Terterov Sergei, Krieger Mark D, Bowen Ira, McComb J Gordon
Division of Neurosurgery, Childrens Hospital Los Angeles, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
J Neurosurg Pediatr. 2010 Aug;6(2):131-6. doi: 10.3171/2010.5.PEDS09333.
The objective of this study was to determine the role of intracranial CSF examination in detecting true cases of early tumor dissemination. Cerebrospinal fluid dissemination is an ominous feature of pediatric brain tumors, occurring in as many as 30% of medulloblastomas, 25% of supratentorial primitive neuroectodermal tumors (PNETs), and 5% of ependymomas at diagnosis. Detecting early dissemination is important for determining both treatment and prognosis. Dissemination can be detected by evaluating imaging of the full neuraxis and by examining CSF cytology. Neuraxis MR imaging and lumbar CSF cytology evaluation are widely accepted methods for determining dissemination. However, the value of examining intracranial CSF cytology in detecting early dissemination is uncertain.
Under an institutional review board-approved protocol, medical records, pathology reports, and radiology reports for 150 patients who had undergone resection of brain tumors (88 with medulloblastomas, 21 with supratentorial PNETs, and 41 with ependymomas) and who had been evaluated using neuraxis MR imaging studies in the last 15 years were retrospectively reviewed. Radiology results were compared with the CSF cytology results and long-term disease outcomes.
Between lumbar and intracranial CSF cytology results, 7 of 40 were discordant: in 2 intracranial CSF was negative and lumbar CSF was positive, and in 5 the reverse was true. The discordance percentage was 18%, with a kappa statistic of 0.36. Between MR imaging and lumbar CSF cytology results, 11 of 65 were discordant: in 9 the lumbar CSF was negative and MR imaging was positive, and in 2 the reverse was true. The discordance percentage is 17%, with a kappa statistic of 0.27. Between MR imaging and intracranial CSF cytology results, 8 of 52 were discordant: in 3 intracranial CSF was negative and MR imaging was positive, and in 5 the reverse was true. The discordance rate was 15%, with a kappa statistic of 0.41. Patients with positive and negative results on perioperative neuraxis MR imaging studies had a median survival of 26.8 and 33.1 months, respectively (p = 0.02). Patients with positive and negative results on perioperative lumbar CSF cytology had a median survival of 20.1 and 31.4 months, respectively (p = 0.11). Patients with positive and negative results on intracranial CSF cytology had a median survival of 31 and 31.4 months, respectively (p = 0.84).
Discordance exists between the results of neuraxis MR imaging and lumbar and intracranial CSF cytology in perioperative detection of tumor dissemination for pediatric medulloblastoma, supratentorial PNETs, and ependymoma. In 1 case in this series, perioperative dissemination was detected by intracranial CSF cytology, but not by lumbar CSF cytology or neuraxis MR imaging. Isolated intracranial CSF cytology positivity may represent an earlier stage of disseminated disease. Complementary use of perioperative neuraxis MR imaging and lumbar and intracranial CSF cytology can reduce the incidence of missed diagnoses of dissemination. Survival analysis revealed that perioperative neuraxis MR imaging findings are correlated with survival, whereas perioperative lumbar and intracranial CSF cytology findings are not.
本研究的目的是确定颅内脑脊液检查在检测早期肿瘤播散真实病例中的作用。脑脊液播散是小儿脑肿瘤的一个不祥特征，在髓母细胞瘤诊断时发生率高达30%，幕上原始神经外胚层肿瘤（PNETs）为25%，室管膜瘤为5%。检测早期播散对于确定治疗和预后都很重要。播散可通过评估全神经轴成像和检查脑脊液细胞学来检测。神经轴磁共振成像和腰椎脑脊液细胞学评估是确定播散的广泛接受的方法。然而，检查颅内脑脊液细胞学在检测早期播散中的价值尚不确定。
根据机构审查委员会批准的方案，回顾性审查了150例接受脑肿瘤切除术（88例髓母细胞瘤、21例幕上PNETs和41例室管膜瘤）且在过去15年中接受过神经轴磁共振成像研究评估的患者的病历、病理报告和放射学报告。将放射学结果与脑脊液细胞学结果及长期疾病转归进行比较。
在腰椎和颅内脑脊液细胞学结果之间，40例中有7例不一致：2例颅内脑脊液为阴性而腰椎脑脊液为阳性，5例情况相反。不一致率为18%，kappa统计量为0.36。在磁共振成像和腰椎脑脊液细胞学结果之间，65例中有11例不一致：9例腰椎脑脊液为阴性而磁共振成像为阳性，2例情况相反。不一致率为17%，kappa统计量为0.27。在磁共振成像和颅内脑脊液细胞学结果之间，52例中有8例不一致：3例颅内脑脊液为阴性而磁共振成像为阳性，5例情况相反。不一致率为15%，kappa统计量为0.41。围手术期神经轴磁共振成像研究结果为阳性和阴性的患者中位生存期分别为26.8个月和33.1个月（p = 0.02）。围手术期腰椎脑脊液细胞学结果为阳性和阴性的患者中位生存期分别为20.1个月和31.4个月（p = 0.11）。颅内脑脊液细胞学结果为阳性和阴性的患者中位生存期分别为31个月和31.4个月（p = 0.84）。
在小儿髓母细胞瘤、幕上PNETs和室管膜瘤围手术期检测肿瘤播散时，神经轴磁共振成像结果与腰椎和颅内脑脊液细胞学结果之间存在不一致。在本系列病例中有1例，围手术期播散通过颅内脑脊液细胞学检测到，但未通过腰椎脑脊液细胞学或神经轴磁共振成像检测到。孤立的颅内脑脊液细胞学阳性可能代表播散性疾病的早期阶段。围手术期神经轴磁共振成像与腰椎和颅内脑脊液细胞学的联合应用可降低播散漏诊的发生率。生存分析显示，围手术期神经轴磁共振成像结果与生存相关，而围手术期腰椎和颅内脑脊液细胞学结果与生存无关。
