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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 111-116

Platform Presentation

Date of Web Publication21-Apr-2022

Correspondence Address:
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJNO.IJNO_1004_21

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How to cite this article:
. Platform Presentation. Int J Neurooncol 2021;4:111-6

How to cite this URL:
. Platform Presentation. Int J Neurooncol [serial online] 2021 [cited 2022 May 17];4:111-6. Available from: https://www.Internationaljneurooncology.com/text.asp?2021/4/2/111/343562

MR techniques in grading of meningiomas

Gopal Krishna, Seema Rohilla, HK Garg, Ishwar Singh, Rohtas Yadav, Dhara B Dhaulakhandi; PGI Rohtak

Objectives: The advanced MR techniques, Perfusion weighted imaging and Apparent Diffusion Coefficient (ADC) were studied to grade meningiomas. The relative Cerebral Blood Volume (rCBV) and Apparent Diffusion Coefficient (ADC) values may provide accurate diagnosis in the differentiation of different grades of meningiomas. This may be relevant in the planning of surgical excision and postoperative adjuvant radio/chemotherapy. The aspects of molecular genomic and quantitative proteomic techniques along with spectroscopic technologies which may supplement the grading of meningiomas were also studied.

Materials and Methods: Thirty-five patients with meningioma were prospectively studied using conventional MR sequences followed by Diffusion Weighted (DW) imaging having b value of 1000 (minimum ADC values used for analysis). Then, gadobenate dimeglumine/meglumine gadoterate was administered (0.1 mmol/ kg at a rate of 4 mL/s) followed by saline flush (20 mL at a rate of 4 mL/s). Next, T2*W/FFE dynamic images were acquired; dynamics showing maximum fall in intensity was used for creating rCBV and relative Cerebral Blood Flow (rCBF) maps and calculating rCBV.

Results: Both maximum rCBV and minimum ADC within the tumor were not significant for differentiating benign from malignant meningiomas. A cut-off maximum rCBV of 2.5 mL/100 g in peritumoral edema was 75% sensitive, 84.6% specific, and 83.3% accurate in differentiating benign from malignant meningiomas.

Conclusion: Benign and malignant meningiomas can be differentiated based on maximum rCBV in peritumoral edema but ADC values within the tumor are insignificant in differentiating benign and malignant tumors. rCBV values within tumor, however, may be helpful in subtyping meningiomas, especially transitional and meningothelial meningiomas.

Patterns of invasion in glioblastoma have unique radiological features: Varied response to radiotherapy and long-term outcomes

Uday Krishna AS, Ashwini Nargund, Shija Merrin Mathew, Vani Santosh, Naveen T, Dwarkanath Srinivas, V Lokesh; Kidwai Memorial Institute of Oncology

Objective: The aim of this study was to assess the correlation of the three patterns of invasion of glioblastoma (GB) with the respective MRI features, response to radiotherapy, and disease-free survival

Materials and Methods: Histopathology of 62 patients with GB who had undergone maximal safe resection (MSR)/stereotactic biopsy (STB) and referred for adjuvant therapy was reviewed to assess the pattern of invasion. Three patterns were observed: single-cell infiltration, perineuronal satellitosis, and perivascular spread (vessel cooption); majority also had diffuse infiltration patterns in the background. The pre- and postoperative MRI scans were utilized for RT planning of 3DCRT/IMRT/VMAT, the modality decided by the treating oncologist. RT volumes were as per ESTRO-ACROP guidelines. Duration of radiotherapy––the Stupp regimen or a short course of hypofractionated radiotherapy (HFRT) (35Gy/10Fr- planned gap––completion of total dose) was based on the extent of resection (EOR) and KPS at the time of RT. Correlation of the pattern of invasion, MRI characteristics of each on the response to radiotherapy as assessed by RANO criteria, and survival were analyzed with the help of SPSS V21.

Results: MRI findings after stratification of 62 patients, median age 43 years (18–70), M:F::42:20) into type 1:17, type 2:21 and type 3:24- patterns of invasion, were cortical tumors (subtle enhancement) close to SVZ, solid (+/- cystic) lesion in the eloquent cortex or large mass effect crossing the barriers respectively. Among pattern 1, those patients with IDH mutant (40%) and mean dose to C/L SVZ of 30Gy or more had longer DFS at 1 year (70% vs. 29% , P < 0.05). In pattern 2, EOR (MSR/ less) showed a better DFS at 1 year, however without statistical significance. In pattern 3, 58% of patients had post op KPS of <80 and 45% of them underwent HFRT. HFRT in patients with KPS<80 showed higher CR/PR rates compared to the conventional RT. HFRT in low KPS with mMGMT showed higher CR rates (71% vs. 29%) as compared with 40% CR in KPS>80 group unmethylated MGMT. Stable disease and completion of planned adjuvant therapy in pattern three patients was seen in those after HFRT in poor KPS and conventional RT in KPS>80.

Conclusion: Glioblastoma has three patterns of invasion with unique MRI features and aggressiveness for each. Identification of this may guide the choice of adjuvant therapy, patterns of failure, and therapy resistance

Creating a radiomic signature for H3K27M mutation in midline glioma on multimodal MRI

Manali Jadhav, Priyanka Tupe-Waghmare, Archih Rajan, Abhilasha Indoria, Vani Santosh, Madhura Ingalhalikar, Jitender Saini, Alok Mohan Uppar, Manish Beniwal; Symbiosis Centre for Medical Image Analysis

Objectives: H3K27M mutation in diffuse midline glioma is an independent predictor of overall survival, although it has a very poor prognosis. Identification of the mutation using conventional radiological analysis has been found to be difficult and unreliable, whereas the deep location of the tumors in the brain makes biopsy challenging with a substantial risk of morbidity. To alleviate these issues, our work employs radiomics-based machine-learning framework to predict the H3K27M mutation from multi-modal MRI.

Materials and Methods: Retrospective MRI data of 46 patients detected with midline glioma were collected among which 23 patients were H3K27M mutant (average age = 29.9±17, M:F = 8:15) and 23 patients were H3K27M wildtype (average Age = 30.3±16.2, M:F = 14:9). Immunohistochemical staining was performed using the Ventana Benchmark automated staining system to detect the histone H3K27M mutation. The antibody used for identifying the H3K27M mutation was H3K27me3 (Millipore, 07-449; 1:100) (H3.3K27Mme3, Medaysis, RM192, 1:100). The MRI data for all the subjects were acquired on Philips and Siemens scanners (1.5 Tesla and 3 Tesla) and T1WCE, FLAIR, T2W, and DWI-generated ADC maps were used for analysis. Preprocessing included the following steps: NIFTI format conversion, registration of all modalities to T1WCE, and brain extraction using FSL_BET. Followed by automated segmentation into tumor enhancement, edema and necrosis using a U-net and were then manually corrected. Total 1548 radiomic features were extracted using PyRadiomics 2.2.0 library. Ten best features were selected after performing a first-level feature selection (standard t test) and second-level feature reduction by using ANOVA F-values within the training set. Tenfold random forest model was applied.

Results: The average 10-fold cross-validation accuracy was 91%. The precision, sensitivity, and specificity for H3K27M wildtype were 0.62, 0.71, and 0.57 and for H3K27M mutant were 0.67, 0.57, and 0.71, respectively. The top 10 features were extracted and these features included Gray Level Size Zone Matrix (GLSZM) and first-order features from edema region on T2 and FLAIR images and Gray-Level Co-occurrence Matrix (GLCM) and first-order features from T1CE necrosis and enhancement.

Conclusion: Identifying H3K27M status non-invasively from the first MRI scan with such superior accuracy provides evidence that such techniques can be translated to clinical workflow for prognosis and can support consequent tailored treatment planning and therapeutic intervention for improved outcomes. Further validation on larger datasets as well as prospective validation is vital.

Deep learning-based prediction of H3K27M mutation in midline gliomas on multimodal MRI

Priyanka Tupe-Waghmare, Richa Chauhan, Karthik Kulanthaivelu, Maya Bhatt, Piyush Malpure, Manali Jadhav, Abhilasha Indoria, Jitender Saini, Vani Santosh, Madhura Ingalhalikar; Symbiosis Institute of Technology

Objectives: In midline gliomas, patients with H3K27M mutation have poor prognosis and shorter median survival. Moreover, since these tumors are located in deep locations biopsy can be challenging with a substantial risk of morbidity . Our work proposes a non-invasive deep learning-based technique on pre-operative multi-modal MRI to detect the H3K27M mutation. Results demonstrate a testing accuracy of 69.76% on 51 patients. Overall, our preliminary results provide a testimony that multimodal MRI can support identifying H3K27M mutation and with further larger studies can be translated to clinical workflow.

Materials and Methods: Fifty-one subjects with midline gliomas (mutant: n = 28, age=33.39±16.70, M/F=16/12; wildtype: n = 23, age=25.29±13.88, M/F:13/10) were considered for the study that was approved by institutional ethical committee. Pre-processing included brain extraction, inhomogeneity correction and intensity normalization followed by intra-subject affine registration using ANTS and tumor segmentation that was performed using a U-net proposed by Isensee et al. and later corrected manually. The dataset was divided into a training cohort (22 mutant, 18 wildtype) and testing cohort (6 mutant, 5 wildtype). FLAIR, T1ce and T2 modalities were stacked together after pre-processing followed by image augmentation. The CNNs were applied on a boxed region around the tumor for each 2D-axial slice consisting of the tumor . We implemented a novel 23 layered architecture containing 8 convolutional layers, 5 dropouts, 8 max-pool and 2 dense layers. The learning rate started from 0.0003 and then was decreased as the learning progressed by observing the test errors. Multiple CNN architectures (VGG16, Xception, ResNet50 and DenseNet121) were also trained/tested for comparison. For the classifier with best performance, we computed class activation maps (CAMs) from the last convolutional layer using the method by Zhou et al.

Result: Performance of our model (training acc-71.87%, test acc- 69.76% F1 score 0.69) was superior to other standard models. VGG16 performed poorly (training acc- 58.4%) on unseen data and performance of DenseNet121 (training acc- 56.7%) degraded due to overfitting. ResNet50 gave a better performance with training accuracy of 64.42% and F1 score of 0.59.

Conclusion: Our study illustrates the feasibility of employing deep neural nets to identify H3K27M mutation in midline gliomas. Deep models can rapidly test new subjects when compared to radiomics-based models that are computationally expensive and take long time for computing the textures. Identifying H3K27M status non-invasively from the first MRI scan is crucial for consequent tailored treatment planning and therapeutic intervention for improved outcomes.

Integrative molecular characterization of pediatric spinal ependymoma

Anbarasu Lourdusamy, Omar Ahmad, Rebecca Chapman, Lisa C. Storer, Li Luo, Paul R. Heath, Linda Resar, Kenneth J. Cohen, Richard G. Grundy, Anbarasu Lourdusamy; University of Nottingham

Objectives: Pediatric spinal ependymomas are rare primary central nervous system tumors with heterogeneous clinical course. Considering that ependymomas in children are biologically distinct from their adult counterparts, this study aimed to define the molecular landscape of spinal ependymomas in children.

Materials and Methods: In this retrospective study, we have collected tumor samples from 27 spinal ependymoma patients younger than 18 years and carried out the histological review, DNA methylation and gene expression profiling.

Results: Unsupervised analyses with methylation profiles revealed two subgroups where all Grade I tumors (n = 11) were in Group-1, but the Grade II/III tumors split into two groups (n = 7 in Group-1 and n = 9 in Group-2). The Heidelberg classifier assigned Group-1 tumors as spinal myxopapillary ependymomas (SP-MPE), 5 Group-2 tumors as spinal ependymomas (SP-EPN) and failed to classify 4 Group-2 tumors. Copy numbers derived from DNA methylation arrays revealed subgroup-specific genetic alterations and showed that SP-EPN tumors lack MYCN amplification. Gene expression profiling revealed distinct transcriptomic signatures, including overexpression of genes involved in oxidative phosphorylation in SP-MPE that were validated by Western blot analysis. We discovered widespread decreases in DNA methylation at enhancer regions that associated with expression of oncogenic signaling pathways in SP-MPE. Furthermore, transcription factor motifs for master regulators, including HNF1B, PAX3 and ZIC3, were significantly overrepresented in probes specific to distal regulatory regions in SP-MPE.

Conclusions: Our findings show substantial heterogeneity in pediatric spinal ependymoma and uncover novel enhancers and transcriptional pathways specific to the SP-MPE subgroup, providing a foundation for future therapeutic strategies.

BRAF V 600E mutation in pleomorphic xanthoastrocytoma: Correlation with clinicopathological findings and outcomes

Edmond Jonathan Gandham, Daniel Beno, Rekha Pai, Rajesh Balakrishan, Anita Jasper, Mahasampath Gowri, Ranjith K Moorthy, Ari George Chacko, Geeta Chacko; Christian Medical College, Vellore, Tamil Nadu, India

Aim: To study the expression of BRAF V 600E mutation and clinicoradiological outcomes after treatment in patients with pleomorphic xanthoastrocytoma (PXA).

Material and methods: Thirty-three cases of PXA operated between 2007 and 2020, with adequate tissue blocks, were identified from our database. Demographic and clinical data were retrospectively collected from our database and a radiologist reviewed preoperative and postoperative images for preoperative radiological factors, extent of excision and disease recurrence to determine the progression free survival (PFS) and overall survival (OS). Anaplastic PXAs (APXAs) received radiation (RT) and temozolomide-based chemotherapy while PXAs without anaplasia received adjuvant RT if subtotally excised. Expression of BRAF V 600E mutation was performed on paraffin blocks using droplet-digital polymerase chain reaction (DD-PCR) and Sanger sequencing.

Results: There were 20 PXAs (60%) and 13 (40%) APXAs. The median age at diagnosis was 22 years (range 8-52) and the majority were males (n-23; 70 %). 72% presented with seizures. Overall BRAFV600E mutations were noted in 10 of 33 (30%) patients; 8 of 20 (40%) PXAs and 2 of 13 (15%) APXAs were BRAFV600E mutated. Recurrence was seen in 7/13 (55%) in APXA. There were no recurrences in the PXA group. At median follow-up of 45 months, the OS was 54 months and 33 months PXA and APXA groups respectively (p=0.02). The OS in the BRAFV600E mutated patients was 51 months as compared to 41 months in the BRAFV600E non-mutated patients (p=0.364).

Conclusion: BRAFV600E mutation was seen in 40% of the PXAs and 15% of the APXAs. PFS and OS were significantly higher in patients with PXA as compared with APXAs. The subset analysis between the PXA with BRAFV600E mutated and PXA without BRAFV600E mutation didn’t reveal any difference in the PFS and OS.

Limbic system: Anatomical and surgical correlates

Abhidha Shah; Seth G.S. Medical College and K.E.M Hospital

Objective: A fiber dissection technique was used to study the various connections of the limbic system.

Materials and Methods: Six previously frozen and formalin-fixed cadaveric human brains were used. The fiber dissection techniques described by Klingler were adopted. The primary dissection tools used were handmade, thin and wooden and curved metallic spatulas. The anatomical understanding was used to operate 55 patients with limbic and paralimbic tumors during the period 2013 to 2020.

Results: The course, length and anatomical relations of all the structures that make up the limbic system are delineated. Four discrete limbic circuits were anatomically delineated. These were the Papez circuit, the dorsal amygdalofugal pathway, the ventral amygdalofugal pathway and the supracallosal circuit. Papez circuit begins in the hippocampus, continues into the fornix to reach the mamillary body. From there the mamillothalamic tract continues to the anterior nucleus of the thalamus, which in turn connects to the cingulum by means of the anterior thalamic radiations. The cingulum courses around the corpus callosum to end in the entorrhinal cortex which then projects to the hippocampus. The stria terminalis constitutes the dorsal amygdalofugal pathway. The ventral amygdalofugal pathway connects the amygdala with the ventral striatum. The supracallosal circuit consists of the induseum grisium and connects the septal region to the hippocampal formation. All the patients were operated upon succesfully. None of the patients developed any added neurological deficits. Two patients with medial temporal gliomas had recurrences and were re-operated.

Conclusions: Dissection of the brain delineates the anatomical details of the limbic system clearly and assists in providing a three dimensional perspective of the limbic system. Intricate knowledge of the anatomy of this part of the brain aids the neurosurgeon while performing epilepsy surgeries, limbic and paralimbic glioma surgery, pyschosurgery and while approaching various lateral ventricular and third ventricular tumors.

“En-masse” tumor resection strategy for tumors arising from short arcuate fibers

Atul Goel; Seth G.S. Medical College and K.E.M Hospital

Objective: We evaluate the feasibility of surgical strategy of ‘en-masse’ resection for low-grade gliomas arising from the short arcuate fibers.

Materials and Methods: We retrospectively evaluated our series of 74 patients with low grade gliomas involving the short arcuate fibers and who were operated between the years 2016 to June 2019. The tumor resection was done on the premise that gliomas arise from and grew along a specific white fiber tract and the expanding tumor displaced but did not transgress the border formed by adjoining tracts. Although modified as per the situation, an en-masse tumor resection strategy was the basis of surgical resection. Intra-operative motor cortical and subcortical mapping was performed in 14 cases. Awake surgery was performed in 11 patients.

Results: There were 46 males and 28 females. Total/ supratotal tumor resection was achieved in 62 (83.8 %) patients. Forty-seven patients had an essentially en-masse tumor resection. Seventy-one patients improved in their pre-operative complaints. The follow-up ranged from 11 to 56 months. Sixty-two patients who underwent a total or supratotal resection were not given any adjuvant treatment. Twelve patients with subtotal resection were subjected to adjuvant radiotherapy with or without additional chemotherapy.

Conclusions: En-masse tumor resection on the basis of understanding that gliomas arise from and extend along the course of named white fiber tracts and have an expansible growth pattern was successful in performing a safe and radical tumor removal.

Treating glioblastoma with VMAT-based radiation therapy and temozolomide: Can we improve disease outcomes?

Kushal Narang, Tejinder Kataria, Shyam Singh Bisht, Deepak Gupta, Karrthick KP; Medanta The Medicity

Objective: Glioblastoma is universally fatal despite aggressive treatment. However, recent outcomes with advanced treatment techniques have been marginally better than the standard of care Stupp trial. We report our experience using Volumetric Modulated Arc Therapy (VMAT) along with concurrent and adjuvant Temozolomide, with early usage of salvage options for disease progression.

Materials and Methods: A prospectively maintained dataset of adult Glioblastoma patients, treated with maximal safe resection and adjuvant VMAT and Temozolomide, was analyzed. Patients underwent post-operative MRI and radiation planning scans within three weeks of surgery. Target delineation was in accordance with Radiation Therapy Oncology Group (RTOG) guidelines. The T2-FLAIR abnormality with a 2-cm margin (Clinical Target Volume 1; CTV1) was treated to 46 Gy, and the T1-contrast volume with margin (CTV2), up to 60 Gy. Planning Target Volume (PTV) was between 3 and 5 mm. However, CTV1 coverage with 54 to 60 Gy isodose was always attempted, while adequately respecting normal tissue constraints. Temozolomide was administered 30-45 minutes before radiation. Image guidance was used daily. Acute radiation side-effects were stringently monitored. Adjuvant Temozolomide was administered for 6 cycles. In case of severe hematological toxicity or early disease progression, Temozolomide was switched to a metronomic schedule of 75 mg/m2 per day, seven days on and seven days off. Contrast-enhanced MRI, spectroscopy, diffusion and perfusion studies were performed three-monthly. Salvage options including re-surgery, re-irradiation or second-line systemic agents were utilized, based on patient’s clinical condition and molecular characteristics of the tumor.

Results: 266 histologically proven Glioblastoma patients, sequentially treated between September 2010 and December 2018 were analyzed. Median age was 54 years (range 18 to 79 years). MGMT methylation was present in 79/126 (62.7%) specimens, and IDH mutation in 46/78 (59%). With a median follow-up of 15 months (range 1 to 118 months), the 2-year and 5-year PFS was 17% and 5.8%, and 2-year and 5-year OS was 51.1% and 19.6%, respectively. Grade III / IV hematological toxicity was evident in 16/266 (6%) patients. Disease progression was documented in 231 (86.8%) cases. After progression, re-surgery was utilized in 58 (25.1%), re-irradiation in 72 (31.1%), chemotherapy in 133 (57.6%), and all three modalities in 27 (11.7%) patients. Best supportive care alone was used for 74 (32%) patients. The 2-year and 5-year OS after progression was 18.7% and 6.7%, respectively.

Conclusion: Appropriate delivery of high-quality conformal radiation using VMAT and early salvage of progression can help attain favorable long-term outcomes for Glioblastoma.

Seizure outcome of mesial temporal lobe epilepsy surgery for low-grade glioma: Tailored lesionectomy with or without anteromesial temporal lobe resection

Raiyani Vandan, Sardhara Jayesh, Singh Suyash, Behari Sanjay; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, Uttar Pradesh, India

Objective: Mesial temporal lobe epilepsy attributed to low-grade glioma is known for intractable seizures and choice of surgery range from lesionectomy(Lo) to lesionectomy with anteromesial temporal resection(L0+AMTR) is still debatable. We intend to analyze the seizure outcome after lesionectomy alone or with AMTR.

Materials and Methods: Retrospective analyses of patients operated for medial low-grade temporal lobe tumors with seizures were included in study. Preoperative records includes video-EEG, ECOG, MRI(epilepsy protocol), and neuropsychological evaluation for language, memory, and dominance were assessed. Two groups{Lo(group I) and Lo+AMTR(group II)} were assessed after surgery by the international league against epilepsy(ILAE) seizure outcome scale.

Results: Total 39 patients underwent Lo(n = 20) and Lo+AMTR(n = 19) with mean age 26.92 + 12.96 months, and mean duration of seizures was 36.87 46.76 months. Total 23 patients had long-term intractable seizures for >1 year despite of >2 drugs{(Group I(n = 10), Group II(n = 13)}; remaining 16 had frequent seizures of <1year duration. In the postoperative period, on a mean follow-up of 49.72 + 34.10 months, the ILAE outcome scale shown significant difference{p=0.05} in seizure outcome between two groups. 4(40%) patients out of 10 having refractory seizures in group I and 8(80%) from the group-II out of 10 patients could achieved ILAE class-1 outcome after surgery. Histopathology analysis includes low-grade astrocytoma (n = 29) and in 2 patients there were associated CA1 neuronal loss in hippocampus, 1 patient had mesial temporal sclerosis from group II attributed to its intractability in seizures.

Conclusion: For the mesial temporal low-grade glioma presenting with seizures, the seizure outcome by lesionectomy with AMTR is superior than lesionectomy only.

Surgical technique and outcome of the intradural spinal tumor excision using minimally invasive tubular retractor system: My experience with 100 cases

Abhaya Kumar; Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Objectives: Conventionally, intradural spinal tumor excision requires longer skin incision, bilateral subperiosteal muscle stripping, and total laminectomy, thereby decreasing the stability of the spine and increasing the morbidity. Minimally invasive surgery using the tubular retractor system for intradural spinal tumor excision preserves the posterior supporting structures of the spine in the midline and on the contralateral side and decreases morbidity and achieves the resection of the tumor. The objective of this study and presentation is to analyze the surgical technique and outcome of intradural spinal tumor excision using minimally invasive tubular retractor system. I would also like to share the review of literature on the same.

Materials and Methods: A retrospective and prospective study was conducted in patients admitted with intradural spinal tumors who had undergone tumor excision using minimally invasive tubular retractor system and satisfied the inclusion and exclusion criteria. Intradural tumors involving one or two vertebral levels were included in the study. Intramedullary spinal tumor and intradural tumor involving more than two vertebral levels were excluded from the study. The study included the data of the 100 patients, who were operated between May 2010 and October 2020. The steps involved in the surgical technique, extent of resection, intraoperative blood loss, duration of surgery, postoperative complications, duration of stay after the surgery, and postoperative X-ray and MRI were analyzed. Post-op pain and mobilization were noted for analysis.

Results: Out of 100 patients, only two cases were converted to open laminectomy and excision due to increased bleeding from the tumor. Both of them were Meningioma. The histopathology of these cases was meningioma (26), schwannoma (48), ependymoma (11), Pilocytic astrocytoma (10), Dermoid (2), and neurenteric cyst (3). The age group is of 16–70 years . There were cervical-18 thoracic-31 and 51 lumbar tumors. We used tubular retractors with diameter ranging from 22 mm to 30 mm . Expandable retractors were used in 84 cases and nonexpandable in 16 cases . The tumor size (craniocaudal) was ranging from 8 mm to 43 mm. Intraoperative blood loss was 75–200 ml. Gross total resection was achieved in 88 cases and near-total resection in 12 cases. Dura was closed using staplers in all the cases except in two cases. Fibrin sealant was used in all cases. No patient had Cerebrospinal fluid leak or pseudomeningocele. One patient developed suture site infection. VAS for pain, sensory symptoms, Nurick's grade for myelopathy, and MRC grading for power were improved in all the affected patients. Postoperative X-ray showed preserved spinous process and facet joints in all cases. The duration of the hospital stay was ranging from 2 days to 11 days (mean: 6 days).

Conclusions: Posterior or Posterior laterally placed intradural spinal tumors confined to the spinal canal involving one or two vertebral levels can be excised safely and effectively using tubular retractor system, with adding the advantages of the MIS surgery.

Treatment outcome and lessons learned from the management of WHO grade II pediatric intramedullary ependymoma over a decade: Experience from a tertiary care centre

Ved Prakash Maurya, Sanjay Behari, Awadhesh Kumar Jaiswal, Arun Kumar Srivastava, Jayesh Sardhara, Kamlesh Singh Bhaisor; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, Uttar Pradesh, India

Objectives: Intramedullary ependymoma is rare primary tumors in pediatric population as compared to their adult counterpart. WHO grade II pediatric intramedullary ependymoma (PIME) is commonest in frequency though less discussed pathological grade. The occurrence of these tumors along the spinal cord depends on age groups and histological subtypes. This study aimed to share the clinical experience and management outcome of grade II PIME from a tertiary care centre over the period of last ten years.

Materials and Methods: The clinico-radiological details of all histologically proven, newly diagnosed primary pediatric intramedullary ependymoma who underwent management were collected. Recurrent lesions and other spinal cord tumors were excluded. Specific details included: documentation of symptom complex such as intensity of pain at presentation, neurocutaneous stigmata and associated orthopedic deformity (if any) at the time of admission and subsequent follow-up visits at 6 weeks, 6 months and later on yearly basis as per the department policy. Patients with urinary complaints at the time of admission were subjected to urodynamic studies to rule out associated urological disorder. Patients who become symptomatic at the time of growth spurts were evaluated for associated thickened filum terminale. The data were analyzed by using appropriate statistical tests.

Results: The mean age of the study population was 16.3–4.0 years. In our study, mean and median follow-up period was 42.1 months and 31.0 months (range of 2–126 months). The mean survival time of the patients was 119.11 months ( 95% CI= 106, 132). The male to female ratio was 2:1. Pain was noticed in 14 patients [14/18(77.8%)] and 4(22.2%) patients were ambulant at the time of admission. 15(83.3%) patients undergone total excision and subtotal excision was achieved in three patients. After surgical decompression of tumor, there was significant improvement in the modified McCormick’s grade, when median score compared between preoperative period and last follow-up visits [4(2.8-4) Vs. 2(2-3), P= 0.001]. There was one surgical mortality with two symptomatic recurrence after surgical resection.

Conclusions: This study emphasizes early maximal safe resection for the symptomatic patient to achieve a better outcome. Molecular and genetic makeup of the histological subtypes play vital role in deciding the morphology of tumor and recurrence-free survival. Age, gender and vertical extension of tumor have a debatable impact on the overall outcome in PIME.


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