Kao G D, Goldwein J W, Schultz D J, Radcliffe J, Sutton L, Lange B
Hospital of the University of Pennsylvania Department of Radiation Oncology, Philadelphia 19104.
Cancer. 1994 Aug 1;74(3):965-71. doi: 10.1002/1097-0142(19940801)74:3<965::aid-cncr2820740328>3.0.co;2-z.
Despite success in treating children with medulloblastoma/posterior fossa primitive neuroectodermal tumor (PF PNET), some children survive with significant neurocognitive sequelae. This study was performed to understand better the significance of perioperative factors on subsequent full scale intelligence quotient (FSIQ) deterioration in these children.
Twenty-eight children who underwent prospective and serial neurocognitive testing were studied. All children underwent surgery followed by radiotherapy with or without chemotherapy between 1983 and 1987 for medulloblastoma/PF PNET and were disease free when this study was conducted. IQ testing was performed before surgery and after the completion of radiation therapy. The clinical courses of the patients were correlated with changes in the corresponding intelligence quotients of each child. Factors correlating with neurocognitive declines were examined by chi-square or Fisher exact test analysis. Differences in mean IQs were examined by the t test. Factors found to be significant were analyzed by exact logistic regression analysis.
The presence of adverse factors such as neurologic deficits, meningitis, or shunt infections, or the need for repeat surgery was correlated significantly with IQ deficits after treatment. Of the subset of children with one or more of these factors, 13 of 16 (81%) sustained decreases in FSIQ; 7 of 16 (43.8%) had decreases of 20 points of more. In contrast, only 3 of 12 (25%) of the children without the factors sustained FSIQ decreases, and no child sustained a decrease of more than 13 points. The mean FSIQ change after treatment in the group with factors was -15.7 (95% confidence interval [CI]: -24.0, -8.4), and the median was -18. The mean FSIQ change in the group without factors was 4.8 (95% CI: -0.5, 10.1), and the median was 5. The difference in mean FSIQ change between the two groups was significant (P < 0.0001). On univariate analysis, both the presence of adverse factors and an age less than six years correlated with neurocognitive deficit. On regression analysis, only the presence of adverse factors was significant (odds ratio 11.53; 95% CI, 1.65-116.58; P = 0.009), whereas age was not (P = 0.27).
Perioperative events or complications may account for some of the neurocognitive deterioration seen in these children after treatment, especially in the very young. The occurrence of these factors is associated with a significantly greater risk of IQ deterioration. Studies of the neurocognitive effects of treatment for children with medulloblastoma/PF PNET should include an analysis of these postoperative factors.
尽管在治疗髓母细胞瘤/后颅窝原始神经外胚层肿瘤（PF PNET）患儿方面取得了成功，但仍有一些患儿存活下来并伴有严重的神经认知后遗症。进行这项研究是为了更好地了解围手术期因素对这些患儿随后全量表智商（FSIQ）下降的影响。
对28名接受前瞻性和系列神经认知测试的患儿进行了研究。所有患儿在1983年至1987年间因髓母细胞瘤/PF PNET接受了手术，随后接受了放疗，部分患儿还接受了化疗，在本研究开展时均无疾病。在手术前和放疗结束后进行了智商测试。将患者的临床病程与每个患儿相应智商的变化进行关联。通过卡方检验或Fisher精确检验分析与神经认知下降相关的因素。通过t检验检查平均智商的差异。对发现有显著意义的因素进行精确逻辑回归分析。
存在诸如神经功能缺损、脑膜炎或分流感染等不良因素，或需要再次手术，与治疗后的智商缺损显著相关。在具有这些因素中一项或多项的患儿亚组中，16名中有13名（81%）FSIQ持续下降；16名中有7名（43.8%）下降了20分或更多。相比之下，没有这些因素的12名患儿中只有3名（25%）FSIQ持续下降，且没有患儿下降超过13分。有因素组治疗后的平均FSIQ变化为-15.7（95%置信区间[CI]：-24.0，-8.4），中位数为-18。无因素组的平均FSIQ变化为4.8（95%CI：-0.5，10.1），中位数为5。两组平均FSIQ变化的差异具有显著性（P < 0.0001）。单因素分析显示，不良因素的存在和年龄小于6岁均与神经认知缺陷相关。回归分析显示，只有不良因素的存在具有显著性（比值比11.53；95%CI，1.65 - 116.58；P = 0.009），而年龄则无显著性（P = 0.27）。
围手术期事件或并发症可能是这些患儿治疗后出现部分神经认知衰退的原因，尤其是在幼儿中。这些因素的出现与智商下降的风险显著增加相关。对髓母细胞瘤/PF PNET患儿治疗的神经认知影响的研究应包括对这些术后因素的分析。
