National Patterns of Care in the Management of World Health Organization Grade II and III Spinal Ependymomas

Background: Spinal ependymomas are rare, with an incidence of 1 per 100,000. Given the paucity of data for higher grade II and III disease, the management and patterns of care require further investigation. Methods: Our study of 1345 patients with higher-grade spinal ependymoma used χ ² tests and simple and multivariable logistic regression models to assess demographic and clinical factors associated with therapy. Kaplan-Meier and log-rank tests were used to assess overall survival (OS). Results: Most grade II patients received surgery alone (81.1%) compared with 36.8% of grade III. Approximately 60% of patients with grade III ependymomas received radiotherapy (RT) versus 15.3% of grade II (P < 0.001). Patients living ≤32 km (20 miles) from a facility were more likely to receive RT (P < 0.001) than were those living further away. On multivariable logistic regression, grade (grade III, odds ratio, 8.6; P < 0.001) and facility distance were significantly associated with receipt of RT (P < 0.0001). The 5-year and 10-year OS was 94.7%/85.1% for patients with grade II disease and 58.2%/46.4% for grade III disease (P < 0.0001). OS was highest at facilities treating an average of 15 patients over 10 years, corresponding to the top 81st percentile in volume. The 10-year OS was 92.6% at facilities treating at least 15 patients and 88.0% at facilities treating 6–14 patients. Conclusions: Approximately 40% of patients with grade III ependymomas do not receive immediate adjuvant therapy, which may be related to distance from a facility. Patients with this rare tumor may benefit from multidisciplinary care at facilities with a larger volume.