Ependymomas in adults

Geriatric patients undergo surgery less and have worse survival outcomes with intramedullary ependymoma: A surveillance, epidemiology, and end results database analysis

OBJECTIVE

Intramedullary ependymomas account for ∼50 % of all primary tumors in the spinal cord. Though gross total resection has become mainstay, other predictors of survival remain poorly characterized. The present study aims to perform a survival analysis and compare prognostic factors across pediatric, adult and geriatric cohorts.

METHODS

The Surveillance, Epidemiology, and End Results database was employed to isolate cases of intramedullary ependymomas from 2000 to 2021. Cases were grouped based on age: 0-19 years=pediatric, 20-64 years=adult, 65 + years=geriatric. Kaplan Meier followed by multivariate cox regression analyses were used to identify survival trends. Univariate comparison analyses compared age cohorts.

RESULTS

2045 cases were included. Geriatric patients demonstrate increased risk of mortality (pediatric vs geriatric: HR=0.23, CI [0.13-0.39], p < 0.001; adult vs geriatric: HR=0.18, CI [0.15-0.23], p < 0.001). Compared to adult patients (92.7 %), geriatric patients (85.2 %) underwent significantly less surgery (p < 0.001). Sex did not influence pediatric or geriatric survival nor did surgery statistically impact pediatric survival, but otherwise surgery not performed, male patients and grade III tumors significantly worsened overall and age-specific survival. Surgery performed in a pediatric patient led to a longer mean survival of 19.8 months, which is clinically relevant despite not meeting statistical significance. Year of diagnosis did not impact overall (p = 0.79) nor age-specific survival (pediatric: p = 0.98, adult: p = 0.91, geriatric: p = 0.11).

CONCLUSIONS

Geriatric patients suffer from worse survival than those of younger age. Surgery decreases mortality, yet less geriatric patients are receiving surgical resection. No significant survival gains have been made over the last two decades among any age. Further study is needed to optimize medical management to compliment surgical resection and surgery should be considered more often in geriatric patients to improve survival.

Liquid Biopsy for Spinal Tumors: On the Frontiers of Clinical Application

STUDY DESIGN

Narrative review.

OBJECTIVES

This article aims to provide a narrative review of the current state of research for liquid biopsy in spinal tumors and to discuss the potential application of liquid biopsy in the clinical management of patients with spinal tumors.

METHODS

A comprehensive review of the literature was performed using PubMed, Google Scholar, Medline, Embase and Cochrane databases, and the review was limited to articles of English language. All the relevant articles which were identified to be related to liquid biomarker study in spinal tumors, were studied in full text.

RESULTS

Liquid biopsy has revolutionized the field of precision medicine by guiding personalized clinical management of cancer patients based on the liquid biomarker status. In recent years, more research has been done to investigate its potential utilization in patients with tumors from the spine. Herein, we review the liquid biomarkers that have been proposed in different spine malignancies including chordoma, chondrosarcoma, Ewing sarcoma, osteosarcoma, astrocytoma and ependymoma. We also discuss the wide window of opportunity to utilize these liquid biomarkers in diagnosis, treatment response, monitoring, and detection of minimal residual disease in patients with spinal tumors.

CONCLUSIONS

Liquid biomarkers, especially blood-derived circulating tumor DNA, has a promising clinical utility as they are disease-specific, minimally invasive, and the procedure is repeatable. Prospective studies with larger populations are needed to fully establish its use in the setting of spinal tumors.

Intracranial ependymoma: A retrospective analysis of clinical features, treatment modalities, and long-term outcome

Objective

Ependymomas, rare neuroglial tumors originating from ependymal cells, can occur in the CNS and typically affect the brain's ventricles or spinal cord. Prognosis is influenced by tumor grade, location, resection extent, and preoperative Karnofsky Performance Status Scale (KPSS) scores. This study evaluates clinical features, treatment outcomes, and factors affecting prognosis in patients with intracranial ependymomas.

Methods

A retrospective review of 23 patients with intracranial ependymomas, treated from 2018 to 2023, was conducted. Data included demographics, clinical presentations, KPSS scores, imaging findings, and treatment details. Outcomes assessed were postoperative complications, recurrence rates, and functional status. Statistical analysis used SPSS version 26, with significance set at p < 0.05.

Results

The cohort was predominantly male (87.0%), with a mean age of 27 years. Tumors were mostly in the fourth ventricle (82.6%), with an average diameter of 68.9 mm. Complete resection was achieved in 87.0% of cases. Postoperative radiotherapy was given to 91.0% of grade 2 and all grade 3 tumors. Recurrence occurred in 17.4% of grade 2 ependymomas, but none of grade 3. The seven-month mortality rate was 4.3%. Higher preoperative KPSS scores correlated with better outcomes.

Conclusion

Complete tumor resection and postoperative radiotherapy are crucial for improved outcomes in ependymomas. Higher preoperative KPSS scores and tumor location significantly impact prognosis. Tumors in the lateral ventricles are associated with higher recurrence risks. These findings highlight the need for aggressive surgical management and personalized adjuvant therapy to enhance patient outcomes.

Case report on an extremely rare type of ependymoma arising from the thigh

INTRODUCTION

Ependymomas are neuroepithelial neoplasms of the central nervous system that arise from the precursor cells lining the ventricular system and the central canal of the spinal cord. Herein, we report a case of an extremely rare type of ependymoma arising from the thigh. Then, a literature review was performed.

PRESENTATION OF CASE

An 87-year-old female Japanese patient presented with a chief complaint of a mass on the medial aspect of her right thigh. Pathology revealed a grade 2 extra-neural ependymoma. PET-CT and brain MRI showed no neoplastic lesions in the central nervous system, and the tumor was localized only in the right thigh. The tumor was growing and was treated as a low-grade tumor with extensive resection and postoperative adjuvant radiotherapy. The patient has been alive for 3 years, without postoperative recurrence or complications.

DISCUSSION

This case presents a rare extra-neural ependymoma of central nervous system origin arising in the thigh. The pathogenesis is unknown, but a search for neoplastic lesions in the cerebrospinal cord is warranted. Extra-neural ependymomas should be treated as low-grade tumors because they are more prone to recurrence and metastasis than ordinary ependymomas.

CONCLUSION

We experienced an extremely rare extra-neural ependymoma arising in the thigh. A search for tumors in the central nervous system region of the cerebrospinal cord, previous literature, and clinical, imaging, and pathological findings should be consulted to determine a treatment strategy.

The Role of Radiotherapy, Chemotherapy, and Targeted Therapies in Adult Intramedullary Spinal Cord Tumors

Intramedullary primary spinal cord tumors are rare in adults and their classification has recently evolved. Their treatment most frequently relies on maximal safe surgical resection. Herein, we review, in light of the WHO 2021 classification of central nervous system tumors, the knowledge regarding the role of radiotherapy and systemic treatments in spinal ependymomas, spinal astrocytomas (pilocytic astrocytoma, diffuse astrocytoma, spinal glioblastoma IDH wildtype, diffuse midline glioma H3-K27M altered, and high-grade astrocytoma with piloid features), neuro-glial tumors (ganglioglioma and diffuse leptomeningeal glioneuronal tumor), and hemangioblastomas. In spinal ependymomas, radiotherapy is recommended for incompletely resected grade 2 tumors, grade 3 tumors, and recurrent tumors not amenable to re-surgery. Chemotherapy is used in recurrent cases. In spinal astrocytomas, radiotherapy is recommended for incompletely resected grade 2 astrocytomas and grade 3 or 4 tumors as well as recurrent tumors. Chemotherapy is indicated for newly diagnosed high-grade astrocytomas and recurrent cases. In hemangioblastomas not amenable to surgery, radiotherapy is an effective alternative option. Targeted therapies are playing an increasingly important role in the management of some intramedullary primary spinal cord tumor subtypes. BRAF and/or MEK inhibitors have demonstrated efficacy in pilocytic astrocytomas and glioneuronal tumors, belzutifan in von Hippel-Lindau-related hemangioblastomas, and promising results have been reported with ONC201 in diffuse midline glioma H3-K27M altered.

Disappearance of "Elongated Pony Tail Sign" Following Chemoradiotherapy in a Case of Primary Cerebellopontine Angle Ependymoma With Spinal Drop Metastasis: 18 F-FDG PET/CT Scan Findings

ABSTRACT

Ependymomas are rare glial tumors that commonly arise from the lining cells of ventricular system and constitute ~10% of intracranial pediatric malignancies. The incidence of ependymoma in adults is rare. Due to close approximation with the ventricular system, subtentorial ependymomas are more prone to show cerebrospinal fluid metastasis compared with supratentorial ependymomas. We present a case of subtentorial cerebellopontine angle ependymoma with diffuse spinal drop metastases showing "elongated pony tail appearance" in a 69-year-old man with complete metabolic response on 18 F-FDG PET/CT imaging following chemoradiotherapy.

Modeling of brain tumors using in vitro, in vivo, and microfluidic models: A review of the current developments

Brain cancers are some of the most complex diseases to treat, despite the numerous advances science has made in cancer chemotherapy and research. One of the key obstacles to identifying potential cures for this disease is the difficulty in emulating the complexity of the brain and the surrounding microenvironment to understand potential therapeutic approaches. This paper discusses some of the most important in vitro, in vivo, and microfluidic brain tumor models that aim to address these challenges.

Technical aspects of fourth ventricle ependymomas in adults: how I do it

BACKGROUND

Ependymomas in the fourth ventricle in adults are rare entity. Surgical treatment of adult ependymomas is the only treatment modality since no other effective alternative is available. Radical resection often means cure but it is hindered by the nature and location of the lesion.

METHODS

Technical aspects of the fourth ventricle ependymoma surgery in adults are discussed. Anatomy of the area is provided with the step-by-step surgical algorithm.

CONCLUSION

Radical resection of low-grade ependymoma with a detailed understanding of the anatomy in this area is vital considering the high effectiveness of the treatment and its excellent prognosis.

Clinical presentation and extent of resection impacts progression-free survival in spinal ependymomas

PURPOSE

Primary treatment of spinal ependymomas involves surgical resection, however recurrence ranges between 50 and 70%. While the association of survival outcomes with lesion extent of resection (EOR) has been studied, existing analyses are limited by small samples and archaic data resulting in an inhomogeneous population. We investigated the relationship between EOR and survival outcomes, chiefly overall survival (OS) and progression-free survival (PFS), in a large contemporary cohort of spinal ependymoma patients.

METHODS

Adult patients diagnosed with a spinal ependymoma from 2006 to 2021 were identified from an institutional registry. Patients undergoing primary surgical resection at our institution, ≥ 1 routine follow-up MRI, and pathologic diagnosis of ependymoma were included. Records were reviewed for demographic information, EOR, lesion characteristics, and pre-/post-operative neurologic symptoms. EOR was divided into 2 classifications: gross total resection (GTR) and subtotal resection (STR). Log-rank test was used to compare OS and PFS between patient groups.

RESULTS

Sixty-nine patients satisfied inclusion criteria, with 79.7% benefitting from GTR. The population was 56.2% male with average age of 45.7 years, and median follow-up duration of 58 months. Cox multivariate model demonstrated significant improvement in PFS when a GTR was attained (p <.001). Independently ambulatory patients prior to surgery had superior PFS (p <.001) and OS (p =.05). In univariate analyses, patients with a syrinx had improved PFS (p =.03) and were more likely to benefit from GTR (p =.01). Alternatively, OS was not affected by EOR (p =.78).

CONCLUSIONS

In this large, contemporary series of adult spinal ependymoma patients, we demonstrated improvements in PFS when GTR was achieved.

Spinal ependymoma in adults: from molecular advances to new treatment perspectives

Ependymomas are rare glial tumors with clinical and biological heterogeneity, categorized into supratentorial ependymoma, posterior fossa ependymoma, and spinal cord ependymoma, according to anatomical localization. Spinal ependymoma comprises four different types: spinal ependymoma, spinal ependymoma MYCN-amplified, myxopapillary ependymoma, and subependymoma. The clinical onset largely depends on the spinal location of the tumor. Both non-specific and specific sensory and/or motor symptoms can be present. Owing to diverse features and the low incidence of spinal ependymomas, most of the current clinical management is derived from small retrospective studies, particularly in adults. Treatment involves primarily surgical resection, aiming at maximal safe resection. The use of radiotherapy remains controversial and the optimal dose has not been established; it is usually considered after subtotal resection for WHO grade 2 ependymoma and for WHO grade 3 ependymoma regardless of the extent of resection. There are limited systemic treatments available, with limited durable results and modest improvement in progression-free survival. Thus, chemotherapy is usually reserved for recurrent cases where resection and/or radiation is not feasible. Recently, a combination of temozolomide and lapatinib has shown modest results with a median progression-free survival (PFS) of 7.8 months in recurrent spinal ependymomas. Other studies have explored the use of temozolomide, platinum compounds, etoposide, and bevacizumab, but standard treatment options have not yet been defined. New treatment options with targeted treatments and immunotherapy are being investigated. Neurological and supportive care are crucial, even in the early stages. Post-surgical rehabilitation can improve the consequences of surgery and maintain a good quality of life, especially in young patients with long life expectancy. Here, we focus on the diagnosis and treatment recommendations for adults with spinal ependymoma, and discuss recent molecular advances and new treatment perspectives.

Predictors of Progression-Free Survival in Patients With Spinal Intramedullary Ependymoma: A Multicenter Retrospective Study by the Neurospinal Society of Japan

BACKGROUND AND OBJECTIVES

Ependymoma is the most common spinal intramedullary tumor. Although clinical outcomes have been described in the literature, most of the reports were based on limited numbers of cases or been confined to institutional experience. The objective of this study was to analyze more detailed characteristics of spinal intramedullary ependymoma (SIE) and provide clinical factors associated with progression-free survival (PFS).

METHODS

This retrospective observational multicenter study included consecutive patients with SIE in the cervical or thoracic spine treated surgically at a total of 58 institutions between 2009 and 2020. The results of pathological diagnosis at each institute were confirmed, and patients with myxopapillary ependymoma, subependymoma, or unverified histopathology were strictly excluded from this study. Outcome measures included surgical data, surgery-related complications, postoperative systemic adverse events, postoperative adjuvant treatment, postoperative functional condition, and presence of recurrence.

RESULTS

This study included 324 cases of World Health Organization grade II (96.4%) and 12 cases of World Health Organization grade III (3.6%). Gross total resection (GTR) was achieved in 76.5% of cases. Radiation therapy (RT) was applied after surgery in 16 cases (4.8%), all of which received local RT and 5 of which underwent chemotherapy in combination. Functional outcomes were significantly affected by preoperative neurological symptoms, tumor location, extent of tumor resection, and recurrence. Multivariate regression analysis suggested that limited extent of tumor resection or recurrence resulted in poor functional outcomes. Multiple comparisons among the groups undergoing GTR, subtotal resection and biopsy, or partial resection of the tumor showed that the probability of PFS differed significantly between GTR and other extents of resection.

CONCLUSION

When GTR can be safely obtained in the surgery for SIE, functional maintenance and longer PFS can be expected.

Neurologic outcomes for adult spinal cord ependymomas stratified by tumor location: a retrospective cohort study and 2-year outlook

Determine whether craniocaudal spinal cord tumor location affects long-term neurologic outcomes in adults diagnosed with spinal ependymomas (SE). A retrospective cohort analysis of patients aged ≥ 18 years who underwent surgical resection for SE over a ten-year period was conducted. Tumor location was classified as cervical, thoracic, or lumbar/conus. Primary endpoints were post-operative McCormick Neurologic Scale (MNS) scores at < 3 days, 6 weeks, 1 year, and 2 years. One-way ANOVA was performed to detect significant differences in MNS scores between tumor locations. Twenty-eight patients were identified. The average age was 44.2 ± 15.4 years. Sixteen were male, and 13 were female. There were 10 cervical-predominant SEs, 13 thoracic-predominant SEs, and 5 lumbar/conus-predominant SEs. No significant differences were observed in pre-operative MNS scores between tumor locations (p = 0.73). One-way ANOVA testing demonstrated statistically significant differences in post-operative MNS scores between tumor locations at < 3 days (p = 0.03), 6 weeks (p = 0.009), and 1 year (p = 0.003); however, no significant difference was observed between post-operative MNS scores at 2 years (p = 0.13). The mean MNS score for patients with thoracic SEs were higher at all follow-up time points. Tumors arising in the thoracic SE are associated with worse post-operative neurologic outcomes in comparison to SEs arising in other spinal regions. This is likely multifactorial in etiology, owing to both anatomical differences including spinal cord volume as well as variations in tumor characteristics. No significant differences in 2-year MNS scores were observed, suggesting that patients ultimately recover from neurological insult sustained at the time of surgery.

Adult intracranial ependymoma-relevance of DNA methylation profiling for diagnosis, prognosis, and treatment

BACKGROUND

A methylation-based classification of ependymoma has recently found broad application. However, the diagnostic advantage and implications for treatment decisions remain unclear. Here, we retrospectively evaluate the impact of surgery and radiotherapy on outcome after molecular reclassification of adult intracranial ependymomas.

METHODS

Tumors diagnosed as intracranial ependymomas from 170 adult patients collected from 8 diagnostic institutions were subjected to DNA methylation profiling. Molecular classes, patient characteristics, and treatment were correlated with progression-free survival (PFS).

RESULTS

The classifier indicated an ependymal tumor in 73.5%, a different tumor entity in 10.6%, and non-classifiable tumors in 15.9% of cases, respectively. The most prevalent molecular classes were posterior fossa ependymoma group B (EPN-PFB, 32.9%), posterior fossa subependymoma (PF-SE, 25.9%), and supratentorial ZFTA fusion-positive ependymoma (EPN-ZFTA, 11.2%). With a median follow-up of 60.0 months, the 5- and 10-year-PFS rates were 64.5% and 41.8% for EPN-PFB, 67.4% and 45.2% for PF-SE, and 60.3% and 60.3% for EPN-ZFTA. In EPN-PFB, but not in other molecular classes, gross total resection (GTR) (P = .009) and postoperative radiotherapy (P = .007) were significantly associated with improved PFS in multivariable analysis. Histological tumor grading (WHO 2 vs. 3) was not a predictor of the prognosis within molecularly defined ependymoma classes.

CONCLUSIONS

DNA methylation profiling improves diagnostic accuracy and risk stratification in adult intracranial ependymoma. The molecular class of PF-SE is unexpectedly prevalent among adult tumors with ependymoma histology and relapsed as frequently as EPN-PFB, despite the supposed benign nature. GTR and radiotherapy may represent key factors in determining the outcome of EPN-PFB patients.

Clinical Characteristics, Management, and Outcomes of Intramedullary Spinal Cord Ependymomas in Adults: A Systematic Review

BACKGROUND

Intramedullary spinal cord ependymomas (IMSCEs) are rare tumors that mostly occur in adults. Management strategies and related outcomes are heterogeneously reported across the literature, demanding a comprehensive analysis to standardize guidelines. We performed a systematic review of the literature on IMSCEs.

METHODS

A literature search was conducted using 6 databases from inception up to July 28, 2022. Studies with data on clinical characteristics, management strategies, and related outcomes in adult patients with histopathologically confirmed IMSCEs were pooled and analyzed.

RESULTS

The analysis included 69 studies comprising 457 patients (52.7% males). Mean age was 42.4 ± 7.4 years. Sensory deficit (58.0%) was the most prevalent symptom, followed by radicular pain (50.5%). Tumors mostly involved the cervical (64.4%) or thoracic (18.8%) spinal cord and were mostly World Health Organization grade II (80.5%) and classic subtype (72.4%). Gross total resection was performed in most cases (83.4%), with adjuvant radiotherapy delivered in 10.5% of cases. Progression-free survival ≥2 years was reported in 61.1% of cases, and tumor recurrence or progression was reported in only 7.0% of the patients. At last follow-up, 97.4% of patients were alive.

CONCLUSIONS

IMSCEs are uncommon tumors that frequently manifest with debilitating symptoms that require surgical treatment. When feasible, gross total resection may be pursued to improve the patient's functional status and prevent tumor progression, with adjuvant radiotherapy required only in some more aggressive grade III lesions. Future studies should investigate different growth patterns and prognoses based on different IMSCE subtypes.

Holistic Approach to the Diagnosis and Treatment of Patients with Tumor Metastases to the Spine

The treatment of neoplastic spine metastases requires multi-faceted assessment and an interdisciplinary approach to patients. The metastases do not show specific symptoms but are often the first confirmation of the presence of a primary tumor in a patient. The diagnostic process includes imaging and invasive procedures, e.g., biopsy. It is essential to qualify the patient for an appropriate treatment using dedicated scales. Decompression of the spinal cord is a critical issue to save or restore neurological function in a patient with spine metastases. Surgical treatment ought to meet three criteria: release spinal cord and nerve roots, restore the spine’s anatomical relations, and ensure the internal stabilization of the spine. A good result from surgical treatment enables the continuation of radiotherapy, chemotherapy, hormone therapy, and targeted molecular therapy. Stereotactic radiosurgery and stereotactic body radiotherapy are more effective ways of treating spine metastases than conventional external beam radiotherapy. They allow higher doses of radiation, concentrated precisely at the tumor site. Our review summarizes the established and emerging concepts in the treatment of spine metastases. A holistic approach to the patient enables the selection of the appropriate therapy.

Ependymoma: Evaluation and Management Updates

PURPOSE OF REVIEW

To review state of art and relevant advances in the molecular genetics and management of ependymomas of children and adults.

RECENT FINDINGS

Ependymomas may occur either in the brain or in the spinal cord. Compared with intracranial ependymomas, spinal ependymomas are less frequent and exhibit a better prognosis. The new WHO classification of CNS tumors of 2021 has subdivided ependymomas into different histomolecular subgroups with different outcome. The majority of studies have shown a major impact of extent of resection; thus, a complete resection must be performed, whenever possible, at first surgery or at reoperation. Conformal radiotherapy is recommended for grade 3 or incompletely resected grade II tumors. Proton therapy is increasingly employed especially in children to reduce the risk of neurocognitive and endocrine sequelae. Craniospinal irradiation is reserved for metastatic disease. Chemotherapy is not useful as primary treatment and is commonly employed as salvage treatment for patients failing surgery and radiotherapy. Standard treatments are still the mainstay of treatment: the discovery of new druggable pathways will hopefully increase the therapeutic armamentarium in the near future.

Long-term Neurologic Outcome After Spinal Ependymoma Resection With Multimodal Intraoperative Electrophysiological Recording: Cohort Study and Review of the Literature

Objective

To evaluate how multimodal intraoperative neuromonitoring (IONM) changes during spinal ependymoma (SE) resection correlate with long-term neuro-functional outcomes.

Methods

A retrospective analysis of patients aged 18 years or older who underwent surgical resection for SE over a 10-year period was conducted. IONM changes were defined as sustained transcranial motor evoked potential (TcMEP) and/or somatosensory evoked potential (SSEP) signal decrease of 50% or greater from baseline. Primary endpoints were postoperative modified McCormick Neurologic Scale (MNS) scores at postoperative day (POD) < 2, 6 weeks, 1 year, and 2 years. Univariate and multivariate analyses were performed.

Results

Twenty-nine patients were identified. Average age was 44.2±15.4 years. Sixteen (55.2%) were male and 13 (44.8%) were female. Tumor location was 10 cervical-predominant (34.5%), 13 thoracic-predominant (44.8%), and 6 lumbar/conus-predominant (20.7%). A majority (69.0%) were World Health Organization grade 2 tumors. Twentyfour patients (82.8%) achieved gross total resection. Thirteen patients (44.8%) had a sustained documented IONM signal change and 10 (34.5%) had a TcMEP change with or without derangement in SSEP. At POD < 2, 6 weeks, 1 year, and 2 years, MNS was significantly higher for those when analyzing subgroups with either any sustained IONM or TcMEP±SSEP signal attenuation > 50% below baseline (all p<0.05).

Conclusion

Sustained IONM derangements > 50% below baseline, particularly for TcMEP, are significantly associated with higher MNS postoperatively out to 2 years. Intraoperative and postoperative management of these patients warrant special consideration to limit neurologic morbidity.

EZH2 as a new therapeutic target in brain tumors: Molecular landscape, therapeutic targeting and future prospects

Brain tumors are responsible for high mortality and morbidity worldwide. The brain tumor treatment depends on identification of molecular pathways involved in progression and malignancy. Enhancer of zeste homolog 2 (EZH2) has obtained much attention in recent years in field of cancer therapy due to its aberrant expression and capacity in modulating expression of genes by binding to their promoter and affecting methylation status. The present review focuses on EZH2 signaling in brain tumors including glioma, glioblastoma, astrocytoma, ependymomas, medulloblastoma and brain rhabdoid tumors. EZH2 signaling mainly participates in increasing proliferation and invasion of cancer cells. However, in medulloblastoma, EZH2 demonstrates tumor-suppressor activity. Furthermore, EZH2 can regulate response of brain tumors to chemotherapy and radiotherapy. Various molecular pathways can function as upstream mediators of EZH2 in brain tumors including lncRNAs and miRNAs. Owing to its enzymatic activity, EZH2 can bind to promoter of target genes to induce methylation and affects their expression. EZH2 can be considered as an independent prognostic factor in brain tumors that its upregulation provides undesirable prognosis. Both anti-tumor agents and gene therapies such as siRNA have been developed for targeting EZH2 in cancer therapy.

Cauda equina ependymomas: surgical treatment and long-term outcomes in a series of 125 patients

OBJECTIVE

Cauda equina ependymoma (CEE) is a rare tumor for which little information is available on the oncological and clinical outcomes of patients. In this study the authors aimed to address functional, oncological, and quality-of-life (QOL) outcomes in a large series of consecutive patients operated on at their institution during the past 20 years.

METHODS

The records of 125 patients who underwent surgery between January 1998 and September 2018 were reviewed. Analyzed variables included demographic, clinical, radiological, surgical, and histopathological features. Neurological outcomes were graded according to the McCormick and Kesselring scales. The QOL at follow-up was evaluated by administering the EQ-5DL questionnaire.

RESULTS

On admission, 84% of patients had a McCormick grade of I and 76.8% had a Kesselring score of 0. At follow-up (clinical 8.13 years; radiological 5.87 years) most scores were unchanged. Sacral level involvement (p = 0.029) and tumor size (p = 0.002) were predictors of poor functional outcome at discharge. Tumor size (p = 0.019) and repeated surgery (p < 0.001) were predictors of poor outcome. A preoperative McCormick grade ≥ III and Kesselring grade ≥ 2 were associated with worse outcomes (p = 0.035 and p = 0.002, respectively). Myxopapillary ependymoma (MPE) was more frequent than grade II ependymoma (EII). The overall rate of gross-total resection (GTR) was 91.2% and rates were significantly higher for patients with EII (98%) than for those with MPE (84%) (p = 0.0074). On multivariate analysis, the only factor associated with GTR was the presence of a capsule (p = 0.011). Seventeen patients (13.7%) had recurrences (13 MPE, 4 EII; 76.4% vs 23.6%; p = 0.032). The extent of resection was the only factor associated with recurrence (p = 0.0023) and number of surgeries (p = 0.006). Differences in progression-free survival (PFS) were seen depending on the extent of resection at first operation (p < 0.001), subarachnoid seeding (p = 0.041), piecemeal resection (p = 0.004), and number of spine levels involved (3 [p = 0.016], 4 [p = 0.011], or ≥ 5 [p = 0.013]). At follow-up a higher proportion of EII than MPE patients were disease free (94.7% vs 77.7%; p = 0.007). The QOL results were inferior in almost all areas compared to a control group of subjects from the Italian general population. A McCormick grade ≥ 3 and repeated surgeries were associated with a worse QOL (p = 0.006 and p = 0.017).

CONCLUSIONS

An early diagnosis of CEE is important because larger tumors are associated with recurrences and worse functional neurological outcomes. Surgery should be performed with the aim of achieving an en bloc GTR. The histological subtype was not directly associated with recurrences, but some of the features more commonly encountered in MPEs were. The outcomes are in most cases favorable, but the mean QOL perception is inferior to that of the general population.

Glioma-Targeted Therapeutics: Computer-Aided Drug Design Prospective

Amongst the several types of brain cancers known to humankind, glioma is one of the most severe and life-threatening types of cancer, comprising 40% of all primary brain tumors. Recent reports have shown the incident rate of gliomas to be 6 per 100,000 individuals per year globally. Despite the various therapeutics used in the treatment of glioma, patient survival rate remains at a median of 15 months after undergoing first-line treatment including surgery, radiation, and chemotherapy with Temozolomide. As such, the discovery of newer and more effective therapeutic agents is imperative for patient survival rate. The advent of computer-aided drug design in the development of drug discovery has emerged as a powerful means to ascertain potential hit compounds with distinctively high therapeutic effectiveness against glioma. This review encompasses the recent advances of bio-computational in-silico modeling that have elicited the discovery of small molecule inhibitors and/or drugs against various therapeutic targets in glioma. The relevant information provided in this report will assist researchers, especially in the drug design domains, to develop more effective therapeutics against this global disease.

Risk score for outcome prediction after microsurgical resection of spinal ependymoma (SOURSE score)

OBJECTIVE

Microsurgical resection of spinal ependymomas is associated with a considerable risk of postoperative neurological deterioration. We aimed to develop a risk score for outcome prediction after surgery for spinal ependymoma.

MATERIALS AND METHODS

All patients who underwent microsurgical resection of spinal ependymoma between 1980 and 2015 were included. Different perioperative parameters were collected for the score construction. Poor outcome was defined as the modified McCormick Scale (MMCS) >2 at 6 months after surgery.

RESULTS

Of 131 patients (mean age: 45.6 ± 16.7 years; 63 females), 38 cases (29%) showed poor outcome. Based on the univariate analysis, preoperative MMCS, subtotal tumor resection, proximal tumor level on the spinal cord, tumor extension, intramedullary location, and WHO grading were included in the multivariate analysis. The final risk score consisted of the following independent predictors: preoperative MMCS > 1 (1 point), proximal tumor level at Th 10 and higher (1 point), and tumor extension ≥ 3 vertebrae (1 point). The constructed score (0-3 points; Score for OUtcome after Resection of Spinal Ependymoma [SOURSE]) showed high diagnostic accuracy (area under the curve [AUC] = 0.883), which was superior to preoperative MMCS (AUC = 0.798) and Karnofsky Performance Status (AUC = 0.794). Patients scoring 0, 1, 2, and 3 points showed poor outcome in 0%, 12.9%, 54.6%, and 76.2% of the cases respectively.

CONCLUSION

The presented SOURSE score based on preoperative neurologic condition, tumor location, and tumor extension could accurately predict the postoperative outcome in patients undergoing microsurgery of spinal ependymoma. Our data should be validated in a prospective trial.

Myxopapillary ependymomas; proximity to the conus and its effect on presentation and outcomes

Background:

Myxopapillary ependymomas (MPE) are intradural spinal tumors with a predilection to the filum terminale. Damage to conus medullaris during surgery can result in sphincteric and sexual dysfunction. The purpose of this study is to determine how myxopapillary ependymoma proximity to the conus impacts patient presentation, extent of resection, and clinical outcomes.

Methods:

Fifty-one patients who underwent surgical resection of pathologically confirmed myxopapillary ependymoma with at least 1 year of follow-up were included in the study. We collected initial presenting symptoms, distance of the tumor from the conus, extent of resection, and postoperative clinical outcomes including bladder dysfunction.

Results:

Average age was 38 years (range 7–75 years) with a male to female ratio of 1.43:1. Patients most commonly presented with pain symptoms (88%), and 12 patients (23.5%) had urologic symptoms on presentation. The mean tumor distance from the tip of the conus was 1.60 cm (10 cm above to 21 cm below the tip of the conus). Patients with tumors in contact with the conus had a significantly higher rate of preoperative urinary symptoms and were more likely (32% vs. 14%) to suffer postoperative urinary sphincteric disturbances. Tumors with direct invasion of the conus medullaris were more likely to require intralesional resection and fail to achieve a gross total resection (GTR).

Conclusion:

Patients with MPE in close proximity to the conus were more likely to suffer from long-term morbidity related to urologic issues following surgical resection. Adjuvant radiotherapy may be a viable option for patients who fail to achieve GTR.

Systematic review-Time to malignant transformation in low-grade gliomas: Predicting a catastrophic event with clinical, neuroimaging, and molecular markers

Background

Despite an initially indolent course, all WHO grade II, LGGs inevitably transform to malignant, WHO grades III and IV, without current curative options. Malignant transformation (MT) remains unpredictable with limited prognostic markers to steer timing of interventions. The aim of this study was to review and assign predictive value to specific clinical, molecular, and radiological markers impacting MT, thereby justifying timely therapeutic interventions.

Methods

Searches of MEDLINE, Embase, and Cochrane databases were conducted from inception to April 28, 2021 and outputs were analysed in accordance with PRISMA protocol.

Results

From an initial 5,032 articles, 33 articles were included, totalling 5672 patients. Forty-three prognostic factors were registered to significantly impact MT. These were categorised as 7 clinical; 14 neuroimaging; 8 biological/molecular; 3 volumetric; 5 topological; 3 histological; and 3 treatment-related. Following analysis, 10 factors were highlighted: the pre-operative prognosticators were 1. presentation with epileptic seizures; 2. VDE > 8 mm/y; 3. VDE > 4 mm/y; 4. rCBV > 1.75; 5. PTV ≥ 5 cm (65 ml); 6. PTV ≥ 100 ml; and 7. cortical involvement. The post-operative prognosticators were: (1) IDH-wt, (2) TP53 mutation, and (3) temozolomide monotherapy.

Conclusions

The management of LGGs remains controversial, as conservative and invasive treatment may be associated with MT and impaired quality of life, respectively. Our review indicates that MT can be predicted by specific metrics in VDE, PTV, and rCBV, alongside cortical involvement. Additionally, patients with IDH-wt tumours TP53 mutations, or receiving TMZ monotherapy are more likely to undergo MT. Our data may form the basis of a predictive scoring system.

Supratentorial Extraventricular Ependymomas: Imaging Features and the Added Value of Apparent Diffusion Coefficient

OBJECTIVE

To improve the understanding and the diagnosis of intracranial ependymal tumors.

METHODS

The clinical, radiological and prognostic features of 48 supratentorial extraventricular ependymomas and 74 intraventricular ependymomas were summarized and compared.

RESULTS

Supratentorial extraventricular ependymomas, most often located in the frontal lobe (33.3%) and classified as grade III (75.0%), had relatively large eccentric cysts (3.07 ± 2.03 cm), significant enhancement (84.8%), low apparent diffusion coefficient (ADC) values, and associated with higher mortality (41.3%). The majority of intraventricular lesions occurred in the fourth ventricle (86.5%) and classified as grade II (78.4%), had relatively small and multiple cystic changes (1.04 ± 0.87 cm), slight or moderate enhancement (76.9%), high ADC values and associated with lower mortality (20.7%). There were few significant differences between grade II and grade III tumors in these 2 groups, respectively. Young age, high grade and low ADC values are worse prognostic indicators for patients with supratentorial extraventricular ependymomas, but not for those with intraventricular ependymomas.

CONCLUSIONS

Conventional radiological features, combined with clinical manifestations and quantitative information provided by diffusion-weighted imaging, may not only enhance the diagnosis and assist in determining prognosis but also provide a better pathophysiological understanding of intracranial ependymal tumors.

Developing a Radiomics Signature for Supratentorial Extra-Ventricular Ependymoma Using Multimodal MR Imaging

Rationale and Objectives: To build a machine learning-based diagnostic model that can accurately distinguish adult supratentorial extraventricular ependymoma (STEE) from similarly appearing high-grade gliomas (HGG) using quantitative radiomic signatures from a multi-parametric MRI framework.

Materials and Methods: We computed radiomic features on the preprocessed and segmented tumor masks from a pre-operative multimodal MRI dataset [contrast-enhanced T1 (T1ce), T2, fluid-attenuated inversion recovery (FLAIR), apparent diffusion coefficient (ADC)] from STEE (n = 15), HGG-Grade IV (HGG-G4) (n = 24), and HGG-Grade III (HGG-G3) (n = 36) patients, followed by an optimum two-stage feature selection and multiclass classification. Performance of multiple classifiers were evaluated on both unimodal and multimodal feature sets and most discriminative radiomic features involved in classification of STEE from HGG subtypes were obtained.

Results: Multimodal features demonstrated higher classification performance over unimodal feature set in discriminating STEE and HGG subtypes with an accuracy of 68% on test data and above 80% on cross validation, along with an overall above 90% specificity. Among unimodal feature sets, those extracted from FLAIR demonstrated high classification performance in delineating all three tumor groups. Texture-based radiomic features particularly from FLAIR were most important in discriminating STEE from HGG-G4, whereas first-order features from T2 and ADC consistently ranked higher in differentiating multiple tumor groups.

Conclusions: This study illustrates the utility of radiomics-based multimodal MRI framework in accurately discriminating similarly appearing adult STEE from HGG subtypes. Radiomic features from multiple MRI modalities could capture intricate and complementary information for a robust and highly accurate multiclass tumor classification.

An Insight into Pathophysiological Features and Therapeutic Advances on Ependymoma

Simple Summary

Although biological information and the molecular classification of ependymoma have been studied, the treatment systems for ependymoma are still insufficient. In addition, because the disease occurs infrequently, it is difficult to obtain sufficient data to conduct large-scale or randomized clinical trials. Therefore, this study is intended to emphasize the importance of understanding its pathological characteristics and prognosis as well as developing treatments for ependymoma through multilateral studies.

Abstract

Glial cells comprise the non-sensory parts of the central nervous system as well as the peripheral nervous system. Glial cells, also known as neuroglia, constitute a significant portion of the mammalian nervous system and can be viewed simply as a matrix of neural cells. Despite being the “Nervenkitt” or “glue of the nerves”, they aptly serve multiple roles, including neuron repair, myelin sheath formation, and cerebrospinal fluid circulation. Ependymal cells are one of four kinds of glial cells that exert distinct functions. Tumorigenesis of a glial cell is termed a glioma, and in the case of an ependymal cell, it is called an ependymoma. Among the various gliomas, an ependymoma in children is one of the more challenging brain tumors to cure. Children are afflicted more severely by ependymal tumors than adults. It has appeared from several surveys that ependymoma comprises approximately six to ten percent of all tumors in children. Presently, the surgical removal of the tumor is considered a standard treatment for ependymomas. It has been conspicuously evident that a combination of irradiation therapy and surgery is much more efficacious in treating ependymomas. The main purpose of this review is to present the importance of both a deep understanding and ongoing research into histopathological features and prognoses of ependymomas to ensure that effective diagnostic methods and treatments can be developed.

Complete Versus Incomplete Surgical Resection in Intramedullary Ependymomas: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review.

OBJECTIVE

To compare outcomes of complete versus incomplete resection in primary intramedullary spinal cord ependymoma.

METHODS

A comprehensive search of the MEDLINE, CENTRAL, and Embase databases was conducted by 2 independent investigators. Random-effect meta-analysis and meta-regression with seven covariates were performed to evaluate the reason for the heterogeneity among studies. We also used individual patient data in the integrative analysis to compare complete and incomplete resection based on 4 outcomes: progression-free survival (PFS), overall survival (OS), postoperative neurological improvement (PNI), and follow-up neurological improvement (FNI).

RESULTS

A total of 23 studies were identified, including 407 cases. Significant heterogeneity among included studies was observed in risk estimates (I² for PFS, FNI, and PNI were 49.5%, 78.3%, and 87.2%, respectively). The mean follow-up time across cases was 48.6 ± 2.35 months. Cox proportional multivariable analysis revealed that the complete resection can prolong PFS (model, hazard ratio = 0.18, CI 0.05-0.54, P = .004,) and improve the FNI (binary logistic regression, adjusted odds ratio = 16.5, CI 1.6-171, P = .019). However, PNI and OS were similar in patients with incomplete resected spinal cord ependymoma compared with complete resection (binary logistic regression respectively and Cox multivariable analysis, P > .5).

CONCLUSION

The data presented in this study showed that OS was not significantly affected by the degree of surgery. However, complete resection of intramedullary ependymomas provides the optimal outcomes with longer PFS and better long-term neurological outcomes than incomplete resection.

Long-term outcomes of spinal ependymomas: an institutional experience of more than 60 cases

PURPOSE

Spinal ependymomas represent the most common primary intramedullary tumors for which optimal management remains undefined. When possible, gross total resection (GTR) is often the mainstay of treatment, with consideration of radiotherapy (RT) in cases of residual or recurrent tumor. The impact of extent of resection and radiotherapy remain understudied.

OBJECTIVE

Report on a large institutional cohort with lengthy follow-up to provide information on long-term outcomes and to contribute to limited data assessing the value of extent of resection and RT.

METHODS

Patients with pathologically proven primary spinal ependymoma between 1990 and 2018 were identified. Kaplan-Meier estimates were used to calculate progression-free survival (PFS); local-control (LC) and overall survival (OS). Logistic regression was used to analyze variables' association with receipt of RT.

RESULTS

We identified 69 patients with ependymoma of which 4 had leptomeningeal dissemination at diagnosis and were excluded. Of the remaining cohort (n = 65), 42 patients (65%) had Grade II spinal ependymoma, 20 (31%) had Grade I myxopapillary ependymoma and 3 (5%) had Grade III anaplastic ependymoma; 54% underwent GTR and 39% underwent RT. With a median follow-up of 5.7 years, GTR was associated with improved PFS. For grade II lesions, STR+RT yielded better outcomes than STR alone (10y PFS 77.1% vs 68.2%, LC 85.7% vs 50%). Degree of resection was the only significant predictor of adjuvant radiotherapy (p < 0.0001).

CONCLUSION

Our findings confirm the importance of GTR in spinal ependymomas. Adjuvant RT should be utilized in the setting of a subtotal resection with expectation of improved disease-related outcomes.

The Survival and Prognostic Factors of Supratentorial Cortical Ependymomas: A Retrospective Cohort Study and Literature-Based Analysis

Aim

Survival rates and prognostic factors of cortical ependymomas (CEs) remain elusive. This study aimed to perform a comprehensive analysis of prognostic factors, treatment, and outcomes for patients with CEs based on institutional and literature case series.

Materials and Methods

Thirty patients with CEs from our department were included in this study. Furthermore, a systemic review of the literature yielded an additional 106 patients with CEs. Clinical data including patient age, sex, symptoms, tumor location, World Health Organization (WHO) grade, extent of surgery, radiation, recurrence, and survival were recorded and statistically analyzed.

Results

From January 2009 to October 2019, 30 (4.2%) cases were diagnosed as CEs in our department. These series consisted of 19 males and 11 females, 10 continuous patients after 2017 screened for C11orf95-RELA fusion, and 9 patients (90%) were RELA fusion positive. During the follow-up period, nine (30%) patients depicted tumor recurrence or progression; four (13.3%) patients died of tumor progression. The literature review yielded 106 CE cases, with additional 30 cases of our own collected for further analysis. Of these 136 cases, the frontal lobe (40%) was the most common location, and the average age was 22.6 ± 17.6 years. Anaplastic histology/WHO grade III tumors were identified in 68 (50%) patients. Statistically analysis demonstrated that extent of surgery and WHO tumor grade were significant prognostic factors in Kaplan–Meier log-rank testing and Cox proportional hazards models. Gross total resection (GTR) predicted longer progression-free survival (PFS) [P = 0.013, hazard ratio (HR) = 3.012, 95% confidence interval (CI) = 1.257–7.213] and overall survival (OS) (P = 0.003, HR = 5.322, 95% CI = 1.751–16.178). WHO grade III tumors had worse PFS (P = 0.002, HR = 5.17, 95% CI = 1.804–14.816) and OS (P = 0.025, HR = 5.640, 95% CI = 1.248–25.495).

Conclusion

CEs accounted for only 3.5 to 5.7% of ependymomas, with seizures the most common symptom and the frontal lobe the most frequent location. CEs may have higher rate of RELA fusions, but generally favorable prognosis. The extent of surgery and WHO tumor grade were significant prognostic factors for PFS and OS in multivariate analysis. GTTR or WHO grade II tumors had better overall outcome in patients with CEs.

Individualized Prediction of Overall Survival for Primary Intramedullary Spinal Cord Grade II/III Ependymoma

BACKGROUND

The purpose of this study was to develop and validate a nomogram to predict overall survival (OS) for adult patients with primary intramedullary spinal cord grade II/III ependymoma (PISCGE). We also elucidated the effectiveness of postoperative radiotherapy for this disease.

METHODS

Clinical data of patients with PISCGE between 1988 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) registry database. The independent prognostic factors were identified using univariate and multivariate Cox analyses. The nomogram was established from the results of the multivariate Cox analysis. We also use some methods to verify the superiority of the prediction model. The effectiveness of postoperative radiotherapy for PISCGE was assessed through coarsened exact matching and survival analyses.

RESULTS

Multivariate Cox analysis revealed that sex, age, surgical treatment, tumor grade, and marital status were independent prognostic factors of OS. The nomogram model was established based on these factors and validated internally. Calibration plots based on bootstrap resampling validation showed good consistency between the nomogram prediction and actual observation. This model also exhibited favorable discrimination characteristics. A risk classification system based on a nomogram was established to promote risk stratification of PISCGE and optimize clinical management. Moreover, we found no association between radiation treatment and the OS for these patients (P > 0.05).

CONCLUSIONS

We built the first nomogram model and risk classification system for PISCGE patients. Our model accurately estimated the individual OS probability of these patients, and proposes different treatment approaches for patients based on the risk classification system. Furthermore, from our findings, radiotherapy confers no survival advantage to these patients.

Rare Primary Central Nervous System Tumors in Adults: An Overview

Overall, tumors of primary central nervous system (CNS) are quite common in adults with an incidence rate close to 30 new cases/100,000 inhabitants per year. Significant clinical and biological advances have been accomplished in the most common adult primary CNS tumors (i.e., diffuse gliomas). However, most CNS tumor subtypes are rare with an incidence rate below the threshold defining rare disease of 6.0 new cases/100,000 inhabitants per year. Close to 150 entities of primary CNS tumors have now been identified by the novel integrated histomolecular classification published by the World Health Organization (WHO) and its updates by the c-IMPACT NOW consortium (the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy). While these entities can be better classified into smaller groups either by their histomolecular features and/or by their location, assessing their treatment by clinical trials and improving the survival of patients remain challenging. Despite these tumors are rare, research, and advances remain slower compared to diffuse gliomas for instance. In some cases (i.e., ependymoma, medulloblastoma) the understanding is high because single or few driver mutations have been defined. The European Union has launched European Reference Networks (ERNs) dedicated to support advances on the clinical side of rare diseases including rare cancers. The ERN for rare solid adult tumors is termed EURACAN. Within EURACAN, Domain 10 brings together the European patient advocacy groups (ePAGs) and physicians dedicated to improving outcomes in rare primary CNS tumors and also aims at supporting research, care and teaching in the field. In this review, we discuss the relevant biological and clinical characteristics, clinical management of patients, and research directions for the following types of rare primary CNS tumors: medulloblastoma, pineal region tumors, glioneuronal and rare glial tumors, ependymal tumors, grade III meningioma and mesenchymal tumors, primary central nervous system lymphoma, germ cell tumors, spinal cord tumors and rare pituitary tumors.

Comparison of epidemiology, treatments, and outcomes in pediatric versus adult ependymoma

Background

Mounting evidence supports the presence of heterogeneity in the presentation of ependymoma patients with respect to location, histopathology, and behavior between pediatric and adult patients. However, the influence of age on treatment outcomes in ependymoma remains obscure.

Methods

The SEER database years 1975–2016 were queried. Patients with a diagnosis of ependymoma were identified using the International Classification of Diseases for Oncology, Third Edition, coding system. Patients were classified into one of 4 age groups: children (age 0–12 years), adolescents (age 13–21 years), young adults (age 22–45 years), and older adults (age >45 years). The weighed multivariate analysis assessed the impact of age on survival outcomes following surgical treatment.

Results

There were a total of 6076 patients identified with ependymoma, of which 1111 (18%) were children, 529 (9%) were adolescents, 2039 (34%) were young adults, and 2397 (40%) were older adults. There were statistically significant differences between cohorts with respect to race (P < .001), anatomical location (P < .001), extent of resection (P < .001), radiation use (P < .001), tumor grade (P < .001), histological classification (P < .001), and all-cause mortality (P < .001). There was no significant difference between cohorts with respect to gender (P = .103). On multivariate logistic regression, factors associated with all-cause mortality rates included males (vs females), supratentorial location (vs spinal cord tumors), and radiation treatment (vs no radiation).

Conclusions

Our study using the SEER database demonstrates the various demographic and treatment risk factors that are associated with increased rates of all-cause mortality between the pediatric and adult populations following a diagnosis of ependymoma.

Recent advancements in brain tumor targeting using magnetic nanoparticles

Transport of drugs through the blood-brain barrier to the brain and the toxic effects of drugs on the healthy cells can limit the effectiveness of chemotherapeutic agents. In recent years, magnetic nanoparticles (MNPs) have received much attention as targeted therapeutic and diagnostic systems due to their simplicity, ease of preparation and ability to tailor their properties such as their composition, size, surface morphology, etc. for biomedical applications. MNPs are utilized in drug delivery, radio therapeutics, hyperthermia treatment, gene therapy, biotherapeutics and diagnostic imaging. The present review will address the challenges in brain tumor targeting and discuss the application and recent developments in brain tumor targeting using MNPs.

Intracranial ependymomas: molecular insights and translation to treatment

Ependymomas are primary central nervous system tumors (CNS), arising within the posterior fossa and supratentorial regions of the brain, and in the spine. Over the last decade, research has resulted in substantial insights into the molecular characteristics of ependymomas, and significant advances have been made in the establishment of a molecular classification system. Ependymomas both within and between the three CNS regions in which they arise, have been shown to contain distinct genetic, epigenetic and cytogenic aberrations, with at least three molecularly distinct subgroups identified within each region. However, these advances in molecular characterization have yet to be translated into clinical practice, with the standard treatment for ependymoma patients largely unchanged. This review summarizes the advances made in the molecular characterization of intracranial ependymomas, outlines the progress made in establishing preclinical models and proposes strategies for moving toward subgroup-specific preclinical investigations and treatment.

Radiotherapy in addition to surgical resection may not improve overall survival in WHO grade II spinal ependymomas

OBJECTIVES

Spinal ependymomas are rare intramedullary neoplasms. The paucity of cases limits the ability to conduct large prospective studies. Current guidelines recommend maximal safe resection followed by adjuvant radiotherapy (RT) in cases of grade II spinal ependymomas with subtotal resections (STR) and all grade III spinal ependymomas. Herein we assess the impact of RT on survival in grades II and III spinal ependymomas.

PATIENTS AND METHODS

The National Cancer Database was queried for adult patients with WHO grades II or III spinal ependymomas diagnosed between 2004 and 2014 who underwent resection or biopsy. Kaplan-Meier and multivariable Cox regression models were used to determine the impact of radiotherapy on survival.

RESULTS

A total of 1058 patients met inclusion criteria. Most patients (85.9 %) received a biopsy/STR versus gross total resection (GTR, 14.1 %). Radiotherapy was preferentially performed in those with residual tumor (p = 0.001). We found a 10-fold increased hazard of death in grade III versus grade II tumors (HR: 10.33; 95 % CI: 5.01-21.3; p < 0.001). Age positively correlated with worsened survival (HR: 1.04; 95 % CI: 1.02-1.10; p < 0.001). Adjuvant RT did not reduce the hazard of death for the cohort overall (HR: 1.08; 95 % CI: 0.55-2.10; p = 0.810) or among those with grade II tumors (HR: 0.90; 95 % CI: 0.38-2.10; p = 0.810). We found no additional survival benefit of GTR compared to biopsy/STR (HR: 0.52; 95 % CI: 0.19-1.50; p = 0.217).

CONCLUSION

While RT may improve progression-free survival, it may not impact overall survival in surgically resected grade II and III spinal ependymomas. Future studies should evaluate the impact of RT on local recurrence and symptomatic improvement.

Personalizing age-specific survival prediction and risk stratification in intracranial grade II/III ependymoma

BACKGROUND

Models for estimation of survival rates of patients with intracranial grade II/III ependymoma (EPN) are scarce. Considering the heterogeneity in prognostic factors between pediatric and adult patients, we aimed to develop age-specific nomograms for predicting 3-, 5-, and 8-year survival for these patients.

METHODS

A total of 1390 cases (667 children; 723 adults) of intracranial grade II/III EPNs diagnosed between 1988 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database for our study. Univariable and multivariable Cox analyses were employed to identify independent prognostic predictors. Age-specific nomograms were developed based on the results of multivariate Cox analyses. We also evaluated the performance of these predictive models by concordance index, calibration curves, time-dependent receiver operating characteristic curves, and decision curve analyses.

RESULTS

Considerable heterogeneity in prognostic factors was highlighted between pediatric and adult patients. Age, sex, tumor grade, surgery treatment and radiotherapy were identified as significant predictors of overall survival for children, and age, tumor grade, tumor size, surgery treatment, and marital status for adult. Based on these factors, age-specific nomogram models were established and internally validated. These models exhibited favorable discrimination and calibration characteristics. Nomogram-based risk classification systems were also constructed to facilitate risk stratification in EPNs for optimization of clinical management.

CONCLUSIONS

We developed the first nomograms and corresponding risk classification systems for predicting survival in patients with intracranial grade II/III EPN. These easily used tools can assist oncologists in making accurate survival evaluation.

MYCN amplification drives an aggressive form of spinal ependymoma

Spinal ependymal tumors form a histologically and molecularly heterogeneous group of tumors with generally good prognosis. However, their treatment can be challenging if infiltration of the spinal cord or dissemination throughout the central nervous system (CNS) occurs and, in these cases, clinical outcome remains poor. Here, we describe a new and relatively rare subgroup of spinal ependymal tumors identified using DNA methylation profiling that is distinct from other molecular subgroups of ependymoma. Copy number variation plots derived from DNA methylation arrays showed MYCN amplification as a characteristic genetic alteration in all cases of our cohort (n = 13), which was subsequently validated using fluorescence in situ hybridization. The histological diagnosis was anaplastic ependymoma (WHO Grade III) in ten cases and classic ependymoma (WHO Grade II) in three cases. Histological re-evaluation in five primary tumors and seven relapses showed characteristic histological features of ependymoma, namely pseudorosettes, GFAP- and EMA positivity. Electron microscopy revealed cilia, complex intercellular junctions and intermediate filaments in a representative sample. Taking these findings into account, we suggest to designate this molecular subgroup spinal ependymoma with MYCN amplification, SP-EPN-MYCN. SP-EPN-MYCN tumors showed distinct growth patterns with intradural, extramedullary localization mostly within the thoracic and cervical spine, diffuse leptomeningeal spread throughout the whole CNS and infiltrative invasion of the spinal cord. Dissemination was observed in 100% of cases. Despite high-intensity treatment, SP-EPN-MYCN showed significantly worse median progression free survival (PFS) (17 months) and median overall survival (OS) (87 months) than all other previously described molecular spinal ependymoma subgroups. OS and PFS were similar to supratentorial ependymoma with RELA-fusion (ST-EPN-RELA) and posterior fossa ependymoma A (PF-EPN-A), further highlighting the aggressiveness of this distinct new subgroup. We, therefore, propose to establish SP-EPN-MYCN as a new molecular subgroup in ependymoma and advocate for testing newly diagnosed spinal ependymal tumors for MYCN amplification.

Recurrent Extradural Myxopapillary Ependymoma With Oligometastatic Spread

Myxopapillary ependymomas are a slow-growing, grade I type glial tumor in the lumbosacral region. More rarely, they can present as extradural, subcutaneous sacrococcygeal, or perisacral masses, and it is under these circumstances that they are more likely to spread. Here, we report the presentation of a sacrococcygeal mass in patient that was initially resected confirming extradural myxopapillary ependymoma. At initial resection, multiple small pulmonary nodules were detected. This mass recurred 2 years later at the resection site with an interval increase in the previously imaged pulmonary nodules. Resection of both the post-sacral mass and largest lung metastasis confirmed recurrent myxopapillary ependymoma with oligometastatic spread. Because these tumors are rare, with extradural presentation being even more infrequent, to this date there are no definitive therapeutic guidelines for initial treatment and continued surveillance. For myxopapillary ependymoma, current standard of care is first-line maximal surgical resection with or without postoperative radiotherapy depending on the extent of disease and extent of resection. However, there remains insufficient evidence on the role of radiotherapy to oligometastatic foci in providing any further survival benefit or extending time to recurrence. Thus, prospective studies assessing the role of upfront treatment of oligometastases with local resection and adjuvant radiotherapy are needed for improved understanding of extradural myxopapillary ependymoma.

DNA methylation-based classification of ependymomas in adulthood: implications for diagnosis and treatment

Background

Ependymal tumors are glial tumors that commonly manifest in children and young adults. Their classification has remained entirely morphological until recently, and surgery and radiotherapy are the main treatment options, especially in adults. Here we sought to correlate DNA methylation profiles with clinical and pathological characteristics in the prospective cohort of the German Glioma Network.

Methods

Tumors from 122 adult patients with myxopapillary ependymoma, ependymoma, anaplastic ependymoma, subependymoma, or RELA fusion-positive ependymoma classified according to the World Health Organization (WHO) 2016 were subjected to DNA methylation profiling using the Illumina HumanMethylation450 BeadChip platform. Molecular data were correlated with histologic features and clinical characteristics.

Results

At a median follow-up of 86.7 months, only 22 patients experienced progression (18.0%) and 13 patients (10.7%) died. Each tumor could be assigned to one of the previously defined molecular ependymoma subgroups. All histologic subependymomas corresponded to subependymoma (SE) DNA methylation subgroups, but the reverse was not true: 19 histologic ependymomas (WHO grade II) were allocated to molecular SE groups. Similarly, all histological myxopapillary ependymomas were assigned to the molecularly defined spinal myxopapillary ependymoma (SP-MPE) class, but this molecular subgroup additionally included 15 WHO grade II ependymomas by histology. Overall, WHO grade II ependymomas distributed into 7 molecular subgroups.

Conclusion

Most adult patients with ependymoma show a favorable prognosis. Molecular classification may provide diagnostic and prognostic information beyond histology and facilitate patient stratification in future clinical trials. The prognostic significance of a subependymoma or myxopapillary ependymoma DNA methylation phenotype without corresponding histology requires further study.

Key Points

1. Ependymoma diagnosed in adult patients most often shows a good prognosis. 2. Molecular classification can support diagnostic and prognostic information beyond histology.

Downregulated long non-coding RNA LINC00899 inhibits invasion and migration of spinal ependymoma cells via RBL2-dependent FoxO pathway

This study is aimed to clarify the potential role of lncRNA LINC00899 in invasion and migration of spinal ependymoma cells through the FoxO pathway via RBL2. Spinal ependymoma related chip data (GSE50161 and GSE66354) was initially downloaded and differentially expressed lncRNAs were screened out. Fifty-eight cases of spinal ependymoma and normal ependymal tissues were collected. The effects of LINC00899 and RBL2 on the spinal ependymoma cell migration and invasion were determined using the third generation spinal ependymoma cells and transfection with LINC00899 vector, siRNA-LINC00899 and siRNA-RBL2. The expression of LINC00899, pathway and cell proliferation- and apoptosis-related factors was determined. Finally, we also detected cell proliferation, migration, invasion, cycle and apoptosis after transfection. Our results showed that LINC00899 was up-regulated in spinal ependymoma and RBL2 was confirmed as a target gene of LINC00899 and found to be involved in regulation of FoxO pathway. LINC00899 expression increased in spinal ependymoma tissues whereas RBL2 expression decreased. Moreover, we found that siRNA-LINC00899 could elevate RBL2, p21, p27 and Bax levels, decrease FoxO, Bcl-2, Vimentin, Annexin levels, reduced cell proliferation, migration and invasion and enhanced apoptosis. Taken together, our study suggests that down-regulated LINC00899 exerts anti-oncogenic effects on spinal ependymoma via RBL2-dependent FoxO, which provides a novel therapeutic target for the treatment of spinal ependymomas.

Neoplastic Myelopathies

PURPOSE OF REVIEW

This article discusses the diagnosis and management of neoplasms that affect the spinal cord as well as spinal cord disorders that can occur due to cancer treatments.

RECENT FINDINGS

Neoplastic myelopathies are uncommon neurologic disorders but cause significant morbidity when they occur. Primary spinal cord tumors can be classified into intramedullary, intradural extramedullary, or extradural tumors. Diffuse gliomas and ependymal tumors are the most common intramedullary tumors. Diffuse gliomas include the World Health Organization (WHO) grade II and grade III astrocytomas, the grade II and grade III oligodendrogliomas, the grade IV glioblastomas, and newly recognized pediatric diffuse midline gliomas with H3 K27M mutation. The majority of diffuse and anaplastic astrocytomas are IDH-mutant tumors, whereas only 10% of glioblastomas are IDH-mutant. Oligodendrogliomas are typically IDH-mutant and are characterized by the molecular signature of 1p/19q codeletion. Nine distinct molecular subgroups of ependymomas have been identified based on their genetic features and location. NF2 mutations are frequently found in spinal cord ependymomas. Metastatic tumors are the most common tumors of the spine and can be extradural, leptomeningeal, or, rarely, intramedullary. Extradural metastatic spinal cord compression is a neurologic emergency and should be promptly diagnosed as pretreatment neurologic status dictates the posttreatment outcome.

SUMMARY

Neoplastic myelopathies encompass many diagnoses ranging from benign and malignant spinal tumors to paraneoplastic syndromes heralding cancers. The knowledge of the clinical features and management of neoplastic myelopathies is essential to practicing neurologists as early diagnosis and treatment can prevent devastating neurologic sequelae.

Spinal Myxopapillary Ependymoma: The Sapienza University Experience and Comprehensive Literature Review Concerning the Clinical Course of 1602 Patients

BACKGROUND

Spinal myxopapillary ependymoma (sMPE) is an uncommon primary spinal neoplasm infiltrating the spinal cord, conus medullaris (CM), and nerve roots. It is associated with low resection and high recurrence rates. The purpose of this literature review is to evaluate the exact impact of the involvement of the CM and the role played by gross total resection (GTR) on overall survival (OS).

METHODS

The English literature was systematically investigated using MEDLINE, the NIH Library, PubMed, and Google Scholar search engines with relevant queries. Case series reporting details concerning OS, GTR, and CM involvement rate were included, with a differential statistical weight given by the number of patients enrolled. A final cohort of 1602 clinical records was analyzed according to the 3 selected end point variables.

RESULTS

The average age was 36.44 ± 3.41 years, and the CM was involved in 28.4% ± 28.2% of cases. The average GTR rate was 53.94% ± 22.20%. Five- and 10-year OS rates were respectively available in 1170 and 1167 cases, with an average 5- and 10-year OS rate of 94.99% ± 3.87% and 92.31% ± 5.73%. By means of analyses performed both on aggregated and disaggregated data a strong positive statistical connection between GTR and increased OS was demonstrated despite the real clinical advantage could range as low as around 1% of increased OS rate.

CONCLUSIONS

Given the indolent sMPE behavior, it is difficult to evaluate the exact impact of GTR and CM involvement on OS; however, GTR could be associated with a limited survival advantage, whereas CM involvement could be associated with a survival disadvantage.

Clinicopathological and Genetic Features of Supratentorial Cortical Ependymomas

OBJECTIVE

Supratentorial cortical ependymomas (CEs) are rare. These lesions, selectively occurring in the superficial cortex, have not been fully characterized. We analyzed the clinicopathological and genetic features of CEs.

METHODS

Eight patients with CEs from our institution and 84 other reported CE cases were included in the present study. We retrospectively reviewed their clinical characteristics, imaging findings, treatment methods, pathological features, molecular status, and clinical outcomes.

RESULTS

The median age at diagnosis of our 8 patients was 7.5 years. The mean tumor diameter was 70 mm. All the tumors had a cystic appearance, and calcification was observed in 6. Gross total resection was achieved in 6 patients and subtotal resection in 2 patients. Of the 8 tumors, 7 were World Health Organization grade III and 1 was World Health Organization grade II. Six tumors were immunopositive for L1 cell adhesion molecule (L1CAM). We investigated the presence of C11orf95-RELA fusion in 5 patients, all of whom exhibited it. Postoperative radiotherapy was performed for all patients with grade III tumors, except for children aged <3 years. Although 4 patients developed recurrence, all were alive throughout the follow-up period. Compared with previously reported CEs, our patients were younger and had larger tumors; however, the clinical outcomes did not differ significantly.

CONCLUSIONS

Although most CEs in our group were immunopositive for L1CAM and showed C11orf95-RELA fusion, which have been associated with a poor prognosis in supratentorial ependymomas, all our patients had good outcomes. Gross total resection and adjuvant radiotherapy contributed to the relatively favorable prognosis of CEs compared with other supratentorial ependymomas.

Predicting Survival of Patients with Spinal Ependymoma Using Machine Learning Algorithms with the SEER Database

OBJECTIVE

This study was conducted to understand the clinical and demographic factors influencing the overall survival (OS) of patients with spinal ependymoma and to predict the OS with machine learning (ML) algorithms.

METHODS

We compiled spinal ependymoma cases diagnosed between 1973 and 2014 from the Surveillance, Epidemiology, and End Results (SEER) registry. To identify the factors influencing survival, statistical analyses were performed using the Kaplan-Meier method and Cox proportional hazards regression model. In addition, we implemented ML algorithms to predict the OS of patients with spinal ependymoma.

RESULTS

In the multivariate analysis model, age ≥65 years, histologic subtype, extraneural metastasis, multiple lesions, surgery, radiation therapy, and gross total resection (GTR) were found to be independent predictors for OS. Our ML model achieved an area under the receiver operating characteristic curve (AUC) of 0.74 (95% confidence interval [CI], 0.72-0.75) for predicting a 5-year OS of spinal ependymoma and an AUC of 0.81 (95% CI, 0.80-0.83) for predicting a 10-year OS. The stepwise logistic regression model showed poorer performance by an AUC of 0.71 (95% CI, 0.70-0.72) for predicting a 5-year OS and an AUC of 0.75 (95% CI, 0.73-0.77) for predicting a 10-year OS.

CONCLUSIONS

With SEER data, we reaffirmed that therapeutic factors, such as surgery and GTR, were associated with improved OS. Compared with statistical methods, ML techniques showed satisfactory results in predicting OS; however, the dataset was heterogeneous and complex with numerous missing values.

Tanycytic ependymoma of filum terminale: Clinical characteristics and surgical outcomes

Tanycytic ependymoma (TE), a rare subtype of ependymoma, was classified as grade II ependymoma by the World Health Organization in 2000 and 2007. Preoperative diagnosis of TE is challenging due to its similarities to schwannoma and astrocytoma; therefore, differentiation is required. The present study investigated the clinical, imaging and pathological characteristics of TE in the filum terminale. A retrospective analysis was conducted on the clinical, imaging, pathological and immunohistochemical characteristics of 8 patients with TE in the filum terminale and the relevant literature was reviewed. Of the 8 patients 7 were female and 1 was male, with an age range of 24–62 years old. The primary clinical symptom observed was lumbago, accompanied by lower limb pain and numbness. Magnetic resonance imaging predominantly identified isointensity on thoracic (T) 1-weighted images and iso- or hyperintense signal intensity on T2-weighted images, with homogeneous or inhomogeneous enhancement. All patients underwent resection of the tumor through a posterior median approach, and total resection was acighieved in 7 patients. During postoperative follow-up, all patients experienced improvement compared with their preoperative status, and were without tumor recurrence. The present study comprised the largest group of cases with TE in the filum terminale reported so far, to the best of our knowledge, which could foster a better understanding of this disease. Complete surgical resection of the tumor has the greatest effectiveness of any treatment for TE in the filum terminale. Postoperative histological examination, immunohistochemistry and electron microscopy for tumor specimens may assist in its diagnosis and differential diagnosis.

Natural Course of Myxopapillary Ependymoma: Unusual Case Report and Review of Literature

BACKGROUND

Spinal cord ependymomas are the most frequent primary intramedullary tumors of the cord in middle age (40-60 years of age). Myxopapillary ependymomas are low-incidence tumors and occur in the cauda equina and conus medullaris. They are typically described as fleshy, sausage-shaped, vascular lesions.

CASE DESCRIPTION

In this report, we present a 36-year-old woman who was seen in another hospital with complaints of back pain radiating into both legs 5 years ago. Magnetic resonance imaging (MRI) examinations revealed a lesion releated to the spinal cord. At that point, the patient refused the proposed surgical treatment. Five years later, the patient was referred to our clinic with advancement of the complaint to paraparesis. The new MRI showed an intradural mass at the level of T11 and S1. We performed a total intradural tumor resection. Histopathologic examination revealed a myxopapillary ependymoma.

CONCLUSIONS

Myxopapillary ependymomas grow slowly and are well defined by MRI. Advancements in radiologic technology and surgical equipment have allowed this tumor type to be treated successfully. Unfortunately, if untreated, these lesions have poor prognosis and result in clinical symptoms such as paraparesis. Surgical treatment of these lesions using total resection was performed total resection and was associated with an excellent postoperative outcome. We highlight the natural course of myxopapillary ependymomas.