Postoperative radiotherapy of spinal and intracranial ependymomas: analysis of prognostic factors

Supratentorial extra-ventricular ependymoma as a mass lesion in a child: report and literature review

Supratentorial extra-ventricular ependymoma (SEE) are extremely rare in pediatric population and have varied presentation based on size, location, epicentre and compression on neurovascular structure. The authors report a 7-year-old girl presenting with seizure, who had a lobar SEE on MRI scan, successfully treated by microsurgical resection and adjuvant therapy.

Individualized Prediction of Overall Survival for Primary Intramedullary Spinal Cord Grade II/III Ependymoma

BACKGROUND

The purpose of this study was to develop and validate a nomogram to predict overall survival (OS) for adult patients with primary intramedullary spinal cord grade II/III ependymoma (PISCGE). We also elucidated the effectiveness of postoperative radiotherapy for this disease.

METHODS

Clinical data of patients with PISCGE between 1988 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) registry database. The independent prognostic factors were identified using univariate and multivariate Cox analyses. The nomogram was established from the results of the multivariate Cox analysis. We also use some methods to verify the superiority of the prediction model. The effectiveness of postoperative radiotherapy for PISCGE was assessed through coarsened exact matching and survival analyses.

RESULTS

Multivariate Cox analysis revealed that sex, age, surgical treatment, tumor grade, and marital status were independent prognostic factors of OS. The nomogram model was established based on these factors and validated internally. Calibration plots based on bootstrap resampling validation showed good consistency between the nomogram prediction and actual observation. This model also exhibited favorable discrimination characteristics. A risk classification system based on a nomogram was established to promote risk stratification of PISCGE and optimize clinical management. Moreover, we found no association between radiation treatment and the OS for these patients (P > 0.05).

CONCLUSIONS

We built the first nomogram model and risk classification system for PISCGE patients. Our model accurately estimated the individual OS probability of these patients, and proposes different treatment approaches for patients based on the risk classification system. Furthermore, from our findings, radiotherapy confers no survival advantage to these patients.

Is H3K27me3 status really a strong prognostic indicator for pediatric posterior fossa ependymomas? A single surgeon, single center experience

PURPOSE

Posterior fossa ependymomas (PFE) are among the most frequently occurring solid tumors in children. Their definitive treatment is surgical excision and adjuvant radio-chemotherapy. This study aimed to investigate prognostic effects of age, H3K27me3 status, extent of resection, radiation treatment (RT), Ki67 index, WHO grade, and ATRX and H3K27M mutations in PFE patients.

METHODS

This retrospective study included 42 pediatric patients with PFE who had undergone operation at our institution between 1996 and 2018. Patient demographics and treatment information were obtained from patient notes. Information on radiological location of tumors (median vs paramedian), extent of tumor resection, and recurrence was obtained from preoperative and postoperative magnetic resonance imaging. Formalin-fixed paraffin-embedded tumor samples were evaluated for H3K27me3 immunostaining, Ki67 index, WHO grades, and ATRX and H3K27M mutations. Tumor samples with global reduction in H3K27me3 were grouped as posterior fossa ependymoma group A (PFA) and those with H3K27me3 nuclear immunopositivity as posterior fossa ependymoma group B (PFB). We evaluated the cohort's 5-year progression-free survival (PFS) and overall survival (OS).

RESULTS

There were 20 (47.6%) female and 22 (52.4%) male patients in the cohort. The mean age of patients was 4.4 (range, 0.71-14.51) years. Overall, tumors in 31 (73.8%) and 11 (26.2%) patients were found to be PFA and PFB, respectively. There was no statistically significant age or sex difference between PFA and PFB. All patients received chemotherapy, whereas only 28 (66.6%) received RT. The WHO grades of PFA were statistically higher than those of PFB. There was no significant difference between PFA and PFB in terms of extent of resection, disease recurrence, and survival parameters. Nine of 42 tumor samples had ATRX mutations. One patient with PFA showed H3K27M mutation. Age, WHO grade, H3K27me3 status, and RT had no effect on patients' PFS and OS. Patients with total surgical excisions had significantly better PFS and OS rates. Those with Ki67 < 50% also had better OS rates.

CONCLUSIONS

Determining H3K27me3 status by immunohistochemistry is a widely accepted method for molecular subgrouping of PFEs. Most of the reports in the literature state that molecular subgroups of PFEs have significantly different clinical outcomes. However, in our present series, we have shown that the extent of surgical excision is still the most important prognostic indicator in PFEs. We also conclude that the prognostic effect of H3K27me3 status-based molecular subgrouping may be minimized with a more aggressive surgical strategy followed in PFAs.

National trends in management of adult myxopapillary ependymomas

Myxopapillary ependymomas (MPE) are WHO Grade I ependymomas that annually occur in 0.05-0.08 per 100,000 people. Surgical resection is the recommended first line therapy. Due to the rarity of the disease, there is a relatively poor understanding of the use of radiotherapy (RT) in managing this disease. The National Cancer Database (NCDB) was analyzed for patterns of care foradult MPE diagnosed between 2002 and 2016. Of 753 qualifying cases, the majority of patients underwent resection (n = 617, 81.9%). A relatively small portion received RT (n = 103, 13.3%) with most receiving RT post-operatively (n = 98, 95.1%). The likelihood of patients to undergo resection and RT was associated with patient age at diagnosis (p = 0.002), tumor size (p < 0.001), and race (p = 0.017). Chemotherapy was not widely utilized (0.27% of patients). One limitation of our analysis is that there was no data on progression free survival (PFS), an important outcome given the high survival rate in this disease. Surgery remains the primary means to manage adult MPE. For spinal MPE, it is understood that gross total resection (GTR) should be attempted whenever possible as GTR has been associated with improved PFS in several studies. The impact of RT on overall survival (OS) is indeterminate given the 1.6% death rate in the cohort. Analyses of the impact of RT on PFS in a larger database would be beneficial for determining an algorithm for post-operative and definitive RT in this disease entity.

Stereotactic Radiosurgery for Pediatric and Adult Intracranial and Spinal Ependymomas

OBJECTIVE/BACKGROUND

We report efficacy and toxicity outcomes with stereotactic radiosurgery (SRS) for intracranial and spinal ependymoma.

METHODS

We analyzed adult and pediatric patients with newly diagnosed or recurrent intracranial or spinal ependymoma lesions treated with SRS at our institution. Following SRS, local failure (LF) was defined as failure within or adjacent to the SRS target volume, while distant failure (DF) was defined as failure outside of the SRS target volume. Time to LF and DF was analyzed using competing risk analysis with death as a competing risk.Overall survival (OS) was calculated from the date of first SRS to the date of death or censored at the date of last follow-up using the Kaplan-Meier method.

RESULTS

Twenty-one patients underwent SRS to 40 intracranial (n = 30) or spinal (n = 10) ependymoma lesions between 2007 and 2018, most commonly with 18 or 20 Gy in 1 fraction. Median follow-up for all patients after first SRS treatment was 54 months (range 2-157). The 1-year, 2-year, and 5-year rates of survival among patients with initial intracranial ependymoma were 86, 74, and 52%, respectively. The 2-year cumulative incidences of LF and DF after SRS among intracranial ependymoma patients were 25% (95% CI 11-43) and 42% (95% CI 22-60), respectively. No spinal ependymoma patient experienced LF, DF, or death within 2 years of SRS. Three patients had adverse radiation effects.

CONCLUSIONS

SRS is a viable treatment option for intracranial and spinal ependymoma with excellent local control and acceptable toxicity.

Supratentorial Extraventricular Ependymoma: Retrospective Analysis of 15 Patients at a Single Institution

BACKGROUND

Supratentorial extraventricular ependymoma (STEE) is an extremely rare central nervous system (CNS) neoplasm, the clinical characteristics and optimal treatment of which remain unclear. We retrospectively analyzed the clinical characteristics and treatment outcomes of 15 patients with STEE.

METHODS

Fifteen patients with STEE were identified, and their clinical, radiologic, and surgical records were reviewed.

RESULTS

The 15 patients included 6 males (40%) and 9 females (60%), with a median age of 15 years. Nine patients (60%) underwent gross total resection, 5 patients (33.3%) underwent subtotal resection, and 1 patient (6.7%) underwent biopsy. Eight patients received adjuvant radiotherapy, and 3 received adjuvant chemotherapy. The 5-year overall survival (OS) rates of patients with World Health Organization (WHO) grade II and grade III STEE were 100% and 30%, respectively, and the corresponding 2-year progression-free survival (PFS) rates were 77.8% and 20%. The differences in OS and PFS rates between WHO grades II and III STEE were statistically significant (P < 0.01 and 0.02, respectively). Anaplastic histology (WHO grade III) was a poor prognostic factor for PFS (P = 0.04). The recurrence pattern was local recurrence in all patients; all cases were treated primarily by redo surgery. Three patients with recurrent WHO grade II STEE were alive at more than 64, 52, and 44 months after redo surgery.

CONCLUSIONS

STEE is an extremely rare CNS neoplasm. The histological grade of STEE is an important prognostic factor. Microsurgical resection might play a major role in both initial treatment and treatment of recurrent tumors.

Supratentorial extraventricular ependymomas: A retrospective study focused on long-term outcomes and prognostic factors

OBJECTIVE

Supratentorial extraventricular ependymomas are relatively rare. Long-term outcomes and prognostic factor for this rare tumor have not been well established. The purpose of this study was to demonstrateprogression-freesurvival(PFS),overallsurvival(OS), and prognostic factors of such tumor.

PATIENTS AND METHODS

Fifty-five patients with supratentorial extraventricular ependymomas from our hospital were included in this study. Epidemiological characteristics, clinical features, treatment,long-term outcomes, and prognostic factors for PFS and OS were reviewed retrospectively.

RESULTS

The patients consisted of 30 males and 25 females with mean age of 30.0 ± 23.6 years (range, 1-74 years). Twenty-nine tumors were located in the right hemisphere, and 26 in the left side. The 2 most common tumor locations were the frontal (n = 19; 35%) and parietal lobe (n = 11; 20%). All patients underwent surgical resection. Gross-total resection (GTR) was achieved in 42 cases (76%) and subtotal resection (STR) was performed in 13 patients (24%). According to the WHO classification system, 38 tumors (69%) were Grade III (anaplastic ependymoma), and 17 (31%) were Grade II (ependymoma). Three-,5-, and 10 year PFS rates were 60%, 49%, and 36%, respectively. Three-,5-, and 10 year OS rates were 79%, 64%, and 49%, respectively. EOR and tumor grade were identified as prognostic factors for PFS and OS on univariate analysis, multivariate analysis, and Kaplan-Meierlog-rank testing. Subtotal resection (STR) predicted a worse PFS (HR = 4.808; 95%, 1.942-11.905; P = .001) and OS (HR = 5.650; 95%, 2.114-15.152; P = .001). WHO Grade III tumors also had worse PFS (HR = 3.922; 95%, 1.429-18.182; P = .012) and OS (HR = 6.329; 95%, 1.328-30.303; P = 0.021). For patients with tumor recurrence, reoperation was significant prognostic factors for OS (HR = 2.091; 95%, 0.939-4.654; p = .000). Age, sex, tumor side, and postoperativeradiotherapy were not prognostic factors for PFS and OS.

CONCLUSIONS

Most supratentorial extraventricular ependymomas are WHO grade III tumors. STRandWHO Grade III pathology predicted worse PFS and OS. Gross-total resection remains the optimal treatment for patients with supratentorial extraventricular ependymoma. Reoperation should be considered first in cases of recurrence. The role of postoperative radiotherapy as an adjuvant treatment for supratentorial extraventricular ependymoma needs further investigation.

Nanoparticle-mediated knockdown of DNA repair sensitizes cells to radiotherapy and extends survival in a genetic mouse model of glioblastoma

Glioblastoma (GBM) remains incurable, and recurrent tumors rarely respond to standard-of-care radiation and chemo-therapies. Therefore, strategies that enhance the effects of these therapies should provide significant benefits to GBM patients. We have developed a nanoparticle delivery vehicle that can stably bind and protect nucleic acids for specific delivery into brain tumor cells. These nanoparticles can deliver therapeutic siRNAs to sensitize GBM cells to radiotherapy and improve GBM treatment via systemic administration. We show that nanoparticle-mediated knockdown of the DNA repair protein apurinic endonuclease 1 (Ape1) sensitizes GBM cells to radiotherapy and extend survival in a genetic mouse model of GBM. Specific knockdown of Ape1 activity by 30% in brain tumor tissue doubled the extended survival achieved with radiotherapy alone. Ape1 is a promising target for increasing the effectiveness of radiotherapy, and nanoparticle-mediated delivery of siRNA is a promising strategy for tumor specific knockdown of Ape1.

Pediatric Ependymoma

Over the past 150 years since Virchow's initial characterization of ependymoma, incredible efforts have been made in the classification of these tumors and in the care of pediatric patients with this disease. While the advent of modern neurosurgery and the optimization of radiation have provided significant gains, a more complex but incomplete picture of pediatric ependymomas has begun to form through a combination of international collaborations and detailed genetic and histologic characterizations. This review includes and synthesizes the clinical understanding of pediatric ependymoma and their developing molecular insight into what is truly a family of malignancies in which distinct members require different surgical approaches, radiation plans, and targeted therapies.

Supratentorial hemispheric ependymomas: an analysis of 109 adults for survival and prognostic factors

OBJECTIVE Survival rates and prognostic factors for supratentorial hemispheric ependymomas have not been determined. The authors therefore designed a retrospective study to determine progression-free survival (PFS), overall survival (OS), and prognostic factors for hemispheric ependymomas. METHODS The study population consisted of 8 patients from our institution and 101 patients from the literature with disaggregated survival information (n = 109). Patient age, sex, tumor side, tumor location, extent of resection (EOR), tumor grade, postoperative chemotherapy, radiation, time to recurrence, and survival were recorded. Kaplan-Meier survival analyses and Cox proportional hazard models were completed to determine survival rates and prognostic factors. RESULTS Anaplastic histology/WHO Grade III tumors were identified in 62% of cases and correlated with older age. Three-, 5-, and 10-year PFS rates were 57%, 51%, and 42%, respectively. Three-, 5-, and 10-year OS rates were 77%, 71%, and 58%, respectively. EOR and tumor grade were identified on both Kaplan-Meier log-rank testing and univariate Cox proportional hazard models as prognostic for PFS and OS. Both EOR and tumor grade remained prognostic on multivariate analysis. Subtotal resection (STR) predicted a worse PFS (hazard ratio [HR] 4.764, p = 0.001) and OS (HR 4.216, p = 0.008). Subgroup survival analysis of patients with STR demonstrated a 5- and 10-year OS of 28% and 0%, respectively. WHO Grade III tumors also had worse PFS (HR 10.2, p = 0.004) and OS (HR 9.1, p = 0.035). Patients with WHO Grade III tumors demonstrated 5- and 10-year OS of 61% and 46%, respectively. Postoperative radiation was not prognostic for PFS or OS. CONCLUSIONS A high incidence of anaplastic histology was found in hemispheric ependymomas and was associated with older age. EOR and tumor grade were prognostic factors for PFS and OS on multivariate analysis. STR or WHO Grade III pathology, or both, predicted worse overall prognosis in patients with hemispheric ependymoma.

Ependymoma: a heterogeneous tumor of uncertain origin and limited therapeutic options

Ependymomas are tumors that typically occur with an age-based site preference, with adults harboring supratentorial and spinal tumors and pediatric tumors being mainly in the posterior fossa. Despite their similar histologic appearance, the prognosis varies significantly by age and tumor location, with a better prognosis in increasing age. The mainstay of treatment remains surgical excision with or without radiation therapy as the tumor biology is poorly understood and chemotherapy is generally considered to be ineffective. More recently, molecular biology data have increased our understanding of the genetic and epigenetic changes that drive these tumors, but still it will take a lot of effort to find effective chemotherapeutic regimens. Currently, we are trying to define a subset of tumors, for which radiation therapy can be avoided.

Nanoparticle mediated silencing of DNA repair sensitizes pediatric brain tumor cells to γ-irradiation

Medulloblastoma (MB) and ependymoma (EP) are the most common pediatric brain tumors, afflicting 3000 children annually. Radiotherapy (RT) is an integral component in the treatment of these tumors; however, the improvement in survival is often accompanied by radiation-induced adverse developmental and psychosocial sequelae. Therefore, there is an urgent need to develop strategies that can increase the sensitivity of brain tumors cells to RT while sparing adjacent healthy brain tissue. Apurinic endonuclease 1 (Ape1), an enzyme in the base excision repair pathway, has been implicated in radiation resistance in cancer. Pharmacological and specificity limitations inherent to small molecule inhibitors of Ape1 have hindered their clinical development. Here we report on a nanoparticle (NP) based siRNA delivery vehicle for knocking down Ape1 expression and sensitizing pediatric brain tumor cells to RT. The NP comprises a superparamagnetic iron oxide core coated with a biocompatible, biodegradable coating of chitosan, polyethylene glycol (PEG), and polyethyleneimine (PEI) that is able to bind and protect siRNA from degradation and to deliver siRNA to the perinuclear region of target cells. NPs loaded with siRNA against Ape1 (NP:siApe1) knocked down Ape1 expression over 75% in MB and EP cells, and reduced Ape1 activity by 80%. This reduction in Ape1 activity correlated with increased DNA damage post-irradiation, which resulted in decreased cell survival in clonogenic assays. The sensitization was specific to therapies generating abasic lesions as evidenced by NP:siRNA not increasing sensitivity to paclitaxel, a microtubule disrupting agent. Our results indicate NP-mediated delivery of siApe1 is a promising strategy for circumventing pediatric brain tumor resistance to RT.

Supratentorial gross-totally resected non-anaplastic ependymoma: population based patterns of care and outcomes analysis

Observation following gross-total resection (GTR) for non-anaplastic supratentorial ependymomas is often advocated based on small, retrospective series. The purpose of this study is to perform a population-based analysis to examine outcomes for this rare cohort of low-risk patients. A retrospective analysis was conducted utilizing the Surveillance, Epidemiology and End Results Program of the United States National Cancer Institute. We identified patients with supratentorial non-anaplastic ependymoma who underwent GTR alone or GTR followed by radiation. We identified 92 patients who met these criteria. The median age was 17.5 years (range 1-83) with the majority female (58 %) and white (75 %). Radiotherapy (RT) was delivered in half of patients. The 5-/10-year Kaplan-Meier estimated overall survival (OS) and cause-specific survival (CSS) for the overall cohort was 83.2/71.4 and 84.1/78.0 %, respectively. There was no evidence of decreased CSS (HR 0.52 [0.18-1.51]; p = 0.23) or OS (HR 0.63 [0.25-1.59]; p = 0.33) with the omission of RT on univariate analysis. Age ≥18 years correlated with worse OS (HR 4.01 [1.45-11.11]; p = 0.008) and CSS (HR 2.86 [0.99-8.31]; p = 0.05). RT did not impact outcome for this low-risk cohort of patients. Older age correlates with poor prognosis.

Multidisciplinary management of pediatric intracranial ependymoma

Pediatric intracranial ependymoma is a rare disease representing approximately 7% of brain tumors in children aged 15 years or younger. Due to the relative rarity of these tumors, a clear standard therapy has been difficult to establish. The mainstay of treatment is surgical resection and the majority of data demonstrate improved outcome with gross total resection. The standard of care also includes postoperative radiation therapy for most patients with grade II and III tumors. Chemotherapy has been used in many capacities in this disease; however, its optimal role is yet to be defined. Current controversies such as treatment with surgery alone in completely resected tumors, use of chemotherapy for subtotally resected tumors and use of adjuvant postradiation chemotherapy are incorporated into the design of the current Children's Oncology Group clinical trial.

Spinal cord ependymoma in children--results of postoperative radiotherapy

PURPOSE

A retrospective study was performed to evaluate the results of postoperative radiation therapy of spinal cord ependymoma in children.

METHODS AND MATERIALS

Between 1984 and 2005, 28 children with spinal cord ependymoma were treated with radiotherapy, after surgery and in three cases after chemotherapy as well. Median age at diagnosis was 13.3 years (range from 4.7 to 16.2 years). Ependymoma myxopapillare was identified in 13, ependymoma in 12 and anaplastic ependymoma in 3 cases.

RESULTS

With a median follow-up of 8.7 years (range from 3 to 25 years) 22 patients were alive. The overall survival rate of 2, 5 and 10 years was 93%, 85% and 77% respectively, whereas progression free survival rate was 82%, 74% and 74% respectively. Patients with myxopapillary ependymoma had significantly better 5-year overall survival rate 100% than those with other histopathological types 60% (p=0.016). There were 2 relapse incidences observed among 13 patients with myxopapillary ependymoma, both underwent repeated surgery and reirradiation. In the group of 20 patients with gross total resection the overall 5-year survival rate was 100% in comparison with 62.5% with partial surgery, but it did not achieve statistical significance.

CONCLUSIONS

The histological type of ependymoma myxopapillary was a statistical significant favourable prognostic factor. The gross total resection with adjuvant radiotherapy allows obtaining a high total survival rate.

Spinal cord ependymomas in children and adolescents

BACKGROUND

Spinal cord ependymomas are very rare among children and adolescents. Due to their rarity, our current knowledge of these tumors is based on case reports and few retrospective case series.

METHODS

The present review summarizes the currently available literature on childhood spinal cord ependymomas.

RESULTS

Although overall survival rates are favorable, relapse incidence is high, particularly in myxopapillary ependymomas. Since long-term follow-up data are provided in a limited number of studies only, the true relapse incidence is unknown. Maximal safe radical surgery is the backbone of treatment for children with spinal cord ependymomas, but the impact of adjuvant treatment on progression and survival is still unclear. Presently, the decision to initiate non-surgical treatment depends primarily on the WHO grade of the tumor and the extent of resection. In terms of the known side effects, early radiotherapy should be avoided in children with WHO grade II spinal cord ependymomas irrespective of the extent of resection but is indicated in anaplastic spinal cord ependymomas both after complete and incomplete resection. The high relapse incidence in myxopapillary ependymomas argue for the use of early radiotherapy, but its definitive impact on progression has to be proven in larger series. Close surveillance is important due to the high recurrence rate in all patients with spinal cord ependymomas.

CONCLUSION

Prospective collection of both clinical and molecular data from a greater number of patients with spinal cord ependymomas within an international collaboration is the prerequisite to establish standardized management guidelines for these rare CNS tumors.

The complete surgical resection without the radiotherapy for a recurred anaplastic ependymoma at the cervicomedullary junction

The intramedullary anaplastic ependymoma rarely occurs in the cervicomedullary junction. A 45-year-old woman had a history of right arm pain for several months. Magnetic resonance imaging (MRI) of the cervical spine demonstrated an intramedullary tumor with syrinx at the cervicomedullary junction. The patient underwent a partial resection at another institute. Neurologic deficit worsened after the first surgery. The follow up MRI showed that the enlarged enhancing tumor and syrinx still existed with the same size and configuration. Complete surgical resection was achieved in the revision surgery. Final histologic examination confirmed the diagnosis of an anaplastic ependymoma, and since complete surgical resection was achieved the patient did not receive adjuvant radiation or chemotherapy. The patient was followed-up periodically at the outpatient department, and at the 7 months follow-up the muscle tone of the right hand was normal but with mild sensory deficit, and the MRI demonstrated no evidence of recurrent disease. Intramedullary anaplastic ependymoma that occur in the cervicomedullary junction which are completely resected may be followed-up without adjuvant radiation or chemotherapy to attain good clinical outcome.

Prognostic factors and treatment options for paediatric ependymomas

The aim of this study was to determine factors of prognostic relevance for paediatric ependymomas, and evaluate the efficacy of treatment modalities. This is a retrospective study of 43 patients with ependymoma (<18 years) who underwent a combination of surgical excision, chemotherapy, and/or radiotherapy treatment at The Prince of Wales Cancer Centre between 1969 and 2009. Statistical analysis was performed to assess the prognostic relevance of various parameters affecting the two-year and five-year overall survival (OS) and progression-free survival (PFS). The five-year OS and PFS were 50.3% and 44.8% respectively (median follow-up 50 months). Eighteen patients (41.9%) experienced tumour recurrence: 13 had a local recurrence (LR) and five had both LR and distant recurrence. On univariate analysis, a more favourable prognosis in terms of both OS and PFS was evident for supratentorial tumours compared to infratentorial tumours (OS p=0.007, PFS p=0.045), stereotactic radiosurgery/ fractionated stereotactic radiotherapy compared to craniospinal irradiation or local posterior fossa/local brain±boost radiotherapy modalities (OS p=0.047, PFS p=0.031), total radiotherapy dose >50 Gy compared to ≤50 Gy (OS p=0.008, PFS p=0.005), and in patients with no tumour recurrence compared to those with recurrence (OS p=0.03, PFS p<0.001). Although not statistically significant, a more favourable multivariate outcome was evident in patients who underwent complete surgical resection. Chemotherapy treatment and histopathological grade, however, were not relevant to prognosis. This study supports the need to pursue more aggressive treatment for infratentorial and/or recurrent tumours. Ideal treatment involves maximal surgical resection, followed by adjuvant radiotherapy (>50 Gy).

[Ependymomas of the lateral ventricle. A series of 27 cases with review of the literature]

Twenty-seven cases of ependymoma were collected in the French multicentric study dedicated to lateral ventricle tumors. The mean age of patients was 31,5 years. All patients underwent surgery, with complete resection of the tumor in 76% of cases. Histologic examination disclosed 23 grade 2 ependymomas and four grade 3 ependymomas. Postoperative mortality was 7%. Four patients underwent radiotherapy, and five chemotherapy. Local recurrence of the tumor occurred in seven cases, with a mean delay of 48 months. Disseminated disease within the central nervous system was found in only one patient. Median survival in all the 27 patients was 181 months, and median progression-free survival was 106 months. The relevant series of the literature are reviewed in order to precise the prognostic factors of ependymomas and therapeutic strategies.

Clinical presentation, histology, and treatment in 430 patients with primary tumors of the spinal cord, spinal meninges, or cauda equina

OBJECT Patients having a primary tumor of the spinal cord, spinal meninges or cauda equina, are relatively rare. Neurosurgeons encounter and treat such patients, and need to be aware of their clinical presentation, tumor types, treatment options, and potential complications. The purpose of this paper is to report results from a series of 430 patients with primary intraspinal tumors, taken from a larger cohort of 9661 patients with primary tumors of the CNS. METHODS Extensive information on individuals diagnosed (in the year 2000) as having a primary CNS neoplasm was prospectively collected in a Patient Care Evaluation Study conducted by the Commission on Cancer of the American College of Surgeons. Data from US hospital cancer registries were submitted directly to the National Cancer Database. Intraspinal tumor cases were identified based on ICD-O-2 topography codes C70.1, C72.0, and C72.1. Analyses were performed using SPSS. RESULTS Patients with primary intraspinal tumors represented 4.5% of the CNS tumor group, and had a mean age of 49.3 years. Pain was the most common presenting symptom, while the most common tumor types were meningioma (24.4%), ependymoma (23.7%), and schwannoma (21.2%). Resection, surgical biopsy, or both were performed in 89.3% of cases. Complications were low, but included neurological worsening (2.2%) and infection (1.6%). Radiation therapy and chemotherapy were administered to 20.3% and 5.6% of patients, respectively. CONCLUSIONS Data from this study are suitable for benchmarking, describing prevailing patterns of care, and generating additional hypotheses for future studies.

Ependymoma of the spinal cord in children and adolescents: a retrospective series from the HIT database

OBJECT

Reports on spinal cord ependymoma in children are rare. The aim of this study was to evaluate the clinical spectrum, treatment, and outcome of children with primary ependymoma of the spinal cord who were registered in the database of the pediatric German brain tumor studies Hirntumor (HIT) '91 and HIT 2000.

METHODS

Between 1991 and 2007, 29 patients (12 male and 17 female, median age at diagnosis 13.6 years) with primary spinal cord ependymoma (myxopapillary ependymoma WHO Grade I, II, and III tumors in 6, 17, and 6 patients, respectively) were identified. Four patients had neurofibromatosis Type 2.

RESULTS

With a median follow-up of 4.2 years (range 0.48-15 years), 28 patients (96.6%) were alive. Seven patients (24.1%) developed progressive disease or relapse, 2 after gross-total resection (GTR) and 5 after incomplete resection or biopsy. One patient with anaplastic ependymoma (WHO Grade III) died 65 months after diagnosis of disease progression. Primary adjuvant treatment (radiotherapy, chemotherapy, or both) was used in 8 (50%) of 16 patients following GTR and in 9 (82%) of 11 patients who underwent less than a GTR. Three additional patients were treated adjuvantly following progression. Estimated progression-free survival and overall survival rates at 5 years were 72.3% (95% CI 50%-86%) and 100%, respectively. Progression-free survival at 5 years is 84.4% (95% CI 50%-96%) for patients following GTR compared with 57.1% (95% CI 25%-69%) for patients who achieved a less than GTR (p = 0.088, log-rank test). A high relapse incidence (4 of 6) was observed among patients with myxopapillary ependymoma.

CONCLUSIONS

Gross-total resection is the mainstay of treatment for patients with primary spinal cord ependymoma and may be achieved in about 50% of the patients using modern surgical techniques. Primary adjuvant treatment was commonly used in children with spinal cord ependymoma irrespective of the extent of resection or tumor grade. The impact of adjuvant treatment on progression-free and overall survival has to be investigated in a prospective trial.

Adult intracranial WHO grade II ependymomas: long-term outcome and prognostic factor analysis in a series of 114 patients

Ependymomas account for 2% of all intracranial tumors in adults. Considerable controversy continues to exist with regard to their prognostic factors and therapeutic management due to the rarity and the heterogeneity of series reported so far. The authors report a retrospective study of a homogenous population of 114 adult patients harboring WHO grade II intracranial ependymomas from 32 French Neurosurgical Centers between 1990 and 2004. All clinico-radiological and follow-up data were analyzed, and a central pathologic review was performed by two confirmed neuropathologists. The 5- and 10-year overall survival (OS) rates were 86.1% and 81.0%, respectively; the 5- and 10-year progression-free survival (PFS) rates were 74.6% and 58.9%, respectively. On multivariate analysis, the OS rates were associated with preoperative KPS score (P = .027), extent of surgery (P = .008), and tumor location (supratentorial vs infratentorial, P = .012). The multivariate analysis also revealed that the risk of recurrence was associated with incomplete resection (P = .001) and supratentotrial location (P = .038). Moreover, adjuvant radiotherapy (RT) for patients with incompletely resected tumors is responsible for a significant improvement of both overall (P = .005) and progression-free (P = .002) survival. This study clearly supports the major prognostic impact of the extent of surgery in WHO grade II. Interestingly, tumor location also seems to have an actual impact on both OS and PFS. Finally, the prognostic impact of RT was found to be beneficial for incompletely resected tumors.

Temozolomide for recurrent intracranial supratentorial platinum-refractory ependymoma

BACKGROUND

To the authors' knowledge, there currently is no standard therapy for platinum-resistant ependymoma; hence, a need exists for new therapies. In the current study, a retrospective evaluation of temozolomide (TMZ) in adults with recurrent, supratentorial, platinum-refractory, World Health Organization grade 2 ependymoma was performed, with an objective of determining 6-month progression-free survival (PFS).

METHODS

A total of 25 patients, ages 28 to 63 years, with recurrent ependymoma were treated. All patients had previously been treated with surgery, radiotherapy, and platinum-based chemotherapy (cisplatin in 15 patients and carboplatin in 10 patients). Nine patients underwent repeat surgery. Patients were treated at the time of second recurrence with TMZ (5 consecutive days), once every 4 weeks, which was defined as a single cycle. Neurologic evaluation was performed every 4 weeks and neuroradiographic assessment every 8 weeks.

RESULTS

A total of 68 cycles of TMZ (median, 2 cycles; range, 1-6 cycles) was administered. TMZ-related toxicity included leukopenia (7 patients; 1 with grade 3 [grade was determine according to National Cancer Institute Common Toxicity Criteria [version 3.0]), constipation (6 patients; none with grade 3), fatigue (5 patients; none with grade 3), anemia (2; none with grade 3), thrombocytopenia (2; none with grade 3), and deep vein thrombosis (2; none with grade 3). One patient (4%) demonstrated a partial radiographic response, 9 (36%) had stable disease, and 15 (60%) developed progressive disease after 2 cycles of TMZ. Time to tumor progression ranged from 1 to 7 months (median, 2 months). Survival ranged from 2 to 8 months (median, 3 months). The 6-month and 12-month PFS were 2% and 0%, respectively.

CONCLUSIONS

TMZ in this dose schedule demonstrated little efficacy in a cohort of adults with recurrent, intracranial, platinum-refractory ependymoma.

The history of ependymoma management

INTRODUCTION

The ependymomas are relatively not a common tumor. However, most clinicians agree that the radical removal of the tumor is the most important prognostic factor.

MORBIDITY OF TREATMENT

Tumor removal was not sufficient before the era of magnetic resonance imaging (MRI) and resulted in a considerable operative morbidity and mortality. As the microneurosurgical techniques and microsurgical anatomy become popular and the MRI provide more detailed anatomical information preoperatively, radical removal of this complex and complicated tumor can be more feasible. In childhood ependymoma, the treatment-related morbidity and mortality can be the special issues, which can modify the policy of management safe tumor removal and minimal adjuvant treatment, which are extremely important.

RADIATION THERAPY

Radiation treatment has been the option for disseminated disease and residual tumor. With the advancement of detailed MR anatomical information, safer and more delicate radiation becomes possible with newer radiation modalities, three-dimensional conformal radiotherapy, intensity modulating radiotherapy, and tomotherapy.

PROGNOSTIC FACTORS

Although many clinicians believe that the ependymomas are inheritably chemoresistant, the new targets for the treatment are under investigation or clinically tried. Also, the genetic alterations of ependymoma are developing and might be a promising target.

CONCLUSION

The surgical techniques and assistant modalities for tumor removal are still advancing. So, the outcome of ependymoma is still improving. Unfortunately, newer treatment modalities, such as new chemotherapeutic agent and gene modification agent, are still not promising. The history of ependymoma management is still in progress.

Infratentorial ependymomas: prognostic factors and outcome analysis in a multi-center retrospective series of 106 adult patients

OBJECT

This study was undertaken to analyze outcomes and to assess the prognostic impact of age, location, surgery, radiotherapy (RT), and histopathology in a series of adult infratentorial ependymomas.

METHODS

This was a retrospective study of a population of 106 adult patients with infratentorial ependymomas diagnosed between 1990 and 2004. A central pathological review of all cases was performed. Grading was according to the WHO and Marseille's neograding classifications.

RESULTS

The series consisted of 58 males (54.7%) and 48 females (45.3%) in the age range of 18-82 years. Using the WHO classification, 88 patients (83.0%) had grade II and 18 patients (17.0%) grade III ependymomas. Using the Marseille's neograding system, 91 patients were low-grade and 15 high-grade. Gross total resection was achieved in 66 patients (62.3%). Thirty-seven patients (35.0%) received adjuvant RT. The 5- and 10-year overall survival rates for the entire cohort were 86.1% and 80.5%, respectively. On multivariate analysis, a preoperative Karnofski performance status score > 80, no recessus lateral extension and a low histological grade (Marseille's grading) were associated with a longer overall survival. The 5- and 10-year progression-free survival rates for the entire cohort were 70.8% and 57.7%, respectively. On multivariate analysis, no recessus lateral extension, gross total resection and a low histological grade (Marseille's grading) were associated with a longer progression-free survival. Adjuvant RT was significantly associated with a better overall and progression-free survival in incompletely resected WHO grade II ependymomas.

CONCLUSIONS

This study highlights the key role of histology in the clinical outcome and the fact that gross total resection is a main prognostic factor and the treatment of choice for posterior fossa ependymomas. The use of adjuvant RT in patients with incompletely resected WHO grade II ependymomas appears beneficial, but its effect on high-grade tumors remains to be determined.

Long term outcomes following surgical resection of myxopapillary ependymomas

Myxopapillary ependymomas, a specific tumor variant of spinal cord ependymomas, occur most commonly in the lumbosacral region. During the study period, 1,013 patients underwent surgery for spinal cord tumors. Fifty-two of the patients had a myxopapillary ependymoma. Forty-eight of these patients underwent surgery at our institutions. There were four patients who came for consultations only. Fourteen pediatric patients were diagnosed with myxopapillary ependymoma. The overall average age at which a patient was diagnosed was 31.8 years. The average age a child was diagnosed was 12.6 years. The adult mean age was 38.7 years. The clinical presentation was of a slow, indolent course, with average symptom duration of 20.8 months. Overall, the pediatric patients had a much more aggressive clinical course with a much higher rate of local recurrence and dissemination of the tumor within the neural axis (64% versus 32%). The median time to disease recurrence was 88 months for the entire group. The overall survival after 11.5 years of follow-up was 94%. The optimal management of patients harboring myxopapillary ependymomas remains somewhat controversial. Excellent outcomes may be obtained, however, with the use of aggressive surgical techniques. No clear benefit for adjunctive chemotherapy, and radiation therapy was demonstrated.

Cerebral ependymoma in a patient with multiple sclerosis case report and critical review of the literature

BACKGROUND

The concurrence of multiple sclerosis (MS) and brain tumors is a rare but well-recognized condition. The radiologic evidence of the progressive evolution of a mega-plaque in a tumor has never been described. We report the first case of such an occurrence.

METHODS

A 27-year-old woman with a diagnosis of MS was referred to us for an intense frontal headache. Magnetic resonance imaging showed a mass lesion in correspondence of a black hole lesion previously diagnosed. The patient was operated on, with complete removal of the tumor documented by an intraoperative MRI. The histologic examination evidenced an ependymoma. Postoperative radiotherapy was performed.

RESULTS

The patient is well and recurrence-free at 2 years follow-up.

CONCLUSIONS

The present case, documenting the transformation of a mega-plaque into a tumor, suggests a cause-effect relationship between MS and brain tumors.

Resection of myxopapillary ependymomas in children

OBJECT

Currently, the optimal treatment of children harboring myxopapillary ependymomas of the spinal cord remains somewhat debatable. The authors present a retrospective study in which they evaluated the records of patients in whom resection of these lesions had been performed.

METHODS

Fourteen pediatric patients who had undergone resection of a spinal cord tumor between September 1982 and July 2004 were identified from the database as having histologically classified myxopapillary ependymomas. There were 10 boys and four girls ranging in age from 7 to 18 years (mean age 12.6 years); 71% of the patients were boys. The clinical presentation of the tumor's course was slow and indolent, and the patients had a mean symptom duration of 19.6 months. Twelve patients, who underwent a total of 16 operations, were available for long-term follow-up review. Thirteen gross-total resections and three subtotal resections were performed. There were no deaths due to surgery. Postoperatively, patients initially remained at their preoperative level of function or improved. Patients who had undergone previous surgery and radiotherapy were treated more conservatively than patients who were undergoing surgery for the first time. Four children experienced significant complications following treatment.

CONCLUSIONS

As the authors demonstrate in this study, excellent outcomes may be obtained with the use of aggressive surgical techniques with the goal being that of gross-total resection. Despite the best of resections, however, the risk of recurrence remains. Therefore, periodic neuroimaging surveillance of the neuraxis and close clinical follow up are warranted throughout the patient's life. The role for adjunctive chemo- and radiotherapy remains to be defined in the management of myxopapillary ependymomas.

Ependymoma

Ependymomas are rare tumours of neuroectodermal origin classified as myxopapillary ependymoma and subependymoma (grade I), ependymoma (grade II) and anaplastic ependymoma (grade III). The more common location is infratentorial (60%). Age <40 years and extent of surgery appear related to better prognosis, while the role of other prognostic factors, such as tumour grade and tumour site are equivocal. This emphasizes the role of surgery as the standard treatment. Postoperative radiotherapy is indicated in high-grade ependymomas, and is recommended in low-grade ependymomas after subtotal or incomplete resection (confirmed by postoperative MR). Deferral of radiotherapy until recurrence may be considered on an individual basis for patients with MR confirmation of a radical resection. Recommended dose to involved fields is 45-54 Gy for low-grade (grade II) and 54-60 Gy for high-grade ependymomas (grade III). There is no proof that postoperative chemotherapy improves the outcome. At recurrence, platinum-, nitrosourea- or temozolomide-based chemotherapy can be administered, although there is no evidence of efficacy.

[Intracranial ependymomas in adult patients. Prognostic factors, place of surgery and complementary treatment]

Prognostic factors and optimal therapy for adult intracranial ependymoma are still debated. Available data has been generally collected from retrospective and heterogeneous series including pediatric and spinal cases in particular. The goal of this article is to review and discuss the prognostic factors and the various therapeutic strategies suggested in the literature in light of prognostic and decision making features delineated from a multicentric study conducted in France.

Part I: Spinal-cord neoplasms—intradural neoplasms

Intradural spinal-cord tumours are an uncommon but important consideration in the differential diagnosis of patients with back pain, radicular pain, sensorimotor deficits, or sphincter dysfunction. Intradural spinal tumours can be divided into intramedullary and extramedullary spinal-cord tumours on the basis of their anatomical relation to the spinal parenchyma. The heterogeneous cell composition of the intradural compartment allows the formation of neoplasms, arising from glial cells, neurons, and cells of spinal vasculature. Additionally, developmental tumours, metastases, and intradural extension of extradural tumours are represented. In this Review, we discuss the published work on intradural spinal-cord tumours in terms of epidemiological, radiographic, and histological characteristics. Surgical and adjuvant treatment strategies are also reviewed.

Local radiotherapeutic management of ependymomas with fractionated stereotactic radiotherapy (FSRT)

BACKGROUND

To assess the role of Fractionated Stereotactic Radiotherapy (FSRT) in the management of ependymomas.

METHODS

From January 1992 to July 2003, FSRT was performed in 19 patients with histologically confirmed ependymomas. The median age was 15 years, 5 patients were younger than 4 years of age. Twelve patients received FSRT as primary postoperative radiotherapy after surgical resection. In 6 patients irradiation of the posterior fossa was performed with a local boost to the tumor bed, and in 4 patients the tumor bed only was irradiated. In 7 patients FSRT was performed as re-irradiation for tumor progression. This patient group was analyzed separately. A median dose of 54 Gy was prescribed in a median fractionation of 5 x 1.8 Gy per week for primary RT using 6 MeV photons with a linear accelerator. For FSRT as re-irradiation, a median dose of 36 Gy was applied. All recurrent tumors were localized within the former RT-field.

RESULTS

The 5- and 10-year overall survival rates were 77% and 64%, respectively. Patients treated with FSRT for primary irradiation showed an overall survival of 100% and 78% at 3 and 5 years after irradiation of the posterior fossa with a boost to the tumor bed, and a survival rate of 100% at 5 years with RT of the tumor bed only. After re-irradiation with FSRT, survival rates of 83% and 50% at 3-and 5 years, respectively, were obtained.Progression-free survival rates after primary RT as compared to re-irradiation were 64% and 60% at 5 years, respectively.FSRT was well tolerated by all patients and could be completed without interruptions due to side effects. No severe treatment related toxicity > CTC grade 2 for patients treated with FSRT could be observed.

CONCLUSION

The present analysis shows that FSRT is well tolerated and highly effective in the management of ependymal tumors. The rate of recurrences, especially at the field border, is not increased as compared to conventional radiotherapy consisting of craniospinal irradiation and a local boost to the posterior fossa.

Métastase d'un épendymome lombosacré avec très long intervalle libre : cas clinique et revue de la littérature

Ependymoma is rare glial tumour of the central nervous system and is considered to be low-grade. The lumbosacral location of spinal ependymoma is the most common. Prognosis of ependymomas is dependent on tumour location, histological subtype and differentiation, extent of the tumour and of the completeness of the surgical resection. One of the characteristics of this kind of tumour is to present the possibility of a seeding of the entire cerebrospinal axis, by the way of cerebrospinal liquid. We describe the case of a young male patient operated by incomplete resection of a lumbar ependymoma. Six months later, the patient's symptoms reappeared and an external radiotherapy at curative doses and chemotherapy were delivered. Evolution of the remaining tumour was diagnosed 6 years after at the primary site and operated by large incomplete resection. A second session of radiotherapy was therefore administered. Twenty-four years after this episode, cervical pain and gait troubles appear. Complete imaging study concluded to a cervical extramedullary intradural tumour and to the persistence of the primary lumbosacral tumour. Macroscopical complete resection of the cervical tumour was performed and pathological findings concluded to a metastasis of his lumbar ependymoma. External radiotherapy was delivered on this site with a total dose of 50 Gy. Eight years after this episode, the patient is alive without evidence of distant disease. The primary lumbosacral ependymoma is stable. Ependymomas are often recurrent at the primary site, but can seed on the entire cerebrospinal axis. Awareness of such aberrant tumoral behaviour, even after such a long disease free interval, may warrant more careful follow-up of patients with this diagnosis.

Ependymal tumors in childhood

BACKGROUND

Ependymal tumors are classified as ependymoma (benign or low grade) versus anaplastic ependymoma (malignant or high grade). Ependymomas represent 5-10% of intracranial neoplasm in children. In this study, demographic data and the treatment results of pediatric patients with ependymal tumors, treated in a single institute, is reported.

PATIENTS AND METHODS

Between 1989 and 2001, 40 (22 M/18 F) previously untreated patients with a median age of 5.5 years (3 months-15 years), of histologically proven ependymal tumors (except ependymoblastomas) were referred to the Institute of Oncology, University of Istanbul. The localization was supratentorial in 18, infratentorial in 20, both supra and infratentorial in two patients. Histologic subgroups were 18 ependymomas (43.6%), and 22 anaplastic ependymomas (56.4%). Total tumor resection was performed in 20 patients (50%), subtotal in 18 patients (45%), and biopsy only in 2 patients (5%). Postoperative treatment consisted of regional (8 patients) or craniospinal (CSI) (9 patients) radiotherapy (RT) in patients with ependymoma; regional (7 patients) or CSI RT (14 patients) with chemotherapy (ChT) in patients with anaplastic ependymoma; ChT only (1 patient) in patients less than 3 years of age. The standard technique for posterior fossa irradiation was parallel-opposed lateral fields and total dose was 45-54 Gy. Between September 1989 and May 1991 patients received regimen A, which consisted of RT followed by eight-in-one ChT, given every 4 weeks for eight courses. Patients who were treated between June 1991 and July 1994, received regimen B, which included two courses of postoperative "VEC" (vincristine, etoposide, cisplatin) ChT, administered every 3 weeks, followed by RT applied with low dose concomitant cisplatin used as a radiosensitizer. Patients with objective response to postoperative "VEC" continued to have "VEC" after completion of RT for six more courses. From August 1994 on, patients received regimen C, consisting of RT and concomitant infusion of cisplatin followed by "VCPCU" (vincristine, cyclophosphamide, procarbazine, lomustine) administered every 4 weeks for eight courses.

RESULTS

A total of 40 patients were included in the outcome and survival data. The 5-year overall survival (OS) rate was 64.9%, and the 5-year progression-free survival rate was 50.8% for the whole series. Median time for progression or relapse was 24.3 months and there were 19 patients (43.6%) with relapse or progression. Non-metastatic patients (P = 0.0008, 5-year OS rate was 82% vs. 29%), and totally resected patients (P = 0.01, 5-year OS rate was 80% vs. 55%), and > or =3 years of age (P = 0.04, 5-year OS rate was 75% vs. 38%) had significantly better outcome.

CONCLUSIONS

The majority of complete responders were patients who had total tumor removal. Treatment failure occurred mainly within the first 2 years, and outcome was dismal for patients who relapsed or had progressive disease. The median age at diagnosis is 6 years in our patient group; younger children (less than 3 years old) have less favorable outcome. There was no significant difference in survival or progression-free survival between the two histologic subtypes.

Postoperative radiation therapy for grade II and III intracranial ependymoma

PURPOSE

To retrospectively determine the long-term outcome of intracranial ependymoma patients treated with surgery and postoperative radiation therapy.

METHODS AND MATERIALS

Sixty patients were treated at our institution between 1964 and 2000. Forty patients had World Health Organization Grade II ependymoma, and 20 patients had Grade III ependymoma. The median patient age was 10.7 years. The majority of patients were male (55%), had infratentorial tumors (80%), and had subtotal resections (72%). Postoperative radiation therapy was delivered to all patients to a median total dose of 50.4 Gy. Craniospinal radiation therapy was used in the earlier era in only 12 patients (20%).

RESULTS

The median follow-up of surviving patients was 12.5 years. The 5-year and 10-year disease-free survival rates for all patients were 58.4% and 49.5%, respectively. The 5-year and 10-year overall survival rates for all patients were 71.2% and 55.0%, respectively. Supratentorial tumor location was independently associated with a worse disease-free survival. Subtotal resection and supratentorial location predicted a worse overall survival, but this failed to reach statistical significance. No statistically significant effect on prognosis was observed with tumor grade, patient age, or radiation dose or volume.

CONCLUSION

Our long-term follow-up indicates that half of ependymoma patients will have disease recurrences, indicating the need for more effective treatments.

A multicenter retrospective study of chemotherapy for recurrent intracranial ependymal tumors in adults by the Gruppo Italiano Cooperativo di Neuro-Oncologia

BACKGROUND

No data on the role of chemotherapy in recurrent ependymal tumors are available in adults. The aim of the current study was to investigate outcomes after salvage chemotherapy in this setting.

METHODS

A retrospective review was made of the charts of 28 adults (> or = 18 years) with progressive or recurrent ependymal tumors after surgery and radiotherapy, who received chemotherapy between 1993 and 2003 in 3 institutions of the Gruppo Italiano Cooperativo di Neuro-Oncologia network.

RESULTS

Thirteen patients (46.3%) received cisplatin-based chemotherapy (Group A) and 15 (53.7%) received regimens without cisplatin (Group B). Platinum-based chemotherapy yielded 2 complete responses (CR) (15.4%) and 2 (15.4%) partial responses (PR), whereas 7 patients (53.8%) remained stable (SD). After regimens without cisplatin, there were no CR, 2 PR (13.3%), and 11 SD (73.3%). The overall median time to progression was 9.9 months (95% confidence interval [95% CI], 7.5-21.7 months), 9.9 months (5.2-not reached) for Group A and 10.9 months (95% CI, 7.17-23.9 months) for Group B. The overall median survival (OS) was 40.7 months (95% CI, 16-not reached), 31 months (21-not reached) for Group A and 40.7 months (13.4-not reached) for Group B.

CONCLUSIONS

Cisplatin-based chemotherapy achieved a higher response rate, but did not prolong disease progression-free survival or OS. More active regimens for the salvage treatment of ependymal tumors have yet to be found.

Imaging Predictors of Intracranial Ependymomas

OBJECTIVE

To identify significant imaging prognostic factors for intracranial ependymomas.

METHODS

This series includes 32 patients (18 male and 14 female), with an age at surgery ranging from 1 to 69 years (median, 20.5 years). The preoperative images and medical records were reviewed. The following imaging predictors, including tumor size, consistency, signal character, enhanced pattern, calcification, hemorrhage, perifocal edema, and tumor spread, were analyzed by 2 radiologists independently. Overall survival and progression-free survival were calculated by the Kaplan and Meier method. The difference in these imaging predictors in terms of overall survival and progression-free survival was tested for statistical significance by the log-rank test. Multivariate analysis was also performed using the Cox proportional hazard model.

RESULTS

The results revealed that the presence of tumor spread on preoperative images was the only significant imaging predictor in overall and progression-free survivals (P < 0.0001). The hazard ratio of progression-free survival in the presence of tumor spread on preoperative images was 18.59 (95% confidence interval: 1.57-220.13; P = 0.020).

CONCLUSION

The presence of tumor spread on preoperative images is the only significant imaging predictor for patients with intracranial ependymomas.

Review of radiotherapy dose and volume for intracranial ependymoma

BACKGROUND

Radiotherapy (RT) is well established in the management of intracranial ependymoma (EP) and post-operative RT is employed for the majority of patients. There are no randomised trials of RT in EP and evidence for dose and volume relies on retrospective single institution series, usually comprising a heterogeneous mix of relatively small numbers of patients recruited over several decades.

PROCEDURE

The literature including RT dose and response data reported since the early 1990s was reviewed.

RESULTS

Five-year overall survival (OS) ranges from 40 to 79%. There is some evidence of a dose response relationship from <45 Gy to >50 Gy. In the majority of series outcome is related to WHO grade and extent of resection. There is no evidence of benefit for 'prophylactic' craniospinal RT (CSRT). In all series there is a significant risk of local recurrence, usually within the target volume. Early results of conformal RT have suggested that a margin for CTV of 1 cm around the post-operative tumour bed and any residual GTV is feasible.

CONCLUSIONS

The main aims of future studies will be to maximise the number of patients achieving complete resection, and RT dose escalation. Hyperfractionated radiotherapy (HFRT) has been employed in some studies and results are awaited. The role of CSRT needs to be evaluated further for patients presenting with leptomeningeal metastases. Multi-institutional and international studies are necessary to improve understanding of the clinical behaviour, biology and management of EP.

Épendymomes intracrâniens primitifs. Expérience de l’institut Salah-Azaïz

PURPOSE

- To assess the outcome and prognostic factors of patients with primitive intracranial ependymomas treated at the department of radiotherapy of Salah-Azaîz Institute.

METHODS AND MATERIAL

- Between 1972 and 1997, 31 patients aged one to 53 years received postoperative radiotherapy. There were 16 males and 15 females. Location of tumor was infratentorial in 24 cases and supratentoriel in seven cases. Surgical treatment consisted of complete resection in 14, incomplete resection in 13 and unknown type in four patients. All patients were treated with radiotherapy to the craniospinal axis in 26 cases, whole brain in five cases.

RESULTS

- Five years survival rate was 63%. For infratentorial tumors, two patients failed locally, two patients failed locally and at distance and four patients failed only at distance, while one patient with supratentorial tumor relapsed locally. Age, performances status, tumor site, gender and extent of surgery had no impact on survival. The treatment field extent was the only variable predictive of outcome. Patients treated with craniospinal irradiation had a survival rate of 86% compared with 37,5% for patients treated with whole brain irradiation.

CONCLUSION

- Infratentorial ependymomas seem to have a worse prognosis than supratentorial ones. Irradiation field extent should be correlated to prognostic factors.

Intracranial ependymomas in adult patients: analyses of prognostic factors

OBJECTIVE

The goal of our study is to identify significant prognostic factors for a series of intracranial ependymomas in an adult population. Age, location, histology, preoperative clinical status, extent of resection and radiotherapy were examined.

METHODS

Our series includes 34 patients. Ten tumors were located in the brain parenchyma, 5 in the lateral ventricle, 8 in the third and 11 in the fourth ventricle. Seventeen ependymomas were grades 2 and 17 were anaplastic. Surgical resection was gross-total in 27 patients and partial in 7.

RESULTS

At a mean follow-up of 9 years (+/- 1 year) 16 patients died and, among the 18 survivors 14 are in complete remission and 4 present a local recurrence. The 5- and 10-year overall survival rates were respectively 62% and 43%. The 5- and 10-year progression-free survivals were 47% and 43%. Univariate analysis revealed that location in the brain parenchyma and anaplasia are the only statistically significant predictors of poor outcome.

CONCLUSION

We can make out three groups of patients from our series: the first encompasses patients operated on for an intraparenchymal tumor, in all our cases an anaplastic ependymoma, with a 5-year rate of tumor-related deaths of 100%. The second group includes fourth ventricle ependymomas, which are mostly grade 2 tumors. They display a 10-year survival rate of 90%. Last group entails lateral and third ventricle ependymomas, of both low and high grade, with a 10-year survival rate of 60% for lateral ventricle and 35% for third ventricle tumors.

Current management and prognostic factors for adult ependymoma

The optimum therapeutic management in adult ependymoma remains undefined because of the low incidence of this disease and because most of reported series mainly refers to childhood, are retrospective, include a small number of patients and span several decades. The purpose of this article is to analyze, discuss and summarize the current available information regarding the therapeutic approach and the prognostic factors and to provide recommendations for ordinary clinical practice. Some important therapeutic issues like the irradiation dose and volume are also analyzed. Finally, the main open questions as well as current and expected investigation trends are discussed.

Postoperative radiotherapy for intracranial ependymoma: analysis of prognostic factors and patterns of failure

The long-term results of external beam radiotherapy following surgical resection in patients with intracranial ependymomas were evaluated to identify the prognostic factors and the pattern of recurrence. Between June 1961 and January 1999, 48 patients with intracranial ependymoma were treated with external beam irradiation with >40 Gy following surgery. Total doses of 40.5-63.4Gy were delivered to the tumor site in 22-46 fractions over 33-101 days. Six patients with spinal deposit or positive cerebrospinal fluid cytology received whole spinal axis irradiation, and 4 patients received prophylactic spinal irradiation. The median follow-up of surviving patients was 110 months. The 10-year overall and relapse-free survival rates were 47% and 42%, respectively. In multivariate analysis, female gender, lower tumor grade and total resection were found to be associated with better relapse-free survival. Twenty of 26 recurrences developed at the primary tumor site (inside the irradiation field), two at the unirradiated cerebellum and spinal cord, and four at the spinal cord without intracranial failure. Only one of 34 patients with supratentorial tumors developed isolated spinal metastasis, whereas 3 of 14 patients with infratentorial tumors did so. Regarding the late neurotoxicity of radiotherapy, one of the 15 long-term (>4 years) survivors whose psychosocial status could be evaluated showed marked cognitive impairment. It was suggested that the use of new treatment strategies to improve local control would be warranted, and that prophylactic whole spinal axis irradiation appeared to be of more benefit in patients with infratentorial tumors than in those with supratentorial tumors.

Lumbar myxopapillary ependymoma mimicking neurofibroma

OBJECTIVE

To report a case of lumbar myxopapillary ependymoma in whom neuroradiological and surgical findings strongly suggested neurofibroma.

CLINICAL PRESENTATION

The patient presented with a 2 year history of progressive monoparesthesia and monoparesia of his right leg. He reported having minimal fecal and urinary incontinence.

INTERVENTION

Total resection of the tumor was achieved by total L1-L2 laminectomies. There was no attachment to the spinal cord and dura.

CONCLUSION

In spite of contemporary sophisticated neuroradiological facilities, we may still have diagnostic difficulties in some spinal tumors.

The local field in infratentorial ependymoma: does the entire posterior fossa need to be treated?

INTRODUCTION

In the past decade, there have been multiple reports indicating that the predominant problem in the curative treatment of intracranial ependymoma is local failure. As a result, many have recommended local field radiotherapy. For infratentorial ependymoma, there is controversy regarding what constitutes the local field. Some radiation oncologists advocate coverage of the entire posterior fossa, whereas others recommend radiotherapy to the tumor bed and a safety margin.

METHODS AND MATERIALS

From 1984 to 1998, 28 patients with posterior fossa ependymoma were diagnosed at our institution. There were 18 males and 10 females with a median age of 12 years (range, 2-81 years). Four patients (14%) had high-grade ependymoma and 3 (11%) had M+ disease at initial diagnosis. Gross total resection was achieved in 17 (61%) and postoperative radiotherapy (RT) was given to 22 (77%). Radiotherapy fields were craniospinal in 10, whole brain in 1, posterior fossa in 2, and tumor bed with a 2-cm. margin in 9. Median dose to the primary site was 54 Gy (range, 45-55 Gy). All 4 patients with high-grade ependymoma received craniospinal RT. Six patients did not receive RT after surgery. Magnetic resonance imaging (MRI) or computed tomography (CT) scans of the brain at initial diagnosis were compared to MRI or CT scans of patients at relapse to determine if the local relapse was in the tumor bed or nontumor bed posterior fossa. Median follow-up was 127 months (range, 14-188 months).

RESULTS

Six patients have relapsed. For the 11 patients who had craniospinal or whole brain radiotherapy (RT), 3 recurred (tumor bed 1, spine 1, nontumor bed posterior fossa + spine 1). Both patients who failed in the spine had high-grade tumors. Neither of the 2 treated with posterior fossa fields relapsed. For the 9 patients who had tumor bed RT alone and the 6 who did not receive RT, there were 3 relapses; all were in the tumor bed. There were no relapses in the nontumor bed posterior fossa.

CONCLUSION

For nondisseminated, low-grade infratentorial ependymoma, the radiotherapy volume does not need to include the entire posterior fossa. This information can be used to minimize late effects of RT in the era of three-dimensional (conformal) radiotherapy. No conclusion can be reached regarding the appropriate local field for high-grade infratentorial ependymoma because of the small number of patients.