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David Walker, Giorgio Perilongo, Jonathan Punt, Roger E. Taylor Hodder Arnold: London. 2004 531 pp. $119.00, 0-34076-260-8.
Walker and colleagues have assembled an outstanding team of authors, with significant contributions from European collaborators, to write on brain and spinal tumors of childhood. While you cannot necessarily judge a book by its cover, the cover of this multiauthor text very accurately portrays the comprehensive and holistic approach taken throughout the book to address the problem of central nervous system neoplasia in children. The cover depicts advances in science with images of neuronal cells in culture and state-of-the-art neuro-imaging with an MR image of a craniopharyngioma in a child, and it also depicts the care of the psychosocial aspects of the child with an image of children playing together in a circle. The authors kindly acknowledge the work of Dr. Joachin Kuhl, a contributor to the book, who suddenly and unexpectedly died of a brain tumor during the production of the book. His enduring contribution to the book is on the topic of embryonic tumors.
There is no question that we need a book like this. While absolute numbers of tumors in childhood are lower than in adulthood, the wide variety of tumors seen in childhood speaks to the need for a detailed and comprehensive compendium of information as is found within the various chapters of this book.
The book is carefully and thoughtfully divided into sections addressing epidemiology, diagnosis and planning, treatment techniques and neurotoxicity, disease-specific multidisciplinary planning and management, and late consequences and supportive care. The treating physician who is looking after a child with a brain tumor will fully appreciate the relevance of the information that takes one from the moment of diagnosis all the way through to years after treatment.
It was refreshing to read the historical perspective on the developing subspecialty of neuro-oncology (chapter 2). The appendix of this chapter contains a time line that is extremely valuable in showing the rapid escalation of neuro-oncology activities that have come forward in the last 30 years alone.
Chapter 3 on epidemiology by Stiller and Bleyer is state of the art. Contained within this chapter are lists of the known and suspected risk factors that likely contribute to pediatric brain tumors. Chapter 4a on neuro-embryology by Scotting and Appleby succinctly summarizes the control of brain development and contains numerous informative sketches that demonstrate the links of embryologic development of the central nervous system to brain tumorigenesis.
In chapter 5 on pathology and molecular classification, Giangaspero and Wiestler review in excellent detail the large number of tumors that can afflict a child’s brain and spinal cord. A conundrum unsolved to this day is the difference between high-grade gliomas in children and adults. Information regarding this conundrum is provided in this chapter and again in chapters on tumor biology (chapter 4b) and high-grade astrocytic tumors (chapter 14). My only issue with chapter 5 is that the many excellent histopathology color plates are not contained within the chapter but are found instead in chapter 7. Most likely this resulted from a publishing issue and not an editorial one.
Chapter 6 is devoted entirely to a description of clinical syndromes. These days, with the advent of advanced imaging strategies, it is easy to forget the importance of the general clinical and neurologic examinations of the child with a brain tumor. However, the information in this chapter brings us in close touch with the reality of performing a complete history and physical examination, not only to help establish a diagnosis but also to prepare us for the complications that can occur after treatments.
Chapter 7 on diagnostic imaging by Jaspan and Griffiths is a gem. The numerous high-resolution images provided within this chapter cover virtually the entire range of tumor types seen in pediatric neuro-oncology. After rereading this chapter, however, it was still not clear to me what the authors were recommending in terms of spinal imaging for children, for example, with posterior fossa tumors at the time of diagnosis. This particular situation is commonplace, and our policy at the University of Toronto has been to perform immediate spinal imaging in a child in whom we suspect an aggressive tumor such as ependymoma, atypical teratoid rhab-doid tumor, or medulloblastoma. We would not image the spine, however, for a child with suspected cerebellar astrocytoma. These days, in discussions with our neuro-radiologists, we can usually determine which children need spinal imaging at the time of diagnosis of posterior fossa tumors. Performing the spinal imaging at the time of diagnosis simplifies the child’s treatment and stratification into protocols subsequently. In this chapter, it was highly informative to read the authors’ description of the difficulties with interpreting postsurgical changes.
Clinical trials in pediatric neuro-oncology are the sine qua non of the subspecialty and are essential for our future success with pediatric brain tumors. Chapter 8 by Sposto is an excellent review of the concept and theories behind the design of clinical trials. The uninitiated will be well served to learn the fundamental differences in design among phase I, II, and III clinical trials. This particular chapter also provides sufficient detail that students can become familiar with the processes of randomization, power, and numbers of patients needed to answer the study question.
Frequently, the first step in the care for any child with a brain tumor will be surgery. Chapter 9 by Tyagi and Chumas on neurosurgical techniques provides an excellent overview of the different neurosurgical approaches to brain tumors in different regions. MR images are provided of various brain tumors, and arrows have been placed on these images that conveniently depict the different surgical pathways that can be taken to remove tumors in the pineal and suprasellar regions, for example.
Throughout the book, there are numerous, informative case examples that are extremely meaningful. For instance, in chapter 10 on radiotherapy techniques, Kortmann et al. describe some cases that place the theme of the chapter in a clinical context. Additionally, editorial comments decorate the book which underscore some of the controversies that exist in pediatric neuro-oncology. One such example is found in chapter 10 regarding the provision of anesthesia to children undergoing cranio-spinal irradiation. In general, throughout the book, well-constructed tables summarize, with references, the types of trials that have been undertaken in the fields of radiation therapy, chemotherapy, and surgery.
Chapter 11 by Dennis et al. discusses neuropsychological outcomes in children. Although most pediatric neuro-oncologists are familiar with the cerebellar mutism syndrome with subsequent dysarthria that is now well described if poorly understood, cerebellar cognitive affective syndrome may be new to many treating physicians. Because the preponderance of brain tumors in children may be found in the cerebellum or the posterior fossa, it is incumbent on us to understand deficits that can be created after our treatments.
As for disease-specific tumors, these are covered laudably. A comprehensive listing of chemotherapy trials for low-grade gliomas is found in chapter 13a, and chapter 13b provides a description of the rare but well-established complication of the disseminated and progressive low-grade glioma that will require special treatment strategies.
High-grade gliomas are discussed by Wolff and Chastagner in chapter 14. While the numbers of clinical trials that have been performed in adults overshadow those performed in children, it is my strong impression that in this next decade, we will determine those chemo-therapeutic agents that will help improve the prognosis of children with this disease. These advances will come with a greater understanding of the true genetic differences between adult and pediatric high-grade gliomas.
Chapter 15 on brainstem tumors by Walker et al. begins with a figure depicting the anatomical sites where brainstem tumors occur. Brainstem tumors are now classified most effectively on the basis of their location, which (interestingly) correlates with their pathology in most instances. A very good editorial on the use of corticosteroids in symptomatic patients is provided here. A remarkable case is presented of a child with an exophytic medullary brainstem tumor that underwent spontaneous involution. This is a unique phenomenon in pediatric neuro-oncology but one that most large services have witnessed from time to time. As in other chapters, the tables here are very informative and can steer the reader quickly to pertinent references for treatment.
Chapter 17 on ependymomas by Kulkarni et al. contains numerous valuable tables with some excellent information on chemotherapy trials and outcomes. Case studies enhance chapter 18a on germ cell tumors, and in chapter 18b an insightful commentary is given by Jonathan Finlay on some controversial aspects of this type of tumor. I was also pleased to see a complete chapter devoted to the special problem of the infant with a brain tumor.
Chapter 20 by Hayward et al. addresses craniopharyngioma, one of the most vexing tumors known to the pediatric neurosurgeon and neuro-oncologist. The authors have provided a very balanced perspective on management of craniopharyngioma, including an algorithm that will help plan pathways for treatment. The authors have identified certain risk factors for craniopharyngioma, such as ventricular size, tumor size and location, and patient presentation, that predict patient outcome ab initio.
In chapter 22, rare tumors are presented by Grundy and Mallucci. As mentioned above, the numbers of types of tumors that are seen in childhood far exceed those found in adults. Hence, it is appropriate to discuss tumors such as pleomorphic xanthoastrocytoma, desmoplastic ganglioglioma, and dysembryoplastic neuro-epithelial tumors in a separate chapter such as this.
One of the real strengths of the book is section 6 devoted to the late consequences of treatment and supportive care. Chapter 24 by Spoudeas and Kirkham provides an excellent summary of the endocrinologic, neurologic, and general physical long-term effects of treatments in children. The holistic approach to the child with a brain tumor is presented in this section. It is clear that a very large team may need to be mobilized to help care for the child with a brain tumor. A list of more than 30 treating professionals is provided that illustrates this point most effectively. Complementary therapies such as massage therapy and aromatherapy are discussed in chapter 25. Case studies provided in chapter 26 specifically relate to individual children, on a first-name basis, and highlight their needs for rehabilitation.
In summary, this book is highly recommended not only for the neuro-oncology specialist in the academic or community setting but also for primary care physicians, nurses, physiotherapists, rehabilitation experts, and neuropsychologists, all of whom, and more, have opportunities to see, treat, and care for children with brain tumors. The text has been well edited and is supplemented in numerous chapters with excellent case examples, commentaries, and editorials. Details of previous clinical trials can be obtained at a glance from the many highly informative tables. It was refreshing to see the attention being paid to one of the most difficult and exacting disease processes known to the human race.