1
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Boukaka RG, Beuriat PA, Di Rocco F, Vasiljevic A, Szathmari A, Mottolese C. Brainstem tumors in children: a monocentric series in the light of genetic and bio-molecular progress in pediatric neuro-oncology. Front Pediatr 2023; 11:1193474. [PMID: 37936887 PMCID: PMC10626527 DOI: 10.3389/fped.2023.1193474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
Introduction Brainstem tumors represent a challenge. Their management and prognosis vary according to anatomopathological findings and genetic and bio-molecular fingerprints. We present our experience with pediatric brainstem tumors. Material and methods All patients admitted for a brainstem tumor at the Pediatric Neurosurgical Unit at Hôpital Femme Mère Enfant hospital between January 1997 and December 2019 were considered. Patients data were obtained through a retrospective review of the medical records; follow-up was from the last outpatient consultation. Results One hundred and twelve patients were included. Eighty-five patients (75.9%) had open surgery or stereotactic biopsy. Thirty-five patients were treated for hydrocephalus. Sixty-six received an adjuvant treatment. Several protocols were adopted according to the SFOP and SIOP during this time period. The overall survival rate was 45% with a median follow-up of five years (range 1-18 year). However, the survival rate was very different between the diffuse intrinsic pontine gliomas (DIPG) and the others tumor types. If we exclude the DIPG (59 patients), of which only 1 was alive at 3 years, the survival rate was 90.6% (only 5 deaths over 53 patients) with a median follow up of 5 years. Conclusions Our series confirms that benign tumors of the brainstem have a good survival when treated with surgical removal ± adjuvant therapy. Diffuse pontine gliomas continue to have a dismal prognosis. Individualized treatment based on molecular fingerprints may help to select the best adjuvant therapy and hence potentially improve survival.
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Affiliation(s)
- Rel Gerald Boukaka
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de, Lyon, France
| | - Pierre-Aurélien Beuriat
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de, Lyon, France
- Université Claude Bernard, Lyon 1, Lyon, France
| | - Federico Di Rocco
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de, Lyon, France
- Université Claude Bernard, Lyon 1, Lyon, France
| | - Alexandre Vasiljevic
- Department of Pathology and Neuropathology, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Alexandru Szathmari
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de, Lyon, France
| | - Carmine Mottolese
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de, Lyon, France
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2
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Pachocki CJ, Hol EM. Current perspectives on diffuse midline glioma and a different role for the immune microenvironment compared to glioblastoma. J Neuroinflammation 2022; 19:276. [PMCID: PMC9675250 DOI: 10.1186/s12974-022-02630-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 10/25/2022] [Indexed: 11/21/2022] Open
Abstract
Diffuse midline glioma (DMG), formerly called diffuse intrinsic pontine glioma (DIPG), is a high-grade malignant pediatric brain tumor with a near-zero survival rate. To date, only radiation therapy provides marginal survival benefit; however, the median survival time remains less than a year. Historically, the infiltrative nature and sensitive location of the tumor rendered surgical removal and biopsies difficult and subsequently resulted in limited knowledge of the disease, as only post-mortem tissue was available. Therefore, clinical decision-making was based upon experience with the more frequent and histologically similar adult glioblastoma (GBM). Recent advances in tissue acquisition and molecular profiling revealed that DMG and GBM are distinct disease entities, with separate tissue characteristics and genetic profiles. DMG is characterized by heterogeneous tumor tissue often paired with an intact blood–brain barrier, possibly explaining its resistance to chemotherapy. Additional profiling shed a light on the origin of the disease and the influence of several mutations such as a highly recurring K27M mutation in histone H3 on its tumorigenesis. Furthermore, early evidence suggests that DMG has a unique immune microenvironment, characterized by low levels of immune cell infiltration, inflammation, and immunosuppression that may impact disease development and outcome. Within the tumor microenvironment of GBM, tumor-associated microglia/macrophages (TAMs) play a large role in tumor development. Interestingly, TAMs in DMG display distinct features and have low immune activation in comparison to other pediatric gliomas. Although TAMs have been investigated substantially in GBM over the last years, this has not been the case for DMG due to the lack of tissue for research. Bit by bit, studies are exploring the TAM–glioma crosstalk to identify what factors within the DMG microenvironment play a role in the recruitment and polarization of TAMs. Although more research into the immune microenvironment is warranted, there is evidence that targeting or stimulating TAMs and their factors provide a potential treatment option for DMG. In this review, we provide insight into the current status of DMG research, assess the knowledge of the immune microenvironment in DMG and GBM, and present recent findings and therapeutic opportunities surrounding the TAM–glioma crosstalk.
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Affiliation(s)
- Casper J. Pachocki
- grid.5477.10000000120346234Department of Translational Neuroscience, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Elly M. Hol
- grid.5477.10000000120346234Department of Translational Neuroscience, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
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3
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Del Baldo G, Carai A, Abbas R, Cacchione A, Vinci M, Di Ruscio V, Colafati GS, Rossi S, Diomedi Camassei F, Maestro N, Temelso S, Pericoli G, De Billy E, Giovannoni I, Carboni A, Rinelli M, Agolini E, Mackay A, Jones C, Chiesa S, Balducci M, Locatelli F, Mastronuzzi A. Targeted therapy for pediatric diffuse intrinsic pontine glioma: a single-center experience. Ther Adv Med Oncol 2022; 14:17588359221113693. [PMID: 36090803 PMCID: PMC9459464 DOI: 10.1177/17588359221113693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/28/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Diffuse intrinsic pontine glioma (DIPG) is a fatal disease with a median
overall survival (OS) of less than 12 months after diagnosis. Radiotherapy
(RT) still remains the mainstay treatment. Several other therapeutic
strategies have been attempted in the last years without a significant
effect on OS. Although radiological imaging is the gold standard for DIPG
diagnosis, the urgent need to improve the survival has led to the
reconsideration of biopsy with the aim to better understand the molecular
profile of DIPG and support personalized treatment. Methods: In this study, we present a single-center experience in treating DIPG
patients at disease progression combining targeted therapies with standard
of care. Biopsy was proposed to all patients at diagnosis or disease
progression. First-line treatment included RT and nimotuzumab/vinorelbine or
temozolomide. Immunohistochemistry-targeted research included study of
mTOR/p-mTOR pathway and BRAFv600E. Molecular analyses
included polymerase chain reaction, followed by Sanger sequences and/or
next-generation sequencing. Results: Based on the molecular profile, targeted therapy was administered in 9 out of
25 patients, while the remaining 16 patients were treated with standard of
care. Personalized treatment included inhibition of the PI3K/AKT/mTOR
pathway (5/9), PI3K/AKT/mTOR pathway and BRAFv600E (1/9),
ACVR1 (2/9) and PDGFRA (1/9); no
severe side effects were reported during treatment. Response to treatment
was evaluated according to Response Assessment in Pediatric Neuro-Oncology
criteria, and the overall response rate within the cohort was 66%. Patients
treated with targeted therapies were compared with the control cohort of 16
patients. Clinical and pathological characteristics of the two cohorts were
homogeneous. Median OS in the personalized treatment and control cohort was
20.26 and 14.18 months, respectively (p = 0.032). In our
experience, the treatment associated with the best OS was everolimus. Conclusion: Despite the small simple size of our study, our data suggest a prognostic
advantage and a safe profile of targeted therapies in DIPG patients, and we
strongly advocate to reconsider the role of biopsy for these patients.
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Affiliation(s)
- Giada Del Baldo
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Rachid Abbas
- CESP, INSERM, Université Paris Sud, Villejuif, France
| | - Antonella Cacchione
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Mara Vinci
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Di Ruscio
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giovanna Stefania Colafati
- Oncological Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sabrina Rossi
- Pathology Unit, Department of Laboratories, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Nicola Maestro
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sara Temelso
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK.,Division of Cancer Therapeutics, The Institute of Cancer Research, London, UK
| | - Giulia Pericoli
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Emmanuel De Billy
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Isabella Giovannoni
- Pathology Unit, Department of Laboratories, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessia Carboni
- Oncological Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Martina Rinelli
- Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Emanuele Agolini
- Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alan Mackay
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK.,Division of Cancer Therapeutics, The Institute of Cancer Research, London, UK
| | - Chris Jones
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK.,Division of Cancer Therapeutics, The Institute of Cancer Research, London, UK
| | - Silvia Chiesa
- Department of Radiotherapy, Fondazione Policlinico Universitario "A. Gemelli," Catholic University of Sacred Heart, Rome, Italy
| | - Mario Balducci
- Department of Radiotherapy, Fondazione Policlinico Universitario "A. Gemelli," Catholic University of Sacred Heart, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli," Catholic University of Sacred Heart, Rome, Italy
| | - Angela Mastronuzzi
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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4
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Jung IH, Chang KW, Park SH, Moon JH, Kim EH, Jung HH, Kang SG, Chang JH, Chang JW, Chang WS. Stereotactic biopsy for adult brainstem lesions: A surgical approach and its diagnostic value according to the 2016 World Health Organization Classification. Cancer Med 2021; 10:7514-7524. [PMID: 34510820 PMCID: PMC8559459 DOI: 10.1002/cam4.4272] [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] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/17/2021] [Accepted: 09/01/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The brainstem has the critical role of regulating cardiac and respiratory function and it also provides motor and sensory function to the face via the cranial nerves. Despite the observation of a brainstem lesion in a radiological examination, it is difficult to obtain tissues for a pathological diagnosis because of the location and small volume of the brainstem. Thus, we aimed to share our 6-year experience with stereotactic biopsies from brainstem lesions and confirm the value and safety of stereotactic biopsy on this highly eloquent area in this study. METHODS We retrospectively reviewed the medical records of 42 adult patients who underwent stereotactic biopsy on brainstem lesions from 2015 to 2020. The radiological findings, surgical records, pathological diagnosis, and postoperative complications of all patients were analyzed. RESULTS Histopathological diagnoses were made in 40 (95.2%) patients. Astrocytic tumors were diagnosed in 29 (69.0%) patients, diffuse large B cell lymphoma in 5 (11.9%) patients, demyelinating disease in 4 (9.5%) patients, germinoma in 1 (2.4%) patient, and radiation necrosis in 1 (2.4%) patient. In the 40 patients with successful stereotactic biopsy, 10 (25.0%) patients had inconsistent preoperative radiological diagnosis and postoperative pathological diagnosis. In addition, there was a difference between the treatments prescribed by the radiological and pathological diagnoses in 8 out of 10 patients whose diagnoses changed after biopsy. There was no operative mortality among the 42 patients. CONCLUSIONS A pathological diagnosis can be made safely and efficiently in brainstem lesions using stereotactic biopsy. This pathological diagnosis will enable patients to receive appropriate treatment.
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Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Won Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - So Hee Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ju Hyung Moon
- Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Gu Kang
- Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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5
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Qin F, Huang Z, Dong Q, Xu X, Lu T, Chen J, Cheng N, Qiu W, Lu Z. Stereotactic biopsy for lesions in brainstem and deep brain: a single-center experience of 72 cases. ACTA ACUST UNITED AC 2021; 54:e11335. [PMID: 34320122 PMCID: PMC8302144 DOI: 10.1590/1414-431x2021e11335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/26/2021] [Indexed: 11/30/2022]
Abstract
Stereotactic biopsies for lesions in the brainstem and deep brain are rare. This study aimed to summarize our 6-year experience in the accurate diagnosis of lesions in the brain stem and deep brain and to discuss the technical note and strategies. From December 2011 to January 2018, 72 cases of intracranial lesions in the brainstem or deep in the lobes undergoing stereotactic biopsy were retrospectively reviewed. An individualized puncture path was designed based on the lesion's location and the image characteristics. The most common biopsy targets were deep in the lobes (43 cases, 59.7%), including frontal lobe (33 cases, 45.8%), temporal lobe (4 cases, 5.6%), parietal lobe (3 cases, 4.2%), and occipital lobe (3 cases, 4.2 %). There were 12 cases (16.7%) of the brainstem, including 8 cases (11.1%) of midbrain, and 4 cases (5.6%) of pons or brachium pontis. Other targets included internal capsule (2 cases, 2.8%), thalamus (3 cases, 4.2%), and basal ganglion (12 cases, 16.7%). As for complications, one patient developed acute intracerebral hemorrhage in the biopsy area at 2 h post-operation, and one patient had delayed intracerebral hemorrhage at 7 days post-operation. The remaining patients recovered well after surgery. There was no surgery-related death. The CT-MRI-guided stereotactic biopsy of lesions in the brainstem or deep in the brain has the advantages of high safety, accurate diagnosis, and low incidence of complications. It plays a crucial role in the diagnosis of atypical, microscopic, diffuse, multiple, and refractory lesions.
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Affiliation(s)
- Feng Qin
- Department of Neurosurgery, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhenchao Huang
- Department of Neurosurgery, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qing Dong
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xiaofeng Xu
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Tingting Lu
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jianning Chen
- Department of Pathology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Na Cheng
- Department of Pathology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Wei Qiu
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhengqi Lu
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
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6
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Srikanthan D, Taccone MS, Van Ommeren R, Ishida J, Krumholtz SL, Rutka JT. Diffuse intrinsic pontine glioma: current insights and future directions. Chin Neurosurg J 2021; 7:6. [PMID: 33423692 PMCID: PMC7798267 DOI: 10.1186/s41016-020-00218-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/24/2020] [Indexed: 02/06/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a lethal pediatric brain tumor and the leading cause of brain tumor–related death in children. As several clinical trials over the past few decades have led to no significant improvements in outcome, the current standard of care remains fractionated focal radiation. Due to the recent increase in stereotactic biopsies, tumor tissue availabilities have enabled our advancement of the genomic and molecular characterization of this lethal cancer. Several groups have identified key histone gene mutations, genetic drivers, and methylation changes in DIPG, providing us with new insights into DIPG tumorigenesis. Subsequently, there has been increased development of in vitro and in vivo models of DIPG which have the capacity to unveil novel therapies and strategies for drug delivery. This review outlines the clinical characteristics, genetic landscape, models, and current treatments and hopes to shed light on novel therapeutic avenues and challenges that remain.
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Affiliation(s)
- Dilakshan Srikanthan
- Cell Biology Program, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Michael S Taccone
- Cell Biology Program, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Randy Van Ommeren
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada
| | - Joji Ishida
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada
| | - Stacey L Krumholtz
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada
| | - James T Rutka
- Cell Biology Program, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada. .,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, 686 Bay St, Toronto, ON, M5G 0A4, Canada. .,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada. .,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada. .,Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Suite 1503, 555, University Avenue, Toronto, ON, M5G 1X8, Canada.
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7
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Minh Thong P, Minh Duc N. The Role of Apparent Diffusion Coefficient in the Differentiation between Cerebellar Medulloblastoma and Brainstem Glioma. Neurol Int 2020; 12:34-40. [PMID: 33137983 PMCID: PMC7768368 DOI: 10.3390/neurolint12030009] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023] Open
Abstract
For certain clinical circumstances, the differentiation between cerebellar medulloblastoma and brainstem glioma is essential. We aimed to evaluate the role played by the apparent diffusion coefficient (ADC) values in the differentiation between cerebellar medulloblastomas and brainstem gliomas in children. The institutional review board approved this prospective study. Brain magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI) and ADC, was assessed in 32 patients (median age: 7.0 years), divided into two groups, a medulloblastoma group (group 1, n = 22) and a brainstem glioma group (group 2, n = 10). The Mann-Whitney U test was utilized to compare tumor ADCmax, ADCmin, ADCmean, and ADCsd values, and their ratios with the parenchyma values between the two groups. Receiver operating characteristic (ROC) curve analysis and the Youden index were used to calculate the cut-off value, along with the area under the curve (AUC), sensitivity, and specificity. The median ADCmax, ADCmin, and ADCmean values were significantly higher in group 2 than in group 1 (p < 0.05). The median ratios of ADCmin and ADCmean to the parenchyma were significantly higher in group 2 than in group 1 (p < 0.05). The ROC analysis showed that the AUC for the ADCmean ratio was the highest among these parameters, at 98.2%. The ADCmean tumor to parenchyma ratio was a significant and effective parameter for the differentiation between pediatric medulloblastomas and brainstem gliomas.
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Affiliation(s)
- Pham Minh Thong
- Department of Radiology, Hanoi Medical University, Ha Noi 100000, Vietnam; or
| | - Nguyen Minh Duc
- Department of Radiology, Hanoi Medical University, Ha Noi 100000, Vietnam; or
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City 700000, Vietnam
- Department of Radiology, Children’s Hospital 02, Ho Chi Minh City 700000, Vietnam
- Correspondence:
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8
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Pediatric intrinsic brainstem lesions: clinical, imaging, histological characterization, and predictors of survival. Childs Nerv Syst 2020; 36:933-939. [PMID: 31836906 DOI: 10.1007/s00381-019-04453-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 11/26/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Brainstem lesions comprise 10-20% of all pediatric brain tumors. Over the past years, the benefits of stereotactic biopsy versus the use alone of MRI features to guide treatment have been controversial. METHODS Retrospective study with pediatric patients submitted to stereotactic brainstem biopsies between 2008 and 2018. Demographic, clinical, imaging, and surgical characteristics were recorded, as well as the histological diagnosis, complications, and survival. Predictors of survival were evaluated through Cox regression models after multivariate adjustment. RESULTS Twenty-six patients (mean age of 8.8 ± 4.3 years and 14 female). Diagnosis was reached on 84.6% (95% CI 65.1-95.6%) of the patients. Glioma was diagnosed on 20 cases (11 high-grade and 9 low-grade lesions). There was no association between age and gender and the dichotomized histological diagnosis. Contrast enhancement, diffuse distribution, invasion of adjacent structures, and remote injury were present on 62.5%, 75.0%, 62.5%, and 25.0% of the cases. Hydrocephalus at admission was present on almost half of the patients (46.2%). Only radiological invasion of adjacent structures had a possible association with high-grade lesions (p = 0.057). Surgical trajectory was trans-cerebellar in most of the cases (79.9%). There were no major complications and only two minor/transitory complications. Poorer survival was independently associated with high-grade lesions (HR 32.14, 95% CI 1.40-735.98, p = 0.030) and contrast enhancement at MRI (HR 36.54, 95% CI 1.40-952.26, p = 0.031). CONCLUSIONS Stereotactic biopsy was safe and allows successful tissue sampling for a definite diagnosis. Poorer survival was independently associated with high-grade and contrast-enhancing lesions.
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9
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Rashed WM, Maher E, Adel M, Saber O, Zaghloul MS. Pediatric diffuse intrinsic pontine glioma: where do we stand? Cancer Metastasis Rev 2020; 38:759-770. [PMID: 31802357 DOI: 10.1007/s10555-019-09824-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pediatric diffuse intrinsic pontine glioma (DIPG) represents approximately 20% of all pediatric CNS tumors. However, disease outcomes are dismal with a median survival of less than 1 year and a 2-year overall survival rate of less than 10%. Despite extensive efforts to improve survival outcomes, progress towards clinical improvement has been largely stagnant throughout the last 4 decades. Focal radiotherapy remains the standard of care with no promising single-agent alternatives and no evidence for improvement with the addition of a long list of systemic therapies. A better understanding of the biology of DIPG, though not easy due to obstacles in obtaining pathological material to study, is promising for the development of specific individualized treatment for this fatal disease. Recent studies have found epigenetic mutations to be successful predictors and prognostic factors for developing future management policies. The aim of this review is to give a global overview about the epidemiology, diagnosis, and treatment of DIPG. We further examine the controversial biopsy and autopsy issue that is unique to DIPG and assess the subsequent impact this issue has on the research efforts and clinical management of DIPG.
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Affiliation(s)
- Wafaa M Rashed
- Research Department, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt.
| | - Eslam Maher
- Research Department, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
| | - Mohamed Adel
- Armed Forces College of Medicine (AFCM), Cairo, Egypt
| | - Ossama Saber
- Armed Forces College of Medicine (AFCM), Cairo, Egypt
| | - Mohamed Saad Zaghloul
- Radiotherapy Department, National Cancer Institute, Cairo University & Children's Cancer Hospital, Cairo, 57357, Egypt.
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10
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The role of radiation and chemotherapy in adult patients with high-grade brainstem gliomas: results from the National Cancer Database. J Neurooncol 2019; 146:303-310. [PMID: 31873874 DOI: 10.1007/s11060-019-03374-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Surgical resection of high-grade brainstem gliomas is challenging and treatment mostly involves radiation and chemotherapy. In this study, we utilized registry data to determine prognostic features and impact of chemotherapy and radiation on overall survival. METHODS The National Cancer Database was queried from 2006 to 2015 for adult cases with histologically confirmed high-grade brainstem glioma. Covariates including patient demographics, comorbidities, tumor characteristics and treatment parameters were captured. Multivariable Cox proportional hazards regression was performed to identify predictors of survival. RESULTS A total of 422 patients were analyzed. Most patients (66.6%) underwent postoperative radiation with chemotherapy, 9.2% underwent radiation alone, while the remaining had no postoperative treatment (24.2%). Overall median survival was 9.8 months (95% CI 8.8-12). Survival was longer (p < 0.001) in the radiation + chemotherapy group (median: 14.2 months, 95% CI 11.7-17.1) compared to radiation alone (median: 5.7 months, 95% CI 3.7-12) and no postoperative treatment (median: 1.8 months, 95% CI 1.4-4) groups. In multivariable analysis, increasing age was associated with worse survival (HR: 1.87, 95% CI 1.47-2.37, p < 0.001), whereas radiation + chemotherapy was associated with lower mortality compared to radiation alone (HR: 0.67, 95% CI 0.46-0.98, p = 0.038). In subgroup analysis, postoperative chemotherapy with radiation was associated with significant survival benefit compared to radiation alone for grade IV (HR: 0.46, 95% CI 0.28-0.76, p = 0.003), but not for grade III tumors (HR: 0.87, 95% CI 0.48-1.58, p = 0.65). CONCLUSION Analysis from a national registry illustrated the effectiveness of radiation with chemotherapy for adult patients with high-grade brainstem gliomas, particularly grade IV. Further research should identify specific patient profiles and molecular subgroups that are more likely to benefit from multimodality therapy.
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Cohen KJ, Jabado N, Grill J. Diffuse intrinsic pontine gliomas-current management and new biologic insights. Is there a glimmer of hope? Neuro Oncol 2018; 19:1025-1034. [PMID: 28371920 DOI: 10.1093/neuonc/nox021] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) has proven to be one of the most challenging of all pediatric cancers. Owing to a historical reticence to obtain tumor tissue for study, and based on an erroneous assumption that the biology of DIPG would mirror that of supratentorial high-grade astrocytomas, innumerable studies have been undertaken-all of which have had a negligible impact on the natural history of this disease. More recently, improvements in neurosurgical techniques have allowed for the safe upfront biopsy of DIPG, which, together with a wider use of autopsy tissue, has led to an evolving understanding of the biology of this tumor. The discovery of a recurrent somatic gain-of-function mutation leading to lysine 27 to methionine (p.Lys27Met, K27M) substitution in histone 3 variants characterizes more than 85% of DIPG, suggesting for the first time the role of the epigenome and histones in the pathogenesis of this disease, and more unified diagnostic criteria. Along with further molecular insights into the pathogenesis of DIPG, rational targets are being identified and studied in the hopes of improving the otherwise dismal outcome for children with DIPG.
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Affiliation(s)
- Kenneth J Cohen
- Pediatric Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland; Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Université Paris-Saclay & Gustave Roussy Unité Mixte de Recherche 8203 du Centre National de la Recherche Scientifique & Departement de Cancerologie de l'Enfant et de l'Adolescent, Villejuif, France
| | - Nada Jabado
- Pediatric Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland; Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Université Paris-Saclay & Gustave Roussy Unité Mixte de Recherche 8203 du Centre National de la Recherche Scientifique & Departement de Cancerologie de l'Enfant et de l'Adolescent, Villejuif, France
| | - Jacques Grill
- Pediatric Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland; Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Université Paris-Saclay & Gustave Roussy Unité Mixte de Recherche 8203 du Centre National de la Recherche Scientifique & Departement de Cancerologie de l'Enfant et de l'Adolescent, Villejuif, France
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12
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Infinger LK, Stevenson CB. Re-Examining the Need for Tissue Diagnosis in Pediatric Diffuse Intrinsic Pontine Gliomas: A Review. Curr Neuropharmacol 2017; 15:129-133. [PMID: 27109746 PMCID: PMC5327458 DOI: 10.2174/1570159x14666160425114024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/18/2014] [Accepted: 02/08/2016] [Indexed: 01/24/2023] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is a malignant brain tumor of childhood that carries an extremely poor prognosis. There are ~200-300 new cases diagnosed each year, [1, 2] and little progress has been made in changing the prognosis and outcome of the tumor since it was first documented in the literature in 1926 [3]. The median overall survival is 8-11 months [4], with an overall survival rate of 30% at 1 year, and less than 10% at 2 years [4]. This review will provide background information on DIPGs, a historical look at the trends in caring for DIPG, and current trends in diagnosis and treatment. By changing the way we care for these terminal tumors, we can work towards having a better understanding of the underlying molecular biology, and attempt to develop better chemotherapeutic tools to combat the disease.
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Affiliation(s)
| | - Charles B. Stevenson
- Cincinnati Children’s Hospital Medical Center, Division of Pediatric Neurosurgery, USA
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13
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Clerk-Lamalice O, Reddick WE, Li X, Li Y, Edwards A, Glass JO, Patay Z. MRI Evaluation of Non-Necrotic T2-Hyperintense Foci in Pediatric Diffuse Intrinsic Pontine Glioma. AJNR Am J Neuroradiol 2016; 37:1930-1937. [PMID: 27197987 DOI: 10.3174/ajnr.a4814] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/21/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE The conventional MR imaging appearance of diffuse intrinsic pontine glioma suggests intralesional histopathologic heterogeneity, and various distinct lesion components, including T2-hypointense foci, have been described. Here we report the prevalence, conventional MR imaging semiology, and advanced MR imaging features of non-necrotic T2-hyperintense foci in diffuse intrinsic pontine glioma. MATERIALS AND METHODS Twenty-five patients with diffuse intrinsic pontine gliomas were included in this study. MR imaging was performed at 3T by using conventional and advanced MR imaging sequences. Perfusion (CBV), vascular permeability (ve, Ktrans), and diffusion (ADC) metrics were calculated and used to characterize non-necrotic T2-hyperintense foci in comparison with other lesion components, namely necrotic T2-hyperintense foci, T2-hypointense foci, peritumoral edema, and normal brain stem. Statistical analysis was performed by using Kruskal-Wallis and Wilcoxon rank sum tests. RESULTS Sixteen non-necrotic T2-hyperintense foci were found in 12 tumors. In these foci, ADC values were significantly higher than those in either T2-hypointense foci (P = .002) or normal parenchyma (P = .0002), and relative CBV values were significantly lower than those in either T2-hypointense (P = .0002) or necrotic T2-hyperintense (P = .006) foci. Volume transfer coefficient values in T2-hyperintense foci were lower than those in T2-hypointense (P = .0005) or necrotic T2-hyperintense (P = .0348) foci. CONCLUSIONS Non-necrotic T2-hyperintense foci are common, distinct lesion components within diffuse intrinsic pontine gliomas. Advanced MR imaging data suggest low cellularity and an early stage of angioneogenesis with leaky vessels resulting in expansion of the extracellular space. Because of the lack of biopsy validation, the underlying histoarchitectural and pathophysiologic changes remain unclear; therefore, these foci may correspond to a poorly understood biologic event in tumor evolution.
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Affiliation(s)
- O Clerk-Lamalice
- From the Departments of Diagnostic Imaging (O.C.-L., W.E.R., A.E., J.O.G., Z.P.)
| | - W E Reddick
- From the Departments of Diagnostic Imaging (O.C.-L., W.E.R., A.E., J.O.G., Z.P.)
| | - X Li
- Biostatistics (X.L., Y.L.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Y Li
- Biostatistics (X.L., Y.L.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - A Edwards
- From the Departments of Diagnostic Imaging (O.C.-L., W.E.R., A.E., J.O.G., Z.P.)
| | - J O Glass
- From the Departments of Diagnostic Imaging (O.C.-L., W.E.R., A.E., J.O.G., Z.P.)
| | - Z Patay
- From the Departments of Diagnostic Imaging (O.C.-L., W.E.R., A.E., J.O.G., Z.P.)
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14
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Tisnado J, Young R, Peck KK, Haque S. Conventional and Advanced Imaging of Diffuse Intrinsic Pontine Glioma. J Child Neurol 2016; 31:1386-93. [PMID: 27071471 PMCID: PMC5659185 DOI: 10.1177/0883073816634855] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 01/12/2016] [Indexed: 12/11/2022]
Abstract
Diffuse intrinsic pontine glioma is the most common brainstem tumor in pediatric patients. This tumor remains one of the most deadly pediatric brain tumors. The diagnosis primarily relies on clinical symptoms and imaging findings. Conventional MRI provides a noninvasive accurate method of diagnosis of these tumors. Advanced MRI techniques are becoming more widely used and studied as additional noninvasive methods to assist clinicians in initial diagnosis and staging, monitoring disease, as well as in surgical and radiation planning. This article will provide an overview of DIPG and describe the typical imaging findings with a focus on advanced imaging techniques.
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Affiliation(s)
- Jamie Tisnado
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert Young
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kyung K Peck
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sofia Haque
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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15
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High-Grade Glioma of the Ventrolateral Medulla in an Adult: Case Presentation and Discussion of Surgical Considerations. Case Rep Neurol Med 2016; 2016:6813089. [PMID: 27242937 PMCID: PMC4875976 DOI: 10.1155/2016/6813089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 04/03/2016] [Indexed: 11/17/2022] Open
Abstract
Background. High-grade gliomas of the brainstem are rare in adults and are particularly rare in the anterolateral medulla. We describe an illustrative case and discuss the diagnostic and treatment issues associated with a tumor in this location, including differential diagnosis, anatomical considerations for options for surgical management, multimodality treatment, and prognosis. Case Description. A 69-year-old woman presented with a 3-week history of progressive right lower extremity weakness. She underwent an open biopsy via a far lateral approach with partial condylectomy, which revealed a glioblastoma. Concurrent temozolomide and radiation were completed; however, she elected to stop her chemotherapy after 5.5 weeks of treatment. She succumbed to her disease 11 months after diagnosis. Conclusions. Biopsy can be performed relatively safely to provide definitive diagnosis to guide treatment, but long-term prognosis is poor.
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16
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Suo-Palosaari M, Rantala H, Lehtinen S, Kumpulainen T, Salokorpi N. Long-term survival of an infant with diffuse brainstem lesion diagnosed by prenatal MRI: a case report and review of the literature. Childs Nerv Syst 2016; 32:1163-8. [PMID: 26906478 DOI: 10.1007/s00381-016-3045-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/15/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND We describe a unique case of expansive diffuse brainstem lesion diagnosed prenatally by magnetic resonance imaging (MRI) with long-term survival. Findings of fetal and postpartum MRI were highly consistent with the characteristics of diffuse brainstem glioma. METHODS Diagnosis was based on the features of MRI, and histopathology was not confirmed by biopsy. Although the prognosis of diffuse brainstem tumor is usually poor, this child was asymptomatic at birth and the neurological condition is still normal at 4 years of age without any treatment. RESULTS During routine imaging follow-up, diameters of the expansion have remained stable, while the size of the lesion compared to the posterior fossa size has diminished. In addition to brainstem tumor, a skin lesion of the back was observed and MRI of the thoracic spine showed a large asymptomatic extradural cystic lesion suggesting an arachnoid cyst. The pontine tumor of this infant, in agreement with a few previously reported cases, suggests a subgroup of beneficial outcome of expansive diffuse brainstem lesions, particularly in the neonatal period. DISCUSSION In this article, we discuss the prognosis and characteristics of pediatric brainstem tumors and differential diagnosis of neonatal brainstem lesions.
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Affiliation(s)
- M Suo-Palosaari
- Department of Diagnostic Radiology, Oulu University Hospital and University of Oulu, P.O. Box 50, 90029, OYS, Oulu, Finland. .,Medical Research Center, University of Oulu, Oulu, Finland.
| | - H Rantala
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.,PEDEGO Research Group, Medical Research Center, University of Oulu, Oulu, Finland
| | - S Lehtinen
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.,PEDEGO Research Group, Medical Research Center, University of Oulu, Oulu, Finland
| | - T Kumpulainen
- Medical Research Center, University of Oulu, Oulu, Finland.,Department of Neurosurgery, Oulu University Hospital, P.O. Box 21, 90029, OYS, Oulu, Finland
| | - N Salokorpi
- Medical Research Center, University of Oulu, Oulu, Finland.,Department of Neurosurgery, Oulu University Hospital, P.O. Box 21, 90029, OYS, Oulu, Finland
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Rabadán AT, Campero A, Hernández D. Surgical Application of the Suboccipital Subtonsillar Approach to Reach the Inferior Half of Medulla Oblongata Tumors in Adult Patients. Front Surg 2016; 2:72. [PMID: 26793713 PMCID: PMC4710703 DOI: 10.3389/fsurg.2015.00072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 12/24/2015] [Indexed: 11/18/2022] Open
Abstract
Medulla oblongata (MO) tumors are uncommon in adults. Controversies about their treatment arise regarding the need for histological diagnosis in this eloquent area of the brain, weighing benefits of a reliable diagnosis, and the potential disadvantages of invasive procedures. As a broader variety of pathological findings could be found in this localization, the accurate histopathological definition could not only allow an adequate therapy but also can prevent the disastrous consequences of empiric treatments. There are few publications about their surgical management and all belongs to small retrospective cohorts. In this scenario, we are reporting two patients with exophytic or focal lesions in the inferior half of the medulla, who underwent surgery by suboccipital midline subtonsillar approach. This approach was not specifically described to reach MO before, and we found that the lesions produced a mild elevation of the tonsils providing a wide surgical view from the medulla to the foramen of Luchska laterally, and up to the middle cerebellar peduncle, offering a wide and safe access.
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Affiliation(s)
- Alejandra T Rabadán
- Division of Neurosurgery, Institute of Medical Research A. Lanari, University of Buenos Aires , Buenos Aires , Argentina
| | - Alvaro Campero
- Department of Neurosurgery, Hospital Padilla , Tucumán , Argentina
| | - Diego Hernández
- Division of Neurosurgery, Institute of Medical Research A. Lanari, University of Buenos Aires , Buenos Aires , Argentina
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18
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Abstract
Diffuse intrinsic pontine glioma (DIPG) is an aggressive tumor that is universally fatal, and to-date we are at a virtual standstill in improving its grim prognosis. Dearth of tissue due to rarity of biopsy has precluded understanding the elusive biology and frustration continues in reproducing faithful animal models for translational research. Furthermore the intricate anatomy of the pons has forestalled locoregional therapy and drug penetration. Over the last few years, biopsy-driven targeted therapy, development of vitro and xenograft animal models for therapeutic testing, profiling immunotherapeutic strategies and locoregional infusion of drugs in brain stem tumors, now provide a sense of hope in the years ahead. This review aims to discuss current status and advances in the management of these tumors.
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Affiliation(s)
- Soumen Khatua
- Pediatric Neuro-Oncology, Department of Pediatrics, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 87, Houston, TX 77030, USA
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19
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Abstract
Diffuse high-grade gliomas (HGGs) of childhood are a devastating spectrum of disease with no effective cures. The two-year survival for paediatric HGG ranges from 30%, for tumours arising in the cerebral cortex, to less than 10% for diffuse intrinsic pontine gliomas (DIPGs), which arise in the brainstem. Recent genome-wide studies provided abundant evidence that unique selective pressures drive HGG in children compared to adults, identifying novel oncogenic mutations connecting tumorigenesis and chromatin regulation, as well as developmental signalling pathways. These new genetic findings give insights into disease pathogenesis and the challenges and opportunities for improving patient survival in these mostly incurable childhood brain tumours.
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20
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"Occult" post-contrast signal enhancement in pediatric diffuse intrinsic pontine glioma is the MRI marker of angiogenesis? Neuroradiology 2014; 56:405-12. [PMID: 24626721 DOI: 10.1007/s00234-014-1348-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 02/25/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION In diffuse intrinsic pontine gliomas (DIPG), subtracting pre-contrast from post-contrast T1-weighted images (T1WI) occasionally reveals subtle, "occult" enhancement. We hypothesized that this represents intravascular enhancement related to angiogenesis and hence that these tumors should have greater blood volume fractions than do non-enhancing tumors. METHODS We retrospectively screened MR images of 66 patients initially diagnosed with DIPG and analyzed pretreatment conventional and dynamic susceptibility contrast (DSC) perfusion MRI studies of 61 patients. To determine the incidence of occult enhancement, cerebral blood volume (CBV) values were compared in areas of occult enhancement (OcE), no enhancement (NE), and normal-appearing deep cerebellar white matter (DCWM). RESULTS Tumors of 10 patients (16.4 %) had occult enhancement; those of 6 patients (9.8 %) had no enhancement at all. The average CBV in areas of occult enhancement was significantly higher than that in non-enhancing areas of the same tumor (P = .03), within DCWM in the same patient (P = .03), and when compared to anatomically paired/similar regions of interest (ROI) in patients with non-enhancing tumors (P = .005). CONCLUSION Areas of OcE correspond to areas of higher CBV in DIPG, which may be an MRI marker for angiogenesis, but larger scale studies may be needed to determine its potential relevance to grading by imaging, treatment stratification, biopsy guidance, and evaluation of response to targeted therapy.
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21
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Warren KE. Diffuse intrinsic pontine glioma: poised for progress. Front Oncol 2012; 2:205. [PMID: 23293772 PMCID: PMC3531714 DOI: 10.3389/fonc.2012.00205] [Citation(s) in RCA: 186] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 12/11/2012] [Indexed: 12/21/2022] Open
Abstract
Diffuse intrinsic pontine gliomas (DIPGs) are amongst the most challenging tumors to treat. Surgery is not an option, the effects of radiation therapy are temporary, and no chemotherapeutic agent has demonstrated significant efficacy. Numerous clinical trials of new agents and novel therapeutic approaches have been performed over the course of several decades in efforts to improve the outcome of children with DIPG, yet without success. The diagnosis of DIPG is based on radiographic findings in the setting of a typical clinical presentation, and tissue is not routinely obtained as the standard of care. The paradigm for treating children with these tumors has been based on that for supratentorial high-grade gliomas in adults as the biology of these lesions were presumed to be similar. However, recent pivotal studies demonstrate that DIPGs appear to be their own entity. Simply identifying this fact releases a number of constraints and opens opportunities for biologic investigation of these lesions, setting the stage to move forward in identifying DIPG-specific treatments. This review will summarize the current state of knowledge of DIPG, discuss obstacles to therapy, and summarize results of recent biologic studies.
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Affiliation(s)
- Katherine E Warren
- Pediatric Neuro-Oncology Section, Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health Bethesda, MD, USA
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22
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Reyes-Botero G, Mokhtari K, Martin-Duverneuil N, Delattre JY, Laigle-Donadey F. Adult brainstem gliomas. Oncologist 2012; 17:388-97. [PMID: 22382458 DOI: 10.1634/theoncologist.2011-0335] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Brainstem gliomas are uncommon in adults and account for only 1%-2% of intracranial gliomas. They represent a heterogeneous group of tumors that differ from those found in their pediatric counterparts. In adults, a low-grade phenotype predominates, which is a feature that likely explains their better prognosis compared to that in children. Because biopsies are rarely performed, classifications based on the radiological aspect of magnetic resonance imaging results have been proposed to establish treatment strategies and to determine outcomes: (a) diffuse intrinsic low-grade, (b) enhancing malignant glioma, (c) focal tectal gliomas, and (d) exophytic gliomas. Despite significant advances in neuroradiology techniques, a purely radiological classification remains imperfect in the absence of a histological diagnosis. Whereas a biopsy may often be reasonably avoided in the diffuse nonenhancing forms, obtaining histological proof seems necessary in many contrast-enhanced brainstem lesions because of the wide variety of differential diagnoses in adults. Conventional radiotherapy is the standard treatment for diffuse intrinsic low-grade brainstem gliomas in adults (the median survival is 5 years). In malignant brainstem gliomas, radiotherapy is the standard treatment. However, the possible benefit of combined radiotherapy and chemotherapy (temozolomide or other agents) has not been thoroughly evaluated in adults. The role of anti-angiogenic therapies in brainstem gliomas remains to be defined. A better understanding of the biology of these tumors is of primary importance for identifying homogeneous subgroups and for improving therapy options and outcomes.
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Affiliation(s)
- German Reyes-Botero
- Service de Neurologie 2-Division Mazarin, Groupe Hospitalier Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France
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Puget S, Philippe C, Bax DA, Job B, Varlet P, Junier MP, Andreiuolo F, Carvalho D, Reis R, Guerrini-Rousseau L, Roujeau T, Dessen P, Richon C, Lazar V, Le Teuff G, Sainte-Rose C, Geoerger B, Vassal G, Jones C, Grill J. Mesenchymal transition and PDGFRA amplification/mutation are key distinct oncogenic events in pediatric diffuse intrinsic pontine gliomas. PLoS One 2012; 7:e30313. [PMID: 22389665 PMCID: PMC3289615 DOI: 10.1371/journal.pone.0030313] [Citation(s) in RCA: 177] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 12/15/2011] [Indexed: 12/17/2022] Open
Abstract
Diffuse intrinsic pontine glioma (DIPG) is one of the most frequent malignant pediatric brain tumor and its prognosis is universaly fatal. No significant improvement has been made in last thirty years over the standard treatment with radiotherapy. To address the paucity of understanding of DIPGs, we have carried out integrated molecular profiling of a large series of samples obtained with stereotactic biopsy at diagnosis. While chromosomal imbalances did not distinguish DIPG and supratentorial tumors on CGHarrays, gene expression profiling revealed clear differences between them, with brainstem gliomas resembling midline/thalamic tumours, indicating a closely-related origin. Two distinct subgroups of DIPG were identified. The first subgroup displayed mesenchymal and pro-angiogenic characteristics, with stem cell markers enrichment consistent with the possibility to grow tumor stem cells from these biopsies. The other subgroup displayed oligodendroglial features, and appeared largely driven by PDGFRA, in particular through amplification and/or novel missense mutations in the extracellular domain. Patients in this later group had a significantly worse outcome with an hazard ratio for early deaths, ie before 10 months, 8 fold greater that the ones in the other subgroup (p = 0.041, Cox regression model). The worse outcome of patients with the oligodendroglial type of tumors was confirmed on a series of 55 paraffin-embedded biopsy samples at diagnosis (median OS of 7.73 versus 12.37 months, p = 0.045, log-rank test). Two distinct transcriptional subclasses of DIPG with specific genomic alterations can be defined at diagnosis by oligodendroglial differentiation or mesenchymal transition, respectively. Classifying these tumors by signal transduction pathway activation and by mutation in pathway member genes may be particularily valuable for the development of targeted therapies.
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Affiliation(s)
- Stephanie Puget
- Department of Neurosurgery, Necker-Sick Children Hospital, University Paris V Descartes, Paris, France
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Cathy Philippe
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Dorine A. Bax
- Section of Pediatric Oncology, The Institute of Cancer Research/Royal Marsden Hospital, Sutton, Surrey, United Kingdom
| | - Bastien Job
- Formation de Recherche en Evolution 2939 du Centre National de la Recherche Scientifique, Integrated Research Cancer Institute in Villejuif, University Paris XI, Villejuif, France
| | - Pascale Varlet
- Team Glial Plasticity, Unite Mixte de Recherche 894 de l'Institut National de la Santé et de la Recherche Medicale and Department of Neuropathology, Sainte-Anne Hospital, University Paris V Descartes, Paris, France
| | - Marie-Pierre Junier
- Team Glial Plasticity, Unite Mixte de Recherche 894 de l'Institut National de la Santé et de la Recherche Medicale and Department of Neuropathology, Sainte-Anne Hospital, University Paris V Descartes, Paris, France
| | - Felipe Andreiuolo
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Dina Carvalho
- Section of Pediatric Oncology, The Institute of Cancer Research/Royal Marsden Hospital, Sutton, Surrey, United Kingdom
- Life and Health Sciences Research Institute, University Do Minho, Braga, Portugal
- Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Ricardo Reis
- Life and Health Sciences Research Institute, University Do Minho, Braga, Portugal
| | - Lea Guerrini-Rousseau
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Thomas Roujeau
- Department of Neurosurgery, Necker-Sick Children Hospital, University Paris V Descartes, Paris, France
| | - Philippe Dessen
- Formation de Recherche en Evolution 2939 du Centre National de la Recherche Scientifique, Integrated Research Cancer Institute in Villejuif, University Paris XI, Villejuif, France
| | - Catherine Richon
- Functional Genomics Unit, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Vladimir Lazar
- Functional Genomics Unit, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Gwenael Le Teuff
- Department of Biostatistics and Epidemiology, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Christian Sainte-Rose
- Department of Neurosurgery, Necker-Sick Children Hospital, University Paris V Descartes, Paris, France
| | - Birgit Geoerger
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Gilles Vassal
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
| | - Chris Jones
- Section of Pediatric Oncology, The Institute of Cancer Research/Royal Marsden Hospital, Sutton, Surrey, United Kingdom
| | - Jacques Grill
- Unite Mixte de Recherche 8203 du Centre National de la Recherche Scientifique «Vectorology and Anticancer Therapeutics», Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Institute, University Paris XI, Villejuif, France
- * E-mail:
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24
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Parreño MG, Bo X, Kanu OO, Constantini S, Kanner AA. Frameless stereotactic procedures in pediatric patients: safety and diagnostic efficacy. Childs Nerv Syst 2011; 27:2137-40. [PMID: 21660530 DOI: 10.1007/s00381-011-1506-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 05/31/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of our retrospective study was to evaluate the feasibility, safety, and diagnostic yield of a frameless method for stereotactic neurosurgical procedures in pediatric patients. METHODS Twenty-two frameless stereotactic neurosurgical procedures (18 biopsies, 4 catheter placements), using a modified frameless stereotactic navigational system, were performed in 21 pediatric patients in our institution from 2004 to 2009. All procedures were performed by the senior authors (AAK, SC). RESULTS We completed 18 biopsy procedures in 18 patients, yielding usable diagnostic specimens in 100% of the procedures. Of this biopsy group, two patients experienced an asymptomatic hemorrhage per CT, and one patient experienced a transient hemiparesis, recovering to baseline within 1 week after surgery. Four catheter placement procedures were completed in three patients, including one patient who had to have the procedure repeated. We had no peri-operative mortality or technical difficulties related to the catheter placements. CONCLUSIONS Frameless stereotactic neurosurgical procedures in the pediatric population are feasible and can be completed safely for histological tumor diagnosis as well as for accurate placement of intracranial catheters. This method has low rates of morbidity comparable to frame-based procedures, with the advantage of greater operative convenience.
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Affiliation(s)
- Mary G Parreño
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
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25
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Cohen KJ, Heideman RL, Zhou T, Holmes EJ, Lavey RS, Bouffet E, Pollack IF. Temozolomide in the treatment of children with newly diagnosed diffuse intrinsic pontine gliomas: a report from the Children's Oncology Group. Neuro Oncol 2011; 13:410-6. [PMID: 21345842 DOI: 10.1093/neuonc/noq205] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An open-label phase II study (ACNS0126) testing the efficacy of chemoradiotherapy with temozolomide (TMZ) followed by adjuvant TMZ was conducted by the Children's Oncology Group. During the period from July 6, 2004 through September 6, 2005, 63 children with newly diagnosed diffuse intrinsic pontine glioma (DIPG) were enrolled in the study. All patients received TMZ at a dosage of 90 mg/m(2)/day for 42 days to a dose of 59.4 Gy. Four weeks following irradiation, TMZ was given at a dosage of 200 mg/m(2)/day for 5 days every 28 days, for a total of 10 cycles. The primary objective of the statistical analysis was to determine whether the current treatment produced a 1-year event-free survival (EFS) rate higher than the historical baseline of 21.9% observed in CCG-9941. The mean 1-year EFS (± standard deviation) was 14% ± 4.5%, compared with 21.9% ± 5% for CCG-9941. The P value of the test of comparison of 1-year EFS, based on a 1-sided, 1-sample test of proportions, was .96. There was no evidence that temozolomide produced a 1-year EFS rate higher than 21.9%. The mean 1-year OS (± standard deviation) was 40% ± 6.5%, compared with 32% ± 6% for CCG-9941. The median time to death was 9.6 months. Chemoradiotherapy with TMZ followed by adjuvant TMZ is not more effective than previously reported regimens for the treatment of children with DIPG.
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Affiliation(s)
- Kenneth J Cohen
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21287, USA.
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26
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Frazier JL, Lee J, Thomale UW, Noggle JC, Cohen KJ, Jallo GI. Treatment of diffuse intrinsic brainstem gliomas: failed approaches and future strategies. J Neurosurg Pediatr 2009; 3:259-69. [PMID: 19338403 DOI: 10.3171/2008.11.peds08281] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Diffuse intrinsic pontine gliomas constitute ~ 60-75% of tumors found within the pediatric brainstem. These malignant lesions present with rapidly progressive symptoms such as cranial nerve, long tract, or cerebellar dysfunctions. Magnetic resonance imaging is usually sufficient to establish the diagnosis and obviates the need for surgical biopsy in most cases. The prognosis of the disease is dismal, and the median survival is < 12 months. Resection is not a viable option. Standard therapy involves radiotherapy, which produces transient neurological improvement with a progression-free survival benefit, but provides no improvement in overall survival. Clinical trials have been conducted to assess the efficacy of chemotherapeutic and biological agents in the treatment of diffuse pontine gliomas. In this review, the authors discuss recent studies in which systemic therapy was administered prior to, concomitantly with, or after radiotherapy. For future perspective, the discussion includes a rationale for stereotactic biopsies as well as possible therapeutic options of local chemotherapy in these lesions.
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Affiliation(s)
- James L Frazier
- Departments of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Abstract
Central nervous system (CNS) tumors are the most common solid neoplasms in childhood and the second most common malignancies after leukemia in the pediatric age group. Supratentorial tumors are more common in children younger than 2 years old and in adolescents, whereas in patients between 2 and 12 years of age brain tumors originating in the posterior fossa dominate. This implies a relationship between the type of tumor, its location and the age of the patient, which has to be considered in differential diagnoses. Medulloblastoma represents the most common malignant brain tumor in childhood. In the posterior fossa medulloblastomas are approximately as frequent as astrocytomas. Supratentorial astrocytomas are by far the main tumor type. In this report some typical CNS neoplasms in children are discussed and their neuroradiological features are demonstrated.
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Affiliation(s)
- M Sinzig
- Kinderradiologie RZI , Landeskrankenhaus Klagenfurt, Klagenfurt, Osterreich.
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