Neoadjuvant chemotherapy for brain tumors in infants and young children.
OBJECTIVE
Because of their large size and high vascularity, complete removal of brain tumors in infants and young children is often difficult. In most cases the degree of resection is associated with prognosis. Neoadjuvant chemotherapy may facilitate resection by reducing the vascularity of the tumor. The authors evaluated the effectiveness of neoadjuvant chemotherapy in the management of these tumors.


METHODS
The authors performed a retrospective review of infants and young children who underwent tumor removal after neoadjuvant chemotherapy.


RESULTS
Nine consecutive patients underwent resection after neoadjuvant chemotherapy during the period February 2004 to December 2012. The mean age at diagnosis was 18 months (range 2-50 months). The average largest tumor diameter was 71 mm (range 30-130 mm) at initial surgery. Five patients underwent partial resection, and 4 underwent biopsy as the initial surgery. The histopathological diagnoses were ependymoma in 2 patients, anaplastic ependymoma in 1, primitive neuroectodermal tumor (PNET) in 2, choroid plexus carcinoma in 1, atypical teratoid/rhabdoid tumor (AT/RT) in 1, glioblastoma in 1, and embryonal tumor with abundant neuropil and true rosettes in 1. After 2-4 courses of multiagent chemotherapy (mainly with vincristine, cyclophosphamide, etoposide, and cisplatin), the second-look surgery was performed. In 1 patient with a PNET, intratumoral hemorrhage was observed after 2 courses of chemotherapy. The mean interval between the initial and the second-look surgery was 3 months. The tumor volume was reduced to varying degrees in 5 patients (56%) after chemotherapy. Intraoperatively, the vascularity of the tumor was considerably reduced, and the tumor was more circumscribed in all cases. Gross-total resection was achieved in 8 patients (89%) and neartotal resection in 1 (11%). Histopathological examination demonstrated fibrotic tissue circumscribing the tumor in 6 of 9 cases (67%). The average blood loss was 20% of the estimated blood volume, and 3 patients (33%) required a blood transfusion. There was no surgical mortality. One patient had transient dysphasia postoperatively. The mean follow-up period was 28 months. At the last follow-up, 2 patients (22%) had died (1 died of tumor progression and 1 of sepsis), and 4 patients (44%) had no tumor recurrence.


CONCLUSIONS
Neoadjuvant chemotherapy for brain tumors in infants and young children was effective in reduction of tumor vascularity and clarification of the tumor-brain interface, which significantly facilitated maximal tumor resection.
Divisions of 1 Neurosurgery.
Junya
J
Iwama
Hideki
H
Ogiwara
Chikako
C
Kiyotani
Keita
K
Terashima
Kentaro
K
Matsuoka
Hideto
H
Iwafuchi
Nobuhito
N
Morota
D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001932:Brain Neoplasms / Q000188:drug therapy* / Q000601:surgery*; D002277:Carcinoma / Q000188:drug therapy / Q000601:surgery; D018236:Carcinoma, Embryonal / Q000188:drug therapy / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D016545:Choroid Plexus Neoplasms / Q000188:drug therapy / Q000601:surgery; D002945:Cisplatin / Q000008:administration & dosage; D003520:Cyclophosphamide / Q000008:administration & dosage; D004334:Drug Administration Schedule; D004806:Ependymoma / Q000188:drug therapy / Q000601:surgery; D005047:Etoposide / Q000008:administration & dosage; D005260:Female; D005909:Glioblastoma / Q000188:drug therapy / Q000601:surgery; D006801:Humans; D007223:Infant; D008279:Magnetic Resonance Imaging; D008297:Male; D020360:Neoadjuvant Therapy / Q000379:methods*; D018242:Neuroectodermal Tumors, Primitive / Q000188:drug therapy / Q000601:surgery; D012189:Retrospective Studies; D018335:Rhabdoid Tumor / Q000188:drug therapy / Q000601:surgery; D024162:Second-Look Surgery; D016896:Treatment Outcome; D014750:Vincristine / Q000008:administration & dosage
D014750:Vincristine; D005047:Etoposide; D003520:Cyclophosphamide; D002945:Cisplatin
AT/RT = atypical teratoid/rhabdoid tumor; CPC = choroid plexus carcinoma; ETANTR = embryonal tumor with abundant neuropil and true rosettes; GTR = gross-total resection; ICE = ifosfamide, carboplatin, and etoposide; NTR = near-total resection; PNET = primitive neuroectodermal tumor; infantile brain tumors; neoadjuvant chemotherapy; oncology; second-look surgery