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Watanabe G, Conching A, Fry L, Putzler D, Khan MF, Haider MA, Haider AS, Ferini G, Rodriguez-Beato FY, Sharma M, Umana GE, Palmisciano P. Intraventricular Glioma in Pediatric Patients: A Systematic Review of Demographics, Clinical Characteristics, and Outcomes. World Neurosurg 2024; 186:252-262.e10. [PMID: 38608813 DOI: 10.1016/j.wneu.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE We conducted a systematic review on pediatric intraventricular gliomas to survey the patient population, tumor characteristics, management, and outcomes. METHODS PubMed, Scopus, Web-of-Science, and Cochrane were searched using PRISMA guidelines to include studies reporting pediatric patients with intraventricular gliomas. RESULTS A total of 30 studies with 317 patients were included. Most patients were male (54%), diagnosed at a mean age of 8 years (0.2-19), and frequently exhibited headache (24%), nausea and vomiting (21%), and seizures (15%). Tumors were predominantly located in the fourth (48%) or lateral ventricle (44%). Most tumors were WHO grade 1 (68%). Glioblastomas were rarely reported (2%). Management included surgical resection (97%), radiotherapy (27%), chemotherapy (8%), and cerebrospinal fluid diversion for hydrocephalus (38%). Gross total resection was achieved in 59% of cases. Cranial nerve deficit was the most common postsurgical complication (28%) but most were reported in articles published prior to the year 2000 (89%). Newer cases published during or after the year 2000 exhibited significantly higher rates of gross total resection (78% vs. 39%, P < 0.01), lower rates of recurrence (26% vs. 47%, P < 0.01), longer average overall survival time (42 vs. 21 months, P = 0.02), and a higher proportion of patients alive (83% vs. 70%, P = 0.03) than in older cases. CONCLUSIONS Pediatric intraventricular gliomas correlate with parenchymal pediatric gliomas in terms of age at diagnosis and general outcomes. The mainstay of management is complete surgical excision and more recent studies report longer overall survival rates and less cranial nerve complications.
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Affiliation(s)
- Gina Watanabe
- University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii, USA.
| | - Andie Conching
- University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii, USA
| | - Lane Fry
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Dillon Putzler
- University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii, USA
| | | | | | - Ali S Haider
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, Viagrande, Italy
| | | | - Mayur Sharma
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Paolo Palmisciano
- Department of Neurological Surgery, University of California, Davis, Sacramento, California, USA
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Karita H, Tsuda K, Kono M, Yamamoto T, Ihara S. Neoadjuvant Therapy with Everolimus for Subependymal Giant Cell Astrocytoma: A Case Report. NMC Case Rep J 2023; 10:291-297. [PMID: 37953906 PMCID: PMC10635902 DOI: 10.2176/jns-nmc.2022-0375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/31/2023] [Indexed: 11/14/2023] Open
Abstract
Direct surgical resection remains to be the standard treatment for tuberous sclerosis complex (TSC) with subependymal giant cell astrocytoma (SEGA). Medical therapy with everolimus (mammalian target of rapamycin inhibitor or mTOR) serves as a second-line treatment for patients with SEGA who are determined to be ineligible for surgical resection. Some recent studies have reported that neoadjuvant therapy for SEGA may be a useful, novel treatment. In this study, we herein present a case of SEGA and demonstrate the efficacy of preoperative everolimus therapy. We have also examined the utility and safety of neoadjuvant therapy for SEGA and investigated four previously reported cases of preoperative administration of mTOR inhibitors. In these cases, everolimus was administered preoperatively to shrink the tumor although the duration of treatment varied. Afterward, gross total tumor removal was conducted in all the cases. No postoperative complications were reported during the follow-up period. These findings indicate that neoadjuvant therapy with an mTOR inhibitor can be a potential treatment for SEGA. The findings of this present study also suggested that a short administration period of about 2 months may be sufficient to achieve preoperative tumor reduction.
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Affiliation(s)
- Hiroki Karita
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kyoji Tsuda
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Maya Kono
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Satoshi Ihara
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Boop S, Bonda D, Randle S, Leary S, Vitanza N, Crotty E, Novotny E, Friedman S, Ellenbogen RG, Durfy S, Goldstein H, Ojemann JG, Hauptman JS. A Comparison of Clinical Outcomes for Subependymal Giant Cell Astrocytomas Treated with Laser Interstitial Thermal Therapy, Open Surgical Resection, and mTOR Inhibitors. Pediatr Neurosurg 2023; 58:150-159. [PMID: 37232001 DOI: 10.1159/000531210] [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: 03/01/2022] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Subependymal giant cell astrocytoma (SEGA) is the most common CNS tumor in patients with tuberous sclerosis complex (TSC). Although these are benign, their proximity to the foramen of Monroe frequently causes obstructive hydrocephalus, a potentially fatal complication. Open surgical resection has been the mainstay of treatment; however, this can cause significant morbidity. The development of mTOR inhibitors has changed the treatment landscape, but there are limitations to their use. Laser interstitial thermal therapy (LITT) is an emerging treatment modality that has shown promise in treatment of a variety of intracranial lesions, including SEGAs. We present a single institution, retrospective study of patients treated for SEGAs with LITT, open resection, mTOR inhibitors, or a combination of these modalities. The primary study outcome was tumor volume at most recent follow-up compared with volume at treatment initiation. The secondary outcome was clinical complications associated with treatment modality. METHODS Retrospective chart review was performed to identify patients with SEGAs treated at our institution from 2010 to 2021. Demographics, treatment information, and complications were collected from the medical record. Tumor volumes were calculated from imaging obtained at initiation of treatment and at most recent follow-up. Kruskal-Wallis nonparametric testing was used to assess differences in tumor volume and follow-up duration between groups. RESULTS Four patients underwent LITT (3 with LITT only), three underwent open surgical resection, and four were treated with mTOR inhibitors only. Mean percent tumor volume reduction for each group was 48.6 ± 13.8, 90.7 ± 39.8, and 67.1 ± 17.2%, respectively. No statistically significant difference was identified comparing percent tumor volume reduction between the three groups (p = 0.0513). Additionally, there was no statistically significant difference in follow-up duration between groups (p = 0.223). Only 1 patient in our series required permanent CSF diversion and 4 discontinued or decreased the dose of mTOR inhibitor due to either cost or side effects. CONCLUSIONS Our study suggests that LITT could be considered as a treatment option for SEGAs as it was effective in reducing tumor volume with very few complications. This modality is less invasive than open resection and may be an alternative for patients who are not candidates for mTOR inhibitors. We recommend an updated paradigm for SEGA treatment which includes LITT in select cases after consideration of patient-specific factors.
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Affiliation(s)
- Scott Boop
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - David Bonda
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Stephanie Randle
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Sarah Leary
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Nicholas Vitanza
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Seattle Children's, University of Washington, Fred Hutch Cancer Research Center, Seattle, Washington, USA
| | - Erin Crotty
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Edward Novotny
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Seth Friedman
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sharon Durfy
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Hannah Goldstein
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jeffrey G Ojemann
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jason S Hauptman
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
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Subependymal giant-cell astrocytoma: a surgical review in the modern era of mTOR inhibitors. Neurochirurgie 2022; 68:627-636. [PMID: 35907444 DOI: 10.1016/j.neuchi.2022.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/05/2022] [Accepted: 07/15/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Surgical removal has been the historical treatment for subependymal giant-cell astrocytoma (SEGA) in tuberous sclerosis complex (TSC) patients. In the past decade, mTOR inhibitors have shown efficacy in the treatment of SEGA, significantly reducing tumor size. The aim of this study was to assess the safety and efficacy of surgical treatment at a time when mTOR inhibitors have changed standard treatment. MATERIAL AND METHODS We conducted a single-center retrospective study including all patients treated by surgery for SEGA from October 2003 to September 2019, with a review of all SEGA surgical case series, following PRISMA guidelines. Research focused on demographics, surgical indications, surgical approach, use of CSF shunt, morbidity and mortality, resection quality, recurrence rate and treatment of recurrence, follow-up and long-term clinical status. RESULTS Eleven patients were included, with a median age at surgery of 16.0 years. Gross total resection was achieved in 8 patients (72%), with no permanent morbidity. One patient needed further surgery for tumor recurrence. Eighteen studies were reviewed, totaling 263 TSC patients affected by SEGA and 286 surgical procedures. Gross total resection was achieved in 81.1% of cases, mortality was 4.9% and permanent morbidity 6.1%. Tumor recurrence occurred in 11.5% of cases, and was secondary to partial tumor resection at first surgery in the majority of cases. CONCLUSION Surgical treatment of SEGA is still a valid and effective option. Morbidity is low and complete disappearance of SEGA can be achieved in selected cases.
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Grossen A, Gavula T, Chrusciel D, Evans A, McNall-Knapp R, Taylor A, Fossey B, Brakefield M, Carter C, Schwartz N, Gross N, Jea A, Desai V. Multidisciplinary neurocutaneous syndrome clinics: a systematic review and institutional experience. Neurosurg Focus 2022; 52:E2. [DOI: 10.3171/2022.2.focus21776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 02/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Neurocutaneous syndromes have variable multisystem involvement. The multiorgan involvement, potential pathologies, and various treatment options necessitate collaboration and open discussion to ensure optimal treatment in any given patient. These disorders provide quintessential examples of chronic medical conditions that require a lifelong, multidisciplinary approach. The objectives of this study were to 1) perform a systematic review, thoroughly assessing different multidisciplinary clinic layouts utilized in centers worldwide; and 2) characterize an institutional experience with the management of these conditions, focusing on the patient demographics, clinical presentation, complications, and therapeutic strategies seen in a patient population.
METHODS
A systematic review of studies involving multidisciplinary clinics and their reported structure was performed according to PRISMA guidelines using the PubMed database. Then a retrospective chart review of patients enrolled in the Oklahoma Children’s Hospital Neurocutaneous Syndromes Clinic was conducted.
RESULTS
A search of the PubMed database yielded 251 unique results. Of these, 15 papers were included in the analysis, which identified 16 clinics that treated more than 2000 patients worldwide. The majority of these clinics treated patients with neurofibromatosis (13/16). The remaining clinics treated patients with von Hippel–Lindau syndrome (n = 1), tuberous sclerosis complex (n = 1), and multiple neurocutaneous syndromes (n = 1). The most commonly represented subspecialties in these clinics were genetics (15/16) and neurology (13/16). Five clinics (31%) solely saw pediatric patients, 10 clinics saw a combination of children and adults, and the final clinic had separate pediatric and adult clinics. The retrospective chart review of the Neurocutaneous Syndromes Clinic demonstrated that 164 patients were enrolled and seen in the clinic from April 2013 to December 2021. Diagnoses were made based on clinical findings or results of genetic testing; 115 (70%) had neurofibromatosis type 1, 9 (5.5%) had neurofibromatosis type 2, 35 (21%) had tuberous sclerosis complex, 2 (1%) had von Hippel–Lindau syndrome, 2 (1%) had Gorlin syndrome, and the remaining patient (0.6%) had Aarskog-Scott syndrome. Patient demographics, clinical presentation, complications, and therapeutic strategies are also discussed.
CONCLUSIONS
To the best of the authors’ knowledge, this is the first detailed description of a comprehensive pediatric neurocutaneous clinic in the US that serves patients with multiple syndromes. There is currently heterogeneity between described multidisciplinary clinic structures and practices. More detailed accounts of clinic compositions and practices along with patient data and outcomes are needed in order to establish the most comprehensive and efficient multidisciplinary approach for neurocutaneous syndromes.
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Affiliation(s)
- Audrey Grossen
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Theresa Gavula
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Deepti Chrusciel
- Department of Pediatric Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Alexander Evans
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Rene McNall-Knapp
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ashley Taylor
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Benay Fossey
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Margaret Brakefield
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Carrick Carter
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Nadine Schwartz
- Department of Pediatric Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Naina Gross
- Department of Pediatric Neurosurgery, Saint Francis Hospital, Tulsa, Oklahoma
| | - Andrew Jea
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
| | - Virendra Desai
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Oklahoma City, Oklahoma
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Iyer RR, Strahle JM, Groves ML. Neurosurgical Considerations of Neurocutaneous Syndromes. Neurosurg Clin N Am 2021; 33:81-89. [PMID: 34801145 DOI: 10.1016/j.nec.2021.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The phakomatoses are a group of genetic and acquired disorders characterized by neurologic, cutaneous, and often ocular manifestations, thus commonly referred to as neurocutaneous syndromes. In several of these conditions the underlying genetic pathophysiology has been elucidated, which will continue to play an important role in advancing therapeutic techniques. This article focuses on several examples of such neurocutaneous syndromes, with special attention to the relevant neurosurgical considerations of these patients.
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Affiliation(s)
- Rajiv R Iyer
- Department of Neurosurgery/Division of Pediatric Neurosurgery, University of Utah/Primary Children's Hospital, 100 N. Mario Capecchi Drive Suite 3850, Salt Lake City, UT 84113, USA.
| | - Jennifer M Strahle
- Pediatric Neuro Spine Program, Pediatric Cerebrovascular Surgery, Division of Pediatric Neurosurgery, Department of Neurosurgery, Washington University School of Medicine, 1 Childrens Pl Suite 4S20, St. Louis, MO 63110, USA
| | - Mari L Groves
- Department of Neurosurgery, Johns Hopkins School of Medicine, 600 N. Wolfe Street Phipps 554, Baltimore, MD 21287, USA
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Updated International Tuberous Sclerosis Complex Diagnostic Criteria and Surveillance and Management Recommendations. Pediatr Neurol 2021; 123:50-66. [PMID: 34399110 DOI: 10.1016/j.pediatrneurol.2021.07.011] [Citation(s) in RCA: 260] [Impact Index Per Article: 86.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disease affecting multiple body systems with wide variability in presentation. In 2013, Pediatric Neurology published articles outlining updated diagnostic criteria and recommendations for surveillance and management of disease manifestations. Advances in knowledge and approvals of new therapies necessitated a revision of those criteria and recommendations. METHODS Chairs and working group cochairs from the 2012 International TSC Consensus Group were invited to meet face-to-face over two days at the 2018 World TSC Conference on July 25 and 26 in Dallas, TX, USA. Before the meeting, working group cochairs worked with group members via e-mail and telephone to (1) review TSC literature since the 2013 publication, (2) confirm or amend prior recommendations, and (3) provide new recommendations as required. RESULTS Only two changes were made to clinical diagnostic criteria reported in 2013: "multiple cortical tubers and/or radial migration lines" replaced the more general term "cortical dysplasias," and sclerotic bone lesions were reinstated as a minor criterion. Genetic diagnostic criteria were reaffirmed, including highlighting recent findings that some individuals with TSC are genetically mosaic for variants in TSC1 or TSC2. Changes to surveillance and management criteria largely reflected increased emphasis on early screening for electroencephalographic abnormalities, enhanced surveillance and management of TSC-associated neuropsychiatric disorders, and new medication approvals. CONCLUSIONS Updated TSC diagnostic criteria and surveillance and management recommendations presented here should provide an improved framework for optimal care of those living with TSC and their families.
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Mo F, Pellerino A, Rudà R. Subependymal Giant Cell Astrocytomas (SEGAs): a Model of Targeting Tumor Growth and Epilepsy. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00673-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Tomoto K, Fujimoto A, Inenaga C, Okanishi T, Imai S, Ogai M, Fukunaga A, Nakamura H, Sato K, Obana A, Masui T, Arai Y, Enoki H. Experience using mTOR inhibitors for subependymal giant cell astrocytoma in tuberous sclerosis complex at a single facility. BMC Neurol 2021; 21:139. [PMID: 33784976 PMCID: PMC8011204 DOI: 10.1186/s12883-021-02160-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Subependymal giant cell astrocytoma (SEGA) is occasionally seen in tuberous sclerosis complex (TSC). Two main options are currently available for treating SEGA: surgical resection or pharmacotherapy using mammalian target of rapamycin inhibitors (mTORi). We hypothesized that opportunities for surgical resection of SEGA would have reduced with the advent of mTORi. METHODS We retrospectively reviewed the charts of patients treated between August 1979 and July 2020, divided into a pre-mTORi era group (Pre-group) of patients treated before November 2012, and a post-mTORi era group (Post-group) comprising patients treated from November 2012, when mTORi became available in Japan for SEGA. We compared groups in terms of treatment with surgery or mTORi. We also reviewed SEGA size, rate of acute hydrocephalus, recurrence of SEGA, malignant transformation and adverse effects of mTORi. RESULTS In total, 120 patients with TSC visited our facility, including 24 patients with SEGA. Surgical resection was significantly more frequent in the Pre-group (6 of 7 patients, 86 %) than in the Post-group (2 of 17 patients, 12 %; p = 0.001). Acute hydrocephalus was seen in 1 patient (4 %), and no patients showed malignant transformation of SEGA. The group treated using mTORi showed significantly smaller SEGA compared with the group treated under a wait-and-see policy (p = 0.012). Adverse effects of pharmacotherapy were identified in seven (64 %; 6 oral ulcers, 1 irregular menstruation) of the 11 patients receiving mTORi. CONCLUSIONS The Post-group underwent surgery significantly less often than the Pre-group. Since the treatment option to use mTORi in the treatment of SEGA in TSC became available, opportunities for surgical resection have decreased in our facility.
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Affiliation(s)
- Kyoichi Tomoto
- Department of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Ayataka Fujimoto
- Department of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan.
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan.
| | - Chikanori Inenaga
- Department of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Tohru Okanishi
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Shin Imai
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Masaaki Ogai
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Akiko Fukunaga
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Hidenori Nakamura
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Keishiro Sato
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Akira Obana
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Takayuki Masui
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Yoshifumi Arai
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
| | - Hideo Enoki
- Tuberous Sclerosis Complex Board, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Nakaku, Hamamatsu, 430-8558, Shizuoka, Japan
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MRI-based diagnosis and treatment of pediatric brain tumors: is tissue sample always needed? Childs Nerv Syst 2021; 37:1449-1459. [PMID: 33821340 PMCID: PMC8084800 DOI: 10.1007/s00381-021-05148-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/24/2021] [Indexed: 11/23/2022]
Abstract
Traditional management of newly diagnosed pediatric brain tumors (PBTs) consists of cranial imaging, typically magnetic resonance imaging (MRI), and is frequently followed by tissue diagnosis, through either surgical biopsy or tumor resection. Therapy regimes are typically dependent on histological diagnosis. To date, many treatment regimens are based on molecular biology. The scope of this article is to discuss the role of diagnosis and further treatment of PBTs based solely on MRI features, in light of the latest treatment protocols. Typical MRI findings and indications for surgical biopsy of these lesions are described.
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Desai VR, Jenson AV, Hoverson E, Desai RM, Boghani Z, Lee MR. Stereotactic laser ablation for subependymal giant cell astrocytomas: personal experience and review of the literature. Childs Nerv Syst 2020; 36:2685-2691. [PMID: 32468241 DOI: 10.1007/s00381-020-04638-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/22/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Subependymal giant cell astrocytomas (SEGAs) are rare tumors typically found in tuberous sclerosis patients. They typically grow in the region of the foramen of Monro and can occlude it, leading to hydrocephalus. Currently, gross total resection is the standard of care, with low rates of recurrence but high rates of complication, especially with larger lesions. Laser interstitial thermal therapy (LITT) is a newly emerging treatment modality for a variety of pathologies. Here, we present a case series of SEGAs managed via LITT and endoscopic, stereotactic septostomy. METHODS A retrospective chart review was performed to identify three cases in which SEGAs were treated via LITT and septostomy. Stereotactic ablation was performed via magnetic resonance (MR) thermometry with laser output set to 69% for 2.5 min, with post-ablation scans for visualization of treatment area. RESULTS Average age at surgery was 8.2 years. Pre-operative tumor volumes were 0.43, 1.51, and 3.88 cm3. Post-operative tumor volumes were 0.25, 0.21, and 0.68 cm3. Mean tumor volume reduction was 70%. No complications occurred. CONCLUSION LITT with septostomy should be considered a viable primary or adjunct treatment modality for SEGAs.
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Affiliation(s)
- Virendra R Desai
- Pediatric Neurosurgery, Dell Children's Medical Center, Department of Neurosurgery, The University of Texas at Austin Dell Medical School, Austin, TX, USA. .,Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Scurlock Tower, Suite 944, 6560 Fannin Street, Houston, TX, 77030, USA.
| | - Amanda V Jenson
- Pediatric Neurosurgery, Dell Children's Medical Center, Department of Neurosurgery, The University of Texas at Austin Dell Medical School, Austin, TX, USA.,Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Scurlock Tower, Suite 944, 6560 Fannin Street, Houston, TX, 77030, USA
| | - Eric Hoverson
- Pediatric Neurosurgery, Dell Children's Medical Center, Department of Neurosurgery, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Rajendra M Desai
- Department of Radiology, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Zain Boghani
- Pediatric Neurosurgery, Dell Children's Medical Center, Department of Neurosurgery, The University of Texas at Austin Dell Medical School, Austin, TX, USA.,Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Scurlock Tower, Suite 944, 6560 Fannin Street, Houston, TX, 77030, USA
| | - Mark R Lee
- Pediatric Neurosurgery, Dell Children's Medical Center, Department of Neurosurgery, The University of Texas at Austin Dell Medical School, Austin, TX, USA.,Department of Neurosurgery, The Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
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Frassanito P, Noya C, Tamburrini G. Current trends in the management of subependymal giant cell astrocytomas in tuberous sclerosis. Childs Nerv Syst 2020; 36:2527-2536. [PMID: 32978642 DOI: 10.1007/s00381-020-04889-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The management of subependymal giant cells astrocytomas (SEGAs) has been traditionally represented by surgical treatment through an open craniotomic approach. Though open surgery still represents a major option in the management of this kind of tumors, the introduction of mTOR inhibitors in the clinical practice, technological advances in neuroendoscopy and the more recent use of laser interstitial therapy have significantly enlarged the range of available management opportunities. METHODS A thorough review of the literature has been performed. Accordingly, current views in open surgical treatment, medical therapy, endoscopic tumor removal and new trends (such as laser interstitial thermal therapy) are discussed. RESULTS The risk of significant neurological morbidity (5-50%) complicating open surgery has been for a long time representing a main drawback in the management of SEGAs. More recent series report a significant reduction of morbidity and mortality. The mTOR inhibitors have demonstrated efficacy in both warranting a tumor reduction by up to 60% of the tumor size and helping the control of seizures. However, the reported rate of side effects is as high as 30% and tumor recurrence is a documented occurrence at the time of mTOR inhibitor discontinuation. Endoscopic tumor removal has been more extensively considered an option due to the acquisition of new tools. Limits are still represented by tumor size (< 3 cm) and broad attachment of the tumor to the basal ganglia. Laser interstitial thermal therapy (LITT) is the more recently considered option. Though promising, only short follow-up is available so far, while data on medium- and long-term results of this treatment are completely lacking to date. CONCLUSIONS Surgical treatment remains a mainstay of the management of SEGAs. The indication for an open craniotomic approach should be balanced with an endoscopic tumor removal or LITT according to patient conditions, presence or not of an active hydrocephalus and extension of the attachment of the tumor to the basal ganglia. The mTOR inhibitors do have a definite role both as primary and as adjuvant treatment, but consistent limitations are represented up to now by a not negligible rate of complications and the uncertainties related to the possibility of tumor recurrence once the medical treatment is discontinued.
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Affiliation(s)
- Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy.
| | - Carolina Noya
- Pediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy.,Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy.,Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy
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13
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Giordano F, Moscheo C, Lenge M, Biagiotti R, Mari F, Sardi I, Buccoliero AM, Mongardi L, Aronica E, Guerrini R, Genitori L. Neurosurgical treatment of subependymal giant cell astrocytomas in tuberous sclerosis complex: a series of 44 surgical procedures in 31 patients. Childs Nerv Syst 2020; 36:951-960. [PMID: 31853898 DOI: 10.1007/s00381-019-04449-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Subependymal giant cell astrocytomas (SEGA) are benign tumors characteristic of tuberous sclerosis complex (TSC) that may cause hydrocephalus. Various treatments are nowadays available as mTOR inhibitors or surgery. Surgery is still a valid option especially for symptomatic and larger tumors. METHODS From January 1994 to December 2015, 31 TSC patients harboring SEGA underwent surgery at the Department of Neurosurgery of the Meyer Pediatric Hospital, Florence. Indications for surgery were tumor size and location, growth and cystization/hemorrhage, and hydrocephalus. Clinical data, preoperative and postoperative MRI, recurrence rate, further surgical procedures, and related complications were analyzed. RESULTS A total of 44 surgeries were performed in 31 TSC patients affected by SEGA, achieving gross total removal (GTR) and subtotal removal (STR), respectively, in 36 and 8 patients. Recurrences occurred in 11 patients; 9 of them underwent further surgical procedures and 2 were treated with mTOR pathway inhibitors. Surgical morbidity and mortality were, respectively, 22.7% and 2.3%. After a mean follow-up of 4.9 years, 90% of patients were tumor-free with good neurological status in 93.3%; twelve (40%) had a ventriculo-peritoneal shunt (VPS) for hydrocephalus. CONCLUSIONS The present series confirms that the surgical approach, combined with mTOR inhibitors, is still a valid option for the treatment of SEGAs.
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Affiliation(s)
- Flavio Giordano
- Department of Neurosurgery, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy.
| | - Carla Moscheo
- Neuro-oncology Unit, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Matteo Lenge
- Department of Neurosurgery, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy.,3. Pediatric Neurology, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Roberto Biagiotti
- Division of Prenatal Diagnosis, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Francesco Mari
- 3. Pediatric Neurology, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Iacopo Sardi
- Neuro-oncology Unit, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Anna Maria Buccoliero
- Pathology Unit, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Lorenzo Mongardi
- Neurosurgery, Sant'Anna Hospital, Via Aldo Moro, Ferrara, 44124, Italy
| | - Eleonora Aronica
- Department of (Neuro) Pathology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Renzo Guerrini
- 3. Pediatric Neurology, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
| | - Lorenzo Genitori
- Department of Neurosurgery, Children's Hospital A. Meyer, University of Florence, viale Pieraccini 24, Florence, 50139, Italy
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14
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Fohlen M, Ferrand-Sorbets S, Delalande O, Dorfmüller G. Surgery for subependymal giant cell astrocytomas in children with tuberous sclerosis complex. Childs Nerv Syst 2018; 34:1511-1519. [PMID: 29766265 DOI: 10.1007/s00381-018-3826-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/06/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Subependymal giant cell astrocytomas (SEGAs) are low-grade intraventricular glial tumors that develop in 10-15% of patients with tuberous sclerosis complex; they often cause hydrocephalus and are potentially accessible to a surgical treatment. Our aim is to evaluate morbidity and results after surgery in symptomatic and asymptomatic patients. METHOD We present a retrospective series of 18 pediatric patients operated on for SEGA between 2006 and 2016 at our institution. We reviewed surgical indications, preoperative clinical and radiologic data, surgical management, and clinical and radiological follow-up. RESULTS Mean age at surgery was 10.7 years. The surgical decision was based on clinical signs of raised intracranial pressure due to hydrocephalus in 8 and on radiological findings without any clinical signs in the other 10 patients (increased in SEGA volume with or without ventricular enlargement). Surgical treatment consisted in a frontal trans-ventricular microsurgical approach in 17 patients and an endoscopic approach in 1. External ventricular drainage was placed in all the patients but 1. Ventriculoperitoneal shunting (VPS) became necessary in 6 patients, all of them presenting with a preoperative active hydrocephalus. Morbidity appeared very low with meningitis occurring in 1 patient. Resection was complete in 15 children with no recurrence during a mean follow-up of 5.25 years and incomplete in 3 requiring a second surgery. CONCLUSION Surgery of SEGA represents a very effective treatment with low morbidity and no mortality in the present series. In patients operated before the onset of clinical signs of hydrocephalus, internal VPS could be avoided whereas in others, an additional shunt surgery became necessary. This gives arguments in favor of a regular MRI surveillance in tuberous sclerosis complex patients with SEGA in order to best propose resective surgery once a growth of tumor and/or ventricular size have been confirmed but before raised intracranial pressure occurs.
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Affiliation(s)
- Martine Fohlen
- Department of Pediatric Neurosurgery, Fondation Ophtalmologique A. de Rothschild, Paris, France.
| | - Sarah Ferrand-Sorbets
- Department of Pediatric Neurosurgery, Fondation Ophtalmologique A. de Rothschild, Paris, France
| | - Olivier Delalande
- Department of Pediatric Neurosurgery, Fondation Ophtalmologique A. de Rothschild, Paris, France
| | - Georg Dorfmüller
- Department of Pediatric Neurosurgery, Fondation Ophtalmologique A. de Rothschild, Paris, France
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15
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Karsy M, Patel DM, Bollo RJ. Trapped ventricle after laser ablation of a subependymal giant cell astrocytoma complicated by intraventricular gadolinium extravasation: case report. J Neurosurg Pediatr 2018; 21:523-527. [PMID: 29451453 DOI: 10.3171/2017.11.peds17518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Magnetic resonance imaging-guided stereotactic laser ablation of intracranial targets, including brain tumors, has expanded dramatically over the past decade, but there have been few reports of complications, especially those occurring in a delayed fashion. Laser ablation of subependymal giant cell astrocytomas (SEGAs) is an attractive alternative to maintenance immunotherapy in some children with tuberous sclerosis complex (TSC); however, the effect of treatment on disease progression and the nature and frequency of potential complications remains largely unknown. The authors report the case of a 5-year-old boy with TSC who underwent stereotactic laser ablation of a SEGA at the right foramen of Monro on 2 separate occasions. After the second ablation, immediate posttreatment MRI revealed gadolinium extravasation from the tumor into the lateral ventricle. Nine months later, the patient presented with papilledema and delayed obstructive hydrocephalus secondary to intraventricular adhesions causing a trapped right lateral ventricle. This was successfully treated with endoscopic septostomy. The authors discuss the potential cause and clinical management of a delayed complication not previously reported after a relatively novel surgical therapy.
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Affiliation(s)
- Michael Karsy
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Daxa M Patel
- 1Division of Pediatric Neurosurgery and.,2Department of Neurosurgery, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Robert J Bollo
- 1Division of Pediatric Neurosurgery and.,2Department of Neurosurgery, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah
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Presurgical Administration of mTOR Inhibitors in Patients with Large Subependymal Giant Cell Astrocytoma Associated with Tuberous Sclerosis Complex. World Neurosurg 2017; 107:1053.e1-1053.e6. [DOI: 10.1016/j.wneu.2017.08.122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 01/27/2023]
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17
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Katz JS, Frankel H, Ma T, Zagzag D, Liechty B, Zeev BB, Tzadok M, Devinsky O, Weiner HL, Roth J. Unique findings of subependymal giant cell astrocytoma within cortical tubers in patients with tuberous sclerosis complex: a histopathological evaluation. Childs Nerv Syst 2017; 33:601-607. [PMID: 28074282 DOI: 10.1007/s00381-017-3335-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 01/03/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Tuberous sclerosis is associated with three central nervous system pathologies: cortical/subcortical tubers, subependymal nodules (SENs), and subependymal giant cell astrocytomas (SEGAs). Tubers are associated with epilepsy, which is often medication-resistant and often leads to resective surgery. Recently, mammalian target of rapamycin inhibitors (mTORi) have been shown to be effective reducing seizure burden in some patients with tuberous sclerosis complex (TSC)-related refractory epilepsy. mTORi have also been shown to be an alternative for surgery treating SEGAs. We describe several cases of resected tubers that contained SEGA tissue without an intraventricular SEGA. METHODS After institutional review board (IRB) protocol approval, we retrospectively reviewed the surgical-pathological data for all TSC patients who underwent cortical resections for treatment of refractory epilepsy at NYU Langone Medical Center and Tel Aviv Medical Center between 2003 and 2013. Data included demographics, epilepsy type, MRI characteristics, epilepsy outcome, and histopathological staining. RESULTS We reviewed cortical resections from 75 patients with complete pathological studies. In three patients, cortical lesions demonstrated histopathological findings consistent with a SEGA within the resected tuber tissue, with no intraventricular SEGA. All lesions were cortically based and none had any intraventricular extension. No patient had been treated before surgery with an mTORi. Two of the three patients remain Engel grade I-II. All lesions stained positive for glial fibrillary acidic protein (GFAP), synaptophysin, and neuronal nuclear antigen (NeuN). CONCLUSION This is the first description of cortical tubers harboring SEGA tissue. This observation though preliminary may suggest a subgroup of patients with intractable epilepsy in whom mTORi may be considered before surgical intervention.
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Affiliation(s)
- Joel S Katz
- Department of Neurosurgery, OhioHealth, Grant and Riverside Medical Center, 111 S Grant Avenue, Columbus, OH, 43215, USA
| | - Hyman Frankel
- Department of Neurosurgery, Division of Pediatric Neurosurgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA
| | - Tracy Ma
- Department of Neurosurgery, Division of Pediatric Neurosurgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA
| | - David Zagzag
- Department of Neurosurgery, Division of Pediatric Neurosurgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA.,Department of Pathology, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA
| | - Benjamin Liechty
- Department of Pathology, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA
| | - Bruria Ben Zeev
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
| | - Michal Tzadok
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA
| | - Howard L Weiner
- Department of Neurosurgery, Texas Children's Hospital, 6701 Fannin Street, Suite 1230.01, Houston, TX, 77030, USA
| | - Jonathan Roth
- Department of Pediatric Neurosurgery Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizman Street, 64239, Tel Aviv, Israel.
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18
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Vascular hyperpermeability as a hallmark of phacomatoses: is the etiology angiogenesis comparable with mechanisms seen in inflammatory pathways? Part I: historical observations and clinical perspectives on the etiology of increased CSF protein levels, CSF clotting, and communicating hydrocephalus: a comprehensive review. Neurosurg Rev 2017; 41:957-968. [PMID: 28265819 DOI: 10.1007/s10143-017-0839-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/18/2017] [Accepted: 02/21/2017] [Indexed: 10/20/2022]
Abstract
Phacomatoses are a special group of familial hamartomatous syndromes with unique neuro-cutaneous manifestations as well as disease characteristic tumors. Neurofibromatosis 2 (NF2) and tuberous sclerosis complex (TSC) are representatives of this family. Vestibular schwannoma (VS) and subependymal giant cell tumor (SGCT) are two of the most common intracranial tumors associated with NF2 and TSC, respectively. These tumors can present with obstructive hydrocephalus due to their location adjacent to or in the ventricles. However, both tumors are also known to have a unique association with an elevated protein concentration in the cerebrospinal fluid (CSF), sometimes in association with non-obstructive (communicating) hydrocephalus (HCP), the causality of which has been unclear. Furthermore, SGCTs have repeatedly been shown to have a predisposition for CSF clotting, causing debilitating obstructions and recurrent malfunctions in shunted patients. However, the exact relation between high protein levels and spontaneous clotting of the CSF is not clear, nor is the mechanism understood by which CSF may clot in SGCTs. Elevated protein levels in the CSF are thought to be caused by increased vascular permeability and dysregulation of the blood-brain barrier. The two presumed underlying pathophysiologic mechanisms for that, in the context of tumorigenesis, are angiogenesis and inflammation. Both mechanisms are correlated to the Pi3K/Akt/mTOR pathway which is a major tumorigenesis pathway in nearly all phacomatoses. In this review, we discuss the influence of angiogenesis and inflammation on vascular permeability in VSs and SGCTs at the phenotypic level as well as their possible genetic and molecular determinants. Part I describes the historical perspectives and clinical aspects of the relationship between vascular permeability, abnormal CSF protein levels, clotting of the CSF, and communicating HCP. Part II describes different cellular and molecular pathways involved in angiogenesis and inflammation in these two tumors and the correlation between inflammation and coagulation. Interestingly, while increased angiogenesis can be observed in both VS and SGCT, inflammatory processes seem more prominent in SGCT. Both pathologies are characterized by different subgroups of tumor-associated macrophages (TAM): the pro-inflammatory, M1 type is predominating in SGCTs while pro-angiogenetic, M2 type is predominating in VSs. We suggest that lack of NF2 protein in VS and lack of TSC1/2 proteins in SGCT determine this fundamental difference between the two tumor types, by defining the predominant TAM type. Since inflammatory reactions and coagulation processes are tightly connected, a "pro-inflammatory state" of SGCT can be used to explain the observed associated enhanced CSF clotting process. These distinct cellular and molecular differences may have direct therapeutic implications on tumors that are unique to certain phacomatoses or those with similar genetics.
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19
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Kasper E, Laviv Y, Sebai MAE, Lin N, Butler W. Subependymal Giant Cell Astrocytoma: Associated Hyperproteinorrhachia Causing Shunt Failures and Nonobstructive Hydrocephalus - Report of Successful Treatment with Long-term Follow-up. Asian J Neurosurg 2017; 12:746-750. [PMID: 29114301 PMCID: PMC5652113 DOI: 10.4103/ajns.ajns_231_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Subependymal giant cell astrocytomas (SEGAs) are histologically benign tumors most frequently associated with tuberous sclerosis complex (TSC). Despite their benign histopathological appearance, they may cause unfavorable outcomes due to their intraventricular location. Rarely, SEGA may be associated with hyperproteinorrhachia (high levels of proteins in the cerebrospinal fluid [CSF]), which causes malresorptive, communicating hydrocephalus; certainly, this scenario makes shunt obstruction likely in this patient population. In this report, we illustrate the case of hyperproteinorrhachia in an SEGA patient with known TSC, who presented repeatedly with shunt failure from proteinaceous shunt obstruction. Subsequent surgical resection of the main intraventricular lesion resulted in a dramatic drop in the CSF protein levels and has since prevented further shunt failures. Different treatment concepts and possible pathophysiology are discussed and the pertinent literature is reviewed.
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Affiliation(s)
- Ekkehard Kasper
- Department of Surgery, Beth Israel Deaconess Medical Center, Division of Neurosurgery, Harvard Medical School, Boston, MA, USA
| | - Yosef Laviv
- Department of Surgery, Beth Israel Deaconess Medical Center, Division of Neurosurgery, Harvard Medical School, Boston, MA, USA
| | - Mohammed-Adeeb E Sebai
- Department of Surgery, Beth Israel Deaconess Medical Center, Division of Neurosurgery, Harvard Medical School, Boston, MA, USA
| | - Ning Lin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - William Butler
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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20
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EFFECTS: an expanded access program of everolimus for patients with subependymal giant cell astrocytoma associated with tuberous sclerosis complex. BMC Neurol 2016; 16:126. [PMID: 27502586 PMCID: PMC4976509 DOI: 10.1186/s12883-016-0658-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 08/02/2016] [Indexed: 01/04/2023] Open
Abstract
Background Everolimus, a mammalian target of rapamycin (mTOR) inhibitor, has been shown to be effective and safe in the treatment of subependymal giant cell astrocytoma (SEGA) associated with tuberous sclerosis complex (TSC). The Everolimus For Fast Expanded aCcess in TSC SEGA (EFFECTS) study was designed to provide everolimus access to patients with SEGA associated with TSC and to mainly assess the safety and also efficacy of everolimus in a real-world setting. Methods EFFECTS was a phase 3b, open-label, noncomparative, multicenter, expanded access study. Eligible patients were ≥ 3 years of age, with a definite diagnosis of TSC, and with at least one SEGA lesion identified by MRI or CT scan. Patients received once daily everolimus (dose adjusted to attain a trough level of 5-15 ng/mL). Safety evaluation was the primary objective and included collection of adverse events (AEs) and serious AEs, with their severity and relationship to everolimus. Efficacy evaluation, which was the secondary objective, was based on the best overall response as per medical judgment. Results Of the 120 patients enrolled, 100 (83.3 %) completed the study. Median age of patients was 11 years (range, 1-47). Median daily dose of everolimus was 5.82 mg (range, 2.0–11.8). Median duration of exposure was 56.5 weeks (range, 0.3–130). The overall incidence of AEs was 74.2 %. Aphthous stomatitis (18 [15.0 %]), pyrexia (18 [15.0 %]), bronchitis (11 [9.2 %]), and stomatitis (10 [8.3 %]) were the most common AEs reported. Overall, 25 patients had grade 3 AEs; most frequent was stomatitis (4 [3.3 %]). Grade 4 AEs were reported in three (2.5 %) patients. A total of 62 (51.7 %) patients had suspected drug-related AEs, of which 15 (12.5 %) were of grade 3 or 4. In eight (6.7 %) patients, AEs led to drug discontinuation. With regard to efficacy, 81 (67.5 %) patients had a partial response, 35 (29.2 %) had a stable disease, and one (0.8 %) had progressive disease. The response was unknown in three (2.5 %) patients. Conclusion This study confirms the acceptable safety profile of everolimus in patients with SEGA associated with TSC in a real-world setting. The results further support the efficacy of everolimus in the treatment of SEGA associated with TSC. (EudraCT: 2010-022583-13)
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van Scheppingen J, Iyer AM, Prabowo AS, Mühlebner A, Anink JJ, Scholl T, Feucht M, Jansen FE, Spliet WG, Krsek P, Zamecnik J, Buccoliero AM, Giordano F, Genitori L, Kotulska K, Jozwiak S, Jaworski J, Liszewska E, van Vliet EA, Aronica E. Expression of microRNAs miR21, miR146a, and miR155 in tuberous sclerosis complex cortical tubers and their regulation in human astrocytes and SEGA-derived cell cultures. Glia 2016; 64:1066-82. [PMID: 27014996 DOI: 10.1002/glia.22983] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 02/29/2016] [Accepted: 03/02/2016] [Indexed: 12/23/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic disease presenting with multiple neurological symptoms including epilepsy, mental retardation, and autism. Abnormal activation of various inflammatory pathways has been observed in astrocytes in brain lesions associated with TSC. Increasing evidence supports the involvement of microRNAs in the regulation of astrocyte-mediated inflammatory response. To study the role of inflammation-related microRNAs in TSC, we employed real-time PCR and in situ hybridization to characterize the expression of miR21, miR146a, and miR155 in TSC lesions (cortical tubers and subependymal giant cell astrocytomas, SEGAs). We observed an increased expression of miR21, miR146a, and miR155 in TSC tubers compared with control and perituberal brain tissue. Expression was localized in dysmorphic neurons, giant cells, and reactive astrocytes and positively correlated with IL-1β expression. In addition, cultured human astrocytes and SEGA-derived cell cultures were used to study the regulation of the expression of these miRNAs in response to the proinflammatory cytokine IL-1β and to evaluate the effects of overexpression or knockdown of miR21, miR146a, and miR155 on inflammatory signaling. IL-1β stimulation of cultured glial cells strongly induced intracellular miR21, miR146a, and miR155 expression, as well as miR146a extracellular release. IL-1β signaling was differentially modulated by overexpression of miR155 or miR146a, which resulted in pro- or anti-inflammatory effects, respectively. This study provides supportive evidence that inflammation-related microRNAs play a role in TSC. In particular, miR146a and miR155 appear to be key players in the regulation of astrocyte-mediated inflammatory response, with miR146a as most interesting anti-inflammatory therapeutic candidate.
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Affiliation(s)
- J van Scheppingen
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A M Iyer
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A S Prabowo
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A Mühlebner
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - J J Anink
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - T Scholl
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - M Feucht
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - F E Jansen
- Department of Pediatric Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W G Spliet
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P Krsek
- Department of Pediatric Neurology, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - J Zamecnik
- Department of Pathology and Molecular Medicine, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - A M Buccoliero
- Pathology Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - F Giordano
- Department of Neurosurgery, Anna Meyer Children's Hospital, Florence, Italy
| | - L Genitori
- Department of Neurosurgery, Anna Meyer Children's Hospital, Florence, Italy
| | - K Kotulska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - S Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - J Jaworski
- Laboratory of Molecular and Cellular Neurobiology, International Institute of Molecular and Cell Biology, Warsaw, Poland
| | - E Liszewska
- Laboratory of Molecular and Cellular Neurobiology, International Institute of Molecular and Cell Biology, Warsaw, Poland
| | - E A van Vliet
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - E Aronica
- Department of (Neuro)Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, Amsterdam, the Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), the Netherlands
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22
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Hidalgo ET, Ali A, Weiner HL, Harter DH. Resection of Intraventricular Tumors in Children by Purely Endoscopic Means. World Neurosurg 2015; 87:372-80. [PMID: 26704210 DOI: 10.1016/j.wneu.2015.11.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Neuroendoscopy is increasingly being used in the management of intraventricular brain tumors. The role of endoscopy in diagnostic biopsy is well established. Expansion of these techniques may allow for definitive resection of intraventricular tumors. We report the feasibility and outcomes of endoscopic resection of select intraventricular tumors in children. METHODS The clinical characteristics of 11 children with solid intraventricular tumors who underwent tumor resection were reviewed. Twelve procedures were performed. RESULTS Gross-total resection was achieved in 11 of 12 cases (92%). Maximal tumor diameter ranged from 9 to 26 mm (mean, 16.6 mm). Pathologic results included subependymal giant cell astrocytomas, ependymomas, nongerminomatous germ cell tumors, and pilocytic astrocytomas. Mean follow-up was 35 months (range, 10-109 months). All patients returned to their neurologic baselines after surgery. Local tumor recurrence occurred in 1 patient and distant recurrence in another. In 1 patient, a transitory intraoperative increase of intracranial pressure without clinical implications occurred. There was no permanent morbidity or mortality in this series. Hydrocephalus was present preoperatively in 5 cases and was treated either with tumor removal alone or with an additional endoscopic third ventriculostomy. No patient required a ventriculoperitoneal shunt. CONCLUSIONS Neuroendoscopic gross-total resection of solid intraventricular tumors is a safe and efficacious procedure in carefully selected pediatric patients.
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Affiliation(s)
- Eveline Teresa Hidalgo
- Department of Neurosurgery, NYU Division of Pediatric Neurosurgery, New York University School of Medicine, New York
| | - Aryan Ali
- Shaheed Aso Hospital, Kurdistan, Sulaimaniyah, Qirga, Kaniba, Iraq
| | - Howard L Weiner
- Department of Neurosurgery, NYU Division of Pediatric Neurosurgery, New York University School of Medicine, New York
| | - David H Harter
- Department of Neurosurgery, NYU Division of Pediatric Neurosurgery, New York University School of Medicine, New York.
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