Intracranial ependymomas in children

Posterior fossa ependymoma in children: A long-term single-center experience

INTRODUCTION

Ependymomas in the posterior fossa have poor prognosis. This study reports a single-center pediatric series, focusing on the value of surgical resection.

MATERIAL AND METHODS

A single-center retrospective study included all patients operated on by the senior author (CM) for posterior fossa ependymoma from 2002 to 2018. Medical and surgical data were extracted from the hospital's medical database.

RESULTS

Thirty-four patients were included. Age ranged from 6 months to 18 years, with a median of 4.7 years. Fourteen patients underwent initial endoscopic third ventriculocisternostomy before the direct surgical resection. Surgical removal was complete in 27 patients. There were 32 surgeries for second-look, local recurrence or metastasis despite complementary chemotherapy and/or radiotherapy. Twenty patients were WHO grade 2 and 14 grade 3. Sixteen patients showed recurrence (47%). Overall survival was 61.8% at a mean 10.1 years' follow-up. Morbidities comprised facial nerve palsy, swallowing disorder, and transient cerebellar syndrome. Fifteen patients had normal schooling, 6 had special assistance; 4 patients reached university, 3 of whom experienced difficulties. Three patients had a job.

CONCLUSION

Posterior fossa ependymomas are aggressive tumors. Complete surgical removal is the most important prognostic factor, despite risk of sequelae. Complementary treatment is mandatory, but no targeted therapy has so far proved effective. It is important to continue the search for molecular markers in order to improve outcomes.

Impairments that influence physical function among survivors of childhood cancer

Children treated for cancer are at increased risk of developing chronic health conditions, some of which may manifest during or soon after treatment while others emerge many years after therapy. These health problems may limit physical performance and functional capacity, interfering with participation in work, social, and recreational activities. In this review, we discuss treatment-induced impairments in the endocrine, musculoskeletal, neurological, and cardiopulmonary systems and their influence on mobility and physical function. We found that cranial radiation at a young age was associated with broad range of chronic conditions including obesity, short stature, low bone mineral density and neuromotor impairments. Anthracyclines and chest radiation are associated with both short and long-term cardiotoxicity. Although numerous chronic conditions are documented among individuals treated for childhood cancer, the impact of these conditions on mobility and function are not well characterized, with most studies limited to survivors of acute lymphoblastic leukemia and brain tumors. Moving forward, further research assessing the impact of chronic conditions on participation in work and social activities is required. Moreover, interventions to prevent or ameliorate the loss of physical function among children treated for cancer are likely to become an important area of survivorship research.

Posterior fossa ependymomas: new radiological classification with surgical correlation

PURPOSE

The key determinant of long-term outcome in infratentorial ependymomas remains the extent of surgical resection. We describe a new radiological classification system which is validated against surgical findings and correlated with risk of post-operative residual tumour.

METHODS

Twenty-five consecutive patients (12 females, mean age 4.9 years, range 0.5-17 years) with infratentorial ependymomas were studied. Lesions were classified on pre-operative MRI according to the pattern of extension, brainstem displacement and involvement of the obex, as lateral-type or midfloor-type tumours. Twenty-one operative records were reviewed with respect to the microanatomical tumour origin by a paediatric neurosurgeon, blinded to MRI findings. Follow-up imaging studies were evaluated for residual tumour.

RESULTS

There were 15 cases of midfloor-type tumour (anterior displacement of brainstem, infiltration of obex) and 10 cases of lateral-type tumour (lateral displacement of brainstem, obex free of tumour). Extension into prepontine or cerebellopontine cisterns was more common in lateral-type tumours. Agreement between the radiological classification and tumour origin, as defined by operative records, was seen in 18 out of 20 cases. Risk of residual tumour in lateral-type tumours was more than twice that of midfloor-type tumours (80% vs. 33%, p=0.04). Risk of tumour residual was also significantly higher when vessel encasement or prepontine extension was observed.

CONCLUSIONS

Infratentorial ependymomas can be pre-operatively classified as lateral-type or midfloor-type tumours. This correlates well with operative findings. Lateral-type tumours have significantly increased risk of residual tumour compared to midfloor- type tumours and this may influence intensity of imaging surveillance.

The history of ependymoma management

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.

Factors associated with neurological recovery of brainstem function following postoperative conformal radiation therapy for infratentorial ependymoma

PURPOSE

To identify risk factors associated with incomplete neurological recovery in pediatric patients with infratentorial ependymoma treated with postoperative conformal radiation therapy (CRT).

METHODS

The study included 68 patients (median age +/- standard deviation of 2.6 +/- 3.8 years) who were followed for 5 years after receiving CRT (54-59.4 Gy) and were assessed for function of cranial nerves V to VII and IX to XII, motor weakness, and dysmetria. The mean (+/- standard deviation) brainstem dose was 5,487 (+/-464) cGy. Patients were divided into four groups representing those with normal baseline and follow-up, those with abnormal baseline and full recovery, those with abnormal baseline and partial or no recovery, and those with progressive deficits at 12 (n = 62 patients), 24 (n = 57 patients), and 60 (n = 50 patients) months. Grouping was correlated with clinical and treatment factors.

RESULTS

Risk factors (overall risk [OR], p value) associated with incomplete recovery included gender (male vs. female, OR = 3.97, p = 0.036) and gross tumor volume (GTV) (OR/ml = 1.23, p = 0.005) at 12 months, the number of resections (>1 vs. 1; OR = 23.7, p = 0.003) and patient age (OR/year = 0.77, p = 0.029) at 24 months, and cerebrospinal fluid (CSF) shunting (Yes vs. No; OR = 21.9, p = 0.001) and GTV volume (OR/ml = 1.18, p = 0.008) at 60 months. An increase in GTV correlated with an increase in the number of resections (p = 0.001) and CSF shunting (p = 0.035); the number of resections correlated with CSF shunting (p < 0.0001), and male patients were more likely to undergo multiple tumor resections (p = 0.003). Age correlated with brainstem volume (p < 0.0001). There were no differences in outcome based on the absolute or relative volume of the brainstem that received more than 54 Gy.

CONCLUSIONS

Incomplete recovery of brainstem function after CRT for infratentorial ependymoma is related to surgical morbidity and the volume and the extent of tumor.

The molecular biology of ependymomas

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.

Intraventricular gliomas

Gliomas are the most common primary brain tumor in adults, and those within or relating to the ventricular surface represent a less common but important subcategory. The most common intraventricular gliomas include ependymomas, SEs, and SEGAs. Other less common varieties have been reported, including chordoid gliomas, glioblastoma multiforme, and mixed glial-neuronal tumors. Each type of intraventricular glioma is associated with its own unique constellation of epidemiologic, clinical, radiologic, and pathologic defining characteristics. Each tumor type has its own management considerations and nuances with unique prognostic indicators and outcomes. The outcome for certain intraventricular gliomas (especially ependymomas) remains relatively poor. Future advancements in surgical technique are likely to have only a modest impact on improvement of outcome. Translational research aiming to advance the knowledge of tumor biology into new targeted cellular and molecular therapies holds tremendous promise to improve the overall outcome. Additionally, more thorough delineation of prognostic factors as well as modifications and refinements to radiation and chemotherapy may help to improve the still significantly poor outcomes for patients harboring these lesions. Future cooperative intra- and interinstitutional efforts between scientists and clinicians will hopefully culminate in an improved outlook and eventual cure for patients with gliomas.

Surveillance neuroimaging in childhood intracranial ependymoma: how effective, how often, and for how long?

OBJECT

The authors examined images obtained in 52 children with intracranial ependymomas to determine risk factors for tumor recurrence and to assess the impact of surveillance imaging on patient outcome.

METHODS

Data obtained in all children with intracranial ependymomas were prospectively entered into a database from January 1987 to June 2000. The imaging and clinical details in all patients were reviewed. Fifty-two children with histologically proven intracranial ependymomas were treated at the authors' institution; recurrences developed in 28 (54%) of them, with a median time from surgery to first recurrence of 14.5 months (range 3-65 months). Of these tumor recurrences, 43% were asymptomatic and were noted on surveillance imaging. Seventeen children died, all of whom had recurrences. Incomplete excision of the primary tumor was significantly associated with reduced time to recurrence (p = 0.0144) and time to death (p = 0.0472). The age of the patient, location of the primary tumor, histological findings, and the presence or absence of spinal metastases on preoperative imaging were not significantly associated with outcome. The risk of death at any given time was 12-fold greater in patients in whom a recurrence was identified due to symptoms rather than on surveillance images (p = 0.016).

CONCLUSIONS

Recurrent childhood ependymoma has a poor prognosis. The extent of the initial local tumor resection is the factor most closely associated with outcome. Surveillance imaging reveals a substantial number of asymptomatic recurrences, and survival appears to be improved in these patients compared with those identified by symptoms. The improvement in survival is thought to be greater than that expected just from earlier diagnosis.

Intracranial ependymomas in children: a critical review of prognostic factors and a plea for cooperation

BACKGROUND

Current controversies in pediatric intracranial ependymoma include histologic categorization and management. Most of our knowledge of this disease comes from single-institution reports.

METHODS

A literature search was done, covering the period 1976-1996. The aim of this review is to analyze the prognostic factors reported in the literature over the last 20 years.

RESULTS

Forty-five series were reviewed, including more than 1,400 children. The largest series reported on 92 patients, and the accrual rate ranged from 0.32-12 patients per year. None of the prognostic factors reported achieved a consensus throughout the different series. Histology remains a major issue, and the range in the incidence of anaplastic ependymo mas (7-89%) highlights the difficulty in agreeing on a histological grading system. The role of surgery on the outcome seems to be determinant. Recent series based on homogeneous imaging-documented extents of resection strongly support the benefit of postoperative radiotherapy. The lack of a proven, effective chemotherapy regimen precludes its use except in prospective pilot studies.

CONCLUSIONS

Limited information is available from single-institution reports in ependymoma. Only large national or international studies can provide enough information to allow a multivariate analysis of the prognostic factors, and thus lead to new therapeutic proposals.

Second-look surgery for incompletely resected fourth ventricle ependymomas: technical case report

OBJECTIVE AND IMPORTANCE

The prognosis for patients with ependymomas is related to the adequacy of surgical clearance. It is, however, often not possible to obtain a macroscopically complete resection of tumors arising in the posterior fossa. This may be because of the involvement of structures, the sacrifice of which would result in unacceptable morbidity, or because of metastatic lesions at diagnosis. For those patients in whom initial surgery was incomplete, elective second-look surgery may allow more complete clearance of tumor.

INTERVENTION

We have performed second-look surgery for fourth ventricle ependymomas in five patients: two women, aged 26 and 27 years, and three male patients, aged 4 months, 19 months, and 18 years. The 19-month-old male patient underwent early second-look surgery without receiving any interim chemotherapy. Second-look surgery on the other four patients was performed after they had received chemotherapy. No additional major morbidity was associated with the subsequent surgery, which achieved macroscopically complete clearances in four of the five patients. Three of four patients who underwent macroscopically complete resections were well, without clinical or radiological evidence of recurrent tumor, at 23, 25, and 34 months after their second operations. The 10-month-old patient who underwent early second-look complete resection relapsed locally at 33 months after surgery. Complete resection was not possible in one patient who had progressive tumor 8 months after second-look surgery.

CONCLUSION

For patients in whom complete excision of fourth ventricle ependymomas is not possible at initial surgery, second-look procedures may enable macroscopic clearance to be achieved with little morbidity. A larger study is needed to evaluate this approach to treatment.

Intracranial ependymomas of childhood. Lack of correlation of histopathology and clinical outcome

The histopathology of 66 children with the diagnosis of ependymoma who were operated on at our institution between 1954 and 1994 were reviewed. We performed an initial analysis using the entire study cohort to determine which histopathological features associated with each other in a statistically significant fashion in an attempt to identify combinations of features that together might be useful in predicting outcome. A detailed outcome analysis was then performed on the 37 most recent cases who survived the postoperative period, in whom pre- and post-imaging studies as well as long term follow-up were obtained, in order to identify the histopathological features and combinations of features that were predictive of overall and progression-free survival. Five- and ten-year progression-free survivals were 45.1% and 36.1%, respectively. Overall survivals were 57.1% and 45.0%, respectively. Of the eight individual histopathological features, only the presence of necrosis was found to correlate with a less favorable overall and progression-free survival (PFS) (p = 0.06 and 0.03, respectively). In addition, the combination of necrosis with vascular proliferation or nuclear pleomorphism was associated with a worse PFS (p = 0.01 and 0.02, respectively). However, when other clinical predictive factors were included in a multivariate regression analysis, none of the histological features or combinations of features were independently associated with outcome. In addition, no relationship was found between the pattern of rosettes (true rosette, pseudorosette, or perivascular pseudorosette) and clinical outcome. In conclusion, although this study found an association between certain histopathological features and clinical outcome in children with ependymomas, these relationships did not reach statistical significance on multivariate analysis and, thus, do not provide sufficient evidence for modifying therapy based on histopathology alone.

Intracranial ependymomas of childhood: long-term outcome and prognostic factors

A detailed outcome analysis was performed on 40 children with intracranial ependymomas treated at our institution between 1975 and 1993 to identify those factors that were predictive of overall and progression-free survival. Three patients (7.5%) who were treated in the first 5 years of the study died within 3 months of surgery and were excluded from further outcome assessments. Eight (22%) of the 37 patients who survived the perioperative period had evidence of leptomeningeal dissemination at presentation, on the basis of either imaging (three children) and/or cytological (six children) results. The 5- and 10-year progression-free survival rates among these 37 patients were 45.1 and 36.1%, respectively; overall survival rates were 57.1 and 45.0%, respectively. The site of progression was local in 17 of 19 patients with progressive disease. Three factors were found to have a significant association (P < or = 0.05) with the outcome on both univariate and multivariate analyses: 1) the extent of the resection, 2) the age of the patient at diagnosis, and 3) the duration of the symptoms before diagnosis. The 5-year progression-free and overall survivals were 8.9 and 22%, respectively, among patients who had evidence of residual disease on postoperative imaging studies, compared with 68 and 80% rates among patients with no apparent residual disease (P = 0.0001 and P < 0.0001, respectively). Patients younger than 3 years fared significantly worse than older children (5-year progression-free and overall survival rates of 12 and 22%, respectively, in the younger children versus 60 and 75% in older children (P = 0.003 and P = 0.01, respectively). In addition, patients with a duration of symptoms before diagnosis of < 1 month had a worse outcome than those with a more protracted course (5-year progression-free and overall survival rates of 33 and 33%, respectively, versus rates of 53 and 64%, respectively (P = 0.02 for both). Neither the finding of evidence for dissemination at presentation nor the detection of anaplastic histological features (e.g., dense cellularity or high numbers of mitoses) were associated with a significantly worse outcome in this series. The combination of variables that had the strongest association with both favorable and unfavorable outcomes was the combination of the age of the patient and the resection extent. Only 2 of 17 patients older than 3 years with gross total resections have died, whereas 13 of 20 children who were either younger than 3 years or had radiologically incomplete resections have died (P < 0.0001).(ABSTRACT TRUNCATED AT 400 WORDS)

Fourth ventricle ependymomas. A study of 20 cases with survival analysis

Twenty patients with fourth ventricle ependymoma were treated surgically at our Neurosurgery Division between January 1976 and December 1990. Ependymoblastomas and mixed gliomas operated on in the same period have not been considered. A statistical analysis of our cases and a review of the largest published series show that favourable prognostic factors are: age over 16, post-operative radiotherapy to the posterior cranial fossa and a good Karnofsky performance status (KPS) after operation. The 5-year survival rate of patients under 16 was 20%, in comparison with 60% of adults (p = 0.013). Post-operative radiotherapy to the posterior cranial fossa improved the survival markedly (5-year survival rate 68%, versus 18% without treatment; p = 0.011). The differences of survival are also significant according to a multivariate analysis (p = 0.038). Patients with a post-operative KPS over 70 had a 5-year survival rate of 61% as against 17% of the group with a worse clinical condition (p = 0.032); the multivariate analysis confirmed also that this difference was significant (p = 0.046). Pre-operative symptoms and signs, and KPS, histological grade and extent of surgical removal seem to influence the prognosis, even if the differences of survival are not statistically significant. The statistical relevance of postoperative residual tumour on CT or MRI was brought out on multivariate analysis (p = 0.044).

Scale for assessing quality of life of children survivors of cranial posterior fossa tumors

BACKGROUND

Evaluation of quality of life of survivors of brain tumors is an important aspect of outcome that must be included in clinical studies.

METHODS

We have developed a new scale for assessing quality of life (QL) of pediatric long-term survivors of posterior fossa tumors based on their physical, psychointellectual, and endocrine/growth status. We have studied 39 patients, with a median follow-up of 9 years. Twenty-five had cerebellar astrocytoma (CA), 6 medulloblastoma (MDB), 5 brain-stem glioma (BSG) and 3 ependymoma of IV ventricle (EPD).

RESULTS

Sixty-six percent of children showed neurologic and/or visual sequelae. Little or no significant disability (Bloom's levels I-II) were present in 66%. Psychointellectual dysfunction was present in 44%, with an IQ < 90 in 39%. Endocrine and growth disorders were found in 26%, mostly stature anomalies. According to our scale, QL scores were high in 19 patients (49%), intermediate in 8 (20%), and low in the remaining 12 (31%). Unfavourable outcomes were related to age of less than 4 years, tumors other than CA (MDB, BSG, EPD), incomplete tumoral resection, and employment of radiotherapy and chemotherapy.

CONCLUSION

Our results are comparable to others previously reported, and this supports the validity of our scale. We consider that this scale is applicable to evaluate QL of children survivors of cranial tumors.