A systematic review of outcome in intramedullary ependymoma and astrocytoma

A comprehensive evaluation of imaging features in pediatric spinal gliomas and their value in predicting tumor grade and histology

PURPOSE

Pediatric spinal cord gliomas (PSGs) are rare in children and few reports detail their imaging features. We tested the association of tumoral grade with imaging features and proposed a novel approach to categorize post-contrast enhancement patterns in PSGs.

METHODS

This single-center, retrospective study included patients <21 years of age with preoperative spinal MRI and confirmed pathological diagnosis of PSG from 2000-2022. Tumors were classified using the 5th edition of the WHO CNS Tumors Classification. Two radiologists reviewed multiple imaging features, and classified enhancement patterns using a novel approach. Fisher's exact test determined associations between imaging and histological features.

RESULTS

Forty-one PSGs were reviewed. Thirty-four were intramedullary, and seven were extramedullary. Pilocytic astrocytoma was the most common tumor (39.02%). Pain and weakness were the most prevalent symptoms. Seven patients (17.07%) died. Cyst, syringomyelia, and leptomeningeal enhancement were associated with tumor grade. Widening of the spinal canal was observed only in low-grade astrocytomas. There was a significant association between tumor grade and contrast enhancement pattern. Specifically, low-grade PSGs were more likely to exhibit type 1A enhancement (mass-like, with well-defined enhancing margins) and less likely to exhibit type 1B enhancement (mass-like, with ill-defined enhancing margins).

CONCLUSION

PSGs display overlapping imaging features, making grade differentiation challenging based solely on imaging. The correlation between tumor grade and contrast enhancement patterns suggests a potential diagnostic avenue, requiring further validation with larger, multicenter studies. Furthermore, Low-grade PSGs display cysts and syringomyelia more frequently, and leptomeningeal enhancement is less common.

Predictors of Functional Independence in Children with Spinal Cord Tumors After Surgery: From Physiotherapist Perspective

Knowledge of the factors affecting functional outcomes has an important role in the development of the care plan in children with spinal cord tumors. Retrospective study was planned to determine predictors of functional independence in children with spinal cord tumors. Data from 80 children treated for spinal cord tumors over 2001-2020-year period was analyzed. Results showed that key predictors such as younger age, higher KPS, and better initial WeeFIM scores were strongly associated with improved functional outcomes. Further multicenter prospective studies are recommended to validate these findings and explore long-term functional outcomes to enhance rehabilitation strategies for this patient population.

The application value and improved warning criterion of D-wave monitoring in intramedullary spinal cord tumor surgery

BACKGROUND CONTEXT

The primary treatment method for intramedullary spinal cord tumor (IMSCT) is surgical resection, but this procedure carries a significant risk of neurological damage. Intraoperative neurophysiological monitoring (IONM) has become a necessary adjunctive tool for IMSCT resection.

PURPOSE

The current study aimed to explore the application value of D-wave monitoring in IMSCT surgery, and tried to investigate a tailored criterion for its early warning.

STUDY DESIGN

A retrospective clinical study.

PATIENT SAMPLE

A retrospective analysis was conducted based on the data of patients who underwent IMSCT surgeries performed by the same neurosurgical team at our hospital. IONM was applied in all surgeries. According to inclusion and exclusion criteria, ultimately 90 patients were enrolled in the study.

OUTCOME MEASURES

The McCormick Scale (MMS) was applied to assess the functional outcome through outpatient visits or telephone follow-up at one month and six months postoperatively. Patients with an MMS grade over II one month after surgery were considered to have newly developed postoperative motor dysfunction (PMD). If the MMS grade could be restored to I or II six months after surgery, it was defined as a short-term PMD. Otherwise, it was defined as a long-term PMD.

METHODS

The predictive value of different IONM modalities, including somatosensory evoked potential (SEP), muscle motor evoked potential (MEP), and D-wave for PMD, was assessed with sensitivity, specificity, positive predictive value, negative predictive value, and subsequent logistic regression analysis. At last, the cut-off value of the D-wave amplitude reduction ratio for predicting PMD was obtained through the receiver operating characteristic (ROC) curve analysis.

RESULTS

SEP showed the worst performance in predicting short-term and long-term PMD. Significant MEP changes were indicated as an independent predictive factor for short-term PMD (OR 5.062, 95% CI 1.947-13.166, p=.001), while D-wave changes were demonstrated as an independent predictor for long-term PMD (OR 339.433, 95% CI 11.337-10770.311, p=.001). The optimum cut-off value of the D-wave amplitude reduction ratio for predicting long-term PMD was 42.18%, with a sensitivity of 100% and a specificity of 93.8% (AUC=0.981, p<.001).

CONCLUSIONS

D-wave monitoring showed extremely high specificity in predicting PMD compared to SEP and MEP monitoring. Moreover, the authors suggested that a D-wave amplitude reduction of over 40% during IMSCT surgery generally indicates long-term PMD for patients.

Translational research of boron neutron capture therapy for spinal cord gliomas using rat model

Boron neutron capture therapy (BNCT) is a type of targeted particle radiation therapy with potential applications at the cellular level. Spinal cord gliomas (SCGs) present a substantial challenge owing to their poor prognosis and the lack of effective postoperative treatments. This study evaluated the efficacy of BNCT in a rat SCGs model employing the Basso, Beattie, and Bresnahan (BBB) scale to assess postoperative locomotor activity. We confirmed the presence of adequate in vitro boron concentrations in F98 rat glioma and 9L rat gliosarcoma cells exposed to boronophenylalanine (BPA) and in vivo tumor boron concentration 2.5 h after intravenous BPA administration. In vivo neutron irradiation significantly enhanced survival in the BNCT group when compared with that in the untreated group, with a minimal BBB scale reduction in all sham-operated groups. These findings highlight the potential of BNCT as a promising treatment option for SCGs.

Predicting the Probability of Tumor-Specific Survival in Patients Diagnosed With Primary Tumors in the Spinal Cord Using Nomogram Models

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The goal of this study was to develop a useful clinical prediction nomogram to accurately predict the cancer-specific survival (CSS) of patients with primary spinal cord tumor (SCT), thereby formulating scientific prevention and aiding clinical decision-making.

METHODS

In this study, patients with SCT diagnoses from the surveillance, epidemiology, and end results (SEER) database (2000-2018) were taken into account. Initially, a nomogram was created using the CSS-associated independent factors that were determined from both univariate and multivariable Cox regression analyses. Furthermore, the nomogram's capacity for calibration, ability to discriminate, and actual clinical effectiveness were assessed through calibration curves, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA), respectively. Finally, a strategy for categorizing SCT patients' risk was developed.

RESULTS

This study included 909 SCT individuals. A novel nomogram was developed to forecast SCT patients' CSS, taking into account age, histological type, tumor grade, tumor stage, and radiotherapy. These factors were identified as independent prognostic indicators for CSS in SCT patients. Elderly SCT patients with distant metastasis, advanced tumor grade, received radiotherapy, and confirmed lymphoma have a poor prognosis. Meanwhile, the risk classification system could differentiate SCT patients and realize targeted management.

CONCLUSIONS

The developed nomogram has the ability to accurately forecast the CSS in SCT individuals, aiding in precise decision-making during clinical practice, enhancing health planning, maximizing treatment advantages, and ultimately improving patient prognosis.

Postoperative Recovery of Gait Function at Early Phase Is Delayed in Patients with Spinal Tumors with Impairment of the Joint Position Sense in the Big Toe: A Retrospective Cohort Study

Introduction

We investigated the effect of preoperative joint position sense in the big toe on the postoperative recovery of gait function after spinal tumor surgery.

Methods

Seventy-three patients with spinal tumors who underwent surgery at our hospital between 2014 and 2019 and could be followed for at least 6 months after surgery were included. The patients were divided into the cervical spinal (41 cases) and thoracic spinal (32 cases) groups according to the localization of the tumor. These groups were further classified into an Impaired group (cervical spinal, 34 cases; thoracic spinal, 19 cases) and an Intact group (cervical spinal, 7 cases; thoracic spinal, 13 cases) according to the presence or absence of preoperative joint position sense in the big toe. The amount of change in ambulatory function from the preoperative period to 3 and 6 months postoperatively was compared between the Impaired and Intact groups within each tumor localization category.

Results

Impaired preoperative joint position sense in the big toe in patients undergoing thoracic spinal tumor surgery delayed the recovery of gait function in the early postoperative period.

Conclusions

In patients with thoracic spinal tumor surgery, the absence of preoperative joint position sense in the big toe delayed the recovery of postoperative gait function.

The Impact of Adjuvant Radiotherapy on Clinical Performance Status in Patients With Grade II Spinal Cord Astrocytoma - A Nationwide Analysis by the Neurospinal Society of Japan

OBJECTIVE

The impact of adjuvant radiotherapy on overall survival (OS) and progression-free survival (PFS) of patients with grade II spinal cord astrocytomas remains controversial. Additionally, the relationship between progression and clinical deterioration after radiotherapy has not been well investigated.

METHODS

This study included 53 patients with grade II intramedullary spinal cord astrocytomas treated by either subtotal, partial resection or open biopsy. Their clinical performance status was assessed immediately before operation and 1, 6, 12, 24, and 60 months after surgery by Karnofsky Performance Scale (KPS). Patients with and without adjuvant radiotherapy were compared.

RESULTS

The groups with and without radiation comprised 23 and 30 patients with a mean age of 50.3 ± 22.6 years (range, 2-88 years). The mean overall disease progression rate was 47.1% during a mean follow-up period of 48.4 ± 39.8 months (range, 2.5-144.5 months). In the radiation group, 11 patients (47.8%) presented with progressive disease, whereas 14 patients (46.7%) presented with progressive disease in the group without radiation. There were no significant differences in OS or PFS among patients with or without adjuvant radiotherapy. KPS in both groups, especially radiation group, gradually decreased after operation and deteriorated before the confirmation of disease progression.

CONCLUSION

Adjuvant radiotherapy did not show effectiveness regarding PFS or OS in patients with grade II spinal cord astrocytoma according to classical classification based on pathohistological findings.

Clinical Characteristics, Management, and Outcomes of Intramedullary Spinal Cord Ependymomas in Adults: A Systematic Review

BACKGROUND

Intramedullary spinal cord ependymomas (IMSCEs) are rare tumors that mostly occur in adults. Management strategies and related outcomes are heterogeneously reported across the literature, demanding a comprehensive analysis to standardize guidelines. We performed a systematic review of the literature on IMSCEs.

METHODS

A literature search was conducted using 6 databases from inception up to July 28, 2022. Studies with data on clinical characteristics, management strategies, and related outcomes in adult patients with histopathologically confirmed IMSCEs were pooled and analyzed.

RESULTS

The analysis included 69 studies comprising 457 patients (52.7% males). Mean age was 42.4 ± 7.4 years. Sensory deficit (58.0%) was the most prevalent symptom, followed by radicular pain (50.5%). Tumors mostly involved the cervical (64.4%) or thoracic (18.8%) spinal cord and were mostly World Health Organization grade II (80.5%) and classic subtype (72.4%). Gross total resection was performed in most cases (83.4%), with adjuvant radiotherapy delivered in 10.5% of cases. Progression-free survival ≥2 years was reported in 61.1% of cases, and tumor recurrence or progression was reported in only 7.0% of the patients. At last follow-up, 97.4% of patients were alive.

CONCLUSIONS

IMSCEs are uncommon tumors that frequently manifest with debilitating symptoms that require surgical treatment. When feasible, gross total resection may be pursued to improve the patient's functional status and prevent tumor progression, with adjuvant radiotherapy required only in some more aggressive grade III lesions. Future studies should investigate different growth patterns and prognoses based on different IMSCE subtypes.

Complete Versus Incomplete Surgical Resection in Intramedullary Astrocytoma: Systematic Review with Individual Patient Data Meta-Analysis

STUDY DESIGN

Systematic reviewBackground: Considering the infiltrative nature of intramedullary astrocytoma, the goal of surgery is to have a better patient related outcome.

OBJECTIVE

To compare the overall survival (OS) and neurologic outcomes of complete vs incomplete surgical resection for patients with intramedullary astrocytoma.

METHODS

A comprehensive search of MEDLINE, CENTRAL and EMBASE was conducted by two independent reviewers. Individual patient data (IPD) analysis and multivariate Cox Proportional Hazard Model was developed to measure the effect of surgical strategies on OS, post-operative neurological improvement (PNI), and neurological improvement in the last follow up (FNI).

RESULTS

We included 1079 patients from 35 studies. Individual patient data of 228 patients (13 articles) was incorporated into the integrative IPD analysis. Kaplan-Meier survival analysis showed complete resection (CR) significantly improved OS in comparison with the incomplete resection (IR) (log-rank test, P = .004). In the multivariate IPD analysis, three prognostic factors had significant effect on the OS: (1) Extent of Resection, (2) pathology grade, and (3) adjuvant therapy. We observed an upward trend in the popularity of chemotherapy, but CR, IR, and radiotherapy had relatively stable trends during three decades.

CONCLUSION

Our study shows that CR can improve OS when compared to IR. Patients with spinal cord astrocytoma undergoing CR had similar PNI and FNI compared to IR. Therefore, CR should be the primary goal of surgery, but intraoperative decisions on the extent of resection should be relied on to prevent neurologic adverse events. Due to significant effect of adjuvant therapy on OS, PNI and FNI, it could be considered as the routine treatment strategy for spinal cord astrocytoma.

Current management in the treatment of intramedullary ependymomas in children

PURPOSE

Current management of pediatric intramedullary ependymoma is extrapolated from adult series since large studies in children are unavailable. This has led us to share our experience with this rare tumor and compare it to the literature and to review and highlight important aspects of current management and point out inconsistencies.

METHODS

This is a retrospective analysis of patients with intramedullary ependymoma managed at our institution between 2004 and 2021.

RESULTS

During the study period, 5 patients were treated for intramedullary ependymoma. Cases of myxopapillary ependymoma were excluded. The mean age of our cohort was 11.2 years. We identified 4 cases of grade II ependymoma and 1 case of grade III ependymoma. Gross tumor removal (GTR) was achieved in two patients (40%) of patients. One patient was treated with radiotherapy for recurrence and two patients received chemotherapy. There were no cases of recurrence among patients treated with GTR, but in all patients treated with STR. Eighty percent of patients either improved or stayed stable neurologically. During follow-up (mean 73 months), 2 patients died of disease.

CONCLUSION

GTR and tumor grade remain the key prognostic factor of long-term tumor-free survival. Many questions prevail regarding outcomes, correct use of adjuvant therapy, and prognostic factors.

Characterization and Treatment of Spinal Tumors

The prevalence of spinal tumors is rare in comparison to brain tumors which encompass most central nervous system tumors. Tumors of the spine can be divided into primary and metastatic tumors with the latter being the most common presentation. Primary tumors are subdivided based on their location on the spinal column and in the spinal cord into intramedullary, intradural extramedullary, and primary bone tumors. Back pain is a common presentation in spine cancer patients; however, other radicular pain may be present. Magnetic resonance imaging (MRI) is the imaging modality of choice for intradural extramedullary and intramedullary tumors. Plain radiographs are used in the initial diagnosis of primary bone tumors while Computed tomography (CT) and MRI may often be necessary for further characterization. Complete surgical resection is the treatment of choice for spinal tumors and may be curative for well circumscribed lesions. However, intralesional resection along with adjuvant radiation and chemotherapy can be indicated for patients that would experience increased morbidity from damage to nearby neurological structures caused by resection with wide margins. Even with the current treatment options, the prognosis for aggressive spinal cancer remains poor. Advances in novel treatments including molecular targeting, immunotherapy and stem cell therapy provide the potential for greater control of malignant and metastatic tumors of the spine.

Primary Spinal Cord Astrocytomas: Two-Center Clinical Experience of Low- and High-Grade Lesions

OBJECTIVE

Primary spinal cord astrocytomas are rare, fatal, and poorly studied.

METHODS

This study included a 2-center, retrospective analysis of primary spinal cord astrocytoma patients from 1997 to 2020. Patients with drop metastases or without at least one follow-up were excluded.

RESULTS

Seven World Health Organization grade I, 6 grade II, 7 grade III, and 4 grade IV astrocytoma patients were included. Older patients had higher grades (median 20 years in grade I vs. 36.5 in grade IV). The median follow-up was 15 months. Thirteen patients were discharged to rehabilitation. Eight patients demonstrated radiographic progression. Adjuvant therapy was utilized more in higher grades (5 of 13 grades III vs. all 11 grades IIIIV). Six patients died (1 death in grades III vs. 5 in grades IIIIV). Ten patients had worsened symptoms at the last follow-up. The median progression-free survival in grade I, II, III, and IV tumors was 116, 36, 8, and 8.5 months, respectively. The median overall survival in grade I, II, III, and IV tumors was 142, 69, 19, and 12 months, respectively. Thrombotic complications occurred in 2 patients, one with isocitrate dehydrogenasewild type glioblastoma.

CONCLUSIONS

Outcomes worsen with higher grades and lead to difficult postoperative periods. Clinicians should be vigilant for thromboembolic complications. Further research is needed to understand these rare tumors.

Extra-Neural Metastases of Late Recurrent Myxopapillary Ependymoma to Left Lumbar Paravertebral Muscles: Case Report and Review of the Literature

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.

Surgical approaches to intramedullary spinal cord astrocytomas in the age of genomics

Intramedullary astrocytomas represent approximately 30%–40% of all intramedullary tumors and are the most common intramedullary tumor in children. Surgical resection is considered the mainstay of treatment in symptomatic patients with neurological deficits. Gross total resection (GTR) can be difficult to achieve as astrocytomas frequently present as diffuse lesions that infiltrate the cord. Therefore, GTR carries a substantial risk of new post-operative deficits. Consequently, subtotal resection and biopsy are often the only surgical options attempted. A midline or paramedian sulcal myelotomy is frequently used for surgical resection, although a dorsal root entry zone myelotomy can be used for lateral tumors. Intra-operative neuromonitoring using D-wave integrity, somatosensory, and motor evoked potentials is critical to facilitating a safe resection. Adjuvant radiation and chemotherapy, such as temozolomide, are often administered for high-grade recurrent or progressive lesions; however, consensus is lacking on their efficacy. Biopsied tumors can be analyzed for molecular markers that inform clinicians about the tumor’s prognosis and response to conventional as well as targeted therapeutic treatments. Stratification of intramedullary tumors is increasingly based on molecular features and mutational status. The landscape of genetic and epigenetic mutations in intramedullary astrocytomas is not equivalent to their intracranial counterparts, with important difference in frequency and type of mutations. Therefore, dedicated attention is needed to cohorts of patients with intramedullary tumors. Targeted therapeutic agents can be designed and administered to patients based on their mutational status, which may be used in coordination with traditional surgical resection to improve overall survival and functional status.

Predictors of survival and time to progression following operative management of intramedullary spinal cord astrocytomas

PURPOSE

Surgical resection is considered standard of care for primary intramedullary astrocytomas, but the infiltrative nature of these lesions often precludes complete resection without causing new post-operative neurologic deficits. Radiotherapy and chemotherapy serve as potential adjuvants, but high-quality data evaluating their efficacy are limited. Here we analyze the experience at a single comprehensive cancer center to identify independent predictors of postoperative overall and progression-free survival.

METHODS

Data was collected on patient demographics, tumor characteristics, pre-operative presentation, resection extent, long-term survival, and tumor progression/recurrence. Kaplan-Meier curves modeled overall and progression-free survival. Univariable and multivariable accelerated failure time regressions were used to compute time ratios (TR) to determine predictors of survival.

RESULTS

94 patients were included, of which 58 (62%) were alive at last follow-up. On multivariable analysis, older age (TR = 0.98; p = 0.03), higher tumor grade (TR = 0.12; p < 0.01), preoperative back pain (TR = 0.45; p < 0.01), biopsy [vs GTR] (TR = 0.18; p = 0.02), and chemotherapy (TR = 0.34; p = 0.02) were significantly associated with poorer survival. Higher tumor grade (TR = 0.34; p = 0.02) and preoperative bowel dysfunction (TR = 0.31; p = 0.02) were significant predictors of shorter time to detection of tumor growth.

CONCLUSION

Tumor grade and chemotherapy were associated with poorer survival and progression-free survival. Chemotherapy regimens were highly heterogeneous, and randomized trials are needed to determine if any optimal regimens exist. Additionally, GTR was associated with improved survival, and patients should be counseled about the benefits and risks of resection extent.

Intramedullary Spinal Cord Lesions: A Single-Center Experience

Objective: Spinal cord tumors constitute a small part of spinal surgery owing to their rarity. This retrospective study describes their current management.Methods: Forty-eight patients were treated for an intramedullary tumor between 2014 and 2020 at a single institution. Patients’ files were retrospectively studied. We detailed clinical status according to neurological deficit and ambulatory ability using the modified McCormick Scale, radiological features like number of levels, associated syringomyelia, surgical technique with or without intraoperative electrophysiological monitoring, pathological findings, and postoperative outcome.Results: The median age of this population was 43 years, including 5 patients under 18 years. The median delay before first neurosurgical contact was 3 months after the first clinical complaint. Treatment was gross total resection in 43.8%, subtotal resection in 50.0%, and biopsy in 6.2%. A laminectomy was performed for all the patients except 2 operated using the laminoplasty technique. Pathological findings were ependymoma in 43.8%, hemangioblastoma in 20.8%, and pilocytic astrocytoma in 10.4%. Six patients were reoperated for a tumor recurrence less than 2 years after the first surgical resection. One patient was reoperated for a postoperative cervical kyphosis.Conclusion: Intramedullary tumors are still a challenging disease and they are treated by various surgical techniques. They must be managed in a specialized center including a trained surgical, radiological, electrophysiological, and pathological team. Arthrodesis must be discussed before performing extensive laminectomy to avoid postoperative kyphosis.

Magnetic resonance imaging indicators for neurological outcome after surgery in patients with intramedullary spinal ependymomas

This is a retrospective study. The aim of this study was to determine the indicators of neurological outcome after surgery in patients with intramedullary spinal ependymomas by using magnetic resonance imaging (MRI).A total of 106 consecutive patients (mean age: 42.4 ± 1.3 years; 52.8% male) diagnosed with intramedullary spinal ependymomas were retrospectively recruited. All patients underwent spine MRI and subsequent surgical resection for the spinal tumors. Data regarding clinical symptoms and pathological grades of tumors were collected from clinical records. The McCormick score was used for grading patients' neurological status before and after surgery at 12 months. Good outcome was defined as stable McCormick score (McC) score (no change of McC score between preoperation and post-operation at 12 months) or improvement in McC score (post-operative McC score at 12 months < preoperative McC score). Poor outcome was determined when there was an increase in McC score at 12 months after surgery. The MRI characteristics of spinal ependymomas between patients with good and poor neurological outcomes were compared. Logistic regression was performed to assess the association between MRI characteristics of tumors and post-operative neurological outcomes.Patients with poor neurological outcomes had larger longitudinal length (4.7 ± 0.5 vs 3.3 ± 0.2, P = .004) and higher enhancement signal-to-noise-ratio (SNR) (102.4 ± 12.3 vs 72.8 ± 4.6, P = .022) than those with good neurological outcomes. After adjusting for confounding factors, longitudinal length (OR, 0.768; 95% CI, 0.604-0.976; P = .031) and enhancement SNR (OR, 0.988; 95% CI, 0.978-0.999; P = .026) of spinal ependymomas were significantly associated with poor neurological prognosis.The longitudinal length of tumor and enhancement SNR on T1-weighted images are independently associated with neurological outcome after surgery.

Prognostic Factors Independently Associated With Improved Progression-Free Survival After Surgical Resection in Patients With Spinal Cord Astrocytomas: An Institutional Case Series

BACKGROUND

Spinal astrocytomas are rare tumors in which the extent of resection and adjuvant therapy remain controversial. A number of new molecular markers are used, but their utility in spinal cord tumors remains unclear.

OBJECTIVE

To determine prognostic indicators of progression-free survival (PFS) in patients with spinal astrocytomas.

METHODS

A retrospective chart review identified all patients managed at a single institution for spinal cord astrocytomas between 1999 and 2019. Data collected included baseline demographics, presenting signs and symptoms, tumor size, operative outcomes, and adjuvant treatment. Pathological data including histopathological grade, proliferative index, and molecular profile were collected. Duration of follow-up, presence of tumor progression, and status at last follow-up were documented. Univariate and multivariate analyses were performed to determine predictors of PFS.

RESULTS

Seventy-five patients were included in our study with an average age of 42 ± 17 yr. The thoracic spine was the most commonly involved spinal segment (50 patients), and most patients had grade I or grade II tumors (50 patients). On univariate analysis, gross total resection (GTR), lower tumor grade, and low Ki-67 index were associated with lower tumor progression (P-values .01, .04, and .00013, respectively). On multivariate Cox regression analysis, GTR, adjuvant chemotherapy and radiation, and low Ki-67 index were independent predictors of PFS (P-values .009, .011, and .031, respectively).

CONCLUSION

In spinal astrocytomas, GTR, adjuvant therapy, and low Ki-67 are independently associated with improved PFS. These data may help guide management of these tumors and provide important prognosticating information.

Analyses of DNA Methylation Profiling in the Diagnosis of Intramedullary Astrocytomas

Intramedullary astrocytomas (IMAs) consist of a heterogeneous group of rare central nervous system (CNS) tumors associated with variable outcomes. A DNA methylation-based classification approach has recently emerged as a powerful tool to further classify CNS tumors. However, no DNA methylation-related studies specifically addressing to IMAs have been performed yet. In the present study, we analyzed 16 IMA samples subjected to morphological and molecular analyses, including DNA methylation profiling. Among the 16 samples, only 3 cases were classified in a reference methylation class (MC) with the recommended calibrated score (≥0.9). The remaining cases were either considered “no-match” cases (calibrated score <0.3, n = 7) or were classified with low calibrated scores (ranging from 0.32 to 0.53, n = 6), including inconsistent classification. To obtain a more comprehensive tool for pathologists, we used different unsupervised analyses of DNA methylation profiles, including our data and those from the Heidelberg reference cohort. Even though our cohort included only 16 cases, hypotheses regarding IMA-specific classification were underlined; a potential specific MC of PA_SPINE was identified and high-grade IMAs, probably consisting of H3K27M wild-type IMAs, were mainly associated with ANA_PA MC. These hypotheses strongly suggest that a specific classification for IMAs has to be investigated.

Spinal intramedullary schwannomas-report of a case and extensive review of the literature

Intramedullary schwannomas (IMS) represent exceptional rare pathologies. They commonly present as solitary lesions; only five cases of multiple IMS have been described so far. Here, we report the sixth case of a woman with multiple IMS. Additionally, we performed the first complete systematic review of the literature for all cases reporting IMS. We performed a systematic review of the literature in PubMed, EMBASE and Cochrane Central Register of Controlled (CENTRAL) to retrieve all relevant studies and case reports on IMS. In a second step, we analysed all reported studies with respect to additional cases, which were not identified through the database search. Studies published in other languages than English were included. One hundred nineteen studies including 165 reported cases were included. In only five cases, the patients harboured more than one IMS. Gender ratio showed a ratio of nearly 3:2 (male:female); mean age of disease presentation was 40.2 years; 11 patients suffered from neurofibromatosis (NF) type 1 or 2 (6.6%). IMS are rare. Our first systematic review on this pathology revealed 166 cases, including the here reported case of multiple IMS. Our review offers a basis for further investigation on this disease.

Complete Versus Incomplete Surgical Resection in Intramedullary Ependymomas: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review.

OBJECTIVE

To compare outcomes of complete versus incomplete resection in primary intramedullary spinal cord ependymoma.

METHODS

A comprehensive search of the MEDLINE, CENTRAL, and Embase databases was conducted by 2 independent investigators. Random-effect meta-analysis and meta-regression with seven covariates were performed to evaluate the reason for the heterogeneity among studies. We also used individual patient data in the integrative analysis to compare complete and incomplete resection based on 4 outcomes: progression-free survival (PFS), overall survival (OS), postoperative neurological improvement (PNI), and follow-up neurological improvement (FNI).

RESULTS

A total of 23 studies were identified, including 407 cases. Significant heterogeneity among included studies was observed in risk estimates (I² for PFS, FNI, and PNI were 49.5%, 78.3%, and 87.2%, respectively). The mean follow-up time across cases was 48.6 ± 2.35 months. Cox proportional multivariable analysis revealed that the complete resection can prolong PFS (model, hazard ratio = 0.18, CI 0.05-0.54, P = .004,) and improve the FNI (binary logistic regression, adjusted odds ratio = 16.5, CI 1.6-171, P = .019). However, PNI and OS were similar in patients with incomplete resected spinal cord ependymoma compared with complete resection (binary logistic regression respectively and Cox multivariable analysis, P > .5).

CONCLUSION

The data presented in this study showed that OS was not significantly affected by the degree of surgery. However, complete resection of intramedullary ependymomas provides the optimal outcomes with longer PFS and better long-term neurological outcomes than incomplete resection.

Correlation of Intraoperative Neurophysiological Parameters and Outcomes in Patients with Intramedullary Tumors

Introduction

Intramedullary spinal cord tumors (IMSCT) account for about 2%-4% of all central nervous system tumors. Surgical resection is the main treatment step, but might cause damage to functional tissues. Intraoperative neuromonitoring (IONM) is an adopted measure to decrease surgical complications. Below, we describe the results of IMSCT submitted to surgery under IONM at a tertiary institution.

Methods

The sample consisted of consecutive patients with IMSCT admitted to the Neurological Institute of Curitiba from January 2007 to November 2016. A total of 47 patients were surgically treated. Twenty-three were male (48.9%) and 24 were female (51.1%). The mean age was 42.77 years. The mean follow-up time was 42.7 months.

Results

Neurological status improved in 29 patients (62%), stable in 6 (13%), and worse in 12 (25%). Patients who presented with motor symptoms at initial diagnosis had a worse outcome compared to patients with sensory impairment and pain (P = 0.026). Patients with a change in electromyography had worse neurological outcomes compared to patients who did not show changes in monitoring (P = 0.017).

Discussion and Conclusion

No prospective randomized high evidence study has been performed to date to compare clinical evolution after surgery with or without monitoring. In our sample, surgical resection was well succeeded mainly in oligosymptomatic patients with low preoperative McCormick classification and no worsening of IONM during surgery. We believe that microsurgical resection of IMSCT with simultaneous IONM is the gold standard treatment and achieved with good results.

Challenges in diagnosis and management of adult spinal cord gliomas

Intramedullary spinal cord gliomas have very low incidence rates. They are associated with difficulties in diagnosis and treatment, and cause significant morbidity. Their clinical presentation and their appearance at magnetic resonance imaging are not specific. They can mimic inflammatory, infectious, vascular disorders or other neoplastic lesions. Primary treatment is surgery. Surgical resection can often be total for ependymomas, but difficult for infiltrating astrocytomas. Radiotherapy is indicated for malignant tumors, but remains controversial in some indications. Chemotherapy is reserved for recurrence, but small retrospective series are available. Genetic studies have revealed genetic alterations which could have a potential impact on treatment in the near future.

Image-Guided Robotic Radiosurgery for the Management of Intramedullary Spinal Cord Metastases-A Multicenter Experience

Simple Summary

Due to recent medical advancements, patients suffering from metastatic cancer have a prolonged life expectancy compared to several decades ago. Thus, the number of patients who experience metastasis to the spinal cord is increasing. Intramedullary metastases bear a dismal prognosis and cause considerable morbidity. Limited data are available on the treatment of such lesions. As surgery may be the mainstay of treatment for resectable and localized metastatic spread, previous case reports and series suggest radiosurgery to be a treatment alternative. This first multicenter study analyzes the efficacy of robotic radiosurgery (RRS) for the management of intramedullary metastases. Outcomes provide evidence that RRS is a safe, time-saving and effective treatment modality, especially for patients with unresectable lesions. Most patients die from systemic disease progression, while the majority of treated lesions remain controlled until death. Most symptoms improve or stay stable after treatment. These findings may guide further palliative care of affected patients.

Abstract

Background: Intramedullary metastases are rare and bear a dismal prognosis. Limited data are available on the treatment of such lesions. As surgery may be the mainstay of treatment for patients with resectable and localized metastatic spread, previous case reports and case series suggest radiosurgery to be another viable treatment modality. This multicenter study analyzes the efficacy and safety of robotic radiosurgery (RRS) for intramedullary metastases. Methods: Patients who received RRS for the treatment of at least one intramedullary metastasis were included. Results: Thirty-three patients with 46 intramedullary metastases were treated with a median dose of 16 Gy prescribed to a median isodose of 70%. The local control was 79% after a median follow-up of 8.5 months. The median overall survival (OS) was 11.7 months, with a 12- and 24-month OS of 47 and 31%. The 12-month progression-free survival was 42% and at 24 months 25%. In addition, 57% of patients showed either an improved or stable neurological function after treatment delivery. Systemic disease progression was the main cause of death. No significant treatment-related toxicities were observed. Conclusions: RRS appears to be a safe, time-saving and effective treatment modality for intramedullary metastases, especially for patients with unresectable lesions and high burden of disease.

Canadian Pediatric Neuro-Oncology Standards of Practice

Primary CNS tumors are the leading cause of cancer-related death in pediatrics. It is essential to understand treatment trends to interpret national survival data. In Canada, children with CNS tumors are treated at one of 16 tertiary care centers. We surveyed pediatric neuro-oncologists to create a national standard of practice to be used in the absence of a clinical trial for seven of the most prevalent brain tumors in children. This allowed description of practice across the country, along with a consensus. This had a multitude of benefits, including understanding practice patterns, allowing for a basis to compare in future research and informing Health Canada of the current management of patients. This also allows all children in Canada to receive equivalent care, regardless of location.

[Visual fluorescence combined with laser spectroscopy in surgery for intramedullary spinal cord tumors]

BACKGROUND

Surgical treatment of intramedullary spinal cord tumors is aimed at total resection of tumor with maximum preservation of neurological and functional status. In some cases, intramedullary tumors have unclear dissection plane or gliosis zone. This area is not a tumor and does not require resection. However, it is difficult to distinguish visually intact spinal cord tissue and tumor at the last surgical stages. Thus, we evaluated the effectiveness of fluorescence combined with laser spectroscopy in surgical treatment of intramedullary spinal cord tumors.

OBJECTIVE

To determine the effectiveness of visual fluorescence combined with laser spectroscopy in surgery for intramedullary spinal cord tumors.

MATERIAL AND METHODS

There were 850 patients with intramedullary spinal cord tumors for the period 2001-2019. In 35 cases, intraoperative fluoroscopy with laser spectroscopy were used. All patients underwent a comprehensive pre- and postoperative clinical and instrumental examination (general and neurological status, McCormick grade, spinal cord MRI). Carl Zeiss OPMI Pentero microscope with a fluorescent module was used for intraoperative fluorescence diagnosis. A domestic preparation 5-ALA «ALASENS» (State Research Center NIOPIK, Moscow, Russia) was used for induction of visible fluorescence. Laser spectroscopy was carried out using a LESA-01-BIOSPEK spectrum analyzer. Morphological analysis of intramedullary spinal cord tumors was performed in the neuromorphology laboratory of the Burdenko Neurosurgery Center.

RESULTS

Intramedullary anaplastic ependymoma and astrocytoma, as well as conventional ependymoma were characterized by the highest index of 5-ALA accumulation. Intramedullary hemangioblastoma and cavernoma do not accumulate 5-aminolevulinic acid due to morphological structure of these tumors. In particular, there are no cells capable of capturing and processing 5-ALA in these tumors. Sensitivity of visual fluorescence combined with laser spectroscopy varies from 0% to 100% depending on the histological type of tumor: hemangiogblastoma and cavernoma - 0%, low-grade astrocytoma - 70%, high-grade astrocytoma - 80%, ependymoma - 92%, anaplastic ependymoma 100%. Dissection plane is absent in anaplastic ependymoma, high-grade astrocytoma. We often observed gliosis during resection of ependymoma. This tissue is not a part of tumor. Intraoperative metabolic navigation with neurophysiological monitoring are advisable for total tumor resection in case of unclear dissection plane and peritumoral gliosis.

CONCLUSION

Visual fluorescence combined with laser spectroscopy is a perspective method for intraoperative imaging of tumor remnants and total resection of intramedullary spinal cord tumors with minimum risk of neurological impairment.

Clinical, radiological and molecular characterization of intramedullary astrocytomas

Intramedullary astrocytomas (IMAs) are rare tumors, and few studies specific to the molecular alterations of IMAs have been performed. Recently, KIAA1549-BRAF fusions and the H3F3A p.K27M mutation have been described in low-grade (LG) and high-grade (HG) IMAs, respectively. In the present study, we collected clinico-radiological data and performed targeted next-generation sequencing for 61 IMAs (26 grade I pilocytic, 17 grade II diffuse, 3 LG, 3 grade III and 12 grade IV) to identify KIAA1549-BRAF fusions and mutations in 33 genes commonly implicated in gliomas and the 1p/19q regions. One hundred seventeen brain astrocytomas were analyzed for comparison. While we did not observe a difference in clinico-radiological features between LG and HG IMAs, we observed significantly different overall survival (OS) and event-free survival (EFS). Multivariate analysis showed that the tumor grade was associated with better OS while EFS was strongly impacted by tumor grade and surgery, with higher rates of disease progression in cases in which only biopsy could be performed. For LG IMAs, EFS was only impacted by surgery and not by grade. The most common mutations found in IMAs involved TP53, H3F3A p.K27M and ATRX. As in the brain, grade I pilocytic IMAs frequently harbored KIAA1549-BRAF fusions but with different fusion types. Non-canonical IDH mutations were observed in only 2 grade II diffuse IMAs. No EGFR or TERT promoter alterations were found in IDH wild-type grade II diffuse IMAs. These latter tumors seem to have a good prognosis, and only 2 cases underwent anaplastic evolution. All of the HG IMAs presented at least one molecular alteration, with the most frequent one being the H3F3A p.K27M mutation. The H3F3A p.K27M mutation showed significant associations with OS and EFS after multivariate analysis. This study emphasizes that IMAs have distinct clinico-radiological, natural evolution and molecular landscapes from brain astrocytomas.

RELA fusion-positive ependymoma accompanied by extensive desmoplasia: a case report

We report a case of 33-year-old Japanese male who presented with a headache and visual disturbances. Magnetic resonance imaging revealed a large tumor in the left frontal lobe, measuring 7 cm in diameter, which was diagnosed as supratentorial anaplastic ependymoma accompanied by extensive desmoplasia. The patient underwent a gross total resection. Histologically, the tumor cells had oval or short, spindle-shaped nuclei, and proliferating cells in perivascular pseudorosettes with anucleate zones and mitotic figures. Desmoplasia with abundant collagen fibers among the tumor cells was detected at numerous sites, and perinuclear dot- or ring-like immunoreactivity for epithelial membrane antigen was identified. Five years and six months after the initial procedure, a small recurrent tumor was identified at the removal site. The patient underwent a second total resection. The histology of the resected tumor showed decreased collagen production and more apparent anaplastic features as compared to those of the initial tumor. In addition to the histological findings, molecular examinations revealed ependymoma, RELA fusion positive. Although not commonly observed, this case suggests that desmoplasia could be associated with ependymomas, including RELA fusion-positive variant. Moreover, our findings indicate that high-grade ependymoma requires careful, long-term follow-up even if gross total resection is performed.

Rare Primary Central Nervous System Tumors in Adults: An Overview

Overall, tumors of primary central nervous system (CNS) are quite common in adults with an incidence rate close to 30 new cases/100,000 inhabitants per year. Significant clinical and biological advances have been accomplished in the most common adult primary CNS tumors (i.e., diffuse gliomas). However, most CNS tumor subtypes are rare with an incidence rate below the threshold defining rare disease of 6.0 new cases/100,000 inhabitants per year. Close to 150 entities of primary CNS tumors have now been identified by the novel integrated histomolecular classification published by the World Health Organization (WHO) and its updates by the c-IMPACT NOW consortium (the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy). While these entities can be better classified into smaller groups either by their histomolecular features and/or by their location, assessing their treatment by clinical trials and improving the survival of patients remain challenging. Despite these tumors are rare, research, and advances remain slower compared to diffuse gliomas for instance. In some cases (i.e., ependymoma, medulloblastoma) the understanding is high because single or few driver mutations have been defined. The European Union has launched European Reference Networks (ERNs) dedicated to support advances on the clinical side of rare diseases including rare cancers. The ERN for rare solid adult tumors is termed EURACAN. Within EURACAN, Domain 10 brings together the European patient advocacy groups (ePAGs) and physicians dedicated to improving outcomes in rare primary CNS tumors and also aims at supporting research, care and teaching in the field. In this review, we discuss the relevant biological and clinical characteristics, clinical management of patients, and research directions for the following types of rare primary CNS tumors: medulloblastoma, pineal region tumors, glioneuronal and rare glial tumors, ependymal tumors, grade III meningioma and mesenchymal tumors, primary central nervous system lymphoma, germ cell tumors, spinal cord tumors and rare pituitary tumors.

Spinal Cord Ependymomas With MYCN Amplification Show Aggressive Clinical Behavior

Adult spinal cord ependymomas are typically low grade and have a relatively favorable clinical course following gross total resection. We report 4 cases of anaplastic spinal cord ependymoma with MYCN amplification, an exceptionally rare finding. All cases occurred in the spinal cord of adolescent and young adult women and had morphological and immunohistochemical features of anaplastic ependymomas (World Health Organization grade III). Chromosomal microarray analysis demonstrated amplification of 2p24 (including MYCN) in all cases. One patient died 6 months after surgery. Another patient recently had removal of metastatic nodules in the thoracic region, following gross total resection and adjuvant radiation therapy of a lumbar ependymoma 1 year previously. One patient responded well after chemotherapy but died after multiple relapses 82 months after diagnosis. We found MYCN amplification reported in 2 other ependymomas, both anaplastic and arising in the spinal cord of adult females (Brain Pathol 2001;11:133-43). One patient had multiple recurrences in the spinal cord and an intracranial metastasis. Although MYCN amplification is rare in ependymomas, the current and previously reported cases suggest that this is associated with higher-grade histology, spinal location, and often unfavorable prognosis. The clinical significance and therapeutic implications of MYCN amplification in ependymomas require further evaluation.

Adult primary high-grade spinal glioma: a nationwide analysis of current trends in treatment and outcomes

PURPOSE

High-grade spinal glioma (HGSG) is an extremely rare, malignant neoplasm insufficiently described in the literature. We sought to investigate the effect of epidemiological risk factors and treatment strategies on the prognosis of HGSGs using the National Cancer Database (NCDB).

METHODS

Patients with diagnosis codes specific for HGSG were queried from the NCDB during the years 2004-2016. Kaplan-Meier curves were generated with log-rank testing performed to assess factors affecting survival. Univariate and multivariate Cox regression analysis was also performed to investigate overall survival.

RESULTS

396 patients were identified with a histologically-confirmed diagnosis of HGSG between 2004-2016. The mean survival time for all patients was 24.5 months (SD: 20.3). Multivariate Cox proportional-hazards regression analysis revealed that tumor size of 26-50 mm (HR 4.96, 95% CI 1.76-13.98, p < 0.01) and greater than 50 mm (HR 4.67, 95% CI 1.43-15.23, p = 0.01) were associated with worsened overall survival in comparison to lesions less than 26 mm. While quality of life was not investigated, both Kaplan-Meier log-rank testing and regression analysis failed to demonstrate an association of survival outcomes with extent of resection, radiotherapy, or chemotherapy.

CONCLUSION

The current study represents the largest retrospective analysis of adult primary high-grade spinal glioma to date. Our analysis found no relationship between the extent of surgical resection and survival outcomes. In addition, we failed to show any statistically significant survival benefit with radiotherapy or chemotherapy. This disease process has a poor prognosis without a current modality of treatment that improves survival.

Surgical Management of Intramedullary Spinal Cord Tumors

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.

Radiotherapy in addition to surgical resection may not improve overall survival in WHO grade II spinal ependymomas

OBJECTIVES

Spinal ependymomas are rare intramedullary neoplasms. The paucity of cases limits the ability to conduct large prospective studies. Current guidelines recommend maximal safe resection followed by adjuvant radiotherapy (RT) in cases of grade II spinal ependymomas with subtotal resections (STR) and all grade III spinal ependymomas. Herein we assess the impact of RT on survival in grades II and III spinal ependymomas.

PATIENTS AND METHODS

The National Cancer Database was queried for adult patients with WHO grades II or III spinal ependymomas diagnosed between 2004 and 2014 who underwent resection or biopsy. Kaplan-Meier and multivariable Cox regression models were used to determine the impact of radiotherapy on survival.

RESULTS

A total of 1058 patients met inclusion criteria. Most patients (85.9 %) received a biopsy/STR versus gross total resection (GTR, 14.1 %). Radiotherapy was preferentially performed in those with residual tumor (p = 0.001). We found a 10-fold increased hazard of death in grade III versus grade II tumors (HR: 10.33; 95 % CI: 5.01-21.3; p < 0.001). Age positively correlated with worsened survival (HR: 1.04; 95 % CI: 1.02-1.10; p < 0.001). Adjuvant RT did not reduce the hazard of death for the cohort overall (HR: 1.08; 95 % CI: 0.55-2.10; p = 0.810) or among those with grade II tumors (HR: 0.90; 95 % CI: 0.38-2.10; p = 0.810). We found no additional survival benefit of GTR compared to biopsy/STR (HR: 0.52; 95 % CI: 0.19-1.50; p = 0.217).

CONCLUSION

While RT may improve progression-free survival, it may not impact overall survival in surgically resected grade II and III spinal ependymomas. Future studies should evaluate the impact of RT on local recurrence and symptomatic improvement.