Predictive Factors of Long-Term Neurologic Outcome and Progression-Free Survival in Intramedullary Spinal Cord Tumors: A 10-year Single-Center Cohort Study and Review of the Literature

BACKGROUND

Intramedullary spinal cord tumors (IMSCTs) are a rare subgroup of neoplasms, encompassing both benign, slow-growing masses, and malignant lesions; radical surgical excision represents the cornerstone of treatment for such pathologies regardless of histopathology, which, on the other hand, is a known predictor of survival and neurologic outcome postsurgery. The present study aims to investigate the relevance of other factors in predicting survival and long-term functional outcomes.

METHODS

We conducted a review of current literature on functional outcomes of IMSCTs, as well as a 10-years prospective analysis of a wide cohort of patients with diagnosis of IMSCTs who underwent surgical resection at our institution.

RESULTS

Our series encompasses 60 patients with IMSCTS, among which 36 ependymomas, 6 cavernous angiomas, 5 hemangioblastomas, 6 WHO Grade I-IV astrocytomas, 3 intramedullary spinal metastases and 4 miscellaneous tumors. GTR was achieved in 76,67% of patients, with high preoperative McCormick grade, syringomyelia and changes at neurophysiologic monitoring being the strongest predictors at multivariate analysis (P = 0.0027, P = 0.0017 and P = 0.001 respectively).

CONCLUSIONS

Consistently with literature, preoperative neurologic function is the most important factor predicting long-term functional outcome (0.17, CI 0.069-0.57 with P = 0.0018), advocating for early surgery in the management of IMSCTs, whereas late complications such as myelopathy and neuropathic pain were present regardless of preoperative function.

Association Between Urbanicity and Outcomes Among Patients with Spinal Cord Ependymomas in the United States

BACKGROUND

Spinal cord ependymomas (SCEs) represent the most common intramedullary spinal cord tumors among adults. Research shows that access to neurosurgical care and patient outcomes can be greatly influenced by patient location. This study investigates the association between the outcomes of patients with SCE in metropolitan and nonmetropolitan areas.

METHODS

Cases of SCE between 2004 and 2019 were identified within the Central Brain Tumor Registry of the United States, a combined dataset including the Centers for Disease Control and Prevention's National Program of Cancer Registries and National Cancer Institute's Surveillance, Epidemiology, and End Results Program data. Multivariable logistic regression models were constructed to evaluate the association between urbanicity and SCE treatment, adjusted for age at diagnosis, sex, race and ethnicity. Survival data was available from 42 National Program of Cancer Registries (excluding Kansas and Minnesota, for which county data are unavailable), and Cox proportional hazard models were used to understand the effect of surgical treatment, county urbanicity, age at diagnosis, and the interaction effect between age at diagnosis and surgery, on the survival time of patients.

RESULTS

Overall, 7577 patients were identified, with 6454 (85%) residing in metropolitan and 1223 (15%) in nonmetropolitan counties. Metropolitan and nonmetropolitan counties had different age, sex, and race/ethnicity compositions; however, demographics were not associated with differences in the type of surgery received when stratified by urbanicity. Irrespective of metropolitan status, individuals who were American Indian/Alaska Native non-Hispanic and Hispanic (all races) were associated with reduced odds of receiving surgery. Individuals who were Black non-Hispanic and Hispanic were associated with increased odds of receiving comprehensive treatment. Diagnosis of SCE at later ages was linked with elevated mortality (hazard ratio = 4.85, P < 0.001). Gross total resection was associated with reduced risk of death (hazard ratio = 0.37, P = 0.004), and age did not interact with gross total resection to influence risk of death.

CONCLUSIONS

The relationship between patients' residential location and access to neurosurgical care is critical to ensuring equitable distribution of care. This study represents an important step in delineating areas of existing disparities.

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.

Current management in the treatment of intramedullary ependymomas in children

PURPOSE

Current management of pediatric intramedullary ependymoma is extrapolated from adult series since large studies in children are unavailable. This has led us to share our experience with this rare tumor and compare it to the literature and to review and highlight important aspects of current management and point out inconsistencies.

METHODS

This is a retrospective analysis of patients with intramedullary ependymoma managed at our institution between 2004 and 2021.

RESULTS

During the study period, 5 patients were treated for intramedullary ependymoma. Cases of myxopapillary ependymoma were excluded. The mean age of our cohort was 11.2 years. We identified 4 cases of grade II ependymoma and 1 case of grade III ependymoma. Gross tumor removal (GTR) was achieved in two patients (40%) of patients. One patient was treated with radiotherapy for recurrence and two patients received chemotherapy. There were no cases of recurrence among patients treated with GTR, but in all patients treated with STR. Eighty percent of patients either improved or stayed stable neurologically. During follow-up (mean 73 months), 2 patients died of disease.

CONCLUSION

GTR and tumor grade remain the key prognostic factor of long-term tumor-free survival. Many questions prevail regarding outcomes, correct use of adjuvant therapy, and prognostic factors.

Surgical approaches to intramedullary spinal cord astrocytomas in the age of genomics

Intramedullary astrocytomas represent approximately 30%–40% of all intramedullary tumors and are the most common intramedullary tumor in children. Surgical resection is considered the mainstay of treatment in symptomatic patients with neurological deficits. Gross total resection (GTR) can be difficult to achieve as astrocytomas frequently present as diffuse lesions that infiltrate the cord. Therefore, GTR carries a substantial risk of new post-operative deficits. Consequently, subtotal resection and biopsy are often the only surgical options attempted. A midline or paramedian sulcal myelotomy is frequently used for surgical resection, although a dorsal root entry zone myelotomy can be used for lateral tumors. Intra-operative neuromonitoring using D-wave integrity, somatosensory, and motor evoked potentials is critical to facilitating a safe resection. Adjuvant radiation and chemotherapy, such as temozolomide, are often administered for high-grade recurrent or progressive lesions; however, consensus is lacking on their efficacy. Biopsied tumors can be analyzed for molecular markers that inform clinicians about the tumor’s prognosis and response to conventional as well as targeted therapeutic treatments. Stratification of intramedullary tumors is increasingly based on molecular features and mutational status. The landscape of genetic and epigenetic mutations in intramedullary astrocytomas is not equivalent to their intracranial counterparts, with important difference in frequency and type of mutations. Therefore, dedicated attention is needed to cohorts of patients with intramedullary tumors. Targeted therapeutic agents can be designed and administered to patients based on their mutational status, which may be used in coordination with traditional surgical resection to improve overall survival and functional status.

Perioperative outcomes and survival after surgery for intramedullary spinal cord tumors: a single-institution series of 302 patients

OBJECTIVE

Intramedullary spinal cord tumors (IMSCTs) are rare neoplasms whose treatment is often technically challenging. Given the low volume seen at most centers, perioperative outcomes have been reported infrequently. Here, the authors present the largest single-institution series of IMSCTs, focusing on the clinical presentation, histological makeup, perioperative outcomes, and long-term survival of surgically treated patients.

METHODS

A cohort of patients operated on for primary IMSCTs at a comprehensive cancer center between June 2002 and May 2020 was retrospectively identified. Data on patient demographics, tumor histology, neuraxial location, baseline neurological status, functional deficits, and operative characteristics were collected. Perioperative outcomes of interest included length of stay, postoperative complications, readmission, reoperation, and discharge disposition. Data were compared across tumor histologies using the Kruskal-Wallis H test, chi-square test, and Fisher exact test. Pairwise comparisons were conducted using Tukey's honest significant difference test, chi-square test, and Fisher exact test. Long-term survival was assessed across tumor categories and histological subtype using the log-rank test.

RESULTS

Three hundred two patients were included in the study (mean age 34.9 ± 19 years, 77% white, 57% male). The most common tumors were ependymomas (47%), astrocytomas (31%), and hemangioblastomas (11%). Ependymomas and hemangioblastomas disproportionately localized to the cervical cord (54% and 59%, respectively), whereas astrocytomas were distributed almost equally between the cervical cord (36%) and thoracic cord (38%). Clinical presentation, extent of functional dependence, and postoperative 30-day outcomes were largely independent of underlying tumor pathology, although tumors of the thoracic cord had worse American Spinal Injury Association (ASIA) grades than cervical tumors. Rates of gross-total resection were lower for astrocytomas than for ependymomas (54% vs 84%, p < 0.01) and hemangioblastomas (54% vs 100%, p < 0.01). Additionally, 30-day readmission rates were significantly higher for astrocytomas than ependymomas (14% vs 6%, p = 0.02). Overall survival was significantly affected by the underlying pathology, with astrocytomas having poorer associated prognoses (40% at 15 years) than ependymomas (81%) and hemangioblastomas (66%; p < 0.01) and patients with high-grade ependymomas and astrocytomas having poorer long-term survival than those with low-grade lesions (p < 0.01).

CONCLUSIONS

The neuraxial location of IMSCTs, extent of resection, and postoperative survival differed significantly across tumor pathologies. However, perioperative outcomes did not vary significantly across tumor cohorts, suggesting that operative details, rather than pathology, may have a stronger influence on the short-term clinical course, whereas pathology appears to have a stronger impact on long-term survival.

A novel online calculator to predict nonroutine discharge, length of stay, readmission, and reoperation in patients undergoing surgery for intramedullary spinal cord tumors

BACKGROUND CONTEXT

Intramedullary spinal cord tumors (IMSCTs) are rare tumors associated with significant morbidity and mortality. Surgical resection is often indicated for symptomatic lesions but may result in new neurological deficits and decrease quality of life. Identifying predictors of these adverse outcomes may help target interventions designed to reduce their occurrence. Nonetheless, most prior studies have employed population-level datasets with limited granularity.

PURPOSE

To determine independent predictors of nonroutine discharge, prolonged length of stay (LOS), and 30 day readmission and reoperation, and to deploy these results as a web-based calculator.

STUDY DESIGN

Retrospective cohort study PATIENT SAMPLE: A total of 235 patients who underwent resection of IMSCTs at a single comprehensive cancer center.

OUTCOME MEASURES

Nonroutine discharge, prolonged LOS, 30 day readmission, and 30 day reoperation METHODS: Patients who underwent surgery from June 2002 to May 2020 at a single tertiary center were included. Data was collected on patient demographics, clinical presentation, tumor histology, surgical procedures, and 30 day readmission and reoperation. Functional status was assessed using the Modified McCormick Scale (MMS) and queried preoperative neurological symptoms included weakness, urinary and bowel dysfunction, numbness, and back and radicular pain. Variables significant on univariable analysis at the α≤0.15 level were entered into a stepwise multivariable logistic regression model.

RESULTS

Of 235 included cases, 131 (56%) experienced a nonhome discharge and 68 (29%) experienced a prolonged LOS. Of 178 patients with ≥ 30 days of follow-up, 17 (9.6%) were readmitted within 30 days and 13 (7.4%) underwent reoperation. Wound dehiscence (29%) was the most common reason for readmission. Nonhome discharge was independently predicted by older age (OR=1.03/year; p<.01), thoracic location of the tumor (OR=2.36; p=.01), presenting with bowel dysfunction (OR=4.09; p=.03), and longer incision length (OR=1.44 per level; p=.03). Independent predictors of prolonged LOS included presenting with urinary incontinence (OR=2.65; p=.05) or a higher preoperative white blood cell count (OR=1.08 per 10³/μL); p=.01), while GTR predicted shorter LOS (OR=0.40; p=.02). Independent predictive factors for 30 day unplanned readmission included experiencing ≥1 complications during the first hospitalization (OR=6.13; p<.01) and having a poor (A-C) versus good (D-E) baseline neurological status on the ASIA impairment scale (OR=0.23; p=.03). The only independent predictor of unplanned 30 day reoperation was experiencing ≥1 inpatient complications during the index hospitalization (OR=6.92; p<.01). Receiver operating curves for the constructed models produced C-statistics of 0.67-0.77 and the models were deployed as freely available web-based calculators (https://jhuspine5.shinyapps.io/Intramedullary30day).

CONCLUSIONS

We found that neurological presentation, patient demographics, and incision length were important predictors of adverse perioperative outcomes in patients with IMSCTs. The calculators can be used by clinicians for risk stratification, preoperative counseling, and targeted interventions.

Therapeutic Approaches in Adult Primary Spinal Cord Astrocytoma: A Systematic Review

Simple Summary

Adult primary spinal cord astrocytoma (SCA) is a very rare disease, with no standardized consensus about its therapy. We focus on treatment efficacy based on systematic review: only 18 papers were eligible for the analysis, including 285 patients. No clinical trials results were available. Not enough data were extracted to determine a univocal treatment plan for SCA. Given the rarity of these diseases, a collaboration among institutions is mandatory to establish a standard for study conduction (homogenous inclusion criteria and method of analysis), to perform homogenous studies and define future evidence-based recommendation. Contextually, multicentric clinical trials with molecular investigations are strongly advised to better manage SCA and unveil their biology.

Abstract

The issue: Gliomas are primary tumors arising from supporting cells of the central nervous system (CNS), usually in the brain. The 2021 World Health Organization (WHO) classifies gliomas as adult-type diffuse gliomas or circumscribed astrocytic gliomas depending on their histology and molecular features. Spinal astrocytic gliomas are very rare, and nowadays no standard of therapy is available. Treatment options are limited: surgery is often not radical, and adjuvant therapies include mostly radiotherapy (RT) or systemic chemotherapy (CHT). There is lack of knowledge about the efficacy and safety of therapies and their multidisciplinary approaches. The aim of the review: A systematic review of the literature from January 2000 to June 2021 was performed, including both clinical trials and observational studies on histological adult primary spinal cord astrocytomas (SCA), with a minimum follow-up of 6 months and reporting the overall survival, progression-free survival or clinical neurological outcome after any therapeutic approach (surgery, RT or CHT). What are the main findings? A total of 1197 citations were identified by the Medline search and additional records; based on our inclusion criteria, 18 studies were included with a total of 285 adult patients. We documented the lack of any clinical trial. What are the conclusions? The available literature data are limited to series/retrospective studies, including heterogeneous patients, i.e., astrocytoma as well as ependymoma or pediatric/adult age, with scanty data on the outcomes of interest. No clinical trials have been run. Due to the rarity of this disease, multicentric clinical trials with molecular investigations are mandatory to better manage such a rare disease.

Magnetic resonance imaging indicators for neurological outcome after surgery in patients with intramedullary spinal ependymomas

This is a retrospective study. The aim of this study was to determine the indicators of neurological outcome after surgery in patients with intramedullary spinal ependymomas by using magnetic resonance imaging (MRI).A total of 106 consecutive patients (mean age: 42.4 ± 1.3 years; 52.8% male) diagnosed with intramedullary spinal ependymomas were retrospectively recruited. All patients underwent spine MRI and subsequent surgical resection for the spinal tumors. Data regarding clinical symptoms and pathological grades of tumors were collected from clinical records. The McCormick score was used for grading patients' neurological status before and after surgery at 12 months. Good outcome was defined as stable McCormick score (McC) score (no change of McC score between preoperation and post-operation at 12 months) or improvement in McC score (post-operative McC score at 12 months < preoperative McC score). Poor outcome was determined when there was an increase in McC score at 12 months after surgery. The MRI characteristics of spinal ependymomas between patients with good and poor neurological outcomes were compared. Logistic regression was performed to assess the association between MRI characteristics of tumors and post-operative neurological outcomes.Patients with poor neurological outcomes had larger longitudinal length (4.7 ± 0.5 vs 3.3 ± 0.2, P = .004) and higher enhancement signal-to-noise-ratio (SNR) (102.4 ± 12.3 vs 72.8 ± 4.6, P = .022) than those with good neurological outcomes. After adjusting for confounding factors, longitudinal length (OR, 0.768; 95% CI, 0.604-0.976; P = .031) and enhancement SNR (OR, 0.988; 95% CI, 0.978-0.999; P = .026) of spinal ependymomas were significantly associated with poor neurological prognosis.The longitudinal length of tumor and enhancement SNR on T1-weighted images are independently associated with neurological outcome after surgery.

Clinical Prediction Modeling in Intramedullary Spinal Tumor Surgery

Artificial intelligence is poised to influence various aspects of patient care, and neurosurgery is one of the most uprising fields where machine learning is being applied to provide surgeons with greater insight about the pathophysiology and prognosis of neurological conditions. This chapter provides a guide for clinicians on relevant aspects of machine learning and reviews selected application of these methods in intramedullary spinal cord tumors. The potential areas of application of machine learning extend far beyond the analyses of clinical data to include several areas of artificial intelligence, such as genomics and computer vision. Integration of various sources of data and application of advanced analytical approaches could improve risk assessment for intramedullary tumors.

Novel Clinical Insights into Spinal Hemangioblastoma in Adults: A Systematic Review

BACKGROUND

Hemangioblastomas (HBs) are well-vascularized, benign central nervous system tumors and the third most common primary spinal cord tumor after astrocytoma/ependymoma, occurring sporadically or as a part of autosomal dominant von Hippel-Lindau disease, in which tumors are often multiple and prone to relapse. Spinal HBs are commonly located in the cervical cord and associated with a syrinx formation. Owing to location and growth trends, they may cause significant neurological deficit, impairing quality of life. We conducted a systematic review to understand better clinical insights into spinal HB in adults and compare spinal HB versus posterior cranial fossa HB.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews, we reviewed the English-language literature on adult spinal HB in the MEDLINE/PubMed database over the last 40 years.

RESULTS

We reviewed 237 articles on adult spinal HB and analyzed national and continental distribution, clinical symptoms, tumor location and presence of syringomyelia, treatment strategies and postoperative complications, histology and immunochemistry, and treatment outcomes. We compared individual characteristics in sporadic and von Hippel-Lindau disease spinal HBs. Finally, we compared features of posterior cranial fossa and spinal HBs.

CONCLUSIONS

Spinal cord HBs most commonly have a dorsal intramedullary location. Total surgical tumor resection is the first treatment option; preoperative embolization may be performed to reduce intraoperative bleeding and surgical time. HBs located in the spine have decreased mortality and rate of infection, but increased rates of cardiopulmonary complications compared with HBs in the posterior cranial fossa.

Driver Genetic Mutations in Spinal Cord Gliomas Direct the Degree of Functional Impairment in Tumor-Associated Spinal Cord Injury

Genetic analysis in glioma has been developed recently. Spinal cord glioma is less common than intracranial glioma. Thus, the clinical significance of genetic mutations in spinal cord gliomas remains unclear. Furthermore, because the spinal cord is an important communication channel between the brain and the rest of the body, increased attention should be paid to its functional prognosis. In this study, we investigated the functional prognosis and driver genetic mutations in eight patients with spinal cord gliomas (World Health Organization grade I, three cases; grade II, two cases; grade III/IV, three cases). IDH mutations were detected in all grade II cases and H3F3A mutations were detected in all grade III/IV cases. The functional status of grade I and II gliomas remained unchanged or improved 1 year after surgery, whereas grade III/IV gliomas remained unchanged or deteriorated. Spinal glioma progenitor cells with H3F3A mutations were associated with accelerated tumor-associated spinal cord injury, which led to functional impairment. Conversely, the presence of IDH mutations, which are rarely reported in spinal gliomas, indicated a relatively favorable functional prognosis.

MICROSURGICAL MANAGEMENT OF LOW-GRADE SPINAL CORD ASTROCYTOMA IN ADULTS: A PERSONAL CASE SERIES REPORT AND BRIEF LITERATURE REVIEW

Astrocytoma is the second most common intramedullary tumor of predominantly low-grade malignancy in adult patients. Adult astrocytomas have better-quality prognosis compared with astrocytomas in children. Although a standardized surgical management protocol for spinal cord glioma is currently unavailable, surgery of low-grade astrocytoma should be aimed at gross total resection to preserve neurological function and to improve the outcome. Herein, we present a personal case series of four consecutive adult spinal cord astrocytoma patients who were operated on during the last few years. Tumor resection was performed in all patients utilizing microsurgical technique and intraoperative neurophysiologic monitoring. We also provide a literature review of the treatment of intramedullary astrocytoma in adults and discuss contemporary surgical management and prognosis.

Management of Myelopathy due to Anterior Soft-Tissue Compression in Vertebral Hemangioma

OBJECTIVE

Vertebral hemangiomas are benign but highly vascular lesions and are one of the most common lesions of the vertebral column. Anterior soft-tissue compression of spinal cord due to vertebral body hemangioma is challenging to manage. Our objective was to assess long-term clinical and radiologic effects of direct transpedicular absolute alcohol embolization, laminectomy, and short-segment instrumented fusion on resolution of extraosseous epidural soft tissue and improvement in myelopathy in cases of vertebral hemangioma causing anterior soft-tissue compression.

MATERIALS AND METHODS

This was a retrospective analysis that included patients with single-level vertebral hemangioma with anterior intraspinal soft-tissue growth causing spinal cord compression and clinical features of myelopathy between June 2007 and June 2019 at authors' institute. Transpedicular vertebral body injection of absolute alcohol, laminectomy, and pedicle screw rod instrumentation was performed in all patients. Clinicoradiologic outcomes of surgery were noted. We proposed a grading system for the extent of anterior extraosseous epidural soft-tissue compression.

RESULTS

In total, 14 patients were included in study. Their mean age was 28.4 ± 14.4 years. Mean follow-up duration was 67.5 ± 36.2 months. All patients had preoperative radiologic grade 4 compression. Postoperative radiologic grading improved to grade 1 in 4 (28.6%), grade 2 in 8 (57.1%), and grade 3 in 2 (14.3%). All the patients improved neurologically after surgery. Eleven patients improved to American Spinal Injury Association (ASIA) grade E, 2 improved to ASIA D, and 1 improved to ASIA C at the last follow-up visit.

CONCLUSIONS

Vertebral hemangiomas with anterior extraosseous epidural extension causing spinal canal compromise and myelopathy can be managed with direct transpedicular ethanol embolization, laminectomy, and short-segment instrumented fusion with resolution of the extraosseous soft tissue and improvement in myelopathy. The procedure is relatively simple, cost effective, and has a good outcome.

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

STUDY DESIGN

Systematic review.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical and Radiologic Prognostic Factors in Intramedullary Spinal Cord Lesions

OBJECTIVE

The present study aimed to perform a comprehensive data analysis of 47 consecutive patients treated in 8 years and to observe how clinical, radiologic, and surgical factors affect early and long-term outcomes, recurrence rate, and survival.

METHODS

Clinical, radiologic, and surgical data were collected retrospectively from the review of a prospectively collected database. The neurologic disability was evaluated according to the modified Rankin Scale (mRS). Radiologic data were obtained by direct measurement performed on magnetic resonance imaging (MRI). Univariate and multivariate statistical analysis was performed.

RESULTS

From 2008 to 2016, 47 consecutive patients underwent microsurgical resection of intramedullary lesions (28 males and 19 females; mean age, 41.2 years). Ependymoma (53.2%), astrocytoma (14.9%), hemangioblastoma (14.9%), and cavernous angioma (6.4%) were the most frequent tumor histology. The mean follow-up duration was 69.3 months. Gross total tumor resection was performed in 80.8% of cases. Forty-two patients (89.4%) were alive at last follow-up. Five-year overall survival and recurrence-free survival were 92% and 82%, respectively.

CONCLUSIONS

Among the examined variables, age seemed to strongly correlate with outcomes; better chances of recovery and a good postoperative outcome were observed in younger patients. Surfacing lesions had a better early functional outcome than did intramedullary located lesions. Patients' preoperative neurologic and functional status (mRS score ≤2) had a significant impact on late neurologic outcome. Progression-free survival correlated with the extent of tumor resection. Surgery should probably be performed before patients' neurologic decline, aiming to achieve maximal resection without compromising patients' quality of life.

Multicentric Spinal Pilocytic Astrocytoma Presenting with Syringomyelia

Pilocytic spinal cord astrocytomas make up 21% of intramedullary tumors. Only 20% of those tumors are associated with syringomyelia. To our knowledge, this is the first report of an adult presenting with multiple spinal pilocytic astrocytomas associated with syringomyelia. We report a case of a 27-year-old woman who had neck and arm pain for months. She underwent cervical magnetic resonance imaging (MRI) that demonstrated a syrinx from C2 and extending to C6. A coronal view of the MRI showed multiple mural nodules. Total excision of multicentric nodules within a cyst was performed with an uneventful intraoperative and postoperative period and the patient was discharged home with moderate right-hand numbness.

Outcome Features Analysis in Intramedullary Tumors of the Cervicomedullary Junction: A Surgical Series

OBJECT

 The aim of this study is to investigate the impact of surgery for different cervicomedullary lesions on symptomatic pattern expression and postoperative outcome. We focused on specific outcome features of the early and late postoperative assessments. The former relies on surgery-related transient and permanent morbidity and feasibility of radicality in eloquent areas, whereas the latter on long-term course in lower grade tumors and benign tumorlike lesions (cavernomas, etc.).

MATERIAL AND METHODS

 We retrospectively analyzed 28 cases of intramedullary tumors of the cervicomedullary junction surgically treated at our institution between 1990 and 2018. All cases were stratified for gender, histology, macroscopic appearance, location, surgical approach, and presence of a plane of dissection (POD). Mean follow-up was 5.6 years and it was performed via periodic magnetic resonance imaging (MRI) and functional assessments (Karnofsky Performance Scale [KPS] and modified McCormick [MC] grading system).

RESULTS

 In all, 78.5% were low-grade tumors (or benign lesions) and 21.5% were high-grade tumors. Sixty-one percent underwent median suboccipital approach, 18% a posterolateral approach, and 21% a posterior cervical approach. Gross total resection was achieved in 54% of cases, near-total resection (>90%) in 14%, and subtotal resection (50-90%) in 32% of cases. Early postoperative morbidity was 25%, but late functional evaluation in 79% of the patients showed KPS > 70 and MC grade I; only 21% of cases showed KPS < 70 and MC grades II and III at late follow-up. Mean overall survival was 7 years in low-grade tumors or cavernomas and 11.7 months in high-grade tumors. Progression-free survival at the end of follow-up was 71% (evaluated mainly on low-grade tumors).

CONCLUSIONS

 The surgical goal should be to achieve maximal cytoreduction and minimal postoperative neurologic damage. Functional outcome is influenced by the presence of a POD, radicality, histology, preoperative status, and employment of advanced neuroimaging planning and intraoperative monitoring.

Predictive Value of Transcranial Evoked Potential Monitoring for Intramedullary Spinal Cord Tumors

BACKGROUND

 Intraoperative neurophysiologic monitoring (IONM) has increased patient safety and extent of resection in patients with eloquent brain tumors. Despite its comprehensive capability for the resection of intramedullary spinal cord tumors (ISCTs), the application during the resection of these tumors is controversial.

METHODS

 We retrospectively analyzed the resection of ISCTs in 83 consecutive cases. IONM was performed in all cases. Each patient's motor status and the McCormick scale was determined preoperatively, directly after surgery, at the day of discharge, and at long-term follow-up.

RESULTS

 IONM was feasible in 71 cases (85.5%). Gross total resection was performed in 75 cases (90.4%). Postoperatively, patients showed new transient deficits in 12 cases (14.5%) and new permanent deficits in 12 cases (14.5%). The mean McCormick variance between baseline and long-term follow-up was - 0.08 ± 0.54. IONM's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the patient's motor status at the day of discharge was 75.0%, 64.7%, 45.5%, and 86.8%. It was 88.9%, 59.7%, 24.2%, and 97.4% for the motor outcome at long-term follow-up. Patients experienced postoperative complications in 15 cases (18.1%).

CONCLUSION

 IONM, as performed in the present study, shows a high sensitivity and NPV but low specificity and PPV, particularly for the patient's motor status at the long-term follow-up. As far as practicable by a retrospective study on IONM, our results confirm IONM's usefulness for its application during the resection of ISCTs. However, these results must be approved by a prospective study.

Intramedullary spinal cord tumours - a single Centre, 10-year review of clinical and pathological outcomes

BACKGROUND

Intramedullary spinal cord tumours are relatively rare tumours of the central nervous system. Surgical outcomes are affected by many variables, including pre-operative neurological function, tumour histology and extent of resection. Emphasis remains on surgical treatment due to limited adjunctive therapeutic options and poor drug penetration.

OBJECTIVE

To identify clinically relevant predictors of progression free survival by retrospectively analysing the extent of resection, pre- and post-operative neurological function and histology in intramedullary spinal cord tumours from a single neurosurgical centre over 10 years.

METHODS

Forty-three adult cases were identified from a surgical database. Variables collected included pre-and post-operative Frankel Grade and Modified McCormick Scale assessments, tumour histology, extent of resection and length of follow up. Chi-Squared, Kaplan-Mier Survival and Mann-Whitney U-tests were completed.

RESULTS

Ependymoma (41.9%) and haemangioblastoma (14.0%) were the commonest tumour histologies. In total, 17 different histological tumours were identified in the series. There was a statistically significant relationship between identification of the tumour plane and extent of resection (p < 0.01), along with the extent of resection and recurrence (p = 0.04). Compared to the other histological subtypes, ependymoma's demonstrated a significantly greater extent of resection (p = 0.01). There was a significant relationship between the grade of tumour and progression-free survival (p < 0.01).

CONCLUSION

Tumour plane and the extent of tumour resection are significant determinants of progression-free survival. Ependymoma, whilst being the commonest histology in our series were also the most resectable. Whilst complete resection reduces the rate of recurrence, tumour grade is the most important predictor of outcome. Given the importance of the extent of resection, and following a similar trend to other low volume pathologies, these tumours should only be tackled by neurosurgeons with experience in their resection.

Surgical management of spinal intramedullary tumors: Ten-year experience in a single institution

Despite their rare occurrence, intramedullary spinal cord tumors can cause considerable morbidity and mortality without treatment. Timing of surgery, extent of resection and selection of favorable treatment option are important considerations for a good surgical outcome. In this clinical study, we report our patient series and convey our treatment strategy. We retrospectively reviewed 91 patients with primary intramedullary spinal cord tumors who underwent microsurgical resection at our institution between 2008 and 2018. Data were collected consisting of age, sex, location and histology of tumor, extent of resection, presenting symptoms and neurological outcomes. Modified McCormick Scale was used to assess neurological status of patients. 47 female and 44 male patients were followed-up for a mean period of 35.7 months. The most frequent pathological diagnosis was ependymoma in 56 patients, followed by astrocytoma in 21 and hemangioblastoma in 5 patients. The rest of the tumors consisted of 3 cavernomas, 3 mature cystic teratomas, 2 PNET, one epidermoid tumor. Gross total resection was achieved in 67 patients, while subtotal resection and biopsy was performed in 15 and 9 respectively. The most commonly involved localization was cervical (n = 39), followed by thoracic region (n = 24). Despite immediate postoperative worsening of neurological status, a great number of patients improved at the last follow-up. Gross total resection remains the primary goal of treatment while adjuvant radiation and/or chemotherapy may be alternative options for high grade tumors. Preoperative neurological status was the most important and the strongest predictor of functional outcome.

Posterolateral myelotomy for intramedullary spinal cord tumors: the other way to do it?

BACKGROUND AND PURPOSE

To evaluate posterolateral myelotomy (PLM) as a surgical method for all cases of intramedullary spinal cord tumors (IMSCT) by assessing the surgical and functional outcomes of patients treated in our clinic.

MATERIALS AND METHODS

Patients with IMSCT who underwent surgery using PLM from 2013 to 2018 were reviewed retrospectively. Objective and quantitative assessment of the preoperative, postoperative, and follow-up neurological status was performed by using the modified McCormick functional schema and sensory pain scale.

RESULTS

A total of 33 operations were performed on 27 patients who met the inclusion criteria. The mean grade on the McCormick functional schema increased insignificantly from 2.0 preoperatively to 2.3 immediately postoperatively and decreased back to 2.1 at the follow-up examination. Just one patient exhibited a transient proprioception deficit. Significant pain relief was observed as expressed in an improvement of mean grade on the sensory pain scale. Only in two cases was late neuropathic pain reported. A gross total resection/subtotal resection (GTR/STR) was achieved in all cases of hemangioblastoma and cavernoma, while for the majority of astrocytomas, only partial removal was accomplished. For ependymoma, which represents the most common IMSCT, a GTR/STR was realized in 12 cases (86%). A statistically significant difference (p = 0.027) was found when comparing the extent of tumor resection (EOR) between the two most common IMSCT, i.e., ependymoma and astrocytoma.

CONCLUSION

PLM may be considered a reliable surgical method for IMSCT, as it combines a satisfactory EOR with reduced risk of tissue damage and excellent pain relief.

Intramedullary spinal cord ependymoma and astrocytoma: intraoperative frozen-section diagnosis, extent of resection, and outcomes

OBJECTIVEThe intraoperative differentiation of ependymomas from astrocytomas is important because neurosurgical strategies differ between these two tumor groups. Previous studies have reported that the diagnostic accuracy of intraoperative frozen sections of intracranial central nervous system (CNS) tumors is higher than 83%-97%, whereas that for spinal intramedullary tumors remains unknown. Herein, authors tested the hypothesis that intraoperative frozen-section diagnosis is the gold standard for a differential diagnosis of intramedullary spinal cord tumors.METHODSThe clinical characteristics, intraoperative histological diagnosis from frozen sections, extent of tumor resection, progression-free survival (PFS), and overall survival (OS) of 49 cases of intramedullary spinal cord ependymomas (n = 32) and astrocytomas (n = 17) were retrospectively evaluated.RESULTSThe frozen-section diagnosis and final diagnosis with permanent sections agreed in 23 (72%) of 32 cases of ependymoma. Of the 9 cases of ependymoma in which the frozen-section diagnosis disagreed with the final diagnosis, 4 were incorrectly diagnosed as astrocytoma and the other 5 cases had a nonspecific diagnosis, such as glioma. Nonetheless, gross-total resection was achieved in 6 of these 9 cases given the presence of a dissection plane. The frozen-section diagnosis and final diagnosis agreed in 12 (71%) of 17 cases of astrocytoma. Of the 5 cases of astrocytoma in which the frozen-section diagnosis disagreed with the final diagnosis, 1 was incorrectly diagnosed as ependymoma and the other 4 had a nonspecific diagnosis. Gross-total resection was achieved in only 1 of these 5 cases.A relationship between the size of tumor specimens and the diagnostic accuracy of frozen sections was not observed. Ependymal rosettes and perivascular pseudorosettes were observed in 30% and 57% of ependymomas, respectively, but were absent in astrocytomas.Progression-free survival and OS were both significantly longer in cases of ependymoma than in cases of astrocytoma (p < 0.001). Gross-total resection was achieved in 69% of ependymomas and was associated with longer PFS (p = 0.041). In the astrocytoma group, gross-total resection was achieved in only 12% and there was no relationship between extent of resection and OS. Tumor grades tended to correlate with OS in astrocytomas (p = 0.079).CONCLUSIONSThe diagnostic accuracy of intraoperative frozen sections was lower for intramedullary spinal cord ependymomas and astrocytomas in the present study than that for intracranial CNS tumors reported on in the literature. Surgical strategies need to be selected based on multiple factors, such as clinical characteristics, preoperative imaging, frozen-section diagnosis, and intraoperative findings of the tumor plane.

Surgical Treatment of Intra- and Juxtamedullary Spinal Cord Tumors: A Population Based Observational Cohort Study

Objective: Intramedullary spinal cord tumors (IMSCT) are rare entities and high-level evidence regarding optimal treatment is lacking. We aim to describe the demographics, histopathological distribution, onset symptoms, treatment strategies, and functional outcome for patients surgically treated for IMSCT.

Methods: We performed a retrospective review of a consecutive population-based cohort of 95 patients who underwent surgery for intra- or juxtamedullary tumors at a single institution during the period 2004–2017.

Results: When gross total resection (GTR) was achieved, we found no case of local tumor recurrence even in the absence of adjuvant radio- or chemotherapy. Meanwhile, we found a 50% progression rate on long-term MRI follow-up in patients where only a partial resection was possible. At long-term follow-up, there was no significant alteration in functional status, while a significant reduction in share of patients reporting pain, compared to preoperative status, was identified. Poor preoperative functional status and postoperative tumor remnant were identified as individual risk factors for further functional decline.

Conclusion: Gross total resection, with minimal post-operative neurological deterioration, is possible in the majority of the cases, especially in the presence of an identifiable resection plane between tumor and healthy spinal cord. Since long-term progression-free survival could be achieved by GTR without additional adjuvant treatment, we emphasize that low-grade tumors should not be subject to radiotherapy. Treatment of high-grade or diffusely infiltrating tumors, tumor remnants, or metastases should be individualized.

Molecular foundations of primary spinal tumors-implications for surgical management

Primary spinal tumors are rare lesions that require careful clinical management due to their intimate relationship with critical neurovascular structures and the significant associated risk of morbidity. While the advent of molecular and genomic profiling is beginning to impact the management of the cranial counterparts, translation for spinal tumors has lagged behind. Maximal safe surgical resection remains the mainstay of patients with primary spinal tumors, with extent of resection and histology the only consistently identified independent predictors of survival. Adjuvant therapy has had limited impact. To develop targeted neoadjuvant and adjuvant therapies, improve prognostication, and enhance patient selection in spinal oncology, a thorough understanding of the current molecular and genomic landscape of spinal tumors is required. In this review, we detail the epidemiology, current standard-of-care, and molecular features of the most commonly encountered intramedullary spinal cord tumors (IMSCT), intradural extramedullary (IDEM) tumors, and primary spinal column malignancies (PSCM). We further discuss current efforts and future opportunities for integrating molecular advances in spinal oncology with clinical management.

A systematic review of outcome in intramedullary ependymoma and astrocytoma

The objective was to determine the impact of surgical resection and adjuvant therapies on survival in intramedullary ependymoma and astrocytoma. Secondary goals were to determine predictors of survival in surgical patients including histological grading, age and gender. Searching of Medline, Embase and Clinicaltrials.gov databases were performed. Multivariate analyses were performed for overall survival (OS) and progression-free survival (PFS) through Monte Carlo methods and Maximum Likelihood Estimation. 57 articles detail results for 3022 patients. Meta-analysis revealed the following factors to have a statistically significant effect on OS. Patients undergoing gross-total resection (GTR) are 5.37 times more likely to survive than patients with lesser volumes of tumor resected (HR for OS 1.68, p < 0.01). High-grade tumors were associated with a 14 times risk of death over low-grade tumors (HR for OS 2.64, p < 0.01). Radiation increased the risk of mortality in low-grade tumors (HR for OS 5.20, p < 0.01), but decreased mortality in high-grade lesions (HR for OS 2.46, p < 0.01). Adult patients were more likely to die from disease compared with pediatric patients by a factor of 1.6 (HR for OS 0.47, p < 0.01). In PFS, radiotherapy was associated with a reduced time to recurrence (HR for PFS 1.90, p < 0.01). There was a male predominance of 58%. Gender did not influence survival. 79% of patients demonstrated stable or improved functional neurological outcomes six months post-operatively. Our data indicates GTR improves OS in all tumor grades. Radiation improves OS only in the presence of high-grade histology. Advancing age and high-grade histology are negative prognostic indicators.

Recent advances in intradural spinal tumors

Intradural spinal tumors are rare tumors of the central nervous system. Due to the eloquence of the spinal cord and its tracts, the compact architecture of the cord and nerves, and the infiltrative nature of some of these tumors, surgical resection is difficult to achieve without causing neurological deficits. Likewise, chemotherapy and radiotherapy are utilized more cautiously in the treatment of intradural spinal tumors than their cranial counterparts. Targeted therapies aimed at the genetic alterations and molecular biology tailored to these tumors would be helpful but are lacking.Here, we review the major types of intradural spinal tumors, with an emphasis on genetic alterations, molecular biology, and experimental therapies for these difficult to treat neoplasms.

Long-term outcome of treatment of vertebral body hemangiomas with direct ethanol injection and short-segment stabilization

BACKGROUND

Vertebral body hemangiomas with myelopathy are difficult to manage.

OBJECTIVE

The objective of this study was to evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented short-segment fusion in vertebral hemangioma (VH) with myelopathy and long-term outcome (>24 months).

CLINICAL MATERIALS AND METHODS

This prospective study included symptomatic VH with cord compression with myelopathy. Pathologic fractures and deformity or multilevel pathologies were excluded from the study. Surgery consisted of intraoperative bilateral pedicular absolute alcohol (<1% hydrated ethyl alcohol) injection, laminectomy, and cord decompression at the level of pathology followed by a short-segment instrumented fusion using pedicle screws.

RESULTS

The study included 33 patients (mean 26.9±13.2, range: 10-68 years, 18 females). The clinical features of the study were myelopathy in all patients (5 paraplegic), sphincter involvement (13), and mid back or lower back pain (7). The preoperative American Spinal Injury Association (ASIA) scores were A (7), B (11), C (6), D (8), and E (1). Majority of the patients had single vertebral involvement (30) and three patients had multiple-level involvement. Six patients underwent surgery earlier (one underwent alcohol embolization). The mean surgical time was 124±39 minutes, and the average blood loss was 274±80 cc. The mean amount of absolute alcohol injected was 14.6±5.7 cc (two patients required 20 and 25 cc). Immediate embolization was achieved in all patients, allowing laminectomy and easy removal of soft-tissue hemangioma. Post surgery, one patient had transient deterioration, and the condition of the rest of the patients improved (sphincters improved in nine patients) at a follow-up ranging 28-103 months (mean 47.6±22.3). Follow-up ASIA scores were E (26), D (4), B (2), and C (1). All patients showed evidence of bone sclerosis and relief of cord compression on follow-up imaging.

CONCLUSIONS

This is the largest study in literature showing excellent improvement, low reoperation rates after ethanol embolization, and short-segment fixation.

Spinal cord astrocytomas: progresses in experimental and clinical investigations for developing recovery neurobiology-based novel therapies

Spinal cord astrocytomas (SCAs) have discernibly unique signatures in regards to epidemiology, clinical oncological features, genetic markers, pathophysiology, and research and therapeutic challenges. Overall, there are presently very limited clinical management options for high grade SCAs despite progresses made in validating key molecular markers and standardizing tumor classification. The endeavors were aimed to improve diagnosis, therapy design and prognosis assessment, as well as to define more effective oncolytic targets. Efficacious treatment for high grade SCAs still remains an unmet medical demand. This review is therefore focused on research state updates that have been made upon analyzing clinical characteristics, diagnostic classification, genetic and molecular features, tumor initiation cell biology, and current management options for SCAs. Particular emphasis was given to basic and translational research endeavors targeting SCAs, including establishment of experimental models, exploration of unique profiles of SCA stem cell-like tumor survival cells, characterization of special requirements for effective therapeutic delivery into the spinal cord, and development of donor stem cell-based gene-directed enzyme prodrug therapy. We concluded that precise understanding of molecular oncology, tumor survival mechanisms (e.g., drug resistance, metastasis, and cancer stem cells/tumor survival cells), and principles of Recovery Neurobiology can help to create clinically meaningful experimental models of SCAs. Establishment of such systems will expedite the discovery of efficacious therapies that not only kill tumor cells but simultaneously preserve and improve residual neural function.

Pediatric intramedullary spinal cord tumor outcomes using the WeeFIM scale

PURPOSE

The Functional Independence Measure for children (WeeFIM) is a user-friendly functional outcomes tool that has been validated across other traditional functional scales. Historically, the significant neurologic and functional deficits of intramedullary spinal cord tumors (IMSCTs) have been monitored by coarse or overbearing functional outcomes tools that make it difficult to measure the slow improvement/decline seen in these patients. This study is the first to report WeeFIM outcomes on a series of IMSCTs with emphasis on an aggressive surgical strategy.

METHODS

A retrospective review from 2005 to 2014 was performed for nine patients who underwent resective surgery for intramedullary spinal cord tumors with intraoperative ultrasound and neurophysiologic monitoring. WeeFIM scales were assessed at admission and discharge to evaluate changes in severity of disability and need for assistance.

RESULTS

At the time of this submission, 7/9 patients are alive. The mean WeeFIM improvement was 27 points (8-50 points) with a mean WeeFIM efficiency of 2.0 points/day.

CONCLUSIONS

The WeeFIM scale is an appropriate and useful scale for measuring postoperative improvements in patients with IMSCTs undergoing aggressive resective surgery. Attention to intraoperative spinal cord monitoring and prevention of spinal column instability may prevent morbidity related to surgery, and functional outcomes do not appear to be compromised by an aggressive surgical approach.

Adult pilocytic astrocytoma of conus medullaris: clinical considerations and review of the literature

Astrocytomas are responsible for 30% of all primitive intramedullary tumors with cervicothoracic predominance. However, only about one hundred cases of intramedullary pilocytic astrocytomas were described. The authors described the case of a 69 year-old patient presenting with a broad-base gait, bilateral pain and dysesthesia of inferior limbs with a diagnosis of an intra-axial cystic lesion centered to the conus medullaris, diagnosed as pilocytic astrocytoma of conus medullaris (PACM) after surgery. To the best of our knowledge, only two previous reports concerning PACM were made. As benign lesions associated with long survivals, function should be the mainstay of treatment of PACM. Surgical resection should be performed. Adjuvant radiotherapy or chemotherapy has no establish role in pilocytic astrocytic lesions.

Intramedullary ependymoma: long-term outcome after surgery

BACKGROUND

Overall (OS) and progression-free survival (PFS) of patients undergoing spinal ependymoma resection has been frequently reported. Contrarily, OS and PFS of purely intramedullary ependymomas have not been clearly determined yet.

METHODS

The data of 37 patients undergoing resection of an intramedullary ependymoma (IE) from January 2000 to December 2016 were analysed retrospectively.

RESULTS

The mean age was 46 years. The male:female ratio was 24:13. The median duration of symptoms was 12 months. Sixty-two per cent of ependymomas were in the cervical, 24% in the thoracic, and 14% in the conus region in our series. The median volume was 1.3 ml. A syrinx was found in 49% and a cyst in 32%. GTR was achieved in 89%, STR in three (8%), and PR in one patient (3%). Median follow-up was 114 months. PFS was 87%, 82%, and 82% at 5, 10, and 15 years, respectively. OS was 97%, 88%, and 63% at 5, 10, and 15 years, respectively. There was a significant difference in PFS depending on the extent of resection and in OS depending on the pre-operative clinical status. There was no significant difference in OS and PFS regarding the other examined influencing factors.

CONCLUSION

GTR resection was the most important factor influencing PFS. According to our results OS of IEs is much worse than that of spinal ependymomas. Our analysis confirms that patients with good pre-operative (McCormick grade 1 and 2) clinical status have significantly better OS than patients with McCormick grade 3 and higher.

Logistic regression analysis of risk factors for postoperative recurrence of spinal tumors and analysis of prognostic factors

The aim of the present study was to investigate the risk factors for postoperative recurrence of spinal tumors by logistic regression analysis and analysis of prognostic factors. In total, 77 male and 48 female patients with spinal tumor were selected in our hospital from January, 2010 to December, 2015 and divided into the benign (n=76) and malignant groups (n=49). All the patients underwent microsurgical resection of spinal tumors and were reviewed regularly 3 months after operation. The McCormick grading system was used to evaluate the postoperative spinal cord function. Data were subjected to statistical analysis. Of the 125 cases, 63 cases showed improvement after operation, 50 cases were stable, and deterioration was found in 12 cases. The improvement rate of patients with cervical spine tumor, which reached 56.3%, was the highest. Fifty-two cases of sensory disturbance, 34 cases of pain, 30 cases of inability to exercise, 26 cases of ataxia, and 12 cases of sphincter disorders were found after operation. Seventy-two cases (57.6%) underwent total resection, 18 cases (14.4%) received subtotal resection, 23 cases (18.4%) received partial resection, and 12 cases (9.6%) were only treated with biopsy/decompression. Postoperative recurrence was found in 57 cases (45.6%). The mean recurrence time of patients in the malignant group was 27.49±6.09 months, and the mean recurrence time of patients in the benign group was 40.62±4.34. The results were significantly different (P<0.001). Recurrence was found in 18 cases of the benign group and 39 cases of the malignant group, and results were significantly different (P<0.001). Tumor recurrence was shorter in patients with a higher McCormick grade (P<0.001). Recurrence was found in 13 patients with resection and all the patients with partial resection or biopsy/decompression. The results were significantly different (P<0.001). Logistic regression analysis of total resection-related factors showed that total resection should be the preferred treatment for patients with benign tumors, thoracic and lumbosacral tumors, and lower McCormick grade, as well as patients without syringomyelia and intramedullary tumors. Logistic regression analysis of recurrence-related factors revealed that the recurrence rate was relatively higher in patients with malignant, cervical, thoracic and lumbosacral, intramedullary tumors, and higher McCormick grade and patient received partial resection or biopsy. Tumor property, tumor location, McCormick grade, tumor resection, and intramedullary tumors are risk factors for the recurrence of spinal tumors. Clinical assessment of these risk factors may be helpful in selecting appropriate treatment strategies.

Clinical and pathological outcomes after resection of intramedullary spinal cord tumors: a single-institution case series

OBJECTIVE The objective of this study was to identify clinically relevant predictors of progression-free survival and functional outcomes in patients who underwent surgery for intramedullary spinal cord tumors (ISCTs). METHODS An institutional spinal tumor registry and billing records were reviewed to identify adult patients who underwent resection of ISCTs between 1993 and 2014. Extensive data were collected from patient charts and operative notes, including demographic information, extent of resection, tumor pathology, and functional and oncological outcomes. Survival analysis was used to determine important predictors of progression-free survival. Logistic regression analysis was used to evaluate the association between an "optimal" functional outcome on the Frankel or McCormick scale at 1-year follow-up and various clinical and surgical characteristics. RESULTS The consecutive case series consisted of 63 patients (50.79% female) who underwent resection of ISCTs. The mean age of patients was 41.92 ± 14.36 years (range 17.60-75.40 years). Complete microsurgical resection, defined as no evidence of tumor on initial postoperative imaging, was achieved in 34 cases (54.84%) of the 62 patients for whom this information was available. On univariate analysis, the most significant predictor of progression-free survival was tumor histology (p = 0.0027). Patients with Grade I/II astrocytomas were more likely to have tumor progression than patients with WHO Grade II ependymomas (HR 8.03, 95% CI 2.07-31.11, p = 0.0026) and myxopapillary ependymomas (HR 8.01, 95% CI 1.44-44.34, p = 0.017). Furthermore, patients who underwent radical or subtotal resection were more likely to have tumor progression than those who underwent complete resection (HR 3.46, 95% CI 1.23-9.73, p = 0.018). Multivariate analysis revealed that tumor pathology was the only significant predictor of tumor progression. On univariate analysis, the most significant predictors of an "optimal" outcome on the Frankel scale were age (OR 0.94, 95% CI 0.89-0.98, p = 0.0062), preoperative Frankel grade (OR 4.84, 95% CI 1.33-17.63, p = 0.017), McCormick score (OR 0.22, 95% CI 0.084-0.57, p = 0.0018), and region of spinal cord (cervical vs conus: OR 0.067, 95% CI 0.012-0.38, p = 0.0023; and thoracic vs conus: OR 0.015: 95% CI 0.001-0.20, p = 0.0013). Age, tumor pathology, and region were also important predictors of 1-year McCormick scores. CONCLUSIONS Extent of tumor resection and histopathology are significant predictors of progression-free survival following resection of ISCTs. Important predictors of functional outcomes include tumor histology, region of spinal cord in which the tumor is present, age, and preoperative functional status.

Management of primary thalamic low-grade glioma in pediatric patients: results of the multicenter treatment studies HIT-LGG 1996 and SIOP-LGG 2004

Background

Thalamic low-grade glioma (LGG) poses a special therapeutic challenge, as complete resection is often not possible. To determine the survival outcomes of mono- and bithalamic LGG, we analyzed a large cohort of pediatric patients.

Methods

From 1996 until 2012, 2618 patients were registered in the HIT-LGG 1996 and the SIOP-LGG 2004 studies. A total of 102 of these 2618 patients (3.9%) were diagnosed with a thalamic LGG with a median age at diagnosis of 8.0 years (range, 0.4-17.5 years); 87 patients (85%) had monothalamic and 15 patients (15%) had bithalamic LGG.

Results

Ninety patients received at least one surgical procedure. Thirty-one patients received radiotherapy and 24 patients received chemotherapy as a first-line, nonsurgical treatment indicated by radiological tumor progression or severe/progressive clinical symptoms. Patients with monothalamic tumors showed a 10-year overall survival (OS) rate of 91%, whereas patients with bithalamic tumors only reached 65% (P = .001). Bithalamic tumors more frequently showed diffuse histology than monothalamic tumors. Patients with diffuse astrocytoma had a lower 10-year OS (68%) than those with pilocytic astrocytoma (93%). The 10-year progression-free survival rate after the start of first nonsurgical treatment was 53% in the radiotherapy group and 34% in the chemotherapy group.

Conclusions

Thalamic glioma was manageable using a strategy that included surgery, observation, chemotherapy, and/or radiotherapy. Radiotherapy could be successfully deferred or obviated in a number of patients. Survival was high in among patients with monothalamic tumors. The worse prognosis associated with bithalamic tumors correlates with the higher rate of diffuse histology in this subgroup, precluding total or near-total resection.