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Wei Z, Li J, Jin Y, Liu Y, Wang P, Cao Y, Zhao Q. The application and value of radiotherapy at the primary site in patients with high-risk neuroblastoma. Br J Radiol 2022; 95:20211086. [PMID: 35312349 PMCID: PMC10996409 DOI: 10.1259/bjr.20211086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/22/2022] [Accepted: 03/14/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To retrospectively analyze radiotherapy (RT) regimens for patients with high-risk neuroblastoma (HRNB) at the primary site after surgery, and to further analyze the characteristics of patients who would benefit more from RT. METHODS 98 pediatric patients with HRNB were analyzed for local control (LC), RT dose, extent of excision and prognostic factors. Among them, 69 children received RT. RESULTS The 3 year LC rates were 96.9 and 62.1% (p < 0.001) in the RT and non-RT groups, respectively. In the non-RT group, LC was better in patients with complete macroscopic resection (CME) than in those with incomplete macroscopic resection (IME) (p = 0.026), while in the RT group, no significant difference in LC was found (p = 0.985). Among patients with IME, the LC was 100% in patients with RT doses >= 36 Gy and 66.7% in patients with doses <36 Gy. CONCLUSION RT is valuable, provides patients with excellent LC, and is safe in the short term. RT had a complementary therapeutic effect on incompletely resected tumors, thus bringing their LC to the level of patients with CME. For patients with IME, RT at a dose of not less than 36 Gy may improve LC. ADVANCES IN KNOWLEDGE This study analysed the role of radiotherapy in HRNB, investigated the dose of RT depending on the degree of resection, and explored the characteristics of patients who would benefit more from RT.
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Affiliation(s)
- Zixuan Wei
- Department of Pediatric Oncology, Tianjin Medical University
Cancer Institute and Hospital, National Clinical Research Center for
Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin,
Tianjin’s Clinical Research Center for Cancer,
Tianjin, China
| | - Jie Li
- Department of Pediatric Oncology, Tianjin Medical University
Cancer Institute and Hospital, National Clinical Research Center for
Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin,
Tianjin’s Clinical Research Center for Cancer,
Tianjin, China
| | - Yan Jin
- Department of Pediatric Oncology, Tianjin Medical University
Cancer Institute and Hospital, National Clinical Research Center for
Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin,
Tianjin’s Clinical Research Center for Cancer,
Tianjin, China
| | - Yun Liu
- Department of Pediatric Oncology, Tianjin Medical University
Cancer Institute and Hospital, National Clinical Research Center for
Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin,
Tianjin’s Clinical Research Center for Cancer,
Tianjin, China
| | - Peiguo Wang
- Department of Radiotherapy, Tianjin Medical University Cancer
Institute and Hospital, National Clinical Research Center for Cancer,
Key Laboratory of Cancer Prevention and Therapy of Tianjin,
Tianjin’s Clinical Research Center for Cancer,
Tianjin, China
| | - Yanna Cao
- Department of Pediatric Oncology, Tianjin Medical University
Cancer Institute and Hospital, National Clinical Research Center for
Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin,
Tianjin’s Clinical Research Center for Cancer,
Tianjin, China
| | - Qiang Zhao
- Department of Pediatric Oncology, Tianjin Medical University
Cancer Institute and Hospital, National Clinical Research Center for
Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin,
Tianjin’s Clinical Research Center for Cancer,
Tianjin, China
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Abstract
Neuroblastomas are tumours of sympathetic origin, with a heterogeneous clinical course ranging from localized or spontaneously regressing to widely metastatic disease. Neuroblastomas recapitulate many of the features of sympathoadrenal development, which have been directly targeted to improve the survival outcomes in patients with high-risk disease. Over the past few decades, improvements in the 5-year survival of patients with metastatic neuroblastomas, from <20% to >50%, have resulted from clinical trials incorporating high-dose chemotherapy with autologous stem cell transplantation, differentiating agents and immunotherapy with anti-GD2 monoclonal antibodies. The next generation of trials are designed to improve the initial response rates in patients with high-risk neuroblastomas via the addition of immunotherapies, targeted therapies (such as ALK inhibitors) and radiopharmaceuticals to standard induction regimens. Other trials are focused on testing precision medicine strategies for patients with relapsed and/or refractory disease, enhancing the antitumour immune response and improving the effectiveness of maintenance regimens, in order to prolong disease remission. In this Review, we describe advances in delineating the pathogenesis of neuroblastoma and in identifying the drivers of high-risk disease. We then discuss how this knowledge has informed improvements in risk stratification, risk-adapted therapy and the development of novel therapies.
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Liu KX, Naranjo A, Zhang FF, DuBois SG, Braunstein SE, Voss SD, Khanna G, London WB, Doski JJ, Geiger JD, Kreissman SG, Grupp SA, Diller LR, Park JR, Haas-Kogan DA. Prospective Evaluation of Radiation Dose Escalation in Patients With High-Risk Neuroblastoma and Gross Residual Disease After Surgery: A Report From the Children's Oncology Group ANBL0532 Study. J Clin Oncol 2020; 38:2741-2752. [PMID: 32530765 DOI: 10.1200/jco.19.03316] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE A primary objective of the Children's Oncology Group (COG) ANBL0532 phase III study was to assess the effect of increasing local dose of radiation to a residual primary tumor on the cumulative incidence of local progression (CILP) in patients with high-risk neuroblastoma. PATIENTS AND METHODS Newly diagnosed patients with high-risk neuroblastoma were randomly assigned or assigned to receive single or tandem autologous stem-cell transplantation (SCT) after induction chemotherapy. Local control consisted of surgical resection during induction chemotherapy and radiotherapy after last SCT. Patients received 21.6 Gy to the preoperative primary tumor volume. For patients with incomplete surgical resection, an additional boost of 14.4 Gy was delivered to the gross residual tumor, for a total dose of 36 Gy. CILP (primary end point) and event-free (EFS) and overall survival (OS; secondary end points) were compared with the COG A3973 historical cohort, in which all patients received single SCT and 21.6 Gy without a boost. RESULTS For all patients in ANBL0532 receiving radiotherapy (n = 323), 5-year CILP, EFS, and OS rates were 11.2% ± 1.8%, 56.2% ± 3.4%, and 68.4% ± 3.2% compared with 7.1% ± 1.4% (P = .0590), 47.0% ± 3.5% (P = .0090), and 57.4% ± 3.5% (P = .0088) for all patients in A3973 receiving radiotherapy (n = 328), respectively. Five-year CILP, EFS, and OS rates for patients in A3973 with incomplete resection and radiotherapy (n = 47) were 10.6% ± 4.6%, 48.9% ± 10.1%, and 56.9% ± 10.0%, respectively. In comparison, 5-year CILP, EFS, and OS rates for patients in ANBL0532 who were randomly assigned or assigned to single SCT and received boost radiotherapy (n = 74) were 16.3% ± 4.3% (P = .4126), 50.9% ± 7.0% (P = .5084), and 68.1% ± 6.7% (P = .2835), respectively. CONCLUSION Boost radiotherapy to gross residual tumor present at the end of induction did not significantly improve 5-year CILP. These results highlight the need for new strategies to decrease the risk of locoregional failure.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham & Women's Hospital, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Arlene Naranjo
- Children's Oncology Group Statistics and Data Center, University of Florida, Gainesville, FL
| | - Fan F Zhang
- Children's Oncology Group Statistics and Data Center, Monrovia, CA
| | - Steven G DuBois
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Stephan D Voss
- Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Geetika Khanna
- Department of Radiology, St Louis Children's Hospital, St Louis, MO
| | - Wendy B London
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | - John J Doski
- Department of Surgery/Pediatric Surgery Division, University of Texas Health Science Center, San Rosa Children's Hospital, San Antonio, TX
| | - James D Geiger
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Susan G Kreissman
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Stephan A Grupp
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA
| | - Julie R Park
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham & Women's Hospital, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Jo JH, Ahn SD, Koh M, Kim JH, Lee SW, Song SY, Yoon SM, Kim YS, Kim SS, Park JH, Jung J, Choi EK. Patterns of recurrence after radiation therapy for high-risk neuroblastoma. Radiat Oncol J 2019; 37:224-231. [PMID: 31591871 PMCID: PMC6790795 DOI: 10.3857/roj.2019.00353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/16/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose To investigate the patterns of recurrence in patients with neuroblastoma treated with radiation therapy to the primary tumor site. Materials and Methods We retrospectively analyzed patients with high-risk neuroblastoma managed with definitive treatment with radiation therapy to the primary tumor site between January 2003 and June 2017. These patients underwent three-dimensional conformal radiation therapy or intensity-modulated radiation therapy. A total of 14–36 Gy was delivered to the planning target volume, which included the primary tumor bed and the selected metastatic site. The disease stage was determined according to the International Neuroblastoma Staging System (INSS). We evaluated the recurrence pattern (i.e., local or systemic), progression-free survival, and overall survival. Results A total of 40 patients with high-risk neuroblastoma were included in this study. The median patient age was 4 years (range, 1 to 11 years). Thirty patients (75%) had INSS stage 4 neuroblastoma. At the median follow-up of 58 months, there were 6 cases of local recurrence and 10 cases of systemic recurrence. Among the 6 local failure cases, 4 relapsed adjacent to the radiation field. The other 2 relapsed in the radiation field (i.e., para-aortic and retroperitoneal areas). The main sites of distant metastasis were the bone, lymph nodes, and bone marrow. The 5-year progression-free survival was 70.9% and the 5-year overall survival was 74.3%. Conclusion Radiation therapy directed at the primary tumor site provides good local control. It seems to be adequate for disease control in patients with high-risk neuroblastoma after chemotherapy and surgical resection.
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Affiliation(s)
- Ji Hwan Jo
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Minji Koh
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Wook Lee
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Si Yeol Song
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Kyung Choi
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Braunstein SE, London WB, Kreissman SG, Villablanca JG, Davidoff AM, DeSantes K, Castleberry RP, Murray K, Diller L, Matthay K, Cohn SL, Shulkin B, von Allmen D, Parisi MT, Van Ryn CC, Park JR, Quaglia MPL, Haas-Kogan DA. Role of the extent of prophylactic regional lymph node radiotherapy on survival in high-risk neuroblastoma: A report from the COG A3973 study. Pediatr Blood Cancer 2019; 66:e27736. [PMID: 30968542 PMCID: PMC7281832 DOI: 10.1002/pbc.27736] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 02/18/2019] [Accepted: 03/09/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Neuroblastoma is the most common extracranial solid pediatric malignancy, with poor outcomes in high-risk disease. Standard treatment approaches employ an increasing array of aggressive multimodal therapies, of which local control with surgery and radiotherapy remains a backbone; however, the benefit of broad regional nodal irradiation remains controversial. We analyzed centrally reviewed radiation therapy data from patients enrolled on COG A3973 to evaluate the impact of primary site irradiation and the extent of regional nodal coverage stratified by extent of surgical resection. METHODS Three hundred thirty high-risk neuroblastoma patients with centrally reviewed radiotherapy plans were analyzed. Outcome was evaluated by the extent of nodal irradiation. For the 171 patients who also underwent surgery (centrally reviewed), outcome was likewise analyzed according to the extent of resection. Overall survival (OS), event-free survival (EFS), and cumulative incidence of local progression (CILP) were examined by Kaplan-Meier, log-rank test (EFS, OS), and Grey test (CILP). RESULTS The five-year CILP, EFS, and OS for all 330 patients receiving radiotherapy on A3973 were 8.5% ± 1.5%, 47.2% ± 3.0%, and 59.7% ± 3.0%, respectively. There were no significant differences in outcomes based on the extent of lymph node irradiation regardless of the degree of surgical resection (< 90% or ≥90%). CONCLUSION Although local control remains a significant component of treatment of high-risk neuroblastoma, our results suggest there is no benefit of extensive lymph node irradiation, irrespective of the extent of surgical resection preceding stem cell transplant.
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Affiliation(s)
| | - Wendy B. London
- Department of Pediatric Oncology/Hematology, Biostatistics Division, Dana Farber/Children’s Hospital Cancer Center
| | | | - Judith G. Villablanca
- Department of Pediatrics, Keck School of Medicine, University of Southern California
| | - Andrew M. Davidoff
- Department of Surgery, Pediatrics Division, St. Jude’s Children’s Research Hospital
| | | | | | - Kevin Murray
- Department of Pediatrics, University of Louisville
| | - Lisa Diller
- Department of Pediatric Oncology/Hematology, Dana Farber/Children’s Hospital Cancer Center
| | - Katherine Matthay
- Department of Pediatric Hematology-Oncology, University of California, San Francisco
| | - Susan L. Cohn
- Department of Pediatrics, Section of Hematology/Oncology, University of Chicago
| | - Barry Shulkin
- Department of Diagnostic Imaging, Pediatrics Division, St. Jude’s Children’s Research Hospital
| | | | | | - C. Collin Van Ryn
- Department of Biostatistics, University of Florida, College of Public Health
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Hill-Kayser CE, Tochner Z, Li Y, Kurtz G, Lustig RA, James P, Balamuth N, Womer R, Mattei P, Grupp S, Mosse YP, Maris JM, Bagatell R. Outcomes After Proton Therapy for Treatment of Pediatric High-Risk Neuroblastoma. Int J Radiat Oncol Biol Phys 2019; 104:401-408. [PMID: 30738983 DOI: 10.1016/j.ijrobp.2019.01.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/04/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Patients with high-risk neuroblastoma (HR-NBL) require radiation to the primary tumor site and sites of persistent metastatic disease. Proton radiation therapy (PRT) may promote organ sparing, but long-term outcomes have not been studied. METHODS AND MATERIALS Sequential patients with HR-NBL received PRT: 2160 cGy (relative biological effectiveness) to primary tumor bed and persistent metastatic sites, with 3600 cGy (relative biological effectiveness) to gross residual disease. RESULTS From September 2010 through September 2015, 45 patients with HR-NBL received PRT after systemic therapy, primary tumor resection, and high-dose chemotherapy with stem cell rescue. Median age was 46 months at the time of PRT (range, 10 months to 12 years); 23 patients (51%) were male. Primary tumors were adrenal in 40 (89%); 11 (24%) received boost. Ten metastatic sites in 8 patients were radiated. Double scattered proton beams were used for 19 (42%) patients, in combination with x-rays for 2 (5%). The remaining 26 (58%) received pencil beam scanning, available since January 2013. We observed 97% freedom from primary site recurrence at 3, 4, and 5 years. Overall survival rates were 89%, 80%, and 80% and disease-free survival rates were 77%, 70%, and 70%, at 3, 4, and 5 years, respectively. With median follow-up of 48.7 months from diagnosis (range, 11-90 months) for all patients (57.4 months for those alive), 37 (82%) patients are alive, and 32 (71%) are without evidence of disease. One patient experienced locoregional recurrence; the remaining 12 (27%) experienced relapse at distant, nonradiated sites. Acute toxicities during treatment were mainly grade 1. No patient has experienced World Health Organization grade 3 or 4 long-term renal or hepatic toxicity. Pencil beam scanning plans required less planning time and resources than double scattered plans. CONCLUSIONS We observe excellent outcomes in patients treated with PRT for HR-NBL from 2010 through 2015, with 82% of patients alive and 97% free of primary site recurrence. No patient has experienced long-term renal or liver toxicity. This treatment maximizes normal tissue preservation and is appropriate for this patient population.
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Affiliation(s)
- Christine E Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Zelig Tochner
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yimei Li
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Goldie Kurtz
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert A Lustig
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul James
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Naomi Balamuth
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Womer
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Mattei
- Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Grupp
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yael P Mosse
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John M Maris
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rochelle Bagatell
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Arumugam S, Manning-Cork NJ, Gains JE, Boterberg T, Gaze MN. The Evidence for External Beam Radiotherapy in High-Risk Neuroblastoma of Childhood: A Systematic Review. Clin Oncol (R Coll Radiol) 2018; 31:182-190. [PMID: 30509728 DOI: 10.1016/j.clon.2018.11.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/27/2018] [Indexed: 12/15/2022]
Abstract
AIMS External beam radiotherapy is widely used in various ways in the management of neuroblastoma. Despite extensive clinical experience, the precise role of radiotherapy in neuroblastoma remains unclear. The purpose of this systematic review was to survey the published literature to identify, without bias, the evidence for the clinical effectiveness of external beam radiotherapy as part of the initial multimodality treatment of high-risk neuroblastoma. We considered four areas: treatment of the tumour bed and residual primary tumour, identification of any dose-response relationship, treatment of metastatic sites, identification of any technical advances that may be beneficial. We also aimed to define uncertainties, which may be clarified in future clinical trials. MATERIALS AND METHODS Bibliographic databases were searched for neuroblastoma and radiotherapy. Reviewers assessed 1283 papers for inclusion by title and abstract, with consensus achieved through discussion. Data extraction on 57 included papers was carried out by one reviewer and checked by another. Studies were assessed for their level of evidence and risk of bias, and a descriptive analysis of data was carried out. RESULTS Fifteen papers provided some evidence that radiotherapy to the tumour bed and residual tumour may possibly be of value. However, there is a significant risk of bias and no evidence that all subgroups will benefit. There is some suggestion from six papers that dose may be important, but no hard evidence. It remains unclear whether irradiation of metastatic sites is helpful. Technical advances may be of value in radiotherapy of high-risk neuroblastoma. CONCLUSIONS There are data that show that radiotherapy is of some efficacy in the management of high-risk neuroblastoma, but there is no level one evidence that shows that it is being used in the best possible way. Prospective randomised trials are necessary to provide more evidence to guide development of optimal radiotherapy treatment schedules.
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Affiliation(s)
- S Arumugam
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - N J Manning-Cork
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - T Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Gent, Belgium
| | - M N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK.
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Nakagawara A, Li Y, Izumi H, Muramori K, Inada H, Nishi M. Neuroblastoma. Jpn J Clin Oncol 2018; 48:214-241. [PMID: 29378002 DOI: 10.1093/jjco/hyx176] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Indexed: 02/07/2023] Open
Abstract
Neuroblastoma is one of the most common solid tumors in children and has a diverse clinical behavior that largely depends on the tumor biology. Neuroblastoma exhibits unique features, such as early age of onset, high frequency of metastatic disease at diagnosis in patients over 1 year of age and the tendency for spontaneous regression of tumors in infants. The high-risk tumors frequently have amplification of the MYCN oncogene as well as segmental chromosome alterations with poor survival. Recent advanced genomic sequencing technology has revealed that mutation of ALK, which is present in ~10% of primary tumors, often causes familial neuroblastoma with germline mutation. However, the frequency of gene mutations is relatively small and other aberrations, such as epigenetic abnormalities, have also been proposed. The risk-stratified therapy was introduced by the Japan Neuroblastoma Study Group (JNBSG), which is now moving to the Neuroblastoma Committee of Japan Children's Cancer Group (JCCG). Several clinical studies have facilitated the reduction of therapy for children with low-risk neuroblastoma disease and the significant improvement of cure rates for patients with intermediate-risk as well as high-risk disease. Therapy for patients with high-risk disease includes intensive induction chemotherapy and myeloablative chemotherapy, followed by the treatment of minimal residual disease using differentiation therapy and immunotherapy. The JCCG aims for better cures and long-term quality of life for children with cancer by facilitating new approaches targeting novel driver proteins, genetic pathways and the tumor microenvironment.
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Affiliation(s)
| | - Yuanyuan Li
- Laboratory of Molecular Biology, Life Science Research Institute, Saga Medical Center Koseikan
| | - Hideki Izumi
- Laboratory of Molecular Biology, Life Science Research Institute, Saga Medical Center Koseikan
| | | | - Hiroko Inada
- Department of Pediatrics, Saga Medical Center Koseikan
| | - Masanori Nishi
- Department of Pediatrics, Saga University, Saga 849-8501, Japan
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9
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A single center clinical analysis of children with high-risk neuroblastoma. Oncotarget 2018; 8:30357-30368. [PMID: 28423674 PMCID: PMC5444748 DOI: 10.18632/oncotarget.15996] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 02/13/2017] [Indexed: 11/25/2022] Open
Abstract
The current multidisciplinary treatment for patients with high-risk neuroblastoma (NB) is the common census. However, protocols and opinions are different in different regions and institutions. We aimed to assess the protocol formulated by Chinese Children's Cancer Group study in 2009, and the impact of surgery extent was highlightly evaluated. METHODS This study enrolled patients with high-risk neuroblastoma between 2009 and 2014 in Department of Pediatric Oncology of Tianjin Medical University Cancer Institute and Hospital. The clinical characteristics of patients were illustrated and surgery extent was evaluated by the impact on survival rate. RESULTS The 3-year overall survival (OS) and progression-free survival (PFS) were 56.2% and 50.5%, respectively. LDH (P<0.001), bone marrow metastasis at time of diagnosis (P=0.001), bone marrow negative after neoadjuvant chemotherapy (P<0.001), radiotherapy (P<0.001) were significant predictors of OS and PFS. And surgery extent had no impact on the enhancement of high-risk neuroblastoma patients in short time. CONCLUSIONS This study showed no substantial survival benefit in patients with high-risk NB undergoing gross total tumor resection. Multidisciplinary intensive treatment was essential, especially for patients received subtotal tumor resection. Longer term follow-up is needed to survey complications in surviving patients who received intensive chemotherapy and radiotherapy.
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10
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Pandit-Taskar N, Modak S. Norepinephrine Transporter as a Target for Imaging and Therapy. J Nucl Med 2017; 58:39S-53S. [PMID: 28864611 DOI: 10.2967/jnumed.116.186833] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/19/2017] [Indexed: 01/01/2023] Open
Abstract
The norepinephrine transporter (NET) is essential for norepinephrine uptake at the synaptic terminals and adrenal chromaffin cells. In neuroendocrine tumors, NET can be targeted for imaging as well as therapy. One of the most widely used theranostic agents targeting NET is metaiodobenzylguanidine (MIBG), a guanethidine analog of norepinephrine. 123I/131I-MIBG theranostics have been applied in the clinical evaluation and management of neuroendocrine tumors, especially in neuroblastoma, paraganglioma, and pheochromocytoma. 123I-MIBG imaging is a mainstay in the evaluation of neuroblastoma, and 131I-MIBG has been used for the treatment of relapsed high-risk neuroblastoma for several years, however, the outcome remains suboptimal. 131I-MIBG has essentially been only palliative in paraganglioma/pheochromocytoma patients. Various techniques of improving therapeutic outcomes, such as dosimetric estimations, high-dose therapies, multiple fractionated administration and combination therapy with radiation sensitizers, chemotherapy, and other radionuclide therapies, are being evaluated. PET tracers targeting NET appear promising and may be more convenient options for the imaging and assessment after treatment. Here, we present an overview of NET as a target for theranostics; review its current role in some neuroendocrine tumors, such as neuroblastoma, paraganglioma/pheochromocytoma, and carcinoids; and discuss approaches to improving targeting and theranostic outcomes.
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Affiliation(s)
| | - Shakeel Modak
- Memorial Sloan Kettering Cancer Center, New York, New York
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Ferris MJ, Danish H, Switchenko JM, Deng C, George BA, Goldsmith KC, Wasilewski KJ, Cash WT, Khan MK, Eaton BR, Esiashvili N. Favorable Local Control From Consolidative Radiation Therapy in High-Risk Neuroblastoma Despite Gross Residual Disease, Positive Margins, or Nodal Involvement. Int J Radiat Oncol Biol Phys 2016; 97:806-812. [PMID: 28244417 DOI: 10.1016/j.ijrobp.2016.11.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/27/2016] [Accepted: 11/21/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To report the influence of radiation therapy (RT) dose and surgical pathology variables on disease control and overall survival (OS) in patients treated for high-risk neuroblastoma at a single institution. METHODS AND MATERIALS We conducted a retrospective study of 67 high-risk neuroblastoma patients who received RT as part of definitive management from January 2003 until May 2014. RESULTS At a median follow-up of 4.5 years, 26 patients (38.8%) failed distantly; 4 of these patients also failed locally. One patient progressed locally without distant failure. Local control was 92.5%, and total disease control was 59.5%. No benefit was demonstrated for RT doses over 21.6 Gy with respect to local relapse-free survival (P=.55), disease-free survival (P=.22), or OS (P=.72). With respect to local relapse-free survival, disease-free survival, and OS, no disadvantage was seen for positive lymph nodes on surgical pathology, positive surgical margins, or gross residual disease. Of the patients with gross residual disease, 75% (6 of 8) went on to have no evidence of disease at time of last follow-up, and the 2 patients who failed did so distantly. CONCLUSIONS Patients with high-risk neuroblastoma in this series maintained excellent local control, with no benefit demonstrated for radiation doses over 21.6 Gy, and no disadvantage demonstrated for gross residual disease after surgery, positive surgical margins, or pathologic lymph node positivity. Though the limitations of a retrospective review for an uncommon disease must be kept in mind, with small numbers in some of the subgroups, it seems that dose escalation should be considered only in exceptional circumstances.
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Affiliation(s)
- Matthew J Ferris
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Hasan Danish
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Winship Cancer Institute, Emory University, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Claudia Deng
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bradley A George
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kelly C Goldsmith
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Karen J Wasilewski
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - W Thomas Cash
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mohammad K Khan
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Natia Esiashvili
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
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12
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Abstract
Neuroblastoma is the most common extracranial solid tumour occurring in childhood and has a diverse clinical presentation and course depending on the tumour biology. Unique features of these neuroendocrine tumours are the early age of onset, the high frequency of metastatic disease at diagnosis and the tendency for spontaneous regression of tumours in infancy. The most malignant tumours have amplification of the MYCN oncogene (encoding a transcription factor), which is usually associated with poor survival, even in localized disease. Although transgenic mouse models have shown that MYCN overexpression can be a tumour-initiating factor, many other cooperating genes and tumour suppressor genes are still under investigation and might also have a role in tumour development. Segmental chromosome alterations are frequent in neuroblastoma and are associated with worse outcome. The rare familial neuroblastomas are usually associated with germline mutations in ALK, which is mutated in 10-15% of primary tumours, and provides a potential therapeutic target. Risk-stratified therapy has facilitated the reduction of therapy for children with low-risk and intermediate-risk disease. Advances in therapy for patients with high-risk disease include intensive induction chemotherapy and myeloablative chemotherapy, followed by the treatment of minimal residual disease using differentiation therapy and immunotherapy; these have improved 5-year overall survival to 50%. Currently, new approaches targeting the noradrenaline transporter, genetic pathways and the tumour microenvironment hold promise for further improvements in survival and long-term quality of life.
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13
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Luksch R, Castellani MR, Collini P, De Bernardi B, Conte M, Gambini C, Gandola L, Garaventa A, Biasoni D, Podda M, Sementa AR, Gatta G, Tonini GP. Neuroblastoma (Peripheral neuroblastic tumours). Crit Rev Oncol Hematol 2016; 107:163-181. [PMID: 27823645 DOI: 10.1016/j.critrevonc.2016.10.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 09/05/2016] [Accepted: 10/03/2016] [Indexed: 02/07/2023] Open
Abstract
Peripheral neuroblastic tumours (PNTs), a family of tumours arising in the embryonal remnants of the sympathetic nervous system, account for 7-10% of all tumours in children. In two-thirds of cases, PNTs originate in the adrenal glands or the retroperitoneal ganglia. At least one third present metastases at onset, with bone and bone marrow being the most frequent metastatic sites. Disease extension, MYCN oncogene status and age are the most relevant prognostic factors, and their influence on outcome have been considered in the design of the recent treatment protocols. Consequently, the probability of cure has increased significantly in the last two decades. In children with localised operable disease, surgical resection alone is usually a sufficient treatment, with 3-year event-free survival (EFS) being greater than 85%. For locally advanced disease, primary chemotherapy followed by surgery and/or radiotherapy yields an EFS of around 75%. The greatest problem is posed by children with metastatic disease or amplified MYCN gene, who continue to do badly despite intensive treatments. Ongoing trials are exploring the efficacy of new drugs and novel immunological approaches in order to save a greater number of these patients.
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Affiliation(s)
- Roberto Luksch
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | | | - Paola Collini
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Massimo Conte
- Giannina Gaslini Children's Research Hospital, Genoa, Italy
| | | | - Lorenza Gandola
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Davide Biasoni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marta Podda
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Gemma Gatta
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gian Paolo Tonini
- Neuroblastoma Laboratory, Paediatric Research Institute, Padua, Italy
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14
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Casey DL, Kushner BH, Cheung NKV, Modak S, LaQuaglia MP, Wolden SL. Local Control With 21-Gy Radiation Therapy for High-Risk Neuroblastoma. Int J Radiat Oncol Biol Phys 2016; 96:393-400. [PMID: 27473818 PMCID: PMC5476959 DOI: 10.1016/j.ijrobp.2016.05.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/27/2016] [Accepted: 05/19/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate local control after 21-Gy radiation therapy (RT) to the primary site in patients with high-risk neuroblastoma. METHODS AND MATERIALS After receiving dose-intensive chemotherapy and gross total resection (GTR), 246 patients (aged 1.2-17.9 years, median 4.0 years) with high-risk neuroblastoma underwent RT to the primary site at Memorial Sloan Kettering from 2000 to 2014. Radiation therapy consisted of 21 Gy in twice-daily fractions of 1.5 Gy each. Local failure (LF) was correlated with biologic prognostic factors and clinical findings at the time of diagnosis and start of RT. RESULTS Median follow-up of surviving patients was 6.4 years. Cumulative incidence of LF was 7.1% at 2 years after RT and 9.8% at 5 years after RT. The isolated LF rate was 3.0%. Eighty-six percent of all local failures were within the RT field. Local control was worse in patients who required more than 1 surgical resection to achieve GTR (22.4% vs 8.3%, P=.01). There was also a trend toward inferior local control with MYCN-amplified tumors or serum lactate dehydrogenase ≥1500 U/L (P=.09 and P=.06, respectively). CONCLUSION After intensive chemotherapy and maximal surgical debulking, hyperfractionated RT with 21 Gy in high-risk neuroblastoma results in excellent local control. Given the young patient age, concern for late effects, and local control >90%, dose reduction may be appropriate for patients without MYCN amplification who achieve GTR.
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Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brian H Kushner
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nai-Kong V Cheung
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shakeel Modak
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael P LaQuaglia
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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15
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Taunk NK, Kushner B, Ibanez K, Wolden S. Short-Interval Retreatment With Stereotactic Body Radiotherapy (SBRT) for Pediatric Neuroblastoma Resulting in Severe Myositis. Pediatr Blood Cancer 2016; 63:731-3. [PMID: 26806854 PMCID: PMC5029085 DOI: 10.1002/pbc.25863] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/06/2015] [Accepted: 11/10/2015] [Indexed: 12/25/2022]
Abstract
We report a severe and not previously reported toxicity after short-interval retreatment with stereotactic body radiotherapy (SBRT) in a pediatric patient with neuroblastoma. This patient experienced Grade III radiation myositis after treatment with conventional radiation therapy followed by high-dose SBRT for persistent disease a short interval after the initial radiotherapy course. While SBRT shows outstanding rates of local control in adult disease, data in pediatric cancers are extremely limited. In this report, we discuss the rationale of SBRT in this patient's multimodality neuroblastoma treatment, management of the toxicity, and future perspectives on the use of SBRT in pediatric cancer.
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Affiliation(s)
- Neil K. Taunk
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian Kushner
- Department of Pediatric Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Katarzyna Ibanez
- Department of Neurology, Rehabilitation Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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16
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Yeung F, Chung PHY, Tam PKH, Wong KKY. Is complete resection of high-risk stage IV neuroblastoma associated with better survival? J Pediatr Surg 2015; 50:2107-11. [PMID: 26377869 DOI: 10.1016/j.jpedsurg.2015.08.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 08/24/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND The role of surgery in the management of stage IV neuroblastoma is controversial. In this study, we attempted to study if complete tumor resection had any impact on event-free survival (EFS) and overall survival (OS). METHODS A retrospective analysis of patients with stage IV neuroblastoma between November 2000 and July 2014 in a tertiary referral center was performed. Demographics data, extent of surgical resection, and outcomes were analyzed. RESULTS A total of 34 patients with stage IV neuroblastoma according to International Neuroblastoma Staging System (INSS) were identified. The median age at diagnosis and operation was 3.5 (±1.9) years and 3.8 (±2.0) years, respectively. Complete gross tumor resection (CTR) was achieved in twenty-four patients (70.1%), in which one of the patients had nephrectomy and another had distal pancreatectomy. Gross total resection (GTR) with removal of >95% of tumor was performed in six patients (17.6%) and subtotal tumor resection (STR) with removal of >50%, but <95% of tumor was performed in four patients (11.8%). There was no statistical significance in terms of 5-year EFS and OS among the 3 groups. There was no surgery-related mortality or morbidity. CONCLUSIONS From our center's experience, as there was no substantial survival benefit in stage IV neuroblastoma patients undergoing complete tumor resection, organ preservation and minimalization of morbidity should also be taken into consideration.
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Affiliation(s)
- Fanny Yeung
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Patrick Ho Yu Chung
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Paul Kwong Hang Tam
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Kenneth Kak Yuen Wong
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.
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17
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Parikh NS, Howard SC, Chantada G, Israels T, Khattab M, Alcasabas P, Lam CG, Faulkner L, Park JR, London WB, Matthay KK. SIOP-PODC adapted risk stratification and treatment guidelines: Recommendations for neuroblastoma in low- and middle-income settings. Pediatr Blood Cancer 2015; 62:1305-16. [PMID: 25810263 PMCID: PMC5132052 DOI: 10.1002/pbc.25501] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/30/2015] [Indexed: 12/11/2022]
Abstract
Neuroblastoma is the most common extracranial solid tumor in childhood in high-income countries (HIC), where consistent treatment approaches based on clinical and tumor biological risk stratification have steadily improved outcomes. However, in low- and middle- income countries (LMIC), suboptimal diagnosis, risk stratification, and treatment may occur due to limited resources and unavailable infrastructure. The clinical practice guidelines outlined in this manuscript are based on current published evidence and expert opinions. Standard risk stratification and treatment explicitly adapted to graduated resource settings can improve outcomes for children with neuroblastoma by reducing preventable toxic death and relapse.
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Affiliation(s)
- Nehal S. Parikh
- Department of PediatricsDivision of Hematology‐OncologyConnecticut Children's Medical CenterHartfordConnecticut
| | | | | | - Trijn Israels
- VU University Medical CenterAmsterdamthe Netherlands
| | - Mohammed Khattab
- Department of PaediatricsChildren's Hospital of RabatRabatMorocco
| | - Patricia Alcasabas
- University of the Philippines‐Philippine General HospitalManilaPhilippines
| | - Catherine G. Lam
- Department of Oncology and International Outreach ProgramSt. Jude Children's Research HospitalMemphisTennessee
| | | | - Julie R. Park
- Seattle Children's HospitalUniversity of Washington School of Medicine and Fred Hutchinson Cancer Research CenterSeattleWashington
| | - Wendy B. London
- Harvard Medical SchoolBoston Children's Hospital and Dana Farber Cancer InstituteBostonMaryland
| | - Katherine K. Matthay
- Department of PediatricsUCSF School of Medicine and UCSF Benioff Children's HospitalSan FranciscoCalifornia
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18
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Kandula S, Sutter A, Prabhu RS, Jegadeesh N, Esiashvili N. Reassessing dose constraints of organs at risk in children with abdominal neuroblastoma treated with definitive radiation therapy: a correlation with late toxicity. Pediatr Blood Cancer 2015; 62:970-5. [PMID: 25545501 DOI: 10.1002/pbc.25372] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/29/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND In children treated with definitive radiation therapy (RT) for abdominal neuroblastoma, normal tissue constraints for organs at risk (OARs) are not well-standardized or evidence-based. In this study, we analyze dosimetric data of principal abdominal OARs, reassess existing RT planning constraints, and examine corresponding acute and late toxicity to OARs. PROCEDURE The treatment plans of 30 consecutive children who underwent definitive RT for high-risk abdominal neuroblastoma were reviewed. Dose-volume histogram (DVH) statistics were recorded for the ipsilateral kidney (if unresected), contralateral kidney, and liver. DVH data were analyzed to determine if OAR constraints from recent protocols were met and correlated with the development of toxicity. RESULTS The median follow-up period was 53.0 months. Ten, thirteen, and ten percent of patients' RT plans did not meet OAR DVH constraints for the liver, ipsilateral kidney, and contralateral kidney, respectively. Of the three patients whose plans did not achieve ipsilateral kidney DVH constraint(s), two developed evidence of late ipsilateral kidney hypoplasia, but maintained normal laboratory kidney function. No patient experienced late toxicity of the contralateral kidney nor developed RT-related late hepatic complications. CONCLUSIONS In children treated for abdominal neuroblastoma, the risk of developing clinically significant RT-related late toxicity of the kidney and liver is not appreciable, even when current DVH parameters for OARs are not achieved in planning. Toxicity outcomes did not necessarily correlate with present-day OAR dose constraints. Currently utilized DVH constraints are highly variable, and must be further studied and supported by toxicity outcomes to more accurately characterize risk of complications.
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Affiliation(s)
- Shravan Kandula
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
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19
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Abstract
In patients with high-risk metastatic neuroblastoma, the benefit of radiation therapy (RT) to metastatic sites as part of primary treatment has not been fully investigated. The purpose of this single-institution study was to evaluate local control of irradiated metastatic sites, and characterize metastatic disease burden and anatomic distribution in patients with high-risk metastatic neuroblastoma. The records of all patients diagnosed with stage 4 neuroblastoma between August 2000 and January 2010 were reviewed. Exclusion criteria included: bone-marrow only metastatic site, total body irradiation, or no imaging follow-up. A total of 37 patients met eligibility criteria. Median follow-up period for patients without relapse was 61 months. Five-year overall survival for all patients was 67%. Thirteen patients (35%) received RT to a metastatic site as part of their primary treatment. Among these patients, in-field recurrence occurred in three patients (23%), including two of three treated calvarial sites. In patients treated with or without RT to a metastatic site, respectively, there was no significant difference in 5-year overall survival (73% vs. 63%, P=0.84) or relapse-free survival (46% and 55%, P=0.48). Current metastatic site RT dose may be suboptimal, and certain locations may predict for a poor response. Further studies are necessary to elucidate the optimal role of RT to metastatic sites.
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20
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Mazloom A, Louis CU, Nuchtern J, Kim E, Russell H, Allen-Rhoades W, Krance R, Paulino AC. Radiation therapy to the primary and postinduction chemotherapy MIBG-avid sites in high-risk neuroblastoma. Int J Radiat Oncol Biol Phys 2014; 90:858-62. [PMID: 25245583 DOI: 10.1016/j.ijrobp.2014.07.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/17/2014] [Accepted: 07/14/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Although it is generally accepted that consolidation therapy for neuroblastoma includes irradiation of the primary site and any remaining metaiodobenzylguanidine (MIBG)-avid metastatic sites, limited information has been published regarding the efficacy of this approach. METHODS AND MATERIALS Thirty patients with high-risk neuroblastoma were treated at 1 radiation therapy (RT) department after receiving 5 cycles of induction chemotherapy and resection. All patients had at least a partial response after induction therapy, based upon international neuroblastoma response criteria. The primary sites were treated with 24 to 30 Gy whereas the MIBG-avid metastatic sites were treated with 24 Gy. RT was followed by high-dose chemotherapy with autologous stem cell rescue and 6 months of cis-retinoic acid. RESULTS The 5-year progression-free survival (PFS) and overall survival (OS) rates were 48% and 59%, respectively. The 5-year locoregional control at the primary site was 84%. There were no differences in locoregional control according to degree of primary surgical resection. The 5-year local control rate for metastatic sites was 74%. The 5-year PFS rates for patients with 0, 1, 2, and >3 postinduction MIBG sites were 66%, 57%, 20%, and 0% (P<.0001), respectively, whereas 5-year OS rates were 80%, 57%, 50%, and 0%, respectively (P<.0001). CONCLUSIONS RT to the primary site and postinduction MIBG-positive metastatic sites was associated with 84% and 74% local control, respectively. The number of MIBG-avid sites present after induction chemotherapy and surgery was predictive of progression-free and overall survival.
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Affiliation(s)
- Ali Mazloom
- Houston Methodist Hospital, Texas Children's Hospital, and Baylor College of Medicine, Houston, Texas
| | - Chrystal U Louis
- Houston Methodist Hospital, Texas Children's Hospital, and Baylor College of Medicine, Houston, Texas
| | - Jed Nuchtern
- Houston Methodist Hospital, Texas Children's Hospital, and Baylor College of Medicine, Houston, Texas
| | - Eugene Kim
- Houston Methodist Hospital, Texas Children's Hospital, and Baylor College of Medicine, Houston, Texas
| | - Heidi Russell
- Houston Methodist Hospital, Texas Children's Hospital, and Baylor College of Medicine, Houston, Texas
| | - Wendy Allen-Rhoades
- Houston Methodist Hospital, Texas Children's Hospital, and Baylor College of Medicine, Houston, Texas
| | - Robert Krance
- Houston Methodist Hospital, Texas Children's Hospital, and Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- Houston Methodist Hospital, Texas Children's Hospital, and Baylor College of Medicine, Houston, Texas.
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Polishchuk AL, Li R, Hill-Kayser C, Little A, Hawkins RA, Hamilton J, Lau M, Tran HC, Strahlendorf C, Lemons RS, Weinberg V, Matthay KK, DuBois SG, Marcus KJ, Bagatell R, Haas-Kogan DA. Likelihood of Bone Recurrence in Prior Sites of Metastasis in Patients With High-Risk Neuroblastoma. Int J Radiat Oncol Biol Phys 2014; 89:839-45. [DOI: 10.1016/j.ijrobp.2014.04.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/04/2014] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
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Treatment of high-risk neuroblastoma in children: recent clinic trial results. ACTA ACUST UNITED AC 2013. [DOI: 10.4155/cli.13.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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23
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Hill-Kayser C, Tochner Z, Both S, Lustig R, Reilly A, Balamuth N, Womer R, Maris J, Grupp S, Bagatell R. Proton versus photon radiation therapy for patients with high-risk neuroblastoma: the need for a customized approach. Pediatr Blood Cancer 2013; 60:1606-11. [PMID: 23737005 DOI: 10.1002/pbc.24606] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 04/29/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Proton therapy for treatment for high-risk neuroblastoma may offer sparing of organs at risk (OAR) when compared to intensity-modulated X-ray therapy (IMXT). PROCEDURE Double-scattered proton plans and IMXT plans delivering 2,160 cGy to the primary tumor site and other residual disease were developed for 13 consecutive HR-NBL patients. Radiation doses to target volumes and OAR were calculated to determine the optimal modality for each. RESULTS All patients received radiation (5/13 ≥ 2 sites). No patient has experienced local recurrence or clinical organ toxicity. Coverage was excellent using both protons and IMXT: median % dose delivered to 95% clinical target volume was 99% and 100%, respectively. For nine patients with lateralized disease, proton therapy offered sparing of the contralateral kidney both with regard to median dose and dose to 20% (median <1 cGy vs. 362 cGy, P = 0.01; median 100 cGy vs. 634 cGy, P = 0.02, respectively). Proton therapy did not reduce ipsilateral kidney dose, and for 2 select patients with lateralized disease IMXT improved overall bilateral renal sparing. Proton therapy improved median bowel (median 33 cGy vs. 590 cGy, P = 0.01), total body (median <1 cGy vs. 30 cGy, P = 0.15), and liver dose (median <1 cGy vs. 529, P < 0.001). When chest RT was required, proton therapy decreased median heart dose and mean lung dose. CONCLUSIONS For most patients (11/13), proton therapy offered the optimal combination of target coverage and organ sparing, and is a feasible treatment for HR-NBL. We recommend a customized approach with careful evaluation of renal dosimetry; IMXT may be preferred for select patients.
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Affiliation(s)
- Christine Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Pai Panandiker AS, Beltran C, Billups CA, McGregor LM, Furman WL, Davidoff AM. Intensity modulated radiation therapy provides excellent local control in high-risk abdominal neuroblastoma. Pediatr Blood Cancer 2013; 60:761-5. [PMID: 23024112 DOI: 10.1002/pbc.24350] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 09/05/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Locoregional failure is a significant concern in patients with high-risk abdominal neuroblastoma (NB) receiving radiotherapy. Locoregional control outcomes were studied in children with NB receiving intensity modulated radiotherapy (IMRT). PROCEDURE Twenty children (11 females, 9 males) with NB (median age at diagnosis 3.4 years) receiving IMRT were analyzed for locoregional failure, outcomes, and toxicities. IMRT doses were 23.4 Gy (n = 12), 30 Gy (n = 1), 30.6 Gy (n = 5), and 36.0 Gy (n = 2) based on extent of resection. Five patients had tumors with MYCN amplification, and 19 had metastatic disease. All patients were treated consistently using reproducible immobilization techniques; physiological motion was assessed by 4D-CT, and target localization by cone-beam computed tomography. ICRU 62 volumetric conventions were employed based on institutional data for pediatric target volume and organ motion. RESULTS No patient developed primary site infield or locoregional failure at a median follow-up of 2.2 years. Distant failure (median time to distant failure 1.6 years) occurred in the brain, lungs, or skeletal sites in eight patients, five of whom died. The 2-year event-free survival was 58.5 ± 13.3% and cumulative incidence of local and distant failures was 0% and 41.5 ± 11.9%, respectively. Asymptomatic loose stool during RT occurred in nearly all patients, but required no intervention. CONCLUSIONS IMRT is feasible, safe in the short term, and yields excellent locoregional control. Despite subtotal resection in some cases, locoregional control appeared to be increased by conformal radiotherapy with ICRU 62-compliant volumes. Dose escalation beyond 30.6 Gy may be unnecessary with improved target volume coverage.
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Affiliation(s)
- Atmaram S Pai Panandiker
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA.
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25
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Zaghloul MS. Intensity modulated radiotherapy (IMRT) for pediatric cancer patients: the advantage and fear of second malignant neoplasm. J Egypt Natl Canc Inst 2012; 25:1-3. [PMID: 23499200 DOI: 10.1016/j.jnci.2012.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 11/19/2012] [Indexed: 10/27/2022] Open
Abstract
Intensity-modulated radiotherapy is used for delivering more efficient homogenous dose to the target and lowering of dose to the surrounding normal tissues. However, a second malignant neoplasm may develop after prolonged latent period. The use of modern precise radiotherapy techniques in the pediatric age group has many controversial issues in spite of its proven dosimetric distribution advantages and the considerable decrease of normal tissue complication probability (NTCP). This concern is due to many factors; mainly the exposure of a larger volume of normal tissues to low dose radiotherapy. Children have more proliferating tissues compared to the adults. However, the epidemiological data did not detect an increase in the incidence of radiation-induced second malignancy. This issue is still controversial as IMRT and other precise radiotherapy techniques were not widely used except recently. This may entail a thorough careful follow up for children treated with these techniques to detect any incidence increase.
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Nazmy MS, Khafaga Y. Clinical experience in pediatric neuroblastoma intensity modulated radiotherapy. J Egypt Natl Canc Inst 2012; 24:185-9. [DOI: 10.1016/j.jnci.2012.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 10/02/2012] [Accepted: 10/05/2012] [Indexed: 11/27/2022] Open
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Gaze MN, Boterberg T, Dieckmann K, Hörmann M, Gains JE, Sullivan KP, Ladenstein R. Results of a quality assurance review of external beam radiation therapy in the International Society of Paediatric Oncology (Europe) Neuroblastoma Group's High-risk Neuroblastoma Trial: a SIOPEN study. Int J Radiat Oncol Biol Phys 2012; 85:170-4. [PMID: 22749633 DOI: 10.1016/j.ijrobp.2012.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 05/01/2012] [Accepted: 05/03/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE Radiation therapy is important for local control in neuroblastoma. This study reviewed the compliance of plans with the radiation therapy guidelines of the International Society of Paediatric Oncology (Europe) Neuroblastoma Group (SIOPEN) High-Risk Trial protocol. METHODS AND MATERIALS The SIOPEN trial central electronic database has sections to record diagnostic imaging and radiation therapy planning data. Individual centers may upload data remotely, but not all centers involved in the trial chose to use this system. A quality scoring system was devised based on how well the radiation therapy plan matched the protocol guidelines, to what extent deviations were justified, and whether adverse effects may result. Central review of radiation therapy planning was undertaken retrospectively in 100 patients for whom complete diagnostic and treatment sets were available. Data were reviewed and compared against protocol guidelines by an international team of radiation oncologists and radiologists. For each patient in the sample, the central review team assigned a quality assurance score. RESULTS It was found that in 48% of patients there was full compliance with protocol requirements. In 29%, there were deviations for justifiable reasons with no likely long-term adverse effects resulting. In 5%, deviations had occurred for justifiable reasons, but that might result in adverse effects. In 1%, there was a deviation with no discernible justification, which would not lead to long-term adverse events. In 17%, unjustified deviations were noted, with a risk of an adverse outcome resulting. CONCLUSIONS Owing to concern over the proportion of patients in whom unjustified deviations were observed, a protocol amendment has been issued. This offers the opportunity for central review of radiation therapy plans before the start of treatment and the treating clinician a chance to modify plans.
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Affiliation(s)
- Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
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Matthay KK, Weiss B, Villablanca JG, Maris JM, Yanik GA, Dubois SG, Stubbs J, Groshen S, Tsao-Wei D, Hawkins R, Jackson H, Goodarzian F, Daldrup-Link H, Panigrahy A, Towbin A, Shimada H, Barrett J, Lafrance N, Babich J. Dose escalation study of no-carrier-added 131I-metaiodobenzylguanidine for relapsed or refractory neuroblastoma: new approaches to neuroblastoma therapy consortium trial. J Nucl Med 2012; 53:1155-63. [PMID: 22700000 DOI: 10.2967/jnumed.111.098624] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED (131)I-metaiodobenzylguanidine (MIBG) is specifically taken up in neuroblastoma, with a response rate of 20%-37% in relapsed disease. Nonradioactive carrier MIBG molecules inhibit uptake of (131)I-MIBG, theoretically resulting in less tumor radiation and increased risk of cardiovascular toxicity. Our aim was to establish the maximum tolerated dose of no-carrier-added (NCA) (131)I-MIBG, with secondary aims of assessing tumor and organ dosimetry and overall response. METHODS Eligible patients were 1-30 y old with resistant neuroblastoma, (131)I-MIBG uptake, and cryopreserved hematopoietic stem cells. A diagnostic dose of NCA (131)I-MIBG was followed by 3 dosimetry scans to assess radiation dose to critical organs and soft-tissue tumors. The treatment dose of NCA (131)I-MIBG (specific activity, 165 MBq/μg) was adjusted as necessary on the basis of critical organ tolerance limits. Autologous hematopoietic stem cells were infused 14 d after therapy to abrogate prolonged myelosuppression. Response and toxicity were evaluated on day 60. The NCA (131)I-MIBG was escalated from 444 to 777 MBq/kg (12-21 mCi/kg) using a 3 + 3 design. Dose-limiting toxicity (DLT) was failure to reconstitute neutrophils to greater than 500/μL within 28 d or platelets to greater than 20,000/μL within 56 d, or grade 3 or 4 nonhematologic toxicity by Common Terminology Criteria for Adverse Events (version 3.0) except for predefined exclusions. RESULTS Three patients each were evaluable at 444, 555, and 666 MBq/kg without DLT. The dose of 777 MBq/kg dose was not feasible because of organ dosimetry limits; however, 3 assigned patients were evaluable for a received dose of 666 MBq/kg, providing a total of 6 patients evaluable for toxicity at 666 MBq/kg without DLT. Mean whole-body radiation was 0.23 mGy/MBq, and mean organ doses were 0.92, 0.82, and 1.2 mGy/MBq of MIBG for the liver, lung, and kidney, respectively. Eight patients had 13 soft-tissue lesions with tumor-absorbed doses of 26-378 Gy. Four of 15 patients had a complete (n = 1) or partial (n = 3) response, 1 had a mixed response, 4 had stable disease, and 6 had progressive disease. CONCLUSION NCA (131)I-MIBG with autologous peripheral blood stem cell transplantation is feasible at 666 MBq/kg without significant nonhematologic toxicity and with promising activity.
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Rich BS, McEvoy MP, LaQuaglia MP, Wolden SL. Local control, survival, and operative morbidity and mortality after re-resection, and intraoperative radiation therapy for recurrent or persistent primary high-risk neuroblastoma. J Pediatr Surg 2011; 46:97-102. [PMID: 21238648 DOI: 10.1016/j.jpedsurg.2010.09.068] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 09/30/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND/PURPOSE Patients with locally recurrent or persistent high-risk neuroblastoma are difficult to treat. We describe our experience using intraoperative radiation therapy (IORT) after re-resection in this high-risk population. METHODS We retrospectively reviewed 44 consecutive patients who received IORT at our institution between April 2000 and September 2009 after gross total resection of recurrent/persistent tumor. Specifically, we evaluated local recurrence rates, complications, and overall survival. RESULTS The median age at diagnosis was 41.5 months. Median follow-up after IORT was 10.5 months. Each patient received prior chemotherapy and surgery, while 94.5% had previous external beam radiation therapy. MYCN was amplified in 34% of patients. There were no operative or postoperative deaths, and 18 patients (40.9%) had postoperative complications. There was a 50.4% probability of local control. MYCN amplification did not affect local control (local recurrence rate of 53.9% vs 52.4%, P = .89). Median overall survival was 18.7 months (95% confidence interval, 11.7-25.6 months). Mean survival for MYCN-amplified patients was 13.0 vs 39.2 months for those without MYCN amplification (P = .035). CONCLUSIONS Intraoperative radiation therapy after re-resection of locally recurrent/persistent neuroblastoma results in a reasonable rate of local control with acceptable morbidity and survival. This approach should be considered in this high-risk population.
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Affiliation(s)
- Barrie S Rich
- Department of Surgery, Pediatric Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Robbins JR, Krasin MJ, Pai Panandiker AS, Watkins A, Wu J, Santana VM, Furman WL, Davidoff AM, McGregor LM. Radiation therapy as part of local control of metastatic neuroblastoma: the St Jude Children's Research Hospital experience. J Pediatr Surg 2010; 45:678-86. [PMID: 20385270 PMCID: PMC2897834 DOI: 10.1016/j.jpedsurg.2009.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Revised: 09/19/2009] [Accepted: 11/08/2009] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of the study was to compare outcomes of pediatric patients with high-risk metastatic neuroblastoma who received radiotherapy (RT) with those of patients who did not. PATIENTS AND METHODS We reviewed the records of 63 patients with newly diagnosed metastatic neuroblastoma treated at our institution (1989-2001) to investigate their characteristics at presentation, dose and field of RT, treatment response, and failure patterns. RESULTS Seventeen patients received RT, and 46 did not. In the RT group, a greater percentage of patients had residual disease before consolidation than did those in the no-RT group (88.2% vs 69.6%, P = .008). Gross total resection was achieved less often in the RT group (65% vs 89%, P = .055), but the 5-year cumulative incidences of local failure were similar (35.3% +/- 12.4% vs 32.6% +/- 7.1%). Although there was no difference in 5-year event-free survival, overall survival was better in the no-RT group (47.8% +/- 7.2% vs 23.5% +/- 9.2%, P = .026). CONCLUSION The addition of RT to the therapy of a group of patients with more residual locoregional disease appeared to improve the local failure rate to approximately that of patients with less residual disease. Radiotherapy may provide even greater benefit to those with less residual disease before consolidation.
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Affiliation(s)
- Jared R. Robbins
- Department of Oncology, St. Jude Children’s Research Hospital; Memphis, Tennessee
| | - Matthew J. Krasin
- Department of Radiological Sciences, St. Jude Children’s Research Hospital; Memphis, Tennessee
| | | | - Amy Watkins
- Department of Biostatistics, St. Jude Children’s Research Hospital; Memphis, Tennessee
| | - Jianrong Wu
- Department of Biostatistics, St. Jude Children’s Research Hospital; Memphis, Tennessee
| | - Victor M. Santana
- Department of Oncology, St. Jude Children’s Research Hospital; Memphis, Tennessee
- Department of Pediatrics, The University of Tennessee Health Science Center; Memphis, Tennessee
| | - Wayne L. Furman
- Department of Oncology, St. Jude Children’s Research Hospital; Memphis, Tennessee
- Department of Pediatrics, The University of Tennessee Health Science Center; Memphis, Tennessee
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children’s Research Hospital; Memphis, Tennessee
- Department of Surgery, The University of Tennessee Health Science Center; Memphis, Tennessee
| | - Lisa M. McGregor
- Department of Oncology, St. Jude Children’s Research Hospital; Memphis, Tennessee
- Department of Pediatrics, The University of Tennessee Health Science Center; Memphis, Tennessee
- Correspondence: Lisa M. McGregor, MD, PhD, Department of Oncology, Mail Stop 260, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105-2794, Telephone: (901) 595-4445, Fax: (901) 521-9005.
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Abstract
Neuroblastoma, the most common extracranial pediatric solid tumor remains a clinical enigma with outcomes ranging from cure in >90% of patients with locoregional tumors with little to no cytotoxic therapy, to <30% for those >18months of age at diagnosis with metastatic disease despite aggressive multimodality therapy. Age, stage and amplification of the MYCN oncogene are the most validated prognostic markers. Recent research has shed light on the biology of neuroblastoma allowing more accurate stratification of patients which has permitted reducing or withholding cytotoxic therapy without affecting outcome for low-risk patients. However, for children with high-risk disease, the development of newer therapeutic strategies is necessary. Current surgery and radiotherapy techniques in conjunction with induction chemotherapy have greatly reduced the risk of local relapse. However, refractory or recurrent osteomedullary disease occurs in most patients with high-risk neuroblastoma. Toxicity limits for high-dose chemotherapy appear to have been reached without further clinical benefit. Neuroblastoma is the first pediatric cancer for which monoclonal-antibody-based immunotherapy has been shown to be effective, particularly for metastatic osteomedullary disease. Radioimmunotherapy appears to be a critical component of a recent, successful regimen for treating patients who relapse in the central nervous system, a possible sanctuary site. Efforts are under way to refine and enhance antibody-based immunotherapy and to determine its optimal use. The identification of newer tumor targets and the harnessing of cell-mediated immunotherapy may generate novel therapeutic approaches. It is likely that a combination of therapeutic modalities will be required to improve survival and cure rates.
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Pai Panandiker AS, McGregor L, Krasin MJ, Wu S, Xiong X, Merchant TE. Locoregional tumor progression after radiation therapy influences overall survival in pediatric patients with neuroblastoma. Int J Radiat Oncol Biol Phys 2009; 76:1161-5. [PMID: 19679408 DOI: 10.1016/j.ijrobp.2009.03.068] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 02/24/2009] [Accepted: 03/02/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE There is renewed attention to primary site irradiation and local control for patients with high-risk neuroblastoma (NB). We conducted a retrospective review to identify factors that might predict for locoregional tumor control and its impact on overall survival. METHODS AND MATERIALS Between July 2000 through August 2006, a total of 44 pediatric patients with NB received radiation therapy (RT) with curative intent using computed tomography (CT)-based treatment planning. The median age was 3.4 years and the median cumulative dose was 23.4 Gy. Overall survival and locoregional tumor control were measured from the start of RT to the date of death or event as determined by CT/magnetic resonance imaging/meta-iodobenzylguanidine. The influence of age at irradiation, gender, race, cumulative radiation dose, International Neuroblastoma Staging System stage, treatment protocol and resection status was determined with respect to locoregional tumor control. RESULTS With a median follow-up of 34 months +/- 21 months, locoregional tumor progression was observed in 11 (25%) and was evenly divided between primary site and adjacent nodal/visceral site failure. The influence of locoregional control reached borderline statistical significance (p = 0.06). Age (p = 0.5), dose (p = 0.6), resection status (p = 0.7), and International Neuroblastoma Staging System stage (p = 0.08) did not influence overall survival. CONCLUSIONS Overall survival in high-risk neuroblastoma is influenced by locoregional tumor control. Despite CT-based planning, progression in adjacent nodal/visceral sites appears to be common; this requires further investigation regarding target volume definitions, dose, and the effects of systemic therapy.
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Affiliation(s)
- Atmaram S Pai Panandiker
- Division of Radiation Oncology, Department of Radiological Sciences, St. Jude Children's Research Hospital, MS220, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA.
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Sultan I, Ghandour K, Al-Jumaily U, Hashem S, Rodriguez-Galindo C. Local control of the primary tumour in metastatic neuroblastoma. Eur J Cancer 2009; 45:1728-32. [PMID: 19447607 DOI: 10.1016/j.ejca.2009.04.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Accepted: 04/20/2009] [Indexed: 01/31/2023]
Abstract
The previous studies have stressed on the importance of loco-regional control in the management of high-risk neuroblastoma. We searched the Surveillance, Epidemiology and End-Results (SEER) database for patients older than 2years with metastatic neuroblastoma who were diagnosed from 1998 to 2005. We identified 291 patients (mean age, 4.35years). The 5-year survival estimate was 53.2%+/-6.4% for patients who had complete resection of their primary tumours (n=116) and 35.7%+/-4.7% for patients who did not have complete resection (p=0.003). External-beam radiotherapy did not affect survival (p=0.79); this finding has to be taken with caution due to the study limitations.
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Affiliation(s)
- Iyad Sultan
- Department of Pediatric Oncology, King Hussein Cancer Centre (KHCC), Al-Jubeiha, Amman, Jordan.
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Modak S, Kushner BH, LaQuaglia MP, Kramer K, Cheung NKV. Management and outcome of stage 3 neuroblastoma. Eur J Cancer 2009; 45:90-8. [PMID: 18996003 PMCID: PMC3727624 DOI: 10.1016/j.ejca.2008.09.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 08/24/2008] [Accepted: 09/25/2008] [Indexed: 11/20/2022]
Abstract
PURPOSE The management of patients with International Neuroblastoma Staging System (INSS) stage 3 neuroblastoma (NB) is not consistent worldwide. We describe a single centre approach at Memorial Sloan-Kettering Cancer Centre (MSKCC) from 1991 to 2007 that minimises therapy except for those patients with MYCN-amplified NB. METHODS In this retrospective analysis of 69 patients, tumour MYCN was not amplified in 53 and amplified in 16. Event-free survival (EFS) and overall survival (OS) were determined by Kaplan-Meier analysis. RESULTS Fourteen patients with non-MYCN-amplified tumours were treated with surgery alone (group A) and the remaining 39 (group B) with surgery following chemotherapy that was initiated and administered at non-MSKCC institutions. Chemotherapy was discontinued after surgery in 38/39 of the latter. The 10-year EFS and OS for all patients with MYCN-non-amplified NB were 74.9+/-16.9% and 92.6+/-5.5%, respectively. There was no difference in OS between groups A and B (p=0.2; 10-year OS for groups A and B was 84.6+/-14% and 97.1+/-2.9%, respectively). Patients with MYCN-amplified disease (group C) underwent dose-intensive induction, tumour resection and local radiotherapy: 13 achieved complete or very good partial remission, and 10 received myeloablative chemotherapy. 11/16 patients also received 3F8-based immunotherapy: 10 remain free of disease. The 10-year EFS and OS for patients with MYCN-amplified neuroblastoma treated with immunotherapy were both 90.9+/-8.7%. CONCLUSION Patients with MYCN-non-amplified stage 3 NB can be successfully treated with surgery without the need for radiotherapy or continuation of chemotherapy. Combination of dose-intensive chemotherapy, surgery, radiotherapy and immunotherapy was associated with a favourable outcome for most patients with MYCN-amplified stage 3 NB.
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Affiliation(s)
- Shakeel Modak
- Department of Paediatrics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States
| | - Brian H. Kushner
- Department of Paediatrics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States
- Tel.: +1 212 639 6793
| | - Michael P. LaQuaglia
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States
- Tel.: +1 212 639 7002
| | - Kim Kramer
- Department of Paediatrics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States
- Tel.: +1 212 639 6410
| | - Nai-Kong V. Cheung
- Department of Paediatrics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States
- Tel.: +1 646 888 2313
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Hillbrand M, Georg D, Gadner H, Pötter R, Dieckmann K. Abdominal cancer during early childhood: a dosimetric comparison of proton beams to standard and advanced photon radiotherapy. Radiother Oncol 2008; 89:141-9. [PMID: 18692928 DOI: 10.1016/j.radonc.2008.06.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 06/11/2008] [Accepted: 06/19/2008] [Indexed: 11/16/2022]
Abstract
PURPOSE Evaluation of dosimetric benefits of advanced radiotherapy techniques for the treatment of abdominal lesions during early childhood. PATIENTS AND METHODS Treatment planning was performed for five Neuroblastoma (NBL) and four Wilms Tumor (WT) patients. Opposing fields (2F), photon intensity modulated radiotherapy (IMXT) and two proton techniques (passively scattered (PT) and scanned beams (IMPT)) were considered. Averaged dose-volume histograms, associated dosimetric parameters and a radiobiological model for the estimation of the therapy related carcinogenic effect were evaluated. RESULTS With respect to the 2F technique, both proton techniques enabled to reduce mean liver and kidney dose by 40-60%; Organ fractions irradiated at the level of the tolerance dose were reduced by 65% for kidneys and 75% for the liver in NBL patients and by additional 10% for WT patients. IMXT enabled to reduce parameters related to the steep high-dose gradient, e.g., V(15Gy) for the kidneys was reduced by a factor 2-3 compared to 2F. V(12Gy) was reduced by 40% in the liver. On the other side, the improvement of those parameters characterizing the low isodose domain was limited for IMXT. The risk for radiation-induced secondary cancer was doubled for IMXT and even more increased for PT if secondary neutrons were taken into account, while this risk remained the same or was reduced by IMPT with respect to 2F. CONCLUSIONS Proton beams improved all dosimetric parameters for NBL and WT patients compared to photon techniques. This improvement was limited for IMXT mainly to parameters related to the steep high-dose gradient. Further research is needed to minimize uncertainties for secondary cancer estimations.
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Affiliation(s)
- Martin Hillbrand
- Department of Radiotherapy and Radiobiology, AKH Vienna, Medical University Vienna, Austria.
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Wolden SL, Barker CA, Kushner BH, Bodduluri H, Della-Biancia C, Kramer K, Modak S, Cheung NKV. Brain-sparing radiotherapy for neuroblastoma skull metastases. Pediatr Blood Cancer 2008; 50:1163-8. [PMID: 17973314 DOI: 10.1002/pbc.21384] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Neuroblastoma (NB) frequently metastasizes to the skull, often diffusely involving the calvarium and skull base. Radiotherapy may enhance local control; however, irradiating the brain is undesirable in young patients. The purpose of this study was to describe the technique, outcome and toxicities in patients with high risk NB metastatic to the skull treated with brain-sparing skull radiotherapy (BSRT). PROCEDURE Between 1999 and 2007, 31 patients with INSS stage four high risk NB, aged 2-32 years (median 6 years), underwent multimodality therapy, including radiotherapy to the whole skull using a brain-sparing technique never previously described in this population. Dosimetric analyses were performed to compare the BSRT technique to a whole brain radiotherapy (WBRT) technique. Patients were either treated to consolidate upfront induction therapy (n = 22) or to palliate relapsed disease (n = 9). RESULTS Thirty of 31 patients (97%) completed the full course of BSRT. Median follow-up was 19 months (range 1-83 months). Radiographic response to therapy was noted in 89% of patients. The actuarial rate of disease control in the skull was 89% and 60% 1 year after starting BSRT in patients treated in consolidation and for palliation, respectively. BSRT delivered half of the mean radiation dose to the brain when dosimetrically compared to whole brain radiotherapy. Few patients experienced significant toxicity. CONCLUSIONS BSRT in NB patients with diffuse skull metastases offers dosimetric advantages over WBRT and results in good local control when used in the consolidative setting. The technique is well tolerated and while toxicity appears acceptable, longer follow-up is necessary.
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Affiliation(s)
- Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
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Gillis AM, Sutton E, Dewitt KD, Matthay KK, Weinberg V, Fisch BM, Chan A, Gooding C, Daldrup-Link H, Wara WM, Farmer DL, Harrison MR, Haas-Kogan D. Long-Term Outcome and Toxicities of Intraoperative Radiotherapy for High-Risk Neuroblastoma. Int J Radiat Oncol Biol Phys 2007; 69:858-64. [PMID: 17517478 DOI: 10.1016/j.ijrobp.2007.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 04/03/2007] [Accepted: 04/04/2007] [Indexed: 12/16/2022]
Abstract
PURPOSE To review a historical cohort of consecutively accrued patients with high-risk neuroblastoma treated with intraoperative radiotherapy (IORT) to determine the therapeutic effect and late complications of this treatment. METHODS AND MATERIALS Between 1986 and 2002, 31 patients with newly diagnosed high-risk neuroblastoma were treated with IORT as part of multimodality therapy. Their medical records were reviewed to determine the outcome and complications. Kaplan-Meier probability estimates of local control, progression-free survival, and overall survival at 36 months after diagnosis were recorded. RESULTS Intraoperative radiotherapy to the primary site and associated lymph nodes achieved excellent local control at a median follow-up of 44 months. The 3-year estimate of the local recurrence rate was 15%, less than that of most previously published series. Only 1 of 22 patients who had undergone gross total resection developed recurrence at the primary tumor site. The 3-year estimate of local control, progression-free survival, and overall survival was 85%, 47%, and 60%, respectively. Side effects attributable to either the disease process or multimodality treatment were observed in 7 patients who developed either hypertension or vascular stenosis. These late complications resulted in the death of 2 patients. CONCLUSIONS Intraoperative radiotherapy at the time of primary resection offers effective local control in patients with high-risk neuroblastoma. Compared with historical controls, IORT achieved comparable control and survival rates while avoiding many side effects associated with external beam radiotherapy in young children. Although complications were observed, additional analysis is needed to determine the relative contributions of the disease process and specific components of the multimodality treatment to these adverse events.
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Affiliation(s)
- Amy M Gillis
- Department of Radiation Oncology, University of California, San Francisco, School of Medicine, San Francisco, CA 94115-1708, USA
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Paulino AC, Ferenci MS, Chiang KY, Nowlan AW, Marcus RB. Comparison of conventional to intensity modulated radiation therapy for abdominal neuroblastoma. Pediatr Blood Cancer 2006; 46:739-44. [PMID: 16302219 DOI: 10.1002/pbc.20456] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare three different techniques of irradiating abdominal neuroblastoma. PATIENTS AND METHODS Six children with a median age of 4.1 years underwent radiotherapy (RT) to the primary site as part of treatment for high-risk neuroblastoma. Four had midline disease while two had well-lateralized lesions. Three different RT techniques were compared. Technique A used parallel-opposed AP/PA fields prescribed to the midplane of the patient. For Techniques B and C, intensity modulated radiation therapy (IMRT) plans were developed using inverse treatment planning with a sliding window or dynamic multileaf collimator approach, seven coplanar beams, and a 0.25 x 0.5 cm minimum beam resolution. The clinical target volume (CTV) included the tumor present prior to second look surgery but after induction chemotherapy with a 1.5 cm margin. The planning target volume (PTV) was the CTV with a 0.5 cm margin. The CTV was planned to receive 100% of the prescribed dose. For Technique C, the vertebral bodies adjacent to the tumor were included in the PTV to minimize heterogeneity of dose. Six MV photons were used for all techniques. Bilateral kidneys, liver, spine, spleen, stomach and bilateral iliac crests were contoured. RESULTS Dose to the PTV and CTV were not significantly different using the three techniques. In comparison to Technique A, Techniques B and C delivered a lower mean dose to the bilateral kidneys in the four children with midline tumors but not the two children with a lateralized tumor where the contralateral kidney received a higher mean dose. Dose to the spine was less homogeneous with Technique B compared to Techniques A and C. The spleen, liver and stomach mean doses were higher using Techniques B and C compared to Technique A. CONCLUSION Although Technique C was the best method of RT delivery in midline tumors with respect to kidney doses, this was at a cost of a higher mean dose to the liver, stomach, and spleen. This, together with the theoretical increase in secondary malignancies, should be considered when treating a child with IMRT techniques. IMRT was not found to be better than the conventional AP/PA field for lateralized tumors.
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Affiliation(s)
- Arnold C Paulino
- Department of Radiation Oncology, Emory Clinic and Emory University, Atlanta, Georgia, USA.
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Fenig E, Mishaeli M, Yerushalmi R, Sever ZB, Ash S, Kornreich L, Yaniv I, Steinmetz A. Treatment of neuroblastoma using the fused imaging guided radiotherapy (FIGURA) system. Clin Nucl Med 2006; 31:256-8. [PMID: 16622330 DOI: 10.1097/01.rlu.0000214481.43868.bf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to describe our department's experience with the fused imaging-guided radiotherapy (FIGURA) system for planning radiation treatment of high-risk neuroblastoma. PATIENTS AND METHODS Between 1999 and 2002, 11 patients received radiation therapy as consolidation after chemotherapy in 9 and for palliation in 2. Diagnostic metaiodobenzylguanidine (MIBG) imaging was used, which is specific for neuroblastoma, to identify the residual tumor, followed by computed tomography scanning in the radiation treatment position. The FIGURA software fused the images obtained by the 2 modalities and transferred the result to a 3-dimensional radiation treatment planning system. Radiation was delivered at a total dose of 25.2 Gy according to the FIGURA. RESULTS Five patients achieved complete remission and 2 partial remission; 3 were stabilized. One child with a highly rapid progressive course died of the disease. CONCLUSION FIGURA is a new, feasible technique for defining target volumes. By using standard hospital equipment, it is possible to treat residual disease identified by sensitive metaiodobenzylguanidine imaging and localized with the anatomic computed tomography scan. Treating a more accurate target volume spares normal tissue and organs and minimizes side effects.
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Affiliation(s)
- Eyal Fenig
- Institute of Oncology, Radiation Therapy Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqwa, Israel.
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Browne M, Kletzel M, Cohn SL, Seshadri R, Reynolds M. Excellent local tumor control regardless of extent of surgical resection after treatment on the Chicago Pilot II protocol for neuroblastoma. J Pediatr Surg 2006; 41:271-6. [PMID: 16410146 DOI: 10.1016/j.jpedsurg.2005.10.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Our aim was to investigate the impact of the extent of surgical resection on local recurrence and survival in high-risk patients treated with the Chicago Pilot II protocol. METHODS Retrospective chart review was performed on 30 patients enrolled in the Chicago Pilot II protocol between 1995 and 2003. Variables studied were location of tumor, extent of resection, timing and location of recurrence, MYCN amplification, surgical complications, event-free survival, and overall survival (OS). Operative reports and postoperative meta-iodobenzylguanidine scans were used to assess extent of resection. Complete resection (CR) was defined as no gross residual tumor including primary and nodal disease. RESULTS Three-year event-free survival and OS of this cohort of 30 patients was 58% and 82%, respectively. Only 1 patient developed a local recurrence, whereas metastatic recurrent disease was observed in 13 (43%) of the 30; and this subset had a significantly worse OS (23% vs 94%, P = .001). The most common relapse location was in bone. Patients with incomplete resection (IR) (11/30) and CR (19/30) had recurrence rates of 64% (7/11) and 32% (6/19, P = .12), respectively. Event-free survival was significantly better for patients with CR (68%) vs IR (27%; P = .05; odds ratio, 2.9). Overall survival rates for patients with CR vs IR were 68% vs 55%, respectively (P = .25). CONCLUSIONS Recurrence rate was the significant determinant of survival. Patients with CR had lower recurrence rates; however, they did not have improved local control. Final outcome of patients with unfavorable neuroblastoma will be determined by metastatic recurrence, not by extent of resection.
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Affiliation(s)
- Marybeth Browne
- Department of Surgery, Children's Memorial Hospital, Chicago, IL 60614, USA
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von Allmen D, Grupp S, Diller L, Marcus K, Ecklund K, Meyer J, Shamberger RC. Aggressive surgical therapy and radiotherapy for patients with high-risk neuroblastoma treated with rapid sequence tandem transplant. J Pediatr Surg 2005; 40:936-41; discussion 941. [PMID: 15991174 DOI: 10.1016/j.jpedsurg.2005.03.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE The treatment approach for patients with high-risk neuroblastoma has been one of dose intensification chemotherapy and aggressive treatment of the primary tumor. Local tumor control is examined in high-risk patients treated with tandem stem cell transplant, aggressive surgery, and selected radiation therapy (XRT). METHODS Seventy-six patients with high-risk stage III/IV neuroblastoma were treated on a standard protocol incorporating aggressive surgical resection with or without local XRT followed by tandem high-dose chemotherapy and stem cell rescue. Patients were evaluated for degree of surgical resection, site of progression, and outcome. RESULTS Overall event-free survival for the series is 56%. Forty-eight had gross total resection, 12 had greater than 90% resection, 10 had 50% to 90% resection, and 6 had biopsy only or no surgery. Surgical complications occurred in 29% with no deaths. There were no isolated local failures. Two patients had local recurrence after gross total resection. Surgeon assessment of completeness of resection agreed with postoperative radiological findings 66% of the time. CONCLUSION Aggressive surgical treatment with local XRT and myeloablative chemotherapy with stem cell rescue provides excellent local control in high-risk neuroblastoma, although distant failures, particularly osseous, remain a problem. Poor correlation exists between the surgeon's perception of completeness of resection and findings on postoperative imaging studies.
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Affiliation(s)
- Daniel von Allmen
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC 27599, USA.
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Paulino AC, Fowler BZ. Risk factors for scoliosis in children with neuroblastoma. Int J Radiat Oncol Biol Phys 2005; 61:865-9. [PMID: 15708267 DOI: 10.1016/j.ijrobp.2004.07.719] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2004] [Revised: 07/15/2004] [Accepted: 07/23/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine the risk factors for scoliosis in children treated for neuroblastoma. METHODS AND MATERIALS From 1957 to 1997, 58 children with neuroblastoma were treated at one institution and have survived a minimum of 5 years. There were 35 boys and 23 girls with a median age of 6 months (range, 2 weeks to 15 years) at initial diagnosis. Primary site was located in the adrenal gland in 25 (43.1%), abdominal/nonadrenal in 16 (27.6%), thoracic in 12 (20.7%), cervical in 3 (5.3%), and pelvic region in 2 (3.5%). The International Neuroblastoma Staging System (INSS) stage was Stage 1 in 10 (17.2%), Stage 2A in 7 (12.1%), Stage 2B in 5 (8.6%), Stage 3 in 22 (37.9%), Stage 4 in 4 (6.9%), and Stage 4S in 10 (17.2%). Thirty-three (56.9%) received chemotherapy whereas 5 (8.6%) had a laminectomy as part of the surgical procedure. Twenty-seven (46.6%) received radiotherapy (RT). Beam energy was 1.25 MV in 11 (41%), 250 kV in 10 (37%), 4 MV in 4 (15%), and 6-MV photons in 1 patient. One patient received 300 cGy in 1 fraction total skin RT using 6-MeV electrons. For the remaining patients, fraction size was 100 cGy in 6 (22%), 150-180 cGy in 11 (41%), 200 cGy in 4 (15%), and 250-300 cGy in 3. Three patients had total body irradiation at 333 cGy for 3 fractions. For all children who received RT, median total dose was 2000 cGy (range, 300-3900 cGy). Patients who were treated with RT had plain films of the irradiated area every 1 to 2 years until at least the age of puberty. Median follow-up was 10 years (range, 5-46 years). RESULTS The overall 5-, 10-, and 15-year scoliosis-free rates were 87.6%, 79.0%, and 76.0% respectively. Twelve (21%) developed scoliosis at a median time of 51 months (range, 8-137 months). The degree of scoliosis was mild (< or =20 degrees ) in 8 (67%). Four had scoliosis ranging from 30 degrees to 66 degrees ; 3 of these patients required surgical intervention, whereas 1 had an underlying Duchenne muscular dystrophy which manifested itself 8 years after diagnosis of neuroblastoma. Median time to scoliosis was 23 months (range, 8-54 months) in children who had a laminectomy. On multivariate analysis, both history of laminectomy (p = 0.0005) and use of RT (p = 0.0284) were found to be risk factors for development of scoliosis. Gender, age at diagnosis, INSS stage, primary site, and use of chemotherapy were not found to be significant. Both RT fraction size and beam energy were also not significant, but increasing total RT dose was found to be significant (p = 0.0039). The 15-year scoliosis-free rates were 20% for children who had a laminectomy and 81.3% for those who did not have a laminectomy. The 15-year scoliosis-free rates for children treated with RT doses 0 cGy, 1-1750 cGy, 1751-2300 cGy, and >2300 cGy were 91.7%, 87.5%, 51.4%, and 44.4% respectively. CONCLUSIONS Treatment-related factors, namely laminectomy and radiotherapy, were found to increase the risk of scoliosis in patients with neuroblastoma. Children who had a laminectomy were more likely to manifest scoliosis earlier. Increasing RT dose was found to impact adversely on the development of scoliosis.
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Affiliation(s)
- Arnold C Paulino
- Department of Radiation Oncology, Emory Clinic, Emory University, Atlanta, GA, USA.
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Saran F. New technology for radiotherapy in paediatric oncology. Eur J Cancer 2004; 40:2091-105. [PMID: 15341984 DOI: 10.1016/j.ejca.2003.12.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Revised: 11/26/2003] [Accepted: 12/03/2003] [Indexed: 10/26/2022]
Affiliation(s)
- Frank Saran
- Department of Radiotherapy, Royal Marsden Hospital NHS Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK.
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Abstract
Neuroblastoma is the most common extra-cranial solid tumor in children and has a heterogeneous clinical presentation and course. Clinical and biologic features of this disease have been used to develop risk-based therapy. Patients with low-risk disease can be treated with surgery alone. Patients with intermediate-risk features have an excellent prognosis after treatment with surgery and a relatively short course of standard dose chemotherapy. Unfortunately, most children with neuroblastoma present with advanced disease. More than 60% of patients with high-risk features will succumb to their disease despite intensive therapy including a myeloablative consolidation. Research efforts to understand the biologic basis of neuroblastoma and to identify new, more effective therapies are essential to improve the outcome for these children.
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Affiliation(s)
- Robert E Goldsby
- Division of Pediatric Hematology/Oncology, University of California, San Francisco 94143-0106, USA
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La Quaglia MP, Kushner BH, Su W, Heller G, Kramer K, Abramson S, Rosen N, Wolden S, Cheung NKV. The impact of gross total resection on local control and survival in high-risk neuroblastoma. J Pediatr Surg 2004; 39:412-7; discussion 412-7. [PMID: 15017562 DOI: 10.1016/j.jpedsurg.2003.11.028] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSE Gross total resection of the primary tumor in treatment of high-risk neuroblastoma remains controversial. Furthermore, there are few reports of the effect of primary tumor resection on local control as opposed to overall survival. The authors reviewed their institutional experience to assess the effect of primary tumor resection on local control and overall survival. METHODS A total of 141 patients were treated on protocol between November 1, 1979 and June 25, 2002 and are the subject of this report. Gross total resection was assessed by review of operative notes, postoperative computerized axial tomograms, and postoperative meta-iodobenzyl guanidine (MIBG)1 scans when available. RESULTS The median age was 3.3 years, and all patients were International Neuroblastoma Staging System (INSS) stage 4 with 79% having metastases to cortical bone. The primary site was the adrenal gland in 74%, the central abdominal compartment in 13%, the posterior mediastinum in 7%, and other sites in 6%. Gross total resection was accomplished in 103 (73%) but was more than 90% for the last 3 protocols. Five kidneys were lost overall. The probability of local progression was 50% in unresected patients compared with 10% in patients undergoing gross total resection (P <.01). Overall survival rate in resected patients was 50% compared with 11% in unresected patients (P <.01). CONCLUSIONS Our data indicate that local control and overall survival rate are correlated with gross total resection of the primary tumor in high-risk neuroblastoma. Gross total resection should be part of the management of stage 4 neuroblastoma in patients greater than 1 year of age.
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Affiliation(s)
- Michael P La Quaglia
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Marcus KJ, Shamberger R, Litman H, von Allmen D, Grupp SA, Nancarrow CM, Goldwein J, Grier HE, Diller L. Primary tumor control in patients with stage 3/4 unfavorable neuroblastoma treated with tandem double autologous stem cell transplants. J Pediatr Hematol Oncol 2003; 25:934-40. [PMID: 14663275 DOI: 10.1097/00043426-200312000-00005] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the efficacy and toxicity of local radiotherapy in achieving local control in patients with stage 4 or high-risk stage 3 neuroblastoma treated with induction chemotherapy and tandem stem cell transplants. METHODS Fifty-two children with stage 4 or high-risk stage 3 neuroblastoma were treated on a standardized protocol that included five cycles of induction chemotherapy, surgical resection of the primary tumor when feasible, local radiotherapy, and then consolidation with tandem myeloablative cycles with autologous peripheral blood stem cell rescue. Local radiotherapy (10.5-18 Gy) was administered to patients with gross or microscopic residual disease prior to the myeloablative cycles. Thirty-seven patients received local radiotherapy to the primary tumor or primary tumor bed. Two patients with unknown primaries each received radiotherapy to single, unresectable, bulky metastatic sites. The second of the myeloablative regimens included 12 Gy of total body irradiation. RESULTS Of the 52 consecutively treated patients analyzed, 44 underwent both transplants, 6 underwent a single transplant, and 2 progressed during induction. Local radiotherapy did not prolong recovery of hematopoiesis following transplants, did not increase peritransplant morbidity, and did not prolong the hospital stay compared with patients who had not received local radiotherapy. Local control was excellent. Of 11 patients with disease recurrence after completion of therapy, 9 failed in bony metastatic sites 3 to 21 months after the completion of therapy, 1 recurred 67 months following therapy in the previously bulky metastatic site that had been irradiated, and 1 had local recurrence concurrent with distant progression 15 months following the second transplant. The three-year event-free survival was 63%, with a median follow-up of 29.5 months. The actuarial probability of local control was 97%. CONCLUSIONS The use of induction chemotherapy, aggressive multimodality therapy for the primary tumor, followed by tandem myeloablative cycles with stem cell transplant in patients with stage 4 or high risk stage 3 neuroblastoma has resulted in acceptable toxicity, a very low local recurrence risk, and an improvement in survival.
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Affiliation(s)
- Karen J Marcus
- Division of Radiation Oncology, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02155, USA.
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Haas-Kogan DA, Swift PS, Selch M, Haase GM, Seeger RC, Gerbing RB, Stram DO, Matthay KK. Impact of radiotherapy for high-risk neuroblastoma: a Children's Cancer Group study. Int J Radiat Oncol Biol Phys 2003; 56:28-39. [PMID: 12694821 DOI: 10.1016/s0360-3016(02)04506-6] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To assess the effect of local radiation administered to primary disease sites in children with high-risk neuroblastoma. MATERIALS AND METHODS A total of 539 eligible patients were entered on protocol CCG-3891, consisting of chemotherapy, primary surgery, and 10 Gy of external beam radiation therapy (EBRT) to gross residual disease, followed by randomized assignment to continuation chemotherapy (CC) or autologous bone marrow transplantation (ABMT). ABMT patients received total body irradiation (TBI). RESULTS Estimated event-free survival and overall survival at 5 years were 25% +/- 2% and 35% +/- 2%, respectively. Estimated 5-year locoregional recurrence rates were 51% +/- 5% and 33% +/- 7% for CC and ABMT patients (p = 0.004). For patients who received 10 Gy of EBRT to the primary, the addition of 10 Gy of TBI and ABMT decreased local recurrence compared with CC (22% +/- 12% and 52% +/- 8%, p = 0.022). EBRT did not increase acute toxicity, except for increased total parenteral nutrition administration. CONCLUSIONS In combination with EBRT to the primary tumor site, the addition of 10 Gy of TBI as a component of high-dose chemotherapy with ABMT improved local control compared with CC without TBI. Results suggest a dose-response relationship for local EBRT. Short-term toxicity of local EBRT is limited.
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Affiliation(s)
- Daphne A Haas-Kogan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA.
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Kushner BH, Wolden S, LaQuaglia MP, Kramer K, Verbel D, Heller G, Cheung NK. Hyperfractionated low-dose radiotherapy for high-risk neuroblastoma after intensive chemotherapy and surgery. J Clin Oncol 2001; 19:2821-8. [PMID: 11387353 DOI: 10.1200/jco.2001.19.11.2821] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess prognostic factors for local control in high-risk neuroblastoma patients treated with hyperfractionated 21-Gy total dose to consolidate remission achieved by dose-intensive chemotherapy and surgery. PATIENTS AND METHODS Patients with high-risk neuroblastoma in first remission received local radiotherapy (RT) totaling 21 Gy in twice-daily 1.5-Gy fractions. RT to the primary site followed dose-intensive chemotherapy and tumor resection; the target field encompassed the extent of tumor at diagnosis, plus 3-cm margins and regional lymph nodes. RT to distant sites followed radiologic evidence of response. Local failure was correlated with clinical factors (including other consolidative treatments) and biologic findings. RESULTS Of 99 consecutively irradiated patients followed for a median of 21.1 months from RT, 10 relapsed in or at margins of RT fields at 1 to 27 months (median, 14 months). At 36 months after RT, the probability of primary-site failure was 10.1% +/- 5.3%. No primary-site relapses occurred among the 23 patients whose tumors were excised at diagnosis, but there were three such relapses among the seven patients who were irradiated with evidence of residual disease in the primary site. Four of 18 patients with MYCN-amplified disease and serum lactate dehydrogenase greater than 1,500 U/L had local failures (23.4% +/- 10.7% risk at 18 months). Acute radiotoxicities were insignificant, but three of 35 patients followed for > or = 36 months had short stature from decreased growth of irradiated vertebra. CONCLUSION Hyperfractionated 21-Gy RT is well tolerated and, together with dose-intensive chemotherapy and surgery, may help in local control of high-risk neuroblastoma. Extending the RT field to definitively encompass regional nodal groups may improve results. Visible residual disease may warrant higher RT dosing. Patients with biologically unfavorable disease may be at increased risk for local failure. RT to the primary site may not be necessary when tumors are excised at diagnosis.
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Affiliation(s)
- B H Kushner
- Departments of Epidemiology and Biostatistics, Pediatrics, and Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY
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Park JR, Slattery J, Gooley T, Hawkins D, Lindsley K, Villablanca JG, Matthay KK, Sanders JE. Phase I topotecan preparative regimen for high-risk neuroblastoma, high-grade glioma, and refractory/recurrent pediatric solid tumors. MEDICAL AND PEDIATRIC ONCOLOGY 2000; 35:719-23. [PMID: 11107155 DOI: 10.1002/1096-911x(20001201)35:6<719::aid-mpo52>3.0.co;2-v] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We evaluated the toxicity and maximum tolerated dose of topotecan in a novel myeloablative regimen as treatment for high-risk pediatric tumors. Patients received an assigned topotecan dosage in combination with fixed doses of carboplatin and thiotepa, followed by autologous hematopoietic stem cells infusion. Topotecan dose was escalated in cohorts of four patients until the maximum tolerated dose of topotecan was defined or until accrual of 30 patients. Pharmacokinetics of topotecan were examined, and event-free survival was estimated. We describe preliminary results following treatment of 25 pediatric patients with high-risk solid tumors.
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Affiliation(s)
- J R Park
- Department of Pediatrics, Children's Hospital and Regional Medical Center, University of Washington, Seattle, Washington 98105, USA.
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