Primary brain tumors in children under age 3 years

Brain tumors in the first two years of life

Background

Brain tumors in the first years of life are frequently encountered recently with the advancement in neuroimaging, neurosurgery and neuroanethesia where early diagnosis of these lesions became available even before birth. Their management is challenging where the surgery is technically demanding, radiotherapy is omitted in this age because of its late sequelae and chemotherapy role may be beneficial, but it is limited also by its side effects and neurotoxicity. The aim of this article is to review the current literature about the brain tumors in the first two years of life, their diagnosis and treatment.

Main body

Brain tumors in the first two years of life encompass mainly fetal/congenital tumors and infantile tumors. They account for 1.4–18% of cases of pediatric brain tumor, and most of them are diagnosed in the first year of life. The main histopathologies diagnosed are glial tumors, choroid plexus tumors, medulloblastoma and other embryonal tumors, teratoma and ependymoma. They are mainly supratentorial. Large head and bulging fontanelles are the main presenting symptoms and signs secondary to increased intracranial pressure secondary to large tumors or associated hydrocephalus. Prenatal and postnatal ultrasonography represents the initial imaging step in the diagnosis that should be complemented by MRI and CT brain. The main and first line of treatment of infantile brain tumors is surgical excision as the prognosis is directly related to the extent of resection besides surgery offers specimens for histopathological diagnosis and adjuvant chemotherapy is given for residual irresectable cases and malignant tumors with the main aim to delay radiotherapy beyond the age of three years.

Conclusion

Brain tumors in the first two years of life are a challenging group of different histopathological entities with underlying specific molecular characterization and genetic predispositions. They have aggressive behavior and general poor prognosis with limited options of management. Individualized multidisciplinary management for each case is needed, and future studies for therapeutic medications targeting underlying molecular biology may improve their outcome.

CoMB-Deep: Composite Deep Learning-Based Pipeline for Classifying Childhood Medulloblastoma and Its Classes

Childhood medulloblastoma (MB) is a threatening malignant tumor affecting children all over the globe. It is believed to be the foremost common pediatric brain tumor causing death. Early and accurate classification of childhood MB and its classes are of great importance to help doctors choose the suitable treatment and observation plan, avoid tumor progression, and lower death rates. The current gold standard for diagnosing MB is the histopathology of biopsy samples. However, manual analysis of such images is complicated, costly, time-consuming, and highly dependent on the expertise and skills of pathologists, which might cause inaccurate results. This study aims to introduce a reliable computer-assisted pipeline called CoMB-Deep to automatically classify MB and its classes with high accuracy from histopathological images. This key challenge of the study is the lack of childhood MB datasets, especially its four categories (defined by the WHO) and the inadequate related studies. All relevant works were based on either deep learning (DL) or textural analysis feature extractions. Also, such studies employed distinct features to accomplish the classification procedure. Besides, most of them only extracted spatial features. Nevertheless, CoMB-Deep blends the advantages of textural analysis feature extraction techniques and DL approaches. The CoMB-Deep consists of a composite of DL techniques. Initially, it extracts deep spatial features from 10 convolutional neural networks (CNNs). It then performs a feature fusion step using discrete wavelet transform (DWT), a texture analysis method capable of reducing the dimension of fused features. Next, the CoMB-Deep explores the best combination of fused features, enhancing the performance of the classification process using two search strategies. Afterward, it employs two feature selection techniques on the fused feature sets selected in the previous step. A bi-directional long-short term memory (Bi-LSTM) network; a DL-based approach that is utilized for the classification phase. CoMB-Deep maintains two classification categories: binary category for distinguishing between the abnormal and normal cases and multi-class category to identify the subclasses of MB. The results of the CoMB-Deep for both classification categories prove that it is reliable. The results also indicate that the feature sets selected using both search strategies have enhanced the performance of Bi-LSTM compared to individual spatial deep features. CoMB-Deep is compared to related studies to verify its competitiveness, and this comparison confirmed its robustness and outperformance. Hence, CoMB-Deep can help pathologists perform accurate diagnoses, reduce misdiagnosis risks that could occur with manual diagnosis, accelerate the classification procedure, and decrease diagnosis costs.

From first symptoms to diagnosis: Initial clinical presentation of primary brain tumors

Background:

Despite modern imaging methods, a long symptom-to-diagnosis interval can be observed in patients with primary brain tumors.

Objective:

The study evaluated the initial and subsequent clinical presentation of patients with brain tumors in the context of time to diagnosis, localization, histology, and tumor grading.

Methods:

In this retrospective analysis of 85 consecutive patients with primary brain tumors, we assessed the presenting symptoms and signs. The analyses were based on entries from medical records at the Department of Neurology of Zurich University Hospital between 2005 and 2010.

Results:

A total of 54 men and 31 women with a mean age at diagnosis of 48 years were included. 60% of the patients present with a malignant tumor (World Health Organization grading III–IV), 24.7% with a benign tumor (I–II), and 15.3% were not classified. The interval between symptom onset and diagnosis varied from 1 day to 96 months (median: 39 days). High-grade tumors (III–IV) were diagnosed significantly earlier than low-grade tumors (II) after the first symptoms occurred (median: 26 vs. 138 days; z = −3.847, p < 0.001).

Conclusions:

Symptoms with a short symptom-to-diagnosis interval such as nausea/vomiting, seizures, as well as of personality change are assumed to contribute to a faster diagnosis in high-grade tumors. Visual disturbances and headaches, although occurring relatively seldom, did not contribute to a decrease in time to diagnosis and should therefore be considered for further diagnostic workup.

Pediatric brain tumor care in a Sub-Saharan setting: current poise of a precariously loaded dice

OBJECTIVE

To evaluate the current status of pediatric brain tumor (PBT) care and identify determinants and profiles of survival and school attendance.

METHODS

An 8-year institution-based prospective longitudinal study. All cases investigated with neuroimaging and treated were enrolled. Data was analyzed with SPSS (Inc) Chicago IL, USA version 23. Chi Square test, One-way ANOVA and confidence limits were used to evaluate associations at the 95% level of significance. Ethical approval for our study was obtained Health Research Ethics Committee of our hospital.

RESULTS

Among 103 patients enrolled, 92 satisfied our study criteria. There were 45 males and 39 females, M: F = 0.8. The mean age was 9.5 ± 2.1 years 95%CI with a range of 7 months to 16 years. The most common symptom was headache for supratentorial lesions (73%) and gait disturbance (80.2%) for infratentorial lesions. More tumors were supratentorial in location 51 (55.4%), 35 (38.1%) were infratentorial and 6 (6.5%) were transtentorial. Craniopharyngiomas (n = 23), medulloblastomas (n = 22) and astrocytomas (n = 15) were the most common tumors. Hemoglobin genotype (AA and AS) had some influence on tumor phenotype FT, P = 0.033. 76 cases were microsurgically resected while 16 patients were treated with radiotherapy alone. The 30-day mortality for operated cases is 7.2 ± 0.7%. Overall 1-year and 5-year survival was 66.7 and 52.3%, respectively. School attendance, performance and outcome varied among treatment subgroups.

CONCLUSION

Survival profile in this series suggests some improvement in comparison to previous studies from our region, Hemoglobin genotype profiles may signature paediatric brain tumor phenotypes in our setting.

Study on Contribution of Biological Interpretable and Computer-Aided Features Towards the Classification of Childhood Medulloblastoma Cells

Diagnosis and Prognosis of brain tumour in children is always a critical case. Medulloblastoma is that subtype of brain tumour which occurs most frequently amongst children. Post-operation, the classification of its subtype is most vital for further clinical management. In this paper a novel approach of pathological subtype classification using biological interpretable and computer-aided textural features is forwarded. The classifier for accurate features prediction is built purely on the feature set obtained by segmentation of the ground truth cells from the original histological tissue images, marked by an experienced pathologist. The work is divided into five stages: marking of ground truth, segmentation of ground truth images, feature extraction, feature reduction and finally classification. Kmeans colour segmentation is used to segment out the ground truth cells from histological images. For feature extraction we used morphological, colour and textural features of the cells followed by feature reduction using Principal Component Analysis. Finally both binary and multiclass classification is done using Support Vector Method (SVM). The classification was compared using six different classifiers and performance was evaluated employing five-fold cross-validation technique. The accuracy achieved for binary and multiclass classification before applying PCA were 95.4 and 62.1% and after applying PCA were 100 and 84.9% respectively. The run-time analysis are also shown. Results reveal that this technique of cell level classification can be successfully adopted as architectural view can be confusing. Moreover it conforms substantially to the pathologist's point of view regarding morphological and colour features, with the addition of computer assisted texture feature.

Delays in diagnosis for children with newly diagnosed central nervous system tumors

Background

United States studies documenting time interval from symptom onset to definitive diagnosis for childhood central nervous system (CNS) tumors are more than a quarter-century old. The purpose of this study is to establish an accurate and contemporary Ohio baseline of the diagnostic interval for children with newly diagnosed CNS tumors.

Methods

Medical records were retrospectively reviewed for 301 children with newly diagnosed CNS tumors from January 2004 to August 2015 at Nationwide Children's Hospital. We obtained comprehensive data on 171 patients (56.8%). Records were reviewed for age, gender, tumor type, presenting symptoms, number of health care visits prior to diagnosis, time interval (in months) from onset of symptoms to definitive diagnosis, and any associated genetic syndromes.

Results

Of the 171 patients with newly diagnosed CNS tumors, 25 children (14.6%) had a known cancer predisposition syndrome (all with neurofibromatosis type 1). Among the remaining 146 children, the median and mean time intervals from symptom onset to definitive diagnosis were 42 days and 138 days (range < 1 to 2190 days), respectively.

Conclusions

We have documented and quantified the contemporary delays in diagnosis of childhood brain tumors in central Ohio to serve as a benchmark for our future planned interventions to reduce the time interval from symptom onset to diagnosis through adaptation of the United Kingdom HeadSmart program throughout the state of Ohio and ultimately throughout the United States.

Epidemiology of brain tumors in children aged two and under: A 10-year single-institute study

The aim of present study was to evaluate the incidence, clinical symptoms, pathological characteristics, surgical treatment strategies and prognosis of brain tumors in children aged two and under. The current study obtained data regarding 32 consecutive infants and young children aged two years and under, who were treated for brain tumors in the Children’s Hospital of Fudan University (Shanghai, China) between 2003 and 2013. The types of tumor, clinical manifestations, location, histological features, applied treatment strategies and outcomes were retrospectively evaluated. The male to female ratio was 1.13:1, and among a total of 32 tumors, 14 (43.8%) were suptratentorial and 18 (56.3%) were infratentorial. Intracranial hypertension was the most common onset symptom, and astrocytoma was the most common tumor type (10 cases; 31.3%), followed by ependymoma (nine cases; 28.1%) and medulloblastoma (six cases; 18.8%). Surgical tumor resection was performed in 20 patients (62.5%), who experienced a mean post-operative survival time of 67.6 months. By contrast, conservative treatment with medications was administered in 12 patients (37.5%), with a mean survival time of 25.3 months. Furthermore, four patients underwent conservative therapy combined with ventriculoperitoneal shunting to relieve intracranial pressure arising from cerebrospinal fluid accumulation, resulting in a mean survival time of 10.5 months. In conclusion, the present study indicates that surgical tumor resection may improve the overall prognosis of infants and young children aged two years and under who presented with brain tumors. In addition, ventriculoperitoneal shunts may facilitate pre- and post-operative improvement in clinical symptoms by relieving intracranial pressure; however, the shunts do not appear to increase long-term survival. Furthermore, high surgical risk is an important prognostic factor in this pediatric patient population.

The gut or the brain?--Gastrointestinal misdiagnoses of infantile brain tumors

PURPOSE

Central nervous system tumors account for the largest number of cancer deaths in childhood. Brain tumors in infants less than 3 years of age are rare; symptoms and signs are often non-specific. Patent anterior fontanelles/unfused cranial sutures in infants can accommodate rising intracranial pressure without acutely compromising the neurological status. We hypothesize that vomiting as the initial symptom, in infants with brain tumors, can possibly lead to extensive gastrointestinal evaluation, delaying the diagnosis of intracranial pathology.

METHODS

We conducted a retrospective chart review of infants less than 3 years of age diagnosed with brain tumors over the period of 4.7 years from February 2008 to October 2012 at Inova Children's Hospital, Virginia.

RESULTS

We identified three of 21 patients (14.3 %) who presented with vomiting and underwent initial or extensive abdominal imaging investigations. All patients were relatively young (median age, 5.4 months). Working diagnoses were pyloric stenosis, viral gastritis, or gastroesophageal reflux. All patients eventually had computed tomography of the head to rule out increased intracranial pressure and were found to have large brain tumors with obstructive hydrocephalus. Tumor locations were cerebral hemispheres (2/3) and posterior fossa (1/3). All patients had biologically aggressive high-grade tumors (glioblastoma multiforme, atypical teratoid rhabdoid tumor, and anaplastic/large cell medulloblastoma) and died within weeks of diagnosis.

CONCLUSIONS

Our study highlights a clinical challenge of persistent vomiting in infants, which in the absence of convincing gastrointestinal pathology after evaluation should raise the physician's suspicion of an underlying intracranial pathology even if neurological features are absent.

Age-dependent presentation of tectal plate tumors: preliminary observations

Tectal plate tumors are intrinsic midbrain tumors that behave more like hamartomas than neoplasms. Postulating that the presentation depends on the age of the affected patients, the authors reassessed the presentation of 10 consecutive patients. All patients presented with headache and papilledema. Four children younger than 10 years presented with a short symptom interval, vomiting, and Parinaud's syndrome. The remaining 6 children presented with a long symptom interval, gait abnormalities, cognitive impairment, vision impairment, tremor, macrocephaly, impaired visual acuity, and ataxia and sometimes with pyramidal signs as well. The difference between groups was statistically significant. Tumor size was similar in the groups. It is therefore concluded that the presentation of tectal plate tumors varies with age.

Diagnosis of childhood astrocytomas

BACKGROUND

Astrocytomas are the most common brain tumours, accounting for 28 - 50% of all primary CNS tumours. Diagnosis of CNS tumours remains difficult because the varied and nonspecific presentations of CNS tumours in childhood. Objectives/method: The clinical presentations of CNS astrocytomas vary with their sites of location; therefore, a period of uncertainty often precedes diagnosis, and approximately 42% of patients with an intracranial process make several visits to various physicians between the onset and diagnosis. However, on clinical suspicion of a brain tumour, a wide range of neuroimaging techniques may be used to assess the diagnosis of paediatric brain lesions. In this review the authors, for ease of presentation, describe the clinical presentations of supratentorial, infratentorial and spinal cord astrocytomas as well as their radiological and pathological features, and discuss their differential diagnoses.

RESULTS/CONCLUSIONS

Understanding and mastering the numerous imaging features of several subtypes of primary brain tumours affecting children, in addition to radiological features of non-tumoural disorders, remains a significant challenge and demands increased awareness of the paediatric brain diseases.

Ependymal tumors

Ependymomas represent a heterogeneous group of glial tumors whose biological behavior depends on various histological, molecular, and clinical variables. The scope of this chapter is to review the clinical and histo-logical features as well as the molecular genetics of ependymomas with special emphasis on their influence on tumor recurrence and prognosis. Furthermore, potential molecular targets for therapy are outlined.

Outcome of children with low-grade cerebellar astrocytoma: long-term complications and quality of life

OBJECTS

To study the long-term outcome of surgically treated low-grade cerebellar astrocytomas in children.

MATERIALS AND METHODS

We followed 31 consecutive patients under 16 years of age who were diagnosed between 1980 and 2005 in a single institution. In 21 of 31 survivors (median follow-up time 7.9 years; range 5.6-27.4 years) who agreed to participate, tumor control, neurological and cognitive complications, and their impact on behavioral and emotional adjustment and health-related quality of life (HRQoL) were comprehensively assessed qualitatively and quantitatively.

RESULTS

Neurological sequelae were found in 43%. However, age-appropriate ability to perform daily life activities was normal in all patients. Remarkably, cognitive deficits leading to significant school problems occurred in 19% and behavioral and emotional adjustment disturbances in 27%. In comparison with healthy controls, the survivors rated their HRQoL similarly or even higher.

CONCLUSION

Childhood low-grade cerebellar astrocytomas have an excellent cure rate by tumor surgery alone. When compared with other pediatric brain tumors, the risk of neurological, cognitive, emotional, and behavioral complications is relatively small. HRQoL is similar to that of healthy controls.

Brain tumors in the first three years of life: a review of twenty cases

OBJECTIVE AND METHOD: To review the clinical and neuropathological findings as well as the type of therapy and outcome in 20 infants under 3 years-old with central nervous system (CNS) tumor. They were treated at the Department of Neurology, "Hospital das Clínicas" University of São Paulo Medical School, from January 1997 to May 2001. RESULTS: Astrocytoma was the most common histological type (n=7), followed by ependymoma (n=3), medulloblastoma (n=2), craniopharyngioma (n=2) and desmoplastic ganglioglioma (n=2). The location of the tumor was predominantly supratentorial. Mean follow-up time was 20.2 months with recurrence in 7 cases. For each type of tumor we have emphasized the treatment currently recommended. CONCLUSION: Although follow-up time is not sufficient for analyzing survival, a trend of improvement in prognosis was noted, compared to another series of cases from our Institution that had been evaluated before 1990.

Presentation of childhood CNS tumours: a systematic review and meta-analysis

BACKGROUND

Suspicion of a CNS tumour is classically raised by symptoms of raised intracranial pressure, focal deficits (including seizures), or papilloedema. Development of guidelines is needed for the identification and referral of children who might have a CNS tumour. We did a systematic literature review and meta-analysis to identify the clinical presentation of childhood CNS tumours to provide evidence to support the development of guidelines to assist with the identification and referral for imaging of children who might have a central nervous system tumour.

METHODS

Medline, Embase, and PubMed were searched for cohort studies and case series in children, published between January, 1991, and August, 2005, detailing the symptoms and signs at diagnosis of a CNS tumour.

FINDINGS

74 papers (n=4171) met the inclusion criteria. 56 symptoms and signs at diagnosis were identified, ranked by frequency, and clustered according to age, anatomical criteria, and genetic criteria. The most frequent symptoms and signs at diagnosis were: headache (33%), nausea and vomiting (32%), abnormalities of gait and coordination (27%), and papilloedema (13%) for intracranial tumours; macrocephaly (41%), nausea and vomiting (30%), irritability (24%), and lethargy (21%) for children aged under 4 years with intracranial tumours; reduced visual acuity (41%), exophthalmia (16%), and optic atrophy (15%) for children with an intracranial tumour and neurofibromatosis; nausea and vomiting (75%), headache (67%), abnormal gait and coordination (60%), and papilloedema (34%) for posterior fossa tumours; unspecified symptoms and signs of raised intracranial pressure (47%), seizures (38%), and papilloedema (21%) for supratentorial tumours; headache (49%), abnormal eye movements (21%), squint (21%), and nausea and vomiting (19%) for central brain tumours; abnormal gait and coordination (78%), cranial nerve palsies (52%), pyramidal signs (33%), headache (23%), and squint (19%) for brainstem tumours; and back pain (67%), abnormalities of gait and coordination (42%), spinal deformity (39%), focal weakness (21%), and sphincter disturbance (20%) for spinal-cord tumours. Other features noted were weight loss, growth failure, and precocious puberty. Symptoms of raised intracranial pressure were absent in more than half of children with brain tumours. Other neurological features were heterogeneous and related to tumour location.

INTERPRETATION

Apart from raised intracranial pressure, motor and visual system abnormalities, weight loss, macrocephaly, growth failure, and precocious puberty also suggest presence of an intracranial tumour. Children with signs and symptoms that could result from a CNS tumour need a thorough visual and motor system examination and an assessment of growth and pubertal status. Occurrence of multiple symptoms and signs should alert clinicians to possible CNS tumours.

Supratentorial cystic hemangioblastoma with infratentorial extension--a unique location and a rare infant case

INTRODUCTION

Supratentorial occurrence of hemangioblastoma is an exceedingly rare event. Even rarer is the occurrence of a supratentorial hemangioblastoma in infancy.

CASE REPORT

We hereby report the case of an 18-month-old girl who presented with irritability, increasing head size, and an open fontanelle. MR scans demonstrated triventricular hydrocephalus and a cystic mass within the left lateral ventricle. There was an 18 x 15 x 13 mm enhancing nodule along the medial aspect of the cyst. The cystic mass was mainly supratentorial but there was a caudal extension through the tentorial incisura that compressed the cerebellum. At surgery, the content of the cyst was xanthochromic. Enhancing medial nodule was extremely vascular and was extirpated totally. The pathological diagnosis was reticular variant of hemangioblastoma.

CONCLUSION

The child is well at 4 years of age. An extensive review of the English literature revealed only three such cases. All three cases survived the operation.

The presenting features of brain tumours: a review of 200 cases

OBJECTIVE

To determine the presenting features of brain tumours in children.

DESIGN

Retrospective case note review.

SETTING

Paediatric and neurosurgical services at the Wessex Neurology Centre and Southampton General Hospital, UK.

PATIENTS

200 patients presenting with a CNS tumour between 1988 and 2001.

RESULTS

The commonest first presenting symptoms were headache (41%), vomiting (12%), unsteadiness (11%), visual difficulties (10%), educational or behavioural problems (10%), and seizures (9%). The commonest symptoms occurring at any time were headache (56%), vomiting (51%), educational or behavioural problems (44%), unsteadiness (40%), and visual difficulties (38%). Neurological signs were present at diagnosis in 88%: 38% had papilloedema, 49% cranial nerve abnormalities, 48% cerebellar signs, 27% long tract signs, 11% somatosensory abnormalities, and 12% a reduced level of consciousness. The median symptom interval was 2.5 months (range 1 day to 120 months). A short symptom interval was significantly associated with high grade tumours and patient age of 3 years or younger.

CONCLUSIONS

The well known predominance of headache in children with CNS tumours is confirmed. Visual, behavioural, and educational symptoms were also prominent. With the exception of seizures, every initial symptom was accompanied by other symptoms or signs by the time of diagnosis. Questions about visual symptoms and educational or behavioural difficulties, as well as the more widely recognised symptoms of raised intracranial pressure and motor dysfunction, are important in the diagnosis of brain tumours, as are vision assessment and the appropriate plotting of growth and head size.

Successful chemotherapy for congenital malignant gliomas: a report of two cases

We describe the cases of 2 patients with a congenital malignant glioma that responded to chemotherapy. In the first case, a 2-month-old boy had a conjugate deviation to the right side and nystagmus. A T(1)-weighted gadolinium-enhanced magnetic resonance image showed a large tumor in his right frontal lobe. The tumor was partially resected, and the histological diagnosis was malignant ganglioglioma. The child then underwent 6 cycles of chemotherapy (mainly carboplatin and etoposide), and the residual tumor shrank. The tumor was then partially resected during a second operation, after which the patient underwent 5 cycles of chemotherapy (a combination of carboplatin, etoposide, vincristine, ifosfamide, cisplatin and cyclophosphamide). The tumor has not recurred in more than 8.5 years. In the second case, a 2-month-old boy had bulging of the anterior fontanel. The T(1)-weighted gadolinium-enhanced magnetic resonance image showed a large suprasellar tumor. The tumor was partially resected, and the histological diagnosis was anaplastic astrocytoma. The patient underwent 8 cycles of chemotherapy (MCNU, carboplatin and etoposide) and the tumor has not recurred in more than 7.5 years. Our experience indicates that, if surgical removal and chemotherapy are done aggressively for malignant gliomas in neonates and infants, long-term survival is possible.

Intracranial tumors in infants

The prognosis in infants with brain tumors has historically been very poor. This study reviews 16 infants under the age of 12 months with brain tumors who presented to our institution between 1988 and 1999. The aim was to describe the clinical presentation, diagnosis, and management of these patients and to establish if newer diagnostic and treatment modalities have improved prognosis in terms of survival and neurocognitive outcome. Charts were reviewed retrospectively for age at diagnosis, time to diagnosis, presenting features, location, histology, surgical and adjuvant treatment, survival, and neurocognitive outcome. Survival has improved. Three quarters of the patients remain alive. The 5-year survival rate was 81%. The 5-year progression-free survival rate was 51%, with a median follow-up time of 70 months. The 5-year survival rate for benign tumors was 100%. None of the children with malignant tumors survived. Morbidity remains high: 8 of 13 survivors had focal neurologic deficits, 7 of 13 had epilepsy, and 7 of 12 had significant cognitive disability. Future treatment protocols should include formal analysis of neurocognitive morbidity, functional outcome, and quality of life measures to provide accurate prognostic information and to prepare families for early intervention programs.