Abstract
Introduction
The optimal time point for surgery of intramedullary spinal astrocytomas and ependymomas is often debated on, as predicting factors are poorly defined. The current single-institutional study was conducted to retrospectively analyze prognostic factors for postoperative functional outcome in these patients.
Material and methods
All consecutive adult patients with intramedullary astrocytomas or ependymomas (except filum terminale ependymomas) were included. Imaging data, McCormick score (MCS), and detailed neurological evaluation were stringently applied preoperatively, 1 week, and 6 months postoperatively for functional evaluation of all patients. End points were early and late functional outcome. Prognostic factors were obtained from univariate and multivariate logistic regression analysis.
Results
Forty-four patients were included (29 ependymomas World Health Organization (WHO) grades I or II, 8 astrocytomas WHO grade I, and 7 astrocytomas WHO grade II). Overall perioperative morbidity was 34%, and there was no mortality. Complete tumor resection was achieved in 79% of ependymomas, 50% of astrocytomas WHO grade I, and 14% of astrocytomas WHO grade II (significantly more often in ependymomas than in astrocytomas, p < 0.05). Early and late functional outcome were highly intercorrelated (p < 0.01), but not correlated to histology. Preoperative MCS <3 and extent of tumor <5 levels were significantly (p = 0.01 and p < 0.05) associated with a favorable outcome (MCS <3) in early and late follow-up.
Conclusion
An MCS of less than 3 and a tumor extent of less than 5 levels are the most important factors for a favorable postoperative functional outcome. Therefore, surgery should be initiated before significant clinical symptomatology or substantial tumor growth occurs.
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This article conveys important information. Despite the fact that surgery is doubtless the best treatment strategy for the tumors included in this series (ependymomas and astrocytomas both pylocitic and diffuse), there is still some argument regarding when it should be recommended. The discussion is certainly more pertinent in cases of incidental tumor finding or in minimally symptomatic patients.
The prevailing idea is that tumor excision should be undertaken at the time of diagnosis. This is based on the fact that not only is surgery the only potentially curative treatment but also because adjuvant treatment plans seem to add little to the arrest or regression of the disease.
This study adds support to the recommendation for early surgery, the authors having found that patients fare better after surgery when lesser extension of the cord is involved by the tumor, and the patient’s preoperative functional level is more favorable.
Interestingly, duration of symptoms did not correlate with tumor type or with preoperative functional status and postoperative outcome. As the authors point out, this only stresses the importance of an early intervention.
Manuel Cunha e Sá, M.D.
Department of Neurosurgery, Hospital Garcia de Orta
Almada, Portugal
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Eroes, C.A., Zausinger, S., Kreth, FW. et al. Intramedullary low grade astrocytoma and ependymoma. Surgical results and predicting factors for clinical outcome. Acta Neurochir 152, 611–618 (2010). https://doi.org/10.1007/s00701-009-0577-x
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DOI: https://doi.org/10.1007/s00701-009-0577-x