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Cacciotti C, Lenzen A, Self C, Pillay-Smiley N. Recurrence Patterns and Surveillance Imaging in Pediatric Brain Tumor Survivors. J Pediatr Hematol Oncol 2024; 46:e227-e232. [PMID: 38447113 PMCID: PMC10956682 DOI: 10.1097/mph.0000000000002850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/11/2024] [Indexed: 03/08/2024]
Abstract
Surveillance magnetic resonance imaging (MRI) is routinely used to detect recurrence in pediatric central nervous system (CNS) tumors. The frequency of neuroimaging surveillance varies without a standardized approach. A single-institutional retrospective cohort study evaluated the frequency of recurrences. This study included 476 patients with the majority diagnosed with low-grade glioma (LGG) (n=138, 29%), high-grade glioma (HGG) (n=77, 16%), ependymoma (n=70, 15%), or medulloblastoma (n=61, 13%). LGG, HGG, and ependymoma patients more commonly had multiply recurrent disease ( P =0.08), with ependymoma patients demonstrating ≥2 relapses in 47% of cases. Recurrent disease was identified by imaging more often than clinical symptoms (65% vs. 32%; P =<0.01). Patients diagnosed with meningioma demonstrated the longest mean time to first relapse (74.7 mo) whereas those with atypical teratoid rhabdoid tumor and choroid plexus carcinoma tended to have the shortest time to relapse (8.9 and 9 mo, respectively). Overall, 22 patients sustained first relapse >10 years from initial diagnosis. With a higher tendency toward detection of tumor recurrence/progression on MRI surveillance in comparison to clinical progression, surveillance imaging is necessary in routine follow up of pediatric CNS tumor survivors. With some relapses >10 years from initial diagnosis, imaging beyond this time point may be useful in particular tumor types. While the study is limited in outcome analysis, earlier detection of recurrence would lead to earlier initiation of treatment and implementation of salvage treatment regimens which can impact survival and quality of life.
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Affiliation(s)
- Chantel Cacciotti
- Children’s Hospital London Health Sciences/Western University, London, Ontario, Canada
| | - Alicia Lenzen
- Ann & Robert H. Lurie Children’s Hospital/Northwestern University, Chicago, IL
| | | | - Natasha Pillay-Smiley
- University of Cincinnati Medical Center and Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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2
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Maa van Roessel I, Bakker B, van Santen HM, Chemaitilly W. Hormone replacement in survivors of childhood cancer and brain tumors: safety and controversies. Endocr Connect 2023; 12:e220382. [PMID: 36347051 PMCID: PMC9782441 DOI: 10.1530/ec-22-0382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 11/09/2022]
Abstract
Childhood cancer survivors are at risk for developing endocrine disorders, including deficits in growth hormone, thyroid hormone and sex hormones. The influence these hormones have on cell growth and metabolism has raised concerns regarding the safety of their use as treatments in survivors of childhood cancer and brain tumors. This article offers a summary of current knowledge, controversies and areas for future research pertaining to this area.
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Affiliation(s)
- Ichelle Maa van Roessel
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, AB Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, AB Utrecht, The Netherlands
| | - Boudewijn Bakker
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, AB Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, AB Utrecht, The Netherlands
| | - Hanneke M van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, AB Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, AB Utrecht, The Netherlands
| | - Wassim Chemaitilly
- Division of Pediatric Endocrinology, UPMC Children’s Hospitalof Pittsburgh, Pittsburgh, Pennsylvania, USA
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Jo J, van den Bent MJ, Nabors B, Wen PY, Schiff D. Surveillance imaging frequency in adult patients with lower-grade (WHO Grade 2 and 3) gliomas. Neuro Oncol 2022; 24:1035-1047. [PMID: 35137214 PMCID: PMC9248400 DOI: 10.1093/neuonc/noac031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
With improved outcome following aggressive treatment in patients with grade 2 and 3 IDH-mutant (IDHmt), 1p/19q codeleted oligodendroglioma and IDHmt, non-codeleted astrocytoma, prolonged surveillance is desirable for early detection of tumor growth and malignant transformation. Current National Comprehensive Cancer Network (NCCN) guidelines provide imaging follow-up recommendations based on molecular classification of lower-grade gliomas, although individualized imaging guidelines based on treatments received and after tumor recurrence are not clearly specified. Other available guidelines have yet to incorporate the molecular biomarkers that inform the WHO classification of gliomas, and in some cases do not adequately consider current knowledge on IDHmt glioma growth rate and recurrence patterns. Moreover, these guidelines also do not provide specific recommendations for concerning clinical symptoms or radiographic findings warranting imaging studies out of prespecified intervals. Focusing on molecularly defined grade 2 and 3 IDHmt astrocytomas and oligodendrogliomas, we review current knowledge of tumor growth rates and time to tumor progression for each tumor type and propose a range of recommended MRI surveillance intervals for both the newly diagnosed and recurrent tumor setting. Additionally, we summarize situations in which imaging is advisable outside of these intervals.
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Affiliation(s)
- Jasmin Jo
- Department of Internal Medicine, Division of Hematology and Oncology, East Carolina University, Greenville, North Carolina, USA
| | - Martin J van den Bent
- Department of Neuro-Oncology/Neurology, Erasmus MC Cancer Institute, Erasmus MC University Medical Center, Rotterdam, Netherland
| | - Burt Nabors
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women’s Cancer Center; Division of Neuro-Oncology, Department of Neurology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - David Schiff
- Corresponding Author: David Schiff, MD, University of Virginia Neuro-Oncology Center, Box 800432 Charlottesville, VA 22908-0432, USA ()
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Surveillance imaging of grade 1 astrocytomas in children: can duration and frequency of follow-up imaging and the use of contrast agents be reduced? Neuroradiology 2020; 63:953-958. [PMID: 33241451 PMCID: PMC7688203 DOI: 10.1007/s00234-020-02609-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022]
Abstract
Purpose The optimum strategy for the surveillance of low-grade gliomas in children has not been established, and there is concern about the use of gadolinium-based contrast agents (GBCAs), particularly in children, due to their deposition in the brain. The number of surveillance scans and the use of GBCAs in surveillance of low-risk tumours should ideally be limited. We aimed to investigate the consistency and utility of our surveillance imaging and also determine to what extent the use of GBCAs contributed to decisions to escalate treatment in children with grade 1 astrocytomas. Methods This was a retrospective single-centre study at a tertiary paediatric hospital. All children with a new diagnosis of a non-syndromic World Health Organization (WHO) grade 1 astrocytoma between 2007 and 2013 were included, with surveillance imaging up to December 2018 included in analysis. The intervals of surveillance imaging were recorded, and imaging and electronic health records were examined for decisions related to treatment escalation. Results Eighty-eight patients had 690 surveillance scans in the study period. Thirty-one patients had recurrence or progression leading to treatment escalation, 30 of whom were identified on surveillance imaging. The use of GBCAs did not appear to contribute to multidisciplinary team (MDT) decisions in the majority of cases. Conclusion Surveillance imaging could be reduced in number and duration for completely resected cerebellar tumours. MDT decisions were rarely made on the basis of post-contrast imaging, and GBCA administration could therefore potentially be restricted in the setting of surveillance of grade 1 astrocytomas in children.
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Abstract
BACKGROUND Clinical practice guidelines suggest that magnetic resonance imaging (MRI) of the brain should be performed at certain time points or intervals distant from diagnosis (interval or surveillance imaging) of cerebral glioma, to monitor or follow up the disease; it is not known, however, whether these imaging strategies lead to better outcomes among patients than triggered imaging in response to new or worsening symptoms. OBJECTIVES To determine the effect of different imaging strategies (in particular, pre-specified interval or surveillance imaging, and symptomatic or triggered imaging) on health and economic outcomes for adults with glioma (grades 2 to 4) in the brain. SEARCH METHODS The Cochrane Gynaecological, Neuro-oncology and Orphan Cancers (CGNOC) Group Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase up to 18 June 2019 and the NHS Economic Evaluation Database (EED) up to December 2014 (database closure). SELECTION CRITERIA We included randomised controlled trials, non-randomised controlled trials, and controlled before-after studies with concurrent comparison groups comparing the effect of different imaging strategies on survival and other health outcomes in adults with cerebral glioma; and full economic evaluations (cost-effectiveness analyses, cost-utility analyses and cost-benefit analyses) conducted alongside any study design, and any model-based economic evaluations on pre- and post-treatment imaging in adults with cerebral glioma. DATA COLLECTION AND ANALYSIS We used standard Cochrane review methodology with two authors independently performing study selection and data collection, and resolving disagreements through discussion. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included one retrospective, single-institution study that compared post-operative imaging within 48 hours (early post-operative imaging) with no early post-operative imaging among 125 people who had surgery for glioblastoma (GBM: World Health Organization (WHO) grade 4 glioma). Most patients in the study underwent maximal surgical resection followed by combined radiotherapy and temozolomide treatment. Although patient characteristics in the study arms were comparable, the study was at high risk of bias overall. Evidence from this study suggested little or no difference between early and no early post-operative imaging with respect to overall survival (deaths) at one year after diagnosis of GBM (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.61 to 1.21; 48% vs 55% died, respectively; very low certainty evidence) and little or no difference in overall survival (deaths) at two years after diagnosis of GBM (RR 1.06, 95% CI 0.91 to 1.25; 86% vs 81% died, respectively; very low certainty evidence). No other review outcomes were reported. We found no evidence on the effectiveness of other imaging schedules. In addition, we identified no relevant economic evaluations assessing the efficiency of the different imaging strategies. AUTHORS' CONCLUSIONS The effect of different imaging strategies on survival and other health outcomes remains largely unknown. Existing imaging schedules in glioma seem to be pragmatic rather than evidence-based. The limited evidence suggesting that early post-operative brain imaging among GBM patients who will receive combined chemoradiation treatment may make little or no difference to survival needs to be further researched, particularly as early post-operative imaging also serves as a quality control measure that may lead to early re-operation if residual tumour is identified. Mathematical modelling of a large glioma patient database could help to distinguish the optimal timing of surveillance imaging for different types of glioma, with stratification of patients facilitated by assessment of individual tumour growth rates, molecular biomarkers and other prognostic factors. In addition, paediatric glioma study designs could be used to inform future research of imaging strategies among adults with glioma.
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Affiliation(s)
- Gerard Thompson
- University of EdinburghCentre for Clinical Brain SciencesChancellor’s Building FU201a49 Little France CrescentEdinburghScotlandUKEH16 4SB
| | - Theresa A Lawrie
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
| | - Ashleigh Kernohan
- Newcastle UniversityInstitute of Health & SocietyBaddiley‐Clark Building, Richardson RoadNewcastle upon TyneUKNE2 4AA
| | - Michael D Jenkinson
- Institute of Translational MedicineUniversity of Liverpool & Department of NeurosurgeryThe Walton Centre NHS Foundation TrustLiverpoolMerseysideUK
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Monroe CL, Travers S, Woldu HG, Litofsky NS. Does Surveillance-Detected Disease Progression Yield Superior Patient Outcomes in High-Grade Glioma? World Neurosurg 2019; 135:e410-e417. [PMID: 31821913 DOI: 10.1016/j.wneu.2019.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Standard follow-up care for patients with high-grade glioma (HGG) involves routine surveillance imaging to detect disease progression, assess treatment response, and monitor clinical symptoms. Although logical in nature, evidence supporting this practice is limited. We hypothesize patients with tumor recurrence detected on routine surveillance imaging will experience superior outcomes relative to symptomatic detection, using measures of survival and postrecurrence neurologic function. METHODS Adult patients receiving treatment for HGG at our institution from 2004 to 2018 were identified, and data including tumor characteristics, imaging results, neurologic status, and survival were extracted from the medical records of patients meeting inclusion criteria. All participants were followed for a minimum of 12 months, or for survival duration. Survival and neurologic function differences were assessed using log rank and 2-sample t tests with 2-sided 0.05 alpha level of significance. RESULTS Of the 74 patients meeting inclusion criteria, 47 (63.5%) had recurrence detected via routine surveillance imaging, and 27 (36.5%) had symptomatic detection outside of the surveillance schedule. Neither median overall survival (14.8 months for surveillance and 15.7 months for symptomatic; P = 0.600) nor postrecurrence neurologic function (assessed by Karnofsky Performance Scale Index and Eastern Cooperative Oncology Group) differed between the surveillance and symptomatic detection groups (P = 0.699 and P = 0.908, respectively). CONCLUSIONS Recurrence detection occurring via routine surveillance imaging did not yield superior patient outcomes relative to symptomatic detection occurring outside of the standard surveillance schedule in patients with HGG. Further evaluation of surveillance imaging and alternative follow-up methods for this patient population may be warranted.
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Affiliation(s)
- Courtney L Monroe
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Sarah Travers
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Henok G Woldu
- Biostatistics and Research Design, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - N Scott Litofsky
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.
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The benefit of surveillance imaging for paediatric cerebellar pilocytic astrocytoma. Childs Nerv Syst 2019; 35:801-805. [PMID: 30770993 DOI: 10.1007/s00381-019-04078-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Paediatric cerebellar pilocytic astrocytomas (PA) (WHO grade 1) are amongst the most common of childhood brain tumours and are generally amenable to resection, with surgery alone being curative in the majority of cases. There is, however, a lack of consensus regarding the frequency and duration of post-treatment MRI surveillance for these tumours. This is important, as follow-up imaging is a significant use of resources and often associated with patient and family anxiety. We have assessed the utility of MRI surveillance in the detection of cerebellar PA recurrence at our regional paediatric neurosurgical centre. MATERIALS AND METHODS The tumour register at Alder Hey Children's Hospital was searched to identify all patients diagnosed between 2007 and 2017, with a confirmed histopathological diagnosis of cerebellar PA. Patient demographics, surgical outcome, number of MRI scans and length of follow-up were recorded for each patient. RESULTS Forty patients met the inclusion criteria. The mean age at diagnosis was 7.8 years (range 2 to 17 years). Complete surgical resection (CR), confirmed by post-operative MRI, was achieved in 36 of the 40 patients, including all 31 cases from 2009 and later for which intraoperative MRI (iMRI) was utilised. There was one case of recurrence after CR (at 2.2 years) out of the 36 cases, whereas all 4 patients with initial partial resections had progressive growth of their tumours and required second surgical interventions. CONCLUSION This series confirms the very low likelihood of recurrence for completely resected cerebellar PAs and suggests that in such cases the duration and frequency of surveillance imaging could be limited to a maximum of 2.5 to 3 years of follow-up imaging. This report also indicates improved complete resection rates over time, probably associated with technical advances including the routine in-house use of iMRI in 2009.
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Bouzidi Y, Barteau E, Lejeune J, Dejobert M, Gravellier B, Sirinelli D, Cottier JP, Morel B. Detection of recurrent brain tumors in children: No significant difference in sensitivity between unenhanced and contrast-enhanced MRI. Neuroradiol J 2019; 32:259-266. [PMID: 31017042 DOI: 10.1177/1971400919845619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI) with a gadolinium injection is currently used in the follow-up of children in remission of cerebral tumors (CTs). Intracerebral gadolinium deposition has been recently reported with unknown risks. The aim of this study was to evaluate the sensitivity of unenhanced brain MRI (U-MRI) in detection of tumor recurrence. METHODS AND MATERIALS A set of 58 U-MRIs of children in remission was retrospectively evaluated by three seniors (a neuroradiologist, a pediatric and a general radiologist) and one junior to look for any recurrence. Clinical, tumoral and imaging data were collected. The final diagnosis was anatomopathological when available, or the clinicoradiological evolution. Sensitivity, specificity, predictive values and interobserver agreement were calculated. A Fisher test and Fleiss kappa coefficient were performed. RESULTS For the seniors, the U-MRI had a sensitivity of 81% (95% confidence interval (CI): 0.56-0.90), and a negative predictive value (NPV) of 82% (95% CI: 0.63-0.94). The U-MRI sensitivity, regardless of the observer, was not significantly different from the contrast-enhanced MRI sensitivity (86%) according to a Fisher test (p > 0.05). No significant difference in sensitivity within the subgroups was found. The interobserver agreement of seniors was good (κ = 0.68). CONCLUSION U-MRI brain was suboptimal for 80% of patients. Three-dimensional millimetric, fluid-attenuated inversion recovery, and diffusion would constitute helpful sequences in follow-up. Further specific studies depending on each tumor type are still required to determine whether a potential abstention of gadolinium intravenous injection should be discussed for children.
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Affiliation(s)
- Yasmina Bouzidi
- 1 Pediatric Radiology Department, Clocheville Hospital, University Hospital Center of Tours, France
| | - Emmanuel Barteau
- 1 Pediatric Radiology Department, Clocheville Hospital, University Hospital Center of Tours, France
| | - Julien Lejeune
- 2 Pediatric Oncologic Department, Clocheville Hospital, University Hospital Center of Tours, France
| | - Maelle Dejobert
- 3 Neuroradiology Department, Bretonneau Hospital, University Hospital Center of Tours, France
| | - Bastien Gravellier
- 1 Pediatric Radiology Department, Clocheville Hospital, University Hospital Center of Tours, France
| | - Dominique Sirinelli
- 1 Pediatric Radiology Department, Clocheville Hospital, University Hospital Center of Tours, France.,4 Faculty of Medicine, Francois Rabelais University, Tours, France
| | - Jean Philippe Cottier
- 3 Neuroradiology Department, Bretonneau Hospital, University Hospital Center of Tours, France.,4 Faculty of Medicine, Francois Rabelais University, Tours, France
| | - Baptiste Morel
- 1 Pediatric Radiology Department, Clocheville Hospital, University Hospital Center of Tours, France.,4 Faculty of Medicine, Francois Rabelais University, Tours, France
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Zaazoue MA, Manley PE, Mehdar MA, Ullrich NJ, Dasenbrock HH, Chordas CA, Goumnerova LC. Optimizing Postoperative Surveillance of Pediatric Low-Grade Glioma Using Tumor Behavior Patterns. Neurosurgery 2019; 86:288-297. [DOI: 10.1093/neuros/nyz072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 02/22/2019] [Indexed: 12/23/2022] Open
Abstract
Abstract
BACKGROUND
Pediatric low-grade gliomas are among the most common childhood neoplasms, yet their post-treatment surveillance remains nonstandardized, relying on arbitrarily chosen imaging intervals.
OBJECTIVE
To optimize postoperative magnetic resonance imaging (MRI) surveillance protocols for pediatric low-grade gliomas.
METHODS
Patients aged 0 to 21 yr with pediatric low-grade gliomas, treated between 1990 and 2016 were retrospectively analyzed. The timing of surveillance imaging and radiologic tumor outcomes were extracted, and the effect of patient age, tumor location, histology, and extent of resection as prognostic factors was studied. An algorithm was developed to analyze the detection efficacy and cost of all possible surveillance protocols.
RESULTS
A total of 517 patients were included with a median follow-up of 7.7 yr (range: 2-25.1 yr) who underwent 8061 MRI scans (mean 15.6 scans per patient). Tumor recurrence was detected radiologically in 292 patients (56.5%), of whom, 143 underwent reoperation. The hazards ratio (HR) of recurrence was higher in patients who underwent biopsy (HR = 3.60; 95% confidence interval (CI): 2.45-5.30; P < .001), subtotal resection (HR = 2.97; 95% CI: 2.18-4.03; P < .001), and near-total resection (HR = 2.03; 95% CI: 1.16-3.54; P = .01), compared to patients with gross total resection (GTR). For all patients, an 8-image surveillance protocol at 0, 3, 6, 12, 24, 36, 60, and 72 mo (total cost: $13 672 per patient) yielded comparative detection rates to the current 15-image protocol ($25 635). For patients who underwent GTR, a 6-image protocol at 0, 3, 9, 24, 36, and 60 mo ($10 254) is sufficient.
CONCLUSION
Our data suggest that postoperative surveillance of pediatric low-grade gliomas can be effectively performed using less frequent imaging compared to current practice, thereby improving adherence to follow-up, and quality-of-life, while reducing costs.
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Affiliation(s)
- Mohamed A Zaazoue
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Peter E Manley
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | | | - Nicole J Ullrich
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Christine A Chordas
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Liliana C Goumnerova
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
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Stevens SP, Main C, Bailey S, Pizer B, English M, Phillips R, Peet A, Avula S, Wilne S, Wheatley K, Kearns PR, Wilson JS. The utility of routine surveillance screening with magnetic resonance imaging (MRI) to detect tumour recurrence in children with low-grade central nervous system (CNS) tumours: a systematic review. J Neurooncol 2018; 139:507-522. [PMID: 29948767 PMCID: PMC6132973 DOI: 10.1007/s11060-018-2901-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/12/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is routinely used as a surveillance tool to detect early asymptomatic tumour recurrence with a view to improving patient outcomes. This systematic review aimed to assess its utility in children with low-grade CNS tumours. METHODS Using standard systematic review methods, twelve databases were searched up to January 2017. RESULTS Seven retrospective case series studies (n = 370 patients) were included, with average follow-up ranging from 5.6 to 7 years. No randomised controlled trials (RCTs) were identified. Due to study heterogeneity only a descriptive synthesis could be undertaken. Imaging was most frequent in the first year post-surgery (with 2-4 scans) reducing to around half this frequency in year two and annually thereafter for the duration of follow-up. Diagnostic yield ranged from 0.25 to 2%. Recurrence rates ranged from 5 to 41%, with most recurrences asymptomatic (range 65-100%). Collectively, 56% of recurrences had occurred within the first year post-treatment (46% in the first 6-months), 68% by year two and 90% by year five. Following recurrence, 90% of patients underwent treatment changes, mainly repeat surgery (72%). Five-year OS ranged from 96 to 100%, while five-year recurrence-free survival ranged from 67 to 100%. None of the studies reported quality of life measures. CONCLUSION This systematic review highlights the paucity of evidence currently available to assess the utility of MRI surveillance despite it being routine clinical practice and costly to patients, their families and healthcare systems. This needs to be evaluated within the context of an RCT.
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Affiliation(s)
- Simon P Stevens
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Caroline Main
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Simon Bailey
- Sir James Spence Institute of Child Health, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Barry Pizer
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Martin English
- Birmingham Women and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Robert Phillips
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Andrew Peet
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Shivaram Avula
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Sophie Wilne
- Queen's Medical Centre, Nottingham University Hospitals' NHS Trust, Nottingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Pamela R Kearns
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Birmingham Women and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Jayne S Wilson
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
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Hessissen L, Parkes J, Amayiri N, Mushtaq N, Sirachainan N, Anacak Y, Mitra D, Figaji A, Schouten-van Meeteren A, Sullivan M, Burger H, Davidson A, Bouffet E, Bailey S. SIOP PODC Adapted treatment guidelines for low grade gliomas in low and middle income settings. Pediatr Blood Cancer 2017; 64 Suppl 5. [PMID: 29297618 DOI: 10.1002/pbc.26737] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 06/22/2017] [Indexed: 12/15/2022]
Abstract
Effective treatment of children with low grade glioma (LGG) requires a functioning multi-disciplinary team with adequate neurosurgical, neuroradiological, pathological, radiotherapy and chemotherapy facilities and personnel. In addition, the treating centre should have the capacity to manage a variety of LGG and treatment-associated complications. These requirements have made it difficult for many centers in low and middle-income countries (LMIC) to offer effective treatment and follow up. This article provides management recommendations for children with LGG according to the level of facilities available.
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Affiliation(s)
- Laila Hessissen
- Department of Hematology and Pediatric Oncology, Hospital University Ibn Sina, Rabat, Morocco
| | - Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Nisreen Amayiri
- Department of Hematology and Oncology, King Hussein Cancer Centre, Amman, Jordan
| | - Naureen Mushtaq
- Department of Pediatric Haematology and Oncology, Aga Khan University Hopsital, Karachi, Pakistan
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Yavuz Anacak
- Department of Radiation Oncology, Ege University School of Medicine & Hospital, Izmir, Turkey
| | - Dipayan Mitra
- Department of Radiology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Anthony Figaji
- Department of Neurosurgery, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | | | - Michael Sullivan
- Department of Paediatric Haematology and Oncology, Royal Hospital for Sick Children, Melbourne, Victoria, Australia
| | - Hester Burger
- Department Medical Physics, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Alan Davidson
- Haematology Oncology Service, Red Cross War Memorial Children's Hospital, Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - Eric Bouffet
- Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Simon Bailey
- Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
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De Oliveira SN, Gonzalez-Gomez I, Panigrahy A, Krieger M, McComb G, Finlay JL, Dhall G. False-positive magnetic resonance imaging findings in follow-up of pediatric patients with tumors of the central nervous system. SAGE Open Med Case Rep 2016; 4:2050313X16666232. [PMID: 27621807 PMCID: PMC5006300 DOI: 10.1177/2050313x16666232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 07/27/2016] [Indexed: 12/28/2022] Open
Abstract
Management of patients with central nervous system tumors relies largely on magnetic resonance imaging scans to document disease progression or recurrence. The finding of new lesions always presents the challenge of differentiating between post-surgical changes, radiation necrosis, gliosis, and tumor, submitting these patients to more aggressive therapy and more toxicity. We reviewed the medical records of three patients with primary central nervous system tumors treated at the Children’s Hospital Los Angeles who had new false-positive magnetic resonance imaging findings suggestive of tumor recurrence. All of them had complete total resection of primary tumor, had received involved-field radiation therapy, had biopsies confirming absence of viable tumor, and all three patients are long-term survivors. These cases exemplify that not everything that enhances on brain or spine magnetic resonance imaging is viable tumor, and a biopsy should always be considered in the decision-making process in evaluation of potentially recurrent central nervous system tumors in pediatric patients. A step-wise approach for such challenging cases is presented in this article.
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Affiliation(s)
| | | | - Ashok Panigrahy
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Mark Krieger
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Gordon McComb
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Girish Dhall
- Children's Hospital Los Angeles, Los Angeles, CA, USA
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Main C, Stevens SP, Bailey S, Phillips R, Pizer B, Wheatley K, Kearns PR, English M, Wilne S, Wilson JS. The impact of routine surveillance screening with magnetic resonance imaging (MRI) to detect tumour recurrence in children with central nervous system (CNS) tumours: protocol for a systematic review and meta-analysis. Syst Rev 2016; 5:143. [PMID: 27577246 PMCID: PMC5006428 DOI: 10.1186/s13643-016-0318-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/16/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study is to assess the impact of routine MRI surveillance to detect tumour recurrence in children with no new neurological signs or symptoms compared with alternative follow-up practices, including periodic clinical and physical examinations and the use of non-routine imaging upon presentation with disease signs or symptoms. METHODS Standard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. Ten electronic databases have been searched, and further citation searching and reference checking will be employed. Randomised and non-randomised controlled trials assessing the impact of routine surveillance MRI to detect tumour recurrence in children with no new neurological signs or symptoms compared to alternative follow-up schedules including imaging upon presentation with disease signs or symptoms will be included. The primary outcome is time to change in therapeutic intervention. Secondary outcomes include overall survival, surrogate survival outcomes, response rates, diagnostic yield per set of images, adverse events, quality of survival and validated measures of family psychological functioning and anxiety. Two reviewers will independently screen and select studies for inclusion. Quality assessment will be undertaken using the Cochrane Collaboration's tools for assessing risk of bias. Where possible, data will be summarised using combined estimates of effect for time to treatment change, survival outcomes and response rates using assumption-free methods. Further sub-group analyses and meta-regression models will be specified and undertaken to explore potential sources of heterogeneity between studies within each tumour type if necessary. DISCUSSION Assessment of the impact of surveillance imaging in children with CNS tumours is methodologically complex. The evidence base is likely to be heterogeneous in terms of imaging protocols, definitions of radiological response and diagnostic accuracy of tumour recurrence due to changes in imaging technology over time. Furthermore, the delineation of tumour recurrence from either pseudo-progression or radiation necrosis after radiotherapy is potentially problematic and linked to the timing of follow-up assessments. However, given the current routine practice of MRI surveillance in the follow-up of children with CNS tumours in the UK and the resource implications, it is important to evaluate the cost-benefit profile of this practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016036802.
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Affiliation(s)
- Caroline Main
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Simon P. Stevens
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Simon Bailey
- Sir James Spence Institute of Child Health, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK
| | - Robert Phillips
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Barry Pizer
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Pamela R. Kearns
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Martin English
- Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Sophie Wilne
- Queen’s Medical Centre, Nottingham University Hospitals’ NHS Trust, Nottingham, UK
| | - Jayne S. Wilson
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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Alford R, Gargan L, Bowers DC, Klesse LJ, Weprin B, Koral K. Postoperative surveillance of pediatric cerebellar pilocytic astrocytoma. J Neurooncol 2016; 130:149-154. [PMID: 27502785 DOI: 10.1007/s11060-016-2222-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 07/22/2016] [Indexed: 10/21/2022]
Abstract
The purpose of this study was to identify the optimal frequency and duration of magnetic resonance imaging follow-up in children who had gross totally resected cerebellar pilocytic astrocytomas (CPAs). Our hypothesis was that following two MR examinations, separated by at least 3 months, showing no evidence of tumor, gross totally resected CPAs did not recur and no further imaging follow-up was necessary. Retrospective review of Neuro-Oncology database from 1/2000 to 7/2013 yielded 53 patients with CPAs that had preoperative imaging and >2 years post-operative imaging follow-up available. Pilocytic astrocytomas with brainstem involvement and patients with neurofibromatosis type I were excluded. Preoperative tumor volumes were calculated. The dates and reports of the examinations were tabulated. The median number of follow-up examinations was 9 over a median follow-up time of 6.05 years (2.07-12.28 years). Two consecutive MR examinations over at least a 3 month span demonstrated the smallest negative likelihood ratio of future recurrence (0.15). There was no association of recurrence with preoperative tumor volume. Among the 35 patients with gross total resection of their tumor and greater than two negative follow-up examinations, one recurrence (2.9 %) was identified, occurring 6.4 years after initial resection. Gross totally resected pediatric CPAs can recur, but this is exceedingly rare. Frequent surveillance (every 3-6 months) is suggested in patients with CPAs until absence of tumor is concluded on imaging and documented on two consecutive studies spaced at least 3 months apart. The likelihood of recurrence thereafter is low.
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Affiliation(s)
- Raphael Alford
- Department of Radiology, University of Texas Southwestern Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
| | - Lynn Gargan
- Department of Neuro-Oncology, Children's Health, Dallas, TX, 75235, USA
| | - Daniel C Bowers
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, 75235, USA.,Department of Pediatrics, Children's Health, Dallas, TX, 75235, USA
| | - Laura J Klesse
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, 75235, USA.,Department of Pediatrics, Children's Health, Dallas, TX, 75235, USA
| | - Bradley Weprin
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, 75235, USA.,Department of Neurosurgery, Children's Health, Dallas, TX, 75235, USA
| | - Korgun Koral
- Department of Radiology, University of Texas Southwestern Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA. .,Department of Radiology, Children's Health, Dallas, TX, 75235, USA.
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Nandigam K, Mechtler LL, Smirniotopoulos JG. Neuroimaging of Neurocutaneous Diseases. Neurol Clin 2014; 32:159-92. [DOI: 10.1016/j.ncl.2013.07.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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