Stereotactic radiosurgery for pediatric recurrent intracranial ependymomas

Clinical article

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Object

To evaluate the role of stereotactic radiosurgery (SRS) in patients with recurrent or residual intracranial ependymomas after resection and fractionated radiation therapy (RT), the authors assessed overall survival, distant tumor relapse, progression-free survival (PFS), and complications.

Methods

The authors retrospectively reviewed the records of 21 children with ependymomas who underwent SRS for 32 tumors. There were 17 boys and 4 girls with a median age of 6.9 years (range 2.9–17.2 years) in the patient population. All patients underwent resection of an ependymoma followed by cranial or neuraxis (if spinal metastases was confirmed) RT. Eleven patients had adjuvant chemotherapy. Twelve patients had low-grade ependymomas (17 tumors), and 9 patients had anaplastic ependymomas (15 tumors). The median radiosurgical target volume was 2.2 cm3 (range 0.1–21.4 cm3), and the median dose to the tumor margin was 15 Gy (range 9–22 Gy).

Results

Follow-up imaging demonstrated therapeutic control in 23 (72%) of 32 tumors at a mean follow-up period of 27.6 months (range 6.1–72.8 months). Progression-free survival after the initial SRS was 78.4%, 55.5%, and 41.6% at 1, 2, and 3 years, respectively. Factors associated with a longer PFS included patients without spinal metastases (p = 0.033) and tumor volumes < 2.2 cm3 (median tumor volume 2.2 cm3, p = 0.029). An interval ≥18 months between RT and SRS was also associated with longer survival (p = 0.035). The distant tumor relapse rate despite RT and SRS was 33.6%, 41.0%, and 80.3% at 1, 2, and 3 years, respectively. Factors associated with a higher rate of distant tumor relapse included patients who had spinal metastases before RT (p = 0.037), a fourth ventricle tumor location (p = 0.002), and an RT to SRS interval < 18 months (p = 0.015). The median survival after SRS was 27.6 months (95% CI 19.33–35.87 months). Overall survival after SRS was 85.2%, 53.2%, and 23.0% at 1, 2, and 3 years, respectively. Adverse radiation effects developed in 2 patients (9.5%).

Conclusions

Stereotactic radiosurgery offers an additional option beyond repeat surgery or RT in pediatric patients with residual or recurrent ependymomas after initial management. Patients with smaller-volume tumors and a later recurrence responded best to radiosurgery.

Abbreviations used in this paper: ARE = adverse radiation effect; GTR = gross-total resection; OS = overall survival; PFS = progression-free survival; RT = radiation therapy; SRS = stereotactic radiosurgery; STR = subtotal resection.

Article Information

Address correspondence to: L. Dade Lunsford, M.D., Department of Neurological Surgery, University of Pittsburgh, UPMC Presbyterian, 200 Lothrop Street, Suite B-400, Pittsburgh, Pennsylvania 15213. email: lunsfordld@upmc.edu.

© AANS, except where prohibited by US copyright law."

Headings

Figures

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    Kaplan-Meier plot showing OS from the time of initial diagnosis (upper) and from the time of SRS (lower) in pediatric patients with intracranial ependymomas.

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    Kaplan-Meier plot showing PFS (upper) and distant tumor relapse (lower) after radiosurgery.

References

1

Afra DMüller WSlowik FWilcke OBudka HTuroczy L: Supratentorial lobar ependymomas: reports on the grading and survival periods in 80 cases, including 46 recurrences. Acta Neurochir (Wien) 69:2432511983

2

Aggarwal RYeung DKumar PMuhlbauer MKun LE: Efficacy and feasibility of stereotactic radiosurgery in the primary management of unfavorable pediatric ependymoma. Radiother Oncol 43:2692731997

3

Calvo FAHornedo Jde la Torre ASachetti AArellano AAramburo P: Intracranial tumors with risk of dissemination in neuroaxis. Int J Radiat Oncol Biol Phys 9:129713011983

4

Ernestus RISchröder RStützer HKlug N: Prognostic relevance of localization and grading in intracranial ependymomas of childhood. Childs Nerv Syst 12:5225261996

5

Figarella-Branger DGambarelli DDollo CDevictor BPerez-Castillo AMGenitori L: Infratentorial ependymomas of childhood. Correlation between histological features, immunohistological phenotype, silver nucleolar organizer region staining values and post-operative survival in 16 cases. Acta Neuropathol 82:2082161991

6

Goldwein JWGlauser TAPacker RJFinlay JLSutton LNCurran WJ: Recurrent intracranial ependymomas in children. Survival, patterns of failure, and prognostic factors. Cancer 66:5575631990

7

Goldwein JWLeahy JMPacker RJSutton LNCurran WJRorke LB: Intracranial ependymomas in children. Int J Radiat Oncol Biol Phys 19:149715021990

8

Grabb PALunsford LDAlbright ALKondziolka DFlickinger JC: Stereotactic radiosurgery for glial neoplasms of childhood. Neurosurgery 38:6967021996

9

Healey EABarnes PDKupsky WJScott RMSallan SEBlack PM: The prognostic significance of postoperative residual tumor in ependymoma. Neurosurgery 28:6666721991

10

Hodgson DCGoumnerova LCLoeffler JSDutton SBlack PMAlexander E III: Radiosurgery in the management of pediatric brain tumors. Int J Radiat Oncol Biol Phys 50:9299352001

11

Horn BHeideman RGeyer RPollack IPacker RGoldwein J: A multi-institutional retrospective study of intracranial ependymoma in children: identification of risk factors. J Pediatr Hematol Oncol 21:2032111999

12

Jawahar AKondziolka DFlickinger JCLunsford LD: Adjuvant stereotactic radiosurgery for anaplastic ependymoma. Stereotact Funct Neurosurg 73:23301999

13

Kano HNiranjan AKondziolka DFlickinger JCLunsford LD: Outcome predictors for intracranial ependymoma radiosurgery. Neurosurgery 64:2792882009

14

Krieger MDMcComb JG: The role of stereotactic radiotherapy in the management of ependymomas. Childs Nerv Syst 25:126912732009

15

Liu AKForeman NKGaspar LETrinidad EHandler MH: Maximally safe resection followed by hypofractionated reirradiation for locally recurrent ependymoma in children. Pediatr Blood Cancer 52:8048072009

16

Lyons MKKelly PJ: Posterior fossa ependymomas: report of 30 cases and review of the literature. Neurosurgery 28:6596651991

17

Massimino MGiangaspero FGarrè MLGenitori LPerilongo GCollini P: Salvage treatment for childhood ependymoma after surgery only: pitfalls of omitting “at once” adjuvant treatment. Int J Radiat Oncol Biol Phys 65:144014452006

18

Merchant TEBoop FAKun LESanford RA: A retrospective study of surgery and reirradiation for recurrent ependymoma. Int J Radiat Oncol Biol Phys 71:87972008

19

Moss SDRockswold GLChou SNYock DBerger MS: Radiation-induced meningiomas in pediatric patients. Neurosurgery 22:7587611988

20

Perilongo GMassimino MSotti GBelfontali TMasiero LRigobello L: Analyses of prognostic factors in a retrospective review of 92 children with ependymoma: Italian Pediatric Neuro-Oncology Group. Med Pediatr Oncol 29:79851997

21

Pollack IFGerszten PCMartinez AJLo KHShultz BAlbright AL: Intracranial ependymomas of childhood: longterm outcome and prognostic factors. Neurosurgery 37:6556671995

22

Reni MGatta GMazza EVecht C: Ependymoma. Crit Rev Oncol Hematol 63:81892007

23

Rezai ARWoo HHLee MCohen HZagzag DEpstein FJ: Disseminated ependymomas of the central nervous system. J Neurosurg 85:6186241996

24

Rosenblum MK: Ependymal tumors: a review of their diagnostic surgical pathology. Pediatr Neurosurg 28:1601651998

25

Rousseau PHabrand JLSarrazin DKalifa CTerrier-Lacombe MJRekacewicz C: Treatment of intracranial ependymomas of children: review of a 15-year experience. Int J Radiat Oncol Biol Phys 28:3813861994

26

Schiffer DChiò ACravioto HGiordana MTMigheli ASoffietti R: Ependymoma: internal correlations among pathological signs: the anaplastic variant. Neurosurgery 29:2062101991

27

Stafford SLPollock BEFoote RLGorman DANelson DFSchomberg PJ: Stereotactic radiosurgery for recurrent ependymoma. Cancer 88:8708752000

28

Stavrou TBromley CMNicholson HSByrne JPacker RJGoldstein AM: Prognostic factors and secondary malignancies in childhood medulloblastoma. J Pediatr Hematol Oncol 23:4314362001

29

Vinchon MLeblond PNoudel RDhellemmes P: Intracranial ependymomas in childhood: recurrence, reoperation, and outcome. Childs Nerv Syst 21:2212262005

30

Weprin BEHall WACho KHSperduto PWGerbi BJMoertel C: Stereotactic radiosurgery in pediatric patients. Pediatr Neurol 15:1931991996

31

Zoeller GKBrathwaite CDSandberg DI: Malignant transformation of an optic pathway glioma without prior radiation therapy. Case report. J Neurosurg Pediatr 5:5075102010

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