The risks of metastases from shunting in children with primary central nervous system tumors

Abstract

The authors reviewed the hospital charts of 415 pediatric patients treated for benign or malignant primary brain tumors over the past 20 years at the Children's Hospital Medical Center, Seattle. Patients' ages ranged from the neonatal period to 18 years. A shunt was placed in 152 patients (37%), 45 before and 94 after surgery. Confirmation of extraneural metastases was based on clinical and diagnostic examination. Factors analyzed as possibly influencing the occurrence of extraneural metastases were: 1) the shunt: type, valve, location, filter, and revisions; 2) extent of resection; 3) pathology; and 4) treatment regimen. Eight of the 415 patients developed extraneural metastases during life. All eight patients had a medulloblastoma (cerebellar primitive neuroectodermal tumor). These eight patients were separated into Group A (without a shunt) and Group B (with a shunt). In Group A (five patients), the mean interval from primary diagnosis to metastasis was 15 months. Two children had gross total resection of the tumor. The predominant location of metastases in Group A was: bone (two cases); cervical lymph nodes (one); lung/bone (one); and retroperitoneal pelvic mass (one). Three Group A patients had a simultaneous central nervous system (CNS) recurrence. Of the three Group B patients, two had a ventriculoperitoneal (VP) shunt and one a ventriculoatrial (VA) shunt; all were placed postoperatively. One Group B patient had a simultaneous CNS recurrence. No shunt revisions were performed in these three patients. The mean time from primary diagnosis to metastasis was 25 months. One patient had a total tumor resection. The predominant location of metastases was bone (one case), retroperitoneal pelvic mass (one), and abdominal cavity with ascites (one case). Only one patient in the entire series had a filter placed; this resulted in shunt obstruction and was removed 1 month following placement. It is concluded that cerebrospinal fluid shunts, regardless of type, location, revision rate, or filter insertion, do not predispose pediatric patients with brain tumors to develop extraneural metastases. A diagnosis of shunt-related metastases should be based on the development of intra-abdominal (VP shunt) or pulmonary (VA shunt) dissemination primarily with or without additional sites. The diagnosis of medulloblastoma is an important factor related to metastasis occurrence while the extent of resection and postoperative therapy are not influential.

Outcomes of Surgery and Craniospinal Radiotherapy for Adult Patients with Medulloblastoma

“…Most frequently bone and bone marrow involvements are observed. [28] In our patients, no distant metastasis was detected.…”

Pinealoblastoma with Shunt IVletastasis: A Case Report

“…This is especially true in cases of intraperitoneal metastases , in which meningeal dissemination has been documented in virtually every patien t. Once peritoneal metastases develop , they may or may not be associated with ascites(5) Berger et al (1) reported that no children with extraneural metastases developed ascites in the absence of a VP shunt and that pineal germ -cell tumors had a slightly increased incidence of abdominal dissemination with a VP shunt in place. Paine et al (6) found in 12 cases of germinomas with VP shunt metastasis that the principal site of VP shunt metastasis was related to the site of the distal aspect of the shunt tube , involving the peritoneal , retroperitoneal , and pelvic cavities.…”

Role of ventriculoperitoneal shunting in patients with neoplasms of the central nervous system: An analysis of 59 cases

“…This issue is further complicated by the fact that a number of late-and end-stage brain cancer patients are in an immunocompromised state, due to leukopenia from myelosuppression following prior chemotherapy, or secondary to steroid treatment for edema control, which may lead to additional complications. Such frail patients are also at increased risk from anesthesia and may be at an increased risk of surgery-or shunt-related complications (18,40,44,45).…”

“…However, despite the fact that it is considered a minor invasive procedure, it does involve certain risks, such as hemorrhage, shunt malfunction, or infection (19)(20)(21); in addition, it may rarely result in peritoneal carcinomatosis due to seeding from the central nervous system (CNS) tumors (22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39). Nevertheless, not all studies have encountered peritoneal seeding via VPS (16,30,40).…”