Long-term survival in children under 3 years of age with low-grade astrocytoma

The magnitude and predictors of therapy abandonment in pediatric central nervous system tumors in low- and middle-income countries: Systematic review and meta-analysis

BACKGROUND

Outcomes of pediatric central nervous system (CNS) tumors in low- to middle-income countries (LMIC) are poorer than their high-income counterparts. Abandonment of therapy is increasingly recognized as a key contributor to this disparity, but has been poorly quantified. We performed a meta-analysis to determine the magnitude of abandonment in pediatric CNS tumors in LMIC, and risk factors and interventions aimed at reducing this.

PATIENTS AND METHODS

We searched seven databases for pediatric CNS tumor cohorts followed up from diagnosis and treated in LMIC. All languages were included. Two reviewers independently selected articles and extracted data on abandonment rates (ARs) and predictors. The authors were contacted for additional information.

RESULTS

Of 50 660 publications, 643 in five languages met criteria for full review; 131 met analysis inclusion criteria. ARs were not reported in the majority, and a small number were available from the authors. Available ARs ranged from 0% to 59%, from 38 studies (2497 children in 14 countries), and these were quantitatively analyzed. Lower-middle-income countries had higher ARs than upper-middle-income countries (27%, 95% confidence interval [CI] 20%-36% vs 9%, 95% CI 6%-14%, P < 0.0001), with significant heterogeneity within each (LMIC I₂  = 78%, P < 0.00001, UMIC I₂  = 85%, P < 0.00001). Common predictors for abandonment included distance to treatment centers, financial hardship, and prognostic misconceptions.

CONCLUSION

In LMICs, ARs are highest in lower-MICs. However, the paucity of published data limits further evaluation. Given the increasing burden of pediatric CNS tumors in LMIC, addressing deficits in abandonment reporting is critical. Consistent reporting is needed for developing interventions to improve outcomes.

Outcome of supratentorial intraaxial extra ventricular primary pediatric brain tumors: A prospective study

Introduction:

Tumors of the central nervous system (CNS) are the second most frequent malignancy of childhood and the most common solid tumor in this age group. CNS tumors represent approximately 17% of all malignancies in the pediatric age range, including adolescents. Glial neoplasms in children account for up to 60% of supratentorial intraaxial tumors. Their histological distribution and prognostic features differ from that of adults.

Aims and Objectives:

To study clinical and pathological characteristics, and to analyze the outcome using the Engel's classification for seizures, Karnofsky's score during the available follow-up period of minimum 1 year following the surgical and adjuvant therapy of supratentorial intraaxial extraventricular primary pediatric (SIEPP) brain tumors in children equal or less than 18 years.

Materials and Methods:

The study design is a prospective study done in NIMS from October 2008 to January 2012. All the patients less than 18 years of age operated for SIEPP brain tumors proven histopathologically were included in the study. All the patients with recurrent or residual primary tumors or secondaries were excluded from the study. Post operative CT or magnetic resonance imaging (MRI) is done following surgery.

Results and Analysis:

There were 2, 8 and 20 patients in the age range of 0-2 years, >2-10 years and 10-18 years, respectively. There were 21 male patients and 9 female patients. Out of 30 patients, 16 had lesion in the temporal lobe, 6 in frontal lobe, 4 in thalamus, 3 in parietal lobe and 1 in occipital lobe. Out of 30 patients, 11 patients had malignant lesions and nineteen patients had benign lesions. Gross total excision could be achieved in 19 patients and subtotal in 11 patients. Seven patients had mortality and four of the remaining 23 patients had increased deficits postoperatively. Remaining 19 patients either improved or remained same.

Conclusions:

SIEPP brain tumors have male preponderance, occur in 95% of patients in the age range of 7-18 years and have temporal lobe as the most common site of origin. The seizure presentation has good outcome compared to raised intracranial pressure features. The seizure control is quite good irrespective of subtotal or gross total excision in temporal lobe low grade tumors. All PNETs have survival of less than 1 year even with adjuvant chemo and radiotherapy.

Surgical treatment of brain tumors in infants younger than six months of age and review of the literature

OBJECTIVE

Brain tumors are rare in infants who are younger than six months of age. These tumors can be challenging to treat surgically. We analyzed a modern series of patients treated by a multidisciplinary team at a tertiary care center and performed a literature review of this unique population.

METHODS

Retrospective clinical data were collected for patients surgically treated for intracranial mass lesions at The Children's Hospital of Philadelphia from 1998 to 2007. Dermoid cysts and other skull-based lesions were excluded from the analysis.

RESULTS

Sixteen patients younger than six months of age underwent surgery for primary intracranial mass lesions. The median age of the patients at surgery was 5.2 months (range, 1.4-6 months of age). Children most often presented with a bulging fontanelle, hydrocephalus, or macrocephaly (seven patients). Vomiting was seen in five patients, cranial nerve palsies in one patient, and seizures in three patients. All patients had tumor resections and postoperatively were monitored in the intensive care unit. The final pathology consisted of atypical teratoid/rhabdoid tumor (three patients), primitive neuroectodermal tumor/medulloblastoma (three patients), choroid plexus papilloma (two patients), astrocytoma (two patients), ganglioglioma (two patients), desmoplastic infantile ganglioglioma (two patients), glioblastoma multiforme (one patient), and choroid plexus carcinoma (one patient). Two intraoperative deaths occurred. Of the surviving 14, a gross total resection was achieved in four. Adjuvant therapy was determined by a multidisciplinary team composed of neuro-oncology, neurosurgery, and radiation oncology. Seven patients were treated with chemotherapy, and one patient had proton beam therapy. Five-year overall survival was 45%. The eight surviving patients had neurological sequelae, and developmental outcome was variable.

CONCLUSIONS

Brain tumors are uncommon in children younger than six months of age. Patients present with a variety of tumor pathologies. Children who survive have neurological sequelae. More studies are necessary to understand the impact that different treatment options, tumor pathology, and tumor location have on neurological outcome.

Outcomes of multidisciplinary management in pediatric low-grade gliomas

PURPOSE

To evaluate the outcomes in pediatric low-grade gliomas managed in a multidisciplinary setting.

METHODS AND MATERIALS

We conducted a single-institution retrospective study of 181 children with Grade I-II gliomas. Log-rank and stepwise Cox proportional hazards models were used to analyze freedom from progression (FFP) and overall survival (OS).

RESULTS

Median follow-up was 6.4 years. Thirty-four (19%) of patients had neurofibromatosis Type 1 (NF1) and because of their favorable prognosis were evaluated separately. In the 147 (81%) of patients without NF1, actuarial 7-year FFP and OS were 67 ± 4% (standard error) and 94 ± 2%, respectively. In this population, tumor location in the optic pathway/hypothalamus was associated with worse FFP (39% vs. 76%, p < 0.0003), but there was no difference in OS. Age ≤5 years was associated with worse FFP (52% vs. 75%, p < 0.02) but improved OS (97% vs. 92%, p < 0.05). In those with tissue diagnosis, gross total resection (GTR) was associated with improved 7-year FFP (81% vs. 56%, p < 0.02) and OS (100% vs. 90%, p < 0.03). In a multivariate model, only location in the optic pathway/hypothalamus predicted worse FFP (p < 0.01). Fifty patients received radiation therapy (RT). For those with less than GTR, adjuvant RT improved FFP (89% vs. 49%, p < 0.003) but not OS. There was no difference in OS between patient groups given RT as adjuvant vs. salvage therapy. In NF1 patients, 94% of tumors were located in the optic pathway/hypothalamus. With a conservative treatment strategy in this population, actuarial 7-year FFP and OS were 73 ± 9% and 100%, respectively.

CONCLUSIONS

Low-grade gliomas in children ≤5 years old with tumors in the optic pathway/hypothalamus are more likely to progress, but this does not confer worse OS because of the success of salvage therapy. When GTR is not achieved, adjuvant RT improves FFP but not OS. Routine adjuvant RT can be avoided and instead reserved as salvage.

Activation of the Hedgehog pathway in pilocytic astrocytomas

Pilocytic astrocytoma is commonly viewed as a benign lesion. However, disease onset is most prevalent in the first two decades of life, and children are often left with residual or recurrent disease and significant morbidity. The Hedgehog (Hh) pathway regulates the growth of higher WHO grade gliomas, and in this study, we have evaluated the activation and operational status of this regulatory pathway in pilocytic astrocytomas. Expression levels of the Hh pathway transcriptional target PTCH were elevated in 45% of tumor specimens analyzed (ages 1–22 years) and correlated inversely with patient age. Evaluation of a tissue array revealed oligodendroglioma-like features, pilomyxoid features, infiltration, and necrosis more commonly in specimens from younger patients (below the median patient age of 10 years). Immunohistochemical staining for the Hh pathway components PTCH and GLI1 and the proliferation marker Ki67 demonstrated that patients diagnosed before the age of 10 had higher staining indices than those diagnosed after the age of 10. A significant correlation between Ki67 and PTCH and GLI1 staining indices was measured, and 86% of Ki67-positive cells also expressed PTCH. The operational status of the Hh pathway was confirmed in primary cell culture and could be modulated in a manner consistent with a ligand-dependent mechanism. Taken together, these findings suggest that Hh pathway activation is common in pediatric pilocytic astrocytomas and may be associated with younger age at diagnosis and tumor growth.

Outcome and prognostic features in pediatric gliomas: a review of 6212 cases from the Surveillance, Epidemiology, and End Results database

BACKGROUND

Pediatric gliomas are rare and heterogeneous tumors. The Surveillance, Epidemiology, and End Results (SEER) database allows a large-scale analysis of the clinical characteristics and prognostic features of these tumors.

METHODS

The authors analyzed available SEER data on 6212 patients younger than 20 years at diagnosis of glioma (1973-2005), according to 4 age categories: <1 year, 1-3 years, 3-5 years, and 5-20 years.

RESULTS

The overall 5- and 10-year survival estimates were 71%+/-0.62% (standard error) and 68%+/-0.67%, respectively. Forty-one percent of gliomas were cerebral; the frequency of cerebellar tumors (22%-32% of gliomas) increased sharply after the first year of life. Of the tumors for which grade was available, 77% were low grade (grade I or II). Tumor grade emerged as the most significant independent prognostic factor in all age groups except the youngest age group, in which extent of resection was most significant. Surgery other than gross total resection was an adverse prognostic factor (hazard ratio, 2.18; 95% confidence interval, 1.78-2.67). Age<3 years predicted a greater likelihood of survival in patients with high-grade gliomas and brainstem tumors. Conversely, age<3 years predicted a lower likelihood of survival in patients with low-grade gliomas. Children aged<1 year received less radiotherapy than older patients (P<.0001) and were less likely to undergo gross total resection (P<.0001).

CONCLUSIONS

The survival of children with gliomas is influenced by histologic subtype, age, and extent of resection. Despite its limitations, the SEER database provides a useful tool for studies of rare tumors such as pediatric gliomas.

Infratentorielle Tumoren

This article gives an overview concerning the typical infratentorial tumors of adults.