Bio

Clinical Focus


  • Cancer > Neuro Oncology
  • Neuro-Oncology
  • Neurology - Child Neurology
  • Neurology

Academic Appointments


Administrative Appointments


  • Director, Program in Human Biology, School of Humanities and Sciences (2012 - Present)
  • Chief, Division of Child Neurology, Department of Neurology (2008 - Present)

Professional Education


  • Residency:Johns Hopkins University (1994) MD
  • Residency:Johns Hopkins University (1991) MD
  • Board Certification: Neuro-Oncology, United Council for Neurologic Subspecialties (2008)
  • Fellowship:The Children's Hospital of Philadelphia (1995) PA
  • Internship:Johns Hopkins University (1990) MD
  • Medical Education:UCSF School of Medicine (1989) CA
  • Board Certification: Neurology - Child Neurology, American Board of Psychiatry and Neurology (1998)
  • B.A., Stanford University, Human Biology (1985)
  • M.D., UCSF, Medicine (1989)

Research & Scholarship

Current Research and Scholarly Interests


Clinical neuro-oncology: My research explores the epidemiology, natural history, and disease patterns of brain tumors and other cancers in childhood, as well as prospective clinical trials for treating these neoplasms. Research interests also include neurologic effects of cancer and its therapies.

Clinical Trials


  • Efficacy and Safety of Donepezil Hydrochloride in Preadolescent and Adolescent Children With Attention Impairment Following Cancer Treatment Not Recruiting

    The purpose of this study is to evaluate the efficacy, safety and tolerability of donepezil in children with persistent attention impairment that is present at least 12 months after the completion of cancer treatment.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jennifer Lew, (650) 725 - 4318.

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  • Imetelstat Sodium in Treating Younger Patients With Recurrent or Refractory Brain Tumors Recruiting

    This molecular biology and phase II trial studies how well imetelstat sodium works in treating younger patients with recurrent or refractory brain tumors. Imetelstat sodium may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth.

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  • Bevacizumab and Lapatinib in Children With Recurrent or Refractory Ependymoma Not Recruiting

    The goal of this clinical research study is to learn if the combination of Avastin (bevacizumab) and Tykerb (lapatinib) can help to control ependymoma in pediatric patients. The safety of this drug combination will also be studied.

    Stanford is currently not accepting patients for this trial. For more information, please contact Carissa Bailey, (650) 725 - 4708.

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  • Arsenic Trioxide and Radiation Therapy in Treating Young Patients With Newly Diagnosed Gliomas Not Recruiting

    RATIONALE: Drugs used in chemotherapy, such as arsenic trioxide, work in different ways to stop tumor cells from dividing so they stop growing or die. Radiation therapy uses high-energy x-rays to damage tumor cells and may be an effective treatment for patients with glioma. Drugs such as arsenic trioxide may also make the tumor cells more sensitive to radiation therapy. Combining arsenic trioxide with radiation therapy may kill more tumor cells. PURPOSE: Phase I trial to study the effectiveness of combining arsenic trioxide with radiation therapy in treating patients who have newly diagnosed gliomas.

    Stanford is currently not accepting patients for this trial. For more information, please contact Min Wang, (650) 736 - 4281.

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  • An Open-Labeled, Extended-Use of XERECEPT (hCRF) for Patients in Studies NTI 0302, 0303, or Other Designated Studies Not Recruiting

    The purpose of this study is to examine the long-term safety and tolerability of human corticotropin-releasing factor (hCRF), XERECEPT®, in patients requiring dexamethasone (Decadron) to treat peritumoral brain edema. This open-label, extended-use study is open to all patients who participate in either of the blinded studies, NTI 0302, NTI 0303, or other designated studies, including patients who may have discontinued blinded study medication early but completed the protocol-stipulated follow-up periods.

    Stanford is currently not accepting patients for this trial. For more information, please contact Lynn Adler, (650) 725 - 8630.

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  • Phase I Trial of Arsenic Trioxide and Stereotactic Radiotherapy for Recurrent Malignant Glioma Not Recruiting

    To investigate the safety of delivering arsenic trioxide (ATO) in combination with stereotactic radiotherapy in recurrent malignant glioma by performing an open label, Phase I dose escalation trial. Results from this study will provide a basis for further study of ATO combined with radiation therapy as a radiosensitizer for malignant brain tumors in future Phase II studies.

    Stanford is currently not accepting patients for this trial. For more information, please contact Laurie Tupper, (650) 498 - 4143.

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  • Single-agent Erlotinib in Patients Previously Treated With Oral Etoposide in Protocol OSI-774-205 Not Recruiting

    Patients that were assigned to the oral etoposide treatment arm in protocol OSI-774-205 and either progressed while on study or discontinued due to unacceptable toxicity related to etoposide will be allowed to participate in this study to assess the safety profile of single-agent erlotinib in patients with recurrent or refractory pediatric ependymoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Carissa Bailey, (650) 725 - 4708.

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  • Chemotherapy Followed by Radiation Therapy in Treating Younger Patients With Newly Diagnosed Localized Central Nervous System Germ Cell Tumors Recruiting

    Drugs used as chemotherapy, such as carboplatin, etoposide, and ifosfamide work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Radiation therapy uses high-energy x rays to kill tumor cells. Giving chemotherapy with radiation therapy may kill more tumor cells. This phase II trial studies how well chemotherapy and radiation therapy work in treating younger patients with newly diagnosed central nervous system germ cell tumors.

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  • Risk-Adapted Therapy for Young Children With Embryonal Brain Tumors, Choroid Plexus Carcinoma, High Grade Glioma or Ependymoma Recruiting

    RATIONALE: In this study a combination of anti-cancer drugs (chemotherapy) is used to treat brain tumors in young children. Using chemotherapy gives the brain more time to develop before radiation is given. The chemotherapy in this study includes the drug methotrexate. This drug was an important part of the two clinical trials which resulted in the best survival results for children less than 3 years of age with medulloblastoma. Most patients treated on this trial will also receive radiation which is carefully targeted to the area of the tumor. This type of radiation (focal conformal or proton beam radiotherapy) may result in fewer problems with thinking and learning than radiation to the whole brain and spinal cord. PURPOSE: This clinical trial is studying how well giving combination chemotherapy together with radiation therapy works in treating young patients with newly diagnosed central nervous system tumors.

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  • Brain Function in Young Patients Receiving Methotrexate for Acute Lymphoblastic Leukemia Not Recruiting

    This clinical trial is looking at brain function in young patients receiving methotrexate for acute lymphoblastic leukemia. Learning about the long-term effects of methotrexate on brain function may help doctors plan cancer treatment.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jennifer Lew, (650) 725 - 4318.

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  • Vismodegib in Treating Younger Patients With Recurrent or Refractory Medulloblastoma Not Recruiting

    This phase II trial studies how well vismodegib works in treating younger patients with recurrent or refractory medulloblastoma. Vismodegib may slow the growth of tumor cells.

    Stanford is currently not accepting patients for this trial. For more information, please contact Christina Huang, 650-723-0574.

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  • Selumetinib in Treating Young Patients With Recurrent or Refractory Low Grade Glioma Recruiting

    This phase I/II trial studies the side effects and the best dose of selumetinib and how well it works in treating young patients with recurrent or refractory low grade glioma. Selumetinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.

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  • DNA Analysis of Tumor Tissue Samples From Patients With Diffuse Brain Stem Glioma Not Recruiting

    This multi-institutional study will prospectively collect tumor and constitutional tissue samples from patients with diffuse brainstem glioma and other types of brainstem gliomas either during therapy or at autopsy to perform an extensive analysis of genetic and molecular abnormalities in these tumors.

    Stanford is currently not accepting patients for this trial. For more information, please contact Carissa Bailey , 650-725-4708.

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  • Intrathecal and Systemic Chemotherapy Combined With Radiation Therapy in Treating Young Patients With Newly Diagnosed Central Nervous System Atypical Teratoid/Rhabdoid Tumors Not Recruiting

    RATIONALE: Drugs used in chemotherapy work in different ways to stop tumor cells from dividing so they stop growing or die. Radiation therapy uses high-energy x-rays to damage tumor cells. Giving more than one chemotherapy drug with radiation therapy may kill more tumor cells. PURPOSE: This phase II trial is studying how well giving intrathecal and systemic combination chemotherapy together with radiation therapy works in treating young patients with newly diagnosed central nervous system (CNS) atypical teratoid/rhabdoid tumors.

    Stanford is currently not accepting patients for this trial. For more information, please contact Paul Fisher, (650) 725 - 8630.

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  • Erlotinib Versus Oral Etoposide in Patients With Recurrent or Refractory Pediatric Ependymoma Not Recruiting

    This is a phase 2 study to evaluate the efficacy of single-agent erlotinib versus oral etoposide in patients with recurrent or refractory pediatric ependymoma.

    Stanford is currently not accepting patients for this trial. For more information, please contact Carissa Bailey, (650) 725 - 4708.

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  • Methylphenidate HCl or Modafinil in Treating Young Patients With Excessive Daytime Sleepiness After Cancer Therapy Not Recruiting

    RATIONALE: Methylphenidate hydrochloride or modafinil may help reduce daytime sleepiness and improve the quality of life of patients with excessive daytime sleepiness after cancer therapy. It is not yet known whether methylphenidate hydrochloride or modafinil are more effective than a placebo in reducing daytime sleepiness in these patients. PURPOSE: This randomized phase II trial is studying methylphenidate hydrochloride or modafinil to see how well they work compared with a placebo in treating young patients with excessive daytime sleepiness after cancer therapy.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jennifer Lew, (650) 725 - 4318.

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  • XERECEPT® (hCRF) for Primary Glioma Patients Requiring Dexamethasone to Treat Peritumoral Brain Edema Not Recruiting

    The purpose of this study is to examine the safety and efficacy of XERECEPT (human Corticotropin-Releasing Factor, or hCRF) compared to dexamethasone in patients with primary malignant glioma who require increased dexamethasone doses to control symptom of peritumoral brain edema.

    Stanford is currently not accepting patients for this trial. For more information, please contact Cathy Recht, (650) 725 - 8630.

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  • XERECEPT® (hCRF) for Patients Requiring Dexamethasone to Treat Edema Associated With Brain Tumors Not Recruiting

    The purpose of this study is to compare the safety and efficacy of XERECEPT® to dexamethasone (Decadron) a common treatment for symptoms of brain swelling (edema). This study is specifically aimed at patients who require chronic high doses of dexamethasone to manage symptoms.

    Stanford is currently not accepting patients for this trial. For more information, please contact Lynn Adler, (650) 725 - 8630.

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  • Phase I Rindopepimut After Conventional Radiation in Children w/ Diffuse Intrinsic Pontine Gliomas Not Recruiting

    This is a research study of patients with diffuse intrinsic pontine gliomas. We hope to learn about the safety and efficacy of treating pediatric diffuse intrinsic pontine glioma patients with the EGFRvIII peptide vaccine after conventional radiation.

    Stanford is currently not accepting patients for this trial. For more information, please contact Christina Huang, 650-723-0574.

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Teaching

2013-14 Courses


Publications

Journal Articles


  • Diffusion-weighted MRI derived apparent diffusion coefficient identifies prognostically distinct subgroups of pediatric diffuse intrinsic pontine glioma. Journal of neuro-oncology Lober, R. M., Cho, Y., Tang, Y., Barnes, P. D., Edwards, M. S., Vogel, H., Fisher, P. G., Monje, M., Yeom, K. W. 2014; 117 (1): 175-182

    Abstract

    While pediatric diffuse intrinsic pontine gliomas (DIPG) remain fatal, recent data have shown subgroups with distinct molecular biology and clinical behavior. We hypothesized that diffusion-weighted MRI can be used as a prognostic marker to stratify DIPG subsets with distinct clinical behavior. Apparent diffusion coefficient (ADC) values derived from diffusion-weighted MRI were computed in 20 consecutive children with treatment-naïve DIPG tumors. The median ADC for the cohort was used to stratify the tumors into low and high ADC groups. Survival, gender, therapy, and potential steroid effects were compared between the ADC groups. Median age at diagnosis was 6.6 (range 2.3-13.2) years, with median follow-up seven (range 1-36) months. There were 14 boys and six girls. Seventeen patients received radiotherapy, five received chemotherapy, and six underwent cerebrospinal fluid diversion. The median ADC of 1,295 × 10(-6) mm(2)/s for the cohort partitioned tumors into low or high diffusion groups, which had distinct median survivals of 3 and 13 months, respectively (log-rank p < 0.001). Low ADC tumors were found only in boys, whereas high ADC tumors were found in both boys and girls. Available tissue specimens in three low ADC tumors demonstrated high-grade histology, whereas one high ADC tumor demonstrated low-grade histology with a histone H3.1 K27M mutation and high-grade metastatic lesion at autopsy. ADC derived from diffusion-weighted MRI may identify prognostically distinct subgroups of pediatric DIPG.

    View details for DOI 10.1007/s11060-014-1375-8

    View details for PubMedID 24522717

  • Surveillance imaging in children with malignant CNS tumors: low yield of spine MRI. Journal of neuro-oncology Perreault, S., Lober, R. M., Carret, A., Zhang, G., Hershon, L., Décarie, J., Vogel, H., Yeom, K. W., Fisher, P. G., Partap, S. 2014; 116 (3): 617-623

    Abstract

    Magnetic resonance imaging (MRI) is routinely obtained in patients with central nervous system (CNS) tumors, but few studies have been conducted to evaluate this practice. We assessed the benefits of surveillance MRI and more specifically spine MRI in a contemporary cohort. We evaluated MRI results of children diagnosed with CNS tumors from January 2000 to December 2011. Children with at least one surveillance MRI following the diagnosis of medulloblastoma (MB), atypical teratoid rhabdoid tumor (ATRT), pineoblastoma (PB), supratentorial primitive neuroectodermal tumor, supratentorial high-grade glioma (World Health Organization grade III-IV), CNS germ cell tumors or ependymoma were included. A total of 2,707 brain and 1,280 spine MRI scans were obtained in 258 patients. 97 % of all relapses occurred in the brain and 3 % were isolated to the spine. Relapse was identified in 226 (8 %) brain and 48 (4 %) spine MRI scans. The overall rate of detecting isolated spinal relapse was 9/1,000 and 7/1,000 for MB patients. MRI performed for PB showed the highest rate for detecting isolated spinal recurrence with 49/1,000. No initial isolated spinal relapse was identified in patients with glioma, supratentorial primitive neuroectodermal tumor and ATRT. Isolated spinal recurrences are infrequent in children with malignant CNS tumors and the yield of spine MRI is very low. Tailoring surveillance spine MRI to patients with higher spinal relapse risk such as PB, MB with metastatic disease and within 3 years of diagnosis could improve allocation of resources without compromising patient care.

    View details for DOI 10.1007/s11060-013-1347-4

    View details for PubMedID 24401959

  • Relapse patterns in pediatric embryonal central nervous system tumors JOURNAL OF NEURO-ONCOLOGY Perreault, S., Lober, R. M., Carret, A., Zhang, G., Hershon, L., Decarie, J., Yeom, K., Vogel, H., Fisher, P. G., Partap, S. 2013; 115 (2): 209-215

    Abstract

    Embryonal tumors of the central nervous system (CNS) share histological features and were therefore initially grouped as primitive neuroectodermal tumors (PNET) and treated similarly. We sought to determine the relapse patterns of specific embryonal CNS tumors. We conducted a historical cohort study of children diagnosed with CNS embryonal tumors from January 2000 to December 2011 in two pediatric neuro-oncology centers. Patients of 21 years of age or younger at time of presentation with a diagnosis of medulloblastoma, supratentorial PNET, pineoblastoma or atypical teratoid/rhabdoid tumor (ATRT) and at least one surveillance MRI were included. A total of 133 patients met inclusion criteria and 49 (37 %) patients relapsed during the observation period. The majority (79 %) of sPNET relapses were local, whereas all (100 %) PB relapses were associated with diffuse leptomeningeal disease. Relapse patterns for MB were more diverse with local recurrence in 27 %, distant recurrence in 35 % and diffuse leptomeningeal disease in 38 %. The frequency of relapses involving the spine differed (p < 0.001) between tumor types (MB 28/55 [51 %], sPNET 3/33 [9 %], ATRT 3/7 [43 %] and PB 12/12 [100 %]). No sPNET patients had isolated spinal relapse (0/14). Embryonal tumors were found to have divergent patterns of recurrence. While medulloblastoma has variable relapse presentations, sPNET relapses locally and pineoblastoma recurs with diffuse leptomeningeal disease involving the spine. These results point toward possibly new upfront treatment stratification among embryonal tumors in accordance with relapse pattern.

    View details for DOI 10.1007/s11060-013-1213-4

    View details for Web of Science ID 000325821900009

    View details for PubMedID 23921420

  • Prognostic role for diffusion-weighted imaging of pediatric optic pathway glioma. Journal of neuro-oncology Yeom, K. W., Lober, R. M., Andre, J. B., Fisher, P. G., Barnes, P. D., Edwards, M. S., Partap, S. 2013; 113 (3): 479-483

    Abstract

    Optic pathway glioma (OPG) has an unpredictable course, with poor correlation between conventional imaging features and tumor progression. We investigated whether diffusion-weighted MRI (DWI) predicts the clinical behavior of these tumors. Twelve children with OPG (median age 2.7 years; range 0.4-6.2 years) were followed for a median 4.4 years with DWI. Progression-free survival (time to requiring therapy) was compared between tumors stratified by apparent diffusion coefficient (ADC) from initial pre-treatment scans. Tumors with baseline ADC greater than 1,400 × 10(-6) mm(2)/s required treatment earlier than those with lower ADC (log-rank p = 0.002). In some cases, ADC increased leading up to treatment, and declined following treatment with surgery, chemotherapy, or radiation. Baseline ADC was higher in tumors that eventually required treatment (1,562 ± 192 × 10(-6) mm(2)/s), compared with those conservatively managed (1,123 ± 114 × 10(-6) mm(2)/s) (Kruskal-Wallis test p = 0.013). Higher ADC predicted earlier tumor progression in this cohort and in some cases declined after therapy. Evaluation of OPG with DWI may therefore be useful for predicting tumor behavior and assessing treatment response.

    View details for DOI 10.1007/s11060-013-1140-4

    View details for PubMedID 23673514

  • A phase I trial of arsenic trioxide chemoradiotherapy for infiltrating astrocytomas of childhood. Neuro-oncology Cohen, K. J., Gibbs, I. C., Fisher, P. G., Hayashi, R. J., Macy, M. E., Gore, L. 2013; 15 (6): 783-787

    Abstract

    Background Arsenic trioxide (ATO) has demonstrated preclinical evidence of activity in the treatment of infiltrating astrocytomas. Methods We conducted a phase I trial of ATO given concomitantly with radiation therapy in children with newly diagnosed anaplastic astrocytoma, glioblastoma, or diffuse intrinsic pontine glioma. Eligible patients received a fixed daily dose of 0.15 mg/kg of ATO once a week, with each subsequent cohort of patients receiving an additional dose per week up to a planned frequency of ATO administration 5 days per week as tolerated. Twenty-four children were enrolled and 21 children were evaluable. Results ATO was well tolerated throughout the entire dose escalation, resulting in confirmation of safety when administered 5 days per week during irradiation. Conclusions The recommended dose of ATO during conventional irradiation is 0.15 mg/kg given on a daily basis with each fraction of radiation therapy administered.

    View details for DOI 10.1093/neuonc/not021

    View details for PubMedID 23460318

  • Changes in health status among aging survivors of pediatric upper and lower extremity sarcoma: a report from the childhood cancer survivor study. Archives of physical medicine and rehabilitation Marina, N., Hudson, M. M., Jones, K. E., Mulrooney, D. A., Avedian, R., Donaldson, S. S., Popat, R., West, D. W., Fisher, P., Leisenring, W., Stovall, M., Robison, L. L., Ness, K. K. 2013; 94 (6): 1062-1073

    Abstract

    To evaluate health status and participation restrictions in survivors of childhood extremity sarcomas.Members of the Childhood Cancer Survivor Study cohort with extremity sarcomas who completed questionnaires in 1995, 2003, or 2007 were included.Cohort study of survivors of extremity sarcomas.Childhood extremity sarcoma survivors (N=1094; median age at diagnosis, 13y (range, 0-20y); current age, 33y (range, 10-53y); 49% male; 87.5% white; 75% had lower extremity tumors) who received their diagnosis and treatment between 1970 and 1986.Not applicable.Prevalence rates for poor health status in 6 domains and 5 suboptimal social participation categories were compared by tumor location and treatment exposure with generalized estimating equations adjusted for demographic/personal factors and time/age.In adjusted models, when compared with upper extremity survivors, lower extremity survivors had an increased risk of activity limitations but a lower risk of not completing college. Compared with those who did not have surgery, those with limb-sparing (LS) and upper extremity amputations (UEAs) were 1.6 times more likely to report functional impairment, while those with an above-the-knee amputation (AKA) were 1.9 times more likely to report functional impairment. Survivors treated with LS were 1.5 times more likely to report activity limitations. Survivors undergoing LS were more likely to report inactivity, incomes <$20,000, unemployment, and no college degree. Those with UEAs more likely reported inactivity, unmarried status, and no college degree. Those with AKA more likely reported no college degree. Treatment with abdominal irradiation was associated with an increased risk of poor mental health, functional impairment, and activity limitation.Treatment of lower extremity sarcomas is associated with a 50% increased risk for activity limitations; upper extremity survivors are at a 10% higher risk for not completing college. The type of local control influences health status and participation restrictions. Both of these outcomes decline with age.

    View details for DOI 10.1016/j.apmr.2013.01.013

    View details for PubMedID 23380347

  • Anti-N-methyl-D-aspartate Receptor Encephalitis: What's in a Name? JOURNAL OF PEDIATRICS Campen, C. J., Fisher, P. G. 2013; 162 (4): 673-675

    View details for DOI 10.1016/j.jpeds.2012.11.074

    View details for Web of Science ID 000316728900007

    View details for PubMedID 23305956

  • Trends in the diagnosis and treatment of pediatric primary spinal cord tumors. Journal of neurosurgery. Pediatrics Hayden Gephart, M. G., Lober, R. M., Arrigo, R. T., Zygourakis, C. C., Guzman, R., Boakye, M., Edwards, M. S., Fisher, P. G. 2012; 10 (6): 555-559

    Abstract

    Pediatric primary spinal cord tumors (PSCTs) are rare, with limited comprehensive data regarding incidence and patterns of diagnosis and treatment. The authors evaluated trends in the diagnosis and treatment of PSCTs using a nationwide database.The Surveillance, Epidemiology, and End Results (SEER) registry was queried for the years 1975-2007, evaluating clinical patterns in 330 patients 19 years of age or younger in whom a pediatric PSCT had been diagnosed. Histological diagnoses were grouped into pilocytic astrocytoma, other low-grade astrocytoma, ependymoma, and high-grade glioma. Patient demographics, tumor pathology, use of external beam radiation (EBR), and overall survival were analyzed.The incidence of pediatric PSCT was 0.09 case per 100,000 person-years and did not change over time. Males were more commonly affected than females (58% vs 42%, respectively; p < 0.006). Over the last 3 decades, the specific diagnoses of pilocytic astrocytoma and ependymoma increased, whereas the use of EBR decreased (60.6% from 1975 to 1989 vs 31.3% from 1990 to 2007; p < 0.0001). The 5- and 10-year survival rates did not differ between these time periods.While the incidence of pediatric PSCT has not changed over time, the pattern of pathological diagnoses has shifted, and pilocytic astrocytoma and ependymoma have been increasingly diagnosed. The use of EBR over time has declined. Relative survival of patients with low-grade PSCT has remained high regardless of the pathological diagnosis.

    View details for DOI 10.3171/2012.9.PEDS1272

    View details for PubMedID 23061821

  • 50 years ago in The Journal of Pediatrics: Sensory neuropathy in a child. journal of pediatrics Fisher, P. G. 2012; 161 (6): 1034-?

    View details for DOI 10.1016/j.jpeds.2012.06.061

    View details for PubMedID 23171486

  • Trends in the diagnosis and treatment of pediatric primary spinal cord tumors Clinical article JOURNAL OF NEUROSURGERY-PEDIATRICS Gephart, M. G., Lober, R. M., Arrigo, R. T., Zygourakis, C. C., Guzman, R., Boakye, M., Edwards, M. S., Fisher, P. G. 2012; 10 (6): 555-559
  • Concurrent cyclophosphamide and craniospinal radiotherapy for pediatric high-risk embryonal brain tumors JOURNAL OF NEURO-ONCOLOGY Campen, C. J., Dearlove, J., Partap, S., Murphy, P., Gibbs, I. C., Dahl, G. V., Fisher, P. G. 2012; 110 (2): 287-291

    Abstract

    Embryonal tumors are an aggressive subtype of high-grade, pediatric central nervous system (CNS) tumors often with dismal survival rates. The 5-year survival for highest-risk embryonal tumors may be as low as 10 %. We report feasibility and efficacy from our experience using intravenous (IV) cyclophosphamide concurrently with craniospinal radiation (CSI) in high-risk embryonal CNS tumors of childhood. Ten consecutive children (aged: 3.5-15.5 years, median: 10.2 years, six male) with high-risk embryonal tumors, including: large cell/anaplastic medulloblastoma (6), atypical teratoid rhabdoid tumor (1), and leptomeningeal primitive neuroectodermal tumor (3), were treated with IV cyclophosphamide 1 g/M(2) on days 1 and 2 of CSI. Following a median of 36 Gy CSI plus tumor boosts, adjuvant treatment consisted of 21 doses of oral etoposide (7) and alkylator based chemotherapy from five to eight cycles in all. Of the ten patients thus treated, six remain alive with no evidence of disease and four are deceased. Median survival was 3.3 years, with a 3-year progression-free survival of 50 % (5/10). Median follow-up was: 3.3 years (range: 5 months-12.9 years) in the five patients with progression, median time-to-progression was: 1.3 years (range: 1 month-3 years). Median follow-up in the patients without progression is 8.8 years (range: 3-12.9 years). Complications due to adjuvant chemotherapy were typical and included myelosupression (10), necessitating shortened duration of chemotherapy in three, and hemorrhagic cystitis (1). In high-risk embryonal CNS tumors, cyclophosphamide given concurrently with CSI is well tolerated. Early results suggest that a phase II trial is warranted.

    View details for DOI 10.1007/s11060-012-0969-2

    View details for Web of Science ID 000311208100017

    View details for PubMedID 22941430

  • 50 years ago in The Journal of Pediatrics: the effect of degree of hypoxia on the electroencephalogram in infants. journal of pediatrics Fisher, P. G. 2012; 161 (4): 614-?

    View details for DOI 10.1016/j.jpeds.2012.05.018

    View details for PubMedID 22999578

  • 50 years ago in The Journal of Pediatrics: the surgical management of meningoceles and meningomyeloceles. journal of pediatrics Lober, R. M., Fisher, P. G. 2012; 161 (4): 734-?

    View details for DOI 10.1016/j.jpeds.2012.05.019

    View details for PubMedID 22999580

  • Cancer in Children with Nonchromosomal Birth Defects JOURNAL OF PEDIATRICS Fisher, P. G., Reynolds, P., Von Behren, J., Carmichael, S. L., Rasmussen, S. A., Shaw, G. M. 2012; 160 (6): 978-983

    Abstract

    To examine whether the incidence of childhood cancer is elevated in children with birth defects but no chromosomal anomalies.We examined cancer risk in a population-based cohort of children with and without major birth defects born between 1988 and 2004, by linking data from the California Birth Defects Monitoring Program, the California Cancer Registry, and birth certificates. Cox proportional hazards models generated hazard ratios (HRs) and 95% CIs based on person-years at risk. We compared the risk of childhood cancer in infants born with and without specific types of birth defects, excluding infants with chromosomal anomalies.Of the 4869 children in the birth cohort with cancer, 222 had a major birth defect. Although the expected elevation in cancer risk was observed in children with chromosomal birth defects (HR, 12.44; 95% CI, 10.10-15.32), especially for the leukemias (HR, 28.99; 95% CI, 23.07-36.42), children with nonchromosomal birth defects also had an increased risk of cancer (HR, 1.58; 95% CI, 1.33-1.87), but instead for brain tumors, lymphomas, neuroblastoma, and germ cell tumors.Children with nonchromosomal birth defects are at increased risk for solid tumors, but not leukemias. Dysregulation of early human development likely plays an important role in the etiology of childhood cancer.

    View details for DOI 10.1016/j.jpeds.2011.12.006

    View details for Web of Science ID 000304377300019

    View details for PubMedID 22244463

  • The Eyes Have It! The Significance of Unilateral Ptosis JOURNAL OF PEDIATRICS Lopez, J., Fisher, P. G. 2012; 160 (4): 703-?

    View details for DOI 10.1016/j.jpeds.2011.11.052

    View details for Web of Science ID 000302489800038

    View details for PubMedID 22221564

  • Complete Ocular Paresis in a Child with Posterior Fossa Syndrome PEDIATRIC NEUROSURGERY Afshar, M., Link, M., Edwards, M. S., Fisher, P. G., Fredrick, D., Monje, M. 2012; 48 (1): 51-54

    Abstract

    Posterior fossa syndrome (PFS), also known as cerebellar affective syndrome, is characterized by emotional lability and decreased speech production following injury or surgery to the cerebellum. Rarely, oculomotor dysfunction has been described in association with PFS. Here, we report a case of complete ocular paresis associated with PFS in an 11-year-old male following medulloblastoma resection.

    View details for DOI 10.1159/000339382

    View details for Web of Science ID 000309885700010

    View details for PubMedID 22906880

  • Birth Anomalies and Obstetric History as Risks for Childhood Tumors of the Central Nervous System PEDIATRICS Partap, S., Maclean, J., Von Behren, J., Reynolds, P., Fisher, P. G. 2011; 128 (3): E652-E657

    Abstract

    The causes of childhood central nervous system (CNS) tumors are largely unknown. Birth characteristics have been examined as possible risk factors for childhood CNS tumors, although the studies have been underpowered and inconclusive. We hypothesized that birth anomalies and a mother's history of previous pregnancy losses, as a proxy for genetic defects, increase the risk for CNS tumors.From the California Cancer Registry, we identified 3733 patients aged 0 to 14 years with CNS tumors, diagnosed from 1988 through 2006 and linked to a California birth certificate. Four controls were matched to each patient. We calculated odds ratios (ORs) for the reported presence of a birth defect and for history of pregnancy losses by using logistic regression, adjusted for race, Hispanic ethnicity, maternal age, birth weight, and birth order.Offspring from mothers who had ? 2 fetal losses after 20 weeks' gestation had a threefold risk for CNS tumors (OR: 3.13 [95% confidence interval (CI): 1.32-7.41]) and a 14-fold risk for high-grade glioma (OR: 14.28 [95% CI: 1.56-130.65]). Birth defects increased risk for the CNS cancers medulloblastoma (OR: 1.70 [95% CI: 1.12-2.57]), primitive neuroectodermal tumor (OR: 3.64 [95% CI: 1.54-8.56]), and germ cell tumors (OR: 6.40 [95% CI: 2.09-19.56]).Multiple pregnancy losses after 20 weeks' gestation and birth defects increase the risk of a childhood CNS tumor. Previous pregnancy losses and birth defects may be surrogate markers for gene defects in developmental pathways that lead to CNS tumorigenesis.

    View details for DOI 10.1542/peds.2010-3637

    View details for Web of Science ID 000295406100022

    View details for PubMedID 21824884

  • Liposomal cytarabine for central nervous system embryonal tumors in children and young adults JOURNAL OF NEURO-ONCOLOGY Partap, S., Murphy, P. A., Vogel, H., Barnes, P. D., Edwards, M. S., Fisher, P. G. 2011; 103 (3): 561-566

    Abstract

    To assess the tolerability and efficacy of liposomal cytarabine (LC), an encapsulated, sustained-release, intrathecal (IT) formulation of cytosine arabinoside, in de novo and relapsed central nervous system (CNS) embryonal tumors in children and young adults. We studied retrospectively all patients less than age 30 at our institution treated consecutively with LC for medulloblastoma (MB), primitive neuroectodermal tumor (PNET), and atypical teratoid rhabdoid tumor (ATRT). Seventeen patients received LC (2 mg/kg up to 50 mg, every 2 weeks to monthly) at diagnosis of high-risk CNS embryonal tumor (2 PNET, 3 ATRT) or relapse of MB (12 MB; 9 had leptomeningeal metastases). Sixteen patients received concurrent systemic chemotherapy. A total of 108 doses were administered (IT 82, intraventricular 26) with a mean of six (range 1-16) treatments per patient. Only three administrations were associated with adverse effects of arachnoiditis or headache. None developed malignant cerebrospinal fluid (CSF) cytology while receiving LC. All the six evaluable patients with malignant CSF cytology and treated with at least two doses cleared their CSF (mean 3 doses, range 1-5). Median overall survival in relapse patients was 9.1 months. Five patients (4 de novo and 1 relapsed) remain alive in complete remission for a median 26.8 months from first LC. Liposomal cytarabine is an easily administered, well-tolerated, and active drug in patients with high-risk embryonal neoplasms. One-third of our cohort remains in remission from otherwise fatal diagnoses. Our findings warrant a phase II trial of LC in newly diagnosed or recurrent CNS embryonal tumors.

    View details for DOI 10.1007/s11060-010-0419-y

    View details for Web of Science ID 000291703000018

    View details for PubMedID 20859651

  • Hedgehogs, Flies, Wnts and MYCs: The Time Has Come for Many Things in Medulloblastoma JOURNAL OF CLINICAL ONCOLOGY Monje, M., Beachy, P. A., Fisher, P. G. 2011; 29 (11): 1395-1398

    View details for DOI 10.1200/JCO.2010.34.0547

    View details for Web of Science ID 000289276900016

    View details for PubMedID 21357776

  • Hedgehog-responsive candidate cell of origin for diffuse intrinsic pontine glioma PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Monje, M., Mitra, S. S., Freret, M. E., Raveh, T. B., Kim, J., Masek, M., Attema, J. L., Li, G., Haddix, T., Edwards, M. S., Fisher, P. G., Weissman, I. L., Rowitch, D. H., Vogel, H., Wong, A. J., Beachy, P. A. 2011; 108 (11): 4453-4458

    Abstract

    Diffuse intrinsic pontine gliomas (DIPGs) are highly aggressive tumors of childhood that are almost universally fatal. Our understanding of this devastating cancer is limited by a dearth of available tissue for study and by the lack of a faithful animal model. Intriguingly, DIPGs are restricted to the ventral pons and occur during a narrow window of middle childhood, suggesting dysregulation of a postnatal neurodevelopmental process. Here, we report the identification of a previously undescribed population of immunophenotypic neural precursor cells in the human and murine brainstem whose temporal and spatial distributions correlate closely with the incidence of DIPG and highlight a candidate cell of origin. Using early postmortem DIPG tumor tissue, we have established in vitro and xenograft models and find that the Hedgehog (Hh) signaling pathway implicated in many developmental and oncogenic processes is active in DIPG tumor cells. Modulation of Hh pathway activity has functional consequences for DIPG self-renewal capacity in neurosphere culture. The Hh pathway also appears to be active in normal ventral pontine precursor-like cells of the mouse, and unregulated pathway activity results in hypertrophy of the ventral pons. Together, these findings provide a foundation for understanding the cellular and molecular origins of DIPG, and suggest that the Hh pathway represents a potential therapeutic target in this devastating pediatric tumor.

    View details for DOI 10.1073/pnas.1101657108

    View details for Web of Science ID 000288450900040

    View details for PubMedID 21368213

  • Dorsolateral Midbrain MRI Abnormalities and Ocular Motor Deficits Following Cytarabine-Based Chemotherapy for Acute Myelogenous Leukemia JOURNAL OF NEURO-OPHTHALMOLOGY Doan, T., Lacayo, N., Fisher, P. G., Liao, Y. J. 2011; 31 (1): 52-53

    View details for DOI 10.1097/WNO.0b013e3181e91174

    View details for Web of Science ID 000287238700013

    View details for PubMedID 20881617

  • Clinical Practice Guideline-Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure PEDIATRICS Duffner, P. K., Berman, P. H., Baumann, R. J., Fisher, P. G., Green, J. L., Schneider, S. 2011; 127 (2): 389-394
  • A Phase II Study of Metronomic Oral Topotecan for Recurrent Childhood Brain Tumors PEDIATRIC BLOOD & CANCER Minturn, J. E., Janss, A. J., Fisher, P. G., Allen, J. C., Patti, R., Phillips, P. C., Belasco, J. B. 2011; 56 (1): 39-44

    Abstract

    The prognosis for recurrent or refractory brain tumors in children is poor with conventional therapies. Topotecan is a topoisomerase I inhibitor with good central nervous system (CNS) penetration following oral administration. Increased efficacy of topotecan has been demonstrated with prolonged low-dose daily treatment in pre-clinical models. To investigate further this drug delivered orally in pediatric CNS malignancies, a phase II study in children with recurrent or refractory brain tumors was performed.Patients ? 21 years of age at diagnosis with a recurrent, progressive, or refractory primary CNS malignancy and measurable disease, were eligible. Patients enrolled into four strata: ependymoma (N = 4), high-grade glioma (HGG) (N = 6), brainstem glioma (BSG) (N = 13), and primitive neuroectodermal tumor (PNET) (N = 8). Oral topotecan was administered once daily at a dose of 0.8 mg/m(2)/day for 21 consecutive days repeated every 28 days. Response and toxicity profiles were evaluated.Twenty-six patients were evaluable (median age 9.2 years; 10 males). Two objective responses were observed in PNET patients with disseminated tumor at study entry. These two patients remain alive and in remission 7 and 9.5 years off study. Four other patients (two BSG, one PNET, and one HGG) had stable disease (median 4.6 months). The most common toxicities were hematologic.Daily oral topotecan at a dose of 0.8 mg/m(2)/day can be safely administered to children with recurrent or refractory brain tumors. This regimen identified activity in recurrent PNET. The prolonged progression free survival (PFS) in two PNET patients justifies consideration of this regimen in more advanced clinical trials.

    View details for DOI 10.1002/pbc.22690

    View details for Web of Science ID 000284790400008

    View details for PubMedID 21108437

  • Neurological complications following treatment of children with brain tumors. Journal of pediatric rehabilitation medicine Monje, M., Fisher, P. G. 2011; 4 (1): 31-36

    Abstract

    Brain tumors and their treatments in children result in a range of neurological complications that can affect daily function and rehabilitation potential, including neurocognitive sequelae, ototoxicity, seizure disorders, stroke, and peripheral neuropathy. Deficits in cognitive function, particularly learning and memory, attention and speed of information processing, can be debilitating. With new insights to the cellular and molecular etiology of these deficits, new therapies for cognitive decline after therapy are emerging. Management strategies for other neurological complications are also emerging.

    View details for DOI 10.3233/PRM-2011-0150

    View details for PubMedID 21757808

  • Loss of SMARCB1/INI1 expression in poorly differentiated chordomas ACTA NEUROPATHOLOGICA Mobley, B. C., McKenney, J. K., Bangs, C. D., Callahan, K., Yeom, K. W., Schneppenheim, R., Hayden, M. G., Cherry, A. M., Gokden, M., Edwards, M. S., Fisher, P. G., Vogel, H. 2010; 120 (6): 745-753

    Abstract

    Chordomas are malignant neoplasms that typically arise in the axial spine and primarily affect adults. When chordomas arise in pediatric patients they are more likely to display unusual histological features and aggressive behavior. We noted the absence of SMARCB1/INI1 expression by immunohistochemistry in an index case of poorly differentiated chordoma of the sacrum, leading us to further examine SMARCB1/INI1 expression as well as that of brachyury, a highly specific marker of notochordal differentiation, in 3 additional poorly differentiated chordomas of the clivus, 10 typical chordomas, and 8 atypical teratoid/rhabdoid tumors (AT/RTs). All 4 poorly differentiated chordomas and all AT/RTs lacked nuclear expression of SMARCB1/INI1, while the 10 typical chordomas maintained strong nuclear SMARCB1/INI1 immunoreactivity. All 10 typical and 4 poorly differentiated chordomas expressed brachyury; all 8 AT/RTs were brachyury immunonegative. Cytogenetic evaluation utilizing FISH probes near the SMARCB1/INI1 locus on chromosome 22q was also performed in all of the poorly differentiated chordomas in this series. Three of the four poorly differentiated chordomas had evidence for deletion of this region by FISH. Analysis of the SMARCB1/INI1 gene sequence was performed using formalin-fixed paraffin-embedded tissue in all cases and no point mutations were observed. In summary, all poorly differentiated chordomas in this series showed the absence of SMARCB1/INI1 expression, and were reliably distinguished from AT/RTs, clinically by their characteristic primary sites of origin and pathologically by strong nuclear brachyury expression. Our findings reveal a likely role for SMARCB1/INI1 in a subset of chordomas with aggressive features.

    View details for DOI 10.1007/s00401-010-0767-x

    View details for Web of Science ID 000284593200005

    View details for PubMedID 21057957

  • Birth Weight and Order as Risk Factors for Childhood Central Nervous System Tumors JOURNAL OF PEDIATRICS Maclean, J., Partap, S., Reynolds, P., Von Behren, J., Fisher, P. G. 2010; 157 (3): 450-455

    Abstract

    To determine whether birth characteristics related to maternal-fetal health in utero are associated with the development of childhood central nervous system tumors.We identified, from the California Cancer Registry, 3733 children under age 15 diagnosed with childhood central nervous system tumors between 1988 and 2006 and linked these cases to their California birth certificates. Four controls per case, matched on birth date and sex, were randomly selected from the same birth files. We evaluated associations of multiple childhood CNS tumor subtypes with birth weight and birth order.Low birth weight was associated with a reduced risk of low-grade gliomas (OR=0.67; 95% CI, 0.46 to 0.97) and high birth weight was associated with increased risk of high-grade gliomas (OR=1.57; 95% CI, 1.16 to 2.12). High birth order (fourth or higher) was associated with decreased risk of low-grade gliomas (OR=0.75; 95% CI, 0.56 to 0.99) and increased risk of high-grade gliomas (OR=1.32; 95% CI, 1.01 to 1.72 for second order).Factors that drive growth in utero may increase the risk of low-grade gliomas. There may be a similar relationship in high-grade gliomas, although other factors, such as early infection, may modify this association. Additional investigation is warranted to validate and further define these findings.

    View details for DOI 10.1016/j.jpeds.2010.04.006

    View details for Web of Science ID 000281116100023

    View details for PubMedID 20553692

  • Intramedullary papillary ependymoma with choroid plexus differentiation and cerebrospinal fluid dissemination to the brain Case report JOURNAL OF NEUROSURGERY-PEDIATRICS Dulai, M. S., Caccamo, D. V., Briley, A. L., Edwards, M. S., Fisher, P. C., Lehman, N. L. 2010; 5 (5): 511-517

    Abstract

    This 8-year-old girl presented with a papillary ependymoma in the thoracic spinal cord. Resection was followed by recurrence at the primary site and later in the lumbosacral thecal sac, followed by cerebrospinal fluid dissemination to the brain approximately 5 years after her initial presentation. The tumor showed cytological and immunohistochemical features overlapping those of classic ependymomas and choroid plexus tumors similar to those seen in uncommon supratentorial papillary ependymomas, also known as papillary tumors of the pineal region. The histopathological and clinical courses of this rare spinal papillary ependymoma exhibiting mixed ependymal and choroid plexus-like differentiation are discussed.

    View details for DOI 10.3171/2009.12.PEDS09130

    View details for Web of Science ID 000277131500016

    View details for PubMedID 20433266

  • 50 Years Ago in THE JOURNAL OF PEDIATRICS A Critical Evaluation of Therapy of Febrile Seizures JOURNAL OF PEDIATRICS Campen, C. J., Fisher, P. G. 2010; 156 (3): 449-449
  • Oncogenic BRAF Mutation with CDKN2A Inactivation Is Characteristic of a Subset of Pediatric Malignant Astrocytomas CANCER RESEARCH Schiffman, J. D., Hodgson, J. G., VandenBerg, S. R., Flaherty, P., Polley, M. C., Yu, M., Fisher, P. G., Rowitch, D. H., Ford, J. M., Berger, M. S., Ji, H., Gutmann, D. H., James, C. D. 2010; 70 (2): 512-519

    Abstract

    Malignant astrocytomas are a deadly solid tumor in children. Limited understanding of their underlying genetic basis has contributed to modest progress in developing more effective therapies. In an effort to identify such alterations, we performed a genome-wide search for DNA copy number aberrations (CNA) in a panel of 33 tumors encompassing grade 1 through grade 4 tumors. Genomic amplifications of 10-fold or greater were restricted to grade 3 and 4 astrocytomas and included the MDM4 (1q32), PDGFRA (4q12), MET (7q21), CMYC (8q24), PVT1 (8q24), WNT5B (12p13), and IGF1R (15q26) genes. Homozygous deletions of CDKN2A (9p21), PTEN (10q26), and TP53 (17p3.1) were evident among grade 2 to 4 tumors. BRAF gene rearrangements that were indicated in three tumors prompted the discovery of KIAA1549-BRAF fusion transcripts expressed in 10 of 10 grade 1 astrocytomas and in none of the grade 2 to 4 tumors. In contrast, an oncogenic missense BRAF mutation (BRAF(V600E)) was detected in 7 of 31 grade 2 to 4 tumors but in none of the grade 1 tumors. BRAF(V600E) mutation seems to define a subset of malignant astrocytomas in children, in which there is frequent concomitant homozygous deletion of CDKN2A (five of seven cases). Taken together, these findings highlight BRAF as a frequent mutation target in pediatric astrocytomas, with distinct types of BRAF alteration occurring in grade 1 versus grade 2 to 4 tumors.

    View details for DOI 10.1158/0008-5472.CAN-09-1851

    View details for Web of Science ID 000278485500011

    View details for PubMedID 20068183

  • Cerebrovascular disease in childhood cancer survivors A Children's Oncology Group Report NEUROLOGY Morris, B., Partap, S., Yeom, K., Gibbs, I. C., Fisher, P. G., King, A. A. 2009; 73 (22): 1906-1913

    Abstract

    Curative therapy for childhood cancer has dramatically improved over past decades. Therapeutic radiation has been instrumental in this success. Unfortunately, irradiation is associated with untoward effects, including stroke and other cerebrovascular disease (CVD). The Children's Oncology Group (COG) has developed guidelines for screening survivors at risk for persistent or late sequelae of cancer therapy.This review summarizes the pathophysiology and relevant manifestations of radiation-induced CVD and outlines the specific patient groups at risk for early-onset stroke. The reader will be alerted to the availability of the COG recommendations for monitoring, and, when applicable, specific screening and treatment recommendations will be highlighted.A multidisciplinary task force critically reviewed the existing literature and scored the evidence to establish the current COG guidelines for monitoring health of survivors treated with head and neck irradiation.Previous head and neck exposure to therapeutic radiation is associated with latent CVD and increased risk for stroke in some patient groups. Common manifestations of radiation-induced CVD includes steno-occlusive disease, moyamoya, aneurysm, mineralizing microangiopathy, vascular malformations, and strokelike migraines.Risk for stroke is increased in survivors of pediatric CNS tumors, Hodgkin lymphoma, and acute lymphoblastic leukemia who received radiation to the brain and/or neck. As the population of survivors ages, vigilance for stroke and cerebrovascular disease needs to continue based on specific exposures during curative cancer therapy.

    View details for DOI 10.1212/WNL.0b013e3181c17ea8

    View details for Web of Science ID 000272205200015

    View details for PubMedID 19812380

  • Medulloblastoma Incidence has not Changed Over Time A CBTRUS Study JOURNAL OF PEDIATRIC HEMATOLOGY ONCOLOGY Partap, S., Curran, E. K., Propp, J. M., Le, G. M., Sainani, K. L., Fisher, P. G. 2009; 31 (12): 970-971

    Abstract

    Earlier studies have reported changes in the incidence of medulloblastoma (MB) but have conflicted, likely because of small sample size or misclassification of MB with primitive neuroectodermal tumor (PNET). The incidence of MB and PNET from 1985 to 2002 was determined from the Central Brain Tumor Registry of the United States, a large population-based cancer registry, using strict histologic and site codes. No statistically significant change in MB incidence was observed over the last 2 decades, but there was an increase in MB and PNET combined.

    View details for Web of Science ID 000272658700019

    View details for PubMedID 19887963

  • Do children and adults differ in survival from medulloblastoma? A study from the SEER registry JOURNAL OF NEURO-ONCOLOGY Curran, E. K., Le, G. M., Sainani, K. L., Propp, J. M., Fisher, P. G. 2009; 95 (1): 81-85

    Abstract

    Studies investigating whether adults have diminished survival from medulloblastoma (MB) compared with children have yielded conflicting results. We sought to determine in a population-based registry whether adults and children with MB differ in survival, and to examine whether dissimilar use of chemotherapy might contribute to any disparity. 1,226 MB subjects were identified using the Surveillance Epidemiology and End Results (SEER-9) registry (1973-2002) and survival analysis performed. MB was defined strictly to exclude non-cerebellar primitive neuro-ectodermal tumors. Patients were stratified by age at diagnosis: <3 years (infants), 3-17 years (children) and >or=18 years (adults). Because the SEER-9 registry lacks treatment data, a subset of 142 patients were identified using the San Francisco-Oakland SEER registry (1988-2003) and additional analyses performed. There was no significant difference in survival between children and adults with MB in either the SEER-9 (P = 0.17) or SFO (P = 0.89) cohorts but infants fared worse compared to both children (P < 0.01) and adults (P < 0.01). In the SFO sample, children and adults who received chemotherapy plus radiation therapy (XRT) did not differ in survival. Among patients treated with XRT alone, children showed increased survival (P = 0.04) compared with adults. Children and adults with MB do not differ with respect to overall survival, yet infants fare significantly worse. For children and adults with MB treated with both XRT and chemotherapy, we could not demonstrate a survival difference. Similar outcomes between adult and childhood MB may justify inclusion of adults in pediatric cooperative trials for MB.

    View details for DOI 10.1007/s11060-009-9894-4

    View details for Web of Science ID 000269884600010

    View details for PubMedID 19396401

  • Incidence Patterns of Central Nervous System Germ Cell Tumors A SEER Study JOURNAL OF PEDIATRIC HEMATOLOGY ONCOLOGY Goodwin, T. L., Sainani, K., Fisher, P. G. 2009; 31 (8): 541-544

    Abstract

    Incidence patterns of central nervous system (CNS) germ cell tumors (GCTs) have been reported, but the influence of underlying host risk factors has not been rigorously explored. We aimed to determine in a large, population-based cancer registry how age, sex, and race, influence the occurrence of CNS GCTs in the pediatric population.Using the Surveillance, Epidemiology, and End Results registry, we identified cases of histologically confirmed GCTs in children, adolescents, and young adults (age 0 to 29 y), diagnosed between 1973 and 2004. The cases were limited to only those with the International Classification of Childhood Cancer Xa: intracranial and intraspinal germ-cell tumors. Incidence rates (per 10,000) for each sex and race were plotted for single-age groups, and then stratified by tumor location and pathology subtype.The sample included a total of 638 cases (490 males). Males had significantly higher rates of CNS GCTs than females. Male and female rates diverged significantly starting at the age of 11 years and remained widely discrepant until the age of 30 years. There were more germinomas than nongerminomas in both sexes. Germinomas peaked in incidence during adolescence, whereas nongerminoma incidence remained relatively constant in children and young adults. Tumor location differed strikingly by sex (P<0.0001) with pineal location more common in males (61.0% vs. 15.5%). Asian race was associated with a higher rate of CNS GCTs than other races.Males have higher incidence of CNS GCTs, primarily germinomas, than females, starting in the second decade. Pineal location is strongly associated with male sex, with pineal germinomas representing over half of all CNS GCTs in males. Asian-Americans have higher rates than other races. These findings suggest a robust but poorly understood influence of sex, either genetic or hormonal, and race on the occurrence of CNS GCTs.

    View details for Web of Science ID 000268815000003

    View details for PubMedID 19636276

  • Incidence patterns for ependymoma: a Surveillance, Epidemiology, and End Results study Clinical article JOURNAL OF NEUROSURGERY McGuire, C. S., Sainani, K. L., Fisher, P. G. 2009; 110 (4): 725-729

    Abstract

    Previous small studies disagree about which clinical risk factors influence ependymoma incidence. The authors analyzed a large, population-based cancer registry to examine the relationship of incidence to patient age, sex, race, and tumor location, and to determine incidence trends over the past 3 decades.Data were obtained from the Surveillance, Epidemiology, and End Results (SEER-9) study, which was conducted from 1973 to 2003. Histological codes were used to define ependymomas. Age-adjusted incidence rates were compared by confidence intervals in the SEER*Stat 6.2 program. Multiplicative Poisson regression and Joinpoint analysis were used to determine annual percentage change and to look for sharp changes in incidence, respectively.From the SEER database, 1402 patients were identified. The incidence rate per 100,000 person-years was significantly higher in male than in female patients (males 0.227 +/- 0.029, females 0.166 +/- 0.03). For children, the age at diagnosis differed significantly by tumor location, with the mean age for patients with infratentorial tumors calculated as 5 +/- 0.4 years; for supratentorial tumors it was 7.77 +/- 0.6 years, and for spinal lesions it was 12.16 +/- 0.8 years. (Values are expressed as the mean +/- standard error [SE].) Adults showed no difference in the mean age of incidence by location, although most tumors in this age group were spinal. Between 1973 and 2003, the incidence increased significantly among adults but not among children, and there were no sharp changes at any single year, both before and after age adjustment.Males have a higher incidence of ependymoma than do females. A biological explanation remains elusive. Ependymoma occurs within the CNS at distinct locations at different ages, consistent with hypotheses postulating distinct populations of radial glial stem cells within the CNS. Ependymoma incidence appears to have increased over the past 3 decades, but only in adults.

    View details for DOI 10.3171/2008.9.JNS08117

    View details for Web of Science ID 000264594300017

    View details for PubMedID 19061350

  • Levetiracetam For Seizures in Children With Brain Tumors and Other Cancers PEDIATRIC BLOOD & CANCER Partap, S., Fisher, P. G. 2009; 52 (2): 288-289

    Abstract

    Children with brain tumors and other cancers can suffer from seizures. Unfortunately, most antiepileptic therapies are metabolized by the hepatic cytochrome P450 (CYP) system. Levetiracetam, a newer anticonvulsant, does not undergo CYP metabolism and does not alter the pharmacokinetics of chemotherapy, antiemetics, and corticosteroids, which are metabolized by the liver. We studied 23 patients with cancer and seizures treated with levetiracetam. Over 95% of patients had fewer seizures, with 65.2% becoming seizure free; only one patient experienced an adverse reaction. Levetiracetam is effective and well tolerated in children with brain tumors and other cancers, who are often on multiple enzyme-inducing drugs.

    View details for DOI 10.1002/pbc.21772

    View details for Web of Science ID 000261796000032

    View details for PubMedID 18831033

  • Neurological complications in children. Cancer treatment and research Partap, S., Fisher, P. G. 2009; 150: 133-143

    View details for DOI 10.1007/b109924_9

    View details for PubMedID 19834666

  • Reproductive health issues in survivors of childhood and adult brain tumors. Cancer treatment and research Goodwin, T., Delasobera, B. E., Fisher, P. G. 2009; 150: 215-222

    View details for DOI 10.1007/b109924_14

    View details for PubMedID 19834671

  • Gender Affects Survival for Medulloblastoma Only in Older Children and Adults: A Study From the Surveillance Epidemiology and End Results Registry PEDIATRIC BLOOD & CANCER Curran, E. K., Sainani, K. L., Le, G. M., Propp, J. A., Fisher, P. G. 2009; 52 (1): 60-64

    Abstract

    Males have a higher incidence of medulloblastoma (MB) than females, but the effect of gender on survival is unclear. Studies have yielded conflicting results, possibly due to small sample sizes or differences in how researchers defined MB. We aimed to determine the effect of gender on survival in MB using a large data set and strict criteria for defining MB.A sample of 1,226 subjects (763 males and 463 females) was identified from 1973 to 2002, using the Surveillance Epidemiology and End Results (SEER-9) registry. MB was strictly defined to exclude non-cerebellar embryonal tumors (primitive neuro-ectodermal tumors). Because children <3 years of age are known to have worse survival, patients were stratified by age <3 years at diagnosis (95 males, 82 females) and >3 years (668 males, 381 females).Overall, there was no significant difference in survival between males and females (log rank P = 0.22). However, among subjects >3 years, females had significantly greater survival than males (log rank P = 0.02). In children <3 years, there was a non-significant trend toward poorer survival in females (median survival: males 27 months, females 13 months; log rank P = 0.24). This interaction between age group and gender was statistically significant (P = 0.03).Females with MB have a survival advantage only in subjects >3 years. In children <3 years, females may even have poorer outcome. The effect of gender on survival and incidence in MB warrants additional biologic investigation, and may differ in very young children with MB.

    View details for DOI 10.1002/pbc.21832

    View details for Web of Science ID 000261300000015

    View details for PubMedID 19006250

  • Both Location and Age Predict Survival in Ependymoma: A SEER Study PEDIATRIC BLOOD & CANCER McGuire, C. S., Sainani, K. L., Fisher, P. G. 2009; 52 (1): 65-69

    Abstract

    Studies have suggested that supratentorial ependymomas have better survival than infratentorial tumors, with spinal tumors having the best prognosis, but these data have been based on small samples. Using a population-based registry of ependymomas, we analyzed how age, gender, location, race and radiotherapy influence survival in children.We queried the Surveillance Epidemiology End Results database (SEER-17) from 1973 to 2003, strictly defining ependymomas by histology. Site codes were used to distinguish between supratentorial, infratentorial, and spinal tumors when available. Outcomes were compared by location, age, gender, race and radiotherapy, using Kaplan-Meier analysis and logrank tests. Cox regression was completed, incorporating all significant covariates from univariate analysis.Six hundred thirty-five children were identified with an overall 5-year survival of 57.1 +/- standard error (SE) 2.3%. Increasing age was associated with improved survival (P < 0.0001). Five-year survival by location was 59.5 +/- SE 5.5% supratentorial, 57.1 +/- SE 4.1% infratentorial and 86.7 +/- SE 5.2% spinal. Radiotherapy of the infratentorial tumors resulted in significantly improved survival in both univariate analysis (logrank P < 0.018) and multivariate analysis restricted to this tumor location (P = 0.033). Using multivariate analysis that incorporated all tumor locations, age (P < 0.001) and location (P = 0.020) were significant predictors for survival.Age and location independently influence survival in ependymoma. Spinal tumors are associated with a significantly better prognosis than both supratentorial and infratentorial tumors, and may represent a distinct biological entity. Radiotherapy appears beneficial for survival in patients with infratentorial ependymoma.

    View details for DOI 10.1002/pbc.21806

    View details for Web of Science ID 000261300000016

    View details for PubMedID 19006249

  • Outcome analysis of childhood low-grade astrocytomas PEDIATRIC BLOOD & CANCER Fisher, P. G., Tihan, T., Goldthwaite, P. T., Wharam, M. D., Carson, B. S., Weingart, J. D., Repka, M. X., Cohen, K. J., Burger, P. C. 2008; 51 (2): 245-250

    Abstract

    We aimed to determine the long-term natural history of low-grade astrocytomas (LGA) in children, with respect to pathology, and to evaluate influence of treatment on survival.A consecutive cohort of patients < or =21 years with surgically confirmed LGA from 1965 to 1996 was assembled. All available pathology specimens were reviewed, masked to original diagnosis, patient data, and neuroimaging.Two hundred seventy-eight children (160 males; mean age 9.1 years; tumor location: 77 cerebrum, 62 cerebellum, 51 hypothalamic, 30 thalamus, 9 ventricle, 40 brainstem, and 9 spine) were assessed. Among 246 specimens reviewed, diagnoses were 135 pilocytic astrocytoma (PA), 27 diffuse astrocytoma (DA), 75 unclassifiable well-differentiated astrocytoma (NOS), and 9 subependymal giant cell astrocytoma. At 5 and 10 years from initial surgery, for all LGA overall survival (OS) was 87% and 83%, while progression-free survival (PFS) was 55% and 42%, respectively. Original pathology diagnoses did not predict PFS (P = 0.47), but reviewed diagnoses were significantly associated with PFS (P = 0.007). Reviewed diagnoses were highly associated with OS (P < 0.0001), with 5-year OS for PA 96%, DA 48%, and NOS 86%; these differences remained significant when stratified by location or extent of resection. Among patients with residual tumor after surgery, 5-year PFS was 48% with observation alone (n = 114), no different (P = 0.32) from that achieved with immediate irradiation (n = 86).LGA, particularly PA, have excellent long-term OS. While tumor location and resection extent affect outcome, pathologic diagnosis when carefully interpreted significantly influences long-term survival. Immediate postoperative irradiation does not confer an advantage in delaying first progression in children with residual PA.

    View details for DOI 10.1002/pbc.21563

    View details for Web of Science ID 000256871800018

    View details for PubMedID 18386785

  • Identification of a novel p53 in-frame deletion in a Li-Fraumeni-like family PEDIATRIC BLOOD & CANCER Schiffman, J. D., Chun, N., Fisher, P. G., Dahl, G. V., Ford, J. M., Eggerding, F. A. 2008; 50 (4): 914-916

    Abstract

    We describe a 2-year-old female with a completely resected cerebral pilocytic astrocytoma who subsequently developed B-progenitor acute lymphoblastic leukemia (ALL). Her father and paternal uncle were previously diagnosed with glioblastoma multiforme. Sequence analysis of the patient's p53 gene revealed a novel germline three base-pair deletion (339_341delCTT) in exon 4, resulting in removal of an evolutionarily conserved phenylalanine amino acid residue at codon 113. The same mutation was found in the patient's two clinically unaffected siblings. The in-frame deletion we describe has not previously been reported and adds to our understanding of the biologic effects of p53 gene mutation in Li-Fraumeni syndrome (LFS).

    View details for DOI 10.1002/pbc.21247

    View details for Web of Science ID 000253661200049

    View details for PubMedID 17554785

  • Multi-institutional phase II study of temozolomide administered twice daily in the treatment of recurrent high-grade gliomas CANCER Balmaceda, C., Peereboom, D., Pannullo, S., Cheung, Y. K., Fisher, P. G., Alavi, J., Sisti, M., Chen, J., Fine, R. L. 2008; 112 (5): 1139-1146

    Abstract

    The prognosis for patients with recurrent high-grade gliomas is poor and treatment options are limited. Current chemotherapeutic regimens can improve clinical outcomes, but extend survival by only a few months. Temozolomide is a methylating agent that is typically administered once daily. Because preclinical studies suggested that a twice-daily dosing schedule might be more effective, the safety and efficacy of twice-daily dosing of temozolomide were studied in patients with recurrent gliomas at their first, second, or third recurrence.This multi-institutional trial enrolled 120 patients with recurrent glioblastoma multiforme (GBM), anaplastic astrocytoma (AA), or anaplastic oligodendroglioma (AO). An initial oral dose of 200 mg/m(2) of temozolomide was followed by 9 consecutive doses of 90-mg/m(2) every 12 hours. Treatment cycles were repeated every 28 days. Doses were escalated to 100 mg/m(2) twice daily in the absence of unacceptable toxicity or were reduced if unacceptable toxicity occurred.For GBM, AA, and AO patients, respectively, the median progression-free survival (PFS) was 4.2 months, 5.8 months, and 7.7 months, whereas the median overall survival (OS) was 8.8 months, 14.6 months, and 18 months. The overall response rate (partial and complete) for the GBM, AA, and AO patients was 31%, 46%, and 46%, respectively. Grade 3/4 toxicities included neutropenia (1.1%), thrombocytopenia (3.6%), and anemia (0.3%) (graded according to the World Health Organization grading system).Twice-daily dosing may enhance the efficacy of temozolomide in the treatment of recurrent gliomas without increasing toxicity. This regimen compares favorably with other dosing schedules of temozolomide reported in the literature.

    View details for DOI 10.1002/cncr.23167

    View details for Web of Science ID 000253569100025

    View details for PubMedID 18246536

  • Treatment of children with diffuse intrinsic brain stem glioma with radiotherapy, vincristine and oral VP-16: A children's oncology group phase II study PEDIATRIC BLOOD & CANCER Korones, D. N., Fisher, P. G., Kretschmar, C., Zhou, T., Chen, Z., Kepner, J., Freeman, C. 2008; 50 (2): 227-230

    Abstract

    The prognosis for children with brain stem glioma remains grim. Based on studies suggesting efficacy of vincristine and oral VP-16, The Pediatric Oncology Group (POG, now part of the Children's Oncology Group) conducted a study using these agents in combination with standard external beam radiation for children with newly diagnosed brain stem glioma.Children were eligible for the study if they 3-21 years of age, had MRI-evidence of a diffuse intrinsic pontine glioma, and had neurologic deficits of <6 months duration. Patients received local radiotherapy to a dosage of 54 Gy. Chemotherapy consisted of two 28-day cycles of vincristine, 1.5 mg/m(2), days 1, 8, and 15 and oral VP-16, 50 mg/m(2), days 1-21, starting concurrent with radiation, and continuing for ten cycles following radiation.Of the 31 children enrolled, 30 were eligible and evaluable for survival and toxicity. Their median age was 8 years (range 3-14 years). Seven patients (23%) had a partial response following radiation, 18 (60%) had stable disease, 2 (7%) had progressive disease, and response in 3 patients (10%) was not measured. All 30 children have died. Overall survival at 1 year was 27 +/- 7% and at 2 years, 3 +/- 2%. The median survival was 9 months (range 3-36 months). Hematologic toxicity was significant; other toxicities included constipation, mucositis, emesis, and infection.The addition of vincristine and oral VP-16 to standard external beam radiation causes moderate toxicity and does not improve survival of children with diffuse intrinsic brain stem glioma.

    View details for DOI 10.1002/pbc.21154

    View details for Web of Science ID 000252006000009

    View details for PubMedID 17278121

  • In cyclosporine-induced neurotoxicity, is tacrolimus an appropriate substitute or is it out of the frying pan and into the fire? Response PEDIATRIC BLOOD & CANCER Minn, A. Y., Fisher, P. G., Barnes, P. D., Dahl, G. V. 2008; 50 (2): 427-427

    View details for DOI 10.1002/pbc.21210

    View details for Web of Science ID 000252006000062

  • Family history of cancer among children with brain tumors - A critical review JOURNAL OF PEDIATRIC HEMATOLOGY ONCOLOGY Dearlove, J. V., Fisher, P. G., Buffler, P. A. 2008; 30 (1): 8-14

    Abstract

    The occurrence of brain tumors in children has been anecdotally associated with an increased cancer incidence among relatives. This study rigorously reviewed the epidemiologic literature regarding family history of cancer in children with brain tumors. Six case-control and 10 cohort studies remained after applying stringent inclusion criteria. Most studies found no significant increase in cancer risk among relatives of childhood brain tumor patients. Those associations that were detected were often of borderline significance or demonstrated wide confidence intervals. There is limited evidence that a family history of cancer is more common among families of childhood brain tumor patients.

    View details for Web of Science ID 000252486900003

    View details for PubMedID 18176173

  • Verbal memory impairments in children after cerebellar tumor resection BEHAVIOURAL NEUROLOGY Kirschen, M. P., Davis-Ratner, M. S., Milner, M. W., Chen, S. H., Schraedley-Desmond, P., Fisher, P. G., Desmond, J. E. 2008; 20 (1-2): 39-53

    Abstract

    This study was designed to investigate cerebellar lobular contributions to specific cognitive deficits observed after cerebellar tumor resection. Verbal working memory (VWM) tasks were administered to children following surgical resection of cerebellar pilocytic astrocytomas and age-matched controls. Anatomical MRI scans were used to quantify the extent of cerebellar lobular damage from each patient's resection. Patients exhibited significantly reduced digit span for auditory but not visual stimuli, relative to controls, and damage to left hemispheral lobule VIII was significantly correlated with this deficit. Patients also showed reduced effects of articulatory suppression and this was correlated with damage to the vermis and hemispheral lobule IV/V bilaterally. Phonological similarity and recency effects did not differ overall between patients and controls, but outlier patients with abnormal phonological similarity effects to either auditory or visual stimuli were found to have damage to hemispheral lobule VIII/VIIB on the left and right, respectively. We postulate that damage to left hemispheral lobule VIII may interfere with encoding of auditory stimuli into the phonological store. These data corroborate neuroimaging studies showing focal cerebellar activation during VWM paradigms, and thereby allow us to predict with greater accuracy which specific neurocognitive processes will be affected by a cerebellar tumor resection.

    View details for DOI 10.3233/BEN-2008-0216

    View details for Web of Science ID 000267118100005

    View details for PubMedID 19491473

  • Congenital glioblastoma multiforme: Case report and review of the literature PEDIATRIC NEUROSURGERY Hou, L. C., Bababeygy, S. R., Sarkissian, V., Fisher, P. G., Vogel, H., Barnes, P., Huhn, S. L. 2008; 44 (4): 304-312

    Abstract

    Congenital glioblastoma multiforme is a rare primary brain tumor that has a unique biology distinct from pediatric and adult variants. In this report, we present a case of congenital glioblastoma with complicated management course. A literature review of previously reported cases is included to illustrate the epidemiology and natural history of this disease. A 9-month-old male infant developed acute lethargy, hemiparesis and unilaterally dilated pupil. Imaging studies revealed a large hemispheric tumor, resulting in significant midline shift suggestive of impending herniation. Emergent tumor cystic fluid drainage was performed at initial presentation. A frontotemporoparietal craniotomy was performed on the following day to attempt a gross total resection. Adjuvant chemotherapy consisting of oral temozolomide was administered. The patient eventually succumbed 4 months later due to aggressive tumor progression. Congenital glioblastoma should be included in the differential diagnosis of infants with large intracranial tumors. Although surgical intervention may increase survival, the overall outcome remains poor despite maximal multimodal treatment.

    View details for DOI 10.1159/000134922

    View details for Web of Science ID 000258318800008

    View details for PubMedID 18504417

  • Update on new treatments and developments in childhood brain tumors CURRENT OPINION IN PEDIATRICS Partap, S., Fisher, P. G. 2007; 19 (6): 670-674

    Abstract

    Childhood primary central nervous system tumors remain a therapeutic conundrum. As the second most common pediatric cancer, brain tumors lead to significantly worse survival and long-term effects compared with those seen with hematologic malignancies and other solid tumors. This review discusses current management strategies in three pediatric brain tumors, the long-term effects of therapy, as well as novel laboratory findings that may alter future treatment strategies.The current literature focuses on tactics to predict those at risk of treatment failure and long-term effects. By analyzing tumors at a molecular genetics level rather than traditional histology, new data have begun to emerge on methods to begin to consider targeted therapies, tailored to the individual child. Furthermore, as survivorship has improved with current radiation and chemotherapy regimens, long-term effects have been identified and merit clinical attention.Even though long-term survival for children with a brain tumor approaches 70%, the need for improved treatment regimens is striking. Secondary malignancies, neurocognitive deficits and treatment failure continue to afflict these children and young adults. The current review will inform clinicians of the challenges faced by basic scientists and clinicians when treating brain tumors, and point to future research directions.

    View details for Web of Science ID 000251347800010

    View details for PubMedID 18025934

  • Impaired human hippocampal neurogenesis after treatment for central nervous system ANNALS OF NEUROLOGY Monje, M. L., Vogel, H., Masek, M., Ligon, K. L., Fisher, P. G., Palmer, T. D. 2007; 62 (5): 515-520

    Abstract

    The effects of cancer treatments such as cranial radiation and chemotherapy on human hippocampal neurogenesis remain unknown. In this study, we examine neuropathological markers of neurogenesis and inflammation in the human hippocampus after treatment for acute myelogenous leukemia or medulloblastoma. We demonstrate a persistent radiation-induced microglial inflammation that is accompanied by nearly complete inhibition of neurogenesis after cancer treatment. These findings are consistent with preclinical animal studies and suggest potential therapeutic strategies.

    View details for DOI 10.1002/ana.21214

    View details for Web of Science ID 000251383300012

    View details for PubMedID 17786983

  • A syndrome of irreversible leukoencephalopathy following pediatric allogeneic bone marrow transplantation PEDIATRIC BLOOD & CANCER Minn, A. Y., Fisher, P. G., Barnes, P. D., Dahl, G. V. 2007; 48 (2): 213-217

    Abstract

    Despite decreases in overall mortality following bone marrow transplantation (BMT), a number of complications such as neurotoxicity have been described and often associated with immunosuppressive agents. The syndrome of reversible posterior leukoencephalopathy has been described in patients receiving cyclosporin and FK-506. We report here a subset of children who developed a syndrome of previously undescribed irreversible leukoencephalopathy following allogeneic BMT.Between 1996 and 2002, 138 pediatric patients received an allogeneic BMT at Lucile Salter Packard Children's Hospital at Stanford. Six cases of irreversible leukoencephalopathy were observed. Cases were defined as children who exhibited progressive and continued, severe neurologic deterioration lasting greater than 2 weeks and consistent with non-localizing, central nervous system abnormalities. Medical records and magnetic resonance images (MRIs) were reviewed.Median age of the affected patients at BMT was 7.8 years. All six received cyclosporine, and [corrected] one had elevated drug levels. Encephalopathy occurred at a median of 53 days (range 14-77) following BMT. Symptoms at onset of leukoenceophalopathy included confusion and altered mental status, sluggish pupillary responses, abnormal movements, and seizures. Two patients died during their neurologic decline. Four patients remain alive with persistent encephalopathy. MRI showed abnormalities in all patients including periventricular or subcortical white matter involvement in all, and basal ganglia lesions in three.We report a syndrome of irreversible neurologic deficits and cerebral white matter abnormalities following allogeneic BMT, yet not associated with elevated cyclosporin levels. A precise mechanism for this syndrome is lacking and warrants further consideration.

    View details for DOI 10.1002/pbc.20731

    View details for Web of Science ID 000242875800016

    View details for PubMedID 16365853

  • Advances toward an understanding of brainstem gliomas JOURNAL OF CLINICAL ONCOLOGY Donaldson, S. S., Laningham, F., Fisher, P. G. 2006; 24 (8): 1266-1272

    Abstract

    The diagnosis of brainstem glioma was long considered a single entity. However, since the advent of magnetic resonance imaging in the late 1980s, neoplasms within this anatomic region are now recognized to include several tumors of varying behavior and natural history. More recent reports of brainstem tumors include diverse sites such as the cervicomedullary junction, pons, midbrain, or the tectum. Today, these tumors are broadly categorized as either diffuse intrinsic gliomas, most often in the pons, or the nondiffuse brainstem tumors originating at the tectum, focally in the midbrain, dorsal and exophytic to the brainstem, or within the cervicomedullary junction. Although we briefly discuss the nondiffuse tumors, we focus specifically on those diffuse brainstem tumors that regrettably still carry a bleak prognosis.

    View details for DOI 10.1200/JCO.2005.04.6599

    View details for Web of Science ID 000236235700006

    View details for PubMedID 16525181

  • Etoposide, vincristine, and cyclosporin a with standard-dose radiation therapy in newly diagnosed diffuse intrinsic brainstem gliomas: A pediatric oncology group Phase I study PEDIATRIC BLOOD & CANCER Greenberg, M. L., Fisher, P. G., Freeman, C., Korones, D. N., Bernstein, M., Friedman, H., Blaney, S., Hershon, L., Zhou, T. N., Chen, Z. J., Kretschmar, C. 2005; 45 (5): 644-648

    Abstract

    Brainstem gliomas (BSGs) are resistant to all therapy. Based on their imaging characteristics, we postulated that inhibition of P-glycoprotein (P-gp) associated with endothelial cells of the blood-brain barrier might enhance penetration of xenobiotic antineoplastics.Seven patients were enrolled in a Phase I study of etoposide, continuous infusion cyclosporine A given with and escalating doses of vincristine and concomitant standard-dose irradiation.Six patients were entered at the first level and one at the second. Closure of the study was mandated by dose-limiting neurotoxicity, consisting of seizures associated with white-matter changes, and alteration of consciousness with bulbar signs. One patient had tumor necrosis at 6 weeks, suggesting some tumor effect. Median survival for the group was 11 months, and for the patients who completed more than 1 month of therapy it was 11 months.This regimen proved excessively toxic.

    View details for DOI 10.1002/pbc.20382

    View details for Web of Science ID 000231623800004

    View details for PubMedID 16110498

  • Profile of daily life in children with brain tumors: An assessment of health-related quality of life JOURNAL OF CLINICAL ONCOLOGY Bhat, S. R., Goodwin, T. L., Burwinkle, T. M., Lansdale, M. F., Dahl, G. V., Huhn, S. L., Gibbs, I. C., Donaldson, S. S., Rosenblum, R. K., Varni, J. W., Fisher, P. G. 2005; 23 (24): 5493-5500

    Abstract

    The survival of children with CNS tumors approaches 70%, yet health-related quality of life (HRQOL) has not been investigated rigorously in this population. We aimed to show that universal assessment of HRQOL could be obtained easily by using the PedsQL 4.0 and to provide a composite profile of their daily lives.The PedsQL was administered to all patients seen in the neuro-oncology clinic at Lucile Packard Children's Hospital (Palo Alto, CA) from December 2001, to September 2002. Patients were compared with healthy controls by using two-sided t tests to evaluate statistically significant differences.One hundred thirty-four patients (73 male; mean age +/- standard deviation, 11.8 +/- 5.4 years; 55 had low-grade glioma, 32 had medulloblastoma/primitive neuroectodermal tumor/embryonal tumor, 17 had malignant astrocytoma, nine had germ-cell tumor, and 21 had other types of tumors) were assessed, each in less than 20 minutes. Scores on both child and parent-proxy reports for the total HRQOL, psychosocial, physical, emotional, social, and school-functioning scales were all significantly lower than controls (P < .01). Patients with low-grade glioma were reported to have the highest total HRQOL. Children receiving radiation therapy (XRT) but no chemotherapy had significantly lower total, psychosocial, emotional, and social functioning than those receiving other treatments, including XRT plus chemotherapy.The PedsQL can be used to assess HRQOL rapidly and easily in children with CNS tumors, who have significantly worse HRQOL than healthy children. Children receiving XRT fare worse overall; chemotherapy added to XRT does not seem to worsen HRQOL. Assessment of HRQOL should be included as an outcome in future clinical trials.

    View details for DOI 10.1200/JCO.2005.10.190

    View details for Web of Science ID 000231371700020

    View details for PubMedID 16110009

  • Malignant gliomas in 2005 - Where to GO from here? JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Fisher, P. G., Buffler, P. A. 2005; 293 (5): 615-617

    View details for Web of Science ID 000226694200026

    View details for PubMedID 15687318

  • Biologic risk stratification of medulloblastoma: The real time is now JOURNAL OF CLINICAL ONCOLOGY Fisher, P. G., Burger, P. C., Eberhart, C. G. 2004; 22 (6): 971-974

    View details for DOI 10.1200/JCO.2004.12.939

    View details for Web of Science ID 000220287900001

    View details for PubMedID 14970187

  • Cortical ependymoma - A case report and review PEDIATRIC NEUROSURGERY Lehman, N. L., Jorden, M. A., Huhn, S. L., Barnes, P. D., Nelson, G. B., Fisher, P. G., Horoupian, D. S. 2003; 39 (1): 50-54

    Abstract

    The authors report a rare case of a cortical ependymoma in a 10-year-old boy. The patient presented with complex partial seizures and a well-circumscribed, right frontal cortical mass. Routine microscopy showed a glial tumor with diverse histologic features. Immunohistochemistry and electron microscopy were required to establish the definitive diagnosis of cortical ependymoma. Cortical-based pediatric brain tumors range from World Health Organization grade I to III lesions and require significantly different treatment and follow-up. This case illustrates the importance of establishing an accurate neuropathologic tissue diagnosis of all pediatric cortical tumors.

    View details for DOI 10.1159/000070881

    View details for Web of Science ID 000183529400012

    View details for PubMedID 12784079

  • Radiation therapy for intracranial germ cell tumors INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS Haas-Kogan, D. A., Missett, B. T., Wara, W. M., Donaldson, S. S., Lamborn, K. R., Prados, M. D., Fisher, P. G., Huhn, S. L., Fisch, B. M., Berger, M. S., Le, Q. T. 2003; 56 (2): 511-518

    Abstract

    To review the combined experiences of University of California, San Francisco, and Stanford University Medical Center in the treatment of intracranial germ cell tumors (GCT) and to assess the impact of craniospinal radiation (CSI) on patterns of relapse, progression-free survival (PFS), and overall survival (OS).Ninety-three patients received radiation for newly diagnosed intracranial GCTs, including 49 germinomas, 16 nongerminomatous GCTs (NGGCT), and 28 with no biopsy. Median follow-up for surviving patients was 4.5 years (range 0.25-34). Tests for variables correlating with OS and PFS were conducted using Cox proportional hazards model.Five-year PFS and OS rates were 60% +/- 15% and 68% +/- 14% for patients with NGGCT and 88% +/- 5% and 93% +/- 4% for those with germinoma. Of 6 patients with localized NGGCT who did not receive CSI, 1 experienced an isolated spinal recurrence but was salvaged. Of 41 patients with localized germinoma, 6 who received CSI and 35 who did not, no isolated spinal cord relapses occurred. Twenty-one patients with localized germinoma received neither CSI nor whole brain radiation. Of these, none of 18 with ventricular radiation relapsed. One of 3 patients with primary tumor radiation relapsed intracranially but had only received 11 Gy at initial treatment. On multivariate analysis, germinoma histology but not CSI correlated with improved PFS and OS.CSI is not indicated in the treatment of localized germinomas. For patients with localized germinomas treated with radiation alone, we recommend ventricular irradiation followed by primary tumor boost to a total of 45-50 Gy.

    View details for DOI 10.1016/S0360-3016(02)04611-4

    View details for Web of Science ID 000182861500026

    View details for PubMedID 12738328

  • Intrathecal thiotepa: Reappraisal of an established therapy JOURNAL OF PEDIATRIC HEMATOLOGY ONCOLOGY Fisher, P. G., Kadan-Lottick, N. S., Korones, D. N. 2002; 24 (4): 274-278

    Abstract

    Intrathecal thiotepa is recommended as a treatment of leptomeningeal metastases (LM) in children, although published data to support this approach are limited. The authors sought to determine the efficacy of intrathecal thiotepa for pediatric LM.The authors reviewed all children treated with intrathecal thiotepa for LM at two tertiary children's hospitals, assessing outcome by cerebrospinal fluid cytology, neuroimaging, neurologic examination, and overall survival rate.Fifteen children with LM evidenced by malignant cells in the cerebrospinal fluid (mean age 7.3 years; five medulloblastoma, one anaplastic astrocytoma, one glioblastoma, one retinoblastoma, one neuroblastoma, two rhabdomyosarcoma, one non-Hodgkin lymphoma, two acute lymphoblastic leukemia, and one acute myelogenous leukemia) were treated with intrathecal thiotepa at 5 to 11.5 mg/m2 per dose for two to seven doses. Five children received concomitant craniospinal irradiation; 12 received simultaneous systemic or other intrathecal chemotherapy, or both. Four children experienced clearance of malignant cells from the spinal fluid, but this response was sustained in only two. All four children with cytologic response received concurrent radiotherapy, chemotherapy, or both. No patients showed partial or complete response on neuroimaging. Only one child had improvement on the neurologic examination; six were unchanged and eight had worsening neurologic signs. Median survival was 15.1 weeks, with a 1-year overall survival rate of 26.7% (standard error 11.4%).The unfavorable outcomes observed suggest that intrathecal thiotepa adds little to combination therapy for pediatric LM.

    View details for Web of Science ID 000175481200009

    View details for PubMedID 11972095

  • Surveillance neuroimaging to detect relapse in childhood brain tumors: A pediatric oncology group study JOURNAL OF CLINICAL ONCOLOGY Minn, A. Y., Pollock, B. H., Garzarella, L., Dahl, G. V., Kun, L. E., Ducore, J. M., Shibata, A., Kepner, J., Fisher, P. G. 2001; 19 (21): 4135-4140

    Abstract

    To investigate the prognostic significance of surveillance neuroimaging for detection of relapse among children with malignant brain tumors.A historical cohort study examined all children who experienced relapse from 1985 to 1999 on one of 10 Pediatric Oncology Group trials for malignant glioma, medulloblastoma, or ependymoma.For all 291 patients (median age at diagnosis, 8.2 years), median time to first relapse was 8.8 months (range, 0.6 to 115.6 months). Ninety-nine relapses were radiographic, and 192, clinical; median time to relapse was 15.7 versus 6.6 months, respectively (P = .0001). When stratified by pathology, radiographic and clinical groups showed differences in median time to relapse for malignant glioma (7.8 v 4.3 months, respectively; P = .041) and medulloblastoma (23.6 v 8.9 months, respectively; P = .0006) but not ependymoma (19.5 v 13.3 months, respectively; P = .19). When stratified by early (< 8.8 months) or late (> or = 8.8 months) time to relapse, 115 early relapses were clinical, and 32, radiographic; for late relapses, 77 were clinical, and 67, radiographic (P = .001). Overall survival (OS) from relapse was significantly longer for radiographic compared with clinical detection (median, 10.8 months; 1-year OS, 46% v median, 5.5 months; 1-year OS, 33%; P = .002), but this trend did not retain significance when analyzed by pathology subgroups.Surveillance neuroimaging detects a proportion of asymptomatic relapses, particularly late relapses, and may provide lead time for other therapies on investigational trials. During the first year after diagnosis, radiographic detection of asymptomatic relapse was infrequent. A prospective study is needed to formulate a rational surveillance schedule based on the biologic behavior of these tumors.

    View details for Web of Science ID 000171901100006

    View details for PubMedID 11689581

  • A guide to children with acute and chronic headaches. Journal of pediatric health care Rosenblum, R. K., Fisher, P. G. 2001; 15 (5): 229-235

    Abstract

    Children with acute and chronic headaches are often seen by primary care providers. A complete, elaborate history, obtained from both the parents and child, is key in diagnosing and managing the child who presents with a headache. A thorough social and educational history may reveal significant school or family stresses. Historic features of concern must be explored immediately. A thorough physical examination with a focused neurologic examination must be done Focal neurologic findings may indicate serious organic problems. A comprehensive approach to the management of headaches in children consisting of reassurance, education, pharmacologic interventions, and nonpharmacologic interventions is presented. A two-tiered management plan is used in conjunction with medications. The aim of this article is to provide the novice or experienced practitioner with a comprehensive review of acute and chronic headache pathogenesis, assessment, and management. This review includes migraines and other nonmigraine types of headaches.

    View details for PubMedID 11562640

  • Rapid deterioration of a newborn with congenital spinal cord astrocytoma MEDICAL AND PEDIATRIC ONCOLOGY Colby, C., Rozance, P., Goodwin, T. L., Fisher, P. G. 2001; 36 (4): 500-502

    View details for Web of Science ID 000167593000013

    View details for PubMedID 11260577

  • Visual loss caused by pseudotumor cerebri in an infant on peritoneal dialysis PEDIATRIC NEPHROLOGY Belson, A., Alcorn, D. M., Yorgin, P. D., Fisher, P. G., Sarwal, M. 2001; 16 (3): 216-218

    Abstract

    Infants with chronic renal insufficiency have multiple risk factors for developing pseudotumor cerebri (PTC) and are at particular risk for being diagnosed with PTC late, because of their inability to express symptoms. We describe a 13-month-old infant dependent on peritoneal dialysis, without evidence of central nervous system infection or inflammation, who developed acute vision loss secondary to PTC. Signs of PTC in infants include torticollis, inattentiveness, inability to track, facial paresis, or new-onset strabismus. Physicians responsible for the care of children with renal failure should be aware of the potential for PTC, as the diagnosis should be made as early as possible to prevent permanent visual loss.

    View details for Web of Science ID 000167661800003

    View details for PubMedID 11322367

  • Prognostic implications for gadolinium enhancement of the meninges in low-grade astrocytomas of childhood PEDIATRIC NEUROSURGERY Hurwitz, M. D., Burger, P. C., Goldthwaite, P. T., Tihan, T., Wharam, M. D., Fisher, P. G. 2001; 34 (2): 88-93

    Abstract

    Persistent gadolinium enhancement on MRI of the meninges in some children with low-grade astrocytomas (LGA) is a widely recognized phenomenon. The relationship of this finding with the clinical course is unclear.From a consecutive cohort of 282 children with pathologically confirmed LGA we identified all patients with asymptomatic gadolinium enhancement of the meninges found on surveillance MRI. A nested case-control study was performed, comparing patients with meningeal enhancement to controls without enhancement.Twenty-one children were identified with meningeal enhancement. The median follow-up was 5.2 years with enhancement noted for a median of 2.2 years. The 5-year overall survival for this cohort was 91.2% (Greenwood SE 8.0%), and the 5-year progression-free survival was 20.9% (SE 11.9%). Five patients are now free of disease, while 15 continue to have stable disease. The overall and progression-free survival was not significantly different compared to controls.Gadolinium enhancement of the meninges on MRI may occur in a significant number of children with LGA, particularly juvenile pilocytic astrocytoma, but does not appear to affect progression-free or overall survival. Change in management based on this finding alone is unwarranted.

    View details for Web of Science ID 000167991100005

    View details for PubMedID 11287808

  • Daily low-dose carboplatin as a radiation sensitizer for newly diagnosed malignant glioma JOURNAL OF NEURO-ONCOLOGY Peterson, K., Harsh, G., Fisher, P. G., Adler, J., Le, Q. 2001; 53 (1): 27-32

    Abstract

    Surgical resection followed by local field radiotherapy is currently our most effective approach to treatment for most patients with malignant glioma. Carboplatin chemotherapy has direct cytotoxic effects on glioma cells and acts as a radiation sensitizer to enhance cell killing. Its demonstrated efficacy as a sensitizer in other solid tumors led to this clinical trial of carboplatin as a radiation sensitizer in the treatment of newly diagnosed glioblastoma multiforme (GBM) and anaplastic astrocytoma (AA). Fourteen patients (nine GBM and five AA) were treated with daily low-dose carboplatin 25 mg/m2 intravenously within 2 h of their fractionated radiotherapy to a total dose of 600 mg/m2. No significant toxicities attributable to this combined therapy were observed. All patients have progressed, with median time to progression of 16 weeks. Eleven patients have died, with median survival of 38 weeks for the entire cohort. Although this regimen appeared safe, there was no benefit in survival time compared to historical patients treated with radiotherapy. The limitations and future potential for the strategy of radiation sensitization are discussed.

    View details for Web of Science ID 000170979800004

    View details for PubMedID 11678427

  • A clinicopathologic reappraisal of brain stem tumor classification - Identification of pilocytic astrocytoma and fibrillary astrocytoma as distinct entities CANCER Fisher, P. G., Breiter, S. N., Carson, B. S., Wharam, M. D., Williams, J. A., Weingart, J. D., Foer, D. R., Goldthwaite, P. T., Tihan, T., Burger, P. C. 2000; 89 (7): 1569-1576

    Abstract

    Brain stem tumors in children have been classified pathologically as low grade or high grade gliomas and descriptively as diffuse gliomas, intrinsic gliomas, midbrain tumors, tectal gliomas, pencil gliomas, dorsal exophytic brain stem tumors, pontine gliomas, focal medullary tumors, cervicomedullary tumors, focal gliomas, or cystic gliomas.To search for a simplified and prognostic clinicopathologic scheme for brain stem tumors, the authors reviewed a consecutive cohort of patients younger than age 21 years with tumors diagnosed from 1980 through 1997. Pathology specimens and neuroimaging were classified by masked review. Statistical and survival analysis along with Cox proportional hazards regression was performed.Seventy-six patients were identified, with initial diagnostic magnetic resonance imaging available for 51 and pathology specimens for 48 patients. Twenty cases were classified histologically as pilocytic astrocytoma (PA), 14 as fibrillary astrocytoma (FA), and 14 as other tumors or indeterminate pathology. For all tumors, characteristics significantly associated with a worse survival rate were: symptom duration less than 6 months before diagnosis (P = 0.004); abducens palsy at presentation (P < 0.0001); pontine location (P = 0.0002); and engulfment of the basilar artery (P = 0.006). Pilocytic astrocytoma was associated with location outside the ventral pons (P = 0.001) and dorsal exophytic growth (P = 0.013); Fibrillary astrocytoma was associated with symptoms less than 6 months (P = 0. 006), abducens palsy (P < 0.001), and engulfment of the basilar artery (P = 0.002). Pilocytic astrocytoma showed 5-year overall survival (OS) of 95% (standard error [SE], 5%) compared with FA 1-year OS of 23% (SE, 11%;P < 0.0001).Brain stem tumors can be succinctly and better biologically classified as diffusely infiltrative brain stem gliomas-generally FA located in the ventral pons that present with abducens palsy, often engulf the basilar artery, and carry a grim prognosis-and focal brain stem gliomas-frequently PA arising outside the ventral pons, often with dorsal exophytic growth, a long clinical prodrome, and outstanding prognosis for survival. Our findings emphasize the individuality of PA as a distinct clinicopathologic entity with an exceptional prognosis.

    View details for Web of Science ID 000089411300022

    View details for PubMedID 11013373

  • Management of children with metastatic spinal myxopapillary ependymoma using craniospinal irradiation MEDICAL AND PEDIATRIC ONCOLOGY Chinn, D. M., Donaldson, S. S., Dahl, G. V., Wilson, J. D., Huhn, S. L., Fisher, P. C. 2000; 35 (4): 443-445

    View details for Web of Science ID 000089577700013

    View details for PubMedID 11025481

  • Meningeal leukemia with cerebrospinal fluid block MEDICAL AND PEDIATRIC ONCOLOGY Fisher, P. G., Chiello, C. 2000; 34 (4): 281-283

    View details for Web of Science ID 000086052800015

    View details for PubMedID 10742072

  • Case study: Suprasellar germinoma presenting with psychotic and obsessive-compulsive symptoms JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY Mordecai, D., Shaw, R. J., Fisher, P. G., Mittelstadt, P. A., Guterman, T., Donaldson, S. S. 2000; 39 (1): 116-119

    Abstract

    This case describes a 13-year-old boy who had a suprasellar germinoma involving the bilateral basal ganglia. His presenting symptoms included left-sided weakness, diabetes insipidus, a decline in academic functioning as well as psychotic and obsessive-compulsive symptoms. His neuroradiological findings and clinical symptoms lend support to the potential role of the basal ganglia in psychotic and obsessive-compulsive symptomatology.

    View details for Web of Science ID 000084518400024

    View details for PubMedID 10638075

  • Pediatric astrocytomas with monomorphous pilomyxoid features and a less favorable outcome JOURNAL OF NEUROPATHOLOGY AND EXPERIMENTAL NEUROLOGY Tihan, T., Fisher, P. G., Kepner, J. L., Godfraind, C., McComb, R. D., Goldthwaite, P. T., Burger, P. C. 1999; 58 (10): 1061-1068

    Abstract

    Among tumors classified as pilocytic astrocytoma (PA) in the Johns Hopkins Hospital Department of Pathology files, we identified 18 cases with a distinctive monomorphous pilomyxoid histological pattern and a higher recurrence rate than that of PA with classical histological features (classical PA). The majority of the tumors occurred in infants and young children and involved the hypothalamic/chiasmatic region. The tumors were histologically similar to PA, but they were more monomorphous and more myxoid. Rosenthal fibers were not seen and only 1 of 18 tumors had eosinophilic granular bodies. At the end of the follow-up period, 6 patients were dead and 12 were alive with evidence of disease. Progression free survival (PFS) at 1 year was 38.7%. In comparison, we identified a control group of 13 classical PAs in the same age range and location as the study group. In this group, PFS at 1 year was 69.2%, which was significantly better than that for pilomyxoid tumors (p = 0.04). There was no CSF dissemination or death due to tumor progression among patients with classical PA. Eight of these patients are alive with recurrent disease, and 4 have no evidence of disease. While the monomorphous pilomyxoid tumors have some resemblance to classical PA, our results suggest that the former is a more aggressive variant or a separate entity that needs to be recognized for prognostic purposes.

    View details for Web of Science ID 000083076100004

    View details for PubMedID 10515229

  • Hyperfractionated radiotherapy in the management of diffuse intrinsic brainstem tumors: When is enough enough? INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS Fisher, P. G., Donaldson, S. S. 1999; 43 (5): 947-949

    View details for Web of Science ID 000079279100001

    View details for PubMedID 10192338

  • Outcomes and failure patterns in childhood craniopharyngiomas CHILDS NERVOUS SYSTEM Fisher, P. G., Jenab, J., Goldthwaite, P. T., Tihan, T., Wharam, M. D., Foer, D. R., Burger, P. C. 1998; 14 (10): 558-563

    Abstract

    Past studies of craniopharyngiomas in children have shown overall survival (OS) up to 95% at 5 years and 80% progression-free survival (PFS) at 5 years, although many of these series predate modern neuroimaging and current therapeutic management. Moreover, little mention has been made of failure patterns for craniopharyngioma in children. To obtain a contemporary assessment of outcome among pediatric craniopharyngioma patients, and also to determine the failure patterns for this tumor, we completed a retrospective study of a consecutive cohort of all children with craniopharyngioma diagnosed at the Johns Hopkins Hospital from 1980 to 1996. Resection was performed in 30 children, in 8 of whom gross total resection (GTR) was achieved. Initial treatment took the form of GTR followed by observation for 8, subtotal resection (STR) plus observation in 11, and STR followed immediately by radiotherapy in 8. The timing of radiotherapy following STR was unclear for 3. OS was 95.2% (SE= 4.7%) at 5 years, with only 2 children dying after 4 years from diagnosis. Five-year PFS was 59.4% (SE=10.2%). Before surgery, 19 children had visual loss and 15, endocrine deficits; after surgery, 21 children had visual loss and 29, endocrine deficits. Median time to relapse was 0.98 years (SD=2.5 years). Radiographic (n=4) and clinical (n=7) relapses did not differ in time to progression (P=0.32), but radiographic relapses were significantly associated with age at diagnosis less than 5 years (P=0.02). Degree of resection was not significantly associated with PFS (P=0.32) or with postoperative visual or endocrine deficits. Absence of calcification on diagnostic neuroimaging (n=8) was significantly associated with improved PFS [5-year PFS 100% vs. 42.9% (SE=14.7%), P=0.02], even when adjusted for extent of resection (P=0.03). Preoperative visual loss was predictive of postoperative visual loss (P=0.03). Survival for children diagnosed with craniopharyngioma in the current era is outstanding, even with relapse, although postoperative visual and endocrinological morbidities are high. Failures occurred both radiographically and clinically, typically in the first 3-4 years after surgery, suggesting a need for close surveillance initially with neuroimaging, particularly in younger children, and also clinical examination. The short times to relapse observed here may stem from a tendency to delay radiotherapy until recurrence. Lack of calcification at diagnosis is associated with a tendency to remain free of relapse.

    View details for Web of Science ID 000076744200006

    View details for PubMedID 9840379

  • Rethinking brain tumors in babies and more ANNALS OF NEUROLOGY Fisher, P. G. 1998; 44 (3): 300-302

    View details for Web of Science ID 000075744700002

    View details for PubMedID 9749594

  • Lessons learned from the clinical cooperative trials groups for childhood brain tumors NEUROSURGERY QUARTERLY Fisher, P. G., Fry, T. J., Wharam, M. D. 1998; 8 (3): 216-231
  • Salvage therapy after postoperative chemotherapy for primary brain tumors in infants and very young children CANCER Fisher, P. G., Needle, M. N., Cnaan, A., Zhao, H. Q., Geyer, J. R., Molloy, P. T., Goldwein, J. W., Herman-Liu, A. B., Phillips, P. C. 1998; 83 (3): 566-574

    Abstract

    A trend toward the use of prolonged postoperative chemotherapy, with radiotherapy deferred until relapse, has emerged for very young children with malignant brain tumors. This study was undertaken to determine the failure patterns among infants who receive such treatment and to evaluate their responses to first salvage therapy, particularly radiotherapy, after postoperative chemotherapy.A retrospective cohort was assembled, which comprised all children younger than 36 months with biopsy-proven malignant brain tumors diagnosed during the years 1987-1993 at 3 pediatric oncology referral centers. Fifty-eight children were treated with postoperative chemotherapy without irradiation, 40 of whom experienced relapse of their malignancy. These patients' charts were reviewed for failure patterns. Thirty-five of these children received salvage therapy. Statistical and survival analysis with the Cox proportional hazards regression model was performed.Among the 40 children who experienced relapse, 30 of 31 (97%) with solitary disease at initial diagnosis relapsed at the primary site of disease. Thirty-seven of 39 infants (95%) developed relapse that included their primary site of disease. Sixty percent of relapses were asymptomatic and were detected by magnetic resonance imaging (MRI) surveillance rather than by clinical examination. Two-year progression free survival (PFS) after relapse for infants who received salvage therapy was 29% (standard error [SE] = 8%). For infants who received radiotherapy alone, the 2-year PFS was 21% (SE = 9%). PFS did not differ according to whether relapses were detected clinically or radiographically or treated by radiotherapy, chemotherapy, surgery, or multimodal therapy.Relapse of brain tumors in infants after prolonged postoperative chemotherapy is largely a problem of local disease control. Salvage is possible after prolonged postoperative chemotherapy, but it yields few instances of long term, progression free survival. No therapeutic modality is superior for salvage at relapse. A strategy of reserving radiotherapy for the salvage of infants whose brain tumors relapse during postoperative chemotherapy demonstrated only limited effectiveness.

    View details for Web of Science ID 000074982100027

    View details for PubMedID 9690551

  • Third ventricular choroid plexus papilloma with psychosis - Case report JOURNAL OF NEUROSURGERY Carson, B. S., Weingart, J. D., Guarnieri, M., Fisher, P. G. 1997; 87 (1): 103-105

    Abstract

    This 9-year-old boy with a history of behavioral problems and worsening psychosis responded initially to treatment with haloperidol. However, a magnetic resonance image obtained as part of his psychiatric evaluation revealed an anterior third ventricle tumor and mild-to-moderate hydrocephalus. The resected tumor was found on pathological examination to be a choroid plexus papilloma. The patient had an uneventful postoperative course and remained free of psychosis or mood disorder at 1-year follow-up examination.

    View details for Web of Science ID A1997XF33100017

    View details for PubMedID 9202274

  • PARANEOPLASTIC OPSOCLONUS NEUROLOGY Fisher, P. G., Singer, H. S. 1995; 45 (7): 1421-1421

    View details for Web of Science ID A1995RJ27900043

    View details for PubMedID 7677891

  • ANTI-HU ANTIBODY IN A NEUROBLASTOMA-ASSOCIATED PARANEOPLASTIC-SYNDROME PEDIATRIC NEUROLOGY Fisher, P. G., Wechsler, D. S., Singer, H. S. 1994; 10 (4): 309-312

    Abstract

    A 20-month-old infant with Turner syndrome presented with opsoclonus-myoclonus and tonic pupils in association with an abdominal neuroblastoma. Despite complete removal of the tumor, the child developed progressive hearing loss, areflexia, and seizures. Immunohistochemical and Western blot studies of serum and cerebrospinal fluid revealed the presence of anti-Hu antineuronal antibody, which cross-reacted with areas of the patient's tumor. Treatment with intravenous immunoglobulin coincided with the resolution of opsoclonus-myoclonus and the cessation of new neurologic symptoms. This case provides direct support for the autoimmune basis of paraneoplastic symptoms associated with neuroblastoma and suggests that treatment with intravenous immunoglobulin may be of value.

    View details for Web of Science ID A1994NU41300007

    View details for PubMedID 8068157

Conference Proceedings


  • Childhood cerebellar hemangioblastoma does not predict germline or somatic mutations in the von Hippel-Landau tumor suppressor gene Fisher, P. G., Tontiplaphol, A., Pearlman, E. M., Duffner, P. K., Hyder, D. J., Stolle, C. A., Vortmeyer, A. O., Zhuang, Z. P. WILEY-LISS. 2002: 257-260

    Abstract

    Tumor suppressor gene "knockout" models would predict that children who present with hemangioblastoma are likely to harbor germline mutation of the von Hippel-Lindau gene. We screened 6 pediatric patients with cerebellar hemangioblastoma for germline or somatic mutations of the von Hippel-Lindau gene. Two had prior clinical manifestations of von Hippel-Lindau disease and, as expected, had germline von Hippel-Lindau gene mutations. Four children with solitary hemangioblastoma did not have a detectable germline deletion, rearrangement, or point mutation in their von Hippel-Lindau gene, and tumor specimens in 3 of these 4 showed no somatic von Hippel-Lindau allelic loss. Solitary cerebellar hemangioblastoma in children does not predict a germline or somatic mutation in the von Hippel-Lindau tumor suppressor gene. The tumorigenesis of hemangioblastoma in younger patients may differ from that in adults, and may involve a molecular process unrelated to the von Hippel-Lindau tumor suppressor pathway.

    View details for DOI 10.1002/ana.10107

    View details for Web of Science ID 000173636200017

    View details for PubMedID 11835384

  • Weekly dosing of carboplatin increases risk of allergy in children Yu, D. Y., Dahl, G. V., Shames, R. S., Fisher, P. G. LIPPINCOTT WILLIAMS & WILKINS. 2001: 349-352

    Abstract

    Carboplatin (CBDCA) has been used increasingly to treat pediatric low-grade gliomas. Allergic reactions to CBDCA have been reported in 2% to 30% of children. The reason for this high incidence of allergy is unclear.To determine the risk factors for CBDCA allergy, an historic cohort study was conducted for all children who received the drug during a 6-year period at the Lucile Salter Packard Children's Hospital at Stanford. The patients' medical records were reviewed for data on age, tumor type, CBDCA dose schedule, total number of doses, cumulative dosage, dose per treatment, other chemotherapy administered, and allergic reaction.Fifty-four children (mean age 7.2 years, 35 boys) were identified. Six children (11.1%) had an allergic reaction to CBDCA. All reactors had low-grade gliomas treated with weekly CBDCA and vincristine, with a dosage per treatment <500 mg/m2. Overall, six (75%) of eight children administered weekly CBDCA, 6 (46.2%) of 13 children with brain tumors, and 6 (40%) of 15 administered CBDCA dosage <500 mg/m2 manifested allergic reactions. Patients receiving more than five doses had significant risk for CBDCA allergy (relative risk [RR] = 11.8; 95% confidence interval [CI]: 1.5-94.1). Using logistic regression with multiple variables, weekly dose schedule was the most predictive covariate for allergic reaction (P < 0.000 1), and other factors were unrelated or redundant.Children with low-grade gliomas receiving CBDCA weekly are at significantly increased risk for CBDCA allergy. The repetitive, weekly dosing schedule of CBDCA appears to be a key risk factor for allergic reaction in brain tumor patients. The high frequency of allergy with weekly CBDCA warrants further consideration when planning future trials.

    View details for Web of Science ID 000170884300006

    View details for PubMedID 11563768

  • No responses to oral etoposide in 15 patients with recurrent brain tumors Korones, D. N., Fisher, P. G., Cohen, K. J., Dubowy, R. L. WILEY-LISS. 2000: 80-82

    View details for Web of Science ID 000087946900015

    View details for PubMedID 10881014

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