The 16 mo. infant girl was admitted 12/19/96 with a 1-mo. history of developemental regression, inability to walk, and dyconjugate gaze. A CT scan in india (where family was visiting relatives) revealed a posterior fossa mass with hydrocephalus, and a VP shunt was placed. MRI scan here (12/20/96) showed a 4.2 x 3.8-cm enhancing mass in the 4th ventricle extending to C1-C2 and compressing the midbrain. The same day the child underwent gross total resection of the tumor (Dr. feldstein), with diagnosis of malignant ependymoma. Post-op MRI (12/23) showed minimal residual enhancement in the right lateral surgical bed, and a spine study demodstrated subarachnoid to the anterior mid-cervical region. The child was seen in consultation 12/23 and discharged 12/24 on Decadron.

Examination in clinic 12/30/96 showed a well-developed infant in no distress, afebrile, wt. 10kg, ht. 79 cm, with a right VP shunt. There was a 3 x 3 cm hemangioma over the right nipple. Neurologic exam was nonfocal with mild hyperreflexia and hypotonia. She was readmitted 12/31/96 with CSF leak. CT scan 1/1/97 showed moderate ventricular dialatation and post-operative changes. Culture of subgaleal CSF was positive for staph warneri, sensitive to oxacillin. Decadron was stopped 1/3/97. A 5-Fr double-lumen Broviac cather was inserted 1/5. She had transient fever 1/7 with negative cultures. CSF cytology revealed rare malignant cells. An audiogram 1/10 was normal. Creatinine clearence was 136 cc/min/173 m2.

01/13/97    -     Start chemotherapy: CCG-9921 induction Regimen B (vincristine, carboplatin, ifosfamide,                                 etoposide). Course 1.
01/15/97    -     Shaking chills, RSV pos, Blood cult neg, RBC tx
01/18/97    -     Discharged on fluconazole and G-CSF. To start Bactrim 25 mg bid qMTW.
01/21/97    -    Vincristine.
01/22/97    -    Low grade temp. K 2.9. K bolus, Plt tx.
01/23/97    -    Admitted fever/neutropenia/mild dehydration. Loose stool. Vanco/ceftaz. RSV pos. C. diff                                 tox. neg. Blood cult neg. RBC, plt tx.
01/28/97    -    Vincristine.
01/29/97    -    Anorexia. TPN started.
02/05/97    -    Induction course 2. senokot. G-CSF 10 mcg/kg.
02/10/97    -    NGT feeding.
02/12/97    -    Vincristine. plt tx (2/14). Discharged 2/15. G-CSF.
02/19/97    -    Vincristine. plt tx (2/21). Continue NGT feeding.
02/26/97    -    Audiogram nl. Induction Course 3, tolerated well. RBT tx.
03/04/97    -    Vincristine.
03/10/97    -    Vincristine.
03/14/97    -    Cranial MRI: no evidence of tumor.
03/18/97    -     E. coli UTI. Augmentin, then Keflex.
03/26/97    -     Induction Course 4. G-CSF
03/26/97    -    Audiogram nl. Briviac repair.
04/08/97    -    Admitted fever/neutropenia. Blood cult. pos. Staph epi, Staph aureus, enterococcus.Vanco/ceftaz.
04/18/97    -    New CVL. Induction course 5. G-CSF.
05/12/97    -    Cranial MRI: new nodular enhancement roof of 4th ventricle.
05/13/97    -    Spine MRI: punctate enhancing nodule postrier to cord at T6
05/16/97    -    Suboccipital craniotomy and resection of recurrent ependymoma.
05/21/97    -    Cranial MRI neg.
05/29/97    -    seen post-op. R eye deviation, head tilt, L leg weekness. LP:CSF w/malignant cells. Treatment                               discussion, recommended 2 courses of VCR/Pt CTX/VP16 as per Regimen A induction followed by                         VCR/CTX attempting to delay RT for 6-12 mos.
06/04/97    -    Reinduction Course 1, tolerated well. G-CSF
06/11/97    -    Vincristine. Admitted fever/neutropenia. ceftaz. Blood cult. neg.
06/04/97    -    Vincristine.
06/11/97    -    Vincristine. Admitted fever/neutropenia. Ceftaz. Blood cult. neg.
06/18/97    -    Vincristine.
06/20/97    -    Still neutripenic. Leaking CVL removed. Discharged 6/22 on G-CSF.
06/23/97    -    Well but neutropenic. RBC, plt tx. G-CSF continued. PT, speech therapy.
07/01/97    -    Portocath placement. Admit for reinduction Course 2.
07/24/97    -    LP done in OR showed - pathology. Cranial & spine MRI done.
08/01/97    -    Spine MRI -.
08/20/97    -    Admit for VCR/Cytoxan course #1 - no problems.
08/22/97    -    Went for ER for temp 101 ax - Ceftriaxone given X 2 days & placed on Amoxicillin 8/23 for o.m.?
09/19/97    -    Admit for VCR/Cytoxan course #2.
10/17/97    -    Admit for VCR/Cytoxan course #3.
11/14/97    -    Admit for VCR/Cytoxan course #4.
11/26/97    -    MRI head & spine - 4th ventrical mass lesion removed spine - neurogenic bladder.
12/12/97    -    Admit for VCR/Cytoxan course #5.
01/09/98    -    Admit for VCR/Cytoxan course #6.
02/13/98    -    Admit for VCR/Cytoxan course #7. VCR/CTX
02/26/98    -    Presents w/ache swallowing weakness & irritability. MRI: abn. enhancing mass lesion lower 4th                        ventrical and poutomedullary/cervicalmedullary junction. No hydrocephalus. No evidence of tumor in                        cervical card. Rad. o.r.c consult.
03/02/98    -    Reoperation w/gross resection of tumor. Path: ependymoma CSF; autolysed cells. Post-op                                prolonged intubation for vocal card paresis. ?seizures. EEO (3/3) - no epieptiform discharges.                         Asymmetric sleep orcuitecture. Dilantin given
03/20/98    -    Direct laryugoscope and trakeitomy(Dr. Keller).
03/23/98    -    Start RT.
03/27/98    -    MRI: mild enhc. sup. aspect operative site.
05/01/98    -    Completed RT.
05/27/98    -    Fever. Ceftriaxone. Cyanotx episodes. Vaniells exposure.
06/02/98    -    Admitted w/vaniella. Exposure Acyclovir.
06/21/98    -    Direct laryugoscory: vocal and paralysis resolved
07/15/98    -    Fever. Ceftriaxone. Gaining Wt.
10/16/98    -    Was admitted with a V-P shunt obstruction and hydrocephalus, was taken to the OR 10/16 for                       shunt revision. Post-op she had trouble mintaining her blood pressures-treated with Dopamine                       and hydrocortisone for adrenal insufficiency. She also had left sided weakness for which she is                        receiving physical therapy.