Neurosurgical treatment of pediatric brain tumors - results from a single center multidisciplinary setup

Abstract

Objective: The challenge of pediatric brain tumor surgery is given due to a relative low prevalence but high heterogeneity in age, localization, and pathology. Improvements of long-term overall survival rates were achieved during the past decades stressing the importance of a multidisciplinary decision process guided by a national treatment protocol. We reviewed the entire spectrum of pediatric brain tumor surgeries from the perspective of an interdisciplinary pediatric neuro-oncology center in Germany.

Methods: Every patient who underwent brain tumor surgery from January 2010 to June 2017 in our Pediatric Neurosurgery department was retrospectively included and evaluated regarding the course of treatment. Perioperative data such as tumor localization, timing of surgery, extent of resection, neuropathological diagnosis, transfusion rates, oncologic and radiation therapy, and neurological follow-up including morbidity and mortality were evaluated.

Results: Two hundred ninety-three pediatric brain tumor patients were applicable (age: 8.28 ± 5.62 years, 1.22:1.0 m:f). A total of 531 tumor surgical interventions was performed within these patients (457 tumor resections, 74 tumor biopsies; mean interventions per patient 1.8 ± 1.2). Due to a critical neurologic status, 32 operations (6%) were performed on the day of admission. In 65.2% of all cases, tumor were approached supratentorially. Most frequent diagnoses of the cases were glial tumors (47.8%) and embryonal tumors (17.6%). Preoperative planned extent of resection was achieved in 92.7%. Pre- and postoperative neurologic deficits resolved completely in 30.7%, whereas symptom regressed in 28.6% of surgical interventions. New postoperative neurologic deficit was observed in 10.7%, which resolved or improved in 80% of these cases during 30 days. The mortality rate was 1%.

Conclusion: We outlined the center perspective of a specialized pediatric neuro-oncological center describing the heterogeneous distribution of cases regarding age-related prevalence, tumor localization, and biology, which requires a high multidisciplinary expertise. The study contributes to define challenges in treating pediatric brain tumors and to develop quality indicators for pediatric neuro-oncological surgery. We assume that an adequate volume load of patients within a interdisciplinary infrastructure is warranted to aim for effective treatment and decent quality of life for the majority of long-term surviving pediatric tumor patients.

Keywords: Ependymoma; Extent of resection; High grade glioma; Medulloblastoma; Morbidity; Neurologic deficits; Pediatric brain tumor; Pilocytic Astrocytoma; Transfusion rates.

Fig. 1

The number of treated tumor patients on a yearly basis during the study period between 01/2010 and 6/2017 as marked in blue. Subsequent surgeries of these patients were also evaluated from the time period between 2000 and 2020 as marked in orange. The number of tumor surgeries which are not included in the study are marked in gray

Fig. 2

Age dependent variation in extent of resection (A) and comparison between MDT plan, surgeon evaluation, neuro-radiologist evaluation without significant differences in observed rates (B). A significant difference between EOR rates was observed between primary tumor surgeries compared to secondary tumor surgeries

Fig. 3

Age dependent rate for the need of transfusion showed an obvious correlation

Fig. 4

Distribution of tumor location (A) and group of histological diagnosis (B)

Fig. 5

Preoperative neurological deficits were present in the vast majority of cases (A), which showed heterogeneous development over time after surgery (B). New neurological deficits after surgery were observed in 10.7% of cases (C), which developed postoperatively more favorable compared to preexisting neurological deficits with 5.3% resolving, 2.7% regressive, and 2.8% persistent deficits (D). No significant differences were seen in age dependent distribution of postoperative neurological deficits, however with relatively lower rates of progressive or persistent neurological deficits in infants at an age < 1 year and relatively higher rates in children with the age between 1 and 3 years (E)