Frederick A. Boop

Background: Reirradiation is used for children and adolescents with recurrent ependymoma after prior surgery and focal irradiation. This study assessed the long-term benefits and risks of a second course of fractionated radiotherapy, patient selection, factors associated with progression-free survival (PFS) and overall survival (OS), and the role of craniospinal irradiation (CSI) at first recurrence. Methods: From July 1994 to January 2024, 150 pediatric ependymoma patients at St. Jude Children’s Research Hospital received a second course of fractionated radiotherapy. Sixty-four were enrolled in a prospective trial. Inclusion required conventional fractionation (≥50.4 Gy) for both courses, with CSI for metastatic disease. Kaplan-Meier estimates measured PFS and OS, Cox models assessed associations with covariates, and competing risks analysis evaluated necrosis and death from complications. Results: At 10 and 20 years, PFS/OS for the cohort were 19.5%/34.3% and 9.0%/13.1%, respectively. Females had significantly better outcomes, and survival varied by initial failure pattern. No significant difference in PFS (P = .1351) or OS (P = .2705) was found between focal irradiation and CSI for patients with local failure (LF). Necrosis was higher with proton therapy vs photons; grade 3 necrosis after reirradiation occurred in 19.9%. The 10-year cumulative incidence of death from complications or secondary tumors was 8.5%. Conclusions: A second course of conventionally fractionated radiotherapy can extend survival in recurrent pediatric ependymoma, but prognosis remains poor, especially for those with combined LF and distant failure or adverse features. Craniospinal irradiation did not improve outcomes for LFs. Proton therapy increased necrosis risk, emphasizing the need for careful selection and follow-up.

Advocacy, one of the five domains of global neurosurgery, represents a powerful avenue to influence public policy to expand access to safe, timely, and affordable neurosurgical care. In this manuscript, we characterize advocacy in global neurosurgery, describe specific neurosurgeon-led initiatives, and delineate how neurosurgeons can become involved in global neurosurgery advocacy efforts. Advocacy in global neurosurgery involves working together in organized neurosurgery with organizations focused on clinical provisions, training, and policy initiatives. Effective advocacy uses a data-driven approach with myriad facilitators, including collaboration and approach strategies for sharing information and a variety of contextual, ideological, and practical barriers. The main action fronts for global neurosurgery include identifying needs, broadening access, and assuring quality. Neurosurgery-led initiatives transforming public policy have occurred on regional and global scales and accelerated since 2019. Folate fortification of staple foods to prevent neural tube defects represents a recent and notably successful area of advocacy and remains in progress. Neurosurgeons who aspire to become involved in advocacy efforts must obtain competencies and skills distinct from, yet complementary to, the traditional neurosurgical training curriculum.

Low-grade gliomas are the most common brain tumor of childhood, and complete resection offers a high likelihood of cure. However, in many instances, tumors may not be surgically accessible without substantial morbidity, particularly in regard to gliomas arising from the optic or hypothalamic regions, as well as the brainstem. When gross total resection is not feasible, alternative treatment strategies must be considered. While conventional chemotherapy and radiation therapy have long been the backbone of adjuvant therapy for low-grade glioma, emerging techniques and technologies are rapidly changing the landscape of care for patients with this disease. This article seeks to review the current and emerging modalities of treatment for pediatric low-grade glioma.

Purpose Pediatric-type diffuse high-grade gliomas are the leading cause of cancer-related morbidity and mortality in children. More than 30% of diffuse hemispheric gliomas (DHG) in adolescents harbor histone H3 G34 mutations and are recognized by the World Health Organization as a distinct tumor entity. By reporting bibliometric characteristics of the most cited publications on H3 G34-mutant DHG (H3 G34 DHG), we provide an overview of emerging literature and speculate where future research efforts may lead. Methods One hundred fourteen publications discussing H3 G34 DHG were identified, categorized as basic science (BSc), clinical (CL), or review (R), and ranked by citation number. Various bibliometric parameters were summarized, and a comparison between article types was performed. Results Articles within this study represent principal investigators from 15 countries and were published across 63 journals between 2012 and 2024, with 36.84% of articles originating in the United States. Overall median values were as follows: citation count, 20 (range, 0–2591), number of authors, 9 (range, 2–78), and year of publication, 2020 (range, 2012–2024). Among the top ten most cited articles, BSc articles accounted for all ten reports. Compared to CL and R articles, BSc articles were published in journals with higher impact factors. Conclusion We establish variability in bibliometric parameters for the most cited publications on H3 G34 DHG. Our findings demonstrate a paucity of high-impact and highly cited CL reports and acknowledge an unmet need to intersect basic mechanism with clinical data to inform novel therapeutic approaches.

Since our last Special Annual Issue dedicated to the topic of ependymoma in 2009, critical advancements have been made in the understanding of this disease which is largely confined to childhood. In the era of molecular profiling, the prior classification of ependymoma based on histology has become largely irrelevant, with multiple new subtypes of this disease now being described in the newest 2021 WHO CNS Tumor Classification System. Despite our advancements in understanding the underlying biology of these tumors, the mainstays of treatment—gross total surgical resection followed by confocal radiation therapy—have continued to yield the best treatment results across multiple studies and centers. Here, we provide an update on our understanding of the advancements made in tumor biology, surgical, and oncologic management of this disease. As we move into an era of more personalized medicine, it is critical to reflect on our historical understanding of different disease entities, to better understand the future directions of our treatments.

Thank you for the opportunity to serve on this committee. It appears the WFNS has assembled an all-star cast of neurosurgeons interested in Global Neurosurgery. I am honored to serve as External Relations Lead. Listed below are a few examples of projects the group is working on that fit with your deliverables (specific, measurable, achievable, relevant, time-based). I look forward to learning of other initiatives from the group as we develop synergies moving forward.

Neurosurgical advocates for global surgery/neurosurgery at the 75th World Health Assembly gathered in person for the first time after the COVID-19 pandemic in Geneva, Switzerland, in May 2022. This article reviews the significant progress in the global health landscape targeting neglected neurosurgical patients, emphasizing high-level policy advocacy and international efforts to support a new World Health Assembly resolution in mandatory folic acid fortification to prevent neural tube defects. The process of developing global resolutions through the World Health Organization and its member states is summarized. Two new global initiatives focused on the surgical patients among the most vulnerable member states are discussed, the Global Surgery Foundation and the Global Action Plan on Epilepsy and other Neurological Disorders. Progress toward a neurosurgery-inspired resolution on mandatory folic acid fortification to prevent spina bifida-folate is described. In addition, priorities for moving the global health agenda forward for the neurosurgical patient as it relates to the global burden of neurological disease are reviewed after the COVID-19 pandemic.