The role of postoperative radiotherapy in pediatric patients with grade II intracranial ependymomas: a population-based, propensity score-matched study

Do We Need Radiotherapy in Grade II Ependymoma?

Purpose/Objectives

The debate on whether radiotherapy (RT) is an essential part of primary treatment in patients with grade II ependymoma (G2E) is still ongoing, and this study aimed to evaluate its role.

Materials/Methods

A retrospective analysis of all the consecutive patients treated due to G2E in years 1985–2019 was performed. The group consisted of 116 patients with a small predominance of woman (55% vs. 45%) and the location of the tumor in the brain (58% vs. 42%). All had surgery as the primary treatment with 47% R0 resection. Radical RT was applied in 81 patients. In majority of cases (91%), patients received local irradiation.

Results

Median follow-up was 65 months, and during that time, 17 patients died. Five- and 10-year overall survival (OS) of the whole group was 87% and 83%. Radical surgery (R0 vs. R1/2) improved OS (p = 0.004), but the difference was observed only in patients with brain lesions (p = 0.01). Five- and 10-year progression-free survival (PFS) was 68% and 51%, respectively. Looking at the treatment of recurrence, those who received RT as a part of the treatment of the recurrent tumor had better OS (p = 0.048)—5- and 10-year OS of 85% and 78% vs. 66% and 57%. In the multivariate analysis, radical surgery (R0 vs. R1/2) and the use of RT in the primary treatment improved PFS (p = 0.006 and 0.007). Based on the location of the tumor, the positive influence of RT on PFS was observed only in the case of patients with brain tumors (p = 0.01). Also, comparing R1/2 surgery with R0 resection—the benefit of RT was only observed in R1/2 group (0.02).

Conclusions

RT in the case of patients with G2E is a valuable treatment of the recurrent disease. Patients with brain lesions after nonradical surgery might benefit from the local irradiation in terms of PFS.

Polish Multi-Institutional Study of Children with Ependymoma-Clinical Practice Outcomes in the Light of Prospective Trials

We performed a multi-institutional analysis of 74 children with ependymoma to evaluate to what extent the clinical outcome of prospective trials could be reproduced in routine practice. The evaluation of factors that correlated with outcome was performed with a log rank test and a Cox proportional-hazard model. Survival was estimated with the Kaplan–Meier method. The majority of patients had brain tumours (89%). All had surgery as primary treatment, with adjuvant radiotherapy (RTH) and chemotherapy (CTH) applied in 78% and 57%, respectively. Median follow-up was 80 months and 18 patients died. Five- and 10-year overall survival (OS) was 83% and 73%. Progression was observed in 32 patients, with local recurrence in 28 cases. The presence of metastases was a negative prognostic factor for OS. Five- and 10-year progression-free survival (PFS) was 55% and 40%, respectively. The best outcome in patients with non-disseminated brain tumours was observed when surgery was followed by RTH (+/−CTH afterwards; p = 0.0001). Children under 3 years old who received RTH in primary therapy had better PFS (p = 0.010). The best outcome of children with ependymoma is observed in patients who received radical surgery followed by RTH, and irradiation should not be omitted in younger patients. The role of CTH remains debatable.

Treatment trends and overall survival in patients with grade II/III ependymoma: The role of tumor grade and location

BACKGROUND

Treatment of ependymoma (EPN) is guided by associated tumor features, such as grade and location. However, the relationship between these features with treatments and overall survival in EPN patients remains uncharacterized. Here, we describe the change over time in treatment strategies and identify tumor characteristics that influence treatment and survival in EPN.

METHODS AND MATERIALS

Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 18 Registries (1973-2016) database, we identified patients with EPN microscopically confirmed to be grade II (EPN-GII) or III (EPN-GIII) tumors between 2004-2016. Overall survival (OS) was analyzed using Kaplan-Meier survival estimates and multivariable Cox proportional hazard models. A sub-analysis was performed by tumor location (supratentorial, posterior fossa, and spine). Change over time in rates of gross total resection (GTR), radiotherapy (RT), and chemotherapy (CS) were analyzed using linear regression, and predictors of treatment were identified using multivariable logistic regression models.

RESULTS

Between 2004-2016, 1,671 patients were diagnosed with EPN, of which 1,234 (74 %) were EPN-GII and 437 (26 %) EPN-GIII. Over the study period, EPN-GII patients underwent a less aggressive treatment (48 % vs 27 %, GTR; 60 % vs 30 %, RT; 22 % vs 2%, CS; 2004 vs 2016; p < 0.01 for all). Age, tumor size, location, and grade were positive predictors of undergoing treatment. Univariate analysis revealed that tumor grade and location were significantly associated with OS (p < 0.0001 for both). In multivariable Cox regression, tumor grade was an independent predictor of OS among patients in the cohort (grade III, HR 3.89 [2.84-5.33]; p < 0.0001), with this finding remaining significant across all tumor locations.

CONCLUSIONS

In EPN, tumor grade and location are predictors of treatment and overall survival. These findings support the importance of histologic WHO grade and location in the decision-making for treatment and their role in individualizing treatment for different patient populations.

Personalizing age-specific survival prediction and risk stratification in intracranial grade II/III ependymoma

BACKGROUND

Models for estimation of survival rates of patients with intracranial grade II/III ependymoma (EPN) are scarce. Considering the heterogeneity in prognostic factors between pediatric and adult patients, we aimed to develop age-specific nomograms for predicting 3-, 5-, and 8-year survival for these patients.

METHODS

A total of 1390 cases (667 children; 723 adults) of intracranial grade II/III EPNs diagnosed between 1988 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database for our study. Univariable and multivariable Cox analyses were employed to identify independent prognostic predictors. Age-specific nomograms were developed based on the results of multivariate Cox analyses. We also evaluated the performance of these predictive models by concordance index, calibration curves, time-dependent receiver operating characteristic curves, and decision curve analyses.

RESULTS

Considerable heterogeneity in prognostic factors was highlighted between pediatric and adult patients. Age, sex, tumor grade, surgery treatment and radiotherapy were identified as significant predictors of overall survival for children, and age, tumor grade, tumor size, surgery treatment, and marital status for adult. Based on these factors, age-specific nomogram models were established and internally validated. These models exhibited favorable discrimination and calibration characteristics. Nomogram-based risk classification systems were also constructed to facilitate risk stratification in EPNs for optimization of clinical management.

CONCLUSIONS

We developed the first nomograms and corresponding risk classification systems for predicting survival in patients with intracranial grade II/III EPN. These easily used tools can assist oncologists in making accurate survival evaluation.