Medulloblastoma in childhood: long-term results of treatment

Radiation-Induced Brain Injury: Age Dependency of Neurocognitive Dysfunction Following Radiotherapy

Cranial radiotherapy is a known risk factor for neurocognitive impairment in cancer survivors. Although radiation-induced cognitive dysfunction is observed in patients of all ages, children seem to be more vulnerable than adults to suffering age-related deficits in neurocognitive skills. So far, the underlying mechanisms by which IR negatively influences brain functions as well as the reasons for the profound age dependency are still insufficiently known. We performed a comprehensive Pubmed-based literature search to identify original research articles that reported on age dependency of neurocognitive dysfunction following cranial IR exposure. Numerous clinical trials in childhood cancer survivors indicate that the severity of radiation-induced cognitive dysfunction is clearly dependent on age at IR exposure. These clinical findings were related to the current state of experimental research providing important insights into the age dependency of radiation-induced brain injury and the development of neurocognitive impairment. Research in pre-clinical rodent models demonstrates age-dependent effects of IR exposure on hippocampal neurogenesis, radiation-induced neurovascular damage and neuroinflammation.

Height after photon craniospinal irradiation in pediatric patients treated for central nervous system embryonal tumors

BACKGROUND

We modeled height after craniospinal irradiation (CSI) in pediatric patients with central nervous system (CNS) embryonal tumors to identify factors that impair stature.

PROCEDURE

During 1996-2012, 212 pediatric patients (131 male) with CNS embryonal tumors received postoperative CSI: 23.4 Gy (n = 147) or ≥36 Gy (n = 65), similar postirradiation chemotherapy, and were followed for at least 5 years without tumor progression or other event. The group was further characterized by age at CSI and hormone-replacement therapy received. Models were developed to identify factors associated with growth impairment and estimate final height.

RESULTS

With median follow up of 10.2 years (range 5.0-20.4 years), the mean final height z-scores at 18 years of age, compared to United States standards, were -1.3 for female and -1.5 for male survivors. Younger age at the time of CSI, higher CSI dose, and female sex were associated with height impairment. Factors associated with higher growth rates before 15 years of age were older age at CSI, male sex, CSI dose < 36 Gy, replacement therapy for growth hormone (GH) and central adrenal insufficiency, and white race. Growth after age 15 in male survivors was associated with treatment of gonadotropin deficiency. Linear mixed-effects models were developed using clinical factors to estimate final height, demonstrate the unique growth curve of this cohort, and interactions between clinical variable and radiation dose.

CONCLUSIONS

CSI significantly impaired height at current doses used to treat standard- or high-risk CNS embryonal tumors. Measures to reduce the impact of CSI on height should be sought, with our models serving as benchmarks.

Endocrinologic Consequences of Pediatric Posterior Fossa Tumours

Intracranial tumors are the second most frequent malignancies in children and posterior fossa is a common location for these neoplasias during childhood. Recent advances in surgical techniques, radiotherapy and chemotherapy resulted in dramatic increase in the survival rates of these children, however they are still source of a significant morbidity and mortality. Endocrinological complications and late sequelae of childhood posterior fossa tumours are common among the survivors of these tumours and include growth retardation, hypothyroidism, pubertal disorders, gonadal dysfunction and osteopenia. These complications have significant impact on the quality of life of the survivors of childhood posterior fossa tumours. In this paper, the frequency, etiology, and management of these complications will be reviewed.

Treatment developments and the unfolding of the quality of life discussion in childhood medulloblastoma: a review

PURPOSE

To describe how the quality of life (QOL) discussion in childhood medulloblastoma (MB) relates to treatment developments, survival and sequelae from 1920 to 2014.

METHODS

Articles containing "childhood medulloblastoma" and "quality of life" were identified in PubMed. Those containing phrases pertaining to psychological, emotional, behavioral or social adjustment in the title, abstract or keywords were selected. Inclusion of relevant older publications was assured by cross-checking references.

RESULTS

1920-1930s: suction, electro-surgery, kilovolt (KV) irradiation. Survival = months. Focus on operative mortality, symptoms and survival. 1940s: radiotherapy improved. 1950s: chemotherapy and intubation. Survival = years. Opinions oscillated between optimism/awareness of physical sequelae of radiotherapy. 1960s: magnified vision, ventriculo-peritoneal (VP) shunts, megavolt (MV) irradiation. Long-term survival shifted the attention towards neurological problems, disability and carcinogenesis of radiotherapy. 1970s: CT, microscope, bipolar coagulation, shunt filters, neuroanesthesia, chemotherapy trials and staging studies. Operative mortality decreased and many patients (re)entered school; emphasis on neuropsychological sequelae, IQ and academic performance. 1980s: magnetic resonance imaging (MRI), Cavitron ultrasonic aspiration (CUSA), laser surgery, hyper-fractionated radiotherapy (HFRT). Cerebellar mutism, psychological and social issues. 1990s: pediatric neurosurgery, proton beams, stem cell rescue. Reflections on QOL as such. 21st century: molecular genetics. Premature aging, patterns of decline, risk- and resilience factors.

DISCUSSION

QOL is a critical outcome measure. Focus depends on survival and sequelae, determined after years of follow-up. Detailed measurements are limited by time, money and human resources, and self-reporting questionnaires represent a crude measure limited by subjectivity. Therapeutic improvements raise the question of QOL versus cure. QOL is a potential primary research endpoint; multicenter international studies are needed, as are web-based tools that work across cultures.

Intact language skills and semantic processing speed following the use of fractionated cranial irradiation therapy for the treatment of childhood medulloblastoma: a 4-year follow-up study

Recent advances in the delivery of cranial radiation therapy aim to reduce the adverse neurocognitive outcomes associated with successful treatments. Damage to white matter tracts following cranial radiation may result in a reduction in information processing speed, which in turn may lead to declines in academic achievement and performance scores on neurocognitive testing. This study reports on language outcomes and neurophysiological measures reflecting the efficiency of the brain's capacity to process semantic information in a 14-year-old female following treatment, which included fractionated cranial radiation dosages, for medulloblastoma at age 10 years 3 months. The findings suggest processing skills on par with her peers and stability in general language skill over the 4 years post-treatment.

[Growth hormone deficiency after treatment of medulloblastoma with radiotherapy in childhood: case report]

Craniospinal radiation therapy for treatment of brain tumors may result in growth hormone (GH) insufficiency with resultant linear growth retardation, one of the most common complications. We report the case of a 10-year-old boy presenting headache associated to vertigo, nausea and vomiting. A CT scan showed an homogeneous mass in the left cerebelar hemisphere, that was surgically removed. The histopathological examination revealed medulloblastoma and the patient was submitted to craniospinal radiation. He did not present tumor recurrence nor neurological or cognitive deficits during 4 years, but evolved to short stature due to GH deficiency. Nowadays, he is being receiving GH 0,1 U/kg/day and has presented 4cm stature increment after 6 months. The present case highlights the importance in carefully monitoring of children after cranial radiation for oncologic treatment, because they may develop hormonal deficiencies, that can be successfully replaced.

[Late effects of ionizing radiations on the thyroid gland]

The thyroid is the purest endocrine gland in the body and is likely to produce clinically significant abnormalities after external radiotherapy. Functional clinical modifications after direct irradiation exceeding 30 Gy are essentially related to hypothyroidism which may be clinically overt or subclinical with normal serum free thyroxine levels and high thyrotropin concentrations; the risk of hyperthyroidism, silent thyroiditis and Hashimoto's disease is also increased. Secondary hypothyroidism related to irradiation of the hypothalamus and the pituitary gland may arise with doses over 40-50 Gy following treatment for brain and nasopharyngeal tumors--Morphological glandular modifications induced by radiotherapy are responsible for the appearance of benign adenomas, more rarely cystic degenerations and specially well differentiated papillary or follicular carcinomas among children and adults. After irradiation during childhood for benign or malignant tumors, thyroid cancers are more frequent, higher for younger children, and the relative excess risk is increased from 15.6-to 53-fold; tumors can belatedly occur, more than 35 years after initial therapy. Thereby, in order to limit excess morbidity, it is evident that long term supervision with careful clinical and biological evaluations is necessary for patients who previously received neck, upper mediastinum and pituitary radiation therapy.

Radiosurgery for cerebral AVMs in children and adolescents: the neurobehavioral outcome

Eight patients, ranging in age from 9 to 18 years, were treated for arteriovenous malformations using gamma knife radiosurgery and were evaluated an average of 6 years after treatment to record potential effects of radiosurgery on cognitive and neuropsychological performance. Tests for general intelligence, nonverbal intelligence, memory and its components, and attention performance were administered to patients and compared with test results of age-matched siblings or first cousins. No statistically significant difference was found between the performance of patients and controls in any of the tests administered. Additionally, a specially designed questionnaire completed by the patients, their parents, and their teachers revealed that the patients' emotional and relational behavior was stable and unchanged after treatment. No correlation was found between the neurocognitive test performance and the lesion volumes irradiated, but the lesion site was found to contribute to the type of deficit recorded after treatment. The less invasive nature of the radiosurgical approach, combined with the brevity or absence of hospitalization, presumably contributed to the patients successful physical, mental, and emotional recovery.

Neuropsychological status of children treated for brain tumors: a critical review and integrative analysis

The literature on the neuropsychological status of children with primary brain tumors was reviewed to identify English-language publications reporting the results of standardized, quantitative measures of patient function. The 22 studies that met these review criteria, representing 544 patients, were evaluated to assess the relationship between traditional risk factors (age at diagnosis, tumor location, radiation therapy, and time since completion of treatment), as well as subsequent intellectual development, academic achievement, psychosocial adjustment, and neuropsychological status. The impact of other potentially salient factors, such as seizures and sensory and motor deficits, was evaluated when possible. Despite inconsistent reporting of demographic and treatment-related effects across studies which precluded formal meta-analysis, we were able to confirm the primary importance of radiation therapy volume and age at treatment on IQ. No effects were detected for tumor location. Younger children treated with cranial (whole brain) irradiation showed a 14-point deficit in IQ as compared with their older counterparts. No significant differences were noted between older children receiving local or cranial irradiation, although both groups had IQ levels 12-14 points lower than those not irradiated. The high-risk groups identified in this study require increased clinical surveillance. Definitive evaluation of potential risk factors for neuropsychological impairment will depend on more complete reporting of relevant patient characteristics and interinstitutional studies.

Medulloblastoma: freedom from relapse longer than 8 years--a therapeutic cure?

Seventy-seven patients presenting with medulloblastoma between 1958 and 1986 were treated at Stanford University Medical Center and studied retrospectively. Multimodality therapy utilized surgical extirpation followed by megavoltage irradiation. In 15 cases chemotherapy was used as adjunctive treatment. The 10- and 15-year actuarial survival rates were both 41% with an 18-year maximum follow-up period (median 4.75 years). There were no treatment failures after 8 years of tumor-free survival. Gross total removal of tumor was achieved in 22 patients (32%); the surgical mortality rate was 3.9%. No significant difference was noted in the incidence of metastatic disease between shunted and nonshunted patients. The classical form of medulloblastoma was present in 67% of cases while the desmoplastic subtype was found in 16%. Survival rates were best for patients presenting after 1970, for those with desmoplastic tumors, and for patients receiving high-dose irradiation (greater than or equal to 5000 cGy) to the posterior fossa. Although early data on freedom from relapse suggested a possible beneficial effect from chemotherapy, long-term follow-up results showed no advantage from this modality of treatment. The patterns of relapse and survival were examined; 64% of relapses occurred within the central nervous system, and Collins' rule was applicable in 83% of cases beyond the period of risk. Although patients treated for recurrent disease could be palliated, none were long-term survivors. The study data indicate that freedom from relapse beyond 8 years from diagnosis can be considered as a cure in this disease. Long-term follow-up monitoring is essential to determine efficacy of treatment and to assess survival patterns accurately.

The role of prophylactic spinal irradiation in localized intracranial ependymoma

A review of the clinical literature on ependymoma, published between 1969 and 1989, was carried out to assess the influence of tumor grade and site, tumor control at the primary site, and extent of irradiation on the incidence of spinal seeding after initial treatment. The pooled data show that the incidence of seeding was 8.4% (7/83) for high grade tumors and 4.5% (6/132) for low grade tumors. Seeding occurred more frequently in infratentorial tumors than in supratentorial tumors. For high grade tumors the incidence was 0% (0/26) for supratentorial and 15.7% (6/38) for infratentorial lesions; for low grade tumors the respective incidence was 2.7% (1/37) and 5.5% (4/73). Spinal seeding was 9.5% (15/157) in the event of failure at the primary site compared to 3.3% (4/122) when local control was achieved. The development of spinal metastases was not influenced by the extent of irradiation. For high grade tumors the incidence was 9.4% (5/53) with spinal irradiation and 6.7% (2/30) without prophylactic treatment; for low grade tumors the respective values were 9.3% (4/43) and 2.2% (2/89). These results indicate that tumor grade, tumor localization, and control of the tumor at the primary site are all factors which may influence the risk of spinal seeding. On the present evidence spinal metastases are not prevented by prophylactic spinal irradiation, regardless of tumor grade and site.

Cognitive deficits in long-term survivors of childhood brain tumors

Improvements in survival for patients who had childhood brain tumors has led to an increasing emphasis on the quality of life for these long-term survivors. Initial survival studies relied on global descriptions of functional abilities to assess cognitive deficits and reported that from 20% to 40% of long-term survivors had obvious partial disability and less than 10% were severely disabled. Formal neuropsychological testing has revealed that from 40% to 100% of long-term survivors have some form of cognitive deficit in various intelligence quotients, visual/perceptual skills, learning abilities, and adaptive behavior. Prospective, controlled studies have found a younger age at diagnosis, radiotherapy, methotrexate chemotherapy, tumor location and time interval to testing to be important (alone or in combination) and related to a high risk of subsequent cognitive deficits. Some variables play an as yet unresolved role. However, despite the progress of the last decade, future prospective studies are needed to define the role of certain variables in the development of cognitive deficits that maximize survival while minimizing cognitive deficits.

Efficacy of postoperative chemotherapy using cisplatin plus etoposide in young children with brain tumors

Neuraxis radiation therapy (RT) for primary intracranial tumors is associated with major late effects if administered to very young children. To control residual tumor and to delay RT, we treated eight young children (median age 6.5 months) with primary central nervous system (CNS) tumors using combination chemotherapy: cisplatin, 20 mg/M2/day plus VP-16, 75 mg/M2/day i.v. for 5 days, given q. 3-6 weeks for 8 cycles. The tumors were medulloblastoma (one), malignant ependymoma (two), primitive neuroectodermal tumor PNET (two), malignant glioma (two), astrocytoma (one). Six had measurable disease; three had positive cerebrospinal fluid (CSF) cytopathology. All patients with measurable tumor had initial objective responses (three) complete response [CR], one partial response [PR], two minor response [MR], including cytopathology (three CR of three) and metastatic deposits (two CR of two). One patient relapsed during chemotherapy. Median time to disease progression was 17.5 months; median survival was 34 months. Three patients, none of whom received RT, have prolonged progression-free intervals of 47-67 months to date. Neurodevelopmental progress continued during and after chemotherapy. Chemotherapy toxicity was mild. Median neutrophil nadir was 312/mm3, platelets 72,000. Fever during neutropenia occurred in six of 61 courses. Moderate high-frequency auditory losses were detected in three patients, and mild renal injury (GFR less than 70 ml/min) was detected in two of seven evaluable children. This pilot study demonstrates the apparent efficacy and mild toxicity of 5 day courses of cisplatin plus VP-16, with delayed RT, in young children with CNS neoplasms. A POG treatment protocol that incorporates cisplatin plus VP-16 is evaluating primary chemotherapy with delayed radiotherapy in larger numbers of pediatric brain tumor patients.

Thyroid dysfunction after radiotherapy and chemotherapy of brain tumours

We investigated thyroid function in 119 survivors of treatment for brain tumours not involving the hypothalamo-pituitary region. Cranial irradiation did not effect thyroid function but 11 of 47 children (23%) who had spinal irradiation had raised concentrations of thyroid stimulating hormone. Chemotherapy further increased the incidence of thyroid dysfunction: two of four patients who had cranial irradiation and chemotherapy and 20 of 29 patients (69%) who had spinal irradiation and chemotherapy had increased thyroid stimulating hormone concentrations. Only six patients with raised thyroid stimulating hormone concentrations had low serum thyroxine concentrations. Four children had secondary hypothyroidism. Thyroid function should be monitored in children who have received chemotherapy or radiotherapy. A rise in thyroid stimulating hormone concentrations is the most sensitive indicator of thyroid dysfunction. Children with raised thyroid stimulating hormone concentrations should be treated with thyroxine.

Nystagmus after medulloblastoma

Ten survivors of medulloblastoma were examined for residual opthalmological signs. Gaze-evoked nystagmus occurred in six children, four of whom also had pronounced upbeat nystagmus. This is a rare and specific type of nystagmus associated with lesions of the cerebellar vermis and medulla, and has not been described previously as a long-term sequel of medulloblastoma. The recognition of upbeat nystagmus is important because visual acuity may be reduced in upward gaze and difficulties at school may ensue for these children, who may be already intellectually and behaviourally compromised.

Assessment of quality of survival in children with medulloblastoma and cerebellar astrocytoma

To determine the quality of survival for children with posterior fossa tumors, comprehensive neuropsychological, behavioral, and academic assessment and physician ratings of functional status were obtained on 15 brain tumor patients (ages 6-19 years) at a median of 20 months post-diagnosis. More than 50% of the children (whether irradiated or not) experienced major problems in academic, motor, sensory, cognitive, and emotional function. All but two children were reported by teachers to be "slow workers," and four of 15 patients were able to maintain their school work in regular classes. Although 80% of the patients were rated by physicians as having "excellent" or "good" functional status, no relationship was found between these global ratings and psychometric measures. Although the affected site was the posterior fossa, deficits also involved higher cortical function. These findings indicate the need for further evaluation of treatment effects and the provision of intervention for survivors.

Late recurrence of primitive neuroectodermal tumor/medulloblastoma

The period of risk for recurrence of primitive neuroectodermal tumor/medulloblastoma (PNET/MB) is not clearly defined. With current treatment since more than 50% of children with PNET/MB can be expected to survive for at least 5 years after diagnosis, determining the evidence of "late" recurrence is of increasing concern. Collins has stated that patients with embryonal tumors who survive, disease free, for a period of time equal to the age at diagnosis plus 9 months can be declared cured. This, so-called Collins' law has been applied to patients with PNET/MB. To determine the incidence of "late" recurrence, factors which impact on recurrence and applicability of Collins' law, the authors studied all patients diagnosed with PNET/MB at the Children's Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, and Geisinger Medical Center, Danville, Pennsylvania, between 1970 and 1984. For the 44 patients in this study, the disease-free survival at 5, 10, and 12 years was 54%, 41% and 30%, respectively. For children surviving 5 years, the actuarial survival at 10 years was 75% and at 12 years, 51%. Age, sex, dose of radiotherapy, chemotherapy, or extent of surgery were not predictive of late relapse. Recurrence in three of seven patients (43%) occurred outside the "period of risk" as predicted by Collins. It appears that the "period of risk" for recurrent central nervous system tumors after PNET/MB is as yet undefined and probably indefinite.

Medulloblastoma: the Duke University Medical Center experience

We have reviewed the clinical experience in the treatment of medulloblastoma with radiotherapy at Duke University Medical Center. One hundred and twenty-seven patients treated between January 1, 1940 and December 31, 1983 were evaluated. The irradiation technique was reviewed and all irradiation doses were recalculated as minimum tumor doses in Gray (Gy). The mean follow-up was 24.4 years and the median follow-up was 26.5 years. The energy of the treatment machine was known in 102 cases. Sixty patients were treated with orthovoltage equipment and 42 patients were treated with megavoltage equipment. As a gross assessment of the impact of the details of radiotherapy treatment upon outcome, patients were grouped into excellent, good, fair, and poor treatment groups. Patients undergoing cranio-spinal axis (CSA) irradiation and receiving greater than or equal to 52 Gy to the posterior fossa and greater than or equal to 30 Gy to the clinically uninvolved remainder of the CSA were classified as having "excellent" technique. Patients undergoing CSA irradiation and receiving 40 to 52 Gy to the posterior fossa and greater than or equal to 20 Gy to the remainder of the CSA were classified as "good." Patients receiving 20 to 40 Gy to the posterior fossa and greater than or equal to 10 Gy to the spinal axis with or without prophylactic cranial irradiation were designated "fair." Any patient not fulfilling the above minimum criteria was categorized as "poor." The actuarial 5-year survival for the entire population was 33%. The 10-year survival was 21%. In 93 patients for whom records were detailed enough to allow categorization of treatment technique, 5-year actuarial survivals were: Excellent 37% (n = 17), Good 55% (n = 13), Fair 35% (n = 23), Poor 20% (n = 40). A complete surgical resection was not correlated with improved disease-free survival (DFS) in the excellent and good groups, but was correlated with an improved DFS in the fair and poor groups. The posterior fossa accounted for 62% of the failures in the 55 patients completing irradiation where the initial site of failure was known. An examination of patterns of failure in the spinal canal failed to demonstrate a dose response relationship above 10 Gy for spinal canal prophylactic irradiation. No patient developed recurrence beyond their period of risk as defined by "Collins' Law."(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term endocrine sequelae after treatment of medulloblastoma: prospective study of growth and thyroid function

Endocrine evaluations were performed prospectively in 22 patients with medulloblastoma (ages 2 1/2 to 23 1/2 years at diagnosis), after craniospinal radiation with or without adjuvant chemotherapy. The mean craniospinal hypothalamic-pituitary). and thyroid radiation doses were 3600 and 2400 rads, respectively. Fourteen (73%) of 19 patients who had not yet completed their growth experienced a decrease in growth velocity. However, only three of 10 of these children, who underwent growth hormone stimulation tests, had evidence of deficient growth hormone responses, suggesting that growth hormone secretory or regulatory dysfunction, rather than absolute growth hormone deficiency, is present in the majority of these children. Elevated thyroid-stimulating hormone levels were noted in 15 of 22 patients; one patient had hypothalamic hypothyroidism. Thus, the late effects of therapy for medulloblastoma include frequent endocrine morbidity involving hypothalamic-pituitary and thyroid dysfunction.

Medulloblastomas: a review of modern management with a report on 75 cases

The authors summarize the 8-year experience of a tertiary medical center with 75 cases of medulloblastoma in Saudi Arabia. A discussion of the evolution of modern management of this difficult problem ensues. As 5-year survival statistics approach 80% in some institutions, attention is being focused on the long-term effects of modern therapy and the quality of life led by these children.

Adjuvant chemotherapy for medulloblastoma

The use of adjuvant chemotherapy for cerebellar medulloblastoma is controversial. Twenty-one children and adolescents were treated with adjuvant low-dose cyclophosphamide and vincristine following surgery and radiotherapy. With a mean observation period of 6 years, the disease-free survival is 81%.

Improving the therapeutic ratio of craniospinal irradiation in medulloblastoma

Radiation therapy delivered to the entire cerebrospinal axis is indicated for a number of pediatric brain tumors, especially medulloblastoma. Improved radiotherapy techniques have changed the near fatal prognosis for children with medulloblastoma to a 50%, 5-year survival. Nevertheless, the treatment results in substantial acute toxicity, and many survivors have serious sequelae. Further improvement in survival with optimal surgery and radiotherapy is not expected unless chemotherapy is added. Refinements in radiotherapy technique, however, can improve the therapeutic ratio of the treatment by lowering its side effects. In the last year children who required craniospinal irradiation at M. D. Anderson Hospital were treated with 6 MV photons to the brain and primary tumor and with 15-17 MeV electrons to the spinal canal. The elective dose to the whole brain was 30 Gy in 17 fractions and 30 Gy in 20 fractions to the spine. The primary tumor received an additional 20-25 Gy. An electron-beam dose distribution was drawn on a computerized tomography (CT) reconstructed sagittal plane. The electron energy was selected so that the 90% isodose line was at least 3 mm anterior to the cord after correction for bone heterogeneity. The treatment was well tolerated in the first five patients. It is projected that the current technique will cause fewer late effects and improve the tolerance to chemotherapy.

Age at treatment and long-term performance results in medulloblastoma

Medulloblastoma is highly radioresponsive, and recent treatment results have improved greatly since the introduction of megavoltage machine in 1960s. There is increasing evidence for the potential cure of medulloblastoma if properly treated in its early stages. The curable group represents approximately 75% of diagnosed patients. Long-term treatment effects were examined in this study. The study reveals age-dependent late effects in learning ability; the patients less than 4-years-old at treatment had major learning problems; patients of 5 to 7 years old performed at satisfactory-to-low passing levels in school work; patients older than 8 years old had no major intellectual impairment. Short stature was common when growth potential was present at the time of therapy, but endocrine tests were generally negative. These observations indicate special educational requirement needs, especially for children treated at a young age.

Calcified basal ganglionic mass 12 years after radiation therapy for medulloblastoma

A patient treated 12 years previously with an operation and radiation therapy for a medulloblastoma developed weakness of the left hand and perivascular calcification involving the right internal capsule and caudate nucleus. These findings are considered possible long-term complications of the radiation therapy.

Growth and endocrine function after treatment for medulloblastoma

Children with medulloblastoma in Bristol are treated surgically and with craniospinal irradiation, and in some cases chemotherapy. Thirteen medium or long term survivors were investigated to determine their growth and endocrine function. Their rate of growth was considerably reduced through the first year of their illness and after spinal irradiation spinal growth was poor. Nine children developed growth hormone deficiency. They were clinically euthyroid but 7 had raised basal thyroid stimulating hormone values. Gonadal function was abnormal in all but the youngest child. The rate of survival is increasing in children with medulloblastoma but this is associated with appreciable endocrine abnormalities. Some of these problems are present shortly after treatment ends but others may develop later and long term surveillance is therefore essential.

Intracranial calcification in survivors of childhood medulloblastoma

Computerised tomography scans of the brain have been performed on 5 children who have survived at least 5 years after treatment with surgery and radiotherapy for medulloblastoma. Intracranial calcification of varying degrees of the basal ganglia and of the frontal and parietal cortex was detected in the 3 children who were irradiated under age 5 years.

Medulloblastoma: survey of factors possibly influencing the prognosis

In a series of 310 cases the role of the factors age, sex, location of the tumour (midline or lateral), and medulloblastoma type (classic or desmoplastic) were analysed with regard to the prognosis. The influence of therapy is not considered because of the inhomogeneity of the material and the view nowadays that treatment is insufficient. The occurrence of lateral (or hemispheric) medulloblastomas increases in the group of the 11-15 years old patients. The proportion of the desmoplastic type is greater in adults than in children, but they are distributed almost equally medially and laterally. There seems to be no definite correlation between sex and the survival time. The mean survival time increases with age. With regard to the histological subclassification into children and adults, the mean survival times are nearly identical. The only obvious factor with a decisive influence on the prognosis seems to be the time of appearance of the tumour. Additionally, the data support the conclusion that a desmoplastic medulloblastoma should be considered as a histological variant without clinical relevance.