Long-term neurological outcome of childhood brain tumors treated by surgery only

S, Xing M, Tonning Olsson I, de Blank PMK, Lange KR, Salloum R, Srivastava D, Leisenring WM, Howell RM, Oeffinger KC, Robison LL, Armstrong GT, Krull KR, Brinkman TM. Evolving therapies, neurocognitive outcomes, and functional independence in adult survivors of childhood glioma

BACKGROUND

Treatment of childhood glioma has evolved to reduce radiotherapy exposure with the goal of limiting late toxicity. However, the associations between treatment changes and neurocognition, and the contribution of neurocognition and chronic health conditions to attainment of adult independence, remain unknown.

METHODS

Adult survivors of childhood glioma diagnosed in 1970-1999 in the Childhood Cancer Survivor Study (n = 1284; median [minimum-maximum] 30 [18-51] years of age at assessment; 22 [15-34] years from diagnosis) self-reported neurocognitive impairment and chronic health conditions. Multivariable models evaluated associations between changes in treatment exposures (surgery only, chemotherapy [with or without surgery], cranial radiation [with or without chemotherapy and/or surgery]), and neurocognitive impairment. Latent class analysis with 5 indicators (employment, independent living, assistance with routine and/or personal care needs, driver's license, marital or partner status) identified classes of functional independence. Path analysis tested associations among treatment exposures, neurocognitive impairment, chronic health conditions, and functional independence. Statistical tests were 2-sided.

RESULTS

Cranial radiation exposure decreased over time (51%, 1970s; 46%, 1980s; 27%, 1990s]. However, compared with siblings, survivors with any treatment exposure were at elevated risk for neurocognitive impairment, including surgery only (eg, memory: relative risk = 2.22; task efficiency: relative risk = 1.88; both P < .001). Three classes of functional independence were identified: independent (58%), moderately independent (20%), and nonindependent (22%). Cranial radiation was associated with nonindependence through impaired task efficiency (β = 0.06), sensorimotor (β = 0.06), and endocrine (β = 0.10) chronic health conditions and through the associations between these conditions and task efficiency (each β = 0.04). Sensorimotor and endocrine chronic health conditions were associated with nonindependence through memory.

CONCLUSION

Most long-term glioma survivors achieve adult independence. However, functional nonindependence is associated with treatment-related neurocognitive impairment and chronic health conditions.

Long term quality of life outcomes following surgical resection alone for benign paediatric intracranial tumours

PURPOSE

Survivors of paediatric intracranial tumours are at increased risk of psychosocial, neuro-developmental, and functional impairment. This study aimed to evaluate long-term health-related quality-of-life (HRQOL) outcomes in patients with benign paediatric brain tumours treated curatively with surgical resection alone.

METHODOLOGY

This was a cross-sectional study of patients with benign paediatric intracranial tumours managed with surgery alone between 2000 and 2015. Eligible patients with a minimum of 5-years follow-up after surgery were identified. Validated health-related quality of life (HRQOL) questionnaires were administered: SF-36, QLQ-BN20, QLQ-C30 and PedsQL™.

RESULTS

Twenty-three patients participated (median age at surgery 13 years; range 1-18; 12 male). The most common diagnosis was pilocytic astrocytoma (n = 15). Median time from surgery to participation was 11 years(range 6-19). Fourteen patients achieved A-level qualifications and two obtained an undergraduate degree. Twelve patients were employed, eight were studying and three were unemployed or volunteering. HRQOL outcomes demonstrated significant limitation from social functioning (p = 0.03) and cognitive functioning (p = 0.023) compared to the general population. Patients also experienced higher rates of loss of appetite (p = 0.009) and nausea and vomiting (p = 0.031). Ten patients were under transitional teenager and young-adult (TYA) clinic follow-up. TYA patients achieved higher levels of education (p = 0.014), were more likely to hold a driver's license (p = 0.041) compared to patients not followed-up through these services.

CONCLUSIONS

Childhood brain-tumour survivors have a greater risk of developing psychological, neuro-cognitive and physical impairment. Early comprehensive assessment, specialist healthcare and TYA services are vital to support these patients.

Survival and long-term socioeconomic consequences of childhood and adolescent onset of brain tumours

AIM

To evaluate survival distributions, long-term socioeconomic consequences, and health care costs in patients with childhood and adolescent onset of brain tumours in a Danish nationwide prospective cohort study.

METHOD

A search of national registries identified 2283 patients (1198 males, 1085 females; mean age 9 years 6 months [SD 5 years 7 months]) diagnosed with a brain tumour between 1980 and 2015 and aged no older than 18 years at diagnosis. These were compared with sex-, age-, and residency-matched comparison individuals. Patients with malignant tumours were compared with those with benign tumours. Survival distributions were estimated by the Kaplan-Meier method and hazard ratio by the Cox proportional hazard model. Socioeconomic data at age 20 and 30 years were assessed.

RESULTS

The probability of mortality was highest during the first year after tumour diagnosis. In young adulthood, the patients were generally less likely to be married, had lower grade-point averages, educational levels, and income, were less likely to be in employment, and had higher health care costs than comparison individuals. Patients with malignant tumours had worse outcomes with respect to education, employment, and health care costs than those with benign tumours.

INTERPRETATION

A diagnosis of brain tumour in childhood and adolescence adversely affects survival and has negative long-term socioeconomic consequences, especially in patients with malignant tumours. These patients require continuous social support.

Quality of life in children with brain tumors post radiotherapy in a lower-middle income country

Indonesia is a rapidly growing lower-middle-income country (LMIC) located in Southeast Asia. It has 267.3 million inhabitants, with 31.6% (84.4 million) children. According to GLOBOCAN 2020, Indonesia had the highest prevalence of pediatric cancer cases in Southeast Asia (43.5%), and brain tumors had the third-highest incidence in Indonesia. Treating children with brain tumors with radiotherapy is challenging, especially the late treatment effects that can affect their quality of life (QoL). This study aimed to show the QoL in children with brain tumors after radiotherapy in Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia, based on PedsQL™ 4.0 generic core scale and the possible affecting factors. In this cross-sectional study, 26 of 88 children with brain tumors after radiotherapy were assessed by the PedsQL™ 4.0 generic core scale. Of the 88 patients who had brain tumor radiotherapy in 2014-2019, 31 patients were lost to follow-up, 28 were confirmed dead, and 29 were assured alive. One-year, three-year, and five-year overall survival were 71.6%, 43.2%, and 5.7%, respectively. The mean of children's QoL was 70.686 and 70.152 based on child self-report and parent proxy-report. Family income > 290 USD (regional minimum wage) was a factor that improved the QoL in children with brain tumors after radiotherapy (p = 0.008). QoL in children with brain tumors after radiotherapy could be influenced by family income.

Postoperative facial palsy after pediatric posterior fossa tumor resection

OBJECTIVE

Facial palsy can be caused by masses within the posterior fossa and is a known risk of surgery for tumor resection. Although well documented in the adult literature, postoperative facial weakness after posterior fossa tumor resection in pediatric patients has not been well studied. The objective of this work was to determine the incidence of postoperative facial palsy after tumor surgery, and to investigate clinical and radiographic risk factors.

METHODS

A retrospective analysis was conducted at a single large pediatric hospital. Clinical, radiographic, and histological data were examined in children who were surgically treated for posterior fossa tumors between May 1, 1994, and June 1, 2011. The incidence of postoperative facial weakness was documented. A multivariate logistic regression model was used to analyze the predictive ability of clinicoradiological variables for facial weakness.

RESULTS

A total of 163 patients were included in this study. The average age at surgery was 7.4 ± 4.7 years, and tumor pathologies included astrocytoma (44%), medulloblastoma (36%), and ependymoma (20%). The lesions of 27 patients (17%) were considered high grade in nature. Thirteen patients (8%) exhibited preoperative symptoms of facial palsy. The overall incidence of postoperative facial palsy was 26% (43 patients), and the incidence of new postoperative facial palsy in patients without preoperative facial weakness was 20% (30 patients). The presence of a preoperative facial palsy had a large and significant effect in univariate analysis (OR 11.82, 95% CI 3.07-45.44, p < 0.01). Multivariate logistic regression identified recurrent operation (OR 4.45, 95% CI 1.49-13.30, p = 0.01) and other preoperative cranial nerve palsy (CNP; OR 3.01, 95% CI 1.24-7.29, p = 0.02) as significant risk factors for postoperative facial weakness.

CONCLUSIONS

Facial palsy is a risk during surgical resection of posterior fossa brain tumors in the pediatric population. The study results suggest that the incidence of new postoperative facial palsy can be as high as 20%. The presence of preoperative facial palsy, an operation for recurrent tumor, and the presence of other preoperative CNPs were found to be significant risk factors for postoperative facial weakness.

Ataxia and mobility in children following surgical resection of posterior fossa tumour: A longitudinal cohort study

PURPOSE

To report the course of ataxia in children up to 2 years post-operatively, following surgical resection of a posterior fossa tumour (PFT).

METHODS

Thirty-five children, (median age 9 years, range 4-15) having resection of PFT, were assessed using the Scale for the Assessment and Rating of Ataxia (SARA), Brief Ataxia Rating Scale (BARS) and the mobility domain of the Paediatric Evaluation of Disability Index (PEDI-m) at initial post-operative period (baseline), 3 months, 1 year and 2 years post-operatively.

RESULTS

Baseline median scores of the SARA and BARS were 8.5 (range 0-35.5), and 7 (0-25) respectively. Ataxia improved at 3 months (median SARA and BARS reduction 3.5 and 4, respectively). Additional gradual improvements in SARA were recorded at 1 (median reduction 2) and 2 years post-operatively (median reduction 0.5). Median baseline PEDI-m was 54.75 (range 15.2-100) with improvement at 3 months (median increase 36.95) and small improvement at 1 year (median increase 2.5) and 2 years (median increase 5.8). Children with medulloblastoma and midline tumours (median baseline SARA 10 and 11, respectively) demonstrated more severe ataxia than children with low-grade gliomas and unilateral tumours (median baseline SARA 7.5 and 6.5, respectively).

CONCLUSION

The largest improvement in ataxia scores and functional mobility scores is demonstrated within the first 3 months post-operatively, but ongoing gradual improvement is observed at 2 years. Children with medulloblastoma and midline tumour demonstrated higher ataxia scores long term.

Cognitive functions of children with brain tumor in the treatment process

Introduction

This study assesses the cognitive functions of children with brain tumor, including orientation, spatial perception, praxis, visuomotor constructions and thinking operations. The aim of the study was to assess the cognitive functions of children with brain tumor in the treatment process and the effects of different treatments on cognitive functionality.

Method

Cognitive functions of children with brain tumor ( n = 102) and children with typical development ( n = 90) were assessed with the Dynamic Occupational Therapy Assessment for Children. Children with brain tumor were divided into four subgroups according to the treatment they received. Multiple comparisons were analyzed using the Kruskal–Wallis test and binary comparisons were analyzed using the Mann–Whitney U test.

Results

Cognitive functions of children with brain tumor were weaker than children with typical development. Children who received chemotherapy, radiotherapy, surgery and both chemotherapy and radiotherapy had weaker cognitive functions.

Conclusions

Children with brain tumor whose treatment process is continuing are cognitively affected and their occupational performance in daily living tasks is weakened. In these children, cognitive- and occupation-based early intervention approaches should be developed and implemented. Especially when children start receiving radiotherapy, it may also be useful to start cognitive occupational therapy programs simultaneously for preserving children’s cognitive functionality.

Effects of the growth pattern of medulloblastoma on short-term neurological impairments after surgery: results from the prospective multicenter HIT-SIOP PNET 4 study

OBJECTIVE

Extensive resection of a tumor in the posterior fossa in children is associated with the risk of neurological deficits. The objective of this study was to prospectively evaluate the short-term neurological morbidity in children after medulloblastoma surgery and relate this to the tumor's growth pattern and to the extent of resection.

METHODS

In 160 patients taking part in the HIT-SIOP PNET 4 (Hyperfractionated Versus Conventionally Fractionated Radiotherapy in Standard Risk Medulloblastoma) trial, neurosurgeons prospectively responded to questions concerning the growth pattern of the tumor they had resected. The extent of resection (gross, near, or subtotal) was evaluated using MRI. The patients' neurological status before resection and around 30 days after resection was recorded.

RESULTS

Invasive tumor growth, defined as local invasion in the brain or meninges, cranial nerve, or major vessel, was reported in 58% of the patients. After surgery almost 70% of all patients were affected by one or several neurological impairments (e.g., impaired vision, impaired extraocular movements, and ataxia). However, this figure was very similar to the preoperative findings. Invasive tumor growth implied a significantly higher number of impairments after surgery (p = 0.03) and greater deterioration regarding extraocular movements (p = 0.012), facial weakness (p = 0.048), and ataxia in the arms (p = 0.014) and trunk (p = 0.025) compared with noninvasive tumor growth. This deterioration was not dependent on the extent of resection performed. Progression-free survival (PFS) at 5 years was 80% ± 4% and 76% ± 5% for patients with invasive and noninvasive tumor growth, respectively, with no difference in the 5-year PFS for extent of resection.

CONCLUSIONS

Preoperative neurological impairments and invasive tumor growth were strong predictors of deterioration in short-term neurological outcome after medulloblastoma neurosurgery, whereas the extent of resection was not. Neither tumor invasiveness nor extent of resection influenced PFS. These findings support the continuation of maximal safe resection in medulloblastoma surgery where functional risks are not taken in areas with tumor invasion.

Visual Complications of Pediatric Posterior Fossa Tumors: Analysis of Outcomes

OBJECTIVE

Visual abnormalities are common among children with posterior fossa tumors, resulting from disruption of ocular afferent and efferent systems due to the tumor or surgery. This study describes the visual complications and outcomes associated with these tumors.

METHODS

Clinical and radiographic data of patients who underwent index surgery for resection of posterior fossa tumor from 2007 to 2016 were reviewed. Descriptive statistics, univariate, and multivariate regression were performed to assess factors contributing to visual acuity and postoperative strabismus.

RESULTS

There were 182 patients who underwent posterior fossa craniotomy for neoplasm were included. Ophthalmologic symptoms were the fourth most common presenting complaint; initial ophthalmologic examination was abnormal in 40% of patients. Evaluation of visual acuity demonstrated a good outcome in 88% of patients following treatment. The most common postoperative oculomotor finding was esotropia (29%) which resolved spontaneously in more than half of patients. A good outcome was obtained in all patients who underwent surgery for esotropia. Hypertropia was noted in 14% of the cohort and less than half resolved spontaneously; less than half undergoing strabismus surgery for hypertropia had a good outcome. Multivariate analysis confirmed the association between cerebellar mutism and postoperative esotropia and hypertropia. Clinically significant pathological nystagmus was seen in 8% of the cohort.

CONCLUSIONS

Our results indicate a good visual outcome in the majority of pediatric patients undergoing resection of posterior fossa tumors. Ophthalmologic complications should be appropriately evaluated and addressed to allow for the best possible vision to survivors of posterior fossa tumors.

Incidence and prognostic factors of ataxia in children with posterior fossa tumors

Background

There is minimal literature specific to motor outcomes in children with posterior fossa tumors (PFTs) despite ataxia being a significant problem in this group. This study aims to report children's physical outcomes following management of PFT and determine which factors affect severity of ataxia and functional limitations.

Methods

Forty-two children aged between 5 and 17 and between 1 and 4 years following surgery for PFT were assessed using the Scale for the Assessment and Rating of Ataxia (SARA), the Brief Ataxia Rating Scale (BARS), and the mobility Pediatric Evaluation of Disability Inventory (PEDI) subscale to determine prevalence and severity of ataxia and a measure of physical function. Analysis was undertaken comparing impact of tumor location, tumor histology, adjuvant treatment, age at diagnosis, presence of preoperative ataxia, and presence of cerebellar mutism syndrome (CMS) on ataxia and physical function scores.

Results

Seventy-one percent of children demonstrated a SARA and BARS score greater than 2. A total of 48% of children had a PEDI-m score greater than 90. There was no correlation between age at diagnosis or preoperative ataxia and assessment scores. There was a significant difference in SARA/BARS and PEDI-mobility scores depending on tumor histology, tumor location, and presence of CMS.

Conclusions

A high proportion of children (>1 year) following surgery for PFT continue to present with ataxia. Higher ataxia and lower physical function scores were demonstrated in children with medulloblastoma and midline tumors and those diagnosed with CMS. The high prevalence of ataxia demonstrates the need for further research regarding rehabilitation management in this population.

Visual and ocular motor outcomes in children with posterior fossa tumors

PURPOSE

To describe the clinical characteristics and visual and ocular motor outcomes of a large cohort of pediatric patients treated for tumors of the posterior cranial fossa.

METHODS

The medical records of all patients with posterior fossa tumors evaluated by the ophthalmology services at two large tertiary care academic hospitals between 2005 and 2011 were reviewed retrospectively. Data abstracted for each study patient included demographic information, presenting signs and symptoms, pathologic diagnosis, and results of the most recent ophthalmology examination.

RESULTS

A total of 139 patients were included. Visual outcomes were categorized as "good" (bilateral acuity of 20/20-20/40) in 101 patients (72.7%), "fair" (<20/40-20/200 in one or both eyes) in 12 patients (8.6%), or "poor" (<20/200 in one or both eyes) in 9 patients (6.5%). Patients with medulloblastoma and ependymoma had a significantly greater risk of a poor or fair visual outcome than those with juvenile pilocytic astrocytoma (both P < 0.05), independent of age and sex. Thirty-two patients (23.0%) developed nystagmus, and 59 patients (42.4%) developed strabismus. Twenty-four patients (17.3%) underwent eye muscle surgery for persistent strabismus.

CONCLUSIONS

The majority of patients had good visual outcomes, although ocular motor abnormalities were common. Tumor type was a significant risk factor for permanent vision loss.

Cerebellar mutism syndrome in children with brain tumours of the posterior fossa

Background

Central nervous system tumours constitute 25% of all childhood cancers; more than half are located in the posterior fossa and surgery is usually part of therapy. One of the most disabling late effects of posterior fossa tumour surgery is the cerebellar mutism syndrome (CMS) which has been reported in up to 39% of the patients but the exact incidence is uncertain since milder cases may be unrecognized. Recovery is usually incomplete. Reported risk factors are tumour type, midline location and brainstem involvement, but the exact aetiology, surgical and other risk factors, the clinical course and strategies for prevention and treatment are yet to be determined.

Methods

This observational, prospective, multicentre study will include 500 children with posterior fossa tumours. It opened late 2014 with participation from 20 Nordic and Baltic centres. From 2016, five British centres and four Dutch centres will join with a total annual accrual of 130 patients. Three other major European centres are invited to join from 2016/17. Follow-up will run for 12 months after inclusion of the last patient. All patients are treated according to local practice. Clinical data are collected through standardized online registration at pre-determined time points pre- and postoperatively. Neurological status and speech functions are examined pre-operatively and postoperatively at 1–4 weeks, 2 and 12 months. Pre- and postoperative speech samples are recorded and analysed. Imaging will be reviewed centrally. Pathology is classified according to the 2007 WHO system. Germline DNA will be collected from all patients for associations between CMS characteristics and host genome variants including pathway profiles.

Discussion

Through prospective and detailed collection of information on 1) differences in incidence and clinical course of CMS for different patient and tumour characteristics, 2) standardized surgical data and their association with CMS, 3) diversities and results of other therapeutic interventions, and 4) the role of host genome variants, we aim to achieve a better understanding of risk factors for and the clinical course of CMS - with the ultimate goal of defining strategies for prevention and treatment of this severely disabling condition.

Trial registration

Clinicaltrials.gov: NCT02300766, date of registration: November 21, 2014.

A Review of Visual and Oculomotor Outcomes in Children With Posterior Fossa Tumors

Tumors of the posterior fossa represent the most common solid malignancy of childhood and can affect the visual system in several ways. This article outlines the relevant visual anatomy affected by these tumors and reviews the visual and oculomotor outcomes associated with the following 3 most common tumor types-medulloblastoma, juvenile pilocytic astrocytoma, and ependymoma. The available data suggest that the rate of permanent vision loss is low (5.9%-8.3%), with patients having juvenile pilocytic astrocytoma demonstrating the best outcomes. The rate of long-term strabismus (25%-29.1%) and nystagmus (12.5%-18%) is higher and associated with significant morbidity.

Multidisciplinary rehabilitation for children with brain tumors: A systematic review

BACKGROUND

There is an increasing need to assess the evidence of a multidisciplinary approach for both short-term and long-term management of neurological sequelae arising from the diagnosis and treatment of brain tumors in childhood.

METHODS

We performed a systematic review of the evidence base for multidisciplinary paediatric brain tumor rehabilitation using seven databases. PRISMA guidelines were adhered to and the review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42014015070).

RESULTS

The literature search identified 3,061 results. Three service evaluations were included. The review identified limited evidence in favor of multidisciplinary rehabilitation for children with brain tumors. Due to the lack of controlled trial data and heterogeneity of the interventions and outcome measures, no meta-analysis could be performed.

CONCLUSIONS

Studies utilising a coordinated multi-centre approach with standardized outcome measures are recommended in order to enable robust assessment of the efficacy of multidisciplinary rehabilitation services.

Multiprofessional follow-up programmes are needed to address psychosocial, neurocognitive and educational issues in children with brain tumours

AIM

The aim of this study was to coordinate the structured psychosocial, neurocognitive and educational follow-up of children treated for brain tumours with the medical protocol and apply the model in two Swedish healthcare regions.

METHODS

We invited all children living in the two regions, who had been diagnosed with a brain tumour from October 1, 2010, through June 30, 2012, to participate along with their parents. The follow-up programme evaluated the emotional status of the parents and patients and assessed the children's general cognitive level, working memory, speed of performance, executive functions and academic achievement from diagnosis through to adult care.

RESULTS

During the study period, 61 children up to the age of 17.1 years were diagnosed with a brain tumour, but 18 of these were excluded for various reasons. The majority of the mothers (70%) displayed significantly poor emotional status, as did 34% of the fathers and 21% of the children. The majority of the children (57%) also showed poor neurocognitive performance and needed special adaptations at school (66%).

CONCLUSION

Our findings indicate the need for coordinated, multiprofessional follow-up programmes, well anchored in the healthcare organisation, for children diagnosed with brain tumours.

Hyponatremia and poor cognitive outcome following pediatric brain tumor surgery

OBJECT

Pediatric intracranial neoplasms are common and cause substantial neurological morbidity. Postoperative hyponatremia is also common and may exacerbate neurological injury. The authors performed an exploratory analysis to evaluate an exposure-response relationship between hyponatremia severity and cognitive function at discharge.

METHODS

A retrospective cohort of patients 0-19 years old who underwent a first intracranial neoplasm surgery at a pediatric tertiary care hospital was reviewed. Outcome was assessed by Pediatric Cerebral Performance Category (PCPC) score of 1-6 at hospital discharge. Poor outcome was defined as PCPC score 3-6, corresponding to moderate or worse disability.

RESULTS

Of 319 total children, 80 (25%) had poor outcomes. One hundred thirty-seven children (43%) had serum sodium concentrations ≤ 131-135 mEq/L and 39 (12%) had serum sodium concentrations ≤ 130 mEq/L. Lower nadir sodium concentration and longer duration of hyponatremia were significantly associated with worsening PCPC score (p < 0.001). Rapid sodium decreases and more hyponatremic episodes were also significantly associated with worsening PCPC score (p < 0.001). After adjustment for patient factors, tumor characteristics, and measures of sodium disruption, multivariable analysis revealed noncortical tumor locations and lower nadir sodium concentration (adjusted odds ratio 0.86, 95% confidence interval 0.78-0.95) were important independent risk factors for poor cognitive outcome.

CONCLUSIONS

Neurocognitive disability and hyponatremia are common in children undergoing surgery for intracranial neoplasms. This study found a significant association between severity of hyponatremia and worsened cognitive outcome, with an apparent exposure-response relationship. These data support the need for careful postoperative monitoring of serum sodium. Further research is needed to determine if prevention and treatment of hyponatremia can improve outcomes in these children.

Inter-rater reliability and validity of two ataxia rating scales in children with brain tumours

OBJECTIVES

This study aimed to investigate the inter-rater reliability and construct validity of the Scale for the Assessment and Rating of Ataxia (SARA) and Brief Ataxia Rating Scale (BARS) in children with posterior fossa tumours. These scales have been developed for adults with genetic ataxias, and the performance of these scales in children with brain tumours has not previously been described.

METHODS

The participants, who had undergone surgical resection for a posterior fossa tumour (inclusion criteria age 4-18 years), were recruited from the neuro-oncology service at a tertiary children's hospital. Children were assessed using the SARA, BARS and Paediatric Evaluation of Disability Index (PEDI) mobility domain, a measure of function. Children were independently rated by two therapists to determine the inter-rater reliability of the SARA and BARS. The construct validity was determined by assessing the correlation between the two scales with the PEDI.

RESULTS

Forty-four children were recruited. Inter-rater reliability was good for both scales, demonstrating the strong correlations (SARA, r = 0.94; BARS, r = 0.91) and the good consistency (93 % of SARA and 90 % of BARS paired scores differing by less than 2 points) between two raters. Both ataxia scales demonstrated a strong negative correlation with the mobility domain of the PEDI (SARA, r = -0.77; BARS, r = -0.76), indicating that more severe ataxia was associated with worse mobility. The mean time for completion of the SARA was 4.5 and 2.7 min for the BARS.

CONCLUSIONS

The SARA and BARS are reliable and valid measures and appear to be of equal value in determining the severity of ataxia in children with posterior fossa tumours.

Impairments that influence physical function among survivors of childhood cancer

Children treated for cancer are at increased risk of developing chronic health conditions, some of which may manifest during or soon after treatment while others emerge many years after therapy. These health problems may limit physical performance and functional capacity, interfering with participation in work, social, and recreational activities. In this review, we discuss treatment-induced impairments in the endocrine, musculoskeletal, neurological, and cardiopulmonary systems and their influence on mobility and physical function. We found that cranial radiation at a young age was associated with broad range of chronic conditions including obesity, short stature, low bone mineral density and neuromotor impairments. Anthracyclines and chest radiation are associated with both short and long-term cardiotoxicity. Although numerous chronic conditions are documented among individuals treated for childhood cancer, the impact of these conditions on mobility and function are not well characterized, with most studies limited to survivors of acute lymphoblastic leukemia and brain tumors. Moving forward, further research assessing the impact of chronic conditions on participation in work and social activities is required. Moreover, interventions to prevent or ameliorate the loss of physical function among children treated for cancer are likely to become an important area of survivorship research.

2-deoxy-2-(18F)fluoro-D-glucose positron emission tomography/computed tomography imaging in paediatric oncology

Positron emission tomography (PET) is a minimally invasive technique which has been well validated for the diagnosis, staging, monitoring of response to therapy, and disease surveillance of adult oncology patients. Traditionally the value of PET and PET/computed tomography (CT) hybrid imaging has been less clearly defined for paediatric oncology. However recent evidence has emerged regarding the diagnostic utility of these modalities, and they are becoming increasingly important tools in the evaluation and monitoring of children with known or suspected malignant disease. Important indications for 2-deoxy-2-(¹⁸F)fluoro-D-glucose (FDG) PET in paediatric oncology include lymphoma, brain tumours, sarcoma, neuroblastoma, Langerhans cell histiocytosis, urogenital tumours and neurofibromatosis type I. This article aims to review current evidence for the use of FDG PET and PET/CT in these indications. Attention will also be given to technical and logistical issues, the description of common imaging pitfalls, and dosimetric concerns as they relate to paediatric oncology.

The surgical management of pediatric brain tumors causing epilepsy: consideration of the epileptogenic zone

OBJECTIVE

Children suffering from epilepsy with suspected low-grade tumors may benefit from a surgical approach that considers the epileptogenic zone, which can be more extensive than the tumor region. This study aimed to determine the prevalence of epilepsy in children undergoing supratentorial tumor resection and the factors predictive of postoperative seizure freedom in children with low-grade tumors.

METHODS

Subjects 3 months to 21 years undergoing supratentorial brain tumor resection between 2007 and 2011 were included in this retrospective study. Children with supratentorial, cortically based tumors and a preoperative diagnosis of epilepsy were considered epilepsy surgery candidates. Pre- and postoperative MRI were reviewed and scored for extent of resection, adjacent dysplasia, and remaining abnormal cortex postoperatively.

RESULTS

The prevalence of seizures in all cases of supratentorial tumors was 46/87 (53 %). Eighteen were epilepsy surgery candidates. Eight of 18 (44 %) were seizure-free postoperatively with a mean follow-up of 39 months. Children who were seizure free postoperatively had tried fewer anticonvulsants than those with continued seizures (1.7 v. 2.9, p = 0.01). Presurgical evaluation was nonstandardized, and a more extensive workup and resection were performed in children who continued to have seizures postoperatively.

CONCLUSIONS

All epilepsy surgery candidates had low-grade tumors on histological evaluation, indicating that a surgical approach that takes into consideration the epileptogenic zone is reasonable in this population. Gross total resection should be the goal, with additional attention to resection of the epileptogenic zone when located in the noneloquent cortex.

Morbidity in survivors of child and adolescent meningioma

BACKGROUND

The extent of initial surgical resection has been identified as the strongest prognostic indicator for survival in child and adolescent meningioma. Given the paucity of data concerning long-term outcome, the authors undertook a meta-analysis to analyze morbidity in survivors of this disease.

METHODS

Individual patient data were obtained from 19 case series published over the last 23 years through direct communication with the authors. Ordinal logistic regression models were used to assess the influence of risk factors on morbidity.

RESULTS

Of 261 patients, 48% reported a completely normal life with no morbidity, and 25% had moderate/severe meningioma-associated morbidity at last follow-up. Multivariate analysis identified relapse as the only independent variable associated with an increased risk of morbidity (odds ratio, 4.02; 95% confidence interval, 2.11-7.65; P ≤ .001). Univariate analysis also revealed an increased risk for patients with neurofibromatosis (odds ratio, 1.90; 95% confidence interval, 1.04-3.48; P = .04). Subgroup analysis identified a higher incidence of morbidity among patients who had intracranial tumors with a skull base location compared with a nonskull base location (P ≤ .001). Timing at which morbidity occurred was available for 70 patients, with persistence of preoperative tumor-related symptoms in 67% and as a result of therapy in 20%.

CONCLUSIONS

The majority of survivors of child and adolescent meningioma had no or only mild long-term morbidity, whereas 25% had moderate/severe morbidity, with a significantly increased risk in patients with relapsed disease. In the majority, morbidity occurred as a consequence of the tumor itself, justifying aggressive surgery to achieve gross total resection. However, for patients with neurofibromatosis and skull base meningioma, a more cautious surgical approach should be reserved.

An infant with prenatally diagnosed congenital anaplastic astrocytoma who remains disease-free after proton therapy

The authors present a rare of prenatally diagnosed congenital anaplastic astrocytoma. A 9-month-old boy had three recurrences despite two surgical resections and various chemotherapeutic regimens. He underwent the 3rd gross tumor removal at 11 months of age, followed by proton therapy, and now he remains disease-free for 3 yr without a significant neurocognitive dysfunction. This is the 1st case of a pediatric tumor treated by proton therapy in Korea, and proton therapy may be a treatment of choice for a congenital anaplastic astrocytoma in infants and young children, considering limitation of radiation therapy.

A decision analysis tool for the assessment of posterior fossa tumour surgery outcomes in children--the "Liverpool Neurosurgical Complication Causality Assessment Tool"

INTRODUCTION

Complications may occur following posterior fossa tumour surgery in children. Such complications are subjectively and inconsistently reported even though they may have significant long-term behavioural and cognitive consequences for the child. This makes comparison of surgeons, programmes and treatments problematic.

MATERIALS AND METHODS

We have devised a causality tool for assessing if an adverse event after surgery can be classified as a surgical complication using a series of simple questions, based on a tool used in assessing adverse drug reactions. This tool, which we have called the "Liverpool Neurosurgical Complication Causality Assessment Tool", was developed by reviewing a series of ten posterior fossa tumour cases with a panel of neurosurgery, neurology, oncology and neuropsychology specialists working in a multidisciplinary paediatric tumour treatment programme.

DISCUSSION AND CONCLUSION

We have demonstrated its use and hope that it may improve reliability between different assessors both in evaluating the outcomes of existing programmes and treatments as well as aiding in trials which may directly compare the effects of surgical and medical treatments.

Neurocognitive dysfunction in survivors of childhood brain tumors

Newer treatments have resulted in increasing numbers of survivors of childhood cancer, for whom neurological and neurocognitive toxicity directly impacts overall functioning and quality of life. There are multiple disease- and host-related factors that influence the development of cancer-related neurocognitive dysfunction, which can progress over time and lead to significant functional impairments. This article provides an overview of the types of neurocognitive deficits seen in survivors of childhood brain tumors, the tools used to assess neurocognitive function, and the factors that impact its severity. This provides a framework for consideration of potential areas for primary prevention by reducing treatment-related toxicity as well as interventions, using behavioral and pharmacologic treatments.

Marriage and divorce among childhood cancer survivors

Many childhood cancer survivors have psychosocial late effects. We studied the risks for cohabitation and subsequent separation. Through the Danish Cancer Register, we identified a nationwide, population-based cohort of all 1877 childhood cancer survivors born from 1965 to 1980, and in whom cancer was diagnosed between 1965 and 1996 before they were 20 years of age. A sex-matched and age-matched population-based control cohort was used for comparison (n=45,449). Demographic and socioeconomic data were obtained from national registers and explored by discrete-time Cox regression analyses. Childhood cancer survivors had a reduced rate of cohabitation [rate ratio (RR) 0.78; 95% confidence interval (CI): 0.73-0.83], owing to lower rates among survivors of both noncentral nervous system (CNS) tumors (RR 0.88; 95% CI: 0.83-0.95) and CNS tumors (RR 0.52; 95% CI: 0.45-0.59). Male CNS tumor survivors had a nonsignificantly lower rate (RR 0.47; 95% CI: 0.38-0.58) than females (RR 0.56; 95% CI: 0.47-0.68). The rates of separation were almost identical to those of controls. In conclusion, the rate of cohabitation was lower for all childhood cancer survivors than for the population-based controls, with the most pronounced reduction among survivors of CNS tumors. Mental deficits after cranial irradiation are likely to be the major risk factor.

Development of a parent-report cognitive function item bank using item response theory and exploration of its clinical utility in computerized adaptive testing

OBJECTIVE

The purpose of this study is to report the reliability, validity, and clinical utility of a parent-report perceived cognitive function (pedsPCF) item bank.

METHODS

From the U.S. general population, 1,409 parents of children aged 7-17 years completed 45 pedsPCF items. Their psychometric properties were evaluated using Item Response Theory (IRT) approaches. Receiver operating characteristic (ROC) curves and discriminant function analysis were used to predict clinical problems on child behavior checklist (CBCL) scales. A computerized adaptive testing (CAT) simulation was used to evaluate clinical utility.

RESULTS

The final 43-item pedsPCF item bank demonstrates no item bias, has acceptable IRT parameters, and provides good prediction of related clinical problems. CAT simulation resulted in correlations of 0.98 between CAT and the full-length pedsPCF.

CONCLUSIONS

The pedsPCF has sound psychometric properties, U.S. general population norms, and a brief-yet-precise CAT version is available. Future work will evaluate pedsPCF in other clinical populations in which cognitive function is important.

A systematic review of studies on psychosocial late effects of childhood cancer: structures of society and methodological pitfalls may challenge the conclusions

High survival rates after childhood cancer raise attention to possible psychosocial late effects. We focus on predictors of psychosocial outcomes based on diagnosis, treatment, demography, somatic disease, and methodological problems. Overall, survivors evaluate their health-related quality of life to be normal or even better than controls, although virtually all diagnostic subgroups report psychosocial impairment. Central nervous system tumor survivors have significant psychosocial problems. Negative outcomes were associated with cranial radiation therapy, female gender, and young age at diagnosis. Significant methodological problems hamper current knowledge. Systematic registration of psychosocial and somatic problems at diagnosis and prospectively through protocols is needed.

Neuropsychological differences between survivors of supratentorial and infratentorial brain tumours

BACKGROUND

The purpose of this study is to evaluate the relationship between brain tumour location and core areas of cognitive and behavioural functioning for paediatric brain tumour survivors. The extant literature both supports and refutes an association between paediatric brain tumour location and neurocognitive outcomes. We examined neuropsychological test data to identify any differences in neurocognitive and behavioural profile associated with supratentorial versus infratentorial tumour location.

METHODS

Following Institutional Review Board approval, the medical records and neuropsychological test data collected between 1997 and 2002 for 70 children treated for brain tumour at Children's Hospital Los Angeles were reviewed. Fifty-one per cent of the participants had tumours located in the supratentorial regions of the brain, whereas 49% had infratentorial tumours. Primary medical treatments involved tumour resection (90%), cranial radiation therapy (76%), chemotherapy (71%), and 59% all three medical procedures. The two tumour location groups did not differ significantly in the cumulative treatment dose of irradiation to the tumour bed or in the dose delivered to the whole brain. Neuropsychological test data included measures of verbal and non-verbal intellectual functioning, attention/working memory, processing speed, verbal and visual memory, fine motor skills, visual-motor integration, academic achievement, and social-emotional functioning. Differences between the two groups were evaluated using anova, t-tests and chi-squared statistical tests.

RESULTS

The supratentorial and infratentorial tumour location groups did not differ on measures of intellectual functioning. However, survivors of infratentorial tumours performed more poorly on selected measures of more specific cognitive functions and on parent-report of social-emotional functioning relative to survivors of supratentorial tumours, even when age at diagnosis was held as a covariate. Higher frequency of auditory deficits was noted in the infratentorial tumour group and was associated with lowered academic achievement scores.

CONCLUSIONS

The differences by location found in more specific neurocognitive and social-emotional variables, after controlling for age at diagnosis, may possibly reflect tumour location-specific effects. However, this interpretation remains tentative given the limitations in our study and inability to control for the range of medical and treatment-related factors that may have contributed towards the outcomes observed in our sample. At the same time, most of our findings appear consistent with reports from recent studies in this area.

Stereotactic radiotherapy and radiosurgery in pediatric patients: analysis of indications and outcome

INTRODUCTION

We describe indications, outcomes, and risk profiles of fractionated stereotactic radiotherapy (SRT) and single fraction "radiosurgery" (SRS) in pediatric patients compared to the adult population and evaluate the causal role of SRS and SRT in inducing new neurological complications.

MATERIALS AND METHODS

Six children with AVMs and 12 children with neoplastic diseases were prospectively followed for >2 years after SRT/S. The survival, control of pathology, and specified neurological complications were analyzed. In tumor patients, the median overall survival time was 45 months (range 5-103) and the median progression free survival time was 35 months (range 5-98).

RESULTS

Control or regression of the tumor was obtained in 83% of patients with neoplastic disease. Three patients with malignant tumors died from disease progression. In AVMs the median time follow up was 52 months (range 27-100). All AVMs were obliterated. New neurological deficits occurred in 67%. SRT/S was considered the direct cause in 25%. All the neurological deficiencies related to SRT/S were focal and related to the irradiated areas. In tumor patients, midline lesions, malignant diagnosis, and additional treatment with surgery, chemotherapy, and craniospinal irradiation seemed to increase the risk of new deficits after SRT/S. In AVM patients, a high Spetzler-Martin grade seemed to carry a higher complication risk.

CONCLUSION

The risk of uncontrolled tumor disease or the risk of hemorrhage of non-obliterated AVM must be balanced against the overall risks and benefits of SRT/S. Following SRT/S, the risk of worsening pre-existing deficits is relatively high. The risk of inducing new long-term deficits is relatively low.

Computerized tracking to train dexterity after cerebellar tumour: a single-case experimental study

PRIMARY OBJECTIVE

In a child with pure ataxia after tumour removal, does dexterity training at the right elbow improve dexterity at the right elbow? Does improvement in dexterity transfer to improvement in upper limb activity?

RESEARCH DESIGN

Single-case experimental study with 2-week baseline, 2-week intervention and 2-week follow-up phases and assessment by a blinded assessor.

METHODS AND PROCEDURES

A 5-year old child 3 years after surgical resection of a low-grade cerebellar tumour underwent to dexterity training. Dexterity was measured using a Finger-to-Nose Test and upper limb activity was measured using the 9-Hole Peg Test. Measures were collected every 2 or 3 days over the 6-week period of the study.

RESULTS

Finger-to-Nose Test showed visible but not statistical improvement between baseline and intervention phases in terms of smoothness of movement. On withdrawal of the intervention, visual analysis showed that scores remained at the same level. The 9-Hole Peg Test showed visible but not statistical improvement in terms of speed and smoothness of movement. On withdrawal of the intervention, visual analysis showed that improvement in speed was maintained during follow-up, but smoothness decreased.

CONCLUSIONS

There is some evidence that dexterity can be trained and that improvement carries over to activity.

Development of the Japanese version of the Pediatric Quality of Life Inventory Brain Tumor Module

Background

The Pediatric Quality of Life Inventory™ (PedsQL™) is a widely-used modular instrument for measuring health-related quality of life in children aged 2 to 18 years. The PedsQL™ Brain Tumor Module is comprised of six scales: Cognitive Problems, Pain and Hurt, Movement and Balance, Procedural Anxiety, Nausea, and Worry. In the present study, we developed the Japanese version of the PedsQL™ Brain Tumor Module and investigated its feasibility, reliability, and validity among Japanese children and their parents.

Methods

Translation equivalence and content validity were verified using the standard back-translation method and cognitive debriefing tests. Participants were recruited from 6 hospitals in Japan and the Children's Cancer Association of Japan, and questionnaires were completed by 137 children with brain tumors and 166 parents. Feasibility of the questionnaire was determined based on the amount of time required to complete the form and the percentage of missing values. Internal consistency was assessed using Cronbach's coefficient alpha. Test-retest reliability was assessed by retesting 22 children and 27 parents. Factorial validity was verified by exploratory factor analyses. Known-groups validity was described with regard to whole brain irradiation, developmental impairment, infratentorial tumors, paresis, and concurrent chemotherapy. Convergent and discriminant validity were determined using Generic Core Scales and State-Trait Anxiety Inventory for children.

Results

Internal consistency was relatively high for all scales (Cronbach's coefficient alpha > 0.70) except the Pain and Hurt scale for the child-report, and sufficient test-retest reliability was demonstrated for all scales (intraclass correlation coefficient = 0.45-0.95). Factorial validity was supported through exploratory factor analysis (factor-item correlation = 0.33-0.96 for children, 0.55-1.00 for parents). Evaluation of known-groups validity confirmed that the Cognitive Problems scale was sensitive for developmental impairment, the Movement and Balance scale for infratentorial tumors or paresis, and the Nausea scale for a patient currently undergoing chemotherapy. Convergent and discriminant validity with the PedsQL™ Generic Core Scales and State-Trait Anxiety Inventory for children were acceptable.

Conclusions

The Japanese version of the PedsQL™ Brain Tumor Module is suitable for assessing health-related quality of life in children with brain tumors in clinical trials and research studies.

Health-related quality of life in long-term survivors of childhood brain tumors

BACKGROUND

To identify predictors for health-related quality of life (HRQOL) in survivors of childhood brain tumors and its relationship to cognitive function.

PROCEDURE

One hundred twenty-six consecutive Danish childhood brain tumor patients treated 1970-1997 and being 7.9-40.4 years at follow-up were assessed for general intelligence (IQ) and administered the Minneapolis-Manchester Quality of Life (MMQL) questionnaire.

RESULTS

In multivariate linear regression treatment with RT was the most important risk factor for reduced HRQOL. Lower scores for physical functioning and energy, social functioning, cognitive functioning, body image, outlook of life, and intimate relations were significantly related to RT. Tumor location in the posterior fossa was associated with lower scores for physical functioning and energy, and tumor site in the third ventricle region was associated with lower scores for body image. Younger age at diagnosis was associated with lower scores for social functioning and intimate relations, and younger age at follow-up was associated with more physical symptoms. When IQ was included as a covariate, RT only remained significant for social functioning and intimate relations while tumor location in the third ventricle region remained significant for body image, younger age at diagnosis for social functioning and intimate relations, and younger age at follow-up for physical symptoms. In contrasts, neither gender nor presence of hydrocephalus requiring shunt inserted predicted significantly reduced HRQOL in the multivariate analyses.

CONCLUSION

RT is an important predictor of HRQOL primarily due to its effect on general intelligence, which suggests that IQ is a strong determinant of HRQOL.

Neurologic sequelae of brain tumors in children

Neurologic signs and symptoms are often the initial presenting features of a primary brain tumor and may also emerge during the course of therapy or as late effects of the tumor and its treatment. Variables that influence the development of such neurologic complications include the type, size, and location of the tumor, the patient's age at diagnosis, and the treatment modalities used. Heightened surveillance and improved neuroimaging modalities have been instrumental in detecting and addressing such complications, which are often not appreciated until many years after completion of therapy. As current brain tumor therapies are continually refined and newer targeted therapies are developed, it will be important for future cooperative group studies to include systematic assessments to determine the incidence of neurologic complications and to provide a framework for the development of novel strategies for prevention and intervention.

Late effects of therapy for pediatric brain tumor survivors

Approximately 2 of every 3 of all pediatric patients with brain tumors will be long-term survivors. However, there is a steep cost for pediatric brain tumor survivors, and the group as a whole faces significantly more late effects than many other survivors of pediatric cancers. Most of these effects can be attributed to direct neurologic damage to the developing brain caused by the tumor and its removal, the long-term toxicity of chemotherapy, or the effects of irradiation on the central nervous system. The late effects experienced by childhood brain tumor survivors involve multiple domains. This article will review the significant late effects that occur within the medical, neurocognitive, psychosocial, and economic domains of the survivorship experience. We conclude by discussing how the late effects in different domains often coexist and can create a complex set of obstacles that pose significant challenges for a survivor of a pediatric brain tumor on a daily basis.

Transitioning Survivors of Central Nervous System Tumors: Challenges for Patients, Families, and Health Care Providers

Survivors of central nervous system tumors (SCNST) are a growing group of cancer survivors who require risk-based, long-term health care due to the chemotherapy, surgery, and radiation they have received.Although treatment strategies are being developed to reduce morbidity and mortality, ultimately this subgroup of pediatric cancer survivors often faces moderate to severe late effects of their treatment.As a result, they will need lifelong health care that includes risk-based health care due to cancer treatment exposures as well as primary adult health care, including primary and secondary preventative care. The best way to accomplish lifelong health care for SCNST as they enter adulthood is not clearly defined. In this article, the authors plan to (1) present an overview of the complexities of health care problems that make transition challenging for SCNST; (2) review the evolving transition literature; (3) explore the barriers to successful transition; (4) discuss methods to facilitate transition; (5) describe approaches, strategies, and models for survivorship care in SCNST; (6) present issues for consideration when transitioning SCNST; and (7) provide information on transition-related resources.

Medical, psychological, cognitive and educational late-effects in pediatric low-grade glioma survivors treated with surgery only

BACKGROUND

Surgical resection is often the only treatment necessary for pediatric low-grade gliomas (LGGs) and is thought to define a population with an excellent long-term prognosis. The goal of this study was to describe the multidimensional late-effects of pediatric LGG survivors treated exclusively with surgery.

METHODS

A retrospective chart review of "surgery-only" LGG survivors followed at Dana-Farber/Children's Hospital Cancer Care was undertaken. Patients had to be diagnosed with an LGG before the age of 22 years, treated with "surgery-only" and be at least 2 years from diagnosis.

RESULTS

Sixty survivors were eligible with a median age at the time of review of 16.3 years and the median time since diagnosis of 8.4 years. Tumor locations were predominantly posterior fossa (47%) or cortical (33%). Eighty-five percent of patients had at least one ongoing late-effect, and 28% had three or more. The most common late-effects consisted of motor dysfunction (43%), visual problems (32%), anxiety (19%), social difficulties (19%), seizure disorders (17%), depression (15%), poor coordination/ataxia (14%), behavioral problems (13%), and endocrinopathies (10%). Nine patients had a history of suicidal ideation; two with suicide attempts. The mean full-scale IQ was normal, however, the number of survivors scoring one standard deviation below the mean was twice the expected number. Special education services were utilized by more than half of the survivors.

CONCLUSIONS

"Surgery-only" LGG survivors may be more affected by their tumor and its resection than previously appreciated. A prospective study is needed to address this survivor population.

Survival and late effects on development of patients with infantile brain tumor

BACKGROUND

Most infants with brain tumor may have a poor prognosis. The aim of the present study was to retrospectively analyze the survival and outcome with regard to mental and physical development in 11 subjects with brain tumor; these tumors were diagnosed when the patients were under 1 year of age.

METHODS

The histological diagnoses of these tumors were astrocytoma, n = 3; pineocytoma, n = 2; teratoma, n = 1; ependymoma, n = 1; atypical teratoid/rhabdoid tumor, n = 1; glioblastoma, n = 1; medulloblastoma, n = 1; and choroid plexus papilloma, n = 1. Surgical resection was performed in eight patients, and adjuvant chemotherapy was administered to all except one patient with choroid plexus papilloma. Radiotherapy was additionally performed for four of the 10 chemotherapy patients.

RESULTS

Six patients survived. Among the surviving patients, five were under no treatment for 50-167 months after the diagnosis (median duration, 89 months), while one received chemotherapy for 20 months. Five patients exhibited mental retardation, and one patient experienced normal development after surgical removal of his choroid plexus papilloma. Diencephalic syndrome developed in one patient with pilomyxoid astrocytoma that necessitated hormone replacement therapy, and bodyweight over +2 SD was observed in two patients. The remaining five patients died 11-111 months after diagnosis (median duration, 24 months).

CONCLUSION

The prognosis of infantile brain tumor with regard to mortality and developmental outcome remains poor. Furthermore, survivors require comprehensive medical and social support for an extended period.

Evolution of neurological impairment in pediatric infratentorial ependymoma patients

BACKGROUND

Infratentorial ependymoma is a common central nervous system tumor of childhood and in patients >1 year of age is treated with maximally feasible surgical resection and radiotherapy. Because of this tumor typically arises within the 4th ventricle and can invade the brainstem, patients are at risk for significant neurological impairment.

PURPOSE

To characterize the incidence, evolution, and persistence of neurologic impairment in children with infratentorial ependymoma following maximal safe surgery and conformal or intensity-modulated radiation therapy (CRT/IMRT).

PATIENTS AND METHODS

After surgical resection, 96 children with non-metastatic infratentorial ependymoma were enrolled on a phase II study of image-guided radiation therapy and were prospectively followed with interval comprehensive neurological examinations. Late adverse neurological severity was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 3.0.

RESULTS

The most common deficits detected at baseline examination were limb dysmetria, cranial nerve VI/VII palsy, limb paresis, dysphagia, and truncal ataxia/hypotonia. When present, gait dysfunction and dysphagia were often severe. Oculomotor dysfunction, facial paresis, dysphagia, and gait impairment improved over time. With the exception of hearing loss, in the survivor cohort, very few severe late effects (CTCAE Grade 3/4/5) were present at 60 months survival.

CONCLUSION

In general, neurological deficits were maximal in the post-operative period and either remained stable or improved during radiation and the post-treatment evaluation period. With the exception of hearing, the majority of chronic residual neurological deficits in this at-risk population are mild and only minimally intrude upon daily life.

Proton versus photon radiotherapy for common pediatric brain tumors: comparison of models of dose characteristics and their relationship to cognitive function

BACKGROUND

To determine whether proton radiotherapy has clinical advantages over photon radiotherapy, we modeled the dose characteristics of both to critical normal tissue volumes using data from patients with four types of childhood brain tumors.

PROCEDURES

Three-dimensional imaging and treatment planning data, including targeted tumor and normal tissues contours, were acquired for 40 patients, 10 each with optic pathway glioma (OPG), craniopharyngioma (CR), infratentorial ependymoma (EP), or medulloblastoma (MB). Dose-volume data were collected for the entire brain, temporal lobes, cochlea, and hypothalamus from each patient. The data were averaged and compared based on treatment modality (protons vs. photons) using dose-cognitive effects models. Outcomes were estimated over 5 years.

RESULTS

Relatively small critical normal tissue volumes such as the cochlea and hypothalamus may be spared from radiation exposure when not adjacent to the primary tumor volume. Larger normal tissue volumes such as the supratentorial brain or temporal lobes receive less of the low and intermediate doses. When applied to longitudinal models of radiation dose-cognitive effects, these differences resulted in clinically significant higher IQ scores for patients with MB and CR and academic reading scores in patients with OPG. Extreme differences between proton and photon dose distributions precluded meaningful comparison of protons and photons for patients with EP.

CONCLUSIONS

Differences in the overall dose distributions, as indicated by modeling changes in cognitive function, showed that a reduction in the lower-dose volumes or mean dose would have long-term, clinical advantages for children with MB, CR, and OPG.

Nuclear Medicine in Pediatric Neurology and Neurosurgery: Epilepsy and Brain Tumors

In pediatric drug-resistant epilepsy, nuclear medicine can provide important additional information in the presurgical localization of the epileptogenic focus. The main modalities used are interictal (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) and ictal regional cerebral perfusion study with single-photon emission computed tomography (SPECT). Nuclear medicine techniques have a sensitivity of approximately 85% to 90% in the localization of an epileptogenic focus in temporal lobe epilepsy; however, in this clinical setting, they are not always clinically indicated because other techniques (eg, icterictal and ictal electroencephalogram, video telemetry, magnetic resonance imaging [MRI]) may be successful in the identification of the epileptogenic focus. Nuclear medicine is very useful when MRI is negative and/or when electroencephalogram and MRI are discordant. A good technique to identify the epileptogenic focus is especially needed in the setting of extra-temporal lobe epilepsy; however, in this context, identification of the epileptogenic focus is more difficult for all techniques and the sensitivity of the isotope techniques is only 50% to 60%. This review article discusses the clinical value of the different techniques in the clinical context; it also gives practical suggestions on how to acquire good ictal SPECT and interictal FDG-PET scans. Nuclear medicine in pediatric brain tumors can help in differentiating tumor recurrence from post-treatment sequelae, in assessing the response to treatment, in directing biopsy, and in planning therapy. Both PET and SPECT tracers can be used. In this review, we discuss the use of the different tracers available in this still very new, but promising, application of radioisotope techniques.

Surviving childhood cancer: the impact on life

With modern therapies, most children diagnosed with cancer are expected to reach adulthood. Therefore, there are large and ever-increasing numbers of children and young adults in our population who are survivors of childhood cancer. Many of the therapies responsible for improved cancer survival rates can also damage normal cells and tissues. As more children survive cancer, the physical and emotional costs of enduring cancer therapy become increasingly important. Although most childhood cancer survivors are now expected to survive, they remain at risk for relapse, second malignant neoplasms, organ dysfunction, and a negative psychologic impact. Individual risk is quite variable and is dependent on multiple factors including the type and site of cancer, the therapy utilized, and the individual's constitution. The risks are likely to change as we learn more about the specific long-term effects of cancer therapy, develop more refined and targeted therapies, and develop and apply more effective preventative strategies or therapeutic interventions. Guidelines for long-term follow-up have been established and are available to help facilitate appropriate monitoring of and care for potential late effects.

Leaving home after cancer in childhood: a measure of social independence in early adulthood

BACKGROUND

Previous studies on psychosocial outcomes for childhood and adolescent cancer survivors have found diverse results concerning social independence. As a measure of social independence, we investigated whether cancer survivors displayed the same patterns of leaving home as population-based control group.

PROCEDURE

We identified 1,597 patients in the Danish Cancer Register, born in 1965-1980, in whom a primary cancer was diagnosed before they reached the age of 20 in the period 1965-1995. The patients were compared with a random sample of the general population (n = 43,905) frequency matched on sex and date of birth. By linking the two cohorts to registers in Statistics Denmark, we obtained socioeconomic data for the period 1980-1997. The relative risk for leaving home was estimated with discrete-time Cox regression models.

RESULTS

The risk for leaving home of survivors of hematological malignancies and solid tumors did not differ significantly from that of the control cohort. Adjustments for possible socioeconomic confounders did not change this pattern. In contrast, survivors of central nervous system (CNS) tumors had a significantly reduced risk for leaving home, which was most pronounced for men (relative risk, men: 0.66; 95% confidence interval, 0.55-0.80; women: 0.88, 95% confidence interval, 0.80-0.97).

CONCLUSION

Overall, the psychosocial effects of cancer in childhood or adolescence and its treatment on the survivor and family did not appear to impede social independence in early adulthood, except for survivors of CNS tumors.

Increased fluorine-18 2-fluoro-2-deoxy-D-glucose (FDG) uptake in childhood CNS tumors is correlated with malignancy grade: a study with FDG positron emission tomography/magnetic resonance imaging coregistration and image fusion

PURPOSE Positron emission tomography (PET) has been used in grading of CNS tumors in adults, whereas studies of children have been limited. PATIENTS AND METHODS Nineteen boys and 19 girls (median age, 8 years) with primary CNS tumors were studied prospectively by fluorine-18 2-fluoro-2-deoxy-D-glucose (FDG) PET with (n = 16) or without (n = 22) H(2)(15)O-PET before therapy. Image processing included coregistration to magnetic resonance imaging (MRI) in all patients. The FDG uptake in tumors was semiquantitatively calculated by a region-of-interest-based tumor hotspot/brain index. Eight tumors without histologic confirmation were classified as WHO grade 1 based on location, MRI, and clinical course (22 to 42 months). Results Four grade 4 tumors had a mean index of 4.27 +/- 0.5, four grade 3 tumors had a mean index of 2.47 +/- 1.07, 10 grade 2 tumors had a mean index of 1.34 +/- 0.73, and eight of 12 grade 1 tumors had a mean index of -0.31 +/- 0.59. Eight patients with no histologic confirmation had a mean index of 1.04. For these 34 tumors, FDG uptake was positively correlated with malignancy grading (n = 34; r = 0.72; P < .01), as for the 26 histologically classified tumors (n = 26; r = 0.89; P < .01). The choroid plexus papilloma (n = 1) and the pilocytic astrocytomas (n = 3) had a mean index of 3.26 (n = 38; r = 0.57; P < .01). H(2)(15)O-uptake showed no correlation with malignancy. Digitally performed PET/MRI coregistration increased information on tumor characterization in 90% of cases. CONCLUSION FDG PET of the brain with MRI coregistration can be used to obtain a more specific diagnosis with respect to malignancy grading. Improved PET/MRI imaging of the benign hypermetabolic tumors is needed to optimize clinical use.

Brain tumors in children

Pediatric brain tumors are a challenging group of very divergent diseases. Considerable controversy exists concerning the accurate diagnosis and treatment of these patients. Aggressive therapy is often needed to cure aggressive and potentially lethal disease, yet late effects, especially injury to the developing brain, remain a profound problem. The discipline of pediatric neuro-oncology remains one of the most productive areas for continued clinical and basic research because of these and other challenges.

Evaluation of quality of life in long-term survivors of paediatric brain stem tumors, treated with radiotherapy

The quality of life in long-term survivors of paediatric brain stem tumors, treated with radiotherapy is evaluated. They suffer predominantly from pre-treatment neurological impairments, which seriously influence their quality of life. The most often observed treatment sequelae are pituitary insufficiency and hearing loss.