Interstitial irradiation of a large, low grade ependymoma with stereotactically implanted iodine-125 seeds. Case report

In this case report a patient with a large intraventricular benign ependymoma is presented. The tumour was treated with stereotactically implanted Iodine-125 seeds and interstitial irradiation. Extension (diameter: 6.5 cm) and volume (112.5 ml) of the lesion caused the application of an unusually low dose (tumour surface dose: 40 Gy). The tumour shrank significantly within a few weeks. Follow-up at nearly 5 years shows the patient to be tumour free.

Significance of gadolinium-enhanced magnetic resonance imaging in differentiating spinal cord radiation myelopathy from tumor. Case report

A young woman with a fourth ventricular ependymoma underwent radiotherapy following tumor excision. Twenty months later she developed a progressive neurological deficit at the C-2 vertebral level. Gadolinium-enhanced magnetic resonance imaging, showed an intramedullary lesion at the C-2 level. Although radiation myelopathy was suspected, tumor recurrence could not be excluded. Re-exploration and histopathology both confirmed a diagnosis of radiation myelopathy. A retrospective review of the case indicated findings favoring radiation myelopathy. The pertinent literature is reviewed and the findings discussed.

Treatment of tumours of the pineal region and posterior part of the third ventricle

The evaluation of tumours located in the posterior part of the third ventricle or pineal region is achieved best by magnet resonance imaging (MRI). It shows the exact localization and extent, the involvement of neighbouring structures like thalamus or quadrigeminal plate and the displacement of the large veins, the internal cerebral veins, the vein of Galen and the veins of Rosenthal. If only CT is available, angiography should be performed prior to operation to identify the course of the veins. In children with a pineal region tumour the "tumour markers" AFP and beta-HCG should be determined before operation. We approach the rare tumours entirely located within the posterior part of the third ventricle by the posterior interhemispheric transcallosal route with the patient in prone position with the head elevated. The same approach is used for pineal region tumours extending above the internal cerebral veins. Tumours arising from the posterior thalamus extending into the thalamus and ventricle as well, are better approached by the posterior transcortical transventricular route since the lateral view is rather limited by the midline approach. The most frequent tumours in the pineal region are approached if they are located below the internal veins by the infratentorial, supracerebellar route in the sitting position. A total of 60 cases are evaluated. If AFP and/or beta-HCG are positive a highly malignant nongerminomatous germ-cell tumour must be suspected. We recommend initial chemotherapy with a combination of Vinblastine, Ifosfamide and Cis-platin without biopsy to avoid tumour seeding. After the "markers" are normalized operative removal of the residual tumour and radiotherapy should be carried out. In a series of 13 children operated on for pineal region tumours a rigid neuropsychological and endocrine evaluation was performed with encouraging results. During the last 10 years we have performed 49 open operations and 11 stereotactic biopsies. 40% of the patients were children under the age of 18. 40% of the tumours in childhood and 60% in adults were benign. In childhood 24% were germinomas and 20% non-germinomatous germ cell tumours.

Clinicopathological experience with intraventricular neurocytomas

Intraventricular neurocytoma is a rare clinicopathological entity that has been recently described. We are reporting our experience with four diagnosed cases and the previously reported cases from the available literature are reviewed. These neoplasms occur mainly in young adults, and their histological diagnosis is difficult on light microscope, because they are almost indistinguishable from oligodendrogliomas. Nevertheless, the presence of tumoral cells arranged around nucleus-free fibrillary zones, resembling the large rosettes of pineocytomas and the immunohistochemical demonstration of synaptophysin are useful data for the pathological diagnosis. This diagnosis is easy on electron microscope, because it demonstrates the neuronal nature of tumoral cells. Regarding prognosis, we have found increasing evidence that these tumors are associated with a favourable course after surgery, and at present there is no clear evidence of the usefulness of radiotherapy.

Intraventricular hemangiopericytoma--case report

A very rare large intraventricular hemangiopericytoma occurred in a 41-year-old male with a 2-month history of headache and paresthesia of the right shoulder and arm. The tumor was partially removed, followed by 50 Gy local Linac irradiation given over 6 weeks. Four months later the residual tumor demonstrated a marked decrease in size and vascularity. The residual tumor was totally removed with less operative bleeding than at the initial operation. This is the first reported case of hemangiopericytoma located in the trigone of the lateral ventricle.

Radiotherapy of primary brain tumours in the region of the third ventricle

Patients (n = 18) with a primary brain tumour near the third ventricle and treated by radiotherapy were retrospectively analysed. Four different subgroups of patients, according to the histology (germ cell tumours, astrocytomas, other histologies, no histology) were separately discussed. Third ventricle tumours were more frequent in younger patients (less than 30 years). Five years actuarial disease free survival was 62%. Six out of 18 patients died of disease, the others are currently alive without evidence of disease.

[Apathy syndrome as a sequela of postoperative irradiation of brain tumors in children]

The somnolence syndrome is a postirradiation syndrome in children. It is to be found after cranial irradiation of chemotherapeutically treated children with ALL (acute lymphocytic leukaemia). Rarely, however, it is a radiation sequela of operated cerebral tumors. We report on such a case of somnolence syndrome, review the literature and discuss the diagnostic and therapeutic problems.

Elevated serum bromide concentrations following repeated halothane anaesthesia in a child

A 20-month-old child received 25 brief halothane general anaesthetics over a five-week period to allow cranial irradiation treatments for a posterior fossa ependymoma. Personality change during the last week of the treatment protocol raised the question of possible bromide intoxication. Serum bromide concentrations, using a gold chloride assay technique, were monitored at that time, and at four- and six-week intervals thereafter. Serum bromide concentrations demonstrated a four-fold change during this period ranging from peak levels of 2.2 mEq.L-1 (176 micrograms.kg-1) during the fifth week of treatment decreasing to less than 0.5 mEq.L-1 (less than 40 micrograms.ml-1) six weeks following the end of treatments. This demonstrates the possibility for repetitive, short halothane exposures to result in elevations of serum bromide and the potential of bromide intoxication in paediatric neuro-oncology patients.

[An adult case of malignant choroid plexus papilloma in the lateral ventricle and the cerebellopontine angle revealed simultaneously]

An adult case of malignant choroid plexus papilloma is very rare. This report is an adult case of malignant choroid plexus papilloma revealed in the lateral ventricle and in the cerebellopontine (CP) angle simultaneously. A 37-year-old man was admitted to the hospital complaining of headache, nausea, and a floating sensation on August 29, 1984. Neurological examination on admission revealed bilateral papilledema, left dysmetria and horizontal nystagmus. CT scan revealed a slightly high density round mass in the right lateral ventricle and a cystic mass with mural nodule in the left CP angle. The intraventricular mass and mural nodule were enhanced moderately and homogeneously. The initial surgery was for removal of the CP angle tumor, and 8 days later removal of the lateral ventricle tumor was carried out. The histology of these tumors was the same and revealed malignant choroid plexus papilloma. Postoperative radiation therapy was carried out 70Gy to the brain (whole brain; 50Gy, focal; 20Gy) and 30Gy to the whole spine. About 2 years later paraparesis, lower cranial nerve palsy, and disturbance of consciousness had progressed gradually. He died of the severe recurrence of the tumor in the brain stem, and multiple dissemination in the spinal cord on September 6, 1987. There was no recurrence of tumor in the right lateral ventricle. This is a very rare case of malignant choroid plexus papilloma which was revealed in both the supra- and infratentorial regions simultaneously. They may have developed independently or they may have arisen through subarachnoid seeding. Radical removal of the tumor is important to prevent recurrence of malignant choroid plexus papilloma.

Adjunctive treatment for recurrent childhood ependymoma of the IV ventricle: chemotherapy with CDDP and MCNU

The prognosis of recurrent IV-ventricle ependymoma in children is poor. Three cases of recurrent ependymoma were treated with combination chemotherapy using cis-diamine dichloro platinum (II) (CDDP) and methyl-6-(3-(2-chloroethyl)-3-nitrosoureido)-6-deoxy-alpha-D-glucopyrano side (MCNU). The patients were 2-, 3-, and 6-year-old boys. The interval between the first operation with irradiation and recurrence was 1 year and 5 months to 2 years. Two cases showed a recurrence at the original site; in the other case, a right sylvian tumor deposit was found via computed tomography. The therapeutic regiment for recurrent ependymomas was as follows: (1) the tumor was debulked if possible; (2) additional local irradiation of 30 Gy was administered; (3) combined treatment of 100 mg/m2 CDDP and 80 mg/m2 MCNU over 24 h was given 5 times with an interval of 6 weeks between treatments. The patients tolerated the therapy well with only mild side effects. Remission lasted 1 year in two patients and has lasted for 8 months in one.

5-Iodo-2-deoxyuridine administered into the lateral cerebral ventricle as a radiosensitizer in the treatment of disseminated glioma

A rat brain tumor model (Fischer 344 rats) with the clinical and pathological features of dissemination via the cerebrospinal fluid (CSF) pathways was used to demonstrate the efficacy of 5-iodo-2-deoxyuridine (IUDR) as a radiosensitizer when it is administered directly into the CSF. Stereotaxic implantation of 9L gliosarcoma cells (5 X 10(5) into the CSF of the lateral cerebral ventricle resulted in widespread dissemination and median survival of 18.5 and 20 days (range, 10-22) in two experiments. A continuous 7-day infusion of IUDR into the CSF starting on the day of tumor implantation did not provide any beneficial effect. Irradiation of the cranial spinal axis with 800 rad on days 4, 6, and 7 after implantation achieved an increase in survival time that was modest but statistically significant. However, the combination of IUDR infusion and radiotherapy resulted in marked improvement in survival time and a 10% cure rate (two of 20 rats). This is the first demonstration in vivo that IUDR administered into the CSF can be a potent radiosensitizer.

[Recurrent germinoma successfully treated with cisplatin. Case report]

A 23-year-old male with a suprasellar germinoma was initially treated with local irradiation, and the tumor completely disappeared. Three months later, he complained of pain in the left thigh. Myelography revealed multiple spinal metastases at the Th5 to Th8 and Th11 to L5 levels. The tumors were removed through a laminectomy, and the histopathological diagnosis was typical germinoma. Whole spinal irradiation was administered postoperatively. Neurological examination on discharge revealed no abnormality other than hypalgesia over the left L5 segment. Six years later, tumor was found in the lateral ventricles. The human chorionic gonadotropin (HCG) and HCG beta subunit levels were markedly elevated in both serum and cerebrospinal fluid (CSF). Irradiation considerably decreased the size of the tumor but did not completely eradicate it. Subsequent chemotherapy with cisplatin resulted in complete disappearance of the intraventricular tumor, as evidenced by computed tomography (CT). The serum and CSF levels of HCG and HCG beta subunit were well correlated with the tumor size, as shown by CT. The authors emphasize the curative potential of cisplatin in the treatment of recurrent germinoma.

Curability of third ventricular region tumours. A multidisciplinary approach to evaluate the places of operative, radiation and chemotherapy

Between 1976 and 1988, 17 patients suffering from tumours located in the third ventricular region were entered into a retrospective study. There were 11 males and 6 females aged from 2 to 30. These tumours were located in the pineal area (n = 12), in the floor of the third ventricle (n = 3), in the roof of the third ventricle (n = 1) and multiple midline tumours (n = 1). A ventriculoperitoneal shunt was performed in 13 patients. In 8 patients the tumour was operated upon directly. 2 patients did not undergo surgery. A histological examination was performed in 13 cases with identification of 9 germinomas, 2 pinealoblastomas and one astrocytoma. In one case the plasma and cerebro-spinal-fluid level of tumour markers (human béta chorionic gonadotrophin & alpha feto protein) were elevated. All patients received 45 to 60 grays by cobalt megavoltage irradiation on the tumoural volume, 8 of them receiving additional whole brain and spinal irradiation ranging from 30 to 36 grays. One patient had chemotherapy in addition to radiotherapy. The 5 years survival rate was 74% and the mean follow-up period was 5 years. Five deaths occurred: 1 during irradiation, 3 following a relapse and 1 unexplained death later on. There were no neurological sequelae related to irradiation but 7 patients (37%) had pituitary insufficiency. The irradiation dose level required to obtain local control, the methods of spinal prophylactic treatment and the role of chemotherapy are discussed.

Choroid plexus papillomas: long-term follow-up results in a surgically treated series

The medical records and histological specimens from 26 patients with choroid plexus papillomas operated on at one institution were reviewed retrospectively. Four patients died perioperatively, and 21 of the remaining 22 patients were followed through March, 1986; the patient lost to follow-up review was last seen 14 years postoperatively. Of the 14 patients who underwent gross total removal of their tumor, one had a recurrence at 11 years postoperatively and two died in the perioperative period. Of the 12 patients who underwent subtotal removal of their tumor, two died in the perioperative period. The two patients who did not have radiation therapy postoperatively are free of apparent disease at 6 and 8 years after their operation. Eight patients underwent radiation therapy after subtotal removal of their tumor; four of these remain alive and well, and four have died of progressive disease. The role of irradiation in the treatment of subtotally resected lesion remains controversial, but this therapy is thought to be indicated for recurrent disease after a surgical excision that is as complete as possible. Histopathologically, the presence of occasional mitotic figures, microscopic infiltration, ependymal differentiation, or mild to moderate atypia was not correlated with likelihood of complete resectability or tendency to recurrence.

[Radiation-induced meningioma--a case report]

A case of meningioma following irradiation for a tumor of the third ventricle is reported. A four year old girl was admitted complaining of headache and vomiting. The pneumoventriculography revealed marked hydrocephalus and a mass lesion at the third ventricle. Under the diagnosis of a tumor of the third ventricle, ventriculo-atrial shunt and radiation therapy were performed. Totally, 4170 rad irradiation was directed from left temporal area through a single portal. Though she had no complaints for fourteen years, at the age of eighteen, she was admitted complaining of right hemiparasis and general convulsion. CT scan and left carotid angiogram revealed a left fronto-temporal tumor diagnosed as meningioma. Histological examination showed transitional type meningioma. The post-operative course was uneventful, and discharged without neurological sign except for slight right hemiparesis. A review of available literature revealed about 150 cases of post irradiated meningiomas. However, there were only 18 cases of meningiomas following irradiation for the treatment of brain tumors. These reported cases were also discussed.

Periventricular metastases of a primary intracranial alpha-fetoprotein-producing germ cell tumor

Periventricular subependymal lesions were found on CT scan in a young man with growth failure, diabetes insipidus, mental deterioration, and hypogonadism with delayed puberty. An initial very good response to radiotherapy was followed a few months later by a relapse, presenting as a very large tumor in the base of the frontal lobes. Serum alpha-fetoprotein at the time of the relapse was very elevated suggesting that the tumor was largely composed of an endodermal sinus tumor component, which was confirmed at autopsy. The purpose of this report is to stress the importance of the use of tumor markers in a particular clinical and neuroradiological setting.

Response of a recurrent choroid plexus tumor to combination chemotherapy

Choroid Plexus tumors are rare. Surgery and biopsy is diagnostic, and radiotherapy has been used as the treatment of choice for choroid plexus carcinoma (CPC) and recurrent choroid plexus papilloma (CPP). We report the first case of CPP responding to combination chemotherapy consisting of cisplatin, bleomycin and vinblastine (CBV). This chemotherapy regimen should be considered for future trials in patients with choroid plexus tumors and recurrence after surgery and/or radiotherapy.

Stereotactic intracavitary irradiation of cystic neoplasms of the brain

Ten patients with intracranial cystic tumors underwent stereotactic intracavitary irradiation using 32P colloidal chromic phosphate. Accurate dosimetry (25,000-30,000 rad to the cast wall) was achieved by volume estimation using computed tomography. Between 1 and 15 months after surgery both craniopharyngioma and astrocytoma cysts regressed. Neurological, visual, and endocrinological deficits either stabilized or improved. Intracavitary irradiation should be the primary method of treating solitary cystic tumors of the brain.

Operative approaches to midline tumors

We have now operated and confirmed 80 tumors of the pineal region. Our experience is that 30 percent of these are benign, encapsulated and can be removed, and that only 30 percent represent germinomas. Another 30 percent are astrocytomas of varying grade. The preferred therapy in the majority of these tumors is radiotherapy and its extent depends upon the analysis of the lumbar spinal fluid. Chemotherapy has been reserved for tumors of the primitive embryonic type. The result of surgery for benign tumors has been excellent and the recurrence rate extremely low. In the germinoma series, the response to radiation therapy in our experience has been promising initially with resolution of the tumor by CT scan. However, we have noted recurrence of some of these tumors after radiotherapy approximately 6 to 8 years after the institution of therapy. The pineoblastomas are extremely difficult to treat by whatever means and the same holds true for the malignant pineocytomas. Our experience is too limited to say what the outcome will be in the chemotherapeutic management of the more primitive and embryonal tumors.

Atypical pineal teratoma: clinical and computer tomographic features of two patients with disseminated ependymal lesions

Two cases of atypical pineal teratoma (APT) with massive ventricular dissemination are reported; the diagnosis was based on CT appearances and characteristic neurological and endocrinological abnormalities. Both patients responded well to radiotherapy. The CT features and the management of these patients are discussed.

Sylvian aqueduct syndrome. Chronology of tumors in the pineal region in view of ocular movement

We experienced 21 cases of tumors (13 of pinealoma of the two-cell pattern and eight of tumors originating from the posterior part of the third ventricle). We carefully observed the eye movements of these patients during their respective clinical courses and found changes in abnormal eye movements along with remission following cobalt irradiation therapy or ventriculo-peritoneal shunt as well as with relapse on recurrence of tumors. From the neurotological viewpoint, we divided the development of these abnormal eye movements into four chronological stages. We emphasized the importance of the early diagnosis of tumors manifesting Sylvian aqueduct syndrome. Careful observation and analysis of eye movement will be a great help in making diagnoses as well as decisions for further examination and treatment.