Brain tumors in childhood and adolescence

Neurosurgical treatment of pediatric brain tumors - results from a single center multidisciplinary setup

OBJECTIVE

The challenge of pediatric brain tumor surgery is given due to a relative low prevalence but high heterogeneity in age, localization, and pathology. Improvements of long-term overall survival rates were achieved during the past decades stressing the importance of a multidisciplinary decision process guided by a national treatment protocol. We reviewed the entire spectrum of pediatric brain tumor surgeries from the perspective of an interdisciplinary pediatric neuro-oncology center in Germany.

METHODS

Every patient who underwent brain tumor surgery from January 2010 to June 2017 in our Pediatric Neurosurgery department was retrospectively included and evaluated regarding the course of treatment. Perioperative data such as tumor localization, timing of surgery, extent of resection, neuropathological diagnosis, transfusion rates, oncologic and radiation therapy, and neurological follow-up including morbidity and mortality were evaluated.

RESULTS

Two hundred ninety-three pediatric brain tumor patients were applicable (age: 8.28 ± 5.62 years, 1.22:1.0 m:f). A total of 531 tumor surgical interventions was performed within these patients (457 tumor resections, 74 tumor biopsies; mean interventions per patient 1.8 ± 1.2). Due to a critical neurologic status, 32 operations (6%) were performed on the day of admission. In 65.2% of all cases, tumor were approached supratentorially. Most frequent diagnoses of the cases were glial tumors (47.8%) and embryonal tumors (17.6%). Preoperative planned extent of resection was achieved in 92.7%. Pre- and postoperative neurologic deficits resolved completely in 30.7%, whereas symptom regressed in 28.6% of surgical interventions. New postoperative neurologic deficit was observed in 10.7%, which resolved or improved in 80% of these cases during 30 days. The mortality rate was 1%.

CONCLUSION

We outlined the center perspective of a specialized pediatric neuro-oncological center describing the heterogeneous distribution of cases regarding age-related prevalence, tumor localization, and biology, which requires a high multidisciplinary expertise. The study contributes to define challenges in treating pediatric brain tumors and to develop quality indicators for pediatric neuro-oncological surgery. We assume that an adequate volume load of patients within a interdisciplinary infrastructure is warranted to aim for effective treatment and decent quality of life for the majority of long-term surviving pediatric tumor patients.

Epidemiology of paediatric central nervous system tumours in Queensland, Australia

Within Australia, there is little epidemiologic information regarding paediatric central nervous system (CNS) tumours. This study examined the epidemiology of childhood CNS tumours at Queensland Children's Hospital (QCH), the major paediatric referral centre for Queensland and northern New South Wales. We assessed the data from 221 newly diagnosed childhood CNS tumours across a five-year period from 2015 to 2019. Recurrent tumours were excluded. Data was collected on patient age, gender, histopathological diagnosis, tumour grade, anatomical site, and residential geographical location. The incidence within this period ranged from 2.65 to 3.85 cases per 100,000 children. The median symptom interval was 30 days (IQR 14-122) with presenting features similar to previous studies. The symptom interval was shorter for children zero to three years compared to children four years or older. The most frequent tumour was pilocytic astrocytoma, followed by medulloblastoma and Langerhans cell histiocytosis. The posterior fossa was the most frequent anatomical location for tumours. Our study demonstrated a shorter symptom interval in comparison to previous literature. The study was able to determine the incidence and presenting features within an Australian population.

Intracranial tumors in children: a 10-year review from a single tertiary health-care center

OBJECTIVE

Brain tumors are the second most common pediatric malignancy and the most common cause of cancer-related mortality and morbidities. Major advances in terms of surgery, radiation, and chemotherapy have led to better outcomes in developed countries. Delayed diagnosis, advanced disease at presentation, late referrals, nosocomial infections, delays to radiotherapy, and poor support services are the major reasons for poorer outcomes in developing countries. Little is known about the profile of brain tumors in Pakistan. This study aims to evaluate the epidemiology, management, and clinical outcomes of children with brain tumors in Pakistan in a single tertiary care center.

METHODS/MATERIALS

All children (0-16 years) with primary CNS tumors from 2004 to 2014 at Aga Khan University Hospital were reviewed retrospectively for clinical data, demographics, radiological findings, management, and outcome.

RESULTS

One hundred seventy-five children were included in the study. Male to female ratio was 1.4:1. Most of the patients were in 5-10 years age group (38.9%). Most common presenting complains were headache 115 (65.7%) and vomiting 100 (57.1%). Predominant site was infratentorial 93 (53%). Glial tumors were 105 (60%) followed by embryonal 40(22.9%), craniopharyngiomas 25 (14.3%), and germ cell 1 (0.6%). Astrocytomas (25.7%) were the most common glial tumors while medulloblastoma (15.4%) was the most common embryonal tumor. Majority of the patients underwent surgical resection (78.8%). Radiation was given to 47 (26.8%) patients. A half of the patients, 89 (50%), were lost to follow-up. Forty-two (24%) patients expired, 20 (11.4%) are alive with residual disease while 15 patients (8.5%) were cured with no evidence of recurrence and regular follow-ups.

CONCLUSION

This is the only study from Pakistan showing demographics of the childhood brain tumors. Significant improvement needs to be made for timely diagnosis, early referrals, and collaborated team efforts with multidisciplinary tumor board to improve outcome.

[Brain tumors in children: about 136 cases]

Les tumeurs cérébrales sont les tumeurs solides les plus diagnostiquées chez les enfants de moins de 15 ans dans le monde. Toutefois, peu de publications ont rapporté le profil épidémiologique et anatomopathologique de ces tumeurs en Afrique et particulièrement au Maroc. Les auteurs rapportent les particularités épidémiologiques et anatomopathologiques des tumeurs cérébrales primitives de l'enfant dans la région de Marrakech (Sud du Maroc). C'est une étude rétrospective réalisée au service d'anatomie pathologique du CHU Mohammed VI de Marrakech de 2004 à 2016. Cent trente-six cas de tumeurs cérébrales primitives étaient diagnostiqués avec une moyenne de 11,33 cas par an. L'âge moyen était de 8,28 ans. Le sex-ratio (H/F) était de 1,6 avec une légère prédominance masculine. Ces tumeurs étaient infra-tentorielles dans 61,53% des cas et siégeaient en supra-tentoriel dans 38,47% des cas. A l'étage infra-tentoriel, les tumeurs des hémisphères cérebelleux occupaient le premier rang (61,4%). Parmi les dix-huit types histologiques diagnostiqués, l'astrocytome et le médulloblastome représentaient ensemble 46,32% (29,41% et 16,91% respectivement). Dans notre contexte, la majorité des tumeurs cérébrales de l'enfant prédominait dans les 2 groupes d'âge: 5-9 ans et 10-15 ans. Les résultats épidémiologiques de ces tumeurs au sud du Maroc concordent majoritairement avec ceux déjà publiés du Nord du pays et des autres pays non Africains.

Incidence and survival of childhood central nervous system tumors: A report of the regional registry of childhood cancers in Auvergne-Limousin

INTRODUCTION

Central nervous system tumors (CNST) are the most lethal of solid tumors in childhood cancer.

PATIENTS AND METHODS

We report incidence and survival data for all CNST (International Classification of Diseases for Oncology third edition, category III or Xa) recorded in children under 15 years of age by the Auvergne-Limousin cancer registry for the period 1986-2009.

RESULTS

Annual incidence of all CNST was 3.27 per 100,000 and the male to female ratio was 0.95. Over 45.0% of CNST were glial. Astrocytomas (36.2%) showed the highest incidence for each age group except between 1 and 4 years where embryonal tumors were more common. For all CNST, no significant variation in incidence over time was observed for the evaluated period of 23 years (annual percent change: -0.4%, 95% CI, [-2.8-2.1]). Globally, 5 years overall survival was 67% [59-73] and had increased by more than 16% between 1986-1999 and 2000-2009, mainly due to better survival for astrocytomas, other gliomas, ependymomas and choroid plexus tumors (P=0.01).

CONCLUSION

We report that the incidence of CNST in Auvergne-Limousin is similar to that in the literature and did not increase between 1986 and 2009. In addition, 5 years overall survival increased after 1999, especially for surgically treatable tumors.

Trends in incidence of primary brain cancer in New Zealand, 1995 to 2010

OBJECTIVE

Case-control studies have linked mobile phone use to an increased risk of glioma in the most exposed brain areas, the temporal and parietal lobes, although inconsistently. We examined time trends in the incidence rates of brain malignancies in New Zealand from 1995 to 2010.

METHODS

Data from the New Zealand Cancer Registry was used to calculate incidence rates of primary brain cancer, by age, gender, morphology and anatomical site. Log-linear regression analysis was used to assess trends in the annual incidence of primary brain cancer; annual percentage changes and their 95% confidence intervals were estimated.

RESULTS

No consistent increases in all primary brain cancer, glioma, or temporal or parietal lobe glioma were seen. At ages 10-69, the incidence of all brain cancers declined significantly. Incidence of glioma increased at ages over 70.

CONCLUSION

In New Zealand, there has been no consistent increase in incidence rates of primary brain cancers. An increase in glioma at ages over 70 is likely to be due to improvements in diagnosis. As with any such studies, a small effect, or one with a latent period of more than 10 to 15 years, cannot be excluded.

Imaging characteristics of primary intracranial teratoma

BACKGROUND

Primary intracranial teratomas are rare intracranial neoplasms, and are subdivided into mature, immature, and those with malignant transformation. To date, only a few studies of teratoma imaging have been reported.

PURPOSE

To describe and characterize the magnetic resonance imaging (MRI) findings in a series of 18 patients (16 men/boys and 2 women/girls; mean age, 14.5 years) with pathologically proven teratomas.

MATERIAL AND METHODS

Findings from medical records and imaging examinations in 18 patients with pathologically confirmed intracranial teratomas from 2001 to 2011 were retrospectively reviewed at our two institutions. Two radiologists evaluated the lesion location, shape, size, number, edge, homogeneous or heterogeneous appearance, attenuation, signal intensity, and degree of enhancement.

RESULTS

All tumors were located within the pineal (n = 13), parasellar (n = 2), or suprasellar (n = 3) regions. The lesions appeared of mixed intensity on MRI, reflecting the histologic heterogeneity, including fibrosis, fatty tissue, calcification, cysts, and keratinocytes. In mature teratomas (n = 9), seven of nine tumors showed non-enhanced multilocularity or heterogeneous enhancement of the cyst wall on contrast-enhanced T1-weighted (T1W) images. Two of nine tumors showed moderate, heterogeneous enhancement in the solid portion of the lesion; whereas in immature (n = 7) or malignant transformation (n = 2) teratomas, heterogeneous, ring-like, intratumoral patchy enhancement was noted on T1W images with contrast.

CONCLUSION

Primary intracranial teratomas are usually localized in the pineal and the suprasellar regions, and often present an ovoid or lobulated mass with or without multilocularity on MRI. Marked enhancement of the solid portion or the thick wall of the tumor was the key feature for distinguishing mature teratoma and malignant teratoma.

Congenital intracranial immature teratoma of the lateral ventricle: a case report and review of the literature

OBJECTIVE

Congenital intracranial tumors are very rare and only account for 0.5-1.5% of all childhood brain tumors. The most common type of these tumors present at birth is teratomas, which represent 0.5% of all intracranial tumors. Most teratomas are midline tumors located predominantly in the sellar and pineal regions. In this study, we report a neonatal intracranial immature teratoma at the lateral ventricle because of its rare location.

CASE REPORT

A 3-day-old female neonate presented with a history of irritability, vomiting, and recurrent generalized clonic seizures since birth. A head computed tomographic scan and magnetic resonance imaging disclosed a large tumor filling the right lateral ventricle and extending into the ipsilateral posterior fossa. With right parieto-occipital craniotomy, large grayish-white lobulated vascular mass was encountered and total removal of tumor was performed. Histological examination revealed the diagnosis of immature teratoma.

CONCLUSION

The prognosis of congenital intracranial immature teratoma is usually poor because the lesions are extensive when they are identified. Prenatal ultrasonography is necessary for the prenatal diagnosis. Fetal magnetic resonance imaging should be made for the evaluation of intracranial tumor. If the tumor is detected before the 24 week of gestation, termination of the pregnancy should be considered.

Pediatric brain tumors in Nigeria: clinical profile, management strategies, and outcome

INTRODUCTION

Although modern neuroimaging has facilitated early care of brain tumors in children worldwide, there are, however, few published reports on clinical profile, treatment, and outcome of brain tumors in children from our subregion.

PURPOSE

We aimed to retrospectively study the clinical profile and outcome of pediatric brain tumors in a tertiary referral center from a developing country.

METHODS

Forty pediatric patients with histologically verified brain tumors managed by the authors over a 13-year period (May 1994-April 2006) were studied. Patients' data from clinical, radiological, and pathology records were analyzed using the statistical package for social sciences version 16.

RESULTS

The mean age was 9.75 years (range 1-15 years). Twenty-two males, 18 females. Common presenting symptoms were headaches (23 patients, 57.5%) and seizures (15 patients, 37.5%). Hyperreflexia (72.5%) and focal motor deficits (62.5%) were the most common neurologic signs. The mean interval from onset of symptoms to neurosurgical diagnosis was 13.4 months (95% CI). All patients had tumor resection, while 11 (27.5%) patients received adjuvant radiotherapy. Hydrocephalus occurred in 19 (47.5%) patients and was associated with early presentation (X2 = 10.65, p < 0.01). Low-grade astrocytoma (25%) and medulloblastoma (25%) were the most common tumors. Survival at 1 and 5 years were 56 and 47%, respectively.

CONCLUSION

Focal motor signs and elevated intracranial pressure are the salient presenting features of brain tumors in children seen in Nigeria. Those of them with hydrocephalus are likely to present early. The outcome for pediatric brain tumors remains poor.

Delays in diagnosis of paediatric cancers: a systematic review and comparison with expert testimony in lawsuits

Delayed diagnosis of paediatric cancers is reported regularly and is a source of remorse for physicians and parents and a leading cause of malpractice claims. We did a systematic review of information about the distribution, determinants, and consequences of time to diagnosis of paediatric malignancies and compared these findings with those of court-appointed expert witnesses in malpractice claims in Canada and France. Time to diagnosis varied widely between tumour types in the 98 relevant studies (medians ranged from 2-260 weeks) without any significant decrease with time. Determinants of a long delay in diagnosis included older age, qualification of the first physician contacted, non-specific symptoms, histological type, and tumour localisation. Delayed diagnosis was associated with poor outcome for retinoblastoma and possibly for leukaemia, nephroblastoma, and rhabdomyosarcoma (data were insufficient for definitive conclusions). It was not associated with an adverse outcome for most CNS tumours, osteosarcoma or Ewing's sarcoma, and, paradoxically, was frequently associated with better outcomes than was short time to diagnosis in these cancers. A third of the court-appointed experts provided testimony concordant with the medical literature. The relations between delay in diagnosis and outcome are complex and probably depend more on tumour biology than on parental or medical factors.

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.

Long time to diagnosis of medulloblastoma in children is not associated with decreased survival or with worse neurological outcome

BACKGROUND

The long time to diagnosis of medulloblastoma, one of the most frequent brain tumors in children, is the source of painful remorse and sometimes lawsuits. We analyzed its consequences for tumor stage, survival, and sequelae.

PATIENTS AND METHODS

This retrospective population-based cohort study included all cases of pediatric medulloblastoma from a region of France between 1990 and 2005. We collected the demographic, clinical, and tumor data and analyzed the relations between the interval from symptom onset until diagnosis, initial disease stage, survival, and neuropsychological and neurological outcome.

RESULTS

The median interval from symptom onset until diagnosis for the 166 cases was 65 days (interquartile range 31-121, range 3-457). A long interval (defined as longer than the median) was associated with a lower frequency of metastasis in the univariate and multivariate analyses and with a larger tumor volume, desmoplastic histology, and longer survival in the univariate analysis, but not after adjustment for confounding factors. The time to diagnosis was significantly associated with IQ score among survivors. No significant relation was found between the time to diagnosis and neurological disability. In the 62 patients with metastases, a long prediagnosis interval was associated with a higher T stage, infiltration of the fourth ventricle floor, and incomplete surgical resection; it nonetheless did not influence survival significantly in this subgroup.

CONCLUSIONS

We found complex and often inverse relations between time to diagnosis of medulloblastoma in children and initial severity factors, survival, and neuropsychological and neurological outcome. This interval appears due more to the nature of the tumor and its progression than to parental or medical factors. These conclusions should be taken into account in the information provided to parents and in expert assessments produced for malpractice claims.

Diagnostic delay of pediatric brain tumors in Israel: a retrospective risk factor analysis

PURPOSE

Pediatric brain tumors (PBTs) are the most common solid tumors and the leading cause of cancer-related morbidity and mortality in childhood. Previous studies have shown a significant delay between the onset of symptoms and the diagnosis of these tumors. Delayed diagnosis of PBTs may lead to acute situations and irreversible neurological damage. In this study, we looked for the incidence of delayed diagnosis of PBTs in Israel. We tried to find the reasons for these delays and the associated risk factors in order to provide a feedback to the system for improved education and earlier diagnosis.

METHODS

We analyzed the charts of 330 consecutive children aged 0-18 years diagnosed with brain tumors, between the years 1996 and 2004. In the cases where delay in diagnosis was suspected, further information was collected from a family interview.

RESULTS

The average "time to diagnosis" was 7.7 months (SD ± 16.7). Symptomatic deterioration from the first symptom until diagnosis was found in about 50% of the cases. Unacceptable delay in diagnosis was found in 27% of the children. The major reason for delay was "delay in indicated imaging." Symptoms that were found to be associated with delayed diagnosis were torticollis, ataxia, and motor dysfunction. Interestingly, the examination by specialists such as ophthalmologists or neurologists was also associated with delayed diagnosis.

CONCLUSIONS

There is an unacceptable rate of delay in the diagnostic process of PBTs in Israel. Greater awareness and familiarity with signs and symptoms associated with these tumors and lowering imaging threshold might minimize this phenomenon.

Interval between onset of symptoms and diagnosis of medulloblastoma in children: distribution and determinants in a population-based study

Hospital-based studies have reported long delays in the diagnosis of paediatric brain tumours. Our objective was to describe the duration between onset of symptoms and diagnosis of medulloblastoma in children and study their clinical determinants in a population-based study. This retrospective cohort study included all paediatric medulloblastoma from a region of France from 1990 to 2005. The median interval from symptom onset until diagnosis for these 166 patients was 65 days and did not decrease during the study period. The most frequent manifestations were: vomiting (88%), headaches (79%), psychomotor regression (60% of children under 3 years), psychological symptoms (27%), strabismus (26%), and asthenia (25%). For one third of the children under 3 years, the diagnosis was made only after life-threatening signs of intracranial hypertension appeared. The prediagnosis interval was significantly longer (median 91 vs. 60 days, p = 0.001) in children with psychological symptoms (27%). Causes for intervals that exceeded the median (65 days) included inconsistent (25%) or late (36%) combination of headaches and vomiting, a period of spontaneous symptom remission (14%-20%), no (24%) or late (57%) neurological signs, psychological symptoms (35%), and a normal neurological examination (27%). Time to medulloblastoma diagnosis in children remains fairly long, despite advances in imaging. Primary-care physicians must be suspicious not only of suggestive neurological signs, but also of non-specific symptoms that persist or are multiple. A meticulous neurological examination and cerebral imaging for such patients might facilitate earlier diagnosis.

Descriptive epidemiology of CNS tumors in France: results from the Gironde Registry for the period 2000-2007

An increase in the incidence of CNS tumors has been observed in many countries in the last decades. The reality of this trend has been much debated, as it has happened during a period when computer-assisted tomography and MRI have dramatically improved the detection of these tumors. The Gironde CNS Tumor Registry provides here the first data on CNS tumor incidence and trends in France for all histological types, including benign and malignant tumors, for the period 2000-2007. Incidence rates were calculated globally and for each histological subtype. For trends, a piecewise log-linear model was used. The overall annual incidence rate was found to be 17.6/100 000. Of this rate, 7.9/100 000 were neuroepithelial tumors and 6.0/100 000 were meningiomas. An overall increase in CNS tumor incidence was observed from 2000 to 2007, with an annual percent change (APC) of +2.33%, which was explained mainly by an increase in the incidence of meningiomas over the 8-year period (APC = +5.4%), and also more recently by an increase in neuroepithelial tumors (APC = +7.45% from 2003). The overall increase was more pronounced in women and in the elderly, with an APC peaking at +24.65% in subjects 85 and over. The increase in the incidence rates we observed may have several explanations: not only improvements in registration, diagnosis, and clinical practice, but also changes in potential risk factors.

Population-based epidemiological study of primary intracranial tumors in childhood

OBJECT

Brain tumors are the most common solid tumors in children and their prognosis is poor. Epidemiologic data from a population-based cancer registry provide the information necessary to determine the incidence rate of pediatric brain tumors. The aim of this study was to determine the epidemiology of childhood primary intracranial tumors in Kumamoto Prefecture, Japan.

METHODS

We surveyed 210 patients younger than 15 years who were diagnosed with primary intracranial tumors between 1989 and 2008; 159 (75.7%) of the tumors were confirmed microscopically.

RESULTS

The age-adjusted annual incidence rate was 36.1 cases per million children. The boys/girls ratio was 1.31. The age-specific annual incidence rate was 28.5-, 40.9-, and 38.4 cases per million for the 0- to 4-, 5- to 9-, and 10- to 14-year age group, respectively. The incidence was highest in 10- to 14-year-old boys (53.6 per million) and lowest in 10- to 14-year-old girls (22.6 per million). The most common tumor was astrocytoma (35.7%) with an annual incidence rate of 13.2 per million, followed by germ cell tumor (14.3%, 5.0 per million), craniopharyngioma (10.5%, 3.8 per million), medulloblastoma (10.0%, 3.7 per million), and ependymoma (4.8%, 1.5 per million). The distribution of the tumor type varied with the patient age and gender. Although there were no germ cell tumors in 0- to 4-year-old boys, they were the second-most common tumor in 10- to 14-year-old boys. Conversely, while there were no medulloblastomas in 10- to 14-year-old girls, their incidence was high in 0- to 4-year-old girls.

CONCLUSIONS

In this Kumamoto survey, the incidence rate of primary intracranial tumors in children was similar to that in Western countries. However, the incidence and relative frequency of particular histological types of childhood brain tumors such as germ cell tumors and craniopharyngiomas were different between Japan and Western countries.

An international case-control study of maternal diet during pregnancy and childhood brain tumor risk: a histology-specific analysis by food group

PURPOSE

Maternal dietary data from an international collaborative case-control study on childhood brain tumors were used to evaluate associations between histology-specific risk and consumption of specific food groups during pregnancy.

METHODS

Nine study centers from seven countries contributed 1218 cases and 2223 controls. Most cases were diagnosed between 1982 and 1992 and ranged in age from 0 to 19 years. Dietary consumption was measured as average grams per day.

RESULTS

Foods generally associated with increased risk were cured meats, eggs/dairy, and oil products; foods generally associated with decreased risk were yellow-orange vegetables, fresh fish, and grains. The cured meat association was specific to astrocytomas (odds ratio [OR] range=1.8-2.5 across astrocytoma subtypes for 4th vs. 1st quartile of consumption, p trends

CONCLUSIONS

These results suggest the need for dietary analysis not only by brain tumor histology, but also by specific foods within a broad food group.

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Key Words

• childhood neoplasms
• brain tumors
• diet
• n-nitroso compounds
• cured meat products
• vegetables

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MESH Headings

• Adolescent
• Brain Neoplasms/epidemiology
• Brain Neoplasms/etiology
• Case-Control Studies
• Child
• Child, Preschool
• Diet/adverse effects
• Female
• Humans
• Infant
• Infant, Newborn
• Male
• Meat Products/adverse effects
• Nitroso Compounds/adverse effects
• Pregnancy
• Prenatal Exposure Delayed Effects
• Risk Factors
• Vegetables
• Young Adult

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Grants

• P30 ES007048 NIEHS NIH HHS
• N01 CN025403 NCI NIH HHS
• P01 CA017054-30 NCI NIH HHS
• N01 PC035139 NCI NIH HHS
• CA47081 NCI NIH HHS
• CA17054 NCI NIH HHS
• N01-CN-25403 NCI NIH HHS
• P01 CA017054 NCI NIH HHS
• P30 ES007048-029003 NIEHS NIH HHS
• CA47082 NCI NIH HHS
• N01 CN005230 NCI NIH HHS
• 5P30 ES07048 NIEHS NIH HHS

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Affiliation(s)

Janice M Pogoda USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
Susan Preston-Martin
Geoffrey Howe
Flora Lubin
Beth A Mueller
Elizabeth A Holly
Graziella Filippini
Raphael Peris-Bonet
Margaret R E McCredie
Sylvaine Cordier
Won Choi

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Clinical epidemiology for childhood primary central nervous system tumors

This work was conducted by the French Brain Tumor Data Bank (FBTDB) and aims to prospectively record all primary central nervous system tumors (PCNST), in France, for which histological diagnosis is available. Results concerning children are presented. This study analyzes the childhood cases (0-19 years) of newly diagnosed and histologically confirmed PCNST (during the years 2004-2006) which have been recorded by the FBTDB. All French neuropathology and neurosurgery departments participated in this program. Neurosurgeons and neuropathologists completed a data file containing socio-demographic, clinical, radiologic and anatomopathologic information. The Tumor Registry from Herault was authorized to compile the data files with personal identifiers. About 1,017 cases (533 boys and 484 girls) of newly diagnosed childhood PCNST have been recorded (gliomas: 52%, all other neuroepithelial tumors: 31%, craniopharyngioma: 5%, germ cell tumors, meningioma and neurinoma: approximately 3% each, all histological subtypes have been detailed). Tumor resections were performed in 83.3%, and biopsies in 16.7%. The distributions by histology, cryopreservation of the samples, age, sex, tumor site and surgery have been detailed. To our knowledge, this work is the first databank in Europe dedicated to PCNST that includes the collection of clinical, radiological and histological data (including cryopreservation of the specimen). The long term goals of the FBTDB are to create a national registry and a network to perform epidemiological studies, to implement clinical and basic research protocols, and to evaluate and harmonize the healthcare of children and adult patients affected by PCNST.

Brain tumors in the first three years of life: a review of twenty cases

OBJECTIVE AND METHOD: To review the clinical and neuropathological findings as well as the type of therapy and outcome in 20 infants under 3 years-old with central nervous system (CNS) tumor. They were treated at the Department of Neurology, "Hospital das Clínicas" University of São Paulo Medical School, from January 1997 to May 2001. RESULTS: Astrocytoma was the most common histological type (n=7), followed by ependymoma (n=3), medulloblastoma (n=2), craniopharyngioma (n=2) and desmoplastic ganglioglioma (n=2). The location of the tumor was predominantly supratentorial. Mean follow-up time was 20.2 months with recurrence in 7 cases. For each type of tumor we have emphasized the treatment currently recommended. CONCLUSION: Although follow-up time is not sufficient for analyzing survival, a trend of improvement in prognosis was noted, compared to another series of cases from our Institution that had been evaluated before 1990.

Congenital intracranial teratoma with massive macrocephaly and skull rupture

OBJECTIVE

Congenital intracranial tumors are rare and only account for 0.5-1.5% of all pediatric brain tumors. Teratoma is the most frequently encountered intracranial tumor at birth. Massive congenital intracranial teratoma is an extremely rare neoplasm with a poor prognosis. They grow rapidly and cause extensive destruction in the brain. Herein we report a massive intracranial teratoma causing skull rupture.

CASE REPORT

A fetus with a congenital intracranial teratoma presenting with a disproportionately enlarged head at 25 weeks of gestation is presented. Since it was the first admission of the mother to a medical expert for a prenatal examination, there was noprevious follow-up data. Prenatal ultrasonography demonstrated a huge, heterogeneous intracranial mass, and midline structures and ventricles could not be observed. No heartbeat was detected. Autopsy was perforated, and histopathologic examination of the samples taken from the intracranial mass revealed an immature teratoma.

CONCLUSION

Although congenital intracranial teratomas are rare, they may reach enormous sizes. Regular follow-up of the fetus may lead to early diagnosis of immature intracranial teratomas and prevent the mother from having further complications either due to intrauterine fetal death orpsychological trauma of giving birth to a heavily malformed baby.

Presentation of childhood CNS tumours: a systematic review and meta-analysis

BACKGROUND

Suspicion of a CNS tumour is classically raised by symptoms of raised intracranial pressure, focal deficits (including seizures), or papilloedema. Development of guidelines is needed for the identification and referral of children who might have a CNS tumour. We did a systematic literature review and meta-analysis to identify the clinical presentation of childhood CNS tumours to provide evidence to support the development of guidelines to assist with the identification and referral for imaging of children who might have a central nervous system tumour.

METHODS

Medline, Embase, and PubMed were searched for cohort studies and case series in children, published between January, 1991, and August, 2005, detailing the symptoms and signs at diagnosis of a CNS tumour.

FINDINGS

74 papers (n=4171) met the inclusion criteria. 56 symptoms and signs at diagnosis were identified, ranked by frequency, and clustered according to age, anatomical criteria, and genetic criteria. The most frequent symptoms and signs at diagnosis were: headache (33%), nausea and vomiting (32%), abnormalities of gait and coordination (27%), and papilloedema (13%) for intracranial tumours; macrocephaly (41%), nausea and vomiting (30%), irritability (24%), and lethargy (21%) for children aged under 4 years with intracranial tumours; reduced visual acuity (41%), exophthalmia (16%), and optic atrophy (15%) for children with an intracranial tumour and neurofibromatosis; nausea and vomiting (75%), headache (67%), abnormal gait and coordination (60%), and papilloedema (34%) for posterior fossa tumours; unspecified symptoms and signs of raised intracranial pressure (47%), seizures (38%), and papilloedema (21%) for supratentorial tumours; headache (49%), abnormal eye movements (21%), squint (21%), and nausea and vomiting (19%) for central brain tumours; abnormal gait and coordination (78%), cranial nerve palsies (52%), pyramidal signs (33%), headache (23%), and squint (19%) for brainstem tumours; and back pain (67%), abnormalities of gait and coordination (42%), spinal deformity (39%), focal weakness (21%), and sphincter disturbance (20%) for spinal-cord tumours. Other features noted were weight loss, growth failure, and precocious puberty. Symptoms of raised intracranial pressure were absent in more than half of children with brain tumours. Other neurological features were heterogeneous and related to tumour location.

INTERPRETATION

Apart from raised intracranial pressure, motor and visual system abnormalities, weight loss, macrocephaly, growth failure, and precocious puberty also suggest presence of an intracranial tumour. Children with signs and symptoms that could result from a CNS tumour need a thorough visual and motor system examination and an assessment of growth and pubertal status. Occurrence of multiple symptoms and signs should alert clinicians to possible CNS tumours.

Congenital cavernous sinus cystic teratoma

Teratomas represent 0.5% of all intracranial tumors. These benign tumors contain tissue representative of the three germinal layers. Most teratomas are midline tumors located predominantly in the sellar and pineal regions. The presence of a teratoma in the cavernous sinus is very rare. Congenital teratomas are also rare, especially those of a cystic nature. To our knowledge, this would be the first case report of a congenital, rapidly growing cystic teratoma within the cavernous sinus. A three-month-old boy presented with a past medical history of easy irritability and poor oral intake. A magnetic resonance image (MRI) scan of the head disclosed a large expanding cystic tumor filling the right cavernous sinus and extending into the pterygopalatine fossa through the foramen rotunda. These scans also demonstrated a small area of mixed signal intensity, the result of the different tissue types conforming to the tumor. Heterogeneous enhancement was seen after the infusion of contrast medium. However, this was a cystic tumor with a large cystic portion. Thus, a presumptive diagnosis of cystic glioma was made. With the use of a right frontotemporal approach, extradural dissection of the tumor was performed. The lesion entirely occupied the cavernous sinus, medially displacing the Gasserian ganglion and trigeminal branches (predominantly V1 and V2). The lesion was composed of different tissues, including fat, muscle and mature, brain-like tissue. The tumor was completely removed, and the pathological report confirmed the diagnosis of a mature teratoma. There was no evidence of recurrence. Despite the location of the lesion in the cavernous sinus, total removal can be achieved with the use of standard microsurgical techniques.

[Presenting signs and symptoms of central nervous system tumors according to age]

INTRODUCTION

Central nervous system tumors are the second most frequent group of neoplasms in children and are the main cause of cancer-related deaths in the pediatric population. There are no specific clinical findings. Consequently clinical data that would aid diagnosis are required.

OBJECTIVE

To establish the presenting signs and symptoms of brain tumors in childhood according to age and identify their influence on diagnostic delay.

PATIENTS AND METHODS

We retrospectively studied 69 patients with central nervous system tumors diagnosed between January 1997 and December 2002 in the Virgen del Rocío children's hospital.

RESULTS

At diagnosis, 60.9 % of the patients were in the most advanced clinical stages. The most commonly found signs were papilledema, ataxia and squint, with no differences among age groups. The most frequent symptoms were vomiting, headache and behavior changes (irritability in children aged less than 5 years and unhappiness in children aged more than 5 years). Diagnostic delay was longer in older children.

CONCLUSIONS

The diagnostic signs and symptoms of central nervous tumors are non-specific. A high index of suspicion is required for early diagnosis.

Morphological pattern and frequency of intracranial tumors in children

BACKGROUND

Brain tumors are the second most common neoplasm in children. Pattern of primary brain tumors in children has not been reported in Iran. Brain tumors have been the subject of controversy both with respect to pattern of occurrence and to potential causes.

OBJECTIVE

To determine the age, sex, location, and histologic diagnosis of intracranial tumors in children less than 15 years of age.

MATERIALS AND METHODS

A retrospective study of 619 children who were admitted to the neurosurgical center between 1978 and 2003 was performed. Charts were reviewed to extract information about demographics, location, and histopathological diagnosis of tumors. All patients entered into this study had pathologically proven brain tumor. The frequency distribution of brain tumors by age and sex, location, and histopathology was calculated.

RESULTS

The male-female ratio, 58.1 to 41.9%, vary significantly (p<0.05). The mean age of the patients at time of diagnosis was 8.8 years (SD=3.9). Fifty-one percent of brain tumors were located in supratentorial, and 49.0% in the infratentorial region. In supratentorial region, 57.0% of the tumors were in the hemispheric. In infratentorial region, 68% of the tumors were in the midline. The mixed five most common histological diagnoses in patients were astrocytoma (40.4%), followed by medulloblastoma (18.4%), ependymoma (10.5%), craniopharyngioma (8.8%), and meningioma (4.2%). Most of the brain tumor types (85%) occurred in children between 5 to 15 years of age. Astrocytoma occurred mostly in children aged 5-15 years (87%).

CONCLUSION

Males were affected more than females. A significant male predominance was observed in craniopharyngioma and medulloblastoma. Astrocytoma was the first most common brain tumor in all age groups. Certain tumor types show a predilection for the certain period of life.

Massive congenital intracranial immature teratoma of the lateral ventricle with retro-orbital extension: a case report and review of the literature

Germ cell tumors comprise 0.4-3.1% of all intracranial tumors, and teratoma constitutes 9-30% of them. Congenital intracranial tumors are very rare and only account for 0.5-1.5% of all childhood brain tumors. The most common type of these tumors present at birth is teratomas, which represent 0.5% of all intracranial tumors. Most teratomas are midline tumors located predominantly in the sellar and pineal regions. In this study, we report a neonatal intracranial immature teratoma at the lateral ventricle because of its rare location. A 5-day-old female neonate presented with a history of irritability and left eye protrusion since birth. A head computed tomographic (CT) scan and magnetic resonance imaging (MRI) disclosed a large tumor filling the left lateral ventricle and extending into the ipsilateral retro-orbital space. With left frontotemporoparietal craniotomy, a large grayish-white lobulated vascular mass was encountered, and total removal of tumor was performed. Histological examination revealed the diagnosis of immature teratoma. The prognosis of congenital intracranial immature teratoma is usually poor because the lesions are extensive when they are identified. Prenatal ultrasonography is necessary for the prenatal diagnosis. Fetal MRI should be made for the evaluation of intracranial tumor. If the tumor is detected before the 24th week of gestation, termination of the pregnancy should be considered.

Local targeting of malignant gliomas by the diffusible peptidic vector 1,4,7,10-tetraazacyclododecane-1-glutaric acid-4,7,10-triacetic acid-substance p

PURPOSE

Malignant glial brain tumors consistently overexpress neurokinin type 1 receptors. In classic seed-based brachytherapy, one to several rigid (125)I seeds are inserted, mainly for the treatment of small low-grade gliomas. The complex geometry of rapidly proliferating high-grade gliomas requires a diffusible system targeting tumor-associated surface structures to saturate the tumor, including its margins.

EXPERIMENTAL DESIGN

We developed a new targeting vector by conjugating the chelator 1,4,7,10-tetraazacyclododecane-1-glutaric acid-4,7,10-triacetic acid to Arg(1) of substance P, generating a radiopharmaceutical with a molecular weight of 1,806 Da and an IC(50) of 0.88 +/- 0.34 nmol/L. Cell biological studies were done with glioblastoma cell lines. neurokinin type-1 receptor (NK1R) autoradiography was done with 58 tumor biopsies. For labeling, (90)Y was mostly used. To reduce the "cross-fire effect" in critically located tumors, (177)Lut and (213)Bi were used instead. In a pilot study, we assessed feasibility, biodistribution, and early and long-term toxicity following i.t. injection of radiolabeled 1,4,7,10-tetraazacyclododecane-1-glutaric acid-4,7,10-triacetic acid substance P in 14 glioblastoma and six glioma patients of WHO grades 2 to 3.

RESULTS

Autoradiography disclosed overexpression of NK1R in 55 of 58 gliomas of WHO grades 2 to 4. Internalization of the peptidic vector was found to be specific. Clinically, the radiopharmeutical was distributed according to tumor geometry. Only transient toxicity was seen as symptomatic radiogenic edema in one patient (observation period, 7-66 months). Disease stabilization and/or improved neurologic status was observed in 13 of 20 patients. Secondary resection disclosed widespread radiation necrosis with improved demarcation.

CONCLUSIONS

Targeted radiotherapy using diffusible peptidic vectors represents an innovative strategy for local control of malignant gliomas, which will be further assessed as a neoadjuvant approach.

The presenting features of brain tumours: a review of 200 cases

OBJECTIVE

To determine the presenting features of brain tumours in children.

DESIGN

Retrospective case note review.

SETTING

Paediatric and neurosurgical services at the Wessex Neurology Centre and Southampton General Hospital, UK.

PATIENTS

200 patients presenting with a CNS tumour between 1988 and 2001.

RESULTS

The commonest first presenting symptoms were headache (41%), vomiting (12%), unsteadiness (11%), visual difficulties (10%), educational or behavioural problems (10%), and seizures (9%). The commonest symptoms occurring at any time were headache (56%), vomiting (51%), educational or behavioural problems (44%), unsteadiness (40%), and visual difficulties (38%). Neurological signs were present at diagnosis in 88%: 38% had papilloedema, 49% cranial nerve abnormalities, 48% cerebellar signs, 27% long tract signs, 11% somatosensory abnormalities, and 12% a reduced level of consciousness. The median symptom interval was 2.5 months (range 1 day to 120 months). A short symptom interval was significantly associated with high grade tumours and patient age of 3 years or younger.

CONCLUSIONS

The well known predominance of headache in children with CNS tumours is confirmed. Visual, behavioural, and educational symptoms were also prominent. With the exception of seizures, every initial symptom was accompanied by other symptoms or signs by the time of diagnosis. Questions about visual symptoms and educational or behavioural difficulties, as well as the more widely recognised symptoms of raised intracranial pressure and motor dysfunction, are important in the diagnosis of brain tumours, as are vision assessment and the appropriate plotting of growth and head size.

Gamma knife radiosurgery for intracranial mature teratoma—long-term results and review of literature

BACKGROUND

The purpose of this report is to present long-term outcomes of gamma knife radiosurgery for intracranial mature teratoma after debulking surgery.

METHODS

Three patients with intracranial mature teratoma had initial target volumes of 5.4, 18.7, and 5.1 cm(3), respectively, and were treated by gamma knife radiosurgery between 1993 and 2004. Marginal doses of 17, 12.5, and 13.5 Gy, respectively, were delivered to the tumors at isodose levels of 50%, 50%, and 62%, respectively. The first patient received radiosurgery after surgical removal and conventional radiotherapy. The second patient received similar management, including surgery and radiotherapy, with tumor recurrence. Two additional operations and subsequent radiosurgery were performed on this patient. Based on the favorable results of the first 2 patients, we performed radiosurgery instead of conventional radiotherapy after subtotal surgical removal in the last patient. By reviewing literatures concerning the therapeutic modalities and the long-term results of our 3 patients, we discuss the role of radiosurgery in treating intracranial mature teratoma.

RESULTS

A follow-up period of 121, 89, and 31 months, respectively, demonstrated tumor volume reduction rates of 70%, 89%, and 48%, respectively. No evidence of further tumor progression and no radiosurgery-related complication or morbidity was noted. The school performances of the affected children are all above average.

CONCLUSIONS

Gamma knife radiosurgery provides a safe and effective alternative as the adjuvant treatment of intracranial mature teratoma after surgical debulking. Previous conventional radiotherapy does not alter final tumor control. Radiosurgery should be considered when residual tumor growth continues with no related symptoms or evaluations of tumor markers during follow-up.

Primary pediatric brain tumors: statistics of Taipei VGH, Taiwan (1975-2004)

BACKGROUND

The purpose of the current study was to investigate a hospital series of 986 cases of primary pediatric brain tumors in Taiwan.

METHODS

The authors reviewed the database of primary pediatric brain tumors in patients < 18 years of age collected in Taipei Veterans General Hospital (Taipei VGH) from 1975 to May 2004. Age and gender distribution, location, and classification of brain tumors were analyzed. Intracranial tumors with diagnostic imaging were included. Nontumoral lesions, cysts, and vascular malformations were excluded.

RESULTS

The mean age of these 986 patients was 7.8 years, and the male to female ratio was 1.4:1. Supratentorial (including pineal-quadrigeminal) located tumors (58.3%) was predominant to infratentorial tumors (41.1%). In these series, 886 patients had either histologic diagnosis (842 patients) or clinical diagnosis (44 patients). The most common 5 categories of tumors were astrocytic tumors (31.1%), germ cell tumors (14.0%), medulloblastomas (13.3%), craniopharyngiomas (8.3%), and ependymal tumors (5.8%). Atypical teratoid/rhabdoid tumors (AT/RTs), a rare but highly malignant tumor, were 2.1%. The high incidence of primary intracranial germ cell tumors correlated with reported series from Japan and Korea. For the remaining 100 patients without diagnostic classifications, the majority were most likely astrocytic tumors in brain stem.

CONCLUSIONS

The authors analyzed a large hospital series of primary brain tumors in children. Both histologically verified and unverified tumors were recruited to avoid selective bias. Although it was not a study of a population-based brain tumor registry, it could still be representative of primary pediatric brain tumors in Taiwan.

Incidence of childhood brain tumors in Syria (1993-2002)

OBJECTIVE

To determine whether the incidence and location of childhood CNS tumors in Syria follows the same pattern described in Western and Far Eastern countries.

PATIENTS AND METHODS

We analyzed the data compiled from 367 children with brain tumors operated on in our Department of Neurosurgery between 1993 and mid-2002. We excluded all vascular and metastatic lesions and adopted the latest WHO classification in grouping all glial tumors.

RESULTS

We found that 47% of brain tumors were located in the supratentorial, and 53% in the infratentorial region. The ratio of male to female occurrence was 1:1.2 (52% males, 48% females). For lesions in the supratentorial space, the distribution was 56% males and 44% females, while in the posterior fossa, the distribution was 61% males and 39% females. Low-grade tumors (WHO I/II) constituted 53.5% of all lesions, and the rest were high grade tumors (WHO III/IV) 46.5%. The most common tumor found in our childhood population was medulloblastoma (27.5%), followed by astrocytoma (25.8%), then craniopharyngioma (14.1%). The most common tumor in the posterior fossa was medulloblastoma (53.5%), followed by astrocytoma (22.5%), then ependymoma (17%). The most common tumors in the supratentorial space were astrocytoma and craniopharyngioma.

CONCLUSIONS

In our patient population, the incidence and distribution of CNS tumors were somehow different than those reported by authors from the Western and Far Eastern countries. Whether these results are unique to Syria, or reflect a regional difference in the disease distribution between the Middle East region and the rest of the world, remains to be determined.

Health Effects of Chronic Pesticide Exposure: Cancer and Neurotoxicity

Pesticides are widely used in agricultural and other settings, resulting in continuing human exposure. Epidemiologic studies indicate that, despite premarket animal testing, current exposures are associated with risks to human health. In this review, we describe the routes of pesticide exposures occurring today, and summarize and evaluate the epidemiologic studies of pesticide-related carcinogenicity and neurotoxicity in adults. Better understanding of the patterns of exposure, the underlying variability within the human population, and the links between the animal toxicology data and human health effects will improve the evaluation of the risks to human health posed by pesticides. Improving epidemiology studies and integrating this information with toxicology data will allow the human health risks of pesticide exposure to be more accurately judged by public health policy makers.

Giant cavernous sinus teratoma: a clinical example of a rare entity: case report

OBJECTIVE AND IMPORTANCE

Teratomas represent 0.5% of all intracranial tumors. These benign tumors have tissue representative of the three germinal layers: ectoderm, mesoderm, and endoderm. Most teratomas are midline tumors located predominantly in the sellar and pineal regions. Cavernous sinus location is very rare; only two purely intracavernous teratomas have been reported.

CLINICAL PRESENTATION

A 14-year-old boy presented with a history of progressive right eye proptosis and visual acuity impairment, headaches, and a neuralgia-like facial pain in the right V1 distribution. A head computed tomographic scan and magnetic resonance imaging disclosed a large tumor filling the right cavernous sinus and extending into the ipsilateral middle fossa. These scans also demonstrated mixed signals derived from different tissues conforming to the tumor (fat, cartilage, muscle strands, bone, and a primordial tooth). Heterogeneous enhancement was seen after infusion of contrast medium. Significant bone erosion and remodeling was evident in the middle fossa floor and right orbit, with secondary proptosis. A presumptive diagnosis of mature teratoma was made.

INTERVENTION

With the use of a right frontotemporal interfascial approach, a combined extra- and intradural dissection of the tumor was performed. The lesion entirely occupied the cavernous sinus, laterally displacing the Gasserian ganglion and trigeminal branches (predominantly V1 and V2). The internal carotid artery and Cranial Nerve VI were medially displaced by the tumor mass. The lesion was composed of different tissues, including hair, fat, cartilage, muscle, nerve-like tissue, bone, and a primordial tooth. The tumor was removed completely, and the pathological report confirmed the diagnosis of a mature teratoma. There was no evidence of recurrence at the 8-month follow-up examination.

CONCLUSION

Because of the lesion's location in the lateral wall of the cavernous sinus, a total removal was achieved with the use of standard microsurgical techniques. Knowledge of the microanatomy is essential in treating intracavernous pathology. We present the third reported case of a giant mature teratoma of the cavernous sinus.

Tumor-related epilepsy in children

A 10-year retrospective review of 15 children with cerebral tumors and seizures was conducted to study the factors responsible for delay in the diagnosis of tumors and to assess outcome following surgery. Mean duration of seizures prior to surgery was 37 months. Ninety-three percent had no focal neurologic deficits. Head computed tomography was abnormal in 64%, whereas magnetic resonance imaging was abnormal in all patients. Electroencephalography showed focal abnormalities ipsilateral to the tumor in 73%. There was no surgical mortality. Eighty percent were seizure free or had rare seizures following surgery. Factors contributing to a delayed diagnosis of the brain tumor included a nonfocal neurologic examination and delay in obtaining an appropriate neuroimaging study. We believe that head magnetic resonance imaging should be the investigation of choice in partial epilepsies.