Anaplastic Ependymoma

Anaplastic Ependymoma

Harsha Dod 17 Apr 2010 09:50

65 year lady, presented with numbness and paraesthesia in right upper limb.
A well defined predominantly cystic mass lesion in left posterior parietal region. Mild peripheral enhancement and peri lesional edema.
Operated.

HPR Anaplastic Ependymoma Grade III.
GFAF positive
Focal EMA positive
MIB I labelling index 11 %

Radiotherapy , volume and dose.

Re: Anaplastic Ependymoma

Rohit Malde 17 Apr 2010 14:35

There are no major randomised trials for ependymomas, however various institutional series have consistently demonstarted a benefit in neurological progression free survival and overall survival with RT

Volumes:

Mark your GTV as determined from the preop scans + taking into account any residual disease

CTV - GTV + 2 cm (edit your margins at sites of natural barriers ie midline and falx cerebelli and falx cerebri + bones

PTV = CTV + 0.5 cm margin in all directions

Dose: 54 Gy / 30 # / 6 weeks

Chemo following radiation is highly controversial, but i gather you dont wanna now about it anyways.

Re: Anaplastic Ependymoma

Harsha Dod 19 Apr 2010 04:09

Is cranio spinal radiation required in Ependymoma ?

I would like to know the evidence for use of chemo.

Re: Anaplastic Ependymoma

Rohit Malde 19 Apr 2010 10:02

Craniospinal RT has now almost become obsolete in Ependymomas.
The only indication being if CSF cytology was positive or there was evidence of tumour seedings as evident on MRI imaging.

Reference:
http://www.ncbi.nlm.nih.gov/pubmed/15667957

This retrospective study (60 pts) showed that there was no benefit for CSI.

The 5-year and 10-year disease-free survival rates for patients treated with local field radiation therapy were 62.1% and 56.0%, compared with 44.9% and 26.9% for those treated with craniospinal irradiation (p = 0.13). Similarly, the 5-year and 10-year overall survival rates for patients treated with local field irradiation were 74.8% and 62.9%, compared with 57.1% and 28.6% for those treated with craniospinal irradiation (p = 0.11).

If you read the discussion part there are numerous other studies, (at least 8 references) consistently showing no benefit for CSI.

Chemotherapy is controversial and open for debate.

Scenario as an adjuvant following RT

In one study pts underwent postoperative chemotherapy and radiation after subtotal resection of an intracranial ependymoma. The five-year progression-free survival rate was 74 percent, a value that appears higher than published survival results for radiation alone. In contrast, two small studies did not support the role of chemotherapy after surgical resection and RT.

Study for chemo

1. http://www.ncbi.nlm.nih.gov/pubmed/9217048

Study against chemo

1. http://www.ncbi.nlm.nih.gov/pubmed/9525716
2. http://www.ncbi.nlm.nih.gov/pubmed/8614396

If you read those references, you ll get loads of cross references.

As of 2010, there are very few centres in the world advocating chemo, and of course these should be in the setting of a trial and should be considered experimental.

Scenario in the immediation postop setting instead or before consideration of RT

Chemotherapy may have a role in delaying or avoiding postoperative cranial irradiation in children less than three years old
as we all know RT in that age group can have disastrous late effects, but that has to be balanced against delaying RT.

This approach has been advocated by the UKCCSG / SIOP group as demonstrated in this prospective study

http://www.ncbi.nlm.nih.gov/pubmed/17644039