I'd like to invite Dr. Roman Hosek from Bosnia here to talk about brain tumors in teens and how to deal with strange pathological findings. Thanks for joining us. Hopefully that's your talk title. Yes, thank you. And you are from Bosnia. Thank you. I can start, yeah? Here we go. It works. Mr. President, Professor Boop, chairs, dear colleagues, let me share with you my experience with the problems I found in the last years concerning the new WHO classification of brain tumors and with the diagnosis which was strange for me and after the surgery I had dilemma how to deal with that in teenagers, the young people which are not actually pediatrics but also not adults. So I'm coming from Sarajevo. We're doing approximately 350 brain tumors a year and what's happened actually when we found new classification, we know that still there is the rule that more extensive surgical resection for glioma is associated with longer progression free and overall survival. But we are not sure is it true still or not or is it completely true. There is no first class evidence for many cases, many different diagnosis still. So two years ago we get the WHO classification of tumors and we had the blue book with this classification and I tried to implement it in my practice and I found some different things and problems I would like to talk about. So previous classification was based on essentially on morphology alone and new one is, as you know, based on molecular analysis and biomarkers also. This is very important for some diagnosis, some kind of tumors and we know that all neuropathologists mostly have dilemma sometimes for the diagnosis and if you compare two different pathologists, the agreement for some diagnosis is 60 to 70%. That means that three different pathologists will give you 50% of agreement for some diagnosis, especially for those we find now in the new classification. So we have the problem sometimes when we send the samples from the frozen, from the operating room, we get the different findings from different pathologists and then we don't know how to deal with this pathology during the surgery. But now we have the molecular markers which could improve or techniques or approach to this patient. What's important here, what I want to talk to you is that in the children, there is some guidelines as how to approach to the patient after the surgery and also there is some guidances for the adults. But if you're looking, for example, in new classification for oligodendroglioma in children, there is no IDH mutation and there is no 1p19 co-codylation as the adults have that. So there is, that's happened because of altered genes. Those genes are different in same tumor in adults, same tumor in teenagers and same tumor in children. But approach is obviously different now. So what's happened in new classification? Let's see just few diagnoses. For example, we have now three different kind of anaplastic astrocytoma. But this is for the adults. For the teenagers, the still we have, let me say, only one anaplastic because they have no, for oligodendroglioma as I say, there is no IDH plus or minus diagnosis. There is only one type of oligodendro. Also for glioblastoma, we have now seven different kind of glioblastoma. So we have to modify the approach for those patients after the surgery. So I would like to show you this case. I operated on three years ago before new classification. And what's interesting is it's classical to our approach, nothing special. And we see a nice picture, let me say, later on. But diagnosis from the beginning in 2015 was epithelial hemangioendothelioma. To be honest, I didn't know even what does it mean actually. So I asked the pathologist what does it mean, which grade is that, what I should do to send to radiotherapy or chemotherapy. I tried to find some guidances and they explained me in two pages what does it mean. Does it mean actually that I did good surgery, I don't do nothing more, that's all. So I was happy it was in this classification grade one. So I sent the patient home and I was happy. But two years later, new classification came, actually one and a half. And they called me, they told me it's grade three actually. So what's happened with this guy, I almost lose him. And the diagnosis was now grade three. So we have to recall the patient back and ask for the radio or chemotherapy even. We have a very nice postoperative MRI even after the three years. So my dilemma was it was the wrong decision to do nothing after the surgery or it was up to the classification. Second case also, at the early beginning looking to the MRI told maybe it should be grade one or grade two, some astral something. It could be something nice. Also, postoperatively looks good. But also, if you are looking to do pathological findings, they told me during the surgery it's probably grade two. But final findings was grade three astrobasoma which is very aggressive. So even if you are looking, during the surgery, if you want to remove all the tumor and you have the findings that is grade one, so you don't have to be so aggressive maybe because you will send the patients, you will check it later on. But if you see these different pathological findings, you know that you have be much more aggressive for this kind of diagnosis, pathological diagnosis for sure. And as we see, this is a new classification, grade three. And yeah, we are trying to deal with that. And recently, European Association for Neuro-Oncology gave us some guidelines. This is from last year, comparing with those new classification on WHO. And they sent, they gave us some recommendation, especially for the astrocytic and oligodendrogliomas because they are now divided into subgroups. They are not all together now in the new classification previously. And is it based on the molecular findings now? So we have to thinking in different way how to treat the patient after the surgery. So the morphological findings, it's not enough now. And the surgery is not enough now. So also for diffuse glioma, we know that they are mostly or probably especially those which are mutant types that there are diffuse disease. And whatever you do, for example, here you see that there is the tumor MR. We find only the tumor here. But those black spots show us that the tumor tissue is, tumor cells are everywhere. So it's impossible to remove all the tumor. And as I want to show you some cases. Yes, we have some recommendation for that. And if you are looking to this chart here, you see that, for example, for the age less than 40, we don't have to do nothing. Just wait and see. Or even send the patient to radiotherapy. And also for the children, we have the recommendation. But for the teenagers, 10, 15, 20 years, there is no any recommendation how to deal with that. So I had a dilemma with these cases. For example, this glioblastoma, even we did the night surgery, look at here, one year later on. And we find that this glioblastoma, we see that 14 months later on, we have the tumor everywhere in the brain. So those recommendations probably should be based on the genetics of this patient. And then we will know that temozolomide is not enough. And also maybe we should try another things. For example, Avastin or something, even we don't know is it good or not. Also, we have some, another classification, another recommendation. But look at here, for example, this anaplastic pleomorphic xanthocytosatoma, they tell us now in the guidelines from the last year that we should send the patient to the radiotherapy and give some chemotherapy also. And then watch and wait. But if you have, and also there is some recommendation how to deal with this radiotherapy, chemotherapy. And we have to thinking about the problems in the pediatrics and the teenagers. Do we really need to send them to chem or radiotherapy and accept the surgery? If I am looking to this picture, of course, we need the surgery here. And even if it's grade two, if this young children recommendation say less than 30 years, we should send it to the chemotherapy and the local radiotherapy. Because even we don't know or we know is there remnant or not, patient should be sent to the radiotherapy, localized radiotherapy, and also sometime even the chemo. This guidelines is sometime confuse us. And we are, me personally, I'm not sure that I'm smart and two years ago with those guidelines, I think it's much more confused than earlier. Why? Because they still say surgery is crucial treatment, but we should also send to the radiotherapy. We have no confirmation for that. We have no evidence base that is good. But let's send the patient to radiotherapy and chemotherapy. And they say that for the pediatric patients, for example, for epidemomas. They say that for the adults, but nothing say it for teenagers for the age of 15 years, 18 years, 20. And we know that also young children from one year or less should be treated with chemo. But for the people who are not even pediatrics or adults, there is not any suggestion how to deal with. And we actually know for this case, for example, that there is nine different subgroups of epidemomas and every groups have different approach concerning the new classification. And there is some guidelines which say that surgery is still evidence class one, the best option. But still we have to collaborate with our colleagues, oncologists, pathologists, and so. And if you see this picture, as neurosurgeons probably we will say we have to operate this patient at least for the hydrocephalus. And of course, we recommend the surgery, simple approach, the usual nice post-operative findings. But you see here, it's anaplastic polymorphic santoastrocytoma. As we seen earlier, this is for the radiotherapy, see here. So I don't know is it a good option to leave this tumor there and send to the radiotherapy. I don't know who will do that. But if you follow recommendation, it will happen. So I'm not sure did I make mistake with surgery in this case. No, I don't think so. I don't think so that we have, we cannot follow the recommendation even from last year. Completely, yes. This is the child after the surgery two or three years later on. She's happy with surgery. So, but we have to be honest. We have to follow some new things. We have to look at genomic alteration, try to find the personalized therapy. And these findings could help us in the future have to deal with this stranger diagnosis in the future. As we say, multidisciplinary approach, of course. And for last but not least, this is the young guy came to us comatose during the night. And of course, we decided to operate him very early in the morning to perform, to help him, to find him. It was pilonicid astrocytoma. And three years later, he was good. But we cannot be happy. The guy, he grows very well in six weeks postoperatively. I was happy. He was happy. His parents was happy. But if we are looking to this, his diagnosis, it's now looks dangerous much more than in previous classification. So never celebrate too early, I can say. And never follow recommendations too strongly as we're trying to do. Thank you. Thank you. Do you have any questions? Please. I would like, thank you for this very beautiful talk. And you have expressed all the problems that we have between the young and the teens. But they can in 50 minutes. Many problems there. But I just want to talk about ependymomas. You have said that we should make radiotherapy. This is what it is said. But in the era of molecular biology, I think that first we have to distinguish between posterior foci ependymoma and supratentorial ependymoma. And now, in our group, we are looking to have the tools in molecular biology. And maybe in the supratentorial ependymomas, when we don't have the relafusion, maybe we can, when we do a total resection, maybe we could spare children from irradiation. This is the idea. I think that this radiotherapy for all this ependymoma will, the shim will evolve in the future with this news in molecular biology. Thank you. Thank you for comment. No. Yeah. Yes, I agree. I agree. We know that the spinal ependymomas, posterior foci, supratentorial are actually different. And we confirm that with new findings. Yeah. We should be careful with deciding what to do in the future. Yeah. Great. Thank you.

brain tumors

teenagers

diagnosis

treatment

molecular analysis