Tumor control after surgery for spinal myxopapillary ependymomas: distinct outcomes in adults versus children

Feldman, William B.; Clark, Aaron J.; Safaee, Michael; Ames, Christopher P.; Parsa, Andrew T.

doi:10.3171/2013.6.spine12927

Cited by 91 publications

(68 citation statements)

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“…The total recurrence rate was 15.5% in 232 patients who underwent complete resection, compared with 32.6% in 135 patients who underwent partial resection. 9 Though not exclusively MPEs, in 31 cases of spinal ependymomas Chang et al also found a correlation between extent of resection and PFS. 6 Neither of these studies, however, differentiated between gross-total removal with capsular violation (en bloc) and GTR.…”

Section: Discussionmentioning

confidence: 99%

“…2,5,15 In the large systematic analysis by Feldman et al, radiotherapy did not improve the overall tumor recurrence regardless of the extent of resection. 9 In our study, no patient with an en bloc resection underwent adjuvant radiotherapy. Of those with capsular violation (GTR or STR), we did find a trend of lower recurrence rates (16.7% vs 31.6%, p = 0.43) and longer PFS at 5 years (83.3% vs 49.9%, p = 0.16) in patients who received adjuvant radiotherapy.…”

Section: Fig 2 Influence Of Extent Of Resection On Pfs Kaplan-meiementioning

confidence: 99%

“…The role of adjuvant radiation therapy remains controversial in MPE. Some authors did not find a beneficial role for radiotherapy regardless of extent of resection, 9 while others successfully used adjuvant radiotherapy to reduce the rate of tumor progression. 2,5,15 In the large systematic analysis by Feldman et al, radiotherapy did not improve the overall tumor recurrence regardless of the extent of resection.…”

Section: Fig 2 Influence Of Extent Of Resection On Pfs Kaplan-meiementioning

confidence: 99%

“…5,7,8,15,17,22 MPEs have a male predominance, most commonly presenting in the 3rd or 4th decade of life and often proceeded by a 6-to 24-month history of low-back pain; bladder dysfunction; and motor, sensory, and gait abnormalities. 2,4,9 Magnetic resonance imaging remains the preferred modality to diagnose MPE, as it identifies the tumor and its relation to the surrounding soft tissues and the cauda equina. It also helps detect leptomeningeal spread along the spinal axis.…”

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confidence: 99%

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Outcomes following myxopapillary ependymoma resection: the importance of capsule integrity

Abdulaziz¹,

Mallory²,

Bydon

et al. 2015

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OBJECT While extent of resection has been shown to correlate with outcomes after myxopapillary ependymoma (MPE) resection, the effect of capsular violation has not been well studied. The role of adjuvant radiation also remains controversial. In this paper the authors' goals were to evaluate outcomes following resection of MPE based on intraoperative capsular violation and to explore the role of adjuvant radiotherapy in cases of capsular violation. METHODS A retrospective review of patients undergoing resection of MPE at 2 academic institutions between 1990 and 2013 was performed. Cases with dissemination at presentation, less than 12 months of follow-up, or incomplete records were excluded. Extent of resection was defined as en bloc if all visible tumor was removed without capsular violation, gross-total resection (GTR) if all visible tumor was removed, but with capsular violation, and subtotal resection (STR) if a known residual was left at the time of surgery. Postoperative MR images were reviewed to confirm the extent of resection. Primary outcomes were progression-free survival (PFS) and overall recurrence rates. The effects of extent of resection, capsular violation, and adjuvant radiotherapy on recurrence rates and PFS were analyzed using Kaplan-Meier statistics. Associations between recurrence and preoperative variables were evaluated using Fisher exact methods and t-tests where appropriate. RESULTS Of the 107 patients reviewed, 58 patients (53% were male) met inclusion criteria. The mean age at surgery was 40.8 years (range 7–68 years). The median follow-up was 51.5 months (range 12–243 months). Extent of resection was defined as en bloc in 46.5% (n = 27), GTR in 34.5% (n = 20), and STR in 18.9% (n = 11). No recurrences were noted in the en bloc group, compared with 15% (n = 3) and 45% (n = 5) in the GTR and STR groups. En bloc resection was achieved most frequently in tumors involving the conus. Twelve patients (20%) underwent adjuvant radiotherapy following either STR or GTR. The overall recurrence rate was 13.8% (n = 8), and the 5-year PFS was 81%. Capsular violation was associated with a higher recurrence rate (p = 0.005). Adjuvant radiotherapy showed a nonsignificant trend of lower recurrence rates (16.7% vs 31.6%, p = 0.43) and longer PFS at 5 years (83.3% vs 49.9%, p = 0.16) in cases of capsular violation. CONCLUSIONS A strong correlation between capsular violation and recurrence was found following removal of MPE and should be assessed when defining extent of resection in future studies. Although the use of adjuvant radiotherapy in cases of capsular violation showed a trend toward improved PFS, further investigation is needed to establish its role as salvage therapy also appears to be effective at halting disease progression.

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Section: Discussionmentioning

confidence: 99%

Section: Fig 2 Influence Of Extent Of Resection On Pfs Kaplan-meiementioning

confidence: 99%

Section: Fig 2 Influence Of Extent Of Resection On Pfs Kaplan-meiementioning

confidence: 99%

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confidence: 99%

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Outcomes following myxopapillary ependymoma resection: the importance of capsule integrity

Abdulaziz¹,

Mallory²,

Bydon

et al. 2015

FOC

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“…21 Myxopapillary ependymomas should be treated according to this policy as well, aiming for a GTR regardless of their size. 12,23 The strategy for small tumors is to attempt in toto removal, with resection of the filum. With large tumors filling out the spinal canal completely and/ or extending cranially beyond the conus, en bloc removals are impossible without significant neurological deficits and should not be attempted.…”

Section: Surgical Managementmentioning

confidence: 99%

Spinal ependymomas. Part 2: Ependymomas of the filum terminale

Klekamp

2015

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OBJECT Ependymomas of the filum terminale provide specific surgical challenges due to their often enormous size, contact with nerve roots of the cauda equina and conus, and potential for subarachnoid dissemination. This study presents treatment results for these tumors over a 30-year period. METHODS Among 1447 patients with tumors of the spinal canal treated between 1980 and 2014, 618 patients presented with extramedullary tumors. Of these, 42 patients (25 males, 17 females) demonstrated a myxopapillary ependymoma in the lumbosacral region. Thirty-four patients underwent 36 operations for 39 such tumors. The mean patient age was 38 ± 14 years (range 11−73 years), with an average clinical history of 37 ± 67 months. Patients were followed through outpatient visits and questionnaires, with a mean follow-up of 10 years (127 ± 100 months). Twenty-seven operations were performed to treat de novo tumors and the remainder were undertaken on recurrent tumors. Short-term results were determined for individual symptoms, and tumor recurrence rates were calculated with Kaplan-Meier statistical analyses. RESULTS Subarachnoid dissemination was observed in 11 patients and was related to previous surgery in 9 patients and associated with extensive tumors in 2 patients. Gross-total resections (GTR) were achieved in 28 operations (77.7%) and subtotal resections in the remainder. Subtotal resections were restricted to unencapsulated ependymomas (61.5%). Radiotherapy was employed after 6 operations on unencapsulated tumors, with 5 of these also demonstrating subarachnoid seeding. Permanent surgical morbidity affected 3 patients who experienced permanent worsening of bladder function, while 7 patients showed no postoperative changes, and the remaining 26 operations were followed by improvements. Long-term outcome depended on the amount of resection and the presence of a tumor capsule. Eight of 9 tumor recurrences affected unencapsulated tumors, of which 3 had undergone GTR. The overall recurrence rates were 6.6%, 19.0%, and 37.0% after 1, 10, and 20 years, respectively. For unencapsulated ependymomas, the corresponding rates were 15.6%, 32.5%, and 66.2% after 1, 10, and 20 years, respectively, with significantly lower rates of 9.1% after 10 and 20 years for encapsulated tumors. Postoperative radiotherapy tended to prolong the recurrence-free interval for patients with unencapsulated tumors. Five patient deaths occurred during follow-up, of which 2 deaths were tumor related and occurred at 216 and 287 months after surgery. CONCLUSION Extramedullary ependymomas are slow-growing tumors in the lumbosacral region, sometimes with an indolent course for long periods of time. Despite their delicate location and often enormous size, surgical morbidity in experienced hands is low, with good chances for postoperative clinical improvements and very low recurrence rates after GTR for encapsulated tumors. The role of postoperative radiotherapy remains controversial. Radiotherapy may be considered after incomplete resections of unencapsulated tumors and/or for patients with subarachnoid dissemination.