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Object: Complete ependymoma resection ensures a better prognosis for children with this tumor, but the complete excision of infratentorial ependymomas involves serious risks. Second-look surgery for tumor remnants may be less harmful and enable complete removal. There is a potential, although still unclear, role for neoadjuvant chemotherapy in preparation for further surgery., Methods: Since 1994, the authors have adopted two successive protocols for intracranial ependymoma, both including a phase of adjuvant chemotherapy for children with surgical tumor remnants with a plan for potential second-look surgery before radiotherapy., Results: In the first protocol, 9 of 63 children underwent further surgery, and 6 became tumor free with no additional sequelae. Their prognosis for progression-free survival and freedom from local relapse was comparable to that of children who were operated on only once. In the second protocol, efforts were made to achieve complete resection and 29 of 110 patients underwent reoperations: 9 after the first surgery, 17 after chemotherapy, and 3 soon after radiotherapy. Fourteen of the 29 patients became tumor free, 1 of them with worsening neurological symptoms. The outcome of the 66 patients who became tumor free after 1 operation was compared with that of the 14 who became tumor free after reoperation. The 3-year progression-free survival of the 66 patients compared with the 14 other patients was 71.4% ± 6.9% and 90% ± 9.5%, respectively; the 3-year freedom from local relapse was 84.7% ± 5.9% and 90% ± 9.5%, respectively; and the 3-year overall survival was 85.9% ± 5.4% and 87.5% ± 11.7%, respectively., Conclusions: Second-look surgery proved feasible with no major morbidity, and results improved with time. Local tumor control was comparable in patients undergoing 1 or more resections.

Purpose: The protocols of the 1990s omitted or delayed irradiation, using upfront chemotherapy to spare the youngest children with ependymoma the sequelae of radiotherapy (RT). We treated 41 children under the age of 3 years with intracranial ependymoma between 1994 and 2003., Patients and Methods: After surgery, chemotherapy was given as follows: regimen I with four blocks of vincristine, high-dose methotrexate 5 g/m(2), and cyclophosphamide 1.5 g/m(2) alternating with cisplatin 90 mg/m(2) plus VP16 450 mg/m(2) for 14 months; subsequently, regimen II was used: VEC (VCR, VP16 300 mg/m(2), and cyclophosphamide 3 g/m(2)) for 6 months. Radiotherapy was planned for residual tumor after the completion of chemotherapy or for progression., Results: We treated 23 boys and 18 girls who were a median 22 months old; 14 were given regimen I, 27 were given regimen II; 22 underwent complete resection, 19 had residual tumor. Ependymoma was Grade 2 in 25 patients and Grade 3 in 16; tumors were infratentorial in 37 patients and supratentorial in 4. One child had intracranial metastases; 29 had progressed locally after a median 9 months. Event-free survival was 26% at 3 and 5 years and 23% at 8 years. One child died of sepsis, and another developed a glioblastoma 72 months after RT. Progression-free survival was 27% at 3, 5, and 8 years, and overall survival was 48%, 37%, and 28% at 3, 5, and 8 years, respectively. Of the 13 survivors, 6 never received RT; their intellectual outcome did not differ significantly in those children than in those without RT., Conclusions: Our results confirm poor rates of event-free survival and overall survival for up-front chemotherapy in infant ependymoma. No better neurocognitive outcome was demonstrated in the few survivors who never received RT., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Neurotrauma is one of the most important causes of death in the pediatric age group. Head injury is responsible for both primary and secondary brain damage. The outcome of children with brain injury depends on the nature of the primary damage and on how well secondary brain damage can be limited. Appropriate critical care management at the scene and in hospital can prevent secondary brain damage that would otherwise result from cerebral reactions. Hypoxia and hypotension are major early complications of aggravation of secondary brain damage that are amenable to emergency maneuvers at the scene. In the literature, the influence of initial critical care management and early complications on the outcome of children with severe head injury is not clearly documented., Methods and Results: We have prospectively examined the impact of the management at the scene on outcome in 40 children admitted to our Pediatric Intensive Care Unit with severe head injury (Glasgow Coma Scale < or = 8). The outcome of these children was assessed using the Glasgow Outcome Score (GOS). The results were evaluated by univariate and multivariate analysis. In our series the length of time before admission to an intensive care unit appears to have influenced the outcome among survivors, while the severity of injury is the only factor statistically associated with early complications (hypoxia and hypotension). With regard to the impact of early complications on outcome, the multivariate analysis showed that hypoxia and hypotension were significantly associated with GOS, independently of the GCS., Conclusion: Our results confirm the need for a precise treatment strategy for the initial management of children with neurotrauma to decrease the incidence of secondary brain damage attributable to hypoxia and hypotension.