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del Río RJ, Cicutti SE, Moreira DC, Ramos JDG. New CNS tumor classification: The importance in pediatric neurosurgical practice. Surg Neurol Int 2024; 15:130. [PMID: 38742003 PMCID: PMC11090558 DOI: 10.25259/sni_681_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 03/26/2024] [Indexed: 05/16/2024] Open
Abstract
Background The management of the central nervous system (CNS) tumors in the pediatric population is crucial in neurosurgical practice. The World Health Organization (WHO) has evolved its classification of CNS tumors from the 19th century to the 5th edition, published in 2021, incorporating molecular advancements. This transition from morphology to molecular characterization is ongoing. Methods This manuscript analyzes the modifications introduced in the 5th edition of WHO's CNS tumor classification, particularly focusing on pediatric tumor families. The paper integrates clinical, morphological, and molecular information, aiming to guide pediatric neurosurgeons in their daily practice and interdisciplinary discussions. Results The 5th edition of the WHO classification introduces a hybrid taxonomy that incorporates both molecular and histological components. The terminology shifts from "entity" to "type" and "subtype," aiming to standardize terminology. Tumor grading experiences changes, integrating molecular biomarkers for prognosis. The concept of integrated layered diagnosis is emphasized, where molecular and histological information is combined systematically. Conclusion The 5th edition of the WHO CNS classification signifies a paradigm shift toward molecular characterization. The incorporation of molecular advances, the layered diagnostic approach, and the inclusion of clinical, morphological, and molecular information aim to provide comprehensive insights into pediatric CNS tumors. This classification offers valuable guidance for pediatric neurosurgeons, aiding in precise diagnosis and treatment planning for these complex neoplasms.
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Affiliation(s)
- Ramiro José del Río
- Department of Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Ciudad Autónoma de Buenos Aires, Argentina
| | - Santiago Ezequiel Cicutti
- Department of Neurosurgery, Hospital de Pediatría Juan P. Garrahan, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel C. Moreira
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, United States
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Lundar T, Due-Tønnessen BJ, Frič R, Sundseth J, Brandal P, Due-Tønnessen P. Outcome after treatment of pediatric supratentorial ependymoma: long-term follow-up of a single consecutive institutional series of 26 patients. Br J Neurosurg 2024; 38:514-522. [PMID: 34096810 DOI: 10.1080/02688697.2021.1914821] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/16/2021] [Accepted: 04/06/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term outcome after surgical treatment of supratentorial ependymoma (STE) in children has not been extensively reported. FINDINGS We identified 26 children who underwent primary tumor resection of STE between 1953 and 2011, with at least 8 years follow-up. Ten patients (38%) had anaplastic and 16 had low grade ependymoma. Four of 15 children (26%) treated in the years 1953-1976 survived more than 5 years, but the observed 10-year survival was only 7%. One patient lived for 37 years, and second surgery for a local recurrent lesion disclosed a glioblastoma, possibly secondary to radiotherapy. In contrast, the observed 5-year survival rate for 11 children treated in the years 1992-2011 was 8/11 (73%) and observed 10- and 25-year survival rates were 70% and 66%, respectively. Eight patients were alive and tumor-free with follow-up periods of 8-27 (median 18) years, all treated after 1992. Five of these long-term survivors were 23-39 years old with full-time (n = 3) or part-time (n = 2) work. The last three patients were still children (9-12 years old): one with good function and two with major neurological deficits. The majority of patients (n = 18) received adjuvant radiotherapy and eight children no adjuvant treatment. Repeated resections for residual or recurrent tumor were necessary in 11 patients (42%), mostly due to local disease with progressive clinical symptoms. Eight patients underwent only one repeat resection, whereas three patients had two or more repeat resections within 18 years after initial surgery. Four patients were tumor-free after repeated resections at the latest follow-up, 2-13 years after last surgery. CONCLUSION Pediatric STE has a marked risk for local recurrence even after gross total resection and postoperative radiotherapy, but survival has increased following the introduction of modern treatment in recent years. Repeated surgery is an important part of treatment and may lead to persistent tumor control.
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Affiliation(s)
- Tryggve Lundar
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
- Department of Neurosurgery, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Radek Frič
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Jarle Sundseth
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Petter Brandal
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Paulina Due-Tønnessen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
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Falco J, Broggi M, Schiariti M, Vetrano IG, Esposito S, Ferroli P, Acerbi F. The role of sodium fluorescein in pediatric supratentorial intra-axial tumor resection: new insights from a monocentric series of 33 consecutive patients. Childs Nerv Syst 2022; 39:1463-1471. [PMID: 36520160 DOI: 10.1007/s00381-022-05764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Surgical resection represents the mainstay of treatment, in pediatric central nervous system (CNS) tumors, and aggressive resection correlates with prognosis for several histotypes. Sodium fluorescein (SF), a green, water-soluble dye, is used as neurosurgical fluorescent tracer thanks to its property to accumulate in cerebral regions of blood-brain barrier disruption, acting as a valid tool to improve the extent of resection in tumors enhancing at preoperative MRI. Brain neoplasms represent a heterogeneous group of tumors in the pediatric age, constituting the most common solid cancers; they typically show a varying degree of contrast enhancement on MRI. MATERIALS AND METHODS In March 2016, the authors started a prospective, observational trial to evaluate intraoperative fluorescence's characteristics of CNS tumors, the percentage of extent of resection, thanks to fluorescein aid, and side effects related to fluorescein administration. This report is based on a retrospective analysis of a group of 33 consecutive pediatric patients harboring a supratentorial lesion. RESULTS In 17 of 33 (51.5%) procedures, fluorescence was reported as intense; in 14 of 33 (42.4%), moderate; and in 2 of 33 (6.1%), slight. Intraoperative fluorescence corresponds to preoperative-MRI-documented contrast enhancement. In 28 of 33 (84.8%) surgical procedures, SF was considered useful; in 2 of 33 (6.1%), partial useful; and in 3 of 33 (9.1%), not essential because the tumor was already recognizable. No adverse effect to SF administration was registered. CONCLUSION Fluorescein-guided surgery with a dedicated filter on the microscope is a safe and effective technique to improve visualization and resection of different pediatric brain tumors.
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Affiliation(s)
- Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Ignazio Gaspare Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Silvia Esposito
- Developmental Neurology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.
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Ritzmann TA, Chapman RJ, Kilday JP, Thorp N, Modena P, Dineen RA, Macarthur D, Mallucci C, Jaspan T, Pajtler KW, Giagnacovo M, Jacques TS, Paine SML, Ellison DW, Bouffet E, Grundy RG. SIOP Ependymoma I: Final results, long-term follow-up, and molecular analysis of the trial cohort-A BIOMECA Consortium Study. Neuro Oncol 2022; 24:936-948. [PMID: 35018471 PMCID: PMC9159435 DOI: 10.1093/neuonc/noac012] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND SIOP Ependymoma I was a non-randomised trial assessing event free and overall survival (EFS/OS) of non-metastatic intracranial ependymoma in children aged 3-21 years treated with a staged management strategy. A further aim was to assess the response rate (RR) of subtotally resected (STR) ependymoma to vincristine, etoposide, and cyclophosphamide (VEC). We report final results with 12-year follow-up and post hoc analyses of recently described biomarkers. METHODS Seventy-four participants were eligible. Children with gross total resection (GTR) received radiotherapy, whilst those with STR received VEC before radiotherapy. DNA methylation, 1q, hTERT, ReLA, Tenascin-C, H3K27me3, and pAKT status were evaluated. RESULTS Five- and ten-year EFS was 49.5% and 46.7%, OS was 69.3% and 60.5%. GTR was achieved in 33/74 (44.6%) and associated with improved EFS (P = .003, HR = 2.6, 95% confidence interval (CI) 1.4-5.1). Grade 3 tumours were associated with worse OS (P = .005, HR = 2.8, 95%CI 1.3-5.8). 1q gain and hTERT expression were associated with poorer EFS (P = .003, HR = 2.70, 95%CI 1.49-6.10 and P = .014, HR = 5.8, 95%CI 1.2-28) and H3K27me3 loss with worse OS (P = .003, HR = 4.6, 95%CI 1.5-13.2). Methylation profiles showed expected patterns. 12 participants with STR did not receive chemotherapy; a protocol violation. However, best chemotherapy RR was 65.5% (19/29, 95%CI 45.7-82.1), exceeding the prespecified 45%. CONCLUSIONS Participants with totally resected ependymoma had the best outcomes. RR of STR to VEC exceeded the pre-specified efficacy criterion. However, cases of inaccurate stratification highlighted the need for rapid central review. 1q gain, H3K27me3 loss, and hTERT expression were all associated with poorer survival outcomes.
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Affiliation(s)
- Timothy A Ritzmann
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rebecca J Chapman
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
| | - John-Paul Kilday
- Children’s Brain Tumour Research Network (CBTRN), Royal Manchester Children’s Hospital, Manchester, UK
- The Centre for Paediatric, Teenage and Young Adult Cancer, University of Manchester, Manchester, UK
| | - Nicola Thorp
- The Clatterbridge Cancer Centre, Liverpool, UK
- The Christie Hospital Proton Beam Therapy Centre, Manchester, UK
| | | | - Robert A Dineen
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Donald Macarthur
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Conor Mallucci
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Timothy Jaspan
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kristian W Pajtler
- Hopp Children’s Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neuro-oncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology, and Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Thomas S Jacques
- UCL GOS Institute of Child Health, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Simon M L Paine
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David W Ellison
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Eric Bouffet
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Richard G Grundy
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Affiliation(s)
- Alan R Cohen
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
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6
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Tripathi M, Deora H, Tripathi S, Ballari N. Role of gamma knife radiosurgery in the management of intracranial pathologies of pediatric population: Current concepts, limitations, and future directions. J Pediatr Neurosci 2022. [DOI: 10.4103/jpn.jpn_51_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Baliga S, Gandola L, Timmermann B, Gail H, Padovani L, Janssens GO, Yock TI. Brain tumors: Medulloblastoma, ATRT, ependymoma. Pediatr Blood Cancer 2021; 68 Suppl 2:e28395. [PMID: 32386126 DOI: 10.1002/pbc.28395] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 01/15/2023]
Abstract
Children with medulloblastoma, atypical teratoid rhabdoid tumor (ATRT), and ependymoma are treated with a multidisciplinary approach including surgery, radiotherapy, and chemotherapy. Lower doses of craniospinal irradiation and tumor bed boost together with chemotherapy are the current standard of care for average-risk medulloblastoma in the Children's Oncology Group (COG). The International Society of Pediatric Oncology (SIOP) is examining the role of hyperfractionated craniospinal irradiation and chemotherapy in high-risk patients. The recent stratification of medulloblastoma into specific molecular risk groups has prompted both COG and SIOP to reexamine the role of these modalities in these different risk groups to maximize cure rates and minimize long-term complications. Proton therapy has shown lower rates of neurocognitive and endocrine complications compared with photons. Ependymomas are treated with maximal surgical resection and adjuvant radiation therapy. The role of chemotherapy in ependymoma is currently being studied in both COG and SIOP. Likewise, for ATRT the role of different high-dose chemotherapy regimens together with local radiation therapy in infants, or craniospinal radiation in older children, is the current focus of research.
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Affiliation(s)
- Sujith Baliga
- Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.,Radiation Oncology, The Ohio State University Wexner Medical Center-The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Lorenza Gandola
- Department of Radiation Oncology, Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Horan Gail
- Department of Oncology, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Laetitia Padovani
- Department of Radiation Oncology, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center and Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Torunn I Yock
- Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Zhao L, Jiang Y, Wang Y, Bai Y, Liu L, Li Y. Case Report: Sellar Ependymomas: A Clinic-Pathological Study and Literature Review. Front Endocrinol (Lausanne) 2021; 12:551493. [PMID: 34168614 PMCID: PMC8218727 DOI: 10.3389/fendo.2021.551493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/19/2021] [Indexed: 11/20/2022] Open
Abstract
Ependymomas are primary glial tumors arising from cells related to the ependymal lining of the ventricular system. They are classified into at least nine different molecular subtypes according to molecular phenotype, histological morphology, and tumor location. Primary sellar ependymoma is an extremely rare malignancy of the central nervous system, with only 12 known cases reported in humans. We herein report a case of ependymoma located at the pituitary region in a 44-year-old female patient and discuss the molecular subtype, natural history, clinical presentation, radiological findings, histological features, immunohistochemical characteristics, ultrastructural examinations, treatment, and prognosis of sellar ependymoma. This case report may serve as a helpful reference for clinicians and radiologists in clinical practice.
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Affiliation(s)
- Liyan Zhao
- Department of Clinical Laboratory, Second Hospital of Jilin University, Changchun, China
| | - Yining Jiang
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Yubo Wang
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Yang Bai
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Liping Liu
- Department of Clinical Laboratory, Second Hospital of Jilin University, Changchun, China
| | - Yunqian Li
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
- *Correspondence: Yunqian Li,
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Bhatt H, Bhatti MI, Patel C, Leach P. Paediatric posterior fossa tumour resection rates in a small volume centre: the past decade's experience. Br J Neurosurg 2020; 35:451-455. [PMID: 33307861 DOI: 10.1080/02688697.2020.1859085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Paediatric brain tumour resection rates have been shown to correlate with outcome and, it is argued, are linked to operator volume and caseload. The British paediatric neurosurgery community has previously debated centralisation of paediatric neuro-oncology. At the 2018 British Paediatric Neurosurgery Group (BPNG) meeting, a commitment was made to prospectively collect tumour resection data at each Neurosurgical Unit (NSU). Here we review our prospectively-collected 10-year database of the three commonest paediatric posterior fossa tumours - astrocytomas, medulloblastomas and ependymomas. MATERIALS AND METHODS Our primary outcome was extent of resection (EOR) on post-operative MRI scans reviewed by neuro-radiologists. Secondary outcomes comprised neurosurgical morbidity including infection, need for cerebrospinal fluid (CSF) diversion and the occurrence of posterior fossa syndrome (PFS). RESULTS 55 children had 62 operations, where our complete resection rates for pilocytic astrocytomas, medulloblastomas and ependymomas were 77%, 79% and 63%, respectively. Both our primary and secondary outcomes were in keeping with the published literature and we discuss here some of the factors which may contribute towards favourable outcomes in a small volume centre. CONCLUSION Our results suggest that small volume centres can expect equivalent results to larger volume NSUs with regards to paediatric brain tumour surgery. Continuing efforts nationally for data collection on resection rates and operative outcomes is a key step towards optimising management in these children.
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Affiliation(s)
- Harsh Bhatt
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | | | - Chirag Patel
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Paul Leach
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
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Wang Q, Cheng J, Li J, Zhang S, Liu W, Ju Y, Hui X. The Survival and Prognostic Factors of Supratentorial Cortical Ependymomas: A Retrospective Cohort Study and Literature-Based Analysis. Front Oncol 2020; 10:1585. [PMID: 32974195 PMCID: PMC7472988 DOI: 10.3389/fonc.2020.01585] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/23/2020] [Indexed: 02/05/2023] Open
Abstract
Aim Survival rates and prognostic factors of cortical ependymomas (CEs) remain elusive. This study aimed to perform a comprehensive analysis of prognostic factors, treatment, and outcomes for patients with CEs based on institutional and literature case series. Materials and Methods Thirty patients with CEs from our department were included in this study. Furthermore, a systemic review of the literature yielded an additional 106 patients with CEs. Clinical data including patient age, sex, symptoms, tumor location, World Health Organization (WHO) grade, extent of surgery, radiation, recurrence, and survival were recorded and statistically analyzed. Results From January 2009 to October 2019, 30 (4.2%) cases were diagnosed as CEs in our department. These series consisted of 19 males and 11 females, 10 continuous patients after 2017 screened for C11orf95-RELA fusion, and 9 patients (90%) were RELA fusion positive. During the follow-up period, nine (30%) patients depicted tumor recurrence or progression; four (13.3%) patients died of tumor progression. The literature review yielded 106 CE cases, with additional 30 cases of our own collected for further analysis. Of these 136 cases, the frontal lobe (40%) was the most common location, and the average age was 22.6 ± 17.6 years. Anaplastic histology/WHO grade III tumors were identified in 68 (50%) patients. Statistically analysis demonstrated that extent of surgery and WHO tumor grade were significant prognostic factors in Kaplan–Meier log-rank testing and Cox proportional hazards models. Gross total resection (GTR) predicted longer progression-free survival (PFS) [P = 0.013, hazard ratio (HR) = 3.012, 95% confidence interval (CI) = 1.257–7.213] and overall survival (OS) (P = 0.003, HR = 5.322, 95% CI = 1.751–16.178). WHO grade III tumors had worse PFS (P = 0.002, HR = 5.17, 95% CI = 1.804–14.816) and OS (P = 0.025, HR = 5.640, 95% CI = 1.248–25.495). Conclusion CEs accounted for only 3.5 to 5.7% of ependymomas, with seizures the most common symptom and the frontal lobe the most frequent location. CEs may have higher rate of RELA fusions, but generally favorable prognosis. The extent of surgery and WHO tumor grade were significant prognostic factors for PFS and OS in multivariate analysis. GTTR or WHO grade II tumors had better overall outcome in patients with CEs.
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Affiliation(s)
- Qiguang Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Cheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiuhong Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Si Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wenke Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Ju
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xuhui Hui
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
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Adult cerebellopontine angle ependymoma presenting as an isolated cisternal mass: A case report. J Med Imaging Radiat Sci 2020; 51:689-693. [PMID: 32888857 DOI: 10.1016/j.jmir.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 08/02/2020] [Accepted: 08/09/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Ependymomas represent approximately 2%-8% of all primary intracranial brain tumors. The occurrence of extra-axial posterior fossa ependymomas in adults is rare. CASE AND OUTCOMES We report a case of extra-axial cerebellopontine (CP) angle ependymoma in an adult patient, managed through gross total resection (GTR) and adjuvant radiotherapy. At her one-year postoperative visit, the patient remained clinically stable without any symptoms or focal neurological deficit and a follow up MRI showed no evidence of tumor recurrence. DISCUSSION Only six cases of adult cerebellopontine angle ependymomas have been reported in the English literature, with the left side affected more commonly. Including this case, the mean age of the reported cases of adult extra-axial CP angle ependymoma is 44.14 years (range 22-66 years). Men accounted for five out of seven cases (71.4%). Maximal surgical resection is the mainstay of treatment in extra-axial CP angle ependymomas. Among seven reported cases, five received GTR and two had subtotal resection (STR). Patients were followed an average of 13.6 months (range 2-30 months) and only two patients with STR died during the follow-up period (6 weeks and 2 months after surgery). Six of the seven reported cases (including this one) received adjuvant radiotherapy. CONCLUSION Although rare, extra-axial CP angle ependymomas should be considered as a differential diagnosis to other lesions of the CPA. Radical resection, whenever possible, is usually associated with a good outcome. Adjuvant radiotherapy remains an optional treatment with an unknown impact on overall and progression-free survival.
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12
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Labuschagne JJ. 5-Aminolevulinic Acid-Guided Surgery for Recurrent Supratentorial Pediatric Neoplasms. World Neurosurg 2020; 141:e763-e769. [PMID: 32526366 DOI: 10.1016/j.wneu.2020.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The use of 5-aminolevulinic acid (5-ALA) in pediatric neuro-oncology is considered off-label, and little data are available on its use in tumor recurrence surgery. Here we present our experience with 5-ALA fluorescence-guided surgery for recurrent supratentorial tumors in the pediatric population. METHODS Eleven pediatric patients presenting with recurrence of a supratentorial high-grade malignancy (5 glioblastoma [GBM], 6 non-GBM) underwent 5-ALA-assisted surgery. Biopsy specimens were obtained from pathological and normal-appearing areas of the tumor margin. RESULTS From the margin of the tumor displaying solid fluorescence, a total of 36 samples were obtained. All of these histological samples were found to harbor tumor cells. From areas of vague enhancement, a total of 49 histological samples were taken, of which 38 samples (77%) harbored tumor cells. There was no significant difference in the percentage of biopsy-positive vague fluorescent areas between the GBM cases (80%) and non-GBM cases (75%). A total of 59 biopsy specimens were taken from the tumor margin that appeared completely negative for fluorescence. On analysis, 24 (40.7%) of these specimens demonstrated tumor cells. There was no significant difference in the number of false-negative biopsies between the GBM group (40%) and the non-GBM group (41%). CONCLUSIONS The positive predictive value of solid fluorescence is high in recurrent disease but is substantially lower in areas of vague fluorescence. The rate of false-negative fluorescence is high. 5-ALA should be considered as an adjuvant in revision surgery with the aforementioned caveats in mind.
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Affiliation(s)
- Jason John Labuschagne
- Department of Neurosurgery, University of the Witwatersrand, Johannesburg and Department of Paediatric Neurosurgery, Nelson Mandela Children's Hospital, Johannesburg, South Africa.
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Quintero Escobar M, Maschietto M, Krepischi ACV, Avramovic N, Tasic L. Insights into the Chemical Biology of Childhood Embryonal Solid Tumors by NMR-Based Metabolomics. Biomolecules 2019; 9:biom9120843. [PMID: 31817982 PMCID: PMC6995504 DOI: 10.3390/biom9120843] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 01/19/2023] Open
Abstract
Most childhood cancers occur as isolated cases and show very different biological behavior when compared with cancers in adults. There are some solid tumors that occur almost exclusively in children among which stand out the embryonal solid tumors. These cancers main types are neuroblastoma, nephroblastoma (Wilms tumors), retinoblastoma and hepatoblastomas and tumors of the central nervous system (CNS). Embryonal solid tumors represent a heterogeneous group of cancers supposedly derived from undifferentiated cells, with histological features that resemble tissues of origin during embryogenesis. This key observation suggests that tumorigenesis might begin during early fetal or child life due to the errors in growth or pathways differentiation. There are not many literature data on genomic, transcriptomic, epigenetic, proteomic, or metabolomic differences in these types of cancers when compared to the omics- used in adult cancer research. Still, metabolomics by nuclear magnetic resonance (NMR) in childhood embryonal solid tumors research can contribute greatly to understand better metabolic pathways alterations and biology of the embryonal solid tumors and potential to be used in clinical applications. Different types of samples, such as tissues, cells, biofluids, mostly blood plasma and serum, can be analyzed by NMR to detect and identify cancer metabolic signatures and validated biomarkers using enlarged group of samples. The literature search for biomarkers points to around 20-30 compounds that could be associated with pediatric cancer as well as metastasis.
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Affiliation(s)
- Melissa Quintero Escobar
- Biological Chemistry Group, Department of Organic Chemistry, Institute of Chemistry, University of Campinas (UNICAMP), Campinas 13083-970, Brazil;
- Laboratory of Blood Coagulation, Department of Medical Physiopathology, Hemocentro, University of Campinas (UNICAMP), Campinas 13083-878, Brazil
| | - Mariana Maschietto
- Research Center, Boldrini Children’s Hospital, Campinas 13083-884, Brazil;
| | - Ana C. V. Krepischi
- Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of Sao Paulo (USP), Sao Paulo 05508-0970, Brazil;
| | - Natasa Avramovic
- Institute of Medical Chemistry, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia;
| | - Ljubica Tasic
- Biological Chemistry Group, Department of Organic Chemistry, Institute of Chemistry, University of Campinas (UNICAMP), Campinas 13083-970, Brazil;
- Correspondence: ; Tel.: +55-19-3521-1106
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Ruangkanchanasetr R, Swangsilpa T, Puataweepong P, Dhanachai M, Hansasuta A, Boongird A, Sirachainan N, Hongeng S. Outcome of postoperative radiation therapy for pediatric intracranial ependymoma: a single-institution review. Childs Nerv Syst 2019; 35:1313-1321. [PMID: 31203397 DOI: 10.1007/s00381-019-04198-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/07/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE To report outcome of postoperative radiotherapy (RT) in both new and recurrent grade II and III intracranial ependymomas in children treated at Ramathibodi Hospital. MATERIALS AND METHODS Between 2006 and 2017, 24 pediatric intracranial ependymomas treated with postoperative RT were retrospectively reviewed. The median age at diagnosis was 44.5 months (range, 4-165 months). There were 14 (58%) males. Fourteen (58%) patients had infratentorial tumor. The median maximal diameter of tumor at diagnosis was 4.45 cm (range, 2.2-10 cm). Fourteen (58%) patients had anaplastic tumor. Gross total resections were performed in 14 (58%) patients. The median prescribed dose was 54 Gy (range, 45-60 Gy). The median total treatment time was 43 days (range, 37-78 days). RESULTS The median clinical follow-up time was 44.5 months (range, 1-146 months). There were nine recurrences, five of which occurred at the primary tumor site. The estimated 5-year progression-free survival rate was 56%. The estimated 5-year overall survival rate was 75%. Extent of resection was the only factor associated with improved progression-free survival and overall survival after univariate testing. Six from nine patients with recurrent diseases underwent further surgery or further RT. These six patients had better median overall survival than the three who did not. Acute complication was mostly transient and tolerable. No late radiation effect was found. CONCLUSIONS Postoperative radiation is an effective treatment. GTR is associated with better PFS and OS. Aggressive salvage local treatments for recurrent patients can result in good overall survival. Longer follow-up is needed in account for late relapse.
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Affiliation(s)
- Rawee Ruangkanchanasetr
- Radiation and Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
| | - Thiti Swangsilpa
- Radiation and Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Putipun Puataweepong
- Radiation and Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Mantana Dhanachai
- Radiation and Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Ake Hansasuta
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Atthaporn Boongird
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Suradej Hongeng
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
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Abstract
PURPOSE OF REVIEW This review discusses the evidence base behind current and emerging strategies of management of intracranial and spinal ependymomas in children, with a particular focus on aspects of surgical techniques, challenges and complications. RECENT FINDINGS The cornerstone of management remains maximal safe resective surgery, which has repeatedly been shown to correlate with improved survival. This is followed by focal conformal radiotherapy, although good results using proton beam therapy, with the potential for diminished side effects, are emerging. The role of chemotherapy remains largely unproven for paediatric ependymoma. Despite optimal management strategies, many children with ependymoma suffer from tumour recurrence. The standard of care for paediatric ependymoma comprises surgery and radiotherapy. Results of ongoing clinical trials will help shape its management in order to leverage our increasingly sophisticated understanding of the genetic drivers behind these tumours into survival benefit for this challenging group of patients.
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Affiliation(s)
- Sebastian M Toescu
- Developmental Imaging and Biophysics Section, UCL-GOS Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.,Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.
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Schwake M, Schipmann S, Müther M, Köchling M, Brentrup A, Stummer W. 5-ALA fluorescence-guided surgery in pediatric brain tumors-a systematic review. Acta Neurochir (Wien) 2019; 161:1099-1108. [PMID: 30989383 DOI: 10.1007/s00701-019-03898-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better differentiation between tumor and normal brain tissue, allowing a higher degree of resection, and improves patient outcomes. In recent years, several reports have emerged regarding the use of 5-ALA in other brain tumor entities, including pediatric brains tumors. Since gross total resection (GTR) of many brain tumors in children is crucial and the role of 5-ALA-guided resection of these tumors is not clear, we sought to perform a comprehensive literature review on this topic. METHODS A systematic literature review of EMBASE and MEDLINE/PubMed databases revealed 19 eligible publications encompassing 175 5-ALA-guided operations on pediatric brain tumors. To prevent bias, publications were revised independently by two authors. RESULTS We found that 5-ALA-guided resection enabled the surgeons to identify the tumor more easily and was considered helpful mainly in cases of glioblastoma (GBM, 21/27, 78%), anaplastic ependymoma WHO grade III (10/14, 71%), and anaplastic astrocytoma (4/6, 67%). In contrast, cases of pilocytic astrocytomas (PAs) and medulloblastomas 5-ALA-guided surgery did not show consistent fluorescent signals and 5-ALA was considered helpful only in 12% and 22% of cases, respectively. Accumulation of fluorescent porphyrins seems to depend on WHO tumor grading. One important finding is that when 5-ALA-guided resections were considered helpful, the degree of resection was higher than is cases where it was not helpful. The rate of adverse events related to 5-ALA was negligible, especially new postoperative sequelae. CONCLUSION 5-ALA could play a role in resection of pediatric brain tumors. However, further prospective clinical trials are needed.
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Central nervous system ependymoma: clinical implications of the new molecular classification, treatment guidelines and controversial issues. Clin Transl Oncol 2019; 21:1450-1463. [PMID: 30868390 DOI: 10.1007/s12094-019-02082-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
Abstract
Ependymoma is an uncommon neuroepithelial tumor that may arise anywhere within the neuroaxis, both in children and in adults. It has been classically graded upon histopathological features, yet with limited clinical utility. Recently, DNA methylation profiling has provided a novel classification of ependymoma in nine molecular subgroups. This stratification method harbors prognostic value with supratentorial RELA-fusion and posterior fossa group A tumors showing a significantly shorter survival compared to the rest. Currently, the treatment of choice involves maximal safe resection and, in cases of residual disease, adjuvant conformal radiotherapy. Second-look surgery is also a feasible and recommended option for incompletely resected tumors. The role of chemotherapy is not yet established and can be considered in infants and children with relapsing disease or prior to re-intervention. Although targeted agents do not seem to play a role as adjuvant therapy, they are currently being tested for recurrent disease.
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Khalid S, Kelly R, Carlton A, Wu R, Peta A, Melville P, Maasarani S, Meyer H, Adogwa O. Adult intradural intramedullary astrocytomas: a multicenter analysis. JOURNAL OF SPINE SURGERY 2019; 5:19-30. [PMID: 31032435 DOI: 10.21037/jss.2018.12.06] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Intramedullary tumors constitute approximately 20-30% of all spinal cord tumors and approximately 30-40% of these are astrocytomas. Furthermore, they comprise only about 2-4% of all primary central nervous system (CNS) tumors. Due to their rarity and poor prognosis, large population-based studies are needed to assess the epidemiology and survival risk factors associated with these tumors in the hope of improving outcomes. The authors undertook this retrospective study to explore factors that may influence survival in adult patients with intramedullary astrocytomas. Methods Utilizing the Surveillance, Epidemiology, and End Results (SEER) database, a prospective cancer registry, the authors retrospectively assessed survival in histologically confirmed, intramedullary spinal cord astrocytomas in patients 18 years of age and older. Survival was described with Kaplan-Meier curves and multivariate regression analysis was used to assess the association of several variables with survival while controlling for confounding variables. Results Analysis by multivariate regression of 131 cases showed that increasing age of diagnosis [hazard ratio (HR) 1.52, 95% CI: 1.17-1.99, P=0.001], WHO grade IV classification (HR 8.85, 95% CI: 2.83-27.69, P<0.001), tumor invasiveness (HR 2.94, 95% CI: 1.00-8.64, P=0.047), and sub-total resection (HR 5.80, 95% CI: 1.20-28.03, P=0.029) were associated with statistically significant decreases in survival. Conclusions This study suggest that older age, higher WHO grade, tumor invasiveness as well as sub-total resection were all associated with a worse prognosis.
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Affiliation(s)
- Syed Khalid
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Ryan Kelly
- Georgetown University School of Medicine, Washington, D.C., USA
| | | | - Rita Wu
- Chicago Medical School, North Chicago, IL, USA
| | - Akhil Peta
- Chicago Medical School, North Chicago, IL, USA
| | | | | | - Haley Meyer
- Chicago Medical School, North Chicago, IL, USA
| | - Owoicho Adogwa
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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Indelicato DJ, Bradley JA, Rotondo RL, Nanda RH, Logie N, Sandler ES, Aldana PR, Ranalli NJ, Beier AD, Morris CG, Mendenhall NP. Outcomes following proton therapy for pediatric ependymoma. Acta Oncol 2018; 57:644-648. [PMID: 29239262 DOI: 10.1080/0284186x.2017.1413248] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Proton therapy can reduce the low and intermediate radiation dose to uninvolved brain tissue in children with intracranial ependymomas, which may improve functional outcomes and reduce second malignancies in survivors. Accordingly, ependymoma has become the most common pediatric tumor treated with proton therapy, yet data on efficacy and toxicity are limited. MATERIAL AND METHODS Between June 2007 and February 2017, 179 children (≤21 years old) with nonmetastatic grade II/III intracranial ependymoma received proton therapy at our institution. Median age, 3.5 years (range, 0.7-21); 58% were male. Most (66%) tumors were in the posterior fossa and classified as WHO grade III (67%). 27% underwent multiple operations to maximize the extent of resection; ultimately 85% had a gross total or near total tumor resection before radiotherapy. 33% received preradiation chemotherapy. Median radiation dose in children ≤3 years old, 54 Gy(RBE). Most (>90%) children over 3 years old received 59.4 Gy(RBE). Patient and treatment variables were assessed for correlation with disease control. RESULTS Median follow-up, 3.2 years. 3-year local control, progression-free survival, and overall survival rates were 85%, 76%, and 90%, respectively. First site of progression was local, metastatic, or simultaneous in 14, 17 and 6 patients, respectively. On multivariate analysis, subtotal resection was associated with inferior local control (67% vs. 88%; p ≤ .01) and progression-free survival (59% vs. 79%; p < .05). Male sex was associated with inferior progression-free (67% vs. 87%; p< .05) and overall survival (84% vs. 99%; p < .01). The 3-year CTCAE grade 2 + brainstem toxicity rate was 5.5% (95% CI: 2.9-10.2), including 1 grade 5 toxicity. CONCLUSIONS This series of proton therapy for pediatric intracranial ependymoma demonstrates disease control comparable to photon series without unexpected toxicity. Subtotal resection and male sex were associated with inferior disease control. Additional follow-up to quantify the expected reductions in late toxicity with proton therapy is ongoing.
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Affiliation(s)
- Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Ronny L. Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Ronica H. Nanda
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Natalie Logie
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Eric S. Sandler
- Department of Pediatric Hematology-Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Philipp R. Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nathan J. Ranalli
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Alexandra D. Beier
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Hashmi FA, Rai HH, Khan MF, Bari ME. Prognostic Implications of Histological Clear Cells in High-Grade Intracranial Ependymal Tumors: A Retrospective Analysis from a Tertiary Care Hospital in Pakistan. Asian J Neurosurg 2018; 13:307-313. [PMID: 29682026 PMCID: PMC5898097 DOI: 10.4103/ajns.ajns_280_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Clear cell variant in ependymal tumors is rare. We aimed to compare the features and outcome of the World Health Organization (WHO) Grade 3 ependymal tumors with clear cells to the WHO Grade 3 classic anaplastic ependymoma (AE). Materials and Methods: A retrospective cohort study conducted at the Department of Neurosurgery, Aga Khan University, Pakistan, from 2003 to 2013. The medical records and radiology of patients with proven histopathology were reviewed. The analysis was done on SPSS 20. Results: Nine cases of clear cell variant and 23 cases of classic AE were found, both of which combined equated to 4% of the total tumor burden in 11 years. The median age of clear cell ependymoma (CCE) and AE were 49 and 37 years, respectively. Presenting symptoms included headache in 66% of CCE and 63% in AE, raised intracranial pressure accounting for 33% of CCE and 54% of AE, dizziness in 22% CCE and 39% AE, while seizures presented equally in both. Supratentorial location was observed in 77% CCE and 48% AE. Both showed hypointense signals on T1-weighted images of magnetic resonance imaging (MRI) while T2-weighted images showed hyperintensity in all cases of CCE but only 80% of AE. MRI characteristics such as the presence of cystic component were found in 89% of CCE and 68% of AE, necrosis in 33% CCE, and 22% AE, hemorrhagic in 22% CCE and 9% AE, and equivalent contrast enhancement. Gross total resection was achieved in 5 (55%) patients of CCE, compared to 6 (26%) patients in AE. Subtotal resection was done in 4 (44%) patients of CCE and 15 (65%) patients of AE. Radiotherapy was given to 5 (55%) patients of CCE and 12 (52%) patients of AE. Recurrence was observed in 77% cases of CCE and 70% of AE, with metastasis in 29% of AE and in only one patient of CCE. Repeat surgery was done in 3 (33%) cases of CCE and 8 (35%) cases of AE. Median progression-free survival and overall survival were 9 and 13 months, respectively, in CCE while 14 and 18 months, respectively, for AE. Conclusion: Clear cells in the WHO Grade 3 ependymal tumors are found mainly in a comparatively older adult population with a predilection for supratentorial location and are more aggressive in behavior with poorer outcome than AE.
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Affiliation(s)
- Fauzan Alam Hashmi
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Hamid Hussain Rai
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Faheem Khan
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Ehsan Bari
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
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Establishment of primary cell culture and an intracranial xenograft model of pediatric ependymoma: a prospect for therapy development and understanding of tumor biology. Oncotarget 2018; 9:21731-21743. [PMID: 29774098 PMCID: PMC5955158 DOI: 10.18632/oncotarget.24932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/06/2018] [Indexed: 12/19/2022] Open
Abstract
Background Ependymoma (EPN), the third most common pediatric brain tumor, is a central nervous system (CNS) malignancy originating from the walls of the ventricular system. Surgical resection followed by radiation therapy has been the primary treatment for most pediatric intracranial EPNs. Despite numerous studies into the prognostic value of histological classification, the extent of surgical resection and adjuvant radiotherapy, there have been relatively few studies into the molecular and cellular biology of EPNs. Results We elucidated the ultrastructure of the cultured EPN cells and characterized their profile of immunophenotypic pluripotency markers (CD133, CD90, SSEA-3, CXCR4). We established an experimental EPN model by the intracerebroventricular infusion of EPN cells labeled with multimodal iron oxide nanoparticles (MION), thereby generating a tumor and providing a clinically relevant animal model. MRI analysis was shown to be a valuable tool when combined with effective MION labeling techniques to accompany EPN growth. Conclusions We demonstrated that GFAP/CD133+CD90+/CD44+ EPN cells maintained key histopathological and growth characteristics of the original patient tumor. The characterization of EPN cells and the experimental model could facilitate biological studies and preclinical drug screening for pediatric EPNs. Methods In this work, we established notoriously challenging primary cell culture of anaplastic EPNs (WHO grade III) localized in the posterior fossa (PF), using EPNs obtained from 1 to 10-year-old patients (n = 07), and then characterized their immunophenotype and ultrastructure to finally develop a xenograft model.
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Wang M, Zhang R, Liu X, Li D, Zhao P, Zuo Y, Zhang P, Wang J, Sun H. Supratentorial Cortical Ependymomas: A Retrospective Series of 13 Cases at a Single Center. World Neurosurg 2018; 112:e772-e777. [PMID: 29408575 DOI: 10.1016/j.wneu.2018.01.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Cortical ependymomas (CEs), supratentorial ependymomas that selectively involve the cerebral cortex, are relatively rare neoplasms that have not been extensively described. The purpose of our study was to identify the clinical features, radiologic characteristics, and treatment of a series of such tumors. METHODS Thirteen patients with CEs from our hospital were included in this study. Epidemiologic characteristics, clinical features, imaging findings, treatment methods, and clinical outcomes were reviewed retrospectively. RESULTS The patients consisted of 7 men and 6 women with mean age of 31.1 ± 23.2 years (range, 4-74 years). The most common clinical manifestation was seizure (n = 11; 85%), followed by headache (n = 2; 15%). None of the tumors were incidentally detected. Eight CEs were located in the right hemisphere and 5 in the left side. The 2 most common tumor locations were the frontal (n = 5; 38%) and parietal lobe (n = 5; 38%). All patients underwent surgical resection. Gross total resection was achieved in 12 patients (92%), and subtotal resection was performed in 1 patient (8%). Ten of the 11 patients who presented with seizure are seizure-free after surgery (91% seizure-free rate). According to the World Health Organization classification system, 9 tumors (69%) were Grade II (ependymoma) and 4 (31%) were Grade III (anaplastic ependymoma). The mean follow-up was 52 months (range, 20-88 months). No recurrence was observed in patients with Grade II CEs. Of 4 patients with Grade III CEs, 2 (50%) suffered from tumor recurrence after initial treatment. CONCLUSIONS CEs are a rare subset of supratentorial ependymomas that selectively involve the cerebral cortex. Most CEs are low grade and present with seizures. Anaplastic CEs show a greater recurrence rate and a relatively poor prognosis. Gross total resection with or without adjuvant radiotherapy is currently the optimal treatment for CEs. CEs seem to have a more favorable prognosis than other supratentorial ependymomas.
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Affiliation(s)
- Mengmeng Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rende Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xueyou Liu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dongming Li
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peichao Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuchao Zuo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junkuan Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongwei Sun
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Adult Spinal Ependymomas: An Epidemiologic Study. World Neurosurg 2017; 111:e53-e61. [PMID: 29225135 DOI: 10.1016/j.wneu.2017.11.165] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/25/2017] [Accepted: 11/28/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In adults, spinal ependymomas constitute only 3% to 6% of central nervous system tumors. Because of their rarity and poor prognosis, large population-based studies are needed to assess the epidemiology and survival risk factors associated with these tumors in the hope of improving outcome. The authors undertook this retrospective study to explore factors that may influence survival in adult patients with spinal ependymomas. METHODS Using the Surveillance, Epidemiology, and End Results database, a prospective cancer registry, the authors retrospectively assessed survival in histologically confirmed spinal ependymomas in patients 18 years of age and older. Survival was described with Kaplan-Meier curves, and a multivariate regression analysis was used to assess the association of several variables with survival while controlling for confounding variables. RESULTS Overall survival at 1 year, 3 years, and 5 years after diagnosis was 97.0%, 94.3%, and 93.3%, respectively. Patient age at diagnosis (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.04-1.07, P < 0.001), tumor grade IV (HR 11.11, 95% CI 1.27-97.02, P = 0.032), and the use of radiation therapy during the course of treatment (HR 4.42, 95% CI 1.69-11.57, P = 0.003) were each associated with decreased survival. Gross total resection (HR 0.42, 95% CI 0.20-1.10, P = 0.026) was associated with improved overall survival. Gender, tumor size, and tumor extension were not found to impact survival. CONCLUSIONS High-grade ependymomas occurring in the spine have a much worse prognosis than do those with lower grades. Early diagnosis and surgery appear to be associated with improved survival and outcomes, whereas radiation therapy has an unclear role.
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Lummus SC, Donson AM, Gowan K, Jones KL, Vibhakar R, Foreman NK, Kleinschmidt-DeMasters BK. p16 Loss and E2F/cell cycle deregulation in infant posterior fossa ependymoma. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26656. [PMID: 28548702 PMCID: PMC5647247 DOI: 10.1002/pbc.26656] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 05/02/2017] [Accepted: 05/10/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Posterior fossa (PF) ependymomas (EPNs) in infants less than 1 year of age (iEPN-PF) have a poorer clinical outcome than EPNs in older children. While radiation therapy is the standard of care for the latter, it is withheld in infants to avoid neurotoxicity to immature brain. It is unknown whether the adverse outcome in iEPN-PFs is due to treatment differences or aggressive biology. We examined this question using molecular profiling. METHODS Six anaplastic iEPN-PFs were subjected to transcriptomic analysis and FISH for p16 loss and gains of 1q, and compared with anaplastic PF EPNs from older children. Results were validated by immunohistochemistry (IHC). RESULTS All six iEPN-PFs were grouped within EPN PF subgroup A (PFA). E2F targets and G2M checkpoint were identified as the most enriched gene sets in iEPN-PF, which was validated in a larger independent cohort. Accordingly, MIB-1 IHC demonstrated a higher mitotic rate in iEPN-PFs than noninfant anaplastic EPN PFA. Genetic and protein analyses demonstrated that p16 loss and low p16 protein expression is a hallmark of iEPN-PF, and that none harbored 1q gains. Kaplan-Meier analysis confirmed the poorer clinical outcome of the iEPN-PF cohort. CONCLUSIONS Biological differences, characterized by loss of p16 expression without gains of 1q in iEPN-PFs, as well as deregulated E2F target gene transcription, are indicative of deregulated p16-CDK4/6-pRB-E2F pathway activity. This may underlie the poor clinical outcome seen in this group of iEPN-PFs, rather than the withholding of radiation therapy. Results suggest a potential actionable therapy for iEPN-PF, namely cyclin-dependent kinase 4/6 (CDK4/6) inhibitors.
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Affiliation(s)
- Seth C. Lummus
- Department of Pathology, The University of Colorado School of Medicine, Aurora, Colorado,Children’s Hospital Colorado, Aurora, Colorado
| | - Andrew M. Donson
- Children’s Hospital Colorado, Aurora, Colorado,Department of Pediatrics, The University of Colorado School of Medicine, Aurora, Colorado
| | - Katherine Gowan
- Department of Pediatrics, The University of Colorado School of Medicine, Aurora, Colorado
| | - Kenneth L. Jones
- Department of Pediatrics, The University of Colorado School of Medicine, Aurora, Colorado
| | - Rajeev Vibhakar
- Children’s Hospital Colorado, Aurora, Colorado,Department of Pediatrics, The University of Colorado School of Medicine, Aurora, Colorado
| | - Nicholas K. Foreman
- Children’s Hospital Colorado, Aurora, Colorado,Department of Pediatrics, The University of Colorado School of Medicine, Aurora, Colorado,Department of Neurosurgery, The University of Colorado School of Medicine, Aurora, Colorado
| | - B. K. Kleinschmidt-DeMasters
- Department of Pathology, The University of Colorado School of Medicine, Aurora, Colorado,Department of Neurosurgery, The University of Colorado School of Medicine, Aurora, Colorado,Department of Neurology, The University of Colorado School of Medicine, Aurora, Colorado
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25
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Chai YH, Jung S, Lee JK, Kim IY, Jang WY, Moon KS, Kim JH, Lee KH, Kim SK, Jung TY. Ependymomas: Prognostic Factors and Outcome Analysis in a Retrospective Series of 33 Patients. Brain Tumor Res Treat 2017; 5:70-76. [PMID: 29188207 PMCID: PMC5700030 DOI: 10.14791/btrt.2017.5.2.70] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/26/2017] [Accepted: 09/29/2017] [Indexed: 12/19/2022] Open
Abstract
Background The purpose of this study was to evaluate the prognostic factors and outcomes in patients with ependymoma to management plans. Methods Between 1997 and 2013, 33 patients with 25 ependymomas (WHO grade II) and eight anaplastic ependymomas (WHO grade III) were pathologically diagnosed. Six were pediatric patients (mean age, 6.15 years; range, 1.3–11 years), while 27 were adults (mean age, 47.5 years; range, 19–70 years). Of those, there were 12 adult patients with totally resected ependymomas without anaplastic pathology and adjuvant treatment. Prognostic factors were assessed in ependymoma patients. Prognostic factors were studied using Kaplan-Meier estimates in subgroups. Results For six pediatric patients, the progression-free survival (PFS) was 43.7±13.5 months, and the overall survival (OS) was 58.1±13.7 months. For 27 adult patients, the PFS was 125.6±14.3 months, and the OS was 151.2±12.5 months. Age demonstrated a statistically significant effect on PFS (p=0.03) and OS (p=0.03). In adult ependymomas, the extent of tumor removal significantly affected PFS (p=0.03) and trended towards an effect on OS (p=0.06). Out of 12 patients with totally resected ependymomas without anaplastic pathology and adjuvant treatment, one patient showed tumor recurrence during follow-up (mean, 93.5 months; range, 27.9–162.7 months). Conclusion Adult patients with ependymomas were found to have better survival rates compared to pediatric patients. We suggest that totally resected adult ependymomas without anaplastic pathology could be observed without any adjuvant treatment, regardless of the tumor location.
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Affiliation(s)
- Yong-Hyun Chai
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - Jung-Kil Lee
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - In-Young Kim
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - Woo-Youl Jang
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - Jae-Hyoo Kim
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - Kyung-Hwa Lee
- Department of Pathology, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - Seul-Kee Kim
- Department of Radiology, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Korea
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26
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Song SW, Dho YS, Kim JW, Kim YH, Paek SH, Kim DG, Jung HW, Park SH, Choi SH, Kim TM, Lee ST, Kim IH, Lee SH, Park CK. Recursive partitioning analysis for disease progression in adult intracranial ependymoma patients. J Clin Neurosci 2017; 46:72-78. [PMID: 28890044 DOI: 10.1016/j.jocn.2017.08.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Abstract
Intracranial ependymomas are rare tumors in adults. Although recent advancements from demographic, clinical, and biological studies provide new perspectives on this rare tumor, they are not yet widely applied in clinical practice. Currently, most ependymoma patients are treated in the same way: via surgical resection with adjuvant radiation therapy. However, it is reasonable to apply more aggressive treatment for high-risk patients. From this point of view, we performed a study to investigate risk grouping for disease progression of intracranial ependymomas in adults. A total of 53 patients were included in this study. Data were extracted for patient and tumor characteristics, extent of resection, progression-free survival (PFS), and overall survival. Prognostic variables from univariate and multivariate survival analyses were included in a recursive partitioning analysis for the hierarchical risk grouping of the estimated PFS. Three risk groups were defined based on the clinical prognostic factors. Survival analysis showed significant differences in mean PFS between the different groups: 160.5±22.1months in the complete resection group, 100.4±36.8months in the incomplete-resection and intraventricular-location group, and 23.5±6.9months in the incomplete-resection and extraventricular-location group (p<0.001). The risk of disease progression in adult intracranial ependymoma patients could be stratified by degree of resection and tumor location. In clinical practice, this result could provide useful information, such as when "second-look" surgery should be performed or whether small tumors invading the fourth ventricle floor should be resected at the expense of neurological deficit.
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Affiliation(s)
- Sang Woo Song
- Department of Neurosurgery, Konkuk University College of Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Yun-Sik Dho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Won Jung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung Hong Choi
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tae Min Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Il Han Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang Hyung Lee
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea.
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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27
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Leeper H, Felicella MM, Walbert T. Recent Advances in the Classification and Treatment of Ependymomas. Curr Treat Options Oncol 2017; 18:55. [PMID: 28795287 DOI: 10.1007/s11864-017-0496-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OPINION STATEMENT Ependymomas are a subgroup of ependymal glia-derived neoplasms that affect children as well as adults. Arising within any CNS compartment, symptoms at presentation can range from acute onset due to increased intracranial pressure to insidious myelopathy. The overall survival (OS) outcomes in adult patients across the subgroups is heterogeneous with subependymoma having an excellent prognosis often even in the absence of any treatment, whereas supratentorial ependymomas tend to be higher grade in nature and may have an OS of 5 years despite gross total resection and adjuvant radiation. The rarity of ependymal tumors, together still only representing 1.8% of all primary CNS tumors, has been a long-standing challenge in defining optimal treatment guidelines via prospective randomized trials. Retrospective studies have supported maximal safe resection, ideally gross total resection, as the optimal treatment with adjuvant radiation therapy proffering additional tumor control. The evidence for efficacy of chemotherapy and targeted agents in adult ependymomas is minimal. Recent investigations of the molecular, genetic, and DNA methylation profiles of ependymal tumors across all age groups and CNS compartments have identified distinct oncogenic gene products as well as nine molecular subgroups correlating with similar outcomes. The 2016 World Health Organization of Tumors of the Central Nervous System update addresses some of these findings, although their clinical significance has not yet been fully validated. There are inconsistent survival outcomes in retrospective studies for ependymomas graded as II versus III, bringing into question the validity of histologic grading which is subject to high interobserver variability in part due to inconsistent application of mitotic count parameters.
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Affiliation(s)
- Heather Leeper
- Department of Neurology, NorthShore University Health System, 2650 Ridge Ave, Evanston, IL, 60021, USA
| | - Michelle M Felicella
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Tobias Walbert
- Departments of Neurosurgery and Neurology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA.
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28
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Rethinking childhood ependymoma: a retrospective, multi-center analysis reveals poor long-term overall survival. J Neurooncol 2017; 135:201-211. [PMID: 28733870 PMCID: PMC5658456 DOI: 10.1007/s11060-017-2568-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/13/2017] [Indexed: 11/24/2022]
Abstract
Ependymoma is the third most common brain tumor in children, but there is a paucity of large studies with more than 10 years of follow-up examining the long-term survival and recurrence patterns of this disease. We conducted a retrospective chart review of 103 pediatric patients with WHO Grades II/III intracranial ependymoma, who were treated at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and Chicago’s Ann & Robert H. Lurie Children’s Hospital between 1985 and 2008, and an additional 360 ependymoma patients identified from the Surveillance Epidemiology and End Results (SEER) database. For the institutional cohort, we evaluated clinical and histopathological prognostic factors of overall survival (OS) and progression-free survival (PFS) using the log-rank test, and univariate and multivariate Cox proportional-hazards models. Overall survival rates were compared to those of the SEER cohort. Median follow-up time was 11 years. Ten-year OS and PFS were 50 ± 5% and 29 ± 5%, respectively. Findings were validated in the independent SEER cohort, with 10-year OS rates of 52 ± 3%. GTR and grade II pathology were associated with significantly improved OS. However, GTR was not curative for all children. Ten-year OS for patients treated with a GTR was 61 ± 7% and PFS was 36 ± 6%. Pathological examination confirmed most recurrent tumors to be ependymoma, and 74% occurred at the primary tumor site. Current treatment paradigms are not sufficient to provide long-term cure for children with ependymoma. Our findings highlight the urgent need to develop novel treatment approaches for this devastating disease.
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29
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Chowdhary S, Damlo S, Chamberlain MC. Cerebrospinal Fluid Dissemination and Neoplastic Meningitis in Primary Brain Tumors. Cancer Control 2017; 24:S1-S16. [PMID: 28557973 DOI: 10.1177/107327481702400118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Neoplastic meningitis, also known as leptomeningeal disease, affects the entire neuraxis. The clinical manifestations of the disease may affect the cranial nerves, cerebral hemispheres, or the spine. Because of the extent of disease involvement, treatment options and disease staging should involve all compartments of the cerebrospinal fluid (CSF) and subarachnoid space. Few studies of patients with primary brain tumors have specifically addressed treatment for the secondary complication of neoplastic meningitis. Therapy for neoplastic meningitis is palliative in nature and, rarely, may have a curative intent. METHODS A review of the medical literature pertinent to neoplastic meningitis in primary brain tumors was performed. The complication of neoplastic meningitis is described in detail for the various types of primary brain tumors. RESULTS Treatment of neoplastic meningitis is complicated because determining who should receive aggressive, central nervous system (CNS)-directed therapy is difficult. In general, the therapeutic response of neoplastic meningitis is a function of CSF cytology and, secondarily, of the clinical improvement in neurological manifestations related to the disease. CSF cytology may manifest a rostrocaudal disassociation; thus, consecutive, negative findings require that both lumbar and ventricular cytological testing are performed to confirm the complete response. Based on data from several prospective, randomized trials extrapolated to primary brain tumors, the median rate of survival for neoplastic meningitis is several months. Oftentimes, therapy directed at palliation may improve quality of life by protecting patients from experiencing continued neurological deterioration. CONCLUSIONS Neoplastic meningitis is a complicated disease in which response to therapy varies by histology. Thus, survival rates after CNS-directed therapy will differ by the underlying primary tumor. Optimal therapy of neoplastic meningitis is poorly defined, and few guidelines exist to guide clinicians on the most appropriate choice of therapy.
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Affiliation(s)
| | | | - Marc C Chamberlain
- Seattle Cancer Care Alliance, Cascadian Therapeutics, Seattle, Washington, USA.
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30
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Central nervous system gliomas. Crit Rev Oncol Hematol 2017; 113:213-234. [DOI: 10.1016/j.critrevonc.2017.03.021] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 03/16/2017] [Accepted: 03/20/2017] [Indexed: 12/22/2022] Open
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31
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Theeler BJ, Gilbert MR. Investigating therapies in ependymoma. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1191347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Brett J. Theeler
- Department of Neurology, Walter Reed National Military Medical Center, Neurology and John P. Murtha Cancer Center, Bethesda, MD, USA
| | - Mark R. Gilbert
- Neuro-Oncology Branch, National Institutes of Health, Bethesda, MD, USA
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32
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Gramatzki D, Roth P, Felsberg J, Hofer S, Rushing EJ, Hentschel B, Westphal M, Krex D, Simon M, Schnell O, Wick W, Reifenberger G, Weller M. Chemotherapy for intracranial ependymoma in adults. BMC Cancer 2016; 16:287. [PMID: 27108407 PMCID: PMC4842281 DOI: 10.1186/s12885-016-2323-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 04/19/2016] [Indexed: 11/29/2022] Open
Abstract
Background Ependymal tumors in adults are rare, accounting for less than 4 % of primary tumors of the central nervous system in this age group. The low prevalence of intracranial ependymoma in adults limits the ability to perform clinical trials. Therefore, treatment decisions are based on small, mostly retrospective studies and the role of chemotherapy has remained unclear. Methods We performed a retrospective study on 17 adult patients diagnosed with intracranial World Health Organisation grade II or III ependymoma, who were treated with chemotherapy at any time during the disease course. Benefit from chemotherapy was estimated by applying Macdonald criteria. Progression-free (PFS) and overall survival (OS) were calculated from start of chemotherapy, using the Kaplan-Meier method. Results Eleven patients had supratentorial and 6 infratentorial tumors. Ten patients were treated with temozolomide (TMZ), 3 with procarbazine/lomustine/vincristine (PCV), 3 with platinum-based chemotherapy and 1 patient received epirubicin/ifosfamide. Response rates were as follows: TMZ 8/10 stable disease; PCV 3/3 stable disease; platinum-based chemotherapy 1/3 partial response; epirubicin/ifosfamide 1/1 complete response. PFS rates at 6, 12 and 24 months were 52.9, 35.3 and 23.5 %. OS rates at 6, 12 and 24 months were 82.4, 82.4 and 70.1 %. There was no indication for a favourable prognostic role of O6-methylguanyl-DNA-methyltransferase (MGMT) promoter methylation which was detected in 3/12 investigated tumors. Conclusions Survival outcomes in response to chemotherapy in adult intracranial ependymoma patients vary substantially, but individual patients may respond to any kind of chemotherapy. There were too few patients to compare survival data between chemotherapeutic subgroups. Electronic supplementary material The online version of this article (doi:10.1186/s12885-016-2323-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dorothee Gramatzki
- Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.
| | - Patrick Roth
- Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland
| | - Jörg Felsberg
- Department of Neuropathology, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.,German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69121, Heidelberg, Germany
| | - Silvia Hofer
- Department of Oncology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Elisabeth J Rushing
- Department of Neuropathology, University Hospital Zurich, Schmelzbergstrasse 12, 8091, Zurich, Switzerland
| | - Bettina Hentschel
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Härtelstrasse 16-18, 04107, Leipzig, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - Dietmar Krex
- Department of Neurosurgery, Technical University Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Matthias Simon
- Department of Neurosurgery, University of Bonn Medical School, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Ludwig Maximilian University Munich, Marchionistrasse 15, 81377, Munich, Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), and Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany.,Department of General Neurology, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Guido Reifenberger
- German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69121, Heidelberg, Germany.,Department of General Neurology, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.,Department of General Neurology, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
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33
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Wu J, Armstrong TS, Gilbert MR. Biology and management of ependymomas. Neuro Oncol 2016; 18:902-13. [PMID: 27022130 DOI: 10.1093/neuonc/now016] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 01/04/2016] [Indexed: 12/20/2022] Open
Abstract
Ependymomas are rare primary tumors of the central nervous system in children and adults that comprise histologically similar but genetically distinct subgroups. The tumor biology is typically more associated with the site of origin rather than being age-specific. Genetically distinct subgroups have been identified by genomic studies based on locations in classic grade II and III ependymomas. They are supratentorial ependymomas with C11orf95-RELA fusion or YAP1 fusion, infratentorial ependymomas with or without a hypermethylated phenotype (CIMP), and spinal cord ependymomas. Myxopapillary ependymomas and subependymomas have different biology than ependymomas with typical WHO grade II or III histology. Surgery and radiotherapy are the mainstays of treatment, while the role of chemotherapy has not yet been established. An in-depth understanding of tumor biology, developing reliable animal models that accurately reflect tumor molecule features, and high throughput drug screening are essential for developing new therapies. Collaborative efforts between scientists, physicians, and advocacy groups will enhance the translation of laboratory findings into clinical trials. Improvements in disease control underscore the need to incorporate assessment and management of patients' symptoms to ensure that treatment advances translate into improvement in quality of life.
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Affiliation(s)
- Jing Wu
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (J.W., M.R.G.); Department of Family Health, University of Texas Health Science Center at Houston, Houston, Texas (T.S.A.)
| | - Terri S Armstrong
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (J.W., M.R.G.); Department of Family Health, University of Texas Health Science Center at Houston, Houston, Texas (T.S.A.)
| | - Mark R Gilbert
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland (J.W., M.R.G.); Department of Family Health, University of Texas Health Science Center at Houston, Houston, Texas (T.S.A.)
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Hollon T, Nguyen V, Smith BW, Lewis S, Junck L, Orringer DA. Supratentorial hemispheric ependymomas: an analysis of 109 adults for survival and prognostic factors. J Neurosurg 2016; 125:410-8. [PMID: 26745489 DOI: 10.3171/2015.7.jns151187] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Survival rates and prognostic factors for supratentorial hemispheric ependymomas have not been determined. The authors therefore designed a retrospective study to determine progression-free survival (PFS), overall survival (OS), and prognostic factors for hemispheric ependymomas. METHODS The study population consisted of 8 patients from our institution and 101 patients from the literature with disaggregated survival information (n = 109). Patient age, sex, tumor side, tumor location, extent of resection (EOR), tumor grade, postoperative chemotherapy, radiation, time to recurrence, and survival were recorded. Kaplan-Meier survival analyses and Cox proportional hazard models were completed to determine survival rates and prognostic factors. RESULTS Anaplastic histology/WHO Grade III tumors were identified in 62% of cases and correlated with older age. Three-, 5-, and 10-year PFS rates were 57%, 51%, and 42%, respectively. Three-, 5-, and 10-year OS rates were 77%, 71%, and 58%, respectively. EOR and tumor grade were identified on both Kaplan-Meier log-rank testing and univariate Cox proportional hazard models as prognostic for PFS and OS. Both EOR and tumor grade remained prognostic on multivariate analysis. Subtotal resection (STR) predicted a worse PFS (hazard ratio [HR] 4.764, p = 0.001) and OS (HR 4.216, p = 0.008). Subgroup survival analysis of patients with STR demonstrated a 5- and 10-year OS of 28% and 0%, respectively. WHO Grade III tumors also had worse PFS (HR 10.2, p = 0.004) and OS (HR 9.1, p = 0.035). Patients with WHO Grade III tumors demonstrated 5- and 10-year OS of 61% and 46%, respectively. Postoperative radiation was not prognostic for PFS or OS. CONCLUSIONS A high incidence of anaplastic histology was found in hemispheric ependymomas and was associated with older age. EOR and tumor grade were prognostic factors for PFS and OS on multivariate analysis. STR or WHO Grade III pathology, or both, predicted worse overall prognosis in patients with hemispheric ependymoma.
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Affiliation(s)
| | - Vincent Nguyen
- Temple University Medical School, Philadelphia, Pennsylvania
| | | | | | - Larry Junck
- Neurology, University of Michigan, Ann Arbor, Michigan; and
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35
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Asaid M, Preece PD, Rosenthal MA, Drummond KJ. Ependymoma in adults: Local experience with an uncommon tumour. J Clin Neurosci 2015; 22:1392-6. [DOI: 10.1016/j.jocn.2015.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 02/22/2015] [Accepted: 03/03/2015] [Indexed: 11/30/2022]
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36
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Sayegh ET, Aranda D, Kim JM, Oh T, Parsa AT, Oh MC. Prognosis by tumor location in adults with intracranial ependymomas. J Clin Neurosci 2014; 21:2096-101. [PMID: 25037313 DOI: 10.1016/j.jocn.2014.05.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 05/17/2014] [Indexed: 10/25/2022]
Abstract
Intracranial ependymomas are rare tumors in adults. Thus, factors affecting prognosis are poorly understood. We performed a study to investigate whether tumor location is an important prognostic factor in adults who undergo surgery for intracranial ependymomas. PubMed was searched to identify studies that reported clinical outcomes in adult patients with intracranial ependymoma. Data were extracted for patient and tumor characteristics, extent of resection, progression-free survival (PFS), and overall survival (OS). Tumors were categorized as supratentorial or infratentorial and extraventricular or intraventricular. Presenting clinical features and tumor characteristics were tabulated. Kaplan-Meier and multivariate Cox regression survival analyses were performed to determine PFS and OS by tumor location. Extent of resection was also analyzed by tumor location. A total of 183 patients were included in the meta-analysis. Patients presented at a mean of 8.2months with a myriad of clinical features. The mean tumor size was 3.38 cm, and 19.3% of tumors were cystic. Supratentorial tumors were most commonly located in the frontal and parietal lobes, and infratentorial tumors in the fourth ventricle. Supratentorial tumors demonstrated significantly poorer PFS (p<0.001) and OS (p=0.003) than infratentorial tumors, despite a higher rate of gross total resection (GTR) for the supratentorial tumors (72.6% versus 42.1%). Extraventricular ependymomas displayed significantly poorer PFS than intraventricular ependymomas (p=0.009). In summary, supratentorial ependymomas have significantly poorer PFS and OS than their infratentorial counterparts, despite being more conducive to GTR, suggesting increased clinical aggressiveness. Extraventricular location is also associated with significantly poorer PFS than intraventricular location.
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Affiliation(s)
- Eli T Sayegh
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - Derick Aranda
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Joseph M Kim
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Taemin Oh
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - Andrew T Parsa
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - Michael C Oh
- Methodist Brain and Spine Institute, 1411 N. Beckley Avenue, Pav. III, Ste. 152, Dallas, TX 75203, USA.
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Iqbal MS, Lewis J. An overview of the management of adult ependymomas with emphasis on relapsed disease. Clin Oncol (R Coll Radiol) 2013; 25:726-33. [PMID: 23972764 DOI: 10.1016/j.clon.2013.07.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 04/08/2013] [Accepted: 06/04/2013] [Indexed: 11/16/2022]
Abstract
Ependymomas are rare neoplasms of the central nervous system. Disease-free survival after relapse is poor and approaches to treatment in recurrent disease often palliative. This overview summarises the management of primary disease for which broad consensus exists. We also extensively review treatment options in relapsed disease for which approaches to treatment are varied due to the paucity of literature evidence. Incorporated in this overview is a survey of UK neuro-oncology units to form a snapshot of current UK practise with respect to preferred systemic therapy regimens for patients with recurrent ependymoma. The outcome reflects a preference for mainly oral-based regimens. Universal guidance is lacking in the management of non-operable irradiated recurrent ependymoma and there are worthy therapeutic avenues for further investigation, in particular the role of radical re-irradiation and also the potential of bevacizumab in advanced disease. It is hoped that advances can be achieved by multicentre collaboration in future studies to overcome the difficulties posed by achieving meaningful data in such a rare tumour with extensive natural history.
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Abstract
OPINION STATEMENT Survival rates for patients with ependymoma, a glial tumor arising from the ependymal cells lining the ventricles of the brain and spinal cord canal, have changed little during the past decade. Contemporary "standard" therapy for children and adults with ependymoma consists of maximal surgical resection followed by focal irradiation except in cases of disseminated disease. Despite refinements in radiotherapy techniques and improvements in survival for patients with gross totally resected, nonanaplastic disease, many therapeutic challenges remain, especially for patients with unresectable, macroscopic, metastatic, or anaplastic disease. Moreover, radiotherapy to the developing central nervous system, especially in patients younger than age 5 years, can have potential long-term neurocognitive and neuroendocrine sequelae. Chemotherapy has not played a role in most treatment regimens for ependymoma to date, but due to the ongoing therapeutic challenges for a subset of patients, this modality is being reinvestigated in a few ongoing studies. Early recognition of patients who will not respond to primary therapy is imperative to modify treatment regimens, such as intensification with the addition of adjuvant chemotherapy, the use of novel experimental therapies, or their combination. Refinements in patient stratification schemes that are based on a combination of clinical variables and molecular profiles also require improved knowledge of tumor biology. Several molecular alterations have been identified already, some of which may be of prognostic significance. Furthermore, disruption of molecular alterations in signaling pathways involved in the development and maintenance of ependymoma by using novel molecularly targeted therapies may improve outcomes and reduce toxicity for patients with ependymoma.
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Intracranial ependymoma: long-term results in a series of 21 patients treated with stereotactic (125)iodine brachytherapy. PLoS One 2012; 7:e47266. [PMID: 23144811 PMCID: PMC3489891 DOI: 10.1371/journal.pone.0047266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Accepted: 09/13/2012] [Indexed: 12/04/2022] Open
Abstract
Background We evaluated the long-term outcome in patients harboring intracranial ependymomas treated with interstitial brachytherapy (IBT). Methods Twenty-one patients (M/F = 9/12; median age: 29 years; range: 8–70 years), diagnosed with intracranial ependymoma (1 WHO I, 11 WHO II, 9 WHO III) were treated with IBT using stereotactically implanted 125Iodine seeds between 1987 and 2010, either primarily, as adjuvant therapy following incomplete resection, or as salvage treatment upon tumor recurrence. Sixteen of 21 patients underwent microsurgical resection prior to IBT; in 5 patients, IBT was performed primarily after stereotactic biopsy for histological diagnosis. The cumulative tumor surface dose ranged from 50–65 Gy treating a median tumor volume of 3.6 ml (range, 0.3–11.6 ml). A median follow-up period of 105.3 months (range, 12.7–286.2 months) was evaluated. Results Actuarial 2-, 5- and 10-years overall- and disease-specific survival rates after IBT were each 90% and 100% at all times for ependymomas WHO I/II, for anaplastic ependymomas WHO III 100%, 100%, 70% and 100%, 100%, 86%, respectively. The neurological status of seven patients improved, while there was no change in 12 and deterioration in 2 patients, respectively. Follow-up MR images disclosed a complete tumor remission in 3, a partial remission in 12 and a stable disease in 6 patients. Treatment-associated morbidity only occurred in a single patient. Conclusions This study shows that stereotactic IBT for intracranial ependymomas is safe and can provide a high degree of local tumor control. Due to the low rate of side effects, IBT may evolve into an attractive alternative to microsurgery in ependymomas located in eloquent areas or as a salvage treatment.
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Vaidya K, Smee R, Williams JR. Prognostic factors and treatment options for paediatric ependymomas. J Clin Neurosci 2012; 19:1228-35. [PMID: 22840355 DOI: 10.1016/j.jocn.2012.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 02/07/2012] [Accepted: 02/14/2012] [Indexed: 01/22/2023]
Abstract
The aim of this study was to determine factors of prognostic relevance for paediatric ependymomas, and evaluate the efficacy of treatment modalities. This is a retrospective study of 43 patients with ependymoma (<18 years) who underwent a combination of surgical excision, chemotherapy, and/or radiotherapy treatment at The Prince of Wales Cancer Centre between 1969 and 2009. Statistical analysis was performed to assess the prognostic relevance of various parameters affecting the two-year and five-year overall survival (OS) and progression-free survival (PFS). The five-year OS and PFS were 50.3% and 44.8% respectively (median follow-up 50 months). Eighteen patients (41.9%) experienced tumour recurrence: 13 had a local recurrence (LR) and five had both LR and distant recurrence. On univariate analysis, a more favourable prognosis in terms of both OS and PFS was evident for supratentorial tumours compared to infratentorial tumours (OS p=0.007, PFS p=0.045), stereotactic radiosurgery/ fractionated stereotactic radiotherapy compared to craniospinal irradiation or local posterior fossa/local brain±boost radiotherapy modalities (OS p=0.047, PFS p=0.031), total radiotherapy dose >50 Gy compared to ≤50 Gy (OS p=0.008, PFS p=0.005), and in patients with no tumour recurrence compared to those with recurrence (OS p=0.03, PFS p<0.001). Although not statistically significant, a more favourable multivariate outcome was evident in patients who underwent complete surgical resection. Chemotherapy treatment and histopathological grade, however, were not relevant to prognosis. This study supports the need to pursue more aggressive treatment for infratentorial and/or recurrent tumours. Ideal treatment involves maximal surgical resection, followed by adjuvant radiotherapy (>50 Gy).
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Affiliation(s)
- K Vaidya
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Level 2, High Street, Randwick, New South Wales 2031, Australi
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Patel TR, Yu JB, Piepmeier JM. Role of neurosurgery and radiation therapy in the management of brain tumors. Hematol Oncol Clin North Am 2012; 26:757-77. [PMID: 22794282 DOI: 10.1016/j.hoc.2012.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In the United States, approximately 65,000 people are diagnosed with primary brain tumors each year, with an incidence of 19.3 cases per 100,000 person-years. These numbers represent a wide spectrum of disease, from benign to malignant, and prognosis varies widely based on disease. Treatment of primary brain tumors most often uses a combination of surgery and radiation. However, over the past several generations, technological advancements have significantly altered the treatment paradigm. This article reviews the current role of neurosurgery and radiation therapy in the management of primary brain tumors.
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Affiliation(s)
- Toral R Patel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520, USA
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Newton HB, Rudà R, Soffietti R. Ependymomas, neuronal and mixed neuronal-glial tumors, dysembroblastic neuroepithelial tumors, pleomorphic xanthoastrocytomas, and pilocytic astrocytomas. HANDBOOK OF CLINICAL NEUROLOGY 2012; 105:551-567. [PMID: 22230518 DOI: 10.1016/b978-0-444-53502-3.00008-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Herbert B Newton
- Department of Neurology, The Ohio State University Medical Center, Columbus, OH, USA.
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Pediatric intracranial ependymoma: the roles of surgery, radiation and chemotherapy. J Neurooncol 2011; 106:367-75. [DOI: 10.1007/s11060-011-0671-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Accepted: 07/14/2011] [Indexed: 11/29/2022]
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Aguilera DG, Mazewski C, Schniederjan MJ, Leong T, Boydston W, Macdonald TJ. Neurofibromatosis-2 and spinal cord ependymomas: Report of two cases and review of the literature. Childs Nerv Syst 2011; 27:757-64. [PMID: 21132433 DOI: 10.1007/s00381-010-1351-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 11/16/2010] [Indexed: 10/18/2022]
Abstract
OBJECT The incidence of ependymoma in patients with neurofibromatosis-2 (NF-2) is low and information regarding treatment and prognosis is lacking. We present two cases of cervicomedullary tumors in patients with NF-2 from our institution, and we provide a review of the literature in order to summarize the known clinical information about this rare occurrence. PATIENTS AND METHODS Patient #1 had histological confirmation of ependymoma and was treated with subtotal resection followed by observation and has had no evidence of progression for 11 months. Patient #2 has been observed for 4 1/2 years without treatment for a cervicomedullary tumor, which appears to be an ependymoma by imaging. Although it has increased in size very slowly, there have been no clinical symptoms. Among the additional 21 cases of NF-2 and ependymoma from the literature, the most common location is the cervical spine (70%), and the median age at diagnosis is 15 years. Surgical resection was performed in 85% of the cases and subtotal resection in 64% of cases. Fifteen patients (75%) were reported alive at the time of the published reports, with survival ranging from 0.1 to 10 years, and the 8-year survival estimated as 51%. Survival was related to the location of the tumor. CONCLUSIONS We conclude from our two cases and review of the existing literature that NF-2 associated spinal ependymomas have an indolent course and typically can be observed or treated by surgical excision alone.
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Affiliation(s)
- Dolly G Aguilera
- Aflac Cancer Center and Blood Disorders Service at Children's Health Care of Atlanta, Emory University School of Medicine, Atlanta, GA 30322, USA
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Shonka NA. Targets for therapy in ependymoma. Target Oncol 2011; 6:163-9. [DOI: 10.1007/s11523-011-0170-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 02/03/2011] [Indexed: 11/29/2022]
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Weber DC, Zilli T, Do HP, Nouet P, Gumy Pause F, Pause FG, Pica A. Intensity modulated radiation therapy or stereotactic fractionated radiotherapy for infratentorial ependymoma in children: a multicentric study. J Neurooncol 2010; 102:295-300. [PMID: 20725849 DOI: 10.1007/s11060-010-0318-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 07/19/2010] [Indexed: 10/19/2022]
Abstract
This study was to evaluate the treatment dosimetry, efficacy and toxicity of intensity modulated radiation therapy (IMRT) and fractionated stereotactic radiotherapy (FSRT) in the management of infratentorial ependymoma. Between 1999 and 2007, seven children (median age, 3.1 years) with infratentorial ependymoma were planned with either IMRT (3 patients) or SFRT (4 patients), the latter after conventional posterior fossa irradiation. Two children underwent gross total resection. Median prescribed dose was 59.4 Gy (range, 55.8-60). The median follow-up for surviving patients was 4.8 years (range, 1.3-8). IMRT (median dose, 59.4 Gy) and FSRT (median dose, 55.8 Gy) achieved similar optimal target coverage. Percentages of maximum doses delivered to the cochleae (59.5 vs 85.0% Gy; P = 0.05) were significantly inferior with IMRT, when compared to FSRT planning. Percentages of maximum doses administered to the pituitary gland (38.2 vs 20.1%; P = 0.05) and optic chiasm (38.1 vs 14.1%; P = 0.001) were, however, significantly higher with IMRT, when compared to FSRT planning. No recurrences were observed at the last follow-up. The estimated 3-year progression-free survival and overall survival were 87.5 and 100%, respectively. No grade >1 acute toxicity was observed. Two patients presented late adverse events (grade 2 hypoacousia) during follow-up, without cognitive impairment. IMRT or FSRT for infratentorial ependymomas is effective and associated with a tolerable toxicity level. Both treatment techniques were able to capitalize their intrinsic conformal ability to deliver high-dose radiation. Larger series of patients treated with these two modalities will be necessary to more fully evaluate these delivery techniques.
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Affiliation(s)
- Damien C Weber
- Département de l'Imagerie Médical et Science de l'Information, Geneva University Hospital, 1211, Geneva 14, Switzerland.
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Intracranial ependymomas treated with radiotherapy: long-term results from a single institution. J Neurooncol 2010; 102:451-7. [DOI: 10.1007/s11060-010-0344-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 08/04/2010] [Indexed: 10/19/2022]
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Abstract
The role of cytology of cerebrospinal fluid (CSF) has not been established in pediatric ependymoma. Thirty-two children with metastatic ependymoma were analyzed: 11 patients had only positive CSF cytology, 6 had only positive magnetic resonance imaging (MRI) findings, and 15 had both CSF cytology and MRI positive. Twenty-two patients relapsed. Five-year event-free survival was 27.3%+/-13.4% for children with only CSF positive (M1) versus 26.1%+/-10.2% for patients with positive spine MRI positive (with or without CSF positive, M3) (P=0.87). In conclusion, 34% of the patients with metastatic ependymoma were identified based on CSF cytology only and their outcome was comparable to patients with macroscopic disease. CSF cytology is a useful tool to stage newly diagnosed patients with ependymoma.
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Abstract
Ependymomas are rare primary central nervous system tumors in adults. They occur most commonly in the spinal cord, where histopathologic evaluation is critical to differentiate the grade I myxopapillary ependymoma from the grade II ependymoma or grade III anaplastic ependymoma. Brain ependymomas are either grade II or III. Treatment for all grades and types includes maximum surgical resection. For myxopapillary ependymoma, complete removal while maintaining capsule integrity may be curative. Some grade II ependymomas may be observed carefully after imaging confirms complete resection, but grade III tumors require adjuvant radiation treatment. Radiation commonly is given to the region of tumor, except in cases in which there is imaging or cerebrospinal fluid evidence of tumor dissemination. Chemotherapy has not been studied extensively, although most reports suggest only modest benefit. Ongoing laboratory studies have uncovered important signal transduction pathways that may be better therapeutic targets, leading to the development of clinical trials using targeted agents.
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Affiliation(s)
- Mark R Gilbert
- Department of Neuro-oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77025, USA.
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Belcher R, Chahal HS, Evanson J, Afshar F, Marino S, Grossman AB. Recurrent pituitary ependymoma: a complex clinical problem. Pituitary 2010; 13:176-82. [PMID: 18704689 DOI: 10.1007/s11102-008-0139-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Ependymomas rarely arise from the region of the pituitary fossa, with only four cases previously reported in the literature. We present a complex case of a recurrent ependymoma of the parasellar region which has been difficult to clinically manage due to its tendency to recurrence. Our patient has had four operations over the last 28 years, with external beam radiotherapy, but still has residual tumor and is currently panhypopituitary and with significant visual loss. We believe there is considerable uncertainty as to the optimal management of any future progression, which seems likely, and are currently considering the use of radiosurgery with careful sparing of the optic chiasm, or possibly the chemotherapeutic agent temozolomide. Our case emphasises the recurrent nature of this rare but difficult tumor.
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Affiliation(s)
- Rosie Belcher
- Department of Endocrinology, Barts and the London School of Medicine, London, UK
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