Presentation and symptom interval in children with central nervous system tumors. A single-center experience

Early ophthalmological tumour signs and diagnostic interval in children with brain tumours

BACKGROUND

Children with brain tumours often suffer from late diagnosis, impacting cure rates and risk of permanent sequelae. Ophthalmological symptoms are common, and we aimed to investigate the frequency, diagnostic interval, and prognostic value of early-onset ophthalmological brain tumour signs.

METHODS

The study is based on data from national Danish health registries and medical files from hospitals and private ophthalmologists collected from all children diagnosed with a primary brain tumour in Denmark during 2007-2017.

RESULTS

Among 437 included children, 51.7% (n = 226) had ophthalmological tumour signs prior to diagnosis, and 10.8% (n = 47) had ophthalmological symptoms as their initial tumour manifestation. The most common ophthalmological signs in total before diagnosis were reduced visual acuity (n = 73; 16.7%), diplopia (n = 65; 14.9%), abnormal optic nerve (n = 59; 13.5%), and strabismus (n = 50; 11.4%). The median time from initial symptom onset to diagnosis was 12.6 weeks for all children, 15.9 weeks for those with ophthalmological symptoms as their initial tumour sign (p = 0.28), and 12.5 weeks for those with ophthalmological tumour signs at any time before diagnosis (p = 0.71). Children with ophthalmological signs before diagnosis had a higher risk of death (HR: 2.11; 95% CI: 1.32-3.39; p = 0.002).

CONCLUSIONS

Ophthalmological tumour signs are frequent in children with brain tumours, and the diagnostic interval is long regardless of ophthalmological tumour signs being present or not. Taken together with the higher risk of death in the group with ophthalmological tumour signs, this study emphasises the importance of the ophthalmological assessment to ensure timely diagnosis.

Paediatric Central Nervous System Tumours: Symptomatology and Total Diagnostic Interval in a New Zealand Cohort

BACKGROUND

Central nervous system (CNS) tumours are the leading cause of paediatric oncologic death and survivors face high rates of persistent disability. Timeframe from initial symptom to diagnostic radiography [total diagnostic interval (TDI)] is associated with increased morbidity and mortality. Interventions such as HeadSmart and Brain Pathways Guidelines UK have reduced TDI in the United Kingdom through public and professional education campaigns.

AIMS

The overarching aim of this project is to reduce TDI for brain tumours across New Zealand. As there are no local data for TDI in paediatric CNS tumours, we sought baseline data prior to local interventions, which would then inform interventions in the next project phase.

METHODS

Retrospective analysis of patients ≤ 18 years with a CNS tumour in the CHOC catchment between 2015 and 2020. Demographics, tumour type, presenting symptoms/signs, referral pathways and TDI were recorded.

RESULTS

Of 72 cases, median TDI was 9 weeks (0-156 weeks). This was lower in patients aged < 4 years compared with > 4 years (4 weeks vs. 13 weeks), in high grade tumours compared to low grade (4 weeks vs. 13 weeks), and in other ethnicities compared with Māori/Pasifika (6 weeks vs. 16.5 weeks) (p < 0.05 for all comparisons). Symptomatology was similar to Brain Pathways, however, some signs including head circumference were poorly recorded and identify areas for improvement.

CONCLUSIONS

Median TDI is higher than recommended targets, and there is ethnic disparity. This gives impetus for local intervention, using strategies comparable to Brain Pathways.

Delay in the Diagnosis of Pediatric Brain Tumors in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Vague symptoms and a lack of pathognomonic features hinder the timely diagnosis of pediatric brain tumors (PBTs). However, patients in low- and middle-income countries (LMICs) must also bear the brunt of a multitude of additional factors contributing to diagnostic delays and subsequently affecting survival. Therefore, this study aims to assess these factors and quantify the durations associated with diagnostic delays for PBTs in LMICs.

METHODS

A systematic review of extant literature regarding children from LMICs diagnosed with brain tumors was conducted. Articles published before June 2023 were identified using PubMed, Google Scholar, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. A meta-analysis was conducted using a random-effects model through R Statistical Software. Quality was assessed using the Newcastle Ottawa Scale.

RESULTS

A total of 40 studies including 2483 patients with PBT from 21 LMICs were identified. Overall, nonspecific symptoms (62.5%) and socioeconomic status (45.0%) were the most frequently reported factors contributing to diagnostic delays. Potential sources of patient-associated delay included lack of parental awareness (45.0%) and financial constraints (42.5%). Factors contributing to health care system delays included misdiagnoses (42.5%) and improper referrals (32.5%). A pooled mean prediagnostic symptomatic interval was calculated to be 230.77 days (127.58-333.96), the patient-associated delay was 146.02 days (16.47-275.57), and the health care system delay was 225.05 days (-64.79 to 514.89).

CONCLUSION

A multitude of factors contribute to diagnostic delays in LMICs. The disproportionate effect of these factors is demonstrated by the long interval between symptom onset and the definitive diagnosis of PBTs in LMICs, when compared with high-income countries. While evidence-based policy recommendations may improve the pace of diagnosis, policy makers will need to be cognizant of the unique challenges patients and health care systems face in LMICs.

Patient- and parent-reported diagnostic delay in children with central nervous system tumors in Denmark

BACKGROUND

Diagnostic delays in childhood tumors of the central nervous system (CNS) pose a significant challenge. The aim of this study was to map diagnostic delay and presenting symptoms in Denmark.

METHODS

The study was a retrospective questionnaire study, mapping delay and symptoms in pediatric patients (0-17 years), diagnosed with a CNS tumor from 2015 to 2019. Descriptive analysis was performed to measure delay in days, reported as total diagnostic interval (TDI), patient interval (PI), and diagnostic interval (DI). Analysis of symptoms, contacts to healthcare professionals, and socioeconomic status was also performed.

RESULTS

We included 89 patients (median age 7.0 years, 54% male). The TDI was median of 106 days (range: 0-2694 days). Low-grade tumors had longer TDI than high-grade tumors (125 vs. 43 days; p ≤ .02). Patients aged 15-17 displayed the longest TDI (median 665 days). Number of symptoms at onset were inversely associated with longer TDI in patients presenting one symptom (247 days) and patients presenting two to three (110 days) or greater than three complaints (66 days). PI was not associated with sex (p = .14), tumor grade (p = .63), location (p = .32), or socioeconomic status (p = .82). Most frequent single complaint at onset was headache (19%), most frequent combination of symptoms was headache and vomiting (60%).

CONCLUSION

We found TDIs longer than reported in contemporary publications. TDI was longer in patients with low-grade tumors and only few symptoms at the time of onset. The findings support the crucial need of awareness and improved diagnostic tools to recognize and interpret symptoms to promote timely diagnosis.

Hjernetegn.dk-The Danish Central Nervous System Tumor Awareness Initiative Digital Decision Support Tool: Design and Implementation Report

BACKGROUND

Childhood tumors in the central nervous system (CNS) have longer diagnostic delays than other pediatric tumors. Vague presenting symptoms pose a challenge in the diagnostic process; it has been indicated that patients and parents may be hesitant to seek help, and health care professionals (HCPs) may lack awareness and knowledge about clinical presentation. To raise awareness among HCPs, the Danish CNS tumor awareness initiative hjernetegn.dk was launched.

OBJECTIVE

This study aims to present the learnings from designing and implementing a decision support tool for HCPs to reduce diagnostic delay in childhood CNS tumors. The aims also include decisions regarding strategies for dissemination and use of social media, and an evaluation of the digital impact 6 months after launch.

METHODS

The phases of developing and implementing the tool include participatory co-creation workshops, designing the website and digital platforms, and implementing a press and media strategy. The digital impact of hjernetegn.dk was evaluated through website analytics and social media engagement.

IMPLEMENTATION (RESULTS)

hjernetegn.dk was launched in August 2023. The results after 6 months exceeded key performance indicators. The analysis showed a high number of website visitors and engagement, with a plateau reached 3 months after the initial launch. The LinkedIn campaign and Google Search strategy also generated a high number of impressions and clicks.

CONCLUSIONS

The findings suggest that the initiative has been successfully integrated, raising awareness and providing a valuable tool for HCPs in diagnosing childhood CNS tumors. The study highlights the importance of interdisciplinary collaboration, co-creation, and ongoing community management, as well as broad dissemination strategies when introducing a digital support tool.

Neurosurgical treatment of pediatric brain tumors - results from a single center multidisciplinary setup

OBJECTIVE

The challenge of pediatric brain tumor surgery is given due to a relative low prevalence but high heterogeneity in age, localization, and pathology. Improvements of long-term overall survival rates were achieved during the past decades stressing the importance of a multidisciplinary decision process guided by a national treatment protocol. We reviewed the entire spectrum of pediatric brain tumor surgeries from the perspective of an interdisciplinary pediatric neuro-oncology center in Germany.

METHODS

Every patient who underwent brain tumor surgery from January 2010 to June 2017 in our Pediatric Neurosurgery department was retrospectively included and evaluated regarding the course of treatment. Perioperative data such as tumor localization, timing of surgery, extent of resection, neuropathological diagnosis, transfusion rates, oncologic and radiation therapy, and neurological follow-up including morbidity and mortality were evaluated.

RESULTS

Two hundred ninety-three pediatric brain tumor patients were applicable (age: 8.28 ± 5.62 years, 1.22:1.0 m:f). A total of 531 tumor surgical interventions was performed within these patients (457 tumor resections, 74 tumor biopsies; mean interventions per patient 1.8 ± 1.2). Due to a critical neurologic status, 32 operations (6%) were performed on the day of admission. In 65.2% of all cases, tumor were approached supratentorially. Most frequent diagnoses of the cases were glial tumors (47.8%) and embryonal tumors (17.6%). Preoperative planned extent of resection was achieved in 92.7%. Pre- and postoperative neurologic deficits resolved completely in 30.7%, whereas symptom regressed in 28.6% of surgical interventions. New postoperative neurologic deficit was observed in 10.7%, which resolved or improved in 80% of these cases during 30 days. The mortality rate was 1%.

CONCLUSION

We outlined the center perspective of a specialized pediatric neuro-oncological center describing the heterogeneous distribution of cases regarding age-related prevalence, tumor localization, and biology, which requires a high multidisciplinary expertise. The study contributes to define challenges in treating pediatric brain tumors and to develop quality indicators for pediatric neuro-oncological surgery. We assume that an adequate volume load of patients within a interdisciplinary infrastructure is warranted to aim for effective treatment and decent quality of life for the majority of long-term surviving pediatric tumor patients.

Total diagnostic interval in children with brain tumours in a middle-income country: national experience from Serbia

PURPOSE

The aim was to evaluate the total diagnostic interval (TDI) and presenting complaints in children with brain tumours in Serbia.

METHODS

This study retrospectively analysed 212 children aged 0-18 years newly diagnosed with brain tumours in two tertiary centres from mid-March 2015 to mid-March 2020 covering virtually all children with brain tumours in Serbia. TDI was calculated as the difference between the date of diagnosis and the date of symptom onset presented as a median in weeks. This variable has been evaluable for 184 patients.

RESULTS

Overall TDI was 6 weeks. TDI was significantly longer in patients with low-grade tumours (11 weeks) than in patients with high-grade tumours (4 weeks). Children with the most frequent complaints (headache, nausea/vomiting and gait disturbance) were more likely to be diagnosed sooner. Patients with a single complaint had significantly longer TDI (12.5 weeks) contrasted to patients with multiple complaints (5 weeks).

CONCLUSION

TDI with a median of 6 weeks is similar to other developed countries. Our study supports the view that low-grade tumours will present later than high-grade tumours. Children with the commonest complaints and children with multiple complaints were more likely to be diagnosed sooner.

Nutritional status and inflammatory markers as survival predictors in pediatric central nervous system tumors

BACKGROUND & AIMS

Central nervous system tumors (CNS) are the second most common malignancies in childhood. Inflammation and changes in nutritional status play an important role and can be used as prognostic markers. Thus, this study aimed to evaluate the predictive ability of nutritional status and inflammatory markers on overall survival (OS) of pediatric patients with CNS.

METHODS

In this retrospective cohort study, 103 patients were followed for 5 years. Clinical, anthropometric, and hematological data were collected. Body mass index for age (BMI/A), neutrophil-to-lymphocyte ratio (NLR) and systemic inflammation response index (SIRI) were calculated. OS curves were calculated using the Kaplan Meier method and evaluated using the Log-Rank test. The Cox proportional hazards model was performed to identify independent variables associated with prognostic factors, generating hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Nutritional status did not significantly affect OS. However, patients with NLR ≥2.18 and SIRI ≥1249.18 had significantly lower OS in 5 years. Only treatment and high NLR were identified as independent prognostic factors for worse OS. Treatment with exclusive radiotherapy or chemotherapy (HR: 16.22, 95% CI: 2.19-120.07) and NLR (HR: 1.94, 95% CI: 1.02-3.69) were identified as independent prognostic factors for worse OS at 5 years.

CONCLUSION

High pretreatment NLR was shown to be an independent prognostic factor for OS in pediatric patients with CNS.

The effects of educational interventions and the COVID-19 pandemic on the time to diagnosis in pediatric patients with primary central nervous system tumors

Background

Primary central nervous system tumors are a leading cause of death and disability amongst pediatric cancer patients. Akron Children's Hospital published data in 2018 on response time for brain tumor diagnosis and implemented components of an established program to decrease diagnostic delays and thereby reduce tumor- and treatment-related morbidities. This study evaluates if there was an improvement in the total diagnostic interval (TDI, time from symptom onset to diagnosis) after provider education. During the study, the COVID-19 pandemic forced alterations in care delivery. The impact this had on the TDI was also assessed.

Methods

A retrospective chart review was performed, and patients were separated into 2008-2017 (historical) and 2018-2021 (posteducation) groups to assess the effect of educational interventions on TDI. The posteducation cohort was analyzed separately to assess the impact of COVID-19 pandemic.

Results

The 85 patients studied in the post-education group showed a median TDI of 31 days. Though not statistically significant (P = .939), this represents an 11-day decrease in median TDI compared to the historical group (42 days). In addition, the posteducation group showed an increase in the average number of healthcare provider visits (HCP, 2.4 historical to 3.2 posteducation, P = .009). The pre-COVID-19 group (median TDI 43.5 days) did not differ statistically from the post-COVID-19 group (30-day median TDI).

Conclusion

The nonsignificant decrease in TDI and concurrent increase in HCP visits after implementation of education suggests a potential gap amongst providers in working-up primary CNS tumors. These results will influence expansion of education to further improve TDI.

Delay in the diagnosis of paediatric brain tumours: a systematic review

PURPOSE

A delay in obtaining a diagnosis has been associated with inferior outcomes across several cancer types, including paediatric brain tumours. However, no clear evidence exists in this population. We aimed to quantify the reported pre-diagnostic symptom interval (PSI) as the time from onset of first symptoms to diagnosis in the literature, in addition to evaluating the relationship between delay and outcomes, including survival.

METHODS

A systematic review of the literature was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Wiley Online Library, Web of Science and EMBASE databases were searched. We considered all sources published between 1st January 2010 and 5th November 2022. Children and adolescents aged under 21 years, with new symptomatic primary brain tumour diagnoses, were included.

RESULTS

Of 3123 studies identified, 11 were included for analysis. Owing to study heterogeneity, a quantitative meta-analysis was not feasible; however, a narrative synthesis was performed. The median reported PSI varied widely, ranging between 28 and 760.8 days. We failed to identify a significant association between prolonged PSI and inferior overall survival. Few factors were consistently associated with prolonged PSI, amongst them only tumour grade and patient age.

CONCLUSION

Delayed diagnosis of paediatric brain tumours was not associated with inferior survival within this review. This 'waiting time' paradox appears to result from several confounding factors including tumour biology, patient population and key systematic factors that were inconsistently reported. Diagnostic interval clearly presents a complex variable, reflected further by disparity in the reporting of delay within the literature. Ultimately diagnostic interval is unlikely to provide a meaningful representation for all tumour types and should not detract from sharp clinical acumen and prompt diagnosis.

Parental Awareness of Headaches Among Elementary School-Aged Children in Makkah, Saudi Arabia: A Cross-Sectional Study

Background Headaches are a prevalent form of pain experienced in the skull, face, and facial structures, categorized into two types: primary and secondary. Primary headaches are more frequently observed in children and can be triggered by sleep disturbances, vision problems, malnutrition, and other medical conditions. Despite their prevalence among children, these headaches often go unrecognized and untreated, and there seems to be insufficient parental awareness regarding childhood headaches. This study aims to determine the prevalence of childhood headaches and assess awareness about this among parents of elementary school-aged children in Makkah, Saudi Arabia, to enhance parental understanding of this issue. Methods Data were collected through an online survey created using Google Forms (Google LLC, Mountain View, California, United States), distributed to parents residing in Makkah. The survey was disseminated in March 2023. Results A total of 499 parents completed the study questionnaire, comprising 399 mothers and 100 fathers, with a mean parental age of 37.1 ± 13.9 years. Of the participants, 89.2% were married, 91% were Saudi nationals, and 105 had secondary education. Parents reported that 13.2% of their children complained of headaches, with 55.3% describing them as occasional. Among the respondents, 178 parents sought medical care for their children's headaches primarily out of fear. It was found that 69.7% of parents with higher education had good knowledge regarding childhood headaches, while 59.8% of employed parents had good knowledge compared to 43.8% of others. Conclusion This study revealed a lack of adequate knowledge and awareness among parents regarding headaches in children residing in Makkah. Therefore, we recommend conducting further research and implementing educational initiatives to enhance parental understanding of childhood headaches in Makkah and other regions of Saudi Arabia.

Musculoskeletal misdiagnoses in children with brain tumors: A nationwide, multicenter case-control study

OBJECTIVE

Childhood brain tumors belong to the cancer type with the longest diagnostic delay, the highest health care utilization prior to diagnosis, and the highest burden of long-term sequelae. We aimed to clarify whether prior musculoskeletal diagnoses in childhood brain cancer were misdiagnoses and whether it affected the diagnostic delay.

STUDY DESIGN

In this retrospective, chart-reviewed case-control study we compared 28 children with brain tumors and a prior musculoskeletal diagnosis to a sex and age-matched control group of 56 children with brain tumors and no prior musculoskeletal diagnosis. Using the Danish registries, the cases were identified from consecutive cases of childhood brain cancers in Denmark over 23 years (1996-2018).

RESULTS

Of 931 children with brain tumors, 3% (28/931) had a prior musculoskeletal diagnosis, of which 39% (11/28) were misdiagnoses. The misdiagnoses primarily included torticollis-related diagnoses which tended to a longer time interval from first hospital contact until a specialist was involved: 35 days (IQR 6-166 days) compared to 3 days (IQR 1-48 days), p = 0.07. When comparing the 28 children with a prior musculoskeletal diagnosis with a matched control group without a prior musculoskeletal diagnosis, we found no difference in the non-musculoskeletal clinical presentation, the diagnostic time interval, or survival. Infratentorial tumor location was associated with a seven-fold risk of musculoskeletal misdiagnosis compared to supratentorial tumor location.

CONCLUSION

Musculoskeletal misdiagnoses were rare in children with brain tumors and had no significant association to the diagnostic time interval or survival. The misdiagnoses consisted primarily of torticollis- or otherwise neck-related diagnoses.

Identifying Posterior Fossa Abnormality in Pediatric Aerodigestive Patients, a Case Series

OBJECTIVES

Multidisciplinary clinics like Aerodigestive programs focus on issues associated with airway, pulmonary, and gastrointestinal issues. Rarely, significant neurological issues like posterior fossa abnormality are identified as the primary etiology. We describe 3 such patients and compare their clinical presentation to the other patients seen in Aerodigestive clinic.

METHODS

A retrospective chart review was conducted to review the 3 posterior fossa patients and the remainder of children that were referred to the Aerodigestive Clinic at Children's Hospital Los Angeles from June 2016 to August 2018. Clinical characteristics including triple endoscopies and sleep studies were recorded.

RESULTS

Of the 110 patients included for review, 3 patients (3%) had an underlying posterior fossa abnormality; all of whom had symptoms of sleep disordered breathing along with dysphagia compared with 30% incidence of this symptom profile in the remaining Aerodigestive population.

CONCLUSION

Presence of sleep disordered breathing and dysphagia, with underlying vomiting history, warrants considering evaluation for posterior fossa abnormalities in addition to traditional workup for aerodigestive disorders. Due to the rarity of this presentation and small sample size, future studies with multicenter collaboration may help better describe identifiers to delineate this population with similar aerodigestive symptoms and clarify diagnostic algorithms.

Ophthalmological Findings in Youths With a Newly Diagnosed Brain Tumor

Importance

Visual impairment is an irreversible adverse effect in individuals who experienced a childhood brain tumor. Ophthalmological evaluation at diagnosis enables early detection of vision loss, decision-making about treatment, and when applicable, the timely use of visual interventions. However, awareness of visual impairment in clinical practice is suboptimal, and adherence to ophthalmological evaluation needs to be improved.

Objective

To assess the prevalence and types of abnormal ophthalmological findings in youths with a newly diagnosed brain tumor.

Design, Setting, and Participants

In this nationwide, prospective cohort study, youths aged 0 to 18 years with a newly diagnosed brain tumor between May 15, 2019, and August 11, 2021, were consecutively enrolled in 4 hospitals in the Netherlands, including the dedicated tertiary referral center for pediatric oncology care.

Exposures

A standardized and comprehensive ophthalmological examination, including orthoptic evaluation, visual acuity testing, visual field examination, and ophthalmoscopy, was performed within 4 weeks from brain tumor diagnosis.

Main Outcomes and Measures

The main outcomes were prevalence and types of visual symptoms and abnormal ophthalmological findings at brain tumor diagnosis.

Results

Of 170 youths included in the study (96 [56.5%] male; median age, 8.3 years [range, 0.2-17.8 years]), 82 (48.2%) had infratentorial tumors; 53 (31.2%), supratentorial midline tumors; and 35 (20.6%), cerebral hemisphere tumors. A total of 161 patients (94.7%) underwent orthoptic evaluation (67 [41.6%] preoperatively; 94 [58.4%] postoperatively); 152 (89.4%), visual acuity testing (63 [41.4%] preoperatively; 89 [58.6%] postoperatively); 121 (71.2%), visual field examination (49 [40.4%] preoperatively; 72 [59.6%] postoperatively); and 164 (96.5%), ophthalmoscopy (82 [50.0%] preoperatively; 82 [50.0%] postoperatively). Overall, 101 youths (59.4%) presented with visual symptoms at diagnosis. Abnormal findings were found in 134 patients (78.8%) during ophthalmological examination. The most common abnormal findings were papilledema in 86 of 164 patients (52.4%) who underwent ophthalmoscopy, gaze deficits in 54 of 161 (33.5%) who underwent orthoptic evaluation, visual field defects in 32 of 114 (28.1%) with reliable visual field examination, nystagmus in 40 (24.8%) and strabismus in 32 (19.9%) of 161 who underwent orthoptic evaluation, and decreased visual acuity in 13 of 152 (8.6%) with reliable visual acuity testing. Forty-five of 69 youths (65.2%) without visual symptoms at diagnosis had ophthalmological abnormalities on examination.

Conclusions and Relevance

The results of this study suggest that there is a high prevalence of abnormal ophthalmological findings in youths at brain tumor diagnosis regardless of the presence of visual symptoms. These findings support the need of standardized ophthalmological examination and the awareness of ophthalmologists and referring oncologists, neurologists, and neurosurgeons for ophthalmological abnormalities in this patient group.

Involvement of the optic pathway and outcome of visual function in patients with neurohypophyseal germ cell tumor

BACKGROUND

Patients with neurohypophyseal germ cell tumors (GCTs) typically present with visual problems. Hence, this study aimed to assess optic pathway involvement based on clinical and radiological findings and to validate the outcome of visual function.

METHODS

A total of 16 patients with newly diagnosed neurohypophyseal GCTs who were treated at the University of Tsukuba Hospital between 2000 and 2020 were included in this study.

RESULTS

The median interval from symptom onset to diagnosis was 173.5 days (range, 33-1588 days). Patients with visual disturbance at diagnosis had a longer time to diagnosis compared with those without. Ophthalmologic abnormalities were frequently observed, with an incidence rate of 69%. Fifty percent of patients exhibited optic pathway involvement detected via magnetic resonance imaging (MRI). Visual impairment was more severe in the patients with optic pathway involvement (p = 0.002). Post-treatment visual impairment was improved but was still significantly severe in patients with optic pathway involvement than in those without involvement (p = 0.010). Visual field deficit more likely remained with an improvement rate of 50%, whereas the improvement rate of visual acuity was 78%. Further, none developed late-onset visual deterioration during the follow-up period.

CONCLUSIONS

Visual disturbance and optic pathway involvement are common in neurohypophyseal GCTs. Visual impairment particularly in patients with optic pathway involvement on MRI is more likely to remain at follow-up, although the outcome of visual function is acceptable in most cases.

Presenting symptoms and time to diagnosis for Pediatric Central Nervous System Tumors in Qatar: a report from Pediatric Neuro-Oncology Service in Qatar

INTRODUCTION

There are no previous published reports on primary pediatric tumors of the central nervous system (CNS) in Qatar. We undertook this retrospective cohort study to review the diagnosis of CNS tumors in children in Qatar to analyze the presentation characteristics including symptoms, referral pathways, and time to diagnosis.

METHODS

All children registered with Pediatric Neuro-Oncology service (PNOS) were included in the study. Data from the time of diagnosis (October 2007 to February 2020) were reviewed retrospectively. Presenting symptoms were recorded and pre-diagnosis symptom interval (PSI) was calculated from the onset of the first symptom to the date of diagnostic imaging.

RESULTS

Of the 61 children registered with PNOS during the study period, 51 were included in the final analysis. Ten children were excluded because they were either diagnosed outside Qatar (n = 7) or were asymptomatic at the time of diagnosis (n = 3). The median age was 45 (range 1-171) months. Common tumor types included low-grade glioma (LGG) (47.1%) and medulloblastoma/primitive neuro-ectodermal tumors (PNET) (23.5%). Nine children had an underlying neurocutaneous syndrome. Thirty-eight patients (74.5%) had at least one previous contact with healthcare (HC) professional, but 27 (52%) were still diagnosed through the emergency department (ED). Presenting symptoms included headache, vomiting (36.2%), oculo-visual symptoms (20.6%), motor weakness (18.9%), seizures, ataxia (17.2% each), irritability, cranial nerve palsies (12% each), and endocrine symptoms (10.3%). Median PSI was 28 days (range 1-845 days) for all CNS tumors. Longest PSI was seen with germ cell tumors (median 146 days), supratentorial location (39 days), and age above 3 years (30 days). Tumor characteristics of biological behavior (high-grade tumor) and location (infratentorial) were significantly associated with shorter PSI, as were presenting symptoms of ataxia, head tilt, and altered consciousness.

CONCLUSIONS

Although overall diagnostic times were acceptable, some tumor types were diagnosed after a significant delay. The awareness campaign, such as the "HeadSmart" campaign in the United Kingdom (UK), can improve diagnostic times in Qatar. Further research is required to better understand the reasons for the delay.

Time to diagnosis and clinical characteristics in pediatric brain tumor patients

PURPOSE

We aimed to identify factors that affect the time to diagnosis in pediatric brain tumors and investigate the effect of time to diagnosis on clinical outcome.

METHODS

A retrospective study of children with brain tumors aged less than 18 years diagnosed at the University of Tsukuba Hospital over a period of 7 years was conducted.

RESULTS

Eighty-five consecutive patients, with a mean age of 9.1 years, were included in the study. The median interval from symptom onset to diagnosis was 45 days (range 0-1673); median interval from symptom onset to first presentation was 31.0 days; and median interval from first presentation to diagnosis was 13.5 days. Germinoma had the longest interval from symptom onset to first presentation, and from first presentation to diagnosis. Patients presenting with endocrine disorder had a significantly longer interval from symptom onset to first presentation (p = 0.019); those with visual disturbance (p = 0.016) or endocrine disorder (p = 0.030) had significantly longer intervals from first presentation to diagnosis.

CONCLUSION

Pediatric brain tumor patients with germinoma and presenting symptoms of endocrine disorder or visual disturbance have a longer time to diagnosis. Although improved prognosis is not clearly related to a shorter time to diagnosis, we believe that early diagnosis can lead to improved treatment and better quality of life. A detailed medical history and neuroimaging studies at the earliest time possible are important for early diagnosis.

The Role of Time as a Prognostic Factor in Pediatric Brain Tumors: a Multivariate Survival Analysis

There is no evidence that prolonged pre diagnostic symptomatic intervals (PSI) increases the risk of death in pediatric brain tumors. When investigating the role of time previous research had not controlled for confounding variables or measured the pretreatment interval (PTI). We use the term global delay interval (GDI) to describe the sum of PSI and PTI. The aim of this research was to evaluate whether there was a decrease in the probability of survival in children with brain tumors due to a prolonged PSI, PTI and GDI, using a multivariate survival analysis. We retrospective review 127 clinical records labeled with the diagnosis of CNS tumors attended at a specialized pediatric center in Mexico City from January 2008 to December 2012. Patients with PSI and GDI diagnosed between 3 and 6 months showed statistical lower probability of surviving that those with intervals <3 months even when adjusting for age, sex, localization and tumor grade. When stratified for the place of residency and adjusted for sex, age, localization, grade of tumor, type of surgery and coadjuvant therapy, a GDI between 3 and 6 months showed to be a risk factor for the overall survival of brain tumors compared with an interval < 3 months. When analyzing the interaction, high grade tumors are at more risk of dying when GDI was between 3 and 6 months compared to <3 months. Prolonged PSI and GDI showed to be a potential prognostic factor for survival in CNS tumors, especially in high grade tumors. Future prospective research should measure the PSI, PTI and GDI and adjust for covariates in order to properly infer the effect of time in pediatric brain tumors.

The Management of Childhood Intracranial Tumours and the Role of the Ophthalmologist

OBJECTIVE

This study looked at a single paediatric neuro-oncology centre's experience of childhood intracranial tumours seen in the ophthalmology clinic over an approximately five-year period. This was used to analyse the role of the ophthalmologist in their long term follow up.

METHODS

A database was compiled of all children discussed at the neuro-oncology multi-disciplinary team (MDT) meeting between January 2012 and April 2017. All children who had an intracranial tumour determined by histology or suspected on neuro-imaging, who had also been seen in the ophthalmology clinic, were included. A retrospective case review was performed to create a record for each child.

RESULTS

The database contained 129 children of which 82 (64%) were boys and 47 (36%) were girls. Of these 89 (69%) had a histological diagnosis and 40 (31%) had a tumour suspected on neuroimaging. The most common tumour locations were the posterior fossa (n = 54, 42%), diencephalon (n = 20, 16%) and the visual pathways (n = 17, 13%). Papilloedema at first presentation was only found in 39 (30%) children. The most common other neuro-ophthalmic manifestations were non-paralytic strabismus (n=33), sixth nerve palsy (n=19) and seventh nerve palsy (n=12). Non-paralytic strabismus was a presenting symptom in only one case. There were 13 ophthalmic surgical procedures required for these children, the most common being strabismus surgery.

CONCLUSION

We report the types and locations of paediatric intracranial tumours seen in the ophthalmology clinic as well as their neuro-ophthalmic manifestations. Only 30% presented with papilloedema and approximately 10% required an ophthalmic surgical procedure.

Clinical presentation of young people (10-24 years old) with brain tumors: results from the international MOBI-Kids study

Introduction

We used data from MOBI-Kids, a 14-country international collaborative case–control study of brain tumors (BTs), to study clinical characteristics of the tumors in older children (10 years or older), adolescents and young adults (up to the age of 24).

Methods

Information from clinical records was obtained for 899 BT cases, including signs and symptoms, symptom onset, diagnosis date, tumor type and location.

Results

Overall, 64% of all tumors were low-grade, 76% were neuroepithelial tumors and 62% gliomas. There were more males than females among neuroepithelial and embryonal tumor cases, but more females with meningeal tumors. The most frequent locations were cerebellum (22%) and frontal (16%) lobe. The most frequent symptom was headaches (60%), overall, as well as for gliomas, embryonal and ‘non-neuroepithelial’ tumors; it was convulsions/seizures for neuroepithelial tumors other than glioma, and visual signs and symptoms for meningiomas. A cluster analysis showed that headaches and nausea/vomiting was the only combination of symptoms that exceeded a cutoff of 50%, with a joint occurrence of 67%. Overall, the median time from first symptom to diagnosis was 1.42 months (IQR 0.53–4.80); it exceeded 1 year in 12% of cases, though no particular symptom was associated with exceptionally long or short delays.

Conclusions

This is the largest clinical epidemiology study of BT in young people conducted so far. Many signs and symptoms were identified, dominated by headaches and nausea/vomiting. Diagnosis was generally rapid but in 12% diagnostic delay exceeded 1 year with none of the symptoms been associated with a distinctly long time until diagnosis.

Electronic supplementary material

The online version of this article (10.1007/s11060-020-03437-4) contains supplementary material, which is available to authorized users.

Management of Childhood Headache in the Emergency Department. Review of the Literature

Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.

Social determinants of health affecting treatment of pediatric brain tumors

OBJECTIVE

Little is understood about the role that health disparities play in the treatment and management of brain tumors in children. The purpose of this study was to determine if health disparities impact the timing of initial and follow-up care of patients, as well as overall survival.

METHODS

The authors conducted a retrospective study of pediatric patients (< 18 years of age) previously diagnosed with, and initially treated for, a primary CNS tumor between 2005 and 2012 at Monroe Carell Jr. Children's Hospital at Vanderbilt. Primary outcomes included time from symptom presentation to initial neurosurgery consultation and percentage of missed follow-up visits for ancillary or core services (defined as no-show visits). Core services were defined as healthcare interactions directly involved with CNS tumor management, whereas ancillary services were appointments that might be related to overall care of the patient but not directly focused on treatment of the tumor. Statistical analysis included Pearson's chi-square test, nonparametric univariable tests, and multivariable linear regression. Statistical significance was set a priori at p < 0.05.

RESULTS

The analysis included 198 patients. The median time from symptom onset to initial presentation was 30.0 days. A mean of 7.45% of all core visits were missed. When comparing African American and Caucasian patients, there was no significant difference in age at diagnosis, timing of initial symptoms, or tumor grade. African American patients missed significantly more core visits than Caucasian patients (p = 0.007); this became even more significant when controlling for other factors in the multivariable analysis (p < 0.001). African American patients were more likely to have public insurance, while Caucasian patients were more likely to have private insurance (p = 0.025). When evaluating survival, no health disparities were identified.

CONCLUSIONS

No significant health disparities were identified when evaluating the timing of presentation and survival. A racial disparity was noted when evaluating missed follow-up visits. Future work should focus on identifying reasons for differences and whether social determinants of health affect other aspects of treatment.

Patterns, treatments, and outcomes of pediatric central nervous system tumors in Sudan: a single institution experience

PURPOSE

Studies of epidemiology, treatment modalities, and outcomes of childhood central nervous system (CNS) tumors in Sudan are scarce. To address this shortcoming, we evaluated baseline information about the epidemiology, treatment types, and outcomes of childhood CNS tumors at the National Cancer Institute, University of Gezira (NCI-UG) in Wad Madani, Sudan.

METHODS

We performed a retrospective health facility-based study of children with CNS tumors who were treated at the NCI-UG from January 2000 to December 2015.

RESULTS

A total of 62 (5.4% of all childhood cancers) pediatric patients with CNS tumors were identified over the study period. Tumors were more common among male children and involved the infratentorial compartment in 58% of cases. The median age at diagnosis was 9 years (range, 2-14 years). Approximately 60% (n = 37) of the study population had histology-determined diagnoses. Astrocytomas and medulloblastomas were the most common tumors in these cases. The mean time to diagnosis was 6 months (SD, 9). During the study period, the number of children with CNS tumors who were referred for treatment at the NCI-UG increased every year. Of the 37 patients who received surgical interventions, 8 received gross total resections, 20 received partial resections, and 24 received postoperative radiotherapy. The treatment abandonment rate was 11%. The 2-year and 5-year survival rates were 33% and 13%, respectively.

CONCLUSION

Our findings reveal a high incidence of poor outcomes for patients with CNS tumors in Sudan, which is most likely due to many distinct factors.