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Mohan D, Nambirajan A, Malik R, Sharma A, Suri V, Kaur K, Doddamani R, Garg A, Gupta S, Mallick S, Sharma MC. MYCN immunohistochemistry as surrogate marker for MYCN-amplified spinal ependymomas. Hum Cell 2024; 37:704-713. [PMID: 38411836 DOI: 10.1007/s13577-024-01037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/21/2024] [Indexed: 02/28/2024]
Abstract
MYCN (master regulator of cell cycle entry and proliferative metabolism) gene amplification defines a molecular subgroup of spinal cord ependymomas that show high-grade morphology and aggressive behavior. Demonstration of MYCN amplification by DNA methylation or fluorescence-in situ hybridization (FISH) is required for diagnosis. We aimed to (i) assess prevalence and clinicopathological features of MYCN-amplified spinal ependymomas and (ii) evaluate utility of immunohistochemistry (IHC) for MYCN protein as a surrogate for molecular testing. A combined retrospective-prospective study spanning 8 years was designed during which all spinal cord ependymomas with adequate tissue were subjected to MYCN FISH and MYCN IHC. Among 77 spinal cord ependymomas included, MYCN amplification was identified in 4 samples from 3 patients (3/74, 4%) including two (1st and 2nd recurrences) from the same patient. All patients were adults (median age at diagnosis of 32 years) including two females and one male. The index tumors were located in thoracic (n = 2) and lumbar (n = 1) spinal cord. One of the female patients had neurofibromatosis type 2 (NF2). All four tumors showed anaplastic histology. Diffuse expression of MYCN protein was seen in all four MYCN-amplified samples but in none of the non-amplified cases, thus showing 100% concordance with FISH results. On follow-up, the NF2 patient developed widespread spinal dissemination while another developed recurrence proximal to the site of previous excision. To conclude, MYCN-amplified spinal ependymomas are rare tumors, accounting for ~ 4% of spinal cord ependymomas. Within the limitation of small sample size, MYCN IHC showed excellent concordance with MYCN gene amplification.
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Affiliation(s)
- Divya Mohan
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Aruna Nambirajan
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Rafat Malik
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Agrima Sharma
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Vaishali Suri
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kavneet Kaur
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ramesh Doddamani
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ajay Garg
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Subhash Gupta
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Supriya Mallick
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Mehar Chand Sharma
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Davison MA, Lilly DT, Patel AA, Kashkoush A, Chen X, Wei W, Benzel EC, Prayson RA, Chao S, Angelov L. Clinical presentation and extent of resection impacts progression-free survival in spinal ependymomas. J Neurooncol 2024; 167:437-446. [PMID: 38438766 PMCID: PMC11096218 DOI: 10.1007/s11060-024-04623-4] [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: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 03/06/2024]
Abstract
PURPOSE Primary treatment of spinal ependymomas involves surgical resection, however recurrence ranges between 50 and 70%. While the association of survival outcomes with lesion extent of resection (EOR) has been studied, existing analyses are limited by small samples and archaic data resulting in an inhomogeneous population. We investigated the relationship between EOR and survival outcomes, chiefly overall survival (OS) and progression-free survival (PFS), in a large contemporary cohort of spinal ependymoma patients. METHODS Adult patients diagnosed with a spinal ependymoma from 2006 to 2021 were identified from an institutional registry. Patients undergoing primary surgical resection at our institution, ≥ 1 routine follow-up MRI, and pathologic diagnosis of ependymoma were included. Records were reviewed for demographic information, EOR, lesion characteristics, and pre-/post-operative neurologic symptoms. EOR was divided into 2 classifications: gross total resection (GTR) and subtotal resection (STR). Log-rank test was used to compare OS and PFS between patient groups. RESULTS Sixty-nine patients satisfied inclusion criteria, with 79.7% benefitting from GTR. The population was 56.2% male with average age of 45.7 years, and median follow-up duration of 58 months. Cox multivariate model demonstrated significant improvement in PFS when a GTR was attained (p <.001). Independently ambulatory patients prior to surgery had superior PFS (p <.001) and OS (p =.05). In univariate analyses, patients with a syrinx had improved PFS (p =.03) and were more likely to benefit from GTR (p =.01). Alternatively, OS was not affected by EOR (p =.78). CONCLUSIONS In this large, contemporary series of adult spinal ependymoma patients, we demonstrated improvements in PFS when GTR was achieved.
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Affiliation(s)
- Mark A Davison
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel T Lilly
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Arpan A Patel
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Kashkoush
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaoying Chen
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wei Wei
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward C Benzel
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Richard A Prayson
- Department of Anatomic Pathology, The Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel Chao
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
- Neurologic Oncology and Radiosurgery Fellowships, Neurological Surgery, CCLCM at CWRU, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, 9500 Euclid Ave., CA-51, 44195, Cleveland, OH, USA.
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3
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Sperber J, Owolo E, Abu-Bonsrah N, Neff C, Baeta C, Sun C, Dalton T, Sykes D, Bishop BL, Kruchko C, Barnholtz-Sloan JS, Walsh KM, Larry Lo SF, Sciubba D, Ostrom QT, Goodwin CR. Association Between Urbanicity and Outcomes Among Patients with Spinal Cord Ependymomas in the United States. World Neurosurg 2024; 181:e107-e116. [PMID: 37619838 PMCID: PMC10872827 DOI: 10.1016/j.wneu.2023.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Spinal cord ependymomas (SCEs) represent the most common intramedullary spinal cord tumors among adults. Research shows that access to neurosurgical care and patient outcomes can be greatly influenced by patient location. This study investigates the association between the outcomes of patients with SCE in metropolitan and nonmetropolitan areas. METHODS Cases of SCE between 2004 and 2019 were identified within the Central Brain Tumor Registry of the United States, a combined dataset including the Centers for Disease Control and Prevention's National Program of Cancer Registries and National Cancer Institute's Surveillance, Epidemiology, and End Results Program data. Multivariable logistic regression models were constructed to evaluate the association between urbanicity and SCE treatment, adjusted for age at diagnosis, sex, race and ethnicity. Survival data was available from 42 National Program of Cancer Registries (excluding Kansas and Minnesota, for which county data are unavailable), and Cox proportional hazard models were used to understand the effect of surgical treatment, county urbanicity, age at diagnosis, and the interaction effect between age at diagnosis and surgery, on the survival time of patients. RESULTS Overall, 7577 patients were identified, with 6454 (85%) residing in metropolitan and 1223 (15%) in nonmetropolitan counties. Metropolitan and nonmetropolitan counties had different age, sex, and race/ethnicity compositions; however, demographics were not associated with differences in the type of surgery received when stratified by urbanicity. Irrespective of metropolitan status, individuals who were American Indian/Alaska Native non-Hispanic and Hispanic (all races) were associated with reduced odds of receiving surgery. Individuals who were Black non-Hispanic and Hispanic were associated with increased odds of receiving comprehensive treatment. Diagnosis of SCE at later ages was linked with elevated mortality (hazard ratio = 4.85, P < 0.001). Gross total resection was associated with reduced risk of death (hazard ratio = 0.37, P = 0.004), and age did not interact with gross total resection to influence risk of death. CONCLUSIONS The relationship between patients' residential location and access to neurosurgical care is critical to ensuring equitable distribution of care. This study represents an important step in delineating areas of existing disparities.
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Affiliation(s)
- Jacob Sperber
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Edwin Owolo
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nancy Abu-Bonsrah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon, Africa
| | - Corey Neff
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA; Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA; Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
| | - Cesar Baeta
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chuxuan Sun
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA; Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tara Dalton
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - David Sykes
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brandon L Bishop
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA; Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, Maryland, USA; Center for Biomedical Informatics & Information Technology (CBIIT), National Cancer Institute, Bethesda, Maryland, USA
| | - Kyle M Walsh
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA; The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, New York, New York, USA
| | - Daniel Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, New York, New York, USA
| | - Quinn T Ostrom
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA; Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA; The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.
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Rao S, Sugur H, Konar S, Arivazhagan A, Santosh V. MYCN amplification in spinal ependymoma: A five-year retrospective study. Neuropathology 2023; 43:457-462. [PMID: 37221449 DOI: 10.1111/neup.12912] [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: 03/21/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
Spinal ependymoma with MYCN amplification is a newly recognized type of spinal ependymoma that is known to be associated with poor prognosis. Available studies on this relatively rare tumor type have observed that these tumors tend to disseminate along the spinal cord and behave aggressively with worse overall and progression-free survival compared to the other types of ependymoma. In this study, we describe the clinical and histopathological features of spinal ependymomas in a single institution cohort with emphasis on those with MYCN amplification.
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Affiliation(s)
- Shilpa Rao
- Department of Neuropathology and Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Harsha Sugur
- Department of Neuropathology and Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Subhas Konar
- Department of Neuropathology and Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Arimappamagan Arivazhagan
- Department of Neuropathology and Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Vani Santosh
- Department of Neuropathology and Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
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Ramwani R, Bassi D, Velasco A. Incidental Discovery of a Presacral Extradural Myxopapillary Ependymoma. Clin Med Res 2021; 19:94-98. [PMID: 33985980 PMCID: PMC8231692 DOI: 10.3121/cmr.2021.1561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/21/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022]
Abstract
Ependymoma is a malignant central nervous system tumor arising from the lining of the ventricles or central canal of the spinal cord. Extradural spinal ependymomas arise from heterotopic ependymal cells or the coccygeal medullary vestige and are extremely infrequent. We present a rare case of presacral extradural ependymoma. Extradural ependymomas typically demonstrate an extraneural spread and, thus, surveillance of the entire central nervous system is not typically recommended. A radiograph of the chest, liver profile, and attention to palpable lymphadenopathy (especially inguinal) on physical examination are vital for surveillance. Obtaining an R0 resection is the most important prognostic factor in survival and local recurrence.
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Affiliation(s)
- Roshini Ramwani
- Department of General Surgery, Marshfield Medical Center, Marshfield, WI USA
| | - Deepa Bassi
- Department of Pathology, Marshfield Clinic Health System, Marshfield, WI USA
| | - Alfonso Velasco
- Department of General Surgery, Marshfield Medical Center, Marshfield, WI USA
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6
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Ehret F, Kufeld M, Fürweger C, Haidenberger A, Windisch P, Senger C, Kord M, Träger M, Kaul D, Schichor C, Tonn JC, Muacevic A. Image-Guided Robotic Radiosurgery for the Management of Spinal Ependymomas. Front Oncol 2021; 11:654251. [PMID: 33996577 PMCID: PMC8117154 DOI: 10.3389/fonc.2021.654251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background Ependymomas are rare neoplasms of the central nervous system (CNS), usually localized intracranially and most commonly diagnosed in children. Spinal ependymomas are more frequent in young adults. They are either primary lesions or manifest as disseminated seeding of cranial tumors. Data on the management of spinal ependymoma lesions remain scarce, especially concerning stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). The purpose of this study is to report the treatment outcomes of two institutions using robotic radiosurgery (RRS) for the treatment of spinal ependymomas. Materials and Methods All patients with a histopathologically confirmed diagnosis of an ependymoma WHO grade II or III who were treated with RRS for one or more spinal lesions were included in this analysis. Results Twelve patients underwent RRS for the treatment of 32 spinal ependymoma lesions between 2005 and 2020. Two patients were below the age of 18 when treated, whereas nine patients (75%) suffered from a primary spinal ependymoma. The median dose was 15 Gy prescribed to a median isodose of 70%, with 27 lesions (84%) receiving a single-session treatment. The local control (LC) after a median follow-up of 56.7 months was 84%. LC rates at 1, 3, and 5 years were 92, 85, and 77%, respectively. The Kaplan-Meier estimated overall survival after 1, 3, and 5 years were 75, 75, and 64%, respectively. Five patients died, all of them suffering from an anaplastic ependymoma, with widespread CNS tumor progression being the reason for death in four patients. The majority of patients (58%) showed a stable neurological status at the last available follow-up. Overall, the treatment was well tolerated. Conclusion RRS appears to be a safe and efficient treatment modality for managing primary and secondary spinal ependymal tumors in patients with multiple lesions and local recurrences.
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Affiliation(s)
- Felix Ehret
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany.,European Cyberknife Center, Munich, Germany
| | | | - Christoph Fürweger
- European Cyberknife Center, Munich, Germany.,Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Cologne, Germany
| | | | - Paul Windisch
- European Cyberknife Center, Munich, Germany.,Department of Radiation Oncology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Carolin Senger
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, Berlin, Germany
| | - Melina Kord
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany
| | - Malte Träger
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany
| | - David Kaul
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany.,German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Schichor
- Department of Neurosurgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jörg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University Munich, Munich, Germany
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Gitto L, Serinelli S, Galbraith K, Williams M, Mirchia K, Galgano MA, Krishnamurthy S, de la Roza G, Viapiano MS, Walker JM, Jour G, Serrano J, DeLorenzo M, Snuderl M, Richardson TE. Anaplastic Transformation in Myxopapillary Ependymoma: A Report of 2 Cases and Review of the Literature. J Neuropathol Exp Neurol 2021; 79:1044-1053. [PMID: 32743660 DOI: 10.1093/jnen/nlaa077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/04/2020] [Accepted: 06/29/2020] [Indexed: 12/12/2022] Open
Abstract
Myxopapillary ependymoma (MPE) is a relatively common neoplasm arising primarily in the filum terminale/lumbosacral region of the spinal cord. It is designated as a grade I tumor in the most recent WHO Classification of Tumours of the CNS, although aggressive clinical behavior can be observed, especially in cases arising in an extradural location. Anaplastic transformation in MPE is exceedingly rare with <20 examples reported in the English literature, and consensus on diagnostic features and definitive grading remain to be determined. Here, we present 2 cases of recurrent MPE with anaplastic features, both of which had histology consistent with conventional MPE as well as areas with significant atypia, frequent mitotic figures, elevated Ki-67 proliferation indices (>10%-50%), necrosis, and focal vascular proliferation. Targeted next-generation sequencing panels revealed no definitive pathogenic mutations or fusion proteins in either case. Copy number profiling, methylation profiling, and t-Distributed Stochastic Neighbor Embedding were performed to investigate the molecular characteristics of these tumors. To the best of our knowledge, these are the first reported cases of MPE with anaplastic features with methylation profiling data. In addition, we review the literature and discuss common histologic and molecular findings associated with anaplastic features in MPE.
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8
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Thakar S, Sivaraju L, Ghosal N, Aryan S, Hegde AS. Fatal holocord recurrence of a pregnancy-related, low-grade spinal ependymoma: case report and review of an unusual clinical phenomenon. Spinal Cord Ser Cases 2020; 6:93. [PMID: 33009374 DOI: 10.1038/s41394-020-00343-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Pregnancy-related spinal tumors (PRSTs) are unusual tumors that present during pregnancy or within a year after delivery. We describe a fatal holocord recurrence of a spinal ependymoma, which, to the best of our knowledge, is one of the most extensive PRSTs reported thus far. CASE PRESENTATION A 21-year-old primigravida presented at 6 months of gestation with urinary incontinence for 2 months and spastic paraparesis for 1 month. MRI showed a conus intramedullary lesion from T10 to 12. Near-total resection of the lesion was performed. The histopathological diagnosis was that of a cellular ependymoma (WHO grade II). The patient presented 6 months later with progressive quadriparesis and breathing difficulty. MRI demonstrated holocord recurrence of the tumor with edema extending to the pontomedullary junction. The patient succumbed to respiratory failure before decompression of the tumor could be performed. DISCUSSION This case highlights an unusual clinical course of a pregnancy-related, low-grade spinal ependymoma. The possible hormonal and genetic mechanisms underlying the aggressive involvement of the entire spinal cord by the recurrent tumor are discussed in the light of a literature review. Future studies may shed light on the possibility of utilizing these mechanisms as therapeutic targets to alter the clinical course of aggressive spinal ependymomas.
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Affiliation(s)
- Sumit Thakar
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India.
| | - Laxminadh Sivaraju
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Nandita Ghosal
- Department of Pathology, Sri Sathya Sai Institute of Higher Medical Sciences, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Saritha Aryan
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
| | - Alangar S Hegde
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, EPIP Area, Whitefield, Bangalore, Karnataka, 560066, India
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9
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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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10
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Swanson AA, Raghunathan A, Jenkins RB, Messing-Jünger M, Pietsch T, Clarke MJ, Kaufmann TJ, Giannini C. Spinal Cord Ependymomas With MYCN Amplification Show Aggressive Clinical Behavior. J Neuropathol Exp Neurol 2020; 78:791-797. [PMID: 31373367 DOI: 10.1093/jnen/nlz064] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/16/2019] [Accepted: 06/27/2019] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Amy A Swanson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Aditya Raghunathan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Robert B Jenkins
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Martina Messing-Jünger
- Department of Pediatric Neurosurgery, Asklepios Children's Hospital, St. Augustin, Germany
| | - Torsten Pietsch
- Institute of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn, Bonn, Germany
| | | | | | - Caterina Giannini
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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11
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Elsamadicy AA, Koo AB, David WB, Lee V, Zogg CK, Kundishora AJ, Hong CS, DeSpenza T, Reeves BC, Kahle KT, DiLuna M. Comparison of epidemiology, treatments, and outcomes in pediatric versus adult ependymoma. Neurooncol Adv 2020; 2:vdaa019. [PMID: 32642681 PMCID: PMC7212900 DOI: 10.1093/noajnl/vdaa019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background Mounting evidence supports the presence of heterogeneity in the presentation of ependymoma patients with respect to location, histopathology, and behavior between pediatric and adult patients. However, the influence of age on treatment outcomes in ependymoma remains obscure. Methods The SEER database years 1975–2016 were queried. Patients with a diagnosis of ependymoma were identified using the International Classification of Diseases for Oncology, Third Edition, coding system. Patients were classified into one of 4 age groups: children (age 0–12 years), adolescents (age 13–21 years), young adults (age 22–45 years), and older adults (age >45 years). The weighed multivariate analysis assessed the impact of age on survival outcomes following surgical treatment. Results There were a total of 6076 patients identified with ependymoma, of which 1111 (18%) were children, 529 (9%) were adolescents, 2039 (34%) were young adults, and 2397 (40%) were older adults. There were statistically significant differences between cohorts with respect to race (P < .001), anatomical location (P < .001), extent of resection (P < .001), radiation use (P < .001), tumor grade (P < .001), histological classification (P < .001), and all-cause mortality (P < .001). There was no significant difference between cohorts with respect to gender (P = .103). On multivariate logistic regression, factors associated with all-cause mortality rates included males (vs females), supratentorial location (vs spinal cord tumors), and radiation treatment (vs no radiation). Conclusions Our study using the SEER database demonstrates the various demographic and treatment risk factors that are associated with increased rates of all-cause mortality between the pediatric and adult populations following a diagnosis of ependymoma.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Victor Lee
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cheryl K Zogg
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christopher S Hong
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tyrone DeSpenza
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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12
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Ghasemi DR, Sill M, Okonechnikov K, Korshunov A, Yip S, Schutz PW, Scheie D, Kruse A, Harter PN, Kastelan M, Wagner M, Hartmann C, Benzel J, Maass KK, Khasraw M, Sträter R, Thomas C, Paulus W, Kratz CP, Witt H, Kawauchi D, Herold-Mende C, Sahm F, Brandner S, Kool M, Jones DTW, von Deimling A, Pfister SM, Reuss DE, Pajtler KW. MYCN amplification drives an aggressive form of spinal ependymoma. Acta Neuropathol 2019; 138:1075-1089. [PMID: 31414211 PMCID: PMC6851394 DOI: 10.1007/s00401-019-02056-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 12/21/2022]
Abstract
Spinal ependymal tumors form a histologically and molecularly heterogeneous group of tumors with generally good prognosis. However, their treatment can be challenging if infiltration of the spinal cord or dissemination throughout the central nervous system (CNS) occurs and, in these cases, clinical outcome remains poor. Here, we describe a new and relatively rare subgroup of spinal ependymal tumors identified using DNA methylation profiling that is distinct from other molecular subgroups of ependymoma. Copy number variation plots derived from DNA methylation arrays showed MYCN amplification as a characteristic genetic alteration in all cases of our cohort (n = 13), which was subsequently validated using fluorescence in situ hybridization. The histological diagnosis was anaplastic ependymoma (WHO Grade III) in ten cases and classic ependymoma (WHO Grade II) in three cases. Histological re-evaluation in five primary tumors and seven relapses showed characteristic histological features of ependymoma, namely pseudorosettes, GFAP- and EMA positivity. Electron microscopy revealed cilia, complex intercellular junctions and intermediate filaments in a representative sample. Taking these findings into account, we suggest to designate this molecular subgroup spinal ependymoma with MYCN amplification, SP-EPN-MYCN. SP-EPN-MYCN tumors showed distinct growth patterns with intradural, extramedullary localization mostly within the thoracic and cervical spine, diffuse leptomeningeal spread throughout the whole CNS and infiltrative invasion of the spinal cord. Dissemination was observed in 100% of cases. Despite high-intensity treatment, SP-EPN-MYCN showed significantly worse median progression free survival (PFS) (17 months) and median overall survival (OS) (87 months) than all other previously described molecular spinal ependymoma subgroups. OS and PFS were similar to supratentorial ependymoma with RELA-fusion (ST-EPN-RELA) and posterior fossa ependymoma A (PF-EPN-A), further highlighting the aggressiveness of this distinct new subgroup. We, therefore, propose to establish SP-EPN-MYCN as a new molecular subgroup in ependymoma and advocate for testing newly diagnosed spinal ependymal tumors for MYCN amplification.
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Affiliation(s)
- David R Ghasemi
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Martin Sill
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Konstantin Okonechnikov
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Andrey Korshunov
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- Department of Neuropathology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stephen Yip
- Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Peter W Schutz
- Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - David Scheie
- Department of Pathology, Rigshospitalet, Copenhagen, Denmark
| | - Anders Kruse
- Spine Section, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Patrick N Harter
- Institute of Neurology (Edinger-Institute), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt am Main, Germany
| | - Marina Kastelan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW, Australia
- The Brain Cancer Group, Sydney, NSW, Australia
| | - Marlies Wagner
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Frankfurt, Germany
- Institute of Neuroradiology, Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Christian Hartmann
- Department of Neuropathology, Hannover Medical School, Hannover, Germany
| | - Julia Benzel
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Kendra K Maass
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology, and Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mustafa Khasraw
- Royal North Shore Hospital, The University of Sydney, Sydney, Australia
| | - Ronald Sträter
- Department of Pediatric Hematology/Oncology, University of Münster, Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Christian P Kratz
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Hendrik Witt
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology, and Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Daisuke Kawauchi
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | | | - Felix Sahm
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- Department of Neuropathology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Brandner
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Marcel Kool
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - David T W Jones
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Pediatric Glioma Research Group, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andreas von Deimling
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- Department of Neuropathology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan M Pfister
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology, and Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - David E Reuss
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.
- Department of Neuropathology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Kristian W Pajtler
- Hopp-Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.
- Department of Pediatric Oncology, Hematology, and Immunology, University Hospital Heidelberg, Heidelberg, Germany.
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13
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Azad TD, Jiang B, Bettegowda C. Molecular foundations of primary spinal tumors-implications for surgical management. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:222. [PMID: 31297387 DOI: 10.21037/atm.2019.04.46] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Primary spinal tumors are rare lesions that require careful clinical management due to their intimate relationship with critical neurovascular structures and the significant associated risk of morbidity. While the advent of molecular and genomic profiling is beginning to impact the management of the cranial counterparts, translation for spinal tumors has lagged behind. Maximal safe surgical resection remains the mainstay of patients with primary spinal tumors, with extent of resection and histology the only consistently identified independent predictors of survival. Adjuvant therapy has had limited impact. To develop targeted neoadjuvant and adjuvant therapies, improve prognostication, and enhance patient selection in spinal oncology, a thorough understanding of the current molecular and genomic landscape of spinal tumors is required. In this review, we detail the epidemiology, current standard-of-care, and molecular features of the most commonly encountered intramedullary spinal cord tumors (IMSCT), intradural extramedullary (IDEM) tumors, and primary spinal column malignancies (PSCM). We further discuss current efforts and future opportunities for integrating molecular advances in spinal oncology with clinical management.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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National Patterns of Care in the Management of World Health Organization Grade II and III Spinal Ependymomas. World Neurosurg 2019; 124:e580-e594. [PMID: 30641236 DOI: 10.1016/j.wneu.2018.12.159] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/27/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Spinal ependymomas are rare, with an incidence of 1 per 100,000. Given the paucity of data for higher grade II and III disease, the management and patterns of care require further investigation. METHODS Our study of 1345 patients with higher-grade spinal ependymoma used χ2 tests and simple and multivariable logistic regression models to assess demographic and clinical factors associated with therapy. Kaplan-Meier and log-rank tests were used to assess overall survival (OS). RESULTS Most grade II patients received surgery alone (81.1%) compared with 36.8% of grade III. Approximately 60% of patients with grade III ependymomas received radiotherapy (RT) versus 15.3% of grade II (P < 0.001). Patients living ≤32 km (20 miles) from a facility were more likely to receive RT (P < 0.001) than were those living further away. On multivariable logistic regression, grade (grade III, odds ratio, 8.6; P < 0.001) and facility distance were significantly associated with receipt of RT (P < 0.0001). The 5-year and 10-year OS was 94.7%/85.1% for patients with grade II disease and 58.2%/46.4% for grade III disease (P < 0.0001). OS was highest at facilities treating an average of 15 patients over 10 years, corresponding to the top 81st percentile in volume. The 10-year OS was 92.6% at facilities treating at least 15 patients and 88.0% at facilities treating 6-14 patients. CONCLUSIONS Approximately 40% of patients with grade III ependymomas do not receive immediate adjuvant therapy, which may be related to distance from a facility. Patients with this rare tumor may benefit from multidisciplinary care at facilities with a larger volume.
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