1
|
Arfuso M, Kuril S, Shah H, Hanson D. Pediatric Neuroglial Tumors: A Review of Ependymoma and Dysembryoplastic Neuroepithelial Tumor. Pediatr Neurol 2024; 156:139-146. [PMID: 38781722 DOI: 10.1016/j.pediatrneurol.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/22/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Melissa Arfuso
- Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey
| | | | - Harshal Shah
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Derek Hanson
- Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey; Hackensack Meridian School of Medicine, Nutley, New Jersey.
| |
Collapse
|
2
|
Chan PP, Whipple NS, Ramani B, Solomon DA, Zhou H, Linscott LL, Kestle JRW, Bruggers CS. Patterns of Extraneural Metastases in Children With Ependymoma. J Pediatr Hematol Oncol 2023; 45:e272-e278. [PMID: 36730676 DOI: 10.1097/mph.0000000000002587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/04/2022] [Indexed: 02/04/2023]
Abstract
Ependymomas account for 10% of all malignant pediatric central nervous system tumors. Standard therapy includes maximal safe surgical resection, followed by focal radiation. Despite the aggressive therapy, progression-free survival is poor. Most ependymoma relapses occur locally at the original tumor site. Extraneural presentations of ependymoma are extremely rare, and no standard of care treatment exists. We present a single-institution case series of 3 patients who experienced extraneural relapses of supratentorial ependymoma and describe their treatment and outcome. These cases of extraneural relapse highlight the possible modes of extraneural spread, including hematogenous, lymphatic, and microscopic seeding through surgical drains and shunts. In addition, they illustrate the increase in histologic grade and mutational burden that may occur at the time of relapse. These cases illustrate the role of aggressive, individualized treatment interventions using a combination of surgery, radiation, and chemotherapy.
Collapse
Affiliation(s)
| | | | - Biswarathan Ramani
- Department of Pathology, University of California San Francisco, San Francisco, CA
| | - David A Solomon
- Department of Pathology, University of California San Francisco, San Francisco, CA
| | | | - Luke L Linscott
- Department of Radiology, Primary Children's Hospital, Salt Lake City, UT
| | | | | |
Collapse
|
3
|
Ritzmann TA, Chapman RJ, Kilday JP, Thorp N, Modena P, Dineen RA, Macarthur D, Mallucci C, Jaspan T, Pajtler KW, Giagnacovo M, Jacques TS, Paine SML, Ellison DW, Bouffet E, Grundy RG. SIOP Ependymoma I: Final results, long-term follow-up, and molecular analysis of the trial cohort-A BIOMECA Consortium Study. Neuro Oncol 2022; 24:936-948. [PMID: 35018471 PMCID: PMC9159435 DOI: 10.1093/neuonc/noac012] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND SIOP Ependymoma I was a non-randomised trial assessing event free and overall survival (EFS/OS) of non-metastatic intracranial ependymoma in children aged 3-21 years treated with a staged management strategy. A further aim was to assess the response rate (RR) of subtotally resected (STR) ependymoma to vincristine, etoposide, and cyclophosphamide (VEC). We report final results with 12-year follow-up and post hoc analyses of recently described biomarkers. METHODS Seventy-four participants were eligible. Children with gross total resection (GTR) received radiotherapy, whilst those with STR received VEC before radiotherapy. DNA methylation, 1q, hTERT, ReLA, Tenascin-C, H3K27me3, and pAKT status were evaluated. RESULTS Five- and ten-year EFS was 49.5% and 46.7%, OS was 69.3% and 60.5%. GTR was achieved in 33/74 (44.6%) and associated with improved EFS (P = .003, HR = 2.6, 95% confidence interval (CI) 1.4-5.1). Grade 3 tumours were associated with worse OS (P = .005, HR = 2.8, 95%CI 1.3-5.8). 1q gain and hTERT expression were associated with poorer EFS (P = .003, HR = 2.70, 95%CI 1.49-6.10 and P = .014, HR = 5.8, 95%CI 1.2-28) and H3K27me3 loss with worse OS (P = .003, HR = 4.6, 95%CI 1.5-13.2). Methylation profiles showed expected patterns. 12 participants with STR did not receive chemotherapy; a protocol violation. However, best chemotherapy RR was 65.5% (19/29, 95%CI 45.7-82.1), exceeding the prespecified 45%. CONCLUSIONS Participants with totally resected ependymoma had the best outcomes. RR of STR to VEC exceeded the pre-specified efficacy criterion. However, cases of inaccurate stratification highlighted the need for rapid central review. 1q gain, H3K27me3 loss, and hTERT expression were all associated with poorer survival outcomes.
Collapse
Affiliation(s)
- Timothy A Ritzmann
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rebecca J Chapman
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
| | - John-Paul Kilday
- Children’s Brain Tumour Research Network (CBTRN), Royal Manchester Children’s Hospital, Manchester, UK
- The Centre for Paediatric, Teenage and Young Adult Cancer, University of Manchester, Manchester, UK
| | - Nicola Thorp
- The Clatterbridge Cancer Centre, Liverpool, UK
- The Christie Hospital Proton Beam Therapy Centre, Manchester, UK
| | | | - Robert A Dineen
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Donald Macarthur
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Conor Mallucci
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Timothy Jaspan
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kristian W Pajtler
- Hopp Children’s Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neuro-oncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology, and Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Thomas S Jacques
- UCL GOS Institute of Child Health, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Simon M L Paine
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David W Ellison
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Eric Bouffet
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Richard G Grundy
- Children’s Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
4
|
Napieralska A, Mizia-Malarz A, Stolpa W, Pawłowska E, Krawczyk MA, Konat-Bąska K, Kaczorowska A, Brąszewski A, Harat M. Polish Multi-Institutional Study of Children with Ependymoma-Clinical Practice Outcomes in the Light of Prospective Trials. Diagnostics (Basel) 2021; 11:diagnostics11122360. [PMID: 34943596 PMCID: PMC8700631 DOI: 10.3390/diagnostics11122360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/29/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022] Open
Abstract
We performed a multi-institutional analysis of 74 children with ependymoma to evaluate to what extent the clinical outcome of prospective trials could be reproduced in routine practice. The evaluation of factors that correlated with outcome was performed with a log rank test and a Cox proportional-hazard model. Survival was estimated with the Kaplan–Meier method. The majority of patients had brain tumours (89%). All had surgery as primary treatment, with adjuvant radiotherapy (RTH) and chemotherapy (CTH) applied in 78% and 57%, respectively. Median follow-up was 80 months and 18 patients died. Five- and 10-year overall survival (OS) was 83% and 73%. Progression was observed in 32 patients, with local recurrence in 28 cases. The presence of metastases was a negative prognostic factor for OS. Five- and 10-year progression-free survival (PFS) was 55% and 40%, respectively. The best outcome in patients with non-disseminated brain tumours was observed when surgery was followed by RTH (+/−CTH afterwards; p = 0.0001). Children under 3 years old who received RTH in primary therapy had better PFS (p = 0.010). The best outcome of children with ependymoma is observed in patients who received radical surgery followed by RTH, and irradiation should not be omitted in younger patients. The role of CTH remains debatable.
Collapse
Affiliation(s)
- Aleksandra Napieralska
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, 44-101 Gliwice, Poland
- Correspondence:
| | - Agnieszka Mizia-Malarz
- Department of Pediatrics, Medical University of Silesia, 40-752 Katowice, Poland; (A.M.-M.); (W.S.)
| | - Weronika Stolpa
- Department of Pediatrics, Medical University of Silesia, 40-752 Katowice, Poland; (A.M.-M.); (W.S.)
| | - Ewa Pawłowska
- Department of Oncology and Radiotherapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdansk, Poland;
| | - Małgorzata A. Krawczyk
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, 80-210 Gdansk, Poland;
| | - Katarzyna Konat-Bąska
- Wroclaw Comprehensive Cancer Center, 53-413 Wrocław, Poland;
- Department of Oncology, Wroclaw Medical University, 53-413 Wrocław, Poland
| | - Aneta Kaczorowska
- Department of Children Oncology and Haematology, Wroclaw Medical University, 53-413 Wrocław, Poland;
| | - Arkadiusz Brąszewski
- Department of Neurooncology and Radiosurgery, Franciszek Lukaszczyk Memorial Oncology Center, 85-796 Bydgoszcz, Poland; (A.B.); (M.H.)
| | - Maciej Harat
- Department of Neurooncology and Radiosurgery, Franciszek Lukaszczyk Memorial Oncology Center, 85-796 Bydgoszcz, Poland; (A.B.); (M.H.)
- Department of Oncology and Brachytherapy, Nicolas Copernicus University, Collegium Medicum, 85-067 Bydgoszcz, Poland
| |
Collapse
|
5
|
Bennett J, Erker C, Lafay-Cousin L, Ramaswamy V, Hukin J, Vanan MI, Cheng S, Coltin H, Fonseca A, Johnston D, Lo A, Zelcer S, Alvi S, Bowes L, Brossard J, Charlebois J, Eisenstat D, Felton K, Fleming A, Jabado N, Larouche V, Legault G, Mpofu C, Perreault S, Silva M, Sinha R, Strother D, Tsang DS, Wilson B, Crooks B, Bartels U. Canadian Pediatric Neuro-Oncology Standards of Practice. Front Oncol 2020; 10:593192. [PMID: 33415075 PMCID: PMC7783450 DOI: 10.3389/fonc.2020.593192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
Primary CNS tumors are the leading cause of cancer-related death in pediatrics. It is essential to understand treatment trends to interpret national survival data. In Canada, children with CNS tumors are treated at one of 16 tertiary care centers. We surveyed pediatric neuro-oncologists to create a national standard of practice to be used in the absence of a clinical trial for seven of the most prevalent brain tumors in children. This allowed description of practice across the country, along with a consensus. This had a multitude of benefits, including understanding practice patterns, allowing for a basis to compare in future research and informing Health Canada of the current management of patients. This also allows all children in Canada to receive equivalent care, regardless of location.
Collapse
Affiliation(s)
- Julie Bennett
- Division of Neuro-Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Craig Erker
- Division of Pediatric Hematology/Oncology, IWK Health Centre, Halifax, NS, Canada
| | - Lucie Lafay-Cousin
- Department of Oncology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Vijay Ramaswamy
- Division of Neuro-Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Juliette Hukin
- Division of Hematology, Oncology and Bone Marrow Transplant, British Columbia Children's Hospital, Vancouver, BC, Canada
| | | | - Sylvia Cheng
- Division of Hematology, Oncology and Bone Marrow Transplant, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Hallie Coltin
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Adriana Fonseca
- Division of Neuro-Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Donna Johnston
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Andrea Lo
- Division of Radiation Oncology and Developmental Radiotherapeutics, BC Cancer Centre, Vancouver, BC, Canada
| | - Shayna Zelcer
- Division of Pediatric Hematology/Oncology, London Health Sciences Centre, London, ON, Canada
| | - Saima Alvi
- Pediatric Oncology, Saskatchewan Cancer Agency, Regina, SK, Canada
| | - Lynette Bowes
- Division of Pediatrics, Memorial University, St. John's, NF, Canada
| | - Josée Brossard
- Division of Pediatric Hematology/Oncology, Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Janie Charlebois
- Division of Pediatric Hematology/Oncology, Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - David Eisenstat
- Division of Pediatric Hematology/Oncology & Palliative Care, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Kathleen Felton
- Division of Pediatric Hematology/Oncology, Jim Pattison Children's Hospital, Saskatoon, SK, Canada
| | - Adam Fleming
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Nada Jabado
- Division of Hematology/Oncology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Valérie Larouche
- Division of Hematology/Oncology, CHU de Quebec, Quebec City, QC, Canada
| | - Geneviève Legault
- Division of Hematology/Oncology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Chris Mpofu
- Division of Pediatric Hematology/Oncology, Jim Pattison Children's Hospital, Saskatoon, SK, Canada
| | | | - Mariana Silva
- Division of Pediatrics, Queen's University, Kingston, ON, Canada
| | - Roona Sinha
- Division of Pediatric Hematology/Oncology, Jim Pattison Children's Hospital, Saskatoon, SK, Canada
| | - Doug Strother
- Department of Oncology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Beverly Wilson
- Division of Pediatric Hematology/Oncology & Palliative Care, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Bruce Crooks
- Division of Pediatric Hematology/Oncology, IWK Health Centre, Halifax, NS, Canada
| | - Ute Bartels
- Division of Neuro-Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
6
|
Ritzmann TA, Rogers HA, Paine SML, Storer LCD, Jacques TS, Chapman RJ, Ellison D, Donson AM, Foreman NK, Grundy RG. A retrospective analysis of recurrent pediatric ependymoma reveals extremely poor survival and ineffectiveness of current treatments across central nervous system locations and molecular subgroups. Pediatr Blood Cancer 2020; 67:e28426. [PMID: 32614133 DOI: 10.1002/pbc.28426] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Relapse occurs in 50% of pediatric ependymoma cases and has poor prognosis. Few studies have investigated the clinical progress of relapsed disease, and treatment lacks a standardized approach. METHODS AND MATERIALS We analyzed 302 pediatric ependymoma cases. Tumor, demographic, and treatment variables were investigated for association with relapse risk, time to recurrence, and survival after relapse. DNA methylation profiling was performed for 135/302 cases, and predominant subgroups were EPN_PFA (n = 95) and EPN_RELA (n = 24). Chromosome 1q status was ascertained for 185/302 cases by fluorescent in-situ hybridization (FISH), multiplex ligation-dependent probe amplification (MLPA), and DNA methylation profiles. RESULTS Sixty-two percent of cases relapsed, with a median of two recurrences with no difference between posterior fossa and supratentorial locations (66% vs 55% relapse rate). One hundred seventeen (38%) cases relapsed within two years and five (2%) beyond 10 years. The late relapses were clinically heterogeneous. Tumor grade and treatment affected risk and time to relapse variably across subgroups. After relapse, surgery and irradiation delayed disease progression with a minimal impact on survival across the entire cohort. In the EPN_PFA and EPN_RELA groups, 1q gain was independently associated with relapse risk (subhazard ratio [SHR] 4.307, P = 0.027 and SHR 1.982, P = 0.010, respectively) while EPN_PFA had increased relapse risk compared with EPN_RELA (SHR = 0.394, P = 0.018). CONCLUSIONS Recurrent pediatric ependymoma is an aggressive disease with poor outcomes, for which current treatments are inadequate. We report that chromosome 1q gain increases relapse risk in common molecular subgroups in children but a deeper understanding of the underlying biology at relapse and novel therapeutic approaches are urgently needed.
Collapse
Affiliation(s)
- Timothy A Ritzmann
- Children's Brain Tumor Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hazel A Rogers
- Children's Brain Tumor Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Simon M L Paine
- Department of Neuropathology, Nottingham University Hospital, Nottingham, UK
| | - Lisa C D Storer
- Children's Brain Tumor Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Thomas S Jacques
- Developmental Biology and Cancer Programme, UCL GOS Institute of Child Health and Department of Histopathology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Rebecca J Chapman
- Children's Brain Tumor Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - David Ellison
- Department of Pathology, St Jude Children's Hospital, Memphis, Tennessee
| | - Andrew M Donson
- Department of Pediatrics, University of Colorado, Denver, Aurora, Colorado
| | - Nicholas K Foreman
- Department of Pediatrics, University of Colorado, Denver, Aurora, Colorado
| | - Richard G Grundy
- Children's Brain Tumor Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
7
|
Byer L, Kline CN, Coleman C, Allen IE, Whitaker E, Mueller S. A systematic review and meta-analysis of outcomes in pediatric, recurrent ependymoma. J Neurooncol 2019; 144:445-452. [PMID: 31502040 DOI: 10.1007/s11060-019-03255-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/25/2019] [Accepted: 07/31/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to determine outcomes in recurrent pediatric ependymoma. METHODS We performed a systematic review of PubMed, Embase, Web of Science and the Cochrane Library for studies reporting on survival outcomes for pediatric patients with recurrent ependymoma. We then performed a meta-analysis of all eligible results. Survival outcomes were identified across location of recurrence, therapy at recurrence, and age at recurrence. RESULTS Eleven studies met final inclusion criteria. Pooled median progression free survival (PFS) from date of first recurrence was 6.7 months (95% confidence interval [95% CI] 4.7-8.8). Pooled median overall survival (OS) from date of first recurrence was 11.2 months (95% CI 6.4-16.0). Participants with supratentorial recurrences demonstrated a shorter OS of 8.3 months (95% CI 3.2-13.3) compared to 20.1 months (95% CI 8.4-31.7) for those with infratentorial recurrence. Patients who underwent surgery at recurrence had a median OS of 24.2 months (95% CI 14.2-34.1) compared to 29.2 months (95% CI 17.4-41.1) in those who received radiation compared to 19.3 months (95% CI 10.3-28.3) in those who received chemotherapy. Patients younger than age 3 years at time of recurrence demonstrated a median OS of 31.0 months (95% CI - 25.3-87.3) compared to 17.5 months (95% CI 9.9-25.2) for those that recurred beyond 3 years of age. CONCLUSIONS Our findings illustrate that children with recurrent ependymoma suffer from poor outcomes; however, these outcomes range widely depending on patient, tumor, and treatment characteristics. New therapies and treatment strategies are needed to improve outcomes in this group.
Collapse
Affiliation(s)
- Lennox Byer
- School of Medicine, University of California, San Francisco, 513 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Cassie N Kline
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA, 94158, USA
- Department of Neurology, University of California, San Francisco, Box 0434, 625 Nelson Rising Lane, San Francisco, CA, 94158, USA
| | - Christina Coleman
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital, Oakland, 747 52nd Street, Oakland, CA, 94609, USA
| | - Isabel E Allen
- Department of Epidemiology & Biostatistics, University of California, San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA, 94158, USA
| | - Evans Whitaker
- UCSF Health Sciences Library, University of California, San Francisco, 530 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Sabine Mueller
- Department of Neurology, University of California, San Francisco, Box 0434, 625 Nelson Rising Lane, San Francisco, CA, 94158, USA.
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital, Oakland, 747 52nd Street, Oakland, CA, 94609, USA.
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA, USA.
- University Children's Hospital Zuerich, Zurich, Switzerland.
| |
Collapse
|
8
|
Rajagopal R, Foo JC, Jawin V, Qaddoumi I, Bouffet E. High-dose chemotherapy with autologous stem cell transplantation in infants and young children with ependymoma: A 10-year experience with the Head Start II protocol. Pediatr Transplant 2019; 23:e13421. [PMID: 31012212 DOI: 10.1111/petr.13421] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 03/03/2019] [Accepted: 03/19/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Revathi Rajagopal
- Division of Hematology-Oncology, Department of Pediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Jen Chun Foo
- Division of Hematology-Oncology, Department of Pediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Vida Jawin
- Division of Hematology-Oncology, Department of Pediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Ibrahim Qaddoumi
- Division of Neuro-oncology, Department of Pediatric Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Eric Bouffet
- Division of Neuro-oncology, Department of Pediatric Hematology-Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Merchant TE, Bendel AE, Sabin ND, Burger PC, Shaw DW, Chang E, Wu S, Zhou T, Eisenstat DD, Foreman NK, Fuller CE, Anderson ET, Hukin J, Lau CC, Pollack IF, Laningham FH, Lustig RH, Armstrong FD, Handler MH, Williams-Hughes C, Kessel S, Kocak M, Ellison DW, Ramaswamy V. Conformal Radiation Therapy for Pediatric Ependymoma, Chemotherapy for Incompletely Resected Ependymoma, and Observation for Completely Resected, Supratentorial Ependymoma. J Clin Oncol 2019; 37:974-983. [PMID: 30811284 DOI: 10.1200/jco.18.01765] [Citation(s) in RCA: 140] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Children's Oncology Group trial ACNS0121 estimated event-free survival (EFS) and overall survival for children with intracranial ependymoma treated with surgery, radiation therapy, and-selectively-with chemotherapy. Treatment was administered according to tumor location, histologic grade, and extent of resection. The impacts of histologic grade, focal copy number gain on chromosome 1q, and DNA methylation profiles were studied for those undergoing surgery and immediate postoperative conformal radiation therapy (CRT). METHODS ACNS0121 included 356 newly diagnosed patients (ages 1 to 21 years). Patients with classic supratentorial ependymoma were observed after gross total resection (GTR). Those undergoing subtotal resection received chemotherapy, second surgery, and CRT. The remaining patients received immediate postoperative CRT after near-total resection or GTR. CRT was administered with a 1.0-cm clinical target volume margin. The cumulative total dose was 59.4 Gy, except for patients who underwent GTR and were younger than age 18 months (who received 54 Gy). Patients were enrolled between October 2003 and September 2007 and were observed for 5 years. Supratentorial tumors were evaluated for RELA fusion; infratentorial tumors, for chromosome 1q gain. Classification of posterior fossa groups A and B was made by methylation profiles. RESULTS The 5-year EFS rates were 61.4% (95% CI, 34.5% to 89.6%), 37.2% (95% CI, 24.8% to 49.6%), and 68.5% (95% CI, 62.8% to 74.2%) for observation, subtotal resection, and near-total resection/GTR groups given immediate postoperative CRT, respectively. The 5-year EFS rates differed significantly by tumor grade (P = .0044) but not by age, location, RELA fusion status, or posterior fossa A/posterior fossa B grouping. EFS was higher for patients with infratentorial tumors without 1q gain than with 1q gain (82.8% [95% CI, 74.4% to 91.2%] v 47.4% [95% CI, 26.0% to 68.8%]; P = .0013). CONCLUSION The EFS for patients with ependymoma younger than 3 years of age who received immediate postoperative CRT and for older patients is similar. Irradiation should remain the mainstay of care for most subtypes.
Collapse
Affiliation(s)
| | - Anne E Bendel
- 2 Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Noah D Sabin
- 1 St Jude Children's Research Hospital, Memphis, TN
| | - Peter C Burger
- 3 Johns Hopkins University/Sidney Kimmel Cancer Center, Baltimore, MD
| | | | - Eric Chang
- 5 University of Southern California, Los Angeles, CA.,6 Norris Cancer Center, Los Angeles, CA
| | - Shengjie Wu
- 1 St Jude Children's Research Hospital, Memphis, TN
| | - Tianni Zhou
- 7 California State University, Long Beach, CA
| | - David D Eisenstat
- 8 University of Alberta and University of Alberta Hospital, Edmonton, Alberta, Canada.,9 Edmonton Clinic Health, Edmonton, Alberta, Canada
| | | | | | | | - Juliette Hukin
- 12 British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Ching C Lau
- 13 Connecticut Children's Medical Center, Hartford, CT.,15 University of Connecticut School of Medicine, Farmington, CT
| | - Ian F Pollack
- 16 Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | | | - Robert H Lustig
- 18 University of California, San Francisco, School of Medicine, San Francisco, CA
| | - Floyd D Armstrong
- 19 University of Miami Miller School of Medicine-Sylvester Cancer Center, Miami, FL
| | | | | | | | - Mehmet Kocak
- 1 St Jude Children's Research Hospital, Memphis, TN
| | | | | |
Collapse
|
10
|
Khatua S, Mangum R, Bertrand KC, Zaky W, McCall D, Mack SC. Pediatric ependymoma: current treatment and newer therapeutic insights. Future Oncol 2018; 14:3175-3186. [PMID: 30418040 DOI: 10.2217/fon-2018-0502] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Advances in genomic, transcriptomic and epigenomic profiling now identifies pediatric ependymoma as a defined biological entity. Molecular interrogation has segregated these tumors into distinct biological subtypes based on anatomical location, age and clinical outcome, which now defines the need to tailor therapy even for histologically similar tumors. These findings now provide reasons for a paradigm shift in therapy, which should profile future clinical trials focused on targeted therapeutic strategies and risk-based treatment. The need to diagnose and differentiate the aggressive variants, which include the posterior fossa group A and the supratentorial RELA fusion subtypes, is imperative to escalate therapy and improve survival.
Collapse
Affiliation(s)
- Soumen Khatua
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ross Mangum
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA.,Department of Pediatric Hematology & Oncology, Texas Children's Cancer & Hematology Centers, Houston, TX 77030, USA
| | - Kelsey C Bertrand
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA.,Department of Pediatric Hematology & Oncology, Texas Children's Cancer & Hematology Centers, Houston, TX 77030, USA
| | - Wafik Zaky
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - David McCall
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Stephen C Mack
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA.,Department of Pediatric Hematology & Oncology, Texas Children's Cancer & Hematology Centers, Houston, TX 77030, USA
| |
Collapse
|
11
|
De B, Khakoo Y, Souweidane MM, Dunkel IJ, Patel SH, Gilheeney SW, De Braganca KC, Karajannis MA, Wolden SL. Patterns of relapse for children with localized intracranial ependymoma. J Neurooncol 2018; 138:435-445. [PMID: 29511977 DOI: 10.1007/s11060-018-2815-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
Abstract
We examined patterns of relapse and prognostic factors in children with intracranial ependymoma. Records of 82 children diagnosed with localized intracranial ependymoma were reviewed. 52% first presented to our institution after relapse. Median age at initial diagnosis was 4 years (range 0-18 years). Gender was 55% male. Initial tumor location was infratentorial in 71% and supratentorial in 29%. Histology was WHO Grade II in 32% and Grade III in 68%. As part of definitive management, 99% had surgery, 70% received RT (26% 2D/3D-conformal RT[CRT], 22% intensity-modulated RT [IMRT], 22% proton), and 37% received chemotherapy. Median follow-up was 4.6 years (range 0.2-32.9). Overall, 74% of patients relapsed (50% local, 17% distant, 7% local + distant) at a median 1.5 (range 0.1-17.5) years. Five-year OS and FFS for patients presenting prior to relapse are 70% (95% confidence interval [CI], 50-83%) and 48% (95% CI 30-64%), respectively. On log-rank, superior overall survival (OS) was demonstrated for gross total resection (p = 0.03). Superior failure-free survival (FFS) was demonstrated for age < 5 years (p = 0.04). No difference in OS or FFS was found between 2D/3D-CRT versus IMRT/proton (p > 0.05). On multivariate analysis, age ≤ 5 was independently associated with a lower risk of death and failure versus older patients (p < 0.05). Contrary to previous reports, young age may not be a poor prognostic factor in patients who can tolerate intensive treatment. Future studies examining patients stratified by clinical and molecular attributes are warranted.
Collapse
Affiliation(s)
- Brian De
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark M Souweidane
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Ira J Dunkel
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Suchit H Patel
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Stephen W Gilheeney
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin C De Braganca
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| |
Collapse
|
12
|
Abstract
Ependymoma is a locally aggressive tumor with metastatic potential that arises in diverse locations throughout the brain and spine in children. Tumor and treatment may result in significant morbidity. Cure remains elusive for many patients owing to diverse biology and resistance to conventional therapy. The implementation of systematic postoperative irradiation in clinical trials during the past 20 years has increased the proportion of patients achieving durable disease control with excellent results, as measured by objective functional outcome measures. Clinical, pathologic, and molecular risk stratification should be used to refine treatment regimens for children with ependymoma to reduce the risk of complications associated with therapy and increase the rate of disease control in the setting of combined modality or more intensive therapy. This review covers standards of care and current clinical trials for children with ependymoma, emphasizing the history and evolution of treatment regimens during the past 20 years and the clinical questions they hoped to address.
Collapse
|
13
|
A Review of Visual and Oculomotor Outcomes in Children With Posterior Fossa Tumors. Semin Pediatr Neurol 2017; 24:100-103. [PMID: 28941523 DOI: 10.1016/j.spen.2017.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Tumors of the posterior fossa represent the most common solid malignancy of childhood and can affect the visual system in several ways. This article outlines the relevant visual anatomy affected by these tumors and reviews the visual and oculomotor outcomes associated with the following 3 most common tumor types-medulloblastoma, juvenile pilocytic astrocytoma, and ependymoma. The available data suggest that the rate of permanent vision loss is low (5.9%-8.3%), with patients having juvenile pilocytic astrocytoma demonstrating the best outcomes. The rate of long-term strabismus (25%-29.1%) and nystagmus (12.5%-18%) is higher and associated with significant morbidity.
Collapse
|
14
|
Sato M, Gunther JR, Mahajan A, Jo E, Paulino AC, Adesina AM, Jones JY, Ketonen LM, Su JM, Okcu MF, Khatua S, Dauser RC, Whitehead WE, Weinberg J, Chintagumpala MM. Progression-free survival of children with localized ependymoma treated with intensity-modulated radiation therapy or proton-beam radiation therapy. Cancer 2017; 123:2570-2578. [PMID: 28267208 DOI: 10.1002/cncr.30623] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND The treatment for childhood intracranial ependymoma includes maximal surgical resection followed by involved-field radiotherapy, commonly in the form of intensity-modulated radiation therapy (IMRT). Proton-beam radiation therapy (PRT) is used at some centers in an effort to decrease long-term toxicity. Although protons have the theoretical advantage of a minimal exit dose to the surrounding uninvolved brain tissue, it is unknown whether they have the same efficacy as photons in preventing local recurrence. METHODS A retrospective review of medical records from September 2000 to April 2013 was performed. Seventy-nine children with newly diagnosed localized intracranial ependymomas treated with either IMRT (n = 38) or PRT (n = 41) were identified, and progression-free survival (PFS) was analyzed with Kaplan-Meier and Cox multivariate analyses. RESULTS The median age at diagnosis was 3.7 years for all patients (range, 0.4-18.7 years). There were 54 patients with infratentorial tumors (68% of the total population). Patients treated with PRT were younger (median age, 2.5 vs 5.7 years; P = .001) and had a shorter median follow-up (2.6 vs 4.9 years; P < .0001). Gross total resection (GTR) was achieved in 67 patients (85%) and was more frequent in the PRT group versus the IMRT group (93% vs 76%; P = .043). The 3-year PFS rates were 60% and 82% with IMRT and PRT, respectively (P = .031). CONCLUSIONS Children with localized ependymomas treated with PRT have a 3-year PFS rate comparable to that of children treated with IMRT. This analysis suggests that local control is not compromised by the use of PRT. The data also support GTR as the only prognostic factor for PFS. Cancer 2017;123:2570-78. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Mariko Sato
- University of Iowa Children's Hospital, Iowa City, Iowa
| | | | - Anita Mahajan
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eunji Jo
- Biostatistics and Informatics Shared Resource, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adekunle M Adesina
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Jeremy Y Jones
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Leena M Ketonen
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack M Su
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - M Fatih Okcu
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Soumen Khatua
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert C Dauser
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - William E Whitehead
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Jeffrey Weinberg
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Murali M Chintagumpala
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
15
|
Current therapy and the evolving molecular landscape of paediatric ependymoma. Eur J Cancer 2017; 70:34-41. [DOI: 10.1016/j.ejca.2016.10.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/25/2016] [Accepted: 10/12/2016] [Indexed: 01/13/2023]
|
16
|
Abstract
Over the past 150 years since Virchow's initial characterization of ependymoma, incredible efforts have been made in the classification of these tumors and in the care of pediatric patients with this disease. While the advent of modern neurosurgery and the optimization of radiation have provided significant gains, a more complex but incomplete picture of pediatric ependymomas has begun to form through a combination of international collaborations and detailed genetic and histologic characterizations. This review includes and synthesizes the clinical understanding of pediatric ependymoma and their developing molecular insight into what is truly a family of malignancies in which distinct members require different surgical approaches, radiation plans, and targeted therapies.
Collapse
Affiliation(s)
- Nicholas A Vitanza
- Division of Child Neurology, Department of Neurology, Lucile Packard Children's Hospital at Stanford, Stanford University, Palo Alto, CA, USA
| | - Sonia Partap
- Division of Child Neurology, Department of Neurology, Lucile Packard Children's Hospital at Stanford, Stanford University, Palo Alto, CA, USA
| |
Collapse
|
17
|
Abstract
Ependymomas are a heterogeneous group of neuroepithelial tumors of children and adults. In pediatric cases, the standard of care has long consisted of neurosurgical resection to the greatest extent acceptable followed by adjuvant involved field irradiation. Complete macroscopic surgical resection has remained the only consistent clinical variable known to improve survival. Adjuvant chemotherapy has yet to predictably affect outcome, possibly due to the molecular heterogeneity of histologically similar tumors. The administration of chemotherapy subsequently remains limited to clinical trials. However, recent comprehensive genomic, transcriptomic, and epigenetic interrogations of ependymomas have uncovered unique molecular characteristics and subtypes that correlated with clinical features such as age, neuroanatomical location, and prognosis. These findings represent a potential paradigm shift and provide a biologic rationale for targeted therapeutic strategies and risk-adapted administration of conventional treatment modalities. In this review, we focus on intracranial WHO grade II and III ependymoma of children and discuss conventional management strategies, followed by recent biologic findings and novel therapeutics currently under investigation.
Collapse
|
18
|
Sarıkafa Ş, Çelik SE, Yarikkaya E, Sayılgan A. Malignant Transformation of Grade II Ependymoma in a 2-Year-Old Child: Case Report. J Neurol Surg Rep 2015; 76:e151-5. [PMID: 26251794 PMCID: PMC4520988 DOI: 10.1055/s-0035-1549311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/22/2014] [Indexed: 11/13/2022] Open
Abstract
Ependymomas are central nervous system neoplasms that account for a third of all posterior fossa tumors in children. The most common location for infratentorial ependymoma is within the fourth ventricle. We present a case report of malignant transformation of an infratentorial grade II ependymoma in a 2-year-old child who presented with vomiting and visual disturbance. An infratentorial brain tumor in the left cerebellar area was totally removed, and the initial pathologic diagnosis was grade II ependymoma. The tumor recurred aggressively 1 year later; subtotal removal and adjuvant chemotherapy were performed. After a second operation, a histopathologic study was performed. The second specimen was defined as a grade III anaplastic ependymoma. Transformation to grade III anaplastic ependymoma is possible for a grade II ependymoma but very rare. The diagnosis of the anaplastic variant of intracranial ependymomas is difficult. Surgical treatment remains the mainstay of the treatment for all cases. Ependymomas in young infants have a worse prognosis than older children, so we need individual clinical evaluation and close follow-up of such cases. This article highlights the requirement of a close follow-up for grade II ependymomas for anaplastic transformation.
Collapse
Affiliation(s)
- Şule Sarıkafa
- Department of Neurosurgery, Okmeydanı Training and Research Hospital, Istanbul, Turkey
| | - Suat Erol Çelik
- Department of Neurosurgery, Okmeydanı Training and Research Hospital, Istanbul, Turkey
| | - Enver Yarikkaya
- Department of Pathology, Okmeydanı Training and Research Hospital, Istanbul, Turkey
| | - Ayşe Sayılgan
- Department of Pathology, Okmeydanı Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
19
|
Molecular Biology of Pediatric Brain Tumors and Impact on Novel Therapies. Curr Neurol Neurosci Rep 2015; 15:10. [DOI: 10.1007/s11910-015-0532-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
20
|
Antony R, Wong KE, Patel M, Olch AJ, McComb G, Krieger M, Gilles F, Sposto R, Erdreich-Epstein A, Dhall G, Gardner S, Finlay JL. A retrospective analysis of recurrent intracranial ependymoma. Pediatr Blood Cancer 2014; 61:1195-201. [PMID: 24615997 DOI: 10.1002/pbc.24996] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/30/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Recurrence occurs in almost 50% of patients with intracranial ependymoma, and their outcome following recurrence is poor. METHODS We retrospectively reviewed the medical records of 22 patients with intracranial ependymoma and subsequent relapse(s) (59 recurrences) treated at Children's Hospital Los Angeles or New York University between January 1997 and December 2012. RESULTS Median duration of follow-up was 52 months (7-171 months). Median age at initial diagnosis was 4 years (0.3-19 years) with 8 patients younger than 3 years at presentation. Eleven patients had anaplastic and 11 cellular pathologies. Eighteen patients had infratentorial tumors at diagnosis and 3 (all infratentorial) had metastatic spinal cord involvement at presentation. Cerebrospinal fluid involvement was not identified at diagnosis or relapse. Median time to first recurrence was 16 months (1.3 to 115 months). The number of recurrences in each patient ranged from 1 to 9 (median = 2). Thirty-seven recurrences (63%) were detected asymptomatically by surveillance imaging. Fifteen recurrences (26%) arose outside the initial tumor site. Recurrences were treated by surgical resection (45), with irradiation (30), and with various oral chemotherapies (23) with (7) or without (16) conventional chemotherapy. The 5 and 10 year overall survival rates from first recurrence were 0.37 ± 0.14 and 0.25 ± 0.14. CONCLUSION Prolonged (5-10 year) survival from first relapse was noted in over one-quarter of our patients. It remains unclear whether early radiographic diagnosis, differing treatment modalities beyond radical surgical resection or possibly unrecognized biological differences contributed towards this prolonged survival.
Collapse
Affiliation(s)
- Reuben Antony
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Pollack IF, Jakacki RI, Butterfield LH, Okada H. Ependymomas: development of immunotherapeutic strategies. Expert Rev Neurother 2013; 13:1089-98. [PMID: 24117271 PMCID: PMC3972122 DOI: 10.1586/14737175.2013.840420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ependymomas are among the most challenging childhood brain tumors. Although 50-70% of ependymomas are cured with surgery and irradiation, a significant percentage of tumors recur. Ependymomas that are not amenable to complete resection at diagnosis have a particularly poor prognosis, and the vast majority of affected children experience tumor recurrence. Although transient responses have been observed in recurrent tumors treated with re-irradiation and several chemotherapy regimens, long-term disease control is rarely achieved. Children with recurrent disease commonly experience cumulative neurological morbidity from repeated surgical and adjuvant therapy interventions and almost universally succumb to refractory tumor progression. Accordingly, conceptually new treatment approaches are needed, both to decrease the risk of tumor recurrence and to enhance disease control in those children who experience recurrent disease. This article reviews the current application of risk-based treatment stratification at diagnosis, the rationale for exploring the role of novel therapeutic strategies such as immunotherapy at recurrence and the concept behind a vaccine-based trial for these tumors.
Collapse
Affiliation(s)
- Ian F. Pollack
- Department of Neurosurgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Immunology, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Cancer Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Regina I. Jakacki
- Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Immunology, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Cancer Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lisa H Butterfield
- Department of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Immunology, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Cancer Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hideho Okada
- Department of Neurosurgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Immunology, Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Cancer Institute, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
22
|
Aizer AA, Ancukiewicz M, Nguyen PL, Macdonald SM, Yock TI, Tarbell NJ, Shih HA, Loeffler JS, Oh KS. Natural history and role of radiation in patients with supratentorial and infratentorial WHO grade II ependymomas: results from a population-based study. J Neurooncol 2013; 115:411-9. [PMID: 24057324 DOI: 10.1007/s11060-013-1237-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 09/06/2013] [Indexed: 11/29/2022]
Abstract
Patients with World Health Organization (WHO) grade II supratentorial ependymomas are commonly observed after gross total resection (GTR), although supporting data are limited. We sought to characterize the natural history of such tumors. We used the Surveillance, Epidemiology, and End Results program to identify 112 patients ages 0-77 diagnosed with WHO grade II ependymomas between 1988 and 2007, of whom 63 (56 %) and 49 (44 %) had supratentorial and infratentorial primaries, respectively. Inclusion criteria were strict to ensure patient homogeneity. Of 33 patients with supratentorial tumors after GTR, 18 (55 %) received adjuvant radiation therapy and 15 (45 %) did not. Ependymoma-specific mortality (ESM) was the primary endpoint. With a median follow up of 4.5 years, only 1 of 33 patients with supratentorial ependymoma died of their disease after GTR; the 5-year estimate of ESM in this population was 3.3 % (95 % CI 0.2-14.8 %). Among patients with infratentorial ependymomas after GTR, the 5-year estimate of ESM was 8.7 % (95 % CI 1.4-24.6 %). In patients with subtotally resected tumors, 5-year estimates of ESM in patients with supratentorial and infratentorial primaries were 20.1 % (95 % CI 8.0-36.2 %) and 12.3 % (95 % CI 2.9-28.8 %), respectively. Among the whole cohort, on both univariable and multivariable regression, extent of resection was predictive of ESM, while tumor location and use of radiation were not. After GTR, patients with WHO grade II supratentorial ependymomas have a very favorable natural history with low associated cancer-specific mortality. Observation, with radiation reserved as a salvage option, may be a reasonable postoperative strategy in this population.
Collapse
Affiliation(s)
- Ayal A Aizer
- Harvard Radiation Oncology Program, Department of Radiation Oncology, Massachusetts General Hospital, 55 Fruit Street, Lunder LL3, Boston, MA, 02114, USA,
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
OPINION STATEMENT Survival rates for patients with ependymoma, a glial tumor arising from the ependymal cells lining the ventricles of the brain and spinal cord canal, have changed little during the past decade. Contemporary "standard" therapy for children and adults with ependymoma consists of maximal surgical resection followed by focal irradiation except in cases of disseminated disease. Despite refinements in radiotherapy techniques and improvements in survival for patients with gross totally resected, nonanaplastic disease, many therapeutic challenges remain, especially for patients with unresectable, macroscopic, metastatic, or anaplastic disease. Moreover, radiotherapy to the developing central nervous system, especially in patients younger than age 5 years, can have potential long-term neurocognitive and neuroendocrine sequelae. Chemotherapy has not played a role in most treatment regimens for ependymoma to date, but due to the ongoing therapeutic challenges for a subset of patients, this modality is being reinvestigated in a few ongoing studies. Early recognition of patients who will not respond to primary therapy is imperative to modify treatment regimens, such as intensification with the addition of adjuvant chemotherapy, the use of novel experimental therapies, or their combination. Refinements in patient stratification schemes that are based on a combination of clinical variables and molecular profiles also require improved knowledge of tumor biology. Several molecular alterations have been identified already, some of which may be of prognostic significance. Furthermore, disruption of molecular alterations in signaling pathways involved in the development and maintenance of ependymoma by using novel molecularly targeted therapies may improve outcomes and reduce toxicity for patients with ependymoma.
Collapse
|
24
|
Abstract
Pediatric intracranial ependymoma is a rare disease representing approximately 7% of brain tumors in children aged 15 years or younger. Due to the relative rarity of these tumors, a clear standard therapy has been difficult to establish. The mainstay of treatment is surgical resection and the majority of data demonstrate improved outcome with gross total resection. The standard of care also includes postoperative radiation therapy for most patients with grade II and III tumors. Chemotherapy has been used in many capacities in this disease; however, its optimal role is yet to be defined. Current controversies such as treatment with surgery alone in completely resected tumors, use of chemotherapy for subtotally resected tumors and use of adjuvant postradiation chemotherapy are incorporated into the design of the current Children's Oncology Group clinical trial.
Collapse
Affiliation(s)
- David B Mansur
- Department of Radiation Oncology & Pediatrics, Case Western Reserve University School of Medicine, University Hospitals & Seidman Cancer Center, Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106-6068, USA.
| |
Collapse
|
25
|
Abstract
Despite the claim in the published literature, the introduction of proton therapy for children is not analogous to the evolution of conformal photon irradiation relying on the understanding of the impact of altered dose distributions. The differences in radiobiological effect when comparing photons with protons mean that we are comparing a known entity with an unknown entity: the dose-volume histogram for proton therapy might mean something substantially different from the dose-volume histogram for photon therapy. The multifaceted difference between the 2 modalities supports the argument for careful evaluation, follow-up, and clinical trials with adverse event monitoring when using proton therapy in children. We review the current data on the outcome of proton therapy in a range of pediatric tumors and compare them with the often excellent results of photon therapy in the setting of multidisciplinary management of childhood cancer. It is hoped that the apparent dosimetric advantage of proton therapy over photons will lead to improved indications for therapy, disease control, and functional outcomes. Although physical dose distribution is of clear importance, the multimodality management of children by an expert pediatric oncology team and the availability of ancillary measures that improve the quality of treatment delivery may be more important than the actual beam. In addition, current estimates of the benefit of proton therapy over photon therapy based on toxicity reduction will only be realized when survivorship has been achieved. Once substantive proton therapy data become available, it will be necessary to demonstrate benefit in clinically relevant outcome measures in comparison with best existing photon outcome data. Such an effort will require improved funding and appreciation for late effects research. Only real clinical outcome data combined with better understanding of the radiobiological differences between protons and photons will help us to further reduce side effects in children and exploit the full curative potential of this relatively new modality.
Collapse
Affiliation(s)
- Thomas E Merchant
- Division of Radiation Oncology, Department of Radiologic Sciences, St. Jude Children's Research Hospital, Memphis, TN 38105-2794, USA.
| |
Collapse
|
26
|
Garvin JH, Selch MT, Holmes E, Berger MS, Finlay JL, Flannery A, Goldwein JW, Packer RJ, Rorke-Adams LB, Shiminski-Maher T, Sposto R, Stanley P, Tannous R, Pollack IF. Phase II study of pre-irradiation chemotherapy for childhood intracranial ependymoma. Children's Cancer Group protocol 9942: a report from the Children's Oncology Group. Pediatr Blood Cancer 2012; 59:1183-9. [PMID: 22949057 DOI: 10.1002/pbc.24274] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 07/09/2012] [Indexed: 11/10/2022]
Abstract
PURPOSE Standard therapy for childhood intracranial ependymoma is maximal tumor resection followed by involved-field irradiation. Although not used routinely, chemotherapy has produced objective responses in ependymoma, both at recurrence and in infants. Because the presence of residual tumor following surgery is consistently associated with inferior outcome, the potential impact of pre-irradiation chemotherapy was investigated. METHODS Between 1995 and 1999, the Children's Cancer Group undertook a Phase II trial of pre-irradiation chemotherapy in children 3-21 years of age with intracranial ependymoma and radiological evidence of post-operative residual tumor. RESULTS Of 84 patients, 41 had residual tumor, and were given four cycles of cisplatin-based chemotherapy prior to irradiation. Of 35 patients fully evaluable for response to chemotherapy, 14 (40%) demonstrated complete response, 6 (17%) partial response, 10 (29%) minor response or stable disease, and 5 (14%) demonstrated progressive tumor growth. For the entire group, 5-year overall survival (OS) and event-free survival (EFS) was 71 ± 6%, and 57 ± 6%, respectively. The pre-irradiation chemotherapy group demonstrated EFS comparable to that of patients with no residual tumor who received irradiation alone (55 ± 8% vs. 58 ± 9%, P = 0.45). Any benefit of chemotherapy was restricted to patients with greater than 90% tumor resection. CONCLUSIONS Children with near total resection of ependymoma may benefit from pre-irradiation chemotherapy. Patients with subtotal resection have inferior outcome despite responses to chemotherapy, and should be considered for second-look surgery prior to irradiation. Pediatr Blood Cancer 2012; 59: 1183-1189. © 2012 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- James H Garvin
- Division of Pediatric Oncology, Columbia University Medical Center, New York, New York
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Benesch M, Frappaz D, Massimino M. Spinal cord ependymomas in children and adolescents. Childs Nerv Syst 2012; 28:2017-28. [PMID: 22961356 DOI: 10.1007/s00381-012-1908-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 08/25/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal cord ependymomas are very rare among children and adolescents. Due to their rarity, our current knowledge of these tumors is based on case reports and few retrospective case series. METHODS The present review summarizes the currently available literature on childhood spinal cord ependymomas. RESULTS Although overall survival rates are favorable, relapse incidence is high, particularly in myxopapillary ependymomas. Since long-term follow-up data are provided in a limited number of studies only, the true relapse incidence is unknown. Maximal safe radical surgery is the backbone of treatment for children with spinal cord ependymomas, but the impact of adjuvant treatment on progression and survival is still unclear. Presently, the decision to initiate non-surgical treatment depends primarily on the WHO grade of the tumor and the extent of resection. In terms of the known side effects, early radiotherapy should be avoided in children with WHO grade II spinal cord ependymomas irrespective of the extent of resection but is indicated in anaplastic spinal cord ependymomas both after complete and incomplete resection. The high relapse incidence in myxopapillary ependymomas argue for the use of early radiotherapy, but its definitive impact on progression has to be proven in larger series. Close surveillance is important due to the high recurrence rate in all patients with spinal cord ependymomas. CONCLUSION Prospective collection of both clinical and molecular data from a greater number of patients with spinal cord ependymomas within an international collaboration is the prerequisite to establish standardized management guidelines for these rare CNS tumors.
Collapse
Affiliation(s)
- Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 38, 8036 Graz, Austria.
| | | | | |
Collapse
|
28
|
Vaidya K, Smee R, Williams JR. Prognostic factors and treatment options for paediatric ependymomas. J Clin Neurosci 2012; 19:1228-35. [PMID: 22840355 DOI: 10.1016/j.jocn.2012.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 02/07/2012] [Accepted: 02/14/2012] [Indexed: 01/22/2023]
Abstract
The aim of this study was to determine factors of prognostic relevance for paediatric ependymomas, and evaluate the efficacy of treatment modalities. This is a retrospective study of 43 patients with ependymoma (<18 years) who underwent a combination of surgical excision, chemotherapy, and/or radiotherapy treatment at The Prince of Wales Cancer Centre between 1969 and 2009. Statistical analysis was performed to assess the prognostic relevance of various parameters affecting the two-year and five-year overall survival (OS) and progression-free survival (PFS). The five-year OS and PFS were 50.3% and 44.8% respectively (median follow-up 50 months). Eighteen patients (41.9%) experienced tumour recurrence: 13 had a local recurrence (LR) and five had both LR and distant recurrence. On univariate analysis, a more favourable prognosis in terms of both OS and PFS was evident for supratentorial tumours compared to infratentorial tumours (OS p=0.007, PFS p=0.045), stereotactic radiosurgery/ fractionated stereotactic radiotherapy compared to craniospinal irradiation or local posterior fossa/local brain±boost radiotherapy modalities (OS p=0.047, PFS p=0.031), total radiotherapy dose >50 Gy compared to ≤50 Gy (OS p=0.008, PFS p=0.005), and in patients with no tumour recurrence compared to those with recurrence (OS p=0.03, PFS p<0.001). Although not statistically significant, a more favourable multivariate outcome was evident in patients who underwent complete surgical resection. Chemotherapy treatment and histopathological grade, however, were not relevant to prognosis. This study supports the need to pursue more aggressive treatment for infratentorial and/or recurrent tumours. Ideal treatment involves maximal surgical resection, followed by adjuvant radiotherapy (>50 Gy).
Collapse
Affiliation(s)
- K Vaidya
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Level 2, High Street, Randwick, New South Wales 2031, Australi
| | | | | |
Collapse
|
29
|
Stereotactic radiosurgery for patients with recurrent intracranial ependymomas. J Neurooncol 2012; 108:507-12. [DOI: 10.1007/s11060-012-0851-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 03/12/2012] [Indexed: 10/28/2022]
|
30
|
Venkatramani R, Dhall G, Patel M, Grimm J, Hawkins C, McComb G, Krieger M, Wong K, O'Neil S, Finlay JL. Supratentorial ependymoma in children: to observe or to treat following gross total resection? Pediatr Blood Cancer 2012; 58:380-3. [PMID: 21370439 DOI: 10.1002/pbc.23086] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 01/24/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND The standard treatment for ependymoma is surgical resection followed by postoperative irradiation to the local site. The role of radiation therapy in completely resected supratentorial ependymoma has been questioned over the past two decades. PROCEDURE Retrospective review of the medical records of all consecutively diagnosed supratentorial ependymoma patients at Children's Hospital Los Angeles between January 1999 and December 2009. RESULTS Ten patients (three females) were included. The median age at presentation was 5.6 years (range 1.8-15.6 years). Reviewed histology was anaplastic ependymoma in seven patients and cellular ependymoma in three patients. Gross total resection was achieved in six patients; five were observed and one received chemotherapy. In the four patients who underwent subtotal resection, one was observed, two received local irradiation and one received irradiation and chemotherapy. The median length of follow up was 43 (range 22-81) months. Four relapses were observed; two patients who underwent initial gross total resection. All patients who underwent gross total resection were alive at the time of preparation of this article. The 5-year progression-free and overall survival rates were 53 ± 19% and 86 ± 13% respectively. CONCLUSIONS Radiation therapy was avoided in five patients following gross total resection, four of whom had anaplastic histology. In some children with completely resected supratentorial ependymoma, surgery alone may be an acceptable treatment option.
Collapse
Affiliation(s)
- Rajkumar Venkatramani
- Division of Hematology/Oncology, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
|
32
|
Rajappa P, Krass J, Riina HA, Boockvar JA, Greenfield JP. Super-selective basilar artery infusion of bevacizumab and cetuximab for multiply recurrent pediatric ependymoma. Interv Neuroradiol 2011; 17:459-65. [PMID: 22192550 DOI: 10.1177/159101991101700410] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 10/09/2011] [Indexed: 11/17/2022] Open
Abstract
Ependymoma is a central nervous system tumor associated with a poor prognosis due to limited efficacy of current medical treatment modalities, often resulting in multiple surgical re-resections with each tumor recurrence. As traditional chemotherapeutic regimens have proved unsuccessful in long-term control of subtotally resected ependymoma, other agents targeting the tumor microenvironement including the angiogenic factors supplying neovascularization have recently been used. Anti-angiogenic agents such as bevacizumab are routinely used in adult patients with recurrent glioma. Selective intra-arterial cerebral infusion (SIACI) of biological agents within tumor-supplying cerebral vasculature has recently been re-examined as a means to avoid the systemic side-effects associated with intravenous use of bevacizumab. This technical paper describes the first reported use of SIACI for delivery of two targeted biologic agents, bevacizumab and cetuximab in a pediatric patient utilizing the basilar artery to selectively administer the drugs to the tumor microenvironment. We believe this method for therapeutic delivery will both broaden treatment options and better refine treatment methodology as the multi-modality treatment approach often required to treat patients with pediatric ependymomas and other intracranial malignancies evolves.
Collapse
Affiliation(s)
- P Rajappa
- Weill Cornell Brain Tumor Center, Department of Neurological Surgery, Weill Cornell Medical College of Cornell University, New York, NY 10065, USA
| | | | | | | | | |
Collapse
|
33
|
Nagasawa DT, Smith ZA, Cremer N, Fong C, Lu DC, Yang I. Complications associated with the treatment for spinal ependymomas. Neurosurg Focus 2011; 31:E13. [DOI: 10.3171/2011.7.focus11158] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal cord ependymomas are rare neoplasms, comprising approximately 5% of all CNS tumors and 15% of all spinal cord tumors. Although surgery was once reserved for diagnosis alone, the evolution of surgical practices has elevated resection to the treatment of choice for these lesions. While technological advances continue to improve the capacity for gross-total resections and thus decrease the risk of recurrence, ependymoma spinal surgery still contains a variety of potential complications. The presence of neurological deficits and deterioration are not uncommonly associated with spinal cord ependymoma surgery, including sensory loss, dorsal column dysfunction, dysesthetic syndrome, and bowel and bladder dysfunction, particularly in the immediate postoperative period. Surgical treatment may also lead to wound complications and CSF leaks, with increased risk when radiotherapy has been involved. Radiation therapy may also predispose patients to radiation myelopathy and ultimately result in neurological damage. Additionally, resections of spinal ependymomas have been associated with postoperative spinal instability and deformities, particularly in the pediatric population. Despite the advances in microsurgical techniques and intraoperative cord monitoring modalities, there remain a number of serious complications related to the treatment of spinal ependymoma tumors. Identification and acknowledgment of these potential problems may assist in their prevention, early detection, and increased quality of life for patients afflicted with this disease.
Collapse
Affiliation(s)
- Daniel T. Nagasawa
- 1Department of Neurological Surgery, University of California Los Angeles; and
| | - Zachary A. Smith
- 2Los Angeles Spine Clinic, Good Samaritan Hospital, Los Angeles, California
| | - Nicole Cremer
- 1Department of Neurological Surgery, University of California Los Angeles; and
| | - Christina Fong
- 1Department of Neurological Surgery, University of California Los Angeles; and
| | - Daniel C. Lu
- 1Department of Neurological Surgery, University of California Los Angeles; and
| | - Isaac Yang
- 1Department of Neurological Surgery, University of California Los Angeles; and
| |
Collapse
|
34
|
Houjami M, Sahraoui S, Benchakroun N, Jouhadi H, Tawfiq N, Benider A. [Intracranial ependymomas: retrospective study of 16 cases]. Cancer Radiother 2011; 15:136-9. [PMID: 21256791 DOI: 10.1016/j.canrad.2010.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Revised: 02/28/2010] [Accepted: 09/23/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE To report the epidemiological, clinical aspects and therapeutic results of intracranial ependymomas in Morocco. PATIENTS AND METHODS Our retrospective study concerned 16 cases of intracranial ependymomas, treated from January 1995 to December 2002 at the radiotherapy department of Ibn Rochd Hospital of Casablanca, Morocco. RESULTS The average age was 15 years and complete surgery was possible in two cases. All the patients received cranial radiotherapy, combined with chemotherapy in six cases. Overall survival and progression-free survival at 5 years were respectively 50% and 31%. Eleven patients had local recurrence after an average period of 21 months. Progression-free survival at 5 years was better if complete resection: 100% vs. 28.6% in cases of incomplete resection, and depending on the histological type with 50% for classic ependymomas and 16.6% for anaplastic. CONCLUSION Ependymomas are rare tumors and complete resection is the standard treatment followed by postoperative radiotherapy. The place of chemotherapy remains to be defined.
Collapse
Affiliation(s)
- M Houjami
- Centre d'Oncologie, CHU Ibn Rochd, Casablanca, Maroc.
| | | | | | | | | | | |
Collapse
|
35
|
Benesch M, Weber-Mzell D, Gerber NU, von Hoff K, Deinlein F, Krauss J, Warmuth-Metz M, Kortmann RD, Pietsch T, Driever PH, Quehenberger F, Urban C, Rutkowski S. Ependymoma of the spinal cord in children and adolescents: a retrospective series from the HIT database. J Neurosurg Pediatr 2010; 6:137-44. [PMID: 20672934 DOI: 10.3171/2010.5.peds09553] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Reports on spinal cord ependymoma in children are rare. The aim of this study was to evaluate the clinical spectrum, treatment, and outcome of children with primary ependymoma of the spinal cord who were registered in the database of the pediatric German brain tumor studies Hirntumor (HIT) '91 and HIT 2000. METHODS Between 1991 and 2007, 29 patients (12 male and 17 female, median age at diagnosis 13.6 years) with primary spinal cord ependymoma (myxopapillary ependymoma WHO Grade I, II, and III tumors in 6, 17, and 6 patients, respectively) were identified. Four patients had neurofibromatosis Type 2. RESULTS With a median follow-up of 4.2 years (range 0.48-15 years), 28 patients (96.6%) were alive. Seven patients (24.1%) developed progressive disease or relapse, 2 after gross-total resection (GTR) and 5 after incomplete resection or biopsy. One patient with anaplastic ependymoma (WHO Grade III) died 65 months after diagnosis of disease progression. Primary adjuvant treatment (radiotherapy, chemotherapy, or both) was used in 8 (50%) of 16 patients following GTR and in 9 (82%) of 11 patients who underwent less than a GTR. Three additional patients were treated adjuvantly following progression. Estimated progression-free survival and overall survival rates at 5 years were 72.3% (95% CI 50%-86%) and 100%, respectively. Progression-free survival at 5 years is 84.4% (95% CI 50%-96%) for patients following GTR compared with 57.1% (95% CI 25%-69%) for patients who achieved a less than GTR (p = 0.088, log-rank test). A high relapse incidence (4 of 6) was observed among patients with myxopapillary ependymoma. CONCLUSIONS Gross-total resection is the mainstay of treatment for patients with primary spinal cord ependymoma and may be achieved in about 50% of the patients using modern surgical techniques. Primary adjuvant treatment was commonly used in children with spinal cord ependymoma irrespective of the extent of resection or tumor grade. The impact of adjuvant treatment on progression-free and overall survival has to be investigated in a prospective trial.
Collapse
Affiliation(s)
- Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Proton beam therapy following resection for childhood ependymoma. Childs Nerv Syst 2010; 26:285-91. [PMID: 20024657 DOI: 10.1007/s00381-009-1059-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 11/17/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Proton radiation therapy is a form of radiation with physical properties that can provide an advantage in normal tissue sparing compared to the more commonly used photon therapy. DISCUSSION The greatest benefit may be for young patients with tumors requiring relatively high doses of radiation and adjacent to critical structures. Children with central nervous system ependymomas meet these criteria and have a very high likelihood of benefit from proton radiation. At present, proton radiation is limited to select centers. However, knowledge of many of the physical advantages of proton therapy has spread rapidly over the past several years, and its availability is becoming more widespread.
Collapse
|
37
|
Abstract
The authors provide an update on most issues related to biology, diagnosis, and treatment of children with ependymoma based on a literature review. Ependymoma is the third most common brain tumor in children and overall survival ranges from 24% to 75% at 5 years. The extent of surgical resection remains the principal risk factor that clearly influences outcome. The influence of age, location, grade, or stage has proved to be more controversial. Current standard therapy includes surgical resection and radiotherapy. Chemotherapy has a role in infants to avoid/delay radiotherapy and can be helpful to improve resectability. About half of patients will experience relapse, and outcome is dismal. New radiation modalities, reirradiation, chemotherapy, or targeted agents have been tested with promising results. Results of multi-institutional clinical trials are awaited to determine the best first-line treatment, while results of early phase I/ II trials will explore directed therapies based on new biologic factors.
Collapse
|
38
|
Sangra M, Thorp N, May P, Pizer B, Mallucci C. Management strategies for recurrent ependymoma in the paediatric population. Childs Nerv Syst 2009; 25:1283-91. [PMID: 19484246 DOI: 10.1007/s00381-009-0914-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The management of recurrent ependymoma within the paediatric population remains a therapeutic challenge. The options available are varied and patients may have already received prior radio- or chemotherapy. As yet, no consensus exists regarding their optimal treatment. We review the literature and present our contemporary management strategies for this interesting group of patients. RESULTS AND DISCUSSION Survival following recurrence is poor and those prognostic factors that predispose to recurrence include extent of surgical resection and the timing of administration of adjuvant therapy. The extent of resection at re-operation can confer a survival advantage, without a necessary increase in morbidity. Strategies aimed at improving surgical resection at first diagnosis include improving and centralising post-surgical radiological review, defining what are true residuals, and centralising surgical review of incompletely resected tumours. Re-irradiation can improve survival, and with the use of conformal radiation fields need not necessarily lead to neuropsychological damage. Cisplatin and etoposide remain the most effective chemotherapeutic agents to date and with an increase in the understanding of tumour biology this may improve further. Because of the complex nature of this group of patients, decisions regarding their management require the involvement of a paediatric neurosurgeon, paediatric neuro-oncologist and paediatric radiation oncologist.
Collapse
Affiliation(s)
- M Sangra
- Department of Neurosurgery, Royal Liverpool Children's Hospital NHS Trust, Liverpool, L12 2AP, UK.
| | | | | | | | | |
Collapse
|
39
|
New chemotherapy strategies and biological agents in the treatment of childhood ependymoma. Childs Nerv Syst 2009; 25:1275-82. [PMID: 19212772 PMCID: PMC2738756 DOI: 10.1007/s00381-009-0809-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Indexed: 02/05/2023]
Abstract
INTRODUCTION With the limited role of current treatment regimens and potential associated side effects of radiation in young children with ependymoma, considerable effort is being focused on new chemotherapeutic strategies and biologic agents. DISCUSSION AND CONCLUSION Identification of those molecular changes underlying the development of ependymoma may, in time, lead to the development of not only novel therapeutic agents, but also specific patient-tailored therapies directed against known cell-signaling pathways.
Collapse
|
40
|
Hsu W, Pradilla G, Constantini S, Jallo GI. Surgical considerations of spinal ependymomas in the pediatric population. Childs Nerv Syst 2009; 25:1253-9. [PMID: 19360418 DOI: 10.1007/s00381-009-0882-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective of this manuscript is to discuss current management strategies regarding pediatric patients with intramedullary spinal cord ependymomas. Spinal ependymoma is the second most common spinal cord tumor in children. The clinical evaluation of these patients, operative techniques, postoperative management considerations, and long-term outcomes are discussed. INTRODUCTION The gold standard for the treatment of spinal ependymoma continues to be gross total resection. Patients with residual tumor postoperatively may benefit from adjuvant radiation therapy. Intraoperative monitoring is critical to minimize permanent postoperative neurologic deficit. CONCLUSION Patients requiring multilevel laminectomy may benefit from concomitant laminoplasty or instrumented fusion to avoid progressive spinal column deformity.
Collapse
Affiliation(s)
- Wesley Hsu
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Meyer Bldg. 8-161, 600 N. Wolfe St., Baltimore, MD 21287, USA.
| | | | | | | |
Collapse
|
41
|
Abstract
INTRODUCTION The ependymomas are relatively not a common tumor. However, most clinicians agree that the radical removal of the tumor is the most important prognostic factor. MORBIDITY OF TREATMENT Tumor removal was not sufficient before the era of magnetic resonance imaging (MRI) and resulted in a considerable operative morbidity and mortality. As the microneurosurgical techniques and microsurgical anatomy become popular and the MRI provide more detailed anatomical information preoperatively, radical removal of this complex and complicated tumor can be more feasible. In childhood ependymoma, the treatment-related morbidity and mortality can be the special issues, which can modify the policy of management safe tumor removal and minimal adjuvant treatment, which are extremely important. RADIATION THERAPY Radiation treatment has been the option for disseminated disease and residual tumor. With the advancement of detailed MR anatomical information, safer and more delicate radiation becomes possible with newer radiation modalities, three-dimensional conformal radiotherapy, intensity modulating radiotherapy, and tomotherapy. PROGNOSTIC FACTORS Although many clinicians believe that the ependymomas are inheritably chemoresistant, the new targets for the treatment are under investigation or clinically tried. Also, the genetic alterations of ependymoma are developing and might be a promising target. CONCLUSION The surgical techniques and assistant modalities for tumor removal are still advancing. So, the outcome of ependymoma is still improving. Unfortunately, newer treatment modalities, such as new chemotherapeutic agent and gene modification agent, are still not promising. The history of ependymoma management is still in progress.
Collapse
Affiliation(s)
- Kyu-Won Shim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, South Korea
| | | | | |
Collapse
|
42
|
Abstract
INTRODUCTION The application of conformal radiation therapy in the treatment of pediatric ependymoma is a success story resulting from advances in radiation therapy planning and delivery. These advances occurred at a time when clinical trial results confirmed that radiotherapy avoidance strategies were unsuccessful. DISCUSSION Investigators have been keen to confirm the promise of newer radiation therapy methods even for the youngest children. When preliminary results suggested that high-dose focal irradiation could be safely administered through systematic targeting and that cognitive function could be preserved, investigators moved to include conformal therapy in the frontline management of children regardless of age. The results with postoperative conformal radiation therapy were further enhanced when neurosurgeons increased the rate of gross-total resection and recognized that second surgery could be safely accomplished after incomplete initial resection. With more than a decade of experience, the role of conformal radiation therapy in the treatment of childhood ependymoma has been firmly established as investigators consider new trials to increase disease control and improve functional outcomes.
Collapse
Affiliation(s)
- Thomas E Merchant
- Department of Radiological Sciences, Mail Stop 220, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA.
| |
Collapse
|
43
|
Conter C, Carrie C, Bernier V, Geoffray A, Pagnier A, Gentet JC, Lellouch-Tubiana A, Chabaud S, Frappaz D. Intracranial Ependymomas in Children: Society of Pediatric Oncology Experience With Postoperative Hyperfractionated Local Radiotherapy. Int J Radiat Oncol Biol Phys 2009; 74:1536-42. [DOI: 10.1016/j.ijrobp.2008.09.051] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 09/06/2008] [Accepted: 09/28/2008] [Indexed: 10/20/2022]
|
44
|
Mueller S, Chang S. Pediatric brain tumors: current treatment strategies and future therapeutic approaches. Neurotherapeutics 2009; 6:570-86. [PMID: 19560746 PMCID: PMC5084192 DOI: 10.1016/j.nurt.2009.04.006] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 04/11/2009] [Accepted: 04/13/2009] [Indexed: 01/19/2023] Open
Abstract
Pediatric CNS tumors are the most common solid tumors of childhood and the second most common cancer after hematological malignancies accounting for approximate 20 to 25% of all primary pediatric tumors. With over 3,000 new cases per year in the United States, childhood CNS tumors are the leading cause of death related to cancer in this population. The prognosis for these patients has improved over the last few decades, but current therapies continue to carry a high risk of significant side effects, especially for the very young. Currently a combination of surgery, radiation, and chemotherapy is often used in children greater than 3 years of age. This article will outline current and future therapeutic strategies for the most common pediatric CNS tumors, including primitive neuroectodermal tumors such as medulloblastoma, as well as astrocytomas and ependymomas.
Collapse
Affiliation(s)
- Sabine Mueller
- Department of Neurology, Division of Child Neurology, University of San Francisco, San Francisco, California, USA.
| | | |
Collapse
|
45
|
Massimino M, Buttarelli FR, Antonelli M, Gandola L, Modena P, Giangaspero F. Intracranial ependymoma: factors affecting outcome. Future Oncol 2009; 5:207-16. [PMID: 19284379 DOI: 10.2217/14796694.5.2.207] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Ependymomas account for 2-9% of all neuroepithelial tumors, amounting to 6-12% of all intracranial tumors in children and up to 30% of those in children younger than 3 years. Recent findings provide evidence that intracranial and spinal ependymomas share similar molecular profiles with the radial glia of their corresponding locations. The management of intracranial ependymoma is still not optimal. The 5-year progression-free survival for children with ependymoma ranges between 30 and 50% with a worse prognosis for patients with residual disease after surgery. The prognostic relevance of most factors are still being debated. Recent studies, in which the current WHO classification criteria were applied, reported the relationship between histological grade and outcome. Biomolecular studies have identified that gain of 1q25 and EGFR overexpression correlate to poor prognosis, whereas low expression of nucleolin correlated with a favorable outcome. Ependymomas have been considered a 'surgical disease', where completeness of excision can be reached in approximately half of the cases. At present the standard treatment is radiation therapy for all patients after gross-total or near-total resection. For high-risk patients, with residual tumor, an interesting, although experimental, approach could be chemotherapy followed by secondary surgery and postoperative conformal irradiation.
Collapse
Affiliation(s)
- Maura Massimino
- Division of Pediatric Oncology, Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | | | | | | |
Collapse
|
46
|
Rodríguez D, Cheung MC, Housri N, Quinones-Hinojosa A, Camphausen K, Koniaris LG. Outcomes of malignant CNS ependymomas: an examination of 2408 cases through the Surveillance, Epidemiology, and End Results (SEER) database (1973-2005). J Surg Res 2009; 156:340-51. [PMID: 19577759 DOI: 10.1016/j.jss.2009.04.024] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 02/02/2009] [Accepted: 04/09/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Determine the role of surgery and radiation therapy for patients with malignant CNS ependymomas. METHODS The Surveillance, Epidemiology, and End Results (SEER) database (1973-2005) was queried. RESULTS Overall, a total of 2408 cases of malignant ependymomas were identified. Of these, 2132 cases (88.5%) were identified as WHO grade II ependymomas and 276 cases (11.5%) as WHO grade III (anaplastic) ependymomas. The annual incidence of ependymomas was approximately 1.97 cases per million in 2005. Overall median survival for all patients was 230 mo, with a significant difference between women and men (262 mo versus196 mo, respectively) (P=0.004). Median age at diagnosis was 37 y among females and 34 y in males. Patients who successfully underwent surgical resection had a considerably longer median survival (237 mo versus 215 mo, P<0.001) as well as a significantly improved five-year survival (72.4% versus 52.6%, P<0.001). Univariate analysis demonstrated that age, gender, ethnicity, primary tumor site, WHO grade and surgical resection were significant predictors of improved survival for ependymoma patients. Multivariate analysis identified that a WHO grade III tumor, male gender, patient age, intracranial tumor locations and failure to undergo surgical resection were independent predictors of poorer outcomes. Multivariate analysis of partially resection cases revealed that lack of radiation was a sign of poor prognosis (HR 1.748, P=0.024). CONCLUSION Surgical extirpation of ependymomas is associated with significantly improved patient survival. For partially resected tumors, radiation therapy provides significant survival benefit.
Collapse
Affiliation(s)
- Dayron Rodríguez
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136, USA
| | | | | | | | | | | |
Collapse
|
47
|
Merchant TE, Li C, Xiong X, Kun LE, Boop FA, Sanford RA. Conformal radiotherapy after surgery for paediatric ependymoma: a prospective study. Lancet Oncol 2009; 10:258-66. [PMID: 19274783 DOI: 10.1016/s1470-2045(08)70342-5] [Citation(s) in RCA: 342] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Therapy for ependymoma includes aggressive surgical intervention and radiotherapy administered by use of methods that keep the risk of side-effects to a minimum. We extended this treatment approach to include children under the age of 3 years with the aim of improving tumour control. METHODS Between July 11, 1997, and Nov 18, 2007, 153 paediatric patients (median age 2.9 years [range 0.9-22.9 months]) with localised ependymoma were treated. 85 patients had anaplastic ependymoma; the tumours of 122 were located in the infratentorial region, and 35 had received previous chemotherapy. Patients received conformal radiotherapy after definitive surgery (125 patients had undergone gross total, 17 near total, and 11 subtotal resection). Doses of 59.4 Gy (n=131) or 54.0 Gy (n=22) were prescribed to a 10 mm margin around the target volume. Disease control, patterns of failure, and complications were recorded for patients followed over 10 years. Overall survival, event-free survival (EFS), cumulative incidence of local recurrences, and cumulative incidence of distant recurrences were assessed. Variables considered included tumour grade, tumour location, ethnic origin, sex, age when undergoing conformal radiotherapy, total radiotherapy dose, number of surgical procedures, surgery extent, and preradiotherapy chemotherapy. FINDINGS After a median follow-up of 5.3 years (range 0.4-10.4), 23 patients had died and tumour progression noted in 36, including local (n=14), distant (n=15), and combined failure (n=7). 7-year local control, EFS, and overall survival were 87.3% (95% CI 77.5-97.1), 69.1% (56.9-81.3), and 81.0% (71.0-91.0), respectively. The cumulative incidences of local and distant failure were 16.3% (9.6-23.0) and 11.5% (5.9-17.1), respectively. In the 107 patients treated with immediate postoperative conformal radiotherapy (without delay or chemotherapy), 7-year local control, EFS, and overall survival were 88.7% (77.9-99.5), 76.9% (63.4-90.4), and 85.0% (74.2-95.8), respectively; the cumulative incidence of local and distant failure were 12.6% (5.1-20.1), and 8.6% (2.8-14.3), respectively. The incidence of secondary malignant brain tumour at 7 years was 2.3% (0-5.6) and brainstem necrosis 1.6% (0-4.0). Overall survival was affected by tumour grade (anaplastic vs differentiated: HR 3.98 [95% CI 1.51-10.48]; p=0.0052), extent of resection (gross total vs near total or subtotal: 0.16 [0.07-0.37]; p<0.0001), and ethnic origin (non-white vs white: 3.0 [1.21-7.44]; p=0.018). EFS was affected by tumour grade (anaplastic vs differentiated: 2.52 [1.2705.01]; p=0.008), extent of resection (gross total vs near total or subtotal: 0.20 [0.11-0.39]; p<0.0001]), and sex (male vs female: 2.19 [1.03-4.66]; p=0.042). Local failure was affected by extent of resection (gross total vs near total or subtotal: 0.16 [0.067-0.38]; p<0.0001), sex (male vs female: 3.85 [1.10-13.52]; p=0.035), and age (<3 years vs >/=3 years: 3.25 [1.30-8.16]; p=0.012). Distant recurrence was only affected by tumour grade (anaplastic vs differentiated: 4.1 [1.2-14.0]; p=0.017). INTERPRETATION Treatment of ependymoma should include surgery with the aim of gross-total resection and conformal, high-dose, postoperative irradiation. Future trials might consider treatment stratification based on sex and age.
Collapse
Affiliation(s)
- Thomas E Merchant
- Department of Radiological Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | | | | |
Collapse
|
48
|
Takita C, Hatoum GF. CNS Tumors in Children. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
49
|
Buccoliero AM, Castiglione F, Rossi Degl'Innocenti D, Paglierani M, Maio V, Gheri CF, Garbini F, Moncini D, Taddei A, Sardi I, Sanzo M, Giordano F, Mussa F, Genitori L, Taddei GL. O6-Methylguanine-DNA-methyltransferase in recurring anaplastic ependymomas: PCR and immunohistochemistry. J Chemother 2008; 20:263-8. [PMID: 18467255 DOI: 10.1179/joc.2008.20.2.263] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Ependymomas are the third most common brain tumor in children. The post surgical management is controversial. There are no convincing data on an effective role for chemotherapy. O(6)-Methylguanine-DNA-Methyltransferase (MGMT) is a DNA repair protein considered to be a chemosensitivity predictor. Hypermethylation of the MGMT gene promoter is an important cause of MGMT inactivation. We evaluated the MGMT gene promoter methylation and the immunohistochemical MGMT protein expression in 12 recurrent anaplastic ependymomas affecting children. Our purpose was to investigate the molecular rationale of the administration of alkylating agents to children affected by recurrent anaplastic ependymomas. All ependymomas lacked MGMT promoter hypermethylation and 9 (75%) showed high MGMT protein expression (>50% tumoral cells). Differences between different recurrences in the same patient were not observed. These results may indicate MGMT as a factor of chemoresistance to alkylating drugs in anaplastic ependymomas and support the uncertainties regarding the actual benefit of chemotherapy for patients with anaplastic ependymomas.
Collapse
Affiliation(s)
- A M Buccoliero
- Department of Human Pathology and Oncology, University of Florence, Florence, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Abstract
Intracranial ependymomas are the third most common primary brain tumor in the pediatric population. Although an anaplastic variant is recognized, numerous studies examining the prognostic implications of histological features, such as necrosis, endothelial proliferation and mitoses, have yielded contradictory results. In order to improve outcome prediction in affected patients and to refine therapeutic decision-making, there is a strong need for identifying relevant biological correlates of tumor behavior. The molecular biology of tumors is a rapidly expanding field and includes investigations into cytogenetics, oncogenes, growth factors, growth factor receptors, hormonal receptors, proliferation markers, apoptosis, cell cycle genes and cell adhesion molecules, as well as factors potentially related to therapeutic resistance, such as the multidrug resistance gene. The molecular biology of astrocytic tumors in adults has been the subject of many studies; however, relatively few studies have been focused on ependymomas. Herein we review potential oncological markers in ependymomas that have been identified to date and highlight the limitations of our current knowledge as a basis for defining areas for future investigation.
Collapse
Affiliation(s)
- R L Hamilton
- Department of Pathology, University of Pittsburgh, PA, USA.
| | | |
Collapse
|