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Mohan D, Nambirajan A, Malik R, Sharma A, Suri V, Kaur K, Doddamani R, Garg A, Gupta S, Mallick S, Sharma MC. MYCN immunohistochemistry as surrogate marker for MYCN-amplified spinal ependymomas. Hum Cell 2024; 37:704-713. [PMID: 38411836 DOI: 10.1007/s13577-024-01037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/21/2024] [Indexed: 02/28/2024]
Abstract
MYCN (master regulator of cell cycle entry and proliferative metabolism) gene amplification defines a molecular subgroup of spinal cord ependymomas that show high-grade morphology and aggressive behavior. Demonstration of MYCN amplification by DNA methylation or fluorescence-in situ hybridization (FISH) is required for diagnosis. We aimed to (i) assess prevalence and clinicopathological features of MYCN-amplified spinal ependymomas and (ii) evaluate utility of immunohistochemistry (IHC) for MYCN protein as a surrogate for molecular testing. A combined retrospective-prospective study spanning 8 years was designed during which all spinal cord ependymomas with adequate tissue were subjected to MYCN FISH and MYCN IHC. Among 77 spinal cord ependymomas included, MYCN amplification was identified in 4 samples from 3 patients (3/74, 4%) including two (1st and 2nd recurrences) from the same patient. All patients were adults (median age at diagnosis of 32 years) including two females and one male. The index tumors were located in thoracic (n = 2) and lumbar (n = 1) spinal cord. One of the female patients had neurofibromatosis type 2 (NF2). All four tumors showed anaplastic histology. Diffuse expression of MYCN protein was seen in all four MYCN-amplified samples but in none of the non-amplified cases, thus showing 100% concordance with FISH results. On follow-up, the NF2 patient developed widespread spinal dissemination while another developed recurrence proximal to the site of previous excision. To conclude, MYCN-amplified spinal ependymomas are rare tumors, accounting for ~ 4% of spinal cord ependymomas. Within the limitation of small sample size, MYCN IHC showed excellent concordance with MYCN gene amplification.
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Affiliation(s)
- Divya Mohan
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Aruna Nambirajan
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Rafat Malik
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Agrima Sharma
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Vaishali Suri
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kavneet Kaur
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ramesh Doddamani
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ajay Garg
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Subhash Gupta
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Supriya Mallick
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Mehar Chand Sharma
- Departments of Pathology, Neurosurgery, Neuroradiology and Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Davison MA, Lilly DT, Patel AA, Kashkoush A, Chen X, Wei W, Benzel EC, Prayson RA, Chao S, Angelov L. Clinical presentation and extent of resection impacts progression-free survival in spinal ependymomas. J Neurooncol 2024; 167:437-446. [PMID: 38438766 PMCID: PMC11096218 DOI: 10.1007/s11060-024-04623-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 03/06/2024]
Abstract
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.
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Affiliation(s)
- Mark A Davison
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel T Lilly
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Arpan A Patel
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Kashkoush
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaoying Chen
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wei Wei
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward C Benzel
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Richard A Prayson
- Department of Anatomic Pathology, The Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel Chao
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
- Neurologic Oncology and Radiosurgery Fellowships, Neurological Surgery, CCLCM at CWRU, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, 9500 Euclid Ave., CA-51, 44195, Cleveland, OH, USA.
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3
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Barbagli G, Hussein A, Quiceno E, Prim M, Soto Rubio D, Baaj A. Resection of an Intradural Intramedullary C7-T1 Tumor: Technical Nuances and Complication Management. World Neurosurg 2024; 184:41. [PMID: 38218443 DOI: 10.1016/j.wneu.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
Primary spinal cord tumors are relatively rare, comprising approximately 4%-16% of all tumors originating from the central nervous system. These tumors are anatomically separable into 2 broad categories: intradural intramedullary and intradural extramedullary. Intramedullary tumors are composed predominantly of gliomas (infiltrative astrocytoma) and ependymomas.1-4 The primary treatment approach for these tumors is surgical resection, aiming to preserve neurologic function.5-9 In Video 1, the authors showcase a step-by-step approach for microsurgical resection of a primary spinal ependymoma, with emphasis on microsurgical technique and utility of adjunct equipment, such as intraoperative ultrasound and neuromonitoring.10,11 The patient consented to the procedure.
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Affiliation(s)
- Giovanni Barbagli
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA.
| | - Amna Hussein
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Esteban Quiceno
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Michael Prim
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Diego Soto Rubio
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Ali Baaj
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
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Villanueva-Castro E, Meraz-Soto JM, Hernández-Dehesa IA, Tena-Suck ML, Hernández-Reséndiz R, Mateo-Nouel EDJ, Ponce-Gómez JA, Arriada-Mendicoa JN. Spinal Ependymomas: An Updated WHO Classification and a Narrative Review. Cureus 2023; 15:e49086. [PMID: 38125233 PMCID: PMC10731541 DOI: 10.7759/cureus.49086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Ependymomas are neuroepithelial tumors that develop from ependymal cells found in the brain parenchyma and can spread to any part of the spinal cord. Three to six percent of all malignancies affecting the central nervous system (CNS) are ependymomas. Even the most talented surgeons are challenged by spinal cord ependymomas; as a result, research into this clinical phenomenon should continue. Since 1979, the World Health Organization (WHO) has published a classification and grading system for CNS malignancies to ensure consistent diagnostic standards worldwide. The WHO prepared an update on these tumors, paying particular attention to molecular techniques to categorize the therapeutic management of each patient with greater accuracy and clarity. We thoroughly reviewed the literature on the epidemiology, etiology, diagnosis, and treatment of spinal ependymomas since there has not been a recent review of these tumors. This included modifications to the 2021 WHO Classification of Tumors of the Central Nervous System.
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Affiliation(s)
- Eliezer Villanueva-Castro
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Juan Marcos Meraz-Soto
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | | | - Martha Lilia Tena-Suck
- Department of Neuropathology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | | | - Edgardo de Jesus Mateo-Nouel
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Juan Antonio Ponce-Gómez
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
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Naito K, Umebayashi D, Kurokawa R, Endo T, Mizuno M, Hoshimaru M, Kim P, Hida K, Takami T. Predictors of Progression-Free Survival in Patients With Spinal Intramedullary Ependymoma: A Multicenter Retrospective Study by the Neurospinal Society of Japan. Neurosurgery 2023; 93:1046-1056. [PMID: 37255289 DOI: 10.1227/neu.0000000000002538] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/29/2023] [Indexed: 06/01/2023] Open
Abstract
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.
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Affiliation(s)
- Kentaro Naito
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka , Japan
| | - Daisuke Umebayashi
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto , Japan
| | - Ryu Kurokawa
- Department of Neurologic Surgery, Dokkyo Medical University, Tochigi , Japan
| | - Toshiki Endo
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University, Miyagi , Japan
| | - Masaki Mizuno
- Department of Minimum-Invasive Neurospinal Surgery, Mie University, Mie , Japan
| | | | - Phyo Kim
- Neurologic Surgery, Symphony Clinic, Tochigi , Japan
| | - Kazutoshi Hida
- Department of Neurosurgery, Sapporo Azabu Neurosurgical Hospital, Hokkaido , Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Osaka , Japan
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Chee K, Chatain GP, Kortz MW, Serva S, Shrestha K, Ung TH, Witt JP, Finn M. Neurologic outcomes for adult spinal cord ependymomas stratified by tumor location: a retrospective cohort study and 2-year outlook. Neurosurg Rev 2023; 46:258. [PMID: 37773424 PMCID: PMC10542475 DOI: 10.1007/s10143-023-02166-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/21/2023] [Accepted: 09/24/2023] [Indexed: 10/01/2023]
Abstract
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.
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Affiliation(s)
- Keanu Chee
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA.
| | - Grégoire P Chatain
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Michael W Kortz
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Stephanie Serva
- Department of Neurosurgery, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Keshari Shrestha
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Timothy H Ung
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Jens-Peter Witt
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Michael Finn
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
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Yamaguchi J, Ohka F, Motomura K, Saito R. Latest classification of ependymoma in the molecular era and advances in its treatment: a review. Jpn J Clin Oncol 2023; 53:653-663. [PMID: 37288489 DOI: 10.1093/jjco/hyad056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 06/09/2023] Open
Abstract
Ependymoma is a rare central nervous system (CNS) tumour occurring in all age groups and is one of the most common paediatric malignant brain tumours. Unlike other malignant brain tumours, ependymomas have few identified point mutations and genetic and epigenetic features. With advances in molecular understanding, the latest 2021 World Health Organization (WHO) classification of CNS tumours divided ependymomas into 10 diagnostic categories based on the histology, molecular information and location; this accurately reflected the prognosis and biology of this tumour. Although maximal surgical resection followed by radiotherapy is considered the standard treatment method, and chemotherapy is considered ineffective, the validation of the role of these treatment modalities continues. Although the rarity and long-term clinical course of ependymoma make designing and conducting prospective clinical trials challenging, knowledge is steadily accumulating and progress is being made. Much of the clinical knowledge obtained from clinical trials to date was based on the previous histology-based WHO classifications, and the addition of new molecular information may lead to more complex treatment strategies. Therefore, this review presents the latest findings on the molecular classification of ependymomas and advances in its treatment.
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Affiliation(s)
- Junya Yamaguchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumiharu Ohka
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuya Motomura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Dauleac C, Manet R, Meyronet D, Jacquesson T, Berhouma M, Robinson P, Berthiller J, Jouanneau E, Barrey CY, Mertens P. Prognostic factors for progression-free survival of the filum terminale ependymomas in adults. Neurochirurgie 2022; 68:273-279. [PMID: 34998798 DOI: 10.1016/j.neuchi.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/10/2021] [Accepted: 12/11/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To define the prognostic factors for progression and to determine the impact of the histological grading (according to the World Health Organization) on the progression-free survival (PFS) of filum terminale ependymomas. METHODS A retrospective chart review of 38 patients with ependymoma of the filum terminale was performed, focusing on demographic data, preoperative symptoms, tumor size, quality of resection, presence of a tumor capsule, and histological grade. RESULTS Gross total resection (GTR) was achieved in 30 patients (78.9%). Histopathological analysis found 21 (55.3%) myxopapillary grade I ependymoma (MPE), 16 (42.1%) ependymoma grade II (EGII), and 1 (2.6%) ependymoma grade III. There was no significant difference between the mean ± SD volume of MPE (5840.5 ± 5244.2 mm3) and the one of EGII (7220.3 ± 6305.9 mm3, p=0.5). The mean ± SD follow-up was 54.1 ± 38.4 months. At last follow-up, 30 (78.9%) patients were free of progression. In multivariate analysis, subtotal resection (p=0.015) and infiltrative tumor (p=0.03) were significantly associated with progression. The PFS was significantly higher in patients with encapsulated tumor than in patients with infiltrative tumor (log-rank p=0.01) and in patients who had a GTR in comparison with those who had an incomplete resection (log-rank p=0.05). There was no difference in PFS between patient with MPE and EGII (p=0.1). CONCLUSION The progression of ependymoma of the filum terminale highly depends on the quality of resection, and whether the tumor is encapsulated. Except for anaplastic grade, histopathological type does not influence progression.
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Affiliation(s)
- Corentin Dauleac
- Service de Neurochirurgie, Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Lyon, France; Université de Lyon I, Université de Lyon, Lyon, France.
| | - Romain Manet
- Service de Neurochirurgie, Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Lyon, France
| | - David Meyronet
- Université de Lyon I, Université de Lyon, Lyon, France; Service d'Anatomo-pathologie, Hospices Civils de Lyon, Lyon, France
| | - Timothée Jacquesson
- Service de Neurochirurgie, Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Lyon, France; Université de Lyon I, Université de Lyon, Lyon, France
| | - Moncef Berhouma
- Service de Neurochirurgie, Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Lyon, France; Université de Lyon I, Université de Lyon, Lyon, France
| | - Philip Robinson
- Unité d'Appui Méthodologique, Département de la Recherche Clinique et Innovation, Hospices Civils de Lyon, Lyon, France
| | - Julien Berthiller
- Unité d'Appui Méthodologique, EPICIME, Cellule Innovation DRCI, Hospices Civils de Lyon, Lyon, France
| | - Emmanuel Jouanneau
- Service de Neurochirurgie, Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Lyon, France; Université de Lyon I, Université de Lyon, Lyon, France
| | - Cédric Y Barrey
- Service de Neurochirurgie, Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Lyon, France; Université de Lyon I, Université de Lyon, Lyon, France
| | - Patrick Mertens
- Service de Neurochirurgie, Hospices Civils de Lyon, Hôpital neurologique Pierre Wertheimer, Lyon, France; Université de Lyon I, Université de Lyon, Lyon, France
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Gembruch O, Chihi M, Haarmann M, Parlak A, Oppong MD, Rauschenbach L, Michel A, Jabbarli R, Ahmadipour Y, Sure U, Dammann P, Özkan N. Surgical outcome and prognostic factors in spinal cord ependymoma: a single-center, long-term follow-up study. Ther Adv Neurol Disord 2021; 14:17562864211055694. [PMID: 34790260 PMCID: PMC8591778 DOI: 10.1177/17562864211055694] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 10/08/2021] [Indexed: 12/03/2022] Open
Abstract
Objective: Spinal cord ependymomas account for 3–6% of all central nervous system tumors and around 60% of all intramedullary tumors. The aim of this study was to analyze the neurological outcome after surgery and to determine prognostic factors for functional outcome. Patients and Methods: Patients treated surgically due to a spinal cord ependymoma between 1990 and 2018 were retrospectively included. Demographics, neurological symptoms, radiological parameters, histopathology, and neurological outcome (using McCormick Score [MCS]) were analyzed. Possible prognostic factors for neurological outcome were evaluated. Results: In total, 148 patients were included (76 males, 51.4%). The mean age was 46.7 ± 15.3 years. The median follow-up period was 6.8 ± 5.4 years. The prevalence was mostly in the lumbar spine (45.9%), followed by the thoracic spine (28.4%) and cervical spine (25.7%). Gross-total resection was achieved in 129 patients (87.2%). The recurrence rate was 8.1% and depended on the extent of tumor resection (p = 0.001). Postoperative temporary neurological deterioration was observed in 63.2% of patients with ependymomas of the cervical spine, 50.0% of patients with ependymomas of the thoracic spine, and 7.4% of patients with ependymomas of the lumbosacral region. MCS 1–2 was detected in nearly two-thirds of patients with cervical and thoracic spinal cord ependymoma 36 months after surgery. Neurological recovery was superior in thoracic spine ependymomas compared with cervical spine ependymomas. Poor preoperative functional condition (MCS >2), cervical and thoracic spine location, and tumor extension >2 vertebrae were independent predictors of poor neurological outcome. Conclusion: Neurological deterioration was seen in the majority of cervical and thoracic spine ependymomas. Postoperative improvement was less in thoracic cervical spine ependymomas compared with thoracic spine ependymomas. Poor preoperative status and especially tumor extension >2 vertebrae are predictors of poor neurological outcome (MCS >2).
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Affiliation(s)
- Oliver Gembruch
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Merle Haarmann
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ahmet Parlak
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Anna Michel
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Neriman Özkan
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Risk score for outcome prediction after microsurgical resection of spinal ependymoma (SOURSE score). Clin Neurol Neurosurg 2021; 209:106923. [PMID: 34560387 DOI: 10.1016/j.clineuro.2021.106923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/19/2021] [Accepted: 08/22/2021] [Indexed: 11/20/2022]
Abstract
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.
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Pojskić M, Nguyen V, Lakičević G, Arnautović KI. Microsurgical Resection of Brain Stem Ependymoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 18:E240-E241. [PMID: 31504845 PMCID: PMC7594175 DOI: 10.1093/ons/opz252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/31/2019] [Indexed: 11/12/2022] Open
Abstract
The brainstem is a less-common location for ependymomas than the spinal cord where they are the most common adult intramedullary tumor.1-18 In this first video case report in the peer-reviewed literature, we demonstrate microsurgical resection of a medulla oblongata ependymoma. There are several case reports of medulla oblongata ependymomas1,3,5,6,13 and a few series of spinal cord ependymomas that included cases of ependymomas of the cervicomedullary junction.9,10 The goal of surgery was to stabilize the preoperative neurological function; favorable outcome is achieved in patients with good preoperative statuses and well-defined tumor boundaries.9 Although gross total resection (GTR) provides the best overall outcome, it is most effective for classic grade II tumors, but not grade I (myxopapillary) and ependymomas, which have a lower GTR rate.14,15 A 55-yr-old patient developed 4-extremity weakness and dysphagia. Pre-/postcontrast magnetic resonance imaging (MRI) revealed centrally located brainstem lesion situated at the lower half of the medulla oblongata. Surgery, performed by the senior author, was performed in the prone position with a small suboccipital craniectomy and C1 posterior arch removal, followed by pia opening and posterior midline myelotomy. Tumor was debulked, dissected from the white matter, and resected. Histology revealed ependymoma (World Health Organization grade II). Postoperative pre-/postcontrast MRI revealed total resection. The patient's neurological deficit completely resolved postoperatively. Written consent was obtained from the patient.
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Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Vincent Nguyen
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Goran Lakičević
- Department of Neurosurgery, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
| | - Kenan I Arnautović
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee
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Millesi M, Kiesel B, Mazanec V, Wadiura LI, Wöhrer A, Herta J, Wolfsberger S, Novak K, Furtner J, Rössler K, Knosp E, Widhalm G. 5-ALA fluorescence for intraoperative visualization of spinal ependymal tumors and identification of unexpected residual tumor tissue: experience in 31 patients. J Neurosurg Spine 2021; 34:374-382. [PMID: 33276339 DOI: 10.3171/2020.6.spine20506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gross-total resection (GTR) is the treatment of choice in the majority of patients suffering from spinal ependymal tumors. In such tumors, the extent of resection (EOR) is considered the key factor for tumor recurrence and thus patient prognosis. However, incomplete resection is not uncommon and leads to increased risk of tumor recurrence. One important cause of incomplete resection is insufficient intraoperative visualization of tumor tissue as well as residual tumor tissue. Therefore, the authors investigated the value of 5-aminolevulinic acid (5-ALA)-induced fluorescence in a series of spinal ependymal tumors for improved tumor visualization. METHODS Adult patients who underwent preoperative 5-ALA administration and surgery for a spinal ependymal tumor were included in this study. For each tumor, a conventional white-light microsurgical resection was performed. Additionally, the fluorescence status (strong, vague, or no fluorescence) and fluorescence homogeneity (homogenous or inhomogeneous) of the spinal ependymal tumors were evaluated during surgery using a modified neurosurgical microscope. In intramedullary tumor cases with assumed GTR, the resection cavity was investigated for potential residual fluorescing foci under white-light microscopy. In cases with residual fluorescing foci, these areas were safely resected and the corresponding samples were histopathologically screened for the presence of tumor tissue. RESULTS In total, 31 spinal ependymal tumors, including 27 intramedullary tumors and 4 intradural extramedullary tumors, were included in this study. Visible fluorescence was observed in the majority of spinal ependymal tumors (n = 25, 81%). Of those, strong fluorescence was noted in 23 of these cases (92%), whereas vague fluorescence was present in 2 cases (8%). In contrast, no fluorescence was observed in the remaining 6 tumors (19%). Most ependymal tumors demonstrated an inhomogeneous fluorescence effect (17 of 25 cases, 68%). After assumed GTR in intramedullary tumors (n = 15), unexpected residual fluorescing foci within the resection cavity could be detected in 5 tumors (33%). These residual fluorescing foci histopathologically corresponded to residual tumor tissue in all cases. CONCLUSIONS This study indicates that 5-ALA fluorescence makes it possible to visualize the majority of spinal ependymal tumors during surgery. Unexpected residual tumor tissue could be detected with the assistance of 5-ALA fluorescence in approximately one-third of analyzed intramedullary tumors. Thus, 5-ALA fluorescence might be useful to increase the EOR, particularly in intramedullary ependymal tumors, in order to reduce the risk of tumor recurrence.
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Affiliation(s)
- Matthias Millesi
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Barbara Kiesel
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Vanessa Mazanec
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Lisa I Wadiura
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Adelheid Wöhrer
- 2Division of Neuropathology and Neurochemistry, Department of Neurology
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | | | - Stefan Wolfsberger
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | | | - Julia Furtner
- 3Department of Biomedical Imaging and Image-Guided Therapy; and
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Karl Rössler
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Engelbert Knosp
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Georg Widhalm
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
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Savoor R, Sita TL, Dahdaleh NS, Helenowski I, Kalapurakal JA, Marymont MH, Lukas R, Kruser TJ, Smith ZA, Koski T, Ganju A, Sachdev S. Long-term outcomes of spinal ependymomas: an institutional experience of more than 60 cases. J Neurooncol 2020; 151:241-247. [PMID: 33179213 DOI: 10.1007/s11060-020-03658-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Rohan Savoor
- Department of Radiation Oncology, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 1820, Chicago, IL, 60611, USA
| | - Timothy L Sita
- Department of Radiation Oncology, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 1820, Chicago, IL, 60611, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 2200, Chicago, IL, 60611, USA
| | - Irene Helenowski
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - John A Kalapurakal
- Department of Radiation Oncology, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 1820, Chicago, IL, 60611, USA
| | - Maryanne H Marymont
- Department of Radiation Oncology, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 1820, Chicago, IL, 60611, USA
| | - Rimas Lukas
- Department of Neurology, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Dr, Abbott Hall 1114, Chicago, IL, 60611, USA
| | - Timothy J Kruser
- Department of Radiation Oncology, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 1820, Chicago, IL, 60611, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Oklahoma University School of Medicine, 1000 N. Lincoln Blvd. Suite 4000, Oklahoma City, OK, 73104, USA
| | - Tyler Koski
- Department of Neurological Surgery, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 2200, Chicago, IL, 60611, USA
| | - Aruna Ganju
- Department of Neurological Surgery, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 2200, Chicago, IL, 60611, USA
| | - Sean Sachdev
- Department of Radiation Oncology, Northwestern Lou and Jean Malnati Brain Tumor Institute, Northwestern University Robert H. Lurie Comprehensive Cancer Center, 676 N. St Clair Street, Suite 1820, Chicago, IL, 60611, USA.
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14
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National trends in management of adult myxopapillary ependymomas. J Clin Neurosci 2020; 73:162-167. [PMID: 31987634 DOI: 10.1016/j.jocn.2019.12.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/20/2019] [Indexed: 01/13/2023]
Abstract
Myxopapillary ependymomas (MPE) are WHO Grade I ependymomas that annually occur in 0.05-0.08 per 100,000 people. Surgical resection is the recommended first line therapy. Due to the rarity of the disease, there is a relatively poor understanding of the use of radiotherapy (RT) in managing this disease. The National Cancer Database (NCDB) was analyzed for patterns of care foradult MPE diagnosed between 2002 and 2016. Of 753 qualifying cases, the majority of patients underwent resection (n = 617, 81.9%). A relatively small portion received RT (n = 103, 13.3%) with most receiving RT post-operatively (n = 98, 95.1%). The likelihood of patients to undergo resection and RT was associated with patient age at diagnosis (p = 0.002), tumor size (p < 0.001), and race (p = 0.017). Chemotherapy was not widely utilized (0.27% of patients). One limitation of our analysis is that there was no data on progression free survival (PFS), an important outcome given the high survival rate in this disease. Surgery remains the primary means to manage adult MPE. For spinal MPE, it is understood that gross total resection (GTR) should be attempted whenever possible as GTR has been associated with improved PFS in several studies. The impact of RT on overall survival (OS) is indeterminate given the 1.6% death rate in the cohort. Analyses of the impact of RT on PFS in a larger database would be beneficial for determining an algorithm for post-operative and definitive RT in this disease entity.
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15
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Leber SL, Leber KA, Haybaeck J. Spinal melanotic ependymoma: A case report and review of literature. Pathol Res Pract 2019; 215:152380. [DOI: 10.1016/j.prp.2019.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/03/2019] [Accepted: 03/03/2019] [Indexed: 11/15/2022]
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Sun XY, Wang W, Zhang TT, Kong C, Sun SY, Guo MC, Ding JZ, Lu SB. Factors associated with postoperative outcomes in patients with intramedullary Grade II ependymomas: A Systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e16185. [PMID: 31232977 PMCID: PMC6637017 DOI: 10.1097/md.0000000000016185] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Most of the previous studies combined all types of intramedullary ependymomas without providing accurate pathological subtypes. In addition, it was very difficult to evaluate the factors associated with postoperative outcomes of patients with different pathological subtypes of intramedullary Grade II ependymomas by traditional meta-analysis. This study evaluated the factors related with postoperative outcomes of patients with intramedullary Grade II ependymomas. METHODS Individual patient data analysis was performed using PubMed, Embase, and the Cochrane Central Register of Controlled Trials. The search included articles published up to April 2018 with no lower date limit on the search results. The topics were intramedullary Grade II ependymomas. Progression-free survival (PFS) and overall survival (OS) were analyzed by Kaplan-Meier survival analysis (log-rank test). The level of significance was set at P < .05. RESULTS A total of 21 studies with 70 patients were included in this article. PFS of patients who underwent total resection was much longer than the PFS of those who received subtotal resection (P < .001). Patients who received adjuvant therapy (P = .005) or radiotherapy and chemotherapy (P < .001) seemed to have shorter PFS than others; PFS of patients who had cerebrospinal fluid disease dissemination (P = .022) or scoliosis (P = .001) were significantly shorter than others. OS of cellular ependymoma patients was less than giant cell ependymoma patients (P < .001). CONCLUSIONS PFS of patients who received total resection was much longer than those who received subtotal resection. Patients treated with adjuvant therapy or radiotherapy and chemotherapy appeared to have shorter PFS than others; PFS of patients with cerebrospinal fluid disease dissemination or scoliosis were significantly shorter than others. Cellular ependymomas would have better OS than giant cell ependymoma. However, giant cell ependymoma patients might have the worst OS.
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Affiliation(s)
- Xiang-Yao Sun
- Department of Orthopedics, Xuanwu Hospital Capital Medical University
- National Clinical Research Center for Geriatric Diseases
- Capital Medical University
| | - Wei Wang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University
- National Clinical Research Center for Geriatric Diseases
- Capital Medical University
| | - Tong-Tong Zhang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University
- Capital Medical University
- Department of Orthopaedics, ChuiYangLiu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Chao Kong
- Department of Orthopedics, Xuanwu Hospital Capital Medical University
- National Clinical Research Center for Geriatric Diseases
| | - Si-Yuan Sun
- Department of Orthopedics, Xuanwu Hospital Capital Medical University
- National Clinical Research Center for Geriatric Diseases
- Capital Medical University
| | - Ma-Chao Guo
- Department of Orthopedics, Xuanwu Hospital Capital Medical University
- National Clinical Research Center for Geriatric Diseases
- Capital Medical University
| | - Jun-Zhe Ding
- Department of Orthopedics, Xuanwu Hospital Capital Medical University
- National Clinical Research Center for Geriatric Diseases
- Capital Medical University
| | - Shi-Bao Lu
- Department of Orthopedics, Xuanwu Hospital Capital Medical University
- National Clinical Research Center for Geriatric Diseases
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Fonseca L, Cicuendez M, Martínez-Ricarte F, Martínez-Saez E, Cordero E, Bescos A. A rare case of an intramedullary metastasis of a myxopapillary ependymoma. Surg Neurol Int 2019; 10:83. [PMID: 31528421 PMCID: PMC6744754 DOI: 10.25259/sni-96-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 04/11/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Myxopapillary ependimoma (MPE) is a benign slow-growing tumor, and it has been designated histologically as a Grade I neoplasm according to the 2016 World Health Organization classification. Despite the benign character, dissemination and metastasis have occasionally been reported. The retrograde dissemination to other levels of the neuraxis is extremely rare, being more frequent to the intracranial compartment. Case Description: We hereby present a case of medullary metastasis of cauda equina MPE, with a history of having undergone a subtotal resection and postoperative adjuvant radiotherapy. The patient presents complaints of night dorsal pain attributable to intradural metastasis twenty-one years after the first surgical intervention. Conclusion: The case reported highlights the importance of long follow-up in patients with MPE, since the possibility of secondary seeding to distant craniospinal sites or local spinal sites after surgery, and radiotherapy should be considered in metastatic disease.
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Affiliation(s)
- Lino Fonseca
- Department of Neurosurgery, Centro Hospitalar Lisboa Central-Hospital São José, Serrano, Lisboa, Portugal, Barcelona, Spain
| | - Marta Cicuendez
- Department of Neurosurgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Elena Martínez-Saez
- Department of Pathology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Esteban Cordero
- Department of Neurosurgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Agustín Bescos
- Department of Neurosurgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Sudhan MD, Satyarthee GD, Joseph L, Sharma MC, Kakkar A, Sharma BS. Management and Outcome Analysis of Conus and Filum ependymoma: A Tertiary Center Study. Asian J Neurosurg 2019; 14:821-827. [PMID: 31497108 PMCID: PMC6703025 DOI: 10.4103/ajns.ajns_326_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Spinal ependymomas constitute approximately 2%-8% of primary adult central nervous system tumors. Authors analyzed demographic, clinical, radiological, surgical, and histopathological factors which correlated with the postoperative neurological outcome of patients who underwent surgery for conus and filum ependymoma (CFE). Materials and Methods A retrospective analysis of 31 patients regarding clinical feature, imaging study, surgical management, and McCormick grading system for assessing functional neurological status was carried out, who underwent surgical management for CFE between January 2009 and April 2014. Final neurological outcome at follow-up period was correlated with various factors in search to find out probable prognostic factors affecting final neurological outcome following surgical management. Results The myxopapillary ependymoma was observed in 55% of cases (n = 17), while 39% cases (n = 12) had Grade II ependymoma and rest 6% (n = 2) cases had anaplastic ependymomas. The mean age was 30 years (range 7-60 years) with male to female ratio of 1:0.82. Patients predominantly presented with pain (80.65%); mean duration of symptoms was 28.61 months. Only, the preoperative McCormick grade was found to be the statistically significant prognostic factor (P = 0.045), affecting neurological outcome however, the age, sex, duration of symptoms, location of the tumor, extent of the tumor, extradural spread, degree of surgical excision, vascularity of tumor, and histopathological World Health Organization grades were not found to be significant prognostic factors in the current study. Conclusion The preoperative McCormick score was found to be the only statistically significant factor predicting the functional and neurological outcome after surgery, so surgical treatment should be offered early in the course of the disease to provide chance of preservation and good neurological recovery.
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Affiliation(s)
| | - Guru Dutta Satyarthee
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Leve Joseph
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Mehar Chand Sharma
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Aanchal Kakkar
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
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20
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Byun HK, Yi S, Yoon HI, Kim SH, Cho J, Suh CO. Clinical outcomes of radiotherapy for spinal cord ependymoma with adverse prognostic features: a single-center study. J Neurooncol 2018; 140:649-657. [PMID: 30203166 DOI: 10.1007/s11060-018-2995-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/04/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE This study evaluated the outcomes of radiotherapy (RT) for spinal ependymoma with adverse features, such as incomplete resection or disseminated disease. METHODS Twenty-five patients underwent RT for spinal cord ependymoma during 1991-2016. Twenty-four patients had gross disease on the pre-RT spinal magnetic resonance images. Six patients (24%) had disseminated disease. The World Health Organization grades were I (12 patients), II (12 patients), and III (1 patient). The RT fields were the tumor bed plus margin in 19 patients (76%), the entire craniospinal axis in 5 patients (20%), and the entire spinal canal with posterior cranial fossa in 1 patient (4%). The median RT dose was 50.4 Gy (range 44.0-59.4 Gy). RESULTS The median follow-up was 49 months (range 9-321 months), with 5-year overall and progression-free survival rates of 83.7% and 70.8%, respectively. Relative to patients with grade II/III ependymoma, patients with grade I ependymoma had higher 5-year rates of overall survival (100% vs. 69.4%, P = .088) and progression-free survival (100% vs. 42.3%, P = .02). Disease progression was observed in 4 patients who had grade II ependymoma, including 2 of 6 patients with disseminated disease and 2 of 19 patients with localized disease. Twelve patients (48%) exhibited improved neurological function. One patient who underwent craniospinal irradiation developed late hypopituitarism. No other RT-related late toxicities were observed. CONCLUSIONS Favorable survival outcomes were achieved using RT for spinal ependymoma with adverse prognostic features. Thus, RT may be an effective treatment option when complete tumor removal cannot be achieved.
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Affiliation(s)
- Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Se Hoon Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaeho Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Cachia D, Johnson DR, Kaufmann TJ, Lowe S, Andersen S, Olar A, Cooper SL, Frankel BM, Gilbert MR. Case-based review: ependymomas in adults. Neurooncol Pract 2018; 5:142-153. [PMID: 31386035 DOI: 10.1093/nop/npy026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Ependymomas are rare primary central nervous system (CNS) tumors in adults. They occur most commonly in the spinal cord, and have classically been graded histologically into World Health Organization (WHO) grades I, II, or III based on the level of anaplasia. Recent data are showing that genetic heterogeneity occurs within the same histological subgroup and that ependymomas arising from different CNS locations have different molecular signatures. This has renewed interest in developing targeting therapies based on molecular profiles especially given the variable outcomes with radiation and the poor results with cytotoxic agents. In this paper, we present the case of a 46-year-old woman with a classic presentation of spinal cord ependymoma and discuss the current histopathological and molecular classification for ependymomas as well as current guidelines for patient management.
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Affiliation(s)
- David Cachia
- Department of Neuro-surgery, Medical University of South Carolina, Charleston, USA
| | - Derek R Johnson
- Department of Neurology and Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Stephen Lowe
- Department of Neuro-surgery, Medical University of South Carolina, Charleston, USA
| | - Samuel Andersen
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, USA
| | - Adriana Olar
- Department of Neuro-surgery, Medical University of South Carolina, Charleston, USA.,Department of Pathology and Laboratory Medicine and Neurosurgery, Medical University of South Carolina, Charleston, USA
| | - Samuel Lewis Cooper
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, USA
| | - Bruce M Frankel
- Department of Neuro-surgery, Medical University of South Carolina, Charleston, USA
| | - Mark R Gilbert
- Department of Neuro-Oncology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Wostrack M, Ringel F, Eicker SO, Jägersberg M, Schaller K, Kerschbaumer J, Thomé C, Shiban E, Stoffel M, Friedrich B, Kehl V, Vajkoczy P, Meyer B, Onken J. Spinal ependymoma in adults: a multicenter investigation of surgical outcome and progression-free survival. J Neurosurg Spine 2018; 28:654-662. [PMID: 29521579 DOI: 10.3171/2017.9.spine17494] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal ependymomas are rare glial neoplasms. Because their incidence is low, only a few larger studies have investigated this condition. There are no clear data concerning prognosis and therapy. The aim of the study was to describe the natural history, perioperative clinical course, and local tumor control of adult patients with spinal ependymomas who were surgically treated under modern treatment standards. METHODS The authors performed a multicenter retrospective study. They identified 158 adult patients with spinal ependymomas who had received surgical treatment between January 2006 and June 2013. The authors analyzed the clinical and histological aspects of these cases to identify the predictive factors for postoperative morbidity, tumor resectability, and recurrence. RESULTS Gross-total resection (GTR) was achieved in 80% of cases. At discharge, 37% of the patients showed a neurological decline. During follow-up the majority recovered, whereas 76% showed at least preoperative status. Permanent functional deterioration remained in 2% of the patients. Transient deficits were more frequent in patients with cervically located ependymomas (p = 0.004) and in older patients (p = 0.002). Permanent deficits were independently predicted only by older age (p = 0.026). Tumor progression was observed in 15 cases. The 5-year progression-free survival (PFS) rate was 80%, and GTR (p = 0.037), WHO grade II (p = 0.009), and low Ki-67 index (p = 0.005) were independent prognostic factors for PFS. Adjuvant radiation therapy was performed in 15 cases. No statistically relevant effects of radiation therapy were observed among patients with incompletely resected ependymomas (p = 0.079). CONCLUSIONS Due to its beneficial value for PFS, GTR is important in the treatment of spinal ependymoma. Gross-total resection is feasible in the majority of cases, with acceptable rates of permanent deficits. Also, Ki-67 appears to be an important prognostic factor and should be included in a grading scheme for spinal ependymomas.
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Affiliation(s)
- Maria Wostrack
- 1Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich
| | - Florian Ringel
- 1Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich
- 8Department of Neurosurgery, University Clinic Johannes Gutenberg-University Mainz
| | - Sven O Eicker
- 4Department of Neurosurgery, University Medical Center Hamburg-Eppendorf
| | - Max Jägersberg
- 3Department of Neurosurgery, University of Geneva Medical Center, Geneva, Switzerland; and
| | - Karl Schaller
- 3Department of Neurosurgery, University of Geneva Medical Center, Geneva, Switzerland; and
| | | | - Claudius Thomé
- 5Department of Neurosurgery, Medical University Innsbruck, Austria
| | - Ehab Shiban
- 1Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich
| | - Michael Stoffel
- 1Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich
- 9Department of Neurosurgery, Helios Clinic, Krefeld, Germany
| | - Benjamin Friedrich
- 7Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich
| | - Victoria Kehl
- 6Institute for Medical Statistics and Epidemiology, Technical University of Munich
| | | | - Bernhard Meyer
- 1Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich
| | - Julia Onken
- 2Department of Neurosurgery, Charité University, Berlin
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Wild F, Hartmann C, Heissler HE, Hong B, Krauss JK, Nakamura M. Surgical Treatment of Spinal Ependymomas: Experience in 49 Patients. World Neurosurg 2018; 111:e703-e709. [DOI: 10.1016/j.wneu.2017.12.159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 11/25/2022]
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24
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Natural history of intramedullary spinal cord ependymoma in patients preferring nonoperative treatment. J Neurooncol 2017; 135:93-98. [DOI: 10.1007/s11060-017-2552-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
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25
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Sweeney KJ, Reynolds M, Farrell M, Bolger C. Gross total resection rates of grade II/III intramedullary ependymomas using the surgical strategy of en-bloc resection without intra-operative neurophysiological monitoring. Br J Neurosurg 2016; 31:364-368. [PMID: 28019107 DOI: 10.1080/02688697.2016.1270419] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Grade II and III intramedullary ependymomas [IME] are circumscribed with a plane of cleavage that should facilitate high gross total resection rates (GTR). Gross total resection of grade II/III IME is superior to subtotal resection (STR) and radiotherapy (RTx) for progression-free and overall survival. We sought to compare our GTR with other series that have utilised standard intraoperative monitoring techniques and we explored factors that may influence rates of resection. MATERIALS AND METHODS Database search and retrospective chart and radiological review of all grade II or III spinal ependymomas over a 10-year period from the senior authors practice. Comprehensive PubMed search to identify similar series that identified histology, McCormick Function scores (MCC) preoperatively and post-operatively, surgical strategy and use of intraoperative monitoring. Standard statistical analysis was performed. RESULTS Seventeen patients were identified: 16 grade II and one grade 3. GTR was 94.12%. Factors that correlated with a decline in MCC were longitudinal extension of the tumour (p = 0.0238) and presentation with motor signs and symptoms (p = 0.0223). There was no statistical difference between preoperative factors that influence post-operative outcomes in the current study when compared with other published series. There was no statistical difference between preoperative and postoperative MCC scores between our series and other published series. DISCUSSION The current series with a GTR of 94.12% compares favourably with other published series with GTRs of 55.8-84% with no significant difference in functional outcomes. Series with low GTRs should examine their operative strategy or false-positive alarm rates which may lead to higher STRs. This series should be viewed as a unique opportunity to benchmark GTRs of circumscribed intramedullary tumours.
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Affiliation(s)
- Kieron J Sweeney
- a Beaumont Hospital , The National Centre for Neurosurgery , Ireland
| | - Matt Reynolds
- b Department of Neurological Surgery , Washington University Medical School
| | - Michael Farrell
- c Department of Neuropathology , Beaumont Hospital , Ireland
| | - Ciaran Bolger
- a Beaumont Hospital , The National Centre for Neurosurgery , Ireland
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26
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Merhemic Z, Stosic-Opincal T, Thurnher MM. Neuroimaging of Spinal Tumors. Magn Reson Imaging Clin N Am 2016; 24:563-79. [DOI: 10.1016/j.mric.2016.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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27
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Bates JE, Choi G, Milano MT. Myxopapillary ependymoma: a SEER analysis of epidemiology and outcomes. J Neurooncol 2016; 129:251-8. [PMID: 27306443 DOI: 10.1007/s11060-016-2167-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/01/2016] [Indexed: 12/15/2022]
Abstract
Myxopapillary ependymoma (MPE) is an exceedingly rare tumor histology. While surgery is clearly the treatment of choice, controversy exists regarding the role of adjuvant radiotherapy (RT). Using the Surveillence, epidemiology, and end results (SEER) database, we aimed to determine the epidemiology, prognostic factors, and treatment-related outcomes for MPE. A total of 773 cases were found in the SEER database. The incidence in the American population was found to be 1.00 per million person-years. On multivariate analysis, receipt of surgery (HR = 0.14, CI = 0.06-0.35, p < 0.001), receipt of RT (HR = 4.06, CI = 1.87-8.81, p < 0.001), age less than 30 (HR = 0.24, CI = 0.08-0.72, p = 0.01), and Caucasian race (HR = 0.37, CI = 0.13-0.996, p = 0.049) were statistically significant prognostic factors. The mean tumor size among those receiving RT (4.6 cm) was significantly larger than among those not receiving RT (3.2 cm, p = 0.0002). Those who lived in metropolitan areas were more likely to receive RT than those who did not. Given multiple previous studies show that RT improves PFS and the discrepancy in tumor size, selection bias is likely a significant contributor to the apparent negative impact of RT on OS. Regardless, surgery remains the most crucial aspect in the care of patients with MPE.
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Affiliation(s)
- James E Bates
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Ave, 647, Rochester, NY, 14642, USA
| | - Gyujae Choi
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Ave, 647, Rochester, NY, 14642, USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Ave, 647, Rochester, NY, 14642, USA.
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28
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Celano E, Salehani A, Malcolm JG, Reinertsen E, Hadjipanayis CG. Spinal cord ependymoma: a review of the literature and case series of ten patients. J Neurooncol 2016; 128:377-86. [PMID: 27154165 DOI: 10.1007/s11060-016-2135-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 05/01/2016] [Indexed: 02/06/2023]
Abstract
Spinal cord ependymoma (SCE) is a rare tumor that is most commonly low-grade. Complete surgical resection has been established as first-line treatment and can be curative. However, SCEs tend to recur when complete tumor resection is not possible. Evidence supporting the use of adjuvant radiation and chemotherapy is not definitive. We review the most recent literature on SCE covering a comprehensive range of topics spanning the biology, presentation, clinical management, and outcomes. In addition, we present a case series of ten SCE patients with the goal of contributing to existing knowledge of this rare disease.
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Affiliation(s)
- Emma Celano
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Erik Reinertsen
- Emory University School of Medicine, Atlanta, GA, USA.,Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel Philips Ambulatory Care Center, 10 Union Square, 5th Floor, Suite 5E, New York, NY, 10003, USA.
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29
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Giammattei L, Penet N, Parker F, Messerer M. Intramedullary ependymoma: Microsurgical resection technique. Neurochirurgie 2016; 63:398-401. [PMID: 27131635 DOI: 10.1016/j.neuchi.2016.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/15/2016] [Accepted: 01/15/2016] [Indexed: 12/31/2022]
Abstract
Spinal ependymomas are predominantly slow-growing lesions constituting approximately 30-88% of primary spinal intramedullary tumors. They usually present as circumscribed lesions, with regular margins and a clear surgical plane. Gross-total resection is often feasible and potentially curative but neurosurgeons should keep in mind that the ultimate goal of surgery is the preservation of spinal cord function. We present the surgical technique to safely resect an intramedullary ependymoma using a posterior median sulcus approach. A brief description of current management of this pathology is also presented.
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Affiliation(s)
- L Giammattei
- University of Paris Sud, Kremlin-Bicêtre Hospital, Division of Neurosurgery, 78, rue du General-Leclerc, 94275 Kremlin-Bicêtre cedex, France; Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Division of Neurosurgery, Milan, Italy.
| | - N Penet
- University of Paris Sud, Kremlin-Bicêtre Hospital, Division of Neurosurgery, 78, rue du General-Leclerc, 94275 Kremlin-Bicêtre cedex, France
| | - F Parker
- University of Paris Sud, Kremlin-Bicêtre Hospital, Division of Neurosurgery, 78, rue du General-Leclerc, 94275 Kremlin-Bicêtre cedex, France
| | - M Messerer
- University of Paris Sud, Kremlin-Bicêtre Hospital, Division of Neurosurgery, 78, rue du General-Leclerc, 94275 Kremlin-Bicêtre cedex, France
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30
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Abstract
OBJECT
Ependymomas of the filum terminale provide specific surgical challenges due to their often enormous size, contact with nerve roots of the cauda equina and conus, and potential for subarachnoid dissemination. This study presents treatment results for these tumors over a 30-year period.
METHODS
Among 1447 patients with tumors of the spinal canal treated between 1980 and 2014, 618 patients presented with extramedullary tumors. Of these, 42 patients (25 males, 17 females) demonstrated a myxopapillary ependymoma in the lumbosacral region. Thirty-four patients underwent 36 operations for 39 such tumors. The mean patient age was 38 ± 14 years (range 11−73 years), with an average clinical history of 37 ± 67 months. Patients were followed through outpatient visits and questionnaires, with a mean follow-up of 10 years (127 ± 100 months). Twenty-seven operations were performed to treat de novo tumors and the remainder were undertaken on recurrent tumors. Short-term results were determined for individual symptoms, and tumor recurrence rates were calculated with Kaplan-Meier statistical analyses.
RESULTS
Subarachnoid dissemination was observed in 11 patients and was related to previous surgery in 9 patients and associated with extensive tumors in 2 patients. Gross-total resections (GTR) were achieved in 28 operations (77.7%) and subtotal resections in the remainder. Subtotal resections were restricted to unencapsulated ependymomas (61.5%). Radiotherapy was employed after 6 operations on unencapsulated tumors, with 5 of these also demonstrating subarachnoid seeding. Permanent surgical morbidity affected 3 patients who experienced permanent worsening of bladder function, while 7 patients showed no postoperative changes, and the remaining 26 operations were followed by improvements. Long-term outcome depended on the amount of resection and the presence of a tumor capsule. Eight of 9 tumor recurrences affected unencapsulated tumors, of which 3 had undergone GTR. The overall recurrence rates were 6.6%, 19.0%, and 37.0% after 1, 10, and 20 years, respectively. For unencapsulated ependymomas, the corresponding rates were 15.6%, 32.5%, and 66.2% after 1, 10, and 20 years, respectively, with significantly lower rates of 9.1% after 10 and 20 years for encapsulated tumors. Postoperative radiotherapy tended to prolong the recurrence-free interval for patients with unencapsulated tumors. Five patient deaths occurred during follow-up, of which 2 deaths were tumor related and occurred at 216 and 287 months after surgery.
CONCLUSION
Extramedullary ependymomas are slow-growing tumors in the lumbosacral region, sometimes with an indolent course for long periods of time. Despite their delicate location and often enormous size, surgical morbidity in experienced hands is low, with good chances for postoperative clinical improvements and very low recurrence rates after GTR for encapsulated tumors. The role of postoperative radiotherapy remains controversial. Radiotherapy may be considered after incomplete resections of unencapsulated tumors and/or for patients with subarachnoid dissemination.
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