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Wang E, Gutkin PM, Oh J, Pollom E, Soltys SG, Grant GA, Prolo LM, Chang S, Li G, Fisher PG, Partap S, Campen CJ, Gibbs IC, Hiniker SM. Stereotactic radiosurgery for recurrent pediatric brain tumors: clinical outcomes and toxicity. Neurosurg Focus 2022; 53:E2. [DOI: 10.3171/2022.8.focus22361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Recurrence of brain tumors in children after the initial course of treatment remains a problem. This study evaluated the efficacy and safety of reirradiation using stereotactic radiosurgery (SRS) in patients with recurrent pediatric primary brain tumors.
METHODS
This IRB-approved retrospective review included pediatric patients with recurrent primary brain tumors treated at Stanford University from 2000 to 2019 using frameless SRS. Time to local failure (LF) and distant intracranial failure (DIF) were measured from the date of SRS and analyzed using competing risk analysis. Overall survival (OS) and progression-free survival (PFS) were analyzed with the Kaplan-Meier method.
RESULTS
In total, 37 patients aged 2–24 years (median age 11 years at recurrence) were treated for 48 intracranial tumors. Ependymoma (38%) and medulloblastoma (22%) were the most common tumor types. The median (range) single fraction equivalent dose of SRS was 16.4 (12–24) Gy. The median (range) follow-up time was 22.9 (1.5–190) months. The median OS of all patients was 36.8 months. Eight of 40 (20%) lesions with follow-up imaging locally recurred. The 2-year cumulative incidence of LF after reirradiation with SRS was 12.8% (95% CI 4.6%–25.4%). The 2-year cumulative incidence of DIF was 25.3% (95% CI 12.9%–39.8%). The median PFS was 18 months (95% CI 8.9–44). Five (10.4%) patients developed toxicities potentially attributed to SRS, including cognitive effects and necrosis.
CONCLUSIONS
Reirradiation using SRS for recurrent pediatric brain tumors appears safe with good local control. Innovations that improve overall disease control should continue because survival outcomes after relapse remain poor.
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Affiliation(s)
- Elyn Wang
- Department of Radiation Oncology, Stanford University, Stanford
| | | | - Justin Oh
- Department of Radiation Oncology, Stanford University, Stanford
| | - Erqi Pollom
- Department of Radiation Oncology, Stanford University, Stanford
| | - Scott G. Soltys
- Department of Radiation Oncology, Stanford University, Stanford
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University, Stanford; and
| | - Laura M. Prolo
- Department of Neurosurgery, Stanford University, Stanford; and
| | - Steven Chang
- Department of Neurosurgery, Stanford University, Stanford; and
| | - Gordon Li
- Department of Neurosurgery, Stanford University, Stanford; and
| | - Paul G. Fisher
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Sonia Partap
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Cynthia J. Campen
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Iris C. Gibbs
- Department of Radiation Oncology, Stanford University, Stanford
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Ehret F, Kaul D, Budach V, Lohkamp LN. Applications of Frameless Image-Guided Robotic Stereotactic Radiotherapy and Radiosurgery in Pediatric Neuro-Oncology: A Systematic Review. Cancers (Basel) 2022; 14:cancers14041085. [PMID: 35205834 PMCID: PMC8869944 DOI: 10.3390/cancers14041085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/03/2022] [Accepted: 02/09/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND CyberKnife-based robotic radiosurgery (RRS) is a widely used treatment modality for various benign and malignant tumors of the central nervous system (CNS) in adults due to its high precision, favorable safety profile, and efficacy. Although RRS is emerging in pediatric neuro-oncology, scientific evidence for treatment indications, treatment parameters, and patient outcomes is scarce. This systematic review summarizes the current experience and evidence for RRS and robotic stereotactic radiotherapy (RSRT) in pediatric neuro-oncology. METHODS We performed a systematic review based on the databases Ovid Medline, Embase, Cochrane Library, and PubMed to identify studies and published articles reporting on RRS and RSRT treatments in pediatric neuro-oncology. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied herein. Articles were included if they described the application of RRS and RSRT in pediatric neuro-oncological patients. The quality of the articles was assessed based on their evidence level and their risk for bias using the original as well as an adapted version of the Newcastle Ottawa Quality Assessment Scale (NOS). Only articles published until 1 August 2021, were included. RESULTS A total of 23 articles were included after final review and removal of duplicates. Articles reported on a broad variety of CNS entities with various treatment indications. A majority of publications lacked substantial sample sizes and a prospective study design. Several reports included adult patients, thereby limiting the possibility of data extraction and analysis of pediatric patients. RRS and RSRT were mostly used in the setting of adjuvant, palliative, and salvage treatments with decent local control rates and acceptable short-to-intermediate-term toxicity. However, follow-up durations were limited. The evidence level was IV for all studies; the NOS score ranged between four and six, while the overall risk of bias was moderate to low. CONCLUSION Publications on RRS and RSRT and their application in pediatric neuro-oncology are rare and lack high-quality evidence with respect to entity-related treatment standards and long-term outcomes. The limited data suggest that RRS and RSRT could be efficient treatment modalities, especially for children who are unsuitable for surgical interventions, suffer from tumor recurrences, or require palliative treatments. Nevertheless, the potential short-term and long-term adverse events must be kept in mind when choosing such a treatment. Prospective studies are necessary to determine the actual utility of RRS and RSRT in pediatric neuro-oncology.
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Affiliation(s)
- Felix Ehret
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.)
- European Radiosurgery Center, 81377 Munich, Germany
- Correspondence:
| | - David Kaul
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Volker Budach
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany
| | - Laura-Nanna Lohkamp
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON M5T 2S8, Canada;
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The rationale and development of a CyberKnife© registry for pediatric patients with CNS lesions. Childs Nerv Syst 2021; 37:871-878. [PMID: 33170358 DOI: 10.1007/s00381-020-04944-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND CyberKnife© Radiosurgery (CKRS) is a recognized treatment concept for CNS lesions in adults due to its high precision and efficacy beside a high patient comfort. However, scientific evidence for this treatment modality in pediatric patients is scarce. A dedicated registry was designed to document CyberKnife© procedures in children, aiming to test the hypothesis that it is safe and efficient for the treatment of CNS lesions. METHODS The CyberKnife© registry is designed as a retrospective and prospective multicenter observational study (German Clinical Trials Register ( https://www.drks.de ), DRKS-ID 00016973). Patient recruitment will be ongoing throughout a 5-year period and includes collection of demographic, treatment, clinical, and imaging data. Follow-up results will be monitored for 10 years. All data will be registered in a centralized electronic database at the Charité-Universitätsmedizin. The primary endpoint is stable disease for benign and vascular lesions at 5 years of follow-up and local tumor control for malign lesions at 1- and 2-year follow-up. Secondary endpoints are radiation toxicity, side effects, and neurocognitive development. CONCLUSION The CyberKnife© registry intends to generate scientific evidence for all treatment- and outcome-related aspects in pediatric patients with treated CNS lesions. The registry may define safety and efficacy of CKRS in children and serve as a basis for future clinical trials, inter-methodological comparisons and changes of treatment algorithms.
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Setiawan CT, Landrigan-Ossar M. Pediatric Anesthesia Outside the Operating Room: Case Management. Anesthesiol Clin 2020; 38:587-604. [PMID: 32792186 DOI: 10.1016/j.anclin.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anesthesiology teams care for children in diverse locations, including diagnostic and interventional radiology, gastroenterology and pulmonary endoscopy suites, radiation oncology units, and cardiac catheterization laboratories. To provide safe, high-quality care, anesthesiologists working in these environments must understand the unique environmental and perioperative considerations and risks involved with each remote location and patient population. Once these variables are addressed, anesthesia and procedural teams can coordinate to ensure that patients and families receive the same high-quality care that they have come to expect in the operating room. This article also describes some of the considerations for anesthetic care in outfield locations.
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Affiliation(s)
- Christopher Tan Setiawan
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Anesthesiology, Children's Medical Center, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Mary Landrigan-Ossar
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA.
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Spina A, Gagliardi F, Boari N, Bailo M, Mortini P. Does Stereotactic Radiosurgery Positively Impact the Local Control of Atypical Teratoid Rhabdoid Tumors? World Neurosurg 2017; 104:612-618. [PMID: 28461278 DOI: 10.1016/j.wneu.2017.04.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Atypical teratoid rhabdoid tumors (ATRTs) are rare and aggressive tumors, usually affecting patients younger than 3 years of age, that are characterized by a poor prognosis. Nowadays multimodal management, including surgery, chemotherapy and radiation therapy (RT), is advocated depending on the patients' age and tumor stage, even if no consensus exists regarding the best treatment modality. Local RT seems to be the most effective treatment in prolonging progression-free and overall survival rates, although RT might not be used on younger children because of the risk of neurocognitive and endocrine sequelae. Stereotactic radiosurgery (SRS) is a valuable alternative therapeutic option to conventional RT because of the more conformal dose delivery. The aim of this study was to review the available literature on SRS in the management of ATRT. METHODS The authors carried out a systematic review of PubMed, Web of Science, and Google Scholar for clinical reports dealing with SRS for the management of ATRT. RESULTS Nine studies describing 12 patients treated with SRS for ATRT were included in the analysis. Patient's clinical features, radiosurgical treatment characteristics, and follow-up data of the pertinent literature were reviewed critically. SRS represents a feasible and effective therapeutic option in the management of ATRT. Local control has been reported in 66.7% of cases; however, 33.3% of patients experienced poor survival because of craniospinal tumor dissemination. CONCLUSION SRS should be considered in the multimodal treatment of ATRT, and future studies should focus on a better definition of the role played by SRS in their management.
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Affiliation(s)
- Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Nicola Boari
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Michele Bailo
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Wong K, Opimo AB, Olch AJ, All S, Waxer JF, Clark D, Cheng J, Chlebik A, Erdreich-Epstein A, Krieger MD, Tamrazi B, Dhall G, Finlay JL, Chang EL. Re-irradiation of Recurrent Pineal Germ Cell Tumors with Radiosurgery: Report of Two Cases and Review of Literature. Cureus 2016; 8:e585. [PMID: 27239400 PMCID: PMC4882159 DOI: 10.7759/cureus.585] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Primary intracranial germ cell tumors are rare, representing less than 5% of all central nervous system tumors. Overall, the majority of germ cell tumors are germinomas and approximately one-third are non-germinomatous germ cell tumors (NGGCT), which include teratoma, embryonal carcinoma, yolk sac tumor (endodermal sinus tumor), choriocarcinoma, or mixed malignant germ cell tumor. Germ cell tumors may secrete detectable levels of proteins into the blood and/or cerebrospinal fluid, and these proteins can be used for diagnostic purposes or to monitor tumor recurrence. Germinomas have long been known to be highly curable with radiation therapy alone. However, many late effects of whole brain or craniospinal irradiation have been well documented. Strategies have been developed to reduce the dose and volume of radiation therapy, often in combination with chemotherapy. In contrast, patients with NGGCT have a poorer prognosis, with about 60% cured with multimodality chemoradiation. There are no standard approaches for relapsed germ cell tumors. Options may be limited by prior treatment. Radiation therapy has been utilized alone or in combination with chemotherapy or high-dose chemotherapy and transplant. We discuss two cases and review options for frameless radiosurgery or fractionated radiotherapy.
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Affiliation(s)
- Kenneth Wong
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | | | - Arthur J Olch
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Sean All
- College of Medicine, University of Central Florida College of Medicine, Orlando, FL
| | - Jonathan F Waxer
- School of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Desirae Clark
- Radiation Oncology Program, Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA
| | - Justine Cheng
- Mechanical Engineering Department, Massachusetts Institute of Technology, Cambridge, MA
| | - Alisha Chlebik
- Radiation Oncology Program, Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA
| | - Anat Erdreich-Epstein
- Neuro-Oncology Program, Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA ; Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Mark D Krieger
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Benita Tamrazi
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Girish Dhall
- Pediatric Neuro-Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Jonathan L Finlay
- Pediatric Neuro-Oncology, The Ohio State University, Nationwide Children's Hospital
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
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