ID #375 Critical disparities in pediatric ependymoma outcomes multicenter experience from three low and middle income countries
Selma Çakmakcı, Rahat Ul Ain, Julieta Hoveyan, Harun Demirci, Laeeq Ur Rehman, Eduard Asatryan, Süheyla Aytaç Arslan, Servet Güreşçi, Ayşe Özdemir Gökce, Rabia Qaiser, Mahvish Hussain, Derya Özyörük, Neriman Sarı, Nisreen Amayiri, Maryam Fouladi, Simon Bailey, Eric Bouffet, Ibrahim Qaddoumi, Naureen MushtaqAbstract
Background
Ependymomas, the third most common pediatric brain tumor, represent 5-10% of pediatric CNS tumors, with outcomes heavily influenced by extent of resection and radiotherapy access. Data from low- and middle-income countries (LMICs) remain limited, particularly regarding inequities in surgical care and treatment access.
Methods
This retrospective multicenter cohort included 62 pediatric ependymoma patients from three LMIC centers (Turkey: 33, Pakistan: 21, Armenia: 8) treated between 2004-2024. Data were collected on demographics, clinical presentation, tumor characteristics, histopathology, surgical outcomes, treatment modalities, and follow-up. Median age was 6.2 years (range 0.6-17); 50% female. Median follow-up was 21 months (range 1-180). Data completeness varied across centers. Survival outcomes were analyzed using Kaplan-Meier methods with log-rank testing.
Results
Median time from symptom onset to diagnosis was 50 days, and median surgery-to-radiotherapy interval was 48 days. Tumor locations: posterior fossa (38), supratentorial (14), spinal (10). WHO grade distribution was II (36) and III (22). Gross total resection (GTR) was achieved in 25 patients, subtotal resection (STR) in 29, biopsy in 1. Radiotherapy was administered to 35 patients. Overall 3-year event-free survival (EFS) was 51% and overall survival (OS) was 71.2%. Significant outcome differences existed between countries: 3-year OS was 90% (Turkey), 23% (Pakistan), and 75% (Armenia) (p < 0.001). Corresponding 3-year EFS rates were 58.7%, 26.8%, and 62.5% (p = 0.03). Notably, 7 of 21 Pakistani patients (33%) died postoperatively, 6 within the first week. GTR significantly improved 3-year EFS (80.7% vs 27.4% for STR, p < 0.001) and OS (100% vs 54.6% for STR, p < 0.001). Radiotherapy was associated with improved EFS (61.4% vs 28.3%, p = 0.001) and OS (94.3% vs 29%, p < 0.001). Female gender was associated with better EFS (68% vs 35%, p = 0.028). For patients under 3 years (n = 17), 3-year EFS was 47.8 % and OS was 73.4%; half received multi-agent chemotherapy.
Conclusion
This multi-center LMIC study demonstrates marked disparities in pediatric ependymoma outcomes, driven by delayed diagnosis, limited surgical resources, inadequate postoperative care, and restricted radiotherapy access. The 33% early postoperative mortality in one center underscores urgent needs for improved perioperative care, infection control, and resource allocation in resource-limited settings.