Pt: Kantamneni, Kinnera
DX: Ependymoma (PF, T4M3)
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. difftox. 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
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 -
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.
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
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
05/01/98 - Completed RT.
05/27/98 - Fever. Ceftriaxone. Cyanotx episodes.
06/02/98 - Admitted w/vaniella. Exposure Acyclovir.
06/21/98 - Direct laryugoscory: vocal and paralysis
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.