Brainstem tumors: Current management and future directions

 

PDF Download Buy Article Permissions and Reprints

Abstract

Tumors arising in the brainstem comprise 10–20% of all pediatric central nervous system (CNS) tumors and account for a small percentage in adults. The prognosis for these tumors was considered uniformly poor prior to the era of modern neuroimaging and the location was fraught with disaster being considered a ‘no man’s land’ for neurosurgeons. Following the introduction of advanced imaging modalities and neurophysiological monitoring, striking progress has occurred in the management of these lesions. Brainstem tumors are presently classified based on their anatomic location, focality, and histopathology. This article reviews the current classification of brainstem tumors, current management options, and future directions in the treatment for these rare tumors.

• References

• 1 Zhang C, Yao Y, Wang Y, Chen Z, Wu J, Mao Y. etal Temozolomide for adult brain stem glioblastoma: Case report of a long-term survivor. Int J Neurosci 2010; 120: 787-791
  CrossrefPubMedGoogle Scholar
• 2 Guy G, Jan M, Guegan Y, Aubin ML, Fischer C, Ben-Hassel M. et al [Surgical lesions of the brain stem]. Neurochirurgie 1989; 35 (Suppl. 01) 1-133
  PubMedGoogle Scholar
• 3 Allen J. Brain stem glioma. Neurol Neurosurg Update Series 1983; 4: 2-7
  PubMedGoogle Scholar
• 4 Walker DA, Punt JA, Sokal M. Clinical management of brainstem glioma. Arch Dis Child 1999; 80: 558-564
  CrossrefPubMedGoogle Scholar
• 5 Berger MS, Edwards MS, La Masters D, Davis RL, Wilson CB. Pediatric brain stem tumors: Radiographic, pathological, and clinical correlations. Neurosurgery 1983; 12: 298-302
  CrossrefPubMedGoogle Scholar
• 6 Littman P, Jarrett P, Bilaniuk LT, Rorke LB, Zimmerman RA, Bruce DA. et al Pediatric brain stem gliomas. Cancer 1980; 45: 2787-2792
  CrossrefPubMedGoogle Scholar
• 7 Fulton DS, Levin VA, Wara WM, Edwards MS, Wilson CB. Chemotherapy of pediatric brain-stem tumors. J Neurosurg 1981; 54: 721-725
  CrossrefPubMedGoogle Scholar
• 8 Albright AL, Pollack IF. Brainstem gliomas. In: Winn HR. editor Youmans Neurological Surgery. Vol. 3. 5^th ed Philadelphia: Saunders; 2004. p 3663-3669
  Google Scholar
• 9 Recinos PF, Sciubba DM, Jallo GI. Brainstem tumors: Where are we today?. Pediatr Neurosurg 2007; 43: 192-201
  CrossrefPubMedGoogle Scholar
• 10 Weiner HL, Freed D, Woo HH, Rezai AR, Kim R, Epstein FJ. Intra-axial tumors of the cervicomedullary junction: Surgical results and longterm outcome. Pediatr Neurosurg 1997; 27: 12-18
  CrossrefPubMedGoogle Scholar
• 11 Epstein F, Wisoff JH. Intrinsic brainstem tumors in childhood: Surgical indications. J Neurooncol 1988; 6: 309-317
  PubMedGoogle Scholar
• 12 Hoffman HJ, Becker L, Craven MA. A clinically and pathologically distinct group of benign brain stem gliomas. Neurosurgery 1980; 7: 243-248
  CrossrefPubMedGoogle Scholar
• 13 Stroink AR, Hoffman HJ, Hendrick EB, Humphreys RP, Davidson G. Transependymal benign dorsally exophytic brain stem gliomas in childhood: Diagnosis and treatment recommendations. Neurosurgery 1987; 20: 439-444
  CrossrefPubMedGoogle Scholar
• 14 Alvisi C, Cerisoli M, Maccheroni ME. Long-term results of surgically treated brainstem gliomas. Acta Neurochir (Wien) 1985; 76: 12-17
  CrossrefPubMedGoogle Scholar
• 15 Epstein F, McCleary EL. Intrinsic brain-stem tumors of childhood: Surgical indications. J Neurosurg 1986; 64: 11-15
  CrossrefPubMedGoogle Scholar
• 16 Epstein F. A staging system for brain stem gliomas. Cancer 1985; 56 (07) Suppl 1804-1806
  CrossrefPubMedGoogle Scholar
• 17 Barkovich AJ, Krischer J, Kun LE, Packer R, Zimmerman RA, Freeman CR. et al Brain stem gliomas: A classification system based on magnetic resonance imaging. Pediatr Neurosurg 1990; 16: 73-83
  CrossrefPubMedGoogle Scholar
• 18 Fischbein NJ, Prados MD, Wara W, Russo C, Edwards MS, Barkovich AJ. Radiologic classification of brain stem tumors: Correlation of magnetic resonance imaging appearance with clinical outcome. Pediatr Neurosurg 1996; 24: 9-23
  CrossrefPubMedGoogle Scholar
• 19 Albright AL. Brain stem gliomas. In: J Y, editor Neurological Surgery. Philadelphia: Saunders; 1996. p 2603-2611
  Google Scholar
• 20 Dechambre S, Duprez T, Lecouvet F, Raftopoulos C, Gosnard G. Diffusion-weighted MRI postoperative assessment of an epidermoid tumour in the cerebellopontine angle. Neuroradiology 1999; 41: 829-831
  CrossrefPubMedGoogle Scholar
• 21 Murakami N, Matsushima T, Kuba H, Ikezaki K, Morioka T, Mihara F. et al Combining steady-state constructive interference and diffusion-weighted magnetic resonance imaging in the surgical treatment of epidermoid tumors. Neurosurg Rev 1999; 22: 159-162
  CrossrefPubMedGoogle Scholar
• 22 Recinos PF, Roonprapunt C, Jallo GI. Intrinsic brainstem epidermoid cyst. Case report and review of the literature. J Neurosurg 2006; 104 (04) Suppl 285-289
  CrossrefPubMedGoogle Scholar
• 23 Albright AL, Packer RJ, Zimmerman R, Rorke LB, Boyett J, Hammond GD. Magnetic resonance scans should replace biopsies for the diagnosis of diffuse brain stem gliomas: A report from the Children’s Cancer Group. Neurosurgery 1993; 33: 1026-1029 ; discussion 1029-1030
  CrossrefPubMedGoogle Scholar
• 24 Jallo GI, Biser-Rohrbaugh A, Freed D. Brainstem gliomas. Childs Nerv Syst 2004; 20: 143-153
  CrossrefPubMedGoogle Scholar
• 25 Choux M, Lena G, Do L. Brainstem tumors. In: Choux M, Di Rocco C, Hockley A. editors Pediatric Neurosurgery. New York: Churchill Livingstone; 2000. p 471-491
  Google Scholar
• 26 Albright AL, Guthkelch AN, Packer RJ, Price RA, Rourke LB. Prognostic factors in pediatric brain-stem gliomas. J Neurosurg 1986; 65: 751-755
  CrossrefPubMedGoogle Scholar
• 27 Mandell LR, Kadota R, Freeman C, Douglass EC, Fontanesi J, Cohen ME. et al There is no role for hyperfractionated radiotherapy in the management of children with newly diagnosed diffuse intrinsic brainstem tumors: Results of a Pediatric Oncology Group phase III trial comparing conventional vs hyperfractionated radiotherapy. Int J Radiat Oncol Biol Phys Mar 1999; 43: 959-964
  PubMedGoogle Scholar
• 28 Epstein FJ, Farmer JP. Brain-stem glioma growth patterns. J Neurosurg 1993; 78: 408-412
  CrossrefPubMedGoogle Scholar
• 29 Morota N, Deletis V. The importance of brainstem mapping in brainstem surgical anatomy before the fourth ventricle and implication for intraoperative neurophysiological mapping. Acta Neurochir (Wien) 2005; 148: 499-509
  PubMedGoogle Scholar
• 30 Morota N, Deletis V, Lee M, Epstein FJ. Functional anatomic relationship between brain-stem tumors and cranial motor nuclei. Neurosurgery 1996; 39: 787-793 ; discussion 793-784
  CrossrefPubMedGoogle Scholar
• 31 Morota N, Deletis V, Epstein FJ, Kofler M, Abbott R, Lee M. et al Brain stem mapping: Neurophysiological localization of motor nuclei on the floor of the fourth ventricle. Neurosurgery 1995; 37: 922-929 discussion 929-30
  CrossrefPubMedGoogle Scholar
• 32 Sala F, Krzan MJ, Deletis V. Intraoperative neurophysiological monitoring in pediatric neurosurgery: Why when, how?. Childs Nerv Syst 2002; 18: 264-287
  CrossrefPubMedGoogle Scholar
• 33 Bricolo A. Surgical management of intrinsic brain stem gliomas. Oper Tech Neurosurg 2000; 3: 137-154
  CrossrefPubMedGoogle Scholar
• 34 Abbott R. Tumors of the medulla. Neurosurg Clin N Am 1993; 4: 519-527
  PubMedGoogle Scholar
• 35 Jallo GI, Kothbauer KF, Epstein FJ. Surgical Management of Cervicomedullary and Dorsally Exophytic Brain Stem Tumors. Oper Tech Neurosurg 2000; 3: 131-136
  CrossrefPubMedGoogle Scholar
• 36 Pollack IF, Hoffman HJ, Humphreys RP, Becker L. The long-term outcome after surgical treatment of dorsally exophytic brain-stem gliomas. J Neurosurg 1993; 78: 859-863
  CrossrefPubMedGoogle Scholar
• 37 Epstein F, Wisoff J. Intra-axial tumors of the cervicomedullary junction. J Neurosurg 1987; 67: 483-487
  CrossrefPubMedGoogle Scholar
• 38 Abbott R, Shiminski-Maher T, Epstein FJ. Intrinsic tumors of the medulla: Predicting outcome after surgery. Pediatr Neurosurg 1996; 25: 41-44
  CrossrefPubMedGoogle Scholar
• 39 Abbott R, Shiminski-Maher T, Wisoff JH, Epstein FJ. Intrinsic tumors of the medulla: Surgical complications. Pediatr Neurosurg 1991; 17: 239-244
  CrossrefPubMedGoogle Scholar
• 40 Shiminski-Maher T. Brainstem tumors in childhood: Preparing patients and families for long- and short-term care. Pediatr Neurosurg 1996; 24: 267-271
  CrossrefPubMedGoogle Scholar
• 41 Jallo GI, Shiminski-Maher T, Velazquez L, Abbott R, Wisoff J, Epstein F. Recovery of lower cranial nerve function after surgery for medullary brainstem tumors. Neurosurgery 2005; 56: 74-77 ; discussion 78
  CrossrefPubMedGoogle Scholar
• 42 Shiminski-Maher T, Abbott R, Wisoff JH, Epstein FJ. Current trends in the management of brainstem tumors in childhood. J Neurosci Nurs 1991; 23: 356-362
  CrossrefPubMedGoogle Scholar
• 43 Li KW, Roonprapunt C, Lawson HC, Abbott IR, Wisoff J, Epstein F. et al Endoscopic third ventriculostomy for hydrocephalus associated with tectal gliomas. Neurosurg Focus 2005; 18: E2
  CrossrefPubMedGoogle Scholar
• 44 Packer RJ, Boyett JM, Zimmerman RA, Albright AL, Kaplan AM, Rorke LB. et al Outcome of children with brain stem gliomas after treatment with 7800 cGy of hyperfractionated radiotherapy, A Childrens Cancer Group Phase I/II Trial. Cancer 1994; 74: 1827-1834
  CrossrefPubMedGoogle Scholar
• 45 Robertson PL, Allen JC, Abbott IR, Miller DC, Fidel J, Epstein FJ. Cervicomedullary tumors in children: A distinct subset of brainstem gliomas. Neurology 1994; 44: 1798-1803
  CrossrefPubMedGoogle Scholar
• 46 Allen JC, Siffert J. Contemporary chemotherapy issues for children with brainstem gliomas. Pediatr Neurosurg 1996; 24: 98-102
  CrossrefPubMedGoogle Scholar
• 47 Nelson Jr MD, Soni D, Baram TZ. Necrosis in pontine gliomas: Radiation induced or natural history?. Radiology 1994; 191: 279-282
  CrossrefPubMedGoogle Scholar
• 48 Packer RJ, Zimmerman RA, Kaplan A, Wara WM, Rorke LB, Selch M. et al Early cystic/necrotic changes after hyperfractionated radiation therapy in children with brain stem gliomas. Data from the Childrens Cancer Group. Cancer 1993; 71: 2666-2674
  CrossrefPubMedGoogle Scholar
• 49 Bobo RH, Laske DW, Akbasak A, Morrison PF, Dedrick RL, Oldfield EH. Convection-enhanced delivery of macromolecules in the brain. Proc Natl Acad Sci U S A 1994; 91: 2076-2080
  CrossrefPubMedGoogle Scholar
• 50 Groothuis DR, Ward S, Itskovich AC, Dobrescu C, Allen CV, Dills C. et al Comparison of 14C-sucrose delivery to the brain by intravenous intraventricular, and convection-enhanced intracerebral infusion. J Neurosurg 1999; 90: 321-331
  CrossrefPubMedGoogle Scholar
• 51 Occhiogrosso G, Edgar MA, Sandberg DI, Souweidane MM. Prolonged convection-enhanced delivery into the rat brainstem. Neurosurgery 2003; 52: 388-394
  CrossrefPubMedGoogle Scholar
• 52 Lee J, Jallo GI, Guarnieri M, Carson Sr BS, Penno MB. A novel brainstem tumor model: Guide screw technology with functional, radiological, and histopathological characterization. Neurosurg Focus 2005; 18: E11
  PubMedGoogle Scholar
• 53 Frazier JL, Lee J, Thomale UW, Noggle JC, Cohen KJ, Jallo GI. Treatment of diffuse intrinsic brainstem gliomas: Failed approaches and future strategies. J Neurosurg Pediatr 2009; 3: 259-269
  CrossrefPubMedGoogle Scholar
• 54 Miura F, Moriuchi S, Maeda M, Sano A, Maruno M, Tsanaclis AM. et al Sustained release of low-dose ganciclovir from a silicone formulation prolonged the survival of rats with gliosarcomas under herpes simplex virus thymidine kinase suicide gene therapy. Gene Ther 2002; 9: 1653-1658
  CrossrefPubMedGoogle Scholar
• 55 Burrows FJ, Gore M, Smiley WR, Kanemitsu MY, Jolly DJ, Read SB. et al Purified herpes simplex virus thymidine kinase retroviral particles: III. Characterization of bystander killing mechanisms in transfected tumor cells. Cancer Gene Ther 2002; 9: 87-95
  CrossrefPubMedGoogle Scholar
• 56 Todo T, Rabkin SD, Martuza RL. Evaluation of ganciclovir-mediated enhancement of the antitumoral effect in oncolytic, multimutated herpes simplex virus type 1 (G207) therapy of brain tumors. Cancer Gene Ther 2000; 7: 939-946
  CrossrefPubMedGoogle Scholar
• 57 De Bouard S, Guillamo JS, Christov C, Lefévre N, Brugières P, Gola E. et al Antiangiogenic therapy against experimental glioblastoma using genetically engineered cells producing interferon-alpha, angiostatin, or endostatin. Hum Gene Ther 2003; 14: 883-895
  CrossrefPubMedGoogle Scholar
• 58 Ruan S, Okcu MF, Pong RC, Andreeff M, Levin V, Hsieh JT. et al Attenuation of WAF1/Cip1 expression by an antisense adenovirus expression vector sensitizes glioblastoma cells to apoptosis induced by chemotherapeutic agents 1,3-bis(2-chloroethyl)-1-nitrosourea and cisplatin. Clin Cancer Res 1999; 5: 197-202
  PubMedGoogle Scholar
• 59 Miller CR, Williams CR, Buchsbaum DJ, Gillespie GY. Intratumoral 5-fluorouracil produced by cytosine deaminase/5-fluorocytosine gene therapy is effective for experimental human glioblastomas. Cancer Res 2002; 62: 773-780
  PubMedGoogle Scholar
• 60 Yamanaka R, Yajima N, Tsuchiya N, Honma J, Tanaka R, Ramsey J. et al Administration of interleukin-12 and -18 enhancing the antitumor immunity of genetically modified dendritic cells that had been pulsed with Semliki forest virus-mediated tumor complementary DNA. J Neurosurg 2002; 97: 1184-1190
  CrossrefPubMedGoogle Scholar
• 61 Rand V, Huang J, Stockwell T, Ferriera S, Buzko O, Levy S. et al Sequence survey of receptor tyrosine kinases reveals mutations in glioblastomas. Proc Natl Acad Sci U S A 2005; 102: 14344-14349
  CrossrefPubMedGoogle Scholar