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Spectroscopic measurement of 5-ALA-induced intracellular protoporphyrin IX in pediatric brain tumors. Acta Neurochir (Wien) 2019; 161:2099-2105. [PMID: 31435824 DOI: 10.1007/s00701-019-04039-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/09/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better delineation between tumor and normal brain, allowing improved resection and improved patients' outcome. Recently, several reports were published regarding 5-ALA for resection of pediatric brain tumors. The aim of the study was to determine the intracellular fluorescence of protoporphyrin IX (PPIX) in pediatric brain tumors by hyperspectral imaging and to compare it with visually observed intraoperative fluorescence. METHODS 5-ALA was administered orally 4 h prior to surgery. During tumor resection, the surgeon assessed the fluorescence signal to be strong, weak, or absent. Subsequently, fluorescence intensity of tumor samples was measured via spectroscopy. In addition, clinical data, imaging, and laboratory data were analyzed. RESULTS Eleven children (1-16 years) were operated. Tumor entities included three (n = 3) medulloblastomas, two (n = 2) pilocytic astrocytomas (PA), two (n = 2) anaplastic ependymomas and one (n = 1) diffuse astrocytoma, anaplastic astrocytoma (n = 1), pilomyxoid astrocytoma (n = 1) and anaplastic pleomorphic xanthoastrocytoma (n = 1). Strong fluorescence was visible in all anaplastic tumors and one PA; one PA demonstrated weak fluorescence. Visible fluorescence was strongly associated with intracellular fluorescence intensity and PPIX concentration (P < 0.05). Within all tumors with visible fluorescence, the intracellular PPIX concentration was greater than 4 μg/ml. Except for moderate and transient elevation of liver enzymes, no 5-ALA related adverse events were reported. CONCLUSION We demonstrate a strong association between intraoperative observations and spectrometric measurements of PPIX fluorescence in tumor tissue. As in former studies, fluorescence signal was more commonly observed in malignant glial tumors. Further prospective controlled trials should be conducted to investigate the feasibility of 5-ALA-guided resection of pediatric brain tumors.
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Capozza MA, Trombatore G, Triarico S, Mastrangelo S, Attinà G, Maurizi P, Ruggiero A. Adult medulloblastoma: an overview on current and future strategies of treatment. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1663170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Michele Antonio Capozza
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giovanna Trombatore
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Silvia Triarico
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giorgio Attinà
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
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Liu JJ, Sun YL, DU SX, Li CD, Gong XJ, Li M, Wu WS, Sun LM. [Risk factors for recurrence within 2 years in children with medulloblastoma]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:761-765. [PMID: 31416499 PMCID: PMC7389898 DOI: 10.7499/j.issn.1008-8830.2019.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/17/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the risk factors for recurrence of medulloblastoma (MB) within 2 years and their influence on progression-free survival (PFS). METHODS A retrospective analysis was performed for the clinical data of 123 children with MB who were admitted from January to December, 2017. According to the presence or absence of recurrence, they were divided into recurrence group with 30 children and non-recurrence group with 93 children. The risk factors for recurrence within 2 years were analyzed, and PFS was compared between the children with different risk factors. RESULTS Large-cell/anaplastic type and M stage were risk factors for MB recurrence within 2 years. The risk of recurrence in the children with M+ MB was 3.525 times that in those with M0 MB, and the risk of recurrence in the children with large-cell/anaplastic MB was 3.358 times that in those with classic MB (P<0.05). The survival analysis showed that the median PFS time was 20 months in the children with M+ MB, and the 20-month PFS rate was 50% ± 11% in the children with M+ MB and 81% ± 5% in those with M0 MB (P<0.05). The 20-month PFS rate was 80% ± 5% in the children with classic MB, 65% ± 10% in those with desmoplastic/nodular MB, 86% ± 13% in those with MB with extensible nodularity, and 36% ± 20% in those with large-cell/anaplastic MB (P<0.05). CONCLUSIONS Recurrence is an important influencing factor for the prognosis of MB, and M+ stage and large-cell/anaplastic MB are risk factors for recurrence. Children with such risk factors tend to have a low PFS rate.
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Affiliation(s)
- Jing-Jing Liu
- Beijing Shijitan Hospital of Capital Medical University, Beijing 100038, China.
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Bleil CB, Bizzi JWJ, Bedin A, de Oliveira FH, Antunes ÁCM. Survival and prognostic factors in childhood medulloblastoma: A Brazilian single center experience from 1995 to 2016. Surg Neurol Int 2019; 10:120. [PMID: 31528456 PMCID: PMC6744760 DOI: 10.25259/sni-237-2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 04/08/2019] [Indexed: 12/30/2022] Open
Abstract
Background: Medulloblastoma is the most common malignant brain tumor in the pediatric population. Despite prognosis improvement in the past two decades, one-third of the patients still remain incurable. New evidence suggests that medulloblastoma comprises four distinct entities; therefore, treatment de-escalation is required. The aim of this article is to evaluate epidemiological data from patients treated at our institution. The primary objective is to analyze overall survival (OS) and event-free survival (EFS) and the secondary objective is to identify prognostic factor from this cohort. Methods: We retrospectively analyzed 69 patients who underwent surgical resection for medulloblastoma among 423 children from the tumor registry data bank of Santo Antônio Children’s Hospital from 1995 to 2016. Kaplan–Meier method and Cox regression analysis were used to identify OS, EFS, and prognostic factors. Results: The 5-year OS and EFS rates found were 44.5% and 36.4%, respectively. The extent of resection and radiotherapy as adjuvant treatments was positively correlated to outcome while metastatic disease at diagnosis was negatively related to OS. Age younger than 3 years old did not have a worse outcome in our cohort. Conclusion: Similar results to population-based studies were found, but we still face difficulties due to living in a developing country. In the near future, we look forward to new diagnostic techniques that will enable us to classify medulloblastomas according to molecular subgroups.
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Affiliation(s)
- Cristina Birlem Bleil
- Department of Pediatric Neurosurgery, Santo Antonio Children's Hospital, Santa Casa de Misericórdia de Porto Alegre
| | | | - Andre Bedin
- Department of Pediatric Neurosurgery, Santo Antonio Children's Hospital, Santa Casa de Misericórdia de Porto Alegre
| | - Francine Hehn de Oliveira
- Departments of Pathology, School of Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Ápio Cláudio Martins Antunes
- Neurosurgery, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Abstract
OPINION STATEMENT Medulloblastoma (MB) is a malignant embryonal tumor of the posterior fossa and is the most common type of brain cancer in pediatric patients. In contrast, adult MB is very rare with an incidence of 0.6 per million per year and mostly affects young adults below the age of 40. Recent molecular analyses of pediatric and adult MB have classified these tumors into at least four individual molecular subgroups (SHH, WNT, group 3, and group 4) with distinct demographics, histology, and prognosis. The discrete biological composition of these tumors likely explains the marked heterogeneity in responses seen to conventional therapies such as radiation and cytotoxic chemotherapies. Given the low incidence of adult MB, prospective studies are challenging and scarce, and management guidelines are largely derived from the pediatric MB patient population and retrospective data. However, adult MB is clinically and molecularly distinct from pediatric MB and a comprehensive review of published literature on adult MB highlighting their differences is warranted. Here, we review the management of adult MB focusing on recent studies exploring the effectiveness of upfront chemotherapy, clinical trials in the context of molecular subgroup-specific therapies, and the potential role of immunotherapy in treating this disease.
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56
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Bouffet E. Management of high-risk medulloblastoma. Neurochirurgie 2019; 67:61-68. [PMID: 31229532 DOI: 10.1016/j.neuchi.2019.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/02/2019] [Accepted: 05/07/2019] [Indexed: 11/29/2022]
Abstract
Medulloblastoma is the most common malignant brain tumors in children. Current management combines surgery, radiotherapy, and chemotherapy. Current treatment of medulloblastoma is based on a clinical risk-stratification system that takes into account age, extent of resection and metastatic status. High-risk medulloblastoma patients are defined by the presence of metastatic disease and/or an incomplete resection with a residual amount of tumour>1.5 cm2. This review describes the evolution in the management of high-risk medulloblastoma patients during recent 4 decades and recent changes in the definition of high-risk patients as a result of major advances in the understanding of the molecular heterogeneity of medulloblastomas.
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Affiliation(s)
- E Bouffet
- Paediatric Neuro-Oncology Program, University of Toronto, Hospital for Sick Children, 555 University Avenue, M5G 1X8 Toronto, Ontario, Canada.
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Schwake M, Schipmann S, Müther M, Köchling M, Brentrup A, Stummer W. 5-ALA fluorescence-guided surgery in pediatric brain tumors-a systematic review. Acta Neurochir (Wien) 2019; 161:1099-1108. [PMID: 30989383 DOI: 10.1007/s00701-019-03898-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/28/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND 5-Aminolevulinic acid (5-ALA)-guided resection of gliomas in adults enables better differentiation between tumor and normal brain tissue, allowing a higher degree of resection, and improves patient outcomes. In recent years, several reports have emerged regarding the use of 5-ALA in other brain tumor entities, including pediatric brains tumors. Since gross total resection (GTR) of many brain tumors in children is crucial and the role of 5-ALA-guided resection of these tumors is not clear, we sought to perform a comprehensive literature review on this topic. METHODS A systematic literature review of EMBASE and MEDLINE/PubMed databases revealed 19 eligible publications encompassing 175 5-ALA-guided operations on pediatric brain tumors. To prevent bias, publications were revised independently by two authors. RESULTS We found that 5-ALA-guided resection enabled the surgeons to identify the tumor more easily and was considered helpful mainly in cases of glioblastoma (GBM, 21/27, 78%), anaplastic ependymoma WHO grade III (10/14, 71%), and anaplastic astrocytoma (4/6, 67%). In contrast, cases of pilocytic astrocytomas (PAs) and medulloblastomas 5-ALA-guided surgery did not show consistent fluorescent signals and 5-ALA was considered helpful only in 12% and 22% of cases, respectively. Accumulation of fluorescent porphyrins seems to depend on WHO tumor grading. One important finding is that when 5-ALA-guided resections were considered helpful, the degree of resection was higher than is cases where it was not helpful. The rate of adverse events related to 5-ALA was negligible, especially new postoperative sequelae. CONCLUSION 5-ALA could play a role in resection of pediatric brain tumors. However, further prospective clinical trials are needed.
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Nobre L, Pauck D, Golbourn B, Maue M, Bouffet E, Remke M, Ramaswamy V. Effective and safe tumor inhibition using vinblastine in medulloblastoma. Pediatr Blood Cancer 2019; 66:e27694. [PMID: 30848061 DOI: 10.1002/pbc.27694] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 02/07/2019] [Accepted: 02/15/2019] [Indexed: 01/23/2023]
Abstract
Most medulloblastoma protocols worldwide include vincristine during radiation and chemotherapy. A significant dose-limiting toxicity is peripheral neuropathy; however, there is a paucity of data to support the view that omission of vincristine does not impact survival. Herein we report two adolescent patients with Group 4 and SHH medulloblastoma, where vinblastine successfully replaced vincristine with resolution of their peripheral neuropathy. We furthermore show vinblastine is highly active in vitro and demonstrates equivalent antitumoral activity compared to vincristine. Substitution of vincristine with vinblastine in future studies should be considered for all patients with medulloblastoma, particularly those with hereditary neuropathy, severe vincristine toxicity, and adults.
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Affiliation(s)
- Liana Nobre
- Programme in Developmental and Stem Cell Biology, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Pauck
- Department of Pediatric Neuro-Oncogenomics, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Consortium for Translational Cancer Research (DKTK), partner site Essen/Düsseldorf, Düsseldorf, Germany.,Department of Pediatric Oncology, Hematology, and Clinical Immunology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany.,Department of Neuropathology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Brian Golbourn
- Department of Neurological Surgery, Children's Hospital Pittsburgh, Pittsburgh, Pennsylvania
| | - Mara Maue
- Department of Pediatric Neuro-Oncogenomics, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Consortium for Translational Cancer Research (DKTK), partner site Essen/Düsseldorf, Düsseldorf, Germany.,Department of Pediatric Oncology, Hematology, and Clinical Immunology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany.,Department of Neuropathology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Eric Bouffet
- Programme in Developmental and Stem Cell Biology, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Marc Remke
- Department of Pediatric Neuro-Oncogenomics, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Consortium for Translational Cancer Research (DKTK), partner site Essen/Düsseldorf, Düsseldorf, Germany.,Department of Pediatric Oncology, Hematology, and Clinical Immunology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany.,Department of Neuropathology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Vijay Ramaswamy
- Programme in Developmental and Stem Cell Biology, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
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Twenty years experience in treating childhood medulloblastoma: Between the past and the present. Cancer Radiother 2019; 23:179-187. [PMID: 31109839 DOI: 10.1016/j.canrad.2018.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 05/09/2018] [Accepted: 05/15/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE Medulloblastoma is the most common primary malignant central nervous system tumour in children. These last decades, treatment modalities have largely evolved resulting in better survival rates. Nevertheless, long-term toxicity is a major concern in this setting. The purpose of this study was to analyse the clinical results and medical outcomes of a cohort of paediatric patients treated for medulloblastoma in Xhinhua Hospital in Shanghai. These results are compared with those from other centres reported in literature. PATIENTS AND METHODS This was a retrospective study conducted at Xhinhua Hospital in Shanghai, China. It included 121 patients treated for medulloblastoma from 1993 to December 2013. RESULTS Mean age at diagnosis was 6.7 years (range: 1-14.3 years). Total surgical resection was achieved in 60% of the cases. Classic medulloblastoma was found in 59% of the cases. Adjuvant radiotherapy was delivered in all cases and chemotherapy concerned 70.2% of the studied cohort. The median follow-up time of the study was 84 months (range: 24-120 months). Five- and 10 years progression-free survival rates were 83.2%, and 69.5% and 5 years and 10 years. Overall survival rates were 82.5%, and 72.5%. Patient's age significantly influenced survival: patients under 3 years old had the worse outcomes (P=0.01). T and M stages also significantly impacted survival rates: advanced stages were associated with lower rates (P=0.08 and 0.05 respectively). Finally, patients receiving temezolomide had bad outcomes when compared to the new standard protocol used in the department (P=0.03). The most commonly reported late toxicity was growth suppression in 35 patients (52.2%). Hypothyroidism requiring hormone replacement was recorded in 29% of the cases. Hearing loss, and problems including poor concentration, poor memory and learning difficulties were reported in 19% and 25% of the cases respectively. Second cancers were noted in three cases. CONCLUSION Overall, our results are comparable to those reported in literature. Nevertheless, efforts should be made to ensure longer follow-ups and correctly assess treatment-related toxicity.
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61
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Preradiation Chemotherapy for Adult High-risk Medulloblastoma: A Trial of the ECOG-ACRIN Cancer Research Group (E4397). Am J Clin Oncol 2019; 41:588-594. [PMID: 27635620 DOI: 10.1097/coc.0000000000000326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To assess the long-term outcomes and objective response (OR) to preradiation chemotherapy and radiation in adult high-risk medulloblastoma. MATERIALS AND METHODS In this prospective phase II trial, adults with high-risk medulloblastoma were treated with 3 cycles of preradiation cisplatin, etoposide, cyclophosphamide, and vincristine followed by craniospinal radiation (CSI). OR, progression-free survival (PFS), overall survival (OS), and toxicities were assessed. RESULTS Eleven patients were enrolled over a 6-year period. Six (55%) had subarachnoid metastases. Two (18%) had an OR to preradiation chemotherapy. Two (18%) progressed while on chemotherapy. Completion of CSI was not compromised. The OR rate after chemotherapy and radiation was 45% (5/11). Nonevaluable patients at both time-points weakened the response data conclusions. Median PFS was 43.8 months. Five-year PFS was 27%. Five-year OS was 55%. Nonmetastatic (M0) and metastatic (M+) patients had similar outcomes. CONCLUSIONS The OR to this preradiation chemotherapy regimen is lower than anticipated from the adult and pediatric literature raising a question about comparative efficacy of chemotherapy in different age groups. The OS achieved is similar to retrospective adult series, but worse than pediatric outcomes. Although this regimen can be administered without compromising delivery of CSI, our results do not provide support for the use of this neoadjuvant chemotherapy for adult medulloblastoma.
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Thomas A, Noël G. Medulloblastoma: optimizing care with a multidisciplinary approach. J Multidiscip Healthc 2019; 12:335-347. [PMID: 31118657 PMCID: PMC6498429 DOI: 10.2147/jmdh.s167808] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Medulloblastoma is a malignant tumor of the cerebellum and the most frequent malignant brain tumor in children. The standard of care consists of maximal resection surgery, followed by craniospinal irradiation and chemotherapy. Such treatment allows long-term survival rates of nearly 70%; however, there are wide disparities among patient outcomes, and in any case, major long-term morbidity is observed with conventional treatment. In the last two decades, the molecular understanding of medulloblastoma has improved drastically, allowing us to revolutionize our understanding of medulloblastoma pathophysiological mechanisms. These advances led to an international consensus in 2010 that defined four prognostic molecular subgroups named after their affected signaling pathways, that is, WNT, SHH, Group 3 and Group 4. The molecular understanding of medulloblastoma is starting to translate through to clinical settings due to the development of targeted therapies. Moreover, recent improvements in radiotherapy modalities and the reconsideration of craniospinal irradiation according to the molecular status hold promise for survival preservation and the reduction of radiation-induced morbidity. This review is an overview of the current knowledge of medulloblastoma through a molecular approach, and therapeutic prospects currently being developed in surgery, radiotherapy and targeted therapies to optimize the treatment of medulloblastoma with a multidisciplinary approach will also be discussed.
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Affiliation(s)
- Alice Thomas
- Radiotherapy Department, Centre Paul Strauss, UNICANCER, F-67065 Strasbourg, France,
| | - Georges Noël
- Radiotherapy Department, Centre Paul Strauss, UNICANCER, F-67065 Strasbourg, France, .,Radiobiology Lab, CNRS, IPHC UMR 7178, Centre Paul Strauss, UNICANCER, F-67000 Strasbourg, France,
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Fults DW, Taylor MD, Garzia L. Leptomeningeal dissemination: a sinister pattern of medulloblastoma growth. J Neurosurg Pediatr 2019; 23:613-621. [PMID: 30771762 DOI: 10.3171/2018.11.peds18506] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 11/21/2018] [Indexed: 01/29/2023]
Abstract
Leptomeningeal dissemination (LMD) is the defining pattern of metastasis for medulloblastoma. Although LMD is responsible for virtually 100% of medulloblastoma deaths, it remains the least well-understood part of medulloblastoma pathogenesis. The fact that medulloblastomas rarely metastasize outside the CNS but rather spread almost exclusively to the spinal and intracranial leptomeninges has fostered the long-held belief that medulloblastoma cells spread directly through the CSF, not the bloodstream. In this paper the authors discuss selected molecules for which experimental evidence explains how the effects of each molecule on cell physiology contribute mechanistically to LMD. A model of medulloblastoma LMD is described, analogous to the invasion-metastasis cascade of hematogenous metastasis of carcinomas. The LMD cascade is based on the molecular themes that 1) transcription factors launch cell programs that mediate cell motility and invasiveness and maintain tumor cells in a stem-like state; 2) disseminating medulloblastoma cells escape multiple death threats by subverting apoptosis; and 3) inflammatory chemokine signaling promotes LMD by creating an oncogenic microenvironment. The authors also review recent experimental evidence that challenges the belief that CSF spread is the sole mechanism of LMD and reveal an alternative scheme in which medulloblastoma cells can enter the bloodstream and subsequently home to the leptomeninges.
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Affiliation(s)
- Daniel W Fults
- 1Department of Neurosurgery, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Michael D Taylor
- 2Division of Neurosurgery, Arthur and Sonia Labatt Brain Tumour Research Center, and Program in Developmental and Stem Cell Biology, Hospital for Sick Children, University of Toronto, Ontario, Canada; and
| | - Livia Garzia
- 3Cancer Research Program, Research Institute of the McGill University Health Center and Department of Surgery, McGill University, Montreal, Quebec, Canada
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Abstract
Medulloblastoma (MB) comprises a biologically heterogeneous group of embryonal tumours of the cerebellum. Four subgroups of MB have been described (WNT, sonic hedgehog (SHH), Group 3 and Group 4), each of which is associated with different genetic alterations, age at onset and prognosis. These subgroups have broadly been incorporated into the WHO classification of central nervous system tumours but still need to be accounted for to appropriately tailor disease risk to therapy intensity and to target therapy to disease biology. In this Primer, the epidemiology (including MB predisposition), molecular pathogenesis and integrative diagnosis taking histomorphology, molecular genetics and imaging into account are reviewed. In addition, management strategies, which encompass surgical resection of the tumour, cranio-spinal irradiation and chemotherapy, are discussed, together with the possibility of focusing more on disease biology and robust molecularly driven patient stratification in future clinical trials.
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Central Nervous System Tumors. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-97145-2_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Medulloblastomas in adolescents and adults - Can the pediatric experience be extrapolated? Neurochirurgie 2018; 67:76-82. [PMID: 30554773 DOI: 10.1016/j.neuchi.2018.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 08/27/2018] [Accepted: 10/06/2018] [Indexed: 01/07/2023]
Abstract
Adult medulloblastomas are orphan diseases that differ from their pediatric counterpart. Most are classified as classic or desmoplastic and fall in the SHH subgroup, mainly with loss-of-function mutations in PTCH1 and some by TP53-mutation due to underlying germline mutation. Activation of the WNT pathway is sporadic, although underlying Turcot syndrome may be present. One-third of tumors are issued from group 4. Most adult studies are small non-randomized retrospective heterogeneous studies performed at a single center with short follow-up. Standard craniospinal irradiation followed by maintenance chemotherapy (CCNU, cisplatin-vincristine) results in a 4-year event-free survival (EFS) and overall survival (OS) of 68% and 89% respectively in standard-risk adults, and in a 4-year EFS and OS of 50% and 90%, respectively in high-risk adults. Several pooled analyses point out the potential role of chemotherapy in adults. The feasibility of pediatric protocols in adults is sometimes hampered because of blood and peripheral nerve toxicity. In the near future, subgroups of medulloblastomas may be treated by personalized therapies. With prolonged follow-up, adults fare worse. Long-term sequelae and second line treatment are not well defined in adults. Prospective studies are ongoing to define optimal first-line and relapse treatments.
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Khatua S, Song A, Citla Sridhar D, Mack SC. Childhood Medulloblastoma: Current Therapies, Emerging Molecular Landscape and Newer Therapeutic Insights. Curr Neuropharmacol 2018; 16:1045-1058. [PMID: 29189165 PMCID: PMC6120114 DOI: 10.2174/1570159x15666171129111324] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 11/06/2017] [Accepted: 11/27/2017] [Indexed: 12/21/2022] Open
Abstract
Background: Medulloblastoma is the most common malignant brain tumor in children, currently treated uniformly based on histopathology and clinico-radiological risk stratification leading to unpredictable relapses and therapeutic failures. Identification of molecular subgroups have thrown light on the reasons for these and now reveals clues to profile molecularly based personalized therapy against these tumors. Methods: Research and online contents were evaluated for pediatric medulloblastoma which included latest information on the molecular subgroups and their clinical relevance and update on efforts to translate them into clinics. Results: Scientific endeavors over the last decade have clearly identified four molecular variants (WNT, SHH, Group 3, and Group 4) and their demographic, genomic, and epigenetic profile. Latest revelations include significant heterogeneity within these subgroups and 12 different subtypes of MB are now identified with disparate outcomes and biology. These findings have important implications for stratification and profiling future clinical trials against these formidable tumors. Conclusion: With the continued outpouring of genomic/epigenomic data of these molecular subgroups and evolution of further subtypes in each subgroup, the challenge lies in comprehensive evaluation of these informations. Current and future endeavors are now needed to profile personalized therapy for each child based on the molecular risk stratification of medulloblastoma, with a hope to improve survival outcome and reduce relapses.
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Affiliation(s)
- Soumen Khatua
- Department of Pediatrics, MD Anderson Cancer Center, The University of Texas Health Science Center at Houston, Pediatrics Houston, Texas, United States
| | - Anne Song
- Department of Stem Cell Biology and Regenerative Medicine, Lerner Research Institute, Cleveland Clinic, The University of Texas Health Science Center at Houston, Pediatrics Houston, Texas, United States
| | - Divyaswathi Citla Sridhar
- Department of Pediatrics, The University of Texas Health Science Center at Houston, Pediatrics Houston, Texas, United States
| | - Stephen C Mack
- Department of Stem Cell Biology and Regenerative Medicine, Lerner Research Institute, Cleveland Clinic, The University of Texas Health Science Center at Houston, Pediatrics Houston, Texas, United States
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Abstract
INTRODUCTION Integrated genomics has significantly advanced our understanding of medulloblastoma heterogeneity. It is now clear that it actually comprises at least four distinct molecular subgroups termed Wnt/Wingless (WNT), Sonic Hedgehog (SHH), Group 3, and Group 4 with stark clinical and biological differences. Areas covered: This paper reviews advances in the classification and risk stratification of medulloblastoma, specifically integrating subgroup with clinical and cytogenetic risk factors, with a summary of the potential to lead to more precise therapies. Moreover, the current state of preclinical modeling is summarized with respect to their utility in generating new treatments and correlation with genomic discoveries. Opportunities and challenges in developing new treatment paradigms are summarized and discussed, specifically new therapies for very high-risk metastatic/MYC-amplified Group 3 and TP53-mutant SHH and reductions in therapy for lower risk groups. Expert commentary: Survival across medulloblastoma has been stagnant for over 30 years, and new treatment paradigms are urgently required. Current therapy significantly over treats a high proportion of patients leaving them with lifelong side effects; while many patients still succumb to their disease. Applying biological advances could improve quality of life for a significant proportion of patients while offering new upfront approaches to the highest risk patients.
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Affiliation(s)
- Carolina Nör
- a Programme in Developmental and Stem Cell Biology , Hospital for Sick Children , Toronto , ON , Canada.,b Labatt Brain Tumour Research Centre , Hospital for Sick Children , Toronto , ON , Canada
| | - Vijay Ramaswamy
- b Labatt Brain Tumour Research Centre , Hospital for Sick Children , Toronto , ON , Canada.,c Division of Haematology/Oncology , Hospital for Sick Children , Toronto , ON , Canada
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69
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Murase M, Saito K, Abiko T, Yoshida K, Tomita H. Medulloblastoma in Older Adults: A Case Report and Literature Review. World Neurosurg 2018; 117:25-31. [PMID: 29883827 DOI: 10.1016/j.wneu.2018.05.216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Medulloblastoma is a malignant tumor of the posterior fossa and is predominantly seen in children younger than 15 years of age. This tumor is uncommon in adults, especially those older than 40 years of age, and reports of cases in patients older than 60 years of age are particularly rare. Although surgery and radiotherapy play important roles in treatment of medulloblastoma in adults, addition of chemotherapy is controversial, especially prior to radiotherapy. CASE DESCRIPTION We present a case of a 63-year-old woman with an atypical medulloblastoma in the cerebellum and a lesion in the suprasellar area that did not appear to be a metastasis of the medulloblastoma. The patient underwent a subtotal resection of the cerebellar medulloblastoma, which was classified histologically as classic subtype and molecularly as non-Wingless/non-Sonic hedgehog subtype in World Health Organization 2016 classification. Then she underwent postoperative chemotherapy followed by radiotherapy. We administered chemotherapy to facilitate therapeutic diagnosis of the suprasellar lesion. The combination treatment resulted in the disappearance of the cerebellar medulloblastoma with treatment toxicity well tolerated. Additionally, the suprasellar lesion remains under control. CONCLUSIONS Even in adults over 60 years of age, medulloblastoma should be included in the differential diagnosis of a cerebellar mass. Chemotherapy for adult medulloblastoma has the potential to be efficacious and tolerable.
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Affiliation(s)
- Makoto Murase
- Department of Neurosurgery, Ashikaga Red Cross Hospital, Ashikaga-shi, Tochigi, Japan.
| | - Katsuya Saito
- Department of Neurosurgery, Ashikaga Red Cross Hospital, Ashikaga-shi, Tochigi, Japan
| | - Tomohiro Abiko
- Department of Neurosurgery, Ashikaga Red Cross Hospital, Ashikaga-shi, Tochigi, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hideyuki Tomita
- Department of Neurosurgery, Ashikaga Red Cross Hospital, Ashikaga-shi, Tochigi, Japan
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70
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Sung KW, Lim DH, Shin HJ. Tandem High-dose Chemotherapy and Autologous Stem Cell Transplantation in Children with Brain Tumors : Review of Single Center Experience. J Korean Neurosurg Soc 2018; 61:393-401. [PMID: 29742883 PMCID: PMC5957321 DOI: 10.3340/jkns.2018.0039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/02/2018] [Accepted: 03/08/2018] [Indexed: 11/27/2022] Open
Abstract
The prognosis of brain tumors in children has improved for last a few decades. However, the prognosis remains dismal in patients with recurrent brain tumors. The outcome for infants and young children in whom the use of radiotherapy (RT) is very limited because of unacceptable long-term adverse effect of RT remains poor. The prognosis is also not satisfactory when a large residual tumor remains after surgery or when leptomeningeal seeding is present at diagnosis. In this context, a strategy using high-dose chemotherapy and autologous stem cell transplantation (HDCT/auto-SCT) has been explored to improve the prognosis of recurrent or high-risk brain tumors. This strategy is based on the hypothesis that chemotherapy dose escalation might result in improvement in survival rates. Recently, the efficacy of tandem HDCT/auto-SCT has been evaluated in further improving the outcome. This strategy is based on the hypothesis that further dose escalation might result in further improvement in survival rates. At present, the number of studies employing tandem HDCT/auto-SCT for brain tumors is limited. However, results of these pilot studies suggest that tandem HDCT/auto-SCT may further improve the outcome. In this review, we will summarize our single center experience with tandem HDCT/auto-SCT for recurrent or high-risk brain tumors.
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Affiliation(s)
- Ki Woong Sung
- Department of Pediatrics, Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Pediatrics, Neurosurgery, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jin Shin
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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71
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Lim DH. Radiation Therapy against Pediatric Malignant Central Nervous System Tumors : Embryonal Tumors and Proton Beam Therapy. J Korean Neurosurg Soc 2018; 61:386-392. [PMID: 29742879 PMCID: PMC5957314 DOI: 10.3340/jkns.2018.0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/04/2018] [Accepted: 02/14/2018] [Indexed: 11/27/2022] Open
Abstract
Radiation therapy is highly effective for the management of pediatric malignant central nervous system (CNS) tumors including embryonal tumors. With the increment of long-term survivors from malignant CNS tumors, the radiation-related toxicities have become a major concern and we need to improve the treatment strategies to reduce the late complications without compromising the treatment outcomes. One of such strategies is to reduce the radiation dose to craniospinal axis or radiation volume and to avoid or defer radiation therapy until after the age of three. Another strategy is using particle beam therapy such as proton beams instead of photon beams. Proton beams have distinct physiologic advantages over photon beams and greater precision in radiation delivery to the tumor while preserving the surrounding healthy tissues. In this review, I provide the treatment principles of pediatric CNS embryonal tumors and the strategic improvements of radiation therapy to reduce treatment-related late toxicities, and finally introduce the increasing availability of proton beam therapy for pediatric CNS embryonal tumors compared with photon beam therapy.
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Affiliation(s)
- Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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72
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Chastagner P. Medulloblastoma: A turning point from fundamental advances to improved survival and decreased sequelae. Neurochirurgie 2018; 67:3-5. [PMID: 29448992 DOI: 10.1016/j.neuchi.2017.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 10/29/2017] [Indexed: 10/18/2022]
Affiliation(s)
- P Chastagner
- Service d'oncologie pédiatrique, université de Lorraine, CHRU de Nancy, 54500 Vandoeuvre-lès-Nancy, France.
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73
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Chastagner P. WITHDRAWN: Medulloblastoma: A turning point from fundamental advances to improved survival and decreased sequelae. Neurochirurgie 2018:S0028-3770(18)30001-8. [PMID: 29433819 DOI: 10.1016/j.neuchi.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 11/13/2017] [Accepted: 11/14/2017] [Indexed: 11/23/2022]
Abstract
The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.neuchi.2017.10.006. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.
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Affiliation(s)
- P Chastagner
- Service de neurochirurgie et chirurgie de la face pédiatrique, hôpital d'Enfants, CHRU de Nancy et université de Lorraine, 4, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France.
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74
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Timmermann B, Kortmann RD. Embryonal Tumors. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_5-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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75
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Long-term outcomes of adult medulloblastoma patients treated with radiotherapy. J Neurooncol 2017; 136:95-104. [PMID: 29019042 DOI: 10.1007/s11060-017-2627-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 10/02/2017] [Indexed: 12/29/2022]
Abstract
Medulloblastoma (MB) is rare in adults and treatment guidelines are consequently not well-established. Few modern series have reported long-term follow-up and treatment sequelae. We examined long-term outcomes of adult MB patients at one institution. Records of 29 consecutive patients (18 male, 11 female) aged ≥ 18 years who received radiotherapy (RT) for primary MB from 1990 to 2016 were reviewed. Median age at diagnosis was 28 years (range 18-72 years). Seventeen patients were standard risk and 12 were high risk. Nineteen patients had gross total resection, seven had subtotal resection, and three had biopsy only. Median craniospinal irradiation and boost doses were 36 Gy (range 23.4-39.6 Gy) and 55.8 Gy (range 54-59.4 Gy), respectively. Of 24 patients receiving chemotherapy, 20 received concurrent + adjuvant and 4 received adjuvant only. At median follow-up of 9.0 years (range 1.1-20.5 years), five patients recurred: four in the posterior fossa and one in both the posterior fossa and above the tentorium. Five patients died: two of disease progression and three after possible treatment complications (seizure, lobar pneumonia, and multifactorial sepsis). At last follow-up, 23 patients were alive with no evidence of disease. Long-term effects include executive dysfunction (n = 17), weakness/ataxia (n = 16), and depression/anxiety (n = 13). Kaplan-Meier estimates of 10-year overall survival and failure-free survival are 83% (95% confidence interval [CI] 59-93%) and 79% (CI 55-91%), respectively. Despite encouraging disease control in this cohort, long-term sequelae may limit quality of life. Multimodality pediatric regimens using lower RT doses may be considered to reduce treatment-related morbidity.
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76
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Wong KK, All S, Waxer J, Olch AJ, Venkatramani R, Dhall G, Davidson TB, Zaky W, Finlay JL. Radiotherapy after high-dose chemotherapy with autologous hematopoietic cell rescue: Quality assessment of Head Start III. Pediatr Blood Cancer 2017; 64. [PMID: 28379644 DOI: 10.1002/pbc.26529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 02/21/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND The use of high-dose chemotherapy with autologous hematopoietic cell rescue (AuHCR) in Head Start III is a potentially curative approach for the management of young children with central nervous system neoplasms. We report the potential influence of quality and timing of radiation therapy on the survival of patients treated on the study. PROCEDURE Between 2003 and 2009, 220 children with newly diagnosed central nervous system neoplasms were enrolled on the study. Radiation therapy was indicated following AuHCR for children between 6 and 10 years old or those younger than 6 years with residual tumor preconsolidation. Records were received for 42 patients and reviewed to determine adherence to protocol treatment volume and dose guidelines. Of these patients, seven were irradiated prior to consolidation, and additional four patients who initially avoided radiation therapy after AuHCR were subsequently treated at relapse. RESULTS Of the 31 patients who were fully evaluable, 2 refused radiation therapy until recurrence and 4 progressed between recovery from AuHCR and radiation therapy. Of the remaining 25 patients, 8 had violations in their indication, dose, or treatment volume. All violations occurred in patients under 6 years of age. Two patients could have avoided radiation therapy. There were 6 violations in the 23 patients who received radiation therapy for guideline indications. CONCLUSION All protocol violations occurred in patients under 6 years of age and were associated with decreased overall survival as was the time to start radiotherapy of greater than 11 weeks. When indicated, starting radiation therapy soon after neutrophil and platelet recovery may improve the outcome for these high-risk children.
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Affiliation(s)
- Kenneth K Wong
- Children's Hospital Los Angeles, Los Angeles, California.,Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sean All
- University of Central Florida College of Medicine, Orlando, Florida
| | - Jonathan Waxer
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Arthur J Olch
- Children's Hospital Los Angeles, Los Angeles, California.,Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Rajkumar Venkatramani
- Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Girish Dhall
- Children's Hospital Los Angeles, Los Angeles, California
| | - Tom Belle Davidson
- Division of Hematology/Oncology, University of California Los Angeles, Pediatrics, Los Angeles, California
| | - Wafik Zaky
- MD Anderson Cancer Center, Pediatrics Neuro-oncology Program, Houston, Texas
| | - Jonathan L Finlay
- Department of Pediatrics, Division of Hematology, Oncology and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
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77
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Impact of radiation technique, radiation fraction dose, and total cisplatin dose on hearing : Retrospective analysis of 29 medulloblastoma patients. Strahlenther Onkol 2017; 193:910-920. [PMID: 28887665 DOI: 10.1007/s00066-017-1205-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 08/17/2017] [Indexed: 01/07/2023]
Abstract
PURPOSE To analyze the incidence and degree of sensorineural hearing loss (SNHL) resulting from different radiation techniques, fractionation dose, mean cochlear radiation dose (Dmean), and total cisplatin dose. MATERIAL AND METHODS In all, 29 children with medulloblastoma (58 ears) with subclinical pretreatment hearing thresholds participated. Radiotherapy (RT) and cisplatin had been applied sequentially according to the HIT MED Guidance. Audiological outcomes up to the latest follow-up (median 2.6 years) were compared. RESULTS Bilateral high-frequency SNHL was observed in 26 patients (90%). No significant differences were found in mean hearing threshold between left and right ears at any frequency. A significantly better audiological outcome (p < 0.05) was found after tomotherapy at the 6 kHz bone-conduction threshold (BCT) and left-sided 8 kHz air-conduction threshold (ACT) than after a combined radiotherapy technique (CT). Fraction dose was not found to have any impact on the incidence, degree, and time-to-onset of SNHL. Patients treated with CT had a greater risk of SNHL at high frequencies than tomotherapy patients even though Dmean was similar. Increase in severity of SNHL was seen when the total cisplatin dose reached above 210 mg/m2, with the highest abnormal level found 8-12 months after RT regardless of radiation technique or fraction dose. CONCLUSION The cochlear radiation dose should be kept as low as possible in patients who receive simultaneous cisplatin-based chemotherapy. The risk of clinically relevant HL was shown when Dmean exceeds 45 Gy independent of radiation technique or radiation regime. Cisplatin ototoxicity was shown to have a dose-dependent effect on bilateral SNHL, which was more pronounced in higher frequencies.
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78
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Holgado BL, Guerreiro Stucklin A, Garzia L, Daniels C, Taylor MD. Tailoring Medulloblastoma Treatment Through Genomics: Making a Change, One Subgroup at a Time. Annu Rev Genomics Hum Genet 2017; 18:143-166. [DOI: 10.1146/annurev-genom-091416-035434] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Borja L. Holgado
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
- The Arthur and Sonia Labatt Brain Tumor Research Centre, The Hospital for Sick Children, Toronto, Ontario M5G 0A4, Canada
| | - Ana Guerreiro Stucklin
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
- The Arthur and Sonia Labatt Brain Tumor Research Centre, The Hospital for Sick Children, Toronto, Ontario M5G 0A4, Canada
| | - Livia Garzia
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
- The Arthur and Sonia Labatt Brain Tumor Research Centre, The Hospital for Sick Children, Toronto, Ontario M5G 0A4, Canada
| | - Craig Daniels
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
- The Arthur and Sonia Labatt Brain Tumor Research Centre, The Hospital for Sick Children, Toronto, Ontario M5G 0A4, Canada
| | - Michael D. Taylor
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
- The Arthur and Sonia Labatt Brain Tumor Research Centre, The Hospital for Sick Children, Toronto, Ontario M5G 0A4, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A1, Canada
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
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79
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Chaikh A, Balosso J. Agreement between gamma passing rates using computed tomography in radiotherapy and secondary cancer risk prediction from more advanced dose calculated models. Quant Imaging Med Surg 2017; 7:292-298. [PMID: 28811995 DOI: 10.21037/qims.2017.06.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND During the past decades, in radiotherapy, the dose distributions were calculated using density correction methods with pencil beam as type 'a' algorithm. The objectives of this study are to assess and evaluate the impact of dose distribution shift on the predicted secondary cancer risk (SCR), using modern advanced dose calculation algorithms, point kernel, as type 'b', which consider change in lateral electrons transport. METHODS Clinical examples of pediatric cranio-spinal irradiation patients were evaluated. For each case, two radiotherapy treatment plans with were generated using the same prescribed dose to the target resulting in different number of monitor units (MUs) per field. The dose distributions were calculated, respectively, using both algorithms types. A gamma index (γ) analysis was used to compare dose distribution in the lung. The organ equivalent dose (OED) has been calculated with three different models, the linear, the linear-exponential and the plateau dose response curves. The excess absolute risk ratio (EAR) was also evaluated as (EAR = OED type 'b' / OED type 'a'). RESULTS The γ analysis results indicated an acceptable dose distribution agreement of 95% with 3%/3 mm. Although, the γ-maps displayed dose displacement >1 mm around the healthy lungs. Compared to type 'a', the OED values from type 'b' dose distributions' were about 8% to 16% higher, leading to an EAR ratio >1, ranged from 1.08 to 1.13 depending on SCR models. CONCLUSIONS The shift of dose calculation in radiotherapy, according to the algorithm, can significantly influence the SCR prediction and the plan optimization, since OEDs are calculated from DVH for a specific treatment. The agreement between dose distribution and SCR prediction depends on dose response models and epidemiological data. In addition, the γ passing rates of 3%/3 mm does not translate the difference, up to 15%, in the predictions of SCR resulting from alternative algorithms. Considering that modern algorithms are more accurate, showing more precisely the dose distributions, but that the prediction of absolute SCR is still very imprecise, only the EAR ratio could be used to rank radiotherapy plans.
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Affiliation(s)
- Abdulhamid Chaikh
- Department of Radiation Oncology and Medical physics, University Hospital of Grenoble Alpes (CHU-GA), France.,France HADRON national research infrastructure, IPNL, Lyon, France
| | - Jacques Balosso
- Department of Radiation Oncology and Medical physics, University Hospital of Grenoble Alpes (CHU-GA), France.,France HADRON national research infrastructure, IPNL, Lyon, France.,University Grenoble Alpes, Grenoble, France
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80
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Kline CN, Packer RJ, Hwang EI, Raleigh DR, Braunstein S, Raffel C, Bandopadhayay P, Solomon DA, Aboian M, Cha S, Mueller S. Case-based review: pediatric medulloblastoma. Neurooncol Pract 2017; 4:138-150. [PMID: 29692919 DOI: 10.1093/nop/npx011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Medulloblastoma is the most common malignant brain tumor affecting children. These tumors are high grade with propensity to metastasize within the central nervous system and, less frequently, outside the neuraxis. Recent advancements in molecular subgrouping of medulloblastoma refine diagnosis and improve counseling in regards to overall prognosis. Both are predicated on the molecular drivers of each subgroup-WNT-activated, SHH-activated, group 3, and group 4. The traditional therapeutic mainstay for medulloblastoma includes a multimodal approach with surgery, radiation, and multiagent chemotherapy. As we discover more about the molecular basis of medulloblastoma, efforts to adjust treatment approaches based on molecular risk stratification are under active investigation. Certainly, the known neurological, developmental, endocrine, and psychosocial injury related to medulloblastoma and its associated therapies motivate ongoing research towards improving treatment for this life-threatening tumor while at the same time minimizing long-term side effects.
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Affiliation(s)
- Cassie N Kline
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - Roger J Packer
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - Eugene I Hwang
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - David R Raleigh
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - Steve Braunstein
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - Corey Raffel
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - Pratiti Bandopadhayay
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - David A Solomon
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - Mariam Aboian
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - Soonmee Cha
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
| | - Sabine Mueller
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158 (C.K., S.M.); Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P.); Brain Tumor Institute, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Children's National Health Systems, 111 Michigan Avenue NW, Washington, DC 20010 (R.P., E.H.); Department of Radiation Oncology, University of California, 1825 4th Street, San Francisco, San Francisco, CA 94158 (D.R., S.B.); Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94143 (C.R., S.M.); Dana-Farber/Boston Children's Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02215 (P.B.); Department of Pediatrics, Harvard Medical School, Boston, MA 02215 (P.B.); Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142 (P.B.); Division of Neuropathology, Department of Pathology, University of California, San Francisco, 505 Parnassus Avenue, M551, Box 0102 San Francisco, CA 94143 (D.S.); Department of Radiology, University of California, San Francisco, 550 Parnassus Avenue, M327, San Francisco, CA 94143 (M.A., S.C.); Department of Neurology, Neurosurgery and Pediatrics, University of California, San Francisco, 550 Sandler Neurosciences, 625 Nelson Rising Lane, 402B, Box 0434, San Francisco, CA 94158 (S.M.)
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81
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Huang PI, Lin SC, Lee YY, Ho DMT, Guo WY, Chang KP, Chang FC, Liang ML, Chen HH, Liu YM, Yen SH, Wong TT, Chen YW. Large cell/anaplastic medulloblastoma is associated with poor prognosis-a retrospective analysis at a single institute. Childs Nerv Syst 2017; 33:1285-1294. [PMID: 28488086 DOI: 10.1007/s00381-017-3435-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/26/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Medulloblastoma (MB) is the most commonly occurring malignant pediatric brain tumor worldwide. However, a recent study found that the treatment outcomes in those with high-risk disease receiving conventional treatment were suboptimal. This study aimed to assess outcomes and treatment strategies for specific histologic subtypes of pediatric MB. METHODS A total of 114 pediatric patients (age < 20 years) diagnosed with MB between March 1998 and August 2011 were retrospectively reviewed; 52 that were treated with surgery followed by adjuvant radiotherapy (RT) and chemotherapy (CHT) were included. RESULTS The 5-year overall survival (OS) and relapse-free survival (RFS) rates were 73 and 69%, respectively. Median time to relapse was 17 months with a median survival time of 6 months after relapse. Patients of average risk had a better 5-year OS rate compared with high-risk patients (p = 0.027). The 5-year RFS of high-risk patients was lower compared with average risk (p = 0.038). A greater proportion of patients with large cell/anaplastic (LC/A) MB had recurrence than classic MB with 5-year RFS rate of 34 and 76%, respectively (p = 0.001), and OS rate of 56 and 76%, respectively (p = 0.04). CONCLUSION High-risk group and histology of LC/A were the most significant factors associated with worse OS and RFS. Patients with LC/A-MB had higher relapse rates and worse survival than those with classic MB. LC/A-MB carries a high risk for recurrence and should be treated with the more aggressive strategies.
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Affiliation(s)
- Pin-I Huang
- Division of Radiotherapy, Department of Oncology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Chieh Lin
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Yen Lee
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Pediatric Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Donald Ming-Tak Ho
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pathology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Wan-Yuo Guo
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Kai-Ping Chang
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Feng-Chi Chang
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Muh-Lii Liang
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Pediatric Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Hsin-Hung Chen
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Pediatric Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Yu-Ming Liu
- Division of Radiotherapy, Department of Oncology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sang-Hue Yen
- Division of Radiotherapy, Department of Oncology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Tai-Tong Wong
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Pediatric Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Yi-Wei Chen
- Division of Radiotherapy, Department of Oncology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan. .,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.
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82
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Kumar N, Miriyala R, Thakur P, Madan R, Salunke P, Yadav B, Gupta A. Impact of acute hematological toxicity on treatment interruptions during cranio-spinal irradiation in medulloblastoma: a tertiary care institute experience. J Neurooncol 2017; 134:309-315. [PMID: 28577033 DOI: 10.1007/s11060-017-2524-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/29/2017] [Indexed: 11/26/2022]
Abstract
To analyze treatment interruptions due to acute hematological toxicity in patients of medulloblastoma receiving cranio-spinal irradiation (CSI). Prospectively collected data from case records of 52 patients of medulloblastoma treated between 2011 and 2014 was evaluated. Blood counts were monitored twice a week during CSI. Spinal irradiation was interrupted for patients with ≥grade 2 hematological toxicity and resumed after recovery to grade 1 level (TLC >3000; platelet count >75,000). Treatment interruptions and hematological toxicity were analyzed. Median age was 11 years. All patients received adjuvant CSI of 36 Gy, followed by boost of 18 Gy to posterior fossa, at 1.8 Gy per fraction. Concurrent chemotherapy was not given. Adjuvant chemotherapy was given after CSI for high risk patients. Spinal fields were interrupted in 73.1% of patients. Cause of first interruption was leucopenia in 92.1%, thrombocytopenia in 2.6%, and both in 5.3%. Median number of fractions at first interruption was 8, with 25% of interruptions in first week. Median duration for hematological recovery after nadir was 5 days for leucopenia and 3 days for thrombocytopenia. Half of the patients had at least 2 interruptions, and 19% subsequently developed grade 3 toxicity. On multivariate analysis, significant correlation with duration of delay was observed for pre-treatment haemoglobin, number of fractions at first interruption, grade and duration of recovery of leucopenia. Acute hematological toxicity with CSI is frequently under-reported. Patients with low pre-treatment hemoglobin, early onset leucopenia, profound leucopenia and prolonged recovery times are at a higher risk of having protracted courses of irradiation. Frequent monitoring of blood counts and timely interruption of spinal fields of irradiation at grade 2 level of hematological toxicity minimizes the risk of grade 3 and grade 4 toxicity, while reducing the interruptions in irradiation of the gross tumour bed.
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Affiliation(s)
- Narendra Kumar
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Raviteja Miriyala
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pragyat Thakur
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Renu Madan
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pravin Salunke
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Budhi Yadav
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ankita Gupta
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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83
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Pediatric Medulloblastoma: a Case of Recurrent Disease and Resiliency. JOURNAL OF PEDIATRIC NEUROPSYCHOLOGY 2017. [DOI: 10.1007/s40817-017-0032-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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85
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von Bueren AO, Kortmann RD, von Hoff K, Friedrich C, Mynarek M, Müller K, Goschzik T, Zur Mühlen A, Gerber N, Warmuth-Metz M, Soerensen N, Deinlein F, Benesch M, Zwiener I, Kwiecien R, Faldum A, Bode U, Fleischhack G, Hovestadt V, Kool M, Jones D, Northcott P, Kuehl J, Pfister S, Pietsch T, Rutkowski S. Treatment of Children and Adolescents With Metastatic Medulloblastoma and Prognostic Relevance of Clinical and Biologic Parameters. J Clin Oncol 2016; 34:4151-4160. [PMID: 27863192 DOI: 10.1200/jco.2016.67.2428] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To assess an intensified treatment in the context of clinical and biologic risk factors in metastatic medulloblastoma. Patients and Methods Patients (4 to 21 years old, diagnosed between 2001 and 2007) received induction chemotherapy, dose-escalated hyperfractionated craniospinal radiotherapy, and maintenance chemotherapy. Subgroup status and other biologic parameters were assessed. Results In 123 eligible patients (median age, 8.2 years old; median follow-up, 5.38 years), 5-year event-free survival (EFS) and overall survival (OS) were 62% (95% CI, 52 to 72) and 74% (95% CI, 66 to 82), respectively. OS was superior compared with the precedent HIT '91 trial. The 5-year EFS and OS were both 89% (95% CI, 67 to 100) for desmoplastic/nodular (n = 11), 61% (95% CI, 51 to 71) and 75% (95% CI, 65 to 85) for classic (n = 107), and 20% (95% CI, 0 to 55) and 40% (95% CI, 0 to 83) for large-cell/anaplastic (n = 5) medulloblastoma ( P < .001 for EFS; P = .001 for OS). Histology (hazard ratio, 0.19 for desmoplastic/nodular and 45.97 for large-cell/anaplastic medulloblastoma) and nonresponse to the first chemotherapy cycle (hazard ratio, 1.97) were independent risk factors (EFS). Among 81 (66%) patients with tumor material, 5-year EFS and OS differed between low-risk (wingless [WNT], n = 4; both 100%), high-risk ( MYCC/ MYCN amplification; n = 5, both 20%), and intermediate-risk patients (neither; n = 72, 63% and 73%, respectively). Survival rates were different between molecular subgroups (WNT, n = 4; sonic hedgehog [SHH; n = 4]; group 4 [n = 41]; group 3 with [n = 3] or without [n = 17] MYCC/MYCN amplification; P < .001). All cases showed p53 immuno-negativity. There was no association between patients with nonresponding tumors to induction chemotherapy and WNT ( P = .143) or MYCC/MYCN status ( P = .075), histologic subtype ( P = .814), or molecular subtype ( P = .383), as assessed by Fisher's exact test. Conclusion This regimen was feasible and conferred overall favorable survival. Our data confirm the relevance of subgroup status and biologic parameters (WNT/ MYCC/ MYCN status) in a homogeneous prospective trial population, and show that metastatic group 3 patients do not uniformly have poor outcomes. Biologic subgroup, MYCC/ MYCN status, response to induction chemotherapy, and histologic subtype may serve for improved treatment stratification.
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Affiliation(s)
- André O von Bueren
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Rolf-Dieter Kortmann
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Katja von Hoff
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Carsten Friedrich
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Martin Mynarek
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Klaus Müller
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Tobias Goschzik
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Anja Zur Mühlen
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Nicolas Gerber
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Monika Warmuth-Metz
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Niels Soerensen
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Frank Deinlein
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Martin Benesch
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Isabella Zwiener
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Robert Kwiecien
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Andreas Faldum
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Udo Bode
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Gudrun Fleischhack
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Volker Hovestadt
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Marcel Kool
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - David Jones
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Paul Northcott
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Joachim Kuehl
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Stefan Pfister
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Torsten Pietsch
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
| | - Stefan Rutkowski
- André O. von Bueren, Katja von Hoff, Carsten Friedrich, Martin Mynarek, and Stefan Rutkowski, University Medical Center Hamburg-Eppendorf, Hamburg; André O. von Bueren, University Medical Center Goettingen, Goettingen; Rolf-Dieter Kortmann and Klaus Müller, University of Leipzig; Carsten Friedrich, University Hospital Leipzig, Leipzig; Katja von Hoff, Nicolas Gerber, Monika Warmuth-Metz, Niels Soerensen, Frank Deinlein, and Joachim Kuehl, University of Wuerzburg, Wuerzburg; Tobias Goschzik, Anja zur Mühlen, and Torsten Pietsch, University of Bonn Medical Center; Udo Bode, University Hospital of Bonn, Bonn; Isabella Zwiener and Andreas Faldum, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz; Robert Kwiecien and Andreas Faldum, University of Muenster, Muenster; Gudrun Fleischhack, University Hospital of Essen, Essen; Volker Hovestadt, Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Research Center; Marcel Kool, David Jones, Paul Northcott, and Stefan Pfister, German Cancer Consortium; Stefan Pfister, University Hospital and National Center for Tumor Diseases, Heidelberg, Germany; Nicolas Gerber, University Children's Hospital, Zurich, Switzerland; Martin Benesch, Medical University of Graz, Graz, Austria; and Paul Northcott, St Jude Children's Research Hospital, Memphis, TN
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Abstract
Medulloblastoma accounts for nearly 10% of all childhood brain tumors. These tumors occur exclusively in the posterior fossa and have the potential for leptomeningeal spread. Treatment includes a combination of surgery, radiation therapy (in patients >3 years old). Patients >3 years old are stratified based on the volume of postoperative residual tumor and the presence or absence of metastases into "standard risk" and "high risk" categories with long-term survival rates of approximately 85% and 70%, respectively. Outcomes are inferior in infants and children younger than 3 years with exception of those patients with the medulloblastoma with extensive nodularity histologic subtype. Treatment for medulloblastoma is associated with significant morbidity, especially in the youngest patients. Recent molecular subclassification of medulloblastoma has potential prognostic and therapeutic implications. Future incorporation of molecular subgroups into treatment protocols will hopefully improve both survival outcomes and posttreatment quality of life.
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Affiliation(s)
- Nathan E Millard
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin C De Braganca
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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87
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Nazemi KJ, Shen V, Finlay JL, Boyett J, Kocak M, Lafond D, Gardner SL, Packer RJ, Nicholson HS. High Incidence of Veno-Occlusive Disease With Myeloablative Chemotherapy Following Craniospinal Irradiation in Children With Newly Diagnosed High-Risk CNS Embryonal Tumors: A Report From the Children's Oncology Group (CCG-99702). Pediatr Blood Cancer 2016; 63:1563-70. [PMID: 27203542 PMCID: PMC4955719 DOI: 10.1002/pbc.26074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/18/2016] [Accepted: 04/28/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND The outcomes with high-risk central nervous system (CNS) embryonal tumors remain relatively poor despite aggressive treatment. The purposes of this study using postirradiation myeloablative chemotherapy with autologous hematopoietic stem cell rescue (ASCR) were to document feasibility and describe toxicities of the regimen, establish the appropriate dose of thiotepa, and estimate the overall survival (OS) and event-free survival (EFS). PROCEDURE The Children's Cancer Group conducted this pilot study in children and adolescents with CNS embryonal tumors. The treatment consisted of induction chemotherapy to mobilize hematopoietic stem cells, chemoradiotherapy, and myeloablative consolidation chemotherapy with ASCR. RESULTS The study accrued 25 subjects in 40 months and was closed early due to toxicity, namely, veno-occlusive disease (VOD) of the liver, more recently termed sinusoidal obstructive syndrome (SOS). Of 24 eligible subjects, three of 11 (27%) receiving thiotepa Dose Level 1 (150 mg/m(2) /day × 3 days) and three of 12 (25%) receiving de-escalated Dose Level 0 (100 mg/m(2) /day × 3 days) experienced VOD/SOS. One additional subject experienced toxic death attributed to septic shock; postmortem examination revealed clinically undiagnosed VOD/SOS. The 2-year EFS and OS were 54 ± 10% and 71 ± 9%, respectively. The 5-year EFS and OS were 46 ± 11% and 50 ± 11%. CONCLUSIONS The treatment regimen was deemed to have an unacceptable rate of VOD/SOS. There was complete recovery in all six cases. The overall therapeutic strategy using a regimen less likely to cause VOD/SOS may merit further evaluation for the highest risk patients.
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Affiliation(s)
- Kellie J. Nazemi
- Oregon Health & Science University, Doernbecher Children's Hospital, Department of Pediatrics, Division of Pediatric Hematology-Oncology, 3181 SW Sam Jackson Park Road, CDRC-P, Portland, Oregon 97239
| | - Violet Shen
- Children's Hospital of Orange County, Cancer Institute, 1201 West LaVeta, Orange, California 92868
| | | | - James Boyett
- Saint Jude Children's Research Hospital, Biostatistics, 262 Danny Thomas Place, MS763, Memphis, Tennessee 38105-3678
| | - Mehmet Kocak
- University of Tennessee Health Science Center, Department of Preventive Medicine, 66 N. Pauline Street, Suite 633, Memphis, Tennessee 38103
| | - Deborah Lafond
- Children's National Health System, Department of Hematology-Oncology, 111 Michigan Avenue NW, Washington, DC 20010-2970
| | - Sharon L. Gardner
- New York University Langone Medical Center, Hassenfeld Children's Center, 160 East 32 Street, 2 Floor, New York, NY 10016
| | - Roger J. Packer
- Children's National Health System, Center for Neuroscience and Behavioral Medicine, Brain Tumor Institute, 111 Michigan Avenue NW, Washington, DC 20010-2970
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88
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Blockade of Inhibitors of Apoptosis Proteins in Combination with Conventional Chemotherapy Leads to Synergistic Antitumor Activity in Medulloblastoma and Cancer Stem-Like Cells. PLoS One 2016; 11:e0161299. [PMID: 27537345 PMCID: PMC4990200 DOI: 10.1371/journal.pone.0161299] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 08/03/2016] [Indexed: 11/19/2022] Open
Abstract
Background Medulloblastoma (MB) is the most common pediatric primary malignant brain tumor. Approximately one-third of MB patients succumb to treatment failure and some survivors suffer detrimental side effects. Hence, the purpose of this study is to explore new therapeutic regimens to overcome chemotherapeutic agent resistance or reduce chemotherapy-induced toxicity. Methods We detected the expression of inhibitors of apoptosis proteins (IAPs) in MB and CD133+ MB cell lines and MB tissues using immunoblotting and immunohistochemical staining. The antitumor effects of inhibitors against IAPs on MB or CD133+ MB cells were evaluated by MTT assay, Annexin V/PI analysis, and caspase-3/7 activity. Autophagy was assessed by the conversion of light chain (LC) 3-I to LC3-II and Cyto-ID autophagy detection kit. Results MB cells showed higher expression of IAPs compared to normal astrocytes and normal brain tissues. Conventional chemotherapeutic agents combined with small-molecule IAP inhibitors (LCL161 or LBW242) showed a synergistic effect in MB cells. Combined treatments triggered apoptosis in MB cells through activation of caspase-3/7 and autophagic flux simultaneously. In addition, we found that CD133+ MB cells with features of cancer stem cells displayed higher levels of X-linked inhibitor of apoptosis (XIAP) and cellular inhibitor of apoptosis 1/2 (cIAP1/2), and were hypersensitive to treatment with IAP inhibitors. Conclusions These results shed light on the biological effects of combination therapy on MB cells and illustrate that IAP inhibitors are more effective for CD133+ stem-like MB cells.
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89
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van As JW, van den Berg H, van Dalen EC. Platinum-induced hearing loss after treatment for childhood cancer. Cochrane Database Syst Rev 2016; 2016:CD010181. [PMID: 27486906 PMCID: PMC6466671 DOI: 10.1002/14651858.cd010181.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Platinum-based therapy, including cisplatin, carboplatin, oxaliplatin or a combination of these, is used to treat a variety of paediatric malignancies. Unfortunately, one of the most important adverse effects is the occurrence of hearing loss or ototoxicity. There is a wide variation in the reported prevalence of platinum-induced ototoxicity and the associated risk factors. More insight into the prevalence of and risk factors for platinum-induced hearing loss is essential in order to develop less ototoxic treatment protocols for the future treatment of children with cancer and to develop adequate follow-up protocols for childhood cancer survivors treated with platinum-based therapy. OBJECTIVES To evaluate the existing evidence on the association between childhood cancer treatment including platinum analogues and the occurrence of hearing loss. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 8), MEDLINE (PubMed) (1945 to 23 September 2015) and EMBASE (Ovid) (1980 to 23 September 2015). In addition, we searched reference lists of relevant articles and the conference proceedings of the International Society for Paediatric Oncology (2008 to 2014), the American Society of Pediatric Hematology/Oncology (2008 to 2015) and the International Conference on Long-Term Complications of Treatment of Children and Adolescents for Cancer (2010 to 2015). Experts in the field provided information on additional studies. SELECTION CRITERIA All study designs, except case reports, case series (i.e. a description of non-consecutive participants) and studies including fewer than 100 participants treated with platinum-based therapy who had an ototoxicity assessment, examining the association between childhood cancer treatment including platinum analogues and the occurrence of hearing loss. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. One review author performed data extraction and risk of bias assessment, which was checked by another review author. MAIN RESULTS We identified 13 eligible cohort studies including 2837 participants with a hearing test after treatment with a platinum analogue for different types of childhood cancers. All studies had methodological limitations, with regard to both internal (risk of bias) and external validity. Participants were treated with cisplatin, carboplatin or both, in varying doses. The reported prevalence of hearing loss varied considerably between 0% and 90.1%; none of the studies provided data on tinnitus. Three studies reported a prevalence of 0%, but none of these studies provided a definition for hearing loss and there might be substantial or even complete overlap in included participants between these three studies. When only studies that did provide a definition for hearing loss were included, the prevalence of hearing loss still varied widely between 1.7% and 90.1%. All studies were very heterogeneous with regard to, for example, definitions of hearing loss, used diagnostic tests, participant characteristics, (prior) anti-tumour treatment, other ototoxic drugs and length of follow-up. Therefore, pooling of results was not possible.Only two studies included a control group of people who had not received platinum treatment. In one study, the prevalence of hearing loss was 67.1% (95% confidence interval (CI) 59.3% to 74.1%) in platinum-treated participants, while in the control participants it was 7.4% (95% CI 6.2% to 8.8%). However, hearing loss was detected by screening in survivors treated with platinum analogues and by clinical presentation in control participants. It is uncertain what the effect of this difference in follow-up/diagnostic testing was. In the other study, the prevalence of hearing loss was 20.1% (95% CI 17.4% to 23.2%) in platinum-treated participants and 0.4% (95% CI 0.12% to 1.6%) in control participants. As neither study was a randomized controlled trial or controlled clinical trial, the calculation of a risk ratio was not feasible as it is very likely that both groups differed more than only the platinum treatment.Only two studies evaluated possible risk factors using multivariable analysis. One study identified a significantly higher risk of hearing loss in people treated with cisplatin 400 mg/m(2) plus carboplatin 1700 mg/m(2) as compared to treatment with cisplatin 400 mg/m(2) or less, irrespective of the definition of hearing loss. They also identified a significantly higher risk of hearing loss in people treated with non-anthracycline aminoglycosides antibiotics (using a surrogate marker) as compared to people not treated with them, for three out of four definitions of hearing loss. The other study reported that age at treatment (odds ratio less than 1 for each single-unit increase) and single maximum cisplatin dose (odds ratio greater than 1 for each single-unit increase) were significant predictors for hearing loss, while gender was not. AUTHORS' CONCLUSIONS This systematic review shows that children treated with platinum analogues are at risk for developing hearing loss, but the exact prevalence and risk factors remain unclear. There were no data available for tinnitus. Based on the currently available evidence we can only advise that children treated with platinum analogues are screened for ototoxicity in order to make it possible to diagnose hearing loss early and to take appropriate measures. However, we are unable to give recommendations for specific follow-up protocols including frequency of testing. Counselling regarding the prevention of noise pollution can be considered, such as the use of noise-limiting equipment, avoiding careers with excess noise and ototoxic medication. Before definitive conclusions on the prevalence and associated risk factors of platinum-induced ototoxicity can be made, more high-quality research is needed. Accurate and transparent reporting of findings will make it possible for readers to appraise the results of these studies critically.
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Affiliation(s)
- Jorrit W van As
- Princess Máxima Center for Pediatric Oncologyc/o Cochrane Childhood CancerHeidelberglaan 25UtrechtNetherlands3584 CS
| | - Henk van den Berg
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric OncologyPO Box 22660AmsterdamNetherlands1100 DD
| | - Elvira C van Dalen
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
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90
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Bass JK, Knight KR, Yock TI, Chang KW, Cipkala D, Grewal SS. Evaluation and Management of Hearing Loss in Survivors of Childhood and Adolescent Cancers: A Report From the Children's Oncology Group. Pediatr Blood Cancer 2016; 63:1152-62. [PMID: 26928933 PMCID: PMC5520626 DOI: 10.1002/pbc.25951] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/15/2016] [Accepted: 02/01/2016] [Indexed: 11/07/2022]
Abstract
Hearing loss (HL) is common in childhood cancer survivors exposed to platinum chemotherapy and/or cranial radiation and can severely impact quality of life. Early detection and appropriate management can mitigate academic, speech, language, social, and psychological morbidity resulting from hearing deficits. This review is targeted as a resource for providers involved in aftercare of childhood cancers. The goal is to promote early identification of survivors at-risk for HL, appropriate evaluation and interpretation of diagnostic tests, timely referral to an audiologist when indicated, and to increase knowledge of current therapeutic options.
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Affiliation(s)
- Johnnie K. Bass
- Rehabiliation Services, St Jude Children’s Research Hospital, Memphis, TN
| | - Kristin R. Knight
- Child Development and Rehabilitation Center, Oregon Health and Science University, Portland, OR
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Kay W. Chang
- Department of Otolaryngology, Stanford University, Stanford, CA
| | - Douglas Cipkala
- Center for Cancer and Blood Diseases, Peyton Manning Children’s Hospital at St. Vincent, Indianapolis, IN
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91
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Massimino M, Biassoni V, Gandola L, Garrè ML, Gatta G, Giangaspero F, Poggi G, Rutkowski S. Childhood medulloblastoma. Crit Rev Oncol Hematol 2016; 105:35-51. [PMID: 27375228 DOI: 10.1016/j.critrevonc.2016.05.012] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 04/05/2016] [Accepted: 05/25/2016] [Indexed: 01/06/2023] Open
Abstract
Medulloblastoma accounts for 15-20% of childhood nervous system tumours. The risk of dying was reduced by 30% in the last twenty years. Patients are divided in risk strata according to post-surgical disease, dissemination, histology and some molecular features such as WNT subgroup and MYC status. Sixty to 70% of patients older than 3 years are assigned to the average-risk group. High-risk patients include those with disseminated and/or residual disease, large cell and/or anaplastic histotypes, MYC genes amplification. Current and currently planned clinical trials will: (1) evaluate the feasibility of reducing both the dose of craniospinal irradiation and the volume of the posterior fossa radiotherapy (RT) for those patients at low biologic risk, commonly identified as those having a medulloblastoma of the WNT subgroup; (2) determine whether intensification of chemotherapy (CT) or irradiation can improve outcome in patients with high-risk disease; (3) find target therapies allowing tailored therapies especially for relapsing patients and those with higher biological risk.
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Affiliation(s)
- Maura Massimino
- Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan Italy.
| | | | - Lorenza Gandola
- Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan Italy.
| | | | - Gemma Gatta
- Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan Italy.
| | | | | | - Stefan Rutkowski
- University Medical Center Hamburg-Eppendorf, Department of Pediatric Hematology and Oncology, Hamburg, Germany.
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92
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IGF1R as a Key Target in High Risk, Metastatic Medulloblastoma. Sci Rep 2016; 6:27012. [PMID: 27255663 PMCID: PMC4891740 DOI: 10.1038/srep27012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 05/12/2016] [Indexed: 12/21/2022] Open
Abstract
Risk or presence of metastasis in medulloblastoma causes substantial treatment-related morbidity and overall mortality. Through the comparison of cytokines and growth factors in the cerebrospinal fluid (CSF) of metastatic medulloblastoma patients with factors also in conditioned media of metastatic MYC amplified medulloblastoma or leptomeningeal cells, we were led to explore the bioactivity of IGF1 in medulloblastoma by elevated CSF levels of IGF1, IGF-sequestering IGFBP3, IGFBP3-cleaving proteases (MMP and tPA), and protease modulators (TIMP1 and PAI-1). IGF1 led not only to receptor phosphorylation but also accelerated migration/adhesion in MYC amplified medulloblastoma cells in the context of appropriate matrix or meningothelial cells. Clinical correlation suggests a peri-/sub-meningothelial source of IGF-liberating proteases that could facilitate leptomeningeal metastasis. In parallel, studies of key factors responsible for cell autonomous growth in MYC amplified medulloblastoma prioritized IGF1R inhibitors. Together, our studies identify IGF1R as a high value target for clinical trials in high risk medulloblastoma.
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93
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O'Leary B, Mandeville HC, Fersht N, Solda F, Mycroft J, Zacharoulis S, Vaidya S, Saran F. Craniospinal irradiation with concomitant and adjuvant temozolomide--a feasibility assessment of toxicity in patients with glioblastoma with a PNET component. J Neurooncol 2016; 127:295-302. [PMID: 26842817 DOI: 10.1007/s11060-015-2033-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 12/26/2015] [Indexed: 12/22/2022]
Abstract
There is no standard treatment for glioblastoma with elements of PNET (GBM-PNET). Conventional treatment for glioblastoma is surgery followed by focal radiotherapy with concurrent temozolomide. Given the increased propensity for neuroaxial metastases seen with GBM-PNETs, craniospinal irradiation (CSI) with temozolomide (TMZ) could be a feasible treatment option but little is known regarding its toxicity. The clinical records of all patients treated at two UK neuro-oncology centres with concurrent CSI and TMZ were examined for details of surgery, radiotherapy, chemotherapy and toxicities related to the CSI-TMZ component of their treatment. Eight patients were treated with CSI-TMZ, the majority (6/8) for GBM-PNET. All patients completed radiotherapy to the craniospinal axis 35-40 Gy in 20-24 daily fractions with a focal boost to the tumour of 14-23.4 Gy in 8-13 daily fractions. Concurrent TMZ was administered at 75 mg/m(2) for seven of the cohort, with the other patient receiving 50 mg/m(2). The most commonly observed non-haematological toxicities were nausea and vomiting, with all patients experiencing at least grade 2 symptoms of either or both. All patients had at least grade 3 lymphopaenia. Two patients experience grade 4 neutropaenia and grade 3 thrombocytopaenia. Three of the eight patients required omission of TMZ for part of their chemoradiotherapy and 3/8 required hospital admission at some point during chemoradiotherapy. The addition of TMZ to CSI did not interrupt radiotherapy. Principal toxicities were neutropaenia, lymphopaenia, thrombocytopaenia, nausea and vomiting. Treatment with CSI-TMZ merits further investigation and may be suitable for patients with tumours at high-risk of metastatic spread throughout the CNS who have TMZ-sensitive pathologies.
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Affiliation(s)
- Ben O'Leary
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
- The Institute of Cancer Research, 237 Fulham Rd, London, SW3 6JB, UK
| | - Henry C Mandeville
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
| | - Naomi Fersht
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Francesca Solda
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Julie Mycroft
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
| | - Stergios Zacharoulis
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
| | - Sucheta Vaidya
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK
| | - Frank Saran
- The Royal Marsden Hospital NHS Trust, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK.
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94
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Lavoie Smith EM, Li L, Chiang C, Thomas K, Hutchinson RJ, Wells EM, Ho RH, Skiles J, Chakraborty A, Bridges CM, Renbarger J. Patterns and severity of vincristine-induced peripheral neuropathy in children with acute lymphoblastic leukemia. J Peripher Nerv Syst 2016; 20:37-46. [PMID: 25977177 DOI: 10.1111/jns.12114] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 04/10/2015] [Accepted: 04/11/2015] [Indexed: 12/12/2022]
Abstract
Vincristine, a critical component of combination chemotherapy treatment for pediatric acute lymphoblastic leukemia (ALL), can lead to vincristine-induced peripheral neuropathy (VIPN). Longitudinal VIPN assessments were obtained over 12 months from newly diagnosed children with ALL (N = 128) aged 1-18 years who received vincristine at one of four academic children's hospitals. VIPN assessments were obtained using the Total Neuropathy Score-Pediatric Vincristine (TNS©-PV), National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE©), Balis© grading scale, and Pediatric Neuropathic Pain Scale©-Five (PNPS©-5). Of children who provided a full TNS©-PV score, 85/109 (78%) developed VIPN (TNS©-PV ≥4). Mean TNS©-PV, grading scale, and pain scores were low. CTCAE©-derived grades 3 and 4 sensory and motor VIPN occurred in 1.6%/0%, and 1.9%/0% of subjects, respectively. VIPN did not resolve in months 8-12 despite decreasing dose density. VIPN was worse in older children. Partition cluster analysis revealed 2-3 patient clusters; one cluster (n = 14) experienced severe VIPN. In this population, VIPN occurs more commonly than previous research suggests, persists throughout the first year of treatment, and can be severe.
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Affiliation(s)
| | - Lang Li
- School of Medicine, Indiana University, Indianapolis, IN, USA
| | - ChienWei Chiang
- School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Karin Thomas
- Department of Nursing, Children's Hospital Colorado, Aurora, CO, USA
| | | | | | - Richard H Ho
- Department of Pediatrics, Vanderbilt University, Nashville, TN, USA
| | - Jodi Skiles
- School of Medicine, Indiana University, Indianapolis, IN, USA
| | | | - Celia M Bridges
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Jamie Renbarger
- School of Medicine, Indiana University, Indianapolis, IN, USA
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95
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Adjuvant chemotherapy in adult medulloblastoma: is it an option for average-risk patients? J Neurooncol 2016; 128:235-40. [DOI: 10.1007/s11060-016-2097-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 02/28/2016] [Indexed: 10/22/2022]
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96
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Murphy ES, Chao ST, Angelov L, Vogelbaum MA, Barnett G, Jung E, Recinos VR, Mohammadi A, Suh JH. Radiosurgery for Pediatric Brain Tumors. Pediatr Blood Cancer 2016; 63:398-405. [PMID: 26536284 DOI: 10.1002/pbc.25831] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/13/2015] [Indexed: 11/05/2022]
Abstract
The utility of radiosurgery for pediatric brain tumors is not well known. For children, radiosurgery may have an important role for treating unresectable tumors, residual disease, or tumors in the recurrent setting that have received prior radiotherapy. The available evidence demonstrates utility for some children with primary brain tumors resulting in good local control. Radiosurgery can be considered for limited residual disease or focal recurrences. However, the potential toxicities are unique and not insignificant. Therefore, prospective studies need to be performed to develop guidelines for indications and treatment for children and reduce toxicity in this population.
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Affiliation(s)
- Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene Barnett
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Jung
- Department of Radiation Oncology, John R. Marsh Cancer Center, Hagerstown, MD, USA
| | - Violette R Recinos
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza Mohammadi
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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97
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Brandes AA, Franceschi E. Shedding light on adult medulloblastoma: current management and opportunities for advances. Am Soc Clin Oncol Educ Book 2015:e82-7. [PMID: 24857151 DOI: 10.14694/edbook_am.2014.34.e82] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Few evidence-based guidelines are available for the treatment of adult medulloblastoma, an extremely rare disease. Therapeutic regimens, typically modeled following pediatric protocols, consist of surgical resection followed by radiotherapy with or without adjuvant chemotherapy. Because of the rarity of this disease in adults, any treatment undertaken is based mainly on small and retrospective studies. Unlike pediatric patients, adults with medulloblastoma have been treated according to risk-adapted therapeutic strategies in only a few prospective studies. Overall, approximately 30% of patients experience recurrence and die of disease-related causes. Although the patients could respond to second-line treatments, the prognosis of patients with recurrence remains dismal. An important challenge for the future will be the biologic characterization of medulloblastoma in adults, with the identification of specific genetic patterns of patients with different prognosis and different response to targeted treatments.
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Affiliation(s)
- Alba A Brandes
- From the Department of Medical Oncology, Azienda USL-IRCCS Institute of Neurological Science, Bologna, Italy
| | - Enrico Franceschi
- From the Department of Medical Oncology, Azienda USL-IRCCS Institute of Neurological Science, Bologna, Italy
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98
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Vivekanandan S, Breene R, Ramanujachar R, Traunecker H, Pizer B, Gaze MN, Saran F, Thorp N, English M, Wheeler KA, Michalski A, Walker DA, Saunders D, Cowie F, Cameron A, Picton SV, Parashar D, Horan G, Williams MV. The UK Experience of a Treatment Strategy for Pediatric Metastatic Medulloblastoma Comprising Intensive Induction Chemotherapy, Hyperfractionated Accelerated Radiotherapy and Response Directed High Dose Myeloablative Chemotherapy or Maintenance Chemotherapy (Milan Strategy). Pediatr Blood Cancer 2015; 62:2132-9. [PMID: 26274622 DOI: 10.1002/pbc.25663] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 06/19/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Historically, the 5-year overall survival (OS) for metastatic medulloblastoma (MMB) was less than 40%. The strategy of post-operative induction chemotherapy (IC) followed by hyperfractionated accelerated radiotherapy (HART) and response directed high dose chemotherapy (HDC) was reported in a single center study to improve 5-year OS to 73%. We report outcomes of this strategy in UK. METHODS Questionnaires were sent to all 20 UK pediatric oncology primary treatment centers to collect retrospective data on delivered treatment, toxicity and survival with this strategy in children aged 3-19 years with MMB. RESULTS Between February 2009 and October 2011, 34 patients fulfilled the entry criteria of the original study. The median age was 7 years (range 3-15). Median interval from surgery to HART was 109 versus 85 days in the original series. The incidence of grade 3 or 4 hematological toxicities with IC and HDC was 83-100%. All 16 patients who achieved complete response by the end of the regimen remain in remission but only three of 18 patients with lesser responses are still alive (P < 0.0001). With a median follow-up of 45 months for survivors, the estimated 3-year OS is 56% (95% CI 38, 71). This result is outside the 95% CI of the original study results and encompasses the historical survival result of 40%. CONCLUSION Within the limits of statistical significance, we did not replicate the improved survival results reported in the original series. The reasons include differences in patient sub-groups and protocol administration. International randomized phase III studies are needed.
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Affiliation(s)
- Sindu Vivekanandan
- Clinical Oncology, Cambridge University Hospitals NHS Foundation Trust Addenbrooke's Hospital, Cambridge, UK
| | - Richard Breene
- Paediatric Oncology, Cambridge University Hospitals NHS Foundation Trust Addenbrooke's Hospital, Cambridge, UK
| | - Ramya Ramanujachar
- Paediatric Oncology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Barry Pizer
- Paediatric Oncology, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Mark N Gaze
- Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Frank Saran
- Clinical Oncology, The Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Nicky Thorp
- Clinical Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - Martin English
- Paediatric Oncology, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Kate Ah Wheeler
- Paediatric Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony Michalski
- Paediatric Oncology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - David A Walker
- Paediatric Oncology, Nottingham Children's Hospital University of Nottingham, Nottingham, UK
| | - Daniel Saunders
- Clinical Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Fiona Cowie
- Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Alison Cameron
- Clinical Oncology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Susan V Picton
- Paediatric Oncology, The Leeds Teaching Hospitals, Leeds, UK
| | - Deepak Parashar
- Cancer Research Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Gail Horan
- Clinical Oncology, Cambridge University Hospitals NHS Foundation Trust Addenbrooke's Hospital, Cambridge, UK
| | - Michael V Williams
- Clinical Oncology, Cambridge University Hospitals NHS Foundation Trust Addenbrooke's Hospital, Cambridge, UK
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99
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Cox MC, Kusters JM, Gidding CE, Schieving JH, van Lindert EJ, Kaanders JH, Janssens GO. Acute toxicity profile of craniospinal irradiation with intensity-modulated radiation therapy in children with medulloblastoma: A prospective analysis. Radiat Oncol 2015; 10:241. [PMID: 26597178 PMCID: PMC4657242 DOI: 10.1186/s13014-015-0547-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To report on the acute toxicity in children with medulloblastoma undergoing intensity-modulated radiation therapy (IMRT) with daily intrafractionally modulated junctions. METHODS Newly diagnosed patients, aged 3-21, with standard-risk (SR) or high-risk (HR) medulloblastoma were eligible. A dose of 23.4 or 36.0 Gy in daily fractions of 1.8 Gy was prescribed to the craniospinal axis, followed by a boost to the primary tumor bed (54 or 55.8 Gy) and metastases (39.6-55.8 Gy), when indicated. Weekly, an intravenous bolus of vincristine was combined for patients with SR medulloblastoma and patients participating in the COG-ACNS-0332 study. Common toxicity criteria (CTC, version 2.0) focusing on skin, alopecia, voice changes, conjunctivitis, anorexia, dysphagia, gastro-intestinal symptoms, headache, fatigue and hematological changes were scored weekly during radiotherapy. RESULTS From 2010 to 2014, data from 15 consecutive patients (SR, n = 7; HR, n = 8) were collected. Within 72 h from onset of treatment, vomiting (66 %) and headache (46 %) occurred. During week 3 of treatment, a peak incidence in constipation (33 %) and abdominal pain/cramping (40 %) was observed, but only in the subgroup of patients (n = 9) receiving vincristine (constipation: 56 vs 0 %, P = .04; pain/cramping: 67 vs 0 %, P = .03). At week 6, 73 % of the patients developed faint erythema of the cranial skin with dry desquamation (40 %) or moist desquamation confined to the skin folds of the auricle (33 %). No reaction of the skin overlying the spinal target volume was observed. CONCLUSIONS Headache at onset and gastro-intestinal toxicity, especially in patients receiving weekly vincristine, were the major complaints of patients with medulloblastoma undergoing craniospinal irradiation with IMRT.
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Affiliation(s)
- Maurice C Cox
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Johannes M Kusters
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Corrie E Gidding
- Department of Pediatric Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Jolanda H Schieving
- Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Erik J van Lindert
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Johannes H Kaanders
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Center for Pediatric Oncology, Utrecht, 3584, CX, The Netherlands.
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100
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Pompe RS, von Bueren AO, Mynarek M, von Hoff K, Friedrich C, Kwiecien R, Treulieb W, Lindow C, Deinlein F, Fleischhack G, Kuehl J, Rutkowski S. Intraventricular methotrexate as part of primary therapy for children with infant and/or metastatic medulloblastoma: Feasibility, acute toxicity and evidence for efficacy. Eur J Cancer 2015; 51:2634-42. [DOI: 10.1016/j.ejca.2015.08.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 07/27/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022]
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