Surgical outcomes in spinal cord ependymomas and the importance of extent of resection in children and young adults

Clinical presentation and extent of resection impacts progression-free survival in spinal ependymomas

PURPOSE

Primary treatment of spinal ependymomas involves surgical resection, however recurrence ranges between 50 and 70%. While the association of survival outcomes with lesion extent of resection (EOR) has been studied, existing analyses are limited by small samples and archaic data resulting in an inhomogeneous population. We investigated the relationship between EOR and survival outcomes, chiefly overall survival (OS) and progression-free survival (PFS), in a large contemporary cohort of spinal ependymoma patients.

METHODS

Adult patients diagnosed with a spinal ependymoma from 2006 to 2021 were identified from an institutional registry. Patients undergoing primary surgical resection at our institution, ≥ 1 routine follow-up MRI, and pathologic diagnosis of ependymoma were included. Records were reviewed for demographic information, EOR, lesion characteristics, and pre-/post-operative neurologic symptoms. EOR was divided into 2 classifications: gross total resection (GTR) and subtotal resection (STR). Log-rank test was used to compare OS and PFS between patient groups.

RESULTS

Sixty-nine patients satisfied inclusion criteria, with 79.7% benefitting from GTR. The population was 56.2% male with average age of 45.7 years, and median follow-up duration of 58 months. Cox multivariate model demonstrated significant improvement in PFS when a GTR was attained (p <.001). Independently ambulatory patients prior to surgery had superior PFS (p <.001) and OS (p =.05). In univariate analyses, patients with a syrinx had improved PFS (p =.03) and were more likely to benefit from GTR (p =.01). Alternatively, OS was not affected by EOR (p =.78).

CONCLUSIONS

In this large, contemporary series of adult spinal ependymoma patients, we demonstrated improvements in PFS when GTR was achieved.

The evolution of spinal cord surgery: history, people, instruments, and results

INTRODUCTION

Spinal cord surgery has and always will be a challenging operation with satisfying results, but also with potentially devastating results. Over the last century, there has been an evolution in the way we perceive and conduct spinal cord surgery. The phenomenal evolution in technology from the very first x-ray pictures helps to localize the spinal pathology through the use of high-resolution MRI and ultrasonography that allows for high precision surgery with relatively minimal exposure.

METHODS

The advancements in the surgical technique and the utilization of neuromonitoring allow for maximal safe resection of these delicate and intricate tumors. We also are beginning to understand the biology of spinal cord tumors and vascular lesions, as in the recent 2021 WHO classification which identifies specific entities such as spinal ependymomas, MYCN-amplified, as separate entity from the other subtypes of ependymomas. Surgeons have also accepted the importance of maximal safe resection for most of the spinal cord pathologies rather than just performing biopsy and adjuvant treatment.

CONCLUSION

There have been significant advances since the first resection of an intramedullary tumor including diagnosis, imaging, and surgical technique for children. These advances have improved the prognosis and outcome in these children.

Clinical Characteristics, Management, and Outcomes of Intramedullary Spinal Cord Ependymomas in Adults: A Systematic Review

BACKGROUND

Intramedullary spinal cord ependymomas (IMSCEs) are rare tumors that mostly occur in adults. Management strategies and related outcomes are heterogeneously reported across the literature, demanding a comprehensive analysis to standardize guidelines. We performed a systematic review of the literature on IMSCEs.

METHODS

A literature search was conducted using 6 databases from inception up to July 28, 2022. Studies with data on clinical characteristics, management strategies, and related outcomes in adult patients with histopathologically confirmed IMSCEs were pooled and analyzed.

RESULTS

The analysis included 69 studies comprising 457 patients (52.7% males). Mean age was 42.4 ± 7.4 years. Sensory deficit (58.0%) was the most prevalent symptom, followed by radicular pain (50.5%). Tumors mostly involved the cervical (64.4%) or thoracic (18.8%) spinal cord and were mostly World Health Organization grade II (80.5%) and classic subtype (72.4%). Gross total resection was performed in most cases (83.4%), with adjuvant radiotherapy delivered in 10.5% of cases. Progression-free survival ≥2 years was reported in 61.1% of cases, and tumor recurrence or progression was reported in only 7.0% of the patients. At last follow-up, 97.4% of patients were alive.

CONCLUSIONS

IMSCEs are uncommon tumors that frequently manifest with debilitating symptoms that require surgical treatment. When feasible, gross total resection may be pursued to improve the patient's functional status and prevent tumor progression, with adjuvant radiotherapy required only in some more aggressive grade III lesions. Future studies should investigate different growth patterns and prognoses based on different IMSCE subtypes.

Current management in the treatment of intramedullary ependymomas in children

PURPOSE

Current management of pediatric intramedullary ependymoma is extrapolated from adult series since large studies in children are unavailable. This has led us to share our experience with this rare tumor and compare it to the literature and to review and highlight important aspects of current management and point out inconsistencies.

METHODS

This is a retrospective analysis of patients with intramedullary ependymoma managed at our institution between 2004 and 2021.

RESULTS

During the study period, 5 patients were treated for intramedullary ependymoma. Cases of myxopapillary ependymoma were excluded. The mean age of our cohort was 11.2 years. We identified 4 cases of grade II ependymoma and 1 case of grade III ependymoma. Gross tumor removal (GTR) was achieved in two patients (40%) of patients. One patient was treated with radiotherapy for recurrence and two patients received chemotherapy. There were no cases of recurrence among patients treated with GTR, but in all patients treated with STR. Eighty percent of patients either improved or stayed stable neurologically. During follow-up (mean 73 months), 2 patients died of disease.

CONCLUSION

GTR and tumor grade remain the key prognostic factor of long-term tumor-free survival. Many questions prevail regarding outcomes, correct use of adjuvant therapy, and prognostic factors.

Neuromuscular rehabilitation interventions and COVID-19 management in a case of incomplete paraplegia with neurogenic bladder, post T3-T5 ependymoma

Spinal ependymomas are a group of mostly slow-growing tumors that can cause non-traumatic spinal cord injury with insidious clinical symptomatology ranging from neck or back pain to as-sociated sensory-motor impairment. Due to their neurological and systemic frailty, patients with spinal cord injury might be especially vulnerable to the effects of SARS-CoV-2 infection and the resulting respiratory impairment. CASE PRESENTATION: We present the case of a 66 year old women admitted in our Neuromuscular Rehabilitation Clinic Division for severe in-complete paraplegia and neurogenic bladder. She was previously diagnosed in the Neurosurgi-cal Ward with a thoracic grade II (classic) ependymoma and underwent a gross tumor resection. During the neurorehabilitation program the patient was diagnosed with COVID-19. The multi-drug related treatments were associated with supportive oxygen therapy and neuromuscular and respiratory rehabilitation techniques. RESULTS: Despite of the patient’s favorable rehabili-tation, consisting of walking abilities with support in a walking frame on short distances, her prognosis may be worsened by resting neurogenic bladder symptoms. COVID-19 has led to im-portant acute respiratory morbidity in our patient, regardless of the mild course of the disease, and might further cause a post-infectious respiratory impairment. ONCLUSION: Spinal cord in-jury remains a life-long condition and emphasizes the necessity of supporting the affected pati-ents on the long run. Keywords: students, balance, postural stability, physical exercise, progress, motor skills

Treatment strategy for multisegmental cervicomedullary ependymoma: illustrative case

BACKGROUND

Сervicomedullary ependymoma (CME) is a rare tumor of the central nervous system. The CME treatment strategy is insufficiently represented in the literature and is a complex task for neurosurgeons.

OBSERVATIONS

The authors describe an infrequent case of a large multisegmental CME that extended from the medulla oblongata to the cervical spinal cord at the level of the sixth cervical vertebra in a 21-year-old female. Neurological disorders presented with headache, dysphagia, hypophonia, and weakness in the limbs. Subtotal removal of the tumor was performed according to intraoperative neurophysiological monitoring (IONM) results. A wait-and-see approach with patient follow-up was chosen.

LESSONS

Total tumor removal of the CME is the most important favorable prognostic factor. Subtotal resection can be considered if the borders of the tumor are unclear and the result of IONM is unfavorable. The role of postoperative radiation therapy in the case of subtotal removal of the tumor remains controversial.

Pediatric Myxopapillary Ependymomas: A Clinicopathologic Evaluation

Myxopapillary ependymomas (MPEs) have an indolent clinical course, corresponding to World Health Organization Grade I. A total of 13 pediatric MPEs have been reported in the literature with "anaplastic features," including elevated proliferative activity (≥5 mitoses/10 high-power fields), necrosis, and microvascular proliferation. No consensus exists regarding the prognostic significance of such features. A retrospective clinicopathologic review of pediatric MPEs diagnosed between 1996 and 2018 at Mayo Clinic was performed. Totally, 8 pediatric MPEs (6 male; age: 7.52 to 16.88 y) were identified. Totally, 3 had disseminated disease at presentation. All patients underwent surgical resection (7 gross total; 1 subtotal). Totally, 5 cases harbored ≥5 mitoses/10 high-power fields (range: 5 to 9), 3 of which showed necrosis (2 with disseminated disease). Postsurgery, 2 patients received radiation; one with disseminated disease and another with increased mitotic activity/necrosis; neither has recurred (follow-up: 1.18 and 3.19 y). In all, 2 patients with disseminated disease, elevated mitotic activity, and necrosis had new metastatic disease/progression of nonresected metastatic foci (2.6 and 26.8 mo), received radiation therapy, and remain progression free (3.01 and 9.34 y). All patients are alive (median follow-up 1.31 y, range: 0.66 to 11.75). Among pediatric MPEs, the concurrent presence of elevated mitotic activity and necrosis may be associated with an aggressive clinical course, warranting closer surveillance and consideration of adjuvant therapies.

Bicentric Treatment Outcomes After Proton Therapy for Nonmyxopapillary High-Grade Spinal Cord Ependymoma in Children

PURPOSE

Few studies report outcomes in children treated with radiation for nonmyxopapillary ependymoma of the spinal cord, and little evidence exists to inform decisions regarding target volume and prescription dose. Moreover, virtually no mature outcome data exist on proton therapy for this tumor. We describe our combined institutional experience treating pediatric classical/anaplastic ependymoma of the spinal cord with proton therapy.

METHODS AND MATERIALS

Between 2008 and 2019, 14 pediatric patients with nonmetastatic nonmyxopapillary grade II (n = 6) and grade III (n = 8) spinal ependymoma received proton therapy. The median age at radiation was 14 years (range, 1.5-18 years). Five tumors arose within the cervical cord, 3 within the thoracic cord, and 6 within the lumbosacral cord. Before radiation therapy, 3 patients underwent subtotal resection, and 11 underwent gross-total or near total resection. Two patients received chemotherapy. For radiation, the clinical target volume received 50.4 Gy (n = 8), 52.2 (n = 1), or 54 Gy (n = 5), with the latter receiving a boost to the gross tumor volume after the initial 50.4 Gy, modified to respect spinal cord tolerance.

RESULTS

With a median follow-up of 6.3 years (range, 1.5-14.8 years), no tumors progressed. Although most patients experienced neurologic sequela after surgery, only 1 developed additional neurologic deficits after radiation: An 18-year-old male who received 54 Gy after gross total resection of a lumbosacral tumor developed grade 2 erectile dysfunction. There were 2 cases of musculoskeletal toxicity attributable to surgery and radiation. At analysis, no patient had developed cardiac, pulmonary, or other visceral organ complications or a second malignancy.

CONCLUSION

Radiation to a total dose of 50 to 54 Gy can be safely delivered and plays a beneficial role in the multidisciplinary management of children with nonmyxopapillary spinal cord ependymoma. Proton therapy may reduce late radiation effects and is not associated with unexpected spinal cord toxicity.

Microsurgical Resection of Brain Stem Ependymoma: 2-Dimensional Operative Video

The brainstem is a less-common location for ependymomas than the spinal cord where they are the most common adult intramedullary tumor.1-18 In this first video case report in the peer-reviewed literature, we demonstrate microsurgical resection of a medulla oblongata ependymoma.  There are several case reports of medulla oblongata ependymomas1,3,5,6,13 and a few series of spinal cord ependymomas that included cases of ependymomas of the cervicomedullary junction.9,10 The goal of surgery was to stabilize the preoperative neurological function; favorable outcome is achieved in patients with good preoperative statuses and well-defined tumor boundaries.9 Although gross total resection (GTR) provides the best overall outcome, it is most effective for classic grade II tumors, but not grade I (myxopapillary) and ependymomas, which have a lower GTR rate.14,15  A 55-yr-old patient developed 4-extremity weakness and dysphagia. Pre-/postcontrast magnetic resonance imaging (MRI) revealed centrally located brainstem lesion situated at the lower half of the medulla oblongata. Surgery, performed by the senior author, was performed in the prone position with a small suboccipital craniectomy and C1 posterior arch removal, followed by pia opening and posterior midline myelotomy. Tumor was debulked, dissected from the white matter, and resected. Histology revealed ependymoma (World Health Organization grade II). Postoperative pre-/postcontrast MRI revealed total resection. The patient's neurological deficit completely resolved postoperatively.  Written consent was obtained from the patient.

Complete Versus Incomplete Surgical Resection in Intramedullary Ependymomas: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review.

OBJECTIVE

To compare outcomes of complete versus incomplete resection in primary intramedullary spinal cord ependymoma.

METHODS

A comprehensive search of the MEDLINE, CENTRAL, and Embase databases was conducted by 2 independent investigators. Random-effect meta-analysis and meta-regression with seven covariates were performed to evaluate the reason for the heterogeneity among studies. We also used individual patient data in the integrative analysis to compare complete and incomplete resection based on 4 outcomes: progression-free survival (PFS), overall survival (OS), postoperative neurological improvement (PNI), and follow-up neurological improvement (FNI).

RESULTS

A total of 23 studies were identified, including 407 cases. Significant heterogeneity among included studies was observed in risk estimates (I² for PFS, FNI, and PNI were 49.5%, 78.3%, and 87.2%, respectively). The mean follow-up time across cases was 48.6 ± 2.35 months. Cox proportional multivariable analysis revealed that the complete resection can prolong PFS (model, hazard ratio = 0.18, CI 0.05-0.54, P = .004,) and improve the FNI (binary logistic regression, adjusted odds ratio = 16.5, CI 1.6-171, P = .019). However, PNI and OS were similar in patients with incomplete resected spinal cord ependymoma compared with complete resection (binary logistic regression respectively and Cox multivariable analysis, P > .5).

CONCLUSION

The data presented in this study showed that OS was not significantly affected by the degree of surgery. However, complete resection of intramedullary ependymomas provides the optimal outcomes with longer PFS and better long-term neurological outcomes than incomplete resection.

Multisegmental versus monosegmental intramedullary spinal cord ependymomas: perioperative neurological functions and surgical outcomes

Multiple factors, such as tumor size, lateralization, tumor location, accompanying syringomyelia, and regional spinal cord atrophy, may affect the resectability and clinical prognosis of intramedullary spinal cord ependymomas. However, whether long-segmental involvement of the spinal cord may impair functional outcomes remains unclear. This study was aimed to compare perioperative neurological functions and long-term surgical outcomes between multisegmental ependymomas and their monosegmental counterparts. A total of 62 patients with intramedullary spinal cord ependymoma (WHO grade II) were enrolled, and all of them underwent surgical resection. The patients were classified into the multisegmental group (n = 43) and the monosegmental group (n = 19). Perioperative and long-term (average follow-up period, 47.3 ± 21.4 months) neurological functions were evaluated using the modified McCormick (mMC) scale and the modified Japanese Orthopaedic Association (mJOA) scoring system. Preoperative neurological functions in the multisegmental group were significantly worse than those in the monosegmental group (P < 0.05). However, postoperative short-term neurological functions, as well as long-term functional outcomes, were similar between the two groups (P > 0.05). Logistic regression analysis showed that preoperative mMC and mJOA scores were significantly correlated with neurological improvement during the follow-up period (P < 0.05). Multisegmental involvement of the spinal cord is associated with worse neurological functions in patients with intramedullary spinal cord ependymoma, while the long-term prognosis is not affected. The preoperative neurological status of the patient is the only predictor of long-term functional improvement.

Outcome After Treatment of Spinal Ependymoma in Children and Adolescents: Long-Term Follow-up of a Single Consecutive Institutional Series of 33 Patients Treated Over Eight Decades

BACKGROUND

Long-term outcomes for pediatric patients treated for spinal ependymoma are unknown.

METHODS

We performed a retrospective analysis of outcome data from 33 children and young adults (0-22 years) who were operated on for a spinal ependymoma at our institution during the last 8 decades (1938-2019).

RESULTS

Nineteen patients are alive, with follow-up period up to 60 years. Twelve of them are tumor-free, and 7 are alive with disease. Fourteen patients are dead, 9 of them due to recurrent and/or progressive disease 1-56 years (median: 11 years) after the initial surgery. Four of the deceased patients were treated before 1948, 3 of them with excellent long-term survival for 62-66 years after the initial surgery. Tumor recurrence was observed in half of the patients, both local at the site of the primary tumor resection as well as widespread intraspinal presentations. Recurrences were observed within months but also occurred after up to 20 years after initial treatment. After the implementation of magnetic resonance imaging in 1987, details of recurrent disease became more easily demonstrated. Repeated resections were performed when the symptomatic spinal disease was in progress (n = 11). Furthermore, 2 patients have intracranial tumor manifestations, 1 of them underwent resection of a suprasellar tumor in 1991. Four deceased patients experienced aggressive extraspinal progressive disease requiring multiple surgeries, including pulmonary metastasis in 1 of them.

CONCLUSIONS

Pediatric spinal ependymomas can be treated with favorable results and functional outcome may be good even after more than half a century of follow-up. Nevertheless, unexpected and late recurrences may occur, and life-long follow-up is therefore recommended.

Survival and Prognostic Factors of Adult Intracranial Ependymoma: A Single-institutional Analysis of 236 Patients

Adult intracranial ependymomas (EPNs) are extremely rare brain tumors. Currently, clinical and molecular factors that could inform individualized treatment strategies are still lacking for EPNs in this age group. The aim of this study was to investigate potential prognostic indicators and rational therapeutic management in a large cohort of adult intracranial EPNs. Adult patients who underwent resection of World Health Organization (WHO) grade II or III intracranial EPNs were included. The demographic features, clinicopathologic manifestations, molecular subgroups, and outcomes were retrospectively analyzed. Overall survival and progression-free survival were calculated using the Kaplan-Meier analysis. Potential prognostic indicators were identified using multivariable Cox proportional hazards model. This cohort included 236 adult patients with a mean age of 36.2 years (range: 18 to 72 y) at diagnosis. The tumor location was supratentorial (ST) in 102 (43.2%) and infratentorial in 134 (56.8%). Pathologic analysis revealed 43.1% of ST-EPNs with RELA fusion and 88.1% of posterior fossa ependymomas (PF-EPNs) with positive H3K27me3 staining. Gross total removal was achieved in 169 cases (71.6%). During follow-up, 97 (41.1%) patients had disease progression and 39 (16.5%) died. Kaplan-Meier analysis showed that patients with H3K27me3-positive PF-EPN had excellent survival, whereas patients with RELA fusion-positive ST-EPN or H3K27me3-negative PF-EPN had poor prognosis (progression-free survival: P=1.3E-16, overall survival: P=2.5E-12). Multivariate analysis showed that molecular subgroup, extent of resection, and Ki-67 index were strong independent prognostic indicators. In conclusion, our study provides essential information on the prognostic prediction of adult intracranial EPNs that will assist in establishing appropriate risk stratification and individualized treatment strategies in future clinical trials.

Cervicomedullary Ependymoma with Hemorrhage: A Case Report and Review of Literature

Ependymoma is a rare tumor central nervous system that arises from the ependymal lining of the ventricles or the central canal of the spinal cord. They are of neuroectodermal in origin and constitute about 30%–86% of tumors arising in the spinal cord. The occurrence of these tumors in the cervicomedullary region is very rare. Sudden symptomatic neurologic presentations due to hemorrhage in cervicomedullary ependymoma is very rare and so far have never been reported. Mostly presenting as neurologic deficits involving limbs, these tumors pose a technical challenge in their removal. We present a patient who presented with sudden-onset dysesthesia of the upper and lower limbs. On imaging, he was found to have a cystic medullary tumor extending to the cervical region with hemorrhage. We discuss the epidemiology, surgical challenges, and outcome along with review of literature of these rare tumors located in this precarious location.

Surgical Management of Intramedullary Spinal Cord Tumors

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.

Chronic Back Pain in a Young Female Patient: A Case of Ependymoma Originating from the Conus Medullaris

We present the case of a 14-year-old Malay girl with an ependymoma of the conus medullaris who presented to multiple general practitioner clinics with a 24-month history of chronic low back pain. The pain was symptomatically managed as a simple musculoskeletal pain and sciatica. Further imaging to aid diagnosis was delayed until the appearance of severe pain with neurological deficits. Magnetic resonance imaging revealed an enhancing spinal mass at L1 through L3, and histopathological investigations confirmed the grade II ependymoma according to the World Health Organization classification. She underwent gross resection of the tumor. After the surgery, she developed neurogenic urinary bladder and bowel, which required intermittent self-catheterization, intermittent enema use, and intensive physical therapy.

Current and Emerging Methods of Management of Ependymoma

PURPOSE OF REVIEW

This review discusses the evidence base behind current and emerging strategies of management of intracranial and spinal ependymomas in children, with a particular focus on aspects of surgical techniques, challenges and complications.

RECENT FINDINGS

The cornerstone of management remains maximal safe resective surgery, which has repeatedly been shown to correlate with improved survival. This is followed by focal conformal radiotherapy, although good results using proton beam therapy, with the potential for diminished side effects, are emerging. The role of chemotherapy remains largely unproven for paediatric ependymoma. Despite optimal management strategies, many children with ependymoma suffer from tumour recurrence. The standard of care for paediatric ependymoma comprises surgery and radiotherapy. Results of ongoing clinical trials will help shape its management in order to leverage our increasingly sophisticated understanding of the genetic drivers behind these tumours into survival benefit for this challenging group of patients.

Clinicopathologic features of anaplastic myxopapillary ependymomas

Myxopapillary ependymomas (MPE) are considered benign (World Health Organization (WHO) grade I) neoplasms with favorable prognosis. However, malignant behavior occurs in a small subset. To our knowledge, only five anaplastic MPEs have been reported without consensus on diagnostic criteria. We retrieved 14 anaplastic MPEs from the pathology archives of six institutions. Each tumor included at least two of the following features: ≥5 mitoses per 10 high power fields, Ki-67 labeling index (LI) ≥10%, microvascular proliferation (MVP) and spontaneous necrosis. These features were typically encountered in the foci of hypercellularity and reduced mucin. There were eight male and six female patients (age range 6-57 years, median = 16.5). Ten tumors displayed anaplasia at initial resection, and 4 were anaplastic at a second surgery for recurrence (ranging from 9 months to 14 years following initial resection). The Ki-67 LI ranged between 8% and 40% in the anaplastic foci and <3% in the foci of classic MPE. There was documented cerebrospinal fluid (CSF) dissemination in seven cases, recurrence following an anaplastic diagnosis in three cases and bone or soft tissue invasion in two cases. One patient suffered lung metastases. Two cases evaluated by targeted next-generation sequencing and one evaluated by fluorescence in situ hybridization (FISH) showed nonspecific chromosomal gains. We conclude that although rare, anaplastic MPE occurs in both pediatric and adult patients, similar to other ependymomas. At a minimum, closer follow-up is recommended, given the concern for aggressive biologic potential. Further study is needed to determine WHO grading criteria and genetic indicators of tumor progression.

A systematic review of outcome in intramedullary ependymoma and astrocytoma

The objective was to determine the impact of surgical resection and adjuvant therapies on survival in intramedullary ependymoma and astrocytoma. Secondary goals were to determine predictors of survival in surgical patients including histological grading, age and gender. Searching of Medline, Embase and Clinicaltrials.gov databases were performed. Multivariate analyses were performed for overall survival (OS) and progression-free survival (PFS) through Monte Carlo methods and Maximum Likelihood Estimation. 57 articles detail results for 3022 patients. Meta-analysis revealed the following factors to have a statistically significant effect on OS. Patients undergoing gross-total resection (GTR) are 5.37 times more likely to survive than patients with lesser volumes of tumor resected (HR for OS 1.68, p < 0.01). High-grade tumors were associated with a 14 times risk of death over low-grade tumors (HR for OS 2.64, p < 0.01). Radiation increased the risk of mortality in low-grade tumors (HR for OS 5.20, p < 0.01), but decreased mortality in high-grade lesions (HR for OS 2.46, p < 0.01). Adult patients were more likely to die from disease compared with pediatric patients by a factor of 1.6 (HR for OS 0.47, p < 0.01). In PFS, radiotherapy was associated with a reduced time to recurrence (HR for PFS 1.90, p < 0.01). There was a male predominance of 58%. Gender did not influence survival. 79% of patients demonstrated stable or improved functional neurological outcomes six months post-operatively. Our data indicates GTR improves OS in all tumor grades. Radiation improves OS only in the presence of high-grade histology. Advancing age and high-grade histology are negative prognostic indicators.

Intradural spinal tumors in adults-update on management and outcome

Among spinal tumors that occur intradurally, meningiomas, nerve sheath tumors, ependymomas, and astrocytomas are the most common. While a spinal MRI is the state of the art to diagnose intradural spinal tumors, in some cases CT scans, angiography, CSF analyses, and neurophysiological examination can be valuable. The management of these lesions depends not only on the histopathological diagnosis but also on the clinical presentation and the anatomical location, allowing either radical resection as with most extramedullary lesions or less invasive strategies as with intramedullary lesions. Although intramedullary lesions are rare and sometimes difficult to manage, well-planned treatment can achieve excellent outcome without treatment-related deficits. Technical advances in imaging, neuromonitoring, minimally invasive approaches, and radiotherapy have improved the outcome of intradural spinal tumors. However, the outcome in malignant intramedullary tumors remains poor. While surgery is the mainstay treatment for many of these lesions, radiation and chemotherapy are of growing importance in recurrent and multilocular disease. We reviewed the literature on this topic to provide an overview of spinal cord tumors, treatment strategies, and outcomes. Typical cases of extra- and intramedullary tumors are presented to illustrate management options and outcomes.

Spinal cord tumors in children: A review of 21 cases treated at the same institution

INTRODUCTION

Spinal cord tumors in children (SCTC) are rare with a frequent diagnostic delay. Its management is multidisciplinary and challenging due to functional implications. The position of surgery is now better established but the role and timing of chemotherapy (CT) and radiotherapy (RT) still remains under debate. Adverse effects of treatments are important to be taken into account, in the follow-up of these children. The aim of this paper was to present a series of 21 cases of SCTC treated at the same institution, to briefly present clinical features, treatments and outcome, with a special focus on spinal deformities in children with this condition.

MATERIAL AND METHODS

Twenty-one consecutive SCTC were referred to our institution from 1990 to 2014. Data regarding age, sex, diagnostic delay, clinical examination, MRI, surgery, pathology, other treatment (CT and RT), orthopedic issues and follow-up of these children were retrospectively recorded.

RESULTS

Mean age was 8years (standard deviation: 5.2years) (range: 4 months-17years). Mean diagnosis delay was 5.5 months (standard deviation: 6.5 months) (range: 0 days-18 months). All children (10 girls, 11 boys) were operated on (10 partial removals, 7 subtotal and 4 gross total removals) as first-line treatment. Pathological results showed 12 juvenile pilocytic astrocytomas, 1 grade III astrocytoma, 1 grade IV astrocytoma, 3 oligodendrogliomas, 2 ependymomas, 1 glioblastoma and 1 rhabdoid tumor. Fourteen children (66.7%) received additional treatment: 12 CT and 7 RT. Ten children had postoperative spinal deformities. Mean follow-up (FU) was 71 months (5 months-180 months), with a median FU at 60 months, where 8 tumor progressions and 4 deaths were observed. Overall, survival (at 5years) was 81% and progression free survival (at 5years) was 67%.

CONCLUSION

Surgery is the goal standard for SCTC and the only appropriate treatment in cases of a low-grade lesion with stable disease on MR follow-up. Additional treatment must be reserved for high-grade lesions or tumor progression not attainable by a second look surgery. Spinal deformities are a frequent complication. Overall, survival and event free survival primarily depends on the pathology. Studies involving more centers are obligatory with the aim of collecting more cases and drawing more definitive conclusions regarding the management of these tumors.

Treatment patterns of children with spine and spinal cord tumors: national outcomes and review of the literature

BACKGROUND

Tumors of the spine in children are rare, and further clinical description is necessary.

OBJECTIVE

This study investigated epidemiology, interventions, and outcomes of pediatric patients with spine and spinal cord tumors.

METHODS

The National Inpatient Sample and Kids' Inpatient Database were used for the study. Outcomes were studied, and bivariate significant trends were analyzed in a multivariate setting.

RESULTS

Analysis of 2870 patients between 2000 and 2009 found a median age of diagnosis of 11 years (Tables 1 and 2). Most were white (65.2%) and had private insurance (62.3%), and 46.8% of procedures were emergent operations. Treatment occurred at teaching (93.6%) and non-children's hospitals (81.1%). Overall mortality rate was 1.7%, non-routine discharges occurred at a rate 19.9%, complications at 21.1%, and average total charges were $66,087. A majority of patients (87.5%) had no intervention, and of those patients receiving treatment, 78.2% underwent surgery and 23.1% had radiotherapy. Treatment with surgery alone increased significantly over time (p < 0.0001). Odds ratio (OR) of mortality was significantly higher in 2006 (OR 3.5) and 2009 (OR 2.6) when compared to 2000. Complications (OR 7.9) and disease comorbidities (OR 1.5) were associated with significantly increased odds of mortality.

CONCLUSIONS

Hospital characteristics, length of stay, and charges remained relatively unchanged. In recent years, there has been a decreasing incidence of spine and spinal cord tumors in children. Notably, a higher mortality rate is evident over time in addition to an increase in the proportion of patients undergoing surgery. The high percentage of emergent operations suggests a weak recognition of spine tumors in children and should prompt a call for increased awareness of this cancer. In spite of these findings, lack of tumor type identification was a limitation to this study.

Correlation between intraoperative ultrasound and postoperative MRI in pediatric tumor surgery

OBJECTIVE Malignant disease of the CNS is the primary etiology for deaths resulting from cancer in the pediatric population. It has been well documented that outcomes of pediatric neurosurgery rely on the extent of tumor resection. Therefore, techniques that improve surgical results have significant clinical implications. Intraoperative ultrasound (IOUS) offers real-time surgical guidance and a more accurate means for detecting residual tumor that is inconspicuous to the naked eye. The objective of this study was to evaluate the correlation of extent of resection between IOUS and postoperative MRI. The authors measured the correlation of extent of resection, negative predictive value, and sensitivity of IOUS and compared them with those of MRI. METHODS This study consisted of a retrospective review of the medical charts of all pediatric patients who underwent neurosurgical treatment of a tumor between August 2009 and July 2015 at Albany Medical Center. Included were patients who were aged ≤ 21 years, who underwent brain or spinal tumor resection, for whom IOUS was used during the tumor resection, and for whom postoperative MRI (with and without contrast) was performed within 1 week of surgery. RESULTS Sixty-two patients met inclusion criteria for the study (33 males, mean age 10.0 years). The IOUS results very significantly correlated with postoperative MRI results (φ = 0.726; p = 0.000000011; negative predictive value 86.3% [95% CI 73.7%-94.3%]). These results exemplify a 71% overall gross-total resection rate and 80% intended gross-total resection rate with the use of IOUS (i.e., excluding cases performed only for debulking purposes). CONCLUSIONS The use of IOUS may play an important role in achieving a greater extent of resection by providing real-time information on tumor volume and location in the setting of brain shift throughout the course of an operation. The authors support the use of IOUS in pediatric CNS tumor surgery to improve clinical outcomes at low cost with minimal additional operating-room time and no identified additional risk.

Primary spinal myxopapillary ependymoma in the pediatric population: a study from the Surveillance, Epidemiology, and End Results (SEER) database

Primary spinal myxopapillary ependymomas (MPE) in children are extremely rare. We examined the patient demographics, treatment modalities, and the associated outcomes of children with MPE using the Surveillance, Epidemiology, and End Results (SEER) national cancer database to gain a better understanding of these tumors. The SEER database (1973-2012) was used to analyze patients 21 years of age and younger with histologically confirmed MPE localized to the spinal cord or cauda equina. We analyzed patient demographics, extent of surgical resection, and radiation treatment. Overall survival was calculated using the Kaplan-Meier method. Statistical significance was defined as p < 0.05, with all data analyzed in IBM SPSS Statistics 21. 122 pediatric patients met inclusion criteria. The median age was 16 years (range 0-21) with 63 % male and 87 % Caucasian. The mean follow-up time was 4.5 years (95 % CI 3.93-5.07). Overall survival at 5 and 10 years was 97 and 95 %, respectively. We found 37 % underwent gross-total resection (GTR), 36 % subtotal resection (STR), and 27 % biopsy only. Patients who received GTR alone (n = 37) had a statistically significant increase in overall survival compared to those who received STR plus adjuvant radiation (n = 20) (Χ² = 5.9, p < 0.05). To our knowledge, this is the largest survival analysis of pediatric patients with MPE. Overall survival is excellent at the 5 and 10-year time points; however, GTR should be the goal of treatment when possible. For patients with MPE, future studies should focus on longer follow-up, the role of radiation, and the therapeutic approach at tumor recurrence.

Acute Paraplegia as a Result of Hemorrhagic Spinal Ependymoma Masked by Spinal Anesthesia: Case Report and Review of Literature

Ependymomas are the most common intramedullary spinal cord tumors in adults. Although a hemorrhage within spinal ependymoma on imaging studies is not uncommon, it has rarely been reported to bea cause of acute neurological deficit. In the present report, we describe a case of a 24-year-old female patient who developed acute paraplegia as a result of hemorrhagic spinal ependymoma immediately after a cesarean delivery under spinal regional anesthesia. We review the literature of hemorrhagic spinal ependymomas presenting with acute neurological deficit and discuss the most appropriate treatment for a good neurological recovery.

Surgical management of intradural spinal cord tumors in children and young adults: A single-center experience with 50 patients

BACKGROUND

Intradural spinal cord tumors (IDSCTs) in children and young adults are rare diseases. This present study is aimed to demonstrate our experience with a large series of children and young adults with IDSCT.

METHODS

A total of 50 patients aged <20 years with IDSCT treated in our department between 1990 and 2010 were included in the study. Clinical, histological, and radiological findings, treatment strategies, and clinical outcome were retrospectively assessed. Depending on the relation to the spinal cord, IDSCT were dichotomized into intramedullary SCT (IMSCT) and extramedullary SCT (EMSCT). The functional outcome was evaluated with the Frankel score assessing the longest available follow-up period.

RESULTS

Mean age was 10.3 years (range 6 months-19 years). IDSCT surgery was performed in 44 patients (88%). A common first symptom in patients with EMSCT was neck and back pain (41%), whereas monoparesis of arms (43%) were often seen in patients with IMSCT. The main duration of the symptoms was longer in patients with IMSCT. The postoperative functional outcome was generally comparable to the preoperative functional condition, while better for EMSCT (P < 0.01). The functional outcome at last follow-up correlated significantly with the preoperative Frankel score (P < 0.002).

CONCLUSION

Due to the mostly mild impact of the surgery on the functional outcome, the surgical treatment of IDSCT in children and young patients can be uniquely advocated.

The Art of Intraoperative Glioma Identification

A major dilemma in brain-tumor surgery is the identification of tumor boundaries to maximize tumor excision and minimize postoperative neurological damage. Gliomas, especially low-grade tumors, and normal brain have a similar color and texture, which poses a challenge to the neurosurgeon. Advances in glioma resection techniques combine the experience of the neurosurgeon and various advanced technologies. Intraoperative methods to delineate gliomas from normal tissue consist of (1) image-based navigation, (2) intraoperative sampling, (3) electrophysiological monitoring, and (4) enhanced visual tumor demarcation. The advantages and disadvantages of each technique are discussed. A combination of these methods is becoming widely accepted in routine glioma surgery. Gross total resection in conjunction with radiation, chemotherapy, or immune/gene therapy may increase the rates of cure in this devastating disease.

Clinical features and long-term outcomes of intraspinal ependymomas in pediatric patients

PURPOSE

The aim of this study was to discuss the clinical manifestations, radiological features, treatment, and long-term outcomes of intraspinal ependymomas (Word Health Organization grade II) in pediatric patients.

METHODS

The data of 15 pediatric patients who underwent microsurgery for intraspinal grade II ependymomas were retrospectively reviewed. Pre- and postoperative magnetic resonance imaging was performed in all patients. The diagnosis of grade II ependymomas was based on pathology. All the follow-up data were obtained during office visits.

RESULTS

There were ten males and five females, with a mean age of 13.7 ± 3.4 years. Four tumors were located in the cervical cord, six in the cervicothoracic cord, four in the thoracic cord, and one in the conus-cauda region, respectively. The most common symptom was motor deficits. Gross total resection (GTR) of the tumor was achieved in 12 cases, and subtotal resection (STR) was achieved in three cases. Regrowth of the residual tumor was observed in two STR cases during a mean follow-up period of 44.8 months. STR was performed again in one case due to clinical progression. At the last follow-up, 12 patients experienced an improvement in the neurological function and three patients maintained their preoperative status.

CONCLUSIONS

Pediatric intraspinal grade II ependymomas are amenable to surgical resection before neurological deficits deteriorate. GTR is the best treatment of choice, and the outcome is favorable. Due to uncertain therapeutic efficacy and possible radiation-induced toxicity, postoperative radiotherapy should be considered carefully for cases of STR.