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Increase of pseudoprogression and other treatment related effects in low-grade glioma patients treated with proton radiation and temozolomide. J Neurooncol 2018; 142:69-77. [DOI: 10.1007/s11060-018-03063-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/24/2018] [Indexed: 12/22/2022]
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Khatua S, Mangum R, Bertrand KC, Zaky W, McCall D, Mack SC. Pediatric ependymoma: current treatment and newer therapeutic insights. Future Oncol 2018; 14:3175-3186. [PMID: 30418040 DOI: 10.2217/fon-2018-0502] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Advances in genomic, transcriptomic and epigenomic profiling now identifies pediatric ependymoma as a defined biological entity. Molecular interrogation has segregated these tumors into distinct biological subtypes based on anatomical location, age and clinical outcome, which now defines the need to tailor therapy even for histologically similar tumors. These findings now provide reasons for a paradigm shift in therapy, which should profile future clinical trials focused on targeted therapeutic strategies and risk-based treatment. The need to diagnose and differentiate the aggressive variants, which include the posterior fossa group A and the supratentorial RELA fusion subtypes, is imperative to escalate therapy and improve survival.
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Affiliation(s)
- Soumen Khatua
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ross Mangum
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA.,Department of Pediatric Hematology & Oncology, Texas Children's Cancer & Hematology Centers, Houston, TX 77030, USA
| | - Kelsey C Bertrand
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA.,Department of Pediatric Hematology & Oncology, Texas Children's Cancer & Hematology Centers, Houston, TX 77030, USA
| | - Wafik Zaky
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - David McCall
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Stephen C Mack
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA.,Department of Pediatric Hematology & Oncology, Texas Children's Cancer & Hematology Centers, Houston, TX 77030, USA
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Deng X, Lin D, Yu L, Xu X, Zhang N, Zhou H, Sheng H, Yin B, Lin F, Xu S, Li D, Fang J, Lu X, Lin J. The role of postoperative radiotherapy in pediatric patients with grade II intracranial ependymomas: a population-based, propensity score-matched study. Cancer Manag Res 2018; 10:5515-5524. [PMID: 30519099 PMCID: PMC6233483 DOI: 10.2147/cmar.s181900] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose The main objectives of this study were to clarify the efficacy of postoperative radiotherapy (PORT) for pediatric intracranial grade II ependymomas (EPNs) and to explore whether various characteristics are associated with different outcomes in patients with and without PORT. Patients and methods Data from patients younger than 18 years diagnosed with grade II intracranial EPNs and treated by surgery, with or without PORT, were obtained from the Surveillance, Epidemiology, and End Results (SEER) database (1973–2013 data set). Propensity score-matched analysis was conducted to balance clinical variables. Patient characteristics were stratified and analyzed. Results In total, data from 632 patients with grade II EPNs treated by cancer-directed surgery with or without PORT were obtained from the SEER database. Multivariable Cox analysis in the matched cohort suggested that undergoing PORT (overall survival [OS], P=0.020; cancer-specific survival [CSS], P=0.031), undergoing gross total resection (GTR; subtotal resection [STR] vs GTR; OS, P<0.001; CSS, P<0.001), and older age (OS, P<0.001; CSS, P<0.001) were the independent predictors of superior prognosis. Stratified analysis demonstrated that patient characteristics, including infratentorial location, younger age, and STR, were associated with benefit from PORT, while the survival advantage was not detected in patients who underwent GTR. Conclusion Propensity score-matched analysis using SEER data indicates survival advantages of PORT. Given the strong prognostic associations with extent of resection and patient age, we recommend PORT for younger patients treated by STR.
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Affiliation(s)
- Xiangyang Deng
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Dongdong Lin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Lisheng Yu
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Xingxing Xu
- Department of Physiology, School of Basic Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Nu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Hui Zhou
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Hansong Sheng
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Fengchun Lin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Shangyu Xu
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Dandong Li
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Junhao Fang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Xiangqi Lu
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
| | - Jian Lin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
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Jaramillo S, Grosshans DR, Philip N, Varan A, Akyüz C, McAleer MF, Mahajan A, McGovern SL. Radiation for ETMR: Literature review and case series of patients treated with proton therapy. Clin Transl Radiat Oncol 2018; 15:31-37. [PMID: 30582019 PMCID: PMC6297264 DOI: 10.1016/j.ctro.2018.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 12/21/2022] Open
Abstract
Background and purpose Embryonal tumors with multilayered rosettes (ETMRs) are aggressive tumors that typically occur in young children. Radiation is often deferred or delayed for these patients due to late effects; proton therapy may mitigate some of these concerns. This study reviews the role of radiation in ETMR and describes initial results with proton therapy. Materials and methods Records of patients with embryonal tumor with abundant neuropil and true rosettes (ETANTR), medulloepithelioma (MEP), and ependymoblastoma (EPL) treated with proton therapy at our institution were retrospectively reviewed. A literature review of cases of CNS ETANTR, MEP, and EPL published since 1990 was also conducted. Results Seven patients were treated with proton therapy. Their median age at diagnosis was 33 months (range 10-57 months) and their median age at radiation start was 42 months (range 17-58 months). Their median overall survival (OS) was 16 months (range 8-64 months), with three patients surviving 36 months or longer. Five patients had disease progression prior to starting radiation; all 5 of these patients failed in the tumor bed. A search of the literature identified 204 cases of ETMR with a median OS of 10 months (range 0.03-161 months). Median OS of 18 long-term survivors (≥36 months) in the literature was 77 months (range 37-184 months). Of these 18 long-term survivors, 17 (94%) received radiotherapy as part of their initial treatment; 14 of them were treated with craniospinal irradiation. Conclusions Outcomes of patients with ETMR treated with proton therapy are encouraging compared to historical results. Further study of this rare tumor is warranted to better define the role of radiotherapy.
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Affiliation(s)
- Sergio Jaramillo
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, United States
| | - David R Grosshans
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Nancy Philip
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Ali Varan
- Department of Pediatric Oncology, Hacettepe University, Institute of Oncology, Ankara, Turkey
| | - Canan Akyüz
- Department of Pediatric Oncology, Hacettepe University, Institute of Oncology, Ankara, Turkey
| | - Mary Frances McAleer
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Susan L McGovern
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
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55
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Huynh M, Marcu LG, Giles E, Short M, Matthews D, Bezak E. Current status of proton therapy outcome for paediatric cancers of the central nervous system - Analysis of the published literature. Cancer Treat Rev 2018; 70:272-288. [PMID: 30326423 DOI: 10.1016/j.ctrv.2018.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/05/2018] [Accepted: 10/06/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The most common solid tumours that develop in children are cancers of the central nervous system. Due to the increased rate of survival over the past decades, greater focus has been placed on the minimisation of long term side effects. In childhood cancer survivors, over 60% report one or more radiation-related late toxicities while half of these adverse events are graded as life-threatening or severe. Proton therapy enables high conformity with the planning target volume and a reduction in dose to areas beyond the target. Owing to the unique nature of dose delivery with proton therapy a reduction of low doses to normal tissues is achievable, and is believed to allow for a decrease in long-term treatment-related side effects. This paper aims to review the published literature around the effectiveness of proton therapy for the treatment of paediatric cancers of the central nervous system, with a focus on treatment outcomes and treatment-related toxicities. METHODS A search strategy utilising the Medline database was created with the intent of including all articles reporting on proton therapy, paediatric cancers, CNS tumours and treatment outcomes. The final search strategy included the following limitations: limited to humans, English, published from 2000 onwards. The final article count total was 74. RESULTS AND CONCLUSIONS Proton therapy for the treatment of paediatric cancers of the central nervous system was found to provide survival and tumour control outcomes comparable to photon therapy. Reduced incidence of severe acute and late toxicities was also reported with the use of proton therapy. This includes reduced severity of endocrine, neurological, IQ and QoL deficits. Currently, extensive follow-up of proton patient populations still needs to be made to determine incidences of late-onset toxicities and secondary malignancies. Current evidence surrounding proton therapy use in paediatric patients supports its effectiveness and potential benefits in reducing the incidence of severe toxicities in later life.
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Affiliation(s)
- Myxuan Huynh
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Loredana Gabriela Marcu
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia; Faculty of Science, University of Oradea, Oradea 410087, Romania
| | - Eileen Giles
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Michala Short
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Donna Matthews
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia; School of Physical Sciences, University of Adelaide, North Terrace, Adelaide, South Australia 5005, Australia.
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56
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Bass JK, Huang J, Hua CH, Bhagat SP, Mendel LL, Onar-Thomas A, Indelicato DJ, Merchant TE. Auditory Outcomes in Patients Who Received Proton Radiotherapy for Craniopharyngioma. Am J Audiol 2018; 27:306-315. [PMID: 30073327 DOI: 10.1044/2018_aja-18-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/18/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Compared to photon-based radiotherapy, protons deliver less radiation to healthy tissue resulting in the potential reduction of late complications such as sensorineural hearing loss (SNHL). We report early auditory outcomes in children treated with proton radiotherapy (PRT) for craniopharyngioma. METHOD Conventional frequency (CF = 0.25-8.0 kHz) audiometry, extended high-frequency (EHF = 9.0-16.0 kHz) audiometry, distortion product otoacoustic emission (DPOAE) testing, and speech-in-noise (SIN) assessments were prospectively and longitudinally conducted on 74 children with a median of 2 post-PRT evaluations (range, 1-5) per patient. The median age at PRT initiation was 10 years, and median follow-up time was 2 years. Ototoxicity was classified using the Chang Ototoxicity Grading Scale (Chang & Chinosornvatana, 2010) and the American Speech-Language-Hearing Association (ASHA) criteria (ASHA, 1994). Comparisons were made between baseline and most recent DPOAE levels, with evidence of ototoxicity based on criterion reductions of ≥ 6 dB. The critical difference values for comparing SIN scores between two conditions (i.e., pre- and post-PRT) were used to determine a significant change between test scores. RESULTS At last evaluation, no patients had SNHL in the CF range, and 2 patients had SNHL (Chang Grade 1a) in the EHF range. Based on the ASHA criteria, a decrease in hearing was observed in 0 patients in the CF range alone, in 9 patients in the EHF range alone, and in 15 patients in both the CF and EHF ranges. DPOAE levels decreased at a faster rate at higher versus lower frequencies. For 41 evaluable patients, SIN perception did not decline over time (p = .6463). CONCLUSION At a median follow-up time of 2 years post-PRT, normal hearing was maintained within the CF range. However, subclinical decreases in hearing were observed, particularly in the EHF range and in the DPOAE level; thus, long-term follow-up is recommended to monitor for potential auditory late effects from PRT.
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Affiliation(s)
- Johnnie K. Bass
- Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, TN
| | - Jie Huang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Shaum P. Bhagat
- Department of Communication Disorders and Sciences, San Jose State University, CA
| | - Lisa Lucks Mendel
- School of Communication Sciences and Disorders, University of Memphis, TN
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | | | - Thomas E. Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN
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Ducassou A, Padovani L, Chaltiel L, Bolle S, Habrand JL, Claude L, Carrie C, Muracciole X, Coche-Dequeant B, Alapetite C, Supiot S, Demoor-Goldschmidt C, Bernier-Chastagner V, Huchet A, Leseur J, Le Prise E, Kerr C, Truc G, Nguyen TD, Bertozzi AI, Frappaz D, Boetto S, Sevely A, Tensaouti F, Laprie A. Pediatric Localized Intracranial Ependymomas: A Multicenter Analysis of the Société Française de lutte contre les Cancers de l'Enfant (SFCE) from 2000 to 2013. Int J Radiat Oncol Biol Phys 2018; 102:166-173. [DOI: 10.1016/j.ijrobp.2018.05.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 05/15/2018] [Indexed: 10/16/2022]
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Ladra MM, MacDonald SM, Terezakis SA. Proton therapy for central nervous system tumors in children. Pediatr Blood Cancer 2018; 65:e27046. [PMID: 29630784 DOI: 10.1002/pbc.27046] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 11/08/2022]
Abstract
Proton therapy is a form of particle therapy with physical properties that provide a superior dose distribution compared to photons. The ability to spare healthy, developing tissues from low dose radiation with proton therapy is well known. The capability to decrease radiation exposure for children has been lauded as an important advance in pediatric cancer care, particularly for central nervous system (CNS) tumors. Favorable clinical outcomes have been reported and justify the increased cost and burden of this therapy. In this review, we summarize the current literature for proton therapy for pediatric CNS malignancies, with a focus on clinical outcomes to date.
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Affiliation(s)
- Matthew M Ladra
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephanie A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
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Estimated IQ Systematically Underestimates Neurocognitive Sequelae in Irradiated Pediatric Brain Tumor Survivors. Int J Radiat Oncol Biol Phys 2018; 101:541-549. [DOI: 10.1016/j.ijrobp.2018.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 11/19/2022]
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Yang CC, Lin SY, Tseng CK. Maintenance of multidomain neurocognitive functions in pediatric patients after proton beam therapy: A prospective case-series study. APPLIED NEUROPSYCHOLOGY-CHILD 2018; 8:389-395. [PMID: 29958017 DOI: 10.1080/21622965.2018.1471996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Proton Beam Therapy (PBT) was developed to minimize the harmful results of radiation therapy as treatment for brain tumors. This study examined the neurocognitive outcomes of PBT in pediatric patients. A total of 8 patients, who received either PBT or photon radiotherapy (XRT), were evaluated with multiple cognitive functions, which include intelligence, memory, executive functions, and attention. Most of patients performed average-to-superior levels of neurocognitive functions (NCF), except that a deterioration of executive functions was revealed in two patients receiving XRT. This study might be the first one to show the maintenance of multidomain NCF after PBT.
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Affiliation(s)
- Chi-Cheng Yang
- Department of Psychology, National Chengchi University , Taipei , Taiwan
| | - Shinn-Yn Lin
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang-Gung University , Taoyuan , Taiwan.,Department of Medical Imaging and Radiological Sciences College of Medicine, Chang-Gung University , Taoyuan , Taiwan.,College of Public Health, Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University , Taipei , Taiwan
| | - Chen-Kan Tseng
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang-Gung University , Taoyuan , Taiwan.,Department of Medical Imaging and Radiological Sciences College of Medicine, Chang-Gung University , Taoyuan , Taiwan
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Proton therapy for pediatric malignancies: Fact, figures and costs. A joint consensus statement from the pediatric subcommittee of PTCOG, PROS and EPTN. Radiother Oncol 2018; 128:44-55. [PMID: 29937209 DOI: 10.1016/j.radonc.2018.05.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/11/2018] [Accepted: 05/15/2018] [Indexed: 12/18/2022]
Abstract
Radiotherapy plays an important role in the management of childhood cancer, with the primary aim of achieving the highest likelihood of cure with the lowest risk of radiation-induced morbidity. Proton therapy (PT) provides an undisputable advantage by reducing the radiation 'bath' dose delivered to non-target structures/volume while optimally covering the tumor with tumoricidal dose. This treatment modality comes, however, with an additional costs compared to conventional radiotherapy that could put substantial financial pressure to the health care systems with societal implications. In this review we assess the data available to the oncology community of PT delivered to children with cancer, discuss on the urgency to develop high-quality data. Additionally, we look at the advantage of combining systemic agents with protons and look at the cost-effectiveness data published so far.
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Indelicato DJ, Bradley JA, Rotondo RL, Nanda RH, Logie N, Sandler ES, Aldana PR, Ranalli NJ, Beier AD, Morris CG, Mendenhall NP. Outcomes following proton therapy for pediatric ependymoma. Acta Oncol 2018; 57:644-648. [PMID: 29239262 DOI: 10.1080/0284186x.2017.1413248] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Proton therapy can reduce the low and intermediate radiation dose to uninvolved brain tissue in children with intracranial ependymomas, which may improve functional outcomes and reduce second malignancies in survivors. Accordingly, ependymoma has become the most common pediatric tumor treated with proton therapy, yet data on efficacy and toxicity are limited. MATERIAL AND METHODS Between June 2007 and February 2017, 179 children (≤21 years old) with nonmetastatic grade II/III intracranial ependymoma received proton therapy at our institution. Median age, 3.5 years (range, 0.7-21); 58% were male. Most (66%) tumors were in the posterior fossa and classified as WHO grade III (67%). 27% underwent multiple operations to maximize the extent of resection; ultimately 85% had a gross total or near total tumor resection before radiotherapy. 33% received preradiation chemotherapy. Median radiation dose in children ≤3 years old, 54 Gy(RBE). Most (>90%) children over 3 years old received 59.4 Gy(RBE). Patient and treatment variables were assessed for correlation with disease control. RESULTS Median follow-up, 3.2 years. 3-year local control, progression-free survival, and overall survival rates were 85%, 76%, and 90%, respectively. First site of progression was local, metastatic, or simultaneous in 14, 17 and 6 patients, respectively. On multivariate analysis, subtotal resection was associated with inferior local control (67% vs. 88%; p ≤ .01) and progression-free survival (59% vs. 79%; p < .05). Male sex was associated with inferior progression-free (67% vs. 87%; p< .05) and overall survival (84% vs. 99%; p < .01). The 3-year CTCAE grade 2 + brainstem toxicity rate was 5.5% (95% CI: 2.9-10.2), including 1 grade 5 toxicity. CONCLUSIONS This series of proton therapy for pediatric intracranial ependymoma demonstrates disease control comparable to photon series without unexpected toxicity. Subtotal resection and male sex were associated with inferior disease control. Additional follow-up to quantify the expected reductions in late toxicity with proton therapy is ongoing.
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Affiliation(s)
- Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Ronny L. Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Ronica H. Nanda
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Natalie Logie
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Eric S. Sandler
- Department of Pediatric Hematology-Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Philipp R. Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nathan J. Ranalli
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Alexandra D. Beier
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Imaging biomarkers of outcome after radiotherapy for pediatric ependymoma. Radiother Oncol 2018; 127:103-107. [DOI: 10.1016/j.radonc.2018.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 12/05/2017] [Accepted: 02/08/2018] [Indexed: 11/17/2022]
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Rudà R, Reifenberger G, Frappaz D, Pfister SM, Laprie A, Santarius T, Roth P, Tonn JC, Soffietti R, Weller M, Moyal ECJ. EANO guidelines for the diagnosis and treatment of ependymal tumors. Neuro Oncol 2018; 20:445-456. [PMID: 29194500 PMCID: PMC5909649 DOI: 10.1093/neuonc/nox166] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Ependymal tumors are rare CNS tumors and may occur at any age, but their proportion among primary brain tumors is highest in children and young adults. Thus, the level of evidence of diagnostic and therapeutic interventions is higher in the pediatric compared with the adult patient population.The diagnosis and disease staging is performed by craniospinal MRI. Tumor classification is achieved by histological and molecular diagnostic assessment of tissue specimens according to the World Health Organization (WHO) classification 2016. Surgery is the crucial initial treatment in both children and adults. In pediatric patients with intracranial ependymomas of WHO grades II or III, surgery is followed by local radiotherapy regardless of residual tumor volume. In adults, radiotherapy is employed in patients with anaplastic ependymoma WHO grade III, and in case of incomplete resection of WHO grade II ependymoma. Chemotherapy alone is reserved for young children <12 months and for adults with recurrent disease when further surgery and irradiation are no longer feasible. A gross total resection is the mainstay of treatment in spinal ependymomas, and radiotherapy is reserved for incompletely resected tumors. Nine subgroups of ependymal tumors across different anatomical compartments (supratentorial, posterior fossa, spinal) and patient ages have been identified with distinct genetic and epigenetic alterations, and with distinct outcomes. These findings may lead to more precise diagnostic and prognostic assessments, molecular subgroup-adapted therapies, and eventually new recommendations pending validation in prospective studies.
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Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science University Hospital, Turin, Italy
| | - Guido Reifenberger
- Institute of Neuropathology, Medical Faculty, Heinrich Heine University Düsseldorf and German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, Düsseldorf, Germany
| | - Didier Frappaz
- Département de Neuro-Oncologie, Centre Léon-Bérard, Institut d’Hématologie et Oncologie Pédiatrique et Adulte, Lyon, France
| | - Stefan M Pfister
- Division of Pediatric Neuro-oncology, German Cancer Research Center, DKTK, Heidelberg, Germany and Department of Pediatric Oncology, Hematology and Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Anne Laprie
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | | | - Patrick Roth
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Joerg Christian Tonn
- Department of Neurosurgery Ludwig-Maximilians-Universität and DKTK partner site, University of Munich, Munich, Germany
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University of Turin and City of Health and Science University Hospital, Turin, Italy
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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De B, Khakoo Y, Souweidane MM, Dunkel IJ, Patel SH, Gilheeney SW, De Braganca KC, Karajannis MA, Wolden SL. Patterns of relapse for children with localized intracranial ependymoma. J Neurooncol 2018; 138:435-445. [PMID: 29511977 DOI: 10.1007/s11060-018-2815-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
Abstract
We examined patterns of relapse and prognostic factors in children with intracranial ependymoma. Records of 82 children diagnosed with localized intracranial ependymoma were reviewed. 52% first presented to our institution after relapse. Median age at initial diagnosis was 4 years (range 0-18 years). Gender was 55% male. Initial tumor location was infratentorial in 71% and supratentorial in 29%. Histology was WHO Grade II in 32% and Grade III in 68%. As part of definitive management, 99% had surgery, 70% received RT (26% 2D/3D-conformal RT[CRT], 22% intensity-modulated RT [IMRT], 22% proton), and 37% received chemotherapy. Median follow-up was 4.6 years (range 0.2-32.9). Overall, 74% of patients relapsed (50% local, 17% distant, 7% local + distant) at a median 1.5 (range 0.1-17.5) years. Five-year OS and FFS for patients presenting prior to relapse are 70% (95% confidence interval [CI], 50-83%) and 48% (95% CI 30-64%), respectively. On log-rank, superior overall survival (OS) was demonstrated for gross total resection (p = 0.03). Superior failure-free survival (FFS) was demonstrated for age < 5 years (p = 0.04). No difference in OS or FFS was found between 2D/3D-CRT versus IMRT/proton (p > 0.05). On multivariate analysis, age ≤ 5 was independently associated with a lower risk of death and failure versus older patients (p < 0.05). Contrary to previous reports, young age may not be a poor prognostic factor in patients who can tolerate intensive treatment. Future studies examining patients stratified by clinical and molecular attributes are warranted.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark M Souweidane
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Ira J Dunkel
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Suchit H Patel
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Stephen W Gilheeney
- 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.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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66
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Zureick AH, Evans CL, Niemierko A, Grieco JA, Nichols AJ, Fullerton BC, Hess CB, Goebel CP, Gallotto SL, Weyman EA, Gaudet DE, Nartowicz JA, Ebb DH, Jones RM, MacDonald SM, Tarbell NJ, Yock TI, Pulsifer MB. Left hippocampal dosimetry correlates with visual and verbal memory outcomes in survivors of pediatric brain tumors. Cancer 2018; 124:2238-2245. [DOI: 10.1002/cncr.31143] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/25/2017] [Accepted: 10/17/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Andrew H. Zureick
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Casey L. Evans
- Department of Psychiatry; Massachusetts General Hospital; Boston Massachusetts
| | - Andrzej Niemierko
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Julie A. Grieco
- Department of Psychiatry; Massachusetts General Hospital; Boston Massachusetts
| | - Alexandra J. Nichols
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Barbara C. Fullerton
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Clayton B. Hess
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Claire P. Goebel
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Sara L. Gallotto
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Elizabeth A. Weyman
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Dillon E. Gaudet
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Jessica A. Nartowicz
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - David H. Ebb
- Department of Pediatrics; Massachusetts General Hospital; Boston Massachusetts
| | - Robin M. Jones
- Department of Neurology; Massachusetts General Hospital; Boston Massachusetts
| | - Shannon M. MacDonald
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Nancy J. Tarbell
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Torunn I. Yock
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
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67
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Bojaxhiu B, Ahlhelm F, Walser M, Placidi L, Kliebsch U, Mikroutsikos L, Morach P, Bolsi A, Lomax T, Pica A, Weber DC. Radiation Necrosis and White Matter Lesions in Pediatric Patients With Brain Tumors Treated With Pencil Beam Scanning Proton Therapy. Int J Radiat Oncol Biol Phys 2018; 100:987-996. [DOI: 10.1016/j.ijrobp.2017.11.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/11/2017] [Accepted: 11/24/2017] [Indexed: 12/21/2022]
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68
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Gentile MS, Yeap BY, Paganetti H, Goebel CP, Gaudet DE, Gallotto SL, Weyman EA, Morgan ML, MacDonald SM, Giantsoudi D, Adams J, Tarbell NJ, Kooy H, Yock TI. Brainstem Injury in Pediatric Patients With Posterior Fossa Tumors Treated With Proton Beam Therapy and Associated Dosimetric Factors. Int J Radiat Oncol Biol Phys 2018; 100:719-729. [DOI: 10.1016/j.ijrobp.2017.11.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 10/13/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022]
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69
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Mochizuki AY, Frost IM, Mastrodimos MB, Plant AS, Wang AC, Moore TB, Prins RM, Weiss PS, Jonas SJ. Precision Medicine in Pediatric Neurooncology: A Review. ACS Chem Neurosci 2018; 9:11-28. [PMID: 29199818 PMCID: PMC6656379 DOI: 10.1021/acschemneuro.7b00388] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Central nervous system tumors are the leading cause of cancer related death in children. Despite much progress in the field of pediatric neurooncology, modern combination treatment regimens often result in significant late effects, such as neurocognitive deficits, endocrine dysfunction, secondary malignancies, and a host of other chronic health problems. Precision medicine strategies applied to pediatric neurooncology target specific characteristics of individual patients' tumors to achieve maximal killing of neoplastic cells while minimizing unwanted adverse effects. Here, we review emerging trends and the current literature that have guided the development of new molecularly based classification schemas, promising diagnostic techniques, targeted therapies, and delivery platforms for the treatment of pediatric central nervous system tumors.
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Affiliation(s)
- Aaron Y. Mochizuki
- Department
of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Isaura M. Frost
- Department
of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Melina B. Mastrodimos
- Department
of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Ashley S. Plant
- Division
of Pediatric Oncology, Children’s Hospital of Orange County, Orange, California 92868, United States
| | - Anthony C. Wang
- Department
of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Theodore B. Moore
- Department
of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Robert M. Prins
- Department
of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
- Jonsson
Comprehensive Cancer Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
- Department
of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, California 90095, United States
| | - Paul S. Weiss
- California
NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
- Department
of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
- Department
of Materials Science and Engineering, University of California, Los Angeles, Los
Angeles, California 90095, United States
- Jonsson
Comprehensive Cancer Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Steven J. Jonas
- California
NanoSystems Institute, University of California, Los Angeles, Los Angeles, California 90095, United States
- Department
of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, United States
- Eli & Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, Los Angeles, California 90095, United States
- Children’s
Discovery and Innovation Institute, University of California, Los Angeles, Los
Angeles, California 90095, United States
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70
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Rethinking childhood ependymoma: a retrospective, multi-center analysis reveals poor long-term overall survival. J Neurooncol 2017; 135:201-211. [PMID: 28733870 PMCID: PMC5658456 DOI: 10.1007/s11060-017-2568-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/13/2017] [Indexed: 11/24/2022]
Abstract
Ependymoma is the third most common brain tumor in children, but there is a paucity of large studies with more than 10 years of follow-up examining the long-term survival and recurrence patterns of this disease. We conducted a retrospective chart review of 103 pediatric patients with WHO Grades II/III intracranial ependymoma, who were treated at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and Chicago’s Ann & Robert H. Lurie Children’s Hospital between 1985 and 2008, and an additional 360 ependymoma patients identified from the Surveillance Epidemiology and End Results (SEER) database. For the institutional cohort, we evaluated clinical and histopathological prognostic factors of overall survival (OS) and progression-free survival (PFS) using the log-rank test, and univariate and multivariate Cox proportional-hazards models. Overall survival rates were compared to those of the SEER cohort. Median follow-up time was 11 years. Ten-year OS and PFS were 50 ± 5% and 29 ± 5%, respectively. Findings were validated in the independent SEER cohort, with 10-year OS rates of 52 ± 3%. GTR and grade II pathology were associated with significantly improved OS. However, GTR was not curative for all children. Ten-year OS for patients treated with a GTR was 61 ± 7% and PFS was 36 ± 6%. Pathological examination confirmed most recurrent tumors to be ependymoma, and 74% occurred at the primary tumor site. Current treatment paradigms are not sufficient to provide long-term cure for children with ependymoma. Our findings highlight the urgent need to develop novel treatment approaches for this devastating disease.
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71
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Shen CJ, Hu C, Ladra MM, Narang AK, Pollack CE, Terezakis SA. Socioeconomic factors affect the selection of proton radiation therapy for children. Cancer 2017; 123:4048-4056. [DOI: 10.1002/cncr.30849] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 05/19/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Colette J. Shen
- Department of Radiation Oncology and Molecular Radiation Sciences; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Chen Hu
- Department of Radiation Oncology and Molecular Radiation Sciences; Johns Hopkins University School of Medicine; Baltimore Maryland
- Division of Biostatistics and Bioinformatics; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Matthew M. Ladra
- Department of Radiation Oncology and Molecular Radiation Sciences; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Amol K. Narang
- Department of Radiation Oncology and Molecular Radiation Sciences; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Craig E. Pollack
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Stephanie A. Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences; Johns Hopkins University School of Medicine; Baltimore Maryland
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72
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Mizumoto M, Oshiro Y, Yamamoto T, Kohzuki H, Sakurai H. Proton Beam Therapy for Pediatric Brain Tumor. Neurol Med Chir (Tokyo) 2017; 57:343-355. [PMID: 28603224 PMCID: PMC5566707 DOI: 10.2176/nmc.ra.2017-0003] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cancer is a major cause of childhood death, with central nervous system (CNS) neoplasms being the second most common pediatric malignancy, following hematological cancer. Treatment of pediatric CNS malignancies requires multimodal treatment using a combination of surgery, chemotherapy, and radiotherapy, and advances in these treatments have given favorable results and longer survival. However, treatment-related toxicities have also occurred, particularly for radiotherapy, after which secondary cancer, reduced function of irradiated organs, and retarded growth are significant problems. Proton beam therapy (PBT) is a particle radiotherapy with excellent dose localization that permits treatment of liver and lung cancer by administration of a high dose to the tumor while minimizing damage to surrounding normal tissues. Thus, PBT has the potential advantages for pediatric cancer. In this context, we review the current knowledge on PBT for treatment of pediatric CNS malignancies.
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Affiliation(s)
| | - Yoshiko Oshiro
- Department of Radiation Oncology, University of Tsukuba.,Department of Radiation Oncology, Tsukuba Medical Center Hospital
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73
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Abstract
OPINION STATEMENT Proton therapy is characterized by certain physical properties leading to a reduction in integral dose. As proton therapy becomes more widely available, the ongoing discussion on the real indications for proton therapy becomes more important. In the present article, data on proton therapy for tumors of the central nervous system (CNS) is summarized and discussed in view of modern photon treatments. Still today, no randomized controlled trials are available confirming any clinical benefit of protons in CNS tumors. For certain skull base lesions, such as chordomas and chondrosarcomas, dose escalation is possible with protons thus patients should be referred to a proton center if readily available. For vestibular schwannoma, at present, proton data are inferior to advanced photons. For glioma patients, early data is present for low-grade gliomas, presenting comparable results to photons; dose escalation studies for high-grade gliomas have led to significant side effects, thus strategies of dose-escalation need to rethought. For skull base meningiomas, data from stereotactic series and IMRT present excellent local control with minimal side effects, thus any improvement with protons might only be marginal. The largest benefit is considered in pediatric CNS tumors, due to the intricate radiation sensitivity of children's normal tissue, as well as the potential of long-term survivorship. Long-term data is still lacking, and even recent analyses do not all lead to a clear reduction in side effects with improvement of outcome; furthermore, clinical data seem to be comparable. However, based on the preclinical evidence, proton therapy should be evaluated in every pediatric patient. Protons most likely have a benefit in terms of reduction of long-term side effects, such as neurocognitive sequelae or secondary malignancies; moreover, dose escalation can be performed in radio-resistant histologies. Clinical data with long-term follow-up is still warranted to prove any superiority to advanced photons in CNS tumors. If available, protons should be evaluated for chordoma or chondrosarcoma of the skull base and pediatric tumors. However, many factors are important for excellent oncology care, and no time delay or inferior oncological care should be accepted for the sake of protons only.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany. .,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany.
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74
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Sato M, Gunther JR, Mahajan A, Jo E, Paulino AC, Adesina AM, Jones JY, Ketonen LM, Su JM, Okcu MF, Khatua S, Dauser RC, Whitehead WE, Weinberg J, Chintagumpala MM. Progression-free survival of children with localized ependymoma treated with intensity-modulated radiation therapy or proton-beam radiation therapy. Cancer 2017; 123:2570-2578. [PMID: 28267208 DOI: 10.1002/cncr.30623] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND The treatment for childhood intracranial ependymoma includes maximal surgical resection followed by involved-field radiotherapy, commonly in the form of intensity-modulated radiation therapy (IMRT). Proton-beam radiation therapy (PRT) is used at some centers in an effort to decrease long-term toxicity. Although protons have the theoretical advantage of a minimal exit dose to the surrounding uninvolved brain tissue, it is unknown whether they have the same efficacy as photons in preventing local recurrence. METHODS A retrospective review of medical records from September 2000 to April 2013 was performed. Seventy-nine children with newly diagnosed localized intracranial ependymomas treated with either IMRT (n = 38) or PRT (n = 41) were identified, and progression-free survival (PFS) was analyzed with Kaplan-Meier and Cox multivariate analyses. RESULTS The median age at diagnosis was 3.7 years for all patients (range, 0.4-18.7 years). There were 54 patients with infratentorial tumors (68% of the total population). Patients treated with PRT were younger (median age, 2.5 vs 5.7 years; P = .001) and had a shorter median follow-up (2.6 vs 4.9 years; P < .0001). Gross total resection (GTR) was achieved in 67 patients (85%) and was more frequent in the PRT group versus the IMRT group (93% vs 76%; P = .043). The 3-year PFS rates were 60% and 82% with IMRT and PRT, respectively (P = .031). CONCLUSIONS Children with localized ependymomas treated with PRT have a 3-year PFS rate comparable to that of children treated with IMRT. This analysis suggests that local control is not compromised by the use of PRT. The data also support GTR as the only prognostic factor for PFS. Cancer 2017;123:2570-78. © 2017 American Cancer Society.
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Affiliation(s)
- Mariko Sato
- University of Iowa Children's Hospital, Iowa City, Iowa
| | | | - Anita Mahajan
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eunji Jo
- Biostatistics and Informatics Shared Resource, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adekunle M Adesina
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Jeremy Y Jones
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Leena M Ketonen
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack M Su
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - M Fatih Okcu
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Soumen Khatua
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert C Dauser
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - William E Whitehead
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Jeffrey Weinberg
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Murali M Chintagumpala
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
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75
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Tensaouti F, Ducassou A, Chaltiel L, Bolle S, Muracciole X, Coche-Dequeant B, Alapetite C, Bernier V, Claude L, Supiot S, Huchet A, Kerr C, le Prisé E, Laprie A. Patterns of failure after radiotherapy for pediatric patients with intracranial ependymoma. Radiother Oncol 2017; 122:362-367. [DOI: 10.1016/j.radonc.2016.12.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 11/22/2016] [Accepted: 12/25/2016] [Indexed: 12/20/2022]
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76
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Chapman TR, Ermoian RP. Proton therapy for pediatric cancer: are we ready for prime time? Future Oncol 2017; 13:5-8. [DOI: 10.2217/fon-2016-0373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
| | - Ralph P Ermoian
- Radiation Oncology, University of Washington, Seattle, WA, USA
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77
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Current therapy and the evolving molecular landscape of paediatric ependymoma. Eur J Cancer 2017; 70:34-41. [DOI: 10.1016/j.ejca.2016.10.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/25/2016] [Accepted: 10/12/2016] [Indexed: 01/13/2023]
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78
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Pajtler KW, Mack SC, Ramaswamy V, Smith CA, Witt H, Smith A, Hansford JR, von Hoff K, Wright KD, Hwang E, Frappaz D, Kanemura Y, Massimino M, Faure-Conter C, Modena P, Tabori U, Warren KE, Holland EC, Ichimura K, Giangaspero F, Castel D, von Deimling A, Kool M, Dirks PB, Grundy RG, Foreman NK, Gajjar A, Korshunov A, Finlay J, Gilbertson RJ, Ellison DW, Aldape KD, Merchant TE, Bouffet E, Pfister SM, Taylor MD. The current consensus on the clinical management of intracranial ependymoma and its distinct molecular variants. Acta Neuropathol 2017; 133:5-12. [PMID: 27858204 PMCID: PMC5209402 DOI: 10.1007/s00401-016-1643-0] [Citation(s) in RCA: 232] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 11/05/2022]
Abstract
Multiple independent genomic profiling efforts have recently identified clinically and molecularly distinct subgroups of ependymoma arising from all three anatomic compartments of the central nervous system (supratentorial brain, posterior fossa, and spinal cord). These advances motivated a consensus meeting to discuss: (1) the utility of current histologic grading criteria, (2) the integration of molecular-based stratification schemes in future clinical trials for patients with ependymoma and (3) current therapy in the context of molecular subgroups. Discussion at the meeting generated a series of consensus statements and recommendations from the attendees, which comment on the prognostic evaluation and treatment decisions of patients with intracranial ependymoma (WHO Grade II/III) based on the knowledge of its molecular subgroups. The major consensus among attendees was reached that treatment decisions for ependymoma (outside of clinical trials) should not be based on grading (II vs III). Supratentorial and posterior fossa ependymomas are distinct diseases, although the impact on therapy is still evolving. Molecular subgrouping should be part of all clinical trials henceforth.
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Affiliation(s)
- Kristian W Pajtler
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology and Immunology, University Hospital Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Stephen C Mack
- Department of Stem Cell Biology and Regenerative Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Vijay Ramaswamy
- Division of Neurosurgery, Arthur & Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Christian A Smith
- Division of Neurosurgery, Arthur & Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Hendrik Witt
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Pediatric Oncology, Hematology and Immunology, University Hospital Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Amy Smith
- Arnold Palmer Hospital, Orlando, FL, USA
| | | | - Katja von Hoff
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karen D Wright
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Eugene Hwang
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - Didier Frappaz
- Pediatric Neuro-Oncology Centre Léon Bérard, Lyon, France
| | - Yonehiro Kanemura
- Department of Neurosurgery and Institute for Clinical Research, Osaka National Hospital, Osaka, Japan
| | - Maura Massimino
- Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Piergiorgio Modena
- Laboratory of Genetics, Pathology Unit, S. Anna General Hospital, Como, Italy
| | - Uri Tabori
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Katherine E Warren
- National Cancer Institute, National Institute of Health, Bethesda, MD, USA
| | - Eric C Holland
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Koichi Ichimura
- Division of Brain Tumor Translational Research, National Cancer Center Research Institute, Tokyo, Japan
| | - Felice Giangaspero
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University, Rome, Italy
| | - David Castel
- Département de Cancérologie de l'Enfant et de l'Adolescent, Gustave Roussy, Univ. Paris-Sud, Université Paris-Saclay, Villejuif, France
- UMR8203 "Vectorologie and Thérapeutiques Anticancéreuses", CNRS, Gustave Roussy, Univ. Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Andreas von Deimling
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marcel Kool
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Peter B Dirks
- Division of Neurosurgery, Arthur & Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Richard G Grundy
- Children's Brain Tumour Research Centre, The Medical School, University of Nottingham, Nottingham, UK
| | - Nicholas K Foreman
- Department of Pediatrics, University of Colorado Denver, Aurora, CO, USA
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Andrey Korshunov
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jonathan Finlay
- Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA
| | - Richard J Gilbertson
- Li Ka Shing Centre, CRUK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - David W Ellison
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Kenneth D Aldape
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Thomas E Merchant
- Department of Radiological Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Eric Bouffet
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Stefan M Pfister
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Department of Pediatric Oncology, Hematology and Immunology, University Hospital Heidelberg, Heidelberg, Germany.
- German Cancer Consortium (DKTK), Heidelberg, Germany.
| | - Michael D Taylor
- Division of Neurosurgery, Arthur & Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada.
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Frappaz D, Vasiljevic A, Beuriat PA, Alapetite C, Grill J, Szathmari A, Faure-Conter C. [Pediatric ependymomas: Current diagnosis and therapy]. Bull Cancer 2016; 103:869-879. [PMID: 27717499 DOI: 10.1016/j.bulcan.2016.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/10/2016] [Accepted: 08/30/2016] [Indexed: 11/15/2022]
Abstract
Ependymomas represent 10% of pediatric brain tumors. In the recent WHO 2016 classification, pathology is enriched by localization and molecular biology. Whatever the age, total removal by one or several looks when required remains a major prognostic factor. In children, focal radiation remains a standard, while the role of chemotherapy is matter of randomized studies. In infants, front line chemotherapy is the standard. Inclusion in the SIOP ependymoma II protocol is encouraged. In case of relapse, further surgery and radiation are advised, while inclusion in innovative trials including re-irradiation, and phase I-II should be encouraged. A better understanding of underlying mechanisms of ependymoma cell will provide in the close future, the key to use targeted therapies at time of relapse, and very soon as first line therapy for some subgroups of patients.
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Affiliation(s)
- Didier Frappaz
- Centre Léon-Bérard, institut d'hématologie et oncologie pédiatrique, département de neuro-oncologie, place Professeur-Joseph-Renaut, 69008 Lyon, France.
| | - Alexandre Vasiljevic
- Hospices civils de Lyon, département d'anatomopathologie, 59, boulevard Pinel, 69677 Bron cedex, France
| | - Pierre-Aurelien Beuriat
- Hospices civils de Lyon, département de neurochirurgie pédiatrique, 59, boulevard Pinel, 69677 Bron cedex, France
| | - Claire Alapetite
- Institut Curie, département de radiothérapie, 26, rue d'Ulm, 75005 Paris, France
| | - Jacques Grill
- Département de pédiatrie, Gustave Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Alexandru Szathmari
- Hospices civils de Lyon, département de neurochirurgie pédiatrique, 59, boulevard Pinel, 69677 Bron cedex, France
| | - Cécile Faure-Conter
- Centre Léon-Bérard, institut d'hématologie et oncologie pédiatrique, département de neuro-oncologie, place Professeur-Joseph-Renaut, 69008 Lyon, France
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80
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Giantsoudi D, Adams J, MacDonald SM, Paganetti H. Proton Treatment Techniques for Posterior Fossa Tumors: Consequences for Linear Energy Transfer and Dose-Volume Parameters for the Brainstem and Organs at Risk. Int J Radiat Oncol Biol Phys 2016; 97:401-410. [PMID: 27986346 DOI: 10.1016/j.ijrobp.2016.09.042] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 09/01/2016] [Accepted: 09/27/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE In proton therapy of posterior fossa tumors, at least partial inclusion of the brainstem in the target is necessary because of its proximity to the tumor and required margins. Additionally, the preferred beam geometry results in directing the field distal edge toward this critical structure, raising concerns for brainstem toxicity. Some treatment techniques place the beam's distal edge within the brainstem (dose-sparing techniques), and others avoid elevated linear energy transfer (LET) of the proton field by placing the distal edge beyond it (LET-sparing techniques). Hybrid approaches are also being used. We examine the dosimetric efficacy of these techniques, accounting for LET-dependent and dose-dependent variable relative biologic effectiveness (RBE) distributions. METHODS Six techniques were applied in ependymoma cases: (a) 3-field dose-sparing; (b) 3-field LET-sparing; (c) 2-field dose-sparing, wide angles; (d) 2-field LET-sparing, wide angles; (e) 2-field LET-sparing, steep angles; and (f) 2-field LET-sparing with feathered distal end. Monte Carlo calculated dose, LET, and RBE-weighted dose distributions were compared. RESULTS Decreased LET values in the brainstem by LET-sparing techniques were accompanied by higher, not statistically significant, median dose: 53.6 Gy(RBE), 53.4 Gy(RBE), and 54.3 Gy(RBE) for techniques (b), (d), and (e) versus 52.1 Gy(RBE) for technique (a). Accounting for variable RBE distributions, the brainstem volume receiving at least 55 Gy(RBE) increased from 72.5% for technique (a) to 80.3% for (b) (P<.01) and from 70.7% for technique (c) to 77.6% for (d) (P<.01). Less than 2%, but statistically significant, decrease in maximum variable RBE-weighted brainstem dose was observed for the LET-sparing techniques compared with the corresponding dose-sparing (P=.03 and .004). CONCLUSIONS Extending the proton range beyond the brainstem to reduce LET results in clinically comparable maximum radiobiologic effective dose to this sensitive structure. However this method significantly increasing the brainstem volume receiving RBE-weighted dose higher than 55 Gy(RBE) with possible consequences based on known dose-volume parameters for increased toxicity.
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Affiliation(s)
- Drosoula Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Judith Adams
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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81
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Sherman JC, Colvin MK, Mancuso SM, Batchelor TT, Oh KS, Loeffler JS, Yeap BY, Shih HA. Neurocognitive effects of proton radiation therapy in adults with low-grade glioma. J Neurooncol 2016; 126:157-164. [PMID: 26498439 DOI: 10.1007/s11060-015-1952-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/05/2015] [Indexed: 11/25/2022]
Abstract
To understand neurocognitive effects of proton radiation therapy (PRT) in patients with low-grade glioma, we evaluated 20 patients who received this therapy prospectively and over 5 years with a comprehensive neuropsychological battery. 20 patients were evaluated at baseline and at yearly intervals for up to 5 years with a battery of neuropsychological measures that assessed intellectual, attention, executive, visuospatial and memory functions as well as mood and functional status. We evaluated change in cognitive functioning over time. We analyzed the relationship between cognitive performance and tumor location and also examined whether patients' performance differed from that reported in a study of normative practice effects. Overall, patients exhibited stability in cognitive functioning. Tumor location played a role in performance; those with tumors in the left hemisphere versus in the right hemisphere were more impaired at baseline on verbal measures (p < .05). However, we found greater improvement in verbal memory over time in patients with left than with right hemisphere tumors (p < .05). Results of our study, the first to investigate, in depth, neurocognitive effects of PRT in adults with low-grade gliomas, are promising. We hypothesize that the conformal advantage of PRT may contribute to preservation of cognitive functioning, although larger sample sizes and a longer period of study are required. Our study also highlights the need to consider normative practice effects when studying neurocognitive functioning in response to treatment over time, and the need to utilize comprehensive neuropsychological batteries given our findings that differentiate patients with left and right hemisphere tumors.
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Affiliation(s)
- Janet Cohen Sherman
- Department of Psychiatry and Neurology, Psychology Assessment Center, Massachusetts General Hospital, 1 Bowdoin Square, 7th Floor, Boston, MA, 02114, USA.
| | - Mary K Colvin
- Department of Psychiatry, Psychology Assessment Center, Massachusetts General Hospital, 1 Bowdoin Square, 7th Floor, Boston, MA, 02114, USA
| | - Sarah M Mancuso
- Department of Psychiatry, Psychology Assessment Center, Massachusetts General Hospital, 1 Bowdoin Square, 7th Floor, Boston, MA, 02114, USA
| | - Tracy T Batchelor
- Department of Neurology, Massachusetts General Hospital, 30 Fruit Street, Boston, MA, 02114, USA
| | - Kevin S Oh
- Department of Radiation Oncology, Massachusetts General Hospital, 30 Fruit Street, Boston, MA, 02114, USA
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, 30 Fruit Street, Boston, MA, 02114, USA
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, 30 Fruit Street, Boston, MA, 02114, USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, 30 Fruit Street, Boston, MA, 02114, USA
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82
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Main C, Dandapani M, Pritchard M, Dodds R, Stevens SP, Thorp N, Taylor RE, Wheatley K, Pizer B, Morrall M, Phillips R, English M, Kearns PR, Wilne S, Wilson JS. The effectiveness and safety of proton beam radiation therapy in children with malignant central nervous system (CNS) tumours: protocol for a systematic review. Syst Rev 2016; 5:124. [PMID: 27460473 PMCID: PMC4962509 DOI: 10.1186/s13643-016-0285-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 06/21/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this study is to use a systematic review framework to identify and synthesise the evidence on the use of proton beam therapy (PBT) for the treatment of children with CNS tumours and where possible compare this to the use of photon radiotherapy (RT). METHODS Standard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. Twelve electronic databases have been searched, and further citation, hand searching and reference checking will be employed. Studies assessing the effects of PBT used either alone or as part of a multimodality treatment regimen in children with CNS tumours will be included. Relevant economic evaluations will also be identified. The outcomes are survival (overall, progression-free, event-free, disease-free), local and regional control rates, short- and long-term adverse events, functional status measures and quality of survival. Two reviewers will independently screen and select studies for inclusion in the review. All interventional study designs will be eligible for inclusion in the review. However, initial scoping searches indicate the evidence base is likely to be limited to case series studies, with no studies of a higher quality being identified. Quality assessment will be undertaken using pre-specified criteria and tailored to study design if applicable. Studies will be combined using a narrative synthesis, with differences in results between studies highlighted and discussed in relation to the patient population, intervention and study quality. Where appropriate, if no studies of a comparative design are identified, outcomes will be compared against a range of estimates from the literature for similar populations and treatment regimens from the best available evidence from studies that include the use of advanced conventional photon therapy. DISCUSSION The evidence base for the use of PBT in children with CNS tumours is likely to be relatively sparse, highly heterogeneous and potentially of a low quality with small sample sizes. Furthermore, selection and publication biases may limit the internal and external validity of studies. However, any tentative results from the review on potential treatment effects can be used to plan better quality research studies that are of a design appropriate for outcome comparison with conventional therapy. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015029583.
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Affiliation(s)
- Caroline Main
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Science, University of Birmingham, Birmingham, UK
| | | | | | | | - Simon P. Stevens
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Science, University of Birmingham, Birmingham, UK
| | - Nicky Thorp
- The Clatterbridge Cancer Centre, Liverpool, UK
| | | | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Science, University of Birmingham, Birmingham, UK
| | - Barry Pizer
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | | | - Robert Phillips
- Leeds General Infirmary, Leeds, UK
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Martin English
- Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Pamela R. Kearns
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Science, University of Birmingham, Birmingham, UK
- Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Sophie Wilne
- Queen’s Medical Centre, Nottingham University Hospitals’ NHS Trust, Nottingham, UK
| | - Jayne S. Wilson
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Science, University of Birmingham, Birmingham, UK
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83
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Proton therapy for paediatric CNS tumours — improving treatment-related outcomes. Nat Rev Neurol 2016; 12:334-45. [DOI: 10.1038/nrneurol.2016.70] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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84
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Mizumoto M, Murayama S, Akimoto T, Demizu Y, Fukushima T, Ishida Y, Oshiro Y, Numajiri H, Fuji H, Okumura T, Shirato H, Sakurai H. Proton beam therapy for pediatric malignancies: a retrospective observational multicenter study in Japan. Cancer Med 2016; 5:1519-25. [PMID: 27165972 PMCID: PMC4867672 DOI: 10.1002/cam4.743] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/18/2016] [Accepted: 03/29/2016] [Indexed: 12/19/2022] Open
Abstract
Recent progress in the treatment for pediatric malignancies using a combination of surgery, chemotherapy, and radiotherapy has improved survival. However, late toxicities of radiotherapy are a concern in long‐term survivors. A recent study suggested reduced secondary cancer and other late toxicities after proton beam therapy (PBT) due to dosimetric advantages. In this study, we evaluated the safety and efficacy of PBT for pediatric patients treated in Japan. A retrospective observational study in pediatric patients who received PBT was performed. All patients aged <20 years old who underwent PBT from January 1983 to August 2014 at four sites in Japan were enrolled in the study. There were 343 patients in the study. The median follow‐up periods were 22.6 months (0.4–374.3 months) for all patients and 30.6 months (0.6–374.3 months) for survivors. The estimated 1‐, 3‐, 5‐, and 10‐year survival rates were 82.7% (95% CI: 78.5–87.0%), 67.4% (61.7–73.2%), 61.4% (54.8–67.9%), and 58.7% (51.5–65.9%), respectively. Fifty‐two events of toxicity ≥ grade 2 occurred in 43 patients. Grade 4 toxicities of myelitis, visual loss (two cases), cerebral vascular disease, and tissue necrosis occurred in five patients. This study provides preliminary results for PBT in pediatric patients in Japan. More experience and follow‐up with this technique are required to establish the efficacy of PBT in this patient population.
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Affiliation(s)
- Masashi Mizumoto
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shigeyuki Murayama
- Division of Proton Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Yusuke Demizu
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Takashi Fukushima
- Department of Child Health, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuji Ishida
- Division of Pediatrics, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Yoshiko Oshiro
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruko Numajiri
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroshi Fuji
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Toshiyuki Okumura
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroki Shirato
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
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85
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Proton Therapy in Children: A Systematic Review of Clinical Effectiveness in 15 Pediatric Cancers. Int J Radiat Oncol Biol Phys 2016; 95:267-278. [DOI: 10.1016/j.ijrobp.2015.10.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 10/05/2015] [Accepted: 10/13/2015] [Indexed: 12/31/2022]
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86
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Pencil beam scanning proton therapy for pediatric intracranial ependymoma. J Neurooncol 2016; 128:137-145. [DOI: 10.1007/s11060-016-2090-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 02/25/2016] [Indexed: 10/22/2022]
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87
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Bindra RS, Wolden SL. Advances in Radiation Therapy in Pediatric Neuro-oncology. J Child Neurol 2016; 31:506-16. [PMID: 26271789 DOI: 10.1177/0883073815597758] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 06/29/2015] [Indexed: 01/04/2023]
Abstract
Radiation therapy remains a highly effective therapy for many pediatric central nervous system tumors. With more children achieving long-term survival after treatment for brain tumors, late-effects of radiation have become an important concern. In response to this problem, treatment protocols for a variety of pediatric central nervous system tumors have evolved to reduce radiation fields and doses when possible. Recent advances in radiation technology such as image guidance and proton therapy have led to a new era of precision treatment with significantly less exposure to healthy tissues. These developments along with the promise of molecular classification of tumors and targeted therapies point to an optimistic future for pediatric neuro-oncology.
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Affiliation(s)
- Ranjit S Bindra
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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88
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Sands SA. Proton Beam Radiation Therapy: The Future May Prove Brighter for Pediatric Patients With Brain Tumors. J Clin Oncol 2016; 34:1024-6. [PMID: 26811526 DOI: 10.1200/jco.2015.65.4350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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89
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Kahalley LS, Ris MD, Grosshans DR, Okcu MF, Paulino AC, Chintagumpala M, Moore BD, Guffey D, Minard CG, Stancel HH, Mahajan A. Comparing Intelligence Quotient Change After Treatment With Proton Versus Photon Radiation Therapy for Pediatric Brain Tumors. J Clin Oncol 2016; 34:1043-9. [PMID: 26811522 DOI: 10.1200/jco.2015.62.1383] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Compared with photon radiation (XRT), proton beam radiation therapy (PBRT) reduces dose to normal tissues, which may lead to better neurocognitive outcomes. We compared change in intelligence quotient (IQ) over time in pediatric patients with brain tumors treated with PBRT versus XRT. PATIENTS AND METHODS IQ scores were available for 150 patients (60 had received XRT, 90 had received PBRT). Linear mixed models examined change in IQ over time since radiation therapy (RT) by RT group, controlling for demographic/clinical characteristics. Craniospinal and focal RT subgroups were also examined. RESULTS In the PBRT group, no change in IQ over time was identified (P = .130), whereas in the XRT group, IQ declined by 1.1 points per year (P = .004). IQ slopes did not differ between groups (P = .509). IQ was lower in the XRT group (by 8.7 points) versus the PBRT group (P = .011). In the craniospinal subgroup, IQ remained stable in both the PBRT (P = .203) and XRT groups (P = .060), and IQ slopes did not differ (P = .890). IQ was lower in the XRT group (by 12.5 points) versus the PBRT group (P = .004). In the focal subgroup, IQ scores remained stable in the PBRT group (P = .401) but declined significantly in the XRT group by 1.57 points per year (P = .026). IQ slopes did not differ between groups (P = .342). CONCLUSION PBRT was not associated with IQ decline or impairment, yet IQ slopes did not differ between the PBRT and XRT groups. It remains unclear if PBRT results in clinically meaningful cognitive sparing that significantly exceeds that of modern XRT protocols. Additional long-term data are needed to fully understand the neurocognitive impact of PBRT in survivors of pediatric brain tumors.
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Affiliation(s)
- Lisa S Kahalley
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - M Douglas Ris
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David R Grosshans
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Fatih Okcu
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Arnold C Paulino
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Murali Chintagumpala
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bartlett D Moore
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Danielle Guffey
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles G Minard
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Heather H Stancel
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anita Mahajan
- Lisa S. Kahalley, M. Douglas Ris, M. Fatih Okcu, Murali Chintagumpala, Danielle Guffey, Charles G. Minard, and Heather H. Stancel, Baylor College of Medicine, Houston; and David R. Grosshans, Arnold C. Paulino, Bartlett D. Moore, and Anita Mahajan, The University of Texas MD Anderson Cancer Center, Houston, TX
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Eaton BR, MacDonald SM, Yock TI, Tarbell NJ. Secondary Malignancy Risk Following Proton Radiation Therapy. Front Oncol 2015; 5:261. [PMID: 26636040 PMCID: PMC4659915 DOI: 10.3389/fonc.2015.00261] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/09/2015] [Indexed: 01/17/2023] Open
Abstract
Radiation-induced secondary malignancies are a significant, yet uncommon cause of morbidity and mortality among cancer survivors. Secondary malignancy risk is dependent upon multiple factors including patient age, the biological and genetic predisposition of the individual, the volume and location of tissue irradiated, and the dose of radiation received. Proton therapy (PRT) is an advanced particle therapy with unique dosimetric properties resulting in reduced entrance dose and minimal to no exit dose when compared with standard photon radiation therapy. Multiple dosimetric studies in varying cancer subtypes have demonstrated that PRT enables the delivery of adequate target volume coverage with reduced integral dose delivered to surrounding tissues, and modeling studies taking into account dosimetry and radiation cell biology have estimated a significantly reduced risk of radiation-induced secondary malignancy with PRT. Clinical data are emerging supporting the lower incidence of secondary malignancies after PRT compared with historical photon data, though longer follow-up in proton treated cohorts is awaited. This article reviews the current dosimetric and clinical literature evaluating the incidence of and risk factors associated with radiation-induced secondary malignancy following PRT.
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Affiliation(s)
- Bree R Eaton
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
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Laprie A, Hu Y, Alapetite C, Carrie C, Habrand JL, Bolle S, Bondiau PY, Ducassou A, Huchet A, Bertozzi AI, Perel Y, Moyal É, Balosso J. Paediatric brain tumours: A review of radiotherapy, state of the art and challenges for the future regarding protontherapy and carbontherapy. Cancer Radiother 2015; 19:775-89. [PMID: 26548600 DOI: 10.1016/j.canrad.2015.05.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/18/2015] [Accepted: 05/21/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Brain tumours are the most frequent solid tumours in children and the most frequent radiotherapy indications in paediatrics, with frequent late effects: cognitive, osseous, visual, auditory and hormonal. A better protection of healthy tissues by improved beam ballistics, with particle therapy, is expected to decrease significantly late effects without decreasing local control and survival. This article reviews the scientific literature to advocate indications of protontherapy and carbon ion therapy for childhood central nervous system cancer, and estimate the expected therapeutic benefits. MATERIALS AND METHODS A systematic review was performed on paediatric brain tumour treatments using Medline (from 1966 to March of 2014). To be included, clinical trials had to meet the following criteria: age of patients 18 years or younger, treated with radiation, and report of survival. Studies were also selected according to the evidence level. A secondary search of cited references found other studies about cognitive functions, quality of life, the comparison of photon and proton dosimetry showing potential dose escalation and/or sparing of organs at risk with protontherapy; and studies on dosimetric and technical issues related to protontherapy. RESULTS A total of 7051 primary references published were retrieved, among which 40 clinical studies and 60 papers about quality of life, dose distribution and dosimetry were analysed, as well as the ongoing clinical trials. These papers have been summarized and reported in a specific document made available to the participants of a final 1-day workshop. Tumours of the meningeal envelop and bony cranial structures were excluded from the analysis. Protontherapy allows outstanding ballistics to target the tumour area, while substantially decreasing radiation dose to the normal tissues. There are many indications of protontherapy for paediatric brain tumours in curative intent, either for localized treatment of ependymomas, germ-cell tumours, craniopharyngiomas, low-grade gliomas; or panventricular irradiation of pure non-secreting germinoma; or craniospinal irradiation of medulloblastomas and metastatic pure germinomas. Carbon ion therapy is just emerging and may be studied for highly aggressive and radioresistant tumours, as an initial treatment for diffuse brainstem gliomas, and for relapse of high-grade gliomas. CONCLUSION Both protontherapy and carbon ion therapy are promising for paediatric brain tumours. The benefit of decreasing late effects without altering survival has been described for most paediatric brain tumours with protontherapy and is currently assessed in ongoing clinical trials with up-to-date proton devices. Unfortunately, in 2015, only a minority of paediatric patients in France can receive protontherapy due to the lack of equipment.
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Affiliation(s)
- A Laprie
- Université Paul-Sabatier, Toulouse, France; Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France.
| | - Y Hu
- GCS-Étoile-France-Hadron, Lyon, France
| | - C Alapetite
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France
| | - C Carrie
- GCS-Étoile-France-Hadron, Lyon, France; Centre Léon-Bérard, Lyon, France
| | - J-L Habrand
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France; Université Paris Sud, Orsay, France; Archade-France-Hadron, Caen, France; Centre François-Baclesse, Caen, France; Gustave-Roussy, Villejuif, France
| | - S Bolle
- Institut Curie Paris Orsay (ICPO)-France-Hadron, Orsay, France; Impact-France-Hadron, Nice, France
| | - P-Y Bondiau
- Centre Antoine-Lacassagne, Nice, France; CHU de Bordeaux, Bordeaux, France
| | - A Ducassou
- Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France
| | - A Huchet
- Hôpital des Enfants, Toulouse, France
| | - A-I Bertozzi
- Périclès-France-Hadron, Toulouse, France; Université Grenoble Alpes, Grenoble, France
| | - Y Perel
- Université Grenoble Alpes, Grenoble, France
| | - É Moyal
- Université Paul-Sabatier, Toulouse, France; Institut Claudius-Regaud, institut universitaire du cancer de Toulouse (IUCT)-Oncopole, radiation oncology, 1, avenue Irene-Joliot-Curie, 31059 Toulouse, France; Périclès-France-Hadron, Toulouse, France
| | - J Balosso
- GCS-Étoile-France-Hadron, Lyon, France; CHU de Grenoble, Grenoble, France
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92
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Giantsoudi D, Sethi RV, Yeap BY, Eaton BR, Ebb DH, Caruso PA, Rapalino O, Chen YLE, Adams JA, Yock TI, Tarbell NJ, Paganetti H, MacDonald SM. Incidence of CNS Injury for a Cohort of 111 Patients Treated With Proton Therapy for Medulloblastoma: LET and RBE Associations for Areas of Injury. Int J Radiat Oncol Biol Phys 2015; 95:287-296. [PMID: 26691786 DOI: 10.1016/j.ijrobp.2015.09.015] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 09/03/2015] [Accepted: 09/11/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Central nervous system (CNS) injury is a rare complication of radiation therapy for pediatric brain tumors, but its incidence with proton radiation therapy (PRT) is less well defined. Increased linear energy transfer (LET) and relative biological effectiveness (RBE) at the distal end of proton beams may influence this risk. We report the incidence of CNS injury in medulloblastoma patients treated with PRT and investigate correlations with LET and RBE values. METHODS AND MATERIALS We reviewed 111 consecutive patients treated with PRT for medulloblastoma between 2002 and 2011 and selected patients with clinical symptoms of CNS injury. Magnetic resonance imaging (MRI) findings for all patients were contoured on original planning scans (treatment change areas [TCA]). Dose and LET distributions were calculated for the treated plans using Monte Carlo system. RBE values were estimated based on LET-based published models. RESULTS At a median follow-up of 4.2 years, the 5-year cumulative incidence of CNS injury was 3.6% for any grade and 2.7% for grade 3+. Three of 4 symptomatic patients were treated with a whole posterior fossa boost. Eight of 10 defined TCAs had higher LET values than the target but statistically nonsignificant differences in RBE values (P=.12). CONCLUSIONS Central nervous system and brainstem injury incidence for PRT in this series is similar to that reported for photon radiation therapy. The risk of CNS injury was higher for whole posterior fossa boost than for involved field. Although no clear correlation with RBE values was found, numbers were small and additional investigation is warranted to better determine the relationship between injury and LET.
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Affiliation(s)
- Drosoula Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Roshan V Sethi
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Bree R Eaton
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - David H Ebb
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul A Caruso
- Department of Radiology (O.R.) at the Massachusetts General Hospital, Boston, Massachusetts
| | - Otto Rapalino
- Department of Radiology (O.R.) at the Massachusetts General Hospital, Boston, Massachusetts
| | - Yen-Lin E Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Judith A Adams
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
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93
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Eaton BR, Chowdhry V, Weaver K, Liu L, Ebb D, MacDonald SM, Tarbell NJ, Yock TI. Use of proton therapy for re-irradiation in pediatric intracranial ependymoma. Radiother Oncol 2015; 116:301-8. [DOI: 10.1016/j.radonc.2015.07.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 07/06/2015] [Accepted: 07/16/2015] [Indexed: 10/23/2022]
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Abstract
Radiation therapy (RT) plays a critical role in the local tumor control of benign and low-grade central nervous system tumors in children but is not without the risk of long-term treatment-related sequelae. Proton therapy (PRT) is an advanced RT modality with a unique dose-deposition pattern that allows for treatment of a target volume with reduced scatter dose delivered to normal tissues compared with conventional photon RT and is now increasingly utilized in children with the hope of mitigating radiation-induced late effects. This article reviews the current literature evaluating the use of PRT in benign and low-grade pediatric central nervous system tumors such as low-grade glioma, craniopharyngioma, and ependymoma. Multiple dosimetric studies support the use of PRT by demonstrating the ability of PRT to better spare critical structures important for cognitive development, endocrine function, and hearing preservation and to reduce the total body dose associated with second malignancy risk. Early clinical data demonstrate that PRT is well tolerated with rates of local tumor control comparable to conventional photon RT series, and long-term clinical data are awaited.
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95
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Pulsifer MB, Sethi RV, Kuhlthau KA, MacDonald SM, Tarbell NJ, Yock TI. Early Cognitive Outcomes Following Proton Radiation in Pediatric Patients With Brain and Central Nervous System Tumors. Int J Radiat Oncol Biol Phys 2015; 93:400-7. [PMID: 26254679 DOI: 10.1016/j.ijrobp.2015.06.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/07/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To report, from a longitudinal study, cognitive outcome in pediatric patients treated with proton radiation therapy (PRT) for central nervous system (CNS) tumors. METHODS AND MATERIALS Sixty patients receiving PRT for medulloblastoma (38.3%), gliomas (18.3%), craniopharyngioma (15.0%), ependymoma (11.7%), and other CNS tumors (16.7%) were administered age-appropriate measures of cognitive abilities at or near PRT initiation (baseline) and afterward (follow-up). Patients were aged ≥ 6 years at baseline to ensure consistency in neurocognitive measures. RESULTS Mean age was 12.3 years at baseline; mean follow-up interval was 2.5 years. Treatment included prior surgical resection (76.7%) and chemotherapy (61.7%). Proton radiation therapy included craniospinal irradiation (46.7%) and partial brain radiation (53.3%). At baseline, mean Wechsler Full Scale IQ was 104.6; means of all 4 Index scores were also in the average range. At follow-up, no significant change was observed in mean Wechsler Full Scale IQ, Verbal Comprehension, Perceptual Reasoning/Organization, or Working Memory. However, Processing Speed scores declined significantly (mean 5.2 points), with a significantly greater decline for subjects aged <12 years at baseline and those with the highest baseline scores. Cognitive outcome was not significantly related to gender, extent of radiation, radiation dose, tumor location, histology, socioeconomic status, chemotherapy, or history of surgical resection. CONCLUSIONS Early cognitive outcomes after PRT for pediatric CNS tumors are encouraging, compared with published outcomes from photon radiation therapy.
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Affiliation(s)
- Margaret B Pulsifer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.
| | - Roshan V Sethi
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen A Kuhlthau
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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96
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Imaging Changes in Pediatric Intracranial Ependymoma Patients Treated With Proton Beam Radiation Therapy Compared to Intensity Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2015; 93:54-63. [PMID: 26279024 DOI: 10.1016/j.ijrobp.2015.05.018] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 04/17/2015] [Accepted: 05/12/2015] [Indexed: 11/22/2022]
Abstract
PURPOSE The clinical significance of magnetic resonance imaging (MRI) changes after radiation therapy (RT) in children with ependymoma is not well defined. We compared imaging changes following proton beam radiation therapy (PBRT) to those after photon-based intensity modulated RT (IMRT). METHODS AND MATERIALS Seventy-two patients with nonmetastatic intracranial ependymoma who received postoperative RT (37 PBRT, 35 IMRT) were analyzed retrospectively. MRI images were reviewed by 2 neuroradiologists. RESULTS Sixteen PBRT patients (43%) developed postradiation MRI changes at 3.8 months (median) with resolution by 6.1 months. Six IMRT patients (17%) developed changes at 5.3 months (median) with 8.3 months to resolution. Mean age at radiation was 4.4 and 6.9 years for PBRT and IMRT, respectively (P = .06). Age at diagnosis (>3 years) and time of radiation (≥3 years) was associated with fewer imaging changes on univariate analysis (odds ratio [OR]: 0.35, P = .048; OR: 0.36, P = .05). PBRT (compared to IMRT) was associated with more frequent imaging changes, both on univariate (OR: 3.68, P = .019) and multivariate (OR: 3.89, P = .024) analyses. Seven (3 IMRT, 4 PBRT) of 22 patients with changes had symptoms requiring intervention. Most patients were treated with steroids; some PBRT patients also received bevacizumab and hyperbaric oxygen therapy. None of the IMRT patients had lasting deficits, but 2 patients died from recurrent disease. Three PBRT patients had persistent neurological deficits, and 1 child died secondarily to complications from radiation necrosis. CONCLUSIONS Postradiation MRI changes are more common with PBRT and in patients less than 3 years of age at diagnosis and treatment. It is difficult to predict causes for development of imaging changes that progress to clinical significance. These changes are usually self-limiting, but some require medical intervention, especially those involving the brainstem.
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97
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Ladra MM, Mandeville HC, Niemierko A, Padera TP, Friedmann AM, MacDonald SM, Ebb D, Chen YL, Tarbell NJ, Yock TI. Local failure in parameningeal rhabdomyosarcoma correlates with poor response to induction chemotherapy. Int J Radiat Oncol Biol Phys 2015; 92:358-67. [PMID: 25864172 DOI: 10.1016/j.ijrobp.2015.01.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/03/2015] [Accepted: 01/30/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Local control remains a challenge in pediatric parameningeal rhabdomyosarcoma (PM-RMS), and survival after local failure (LF) is poor. Identifying patients with a high risk of LF is of great interest to clinicians. In this study, we examined whether tumor response to induction chemotherapy (CT) could predict LF in embryonal PM-RMS. METHODS We identified 24 patients with embryonal PM-RMS, age 2 to 18 years, with complete magnetic resonance imaging and gross residual disease after surgical resection. All patients received proton radiation therapy (RT), median dose 50.4 GyRBE (50.4-55.8 GyRBE). Tumor size was measured before initial CT and before RT. RESULTS With a median follow-up time of 4.1 years for survivors, LF was seen in 9 patients (37.5%). The median time from the initiation of CT to the start of RT was 4.8 weeks. Patients with LF had a similar initial (pre-CT) tumor volume compared with patients with local controlled (LC) (54 cm(3) vs 43 cm(3), P=.9) but a greater median volume before RT (pre-RT) (40 cm(3) vs 7 cm(3), P=.009) and a smaller median relative percent volume reduction (RPVR) in tumor size (0.4% vs 78%, P<.001). Older age (P=.05), larger pre-RT tumor volume (P=.03), and smaller RPVR (P=.003) were significantly associated with actuarial LF on univariate Cox analysis. CONCLUSIONS Poor response to induction CT appears to be associated with an increased risk of LF in pediatric embryonal PM-RMS.
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Affiliation(s)
- Matthew M Ladra
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Andrzej Niemierko
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy P Padera
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alison M Friedmann
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Ebb
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yen-Lin Chen
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy J Tarbell
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Torunn I Yock
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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98
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Hill-Kayser C, Kirk M. Brainstem-sparing craniospinal irradiation delivered with pencil beam scanning proton therapy. Pediatr Blood Cancer 2015; 62:718-20. [PMID: 25557901 DOI: 10.1002/pbc.25378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/06/2014] [Indexed: 11/05/2022]
Abstract
Delivery of craniospinal irradiation (CSI) is a curative approach to recurrent ependymoma, but is associated with risks from re-irradiation, particularly of the brainstem. Pencil beam scanning proton therapy allows delivery of CSI with sparing of normal tissues. Here, we describe a case of brainstem-sparing CSI that resulted in excellent coverage of the craniospinal axis with minimal radiation to brainstem. This is a novel concept that compares favorably to previously described methods using x-rays that may result in underdosing of surrounding tissues in effort to spare brainstem.
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Affiliation(s)
- Christine Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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99
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Jones B. Towards Achieving the Full Clinical Potential of Proton Therapy by Inclusion of LET and RBE Models. Cancers (Basel) 2015; 7:460-80. [PMID: 25790470 PMCID: PMC4381269 DOI: 10.3390/cancers7010460] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/19/2015] [Accepted: 03/06/2015] [Indexed: 12/13/2022] Open
Abstract
Despite increasing use of proton therapy (PBT), several systematic literature reviews show limited gains in clinical outcomes, with publications mostly devoted to recent technical developments. The lack of randomised control studies has also hampered progress in the acceptance of PBT by many oncologists and policy makers. There remain two important uncertainties associated with PBT, namely: (1) accuracy and reproducibility of Bragg peak position (BPP); and (2) imprecise knowledge of the relative biological effect (RBE) for different tissues and tumours, and at different doses. Incorrect BPP will change dose, linear energy transfer (LET) and RBE, with risks of reduced tumour control and enhanced toxicity. These interrelationships are discussed qualitatively with respect to the ICRU target volume definitions. The internationally accepted proton RBE of 1.1 was based on assays and dose ranges unlikely to reveal the complete range of RBE in the human body. RBE values are not known for human (or animal) brain, spine, kidney, liver, intestine, etc. A simple efficiency model for estimating proton RBE values is described, based on data of Belli et al. and other authors, which allows linear increases in α and β with LET, with a gradient estimated using a saturation model from the low LET α and β radiosensitivity parameter input values, and decreasing RBE with increasing dose. To improve outcomes, 3-D dose-LET-RBE and bio-effectiveness maps are required. Validation experiments are indicated in relevant tissues. Randomised clinical studies that test the invariant 1.1 RBE allocation against higher values in late reacting tissues, and lower tumour RBE values in the case of radiosensitive tumours, are also indicated.
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Affiliation(s)
- Bleddyn Jones
- Gray Laboratory, CRUK/MRC Oxford Oncology Institute, The University of Oxford, ORCRB-Roosevelt Drive, Oxford OX3 7DQ, UK.
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100
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Patel S, Kostaras X, Parliament M, Olivotto IA, Nordal R, Aronyk K, Hagen N. Recommendations for the referral of patients for proton-beam therapy, an Alberta Health Services report: a model for Canada? ACTA ACUST UNITED AC 2014; 21:251-62. [PMID: 25302033 DOI: 10.3747/co.21.2207] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Compared with photon therapy, proton-beam therapy (pbt) offers compelling advantages in physical dose distribution. Worldwide, gantry-based proton facilities are increasing in number, but no such facilities exist in Canada. To access pbt, Canadian patients must travel abroad for treatment at high cost. In the face of limited access, this report seeks to provide recommendations for the selection of patients most likely to benefit from pbt and suggests an out-of-country referral process. METHODS The medline, embase, PubMed, and Cochrane databases were systematically searched for studies published between January 1990 and May 2014 that evaluated clinical outcomes after pbt. A draft report developed through a review of evidence was externally reviewed and then approved by the Alberta Health Services Cancer Care Proton Therapy Guidelines steering committee. RESULTS Proton therapy is often used to treat tumours close to radiosensitive tissues and to treat children at risk of developing significant late effects of radiation therapy (rt). In uncontrolled and retrospective studies, local control rates with pbt appear similar to, or in some cases higher than, photon rt. Randomized trials comparing equivalent doses of pbt and photon rt are not available. SUMMARY Referral for pbt is recommended for patients who are being treated with curative intent and with an expectation for long-term survival, and who are able and willing to travel abroad to a proton facility. Commonly accepted indications for referral include chordoma and chondrosarcoma, intraocular melanoma, and solid tumours in children and adolescents who have the greatest risk for long-term sequelae. Current data do not provide sufficient evidence to recommend routine referral of patients with most head-and-neck, breast, lung, gastrointestinal tract, and pelvic cancers, including prostate cancer. It is recommended that all referrals be considered by a multidisciplinary team to select appropriate cases.
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Affiliation(s)
- S Patel
- Department of Radiation Oncology, Cross Cancer Institute, and Department of Oncology, University of Alberta, Edmonton, AB
| | - X Kostaras
- Guideline Utilization Resource Unit, Alberta Health Services, Calgary, AB
| | - M Parliament
- Department of Radiation Oncology, Cross Cancer Institute, and Department of Oncology, University of Alberta, Edmonton, AB
| | - I A Olivotto
- Division of Radiation Oncology, Tom Baker Cancer Centre, and University of Calgary, Calgary, AB
| | - R Nordal
- Division of Radiation Oncology, Tom Baker Cancer Centre, and University of Calgary, Calgary, AB
| | - K Aronyk
- Division of Neurosurgery, University of Alberta, Edmonton, AB
| | - N Hagen
- Guideline Utilization Resource Unit, Alberta Health Services, Calgary, AB
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