Cancer Network. Neuro Oncol 2014; 17:588-95. [PMID: 25301811 DOI: 10.1093/neuonc/nou293] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Spinal myxopapillary ependymomas (MPEs) are slowly growing ependymal gliomas with preferential manifestation in young adults. The aim of this study was to assess the outcome of patients with MPE treated with surgery, radiotherapy (RT), and/or chemotherapy. METHODS The medical records of 183 MPE patients (male: 59%) treated at the MD Anderson Cancer Center and 11 institutions from the Rare Cancer Network were retrospectively reviewed. Mean patient' age at diagnosis was 35.5 ± 15.8 years. Ninety-seven (53.0%) patients underwent surgery without RT, and 86 (47.0%) were treated with surgery and/or RT. Median RT dose was 50.4 Gy. Median follow-up was 83.9 months. RESULTS Fifteen (8.2%) patients died, 7 of unrelated cause. The estimated 10-year overall survival was 92.4% (95% CI: 87.7-97.1). Treatment failure was observed in 58 (31.7%) patients. Local failure, distant spinal relapse, and brain failure were observed in 49 (26.8%), 17 (9.3%), and 11 (6.0%) patients, respectively. The estimated 10-year progression-free survival was 61.2% (95% CI: 52.8-69.6). Age (<36 vs ≥36 y), treatment modality (surgery alone vs surgery and RT), and extent of surgery were prognostic factors for local control and progression-free survival on univariate and multivariate analysis. CONCLUSIONS In this series, treatment failure of MPE occurred in approximately one third of patients. The observed recurrence pattern of primary spinal MPE was mainly local, but a substantial number of patients failed nonlocally. Younger patients and those not treated initially with adjuvant RT or not undergoing gross total resection were significantly more likely to present with tumor recurrence/progression.
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Affiliation(s)
- Damien C Weber
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Yucai Wang
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Robert Miller
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Salvador Villà
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Renata Zaucha
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Alessia Pica
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Philip Poortmans
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Yavuz Anacak
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Gokhan Ozygit
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Birgitta Baumert
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Guy Haller
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Matthias Preusser
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
| | - Jing Li
- Center of Proton Therapy, Paul Scherrer Institute, Villigen/Würenlingen, Switzerland (D.C.W.); Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas (Y.W., J.L.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (R.M.); Department of Radiation Oncology, Catalan Institute of Oncology, Badalona, Spain (S.V.); Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland (R.Z.); Department of Radiation Oncology, Inselspital, Bern, Switzerland (A.P.); Department of Radiation Oncology, Dr Bernard Verbeeten Instituut, Tilburg, the Netherlands (P.P.); Department of Radiation Oncology, Ege University Medical School, Izmir, Turkey (Y.A.); Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey (G.O.); Department of Robert-Janker-Klinik in Germany, Bonn, Germany (B.B.); Department of Clinical Epidemiology Unit, Department of Community Medicine, Geneva University Hospital, Geneva, Switzerland (G.H.); Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria (M.P.)
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Kukreja S, Ambekar S, Sharma M, Sin AH, Nanda A. Outcome predictors in the management of spinal myxopapillary ependymoma: an integrative survival analysis. World Neurosurg 2014; 83:852-9. [PMID: 25108296 DOI: 10.1016/j.wneu.2014.08.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 04/23/2014] [Accepted: 08/05/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The results in earlier studies have described a variable association with age, extent of resection, and radiotherapy (RT) correlating with the survival of myxopapillary ependymomas. The aim of our study is to perform a survival analysis on patient data gathered from a comprehensive review of the literature and determine the influence of these factors on progression-free (PFS) and overall survival (OS). METHODS A PubMed search was performed to select the articles containing information about the critical events (recurrence/death), time to events, and treatment characteristics (extent of resection with or without RT) in the patients with spinal myxopapillary ependymomas. RESULTS A total of 337 patients with information regarding the critical events, time to events, and treatment characteristics was selected for the inclusion. Patients in gross-total resection group had better PFS and OS (P = 0.001, P = 0.000 respectively). The patients in older age group (>35 years) had better PFS (P = 0.008). Overall PFS did not improve if RT was combined with surgery compared with surgery alone; however, the adjuvant RT benefitted the patients age ≤35 years. RT dose >50 Gy had significant influence on the PFS (P = 0.034). CONCLUSION Gross-total resection plays the most important role in improving PFS and OS. Older patients had better PFS; however, the influence of adjuvant RT was significant in younger age groups. A dose of >50 Gy improves the results, but a randomized controlled study is warranted to arrive at a definite conclusion.
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Affiliation(s)
- Sunil Kukreja
- Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana, USA
| | - Sudheer Ambekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana, USA
| | - Mayur Sharma
- Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana, USA
| | - Anthony Hunkyun Sin
- Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana, USA
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana, USA.
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Kukreja S, Ambekar S, Sin AH, Nanda A. Cumulative survival analysis of patients with spinal myxopapillary ependymomas in the first 2 decades of life. J Neurosurg Pediatr 2014; 13:400-7. [PMID: 24527863 DOI: 10.3171/2014.1.peds13532] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECT Reports of myxopapillary ependymomas (MPEs) of the spinal cord in pediatric patients are scarce. In the literature, various authors have shared their experiences with small groups of patients, which makes it difficult to create a consensus regarding the treatment approach for spinal MPEs in young patients. The aim of this study was to perform a survival analysis of patients in the first 2 decades of life whose cases were selected from the published studies, and to examine the influence of various factors on outcomes. METHODS A comprehensive search of studies published in English was performed on PubMed. Patients whose age was ≤ 20 years were included for integrative analysis. Information about age, treatment characteristics, critical events (progression, recurrence, and death), time to critical events, and follow-up duration was recorded. The degree of association of the various factors with the survival outcome was calculated by using Kaplan-Meier estimator and Cox proportional hazard model techniques. RESULTS A total of 95 patients were included in the analysis. The overall rate of recurrence (RR) was 34.7% (n = 33), with a median time to recurrence of 36 months (range 2-100 months). Progression-free survival (PFS) and overall survival rates at 5 years were 73.7% and 98.9%, respectively. Addition of radiotherapy (RT) following resection significantly improved PFS (log-rank test, p = 0.008). In patients who underwent subtotal resection (STR), administering RT (STR + RT) improved outcome with the lowest failure rates (10.3%), superior to patients who underwent gross-total resection (GTR) alone (RR 43.1%; log-rank test, p < 0.001). Addition of RT to patients who underwent GTR was not beneficial (log-rank test, p = 0.628). In patients who had disseminated tumor at presentation, adjuvant RT controlled the disease effectively. High-dose RT (≥ 50 Gy) did not change PFS (log-rank test, p = 0.710). CONCLUSIONS Routine inclusion of RT in the treatment protocol for spinal MPEs in young patients should be considered. Complete resection is always the goal of tumor resection. However, when complete resection does not seem to be possible in complex lesions, RT should be used as an adjunct to avoid aggressive resection and to minimize inadvertent injury to the surrounding neural tissues. High-dose RT (≥ 50 Gy) did not provide additional survival benefits, although this association needs to be evaluated by prospective studies.
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Affiliation(s)
- Sunil Kukreja
- Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana
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Wang H, Zhang S, Rehman SK, Zhang Z, Li W, Makki MS, Zhou X. Clinicopathological features of myxopapillary ependymoma. J Clin Neurosci 2014; 21:569-73. [DOI: 10.1016/j.jocn.2013.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 05/22/2013] [Accepted: 05/26/2013] [Indexed: 11/16/2022]
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Safaee M, Oh MC, Mummaneni PV, Weinstein PR, Ames CP, Chou D, Berger MS, Parsa AT, Gupta N. Surgical outcomes in spinal cord ependymomas and the importance of extent of resection in children and young adults. J Neurosurg Pediatr 2014; 13:393-9. [PMID: 24506340 DOI: 10.3171/2013.12.peds13383] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Ependymomas are a common type of CNS tumor in children, although only 13% originate from the spinal cord. Aside from location and extent of resection, the factors that affect outcome are not well understood. METHODS The authors performed a search of an institutional neuropathology database to identify all patients with spinal cord ependymomas treated over the past 20 years. Data on patient age, sex, clinical presentation, symptom duration, tumor location, extent of resection, use of radiation therapy, surgical complications, presence of tumor recurrence, duration of follow-up, and residual symptoms were collected. Pediatric patients were defined as those 21 years of age or younger at diagnosis. The extent of resection was defined by the findings of the postoperative MR images. RESULTS A total of 24 pediatric patients with spinal cord ependymomas were identified with the following pathological subtypes: 14 classic (Grade II), 8 myxopapillary (Grade I), and 2 anaplastic (Grade III) ependymomas. Both anaplastic ependymomas originated in the intracranial compartment and spread to the spinal cord at recurrence. The mean follow-up duration for patients with classic and myxopapillary ependymomas was 63 and 45 months, respectively. Seven patients with classic ependymomas underwent gross-total resection (GTR), while 4 received subtotal resection (STR), 2 received STR as well as radiation therapy, and 1 received radiation therapy alone. All but 1 patient with myxopapillary ependymomas underwent GTR. Three recurrences were identified in the Grade II group at 45, 48, and 228 months. A single recurrence was identified in the Grade I group at 71 months. The mean progression-free survival (PFS) was 58 months in the Grade II group and 45 months in the Grade I group. CONCLUSIONS Extent of resection is an important prognostic factor in all pediatric spinal cord ependymomas, particularly Grade II ependymomas. These data suggest that achieving GTR is more difficult in the upper spinal cord, making tumor location another important factor. Although classified as Grade I lesions, myxopapillary ependymomas had similar outcomes when compared with classic (Grade II) ependymomas, particularly with respect to PFS. Long-term complications or new neurological deficits were rare. Among patients with long-term follow-up, those who underwent GTR had a recurrence rate of 20% compared with 40% among those with STR or biopsy only, suggesting that extent of resection is perhaps a more important prognostic factor than histological grade in predicting PFS, which has been suggested by other data in the literature. Given the relative paucity of these lesions, collaborative multiinstitutional studies are needed, and such efforts should also focus on molecular and genetic analysis to refine the current classification system.
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Lundar T, Due-Tønnessen BJ, Scheie D, Brandal P. Pediatric spinal ependymomas: an unpredictable and puzzling disease. Long-term follow-up of a single consecutive institutional series of ten patients. Childs Nerv Syst 2014; 30:2083-8. [PMID: 25079883 PMCID: PMC4223574 DOI: 10.1007/s00381-014-2491-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/07/2014] [Indexed: 11/24/2022]
Abstract
METHODS Ten consecutive children (0-18 years) who underwent primary tumor resection for a spinal ependymoma between 1980 and 2011 were included in this retrospective study. Gross motor function and activities of daily life were scored according to the Barthel Index. CONCLUSION Three out of six pediatric patients treated for spinal myxopapillary ependymoma are disease-free after 11 to 33 years of follow-up. The other three have progressive disease, after relapses occurring after 4.5, 7, and 20 years, respectively. One out of two patients with grade II ependymoma had progressive disease from 10 years after initial surgery but is in full-time work in spite of widespread metastatic disease after 32 years. One of the two children with grade III tumor died from progressive disease 17 years from primary diagnosis, while the last one is tumor-free after 19 years. The quality of life is good for three of the four patients with widespread disease, and they are managed conservatively aiming at symptomatic treatment intervention if necessary. We strongly advocate lifelong follow-up for children treated for spinal ependymomas.
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Affiliation(s)
- Tryggve Lundar
- Department of Neurosurgery, Oslo University Hospital, Postboks 4950, Nydalen, 0424, Oslo, Norway,
| | | | - David Scheie
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Petter Brandal
- Department of Oncology, Oslo University Hospital, Oslo, Norway
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Histologic grade and extent of resection are associated with survival in pediatric spinal cord ependymomas. Childs Nerv Syst 2013; 29:2057-64. [PMID: 23677177 DOI: 10.1007/s00381-013-2149-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/03/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Prognostic factors affecting outcomes in pediatric spinal cord ependymomas are limited. We sought to investigate potential associations between extent of resection and histologic grade on progression-free survival (PFS) and overall survival (OS). METHODS A comprehensive literature search was performed to identify pediatric patients who underwent surgical resection for spinal cord ependymomas. Only manuscripts with clearly defined age, tumor grade, extent of resection, and clinical follow-up were included. RESULTS A total of 80 patients were identified with a histologic distribution as follows: 36 % myxopapillary (grade I), 54 % classical (grade II), and 10 % anaplastic (grade III). There was no association between tumor grade and PFS. The only factor associated with improved PFS was gross total resection (GTR), which remained significant in a multivariate model (hazard ratio (HR) = 0.248, p = 0.022). Moreover, older age (HR = 0.818, p = 0.026), GTR (HR = 0.042, p = 0.013), and anaplastic grade (HR = 19.847, p = 0.008) demonstrated a significant association with OS in a multivariate model. CONCLUSIONS Among pediatric patients with spinal cord ependymomas, PFS did not differ across histologic grades but was prolonged among patients who underwent GTR. Age, extent of resection, and tumor grade were all significantly associated with survival.
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Feldman WB, Clark AJ, Safaee M, Ames CP, Parsa AT. Tumor control after surgery for spinal myxopapillary ependymomas: distinct outcomes in adults versus children: a systematic review. J Neurosurg Spine 2013; 19:471-6. [PMID: 23971762 DOI: 10.3171/2013.6.spine12927] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECT Myxopapillary ependymomas (MPEs) are rare WHO Grade I tumors found in the conus medullaris, cauda equina, and filum terminale. Treatment generally consists of resection with or without adjuvant radiotherapy. Evidence-based guidelines for surgical management are lacking due to the rarity of this tumor. METHODS An English-language PubMed search was performed using the key words "myxopapillary" and "ependymoma." Reports describing fewer than 3 patients or those lacking data on the extent of resection or radiotherapy were excluded. A total of 28 articles describing 475 patients met the authors' inclusion criteria. Patients were grouped by extent of resection and whether or not they underwent adjuvant radiotherapy. Differences in recurrence rates were assessed by chi-square test. RESULTS The overall recurrence rate was 15.5% in patients treated by gross-total resection (GTR) and 32.6% in patients treated by subtotal resection (STR), irrespective of whether they underwent adjuvant therapy (p < 0.001). Regardless of the extent of resection, adjuvant radiotherapy was not associated with a decrease in recurrence rates. The overall recurrence rate was 15.6% in patients who underwent GTR and radiotherapy compared with 15.9% in patients who underwent GTR alone (p = 0.58), and it was 29.3% in patients who underwent STR and radiotherapy compared with 35.1% in those who underwent STR alone (p = 0.53). The difference between recurrence rates for patients who underwent GTR alone versus STR and radiotherapy was statistically significant (p = 0.02). Subgroup analysis demonstrated significantly higher recurrence rates in pediatric patients compared with adults (40.5% vs 23.4%, respectively; p = 0.02). Even in the setting of GTR alone, recurrence rates were higher in pediatric patients (65% vs 7.6%; p < 0.001). CONCLUSIONS Gross-total resection alone is associated with decreased recurrence rates compared with STR with or without radiotherapy. The authors' results suggest that treatment goals should include attempted GTR whenever possible. The observation that children benefitted from radiation therapy to a greater extent than did adults suggests that biological differences between tumors in these patient populations warrants more rigorous scientific studies.
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Affiliation(s)
- William B Feldman
- Department of Neurological Surgery, University of California, San Francisco, California
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Wang H, Zhang S, Wu C, Zhang Z, Qin T. Melanocytomas of the central nervous system: a clinicopathological and molecular study. Eur J Clin Invest 2013; 43:809-15. [PMID: 23683178 DOI: 10.1111/eci.12109] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 04/22/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Melanocytomas of the Central Nervous System (CNS) are rare and benign lesions. These slow-growing tumours can behave aggressively, with local recurrence. Various genetic aberrations occur in malignant melanomas and raise possible new therapeutic options. However, little information is available regarding these characteristic genetic alterations in melanocytomas of the CNS. This study was designed to better understand the clinicopathological and molecular features of melanocytomas. MATERIALS AND METHODS Twenty cases of melanocytoma were studied by light microscopy, electron microscopy and immunohistochemistry. Clinical characteristics, therapeutic options and prognosis were analysed. BRAF, NRAS and KIT gene mutations were tested by direct DNA sequencing. RESULTS Fourteen of twenty patients had intracranial tumours including one associated with naevus of Ota and six were spinal. Histologically, these tumours contain fusiform and epithelioid cells with little or no cellular pleomorphism and rare mitoses. Immunohistochemical and ultrastructural findings confirmed the origin of tumour cells as melanocytic. None of the melanocytomas harboured BRAF, NRAS and KIT mutations. Patients with complete resection had no tumour recurrence. Moreover, patients with incomplete tumour resection followed by radiotherapy showed a higher local control (LC) rate than incomplete resection alone (P < 0·05). CONCLUSIONS BRAF, NRAS and KIT mutations appear to be rare, if not completely absent in melanocytomas of the CNS. The complete resection of the tumour or incomplete resection followed by radiotherapy should be considered as better therapeutic options to reduce the tumour recurrence.
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Affiliation(s)
- Hai Wang
- Department of Pathology, Nanjing Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Abstract
Pediatric intracranial ependymoma is a rare disease representing approximately 7% of brain tumors in children aged 15 years or younger. Due to the relative rarity of these tumors, a clear standard therapy has been difficult to establish. The mainstay of treatment is surgical resection and the majority of data demonstrate improved outcome with gross total resection. The standard of care also includes postoperative radiation therapy for most patients with grade II and III tumors. Chemotherapy has been used in many capacities in this disease; however, its optimal role is yet to be defined. Current controversies such as treatment with surgery alone in completely resected tumors, use of chemotherapy for subtotally resected tumors and use of adjuvant postradiation chemotherapy are incorporated into the design of the current Children's Oncology Group clinical trial.
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Affiliation(s)
- David B Mansur
- Department of Radiation Oncology & Pediatrics, Case Western Reserve University School of Medicine, University Hospitals & Seidman Cancer Center, Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106-6068, USA.
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Benesch M, Frappaz D, Massimino M. Spinal cord ependymomas in children and adolescents. Childs Nerv Syst 2012; 28:2017-28. [PMID: 22961356 DOI: 10.1007/s00381-012-1908-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 08/25/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal cord ependymomas are very rare among children and adolescents. Due to their rarity, our current knowledge of these tumors is based on case reports and few retrospective case series. METHODS The present review summarizes the currently available literature on childhood spinal cord ependymomas. RESULTS Although overall survival rates are favorable, relapse incidence is high, particularly in myxopapillary ependymomas. Since long-term follow-up data are provided in a limited number of studies only, the true relapse incidence is unknown. Maximal safe radical surgery is the backbone of treatment for children with spinal cord ependymomas, but the impact of adjuvant treatment on progression and survival is still unclear. Presently, the decision to initiate non-surgical treatment depends primarily on the WHO grade of the tumor and the extent of resection. In terms of the known side effects, early radiotherapy should be avoided in children with WHO grade II spinal cord ependymomas irrespective of the extent of resection but is indicated in anaplastic spinal cord ependymomas both after complete and incomplete resection. The high relapse incidence in myxopapillary ependymomas argue for the use of early radiotherapy, but its definitive impact on progression has to be proven in larger series. Close surveillance is important due to the high recurrence rate in all patients with spinal cord ependymomas. CONCLUSION Prospective collection of both clinical and molecular data from a greater number of patients with spinal cord ependymomas within an international collaboration is the prerequisite to establish standardized management guidelines for these rare CNS tumors.
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Affiliation(s)
- Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 38, 8036 Graz, Austria.
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