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Toussaint L, Matysiak W, Alapetite C, Aristu J, Bannink-Gawryszuk A, Bolle S, Bolsi A, Calvo F, Cerron Campoo F, Charlwood F, Demoor-Goldschmidt C, Doyen J, Drosik-Rutowicz K, Dutheil P, Embring A, Engellau J, Goedgebeur A, Goudjil F, Harrabi S, Kopec R, Kristensen I, Lægsdmand P, Lütgendorf-Caucig C, Meijers A, Mirandola A, Missohou F, Montero Feijoo M, Muren LP, Ondrova B, Orlandi E, Pettersson E, Pica A, Plaude S, Righetto R, Rombi B, Timmermann B, Van Beek K, Vela A, Vennarini S, Vestergaard A, Vidal M, Vondracek V, Weber DC, Whitfield G, Zimmerman J, Maduro JH, Lassen-Ramshad Y. Clinical practice in European centres treating paediatric posterior fossa tumours with pencil beam scanning proton therapy. Radiother Oncol 2024; 198:110414. [PMID: 38942120 DOI: 10.1016/j.radonc.2024.110414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/17/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND AND PURPOSE As no guidelines for pencil beam scanning (PBS) proton therapy (PT) of paediatric posterior fossa (PF) tumours exist to date, this study investigated planning techniques across European PT centres, with special considerations for brainstem and spinal cord sparing. MATERIALS AND METHODS A survey and a treatment planning comparison were initiated across nineteen European PBS-PT centres treating paediatric patients. The survey assessed all aspects of the treatment chain, including but not limited to delineations, dose constraints and treatment planning. Each centre planned two PF tumour cases for focal irradiation, according to their own clinical practice but based on common delineations. The prescription dose was 54 Gy(RBE) for Case 1 and 59.4 Gy(RBE) for Case 2. For both cases, planning strategies and relevant dose metrics were compared. RESULTS Seventeen (89 %) centres answered the survey, and sixteen (80 %) participated in the treatment planning comparison. In the survey, thirteen (68 %) centres reported using the European Particle Therapy Network definition for brainstem delineation. In the treatment planning study, while most centres used three beam directions, their configurations varied widely across centres. Large variations were also seen in brainstem doses, with a brainstem near maximum dose (D2%) ranging from 52.7 Gy(RBE) to 55.7 Gy(RBE) (Case 1), and from 56.8 Gy(RBE) to 60.9 Gy(RBE) (Case 2). CONCLUSION This study assessed the European PBS-PT planning of paediatric PF tumours. Agreement was achieved in e.g. delineation-practice, while wider variations were observed in planning approach and consequently dose to organs at risk. Collaboration between centres is still ongoing, striving towards common guidelines.
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Affiliation(s)
- Laura Toussaint
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus N, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus N, Denmark.
| | - Witold Matysiak
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Claire Alapetite
- Institut Curie, Department of Radiation Oncology & Proton Centre, Paris, France
| | - Javier Aristu
- Clínica Universidad de Navarra, Proton Therapy Unit, Madrid, Spain
| | - Agata Bannink-Gawryszuk
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Stephanie Bolle
- Institut Curie, Department of Radiation Oncology & Proton Centre, Paris, France; Institut Gustave Roussy, Department of Radiation Oncology, Villejuif, France; Centro de Protonterapia Quironsalud, Madrid, Spain
| | - Alessandra Bolsi
- Paul Scherrer Institute, Centre for Proton Therapy, ETH Domain, Villigen, Switzerland
| | - Felipe Calvo
- Clínica Universidad de Navarra, Proton Therapy Unit, Madrid, Spain
| | | | - Frances Charlwood
- University of Manchester, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Charlotte Demoor-Goldschmidt
- Centre Regional Francois Baclesse, Department of Radiation Oncology, Caen, France; Angers University Hospital, Department of Paediatric Oncology, Angers, France
| | - Jérôme Doyen
- Centre Antoine Lacassagne, Department of Radiation Oncology, Nice, France
| | - Katarzyna Drosik-Rutowicz
- National Research Institute of Oncology Kraków/Gliwice branch, Department of Radiation Oncology, Kraków, Poland
| | - Pauline Dutheil
- Centre Regional Francois Baclesse, Department of Radiation Oncology, Caen, France
| | - Anna Embring
- Karolinska University Hospital, Department of Radiotherapy, Stockholm, Sweden
| | - Jacob Engellau
- Skåne University Hospital, Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Anneleen Goedgebeur
- PARTICLE Proton Therapy Centre University Hospital Leuven, Department of Radiation Oncology, Leuven, Belgium
| | - Farid Goudjil
- Institut Curie, Department of Radiation Oncology & Proton Centre, Paris, France
| | - Semi Harrabi
- Heidelberg Ion Beam Therapy Centre, University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany
| | - Renata Kopec
- Institute of Nuclear Physics, Polish Academy of Sciences, Kraków, Poland
| | - Ingrid Kristensen
- Skåne University Hospital, Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Peter Lægsdmand
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus N, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus N, Denmark
| | | | - Arturs Meijers
- Paul Scherrer Institute, Centre for Proton Therapy, ETH Domain, Villigen, Switzerland
| | - Alfredo Mirandola
- Radiation Oncology Unit, Clinical Department, National Centre for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Fernand Missohou
- Centre Regional Francois Baclesse, Department of Radiation Oncology, Caen, France
| | | | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus N, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus N, Denmark
| | - Barbora Ondrova
- Proton Therapy Centre Czech, Department of Radiation Oncology, Prague, Czech Republic
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Centre for Oncological Hadrontherapy (CNAO), Pavia, Italy; University of Pavia, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, Pavia, Italy
| | - Erik Pettersson
- Sahlgrenska University Hospital, Department of Therapeutic Radiation Physics, Medical Physics and Biomedical Engineering, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Department of Medical Radiation Sciences, Gothenburg, Sweden
| | - Alessia Pica
- Paul Scherrer Institute, Centre for Proton Therapy, ETH Domain, Villigen, Switzerland
| | - Sandija Plaude
- West German Proton Therapy Centre Essen (WPE), Essen University Hospital, Essen, Germany
| | | | - Barbara Rombi
- Trento Proton Therapy Centre,epartment of Radiation Oncology, APSS Trento, Italy
| | - Beate Timmermann
- West German Proton Therapy Centre Essen (WPE), Essen University Hospital, Essen, Germany; Department of Particle Therapy, University Hospital Essen, Essen, Germany; West German Cancer Centre (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - Karen Van Beek
- PARTICLE Proton Therapy Centre University Hospital Leuven, Department of Radiation Oncology, Leuven, Belgium
| | - Anthony Vela
- Centre Regional Francois Baclesse, Department of Radiation Oncology, Caen, France
| | - Sabina Vennarini
- Paediatric Radiotherapy Unit, IRCCS Foundation Institute of Cancer, Milano, Italy
| | - Anne Vestergaard
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus N, Denmark
| | - Marie Vidal
- Centre Antoine Lacassagne, Department of Radiation Oncology, Nice, France
| | - Vladimir Vondracek
- Proton Therapy Centre Czech, Department of Radiation Oncology, Prague, Czech Republic
| | - Damien C Weber
- Paul Scherrer Institute, Centre for Proton Therapy, ETH Domain, Villigen, Switzerland
| | - Gillian Whitfield
- University of Manchester, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; University of Manchester, Royal Manchester Children's Hospital, The Children's Brain Tumour Research Network, Manchester, United Kingdom
| | - Jens Zimmerman
- Karolinska University Hospital, Department of Radiotherapy Physics and Engineering, Stockholm, Sweden
| | - John H Maduro
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, Groningen, the Netherlands
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Dalmasso C, Alapetite C, Bolle S, Goudjil F, Lusque A, Desrousseaux J, Claude L, Doyen J, Bernier-Chastagner V, Ducassou A, Sevely A, Roques M, Tensaouti F, Laprie A. Brainstem toxicity after proton or photon therapy in children and young adults with localized intracranial ependymoma: A French retrospective study. Radiother Oncol 2024; 194:110157. [PMID: 38367939 DOI: 10.1016/j.radonc.2024.110157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 02/06/2024] [Accepted: 02/10/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND PURPOSE Ependymoma is the third most frequent childhood braintumor. Standard treatment is surgery followed by radiation therapy including proton therapy (PBT). Retrospective studies have reported higher rates of brainstem injury after PBT than after photon therapy (XRT). We report a national multicenter study of the incidence of brainstem injury after XRT versus PBT, and their correlations with dosimetric data. MATERIAL AND METHODS We included all patients aged < 25 years who were treated with PBT or XRT for intracranial ependymoma at five French pediatric oncology reference centers between 2007 and 2020. We reviewed pre-irradiation MRI, follow-up MRIs over the 12 months post-treatment and clinical data. RESULTS Of the 83 patients, 42 were treated with PBT, 37 with XRT, and 4 with both (median dose: 59.4 Gy, range: 53‑60). No new or progressive symptomatic brainstem injury was found. Four patients presented asymptomatic radiographic changes (punctiform brainstem enhancement and FLAIR hypersignal), with median onset at 3.5 months (range: 3.0‑9.4) after radiation therapy, and median offset at 7.6 months (range: 3.7‑7.9). Two had been treated with PBT, one with XRT, and one with mixed XRT-PBT. Prescribed doses were 59.4, 55.8, 59.4 and 54 Gy. CONCLUSION Asymptomatic radiographic changes occurred in 4.8% of patients with ependymoma in a large national series. There was no correlation with dose or technique. No symptomatic brainstem injury was identified.
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Affiliation(s)
- Céline Dalmasso
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France
| | - Claire Alapetite
- Department of Radiation Therapy, Institut Curie, Paris, France; Institut Curie - Centre de Protontherapie d', Orsay, Orsay, France
| | - Stéphanie Bolle
- Institut Curie - Centre de Protontherapie d', Orsay, Orsay, France; Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Farid Goudjil
- Institut Curie - Centre de Protontherapie d', Orsay, Orsay, France
| | - Amélie Lusque
- Department of Biostatistics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France
| | - Jacques Desrousseaux
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France
| | - Line Claude
- Department of Radiation Therapy, Centre Léon Bérard, Lyon, France
| | - Jérome Doyen
- Department of Radiation Therapy, Centre Antoine Lacassagne, Nice, France
| | | | - Anne Ducassou
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France
| | - Annick Sevely
- Department of Radiology, CHU de Toulouse, Toulouse, France
| | - Margaux Roques
- Department of Radiology, CHU de Toulouse, Toulouse, France
| | - Fatima Tensaouti
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France; ToNIC, Toulouse NeuroImaging Center, INSERM, UPS, Toulouse, France
| | - Anne Laprie
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France; ToNIC, Toulouse NeuroImaging Center, INSERM, UPS, Toulouse, France.
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Li MP, Yeo A, Gunewardena R, Drum G, Wiltshire K, Phillips C, Sia J, Wheeler G, Hall L. Is proton beam therapy always better than photon irradiation? Lessons from two cases. J Med Radiat Sci 2024; 71 Suppl 2:90-98. [PMID: 38504608 PMCID: PMC11011607 DOI: 10.1002/jmrs.773] [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: 08/20/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024] Open
Abstract
Proton beam therapy (PBT) is increasingly used to treat cancers, especially in the paediatric and adolescent and young adult (AYA) population. As PBT becomes more accessible, determining when PBT should be used instead of photon irradiation can be difficult. There is a need to balance patient, tumour and treatment factors when making this decision. Comparing the dosimetry between these two modalities plays an important role in this process. PBT can reduce low to intermediate doses to organs at risk (OAR), but photon irradiation has its dosimetric advantages. We present two cases with brain tumours, one paediatric and one AYA, in which treatment plan comparison between photons and protons showed dosimetric advantages of photon irradiation. The first case was an 18-month-old child diagnosed with posterior fossa ependymoma requiring adjuvant radiotherapy. Photon irradiation using volumetric modulated arc therapy (VMAT) had lower doses to the hippocampi but higher doses to the pituitary gland. The second case was a 21-year-old with an optic pathway glioma. There was better sparing of the critical optic structures and pituitary gland using fractionated stereotactic radiation therapy over PBT. The dosimetric advantages of photon irradiation over PBT have been demonstrated in these cases. This highlights the role of proton-to-photon comparative treatment planning to better understand which patients might benefit from photon irradiation versus PBT.
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Affiliation(s)
- Michelle P Li
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Adam Yeo
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
- School of Applied ScienceRMIT UniversityMelbourneVictoriaAustralia
| | | | | | - Kirsty Wiltshire
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Claire Phillips
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Joseph Sia
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Greg Wheeler
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Lisa Hall
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
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Miranda-Lloret P, Plaza-Ramírez E, Simal-Julián JA, Pancucci G, Cañete A, Montoya-Filardi A, Llavador G. Lateral-type posterior fossa ependymomas in pediatric population. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:87-94. [PMID: 38244924 DOI: 10.1016/j.neucie.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/03/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Lateral-type posterior fossa ependymomas are a well-defined subtype of tumours both clinically and pathologically, with a poor prognosis. Their incidence is low and surgical management is challenging. The objective of the present work is to review our series of lateral-tye posterior fossa ependymomas and compare our results with those of previous series. METHODS Among 30 cases of ependymoma operated in our paediatric department in the last ten years, we identified seven cases of lateral-type posterior fossa ependymomas. We then performed a retrospective, descriptive study. RESULTS Mean age of our patients was 3.75 years. 6 cases presented with hydrocephalus. Mean tumour volume at diagnosis was 61 cc. A complete resection was achieved in six cases and a near-total resection in one patient. 5 patients transiently required a gastrostomy and a tracheostomy. Mean follow-up was 58 months. One case progressed along this period and eventually died. 4 cases of hydrocephalus required a ventriculoperitoneal CSF shunt and two were managed with a third ventriculostomy. At last follow-up 4 patients carried a normal life and two displayed a mild restriction according to Lansky´s scale. CONCLUSIONS The aim of surgical treatment in lateral-type posterior fossa ependymomas is complete resection. Neurological deficits associated to lower cranial nerve dysfunction are common but transient. Deeper genetic characterization of these tumours may identify risk factors that guide stratification of adjuvant therapies.
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Affiliation(s)
- Pablo Miranda-Lloret
- Servicios de Neurocirugía, Oncología Pediátrica, Radiología Pediátrica y Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - Estela Plaza-Ramírez
- Servicios de Neurocirugía, Oncología Pediátrica, Radiología Pediátrica y Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Juan Antonio Simal-Julián
- Servicios de Neurocirugía, Oncología Pediátrica, Radiología Pediátrica y Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Giovanni Pancucci
- Servicios de Neurocirugía, Oncología Pediátrica, Radiología Pediátrica y Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Adela Cañete
- Servicios de Neurocirugía, Oncología Pediátrica, Radiología Pediátrica y Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Alejandro Montoya-Filardi
- Servicios de Neurocirugía, Oncología Pediátrica, Radiología Pediátrica y Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Gemma Llavador
- Servicios de Neurocirugía, Oncología Pediátrica, Radiología Pediátrica y Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Miranda-Lloret P, Plaza-Ramírez E, López-Guerrero A, López-Bermeo D, García-Campos T, Vázquez-Sufuentes S, Munárriz PM, López-García E, Londoño-Quiroz A, Ferreras-García C, García-Conde M, Saceda-Gutiérrez J, Giménez-Pando J, Pancucci G, Iglesias-Moroño S. Lateral-type posterior fossa ependymomas in pediatric patients: a national collaborative study. Childs Nerv Syst 2024; 40:407-416. [PMID: 37889277 DOI: 10.1007/s00381-023-06194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE To review a multicentric series of lateral-type posterior fossa ependymomas operated in the last ten years and to analyze the factors related to clinical evolution and tumor survival. METHODS Descriptive, retrospective study. Active members of the Spanish Society of Pediatric Neurosurgery were invited to participate in this multicentric study. Clinical and radiological data were incorporated to an open database. The role of histologic grade, grade of resection, postoperative morbidities, and clinical follow-up was evaluated through bivariate associations (chi-square), Kaplan-Meier's curves (log-rank test), and multivariate analysis (binary logistic regression). RESULTS Fourteen centers entered the study, and 25 cases with a minimum follow-up of 6 months were included. There were 13 boys and 12 girls with a mean age close to 3 years. Mean tumor volume at diagnosis was over 60 cc. A complete resection was achieved in 8 patients and a near-total resection in 5 cases. Fifteen tumors were diagnosed as ependymoma grade 2 and ten as ependymoma grade 3. Major morbidity occurred postoperatively in 14 patients but was resolved in twelve within 6 months. There were six cases of death and 11 cases of tumor progression along the observation period. Mean follow-up was 44.8 months. Major morbidity was significantly associated with histologic grade but not with the degree of resection. Overall and progression-free survival were significantly associated with complete surgical resection. At the last follow-up, 16 patients carried a normal life, and three displayed a mild restriction according to Lansky's scale. CONCLUSIONS Lateral-type posterior fossa ependymomas constitute a specific pathologic and clinical tumor subtype with bad prognosis. Gross total resection is the goal of surgical treatment, for it significantly improves prognosis with no additional morbidity. Neurological deficits associated to lower cranial nerve dysfunction are common, but most are transient. Deeper genetic characterization of these tumors may identify risk factors that guide new treatments and stratification of adjuvant therapies.
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Affiliation(s)
- Pablo Miranda-Lloret
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| | - Estela Plaza-Ramírez
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Antonio López-Guerrero
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Diego López-Bermeo
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Teresa García-Campos
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Silvia Vázquez-Sufuentes
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Pablo M Munárriz
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Elena López-García
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Alejandra Londoño-Quiroz
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Cristina Ferreras-García
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Mario García-Conde
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Javier Saceda-Gutiérrez
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Jorge Giménez-Pando
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Giovanni Pancucci
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Sara Iglesias-Moroño
- Unidad de Neurocirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Avda Fernando Abril Martorell, 106, 46026, Valencia, Spain
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6
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Goudarzi HM, Lim G, Grosshans D, Mohan R, Cao W. Incorporating variable RBE in IMPT optimization for ependymoma. J Appl Clin Med Phys 2024; 25:e14207. [PMID: 37985962 PMCID: PMC10795446 DOI: 10.1002/acm2.14207] [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: 04/25/2023] [Revised: 10/19/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023] Open
Abstract
PURPOSE To study the dosimetric impact of incorporating variable relative biological effectiveness (RBE) of protons in optimizing intensity-modulated proton therapy (IMPT) treatment plans and to compare it with conventional constant RBE optimization and linear energy transfer (LET)-based optimization. METHODS This study included 10 pediatric ependymoma patients with challenging anatomical features for treatment planning. Four plans were generated for each patient according to different optimization strategies: (1) constant RBE optimization (ConstRBEopt) considering standard-of-care dose requirements; (2) LET optimization (LETopt) using a composite cost function simultaneously optimizing dose-averaged LET (LETd ) and dose; (3) variable RBE optimization (VarRBEopt) using a recent phenomenological RBE model developed by McNamara et al.; and (4) hybrid RBE optimization (hRBEopt) assuming constant RBE for the target and variable RBE for organs at risk. By normalizing each plan to obtain the same target coverage in either constant or variable RBE, we compared dose, LETd , LET-weighted dose, and equivalent uniform dose between the different optimization approaches. RESULTS We found that the LETopt plans consistently achieved increased LET in tumor targets and similar or decreased LET in critical organs compared to other plans. On average, the VarRBEopt plans achieved lower mean and maximum doses with both constant and variable RBE in the brainstem and spinal cord for all 10 patients. To compensate for the underdosing of targets with 1.1 RBE for the VarRBEopt plans, the hRBEopt plans achieved higher physical dose in targets and reduced mean and especially maximum variable RBE doses compared to the ConstRBEopt and LETopt plans. CONCLUSION We demonstrated the feasibility of directly incorporating variable RBE models in IMPT optimization. A hybrid RBE optimization strategy showed potential for clinical implementation by maintaining all current dose limits and reducing the incidence of high RBE in critical normal tissues in ependymoma patients.
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Affiliation(s)
| | - Gino Lim
- Department of Industrial EngineeringUniversity of HoustonHoustonTexasUSA
| | - David Grosshans
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Radhe Mohan
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Wenhua Cao
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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Jünger ST, Zschernack V, Messing-Jünger M, Timmermann B, Pietsch T. Ependymoma from Benign to Highly Aggressive Diseases: A Review. Adv Tech Stand Neurosurg 2024; 50:31-62. [PMID: 38592527 DOI: 10.1007/978-3-031-53578-9_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Ependymomas comprise biologically distinct tumor types with respect to age distribution, (epi)genetics, localization, and prognosis. Multimodal risk-stratification, including histopathological and molecular features, is essential in these biologically defined tumor types. Gross total resection (GTR), achieved with intraoperative monitoring and neuronavigation, and if necessary, second-look surgery, is the most effective treatment. Adjuvant radiation therapy is mandatory in high-risk tumors and in case of residual tumor. There is yet growing evidence that some ependymal tumors may be cured by surgery alone. To date, the role of chemotherapy is unclear and subject of current studies.Even though standard therapy can achieve reasonable survival rates for the majority of ependymoma patients, long-term follow-up still reveals a high probability of relapse in certain biological entities.With increasing knowledge of biologically distinct tumor types, risk-adapted adjuvant therapy gains importance. Beyond initial tumor control, and avoidance of therapy-induced morbidity for low-risk patients, intensified treatment for high-risk patients comprises another challenge. With identification of specific risk features regarding molecular alterations, targeted therapy may represent an option for individualized treatment modalities in the future.
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Affiliation(s)
- Stephanie T Jünger
- Department of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn Medical Center, Bonn, Germany.
- Center for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - Valentina Zschernack
- Department of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn Medical Center, Bonn, Germany
| | | | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Center Essen (WPE), West German Cancer Center (WTZ), Germany, German Cancer Consortium, Essen, Germany
| | - Torsten Pietsch
- Department of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn Medical Center, Bonn, Germany
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8
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Singh R, Yu S, Osman M, Inde Z, Fraser C, Cleveland AH, Almanzar N, Lim CB, Joshi GN, Spetz J, Qin X, Toprani SM, Nagel Z, Hocking MC, Cormack RA, Yock TI, Miller JW, Yuan ZM, Gershon T, Sarosiek KA. Radiotherapy-Induced Neurocognitive Impairment Is Driven by Heightened Apoptotic Priming in Early Life and Prevented by Blocking BAX. Cancer Res 2023; 83:3442-3461. [PMID: 37470810 PMCID: PMC10570680 DOI: 10.1158/0008-5472.can-22-1337] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 04/23/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
Although external beam radiotherapy (xRT) is commonly used to treat central nervous system (CNS) tumors in patients of all ages, young children treated with xRT frequently experience life-altering and dose-limiting neurocognitive impairment (NI) while adults do not. The lack of understanding of mechanisms responsible for these differences has impeded the development of neuroprotective treatments. Using a newly developed mouse model of xRT-induced NI, we found that neurocognitive function is impaired by ionizing radiation in a dose- and age-dependent manner, with the youngest animals being most affected. Histologic analysis revealed xRT-driven neuronal degeneration and cell death in neurogenic brain regions in young animals but not adults. BH3 profiling showed that neural stem and progenitor cells, neurons, and astrocytes in young mice are highly primed for apoptosis, rendering them hypersensitive to genotoxic damage. Analysis of single-cell RNA sequencing data revealed that neural cell vulnerability stems from heightened expression of proapoptotic genes including BAX, which is associated with developmental and mitogenic signaling by MYC. xRT induced apoptosis in primed neural cells by triggering a p53- and PUMA-initiated, proapoptotic feedback loop requiring cleavage of BID and culminating in BAX oligomerization and caspase activation. Notably, loss of BAX protected against apoptosis induced by proapoptotic signaling in vitro and prevented xRT-induced apoptosis in neural cells in vivo as well as neurocognitive sequelae. On the basis of these findings, preventing xRT-induced apoptosis specifically in immature neural cells by blocking BAX, BIM, or BID via direct or upstream mechanisms is expected to ameliorate NI in pediatric patients with CNS tumor. SIGNIFICANCE Age- and differentiation-dependent apoptotic priming plays a pivotal role in driving radiotherapy-induced neurocognitive impairment and can be targeted for neuroprotection in pediatric patients.
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Affiliation(s)
- Rumani Singh
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Stacey Yu
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Marwa Osman
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Zintis Inde
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Cameron Fraser
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Abigail H. Cleveland
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina
| | - Nicole Almanzar
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Chuan Bian Lim
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Gaurav N. Joshi
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Johan Spetz
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Xingping Qin
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sneh M. Toprani
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Zachary Nagel
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Matthew C. Hocking
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
- Cancer Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert A. Cormack
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Torunn I. Yock
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Pediatric Radiation Oncology, Francis H. Burr Proton Therapy Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey W. Miller
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Zhi-Min Yuan
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Timothy Gershon
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina
| | - Kristopher A. Sarosiek
- John B. Little Center for Radiation Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Laboratory of Systems Pharmacology, Harvard Program in Therapeutic Science, Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Molecular and Integrative Physiological Sciences Program, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, Massachusetts
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9
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Kang J, Lee KW, Chung Y, Won Y, Hong JB. Extensive Leptomeningeal Spreading of Ependymoma in an Adult: Case Report and Literature Review. Brain Tumor Res Treat 2023; 11:274-280. [PMID: 37953452 PMCID: PMC10641315 DOI: 10.14791/btrt.2023.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/08/2023] [Accepted: 09/01/2023] [Indexed: 11/14/2023] Open
Abstract
Ependymoma is a rare adult tumor that originates from ependymal cells of the central nervous system, primarily occurring in the cerebral ventricles or the central canal of the spinal cord. In this paper, we report a case of extensive leptomeningeal seeding of ependymoma of a 39-year-old male patient, in whom the tumor was found incidentally after head trauma. The MRI exhibited diffuse leptomeningeal infiltrative lesions along with bilateral multiple cerebral sulci, basal cisterns, cerebellopontine angle, cerebellar folia. It also showed multinodular enhancing T1 low T2 high signal intensity lesions along the whole spinal cord. After the tumor biopsy at right temporal lesion, pathologic diagnosis was classic ependymoma (WHO grade 2). The patient has undergone radiation therapy and chemotherapy, and is currently maintaining a stable condition two years after surgery. This report suggests that when considering the differential diagnosis of extensive lesions both in the intracranial and intraspinal space, ependymoma should also be considered.
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Affiliation(s)
- Joonseo Kang
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwon Woo Lee
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeongu Chung
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yusam Won
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Je Beom Hong
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
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10
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Liu KX, Haas-Kogan DA, Elhalawani H. Radiotherapy for Primary Pediatric Central Nervous System Malignancies: Current Treatment Paradigms and Future Directions. Pediatr Neurosurg 2023; 58:356-366. [PMID: 37703864 DOI: 10.1159/000533777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Central nervous system tumors are the most common solid tumors in childhood. Treatment paradigms for pediatric central nervous system malignancies depend on elements including tumor histology, age of patient, and stage of disease. Radiotherapy is an important modality of treatment for many pediatric central nervous system malignancies. SUMMARY While radiation contributes to excellent overall survival rates for many patients, radiation also carries significant risks of long-term side effects including neurocognitive decline, hearing loss, growth impairment, neuroendocrine dysfunction, strokes, and secondary malignancies. In recent decades, clinical trials have demonstrated that with better imaging and staging along with more sophisticated radiation planning and treatment set-up verification, smaller treatment volumes can be utilized without decrement in survival. Furthermore, the development of intensity-modulated radiotherapy and proton-beam radiotherapy has greatly improved conformality of radiation. KEY MESSAGES Recent changes in radiation treatment paradigms have decreased risks of short- and long-term toxicity for common histologies and in different age groups. Future studies will continue to develop novel radiation regimens to improve outcomes in aggressive central nervous system tumors, integrate molecular subtypes to tailor radiation treatment, and decrease radiation-associated toxicity for long-term survivors.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hesham Elhalawani
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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11
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Liang X, Beltran CJ, Liu C, Park C, Lu B, Yaddanapudi S, Tan J, Furutani KM. Selecting Optimal Proton Pencil Beam Scanning Plan Parameters to Reduce Dose Discrepancy between Discrete Spot Plan and Continuous Scanning: A Proof-of-Concept Study. Cancers (Basel) 2023; 15:4084. [PMID: 37627112 PMCID: PMC10452710 DOI: 10.3390/cancers15164084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/25/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
Pencil beam scanning delivered with continuous scanning has several advantages over conventional discrete spot scanning. Such advantages include improved beam delivery efficiency and reduced beam delivery time. However, a move dose is delivered between consecutive spots with continuous scanning, and current treatment planning systems do not take this into account. Therefore, continuous scanning and discrete spot plans have an inherent dose discrepancy. Using the operating parameters of the state-of-the-art particle therapy system, we conducted a proof-of-concept study in which we systematically generated 28 plans for cubic targets with different combinations of plan parameters and simulated the dose discrepancies between continuous scanning and a planned one. A nomograph to guide the selection of plan parameters was developed to reduce the dose discrepancy. The effectiveness of the nomograph was evaluated with two clinical cases (one prostate and one liver). Plans with parameters guided by the nomograph decreased dose discrepancy than those used standard plan parameters. Specifically, the 2%/2 mm gamma passing rate increased from 96.3% to 100% for the prostate case and from 97.8% to 99.7% for the liver case. The CTV DVH root mean square error decreased from 2.2% to 0.2% for the prostate case and from 1.8% to 0.9% for the liver case. The decreased dose discrepancy may allow the relaxing of the delivery constraint for some cases, leading to greater benefits in continuous scanning. Further investigation is warranted.
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Affiliation(s)
- Xiaoying Liang
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Chris J. Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Chunbo Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Chunjoo Park
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Bo Lu
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | | | - Jun Tan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Keith M. Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
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12
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Handeland AH, Indelicato DJ, Fredrik Fjæra L, Ytre-Hauge KS, Pettersen HES, Muren LP, Lassen-Ramshad Y, Stokkevåg CH. Linear energy transfer-inclusive models of brainstem necrosis following proton therapy of paediatric ependymoma. Phys Imaging Radiat Oncol 2023; 27:100466. [PMID: 37457667 PMCID: PMC10345333 DOI: 10.1016/j.phro.2023.100466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/22/2023] [Accepted: 06/24/2023] [Indexed: 07/18/2023] Open
Abstract
Background and Purpose Radiation-induced brainstem necrosis after proton therapy is a severe toxicity with potential association to uncertainties in the proton relative biological effectiveness (RBE). A constant RBE of 1.1 is assumed clinically, but the RBE is known to vary with linear energy transfer (LET). LET-inclusive predictive models of toxicity may therefore be beneficial during proton treatment planning. Hence, we aimed to construct models describing the association between brainstem necrosis and LET in the brainstem. Materials and methods A matched case-control cohort (n = 28, 1:3 case-control ratio) of symptomatic brainstem necrosis was selected from 954 paediatric ependymoma brain tumour patients treated with passively scattered proton therapy. Dose-averaged LET (LETd) parameters in restricted volumes (L50%, L10% and L0.1cm3, the cumulative LETd) within high-dose thresholds were included in linear- and logistic regression normal tissue complication probability (NTCP) models. Results A 1 keV/µm increase in L10% to the brainstem volume receiving dose over 54 Gy(RBE) led to an increased brainstem necrosis risk [95% confidence interval] of 2.5 [0.0, 7.8] percentage points. The corresponding logistic regression model had area under the receiver operating characteristic curve (AUC) of 0.76, increasing to 0.84 with the anterior pons substructure as a second parameter. 19 [7, 350] patients with toxicity were required to associate the L10% (D > 54 Gy(RBE)) and brainstem necrosis with 80% statistical power. Conclusion The established models of brainstem necrosis illustrate a potential impact of high LET regions in patients receiving high doses to the brainstem, and thereby support LET mitigation during clinical treatment planning.
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Affiliation(s)
- Andreas H. Handeland
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | | | - Lars Fredrik Fjæra
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Medical Physics, Oslo University Hospital, Norway
| | | | | | - Ludvig P. Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Camilla H. Stokkevåg
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
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13
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Soffietti R, Pellerino A, Bruno F, Mauro A, Rudà R. Neurotoxicity from Old and New Radiation Treatments for Brain Tumors. Int J Mol Sci 2023; 24:10669. [PMID: 37445846 DOI: 10.3390/ijms241310669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Research regarding the mechanisms of brain damage following radiation treatments for brain tumors has increased over the years, thus providing a deeper insight into the pathobiological mechanisms and suggesting new approaches to minimize this damage. This review has discussed the different factors that are known to influence the risk of damage to the brain (mainly cognitive disturbances) from radiation. These include patient and tumor characteristics, the use of whole-brain radiotherapy versus particle therapy (protons, carbon ions), and stereotactic radiotherapy in various modalities. Additionally, biological mechanisms behind neuroprotection have been elucidated.
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Affiliation(s)
- Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science University Hospital, 10126 Turin, Italy
| | - Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science University Hospital, 10126 Turin, Italy
| | - Francesco Bruno
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science University Hospital, 10126 Turin, Italy
| | - Alessandro Mauro
- Department of Neuroscience "Rita Levi Montalcini", University of Turin and City of Health and Science University Hospital, 10126 Turin, Italy
- I.R.C.C.S. Istituto Auxologico Italiano, Division of Neurology and Neuro-Rehabilitation, San Giuseppe Hospital, 28824 Piancavallo, Italy
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science University Hospital, 10126 Turin, Italy
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14
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Peters S, Frisch S, Stock A, Merta J, Bäumer C, Blase C, Schuermann E, Tippelt S, Bison B, Frühwald M, Rutkowski S, Fleischhack G, Timmermann B. Proton Beam Therapy for Pediatric Tumors of the Central Nervous System-Experiences of Clinical Outcome and Feasibility from the KiProReg Study. Cancers (Basel) 2022; 14:cancers14235863. [PMID: 36497345 PMCID: PMC9737072 DOI: 10.3390/cancers14235863] [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: 07/31/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
As radiotherapy is an important part of the treatment in a variety of pediatric tumors of the central nervous system (CNS), proton beam therapy (PBT) plays an evolving role due to its potential benefits attributable to the unique dose distribution, with the possibility to deliver high doses to the target volume while sparing surrounding tissue. Children receiving PBT for an intracranial tumor between August 2013 and October 2017 were enrolled in the prospective registry study KiProReg. Patient's clinical data including treatment, outcome, and follow-up were analyzed using descriptive statistics, Kaplan-Meier, and Cox regression analysis. Adverse events were scored according to the Common Terminology Criteria for Adverse Events (CTCAE) 4.0 before, during, and after PBT. Written reports of follow-up imaging were screened for newly emerged evidence of imaging changes, according to a list of predefined keywords for the first 14 months after PBT. Two hundred and ninety-four patients were enrolled in this study. The 3-year overall survival of the whole cohort was 82.7%, 3-year progression-free survival was 67.3%, and 3-year local control was 79.5%. Seventeen patients developed grade 3 adverse events of the CNS during long-term follow-up (new adverse event n = 7; deterioration n = 10). Two patients developed vision loss (CTCAE 4°). This analysis demonstrates good general outcomes after PBT.
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Affiliation(s)
- Sarah Peters
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
- Clinic for Particle Therapy, University Hospital Essen, 45147 Essen, Germany
- Correspondence: ; Tel.: +49-201-723-8943
| | - Sabine Frisch
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Annika Stock
- Department of Neuroradiology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Julien Merta
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Christian Bäumer
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Christoph Blase
- AnästhesieNetz Rhein-Ruhr, Westenfelder Str. 62/64, 44867 Bochum, Germany
| | - Eicke Schuermann
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Stephan Tippelt
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Brigitte Bison
- Diagnostic and Interventional Neuroradiology, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany
- Neuroradiological Reference Center for the Pediatric Brain Tumor (HIT) Studies of the German Society of Pediatric Oncology and Hematology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Michael Frühwald
- Pediatric and Adolescent Medicine, Swabian Childrens Cancer Center, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Gudrun Fleischhack
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
- Clinic for Particle Therapy, University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- German Cancer Consortium (DKTK), 45147 Essen, Germany
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15
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Donahue BR, MacDonald S. Protons for pediatric ependymoma: Where are we now? Neuro Oncol 2022; 24:1203-1204. [PMID: 35294554 PMCID: PMC9248382 DOI: 10.1093/neuonc/noac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bernadine R Donahue
- Department of Radiation Oncology, Maimonides Cancer Center, Brooklyn, New York, USA.,Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York, USA
| | - Shannon MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts, USA
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16
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Smith JD, Mandel G, Niazi T, Bradley JA, Indelicato DJ, Khatib Z. Multifocal and Multiphasic Demyelinating Lesions After Radiation for Ependymoma in a Pediatric Population. J Child Neurol 2022; 37:609-616. [PMID: 35619552 DOI: 10.1177/08830738221079476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Radiation treatment is widely used to address unresectable intracranial tumors. Owing to the nature of therapy, healthy tissue and diseased regions will be affected. New insights have shown that not only does this impact brain parenchyma but it causes changes in fluid status, myelination, and the integrity of the blood-brain barrier. This alters how peripheral and central immune systems interact, perpetuating neuroinflammation. Rare case reports in the adult literature have described multifocal, multiphasic demyelinating lesions after radiation. Here we describe 2 pediatric cases of relapsing demyelination after and in conjunction with radiation therapy for ependymoma, consistent with a multiple sclerosis phenotype. Insights into the underpinnings of multiple sclerosis show peripheral inflammation, blood-brain barrier disruption, and antigenic mimicry stimulating neuroinflammation. Here we investigate the role that radiation, tumor burden, and systemic inflammation may play in creating demyelinating disorders. We strive to elucidate common pathophysiology between radiation-induced brain injury and multiple sclerosis.
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Affiliation(s)
- Jacklyn D Smith
- Department of Pediatrics, 5447Nicklaus Children's Hospital, Miami, FL, USA
| | - Gabriel Mandel
- Department of Pediatrics, 5447Nicklaus Children's Hospital, Miami, FL, USA
| | - Toba Niazi
- Division of Neurosurgery, 5447Nicklaus Children's Hospital, Miami, FL, USA
| | - Julie A Bradley
- Department of Radiation Oncology, 50551University of Florida, Jacksonville, FL, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, 50551University of Florida, Jacksonville, FL, USA
| | - Ziad Khatib
- Department of Pediatrics, 5447Nicklaus Children's Hospital, Miami, FL, USA.,Division of Hematology-Oncology, 5447Nicklaus Children's Hospital, Miami, FL, USA
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17
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Indelicato DJ. No Question: Proton Therapy Is Safe. Neuro Oncol 2022; 24:1582-1583. [PMID: 35512698 PMCID: PMC9435487 DOI: 10.1093/neuonc/noac121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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18
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Abstract
PURPOSE OF REVIEW To review state of art and relevant advances in the molecular genetics and management of ependymomas of children and adults. RECENT FINDINGS Ependymomas may occur either in the brain or in the spinal cord. Compared with intracranial ependymomas, spinal ependymomas are less frequent and exhibit a better prognosis. The new WHO classification of CNS tumors of 2021 has subdivided ependymomas into different histomolecular subgroups with different outcome. The majority of studies have shown a major impact of extent of resection; thus, a complete resection must be performed, whenever possible, at first surgery or at reoperation. Conformal radiotherapy is recommended for grade 3 or incompletely resected grade II tumors. Proton therapy is increasingly employed especially in children to reduce the risk of neurocognitive and endocrine sequelae. Craniospinal irradiation is reserved for metastatic disease. Chemotherapy is not useful as primary treatment and is commonly employed as salvage treatment for patients failing surgery and radiotherapy. Standard treatments are still the mainstay of treatment: the discovery of new druggable pathways will hopefully increase the therapeutic armamentarium in the near future.
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Affiliation(s)
- Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Francesco Bruno
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Via Cherasco 15, 10126 Turin, Italy
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19
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Upadhyay R, Liao K, Grosshans DR, McGovern SL, Frances McAleer M, Zaky W, Chintagumpala MM, Mahajan A, Nana Yeboa D, Paulino AC. Quantifying the risk and dosimetric variables of symptomatic brainstem injury after proton beam radiation in pediatric brain tumors. Neuro Oncol 2022; 24:1571-1581. [PMID: 35157767 PMCID: PMC9435496 DOI: 10.1093/neuonc/noac044] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Brainstem toxicity after radiation therapy (RT) is a devastating complication and a particular concern with proton radiation (PBT). We investigated the incidence and clinical correlates of brainstem injury in pediatric brain tumors treated with PBT. METHODS All patients <21 years with brain tumors treated with PBT at our institution from 2007-2019, with a brainstem Dmean >30 Gy and/or Dmax >50.4 Gy were included. Symptomatic brainstem injury (SBI) was defined as any new or progressive cranial neuropathy, ataxia, and/or motor weakness with corresponding radiographic abnormality within brainstem. RESULTS A total of 595 patients were reviewed and 468 (medulloblastoma = 200, gliomas = 114, ependymoma = 87, ATRT = 43) met our inclusion criteria. Median age at RT was 6.3 years and median prescribed RT dose was 54Gy [RBE]. Fifteen patients (3.2%) developed SBI, at a median of 4 months after RT. Grades 2, 3, 4, and 5 brainstem injuries were seen in 7, 5, 1, and 2 patients respectively. Asymptomatic radiographic changes were seen in 51 patients (10.9%). SBI was significantly higher in patients with age ≤3 years, female gender, ATRT histology, patients receiving high-dose chemotherapy with stem cell rescue, and those not receiving craniospinal irradiation. Patients with SBI had a significantly higher V50-52. In 2014, our institution started using strict brainstem dose constraints (Dmax ≤57 Gy, Dmean ≤52.4 Gy, and V54≤10%). There was a trend towards decrease in SBI from 4.4% (2007-2013) to 1.5% (2014-2019) (P = .089) without affecting survival. CONCLUSION Our results suggest a low risk of SBI after PBT for pediatric brain tumors, comparable to photon therapy. A lower risk was seen after adopting strict brainstem dose constraints.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The James Cancer Centre Ohio State University, Columbus, Ohio, USA
| | - Kaiping Liao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wafik Zaky
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Debra Nana Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arnold C Paulino
- Corresponding Author: Arnold C. Paulino, MD, Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0097, Houston, TX 77030, USA ()
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20
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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
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21
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Peters S, Merta J, Schmidt L, Jazmati D, Kramer PH, Blase C, Tippelt S, Fleischhack G, Stock A, Bison B, Rutkowski S, Pietsch T, Kortmann RD, Timmermann B. Evaluation of dose, volume and outcome in children with localized, intracranial ependymoma treated with proton therapy within the prospective KiProReg Study. Neuro Oncol 2021; 24:1193-1202. [PMID: 34964901 PMCID: PMC9248402 DOI: 10.1093/neuonc/noab301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Radiotherapy (RT) of ependymoma in children is an important part of the
interdisciplinary treatment concept. However, feasibility and dose concepts are still
under investigation, particularly in very young children. The aim of this study was to
evaluate the standard dose and volume of proton therapy (PT) in children with
ependymoma. Methods In this analysis, 105 patients with localized, intracranial ependymoma under the age of
18 years treated with PT between 2013 and 2018 were included. Patient characteristics,
treatment, outcome, and follow-up data were analyzed using descriptive statistics,
Kaplan-Meier, and Cox regression analysis. Results The median age of patients at PT was 2.8 years (0.9-17.0 years). The molecular subgroup
analysis was performed in a subset of 50 patients (37 EP-PFA, 2 EP-PFB, 7 EP-RELA, 2
EP-YAP, 2 NEC [not elsewhere classified]). The median total dose was 59.4 Gy (54.0-62.0
Gy). The median follow-up time was 1.9 years. The estimated 3-year overall survival
(OS), local control (LC), and progression-free survival (PFS) rates were 93.7%, 74.1%,
and 55.6%, respectively. Within univariable analysis, female gender and lower dose had a
positive impact on OS, whereas age ≥4 years had a negative impact on OS and PT given
after progression had a negative impact on PFS. In the multivariable analysis, multiple
tumor surgeries were associated with lower PFS. New ≥3° late toxicities occurred in 11
patients. Conclusion For children with localized ependymoma, PT was effective and well tolerable. Multiple
surgeries showed a negative impact on PFS.
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Affiliation(s)
- S Peters
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Essen, Germany.,Clinic for Particle Therapy, University Hospital Essen, Essen, Germany
| | - J Merta
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Essen, Germany
| | - L Schmidt
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany
| | - D Jazmati
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Essen, Germany.,Clinic for Particle Therapy, University Hospital Essen, Essen, Germany
| | - P H Kramer
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany
| | - C Blase
- AnästhesieNetz Rhein-Ruhr, Westenfelder, Bochum, Germany
| | - S Tippelt
- Pediatrics III, University Hospital Essen, Essen, Germany
| | - G Fleischhack
- Pediatrics III, University Hospital Essen, Essen, Germany
| | - A Stock
- Department of Neuroradiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - B Bison
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - S Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Pietsch
- Institute of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn Medical Center, Bonn, Germany
| | - R D Kortmann
- Department of Radiotherapy and Radio-oncology, University Hospital Leipzig, Leipzig, Germany
| | - B Timmermann
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Essen, Germany.,Clinic for Particle Therapy, University Hospital Essen, Essen, Germany.,West German Cancer Center (WTZ). University Hospital Essen, Essen, Germany.,German Cancer Consortium (DKTK), Germany
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22
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Napieralska A, Mizia-Malarz A, Stolpa W, Pawłowska E, Krawczyk MA, Konat-Bąska K, Kaczorowska A, Brąszewski A, Harat M. Polish Multi-Institutional Study of Children with Ependymoma-Clinical Practice Outcomes in the Light of Prospective Trials. Diagnostics (Basel) 2021; 11:diagnostics11122360. [PMID: 34943596 PMCID: PMC8700631 DOI: 10.3390/diagnostics11122360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/29/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022] Open
Abstract
We performed a multi-institutional analysis of 74 children with ependymoma to evaluate to what extent the clinical outcome of prospective trials could be reproduced in routine practice. The evaluation of factors that correlated with outcome was performed with a log rank test and a Cox proportional-hazard model. Survival was estimated with the Kaplan–Meier method. The majority of patients had brain tumours (89%). All had surgery as primary treatment, with adjuvant radiotherapy (RTH) and chemotherapy (CTH) applied in 78% and 57%, respectively. Median follow-up was 80 months and 18 patients died. Five- and 10-year overall survival (OS) was 83% and 73%. Progression was observed in 32 patients, with local recurrence in 28 cases. The presence of metastases was a negative prognostic factor for OS. Five- and 10-year progression-free survival (PFS) was 55% and 40%, respectively. The best outcome in patients with non-disseminated brain tumours was observed when surgery was followed by RTH (+/−CTH afterwards; p = 0.0001). Children under 3 years old who received RTH in primary therapy had better PFS (p = 0.010). The best outcome of children with ependymoma is observed in patients who received radical surgery followed by RTH, and irradiation should not be omitted in younger patients. The role of CTH remains debatable.
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Affiliation(s)
- Aleksandra Napieralska
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, 44-101 Gliwice, Poland
- Correspondence:
| | - Agnieszka Mizia-Malarz
- Department of Pediatrics, Medical University of Silesia, 40-752 Katowice, Poland; (A.M.-M.); (W.S.)
| | - Weronika Stolpa
- Department of Pediatrics, Medical University of Silesia, 40-752 Katowice, Poland; (A.M.-M.); (W.S.)
| | - Ewa Pawłowska
- Department of Oncology and Radiotherapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdansk, Poland;
| | - Małgorzata A. Krawczyk
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, 80-210 Gdansk, Poland;
| | - Katarzyna Konat-Bąska
- Wroclaw Comprehensive Cancer Center, 53-413 Wrocław, Poland;
- Department of Oncology, Wroclaw Medical University, 53-413 Wrocław, Poland
| | - Aneta Kaczorowska
- Department of Children Oncology and Haematology, Wroclaw Medical University, 53-413 Wrocław, Poland;
| | - Arkadiusz Brąszewski
- Department of Neurooncology and Radiosurgery, Franciszek Lukaszczyk Memorial Oncology Center, 85-796 Bydgoszcz, Poland; (A.B.); (M.H.)
| | - Maciej Harat
- Department of Neurooncology and Radiosurgery, Franciszek Lukaszczyk Memorial Oncology Center, 85-796 Bydgoszcz, Poland; (A.B.); (M.H.)
- Department of Oncology and Brachytherapy, Nicolas Copernicus University, Collegium Medicum, 85-067 Bydgoszcz, Poland
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23
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Childhood Malignant Brain Tumors: Balancing the Bench and Bedside. Cancers (Basel) 2021; 13:cancers13236099. [PMID: 34885207 PMCID: PMC8656510 DOI: 10.3390/cancers13236099] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/29/2021] [Accepted: 11/29/2021] [Indexed: 01/28/2023] Open
Abstract
Simple Summary Brain tumors remain the most common childhood solid tumors, accounting for approximately 25% of all pediatric cancers. They also represent the most common cause of cancer-related illness and death in this age group. Recent years have witnessed an evolution in our understanding of the biological underpinnings of many childhood brain tumors, potentially improving survival through both improved risk group allocation for patients to provide appropriate treatment intensity, and novel therapeutic breakthroughs. This review aims to summarize the molecular landscape, current trial-based standards of care, novel treatments being explored and future challenges for the three most common childhood malignant brain tumors—medulloblastomas, high-grade gliomas and ependymomas. Abstract Brain tumors are the leading cause of childhood cancer deaths in developed countries. They also represent the most common solid tumor in this age group, accounting for approximately one-quarter of all pediatric cancers. Developments in neuro-imaging, neurosurgical techniques, adjuvant therapy and supportive care have improved survival rates for certain tumors, allowing a future focus on optimizing cure, whilst minimizing long-term adverse effects. Recent times have witnessed a rapid evolution in the molecular characterization of several of the common pediatric brain tumors, allowing unique clinical and biological patient subgroups to be identified. However, a resulting paradigm shift in both translational therapy and subsequent survival for many of these tumors remains elusive, while recurrence remains a great clinical challenge. This review will provide an insight into the key molecular developments and global co-operative trial results for the most common malignant pediatric brain tumors (medulloblastoma, high-grade gliomas and ependymoma), highlighting potential future directions for management, including novel therapeutic options, and critical challenges that remain unsolved.
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24
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Shah S, Gates K, Mallory C, Rubens M, Maher OM, Niazi TN, Khatib Z, Kotecha R, Mehta MP, Hall MD. Effect of Postoperative Radiation Therapy Timing on Survival in Pediatric and Young Adult Ependymoma. Adv Radiat Oncol 2021; 6:100691. [PMID: 34409202 PMCID: PMC8360936 DOI: 10.1016/j.adro.2021.100691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/05/2021] [Accepted: 03/08/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Postoperative radiation therapy (RT) is commonly used for World Health Organization grade II-III intracranial ependymoma. Clinicians generally aim to begin RT ≤5 weeks after surgery, but postoperative recovery and need for second look surgery can delay the initiation of adjuvant therapy. On ACNS 0831, patients were required to enroll ≤8 weeks after initial surgery and begin adjuvant therapy within 3 weeks after enrollment. The purpose of this study was to determine the optimal timing of RT after surgery. Methods and Materials The National Cancer Database was queried for patients (aged 1-39 years) with localized World Health Organization grade II-III intracranial ependymoma treated with surgery and postoperative RT. Overall survival (OS) curves were plotted based on RT timing (≤5 weeks, 5-8 weeks, and >8 weeks after surgery) and were compared by log-rank test. Factors associated with OS were identified by multivariate analysis. After 2009, complete data were available on whether patients underwent gross total resection or subtotal resection. Planned subset analysis was performed to examine the effect of RT timing on OS in patients with known extent of resection. Results In the final analytical data set of 1043 patients, no difference in 3-year OS was observed in patients who initiated RT ≤5 weeks, 5 to 8 weeks, and >8 weeks after surgery (89.8% vs 89.1% vs 88.4%; P = .796). On multivariate analysis, grade III tumors (hazard ratio, 2.752; 95% confidence interval, 1.969-3.846, P < .001) and subtotal resection (hazard ratio, 2.253; 95% confidence interval, 1.405-3.611, P < .001) were significantly associated with reduced OS. Timing of RT, total RT dose, age, and other factors were not significant. These findings were affirmed in the subset of patients treated between 2010 and 2016, when extent of resection was routinely recorded. Conclusions Delayed postoperative RT was not associated with inferior survival in patients with intracranial ependymoma. Delayed RT initiation may be acceptable in patients who require longer postoperative recovery or referral to an appropriate RT center, but should be minimized whenever practical.
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Affiliation(s)
- Sunny Shah
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Kevin Gates
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Chase Mallory
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Muni Rubens
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Toba N Niazi
- Department of Pediatric Neurosurgery, Nicklaus Children's Hospital, Miami, Florida
| | | | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
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25
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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.
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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
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26
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Mak DY, Laperriere N, Ramaswamy V, Bouffet E, Murray JC, McNall-Knapp RY, Bielamowicz K, Paulino AC, Zaky W, McGovern SL, Okcu MF, Tabori U, Atwi D, Dirks PB, Taylor MD, Tsang DS, Bavle A. Reevaluating surgery and re-irradiation for locally recurrent pediatric ependymoma—a multi-institutional study. Neurooncol Adv 2021; 3:vdab158. [PMID: 34988448 PMCID: PMC8694210 DOI: 10.1093/noajnl/vdab158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The goal of this study was to evaluate extent of surgical resection, and timing and volume of re-irradiation, on survival for children with locally recurrent ependymoma. Methods Children with locally recurrent ependymoma treated with a second course of fractionated radiotherapy (RT2) from 6 North American cancer centers were reviewed. The index time was from the start of RT2 unless otherwise stated. Results Thirty-five patients were included in the study. The median doses for first radiation (RT1) and RT2 were 55.8 and 54 Gy, respectively. Median follow-up time was 5.6 years. Median overall survival (OS) for all patients from RT2 was 65 months. Gross total resection (GTR) was performed in 46% and 66% of patients prior to RT1 and RT2, respectively. GTR prior to RT2 was independently associated with improved progression-free survival (PFS) for all patients (HR 0.41, P = 0.04), with an OS benefit (HR 0.26, P = 0.03) for infratentorial tumors. Median PFS was superior with craniospinal irradiation (CSI) RT2 (not reached) compared to focal RT2 (56.9 months; log-rank P = 0.03). All distant failures (except one) occurred after focal RT2. Local failures after focal RT2 were predominantly in patients with less than GTR pre-RT2. Conclusions Patients with locally recurrent pediatric ependymoma should be considered for re-treatment with repeat maximal safe resection (ideally GTR) and CSI re-irradiation, with careful discussion of the potential side effects of these treatments.
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Affiliation(s)
- David Y Mak
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey C Murray
- Pediatric Hematology/Oncology, Cook Children’s Medical Center, Fort Worth, Texas, USA
| | - Rene Y McNall-Knapp
- Section of Pediatric Hematology/Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kevin Bielamowicz
- Section of Pediatric Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Wafik Zaky
- Division of Pediatrics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan L McGovern
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - M Fatih Okcu
- Section of Pediatric Hematology/Oncology, Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Doaa Atwi
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Peter B Dirks
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael D Taylor
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abhishek Bavle
- Children’s Blood and Cancer Center, Dell Children’s Medical Center of Central Texas, Austin, Texas, USA
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