114 Paediatric spinal cord intramedullary gliomas safe maximal extent of resection to optimize neurological and oncological outcomes

Abstract The reported results of treatment of intramedullary spinal cord tumors (IMSCT) are difficult to interpret because of heterogeneous management strategies, small numbers of patients, and short periods of follow-up. In 1985 we published the early results of operative treatment of 29 patients with IMSCT and were cautiously optimistic that aggressive operative management would have a salutary effect on long-term outcome. In this report, the most recent clinical status of these 29 original patients is reviewed, along with that of 22 additional ones, to assess the intermediate and long-term results of treatment of IMSCT in 51 patients who underwent microsurgical resection between 1981 and 1987. Of these 51 patients, 24 had ependymomas, 18 had astrocytomas, and the remainder had a variety of less common lesions. Thirty-seven patients survive and have been followed for periods up to 72 months (mean 38 months). The neurological conditions of 21 patients are improved or have stabilized following operation. The conditions of 16 patients are worse postoperatively: 11 from operation and 5 from progression of disease. Eight patients are neurologically intact, 7 walk independently but abnormally, 9 ambulate with the aid of a cane or walker, and the remaining 13 are not ambulatory. Twelve of 18 patients with astrocytomas and 2 of 24 patients with ependymomas have died after a mean survival of 10 months from operation. Patients with ependymomas who had gross total resection have fared the best, with no deaths or recurrences, but no relationship could be discerned between the extent of resection and outcome in patients with astrocytomas. The author concludes that radical resection of IMSCT may be performed with initial stabilization or improvement of neurological function in the majority of patients. In patients with ependymomas the extent of resection correlated well with long-term outcome. In patients with astrocytomas. however, there was no such relationship. All 7 patients with astrocytomas of Grades III and IV have died, as have 4 of 11 patients with astrocytomas of Grades I and II.

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TM1-6 Intramedullary spinal cord tumours – a single centre 10 year retrospective review

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-abn.30 ◽

2019 ◽

Vol 90 (3) ◽

pp. e10.1-e10

Author(s):

O Richards ◽

E Goacher ◽

C Derham

Keyword(s):

Spinal Cord ◽

Significant Relationship ◽

Retrospective Review ◽

Progression Free Survival ◽

Extent Of Resection ◽

Tumour Resection ◽

Anatomical Location ◽

Intramedullary Spinal Cord ◽

Free Survival ◽

Spinal Cord Tumours

ObjectivesTo identify clinically relevant predictors of progression free survival by retrospectively analysing the anatomical location, pre- and post-operative function and histology in intramedullary spinal cord tumours from a single neurosurgical centre over 10 years.DesignRetrospective review.Methods49 patients 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.ResultsThere 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<0.01). Compared to the other histological subtypes, ependymoma’s demonstrated a significantly greater extent of resection (p=0.02). There was a significant relationship between the grade of tumour and progression free survival (p<0.01). We did not find a significant relationship between pre- and post-operative neurological function and survival.ConclusionsTumour 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.

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Histologic grade and extent of resection are associated with survival in pediatric spinal cord ependymomas

Child s Nervous System ◽

10.1007/s00381-013-2149-x ◽

2013 ◽

Vol 29 (11) ◽

pp. 2057-2064 ◽

Cited By ~ 12

Author(s):

Michael Safaee ◽

Michael C. Oh ◽

Joseph M. Kim ◽

Derick Aranda ◽

Phiroz E. Tarapore ◽

...

Keyword(s):

Spinal Cord ◽

Extent Of Resection ◽

Histologic Grade

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Treatment of high-grade spinal cord astrocytoma of childhood with “8-in-1” chemotherapy and radiotherapy: a pilot study of CCG-945

Neurosurgical FOCUS ◽

10.3171/foc.1997.3.5.5 ◽

1997 ◽

Vol 3 (5) ◽

pp. E4

Author(s):

Jeffrey C. Allen ◽

Shraga Aviner ◽

Allan J. Yates ◽

James M. Boyett ◽

Joel M. Cherlow ◽

...

Keyword(s):

Spinal Cord ◽

Survival Rates ◽

Extent Of Resection ◽

Leptomeningeal Metastases ◽

High Risk Population ◽

High Grade ◽

High Grade Astrocytoma ◽

Cancer Group ◽

Dismal Prognosis ◽

To Receive

The purpose of this study was to devise an improved method of treating high-grade gliomas of the spinal cord in children who have a dismal prognosis following conventional treatment. Eighteen children with newly diagnosed high-grade astrocytomas arising in the spinal cord were enrolled in the Children's Cancer Group (CCG) protocol 945. Following surgery, they were all assigned to receive two courses of “8-drugs-in-1-day” (8-in-1) chemotherapy prior to radiotherapy and eight additional courses thereafter. A centralized neuropathology review was used to confirm the diagnosis of high-grade astrocytoma in 13 of the 18 children: anaplastic astrocytoma, (eight patients), glioblastoma multiforme (four patients), and mixed malignant glioma (one patient). Diagnoses were discordant in five patients. There were eight boys and five girls in the group with confirmed diagnoses, with a median age of 7 years (range 1-15 years). The extent of resection was confirmed by computerized tomography or magnetic resonance (MR) evaluation in five of 13 patients. There were six gross-total or near-total resections (>90%), four partial or subtotal resections (10-90%), and three biopsies. Six patients showed evidence of leptomeningeal metastases at diagnosis based on staging MR examinations. Eight of the 13 patients completed at least eight of the prescribed 10 courses of chemotherapy; five received craniospinal radiotherapy and five spinal radiotherapy. The 5-year progression-free and total survival rates for the 13 children were 46 ± 14% and 54 ± 14%, respectively. Seven patients suffered a relapse at the primary site, four of whom also had leptomeningeal metastases. Seven of the 13 patients (54%) remain alive at the time of this report at a median of 76 months (range 51-93 months) from study entry. Six patients died between 8 and 38 months after diagnosis, all with active disease. Intensification of therapy may further improve outcome in this high-risk population.

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Treatment of high-grade spinal cord astrocytoma of childhood with “8-in-1” chemotherapy and radiotherapy: a pilot study of CCG-945

Journal of Neurosurgery ◽

10.3171/jns.1998.88.2.0215 ◽

1998 ◽

Vol 88 (2) ◽

pp. 215-220 ◽

Cited By ~ 98

Author(s):

Jeffrey C. Allen ◽

Shraga Aviner ◽

Allan J. Yates ◽

James M. Boyett ◽

Joel M. Cherlow ◽

...

Keyword(s):

Spinal Cord ◽

Survival Rates ◽

Extent Of Resection ◽

Leptomeningeal Metastases ◽

High Risk Population ◽

High Grade ◽

Content Type ◽

High Grade Astrocytoma ◽

Dismal Prognosis ◽

Fine Print

Object. The purpose of this study was to devise an improved method of treating high-grade gliomas of the spinal cord in children who have a dismal prognosis following conventional treatment. Methods. Eighteen children with newly diagnosed high-grade astrocytomas arising in the spinal cord were enrolled in the Children's Cancer Group (CCG) protocol 945. Following surgery, they were all assigned to receive two cycles of “8-drugs-in-1-day” (8-in-1) chemotherapy prior to radiotherapy and eight additional cycles thereafter. A centralized neuropathology review was used to confirm the diagnosis of high-grade astrocytoma in 13 of the 18 children: anaplastic astrocytoma (eight patients), glioblastoma multiforme (four patients), and mixed malignant glioma (one patient). Diagnoses were discordant in five patients. There were eight boys and five girls in the group with confirmed diagnoses, with a median age of 7 years (range 1–15 years). The extent of resection was confirmed by computerized tomography or magnetic resonance (MR) evaluation in five of 13 patients. There were six gross-total or near-total resections (> 90%), four partial or subtotal resections (10–90%), and three biopsies. Six patients showed evidence of leptomeningeal metastases at diagnosis based on staging MR examinations. Eight of the 13 patients completed at least eight of the prescribed 10 cycles of chemotherapy; five received craniospinal radiotherapy and five spinal radiotherapy. Conclusions. The 5-year progression-free and total survival rates for the 13 children were 46 ± 14% and 54 ± 14%, respectively. Seven patients suffered a relapse at the primary site, four of whom also had leptomeningeal metastases. Seven of the 13 patients (54%) remain alive at the time of this report at a median of 76 months (range 51–93 months) from study entry. Six patients died between 8 and 38 months after diagnosis, all with active disease. Intensification of therapy may further improve outcome in this high-risk population.

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Incidence of spinal deformity after resection of intramedullary spinal cord tumors in children who underwent laminectomy compared with laminoplasty

Journal of Neurosurgery Pediatrics ◽

10.3171/ped-08/01/057 ◽

2008 ◽

Vol 1 (1) ◽

pp. 57-62 ◽

Cited By ~ 76

Author(s):

Matthew J. McGirt ◽

Kaisorn L. Chaichana ◽

April Atiba ◽

Ali Bydon ◽

Timothy F. Witham ◽

...

Keyword(s):

Spinal Cord ◽

Functional Outcome ◽

Spinal Deformity ◽

Spinal Cord Tumor ◽

Extent Of Resection ◽

Neurological Function ◽

Karnofsky Performance Scale ◽

Duration Of Symptoms ◽

Intramedullary Spinal Cord

Object Gross-total resection of pediatric intramedullary spinal cord tumor (IMSCT) can be achieved in the majority of cases while preserving long-term neurological function. Nevertheless, postoperative progressive spinal deformity often complicates functional outcome years after surgery. The authors set out to determine whether laminoplasty in comparison with laminectomy has reduced the incidence of subsequent spinal deformity requiring fusion after IMSCT resection at their institution. Methods The first 144 consecutive patients undergoing resection of IMSCTs at a single institution underwent laminectomy with preservation of facet joints. The next 20 consecutive patients presenting for resection of IMSCTs underwent osteoplastic laminotomy regardless of patient or tumor characteristics. All patients were followed up with telephone interviews corroborated by medical records for the following outcomes: 1) neurological and functional status (modified McCormick Scale [MMS] score and Karnofsky Performance Scale [KPS] score); and 2) development of progressive spinal deformity requiring fusion. The incidence of progressive spinal deformity and the long-term neurological function were compared between the laminectomy and osteoplastic laminotomy cohorts. The means are expressed ± the standard deviation. Results Overall, the patients' mean age was 8.6 ± 5 years, and they presented with median MMS scores of 2 (interquartile range [IQR] 2–4). A > 95% resection was achieved in 125 cases (76%). There were no differences (p > 0.10) between patients treated with osteoplastic laminotomy and those treated with laminectomy in terms of the following characteristics: age; sex; duration of symptoms; location of tumor; incidence of preoperative scoliosis (Cobb angle > 10°: 7 [35%] with laminoplasty compared with 49 [34%] with laminectomy); involvement of the cervicothoracic junction (7 [35%] compared with 57 [40%]); thoracolumbar junction (4 [20%] compared with 36 [25%]); tumor size; extent of resection; radiation therapy; histopathological findings; or mean operative spinal levels (7.5 ± 2 compared with 7.5 ± 3). Nevertheless, patients who underwent osteoplastic laminotomy had better median preoperative MMS scores than those treated with laminectomy (2 [IQR 2–2] compared with 2 [IQR 2–4]; p = 0.04). A median of 3.5 years (IQR 1–7 years) after surgery, only 1 patient (5%) in the osteoplastic laminotomy cohort required fusion for progressive spinal deformity, compared with 43 (30%) in the laminectomy cohort (p = 0.027). Adjusting for the inter-cohort difference in preoperative MMS scores, osteoplastic laminotomy was associated with a 7-fold reduction in the odds of subsequent fusion for progressive spinal deformity (odds ratio 0.13, 95% confidence interval 0.02–1.00; p = 0.05). The median MMS and KPS scores were similar between patients who underwent osteoplastic laminotomy and those in whom laminectomy was performed (MMS Score 2 [IQR 2–3] for laminotomy compared with 2 [IQR 2–4] for laminectomy, p = 0.54; KPS Score 90 [IQR 70–100] for laminotomy compared with 90 [IQR 80–90] for laminectomy, p = 0.545) at a median of 3.5 years after surgery. Conclusions In the authors' experience, osteoplastic laminotomy for the resection of IMSCT in children was associated with a decreased incidence of progressive spinal deformity requiring fusion but did not affect long-term functional outcome. Laminoplasty used for pediatric IMSCT resection may decrease the incidence of progressive spinal deformity requiring subsequent spinal stabilization in some patients.

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5-Aminolevulinic Acid Fluorescence-Guided Resection of Intramedullary Ependymoma: Report of 9 Cases

Operative Neurosurgery ◽

10.1227/neu.0b013e31827bc7a3 ◽

2012 ◽

Vol 72 (2) ◽

pp. ons159-ons168 ◽

Cited By ~ 12

Author(s):

Tomoo Inoue ◽

Toshiki Endo ◽

Kenichi Nagamatsu ◽

Mika Watanabe ◽

Teiji Tominaga

Keyword(s):

Spinal Cord ◽

Aminolevulinic Acid ◽

Tumor Resection ◽

Extent Of Resection ◽

Labeling Index ◽

World Health ◽

Histopathological Diagnosis ◽

Glioma Surgery ◽

Ki 67 ◽

Grade Ii

Abstract BACKGROUND: Resection guided by 5-aminolevulinic acid (5-ALA) fluorescence has proved to be useful in intracranial glioma surgery. However, the effects of 5-ALA on spinal cord tumors remain unknown. OBJECTIVE: To evaluate the usefulness of 5-ALA fluorescence-guided resection of intramedullary ependymoma for achieving maximum tumor resection. METHODS: This study included 10 patients who underwent surgical resection of an intramedullary ependymoma. Nine patients were orally administered 5-ALA (20 mg/kg) 2 hours before the induction of anesthesia. 5-ALA fluorescence was visualized with an operating microscope. Tumors were removed in a standardized manner with electro-physiological monitoring. The extent of resection was evaluated on the basis of intra-operative findings and postoperative magnetic resonance imaging. Histopathological diagnosis was established according to World Health Organization 2007 criteria. Cell proliferation was assessed by Ki-67 labeling index. RESULTS: 5-ALA fluorescence was positive in 7 patients (6 grade II and 1 grade III) and negative in 2 patients (grade II). Intraoperative findings were dichotomized: Tumors covered by the cyst were easily separated from the normal parenchyma, whereas tumors without the cyst appeared to be continuous to the spinal cord. In these cases, 5-ALA fluorescence was especially valuable in delineating the ventral and cranial and caudal margins. Ki-67 labeling index was significantly higher in 5-ALA-positive cases compared with 5-ALA-negative cases. All patients improved neurologically or stabilized after surgery. CONCLUSION: 5-ALA fluorescence was useful for detecting tumor margins during surgery for intramedullary ependymoma. When combined with electrophysiological monitoring, fluorescence-guided resection could help to achieve maximum tumor resection safely.

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