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Timmermann B, Alapetite C, Dieckmann K, Kortmann RD, Lassen-Ramshad Y, Maduro JH, Ramos Albiac M, Ricardi U, Weber DC. ESTRO-SIOPE guideline: Clinical management of radiotherapy in atypical teratoid/rhabdoid tumors (AT/RTs). Radiother Oncol 2024; 196:110227. [PMID: 38492671 DOI: 10.1016/j.radonc.2024.110227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND AND PURPOSE Treatment of patients with atypical teratoid/rhabdoid (AT/RT) is challenging, especially when very young (below the age of three years). Radiotherapy (RT) is part of a complex trimodality therapy. The purpose of this guideline is to provide appropriate recommendations for RT in the clinical management of patients not enrolled in clinical trials. MATERIALS AND METHODS Nine European experts were nominated to form a European Society for Radiotherapy and Oncology (ESTRO) guideline committee. A systematic literature search was conducted in PubMed/MEDLINE and Web of Science. They discussed and analyzed the evidence concerning the role of RT in the clinical management of AT/RT. RESULTS Recommendations on diagnostic imaging, therapeutic principles, RT considerations regarding timing, dose, techniques, target volume definitions, dose constraints of radiation-sensitive organs at risk, concomitant chemotherapy, and follow-up were considered. Treating children with AT/RT within the framework of prospective trials or prospective registries is of utmost importance. CONCLUSION The present guideline summarizes the evidence and clinical-based recommendations for RT in patients with AT/RT. Prospective clinical trials and international, large registries evaluating modern treatment approaches will contribute to a better understanding of the best treatment for these children in future.
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Affiliation(s)
- Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Germany, German Cancer Consortium (DKTK), Germany.
| | - Claire Alapetite
- Department of Radiation Oncology and Proton Therapy Center, Institut Curie, Paris-Orsay, France
| | - Karin Dieckmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Rolf-Dieter Kortmann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Germany, German Cancer Consortium (DKTK), Germany; University of Leipzig Medical Center, Leipzig, Germany
| | | | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | | | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen-PSI, Switzerland; Department of Radiation Oncology. Inselspital, Bern University Hospital, University of Bern, Switzerland
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Wagener K, Beckhaus J, Boekhoff S, Friedrich C, Müller HL. Sporadic and neurofibromatosis type 2-associated meningioma in children and adolescents. J Neurooncol 2023; 163:555-563. [PMID: 37402092 DOI: 10.1007/s11060-023-04344-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/13/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE Pediatric meningioma differs not only in its rare incidence from the adult meningioma, but also in its clinical characteristics. Many treatment approaches of pediatric meningioma are based on the study results of adult meningioma studies. The aim of this study was to explore the clinical and epidemiological characteristics of pediatric meningioma. METHODS Data on pediatric patients diagnosed between 1982 and 2021 with NF2-associated or sporadic meningioma and recruited in the trials/registries HIT-ENDO, KRANIOPHARYNGEOM 2000/2007 and KRANIOPHARYNGEOM Registry 2019 were retrospectively analyzed for clinical characteristics, etiology, histology, therapy, and outcome. RESULTS One hundred fifteen study participants were diagnosed with sporadic or NF2-associated meningioma at a median age of 10.6 years. There was a 1:1 sex ratio, with 14% of study participants suffering from NF2. 46% of the meningiomas were located hemispherically, 17% at the optic nerve/ intraorbital and 10% ventricularly. Multiple meningiomas were detected in 69% of NF2 patients and in 9% of sporadic meningiomas. 50% of the meningiomas were WHO grade I, 37% WHO grade II and 6% WHO grade III. Progressions or recurrences occurred after a median interval of 1.9 years. Eight patients (7%) died, 3 of them due to disease. The event-free survival was higher for WHO grade I than for WHO grade II meningioma patients (p = 0.008). CONCLUSIONS The major difference to the preceding literature could be found in the distribution of different WHO grades and their influence on event-free survival. Prospective studies are warranted to assess the impact of different therapeutic regimens. CLINICAL TRIAL REGISTRATION NUMBERS NCT00258453; NCT01272622; NCT04158284.
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Affiliation(s)
- Katharina Wagener
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University of Oldenburg, Klinikum Oldenburg AöR, 26133, Oldenburg, Germany
| | - Julia Beckhaus
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University of Oldenburg, Klinikum Oldenburg AöR, 26133, Oldenburg, Germany
- Division of Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg, 26129, Oldenburg, Germany
| | - Svenja Boekhoff
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University of Oldenburg, Klinikum Oldenburg AöR, 26133, Oldenburg, Germany
| | - Carsten Friedrich
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University of Oldenburg, Klinikum Oldenburg AöR, 26133, Oldenburg, Germany
| | - Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University of Oldenburg, Klinikum Oldenburg AöR, 26133, Oldenburg, Germany.
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Seidel C, Heider S, Hau P, Glasow A, Dietzsch S, Kortmann RD. Radiotherapy in Medulloblastoma-Evolution of Treatment, Current Concepts and Future Perspectives. Cancers (Basel) 2021; 13:cancers13235945. [PMID: 34885055 PMCID: PMC8657317 DOI: 10.3390/cancers13235945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Craniospinal irradiation (CSI) is the backbone of medulloblastoma treatment and the first treatment to achieve a cure in many patients. Within the last decades, significant efforts have been made to enhance efficacy in combination with chemotherapy. With this approach, a majority of low- and standard-risk patients can be cured. In parallel, many clinical trials have dealt with CSI-dose reduction and reduction of boost volume in order to decrease long-term toxicity, particularly neurotoxicity. Within these trials, standardized quality assurance has helped to increase the accuracy of treatment and improve prognosis. More recently, advances of radiotherapy techniques such as proton treatment allowed for better sparing of healthy tissue in order to further diminish detrimental long-term effects. Major future challenges are the adaption of radiotherapy regimens to different molecularly defined disease groups alone or together with new targeted agents. Moreover, and even more importantly, innovative combinatorial treatments are needed in high- and very-high risk situations. Abstract Medulloblastoma is the most frequent malignant brain tumor in children. During the last decades, the therapeutic landscape has changed significantly with craniospinal irradiation as the backbone of treatment. Survival times have increased and treatments were stratified according to clinical and later molecular risk factors. In this review, current evidence regarding the efficacy and toxicity of radiotherapy in medulloblastoma is summarized and discussed mainly based on data of controlled trials. Current concepts and future perspectives based on current risk classification are outlined. With the introduction of CSI, medulloblastoma has become a curable disease. Due to combination with chemotherapy, survival rates have increased significantly, allowing for a reduction in radiation dose and a decrease of toxicity in low- and standard-risk patients. Furthermore, modern radiotherapy techniques are able to avoid side effects in a fragile patient population. However, high-risk patients remain with relevant mortality and many patients still suffer from treatment related toxicity. Treatment needs to be continually refined with regard to more efficacious combinatorial treatment in the future.
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Affiliation(s)
- Clemens Seidel
- Department of Radiation Oncology, University Hospital Leipzig, 04103 Leipzig, Germany; (S.H.); (A.G.); (S.D.); (R.-D.K.)
- Correspondence:
| | - Sina Heider
- Department of Radiation Oncology, University Hospital Leipzig, 04103 Leipzig, Germany; (S.H.); (A.G.); (S.D.); (R.-D.K.)
| | - Peter Hau
- Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, 93053 Regensburg, Germany;
| | - Annegret Glasow
- Department of Radiation Oncology, University Hospital Leipzig, 04103 Leipzig, Germany; (S.H.); (A.G.); (S.D.); (R.-D.K.)
| | - Stefan Dietzsch
- Department of Radiation Oncology, University Hospital Leipzig, 04103 Leipzig, Germany; (S.H.); (A.G.); (S.D.); (R.-D.K.)
| | - Rolf-Dieter Kortmann
- Department of Radiation Oncology, University Hospital Leipzig, 04103 Leipzig, Germany; (S.H.); (A.G.); (S.D.); (R.-D.K.)
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Hau P, Frappaz D, Hovey E, McCabe MG, Pajtler KW, Wiestler B, Seidel C, Combs SE, Dirven L, Klein M, Anazodo A, Hattingen E, Hofer S, Pfister SM, Zimmer C, Kortmann RD, Sunyach MP, Tanguy R, Effeney R, von Deimling A, Sahm F, Rutkowski S, Berghoff AS, Franceschi E, Pineda E, Beier D, Peeters E, Gorlia T, Vanlancker M, Bromberg JEC, Gautier J, Ziegler DS, Preusser M, Wick W, Weller M. Development of Randomized Trials in Adults with Medulloblastoma-The Example of EORTC 1634-BTG/NOA-23. Cancers (Basel) 2021; 13:cancers13143451. [PMID: 34298664 PMCID: PMC8303185 DOI: 10.3390/cancers13143451] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Medulloblastoma is rare after puberty. Among several molecular subgroups that have been described, the sonic hedgehog (SHH) subgroup is highly overrepresented in the post-pubertal population and can be targeted with smoothened (SMO) inhibitors. However, no practice-changing prospective clinical trials have been published in adults to date. Tumors often recur, and treatment toxicity is relevant. Thus, the EORTC 1634-BTG/NOA-23 trial for post-pubertal patients with standard risk medulloblastoma will aim to increase treatment efficacy and to decrease treatment toxicity. Patients will be randomized between standard-dose vs. reduced-dosed radiotherapy, and SHH-subgroup patients will also be randomized between the SMO inhibitor sonidegib (OdomzoTM,, Sun Pharmaceuticals Industries, Inc., New York, USA) in addition to standard radio-chemotherapy vs. standard radio-chemotherapy alone. In ancillary studies, we will investigate tumor tissue, blood and cerebrospinal fluid samples, magnetic resonance images, and radiotherapy plans to gain information that may improve future treatment. Patients will also be monitored long-term for late side effects of therapy, health-related quality of life, cognitive function, social and professional live outcomes, and reproduction and fertility. In summary, EORTC 1634-BTG/NOA-23 is a unique multi-national effort that will help to council patients and clinical scientists for the appropriate design of treatments and future clinical trials for post-pubertal patients with medulloblastoma. Abstract Medulloblastoma is a rare brain malignancy. Patients after puberty are rare and bear an intermediate prognosis. Standard treatment consists of maximal resection plus radio-chemotherapy. Treatment toxicity is high and produces disabling long-term side effects. The sonic hedgehog (SHH) subgroup is highly overrepresented in the post-pubertal and adult population and can be targeted by smoothened (SMO) inhibitors. No practice-changing prospective randomized data have been generated in adults. The EORTC 1634-BTG/NOA-23 trial will randomize patients between standard-dose vs. reduced-dosed craniospinal radiotherapy and SHH-subgroup patients between the SMO inhibitor sonidegib (OdomzoTM, Sun Pharmaceuticals Industries, Inc., New York, USA) in addition to standard radio-chemotherapy vs. standard radio-chemotherapy alone to improve outcomes in view of decreased radiotherapy-related toxicity and increased efficacy. We will further investigate tumor tissue, blood, and cerebrospinal fluid as well as magnetic resonance imaging and radiotherapy plans to generate information that helps to further improve treatment outcomes. Given that treatment side effects typically occur late, long-term follow-up will monitor classic side effects of therapy, but also health-related quality of life, cognition, social and professional outcome, and reproduction and fertility. In summary, we will generate unprecedented data that will be translated into treatment changes in post-pubertal patients with medulloblastoma and will help to design future clinical trials.
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Affiliation(s)
- Peter Hau
- Wilhelm Sander-NeuroOncology Unit, Regensburg University Hospital, 93053 Regensburg, Germany
- Department of Neurology, Regensburg University Hospital, 93053 Regensburg, Germany
- Correspondence: ; Tel.: +49-941-944-18750
| | - Didier Frappaz
- Neuro-Oncology Unit, Centre Léon Bérard, 69008 Lyon, France;
| | - Elizabeth Hovey
- Department of Medical Oncology, Sydney 2052, Australia;
- Nelune Comprehensive Cancer Centre, Prince of Wales Cancer Centre, Sydney 2031, Australia;
| | - Martin G. McCabe
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M20 4GJ, UK;
| | - Kristian W. Pajtler
- Hopp-Children’s Cancer Center Heidelberg (KiTZ), Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (K.W.P.); (S.M.P.)
- Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar der Technischen Universität München, TUM School of Medicine, 81675 Munich, Germany; (B.W.); (C.Z.)
| | - Clemens Seidel
- Department of Radiation-Oncology, University Hospital Leipzig, 04103 Leipzig, Germany; (C.S.); (R.-D.K.)
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar der Technischen Universität München, TUM School of Medicine, 81675 Munich, Germany;
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands;
- Department of Neurology, Haaglanden Medical Center, 2501 CK The Hague, The Netherlands
| | - Martin Klein
- Department of Medical Psychology, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands;
- Brain Tumor Center Amsterdam at Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Antoinette Anazodo
- Nelune Comprehensive Cancer Centre, Prince of Wales Cancer Centre, Sydney 2031, Australia;
- Kids Cancer Centre, Sydney Children’s Hospital, Sydney 2031, Australia;
- School of Women’s and Children’s Health, University of New South Wales, Sydney 2031, Australia
| | - Elke Hattingen
- Department of Neuroradiology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany;
| | - Silvia Hofer
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (M.W.)
| | - Stefan M. Pfister
- Hopp-Children’s Cancer Center Heidelberg (KiTZ), Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (K.W.P.); (S.M.P.)
- Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar der Technischen Universität München, TUM School of Medicine, 81675 Munich, Germany; (B.W.); (C.Z.)
| | - Rolf-Dieter Kortmann
- Department of Radiation-Oncology, University Hospital Leipzig, 04103 Leipzig, Germany; (C.S.); (R.-D.K.)
| | - Marie-Pierre Sunyach
- Department of Radiation Oncology, Centre Leon Berard, 69008 Lyon, France; (M.-P.S.); (R.T.)
| | - Ronan Tanguy
- Department of Radiation Oncology, Centre Leon Berard, 69008 Lyon, France; (M.-P.S.); (R.T.)
| | - Rachel Effeney
- Department of Radiation Oncology, Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia;
| | - Andreas von Deimling
- Department of Neuropathology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (A.v.D.); (F.S.)
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research, 69120 Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (A.v.D.); (F.S.)
- Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research, 69120 Heidelberg, Germany
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Anna S. Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria; (A.S.B.); (M.P.)
| | - Enrico Franceschi
- Medical Oncology Department, Azienda USL/IRCCS Institute of Neurological Sciences, 40139 Bologna, Italy;
| | - Estela Pineda
- Barcelona Translational Genomics and Targeted Therapeutics in Solid Tumors Group, Department of Medical Oncology, Hospital Clinic Barcelona, 08036 Barcelona, Spain;
| | - Dagmar Beier
- Department of Neurology, Odense University Hospital, DK-5000 Odense, Denmark;
| | - Ellen Peeters
- EORTC Headquarters, 1200 Brussels, Belgium; (E.P.); (T.G.); (M.V.)
| | - Thierry Gorlia
- EORTC Headquarters, 1200 Brussels, Belgium; (E.P.); (T.G.); (M.V.)
| | | | - Jacoline E. C. Bromberg
- Erasmus Medical Center Cancer Institute, Department of Neuro-Oncology, 3015 GD Rotterdam, The Netherlands;
| | - Julien Gautier
- Clinical Research Department, Centre Léon Bérard, 69008 Lyon, France;
| | - David S. Ziegler
- Kids Cancer Centre, Sydney Children’s Hospital, Sydney 2031, Australia;
- School of Women’s and Children’s Health, University of New South Wales, Sydney 2031, Australia
- Children’s Cancer Institute, University of New South Wales, Sydney 2031, Australia
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria; (A.S.B.); (M.P.)
| | - Wolfgang Wick
- Department of Neurology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
- Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research, 69120 Heidelberg, Germany
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland; (S.H.); (M.W.)
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Dietzsch S, Braesigk A, Seidel C, Remmele J, Kitzing R, Schlender T, Mynarek M, Geismar D, Jablonska K, Schwarz R, Pazos M, Walser M, Frick S, Gurtner K, Matuschek C, Harrabi SB, Glück A, Lewitzki V, Dieckmann K, Benesch M, Gerber NU, Rutkowski S, Timmermann B, Kortmann RD. Pretreatment central quality control for craniospinal irradiation in non-metastatic medulloblastoma : First experiences of the German radiotherapy quality control panel in the SIOP PNET5 MB trial. Strahlenther Onkol 2020; 197:674-682. [PMID: 33226469 PMCID: PMC8292275 DOI: 10.1007/s00066-020-01707-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/23/2020] [Indexed: 12/13/2022]
Abstract
Purpose Several studies have demonstrated the negative impact of radiotherapy protocol deviations on tumor control in medulloblastoma. In the SIOP PNET5 MB trial, a pretreatment radiotherapy quality control (RT-QC) program was introduced. A first analysis for patients enrolled in Germany, Switzerland and Austria with focus on types of deviations in the initial plan proposals and review criteria for modern radiation technologies was performed. Methods and patients Sixty-nine craniospinal irradiation (CSI) plans were available for detailed analyses. RT-QC was performed according to protocol definitions on dose uniformity. Because of the lack of definitions for high-precision 3D conformal radiotherapy within the protocol, additional criteria for RT-QC on delineation and coverage of clinical target volume (CTV) and planning target volume (PTV) were defined and evaluated. Results Target volume (CTV/PTV) deviations occurred in 49.3% of initial CSI plan proposals (33.3% minor, 15.9% major). Dose uniformity deviations were less frequent (43.5%). Modification of the RT plan was recommended in 43.5% of CSI plans. Unacceptable RT plans were predominantly related to incorrect target delineation rather than dose uniformity. Unacceptable plans were negatively correlated to the number of enrolled patients per institution with a cutoff of 5 patients (p = 0.001). Conclusion This prospective pretreatment individual case review study revealed a high rate of deviations and emphasizes the strong need of pretreatment RT-QC in clinical trials for medulloblastoma. Furthermore, the experiences point out the necessity of new RT-QC criteria for high-precision CSI techniques. Electronic supplementary material The online version of this article (10.1007/s00066-020-01707-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefan Dietzsch
- Department for Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany.
| | - Annett Braesigk
- Department for Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Clemens Seidel
- Department for Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Julia Remmele
- Department for Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Ralf Kitzing
- Department for Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Tina Schlender
- Department for Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Martin Mynarek
- Departement of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dirk Geismar
- Clinic for Particle Therapy, West German Proton Therapy Centre, University of Essen, Essen, Germany
| | - Karolina Jablonska
- Faculty of Medicine, Department of Radiation Oncology, University of Cologne, Cologne, Germany
| | - Rudolf Schwarz
- Department of Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Montserrat Pazos
- Department of Radiotherapy and Radiation Oncology, Ludwig Maximilian University Munich, Munich, Germany
| | - Marc Walser
- Center for Protontherapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Silke Frick
- Department of Radiotherapy and Radiation Oncology, Hospital Bremen Mitte, Bremen, Germany
| | - Kristin Gurtner
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Semi Ben Harrabi
- Department of Radiation Oncology and Radiotherapy, Heidelberg University Hospital, Heidelberg, Germany
| | - Albrecht Glück
- Radiation Oncology, Munich-Schwabing Municipal Hospital, Munich, Germany
| | - Victor Lewitzki
- Department of Radiotherapy, University of Wuerzburg, Wuerzburg, Germany
| | - Karin Dieckmann
- Department of Radiotherapy, Medical University of Vienna, Vienna, Austria
| | - Martin Benesch
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | | | - Stefan Rutkowski
- Departement of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Beate Timmermann
- Clinic for Particle Therapy, West German Proton Therapy Centre, University of Essen, Essen, Germany
| | - Rolf-Dieter Kortmann
- Department for Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
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A dedicated cloud system for real-time upfront quality assurance in pediatric radiation therapy. Strahlenther Onkol 2019; 195:843-850. [DOI: 10.1007/s00066-019-01469-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/03/2019] [Indexed: 10/27/2022]
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Wong KK, All S, Waxer J, Olch AJ, Venkatramani R, Dhall G, Davidson TB, Zaky W, Finlay JL. Radiotherapy after high-dose chemotherapy with autologous hematopoietic cell rescue: Quality assessment of Head Start III. Pediatr Blood Cancer 2017; 64. [PMID: 28379644 DOI: 10.1002/pbc.26529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 02/21/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND The use of high-dose chemotherapy with autologous hematopoietic cell rescue (AuHCR) in Head Start III is a potentially curative approach for the management of young children with central nervous system neoplasms. We report the potential influence of quality and timing of radiation therapy on the survival of patients treated on the study. PROCEDURE Between 2003 and 2009, 220 children with newly diagnosed central nervous system neoplasms were enrolled on the study. Radiation therapy was indicated following AuHCR for children between 6 and 10 years old or those younger than 6 years with residual tumor preconsolidation. Records were received for 42 patients and reviewed to determine adherence to protocol treatment volume and dose guidelines. Of these patients, seven were irradiated prior to consolidation, and additional four patients who initially avoided radiation therapy after AuHCR were subsequently treated at relapse. RESULTS Of the 31 patients who were fully evaluable, 2 refused radiation therapy until recurrence and 4 progressed between recovery from AuHCR and radiation therapy. Of the remaining 25 patients, 8 had violations in their indication, dose, or treatment volume. All violations occurred in patients under 6 years of age. Two patients could have avoided radiation therapy. There were 6 violations in the 23 patients who received radiation therapy for guideline indications. CONCLUSION All protocol violations occurred in patients under 6 years of age and were associated with decreased overall survival as was the time to start radiotherapy of greater than 11 weeks. When indicated, starting radiation therapy soon after neutrophil and platelet recovery may improve the outcome for these high-risk children.
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Affiliation(s)
- Kenneth K Wong
- Children's Hospital Los Angeles, Los Angeles, California.,Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sean All
- University of Central Florida College of Medicine, Orlando, Florida
| | - Jonathan Waxer
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Arthur J Olch
- Children's Hospital Los Angeles, Los Angeles, California.,Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Rajkumar Venkatramani
- Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Girish Dhall
- Children's Hospital Los Angeles, Los Angeles, California
| | - Tom Belle Davidson
- Division of Hematology/Oncology, University of California Los Angeles, Pediatrics, Los Angeles, California
| | - Wafik Zaky
- MD Anderson Cancer Center, Pediatrics Neuro-oncology Program, Houston, Texas
| | - Jonathan L Finlay
- Department of Pediatrics, Division of Hematology, Oncology and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
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Sugie C, Shibamoto Y, Ayakawa S, Mimura M, Komai K, Ishii M, Miyamoto A, Oda K. Craniospinal irradiation using helical tomotherapy: evaluation of acute toxicity and dose distribution. Technol Cancer Res Treat 2011; 10:187-95. [PMID: 21381797 DOI: 10.7785/tcrt.2012.500194] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to evaluate acute toxicity of craniospinal irradiation (CSI) using helical tomotherapy (HT) and compare its dose distribution with that of conventional linac-based plans. Twelve patients with various brain tumors were treated with HT-CSI. Median patient age was 14 years (range: 4-37 years). Median CSI dose was 30.6 Gy in 18 fractions (range: 23.4-40 Gy in 13-25 fractions). Toxicities were assessed according to the Common Terminology Criteria for Adverse Events version 4.0. Before CSI, 11 patients (92%) received neoadjuvant chemotherapy, so acute toxicity was evaluated by comparing patient status before and after CSI. HT-CSI plans were compared with linac-based CSI plans made using Pinnacle(3) planning system in 9 patients. All patients completed planned CSI without interruption. Grade 3 or higher toxicities were leukopenia seen in 11 patients (92%), anorexia in 6 (50%), anemia in 5 (42%), and thrombopenia in 5 (42%). Administration of granulocyte colony-stimulating factor, platelet transfusion and total parenteral nutrition were required in 8 (67%), 5 (42%) and 5 (42%) patients, respectively. HT plans were superior to linac-based plans in terms of homogeneity and conformality in planning target volume (PTV). For most organs at risk (OARs), volumes receiving more than 10 Gy (V10 Gy) or 20 Gy (V20 Gy) were lower in HT plans. However, HT plans significantly increased mean doses to the lung, kidneys and liver, and V5 Gy of 6 OARs including the lung. Despite intensive neoadjuvant chemotherapy, acute toxicity of HT-CSI was acceptable. HT provided better dose distribution in PTV than conventional linac. In most OARs, smaller volumes received >10-20 Gy in HT plans, although larger volumes received 5-10 Gy.
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Affiliation(s)
- C Sugie
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan.
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9
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Brandes AA, Franceschi E, Tosoni A, Reni M, Gatta G, Vecht C, Kortmann RD. Adult neuroectodermal tumors of posterior fossa (medulloblastoma) and of supratentorial sites (stPNET). Crit Rev Oncol Hematol 2009; 71:165-79. [PMID: 19303318 DOI: 10.1016/j.critrevonc.2009.02.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 01/28/2009] [Accepted: 02/13/2009] [Indexed: 11/26/2022] Open
Abstract
Medulloblastoma and supratentorial primitive neuroectodermal tumors are rare diseases in adults. Due to this rarity, few prospective clinical trials have been conducted on medulloblastoma in adults, investigations being based exclusively on retrospective studies; the populations considered in literature are small, and the different treatments given span decades, during which diagnostic procedures, neurosurgical skills and radiotherapy techniques have changed. Unlike pediatric patients, adult medulloblastoma patients have been treated according to risk-adapted therapeutic strategies in only a few series and despite risk-tailored treatments, 20-30% of patients experience recurrence. Although patients could respond to second line treatments, the prognosis of relapsed patients remains dismal. An important challenge for the future will be the biological characterization of medulloblastoma, with the identification of specific genetic patterns of patients with a better or a worse prognosis.
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Affiliation(s)
- Alba A Brandes
- Department of Medical Oncology, Azienda USL-Bellaria-Maggiore Hospital Bologna, Italy.
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10
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Long-term outcome and clinical prognostic factors in children with medulloblastoma treated in the prospective randomised multicentre trial HIT'91. Eur J Cancer 2009; 45:1209-1217. [PMID: 19250820 DOI: 10.1016/j.ejca.2009.01.015] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Accepted: 01/15/2009] [Indexed: 11/24/2022]
Abstract
PURPOSE To analyse long-term outcome and clinical prognostic factors in medulloblastoma. METHODS We analysed 280 patients with medulloblastoma (3-18 years) included from 1991 to 1997 in the randomised multicentre trial HIT'91 comparing pre-('sandwich') and postradiation ('maintenance') chemotherapy (median follow-up of survivors for 10 years). RESULTS In 187 patients with complete staging, overall survival (OS) was higher after maintenance compared to sandwich treatment for M0 (10-year OS 91% and 62%, p=0.001) and M1 patients (10-year OS 70% and 34%, p=0.020). In M2/3 disease, 10-year OS was 42% and 45%. Incomplete staging, metastases, younger age and sandwich chemotherapy were independent adverse risk factors. Twelve percent of all relapses (13 of 107) occurred after more than five years, and 12 patients had secondary neoplasms. CONCLUSIONS After maintenance therapy, long-term survival was excellent in fully assessable patients with localised medulloblastoma, and favourable for M1 patients. Patients should be followed longer for late relapses and secondary tumours.
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Timmermann B, Kortmann RD, Kühl J, Rutkowski S, Dieckmann K, Meisner C, Bamberg M. Role of radiotherapy in anaplastic ependymoma in children under age of 3 years: Results of the prospective German brain tumor trials HIT-SKK 87 and 92. Radiother Oncol 2005; 77:278-85. [PMID: 16300848 DOI: 10.1016/j.radonc.2005.10.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Revised: 09/09/2005] [Accepted: 10/04/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate the outcome of very young children with anaplastic ependymoma after delayed or omitted radiotherapy (RT). MATERIALS AND METHODS Children under age of 3 years with anaplastic ependymoma were enrolled in the HIT-SKK 87 trial from 1987. After surgery, low-risk patients (R0, M0) received maintenance chemotherapy until elective RT at age of three. In high-risk patients (R+, M+) intensive induction chemotherapy was followed by maintenance chemotherapy and subsequently delayed RT. If there was, progression radiotherapy started immediately. In the HIT-SKK 92, trial MTX-based chemotherapy was applied. RT was administered in non-responders only. RESULTS Thirty-four children with anaplastic ependymoma were eligible (age 1.0-33.0 months). All children received chemotherapy. In 13 children, no RT was administered. Preventive RT after chemotherapy was given in nine, and salvage RT in 12 children. OS and PFS rates after 3-year were 55.9 and 27.3%, respectively. Twenty-five children relapsed. Positive impact on survival was observed in children with higher age, M0-stage, complete resection, and treatment with radiotherapy. Without RT only 3/13, children survived. CONCLUSION Delaying RT jeopardizes survival even after intensive chemotherapy. Predominant site of failure is the primary tumor site. RT of the neuraxis should be omitted in localized disease.
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Affiliation(s)
- Beate Timmermann
- Department of Radiooncology, University of Tübingen, Tübingen, Germany.
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12
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Hong TS, Tomé WA, Chappell RJ, Chinnaiyan P, Mehta MP, Harari PM. The impact of daily setup variations on head-and-neck intensity-modulated radiation therapy. Int J Radiat Oncol Biol Phys 2005; 61:779-88. [PMID: 15708257 DOI: 10.1016/j.ijrobp.2004.07.696] [Citation(s) in RCA: 186] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2003] [Revised: 07/07/2004] [Accepted: 07/09/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE Intensity-modulated radiation therapy (IMRT) in the treatment of head-and-neck (H&N) cancer provides the opportunity to diminish normal tissue toxicity profiles and thereby enhance patient quality of life. However, highly conformal treatment techniques commonly establish steep dose gradients between tumor and avoidance structures. Daily setup variations can therefore significantly compromise the ultimate precision of idealized H&N IMRT delivery. This study provides a detailed analysis regarding the potential impact of daily setup variations on the overall integrity of H&N IMRT. METHODS AND MATERIALS A series of 10 patients with advanced H&N cancer were prospectively enrolled in a clinical trial to examine daily H&N radiation setup accuracy. These patients were treated with conventional shrinking field design using three-dimensional treatment planning techniques (not IMRT). Immobilization and alignment were performed using modern H&N practice techniques including conventional thermoplastic masking, baseplate fixation to the treatment couch, three-point laser alignment, and weekly portal film evaluation. After traditional laser alignment, setup accuracy was assessed daily for each patient by measuring 3 Cartesian and 3 angular deviations from the specified isocenter using a high-precision, optically guided patient localization system, which affords submillimeter setup accuracy. These positional errors were then applied to a distinct series of 10 H&N IMRT plans for detailed analysis regarding the impact of daily setup variation (without optical guidance) on the ultimate integrity of IMRT plans over a 30-day treatment course. Dose-volume histogram (DVH), equivalent uniform dose (EUD), mean total dose (mTd), and maximal total dose (MTD) for normal structures were analyzed for IMRT plans with and without incorporation of daily setup variation. RESULTS Using conventional H&N masking and laser alignment for daily positioning, the mean setup error in any single dimension averaged 3.33 mm. However, when all six degrees of freedom were accounted for, using the optically guided patient localization system, the mean composite vector offset was 6.97 mm with a standard deviation of 3.63 mm. Superimposition of mean offset vectors on idealized H&N IMRT treatment plans enabled evaluation of resultant shifts in DVH, EUD, mTd, and MTD calculations. Partial geographic tumor miss (GTV underdosing) and normal tissue overdosing was common when these mean positional offsets were incorporated. The decrease in EUD for defined tumor volumes ranged up to 21% when the largest offset histories were applied, and 3-14% for plans when the least and median offset histories were applied. CONCLUSION The successful implementation of H&N IMRT requires accurate and reproducible treatment delivery over a 6- to 7-week treatment course. The adverse impact of daily setup variation, which occurs routinely with conventional H&N masking techniques, may be considerably greater than recognized. Isocenter verification checks on two-dimensional orthogonal films may not sufficiently alert the clinician to the magnitude of three-dimensional offset vectors and the resultant impact on the quality of overall IMRT delivery. Unrecognized geographic miss and resultant target underdose may occur. Similarly, selected normal structures such as parotid glands may receive higher doses than intended. The results of this study suggest that more rigorous immobilization techniques than conventional masking and routine patient setup tracking methodologies are important for the accurate monitoring and successful delivery of high-quality IMRT for H&N cancer.
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Affiliation(s)
- Theodore S Hong
- Department of Human Oncology, University of Wisconsin Medical School, University Hospital and Clinics, 600 Highland Avenue K4/332, Madison, WI 53792, USA
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13
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Timmermann B, Kortmann RD, Kühl J, Meisner C, Dieckmann K, Pietsch T, Bamberg M. Role of radiotherapy in the treatment of supratentorial primitive neuroectodermal tumors in childhood: results of the prospective German brain tumor trials HIT 88/89 and 91. J Clin Oncol 2002; 20:842-9. [PMID: 11821469 DOI: 10.1200/jco.2002.20.3.842] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the outcome of children with supratentorial primitive neuroectodermal tumors after surgery, irradiation, and chemotherapy and to identify factors predictive for survival. PATIENTS AND METHODS Sixty-three children in the prospective trials HIT 88/89 and HIT 91 were eligible. Complete resection was performed in 21 patients. Patients were randomized for preirradiation chemotherapy, consisting of two cycles of ifosfamide, etoposide, methotrexate, cisplatin, and cytarabine (n = 40), or chemotherapy after irradiation, consisting of eight cycles with cisplatin, vincristine, and lomustine (n = 23). Irradiation volume was recommended to encompass the neuraxis with 35.2-Gy total dose followed by a boost (20.0 Gy) to the primary tumor site (n = 54). Seven patients were irradiated to the tumor region only with a total dose of 54.0 Gy. RESULTS Overall survival at 3 years was 48.4%. Progression occurred in 38 children, with local recurrences in 27 patients. The only significant prognostic factor was dose and volume of radiotherapy (progression-free survival after 3 years was 49.3% with correct treatment compared with 6.7% for 15 children with major violations of radiotherapy). Ten early progressions occurred during adjuvant therapy (eight before and two during radiotherapy), nine of them treated with preirradiation chemotherapy. There was a positive trend in outcome for nonmetastatic and pineal tumors. CONCLUSION Significant predictive factors were dose and volume of radiotherapy. Volume of irradiation should encompass the whole CNS with additional boost to the tumor region. Local doses of at least 54 Gy and a craniospinal dose of 35 Gy are necessary. Preirradiation chemotherapy seems to increase risk of early progression.
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Affiliation(s)
- Beate Timmermann
- Department of Radiooncology, and Institute of Medical Information Processing, University of Tübingen, Tübingen, Germany.
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Weiss E, Krebeck M, Köhler B, Pradier O, Hess CF. Does the standardized helmet technique lead to adequate coverage of the cribriform plate? An analysis of current practice with respect to the ICRU 50 report. Int J Radiat Oncol Biol Phys 2001; 49:1475-80. [PMID: 11286856 DOI: 10.1016/s0360-3016(00)01548-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To investigate whether the standardized helmet technique adequately covers the cribriform plate. METHODS AND MATERIALS For 11 patients with acute leukemia or primary intracerebral neoplasms undergoing irradiation with the standardized helmet technique, three-dimensional isodose distributions were evaluated with special respect to the dose to the cribriform plate and the ocular lenses. RESULTS The average dose received by 95% of the cribriform plate with the standardized helmet technique was 85% of the prescribed dose. To enclose the cribriform plate by the 95% isodose (according to the ICRU 50 report) with a 10-mm safety margin allowing for deviations during treatment planning and delivery, the eye block had to be moved in the ventrocaudal direction with an average vector length of 13.6 mm. Consequently, the mean dose received by 5% of the lenses rose from 18% to 91% of the prescribed total dose. CONCLUSION Sufficient lens shielding is usually not compatible with safe irradiation of the frontobasis by the standardized helmet technique.
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Affiliation(s)
- E Weiss
- Department of Radiotherapy, University of Goettingen, Goettingen, Germany.
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