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Nandoliya KR, Sadagopan NS, Thirunavu V, Houskamp EJ, Karras CL, Chaliparambil RK, Sriram N, Jamshidi P, Raleigh DR, Lukas RV, Magill ST. Post-Surgical Prognosis of Patients with Pineoblastoma: A Systematic Review and Individual Patient Data Analysis with Trends over Time. Cancers (Basel) 2023; 15:3374. [PMID: 37444483 DOI: 10.3390/cancers15133374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Most of the literature on pineoblastoma consists of case reports and single-institution series. The goal of this systematic review and individual patient data (IPD) analysis was to summarize the existing literature, identify factors associated with overall survival (OS), and provide a contemporary update on prognosis for patients with pineoblastoma. Forty-four studies were identified with 298 patients having IPD. Kaplan-Meier analyses were used to report survival outcomes based on age, tumor metastases, extent of resection (EOR), adjuvant therapy, and publication year. Cox regression was performed to identify independent predictors of time to mortality. Multivariable recursive partitioning analysis was used to identify the most important subgroups associated with mortality. Patients were classified based on publication year before and after the last systematic review on this topic (pre-2012 and 2012 onwards) and compared using univariate and multivariable analyses. This study demonstrates that EOR less-than-gross total resection, metastatic presentation, adjuvant chemotherapy without radiation, and tumor presentation in children less than three years old are associated with poorer prognosis. Since 2012, the 5-year actuarial OS has improved from 32.8% to 56.1%, which remained significant even after accounting for EOR, age, and adjuvant therapy. Pineoblastoma remains a severe rare disease, but survival outcomes are improving.
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Affiliation(s)
- Khizar R Nandoliya
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Nishanth S Sadagopan
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Vineeth Thirunavu
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Ethan J Houskamp
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Constantine L Karras
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Rahul K Chaliparambil
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Nikhil Sriram
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Pouya Jamshidi
- Department of Pathology, Northwestern University, Chicago, IL 60611, USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Rimas V Lukas
- Department of Neurology, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Stephen T Magill
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
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Tomita T. Pediatric Pineal Region Tumors: Special Reference to Posterior Interhemispheric Trans-Tentorial Approach. Adv Tech Stand Neurosurg 2023; 48:291-325. [PMID: 37770689 DOI: 10.1007/978-3-031-36785-4_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Pediatric pineal region tumors consist of tumors of pineal gland origin and parapineal origin. The former are comprised of germ cell tumor (GCT) and pineal parenchymal tumor. The latter originate from the surrounding neural structures, such as the midbrain and thalamus; thus, they are often benign gliomas during childhood. Pineal region tumors often cause obstructive hydrocephalus, which is the main cause of presenting symptoms. Advanced imaging discloses precise location and extension of the tumor and associated anomalies such as hydrocephalous, dissemination, hemorrhage, etc. Hydrocephalus has been managed with CSF diversion, mostly using an endoscopic third ventriculostomy. Because of different treatment paradigms for each tumor type, histological confirmation is needed either through biopsy, tumor markers for GCTs, and/or surgical resection sampling. Radical resection of these tumors remains a challenge due to their deep-seated location and involvement of delicate neural and vascular structures. Comparison of common craniotomy approaches, occipital transtentorial (OT) and infratentorial supracerebellar (ITSC), is reviewed for their advantages and disadvantages. Surgical area exposure and blind spots are important factors for successful tumor removal. The surgical techniques and nuances that the author employs for tumor resection via a posterior interhemispheric transtentorial approach are presented.
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Affiliation(s)
- Tadanori Tomita
- Division of Pediatric Neurosurgery, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA.
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Hansford JR, Huang J, Endersby R, Dodgshun AJ, Li BK, Hwang E, Leary S, Gajjar A, Von Hoff K, Wells O, Wray A, Kotecha RS, Raleigh DR, Stoller S, Mueller S, Schild SE, Bandopadhayay P, Fouladi M, Bouffet E, Huang A, Onar-Thomas A, Gottardo NG. Pediatric Pineoblastoma: A pooled outcome study of North American and Australian therapeutic data. Neurooncol Adv 2022; 4:vdac056. [PMID: 35664557 PMCID: PMC9154333 DOI: 10.1093/noajnl/vdac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Pineoblastoma is a rare brain tumor usually diagnosed in children. Given its rarity, no pineoblastoma specific trials have been conducted. Studies have included pineoblastoma accruing for other embryonal tumors over the past 30 years. These included only occasional children with pineoblastoma, making clinical features difficult to interpret and determinants of outcome difficult to ascertain.
Patients and Methods
Centrally or independently reviewed series with treatment and survival data from North American and Australian cases were pooled. To investigate associations between variables, Fisher’s exact tests, Wilcoxon-Mann-Whitney tests, and Spearman correlations were used. Kaplan-Meier plots, log-rank tests, and Cox proportional hazards models were used in survival analyses.
Results
We describe a pooled cohort of 178 pineoblastoma cases from Children’s Oncology Group (n=82) and institutional series (n=96) over 30 years. Children <3 years of age have significantly worse survival compared to older children, with 5-year progression free survival and overall survival estimates of 13.5±5.1% and 16.2±5.3% respectively compared with 60.8±5.6% and 67.3±5.0% for ≥3 years old (both p<0.0001). Multivariable analysis showed male sex was associated with worse PFS in children <3 years of age (Hazard Ratio 3.93, 95% CI 1.80-8.55; p=0.0006), suggestive of sex specific risks needing future validation. For children ≥3 years of age, disseminated disease at diagnosis was significantly associated with an inferior 5-year PFS of 39.2±9.7% (HR 2.88, 95% CI 1.52-5.45; p=0.0012) and 5-year OS of 49.8±9.1% (HR 2.87, 95% CI 1.49-5.53; p=0.0016).
Conclusion
Given the rarity of this tumor, prospective, collaborative international studies will be vital to improving the long-term survival of these patients.
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Affiliation(s)
- Jordan R Hansford
- Children’s Cancer Center, Royal Children’s Hospital; University of Melbourne, Department of Pediatrics; Murdoch Children’s Research Institute, Cell Biology and Cancer Division, Melbourne, VIC, Australia
- Michael Rice Cancer Center; South Australia Health and Medical Research Institute; South Australia Immunogenomics Cancer Institute, Faculty of Health and Medical Sciences University of Adelaide, Adelaide, SA, Australia
| | - Jie Huang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Raelene Endersby
- Brain Tumor Research Program, Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Andrew J Dodgshun
- Christchurch Hospital, Children’s Hematology/Oncology Center, Christchurch, New Zealand
| | - Bryan K Li
- Division of Hematology/Oncology, Cell Biology Research Program, Arthur and Sonia Labatt Brain Tumor Research Institute, Hospital for Sick Children, Department of Pediatrics, Medical Biophysics, Lab Medicine and Pathobiology University of Toronto, ON, Canada
| | - Eugene Hwang
- Children’s National, Division of Oncology, Washington, USA
| | - Sarah Leary
- Seattle Children’s Hospital, University of Washington and Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Amar Gajjar
- St Jude Children’s Research Hospital, Memphis, USA
| | - Katja Von Hoff
- Department of Pediatric Hematology and Oncology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Olivia Wells
- Children’s Cancer Center, Royal Children’s Hospital; University of Melbourne, Department of Pediatrics; Murdoch Children’s Research Institute, Cell Biology and Cancer Division, Melbourne, VIC, Australia
| | - Alison Wray
- Children’s Cancer Center, Royal Children’s Hospital; University of Melbourne, Department of Pediatrics; Murdoch Children’s Research Institute, Cell Biology and Cancer Division, Melbourne, VIC, Australia
- Royal Children’s Hospital, Department of Neurosurgery, Melbourne, Australia
| | - Rishi S Kotecha
- Department of Clinical Hematology, Oncology, Blood and Marrow Transplantation, Perth Children’s Hospital, Perth, WA, Australia
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, WA, Australia
| | - David R Raleigh
- Department of Radiation Oncology and Neurological Surgery, University of California San Francisco, San Francisco, CA
| | - Schuyler Stoller
- Department of Pediatric Oncology, University of California San Francisco, San Francisco, CA
| | - Sabine Mueller
- Department of Pediatric Oncology, University of California San Francisco, San Francisco, CA
| | | | | | - Maryam Fouladi
- Nationwide Children’s Hospital, Department of Neuro-Oncology, Columbus, OH Division of Hematology/Oncology
| | - Eric Bouffet
- Hospital for Sick Children, Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Annie Huang
- Division of Hematology/Oncology, Cell Biology Research Program, Arthur and Sonia Labatt Brain Tumor Research Institute, Hospital for Sick Children, Department of Pediatrics, Medical Biophysics, Lab Medicine and Pathobiology University of Toronto, ON, Canada
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Nicholas G Gottardo
- Brain Tumor Research Program, Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Department of Clinical Hematology, Oncology, Blood and Marrow Transplantation, Perth Children’s Hospital, Perth, WA, Australia
- Paediatrics, School of Medicine, University of Western Australia, Perth, Australia
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Jin MC, Prolo LM, Wu A, Azad TD, Shi S, Rodrigues AJ, Soltys SG, Pollom EL, Li G, Hiniker SM, Grant GA. Patterns of Care and Age-Specific Impact of Extent of Resection and Adjuvant Radiotherapy in Pediatric Pineoblastoma. Neurosurgery 2020; 86:E426-E435. [PMID: 32110805 DOI: 10.1093/neuros/nyaa023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 12/15/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pediatric pineoblastomas are highly aggressive tumors that portend poor outcomes despite multimodal management. Controversy remains regarding optimal disease management. OBJECTIVE To evaluate patterns of care and optimal clinical management of pediatric pineoblastoma. METHODS A total of 211 pediatric (age 0-17 yr) histologically confirmed pineoblastoma patients diagnosed between 2004 and 2015 were queried from the National Cancer Database. Wilcoxon rank-sum statistics and chi-squared analyses were used to compare continuous and categorical variables, respectively. Univariable and multivariable Cox regressions were used to evaluate prognostic impact of covariates. Propensity-score matching was used to balance baseline characteristics. RESULTS Older patients (age ≥ 4 yr) experienced improved overall survival compared to younger patients (age < 4 yr) (hazard ratio [HR] = 0.41; 95% CI 0.25-0.66). Older patients (adjusted odds ratio [aOR] = 5.21; 95% CI 2.61-10.78) and those residing in high-income regions (aOR = 3.16; 95% CI 1.21-8.61) received radiotherapy more frequently. Radiotherapy was independently associated with improved survival in older (adjusted HR [aHR] = 0.31; 95% CI 0.12-0.87) but not younger (aHR = 0.64; 95% CI 0.20-1.90) patients. The benefits of radiotherapy were more pronounced in patients receiving surgery than in those not receiving surgery (aHR [surgical patients] = 0.23; 95% CI 0.08-0.65; aHR [nonsurgical patients] = 0.46; 95% CI 0.22-0.97). Older patients experienced improved outcomes associated with aggressive resection (P = .041); extent of resection was not associated with survival in younger patients (P = .880). CONCLUSION Aggressive tumor resection was associated with improved survival only in older pediatric patients. Radiotherapy was more effective in patients receiving surgery. Age-stratified approaches might allow for improved disease management of pediatric pineoblastoma.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Laura M Prolo
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Adela Wu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Siyu Shi
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Adrian J Rodrigues
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.,Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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5
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AbdelBaki MS, Abu-Arja MH, Davidson TB, Fangusaro JR, Stanek JR, Dunkel IJ, Dhall G, Gardner SL, Finlay JL. Pineoblastoma in children less than six years of age: The Head Start I, II, and III experience. Pediatr Blood Cancer 2020; 67:e28252. [PMID: 32187454 PMCID: PMC8428681 DOI: 10.1002/pbc.28252] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 01/03/2020] [Accepted: 02/15/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND We report the outcomes of patients with pineoblastoma and trilateral retinoblastoma syndrome enrolled on the Head Start (HS) I-III trials. METHODS Twenty-three children were enrolled prospectively between 1991 and 2009. Treatment included maximal surgical resection followed by five cycles of intensive chemotherapy and consolidation with marrow-ablative chemotherapy and autologous hematopoietic cell rescue (HDCx/AuHCR). Irradiation following consolidation was reserved for children over six years of age or those with residual tumor at the end of induction. RESULTS Median age was 3.12 years (range, 0.44-5.72). Three patients withdrew from the study treatment and two patients experienced chemotherapy-related death. Eight patients experienced progressive disease (PD) during induction chemotherapy and did not proceed to HDCx/AuHCR. Ten patients received HDCx/AuHCR; eight experienced PD post-consolidation. Seven patients received craniospinal irradiation (CSI) with a median dose of 20.7 Gy (range, 18-36 Gy) with boost(s) (median dose 27 Gy; range, 18-36 Gy); three received CSI as adjuvant therapy (two post-HDCx/AuHCR) and four upon progression/recurrence. The five-year progression-free survival (PFS) and overall survival (OS) were 9.7% (95% confidence intervals [CI]: 2.6%-36.0%) and 13% (95% CI: 4.5%-37.5%), respectively. Only three patients survived beyond five years. Favorable OS prognostic factors were CSI (hazard ratio [HR] = 0.30 [0.11-0.86], P = 0.025) and HDCx/AuHCR (HR = 0.40 [0.16-0.99], P = 0.047). CONCLUSIONS Within the HS I-III trials, CSI and HDCx/AuHCR were statistically associated with improved survival. The high PD rate during later induction cycles and following consolidation chemotherapy warrants consideration of fewer induction cycles prior to consolidation and the potential intensification of consolidation with multiple cycles of marrow-ablative chemotherapy and irradiation.
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Affiliation(s)
- Mohamed S. AbdelBaki
- The Division of Hematology, Oncology and Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Mohammad H. Abu-Arja
- The Department of Pediatrics, New York-Presbyterian Brooklyn Methodist Hospital, Weill-Cornell College of Medicine, Brooklyn, NY, USA
| | - Tom B. Davidson
- The Division of Hematology, Oncology and Blood & Marrow Transplantation, Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Jason R. Fangusaro
- The Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph R. Stanek
- The Division of Hematology, Oncology and Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Ira J. Dunkel
- The Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Girish Dhall
- The Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation at the University of Alabama at Birmingham, AL, USA
| | - Sharon L. Gardner
- The Stephen D. Hassenfeld Children’s Center for Cancer & Blood Disorders, New York University, New York City, NY, USA
| | - Jonathan L. Finlay
- The Division of Hematology, Oncology and Blood and Marrow Transplant, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio, USA
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6
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7
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Timmermann B, Kortmann RD. Embryonal Tumors. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_5-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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8
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Mynarek M, Pizer B, Dufour C, van Vuurden D, Garami M, Massimino M, Fangusaro J, Davidson T, Gil-da-Costa MJ, Sterba J, Benesch M, Gerber N, Juhnke BO, Kwiecien R, Pietsch T, Kool M, Clifford S, Ellison DW, Giangaspero F, Wesseling P, Gilles F, Gottardo N, Finlay JL, Rutkowski S, von Hoff K. Evaluation of age-dependent treatment strategies for children and young adults with pineoblastoma: analysis of pooled European Society for Paediatric Oncology (SIOP-E) and US Head Start data. Neuro Oncol 2017; 19:576-585. [PMID: 28011926 DOI: 10.1093/neuonc/now234] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Pineoblastoma is a rare pineal region brain tumor. Treatment strategies have reflected those for other malignant embryonal brain tumors. Patients and Methods Original prospective treatment and outcome data from international trial groups were pooled. Cox regression models were developed considering treatment elements as time-dependent covariates. Results Data on 135 patients with pineoblastoma aged 0.01-20.7 (median 4.9) years were analyzed. Median observation time was 7.3 years. Favorable prognostic factors were age ≥4 years (hazard ratio [HR] for progression-free survival [PFS] 0.270, P < .001) and administration of radiotherapy (HR for PFS 0.282, P < .001). Metastatic disease (HR for PFS 2.015, P = .006), but not postoperative residual tumor, was associated with unfavorable prognosis. In 57 patients <4 years old, 5-year PFS/overall survival (OS) were 11 ± 4%/12 ± 4%. Two patients survived after chemotherapy only, while 3 of 16 treated with craniospinal irradiation (CSI) with boost, and 3 of 5 treated with high-dose chemotherapy (HDCT) and local radiotherapy survived. In 78 patients aged ≥4 years, PFS/OS were 72 ± 7%/73 ± 7% for patients without metastases, and 50 ± 10%/55 ± 10% with metastases. Seventy-three patients received radiotherapy (48 conventionally fractionated CSI, median dose 35.0 [18.0-45.0] Gy, 19 hyperfractionated CSI, 6 local radiotherapy), with (n = 68) or without (n = 6) chemotherapy. The treatment sequence had no impact; application of HDCT had weak impact on survival in older patients. Conclusion Survival is poor in young children treated without radiotherapy. In these patients, combination of HDCT and local radiotherapy may warrant further evaluation in the absence of more specific or targeted treatments. CSI combined with chemotherapy is effective for older non-metastatic patients.
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Affiliation(s)
- Martin Mynarek
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Barry Pizer
- Oncology Unit, Alder Hey Children's Hospital, Liverpool, UK
| | - Christelle Dufour
- Brain Tumor Programme, Department of Pediatric and Adolescent Oncology, Institut Gustave Roussy, Villejuif, France
| | - Dannis van Vuurden
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, Netherlands
| | - Miklos Garami
- Second Department of Pediatrics, School of Medicine, Semmelweis University, Budapest, Hungary
| | - Maura Massimino
- Department of Pediatrics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Jason Fangusaro
- Department of Hematology, Oncology and Stem Cell Transplant, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tom Davidson
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | | | - Jaroslav Sterba
- Pediatric Oncology Department, University Hospital Brno, Brno, Czech Republic
| | - Martin Benesch
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical University of Graz, Graz, Austria
| | - Nicolas Gerber
- Department of Oncology, University Children's Hospital Zurich, Zurich, Switzerland
| | - B Ole Juhnke
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Robert Kwiecien
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Torsten Pietsch
- Department of Neuropathology, University of Bonn, Bonn, Germany
| | - Marcel Kool
- Division of Pediatric Neurooncology, German Cancer Research Center, Heidelberg, Germany
| | - Steve Clifford
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - David W Ellison
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Felice Giangaspero
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Pieter Wesseling
- Department of Pathology, VU University Medical Center, Amsterdam, Netherlands.,Department of Pathology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Floyd Gilles
- Department of Pathology (Neuropathology), Children's Hospital Los Angeles and the University of Southern California, Los Angeles, California, USA
| | | | - Jonathan L Finlay
- Department of Pediatrics, Division of Hematology, Oncology and BMT, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katja von Hoff
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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9
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Yi JW, Kim HJ, Choi YJ, Seol YM, Kahng DH, Choi YY, Park EK. Successful treatment by chemotherapy of pineal parenchymal tumor with intermediate differentiation: a case report. Cancer Res Treat 2013; 45:244-9. [PMID: 24155685 PMCID: PMC3804738 DOI: 10.4143/crt.2013.45.3.244] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 10/08/2012] [Indexed: 11/21/2022] Open
Abstract
A 37-year-old male presented with a mass measuring 2.5 cm in size in the midbrain and obstructive hydrocephalus, which had manifested as a headache and dizziness. Magnetic resonance (MR) imaging of the brain showed intermediate enhancement on T1-weighted MR imaging and a high intensity of enhancement on T2-weighted MR. Neurosurgeons performed an occipital craniotomy with partial removal of the tumor and the postoperative diagnosis was a pineal parenchymal tumor with intermediate differentiation. He had undergone irradiation with 54 Gy of radiation on 27 fractions for removal of the remaining tumor approximately one month after surgery. However, in follow-up imaging performed four months after radiotherapy, a remnant mass in the superoposterior aspect of the midbrain was found to have extended to the hypothalamus and the third ventricle. He was treated with six cycles of procarbazine, lomustine, vincristine chemotherapy. At five months since the completion of chemotherapy, the brain MR imaging showed no evidence of any remaining tumor and he no longer displayed any of his initial symptoms.
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Affiliation(s)
- Ji-Won Yi
- Department of Internal Medicine, Pusan National University Hospital, Pusan University College of Medicine, Busan, Korea
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10
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Sonabend AM, Bruce JN. Management paradigms along a histologic spectrum of pineal cell tumors. World Neurosurg 2013; 81:685-7. [PMID: 23928426 DOI: 10.1016/j.wneu.2013.07.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 07/27/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Adam M Sonabend
- Department of Neurological Surgery, Neurological Institute of New York, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Neurological Institute of New York, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, USA.
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11
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Friedrich C, von Bueren AO, von Hoff K, Gerber NU, Ottensmeier H, Deinlein F, Benesch M, Kwiecien R, Pietsch T, Warmuth-Metz M, Faldum A, Kuehl J, Kortmann RD, Rutkowski S. Treatment of young children with CNS-primitive neuroectodermal tumors/pineoblastomas in the prospective multicenter trial HIT 2000 using different chemotherapy regimens and radiotherapy. Neuro Oncol 2012; 15:224-34. [PMID: 23223339 DOI: 10.1093/neuonc/nos292] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Especially in young children, primitive neuroectodermal tumors of the central nervous system (CNS-PNET) and pineoblastomas are associated with an unfavorable outcome, and only a few prospective trials have been conducted thus far. METHODS From January 2001 through January 2005, 17 eligible children aged <4 years with CNS-PNET not otherwise specified (n = 8), ependymoblastoma (n = 1), or pineoblastoma (n = 8) confirmed by central review were prospectively treated in the trial HIT 2000. In nonmetastatic disease (n = 11), up to 5 postoperative cycles of HIT-SKK systemic multiagent chemotherapy (8 months duration), followed by craniospinal radiotherapy (CSI), were given. In metastatic disease (M1-M3, n = 6), treatment consisted of a shorter induction chemotherapy (2-3 months) with carboplatin and etoposide, followed by tandem high-dose chemotherapy (HDCT) in case of good response to induction. During induction and HDCT, patients received intraventricular methotrexate. CSI was applied to all patients with poor response to induction or residual disease after HDCT and was optional for patients with residual disease before HDCT. RESULTS Five-year event-free survival and overall survival rates ± standard error for all eligible patients were 24% ± 10% and 40% ± 12%, respectively (median follow-up of survivors: 8.3 years). Only one patient with nonmetastatic disease remained free of relapse/progressive disease during induction. Three of 6 patients with metastatic disease responded to induction and received tandem-HDCT, followed by preventive CSI, and remain in continuous complete remission. CONCLUSIONS Short intensive induction chemotherapy followed by tandem-HDCT in young children with CNS-PNET/pineoblastomas seems to be superior to the prolonged and less intensive induction regimen.
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Affiliation(s)
- Carsten Friedrich
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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12
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Campen CJ, Dearlove J, Partap S, Murphy P, Gibbs IC, Dahl GV, Fisher PG. Concurrent cyclophosphamide and craniospinal radiotherapy for pediatric high-risk embryonal brain tumors. J Neurooncol 2012; 110:287-91. [PMID: 22941430 DOI: 10.1007/s11060-012-0969-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 08/22/2012] [Indexed: 11/24/2022]
Abstract
Embryonal tumors are an aggressive subtype of high-grade, pediatric central nervous system (CNS) tumors often with dismal survival rates. The 5-year survival for highest-risk embryonal tumors may be as low as 10 %. We report feasibility and efficacy from our experience using intravenous (IV) cyclophosphamide concurrently with craniospinal radiation (CSI) in high-risk embryonal CNS tumors of childhood. Ten consecutive children (aged: 3.5-15.5 years, median: 10.2 years, six male) with high-risk embryonal tumors, including: large cell/anaplastic medulloblastoma (6), atypical teratoid rhabdoid tumor (1), and leptomeningeal primitive neuroectodermal tumor (3), were treated with IV cyclophosphamide 1 g/M(2) on days 1 and 2 of CSI. Following a median of 36 Gy CSI plus tumor boosts, adjuvant treatment consisted of 21 doses of oral etoposide (7) and alkylator based chemotherapy from five to eight cycles in all. Of the ten patients thus treated, six remain alive with no evidence of disease and four are deceased. Median survival was 3.3 years, with a 3-year progression-free survival of 50 % (5/10). Median follow-up was: 3.3 years (range: 5 months-12.9 years) in the five patients with progression, median time-to-progression was: 1.3 years (range: 1 month-3 years). Median follow-up in the patients without progression is 8.8 years (range: 3-12.9 years). Complications due to adjuvant chemotherapy were typical and included myelosupression (10), necessitating shortened duration of chemotherapy in three, and hemorrhagic cystitis (1). In high-risk embryonal CNS tumors, cyclophosphamide given concurrently with CSI is well tolerated. Early results suggest that a phase II trial is warranted.
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Affiliation(s)
- Cynthia J Campen
- Division of Child Neurology, Department of Neurology, Stanford University, Palo Alto, CA 94304, USA.
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13
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Primary pineal tumors: outcome and prognostic factors--a study from the Rare Cancer Network (RCN). Clin Transl Oncol 2012; 14:827-34. [PMID: 22914906 DOI: 10.1007/s12094-012-0869-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 02/06/2012] [Indexed: 01/17/2023]
Abstract
PURPOSE To better define outcome and prognostic factors in primary pineal tumors. MATERIALS AND METHODS Thirty-five consecutive patients from seven academic centers of the Rare Cancer Network diagnosed between 1988 and 2006 were included. Median age was 36 years. Surgical resection consisted of biopsy in 12 cases and resection in 21 (2 cases with unknown resection). All patients underwent radiotherapy and 12 patients received also chemotherapy. RESULTS Histological subtypes were pineoblastoma (PNB) in 21 patients, pineocytoma (PC) in 8 patients and pineocytoma with intermediate differentiation in 6 patients. Six patients with PNB had evidence of spinal seeding. Fifteen patients relapsed (14 PNB and 1 PC) with PNB cases at higher risk (p = 0.031). Median survival time was not reached. Median disease-free survival was 82 months (CI 50 % 28-275). In univariate analysis, age younger than 36 years was an unfavorable prognostic factor (p = 0.003). Patients with metastases at diagnosis had poorer survival (p = 0.048). Late side effects related to radiotherapy were dementia, leukoencephalopathy or memory loss in seven cases, occipital ischemia in one, and grade 3 seizures in two cases. Side effects related to chemotherapy were grade 3-4 leucopenia in five cases, grade 4 thrombocytopenia in three cases, grade 2 anemia in two cases, grade 4 pancytopenia in one case, grade 4 vomiting in one case and renal failure in one case. CONCLUSIONS Age and dissemination at diagnosis influenced survival in our series. The prevalence of chronic toxicity suggests that new adjuvant strategies are advisable.
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Tate M, Sughrue ME, Rutkowski MJ, Kane AJ, Aranda D, McClinton L, McClinton L, Barani IJ, Parsa AT. The long-term postsurgical prognosis of patients with pineoblastoma. Cancer 2011; 118:173-9. [PMID: 21717450 DOI: 10.1002/cncr.26300] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 04/04/2011] [Accepted: 04/05/2011] [Indexed: 01/21/2023]
Abstract
BACKGROUND For this report, the authors comprehensively summarized the existing literature on patients with pineoblastoma and identified the variables and treatments that had an impact patient on outcomes. METHODS A comprehensive search identified 109 studies that collectively described the outcomes of patients with pineoblastoma. Individual patient data were classified based on treatment and were subjected to univariate comparisons. Cox regression analysis included comparisons of survival outcomes controlling for age, extent of resection, and treatment group, and between-group survival comparisons were performed using the Kendall tau (rank correlation) statistic. RESULTS Two hundred ninety-nine patients met inclusion criteria. The overall survival rate was 54% (175 of 299 patients) at a mean follow-up of 31 ± 1.9 months (range, 1-159 months). The analyses demonstrated a markedly worse prognosis for children aged ≤ 5 years compared with older patients (5-year survival rate: 15% for children aged ≤ 5 years vs 57% for children aged ≥ 5 years; log-rank P < .00001). In addition, a graded increase in survival was observed with increasing degrees of resection (5-year survival rate: 84% for patients who underwent gross total resection vs 53% for patients who underwent subtotal resection vs 29% for patients who underwent debulking; log-rank P < .0001). Multivariate analysis indicated that not achieving gross total resection markedly worsened patient survival (subtotal resection: hazard ratio, 6.47; 95% confidence interval, 2.3-19; P = .001. debulking: hazard ratio, 9.27; 95% confidence interval, 3.2-27; P < .0001). CONCLUSIONS The current findings emphasize the importance of aggressive surgical resection in the treatment of pineoblastoma. In addition, the authors conclude that clinical trials should not mix young patients with older patients or patients who undergo subtotal resection with patients who undergo gross total resection, because such heterogeneity may alter the variability of responses to treatment and reduce the likelihood of success.
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Affiliation(s)
- Matthew Tate
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143-0350, USA
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16
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Duffner PK. Risk factors for cognitive decline in children treated for brain tumors. Eur J Paediatr Neurol 2010; 14:106-15. [PMID: 19931477 DOI: 10.1016/j.ejpn.2009.10.005] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Accepted: 10/25/2009] [Indexed: 10/20/2022]
Abstract
The long term effects of central nervous system therapy for children with brain tumors have been the subject of research since the 1970s. Many studies have demonstrated that children treated for brain tumors with surgery and standard radiation therapy have developed intellectual decline which is progressive over at least a decade. Risk factors for this cognitive deterioration have been identified and include perioperative complications, possibly hydrocephalus, high radiation dose, large volume radiation, chemotherapy (especially methotrexate), radiation vasculopathy and young age at the time of treatment. In an effort to reduce long-term neurotoxicity, efforts have been made to develop treatment regimens that reduce the impact of these risk factors. Some of these include reduced neuraxis radiation with and without adjuvant chemotherapy, conformal radiation, chemotherapy only protocols for children with optic pathway-hypothalamic tumors and a series of baby brain tumor studies in which chemotherapy (standard and high dose) has allowed radiation to be delayed, reduced or omitted. Whether these changes in therapy will ultimately improve the quality of life of the long-term survivors is uncertain. Close follow-up of these children will be required throughout their lives.
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Affiliation(s)
- Patricia K Duffner
- University at Buffalo School of Medicine, Hunter James Kelly Research Institute, Center of Excellence in Bioinformatics, 701 Ellicott Street, Buffalo, NY 14203, USA.
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Maarouf M, El Majdoub F, Bührle C, Voges J, Lehrke R, Kocher M, Hunsche S, Treuer H, Sturm V. Pineal parenchymal tumors. Management with interstitial iodine-125 radiosurgery. Strahlenther Onkol 2010; 186:127-34. [PMID: 20339824 DOI: 10.1007/s00066-010-2096-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Accepted: 11/26/2009] [Indexed: 01/31/2023]
Abstract
PURPOSE To evaluate the efficacy of interstitial radiosurgery (IRS) for pineal parenchymal tumors (PPTs). PATIENTS AND METHODS 18 consecutively admitted patients (twelve male and six female, age range 6-68 years, median age 34 years) with PPTs (eight pineocytomas, ten malignant PPTs) were treated at the authors' institution with IRS using stereotactically guided iodine-125 seed implantation ((125)I-IRS) as either primary or salvage therapy. The cumulative tumor surface dose ranged from 40 to 64 Gy. Adjuvant radiotherapy of the whole brain or the craniospine was done in patients with grade III and grade IV PPT. The median follow-up period was 57.4 months (range 6-134 months). RESULTS Overall actuarial 5- and 8-year survival rates after IRS were 100% and 86% for pineocytomas, and the overall actuarial 5-year survival rate was 78% for high-grade PPTs. Follow-up magnetic resonance imaging showed complete remission in 72% (13/18) and partial remission in 28% (5/18) of the cases. One patient developed an out-of-field relapse 4 years after partial remission of a pineocytoma, which had already been treated with IRS. There was no treatment-related mortality. Treatment-related morbidity occurred in two patients only. CONCLUSION This study indicates that stereotactic (125)I-IRS for the management of PPTs is quite efficient and safe. Due to the low rate of side effects, IRS may develop into an attractive alternative to microsurgery in de novo diagnosed pineocytomas. In malignant PPTs, IRS may be routinely applied in a multimodality treatment schedule supplementary to conventional irradiation.
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Affiliation(s)
- Mohammad Maarouf
- Department of Stereotactic and Functional Neurosurgery, University of Cologne, Kerpener Strasse 62, Köln, Germany.
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Gilheeney SW, Saad A, Chi S, Turner C, Ullrich NJ, Goumnerova L, Scott RM, Marcus K, Lehman L, De Girolami U, Kieran MW. Outcome of pediatric pineoblastoma after surgery, radiation and chemotherapy. J Neurooncol 2008; 89:89-95. [PMID: 18415046 DOI: 10.1007/s11060-008-9589-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 03/28/2008] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Pineoblastomas are a category of supratentorial primitive neuroectodermal tumors (sPNETs) occurring in the pineal gland; some studies support the impression that patients with pineoblastomas have a worse prognosis than those with other sPNETs. METHODS We reviewed the medical records and tissue sections of all patients with the diagnosis of pineoblastoma that were treated at the Dana-Farber Cancer Institute/Children's Hospital Boston Pediatric Brain Tumor Program between 1986 and 2005. RESULTS Thirteen patients with the pathologic diagnosis of pineoblastoma were treated at our Hospital; 11 of these cases had complete records suitable for study. The median age was 8 years 8 months (5 F, 6 M). Surgical, radiation and chemotherapeutic regimens varied from case to case. Three patients had gross total resection and are alive and free of disease, versus four of eight with subtotal resection or biopsy only. Patients who received CSI and multi-agent chemotherapy had improved overall survival. CONCLUSIONS Seven of eleven patients with pineoblastoma are currently alive and free of disease, reflecting an improved outcome and longer survival than previously appreciated. Gross total surgical resection appeared to correlate with improved survival, as did treatment with craniospinal irradiation and multi-agent chemotherapy. Further study of this group of patients as a distinct diagnostic entity will be necessary to determine optimal therapy.
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Affiliation(s)
- Stephen W Gilheeney
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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Larouche V, Huang A, Bartels U, Bouffet E. Tumors of the central nervous system in the first year of life. Pediatr Blood Cancer 2007; 49:1074-82. [PMID: 17943961 DOI: 10.1002/pbc.21351] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Among 1,289 infants identified from this literature review, the most common histological diagnoses are astrocytoma (30.5%), medulloblastoma (12.2%), ependymoma (11.1%), and choroid plexus tumors (11%). Most tumors are supratentorial (65%). The most important prognostic factors are histology (malignant vs. benign) and extent of resection. Significant differences are noted for some tumor types by comparison with older children, for example in the aggressive behavior of low grade gliomas and the chemosensitivity of some high grade gliomas. While new techniques of radiation have been introduced in the management of infants, there is still reluctance to consider radiotherapy in this age group.
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Affiliation(s)
- Valerie Larouche
- Paediatric Brain Tumour Program, Division of Paediatric Oncology/Haematology, Hospital for Sick Children, Toronto, Canada
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20
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Hinkes BG, von Hoff K, Deinlein F, Warmuth-Metz M, Soerensen N, Timmermann B, Mittler U, Urban C, Bode U, Pietsch T, Schlegel PG, Kortmann RD, Kuehl J, Rutkowski S. Childhood pineoblastoma: experiences from the prospective multicenter trials HIT-SKK87, HIT-SKK92 and HIT91. J Neurooncol 2006; 81:217-23. [PMID: 16941074 DOI: 10.1007/s11060-006-9221-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 07/12/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To analyze the outcome of children with pineoblastoma (PB), treated within the prospective multicenter trials HIT-SKK87, HIT-SKK92 and HIT91 of German-speaking countries. PATIENTS We report on 11 children suffering from PB. Five children younger than 3 years of age received chemotherapy after surgery until eligible for radiotherapy (HIT-SKK87 and HIT-SKK92). Five of six children older than 3 years were treated after surgery with immediate chemotherapy and craniospinal irradiation, and one child received maintenance chemotherapy after postoperative radiotherapy (HIT91). RESULTS Five of the six older children are still alive in continuous complete remission (CCR) with a median overall survival (OS) and progression free survival (PFS) of 7.9 years. Five of these six HIT91 patients responded to postoperative chemotherapy and radiotherapy. The only patient with tumor progression during initial chemotherapy achieved complete remission with radiotherapy and is alive. In contrast, all five young children died of tumor progression after a median OS of 0.9 years (PFS 0.6 years). They had either metastatic disease (M1) and/or postoperative residual tumor. Response to postoperative chemotherapy was lower than in the older age group, and only one of these children received radiotherapy. CONCLUSIONS Combined chemotherapy and radiotherapy were feasible and effective in the older age group, leading to prolonged remissions in five of six children. Tumor biology may be more aggressive in younger children with PB, who presented more frequently with high-risk features at diagnosis and had poorer response rates to neoadjuvant postoperative chemotherapy. More intensified treatment regimens may be needed for young children with PB.
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Affiliation(s)
- Bernward G Hinkes
- Children's University Hospital, University of Wuerzburg, Josef-Schneider-Str. 2, 97080, Wuerzburg, Germany
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21
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Charalampaki P, Filippi R, Welschehold S, Conrad J, Perneczky A. Tumors of the lateral and third ventricle: removal under endoscope-assisted keyhole conditions. Neurosurgery 2006; 57:302-11; discussion 302-11. [PMID: 16234679 DOI: 10.1227/01.neu.0000176638.86772.2d] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Intraventricular tumors usually are managed by approaches and microsurgical techniques that need retraction and dissection of important brain structures. Minimally invasive endoscopic procedures achieve a remarkable alternative to conventional microneurosurgical techniques. Endoscope-assisted microneurosurgery may be a minimally invasive technique with maximally effective treatment. Using the keyhole concept for planning the surgical strategy, the reduction of the brain retraction is achieved, which is one of the main benefits of this technique. METHODS We treated 35 patients (16 female patients and 19 male patients) with tumors in the lateral (n = 8) and the third (n = 27) ventricle. Patient age at the date of surgery ranged from 5 to 73 years. The follow-up period ranged from 6 to 83 months. The tumors were operated on using transcortical, transcallosal, or suboccipital transtentorial or infratentorial supracerebellar approaches after precise planning of the skin incision, the trephination, and the trajectory to the center of the tumor, performed earlier with a magnetic resonance imaging scan. RESULTS Total removal of the tumor was achieved in 28 patients (78.5%). In 2 patients (6.5%), recurrent tumor occurred. In 5 patients (15%), parts of the tumors remained because of infiltration of eloquent areas. Overall clinical improvement was achieved in 31 patients (87%). Three patients (10%) were unchanged and 1 patient (3%) deteriorated. CONCLUSION Endoscope-assisted keyhole neurosurgery seems to be a safe method of removing tumors in all regions inside the ventricular system with a low risk of permanent neurological deficits. The exact surgical corridor planning on the basis of the keyhole strategy offers less traumatic exposure of even deep-seated endoventricular tumors.
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Affiliation(s)
- Patra Charalampaki
- Department of Neurosurgery, Johannes Gutenberg University, Mainz, Germany.
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22
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Abstract
Malignant brain tumors are not uncommon in infants as their occurrence before the age of three represents 20-25% of all malignant brain tumors in childhood [1]. Genetic predisposition to infantile malignant brain tumors are known in Gorlin syndrome for example who present with desmoplastic medulloblastoma in about 5% of the affected patients. In addition, sequelae from tumor and its treatment are more severe at this age [2]. Thus, malignant brain tumors represent a true therapeutic challenge in neuro-oncology. Before the era of modern imaging and modern neurosurgery these malignant brain tumors were misdiagnosed or could not benefit of the surgical procedures as well as older children because of increased risks in this age group. Since the end of the 80s, noninvasive imaging procedures produce accurate diagnosis of brain tumors and improvement in neurosurgery, neuroanesthesia and perioperative intensive care permit safe tumor resections or at least biopsies. Consequently, the pediatric oncologists are more often confronted with very young children who need a complementary treatment. Before the development of specific approaches for this age group, these children received the same kind of treatment than the older children did, but their survival and quality of life were significantly worse. The reasons of these poor results were probably due in part to the fear of late effects induced by radiation therapy, leading to decrease the necessary doses of irradiation which increased treatment failures without avoiding treatment related complications [3]. At the end of the 80s, pilot studies were performed using postoperative chemotherapy in young medulloblastoma patients. Van Eys treated 12 selected children with medulloblastoma with MOPP regimen and without irradiation; 8 of them were reported to be long term survivors [4]. Subsequently, the pediatric oncology cooperative groups studies have designed therapeutic trials for very young children with malignant brain tumors. Different approaches have been explored: * Prolonged postoperative chemotherapy and delayed irradiation as designed in the POG (Pediatric Oncology Group). * Postoperative chemotherapy without irradiation in the SFOP (Société Française d'Oncologie Pédiatrique) and in the GPO (German Pediatric Oncology) studies. * The role of high-dose chemotherapy with autologous stem cells transplantation was explored in different ways: High-dose chemotherapy given in all patients as proposed in the Head Start protocol. High-dose chemotherapy given in relapsing patients as salvage treatment in the French strategy. In the earliest trials, the same therapy was applied to all histological types of malignant brain tumors and whatever the initial extension of the disease. This attitude was justified by the complexity of the classification of all brain tumors that has evolved over the past few decades leading to discrepancy between the diagnosis of different pathologists for a same tumor specimen. Furthermore, it has become increasingly obvious that the biology of brain tumors in very young children is different from that seen in older children. However, in the analysis of these trials an effort was made to give the results for each histological groups, according to the WHO classification and after a central review of the tumor specimens. All these collected data have brought to an increased knowledge of infantile malignant brain tumors in terms of diagnosis, prognostic factors and response to chemotherapy. Furthermore a large effort was made to study long term side effects as endocrinopathies, cognitive deficits, cosmetic alterations and finally quality of life in long term survivors. Prospective study of sequelae can bring information on the impact of the different factors as hydrocephalus, location of the tumor, surgical complications, chemotherapy toxicity and irradiation modalities. With these informations it is now possible to design therapeutic trials devoted to each histological types, adapted to pronostic factors and more accurate treatment to decrease long term sequelae.
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Affiliation(s)
- Chantal Kalifa
- Pediatric Department, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805, Villejuif cédex, France.
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Reyns N, Hayashi M, Chinot O, Manera L, Péragut JC, Blond S, Régis J. The role of Gamma Knife radiosurgery in the treatment of pineal parenchymal tumours. Acta Neurochir (Wien) 2006; 148:5-11; discussion 11. [PMID: 16172830 DOI: 10.1007/s00701-005-0626-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Accepted: 07/15/2005] [Indexed: 10/25/2022]
Abstract
OBJECT The aim of this study was to document the possible role of Gamma Knife radiosurgery, suitable for the treatment of deep and well limited tumors, in the management of pineal parenchymal tumors (PPT). POPULATION AND METHODS We reviewed retrospectively a series of 13 patients with PPT treated by Gamma Knife radiosurgery during 16 procedures. Mean age was 31 (range 10 to 74). Eight patients had pineocytomas (61.5%), and 5 had pineoblastomas (38.5%). Radiosurgery was performed alone in 6 cases, after partial microsurgical resection in 3 cases, in association with chemotherapy in 3 cases and following conventional fractionated radiotherapy in 1 case. The marginal dose to these tumors ranged from 11 to 20 Gy (mean 15 Gy). RESULTS With a mean follow-up of 34 months (range 6 to 88), all tumors responded to treatment and disappeared or ceased growing. Two patients with pineoblastoma had tumor size progression out of the initial target requiring several radiosurgery procedures. At the end of the follow-up period, 10 out of 12 patients were alive. Two patients with pineoblastoma died because of carcinomatous meningitis or tumor size progression. We observed no mortality or major morbidity related to radiosurgery. CONCLUSION This study confirms that radiosurgery can be an effective and safe primary treatment modality for patients with pineocytomas. It should have a role in multimodality therapy which includes microsurgical resection, fractionated radiotherapy and chemotherapy for the management of malignant pineal tumors.
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Affiliation(s)
- N Reyns
- Department of Neurosurgery, Centre Hospitalier Universitaire, Lille, France
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24
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Massimino M, Gandola L, Spreafico F, Luksch R, Collini P, Giangaspero F, Simonetti F, Casanova M, Cefalo G, Pignoli E, Ferrari A, Terenziani M, Podda M, Meazza C, Polastri D, Poggi G, Ravagnani F, Fossati-Bellani F. Supratentorial primitive neuroectodermal tumors (S-PNET) in children: A prospective experience with adjuvant intensive chemotherapy and hyperfractionated accelerated radiotherapy. Int J Radiat Oncol Biol Phys 2005; 64:1031-7. [PMID: 16343801 DOI: 10.1016/j.ijrobp.2005.09.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Revised: 08/22/2005] [Accepted: 09/13/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Supratentorial primitive neuroectodermal tumors (S-PNET) are rare and have a grim prognosis, frequently taking an aggressive course with local relapse and metastatic spread. We report the results of a mono-institutional therapeutic trial. METHODS AND MATERIALS We enrolled 15 consecutive patients to preradiation chemotherapy (CT) consisting of high-dose methotrexate, high-dose etoposide, high-dose cyclophosphamide, and high-dose carboplatin, craniospinal irradiation (CSI) with hyperfractionated accelerated radiotherapy (HART) plus focal boost, maintenance with vincristine/lomustine or consolidation with high-dose thiotepa followed by autologous stem-cell rescue. RESULTS Median age was 9 years; 7 were male, 8 female. Site of disease was pineal in 3, elsewhere in 12. Six patients were had no evidence of disease after surgery (NED). Of those with evidence of disease after surgery (ED), 2 had central nervous system spread. Of the 9 ED patients, 2 had complete response (CR) and 2 partial response (PR) after CT, 4 stable disease, and 1 progressive disease. Of the 7 ED patients before radiotherapy, 1 had CR, 4 PR, and 2 minor response, thus obtaining a 44% CR + PR after CT and 71% after HART. Because of rapid progression in 2 of the first 5 patients, high-dose thiotepa was systematically adopted after HART in the subsequent 10 patients. Six of 15 patients relapsed (4 locally, 1 locally with dissemination, 1 with dissemination) a mean of 6 months after starting CT, 2 developed second tumors; 5 of 6 relapsers died at a median of 13 months. Three-year progression-free survival, event-free survival, and overall survival were 54%, 34%, and 61%, respectively. CONCLUSION Hyperfractionated accelerated RT was the main tool in obtaining responses in S-PNET; introducing the myeloablative phase improved the prognosis (3/10 vs. 3/5 relapses), though the outcome remained unsatisfactory despite the adoption of this intensive treatment.
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Affiliation(s)
- Maura Massimino
- Neuro-Oncology Functional Unit, Department of Pediatric Oncology, Istituto Nazionale Tumori, Milan, Italy.
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25
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Lee JYK, Wakabayashi T, Yoshida J. Management and Survival of Pineoblastoma: An Analysis of 34 Adults From the Brain Tumor Registry of Japan. Neurol Med Chir (Tokyo) 2005; 45:132-41; discussion 141-2. [PMID: 15782004 DOI: 10.2176/nmc.45.132] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pineoblastoma is a rare tumor in adults, and factors influencing survival are poorly understood. Data from the Brain Tumor Registry of Japan (BTRJ) was analyzed to examine patient, tumor, and treatment characteristics associated with increased survival in adults with pineoblastomas. All pineoblastoma cases in adults aged 16 years or older were identified in the BTRJ. Data were extracted on demographics, presentation, tumor characteristics, treatments, and outcomes. Kaplan-Meier plots, the log rank method, and p value <0.15 was used to screen variables for inclusion in a multivariate Cox regression estimating survival. In the final Cox multivariate model, all variables with p values <0.05 were considered significant predictors of survival, and all variables with p values 0.05-0.099 were considered trends. The BTRJ contained 34 adults with pineoblastomas diagnosed from 1969-1998. The patients were predominantly male (22 patients), with a median age of 35 years (range 16-66 years). Median survival from diagnosis was 25.7 months, with a median follow up of 20.5 months. Median surgical resection was 75-94%, and five of the 34 patients had gross total resection. Twenty-nine of the 34 patients received cranial irradiation therapy with a median dose of 50 Gy (range 30-70 Gy). In the final multivariate model, cranial irradiation > or =40 Gy (p=0.014) and gross total resection (p=0.034) were associated with improved survival. There was a trend towards improved survival for women (p=0.099). Adult pineoblastoma patients have poor survival prognosis. Cranial irradiation therapy using at least 40 Gy and complete surgical resection are associated with improved survival.
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Affiliation(s)
- John Y K Lee
- Department of Neurosurgery, The Nagoya University School of Medicine, Aichi.
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26
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Abstract
Optimal management of pineal region tumors depends on securing an accurate histologic diagnosis to facilitate management customized to the nuances of specific pathologies. As an initial step, surgical intervention by either stereotactic biopsy or open surgery is necessary to obtain tissue for pathologic examination. Stereotactic biopsy has the benefit of relative ease and minimal morbidity but is associated with greater likelihood of diagnostic inaccuracy compared to open surgery where more extensive tissue sampling is possible. The role of surgical debulking in the management of pineal tumors is clearly defined for some tumors but is less evident for others. Among the one third of pineal tumors that are benign or low grade, complete surgical resection is achievable and constitutes optimal management with excellent long-term recurrence-free survival. The benefits of aggressive surgical resection among malignant tumors are less clear but several studies have correlated degree of tumor removal with improved outcome. Advances in technology, surgical technique, and post-operative care have minimized surgical complications, however all surgical procedures in the pineal region, including both stereotactic biopsy and open surgery, are potentially hazardous. Advanced judgment, experience, and expertise are necessary to achieve rates of success sufficient to justify aggressive management. Management strategies using stereotactic biopsy, endoscopy, and radiosurgery can also provide favorable outcomes in some cases. Selective incorporation of these innovations can be expected to improve the already highly favorable outcome for all pineal region tumors.
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Affiliation(s)
- Jeffrey N Bruce
- Department of Neurological Surgery, The Neurological Institute, Columbia University, New York, NY 10032, USA.
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27
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Abstract
Brain tumors are the second most common malignancy in children and the most common solid tumor. The majority of children are treated with surgery alone or in combination with radiation and/or chemotherapy. Recently investigators have used high dose chemotherapy with autologous stem cell rescue (ASCR) in patients with malignant brain tumors. This approach has been most successful in chemosensitive tumors including medulloblastoma, supratentorial primitive neuroectodermal tumors (SPNET) and central nervous system germ cell tumors (CNS GCT). In addition, the use of high dose chemotherapy has enabled the reduction and in many cases elimination of radiation therapy to very young children. To date there have been no prospective randomized studies comparing high dose chemotherapy and ASCR with conventional therapy. Radiation therapy is often not an option for patients with recurrent disease and conventional dose chemotherapy rarely if ever results in long-term survival. Unfortunately, the majority of studies using conventional therapy in order to delay irradiation in young children newly diagnosed with malignant brain tumors have been unsuccessful. Although the numbers are small, preliminary data suggest that not only is survival but also quality of life is superior with the use of high dose chemotherapy. Future studies will most likely include the use of new agents as part of the cytoreduction. In addition, through the use of peripheral blood stem cells and improvements in supportive care, multiple courses of high dose chemotherapy can be administered. High dose chemotherapy with ASCR is a foundation upon which many different types of therapies can be built. Several possibilities include the use of anti-angiogenesis agents, monoclonal antibodies and biologic response modifiers.
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Gururangan S, McLaughlin C, Quinn J, Rich J, Reardon D, Halperin EC, Herndon J, Fuchs H, George T, Provenzale J, Watral M, McLendon RE, Friedman A, Friedman HS, Kurtzberg J, Vredenbergh J, Martin PL. High-dose chemotherapy with autologous stem-cell rescue in children and adults with newly diagnosed pineoblastomas. J Clin Oncol 2003; 21:2187-91. [PMID: 12775745 DOI: 10.1200/jco.2003.10.096] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We evaluated the usefulness of a treatment regimen that included high-dose chemotherapy (HDC) with autologous stem-cell rescue (ASCR) in patients with newly diagnosed pineoblastoma (PBL). PATIENTS AND METHODS Twelve patients with PBL were initially treated with surgery and induction chemotherapy. All but two patients underwent radiotherapy. Subsequently, all patients received HDC using cyclophosphamide (CTX) + melphalan (MEL) or busulfan (Bu) + MEL regimens and ASCR. RESULTS A total of six children and six adults with median ages of 4.2 (range, 0.3 to 19.8 years) and 23 years (range, 23 to 43.7 years), respectively, were treated according to this strategy. Four patients had metastatic disease confined to the neuraxis. Five of 12 patients (42%) had a complete tumor resection at diagnosis. Ten patients received radiotherapy at median doses of 36.0 and 59.4 Gy to the neuraxis and pineal region, respectively. Eleven patients received HDC with CTX + MEL, and one patient received BU + MEL followed by ASCR. Nine patients are alive with no evidence of disease recurrence at a median of 62 months from diagnosis (range, 28 to 125 months), including three patients with metastatic disease and two infants who did not receive any radiotherapy. Three patients have died of progressive disease at 19, 32, and 37 months from diagnosis, respectively. The actuarial 4-year progression-free and overall survivals are 69% (95% confidence interval [CI], 39% to 99%) and 71% (95% CI, 43% to 99%), respectively. CONCLUSION The use of HDC in addition to radiotherapy seems to be an effective treatment for patients with newly diagnosed pineoblastoma.
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Affiliation(s)
- Sridharan Gururangan
- Brain Tumor Center at Duke and the Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA.
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Affiliation(s)
- E Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
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Marec-Berard P, Jouvet A, Thiesse P, Kalifa C, Doz F, Frappaz D. Supratentorial embryonal tumors in children under 5 years of age: an SFOP study of treatment with postoperative chemotherapy alone. MEDICAL AND PEDIATRIC ONCOLOGY 2002; 38:83-90. [PMID: 11813171 DOI: 10.1002/mpo.1277] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND To determine the effectiveness of multiagent chemotherapy as sole post-operative treatment of supratentorial central nervous system (CNS) embryonal tumors in young children. PROCEDURE The data of 25 children under 5 years of age diagnosed with supratentorial embryonal tumors (17 primitive neuroectodermal tumors, four pinealoblastomas, and four medulloepitheliomas) treated exclusively by postoperative chemotherapy (CT) between 1990 and 1997 were reviewed. RESULTS Fifteen tumors were hemispheric and 10 were deeply seated. Four children presented with disseminated leptomeningeal disease. Total resection was performed in nine patients, subtotal in 9, partial in 3, and a diagnostic biopsy only in 2. Two children did not undergo surgery. Twenty-four children relapsed with a median time of 5.5 months. The median overall survival was 12 months, and the 2-, and 5- year survivals were 30 and 14%, respectively. The 2- year disease-free survival was 4%. There was a significantly worse prognosis in patients undergoing incomplete resection and in the group with deeply situated tumors. Four relapses were treated by second surgery followed by high-dose chemotherapy and radiotherapy. Two of them remain in CR2, and all these children are free of late sequelae. CONCLUSIONS CT alone failed to maintain disease-free survival in most of the children, although, disease progression was delayed to some extent. Children under 5 years with supratentorial embryonal tumors should undergo total surgical resection if possible.
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Chastagner P, Bouffet E, Grill J, Kalifa C. What have we learnt from previous phase II trials to help in the management of childhood brain tumours? Eur J Cancer 2001; 37:1981-93. [PMID: 11597375 DOI: 10.1016/s0959-8049(01)00251-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Contrary to major advances in cure rates observed for almost all childhood cancers, progress in reducing brain tumour survival rates remains very limited. Although new drug development in oncology is founded on principles outlined in the organised methodology of phase I, II, and III trials, based on rigorous study design using standardised criteria, this approach has been applied very slowly in the field of neuro-oncology. There are multiple explanations for the paucity of well-conducted prospective clinical trials, such as the rarity and the heterogeneity of these tumours, and the reluctance of some investigators to enroll their patients in constraining trials. Data from the past two decades shows that several methodological problems preclude the drawing of any definite conclusions for the majority of drugs assessed. Among them, the necessity of a central neuropathological and neuroradiological review has been highlighted in, at least, two multicentric studies. Changes in histological diagnosis and grade have been reported in a proportion as high as 20%, and changes in response rate in 14% of the cases. This review of phase II trials for brain tumours reveals a wide array of sometimes arbitrary response definitions, that is if response is defined at all, and most series have enrolled small numbers of patients. We report on the different problems encountered in childhood brain tumours in these phase II trials, and their impact on phase III trials.
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Affiliation(s)
- P Chastagner
- Department of Paediatric Oncology, Hôpital d'Enfants, CHU Nancy, 54500, Vandoeuvre, France.
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Fauchon F, Jouvet A, Paquis P, Saint-Pierre G, Mottolese C, Ben Hassel M, Chauveinc L, Sichez JP, Philippon J, Schlienger M, Bouffet E. Parenchymal pineal tumors: a clinicopathological study of 76 cases. Int J Radiat Oncol Biol Phys 2000; 46:959-68. [PMID: 10705018 DOI: 10.1016/s0360-3016(99)00389-2] [Citation(s) in RCA: 169] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to identify factors that could lead to optimization of the management of pineal parenchymal tumors (PPT) which remains equivocal and controversial. METHODS AND MATERIALS In order to determine factors that influence PPT prognosis, a series of 76 consecutive patients from 12 European centers with histologically proven tumors was retrospectively reviewed. The clinical records and material for histologic review were available in all cases. Follow-up was achieved in 90% of cases. RESULTS According to WHO classification, there were 19 pineocytomas, 28 intermediate and mixed PPT, and 29 pineoblastomas. According to a four-grade institutional classification, there were 11 Grade 1, 27 Grade 2, 20 Grade 3, and 18 Grade 4. Surgical resection was attempted in 44 patients, whereas 30 had biopsy only. In one case, diagnosis was made at autopsy and in another on spinal deposits. Forty-four patients were irradiated following surgery, 15 patients received chemotherapy. Forty-one patients were alive (median follow-up: 85 months); 9 patients died perioperatively; 26 patients relapsed. Univariate analysis showed a good outcome correlated with age above 20 years, tumor diameter less than 25 mm, and low-grade histology. Multivariate analysis confirmed histology and tumor volume to be significant independent prognostic factors. The extent of surgery and radiotherapy had no clear influence on survival. CONCLUSIONS This review highlights the prognostic features of PPT and may help to determine treatment strategies based on radiologic and pathologic characteristics.
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Affiliation(s)
- F Fauchon
- Centre de Radiothérapie Privé, Nice, France.
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Robinson S, Cohen AR. The role of neuroendoscopy in the treatment of pineal region tumors. SURGICAL NEUROLOGY 1997; 48:360-5; discussion 365-7. [PMID: 9315134 DOI: 10.1016/s0090-3019(97)00018-9] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The authors describe a technique for the initial management of patients with pineal region neoplams and symptomatic hydrocephalus. Endoscopic third ventriculostomy and, if possible, tumor biopsy are performed through a single precoronal burr hole. When indicated, formal tumor resection can be performed nonemergently, without the need for ventricular drainage or shunting.
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Affiliation(s)
- S Robinson
- Division of Pediatric Neurosurgery, Rainbow Babies and Childrens Hospital, Cleveland, Ohio 44106, USA
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Abstract
Brain tumors account for 20% of childhood cancers and provide a "frontier" in which improved disease control and functional outcome require coordinated, directed studies in neurosurgery, radiation therapy, and chemotherapy. Among the several brain tumor types common in children, the recent experiences in medulloblastoma, ependymoma, and tumors occurring in infants and very young children are reviewed in the context of recent clinical trials and ongoing investigations.
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Affiliation(s)
- L E Kun
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Plowman PN, Kingston JE, Sebag-Montefiore D, Doughty D. Clinical efficacy of perceived 'CNS friendly' chemoradiotherapy for primary intracranial germ cell tumours. Clin Oncol (R Coll Radiol) 1997; 9:48-53. [PMID: 9039814 DOI: 10.1016/s0936-6555(97)80062-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The optimal treatment of intracranial germ cell tumours (IGCT) is controversial. The late sequelae of craniospinal radiotherapy and the high response rate to chemotherapy have led to new treatment strategies. The morbidity of combined modality therapy has tempered enthusiasm for aggressive chemoradiotherapy. In 1992, we described new lower morbidity chemotherapy and radiotherapy methods to be used in conjunction for IGCT treatment, employing three drugs (vincristine, carboplatin, etoposide) and a differential daily dose neuraxis radiotherapy technique (to replace a shrinking field technique). The chemoradiotherapy had the potential for a graded intensity reduction when high cure rates were maintained. Of 13 IGCT patients treated on this protocol, 8/8 germinomatous GCT and 3/5 non-germinomatous GCTs are in continuing remission. These observations have implications for other CNS tumour treatments in (young) patients, in whom late CNS toxicity (particularly neuropsychological) is a problem.
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Ashley DM, Longee D, Tien R, Fuchs H, Graham ML, Kurtzberg J, Casey J, Olson J, Meier L, Ferrell L, Kerby T, Duncan-Brown M, Stewart E, Colvin OM, Pipas JM, McCowage G, McLendon R, Bigner DD, Friedman HS. Treatment of patients with pineoblastoma with high dose cyclophosphamide. MEDICAL AND PEDIATRIC ONCOLOGY 1996; 26:387-92. [PMID: 8614374 DOI: 10.1002/(sici)1096-911x(199606)26:6<387::aid-mpo3>3.0.co;2-d] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The outcome for patients with pineoblastoma has historically been very poor, with most patients dying of disseminated disease despite irradiation. Furthermore, the low incidence of this tumor has hindered progress toward defining better treatment strategies. Here we report the activity and toxicity of cyclophosphamide administered as a single agent at a dose schedule of 2 g/m2/day for 2 successive days at monthly intervals for a maximum of four courses. Eight patients were evaluated, six newly diagnosed and two recurrent. Amongst the six newly diagnosed patients, there were three patients demonstrating partial responses, and three had stable disease throughout the cyclophosphamide treatment period. All six patients are alive and disease free after further therapy. One patient with recurrent disease demonstrated tumor progression on cyclophosphamide, and the other had stable disease throughout the cyclophosphamide treatment period. Both patients subsequently died of progressive disease. The major toxicity of high dose cyclophosphamide was hematopoietic, with one patient requiring a dose reduction after three courses due to prolonged thrombocytopenia. One patient was also withdrawn from treatment with cyclophosphamide due to impaired pulmonary function. This study demonstrates the activity of high dose cyclophosphamide in the treatment of pineoblastoma and may serve as basis for the design of future studies of this tumor.
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Affiliation(s)
- D M Ashley
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA
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Duffner PK, Krischer JP, Burger PC, Cohen ME, Backstrom JW, Horowitz ME, Sanford RA, Friedman HS, Kun LE. Treatment of infants with malignant gliomas: the Pediatric Oncology Group experience. J Neurooncol 1996; 28:245-56. [PMID: 8832466 DOI: 10.1007/bf00250203] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Although survivals of infants with malignant brain tumors are worse than any other age group, one possible exception to this rule are the malignant gliomas. Eighteen children less than 3 years of age with malignant gliomas (glioblastoma multiforme, anaplastic astrocytoma and malignant glioma) were treated on the Pediatric Oncology Group regimen of prolonged postoperative chemotherapy and delayed irradiation, (1986-1990). Of 10 children evaluable for neuroradiologic response, 6 had partial responses (> 50% reduction) to two cycles of cyclophosphamide and vincristine. Progression free survivals at 1,3 and 5 years were 54.25% +/- 12, 43% +/- 16 and 43% +/- 23 respectively. Survivals at 5 years were 50% +/- 14. Four children were not irradiated after 24 months of chemotherapy due to parental refusal and none have developed recurrent disease. Neither degree of surgical resection, presence or absence of metastases, nor pathology influenced survival but this may reflect small sample size. This study suggests that some malignant gliomas in infants are chemotherapy sensitive and may be associated with a good prognosis. Why infants with these high-grade gliomas fare better than adults is not clear. It is likely that there is something intrinsically different about them that cannot be identified on routine pathologic examination.
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Affiliation(s)
- P K Duffner
- State University of New York, Buffalo School of Medicine and Biomedical Sciences 14222, USA
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