Ganglioglioma: 13 years of experience

The Epidemiology of Brain and Spinal Cord Tumors

CNS tumors are a diverse group of neoplasms that emerge from a variety of different CNS cell types. These tumors may be benign, malignant, or borderline in nature. The majority of high grade glial tumors are fatal, with the exception of pilocytic astrocytoma. Primary malignant CNS tumors occur at a global annual rate of 2.1 to 5.8 per 100,000 persons. Males are more likely to develop malignant brain tumors than females, whereas benign meningiomas are more common in adult females. Additionally, gender inequalities in non-malignant tumors peak between the ages of 25 and 29 years. Only a small number of genetic variants have been associated with survival and prognosis. Notably, central nervous system (CNS) tumors exhibit significant age, gender, and race variation. Race is another factor that affects the incidence of brain and spinal cord tumors. Different races exhibit variation in terms of the prevalence of brain and CNS malignancies. This chapter discusses ongoing research on brain and spinal cord tumor epidemiology, as well as the associated risks and accompanied disorders.

Radiological and clinical outcomes of stereotactic radiosurgery for gangliogliomas: an international multicenter study

OBJECTIVE

The optimal treatment for recurrent and residual gangliogliomas remains unclear. The aim of this study was to evaluate the safety and efficacy of stereotactic radiosurgery (SRS) in the management of patients with recurrent or residual intracranial ganglioglioma.

METHODS

This retrospective multicenter study involved patients managed with SRS for ganglioglioma. The study endpoints included local tumor control and tumor- or SRS-related neurological morbidity following treatment. Factors associated with tumor progression and neurological morbidity were also analyzed.

RESULTS

The cohort included 20 patients (11 males [55%]) with a median age of 24.5 (IQR 14) years who had been managed with SRS for ganglioglioma. Five-year radiological progression-free survival was 85.6%. After SRS, 2 patients (10%) experienced transient neurological deterioration. At a median clinical follow-up of 88.5 (IQR 112.5) months, 1 patient (5%) experienced seizure worsening and 1 (5%) required further resection of the tumor because of radiological progression. No mortality was noted in this series.

CONCLUSIONS

SRS appears to be a safe and effective treatment option for surgically inaccessible, recurrent, and residual gangliogliomas. In this series, the 5-year progression-free survival rate after SRS was 85.6%. Gross-total resection remains the primary treatment of choice for patients with newly diagnosed or recurrent ganglioglioma. SRS may be considered for patients unfit for surgery and those with surgically inaccessible newly diagnosed, residual, and recurrent lesions.

Seizure outcomes and prognostic factors in patients with gangliogliomas associated with epilepsy

Introduction

Ganglioglioma (GG) patients often present with seizures. Although most patients can be seizure-free after tumor resection, some still experience seizures. The present study aimed to analyze a group of GGs patients associated with epilepsy and evaluate the seizure outcomes and prognostic factors.

Methods

This retrospective study involved clinical data collected from medical records of patients diagnosed with GG pathologically and underwent surgical resection in Sanbo Brain Hospital, Capital Medical University. The seizure outcomes were evaluated based on the International League Against Epilepsy (ILAE) seizure outcome classification. The prognostic factors were identified according to univariate and multivariate analysis.

Results

A total of 222 patients were included, with a mean age at surgery of 19.19 ± 10.93 years. All patients were followed up at least for one year with a mean follow-up duration of 6.28 ± 3.17 years. At the final follow-up, 174 (78.4%) patients achieved ILAE Class 1 or 2. Univariate and multivariate analyses revealed that the short duration of seizures and gross total resection were significant positive factors for seizure-free. Bilateral interictal or ictal epileptiform discharges in preoperative video-electroencephalogram (VEEG) were related to poor seizure outcomes.

Conclusion

Surgical resection is an effective treatment for patients with epilepsy associated with GGs. The analysis of predictive factors could effectively guide clinical practice and evaluate the prognosis of epilepsy with GG.

Diagnosis and Therapeutic Management of Ventricular Gangliogliomas: An Illustrated Review

BACKGROUND

Gangliogliomas (GGs) are extremely rare benign neoplasms frequently located within the temporal lobe that usually present with seizures. GGs growing predominantly within the ventricular system (VGGs) are even more infrequent, so definite conclusions concerning their diagnosis and therapeutic management are lacking.

METHODS

A retrospective review of case reports of VGGs was performed from the introduction of modern imaging techniques, including 4 new illustrative cases treated in our department.

RESULTS

Thirty-four cases were collected. Ages ranged from 10 to 71 years (mean, 26.62 years), and 55.9% were male. Most patients developed symptoms related to high intracranial pressure. The lateral ventricles were predominantly involved (58.8%). Obstructive hydrocephalus was observed in 54.5% of patients. Cystic degeneration and calcification were frequently observed. Surgical treatment was carried out in all cases. Morbidity and mortality were 17.6% and 2.9%, respectively. Gross total tumor resection was achieved in 64.5% of patients. Four patients experienced tumor dissemination along the neural axis. More than 90% of patients maintained a good functional status at last follow-up.

CONCLUSIONS

Despite their low incidence, a diagnosis of VGGs should be considered in young male adults who progressively develop intracranial hypertension, caused by a ventricular mass showing signs of cystic degeneration and calcification. Maximal and safe surgical resection represents the gold standard for the treatment of symptomatic VGGs, although total removal is frequently precluded by difficulties in defining appropriate tumor boundaries. Adjuvant radiotherapy should be considered if an incomplete resection was carried out, especially in World Health Organization grade III neoplasms.

Ganglioglioma of optic chiasma: A case report and review of literature

Background:

Gangliogliomas are neoplasms containing both astrocytic and neuronal components. We present a case of gangliogliomas of the optic chiasm, which are extremely rare pathologies.

Case Description:

A 16-year-old female patient referred to our clinic with gradual deterioration of vision for the age of 1 year mostly in the right eye. Ophthalmic examination confirmed reduced visual acuity with only perception of light in the left eye. Brain magnetic resonance imaging showed a solid mass lesion involving the hypothalamus and the optic chiasm, which was hypointense on T1-weighted images, hyperintense on T2-WI, and marked homogenous contrast enhancement. The patient was operated and bulging of the optic chiasm and the site of lamina terminalis was seen. Subtotal resection of the tumor was achieved. Histopathological examination revealed ganglioglioma (WHO Grade I). Follow-up of the patient was for 3 years and 8 months with stable neurologic and radiologic findings.

Conclusion:

To the best of our knowledge, 20 cases, including ours, have been reported in the literature and a presurgical diagnosis of ganglioglioma is very infrequent with confused radiologically with low-grade pilocytic astrocytomas.

Intramedullary spinal cord ganglioglioma: Case report and comparative literature review

INTRODUCTION

Intramedullary spinal cord gangliogliomas (ISCGGs) account for 35-40% of all intramedullary tumors in children. These tumors have a different algorithm for treatment and prognosis than other medullary tumors, such as astrocytomas and spinal ependymomas. The objective of the study was to review the literature and examine an approach to diagnosing and treating this tumor based on a case report of ISCGG diagnosed at our center.

METHOD

An exhaustive review of cases of ISCGG published via the PubMed-NCBI platform between 1911 and 2018 was performed, and each patient's epidemiological characteristics, tumor location, symptoms, radiological diagnosis and treatment were appended.

RESULTS

A total of 167 cases of ISCGG were found, including our own. In our sample, 52% of patients were female and the most commonly affected age group was 0-9 years of age (35% of patients). Motor deficit has been found to be the main symptom in a larger proportion of adults patients versus pediatric patients. On X-ray, this tumor shows greater hyperintensity and contrast uptake than astrocytomas and ependymomas, as well as a higher percentage of intratumoral cysts. The BRAF^V600E mutation is less common in spinal as opposed to supratentorial gangliogliomas. Surgery with complete resection is the treatment of choice. Only 19% of the patients in the sample received radiotherapy, and only 9% received chemotherapy as their only line of treatment.

CONCLUSIONS

ISCGGs are common in the pediatric population and require strong suspicion for proper diagnosis and treatment, as the risk of recurrence of ISCGGs is 3 times greater than that of supratentorial gangliogliomas.

Short-term outcome following surgery for rare brain tumor entities in adults: a Swedish nation-wide registry-based study and comparison with SEER database

Objective

To investigate outcomes after surgery for rare brain tumors using the Swedish Brain Tumor Registry (SBTR).

Methods

This is a nationwide study of patient in the SBTR, validated in the Surveillance, Epidemiology, and End Results (SEER) registries. We included all adults diagnosed 2009–2015 with a rare brain tumor entity (n = 216), defined as ependymoma (EP, n = 64), subependymoma (SUBEP, n = 21), ganglioglioma (GGL, n = 54), pilocytic astrocytoma (PA, n = 56) and primitive neuroectodermal tumor (PNET, n = 21). We analyzed symptomatology, tumor characteristics and outcomes.

Results

Mean age was 38.3 ± 17.2 years in GGL, 36.2 ± 16.9 in PA, 37.0 ± 19.1 in PNET, 51.7 ± 16.3 in EP and 49.8 ± 14.3 in SUBEP. The most common symptom was focal deficit (39.6–71.4%), and this symptom was most common in GGL patients with 64.2% of GGL presenting with seizures. Most patients had no or little restriction in activity before surgery (Performance Status 0–1), although up to 15.0% of PNET patients had a performance status of 4. Gross total resection was achieved in most (> 50%) tumor categories. Incidence of new deficits was 11.1–34.4%. In terms of postoperative complications, 0–4.8% had a hematoma of any kind, 1.9–15.6% an infection, 0–7.8% a venous thromboembolism and 3.7–10.9% experienced a complication requiring reoperation. There were 3 deaths within 30-days of surgery, and a 1-year mortality of 0–14.3%.

Conclusion

We have provided benchmarks for the current symptomatology, tumor characteristics and outcomes after surgery for rare brain tumors as collected by the SBTR and validated our results in an independent registry. These results may aid in clinical decision making and advising patients.

Pediatric Low-Grade Gliomas

Brain tumors constitute the largest source of oncologic mortality in children and low-grade gliomas are among most common pediatric central nervous system tumors. Pediatric low-grade gliomas differ from their counterparts in the adult population in their histopathology, genetics, and standard of care. Over the past decade, an increasingly detailed understanding of the molecular and genetic characteristics of pediatric brain tumors led to tailored therapy directed by integrated phenotypic and genotypic parameters and the availability of an increasing array of molecular-directed therapies. Advances in neuroimaging, conformal radiation therapy, and conventional chemotherapy further improved treatment outcomes. This article reviews the current classification of pediatric low-grade gliomas, their histopathologic and radiographic features, state-of-the-art surgical and adjuvant therapies, and emerging therapies currently under study in clinical trials.

Impact of surgery, adjuvant treatment, and other prognostic factors in the management of anaplastic ganglioglioma

BACKGROUND/PURPOSE

Anaplastic ganglioglioma (AGG) is a rare tumor with both glial and neuronal component accounting for less than 1% of all CNS tumors with limited information about the optimum treatment and outcome of these tumors.

METHOD AND MATERIALS

We did a thorough search of the PubMed with the following MesH terms: "Ganglioglioma; Anaplastic ganglioglioma; Ganglioglioma AND treatment; and Anaplastic ganglioglioma AND survival" to find all possible publications related to AGG to perform an individual patient data analysis and derive the survival outcome and optimum treatment of these tumors.

RESULTS

A total of 56 articles were retrieved pertaining to AGG with 88 patients. However, a total of 40 publications found eligible with 69 patients for individual patient data analysis. Median age for the entire cohort was 16 years (range 0.2-77 years). Surgical details were available for 64 patients. A gross total or near total resection was reported in 21 cases (32.8%), subtotal resection or debulking was reported in 25 cases (39.1%). Surgical details were available for 64 patients. A gross total or near total resection was reported in 21 cases (32.8%), and subtotal resection or debulking was reported in 25 cases (39.1%). Median overall survival (OS) was 29 months [95% CI 15.8-42.2 months] with 2- and 5-year OS 61 and 39.4% respectively.

CONCLUSION

AGG is associated with a dismal. Pediatric age and a gross total resection of tumor confer a better progression-free survival and OS. Hence, surgery should remain the cornerstone of therapy. However, because of modest survival, there is enough opportunity to improve survival with addition of adjuvant radiation and chemotherapy. A whole genome sequencing and molecular characterization would help to derive the best treatment option.

Pediatric intracranial primary anaplastic ganglioglioma

BACKGROUND

Primary intracranial anaplastic gangliogliomas are rare tumors in the pediatric patient group. Most of them present with symptoms of elevated pressure or symptomatic epilepsy. Extraaxial location is far more common than axial location. On MRI examination, they mimic pilocytic astrocytomas. The outcome after surgery depends mainly on the possible amount of surgical resection, and oncological therapy is necessary to prevent recurrence of the disease.

CASE REPORT

An 11-year-old boy presented with headache and double vision due to obstructive hydrocephalus. MRI of the brain revealed an axial partially contrast enhancing lesion in the quadrigeminal plate extending from the cerebellum to the pineal gland and causing hydrocephalus. Subtotal removal of the lesion was performed, and the diagnosis of an anaplastic ganglioglioma was established and confirmed by the reference center. At the latest follow up (3 months), the boy is without any neurological symptoms and scheduled for radiation therapy as well as chemotherapy.

Clinical, Imaging, Histopathological and Molecular Characterization of Anaplastic Ganglioglioma

Anaplastic ganglioglioma (AGG) is a rare and malignant variant of ganglioglioma. According to the World Health Organization classification version 2016, their histopathological grading criteria are still ill-defined. The aim of the present study was to assess the clinical, imaging, histopathological, and molecular characteristics and outcomes of AGGs in a large consecutive and retrospective adult and pediatric case series. Eighteen patients with AGGs (13 adults and 5 children) were identified (14 de novo and 4 secondary) from a cohort of 222 gangliogliomas (GG) (8%) treated at our institution between 2000 and 2015. AGGs represented a very aggressive disease with poor outcome (median progression-free survival, 10 months; median overall survival, 27 months). They were located in the temporal lobe only in 22% and presented with seizures (44%) or increased intracranial pressure (44%) at diagnosis. Concerning histopathological and molecular data, they shared morphological characteristics and BRAF V600E mutation (39%) with their benign counterparts but also showed hTERT promoter mutation (61%), p53 accumulation (39%), ATRX loss (17%), or p.K27M H3F3A mutation (17%). AGGs are malignant neoplasms requiring aggressive oncological treatment. In the perspective of targeted therapies, AGGs should be screened for BRAF V600E, hTERT, ATRX, and mutations of histone genes.

A national perspective of adult gangliogliomas

Gangliogliomas (GG) are rare tumors of the nervous system. Patient characteristics and clinical outcomes of low and high-grade GG have been difficult to elucidate in the adult population. This study aims to further elaborate on GG treatment and overall survival utilizing a larger cohort than previously published. The USA National Cancer Database was utilized to evaluate adult (age 18years and older) patients diagnosed with GG between 2004 and 2006. Descriptive statistics and Kaplan-Meier overall survival estimates were provided. A total of 198 adult GG patients were diagnosed between 2004 and 2006. Of these, 181 (91.4%) were low-grade and 17 (8.6%) high-grade GG. Overall, the median age was 36years; approximately 50% of patients were female, and 86.5% Caucasian. Most patients (59%) had near/gross total resection. Radiation and chemotherapy were prescribed in 18 (9.1%) and 11 (5.7%) patients, respectively. Radiation (64.7% versus 3.9%, p<.0001) and chemotherapy (47.1% versus 1.7%, p<.0001) were more frequently given to patients with high-grade tumors than low-grade. The median overall survival of high-grade GG was 44.4months (95% confidence interval [CI]: 10.5-92.5) while the corresponding estimate for low-grade tumors was not reached. Older age (hazard ratio [HR] 1.72, 95% CI: 1.26-2.34) and high tumor grade (HR 3.91, 95% CI: 1.43-10.8) were found to be associated with poor survival. Adult GG have a temporal lobe predilection and overall gross total resection rate of 59%. Older patients with high-grade tumors had an increased hazard of mortality. High-grade GG were significantly more likely to be treated with radiation therapy and chemotherapy.

Concurrent Intraventricular and Sacral Spinal Drop Metastasis of Ganglioglioma in an Adult Patient: A Case Report and Review of Literature

Gangliogliomas are uncommon tumors of the central nervous system and rarely occur in the lateral ventricle or present with drop metastasis. We report a 49-year-old male who presented with a six-week history of left leg pain and numbness. Clinical examination revealed no focal neurological deficits. Magnetic resonance imaging (MRI) demonstrated enhancing nodular lesions in the sacral spine abutting the S2 nerve root. Further imaging of the neuroaxis demonstrated a cystic lesion in the left frontal horn of the lateral ventricle. Gross total surgical resection of the ventricular lesion was performed through a transcortical approach, followed by resection of the sacral spinal drop metastasis in a staged manner. A histopathological analysis revealed the diagnosis of low-grade ganglioglioma. To our knowledge, this is the first reported case of a low-grade intraventricular ganglioglioma presenting with symptoms associated with drop metastasis in an adult patient.

Ganglioglioma: Single-institutional experience of 24 cases with review of literature

Background:

Ganglioglioma is a common seizure associated tumor. The goal of this study was to observe the postoperative outcome in patients with gangliogliomas.

Material and Methods:

A total 24 patients with gangliogliomas who underwent surgery at our institute from 2008 to 2011 were included. There were 13 males (54%) in our study. A retrospective analysis for the demographic profile, surgery and outcome was performed using STATA software. Literature on this subject was also reviewed, MEDLINE and PUBMED databases were searched.

Observations:

Sixteen patients presented with signs and symptoms of raised intracranial pressure and 12 patients had seizure disorder. Average age at surgery was 20 years (range 7-50 years). Twelve each were located in the temporal lobe and extra-temporal location. Intra-operative electrocorticography (ECoG) alone in three and image guidance alone were used in two patients, respectively. Both ECoG and image guidance were used in one patient and none of them was used in 18 patients. Gross total resection was achieved in 17 patients. After a mean follow-up of 1.6 years (range 3 months to 2.5 years), out of 12 patients with preoperative seizures, 10 (83.3%) were seizure free (Engel class-I) and 2 (16.6%) belonged to Engel class-II. None of the factors, including age at surgery, seizure duration prior to surgery, type of seizures, use of intra-operative ECoG and image guidance, extent of tumor resection, and surgical strategy proved to have significant correlation with postoperative seizure outcome.

Conclusions:

Surgical treatment is effective and safe for patients with gangliogliomas. Neither intra-operative ECoG nor image guidance necessarily leads to better seizure control, although they are useful adjunct for achieving safe and complete tumor resection.

Atypical pediatric ganglioglioma is common and associated with a less favorable clinical course

OBJECT Ganglioglioma (GG) is commonly recognized as a low-grade tumor located in the temporal lobe, often presenting with seizures. Most are amenable to complete resection and are associated with excellent oncological outcome. The authors encountered several GGs in various locations, which seem to have a less favorable clinical course than GGs in the temporal lobe. METHODS The authors performed a single-center retrospective review of all children with a histological diagnosis of GG who were treated at Children's Hospital Colorado between 1997 and 2013. Each tumor was categorized by 2 pediatric neuroradiologists as typical or atypical based on preoperative MRI appearance. Typical lesions were cortically based, within a single cerebral lobe, well-circumscribed, and solid or mixed solid/cystic. The treatment and clinical course of each patient was analyzed. RESULTS Thirty-seven children were identified, with a median age at presentation of 8.2 years and median follow-up of 38.0 months. Eighteen tumors (48.6%) were typical and 19 (51.4%) were atypical. All typical lesions presented with seizures, whereas no atypical lesions did so. Sixteen (88.9%) typical lesions were located in the temporal lobe. In the atypical group, tumor location was variable, including 11 (57.9%) in the brainstem. Death during follow-up was statistically more common in the atypical group (31.6% vs 0%, p = 0.02). Gross-total resection (GTR) was achieved for 15 of 16 typical tumors (93.8%), compared with 3 atypical tumors (15.8%, p < 0.0001). Presentation with seizure or non-brainstem location were each associated with survival (p = 0.02 and 0.004, respectively). The presence of mutation in BRAF exon 15 did not differ between the 2 groups. CONCLUSIONS Pediatric GG with typical imaging features is associated with excellent rates of GTR and overall survival. Atypical GG is commonly encountered, less amenable to GTR, and associated with a worse outcome. This may relate to anatomical or biological characteristics and merits further investigation.

Bilateral Optic Pathway Ganglioglioma: The Fifth Case in the Literature

Gangliogliomas are mixed tumors which contain both glial and neuronal elements. The optic pathway is a very rare location for gangliogliomas, with less than 23 cases reported in the literature. Bilateral involvement of the entire optic pathway was reported in only 4 cases before. Because of similar radiological appearance of other pathological entities such as gliomas and craniopharyngiomas, histopathological diagnosis is essential. We report a ganglioglioma case that involved both optic pathways. A 12-year-old patient suffering from visual deterioration for 6 months was evaluated. After a visual field test and radiological examinations, a microsurgical biopsy procedure was performed. Pathological examination revealed dysplastic/neoplastic ganglion cells and neoplastic glial cells, and the diagnosis was a World Health Organization (WHO) grade 1 ganglioglioma. The patient is scheduled for adjuvant radiotherapy with the hope of prevention of progression.

Pediatric infratentorial ganglioglioma

PURPOSE

Pediatric infratentorial gangliogliomas are exceedingly rare tumors; thus, the factors affecting their outcome are poorly understood and their optimal management has still to be defined.

METHODS

We reviewed the literature on pediatric gangliogliomas with a focus on those located in the posterior fossa to study treatment and outcome data. We added to this review some of our clinical cases.

RESULTS

We found 100 and 80 cases of brainstem and cerebellar pediatric ganglioglioma, respectively, in our literature review. The surgical management varied from biopsy to gross total resection, and adjuvant treatment was given after incomplete resection or at time of progression. A gross total resection should be attempted to remove the contrast enhancing part of the tumor, which may be possible in most of the cerebellar gangliogliomas and some of the brainstem lesions. The cervicomedullary ganglioglioma seems to be the most infiltrative and least amenable to complete resection. Chemotherapy has a limited role and BRAF mutation was reported in 38 to 54 % of cases. The use of radiotherapy exposes the patient to a risk of malignant transformation and should be reserved for unresectable tumors which progress.

CONCLUSION

Pediatric posterior fossa gangliogliomas are rare and challenging tumors due to their frequent infiltrative component involving the brainstem. To date, adjuvant therapy has a limited role that may evolve with time thanks to the use of targeted therapies against BRAF mutation. The surgical resection of well-defined contrast enhancing parts should be attempted even in staged surgeries and balanced with the risks of neurological deterioration.

Seizure Freedom Rates and Prognostic Indicators After Resection of Gangliogliomas: A Review

Gangliogliomas are rare tumors that comprise up to 40% of lesional epilepsy. Seizure control represents an important quality-of-life determinant in patients with these tumors. Here we present results of a literature review addressing rates of seizure freedom in in patients with gangliogliomas. Across studies, seizure freedom occurred in 63%-100% of patients. Many studies included follow-up times of greater than 5 years, suggesting that the responses are durable. We discuss potential prognostic factors associated with seizure freedom, including the duration of epilepsy, patient age, frequency and semiology of seizures, tumor location, extent of surgical resection, and operative strategy, including surgical approach and use of invasive monitoring. Although significant differences in study populations and treatments preclude meta-analysis, we discuss prognostic factors identified in individual studies. Increased extent of resection, lesser duration of epilepsy, and younger age at surgery have been associated with increased seizure freedom rates in at least 2 studies each. Although all studies were retrospective in nature and are consequently limited by the weaknesses inherent to such investigations, the literature suggests that surgery is able to relieve most ganglioglioma patients--regardless of patient demographics, tumor characteristics, and operative variables--of seizures.

Treatment and outcomes for gangliogliomas: a single-center review of 16 patients

Background

Ganglioglioma is a rare and slowly growing benign tumor. We investigated the outcomes of patients who underwent different combination treatments.

Methods

Between 1998 and 2012, 16 patients, including 11 men and 5 women, with a median age of 12.5 years (range, 2.5-65 years) were treated for intracranial gangliogliomas at our institution. The median follow-up period was 5.7 years (range, 48 days-15.6 years). Fifteen cases were included in the outcome assessment because one patient was lost to follow-up. Complete resection was achieved in 8 (53%) patients. Six (40%) patients underwent incomplete resection with or without adjuvant radiotherapy, and one patient with a brainstem tumor underwent only stereotactic biopsy.

Results

Gangliogliomas predominantly affected young (87.5%), male patients and most frequently presented with seizures (64%). Of eight patients who underwent complete resection, seven did not show recurrence, whereas only three of six with incomplete resection showed no recurrence. Four patients with recurrence received salvage treatments (two repeat surgeries and two radiosurgeries). A tumor control rate of 93% (14/15) was achieved at the last follow-up. No recurrence or malignant changes were observed after a median follow-up of 12 and 4.5 years in four patients who received gamma knife (GK) radiosurgery as adjuvant and salvage treatment.

Conclusion

Complete resection produced the best outcomes and incomplete resection followed by adjuvant or salvage treatments showed favorable outcomes. In patients who are not eligible for complete resection because of tumor location or potential neurologic deficits following surgery, GK radiosurgery should be considered for the treatment of residual or recurrent tumors.

Greater Extent of Resection Improves Ganglioglioma Recurrence-Free Survival in Children

BACKGROUND:

Gangliogliomas are rare, low-grade, glial-neural tumors that are most often found in children. They can recur with varying frequency; yet few data are available that adequately predict such events.

OBJECTIVE:

To review our institution's large series of gangliogliomas in children and identify clinical features that predict recurrence-free survival.

METHODS:

Clinical records were retrospectively reviewed from 1990 to 2011. Fifty-three children were identified, and pertinent clinical features were analyzed against survival data to categorize lesions at high risk of recurrence.

RESULTS:

Fifteen children (28%) experienced a recurrence during the study period with a median time to recurrence of 8.8 months and a mean follow-up of 4.2 years. The 5-year recurrence-free survival rate was 70.5%, whereas the overall survival rate was 98.1%. Older age at diagnosis (P = .02), seizure history (P &lt; .001), supratentorial tumor location (P &lt; .001), and greater extent of surgical resection (P &lt; .001) were all associated with improved recurrence-free survival on univariate analysis. Extent of surgical resection was the only clinical variable that retained its significance in multivariate models (P = .01). Patients who received 94% or greater volumetric extent of resection had prolonged recurrence-free survival compared with those individuals who received a less than 94% resection (P = .02).

CONCLUSION:

Attention to specific clinical variables, most notably the extent of surgical resection, can further stratify grade I gangliogliomas into low- and high-risk groups among children. Although 100% resection should remain an operative goal for surgically accessible gangliogliomas, a thorough yet subtotal resection may improve recurrence-free survival.

Intraventricular ganglioglioma prognosis and hydrocephalus: the largest case series and systematic literature review

BACKGROUND

Ganglioglioma is mostly found in cerebral parenchymal, and it is rarely located in the ventricular system. To date, ganglioglioma within the ventricular system has been reported in only 10 cases. Its prognosis and relationship with complicating hydrocephalus are unclear.

METHODS

A total of 7 cases with intraventricular ganglioglioma diagnosed by the surgical pathology examination from June 2004 to April 2011 in our center were retrospectively analyzed. The clinical data were collected from the clinical medical records, and the tumor site, size and basement of tumor were analyzed. Follow up was performed to obtain the clinical outcomes.

RESULTS

The 7 cases included 5 males and 2 females, with disease onset at 23.6 ± 14.9 years old. Epilepsy as the initial symptom was observed in 1 case. Reduced hearing, dizziness and weakness of both lower limbs were found in 1 case. Intracranial hypertension were detected in 5 cases, including 1 case complicating by decreased visual acuity. Tumors were located in the lateral ventricle in 5 cases, while 2 cases in the third ventricle. Hydrocephalus was observed in 5 cases, including 2 cases with severe hydrocephalus, and both underwent ventriculoperitoneal shunting. Total resection of tumors was performed in 5 cases, and 2 cases underwent gross total resection. The mean duration of follow-up was 28.7 months (8-90 months). Intracranial hypertension in all cases disappeared. Even radiotherapy post-surgery, one case with GTR relapsed 1 year later. However, the other 6 cases didn't relapse.

CONCLUSIONS

Ganglioglioma in ventricular system is extremely rare, mainly with the symptoms of intracranial hypertension or seizure. The degree of hydrocephalus is closely related to the site of tumor's basement. The prognosis is good after total resection. The patients with GTR should be followed-up.

BRAF(V600E) mutation is a negative prognosticator in pediatric ganglioglioma

Gangliogliomas are typically low-grade neuroepithelial tumors seen in the pediatric and young adult populations. Despite their often bland histologic appearance, these tumors recur with varying frequencies; however, little data exist that adequately predict ganglioglioma recurrence in children. To identify potential histopathologic features predictive of recurrence-free survival, a series of 53 patients with World Health Organization (WHO) grade I gangliogliomas were evaluated, representing the largest cohort of pediatric gangliogliomas with accompanying histopathologic and survival data. Fifteen patients (28 %) exhibited disease recurrence during the study period. BRAF(V600E) immunohistochemistry was performed on 47 of these tumors. Histopathologic features associated with shorter recurrence-free survival included an absence of oligodendroglial morphology, higher glial cell density, microvascular proliferation, and the presence of a high lymphoplasmacytic inflammatory infiltrate. Eighteen tumors (38.3 %) had positive BRAF(V600E) staining, which was associated with shorter recurrence-free survival. Collectively, the combined use of histopathologic and molecular features to stratify grade I gangliogliomas into low and high-risk groups provides important information relevant to the management of children and young adults with these rare tumors.

Long-term seizure control outcomes after resection of gangliogliomas

BACKGROUND

Gangliogliomas are rare glioneuronal tumors that typically cause refractory seizures during the first 3 decades of life.

OBJECTIVE

To determine the prognosticators of seizure outcome after surgery for ganglioglioma.

METHODS

We reviewed the cases of 66 patients who underwent resection of gangliogliomas at the University of California, San Francisco. Demographic, seizure history, and operative data were examined for statistical association with postoperative seizure outcomes.

RESULTS

Of the 66 patients who underwent surgical resection of ganglioglioma, 49 patients (74%) presented with a history of seizures. Of those 49 patients, 50% presented with intractable epilepsy. Temporal lobe gangliogliomas were present in 76% of the patients who presented with a history of seizures. Electrocorticography was performed on 35% of the patients, and of those patients, 82% underwent extended lesionectomy to remove abnormally epileptogenic extralesional tissue. The median follow-up duration was 6.9 years, during which tumor progression occurred in 38% of patients who underwent subtotal resection and in 8% of patients who underwent gross total resection (P = .02). Overall, 85% of patients were seizure free (International League Against Epilepsy class I or II) 5 years after surgery. Subtotal resection was associated with poor seizure outcomes 1 year after resection (odds ratio = 14.6; 95% confidence interval = 2.4-87.7): rates of seizure freedom were 54% after subtotal resection, 96% after gross total resection, and 93% after gross total resection with intraoperative electrocorticography-guided extended lesionectomy.

CONCLUSION

We report excellent long-term seizure control outcomes after surgery for gangliogliomas. Intraoperative electrocorticography may be a useful adjunct for guiding extended resection in certain pharmacoresistant epilepsy patients with gangliogliomas. Subtotal resection is associated with higher rates of tumor progression and nonoptimal seizure outcomes.

Temporal lobe gangliogliomas associated with chronic epilepsy: long-term surgical outcomes

OBJECTIVE

To review the clinical features and surgical outcome in patients with temporal lobe gangliogliomas associated with intractable chronic epilepsy.

METHODS

The Rush University Surgical Epilepsy Database was queried to identify patients with chronic intractable epilepsy who underwent resection of temporal lobe gangliogliomas at Rush University Medical Center. Medical records were reviewed for age of seizure onset, delay to referral for surgery, seizure frequency and characteristics, pre-operative MRI results, extent of resection, pathological diagnosis, complications, length of follow-up, and seizure improvement.

RESULTS

Fifteen patients were identified. Average duration between seizure onset and surgery was 14.3 years. Complex partial seizures were the most common presenting symptom. Detailed operative data was available for 11 patients - of these, 90.9% underwent complete resection of the amygdala and either partial or complete resection of the hippocampus, in addition to lesionectomy. Average follow-up was 10.4 years (range 1.6-27.5 years), with 14 patients improving to Engel's class I and one patient to Engel's class III. There were no recurrences, and permanent complications were noted in one patient.

CONCLUSIONS

Long-term follow-up of patients with temporal lobe gangliogliomas associated with chronic intractable epilepsy demonstrates excellent results in seizure improvement with surgery and increasingly low incidence of complications with improvements in microsurgical techniques.

Seizure outcome with surgical management of epileptogenic ganglioglioma: a study of 55 patients

BACKGROUND

Ganglioglioma is a common seizure-associated tumor, and some factors that may influence the postoperative seizure outcome have not been discussed or are controversial. The goal of this study was to observe the postoperative seizure outcome and the prognostic factors in patients with epileptogenic gangliogliomas.

METHODS

In this retrospective study, 55 patients with epileptogenic gangliogliomas underwent surgery. Postoperative seizure outcome during follow-up was recorded, and possible postoperative prognostic factors were analyzed.

RESULTS

There were 30 males and 25 females in our study. Twenty patients presented with chronic seizures. The mean age at surgery was 19.39 years, and the mean seizure duration prior to surgery was 4.47 years. Forty-three patients had complex partial seizures, 12 patients had simple partial seizures, and secondary generalization occurred in 18 patients. Brain magnetic resonance imaging (MRI) revealed 32 tumors were located in the temporal lobe and 23 in the extratemporal lobes. Intraoperative electrocorticography (ECoG) and intraoperative ultrasound (IOUS) were used in 42 and 11 patients, respectively. Gross total resection of the tumor was achieved in 42 patients (1 patient underwent reoperation), subtotal resection in 11, and partial resection in 2. Simple lesionectomy and tailored epilepsy surgery were performed in 24 and 31 patients, respectively. After a mean follow-up of 3.27 years, 48 patients, including 1 re-operated patient, were seizure free (Engel class I). None of the factors, including age at surgery, seizure duration prior to surgery, the type of seizures, use of intraoperative ECoG and IOUS, extent of tumor resection, and surgical strategy, proved to be significantly correlated with postoperative seizure outcome.

CONCLUSIONS

Surgical treatment is effective and safe for patients with epileptogenic gangliogliomas. Early surgical intervention is necessary for achieving early seizure control. Neither intraoperative ECoG nor IOUS necessarily leads to better seizure control, although the latter can be helpful in achieving complete tumor resection. Simple lesionectomy is sufficient for favorable postoperative seizure outcome.

Epileptogenic brain lesions in children: the added-value of combined diffusion imaging and proton MR spectroscopy to the presurgical differential diagnosis

PURPOSE

Focal cortical dysplasia (FCD), dysembryoplastic neuroepithelial tumors (DNTs), and gangliogliomas (GGs) share many clinical features, and the presurgical differential diagnosis of these lesions using conventional magnetic resonance imaging (MRI) is challenging in some cases. The purpose of this work was thus to evaluate the capacity of diffusion-weighted imaging (DWI) and proton magnetic resonance spectroscopy (MRS) to distinguish each lesion from the others.

METHODS

Seventeen children (mean age 9.0 ± 4.7 years), who had been referred for epilepsy associated with a brain tumor and operated, were selected. Preoperative MRI examinations were performed on a 1.5 T system and included anatomical images [T2-weighted, fluid-attenuated inversion recovery (FLAIR) and T1 pre- and post-injection images] as well as DWI and MRS [echo time (TE) = 30 and 135 ms]. Apparent diffusion coefficient (ADC) values were calculated in the lesion and healthy control. MRS relative quantification consisted in normalizing each metabolite by the sum (S) of all metabolites (S(TE=135 ms) = NAA+Cr+Cho; S(TE=30 ms) = NAA+Cr+Cho+Glx+mI). Univariate and multivariate analyses were performed in order to determine which criteria could differentiate the different epileptogenic brain lesions.

RESULTS

When taken alone, none of the MRI parameters was able to distinguish each disease from the others. Conventional MRI failed classifying two patients. When adding ADC to the linear discriminant analysis (LDA), one patient was still misclassified. Complete separation of the three groups was possible when combining conventional MRI, diffusion, and MRS either at long or short TE.

CONCLUSION

This study shows the added-value of multimodal MRI and MRS in the presurgical diagnosis of epileptogenic brain lesions in children.

Primary holocord ganglioneuroblastoma

The authors present a case of extensive primary intramedullary spinal CNS ganglioneuroblastoma (GNB) in a 23-year-old man. Central nervous system GNB is a poorly differentiated neuroepithelial tumor composed of neuroblasts and differentiated ganglion cells, and these lesions are extremely uncommon. Most previously reported primary intraaxial neuroblastic tumors were described in the brain. There has been only one other report of primary spinal cord CNS GNB published to date; the clinical course and prognosis for primary spinal cord tumors of this type are unknown. Similar tumor types demonstrate poor prognoses.

This 23-year-old man presented after 9 months of progressive myelopathy. Admission MR imaging showed an intraaxial enhancing mass extending from C-3 to the conus medullaris, with a holocord appearance in several areas. Due to the tumor size, operative intervention was initially limited to biopsy sampling. Chemotherapy resulted in histological maturation, but initial tumor regression was temporary. The patient suffered progressive quadriparesis, and neuroimaging demonstrated slow enlargement of the tumor and an associated syrinx. Nineteen months after diagnosis, the tumor was excised to gross-total resection in a 2-stage operation. One year following resection, the patient had no radiographic recurrence and was functional in a wheelchair with minimal paresis in the upper extremities. This case represents the most extensive example of primary spinal intramedullary CNS GNB reported to date. Holocord tumors present a significant challenge to the neurosurgeon, and resection bears substantial risk of morbidity. In spinal cord CNS GNB, chemotherapy followed by complete resection may be the most effective means of tumor control.

Posterior cranial fossa gangliogliomas

Ganglioglioma (GG) is an uncommon primary lesion of the central nervous system that is typically located supratentorially. There are only a few reports of GG arising from the cerebellum. To the best of our knowledge this is the first case of a cerebellar GG with supratentorial extension and a longstanding history before its recognition. In fact, this 29-year-old male presented with an 11-year history of intermittent headaches. A cranial computerized tomography (CT) performed at the onset of his complaints failed to reveal the tumor. After a particularly longstanding cephalalgic episode, the patient underwent a new CT scan that was also negative. However, magnetic resonance (MR) imaging of the brain revealed a space-occupying lesion in the right cerebellar hemisphere with extension to the level of the superior colliculi and pineal recess. The tumor was partially removed through a midline suboccipital craniotomy and supracerebellar approach. Pathological examination of the tumor showed composition of atypical ganglion cells and astrocytes, indicating the diagnosis of cerebellar GG. At last follow-up, 24 months after surgery, the patient reported a marked improvement of his clinical condition with significant reduction of intensity and frequency of the headache. The present report illustrates how cerebellar GG may remain undetectable by CT and may therefore present with a longstanding history and nonspecific signs and symptoms. MR investigation can lead to the proper diagnosis. Even after partial removal the prognosis remains good and remission of the symptoms may be achieved. In this article, we review the literature and summarize the current understanding of infratentorial GGs.

Paediatric ganglioglioma of the conus medullaris

Gangliogliomas of the conus medullaris are very rare, with only 12 patients reported so far. We report a 6-year-old male who presented with a painless numbness of the left lower limb and with bladder dysfunction. MRI revealed an intramedullary lesion at the T11-T12 vertebral levels. The tumour was subtotally removed. Histopathological examination demonstrated ganglioglioma.

Early surgical intervention in adult patients with ganglioglioma is associated with improved clinical seizure outcomes

Gangliogliomas are rare central nervous system tumors, most commonly affecting children and young adults. Chronic seizure and epilepsy are the most frequent presentation of patients with gangliogliomas. In this report, we review the modern literature regarding the effects of early surgical intervention on the clinical outcome of patients with ganglioglioma. A boolean search of PubMed using key words "ganglioglioma", "adult", "seizure control", "treatment", "surgical intervention", and "observation", alone and in combination was performed. The inclusion criteria for articles were that: (i) clinical outcomes were reported specifically for gangliogliomas; (ii) data were reported for adult patients older than the age of 18 years; (iii) treatment data were included for the treatment of gangliogliomas; and (iv) ganglioglioma was the only pathological diagnosis for the evaluation of the tumor. Data were analyzed as a whole then stratified into two groups: early and late treatment intervention. The query identified a total of 99 articles including 1,089 cases of ganglioglioma meeting our inclusion and exclusion criteria. There was a 55% prevalence of males, representing a statistically significant predilection (51-59%, 95% confidence interval). Seizure control was significantly improved when surgical intervention occurred less than 3 years after symptom onset (78% versus 48%; p = 0.0001). Ganglioglioma in adults represents a rare group of tumors, and our systematic analysis suggests a higher prevalence in males. Our findings also support that an early surgical intervention is significantly associated with improved clinical seizure control.

Dysembryoplastic neuroepithelial tumors and gangliogliomas: clinical results of 52 patients

PURPOSE

Dysembryoplastic neuroepithelial tumors (DNET) and gangliogliomas (GG) are generally associated with epilepsy in young patients. Presurgical work-up and postsurgical results vary from center to center. Seizures are commonly focal with secondary generalization, and surgical treatment is often effective.

METHODS

Twenty-eight patients with DNET and 24 patients with GG were eligible for this retrospective study. The authors present clinical, radiological, and pathological characteristics and seizure outcome of 52 patients histopathologically diagnosed with either a DNET or a GG.

RESULTS

Characteristically the majority of the tumors showed hypointensity on T(1)-weighted images and increased signal intensity on both T(2)-weighted and FLAIR images. At the last follow-up (mean 54.3 months), overall favorable seizure outcome was 94.2% (n = 49). Twenty-six (92.8%) patients with DNET and 21 (87.5%) patients with GG were seizure free. Complete drug withdrawal was achieved in 26 (50%) patients. Shorter duration of epilepsy (p = 0.02), absence of status epilepticus (p = 0.01), absence of edema on MRI (p = 0.03), absence of seizure within the first month of surgery (p = 0.002), and total resection (p = 0.00001) were associated with favorable outcome with respect to seizure.

CONCLUSIONS

Our results indicate that a prompt diagnosis and total resection with additional adjacent structures or cortices when feasible are associated with a high epilepsy cure rate. Not only children but also adults benefit from surgical treatment. Although radiological features of DNETs or GGs are helpful, no definitive differences were found between the two types of tumors. Thus, clinical, radiological, and histopathological findings have to be considered together.

Occipital ganglioglioma in an older adult

Gangliogliomas are rare benign tumors of the central nervous system that typically involve the temporal lobe in younger patients. We present a 63-year-old man with an unusual occipital ganglioma with new seizures resolving after resection. A search of the literature revealed only three reports of occipital ganglioma in adults over 30 years old. Therefore, ganglioglioma of the occipital lobe in older patients is rare, but is a diagnostic consideration.

Gangliogliomas: recent advances in classification and treatment

Gangliogliomas are uncommon neoplasms of the CNS and, as a consequence, few randomized, clinical trials have been performed, thereby limiting treatment guidelines. The best management of newly diagnosed gangliogliomas entails a complete resection, corroborated by postoperative contrast-enhanced MRI. If an incomplete resection is documented, a second attempt at gross total resection should be considered, given the prognostic significance of complete resection. Small-volume residual disease is best managed with involved-field radiotherapy. The role of chemotherapy is uncertain and, in general, would be reserved for patients having previously failed surgery and radiotherapy. This article summarizes the most important available up-to-date information on clinical, prognostic, radiological, pathological and therapeutic findings for gangliogliomas in order to provide valuable guidance for the diagnosis and management of such uncommon tumors. This information may be considered as possible background for future studies designed to clarify the complex management of these tumors.

Pediatric epileptogenic gangliogliomas: seizure outcome and surgical results

OBJECT

Ganglioglioma is the most common neoplasm causing focal epilepsy, accounting for approximately 40% of all epileptogenic tumors and for 1-4% of all pediatric CNS tumors. The optimal surgical treatment for pediatric epileptogenic ganglioglioma has not been fully established. The authors present their experience in the surgical management of these lesions.

METHODS

The authors retrospectively analyzed seizure outcome and surgical results of pediatric patients with ganglioglioma treated with resection. The patients' charts were reviewed for demographic data, clinical presentation, surgical therapy, and follow-up.

RESULTS

The 30 patients (17 boys, 13 girls) had a history of medically intractable epilepsy. Total resection of tumor was achieved with or without adjacent epileptogenic tissue resection in all patients except 1, who underwent cyst fenestration and biopsy. Intraoperative electrocorticography (ECoG) was used in 21 patients. If an active spike focus or profound attenuation was observed in adjacent tissues, resection of those tissues was performed in addition to complete tumor resection (lesionectomy). The interval between onset of seizures and surgery ranged from 1 month to 9 years (mean 1.6 years). Patient age at the time of surgery ranged from 9 months to 16.3 years (mean 8.6 years). Twenty-five patients (83.3%) had complex partial seizures and 5 (16.7%) had simple partial seizures. Eighteen tumors (60%) were temporal (14 temporomesial, 4 temporolateral), and 12 (40%) were extratemporal. The mean follow-up period was 3.4 years (range 1 month-8.16 years). In 2 cases (6.7%), tumor recurrence was observed. Outcome was Engel Class I in 27 cases (90.0%; 14 temporomesial, 4 temporolateral, 9 extratemporal) and Engel Class II in 3 (10.0%; all extratemporal). Tumor resection allowed good seizure control, especially in the 18 cases of temporal ganglioglioma (all Engel Class I postoperatively). Eleven patients underwent removal of extratumoral epileptogenic tissue (anterior temporal neocortex resection in 10, anterior temporal neocortex resection with anterior hippocampectomy in 1) in addition to lesionectomy using intraoperative ECoG.

CONCLUSIONS

Lesionectomy with adjacent temporal neocortex resection using intraoperative ECoG provided good seizure control of pediatric temporal ganglioglioma. For extratemporal ganglioglioma, lesionectomy alone can provide fairly good seizure control. Considering the memory function of the hippocampus, lesionectomy with adjacent temporal neocortical resection can be a safe, feasible, and effective treatment option for epileptogenic gangliogliomas in pediatric patients.

Predictors of tumor progression among children with gangliogliomas. Clinical article

OBJECT

Few reports describe the outcome and prognostic factors for children with gangliogliomas. The objective of this report was to describe the progression-free survival (PFS) for children with low-grade gangliogliomas and identify risk factors for tumor progression.

METHODS

A retrospective study was performed in children with low-grade gangliogliomas who were evaluated and treated in the neuro-oncology department between 1986 and 2006 to determine risk factors for subsequent tumor progression.

RESULTS

A total of 38 children with newly diagnosed gangliogliomas were included in this report. Thirty-four children were treated with surgery alone, 3 with subtotal resection and radiation therapy, and 1 with subtotal resection and chemotherapy. The follow-up ranged from 4 months to 15.8 years (mean 5.7+/-4.2 years [+/-SD]). Seven children have experienced tumor progression, and 1 child died after his tumor subsequently underwent malignant transformation. The 5-year PFS was calculated to be 81.2% using Kaplan-Meier survival analysis. Initial presentation with seizures (p=0.004), tumor location in the cerebral hemisphere (p=0.020), and complete tumor resection (p=0.035) were associated with prolonged PFS. Further analysis of the above significant variables by a Cox regression model identified initial presentation with seizures as being associated with prolonged PFS (p=0.028).

CONCLUSIONS

The PFS and overall survival of children with gangliogliomas are good. Tumors located in the cerebral hemispheres, the achievement of total resection, and seizures at presentation were associated with prolonged PFS. Cox regression analysis identified presenting symptoms including seizures as significant predictive factors of PFS. Prospective studies with larger numbers of children are needed to define the significant factors of tumor progression.

Intraventricular ganglioglioma: a short illustrated review

The following review of the literature describes the ganglioglioma, an uncommon mixed glioneuronal neoplasm, most often of low-grade histology, with a small, albeit well-documented, malignant potential. These tumors exhibit a strong epileptogenic propensity and most often present as new onset seizures or are discovered after a long history of refractory epilepsy. Despite their indolent course, the importance of gross total resection is well recognized to prevent anaplastic and malignant degeneration. Morphologically, the neoplasm is often cystic with an enhancing mural nodule, but can also be entirely solid. They are most often found in the temporal lobe but have been found throughout the neuraxis. An exceedingly rare location of the ganglioglioma is within the lateral ventricle. A systematic literature search revealed only eight reports documenting the occurrence of a ganglioglioma within the lateral ventricle. We describe an illustrative case of an intraventricular ganglioglioma with a prominent cystic component and enhancing mural nodule, which represents the classic radiographic appearance of gangliogliomas described in other locations. A superior parietal lobule approach offered excellent surgical access for tumor removal and the patient has remained free of neurological deficits following surgery. Regardless of location within the central nervous system, ganglioglioma should be on the differential diagnosis for any cystic mass with a mural nodule, particularly in the setting of epilepsy.

Low-grade glial tumors: are they all the same?

The most common diagnosis for supratentorial brain tumors in children is a form of low-grade glioma. In addition to being a diagnosis on its own, this term has become a general category that encompasses many specific diagnoses. Advances in immunohistochemistry and pathology classification schemes have led to the recognition of these diverse pathologies. Even though the numbers of any given tumor type are small, the question has been raised as to whether different pathologies require different treatments. We reviewed the published articles on treatment and outcomes for all pathologies included under the heading "low-grade glioma" to answer this question. Once intervention is deemed necessary, attempted complete surgical resection remains the mainstay of treatment for all diagnoses. Surgically accessible recurrences are also best managed with repeat resection. Unresectable residuals or recurrences can be treated with adjuvant therapies. The only pathologic subgroups that may benefit from more aggressive up-front treatment are the grade II astrocytomas. Radiation is reserved for older children, and chemotherapy protocols are favored in younger children. Although the data from adult radiosurgical studies are promising, data for the pediatric population are not yet available. Many small lesions and small residuals remain unchanged for many years.

Minimum apparent diffusion coefficient for the differential diagnosis of ganglioglioma

OBJECTIVES

The utility of apparent diffusion coefficient (ADC) values was evaluated for the differential diagnosis of ganglioglioma.

METHODS

Ten consecutive patients, five men and five women, aged from 14 to 67 years, with histologically proven supratentorial gangliogliomas, underwent diffusion-weighted magnetic resonance imaging with echo planar imaging technique. The minimum ADC (minADC) of each tumor was pre-operatively determined from several regions of interest. The minADC of ganglioglioma was compared with that of low- or high-grade astrocytomas (astrocytoma, anaplastic astrocytoma and glioblastoma). Tumor cellularity of gangliogliomas was compared with the minADC.

RESULTS

The mean minADC of the gangliogliomas (1.45 +/- 0.20 x 10(-3) mm(2)/s) was significantly higher than that of the low- or high-grade astrocytomas. Tumor cellularity of ganglioglioma was inversely correlated with the minADC value.

DISCUSSION

The minADC value reflects in the low tumor cellularity of gangliogliomas and may provide a method for the differential diagnosis of ganglioglioma.