Neurosurgical treatment of brain tumors in children

Posterior fossa tumors in children: current insights

While in adults most intracranial tumors develop around the cerebral hemispheres, 45 to 60% of pediatric lesions are found in the posterior fossa, although this anatomical region represents only 10% of the intracranial volume. The latest edition of the WHO classification for CNS tumors presented some fundamental paradigm shifts that particularly affected the classification of pediatric tumors, also influencing those that affect posterior fossa. Molecular biomarkers play an important role in the diagnosis, prognosis, and treatment of childhood posterior fossa tumors and can be used to predict patient outcomes and response to treatment and monitor its effectiveness. Although genetic studies have identified several posterior fossa tumor types, differing in terms of their location, cell of origin, genetic mechanisms, and clinical behavior, recent management strategies still depend on uniform approaches, mainly based on the extent of resection. However, significant progress has been made in guiding therapy decisions with biological or molecular stratification criteria and utilizing molecularly targeted treatments that address specific tumor biological characteristics. The primary focus of this review is on the latest advances in the diagnosis and treatment of common subtypes of posterior fossa tumors in children, as well as potential therapeutic approaches in the future.   Conclusion: Molecular biomarkers play a central role, not only in the diagnosis and prognosis of posterior fossa tumors in children but also in customizing treatment plans. They anticipate patient outcomes, measure treatment responses, and assess therapeutic effectiveness. Advances in neuroimaging and treatment have significantly enhanced outcomes for children with these tumors. What is Known: • Central nervous system tumors are the most common solid neoplasms in children and adolescents, with approximately 45 to 60% of them located in the posterior fossa. • Multimodal approaches that include neurosurgery, radiation therapy, and chemotherapy are typically used to manage childhood posterior fossa tumors What is New: • Notable progress has been achieved in the diagnosis, categorization and management of posterior fossa tumors in children, leading to improvement in survival and quality of life.

Myalgia and Hematuria in Association with Clonidine and Arginine Administration for Growth Hormone Stimulation Tests

Growth hormone deficiency (GHD) in children has significant impacts on growth and metabolism. Two-agent GH stimulation tests are commonly used to diagnose GHD, and these tests are generally considered safe. We report the case of a 5-year 5-month-old boy with a history of anaplastic ependymoma who underwent GH stimulation testing for growth deceleration using clonidine and arginine. He developed bilateral calf myalgia and gross hematuria within 24 hours of the tests. Myalgia and hematuria resolved spontaneously. Importantly, the literature review and database searches for hematuria identified 6 cases with clonidine and 20 cases with arginine. This case highlights an unusual combination of adverse reactions to clonidine and arginine in children undergoing GH stimulation testing to assess for GHD. Pediatric endocrinologists need to be aware of the potential for these side effects to allow appropriate management, and further studies are needed to clarify the mechanisms and frequency of these side effects. We recommend that patients and families need to be counselled about hematuria as an association of GH testing with these medications.

Quality of life in survivors of childhood brain tumour and the association of children's diseases on quality of their parents life

OBJECTIVE

Evaluation of children's quality of life (QoL) after finished brain tumour treatment and the association of children's diseases on quality of their parents' life.

METHODS

The study group was consisted of 46 children after brain tumour treatment (aged 4, 5, to 29 years old). The control group was composed of 104 students of primary, secondary, and high schools. One hundred fifty (104 + 46) parents were included in the study. Standardised QoL questionnaires (PEDsQL-4.0, WHOQOL-BREF) were used. Survivors' QoL was assessed from patients' and their parents' point of view, also the association of children's diseases on quality of their parents' life was estimated.

RESULTS

QoL of children after brain tumour treatment was lower than in the control group according to the children (P < 0.001) and their parents (P < 0.001). The survivors worst rated their ability to social functioning (P < 0.0010) and physical functioning (P < 0.001) in comparison with self-assessment of healthy children. According to their parents, the functioning of children in all zones was worse than in the control group, mostly in social (P < 0.001) and physical sphere (P < 0.001), too. QoL of children with low-grade tumour was comparable with QoL of children with high-grade tumour). QoL of survivors' caregivers in study was higher than QoL of parents of control groups (P = 0.023).

CONCLUSIONS

The quality of patients' life after brain tumour treatment is lower in comparison with healthy children. QoL of the parents of survivor is higher than the QoL of healthy children parents. The assessment of QoL of children after brain tumour treatment should be an inherent element of health monitoring.

Determining an Optimal Cutoff of Serum β-Human Chorionic Gonadotropin for Assisting the Diagnosis of Intracranial Germinomas

Background

Beta (β)-human chorionic gonadotropin (β-HCG) is used to confirm the diagnosis and plan treatment of intracranial germinomas. However, the cutoff values of serum β-HCG in diagnosis of intracranial germinomas reported in the literature are inconsistent. To establish an appropriate cutoff value of serum β-HCG for diagnosis of intracranial germinomas, we retrospectively reviewed the records of intracranial tumor patients who received serum β-HCG and α-fetoprotein (AFP) tests for diagnostic purposes at our hospital from 2005 to 2014.

Methods

A total of 93 intracranial germinomas and 289 intracranial non-germ cell tumors were included in this study. Receiver operating characteristic (ROC) analysis was used to evaluate the sensitivity and specificity of 3 cutoffs (0.1, 0.4, and 0.5 mIU/mL) for diagnosing intracranial germinomas. The serum β-HCG level of intracranial germinoma patients was further analyzed to investigate the effect of metastasis status and tumor location on serum β-HCG level.

Results

The area under the ROC curve was 0.81 (P < .001), suggesting β-HCG is an effective marker. Of the 3 cutoff values, 0.1 mIU/mL possessed a highest sensitivity (66.67%) and good specificity (91%). Although there was no β-HCG level difference between metastatic and non-metastatic intracranial germinoma patients, the diagnostic rate of metastatic neurohypophyseal germinomas was significantly higher than that of its non-metastatic counterpart (P < .05), implying that the location of the germinoma might need to be considered when β-HCG is used as a marker to predict metastasis.

Conclusions

Determining an optimal cutoff of serum β-HCG is helpful for assisting the diagnosis of intracranial germinoma.

Resolution of precocious puberty following resection of fourth ventricular medulloblastoma: case report

Medulloblastoma is a malignant embryonal tumor that arises in the cerebellum and invades the fourth ventricle, often resulting in obstructive hydrocephalus. Patients typically present with symptoms related to increased intracranial pressure and cerebellar dysfunction. The authors report a rare case of classic medulloblastoma with central precocious puberty (CPP) as its only presenting symptom. A 7-year-old boy with no prior history of medulloblastoma presented with Tanner Stage IV testicular enlargement and a 4-month history of acne and pubic hair. Laboratory tests of blood samples demonstrated highly elevated luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone. Admission MRI of the brain revealed a mass in the posterior fossa, which bordered and compressed the fourth ventricle. The patient also exhibited mild lateral and third ventriculomegaly. Surgical options were discussed with the neurosurgical department. A suboccipital craniotomy and C-1 laminectomy were performed. A large mass was seen arising from the inferior surface of the vermis, and lying within the fourth ventricle. Gross-total microsurgical resection of the mass was performed. Histopathological investigation characterized the tumor as classic medulloblastoma. Follow-up laboratory tests of blood samples demonstrated a reduction of LH, FSH, and testosterone back to prepubertal levels. The patient then began radiation and chemotherapy. This report demonstrates that mild obstructive hydrocephalus due to a posterior fossa tumor may present with unexpected symptoms, such as CPP. To the authors' knowledge, precocious puberty has not yet been associated with medulloblastoma, although it has been found with other posterior fossa tumors. Extensive imaging of the CNS for patients presenting with CPP is recommended.

Quality of life and symptoms in pediatric brain tumor survivors: a systematic review

Little is known about the quality of life of children and youth under the age of 20 who have completed treatment for a pediatric brain tumor. This systematic review was conducted to (a) describe the health-related quality of life (HRQL) outcomes in pediatric brain tumor survivors, (b) identify instruments used to measure HRQL, and (c) determine the relationship between symptoms and HRQL. Using a systematic search and review methodology, databases searched included CINAHL, Medline, Embase, and PsycInfo. No date restrictions were used. Search results elicited 485 articles, of which16 met the inclusion criteria. Compared with their healthy peers, pediatric brain tumor survivors did worse on most measures of physical, psychosocial, social, and cognitive domains of HRQL. Compared with other cancer patients, survivors scored themselves significantly lower on the Pediatric Quality of Life Inventory (PedsQL) social functioning scale, and parents of brain tumor survivors reported lower PedsQL social and total functioning scores for their children. Other variables that were associated with decreased HRQL were degree of hypothalamic tumor involvement, osteopenia, need for special education, older age at diagnosis, greater than 1 year since treatment, and radiation treatment. In these studies, pediatric brain tumor survivors fared worse compared with other cancer survivors or healthy peers on several HRQL domains. Only 3 studies explored the relationship between symptoms, including pain or fatigue, and HRQL in pediatric brain tumor survivors. The relationship between symptoms and HRQL was not well elucidated. More research is needed to explore the multidimensional symptom experience and HRQL outcomes in pediatric brain tumor survivors.

Symptom experience and quality of life in pediatric brain tumor survivors: a cross-sectional study

CONTEXT

Little is known about the symptom experience and quality of life of children and youths who have completed treatment for a pediatric brain tumor.

OBJECTIVES

This study describes the symptom experience and health-related quality of life of children who have survived a brain tumor.

METHODS

This observational cross-sectional study used a convenience sample of 50 children who were being followed in ambulatory care after they had completed brain tumor treatment. Their symptom experience was measured using the Memorial Symptom Assessment Scale, and health-related quality of life was measured using the Pediatric Quality of Life Inventory.

RESULTS

The median number of symptoms reported by the participants was six. The most prevalent symptoms were lack of energy (52%), feeling drowsy (40%), difficulty with sleep (38%), lack of concentration (36%), and headaches (36%). Among those reporting symptoms, the most distressing symptoms were pain (14%), headaches (12%), lack of energy (8%), and difficulty with sleep (8%). Four symptoms-lack of energy, concentration, pain, and shortness of breath-explained most of the variance in the Pediatric Quality of Life Inventory subscales and total scores.

CONCLUSION

Pediatric brain tumor survivors experience many symptoms after treatment. Care providers should be particularly diligent screening for symptoms, including pain, headaches, lack of energy, and sleep problems, as these symptoms may be particularly distressing for children.

Time to diagnosis of paediatric posterior fossa tumours: an 11-year West of Scotland experience 2000-2011

INTRODUCTION

Brain tumours are the most common solid childhood malignancy accounting for 20% of all paediatric cancers. Of these, posterior fossa tumours comprise approximately 60-70% of all brain tumours in children. Several studies have estimated the median pre-diagnostic interval (PSI) of paediatric brain tumours as approximately 60 days.

OBJECTIVES

The objectives of this retrospective analysis were to (a) identify the common presenting symptoms of posterior fossa tumours, (b) determine the time interval from the first attributable symptom to the radiological diagnosis of a posterior fossa tumour, (c) compare the West of Scotland with other international centres and (d) identify which factors correlate with outcome for these children.

MATERIALS AND METHODS

A retrospective case note review of 69 children diagnosed with posterior fossa tumours from January 2000 to September 2011. Of the 69 children diagnosed during this period, complete data were available for 66 children (M:F = 31:35, Mean age (SD): 7.50 + 4.53 years). Results. Nausea and vomiting (75.8%), headaches (63.6%) and incoordination (51.5%) were recorded as the most common presenting symptoms followed by lethargy (28.8%), cranial nerve palsy (25.8%) and diplopia (24.2%). Fifty-three of the sixty-six children (i.e., 80.3%) demonstrated radiological evidence of hydrocephalus on their initial scan. The majority of children were assessed by less than three specialists after a median PSI of 43.5 days. The only variable significantly associated with PSI was tumour grade (r = - 0.202, p = 0.036). Neither age at diagnosis, number of specialists seen, nor outcome was significantly correlated with PSI. The only factor associated with outcome was tumour grade (r = 0.337, p = 0.006).

CONCLUSION

Despite recent reports indicating poor performance of the UK with respect to time to diagnosis of paediatric brain tumours, the present data indicate that the experience of this cohort is favourably comparable to international standards.

Appraisal of the current staging system for residual medulloblastoma by volumetric analysis

AIM

This study aims to investigate the accuracy of the current staging system of childhood medulloblastoma by using volumetric image analysis on immediate post-operative MRI scans.

MATERIAL AND METHODS

Tumour volume and maximum cross area of residual medulloblastoma were measured on immediate post-operative MR scans of 37 children operated between 1999 and 2005.

RESULTS

Mean preoperative volume was 32 cm(3) (range 4.5-71.9 cm(3)). Mean post-operative volume was 3.3 cm(3) (range 0-23.3 cm(3)). At mean follow-up of 50.08 months (range 6-129), 15 (40%) patients had died. Cut-off limit for residual post-operative tumour volume employed was maximum cross section of 1.5 cm(2), which corresponds to volume of 1.376 cm(3); 14 patients (38%) had no residual tumour, 7 patients (19%) had less than 1.5 cm(2) and 16 patients (43%) had more than 1.5 cm(2) residual tumour in its maximum cross section area. In three patients (8.2%) there was mismatch between the measured maximum cross section area and volume. In particular, in two patients, the cross section areas were more than 1.5 cm(2) but the residual tumour volumes were less than 1.376 cm(3) (the cross section area overestimated the residual volume) and in one case, the cross section area was less than 1.5 cm(2) but the residual tumour volume was more than 1.376 cm(3) (the cross section area underestimated the residual volume; difference statistically significant, Fisher's exact test, p < 0.01).

CONCLUSIONS

It appears that volumetric measurement of residual medulloblastoma on immediate post-operative MRI scans may further improve the accuracy of staging process.

Pediatric low-grade glioma survivors experience high quality of life

PURPOSE

The purpose of this study was to determine pediatric low-grade glioma survivors' quality of life and late morbidity including motor, sensory, and cognitive deficits.

METHODS

We surveyed 49 survivors and their parents (KINDL questionnaire).

RESULTS

Despite tumor and treatment-associated morbidity, survivors (25 boys and 24 girls, median age at diagnosis 7.8 years), but not their parents, rated their total quality of life higher than their peers. Although all survivors had some late morbidity, half of them were able to conduct their daily lives without restriction.

CONCLUSION

These results reflect survivors' effective coping mechanisms and underscore the difficulties of assessing quality of life in pediatric populations.

The pineal volume: a three-dimensional volumetric study in healthy young adults using 3.0 T MR data

It is usually difficult to distinguish small pineal tumors via routine or enhanced magnetic resonance (MR) scan. The knowledge of normal pineal size is helpful to detect small pineal lesions, while very few true volumetric data of pineal glands have been reported. Therefore, we obtained the accurate reference range of normal pineal volumes in 112 individuals aged 20-30 years recruited randomly from a healthy community sample. Transverse and sagittal 3.0T magnetic resonance data were obtained using three-dimensional (3D) T1-weighted FSPGR and T2-weighted SE sequences. True pineal volumes were measured from T1-weighted images, while estimated volumes were calculated using pineal length, width and height. All the glands were divided into three types according to the maximum inner diameter of pineal cysts. The prevalence of asymptomatic pineal cyst is 25.00%, with a slight female predominance. In the whole sample, we found no gender differences of pineal volume, but a significant gender difference of pineal volume index. A significant correlation between pineal volume and asymptomatic cyst was found. After excluding cases with big pineal cysts, there were significant correlations between pineal volume and head circumference, body height and body weight, respectively. This study suggests that asymptomatic pineal cysts may exert an important influence on pineal volume.

[Pediatric intensive care after brain tumor surgery]

INTRODUCTION

Primary brain tumors are the most common solid tumors in children. Surgery is the basis of treatment for these patients, who require postoperative admission to the ICU-P. The aim of this study was to at the epidemiology of brain tumors of patients admitted to our ICU-P and to analyze the progress of these children in the postoperative period.

PATIENTS AND METHODS

Retrospective-prospective study of children admitted to our unit after brain tumor surgery between January 1998 and January 2007. We collected information such as, personal details, clinical characteristics, type of intervention and postoperative period.

RESULTS

We reviewed 161 postoperative periods, corresponding to 134 patients (54.5% male). The mean age was 7 years and 8 months +/- 5 months. The most common location was the posterior fossa (44.8%). The most common histological type was low grade/intermediate astrocytoma (44.7%). The most frequent complication was diabetes insipidus (9.9%). Resection was complete in 58.4% patients. The median stay in the ICU-P was 2 days (0-61 days). 3 patients died after surgery.

CONCLUSIONS

The epidemiology of the group of patients admitted to our ICU-P is similar to the general population. The most common complication is diabetes insipidus.

A role for glutamate in growth and invasion of primary brain tumors

The vast majority of primary brain tumors derive from glial cells and are collectively called gliomas. While, they share some genetic mutations with other cancers, they do present with a unique biology and have developed adaptations to meet specific biological needs. Notably, glioma growth is physically restricted by the skull, and, unless normal brain cells are destroyed, tumors cannot expand. To overcome this challenge, glioma cells release glutamate which causes excitotoxic death to surrounding neurons, thereby vacating room for tumor expansion. The released glutamate also explains peritumoral seizures which are a common symptom early in the disease. Glutamate release occurs via system X(c), a cystine-glutamate exchanger that releases glutamate in exchange for cystine being imported for the synthesis of the cellular antioxidant GSH. It protects tumor cells from endogenously produced reactive oxygen and nitrogen species but also endows tumors with an enhanced resistance to radiation- and chemotherapy. Pre-clinical data demonstrates that pharmacological inhibition of system X(c) causes GSH depletion which slows tumor growth and curtails tumor invasion in vivo. An Food and Drug Administration approved drug candidate is currently being introduced into clinical trials for the treatment of malignant glioma.

Natural progression of an unresected supratentorial ependymoma

Ependymomas are rare gliomas that have been associated with a poor outcome despite aggressive therapy including surgery, chemotherapy and radiation therapy. We present a case report of a 16-year-old male with an untreated supratentorial ependymoma that lay dormant for 15 years without significant morbidity. Supratentorial ependymomas are thought to have a better outcome than infratentorial ependymomas, primarily because of the increased likelihood of achieving a gross total resection in the supratentorial space. Our case report suggests that the improved outcome may be due in part to the biologically benign nature of some supratentorial ependymomas. This highly unusual case illustrates the unpredictable heterogeneity of pediatric ependymomas.