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Nanda RH, Hua CH, Flampouri S, Eaton B, Kaste S, Patni T, Ronckers C, Constine LS, Marks LB, Esiashvili N. Risks of Spinal Abnormalities and Growth Impairment After Radiation to the Spine in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:507-521. [PMID: 38069918 DOI: 10.1016/j.ijrobp.2023.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/03/2023] [Accepted: 10/22/2023] [Indexed: 05/19/2024]
Abstract
PURPOSE A PENTEC (Pediatric Normal Tissue Effects in the Clinic) review was performed to estimate the dose-volume effects of radiation therapy on spine deformities and growth impairment for patients who underwent radiation therapy as children. METHODS AND MATERIALS A systematic literature search was performed to identify published data for spine deformities and growth stunting. Data were extracted from 12 reports of children irradiated to the spine (N = 603 patients). The extracted data were analyzed to find associations between complication risks and the radiation dose (conventional fractionation throughout) as impacted by exposed volumes and age using the mixed-effects logistic regression model. When appropriate, corrections were made for radiation modality, namely orthovoltage beams. RESULTS In the regression analysis, the association between vertebral dose and scoliosis rate was highly significant (P < .001). Additionally, young age at time of radiation was highly predictive of adverse outcomes. Clinically significant scoliosis can occur with doses ≥15 Gy to vertebrae during infancy (<2 years of age). For children irradiated at 2 to 6 years of age, overall scoliosis rates of any grade were >30% with doses >20 Gy; grade 2 or higher scoliosis was correlated with doses ≥30 Gy. Children >6 years of age remain at risk for scoliosis with doses >30 Gy; however, most cases will be mild. There are limited data regarding the effect of dose gradients across the spine on degree of scoliosis. The risk of clinically meaningful height loss was minimal when irradiating small volumes of the spine up to 20 Gy (eg, flank irradiation), except in infants who are more vulnerable to lower doses. Growth stunting was more frequent when larger segments of the spine (eg, the entire spine or craniospinal irradiation) were irradiated before puberty to doses >20 Gy. The effect was modest when patients were irradiated after puberty to doses >20 Gy. CONCLUSIONS To reduce the risk of kyphoscoliosis and growth impairment, the dose to the spine should be kept to <20 Gy for children <6 years of age and to <10 to 15 Gy in infants. The number of vertebral bodies irradiated and dose gradients across the spine should also be limited when possible.
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Affiliation(s)
- Ronica H Nanda
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida.
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sue Kaste
- Departments of Diagnostic Imaging and Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tushar Patni
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Cecile Ronckers
- Division of Childhood Cancer Epidemiology / German Childhood Cancer Registry, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medicin at the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Lawrence B Marks
- Department of Radiation Oncology, Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Turcas A, Kelly SM, Bernier-Chastagner V, Bolle S, Cameron A, Corning C, Clementel E, Dieckmann K, Davila Fajardo R, Gaze MN, Laprie A, Magelssen H, Meroni S, Pignoli E, Safwat A, Scarzello G, Talbot J, Timmermann B, Boterberg T, Mandeville HC. Management of the vertebrae as an organ at risk in paediatric radiotherapy clinical trials: Initial QUARTET experience. Radiother Oncol 2023; 187:109810. [PMID: 37468069 DOI: 10.1016/j.radonc.2023.109810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/04/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
Irradiation of the vertebrae in prepubertal patients, if non-homogenous, can result in future growth deformities including kyphoscoliosis. Vertebral delineation and dosimetry were assessed for 101 paediatric cases reviewed within QUARTET-affiliated trials. Despite the availability of published consensus guidelines, a high variability in vertebral delineation was observed, with impact on dosimetry.
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Affiliation(s)
- Andrada Turcas
- The European Society for Paediatric Oncology (SIOP Europe), Brussels, Belgium; The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium; Oncology Department, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca, Romania; Radiotherapy Department, Oncology Institute "Prof. Dr. Ion Chiricuta" Cluj-Napoca, Romania.
| | - Sarah M Kelly
- The European Society for Paediatric Oncology (SIOP Europe), Brussels, Belgium; The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | | | - Stephanie Bolle
- Department of Radiation Oncology, Gustave Roussy, Paris Saclay University, Villejuif, France
| | - Alison Cameron
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Coreen Corning
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Enrico Clementel
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Karin Dieckmann
- Children's Cancer Research Institute, St Anna Kinderkrebsforschung, Medical University of Vienna, Vienna, Austria; Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Raquel Davila Fajardo
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Anne Laprie
- Radiation Oncology Department, Institut Claudius Regaud- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | | | - Silvia Meroni
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Akmal Safwat
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Giovanni Scarzello
- Radiation Therapy Department, Veneto Institute of Oncology IRCCS, Padua, Italy
| | - James Talbot
- The Royal Marsden Hospital and Institute of Cancer Research, Sutton, UK
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Germany
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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Chung C, Boterberg T, Lucas J, Panoff J, Valteau-Couanet D, Hero B, Bagatell R, Hill-Kayser CE. Neuroblastoma. Pediatr Blood Cancer 2021; 68 Suppl 2:e28473. [PMID: 33818884 PMCID: PMC8785544 DOI: 10.1002/pbc.28473] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 01/01/2023]
Abstract
The survival of patients with high-risk neuroblastoma has improved significantly with the use of intensive multimodality treatment regimens, including chemotherapy, surgery, radiation therapy, myeloablative chemotherapy followed by stem cell rescue, and immunotherapy. This report summarizes the current treatment strategies used in the COG and SIOP for children with neuroblastoma. The improved global collaboration and the adoption of a uniform International Neuroblastoma Risk Group Staging System will help facilitate comparison of homogeneous pretreatment cohorts across clinical trials. Future research strategies regarding the indications for and dosages of radiation therapy to the primary and metastatic sites, and the integration of meta-iodobenzyl guanidine therapy into the multimodal treatment program, are discussed.
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Affiliation(s)
- Christine Chung
- Department of Radiation Oncology, Diablo Valley Oncology and Hematology, Pleasant Hill, California
| | - Tom Boterberg
- Department of Radiation Oncology Ghent University Hospital, Gent, Belgium
| | - John Lucas
- Department of Radiation Oncology St Jude Children's Research Hospital, Memphis, Tennessee
| | - Joseph Panoff
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, South Florida, Florida
| | - Dominique Valteau-Couanet
- Department of Childhood and Adolescent Cancer Gustave Roussy Cancer Campus, Villejuif-Grand, Paris, France
| | - Barbara Hero
- Department of Pediatric Hematology and Oncology, University Children's Hospital, Cologne, Germany
| | - Rochelle Bagatell
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christine E Hill-Kayser
- Department of Radiation Oncology University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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An Analysis of Vertebral Body Growth after Proton Beam Therapy for Pediatric Cancer. Cancers (Basel) 2021; 13:cancers13020349. [PMID: 33477867 PMCID: PMC7832908 DOI: 10.3390/cancers13020349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Radiotherapy has a key role in treatment of pediatric cancer and has greatly improved survival in recent years. However, vertebrae are often included in the irradiated area, and this may affect growth after treatment. In this study, we examined the relationship of the dose of proton beam therapy with subsequent growth of 353 vertebral bodies in 23 children (10 boys, 13 girls) with a median age at treatment of 4 years old and a median observation period of 13.9 months. Most importantly, we found that the growth rate of vertebral bodies decreased even at a low proton beam therapy dose, which indicates the need for careful planning of the irradiation area in this patient population. Growth inhibition was clearly dose-dependent, and proton beam therapy had the same growth inhibitory effect as photon radiotherapy, at least within the irradiated field. Abstract Impairment of bone growth after radiotherapy for pediatric bone cancer is a well-known adverse event. However, there is limited understanding of the relationship between bone growth and irradiation dose. In this study, we retrospectively analyzed bone growth impairment after proton beam therapy for pediatric cancer. A total of 353 vertebral bodies in 23 patients under 12 years old who received proton beam therapy were evaluated. Compared to the non-irradiated vertebral body growth rate, the irradiated vertebral body rate (%/year) was significantly lower: 77.2%, 57.6%, 40.8%, 26.4%, and 14.1% at 10, 20, 30, 40, and 50 Gy (RBE) irradiation, respectively. In multivariate analysis, radiation dose was the only factor correlated with vertebral body growth. Age, gender, and vertebral body site were not significant factors. These results suggest that the growth rate of the vertebral body is dose-dependent and decreases even at a low irradiated dose. This is the first report to show that proton beam therapy has the same growth inhibitory effect as photon radiotherapy within the irradiated field.
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Zhao Q, Liu Y, Zhang Y, Meng L, Wei J, Wang B, Wang H, Xin Y, Dong L, Jiang X. Role and toxicity of radiation therapy in neuroblastoma patients: A literature review. Crit Rev Oncol Hematol 2020; 149:102924. [PMID: 32172225 DOI: 10.1016/j.critrevonc.2020.102924] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/13/2020] [Accepted: 03/02/2020] [Indexed: 11/16/2022] Open
Abstract
Neuroblastoma is the most common extracranial solid tumor, arising from primitive sympathetic ganglion cells, in pediatric patients. The unique features of neuroblastoma include variable clinical behaviors, such as rapid progression to death and maturation to benign ganglioneuroma, followed by regression. Radiation therapy (RT) is usually administered to both the primary tumor bed and persistent metastatic sites after induction chemotherapy for high-risk neuroblastoma. RT to the tumor bed after surgical resection contributes significantly to local disease control and prevention of local relapse, confirming the role of RT. Palliative radiotherapy for metastatic neuroblastoma is also effective and safe and mainly provides symptomatic relief. The late side effects of RT in neuroblastoma patients include growth and developmental failure, hypothyroidism, gastrointestinal dysfunction, neurocognitive defects, pulmonary and cardiac abnormalities, infertility, and secondary cancers. In this article, we reviewed the role and toxicity of RT in neuroblastoma patients.
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Affiliation(s)
- Qin Zhao
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Yang Liu
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Yuyu Zhang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Lingbin Meng
- Department of Internal Medicine, Florida Hospital, Orlando, FL, 32803, USA.
| | - Jinlong Wei
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Bin Wang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Huanhuan Wang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Ying Xin
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun, 130021, China.
| | - Lihua Dong
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Xin Jiang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
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Hoeben BA, Carrie C, Timmermann B, Mandeville HC, Gandola L, Dieckmann K, Ramos Albiac M, Magelssen H, Lassen-Ramshad Y, Ondrová B, Ajithkumar T, Alapetite C, Balgobind BV, Bolle S, Cameron AL, Davila Fajardo R, Dietzsch S, Dumont Lecomte D, van den Heuvel-Eibrink MM, Kortmann RD, Laprie A, Melchior P, Padovani L, Rombi B, Scarzello G, Schwarz R, Seiersen K, Seravalli E, Thorp N, Whitfield GA, Boterberg T, Janssens GO. Management of vertebral radiotherapy dose in paediatric patients with cancer: consensus recommendations from the SIOPE radiotherapy working group. Lancet Oncol 2019; 20:e155-e166. [DOI: 10.1016/s1470-2045(19)30034-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/30/2018] [Accepted: 01/02/2019] [Indexed: 12/15/2022]
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Late vertebral side effects in long-term survivors of irradiated childhood brain tumor. PLoS One 2018; 13:e0209193. [PMID: 30562369 PMCID: PMC6298650 DOI: 10.1371/journal.pone.0209193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/01/2018] [Indexed: 12/11/2022] Open
Abstract
Purpose Long-term side effects of the treatments are common in survivors of irradiated pediatric brain tumors. Ionizing radiation in combination with surgery and chemotherapy during childhood may reduce vertebral height and bone mineral density (BMD), and cause growth failure. The aim of this study was to evaluate the late consequences of tumor treatments on vertebrae in survivors of childhood brain tumors. Methods 72 adult survivors (mean age 27.8 years, standard deviation 6.7) of irradiated childhood brain tumor were studied by spinal magnetic resonance imaging (MRI) for vertebral abnormalities from the national cohort of Finland. Patients were treated in five university hospitals in Finland between the years 1970 and 2008. Subject height and weight were measured and body mass index (BMI) was calculated. The morphology and height/depth ratio of the vertebrae in the middle of the kyphotic thoracic curvature (Th8) and lumbar lordosis (L3) were examined. Vertebrae were analyzed by Genant’s semiquantative (SQ) method and spinal deformity index (SDI) was calculated. BMD was measured by using dual X-ray absorptiometry. Results 4.2% (3/72) of the patients had undiagnosed asymptomatic vertebral fracture and 5.6% (4/72) of patients had radiation-induced decreased vertebral body height. Male patients had flatter vertebrae compared with females. Patient age at the time of irradiation, BMI and irradiation area correlated to vertebral morphology differentially in males and females. BMD had no association with the vertebral shape. Patients who had received craniospinal irradiation were shorter than the general population. Conclusion Childhood brain tumor survivors had a high number of vertebral abnormalities in young adulthood. Irradiation was associated with abnormal vertebral morphology and compromised final height. Male gender may predispose vertebrae to the side effects of irradiation.
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Rao AD, Ladra M, Dunn E, Kumar R, Rao SS, Sehgal S, Dorafshar AH, Morris CD, Terezakis SA. A Road Map for Important Centers of Growth in the Pediatric Skeleton to Consider During Radiation Therapy and Associated Clinical Correlates of Radiation-Induced Growth Toxicity. Int J Radiat Oncol Biol Phys 2018; 103:669-679. [PMID: 30414451 DOI: 10.1016/j.ijrobp.2018.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/31/2018] [Accepted: 10/24/2018] [Indexed: 11/17/2022]
Abstract
With the increasing use of advanced radiation techniques such as intensity modulated radiation therapy, stereotactic radiation therapy, and proton therapy, radiation oncologists now have the tools to mitigate radiation-associated toxicities. This is of utmost importance in the treatment of a pediatric patient. To best use these advanced techniques to mitigate radiation-induced growth abnormalities, the radiation oncologist should be equipped with a nuanced understanding of the anatomy of centers of growth. This article aims to enable the radiation oncologist to better understand, predict, and minimize radiation-mediated toxicities on growth. We review the process of bone development and radiation-induced growth abnormalities and provide an atlas for contouring important growth plates to guide radiation treatment planning. A more detailed recognition of important centers of growth may improve future treatment outcomes in children receiving radiation therapy.
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Affiliation(s)
- Avani D Rao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Matthew Ladra
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Emily Dunn
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rahul Kumar
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sandesh S Rao
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Shuchi Sehgal
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amir H Dorafshar
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Carol D Morris
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Stephanie A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland.
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Johnson SB, Hung J, Kapadia N, Oh KS, Kim M, Hamstra DA. Spinal Growth Patterns After Craniospinal Irradiation in Children With Medulloblastoma. Pract Radiat Oncol 2018; 9:e22-e28. [PMID: 30036592 DOI: 10.1016/j.prro.2018.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/13/2018] [Accepted: 07/05/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE This study aimed to evaluate the impact on spine growth in children with medulloblastoma using either photon or electron craniospinal irradiation (CSI). METHODS AND MATERIALS This was a single institution retrospective review of children who were treated with CSI for medulloblastoma. Spine growth was measured on magnetic resonance imaging scans at defined locations on the basis of a published predictive model of spine growth after CSI. Differences between spine growth in the anterior, middle, and posterior aspect of the designated vertebral segments were also assessed. Differences between the groups treated with photons or electrons were assessed with student's t test. RESULTS A total of 19 patients (10 patients treated with electrons and 9 with photons) with a median follow-up time of 45.5 months (confidence interval, 34.9-55.1 months) were evaluated. Patients treated with electrons were younger than those who received photons (5.1 years [range, 3.8-9.0 years] vs 9.6 years [range, 3.5-12.9 years]); however, there were no differences in other clinical characteristics, treatment, or follow-up between the groups. Spine growth rate for patients treated with electrons fit the predictive model (104% ± 5.2%), but patients treated with photons had growth that was faster than predicted by the model (150% ± 47%) and different from that observed with electrons. The differences between treatment the modalities were statistically significant (P = .03). For patients treated with photons, there were no statistical differences between the growth rate of the anterior vertebral body compared with the posterior aspect, but for patients treated with electrons, a faster spine growth in the anterior L1-L5 lumbar spine was observed compared with the posterior lumbar spine (3.90 vs 2.52 mm/year; P = .006) without differences in the cervical or thoracic spine. CONCLUSIONS The use of electrons to treat the craniospinal axis in children with medulloblastoma resulted in no significant difference in spine growth compared with the predicted spine growth on the basis of previously published models using photons, but with a clinically insignificant faster spine growth rate in the anterior lumbar spine.
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Affiliation(s)
- Skyler B Johnson
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Jonathon Hung
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois
| | - Nirav Kapadia
- Radiation Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kevin S Oh
- Massachusetts General Hospital, Boston, Massachusetts
| | - Michelle Kim
- The University of Michigan, Department of Radiation Oncology, Ann Arbor, Michigan
| | - Daniel A Hamstra
- Department of Radiation Oncology, Beaumont Health, Dearborn, Michigan.
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