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Nanda RH, Hua CH, Flampouri S, Eaton B, Kaste S, Patni T, Ronckers C, Constine LS, Marks LB, Esiashvili N. Risks of Spinal Abnormalities and Growth Impairment After Radiation to the Spine in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:507-521. [PMID: 38069918 DOI: 10.1016/j.ijrobp.2023.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/03/2023] [Accepted: 10/22/2023] [Indexed: 05/19/2024]
Abstract
PURPOSE A PENTEC (Pediatric Normal Tissue Effects in the Clinic) review was performed to estimate the dose-volume effects of radiation therapy on spine deformities and growth impairment for patients who underwent radiation therapy as children. METHODS AND MATERIALS A systematic literature search was performed to identify published data for spine deformities and growth stunting. Data were extracted from 12 reports of children irradiated to the spine (N = 603 patients). The extracted data were analyzed to find associations between complication risks and the radiation dose (conventional fractionation throughout) as impacted by exposed volumes and age using the mixed-effects logistic regression model. When appropriate, corrections were made for radiation modality, namely orthovoltage beams. RESULTS In the regression analysis, the association between vertebral dose and scoliosis rate was highly significant (P < .001). Additionally, young age at time of radiation was highly predictive of adverse outcomes. Clinically significant scoliosis can occur with doses ≥15 Gy to vertebrae during infancy (<2 years of age). For children irradiated at 2 to 6 years of age, overall scoliosis rates of any grade were >30% with doses >20 Gy; grade 2 or higher scoliosis was correlated with doses ≥30 Gy. Children >6 years of age remain at risk for scoliosis with doses >30 Gy; however, most cases will be mild. There are limited data regarding the effect of dose gradients across the spine on degree of scoliosis. The risk of clinically meaningful height loss was minimal when irradiating small volumes of the spine up to 20 Gy (eg, flank irradiation), except in infants who are more vulnerable to lower doses. Growth stunting was more frequent when larger segments of the spine (eg, the entire spine or craniospinal irradiation) were irradiated before puberty to doses >20 Gy. The effect was modest when patients were irradiated after puberty to doses >20 Gy. CONCLUSIONS To reduce the risk of kyphoscoliosis and growth impairment, the dose to the spine should be kept to <20 Gy for children <6 years of age and to <10 to 15 Gy in infants. The number of vertebral bodies irradiated and dose gradients across the spine should also be limited when possible.
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Affiliation(s)
- Ronica H Nanda
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida.
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sue Kaste
- Departments of Diagnostic Imaging and Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tushar Patni
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Cecile Ronckers
- Division of Childhood Cancer Epidemiology / German Childhood Cancer Registry, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medicin at the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Lawrence B Marks
- Department of Radiation Oncology, Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Das A, Gaikwad U, Krishnan G, Rajendran A, Patil S, Subramaniam P, Krishna U, Wakde MG, Chilukuri S, Jalali R. Successful Implementation of Image-Guided Pencil-Beam Scanning Proton Therapy in Medulloblastomas. Diagnostics (Basel) 2023; 13:3378. [PMID: 37958274 PMCID: PMC10647744 DOI: 10.3390/diagnostics13213378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
Medulloblastoma is the most common malignant brain tumour in children, while much rarer in adults. Although the prognosis and outcomes have greatly improved in the era of modern multidisciplinary management, long-term treatment-induced toxicities are common. Craniospinal irradiation followed by a boost to the primary and metastatic tumour sites forms the backbone of treatment. Proton therapy has been endorsed over conventional photon-based radiotherapy due to its superior dosimetric advantages and subsequently lower incidence and severity of toxicities. We report here our experience from South-East Asia's first proton therapy centre of treating 40 patients with medulloblastoma (38 children and adolescents, 2 adults) who received image-guided, intensity-modulated proton therapy with pencil-beam scanning between 2019 and 2023, with a focus on dosimetry, acute toxicities, and early survival outcomes. All patients could complete the planned course of proton therapy, with mostly mild acute toxicities that were manageable on an outpatient basis. Haematological toxicity was not dose-limiting and did not prolong the overall treatment time. Preliminary data on early outcomes including overall survival and disease-free survival are encouraging, although a longer follow-up and data on long-term toxicities are needed.
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Affiliation(s)
- Anindita Das
- Neuro-Oncology Cancer Management Team, Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai 600041, India; (A.D.)
| | - Utpal Gaikwad
- Neuro-Oncology Cancer Management Team, Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai 600041, India; (A.D.)
| | - Ganapathy Krishnan
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai 600041, India
| | - Adhithyan Rajendran
- Department of Diagnostic and Intervention Radiology, Apollo Proton Cancer Centre, Chennai 600041, India
| | - Sushama Patil
- Department of Pathology, Apollo Proton Cancer Centre, Chennai 600041, India
| | - Preethi Subramaniam
- Neuro-Oncology Cancer Management Team, Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai 600041, India; (A.D.)
| | - Uday Krishna
- Neuro-Oncology Cancer Management Team, Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai 600041, India; (A.D.)
| | - Manoj G. Wakde
- Neuro-Oncology Cancer Management Team, Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai 600041, India; (A.D.)
| | - Srinivas Chilukuri
- Paediatric Oncology Cancer Management Team, Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai 600041, India
| | - Rakesh Jalali
- Neuro-Oncology Cancer Management Team, Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai 600041, India; (A.D.)
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Phuong C, Qiu B, Mueller S, Braunstein SE. Precision based approach to tailoring radiotherapy in the multidisciplinary management of pediatric central nervous system tumors. JOURNAL OF THE NATIONAL CANCER CENTER 2023; 3:141-149. [PMID: 39035723 PMCID: PMC11256719 DOI: 10.1016/j.jncc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 03/26/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023] Open
Abstract
Modern day survivorship from childhood malignancies is estimated to be over 80%. However, central nervous system tumors remain the leading cause of cancer mortality in children and is the most common solid tumor in this population. Improved survivorship is, in part, a result of improved multidisciplinary care, often with a combination of surgery, radiation therapy, and systemic therapy. With improved survival, long term effects of treatment and quality of life impacts have been recognized and pose a challenge to maximize the therapeutic ratio of treatment. It has been increasingly more apparent that precise risk stratification, such as with the inclusion of molecular classification, is instrumental in efforts to tailor radiotherapy for appropriate treatment, generally towards de-intensification for this vulnerable patient population. In addition, advances in radiotherapy techniques have allowed greater conformality and accuracy of treatment for those who do require radiotherapy for tumor control. Ongoing efforts to tailor radiotherapy, including de-escalation, omission, or intensification of radiotherapy, continue to improve as increasing insight into tumor heterogeneity is recognized, coupled with advances in precision medicine employing novel molecularly-targeted therapeutics.
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Affiliation(s)
- Christina Phuong
- Department of Radiation Oncology, University of California, San Francisco, United States of America
| | - Bo Qiu
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, United States of America
| | - Sabine Mueller
- Division of Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, United States of America
- Department of Neurology and Neurosurgery, University of California, San Francisco, United States of America
| | - Steve E. Braunstein
- Department of Radiation Oncology, University of California, San Francisco, United States of America
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Ioakeim-Ioannidou M, Giantsoudi D, Niemierko A, Sethi R, Kim DW, Yock TI, Tarbell NJ, Simeone FJ, MacDonald SM. Effects of Proton Craniospinal Radiation on Vertebral Body Growth Retardation in Children. Int J Radiat Oncol Biol Phys 2023; 115:572-580. [PMID: 36055432 DOI: 10.1016/j.ijrobp.2022.08.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 07/22/2022] [Accepted: 08/22/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE It is of great interest to physicians and patients/patients' families to be able to predict the amount of growth decrement after craniospinal irradiation (CSI). Little data exist on the effect of proton CSI. Our aim was to determine the effect of proton CSI on vertebral body (VB) growth retardation, and to identify factors associated with growth delay. METHODS AND MATERIALS We performed a retrospective outcome data analysis of 80 patients <16 years old with central nervous system tumors who received proton radiation therapy (PRT) at the Massachusetts General Hospital between 2002 and 2010 with available spinal magnetic resonance imaging. Forty-eight patients received CSI, and 32 patients with brain tumors who received focal cranial irradiation served as controls. VB height was measured midline using sagittal T1-weighted contrast or noncontrast enhanced magnetic resonance imaging of the spine. Measurements were repeated at multiple levels (C3, C3-C4, T4, T4-T5, C3-T6, T4-T7, L3, L1-L5) on available scans for the duration of follow-up. Data were fitted using a mixed-effects multivariable regression model, including follow-up time, CSI dose, age at CSI, and pretreatment VB percentile as parameters. RESULTS Median follow-up was 69.6 months for patients treated with proton CSI and 52.9 months for the control group. There was a significant association of CSI dose, follow-up time, age at treatment, and pretreatment VB percentile with VB growth retardation. Growth retardation was shown to be independent of gender or growth hormone deficiency. CONCLUSIONS Although the current practice of PRT CSI delivery allows for sparing of the organs anterior to the spine, the vertebral column receives radiation therapy because of its close proximity to the targeted spinal canal. In growing children, the whole VB has generally been included so that growth impairment is even across the VB. We present a quantitative model predicting the growth retardation of patients treated with PRT CSI based on age at treatment, CSI dose, follow-up time, and pretreatment growth percentile.
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Affiliation(s)
- Myrsini Ioakeim-Ioannidou
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Drosoula Giantsoudi
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrzej Niemierko
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Roshan Sethi
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel W Kim
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Torunn I Yock
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy J Tarbell
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - F Joseph Simeone
- Departments of Diagnostic Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Departments of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Late Effects of Craniospinal Irradiation Using Electron Spinal Fields for Pediatric Patients With Cancer. Int J Radiat Oncol Biol Phys 2023; 115:164-173. [PMID: 35716848 DOI: 10.1016/j.ijrobp.2022.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/02/2022] [Accepted: 06/06/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE For children, craniospinal irradiation (CSI) with photons is associated with significant toxic effects. The use of electrons for spinal fields is hypothesized to spare anterior structures but the long-term effects remain uncertain. We studied late effects of CSI using electrons for spinal radiation therapy (RT). METHODS AND MATERIALS Records of 84 consecutive patients treated with CSI using electrons for the spine at a single institution between 1983 and 2014 were reviewed. Median age at RT was 5 (range, 1-14) years. The most common histologies were medulloblastoma/primitive neuroectodermal tumor (59%) and ependymoma (8%). The median prescribed dose to the entire spine was 30 Gy (range, 6-45). A subset of 48 (57%) patients aged 2 to 14 at RT with clinical follow-up for ≥5 years was analyzed for late effects. Height z scores adjusted for age before and after CSI were assessed using stature-for-age charts and compared with a t test. RESULTS At median follow-up of 19 years (range, 0-38 years), the median survival was 22 years (95% confidence interval, 12-28 years) after RT, with 47 patients (56%) alive at last follow-up. On subset analysis for late effects, 19 (40%) patients developed hypothyroidism and 5 (10%) developed secondary malignancies. Other complications reported were esophageal stricture and periaortic hemorrhage in 1 and restrictive pulmonary disease in 1 patient. Median height z score before treatment was -0.4 (36th percentile; interquartile range, -1.0 to 0.0) and at last follow-up was -2.2 (first percentile; interquartile range, -3.1 to -1.6; P < .001). Of 44 patients with spinal curvature assessments, 15 (34%) had scoliosis with median Cobb angle 15° (range, 10°-35°) and 1 (2%) required surgery. CONCLUSIONS Frequent musculoskeletal toxic effects and predominantly decreased height were seen with long-term follow-up. Scoliosis and hypothyroidism were each seen in at least one-third of long-term survivors. However, clinically evident esophageal, pulmonary, and cardiac toxic effects were infrequent.
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Chou B, Hopper A, Elster J, Crawford JR, McConnell K, Chang A, Mundt AJ, MacEwan I. Volumetric de-escalation and improved acute toxicity with proton craniospinal irradiation using a vertebral body-sparing technique. Pediatr Blood Cancer 2022; 69:e29489. [PMID: 34866330 DOI: 10.1002/pbc.29489] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/30/2021] [Accepted: 10/26/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE In growing children, craniospinal irradiation (CSI) has historically treated the entire vertebral body (VB) to avoid potential long-term spinal abnormalities. Vertebral body-sparing proton craniospinal irradiation (VBSpCSI) is a technique that spares the majority of the VB from significant irradiation, and long-term safety outcomes have been reported previously. This retrospective study reviews the acute toxicity profile of children treated with VBSpCSI in a cohort comparison with photon-based craniospinal radiotherapy (3DCRT). METHODS Thirty-eight pediatric CSI patients treated between 2008 and 2018 were retrospectively evaluated for treatment-related toxicity. Acute toxicity outcomes and acute hematologic profiles were compared according to treatment modality, either VBSpCSI or 3DCRT. Statistical analysis was performed using Fisher's exact test for toxicity. RESULTS Twenty-five patients received VBSpCSI and 13 patients received photon CSI. Mean patient age at treatment was 7.5 years (range 2-16). The cohorts were well matched with respect to gender, age, and CSI dose. Patients receiving VBSpCSI had lower rates of grade 2+ gastrointestinal (GI) toxicity (24% vs. 76.5%, p = .005), grade 2+ nausea (24% vs. 61.5%, p = .035), and any-grade esophagitis (0% vs. 38%, p = .0026). Patients treated with VBSpCSI had lower red blood cell transfusion rates (21.7% vs. 60%, p = .049) and grade 4+ lymphopenia (33.3% vs. 77.8%, p = .046). CONCLUSIONS VBSpCSI in children is a volumetric de-escalation from traditional volumes, which irradiate the entire VB to full or intermediate doses. In our study, VBSpCSI was associated with lower rates of acute GI and hematologic toxicities. Long-term growth outcomes and disease control outcomes are needed for this technique.
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Affiliation(s)
- Brian Chou
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Austin Hopper
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Jennifer Elster
- Department of Pediatric Hematology and Oncology, University of California - San Diego, San Diego, California, USA
| | - John R Crawford
- Department of Neurosciences and Pediatrics, University of California - San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Kristen McConnell
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Andrew Chang
- California Protons Cancer Therapy Center, San Diego, California, USA
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Iain MacEwan
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
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Normal tissue exposure and second malignancy risk in vertebral-body-sparing craniospinal irradiation. Med Dosim 2022; 47:142-145. [PMID: 34996678 DOI: 10.1016/j.meddos.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/22/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to compare dose to anterior organs at risk (OARs) and quantify the risk of developing secondary malignancy (SMN) in pediatric patients treated with vertebral-body-sparing (VBS) vs vertebral body (VB) pencil beam scanning proton craniospinal irradiation (CSI). Comparative plans of VBS and VB CSI were created for 10 previously treated patients. Dose-volume histograms were used to evaluate dose to OARs. Absolute excess risk of SMN was calculated according to the organ-specific, radiation-induced cancer incidence based on the organ equivalent dose. OAR dosimetric parameters and absolute excess risk of SMN were compared for VBS and VB plans using the Kruskal-Wallis H test (α = 0.05). VBS CSI leads to significantly lower radiation dose to the heart, esophagus, kidney, liver and bowel. Excluding the vertebral body also significantly decreases the absolute excess risk of SMN for liver, esophagus and bowel. For these reasons, implementation of VBS pencil beam scanning proton CSI should be considered.
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Variation in Proton Craniospinal Irradiation Practice Patterns in the United States: A Pediatric Proton Consortium Registry (PPCR) Study. Int J Radiat Oncol Biol Phys 2021; 112:901-912. [PMID: 34808253 DOI: 10.1016/j.ijrobp.2021.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/03/2021] [Accepted: 11/14/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Craniospinal irradiation (CSI) is commonly used for pediatric brain tumors with a propensity for spread in craniospinal fluid, principally medulloblastoma. Evolving technology has led to the use of highly conformal radiation therapy (RT) techniques for CSI, including proton therapy. Target delineation and plan coverage are critical for CSI, but there is ongoing controversy and variability in these realms, with little available data on practice patterns. We sought to characterize proton CSI practice patterns in the United States by examining CSI plans in the Pediatric Proton/Photon Consortium Registry (PPCR). MATERIALS AND METHODS PPCR was queried for data on proton CSI patients from 2015 to early 2020. Each plan was manually reviewed, determining patient position; prescription dose; and coverage of optic nerves, vertebral bodies, spinal nerve roots, sacral nerves, and cranial foramina, among other variables. Two radiation oncologists blinded to clinical data and treating institution assessed coverage at the 95% prescription isodose line and per published European Society for Paediatric Oncology guidelines. Variability in coverage was assessed with nonparametric tests and univariate and multivariate logistic regression. RESULTS PPCR supplied data for 450 patients, 384 of whom had an evaluable portion of a CSI plan. Most patients (90.3%) were supine. Optic nerves were fully covered in 48.2%; sacral nerves in 87.7%; cranial foramina in 69.3%; and spinal nerves in 95.6%. Vertebral body (VB) sparing was used in 18.6% of skeletally immature cases, increasing over time (P < .001). Coverage in all categories was significantly different among treating institutions, on univariate and multivariate analyses. Cribriform plate deficits were rare, with marginal misses of the foramen ovale (17.4%) and frontal lobe (12%) most common. CONCLUSION We found consistent variation based on treating institution in proton CSI practices including optic nerve, VB, sacral nerve, cranial, and spinal nerve coverage. These data may serve as a baseline quantification of current proton CSI practices in the United States as they continue to evolve.
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Yoo GS, Yu JI, Cho S, Han Y, Oh Y, Lim DH, Nam HR, Lee JW, Sung KW, Shin HJ. Chronological Analysis of Acute Hematological Outcomes after Proton and Photon Beam Craniospinal Irradiation in Pediatric Brain Tumors. Cancer Res Treat 2021; 54:907-916. [PMID: 34665955 PMCID: PMC9296930 DOI: 10.4143/crt.2021.332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 10/14/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose This study aimed to compare the early hematological dynamics and acute toxicities between proton beam craniospinal irradiation (PrCSI) and photon beam craniospinal irradiation (PhCSI) for pediatric brain tumors. Materials and Methods We retrospectively reviewed patients with pediatric brain tumors who received craniospinal irradiation (CSI). The average change in hemoglobin levels (ΔHbavg), absolute lymphocyte counts (ΔALCavg), and platelet counts (ΔPLTavg) from baseline values was evaluated and compared between the PrCSI and PhCSI groups at 1 and 2 weeks after the initiation of CSI, 1 week before and at the end of radiotherapy, and 3–4 weeks after the completion of radiotherapy using t-test and mixed-model analysis. Results The PrCSI and PhCSI groups consisted of 36 and 30 patients, respectively. There were no significant differences in ΔHbavg between the two groups at any timepoint. However, ΔALCavg and ΔPLTavg were significantly lower in the PhCSI group than in PrCSI group at every timepoint, demonstrating that PrCSI resulted in a significantly lower rate of decline and better recovery of absolute lymphocyte and platelet counts. The rate of grade 3 acute anemia was significantly lower in the PrCSI group than in in the PhCSI group. Conclusion PrCSI showed a lower rate of decline and better recovery of absolute lymphocyte and platelet counts than PhCSI in the CSI for pediatric brain tumors. Grade 3 acute anemia was significantly less frequent in the PrCSI group than in the PhCSI group. Further large-scale studies are warranted to confirm these results.
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Affiliation(s)
- Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sungkoo Cho
- Department of Radiation Oncology, Samsung Medical Center, Seoul, Korea
| | - Youngyih Han
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoonjin Oh
- Department of Radiation Oncology, Samsung Medical Center, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Rim Nam
- Department of Radiation Oncology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki-Woong Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Paulino AC, Suzawa HS, Dreyer ZE, Hanania AN, Chintagumpala M, Okcu MF. Scoliosis in Children Treated With Photon Craniospinal Irradiation for Medulloblastoma. Int J Radiat Oncol Biol Phys 2021; 109:712-717. [PMID: 33516438 DOI: 10.1016/j.ijrobp.2020.09.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Scoliosis is a well-recognized complication after abdominal radiation therapy but not reported frequently after craniospinal irradiation (CSI). We examined the incidence and risk factors for scoliosis after CSI in long-term survivors with medulloblastoma. METHODS AND MATERIALS The records of patients with medulloblastoma seen at one institution from 1996 to 2006 were analyzed for the use of CSI and development of scoliosis as documented on physical examination and spinal imaging. RESULTS We identified 35 children with medulloblastoma who were ≤12 years of age at time of CSI with a median 14.3 years (range, 5.8-19.3 years) of follow-up. Twenty-seven (77.1%) were male, and median age at CSI was 6.8 years (range, 2.8-12 years). The cumulative incidence of scoliosis at 15 years was 34.6%. The median time to develop scoliosis was 7.1 years (range, 5-11.7 years) after CSI. Treatment with high dose CSI (34.2-40 Gy) and presence of hemiplegia or hemiparesis were found to be risk factors for development of scoliosis. CONCLUSIONS Scoliosis is an underreported complication of photon craniospinal irradiation.
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Affiliation(s)
- Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas.
| | - Hilary S Suzawa
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - ZoAnn E Dreyer
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Alexander N Hanania
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas
| | | | - Mehmet Fatih Okcu
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
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Suzuki S, Kato T, Murakami M. Impact of lifetime attributable risk of radiation-induced secondary cancer in proton craniospinal irradiation with vertebral-body-sparing for young pediatric patients with medulloblastoma. JOURNAL OF RADIATION RESEARCH 2021; 62:186-197. [PMID: 33341899 PMCID: PMC7948862 DOI: 10.1093/jrr/rraa118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/31/2020] [Indexed: 06/12/2023]
Abstract
We used the method proposed by Schneider et al. Theor Biol Med Model 2011;8:27, to clarify how the radiation-induced secondary cancer incidence rate changes in patients after proton craniospinal irradiation (CSI) without and with vertebral-body-sparing (VBS). Eight patients aged 3-15 years who underwent proton CSI were enrolled in the study. For each case, two types of plan without and with VBS in the target were compared. The prescribed doses were assumed to be 23.4 Gy relative biological effectiveness (RBE) and 36 Gy (RBE). Using the dose-volume histograms of the two plans, the lifetime attributable risk (LAR) was calculated by both methods for each patient based on the dose data calculated using an XiO-M treatment planning system. Eight organs were analyzed as follows: lung, colon, stomach, small intestine, liver, bladder, thyroid and bone. When the prescribed dose used was 23.4 Gy (RBE), the average LAR differences and the average number needed to treat (NNT) between proton CSI without and with VBS were 4.04 and 24.8, respectively, whereas the average LAR difference and the average NNT were larger at 8.65 and 11.6, respectively, when the prescribed dose of 36 Gy (RBE) was used. The LAR for radiation-induced secondary cancer was significantly lower in proton CSI with VBS than without VBS in pediatric patients, especially for the colon, lung, stomach and thyroid. The results of this study could serve as reference data when considering how much of vertebral bodies should be included when performing proton CSI according to age in clinical settings.
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Affiliation(s)
- Shunsuke Suzuki
- Corresponding author. Hokkaido Ohno Memorial Hospital, 2-16-1 Miyanosawa, Nishi-ku, Sapporo City, Hokkaido, 063-0052, Japan. Tel: +81-011-665-0020;
| | - Takahiro Kato
- Department of Radiation Physics and Technology, Southern Tohoku Proton Therapy Center, Koriyama, Japan
- Preparing Section for New Faculty of Medical Science, Fukushima Medical University, Fukushima, Japan
| | - Masao Murakami
- Department of Radiation Oncology, Southern Tohoku Proton Therapy Center, Koriyama, Japan
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12
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Mizumoto M, Oshiro Y, Pan H, Wang F, Kaste SC, Gajjar A, Chemaitilly W, Merchant TE. Height after photon craniospinal irradiation in pediatric patients treated for central nervous system embryonal tumors. Pediatr Blood Cancer 2020; 67:e28617. [PMID: 32715632 DOI: 10.1002/pbc.28617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND We modeled height after craniospinal irradiation (CSI) in pediatric patients with central nervous system (CNS) embryonal tumors to identify factors that impair stature. PROCEDURE During 1996-2012, 212 pediatric patients (131 male) with CNS embryonal tumors received postoperative CSI: 23.4 Gy (n = 147) or ≥36 Gy (n = 65), similar postirradiation chemotherapy, and were followed for at least 5 years without tumor progression or other event. The group was further characterized by age at CSI and hormone-replacement therapy received. Models were developed to identify factors associated with growth impairment and estimate final height. RESULTS With median follow up of 10.2 years (range 5.0-20.4 years), the mean final height z-scores at 18 years of age, compared to United States standards, were -1.3 for female and -1.5 for male survivors. Younger age at the time of CSI, higher CSI dose, and female sex were associated with height impairment. Factors associated with higher growth rates before 15 years of age were older age at CSI, male sex, CSI dose < 36 Gy, replacement therapy for growth hormone (GH) and central adrenal insufficiency, and white race. Growth after age 15 in male survivors was associated with treatment of gonadotropin deficiency. Linear mixed-effects models were developed using clinical factors to estimate final height, demonstrate the unique growth curve of this cohort, and interactions between clinical variable and radiation dose. CONCLUSIONS CSI significantly impaired height at current doses used to treat standard- or high-risk CNS embryonal tumors. Measures to reduce the impact of CSI on height should be sought, with our models serving as benchmarks.
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Affiliation(s)
- Masashi Mizumoto
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Radiation Oncology, University of Tsukuba, Ibaraki, Japan
| | - Yoshiko Oshiro
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Radiation Oncology, University of Tsukuba, Ibaraki, Japan
| | - Haitao Pan
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Fang Wang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Sue C Kaste
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Wassim Chemaitilly
- Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
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13
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Kotecha R, Tom MC, Naik M, Angelov L, Benzel EC, Reddy CA, Prayson RA, Kalfas I, Schlenk R, Krishnaney A, Steinmetz MP, Bingaman W, Suh JH, Chao ST. Analyzing the role of adjuvant or salvage radiotherapy for spinal myxopapillary ependymomas. J Neurosurg Spine 2020; 33:392-397. [PMID: 32357340 DOI: 10.3171/2020.2.spine191534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 02/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to describe the long-term recurrence patterns, prognostic factors, and effect of adjuvant or salvage radiotherapy (RT) on treatment outcomes for patients with spinal myxopapillary ependymoma (MPE). METHODS The authors reviewed a tertiary institution IRB-approved database and collected data regarding patient, tumor, and treatment characteristics for all patients treated consecutively from 1974 to 2015 for histologically confirmed spinal MPE. Key outcomes included relapse-free survival (RFS), postrecurrence RFS, failure patterns, and influence of timing of RT on recurrence patterns. Cox proportional hazards regression and Kaplan-Meier analyses were utilized. RESULTS Of the 59 patients included in the study, the median age at initial surgery was 34 years (range 12-74 years), 30 patients (51%) were female, and the most common presenting symptom was pain (n = 52, 88%). Extent of resection at diagnosis was gross-total resection (GTR) in 39 patients (66%), subtotal resection (STR) in 15 (25%), and unknown in 5 patients (9%). After surgery, 10 patients (17%) underwent adjuvant RT (5/39 GTR [13%] and 5/15 STR [33%] patients). Median follow-up was 6.2 years (range 0.1-35.3 years). Overall, 20 patients (34%) experienced recurrence (local, n = 15; distant, n = 5). The median RFS was 11.2 years (95% CI 77 to not reached), and the 5- and 10-year RFS rates were 72.3% (95% CI 59.4-86.3) and 54.0% (95% CI, 36.4-71.6), respectively.STR was associated with a higher risk of recurrence (HR 6.45, 95% CI 2.15-19.23, p < 0.001) than GTR, and the median RFS after GTR was 17.2 years versus 5.5 years after STR. Adjuvant RT was not associated with improved RFS, regardless of whether it was delivered after GTR or STR. Of the 20 patients with recurrence, 12 (60%) underwent salvage treatment with surgery alone (GTR, n = 6), 4 (20%) with RT alone, and 4 (20%) with surgery and RT. Compared to salvage surgery alone, salvage RT, with or without surgery, was associated with a significantly longer postrecurrence RFS (median 9.5 years vs 1.6 years; log-rank, p = 0.006). CONCLUSIONS At initial diagnosis of spinal MPE, GTR is key to long-term RFS, with no benefit to immediate adjuvant RT observed in this series. RT at the time of recurrence, however, is associated with a significantly longer time to second disease recurrence. Surveillance imaging of the entire neuraxis remains crucial, as distant failure is not uncommon in this patient population.
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Affiliation(s)
- Rupesh Kotecha
- 1Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami
- 2Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Martin C Tom
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | - Mihir Naik
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | | | | | - Chandana A Reddy
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | | | | | | | | | | | | | - John H Suh
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | - Samuel T Chao
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
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14
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Hoppe BS, Mailhot Vega RB, Mendenhall NP, Sandler ES, Slayton WB, Katzenstein H, Joyce MJ, Li Z, Flampouri S. Irradiating Residual Disease to 30 Gy with Proton Therapy in Pediatric Mediastinal Hodgkin Lymphoma. Int J Part Ther 2020; 6:11-16. [PMID: 32582815 PMCID: PMC7302731 DOI: 10.14338/ijpt-19-00077.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/05/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Local relapse is a predominant form of recurrence among pediatric patients with Hodgkin lymphoma (PHL). Although PHL radiotherapy doses have been approximately 20 Gy, adults with Hodgkin lymphoma receiving 30 to 36 Gy experience fewer in-field relapses. We investigated the dosimetric effect of such a dose escalation to the organs at risk (OARs). Materials and Methods: Ten patients with PHL treated with proton therapy to 21 Gy involved-site radiation therapy (ISRT21Gy) were replanned to deliver 30 Gy by treating the ISRT to 30 Gy (ISRT30Gy), delivering 21 Gy to the ISRT plus a 9-Gy boost to postchemotherapy residual volume (rISRTboost), and delivering 30 Gy to the residual ISRT target only (rISRT30Gy). Radiation doses to the OARs were compared. Results: The ISRT30Gy escalated the dose to the target by 42% but also to the OARs. The rISRTboost escalated the residual target dose by 42%, and the OAR dose by only 17% to 26%. The rISRT30Gy escalated the residual target dose by 42% but reduced the OAR dose by 25% to 46%. Conclusion: Boosting the postchemotherapy residual target dose to 30Gy can allow for dose escalation with a slight OAR dose increase. Treating the residual disease for the full 30Gy, however, would reduce the OAR dose significantly compared with ISRT21Gy. Studies should evaluate these strategies to improve outcomes and minimize the late effects.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Eric S Sandler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - William B Slayton
- Department of Pediatric Hematology/Oncology, University of Florida, Gainesville, FL, USA
| | - Howard Katzenstein
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Michael J Joyce
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Stella Flampouri
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
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15
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Medek S, De B, Pater L, Breneman J, Mahajan A, Wolden S, Vatner RE. Practice Patterns Among Radiation Oncologists Treating Pediatric Patients With Proton Craniospinal Irradiation. Pract Radiat Oncol 2019; 9:441-447. [PMID: 31279941 DOI: 10.1016/j.prro.2019.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/11/2019] [Accepted: 06/21/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE Craniospinal irradiation (CSI) is an important component of therapy for many pediatric central nervous system malignancies. Proton therapy is increasingly available and used for minimizing radiation exposure to normal tissues. The absence of an exit dose with proton therapy mandates decisions regarding coverage of the vertebral bodies (VB) in non-skeletally mature patients. Although the contents within the thecal sac represent the true clinical target volume (CTV), some physicians target the entire VB in growing children because of concerns over asymmetrical growth. This study aims to assess current practice patterns regarding VB coverage for pediatric patients undergoing CSI. METHODS AND MATERIALS Pediatric radiation oncologists were identified from the Particle Therapy Co-Operative Group pediatric subcommittee membership or affiliation with US proton centers. Potential participants were contacted by e-mail with a link to an institutional review board-approved, anonymized web-based survey distributed in June 2017 with follow-up in October 2017. The survey used skip logic and included up to 11 questions regarding practice patterns. RESULTS Thirty-three physicians responded to the survey (39%), 5 of which were excluded for lack of recent pediatric proton CSI experience. Of the 28 included responses, 23 physicians sometimes treat the entire VB and 5 physicians report always treating the entire VB. Most common responses regarding anterior CTV expansion for uncertainty were no expansion (n = 9) and 3 to 4 mm (n = 8). Most physicians modify the anterior CTV margin to protect normal structures, most commonly esophagus (n = 15), thyroid (n = 6), heart (n = 5), bowel (n = 4), and pharynx (n = 2). CONCLUSIONS Vertebral body coverage in proton CSI varies among radiation oncologists in respect to target delineation, CTV expansions, and modifications for organs at risk. These data suggest the radiation oncology community may benefit from a standardized approach to pediatric proton-based CSI.
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Affiliation(s)
- Sara Medek
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Brian De
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luke Pater
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John Breneman
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Suzanne Wolden
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ralph E Vatner
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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16
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Hashimoto T, Shimizu S, Takao S, Terasaka S, Iguchi A, Kobayashi H, Mori T, Yoshimura T, Matsuo Y, Tamura M, Matsuura T, Ito YM, Onimaru R, Shirato H. Clinical experience of craniospinal intensity-modulated spot-scanning proton therapy using large fields for central nervous system medulloblastomas and germ cell tumors in children, adolescents, and young adults. JOURNAL OF RADIATION RESEARCH 2019; 60:527-537. [PMID: 31111946 PMCID: PMC6640905 DOI: 10.1093/jrr/rrz022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/28/2019] [Indexed: 06/09/2023]
Abstract
The outcomes of intensity-modulated proton craniospinal irradiation (ipCSI) are unclear. We evaluated the clinical benefit of our newly developed ipCSI system that incorporates two gantry-mounted orthogonal online X-ray imagers with a robotic six-degrees-of-freedom patient table. Nine patients (7-19 years old) were treated with ipCSI. The prescribed dose for CSI ranged from 23.4 to 36.0 Gy (relative biological effectiveness) in 13-20 fractions. Four adolescent and young adult (AYA) patients (15 years or older) were treated with vertebral-body-sparing ipCSI (VBSipCSI). Myelosuppression following VBSipCSI was compared with that of eight AYA patients treated with photon CSI at the same institution previously. The mean homogeneity index (HI) in the nine patients was 0.056 (95% confidence interval: 0.044-0.068). The mean time from the start to the end of all beam delivery was 37 min 39 s ± 2 min 24 s (minimum to maximum: 22 min 49 s - 42 min 51 s). The nadir white blood cell, hemoglobin, and platelet levels during the 4 weeks following the end of the CSI were significantly higher in the VBSipCSI group than in the photon CSI group (P = 0.0071, 0.0453, 0.0024, respectively). The levels at 4 weeks after the end of CSI were significantly higher in the VBSipCSI group than in the photon CSI group (P = 0.0023, 0.0414, 0.0061). Image-guided ipCSI was deliverable in a reasonable time with sufficient HI. Using VBSipCSI, AYA patients experienced a lower incidence of serious acute hematological toxicity than AYA patients treated with photon CSI.
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Affiliation(s)
- Takayuki Hashimoto
- Department of Radiation Medicine, Faculty of Medicine, Hokkaido University
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University
| | - Shinichi Shimizu
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University
| | - Seishin Takao
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University
- Proton Beam Therapy Center, Hokkaido University Hospital
| | - Shunsuke Terasaka
- Department of Neurosurgery, Faculty of Medicine, Hokkaido University
| | - Akihiro Iguchi
- Department of Pediatrics, Faculty of Medicine, Hokkaido University
| | | | - Takashi Mori
- Department of Radiation Oncology, Hokkaido University Hospital
| | | | - Yuto Matsuo
- Proton Beam Therapy Center, Hokkaido University Hospital
| | - Masaya Tamura
- Department of Radiation Medicine, Faculty of Medicine, Hokkaido University
| | - Taeko Matsuura
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University
- Division of Quantum Science and Engineering, Faculty of Engineering, Hokkaido University
| | - Yoichi M Ito
- Department of Statistical Data Science, The Institute of Statistical Mathematics
| | - Rikiya Onimaru
- Department of Radiation Medicine, Faculty of Medicine, Hokkaido University
| | - Hiroki Shirato
- Department of Radiation Medicine, Faculty of Medicine, Hokkaido University
- Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University
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17
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Kotecha R, Mehta MP, Chang EL, Brown PD, Suh JH, Lo SS, Das S, Samawi HH, Keith J, Perry J, Sahgal A. Updates in the management of intradural spinal cord tumors: a radiation oncology focus. Neuro Oncol 2019; 21:707-718. [PMID: 30977511 PMCID: PMC6556849 DOI: 10.1093/neuonc/noz014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Primary spinal cord tumors represent a hetereogeneous group of central nervous system malignancies whose management is complex given the relatively uncommon nature of the disease and variety of tumor subtypes, functional neurologic deficits from the tumor, and potential morbidities associated with definitive treatment. Advances in neuroimaging; integration of diagnostic, prognostic, and predictive molecular testing into tumor classification; and developments in neurosurgical techniques have refined the current role of radiotherapy in the multimodal management of patients with primary spinal cord tumors, and corroborated the need for prospective, multidisciplinary discussion and treatment decision making. Radiotherapeutic technological advances have dramatically improved the entire continuum from treatment planning to treatment delivery, and the development of stereotactic radiosurgery and proton radiotherapy provides new radiotherapy options for patients treated in the definitive, adjuvant, or salvage setting. The objective of this comprehensive review is to provide a contemporary overview of the management of primary intradural spinal cord tumors, with a focus on radiotherapy.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Sunit Das
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Haider H Samawi
- Division of Hematology/Oncology, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Julia Keith
- Department of Anatomical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Perry
- Department of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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18
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Abstract
PURPOSE OF REVIEW The advent of proton beam therapy (PBT) has initiated a paradigm shift in the field of pediatric radiation oncology, with increasing promise to alleviate both short-term and long-term toxicities. Given the dramatic rise in proton therapy centers in the United States, a discussion of the quality of evidence supporting its use in pediatric cancers is warranted. RECENT FINDINGS Proton radiotherapy appears to decrease the incidence and severity of late effects with the strongest evidence in pediatric brain tumor cohorts that shows benefits in neurocognitive, hearing, and endocrine outcomes. However, emerging data has shown that more conservative brainstem dose limits with protons compared with photons are required to limit brainstem toxicity; these modified recommendations have been incorporated into national cooperative group studies. Decreased toxicity in tumors outside of the CNS for PBT have also been reported in sarcomas, Hodgkin disease and neuroblastoma. Similarly, QoL outcomes are improved in brain tumor and other cohorts of patients treated with PBT. SUMMARY The collective findings demonstrate improved understanding and refinement of PBT in pediatric cancers. Data on QOL, toxicity and disease outcomes with PBT should continue to be collected and reported in order to understand the full extent of the risks and benefits associated with PBT.
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19
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El Shafie RA, Böhm K, Weber D, Lang K, Schlaich F, Adeberg S, Paul A, Haefner MF, Katayama S, Sterzing F, Hörner-Rieber J, Löw S, Herfarth K, Debus J, Rieken S, Bernhardt D. Outcome and prognostic factors following palliative craniospinal irradiation for leptomeningeal carcinomatosis. Cancer Manag Res 2019; 11:789-801. [PMID: 30697071 PMCID: PMC6340499 DOI: 10.2147/cmar.s182154] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Leptomeningeal carcinomatosis (LC) is a severe complication of metastatic tumor spread to the central nervous system. Prognosis is dismal with a median overall survival (OS) of ~10–15 weeks. Treatment options include radiotherapy (RT) to involved sites, systemic chemo- or targeted therapy, intrathecal chemotherapy and best supportive care with dexamethasone. Craniospinal irradiation (CSI) is a more aggressive radiotherapeutic approach, for which very limited data exists. Here, we report on our 10-year experience with palliative CSI of selected patients with LC. Patients and methods Twenty-five patients received CSI for the treatment of LC at our institution between 2008 and 2018. Patients were selected individually for CSI based on clinical performance, presenting symptoms and estimated benefit. Median patient age was 53 years (IQR: 45–59), and breast cancer was the most common primary. Additional brain metastases were found in 18 patients (72.0%). RT was delivered at a TomoTherapy machine, using helical intensity-modulated radiotherapy (IMRT). The most commonly prescribed dose was 36 Gy in 20 fractions, corresponding to a median biologically equivalent dose of 40.8 Gy (IQR: 39.0–2.5). Clinical performance and neurologic function were assessed before and in response to therapy, and deficits were retrospectively quantified on the 5-point neurologic function scale (NFS). A Cox proportional hazards model with univariate and multivariate analyses was fitted for survival. Results Twenty-one patients died and four were alive at the time of analysis. Median OS from LC diagnosis was 19.3 weeks (IQR: 9.3–34.0, 95% CI: 11.0–32.0). In univariate analysis, a Karnofsky performance scale index (KPI) ≥70% (P=0.001), age ≤55 years at LC diagnosis (P=0.022), cerebrospinal fluid (CSF) protein <100 mg/dL (P=0.018) and no more than mild or moderate neurologic deficits (NFS ≤2; P=0.007) were predictive of longer OS. So were the neurologic response to treatment (P=0.018) and the application of systemic therapy after RT completion (P=0.029). The presence of CSF flow obstruction was predictive of shorter OS (P=0.026). In multivariate analysis, age at LC diagnosis (P=0.018), KPI (P<0.001) and neurologic response (P=0.037) remained as independent prognostic factors for longer OS. Treatment-associated toxicity was manageable and mostly grades I and II according to the Common Terminology Criteria for Adverse Events v4.0. Eight patients (32%) developed grade III myelosuppression. Neurologic symptom stabilization could be achieved in 40.0% and a sizeable improvement in 28.0% of all patients. Conclusion CSI for the treatment of LC is feasible and may have therapeutic value in carefully selected patients, alleviating symptoms or delaying neurologic deterioration. OS after CSI was comparable to the rates described in current literature for patients with LC. The use of modern irradiation techniques such as helical IMRT is warranted to limit toxicity. Patient selection should take into account prognostic factors such as age, clinical performance, neurologic function and the availability of systemic treatment options.
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Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Karina Böhm
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Fabian Schlaich
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Angela Paul
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Matthias F Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Florian Sterzing
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Department of Radiation Oncology, Klinikum Kempten, Kempten 87439, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sarah Löw
- Department of Neurology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany.,German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
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20
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Rao AD, Ladra M, Dunn E, Kumar R, Rao SS, Sehgal S, Dorafshar AH, Morris CD, Terezakis SA. A Road Map for Important Centers of Growth in the Pediatric Skeleton to Consider During Radiation Therapy and Associated Clinical Correlates of Radiation-Induced Growth Toxicity. Int J Radiat Oncol Biol Phys 2018; 103:669-679. [PMID: 30414451 DOI: 10.1016/j.ijrobp.2018.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/31/2018] [Accepted: 10/24/2018] [Indexed: 11/17/2022]
Abstract
With the increasing use of advanced radiation techniques such as intensity modulated radiation therapy, stereotactic radiation therapy, and proton therapy, radiation oncologists now have the tools to mitigate radiation-associated toxicities. This is of utmost importance in the treatment of a pediatric patient. To best use these advanced techniques to mitigate radiation-induced growth abnormalities, the radiation oncologist should be equipped with a nuanced understanding of the anatomy of centers of growth. This article aims to enable the radiation oncologist to better understand, predict, and minimize radiation-mediated toxicities on growth. We review the process of bone development and radiation-induced growth abnormalities and provide an atlas for contouring important growth plates to guide radiation treatment planning. A more detailed recognition of important centers of growth may improve future treatment outcomes in children receiving radiation therapy.
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Affiliation(s)
- Avani D Rao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Matthew Ladra
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Emily Dunn
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rahul Kumar
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sandesh S Rao
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Shuchi Sehgal
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amir H Dorafshar
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Carol D Morris
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Stephanie A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland.
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21
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De B, Cahlon O, Sine K, Mah D, Hug EB, Wolden SL. Early Axial Growth Outcomes of Pediatric Patients Receiving Proton Craniospinal Irradiation. J Pediatr Hematol Oncol 2018; 40:574-579. [PMID: 29889805 PMCID: PMC6197896 DOI: 10.1097/mph.0000000000001242] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Guidelines on proton craniospinal irradiation (p-CSI) target volume selection in children are lacking. We examined the impact of target volume selection on growth of children receiving p-CSI at a institution. Records of 58 patients who received p-CSI were reviewed. Median age at treatment initiation was 8 years (range, 2 to 18 y). Spinal target volumes included whole vertebral body (WVB) in 67% and partial vertebral body (PVB) in 33%. Height z-scores before and after p-CSI were assessed using Centers for Disease Control and Prevention stature-for-age charts. Maximal Cobb angle and height z-score change were compared for WVB versus PVB p-CSI using a t test. Among 93% of patients with detailed data, median follow-up was 19 months (range, 2 to 58 mo) after radiation therapy initiation. Quantitative growth evaluations were available for 64% of patients. Median change in height z-score was -0.5 (range, -2.1 to +0.7) after treatment, representing a decrease (P<0.001) in age-adjusted height. WVB patients had significantly greater reduction in height z-score versus PVB patients (P=0.004) but no difference in Cobb angle change (P>0.05). Despite reluctance surrounding its use in younger patients, PVB p-CSI was associated with similar spinal curvature and less growth suppression as compared with WVB p-CSI; a trial comparing WVB versus PVB in children may be warranted.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- ProCure Proton Therapy Center, 103 Cedar Grove Lane, Somerset, NJ 08873, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- ProCure Proton Therapy Center, 103 Cedar Grove Lane, Somerset, NJ 08873, USA
| | - Kevin Sine
- ProCure Proton Therapy Center, 103 Cedar Grove Lane, Somerset, NJ 08873, USA
| | - Dennis Mah
- ProCure Proton Therapy Center, 103 Cedar Grove Lane, Somerset, NJ 08873, USA
| | - Eugen B. Hug
- ProCure Proton Therapy Center, 103 Cedar Grove Lane, Somerset, NJ 08873, USA
| | - Suzanne L. Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- ProCure Proton Therapy Center, 103 Cedar Grove Lane, Somerset, NJ 08873, USA
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22
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Johnson SB, Hung J, Kapadia N, Oh KS, Kim M, Hamstra DA. Spinal Growth Patterns After Craniospinal Irradiation in Children With Medulloblastoma. Pract Radiat Oncol 2018; 9:e22-e28. [PMID: 30036592 DOI: 10.1016/j.prro.2018.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/13/2018] [Accepted: 07/05/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE This study aimed to evaluate the impact on spine growth in children with medulloblastoma using either photon or electron craniospinal irradiation (CSI). METHODS AND MATERIALS This was a single institution retrospective review of children who were treated with CSI for medulloblastoma. Spine growth was measured on magnetic resonance imaging scans at defined locations on the basis of a published predictive model of spine growth after CSI. Differences between spine growth in the anterior, middle, and posterior aspect of the designated vertebral segments were also assessed. Differences between the groups treated with photons or electrons were assessed with student's t test. RESULTS A total of 19 patients (10 patients treated with electrons and 9 with photons) with a median follow-up time of 45.5 months (confidence interval, 34.9-55.1 months) were evaluated. Patients treated with electrons were younger than those who received photons (5.1 years [range, 3.8-9.0 years] vs 9.6 years [range, 3.5-12.9 years]); however, there were no differences in other clinical characteristics, treatment, or follow-up between the groups. Spine growth rate for patients treated with electrons fit the predictive model (104% ± 5.2%), but patients treated with photons had growth that was faster than predicted by the model (150% ± 47%) and different from that observed with electrons. The differences between treatment the modalities were statistically significant (P = .03). For patients treated with photons, there were no statistical differences between the growth rate of the anterior vertebral body compared with the posterior aspect, but for patients treated with electrons, a faster spine growth in the anterior L1-L5 lumbar spine was observed compared with the posterior lumbar spine (3.90 vs 2.52 mm/year; P = .006) without differences in the cervical or thoracic spine. CONCLUSIONS The use of electrons to treat the craniospinal axis in children with medulloblastoma resulted in no significant difference in spine growth compared with the predicted spine growth on the basis of previously published models using photons, but with a clinically insignificant faster spine growth rate in the anterior lumbar spine.
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Affiliation(s)
- Skyler B Johnson
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Jonathon Hung
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois
| | - Nirav Kapadia
- Radiation Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kevin S Oh
- Massachusetts General Hospital, Boston, Massachusetts
| | - Michelle Kim
- The University of Michigan, Department of Radiation Oncology, Ann Arbor, Michigan
| | - Daniel A Hamstra
- Department of Radiation Oncology, Beaumont Health, Dearborn, Michigan.
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