1
|
Mahajan A, Stavinoha PL, Rongthong W, Brodin NP, McGovern SL, El Naqa I, Palmer JD, Vennarini S, Indelicato DJ, Aridgides P, Bowers DC, Kremer L, Ronckers C, Constine L, Avanzo M. Neurocognitive Effects and Necrosis in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:401-416. [PMID: 33810950 DOI: 10.1016/j.ijrobp.2020.11.073] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/08/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE A PENTEC review of childhood cancer survivors who received brain radiation therapy (RT) was performed to develop models that aid in developing dose constraints for RT-associated central nervous system (CNS) morbidities. METHODS AND MATERIALS A comprehensive literature search, through the PENTEC initiative, was performed to identify published data pertaining to 6 specific CNS toxicities in children treated with brain RT. Treatment and outcome data on survivors were extracted and used to generate normal tissue complication probability (NTCP) models. RESULTS The search identified investigations pertaining to 2 of the 6 predefined CNS outcomes: neurocognition and brain necrosis. For neurocognition, models for 2 post-RT outcomes were developed to (1) calculate the risk for a below-average intelligence quotient (IQ) (IQ <85) and (2) estimate the expected IQ value. The models suggest that there is a 5% risk of a subsequent IQ <85 when 10%, 20%, 50%, or 100% of the brain is irradiated to 35.7, 29.1, 22.2, or 18.1 Gy, respectively (all at 2 Gy/fraction and without methotrexate). Methotrexate (MTX) increased the risk for an IQ <85 similar to a generalized uniform brain dose of 5.9 Gy. The model for predicting expected IQ also includes the effect of dose, age, and MTX. Each of these factors has an independent, but probably cumulative effect on IQ. The necrosis model estimates a 5% risk of necrosis for children after 59.8 Gy or 63.6 Gy (2 Gy/fraction) to any part of the brain if delivered as primary RT or reirradiation, respectively. CONCLUSIONS This PENTEC comprehensive review establishes objective relationships between patient age, RT dose, RT volume, and MTX to subsequent risks of neurocognitive injury and necrosis. A lack of consistent RT data and outcome reporting in the published literature hindered investigation of the other predefined CNS morbidity endpoints.
Collapse
Affiliation(s)
- Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Peter L Stavinoha
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Warissara Rongthong
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Joshua D Palmer
- Department of Radiation Oncology, James Cancer Hospital at Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
| | - Sabina Vennarini
- Proton Therapy Center, Azienda Provinciale per I Servizi Sanitari, Trento, Italy
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Paul Aridgides
- Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse, New York
| | - Daniel C Bowers
- Division of Pediatric Hematology and Oncology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Leontien Kremer
- Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands; Department of Pediatric Oncology, Princess Máxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - Cecile Ronckers
- Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands; Department of Pediatric Oncology, Princess Máxima Center for Paediatric Oncology, Utrecht, the Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg-Theodor Fontane, Neuruppin, Germany
| | - Louis Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Michele Avanzo
- Medical Physics Department, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| |
Collapse
|
2
|
Tonning Olsson I, Lundgren J, Hjorth L, Munck Af Rosenschöld P, Hammar Å, Perrin S. Neurocognitive development after pediatric brain tumor - a longitudinal, retrospective cohort study. Child Neuropsychol 2024; 30:22-44. [PMID: 36744788 DOI: 10.1080/09297049.2023.2172149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 01/18/2023] [Indexed: 02/07/2023]
Abstract
Survivors of Pediatric Brain Tumors (PBTs) treated with cranial radiation therapy (CRT) often experience a decline in neurocognitive test scores. Less is known about the neurocognitive development of non-irradiated survivors of PBTs. The aim of this study was to statistically model neurocognitive development after PBT in both irradiated and non-irradiated survivors and to find clinical variables associated with the rate of decline in neurocognitive scores. A total of 151 survivors were included in the study. Inclusion criteria: Diagnosis of PBT between 2001 and 2013 or earlier diagnosis of PBT and turning 18 years of age between 2006 and 2013. Exclusion criteria: Death within a year from diagnosis, neurocutaneous syndromes, severe intellectual disability. Clinical neurocognitive data were collected retrospectively from medical records. Multilevel linear modeling was used to evaluate the rate of decline in neurocognitive measures and factors associated with the same. A decline was found in most measures for both irradiated and non-irradiated survivors. Ventriculo-peritoneal (VP) shunting and treatment with whole-brain radiation therapy (WBRT) were associated with a faster decline in neurocognitive scores. Male sex and supratentorial lateral tumor were associated with lower scores. Verbal learning measures were either stable or improving. Survivors of PBTs show a pattern of decline in neurocognitive scores irrespective of treatment received, which suggests the need for routine screening for neurocognitive rehabilitation. However, survivors treated with WBRT and/or a VP shunt declined at a faster rate and appear to be at the highest risk of negative neurocognitive outcomes and to have the greatest need for neurocognitive rehabilitation.
Collapse
Affiliation(s)
- Ingrid Tonning Olsson
- Department of Psychology, Lund University, Lund, Sweden
- Department of Paediatrics, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Paediatrics, Lund University, Lund, Sweden
| | - Johan Lundgren
- Department of Paediatrics, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Paediatrics, Lund University, Lund, Sweden
| | - Lars Hjorth
- Department of Paediatrics, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Paediatrics, Lund University, Lund, Sweden
| | - Per Munck Af Rosenschöld
- Medical Radiation Physics, Lund University, Lund, Sweden
- Radiation Physics, Dept of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Åsa Hammar
- Department of Psychology, Lund University, Lund, Sweden
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Sean Perrin
- Department of Psychology, Lund University, Lund, Sweden
| |
Collapse
|
3
|
Yu QS, Yin YH, Yu XG. Clinical Characteristics, Treatment, and Survival Outcome of Ependymoma in Infants. World Neurosurg 2024; 181:e75-e83. [PMID: 37532021 DOI: 10.1016/j.wneu.2023.07.123] [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: 06/06/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Treatment modalities of ependymoma in infants remain controversial. Postoperative adjuvant radiotherapy could prolong overall survival but has the potential to affect nervous system development in infants. The role of adjuvant chemotherapy in prolonging overall survival for infants with ependymoma is still unclear. Therefore we designed this study to explore the effect of treatment modalities on survival time of infants with ependymoma. METHODS We studied 72 infants with ependymoma from the Surveillance, Epidemiology, and End Results database in this retrospective analysis. Univariate and multivariate Cox proportional hazard models were adopted to determine hazard ratios and compare overall survival. RESULTS Among 72 infants with ependymoma, 35 were male (48.6%) and 37 were female (51.4%). The 5-year overall survival of all patients was 67%. Forty-six infants (63.9%) received gross total resection, 20 (27.8%) received subtotal resection, and 6 (8.3%) did not receive surgical resection or only autopsy. Twenty-one infants (29.2%) received radiotherapy, and 45 (62.5%) received chemotherapy. Multivariate analysis revealed that patients accepted surgical resection (No vs. gross total resection, P < 0.001; No vs. subtotal resection, P = 0.026) and chemotherapy (No vs. Yes, P = 0.024) are the independent prognostic factors for overall survival. CONCLUSIONS Treatment modality is associated with survival time in infants with ependymoma. The extent of resection and chemotherapy were independent prognostic factors for infants with ependymoma.
Collapse
Affiliation(s)
- Qi-Shuai Yu
- Medical School of Nankai University, Tianjin, China; Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yi-Heng Yin
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xin-Guang Yu
- Medical School of Nankai University, Tianjin, China; Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
| |
Collapse
|
4
|
Sleurs C, Fletcher P, Mallucci C, Avula S, Ajithkumar T. Neurocognitive Dysfunction After Treatment for Pediatric Brain Tumors: Subtype-Specific Findings and Proposal for Brain Network-Informed Evaluations. Neurosci Bull 2023; 39:1873-1886. [PMID: 37615933 PMCID: PMC10661593 DOI: 10.1007/s12264-023-01096-9] [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: 10/26/2022] [Accepted: 06/05/2023] [Indexed: 08/25/2023] Open
Abstract
The increasing number of long-term survivors of pediatric brain tumors requires us to incorporate the most recent knowledge derived from cognitive neuroscience into their oncological treatment. As the lesion itself, as well as each treatment, can cause specific neural damage, the long-term neurocognitive outcomes are highly complex and challenging to assess. The number of neurocognitive studies in this population grows exponentially worldwide, motivating modern neuroscience to provide guidance in follow-up before, during and after treatment. In this review, we provide an overview of structural and functional brain connectomes and their role in the neuropsychological outcomes of specific brain tumor types. Based on this information, we propose a theoretical neuroscientific framework to apply appropriate neuropsychological and imaging follow-up for future clinical care and rehabilitation trials.
Collapse
Affiliation(s)
- Charlotte Sleurs
- Department of Cognitive Neuropsychology, Tilburg University, 5037 AB, Tilburg, The Netherlands.
- Department of Oncology, KU Leuven, 3000, Leuven, Belgium.
| | - Paul Fletcher
- Department of Psychiatry, University of Cambridge, Addenbrookes Hospital, Cambridge, CB2 0QQ, UK
- Wellcome Trust MRC Institute of Metabolic Science, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, L14 5AB, UK
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, L14 5AB, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospital NHS Trust, Cambridge, CB2 0QQ, UK
| |
Collapse
|
5
|
Del Baldo G, Vennarini S, Toniutti M, Abbas R, Lorentini S, Piccirilli E, Cacchione A, Megaro G, Di Ruscio V, De Ioris MA, De Salvo A, Albino G, Rossi S, Colafati GS, Carai A, Mastronuzzi A. Unraveling the impact of upfront chemotherapy and proton beam therapy on treatment outcome and follow-up in central nervous system germ cell tumors: a single center experience. Front Oncol 2023; 13:1259403. [PMID: 37860194 PMCID: PMC10584321 DOI: 10.3389/fonc.2023.1259403] [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: 07/15/2023] [Accepted: 08/30/2023] [Indexed: 10/21/2023] Open
Abstract
Background Germ cell tumors (GCT) account for a minority of central nervous system (CNS) malignancies, highly prevalent in adolescents and young adults. Despite their aggressive biological behavior, prognosis is excellent in most cases with risk stratified treatment, consisting in a combination of chemotherapy and radiotherapy. Whole ventricular irradiation (WVI) and craniospinal irradiation, the treatment of choice for localized and metastatic disease, pose significant risk of collateral effects, therefore proton beam radiation (PBT) has been recently proposed for its steep dose fallout. Materials and methods We report our experience in a consecutive series of 17 patients treated for CNS GCT at our Institution from 2015 to 2021. Results Most frequent lesion location were sellar/suprasellar (35%) and bifocal germinoma (35%), followed by pineal (18%) and thalamic (12%). Two patients (12%), had evidence of disseminated disease at the time of diagnosis. At the latest follow-up all but one patient showed complete response to treatment. The only relapse was successfully rescued by additional chemotherapy and PBT. PBT was well tolerated in all cases. No visual, neurological or endocrinological worsening was documented during and after treatment. Neuropsychological evaluation demonstrated preservation of cognitive performance after PBT treatment. Conclusions Our data, albeit preliminary, strongly support the favourable therapeutic profile of PBT for the treatment of CNS germ cell tumors.
Collapse
Affiliation(s)
- Giada Del Baldo
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Sabina Vennarini
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maristella Toniutti
- Department of Medicine DAME-Division of Pediatrics, University of Udine, Udine, Italy
| | - Rachid Abbas
- CESP, INSERM, Université Paris Sud, Villejuif, France
| | - Stefano Lorentini
- Medical Physics Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Eleonora Piccirilli
- Department of Diagnostic Imaging Oncological Neuroradiology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Department of Neuroscience, Imaging and Clinical Sciences, University of Chieti, Chieti, Italy
| | - Antonella Cacchione
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giacomina Megaro
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Valentina Di Ruscio
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Maria Antonietta De Ioris
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Andrea De Salvo
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giulia Albino
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Sabrina Rossi
- Pathology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giovanna Stefania Colafati
- Department of Diagnostic Imaging Oncological Neuroradiology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Department of Neuroscience, Imaging and Clinical Sciences, University of Chieti, Chieti, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Angela Mastronuzzi
- Department of Pediatric Haematology and Oncology, and Cell and Gene Therapy Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| |
Collapse
|
6
|
Peterson RK, King TZ. A systematic review of pediatric neuropsychological outcomes with proton versus photon radiation therapy: A call for equity in access to treatment. J Int Neuropsychol Soc 2023; 29:798-811. [PMID: 36323679 DOI: 10.1017/s1355617722000819] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is increasing interest in the utilization of proton beam radiation therapy (PRT) to treat pediatric brain tumors based upon presumed advantages over traditional photon radiation therapy (XRT). PRT provides more conformal radiation to the tumor with reduced dose to healthy brain parenchyma. Less radiation exposure to brain tissue beyond the tumor is thought to reduce neuropsychological sequelae. This systematic review aimed to provide an overview of published studies comparing neuropsychological outcomes between PRT and XRT. METHOD PubMed, PsychINFO, Embase, Web of Science, Scopus, and Cochrane were systematically searched for peer-reviewed published studies that compared neuropsychological outcomes between PRT and XRT in pediatric brain tumor patients. RESULTS Eight studies were included. Six of the studies utilized retrospective neuropsychological data; the majority were longitudinal studies (n = 5). XRT was found to result in lower neuropsychological functioning across time. PRT was associated with generally stable neuropsychological functioning across time, with the exception of working memory and processing speed, which showed variable outcomes across studies. However, studies inconsistently included or considered medical and sociodemographic differences between treatment groups, which may have impacted neuropsychological outcomes. CONCLUSIONS Despite methodological limitations, including limited baseline neuropsychological evaluations, temporal variability between radiation treatment and first evaluation or initial and follow-up evaluations, and heterogenous samples, there is emerging evidence of sociodemographic inequities in access to PRT. With more institutions dedicating funding towards PRT, there may be the opportunity to objectively evaluate the neuropsychological benefits of patients matched on medical and sociodemographic variables.
Collapse
Affiliation(s)
- Rachel K Peterson
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Science, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Tricia Z King
- Department of Psychology, Georgia State University, Atlanta, USA
- Neuroscience Institute, Georgia State University, Atlanta, USA
| |
Collapse
|
7
|
Unnikrishnan S, Yip AT, Qian AS, Salans MA, Yu JD, Huynh-Le MP, Reyes A, Stasenko A, McDonald C, Kaner R, Crawford JR, Hattangadi-Gluth JA. Neurocognitive Outcomes in Multiethnic Pediatric Brain Tumor Patients Treated With Proton Versus Photon Radiation. J Pediatr Hematol Oncol 2023; 45:e837-e846. [PMID: 37539987 PMCID: PMC10538429 DOI: 10.1097/mph.0000000000002724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND We analyzed post-radiation (RT) neurocognitive outcomes in an ethnically diverse pediatric brain tumor population undergoing photon radiotherapy (XRT) and proton radiotherapy (PRT). PROCEDURE Post-RT neurocognitive outcomes from 49 pediatric patients (37% Hispanic/Latino) with primary brain tumors were analyzed. Tests included cognitive outcomes, behavioral outcomes, and overall intelligence. For each outcome, proportion of patients with cognitive impairment (scores <1.5 SD) was calculated. The Fisher exact tests compared proportion of patients with impairment and t tests compared T-scores between XRT (n=32) and PRT (n=17) groups. Linear regression assessed associations between radiation modality and outcomes. RESULTS Median follow-up was 3.2 and 1.8 years in the XRT and PRT groups, respectively. The median RT dose was 54.0 Gy. We found impairment in 16% to 42% of patients across most neurocognitive domains except executive function. There was no difference in scores between XRT and PRT groups. Regression analyses revealed no association of neurocognitive outcomes with radiation modality. Non-Hispanic patients had better Verbal Comprehension Index and General Ability Index scores than Hispanic patients ( P <0.05). CONCLUSIONS Among pediatric patients with brain tumors receiving RT, all cognitive domains were affected except executive function. Radiation modality was not associated with neurocognitive outcomes. Hispanic patients may be more vulnerable to posttreatment cognitive effects that warrant further study.
Collapse
Affiliation(s)
- Soumya Unnikrishnan
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Anthony T Yip
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Alexander S Qian
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Mia A Salans
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Justin D Yu
- Departments of Radiation Medicine and Applied Sciences
| | | | | | | | - Carrie McDonald
- Departments of Radiation Medicine and Applied Sciences
- Psychiatry
| | | | - John R Crawford
- Neurosciences and Pediatrics, University of California San Diego, La Jolla
| | | |
Collapse
|
8
|
Lassaletta Á, Morales JS, Valenzuela PL, Esteso B, Kahalley LS, Mabbott DJ, Unnikrishnan S, Panizo E, Calvo F. Neurocognitive outcomes in pediatric brain tumors after treatment with proton versus photon radiation: a systematic review and meta-analysis. World J Pediatr 2023; 19:727-740. [PMID: 37154861 PMCID: PMC10348930 DOI: 10.1007/s12519-023-00726-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/05/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Advances in cancer treatments, particularly the development of radiation therapy, have led to improvements in survival outcomes in children with brain tumors. However, radiation therapy is associated with significant long-term neurocognitive morbidity. The present systematic review and meta-analysis aimed to compare the neurocognitive outcomes of children and adolescents with brain tumors treated with photon radiation (XRT) or proton therapy (PBRT). METHODS A systematic search was conducted (PubMed, Embase, Cochrane, and Web of Science from inception until 02/01/2022) for studies comparing the neurocognitive outcomes of children and adolescents with brain tumors treated with XRT vs. PBRT. The pooled mean differences (expressed as Z scores) were calculated using a random effects method for those endpoints analyzed by a minimum of three studies. RESULTS Totally 10 studies (n = 630 patients, average age range: 1-20 years) met the inclusion criteria. Patients who had received PBRT achieved significantly higher scores (difference in Z scores ranging from 0.29-0.75, all P < 0.05 and significant in sensitivity analyses) after treatment than those who had received XRT for most analyzed neurocognitive outcomes (i.e., intelligence quotient, verbal comprehension and perceptual reasoning indices, visual motor integration, and verbal memory). No robust significant differences (P > 0.05 in main analyses or sensitivity analyses) were found for nonverbal memory, verbal working memory and working memory index, processing speed index, or focused attention. CONCLUSIONS Pediatric brain tumor patients who receive PBRT achieve significantly higher scores on most neurocognitive outcomes than those who receive XRT. Larger studies with long-term follow-ups are needed to confirm these results.
Collapse
Affiliation(s)
- Álvaro Lassaletta
- Radiation Oncology Department, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta 1, 28027, Madrid, Spain.
- Pediatric Neuro-Oncology Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain.
| | - Javier S Morales
- MOVE-IT Research Group, Department of Physical Education, Faculty of Education Sciences, University of Cadiz, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital, University of Cádiz, Cádiz, Spain
| | - Pedro L Valenzuela
- Physical Activity and Health Research Group (PaHerg), Research Institute of the Hospital 12 de Octubre ('imas12'), Madrid, Spain
- Systems Biology Department, University of Alcalá, Madrid, Spain
| | - Borja Esteso
- Clinical Neuropsychology Unit, Psychiatry and Clinical Psychology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Lisa S Kahalley
- Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Donald J Mabbott
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
| | | | - Elena Panizo
- Radiation Oncology Department, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta 1, 28027, Madrid, Spain
| | - Felipe Calvo
- Radiation Oncology Department, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta 1, 28027, Madrid, Spain
| |
Collapse
|
9
|
Jalali R, Maitre P. Radiotherapy-Induced Neurocognitive Dysfunction in Brain Tumor Survivors: Burden and Rehabilitation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:197-206. [PMID: 37548740 DOI: 10.1007/978-3-030-12887-6_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Radiotherapy-induced neurocognitive dysfunction after cranial irradiation has an incidence of 40-100%. It may affect both children and adults, and represents a significant burden not only on ill individuals and their caregivers but also on the health care system and society in general. Multiple patient-, tumor-, and treatment-related factors may contribute to development of this complication, but its pathophysiological mechanisms are still not understood clearly. It is hoped that introduction of more advanced techniques for conformal irradiation, optimized dosimetry, and specific prophylactic measures will decrease the risk of neurocognitive decline in brain tumor survivors in the future.
Collapse
Affiliation(s)
- Rakesh Jalali
- Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India.
| | | |
Collapse
|
10
|
Peter JS, Schuemann J, Held KD, McNamara AL. Nano-scale simulation of neuronal damage by galactic cosmic rays. Phys Med Biol 2022; 67:10.1088/1361-6560/ac95f4. [PMID: 36172820 PMCID: PMC9951267 DOI: 10.1088/1361-6560/ac95f4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022]
Abstract
The effects of realistic, deep space radiation environments on neuronal function remain largely unexplored.In silicomodeling studies of radiation-induced neuronal damage provide important quantitative information about physico-chemical processes that are not directly accessible through radiobiological experiments. Here, we present the first nano-scale computational analysis of broad-spectrum galactic cosmic ray irradiation in a realistic neuron geometry. We constructed thousands ofin silicorealizations of a CA1 pyramidal neuron, each with over 3500 stochastically generated dendritic spines. We simulated the entire 33 ion-energy beam spectrum currently in use at the NASA Space Radiation Laboratory galactic cosmic ray simulator (GCRSim) using the TOol for PArticle Simulation (TOPAS) and TOPAS-nBio Monte Carlo-based track structure simulation toolkits. We then assessed the resulting nano-scale dosimetry, physics processes, and fluence patterns. Additional comparisons were made to a simplified 6 ion-energy spectrum (SimGCRSim) also used in NASA experiments. For a neuronal absorbed dose of 0.5 Gy GCRSim, we report an average of 250 ± 10 ionizations per micrometer of dendritic length, and an additional 50 ± 10, 7 ± 2, and 4 ± 2 ionizations per mushroom, thin, and stubby spine, respectively. We show that neuronal energy deposition by proton andα-particle tracks declines approximately hyperbolically with increasing primary particle energy at mission-relevant energies. We demonstrate an inverted exponential relationship between dendritic segment irradiation probability and neuronal absorbed dose for each ion-energy beam. We also find that there are no significant differences in the average physical responses between the GCRSim and SimGCRSim spectra. To our knowledge, this is the first nano-scale simulation study of a realistic neuron geometry using the GCRSim and SimGCRSim spectra. These results may be used as inputs to theoretical models, aid in the interpretation of experimental results, and help guide future study designs.
Collapse
Affiliation(s)
- Jonah S Peter
- Biophysics Program, Harvard University, Boston, MA 02115, United States of America
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114, United States of America
| | - Jan Schuemann
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114, United States of America
| | - Kathryn D Held
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114, United States of America
| | - Aimee L McNamara
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114, United States of America
| |
Collapse
|
11
|
Williams MT, Sugimoto C, Regan SL, Pitzer EM, Fritz AL, Sertorio M, Mascia AE, Vatner RE, Perentesis JP, Vorhees CV. Cognitive and behavioral effects of whole brain conventional or high dose rate (FLASH) proton irradiation in a neonatal Sprague Dawley rat model. PLoS One 2022; 17:e0274007. [PMID: 36112695 PMCID: PMC9481014 DOI: 10.1371/journal.pone.0274007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022] Open
Abstract
Recent studies suggest that ultra-high dose rates of proton radiation (>40 Gy/s; FLASH) confer less toxicity to exposed healthy tissue and reduce cognitive decline compared with conventional radiation dose rates (~1 Gy/s), but further preclinical data are required to demonstrate this sparing effect. In this study, postnatal day 11 (P11) rats were treated with whole brain irradiation with protons at a total dose of 0, 5, or 8 Gy, comparing a conventional dose rate of 1 Gy/s vs. a FLASH dose rate of 100 Gy/s. Beginning on P64, rats were tested for locomotor activity, acoustic and tactile startle responses (ASR, TSR) with or without prepulses, novel object recognition (NOR; 4-object version), striatal dependent egocentric learning ([configuration A] Cincinnati water maze (CWM-A)), prefrontal dependent working memory (radial water maze (RWM)), hippocampal dependent spatial learning (Morris water maze (MWM)), amygdala dependent conditioned freezing, and the mirror image CWM [configuration B (CWM-B)]. All groups had deficits in the CWM-A procedure. Weight reductions, decreased center ambulation in the open-field, increased latency on day-1 of RWM, and deficits in CWM-B were observed in all irradiated groups, except the 5 Gy FLASH group. ASR and TSR were reduced in the 8 Gy FLASH group and day-2 latencies in the RWM were increased in the FLASH groups compared with controls. There were no effects on prepulse trials of ASR or TSR, NOR, MWM, or conditioned freezing. The results suggest striatal and prefrontal cortex are sensitive regions at P11 to proton irradiation, with reduced toxicity from FLASH at 5 Gy.
Collapse
Affiliation(s)
- Michael T. Williams
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Neurology, Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
- Cincinnati Children’s/University of Cincinnati Proton Therapy and Research Center, Cincinnati, OH, United States of America
- * E-mail:
| | - Chiho Sugimoto
- Division of Neurology, Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Samantha L. Regan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Neurology, Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Emily M. Pitzer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Neurology, Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Adam L. Fritz
- Division of Neurology, Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Mathieu Sertorio
- Cincinnati Children’s/University of Cincinnati Proton Therapy and Research Center, Cincinnati, OH, United States of America
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Anthony E. Mascia
- Cincinnati Children’s/University of Cincinnati Proton Therapy and Research Center, Cincinnati, OH, United States of America
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Ralph E. Vatner
- Cincinnati Children’s/University of Cincinnati Proton Therapy and Research Center, Cincinnati, OH, United States of America
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - John P. Perentesis
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Cincinnati Children’s/University of Cincinnati Proton Therapy and Research Center, Cincinnati, OH, United States of America
- Division of Oncology, Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Charles V. Vorhees
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Neurology, Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
- Cincinnati Children’s/University of Cincinnati Proton Therapy and Research Center, Cincinnati, OH, United States of America
| |
Collapse
|
12
|
McCurdy MD, Raghubar KP, Christopher K, Okcu MF, Wilde E, Desai N, Chu ZD, Gragert M, Stancel H, Warren EH, Whitehead WE, Grosshans D, Paulino AC, Chintagumpala M, Kahalley LS. Predicting neurocognitive function in pediatric brain tumor early survivorship: The neurological predictor scale and the incremental validity of tumor size. Pediatr Blood Cancer 2022; 69:e29803. [PMID: 35709014 PMCID: PMC10265925 DOI: 10.1002/pbc.29803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Neurological Predictor Scale (NPS) quantifies cumulative exposure to conventional treatment-related neurological risks but does not capture potential risks posed by tumors themselves. This study evaluated the predictive validity of the NPS, and the incremental value of tumor location and size, for neurocognitive outcomes in early survivorship following contemporary therapies for pediatric brain tumors. PROCEDURE Survivors (N = 69) diagnosed from 2010 to 2016 were administered age-appropriate versions of the Wechsler Intelligence Scales. Hierarchical multiple regressions examined the predictive and incremental validity of NPS score, tumor location, and tumor size. RESULTS Participants (51% female) aged 6-20 years (M = 13.22, SD = 4.09) completed neurocognitive evaluations 5.16 years (SD = 1.29) postdiagnosis. The NPS significantly predicted Full-Scale Intelligence Quotient (FSIQ; ΔR2 = .079), Verbal Comprehension Index (VCI; ΔR2 = 0.051), Perceptual Reasoning Index (PRI; ΔR2 = 0.065), and Processing Speed Index (PSI; ΔR2 = 0.049) performance after controlling for sex, age at diagnosis, and maternal education. Tumor size alone accounted for a significant amount of unique variance in FSIQ (ΔR2 = 0.065), PRI (ΔR2 = 0.076), and PSI (ΔR2 = 0.080), beyond that captured by the NPS and relevant covariates. Within the full model, the NPS remained a significant independent predictor of FSIQ (β = -0.249, P = 0.016), VCI (β = -0.223, P = 0.048), and PRI (β = -0.229, P = 0.037). CONCLUSIONS Tumor size emerged as an independent predictor of neurocognitive functioning and added incrementally to the predictive utility of the NPS. Pretreatment disease burden may provide one of the earliest markers of neurocognitive risk following contemporary treatments. With perpetual treatment advances, measures quantifying treatment-related risk may need to be updated and revalidated to maintain their clinical utility.
Collapse
Affiliation(s)
- Mark D. McCurdy
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Kimberly P. Raghubar
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | | | - M. Fatih Okcu
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Elisabeth Wilde
- Baylor College of Medicine, Houston, TX, US
- University of Utah, Salt Lake City, UT, US
| | - Nilesh Desai
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Zili D. Chu
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Marsha Gragert
- The University of Texas MD Anderson Cancer Center, Houston, TX US
| | | | - Emily H. Warren
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - William E. Whitehead
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX US
| | | | - Murali Chintagumpala
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Lisa S. Kahalley
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| |
Collapse
|
13
|
The Current State of Radiotherapy for Pediatric Brain Tumors: An Overview of Post-Radiotherapy Neurocognitive Decline and Outcomes. J Pers Med 2022; 12:jpm12071050. [PMID: 35887547 PMCID: PMC9315742 DOI: 10.3390/jpm12071050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/17/2022] Open
Abstract
Tumors of the central nervous system are the most common solid malignancies diagnosed in children. While common, they are also found to have some of the lowest survival rates of all malignancies. Treatment of childhood brain tumors often consists of operative gross total resection with adjuvant chemotherapy or radiotherapy. The current body of literature is largely inconclusive regarding the overall benefit of adjuvant chemo- or radiotherapy. However, it is known that both are associated with conditions that lower the quality of life in children who undergo those treatments. Chemotherapy is often associated with nausea, emesis, significant fatigue, immunosuppression, and alopecia. While radiotherapy can be effective for achieving local control, it is associated with late effects such as endocrine dysfunction, secondary malignancy, and neurocognitive decline. Advancements in radiotherapy grant both an increase in lifetime survival and an increased lifetime for survivors to contend with these late effects. In this review, the authors examined all the published literature, analyzing the results of clinical trials, case series, and technical notes on patients undergoing radiotherapy for the treatment of tumors of the central nervous system with a focus on neurocognitive decline and survival outcomes.
Collapse
|
14
|
Kline C, Stoller S, Byer L, Samuel D, Lupo JM, Morrison MA, Rauschecker AM, Nedelec P, Faig W, Dubal DB, Fullerton HJ, Mueller S. An Integrated Analysis of Clinical, Genomic, and Imaging Features Reveals Predictors of Neurocognitive Outcomes in a Longitudinal Cohort of Pediatric Cancer Survivors, Enriched with CNS Tumors (Rad ART Pro). Front Oncol 2022; 12:874317. [PMID: 35814456 PMCID: PMC9259981 DOI: 10.3389/fonc.2022.874317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background Neurocognitive deficits in pediatric cancer survivors occur frequently; however, individual outcomes are unpredictable. We investigate clinical, genetic, and imaging predictors of neurocognition in pediatric cancer survivors, with a focus on survivors of central nervous system (CNS) tumors exposed to radiation. Methods One hundred eighteen patients with benign or malignant cancers (median diagnosis age: 7; 32% embryonal CNS tumors) were selected from an existing multi-institutional cohort (RadART Pro) if they had: 1) neurocognitive evaluation; 2) available DNA; 3) standard imaging. Utilizing RadART Pro, we collected clinical history, genomic sequencing, CNS imaging, and neurocognitive outcomes. We performed single nucleotide polymorphism (SNP) genotyping for candidate genes associated with neurocognition: COMT, BDNF, KIBRA, APOE, KLOTHO. Longitudinal neurocognitive testing were performed using validated computer-based CogState batteries. The imaging cohort was made of patients with available iron-sensitive (n = 28) and/or T2 FLAIR (n = 41) sequences. Cerebral microbleeds (CMB) were identified using a semi-automated algorithm. Volume of T2 FLAIR white matter lesions (WML) was measured using an automated method based on a convolutional neural network. Summary statistics were performed for patient characteristics, neurocognitive assessments, and imaging. Linear mixed effects and hierarchical models assessed patient characteristics and SNP relationship with neurocognition over time. Nested case-control analysis was performed to compare candidate gene carriers to non-carriers. Results CMB presence at baseline correlated with worse performance in 3 of 7 domains, including executive function. Higher baseline WML volumes correlated with worse performance in executive function and verbal learning. No candidate gene reliably predicted neurocognitive outcomes; however, APOE ϵ4 carriers trended toward worse neurocognitive function over time compared to other candidate genes and carried the highest odds of low neurocognitive performance across all domains (odds ratio 2.85, P=0.002). Hydrocephalus and seizures at diagnosis were the clinical characteristics most frequently associated with worse performance in neurocognitive domains (5 of 7 domains). Overall, executive function and verbal learning were the most frequently negatively impacted neurocognitive domains. Conclusion Presence of CMB, APOE ϵ4 carrier status, hydrocephalus, and seizures correlate with worse neurocognitive outcomes in pediatric cancer survivors, enriched with CNS tumors exposed to radiation. Ongoing research is underway to verify trends in larger cohorts.
Collapse
Affiliation(s)
- Cassie Kline
- Division of Oncology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Division of Child Neurology, Department of Neurology, University of California, San Francisco, United States
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Schuyler Stoller
- Division of Child Neurology, Department of Neurology, University of California, San Francisco, United States
| | - Lennox Byer
- UCSF School of Medicine, University of California, San Francisco, United States
| | - David Samuel
- Division of Pediatric Hematology/Oncology, Valley Children’s Hospital, Madera, CA, United States
| | - Janine M. Lupo
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States
| | - Melanie A. Morrison
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States
| | - Andreas M. Rauschecker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States
| | - Pierre Nedelec
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States
| | - Walter Faig
- Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Dena B. Dubal
- Department of Neurology, University of California, San Francisco, CA, United States
| | - Heather J. Fullerton
- Division of Child Neurology, Department of Neurology, University of California, San Francisco, United States
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Sabine Mueller
- Division of Child Neurology, Department of Neurology, University of California, San Francisco, United States
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurological Surgery, University of California, San Francisco, CA, United States
- *Correspondence: Sabine Mueller,
| |
Collapse
|
15
|
Warren EA, Raghubar KP, Cirino PT, Child AE, Lupo PJ, Grosshans DR, Paulino AC, Okcu MF, Minard CG, Ris MD, Mahajan A, Viana A, Chintagumpala M, Kahalley LS. Cognitive predictors of social adjustment in pediatric brain tumor survivors treated with photon versus proton radiation therapy. Pediatr Blood Cancer 2022; 69:e29645. [PMID: 35285129 PMCID: PMC9208675 DOI: 10.1002/pbc.29645] [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: 08/11/2021] [Revised: 01/13/2022] [Accepted: 02/15/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pediatric brain tumor survivors are at risk for poor social outcomes. It remains unknown whether cognitive sparing with proton radiotherapy (PRT) supports better social outcomes relative to photon radiotherapy (XRT). We hypothesized that survivors treated with PRT would outperform those treated with XRT on measures of cognitive and social outcomes. Further, we hypothesized that cognitive performance would predict survivor social outcomes. PROCEDURE Survivors who underwent PRT (n = 38) or XRT (n = 20) participated in a neurocognitive evaluation >1 year post radiotherapy. Group differences in cognitive and social functioning were assessed using analysis of covariance (ANCOVA). Regression analyses examined predictors of peer relations and social skills. RESULTS Age at evaluation, radiation dose, tumor diameter, and sex did not differ between groups (all p > .05). XRT participants were younger at diagnosis (XRT M = 5.0 years, PRT M = 7.6 years) and further out from radiotherapy (XRT M = 8.7 years, PRT M = 4.6 years). The XRT group performed worse than the PRT group on measures of processing speed (p = .01) and verbal memory (p < .01); however, social outcomes did not differ by radiation type. The proportion of survivors with impairment in peer relations and social skills exceeded expectation; χ2 (1) = 38.67, p < .001; χ2 (1) = 5.63, p < .05. Household poverty predicted peer relation difficulties (t = 2.18, p < .05), and verbal memory approached significance (t = -1.99, p = .05). Tumor diameter predicted social skills (t = -2.07, p < .05). CONCLUSIONS Regardless of radiation modality, survivors are at risk for social challenges. Deficits in verbal memory may place survivors at particular risk. Results support monitoring of cognitive and social functioning throughout survivorship, as well as consideration of sociodemographic risk factors.
Collapse
Affiliation(s)
- Emily A.H. Warren
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Kimberly P. Raghubar
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Paul T. Cirino
- Department of Psychology, University of Houston, Houston TX
| | - Amanda E. Child
- Department of Pediatrics, Division of Child and Adolescent Neurology, UT Health, Houston TX
| | - Philip J. Lupo
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - M. Fatih Okcu
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston TX
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Anita Mahajan
- Department of Radiation Oncology, The Mayo Clinic, Rochester MN
| | - Andres Viana
- Department of Psychology, University of Houston, Houston TX
| | - Murali Chintagumpala
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX,Correspondence To: Lisa S. Kahalley, Ph.D., Texas Children’s Hospital, 1102 Bates Ave., Suite 940, Houston, TX 77030-2399, US; Telephone: 832-822-4759; Fax: 832-825-1222; .
| |
Collapse
|
16
|
Al Dahhan NZ, Cox E, Nieman BJ, Mabbott DJ. Cross-translational models of late-onset cognitive sequelae and their treatment in pediatric brain tumor survivors. Neuron 2022; 110:2215-2241. [PMID: 35523175 DOI: 10.1016/j.neuron.2022.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/21/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
Pediatric brain tumor treatments have a high success rate, but survivors are at risk of cognitive sequelae that impact long-term quality of life. We summarize recent clinical and animal model research addressing pathogenesis or evaluating candidate interventions for treatment-induced cognitive sequelae. Assayed interventions encompass a broad range of approaches, including modifications to radiotherapy, modulation of immune response, prevention of treatment-induced cell loss or promotion of cell renewal, manipulation of neuronal signaling, and lifestyle/environmental adjustments. We further emphasize the potential of neuroimaging as a key component of cross-translation to contextualize laboratory research within broader clinical findings. This cross-translational approach has the potential to accelerate discovery to improve pediatric cancer survivors' long-term quality of life.
Collapse
Affiliation(s)
- Noor Z Al Dahhan
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Cox
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada; Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Brian J Nieman
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada; Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada; Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Donald J Mabbott
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada; Department of Psychology, University of Toronto, Toronto, ON, Canada; Department of Psychology, Hospital for Sick Children, Toronto, ON, Canada.
| |
Collapse
|
17
|
Weil CR, Lew FH, Williams VM, Burt LM, Ermoian RP, Poppe MM. Patterns of Care and Utilization Disparities in Proton Radiation Therapy for Pediatric Central Nervous System Malignancies. Adv Radiat Oncol 2022; 7:100868. [DOI: 10.1016/j.adro.2021.100868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022] Open
|
18
|
Cognitive Functions of Pediatric Brain Tumor Survivors Treated With Proton Beam Therapy: A Case Series. J Pediatr Hematol Oncol 2021; 43:e1205-e1209. [PMID: 33235149 DOI: 10.1097/mph.0000000000002011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/16/2020] [Indexed: 10/22/2022]
Abstract
Pediatric brain tumor survivors who received proton beam therapy at the University of Tsukuba Hospital from 2004 to 2011 were retrospectively evaluated for cognitive function. Five patients were included. The median age of diagnosis was 5.4 years (range: 1.5 to 12.5 y) and the median follow-up time was 5.8 years (range: 3.1 to 8.1 y). IQ scores at follow-up were decreased in 2 of 5 patients; 1 underwent whole-brain irradiation and the other was examined just after surgical removal of recurrent tumors. Local proton beam therapy may preserve cognitive function in survivors of pediatric brain tumors.
Collapse
|
19
|
Levitch CF, Malkin B, Latella L, Guerry W, Gardner SL, Finlay JL, Sands SA. Long-term neuropsychological outcomes of survivors of young childhood brain tumors treated on the Head Start II protocol. Neurooncol Pract 2021; 8:609-619. [PMID: 34594573 DOI: 10.1093/nop/npab028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background The Head Start treatment protocols have focused on curing young children with brain tumors while avoiding or delaying radiotherapy through using a combination of high-dose, marrow-ablative chemotherapy and autologous hematopoietic cell transplantation (AuHCT). Late effects data from treatment on the Head Start II (HS II) protocol have previously been published for short-term follow-up (STF) at a mean of 39.7 months post-diagnosis. The current study examines long-term follow-up (LTF) outcomes from the same cohort. Methods Eighteen HS II patients diagnosed with malignant brain tumors <10 years of age at diagnosis completed a neurocognitive battery and parents completed psychological questionnaires at a mean of 104.7 months' post-diagnosis. Results There was no significant change in Full Scale IQ at LTF compared to baseline or STF. Similarly, most domains had no significant change from STF, including verbal IQ, performance IQ, academics, receptive language, learning/memory, visual-motor integration, and externalizing behaviors. Internalizing behaviors increased slightly at LTF. Clinically, most domains were within the average range, except for low average mathematics and receptive language. Additionally, performance did not significantly differ by age at diagnosis or time since diagnosis. Of note, children treated with high-dose methotrexate for disseminated disease or atypical teratoid/rhabdoid tumor displayed worse neurocognitive outcomes. Conclusions These results extend prior findings of relative stability in intellectual functioning for a LTF period. Ultimately, this study supports that treatment strategies for avoiding or delaying radiotherapy using high-dose, marrow-ablative chemotherapy and AuHCT may decrease the risk of neurocognitive and social-emotional declines in young pediatric brain tumor survivors.
Collapse
Affiliation(s)
- Cara F Levitch
- Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Benjamin Malkin
- Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lauren Latella
- Graduate School of Education, Fordham University, Bronx, New York, USA
| | - Whitney Guerry
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sharon L Gardner
- Department of Pediatrics, NYU Langone Health, New York, New York, USA
| | - Jonathan L Finlay
- Department of Pediatrics and Division of Hematology, Oncology, and Blood & Marrow Transplantation, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Stephen A Sands
- Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
20
|
Child AE, Warren EA, Grosshans DR, Paulino AC, Okcu MF, Ris MD, Mahajan A, Orobio J, Cirino PT, Minard CG, Viana AG, Bick J, Woods SP, Chintagumpala M, Kahalley LS. Long-term cognitive and academic outcomes among pediatric brain tumor survivors treated with proton versus photon radiotherapy. Pediatr Blood Cancer 2021; 68:e29125. [PMID: 34114294 PMCID: PMC8316321 DOI: 10.1002/pbc.29125] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/22/2021] [Accepted: 05/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Proton radiotherapy (PRT) may be associated with less neurocognitive risk than photon RT (XRT) for pediatric brain tumor survivors. We compared neurocognitive and academic outcomes in long-term survivors treated with XRT versus PRT. METHODS Survivors underwent neurocognitive evaluation >1 year after craniospinal (CSI) or focal PRT or XRT. Groups were compared using separate one-way analyses of covariance for the CSI and focal groups. RESULTS PRT (n = 58) and XRT (n = 30) subgroups were similar on gender (66% male), age at RT (median = 6.5 years), age at follow-up (median = 14.6 years), and government assistance status (32%). PRT and XRT focal groups differed on follow-up interval, shunt history, and total RT dose (all p < .05), whereas PRT and XRT CSI groups differed on follow-up interval, baseline neurocognitive performance score, boost volume, and CSI dose (all p < .05). The PRT focal group outperformed the XRT focal group on inhibition/switching (p = .04). The PRT CSI group outperformed the XRT CSI group on inattention/impulsivity (both p < .05). Several clinical variables (i.e., RT dose, boost field, baseline performance) predicted neurocognitive outcomes (all p < .05). The PRT focal group performed comparably to population means on most neurocognitive measures, while both CSI groups performed below expectation on multiple measures. The XRT CSI group was most impaired. All groups fell below expectation on processing speed, fine motor, and academic fluency (most p < .01). CONCLUSIONS Findings suggest generally favorable neurocognitive and academic long-term outcomes following focal PRT. Impairment was greatest following CSI regardless of modality. Dosimetry and baseline characteristics are important determinants of outcome alone or in combination with modality.
Collapse
Affiliation(s)
- Amanda E. Child
- Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore MD
| | - Emily A. Warren
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston TX
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Anita Mahajan
- Department of Radiation Oncology, The Mayo Clinic, Rochester MN
| | - Jessica Orobio
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas TX
| | | | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston TX
| | | | | | | | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston TX
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| |
Collapse
|
21
|
Weusthof K, Lüttich P, Regnery S, König L, Bernhardt D, Witt O, Herfarth K, Unterberg A, Jungk C, Farnia B, Combs SE, Debus J, Rieken S, Harrabi S, Adeberg S. Neurocognitive Outcomes in Pediatric Patients Following Brain Irradiation. Cancers (Basel) 2021; 13:cancers13143538. [PMID: 34298751 PMCID: PMC8307409 DOI: 10.3390/cancers13143538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/18/2021] [Accepted: 06/26/2021] [Indexed: 11/16/2022] Open
Abstract
Advanced radiation techniques can reduce the severity of neurocognitive sequelae in young brain tumor patients. In the present analysis, we sought to compare neurocognitive outcomes after proton irradiation with patients who underwent photon radiotherapy (RT) and surgery. Neurocognitive outcomes were evaluated in 103 pediatric brain tumor patients (proton RT n = 26, photon RT n = 30, surgery n = 47) before and after treatment. Comparison of neurocognitive outcomes following different treatment modalities were analyzed over four years after treatment completion. Longitudinal analyses included 42 months of follow-up after proton RT and 55 months after photon RT and surgery. Neurocognitive assessment included standardized tests examining seven domains. A comparison of neurocognitive outcomes after RT (proton and photon with >90% additional surgery) and surgery showed no significant differences in any neurocognitive domain. Neurocognitive functioning tests after proton RT failed to identify alterations compared to baseline testing. Long-term follow up over four years after photon RT showed a decrease in non-verbal intelligence (-9.6%; p = 0.01) and visuospatial construction (-14.9%; p = 0.02). After surgery, there was a decline in non-verbal intelligence (-10.7%; p = 0.01) and processing speed (14.9%; p = 0.002). Differences in neurocognitive outcomes between RT and surgical cohorts in direct intermodal comparison at long-term follow-up were not identified in our study, suggesting that modern radiation therapy does not affect cognition as much as in the past. There were no alterations in long-term neurocognitive abilities after proton RT, whereas decline of processing speed, non-verbal intelligence, and visuospatial abilities were observed after both photon RT and surgery. Domains dependent on intact white matter structures appear particularly vulnerable to brain tumor treatment irrespective of treatment approach.
Collapse
Affiliation(s)
- Katharina Weusthof
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.W.); (S.R.); (L.K.); (K.H.); (J.D.); (S.H.)
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Peggy Lüttich
- Section of Pediatric Brain Tumors, Department of Pediatric Oncology, Hematology and Immunology, University Medical Center for Children and Adolescents, 69120 Heidelberg, Germany; (P.L.); (O.W.)
| | - Sebastian Regnery
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.W.); (S.R.); (L.K.); (K.H.); (J.D.); (S.H.)
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.W.); (S.R.); (L.K.); (K.H.); (J.D.); (S.H.)
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), 69120 Heidelberg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Technische Universität München, 81675 München, Germany; (D.B.); (S.E.C.)
- Department of Radiation Sciences (DRS), Institut für Innovative Radiotherapie (iRT), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Olaf Witt
- Section of Pediatric Brain Tumors, Department of Pediatric Oncology, Hematology and Immunology, University Medical Center for Children and Adolescents, 69120 Heidelberg, Germany; (P.L.); (O.W.)
- Translational Program, Hopp Children’s Cancer Center at NCT Heidelberg (KiTZ), 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.W.); (S.R.); (L.K.); (K.H.); (J.D.); (S.H.)
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (A.U.); (C.J.)
| | - Christine Jungk
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (A.U.); (C.J.)
| | - Benjamin Farnia
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA;
| | - Stephanie E. Combs
- Department of Radiation Oncology, Technische Universität München, 81675 München, Germany; (D.B.); (S.E.C.)
- Department of Radiation Sciences (DRS), Institut für Innovative Radiotherapie (iRT), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.W.); (S.R.); (L.K.); (K.H.); (J.D.); (S.H.)
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital Goettingen, 37075 Goettingen, Germany;
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.W.); (S.R.); (L.K.); (K.H.); (J.D.); (S.H.)
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.W.); (S.R.); (L.K.); (K.H.); (J.D.); (S.H.)
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-56-8201
| |
Collapse
|
22
|
Dell'Oro M, Short M, Wilson P, Bezak E. Normal tissue tolerance amongst paediatric brain tumour patients- current evidence in proton radiotherapy. Crit Rev Oncol Hematol 2021; 164:103415. [PMID: 34242771 DOI: 10.1016/j.critrevonc.2021.103415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 04/28/2021] [Accepted: 07/04/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Proton radiotherapy (PT) is used increasingly for paediatric brain cancer patients. However, as demonstrated here, the knowledge on normal tissue dose constraints, to minimize side-effects, for this cohort is limited. METHODS A search strategy was systematically conducted on MEDLINE® database. 65 papers were evaluated ranging from 2013 to 2021. RESULTS Large variations in normal tissue tolerance and toxicity reporting across PT studies makes estimation of normal tissue dose constraints difficult, with the potential for significant late effects to go unmeasured. Mean dose delivered to the pituitary gland varies from 20 to 30 Gy across literature. Similarly, the hypothalamic dose delivery ranges from 20 to 54.6 Gy for paediatric patients. CONCLUSION There is a significant lack of radiobiological data for paediatric brain cancer patients undergoing proton therapy, often using data from x-ray radiotherapy and adult populations. The way forward is through standardisation of reporting in order to validate relevant dose constraints.
Collapse
Affiliation(s)
- Mikaela Dell'Oro
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia; Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Michala Short
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia
| | - Puthenparampil Wilson
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; UniSA STEM, University of South Australia, Adelaide, SA 5001, Australia
| | - Eva Bezak
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia; Department of Physics, University of Adelaide, Adelaide, SA 5005, Australia
| |
Collapse
|
23
|
Palmer JD, Tsang DS, Tinkle CL, Olch AJ, Kremer LCM, Ronckers CM, Gibbs IC, Constine LS. Late effects of radiation therapy in pediatric patients and survivorship. Pediatr Blood Cancer 2021; 68 Suppl 2:e28349. [PMID: 33818893 DOI: 10.1002/pbc.28349] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/08/2022]
Abstract
Advances in multimodality therapy have led to childhood cancer cure rates over 80%. However, surgery, chemotherapy, and radiotherapy may lead to debilitating or even fatal long-term effects among childhood survivors beyond those inflicted by the primary disease process. It is critical to understand, mitigate, and prevent these late effects of cancer therapy to improve the quality of life of childhood cancer survivors. This review summarizes the various late effects of radiotherapy and acknowledges the Pediatric Normal Tissue Effects in the Clinic (PENTEC), an international collaboration that is systematically analyzing the association between radiation treatment dose/volume and consequential organ toxicities, in developing children as a basis to formulate recommendations for clinical practice of pediatric radiation oncology. We also summarize initiatives for survivorship and surveillance of late normal tissue effects related to radiation therapy among long-term survivors of childhood cancer treated in the past.
Collapse
Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Ohio, Columbus
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Division of Haematology/Oncology, Hospital for Sick Children, University Health Network, Toronto, Canada
| | - Christopher L Tinkle
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Arthur J Olch
- Department of Radiation Oncology, Keck School of Medicine of USC and Children's' Hospital Los Angeles, Los Angeles, California
| | - Leontien C M Kremer
- Department of Pediatrics, Amsterdam UMC, Emma Children's Hospital, Amsterdam, the Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Cecile M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Brandenburg Medical School, Institute for Biostatistics and Registry Research, Neuruppin, Germany
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| |
Collapse
|
24
|
Eaton BR, Goldberg S, Tarbell NJ, Lawell MP, Gallotto SL, Weyman EA, Kuhlthau KA, Ebb DH, MacDonald SM, Yock TI. Long-term health-related quality of life in pediatric brain tumor survivors receiving proton radiotherapy at <4 years of age. Neuro Oncol 2021; 22:1379-1387. [PMID: 32064512 DOI: 10.1093/neuonc/noaa042] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to report long-term health-related quality of life (HRQoL) among brain tumor survivors treated with proton therapy (PRT) at a very young age. METHODS Fifty-nine children <4 years old received PRT between 2000 and 2011. Forty families participated. HRQoL was assessed by child self-report (CSR; age ≥5) and parent proxy report (PPR; age 2+) using the PedsQL Core. RESULTS The median age was 2.5 years (range, 0.3-3.8) at PRT and 9.1 years (5.5-18) at last follow-up. The most common diagnoses were ependymoma (n = 22) and medulloblastoma (n = 7). Median follow-up is 6.7 years (3-15.4). Follow-up mean CSR and PPR scores were: total core (78.4 and 72.9), physical (82.9 and 75.2), psychosocial (76.0 and 71.6), emotional (74.4 and 70.7), social (81.2 and 75.1), and school (72.4 and 69.9). Parent-reported HRQoL fell within a previously defined range for healthy children in 37.5% of patients, and for children with severe health conditions in 45% of patients. PPR HRQoL was stable from baseline to last follow-up among all domains except for social functioning. History of gastrostomy tube was significantly associated with poorer CSR and PPR HRQoL on multivariable analysis. Ninety percent of children functioned in a regular classroom, 14 (36%) used a classroom aid, 9 (23%) used an outside tutor, and 18 (46%) had an individualized education plan. CONCLUSION Long-term HRQoL among brain tumor survivors treated with PRT at a very young age is variable, with over a third achieving HRQoL levels commensurate with healthy children. KEY POINTS 1. One third of survivors reported long-term HRQoL scores comparable to those of healthy children.2. Treatment for hydrocephalus or a feeding tube was associated with significantly lower HRQoL.3. Total core HRQoL scores remained stable from baseline to last follow-up.
Collapse
Affiliation(s)
- Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Saveli Goldberg
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Miranda P Lawell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sara L Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen A Kuhlthau
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - David H Ebb
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
25
|
Mizumoto M, Fuji H, Miyachi M, Soejima T, Yamamoto T, Aibe N, Demizu Y, Iwata H, Hashimoto T, Motegi A, Kawamura A, Terashima K, Fukushima T, Nakao T, Takada A, Sumi M, Oshima J, Moriwaki K, Nozaki M, Ishida Y, Kosaka Y, Ae K, Hosono A, Harada H, Ogo E, Akimoto T, Saito T, Fukushima H, Suzuki R, Takahashi M, Matsuo T, Matsumura A, Masaki H, Hosoi H, Shigematsu N, Sakurai H. Proton beam therapy for children and adolescents and young adults (AYAs): JASTRO and JSPHO Guidelines. Cancer Treat Rev 2021; 98:102209. [PMID: 33984606 DOI: 10.1016/j.ctrv.2021.102209] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/02/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
Children and adolescents and young adults (AYAs) with cancer are often treated with a multidisciplinary approach. This includes use of radiotherapy, which is important for local control, but may also cause adverse events in the long term, including second cancer. The risks for limited growth and development, endocrine dysfunction, reduced fertility and second cancer in children and AYAs are reduced by proton beam therapy (PBT), which has a dose distribution that decreases irradiation of normal organs while still targeting the tumor. To define the outcomes and characteristics of PBT in cancer treatment in pediatric and AYA patients, this document was developed by the Japanese Society for Radiation Oncology (JASTRO) and the Japanese Society of Pediatric Hematology/Oncology (JSPHO).
Collapse
Affiliation(s)
- Masashi Mizumoto
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroshi Fuji
- Department of Radiology and National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuru Miyachi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Toshinori Soejima
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Norihiro Aibe
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Takayuki Hashimoto
- Department of Radiation Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Atsushi Motegi
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Atsufumi Kawamura
- Department of Neurosurgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keita Terashima
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Fukushima
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tomohei Nakao
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akinori Takada
- Department of Radiology, Mie University Hospital, Tsu-shi, Mie, Japan
| | - Minako Sumi
- Department of Radiation Oncology and Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Radiation Oncology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | | | - Kensuke Moriwaki
- Department of Medical Statistics, Kobe Pharmaceutical University, Kobe, Hyogo, Japan
| | - Miwako Nozaki
- Department of Radiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yuji Ishida
- Department of Pediatrics, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keisuke Ae
- Department of Orthopaedic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ako Hosono
- Department of Pediatric Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Hideyuki Harada
- Division of Radiation Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Etsuyo Ogo
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Tetsuo Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Takashi Saito
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroko Fukushima
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ryoko Suzuki
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mitsuru Takahashi
- Department of Orthopaedic Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Medicine, Nagasaki, Japan
| | - Akira Matsumura
- Departments of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hidekazu Masaki
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Sakurai
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| |
Collapse
|
26
|
Uh J, Merchant TE, Conklin HM, Ismael Y, Li Y, Han Y, Sabin ND, Babajani-Feremi A, Indelicato DJ, Hua CH. Diffusion Tensor Imaging-Based Analysis of Baseline Neurocognitive Function and Posttreatment White Matter Changes in Pediatric Patients With Craniopharyngioma Treated With Surgery and Proton Therapy. Int J Radiat Oncol Biol Phys 2021; 109:515-526. [PMID: 32898610 DOI: 10.1016/j.ijrobp.2020.08.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine the preirradiation baseline association of white matter integrity with neurocognitive function and to assess posttreatment changes in pediatric patients with craniopharyngioma treated with proton therapy. METHODS AND MATERIALS Ninety children and adolescents (2-20 years old) with craniopharyngioma were treated with proton therapy (54 Gy[RBE]) in a prospective therapeutic trial. Neurocognitive performance at the postoperative baseline before proton therapy and diffusion tensor imaging (DTI) data acquired at baseline and at annual follow-up were analyzed. Tract-based spatial statistics and structural connectomics were used to derive global and local white matter features from DTI. Baseline DTI features were compared for patients with average and below-average neurocognitive performance. Longitudinal DTI data were analyzed to determine the proton dose effect on white matter structures in relation to the irradiated brain volume and baseline age. RESULTS Before proton therapy, patients with below-average working memory, processing speed, verbal fluency, verbal learning, or fine motor dexterity exhibited more globally degraded white matter structures compared with their counterparts with average performance, as indicated by lower mean fractional anisotropy, decreased global efficiency, or higher modularity. Surgery, obstructive hydrocephalus, and preoperative hypothalamic involvement appeared to be related to this degradation. In local analyses, tract-based spatial statistics revealed left-lateralized associations with verbal and motor functions, which supported surgical approaches to midline tumors via the right hemisphere. The mean fractional anisotropy of the brain and the global efficiency derived from DTI increased over the 5 years after proton therapy. The rate of increase was lower with larger irradiated brain volumes and in older children. CONCLUSIONS Below-average baseline neurocognitive performance in patients with craniopharyngioma before proton therapy appeared to be related to structural degradation of white matter tracts. Posttherapy longitudinal DTI showed improving trends in global integrity and efficiency measures, particularly in children in whom a smaller brain volume was irradiated.
Collapse
Affiliation(s)
- Jinsoo Uh
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Heather M Conklin
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yousef Ismael
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yimei Li
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yuanyuan Han
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Noah D Sabin
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Abbas Babajani-Feremi
- Department of Pediatrics and Department of Anatomy and Neurobiology, University of Tennessee Health Science Center, and Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| |
Collapse
|
27
|
Yahya N, Manan HA. Neurocognitive impairment following proton therapy for paediatric brain tumour: a systematic review of post-therapy assessments. Support Care Cancer 2020; 29:3035-3047. [PMID: 33040284 DOI: 10.1007/s00520-020-05808-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/30/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Proton therapy (PT), frequently utilised to treat paediatric brain tumour (PBT) patients, eliminates exit dose and minimises dose to healthy tissues that theoretically can mitigate treatment-related effects including cognitive deficits. As clinical outcome data are emerging, we aimed to systematically review current evidence of cognitive changes following PT of PBT. MATERIALS AND METHODS We searched PubMed and Scopus electronic databases to identify eligible reports on cognitive changes following PT of PBT according to PRISMA guidelines. Reports were extracted for information on demographics and cognitive outcomes. Then, they were systematically reviewed based on three themes: (1) comparison with photon therapy, (2) comparison with baseline cognitive measures, to population normative mean or radiotherapy-naïve PBT patients and (3) effects of dose distribution to cognition. RESULTS Thirteen reports (median size (range): 70 (12-144)) were included. Four reports compared the cognitive outcome between PBT patients treated with proton to photon therapy and nine compared with baseline/normative mean/radiotherapy naïve from which two reported the effects of dose distribution. Reports found significantly poorer cognitive outcome among patients treated with photon therapy compared with proton therapy especially in general cognition and working memory. Craniospinal irradiation (CSI) was consistently associated with poorer cognitive outcome while focal therapy was associated with minor cognitive change/difference. In limited reports available, higher doses to the hippocampus and temporal lobes were implicated to larger cognitive change. CONCLUSION Available evidence suggests that PT causes less cognitive deficits compared with photon therapy. Children who underwent focal therapy with proton were consistently shown to have low risk of cognitive deficit suggesting the need for future studies to separate them from CSI. Evidence on the effect of dose distribution to cognition in PT is yet to mature.
Collapse
Affiliation(s)
- Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, CODTIS, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, 50300, Kuala Lumpur, Malaysia.
| | - Hanani Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Cheras, 56000, Kuala Lumpur, Malaysia
| |
Collapse
|
28
|
Harrabi SB. [Is proton radiotherapy superior to photon radiotherapy in terms of intellectual outcome?]. Strahlenther Onkol 2020; 196:1135-1138. [PMID: 32997188 PMCID: PMC7686222 DOI: 10.1007/s00066-020-01692-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Semi B Harrabi
- Heidelberger Ionenstrahl-Therapiezentrum (HIT), Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| |
Collapse
|
29
|
Influence of Target Location, Size, and Patient Age on Normal Tissue Sparing- Proton and Photon Therapy in Paediatric Brain Tumour Patient-Specific Approach. Cancers (Basel) 2020; 12:cancers12092578. [PMID: 32927700 PMCID: PMC7563785 DOI: 10.3390/cancers12092578] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Proton radiotherapy produces superior dose distributions compared to photon radiotherapy, reducing side effects. Differences between the two modalities are not fully quantified in paediatric patients for various intracranial tumour sites or age. Understanding these differences may help clinicians estimate the benefit and improve referral across available centres. Our aim was to compare intensity-modulated proton therapy (IMPT) and intensity-modulated photon radiotherapy (IMRT) radiation doses for select paediatric intracranial tumours. METHODS IMPT and IMRT dose distributions for gender-matched paediatric cranial CT-datasets (ages 5, 9 and 13 years) were retrospectively calculated to simulate irradiation of supratentorial (ependymoma) and infratentorial (medulloblastoma) target volumes diameters (1-3 cm) and position (central and 1-2 cm shifts). RESULTS Clinical dosimetric objectives were achieved for all 216 treatment plans. Whilst infratentorial IMPT plans achieved greater maximum dose sparing to optic structures (4.8-12.6 Gy optic chiasm), brainstem sparing was limited (~0.5 Gy). Mean dose difference for optic chiasm was associated with medulloblastoma target position (p < 0.0197). Supratentorial IMPT plans demonstrated greater dose reduction for the youngest patients (pituitary gland p < 0.001). CONCLUSIONS Normal tissue sparing was achieved regardless of patient age for infratentorial tumours. However, for supratentorial tumours, there was a dosimetric advantage of IMPT across 9 vs. 13-year-old patients.
Collapse
|
30
|
Gross JP, Powell S, Zelko F, Hartsell W, Goldman S, Fangusaro J, Lulla RR, Smiley NP, Chang JHC, Gondi V. Improved neuropsychological outcomes following proton therapy relative to X-ray therapy for pediatric brain tumor patients. Neuro Oncol 2020; 21:934-943. [PMID: 30997512 DOI: 10.1093/neuonc/noz070] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Survivors of pediatric brain tumors are at risk for impaired development in multiple neuropsychological domains. The purpose of this study was to compare neuropsychological outcomes of pediatric brain tumor patients who underwent X-ray radiotherapy (XRT) versus proton radiotherapy (PRT). METHODS Pediatric patients who underwent either XRT or PRT and received posttreatment age-appropriate neuropsychological evaluation-including measures of intelligence (IQ), attention, memory, visuographic skills, academic skills, and parent-reported adaptive functioning-were identified. Multivariate analyses were performed to assess differences in neuropsychological outcomes and included tests for interaction between treatment cohort and follow-up time. RESULTS Between 1998 and 2017, 125 patients with tumors located in the supratentorial (17.6%), midline (28.8%), or posterior fossa (53.6%) compartments received radiation and had posttreatment neuropsychological evaluation. Median age at treatment was 7.4 years. The PRT patient cohort had higher estimated SES and shorter median time from radiotherapy completion to last neuropsychological evaluation (6.7 vs 2.6 y, P < 0.001). On multivariable analysis, PRT was associated with higher full-scale IQ (β = 10.6, P = 0.048) and processing speed (β = 14.4, P = 0.007) relative to XRT, with trend toward higher verbal IQ (β = 9.9, P = 0.06) and general adaptive functioning (β = 11.4, P = 0.07). Planned sensitivity analyses truncating follow-up interval in the XRT cohort re-demonstrated higher verbal IQ (P = 0.01) and IQ (P = 0.04) following PRT, with trend toward improved processing speed (P = 0.09). CONCLUSIONS PRT is associated with favorable outcomes for intelligence and processing speed. Combined with other strategies for treatment de-intensification, PRT may further reduce neuropsychological morbidity of brain tumor treatment.
Collapse
Affiliation(s)
- Jeffrey P Gross
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephanie Powell
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Frank Zelko
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William Hartsell
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Radiation Oncology Consultants LLC, Chicago, Illinois.,Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Stewart Goldman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason Fangusaro
- Department of Pediatrics, Emory University School of Medicine and the Aflac Cancer Center, Atlanta, Georgia
| | - Rishi R Lulla
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Natasha Pillay Smiley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Han-Chih Chang
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Radiation Oncology Consultants LLC, Chicago, Illinois.,Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| |
Collapse
|
31
|
Stadskleiv K, Stensvold E, Stokka K, Bechensteen AG, Brandal P. Neuropsychological functioning in survivors of childhood medulloblastoma/CNS-PNET: The role of secondary medical complications. Clin Neuropsychol 2020; 36:600-625. [PMID: 32729777 DOI: 10.1080/13854046.2020.1794045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the long-term cognitive consequences of malignant pediatric brain tumor and its treatment, and factors explaining variability in cognitive functioning among survivors. Method: A geographical cohort of survivors of pediatric medulloblastoma (MB) and supratentorial primitive neuroectodermal tumor (CNS-PNET), treated between 1974 and 2013, was invited to participate. Of the 63 surviving patients, 50 (79%) consented to participation. The participants were tested with a battery of neuropsychological tests covering a wide age range. Verbal cognition, nonverbal cognition, processing speed, attention, memory, executive functioning, and manual dexterity were assessed. The participants were between 5:5 and 51:11 years of age at time of assessment. Assessments took place on average 19 years after primary tumor resective surgery. Results: One participant had a severe intellectual disability. For the rest, IQ varied from 52 to 125, with a mean score of 88.0 (SD 19.7). Twenty-eight (56%) of the participants had full-scale IQ scores in the age-average range or above. Gender, age at operation, time since operation, the presence of secondary medical complications, and treatment variables explained 46% of the variability in IQ scores, F(4,44) = 9.5, p<.001. The presence of endocrine insufficiency in combination with either epilepsy and/or hydrocephalus was associated with lowered IQ, lowered processing speed, and memory impairments. Conclusion: Patients treated for childhood MB and CNS-PNET have a lifelong risk of medical sequelae, including impaired cognitive functioning. This study adds to the literature by demonstrating the importance of following neuropsychological functioning closely, especially processing speed, learning, and memory, in survivors who have multiple secondary medical complications.
Collapse
Affiliation(s)
- Kristine Stadskleiv
- Department of Special Needs Education, University of Oslo, Oslo, Norway.,Department of Clinical Neurosciences for Children, Oslo University Hospital, Oslo, Norway
| | - Einar Stensvold
- The Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pediatric Research, Oslo University Hospital, Oslo, Norway.,Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Kjersti Stokka
- Department of Psychology, University of Oslo, Oslo, Norway
| | | | - Petter Brandal
- Department of Oncology, Oslo University Hospital, Oslo, Norway.,Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway.,Centre for Cancer Biomedicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
32
|
Kahalley LS, Douglas Ris M, Mahajan A, Fatih Okcu M, Chintagumpala M, Paulino AC, Whitehead WE, Minard CG, Stancel HH, Orobio J, Xue JJ, Warren EA, Grosshans DR. Prospective, longitudinal comparison of neurocognitive change in pediatric brain tumor patients treated with proton radiotherapy versus surgery only. Neuro Oncol 2020; 21:809-818. [PMID: 30753584 DOI: 10.1093/neuonc/noz041] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Proton radiotherapy (PRT) reduces the volume of normal tissue receiving radiation dose, which may lead to better neurocognitive outcomes. We examined change in neurocognitive scores over time in pediatric brain tumor patients treated with proton craniospinal irradiation (CSI), proton focal RT, or surgery only. METHODS Patients received annual neurocognitive evaluations for up to 6 years. We examined Full Scale IQ (FSIQ), Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index (PSI) scores. General linear mixed models examined change in scores over time by treatment group, adjusting for significant covariates. RESULTS Scores from 93 patients treated between 2012 and 2017 (22 proton CSI, 31 proton focal, and 40 surgery only) were examined. Treatment groups were similar on gender (51.6% male), age at treatment (median = 9.7 y), and length of follow-up (median = 2.9 y). The surgery only group had proportionately more gliomas (P < 0.001), and the proton CSI group had more infratentorial tumors (P = 0.001) and higher total RT dose (P = 0.004). The proton focal and surgery only groups exhibited stable neurocognitive scores over time across all indexes (all P > 0.05). In the proton CSI group, WMI, PSI, and FSIQ scores declined significantly (P = 0.036, 0.004, and 0.017, respectively), while VCI and PRI scores were stable (all P > 0.05). CONCLUSIONS Focal PRT was associated with stable neurocognitive functioning into survivorship. Outcomes were similar whether patients received focal PRT or no radiotherapy, even in neurocognitive domains known to be particularly radiosensitive. Proton CSI emerged as a neurocognitive risk factor, consistent with photon outcomes research.
Collapse
Affiliation(s)
- Lisa S Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - M Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minneosta
| | - M Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William E Whitehead
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine
| | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Heather H Stancel
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Judy J Xue
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas.,Rice University
| | - Emily A Warren
- University of Houston, Department of Psychology, Houston, Texas
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
33
|
Forsthoefel MK, Ballew E, Unger KR, Ahn PH, Rudra S, Pang D, Collins SP, Dritschilo A, Harter W, Paudel N, Collins BT, Lischalk JW. Early Experience of the First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Center. Front Oncol 2020; 10:861. [PMID: 32547953 PMCID: PMC7273355 DOI: 10.3389/fonc.2020.00861] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/30/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction: Review the early experience with a single-room gantry mounted active scanning proton therapy system. Material and Methods: All patients treated with proton beam radiotherapy (PBT) were enrolled in an institutional review board-approved patient registry. Proton beam radiotherapy was delivered with a 250 MeV gantry mounted synchrocyclotron in a single-room integrated facility within the pre-existing cancer center. Demographic data, cancer diagnoses, treatment technique, and geographic patterns were obtained for all patients. Treatment plans were evaluated for mixed modality therapy. Insurance approval data was collected for all patients treated with PBT. Results: A total of 132 patients were treated with PBT between March 2018 and June 2019. The most common oncologic subsites treated included the central nervous system (22%), gastrointestinal tract (20%), and genitourinary tract (20%). The most common histologies treated included prostate adenocarcinoma (19%), non-small cell lung cancer (10%), primary CNS gliomas (8%), and esophageal cancer (8%). Rationale for PBT treatment included limitation of dose to adjacent critical organs at risk (67%), reirradiation (19%), and patient comorbidities (11%). Patients received at least one x-ray fraction delivered as prescribed (36%) or less commonly due to unplanned machine downtime (34%). Concurrent systemic therapy was administered to 57 patients (43%). Twenty-six patients (20%) were initially denied insurance coverage and required peer-to-peers (65%), written appeals (12%), secondary insurance approval (12%), and comparison x-ray to proton plans (8%) for subsequent approval. Proton beam radiotherapy approval required a median of 17 days from insurance submission. Discussion: Incorporation of PBT into our existing cancer center allowed for multidisciplinary oncologic treatment of a diverse population of patients. Insurance coverage for PBT presents as a significant hurdle and improvements are needed to provide more timely access to necessary oncologic care.
Collapse
Affiliation(s)
- Matthew K Forsthoefel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Elizabeth Ballew
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Keith R Unger
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Peter H Ahn
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sonali Rudra
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Dalong Pang
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - William Harter
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Nitika Paudel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Jonathan W Lischalk
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| |
Collapse
|
34
|
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.
Collapse
|
35
|
Radiation Therapy for Pediatric Brain Tumors using Robotic Radiation Delivery System and Intensity Modulated Proton Therapy. Pract Radiat Oncol 2020; 10:e173-e182. [DOI: 10.1016/j.prro.2019.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/09/2019] [Accepted: 09/11/2019] [Indexed: 12/25/2022]
|
36
|
Grieco JA, Abrams AN, Evans CL, Yock TI, Pulsifer MB. A comparison study assessing neuropsychological outcome of patients with post-operative pediatric cerebellar mutism syndrome and matched controls after proton radiation therapy. Childs Nerv Syst 2020; 36:305-313. [PMID: 31325031 PMCID: PMC7067447 DOI: 10.1007/s00381-019-04299-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/02/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Post-operative pediatric cerebellar mutism syndrome (CMS), characterized by mutism, ataxia/hypotonia, and emotional lability, can result in long-term deficits following resection of posterior fossa (PF) tumors. This longitudinal study compared neuropsychological outcomes of pediatric patients with post-operative CMS to a matched control patient group without CMS. METHODS Fifty-eight PF tumor patients received post-surgical proton radiation therapy (PRT) and testing at baseline and at ≥ 1-year post-PRT over a 10-year period. Of these, 18 (31%) had post-operative CMS with baseline and follow-up neuropsychological test data. Those participants were matched to 18 controls by tumor location, age, gender, and handedness; no significant group differences were found at baseline for clinical/demographic variables. Total mean age at baseline was 7.26 years (SD = 4.42); mean follow-up interval was 3.26 years (SD = 2.24). Areas assessed: overall intelligence, expressive and receptive vocabulary, visuomotor integration, fine motor speed, inhibition, emotional control, depression, and anxiety. RESULTS Patients were 52% male; 86% medulloblastoma/14% ependymoma; 86% craniospinal irradiation/14% focal radiation; and 86% chemotherapy. No group differences were found between most mean baseline scores; expressive vocabulary and fine motor speed were significantly lower in the post-operative CMS group (p < 0.05). Mean change scores revealed no significant differences for the sample; scores were within the normal range except fine motor skills were impaired for both groups. CONCLUSIONS Longitudinal neuropsychological outcomes for post-operative pediatric CMS patients did not differ significantly from matched controls without this condition. Patients were in the normal range in all areas except fine motor speed, which was impaired for both groups independent of CMS diagnosis.
Collapse
Affiliation(s)
- Julie A. Grieco
- Department of Psychiatry, Massachusetts General Hospital,Harvard Medical School
| | - Annah N. Abrams
- Department of Psychiatry, Massachusetts General Hospital,Harvard Medical School
| | - Casey L. Evans
- Department of Psychiatry, Massachusetts General Hospital
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital,Harvard Medical School
| | | |
Collapse
|
37
|
Roth AK, Ris MD, Orobio J, Xue J, Mahajan A, Paulino AC, Grosshans D, Okcu MF, Chintagumpala M, Kahalley L. Cognitive mediators of adaptive functioning outcomes in survivors of pediatric brain tumors treated with proton radiotherapy. Pediatr Blood Cancer 2020; 67:e28064. [PMID: 31736188 PMCID: PMC7433211 DOI: 10.1002/pbc.28064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/10/2019] [Accepted: 10/12/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cranial radiotherapy (RT) is associated with risk for cognitive and adaptive dysfunction. Proton RT (PRT) is a technique hypothesized to spare cognition by reducing exposure to nontarget brain tissue. However, little is known regarding functional outcomes in survivors of pediatric brain tumor (BT) treated with PRT. The present study examined the relationship between cognitive and adaptive outcomes in pediatric BT survivors post-PRT. METHODS Survivors treated with either focal (n = 33) or craniospinal irradiation (CSI; n = 37) PRT completed neurocognitive evaluations approximately 5 years post-treatment. Results of intelligence testing and ratings of adaptive functioning are reported. Mediation models examined the relationship among radiation field, cognition, and adaptive functioning. RESULTS The PRT CSI group demonstrated worse cognitive outcomes than the PRT Focal group across each cognitive index (Cohen's d = 0.56-0.70). Parent ratings of adaptive functioning were also worse in the PRT CSI group than the PRT Focal group (Global Adaptive Composite, d = 0.53; conceptual skills, d = 0.67). Cognitive performance fully mediated the relationship between radiation field and adaptive outcomes, while controlling for group differences in tumor histology and RT dose. CONCLUSIONS Focal PRT survivors demonstrated generally positive outcomes with weaknesses in processing speed and aspects of adaptive functioning. CSI exposure was associated with more consistently poor cognitive and adaptive outcomes. The increased risk for adaptive dysfunction in the PRT CSI group appeared due to the effects of CSI on cognition. Efforts to reduce the volume of tissue exposure to RT remain important.
Collapse
Affiliation(s)
- Alexandra K. Roth
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Judy Xue
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | | | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - David Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Lisa Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| |
Collapse
|
38
|
Vogel J, Grewal A, O’Reilly S, Lustig R, Kurtz G, Minturn JE, Shah AC, Waanders AJ, Belasco JB, Cole KA, Fisher MJ, Phillips PC, Balamuth NJ, Storm PB, Hill-Kayser CE. Risk of brainstem necrosis in pediatric patients with central nervous system malignancies after pencil beam scanning proton therapy. Acta Oncol 2019; 58:1752-1756. [PMID: 31512931 DOI: 10.1080/0284186x.2019.1659996] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background: Radiation therapy (RT) plays an important role in management of pediatric central nervous system (CNS) malignancies. Centers are increasingly utilizing pencil beam scanning proton therapy (PBS-PT). However, the risk of brainstem necrosis has not yet been reported. In this study, we evaluate the rate of brainstem necrosis in pediatric patients with CNS malignancies treated with PBS-PT.Material and methods: Pediatric patients with non-hematologic CNS malignancies treated with PBS-PT who received dose to the brainstem were included. All procedures were approved by the institutional review board. Brainstem necrosis was defined as symptomatic toxicity. The actuarial rate was analyzed by the Kaplan Meier method.Results: One hundred and sixty-six consecutive patients were reviewed. Median age was 10 years (range 0.5-21 years). Four patients (2.4%) had prior radiation. Median maximum brainstem dose in the treated course was 55.4 Gy[RBE] (range 0.15-61.4 Gy[RBE]). In patients with prior RT, cumulative median maximum brainstem dose was 98.0 Gy [RBE] (range 17.0-111.0 Gy [RBE]). Median follow up was 19.6 months (range, 2.0-63.0). One patient who had previously been treated with twice-daily radiation therapy and intrathecal (IT) methotrexate experienced brainstem necrosis. The actuarial incidence of brainstem necrosis was 0.7% at 24 months (95% CI 0.1-5.1%).Conclusion: The rate of symptomatic brainstem necrosis was extremely low after treatment with PBS-PT in this study. Further work to clarify clinical and dosimetric parameters associated with risk of brainstem necrosis after PBS-PT is needed.
Collapse
Affiliation(s)
- J. Vogel
- Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - A. Grewal
- Radiation Oncology, The Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - S. O’Reilly
- Radiation Oncology, The Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - R. Lustig
- Radiation Oncology, The Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - G. Kurtz
- Radiation Oncology, The Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - J. E. Minturn
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - A. C. Shah
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - A. J. Waanders
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - J. B. Belasco
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - K. A. Cole
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - M. J. Fisher
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - P. C. Phillips
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - N. J. Balamuth
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - P. B. Storm
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - C. E. Hill-Kayser
- Radiation Oncology, The Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
39
|
Kahalley LS, Peterson R, Ris MD, Janzen L, Okcu MF, Grosshans DR, Ramaswamy V, Paulino AC, Hodgson D, Mahajan A, Tsang DS, Laperriere N, Whitehead WE, Dauser RC, Taylor MD, Conklin HM, Chintagumpala M, Bouffet E, Mabbott D. Superior Intellectual Outcomes After Proton Radiotherapy Compared With Photon Radiotherapy for Pediatric Medulloblastoma. J Clin Oncol 2019; 38:454-461. [PMID: 31774710 DOI: 10.1200/jco.19.01706] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Proton radiotherapy (PRT) may lessen the neuropsychological risk traditionally associated with cranial radiotherapy for the treatment of pediatric brain tumors by reducing the dose to normal tissue compared with that of photon radiotherapy (XRT). We examined the change in intellectual scores over time in patients with pediatric medulloblastoma treated with craniospinal PRT versus XRT. METHODS Intelligence test scores were obtained for a sample of pediatric patients treated between 2007 and 2018 on the same medulloblastoma protocols that differed only in radiotherapy modality (PRT v XRT). Growth curve analyses compared change in scores over time since diagnosis between groups. RESULTS Longitudinal intelligence data from 79 patients (37 PRT, 42 XRT) were examined. Groups were similar on most demographic/clinical variables, including sex (67.1% male), age at diagnosis (mean, 8.6 years), craniospinal irradiation dose (median, 23.4 Gy), length of follow-up (mean, 4.3 years), and parental education (mean, 14.3 years). Boost dose (P < .001) and boost margin (P = .001) differed between groups. Adjusting for covariates, the PRT group exhibited superior long-term outcomes in global intelligence quotient (IQ), perceptual reasoning, and working memory compared with the XRT group (all P < .05). The XRT group exhibited a significant decline in global IQ, working memory, and processing speed (all P < .05). The PRT group exhibited stable scores over time in all domains with the exception of processing speed (P = .003). CONCLUSION To our knowledge, this is the first study to compare intellectual trajectories between pediatric patients treated for medulloblastoma with PRT versus those treated with XRT on comparable, contemporary protocols. PRT was associated with more favorable intellectual outcomes in most domains compared with XRT, although processing speed emerged as a vulnerable domain for both groups. This study provides the strongest evidence to date of an intellectual sparing advantage with PRT in the treatment of pediatric medulloblastoma.
Collapse
Affiliation(s)
- Lisa S Kahalley
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | | | - M Douglas Ris
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Laura Janzen
- The Hospital for Sick Children, Toronto, ON, Canada
| | - M Fatih Okcu
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | | | - Vijay Ramaswamy
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | | | - David Hodgson
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Derek S Tsang
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - William E Whitehead
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Robert C Dauser
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Michael D Taylor
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | | | | | - Eric Bouffet
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | - Donald Mabbott
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| |
Collapse
|
40
|
Tensaouti F, Ducassou A, Chaltiel L, Bolle S, Habrand JL, Alapetite C, Coche-Dequeant B, Bernier V, Claude L, Carrie C, Padovani L, Muracciole X, Supiot S, Huchet A, Leseur J, Kerr C, Hangard G, Lisbona A, Goudjil F, Ferrand R, Laprie A. Feasibility of Dose Escalation in Patients With Intracranial Pediatric Ependymoma. Front Oncol 2019; 9:531. [PMID: 31293971 PMCID: PMC6598548 DOI: 10.3389/fonc.2019.00531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/31/2019] [Indexed: 12/25/2022] Open
Abstract
Background and purpose: Pediatric ependymoma carries a dismal prognosis, mainly owing to local relapse within RT fields. The current prospective European approach is to increase the radiation dose with a sequential hypofractionated stereotactic boost. In this study, we assessed the possibility of using a simultaneous integrated boost (SIB), comparing VMAT vs. IMPT dose delivery. Material and methods: The cohort included 101 patients. The dose to planning target volume (PTV59.4) was 59.4/1.8 Gy, and the dose to SIB volume (PTV67.6) was 67.6/2.05 Gy. Gross tumor volume (GTV) was defined as the tumor bed plus residual tumor, clinical target volume (CTV59.4) was GTV + 5 mm, and PTV59.4 was CTV59.4 + 3 mm. PTV67.6 was GTV+ 3 mm. After treatment plan optimization, quality indices and doses to target volume and organs at risk (OARs) were extracted and compared with the standard radiation doses that were actually delivered (median = 59.4 Gy [50.4 59.4]). Results: In most cases, the proton treatment resulted in higher quality indices (p < 0.001). Compared with the doses that were initially delivered, mean, and maximum doses to some OARs were no higher with SIB VMAT, and significantly lower with protons (p < 0.001). In the case of posterior fossa tumor, there was a lower dose to the brainstem with protons, in terms of V59 Gy, mean, and near-maximum (D2%) doses. Conclusion: Dose escalation with intensity-modulated proton or photon SIB is feasible in some patients. This approach could be considered for children with unresectable residue or post-operative FLAIR abnormalities, particularly if they have supratentorial tumors. It should not be considered for infratentorial tumors encasing the brainstem or extending to the medulla.
Collapse
Affiliation(s)
- Fatima Tensaouti
- ToNIC, Toulouse NeuroImaging Center, Universite de Toulouse, Inserm, Toulouse, France
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du, Cancer de Toulouse-Oncopole, Toulouse, France
- *Correspondence: Fatima Tensaouti ;
| | - Anne Ducassou
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du, Cancer de Toulouse-Oncopole, Toulouse, France
| | - Léonor Chaltiel
- Department of Biostatistics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Stéphanie Bolle
- Department of Radiotherapy Oncology, Institut Gustave Roussy, Villejuif, France
| | - Jean Louis Habrand
- Department of Radiation Oncology, Centre Francois Baclesse, Caen, France
| | | | | | - Valérie Bernier
- Department of Radiation Oncology, Centre Alexis Vautrin, Vandœuvre-lès-Nancy, France
| | - Line Claude
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Christian Carrie
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | | | | | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancerologie de l'Ouest, Nantes, France
| | - Aymeri Huchet
- Department of Radiation Oncology, Centre Hospitalier et Universitaire, Bordeaux, France
| | - Julie Leseur
- Department of Radiation Oncology, Centre Eugéne Marquis, Rennes, France
| | - Christine Kerr
- Department of Radiation Oncology, Institut Regional du Cancer Montpellier, Val d'Aurelle, Montpellier, France
| | - Grégorie Hangard
- Department of Engineering and Medical Physics, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Albert Lisbona
- Department of Radiation Oncology, Institut de Cancerologie de l'Ouest, Nantes, France
| | - Farid Goudjil
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Régis Ferrand
- Department of Engineering and Medical Physics, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Anne Laprie
- ToNIC, Toulouse NeuroImaging Center, Universite de Toulouse, Inserm, Toulouse, France
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du, Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| |
Collapse
|
41
|
Lawell MP, Bajaj BV, Gallotto SL, Hess CB, Patteson BE, Nartowicz JA, Giblin MJ, Kleinerman RA, Berrington de Gonzalez A, Ebb DH, Tarbell NJ, MacDonald SM, Weyman EA, Yock TI. Increased distance from a treating proton center is associated with diminished ability to follow patients enrolled on a multicenter radiation oncology registry. Radiother Oncol 2019; 134:25-29. [DOI: 10.1016/j.radonc.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 12/10/2018] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
|
42
|
Are further studies needed to justify the use of proton therapy for paediatric cancers of the central nervous system? A review of current evidence. Radiother Oncol 2019; 133:140-148. [DOI: 10.1016/j.radonc.2019.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/31/2018] [Accepted: 01/09/2019] [Indexed: 11/21/2022]
|
43
|
Haas-Kogan D, Indelicato D, Paganetti H, Esiashvili N, Mahajan A, Yock T, Flampouri S, MacDonald S, Fouladi M, Stephen K, Kalapurakal J, Terezakis S, Kooy H, Grosshans D, Makrigiorgos M, Mishra K, Poussaint TY, Cohen K, Fitzgerald T, Gondi V, Liu A, Michalski J, Mirkovic D, Mohan R, Perkins S, Wong K, Vikram B, Buchsbaum J, Kun L. National Cancer Institute Workshop on Proton Therapy for Children: Considerations Regarding Brainstem Injury. Int J Radiat Oncol Biol Phys 2019; 101:152-168. [PMID: 29619963 DOI: 10.1016/j.ijrobp.2018.01.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/21/2017] [Accepted: 01/01/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Proton therapy can allow for superior avoidance of normal tissues. A widespread consensus has been reached that proton therapy should be used for patients with curable pediatric brain tumor to avoid critical central nervous system structures. Brainstem necrosis is a potentially devastating, but rare, complication of radiation. Recent reports of brainstem necrosis after proton therapy have raised concerns over the potential biological differences among radiation modalities. We have summarized findings from the National Cancer Institute Workshop on Proton Therapy for Children convened in May 2016 to examine brainstem injury. METHODS AND MATERIALS Twenty-seven physicians, physicists, and researchers from 17 institutions with expertise met to discuss this issue. The definition of brainstem injury, imaging of this entity, clinical experience with photons and photons, and potential biological differences among these radiation modalities were thoroughly discussed and reviewed. The 3 largest US pediatric proton therapy centers collectively summarized the incidence of symptomatic brainstem injury and physics details (planning, dosimetry, delivery) for 671 children with focal posterior fossa tumors treated with protons from 2006 to 2016. RESULTS The average rate of symptomatic brainstem toxicity from the 3 largest US pediatric proton centers was 2.38%. The actuarial rate of grade ≥2 brainstem toxicity was successfully reduced from 12.7% to 0% at 1 center after adopting modified radiation guidelines. Guidelines for treatment planning and current consensus brainstem constraints for proton therapy are presented. The current knowledge regarding linear energy transfer (LET) and its relationship to relative biological effectiveness (RBE) are defined. We review the current state of LET-based planning. CONCLUSIONS Brainstem injury is a rare complication of radiation therapy for both photons and protons. Substantial dosimetric data have been collected for brainstem injury after proton therapy, and established guidelines to allow for safe delivery of proton radiation have been defined. Increased capability exists to incorporate LET optimization; however, further research is needed to fully explore the capabilities of LET- and RBE-based planning.
Collapse
Affiliation(s)
- Daphne Haas-Kogan
- Department of Radiation Oncology, Harvard Medical School and Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Daniel Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Harald Paganetti
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Anita Mahajan
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Torunn Yock
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Shannon MacDonald
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Maryam Fouladi
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kry Stephen
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John Kalapurakal
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stephanie Terezakis
- Department of Radiation Oncology, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Hanne Kooy
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - David Grosshans
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mike Makrigiorgos
- Department of Radiation Oncology, Harvard Medical School and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kavita Mishra
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Tina Young Poussaint
- Department of Radiology, Harvard Medical School and Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth Cohen
- Department of Pediatrics, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Thomas Fitzgerald
- Department of Radiation Oncology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Vinai Gondi
- Northwestern Medicine Chicago Proton Center, Chicago, Illinois
| | - Arthur Liu
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Dragan Mirkovic
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Radhe Mohan
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Kenneth Wong
- Children's Hospital of Angeles and University of Southern California Keck School of Medicine, Los Angles, California
| | - Bhadrasain Vikram
- Radiation Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Jeff Buchsbaum
- Radiation Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Larry Kun
- Department of Radiation Oncology, University of Texas Southwestern Medical School, Dallas, Texas.
| |
Collapse
|
44
|
Patterns of proton therapy use in pediatric cancer management in 2016: An international survey. Radiother Oncol 2019; 132:155-161. [DOI: 10.1016/j.radonc.2018.10.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/10/2018] [Accepted: 10/22/2018] [Indexed: 01/19/2023]
|
45
|
Tsoutsou P, Montay-Gruel P, Vozenin MC. The Era of Modern Radiation Therapy: Innovations to Spare Normal Tissues. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_70-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
|
46
|
Hu M, Jiang L, Cui X, Zhang J, Yu J. Proton beam therapy for cancer in the era of precision medicine. J Hematol Oncol 2018; 11:136. [PMID: 30541578 PMCID: PMC6290507 DOI: 10.1186/s13045-018-0683-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/28/2018] [Indexed: 02/06/2023] Open
Abstract
Precision radiotherapy, which accurately delivers the dose on a tumor and confers little or no irradiation to the surrounding normal tissue and organs, results in maximum tumor control and decreases the toxicity to the utmost extent. Proton beam therapy (PBT) provides superior dose distributions and has a dosimetric advantage over photon beam therapy. Initially, the clinical practice and study of proton beam therapy focused on ocular tumor, skull base, paraspinal tumors (chondrosarcoma and chordoma), and unresectable sarcomas, which responded poorly when treated with photon radiotherapy. Then, it is widely regarded as an ideal mode for reirradiation and pediatrics due to reducing unwanted side effects by lessening the dose to normal tissue. During the past decade, the application of PBT has been rapidly increasing worldwide and gradually expanding for the treatment of various malignancies. However, to date, the role of PBT in clinical settings is still controversial, and there are considerable challenges in its application. We systematically review the latest advances of PBT and the challenges for patient treatment in the era of precision medicine.
Collapse
Affiliation(s)
- Man Hu
- Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
- Shandong Academy of Medical Sciences, Jinan, China
- Departments of Radiation Oncology and Shandong Province Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, China
| | - Liyang Jiang
- Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
- Shandong Academy of Medical Sciences, Jinan, China
- Departments of Radiation Oncology and Shandong Province Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, China
| | - Xiangli Cui
- Province Key Laboratory of Medical Physics and Technology, Center of Medical Physics and Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, Anhui, China
| | - Jianguang Zhang
- Departments of Radiation Oncology, Zibo Wanjie Cancer Hospital, Zibo, Shandong, China
| | - Jinming Yu
- Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China.
- Shandong Academy of Medical Sciences, Jinan, China.
- Departments of Radiation Oncology and Shandong Province Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, China.
| |
Collapse
|
47
|
Huynh M, Marcu LG, Giles E, Short M, Matthews D, Bezak E. Current status of proton therapy outcome for paediatric cancers of the central nervous system - Analysis of the published literature. Cancer Treat Rev 2018; 70:272-288. [PMID: 30326423 DOI: 10.1016/j.ctrv.2018.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/05/2018] [Accepted: 10/06/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The most common solid tumours that develop in children are cancers of the central nervous system. Due to the increased rate of survival over the past decades, greater focus has been placed on the minimisation of long term side effects. In childhood cancer survivors, over 60% report one or more radiation-related late toxicities while half of these adverse events are graded as life-threatening or severe. Proton therapy enables high conformity with the planning target volume and a reduction in dose to areas beyond the target. Owing to the unique nature of dose delivery with proton therapy a reduction of low doses to normal tissues is achievable, and is believed to allow for a decrease in long-term treatment-related side effects. This paper aims to review the published literature around the effectiveness of proton therapy for the treatment of paediatric cancers of the central nervous system, with a focus on treatment outcomes and treatment-related toxicities. METHODS A search strategy utilising the Medline database was created with the intent of including all articles reporting on proton therapy, paediatric cancers, CNS tumours and treatment outcomes. The final search strategy included the following limitations: limited to humans, English, published from 2000 onwards. The final article count total was 74. RESULTS AND CONCLUSIONS Proton therapy for the treatment of paediatric cancers of the central nervous system was found to provide survival and tumour control outcomes comparable to photon therapy. Reduced incidence of severe acute and late toxicities was also reported with the use of proton therapy. This includes reduced severity of endocrine, neurological, IQ and QoL deficits. Currently, extensive follow-up of proton patient populations still needs to be made to determine incidences of late-onset toxicities and secondary malignancies. Current evidence surrounding proton therapy use in paediatric patients supports its effectiveness and potential benefits in reducing the incidence of severe toxicities in later life.
Collapse
Affiliation(s)
- Myxuan Huynh
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Loredana Gabriela Marcu
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia; Faculty of Science, University of Oradea, Oradea 410087, Romania
| | - Eileen Giles
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Michala Short
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Donna Matthews
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia; School of Physical Sciences, University of Adelaide, North Terrace, Adelaide, South Australia 5005, Australia.
| |
Collapse
|
48
|
Peterson RK, Ashford JM, Scott SM, Wang F, Zhang H, Bradley JA, Merchant TE, Conklin HM. Predicting parental distress among children newly diagnosed with craniopharyngioma. Pediatr Blood Cancer 2018; 65:e27287. [PMID: 29932288 PMCID: PMC6107393 DOI: 10.1002/pbc.27287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Childhood brain tumor diagnoses are stressful for families. Children diagnosed with craniopharyngioma (Cp) present with particularly challenging medical and cognitive problems due to tumor location and associated biophysiologic comorbidities. This study examined parental distress in a sample of families of patients with Cp treated with proton beam therapy to identify factors for targeting psychological intervention. PROCEDURE Prior to (n = 96) and 1 year after (n = 73) proton therapy, parents of children diagnosed with Cp (9.81 ± 4.42 years at baseline; 49% male) completed a self-report measure of distress, the Brief Symptom Inventory (BSI). Children completed cognitive assessment measures at baseline; medical variables were extracted from the study database. RESULTS At baseline, t-tests revealed parents reported higher levels of distress than normative expectations on Anxiety, Depression, Global Severity, and Positive Symptom Distress BSI scales (P < 0.05). Linear mixed effects models revealed parent report measures of child executive dysfunction and behavioral issues were more predictive of parental distress than patients' cognitive performance or medical status (P < 0.05). Models also revealed a significant reduction only in Anxiety over time (t = -2.19, P < 0.05). Extensive hypothalamic involvement at baseline predicted this reduction (P < 0.05). CONCLUSION Parents experience significant distress before their child begins adjuvant therapy for Cp, though parental distress appears largely unrelated to medical complications and more related to parent perceptions of child cognitive difficulties (vs. child performance). Importantly, this may be explained by a negative parent reporting style among distressed parents. Knowledge of socio-emotional functioning in parents related to patient characteristics is important for optimization of psychological intervention.
Collapse
Affiliation(s)
- Rachel K. Peterson
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jason M. Ashford
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Sarah M. Scott
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Fang Wang
- Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Hui Zhang
- Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Julie A. Bradley
- University of Florida Health Proton Therapy Institute, 2015 North Jefferson Street, Jacksonville, FL 32206
| | - Thomas E. Merchant
- Department of Radiation Oncology, St. Jude Children’s Research Hospital Memphis, TN
| | - Heather M. Conklin
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN
| |
Collapse
|
49
|
Peterson RK, Katzenstein JM. Working memory and processing speed among pediatric brain tumor patients treated with photon or proton beam radiation therapy. CHILDRENS HEALTH CARE 2018. [DOI: 10.1080/02739615.2018.1510330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Rachel K. Peterson
- Psychology Department, The Hospital for Sick Children, Toronto, ON, Canada
| | | |
Collapse
|
50
|
Breneman JC, Donaldson SS, Constine L, Merchant T, Marcus K, Paulino AC, Followill D, Mahajan A, Laack N, Esiashvili N, Haas-Kogan D, Laurie F, Olch A, Ulin K, Hodgson D, Yock TI, Terezakis S, Krasin M, Panoff J, Chuba P, Hua CH, Hess CB, Houghton PJ, Wolden S, Buchsbaum J, Fitzgerald TJ, Kalapurakal JA. The Children's Oncology Group Radiation Oncology Discipline: 15 Years of Contributions to the Treatment of Childhood Cancer. Int J Radiat Oncol Biol Phys 2018; 101:860-874. [PMID: 29976498 PMCID: PMC6548440 DOI: 10.1016/j.ijrobp.2018.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/31/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE Our aim was to review the advances in radiation therapy for the management of pediatric cancers made by the Children's Oncology Group (COG) radiation oncology discipline since its inception in 2000. METHODS AND MATERIALS The various radiation oncology disease site leaders reviewed the contributions and advances in pediatric oncology made through the work of the COG. They have presented outcomes of relevant studies and summarized current treatment policies developed by consensus from experts in the field. RESULTS The indications and techniques for pediatric radiation therapy have evolved considerably over the years for virtually all pediatric tumor types, resulting in improved cure rates together with the potential for decreased treatment-related morbidity and mortality. CONCLUSIONS The COG radiation oncology discipline has made significant contributions toward the treatment of childhood cancer. Our discipline is committed to continuing research to refine and modernize the use of radiation therapy in current and future protocols with the goal of further improving the cure rates and quality of life of children with cancer.
Collapse
Affiliation(s)
- John C Breneman
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio.
| | - Sarah S Donaldson
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Louis Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Thomas Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Karen Marcus
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Followill
- Imaging and Radiation Oncology Core (IROC) Houston Quality Assurance Center, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Nadia Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Natia Esiashvili
- Radiation Oncology Department, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Daphne Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fran Laurie
- Imaging and Radiation Oncology Core (IROC) Rhode Island, Lincoln, Rhode Island
| | - Arthur Olch
- Radiation Oncology Program, Keck School of Medicine, University of Southern California, Los Angeles, California; Children's Hospital Los Angeles, Los Angeles, California
| | - Kenneth Ulin
- Imaging and Radiation Oncology Core (IROC) Rhode Island, Lincoln, Rhode Island; University of Massachusetts, Boston, Massachusetts
| | - David Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
| | - Torunn I Yock
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephanie Terezakis
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland
| | - Matt Krasin
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Paul Chuba
- Department of Radiation Oncology, St John Hospital and Medical Center, Detroit, Michigan
| | - Chia-Ho Hua
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Clayton B Hess
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter J Houghton
- Greehey Children's Cancer Research Institute, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, New York
| | | | - Thomas J Fitzgerald
- Imaging and Radiation Oncology Core (IROC) Rhode Island, Lincoln, Rhode Island
| | - John A Kalapurakal
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|