A Diagnostic Algorithm for Posterior Fossa Tumors in Children: A Validation Study

BACKGROUND AND PURPOSE:Primary posterior fossa tumors comprise a large group of neoplasias with variable aggressiveness and short and long-term outcomes. This study aimed to validate the clinical usefulness of a radiologic decision flow chart based on previously published neuroradiologic knowledge for the diagnosis of posterior fossa tumors in children.MATERIALS AND METHODS:A retrospective study was conducted (from January 2013 to October 2019) at 2 pediatric referral centers, Children''s Hospital of Philadelphia, United States, and Great Ormond Street Hospital, United Kingdom. Inclusion criteria were younger than 18 years of age and histologically and molecularly confirmed posterior fossa tumors. Subjects with no available preoperative MR imaging and tumors located primarily in the brain stem were excluded. Imaging characteristics of the tumors were evaluated following a predesigned, step-by-step flow chart. Agreement between readers was tested with the Cohen κ, and each diagnosis was analyzed for accuracy.RESULTS:A total of 148 cases were included, with a median age of 3.4 years (interquartile range, 2.1–6.1 years), and a male/female ratio of 1.24. The predesigned flow chart facilitated identification of pilocytic astrocytoma, ependymoma, and medulloblastoma sonic hedgehog tumors with high sensitivity and specificity. On the basis of the results, the flow chart was adjusted so that it would also be able to better discriminate atypical teratoid/rhabdoid tumors and medulloblastoma groups 3 or 4 (sensitivity = 75%–79%; specificity = 92%–99%). Moreover, our adjusted flow chart was useful in ruling out ependymoma, pilocytic astrocytomas, and medulloblastoma sonic hedgehog tumors.CONCLUSIONS:The modified flow chart offers a structured tool to aid in the adjunct diagnosis of pediatric posterior fossa tumors. Our results also establish a useful starting point for prospective clinical studies and for the development of automated algorithms, which may provide precise and adequate diagnostic tools for these tumors in clinical practice.

In the past 10 years, there has been an exponential increase in knowledge of the molecular characteristics of pediatric brain tumors, which was only partially incorporated in the 2016 World Health Organization Classification of Tumors of the Central Nervous System.¹ The main update in the 2016 Classification was the introduction of the molecular profile of a tumor as an important factor for predicting different biologic behaviors of entities which, on histology, look very similar or even indistinguishable.² A typical example is the 4 main groups of medulloblastoma: wingless (WNT), sonic hedgehog (SHH) with or without the p53 mutation, group 3, and group 4. Although they may appear similar on microscopy, these categories have distinct molecular profiles, epidemiology, prognosis, and embryologic origin.³Subsequent to the publication of the 2016 World Health Organization Classification, further studies have identified even more molecular subgroups of medulloblastoma with possible prognostic implications⁴ and also at least 3 new molecular subgroups of atypical teratoid/rhabdoid tumor (AT/RT)⁵ and several subgroups of ependymoma.⁶ MR imaging shows promise as a technique for differentiating histologic tumors and their molecular subgroups. This capability relies on not only various imaging characteristics but also the location and spatial extension of the tumor, evident on MR imaging, which can be traced to the embryologic origin of the neoplastic cells.^5,7-10One approach to the challenge of identifying imaging characteristics of different tumors in children is to use artificial intelligence. Yet despite this exciting innovation, correctly identifying the location of the mass and its possible use as an element for differential diagnosis still requires the expertise of an experienced radiologist. Previously, D''Arco et al¹¹ proposed a flow chart (Fig 1) for the differential diagnosis of posterior fossa tumors in children based on epidemiologic, imaging signal, and location characteristics of the neoplasm. The aims of the current study were the following: 1) to validate, in a retrospective, large cohort of posterior fossa tumors from 2 separate pediatric tertiary centers, the diagnostic accuracy of that flow chart, which visually represents the neuroadiologist''s mental process in making a diagnosis of posterior fossa tumors in children, 2) to describe particular types of posterior fossa lesions that are not correctly diagnosed by the initial flow chart, and 3) to provide an improved, clinically accessible flow chart based on the results.Open in a separate windowFIG 1.Predesigned radiologic flow chart created according to the literature before diagnostic accuracy analysis. The asterisk indicates brain stem tumors excluded from the analysis. Double asterisks indicate relative to gray matter. Modified with permission from D''Arco et al.¹¹     

Radiotherapy-induced malignancies in breast cancer patients with TP53 pathogenic germline variants (Li–Fraumeni syndrome)

Familial Cancer - The risk of radiotherapy-induced malignancies (RIMs) is a concern when treating Li–Fraumeni syndrome (LFS) or Li–Fraumeni Like (LFL) patients. However, the type of...     

Lower sperm quality and testicular and epididymal structural impairment in adult rats exposed to rosuvastatin during prepuberty

The increase of obesity, bad eating habits and the lack of physical exercises are highly related to dyslipidemias. Rosuvastatin is a lipid‐lowering drug and has been indicated to prevent cardiovascular diseases and to treat dyslipidemias due to its higher efficiency to reduce serum cholesterol concentrations. This study aimed to evaluate the reproductive adverse effects on sexual maturity due to rosuvastatin exposure in juvenile male rats during prepuberty. Three groups were randomly formed with newly weaned rats: control, whose rats received saline solution 0.9% and rosuvastatin at doses of 3 or 10 mg kg^–1 day^–1, administered orally by gavage, from postnatal day 21 until preputial separation (average of 45 days for controls and 49 days for statin‐treated animals), indicative of puberty onset. Male rats were maintained until sexual maturity and were killed on postnatal day 110. In the rosuvastatin‐treated groups, the results showed diminished follicle‐stimulating hormone, luteinizing hormone and testosterone concentrations, increased estradiol and prolactin concentrations, histopathologic alterations on testis and epididymis and decreased sperm quality. Moreover, statin‐exposed groups showed decreased expression of androgen receptor on testis and epididymis and lower expression of aquaporin‐9 on epididymal epithelium. In conclusion, administration of rosuvastatin to prepubertal male rats provoked long‐term hormonal deregulation and impaired reproduction at adulthood.     

Epidermal growth factor receptor 2 immunoexpression in gastric cells of domestic cats with H. heilmannii infection

The aim of this study was to evaluate the immunoexpression of HER-2 in gastric cells of cats infected with Non H. pylori Helicobacter (NHPH) and to investigate an association with the presence of inflammatory infiltrate. Forty-eight paraffin-embedded gastric samples were retrieved from the archives of the Veterinary Anatomic Pathology Laboratory that had previously been shown to be positive for NHPH with the rapid urease test and cytology. Infection by NHPH was confirmed by histopathology using the Warthin-Starry staining. Hematoxylin-eosin stained sections were reviewed to evaluate inflammatory cell infiltrates. Immunohistochemical analysis was done using anti- H. pylori antibody and anti-HER-2 antibody. Molecular analysis was performed by PCR to confirm the presence of Helicobacter. Statistical analysis was performed to determine whether there was an association between the presence of H. Heilmannii and HER-2 expression in gastric samples. All samples were positive for NHPH, by immunohistochemistry, and confirmed by PCR as H. Heilmannii. On histopathologic analysis, 56,3% of the samples had lymphocytes and plasma cells infiltrates, 52,1% of which were mild and 4,2% moderate. The intensity of the inflammatory infiltrate in the gastric mucosa was significantly greater in the complete plasma membrane of parietal cells of gastric glands that had greater HER-2 immunoexpression (p = 0.0001). A statistically significant association (p = 0.007) between the H. Heilmannii infection score and the expression of HER-2 in the lateral membrane of gastric surface cells was observed. HER-2 expression may be increased in feline gastric cells infected by H. Heilmannii and in parietal cells of gastric glands with an increased inflammatory infiltrate.     

Effects of the solvent evaporation technique on the degree of conversion of one-bottle adhesive systems

This study evaluated the effect of four methods of solvent evaporation on the degree of conversion (DC) of seven one-bottle adhesive systems: Excite (EX), ONE-STEP (OS), Optibond Solo Plus (OB), Prime&Bond 2.1 (PB), Prime&Bond NT (NT), Single Bond (SB) and Single Bond Plus (SP) using Fourier Transform Infrared Analysis (FTIR). Adhesive resins were: 1) applied to KBr pellet surfaces and left undisturbed for 30 seconds (condition 1), 2) left undisturbed for 30 seconds and air-dried with an air stream for 10 seconds (condition 2), 3) left undisturbed for 60 seconds (condition 3) and 4) left undisturbed for 60 seconds and air-dried for 10 seconds (condition 4) before curing. FTIR spectra were obtained and the DC was calculated by comparing the ratio of aliphatic/aromatic double carbon bonds before and after light-activation for 10 seconds (XL 3000, 3M). The results of each product were analyzed by one-way repeated measure ANOVA and post-hoc Tukey's test (p<0.05). The DC of PB, NT, OB and SP adhesives was not affected by the four evaporation conditions, while the DC of EX, OS and SB changed according to the evaporation method. The results suggested that the DC of some adhesives was similar regardless of the evaporation method when no water from dentin or rinsing was involved. Other bonding agents showed higher DC after specific conditions of solvent evaporation.