Prognostic Factors and Survival Outcomes of Intracranial Ependymoma Treated with Multimodality Approach

From Diagnosis to Resolution: A Case Study of Myxopapillary Ependymoma Survival

Myxopapillary ependymoma (MPE) is a rare, slow-growing tumor that commonly arises in the lumbosacral region of the spinal cord, within the filum terminale and cauda equina. The frequent presentation of MPE is back, sacral, or leg pain. The tumor's size, site, and extension usually influence these symptoms. MPE is usually evaluated using magnetic resonance imaging (MRI) because of its superior soft tissue contrast. The best treatment modality is total surgical resection, which improves the long-term survival rate, with follow-up imaging recommended to ensure total resolution. Here, we present the case of a 29-year-old male who presented with symptoms suggestive of severe neurological impairment. An MRI scan revealed an intradural lesion arising from the cauda equina with peripheral and intrathecal haemorrhage, consistent with MPE. He was managed with laminectomy and microsurgical resection of the tumor, which achieved total resection. Postoperative follow-up found gradual improvement in his symptoms, and routine surveillance imaging confirmed the complete resolution of the tumor.

Prognostic factors of pediatric ependymomas at a National Cancer Reference Center in Peru

Background

Ependymomas are central nervous system tumors that significantly impact the quality of life and carry a high mortality rate. Both the disease itself and its treatment cause significant morbidity. At a national level in Peru, there are no reports on clinical characteristics of the disease.

Methods

This retrospective study captured patient aged less than 19 years with a diagnosis of ependymoma from 2012 to 2022 at a tertiary center in Lima.

Results

85 patients were included with a median follow-up time was 51.6 months. The 5-year overall survival and progression-free survival were 55.89% (95% CI: 44.28 - 65.99) and 37.71% (95% CI: 26,21-49,16) respectively. The main prognostic factors identified were completed treatment (p=0.019), adjuvant chemotherapy (p=0.048), presence of metastasis (p=0.012), and disease recurrence (p=0.02).

Conclusions

The survival of patients with ependymoma is below that reported in high-income countries. Incomplete treatment and treatment abandonment are factors that negatively impact the prognosis. Further studies are needed to identify barriers in the referral and treatment process for patients with ependymoma.

Intracranial ependymoma with extremely rare extraneural metastasis

Ependymomas account for 1-8% of overall brain tumors. They are most common at the age of 3-4 years. Their metastasis is very rare, and extraneural metastasis is even more unusual. In this report, the ependymoma localized in the posterior fossa with metastasis into femoral diaphysis in a 27-year-old male patient, who was treated in 2001, is presented. As we did not have any other cases of patients having a brain and spinal tumor with extraneural metastases even after 21 years, until 2022, this case was found worthy of being presented. When the literature was examined, it was observed that there is still no standard treatment after surgery for ependymomas and their metastasis. Due to their rarity, the general treatment of extraneural metastasis of ependymomas is also under discussion. It is recommended that clinicians consider admitting patients with rare or hard-to-treat tumors to ongoing clinical trials.

Sacral ependymoma presents 20 years after initial posterior fossa lesion

Posterior fossa ependymomas (PFEs) are designated histologically as low-grade neoplasms. Despite being characterised as benign, cases of metastasis have been reported only a few times with the patients concurrently diagnosed with the primary tumour. Interval drop metastasis or spontaneous second distal tumours are extremely rare and, in most cases, are diagnosed within a few months of primary tumour resection. Here, we report a patient with a grade 2 paediatric PFE exhibiting a 20-year interval to a second sacral ependymoma. The patient was initially diagnosed with a PFE at the age of 10 years and underwent tumour resection and postoperative radiotherapy. In their late 20s, the patient presented with basilar artery occlusion complicated by life-threatening epistaxis. Post-thrombolysis, the patient presented with a large sacral grade 1 myxopapillary ependymoma with cauda equina syndrome-like symptoms. Here, we present a rare case of two ependymomas with a 20-year interval in the same patient with compounding comorbidities.

Spinal Myxopapillary Ependymoma: A Rare Case and Review of Management Strategies

Intramedullary myxopapillary ependymomas are rare spinal cord tumors primarily affecting young adults. Grade 2 tumors are associated with a higher proliferative index and potentially more aggressive behavior compared to grade 1 tumors. We present a case of a 30-year-old male who presented with a three-month history of progressive unilateral lower back pain that was refractory to analgesics. Neurological examination revealed bilateral lower limb weakness and sensory impairments in the L2 region. MRI confirmed a well-defined, enhancing intramedullary lesion at the L2 level, causing cord enlargement and edema. Diagnosis of grade 2 intramedullary myxopapillary ependymoma was made. Complete surgical resection was performed, confirming a grade 2 myxopapillary ependymoma. Postoperatively, the patient demonstrated significant improvement in lower limb function and sensation, with no tumor recurrence during long-term follow-up. Rehabilitation therapy was initiated, while close monitoring for complications and tumor progression was maintained. This case explores the etiology and features of intramedullary myxopapillary ependymomas and underscores the importance of early recognition, accurate diagnosis, and aggressive surgical management.

Does Gross Total Resection Improve Progression-Free and Overall Survival in Pediatric Intracranial Ependymomas? Single-Center Clinical Experience Of 61 Cases

OBJECTIVE

To share our clinical experience of 25 years and identify prognostic factors for progression-free and overall survival in pediatric intracranial ependymomas.

METHODS

In total, 61 children who were treated between 1995 and 2020 in a single institution were included in the study. Medical records of the patients were retrospectively reviewed to obtain and analyze the following data: patient age at first surgery, sex, presenting symptoms, hydrocephalus and any invasive treatment, anatomic site, extent of resection, pathologic grade, time to progression, and time to death. Progression-free and overall survival rates and affecting factors were analyzed by Kaplan-Meier method.

RESULTS

Dysphagia, number of surgeries, and spinal seeding were associated with progression free and overall survival in univariate analysis. The extent of resection, World Health Organization grade, and visual problems were also associated with progression whereas sex was associated with overall survival. Cox regression identified the extent of resection and single surgery as an independent prognostic factor for progression-free survival. No independent factor was found for overall survival.

CONCLUSIONS

This single center experience of 25 years confirms the beneficial effect of gross total resection on disease progression. Although spinal seeding seems to affect survival rates, greater number of cases are needed to reveal its full effect.

Evaluation of dose, volume and outcome in children with localized, intracranial ependymoma treated with proton therapy within the prospective KiProReg Study

Background

Radiotherapy (RT) of ependymoma in children is an important part of the interdisciplinary treatment concept. However, feasibility and dose concepts are still under investigation, particularly in very young children. The aim of this study was to evaluate the standard dose and volume of proton therapy (PT) in children with ependymoma.

Methods

In this analysis, 105 patients with localized, intracranial ependymoma under the age of 18 years treated with PT between 2013 and 2018 were included. Patient characteristics, treatment, outcome, and follow-up data were analyzed using descriptive statistics, Kaplan-Meier, and Cox regression analysis.

Results

The median age of patients at PT was 2.8 years (0.9-17.0 years). The molecular subgroup analysis was performed in a subset of 50 patients (37 EP-PFA, 2 EP-PFB, 7 EP-RELA, 2 EP-YAP, 2 NEC [not elsewhere classified]). The median total dose was 59.4 Gy (54.0-62.0 Gy). The median follow-up time was 1.9 years. The estimated 3-year overall survival (OS), local control (LC), and progression-free survival (PFS) rates were 93.7%, 74.1%, and 55.6%, respectively. Within univariable analysis, female gender and lower dose had a positive impact on OS, whereas age ≥4 years had a negative impact on OS and PT given after progression had a negative impact on PFS. In the multivariable analysis, multiple tumor surgeries were associated with lower PFS. New ≥3° late toxicities occurred in 11 patients.

Conclusion

For children with localized ependymoma, PT was effective and well tolerable. Multiple surgeries showed a negative impact on PFS.

An Insight into Pathophysiological Features and Therapeutic Advances on Ependymoma

Simple Summary

Although biological information and the molecular classification of ependymoma have been studied, the treatment systems for ependymoma are still insufficient. In addition, because the disease occurs infrequently, it is difficult to obtain sufficient data to conduct large-scale or randomized clinical trials. Therefore, this study is intended to emphasize the importance of understanding its pathological characteristics and prognosis as well as developing treatments for ependymoma through multilateral studies.

Abstract

Glial cells comprise the non-sensory parts of the central nervous system as well as the peripheral nervous system. Glial cells, also known as neuroglia, constitute a significant portion of the mammalian nervous system and can be viewed simply as a matrix of neural cells. Despite being the “Nervenkitt” or “glue of the nerves”, they aptly serve multiple roles, including neuron repair, myelin sheath formation, and cerebrospinal fluid circulation. Ependymal cells are one of four kinds of glial cells that exert distinct functions. Tumorigenesis of a glial cell is termed a glioma, and in the case of an ependymal cell, it is called an ependymoma. Among the various gliomas, an ependymoma in children is one of the more challenging brain tumors to cure. Children are afflicted more severely by ependymal tumors than adults. It has appeared from several surveys that ependymoma comprises approximately six to ten percent of all tumors in children. Presently, the surgical removal of the tumor is considered a standard treatment for ependymomas. It has been conspicuously evident that a combination of irradiation therapy and surgery is much more efficacious in treating ependymomas. The main purpose of this review is to present the importance of both a deep understanding and ongoing research into histopathological features and prognoses of ependymomas to ensure that effective diagnostic methods and treatments can be developed.

Is H3K27me3 status really a strong prognostic indicator for pediatric posterior fossa ependymomas? A single surgeon, single center experience

PURPOSE

Posterior fossa ependymomas (PFE) are among the most frequently occurring solid tumors in children. Their definitive treatment is surgical excision and adjuvant radio-chemotherapy. This study aimed to investigate prognostic effects of age, H3K27me3 status, extent of resection, radiation treatment (RT), Ki67 index, WHO grade, and ATRX and H3K27M mutations in PFE patients.

METHODS

This retrospective study included 42 pediatric patients with PFE who had undergone operation at our institution between 1996 and 2018. Patient demographics and treatment information were obtained from patient notes. Information on radiological location of tumors (median vs paramedian), extent of tumor resection, and recurrence was obtained from preoperative and postoperative magnetic resonance imaging. Formalin-fixed paraffin-embedded tumor samples were evaluated for H3K27me3 immunostaining, Ki67 index, WHO grades, and ATRX and H3K27M mutations. Tumor samples with global reduction in H3K27me3 were grouped as posterior fossa ependymoma group A (PFA) and those with H3K27me3 nuclear immunopositivity as posterior fossa ependymoma group B (PFB). We evaluated the cohort's 5-year progression-free survival (PFS) and overall survival (OS).

RESULTS

There were 20 (47.6%) female and 22 (52.4%) male patients in the cohort. The mean age of patients was 4.4 (range, 0.71-14.51) years. Overall, tumors in 31 (73.8%) and 11 (26.2%) patients were found to be PFA and PFB, respectively. There was no statistically significant age or sex difference between PFA and PFB. All patients received chemotherapy, whereas only 28 (66.6%) received RT. The WHO grades of PFA were statistically higher than those of PFB. There was no significant difference between PFA and PFB in terms of extent of resection, disease recurrence, and survival parameters. Nine of 42 tumor samples had ATRX mutations. One patient with PFA showed H3K27M mutation. Age, WHO grade, H3K27me3 status, and RT had no effect on patients' PFS and OS. Patients with total surgical excisions had significantly better PFS and OS rates. Those with Ki67 < 50% also had better OS rates.

CONCLUSIONS

Determining H3K27me3 status by immunohistochemistry is a widely accepted method for molecular subgrouping of PFEs. Most of the reports in the literature state that molecular subgroups of PFEs have significantly different clinical outcomes. However, in our present series, we have shown that the extent of surgical excision is still the most important prognostic indicator in PFEs. We also conclude that the prognostic effect of H3K27me3 status-based molecular subgrouping may be minimized with a more aggressive surgical strategy followed in PFAs.