Nonresective treatment of pineoblastoma: a case report

Outcome and prognostic features in paediatric pineoblastomas: analysis of cases from the Surveillance, Epidemiology, and End Results registry (1990-2007)

BACKGROUND

Paediatric pineoblastomas are rare central nervous system tumours. Patient and treatment factors associated with outcome are poorly defined and limited to small retrospective case series and single case reports.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) cancer registry, we investigated clinical and pathological factors associated with outcome in paediatric pineoblastomas. Paediatric patients (< 16 years old) with pineoblastomas diagnosed between 1990 and 2007 were identified from the SEER database. Kaplan-Meier survival analysis and Cox models were used to examine the effect of variables on overall survival. The variables analysed included patient's age at diagnosis, gender, race, tumour spread and size, surgical resection and the use of adjuvant radiotherapy.

RESULTS

Seventy-eight patients were identified from the database. Twelve patients were excluded as 11 had no surgery and one patient was excluded as the surgical status was unknown. Analysis of the remaining 66 patients revealed a median age at diagnosis of 5.5 years. Three patients underwent biopsy. Seventeen patients underwent full and partial resection, respectively. A further 46 patients underwent surgery the nature of which was not recorded. Thirty-nine patients (59.1%) received adjuvant radiotherapy. Eight patients (12.1%) had both surgery (full or partial resection) and radiotherapy. The median overall survival was 40.5 months. Univariate analysis demonstrated that older age at diagnosis was the only positive predictor of overall survival.

CONCLUSION

This study represents the largest analysis of paediatric pineoblastomas to date. The only clinically relevant prognostic factor was older age at diagnosis. The role of surgery and adjuvant radiotherapy on overall survival remains to be defined.

Clinical, Pathological, and Surgical Outcomes for Adult Pineoblastomas

INTRODUCTION

Pineoblastomas are uncommon primitive neuroectodermal tumors that occur mostly in children; they are exceedingly rare in adults. Few published reports have compared the various aspects of these tumors between adults and children.

METHODS

The authors report a series of 12 pineoblastomas in adults from 2 institutions over 24 years. The clinical, radiologic, and pathologic features and clinical outcomes were compared with previously reported cases in children and adults.

RESULTS

Patient age ranged from 24 to 81 years, and all but 1 patient exhibited symptoms of obstructive hydrocephalus. Three patients underwent gross total resection, and subtotal resection was performed in 3 patients. Diagnostic biopsy specimens were obtained in an additional 6 patients. Pathologically, the tumors had the classical morphologic and immunohistochemical features of pineoblastomas. Postoperatively, 10 patients received radiotherapy, and 5 patients received chemotherapy. Compared with previously reported cases, several differences were noted in clinical outcomes. Of the 12 patients, only 5 (42%) died of their disease (average length of survival, 118 months); 5 patients (42%) are alive with no evidence of disease (average length of follow-up, 92 months). One patient died of unrelated causes, and one was lost to follow-up. Patients with subtotal resections or diagnostic biopsies did not suffer a worse prognosis. Of the 9 patients with biopsy or subtotal resection, 4 are alive, 4 died of their disease, and 1 died of an unrelated hemorrhagic cerebral infarction.

CONCLUSIONS

Although this series is small, the data suggest that pineoblastomas in adults have a less aggressive clinical course than in children.

Outcome and prognostic features in adult pineoblastomas: analysis of cases from the SEER database

BACKGROUND

Adult pineoblastomas (PBL) are rare central nervous system tumors. Patient and treatment factors associated with outcome are poorly defined and limited to small retrospective case series and single case reports. Using the Surveillance, Epidemiology, and End Results (SEER) cancer registry, we investigated clinicopathological factors associated with outcome in adult PBL.

METHODS

Adult patients (≥16 years old) with PBL diagnosed between 1990 and 2007 were identified from the SEER database. Kaplan-Meier survival analysis and Cox models were used to examine the effect of variables on overall survival. The variables analyzed included patient's age at diagnosis, gender, race, tumor location, uni-focal or multi-focal tumor, tumor size, surgical resection, and the use of adjuvant radiotherapy.

RESULTS

Ninety-five patients were identified, with a median age at diagnosis of 39.2 years. Sixty-one patients (64 %) underwent surgery and 44 patients (47.4 %) received adjuvant radiotherapy. Forty-two patients (44 %) had both surgery and radiotherapy. The median overall survival was 176 months. Univariate analysis identified younger age at diagnosis, uni-focal and localized disease as important predictors of overall survival. On multivariate analysis, only age at diagnosis and localized disease emerged as important prognostic factors.

CONCLUSIONS

Despite the numerous limitations of the SEER database, this study represents the largest analysis of adult PBL to date. Clinically relevant prognostic factors were younger age of diagnosis and localized disease. The role of surgery and adjuvant radiotherapy remains to be defined. Our data suggest these treatment modalities may not influence overall survival.

Are stereotactic sample biopsies still of value in the modern management of pineal region tumours? Lessons from a single-department, retrospective series

OBJECTIVE

Recent improvements in imaging-based diagnosis, the broader application of neuroendoscopic techniques and advances in open surgery techniques mean that the need for stereotactic biopsies in the management of pineal region tumours must be reevaluated. The primary aim of this retrospective study was to establish whether stereotactic biopsy is still of value in the modern management of pineal region tumours.

METHODS

From 1985 to 2009, 88 consecutive patients underwent a stereotactic biopsy in our institution (51 males and 37 females; median age at presentation 30; range 2-74).

RESULTS

Accurate tissue diagnoses were obtained in all but one case (i.e. 99%). In one case (1%), three distinct stereotactic procedures were necessary to obtain a tissue diagnosis. There was no mortality or permanent morbidity associated with stereotactic biopsy. One patient (1%) presented an intra-parenchymal hematoma but no related clinical symptoms. Five patients (6%) presented transient morbidity, which lasted for between 2 days and 3 weeks after the biopsy.

CONCLUSIONS

To guide subsequent treatment, we believe that histological diagnosis is paramount. Stereotactic biopsies are currently the safest and the most efficient way of obtaining this essential information. Recent improvements in stereotactic technology (particularly robotic techniques) appear to be very valuable, with almost no permanent morbidity or mortality risk and no decrease in the accuracy rate. In our opinion, other available neurosurgical techniques (such as endoscopic neurosurgery, stereotactic neurosurgery and open microsurgery) are complementary and not competitive.

Pineal parenchymal tumors. Management with interstitial iodine-125 radiosurgery

PURPOSE

To evaluate the efficacy of interstitial radiosurgery (IRS) for pineal parenchymal tumors (PPTs).

PATIENTS AND METHODS

18 consecutively admitted patients (twelve male and six female, age range 6-68 years, median age 34 years) with PPTs (eight pineocytomas, ten malignant PPTs) were treated at the authors' institution with IRS using stereotactically guided iodine-125 seed implantation ((125)I-IRS) as either primary or salvage therapy. The cumulative tumor surface dose ranged from 40 to 64 Gy. Adjuvant radiotherapy of the whole brain or the craniospine was done in patients with grade III and grade IV PPT. The median follow-up period was 57.4 months (range 6-134 months).

RESULTS

Overall actuarial 5- and 8-year survival rates after IRS were 100% and 86% for pineocytomas, and the overall actuarial 5-year survival rate was 78% for high-grade PPTs. Follow-up magnetic resonance imaging showed complete remission in 72% (13/18) and partial remission in 28% (5/18) of the cases. One patient developed an out-of-field relapse 4 years after partial remission of a pineocytoma, which had already been treated with IRS. There was no treatment-related mortality. Treatment-related morbidity occurred in two patients only.

CONCLUSION

This study indicates that stereotactic (125)I-IRS for the management of PPTs is quite efficient and safe. Due to the low rate of side effects, IRS may develop into an attractive alternative to microsurgery in de novo diagnosed pineocytomas. In malignant PPTs, IRS may be routinely applied in a multimodality treatment schedule supplementary to conventional irradiation.

Endoscopic options in management of posterior third ventricular tumors

OBJECTIVE

A spectrum of both radiosensitive and radio-resistant lesions occurs in the region of the posterior third ventricle (PTV). Most of these are associated with hydrocephalus requiring a cerebrospinal fluid diversion procedure. The present study aims to assess the effectiveness of endoscopic biopsy and third ventriculostomy (ETV) in these patients.

MATERIALS AND METHODS

Twenty-four patients with PTV lesions with moderate to severe hydrocephalus were managed prospectively. All patients underwent ETV and biopsy of the lesion during the same procedure. The ETV could be performed in all patients, where as in 23, a successful biopsy could be obtained. The ETV was successful in 22 patients; it failed in 2 patients requiring shunt insertion. A positive biopsy was obtained in all the patients (pinealocytoma 4, pinealoblastoma 10, embryonal cell carcinoma 1, germinoma 2, oligodendroglioma 1, astrocytoma 2, tuberculoma 4). All patients were subsequently managed with further surgery, radiation, and chemotherapy either alone or in combination depending on the pathology. One patient with a tumor bed hematoma required clot evacuation. The follow-up period ranged from 12 to 36 months. Two patients died, one during hospital stay with a tumor bed hematoma and another at 6 months follow-up due to extensive leptomeningeal spread.

CONCLUSIONS

The high yield of endoscopic biopsy (100%) and success of ETV (91%) emphasizes its role in management of the diverse group of PTV lesions in arriving at the optimal definitive management.

Principles of treatment of the pineal region tumors

BACKGROUND

A pineal region tumor is an uncommon deep-seated, heterogeneous group of mass lesions of the brain, and the management strategy of any types of these tumors remains controversial. It is the purpose of this communication to present results of our experience in treating patients with these neoplasms.

METHODS

From 1976 to 1999 about 700 patients with tumors of the pineal region and posterior third ventricle were managed at the Burdenko Neurosurgery Institute. In more than 330 cases the tumor was removed. In this paper we present results of 287 patients with histologically verified pineal region tumors for the period from 1976 to 1999. All of them had verified tumor histology, excluding only five cases in which stereotactic biopsy procedures were uninformative. There are four main groups of tumors: the germ cell tumors-87 (31%); the pineal parenchymal tumors-75 (27%); the glial tumors-77 (27%); and miscellaneous-43 (15%). There were 255 surgical procedures for tumor removal performed in 244 and stereotactically guided biopsies in 61 patients, 168 (58%) with obstructive hydrocephalus who underwent cerebrospinal fluid shunting. Radiation therapy was administered in 145 (51%) and chemotherapy in 16 patients. Follow-up data were collected in 209 cases (80%). Survival was calculated with the Kaplan-Meier product limit method.

RESULTS

The occipital transtentorial and infratentorial supracerebellar approaches were the most commonly used on our series-138 (54%) and 87 (34%), respectively. In the remaining cases, subchoroidal approach, approach through the fourth ventricle, and the combined approaches were used. A total tumor removal was achieved in 148 operations (58%), subtotal in 74 (29%) and partial in 33 (13%). The projected 5-year and 10-year survival rates for patients with malignant pineal tumors, who received irradiation after tumor resection or underwent radiation therapy alone, were: 95% and 88% for pure germinomas, 80% and 50% for high grade gliomas, 44% and 0% for malignant pineal parenchymal tumors, and 20% and 0% for malignant germ cell tumors, respectively.

CONCLUSIONS

Benign pineal tumors should be cured with surgery alone. Malignant tumors should be treated with aggressive resection followed with irradiation and chemotherapy. Pure germinomas, which are exquisitely radiosensitive, can be cured by conventional radiation therapy alone.

Malignant pineal parenchymal tumors in adult patients: patterns of care and prognostic factors

OBJECTIVE

The aim of our study was to analyze patterns of care and to identify prognostic factors in patients at least 18 years of age who received radiotherapy for malignant pineal parenchymal tumors.

METHODS

In a multicenter, retrospective study, we analyzed data for 37 previously published cases and 64 patients treated at the participating institutions.

RESULTS

A total of 56 patients received postoperative radiotherapy, and 45 patients received primary radiotherapy. Chemotherapy was administered to 34 patients. The median follow-up period was 38 months, and median overall survival was 100 months. The variables that significantly influenced overall survival were the extent of disease (localized versus disseminated; P = 0.0002), differentiation (pineal parenchymal tumor of intermediate differentiation versus pineoblastoma; P = 0.001), and residual disease (> or = 50% versus < 50% reduction in size; P < 0.0001). In a multivariate analysis, the parameters turned out to be independent risk factors. The median survival in patients with local or spinal failure was 15 months. Local control was better in older patients (> or = 32 yr versus < 32 yr; P = 0.02). Spinal control was more successful in patients with pineal parenchymal tumors of intermediate differentiation than it was in patients with pineoblastomas (P = 0.03). Nine of 45 treatment failures occurred later than 5 years after treatment.

CONCLUSION

Stage, histological characteristics, and response are independent risk factors in adults with malignant pineal parenchymal tumors. Late relapses are common.