title: Predictors of functional recovery in adults with posterior fossa ependymomas.
abstract: OBJECTIVE
  After complete resection and radiation therapy, the 10-year overall survival rates for adult patients with posterior fossa ependymomas approach 85%. This favorable outcome profile emphasizes the critical importance of functional preservation to this patient population. Here, the authors identify predictors of functional outcome following microsurgical resection of adult posterior fossa ependymomas.
  
  
  METHODS
  The authors identified adult patients with newly diagnosed WHO Grade II posterior fossa ependymomas who underwent microsurgical resection at the Barrow Neurological Institute from 1990 to 2011. Clinical and radiographic variables were collected, including volumetric extent of resection, foramen of Luschka extension, cystic changes, peritumoral T2 signal changes, Karnofsky Performance Scale (KPS) score, National Institutes of Health Stroke Scale (NIHSS) score, progression-free survival (PFS), and overall survival (OS).
  
  
  RESULTS
  Forty-five patients were identified, with a median clinical follow-up of 103 months. The median PFS and OS were 6.8 and 8.6 years, respectively. Extent of resection and adjuvant radiotherapy were predictive of improved PFS (p = 0.005) and were nonsignificantly associated with improved OS. Univariate analysis revealed that tumor size (p < 0.001), cystic changes (p < 0.01), postoperative T2 signal (p < 0.01), and CSF diversion (p = 0.048) predicted functional and neurological recovery rates, based on KPS and NIHSS scores, respectively. Multivariate regression analysis identified tumor size (p < 0.001), cystic changes (p = 0.01), and CSF diversion (p = 0.02) as independent predictors of slower functional recovery, while only tumor size (p = 0.007) was an independent predictor of neurological recovery. Specifically, by 6 weeks postoperatively, baseline KPS score was recovered by only 43.8% of patients with tumors larger than 30 cm(3) (vs 72.4% patients with tumors < 30 cm(3)), 35.3% of patients with cystic tumors (vs 78.6% of patients with noncystic tumors), and 46.7% of patients requiring CSF diversion (vs 70% of patients not requiring CSF diversion).
  
  
  CONCLUSIONS
  Greater extent of resection and adjuvant radiotherapy significantly improve PFS in adult patients with posterior fossa ependymomas. Tumor size, cystic changes, and the need for CSF diversion were independent predictors of the rate of functional recovery in this patient population. Taken together, these functional outcome predictors may guide preoperative estimations of recovery following microsurgical resection.
authors.affiliation: Division of Neurological Surgery.
authors.forename: Zaman
authors.initials: Z
authors.lastname: Mirzadeh
authors.forename: Robert
authors.initials: R
authors.lastname: Bina
authors.forename: Yael
authors.initials: Y
authors.lastname: Kusne
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Coons
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
authors.forename: Nader
authors.initials: N
authors.lastname: Sanai
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003131:Combined Modality Therapy; D003388:Cranial Fossa, Posterior / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D004806:Ependymoma / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D011237:Predictive Value of Tests; D011379:Prognosis; D019292:Skull Base Neoplasms / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D015996:Survival Rate; D016896:Treatment Outcome