Early region-specific impact of adjuvant radiation therapy on cognition and quality of life in adult patients with primary brain tumors.

PURPOSE: While treatments for primary brain tumors increase survival, they have cognitive sequelae. Neurocognition's anatomical distribution makes it susceptible to brain damage. This study aims to evaluate the contribution of radiotherapy on short-term cognitive impairment. METHODS/PATIENTS: Using a prospective database of cognitive rehabilitation in adults operated on for primary brain tumors, a retrospective sub-analysis of the contribution of radiotherapy was performed. Thirty-four subdivisions of 12 neurocognitive regions were delineated in 48 irradiated patients and 30 non-irradiated patients. In the first group, the correlation between radiation dose and deterioration was evaluated. In all patients, the impact of tumor and surgical changes on dysfunction was calculated and compared with dose-dependent response. RESULTS: The correlation between cognitive status and radiation dose is especially strong and significant in the left hemisphere and in specific subdivisions such as the posterior hippocampus or the dorsolateral prefrontal cortex, with the left prevailing over posterior dominance. Memory is the most affected domain 1 month after radiotherapy, as attention is three months later. The hippocampus is involved in various cognitive domains in addition to memory. The prefrontal subregions and the genu of the corpus callosum are more affected by the relationship with disease and surgical changes than by radiation exposure. Patients ongoing a course of radiotherapy do not benefit from concurrent cognitive rehabilitation. CONCLUSIONS: There is a correlation between the dose of radiation received by several encephalic regions and degree of short-term domain-specific cognition decline, considering other factors of risk and cognitive rehabilitation.

Neuropsychiatric Manifestations of a Frontal Lobe Meningioma: A Case Report.

The exclusion of organic causes for psychiatric symptoms is a routine practice in mental healthcare. Brain tumors can elicit a range of mood, behavioral, or cognitive symptoms that mimic mental health disorders, significantly altering a patient's personality and behavior if left undiagnosed or untreated. This case report presents a 56-year-old Middle Eastern male with no prior history of mental illness who exhibited a three-week history of depressive symptoms, social withdrawal, and poor self-care. Despite treatment, his condition deteriorated, manifesting psychomotor retardation, urinary incontinence, paranoia, mood lability, and sexually disinhibited behavior. Neuroimaging revealed a large extra-axial mass in the anterior cranial fossa, indicative of a meningioma, necessitating referral to neurosurgery. CT and MRI scans confirmed a hyperdense mass lesion (7.1 x 7.7 x 7.5 cm), causing structural erosion and a midline shift. This case underscores the importance of considering organic causes in atypical psychiatric presentations. Meningiomas, particularly those in the frontal lobes, can present primarily with psychiatric symptoms, complicating early diagnosis. Neuroimaging is critical for accurate diagnosis and effective management in such cases. Clinicians should be vigilant for organic causes in patients with atypical psychiatric symptoms, especially in those over 50. Early neuroimaging can lead to timely diagnosis and treatment, significantly improving patient outcomes.

Nanotechnology in Advancing Chimeric Antigen Receptor T Cell Therapy for Cancer Treatment.

Chimeric antigen receptor (CAR) T cell therapy has emerged as a groundbreaking treatment for hematological cancers, yet it faces significant hurdles, particularly regarding its efficacy in solid tumors and concerning associated adverse effects. This review provides a comprehensive analysis of the advancements and ongoing challenges in CAR-T therapy. We highlight the transformative potential of nanotechnology in enhancing CAR-T therapy by improving targeting precision, modulating the immune-suppressive tumor microenvironment, and overcoming physical barriers. Nanotechnology facilitates efficient CAR gene delivery into T cells, boosting transfection efficiency and potentially reducing therapy costs. Moreover, nanotechnology offers innovative solutions to mitigate cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Cutting-edge nanotechnology platforms for real-time monitoring of CAR-T cell activity and cytokine release are also discussed. By integrating these advancements, we aim to provide valuable insights and pave the way for the next generation of CAR-T cell therapies to overcome current limitations and enhance therapeutic outcomes.

AB069. Type of personality and cancer-related pain in central nervous system (CNS) tumor patients: a cross-sectional study.

BACKGROUND: Pain is the most common complaint experienced by central nervous system (CNS) tumor patients. Pain, especially cancer pain, involves the whole aspect of a person, such as personality, cognition, and behavior. Personality characteristics play an important role in how a person perceives pain rate and deals with painful situation. This study aimed to describe types of personality and investigate relationship between types of personality and cancer-related pain in CNS patients. METHODS: This study was conducted at Cipto Mangunkusumo General Hospital from January to December 2023, that was determined by random sampling. The analysis included a total of 99 subjects from inpatient settings. In depth interview was used to assess type of personality and Numeric Rating Scale (NRS) was used to assess intensity of pain. Data analyses were carried out using the Chi-squared and Fisher's exact test to assess the relationship between types of personality and cancer-related pain in CNS patients. RESULTS: There were 99 subjects with mean age of 48.37±12.96 years, mostly women (60.6%). The results showed that in patients with CNS tumor, the most common neurological deficit was cancer pain (93.9%), consisting of no-mild pain (30.3%) and moderate-severe pain (69.7%). The prevalence of narcissistic personality was 73.7%, followed by histrionic personality 15.2%, and other personality (11.1%) such as borderline, obsessive-compulsive, and avoidant personality. Narcissistic personality traits were found in 48.5% of patients with moderate-severe pain. However, bivariate analysis showed that there was no significant relationship between types of personality and intensity of pain in CNS tumor patients (P=0.60). CONCLUSIONS: Although there was no significant relationship, cluster B personality (narcissistic, histrionic, and borderline) was found in a large percentage of CNS tumor patients. Research findings showed that intensity of pain was caused by biological components of pain and may be influenced by the patient's perception of pain itself, not solely due to personality. Therefore, it's important for health workers to pay attention and give optimal management to every patient's pain complaint, and not to ignore or minimize it. Psychiatrists can be involved by giving psychotherapy so that patients can deal with their pain in a more adaptive way.

AB068. Psychiatric disorder in central nervous system tumor patients and its related factors.

BACKGROUND: Patients of central nervous system (CNS) tumors have a potential to develop psychiatric disorder. These may present resulting from tumor mass, edema, or patient's failure to adapt to their illness and treatment. The presence of psychiatric disorders may cause disability, decreased daily functioning, reduced quality of life, and even death. In order to provide adequate treatment to patients with CNS tumors, it's important to evaluate the type of psychiatric disorder in patients with spinal and brain tumors. This study aimed to investigate the prevalence of psychiatric disorder dan related factors that exist in patients with brain and spinal tumors. METHODS: In a study conducted at Cipto Mangunkusumo General Hospital from January to December 2023, factors associated with psychiatric disorders in patients with CNS tumors were investigated. The analysis included a total of 161 subjects from inpatient settings. In depth interview was utilized to assess psychiatric disorder. Data analyses were carried out using the Chi-square and Fisher's exact test to assess the relationship between locations of tumor, neurological deficits, and psychiatric disorders. RESULTS: There were 161 subjects with mean age of 48.86±13.13 years, mostly women (59.0%). Patients with spinal tumor have more psychiatric disorders compared to their counterpart with intracranial tumor (79.1% and 76.3% respectively), while the most common psychiatric disorder was adjustment disorder. There is no significant relationship between tumor location and psychiatric disorder. In both patients with intracranial and spinal tumors, the most common neurological deficit was cancer pain (88.2%). However, bivariate analysis showed that among the neurological deficits found in the CNS tumor patients, dysphagia (P=0.02) and incontinence (P=0.02) have significant relationship with depression, while pain (P=0.02) and cognitive dysfunction (P=0.01) have significant relationship with adjustment disorder. It also showed that pain (P<0.001), cognitive dysfunction (P=0.002), and seizure (P=0.03) have significant relationship with organic mental disorder. CONCLUSIONS: Dysphagia, incontinence, pain, cognitive disfunction, and seizure were identified as risk factors for psychiatric disorders in intracranial and spinal tumor patients. The finding underscores the importance of screening and comprehensive psychiatric evaluations in patients with CNS tumors, as psychiatric symptoms may significantly impact their quality of life and treatment outcomes.

Disease burden and healthcare utilization in pediatric low-grade glioma: A United States retrospective study of linked claims and electronic health records.

Background: Despite high long-term survival rates, pediatric low-grade gliomas (pLGGs) are linked with significant tumor- and treatment-associated morbidities that may persist throughout life. The aims of this descriptive cross-sectional pilot study were to characterize health conditions among a cohort of patients with pLGG and explore the feasibility of quantifying disease burden and healthcare resource utilization (HRU). Methods: Optum® Market Clarity Data were used to identify patients aged ≤18 years with an ICD-10 code for brain neoplasm, ≥1 physician notes, and with evidence of pLGG recorded between January 1, 2017 and June 30, 2018. Outcomes including health characteristics, HRU, medications, and procedures were assessed at 6-month intervals over 36 months. Results: One hundred and fifty-four patients were identified with pLGG and over half experienced headache/migraine, respiratory infection, pain, or behavioral issues during the 36-month study period. The most common comorbidities were ocular/visual (including blindness), mental health disorders, seizures, and behavioral/cognition disorders. Most symptoms and comorbidities persisted or increased during the study period, indicating long-term health deficits. HRU, including speciality care visits, filled prescriptions, and administered medications, was common; 74% of patients had prescriptions for anti-infectives, 56% antiemetics, and 52% required pain or fever relief. Sixty-five percent of patients underwent treatment to control their pLGG, the most common being brain surgery. Little decline was observed in medication use during the study period. Conclusions: Patients with pLGG have complex healthcare needs requiring high HRU, often over a long time. Patients need to be optimally managed to minimize disease- and treatment-related burden and HRU.

Comparison of PET/CT and PET/MRI in central nervous system tumors, a narrative review.

BACKGROUND: PET/CT and PET/MRI are two useful imaging modalities in neuro-oncology. Our aim was to review the existing literature on the benefits and drawbacks of using PET/CT and PET/MRI in the diagnosis of central nervous system (CNS) tumors. METHODS: A literature search was conducted using valid databases, limited to English-language articles published between 2010 and 2023, and independently reviewed by two reviewers. A standard data extraction form was used to extract data from the included papers. The results were condensed and narratively presented, accompanied by supporting data from the included investigations. RESULTS: The study analyzed 28 articles, mostly from Europe. The results varied, with some studies comparing PET/CT and PET/MRI, examining specific types of brain tumors, pediatric tumors, or focusing on specific PET/CT or PET/MRI modalities. The synthesis aimed to provide a comprehensive overview of PET/CT and PET/MRI use in CNS malignancies. CONCLUSIONS: PET/MRI offers promising advantages in neuro-oncology diagnosis and follow-up imaging, but its use should be prioritized in appropriate situations.

Locoregional CAR T Cells for the Treatment of CNS Tumors in Children: Investigational Drug Service Pharmacy Activities.

BACKGROUND: A major obstacle in translating the therapeutic potential of chimeric antigen receptor (CAR) T cells to children with central nervous system (CNS) tumors is the blood-brain barrier. To overcome this limitation, preclinical and clinical studies have supported the use of repeated, locoregional intracranial CAR T-cell delivery. However, there is limited literature available describing the process for the involvement of an investigational drug service (IDS) pharmacy, particularly in the setting of a children's hospital with outpatient dosing for CNS tumors. OBJECTIVES: To describe Seattle Children's Hospital's experience in clinically producing CAR T cells and the implementation of IDS pharmacy practices used to deliver more than 300 intracranial CAR T-cell doses to children, as well as to share how we refined the processing techniques from CAR T-cell generation to the thawing of fractionated doses for intracranial delivery. METHODS: Autologous CD4+ and CD8+ T cells were collected and transduced to express HER2, EGFR, or B7-H3-specific CAR T cells. Cryopreserved CAR T cells were thawed by the IDS pharmacy before intracranial delivery to patients with recurrent/refractory CNS tumors or with diffuse intrinsic pontine glioma/diffuse midline glioma. RESULTS: The use of a thaw-and-dilute procedure for cryopreserved individual CAR T-cell doses provides reliable viability and is more efficient than typical thaw-and-wash protocols. Cell viability with the thaw-and-dilute protocol was approximately 75% and was always within 10% of the viability assessed at cryopreservation. Cell viability was preserved through 6 hours after thawing, which exceeded the 1-hour time frame from thawing to infusion. CONCLUSION: As the field of adoptive immunotherapy grows and continues to bring hope to patients with fatal CNS malignancies, it is critical to focus on improving the preparatory steps for CAR T-cell delivery.

Glioblastoma: Overview and Magnetic Resonance Spectroscopy Analysis for Treatment.

Glioblastoma multiforme (GBM) is a very aggressive and fast-growing cancer of the brain that has a low life expectancy. Many new cases are diagnosed every year with each having a very poor prognosis. It is therefore of utmost concern to develop cures for such a devastating condition. Magnetic resonance spectroscopy details certain peaks that are of interest. In particular, later-stage astrocytomas exhibit prominent choline and creatine peaks. The creatine peak is known to enhance glioblastoma survival.

Pathological Evaluation of Diffuse Gliomas Using IDH1 and ATRX in a Resource-Limited Setting.

INTRODUCTION: Classification of gliomas based on tumor histology remains the gold standard in the diagnosis and prognosis of gliomas. However, the recent World Health Organization (WHO) classification has included molecular studies for diagnosis and prognostication. Immunohistochemical markers such as isocitrate dehydrogenase 1 (IDH1) and alpha thalassemia/mental retardation syndrome X-linked (ATRX) can be used for the diagnosis and prognosis of the majority of gliomas. OBJECTIVES: We aim to study the frequencies of IDH1 and ATRX mutations in diffuse gliomas using surrogate immunohistochemical markers and correlate histopathological findings of gliomas with immunohistochemical findings. MATERIAL AND METHODS: This was a retrospective study of one-year duration from January 2022 to December 2022, conducted in the department of pathology. Relevant data was retrieved from medical records. Histopathology blocks were collected and sent for immunohistochemical studies using tissue microarray for IDH1 and ATRX. STATISTICAL ANALYSIS: Qualitative data were expressed in percentages and proportions. The difference in proportion was calculated using the chi-square test, and a p-value of <0.005 was taken as significant. RESULTS: A total of 51 cases of diffuse gliomas were included in the study. The frequency of IDH1-positive diffuse astrocytomas was 33 (64.7%), and loss of ATRX was seen in 12 (23.5%) cases. CONCLUSION: Immunohistochemistry serves as a surrogate marker to detect molecular alterations in diffuse gliomas.

Phase 1 study of NEDD8 activating enzyme inhibitor pevonedistat in combination with chemotherapy in pediatric patients with recurrent or refractory solid tumors (ADVL1615).

PURPOSE: The objective of this study was to determine the recommended Phase 2 dose (RP2D) of pevonedistat, a first in class inhibitor of NEDD8 activating enzyme, in combination with irinotecan (IRN) and temozolomide (TMZ) in children with cancer. METHODS: This Phase 1 study used a rolling 6 design to evaluate escalating doses of pevonedistat in combination with standard doses of IRN and TMZ in pediatric patients with recurrent/refractory solid or CNS tumors. During cycle 1, pevonedistat was administered intravenously on days 1, 8, 10, and 12, with IRN (IV, 50 mg/m2) and TMZ (orally, 100 mg/m2), on days 8-12 of a 28-day cycle. In subsequent cycles, pevonedistat was administered on days 1, 3, and 5, with IRN/TMZ on days 1-5 of a 21-day cycle. RESULTS: Thirty patients enrolled; all were eligible and evaluable for toxicity. Six patients each enrolled on pevonedistat dose levels (DL) 1 (15 mg/m2), 2 (20 mg/m2), 3 (25 mg/m2) and 4 (35 mg/m2) as well as an expanded pharmacokinetic (PK) cohort at DL4. The maximum tolerated dose (MTD) was not exceeded. 2/12 (17 %) patients treated at the RP2D (35 mg/m2) experienced a cycle 1 dose limiting toxicity (DLT). IRN is unlikely to affect the pharmacokinetics of pevonedistat. Two patients had a partial response and 6 patients had prolonged stable disease (> 6 cycles). CONCLUSIONS: Pevonedistat in combination with IRN/TMZ is well tolerated in children with solid or CNS tumors. The RP2D of pevonedistat is 35 mg/m2 on days 1, 3, 5 in combination with IRN/TMZ.

Accelerated Linear Growth during Erdafitinib Treatment: An FGFR-Related, but Growth Factor and Sex Steroid-Independent Mechanism?

INTRODUCTION: Growth acceleration during postnatal growth only occurs during puberty as a physiological event and during catch-up growth mediated by growth-promoting therapies in growth disorders. Here we report on novel observations of skeletal symptoms during treatment with erdafitinib, a tyrosine kinase inhibitor (TKI) prescribed on the basis of a compassionate-use program. METHODS: Analysis of anthropometric, biochemical, clinical, and radiographic data of patients with CNS tumors who revealed an unanticipated growth spurt with initiation of therapy with erdafitinib was performed retrospectively. RESULTS: Linear growth acceleration was independent of sex steroids and IGF1 levels, which is especially remarkable in the context of heavily pretreated pediatric neuro-oncology patients with severe growth impairment before initiation of therapy. Growth acceleration was accompanied by a distinct widening of the growth plate and enhanced metaphyseal mineralization shortly after the start of TKI therapy. CONCLUSIONS: While targeted therapies including TKIs have become an essential part of adult cancer treatment, applications in children are still limited. Off-target effects specific to the pediatric population have been observed in various organ systems; however, knowledge about the effect of TKIs on the growing skeleton is scarce. Treatment with erdafitinib inhibits FGFR3-mediated effects and thus represents a very logical hypothetical framework of growth factor and sex steroid-independent growth acceleration.

Primary central nervous system germ cell tumors in Central America and the Caribbean Region: an AHOPCA 20-year experience.

Background: Primary central nervous system germ cell tumors (GCT) are rare neoplasms in pediatrics. Treatment depends on the histological subtype and extent of the disease. Overall survival (OS) is above 90% for germinomas and 70%-80% for nongerminomatous GCT (NGGCT) in high-income countries (HIC) while data are usually lacking for patients in Low-Middle Income country (LMIC). Objective: This study aims to describe the experience of treating patients with CNS GCT in four of eight countries, members of the Asociación de Hemato-Oncología Pediátrica de Centro América (AHOPCA), and determine their 5-year OS. Design/methods: We conducted a retrospective chart review of patients treated for CNS GCT. Epidemiological and clinical characteristics, histology, treatment modalities, and outcomes were analyzed. Results: From 2001 to 2021, 48 patients were included: 22 from Guatemala, 18 from Nicaragua, three from the Dominican Republic, and five from El Salvador. Thirty-one (64.6%) were boys; the median age at diagnosis was 10.2 years (range: 1 to 17 years). Presenting symptoms were headaches (n = 24, 50%), visual disturbances (n = 17, 35.4%), vomiting (n = 12, 25%), nausea (n = 8, 16.7%), and diabetes insipidus (n = 7, 14.6%). Two patients with NGGCT presented with precocious puberty. Biopsy or tumor resection was performed in 38 cases (79.2%): 23 (88.4%) germinomas, 11 (78.6%) NGGCT, and four (50%) CNS GCT. Eight patients were diagnosed and treated based on CSF tumor marker elevation; four germinomas (BHCG 11.32-29.41 mUI/mL) and four NGGCT (BHCG 84.43-201.97 mUI/mL or positive AFP > 10 UI/mL). Tumor locations included suprasellar (n = 17, 35.4%), pineal (n = 13, 27.1%), thalamus/basal ganglia (n = 5, 10.4%), other (n = 12, 25%), and one bifocal. Four (8.3%) had metastatic disease, and six had positive CSF; staging data were incomplete in 25 patients (52%). Patients were treated with varied chemotherapy and radiotherapy modalities. Nine patients had incomplete data regarding treatment. Five-year OS was 65% (68% for germinoma, 50.6% for NGGCT, and 85.7% for unclassified GCT). Conclusions: Germinoma was the most common histology, and there was a male predominance. More than half of patients had incomplete staging data and treatment was variable across the region. OS is lower compared to HIC. Standardized treatment protocols will aid in adequate staging and treatment planning, prevent complications, and improve survival.

Toxicity profile of high-dose methotrexate in young children with central nervous system tumors.

High-dose methotrexate (HD-MTX) is used in the treatment of children with central nervous system (CNS) tumors; however, toxicity information is limited. We characterized toxicities following 102 administrations of HD-MTX (4.6-13.5 g/m2) infused over 4 or 24 h in 38 children with a CNS tumor before 6 years of age (2010-2020). Delayed clearance of methotrexate occurred following 24% of infusions. Common Terminology Criteria for Adverse Events v5 grade 2-3 mucositis was observed in 47% of individuals, Grade 4 neutropenia in 76%, and grade 3-4 thrombocytopenia in 58%. No neurotoxicity was observed. HD-MTX can be safely used with supportive care and monitoring.

Hjernetegn.dk-The Danish Central Nervous System Tumor Awareness Initiative Digital Decision Support Tool: Design and Implementation Report.

BACKGROUND: Childhood tumors in the central nervous system (CNS) have longer diagnostic delays than other pediatric tumors. Vague presenting symptoms pose a challenge in the diagnostic process; it has been indicated that patients and parents may be hesitant to seek help, and health care professionals (HCPs) may lack awareness and knowledge about clinical presentation. To raise awareness among HCPs, the Danish CNS tumor awareness initiative hjernetegn.dk was launched. OBJECTIVE: This study aims to present the learnings from designing and implementing a decision support tool for HCPs to reduce diagnostic delay in childhood CNS tumors. The aims also include decisions regarding strategies for dissemination and use of social media, and an evaluation of the digital impact 6 months after launch. METHODS: The phases of developing and implementing the tool include participatory co-creation workshops, designing the website and digital platforms, and implementing a press and media strategy. The digital impact of hjernetegn.dk was evaluated through website analytics and social media engagement. IMPLEMENTATION (RESULTS): hjernetegn.dk was launched in August 2023. The results after 6 months exceeded key performance indicators. The analysis showed a high number of website visitors and engagement, with a plateau reached 3 months after the initial launch. The LinkedIn campaign and Google Search strategy also generated a high number of impressions and clicks. CONCLUSIONS: The findings suggest that the initiative has been successfully integrated, raising awareness and providing a valuable tool for HCPs in diagnosing childhood CNS tumors. The study highlights the importance of interdisciplinary collaboration, co-creation, and ongoing community management, as well as broad dissemination strategies when introducing a digital support tool.

From bench to bedside: The promising value of exosomes in precision medicine for CNS tumors.

Exosomes are naturally present extracellular vesicles (EVs) released into the surrounding body fluids upon the fusion of polycystic and plasma membranes. They facilitate intercellular communication by transporting DNA, mRNA, microRNA, long non-coding RNA, circular RNA, proteins, lipids, and nucleic acids. They contribute to the onset and progression of Central Nervous System (CNS) tumors. In addition, they can be used as biomarkers of tumor proliferation, migration, and blood vessel formation, thereby affecting the Tumor Microenvironment (TME). This paper reviews the recent advancements in the diagnosis and treatment of exosomes in various CNS tumors, the promise and challenges of exosomes as natural carriers of CNS tumors, and the therapeutic prospects of exosomes in CNS tumors. Furthermore, we hope this research can contribute to the development of more targeted and effective treatments for central nervous system tumors.

Extracranial metastasis from a frontal embryonal tumor to the parotid: Cytomorphologic features of a rare occurrence.

Embryonal tumors of the central nervous system (CNS) are rare and aggressive malignancies accounting for less than 1% of all central nervous system tumors. The occurrence of metastasis to extracranial sites, especially the parotid region, is highly uncommon. We present a rare case of metastatic frontal embryonal tumor (ET) in the parotid region. A 9-year-old boy presented with a progressively enlarging left parotid mass. Past history revealed that he was a known case of a frontal lobe embryonal tumor. Fine-needle aspiration cytology (FNAC) combined with immunocytochemistry from the parotid revealed a metastatic embryonal tumor. This case report highlights the importance of considering metastatic tumors in evaluating parotid masses, even in pediatric patients, and emphasizes the diagnostic potential of FNAC in diagnosing such rare and unusual tumors for prompt and appropriate patient management.

Secondary cancer risk assessment in healthy organs following craniospinal irradiation.

INTRODUCTION: Medulloblastoma is a central nerves tumor that often occurs in pediatrics. The main radiotherapy technique for this tumor type is craniospinal irradiation (CSI), through which the whole brain and spinal cord are exposed to radiation. Due to the immaturity of healthy organs in pediatrics, radiogenic side effects such as second cancer are more severe. Accordingly, the current study aimed to evaluate the risk of secondary cancer development in healthy organs following CSI. MATERIALS AND METHODS: Seven organs at risk (OARs) including skin, eye lens, thyroid, lung, liver, stomach, bladder, colon, and gonads were considered and the dose received by each OAR during CSI was measured inside an anthropomorphic RANDO phantom by TLDs. Then, the mean obtained dose for each organ was used to estimate the probability of secondary malignancy development according to the recommended cancer risk coefficients for specific organs. RESULTS: The results demonstrated that the stomach and colon are at high risk of secondary malignancy occurrence, while the skin has the lowest probability of secondary cancer development. The total received dose after the treatment course by all considered organs was lower than the corresponding tolerable dose levels. CONCLUSIONS: From the results, it can be concluded that some OARs during CSI are highly at risk of secondary cancer development. This issue may be of concern due to organ immaturity in pediatrics which can intensify the radiogenic effects of radiation exposure. Accordingly, strict shielding the OARs during craniospinal radiotherapy and/or sparing them from the radiation field through modern techniques such as hadron therapy is highly recommended.

Expertise in surgical neuro-oncology. Results of a survey by the EANS neuro-oncology section.

Introduction: Technical advances and the increasing role of interdisciplinary decision-making may warrant formal definitions of expertise in surgical neuro-oncology. Research question: The EANS Neuro-oncology Section felt that a survey detailing the European neurosurgical perspective on the concept of expertise in surgical neuro-oncology might be helpful. Material and methods: The EANS Neuro-oncology Section panel developed an online survey asking questions regarding criteria for expertise in neuro-oncological surgery and sent it to all individual EANS members. Results: Our questionnaire was completed by 251 respondents (consultants: 80.1%) from 42 countries. 67.7% would accept a lifetime caseload of >200 cases and 86.7% an annual caseload of >50 as evidence of neuro-oncological surgical expertise. A majority felt that surgeons who do not treat children (56.2%), do not have experience with spinal fusion (78.1%) or peripheral nerve tumors (71.7%) may still be considered experts. Majorities believed that expertise requires the use of skull-base approaches (85.8%), intraoperative monitoring (83.4%), awake craniotomies (77.3%), and neuro-endoscopy (75.5%) as well as continuing education of at least 1/year (100.0%), a research background (80.0%) and teaching activities (78.7%), and formal interdisciplinary collaborations (e.g., tumor board: 93.0%). Academic vs. non-academic affiliation, career position, years of neurosurgical experience, country of practice, and primary clinical interest had a minor influence on the respondents' opinions. Discussion and conclusion: Opinions among neurosurgeons regarding the characteristics and features of expertise in neuro-oncology vary surprisingly little. Large majorities favoring certain thresholds and qualitative criteria suggest a consensus definition might be possible.

Obstructive Hydrocephalus Due to Aggressive Posterior Fossa Tumor Exhibiting Histological Characteristics of Pilocytic Astrocytoma in Two Adult Neurofibromatosis Type 1 (NF1) Cases.

Neurofibromatosis type 1 (NF1) is an autosomal dominant syndrome caused by germline alteration of the NF1gene. Among various NF1-related manifestations, obstructive hydrocephalus especially in adult NF1 cases is less frequently found. We report two adult NF1 cases exhibiting obstructive hydrocephalus due to an aggressive posterior fossa tumor exhibiting pathological characteristics of pilocytic astrocytoma as NF1-related manifestations. In these two cases, we performed endoscopic third ventriculostomy (ETV) and tumor biopsy as an initial treatment. The initial pathological diagnosis of the tumor is conventional pilocytic astrocytoma. After biopsy both cases revealed rapid tumor growth, therefore, we performed tumor removal, chemotherapy, and radiation therapy during an aggressive clinical course. However, both cases revealed dismal prognosis due to the progression of the tumor in spite of successful management of hydrocephalus by an initial ETV. DNA methylation analysis revealed that the tumor of one case matched high-grade astrocytoma with piloid features (HGAP). Most central nervous system tumors developed in NF1 are less aggressive such as pilocytic astrocytoma; however, recently a few studies revealed that HGAP, which has been a newly introduced malignant tumor in the World Health Organization Classification of Tumors of the Central Nervous System, 5th edition (WHO CNS 5), rarely develops in NF1 cases. These findings suggested that HGAP might be one of the important causes of obstructive hydrocephalus in adult NF1 cases.