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Grieco JA, Evans CL, Yock TI, Pulsifer MB. Psychosocial and executive functioning late effects in pediatric brain tumor survivors after proton radiation. Childs Nerv Syst 2024:10.1007/s00381-024-06579-2. [PMID: 39222091 DOI: 10.1007/s00381-024-06579-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 08/14/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Pediatric brain tumor survivors can experience detrimental effects from radiation treatment. This cross-sectional, large cohort study examined late psychosocial and executive functioning effects in pediatric patients treated ≥ 3 years after proton radiation therapy (PRT). METHODS Parents of 101 pediatric brain tumor survivors completed the Behavior Assessment System for Children and the Behavior Rating Inventory of Executive Function. Standard scores were compared to published normative means, rates of impairment (T-score > 65) were calculated, and demographic and clinical characteristics were examined. RESULTS Mean age at PRT was 8.12 years and mean interval from PRT to assessment was 6.05 years. Half were female (49.5%), 45.5% received craniospinal irradiation (CSI), and 58.4% were diagnosed with infratentorial tumors. All mean T-scores were within normal range. Mean T-scores were significantly elevated compared to the norm on the withdrawal, initiate, working memory, and plan/organize scales. Rates of impairment were notably high in working memory (24.8%), initiate (20.4%), withdrawal (18.1%), and plan/organize (17.0%). Greater withdrawal was significantly associated with CSI and also with chemotherapy and diagnosis of hearing loss. Mean T-scores were significantly lower than the norm on the hyperactivity, aggression, conduct problems, and inhibition scales. No significant problems were identified with social skills or depression. Interval since treatment was not correlated with any scale. CONCLUSION Although psychosocial and executive functioning was within the normal range, on average, social withdrawal and metacognitive executive functioning (working memory, initiating, planning/organizing) were areas of concern. Targeted yearly screening and proactive executive skill and social interventions are needed for this population.
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Affiliation(s)
- Julie A Grieco
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Casey L Evans
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Margaret B Pulsifer
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
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Mahajan A, Stavinoha PL, Rongthong W, Brodin NP, McGovern SL, El Naqa I, Palmer JD, Vennarini S, Indelicato DJ, Aridgides P, Bowers DC, Kremer L, Ronckers C, Constine L, Avanzo M. Neurocognitive Effects and Necrosis in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:401-416. [PMID: 33810950 DOI: 10.1016/j.ijrobp.2020.11.073] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/08/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE A PENTEC review of childhood cancer survivors who received brain radiation therapy (RT) was performed to develop models that aid in developing dose constraints for RT-associated central nervous system (CNS) morbidities. METHODS AND MATERIALS A comprehensive literature search, through the PENTEC initiative, was performed to identify published data pertaining to 6 specific CNS toxicities in children treated with brain RT. Treatment and outcome data on survivors were extracted and used to generate normal tissue complication probability (NTCP) models. RESULTS The search identified investigations pertaining to 2 of the 6 predefined CNS outcomes: neurocognition and brain necrosis. For neurocognition, models for 2 post-RT outcomes were developed to (1) calculate the risk for a below-average intelligence quotient (IQ) (IQ <85) and (2) estimate the expected IQ value. The models suggest that there is a 5% risk of a subsequent IQ <85 when 10%, 20%, 50%, or 100% of the brain is irradiated to 35.7, 29.1, 22.2, or 18.1 Gy, respectively (all at 2 Gy/fraction and without methotrexate). Methotrexate (MTX) increased the risk for an IQ <85 similar to a generalized uniform brain dose of 5.9 Gy. The model for predicting expected IQ also includes the effect of dose, age, and MTX. Each of these factors has an independent, but probably cumulative effect on IQ. The necrosis model estimates a 5% risk of necrosis for children after 59.8 Gy or 63.6 Gy (2 Gy/fraction) to any part of the brain if delivered as primary RT or reirradiation, respectively. CONCLUSIONS This PENTEC comprehensive review establishes objective relationships between patient age, RT dose, RT volume, and MTX to subsequent risks of neurocognitive injury and necrosis. A lack of consistent RT data and outcome reporting in the published literature hindered investigation of the other predefined CNS morbidity endpoints.
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Affiliation(s)
- Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Peter L Stavinoha
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Warissara Rongthong
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Joshua D Palmer
- Department of Radiation Oncology, James Cancer Hospital at Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
| | - Sabina Vennarini
- Proton Therapy Center, Azienda Provinciale per I Servizi Sanitari, Trento, Italy
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Paul Aridgides
- Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse, New York
| | - Daniel C Bowers
- Division of Pediatric Hematology and Oncology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Leontien Kremer
- Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands; Department of Pediatric Oncology, Princess Máxima Center for Paediatric Oncology, Utrecht, the Netherlands
| | - Cecile Ronckers
- Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands; Department of Pediatric Oncology, Princess Máxima Center for Paediatric Oncology, Utrecht, the Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg-Theodor Fontane, Neuruppin, Germany
| | - Louis Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Michele Avanzo
- Medical Physics Department, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
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Thomas T, Grieco JA, Pulsifer M. Long term neuropsychological outcomes of a pediatric ETANTR brain tumor: A case study. APPLIED NEUROPSYCHOLOGY. CHILD 2024; 13:180-189. [PMID: 38447131 DOI: 10.1080/21622965.2024.2322735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Survivors of pediatric brain tumors are at high risk for long-term neuropsychological difficulties. In the current case study, we present longitudinal neuropsychological data spanning 10 years (from age 9 to 19 years) of a patient with a rare, very large, bifrontal, embryonal tumor with abundant neuropil and true rosettes (ETANTR), which is typically associated with poor survivorship and significant neurological impact. Results demonstrated that the patient had largely intact cognitive functioning with specific difficulties in executive functioning, fine motor skills, and adaptive functioning at her most recent neuropsychology 10-year follow-up. These results highlight outcomes for a patient with remarkable resiliency in the context of numerous risk factors (a very large tumor size, multi-modal treatment, and seizure history). Patient protective factors (a high level of cognitive reserve, family support, and appropriate comprehensive educational services) likely contributed to the patient's favorable neuropsychological outcome. The patient's age at brain tumor diagnosis (9 years) and associated treatment was at a critical period of development for emerging higher order cognitive functions which likely impacted acquisition of executive functioning skills and secondarily adaptive skill outcomes. Consequently, pediatric brain tumor survivors with ETANTR or other frontal tumors require targeted screening of executive functions and proactive interventions.
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Affiliation(s)
- Tina Thomas
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie A Grieco
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Margaret Pulsifer
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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4
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L’Hotta AJ, Spence A, Varughese TE, Felts K, Hayashi SS, Jones-White M, LaFentres E, Lieu JEC, Hayashi RJ, King AA. Children with non-central nervous system tumors treated with platinum-based chemotherapy are at risk for hearing loss and cognitive impairments. Front Pediatr 2024; 12:1341762. [PMID: 38571700 PMCID: PMC10987805 DOI: 10.3389/fped.2024.1341762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
Background Childhood cancer survivors (CCS) with chemotherapy induced sensorineural hearing loss (SNHL) are at risk for neurocognitive impairments. The purpose of this study was to determine the relationship between SNHL and cognitive function among CCS. Procedure Inclusion: non-CNS solid tumor diagnosis; history of platinum chemotherapy (cisplatin and/or carboplatin); 8-17 years of age; off anti-cancer treatment for ≥6 months; and English speaking. Exclusion: history of intrathecal chemotherapy, cranial radiation, or baseline neurocognitive disorder. Participants completed the NIH Toolbox Cognition Battery at enrollment. T-tests were used to compare participants with normal hearing to those with hearing loss and the total sample with established Toolbox normative data (mean: 50; SD: 10). Results Fifty-seven individuals enrolled; 52 completed full cognitive testing. Participants were on average 12.2 years of age and 7.0 years since treatment completion. Twenty-one participants (40%) received cisplatin, 27 (52%) carboplatin, and 4 (8%) received both. Fifteen participants (29%) demonstrated SNHL based on the better ear. CCS, regardless of the presence or absence of SNHL, demonstrated significantly lower mean cognitive skills compared to the normative sample in attention, executive function, language- vocabulary and oral reading, processing speed, and fluid, crystallized and total composite scores (all p < 0.01). Participants with SNHL had significantly lower crystallized composite (vocabulary, oral reading) than those with normal hearing (41.9 vs. 47.2, p < 0.05, Cohen's d = 0.62). Conclusions CCS at risk for platinum induced hearing loss but without cranial radiation or intrathecal chemotherapy exposure demonstrate impaired cognitive skills and those with SNHL demonstrate lower crystallized composite scores.
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Affiliation(s)
- Allison J. L’Hotta
- Brown School, Prevention Research Center, Washington University in St. Louis, St. Louis, MO, United States
| | - Anne Spence
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Taniya E. Varughese
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Kara Felts
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Susan S. Hayashi
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Megan Jones-White
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Emily LaFentres
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Judith E. C. Lieu
- Department of Otolaryngology, Division of Pediatric Otolaryngology, Washington University in St. Louis, St. Louis, MO, United States
| | - Robert J. Hayashi
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Allison A. King
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Washington University in St. Louis, St. Louis, MO, United States
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Unnikrishnan S, Yip AT, Qian AS, Salans MA, Yu JD, Huynh-Le MP, Reyes A, Stasenko A, McDonald C, Kaner R, Crawford JR, Hattangadi-Gluth JA. Neurocognitive Outcomes in Multiethnic Pediatric Brain Tumor Patients Treated With Proton Versus Photon Radiation. J Pediatr Hematol Oncol 2023; 45:e837-e846. [PMID: 37539987 PMCID: PMC10538429 DOI: 10.1097/mph.0000000000002724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND We analyzed post-radiation (RT) neurocognitive outcomes in an ethnically diverse pediatric brain tumor population undergoing photon radiotherapy (XRT) and proton radiotherapy (PRT). PROCEDURE Post-RT neurocognitive outcomes from 49 pediatric patients (37% Hispanic/Latino) with primary brain tumors were analyzed. Tests included cognitive outcomes, behavioral outcomes, and overall intelligence. For each outcome, proportion of patients with cognitive impairment (scores <1.5 SD) was calculated. The Fisher exact tests compared proportion of patients with impairment and t tests compared T-scores between XRT (n=32) and PRT (n=17) groups. Linear regression assessed associations between radiation modality and outcomes. RESULTS Median follow-up was 3.2 and 1.8 years in the XRT and PRT groups, respectively. The median RT dose was 54.0 Gy. We found impairment in 16% to 42% of patients across most neurocognitive domains except executive function. There was no difference in scores between XRT and PRT groups. Regression analyses revealed no association of neurocognitive outcomes with radiation modality. Non-Hispanic patients had better Verbal Comprehension Index and General Ability Index scores than Hispanic patients ( P <0.05). CONCLUSIONS Among pediatric patients with brain tumors receiving RT, all cognitive domains were affected except executive function. Radiation modality was not associated with neurocognitive outcomes. Hispanic patients may be more vulnerable to posttreatment cognitive effects that warrant further study.
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Affiliation(s)
- Soumya Unnikrishnan
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Anthony T Yip
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Alexander S Qian
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Mia A Salans
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Justin D Yu
- Departments of Radiation Medicine and Applied Sciences
| | | | | | | | - Carrie McDonald
- Departments of Radiation Medicine and Applied Sciences
- Psychiatry
| | | | - John R Crawford
- Neurosciences and Pediatrics, University of California San Diego, La Jolla
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Ahmed SK, Keole SR. Proton Therapy in the Adolescent and Young Adult Population. Cancers (Basel) 2023; 15:4269. [PMID: 37686545 PMCID: PMC10487250 DOI: 10.3390/cancers15174269] [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: 07/06/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Adolescent and young adult cancer patients are at high risk of developing radiation-associated side effects after treatment. Proton beam radiation therapy might reduce the risk of these side effects for this population without compromising treatment efficacy. METHODS We review the current literature describing the utility of proton beam radiation therapy in the treatment of central nervous system tumors, sarcomas, breast cancer and Hodgkin lymphoma for the adolescent and young adult cancer population. RESULTS Proton beam radiation therapy has utility for the treatment of certain cancers in the young adult population. Preliminary data suggest reduced radiation dose to normal tissues, which might reduce radiation-associated toxicities. Research is ongoing to further establish the role of proton therapy in this population. CONCLUSION This report highlights the potential utility of proton beam radiation for certain adolescent young adult cancers, especially with reducing radiation doses to organs at risk and thereby potentially lowering risks of certain treatment-associated toxicities.
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Affiliation(s)
- Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;
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Lassaletta Á, Morales JS, Valenzuela PL, Esteso B, Kahalley LS, Mabbott DJ, Unnikrishnan S, Panizo E, Calvo F. Neurocognitive outcomes in pediatric brain tumors after treatment with proton versus photon radiation: a systematic review and meta-analysis. World J Pediatr 2023; 19:727-740. [PMID: 37154861 PMCID: PMC10348930 DOI: 10.1007/s12519-023-00726-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/05/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Advances in cancer treatments, particularly the development of radiation therapy, have led to improvements in survival outcomes in children with brain tumors. However, radiation therapy is associated with significant long-term neurocognitive morbidity. The present systematic review and meta-analysis aimed to compare the neurocognitive outcomes of children and adolescents with brain tumors treated with photon radiation (XRT) or proton therapy (PBRT). METHODS A systematic search was conducted (PubMed, Embase, Cochrane, and Web of Science from inception until 02/01/2022) for studies comparing the neurocognitive outcomes of children and adolescents with brain tumors treated with XRT vs. PBRT. The pooled mean differences (expressed as Z scores) were calculated using a random effects method for those endpoints analyzed by a minimum of three studies. RESULTS Totally 10 studies (n = 630 patients, average age range: 1-20 years) met the inclusion criteria. Patients who had received PBRT achieved significantly higher scores (difference in Z scores ranging from 0.29-0.75, all P < 0.05 and significant in sensitivity analyses) after treatment than those who had received XRT for most analyzed neurocognitive outcomes (i.e., intelligence quotient, verbal comprehension and perceptual reasoning indices, visual motor integration, and verbal memory). No robust significant differences (P > 0.05 in main analyses or sensitivity analyses) were found for nonverbal memory, verbal working memory and working memory index, processing speed index, or focused attention. CONCLUSIONS Pediatric brain tumor patients who receive PBRT achieve significantly higher scores on most neurocognitive outcomes than those who receive XRT. Larger studies with long-term follow-ups are needed to confirm these results.
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Affiliation(s)
- Álvaro Lassaletta
- Radiation Oncology Department, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta 1, 28027, Madrid, Spain.
- Pediatric Neuro-Oncology Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain.
| | - Javier S Morales
- MOVE-IT Research Group, Department of Physical Education, Faculty of Education Sciences, University of Cadiz, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital, University of Cádiz, Cádiz, Spain
| | - Pedro L Valenzuela
- Physical Activity and Health Research Group (PaHerg), Research Institute of the Hospital 12 de Octubre ('imas12'), Madrid, Spain
- Systems Biology Department, University of Alcalá, Madrid, Spain
| | - Borja Esteso
- Clinical Neuropsychology Unit, Psychiatry and Clinical Psychology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Lisa S Kahalley
- Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Donald J Mabbott
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
| | | | - Elena Panizo
- Radiation Oncology Department, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta 1, 28027, Madrid, Spain
| | - Felipe Calvo
- Radiation Oncology Department, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta 1, 28027, Madrid, Spain
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Helligsoe ASL, Henriksen LT, Kenborg L, Lassen-Ramshad Y, Wu LM, Winther JF, Hasle H, Amidi A. Neurocognitive function and health-related quality of life in a nationwide cohort of long-term childhood brain tumor survivors. Neurooncol Pract 2023; 10:140-151. [PMID: 36970169 PMCID: PMC10037941 DOI: 10.1093/nop/npac085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Childhood brain tumor survivors are at high risk of late effects, especially neurocognitive impairment. Limited data are available examining neurocognitive function and associations with quality of life (QoL) in childhood brain tumor survivors. Our aim was to examine neurocognitive function in childhood brain tumor survivors, and associations with QoL and symptom burden. Methods Five-year survivors of brain tumors over the age of 15 were identified in the Danish Childhood Cancer Registry (n = 423). Eligible and consenting participants completed neuropsychological tests and questionnaires assessing QoL, insomnia, fatigue, anxiety, and depression. Survivors treated with radiation (n = 59) were statistically compared with survivors not treated with radiation (n = 102). Results In total, 170 survivors participated (40.2% participation rate). Sixty-six percent of the survivors who completed neurocognitive tests (n = 161) exhibited overall neurocognitive impairment. Survivors treated with radiation, especially whole-brain irradiation, exhibited poorer neurocognitive outcomes than survivors not treated with radiation. Neurocognitive outcomes for survivors treated with surgery were below normative expectations. Furthermore, a number of survivors experienced significant fatigue (40%), anxiety (23%), insomnia (13%), and/or depression (6%). Survivors treated with radiation reported lower quality of life (QoL) and higher symptom burden scores than survivors not treated with radiation; particularly in physical functioning, and social functioning with symptoms of fatigue. Neurocognitive impairment was not associated with QoL or symptom burden. Conclusions In this study, a majority of the childhood brain tumor survivors experienced neurocognitive impairment, reduced QoL, and high symptom burden. Although not associated with each other, it is apparent that childhood brain tumor survivors experience not only neurocognitive dysfunction but may also experience QoL impairments and significant symptom burden.
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Affiliation(s)
- Anne Sophie L Helligsoe
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Louise T Henriksen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Line Kenborg
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Denmark
| | | | - Lisa M Wu
- Unit for Psychooncology & Health Psychology, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Jeanette F Winther
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Denmark
- Aarhus University Hospital, Denmark
| | - Henrik Hasle
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Ali Amidi
- Unit for Psychooncology & Health Psychology, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
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Mash LE, Kahalley LS, Raghubar KP, Goodrich-Hunsaker NJ, Abildskov TJ, De Leon LA, MacLeod M, Stancel H, Parsons K, Biekman B, Desai NK, Grosshans DR, Paulino AC, Chu ZD, Whitehead WE, Okcu MF, Chintagumpala M, Wilde EA. Cognitive Sparing in Proton versus Photon Radiotherapy for Pediatric Brain Tumor Is Associated with White Matter Integrity: An Exploratory Study. Cancers (Basel) 2023; 15:cancers15061844. [PMID: 36980730 PMCID: PMC10047305 DOI: 10.3390/cancers15061844] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
Radiotherapy for pediatric brain tumors is associated with reduced white matter structural integrity and neurocognitive decline. Superior cognitive outcomes have been reported following proton radiotherapy (PRT) compared to photon radiotherapy (XRT), presumably due to improved sparing of normal brain tissue. This exploratory study examined the relationship between white matter change and late cognitive effects in pediatric brain tumor survivors treated with XRT versus PRT. Pediatric brain tumor survivors treated with XRT (n = 10) or PRT (n = 12) underwent neuropsychological testing and diffusion weighted imaging >7 years post-radiotherapy. A healthy comparison group (n = 23) was also recruited. Participants completed age-appropriate measures of intellectual functioning, visual-motor integration, and motor coordination. Tractography was conducted using automated fiber quantification (AFQ). Fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD) were extracted from 12 tracts of interest. Overall, both white matter integrity (FA) and neuropsychological performance were lower in XRT patients while PRT patients were similar to healthy control participants with respect to both FA and cognitive functioning. These findings support improved long-term outcomes in PRT versus XRT. This exploratory study is the first to directly support for white matter integrity as a mechanism of cognitive sparing in PRT.
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Affiliation(s)
- Lisa E Mash
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine, Houston, TX 77030, USA
- Psychology Service, Texas Children's Hospital, Houston, TX 77030, USA
| | - Lisa S Kahalley
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX 77030, USA
| | - Kimberly P Raghubar
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine, Houston, TX 77030, USA
- Psychology Service, Texas Children's Hospital, Houston, TX 77030, USA
| | | | - Tracy J Abildskov
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Luz A De Leon
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine, Houston, TX 77030, USA
- Psychology Service, Texas Children's Hospital, Houston, TX 77030, USA
| | - Marianne MacLeod
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine, Houston, TX 77030, USA
- Psychology Service, Texas Children's Hospital, Houston, TX 77030, USA
| | - Heather Stancel
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine, Houston, TX 77030, USA
- Psychology Service, Texas Children's Hospital, Houston, TX 77030, USA
| | - Kelley Parsons
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine, Houston, TX 77030, USA
- Psychology Service, Texas Children's Hospital, Houston, TX 77030, USA
| | - Brian Biekman
- Department of Psychology, University of Houston, Houston, TX 77204, USA
| | - Nilesh K Desai
- Department of Radiology, Division of Neuroradiology, Texas Children's Hospital, Houston, TX 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Arnold C Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Zili D Chu
- Department of Radiology, Division of Neuroradiology, Texas Children's Hospital, Houston, TX 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - William E Whitehead
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Mehmet Fatih Okcu
- Department of Pediatrics, Division of Hematology Oncology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Murali Chintagumpala
- Department of Pediatrics, Division of Hematology Oncology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Elisabeth A Wilde
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Department of Pediatrics, Division of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
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10
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Jurbergs N, Kennedy A, Harman JL. Promoting Completion of Cranial Radiation Therapy Without Sedation in Young Patients With Brain Tumors: A Case Series Illustrating Flexible Application of Empirically Supported Intervention. J Pediatr Hematol Oncol 2023; 45:91-94. [PMID: 36044332 DOI: 10.1097/mph.0000000000002542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/16/2022] [Indexed: 11/25/2022]
Abstract
Repeated anesthesia poses risks to patients but is often utilized to immobilize young children undergoing cranial radiation therapy for brain tumors. To enable young patients to remain still during cranial radiation therapy and thereby avoid sedation, medical and psychosocial clinicians can use behavioral and other supportive interventions. This case series illustrates the utility of behavioral training for motion control in 3 children 6 years old or younger who were treated for brain tumors. We demonstrate the efficacy of flexible, individualized intervention approaches to accommodate patients with brain tumors in the context of emotional dysregulation, significant communication barriers, and profound sensory deficits.
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Affiliation(s)
| | - Amy Kennedy
- Child Life, St. Jude Children's Research Hospital, Memphis, TN
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11
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Mash LE, Kahalley LS, Okcu MF, Grosshans DR, Paulino AC, Stancel H, Leon LD, Wilde E, Desai N, Chu ZD, Whitehead WE, Chintagumpala M, Raghubar KP. Superior verbal learning and memory in pediatric brain tumor survivors treated with proton versus photon radiotherapy. Neuropsychology 2023; 37:204-217. [PMID: 36480379 PMCID: PMC10544942 DOI: 10.1037/neu0000882] [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] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Radiotherapy for pediatric brain tumor has been associated with late cognitive effects. Compared to conventional photon radiotherapy (XRT), proton radiotherapy (PRT) delivers lower doses of radiation to healthy brain tissue. PRT has been associated with improved long-term cognitive outcomes compared to XRT. However, there is limited research comparing the effects of XRT and PRT on verbal memory. METHOD Survivors of pediatric brain tumor treated with either XRT (n = 29) or PRT (n = 51) completed neuropsychological testing > 1 year following radiotherapy. Performance on neuropsychological measures was compared between treatment groups using analysis of covariance. Chi-squared tests of independence were used to compare the frequency of encoding, retrieval, and intact memory profiles between treatment groups. Associations between memory performance and other neurobehavioral measures were examined using Pearson correlation. RESULTS Overall, patients receiving PRT demonstrated superior verbal learning and recall compared to those treated with XRT. Encoding and retrieval deficits were more common in the XRT group than the PRT group, with encoding problems being most prevalent. The PRT group was more likely to engage in semantic clustering strategies, which predicted better encoding and retrieval. Encoding ability was associated with higher intellectual and adaptive functioning, and fewer parent-reported concerns about day-to-day attention and cognitive regulation. CONCLUSION Results suggest that PRT is associated with verbal memory sparing, driven by effective encoding and use of learning strategies. Future work may help to clarify underlying neural mechanisms associated with verbal memory decline, which will better inform treatment approaches. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Lisa E. Mash
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
| | - Lisa S. Kahalley
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
- Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital
| | - M. Fatih Okcu
- Department of Pediatrics, Division of Hematology Oncology, Baylor College of Medicine
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center
| | - Heather Stancel
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
| | - Luz De Leon
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
| | - Elisabeth Wilde
- Department of Neurology, University of Utah School of Medicine
| | - Nilesh Desai
- Department of Pediatrics, Division of Neuroradiology, Baylor College of Medicine
| | - Zili D. Chu
- Department of Pediatrics, Division of Neuroradiology, Baylor College of Medicine
| | | | - Murali Chintagumpala
- Department of Pediatrics, Division of Hematology Oncology, Baylor College of Medicine
| | - Kimberly P. Raghubar
- Department of Pediatrics, Division of Psychology, Baylor College of Medicine
- Psychology Service, Texas Children’s Hospital
- Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital
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12
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Marie Baunsgaard M, Sophie Lind Helligsoe A, Tram Henriksen L, Stamm Mikkelsen T, Callesen M, Weber B, Hasle H, Birkebæk N. Growth hormone deficiency in adult survivors of childhood brain tumors treated with radiation. Endocr Connect 2023; 12:e220365. [PMID: 36507776 PMCID: PMC9874963 DOI: 10.1530/ec-22-0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/12/2022] [Indexed: 12/14/2022]
Abstract
Objective Growth hormone deficiency (GHD) is the most common endocrine late effect in irradiated survivors of childhood brain tumors. This study aimed to determine the prevalence of GHD in adults treated with proton or photon irradiation for a brain tumor in childhood and to detect undiagnosed GHD. Design This study is a cross-sectional study. Methods We investigated GHD in 5-year survivors from two health regions in Denmark treated for childhood brain tumors with cranial or craniospinal irradiation in the period 1997-2015. Medical charts were reviewed for endocrinological and other health data. Survivors without a growth hormone (GH) test at final height were invited to a GH stimulation test. Results Totally 41 (22 females) survivors with a median age of 21.7 years (range: 15.1-33.8 years) at follow-up and 14.8 years (range: 5.1-23.4 years) since diagnosis were included; 11 were treated with proton and 30 with photon irradiation; 18 of 21 survivors were previously found to have GHD; 16 of 20 survivors with no GH test at final height were tested, 8 (50 %) had GHD. In total, 26 of 41 patients (63%) had GHD. Insulin-like growth factor-1 (IGF-1) is associated poorly with the insulin tolerance test (ITT). Conclusion This study identified a high prevalence of undiagnosed GHD in survivors with no GH test at final height. The results stress the importance of screening for GHD at final height in survivors of childhood brain tumors with prior exposure to cranial irradiation, irrespective of radiation modality and IGF-1. Significance statement This cross-sectional study reports a prevalence of 63% of GHD in irradiated childhood brain tumor survivors. Furthermore, the study identified a considerable number of long-term survivors without a GH test at final height, of whom, 50% subsequently were shown to have undiagnosed GHD. Additionally, this study confirmed that a normal serum IGF-1 measurement cannot exclude the diagnosis of GHD in irradiated survivors. This illustrates the need for improvements in the diagnostic approach to GHD after reaching final height in childhood brain tumor survivors at risk of GHD. In summary, our study stresses the need for GHD testing in all adult survivors treated with cranial irradiation for a brain tumor in childhood irrespective of radiation modality.
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Affiliation(s)
- Mette Marie Baunsgaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Sophie Lind Helligsoe
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Louise Tram Henriksen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Torben Stamm Mikkelsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Callesen
- Department of Paediatrics, Odense University Hospital, Odense, Funen, Denmark
| | - Britta Weber
- The Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Hasle
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Birkebæk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
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13
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McCurdy MD, Raghubar KP, Christopher K, Okcu MF, Wilde E, Desai N, Chu ZD, Gragert M, Stancel H, Warren EH, Whitehead WE, Grosshans D, Paulino AC, Chintagumpala M, Kahalley LS. Predicting neurocognitive function in pediatric brain tumor early survivorship: The neurological predictor scale and the incremental validity of tumor size. Pediatr Blood Cancer 2022; 69:e29803. [PMID: 35709014 PMCID: PMC10265925 DOI: 10.1002/pbc.29803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Neurological Predictor Scale (NPS) quantifies cumulative exposure to conventional treatment-related neurological risks but does not capture potential risks posed by tumors themselves. This study evaluated the predictive validity of the NPS, and the incremental value of tumor location and size, for neurocognitive outcomes in early survivorship following contemporary therapies for pediatric brain tumors. PROCEDURE Survivors (N = 69) diagnosed from 2010 to 2016 were administered age-appropriate versions of the Wechsler Intelligence Scales. Hierarchical multiple regressions examined the predictive and incremental validity of NPS score, tumor location, and tumor size. RESULTS Participants (51% female) aged 6-20 years (M = 13.22, SD = 4.09) completed neurocognitive evaluations 5.16 years (SD = 1.29) postdiagnosis. The NPS significantly predicted Full-Scale Intelligence Quotient (FSIQ; ΔR2 = .079), Verbal Comprehension Index (VCI; ΔR2 = 0.051), Perceptual Reasoning Index (PRI; ΔR2 = 0.065), and Processing Speed Index (PSI; ΔR2 = 0.049) performance after controlling for sex, age at diagnosis, and maternal education. Tumor size alone accounted for a significant amount of unique variance in FSIQ (ΔR2 = 0.065), PRI (ΔR2 = 0.076), and PSI (ΔR2 = 0.080), beyond that captured by the NPS and relevant covariates. Within the full model, the NPS remained a significant independent predictor of FSIQ (β = -0.249, P = 0.016), VCI (β = -0.223, P = 0.048), and PRI (β = -0.229, P = 0.037). CONCLUSIONS Tumor size emerged as an independent predictor of neurocognitive functioning and added incrementally to the predictive utility of the NPS. Pretreatment disease burden may provide one of the earliest markers of neurocognitive risk following contemporary treatments. With perpetual treatment advances, measures quantifying treatment-related risk may need to be updated and revalidated to maintain their clinical utility.
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Affiliation(s)
- Mark D. McCurdy
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Kimberly P. Raghubar
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | | | - M. Fatih Okcu
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Elisabeth Wilde
- Baylor College of Medicine, Houston, TX, US
- University of Utah, Salt Lake City, UT, US
| | - Nilesh Desai
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Zili D. Chu
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Marsha Gragert
- The University of Texas MD Anderson Cancer Center, Houston, TX US
| | | | - Emily H. Warren
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - William E. Whitehead
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX US
| | | | - Murali Chintagumpala
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Lisa S. Kahalley
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
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14
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Hagan AJ, Verity SJ. The influence of methylphenidate on sustained attention in paediatric acquired brain injury: a meta-analytical review. Child Neuropsychol 2022:1-32. [PMID: 36000579 DOI: 10.1080/09297049.2022.2112559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Impairment in sustained attention is a common consequence of childhood Acquired Brain Injury (ABI). Whilst methylphenidate provides promise in enhancing "attention" as a unitary construct, little work has explored its effectiveness upon individual attentional domains. The current systematic review and meta-analysis evaluates the utility of methylphenidate on sustained attentional performance across childhood ABI groups. Five databases (PsycINFO, MEDLINE, Embase, Scopus & Cochrane Library) were searched for relevant articles from their inception to March 2022. A purpose-developed evaluation tool was used to assess each study's research quality (QuEST:MAP). Nine of the 1600 identified articles were included within this review (n = 259). Meta-analytical findings reported an overall significant benefit of methylphenidate on sustained attention in childhood ABI (g = -0.33, 95% CI: -0.62 to -0.04). Associated summary effect sizes were relatively small, particularly when adjusting for outlier cases. Subgroup analyses identified a significantly greater benefit of methylphenidate in clinical subgroups with comorbid ADHD diagnoses (p < .01). The current evidence base is characterized by small-scale clinical trials with variable research quality and low generalizability. Further robust research is needed to quantify methylphenidate utility upon individual attentional domains in larger and more representative ABI samples.
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Affiliation(s)
- Alexander J Hagan
- Department of Paediatric Health Psychology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle-Upon-Tyne, UK
| | - Sarah J Verity
- Department of Paediatric Health Psychology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle-Upon-Tyne, UK.,Newcastle University Centre for Cancer, Newcastle University, Newcastle Upon Tyne, UK
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15
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The Current State of Radiotherapy for Pediatric Brain Tumors: An Overview of Post-Radiotherapy Neurocognitive Decline and Outcomes. J Pers Med 2022; 12:jpm12071050. [PMID: 35887547 PMCID: PMC9315742 DOI: 10.3390/jpm12071050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/17/2022] Open
Abstract
Tumors of the central nervous system are the most common solid malignancies diagnosed in children. While common, they are also found to have some of the lowest survival rates of all malignancies. Treatment of childhood brain tumors often consists of operative gross total resection with adjuvant chemotherapy or radiotherapy. The current body of literature is largely inconclusive regarding the overall benefit of adjuvant chemo- or radiotherapy. However, it is known that both are associated with conditions that lower the quality of life in children who undergo those treatments. Chemotherapy is often associated with nausea, emesis, significant fatigue, immunosuppression, and alopecia. While radiotherapy can be effective for achieving local control, it is associated with late effects such as endocrine dysfunction, secondary malignancy, and neurocognitive decline. Advancements in radiotherapy grant both an increase in lifetime survival and an increased lifetime for survivors to contend with these late effects. In this review, the authors examined all the published literature, analyzing the results of clinical trials, case series, and technical notes on patients undergoing radiotherapy for the treatment of tumors of the central nervous system with a focus on neurocognitive decline and survival outcomes.
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16
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Warren EA, Raghubar KP, Cirino PT, Child AE, Lupo PJ, Grosshans DR, Paulino AC, Okcu MF, Minard CG, Ris MD, Mahajan A, Viana A, Chintagumpala M, Kahalley LS. Cognitive predictors of social adjustment in pediatric brain tumor survivors treated with photon versus proton radiation therapy. Pediatr Blood Cancer 2022; 69:e29645. [PMID: 35285129 PMCID: PMC9208675 DOI: 10.1002/pbc.29645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/13/2022] [Accepted: 02/15/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pediatric brain tumor survivors are at risk for poor social outcomes. It remains unknown whether cognitive sparing with proton radiotherapy (PRT) supports better social outcomes relative to photon radiotherapy (XRT). We hypothesized that survivors treated with PRT would outperform those treated with XRT on measures of cognitive and social outcomes. Further, we hypothesized that cognitive performance would predict survivor social outcomes. PROCEDURE Survivors who underwent PRT (n = 38) or XRT (n = 20) participated in a neurocognitive evaluation >1 year post radiotherapy. Group differences in cognitive and social functioning were assessed using analysis of covariance (ANCOVA). Regression analyses examined predictors of peer relations and social skills. RESULTS Age at evaluation, radiation dose, tumor diameter, and sex did not differ between groups (all p > .05). XRT participants were younger at diagnosis (XRT M = 5.0 years, PRT M = 7.6 years) and further out from radiotherapy (XRT M = 8.7 years, PRT M = 4.6 years). The XRT group performed worse than the PRT group on measures of processing speed (p = .01) and verbal memory (p < .01); however, social outcomes did not differ by radiation type. The proportion of survivors with impairment in peer relations and social skills exceeded expectation; χ2 (1) = 38.67, p < .001; χ2 (1) = 5.63, p < .05. Household poverty predicted peer relation difficulties (t = 2.18, p < .05), and verbal memory approached significance (t = -1.99, p = .05). Tumor diameter predicted social skills (t = -2.07, p < .05). CONCLUSIONS Regardless of radiation modality, survivors are at risk for social challenges. Deficits in verbal memory may place survivors at particular risk. Results support monitoring of cognitive and social functioning throughout survivorship, as well as consideration of sociodemographic risk factors.
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Affiliation(s)
- Emily A.H. Warren
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Kimberly P. Raghubar
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Paul T. Cirino
- Department of Psychology, University of Houston, Houston TX
| | - Amanda E. Child
- Department of Pediatrics, Division of Child and Adolescent Neurology, UT Health, Houston TX
| | - Philip J. Lupo
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - M. Fatih Okcu
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston TX
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Anita Mahajan
- Department of Radiation Oncology, The Mayo Clinic, Rochester MN
| | - Andres Viana
- Department of Psychology, University of Houston, Houston TX
| | - Murali Chintagumpala
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston TX
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX,Correspondence To: Lisa S. Kahalley, Ph.D., Texas Children’s Hospital, 1102 Bates Ave., Suite 940, Houston, TX 77030-2399, US; Telephone: 832-822-4759; Fax: 832-825-1222; .
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17
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Al Dahhan NZ, Cox E, Nieman BJ, Mabbott DJ. Cross-translational models of late-onset cognitive sequelae and their treatment in pediatric brain tumor survivors. Neuron 2022; 110:2215-2241. [PMID: 35523175 DOI: 10.1016/j.neuron.2022.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/21/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
Pediatric brain tumor treatments have a high success rate, but survivors are at risk of cognitive sequelae that impact long-term quality of life. We summarize recent clinical and animal model research addressing pathogenesis or evaluating candidate interventions for treatment-induced cognitive sequelae. Assayed interventions encompass a broad range of approaches, including modifications to radiotherapy, modulation of immune response, prevention of treatment-induced cell loss or promotion of cell renewal, manipulation of neuronal signaling, and lifestyle/environmental adjustments. We further emphasize the potential of neuroimaging as a key component of cross-translation to contextualize laboratory research within broader clinical findings. This cross-translational approach has the potential to accelerate discovery to improve pediatric cancer survivors' long-term quality of life.
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Affiliation(s)
- Noor Z Al Dahhan
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Cox
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada; Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Brian J Nieman
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada; Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada; Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Donald J Mabbott
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada; Department of Psychology, University of Toronto, Toronto, ON, Canada; Department of Psychology, Hospital for Sick Children, Toronto, ON, Canada.
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18
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Youn SH, Ha B, Lee EH, Park B, Yang SE, Yu ES, Kim JY. Neurocognitive and psychological functioning of pediatric brain tumor patients undergoing proton beam therapy for three different tumor types. Pediatr Blood Cancer 2022; 69:e29430. [PMID: 34766721 DOI: 10.1002/pbc.29430] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND A high proportion of pediatric patients with brain tumors (BTs) are known to experience a decline in neurocognitive function after treatment. We prospectively examined neuropsychological functioning of patients with BTs of varying tumor types at different time points before, during, and after proton beam therapy. MATERIALS AND METHODS A total of 98 patients with posterior fossa tumors (PFTs; n = 33), germ cell tumors (GCTs; n = 52), and other supratentorial tumors (STTs; n = 13) underwent baseline neuropsychological assessments and 57 patients underwent follow-up assessments. RESULTS All groups displayed significantly lower performance intelligence quotient (PIQ) and processing speed (PS) scores than the normative means at baseline. The PFT group exhibited significantly lower scores for full-scale IQ, PIQ, PS, attention, and executive function. The GCT group displayed full-scale IQ scores within the normal range, but a significantly high proportion had memory deficits. In the STT group, all functions except for the PIQ and PS were intact. Longitudinal evaluations demonstrated stable global IQ scores over time in all groups. In the PFT group, verbal comprehension, attention, and PS improved over time. However, in the GCT group, verbal IQ scores declined significantly and psychological problems worsened over time, which were correlated with poorer neurocognitive function at 3-5 years after treatment. In the STT group, no significant changes were observed. CONCLUSION Because patients with BTs exhibit various types of neurocognitive deficit before radiotherapy, early cognitive treatment tailored to the tumor type maybe beneficial. Interventions for psychological problems and memory function may be necessary, especially for patients with GCT.
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Affiliation(s)
- Sang Hee Youn
- Proton Therapy Center, National Cancer Center, Goyang, Republic of Korea
| | - Boram Ha
- Proton Therapy Center, National Cancer Center, Goyang, Republic of Korea
| | - Eun-Hee Lee
- Proton Therapy Center, National Cancer Center, Goyang, Republic of Korea
| | - Boram Park
- Biostatistics Collaboration Unit, National Cancer Center, Goyang, Republic of Korea
| | - Song Ei Yang
- Proton Therapy Center, National Cancer Center, Goyang, Republic of Korea
| | - Eun-Seung Yu
- Mental Health Clinic, National Cancer Center, Goyang, Republic of Korea
| | - Joo-Young Kim
- Proton Therapy Center, National Cancer Center, Goyang, Republic of Korea
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19
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Kasatkin V, Deviaterikova A, Shurupova M, Karelin A. The feasibility and efficacy of short-term visual-motor training in pediatric posterior fossa tumor survivors. Eur J Phys Rehabil Med 2022; 58:51-59. [PMID: 34247471 PMCID: PMC9980593 DOI: 10.23736/s1973-9087.21.06854-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pediatric posterior fossa tumor (PFT) survivors experience a range of cognitive and motor impairments that require timely rehabilitation of these functions. In Russia, rehabilitation services are only just beginning to be formed; therefore, it is necessary to test rehabilitation protocols for children surviving cancer. AIM To evaluate the efficacy of short-term cognitive and motor training (CMT) aimed on visual-motor integration in PFT survivors using training devices. DESIGN "Single center" quasi randomized controlled experiment. SETTING Outpatients of the Russkoe Pole Rehabilitation Center. POPULATION The 63 children cancer survivors between the ages of 6 and 17 years. METHODS The baseline level of cognitive and motor functions was assessed in all participants. Then the sample of patients split into two subgroups of equal sex, age, and diagnosis. The intervention subgroup received six sessions of CMT for two weeks, and the other subgroup underwent 'empty' two weeks with no intervention. Reassessment of motor and cognitive functions was conducted in all participants. Then the subgroups changed: the first subgroup underwent 'empty' two weeks, and the second subgroup completed the CMT, and further reassessment was provided. RESULTS The primary results demonstrate an increase in gross and fine motor skills, motor coordination, visual-motor integration, and visual processing after CMT. Secondary results show that the age at onset is an important factor in the subsequent decline in cognitive, motor functions, and eye movements. Children with medulloblastoma perform worse on motor tests than children with astrocytoma. A tumor in the IV ventricle is the most harmful, and a tumor in the cerebellar hemispheres is the least harmful to a child's cognitive and motor development. CONCLUSIONS This study shows the effectiveness of a short-term CMT program for children who survived PFT. The study also found that cognitive, motor, and visual-motor functions are affected by the tumor's localization, malignancy, and the child's age at onset. CLINICAL REHABILITATION IMPACT Short-term rehabilitation methods can be useful in pediatric oncological practice. Reconstruction of cognitive functions can occur during the training of more "simple" functions, such as hand-eye integration. The study makes a significant contribution to the methods of short-term rehabilitation in children who survived cancer.
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Affiliation(s)
- Vladimir Kasatkin
- Department of Neurocognitive, Psychophysiological Research and Physical Rehabilitation, Russian Field Rehabilitation Center, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alena Deviaterikova
- Department of Neurocognitive, Psychophysiological Research and Physical Rehabilitation, Russian Field Rehabilitation Center, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia - .,Department of Visual Perception, Russian Academy of Education, Moscow, Russia
| | - Marina Shurupova
- Department of Neurocognitive, Psychophysiological Research and Physical Rehabilitation, Russian Field Rehabilitation Center, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia.,Department of Medical Rehabilitation, Federal Center of Brain and Neurotechnologies, Moscow, Russia.,Department of High Nervous Activity, Lomonosov Moscow State University, Moscow, Russia
| | - Alexander Karelin
- Department of Neurocognitive, Psychophysiological Research and Physical Rehabilitation, Russian Field Rehabilitation Center, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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20
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Ramírez-Guerrero S, Vargas-Cuellar MP, Charry-Sánchez JD, Talero-Gutiérrez C. Cognitive sequelae of radiotherapy in primary brain tumors. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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21
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Cognitive Functions of Pediatric Brain Tumor Survivors Treated With Proton Beam Therapy: A Case Series. J Pediatr Hematol Oncol 2021; 43:e1205-e1209. [PMID: 33235149 DOI: 10.1097/mph.0000000000002011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/16/2020] [Indexed: 10/22/2022]
Abstract
Pediatric brain tumor survivors who received proton beam therapy at the University of Tsukuba Hospital from 2004 to 2011 were retrospectively evaluated for cognitive function. Five patients were included. The median age of diagnosis was 5.4 years (range: 1.5 to 12.5 y) and the median follow-up time was 5.8 years (range: 3.1 to 8.1 y). IQ scores at follow-up were decreased in 2 of 5 patients; 1 underwent whole-brain irradiation and the other was examined just after surgical removal of recurrent tumors. Local proton beam therapy may preserve cognitive function in survivors of pediatric brain tumors.
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22
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Cognitive and Imaging Differences After Proton and Photon Whole Brain Irradiation in a Preclinical Model. Int J Radiat Oncol Biol Phys 2021; 112:554-564. [PMID: 34509550 PMCID: PMC8748279 DOI: 10.1016/j.ijrobp.2021.09.005] [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] [Received: 01/11/2021] [Revised: 08/24/2021] [Accepted: 09/01/2021] [Indexed: 11/22/2022]
Abstract
Purpose: Compared with photon cranial radiation therapy (X-CRT), proton cranial radiation therapy (P-CRT) offers potential advantages in limiting radiation-induced sequalae in the treatment of pediatric brain tumors. This study aims to identify cognitive, functional magnetic resonance and positron emission tomography imaging markers and molecular differences between the radiation modalities. Methods and Materials: Juvenile rats received a single faction of 10 Gy (relative biological effectiveness−weighted dose) delivered with 6 MV X-CRT or at the midspread out Bragg peak of a 100 MeV P-CRT beam. At 3, 6, and 12 months post-CRT, executive function was measured using 5-choice serial reaction time task. At ~12 months post-CRT, animals were imaged with 18F-Flurodeoxy-glucose positron emission tomography imaging followed by functional ex vivo magnetic resonance imaging and stained for markers of neuroinflammation. Results: Irradiated animals had cognitive impairment with a higher number of omissions and lower incorrect and premature responses compared with sham (P ≤ .05). The accuracy of the animals’ X-CRT was less than that of sham (P ≤ .001). No significant difference in rates of cognitive change were found between the radiation modalities. At 12 months post-CRT, glucose metabolism was significantly higher than sham in X-CRT (P = .04) but not P-CRT. Using diffusion tensor imaging, P-CRT brains were found to have higher white matter volume and fiber lengths compared with sham (P < .03). Only X-CRT animals had higher apparent diffusion coefficient values compared with sham (P = .04). P-CRT animals had more connectomic changes compared with X-CRT. Correlative analysis identified several imaging features with cognitive performance. Further-more, microgliosis (P < .05), astrogliosis (P < .01), and myelin thinning (P <.05) were observed in both radiation modalities, with X-CRT showing slightly more inflammation. Conclusions: Both P-CRT and X-CRT lead to neurocognitive changes compared with sham. Although no significant difference was observed in neuroinflammation between the irradiated groups, differences were found in late-term glucose metabolism and brain connectome. Our results indicate that despite relative biological effectiveness weighting of the proton dose there are still differential effects which warrants further investigation.
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23
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Kumar G, Dutta P, Parihar VK, Chamallamudi MR, Kumar N. Radiotherapy and Its Impact on the Nervous System of Cancer Survivors. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2021; 19:374-385. [PMID: 32640964 DOI: 10.2174/1871527319666200708125741] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 12/12/2022]
Abstract
Radiotherapy is routinely used for the treatment of nearly all brain tumors, but it may lead to progressive and debilitating impairments of cognitive function. The growing evidence supports the fact that radiation exposure to CNS disrupts diverse cognitive functions including learning, memory, processing speed, attention and executive functions. The present review highlights the types of radiotherapy and the possible mechanisms of cognitive deficits and neurotoxicity following radiotherapy. The review summarizes the articles from Scopus, PubMed, and Web of science search engines. Radiation therapy uses high-powered x-rays, particles, or radioactive seeds to kill cancer cells, with minimal damage to healthy cells. While radiotherapy has yielded relative success in the treatment of cancer, patients are often plagued with unwanted and even debilitating side effects from the treatment, which can lead to dose reduction or even cessation of treatment. Little is known about the underlying mechanisms responsible for the development of these behavioral toxicities; however, neuroinflammation is widely considered as one of the major mechanisms responsible for radiotherapy-induced toxicities. The present study reviews the different types of radiotherapy available for the treatment of various types of cancers and their associated neurological complications. It also summarizes the doses of radiations used in the variety of radiotherapy, and their early and delayed side effects. Special emphasis is given to the effects of various types of radiations or late side effects on cognitive impairments.
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Affiliation(s)
- Gautam Kumar
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal-576104, Karnataka, India
| | - Priyadarshini Dutta
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal-576104, Karnataka, India
| | - Vipan K Parihar
- Department of Radiation Oncology, University of California, Irvine, CA 92697- 2695, United States
| | - Mallikarjuna R Chamallamudi
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal-576104, Karnataka, India
| | - Nitesh Kumar
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal-576104, Karnataka, India
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24
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Child AE, Warren EA, Grosshans DR, Paulino AC, Okcu MF, Ris MD, Mahajan A, Orobio J, Cirino PT, Minard CG, Viana AG, Bick J, Woods SP, Chintagumpala M, Kahalley LS. Long-term cognitive and academic outcomes among pediatric brain tumor survivors treated with proton versus photon radiotherapy. Pediatr Blood Cancer 2021; 68:e29125. [PMID: 34114294 PMCID: PMC8316321 DOI: 10.1002/pbc.29125] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/22/2021] [Accepted: 05/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Proton radiotherapy (PRT) may be associated with less neurocognitive risk than photon RT (XRT) for pediatric brain tumor survivors. We compared neurocognitive and academic outcomes in long-term survivors treated with XRT versus PRT. METHODS Survivors underwent neurocognitive evaluation >1 year after craniospinal (CSI) or focal PRT or XRT. Groups were compared using separate one-way analyses of covariance for the CSI and focal groups. RESULTS PRT (n = 58) and XRT (n = 30) subgroups were similar on gender (66% male), age at RT (median = 6.5 years), age at follow-up (median = 14.6 years), and government assistance status (32%). PRT and XRT focal groups differed on follow-up interval, shunt history, and total RT dose (all p < .05), whereas PRT and XRT CSI groups differed on follow-up interval, baseline neurocognitive performance score, boost volume, and CSI dose (all p < .05). The PRT focal group outperformed the XRT focal group on inhibition/switching (p = .04). The PRT CSI group outperformed the XRT CSI group on inattention/impulsivity (both p < .05). Several clinical variables (i.e., RT dose, boost field, baseline performance) predicted neurocognitive outcomes (all p < .05). The PRT focal group performed comparably to population means on most neurocognitive measures, while both CSI groups performed below expectation on multiple measures. The XRT CSI group was most impaired. All groups fell below expectation on processing speed, fine motor, and academic fluency (most p < .01). CONCLUSIONS Findings suggest generally favorable neurocognitive and academic long-term outcomes following focal PRT. Impairment was greatest following CSI regardless of modality. Dosimetry and baseline characteristics are important determinants of outcome alone or in combination with modality.
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Affiliation(s)
- Amanda E. Child
- Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore MD
| | - Emily A. Warren
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston TX
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Anita Mahajan
- Department of Radiation Oncology, The Mayo Clinic, Rochester MN
| | - Jessica Orobio
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas TX
| | | | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston TX
| | | | | | | | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston TX
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
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25
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Eaton BR, Fong GW, Ingerski LM, Pulsifer MB, Goyal S, Zhang C, Weyman EA, Esiashvili N, Klosky JL, MacDonald TJ, Ebb DH, MacDonald SM, Tarbell NJ, Yock TI. Intellectual functioning among case-matched cohorts of children treated with proton or photon radiation for standard-risk medulloblastoma. Cancer 2021; 127:3840-3846. [PMID: 34255345 DOI: 10.1002/cncr.33774] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Proton therapy may reduce cognitive deficits after radiotherapy among brain tumor survivors, although current data are limited to retrospective comparisons between historical cohorts. The authors compared intelligence quotient scores within a case-matched cohort of children with medulloblastoma treated with proton radiation (PRT) or photon radiation (XRT) over the same time period. METHODS Among 88 consecutive patients with standard-risk medulloblastoma treated with PRT or XRT at 2 institutions from 2000 to 2009, 50 were matched 1:1 (25 with PRT and 25 with XRT) according to age, gender, date of diagnosis, histology, radiation boost, and craniospinal irradiation dose. One-way analyses of variance were performed to compare the Full-Scale Intelligence Quotient (FSIQ) and associated index scores between the 2 cohorts. RESULTS Neurocognitive data were available for 37 survivors (17 with PRT and 20 with XRT) from the matched cohort. The mean age was 8.5 years (SD, 4.14 years). The median follow-up was 5.3 years (range, 1.0-11.4 years) and 4.6 years (range, 1.1-11.2 years) for the PRT and XRT cohorts, respectively (P = .193). Patients treated with PRT had significantly higher mean FSIQ (99.6 vs 86.2; P = .021), verbal (105.2 vs 88.6; P = .010), and nonverbal scores (103.1 vs 88.9; P = .011) than the XRT-treated cohort. Differences in processing speed (82.9 vs 77.2; P = .331) and working memory (97.0 vs 92.7; P = .388) were not statistically significant. CONCLUSIONS Radiotherapy-associated cognitive effects appear to be more attenuated after proton therapy. Comprehensive prospective studies are needed to appropriately evaluate the neurocognitive advantages of proton therapy.
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Affiliation(s)
- Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Grace W Fong
- Department of Psychology, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lisa M Ingerski
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Margaret B Pulsifer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - James L Klosky
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Tobey J MacDonald
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David H Ebb
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nancy J Tarbell
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Torunn I Yock
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
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26
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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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27
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Ali JS, Ashford JM, Swain MA, Harder LL, Carlson-Green BL, Miller JM, Wallace J, Kaner RJ, Billups CA, Onar-Thomas A, Merchant TE, Gajjar A, Conklin HM. Predictors of Cognitive Performance Among Infants Treated for Brain Tumors: Findings From a Multisite, Prospective, Longitudinal Trial. J Clin Oncol 2021; 39:2350-2358. [PMID: 33945291 DOI: 10.1200/jco.20.01687] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Infants treated for CNS malignancies experience a significantly poorer response to treatment and are particularly at risk for neuropsychological deficits. The literature is limited and inconsistent regarding cognitive outcomes among this group. We investigated predictors of cognitive outcomes in children treated for brain tumors during infancy as part of a large, prospective, multisite, longitudinal trial. PATIENTS AND METHODS One hundred thirty-nine infants with a newly diagnosed CNS tumor were treated with chemotherapy, with or without focal proton or photon radiation therapy (RT). Cognitive assessments were conducted at baseline, 6 months, 1 year, and then annually for 5 years. The median length of follow-up was 816 days (26.8 months). Neurocognitive testing included assessment of intellectual functioning (intellectual quotient [IQ]), parent ratings of executive functioning and emotional and behavioral functioning, and socioeconomic status. RESULTS At baseline, IQ, parent-reported working memory, and parent-reported adaptive functioning were worse than normative expectations. Baseline cognitive difficulties were associated with younger age at diagnosis and lower socioeconomic status. Linear mixed models did not demonstrate a decline in IQ over time. There were increased parent-reported attention and executive problems over time. Increased concerns were related to supratentorial tumor location and CSF diversion. There were no differences in cognitive outcomes based on treatment exposure (chemotherapy-only v chemotherapy with RT and proton v photon focal RT). CONCLUSION Even before adjuvant therapy, young children with brain tumors experience cognitive difficulties that can affect quality of life. Changes in cognitive functioning over time were dependent on tumor location and surgical factors rather than adjuvant therapy. These findings may serve to guide treatment planning and indicate targets for cognitive monitoring and intervention.
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Affiliation(s)
- Jeanelle S Ali
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN
| | - Jason M Ashford
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN
| | - Michelle A Swain
- Children's Health Queensland Hospital, South Brisbane, Australia
| | | | | | | | - Joanna Wallace
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - Ryan J Kaner
- Rady Children's Hospital San Diego, Encinitas, CA
| | - Catherine A Billups
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Arzu Onar-Thomas
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Amar Gajjar
- Department of Pediatric Medicine, Neuro-Oncology Division, St Jude Children's Research Hospital, Memphis, TN
| | - Heather M Conklin
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN
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28
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Eaton BR, Goldberg S, Tarbell NJ, Lawell MP, Gallotto SL, Weyman EA, Kuhlthau KA, Ebb DH, MacDonald SM, Yock TI. Long-term health-related quality of life in pediatric brain tumor survivors receiving proton radiotherapy at <4 years of age. Neuro Oncol 2021; 22:1379-1387. [PMID: 32064512 DOI: 10.1093/neuonc/noaa042] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to report long-term health-related quality of life (HRQoL) among brain tumor survivors treated with proton therapy (PRT) at a very young age. METHODS Fifty-nine children <4 years old received PRT between 2000 and 2011. Forty families participated. HRQoL was assessed by child self-report (CSR; age ≥5) and parent proxy report (PPR; age 2+) using the PedsQL Core. RESULTS The median age was 2.5 years (range, 0.3-3.8) at PRT and 9.1 years (5.5-18) at last follow-up. The most common diagnoses were ependymoma (n = 22) and medulloblastoma (n = 7). Median follow-up is 6.7 years (3-15.4). Follow-up mean CSR and PPR scores were: total core (78.4 and 72.9), physical (82.9 and 75.2), psychosocial (76.0 and 71.6), emotional (74.4 and 70.7), social (81.2 and 75.1), and school (72.4 and 69.9). Parent-reported HRQoL fell within a previously defined range for healthy children in 37.5% of patients, and for children with severe health conditions in 45% of patients. PPR HRQoL was stable from baseline to last follow-up among all domains except for social functioning. History of gastrostomy tube was significantly associated with poorer CSR and PPR HRQoL on multivariable analysis. Ninety percent of children functioned in a regular classroom, 14 (36%) used a classroom aid, 9 (23%) used an outside tutor, and 18 (46%) had an individualized education plan. CONCLUSION Long-term HRQoL among brain tumor survivors treated with PRT at a very young age is variable, with over a third achieving HRQoL levels commensurate with healthy children. KEY POINTS 1. One third of survivors reported long-term HRQoL scores comparable to those of healthy children.2. Treatment for hydrocephalus or a feeding tube was associated with significantly lower HRQoL.3. Total core HRQoL scores remained stable from baseline to last follow-up.
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Affiliation(s)
- Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Saveli Goldberg
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Miranda P Lawell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sara L Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen A Kuhlthau
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - David H Ebb
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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29
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Tsang DS, Kim L, Liu ZA, Janzen L, Khandwala M, Bouffet E, Laperriere N, Dama H, Keilty D, Craig T, Ramaswamy V, Hodgson DC, Mabbott D. Intellectual changes after radiation for children with brain tumors: which brain structures are most important? Neuro Oncol 2021; 23:487-497. [PMID: 33151327 DOI: 10.1093/neuonc/noaa217] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The objective of this study was to evaluate the contribution of radiation dose to different intracranial structures on changes in intellectual function for children with brain tumors. METHODS We evaluated children with brain tumors treated in 2005-2017 who had longitudinal neuropsychological assessments and available photon dosimetric data (if radiation therapy [RT] given). Full Scale Intelligence Quotient (FSIQ) and index scores were evaluated (perceptual reasoning index [PRI], processing speed index [PSI], verbal comprehension index [VCI], and working memory index [WMI]). Multivariable linear mixed effects models were used to model endpoints, with age at RT and dose to different brain regions as fixed effects and patient-specific random intercepts. P-values (P*) were adjusted for multiple comparisons. RESULTS Sixty-nine patients were included, 56 of whom received RT. Median neuropsychological follow-up was 3.2 years. Right temporal lobe mean dose was strongly associated with decline in FSIQ (P* = 0.005); with each gray increase in mean dose, there was a decrease of 0.052 FSIQ points per year. Dose to 50% (D50) of the supratentorial brain was associated with decline in PSI (P* = 0.006) and WMI (P* = 0.001). Right and left hippocampus D50 were individually strongly associated with declines in VCI (P* = 0.009 for each). Presence of a ventriculoperitoneal shunt decreased FSIQ by 10 points. CONCLUSIONS We reported associations between dosimetry to specific brain regions and intellectual outcomes, with suggested avoidance structures during RT planning. These models can help clinicians anticipate changes in neurocognition post-RT and guide selection of an optimal RT plan.
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Affiliation(s)
- 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
| | - Laurence Kim
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Laura Janzen
- Neurosciences and Mental Health Program, Research Institute, Hospital for Sick Children; Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Mohammad Khandwala
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, 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
| | - Hitesh Dama
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Dana Keilty
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Donald Mabbott
- Neurosciences and Mental Health Program, Research Institute, Hospital for Sick Children; Department of Psychology, University of Toronto, Toronto, Ontario, Canada
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30
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Oyefiade A, Paltin I, De Luca CR, Hardy KK, Grosshans DR, Chintagumpala M, Mabbott DJ, Kahalley LS. Cognitive Risk in Survivors of Pediatric Brain Tumors. J Clin Oncol 2021; 39:1718-1726. [PMID: 33886348 DOI: 10.1200/jco.20.02338] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ade Oyefiade
- Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada
| | - Iris Paltin
- The Children's Hospital of Philadelphia, Philadelphia, PA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Cinzia R De Luca
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kristina K Hardy
- Neuropsychology Division, Children's National Hospital, Washington, DC.,Departments of Psychiatry and Behavioral Sciences and Pediatrics, The George Washington University School of Medicine, Washington, DC
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Murali Chintagumpala
- Department of Pediatrics, Baylor College of Medicine, Houston, TX.,Texas Children's Cancer Center, Texas Children's Hospital, Houston, TX
| | - Donald J Mabbott
- Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada
| | - Lisa S Kahalley
- Department of Pediatrics, Baylor College of Medicine, Houston, TX.,Texas Children's Cancer Center, Texas Children's Hospital, Houston, TX.,Psychology Service, Texas Children's Hospital, Houston, TX
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31
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Baroni LV, Sampor C, Gonzalez A, Lubieniecki F, Lamas G, Rugilo C, Bartels U, Heled A, Smith KS, Northcott PA, Bouffet E, Alderete D, Ramaswamy V. Bridging the treatment gap in infant medulloblastoma: molecularly informed outcomes of a globally feasible regimen. Neuro Oncol 2021; 22:1873-1881. [PMID: 32413139 DOI: 10.1093/neuonc/noaa122] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Infant medulloblastoma represents an enormous challenge in neuro-oncology, due to their simultaneous high-risk of recurrence and high risk of severe neurodevelopmental sequelae with craniospinal irradiation. Currently infant medulloblastoma are treated with intensified protocols, either comprising intraventricular methotrexate or autologous transplant, both of which carry significant morbidity and are not feasible in the majority of the world. We sought to evaluate the molecular predictors of outcome in a cohort of infants homogeneously treated with induction chemotherapy, focal radiation and maintenance chemotherapy. METHODS In a retrospective analysis, 29 young children treated with a craniospinal irradiation sparing strategy from Hospital Garrahan in Buenos Aires were profiled using Illumina HumanMethylationEPIC arrays, and correlated with survival. RESULTS Twenty-nine children (range, 0.3-4.6 y) were identified, comprising 17 sonic hedgehog (SHH), 10 Group 3/4, and 2 non-medulloblastomas. Progression-free survival (PFS) across the entire cohort was 0.704 (95% CI: 0.551-0.899). Analysis by t-distributed stochastic neighbor embedding revealed 3 predominant groups, SHHβ, SHHγ, and Group 3. Survival by subtype was highly prognostic with SHHγ having an excellent 5-year PFS of 100% (95% CI: 0.633-1) and SHHβ having a PFS of 0.56 (95% CI: 0.42-1). Group 3 had a PFS of 0.50 (95% CI: 0.25-1). Assessment of neurocognitive outcome was performed in 11 patients; the majority of survivors fell within the low average to mild intellectual disability, with a median IQ of 73.5. CONCLUSIONS We report a globally feasible and effective strategy avoiding craniospinal radiation in the treatment of infant medulloblastoma, including a robust molecular correlation along with neurocognitive outcomes.
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Affiliation(s)
- Lorena V Baroni
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.,Service of Hematology/Oncology, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Claudia Sampor
- Service of Hematology/Oncology, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Adriana Gonzalez
- Service of Interdisciplinary Clinic, Hospital JP Garrahan, Buenos Aires, Argentina
| | | | - Gabriela Lamas
- Service of Pathology, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Carlos Rugilo
- Service of Diagnostic Imaging, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Ute Bartels
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ayala Heled
- Program in Developmental and Stem Cell Biology, Arthur and Sonia Labatt Brain Tumor Research Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kyle S Smith
- Developmental Neurobiology, Brain Tumor Research Division, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Paul A Northcott
- Developmental Neurobiology, Brain Tumor Research Division, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daniel Alderete
- Service of Hematology/Oncology, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Vijay Ramaswamy
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
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Uh J, Merchant TE, Conklin HM, Ismael Y, Li Y, Han Y, Sabin ND, Babajani-Feremi A, Indelicato DJ, Hua CH. Diffusion Tensor Imaging-Based Analysis of Baseline Neurocognitive Function and Posttreatment White Matter Changes in Pediatric Patients With Craniopharyngioma Treated With Surgery and Proton Therapy. Int J Radiat Oncol Biol Phys 2021; 109:515-526. [PMID: 32898610 DOI: 10.1016/j.ijrobp.2020.08.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine the preirradiation baseline association of white matter integrity with neurocognitive function and to assess posttreatment changes in pediatric patients with craniopharyngioma treated with proton therapy. METHODS AND MATERIALS Ninety children and adolescents (2-20 years old) with craniopharyngioma were treated with proton therapy (54 Gy[RBE]) in a prospective therapeutic trial. Neurocognitive performance at the postoperative baseline before proton therapy and diffusion tensor imaging (DTI) data acquired at baseline and at annual follow-up were analyzed. Tract-based spatial statistics and structural connectomics were used to derive global and local white matter features from DTI. Baseline DTI features were compared for patients with average and below-average neurocognitive performance. Longitudinal DTI data were analyzed to determine the proton dose effect on white matter structures in relation to the irradiated brain volume and baseline age. RESULTS Before proton therapy, patients with below-average working memory, processing speed, verbal fluency, verbal learning, or fine motor dexterity exhibited more globally degraded white matter structures compared with their counterparts with average performance, as indicated by lower mean fractional anisotropy, decreased global efficiency, or higher modularity. Surgery, obstructive hydrocephalus, and preoperative hypothalamic involvement appeared to be related to this degradation. In local analyses, tract-based spatial statistics revealed left-lateralized associations with verbal and motor functions, which supported surgical approaches to midline tumors via the right hemisphere. The mean fractional anisotropy of the brain and the global efficiency derived from DTI increased over the 5 years after proton therapy. The rate of increase was lower with larger irradiated brain volumes and in older children. CONCLUSIONS Below-average baseline neurocognitive performance in patients with craniopharyngioma before proton therapy appeared to be related to structural degradation of white matter tracts. Posttherapy longitudinal DTI showed improving trends in global integrity and efficiency measures, particularly in children in whom a smaller brain volume was irradiated.
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Affiliation(s)
- Jinsoo Uh
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Heather M Conklin
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yousef Ismael
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yimei Li
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yuanyuan Han
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Noah D Sabin
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Abbas Babajani-Feremi
- Department of Pediatrics and Department of Anatomy and Neurobiology, University of Tennessee Health Science Center, and Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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Psychological Outcomes, Health-Related Quality of Life, and Neurocognitive Functioning in Survivors of Childhood Cancer and Their Parents. Pediatr Clin North Am 2020; 67:1103-1134. [PMID: 33131537 DOI: 10.1016/j.pcl.2020.07.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Childhood cancer disrupts the lives of patients and their families and affects acute and long-term psychological health. This article summarizes (1) psychological challenges, including depression, anxiety, worries, and posttraumatic stress, as well as positive outcomes such as benefit finding and posttraumatic growth in young survivors and parents; (2) health-related quality of life; (3) interventions to support survivors and parents with psychological difficulties; and (4) neurocognitive problems and interventions to help alleviate them. Although many survivors and parents fare well in the long term, many survivors may benefit from interventions. Interventions should be further evaluated and integrated into routine clinical care.
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34
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Yahya N, Manan HA. Neurocognitive impairment following proton therapy for paediatric brain tumour: a systematic review of post-therapy assessments. Support Care Cancer 2020; 29:3035-3047. [PMID: 33040284 DOI: 10.1007/s00520-020-05808-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/30/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Proton therapy (PT), frequently utilised to treat paediatric brain tumour (PBT) patients, eliminates exit dose and minimises dose to healthy tissues that theoretically can mitigate treatment-related effects including cognitive deficits. As clinical outcome data are emerging, we aimed to systematically review current evidence of cognitive changes following PT of PBT. MATERIALS AND METHODS We searched PubMed and Scopus electronic databases to identify eligible reports on cognitive changes following PT of PBT according to PRISMA guidelines. Reports were extracted for information on demographics and cognitive outcomes. Then, they were systematically reviewed based on three themes: (1) comparison with photon therapy, (2) comparison with baseline cognitive measures, to population normative mean or radiotherapy-naïve PBT patients and (3) effects of dose distribution to cognition. RESULTS Thirteen reports (median size (range): 70 (12-144)) were included. Four reports compared the cognitive outcome between PBT patients treated with proton to photon therapy and nine compared with baseline/normative mean/radiotherapy naïve from which two reported the effects of dose distribution. Reports found significantly poorer cognitive outcome among patients treated with photon therapy compared with proton therapy especially in general cognition and working memory. Craniospinal irradiation (CSI) was consistently associated with poorer cognitive outcome while focal therapy was associated with minor cognitive change/difference. In limited reports available, higher doses to the hippocampus and temporal lobes were implicated to larger cognitive change. CONCLUSION Available evidence suggests that PT causes less cognitive deficits compared with photon therapy. Children who underwent focal therapy with proton were consistently shown to have low risk of cognitive deficit suggesting the need for future studies to separate them from CSI. Evidence on the effect of dose distribution to cognition in PT is yet to mature.
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Affiliation(s)
- Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, CODTIS, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, 50300, Kuala Lumpur, Malaysia.
| | - Hanani Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Cheras, 56000, Kuala Lumpur, Malaysia
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35
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Gross JP, Powell S, Zelko F, Hartsell W, Goldman S, Fangusaro J, Lulla RR, Smiley NP, Chang JHC, Gondi V. Improved neuropsychological outcomes following proton therapy relative to X-ray therapy for pediatric brain tumor patients. Neuro Oncol 2020; 21:934-943. [PMID: 30997512 DOI: 10.1093/neuonc/noz070] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Survivors of pediatric brain tumors are at risk for impaired development in multiple neuropsychological domains. The purpose of this study was to compare neuropsychological outcomes of pediatric brain tumor patients who underwent X-ray radiotherapy (XRT) versus proton radiotherapy (PRT). METHODS Pediatric patients who underwent either XRT or PRT and received posttreatment age-appropriate neuropsychological evaluation-including measures of intelligence (IQ), attention, memory, visuographic skills, academic skills, and parent-reported adaptive functioning-were identified. Multivariate analyses were performed to assess differences in neuropsychological outcomes and included tests for interaction between treatment cohort and follow-up time. RESULTS Between 1998 and 2017, 125 patients with tumors located in the supratentorial (17.6%), midline (28.8%), or posterior fossa (53.6%) compartments received radiation and had posttreatment neuropsychological evaluation. Median age at treatment was 7.4 years. The PRT patient cohort had higher estimated SES and shorter median time from radiotherapy completion to last neuropsychological evaluation (6.7 vs 2.6 y, P < 0.001). On multivariable analysis, PRT was associated with higher full-scale IQ (β = 10.6, P = 0.048) and processing speed (β = 14.4, P = 0.007) relative to XRT, with trend toward higher verbal IQ (β = 9.9, P = 0.06) and general adaptive functioning (β = 11.4, P = 0.07). Planned sensitivity analyses truncating follow-up interval in the XRT cohort re-demonstrated higher verbal IQ (P = 0.01) and IQ (P = 0.04) following PRT, with trend toward improved processing speed (P = 0.09). CONCLUSIONS PRT is associated with favorable outcomes for intelligence and processing speed. Combined with other strategies for treatment de-intensification, PRT may further reduce neuropsychological morbidity of brain tumor treatment.
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Affiliation(s)
- Jeffrey P Gross
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephanie Powell
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Frank Zelko
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William Hartsell
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Radiation Oncology Consultants LLC, Chicago, Illinois.,Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Stewart Goldman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason Fangusaro
- Department of Pediatrics, Emory University School of Medicine and the Aflac Cancer Center, Atlanta, Georgia
| | - Rishi R Lulla
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Natasha Pillay Smiley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Han-Chih Chang
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Radiation Oncology Consultants LLC, Chicago, Illinois.,Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
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36
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Kahalley LS, Douglas Ris M, Mahajan A, Fatih Okcu M, Chintagumpala M, Paulino AC, Whitehead WE, Minard CG, Stancel HH, Orobio J, Xue JJ, Warren EA, Grosshans DR. Prospective, longitudinal comparison of neurocognitive change in pediatric brain tumor patients treated with proton radiotherapy versus surgery only. Neuro Oncol 2020; 21:809-818. [PMID: 30753584 DOI: 10.1093/neuonc/noz041] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Proton radiotherapy (PRT) reduces the volume of normal tissue receiving radiation dose, which may lead to better neurocognitive outcomes. We examined change in neurocognitive scores over time in pediatric brain tumor patients treated with proton craniospinal irradiation (CSI), proton focal RT, or surgery only. METHODS Patients received annual neurocognitive evaluations for up to 6 years. We examined Full Scale IQ (FSIQ), Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index (PSI) scores. General linear mixed models examined change in scores over time by treatment group, adjusting for significant covariates. RESULTS Scores from 93 patients treated between 2012 and 2017 (22 proton CSI, 31 proton focal, and 40 surgery only) were examined. Treatment groups were similar on gender (51.6% male), age at treatment (median = 9.7 y), and length of follow-up (median = 2.9 y). The surgery only group had proportionately more gliomas (P < 0.001), and the proton CSI group had more infratentorial tumors (P = 0.001) and higher total RT dose (P = 0.004). The proton focal and surgery only groups exhibited stable neurocognitive scores over time across all indexes (all P > 0.05). In the proton CSI group, WMI, PSI, and FSIQ scores declined significantly (P = 0.036, 0.004, and 0.017, respectively), while VCI and PRI scores were stable (all P > 0.05). CONCLUSIONS Focal PRT was associated with stable neurocognitive functioning into survivorship. Outcomes were similar whether patients received focal PRT or no radiotherapy, even in neurocognitive domains known to be particularly radiosensitive. Proton CSI emerged as a neurocognitive risk factor, consistent with photon outcomes research.
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Affiliation(s)
- Lisa S Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - M Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minneosta
| | - M Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William E Whitehead
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine
| | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Heather H Stancel
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas
| | - Judy J Xue
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston Texas.,Rice University
| | - Emily A Warren
- University of Houston, Department of Psychology, Houston, Texas
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Radiation Therapy for Pediatric Brain Tumors using Robotic Radiation Delivery System and Intensity Modulated Proton Therapy. Pract Radiat Oncol 2020; 10:e173-e182. [DOI: 10.1016/j.prro.2019.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/09/2019] [Accepted: 09/11/2019] [Indexed: 12/25/2022]
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38
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Roth AK, Ris MD, Orobio J, Xue J, Mahajan A, Paulino AC, Grosshans D, Okcu MF, Chintagumpala M, Kahalley L. Cognitive mediators of adaptive functioning outcomes in survivors of pediatric brain tumors treated with proton radiotherapy. Pediatr Blood Cancer 2020; 67:e28064. [PMID: 31736188 PMCID: PMC7433211 DOI: 10.1002/pbc.28064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/10/2019] [Accepted: 10/12/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cranial radiotherapy (RT) is associated with risk for cognitive and adaptive dysfunction. Proton RT (PRT) is a technique hypothesized to spare cognition by reducing exposure to nontarget brain tissue. However, little is known regarding functional outcomes in survivors of pediatric brain tumor (BT) treated with PRT. The present study examined the relationship between cognitive and adaptive outcomes in pediatric BT survivors post-PRT. METHODS Survivors treated with either focal (n = 33) or craniospinal irradiation (CSI; n = 37) PRT completed neurocognitive evaluations approximately 5 years post-treatment. Results of intelligence testing and ratings of adaptive functioning are reported. Mediation models examined the relationship among radiation field, cognition, and adaptive functioning. RESULTS The PRT CSI group demonstrated worse cognitive outcomes than the PRT Focal group across each cognitive index (Cohen's d = 0.56-0.70). Parent ratings of adaptive functioning were also worse in the PRT CSI group than the PRT Focal group (Global Adaptive Composite, d = 0.53; conceptual skills, d = 0.67). Cognitive performance fully mediated the relationship between radiation field and adaptive outcomes, while controlling for group differences in tumor histology and RT dose. CONCLUSIONS Focal PRT survivors demonstrated generally positive outcomes with weaknesses in processing speed and aspects of adaptive functioning. CSI exposure was associated with more consistently poor cognitive and adaptive outcomes. The increased risk for adaptive dysfunction in the PRT CSI group appeared due to the effects of CSI on cognition. Efforts to reduce the volume of tissue exposure to RT remain important.
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Affiliation(s)
- Alexandra K. Roth
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Judy Xue
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | | | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - David Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Lisa Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
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39
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Kahalley LS, Peterson R, Ris MD, Janzen L, Okcu MF, Grosshans DR, Ramaswamy V, Paulino AC, Hodgson D, Mahajan A, Tsang DS, Laperriere N, Whitehead WE, Dauser RC, Taylor MD, Conklin HM, Chintagumpala M, Bouffet E, Mabbott D. Superior Intellectual Outcomes After Proton Radiotherapy Compared With Photon Radiotherapy for Pediatric Medulloblastoma. J Clin Oncol 2019; 38:454-461. [PMID: 31774710 DOI: 10.1200/jco.19.01706] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Proton radiotherapy (PRT) may lessen the neuropsychological risk traditionally associated with cranial radiotherapy for the treatment of pediatric brain tumors by reducing the dose to normal tissue compared with that of photon radiotherapy (XRT). We examined the change in intellectual scores over time in patients with pediatric medulloblastoma treated with craniospinal PRT versus XRT. METHODS Intelligence test scores were obtained for a sample of pediatric patients treated between 2007 and 2018 on the same medulloblastoma protocols that differed only in radiotherapy modality (PRT v XRT). Growth curve analyses compared change in scores over time since diagnosis between groups. RESULTS Longitudinal intelligence data from 79 patients (37 PRT, 42 XRT) were examined. Groups were similar on most demographic/clinical variables, including sex (67.1% male), age at diagnosis (mean, 8.6 years), craniospinal irradiation dose (median, 23.4 Gy), length of follow-up (mean, 4.3 years), and parental education (mean, 14.3 years). Boost dose (P < .001) and boost margin (P = .001) differed between groups. Adjusting for covariates, the PRT group exhibited superior long-term outcomes in global intelligence quotient (IQ), perceptual reasoning, and working memory compared with the XRT group (all P < .05). The XRT group exhibited a significant decline in global IQ, working memory, and processing speed (all P < .05). The PRT group exhibited stable scores over time in all domains with the exception of processing speed (P = .003). CONCLUSION To our knowledge, this is the first study to compare intellectual trajectories between pediatric patients treated for medulloblastoma with PRT versus those treated with XRT on comparable, contemporary protocols. PRT was associated with more favorable intellectual outcomes in most domains compared with XRT, although processing speed emerged as a vulnerable domain for both groups. This study provides the strongest evidence to date of an intellectual sparing advantage with PRT in the treatment of pediatric medulloblastoma.
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Affiliation(s)
- Lisa S Kahalley
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | | | - M Douglas Ris
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Laura Janzen
- The Hospital for Sick Children, Toronto, ON, Canada
| | - M Fatih Okcu
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | | | - Vijay Ramaswamy
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | | | - David Hodgson
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Derek S Tsang
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - William E Whitehead
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Robert C Dauser
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Michael D Taylor
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | | | | | - Eric Bouffet
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
| | - Donald Mabbott
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto, Toronto, ON, Canada
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40
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Raghubar KP, Orobio J, Ris MD, Heitzer AM, Roth A, Brown AL, Okcu MF, Chintagumpala M, Grosshans DR, Paulino AC, Mahajan A, Kahalley LS. Adaptive functioning in pediatric brain tumor survivors: An examination of ethnicity and socioeconomic status. Pediatr Blood Cancer 2019; 66:e27800. [PMID: 31134755 PMCID: PMC6730637 DOI: 10.1002/pbc.27800] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/11/2019] [Accepted: 04/18/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Survivors of pediatric brain tumor are at risk for adaptive difficulties. The present study examined adaptive functioning in a multiethnic sample of survivors accounting for socioeconomic status, and whether demographic, diagnostic, and/or treatment-related variables predict adaptive outcomes. METHOD Participants included a multiethnic sample of survivors (58 Caucasian, 34 Hispanic, and 22 other non-Caucasian; M age = 14.05 years, SD = 4.33) who were approximately seven years post-treatment. Parents rated adaptive functioning and provided demographic information. Diagnostic and treatment-related information was abstracted from the electronic medical record. RESULTS Parent ratings of adaptive functioning were similar across Caucasian, Hispanic, and other non-Caucasian survivors covarying for family income and primary caregiver education, both of which served as proxies for socioeconomic status. All ethnic groups were rated lower than the normative mean in overall adaptive functioning as well as the specific domains of conceptual, social, and practical skills. Demographic, diagnostic, and treatment-related variables were differentially associated with adaptive functioning in survivors of pediatric brain tumor, though socioeconomic status emerged as a strong significant predictor of adaptive functioning domains. CONCLUSIONS Adaptive outcomes do not differ as a function of ethnicity after accounting for primary caregiver education and family income. Racial and ethnic minorities may be at increased risk for poorer outcomes given their overrepresentation at lower income levels. Assessing demographic and treatment-related variables early on may be helpful in identifying children likely to develop adaptive difficulties.
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Affiliation(s)
- Kimberly P. Raghubar
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Andrew M. Heitzer
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Alexandra Roth
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Austin L. Brown
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - David R. Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Anita Mahajan
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
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41
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Tringale KR, Nguyen T, Bahrami N, Marshall DC, Leyden KM, Karunamuni R, Seibert TM, Kay Gorman M, Connor M, Burkeen J, Piccioni DE, Farid N, Hattangadi-Gluth JA, McDonald CR. Identifying early diffusion imaging biomarkers of regional white matter injury as indicators of executive function decline following brain radiotherapy: A prospective clinical trial in primary brain tumor patients. Radiother Oncol 2019; 132:27-33. [PMID: 30825966 PMCID: PMC6400307 DOI: 10.1016/j.radonc.2018.11.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Executive function (EF) decline is common after brain radiation therapy (RT), yet the etiology is unclear. We analyzed the association between longitudinal changes in frontal lobe white matter microstructure and decline in EF following RT in brain tumor patients on a prospective clinical trial. MATERIALS AND METHODS Diffusion tensor imaging was obtained on 22 patients with brain tumors prior to RT, as well as 3- and 6-months post-RT, in a prospective, observational trial. Fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were calculated within the superficial white matter (SWM) of the anterior cingulate (AC) and dorsolateral prefrontal cortex. Measures of cognitive flexibility, verbal fluency, and verbal set-shifting were obtained pre- and post-RT. Reliable change indices were calculated to determine significant baseline to 6-month EF changes. RESULTS Decreases in FA and increases in MD were observed in the caudal AC (CAC) at 3-months post-RT. CAC changes were characterized by increased RD bilaterally. From baseline to 6-months post-RT, decreased FA and increased MD and RD of the CAC was associated with decline in verbal set-shifting ability, whereas increased MD in the CAC was associated with a decline in cognitive flexibility. CONCLUSION White matter underlying the AC may be particularly vulnerable to radiation effects. Early microstructural loss within AC SWM represents an important biomarker for EF decline, and dose reduction in this region may represent a possibility for cognitive preservation for patients receiving radiotherapy.
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Affiliation(s)
| | - Tanya Nguyen
- Department of Psychiatry, University of California, San Diego, USA
| | - Naeim Bahrami
- Center for Multimodal Imaging and Genetics, University of California, San Diego, USA
| | - Deborah C Marshall
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, USA
| | - Kelly M Leyden
- Center for Multimodal Imaging and Genetics, University of California, San Diego, USA
| | - Roshan Karunamuni
- Center for Multimodal Imaging and Genetics, University of California, San Diego, USA; Department of Radiation Medicine and Applied Sciences, University of California, San Diego, USA
| | - Tyler M Seibert
- Center for Multimodal Imaging and Genetics, University of California, San Diego, USA; Department of Radiation Medicine and Applied Sciences, University of California, San Diego, USA
| | - Mary Kay Gorman
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, USA
| | - Michael Connor
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, USA
| | - Jeff Burkeen
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, USA
| | - David E Piccioni
- Department of Neurosciences, University of California, San Diego, USA
| | - Nikdokht Farid
- Department of Radiology, University of California, San Diego, USA
| | - Jona A Hattangadi-Gluth
- Center for Multimodal Imaging and Genetics, University of California, San Diego, USA; Department of Radiation Medicine and Applied Sciences, University of California, San Diego, USA
| | - Carrie R McDonald
- Department of Psychiatry, University of California, San Diego, USA; Center for Multimodal Imaging and Genetics, University of California, San Diego, USA; Department of Radiation Medicine and Applied Sciences, University of California, San Diego, USA.
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Abstract
Medulloblastoma (MB) comprises a biologically heterogeneous group of embryonal tumours of the cerebellum. Four subgroups of MB have been described (WNT, sonic hedgehog (SHH), Group 3 and Group 4), each of which is associated with different genetic alterations, age at onset and prognosis. These subgroups have broadly been incorporated into the WHO classification of central nervous system tumours but still need to be accounted for to appropriately tailor disease risk to therapy intensity and to target therapy to disease biology. In this Primer, the epidemiology (including MB predisposition), molecular pathogenesis and integrative diagnosis taking histomorphology, molecular genetics and imaging into account are reviewed. In addition, management strategies, which encompass surgical resection of the tumour, cranio-spinal irradiation and chemotherapy, are discussed, together with the possibility of focusing more on disease biology and robust molecularly driven patient stratification in future clinical trials.
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Jaramillo S, Grosshans DR, Philip N, Varan A, Akyüz C, McAleer MF, Mahajan A, McGovern SL. Radiation for ETMR: Literature review and case series of patients treated with proton therapy. Clin Transl Radiat Oncol 2018; 15:31-37. [PMID: 30582019 PMCID: PMC6297264 DOI: 10.1016/j.ctro.2018.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 12/21/2022] Open
Abstract
Background and purpose Embryonal tumors with multilayered rosettes (ETMRs) are aggressive tumors that typically occur in young children. Radiation is often deferred or delayed for these patients due to late effects; proton therapy may mitigate some of these concerns. This study reviews the role of radiation in ETMR and describes initial results with proton therapy. Materials and methods Records of patients with embryonal tumor with abundant neuropil and true rosettes (ETANTR), medulloepithelioma (MEP), and ependymoblastoma (EPL) treated with proton therapy at our institution were retrospectively reviewed. A literature review of cases of CNS ETANTR, MEP, and EPL published since 1990 was also conducted. Results Seven patients were treated with proton therapy. Their median age at diagnosis was 33 months (range 10-57 months) and their median age at radiation start was 42 months (range 17-58 months). Their median overall survival (OS) was 16 months (range 8-64 months), with three patients surviving 36 months or longer. Five patients had disease progression prior to starting radiation; all 5 of these patients failed in the tumor bed. A search of the literature identified 204 cases of ETMR with a median OS of 10 months (range 0.03-161 months). Median OS of 18 long-term survivors (≥36 months) in the literature was 77 months (range 37-184 months). Of these 18 long-term survivors, 17 (94%) received radiotherapy as part of their initial treatment; 14 of them were treated with craniospinal irradiation. Conclusions Outcomes of patients with ETMR treated with proton therapy are encouraging compared to historical results. Further study of this rare tumor is warranted to better define the role of radiotherapy.
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Affiliation(s)
- Sergio Jaramillo
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, United States
| | - David R Grosshans
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Nancy Philip
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Ali Varan
- Department of Pediatric Oncology, Hacettepe University, Institute of Oncology, Ankara, Turkey
| | - Canan Akyüz
- Department of Pediatric Oncology, Hacettepe University, Institute of Oncology, Ankara, Turkey
| | - Mary Frances McAleer
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Susan L McGovern
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
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Grosshans DR, Duman JG, Gaber MW, Sawakuchi G. Particle Radiation Induced Neurotoxicity in the Central Nervous System. Int J Part Ther 2018; 5:74-83. [PMID: 31773021 DOI: 10.14338/ijpt-18-00026.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/16/2018] [Indexed: 11/21/2022] Open
Abstract
For patients with primary or metastatic brain tumors, radiation therapy plays a central role in treatment. However, despite its efficacy, cranial radiation is associated with a range of side effects ranging from mild cognitive impairment to overt brain necrosis. Given the negative effects on patient quality of life, radiation-induced neurotoxicities have been the subject of intense study for decades. Photon-based therapy has been and largely remains the standard of care for the treatment of brain tumors. This is particularly true for patients with metastatic tumors who may need treatment to the whole brain or those with very aggressive tumors and a limited life expectancy. Particle therapy is now becoming more widely available for clinical use with the two most common particles used being protons and carbon ions. For patients with favorable prognoses, particularly childhood brain tumors, proton therapy is increasingly used for treatment. This is, in part, driven by the desire to reduce the potential for radiation-induced side effects, including lasting cognitive impairment, which may potentially be achieved by reducing dose to normal tissues using the unique physical properties of particle therapy. There is also interest in using carbon ion therapy for the treatment of aggressive brain tumors, as this form of particle therapy not only spares normal tissues but may also improve tumor control. The biological effects of particle therapy, both proton and carbon, may differ substantially from those of photon radiation. In this review, we briefly describe the unique physical properties of particle therapy that produce differential biological effects. Focusing on the effects of various radiation types on brain parenchyma, we then describe biological effects and potential mechanisms underlying these, comparing to photon studies and highlighting potential clinical implications.
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Affiliation(s)
- David R Grosshans
- Departments of Radiation and Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph G Duman
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - M Waleed Gaber
- Department of Pediatrics, Texas Children's Cancer Center, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Sawakuchi
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Stavinoha PL, Askins MA, Powell SK, Pillay Smiley N, Robert RS. Neurocognitive and Psychosocial Outcomes in Pediatric Brain Tumor Survivors. Bioengineering (Basel) 2018; 5:E73. [PMID: 30208602 PMCID: PMC6164803 DOI: 10.3390/bioengineering5030073] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/06/2018] [Accepted: 09/08/2018] [Indexed: 01/15/2023] Open
Abstract
The late neurocognitive and psychosocial effects of treatment for pediatric brain tumor (PBT) represent important areas of clinical focus and ongoing research. Neurocognitive sequelae and associated problems with learning and socioemotional development negatively impact PBT survivors' overall health-related quality of life, educational attainment and employment rates. Multiple factors including tumor features and associated complications, treatment methods, individual protective and vulnerability factors and accessibility of environmental supports contribute to the neurocognitive and psychosocial outcomes in PBT survivors. Declines in overall measured intelligence are common and may persist years after treatment. Core deficits in attention, processing speed and working memory are postulated to underlie problems with overall intellectual development, academic achievement and career attainment. Additionally, psychological problems after PBT can include depression, anxiety and psychosocial adjustment issues. Several intervention paradigms are briefly described, though to date research on innovative, specific and effective interventions for neurocognitive late effects is still in its early stages. This article reviews the existing research for understanding PBT late effects and highlights the need for innovative research to enhance neurocognitive and psychosocial outcomes in PBT survivors.
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Affiliation(s)
- Peter L Stavinoha
- The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Martha A Askins
- The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Stephanie K Powell
- Ann and Robert H. Lurie Children's Hospital of Chicago and Northwestern Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Natasha Pillay Smiley
- Ann and Robert H. Lurie Children's Hospital of Chicago and Northwestern Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Rhonda S Robert
- The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Krull KR, Hardy KK, Kahalley LS, Schuitema I, Kesler SR. Neurocognitive Outcomes and Interventions in Long-Term Survivors of Childhood Cancer. J Clin Oncol 2018; 36:2181-2189. [PMID: 29874137 DOI: 10.1200/jco.2017.76.4696] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recent research has demonstrated that survivors of childhood cancer are at risk for a myriad of late effects that affect physical and mental quality of life. We discuss the patterns and prevalence of neurocognitive problems commonly experienced by survivors of CNS tumors and acute lymphoblastic leukemia, the two most commonly researched cancer diagnoses. Research documenting the direct effects of tumor location and treatment type and intensity is presented, and patient characteristics that moderate outcomes (eg, age at diagnosis and sex) are discussed. Potential biologic mechanisms of neurotoxic treatment exposures, such as cranial irradiation and intrathecal and high-dose antimetabolite chemotherapy, are reviewed. Genetic, brain imaging, and neurochemical biomarkers of neurocognitive impairment are discussed. Long-term survivors of childhood cancer are also at risk for physical morbidity (eg, cardiac, pulmonary, endocrine) and problems with health behaviors (eg, sleep); research is reviewed that demonstrates these health problems contribute to neurocognitive impairment in survivors with or without exposure to neurotoxic therapies. We conclude this review with a discussion of literature supporting specific interventions that may be beneficial in the treatment of survivors who already experience neurocognitive impairment, as well as in the prevention of impairment manifestation.
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Affiliation(s)
- Kevin R Krull
- Kevin R. Krull, St Jude Children's Research Hospital, Memphis, TN; Kristina K. Hardy, Children's National Medical Center, Washington, DC; Lisa S. Kahalley, Baylor College of Medicine; Shelli R. Kesler, University of Texas MD Anderson Cancer Center, Houston, TX; and Ilse Schuitema, Leiden University, Leiden, the Netherlands
| | - Kristina K Hardy
- Kevin R. Krull, St Jude Children's Research Hospital, Memphis, TN; Kristina K. Hardy, Children's National Medical Center, Washington, DC; Lisa S. Kahalley, Baylor College of Medicine; Shelli R. Kesler, University of Texas MD Anderson Cancer Center, Houston, TX; and Ilse Schuitema, Leiden University, Leiden, the Netherlands
| | - Lisa S Kahalley
- Kevin R. Krull, St Jude Children's Research Hospital, Memphis, TN; Kristina K. Hardy, Children's National Medical Center, Washington, DC; Lisa S. Kahalley, Baylor College of Medicine; Shelli R. Kesler, University of Texas MD Anderson Cancer Center, Houston, TX; and Ilse Schuitema, Leiden University, Leiden, the Netherlands
| | - Ilse Schuitema
- Kevin R. Krull, St Jude Children's Research Hospital, Memphis, TN; Kristina K. Hardy, Children's National Medical Center, Washington, DC; Lisa S. Kahalley, Baylor College of Medicine; Shelli R. Kesler, University of Texas MD Anderson Cancer Center, Houston, TX; and Ilse Schuitema, Leiden University, Leiden, the Netherlands
| | - Shelli R Kesler
- Kevin R. Krull, St Jude Children's Research Hospital, Memphis, TN; Kristina K. Hardy, Children's National Medical Center, Washington, DC; Lisa S. Kahalley, Baylor College of Medicine; Shelli R. Kesler, University of Texas MD Anderson Cancer Center, Houston, TX; and Ilse Schuitema, Leiden University, Leiden, the Netherlands
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47
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Alias H, Lau SCD, Schuitema I, de Sonneville LMJ. Neuropsychological Consequences for Survivors of Childhood Brain Tumor in Malaysia. Front Psychol 2018; 9:703. [PMID: 29896137 PMCID: PMC5986920 DOI: 10.3389/fpsyg.2018.00703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/23/2018] [Indexed: 01/06/2023] Open
Abstract
Objective: This study aimed to evaluate neuropsychological consequences in survivors of childhood brain tumor. Method: A case-control study was conducted over a period of 4 months in a tertiary referral center in Kuala Lumpur, Malaysia. Fourteen survivors of childhood brain tumor aged 7–18 years, who were off-treatment for at least 1 year and were in remission, and 31 unrelated healthy controls were recruited. The median age at diagnosis was 8.20 years (range: 0.92–12.96 years). The diagnoses of brain tumors were medulloblastoma, germ cell tumor, pineocytoma, pilocystic astrocytoma, suprasellar germinoma, and ependymoma. Eleven survivors received central nervous system irradiation. Seven tasks were selected from the Amsterdam Neuropsychological Tasks program to evaluate alertness (processing speed), and major aspects of executive functioning, such as working memory capacity, inhibition, cognitive flexibility, and sustained attention. Speed, stability and accuracy of responses were the main outcome measures. Results: Survivors of childhood brain tumor showed statistically significant poorer performance on all tasks compared to healthy controls. Both processing speed and accuracy were impaired in the survivors, in particular under more complex task conditions. The survivors demonstrated deficits in alertness, sustained attention, working memory capacity, executive visuomotor control, and cognitive flexibility. Longer duration off treatment appeared to be correlated with poorer alertness, memory capacity, and inhibition. Conclusion: Survivors of childhood brain tumor in our center showed impaired neuropsychological functioning. Development of less toxic treatment protocols is important to prevent late effects of cognitive deficits in survivors of childhood brain tumor.
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Affiliation(s)
- Hamidah Alias
- Department of Pediatrics, UKM Medical Center, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - Sie Chong D Lau
- Department of Pediatrics, UKM Medical Center, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - Ilse Schuitema
- Department of Clinical Child and Adolescent Studies, Faculty of Social Sciences, Leiden University, Leiden, Netherlands
| | - Leo M J de Sonneville
- Department of Clinical Child and Adolescent Studies, Faculty of Social Sciences, Leiden University, Leiden, Netherlands
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Protontherapy of head and neck paragangliomas: A monocentric study. Cancer Radiother 2017; 22:31-37. [PMID: 29269165 DOI: 10.1016/j.canrad.2017.07.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 07/09/2017] [Accepted: 07/19/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE The aim of this study was to assess efficacy and safety of proton beam therapy of paragangliomas of the head and neck, rare benign tumours developed close to crucial structures such as cranial nerves and vascular tissues. PATIENTS AND METHODS Ten patients with a paraganglioma of the head and neck were treated from 2001 to 2014 with image-guided proton therapy. Neurological and ear nose throat symptoms were collected in addition to audiometric testing, before and after the treatment. Acute and late toxicities were assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v4. RESULTS Median age at diagnosis was 52.6years (range: 18.2-65.8years). Proton therapy was the exclusive treatment in six patients and four patients had a postoperative radiotherapy. Median dose was 50.4Gy relative biological effectiveness (RBE; range: 45.0-67.0Gy). With a median follow-up of 24.6months (range: 6.7-46.2 months), local tumour control rate was 100% (stable, n=10). No upper grade 2 acute toxicity was reported. To the latest news, seven patients had controlled symptoms (improved, n=1, stabilized, n=6). One patient out of seven with initial tinnitus had a decrease in his symptoms, while the six other patients had a sustained stabilization. CONCLUSION Proton beam therapy is an effective and well-tolerated treatment modality of skull base paragangliomas, with documented functional benefit. A longer follow-up is planned in order to assess local control and long-term toxicities.
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Altinoz MA, Elmaci İ. Targeting nitric oxide and NMDA receptor-associated pathways in treatment of high grade glial tumors. Hypotheses for nitro-memantine and nitrones. Nitric Oxide 2017; 79:68-83. [PMID: 29030124 DOI: 10.1016/j.niox.2017.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/26/2017] [Accepted: 10/07/2017] [Indexed: 12/31/2022]
Abstract
Glioblastoma multiforme (GBM) is a devastating brain cancer with no curative treatment. Targeting Nitric Oxide (NO) and glutamatergic pathways may help as adjunctive treatments in GBM. NO at low doses promotes tumorigenesis, while at higher levels (above 300 nM) triggers apoptosis. Gliomas actively secrete high amounts of glutamate which activates EGR signaling and mediates degradation of peritumoral tissues via excitotoxic injury. Memantine inhibits NMDA-subtype of glutamate receptors (NMDARs) and induces autophagic death of glioma cells in vitro and blocks glioma growth in vivo. Nitro-memantines may exert further benefits by limiting NMDAR signaling and by delivery of NO to the areas of excessive NMDAR activity leading NO-accumulation at tumoricidal levels within gliomas. Due to the duality of NO in tumorigenesis, agents which attenuate NO levels may also act beneficial in treatment of GBM. Nitrone compounds including N-tert-Butyl-α-phenylnitrone (PBN) and its disulfonyl-phenyl derivative, OKN-007 suppress free radical formation in experimental cerebral ischemia. OKN-007 failed to show clinical efficacy in stroke, but trials demonstrated its high biosafety in humans including elderly subjects. PBN inhibits the signaling pathways of NF-κB, inducible nitric oxide synthase (iNOS) and cyclooxygenase (COX). In animal models of liver cancer and glioblastoma, OKN-007 seemed more efficient than PBN in suppression of cell proliferation, microvascular density and in induction of apoptosis. OKN-007 also inhibits SULF2 enzyme, which promotes tumor growth via versatile pathways. We assume that nitromemantines may be more beneficial concomitant with chemo-radiotherapy while nitrones alone may act useful in suppressing basal tumor growth and angiogenesis.
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Affiliation(s)
- Meric A Altinoz
- Neuroacademy Group, Department of Neurosurgery, Memorial Hospital, Istanbul, Turkey.
| | - İlhan Elmaci
- Neuroacademy Group, Department of Neurosurgery, Memorial Hospital, Istanbul, Turkey
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