Prognostic factors in intramedullary astrocytomas

Impact of extent of resection and adjuvant therapy in diffuse gliomas of the spine

BACKGROUND CONTENT

Diffuse gliomas of the spine (DGS)-consisting of intradural intramedullary glioblastoma, astrocytoma, and oligodendroglioma-are exceedingly rare tumors that account for about 2% of primary spinal cord tumors. Much is unknown about their optimal treatment regimen due to a relative lack of clinical outcome data.

PURPOSE

To provide an updated analysis on treatment and outcomes in DGS.

STUDY DESIGN/SETTING

Observational cohort study using The National Cancer Database (NCDB), a multicenter prospectively collected oncology outcomes database. A systematic literature review was also performed to compare the resulting data to previous series.

PATIENT SAMPLE

Patients with histologically confirmed DGS from 2004 to 2018.

OUTCOME MEASURES

Long-term overall survival and short-term 30/90-day postsurgical mortality, 30-day readmission, and prolonged hospital length of stay.

METHODS

Impact of extent of resection and adjuvant therapy on overall survival was evaluated using Kaplan-Meier estimates and multivariable Cox proportional hazards regression. Univariate and multivariate logistic regression was used to analyze covariables and their prognostic impact on short-term surgical outcomes.

RESULTS

Of the 747 cases that met inclusion criteria, there were 439 astrocytomas, 14 oligodendrogliomas, and 208 glioblastomas. Sixty percent (n=442) of patients received radiation, and 45% (n=324) received chemotherapy. Tumor histology significantly impacted survival; glioblastoma had the poorest survival (median survival time [MS]: 12.3 months), followed by astrocytoma (MS: 70.8 months) and oligodendroglioma (MS: 71.6 months) (p<.001). Gross total resection (GTR) independently conferred a survival benefit in patients with glioblastoma (hazard ratio [HR]: 0.194, p<0.001) and other WHO grade four tumors (HR: 0.223, p=.003). Adjuvant chemotherapy also improved survival in patients with glioblastoma (HR: 0.244, p=.007) and WHO grade four tumors (HR: 0.252, p<.001). Systematic literature review identified 14 prior studies with a combined DGS mortality rate of 1.3%, which is lower than the 4% real-world outcomes calculated from the NCDB. This difference may be explained by selection biases in previously published literature in which only centers with favorable outcomes publish their results.

CONCLUSIONS

There remains a paucity of data regarding treatment paradigms and outcomes for DGS. Our analysis, the largest to date, demonstrates that GTR and adjuvant therapy independently improve survival for certain high-grade subgroups of DGS. This best-available data informs optimal management for such patients.

Complete Versus Incomplete Surgical Resection in Intramedullary Astrocytoma: Systematic Review with Individual Patient Data Meta-Analysis

STUDY DESIGN

Systematic reviewBackground: Considering the infiltrative nature of intramedullary astrocytoma, the goal of surgery is to have a better patient related outcome.

OBJECTIVE

To compare the overall survival (OS) and neurologic outcomes of complete vs incomplete surgical resection for patients with intramedullary astrocytoma.

METHODS

A comprehensive search of MEDLINE, CENTRAL and EMBASE was conducted by two independent reviewers. Individual patient data (IPD) analysis and multivariate Cox Proportional Hazard Model was developed to measure the effect of surgical strategies on OS, post-operative neurological improvement (PNI), and neurological improvement in the last follow up (FNI).

RESULTS

We included 1079 patients from 35 studies. Individual patient data of 228 patients (13 articles) was incorporated into the integrative IPD analysis. Kaplan-Meier survival analysis showed complete resection (CR) significantly improved OS in comparison with the incomplete resection (IR) (log-rank test, P = .004). In the multivariate IPD analysis, three prognostic factors had significant effect on the OS: (1) Extent of Resection, (2) pathology grade, and (3) adjuvant therapy. We observed an upward trend in the popularity of chemotherapy, but CR, IR, and radiotherapy had relatively stable trends during three decades.

CONCLUSION

Our study shows that CR can improve OS when compared to IR. Patients with spinal cord astrocytoma undergoing CR had similar PNI and FNI compared to IR. Therefore, CR should be the primary goal of surgery, but intraoperative decisions on the extent of resection should be relied on to prevent neurologic adverse events. Due to significant effect of adjuvant therapy on OS, PNI and FNI, it could be considered as the routine treatment strategy for spinal cord astrocytoma.

Long-term quality of life and functional outcomes in adults surgically treated for intramedullary spinal cord tumor

Introduction

Intramedullary spinal cord tumors (IMSCTs) are rare but clinically significant entities that may cause severe neurological decline with progressive pain and motor or sensory deterioration. Beyond the beneficial effects of surgical treatment and the long-term progression-free survival, neurological deficits may still persist after surgery, and information about the long-term patients' health-related quality of life (QoL) is still lacking. In this study, we investigate the patients' health perception 15 years after the surgery in an overall patients' wellbeing framework.

Methods

Patients surgically treated for IMSCT over a period from 1996 to 2011 were selected. After a mean of 15 years from the surgery, patient's self-administered questionnaire on disability, pain, sleep quality, and QoL was collected and neurological postoperative evaluation at the chronic stage was reexamined.

Results

Neurological deficits are reported in half of the patients in the postoperative chronic phase. After 15 years of surgery, half of the patients still report mild or severe disability grades associated with significantly higher pain and poor sleep and QoL. In accordance, the neurological condition measured at the chronic stage is significantly related not only to disease-specific symptoms (i.e., pain) but even to sleep quality complaints and poor QoL, measured at 15 years follow-up.

Conclusions

Health-related QoL is an important secondary outcome in patients. Although the progression-free survival, worse postoperative neurological conditions could predict long-term sequelae reflecting patients' poor health perception. It suggests the importance of preserving patients' functional status and globally evaluating patients' wellbeing to handle disease-specific symptoms but even more general aspects of QoL.

Clinical outcomes and a therapeutic indication of intramedullary spinal cord astrocytoma

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Although intramedullary astrocytoma is associated with a high mortality rate, the optimal treatment has not reached a consensus. This study aimed at evaluating neurologic function and overall survival rate (OSR) in the treatment of this tumor.

SETTING

The single institution in Japan.

METHODS

This study enrolled 67 subjects who underwent surgical treatment for intramedullary astrocytoma. Demographic, imaging, and surgical information were collected from each participant. Tumors were histologically categorized using the World Health Organization classification, and subjects were divided into low-grade (I and II; n = 40) and high-grade (III and IV; n = 27) groups. Neurologic status was evaluated using the modified McCormick scale (MMS). OSR was assessed using Kaplan-Meier methods.

RESULTS

The OSR decreased when the pathological grade increased (p < 0.01). Regarding the therapeutic efficacy for low-grade astrocytomas, subjects who underwent gross total resection (GTR) showed a higher OSR than those who did not (p = 0.02). GTR prevented worsening of MMS score, while non-GTR increased the MMS score (p < 0.01). In the high-grade group, 19 and 10 underwent radiation therapy and chemotherapy, respectively. However, both treatments did not improve OSR. Cordotomy was performed for subjects whose lesional area was at the thoracic level, but the OSR did not significantly increase.

CONCLUSIONS

The most beneficial therapeutic strategy for low-grade astrocytomas was GTR, whereas that for the high-grade tumors was unclear. Further studies with a larger sample size are warranted to validate the effective treatment for malignant astrocytomas.

Intraoperative electrophysiology in children - Single institute experience of 96 examinations

Aim

To summarize our experience gathered during the use of different intraoperative electrophysiological modalities in children.

Materials and Methods

We analyzed the data collected from 96 pediatric neurosurgical interventions. During the operations, we used a combination of intraoperative electrophysiological examinations tailored to the actual pathologies. The modalities included cortical and white matter mapping, cranial nerve and cranial nerve nucleus stimulation, motor evoked potential (MEP), somatosensory evoked potential (SSEP), peripheral nerve stimulation, bulbocavernosus reflex, and a special setup for selective dorsal rhizotomy.

Results

The success ratio of the different modalities varied between 25% and 100%. All the applied methods could be used in children.

Conclusion

Although the application of certain intraoperative techniques could be limited due to the ongoing developmental and maturation processes in childhood, we can not exclude the possibility of successful recording in any modality. Thus, we recommend to apply all the available methods in children bearing in mind that the success ratio might be lower than that in the adult population.

Regression of Recurrent Spinal Cord High-Grade Glioma After Convection-Enhanced Delivery of Nimustine Hydrochloride: Case Reports and Literature Review

BACKGROUND

Spinal cord high-grade glioma has poor prognosis. Especially, no treatment protocols have been established for recurrent cases.

OBJECTIVE

To apply a novel treatment method, convection-enhanced delivery (CED), for recurrent high-grade glioma. CED can deliver chemotherapeutic agents directly into the intramedullary lesion and possibly lead to remarkable regression of enlarging tumors that are, otherwise, difficult to control.

METHODS

Two patients developed high-grade glioma in the thoracic spinal cord. Partial resection and chemotherapy and radiotherapy induced remission of the disease. However, following the initial treatment, recurrence was noted in the spinal cord at 6 and 12 mo, respectively. No effective treatment was available for these recurrent lesions. Therefore, the authors decided to use CED to infuse nimustine hydrochloride (ACNU) directly into the spinal cord. During the procedure, the infusion cannula was inserted into the spinal cord lesion under intraoperative computed tomography scan.

RESULTS

After ACNU CED, successive magnetic resonance imaging confirmed remarkable shrinkages of the tumors in both cases. However, the patient's preinfusion symptoms, including bilateral lower extremity weakness, did not change after the treatment. Importantly, overall survivals of the 2 patients were as long as 67 and 33 mo.

CONCLUSION

The authors report the first 2 cases of recurrent spinal cord high-grade glioma. ACNU CED dramatically regressed enhanced mass lesions and provided local tumor controls in the spinal cord.

Adult intradural intramedullary astrocytomas: a multicenter analysis

Background

Intramedullary tumors constitute approximately 20-30% of all spinal cord tumors and approximately 30-40% of these are astrocytomas. Furthermore, they comprise only about 2-4% of all primary central nervous system (CNS) tumors. Due to their rarity and poor prognosis, large population-based studies are needed to assess the epidemiology and survival risk factors associated with these tumors in the hope of improving outcomes. The authors undertook this retrospective study to explore factors that may influence survival in adult patients with intramedullary astrocytomas.

Methods

Utilizing the Surveillance, Epidemiology, and End Results (SEER) database, a prospective cancer registry, the authors retrospectively assessed survival in histologically confirmed, intramedullary spinal cord astrocytomas in patients 18 years of age and older. Survival was described with Kaplan-Meier curves and multivariate regression analysis was used to assess the association of several variables with survival while controlling for confounding variables.

Results

Analysis by multivariate regression of 131 cases showed that increasing age of diagnosis [hazard ratio (HR) 1.52, 95% CI: 1.17-1.99, P=0.001], WHO grade IV classification (HR 8.85, 95% CI: 2.83-27.69, P<0.001), tumor invasiveness (HR 2.94, 95% CI: 1.00-8.64, P=0.047), and sub-total resection (HR 5.80, 95% CI: 1.20-28.03, P=0.029) were associated with statistically significant decreases in survival.

Conclusions

This study suggest that older age, higher WHO grade, tumor invasiveness as well as sub-total resection were all associated with a worse prognosis.

Treatment outcomes of radiotherapy for primary spinal cord glioma

PURPOSE

Spinal cord gliomas are rare, and there is no consensus on the optimal radiotherapy (RT) regimen. Herein, we investigated therapeutic outcomes in spinal cord gliomas to obtain clues for the optimal RT regimen.

METHODS

We assessed 45 patients who received RT for primary spinal cord non-ependymoma gliomas between 2005 and 2017: 37 (82%) received postoperative RT, 6 (13%) underwent definitive RT without surgery, and 2 (5%) received salvage RT for recurrent tumors. Craniospinal irradiation (CSI; median, 40 Gy) was administered in 4 patients with seeding at diagnosis; all other patients received local RT only (median, 50.4 Gy).

RESULTS

In all 23 failures occurred (20 in patients without initial seeding +3 in patients with initial seeding and CSI; median follow-up, 33 months). The 2‑year overall survival and progression-free survival rates were 74 and 54%, respectively. Overall, 13 (32%) new seeding events outside the local RT field developed either first or subsequently. Tumor grade was significantly associated with survival endpoints (p = 0.009, 0.028) and overall seeding rates (p = 0.042). In grade II tumors, seeding developed in 23%, with a dismal prognosis (median, 10 months after RT). In grade III tumors, seeding developed in 45% with diverse prognosis. In grade IV tumors, seeding developed in 45%. The survival of patients with newly developed seeding was significantly worse than the others (2-year 50%, p < 0.001).

CONCLUSION

To encompass a considerable rate of progressive disease seeding, aggressive treatment such as pre-emptive application of CSI needs to be considered for high-grade spinal cord gliomas with adverse features. Prophylactic CSI could be an option for survival prolongation and requires prospective validation.

Quality of Life Outcomes Following Resection of Adult Intramedullary Spinal Cord Tumors

BACKGROUND

Intramedullary spinal cord tumors are rare but clinically significant entities. Resection is critical to prevent permanent neurological deficits. However, no studies have investigated the quality of life (QOL) benefit of resection in adults.

OBJECTIVE

To investigate QOL outcomes after intramedullary spinal cord tumors resection.

METHODS

A consecutive retrospective review of all patients who underwent intramedullary spinal cord tumors resection at a single tertiary care institution between January 2008 and December 2013 was conducted. QOL was measured by the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9). Multivariable regression was used to identify independent predictors of outcomes.

RESULTS

Among 45 patients, the most common pathology was ependymoma (60%). No significant changes between preoperative and postoperative EQ-5D, PDQ, or PHQ-9 were observed. Improvements exceeding the minimal clinically important difference occurred in 28% of patients in EQ-5D, 28% in PDQ, and 16% in PHQ-9. Worse preoperative neurological status predicted worsened EQ-5D (β = -0.09, P = .04) and PDQ (β = 20.77, P < .01), while ependymomas predicted QOL improvement exceeding the minimal clinically important difference in PDQ (OR 14.98, P = .04) and approached significance in EQ-5D (OR 43.52, P = .06). Conversely, cervical tumors predicted worsened PDQ (β = 18.32, P < .01) and failure to achieve EQ-5D minimal clinically important difference (OR <0.01, 95% CI <0.01-0.65, P = .02). Postoperative complications, such as syrinx formation (β = -0.09, P = .04) and cerebrospinal fluid leak (β = 13.85, P = .04), predicted diminished improvement in EQ-5D and PDQ, respectively.

CONCLUSION

Although resection did not significantly improve QOL, it is likely necessary to arrest QOL deterioration. Patients with better preoperative neurological status or ependymoma experienced QOL improvement, while postoperative complications negatively impacted long-term QOL.

ABBREVIATIONS

EQ-5D, EuroQol 5-DimensionsGTR, gross total resectionIMSCT, intramedullary spinal cord tumorsMCID, minimal clinically important differenceMMS, Modified McCormick ScalePDQ, Pain Disability QuestionnairePHQ-9, Patient Health Questionnaire-9POD, plane of dissectionQOL, quality of lifeSSI, surgical site infection.

Spinal cord tumors in children: A review of 21 cases treated at the same institution

INTRODUCTION

Spinal cord tumors in children (SCTC) are rare with a frequent diagnostic delay. Its management is multidisciplinary and challenging due to functional implications. The position of surgery is now better established but the role and timing of chemotherapy (CT) and radiotherapy (RT) still remains under debate. Adverse effects of treatments are important to be taken into account, in the follow-up of these children. The aim of this paper was to present a series of 21 cases of SCTC treated at the same institution, to briefly present clinical features, treatments and outcome, with a special focus on spinal deformities in children with this condition.

MATERIAL AND METHODS

Twenty-one consecutive SCTC were referred to our institution from 1990 to 2014. Data regarding age, sex, diagnostic delay, clinical examination, MRI, surgery, pathology, other treatment (CT and RT), orthopedic issues and follow-up of these children were retrospectively recorded.

RESULTS

Mean age was 8years (standard deviation: 5.2years) (range: 4 months-17years). Mean diagnosis delay was 5.5 months (standard deviation: 6.5 months) (range: 0 days-18 months). All children (10 girls, 11 boys) were operated on (10 partial removals, 7 subtotal and 4 gross total removals) as first-line treatment. Pathological results showed 12 juvenile pilocytic astrocytomas, 1 grade III astrocytoma, 1 grade IV astrocytoma, 3 oligodendrogliomas, 2 ependymomas, 1 glioblastoma and 1 rhabdoid tumor. Fourteen children (66.7%) received additional treatment: 12 CT and 7 RT. Ten children had postoperative spinal deformities. Mean follow-up (FU) was 71 months (5 months-180 months), with a median FU at 60 months, where 8 tumor progressions and 4 deaths were observed. Overall, survival (at 5years) was 81% and progression free survival (at 5years) was 67%.

CONCLUSION

Surgery is the goal standard for SCTC and the only appropriate treatment in cases of a low-grade lesion with stable disease on MR follow-up. Additional treatment must be reserved for high-grade lesions or tumor progression not attainable by a second look surgery. Spinal deformities are a frequent complication. Overall, survival and event free survival primarily depends on the pathology. Studies involving more centers are obligatory with the aim of collecting more cases and drawing more definitive conclusions regarding the management of these tumors.

Clinical Factors for Prognosis and Treatment Guidance of Spinal Cord Astrocytoma

Study Design

Retrospective study.

Purpose

To obtain information useful in establishing treatment guidelines by evaluating baseline clinical features and treatment outcomes of patients with spinal cord astrocytoma (SCA).

Overview of Literature

The optimal management of SCA remains controversial, and there are no standard guidelines.

Methods

The study included 20 patients with low-grade and 13 with high-grade SCA surgically treated between 1989 and 2014. Patients were classified according to the extent of surgical resection. Survival was assessed using Kaplan–Meier plots and compared between groups by log-rank tests. Neurological status was defined by the modified McCormick scale and compared between groups by Mann–Whitney U tests.

Results

Surgical resection was performed for 19 of 20 low-grade (95%) and 10 of 13 high-grade (76.9%) SCA patients. Only nine patients (27.3%) underwent gross total resection, all of whom had low-grade SCA. Of all patients, 51.5% showed deteriorated neurological status compared to preoperative baseline. Median overall survival was significantly longer for low-grade SCA than that (91 months, 78% at 5 years vs. 15 months, 31% at 5 years; p=0.007). Low-grade SCA patients benefited from more aggressive resection, whereas high-grade SCA patients did not. Multivariate analysis revealed histology status (hazard ratio [HR], 0.30; 95% confidence interval [CI], 0.09–0.98; p<0.05) and postoperative neurological status (HR, 0.12; CI, 0.02–0.95; p<0.05) as independent predictors of longer overall survival. Adjuvant radiotherapy had no significant impact on survival rate. However, a trend for increased survival was observed with radiation cordotomy (RCT) in high-grade SCA patients.

Conclusions

Aggressive resection for low-grade and RCT may prolong survival. Preservation of neurological status is an important treatment goal. Given the low incidence of SCA, establishing strong collaborative, interdisciplinary, and multi-institutional study groups is necessary to define optimal treatments.

A retrospective observational study on the treatment outcomes of 26 patients with spinal cord astrocytoma including two cases of malignant transformation

PURPOSE

To determine the biologic behavior and prognostic factors of spinal cord astrocytoma, we reviewed surgical and clinical outcomes. Due to the rarity of spinal cord astrocytoma, there is a lack of research regarding this type of tumor and malignant transformation.

METHODS

We retrospectively reviewed the data from all patients on whom we performed spinal cord tumor removal between 1983 and 2014. Twenty-six patients were pathologically confirmed to have spinal cord astrocytoma or glioblastoma. Surgical extent and disease progression were confirmed by the surgeon based on operative findings, postoperative MRI, and outpatient department (OPD) follow-up.

RESULTS

Pain or neurological deficit was the chief complaint for all patients. With MRI studies, there is a tendency for high-grade astrocytomas to show as enhanced and heterogeneous images. Two of the low-grade astrocytomas showed malignant transformation over the course of 4 and 11 months, respectively. The overall survival (OS) for low-grade astrocytoma was 28-480 months (mean 156.38 months); the OS for high-grade astrocytoma was 1-36 months (mean 12.00 months).

CONCLUSIONS

Two of 12 low-grade cases showed malignant transformations at 4 and 11 months, respectively, based on pathological confirmation. With spinal cord astrocytomas, enhanced MRI results appeared similar to those of a malignant lesion. We suggest close observation and image correlation of low-grade astrocytomas, even when pathologically confirmed as low-grade. In this review, we found that histologic grade is the most important prognostic factor, although it is not always concordant with biologic behaviors.

Surgical Outcomes of High-Grade Spinal Cord Gliomas

Study Design

A retrospective study.

Purpose

The purpose of this study was to obtain useful information for establishing the guidelines for treating high-grade spinal cord gliomas.

Overview of Literature

The optimal management of high-grade spinal cord gliomas remains controversial. We report the outcomes of the surgical management of 14 high-grade spinal glioma.

Methods

We analyzed the outcomes of 14 patients with high-grade spinal cord gliomas who were surgically treated between 1989 and 2012. Survival was charted with the Kaplan-Meier plots and comparisons were made with the log-rank test.

Results

None of the patients with high-grade spinal cord gliomas underwent total resection. Subtotal resection was performed in two patients, partial resection was performed in nine patients, and open biopsy was performed in three patients. All patients underwent postoperative radiotherapy and six patients further underwent radiation cordotomy. The median survival time for patients with high-grade spinal cord gliomas was 15 months, with a 5-year survival rate of 22.2%. The median survival time for patients with World Health Organization grade III tumors was 25.5 months, whereas the median survival time for patients with glioblastoma multiforme was 12.5 months. Both univariate and multivariate Cox proportional hazards models demonstrated a significant effect only in the group that did not include cervical cord lesion as a factor associated with survival (p=0.04 and 0.03).

Conclusions

The surgical outcome of patients diagnosed with high-grade spinal cord gliomas remains poor. Notably, only the model which excluded cervical cord lesions as a factor significantly predicted survival.

D-wave recording during the surgery of a 10-month-old child

PURPOSE

The purpose of this study is to evaluate the possibility of d-wave recording in very young patients during spinal cord surgery.

METHOD

A 10-month-old patient was operated on cystic intramedullary pathology and myelon tethering at level cervical VI. to thoracal III. During the surgical detethering, we did d-wave recording for experimental purposes. After transcranial electric stimulation, we tried to detect the responses with epidural d-wave electrodes proximally and distally from the pathology.

RESULTS

We found that proximally from the pathology, we could detect reproducible d-waves.

CONCLUSION

Though earlier papers reported that due to the immature condition of the myelon d-wave recording is not possible under the age of 21 months, we proved that even in very young patients, the possibility of d-wave recording should not be excluded.

Spinal cord astrocytomas: a modern 20-year experience at a single institution

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To examine the effect of resection on survival and neurological outcome in a modern cohort of patients with spinal cord astrocytomas and identify prognostic factors for survival.

SUMMARY OF BACKGROUND DATA

There are currently no clear treatment guidelines for the management of spinal cord astrocytomas. Additionally there is no conclusive evidence for the surgical resection of these tumors, with some studies even demonstrating worse survival with surgery. However, most studies have examined patients treated prior to the routine use of magnetic resonance imaging and advanced microsurgical techniques.

METHODS

We performed a retrospective review of 46 consecutive patients with spinal cord astrocytomas treated at our institution from 1992 to 2012. Univariate and multivariate analyses were used to identify variables associated with survival.

RESULTS

The majority of patients (67.4%) underwent surgical resection, with the remaining only receiving biopsy. Of those who underwent resection, only 12.5% of patients underwent gross total resection, all of whom had low-grade astrocytomas. Of all patients, 30.7% worsened compared with their preoperative baseline. The occurrence of worsening increased with high tumor grade (52.9% vs. 27.6%, P = 0.086) and an increased extent of resection (66.7% vs. 18.8%, P = 0.0069). Resection did not provide a survival benefit compared with biopsy alone (P = 0.53). Multivariate analysis revealed high-grade histology (hazard ratio, 11.3; 95% confidence interval, 2.41-53.2; P = 0.0021), tumor dissemination (hazard ratio, 4.24; 95% confidence interval, 1.22-14.8; P = 0.023), and an increasing number of tumor involved levels (hazard ratio, 1.31; 95% confidence interval, 0.99-1.74; P = 0.058) to be associated with worse survival.

CONCLUSION

As surgical intervention is associated with a higher rate of neurological complications and lacks a clear benefit, the resection of spinal cord astrocytomas should be reserved for select cases and should be used sparingly.

Anaplastic ependymoma with holocordal and intracranial meningeal carcinomatosis and holospinal bone metastases

BACKGROUND AND IMPORTANCE

Ependymomas are the most frequent intramedullary neoplasms in adult patients. Anaplastic histology, extramedullary location, meningeal dissemination at initial diagnosis, and extraneural metastases are rare findings. We describe a case of extramedullary anaplastic ependymoma that presented with holocordal and intracranial leptomeningeal carcinomatosis and bone metastases in all the vertebral bodies and the sternum. Such an aggressive dissemination at initial diagnosis has not been previously reported.

CLINICAL PRESENTATION

A 36-year-old woman presented with headache, multiple cranial nerve palsies, visual hallucinations, confusion, hemiparesis, hemihipoestesia, episodes of disconnection, and toxic syndrome. Magnetic resonance imaging and positron emission tomography scan revealed leptomeningeal carcinomatosis in the brainstem, the cerebellum, and along the whole spinal cord. Various nodular, intradural extramedullary lesions were present at multiple dorsal and lumbar levels. Metastatic bone disease affected all the vertebral bodies and various extraspinal bones. An intradural and bone biopsy was performed at L4, providing the diagnosis of anaplastic ependymoma (World Health Organization grade III) with focal neuronal differentiation. Despite chemotherapy, the patient's symptoms quickly progressed, and she died 7 weeks after diagnosis.

CONCLUSION

To our knowledge, there are no previous descriptions of ependymomas with this extensive leptomeningeal, spinal, intracranial, and extraneural dissemination at clinical onset. Bone metastases in spinal ependymoma have not been previously reported.

Treatment, prognostic factors, and outcomes in spinal cord astrocytomas

BACKGROUND

Spinal astrocytomas are rare intramedullary CNS tumors for which there is limited consensus on treatment; the importance of the extent of resection (EOR), postoperative radiotherapy, and chemotherapy remains poorly understood. We report on outcomes associated with surgery, postoperative radiotherapy, and chemotherapy in a series of patients treated at M. D. Anderson Cancer Center (MDACC) with the aim of elucidating the role of these treatments in spinal astrocytomas.

METHODS

We retrospectively reviewed charts from a series of 83 patients with histologically confirmed spinal astrocytoma treated at MDACC during 1990-2011. Data collected included patient demographic characteristics, prognostic indicators, and treatment modality at diagnosis. We analyzed overall survival (OS) and progression-free survival (PFS) for pilocytic (World Health Organization [WHO] grade I) and infiltrative (WHO grades II, III, and IV) astrocytomas, separately. Multivariate analysis was performed for the infiltrative patients but not the pilocytic patients because of a limited number of cases.

RESULTS

Higher WHO grade among all patients was associated with worse OS (P < .0001) and PFS (P = .0003). Among patients with infiltrative tumors, neither EOR nor radiotherapy was associated with a difference in outcomes in multivariate analysis; however, among patients with infiltrative astrocytomas, chemotherapy was significantly associated with improved PFS (hazard ratio = .22, P = .0075) but not OS (hazard ratio = .89, P = .83) in multivariate analysis.

CONCLUSION

WHO grade was the strongest prognostic indicator in patients with spinal cord astrocytomas. Our results also show that chemotherapy improved PFS in infiltrative astrocytomas in multivariate analysis, but neither EOR nor radiation therapy influenced outcomes in this group.

Progression of paralysis is the most useful factor for differentiating malignant from benign intramedullary tumors

STUDY DESIGN

Retrospective study.

OBJECTIVES

The purpose of this study was to identify the clinical factors for differentiating malignant from benign intramedullary spinal cord tumors.

SETTING

Niigata, Japan.

METHODS

We conducted a retrospective review of charts and images. Preoperative paralysis including walking ability, urinary function, magnetic resonance imaging (MRI) findings and pathological diagnosis were evaluated in 33 consecutive cases of intramedullary spinal cord tumor, and the clinical factors that were useful for differentiating malignant from benign tumors were identified.

RESULTS

Early progression of paralysis was the most valuable feature for differentiating malignant from benign tumors. Malignant tumors were suspected in only three of ten cases on the basis of MRI findings.

CONCLUSION

Simple assessment of walking ability is easy to perform and is useful for predicting the pathological malignancy of intramedullary tumors of the spinal cord.

Prognostic factors and survival in primary malignant astrocytomas of the spinal cord: a population-based analysis from 1973 to 2007

STUDY DESIGN

Observational cross-sectional study.

OBJECTIVE

Using data from the population-based cancer registries of the Surveillance, Epidemiology and End Results (SEER) program, we analyzed demographic features, tumor and treatment characteristics, as well as survival rates in patients with primary malignant astrocytomas of the spinal cord (PMASC).

SUMMARY OF BACKGROUND DATA

PMASC is a rare neoplasm and is considered to carry the same dismal outcome as their cerebral counterparts. Our current knowledge is incomplete, and understanding the epidemiology, diagnosis, and optimal treatment still poses challenges.

METHODS

The SEER data from 1973 to 2007 were reviewed for pathologically confirmed primary anaplastic astrocytomas (AA) and glioblastomas of the spinal cord (C72.0). We compared the clinical features and outcomes of the cohort in uni- and multivariate fashion. Survival was calculated and compared using Kaplan-Meier curves and log-rank analysis.

RESULTS

Our search criteria retrieved 135 patients diagnosed with PMASC. The median survival for PMASC was 13 months with 1-, 2-, and 5-year survival rates of 51.8%, 32.2%, and 18.7%. Patient diagnosed with AA had a median survival time of 17 months versus 10 months in patients diagnosed with glioblastomas. Adult patients observed markedly prolonged survival compared with the pediatric group, with a 16-month versus 9-month median survival, respectively. Multivariate analysis revealed age at diagnosis, pediatric and adult age groups, sex, tumor histology, and extent of resection as significant predictors of survival. Interestingly, outcomes did not significantly change throughout the last decades or by receiving radiotherapy.

CONCLUSION

Outcome for patients diagnosed with PMASC remains poor and presents an ongoing challenge for professionals in the field of neurospinal medicine and surgery. In our analyses of AA, adult patients, males, and patients undergoing radical resections were associated with increased survival. However, incidence of these lesions is low; hence, building strong collaborative, interdisciplinary, and multi-institutional study groups is necessary to define the optimal treatment of PMASC.

Intramedullary tumors in children

Intramedullary tumors of the spinal cord account for 35-40% of intraspinal tumors in children. The biological behavior of these tumors is of slow progression, and hence aggressive surgery has been advocated. Surgical adjuncts include use of intraoperative neurophysiological monitoring, preoperative ultrasound, microsurgical techniques and ultrasonic suction devices. Osteoplastic laminoplasty approaches avoid post-laminectomy deformities in younger children. Postoperative radiotherapy and more recently chemotherapy regimes have been proposed for incompletely resected tumors.

Adult primary intradural spinal cord tumors: a review

Primary spinal cord tumors constitute 2% to 4% of all central nervous system neoplasms and are characterized based on their location as intramedullary, intradural extramedullary, and extradural. A contemporary literature review of primary intradural spinal cord tumors was performed. Among intramedullary tumors, ependymomas are more common and often can be surgically resected. However, astrocytomas infiltrate the spinal cord and complete resection is rare. Intradural extramedullary tumors include schwannomas, neurofibromas, and meningiomas and are usually amenable to surgical resection. Radiotherapy is reserved for malignant variants and recurrent gliomas, whereas chemotherapy is administered for recurrent primary spinal cord tumors without surgical or radiotherapy options. Early recognition of the signs and symptoms related to primary spinal cord tumors facilitates timely discovery, treatment, potentially minimizes neurologic morbidity, and may improve outcome. Treatment consists of surgical resection, and predictors of outcome include preoperative functional status, histologic grade of tumor, and extent of surgical resection.

Cordotomy for patients with thoracic malignant astrocytoma

Object

The optimal management of malignant astrocytomas remains controversial, and the prognosis of these lesions has been dismal regardless of the administered treatment. In this study the authors investigated the surgical outcomes of cordotomy in patients with thoracic malignant astrocytomas to determine the effectiveness of this procedure.

Methods

Cordotomy was performed in 5 patients with glioblastoma multiforme (GBM) and 2 with anaplastic astrocytoma (AA). A Kaplan-Meier survival analysis was performed, and the associations of the resection level with survival and postoperative complications were retrospectively examined.

Results

Cordotomy was performed in a single stage in 2 patients with GBM and in 2 stages in 3 patients with GBM and 2 patients with AA. In the 2 patients with GBM, cordotomy was performed 2 and 3 weeks after a partial tumor resection. In the 2 patients with AA, the initial treatment consisted of partial tumor resection and subtotal resection combined with radiotherapy, and rostral tumor growth and progressive paralysis necessitated cordotomy 2 and 28 months later. One patient with a secondary GBM underwent cordotomy; the GBM developed 1 year after subtotal resection and radiotherapy for a WHO Grade II astrocytoma. Four patients died 4, 5, 24, and 42 months after the initial operation due to CSF dissemination, and 3 patients (2 with GBM and 1 with AA) remain alive (16, 39, and 71 months). No metastasis to any other organs was noted.

Conclusions

One-stage cordotomy should be indicated for patients with thoracic GBM or AA presenting with complete paraplegia preoperatively. In patients with thoracic GBM, even if paralysis is incomplete, cordotomy should be performed before the tumor disseminates through the CSF. Radical resection should be attempted in patients with AA and incomplete paralysis. If the tumor persists, radiotherapy and chemotherapy are indicated, and cordotomy should be reserved for lesions growing progressively after such second-line treatments.

Diffusion tensor imaging tractography in patients with intramedullary tumors: comparison with intraoperative findings and value for prediction of tumor resectability

Object

The aim of this retrospective study was to evaluate the predictive value of diffusion tensor (DT) imaging with respect to resectability of intramedullary spinal cord tumors and to determine the concordance of this method with intraoperative surgical findings.

Methods

Diffusion tensor imaging was performed in 14 patients with intramedullary lesions of the spinal cord at different levels using a 3-T magnet. Routine MR imaging scans were also obtained, including unenhanced and enhanced T1-weighted images and T2-weighted images. Patients were classified according to the fiber course with respect to the lesion and their lesions were rated as resectable or nonresectable. These results were compared with the surgical findings (existence vs absence of cleavage plane). The interrater reliability was calculated using the κ coefficient of Cohen.

Results

Of the 14 patients (7 male, 7 female; mean age 49.2 ± 15.5 years), 13 had tumors (8 ependymomas, 2 lymphomas, and 3 astrocytoma). One lesion was proven to be a multiple sclerosis plaque during further diagnostic workup. The lesions could be classified into 3 types according to the fiber course. In Type 1 (5 cases) fibers did not pass through the solid lesion. In Type 2 (3 cases) some fibers crossed the lesion, but most of the lesion volume did not contain fibers. In Type 3 (6 cases) the fibers were completely encased by tumor. Based on these results, 6 tumors were considered resectable, 7 were not. During surgery, 7 tumors showed a good cleavage plane, 6 did not. The interrater reliability (Cohen κ) was calculated as 0.83 (p < 0.003), which is considered to represent substantial agreement. The mean duration of follow-up was 12.0 ± 2.9. The median McCormick grade at the end of follow-up was II.

Conclusions

These preliminary data suggest that DT imaging in patients with spinal cord tumors is capable of predicting the resectability of the lesion. A further prospective study is needed to confirm these results and any effect on patient outcome.

Recurrent spinal cord glioblastoma: salvage therapy with bevacizumab

Primary spinal cord tumors constitute 2-4% of all primary central nervous system malignancies in adults of which less than 5% are glioblastoma. A retrospective evaluation to determine toxicity and response to bevacizumab in patients with recurrent spinal cord glioblastoma. Six patients (4 males; 2 females: median age 34 years) with recurrent spinal cord glioblastoma were treated with bevacizumab (10 mg/kg given once every 2 weeks wherein 2 treatments constituted a cycle of therapy). All patients had failed surgery and temozolomide-based chemoradiotherapy and post-radiotherapy temozolomide. Blood counts, chemistry panel, urine protein to creatinine ratio and neurologic examination were obtained bi-weekly. Contrast-enhanced spine MRI was performed after one cycle of therapy and thereafter following every two cycles of bevacizumab. Treatment-related complications included fatigue in six patients, constipation in 4, hypertension in 2, venous thrombosis in 2, and infection without neutropenia in 2. There were three grade 3 toxicities (1 each fatigue, leukopenia and venous thrombosis). There were no treatment-related deaths. After one cycle of bevacizumab, one patient (17%) demonstrated progressive disease, 2 (34%) partial responses and three (51%) stable disease. Overall median response or stable disease duration (disease free progression) was 7 months (range 3-11 months). Overall median survival was 9 months (range of 5-13 months). Bevacizumab is well tolerated, has tolerable toxicity and apparent activity in this small cohort of adults with recurrent spinal cord glioblastoma.

Management of intramedullary cystic pilocytic astrocytoma with rhenium-186 intracavitary irradiation: case report

OBJECTIVE

We report a case of cystic spinal cord pilocytic astrocytoma treated with surgical resection and 2 intracavitary injections of rhenium.

CLINICAL PRESENTATION

A 22-year-old man presented with low-back pain, saddle dysesthesia, and sphincter and sexual dysfunction. Spinal cord magnetic resonance showed a large, cystic, intramedullary tumor extending from T9 to T12.

TREATMENT

Two surgical approaches and 1 computed tomography (CT)-scan guided tapping allowed shrinkage of the cystic component but each time the cyst enlarged and neurological symptoms worsened. Pathological examination allowed the diagnosis of pilocytic astrocytoma. The patient underwent 2 intracystic CT-scan guided injections of rhenium that achieved good control of cystic component.

CONCLUSION

Interstitial intracavitary rhenium brachytherapy of recurrent spinal cord cystic astrocytomas achieved excellent stabilization of the cyst with minor side-effects and dramatic improvement of neurological deficits.

High-grade intramedullary astrocytomas: 30 years' experience at the Neurosurgery Department of the University of Rome "Sapienza"

OBJECT

The goal in this study was to review a series of patients who underwent surgical removal of intramedullary high-grade gliomas, focusing on the functional outcome, recurrence rates, and technical problems continually debated in neurosurgical practice.

METHODS

Between December 1976 and December 2006, 22 patients underwent removal of intramedullary high-grade gliomas. Lesions were located in the cervical spinal cord in 12 patients, and in the thoracic cord in 10.

RESULTS

Histological examinations showed 10 Grade III astrocytomas and 12 glioblastomas. Only 2 of the 22 high-grade astrocytomas could be completely removed. The clinical postoperative status worsened in 14 patients (63.6%), was unchanged in 7 patients (31.8%), and there was 1 case of intraoperative death (4.5%). None of the 22 patients showed improvement in their neurological status postoperatively. In this series, excluding the 1 intraoperative death, all patients died of progression of the malignancy.

CONCLUSIONS

Surgical treatment did not ameliorate the postoperative neurological status; instead, in the majority of cases, it prompted a worsening of the deficit. Radiotherapy and chemotherapy have a little influence on the length of survival. In this series, multimodality treatment of intramedullary high-grade astrocytomas has been shown to increase length of survival without improving the neurological status.

[Intramedullary tumors. Results of a national investigation in private neurosurgery]

The frequency of intramedullary tumors is 0.5 cases per year for 100,000 inhabitants. The study reported herein was a retrospective study conducted from January 1985 to September 2007.

MATERIAL

Seventy-nine cases were distributed in the following manner: ependymomas, 38; astrocytomas, 22; oligodendrogliomas, four; gangliogliomas, two; hemangioblastomas, 10 (nine sporadic cases and one case of Von Hippel-Lindau disease); primitive melanoma, one; and intramedullary neurinomas, two. Three patients were lost to follow-up and 10 patients died.

METHOD

All patients were explored using MRI and were operated using a microsurgical technique. Tumor removal was complete in the cases of ependymoma and hemangioblastoma and subtotal in the cases of astrocytoma.

RESULTS

Ependymoma: 38 cases with three cases of ependymoblastoma. Mean age: 47 years (range, 17-74 years); 17 males and 21 females. Diagnostic delay: less than one year, 11; one year, 15 cases; two years, nine cases; three years, three cases. Seven recurrences with one 35 years after a prior removal. Localizations: cervical and cervicodorsal, 19; dorsal, ten; dorsolumbar, seven; holomedullary, one. Number of levels concerned: 5-12 (with the cysts associated). Mean follow-up was 10 years (range, two months to 35 years). Patients stabilized, 19; worse, six; improved, nine. Patients deceased: four, one by suicide, three cases of ependymoblastoma (survival, seven months). Astrocytomas: 22 cases, with 14 cases of astrocytoma, two pilocytic astrocytoma, four malignant astrocytoma, and two glioblastoma. Mean age: 44 years (range, 22-73 years); 14 males and eight females. Diagnostic delay: malignant tumors, one to nine months; low grades; three to six years (range, eight months to 25 years). Number of levels concerned: two to eight. Mean follow-up: seven years (range, six months to 10 years). Stabilized patients: 13; worse, five; deaths, four. Oligodendroglioma: four cases. Mean age: 58 years; two males and two females. Diagnostic delay: 10months. Localization: cervical, three; dorsal, one. Oligodendroglioma A, two; B, two. Results: two cases stabilized, one case with recurrence, and one patient deceased. Ganglioglioma: two. Both cases were associated with scoliosis. Recurrence in the eighth month and two years for the second case. One patient died. Hemangioblastoma: 10 cases, nine sporadic and one case of Von Hippel-Lindau disease. Nine cervical localizations, one on the medulla cone. Mean age: 45 years (range, 11-54 years); eight males and two females. Total removal in nine cases. One case of recurrence seven years after a prior surgery and operated a second time with no recurrence after 10 years of follow-up. Intramedullary neurinomas: two cases with a total removal and 15 years of follow-up. Primitive melanoma: one case with mediothoracic location. Treatment with surgery plus radiotherapy. Follow-up, seven years without recurrence.

CONCLUSION

Total removal of the intramedullary tumors is a challenge. In cases of removal, the risk of worsening status is 18-19.5%. Subtotal or incomplete removal 27-40% risk of recurrence.

Factors associated with progression-free survival and long-term neurological outcome after resection of intramedullary spinal cord tumors: analysis of 101 consecutive cases

OBJECT

With the introduction of electrophysiological spinal cord monitoring, surgeons have been able to perform radical resection of intramedullary spinal cord tumors (IMSCTs). However, factors associated with tumor resectability, tumor recurrence, and long-term neurological outcome are poorly understood.

METHODS

The authors retrospectively reviewed 101 consecutive cases of IMSCT resection in adults and children at a single institution. Neurological function and MR images were evaluated preoperatively, at discharge, 1 month after surgery, and every 6 months thereafter. Factors associated with gross-total resection (GTR), progression-free survival (PFS), and long-term neurological improvement were assessed using multivariate regression analysis.

RESULTS

The mean age of the patients was 41 +/- 18 years and 17 (17%) of the patients were pediatric. Pathological type included ependymoma in 51 cases, hemangioblastoma in 15, pilocytic astrocytoma in 16, WHO Grade II astrocytoma in 10, and malignant astrocytoma in 9. A GTR was achieved in 60 cases (59%). Independent of histological tumor type, an intraoperatively identifiable tumor plane (OR 25.3, p < 0.0001) and decreasing tumor size (OR 1.2, p = 0.05) were associated with GTR. Thirty-four patients (34%) experienced acute neurological decline after surgery (associated with increasing age [OR 1.04, p = 0.02] and with intraoperative change in motor evoked potentials [OR 7.4, p = 0.003]); in 14 (41%) of these patients the change returned to preoperative baseline within 1 month. In 31 patients (31%) tumor progression developed by last follow-up (mean 19 months). Tumor histology (p < 0.0001) and the presence of an intraoperatively identified tumor plane (hazard ratio [HR] 0.44, p = 0.027) correlated with improved PFS. A GTR resulted in improved PFS for hemangioblastoma (HR 0.004, p = 0.04) and ependymoma (HR 0.2, p = 0.02), but not astrocytoma. Fifty-five patients (55%) maintained overall neurological improvement by last follow-up. The presence of an identifiable tumor plane (HR 3.1, p = 0.0004) and improvement in neurological symptoms before discharge (HR 2.3, p = 0.004) were associated with overall neurological improvement by last follow-up (mean 19 months).

CONCLUSIONS

Gross-total resection can be safely achieved in the vast majority of IMSCTs when an intraoperative plane is identified, independent of pathological type. The incidence of acute perioperative neurological decline increases with patient age but will improve to baseline in nearly half of patients within 1 month. Long-term improvement in motor, sensory, and bladder dysfunction may be achieved in a slight majority of patients and occurs more frequently in patients in whom a surgical plane can be identified. A GTR should be attempted for ependymoma and hemangioblastoma, but it may not affect PFS for astrocytoma. For all tumors, the intraoperative finding of a clear tumor plane of resection carries positive prognostic significance across all pathological types.

Adult primary spinal cord tumors

Primary spinal cord tumors represent 2-4% of all neoplasms of the CNS. Primary spinal cord tumors are anatomically separable into two broad categories: intradural intramedullary and intradural extramedullary. Intramedullary tumors are comprised predominantly of gliomas (infiltrative astrocytomas and ependymomas). Resective surgery can usually be accomplished with spinal ependymomas owing to separation of tumor from spinal cord and, when complete, require no further therapy. By contrast, spinal cord gliomas infiltrate the myelon and, consequently, surgery is nearly always incomplete. Involved-field radiotherapy is most often administered after partial resection. Intradural extramedullary tumors are either peripheral nerve sheath tumors (neurofibromas or schwanommas) or meningiomas. In either instance, complete resection may be accomplished and is often curative. Radiotherapy is reserved for rare malignant variants and for patients in whom surgery is contraindicated. Chemotherapy is administered for recurrent primary spinal cord tumors without other options, that is, reoperation or re-irradiation. Problematic, however, is the lack of clinical trials in general for these CNS tumors and for spinal cord tumors in particular. Consequently, treatment is similar to that for intracranial tumors with a similar histology. Early recognition of the signs and symptoms of primary spinal cord tumors allows for early treatment, potentially minimizes neurologic morbidity and improves outcome. Primary treatment is surgery in essentially all spinal cord tumors, and predictors of outcome include preoperative functional status, histological grade of tumor and extent of surgical resection.

Prognostic factors in intramedullary astrocytomas: a literature review

Astrocytomas affect a significant portion of patients with intramedullary tumors. These infiltratively growing tumors are treated by a variety of methods -- biopsy and decompressive surgery, maximal safe resection, adjuvant oncological therapy. Also, numerous prognostic factors are reported in the literature. Better understanding of factors that influence prognosis may help in treatment planning with the goal of prolonging survival. We have thus undertaken an extensive literature review in order to define factors affecting prognosis. A total of 38 articles were studied. Only tumor grade was consistently reported as the major factor affecting prognosis. The influence of other clinical factors (age, gender, history length, functional status, tumor location or extent, syrinx or cyst presence) can be speculated upon, but cannot be assessed adequately from the available literature. For both low- and high-grade (HG) astrocytomas, maximal safe tumor resection should be the primary treatment objective but is often not feasible in contrast to other intramedullary and spinal neoplasms. Since the biological nature of spinal cord HG glioma is identical to that of the brain, the same treatment algorithm of maximal safe resection followed by concomitant radio- and chemotherapy would be sensible to implement.

EXTENT OF SURGICAL RESECTION OF MALIGNANT ASTROCYTOMAS OF THE SPINAL CORD

OBJECTIVE

The optimal management of malignant intramedullary spinal cord astrocytomas remains controversial. Although radiotherapy has become the standard of care, the relationship between extent of resection and survival remains unclear. We report the outcomes of the surgical management of 35 malignant spinal cord astrocytomas and assess the association of extent of resection with survival after aggressive resection of these tumors.

METHODS

An institutional intramedullary spinal cord tumor database (1990–2002) was reviewed to identify all patients treated for malignant astrocytomas of the spinal cord (anaplastic astrocytoma [AA] or glioblastoma multiforme [GBM]). Length of survival from surgery was charted by Kaplan-Meier plots, and association of extent of resection with survival was assessed via log rank analysis for stratified covariates and Cox proportional-hazards model for continuous covariates.

RESULTS

Twenty-seven (77%) and eight (23%) patients underwent resection of AA and GBM, respectively. Mean age was 29 ±16 years (range, 2–61 yr). Tumor involved six ± four vertebral levels. For AA cases, radical resection (no residual postoperative magnetic resonance enhancement) was achieved in 12 (44%) patients and subtotal resection (residual postoperative magnetic resonance enhancement) was achieved in 15 (56%). No GBM patients underwent radical resection (mean estimated resection, 70%). After surgery, two (6%) patients improved neurologically by modified McCormick score, 19 (54%) remained stable, and 14 (40%) declined. Median overall survival for AA patients was 72 months (85% at 1 yr; 59% at 5 yr). Median overall survival for GBM patients was 9 months (31% at 1 yr; 0% at 5 yr). Subtotal versus radical resection of AA was associated with decreased overall survival (38 versus 78% at 4 yr, P = 0.028). Postoperative tumor dissemination was associated with decreased survival (P = 0.004). When adjusting for multiple comparisons (P &lt; 0.006 needed for significance), a trend of increased survival was observed with radical resection (P = 0.023).

CONCLUSION

Neurological function can be preserved with aggressive resection of malignant intramedullary spinal astrocytomas; however, motor decline may be observed in many cases. Radical resection of AA was associated with a trend of increased overall survival in nondisseminated AA cases. Radical surgery and radiotherapy of GBM was associated with poor survival, similar to historical controls of diagnostic biopsy and radiotherapy. A markedly shorter survival may be expected in cases in which AA disseminates along the neuraxis. Biopsy alone may not provide the best outcomes for patients with malignant spinal cord tumors.

Insidious onset neck pain - a symptom not to be dismissed

Chronic neck pain is an extremely common symptom in the general population. Most cases have underlying musculoskeletal aetiologies and are managed conservatively. However, a very small number of patients presenting with chronic neck pain will have significant underlying pathology, e. g. a spinal cord tumour. Intramedullary spinal cord tumours are uncommon at all ages, particularly in adults, and there are some controversies in their treatment. The case of an 18-year-old man with chronic neck pain who was subsequently shown to have a pilocytic intramedullary astrocytoma is presented. This report highlights the need to consider rare, but potentially serious, diagnoses in individuals presenting with non-resolving, but seemingly innocent, symptoms over a prolonged period.

Prevalence and clinicoepidemiological features of moyamoya disease in Japan: findings from a nationwide epidemiological survey

BACKGROUND AND PURPOSE

The objectives of the present study were to estimate an annual number of patients with moyamoya disease in Japan and to describe the clinicoepidemiological features of the disease.

METHODS

The study consisted of 2 questionnaire surveys, which were distributed to randomly selected departments of neurosurgery, internal medicine, neurology, cerebrovascular medicine, and pediatrics in hospitals throughout Japan. The first survey inquired about the number of the patients treated in 2003, and the second requested additional detailed clinicoepidemiological information about each patient identified in the first survey.

RESULTS

In 2003, the total number of patients treated in Japan was estimated at 7700 (95% confidence interval, 6300 to 9300). Sex ratio (women to men) of the patients was 1.8. For men, the peak of moyamoya disease was observed in patients aged 10 to 14 years and for women aged 20 to 24 years. Annual rate of newly diagnosed cases in 2003 was 0.54 per 100,000 population. Family history of moyamoya disease was found in 12.1% of the patients. The majority (77.9%) were treated as outpatients.

CONCLUSIONS

Although the clinicoepidemiological features of the patients in the present study were almost similar to those obtained in previous ones, the estimated prevalence of moyamoya disease in Japan has almost doubled during the recent decade (3900 in 1994 and 7700 in 2003). The increase could partly be explained by the increase in newly diagnosed cases (0.35 in 1994 and 0.54 in 2003 per 100,000 population).

Surgical treatment of intramedullary spinal cord tumors: prognosis and complications

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To evaluate our recent treatment strategy for intramedullary spinal cord tumors.

SETTING

Department of Orthopaedic Surgery, Keio University, Japan.

METHODS

We reviewed 68 cases of intramedullary tumors (ependymoma, 33; astrocytoma, 23; hemangioblastoma, 12), treated surgically between 1994 and 2003. There were 42 males and 26 females whose mean age at the time of surgery was 43 years. The mean follow-up period was 6.2 years. The tumor malignancy grade according to the WHO classification was astrocytoma grade I, 3; grade II, 8 (low-grade: 11 cases); grade III, 10; grade IV, 2 (high-grade: 12 cases). All ependymomas were grade II. Three of the 12 hemangioblastomas were associated with von Hippel-Lindau disease.

RESULTS

Total excision was achieved in 90% of the ependymomas and functional improvement was obtained when the preoperative neurological deficit was mild. Approximately 50% of low-grade astrocytomas could be totally excised with favorable survival outcomes, suggesting that total excision should be attempted for low-grade astrocytomas. However, total excision of high-grade tumors was difficult and the functional outcomes were poor. Cordotomy should be considered in patients with a thoracic high-grade astrocytoma. Total resection was possible in 92% of hemangioblastoma, and the functional outcomes were good, however, more attention should be paid for tumors with feeding arteries on the ventral side and for those associated with von Hippel-Lindau disease.

CONCLUSIONS

Predictors of good surgical outcome for intramedullary spinal cord tumors were histological grades of the tumors, surgical margins, and neurological status of the patient before surgery.

Radiological Findings, Clinical Course, and Outcome in Asymptomatic Moyamoya Disease

BACKGROUND AND PURPOSE

Although the development of a noninvasive MR examination has increased the opportunity to identify asymptomatic patients with moyamoya disease who have experienced no stroke episodes, their clinical features are still unclear. This was the first multicenter, nation-wide survey focused on asymptomatic moyamoya disease in Japan and was designed to clarify their clinical features.

METHODS

A clinical database of asymptomatic patients with moyamoya disease was collected from 12 participating hospitals in Japan between 2003 and 2006. In total, 40 patients were enrolled in this historical prospective cohort study. Of these, 6 underwent surgical revascularization, including superficial temporal artery to middle cerebral artery anastomosis and/or pial synangiosis. Their demographic and radiological findings as well as outcome were evaluated.

RESULTS

On initial evaluation, cerebral infarction and disturbed cerebral hemodynamics were detected in approximately 20% and 40% of the involved hemispheres, respectively. Angiographical stage was more advanced in more elderly patients. Of 34 nonsurgically treated patients, 7 experienced transient ischemic attack (n=3), ischemic stroke (n=1), or intracranial bleeding (n=3) during follow-up periods (mean, 43.7 months). The annual risk for any stroke was 3.2%. Disease progression was associated with ischemic events or silent infarction in 4 of 5 patients. No cerebrovascular event occurred in the 6 patients who underwent surgical revascularization.

CONCLUSIONS

The findings revealed that asymptomatic moyamoya disease is not a silent disorder and may potentially cause ischemic or hemorrhagic stroke. Asymptomatic patients with moyamoya disease should be carefully followed-up to further clarify their outcome and to establish the management guideline for them.

Part I: Spinal-cord neoplasms—intradural neoplasms

Intradural spinal-cord tumours are an uncommon but important consideration in the differential diagnosis of patients with back pain, radicular pain, sensorimotor deficits, or sphincter dysfunction. Intradural spinal tumours can be divided into intramedullary and extramedullary spinal-cord tumours on the basis of their anatomical relation to the spinal parenchyma. The heterogeneous cell composition of the intradural compartment allows the formation of neoplasms, arising from glial cells, neurons, and cells of spinal vasculature. Additionally, developmental tumours, metastases, and intradural extension of extradural tumours are represented. In this Review, we discuss the published work on intradural spinal-cord tumours in terms of epidemiological, radiographic, and histological characteristics. Surgical and adjuvant treatment strategies are also reviewed.

[Imaging of spinal tumors]

Spinal tumors are often categorized into extradural, intradural extramedullary, or intramedullary. Although this classification represents somewhat of an overgeneralization as a lesion may reside in two compartments, it still helps to characterize spinal tumors. In the intradural, extramedullary space, primary tumors, such as neurofibroma and meningioma, are relatively common. Secondary tumors or leptomeningeal enhancement also occur. In the intramedullary space, primary tumors are far more common than secondary tumors or metastases.

Successful treatment of childhood intramedullary spinal cord astrocytomas with irinotecan and cisplatin

Childhood spinal cord astrocytomas are rare diseases, and their management is controversial. We report here our successful experience using irinotecan and cisplatin in three consecutive infants with progressing intramedullary astrocytomas. The first patient was a 16-month-old girl who presented with a grade III intramedullary astrocytoma that rapidly progressed after surgery and adjuvant chemotherapy. Weekly irinotecan (50 mg/m(2)) and cisplatin (30 mg/m(2)) for four consecutive weeks (one cycle) for a total of four cycles (I/C regimen) was used in order to avoid or delay radiotherapy. Radiological complete remission was achieved 10 months after completion of therapy, and 3.5 years after diagnosis the patient remains disease free. The second patient was a 19-month-old boy with a C3-T4 grade II intramedullary astrocytoma who received up-front vincristine and carboplatin for two months but remained clinically symptomatic. A followup MRI showed a larger tumor, and the patient was switched to the I/C regimen. A marked clinical improvement occurred after the first cycle, and MRI showed a very good partial remission at the end of therapy. At 16 months after diagnosis, the patient remains disease free. The third patient was a 10-month-old girl with a C2-T3 grade II intramedullary astrocytoma. She presented with severe pain that became steroid dependent during the month she was treated with the vincristine-carboplatin regimen. When she was switched to the I/C regimen, the clinical symptoms responded within days. MRI at the end of therapy showed a significant reduction in tumor size, and one year after diagnosis the patient remains symptom free. Using this I/C regimen for childhood intramedullary astrocytoma, we obtained remarkable clinicoradiological responses while avoiding the use of radiotherapy.