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Yoshida T, Sasaki K, Hayakawa T, Kawadai T, Shibasaki T, Kawasaki Y. Recommendation for reducing the crystalline lens exposure dose by reducing imaging field width in cone-beam computed tomography for image-guided radiation therapy: an anthropomorphic phantom study. Radiol Phys Technol 2024; 17:629-636. [PMID: 38691308 DOI: 10.1007/s12194-024-00810-0] [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: 01/23/2024] [Revised: 03/23/2024] [Accepted: 04/26/2024] [Indexed: 05/03/2024]
Abstract
In cone-beam computed tomography (CBCT) for image-guided radiation therapy (IGRT) of the head, we evaluated the exposure dose reduction effect to the crystalline lens and position-matching accuracy by narrowing one side (X2) of the X-ray aperture (blade) in the X-direction. We defined the ocular surface dose of the head phantom as the crystalline lens exposure dose and measured using a radiophotoluminescence dosimeter (RPLD, GD-352 M) in the preset field (13.6 cm) and in each of the fields when blade X2 aperture was reduced in 0.5 cm increments from 10.0 to 5.0 cm. Auto-bone matching was performed on CBCT images acquired five times with blade X2 aperture set to 13.6 cm and 5.0 cm at each position when the head phantom was moved from - 5.0 to + 5.0 mm in 1.0 mm increment. The maximum reduction rate in the crystalline lens exposure dose was - 38.7% for the right lens and - 13.2% for the left lens when blade X2 aperture was 5.0 cm. The maximum difference in the amount of position correction between blade X2 aperture of 13.6 cm and 5.0 cm was 1 mm, and the accuracy of auto-bone matching was similar. In CBCT of the head, reduced blade X2 aperture is a useful technique for reducing the crystalline lens exposure dose while ensuring the accuracy of position matching.
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Affiliation(s)
- Tatsuya Yoshida
- Department of Radiology, Koritsu Tatebayashi Kosei General Hospital, Gunma, Japan.
- Graduate School of Radiological Technology, Gunma Prefectural College of Health Sciences, Gunma, Japan.
| | - Koji Sasaki
- Graduate School of Radiological Technology, Gunma Prefectural College of Health Sciences, Gunma, Japan
| | - Tomoki Hayakawa
- Department of Radiology, Koritsu Tatebayashi Kosei General Hospital, Gunma, Japan
| | - Toshiyuki Kawadai
- Department of Radiology, Koritsu Tatebayashi Kosei General Hospital, Gunma, Japan
| | - Takako Shibasaki
- Department of Radiology, Koritsu Tatebayashi Kosei General Hospital, Gunma, Japan
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2
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Gorodezki D, Schuhmann MU, Ebinger M, Schittenhelm J. Dissecting the Natural Patterns of Progression and Senescence in Pediatric Low-Grade Glioma: From Cellular Mechanisms to Clinical Implications. Cells 2024; 13:1215. [PMID: 39056798 PMCID: PMC11274692 DOI: 10.3390/cells13141215] [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: 05/31/2024] [Revised: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024] Open
Abstract
Pediatric low-grade gliomas (PLGGs) comprise a heterogeneous set of low-grade glial and glioneuronal tumors, collectively representing the most frequent CNS tumors of childhood and adolescence. Despite excellent overall survival rates, the chronic nature of the disease bears a high risk of long-term disease- and therapy-related morbidity in affected patients. Recent in-depth molecular profiling and studies of the genetic landscape of PLGGs led to the discovery of the paramount role of frequent upregulation of RAS/MAPK and mTOR signaling in tumorigenesis and progression of these tumors. Beyond, the subsequent unveiling of RAS/MAPK-driven oncogene-induced senescence in these tumors may shape the understanding of the molecular mechanisms determining the versatile progression patterns of PLGGs, potentially providing a promising target for novel therapies. Recent in vitro and in vivo studies moreover indicate a strong dependence of PLGG formation and growth on the tumor microenvironment. In this work, we provide an overview of the current understanding of the multilayered cellular mechanisms and clinical factors determining the natural progression patterns and the characteristic biological behavior of these tumors, aiming to provide a foundation for advanced stratification for the management of these tumors within a multimodal treatment approach.
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Affiliation(s)
- David Gorodezki
- Department of Hematology and Oncology, University Children’s Hospital Tübingen, 72076 Tübingen, Germany;
| | - Martin U. Schuhmann
- Section of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Martin Ebinger
- Department of Hematology and Oncology, University Children’s Hospital Tübingen, 72076 Tübingen, Germany;
| | - Jens Schittenhelm
- Department of Neuropathology, Institute of Pathology, University Hospital Tübingen, 72076 Tübingen, Germany
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3
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Pollack IF, Felker J, Frederico SC, Raphael I, Kohanbash G. Immunotherapy for pediatric low-grade gliomas. Childs Nerv Syst 2024:10.1007/s00381-024-06491-9. [PMID: 38884777 DOI: 10.1007/s00381-024-06491-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/01/2024] [Indexed: 06/18/2024]
Abstract
Pediatric low-grade gliomas (pLGGs) are the most common brain tumor types affecting children. Although gross-total resection remains the treatment of choice, many tumors are not amenable to complete removal, because they either involve midline structures, such as the optic chiasm or hypothalamus, and are not conducive to aggressive resection, or have diffuse biological features and blend with the surrounding brain. Historically, radiation therapy was used as the second-line option for disease control, but with the recognition that this often led to adverse long-term sequelae, particularly in young children, conventional chemotherapy assumed a greater role in initial therapy for unresectable tumors. A variety of agents demonstrated activity, but long-term disease control was suboptimal, with more than 50% of tumors exhibiting disease progression within 5 years. More recently, it has been recognized that a high percentage of these tumors in children exhibit constitutive activation of the mitogen-activated protein kinase (MAPK) pathway because of BRAF translocations or mutations, NFI mutations, or a host of other anomalies that converged on MAPK. This led to phase 1, 2, and 3 trials that explored the activity of blocking this signaling pathway, and the efficacy of this approach compared to conventional chemotherapy. Despite initial promise of these strategies, not all children tolerate this therapy, and many tumors resume growth once MAPK inhibition is stopped, raising concern that long-term and potentially life-long treatment will be required to maintain tumor control, even among responders. This observation has led to interest in other treatments, such as immunotherapy, that may delay or avoid the need for additional treatments. This chapter will summarize the place of immunotherapy in the current armamentarium for these tumors and discuss prior results and future options to improve disease control, with a focus on our prior efforts and experience in this field.
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Affiliation(s)
- Ian F Pollack
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
| | - James Felker
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Stephen C Frederico
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Itay Raphael
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Gary Kohanbash
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
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Joh-Carnella N, Bauman G, Yock TI, Zelcer S, Youkhanna S, Cacciotti C. Case report: Pediatric low-grade gliomas: a fine balance between treatment options, timing of therapy, symptom management and quality of life. Front Oncol 2024; 14:1366251. [PMID: 38912055 PMCID: PMC11190070 DOI: 10.3389/fonc.2024.1366251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/28/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Pediatric low-grade gliomas (pLGG) are the most common brain tumor in children and encompass a wide range of histologies. Treatment may pose challenges, especially in those incompletely resected or those with multiple recurrence or progression. Case description We report the clinical course of a girl diagnosed with pilocytic astrocytoma and profound hydrocephalus at age 12 years treated with subtotal resection, vinblastine chemotherapy, and focal proton radiotherapy. After radiotherapy the tumor increased in enhancement temporarily with subsequent resolution consistent with pseudoprogression. Despite improvement in imaging and radiographic local control, the patient continues to have challenges with headaches, visual and auditory concerns, stroke-like symptoms, and poor quality of life. Conclusion pLGG have excellent long-term survival; thus, treatments should focus on maintaining disease control and limiting long-term toxicities. Various treatment options exist including surgery, chemotherapy, targeted agents, and radiation therapy. Given the morbidity associated with pLGG, individualized treatment approaches are necessary, with a multi-disciplinary approach to care focused on minimizing treatment side effects, and promoting optimal quality of life for patients.
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Affiliation(s)
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, ON, Canada
| | - Torunn I. Yock
- Department of Pediatric Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Shayna Zelcer
- Division of Hematology/Oncology, Department of Pediatrics, London Health Sciences Centre & Western University, London, ON, Canada
| | - Sabin Youkhanna
- Department Radiation Oncology, London Regional Cancer Centre, London, ON, Canada
| | - Chantel Cacciotti
- Division of Hematology/Oncology, Department of Pediatrics, London Health Sciences Centre & Western University, London, ON, Canada
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Mohamed AA, Alshaibi R, Faragalla S, Mohamed Y, Lucke-Wold B. Updates on management of gliomas in the molecular age. World J Clin Oncol 2024; 15:178-194. [PMID: 38455131 PMCID: PMC10915945 DOI: 10.5306/wjco.v15.i2.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/06/2024] [Accepted: 01/25/2024] [Indexed: 02/20/2024] Open
Abstract
Gliomas are primary brain tumors derived from glial cells of the central nervous system, afflicting both adults and children with distinct characteristics and therapeutic challenges. Recent developments have ushered in novel clinical and molecular prognostic factors, reshaping treatment paradigms based on classification and grading, determined by histological attributes and cellular lineage. This review article delves into the diverse treatment modalities tailored to the specific grades and molecular classifications of gliomas that are currently being discussed and used clinically in the year 2023. For adults, the therapeutic triad typically consists of surgical resection, chemotherapy, and radiotherapy. In contrast, pediatric gliomas, due to their diversity, require a more tailored approach. Although complete tumor excision can be curative based on the location and grade of the glioma, certain non-resectable cases demand a chemotherapy approach usually involving, vincristine and carboplatin. Additionally, if surgery or chemotherapy strategies are unsuccessful, Vinblastine can be used. Despite recent advancements in treatment methodologies, there remains a need of exploration in the literature, particularly concerning the efficacy of treatment regimens for isocitrate dehydrogenase type mutant astrocytomas and fine-tuned therapeutic approaches tailored for pediatric cohorts. This review article explores into the therapeutic modalities employed for both adult and pediatric gliomas in the context of their molecular classification.
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Affiliation(s)
- Ali Ahmed Mohamed
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Rakan Alshaibi
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, United States
| | - Steven Faragalla
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Youssef Mohamed
- College of Osteopathic Medicine, Kansas City University, Joplin, MO 64804, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, United States
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Liu KX, Haas-Kogan DA, Elhalawani H. Radiotherapy for Primary Pediatric Central Nervous System Malignancies: Current Treatment Paradigms and Future Directions. Pediatr Neurosurg 2023; 58:356-366. [PMID: 37703864 DOI: 10.1159/000533777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Central nervous system tumors are the most common solid tumors in childhood. Treatment paradigms for pediatric central nervous system malignancies depend on elements including tumor histology, age of patient, and stage of disease. Radiotherapy is an important modality of treatment for many pediatric central nervous system malignancies. SUMMARY While radiation contributes to excellent overall survival rates for many patients, radiation also carries significant risks of long-term side effects including neurocognitive decline, hearing loss, growth impairment, neuroendocrine dysfunction, strokes, and secondary malignancies. In recent decades, clinical trials have demonstrated that with better imaging and staging along with more sophisticated radiation planning and treatment set-up verification, smaller treatment volumes can be utilized without decrement in survival. Furthermore, the development of intensity-modulated radiotherapy and proton-beam radiotherapy has greatly improved conformality of radiation. KEY MESSAGES Recent changes in radiation treatment paradigms have decreased risks of short- and long-term toxicity for common histologies and in different age groups. Future studies will continue to develop novel radiation regimens to improve outcomes in aggressive central nervous system tumors, integrate molecular subtypes to tailor radiation treatment, and decrease radiation-associated toxicity for long-term survivors.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hesham Elhalawani
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Wang B, Tian P, Sun Q, Zhang H, Han L, Zhu B. A novel, effective machine learning-based RNA editing profile for predicting the prognosis of lower-grade gliomas. Heliyon 2023; 9:e18075. [PMID: 37483735 PMCID: PMC10362151 DOI: 10.1016/j.heliyon.2023.e18075] [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: 01/14/2023] [Revised: 07/02/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
Patients with low-grade glioma (LGG) may survive for long time periods, but their tumors often progress to higher-grade lesions. Currently, no cure for LGG is available. A-to-I RNA editing accounts for nearly 90% of all RNA editing events in humans and plays a role in tumorigenesis in various cancers. However, little is known regarding its prognostic role in LGG. On the basis of The Cancer Genome Atlas (TCGA) data, we used LASSO and univariate Cox regression to construct an RNA editing site signature. The results derived from the TCGA dataset were further validated with Gene Expression Omnibus (GEO) and Chinese Glioma Genome Atlas (CGGA) datasets. Five machine learning algorithms (Decision Trees C5.0, XGboost, GBDT, Lightgbm, and Catboost) were used to confirm the prognosis associated with the RNA editing site signature. Finally, we explored immune function, immunotherapy, and potential therapeutic agents in the high- and low-risk groups by using multiple biological prediction websites. A total of 22,739 RNA editing sites were identified, and a signature model consisting of four RNA editing sites (PRKCSH|chr19:11561032, DSEL|chr18:65174489, UGGT1|chr2:128952084, and SOD2|chr6:160101723) was established. Cox regression analysis indicated that the RNA editing signature was an independent prognostic factor, according to the ROC curve (AUC = 0.823), and the nomogram model had good predictive power (C-index = 0.824). In addition, the predictive ability of the RNA editing signature was confirmed with the machine learning model. The sensitivity of PCI-34051 and Elephantin was significantly higher in the high-risk group than the low-risk group, thus potentially providing a marker to predict the effects of lung cancer drug treatment. RNA editing may serve as a novel survival prediction tool, thus offering hope for developing editing-based therapeutic strategies to combat LGG progression. In addition, this tool may help optimize survival risk assessment and individualized care for patients with low-grade gliomas.
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Affiliation(s)
- Boshen Wang
- Jiangsu Provincial Center for Disease Prevention and Control, Nanjing 210000, Jiangsu, China
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, Jiangsu, China
| | - Peijie Tian
- Department of Pathology, Weifang Medical University, China
| | - Qianyu Sun
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, Jiangsu, China
| | - Hengdong Zhang
- Jiangsu Provincial Center for Disease Prevention and Control, Nanjing 210000, Jiangsu, China
| | - Lei Han
- Jiangsu Provincial Center for Disease Prevention and Control, Nanjing 210000, Jiangsu, China
| | - Baoli Zhu
- Jiangsu Provincial Center for Disease Prevention and Control, Nanjing 210000, Jiangsu, China
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, Jiangsu, China
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Cipri S, Del Baldo G, Fabozzi F, Boccuto L, Carai A, Mastronuzzi A. Unlocking the power of precision medicine for pediatric low-grade gliomas: molecular characterization for targeted therapies with enhanced safety and efficacy. Front Oncol 2023; 13:1204829. [PMID: 37397394 PMCID: PMC10311254 DOI: 10.3389/fonc.2023.1204829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
In the past decade significant advancements have been made in the discovery of targetable lesions in pediatric low-grade gliomas (pLGGs). These tumors account for 30-50% of all pediatric brain tumors with generally a favorable prognosis. The latest 2021 WHO classification of pLGGs places a strong emphasis on molecular characterization for significant implications on prognosis, diagnosis, management, and the potential target treatment. With the technological advances and new applications in molecular diagnostics, the molecular characterization of pLGGs has revealed that tumors that appear similar under a microscope can have different genetic and molecular characteristics. Therefore, the new classification system divides pLGGs into several distinct subtypes based on these characteristics, enabling a more accurate strategy for diagnosis and personalized therapy based on the specific genetic and molecular abnormalities present in each tumor. This approach holds great promise for improving outcomes for patients with pLGGs, highlighting the importance of the recent breakthroughs in the discovery of targetable lesions.
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Affiliation(s)
- Selene Cipri
- Department of Hematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giada Del Baldo
- Department of Hematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Fabozzi
- Department of Hematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Luigi Boccuto
- Healthcare Genetics Program, School of Nursing, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, United States
| | - Andrea Carai
- Department of Neurosciences, Neurosurgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Angela Mastronuzzi
- Department of Hematology/Oncology, Cell Therapy, Gene Therapies and Hemopoietic Transplant, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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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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10
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Sait SF, Giantini-Larsen AM, Tringale KR, Souweidane MM, Karajannis MA. Treatment of Pediatric Low-Grade Gliomas. Curr Neurol Neurosci Rep 2023; 23:185-199. [PMID: 36881254 PMCID: PMC10121885 DOI: 10.1007/s11910-023-01257-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW Pediatric low-grade gliomas and glioneuronal tumors (pLGG) account for approximately 30% of pediatric CNS neoplasms, encompassing a heterogeneous group of tumors of primarily glial or mixed neuronal-glial histology. This article reviews the treatment of pLGG with emphasis on an individualized approach incorporating multidisciplinary input from surgery, radiation oncology, neuroradiology, neuropathology, and pediatric oncology to carefully weigh the risks and benefits of specific interventions against tumor-related morbidity. Complete surgical resection can be curative for cerebellar and hemispheric lesions, while use of radiotherapy is restricted to older patients or those refractory to medical therapy. Chemotherapy remains the preferred first-line therapy for adjuvant treatment of the majority of recurrent or progressive pLGG. RECENT FINDINGS Technologic advances offer the potential to limit volume of normal brain exposed to low doses of radiation when treating pLGG with either conformal photon or proton RT. Recent neurosurgical techniques such as laser interstitial thermal therapy offer a "dual" diagnostic and therapeutic treatment modality for pLGG in specific surgically inaccessible anatomical locations. The emergence of novel molecular diagnostic tools has enabled scientific discoveries elucidating driver alterations in mitogen-activated protein kinase (MAPK) pathway components and enhanced our understanding of the natural history (oncogenic senescence). Molecular characterization strongly supplements the clinical risk stratification (age, extent of resection, histological grade) to improve diagnostic precision and accuracy, prognostication, and can lead to the identification of patients who stand to benefit from precision medicine treatment approaches. The success of molecular targeted therapy (BRAF inhibitors and/or MEK inhibitors) in the recurrent setting has led to a gradual and yet significant paradigm shift in the treatment of pLGG. Ongoing randomized trials comparing targeted therapy to standard of care chemotherapy are anticipated to further inform the approach to upfront management of pLGG patients.
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Affiliation(s)
- Sameer Farouk Sait
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Alexandra M Giantini-Larsen
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, USA
| | - Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Mark M Souweidane
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, USA
| | - Matthias A Karajannis
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Bianchi F, Cocilovo FM, Ruggiero A, Tamburrini G. Optic Pathway Gliomas: The Trends of Basic Research to Reduce the Impact of the Disease on Visual Function. Adv Tech Stand Neurosurg 2023; 48:123-137. [PMID: 37770684 DOI: 10.1007/978-3-031-36785-4_6] [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] [Indexed: 09/30/2023]
Abstract
Pediatric optic pathway gliomas (OPG) are low-grade brain tumors characterized by slow progression and invalidating visual loss. Common therapeutic strategies include surgery, radiotherapy, chemotherapy, and combinations of these modalities, but despite the different treatment strategies, no actual treatment exists to prevent or revert visual impairment. Nowadays, several reports of the literature show promising results regarding NGF eye drop instillation and improvement of visual outcome. Such results seem to be related with the NGF-linked prevention in caspase activation, which reduces retinal ganglion cell loss.Reducing retinal ganglion cell loss results clinically in visual field improvement as well as visual electric potential and optical coherence tomography gain. Nonetheless, visual acuity fails to show significant changes.Visual impairment represents nowadays one of the major issues in dealing with OPGs. Secondary to the interesting results offered by NGF eye drop administration, further studies are warranted to better comprehend potential treatment strategies.
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Affiliation(s)
| | | | - Antonio Ruggiero
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Milan, Italy
| | - Gianpiero Tamburrini
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Milan, Italy
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12
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Jujui-Eam A, Sirachainan N, Hongeng S, Hansasuta A, Boongird A, Tritanon O, Dhanachai M, Swangsilpa T, Ruangkanchanasetr R, Worawongsakul R, Puataweepong P. Long-term treatment outcomes of pediatric low-grade gliomas treated at a university-based hospital. Childs Nerv Syst 2022; 39:1173-1182. [PMID: 36574012 DOI: 10.1007/s00381-022-05809-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/14/2022] [Indexed: 12/28/2022]
Abstract
PURPOSE A multimodality approach is generally considered for pediatric low-grade gliomas (LGG); however, the optimal management remains uncertain. The objective of the study was to evaluate treatment outcomes of pediatric LGG, focusing on long-term survival and factors related to outcomes. METHODS A retrospective review of 77 pediatric LGG cases treated at Ramathibodi Hospital, Thailand between 2000 and 2018 was performed. The inclusion criteria were all pediatric LGG cases aged ≤ 15 years. Diffuse intrinsic pontine gliomas and spinal cord tumors were excluded. RESULTS The median follow-up time was 8.2 years (range, 0.6-19.7). The median age at diagnosis was 6.2 years (interquartile range, 3.6-11.4). Treatments modality included tumor surgery (93%), chemotherapy (40%), and radiation therapy (14%). The 10-year overall survival (OS) and 10-year progression-free survival were 94% and 59%, respectively, for the entire cohort. The 10-year OS was 100% in three subgroups of patients: pilocytic subtype, WHO grade 1 tumors, and recipient of gross total resection. After multivariable analysis, no tumor surgery had a significantly unfavorable influence on overall survival. CONCLUSIONS With a multimodality approach, pediatric LGGs had excellent outcome. Gross total resection is the standard primary treatment. Chemotherapy is the alternative standard treatment in incomplete resection cases, unresectable patients, or patients with progressive disease. Radiation therapy should be reserved as a salvage treatment option because of late complications that usually affect patients' quality of life.
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Affiliation(s)
- Apisak Jujui-Eam
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suradej Hongeng
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ake Hansasuta
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Atthaporn Boongird
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oranan Tritanon
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Mantana Dhanachai
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Thiti Swangsilpa
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Rawee Ruangkanchanasetr
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Rasin Worawongsakul
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand
| | - Putipun Puataweepong
- Radiation Oncology Unit, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, 10400, Bangkok, Thailand.
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Management of Optic Pathway Glioma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14194781. [PMID: 36230704 PMCID: PMC9563939 DOI: 10.3390/cancers14194781] [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: 09/01/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background: OPG accounts for 3−5% of childhood central nervous system (CNS) tumors and about 2% of pediatric glial lesions. Methods: Article selection was performed by searching PubMed, Web of Science, and Cochrane databases. Results: The pooled mortality rate was 0.12 (95%CI 0.09−0.14). Due to the unrepresentative data, improved and not changed outcomes were classified as favorable outcomes and worsened as unfavorable. Meta-analyses were performed to determine the rate of clinical and radiological favorable outcomes. In terms of visual assessment, the pooled rate of a favorable outcome in chemotherapy, radiotherapy, and surgery was 0.74, 0.81, and 0.65, respectively, and the overall pooled rate of the favorable outcome was 0.75 (95%CI 0.70−0.80). In terms of radiological assessment, the rate of a favorable outcome following chemotherapy, radiotherapy, and surgery was 0.71, 0.74, and 0.67, respectively, and the overall pooled rate of the favorable outcome is 0.71 (95%CI 0.65−0.77). The subgroup analysis revealed no significant difference in the rate of clinical and radiological favorable outcomes between the different treatment modalities (p > 0.05). Conclusion: Our analyses showed that each therapeutic modality represents viable treatment options to achieve remission for these patients.
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14
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Kim N, Lim DH. Recent Updates on Radiation Therapy for Pediatric Optic Pathway Glioma. Brain Tumor Res Treat 2022; 10:94-100. [PMID: 35545828 PMCID: PMC9098980 DOI: 10.14791/btrt.2022.0003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022] Open
Abstract
Optic pathway glioma (OPG) is a rare tumor located in optic nerve, optic tract, or optic chiasm. Treatment options for OPG include surgery, radiation therapy (RT), and chemotherapy. Although RT may provide favorable long-term outcomes in manner of either adjuvant or salvage aim, chemotherapy-first approach is increasingly performed due to possible late effects of RT. Proton beam RT may allow normal tissue sparing of radiation exposure compared to conventional X-ray treatment. Therefore, proton beam RT is expected to reduce complications from RT. This review discusses the recent updates on oncologic outcomes of OPG, late toxicities following RT, and compares the outcomes between X-ray treatment and proton beam RT.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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15
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Rady MR, Enayet AE, Refaat A, Taha H, Said W, Maher E, Beltagy MAE. Management and outcome of pediatric brainstem and cerebellar peduncular low-grade gliomas: a retrospective analysis of 62 cases. Childs Nerv Syst 2022; 38:565-575. [PMID: 34787716 DOI: 10.1007/s00381-021-05405-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study was designed to present our experience and recommendations regarding the management of pediatric brainstem and peduncular low-grade gliomas (LGGs). METHODS Retrospective analysis was performed for pathologically proven brainstem or cerebellar peduncular LGGs in patients admitted between 2014 and 2019. These lesions were classified into the dorsal exophytic, focal brainstem, cervicomedullary, lower peduncular, and upper peduncular groups, and this classification was the basis for the surgical approach for the lesions. RESULTS Sixty-two pediatric patients were included, and their distribution among the aforementioned groups were as follows: 12, 12, 3, 16, and 19 cases in the dorsal exophytic, focal brainstem, cervicomedullary, upper peduncular, and lower peduncular groups, respectively. Stereotactic biopsy was performed for all cases in the focal brainstem group, whereas other groups underwent open excision. Gross total resection (GTR) was achieved in 20 cases (40%), near-total resection (NTR) was achieved in 17 cases (34%), and subtotal resection (STR) was achieved in 13 cases (26%). The extent of GTR and NTR for the upper peduncular, lower peduncular, dorsal exophytic, and cervicomedullary groups were 81.2%, 68.4%,75%, and 66.6%, respectively. Then, 32 cases received chemotherapy. The 3- and 5-year progression-free survival rates were 95% (95% confidence interval (CI) 89.5-100%) and 90.3% (95% CI 79.9-100%), respectively. A significant difference in the 3-year progression-free survival rate was observed between the GTR and NTR groups (p = 0.06; 100% vs. 88.2% (95% CI 72.9-100%)). CONCLUSION Surgery plays a definitive curative role in grossly resected cases. Additionally, the role of surgical debulking should be considered, even if GTR is impossible. Meanwhile, chemotherapy showed a beneficial role in patients with focal brainstem lesions and progressive lesions, those with STR, and some patients with NTR.
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Affiliation(s)
- Mohamed Reda Rady
- Neurosurgery Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt.,Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE, 57357), Cairo, Egypt
| | - Abd Elrhman Enayet
- Neurosurgery Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt.,Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE, 57357), Cairo, Egypt
| | - Amal Refaat
- Radiodiagnosis department, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
| | - Hala Taha
- Clinical Pathology Department, Children's Cancer Hospital Egypt (CCHE, Cairo, 57357), Egypt
| | - Waleed Said
- Pediatric Oncology Department, Children's Cancer Hospital Egypt (CCHE, Cairo, 57357), Egypt
| | - Eslam Maher
- Research Department, Children's Cancer Hospital Egypt (CCHE, Cairo, 57357), Egypt
| | - Mohamed A El Beltagy
- Neurosurgery Department, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt. .,Neurosurgery Department, Children's Cancer Hospital Egypt (CCHE, 57357), Cairo, Egypt.
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16
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Rios JD, Velummailum R, Bennett J, Nobre L, Tsang DS, Bouffet E, Hawkins C, Tabori U, Denburg A, Pechlivanoglou P. Clinical and economic impact of molecular testing for BRAF fusion in pediatric low-grade Glioma. BMC Pediatr 2022; 22:13. [PMID: 34980048 PMCID: PMC8722113 DOI: 10.1186/s12887-021-03069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Treatment personalization via tumor molecular testing holds promise for improving outcomes for patients with pediatric low-grade glioma (PLGG). We evaluate the health economic impact of employing tumor molecular testing to guide treatment for patients diagnosed with PLGG, particularly the avoidance of radiation therapy (RT) for patients with BRAF-fusion. Methods We performed a model-based cost-utility analysis comparing two strategies: molecular testing to determine BRAF fusion status at diagnosis against no molecular testing. We developed a microsimulation to model the lifetime health and cost outcomes (in quality-adjusted life years (QALYs) and 2018 CAD, respectively) for a simulated cohort of 100,000 patients newly diagnosed with PLGG after their initial surgery. Results The life expectancy after diagnosis for individuals who did not receive molecular testing was 39.01 (95% Confidence Intervals (CI): 32.94;44.38) years and 40.08 (95% CI: 33.19;45.76) years for those who received testing. Our findings indicate that patients who received molecular testing at diagnosis experienced a 0.38 (95% CI: 0.08;0.77) gain in QALYs and $1384 (95% CI: $-3486; $1204) reduction in costs over their lifetime. Cost and QALY benefits were driven primarily by the avoidance of long-term adverse events (stroke, secondary neoplasms) associated with unnecessary use of radiation. Conclusions We demonstrate the clinical benefit and cost-effectiveness of molecular testing in guiding the decision to provide RT in PLGG. While our results do not consider the impact of targeted therapies, this work is an example of the value of simulation modeling in assessing the long-term costs and benefits of precision oncology interventions for childhood cancer, which can aid decision-making about health system reimbursement. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-03069-1.
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Affiliation(s)
- Juan David Rios
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada
| | - Russanthy Velummailum
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada
| | - Julie Bennett
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Liana Nobre
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Derek S Tsang
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Cynthia Hawkins
- Department of Pathology, Hospital for Sick Children, Toronto, ON, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Avram Denburg
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Petros Pechlivanoglou
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada. .,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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17
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Shen CJ, Terezakis SA. The Evolving Role of Radiotherapy for Pediatric Cancers With Advancements in Molecular Tumor Characterization and Targeted Therapies. Front Oncol 2021; 11:679701. [PMID: 34604027 PMCID: PMC8481883 DOI: 10.3389/fonc.2021.679701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/26/2021] [Indexed: 12/14/2022] Open
Abstract
Ongoing rapid advances in molecular diagnostics, precision imaging, and development of targeted therapies have resulted in a constantly evolving landscape for treatment of pediatric cancers. Radiotherapy remains a critical element of the therapeutic toolbox, and its role in the era of precision medicine continues to adapt and undergo re-evaluation. Here, we review emerging strategies for combining radiotherapy with novel targeted systemic therapies (for example, for pediatric gliomas or soft tissue sarcomas), modifying use or intensity of radiotherapy when appropriate via molecular diagnostics that allow better characterization and individualization of each patient’s treatments (for example, de-intensification of radiotherapy in WNT subgroup medulloblastoma), as well as exploring more effective targeted systemic therapies that may allow omission or delay of radiotherapy. Many of these strategies are still under investigation but highlight the importance of continued pre-clinical and clinical studies evaluating the role of radiotherapy in this era of precision oncology.
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Affiliation(s)
- Colette J Shen
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC, United States
| | - Stephanie A Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, United States
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18
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Sager O, Dincoglan F, Demiral S, Uysal B, Gamsiz H, Colak O, Ozcan F, Gundem E, Elcim Y, Dirican B, Beyzadeoglu M. Concise review of stereotactic irradiation for pediatric glial neoplasms: Current concepts and future directions. World J Methodol 2021; 11:61-74. [PMID: 34026579 PMCID: PMC8127424 DOI: 10.5662/wjm.v11.i3.61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/07/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
Brain tumors, which are among the most common solid tumors in childhood, remain a leading cause of cancer-related mortality in pediatric population. Gliomas, which may be broadly categorized as low grade glioma and high grade glioma, account for the majority of brain tumors in children. Expectant management, surgery, radiation therapy (RT), chemotherapy, targeted therapy or combinations of these modalities may be used for management of pediatric gliomas. Several patient, tumor and treatment-related characteristics including age, lesion size, grade, location, phenotypic and genotypic features, symptomatology, predicted outcomes and toxicity profile of available therapeutic options should be considered in decision making for optimal treatment. Management of pediatric gliomas poses a formidable challenge to the physicians due to concerns about treatment induced toxicity. Adverse effects of therapy may include neurological deficits, hemiparesis, dysphagia, ataxia, spasticity, endocrine sequelae, neurocognitive and communication impairment, deterioration in quality of life, adverse socioeconomic consequences, and secondary cancers. Nevertheless, improved understanding of molecular pathology and technological advancements may pave the way for progress in management of pediatric glial neoplasms. Multidisciplinary management with close collaboration of disciplines including pediatric oncology, surgery, and radiation oncology is warranted to achieve optimal therapeutic outcomes. In the context of RT, stereotactic irradiation is a viable treatment modality for several central nervous system disorders and brain tumors. Considering the importance of minimizing adverse effects of irradiation, radiosurgery has attracted great attention for clinical applications in both adults and children. Radiosurgical applications offer great potential for improving the toxicity profile of radiation delivery by focused and precise targeting of well-defined tumors under stereotactic immobilization and image guidance. Herein, we provide a concise review of stereotactic irradiation for pediatric glial neoplasms in light of the literature.
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Affiliation(s)
- Omer Sager
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Ferrat Dincoglan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Selcuk Demiral
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Bora Uysal
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Hakan Gamsiz
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Onurhan Colak
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Fatih Ozcan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Esin Gundem
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Yelda Elcim
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Bahar Dirican
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Murat Beyzadeoglu
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
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19
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Valiyaveettil D, G A, Malik M, Eaga P, Ahmed SF, Joseph D. "A prospective study of assessment of neurocognitive function in illiterate patients with gliomas treated with chemoradiation": Assessment of neurocognitive function in gliomas. Cancer Treat Res Commun 2020; 26:100288. [PMID: 33352469 DOI: 10.1016/j.ctarc.2020.100288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/16/2020] [Accepted: 11/28/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Neurocognitive functioning (NCF) is an important component of quality of life (QoL) in glioma patients. The neurocognitive toxicity from irradiation of brain tumours may be related to damage to neural progenitor cells (NPC). The aim of our study was to assess the NCF in illiterate glioma patients. METHODS This was a prospective study done in glioma patients admitted for adjuvant treatment. Illiterate and semiliterate post op glioma patients with ECOG PS ≤ 3 were included. Neurocognitive assessment was done using Addenbrooke's Cognitive Examination (ACE-III) questionnaire prior to the start of RT and at 6month and 12 month follow up. The scores were correlated to the doses to sub ventricular zone (SVZ) and sub granular zone (SGZ) regions. RESULTS 20 patients were recruited.16 patients were illiterate and four patients were semiliterate. Median of the mean dose to the SVZ I/L (ipsilateral) was 48.5 Gy and SGZ I/L was 39.5 Gy. In patients who received ≤49 Gy mean dose to SVZ I/L, there was statistically significant improvement in memory, fluency, language and total ACE scores at six months. In patients with SGZ I/L mean dose ≤40 Gy, there was improvement in memory, language, and total ACE score at six months. Similar trend continued at 12 months follow up. CONCLUSIONS NCF assessment by ACE III questionnaire is a useful tool even in illiterate patients. Lower RT doses to the ipsilateral SVZ and SGZ showed significant improvement in total ACE scores at 6 months and improvement in specific domains at 6 and 12 months.
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Affiliation(s)
- Deepthi Valiyaveettil
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Ashalatha G
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Monica Malik
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Hyderabad, India.
| | | | - Syed Fayaz Ahmed
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Deepa Joseph
- All India Institute of Medical Sciences, Rishikesh, India
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20
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Goda JS, Dutta D, Krishna U, Goswami S, Kothavade V, Kannan S, Maitre M, Bano N, Gupta T, Jalali R. Hippocampal radiotherapy dose constraints for predicting long-term neurocognitive outcomes: mature data from a prospective trial in young patients with brain tumors. Neuro Oncol 2020; 22:1677-1685. [PMID: 32227185 PMCID: PMC7690355 DOI: 10.1093/neuonc/noaa076] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Hippocampus is considered to be the seat for neurocognitive functions. Avoidance of hippocampus during radiotherapy to brain may serve to preserve various domains of neurocognition. We aimed to derive radiotherapy dose constraints to hippocampi for preserving neurocognition in young patients with brain tumors by measuring various neurocognitive parameters. METHODS Forty-eight patients with residual/progressive benign or low-grade brain tumors treated with stereotactic conformal radiotherapy (SCRT) to a dose of 54 Gy in 30 fractions underwent prospective neuropsychological assessments at baseline before SCRT and at 6 months and 2, 3, 4, and 5 years. Hippocampi were drawn as per the Radiation Therapy Oncology Group atlas. Longitudinal change in intelligence quotient scores was correlated with hippocampal doses. RESULTS Mean volume of bilateral hippocampi was 4.35 cc (range: 2.12-8.41 cc). Craniopharyngioma was the commonest histologic subtype. A drop of >10% in mean full-scale intelligence quotient (FSIQ) scores at 3 and 5 years post SCRT was observed in patients in whom left hippocampus received a mean dose of 30.7 Gy (P = 0.04) and 31 Gy (P = 0.04), respectively. Mean performance quotient (PQ) scores dropped > 10% at 5 years when the left hippocampus received a dose of > 32 Gy (P = 0.03). There was no significant correlation of radiotherapy doses with verbal quotient, or with doses received by the right hippocampus. Multivariate analysis revealed young age (<13 y) and left hippocampus dose predicted for clinically relevant decline in certain neurocognitive domains. CONCLUSIONS A mean dose of ≤30 Gy to the left hippocampus as a dose constraint for preserving intelligence quotient is suggested. KEY POINTS 1. Children and young adults with benign and low-grade gliomas survive long after therapy.2. Higher dose to the hippocampi may result in long-term neurocognitive impairment.3. Mean dose of <30 Gy to left hippocampus could be used as a pragmatic dose constraint to prevent long-term neurocognitive decline.
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Affiliation(s)
- Jayant S Goda
- Neuro-Oncology Disease Management Group, Tata Memorial Centre, Parel, Mumbai, India
- Homi Bhaba National Institute, Mumbai, India
| | - Debnarayan Dutta
- Neuro-Oncology Disease Management Group, Tata Memorial Centre, Parel, Mumbai, India
- Homi Bhaba National Institute, Mumbai, India
| | - Uday Krishna
- Neuro-Oncology Disease Management Group, Tata Memorial Centre, Parel, Mumbai, India
- Homi Bhaba National Institute, Mumbai, India
| | - Savita Goswami
- Homi Bhaba National Institute, Mumbai, India
- Clinical Psychology, Tata Memorial Centre, Parel, Mumbai, India
| | - Vikas Kothavade
- Neuro-Oncology Disease Management Group, Tata Memorial Centre, Parel, Mumbai, India
| | - Sadhna Kannan
- Homi Bhaba National Institute, Mumbai, India
- Clinical Research Secretariat, Tata Memorial Centre Advanced Centre for Treatment, Research and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Madan Maitre
- Neuro-Oncology Disease Management Group, Tata Memorial Centre, Parel, Mumbai, India
- Homi Bhaba National Institute, Mumbai, India
| | - Nazia Bano
- Neuro-Oncology Disease Management Group, Tata Memorial Centre, Parel, Mumbai, India
- Homi Bhaba National Institute, Mumbai, India
| | - Tejpal Gupta
- Neuro-Oncology Disease Management Group, Tata Memorial Centre, Parel, Mumbai, India
| | - Rakesh Jalali
- Neuro-Oncology Disease Management Group, Tata Memorial Centre, Parel, Mumbai, India
- Homi Bhaba National Institute, Mumbai, India
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21
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Nellan A, Wright E, Campbell K, Davies KD, Donson AM, Amani V, Judd A, Hemenway MS, Raybin J, Foreman NK, Rush S, Dorris K. Retrospective analysis of combination carboplatin and vinblastine for pediatric low-grade glioma. J Neurooncol 2020; 148:569-575. [PMID: 32506370 DOI: 10.1007/s11060-020-03549-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Low-grade glioma (LGG) represent the most common pediatric central nervous system tumor. When total surgical resection is not feasible, chemotherapy is first-line therapy in children. Multiple pediatric LGG chemotherapy regimens have been investigated with variable 2-year event free survival (EFS) rates of 39-69%. To date, treatment of pediatric LGG with a carboplatin and vinblastine (C/VBL) chemotherapy regimen has only been evaluated in a phase 1 dose-finding study. METHODS A retrospective review of pediatric patients with LGG who were treated with C/VBL at Children's Hospital of Colorado or Akron Children's Hospital from 2011 to 2017 was conducted. Data collected included patient demographics, tumor location, disease response, neurofibromatosis 1 (NF1) status, therapy duration and toxicities. Response to therapy was determined by objective findings on imaging and treating physicians' evaluation. RESULTS Forty-six patients were identified for analysis, all of whom were chemotherapy-naive. Only five patients treated in this cohort had NF1. BRAF fusion was identified in 65% (22/34) of tested tumors. Best therapy response was partial response in nine patients and stable disease in twenty-five patients. Twelve patients had progressive disease. One-year, 3-year, and 5-year EFS probabilities for all patients were 69.6%, 39.4%, and 34.5%, respectively. Nine patients had admissions for febrile neutropenia and seven patients experienced one delay in chemotherapy due to neutropenia. Only two patients had to discontinue this chemotherapy regimen because of treatment-related toxicities [carboplatin allergy (n = 1) and vinblastine neuropathy (n = 1)]. CONCLUSION C/VBL achieves similar EFS rates to other single-agent and combination cytotoxic chemotherapy regimens for pediatric LGG with manageable toxicities.
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Affiliation(s)
- Anandani Nellan
- Department of Pediatrics, Morgan Adams Foundation Pediatric Brain Tumor Research Program, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. .,Center for Cancer and Blood Disorders, Morgan Adams Foundation Pediatric Brain Tumor Research Program, University of Colorado School of Medicine, 13123 East 16th Avenue, Box B115, Aurora, CO, 80045, USA.
| | - Erin Wright
- Division of Hematology Oncology, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308, USA
| | - Kristen Campbell
- Department of Pediatrics, Morgan Adams Foundation Pediatric Brain Tumor Research Program, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kurtis D Davies
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew M Donson
- Department of Pediatrics, Morgan Adams Foundation Pediatric Brain Tumor Research Program, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vladimir Amani
- Department of Pediatrics, Morgan Adams Foundation Pediatric Brain Tumor Research Program, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Alexis Judd
- Division of Hematology Oncology, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308, USA
| | - Molly S Hemenway
- Department of Pediatrics, Morgan Adams Foundation Pediatric Brain Tumor Research Program, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer Raybin
- Department of Pediatrics, Morgan Adams Foundation Pediatric Brain Tumor Research Program, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nicholas K Foreman
- Department of Pediatrics, Morgan Adams Foundation Pediatric Brain Tumor Research Program, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Rush
- Division of Hematology Oncology, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308, USA
| | - Kathleen Dorris
- Department of Pediatrics, Morgan Adams Foundation Pediatric Brain Tumor Research Program, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Margin-Free Fractionated Stereotactic Radiation Therapy for Pediatric Brain Tumors. Pract Radiat Oncol 2020; 10:e485-e494. [PMID: 32428764 DOI: 10.1016/j.prro.2020.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/14/2020] [Accepted: 03/09/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE Conventional radiation therapy (RT) to pediatric brain tumors exposes a large volume of normal brain to unwarranted radiation causing late toxicity. We hypothesized that in well demarcated pediatric tumors lacking microscopic extensions, fractionated stereotactic RT (SRT), without target volume expansions, can reduce high dose normal tissue irradiation without affecting local control. METHODS AND MATERIALS Between 2008 and 2017, 52 pediatric patients with brain tumors were treated using the CyberKnife (CK) with SRT in 180 to 200 cGy per fraction. Thirty representative cases were retrospectively planned for intensity modulated RT (IMRT) with 4-mm PTV expansion. We calculated the volume of normal tissue within the high or intermediate dose region adjacent to the target. Plan quality and radiation dose-volume dosimetry parameters were compared between CK and IMRT plans. We also reported overall survival, progression-free survival (PFS), and local control. RESULTS Tumors included low-grade gliomas (n = 28), craniopharyngiomas (n = 16), and ependymomas (n = 8). The volumes of normal tissue receiving high (≥80% of prescription dose or ≥40 Gy) or intermediate (80% > dose ≥50% of the prescription dose or 40 Gy > dose ≥25 Gy) dose were significantly smaller with CK versus IMRT plans (P < .0001 for all comparisons). With a median follow-up of 3.7 years (range, 0.1-9.0), 3-year local control was 92% for all patients. Eight failures occurred: 1 craniopharyngioma (marginal), 2 ependymomas (both in-field), and 5 low-grade gliomas (2 in-field, 1 marginal, and 2 distant). CONCLUSIONS Fractionated SRT using CK without target volume expansion appears to reduce the volume of irradiated tissue without majorly compromising local control in pediatric demarcated brain tumors. These results are hypothesis generating and should be tested and validated in prospective studies.
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Abstract
Brain tumors constitute the largest source of oncologic mortality in children and low-grade gliomas are among most common pediatric central nervous system tumors. Pediatric low-grade gliomas differ from their counterparts in the adult population in their histopathology, genetics, and standard of care. Over the past decade, an increasingly detailed understanding of the molecular and genetic characteristics of pediatric brain tumors led to tailored therapy directed by integrated phenotypic and genotypic parameters and the availability of an increasing array of molecular-directed therapies. Advances in neuroimaging, conformal radiation therapy, and conventional chemotherapy further improved treatment outcomes. This article reviews the current classification of pediatric low-grade gliomas, their histopathologic and radiographic features, state-of-the-art surgical and adjuvant therapies, and emerging therapies currently under study in clinical trials.
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Ryall S, Tabori U, Hawkins C. Pediatric low-grade glioma in the era of molecular diagnostics. Acta Neuropathol Commun 2020; 8:30. [PMID: 32164789 PMCID: PMC7066826 DOI: 10.1186/s40478-020-00902-z] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/21/2020] [Indexed: 12/17/2022] Open
Abstract
Low grade gliomas are the most frequent brain tumors in children and encompass a spectrum of histologic entities which are currently assigned World Health Organisation grades I and II. They differ substantially from their adult counterparts in both their underlying genetic alterations and in the infrequency with which they transform to higher grade tumors. Nonetheless, children with low grade glioma are a therapeutic challenge due to the heterogeneity in their clinical behavior – in particular, those with incomplete surgical resection often suffer repeat progressions with resultant morbidity and, in some cases, mortality. The identification of up-regulation of the RAS–mitogen-activated protein kinase (RAS/MAPK) pathway as a near universal feature of these tumors has led to the development of targeted therapeutics aimed at improving responses while mitigating patient morbidity. Here, we review how molecular information can help to further define the entities which fall under the umbrella of pediatric-type low-grade glioma. In doing so we discuss the specific molecular drivers of pediatric low grade glioma and how to effectively test for them, review the newest therapeutic agents and their utility in treating this disease, and propose a risk-based stratification system that considers both clinical and molecular parameters to aid clinicians in making treatment decisions.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe current advances in pediatric precision therapy through innovations in technology and engineering. A multimodal approach of chemotherapy, surgery and/or radiation therapy has improved survival outcomes for pediatric cancer but with significant early and late toxicities. The pediatric population is particularly vulnerable given their age during treatment. Advances in precision interventions discussed include image guidance, ablation techniques, radiation therapy and novel drug delivery mechanisms that offer the potential for more targeted approach approaches with improved efficacy while limiting acute and late toxicities. RECENT FINDINGS Image-guidance provides improved treatment planning, real time monitoring and targeting when combined with ablative techniques and radiation therapy. Advances in drug delivery including radioisotopes, nanoparticles and antibody drug conjugates have shown benefit in adult malignancies with increasing use in pediatrics. These therapies alone and combined may lead to augmented local antitumor effect while sparing systemic exposure and potentially limiting early and late toxicities. SUMMARY Pediatric cancer medicine often requires a multimodal approach, each with early and late toxicities. Precision interventions and therapies offer promise for more targeted approaches in treating pediatric malignancies and require further investigation to determine long-term benefit.
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Bitterman DS, MacDonald SM, Yock TI, Tarbell NJ, Wright KD, Chi SN, Marcus KJ, Haas-Kogan DA. Revisiting the Role of Radiation Therapy for Pediatric Low-Grade Glioma. J Clin Oncol 2019; 37:3335-3339. [PMID: 31498029 PMCID: PMC9798905 DOI: 10.1200/jco.19.01270] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Danielle S. Bitterman
- Harvard Radiation Oncology Program, Boston, MA,Massachusetts General Hospital, Boston, MA,Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | | | | | | | - Karen D. Wright
- Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Susan N. Chi
- Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Karen J. Marcus
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | - Daphne A. Haas-Kogan
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA,Daphne A. Haas-Kogan, MD, Department of Radiation Oncology, Dana-Farber Cancer Institute, DA-16-22, 450 Brookline Ave, Boston, MA, 02115; e-mail:
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Abstract
PURPOSE OF REVIEW Optic pathway gliomas are low-grade neoplasms that affect the precortical visual pathway of children and adolescents. They can affect the optic nerve, optic chiasm, optic tracts and radiations and can either be sporadic or associated with neurofibromatosis type one. Gliomas isolated to the optic nerve (ONG) represent a subgroup of optic pathway gliomas, and their treatment remains controversial. New developments in ONG treatment have emerged in recent years, and it is necessary for clinicians to have a current understanding of available therapies. RECENT FINDINGS The current review of the literature covers the background of and recent developments in ONG treatment, with a focus on standard chemotherapy, new molecularly targeted therapies, radiation therapy and surgical resection and debulking. SUMMARY Although standard chemotherapy remains the mainstay of ONG treatment, newer molecularly targeted therapies such as mitogen-activated protein kinase kinase inhibitors and bevacizumab represent a promising new treatment modality, and clinical studies are ongoing.
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Abstract
PURPOSE OF REVIEW Pediatric low-grade gliomas (pLGGs) have been treated with similar therapies for the last 30 years. Recent biological insights have allowed a new generation of targeted therapies to be developed for these diverse tumors. At the same time, technological advances may redefine the late toxicities associated with radiation therapy. Understanding recent developments in pLGG therapy is essential to the management of these common pediatric tumors. RECENT FINDINGS It is now well understood that aberrations of the mitogen-activated protein kinase pathway are key to oncogenesis in low-grade gliomas. This understanding, along with the development of available targeted agents, have heralded a new era of understanding and treatment for these patients. Promising, sustained responses are now being seen in early phase trials among patients with multiply recurrent/progressive disease. Also, newer and highly conformal radiation approaches such as proton beam radiotherapy maintain efficacy of radiation but limit radiation-associated toxicities. SUMMARY Novel therapies offer the potential for tumor control with greatly reduced toxicities. However, late effects of these therapies are just now being explored. Improved radiation approaches and targeted agents have the potential to redefine traditional therapy for pLGG.
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Abstract
OBJECTIVES This single-institution report describes long-term disease control and late effects in pediatric patients with low-grade glioma (LGG) following radiotherapy (RT). MATERIALS AND METHODS Twenty-nine pediatric patients with LGG were treated with photon-based RT from 1970 to 2004 (mean age at time of RT, 9.8 y; range, 0.6 to 19 y). One patient underwent gross total resection, 25 underwent subtotal resection or biopsy, and 3 were treated based on radiographic characteristics alone. Three patients underwent chemotherapy before RT. The median RT dose was 54 Gy (range, 40 to 55 Gy). RESULTS The median follow-up was 17.8 years (range, 1.6 to 36.8 y) for all patients and 19.9 years (range, 1.6 to 36.8 y) for all living patients. The 5-, 10-, and 20-year local control and progression-free survival rates were equivalent at 82%, 74%, and 63%, respectively. The 5-, 10-, and 20-year cause-specific survival and overall survival rates were equivalent at 89%, 85%, and 58%, respectively. On univariate analysis, age below 4 years during treatment was associated with significantly inferior local control (P=0.0067), cause-specific survival (P=0.0021), and overall survival (P=0.0021). Of the 23 survivors analyzed for late toxicity, 15 (65%) developed grade 3+ toxicity. The most common Common Terminology Criteria for Adverse Events grade 3 toxicity (30% of survivors) was serious cognitive disability. Four patients (14%) died secondary to treatment complications, all occurring over a decade after completing RT. CONCLUSIONS Over half of children diagnosed with LGG survive >20 years after RT; this report reveals the chronicity of toxicity beyond the typically reported follow-up. Our findings inform the therapeutic ratio of RT in this disease and may help guide late-effect screening recommendations.
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Indelicato DJ, Rotondo RL, Uezono H, Sandler ES, Aldana PR, Ranalli NJ, Beier AD, Morris CG, Bradley JA. Outcomes Following Proton Therapy for Pediatric Low-Grade Glioma. Int J Radiat Oncol Biol Phys 2019; 104:149-156. [PMID: 30684665 DOI: 10.1016/j.ijrobp.2019.01.078] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/10/2019] [Accepted: 01/13/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Dosimetric studies show that proton therapy can reduce the low/intermediate radiation dose to uninvolved tissue in children with low-grade glioma (LGG). For this reason, LGG is the fourth most common pediatric tumor treated with proton therapy, yet clinical outcome data on efficacy and toxicity are limited. METHODS AND MATERIALS We reviewed the medical records of 174 children (≤21 years old) with nonmetastatic LGG enrolled on a prospective protocol and treated with proton therapy between 2007 and 2017. We assessed clinical outcomes and toxicity and analyzed patient, tumor, and treatment-related variables. RESULTS The median age was 10.2 years (range, 2-21). Fifty-eight percent of tumors were World Health Organization grade 1 and 30% were grade 2; 12% were diagnosed on imaging characteristics alone. The most common histology was pilocytic astrocytoma (47%). The most common tumor subsites were diencephalon/optic pathway (52%), caudal brainstem (16%), and cerebellum (13%). Forty-two percent received chemotherapy before radiation therapy. The median follow-up was 4.4 years. The 5-year actuarial rates of local control, progression-free survival, and overall survival were 85% (95% confidence interval [CI], 78%-90%), 84% (95% CI, 77%-89%), and 92% (95% CI, 85%-95%), respectively. On univariate analysis, brainstem/spinal cord tumor location (62% vs 90% elsewhere) and dose <54 GyRBE (67% vs 91% for 54 GyRBE) were associated with inferior local control (P < .01 for both). Twenty-two patients (12.6%) experienced acute nausea or vomiting requiring ondansetron; 2 patients (1.1%) required corticosteroids. Serious toxicities (4% of patients) included brainstem necrosis requiring corticosteroids (n = 2), symptomatic vasculopathy (n = 2), radiation retinopathy (n = 1), epilepsy (n = 1), and death from radiation-induced high-grade glioma (n = 1). Thirty-nine patients (22%) developed new-onset central hormone deficiency. Pseudoprogression was observed in 32.1%. CONCLUSIONS Compared with modern photon series, proton therapy reduces the radiation dose to developing brain tissue, diminishing acute toxicities without compromising disease control.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Haruka Uezono
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | | | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Nathan J Ranalli
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Alexandra D Beier
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Lavan NA, Saran FH, Oelfke U, Mandeville HC. Adopting Advanced Radiotherapy Techniques in the Treatment of Paediatric Extracranial Malignancies: Challenges and Future Directions. Clin Oncol (R Coll Radiol) 2019; 31:50-57. [PMID: 30361128 DOI: 10.1016/j.clon.2018.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/01/2018] [Indexed: 12/25/2022]
Abstract
Geometric uncertainties in radiotherapy are conventionally addressed by defining a safety margin around the radiotherapy target. Misappropriation of such margins could result in disease recurrence from geometric miss or unnecessary irradiation of normal tissue. Numerous quantitative organ motion studies in adults have been published, but the first paediatric-specific studies were only published in recent years. In the very near future, intensity-modulated proton beam therapy and magnetic resonance-guided radiotherapy will be clinically implemented in the UK. Such techniques offer the ability to deliver radiotherapy to the pinnacle of precision and accuracy, if geometric uncertainty relating to internal organ motion and deformation can be optimally managed. The optimal margin to account for internal organ motion in children remains largely undefined. Continuing efforts to characterise motion in children and young people is necessary to optimally define safety margins and to realise the full potential of intensity-modulated radiotherapy, magnetic resonance-guided radiotherapy and intensity-modulated proton beam therapy. This overview offers a timely review of published reports on paediatric organ motion, in anticipation of the increasing application of advanced radiotherapy techniques in paediatric radiotherapy.
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Affiliation(s)
- N A Lavan
- The Institute of Cancer Research, Sutton, UK.
| | - F H Saran
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - U Oelfke
- Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, UK
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Ajithkumar T, Taylor R, Kortmann RD. Radiotherapy in the Management of Paediatric Low-Grade Gliomas. Clin Oncol (R Coll Radiol) 2018; 31:151-161. [PMID: 30528521 DOI: 10.1016/j.clon.2018.11.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/04/2018] [Indexed: 12/18/2022]
Abstract
Paediatric low-grade (World Health Organization grade I-II) gliomas (LGGs) represent a spectrum of primary central nervous system tumours. Local tumour control is the cornerstone in the general management of childhood gliomas. Surgery is the primary treatment of choice in the majority. Non-surgical treatments are recommended for progressive or symptomatic inoperable disease. Although chemotherapy is increasingly used as first non-surgical treatment, radiotherapy remains standard as salvage treatment or as primary treatment in selected cases in which surrounding normal tissue can be optimally preserved. The role of targeted therapies is currently under investigation in clinical trials. Modern high-precision radiotherapy techniques, including proton therapy, have the potential to improve long-term toxicities. There is therefore an urgent need for prospective studies to compare the efficacy and safety of modern radiotherapy with systemic treatment in children with LGGs. New information on molecular genetic patterns in LGGs may also have an impact on the selection and sequencing of radiotherapy.
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Affiliation(s)
- T Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Trust, Cambridge, UK.
| | - R Taylor
- Department of Oncology, Swansea University and South West Wales Cancer Centre, Singleton Hospital, Swansea, UK
| | - R D Kortmann
- Department of Radiation Oncology, University of Leipzig, Leipzig, Germany
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Cherlow JM, Shaw DWW, Margraf LR, Bowers DC, Huang J, Fouladi M, Onar-Thomas A, Zhou T, Pollack IF, Gajjar A, Kessel SK, Cullen PL, McMullen K, Wellons JC, Merchant TE. Conformal Radiation Therapy for Pediatric Patients with Low-Grade Glioma: Results from the Children's Oncology Group Phase 2 Study ACNS0221. Int J Radiat Oncol Biol Phys 2018; 103:861-868. [PMID: 30419305 DOI: 10.1016/j.ijrobp.2018.11.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE To determine the rate of marginal relapse, progression-free survival (PFS), and overall survival (OS) in patients with pediatric low-grade glioma (PLGG) treated with conformal radiation therapy (CRT) with a clinical target volume (CTV) margin of 5 mm in the Children's Oncology Group trial ACNS0221. METHODS AND MATERIALS Patients aged 3 to 21 years with unresectable progressive, recurrent, or residual PLGG were eligible for this study. Patients younger than 10 years were required to have received at least 1 chemotherapy course. Patients with neurofibromatosis type I were not eligible. All patients underwent magnetic resonance imaging-based planning and received 54 Gy CRT in 30 fractions with a 5-mm CTV margin. RESULTS Of 85 eligible patients (median age, 13.6 years) treated between March 2006 and December 2010, 14 were younger than 10 years and 36 received prior chemotherapy. Sixty-six had pilocytic astrocytoma, 15 had other histologic subtypes, and 4 had unbiopsied chiasmatic lesions. Events included 23 relapses (19 central, 4 distant, and no marginal) and 7 deaths. At a median follow-up of 5.15 years, 5-year PFS was 71% ± 6% and OS was 93% ± 4%. Male sex (P = .068) and large tumor size (P = .050) trended toward significance for association with decreased PFS. Age, histology, tumor location, time between diagnosis and study entry, and MIB-1 status were not associated with PFS. OS was negatively associated with male sex (P = .064), non-pilocytic astrocytoma histology (P = .010), and large tumor size (P = .0089). CONCLUSIONS For patients with PLGG, CRT with a CTV margin of 5 mm yields an acceptable PFS and does not lead to a high rate of marginal relapse.
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Affiliation(s)
- Joel M Cherlow
- Department of Radiation Oncology, MemorialCare Long Beach Medical Center Long Beach, California
| | - Dennis W W Shaw
- Department of Diagnostic Imaging, Seattle Children's Hospital, Seattle, Washington
| | - Linda R Margraf
- Department of Pathology, Cook Children's Medical Center, Ft. Worth, Texas
| | - Daniel C Bowers
- Department of Pediatrics, UT Southwestern Medical School, Dallas, Texas
| | - Jie Huang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Maryam Fouladi
- Department of Hematology/Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tianni Zhou
- Department of Mathematics, California State University, Long Beach, California
| | - Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh of UMPC, Pittsburgh, Pennsylvania
| | - Amar Gajjar
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sandy K Kessel
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | - Patricia L Cullen
- Rueckert-Hartman College for Health Professions, Regis University, Denver, Colorado
| | - Kevin McMullen
- Department of Radiation Oncology, Columbus Regional Health, Columbus, Indiana
| | - John C Wellons
- Department of Neurosurgery, Vanderbilt University/Ingram Cancer Center, Nashville, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.
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Radiotherapy Advances in Pediatric Neuro-Oncology. Bioengineering (Basel) 2018; 5:bioengineering5040097. [PMID: 30400370 PMCID: PMC6315761 DOI: 10.3390/bioengineering5040097] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 10/26/2018] [Accepted: 11/01/2018] [Indexed: 12/31/2022] Open
Abstract
Radiation therapy (RT) represents an integral component in the treatment of many pediatric brain tumors. Multiple advances have emerged within pediatric radiation oncology that aim to optimize the therapeutic ratio—improving disease control while limiting RT-related toxicity. These include innovations in treatment planning with magnetic resonance imaging (MRI) simulation, as well as increasingly sophisticated radiation delivery techniques. Advanced RT techniques, including photon-based RT such as intensity-modulated RT (IMRT) and volumetric-modulated arc therapy (VMAT), as well as particle beam therapy and stereotactic RT, have afforded an array of options to dramatically reduce radiation exposure of uninvolved normal tissues while treating target volumes. Along with advances in image guidance of radiation treatments, novel RT approaches are being implemented in ongoing and future prospective clinical trials. As the era of molecular risk stratification unfolds, personalization of radiation dose, target, and technique holds the promise to meaningfully improve outcomes for pediatric neuro-oncology patients.
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Practice Patterns of Stereotactic Radiotherapy in Pediatrics: Results From an International Pediatric Research Consortium. J Pediatr Hematol Oncol 2018; 40:522-526. [PMID: 30247288 DOI: 10.1097/mph.0000000000001290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/OBJECTIVES There is little consensus regarding the application of stereotactic radiotherapy (SRT) in pediatrics. We evaluated patterns of pediatric SRT practice through an international research consortium. MATERIALS AND METHODS Eight international institutions with pediatric expertise completed a 124-item survey evaluating patterns of SRT use for patients 21 years old and younger. Frequencies of SRT use and median margins applied with and without SRT were evaluated. RESULTS Across institutions, 75% reported utilizing SRT in pediatrics. SRT was used in 22% of brain, 18% of spine, 16% of other bone, 16% of head and neck, and <1% of abdomen/pelvis, lung, and liver cases across sites. Of the hypofractionated SRT cases, 42% were delivered with definitive intent. Median gross tumor volume to planning target volume margins for SRT versus non-SRT plans were 0.2 versus 1.4 cm for brain, 0.3 versus 1.5 cm for spine/other bone, 0.3 versus 2.0 cm for abdomen/pelvis, 0.7 versus 1.5 cm for head and neck, 0.5 versus 1.7 cm for lung, and 0.5 versus 2.0 cm for liver sites. CONCLUSIONS SRT is commonly utilized in pediatrics across a range of treatment sites. Margins used for SRT were substantially smaller than for non-SRT planning, highlighting the utility of this approach in reducing treatment volumes.
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Chhabra A, Schneider C, Chowdhary M, Diwanji TP, Mohindra P, Mishra MV. How Histopathologic Tumor Extent and Patterns of Recurrence Data Inform the Development of Radiation Therapy Treatment Volumes in Solid Malignancies. Semin Radiat Oncol 2018; 28:218-237. [PMID: 29933882 DOI: 10.1016/j.semradonc.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The ability to deliver highly conformal radiation therapy using intensity-modulated radiation therapy and particle therapy provides for new opportunities to improve patient outcomes by reducing treatment-related morbidities following radiation therapy. By reducing the volume of normal tissue exposed to radiation therapy (RT), while also allowing for the opportunity to escalate the dose of RT delivered to the tumor, use of conformal RT delivery should also provide the possibility of expanding the therapeutic index of radiotherapy. However, the ability to safely and confidently deliver conformal RT is largely dependent on our ability to clearly define the clinical target volume for radiation therapy, which requires an in-depth knowledge of histopathologic extent of different tumor types, as well as patterns of recurrence data. In this article, we provide a comprehensive review of the histopathologic and radiographic data that provide the basis for evidence-based guidelines for clinical tumor volume delineation.
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Affiliation(s)
- Arpit Chhabra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Craig Schneider
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Mudit Chowdhary
- Department of Radiation Oncology, Rush University, Chicago, IL
| | - Tejan P Diwanji
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD.
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Hessissen L, Parkes J, Amayiri N, Mushtaq N, Sirachainan N, Anacak Y, Mitra D, Figaji A, Schouten-van Meeteren A, Sullivan M, Burger H, Davidson A, Bouffet E, Bailey S. SIOP PODC Adapted treatment guidelines for low grade gliomas in low and middle income settings. Pediatr Blood Cancer 2017; 64 Suppl 5. [PMID: 29297618 DOI: 10.1002/pbc.26737] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 06/22/2017] [Indexed: 12/15/2022]
Abstract
Effective treatment of children with low grade glioma (LGG) 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 manage a variety of LGG and treatment-associated complications. These requirements have made it difficult for many centers in low and middle-income countries (LMIC) to offer effective treatment and follow up. This article provides management recommendations for children with LGG according to the level of facilities available.
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Affiliation(s)
- Laila Hessissen
- Department of Hematology and Pediatric Oncology, Hospital University Ibn Sina, Rabat, Morocco
| | - Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Nisreen Amayiri
- Department of Hematology and Oncology, King Hussein Cancer Centre, Amman, Jordan
| | - Naureen Mushtaq
- Department of Pediatric Haematology and Oncology, Aga Khan University Hopsital, Karachi, Pakistan
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Yavuz Anacak
- Department of Radiation Oncology, Ege University School of Medicine & Hospital, Izmir, Turkey
| | - Dipayan Mitra
- Department of Radiology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Anthony Figaji
- Department of Neurosurgery, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | | | - Michael Sullivan
- Department of Paediatric Haematology and Oncology, Royal Hospital for Sick Children, Melbourne, Victoria, Australia
| | - Hester Burger
- Department Medical Physics, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Alan Davidson
- Haematology Oncology Service, Red Cross War Memorial Children's Hospital, Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - Eric Bouffet
- Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Simon Bailey
- Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
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Indelicato DJ, Bradley JA, Sandler ES, Aldana PR, Sapp A, Gains JE, Crellin A, Rotondo RL. Clinical outcomes following proton therapy for children with central nervous system tumors referred overseas. Pediatr Blood Cancer 2017; 64. [PMID: 28544746 DOI: 10.1002/pbc.26654] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/20/2017] [Accepted: 05/01/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND International, multidisciplinary care of children with central nervous system (CNS) tumors presents unique challenges. The aim of this study is to report patient outcomes of U.K. children referred for proton therapy to a North American facility. METHODS From 2008 to 2016, 166 U.K. children with approved CNS tumors were treated with proton therapy at a single academic medical center in the United States. Median age was 7 years (range, 1-19). Median follow-up was 2.6 years. RESULTS The 3-year actuarial overall survival (OS) and local control (LC) rates were 96% and 91%, respectively, for the overall group, 92% and 85% for the ependymoma subgroup (n = 57), 95% and 88% for the low-grade glioma subgroup (n = 54), and 100% and 100%, respectively, for the craniopharyngioma subgroup (n = 45). Cyst expansion was observed in 13 patients, including one case resulting in visual impairment. Serious side effects included new-onset seizures in three patients (1.8%), symptomatic vasculopathy in three patients (1.8%), and symptomatic brainstem necrosis in one patient (0.6%). CONCLUSIONS In this cohort of British children referred overseas for proton therapy, disease control does not appear compromised, toxicity is acceptable, and improvement in long-term function is anticipated in survivors owing to the reduced brain exposure afforded by proton therapy.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric S Sandler
- Department of Pediatric Hematology/Oncology, Nemours Children's Health System, Jacksonville, Florida
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Amy Sapp
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Jennifer E Gains
- NHS England Radiotherapy Clinical Reference Group, London, United Kingdom
| | - Adrian Crellin
- NHS England Radiotherapy Clinical Reference Group, London, United Kingdom
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Kumar RS, Rotondo RL, Bradley JA, Vern-Gross T, Huh S, Indelicato DJ. Mid-treatment magnetic resonance imaging in pediatric intracranial low-grade gliomas treated with proton beam therapy. Acta Oncol 2017; 56:1243-1247. [PMID: 28339304 DOI: 10.1080/0284186x.2017.1306105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Ronny L. Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | - Soon Huh
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Huynh-Le MP, Walker AJ, Burger PC, Jallo GI, Cohen KJ, Wharam MD, Terezakis SA. Management of pediatric intracranial low-grade gliomas: long-term follow-up after radiation therapy. Childs Nerv Syst 2016; 32:1425-30. [PMID: 27179530 DOI: 10.1007/s00381-016-3100-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The treatment of pediatric intracranial low-grade gliomas (LGG) generally begins with maximal safe resection. Radiation therapy (RT) and chemotherapy are typically reserved for patients with incomplete resection and/or disease progression. We report long-term treatment outcomes and toxicities in a cohort of pediatric patients with LGG after RT. METHODS Thirty-four patients <21 years old with intracranial LGG who were treated with RT at the Johns Hopkins Hospital were included in this retrospective analysis. Patients were evaluated for overall survival (OS), progression-free survival (PFS), recurrence patterns, and treatment toxicities using descriptive statistics, Kaplan-Meier curves, and Cox proportional hazard regressions. RESULTS The mean age at diagnosis was 7.9 years (range 1.2-18.3 years) and mean age at RT was 9.8 years (range 3.0-28.9 years). The median follow-up time was 9.8 years after radiation (range 0.8-33.3 years). The estimated 10-year OS and PFS after RT were 92 and 74 %, respectively. Twelve patients had disease progression after RT, and all recurrences were local. Two patients died due to disease progression 2.3 and 9.1 years after RT. One patient had malignant transformation of LGG to high-grade glioma. No significant predictors of PFS were identified on uni- or multivariate analysis. Late effects of LGG and treatment seen were endocrine deficiencies in 16 patients, visual problems in 10 patients, hearing loss in 4 patients, special education requirements for 5 patients, and a vascular injury/demyelination secondary to RT in 1 patient. CONCLUSION Our study suggests that the use of radiation in patients with intracranial LGG results in excellent OS and PFS with acceptable toxicity at long-term follow-up.
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Affiliation(s)
- Minh-Phuong Huynh-Le
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, 401 N. Broadway, Suite 1440, Baltimore, MD, 21287, USA
| | - Amanda J Walker
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, 401 N. Broadway, Suite 1440, Baltimore, MD, 21287, USA
| | - Peter C Burger
- Department of Pathology, Johns Hopkins Hospital, Baltimore, MD, 21231, USA
| | - George I Jallo
- Department of Neurological Surgery, Johns Hopkins Hospital, Baltimore, MD, 21231, USA
| | - Kenneth J Cohen
- Division of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, MD, 21231, USA
| | - Moody D Wharam
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, 401 N. Broadway, Suite 1440, Baltimore, MD, 21287, USA
| | - Stephanie A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, 401 N. Broadway, Suite 1440, Baltimore, MD, 21287, USA.
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Garcia MA, Solomon DA, Haas-Kogan DA. Exploiting molecular biology for diagnosis and targeted management of pediatric low-grade gliomas. Future Oncol 2016; 12:1493-506. [PMID: 27072750 PMCID: PMC4915741 DOI: 10.2217/fon-2016-0039] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/29/2016] [Indexed: 12/14/2022] Open
Abstract
The majority of brain tumors arising in children are low-grade gliomas. Although historically categorized together as pediatric low-grade gliomas (PLGGs), there is significant histologic and genetic diversity within this group. In general, prognosis for PLGGs is excellent, and limitation of sequelae from tumor and treatment is paramount. Advances in high-throughput genetic sequencing and gene expression profiling are fundamentally changing the way PLGGs are classified and managed. Here, we review the histologic subtypes and highlight how recent advances in elucidating the molecular pathogenesis of these tumors have refined diagnosis and prognostication. Additionally, we discuss how characterizing specific genetic alterations has paved the way for the rational use of targeted therapies that are currently in various phase clinical trials.
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Affiliation(s)
- Michael A Garcia
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - David A Solomon
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, CA, USA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Harvard Medical School, Dana-Farber Cancer Institute, Brigham & Women's Hospital, Boston Children's Hospital, MA, USA
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Krishnatry R, Zhukova N, Guerreiro Stucklin AS, Pole JD, Mistry M, Fried I, Ramaswamy V, Bartels U, Huang A, Laperriere N, Dirks P, Nathan PC, Greenberg M, Malkin D, Hawkins C, Bandopadhayay P, Kieran MW, Manley PE, Bouffet E, Tabori U. Clinical and treatment factors determining long-term outcomes for adult survivors of childhood low-grade glioma: A population-based study. Cancer 2016; 122:1261-9. [PMID: 26970559 DOI: 10.1002/cncr.29907] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/01/2015] [Accepted: 12/23/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND The determinants of outcomes for adult survivors of pediatric low-grade glioma (PLGG) are largely unknown. METHODS This study collected population-based follow-up information for all PLGG patients diagnosed in Ontario, Canada from 1985 to 2012 (n = 1202) and determined factors affecting survival. The impact of upfront radiation treatment on overall survival (OS) was determined for a cohort of Ontario patients and an independent reference cohort from the Surveillance, Epidemiology, and End Results database. RESULTS At a median follow-up of 12.73 years (range, 0.02-33 years), only 93 deaths (7.7%) were recorded, and the 20-year OS rate was 90.1% ± 1.1%. Children with neurofibromatosis type 1 had excellent survival and no tumor-related deaths during adulthood. Adverse risk factors included pleomorphic xanthoastrocytoma (P < .001) and a thalamic location (P < .001). For patients with unresectable tumors surviving more than 5 years after the diagnosis, upfront radiotherapy was associated with an approximately 3-fold increased risk of overall late deaths (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.6-6.6; P = .001) and an approximately 4-fold increased risk of tumor-related deaths (HR, 4.4; 95% CI, 1.3-14.6; P = .013). In a multivariate analysis, radiotherapy was the most significant factor associated with late all-cause deaths (HR, 3.0; 95% CI, 1.3-7.0; P = .012) and tumor-related deaths (HR, 4.4; 95% CI, 1.3-14.6; P = 0.014). A similar association between radiotherapy and late deaths was observed in the independent reference cohort (P < .001). In contrast to early deaths, late mortality was associated not with PLGG progression but rather with tumor transformation and non-oncological causes. CONCLUSIONS The course of PLGG is associated with excellent long-term survival, but this is hampered by increased delayed mortality in patients receiving upfront radiotherapy. These observations should be considered when treatment options are being weighed for these patients.
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Affiliation(s)
- Rahul Krishnatry
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Labatt Brain Tumor Research Centre, University of Toronto, Toronto, Canada.,Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Nataliya Zhukova
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Labatt Brain Tumor Research Centre, University of Toronto, Toronto, Canada.,Program in Genetics and Genome Biology, University of Toronto, Toronto, Canada.,Pediatric Oncology Group of Ontario, Toronto, Canada
| | | | - Jason D Pole
- Pediatric Oncology Group of Ontario, Toronto, Canada
| | - Matthew Mistry
- Labatt Brain Tumor Research Centre, University of Toronto, Toronto, Canada.,Program in Genetics and Genome Biology, University of Toronto, Toronto, Canada.,Hospital for Sick Children and Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Iris Fried
- Hadassah Medical Centre, Jerusalem, Israel
| | - Vijay Ramaswamy
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Ute Bartels
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Annie Huang
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Labatt Brain Tumor Research Centre, University of Toronto, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Normand Laperriere
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Peter Dirks
- Labatt Brain Tumor Research Centre, University of Toronto, Toronto, Canada.,Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Paul C Nathan
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Mark Greenberg
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Pediatric Oncology Group of Ontario, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - David Malkin
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Program in Genetics and Genome Biology, University of Toronto, Toronto, Canada.,Pediatric Oncology Group of Ontario, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Cynthia Hawkins
- Labatt Brain Tumor Research Centre, University of Toronto, Toronto, Canada.,Division of Pathology, University of Toronto, Toronto, Canada
| | - Pratiti Bandopadhayay
- Division of Pediatric Hematology/Oncology, Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, Massachusetts.,Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mark W Kieran
- Division of Pediatric Hematology/Oncology, Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, Massachusetts
| | - Peter E Manley
- Division of Pediatric Hematology/Oncology, Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, Massachusetts
| | - Eric Bouffet
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Uri Tabori
- Division of Hematology/Oncology, University of Toronto, Toronto, Canada.,Labatt Brain Tumor Research Centre, University of Toronto, Toronto, Canada.,Hospital for Sick Children and Institute of Medical Science, University of Toronto, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
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Abstract
Although resection remains the mainstay in the treatment of gliomas, microscopically complete resection of most central nervous system tumors remains challenging, and is, in fact, rarely accomplished. Considering their invasive nature, gross total resections to clearly negative margins often do or would require removal or transection of functional brain, with likely serious neurologic deficits. Consequently, radiotherapy has emerged as an indispensable component of therapy. It is delivered primarily by external-beam radiotherapy or brachytherapy techniques. Herein, we present the biologic principles, techniques, and applications of radiotherapy in glioma treatment today.
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Affiliation(s)
- James W Snider
- Department of Radiation Oncology, Marlene and Stewart Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Marlene and Stewart Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA.
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Abstract
BACKGROUND Low-grade gliomas have good overall survival rates in pediatric patients compared to adults. There are some case series that reported the effectiveness and safety of Gamma Knife radiosurgery, yet they are limited in number of patients. We aimed to review the relevant literature for pediatric low-grade glial tumors treated with stereotactic radiosurgery, specifically Gamma Knife radiosurgery, and to present an exemplary case. CASE DESCRIPTION A 6-year-old boy was admitted to clinic due to head trauma. He was alert, cooperative, and had no obvious motor or sensorial deficit. A head CT scan depicted a hypodense zone at the right caudate nucleus. The brain magnetic resonance imaging (MRI) depicted a mass lesion at the same location. A stereotactic biopsy was performed. Histopathological diagnosis was low-grade astrocytoma (grade II, World Health Organization (WHO) classification, 2007). Gamma Knife radiosurgery was applied to the tumor bed. Tumor volume was 21.85 cm(3). Fourteen gray was given to 50% isodose segment of the lesion (maximal dose of 28 Gy). The tumor has disappeared totally in 4 months, and the patient was tumor-free 21 months after the initial treatment. DISCUSSION AND CONCLUSION The presented literature review represents mostly single-center experiences with different patient and treatment characteristics. Accordingly, a mean/median margin dose of 11.3-15 Gy with Gamma Knife radiosurgery (GKRS) is successful in treatment of pediatric and adult low-grade glial tumor patients. However, prospective studies with a large cohort of pediatric patients should be conducted to make a more comprehensive conclusion for effectiveness and safety of GKRS in pediatric low-grade glial tumors.
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Low-grade gliomas in children: single institutional experience in 198 cases. Childs Nerv Syst 2015; 31:1447-59. [PMID: 26156776 DOI: 10.1007/s00381-015-2800-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 06/22/2015] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In pediatric population (0-18 years), low-grade gliomas (PLGG) are the most frequent brain tumors and majority are amenable for surgical removal. PATIENTS AND METHODS A retrospective review of 198 children diagnosed with PLGG between 1980 and 2010 at HSJD was carried out. Several variables were studied to find prognostic factors related to the outcomes (progression-free survival (PFS) and overall survival (OS)). RESULTS Median age at onset was 88.8 months (3.1 to 214.5 months, SD 53). Surgery was performed in 175 patients (88.4%), achieving gross total resection (GTR) in 77 (44%), subtotal resection (STR) in 87 (49.7%), and 11 (6.3%) biopsies. Pathological review classified 84 tumors as WHO grade I (48%) and 89 as grade II (50.8%). Adjuvant therapy (AT) was given to 75 patients (37.9%), radiotherapy in 24 (12.1%), chemotherapy in 33 (16.7%), and combined in 18 (9.1%). Sixteen patients (8.1%) died, 89 (43.4%) are alive with no evidence of disease, and 93 (47%) alive with disease, median follow-up 65.2 months. Outcome is significantly correlated with age (p = 0001, worse OS for patients younger than 12 months) and extent of tumor resection (p < 0001). OS for GTR/STR/biopsy was >200, 154.3, and 101.9 months, respectively. Patients treated with AT presented worse OS/PFS (p < 0.001) than those not treated. Histology was non significantly related to outcomes. CONCLUSION In our series of PLGG, the best prognostic markers are tumor location (cerebellar) and the extent of tumor resection (GTR). Infants and patients who require adjuvant therapy because of tumor progression or recurrence have worse outcome.
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Greenberger BA, Pulsifer MB, Ebb DH, MacDonald SM, Jones RM, Butler WE, Huang MS, Marcus KJ, Oberg JA, Tarbell NJ, Yock TI. Clinical Outcomes and Late Endocrine, Neurocognitive, and Visual Profiles of Proton Radiation for Pediatric Low-Grade Gliomas. Int J Radiat Oncol Biol Phys 2014; 89:1060-1068. [DOI: 10.1016/j.ijrobp.2014.04.053] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 03/27/2014] [Accepted: 04/29/2014] [Indexed: 12/18/2022]
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Bergthold G, Bandopadhayay P, Bi WL, Ramkissoon L, Stiles C, Segal RA, Beroukhim R, Ligon KL, Grill J, Kieran MW. Pediatric low-grade gliomas: how modern biology reshapes the clinical field. Biochim Biophys Acta Rev Cancer 2014; 1845:294-307. [PMID: 24589977 DOI: 10.1016/j.bbcan.2014.02.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 02/20/2014] [Indexed: 12/17/2022]
Abstract
Low-grade gliomas represent the most frequent brain tumors arising during childhood. They are characterized by a broad and heterogeneous group of tumors that are currently classified by the WHO according to their morphological appearance. Here we review the clinical features of these tumors, current therapeutic strategies and the recent discovery of genomic alterations characteristic to these tumors. We further explore how these recent biological findings stand to transform the treatment for these tumors and impact the diagnostic criteria for pediatric low-grade gliomas.
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Affiliation(s)
| | - Pratiti Bandopadhayay
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, USA; Division of Pediatric Hematology and Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Boston Children's Hospital, Boston, MA, USA
| | - Wenya Linda Bi
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lori Ramkissoon
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA; Center for Molecular Oncologic Pathology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Charles Stiles
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rosalind A Segal
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Neurobiology, Harvard Medical School, Boston, MA, USA
| | - Rameen Beroukhim
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Keith L Ligon
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA; Center for Molecular Oncologic Pathology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jacques Grill
- Departement de Cancerologie de l'enfant et de l'adolescent, Gustave Roussy and Unité Mixte de Recherche 8203 du Centre National de la Recherche Scientifique, Université Paris-Sud, Villejuif, France
| | - Mark W Kieran
- Center for Molecular Oncologic Pathology, Dana-Farber Cancer Institute, Boston, MA, USA; Center for Molecular Oncologic Pathology, Dana-Farber Cancer Institute, Boston, MA, USA.
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48
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Muzumdar D, Ventureyra ECG. Treatment of posterior fossa tumors in children. Expert Rev Neurother 2014; 10:525-46. [DOI: 10.1586/ern.10.28] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lo SS, Chang EL, Sloan AE. Role of stereotactic radiosurgery and fractionated stereotactic radiotherapy in the management of intracranial ependymoma. Expert Rev Neurother 2014; 6:501-7. [PMID: 16623649 DOI: 10.1586/14737175.6.4.501] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ependymoma accounts for 5-10% of all childhood CNS tumors and less than 5% of intracranial tumors in adults. Ependymomas typically have a sharp tumor-brain parenchyma interface and this characteristic lends itself well to stereotactic radiation delivery. Data on the use of stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) for ependymoma in various settings have emerged over the past 10 years. SRS has been used in recurrent disease and as a boost after external beam radiation therapy. FSRT has been used in pediatric brain tumors and can potentially limit the long-term toxicities associated with radiation therapy by reducing the amount of normal brain parenchyma treated. Long-term follow-up is needed to determine the long-term efficacy and toxicities associated with these treatment modalities.
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Affiliation(s)
- Simon S Lo
- Department of Radiation Oncology, Indiana Lions Gamma Knife Center, Indiana University Medical Center, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, USA.
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Radiotherapy in pediatric pilocytic astrocytomas. A subgroup analysis within the prospective multicenter study HIT-LGG 1996 by the German Society of Pediatric Oncology and Hematology (GPOH). Strahlenther Onkol 2013; 189:647-55. [PMID: 23831852 DOI: 10.1007/s00066-013-0357-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 03/25/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE We evaluated clinical outcomes in the subset of patients who underwent radiotherapy (RT) due to progressive pilocytic astrocytoma within the Multicenter Treatment Study for Children and Adolescents with a Low Grade Glioma HIT-LGG 1996. PATIENTS AND METHODS Eligibility criteria were fulfilled by 117 patients. Most tumors (65 %) were located in the supratentorial midline, followed by the posterior fossa (26.5 %) and the cerebral hemispheres (8.5 %). Median age at the start of RT was 9.2 years (range 0.7-17.4 years). In 75 cases, external fractionated radiotherapy (EFRT) was administered either as first-line nonsurgical treatment (n = 58) or after progression following primary chemotherapy (n = 17). The median normalized total dose was 54 Gy. Stereotactic brachytherapy (SBT) was used in 42 selected cases. RESULTS During a median follow-up period of 8.4 years, 4 patients (3.4 %) died and 33 (27.4 %) experienced disease progression. The 10-year overall (OS) and progression-free survival (PFS) rates were 97 and 70 %, respectively. No impact of the RT technique applied (EFRT versus SBT) on progression was observed. The 5-year PFS was 76 ± 5 % after EFRT and 65 ± 8 % after SBT. Disease progression after EFRT was not influenced by gender, neurofibromatosis type 1 (NF1) status, tumor location (hemispheres versus supratentorial midline versus posterior fossa), age or prior chemotherapy. Normalized total EFRT doses of more than 50.4 Gy did not improve PFS rates. CONCLUSION EFRT plays an integral role in the treatment of pediatric pilocytic astrocytoma and is characterized by excellent tumor control. A reduction of the normalized total dose from 54 to 50.4 Gy appears to be feasible without jeopardizing tumor control. SBT is an effective treatment alternative.
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