Choroid plexus tumors in children

Developing a nomogram based on SEER database for predicting prognosis in choroid plexus tumors

Choroid plexus tumors (CPT) are rare and highly vascularized neoplasms that have three histologically confirmed diagnoses, including choroid plexus papilloma, atypical choroid plexus papilloma, and choroid plexus carcinoma (CPC). This study aimed to determine the epidemiology and survival of patients with CPTs and develop a nomogram to quantify the prognosis of the patients with CPT. Data of 808 patients who were diagnosed as CPT between 2000 and 2020 was obtained from the surveillance, epidemiology, and end results database. Descriptive analysis was used to assess the distribution and tumor-related characteristics of the patients with CPT. Independent prognostic factors for patients with CPT were identified by univariate and multivariate Cox regression analysis. The nomogram was established and evaluated by receiver operating characteristic curve, and decision curve analysis (DCA), calibration curves. The independent prognostic factors for patients with CPT are age, tumor size, surgery, chemotherapy, tumor number, pathologies, and race. For the prognostic nomogram, the area under the curve (AUC) of 60-, 120-, and 180-months were 0.855, 0.869 and 0.857 in the training set and 0.836, 0.864 and 0.922 in the test set. The DCA and calibration curve indicated the good performance of the nomogram. Patients with CPTs can be diagnosed at any age. Among the three histopathological tumors, patients with CPC had the worst prognosis. The nomogram was established to predict the prognosis of patients with CPT, which had satisfactory accuracy, and clinical utility may benefit for clinical decision-making.

Case Study of a Complex Neurovascular Disorder: Choroidal Arteriovenous Malformation

This study conducts an in-depth analysis of the management of a complex arteriovenous malformation (AVM) in a 44-year-old individual, who initially manifested with acute left hemiparesis and progressively declined into a comatose state. Diagnostic neuroimaging identified a substantial right fronto-temporal intraparenchymal hematoma via a CT scan. Cerebral angiography further elucidated a choroidal AVM originating from the anterior choroidal artery, accompanied by intranidal aneurysms. The elected treatment strategy was the surgical excision of the AVM. The procedure achieved complete removal of the intracranial AVM, situated in a neurologically sensitive region, leading to notable neurological recovery. This study thoroughly explores and critically evaluates a wide spectrum of treatment approaches for intracranial arteriovenous malformations, including novel endovascular therapies. Despite extensive discourse on AVM in contemporary literature, this report is among the few documenting the treatment of a choroidal AVM via a microsurgical technique, and highlights various therapeutic options.

Tumors of Choroid Plexus and Other Ventricular Tumors

Tumors arising inside the ventricular system are rare but represent a difficult diagnostic and therapeutic challenge. They usually are diagnosed when reaching a big volume and tend to affect young children. There is a wide broad of differential diagnoses with significant variability in anatomical aspects and tumor type. Differential diagnosis in tumor type includes choroid plexus tumors (papillomas and carcinomas), ependymomas, subependymomas, subependymal giant cell astrocytomas (SEGAs), central neurocytomas, meningiomas, and metastases. Choroid plexus tumors, ependymomas of the posterior fossa, and SEGAs are more likely to appear in childhood, whereas subependymomas, central neurocytomas, intraventricular meningiomas, and metastases are more frequent in adults. This chapter is predominantly focused on choroid plexus tumors and radiological and histological differential diagnosis. Treatment is discussed in the light of the modern acquisition in genetics and epigenetics of brain tumors.

Case Report: Detailed Clinical Course and Management Plan for Status Epilepticus Pediatric Patient with Resected Choroid Plexus Papilloma: A Case Report and a Single Center Experience

Choroid plexus papilloma (CPP) is a benign but rare central nervous system (CNS) neoplasm of the choroid plexus. The onset of symptoms is usually in the first decade and may occur at birth (i.e., congenital). It accounts for 0.4-0.6% of all brain tumors. Usually seen in patients who are young children. The object of this clinical case to highlight early surgical intervention, intensive and multidisciplinary care, and pharmaceutical prescriptions can enhance the patient's condition and quality of life. We herein report a rare presentation of CPP in a 6-year-old Sudanese female child with seizures. Who suffered from obstructive hydrocephalus with lateral ventricular choroid plexus papilloma. The patient underwent resection at the age of 6 months in our center's neurosurgery department. Intensive and multidisciplinary follow-up managed to maintain positive outcome and better quality of life in a relatively benign neoplasm. In spite of a wide range of therapeutic options for the management of CPP described in the literature, studies demonstrated that patients with CPP alone and underwent a surgical procedure can live independently as adults and work full-time with uncommon recurrences.

A case report of atypical choroid plexus papilloma in the cervicothoracic spinal cord

Choroid plexus papillomas (CPPs) are uncommon, benign intracranial tumors that can occur in both children and adults. In adults, CPPs are typically identified in the fourth ventricle, whereas in children, they most commonly occur in the lateral ventricle. CPPs that arise from the extraventricular system are extremely rare and difficult to diagnose. We report a case of extraventricular, atypical CPP located in the cervicothoracic spinal cord of a 2-year-old girl.

Role of available adjuvant therapies following surgical resection of atypical choroid plexus papilloma-a systematic review and pooled analysis

Background

Atypical choroid plexus papilloma is a recently introduced entity with intermediate pathological characteristics. These tumors are relatively rare and the optimal management of these tumors is a matter of debate. Therefore, we performed a systematic review and pooled analysis about the effects of adjuvant therapies on outcome measures of these patients. We also compared these effects on totally and partially resected tumors and pediatric and adult populations.

Methods

A systematic search of 3 databases based on inclusion/exclusion criteria was performed. Data extraction was separately performed by 2 authors, and the summarized data were presented in the form of tables. Pooled estimates of different outcome measures were calculated for each adjuvant therapy and presented separately for studies with pediatric, adult, or mixed populations.

Results

A review of 14 included studies consisting of 144 patients revealed the effect of adjuvant treatment on reduction of tumor recurrence, metastasis, and reoperation rates and increasing survival rates in patients with subtotal tumor resection. This advantage was not seen in the case of gross total tumor resection. Almost all outcome measures were more favorable in the pediatric population.

Conclusions

It can be concluded that whenever gross total resection is not feasible, the implementation of adjuvant therapy can improve the outcome and prognosis. In other cases, it should be decided on an individual basis. Also, more aggressive behavior and higher rates of recurrence and mortality in the adult population suggest the consideration of more aggressive adjuvant treatments for adult patients.

Multiple Sclerosis and the Choroid Plexus: Emerging Concepts of Disease Immunopathophysiology

BACKGROUND

The coexistence of multiple sclerosis and intracranial neoplasms is very rare, and whether this occurrence can be explained by a causal relationship or by coincidence remains a matter of debate. Possible roles of the choroid plexus as a site of tumor cell invasion and lymphocyte infiltration into the central nervous system have been hypothesized in recent studies.

METHODS

We describe a 13-year-old boy with concurrent multiple sclerosis and choroid plexus papilloma, then review the published literature with a focus on the pathophysiologic mechanisms of neuroinflammation in multiple sclerosis and the potential role of the choroid plexus in this process.

RESULTS

A growing body of evidence suggests that both physical and functional dysregulation of the choroid plexus may be a common mechanism underlying the pathophysiology of central nervous system inflammation.

CONCLUSIONS

In multiple sclerosis, the choroid plexus could act as a gateway for lymphocyte entry from the peripheral blood into the central nervous system at its earlier stages. However, future studies are needed to identify whether structural alterations of the choroid plexus play a role in the pathophysiology of multiple sclerosis and to provide suitable models to determine their consequences.

Rapidly growing, multifocal, benign choroid plexus tumor in an infant: case report

Choroid plexus papillomas (CPPs) are rare, benign tumors that can arise in young children. Most pediatric patients present with signs of hydrocephalus and require immediate treatment. The natural history of choroid plexus tumors in children without hydrocephalus is poorly defined. In this report, the authors present the very rare case of a child without hydrocephalus but with two intraventricular choroid plexus tumors discovered shortly after birth. Initial imaging had been performed for seizures and showed agenesis of the corpus callosum and enhancing tumors in the third and left lateral ventricles. Sequential imaging demonstrated rapid growth of both tumors. The lateral tumor was removed when the child was 3 months of age. A histological examination of the specimen showed benign features with an elevated mitotic rate. Given the patient's age of under 3 years, the diagnosis was WHO grade I CPP. The third ventricle tumor grew rapidly. A second surgery was performed and this tumor was resected. Again, the pathological diagnosis was WHO grade I CPP. The authors present this rare case and discuss the current relevant literature.

Management of choroid plexus tumors-an institutional experience

Background

Choroid plexus tumors are rare entities. Resection is the mainstay of treatment in grade I and grade II tumors and adjuvant treatment is usually reserved for the less frequent choroid plexus carcinoma (CPC). Outcome is not only related to their histological grade but also dependent on their size, location, and presence of often multifactorial disturbances of cerebrospinal fluid (CSF) circulation.

Methods

Retrospective analysis of 36 consecutive patients operated on a choroid plexus tumor at our institution in a mixed pediatric and adult population between 1991 and 2016.

Results

Twenty-one CPP, 11 atypical choroid plexus papillomas (aCPP), and four CPC were encountered in 17 children and 19 adults. Regardless of histological grading, gross-total resection (GTR) could be achieved in 91.7% of patients. Tumor recurrence (25.0%) was significantly associated with histological grading (p = 0.004), subtotal resection (p = 0.002), and intraoperatively evident zones of tumor infiltration (p = 0.001). Adjuvant therapy was performed in 19.4% of patients, mainly diagnosed with CPC. The 5-year overall survival rate was 95.2% for CPP and 100.0% for both aCPP and CPC. Survival was related to the extent of resection (p = 0.001), tumor progression (p = 0.04), and the presence of leptomeningeal metastases (p = 0.002). Even after resection, either ventricular or subdural shunting was required in 25.0% of patients.

Conclusions

We could confirm that GTR is crucial for treatment of choroid plexus tumors. Parenchymal tumor infiltration as detected intraoperatively was associated with the extent of resection and not limited to CPC. CSF disturbances mandating treatment may persist after resection.

Clinical importance of the anterior choroidal artery: a review of the literature

The anterior choroidal artery (AChA) is a critical artery in brain physiology and function. The AChA is involved in many diseases, including aneurysm, brain infarct, Moyamoya disease (MMD), brain tumor, arteriovenous malformation (AVM), etc. The AChA is vulnerable to damage during the treatment of these diseases and is thus a very important vessel. However, a comprehensive systematic review of the importance of the AChA is currently lacking. In this study, we used the PUBMED database to perform a literature review of the AChA to increase our understanding of its role in neurophysiology. Although the AChA is a small thin artery, it supplies an extremely important region of the brain. The AChA consists of cisternal and plexal segments, and the point of entry into the choroidal plexus is known as the plexal point. During treatment for aneurysms, tumors, AVM or AVF, the AChA cisternal segments should be preserved as a pathway to prevent the infarction of the AChA target region in the brain. In MMD, a dilated AChA provides collateral flow for posterior circulation. In brain infarcts, rapid treatment is necessary to prevent brain damage. In Parkinson disease (PD), the role of the AChA is unclear. In trauma, the AChA can tear and result in intracranial hematoma. In addition, both chronic and non-chronic branch vessel occlusions in the AChA are clinically silent and should not deter aneurysm treatment with flow diversion. Based on the data available, the AChA is a highly essential vessel.

Atypical choroid plexus papilloma: clinicopathological and neuroradiological features

Background Atypical choroid plexus papilloma (APP) is a rare, newly introduced entity with intermediate characteristics. To date, few reports have revealed the magnetic resonance (MR) findings. Purpose To analyze the clinicopathological and MR features of APP. Material and Methods The clinicopathological data and preoperative MR images of six patients with pathologically proven APP were retrospectively reviewed. The MR features including tumor location, contour, signal intensity, degree of enhancement, intratumoral cysts, and necrosis; and flow voids, borders, peritumoral edema, and associated hydrocephalus were analyzed. Results The APP were located in the ventricle (n = 4) and cerebellopontine angle (CPA, n = 2). Tumor dissemination along the spinal subarachnoid space was found in one patient. The tumors appeared as milt-lobulated (n = 5) or round mass (n = 1), with slightly heterogeneous signals (n = 5) or mixed signals (n = 1) on T1-weighted and T2-weighted images. Heterogeneous and strong enhancement were found in five cases on contrast-enhanced images. Three of four intraventricular tumors had a partly blurred border with ventricle wall. Four tumors had mild to moderate extent of surrounding edema signals. A slight hydrocephalus was seen in four patients. Incomplete capsule was seen in four tumors at surgery. Histopathologically, mild nuclear atypia was seen in all tumors with a mitotic rate of 2-5 per 10 high-power fields. Conclusion APP should be included in the differential diagnosis when an intraventricular or CPA tumor appearing as a multi-lobulated solid mass with slight heterogeneity, heterogeneous strong enhancement, partly blurred borders, mild to moderate peritumoral edema, or slight hydrocephalus are present.

Endoscopic monoportal removal of a choroid plexus papilloma in the posterior third ventricle in a child

Currently, only a few reports describe the minimally invasive removal of choroid plexus papillomas (CPPs) and, to the best of the authors' knowledge, no reports detail the resection of such a papilloma through an endoscopic approach in infants. The authors here describe the endoscopic removal of a third ventricle CPP in a child. A 5-month-old male infant presented with progressive macrocephaly, vomiting, and convulsions. A lesion in the posterior third ventricle was detected on brain MRI. Because of the patient's very young age, neuroendoscopy was used as the least invasive technique. The tumor was completely resected through a monoportal neuroendoscopic approach. Histologically, the tumor was classified as a WHO Grade I CPP. After surgery, the patient's condition improved, with no complications during his recovery. Ten-month follow-up neuroimaging revealed no evidence of tumor recurrence or progressive hydrocephaly. In view of the successful neuroendoscopic excision of this posterior third ventricle CPP, the authors believe that this method seems promising in the treatment of young children with intraventricular lesions.

Pediatric choroid plexus tumors: epidemiology, treatments, and outcome analysis on 202 children from the SEER database

Choroid plexus papillomas (CPPs) and carcinomas (CPCs) are rare neoplasms that affect mostly children. Due to their rarity, their epidemiology and outcomes are incompletely understood. The National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program is a well-established population-based group of registries that collects and publishes cancer incidence and survival data representing approximately 28 % of the US population. SEER-STAT v8.1.2 was used to identify patients with ICD-O-3 codes for choroid plexus tumors in patients aged 0-19. Demographics, initial treatment, and follow-up data were collected. Statistical methods including Kaplan-Meier curves, log rank tests, and Cox proportional hazards regression were used to estimate associations between independent variables and survival. The SEER registries contained 107 CPPs (2004-2010) and 95 CPCs (1978-2010). Median follow-up was 38 and 40 months, respectively. More than 75 % of CPCs were diagnosed before the age of 5 years, versus 48 % for CPPs. Sixty-five percent of CPCs and 57 % of CPPs occurred in males. In both groups at least 90 % of children underwent surgical resection. Gross total resection (GTR) was achieved in 67.0 % of CPCs and 63.6 % of CPPs. Almost 17 % of CPCs were treated with radiation versus only 0.9 % of CPPs. More than 98 % of patients with CPP were alive at the last follow-up, versus 62 % of CPC patients. For CPC, surgery was significantly associated with increased overall survival, but contrary to previous reports, extent of surgical resection was not associated with survival. Age, sex, race, and radiation treatment also had no effect on survival. This report, using the SEER datasets, corroborates many findings of previous smaller studies on CPTs. CPC occurs in younger children, with a male predominance, and a much worse prognosis than CPP. As such, these tumors have been treated aggressively with high rates of GTR and radiation treatment. Despite these treatments, overall survival for CPC remains poor.

Choroid plexus tumors in children: a population-based study

BACKGROUND

Choroid plexus tumors are rare neoplasms that primarily occur in children. The use of the SEER (Surveillance, Epidemiology and End Results) database allows for the analysis of the relationship between prognostic factors and survival.

METHODS

We analyzed the SEER database to select pediatric patients (<18 years old) with histologically confirmed diagnoses of choroid plexus papillomas (CPP; WHO Grade 0), atypical CPP (WHO Grade I) and choroid plexus carcinomas (CPC; WHO grade III). In univariate and multivariate analysis, we analyzed the relationship between demographic (age, gender, race, date of diagnosis) and treatment factors (extent of surgical resection, use of adjuvant radiation) on survival.

RESULTS

Overall, 168 pediatric subjects with choroid plexus tumors were identified as follows: 75 cases of CPP, 12 cases of atypical CPP and 81 cases of CPC. The median follow-up time was 3.5 years for CPP and 7.7 years for CPC. The median age at diagnosis was 4 years for CPP (10-90th percentile 0-16 years) and 1 year for CPC (10-90th percentile 0-10 years). In univariate regression analysis, CPC histology (β = -3.2, 95% confidence interval, CI -4.8 to -1.5, p < 0.001) was significantly associated with younger age at diagnosis in comparison to CPP. The mean tumor size was 3.7 cm for CPP and 6.0 cm for CPC (p < 0.001). A higher-grade tumor was associated with significantly increased mortality (hazard ratio, HR = 28.90, 95% CI 3.94-211.83, p = 0.001). Overall survival at 5 years was 98.7% for CPP and 58.5% for CPC (p < 0.001). Among those patients with CPC, gross total resection (GTR) was associated with a significantly lower mortality (HR = 0.21, 95% CI 0.07-0.66, p = 0.007). Overall survival at 5 years was 70.9% after GTR, significantly better than 35.9% after subtotal resection (p = 0.012) and 30% after no surgery (p = 0.003). Radiation treatment was not found to confer a survival benefit in CPC. No demographic characteristics (age, sex, race, date of diagnosis) were significantly associated with mortality.

CONCLUSIONS

Analysis of a pediatric cohort of choroid plexus tumors in children in the SEER database shows that tumor grade is predictive of survival. In cases of CPC, the extent of surgical resection, especially GTR, is significantly associated with increased survival. Radiation did not confer survival benefit.

Treatment of choroid plexus tumors: a 20-year single institutional experience

OBJECT

Choroid plexus tumors (CPTs) are rare intracranial neoplasms that constitute approximately 2%-5% of all pediatric brain tumors. Most of these tumors present with severe hydrocephalus. The optimal perioperative management and oncological care remain a matter of debate. The authors present the epidemiological and clinical features of CPTs from a 20-year single-institutional experience.

METHODS

A total of 39 consecutive patients with pathologically proven CPTs (31 choroid plexus papillomas [CPPs] and 8 choroid plexus carcinomas [CPCs]) were included in this series. Patient demographics, clinical presentation, comorbidities, indications for surgery, radiological studies, tumor location, and all operative variables were reviewed for each case. Multivariate regression analysis was performed to identify independent predictors of tumor recurrence and survival.

RESULTS

The overall mean age (± SD) was 13.13 ± 19.59 years (15.27 ± 21.10 years in the CPP group and 3.66 ± 3.59 years in the CPC group). Hydrocephalus was noted at presentation in 34% of patients. The most common presenting symptoms were headache (32%) and nausea/vomiting (26%). Gross-total resection (GTR) was achieved in 86% of CPPs and in 71% of CPCs (p = 0.57). There was 100% survival in patients with CPPs observed at the 5- and 10-year follow-up and 71% survival in patients with CPCs at the 5-year follow-up. In a multivariate regression analysis, a diagnosis of papilloma, preoperative vision changes, or hydrocephalus; right ventricle tumor location; and GTR were all independently associated with a decreased likelihood of tumor recurrence at last follow-up.

CONCLUSIONS

The authors' study suggests that patients with CPCs are more likely to experience local recurrence and metastasis; hence, GTR with chemotherapy and radiotherapy, particularly for CPCs, is pivotal in preventing recurrence and prolonging survival. While GTR was important for local control following resection of CPPs, it had a minimal effect on prolonging survival in this patient cohort.

Unusual radiologic findings and pathologic growth patterns on choroid plexus papillomas

Objective

Choroid plexus papillomas (CPPs) are generally regarded as benign tumors with typical radiologic and pathologic findings. However, they sometimes have unusual findings. We have analyzed radiologic findings and pathologic growth patterns on CPPs.

Methods

The study group included 5 male and 5 female patients (age range, 3 months to 58 years : median, 29 years). The study group included 3 pediatric and 7 adult patients. All patients underwent surgery; 9 patients had a gross total resection and 1 patient had a subtotal resection. We analyzed the radiologic findings (location, size, mottle-like appearance, enhancement, calcifications, and hydrocephalus) and pathologic growth patterns (typical papillary, papillary and solid, and papillary and tubular).

Results

The median follow-up duration was 21.3 months (range, 4-47.8 months). There were no recurrences after initial treatment. All patients had benign CPPs. Pediatric CPPs were 3.2 cm masses (range, 2.7-4 cm) with homogeneous enhancement and a mottle-like appearance, which pathologically showed the papillary growth pattern. Hydrocephalus was present in all pediatric patients. Postoperatively, subdural hygroma had occurred in two patients. In adults, CPPs were located in the fourth ventricle in 6 patients and suprasellar area in 1 patient. The size varied from 0.5-4.2 cm. Hydrocephalus and calcifications occurred in 3 and 4 patients, respectively. Three patients showed the heterogeneous enhancement without a mottle-like appearance and pathologically showed combined papillary and solid growth in 2 patients and papillary and tubular growth in one. Postoperatively, two patients with large masses had injuries of the brainstem and underwent shunt procedures for aggravation of hydrocephalus.

Conclusion

CPPs may show unusual radiologic findings, which preoperatively give the difficulty to be differentiated from other tumors. CPPs with unusual radiologic findings showed the combined pathologic growth patterns.

Unique challenges faced by pediatric neurosurgeon Harvey Cushing in 1909 at Johns Hopkins: a choroid plexus tumor of the lateral ventricle mimicking a cerebellar lesion

INTRODUCTION

At the turn of the twentieth century, diagnosis of pediatric intracranial lesions frequently relied exclusively on the subtle, nonspecific signs associated with these pathologies. In absence of detailed neuroimaging, erroneous diagnoses and misdirected operative explorations were common within pediatric populations.

METHODS

Following institutional review board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the surgical files from the Johns Hopkins Hospital for the years 1896-1912. Harvey Cushing's neurosurgical cases were collected and further analyzed.

RESULTS

A 9-year-old boy presented with a year-long history of headaches and blindness. His neurological examination was remarkable for focal cranial nerve deficits and cerebellar signs. Cushing diagnosed a cerebellar tumor with hydrocephalus and performed two suboccipital explorations with negative results. The patient died prior to further operative intervention, and the postmortem examination revealed a large choroid plexus tumor within the left lateral ventricle.

CONCLUSIONS

Early neurosurgical diagnosis and operative planning was fraught with difficulties, and surgeons relied solely on history and physical examination for localization of intracranial lesions. Here we report a case of a choroid plexus tumor of the lateral ventricle, which was misdiagnosed by Cushing. This case serves to emphasize the unique challenges faced by pediatric neurosurgeons at the turn of the twentieth century, who relied solely on history and examination to localize intracranial lesions.

Surgical treatment of choroid plexus tumors

PURPOSE

The purpose of this study is to evaluate the results of microsurgical treatment for choroid plexus tumors (CPT) in adult patients.

METHODS

From 1990 to 2008, 14 patients >18 years were treated at our institution for CPT, including seven males and seven females with a mean age of 46 years. Mean follow-up was 40 months. We reviewed the respective patients' charts, operative, and follow-up notes. Telephone interviews were performed as necessary. Neurological status was determined using the Karnofsky performance index pre- and post-operatively and at last follow-up.

RESULTS

This series includes 12 plexus papillomas (CPP) and two atypical plexus papillomas (APP). Ten tumors were located in the fourth ventricle, two tumors in the cerebellopontine angle, one growth each in the third and lateral ventricle. In 12 cases, a complete tumor resection was achieved. No recurrence was observed in these cases. Two recurrent CPP were diagnosed 11 and 25 years after the initial surgery. Brain stem infiltration prevented a complete tumor removal in one case. In the other, the degree of resection after the first operation could not be ascertained. None of the patients received adjuvant chemo- or radiotherapy. In four patients (29%), a permanent ventricular-peritoneal shunt was necessary. Three patients initially presented with a Karnofsky index of 60 or below. During follow-up, three patients (21%) never improved beyond a Karnofsky index of 60.

CONCLUSIONS

Surgery aiming radical excision is the key to successful treatment of CPP and APP in adults. Postoperative outcomes may be less than satisfactory in some patients.

Use of ifosfamide, carboplatin, and etoposide chemotherapy in choroid plexus carcinoma

OBJECT

Choroid plexus carcinomas (CPCs) are rare pediatric tumors with a generally poor prognosis. Although the role of surgery is well recognized, the role of adjuvant chemotherapy and radiation therapy remains unclear. In this paper, the authors' goal was to assess the role of second-look surgery and neoadjuvant ifosfamide, carboplatin, etoposide (ICE) chemotherapy in the management of CPC and to study neurocognitive outcome.

METHODS

The authors performed an institutional retrospective review of patients in whom CPC was diagnosed between 1985 and 2006 at the Hospital for Sick Children in Toronto. Fourteen patients (7 boys and 7 girls) were included. The median age at diagnosis was 18.6 months (range 1.1-65.3 months). Four patients had evidence of metastatic disease at diagnosis. Two of the 14 patients underwent gross-total resection during initial surgery; 12 of the patients received neoadjuvant chemotherapy, 10 of whom underwent second surgery. In total, of 12 patients who received chemotherapy with a curative intent, 11 underwent a greater than 95% resection. Neoadjuvant ICE chemotherapy was given prior to second surgery (median 4 cycles, range 2-5 cycles) and was continued after second resection for a median total of 7 cycles (range 4-16 cycles).

RESULTS

No tumor progression was observed during chemotherapy prior to second surgery. Five patients subsequently experienced tumor progression/relapse. At a median follow-up of 6.9 years (range 1.9-18.5 years), 8 patients are alive. None of the survivors received radiation therapy. However, 6 of 8 display significant neurocognitive and/or sensorial deficit.

CONCLUSIONS

In this experience, second surgery following neoadjuvant ICE chemotherapy led to a high rate of complete or near-complete resection. Chemotherapy appears to facilitate second-look surgery, in particular through a reduction of intraoperative blood loss. Despite radiation avoidance, the majority of survivors experienced significant neurocognitive impairment.

Simultaneous choroid plexus carcinoma and pilocytic astrocytoma in a pediatric patient

Simultaneous primary brain tumors in pediatric patients without prior chemotherapy or radiotherapy, phacomatosis, or known familial history are a rare occurrence. The authors report the case of a 4-year-old boy with simultaneous choroid plexus carcinoma and pilocytic astrocytoma with features of oligodendroglioma. Magnetic resonance imaging studies revealed diffuse heterogeneously enhancing left intraventricular and posterior fossa tumors initially believed most consistent with multicentric choroid plexus carcinomas. A multiple staged resection was carried out for each tumor and gross-total resection was achieved. Upon gross inspection intraoperatively as well as postoperative histological analysis, 2 distinct simultaneous tumors were identified: choroid plexus carcinoma and pilocytic astrocytoma. To the authors' knowledge this is the first case report published identifying 2 distinct tumor types with similar radiological appearances in a pediatric patient with no prior history of radiotherapy, chemotherapy, or phacomatosis.

SUPRATENTORIAL, EXTRAVENTRICULAR CHOROID PLEXUS CARCINOMA IN AN ADULT

OBJECTIVE

Choroid plexus carcinoma (CPCa) is an uncommon tumor rarely occurring in patients older than 2 years of age. The case reported herein represents the first documented example of a primary supratentorial, extraventricular CPCa in an adult. The scant literature regarding this topic is reviewed.

CLINICAL PRESENTATION

A 68-year-old woman presented with transient expressive aphasia. Magnetic resonance imaging demonstrated an avidly enhancing, left temporal, extra-axial mass with associated parenchymal cysts.

INTERVENTION

The tumor was gross-totally removed via a frontotemporal craniotomy. A diagnosis of CPCa was made on histological, immunohistochemical, and ultrastructural grounds. Postoperatively, the patient was treated by local radiotherapy and temozolomide. A magnetic resonance imaging scan 44 months after surgery showed no evidence of residual or recurrent tumor.

CONCLUSION

CPCa infrequently affects adults. Only rarely does it present as a supratentorial, extraventricular mass. Resection is the mainstay of therapy. Adjuvant radiation and chemotherapy are rational treatment options.

Rare intraparenchymal choroid plexus carcinoma resembling atypical teratoid/rhabdoid tumor diagnosed by immunostaining for INI1 protein

The authors present the case of a rare extraventricular, intraparenchymal choroid plexus carcinoma (CPC). This 6-year-old girl presented to the emergency department with a 1-week history of headaches, nausea, and vomiting. Imaging studies revealed an intraaxial cystic and solid mass located in the right frontal lobe with central nodular enhancement and minimally enhancing cyst walls. Gross-total resection was accomplished via craniotomy without complications. The initial pathological diagnosis was atypical teratoid/rhabdoid tumor (AT/RT); however, immunostaining for INI1 protein (using the BAF47/SNF5 antibody) showed retention of nuclear staining in the tumor cells, resulting in a change in the diagnosis to CPC. There was no evidence of recurrence at the last follow-up 2.5 years after treatment, which supports the diagnosis of CPC over AT/RT. This case emphasizes the importance of immunostaining for INI1 protein for distinguishing CPC from AT/RT in cases with atypical or indeterminate features.

Does choroid plexus tumour differ with age?

Choroid plexus neoplasms are rare intracranial neoplasms. Significant differences exist in their presentation and management in paediatric and adult populations. The present study aims to study the differences among the paediatric and adult population, various factors affecting the outcome, and the clinical and histological correlation. This is a retrospective study of 47 patients with choroid plexus neoplasms managed at NIMHANS from 1984 to 2004. The case records and images were retrieved and reviewed. The various histopathological features were outlined and histopathology reviewed accordingly. For follow-up, patients were contacted by letter or telephone and the necessary information obtained. Follow-up was available in 41 out of 47 patients. Sixty per cent patients were in the paediatric age group and 40% were adults. Forty-three per cent of children with tumours were less than 1 year of age. The lateral ventricle was the most common site of involvement in the paediatric group compared with the fourth ventricle in adults. Calcification is seen on CT scan more often in papillomas and in adult tumours. Invasion of surrounding parenchyma may be seen in both papillomas and carcinomas. However, in papillomas it is by nests of tumour cells compared with carcinomas wherein invasion is by individual tumour cells. Hydrocephalus is present irrespective of location and size of the tumour. Gross total excision is more feasible in adults. Large tumour size, excessive blood loss, higher incidence of carcinomas result in partial excision of these tumours in the paediatric group. Subdural collections and tumour bed haematomas are more common complications in the paediatric group after resection of tumour. These tumours have significant differences among paediatric and adult groups. Carcinomas are predominantly seen in younger children. Invasion of brain parenchyma by nests of cells does not carry a poor prognosis. The outcomes are better in adults.

Molecular genetics of pediatric central nervous system tumors

Recent advances in molecular biology have enhanced our understanding of the pathogenesis of brain tumors, particularly in children. The use of molecular diagnostic tools is quickly becoming a standard component in the diagnosis and classification of brain tumors in children, in addition to providing insight leading to treatment stratification and improved outcome prediction. All new protocols involving treatments for brain tumors in children include studies of biomarkers and biologic correlates as a means to identify new targets for therapeutics and possible intervention strategies.

Endoscopically-assisted resection of a choroid plexus vascular malformation traversing the cerebral aqueduct: technical case report

OBJECTIVE

We report a case of a choroid plexus vascular malformation of the cerebral aqueduct, third, and fourth ventricles of an adolescent female that was resected with endoscopic assistance.

CLINICAL PRESENTATION

A 14-year-old girl presented with a 1-week history of headaches and emesis. A noncontrasted computed tomographic scan of the head demonstrated enlarged lateral and third ventricles. Subsequent magnetic resonance imaging scans with and without contrast revealed an enhancing mass originating in the third ventricle, traversing the cerebral aqueduct, and terminating in the fourth ventricle.

RESULTS

We used a suboccipital approach to remove the vascular malformation after endoscopically disconnecting it from its feeding and draining vessels in the third ventricle. Total excision was performed. Postoperative magnetic resonance imaging scans and arteriograms confirmed complete resection of the vascular malformation.

CONCLUSION

Choroid plexus vascular malformations can exist intraventricularly and can be confused with a neoplasm. Resection of these intraventricular lesions can be performed with endoscopic assistance.

Genetics of choroid plexus tumors

Choroid plexus tumors consist of papillomas and carcinomas. A variety of germline and somatic genetic changes have been demonstrated for each of these subtypes. In this paper, the authors summarize the current knowledge of the genetic bases of these tumors.