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7. Late sequelae
7.1. Long term sequelae
Cognitive and focal neurological deficits may have a great
impact on long term survivors of brain tumours, regardless
of the histology and grade of the tumour. Memory loss, apa-
thy, concentration difficulties and personality changes may
have a profound effect, even in those patients who appear to
have a Karnofsky performance status of 90 or 100. Surgery in
the so-called silent areas may contribute to cognitive deficits.
Less clear are the late effects of radiation therapy on cog-
nitive function. Radiotherapy is known to cause the early
somnolence syndrome, but may also cause late sequelae,
in particular delayed leuko-encephalopathy with cognitive
dysfunction and radiation necrosis In individual
patients, it is difficult however to entangle the direct effects
of the tumour on cognition from late effects of treatment. A
recent survey on cognitive deficits in progression free sur-
vivors of low-grade glioma failed to confirm the generally
assumed untoward relation between radiotherapy and cogni-
tive deficits nly in those patients who had been treated
with fraction of 2 Gy or more, evidence of increased cognitive
dysfunction has been observed. The only other associa-
tion with cognitive deficits was treatment with anti-epileptic
drugs. Prior studies have suggested that whole brain radio-
therapy may be associated with more cognitive deficits than
involved field irradiation, although today involved field radio-
therapy is standard practice adiation therapy may also
affect cranial nerves, or induce endocrine dysfunction even
in case of tumours distant from the hypothalamus-pituitary
region eizures may have a great impact on the quality
of life even in patients with well-controlled tumours. Newer
anti-epileptic drugs may have less side-effects and should
be considered, especially in those patients using a multi-drug
regimen. Apart from cognitive deficits, a risk of death of 2.5%
at 2 years has been reported for doses of 50.4 Gy. A risk of
radionecrosis up to 5% at 5 years may occur after 60 Gy to
one third, or 50 Gy to two thirds of the brain volume, and with
50–53 Gy to brain stem with a similar risk for blindness after
50 Gy to the optic chiasm. Also chemotherapy may induce
late sequelae such as lymphoma, leukemia or solid tumours,
as well as lung fibrosis, infertility, renal failure, and signs of
neurotoxicity of the peripheral nervous system.
8. Follow-up
8.1. Follow up
No general guidelines for the follow-up of ependymomas
can be given, these should be tailored to the individual patient
and taking into account tumour grade, previously adminis-
tered treatment and independent prognostic factors as age and
the functional status of the patient. Low-grade glioma patients
should be followed, even with stable lesion since many years.
At some point in time, progression will inevitably occur and
treatment should be installed before irreversible deficits has
developed.
Acknowledgment
The authors thank the members of the EUROCAREWork-
ing Group for permitting the relative survival analysis from
the EUROCARE dataset.
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