Surgical management of pediatric brain tumors

Surgical techniques in the management of supratentorial pediatric brain tumors: 10 years' experience at a tertiary care center in the Middle East

Background:

The goal of this retrospective study is to present the first epidemiological data on pediatric supratentorial central nervous system (CNS) tumors in Lebanon and to review the various surgical management strategies used.

Methods:

We conducted a retrospective case series of all pediatric patients who presented with a supratentorial CNS tumor and underwent surgery at our institution between 2006 and 2016. We collected and analyzed demographic characteristics, tumor location, clinical manifestations, histopathology, and surgical management strategies and outcome, and discussed them after dividing the tumors as per location and in view of published literature.

Results:

Ninety-nine children were studied with a male-to-female ratio of 2.3:1 and a mean age of 8.5 years. The most common location was convexity (44%) and included low-grade and high-grade glial tumors, along with other miscellaneous lesions. The next location was sellar/diencephalic (34%), including craniopharyngiomas, hypothalamic/optic pathway/thalamic gliomas, hamartomas, and pituitary/Rathke’s cyst, where there was notable use of endoscopic techniques (21%). Tumors in the pineal region (13%) were tectal gliomas, germ cell tumors, and pineoblastomas and were mostly treated endoscopically. The last group was lateral intraventricular tumors (8%) and was mostly choroid plexus lesions and ependymomas. Overall, the surgical objective was achieved in 95% with mild/moderate complications in 17%.

Conclusion:

A variety of pathologies may affect the pediatric population in the supratentorial region. Different surgical strategies, including microsurgical and endoscopic techniques, may be employed to remove, debulk, or biopsy these tumors depending on their location, suspected diagnosis, prognosis, and the need for treatment of possible associated hydrocephalus.

Neuroophthalmic Manifestations of Intracranial Tumours in Children

BACKGROUND

All children between 0 and 16 years presenting with brain tumours confirmed by Magnetic Resonance Imaging (MRI) and treated surgically in our institute were included in this study.

OBJECTIVE

The aim of this study is to evaluate the neuroophthalmic and clinical characteristics of intracranial space occupying lesions in children.

METHODS

Neuroophthalmic manifestations along with location of the tumour by contrast-enhanced MRI, type of surgical intervention, and postoperative histopathological diagnosis were evaluated.

RESULTS

In pediatric brain tumours, male preponderance was seen and supratentorial location was more common in general, while in older children, infratentorial tumours were more common than supratentorial tumours. Headache, vomiting, and cerebellar signs were the commonest neurological features. Diminution of vision, diplopia, and strabismus were the commonest ophthalmic symptoms. Papilledema, ophthalmoparesis, and nystagmus were the most frequent ophthalmological signs. Neurological manifestations of seizures, altered sensorium and motor deficits were more frequently seen in supratentorial tumours, while cranial nerve involvement and ataxia were seen in infratentorial tumours. Ophthalmological manifestations including diplopia, strabismus, ophthalmoparesis, and nystagmus were more frequently seen in infratentorial tumours. Astrocytoma was the most frequent histopathological diagnosis followed by medulloblastoma.

CONCLUSION

Diagnosis of pediatric intracranial tumours is complex and requires a multidisciplinary approach for prompt management. An ophthalmologist should have a high index of suspicion for brain tumours especially in patients presenting with common ocular symptoms like diminution of vision, diplopia, and strabismus without any neurological symptoms.

Improving Care in Pediatric Neuro-oncology Patients: An Overview of the Unique Needs of Children With Brain Tumors

Brain tumors represent the most common solid tumors in childhood, accounting for almost 25% of all childhood cancer, second only to leukemia. Pediatric central nervous system tumors encompass a wide variety of diagnoses, from benign to malignant. Any brain tumor can be associated with significant morbidity, even when low grade, and mortality from pediatric central nervous system tumors is disproportionately high compared to other childhood malignancies. Management of children with central nervous system tumors requires knowledge of the unique aspects of care associated with this particular patient population, beyond general oncology care. Pediatric brain tumor patients have unique needs during treatment, as cancer survivors, and at end of life. A multidisciplinary team approach, including advanced practice nurses with a specialty in neuro-oncology, allows for better supportive care. Knowledge of the unique aspects of care for children with brain tumors, and the appropriate interventions required, allows for improved quality of life.

Giant cell reparative granuloma of the pediatric cranium: case report and review of the literature

PURPOSE

Giant cell reparative granulomas are rare bone tumors. Although benign, these tumors are locally destructive and can be highly vascular. They seldom occur in the cranial vault. We describe a multidisciplinary approach to a case of giant cell reparative granuloma of the cranium in a 3-year-old patient.

CASE REPORT

A 3-year-old girl female referred to the pediatric neurosurgery department for evaluation of a retro-auricular mass. She had a history of recurrent otitis media with two subsequent courses of antibiotics without resolution. CT imaging revealed an expansive lesion located in the right mastoid region. Open surgical biopsy revealed a hemorrhagic tumor consistent with a giant cell reparative granuloma. Angiography identified a hypervascular tumor blush that was supplied by the occipital artery. Preoperative transcatheter embolization was performed followed by a multidisciplinary surgical resection and reconstruction. Blood loss was minimal, and the patient recovered well after surgery.

CONCLUSION

Preoperative endovascular embolization and a multidisciplinary intraoperative approach with primary resection and cranial vault reconstruction is an effective approach to hypervascular giant cell reparative granulomas.

Preoperative embolization of hypervascular pediatric brain tumors: evaluation of technical safety and outcome

BACKGROUND

Surgical management of pediatric hypervascular brain tumors is challenging because of the risk of bleeding. We sought to evaluate the technical factors associated with safety and outcome of preoperative embolization of pediatric hypervascular brain tumors.

MATERIALS AND METHODS

Eight pediatric brain tumor patients received preoperative endovascular embolization during the past 8 years. The cases included four choroid plexus papillomas, one yolk sac tumor, one intraventricular meningioma, one astrocytoma, and one hemangioblastoma. Embolization was done by superselection of the feeding arteries with microcatheters followed by slow injection of either n-butyl 2-cyanoacrylate (NBCA) or tris-acryl gelatin microspheres (Embosphere). Surgery for tumor removal was done in the same session right after embolization in all but one patient. Blood loss during surgery and clinical outcome were recorded.

RESULTS

Preoperative embolization was successfully done in all patients. Technical complication was noted in two patients. One patient developed bleeding while embolizing the tumor with Embospheres but was immediately embolized with NBCA without sequel. The other patient experienced tumor bleeding 4 h after embolization with Embospheres, and suffered left hemiparesis despite an emergency surgery. Surgical intervention was successfully done in all patients without procedure-related complication. Surgical blood loss ranged from 50 to 1,600 ml.

CONCLUSION

Though associated with the risk of procedure-related bleeding, preoperative embolization of pediatric hypervascular brain tumors has high technical success rates and can enhance the surgical management. We suggest to perform the embolization and surgery in a single session and to use NBCA as the embolic agent to minimize the procedure-related risk.

Surgical treatment of brain tumors in infants younger than six months of age and review of the literature

OBJECTIVE

Brain tumors are rare in infants who are younger than six months of age. These tumors can be challenging to treat surgically. We analyzed a modern series of patients treated by a multidisciplinary team at a tertiary care center and performed a literature review of this unique population.

METHODS

Retrospective clinical data were collected for patients surgically treated for intracranial mass lesions at The Children's Hospital of Philadelphia from 1998 to 2007. Dermoid cysts and other skull-based lesions were excluded from the analysis.

RESULTS

Sixteen patients younger than six months of age underwent surgery for primary intracranial mass lesions. The median age of the patients at surgery was 5.2 months (range, 1.4-6 months of age). Children most often presented with a bulging fontanelle, hydrocephalus, or macrocephaly (seven patients). Vomiting was seen in five patients, cranial nerve palsies in one patient, and seizures in three patients. All patients had tumor resections and postoperatively were monitored in the intensive care unit. The final pathology consisted of atypical teratoid/rhabdoid tumor (three patients), primitive neuroectodermal tumor/medulloblastoma (three patients), choroid plexus papilloma (two patients), astrocytoma (two patients), ganglioglioma (two patients), desmoplastic infantile ganglioglioma (two patients), glioblastoma multiforme (one patient), and choroid plexus carcinoma (one patient). Two intraoperative deaths occurred. Of the surviving 14, a gross total resection was achieved in four. Adjuvant therapy was determined by a multidisciplinary team composed of neuro-oncology, neurosurgery, and radiation oncology. Seven patients were treated with chemotherapy, and one patient had proton beam therapy. Five-year overall survival was 45%. The eight surviving patients had neurological sequelae, and developmental outcome was variable.

CONCLUSIONS

Brain tumors are uncommon in children younger than six months of age. Patients present with a variety of tumor pathologies. Children who survive have neurological sequelae. More studies are necessary to understand the impact that different treatment options, tumor pathology, and tumor location have on neurological outcome.

Harvey Cushing and pediatric brain tumors at Johns Hopkins: the early stages of development

OBJECT

Harvey Cushing, credited with pioneering the field of neurosurgery as a distinct surgical subspecialty in the US, was at the forefront of neurooncology, publishing seminal papers on the diagnosis and treatment of pediatric brain tumors during the latter part of his career. However, his contributions to the surgical treatment of these lesions during the early stages of his tenure at the Johns Hopkins Hospital, from 1896 to 1912, remain largely unknown.

METHODS

After obtaining institutional review board approval, and through the courtesy of the Alan Mason Chesney Archives, the authors reviewed the Johns Hopkins Hospital surgical files from the years 1896 to 1912. Patients younger than 18 years of age, presenting with symptoms suspicious for an intracranial tumor, and undergoing surgical intervention by Cushing were selected for further analysis.

RESULTS

Of the 40 pediatric patients undergoing surgery for suspected intracranial neoplasms, 26 were male. The mean age among the entire sample was 10.1 years. Cushing used three main operative approaches in the surgical treatment of pediatric intracranial neoplasms: infratentorial/suboccipital, subtemporal, and hemisphere flap. Twenty-three patients had negative findings following both the primary and subsequent surgical interventions conducted by Cushing. Postoperative conditions following the primary surgical intervention were improved in 24 patients. Twelve patients (30%) died during their inpatient stay for the primary intervention. The mean time to the last follow-up was 24.9 months; the mean time to death was 10.0 months.

CONCLUSIONS

Cushing strove to maximize exposure while minimizing blood loss in an attempt to increase his ability to successfully treat pediatric brain tumors. His early contributions to the field of pediatric neurooncology demonstrate his commitment to advancing the field of neurosurgery.

"Groans less, seems more comfortable:" Harvey Cushing's redefinition of success in the operative treatment of pediatric intracranial lesions

BACKGROUND

Challenges to diagnosing and localizing intracranial lesions in pediatric patients were immense during the advent of neurosurgery. For patients with suspected intracranial tumors, but with negative findings on operation, there were few options. The role of palliative surgical interventions, from decompressive craniectomies to lumbar and ventricular punctures, is not well-represented in the literature during this early stage.

OBJECTIVE

To review Harvey Cushing's original surgical files and analyze his use of decompressive procedures in pediatric patients with suspected intracranial tumors, with negative findings during operative interventions.

METHODS

Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912. Patients, ≤18 years old, presenting with suspected intracranial tumors, undergoing surgical intervention by Cushing, without discovery of intracranial pathology, were selected for further analysis.

RESULTS

Of the 23 pediatric patients selected, 17 were male. The mean age was 10.6 years. Cushing used three main operative approaches: infratentorial/suboccipital, subtemporal, and hemisphere flaps. Post-operative condition was improved in 13 and unchanged in three patients. Seven patients died during their inpatient stay. The mean time to follow-up was 34.79 months; the mean time to death was 11.9 months.

CONCLUSIONS

These examples illustrate Cushing's commitment to improving quality of life in patients, offering decompressive procedures, including craniectomies as well as cerebrospinal fluid drainage in the operating room and at the bedside, when attempts at localizing and resecting of suspected tumors were unsuccessful.

Variations in referral patterns for hypophysectomies among pediatric patients with sellar and parasellar tumors

PURPOSE

It has been shown that patients admitted to high-volume hospitals for resection of sellar and parasellar lesions experience reduced mortality and morbidity. It remains unknown what preoperative factors influence admission to high-volume centers. We report a nationwide analysis of patients <18 years of age undergoing neurosurgical intervention for these lesions.

METHODS

A retrospective analysis of the Nationwide Inpatient Sample was performed with additional factors from the Area Resource File. International Classification of Diseases, 9th Revision diagnosis/procedural codes were used to identify patients undergoing resection of tumors from the pituitary gland or related structures. Patients >or=18 years old were excluded. Covariates included age, gender, race, and insurance status. Multivariate analysis was performed using multiple logistic regression models. A p value <0.05 was considered statistically significant.

RESULTS

In total, 1,063 patients were identified. Most (69.8%) were seen at low-volume centers. Mean (median) patient age was 13.7 (15) years. The majority of patients were female (54.8%), white (61.9%), and insured (90.3%). Hispanics were 44% less likely (odds ratio (OR) 0.56, 95% confidence interval (CI) 0.34-0.92, p < 0.05) to be seen at high-volume centers than their Caucasian counterparts. Each increase in 2-year patient age category was associated with greater access to high-volume centers (OR 1.12, 95% CI 1.03-1.23, p < 0.05), relative to 0-2 years old. Female gender, insurance status, county poverty, neurosurgeon density, and calendar year were not significantly associated with admission to high-volume centers.

CONCLUSIONS

Age and racial disparities play a significant role in access neurosurgical care, affecting admission of pediatric patients to high-volume neurosurgical centers across the USA.

Surgical treatment of a clival-C2 atypical teratoid/rhabdoid tumor

The authors present the case of en bloc resection of a clival-C2 atypical teratoid/rhabdoid tumor. These aggressive lesions of early childhood generally occur in the cerebellum or cerebral hemispheres. This 7-year-old boy presented with pain on turning his head and was found to have a clival-C2 mass. A metastatic workup was negative for disseminated disease. A transoral biopsy procedure revealed an atypical teratoid/rhabdoid tumor on histological examination. The tumor was resected via a transoral approach, and the patient's spine was stabilized with posterior instrumented fusion from the occiput to C-5. Postoperatively, the patient underwent 16 months of chemotherapy along with 6 weeks of overlapping radiation therapy. Twenty-seven months after the initial surgery he presented with leg pain and was found to have a solitary metastatic lesion at the conus medullaris. There was no local recurrence at the clivus. The conus tumor was resected and found to be consistent with the primary tumor. Several months later the patient presented with disseminated intrathecal disease and ultimately died 42 months after the initial resection.

Small molecule inhibitors in children with malignant gliomas

Pediatric high grade gliomas (HGG) remain difficult to cure despite recent advances in imaging, neurosurgery, and radiation. Current treatment modalities have demonstrated only modest survival benefit. Research utilizing molecular biologic techniques reveals that the phenotype of HGG is complex and results from dysregulation of numerous inter-related cellular pathways. Knowledge of potential molecular targets along dysregulated pathways has led to the development of novel and highly specific targeted therapies, which include small molecule inhibitors. This article will review small molecule inhibition of cellular pathways involved in gliomagenesis, challenges to small molecule therapy, and future directions in the use of this therapy.