Radiol Oncol 2000; 34(3): 295-300. Ependymomas in adult patients: Results of adjuvant radiotherapy Ramona Mayer1, Ulrike Prettenhofer1, Franz Quehenberger2, Helmut Guss1, Arnulf Hackl1 1 Dept. of Radiotherapy, 2Dept. of Medical Informatics, Statistics and Documentation, University Medical School of Graz, Austria Background. As ependymomas are rare tumours and experiences base on the results of retrospective studies, we assess the survival and pattern of recurrence in eight adult patients with intracranial or spinal ependymoma -who were treated with adjuvant radiotherapy. Patients and methods. The data of a series of adult patients with low/intennediate (7) or high-grade (1) ependymomas receiving postoperative radiotherapy are presented. Between 1985 and 1994, eight patients (mean age 41 years, range 18-55 years) with intracranial (2) or spinal (6) ependymoma were irradiated either after macroscopically complete surgery (4), or incomplete surgery (1) or for salvage after incomplete resection of local recurrence (3). Radiotherapy with a mean dose of 52 Gy (range, 50-54Gy) was given to generous local fields with boost, not to the entire craniospinal axis. Results. Median follow-up was 101 months (range, 12-146 months); the 5-year overall survival and disease-free survival were 100 % and 8z %, respectively. Infield failure occurred in one patient with intracranial and one with spinal ependymoma 77 months after radiotherapy in both cases. Initially, these two patients had been irradiated after incomplete resection ofa recurrent tumour. Two patients with spinal cord tumours showed outfield failure in the spinal cord 38 and 86 months after radiotherapy. No irradiation induced late effects were observed. Conclusions. Adjuvant radiotherapy after incomplete surgery and/or local recurrence and/or high-grade tumours seems to be efficient to prolong local control in this rare disease. Key words: ependymoma-surgery-radiotherapy; radiotherapy, adjuvant; adult Received 10 April 2000 Accepted 24 May 2000 Correspondence to: Dr. Rarnona Mayer, M.D., Dept. of Radiotherapy, University Medical School, Auen-bruggerplatz 32, A-8036 Graz, Austria; Phone: ++43 316 385 2639; Fax: ++43 316 71 01 14; E-mail: ramona.mayer@kfunigraz.ac.at 296 Mayer et al. / Adjuvant radiotherapy far ependymomas Introduction Ependymomas derive from ependymal cells lining the ventricular system and the central spinal canal. They are rare tumours and experiences base on the results of retrospective studies.144 About 60 % of the intracranial ependymomas are located infratentorially, most commonly in the fourth ventricle, while 40 % evolve supratentorially.15 About half of supratentorial tumours are located intraven-tricularly, while the remainder appear to be intraparenchymal, arising perhaps from remote fetal ependymal cell rests.16 Intracranial ependymomas generally occur in children and young adults. Spinal cord tumours, however are seen more frequently in adult patients in the fourth and fifth decade with the lumbosacralis axis as a common site. This study reviews survival and pattern of recurrence in eight adult patients with intra-cranial or spinal ependymoma. Material and methods Patients characteristics From August 1984 through April 1995, eight adult patients with histologically praven ependymoma received radiotherapy at some phase in their treatment. Four patients were irradiated postoperatively after macroscopi-cally complete surgery, one patient after incomplete surgery, and three patients underwent incomplete surgery and postoperative radiotherapy for salvage. Details are given in Table 1. There were 4 male and 4 female patients, their median age was 44 years (range, 18-55 years). Two patients had an intracranial tumour; one supratentorial ependymoma was found in the third ventricle and one infratentorial tumour was located in the fourth ventricle. Six patients had ependymomas of the spinal cord, which were located in the thoracolum- bar and lumbar region in three patients, respectively. No patient had evidence of distant metastases. The tumours were classified according to the degree of histologic differentiation, there were seven low/intermediate-grade and one high-grade tumour. Myxopapillary subtype was found in one patient, papillary in three, cellular and anaplastic subtype in one case, respectively. No information on histologic subtype was evident in 2 patients. In earlier years diagnostic evaluation of the primary tumour included ventriculography and myelography, whereas in recent years, computed tomography and magnetic resonance imaging have usually been performed. Most frequent symptom in patients with spinal tumours was low-back pain. Few days before diagnosis, the tumour caused spastic hemiparesis in three patients. In one patient with spinal ependymoma no information about the kind and duration of symptoms was available. Both patients with intracranial tumours had suffered from headache for 3 years and 2 months, respectively. Few days before diagnosis, the symptoms of increasing intracranial pressure were recorded. Details are shown in Table 1. External radiotherapy Seven patients received a mean dose of 52 Gy (50-54 Gy) to the tumour bed including a safety margin and an additional boost; one patient had a whole-brain irradiation followed by a boost. No irradiation of the entire craniospinal axis was performed. Daily doses were 1.7 - 2.0 Gy 5 days per week. All fields were treated daily. Photon beams were used in five patients, two patients were irradiated with electrons and, in earlier years, one patient had a Cobalt-60 therapy. Treatment planning CT scans for the determination of the target volume were done routinely. No patient had chemotherapy additionally. Radiol Oncol 2000; 34(3): 295-300. 297 Mayer et al. / Adjuvant radiotherapy far ependymomas Table l. Patient's characteristics including the treatment modality and outcome Age Site Grade Symptoms Initial Tirne to Surgery and Progression Outcome Kind Duration surgery failure radiation dose Intervali Site Treatment 18 supratentorial 1 Headache Vertigo Neck stiffness 2 mos 3 days R0 122 mos R2 + 50 Gy 77 mos Infield Radiosurgery 111mos AwD 30 supratentorial cell.l-1 Headache Nausea, Emesis 3 years 6 days R0 + 54 Gy 119 mosNED 53 Th12-S1 1 Dysbasia Hemiparesis 3 mos 6 days R1 + 522 Gy 12 mosNED 44 TH12- L1 myxopap.11 Low back pain Hemiparesis 2mos 4 days R0 + 50 Gy 38 mos 23 mos Outfield