Ependymoma natural history: Difference between revisions

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==Overview==
==Overview==
If left untreated, patients with ependymoma may progress to develop [[nausea]], [[vomiting]], [[headache]], and [[irritability]]. Common complications of ependymoma include [[seizure]], [[hydrocephalus]], [[paralysis|muscle paralysis]], and [[speech problems]].
==Complication==
==Complication==
Common complications associated with ependymomas are:
Common complications associated with ependymomas are:
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*[[Speech problems]]
*[[Speech problems]]
*[[paralysis|Muscle paralysis]]
*[[paralysis|Muscle paralysis]]
==Prognosis==
==Prognosis==
Unfavorable factors affecting outcome include the following:<ref name=Cancergove> Eoendymoma. http://www.cancer.gov/types/brain/hp/child-ependymoma-treatment-pdq#section/_35 URL Accessed on 10 6 2015.</ref>
Unfavorable factors affecting outcome include the following:<ref name=Cancergove> Eoendymoma. http://www.cancer.gov/types/brain/hp/child-ependymoma-treatment-pdq#section/_35 URL Accessed on 10 6 2015.</ref>


*Gain of ''chromosome 1q25'' is present in approximately 20% of pediatric intracranial ependymoma cases and has been reported as a negative [[prognostic|prognostic factor]] by multiple research groups.<ref name="pmid22526017">{{cite journal| author=Godfraind C, Kaczmarska JM, Kocak M, Dalton J, Wright KD, Sanford RA et al.| title=Distinct disease-risk groups in pediatric supratentorial and posterior fossa ependymomas. | journal=Acta Neuropathol | year= 2012 | volume= 124 | issue= 2 | pages= 247-57 | pmid=22526017 | doi=10.1007/s00401-012-0981-9 | pmc=PMC3554251 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22526017  }} </ref><ref name="pmid16609018">{{cite journal| author=Mendrzyk F, Korshunov A, Benner A, Toedt G, Pfister S, Radlwimmer B et al.| title=Identification of gains on 1q and epidermal growth factor receptor overexpression as independent prognostic markers in intracranial ependymoma. | journal=Clin Cancer Res | year= 2006 | volume= 12 | issue= 7 Pt 1 | pages= 2070-9 | pmid=16609018 | doi=10.1158/1078-0432.CCR-05-2363 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16609018  }} </ref>
*Gain of ''chromosome 1q25'' is present in approximately 20% of pediatric intracranial ependymoma cases and has been reported as a negative [[prognostic|prognostic factor]] by multiple research groups.<ref name="pmid22526017">{{cite journal| author=Godfraind C, Kaczmarska JM, Kocak M, Dalton J, Wright KD, Sanford RA et al.| title=Distinct disease-risk groups in pediatric supratentorial and posterior fossa ependymomas. | journal=Acta Neuropathol | year= 2012 | volume= 124 | issue= 2 | pages= 247-57 | pmid=22526017 | doi=10.1007/s00401-012-0981-9 | pmc=PMC3554251 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22526017  }} </ref><ref name="pmid16609018">{{cite journal| author=Mendrzyk F, Korshunov A, Benner A, Toedt G, Pfister S, Radlwimmer B et al.| title=Identification of gains on 1q and epidermal growth factor receptor overexpression as independent prognostic markers in intracranial ependymoma. | journal=Clin Cancer Res | year= 2006 | volume= 12 | issue= 7 Pt 1 | pages= 2070-9 | pmid=16609018 | doi=10.1158/1078-0432.CCR-05-2363 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16609018  }} </ref>
*[[Gene expression]] profile.<ref name="pmid727-38">{{cite journal| author=Koval TM, Myser WC, Hink WF| title=Effects of x-irradiation on cell division, oxygen consumption, and growth medium pH of an insect cell line cultured in vitro. | journal=Radiat Res | year= 1975 | volume= 64 | issue= 3 | pages= 524-32 | pmid=727-38 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=727  }} </ref><ref name="pmid143-57">{{cite journal| author=Sloane NH| title=alpha-Naphthoflavone activation of 6-hydroxymethylbenzo(alpha)pyrene synthetase. | journal=Cancer Res | year= 1975 | volume= 35 | issue= 12 | pages= 3731-4 | pmid=143-57 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=143 }} </ref>
*[[Gene expression]] profile<ref name="pmid22322993">{{cite journal| author=Wani K, Armstrong TS, Vera-Bolanos E, Raghunathan A, Ellison D, Gilbertson R et al.| title=A prognostic gene expression signature in infratentorial ependymoma. | journal=Acta Neuropathol | year= 2012 | volume= 123 | issue= 5 | pages= 727-38 | pmid=22322993 | doi=10.1007/s00401-012-0941-4 | pmc=PMC4013829 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22322993 }} </ref>


*Other factors that have been reported to be associated with poor prognosis for pediatric ependymoma include expression of the enzymatic subunit of [[telomerase]] (hTERT) and expression of the neural stem cell marker Nestin.<ref name="pmid848-60">{{cite journal| author=Allam AM, Hussein AM, Ragab AM| title=Amylase of the thermophilic actinomycete Thermomonospora vulgaris. | journal=Z Allg Mikrobiol | year= 1975 | volume= 15 | issue= 6 | pages= 393-8 | pmid=848-60 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=848 }} </ref>
*Other factors that have been reported to be associated with poor prognosis for pediatric ependymoma include expression of the enzymatic subunit of [[telomerase]] (hTERT) and expression of the neural stem cell marker Nestin.<ref name="pmid16575002">{{cite journal| author=Tabori U, Ma J, Carter M, Zielenska M, Rutka J, Bouffet E et al.| title=Human telomere reverse transcriptase expression predicts progression and survival in pediatric intracranial ependymoma. | journal=J Clin Oncol | year= 2006 | volume= 24 | issue= 10 | pages= 1522-8 | pmid=16575002 | doi=10.1200/JCO.2005.04.2127 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16575002  }} </ref><ref name="pmid23076205">{{cite journal| author=Modena P, Buttarelli FR, Miceli R, Piccinin E, Baldi C, Antonelli M et al.| title=Predictors of outcome in an AIEOP series of childhood ependymomas: a multifactorial analysis. | journal=Neuro Oncol | year= 2012 | volume= 14 | issue= 11 | pages= 1346-56 | pmid=23076205 | doi=10.1093/neuonc/nos245 | pmc=PMC3480268 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23076205 }} </ref>


*Tumor location. Cranial variants of ependymoma have a less favorable outcome than primary [[spinal cord]] ependymomas.[19,20] Location within the spinal cord may also affect outcome, with tumors in the lower portion of the spinal cord having a worse prognosis.<ref name="pmid282-8">{{cite journal| author=Nozaki M| title=[Combined use of bucolome and pyrazolone derivatives (II). Complex formation due to interaction between bucolome and pyrazolones]. | journal=Nihon Yakurigaku Zasshi | year= 1975 | volume= 71 | issue= 6 | pages= 631-9 | pmid=282-8 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=282 }} </ref>
*Tumor location. Cranial variants of ependymoma have a less favorable outcome than primary [[spinal cord]] ependymomas. Location within the spinal cord may also affect outcome, with tumors in the lower portion of the spinal cord having a worse prognosis.<ref name="pmid23259510">{{cite journal| author=Oh MC, Sayegh ET, Safaee M, Sun MZ, Kaur G, Kim JM et al.| title=Prognosis by tumor location for pediatric spinal cord ependymomas. | journal=J Neurosurg Pediatr | year= 2013 | volume= 11 | issue= 3 | pages= 282-8 | pmid=23259510 | doi=10.3171/2012.11.PEDS12292 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23259510 }} </ref>
*Younger age at diagnosis.<ref name="pmid1303-12">{{cite journal| author=White F| title=Epidemiology and infection control. | journal=Dimens Health Serv | year= 1975 | volume= 52 | issue= 12 | pages= 34, 37, 39 | pmid=1303-12 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1303 }} </ref>
*Younger age at diagnosis.<ref name="pmid19387655">{{cite journal| author=Tamburrini G, D'Ercole M, Pettorini BL, Caldarelli M, Massimi L, Di Rocco C| title=Survival following treatment for intracranial ependymoma: a review. | journal=Childs Nerv Syst | year= 2009 | volume= 25 | issue= 10 | pages= 1303-12 | pmid=19387655 | doi=10.1007/s00381-009-0874-y | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19387655 }} </ref>
*[[Anaplastic|Anaplastic histology]].<ref name="pmid1303-12">{{cite journal| author=White F| title=Epidemiology and infection control. | journal=Dimens Health Serv | year= 1975 | volume= 52 | issue= 12 | pages= 34, 37, 39 | pmid=1303-12 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1303  }} </ref><ref name="pmid1230-7">{{cite journal| author=Hunter AL, Klaassen CD| title=Biliary excretion of colchicine in newborn rats. | journal=Drug Metab Dispos | year= 1975 | volume= 3 | issue= 6 | pages= 530-5 | pmid=1230-7 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1230 }} </ref>
*[[Anaplastic|Anaplastic histology]]<ref name="pmid15022291">{{cite journal| author=Korshunov A, Golanov A, Sycheva R, Timirgaz V| title=The histologic grade is a main prognostic factor for patients with intracranial ependymomas treated in the microneurosurgical era: an analysis of 258 patients. | journal=Cancer | year= 2004 | volume= 100 | issue= 6 | pages= 1230-7 | pmid=15022291 | doi=10.1002/cncr.20075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15022291 }} </ref>
*Subtotal resection.<ref name="pmid1303-12">{{cite journal| author=White F| title=Epidemiology and infection control. | journal=Dimens Health Serv | year= 1975 | volume= 52 | issue= 12 | pages= 34, 37, 39 | pmid=1303-12 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1303  }} </ref>
*Subtotal resection<ref name="pmid1303-12">{{cite journal| author=White F| title=Epidemiology and infection control. | journal=Dimens Health Serv | year= 1975 | volume= 52 | issue= 12 | pages= 34, 37, 39 | pmid=1303-12 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1303  }} </ref>
*Lower doses of [[radiation]].<ref name="pmid1228-35">{{cite journal| author=Davison C, Benziger D, Fritz A, Edelson J| title=Absorption and disposition of 2-[4-(2,2-dichlorocyclopropyl)phenoxy]-2-methylpropanoic acid, WIN 35,833, in rats, monkeys, and men. | journal=Drug Metab Dispos | year= 1975 | volume= 3 | issue= 6 | pages= 520-4 | pmid=1228-35 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1228 }} </ref>
*Lower doses of [[radiation]]<ref name="pmid22840355">{{cite journal| author=Vaidya K, Smee R, Williams JR| title=Prognostic factors and treatment options for paediatric ependymomas. | journal=J Clin Neurosci | year= 2012 | volume= 19 | issue= 9 | pages= 1228-35 | pmid=22840355 | doi=10.1016/j.jocn.2012.02.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22840355 }} </ref>
*Immunohistochemical testing has identified increased expression of markers of proliferation (e.g., ''Ki-67'' and ''MIB-1'')<ref name="pmid914-20">{{cite journal| author=Davis JM| title=Overview: maintenance therapy in psychiatry: I. Schizophrenia. | journal=Am J Psychiatry | year= 1975 | volume= 132 | issue= 12 | pages= 1237-45 | pmid=914-20 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=914 }} </ref><ref name="pmid388-95">{{cite journal| author=Nilsson SF, Peterson PA| title=Studies on thyroid hormone-binding proteins. I. The subunit structure of human thyroxine-binding globulin and its interaction with ligands. | journal=J Biol Chem | year= 1975 | volume= 250 | issue= 21 | pages= 8543-53 | pmid=388-95 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=388 }} </ref> and increased expression of ''[[EZH2]]'', a polycomb complex protein involved in epigenetic regulation of gene expression, as prognostic factors for greater risk of treatment failure.<ref name="pmid1499-507">{{cite journal| author=Ezer E, Szporny L| title=A complementary method for the quantitative evaluation of rat stomach with Shay-ulcer. | journal=J Pharm Pharmacol | year= 1975 | volume= 27 | issue= 11 | pages= 866-7 | pmid=1499-507 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1499 }} </ref>
*Immunohistochemical testing has identified increased expression of markers of proliferation (e.g., ''Ki-67'' and ''MIB-1'') and increased expression of ''[[EZH2]]'', a polycomb complex protein involved in epigenetic regulation of gene expression, as prognostic factors for greater risk of treatment failure.<ref name="pmid25586788">{{cite journal| author=Li AM, Dunham C, Tabori U, Carret AS, McNeely PD, Johnston D et al.| title=EZH2 expression is a prognostic factor in childhood intracranial ependymoma: a Canadian Pediatric Brain Tumor Consortium study. | journal=Cancer | year= 2015 | volume= 121 | issue= 9 | pages= 1499-507 | pmid=25586788 | doi=10.1002/cncr.29198 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25586788 }} </ref><ref name="pmid15223962">{{cite journal| author=Wolfsberger S, Fischer I, Höftberger R, Birner P, Slavc I, Dieckmann K et al.| title=Ki-67 immunolabeling index is an accurate predictor of outcome in patients with intracranial ependymoma. | journal=Am J Surg Pathol | year= 2004 | volume= 28 | issue= 7 | pages= 914-20 | pmid=15223962 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15223962 }} </ref><ref name="pmid16342252">{{cite journal| author=Kurt E, Zheng PP, Hop WC, van der Weiden M, Bol M, van den Bent MJ et al.| title=Identification of relevant prognostic histopathologic features in 69 intracranial ependymomas, excluding myxopapillary ependymomas and subependymomas. | journal=Cancer | year= 2006 | volume= 106 | issue= 2 | pages= 388-95 | pmid=16342252 | doi=10.1002/cncr.21608 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16342252 }} </ref>


==References==
==References==
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Latest revision as of 22:19, 26 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ahmad Al Maradni, M.D. [2]

Overview

If left untreated, patients with ependymoma may progress to develop nausea, vomiting, headache, and irritability. Common complications of ependymoma include seizure, hydrocephalus, muscle paralysis, and speech problems.

Complication

Common complications associated with ependymomas are:

Prognosis

Unfavorable factors affecting outcome include the following:[1]

  • Gain of chromosome 1q25 is present in approximately 20% of pediatric intracranial ependymoma cases and has been reported as a negative prognostic factor by multiple research groups.[2][3]
  • Gene expression profile[4]
  • Other factors that have been reported to be associated with poor prognosis for pediatric ependymoma include expression of the enzymatic subunit of telomerase (hTERT) and expression of the neural stem cell marker Nestin.[5][6]
  • Tumor location. Cranial variants of ependymoma have a less favorable outcome than primary spinal cord ependymomas. Location within the spinal cord may also affect outcome, with tumors in the lower portion of the spinal cord having a worse prognosis.[7]
  • Younger age at diagnosis.[8]
  • Anaplastic histology[9]
  • Subtotal resection[10]
  • Lower doses of radiation[11]
  • Immunohistochemical testing has identified increased expression of markers of proliferation (e.g., Ki-67 and MIB-1) and increased expression of EZH2, a polycomb complex protein involved in epigenetic regulation of gene expression, as prognostic factors for greater risk of treatment failure.[12][13][14]

References

  1. ↑ Eoendymoma. http://www.cancer.gov/types/brain/hp/child-ependymoma-treatment-pdq#section/_35 URL Accessed on 10 6 2015.
  2. ↑ Godfraind C, Kaczmarska JM, Kocak M, Dalton J, Wright KD, Sanford RA; et al. (2012). "Distinct disease-risk groups in pediatric supratentorial and posterior fossa ependymomas". Acta Neuropathol. 124 (2): 247–57. doi:10.1007/s00401-012-0981-9. PMC 3554251. PMID 22526017.
  3. ↑ Mendrzyk F, Korshunov A, Benner A, Toedt G, Pfister S, Radlwimmer B; et al. (2006). "Identification of gains on 1q and epidermal growth factor receptor overexpression as independent prognostic markers in intracranial ependymoma". Clin Cancer Res. 12 (7 Pt 1): 2070–9. doi:10.1158/1078-0432.CCR-05-2363. PMID 16609018.
  4. ↑ Wani K, Armstrong TS, Vera-Bolanos E, Raghunathan A, Ellison D, Gilbertson R; et al. (2012). "A prognostic gene expression signature in infratentorial ependymoma". Acta Neuropathol. 123 (5): 727–38. doi:10.1007/s00401-012-0941-4. PMC 4013829. PMID 22322993.
  5. ↑ Tabori U, Ma J, Carter M, Zielenska M, Rutka J, Bouffet E; et al. (2006). "Human telomere reverse transcriptase expression predicts progression and survival in pediatric intracranial ependymoma". J Clin Oncol. 24 (10): 1522–8. doi:10.1200/JCO.2005.04.2127. PMID 16575002.
  6. ↑ Modena P, Buttarelli FR, Miceli R, Piccinin E, Baldi C, Antonelli M; et al. (2012). "Predictors of outcome in an AIEOP series of childhood ependymomas: a multifactorial analysis". Neuro Oncol. 14 (11): 1346–56. doi:10.1093/neuonc/nos245. PMC 3480268. PMID 23076205.
  7. ↑ Oh MC, Sayegh ET, Safaee M, Sun MZ, Kaur G, Kim JM; et al. (2013). "Prognosis by tumor location for pediatric spinal cord ependymomas". J Neurosurg Pediatr. 11 (3): 282–8. doi:10.3171/2012.11.PEDS12292. PMID 23259510.
  8. ↑ Tamburrini G, D'Ercole M, Pettorini BL, Caldarelli M, Massimi L, Di Rocco C (2009). "Survival following treatment for intracranial ependymoma: a review". Childs Nerv Syst. 25 (10): 1303–12. doi:10.1007/s00381-009-0874-y. PMID 19387655.
  9. ↑ Korshunov A, Golanov A, Sycheva R, Timirgaz V (2004). "The histologic grade is a main prognostic factor for patients with intracranial ependymomas treated in the microneurosurgical era: an analysis of 258 patients". Cancer. 100 (6): 1230–7. doi:10.1002/cncr.20075. PMID 15022291.
  10. ↑ White F (1975). "Epidemiology and infection control". Dimens Health Serv. 52 (12): 34, 37, 39. PMID 1303-12 Check |pmid= value (help).
  11. ↑ Vaidya K, Smee R, Williams JR (2012). "Prognostic factors and treatment options for paediatric ependymomas". J Clin Neurosci. 19 (9): 1228–35. doi:10.1016/j.jocn.2012.02.006. PMID 22840355.
  12. ↑ Li AM, Dunham C, Tabori U, Carret AS, McNeely PD, Johnston D; et al. (2015). "EZH2 expression is a prognostic factor in childhood intracranial ependymoma: a Canadian Pediatric Brain Tumor Consortium study". Cancer. 121 (9): 1499–507. doi:10.1002/cncr.29198. PMID 25586788.
  13. ↑ Wolfsberger S, Fischer I, Höftberger R, Birner P, Slavc I, Dieckmann K; et al. (2004). "Ki-67 immunolabeling index is an accurate predictor of outcome in patients with intracranial ependymoma". Am J Surg Pathol. 28 (7): 914–20. PMID 15223962.
  14. ↑ Kurt E, Zheng PP, Hop WC, van der Weiden M, Bol M, van den Bent MJ; et al. (2006). "Identification of relevant prognostic histopathologic features in 69 intracranial ependymomas, excluding myxopapillary ependymomas and subependymomas". Cancer. 106 (2): 388–95. doi:10.1002/cncr.21608. PMID 16342252.

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