1
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Youlden DR, Baade PD, Frazier AL, Gupta S, Gottardo NG, Moore AS, Aitken JF. Temporal changes in childhood cancer incidence and survival by stage at diagnosis in Australia, 2000-2017. Acta Oncol 2023; 62:1256-1264. [PMID: 37647245 DOI: 10.1080/0284186x.2023.2251668] [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: 07/07/2023] [Accepted: 08/20/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The Toronto Paediatric Cancer Stage Guidelines are a compendium of staging systems developed to facilitate collection of consistent and comparable data on stage at diagnosis for childhood cancers by cancer registries. MATERIAL AND METHODS This retrospective, observational cohort study investigated changes in stage-specific incidence and survival for children diagnosed between 2000-2008 compared to 2009-2017 using the population-based Australian Childhood Cancer Registry. Information on mortality for each patient was available to 31st December 2020. Shifts in incidence by stage were evaluated using chi-square tests, and differences in stage-specific five-year observed survival for all causes of death over time were assessed using flexible parametric models. RESULTS Stage was assigned according to the Toronto Guidelines for 96% (n = 7944) of the total study cohort (n = 8292). Changes in the distribution of incidence by stage between the two diagnosis periods were observed for retinoblastoma, with stage 0 increasing from 26% to 37% of cases (p = 0.02), and hepatoblastoma, with metastatic disease increasing from 22% to 39% of cases (p = 0.04). There were large gains in stage-specific survival over time for stage IV rhabdomyosarcoma (five-year adjusted mortality hazard ratio for 2009-2017 compared to 2000-2008 of 0.38, 95% CI 0.19-0.77; p = 0.01), stage M3 for medulloblastoma (HR = 0.41, 95% CI 0.21-0.79; p = 0.01) and metastatic neuroblastoma excluding stage MS (HR = 0.61, 95% CI 0.44-0.84; p < 0.01). CONCLUSION These results indicate that improvements in childhood cancer survival in Australia are most likely due to refined management rather than changes in stage at diagnosis, particularly for metastatic solid tumours. Wide international uptake of the Toronto Guidelines will allow comprehensive evaluation of differences in survival between countries.
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Affiliation(s)
- Danny R Youlden
- Viertel Cancer Research Centre, Cancer Council Queensland, Brisbane, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Peter D Baade
- Viertel Cancer Research Centre, Cancer Council Queensland, Brisbane, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Australia
| | - A Lindsay Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, USA
| | - Sumit Gupta
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Nicolas G Gottardo
- Department of Paediatric and Adolescent Oncology/Haematology, Perth Children's Hospital, Perth, Australia
- Brain Tumour Research Program, Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Andrew S Moore
- Oncology Service, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Joanne F Aitken
- Viertel Cancer Research Centre, Cancer Council Queensland, Brisbane, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
- School of Public Health, The University of Queensland, Brisbane, Australia
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2
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Osuna-Marco MP, Martín-López LI, Tejera ÁM, López-Ibor B. Questions and answers in the management of children with medulloblastoma over the time. How did we get here? A systematic review. Front Oncol 2023; 13:1229853. [PMID: 37456257 PMCID: PMC10340518 DOI: 10.3389/fonc.2023.1229853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Treatment of children with medulloblastoma (MB) includes surgery, radiation therapy (RT) and chemotherapy (CT). Several treatment protocols and clinical trials have been developed over the time to maximize survival and minimize side effects. Methods We performed a systematic literature search in May 2023 using PubMed. We selected all clinical trials articles and multicenter studies focusing on MB. We excluded studies focusing exclusively on infants, adults, supratentorial PNETs or refractory/relapsed tumors, studies involving different tumors or different types of PNETs without differentiating survival, studies including <10 cases of MB, solely retrospective studies and those without reference to outcome and/or side effects after a defined treatment. Results 1. The main poor-prognosis factors are: metastatic disease, anaplasia, MYC amplification, age younger than 36 months and some molecular subgroups. The postoperative residual tumor size is controversial.2. MB is a collection of diseases.3. MB is a curable disease at diagnosis, but survival is scarce upon relapse.4. Children should be treated by experienced neurosurgeons and in advanced centers.5. RT is an essential treatment for MB. It should be administered craniospinal, early and without interruptions.6. Craniospinal RT dose could be lowered in some low-risk patients, but these reductions should be done with caution to avoid relapses.7. Irradiation of the tumor area instead of the entire posterior fossa is safe enough.8. Hyperfractionated RT is not superior to conventional RT9. Both photon and proton RT are effective.10. CT increases survival, especially in high-risk patients.11. There are multiple drugs effective in MB. The combination of different drugs is appropriate management.12. CT should be administered after RT.13. The specific benefit of concomitant CT to RT is unknown.14. Intensified CT with stem cell rescue has no benefit compared to standard CT regimens.15. The efficacy of intraventricular/intrathecal CT is controversial.16. We should start to think about incorporating targeted therapies in front-line treatment.17. Survivors of MB still have significant side effects. Conclusion Survival rates of MB improved greatly from 1940-1970, but since then the improvement has been smaller. We should consider introducing targeted therapy as front-line therapy.
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Affiliation(s)
- Marta P. Osuna-Marco
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
- Faculty of Experimental Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Laura I. Martín-López
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
| | - Águeda M. Tejera
- Faculty of Experimental Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Blanca López-Ibor
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
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3
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Riedemann J, Figaji A, Davidson A, Stannard C, Pillay K, Kilborn T, Parkes J. Sequential improvement in paediatric medulloblastoma outcomes in a low-and-middle-income country setting over three decades. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2021. [DOI: 10.4102/sajo.v5i0.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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4
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Sacerdote C, Mosso ML, Alessi D, Merletti F, Tagliabue G, D'Agostino A, Fabiano S, Savoia F, Piga P, Sessa M, Vetrano F, Gatta G, Maule M. An application of the Toronto Childhood Cancer Stage Guidelines in three population-based cancer registries: The case of central nervous tumors. Pediatr Blood Cancer 2020; 67:e28303. [PMID: 32301558 DOI: 10.1002/pbc.28303] [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: 10/31/2019] [Revised: 03/11/2020] [Accepted: 03/16/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Cancer stage is a determinant of survival of childhood central nervous system (CNS) cancers and could help the interpretation of survival variability among countries. Consensus guidelines to stage childhood malignancies in population cancer registries ("Toronto Childhood Cancer Stage Guidelines") have been recently proposed with the goal of data comparability. Indeed, stage is not systematically recorded in all registries and, when it is, different classification systems are used. We applied the Toronto Childhood Cancer Stage Guidelines to CNS cancer cases of three population-based cancer registries with the aim of evaluating the feasibility of staging this type of cancer and the critical points in the classification of CNS tumors. PROCEDURES The Toronto Childhood Cancer Stage Guidelines were applied to 175 CNS patients, diagnosed from January 1, 2002 to December 31, 2014 in three cancer registries in Italy, and the percentage of cases that could be staged was assessed. RESULTS One hundred eight of 126 (86%) medulloblastomas and other embryonal CNS cancers and 22 of 49 (45%) ependymomas were staged. Using these guidelines, survival of children with localized tumors could be discriminated from that of children with metastatic disease. CONCLUSIONS The use of the Toronto Childhood Cancer Stage Guidelines is feasible for staging medulloblastoma in Italian population-based cancer registries, whereas it is more difficult for ependymomas. In Italy, cerebrospinal fluid examination, one of the decisive tests to stage CNS tumors, is not routinely performed as a first-line diagnosis procedure in ependymoma pediatric patients. A similar exercise by a larger number of cancer registries in different countries could suggest improvements in the childhood cancer staging system.
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Affiliation(s)
- Carlotta Sacerdote
- Unit of Cancer Epidemiology, Citta' della Salute e della Scienza Hospital and Centre for Cancer Prevention, Turin, Italy.,Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Daniela Alessi
- Unit of Cancer Epidemiology, Citta' della Salute e della Scienza Hospital and Centre for Cancer Prevention, Turin, Italy
| | - Franco Merletti
- Unit of Cancer Epidemiology, Citta' della Salute e della Scienza Hospital and Centre for Cancer Prevention, Turin, Italy.,Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanna Tagliabue
- Lombardy Cancer Registry, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Anna D'Agostino
- Lombardy Cancer Registry, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Sabrina Fabiano
- Lombardy Cancer Registry, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Fabio Savoia
- Childhood Cancer Registry of Campania, AORN Santobono-Pausilipon, Naples, Italy
| | - Patrizia Piga
- Childhood Cancer Registry of Campania, AORN Santobono-Pausilipon, Naples, Italy
| | - Marcella Sessa
- Childhood Cancer Registry of Campania, AORN Santobono-Pausilipon, Naples, Italy
| | - Francesco Vetrano
- Childhood Cancer Registry of Campania, AORN Santobono-Pausilipon, Naples, Italy
| | - Gemma Gatta
- Evaluative Epidemiology Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Milena Maule
- Unit of Cancer Epidemiology, Citta' della Salute e della Scienza Hospital and Centre for Cancer Prevention, Turin, Italy.,Department of Medical Sciences, University of Turin, Turin, Italy
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5
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Karschnia P, Barbiero FJ, Schwaiblmair MH, Kaulen LD, Piepmeier JM, Huttner AJ, Becker KP, Fulbright RK, Baehring JM. Leptomeningeal dissemination of low-grade neuroepithelial CNS tumors in adults: a 15-year experience. Neurooncol Pract 2019; 7:118-126. [PMID: 32257290 DOI: 10.1093/nop/npz020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Leptomeningeal dissemination (LD) in adults is an exceedingly rare complication of low-grade neuroepithelial CNS tumors (LGNs). We aimed to determine relative incidence, clinical presentation, and predictors of outcome. Methods We searched the quality control database of the Section of Neuro-Oncology, Yale Cancer Center, for patients with LGN (WHO grade I/II) seen between 2002 and 2017. For cases complicated by LD, we recorded demographics, clinical signs, histopathological diagnosis, and imaging findings. A comprehensive literature review was performed. Results Eleven consecutive patients with LD were identified, representing 2.3% of individuals with LGN seen at our institution between 2002 and 2017 (n = 475). Ependymoma was the predominant histological entity. Mean time interval from diagnosis of LGN to LD was 38.6 ± 10 months. Symptoms were mostly attributed to communicating hydrocephalus. Tumor deposits of LD were either nodular or linear with variable enhancement (nonenhancing lesions in 4 of 11 patients). Localized (surgery, radiosurgery, involved-field, or craniospinal radiation therapy) or systemic treatments (chemotherapy) were provided. All patients progressed radiographically. Median overall survival after LD was 102 months. Survival was prolonged when a combination of localized and systemic therapies was administered (188.5 vs 25.5 months; P = .03). Demographics and tumor spectrum reported in the literature were similar to our cohort. Conclusions LD is a rare complication of LGNs. A high level of suspicion is required for timely diagnosis as early symptoms are nonspecific and commonly do not occur until years after initial tumor diagnosis. Repeated aggressive treatment appears to be beneficial in improving survival.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Frank J Barbiero
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Leon D Kaulen
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Joseph M Piepmeier
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Anita J Huttner
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin P Becker
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Robert K Fulbright
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Joachim M Baehring
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
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6
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Katiyar V, Sharma R, Tandon V, Garg K, Kale SS. Surgical resection of medulloblastoma: How much is sufficient and necessary? A systematic review of literature. Cancer Rep (Hoboken) 2019. [DOI: 10.1002/cnr2.1158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Varidh Katiyar
- NeurosurgeryAll India Institute of Medical Sciences New Delhi India
| | - Ravi Sharma
- NeurosurgeryAll India Institute of Medical Sciences New Delhi India
| | - Vivek Tandon
- NeurosurgeryAll India Institute of Medical Sciences New Delhi India
| | - Kanwaljeet Garg
- NeurosurgeryAll India Institute of Medical Sciences New Delhi India
| | - Shashank S. Kale
- NeurosurgeryAll India Institute of Medical Sciences New Delhi India
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7
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Stage at diagnosis for childhood solid cancers in Australia: A population-based study. Cancer Epidemiol 2019; 59:208-214. [DOI: 10.1016/j.canep.2019.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/16/2019] [Indexed: 12/17/2022]
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8
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The clinical importance of medulloblastoma extent of resection: a systematic review. J Neurooncol 2018; 139:523-539. [DOI: 10.1007/s11060-018-2906-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/14/2018] [Indexed: 11/26/2022]
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9
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Esbenshade AJ, Kocak M, Hershon L, Rousseau P, Decarie JC, Shaw S, Burger P, Friedman HS, Gajjar A, Moghrabi A. A Phase II feasibility study of oral etoposide given concurrently with radiotherapy followed by dose intensive adjuvant chemotherapy for children with newly diagnosed high-risk medulloblastoma (protocol POG 9631): A report from the Children's Oncology Group. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26373. [PMID: 28000417 PMCID: PMC5541391 DOI: 10.1002/pbc.26373] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/13/2016] [Accepted: 10/25/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Children with high-risk medulloblastoma historically have had a poor prognosis. The Children's Oncology Group completed a Phase II study using oral etoposide given with radiotherapy followed by intensive chemotherapy. PROCEDURE Patients enrolled in the study had high-risk disease defined as ≥1.5 cm2 of residual disease postsurgery or definite evidence of central nervous metastasis. All patients underwent surgery followed by radiotherapy. During radiation, the patients received oral etoposide (21 days on, 7 off) at an initial dose of 50 mg/m2 per day (treatment 1), which was reduced to 35 mg/m2 per day (treatment 2) due to toxicity. After radiotherapy, the patients received chemotherapy with three cycles of cisplatin and oral etoposide, followed by eight courses of cyclophosphamide and vincristine. RESULTS Between November 1998 and October 2002, 53 patients were accrued; 15 received treatment 1 and 38 treatment 2. Forty-seven patients (89%) were eligible. Response to radiation was excellent, with 19 (40.4%) showing complete response, 24 (51.1%) partial response, and four (8.5%) no recorded response. The overall 2- and 5-year progression-free survival (PFS) was 76.6 ± 6% and 70.2 ± 7%, respectively. The 2- and 5-year overall survival (OS) was 80.9 ± 6% and 76.6 ± 6%, respectively. Clinical response postradiation and PFS/OS were not significantly different between the treatment groups. There was a trend toward a difference in 5-year PFS between those without and with metastatic disease (P = 0.072). CONCLUSIONS Oral etoposide was tolerable at 35 mg/m2 (21 days on and 7 days off) when given during full-dose irradiation in patients with high-risk medulloblastoma with encouraging survival data.
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Affiliation(s)
- Adam J. Esbenshade
- Monroe Carrell Jr. Children’s Hospital at Vanderbilt and Vanderbilt Ingram Cancer Center
| | - Mehmet Kocak
- University of Tennessee, Health Science Center, Memphis, TN; Nashville, TN
| | - Linda Hershon
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Pierre Rousseau
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | | | - Susan Shaw
- State University of New York Upstate Medical University, Syracuse, NY
| | | | | | - Amar Gajjar
- St. Jude Children’s Research Hospital, Memphis, TN
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10
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Gupta S, Aitken JF, Bartels U, Brierley J, Dolendo M, Friedrich P, Fuentes-Alabi S, Garrido CP, Gatta G, Gospodarowicz M, Gross T, Howard SC, Molyneux E, Moreno F, Pole JD, Pritchard-Jones K, Ramirez O, Ries LAG, Rodriguez-Galindo C, Shin HY, Steliarova-Foucher E, Sung L, Supriyadi E, Swaminathan R, Torode J, Vora T, Kutluk T, Frazier AL. Paediatric cancer stage in population-based cancer registries: the Toronto consensus principles and guidelines. Lancet Oncol 2016; 17:e163-e172. [PMID: 27300676 DOI: 10.1016/s1470-2045(15)00539-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/03/2015] [Accepted: 11/16/2015] [Indexed: 11/16/2022]
Abstract
Population-based cancer registries generate estimates of incidence and survival that are essential for cancer surveillance, research, and control strategies. Although data on cancer stage allow meaningful assessments of changes in cancer incidence and outcomes, stage is not recorded by most population-based cancer registries. The main method of staging adult cancers is the TNM classification. The criteria for staging paediatric cancers, however, vary by diagnosis, have evolved over time, and sometimes vary by cooperative trial group. Consistency in the collection of staging data has therefore been challenging for population-based cancer registries. We assembled key experts and stakeholders (oncologists, cancer registrars, epidemiologists) and used a modified Delphi approach to establish principles for paediatric cancer stage collection. In this Review, we make recommendations on which staging systems should be adopted by population-based cancer registries for the major childhood cancers, including adaptations for low-income countries. Wide adoption of these guidelines in registries will ease international comparative incidence and outcome studies.
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Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Joanne F Aitken
- Cancer Council Queensland, Fortitude Valley, Brisbane, QLD, Australia
| | - Ute Bartels
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - James Brierley
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, ON, Canada
| | - Mae Dolendo
- Southern Philippines Medical Center, Bajada, Davao City, Philippines
| | - Paola Friedrich
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | | | | | - Gemma Gatta
- Evaluative Epidemiology Unit, Fondazione IRCSS Instituto Nazionale dei Tumori, Milan, Italy
| | - Mary Gospodarowicz
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, ON, Canada
| | - Thomas Gross
- Center for Global Health, National Cancer Institute, Bethesda, MD, USA
| | | | | | - Florencia Moreno
- Argentinian Oncopediatric Registry (ROHA), National Cancer Institute, Buenos Aires, Argentina
| | - Jason D Pole
- Pediatric Oncology Group of Ontario, Toronto, ON, Canada
| | | | - Oscar Ramirez
- Registro Poblacional de Cancer de Cali, Universidad del Valle, Oficina, Cali, Valle, Colombia
| | - Lynn A G Ries
- SEER Program, National Cancer Institute, Bethesda, MD, USA
| | | | - Hee Young Shin
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Eva Steliarova-Foucher
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Lillian Sung
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Eddy Supriyadi
- Pediatric Hematology Oncology Division, Department of Pediatrics, Dr Sardjito Hospital, Gadjah Mada University, Yogyakarta, Indonesia
| | | | - Julie Torode
- Union for International Cancer Control, Geneva, Switzerland
| | - Tushar Vora
- Tata Memorial Hospital, Parel, Mumbai, India
| | - Tezer Kutluk
- Union for International Cancer Control, Geneva, Switzerland
| | - A Lindsay Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
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11
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Wong TT, Liu YL, Ho DMT, Chang KP, Liang ML, Chen HH, Lee YY, Chang FC, Lin SC, Hsu TR, Chen KW, Kwang WK, Hou WY, Wang CY, Yen SH, Guo WY, Chen YW. Factors affecting survival of medulloblastoma in children: the changing concept of management. Childs Nerv Syst 2015; 31:1687-98. [PMID: 26351222 DOI: 10.1007/s00381-015-2884-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/10/2015] [Indexed: 01/21/2023]
Abstract
Medulloblastoma (MB) is a type of malignant tumor arising only in the cerebellum that was first defined by Cushing and Bailey in 1920s. In this review paper, we trace the evolution of risk stratification and the correlated changing concept of management in the past years. Outcome analysis of the hospital series of the Taipei Veterans General Hospital, Cheng Hsin General Hospital, and Taipei Medical University Hospital was performed to correlate prognostic indicators with reported studies. The purpose is to provide clues for age-specific and risk-adjusted optimal, effective, but beneficial and protective treatment strategies of these tumors in children.
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Affiliation(s)
- Tai-Tong Wong
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan.
- Pediatric Neurosurgery, Department of Neurosurgery, Taipei Medical University Hospital, 252 Wuxing St, Taipei, 11031, Taiwan.
| | - Yen-Lin Liu
- Department of Pediatrics, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- National Taiwan University and Academia Sinica, Taipei, Taiwan
| | - Donald Ming-Tak Ho
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Kai-Ping Chang
- Department of Pediatrics, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Muh-Lii Liang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Hsin-Hung Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Yi-Yen Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Shih-Chieh Lin
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Ting-Rong Hsu
- Department of Pediatrics, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Kuo-Wei Chen
- Department of Internal Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Wei-Kang Kwang
- Department of Pathology, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Wu-Yu Hou
- Department of Radiology, Chen Hsin General Hospital, Taipei, Taiwan
| | - Chung-Yih Wang
- Department of Radiation Oncology, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Sang-Hue Yen
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wan-You Guo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Yi-Wei Chen
- Department of Oncology, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, 201 Sec 2 Shi Pai Rd, Taipei, 11217, Taiwan.
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12
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Parkes J, Hendricks M, Ssenyonga P, Mugamba J, Molyneux E, Schouten-van Meeteren A, Qaddoumi I, Fieggen G, Luna-Fineman S, Howard S, Mitra D, Bouffet E, Davidson A, Bailey S. SIOP PODC adapted treatment recommendations for standard-risk medulloblastoma in low and middle income settings. Pediatr Blood Cancer 2015; 62:553-64. [PMID: 25418957 DOI: 10.1002/pbc.25313] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 09/16/2014] [Indexed: 01/11/2023]
Abstract
Effective treatment of children with medulloblastoma requires a functioning multi-disciplinary team with adequate neurosurgical, neuroradiological, pathological, radiotherapy and chemotherapy facilities and personnel. In addition the treating centre should have the capacity to effectively screen and manage any tumour and treatment-associated complications. These requirements have made it difficult for many low and middle-income countries (LMIC) centres to offer curative treatment. This article provides management recommendations for children with standard-risk medulloblastoma (localised tumours in children over the age of 3-5 years) according to the level of facilities available.
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Affiliation(s)
- Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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13
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Abstract
This article provides an overview of the intra-axial tumors that affect the cerebellum, which can be categorized by location and age. For each tumor, we review conventional neuroimaging findings and discuss the value of more advanced neuroimaging techniques. Current management strategies are also briefly discussed. Finally, cerebellar paraneoplastic disorders and medication-induced cerebellar disorders are discussed.
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Affiliation(s)
- Thomas J Pfiffner
- DENT Neurologic Institute, 3980 Sheridan Drive, Amherst, NY 14226, USA
| | - Ronak Jani
- DENT Neurologic Institute, 3980 Sheridan Drive, Amherst, NY 14226, USA
| | - Laszlo Mechtler
- DENT Neurologic Institute, Roswell Park Cancer Institute, 3980 Sheridan Drive, Buffalo, NY 14226, USA.
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Akino T, Han X, Nakayama H, McNeish B, Zurakowski D, Mammoto A, Klagsbrun M, Smith E. Netrin-1 promotes medulloblastoma cell invasiveness and angiogenesis, and demonstrates elevated expression in tumor tissue and urine of patients with pediatric medulloblastoma. Cancer Res 2014; 74:3716-26. [PMID: 24812271 DOI: 10.1158/0008-5472.can-13-3116] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Invasion and dissemination of medulloblastoma within the central nervous system is the principal factor predicting medulloblastoma treatment failure and death. Netrin-1 is an axon guidance factor implicated in tumor and vascular biology, including in invasive behaviors. We found that exogenous netrin-1 stimulated invasion of human medulloblastoma cells and endothelial cells in contrast to VEGF-A, which promoted invasion of endothelial cells but not medulloblastoma cells. Furthermore, medulloblastoma cells expressed endogenous netrin-1 along with its receptors, neogenin and UNC5B. Blockades in endogenous netrin-1, neogenin, or UNC5B reduced medulloblastoma invasiveness. Neogenin blockade inhibited netrin-1-induced endothelial cells tube formation and recruitment of endothelial cells into Matrigel plugs, two hallmarks of angiogenesis. In patients with pediatric medulloblastoma, netrin-1 mRNA levels were increased 1.7-fold in medulloblastoma tumor specimens compared with control specimens from the same patient. Immunohistochemical analyses showed that netrin-1 was elevated in medulloblastoma tumors versus cerebellum controls. Notably, urinary levels of netrin-1 were 9-fold higher in patients with medulloblastoma compared with control individuals. Moreover, urinary netrin-1 levels were higher in patients with invasive medulloblastoma compared with patients with noninvasive medulloblastoma. Finally, we noted that urinary netrin-1 levels diminished after medulloblastoma resection in patients. Our results suggest netrin-1 is a candidate biomarker capable of detecting an invasive, disseminated phenotype in patients with medulloblastoma and predicting their disease status.
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Affiliation(s)
- Tomoshige Akino
- Authors' Affiliations: Vascular Biology Program; Departments of Surgery
| | - Xuezhe Han
- Authors' Affiliations: Vascular Biology Program; Departments of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and Department of Neurosurgery, the Fourth Affiliated Hospital of Harbin Medical University, Harbin, PR China
| | - Hironao Nakayama
- Authors' Affiliations: Vascular Biology Program; Departments of Surgery
| | - Brendan McNeish
- Authors' Affiliations: Vascular Biology Program; Departments of Surgery
| | | | - Akiko Mammoto
- Authors' Affiliations: Vascular Biology Program; Departments of Surgery
| | - Michael Klagsbrun
- Authors' Affiliations: Vascular Biology Program; Departments of Surgery, Pathology,
| | - Edward Smith
- Authors' Affiliations: Vascular Biology Program; Departments of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and
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Wong SF, Mak G, Rosenthal MA, Cher L, Gan HK. Local perspective on a rare brain tumour: adult medulloblastoma. Intern Med J 2014; 43:567-72. [PMID: 23279053 DOI: 10.1111/imj.12060] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 11/29/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little contemporary data are available regarding Australian patterns of care in adult medulloblastoma. It is unclear whether treatment, extrapolated from paediatric protocols despite known differences between the two groups, results in comparable efficacy. AIM To perform a retrospective review of patterns of care in adult medulloblastoma, especially with respect to adjuvant chemotherapy, in Australian patients. METHODS All medulloblastoma patients aged 15 years or older at two neuro-oncology institutions were identified from January 1995-May 2011. Patients with supratentorial or peripheral tumours were excluded. Standardised data were extracted from each institution regarding symptoms, disease staging, treatments received, toxicities and survival outcomes. RESULTS Seventeen eligible patients were identified. Median age was 37 years (range 20-67 years). All had good performance status (Eastern Cooperative Oncology Group 0-1). There were 11 standard-risk de novo patients, three high-risk de novo patients and three patients with recurrent disease. Median overall survival (OS) had not been reached for standard-risk patients with median follow up of 58 months. The median OS for high-risk de novo patients was 21 months, while the median OS was 15 months for patients with recurrent disease. Treatment was well tolerated, with haematological toxicities being most common. CONCLUSIONS Combined modality therapy (surgery followed by postoperative radiotherapy and adjuvant chemotherapy) was well tolerated and associated with good outcomes in standard-risk de novo patients. High-risk and recurrent disease patients do extremely poorly regardless of treatment and better treatment strategies are needed in these patients.
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Affiliation(s)
- S F Wong
- Medical Oncology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
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16
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Relapse patterns in pediatric embryonal central nervous system tumors. J Neurooncol 2013; 115:209-15. [PMID: 23921420 DOI: 10.1007/s11060-013-1213-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 07/28/2013] [Indexed: 01/14/2023]
Abstract
Embryonal tumors of the central nervous system (CNS) share histological features and were therefore initially grouped as primitive neuroectodermal tumors (PNET) and treated similarly. We sought to determine the relapse patterns of specific embryonal CNS tumors. We conducted a historical cohort study of children diagnosed with CNS embryonal tumors from January 2000 to December 2011 in two pediatric neuro-oncology centers. Patients of 21 years of age or younger at time of presentation with a diagnosis of medulloblastoma, supratentorial PNET, pineoblastoma or atypical teratoid/rhabdoid tumor (ATRT) and at least one surveillance MRI were included. A total of 133 patients met inclusion criteria and 49 (37 %) patients relapsed during the observation period. The majority (79 %) of sPNET relapses were local, whereas all (100 %) PB relapses were associated with diffuse leptomeningeal disease. Relapse patterns for MB were more diverse with local recurrence in 27 %, distant recurrence in 35 % and diffuse leptomeningeal disease in 38 %. The frequency of relapses involving the spine differed (p < 0.001) between tumor types (MB 28/55 [51 %], sPNET 3/33 [9 %], ATRT 3/7 [43 %] and PB 12/12 [100 %]). No sPNET patients had isolated spinal relapse (0/14). Embryonal tumors were found to have divergent patterns of recurrence. While medulloblastoma has variable relapse presentations, sPNET relapses locally and pineoblastoma recurs with diffuse leptomeningeal disease involving the spine. These results point toward possibly new upfront treatment stratification among embryonal tumors in accordance with relapse pattern.
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Brasme JF, Grill J, Doz F, Lacour B, Valteau-Couanet D, Gaillard S, Delalande O, Aghakhani N, Puget S, Chalumeau M. Long time to diagnosis of medulloblastoma in children is not associated with decreased survival or with worse neurological outcome. PLoS One 2012; 7:e33415. [PMID: 22485143 PMCID: PMC3317660 DOI: 10.1371/journal.pone.0033415] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 02/08/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The long time to diagnosis of medulloblastoma, one of the most frequent brain tumors in children, is the source of painful remorse and sometimes lawsuits. We analyzed its consequences for tumor stage, survival, and sequelae. PATIENTS AND METHODS This retrospective population-based cohort study included all cases of pediatric medulloblastoma from a region of France between 1990 and 2005. We collected the demographic, clinical, and tumor data and analyzed the relations between the interval from symptom onset until diagnosis, initial disease stage, survival, and neuropsychological and neurological outcome. RESULTS The median interval from symptom onset until diagnosis for the 166 cases was 65 days (interquartile range 31-121, range 3-457). A long interval (defined as longer than the median) was associated with a lower frequency of metastasis in the univariate and multivariate analyses and with a larger tumor volume, desmoplastic histology, and longer survival in the univariate analysis, but not after adjustment for confounding factors. The time to diagnosis was significantly associated with IQ score among survivors. No significant relation was found between the time to diagnosis and neurological disability. In the 62 patients with metastases, a long prediagnosis interval was associated with a higher T stage, infiltration of the fourth ventricle floor, and incomplete surgical resection; it nonetheless did not influence survival significantly in this subgroup. CONCLUSIONS We found complex and often inverse relations between time to diagnosis of medulloblastoma in children and initial severity factors, survival, and neuropsychological and neurological outcome. This interval appears due more to the nature of the tumor and its progression than to parental or medical factors. These conclusions should be taken into account in the information provided to parents and in expert assessments produced for malpractice claims.
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Affiliation(s)
- Jean-Francois Brasme
- Department of Pediatric and Adolescent Oncology, Institut Gustave Roussy, Villejuif, France.
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von Hornstein S, Kortmann RD, Pietsch T, Emser A, Warmuth-Metz M, Soerensen N, Straeter R, Graf N, Thieme B, Gnekow AK. Impact of chemotherapy on disseminated low-grade glioma in children and adolescents: report from the HIT-LGG 1996 trial. Pediatr Blood Cancer 2011; 56:1046-54. [PMID: 21319282 DOI: 10.1002/pbc.23006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 12/06/2010] [Indexed: 11/06/2022]
Abstract
BACKGROUND We describe demographic data of disseminated childhood low-grade glioma (DLGG) prospectively recruited in the HIT-LGG 1996 study and evaluate the impact of primary chemotherapy (CT) on the outcome of these tumors, which have previously only been described in small and retrospective series. PATIENTS AND METHODS The multicenter study HIT-LGG 1996 accrued 1181 children and adolescents with low-grade glioma. 61 patients (5.2%) had tumor dissemination, with 2.8% being present at diagnosis. Frequencies of dissemination for different subgroups were calculated. Efficiency of first-line CT with vincristine/carboplatin was defined in 24 children with dissemination prior to first-line non-surgical-treatment. RESULTS Incidence of dissemination was high among infants (16%) with hypothalamic-chiasmatic-glioma (HCG) and diencephalic syndrome. A relevant percentage of HCG showed isolated spinal dissemination. CT achieved objective and overall response rates of 25% and 79% of the primary tumor and a similar response of disseminated lesions. Clinical stabilization or improvement could be achieved in the majority of patients during treatment. However, 20 of 24 patients experienced further progression and 5-year PFS was 6%. Dissemination prior to CT was a negative prognostic factor for PFS within the study (P = 0.005). Overall-survival of primary DLGG was inferior compared to LGG without dissemination at diagnosis (P < 0.001). CONCLUSION Complete MRI scan should be a standard diagnostic procedure in young children with hypothalamic-chiasmatic tumors especially if presenting with diencephalic syndrome. Dissemination in childhood LGG relates to impaired PFS. CT delays progression for responders. Multicenter studies have to evaluate the efficacy of extended treatment strategies in DLGG to improve outcome.
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Pezzolo A, Coco S, Raso A, Parodi F, Pistorio A, Valdora F, Capra V, Zollo M, Aschero S, Basso E, Cama A, Nozza P, Gambini C, Cinalli G, Garrè ML, Iolascon A, Pistoia V, Tonini GP. Loss of 10q26.1-q26.3 in association with 7q34-q36.3 gain or 17q24.3-q25.3 gain predict poor outcome in pediatric medulloblastoma. Cancer Lett 2011; 308:215-24. [PMID: 21652146 DOI: 10.1016/j.canlet.2011.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 05/04/2011] [Accepted: 05/05/2011] [Indexed: 11/28/2022]
Abstract
Medulloblastoma (MB) is the most common malignant brain tumor of childhood. We have investigated for novel chromosomal imbalances and prognostic markers of pediatric MB. Forty MBs out of 64, were analyzed using high resolution prometaphase comparative genomic hybridization. Chromosome 10q26.1-q26.3 loss combined with 17q24.3-q25.3 gain and/or 7q34-q36.3 gain in tumors predicted poor patient's survival. A minimal deleted region of 14.12cM at 10q26.1-q26.3 was refined by LOH analysis. We propose a new prognostic marker for pediatric MB patient risk stratification based on the presence of 10q26.1-q26.3 loss plus 17q24.3-q25.3 gain and/or 7q34-q36.3 gain associations.
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Affiliation(s)
- Annalisa Pezzolo
- Department of Experimental and Laboratory Medicine, IRCCS G. Gaslini Hospital, Genoa, Italy.
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Martínez León M. Meduloblastoma pediátrico, revisión y puesta al día. RADIOLOGIA 2011; 53:134-45. [DOI: 10.1016/j.rx.2010.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 11/08/2010] [Accepted: 11/11/2010] [Indexed: 12/28/2022]
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Pfaff E, Remke M, Sturm D, Benner A, Witt H, Milde T, von Bueren AO, Wittmann A, Schöttler A, Jorch N, Graf N, Kulozik AE, Witt O, Scheurlen W, von Deimling A, Rutkowski S, Taylor MD, Tabori U, Lichter P, Korshunov A, Pfister SM. TP53 Mutation Is Frequently Associated With CTNNB1 Mutation or MYCN Amplification and Is Compatible With Long-Term Survival in Medulloblastoma. J Clin Oncol 2010; 28:5188-96. [DOI: 10.1200/jco.2010.31.1670] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose The role of TP53 mutations in the tumorigenesis of sporadic medulloblastoma (MB) and the value of TP53 mutation status as a prognostic marker are not yet definitely elucidated. A recent report identified TP53 mutations in MB as an adverse prognostic marker. Hence, the current study was conducted to validate the prognostic role of TP53 mutation in MB and to understand its contribution to tumorigenesis. Methods A comprehensive genetic analysis of 310 MB samples was performed by screening for TP53 mutations and further relating the TP53 mutation status to p53 immunostaining, cytogenetic aberrations, and clinical variables. Results Mutation analysis of TP53 revealed mutations in 21 (6.8%) of 310 samples. Germline TP53 mutations were found in two patients with a history suggestive of a hereditary cancer syndrome. TP53 mutation status was not associated with unfavorable prognosis (P = .63) and was not linked to 17p allelic loss but was over-represented in the prognostically favorable WNT subgroup of MB as defined by CTNNB1 mutation (seven of 35 TP53-mutated tumors v 14 of 271 TP53 wild-type tumors; P = .005) and in tumors carrying high-level MYCN amplification (seven of 21 TP53-mutated tumors v 14 of 282 TP53 wild-type tumors; P = .001). Conclusion The contradictory results in the recent literature concerning the prognostic value of TP53 mutation might be explained by different frequencies of WNT MBs, different frequencies of patients with Li-Fraumeni syndrome, and different cumulative doses of alkylating drugs applied in these studies.
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Affiliation(s)
- Elke Pfaff
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Marc Remke
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dominik Sturm
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Axel Benner
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hendrik Witt
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Till Milde
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - André O. von Bueren
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrea Wittmann
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anna Schöttler
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Norbert Jorch
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Norbert Graf
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andreas E. Kulozik
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Olaf Witt
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wolfram Scheurlen
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andreas von Deimling
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stefan Rutkowski
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael D. Taylor
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Uri Tabori
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter Lichter
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrey Korshunov
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stefan M. Pfister
- From the German Cancer Research Center; University Hospital Heidelberg; University of Heidelberg, Heidelberg; University Medical Center Hamburg-Eppendorf, Hamburg; Krankenanstalten Gilead, Bielefeld; University of Saarland, Homburg; Cnopf'sche Kinderklinik, Nürnberg Children's Hospital, Nürnberg, Germany; and the Hospital for Sick Children, Toronto, Ontario, Canada
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Phi JH, Lee J, Wang KC, Cho BK, Kim IO, Park CK, Kim CY, Ahn HS, Kim IH, Kim SK. Cerebrospinal fluid M staging for medulloblastoma: reappraisal of Chang's M staging based on the CSF flow. Neuro Oncol 2010; 13:334-44. [PMID: 21134897 DOI: 10.1093/neuonc/noq171] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Tumor seeding is a strong negative prognostic factor for patients with medulloblastoma. Because Chang's M staging is based primarily on CT and myelographic findings and might be contradictory to the direction of normal cerebrospinal fluid (CSF) flow, seeding patterns and appropriate staging of medulloblastoma need to be revisited in patients diagnosed in the MRI era. We retrospectively reviewed the clinical and radiological data of 86 patients with a diagnosis of medulloblastoma who were treated in the MRI era. The presence of seeding in each subarachnoid space compartment and the patterns of seeding were analyzed in correlation with patient survival data. Thirty-four patients had gross seeding on perioperative MRI. Thirty-two patients had seeding in the spinal compartment. Sixteen and 12 patients had seeding in the infratentorial and supratentorial compartments, respectively. There was an apparent hierarchy of seeding (ie, from seeding in the spinal compartment up to the supratentorial compartment). Patients with seeding in the spinal compartment had longer progression-free survival (P = .038) and a tendency toward better overall survival (P = .053) compared with patients with seeding in intracranial compartments. We modified Chang's M staging based on the CSF flow and termed this approach "CSF M staging." CSF M staging for medulloblastoma, in which intracranial seeding occupies a higher rank than spinal seeding, was a better predictor of patient prognosis. This modified staging method may be applied to metastatic staging of brain tumors located in the fourth ventricle.
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Affiliation(s)
- Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehangno, Jongno-gu, 110-744 Seoul, South Korea
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Mulhern RK, Crisco JJ, Kun LE. Neuropsychological sequelae of childhood brain tumors: A review. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/15374418309533113] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Incidence, risks, and sequelae of posterior fossa syndrome in pediatric medulloblastoma. Int J Radiat Oncol Biol Phys 2009; 77:106-12. [PMID: 19695790 DOI: 10.1016/j.ijrobp.2009.04.058] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 03/30/2009] [Accepted: 04/09/2009] [Indexed: 11/22/2022]
Abstract
PURPOSE To investigate the incidence, risks, severity, and sequelae of posterior fossa syndrome (PFS) in children with medulloblastoma. METHODS AND MATERIALS Between 1990 and 2007, 63 children with medulloblastoma at Emory University and Children's Healthcare of Atlanta were treated with craniectomy followed by radiation. Fifty-one patients were assigned to a standard-risk group, and 12 patients were assigned to a high-risk group. Five patients had <1.5-cm(2) residual tumor, 4 had >or=1.5-cm(2) residual tumor, and the remainder had no residual tumor. Eleven patients had disseminated disease. Patients received craniospinal irradiation at a typical dose of 23.4 Gy or 36 Gy for standard- or high-risk disease, respectively. The posterior fossa was given a total dose of 54 or 55.8 Gy. Nearly all patients received chemotherapy following cooperative group protocols. RESULTS Median follow-up was 7 years. PFS developed in 18 patients (29%). On univariate analysis, brainstem invasion, midline tumor location, younger age, and the absence of radiographic residual tumor were found to be predictors of PFS; the last two variables remained significant on multivariate analysis. From 1990 to 2000 and from 2001 to 2007, the proportions of patients with no radiographic residual tumor were 77% and 94%, respectively. During the same eras, the proportions of patients with PFS were 17% and 39%. Only 4 patients had complete recovery at last follow-up. CONCLUSIONS The incidence of PFS increased in the latter study period and is proportional to more aggressive surgery. Children with midline tumors exhibiting brainstem invasion are at increased risk. With the increased incidence of PFS and the permanent morbidity in many patients, the risks and benefits of complete tumor removal in all patients need to be reexamined.
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Ang C, Hauerstock D, Guiot MC, Kasymjanova G, Roberge D, Kavan P, Muanza T. Characteristics and outcomes of medulloblastoma in adults. Pediatr Blood Cancer 2008; 51:603-7. [PMID: 18649371 DOI: 10.1002/pbc.21588] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Adult medulloblastoma is a rare disease for which there is no internationally accepted standard of care. Treatment regimens have typically been modeled after pediatric protocols. We sought to review the presentation, management, and outcome of patients with adult medulloblastoma treated at the McGill University teaching hospitals over the past 18 years. METHODS Medical records were reviewed to gather demographic and clinical data including presenting symptoms, tumor characteristics, management, survival, and treatment toxicity. RESULTS Twenty-five patients were identified. Eleven patients were female and 14 were male. The median age at diagnosis was 30 (range 17-48). Our 5- and 10-year overall survival (OS) rates were 78% and 30%, respectively. Median OS was 108 months and median progression-free survival time was 63 months. Age, sex, risk, stage, extent of resection, chemotherapy and time between surgery and adjuvant therapy did not significantly influence survival outcomes. The most frequently reported adverse events included sensory neuropathy, nausea, vomiting, febrile neutropenia, and radiation dermatitis. CONCLUSION Adult medulloblastoma has distinct characteristics from the pediatric population including presentation in the lateral cerebellar hemispheres. Late relapses, especially in the posterior fossa, are a significant problem. Further follow-up will be required to ascertain the effect of adjuvant chemotherapy on survival.
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Affiliation(s)
- Celina Ang
- Department of Internal Medicine, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
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Rao RD, Brown PD, Giannini C, Maher CO, Meyer FB, Galanis E, Erickson BJ, Buckner JC. Central Nervous System Tumors. Oncology 2007. [DOI: 10.1007/0-387-31056-8_34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Survival among children with medulloblastoma in Greece: gains from transition to chemotherapy and socio-economic differentials. Eur J Cancer Prev 2007; 16:460-5. [PMID: 17923818 DOI: 10.1097/01.cej.0000243848.74609.9a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Merchant TE, Kun LE, Krasin MJ, Wallace D, Chintagumpala MM, Woo SY, Ashley DM, Sexton M, Kellie SJ, Ahern V, Gajjar A. Multi-institution prospective trial of reduced-dose craniospinal irradiation (23.4 Gy) followed by conformal posterior fossa (36 Gy) and primary site irradiation (55.8 Gy) and dose-intensive chemotherapy for average-risk medulloblastoma. Int J Radiat Oncol Biol Phys 2007; 70:782-7. [PMID: 17892918 PMCID: PMC2716663 DOI: 10.1016/j.ijrobp.2007.07.2342] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Revised: 07/02/2007] [Accepted: 07/04/2007] [Indexed: 11/15/2022]
Abstract
PURPOSE Limiting the neurocognitive sequelae of radiotherapy (RT) has been an objective in the treatment of medulloblastoma. Conformal RT to less than the entire posterior fossa (PF) after craniospinal irradiation might reduce neurocognitive sequelae and requires evaluation. METHODS AND MATERIALS Between October 1996 and August 2003, 86 patients, 3-21 years of age, with newly diagnosed, average-risk medulloblastoma were treated in a prospective, institutional review board-approved, multi-institution trial of risk-adapted RT and dose-intensive chemotherapy. RT began within 28 days of definitive surgery and consisted of craniospinal irradiation (23.4 Gy), conformal PF RT (36.0 Gy), and primary site RT (55.8 Gy). The planning target volume for the primary site included the postoperative tumor bed surrounded by an anatomically confined margin of 2 cm that was then expanded with a geometric margin of 0.3-0.5 cm. Chemotherapy was initiated 6 weeks after RT and included four cycles of high-dose cyclophosphamide, cisplatin, and vincristine. RESULTS At a median follow-up of 61.2 months (range, 5.2-115.0 months), the estimated 5-year event-free survival and cumulative incidence of PF failure rate was 83.0% +/- 5.3% and 4.9% +/- 2.4% (+/- standard error), respectively. The targeting guidelines used in this study resulted in a mean reduction of 13% in the volume of the PF receiving doses >55 Gy compared with conventionally planned RT. The reductions in the dose to the temporal lobes, cochleae, and hypothalamus were statistically significant. CONCLUSION This prospective trial has demonstrated that irradiation of less than the entire PF after 23.4 Gy craniospinal irradiation for average-risk medulloblastoma results in disease control comparable to that after treatment of the entire PF.
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Affiliation(s)
- Thomas E Merchant
- Department of Radiological Sciences, Division of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Santos MA, Viégas CMP, Servidoni RA, Barros MHM, Pinel MI, Araújo CMM. Timing of radiation in children with medulloblastoma/PNET. Pediatr Blood Cancer 2007; 48:416-22. [PMID: 17034032 DOI: 10.1002/pbc.21049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND To evaluate the importance of timing of radiation therapy in children with PNET/medulloblastoma, treated at the Brazilian National Cancer Institute (INCA). PROCEDURE The records of 101 children with confirmed diagnosis of medulloblastoma were retrospectively reviewed. Patients had a median follow-up of 48 months (0.5-241 months). The age varied from 0.8 to 17.5 years (median: 7.6 years) and 21.7% were 3 years old or younger. RESULTS According to the data collected from patients that received treatment for medulloblastoma from 1983 to 2001, the overall survival (OS) rate was 53% and the Disease Free Survival (DFS) rate was 40%. Multivariate analysis showed that under age 3 years, presence of neoplasic cells in the cerebrospinal fluid (CSF) at presentation or subtotal tumor resection resulted in a worse OS. The patients that received a biological effective dose (BED) greater than 44 Gy10 had better prognosis. Two-thirds of the patients had complete response after the initial treatment. Among them, 50% (34 patients) recurred, and of those 34 patients, 42% of them (14 patients) had recurrence in the posterior fossa. CONCLUSION Surgery with total resection of the tumor and absence of neoplasic cells in the CSF are effective predictors of better OS. Radiotherapy was more effective when a BED was greater than 44 Gy10.
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Affiliation(s)
- Marcos A Santos
- Department of Radiation Oncology, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil.
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Mu X, Björk-Eriksson T, Nill S, Oelfke U, Johansson KA, Gagliardi G, Johansson L, Karlsson M, Zackrisson DB. Does electron and proton therapy reduce the risk of radiation induced cancer after spinal irradiation for childhood medulloblastoma? A comparative treatment planning study. Acta Oncol 2006; 44:554-62. [PMID: 16165914 DOI: 10.1080/02841860500218819] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this treatment planning comparison study was to explore different spinal irradiation techniques with respect to the risk of late side-effects, particularly radiation-induced cancer. The radiotherapy techniques compared were conventional photon therapy, intensity modulated x-ray therapy (IMXT), conventional electron therapy, intensity/energy modulated electron therapy (IMET) and proton therapy (IMPT).CT images for radiotherapy use from five children, median age 8 and diagnosed with medulloblastoma, were selected for this study. Target volumes and organs at risk were defined in 3-D. Treatment plans using conventional photon therapy, IMXT, conventional electron therapy, IMET and IMPT were set up. The probability of normal tissue complication (NTCP) and the risk of cancer induction were calculated using models with parameters-sets taken from published data for the general population; dose data were taken from dose volume histograms (DVH). Similar dose distributions in the targets were achieved with all techniques but the absorbed doses in the organs-at-risk varied significantly between the different techniques. The NTCP models based on available data predicted very low probabilities for side-effects in all cases. However, the effective mean doses outside the target volumes, and thus the predicted risk of cancer induction, varied significantly between the techniques. The highest lifetime risk of secondary cancers was estimated for IMXT (30%). The lowest risk was found with IMPT (4%). The risks associated with conventional photon therapy, electron therapy and IMET were 20%, 21% and 15%, respectively. This model study shows that spinal irradiation of young children with photon and electron techniques results in a substantial risk of radiation-induced secondary cancers. Multiple beam IMXT seems to be associated with a particularly high risk of secondary cancer induction. To minimise this risk, IMPT should be the treatment of choice. If proton therapy is not available, advanced electron therapy may provide a better alternative.
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Affiliation(s)
- Xiangkui Mu
- Department of Radiation Sciences, Oncology, Umeå University, SE-901 87, Umeå, Sweden
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Hong TS, Mehta MP, Boyett JM, Donahue B, Rorke LB, Zeltzer PM. Patterns of treatment failure in infants with primitive neuroectodermal tumors who were treated on CCG-921: a phase III combined modality study. Pediatr Blood Cancer 2005; 45:676-82. [PMID: 16007595 DOI: 10.1002/pbc.20184] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE To analyze patterns of treatment failure in infants with primitive neuroectodermal tumors (PNETs) who were treated primarily with chemotherapy in a large multi-institutional study. MATERIALS AND METHODS Sixty-five prospectively staged patients with PNET confirmed by central pathology review, who were 18 months or younger were treated on Children's Cancer Group Study 921 (CCG-921) primarily with chemotherapy. Forty-six patients had posterior fossa (PF) primary tumors and 19 patients had supratentorial (ST) primaries. Patterns of sites of initial treatment failure were analyzed and compared to failure patterns of 180 older children who had PF-PNETs, and 44 older children with ST-PNETs who were treated on the same protocol. RESULTS The entire cohort of younger patients fared much worse than those older than 18 months. Cumulative 5-year relapse incidence (+/-SE) for younger patients with PF-PNETs was 64.5 +/- 8.9% for patients without metastases (M0) compared to 71.4 +/- 13.4% for patients with metastases (M+). The cumulative 5-year relapse incidences for younger patients with ST-PNETs were 64.3 +/- 13.7% for M0 patients compared to 100 +/- 33.3% for M+ patients. Relapses in these patients occurred within 2 years. The overall treatment failure rate was significantly higher for younger compared to older patients with PF-PNET and ST-PNET. There was no statistically significant difference in relapse patterns between patients with PF primary tumors and ST primaries when stratified by stage. There was no statistically significant difference in relapse patterns between M0 and M+ patients. All patients had a high risk of recurrence at primary tumor site. Younger patients who had PF primary tumors without metastasis at presentation were significantly more likely to relapse in PF than older patients. Younger patients were at significant risk of relapse in the spine, but none had it as the sole site of first relapse. CONCLUSIONS Despite aggressive chemotherapy, younger children with PNETs have high rates of treatment failure and fare worse than high-risk, older patients with PF-PNETs, indicating the need to maximize local, regional, and systemic therapies.
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Affiliation(s)
- Theodore S Hong
- Department of Human Oncology, School of Medicine, University of Wisconsin, Madison, WI 53792, USA
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Affiliation(s)
- Arnold C Paulino
- Department of Radiation Oncology, Emory University, and the Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Fiorillo A, Maggi G, Martone A, Migliorati R, D'Amore R, Alfieri E, Greco N, Cirillo S, Marano I. Shunt-related abdominal metastases in an infant with medulloblastoma: long-term remission by systemic chemotherapy and surgery. J Neurooncol 2001; 52:273-6. [PMID: 11519858 DOI: 10.1023/a:1010687121450] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This is the first reported case of long remission of abdominal metastases spread through a ventriculo-peritoneal shunt in an infant diagnosed, four years ago, at age 1 year and 10 months, to have cerebral medulloblastoma. Two years later, while in second complete remission of his cerebral tumor, he showed abdominal metastases, successfully treated by platinum based chemotherapy and surgery. One year later, a second abdominal relapse and hepatic metastases were treated by doxorubicin administration and surgery. Since then the child remained in continuous complete remission. This unusual favorable outcome can be explained by an extreme responsiveness of the tumor, unprotected by the blood brain barrier, to systemic chemotherapy, particularly to doxorubicin administration. The need for careful surveillance of patients with ventriculo-peritoneal shunts is emphasized. Searching for new tools, such as entrapment of doxorubicin in liposomes, able to overcome the blood-brain barrier and to expose brain tumors to effective drugs, probably represents the best choice for future treatment strategies of CNS tumors.
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Affiliation(s)
- A Fiorillo
- Pediatric Oncology Unit of the University Federico II, Naples, Italy
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Chan AW, Tarbell NJ, Black PM, Louis DN, Frosch MP, Ancukiewicz M, Chapman P, Loeffler JS. Adult medulloblastoma: prognostic factors and patterns of relapse. Neurosurgery 2000; 47:623-31; discussion 631-2. [PMID: 10981749 DOI: 10.1097/00006123-200009000-00018] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To determine the patterns of relapse and the prognostic factors for adult medulloblastomas treated in the magnetic resonance imaging era. METHODS Between 1986 and 1996, 32 adult patients (age, > or =16 yr) with medulloblastomas confined to the craniospinal axis were treated in our institutions. Twenty cases involved classic histological features and 12 involved the desmoplastic variant. The Chang staging distribution was as follows: T1, 2; T2, 17; T3, 10; T4, 3; M0, 24; M1, 1; M2, 4; M3, 3. Brainstem invasion was present in nine patients. Lesions were midline in 13 cases and lateral in 19. Resection was complete in 17 cases, subtotal in 6, and partial in 5, with biopsy only in 4 cases. All patients received postoperative radiotherapy, with median doses of 36 Gy to the entire craniospinal axis and 55 Gy to the posterior fossa. Twenty-four patients received chemotherapy (20 before radiotherapy, 3 after radiotherapy, and 1 before and after radiotherapy). RESULTS With a median follow-up period of 5.4 years, 17 patients experienced recurrences. At 5 and 8 years, overall survival rates were 83 and 45% and disease-free survival rates were 57 and 40%, respectively. The 5- and 8-year posterior fossa control rates were 67 and 59%, respectively. Twenty-nine percent of all relapses occurred more than 5 years after treatment. The posterior fossa was the most common site of relapses. In univariate analyses, factors adversely affecting posterior fossa control were less than complete resection (P<0.001), the presence of brainstem invasion (P = 0.02), and the use of chemotherapy (P = 0.03). The overall radiotherapy duration was marginally significant in predicting posterior fossa control, with 5-year posterior fossa control rates of 81 and 49% for durations of less than 48 days and 48 days or more, respectively (P = 0.06). In a multivariate analysis, complete resection was predictive of improved posterior fossa control (P = 0.02) and disease-free survival (P = 0.02) rates. Of the eight low-risk patients who received radiotherapy alone, three experienced recurrences in the bone as the only site of relapse. CONCLUSION Late relapse is common among adult patients with medulloblastomas, and long-term follow-up monitoring is important. Because of the high risk of systemic failure among the low-risk patients treated with radiotherapy alone, the role of chemotherapy for this group of patients needs to be further investigated. Complete resection, the absence of brainstem invasion, and an overall radiotherapy duration of less than 48 days are important prognostic factors.
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Affiliation(s)
- A W Chan
- Department of Radiation Oncology, Massachusetts General Hospital, Boston 02114, USA
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Chan AW, Tarbell NJ, Black PM, Louis DN, Frosch MP, Ancukiewicz M, Chapman P, Loeffler JS. Adult Medulloblastoma: Prognostic Factors and Patterns of Relapse. Neurosurgery 2000. [DOI: 10.1227/00006123-200009000-00018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Frühwald MC, O'Dorisio MS, Rush LJ, Reiter JL, Smiraglia DJ, Wenger G, Costello JF, White PS, Krahe R, Brodeur GM, Plass C. Gene amplification in PNETs/medulloblastomas: mapping of a novel amplified gene within the MYCN amplicon. J Med Genet 2000; 37:501-9. [PMID: 10882752 PMCID: PMC1734623 DOI: 10.1136/jmg.37.7.501] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The pathological entity of primitive neuroectodermal tumour/medulloblastoma (PNET/MB) comprises a very heterogeneous group of neoplasms on a clinical as well as on a molecular level. We evaluated the importance of DNA amplification in medulloblastomas and other primitive neuroectodermal tumours (PNETs) of the CNS. METHOD Restriction landmark genomic scanning (RLGS), a method that allows the detection of low level amplification, was used. RLGS provides direct access to DNA sequences circumventing positional cloning efforts. Furthermore, we analysed several samples by CGH. DESIGN Twenty primary medulloblastomas, five supratentorial PNETs, and five medulloblastoma cell lines were studied. RESULTS Although our analysis confirms that gene amplification is generally a rare event in childhood PNET/MB, we found a total of 17 DNA fragments that were amplified in seven different tumours. Cloning and sequencing of several of these fragments confirmed the previous finding of MYC amplification in the cell line D341 Med and identified novel DNA sequences amplified in PNET/MB. We describe for the first time amplification of the novel gene, NAG, in a subset of PNET/MB. Despite genomic amplification, NAG was not overexpressed in the tumours studied. We have determined that NAG maps less than 50 kb 5' of DDX1 and approximately 400 kb telomeric of MYCN on chromosome 2p24. CONCLUSION We found a similar but slightly higher frequency of amplification than previously reported. We present several DNA fragments that may belong to the CpG islands of novel genes amplified in a small subset of PNET/MB. As an example we describe for the first time the amplification of NAG in the MYCN amplicon in PNET/MB.
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MESH Headings
- Blotting, Northern
- Blotting, Southern
- Brain Neoplasms/genetics
- Brain Neoplasms/pathology
- Cerebellar Neoplasms/genetics
- Cerebellar Neoplasms/pathology
- Child
- Child, Preschool
- Chromosomes, Artificial, Yeast
- Contig Mapping
- CpG Islands
- DNA Mutational Analysis
- DNA, Neoplasm/analysis
- Expressed Sequence Tags
- Female
- Gene Amplification
- Genes, myc/genetics
- Humans
- Male
- Medulloblastoma/genetics
- Medulloblastoma/pathology
- Neoplasm Proteins/genetics
- Neuroectodermal Tumors, Primitive/genetics
- Organ Specificity
- Polymerase Chain Reaction
- Polymorphism, Genetic
- Tumor Cells, Cultured
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Affiliation(s)
- M C Frühwald
- Division of Pediatric Hematology and Oncology, The Ohio State University and the Comprehensive Cancer Center, Columbus 43210, USA.
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Walter AW, Mulhern RK, Gajjar A, Heideman RL, Reardon D, Sanford RA, Xiong X, Kun LE. Survival and neurodevelopmental outcome of young children with medulloblastoma at St Jude Children's Research Hospital. J Clin Oncol 1999; 17:3720-8. [PMID: 10577843 DOI: 10.1200/jco.1999.17.12.3720] [Citation(s) in RCA: 162] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Young children treated for medulloblastoma are at especially high risk for morbidity and mortality from their disease and therapy. This study sought to assess the relationship, if any, between patient outcome and M stage. Neuropsychologic and endocrine outcomes were also assessed. PATIENTS AND METHODS Twenty-nine consecutively diagnosed infants and young children were treated for medulloblastoma at St Jude Children's Research Hospital between November 1984 and December 1995. All patients were treated with the intent of using postoperative chemotherapy to delay planned irradiation. RESULTS The median age at diagnosis was 2.6 years. Six patients completed planned chemotherapy without progressive disease and underwent irradiation at completion of chemotherapy. Twenty-three children experienced disease progression during chemotherapy and underwent irradiation at the time of progression. The 5-year overall survival rate for the entire cohort was 51% +/- 10%. The 5-year progression-free survival rate was 21% +/- 8%. M stage did not impact survival. All patients lost cognitive function during and after therapy at a rate of -3.9 intelligence quotient points per year (P =.0028). Sensory functions declined significantly after therapy (P =.007). All long-term survivors required hormone replacement therapy and had growth abnormalities. CONCLUSION The majority of infants treated for medulloblastoma experienced disease progression during initial chemotherapy. However, more than half of these patients can be cured with salvage radiation therapy, regardless of M stage. The presence of metastatic disease did not increase the risk of dying from medulloblastoma. All patients treated in this fashion have significant neuropsychologic deficits. Our experience demonstrates that medulloblastoma in infancy is a curable disease, albeit at a significant cost.
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Affiliation(s)
- A W Walter
- Departments of Hematology-Oncology, Behavioral Medicine, Radiation Oncology, and Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA.
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Narayana A, Jeswani S, Paulino AC. The cranial-spinal junction in medulloblastoma: does it matter? Int J Radiat Oncol Biol Phys 1999; 44:81-4. [PMID: 10219798 DOI: 10.1016/s0360-3016(98)00479-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE Late effects of treatment in children and young adults with medulloblastoma can be influenced by the technique employed in radiating the craniospinal axis. The purpose of this study is to determine whether the placement of the cranial-spinal junction has an impact on dose to the cervical spinal cord and surrounding organs. METHODS AND MATERIALS Five patients underwent computed tomography (CT) simulation in the prone position for craniospinal irradiation. A dose of 36 Gy was prescribed to the entire neuraxis. The doses to the cervical spinal cord and surrounding organs were calculated using a cranial-spinal junction at the C1-C2 vertebral interspace (high junction) or at the lowest point in the neck, with exclusion of the shoulders in the lateral cranial fields (low junction). The volume of critical organs at risk, as well as dose to these structures using the cranial and spinal field(s) were outlined and calculated using the CMS FOCUS 3-dimensional treatment planning system. RESULTS The average dose to the cervical spinal cord was 11.9% higher than the prescribed dose with the low junction, and 6.7% higher with the high junction. However, doses to the thyroid gland, mandible, pharynx, and larynx were increased by an average of 29.6%, 75.8%, 70.6%, and 227.7%, respectively, by the use of the high junction compared to the low junction. CONCLUSION A higher dose to the cervical spinal cord can be minimized by using a high junction. However, this would be at the cost of substantially increased doses to surrounding organs such as the thyroid gland, mandible, pharynx, and larynx. This can be critical in children and young adults, where hypothyroidism, mandibular hypoplasia, and development of second malignancies may be a late sequela of radiation therapy.
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Affiliation(s)
- A Narayana
- Department of Radiotherapy, Loyola University of Chicago, Maywood, IL, USA
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Zeltzer PM, Boyett JM, Finlay JL, Albright AL, Rorke LB, Milstein JM, Allen JC, Stevens KR, Stanley P, Li H, Wisoff JH, Geyer JR, McGuire-Cullen P, Stehbens JA, Shurin SB, Packer RJ. Metastasis stage, adjuvant treatment, and residual tumor are prognostic factors for medulloblastoma in children: conclusions from the Children's Cancer Group 921 randomized phase III study. J Clin Oncol 1999; 17:832-45. [PMID: 10071274 DOI: 10.1200/jco.1999.17.3.832] [Citation(s) in RCA: 519] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE From 1986 to 1992, "eight-drugs-in-one-day" (8-in-1) chemotherapy both before and after radiation therapy (XRT) (54 Gy tumor/36 Gy neuraxis) was compared with vincristine, lomustine (CCNU), and prednisone (VCP) after XRT in children with untreated, high-stage medulloblastoma (MB). PATIENTS AND METHODS Two hundred three eligible patients with an institutional diagnosis of MB were stratified by local invasion and metastatic stage (Chang T/M) and randomized to therapy. Median time at risk from study entry was 7.0 years. RESULTS Survival and progression-free survival (PFS) +/- SE at 7 years were 55%+/-5% and 54%+/-5%, respectively. VCP was superior to 8-in-1 chemotherapy, with 5-year PFS rates of 63%+/-5% versus 45%+/-5%, respectively (P = .006). Upon central neuropathology review, 188 patients were confirmed as having MB and were the subjects for analyses of prognostic factors. Children aged 1.5 to younger than 3 years had inferior 5-year estimates of PFS, compared with children 3 years old or older (P = .0014; 32%+/-10% v 58%+/-4%, respectively). For MB patients 3 years of age or older, the prognostic effect of tumor spread (MO v M1 v M2+) on PFS was powerful (P = .0006); 5-year PFS rates were 70%+/-5%, 57%+/-10%, and 40%+/-8%, respectively. PFS distributions at 5 years for patients with M0 tumors with less than 1.5 cm2 of residual tumor, versus > or = 1.5 cm2 of residual tumor by scan, were significantly different (P = .023; 78%+/-6% v 54%+/-11%, respectively). CONCLUSION VCP plus XRT is a superior adjuvant combination compared with 8-in-1 chemotherapy plus XRT. For patients with M0 tumors, residual tumor bulk (not extent of resection) is a predictor for PFS. Patients with M0 tumors, > or = 3 years with < or = 1.5 cm2 residual tumor, had a 78%+/-6% 5-year PFS rate. Children younger than 3 years old who received a reduced XRT dosage had the lowest survival rate.
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Affiliation(s)
- P M Zeltzer
- University of California at Irvine Medical Center, Orange, USA
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Fisher PG, Needle MN, Cnaan A, Zhao H, Geyer JR, Molloy PT, Goldwein JW, Herman-Liu AB, Phillips PC. Salvage therapy after postoperative chemotherapy for primary brain tumors in infants and very young children. Cancer 1998; 83:566-74. [PMID: 9690551 DOI: 10.1002/(sici)1097-0142(19980801)83:3<566::aid-cncr27>3.0.co;2-t] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND A trend toward the use of prolonged postoperative chemotherapy, with radiotherapy deferred until relapse, has emerged for very young children with malignant brain tumors. This study was undertaken to determine the failure patterns among infants who receive such treatment and to evaluate their responses to first salvage therapy, particularly radiotherapy, after postoperative chemotherapy. METHODS A retrospective cohort was assembled, which comprised all children younger than 36 months with biopsy-proven malignant brain tumors diagnosed during the years 1987-1993 at 3 pediatric oncology referral centers. Fifty-eight children were treated with postoperative chemotherapy without irradiation, 40 of whom experienced relapse of their malignancy. These patients' charts were reviewed for failure patterns. Thirty-five of these children received salvage therapy. Statistical and survival analysis with the Cox proportional hazards regression model was performed. RESULTS Among the 40 children who experienced relapse, 30 of 31 (97%) with solitary disease at initial diagnosis relapsed at the primary site of disease. Thirty-seven of 39 infants (95%) developed relapse that included their primary site of disease. Sixty percent of relapses were asymptomatic and were detected by magnetic resonance imaging (MRI) surveillance rather than by clinical examination. Two-year progression free survival (PFS) after relapse for infants who received salvage therapy was 29% (standard error [SE] = 8%). For infants who received radiotherapy alone, the 2-year PFS was 21% (SE = 9%). PFS did not differ according to whether relapses were detected clinically or radiographically or treated by radiotherapy, chemotherapy, surgery, or multimodal therapy. CONCLUSIONS Relapse of brain tumors in infants after prolonged postoperative chemotherapy is largely a problem of local disease control. Salvage is possible after prolonged postoperative chemotherapy, but it yields few instances of long term, progression free survival. No therapeutic modality is superior for salvage at relapse. A strategy of reserving radiotherapy for the salvage of infants whose brain tumors relapse during postoperative chemotherapy demonstrated only limited effectiveness.
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Affiliation(s)
- P G Fisher
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California 94305-5235, USA
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42
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del Charco JO, Bolek TW, McCollough WM, Maria BL, Kedar A, Braylan RC, Mickle JP, Buatti JM, Mendenhall NP, Marcus RB. Medulloblastoma: time-dose relationship based on a 30-year review. Int J Radiat Oncol Biol Phys 1998; 42:147-54. [PMID: 9747832 DOI: 10.1016/s0360-3016(98)00197-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Time-dose relationships have proven important in many cancer sites. This study evaluates the time factors involved in the successful postoperative radiotherapy of medulloblastoma, based on a 30-year experience in a single institution. METHODS AND MATERIALS Fifty-three patients with medulloblastoma received postoperative craniospinal radiotherapy with curative intent between 1963 and 1993. Seven patients (13%) underwent biopsy alone, 28 patients (53%) had subtotal excision, and 18 patients (34%) had gross total excision. Eleven patients received adjuvant chemotherapy. The mean posterior fossa dose was 53.1 Gy; most patients received 54.0 Gy (range, 34.3 to 69.6 Gy). For 41 patients receiving once-a-day therapy, the mean dose was 50.6 Gy (range, 34.3 to 56.0 Gy). For 12 patients receiving twice-a-day therapy, the mean dose was 61.8 Gy (range, 52.6 to 69.6 Gy). Minimum follow-up was 2 years, and median follow-up was 10.7 years. Survival, freedom from relapse, and disease control in the posterior fossa were calculated using the Kaplan-Meier method, and multivariate analysis was performed for prognostic factors. Variables related to radiotherapy were examined, including dose to the craniospinal axis, dose to the posterior fossa, fractionation (once-a-day vs. twice-a-day), use of adjuvant chemotherapy, risk group [high (> or =T3b or > or =M1) or low (< or =T3a and M0-MX)], interval between surgery and radiotherapy (excluding patients receiving chemotherapy before radiotherapy), and duration of radiotherapy. RESULTS At 5 and 10 years, overall survival rates were 68 and 64%, respectively, and freedom-from-relapse rates were 61 and 52%, respectively. Rates of disease control in the posterior fossa at 5 and 10 years were 79 and 68%, respectively. At 5 years, absolute survival rates after biopsy alone, subtotal excision, and gross total excision were 43, 67, and 78%, respectively (p=0.04), and posterior fossa control rates were 27, 89, and 83%, respectively (p=0.004). Duration of the treatment course was the only radiotherapy-related variable with a significant impact on freedom from relapse and posterior fossa control. For patients whose radiation treatment duration was < or =45 days, posterior fossa control was 89% at 5 years, compared with 68% for those treated for >45 days (p=0.01). Duration of treatment also affected freedom from relapse at 5 years: < or =45 days (76%) compared with >45 days (43%), p=0.004. CONCLUSION Our study demonstrates that if adequate doses are used, then radiotherapy treatment duration will significantly affect the outcome in terms of control of disease in the posterior fossa and freedom from relapse. Fractions of at least 1.75 Gy given once a day, or a twice-a-day regimen should yield optimal local control results.
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Affiliation(s)
- J O del Charco
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville 32610-0385, USA
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43
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Scheurlen W, Kühl J. Current diagnostic and therapeutic management of CNS metastasis in childhood primitive neuroectodermal tumors and ependymomas. J Neurooncol 1998; 38:181-5. [PMID: 9696369 DOI: 10.1023/a:1005919900622] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metastatic disease is a major problem in the management of the most frequent childhood brain tumors, in ependymoma and primitive neuroectodermal tumors (PNET). Today, contrast enhanced craniospinal MRI and careful analysis of craniospinal fluid are a prerequisite for correct staging of both tumors and imply therapeutic consequences. So far metastatic spread of medulloblastoma and some ependymomas is prevented by conventional chemotherapy and radiotherapy. However, some forms of diffuse metastatic dissemination in medulloblastoma are resistant to conventional therapeutic regimens and require new experimental strategies.
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Affiliation(s)
- W Scheurlen
- Department of Pediatrics, University of Mannheim, Germany
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Ayan I, Kebudi R, Bayindir C, Darendeliler E. Microscopic local leptomeningeal invasion at diagnosis of medulloblastoma. Int J Radiat Oncol Biol Phys 1997; 39:461-6. [PMID: 9308951 DOI: 10.1016/s0360-3016(97)00083-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To document the incidence and outcome of patients with microscopic local leptomeningeal invasion at presentation, children with medulloblastoma were reviewed. METHODS AND MATERIALS Nineteen patients (1-12 years of age), who had surgical resection (14 total, 5 subtotal) and were diagnosed as medulloblastoma, were evaluated for disease extent by pre- and postoperative computerized tomography/magnetic resonance imaging, histopathologic evaluation of leptomeninges adjacent to the resected tumor tissue, myelography/magnetic resonance of the entire spine, and analysis of cerebrospinal fluid cytology. Patients were also reviewed for disease outcome. RESULTS Staging revealed one T2, nine T3a, eight T3b, and one T4 disease. There were 10 M0, 2 M1, 2 M2, 2 M3, and 3 Mx patients according to Chang's classification. Ten out of 19 patients (52.6%) demonstrated microscopic local leptomeningeal invasion. When only the 10 patients with M0 disease were considered, three out of five patients with microscopic local leptomeningeal invasion was found to have one or more relapses. The five other M0 patients without microscopic local invasion were in complete remission at the time of analysis. CONCLUSION The incidence of microscopic local leptomeningeal invasion in patients with medulloblastoma is high. Whereas the impact on survival remains to be determined in larger series, data suggests prognostic role for isolated microscopic local leptomeningeal invasion, thus validity for inclusion in the future staging system.
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Affiliation(s)
- I Ayan
- University of Istanbul, Institute of Oncology, Department of Pediatric Oncology, Turkey
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Friedberg MH, David O, Adelman LS, Heilman CB. Recurrence of medulloblastoma: violation of Collins' law after two decades. SURGICAL NEUROLOGY 1997; 47:571-4. [PMID: 9167782 DOI: 10.1016/s0090-3019(96)00387-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Medulloblastoma is a common tumor of childhood arising in the posterior fossa. The concept of a child with an embryonal tumor surviving the age of diagnosis plus 9 months as the period of risk for recurrence (Collins' Law) has been applied to medulloblastomas. This raises the question of "when should follow-up stop for a patient with this type of tumor?" METHODS We present a case report of a patient with the longest documented exception to Collins' Law for medulloblastoma. RESULTS The longest documented exception to Collins' Law, a medulloblastoma recurring 20 years and 8 months after the period of risk for recurrence is presented. Both the site of recurrence and the histopathology were identical to the original tumor. CONCLUSION We present the longest documented exception to Collins' Law, to emphasize that even after decades the term "cure" should only be used cautiously.
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Affiliation(s)
- M H Friedberg
- Department of Neurosurgery, Tufts University School of Medicine, Tufts New England Medical Center, Boston, Massachusetts 02111, USA
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David KM, Casey AT, Hayward RD, Harkness WF, Phipps K, Wade AM. Medulloblastoma: is the 5-year survival rate improving? A review of 80 cases from a single institution. J Neurosurg 1997; 86:13-21. [PMID: 8988076 DOI: 10.3171/jns.1997.86.1.0013] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A series of 80 cases of medulloblastomas in children undergoing operation and postoperatively followed between 1980 and 1990 at Great Ormond Street Hospital for Children (GOSH) has been reviewed and compared to an earlier series reported from the same institution by McIntosh. The overall 5-year survival rate for the present series was 50%, although three patients died after surviving 5 years. The operative mortality rate was 5%. Survival analysis revealed that the presence or absence of spinal metastases and the necessity for some form of cerebrospinal fluid diversion within 30 days of the operation independently significantly affected survival in this series. Those patients with no spinal metastasis and total tumor removal had a 5-year survival rate of 73%, making this the most favorable subgroup in the series. Patient age and gender, duration of symptoms, Chang T stages, tumor volume, extent of resection, and postoperative chemotherapy were not significant variables. Although these results are better than those reported in the earlier GOSH series, they are not significantly different from the results of the second 5-year cohort of patients described in that article. Radiotherapy remains the greatest advance in treatment, although it is hoped that further improvement will result from the various chemotherapy protocols now being studied and from increasing knowledge of the biological behavior of these tumors.
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Affiliation(s)
- K M David
- Department of Neurosurgery, Great Ormond Street Hospital for Children National Health Service Trust, London, England
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Halperin EC. Impact of radiation technique upon the outcome of treatment for medulloblastoma. Int J Radiat Oncol Biol Phys 1996; 36:233-9. [PMID: 8823280 DOI: 10.1016/s0360-3016(96)00276-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Craniospinal irradiation (CSI) is an essential component of the therapy of medulloblastoma. Because medulloblastoma disseminates via the cerebrospinal fluid (CSF), CSI technique involves the irradiation of all CSF-bearing areas which are at risk for tumor seeding. Underdosing with radiation because of inadequacies in CSI technique will produce dose "cold spots" which have the potential of serving as a nidus for tumor recurrence. A simple mathematic model of subclinical disease in medulloblastoma based on the available data concerning the radiosensitivity of medulloblastoma cell lines as well as the known clinical dose-response relationships support the hypothesis that for most cases of medulloblastoma, the radiotherapist is working in a range of doses arrayed on the steep portion of the tumor control probability curve. Underdosing of CSF-bearing areas because of technical problems at the junction of the cranial and spinal fields of irradiation, placement of shielding blocks in the cribiform plate-subfrontal region, and/or anatomic errors in the design of the caudal end of the CSI fields may lead to significant risks of tumor relapse. One may debate the necessity of a posterior fossa boost encompassing the entire anatomic posterior fossa rather than the primary tumor volume with a margin. This review critically evaluates the potential impact of CSI technique upon the outcome of treatment for medulloblastoma, and suggests future areas of inquiry.
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Affiliation(s)
- E C Halperin
- Duke University Medical Center, Durham, NC 27710, USA.
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Cohen BH, Packer RJ. Chemotherapy for medulloblastomas and primitive neuroectodermal tumors. J Neurooncol 1996; 29:55-68. [PMID: 8817416 DOI: 10.1007/bf00165518] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the past two decades, chemotherapy has proven to be an increasingly more effective modality in the treatment of medulloblastoma. Current evidence suggests that chemotherapy be included as part of standard treatment for all patients with high-risk medulloblastoma. Ongoing multi-centre trials are determining whether chemotherapy should be added to reduced dose radiotherapy as a substitute therapy for standard-dose radiotherapy. The major randomized and non-randomized chemotherapy trials for newly diagnosed patients with medulloblastoma or for patients at recurrence are presented. It is hoped that the addition of chemotherapy will eventually lead to improved survival rates as well as the reduction in the craniospinal radiotherapy dose for patients with medulloblastoma.
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Affiliation(s)
- B H Cohen
- Department of Neurology, Cleveland Clinic Foundation, Ohio, USA
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Khafaga Y, Kandil AE, Jamshed A, Hassounah M, DeVol E, Gray AJ. Treatment results for 149 medulloblastoma patients from one institution. Int J Radiat Oncol Biol Phys 1996; 35:501-6. [PMID: 8655373 DOI: 10.1016/s0360-3016(96)80012-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE Retrospective analysis of patients with medulloblastoma to determine the effectiveness of previous treatments for medulloblastoma and plan for future management strategies. METHODS AND MATERIALS During the period March 1976 to December 1991, 172 patients with cerebellar medulloblastoma were referred to King Faisal Specialist Hospital and Research Center. One hundred and forty-nine patients were treated with curative intent. There were six postoperative deaths, and 10 patients planned for radiotherapy treatment failed to complete the prescribed course. One hundred and thirty-three patients completed a course of radiotherapy after surgery. Adjuvant chemotherapy was not used routinely (six patients only). Tumors were staged retrospectively according to the Chang staging system. There were no T1 patients, 32 patients had T2 tumors, 76 had T3 tumors, and 29 had T4 tumors. The T stage could not be allocated in 12 patients. Ninety-nine patients required a shunting procedure either pre- or postoperatively. Forty-six patients had complete resection of tumor, 91 had incomplete resection, and 6 patients had biopsy only. The extent of resection could not he determined in six patients. The median radiation dose for the whole brain was 34 Gy, spine 32.5 Gy, and posterior fossa 52.8 Gy. Fraction sizes ranged from 1.7-1.8 Gy for craniospinal fields and 2 Gy for the posterior fossa boost. Seventy percent completed the prescribed course within 7 weeks. RESULTS Actuarial survival for the whole group of 149 patients was 53% at 5 years and 38% at 10 years. On univariate analysis, patients with T2 tumors did significantly better as compared to patients with T3 and T4 tumors. Survival of patients who had clinical and radiological complete resection of tumor at surgery was significantly better than patients with incomplete tumor removal. The presence of a ventriculoperitoneal (VP) shunt had a significant negative impact on survival. Treatment failure by site was analyzed with respect to the radiation dose. Doses greater than 50 Gy for the posterior fossa, and greater than 30 Gy for craniospinal axis, resulted in significantly better survival. On multivariate analysis, the only significant prognostic factor was the presence of a VP shunt in patients with T2 tumors. CONCLUSION T stage, VP shunt, radiation doses and extent of surgery were important prognostic factors. In this study, radiation doses of more than 50 Gy to the posterior fossa and 30 Gy to the craniospinal axis resulted in improved survival.
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Affiliation(s)
- Y Khafaga
- Department of Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Vassal G, Terrier-Lacombe MJ, Lellouch-Tubiana A, Valery CA, Sainte-Rose C, Morizet J, Ardouin P, Riou G, Kalifa C, Gouyette A. Tumorigenicity of cerebellar primitive neuro-ectodermal tumors in athymic mice correlates with poor prognosis in children. Int J Cancer 1996; 69:146-51. [PMID: 8608984 DOI: 10.1002/(sici)1097-0215(19960422)69:2<146::aid-ijc14>3.0.co;2-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The histogenesis of medulloblastoma, also described as a cerebellar primitive neuro-ectodermal tumor (PNET), remains controversial and unresolved. In addition, genetic markers which characterize cerebellar PNETs with poor prognosis in children have not been identified. Since xenografts can be valuable tools for better understanding the genetic events involved in cerebellar PNETs, small fragments of tumor samples from 17 children with newly diagnosed cerebellar PNETs were transplanted s.c. into female athymic Swiss mice. Eleven were non-metastatic and 6 were metastatic PNETs. Eight tumors (47%) were tumorigenic. Histological analysis showed 6 typical medulloblastomas, 1 PNET with melanin pigment and 1 PNET with a rhabdoid phenotype. Wide heterogeneity was observed in tumor growth, with a doubling time ranging from 8 to 81 days after the first passage. Tumorigenicity was correlated with the metastatic phenotype of the tumor (p < 0.001). All the patients but one with a tumorigenic tumor relapsed and died. The survival of patients with a non-tumorigenic PNET (67%) was significantly higher than that of patients with a tumorigenic PNET (13%) (p < 0.02). None of the xenografts or tumors from patients exhibited N-myc-gene alteration. Only one xenograft showed c-myc amplification, with an abnormal 15-kilobase fragment. None of the 17 tumors from patients showed amplification or c-myc-gene rearrangement. In conclusion, tumorigenicity of cerebellar PNETs strongly correlates both with the metastatic phenotype of the tumors and with the disease-free survival of the patients. In addition, genetic events other than c-myc-gene amplification might be involved in cerebellar PNETs with poor prognosis.
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Affiliation(s)
- G Vassal
- Department of Pediatrics, Institut Gustave-Roussy, Villejuif, France
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