Surgical outcome following resection of contrast-enhanced pediatric brainstem gliomas

Unveiling the Efficacy of Gamma Knife Radiosurgery for Tectal Plate Gliomas

BACKGROUND AND OBJECTIVES

Tectal plate gliomas (TPGs) are midbrain tumors that grow slowly and have a benign clinical course. Most TPGs are low-grade astrocytomas, but they can encompass various histological tumor types. Gamma Knife radiosurgery (GKRS) is being explored as a potentially safe and effective treatment option for TPGs, although research in this area is limited. This study aims to evaluate GKRS's efficacy and safety in patients with TPG and provide a comprehensive review of existing literature on the topic.

METHODS

This retrospective, single-center study included 48 patients with consecutive TPG who underwent GKRS between September 2005 and June 2022. Patients diagnosed with TPGs based on radiological or tissue-based criteria and who had a minimum follow-up period of 12 months were eligible for inclusion. The primary end points were local control and the absence of GKRS-associated or tumor-associated mortality and morbidity.

RESULTS

During a median follow-up of 28.5 months (range, 12-128), the radiological assessment showed tumor control in all cases, with 16.7% achieving a complete response and 68.8% achieving a partial response. Pseudoprogression occurred in 6.2% of cases, with onset ranging from 3 to 8 months. Clinical outcomes revealed no permanent neurological deterioration, with symptoms improving in 14.6% of patients and remaining stable in the others. One patient in the pseudoprogression group experienced transient Parinaud syndrome. One patient died during follow-up because of unrelated causes. The mean survival time after GKRS was 123.7 months. None of the clinical, radiological, or radiosurgical variables showed a correlation with partial/complete response, clinical improvement, or overall survival.

CONCLUSION

There is limited research available on the management of TPGs, and this study presents the largest patient cohort treated with GKRS, along with a substantial follow-up duration. Despite its limitations, this study demonstrates the efficacy and low-risk profile of GKRS for TPGs.

Clinical, pathological, and radiological features of 80 pediatric diffuse intrinsic pontine gliomas: A single-institute study

Objective

Diffuse intrinsic pontine gliomas (DIPGs) are rare but devastating diseases. This retrospective cross-sectional study aimed to investigate the clinical, radiological, and pathological features of DIPGs.

Materials and methods

The clinical data of 80 pediatric DIPGs under clinical treatment in Beijing Tiantan Hospital from July 2013 to July 2019 were retrospectively collected and studied. A follow-up evaluation was performed.

Results

This study included 48 men and 32 women. The most common symptoms were cranial nerve palsy (50.0%, 40/80 patients) and limb weakness (41.2%, 33/80 patients). Among the 80 patients, 24 cases were clinically diagnosed, 56 cases were pathologically verified, and 45 cases were tested for H3K27 alteration status, with 34 H3K27 alteration cases confirmed. Radiological results indicated that enhancement was common (65.0%, 52/80 patients). Cho/Cr was of predictive value for H3K27 alteration status (P = 0.012, cutoff value = 2.38, AUC = 0.801). Open cranial surgery followed by further chemotherapy and radiotherapy was beneficial for patients' overall survival. Cox regression analysis indicated H3K27 alteration to be the independent prognostic influencing factor for DIPGs in this series (P = 0.002).

Conclusion

DIPGs displayed a wide spectrum of clinical and imaging features. Surgery-suitable patients could benefit from postoperative comprehensive therapy for a better overall survival. H3K27 alteration was the independent prognostic influencing factor for DIPGs.

Exploration of the prognostic value of the resection of adult brainstem high-grade glioma based on competing risk model, propensity score matching, and conditional survival rate

BACKGROUND

Adult brainstem high-grade glioma (HGG) is a refractory disease, and the treatment strategy of resection is still controversial.

OBJECTIVE

To investigate the prognostic value of brainstem HGG resection in adults.

METHODS

We collected 126,386 samples from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2016, and screened 973 patients diagnosed with adult brainstem HGG, who were in turn, grouped into 899 cases of non-resections and 74 cases of resections. Competing risk models were used to screen independent prognostic factors. Propensity score matching (PSM) was performed to reduce the influence of confounding factors. Conditional survival (CS) rate was considered to evaluate the changes in overall survival (OS) and disease-specific survival (DSS) of patients with HGG over time.

RESULTS

Based on the competing risk model and PSM, univariate analysis showed that age ≥ 45 years and male gender were poor prognostic factors for adult brainstem HGG. No previous history of glioma was a beneficial factor. Multivariate analysis revealed only the absence of a history of glioma to be a favorable prognostic factor. Considering the CS rate of the resection group, after the patient had survived for 3 years, the OS and DSS remained unchanged at 100% during the fourth and fifth years, whereas in the non-resection group, the OS and DSS of the patients were 82% and 74%, respectively.

CONCLUSION

Adult brainstem HGG resection has a poor prognosis in the early stage; however, patients have a potentially significant survival benefit after 3 years of survival.

Accuracy of central neuro-imaging review of DIPG compared with histopathology in the International DIPG Registry

BACKGROUND

Diffuse intrinsic pontine glioma (DIPG) remains a clinico-radiologic diagnosis without routine tissue acquisition. Reliable imaging distinction between DIPG and other pontine tumors with potentially more favorable prognoses and treatment considerations is essential.

METHODS

Cases submitted to the International DIPG registry (IDIPGR) with histopathologic and/or radiologic data were analyzed. Central imaging review was performed on diagnostic brain MRIs (if available) by two neuro-radiologists. Imaging features suggestive of alternative diagnoses included nonpontine origin, <50% pontine involvement, focally exophytic morphology, sharply defined margins, and/or marked diffusion restriction throughout.

RESULTS

Among 286 patients with pathology from biopsy and/or autopsy, 23 (8%) had histologic diagnoses inconsistent with DIPG, most commonly nondiffuse low-grade gliomas and embryonal tumors. Among 569 patients with centrally-reviewed diagnostic MRIs, 40 (7%) were classified as non-DIPG, alternative diagnosis suspected. The combined analysis included 151 patients with both histopathology and centrally-reviewed MRI. Of 77 patients with imaging classified as characteristic of DIPG, 76 (99%) had histopathologic diagnoses consistent with DIPG (infiltrating grade II-IV gliomas). Of 57 patients classified as likely DIPG with some unusual imaging features, 55 (96%) had histopathologic diagnoses consistent with DIPG. Of 17 patients with imaging features suggestive of an alternative diagnosis, eight (47%) had histopathologic diagnoses inconsistent with DIPG (remaining patients were excluded due to nonpontine tumor origin). Association between central neuro-imaging review impression and histopathology was significant (p < 0.001), and central neuro-imaging impression was prognostic of overall survival.

CONCLUSIONS

The accuracy and important role of central neuro-imaging review in confirming the diagnosis of DIPG is demonstrated.

Infra-tentorial brain tumor subtypes in children and adults-surgical outcome in an ethnic population with a single regional tertiary center

BACKGROUND

To analyze clinically and radiologically the surgical outcome like residual disease, progression of disease, recurrence, disabilities, event-free survival (EFS), and mortality of different infra-tentorial tumor subtypes in children and adults of a strictly non-migratory and ethnic population.

METHODS

The 410 histologically proved, out of 589, infra-tentorial brain tumor patients were analyzed clinically and by the imaging post-surgically in a single tertiary center for an ethnic region. In this analytico-observational study, retrospectively postoperative records of 589 infra-tentorial brain tumors from November 1998 to December 2018 (20 years) were retrieved, scrutinized, and compiled. The post-operative clinic-radiological records of 410 patients with proved histopathological examination results were included. Statistical law of variance was applied where-ever necessary.

RESULTS

The 63.2% of the all 410 operated infra-tentorial brain tumors were males while females predominated in meningiomas and pineoblastomas. About 31.7% infra-tentorial tumors were children (below 18 years). About 54.1% cases were histologically malignant. The residual tumors comprised 40.2% and symptoms of disease-progression occurred in 10.9%. The tumor recurrence occurred in 14.3% while 6.0% patients developed severe disability. The overall mortality was 11.4% but 18.9% in malignant tumors. The event-free survival (EFS) for all the patients was 66.0%, patients with malignancies had 47.7% and benign group had 87.7%.

CONCLUSION

The study, surgical outcome of infra-tentorial brain tumor subtypes in children and adults (approx. 1/3rd of patients being children), conducted in a tertiary center at a remote land-locked location with non-migratory ethnic population as its catchment area, has a significant epidemiological value for the community and the region.

Brainstem Pilocytic Astrocytoma, a Surgical Disease: 2-Dimensional Operative Video

Brainstem pilocytic astrocytomas are benign lesions that frequently develop in the medulla with an often exophytic component.1-3 These lesions develop in children and young adults and are revealed by lower cranial nerves dysfunction and long tracts involvement. Medulla pilocytic astrocytomas have a better overall prognosis than pontine and midbrain lesions, particularly after surgical resection, which can be curative, allowing the control of the disease and avoiding adjuvant treatments in young patients.2-5 The transcondylar approach with mobilization of the vertebral artery offers the necessary ventral exposure for the resection of such medulla oblongata lesions.6 After exposure, the initial step of resection starts with the cerebellopontine angle occupying exophytic portion after identification of cerebrovascular landmarks. Ultrasonic aspiration on a low setting allows to progressively debulk the tumor and identify the normal medulla tissue while closely following the electrophysiological neuromonitoring. Preservation of the small medulla perforators is the key for successful resection, including minimal use of bipolar coagulation in the vicinity of brainstem tissue. We demonstrate these principles through the case of a 33-year-old woman presenting with a large left medulla oblongata exophytic tumor, with an MRI presentation consistent with pilocytic astrocytoma. The patient consented to the procedure and publication of her images.

Cervicomedullary Gliomas in Pediatric Age: A Systematic Review of the Literature and Tertiary Care Center Experience

INTRODUCTION

Cervicomedullary gliomas (CMGs) are usually low-grade tumors often found in the pediatric age. Histological findings, treatments, and classification have been much the same for 40 years, although histological and molecular classifications have largely been developed for other pediatric CNS tumors. The management and treatment of pediatric CMG are still conducted by many authors according to their anatomical location and characteristics, independently from histology.

METHODS

We conducted a literature review in PubMed (Medline) to identify relevant contributions about pediatric CMG published until December 31, 2021. We also analyzed a series of 10 patients with CMG treated from 2006 to 2021 at IRCCS Istituto Nazionale dei Tumori. The aim of the present review was to see whether and how the diagnosis, treatment, and classification of CMGs in children have developed over time, especially in the context of molecular advancements, and to analyze our single-center experience in the last 15 years.

RESULTS

Thirty articles have been included in the review. Articles have been divided into two historical periods (1981-2000 and 2001-2021) and data from different series were analyzed to see how much the management and treatment of pediatric CMG have changed during years. Analysis of our series of 10 patients affected by CMG was also performed to compare it with the literature.

DISCUSSION

Management and classification of CMG in children have not dramatically changed during years. However, new insight from molecular diagnostics and target therapies and the development of radiological, neurophysiological, and radiotherapy techniques have updated treatment modalities in the last 20 years. Treatment modalities and their innovations have been reviewed and discussed. Further studies are needed to standardize and customize treatment protocols for these tumors.

Prognosis of Patients With Brainstem Glioblastoma Based on "age, surgery and radiotherapy": A SEER Database Analysis

Introduction: Primary brainstem glioma is a rare tumor with a dismal prognosis that poses significant treatment challenges. The purpose of the current study is to identify and determine prognostic factors associated with survival in high-grade brainstem glioma patients. Methods: We gathered the data from the SEER database for the duration of years from 1973 to 2016 to examine the survival of patients particularly reported with the high-grade brainstem glioma and subsequently ascertained the potential impact of demographic features, tumor, and clinical characteristics on the overall survival of these patients. The survival patterns were assessed using Kaplan-Meier curves and Cox proportional hazards models. Propensity score matching (PSM) analysis was performed between patients with or without radiation therapy based on age and surgical resection to investigate the effect of radiotherapy on overall survival (OS). Results: A total 232 patient's data were obtained from the SEER database and included in this study. The median overall survival was 8 months. Kaplan-Meier survival analysis delineated that the patients who were in younger age (P = .001) and underwent surgery (P = .001) exhibited typically a better prognosis. Among 232 patients, a total of 204 patients were categorized as radiotherapy group (RG) received radiation therapy whereas 28 patients were considered as nonradiotherapy group (NRG), who were not receiving radiotherapy. Radiotherapy was associated with an improvement in the overall survival without statistical significance (P = .104). PSM was performed between RG and NRG based on age and surgical resection. After the PSM, 56 patients were included. Overall Survival was significantly different between both groups (P = .038). Conclusion: Furthermore, the patients with high-grade brain glioma who received "both radiotherapy and chemotherapy" exhibited significantly longer survival compared to the patients who received chemotherapy alone. Multivariate analysis showed that treatment with surgery and radiotherapy were considered as the independent prognostic factors (P < .05).

Pseudoprogression is frequent following front-line radiotherapy in pediatric low-grade glioma - results from the German LGG cohort

PURPOSE

Expansion of MRI T2- and/or T1-tumor lesion volume after radiotherapy (RT) may indicate pseudoprogression (PsPD). The differentiation between true progression and PsPD is a clinical challenge and under-investigated in pediatric low-grade glioma (LGG). We evaluated radiological criteria for PsPD following front-line RT and investigated the frequency and duration of PsPD following three RT-modalities within the framework of the [Anonymized for Review] LGG-studies.

METHODS

Baseline and follow-up MRI-scans of 136 patients (72 [52.9%] male, median age at start of RT 11.3 years [range 0.8-25.9]) of the [Anonymized for Review] cohorts (¹²⁵iodine-interstitial RT [IS; n=51], photon-beam [XRT; n=60] or proton-beam RT [PBT; n=25]) were centrally evaluated for: Increasing 1) total tumor-associated T2-lesion, 2) focal tumor-associated T2-lesion and 3) contrast-enhancing tumor over a period of 24 months following RT. The pattern of these criteria initiated "suspicion" of PsPD, their evolution determined "definite" PsPD.

RESULTS

Definite PsPD was radiologically determined in 54/136 (39.7%) without differences in frequency between RT-modalities: IS 22/48 vs. XRT 24/54 vs. PBT 11/20; p=0.780. Definite PsPD occurred at median 6.3 months (IS 7.2 months; XRT 4.4 months; PBT 6.5 months) after RT-initiation and persisted for median 7.2 months (IS 8.5 months; XRT 7 months; PBT 7.4 months). Appearance of necrosis within the focal tumor-associated T2-lesion proved to be a relevant associated predictor of definite PsPD (p<0.001).

CONCLUSIONS

PsPD is frequent following irradiation of pediatric LGG and independent of the RT-modality (IS vs. XRT vs. PBT). Adequate identification of PsPD versus true progression is imperative to prevent unneeded salvage treatment.

The Survival Benefits of Surgical Resection and Adjuvant Therapy for Patients With Brainstem Glioma

Purpose

The role of surgical resection in the treatment of brainstem glioma (BSG) is poorly understood. For pediatric low-grade (LGBSG) group, several monocentric small-scale retrospective studies reported contradictory conclusions. And there was no clinical study focused on surgical resection for adult or pediatric high-grade (HG) patient groups. This study aims to illustrate whether surgical resection and adjuvant therapy provide survival benefits for patients with histologically confirmed BSG.

Patients and Methods

This retrospective cohort study included 529 patients with histologically confirmed BSG in Surveillance Epidemiology and End Results (SEER) database from 2006-2015. Patients were divided into four groups by age and World Health Organization (WHO) grade. Kaplan-Meier curves of CSS were plotted by different treatment options to compare the survival probability. Univariate and multivariable analyses were then conducted to determine the prognosis effects of surgical resection and adjuvant therapy on cancer specific survival (CSS). All analyses were done in four different groups separately.

Results

The final sample included 529 patients. The entire study population was divided into groups of pediatric LG (n=236, 44.6%), pediatric HG (n=37, 7.0%), adult LG (n=204, 38.6%) and adult HG (n=52, 9.8%). 52.7% (n=144) of pediatric patients had pilocytic astrocytoma and 45.3% (n=116) of adult patients had ependymoma. Pediatric LGBSG group had the highest gross total resection (GTR) rate (61.4%) and 5-year CSS rate (88.6%). Kaplan-Meier curves of pediatric LGBSG group revealed that patients treated with GTR had significantly better survival probability (P=0.033). Multivariable analysis identified GTR as independently significant predictor for prolonged CSS in pediatric LGBSG group (HR0.29, 95%CI 0.11-0.78, P=0.015); Surgical resection showed no relation to CSS in other patient groups. Kaplan-Meier curves of adult HGBSG group showed that patients treated with both RT and CT in adult HGBSG group had the best survival probability (P=0.02). However, multivariable analysis showed the combination of radiotherapy (RT) and chemotherapy (CT) was not significantly related to better CSS in adult HGBSG group (HR0.35, 95%CI 0.11-1.09, P=0.070). Adjuvant therapy didn’t associate with better CSS in other patient groups.

Conclusion

Pediatric LGBSG group had the highest GTR rate and the most favorable clinical outcome. GTR can provide significant survival benefits for pediatric LGBSG group.

MR imaging features of diffuse intrinsic pontine glioma and relationship to overall survival: report from the International DIPG Registry

BACKGROUND

This study describes imaging features of diffuse intrinsic pontine glioma (DIPG) and correlates with overall survival (OS) and histone mutation status in the International DIPG Registry (IDIPGR).

METHODS

Four hundred cases submitted to the IDIPGR with a local diagnosis of DIPG and baseline MRI were evaluated by consensus review of 2 neuroradiologists; 43 cases were excluded (inadequate imaging or alternative diagnoses). Agreement between reviewers, association with histone status, and univariable and multivariable analyses relative to OS were assessed.

RESULTS

On univariable analysis imaging features significantly associated with worse OS included: extrapontine extension, larger size, enhancement, necrosis, diffusion restriction, and distant disease. On central review, 9.5% of patients were considered not to have DIPG. There was moderate mean agreement of MRI features between reviewers. On multivariable analysis, chemotherapy, age, and distant disease were predictors of OS. There was no difference in OS between wild-type and H3 mutated cases. The only imaging feature associated with histone status was the presence of ill-defined signal infiltrating pontine fibers.

CONCLUSIONS

Baseline imaging features are assessed in the IDIPGR. There was a 9.5% discordance in DIPG diagnosis between local and central review, demonstrating need for central imaging confirmation for prospective trials. Although several imaging features were significantly associated with OS (univariable), only age and distant disease were significant on multivariable analyses. There was limited association of imaging features with histone mutation status, although numbers are small and evaluation exploratory.

The Surgical Resection of Brainstem Glioma: Outcomes and Prognostic Factors

BACKGROUND

The management of brainstem glioma remains controversial, with increasing evidence supporting surgical resection as the primary treatment for a select subgroup of tumors. However, there remains no consensus on the specific benefits and risks, the selection of surgical candidates, and prognostic factors that may further refine surgical indications.

METHODS

A retrospective single-surgeon chart review was performed for all patients who underwent surgical treatment for radiographically suspected brainstem glioma between 2000 and 2017. Preoperative and postoperative radiographic evaluations on magnetic resonance imaging were conducted. Survival outcomes were collected, and machine-learning techniques were used for multivariate analysis.

RESULTS

Seventy-seven patients with surgical treatment of brainstem glioma were identified, with a median age of 9 years (range, 0-58 years). The cohort included 64% low-grade (I and II) and 36% high-grade (III and IV) tumors. For all patients, the 1-year and 5-year overall survival were 76.4% and 62.3%, respectively. Transient neurologic deficit was present in 34% of cases, and permanent deficit in a further 29%.

CONCLUSIONS

The radical surgical resection of brainstem gliomas can be performed with acceptable risk in well-selected cases and likely confers survival advantage for what is otherwise a rapidly and universally fatal disease. Various radiographic features are useful during patient selection and may guide treatment selection.

Surgical treatment and prognosis of focal brainstem gliomas in children: A 7 year single center experience

This study aims to describe the role of open surgical treatment for focal brainstem gliomas (FBSGs) with the assistance of multimodal neuronavigation and intraoperative neurophysiological monitoring (IOM) in children to investigate the efficacy of microsurgical treatment in pediatric FBSGs. Also the prognostic factors related to the overall survival (OS) of FBSGs to describe the patient and tumor characteristics relevant to prognosis/outcome were focused on. Clinical data of 63 pediatric patients below 16 years of age with FBSGs admitted to the Neurosurgical Unit of Beijing Tiantan Hospital from January 2012 to December 2018 were retrospectively analyzed. All patients underwent initial surgical treatment, followed by magnetic resonance diffusion tensor imaging (DTI), neuronavigation and IOM. Gross or near total resection (GTR or NTR) was achieved in 57/63 (90.5%) cases, and subtotal resection (STR) was achieved in 6/63 (9.5%) cases. Postoperative adjuvant therapy was received by 27/63 (42.9%) cases. Postoperative pathological examination revealed that 36/63 (57.1%) cases had grade I gliomas, 22/63 (34.9%) had grade II, and 5/63 (8.0%) had grade III-IV gliomas according to the WHO classification. The mean Karnofsky score preoperatively was 60, and at the time of follow-up was 90. Consecutively, 6 cases demonstrated disease progression, and 5 of these were deceased. The OS in all patients was 81.2% at 5 years. Histological grade (P < .001) and age at diagnosis (P = .023) showed significant association with prolonged OS. Multimodal neuronavigation and IOM allow very precise intracranial surgery, contributing to a maximally safe resection that might decrease the postoperative disability and mortality rate. This study also showed that pediatric FBSGs were mostly low-grade tumors with excellent surgical outcomes. Consequently, it is suggested that microsurgery can be used to treat FBSGs in children in order to provide better prognosis and survival outcomes.

The Epidemiological Characteristics and Prognostic Factors of Low-Grade Brainstem Glioma: A Real-World Study of Pediatric and Adult Patients

Purpose: Our current understanding of low-grade brainstem glioma (LGBSG) is still limited. This study aimed to conduct a large-scale population-based real-world study to understand the epidemiological characteristics of LGBSG and determine the predictive factors of cancer-specific survival (CSS) and overall survival (OS) of LGBSG patients.

Patients and Methods: We used Surveillance Epidemiology and End Results database to conduct this study of patients with histologically confirmed LGBSG. Patient demographics, tumor characteristics, and treatment options were compared between pediatric and adult patients. Univariate and multivariate analyses were employed to determine prognostic factors of CSS and OS. Kaplan–Meier curve and decision tree were used to confirm the prognostic factors. All variables were further identified by L1-penalized (Lasso) regression and then a nomogram was established to predict the 5- and 8-year CSS and OS rate. The precision of the nomogram was evaluated by calibration plots, Harrell's concordance index, and time-dependent receiver operating characteristic curve. The clinical use of nomogram was estimated by decision curve analysis.

Results: A cohort of 305 patients with LGBSG, including 165 pediatric and 140 adult patients, was analyzed. Adult and pediatric patients showed different patterns concerning tumor size, tumor extension, adjuvant therapy, and survival rate. Univariate analysis revealed that pediatric group, gross total resection (GTR), World Health Organization grade II, radiotherapy, extension to ventricular system, and diffuse astrocytic and oligodendroglial tumor (DAOT) were significantly associated with CSS. Multivariate analysis showed that pediatric group, metastasis, ventricular system involvement, and DAOT were independently associated with CSS. The prognostic factors were further confirmed by Kaplan–Meier curve and decision tree. Kaplan–Meier curve also showed that adjuvant therapy added no benefits in patients with GTR and non-GTR. In addition, the nomogram was developed and the C-index of internal validation for CSS was 0.87 (95% CI, 0.78–0.96).

Conclusion: This study shows that pediatric and adult patients have different tumor characteristics, treatment options, and survival rate. Pediatric group, DAOT, ventricular system involvement, and metastasis were identified as independent prognostic factors for CSS by multivariate analysis. Adjuvant therapy showed no benefits on CSS in patients with GTR and non-GTR. The nomogram was discriminative and clinically useful.

Association between extent of resection on survival in adult brainstem high-grade glioma patients

BACKGROUND

Brainstem high-grade gliomas (HGG) are rare lesions with aggressive behavior that pose significant treatment challenges. The operative use of brainstem safe entry zones has made such lesions surgically accessible, though the benefits of aggressive resection have been unclear. This study aimed to clarify the survival in adult patients.

METHODS

We utilized the SEER database (1973-2015) to analyze the association between survival and demographic data, tumor characteristics, and treatment factors in adult patients with brainstem HGGs. Patients without surgical intervention were excluded. Overall survival (OS) was analyzed using univariable and multivariable Cox regression.

RESULTS

Our dataset included a total of 502 brainstem HGG patients of which only those who had undergone surgical intervention were included in the analysis, totaling 103. Mean age was 42.4 ± 14.1 years with 57.2% (n = 59) male. Median OS of the entire cohort was 11.0 months. Median OS for patients receiving biopsy, subtotal resection, and gross total resection were 8, 11, and 16 months, respectively. Age, extent of resection, and radiation therapy were selected into the multivariable model. A significant decrease in survival was seen in older patients, 50-60 years (HR = 2.77, p = 0.002) and ≥ 60 years (HR = 5.30, p < 0.001), compared to younger patients (18-30 years). Partial resection (HR = 0.32, p = 0.006) and GTR (HR = 0.24, p < 0.001) sustained survival benefits compared to patients with biopsy only. Patients receiving postoperative radiation demonstrated no survival benefit (HR = 1.57, p = 0.161) in multivariable regression.

CONCLUSIONS

While survival of brainstem HGG patients remains poor, for surgically accessible HGGs, STR and GTR were associated with a three and fourfold increase in overall survival when compared to biopsy only.

The incidence of brainstem primitive neuroectodermal tumors of childhood based on SEER data

PURPOSE

Incidence of BS primitive neuroectodermal tumors (BS-PNET) in children is not reported to date. Our main objectives were to estimate the incidence and report the outcome of BS-PNET in children.

METHODS

Data were collected using the Surveillance Epidemiology and End Results cancer registry.

RESULTS

From 1973 to 2013, we identified 83 pediatric patients (aged 0-21 years). Patients were divided into two age groups (0-3 years and 4-21 years). Median overall survival was 53 months. Patients in the older age group had a significant survival advantage (P < 0.001), as did those who received three modalities of therapy (surgery, chemotherapy, and radiation therapy) (P < 0.001) and patients with gross or subtotal tumor resection (P < 0.001).

CONCLUSIONS

This study presents the first estimate of incidence and the largest cohort of pediatric BS-PNETs to date. A high index of suspicion of BS-PNET in similar cases is crucial for diagnosis, treatment, and outcome.

Evaluating extent of resection in pediatric glioblastoma: a multiple propensity score-adjusted population-based analysis

PURPOSE

The benefit of radical resections for glioblastoma patients remains a source of contention in the literature. Few studies have been conducted in pediatric patients, and it is becoming increasingly evident that data regarding adult glioblastoma (GB) patients cannot be generalized to pediatric patients affected by this neoplasm. A comparative effectiveness study is performed for different extent of resection (EOR) groups in the largest cohort of pediatric GB (pGB) patients.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) cancer registry was used to identify pGB patients from 1988 through 2009. Multivariate- and multiple propensity score (mPS)-adjusted analyses were used to determine the effect of gross total resection (GTR), partial resection (PR), and biopsy (Bx) on overall survival. Survival prospects were summarized using direct adjusted survival curves.

RESULTS

A total of 342 pGB patients were identified, and 35.4 % of patients received a GTR, 28.8 % PR, 17.3 % Bx, and 17.0 % did not undergo surgery. In our cohort, a median overall survival of 12 months was observed with 1-, 2-, and 5-year survival rates of 51.7, 28.3, and 15.7 %, respectively. EOR was a predictor of survival in both the multivariate- (P < 0.001) and mPS-adjusted model (P < 0.001). Compared to the GTR group, a higher mortality rate was observed in patients who underwent a PR (HR 1.50; 95 % CI, 1.02-2.21) or Bx (HR 1.87; 95 % CI, 1.18-2.98). There were no significant differences in (adjusted) mortality risk between the PR and Bx groups.

CONCLUSION

Our study suggests that GTR is independently associated with improved survival for pediatric patients with glioblastoma.

Brainstem oligodendroglial tumors in children: two case reports and review of literatures

PURPOSE

There is little information on pediatric oligodendroglial tumor located in the brainstem because of its rarity.

METHODS

Here, we present two pediatric cases of pontine oligodendroglial tumors with radiological findings atypical for diffuse intrinsic pontine glioma.

RESULTS

The first patient was an 8-year-old boy. Brain magnetic resonance imaging (MRI) demonstrated diffuse high-intensity changes in the pons, left middle cerebellar peduncle, and part of the left cerebellar hemisphere on T2-weighted and fluid-attenuated inversion recovery images, with an enhanced spot lesion in the left cerebellar hemisphere. The pathological diagnosis was anaplastic oligodendroglioma, and we identified a mutation in histone H3.3 in the tumor specimen. He succumbed to massive disseminated relapse 7 months from diagnosis despite local radiation therapy. The second patient, a 2-year-old girl, was diagnosed with oligoastrocytoma. Brain MRI revealed a large mass in her rostral pons extended to the fourth ventricle with obstructive hydrocephalus. The tumor recurred with intracranial dissemination 56 months post-surgery.

CONCLUSIONS

Pediatric brainstem oligodendroglial tumors can include histone H3.3-mutated tumors and have a tendency to disseminate throughout the neuroaxis at the time of relapse.

Gamma Knife radiosurgery for low-grade tectal gliomas

BACKGROUND

Tectal gliomas are present in a critical location that makes their surgical treatment difficult. Stereotactic radiosurgery presents an attractive noninvasive treatment option. However, tectal gliomas are also commonly associated with aqueductal obstruction and consequently hydrocephalus. This necessitates some form of CSF diversion procedure before radiosurgery. The aim of the study was to assess the efficacy and safety of Gamma Knife radiosurgery for tectal gliomas.

PATIENTS AND METHODS

Between October 2002 and May 2011, 11 patients with tectal gliomas were treated with Gamma Knife radiosurgery. Five patients had pilocytic astrocytomas and six nonpilocytic astrocytomas. Ten patients presented with hydrocephalus and underwent a CSF diversion procedure [7 V-P shunt and 3 endoscopic third ventriculostomy (ETV)]. The tumor volume ranged between 1.2-14.7 cc (median 4.5 cc). The prescription dose was 11-14 Gy (median 12 Gy).

RESULTS

Patients were followed for a median of 40 months (13-114 months). Tumor control after radiosurgery was seen in all cases. In 6/11 cases, the tumors eventually disappeared after treatment. Peritumoral edema developed in 5/11 cases at an onset of 3-6 months after treatment. Transient tumor swelling was observed in four cases. Four patients developed cysts after treatment. One of these cases required aspiration and eventually disappeared, one became smaller spontaneously, and two remained stable.

CONCLUSION

Gamma Knife radiosurgery is an effective and safe technique for treatment of tectal gliomas. Tumor shrinkage or disappearance after Gamma Knife radiosurgery may preclude the need for a shunt later on.

Brainstem gliomas

Historically, brainstem gliomas have been considered as a single entity. Since the introduction of magnetic resonance (MR) imaging in the late 1980s, these tumors are now regarded as a heterogeneous group of neoplasms with different age of onset, clinical and radiologic presentation, and varying behavior and natural history. This article describes the different subtypes of brainstem gliomas in children and adults. We focus on recent advances in MR such as MR spectroscopy, MR perfusion, and diffusion tensor imaging that often strongly suggest the histopathologic diagnosis of the lesion.

Connexin43 confers Temozolomide resistance in human glioma cells by modulating the mitochondrial apoptosis pathway

Glioblastoma multiforme (GBM) is the most aggressive astrocytoma, and therapeutic options are generally limited to surgical resection, radiotherapy, and Temozolomide (TMZ) chemotherapy. TMZ is a DNA alkylating agent that causes DNA damage and induces cell death. Unfortunately, glioma cells often develop resistance to TMZ treatment, with DNA de-methylation of the MGMT promoter identified as the primary reason. However, the contributions from proteins that normally protect cells against cytotoxic stress in TMZ-induced apoptosis have not been extensively explored. Here, we showed that increasing the level of the gap junction protein, Cx43, in human LN18 and LN229 glioma cells enhances resistance to TMZ treatment while knockdown of Cx43 in these same cells sensitizes them to TMZ treatment. By expressing a channel-dead or a C-terminal truncation mutant of Cx43, we show that Cx43-mediated TMZ resistance involves both channel dependent and independent functions. Expression of Cx43 in LN229 cells decreases TMZ-induced apoptosis, as determined by Annexin V staining. Cx43-mediated chemoresistance appears to be acting via a mitochondrial apoptosis pathway as manifested by the reduction in Bax/Bcl-2 ratio and the release of cytochrome C. Our findings highlight additional mechanisms and proteins that contribute to TMZ resistance, and raise the possibility of increasing TMZ efficiency by targeting Cx43 protein. This article is part of the Special Issue Section entitled 'Current Pharmacology of Gap Junction Channels and Hemichannels'.

Management and outcome of focal low-grade brainstem tumors in pediatric patients: the St. Jude experience

OBJECT

Whereas diffuse intrinsic pontine gliomas generally have a short symptom duration and more cranial nerve involvement, focal brainstem gliomas are commonly low grade, with fewer cranial neuropathies. Although these phenotypic distinctions are not absolute predictors of outcome, they do demonstrate correlation in most cases. Because there is a limited literature on focal brainstem gliomas in pediatric patients, the objective of this paper was to report the management and outcome of these tumors.

METHODS

The authors reviewed the records of all children diagnosed with radiographically confirmed low-grade focal brainstem gliomas from 1986 to 2010. Each patient underwent biopsy or resection for tissue diagnosis. Event-free survival (EFS) and overall survival were evaluated. Univariate analysis was conducted to identify demographic and treatment variables that may affect EFS.

RESULTS

Fifty-two patients (20 girls, 32 boys) with follow-up data were identified. Median follow-up was 10.0 years, and the median age at diagnosis was 6.5 years (range 1-17 years). The tumor locations were midbrain (n = 22, 42%), pons (n = 15, 29%), and medulla (n = 15, 29%). Surgical extirpation was the primary treatment in 25 patients (48%). The 5- and 10-year EFS and overall survival were 59%/98% and 52%/90%, respectively. An event or treatment failure occurred in 24 patients (46%), including 5 deaths. Median time to treatment failure was 3.4 years. Disease progression in the other 19 patients transpired within 25.1 months of diagnosis. Thirteen of these patients received radiation, including 11 within 2 months of primary treatment failure. Although children with intrinsic tumors had slightly better EFS at 5 years compared with those with exophytic tumors (p = 0.054), this difference was not significant at 10 years (p = 0.147). No other variables were predictive of EFS.

CONCLUSIONS

Surgery suffices in many children with low-grade focal brainstem gliomas. Radiation treatment is often reserved for disease progression but offers comparable disease control following biopsy. In the authors' experience, combining an assessment of clinical course, imaging, and tumor biopsy yields a reasonable model for managing children with focal brainstem tumors.

Can multiparametric MRI and FDG-PET predict outcome in diffuse brainstem glioma? A report from a prospective phase-II study

PURPOSE

To study the impact of multiparametric MRI and (18)F-FDG-PET on the outcome of children with diffuse intrinsic pontine gliomas (DIPG).

MATERIALS AND METHODS

Imaging data from a phase-II prospective therapeutic study in children with newly diagnosed DIPG were considered for evaluation. They included baseline MRI with contrast enhancement before treatment. Functional imaging included MR spectroscopy, MR perfusion and FDG-PET studies. All patients (n = 20) had baseline MRI and 11 patients had FDG-PET. Response was assessed by MRI and PET 4 weeks after therapy. Baseline imaging findings were correlated with survival. Presence or absence of adverse parameters on MRI (heterogeneous contrast enhancement, hyperperfusion or increased choline:NAA ratio) was used to develop a cumulative radiological prognostic index (RPI). Sensitivity and specificity of each imaging modality in tumour grading was estimated.

RESULTS

The cumulative RPI was able to classify the patients into different grades and was predictive of overall survival (p = 0.02). MR perfusion also predicted survival (p = 0.039). Sensitivity and specificity of MRI and FDG-PET to detect low-grade gliomas were low to moderate (33-66%), but moderate to high in detecting high-grade gliomas (50-100%). Baseline FDG uptake on PET scan did not correlate with survival (p = 0.7).

CONCLUSIONS

Cumulative RPI was able to classify tumours into different grades and predicted clinical outcome. At baseline, MR hyperperfusion indicated a shorter survival for DIPG patients. Sensitivity and specificity of imaging modalities to detect low-grade gliomas were poor.

Stereotactic iodine-125 brachytherapy for treatment of inoperable focal brainstem gliomas of WHO grades I and II: feasibility and long-term outcome

Microsurgical resection is the most frequently suggested treatment option for accessible focal brainstem gliomas (F-BSG) of World Health Organization (WHO) grades I and II. Because of their location in the highly eloquent brain, however, resection is associated with permanent postoperative morbidity, ranging from 12 to 33 %. Only a few reports have suggested stereotactic brachytherapy (SBT) with implantation of iodine-125 seeds as a local treatment alternative. Between 1993 and 2010, 47 patients were treated with SBT (iodine-125 seeds; cumulative surface dose 50-65 Gy) for inoperable F-BSG, WHO grades I and II, in one of the largest reported patient series. We evaluated procedure-related complications, clinical outcome, and progression-free and overall survival (PFS, OS). Median follow-up was 81.6 months. Procedure-related mortality was zero. Within 30 days of seed implantation six patients (12.8 %) had transient neurological deficits. Two patients (4.3 %) deteriorated permanently. Space-occupying cysts occurred in six patients (12.8 %) after a median of 28.5 months, and required surgical intervention. Nine patients (19.1 %) presented with tumor relapse after a median of 56.6 months (range 7.9-118.0 months). For the remaining 38 patients complete response was observed for 23.4 %, partial response for 29.8 %, and stable disease for 27.7 %. Actuarial PFS was 97.7 ± 2.2, 92.8 ± 4.0, 81.2 ± 6.5, and 62.0 ± 10.4 % after 1, 2, 5, and 10 years, respectively. Corresponding OS was 100 ± 0.0 % (1 and 2 years), 97.4 ± 2.6 % (5 years), and 87.6 ± 7.0 % (10 years). SBT is a comparatively safe, minimally invasive, and highly effective local treatment option for patients with inoperable F-BSG WHO grades I and II; it merits further evaluation in prospective randomized trials.

Radical resection of focal brainstem gliomas: is it worth doing?

OBJECTIVES

Despite revolutionary technical advancement in neuroimaging and operative neurosurgery, surgical extirpation of focal brainstem glioma (BSG) remains steeped in controversy. In this study, we evaluated our senior author's (CT) surgical experience in radically treating these tumours in children to determine the safety and efficacy of such approach.

MATERIALS AND METHODS

Thirty-four consecutive patients aged between 3 and 16 years who underwent endoscope-assisted microsurgery for focal BSG with the intent of radial resection from 1999 to 2005 were evaluated. The clinical outcome at 6 months and long-term survival were analysed.

CONCLUSION

Thirty-one patients had >90% tumour resection and the remainder had >50%. There was no perioperative mortality. The average follow-up was 46 months. Twenty-three patients (74%) harboured low-grade gliomas, whilst the remainder (26%) had high-grade gliomas. Kaplan-Meier survival analysis revealed marked difference in the 5-year survival rates between the two groups (100% vs 33%). Multivariate analysis demonstrated that the degree of tumour resection was not associated with poor outcome at 6 months. This series underscores the benefits of surgical resection for focal BSG. Radical resection can be achieved in a majority of patients with favourable outcome regardless of tumour pathology.

Pediatric brain stem lesions: introduction of a scoring system for clinical evaluation and their treatment analysis

INTRODUCTION

Brainstem lesions in pediatric age group include mainly gliomas. As these are not usually amenable to complete surgical resection, multimodality treatments are used. To assess treatment responses, Karnofsky's Performance Score (KPS) has been the gold standard; however, in pediatric patients, comprehensive neurological examination is more valuable.

OBJECTIVE

Our purpose was to formulate neurological examination based scoring system and compare its effectiveness with KPS.

MATERIALS AND METHODS

A retrospective analysis of 37 pediatric patients with brainstem lesions was performed. All these patients were assessed both pre- and post-treatment and in every follow up using standard KPS and our proposed scoring system, Kumar's and Samir's Score (K&SS). K&SS was devised choosing the common clinical features and those affecting outcome the most. Twenty-two features were hence selected, and points were allotted to each according to their functional importance, with range from 22 to 100.

RESULTS AND DISCUSSION

Twenty-seven had gliomas, and in nonglioma group, seven had brainstem tuberculosis (BSTB). Nineteen patients with BSG were less than 6 years of age. Most gliomas were pilocytic astrocytomas (n = 21). Outcome analysis of patients in both groups using KPS showed deterioration or no change in the scores in majority whereas using K&SS, most patients showed improvement.

CONCLUSION

Gliomas form majority of pediatric brainstem lesions, with high occurrence of BSTB in nongliomatous group. Our proposed scoring system, based on comprehensive neurological examination, is more sensitive than KPS in treatment analysis of brainstem lesions.

Diffusion tensor imaging and white matter tractography in patients with brainstem lesions

BACKGROUND

Diffusion tensor imaging (DTI) and white matter tractography (WMT) are promising techniques for estimating the course, extent, and connectivity patterns of the white matter (WM) structures in the human brain. In this study, we investigated the ability of DTI and WMT to visualize white matter tract involvement for the preoperative surgical planning and postoperative assessment of brainstem lesions.

METHODS

Preoperative and postoperative DTI data (echo-planar, 1.5T) were retrospectively analyzed in 10 patients with brainstem lesions (3 diffuse, 7 focal). WMT applying a tensor deflection algorithm was used to reconstruct WM tracts adjacent to the lesions. Reconstructed tracts included corticospinal tracts and medial lemnisci. The clinical and imaging follow-up data were also compared and analyzed.

FINDINGS

WMT revealed a series of tract alteration patterns including deviation, deformation, infiltration, and apparent tract interruption. WMT reconstructions showed that the major WM tracts were preserved during surgery and improved in position and appearance postoperatively. These findings correlated with the improvement or preservation of neurological function as determined by clinical assessment.

CONCLUSIONS

Compared with the information provided by conventional MR imaging, DTI and WMT provided superior quantification and visualization of lesion involvement in eloquent fibre tracts of the brainstem. Moreover, DTI and WMT were found to be beneficial for white matter recognition in the neurosurgical planning and postoperative assessment of brainstem lesions.

Gamma Knife surgery for focal brainstem gliomas

Object

Focal tumors, a distinct subgroup of which is composed of brainstem gliomas, may have an indolent clinical course. In the past, their management involved monitoring of open-ended imaging studies and shunt placement if cerebrospinal fluid diversion was required. Nonetheless, their treatment remains a significant challenge for neurosurgeons. Gamma Knife surgery (GKS) has recently been tried as an alternative to surgical extirpation. In the present study the authors assess clinical and imaging results in 20 patients who harbored focal brainstem gliomas treated with GKS between 1990 and 2001.

Methods

There were 10 male and 10 female patients with a mean age of 19.1 years. Sixteen tumors were located in the midbrain, three in the pons, and one in the medulla oblongata. The mean tumor volume at the time of GKS was 2.5 cm3. In 10 cases a tumor specimen was obtained either by open surgery or stereotactic biopsy, securing the diagnosis of pilocytic astrocytoma in five patients and nonpilocytic astrocytoma in five others. In the remaining 10 cases, the diagnosis was based on clinical and neuroimaging findings. The prescription Gamma Knife dose varied between 10 and 18 Gy, except in three patients who were receiving a boost to a site in which external-beam radiation was previously delivered. An average of four isocenters were utilized per GKS.

Patients were followed up for a mean of 78.0 months. The tumors disappeared in four patients and shrank in 12 patients. Of these patients, one experienced transitory extrapyramidal symptoms and fluctuating impairment of consciousness (from somnolence to coma) for 6 months. Another patient whose tumor disappeared 3 years following GKS died of stroke 8 years postoperatively. The rest of the patients either remained stable or improved clinically. Tumor progression occurred in four patients; of these four, one patient developed hydrocephalus requiring a ventriculoperitoneal shunt, two showed neurological deterioration, and one 4-year-old boy died of tumor progression.

Conclusions

Gamma Knife surgery may be an effective primary treatment or adjunct to open surgery for focal brainstem gliomas.

Neuropathological spectrum of pilocytic astrocytoma: an Indian series of 120 cases

Pilocytic astrocytomas (PAs) are generally well circumscribed, slowly growing, cystic tumors, occurring in the pediatric age group. Our aims were to retrospectively analyze the neuropathological spectrum of PA, and correlate it with various clinicopathological features. A total of 120 PAs, diagnosed and managed at this center during a 5-year period, were included. The study population had a mean age of 18.9 years, with male predominance (68.3%), and demonstrated predilection for posterior fossa (61.7%). On histopathology, biphasic pattern (89.2%) along with Rosenthal fibers (66.7%) and eosinophilic granular bodies (60%) were present in the majority of cases. Vascular features were characterized by perivascular hyalinization (51.7%), angiomatous proliferation (21.7%) and glomeruloid changes (21.7%). Hemosiderin-laden macrophages were noted in 37.1% of cases. Further, 60.8% showed lymphoplasmacytic infiltration, while atypia and necrosis were present in 25.8% and 1.7% of cases, respectively. Statistical evaluation revealed significant correlation of angiomatous proliferation with age (< or =12 and >12-year age groups) (p=0.011); and of hemosiderin deposition with angiomatous proliferation (p=0.006), perivascular hyalinization (p=0.035), and age (< or =12 and >12-year age groups) (p=0.028). This study emphasizes that though PAs generally display classical histomorphology, diagnosis may be challenging in patients with unusual clinicopathological features, e.g. in older patients, uncommon location, absence of biphasic pattern, or presence of nuclear atypia, mitotic figures and necrosis, and also in cases of small biopsies. In the absence of diagnostic histology enumerated above, vascular features like angiomatous proliferation, glomeruloid changes and perivascular hyalinization, along with hemosiderinladen macrophages and perivascular lymphocytic infiltration should be considered as surrogate histological markers of PA.

Paediatric brain-stem gliomas: MRI, FDG-PET and histological grading correlation

BACKGROUND

MRI and FDG-PET may predict the histological grading of paediatric brain-stem gliomas.

OBJECTIVE

To assess MRI findings and metabolic imaging using FDG-PET of brain-stem gliomas based on histological grading.

MATERIALS AND METHODS

Included in the study were 20 paediatric patients (age 3-14 years, mean 8.2 years) with brain-stem glioma (five glioblastomas, ten anaplastic astrocytomas and five low-grade astrocytomas). MR images were assessed for the anatomical site of tumour origin, focality, pattern of tumour growth, and enhancement.

RESULTS

All glioblastomas were located in the pons and showed diffuse pontine enlargement with focally exophytic features. Eight anaplastic astrocytomas were located in the pons and demonstrated diffuse pontine enlargement without exophytic features. Low-grade astrocytomas were located in the pons, midbrain or medulla and showed focally exophytic growth features and peripheral enhancement. In 12 patients in whom FDG-PET was undertaken, glioblastomas showed hypermetabolic or hypometabolic lesions, anaplastic astrocytomas showed no metabolic change or hypometabolic lesions and low-grade astrocytomas showed hypometabolism compared with the cerebellum.

CONCLUSION

MRI findings correlated well with histological grading of brain-stem gliomas and MRI may therefore predict the histological grading. FDG-PET may be helpful in differentiating between anaplastic astrocytoma and glioblastomas among high-grade tumours.

Paediatric brainstem gliomas: Prognostic factors and management

BACKGROUND

Although most types of tumours involving the brainstem can be surgically removed, patients with diffuse pontine brainstem glioma do not benefit from surgical intervention. The aim of the present study is to establish whether clinical symptoms, their duration prior to diagnosis, the presence of enhancement on MRI scans and the histology of the lesion in paediatric brainstem glioma can guide the surgeon in choosing appropriate management options.

METHODS

We retrospectively reviewed the charts and MRI scans of paediatric patients admitted to Turin's Ospedale Regina Margherita with a diagnosis of brainstem glioma.

RESULTS

Patients with a diffuse pontine tumour on MRI scan (group 1) had a mean duration of symptoms prior to diagnosis of 2.61 months, 77% had symptoms involving at least one cranial nerve at diagnosis, and no MRI scans showed enhancement with gadolinium. No patients underwent radical surgery and 84.6% died. For all other patients (group 2), the mean duration of symptoms at diagnosis was 10.58 months, cranial nerve involvement was present in only 28.5%, and the MRI scans showed enhancement in 78.6%. Radical surgery was the treatment of choice (100%). In this study, survival of patients with diffuse pontine brainstem glioma was 25% at 2 years and survival of patients with any other brainstem glioma was 90% at 2 years.

Treatment options in childhood pontine gliomas

BACKGROUND

Pontine gliomas are the subgroup of brainstem gliomas with the worst prognosis. Controversial treatment approaches are discussed.

PATIENTS AND METHODS

Data of children with pontine gliomas treated in different prospective multi-center studies who were registered in the HIT-GBM database were pooled and analyzed addressing prognostic factors and the relevance of intensive treatment using contingency tables, Kaplan-Meier curves and Cox regression analyses.

RESULTS

From 1983 to 2001, 153 patients (74 males, 79 females, mean age: 8.1 years) with pontine gliomas were registered. Twenty-one tumors were low-grade and 60 were high-grade gliomas (72 undefined histology: 67 no surgery, 5 incomplete data). Sixteen tumors were partially resected, and 125 were irradiated. Ninety children received chemotherapy according to the "HIT-GBM" protocols ("Hirntumor-Glioblastoma multiforme"). The one-year overall survival rate (1YOS) of all patients with pontine glioma was 39.9+/-4.3%. None of the surviving patients had an observation time longer than 3.9 years. Favorable prognostic factors seemed to be age younger than 4 years, low-grade histology and smaller tumor. All three major treatment modalities including resection, irradiation and chemotherapy had prognostic relevance in univariable analysis. Chemotherapy remained beneficial, even if the analysis was restricted to the subgroup of irradiated tumors (1YOS 45.8+/-5.4% vs. 34.4+/-13.5%, P=0.030).

CONCLUSION

Irradiation is an effective element for the treatment of pontine gliomas. Intensive chemotherapy seems to be important in achieving a better OS.