Pediatric posterior fossa incidentalomas

  • Danil A. Kozyrev
  • Shlomi Constantini
  • Deki Tsering
  • Robert Keating
  • Sharif Basal
  • Jonathan RothEmail author
Original Article



Pediatric brain incidentalomas are increasingly being diagnosed. As the posterior fossa (PF) is the location of most brain tumors in children, lesions of this region are of special interest. Currently, the natural history of incidental lesions in the PF is unknown. We present our experience treating such lesions.


A retrospective study was carried out in two large tertiary pediatric centers. Patients were included if they had an incidental PF lesion suspected of being a tumor, and diagnosed before the age of 20 years. We analyzed treatment strategy, pathology, and outcome of operated and non-operated cases.


Seventy children (31 females) with a mean age of 8.4 ± 6.1 years were included. The three most common indications for imaging were headaches (16, assumed to be unrelated to the lesions), workup of unrelated conditions (14), and unspecified reasons (14). Twenty-seven patients (39%) were operated immediately, and 43 followed, of which 12 were eventually operated due to radiological changes, 28.9 ± 16.2 months after diagnosis. The most commonly found pathology was pilocytic astrocytomas (21 of 39 operated cases). Almost 10% were found to be malignant tumors including medulloblastomas (5) and ATRT (1).


Incidental PF lesions in children include both benign and malignant tumors. While certain lesions may be followed, others may require surgical treatment. Specific treatment decisions are based on initial radiological appearance, change in radiological characteristics over time, location, and evolving symptoms. The surgical risks must be balanced vis-à-vis the risk of missing a high-grade tumor and the very rare risk of malignant transformation.


Brain tumor Posterior fossa tumor Incidentalomas Pediatric 



We would like to thank Yaroslava A. Kozyreva for the drawing in this article, and Mrs. Adina Sherer for linguistic editing.


  1. 1.
    Broniscer A, Baker SJ, West AN, Fraser MM, Proko E, Kocak M, Dalton J, Zambetti GP, Ellison DW, Kun LE, Gajjar A, Gilbertson RJ, Fuller CE (2007) Clinical and molecular characteristics of malignant transformation of low-grade glioma in children. J Clin Oncol 25:682–689. CrossRefGoogle Scholar
  2. 2.
    Ishibashi K, Inoue T, Fukushima H, Watanabe Y, Iwai Y, Sakamoto H, Yamasaki K, Hara J, Shofuda T, Kanematsu D, Yoshioka E, Kanemura Y (2016) Pediatric thalamic glioma with H3F3A K27M mutation, which was detected before and after malignant transformation: a case report. Childs Nerv Syst 32:2433–2438. CrossRefGoogle Scholar
  3. 3.
    Soleman J, Roth J, Ram Z, Yalon M, Constantini S (2017) Malignant transformation of a conservatively managed incidental childhood cerebral mass lesion: controversy regarding management paradigm. Childs Nerv Syst 33:2169–2175. CrossRefGoogle Scholar
  4. 4.
    Upadhyaya SA, Ghazwani Y, Wu S, Broniscer A, Boop FA, Gajjar A, Qaddoumi I (2018) Mortality in children with low-grade glioma or glioneuronal tumors: a single-institution study. Pediatr Blood Cancer 65.
  5. 5.
    Roth J, Keating RF, Myseros JS, Yaun AL, Magge SN, Constantini S (2012) Pediatric incidental brain tumors: a growing treatment dilemma. J Neurosurg Pediatr 10:168–174. CrossRefGoogle Scholar
  6. 6.
    Roth J, Soleman J, Paraskevopoulos D, Keating RF, Constantini S (2018) Incidental brain tumors in children: an international neurosurgical, oncological survey. Childs Nerv Syst 34:1325–1333. CrossRefGoogle Scholar
  7. 7.
    Morris Z, Whiteley WN, Longstreth WT Jr, Longstreth WT, Weber F, Lee YC, Tsushima Y, Alphs H, Ladd SC, Warlow C, Wardlaw JM, al-Shahi Salman R (2009) Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 339:b3016. CrossRefGoogle Scholar
  8. 8.
    Perret C, Boltshauser E, Scheer I, Kellenberger CJ, Grotzer MA (2011) Incidental findings of mass lesions on neuroimages in children. Neurosurg Focus 31:E20. CrossRefGoogle Scholar
  9. 9.
    Bredlau AL, Constine LS, Silberstein HJ, Milano MT, Korones DN (2012) Incidental brain lesions in children: to treat or not to treat? J Neuro-Oncol 106:589–594. CrossRefGoogle Scholar
  10. 10.
    Ali ZS, Lang SS, Sutton LN (2014) Conservative management of presumed low-grade gliomas in the asymptomatic pediatric population. World Neurosurg 81:368–373. CrossRefGoogle Scholar
  11. 11.
    Wilne S, Collier J, Kennedy C, Koller K, Grundy R, Walker D (2007) Presentation of childhood CNS tumours: a systematic review and meta-analysis. Lancet Oncol 8:685–695. CrossRefGoogle Scholar
  12. 12.
    Rogers AJ, Maher CO, Schunk JE, Quayle K, Jacobs E, Lichenstein R, Powell E, Miskin M, Dayan P, Holmes JF, Kuppermann N, for the Pediatric Emergency Care Applied Research Network (2013) Incidental findings in children with blunt head trauma evaluated with cranial CT scans. Pediatrics 132:e356–e363. CrossRefGoogle Scholar
  13. 13.
    Maher CO, Piatt JH Jr (2015) Section on neurologic surgery AA of P (2015) incidental findings on brain and spine imaging in children. Pediatrics 135:e1084–e1096. CrossRefGoogle Scholar
  14. 14.
    Jansen PR, Dremmen M, van den Berg A, Dekkers IA, Blanken LME, Muetzel RL, Bolhuis K, Mulder RM, Kocevska D, Jansen TA, de Wit MCY, Neuteboom RF, Polderman TJC, Posthuma D, Jaddoe VWV, Verhulst FC, Tiemeier H, van der Lugt A, White TJH (2017) Incidental findings on brain imaging in the general pediatric population. N Engl J Med 377:1593–1595. CrossRefGoogle Scholar
  15. 15.
    Jagadeesh H, Bernstein M (2014) Patients’ anxiety around incidental brain tumors: a qualitative study. Acta Neurochir 156:375–381. CrossRefGoogle Scholar
  16. 16.
    Mistry M, Zhukova N, Merico D, Rakopoulos P, Krishnatry R, Shago M, Stavropoulos J, Alon N, Pole JD, Ray PN, Navickiene V, Mangerel J, Remke M, Buczkowicz P, Ramaswamy V, Guerreiro Stucklin A, Li M, Young EJ, Zhang C, Castelo-Branco P, Bakry D, Laughlin S, Shlien A, Chan J, Ligon KL, Rutka JT, Dirks PB, Taylor MD, Greenberg M, Malkin D, Huang A, Bouffet E, Hawkins CE, Tabori U (2015) BRAF mutation and CDKN2A deletion define a clinically distinct subgroup of childhood secondary high-grade glioma. J Clin Oncol 33:1015–1022. CrossRefGoogle Scholar
  17. 17.
    Garcia-Gomez JM, Luts J, Julia-Sape M et al (2009) Multiproject-multicenter evaluation of automatic brain tumor classification by magnetic resonance spectroscopy. MAGMA 22:5–18. CrossRefGoogle Scholar
  18. 18.
    Jain R (2011) Perfusion CT imaging of brain tumors: an overview. AJNR Am J Neuroradiol 32:1570–1577. CrossRefGoogle Scholar
  19. 19.
    Leon SP, Folkerth RD, Black PM (1996) Microvessel density is a prognostic indicator for patients with astroglial brain tumors. Cancer 77:362–372.<362::AID-CNCR20>3.0.CO;2-Z CrossRefGoogle Scholar
  20. 20.
    Tate AR, Underwood J, Acosta DM, Julià-Sapé M, Majós C, Moreno-Torres À, Howe FA, van der Graaf M, Lefournier V, Murphy MM, Loosemore A, Ladroue C, Wesseling P, Luc Bosson J, Cabañas ME, Simonetti AW, Gajewicz W, Calvar J, Capdevila A, Wilkins PR, Bell BA, Rémy C, Heerschap A, Watson D, Griffiths JR, Arús C (2006) Development of a decision support system for diagnosis and grading of brain tumours using in vivo magnetic resonance single voxel spectra. NMR Biomed 19:411–434. CrossRefGoogle Scholar
  21. 21.
    Vicente J, Fuster-Garcia E, Tortajada S, García-Gómez JM, Davies N, Natarajan K, Wilson M, Grundy RG, Wesseling P, Monleón D, Celda B, Robles M, Peet AC (2013) Accurate classification of childhood brain tumours by in vivo (1)H MRS - a multi-centre study. Eur J Cancer 49:658–667. CrossRefGoogle Scholar
  22. 22.
    Julia-Sape M, Coronel I, Majos C et al (2012) Prospective diagnostic performance evaluation of single-voxel 1H MRS for typing and grading of brain tumours. NMR Biomed 25:661–673. CrossRefGoogle Scholar
  23. 23.
    Pirotte BJ, Lubansu A, Massager N et al (2010) Clinical interest of integrating positron emission tomography imaging in the workup of 55 children with incidentally diagnosed brain lesions. J Neurosurg Pediatr 5:479–485. CrossRefGoogle Scholar
  24. 24.
    Potts MB, Smith JS, Molinaro AM, Berger MS (2012) Natural history and surgical management of incidentally discovered low-grade gliomas. J Neurosurg 116:365–372. CrossRefGoogle Scholar
  25. 25.
    Duffau H, Pallud J, Mandonnet E (2011) Evidence for the genesis of WHO grade II glioma in an asymptomatic young adult using repeated MRIs. Acta Neurochir 153:473–477. CrossRefGoogle Scholar
  26. 26.
    Jones DT, Hutter B, Jager N et al (2013) Recurrent somatic alterations of FGFR1 and NTRK2 in pilocytic astrocytoma. Nat Genet 45:927–932. CrossRefGoogle Scholar
  27. 27.
    Zhang J, Wu G, Miller CP et al (2013) Whole-genome sequencing identifies genetic alterations in pediatric low-grade gliomas. Nat Genet 45:602–612. CrossRefGoogle Scholar
  28. 28.
    Fouladi M, Pfister SM (2017) MEK and RAF inhibitors: time for a paradigm shift in the treatment of pediatric low-grade gliomas? Neuro-Oncology 19:741–743. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Pediatric Neurosurgery, Dana Children’s HospitalTel Aviv Medical Center, Tel Aviv UniversityTel AvivIsrael
  2. 2.Children’s National Medical CenterWashingtonUSA

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