Diagnosis and treatment of childhood brain tumors: current perspectives

Vision-related quality-of-life in pediatric primary brain tumor patients

PURPOSE

Brain tumors are the leading cause of death from childhood cancer. Although overall survival has improved due to earlier detection, better therapies, and improved surveillance, visual dysfunction and impaired vision-related quality-of-life (VR-QOL) are often unrecognized in children. This project investigated VR-QOL in pediatric brain tumor patients.

METHODS

We evaluated visual impairment and quality-of-life (QOL) in a quality improvement project at one tertiary care center. Patients ≤ 18, greater than 6 months from diagnosis of brain tumor, excluding intrinsic anterior visual pathway tumors, underwent standardized neuro-ophthalmologic examination. Health-related QOL (HR-QOL) (PedsQL Brain Tumor Module) and VR-QOL questionnaires [CVFQ (Children's Visual Function Questionnaire) in children < 8, and EYE-Q in children 8-18] were obtained from patients and parents.

RESULTS

Among 77 patients, craniopharyngiomas (n = 16, 21%) and astrocytomas (n = 15, 20%) were the most common tumors. Among 44/77 (57%) visually impaired children, 7 (16%) were legally blind. Eye-Q median score was 3.40 (interquartile range 3.00-3.75), worse than average scores for normal children. Eye-Q score decreased 0.12 with every 0.1 increase in logMAR visual acuity (p < 0.001). Patients who were legally blind had a significantly lower Eye-Q score than those who were not [0.70 vs. 3.44 (p < 0.001)]. Cognitive HR-QOL scores decreased 1.3 for every 0.1 increase in logMAR visual acuity (p = 0.02).

CONCLUSIONS

Pediatric brain tumor patients' vision, HR-QOL, and VR-QOL were often severely affected even when tumors were considered cured. Visual acuity and legal blindness correlated with VR-QOL. Systematic neuro-ophthalmologic examinations in pediatric primary brain tumor patients are necessary to facilitate early preventative and corrective ophthalmologic interventions.

Visual function in children with primary brain tumors

PURPOSE OF REVIEW

To review the recent advances in understanding how primary brain tumors affect vision in children.

RECENT FINDINGS

Children with primary brain tumors may have vision loss due to involvement of their afferent visual pathways or from papilledema. These vision deficits may go unrecognized until later in life, years after treatment of the primary lesion. Strabismus and cranial nerve palsies may occur as a result of brain tumors. Ophthalmologists can monitor and treat young children at risk for vision loss from amblyopia as a result of effects from their underlying lesion. Advances in imaging techniques have made it possible to quantify damage to the visual pathways with objective tests.

SUMMARY

Systematic referrals for evaluation by an ophthalmologist should occur early in the course of treatment of primary brain tumors as these evaluations may improve visual outcomes and quality of life.

Effects of Brain Tumors on Vision in Children

Central nervous tumors are the leading cause of death from cancer in the pediatric population. Advances in care for pediatric neuro-oncology patients have led to improved survival rates. As survivorship increases, care of the sequelae of the tumor and its treatment become more important for long-term quality of life. A significant portion of the brain is involved in vision. Pediatric brain tumors can distort, damage, and destroy portions of the brain involved in both the afferent and efferent vision pathways. This interruption of normal visual pathways can lead to permanent vision loss or other morbidities such as strabismus and nystagmus. This article reviews the presenting symptoms and signs of brain tumors in children and adolescents, as well as the effects of the tumor and its treatment on the afferent and efferent visual pathways. Strategies for monitoring during treatment, and management of sequelae are reviewed. Through systematic evaluation and monitoring of pediatric neuro-oncology patients, those at risk for vision loss or tumor progression can be identified.

Presenting symptoms of pediatric brain tumors diagnosed in the emergency department

OBJECTIVE

The primary objective of this study is to categorize the symptoms associated with brain tumors as diagnosed in the emergency department (ED). The secondary objective is to detail the specific characteristics of these headaches via a subgroup analysis.

METHODS

A retrospective chart review was performed among patients younger than 18 years presenting to a large urban tertiary care facility. Electronic medical records were searched and reviewed from 2002 to 2011 for inpatient discharge diagnoses using malignant and benign central nervous system tumor International Classification of Diseases, Ninth Revision codes.

RESULTS

The electronic records of ED visits for 87 patients were reviewed. The most frequent signs and symptoms were as follows: headache (66.7%), hydrocephalus (58.6%), nausea/vomiting (49.4%), gait disturbance (42.5%), vision changes (20.7%), seizure (17.2%), behavior/school change (17.2%), cranial nerve deficits (16.1%), altered mental status (16.1%), back/neck pain (16.1%), papilledema (12.6%), facial asymmetry (10.3%), sensory deficits (8.0%), focal motor weakness (6.9%), cranial nerve 6 deficit (6.9%), ptosis (5.7%), macrocephaly (4.6%), asymptomatic (3.4%), and anisocoria (1.1%). The frequencies of location of headache were diffuse (24.1%), frontal (12.1%), occipital (8.6%), and parietal/temporal (6.9%). The severity was described as severe (37.9%) followed by moderate and mild (10.3% and 5.2%, respectively). Most headaches occurred in the morning (13.8%) and night (12.1%), and their quality was predominantly progressively worsening (50.0%)

CONCLUSIONS

Brain tumors diagnosed in the ED most commonly present with headache, hydrocephalus, nausea/vomiting, and gate disturbances. The headaches are described as progressively worsening and diffuse most commonly occurring in the morning and night.

Side effects of oncologic therapies in the pediatric central nervous system: update on neuroimaging findings

The need for early, accurate diagnosis of central nervous system (CNS) complications occurring during and after pediatric cancer treatment is growing because of the improvement in overall survival rates related to innovative and aggressive oncologic therapies. An elevated degree of suspicion is needed to recognize the radiologic features of these CNS complications. Radiologists need familiarity with the early and late side effects of cancer therapy in the pediatric CNS (eg, toxic effects, infection, endocrine or sensory dysfunction, neuropsychologic impairment, second malignancies), in order to accelerate the imaging diagnosis and minimize as much as possible the associated morbidity. Acquisition of knowledge about these complications will enable the development of more appropriate therapeutic trials and more effective patient surveillance and will lead to an improved quality of life by decreasing the long-term sequelae in survivors.