Tumor dissemination through surgical tracts in diffuse intrinsic pontine glioma

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OBJECTIVE

Diffuse intrinsic pontine glioma (DIPG) is a highly aggressive and lethal brainstem tumor in children. In the 1980s, routine biopsy at presentation was abandoned since it was claimed “unnecessary” for diagnosis. In the last decade, however, several groups have reincorporated this procedure as standard of care or in the context of clinical trials. Expert neurosurgical teams report no mortality and acceptable morbidity, and no relevant complications have been previously described. The aim of this study was to review needle tract dissemination as a potential complication in DIPG.

METHODS

The authors retrospectively analyzed the incidence of dissemination through surgical tracts in DIPG patients who underwent biopsy procedures at diagnosis in 3 dedicated centers. Clinical records and images as well as radiation dosimetry from diagnosis to relapse were reviewed.

RESULTS

Four patients (2 boys and 2 girls, age range 6–12 years) had surgical tract dissemination: in 3 cases in the needle tract and in 1 case in the Ommaya catheter tract. The median time from biopsy to identification of dissemination was 5 months (range 4–6 months). The median overall survival was 11 months (range 7–12 months). Disseminated lesions were in the marginal radiotherapy field (n = 2), out of the field (n = 1), and in the radiotherapy field (n = 1).

CONCLUSIONS

Although surgical tract dissemination in DIPG is a rare complication (associated with 2.4% of procedures in this study), it should be mentioned to patients and family when procedures involving a surgical tract are proposed. The inclusion of the needle tract in the radiotherapy field may have only limited benefit. Future studies are warranted to explore the benefit of larger radiotherapy fields in patients with DIPG.

ABBREVIATIONS CED = convection-enhanced delivery; DFCI = Dana-Farber Cancer Institute; DIPG = diffuse intrinsic pontine glioma; GR = Gustave Roussy; HGG = high-grade glioma; PTV = planning target volume; RT = radiotherapy; SJD = Sant Joan de Déu Hospital.

Article Information

Correspondence Andres Morales La Madrid: Hospital Sant Joan de Déu, Barcelona, Spain. amorales@hsjdbcn.org.

INCLUDE WHEN CITING Published online September 7, 2018; DOI: 10.3171/2018.6.PEDS17658.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 1. A and B: Axial Gd-enhanced T1-weighted MR images showing needle tract biopsy and pontine mass after biopsy (A) and pontine mass with needle tract dissemination at relapse (B). C: Image showing different radiotherapy fields with isodose lines. Figure is available in color online only.

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    Case 2. A and B: Axial T2-weighted MR images showing needle tract biopsy before (A) and after (B) DIPG relapse. C: Image showing needle tract dissemination with respect to the spatial relationship to the radiotherapy field. Figure is available in color online only.

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    Case 3. Axial gadolinium-enhanced T1-weighted (left) and axial T2-weighted (right) MR images showing biopsy needle tract dissemination.

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    Case 4. This patient experienced pseudoprogression with cyst formation needing cyst extirpation and intracyst Ommaya reservoir placement. Sagittal T2-weighted MR images show pontine lesion and reservoir Ommaya tract before relapse (left) and disseminated lesions in the intra–Ommaya reservoir tract at relapse (right).

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