1
|
Correia D, Indelicato DJ, Paulino AC, Ermoian R, Mihalcik S, Perkins SM, Hill-Kayser C, Mangona VS, Lee J, Chang JHC, Laack NN, Kwok Y, Perentesis J, Vatner R, Dave R, Gallotto SL, Lawell MP, Bajaj BVM, Allison KW, Perry A, Yock TI. Evolution of Proton Radiation Therapy Brainstem Constraints on the Pediatric Proton/Photon Consortium Registry. Pract Radiat Oncol 2024:S1879-8500(24)00194-2. [PMID: 39128543 DOI: 10.1016/j.prro.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 08/13/2024]
Abstract
PURPOSE Increasing concern that brainstem toxicity incidence after proton radiation therapy might be higher than with photons led to a 2014 University of Florida (UF) landmark paper identifying its risk factors and proposing more conservative dose constraints. We evaluated how practice patterns changed among the Pediatric Proton/Photon Consortium Registry (PPCR). MATERIAL AND METHODS This prospective multicenter cohort study gathered data from patients under the age of 22 years enrolled on the PPCR, treated between 2002 and 2019 for primary posterior fossa brain tumors. After standardizing brainstem contours, we garnered dosimetry data and correlated those meeting the 2014 proton-specific brainstem constraint guidelines by treatment era, histology, and extent of surgical resection. RESULTS A total of 467 patients with evaluable proton radiation therapy plans were reviewed. Median age was 7.1 years (range: <1-21.9), 63.0% (n = 296) were men, 76.0% (n = 357) were White, and predominant histology was medulloblastoma (55.0%, n = 256), followed by ependymoma (27.0%, n = 125). Extent of resection was mainly gross total resection (GTR) (67.0%, n = 312), followed by subtotal resection (STR) or biopsy (20.0%, n = 92), and near total resection (NTR) (9.2%, n = 43). The UF brainstem constraint metrics most often exceeded were the goal D50% of 52.4 gray relative biological equivalents (43.3%, n = 202) and maximal D50% of 54 gray relative biological equivalents (12.6%, n = 59). The compliance rate increased after the new guidelines (2002-2014: 64.0% vs 2015-2019: 74.6%, P = .02), except for ependymoma (46.3% pre- vs 50.0% post-guidelines, P = .86), presenting lower compliance (48.8%) in comparison to medulloblastoma/ primitive neuroectodermal tumors/pineoblastoma (77.7%), glioma (89.1%), and atypical teratoid/rhabdoid tumors (90.9%) (P < .001). Degree of surgical resection did not affect compliance rates (GTR/NTR 71.0% vs STR/biopsy 72.8%, P = .45), even within the ependymoma subset (GTR/NTR 50.5% vs STR/biopsy 38.1%, P = .82). CONCLUSION Since the publication of the UF guidelines, the pediatric proton community has implemented more conservative brainstem constraints in all patients except those with ependymoma, irrespective of residual disease after surgery. Future work will evaluate if this change in practice is associated with decreased rates of brainstem toxicity.
Collapse
Affiliation(s)
- Dora Correia
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Cantonal Hospital Aarau, Aarau, Aargau, Switzerland; Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ralph Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Stephen Mihalcik
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Stephanie M Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Christine Hill-Kayser
- Department of Radiation Oncology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victor S Mangona
- Department of Radiation Oncology, Texas Center for Proton Therapy, Irving, Texas
| | - Jae Lee
- Department of Radiation Oncology, ProCure Proton Therapy Center, Franklin Township, New Jersey
| | - John Han-Chih Chang
- Department of Radiation Oncology, The Oklahoma Proton Center and University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - John Perentesis
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ralph Vatner
- Department of Radiation Oncology, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ronak Dave
- Medical College of Georgia, Augusta University, Augusta, Georgia; Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Sara L Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Miranda P Lawell
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin V M Bajaj
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keith W Allison
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alisa Perry
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
2
|
Li MP, Yeo A, Gunewardena R, Drum G, Wiltshire K, Phillips C, Sia J, Wheeler G, Hall L. Is proton beam therapy always better than photon irradiation? Lessons from two cases. J Med Radiat Sci 2024; 71 Suppl 2:90-98. [PMID: 38504608 PMCID: PMC11011607 DOI: 10.1002/jmrs.773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024] Open
Abstract
Proton beam therapy (PBT) is increasingly used to treat cancers, especially in the paediatric and adolescent and young adult (AYA) population. As PBT becomes more accessible, determining when PBT should be used instead of photon irradiation can be difficult. There is a need to balance patient, tumour and treatment factors when making this decision. Comparing the dosimetry between these two modalities plays an important role in this process. PBT can reduce low to intermediate doses to organs at risk (OAR), but photon irradiation has its dosimetric advantages. We present two cases with brain tumours, one paediatric and one AYA, in which treatment plan comparison between photons and protons showed dosimetric advantages of photon irradiation. The first case was an 18-month-old child diagnosed with posterior fossa ependymoma requiring adjuvant radiotherapy. Photon irradiation using volumetric modulated arc therapy (VMAT) had lower doses to the hippocampi but higher doses to the pituitary gland. The second case was a 21-year-old with an optic pathway glioma. There was better sparing of the critical optic structures and pituitary gland using fractionated stereotactic radiation therapy over PBT. The dosimetric advantages of photon irradiation over PBT have been demonstrated in these cases. This highlights the role of proton-to-photon comparative treatment planning to better understand which patients might benefit from photon irradiation versus PBT.
Collapse
Affiliation(s)
- Michelle P Li
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Adam Yeo
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
- School of Applied ScienceRMIT UniversityMelbourneVictoriaAustralia
| | | | | | - Kirsty Wiltshire
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Claire Phillips
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Joseph Sia
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Greg Wheeler
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Lisa Hall
- Peter MacCallum Cancer CentreMelbourneVictoriaAustralia
| |
Collapse
|
3
|
Wilson JS, Main C, Thorp N, Taylor RE, Majothi S, Kearns PR, English M, Dandapani M, Phillips R, Wheatley K, Pizer B. The effectiveness and safety of proton beam radiation therapy in children and young adults with Central Nervous System (CNS) tumours: a systematic review. J Neurooncol 2024; 167:1-34. [PMID: 38294638 PMCID: PMC10978619 DOI: 10.1007/s11060-023-04510-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/14/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Central nervous system (CNS) tumours account for around 25% of childhood neoplasms. With multi-modal therapy, 5-year survival is at around 75% in the UK. Conventional photon radiotherapy has made significant contributions to survival, but can be associated with long-term side effects. Proton beam radiotherapy (PBT) reduces the volume of irradiated tissue outside the tumour target volume which may potentially reduce toxicity. Our aim was to assess the effectiveness and safety of PBT and make recommendations for future research for this evolving treatment. METHODS A systematic review assessing the effects of PBT for treating CNS tumours in children/young adults was undertaken using methods recommended by Cochrane and reported using PRISMA guidelines. Any study design was included where clinical and toxicity outcomes were reported. Searches were to May 2021, with a narrative synthesis employed. RESULTS Thirty-one case series studies involving 1731 patients from 10 PBT centres were included. Eleven studies involved children with medulloblastoma / primitive neuroectodermal tumours (n = 712), five ependymoma (n = 398), four atypical teratoid/rhabdoid tumour (n = 72), six craniopharyngioma (n = 272), three low-grade gliomas (n = 233), one germ cell tumours (n = 22) and one pineoblastoma (n = 22). Clinical outcomes were the most frequently reported with overall survival values ranging from 100 to 28% depending on the tumour type. Endocrine outcomes were the most frequently reported toxicity outcomes with quality of life the least reported. CONCLUSIONS This review highlights areas of uncertainty in this research area. A well-defined, well-funded research agenda is needed to best maximise the potential of PBT. SYSTEMATIC REVIEW REGISTRATION PROSPERO-CRD42016036802.
Collapse
Affiliation(s)
- Jayne S Wilson
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
| | - Caroline Main
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nicky Thorp
- The Clatterbridge Cancer Centre, Liverpool, UK
- The Christie Hospital Foundation Trust Proton Beam Therapy Centre, Manchester, UK
| | | | - Saimma Majothi
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Pamela R Kearns
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin English
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Madhumita Dandapani
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Queen's Medical Centre, Nottingham University Hospitals' NHS Trust, Nottingham, UK
| | - Robert Phillips
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Barry Pizer
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| |
Collapse
|
4
|
Yu QS, Yin YH, Yu XG. Clinical Characteristics, Treatment, and Survival Outcome of Ependymoma in Infants. World Neurosurg 2024; 181:e75-e83. [PMID: 37532021 DOI: 10.1016/j.wneu.2023.07.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Treatment modalities of ependymoma in infants remain controversial. Postoperative adjuvant radiotherapy could prolong overall survival but has the potential to affect nervous system development in infants. The role of adjuvant chemotherapy in prolonging overall survival for infants with ependymoma is still unclear. Therefore we designed this study to explore the effect of treatment modalities on survival time of infants with ependymoma. METHODS We studied 72 infants with ependymoma from the Surveillance, Epidemiology, and End Results database in this retrospective analysis. Univariate and multivariate Cox proportional hazard models were adopted to determine hazard ratios and compare overall survival. RESULTS Among 72 infants with ependymoma, 35 were male (48.6%) and 37 were female (51.4%). The 5-year overall survival of all patients was 67%. Forty-six infants (63.9%) received gross total resection, 20 (27.8%) received subtotal resection, and 6 (8.3%) did not receive surgical resection or only autopsy. Twenty-one infants (29.2%) received radiotherapy, and 45 (62.5%) received chemotherapy. Multivariate analysis revealed that patients accepted surgical resection (No vs. gross total resection, P < 0.001; No vs. subtotal resection, P = 0.026) and chemotherapy (No vs. Yes, P = 0.024) are the independent prognostic factors for overall survival. CONCLUSIONS Treatment modality is associated with survival time in infants with ependymoma. The extent of resection and chemotherapy were independent prognostic factors for infants with ependymoma.
Collapse
Affiliation(s)
- Qi-Shuai Yu
- Medical School of Nankai University, Tianjin, China; Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yi-Heng Yin
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xin-Guang Yu
- Medical School of Nankai University, Tianjin, China; Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
| |
Collapse
|
5
|
Aslam MA, Ahmad H, Malik HS, Uinarni H, Karim YS, Akhmedov YM, Abdelbasset WK, Awadh SA, Abid MK, Mustafa YF, Farhood B, Sahebkar A. Radiotherapy-associated Sensorineural Hearing Loss in Pediatric Oncology Patients. Curr Med Chem 2024; 31:5351-5369. [PMID: 37190814 DOI: 10.2174/0929867330666230515112245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/08/2023] [Accepted: 03/27/2023] [Indexed: 05/17/2023]
Abstract
During the radiotherapeutic treatment of pediatric oncology patients, they would be at a latent risk of developing ionizing radiation-induced ototoxicity when the cochlea or auditory nerve is located within the radiation field. Sensorineural hearing loss (SNHL) is an irreversible late complication of radiotherapy, and its incidence depends on various factors such as the patient's hearing sensitivity, total radiation dose to the cochlea, radiotherapy fractionation regimen, age and chemoradiation. Importantly, this complication exhibits serious challenges to adult survivors of childhood cancer, as it has been linked to impairments in academic achievement, psychosocial development, independent living skills, and employment in the survivor population. Therefore, early detection and proper management can alleviate academic, speech, language, social, and psychological morbidity arising from hearing deficits. In the present review, we have addressed issues such as underlying mechanisms of radiation-induced SNHL, audiometric findings of pediatric cancer patients treated with radiotherapy, and management and protection measures against radiation-induced ototoxicity.
Collapse
Affiliation(s)
- Muhammad Ammar Aslam
- Department of Emergency Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Hassaan Ahmad
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Hamza Sultan Malik
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Herlina Uinarni
- Department of Anatomy, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
- Radiologist at Pantai Indah Kapuk Hospital, Jakarta, Indonesia
| | | | - Yusuf Makhmudovich Akhmedov
- Department of Pediatric Surgery, Samarkand State Medical Institute, Samarkand, Uzbekistan
- Department of Scientific Affairs, Tashkent State Dental Institute, Makhtumkuli Street 103, Tashkent, 100047, Uzbekistan
| | - Walid Kamal Abdelbasset
- Department of Health and Rehabilitation Sciences, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia
- Department of Physical Therapy, Kasr Al-Aini Hospital, Cairo University, Giza, Egypt
| | - Sura A Awadh
- Department of Anesthesia, Al-Mustaqbal University, Babylon, Iraq
| | - Mohammed Kadhem Abid
- Department of Anesthesia, College of Health & medical Technology, Al-Ayen University, Thi-Qar, Iraq
| | - Yasser Fakri Mustafa
- Department of Pharmaceutical Chemistry, College of Pharmacy, University of Mosul, Mosul 41001, Iraq
| | - Bagher Farhood
- Department of Medical Physics and Radiology, Faculty of Paramedical Sciences, Kashan University of Medical Sciences, Kashan, Iran
| | - Amirhosein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| |
Collapse
|
6
|
Peterson RK, King TZ. A systematic review of pediatric neuropsychological outcomes with proton versus photon radiation therapy: A call for equity in access to treatment. J Int Neuropsychol Soc 2023; 29:798-811. [PMID: 36323679 DOI: 10.1017/s1355617722000819] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is increasing interest in the utilization of proton beam radiation therapy (PRT) to treat pediatric brain tumors based upon presumed advantages over traditional photon radiation therapy (XRT). PRT provides more conformal radiation to the tumor with reduced dose to healthy brain parenchyma. Less radiation exposure to brain tissue beyond the tumor is thought to reduce neuropsychological sequelae. This systematic review aimed to provide an overview of published studies comparing neuropsychological outcomes between PRT and XRT. METHOD PubMed, PsychINFO, Embase, Web of Science, Scopus, and Cochrane were systematically searched for peer-reviewed published studies that compared neuropsychological outcomes between PRT and XRT in pediatric brain tumor patients. RESULTS Eight studies were included. Six of the studies utilized retrospective neuropsychological data; the majority were longitudinal studies (n = 5). XRT was found to result in lower neuropsychological functioning across time. PRT was associated with generally stable neuropsychological functioning across time, with the exception of working memory and processing speed, which showed variable outcomes across studies. However, studies inconsistently included or considered medical and sociodemographic differences between treatment groups, which may have impacted neuropsychological outcomes. CONCLUSIONS Despite methodological limitations, including limited baseline neuropsychological evaluations, temporal variability between radiation treatment and first evaluation or initial and follow-up evaluations, and heterogenous samples, there is emerging evidence of sociodemographic inequities in access to PRT. With more institutions dedicating funding towards PRT, there may be the opportunity to objectively evaluate the neuropsychological benefits of patients matched on medical and sociodemographic variables.
Collapse
Affiliation(s)
- Rachel K Peterson
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Science, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Tricia Z King
- Department of Psychology, Georgia State University, Atlanta, USA
- Neuroscience Institute, Georgia State University, Atlanta, USA
| |
Collapse
|
7
|
Unnikrishnan S, Yip AT, Qian AS, Salans MA, Yu JD, Huynh-Le MP, Reyes A, Stasenko A, McDonald C, Kaner R, Crawford JR, Hattangadi-Gluth JA. Neurocognitive Outcomes in Multiethnic Pediatric Brain Tumor Patients Treated With Proton Versus Photon Radiation. J Pediatr Hematol Oncol 2023; 45:e837-e846. [PMID: 37539987 PMCID: PMC10538429 DOI: 10.1097/mph.0000000000002724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND We analyzed post-radiation (RT) neurocognitive outcomes in an ethnically diverse pediatric brain tumor population undergoing photon radiotherapy (XRT) and proton radiotherapy (PRT). PROCEDURE Post-RT neurocognitive outcomes from 49 pediatric patients (37% Hispanic/Latino) with primary brain tumors were analyzed. Tests included cognitive outcomes, behavioral outcomes, and overall intelligence. For each outcome, proportion of patients with cognitive impairment (scores <1.5 SD) was calculated. The Fisher exact tests compared proportion of patients with impairment and t tests compared T-scores between XRT (n=32) and PRT (n=17) groups. Linear regression assessed associations between radiation modality and outcomes. RESULTS Median follow-up was 3.2 and 1.8 years in the XRT and PRT groups, respectively. The median RT dose was 54.0 Gy. We found impairment in 16% to 42% of patients across most neurocognitive domains except executive function. There was no difference in scores between XRT and PRT groups. Regression analyses revealed no association of neurocognitive outcomes with radiation modality. Non-Hispanic patients had better Verbal Comprehension Index and General Ability Index scores than Hispanic patients ( P <0.05). CONCLUSIONS Among pediatric patients with brain tumors receiving RT, all cognitive domains were affected except executive function. Radiation modality was not associated with neurocognitive outcomes. Hispanic patients may be more vulnerable to posttreatment cognitive effects that warrant further study.
Collapse
Affiliation(s)
- Soumya Unnikrishnan
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Anthony T Yip
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Alexander S Qian
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Mia A Salans
- University of California San Diego School of Medicine
- Departments of Radiation Medicine and Applied Sciences
| | - Justin D Yu
- Departments of Radiation Medicine and Applied Sciences
| | | | | | | | - Carrie McDonald
- Departments of Radiation Medicine and Applied Sciences
- Psychiatry
| | | | - John R Crawford
- Neurosciences and Pediatrics, University of California San Diego, La Jolla
| | | |
Collapse
|
8
|
Liu KX, Haas-Kogan DA, Elhalawani H. Radiotherapy for Primary Pediatric Central Nervous System Malignancies: Current Treatment Paradigms and Future Directions. Pediatr Neurosurg 2023; 58:356-366. [PMID: 37703864 DOI: 10.1159/000533777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Central nervous system tumors are the most common solid tumors in childhood. Treatment paradigms for pediatric central nervous system malignancies depend on elements including tumor histology, age of patient, and stage of disease. Radiotherapy is an important modality of treatment for many pediatric central nervous system malignancies. SUMMARY While radiation contributes to excellent overall survival rates for many patients, radiation also carries significant risks of long-term side effects including neurocognitive decline, hearing loss, growth impairment, neuroendocrine dysfunction, strokes, and secondary malignancies. In recent decades, clinical trials have demonstrated that with better imaging and staging along with more sophisticated radiation planning and treatment set-up verification, smaller treatment volumes can be utilized without decrement in survival. Furthermore, the development of intensity-modulated radiotherapy and proton-beam radiotherapy has greatly improved conformality of radiation. KEY MESSAGES Recent changes in radiation treatment paradigms have decreased risks of short- and long-term toxicity for common histologies and in different age groups. Future studies will continue to develop novel radiation regimens to improve outcomes in aggressive central nervous system tumors, integrate molecular subtypes to tailor radiation treatment, and decrease radiation-associated toxicity for long-term survivors.
Collapse
Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hesham Elhalawani
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
9
|
McLaren DS, Devi A, Kyriakakis N, Kwok-Williams M, Murray RD. The impact of radiotherapy on the hypothalamo-pituitary axis: old vs new radiotherapy techniques. Endocr Connect 2023; 12:e220490. [PMID: 37450854 PMCID: PMC10448592 DOI: 10.1530/ec-22-0490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 07/14/2023] [Indexed: 07/18/2023]
Abstract
Multimodality cancer therapy has led to remarkable improvements in survival of childhood and young adult cancer, with survival rates exceeding 85%. Such remission rates come with their own adverse sequelea or 'late effects'. Although the cause of these late effects is multi-factorial, radiation-related adverse effects are one of the most prevalent. Hypopituitarism is a recognised complication of irradiation of brain tumours distant to the hypothalamo-pituitary (HP) axis when the axis is included within the exposed field. Much of the data concerning the development of hypopituitarism, however, relate to early forms of photon-based radiotherapy. In this narrative review, we discuss advances in individual radiotherapy techniques currently used in treating brain tumours and their theoretical benefits based primarily on dosimetric studies. Increasingly precise radiation techniques, including advances in the delivery of photons (i.e. intensity-modulated radiotherapy) and proton beam therapy, are now available options. The premise behind these newer techniques is to reduce the dose and volume of normal tissue irradiated whilst maintaining an effective radiation dose to target tissue. When treating brain tumours distant to the HP axis the expectation, based upon dosimetric studies, is that newer forms of radiotherapy will less frequently involve the HP axis in the exposed field, and where incorporated within the field it will be exposed to a lower radiotherapy dosage. Intuitively the dosimetric studies should translate into significant reductions in the prevalence of HP dysfunction. These data are promising; however, to date there are minimal robust clinical data to determine if the theoretical benefits of these newer techniques on HP dysfunction is to be realised.
Collapse
Affiliation(s)
- David S McLaren
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Aarani Devi
- Clinical Oncology, Leeds Cancer Centre, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Nikolaos Kyriakakis
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | | | - Robert D Murray
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospital NHS Trust, Leeds, UK
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
| |
Collapse
|
10
|
Yamaguchi J, Ohka F, Motomura K, Saito R. Latest classification of ependymoma in the molecular era and advances in its treatment: a review. Jpn J Clin Oncol 2023; 53:653-663. [PMID: 37288489 DOI: 10.1093/jjco/hyad056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 06/09/2023] Open
Abstract
Ependymoma is a rare central nervous system (CNS) tumour occurring in all age groups and is one of the most common paediatric malignant brain tumours. Unlike other malignant brain tumours, ependymomas have few identified point mutations and genetic and epigenetic features. With advances in molecular understanding, the latest 2021 World Health Organization (WHO) classification of CNS tumours divided ependymomas into 10 diagnostic categories based on the histology, molecular information and location; this accurately reflected the prognosis and biology of this tumour. Although maximal surgical resection followed by radiotherapy is considered the standard treatment method, and chemotherapy is considered ineffective, the validation of the role of these treatment modalities continues. Although the rarity and long-term clinical course of ependymoma make designing and conducting prospective clinical trials challenging, knowledge is steadily accumulating and progress is being made. Much of the clinical knowledge obtained from clinical trials to date was based on the previous histology-based WHO classifications, and the addition of new molecular information may lead to more complex treatment strategies. Therefore, this review presents the latest findings on the molecular classification of ependymomas and advances in its treatment.
Collapse
Affiliation(s)
- Junya Yamaguchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumiharu Ohka
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuya Motomura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
11
|
Peters S, Frisch S, Stock A, Merta J, Bäumer C, Blase C, Schuermann E, Tippelt S, Bison B, Frühwald M, Rutkowski S, Fleischhack G, Timmermann B. Proton Beam Therapy for Pediatric Tumors of the Central Nervous System-Experiences of Clinical Outcome and Feasibility from the KiProReg Study. Cancers (Basel) 2022; 14:cancers14235863. [PMID: 36497345 PMCID: PMC9737072 DOI: 10.3390/cancers14235863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
As radiotherapy is an important part of the treatment in a variety of pediatric tumors of the central nervous system (CNS), proton beam therapy (PBT) plays an evolving role due to its potential benefits attributable to the unique dose distribution, with the possibility to deliver high doses to the target volume while sparing surrounding tissue. Children receiving PBT for an intracranial tumor between August 2013 and October 2017 were enrolled in the prospective registry study KiProReg. Patient's clinical data including treatment, outcome, and follow-up were analyzed using descriptive statistics, Kaplan-Meier, and Cox regression analysis. Adverse events were scored according to the Common Terminology Criteria for Adverse Events (CTCAE) 4.0 before, during, and after PBT. Written reports of follow-up imaging were screened for newly emerged evidence of imaging changes, according to a list of predefined keywords for the first 14 months after PBT. Two hundred and ninety-four patients were enrolled in this study. The 3-year overall survival of the whole cohort was 82.7%, 3-year progression-free survival was 67.3%, and 3-year local control was 79.5%. Seventeen patients developed grade 3 adverse events of the CNS during long-term follow-up (new adverse event n = 7; deterioration n = 10). Two patients developed vision loss (CTCAE 4°). This analysis demonstrates good general outcomes after PBT.
Collapse
Affiliation(s)
- Sarah Peters
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
- Clinic for Particle Therapy, University Hospital Essen, 45147 Essen, Germany
- Correspondence: ; Tel.: +49-201-723-8943
| | - Sabine Frisch
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Annika Stock
- Department of Neuroradiology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Julien Merta
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Christian Bäumer
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Christoph Blase
- AnästhesieNetz Rhein-Ruhr, Westenfelder Str. 62/64, 44867 Bochum, Germany
| | - Eicke Schuermann
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Stephan Tippelt
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Brigitte Bison
- Diagnostic and Interventional Neuroradiology, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany
- Neuroradiological Reference Center for the Pediatric Brain Tumor (HIT) Studies of the German Society of Pediatric Oncology and Hematology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Michael Frühwald
- Pediatric and Adolescent Medicine, Swabian Childrens Cancer Center, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Gudrun Fleischhack
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
- Clinic for Particle Therapy, University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- German Cancer Consortium (DKTK), 45147 Essen, Germany
| |
Collapse
|
12
|
Intraoperative MRI versus intraoperative ultrasound in pediatric brain tumor surgery: is expensive better than cheap? A review of the literature. Childs Nerv Syst 2022; 38:1445-1454. [PMID: 35511271 DOI: 10.1007/s00381-022-05545-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The extent of brain tumor resection (EOR) is a fundamental prognostic factor in pediatric neuro-oncology in association with the histology. In general, resection aims at gross total resection (GTR). Intraoperative imaging like intraoperative US (iOUS) and MRI have been developed in order to find any tumoral remnant but with different costs. Aim of our work is to review the current literature in order to better understand the differences between costs and efficacy of MRI and iOUS to evaluate tumor remnants intraoperatively. METHODS We reviewed the existing literature on PubMed until 31st December 2021 including the sequential keywords "intraoperative ultrasound and pediatric brain tumors", "iUS and pediatric brain tumors", "intraoperative magnetic resonance AND pediatric brain tumors", and "intraoperative MRI AND pediatric brain tumors. RESULTS A total of 300 papers were screened through analysis of title and abstract; 254 were excluded. After selection, a total of 23 articles were used for this systematic review. Among the 929 patients described, a total of 349(38%) of the cases required an additional resection after an iMRI scan. GTR was measured on 794 patients (data of 69 patients lost), and it was achieved in 552(70%) patients. In case of iOUS, GTR was estimated in 291 out of 379 (77%) cases. This finding was confirmed at the post-operative MRI in 256(68%) cases. CONCLUSIONS The analysis of the available literature demonstrates that expensive equipment does not always mean better. In fact, for the majority of pediatric brain tumors, iOUS is comparable to iMRI in estimating the EOR.
Collapse
|
13
|
Donahue BR, MacDonald S. Protons for pediatric ependymoma: Where are we now? Neuro Oncol 2022; 24:1203-1204. [PMID: 35294554 PMCID: PMC9248382 DOI: 10.1093/neuonc/noac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bernadine R Donahue
- Department of Radiation Oncology, Maimonides Cancer Center, Brooklyn, New York, USA.,Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York, USA
| | - Shannon MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
14
|
The Current State of Radiotherapy for Pediatric Brain Tumors: An Overview of Post-Radiotherapy Neurocognitive Decline and Outcomes. J Pers Med 2022; 12:jpm12071050. [PMID: 35887547 PMCID: PMC9315742 DOI: 10.3390/jpm12071050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/17/2022] Open
Abstract
Tumors of the central nervous system are the most common solid malignancies diagnosed in children. While common, they are also found to have some of the lowest survival rates of all malignancies. Treatment of childhood brain tumors often consists of operative gross total resection with adjuvant chemotherapy or radiotherapy. The current body of literature is largely inconclusive regarding the overall benefit of adjuvant chemo- or radiotherapy. However, it is known that both are associated with conditions that lower the quality of life in children who undergo those treatments. Chemotherapy is often associated with nausea, emesis, significant fatigue, immunosuppression, and alopecia. While radiotherapy can be effective for achieving local control, it is associated with late effects such as endocrine dysfunction, secondary malignancy, and neurocognitive decline. Advancements in radiotherapy grant both an increase in lifetime survival and an increased lifetime for survivors to contend with these late effects. In this review, the authors examined all the published literature, analyzing the results of clinical trials, case series, and technical notes on patients undergoing radiotherapy for the treatment of tumors of the central nervous system with a focus on neurocognitive decline and survival outcomes.
Collapse
|
15
|
Horbinski C, Berger T, Packer RJ, Wen PY. Clinical implications of the 2021 edition of the WHO classification of central nervous system tumours. Nat Rev Neurol 2022; 18:515-529. [PMID: 35729337 DOI: 10.1038/s41582-022-00679-w] [Citation(s) in RCA: 108] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 12/19/2022]
Abstract
A new edition of the WHO classification of tumours of the CNS was published in 2021. Although the previous edition of this classification was published just 5 years earlier, in 2016, rapid advances in our understanding of the molecular underpinnings of CNS tumours, including the diversity of clinically relevant molecular types and subtypes, necessitated a new classification system. Compared with the 2016 scheme, the new classification incorporates even more molecular alterations into the diagnosis of many tumours and reorganizes gliomas into adult-type diffuse gliomas, paediatric-type diffuse low-grade and high-grade gliomas, circumscribed astrocytic gliomas, and ependymal tumours. A number of new entities are incorporated into the 2021 classification, especially tumours that preferentially or exclusively arise in the paediatric population. Such a substantial revision of the WHO scheme will have major implications for the diagnosis and treatment of patients with CNS tumours. In this Perspective, we summarize the main changes in the classification of diffuse and circumscribed gliomas, ependymomas, embryonal tumours and meningiomas, and discuss how each change will influence post-surgical treatment, clinical trial enrolment and cooperative studies. Although the 2021 WHO classification of CNS tumours is a major conceptual advance, its implementation on a routine clinical basis presents some challenges that will require innovative solutions.
Collapse
Affiliation(s)
- Craig Horbinski
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Tamar Berger
- Center For Neuro-Oncology, Dana-Farber Cancer Institute and Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Roger J Packer
- Center for Neuroscience and Behavioral Medicine, Brain Tumour Institute, Gilbert Family Neurofibromatosis Type 1 Institute, Children's National Hospital, Washington, DC, USA
| | - Patrick Y Wen
- Center For Neuro-Oncology, Dana-Farber Cancer Institute and Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
16
|
Nogueira LM, Sineshaw HM, Jemal A, Pollack CE, Efstathiou JA, Yabroff KR. Association of Race With Receipt of Proton Beam Therapy for Patients With Newly Diagnosed Cancer in the US, 2004-2018. JAMA Netw Open 2022; 5:e228970. [PMID: 35471569 PMCID: PMC9044116 DOI: 10.1001/jamanetworkopen.2022.8970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Black patients are less likely than White patients to receive guideline-concordant cancer care in the US. Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, tumors surrounded by sensitive tissues, and childhood cancers. OBJECTIVE To evaluate whether there are racial disparities in the receipt of PBT among Black and White individuals diagnosed with all PBT-eligible cancers in the US. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated Black and White individuals diagnosed with PBT-eligible cancers between January 1, 2004, and December 31, 2018, in the National Cancer Database, a nationwide hospital-based cancer registry that collects data on radiation treatment, even when it is received outside the reporting facility. American Society of Radiation Oncology model policies were used to classify patients into those for whom PBT is the recommended radiation therapy modality (group 1) and those for whom evidence of PBT efficacy is still under investigation (group 2). Propensity score matching was used to ensure comparability of Black and White patients' clinical characteristics and regional availability of PBT according to the National Academy of Medicine's definition of disparities. Data analysis was performed from October 4, 2021, to February 22, 2022. EXPOSURE Patients' self-identified race was ascertained from medical records. MAIN OUTCOMES AND MEASURES The main outcome was receipt of PBT, with disparities in this therapy's use evaluated with logistic regression analysis. RESULTS Of the 5 225 929 patients who were eligible to receive PBT and included in the study, 13.6% were Black, 86.4% were White, and 54.3% were female. The mean (SD) age at diagnosis was 63.2 (12.4) years. Black patients were less likely to be treated with PBT than their White counterparts (0.3% vs 0.5%; odds ratio [OR], 0.67; 95% CI, 0.64-0.71). Racial disparities were greater for group 1 cancers (0.4% vs 0.8%; OR, 0.49; 95% CI, 0.44-0.55) than group 2 cancers (0.3% vs 0.4%; OR, 0.75; 95% CI, 0.70-0.80). Racial disparities in PBT receipt among group 1 cancers increased over time (annual percent change = 0.09, P < .001) and were greatest in 2018, the most recent year of available data. CONCLUSIONS AND RELEVANCE In this cross-sectional study, Black patients were less likely to receive PBT than their White counterparts, and disparities were greatest for cancers for which PBT was the recommended radiation therapy modality. These findings suggest that efforts other than increasing the number of facilities that provide PBT will be needed to eliminate disparities.
Collapse
Affiliation(s)
- Leticia M. Nogueira
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Helmneh M. Sineshaw
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Craig E. Pollack
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins School of Nursing, Baltimore, Maryland
| | | | - K. Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| |
Collapse
|
17
|
Weil CR, Lew FH, Williams VM, Burt LM, Ermoian RP, Poppe MM. Patterns of Care and Utilization Disparities in Proton Radiation Therapy for Pediatric Central Nervous System Malignancies. Adv Radiat Oncol 2022; 7:100868. [DOI: 10.1016/j.adro.2021.100868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022] Open
|
18
|
Yip AT, Yu J, Huynh-Le MP, Salans M, Unnikrishnan S, Qian A, Xu R, Kaner R, MacEwan I, Crawford JR, Hattangadi-Gluth JA. Post-treatment Neuroendocrine Outcomes Among Pediatric Brain Tumor Patients: Is there a difference between proton and photon therapy? Clin Transl Radiat Oncol 2022; 34:37-41. [PMID: 35345865 PMCID: PMC8956840 DOI: 10.1016/j.ctro.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/22/2022] [Indexed: 11/29/2022] Open
Abstract
Endocrinopathies were common among pediatric brain tumor survivors. Proton craniospinal irradiation had a lower risk of hypothyroidism. Non-medulloblastoma patients were less likely to develop endocrinopathies. Non-medulloblastoma patients were less likely to need hormone replacement therapy. Sex hormone deficiency was not observed in the proton cohort.
Purpose Pediatric brain tumor patients are vulnerable to radiotherapy (RT) sequelae including endocrinopathies. We compared post-RT neuroendocrine outcomes between pediatric brain tumor patients receiving photons (XRT) versus protons (PRT). Methods Using a prospectively maintained single-institution database, we analyzed 112 pediatric primary brain tumor patients (80 XRT, 32 PRT) from 1996 to 2019. Patient/treatment characteristics and endocrinopathy diagnoses (growth hormone deficiency [GHD], sex hormone deficiency [SHD], hypothyroidism, and requirement of hormone replacement [HRT]) were obtained via chart review. Univariable/multivariable logistic regression identified neuroendocrine outcome predictors. Time-adjusted propensity score models accounted for treatment type. Craniospinal irradiation (CSI) patients were evaluated as a sub-cohort. Results Median follow-up was 6.3 and 4.4 years for XRT and PRT patients respectively. Medulloblastoma was the most common histology (38%). Half of patients (44% in XRT, 60% in PRT) received CSI. Common endocrinopathies were GHD (26% XRT, 38% PRT) and hypothyroidism (29% XRT, 19% PRT). CSI cohort PRT patients had lower odds of hypothyroidism (OR 0.16, 95% CI[0.02–0.87], p = 0.045) on multivariable regression and propensity score analyses. There were no significant differences in endocrinopathies in the overall cohort and in the odds of GHD or HRT within the CSI cohort. SHD developed in 17.1% of the XRT CSI group but did not occur in the PRT CSI group. Conclusion Endocrinopathies were common among pediatric brain tumor survivors. Among CSI patients, PRT was associated with lower risk of hypothyroidism, and potentially associated with lower incidence of SHD. Future studies should involve collaborative registries to explore the survivorship benefits of PRT.
Collapse
|
19
|
Peters S, Merta J, Schmidt L, Jazmati D, Kramer PH, Blase C, Tippelt S, Fleischhack G, Stock A, Bison B, Rutkowski S, Pietsch T, Kortmann RD, Timmermann B. Evaluation of dose, volume and outcome in children with localized, intracranial ependymoma treated with proton therapy within the prospective KiProReg Study. Neuro Oncol 2021; 24:1193-1202. [PMID: 34964901 PMCID: PMC9248402 DOI: 10.1093/neuonc/noab301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Radiotherapy (RT) of ependymoma in children is an important part of the
interdisciplinary treatment concept. However, feasibility and dose concepts are still
under investigation, particularly in very young children. The aim of this study was to
evaluate the standard dose and volume of proton therapy (PT) in children with
ependymoma. Methods In this analysis, 105 patients with localized, intracranial ependymoma under the age of
18 years treated with PT between 2013 and 2018 were included. Patient characteristics,
treatment, outcome, and follow-up data were analyzed using descriptive statistics,
Kaplan-Meier, and Cox regression analysis. Results The median age of patients at PT was 2.8 years (0.9-17.0 years). The molecular subgroup
analysis was performed in a subset of 50 patients (37 EP-PFA, 2 EP-PFB, 7 EP-RELA, 2
EP-YAP, 2 NEC [not elsewhere classified]). The median total dose was 59.4 Gy (54.0-62.0
Gy). The median follow-up time was 1.9 years. The estimated 3-year overall survival
(OS), local control (LC), and progression-free survival (PFS) rates were 93.7%, 74.1%,
and 55.6%, respectively. Within univariable analysis, female gender and lower dose had a
positive impact on OS, whereas age ≥4 years had a negative impact on OS and PT given
after progression had a negative impact on PFS. In the multivariable analysis, multiple
tumor surgeries were associated with lower PFS. New ≥3° late toxicities occurred in 11
patients. Conclusion For children with localized ependymoma, PT was effective and well tolerable. Multiple
surgeries showed a negative impact on PFS.
Collapse
Affiliation(s)
- S Peters
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Essen, Germany.,Clinic for Particle Therapy, University Hospital Essen, Essen, Germany
| | - J Merta
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Essen, Germany
| | - L Schmidt
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany
| | - D Jazmati
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Essen, Germany.,Clinic for Particle Therapy, University Hospital Essen, Essen, Germany
| | - P H Kramer
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany
| | - C Blase
- AnästhesieNetz Rhein-Ruhr, Westenfelder, Bochum, Germany
| | - S Tippelt
- Pediatrics III, University Hospital Essen, Essen, Germany
| | - G Fleischhack
- Pediatrics III, University Hospital Essen, Essen, Germany
| | - A Stock
- Department of Neuroradiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - B Bison
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - S Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Pietsch
- Institute of Neuropathology, DGNN Brain Tumor Reference Center, University of Bonn Medical Center, Bonn, Germany
| | - R D Kortmann
- Department of Radiotherapy and Radio-oncology, University Hospital Leipzig, Leipzig, Germany
| | - B Timmermann
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Essen, Germany.,Clinic for Particle Therapy, University Hospital Essen, Essen, Germany.,West German Cancer Center (WTZ). University Hospital Essen, Essen, Germany.,German Cancer Consortium (DKTK), Germany
| |
Collapse
|
20
|
Napieralska A, Mizia-Malarz A, Stolpa W, Pawłowska E, Krawczyk MA, Konat-Bąska K, Kaczorowska A, Brąszewski A, Harat M. Polish Multi-Institutional Study of Children with Ependymoma-Clinical Practice Outcomes in the Light of Prospective Trials. Diagnostics (Basel) 2021; 11:diagnostics11122360. [PMID: 34943596 PMCID: PMC8700631 DOI: 10.3390/diagnostics11122360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/29/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022] Open
Abstract
We performed a multi-institutional analysis of 74 children with ependymoma to evaluate to what extent the clinical outcome of prospective trials could be reproduced in routine practice. The evaluation of factors that correlated with outcome was performed with a log rank test and a Cox proportional-hazard model. Survival was estimated with the Kaplan–Meier method. The majority of patients had brain tumours (89%). All had surgery as primary treatment, with adjuvant radiotherapy (RTH) and chemotherapy (CTH) applied in 78% and 57%, respectively. Median follow-up was 80 months and 18 patients died. Five- and 10-year overall survival (OS) was 83% and 73%. Progression was observed in 32 patients, with local recurrence in 28 cases. The presence of metastases was a negative prognostic factor for OS. Five- and 10-year progression-free survival (PFS) was 55% and 40%, respectively. The best outcome in patients with non-disseminated brain tumours was observed when surgery was followed by RTH (+/−CTH afterwards; p = 0.0001). Children under 3 years old who received RTH in primary therapy had better PFS (p = 0.010). The best outcome of children with ependymoma is observed in patients who received radical surgery followed by RTH, and irradiation should not be omitted in younger patients. The role of CTH remains debatable.
Collapse
Affiliation(s)
- Aleksandra Napieralska
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, 44-101 Gliwice, Poland
- Correspondence:
| | - Agnieszka Mizia-Malarz
- Department of Pediatrics, Medical University of Silesia, 40-752 Katowice, Poland; (A.M.-M.); (W.S.)
| | - Weronika Stolpa
- Department of Pediatrics, Medical University of Silesia, 40-752 Katowice, Poland; (A.M.-M.); (W.S.)
| | - Ewa Pawłowska
- Department of Oncology and Radiotherapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdansk, Poland;
| | - Małgorzata A. Krawczyk
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, 80-210 Gdansk, Poland;
| | - Katarzyna Konat-Bąska
- Wroclaw Comprehensive Cancer Center, 53-413 Wrocław, Poland;
- Department of Oncology, Wroclaw Medical University, 53-413 Wrocław, Poland
| | - Aneta Kaczorowska
- Department of Children Oncology and Haematology, Wroclaw Medical University, 53-413 Wrocław, Poland;
| | - Arkadiusz Brąszewski
- Department of Neurooncology and Radiosurgery, Franciszek Lukaszczyk Memorial Oncology Center, 85-796 Bydgoszcz, Poland; (A.B.); (M.H.)
| | - Maciej Harat
- Department of Neurooncology and Radiosurgery, Franciszek Lukaszczyk Memorial Oncology Center, 85-796 Bydgoszcz, Poland; (A.B.); (M.H.)
- Department of Oncology and Brachytherapy, Nicolas Copernicus University, Collegium Medicum, 85-067 Bydgoszcz, Poland
| |
Collapse
|
21
|
Cognitive Functions of Pediatric Brain Tumor Survivors Treated With Proton Beam Therapy: A Case Series. J Pediatr Hematol Oncol 2021; 43:e1205-e1209. [PMID: 33235149 DOI: 10.1097/mph.0000000000002011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/16/2020] [Indexed: 10/22/2022]
Abstract
Pediatric brain tumor survivors who received proton beam therapy at the University of Tsukuba Hospital from 2004 to 2011 were retrospectively evaluated for cognitive function. Five patients were included. The median age of diagnosis was 5.4 years (range: 1.5 to 12.5 y) and the median follow-up time was 5.8 years (range: 3.1 to 8.1 y). IQ scores at follow-up were decreased in 2 of 5 patients; 1 underwent whole-brain irradiation and the other was examined just after surgical removal of recurrent tumors. Local proton beam therapy may preserve cognitive function in survivors of pediatric brain tumors.
Collapse
|
22
|
Dell'Oro M, Short M, Wilson P, Bezak E. Normal tissue tolerance amongst paediatric brain tumour patients- current evidence in proton radiotherapy. Crit Rev Oncol Hematol 2021; 164:103415. [PMID: 34242771 DOI: 10.1016/j.critrevonc.2021.103415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 04/28/2021] [Accepted: 07/04/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Proton radiotherapy (PT) is used increasingly for paediatric brain cancer patients. However, as demonstrated here, the knowledge on normal tissue dose constraints, to minimize side-effects, for this cohort is limited. METHODS A search strategy was systematically conducted on MEDLINE® database. 65 papers were evaluated ranging from 2013 to 2021. RESULTS Large variations in normal tissue tolerance and toxicity reporting across PT studies makes estimation of normal tissue dose constraints difficult, with the potential for significant late effects to go unmeasured. Mean dose delivered to the pituitary gland varies from 20 to 30 Gy across literature. Similarly, the hypothalamic dose delivery ranges from 20 to 54.6 Gy for paediatric patients. CONCLUSION There is a significant lack of radiobiological data for paediatric brain cancer patients undergoing proton therapy, often using data from x-ray radiotherapy and adult populations. The way forward is through standardisation of reporting in order to validate relevant dose constraints.
Collapse
Affiliation(s)
- Mikaela Dell'Oro
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia; Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Michala Short
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia
| | - Puthenparampil Wilson
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; UniSA STEM, University of South Australia, Adelaide, SA 5001, Australia
| | - Eva Bezak
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia; Department of Physics, University of Adelaide, Adelaide, SA 5005, Australia
| |
Collapse
|
23
|
Indelicato DJ, Ioakeim-Ioannidou M, Bradley JA, Mailhot-Vega RB, Morris CG, Tarbell NJ, Yock T, MacDonald SM. Proton Therapy for Pediatric Ependymoma: Mature Results From a Bicentric Study. Int J Radiat Oncol Biol Phys 2021; 110:815-820. [PMID: 33508372 DOI: 10.1016/j.ijrobp.2021.01.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/17/2020] [Accepted: 01/20/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE To report the long-term efficacy and toxicity of proton therapy for pediatric ependymoma. METHODS AND MATERIALS Between 2000 and 2019, 386 children with nonmetastatic grade 2/3 intracranial ependymoma received proton therapy at 1 of 2 academic institutions. Median age at treatment was 3.8 years (range, 0.7-21.3); 56% were male. Most (72%) tumors were in the posterior fossa and classified as World Health Organization grade 3 (65%). Eighty-five percent had a gross total or near total tumor resection before radiation therapy; 30% received chemotherapy. Median radiation dose was 55.8 Gy relative biologic effectiveness (RBE) (range, 50.4-59.4). RESULTS Median follow-up was 5.0 years (range, 0.4-16.7). The 7-year local control, progression-free survival, and overall survival rates were 77.0% (95% confidence interval [CI], 71.9%-81.5%), 63.8% (95% CI, 58.0%-68.8%), and 82.2% (95% CI, 77.2%-86.3%), respectively. Subtotal resection was associated with inferior local control (59% vs 80%; P < .005), progression-free survival (48% vs 66%; P < .001), and overall survival (70% vs 84%; P < .05). Male sex was associated with inferior progression-free (60% vs 69%; P < .05) and overall survival (76% vs 89%; P < .05). Posterior fossa tumor site was also associated with inferior progression-free (59% vs 74%; P < .05) and overall survival (79% vs 89%; P < .01). Twenty-one patients (5.4%) required hearing aids; of these, 13 received cisplatin, including the 3 with bilateral hearing loss. Forty-five patients (11.7%) required hormone replacement, typically growth hormone (38/45). The cumulative incidence of grade 2+ brain stem toxicity was 4% and occurred more often in patients who received >54 GyRBE. Two patients (0.5%) died of brain stem necrosis. The second-malignancy rate was 0.8%. CONCLUSION Proton therapy offers disease control commensurate with modern photon therapy without unexpected toxicity. The high rate of long-term survival justifies efforts to reduce radiation exposure in this young population. Independent of radiation modality, this large series confirms extent of resection as the most important modifiable factor for survival.
Collapse
Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | | | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Raymond B Mailhot-Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Nancy J Tarbell
- Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts
| | - Torunn Yock
- Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
24
|
An Insight into Pathophysiological Features and Therapeutic Advances on Ependymoma. Cancers (Basel) 2021; 13:cancers13133221. [PMID: 34203272 PMCID: PMC8269186 DOI: 10.3390/cancers13133221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Although biological information and the molecular classification of ependymoma have been studied, the treatment systems for ependymoma are still insufficient. In addition, because the disease occurs infrequently, it is difficult to obtain sufficient data to conduct large-scale or randomized clinical trials. Therefore, this study is intended to emphasize the importance of understanding its pathological characteristics and prognosis as well as developing treatments for ependymoma through multilateral studies. Abstract Glial cells comprise the non-sensory parts of the central nervous system as well as the peripheral nervous system. Glial cells, also known as neuroglia, constitute a significant portion of the mammalian nervous system and can be viewed simply as a matrix of neural cells. Despite being the “Nervenkitt” or “glue of the nerves”, they aptly serve multiple roles, including neuron repair, myelin sheath formation, and cerebrospinal fluid circulation. Ependymal cells are one of four kinds of glial cells that exert distinct functions. Tumorigenesis of a glial cell is termed a glioma, and in the case of an ependymal cell, it is called an ependymoma. Among the various gliomas, an ependymoma in children is one of the more challenging brain tumors to cure. Children are afflicted more severely by ependymal tumors than adults. It has appeared from several surveys that ependymoma comprises approximately six to ten percent of all tumors in children. Presently, the surgical removal of the tumor is considered a standard treatment for ependymomas. It has been conspicuously evident that a combination of irradiation therapy and surgery is much more efficacious in treating ependymomas. The main purpose of this review is to present the importance of both a deep understanding and ongoing research into histopathological features and prognoses of ependymomas to ensure that effective diagnostic methods and treatments can be developed.
Collapse
|
25
|
Zahnreich S, Schmidberger H. Childhood Cancer: Occurrence, Treatment and Risk of Second Primary Malignancies. Cancers (Basel) 2021; 13:cancers13112607. [PMID: 34073340 PMCID: PMC8198981 DOI: 10.3390/cancers13112607] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 12/14/2022] Open
Abstract
Cancer represents the leading cause of disease-related death and treatment-associated morbidity in children with an increasing trend in recent decades worldwide. Nevertheless, the 5-year survival of childhood cancer patients has been raised impressively to more than 80% during the past decades, primarily attributed to improved diagnostic technologies and multiagent cytotoxic regimens. This strong benefit of more efficient tumor control and prolonged survival is compromised by an increased risk of adverse and fatal late sequelae. Long-term survivors of pediatric tumors are at the utmost risk for non-carcinogenic late effects such as cardiomyopathies, neurotoxicity, or pneumopathies, as well as the development of secondary primary malignancies as the most detrimental consequence of genotoxic chemo- and radiotherapy. Promising approaches to reducing the risk of adverse late effects in childhood cancer survivors include high precision irradiation techniques like proton radiotherapy or non-genotoxic targeted therapies and immune-based treatments. However, to date, these therapies are rarely used to treat pediatric cancer patients and survival rates, as well as incidences of late effects, have changed little over the past two decades in this population. Here we provide an overview of the epidemiology and etiology of childhood cancers, current developments for their treatment, and therapy-related adverse late health consequences with a special focus on second primary malignancies.
Collapse
|
26
|
Targeted Therapy with Sirolimus and Nivolumab in a Child with Refractory Multifocal Anaplastic Ependymoma. REPORTS 2021. [DOI: 10.3390/reports4020012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Pediatric ependymoma (EPN) is the third most common central nervous system (CNS) tumor, with 90% arising intracranially. Management typically involves maximal surgical resection and radiotherapy, but patients’ outcome is poor. Moreover, there are only a few therapeutical options available for recurrent or refractory disease. In this report, we present the case of a 7-year-old girl with relapsed refractory multifocal grade III EPN who failed conventional treatments and experienced a stable and durable response to the immune checkpoint inhibitor (ICPI) nivolumab in association with the mammalian target of rapamycin (m-TOR) inhibitor sirolimus. This experimental therapy was targeted on immune phenotypical analyses of the patient’s last relapse tumor sample, and this procedure should be routinely done to find new possible therapeutical approaches in recurrent solid tumors.
Collapse
|
27
|
Baliga S, Gandola L, Timmermann B, Gail H, Padovani L, Janssens GO, Yock TI. Brain tumors: Medulloblastoma, ATRT, ependymoma. Pediatr Blood Cancer 2021; 68 Suppl 2:e28395. [PMID: 32386126 DOI: 10.1002/pbc.28395] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 01/15/2023]
Abstract
Children with medulloblastoma, atypical teratoid rhabdoid tumor (ATRT), and ependymoma are treated with a multidisciplinary approach including surgery, radiotherapy, and chemotherapy. Lower doses of craniospinal irradiation and tumor bed boost together with chemotherapy are the current standard of care for average-risk medulloblastoma in the Children's Oncology Group (COG). The International Society of Pediatric Oncology (SIOP) is examining the role of hyperfractionated craniospinal irradiation and chemotherapy in high-risk patients. The recent stratification of medulloblastoma into specific molecular risk groups has prompted both COG and SIOP to reexamine the role of these modalities in these different risk groups to maximize cure rates and minimize long-term complications. Proton therapy has shown lower rates of neurocognitive and endocrine complications compared with photons. Ependymomas are treated with maximal surgical resection and adjuvant radiation therapy. The role of chemotherapy in ependymoma is currently being studied in both COG and SIOP. Likewise, for ATRT the role of different high-dose chemotherapy regimens together with local radiation therapy in infants, or craniospinal radiation in older children, is the current focus of research.
Collapse
Affiliation(s)
- Sujith Baliga
- Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.,Radiation Oncology, The Ohio State University Wexner Medical Center-The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Lorenza Gandola
- Department of Radiation Oncology, Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Horan Gail
- Department of Oncology, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Laetitia Padovani
- Department of Radiation Oncology, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center and Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Torunn I Yock
- Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
28
|
Patteson BE, Baliga S, Bajaj BVM, MacDonald SM, Yeap BY, Gallotto SL, Giblin MJ, Weyman EA, Ebb DH, Huang MS, Jones RM, Tarbell NJ, Yock TI. Clinical outcomes in a large pediatric cohort of patients with ependymoma treated with proton radiotherapy. Neuro Oncol 2021; 23:156-166. [PMID: 32514542 DOI: 10.1093/neuonc/noaa139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Treatment for pediatric ependymoma includes surgical resection followed by local radiotherapy (RT). Proton RT (PRT) enables superior sparing of critical structures compared with photons, with potential to reduce late effects. We report mature outcomes, patterns of failure, and predictors of outcomes in patients treated with PRT. METHODS One hundred fifty patients (<22 y) with World Health Organization grades II/III ependymoma were treated with PRT between January 2001 and January 2019 at Massachusetts General Hospital. Demographic, tumor, and treatment-related characteristics were analyzed. Event-free survival (EFS), overall survival (OS), and local control (LC) were assessed. RESULTS Median follow-up was 6.5 years. EFS, OS, and LC for the intracranial cohort (n = 145) at 7 years were 63.4%, 82.6%, and 76.1%. Fifty-one patients recurred: 26 (51.0%) local failures, 19 (37.3%) distant failures, and 6 (11.8%) synchronous failures. One hundred sixteen patients (77.3%) underwent gross total resection (GTR), 5 (3.3%) underwent near total resection (NTR), and 29 (19.3%) underwent subtotal resection (STR). EFS for the intracranial cohort at 7 years for GTR/NTR and STR was 70.3% and 35.2%. With multivariate analysis, the effect of tumor excision persisted after controlling for tumor location. There was no adverse effect on disease control if surgery to RT interval was within 9 weeks of GTR/NTR. CONCLUSION PRT is effective and safe in pediatric ependymoma. Similar to previous studies, GTR/NTR was the most important prognostic factor. Intervals up to 9 weeks from surgery to PRT did not compromise disease outcomes. There was no LC benefit between patients treated with >54 Gray relative biological effectiveness (GyRBE) versus ≤54 GyRBE.
Collapse
Affiliation(s)
- Brooke E Patteson
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Sujith Baliga
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts.,Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Benjamin V M Bajaj
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Sara L Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Megan J Giblin
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - David H Ebb
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mary S Huang
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Robin M Jones
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
29
|
Mizumoto M, Fuji H, Miyachi M, Soejima T, Yamamoto T, Aibe N, Demizu Y, Iwata H, Hashimoto T, Motegi A, Kawamura A, Terashima K, Fukushima T, Nakao T, Takada A, Sumi M, Oshima J, Moriwaki K, Nozaki M, Ishida Y, Kosaka Y, Ae K, Hosono A, Harada H, Ogo E, Akimoto T, Saito T, Fukushima H, Suzuki R, Takahashi M, Matsuo T, Matsumura A, Masaki H, Hosoi H, Shigematsu N, Sakurai H. Proton beam therapy for children and adolescents and young adults (AYAs): JASTRO and JSPHO Guidelines. Cancer Treat Rev 2021; 98:102209. [PMID: 33984606 DOI: 10.1016/j.ctrv.2021.102209] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/02/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
Children and adolescents and young adults (AYAs) with cancer are often treated with a multidisciplinary approach. This includes use of radiotherapy, which is important for local control, but may also cause adverse events in the long term, including second cancer. The risks for limited growth and development, endocrine dysfunction, reduced fertility and second cancer in children and AYAs are reduced by proton beam therapy (PBT), which has a dose distribution that decreases irradiation of normal organs while still targeting the tumor. To define the outcomes and characteristics of PBT in cancer treatment in pediatric and AYA patients, this document was developed by the Japanese Society for Radiation Oncology (JASTRO) and the Japanese Society of Pediatric Hematology/Oncology (JSPHO).
Collapse
Affiliation(s)
- Masashi Mizumoto
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroshi Fuji
- Department of Radiology and National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuru Miyachi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Toshinori Soejima
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Norihiro Aibe
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Takayuki Hashimoto
- Department of Radiation Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Atsushi Motegi
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Atsufumi Kawamura
- Department of Neurosurgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keita Terashima
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Fukushima
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tomohei Nakao
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akinori Takada
- Department of Radiology, Mie University Hospital, Tsu-shi, Mie, Japan
| | - Minako Sumi
- Department of Radiation Oncology and Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Radiation Oncology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | | | - Kensuke Moriwaki
- Department of Medical Statistics, Kobe Pharmaceutical University, Kobe, Hyogo, Japan
| | - Miwako Nozaki
- Department of Radiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yuji Ishida
- Department of Pediatrics, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keisuke Ae
- Department of Orthopaedic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ako Hosono
- Department of Pediatric Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Hideyuki Harada
- Division of Radiation Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Etsuyo Ogo
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Tetsuo Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Takashi Saito
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroko Fukushima
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ryoko Suzuki
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mitsuru Takahashi
- Department of Orthopaedic Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Medicine, Nagasaki, Japan
| | - Akira Matsumura
- Departments of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hidekazu Masaki
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Sakurai
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| |
Collapse
|
30
|
Feasibility of Proton Beam Therapy for Infants with Brain Tumours: Experiences from the Prospective KiProReg Registry Study. Clin Oncol (R Coll Radiol) 2021; 33:e295-e304. [PMID: 33820696 DOI: 10.1016/j.clon.2021.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/16/2021] [Accepted: 03/09/2021] [Indexed: 11/22/2022]
Abstract
AIMS Proton beam therapy (PBT) has increasingly been applied for the treatment of young children when radiotherapy is needed. The treatment requires intensive multimodality care and is logistically demanding. In this analysis, we evaluated our experiences in treating infants with tumours of the central nervous system with PBT. MATERIALS AND METHODS Children younger than 2 years of age treated with PBT for central nervous system tumours enrolled in the prospective registry study KiProReg were retrospectively analysed. Information on patient characteristics, treatment, toxicities and outcome were evaluated. Adverse events were classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE V4.0) before, during and after PBT. RESULTS Between September 2013 and June 2018, 51 infants were eligible. The median age was 19 months (range 11-23 months) at the time of PBT. Tumour entities were ependymoma (51.0%), atypical teratoid rhabdoid tumour (39.0%), high-grade glioma (6.0%), pineoblastoma (2.0%) and medulloblastoma (2.0%). The prescribed median total dose was 54.0 Gy (range 45.0-59.4 Gy). Most received local radiotherapy. In four patients, craniospinal irradiation followed by a boost to the local tumour bed was applied. The median follow-up time was 42.0 months (range 7.3-86.2 months). The estimated 3-year local control, progression-free survival and overall survival rates for all patients were 62.7, 47.1 and 76.5%, respectively. During radiotherapy, 24 events of higher-grade (CTCAE ≥ °III) toxicities were reported. Interruption of radiotherapy for more than 2 days was due to infection (n = 3) or shunt complication (n = 2). Unexpected hospitalisation during radiotherapy affected 12 patients. Late adverse events attributable to radiotherapy included endocrinopathy (CTCAE °II; 7.8%), new onset of hearing loss (CTCAE °III; 5.8%) and visual impairment (CTCAE °IV; 1.9%). Transient radiation-induced imaging changes occurred in five patients (9.8%). CONCLUSIONS Our study indicates that PBT is feasible for very young children with central nervous system tumours, at least in the short term. However, it requires challenging interdisciplinary medical care and high logistical effort. For evaluation of late effects, longer follow-up and evaluation of neurocognitive outcome are desirable. More data have to be gathered to further define the role of radiotherapy in infants over time.
Collapse
|
31
|
Bavle A, Srinivasan A, Choudhry F, Anderson M, Confer M, Simpson H, Gavula T, Thompson JS, Clifton S, Gross NL, McNall-Knapp R. Systematic review of the incidence and risk factors for cerebral vasculopathy and stroke after cranial proton and photon radiation for childhood brain tumors. Neurooncol Pract 2021; 8:31-39. [PMID: 33664967 PMCID: PMC7906269 DOI: 10.1093/nop/npaa061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The aim of our study is to determine the incidence, timing, and risk factors for cerebral vasculopathy after cranial proton and photon radiation for pediatric brain tumors. METHODS We performed a single-institution retrospective review of a cohort of children treated with proton radiation for brain tumors. MRA and/or MRI were reviewed for evidence of cerebral vascular stenosis and infarcts. Twenty-one similar studies (17 photon, 4 proton) were identified by systematic literature review. RESULTS For 81 patients with median follow-up of 3 years, the rates of overall and severe vasculopathy were 9.9% and 6.2% respectively, occurring a median of 2 years post radiation. Dose to optic chiasm greater than 45 Gy and suprasellar location were significant risk factors. Results were consistent with 4 prior proton studies (752 patients) that reported incidence of 5% to 6.7%, 1.5 to 3 years post radiation. With significantly longer follow-up (3.7-19 years), 9 studies (1108 patients) with traditional photon radiation reported a higher rate (6.3%-20%) and longer time to vasculopathy (2-28 years). Significant risk factors were neurofibromatosis type 1 (NF-1; rate 7.6%-60%) and suprasellar tumors (9%-20%). In 10 studies with photon radiation (1708 patients), the stroke rate was 2% to 18.8% (2.3-24 years post radiation). CONCLUSIONS Childhood brain tumor survivors need screening for vasculopathy after cranial radiation, especially with higher dose to optic chiasm, NF-1, and suprasellar tumors. Prospective studies are needed to identify risk groups, and ideal modality and timing, for screening of this toxicity.
Collapse
Affiliation(s)
- Abhishek Bavle
- Children’s Blood and Cancer Center, Dell Children’s Medical Center of Central Texas, Toronto, Canada
| | - Anand Srinivasan
- Blood and Marrow Transplant Program, Hospital for Sick Children, Toronto, Canada
| | - Farooq Choudhry
- Department of Radiology, University of Oklahoma Health Sciences Center (OUHSC) Oklahoma City, OK, US
| | | | | | - Hilarie Simpson
- Department of Radiation Oncology, University of Kansas School of Medicine, Oklahoma City, OK, US
| | - Theresa Gavula
- Department of Pediatrics, OUHSC, Oklahoma City, OK, US
- Jimmy Everest Section of Pediatric Hematology/Oncology, Oklahoma City, OK, US
| | | | | | - Naina L Gross
- Department of Neurosurgery, OUHSC, Oklahoma City, OK, US
| | - Rene McNall-Knapp
- Department of Pediatrics, OUHSC, Oklahoma City, OK, US
- Jimmy Everest Section of Pediatric Hematology/Oncology, Oklahoma City, OK, US
| |
Collapse
|
32
|
Ioakeim-Ioannidou M, MacDonald SM. Evolution of Care of Orbital Tumors with Radiation Therapy. J Neurol Surg B Skull Base 2020; 81:480-496. [PMID: 33072488 DOI: 10.1055/s-0040-1713894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Orbital tumors are rare lesions comprising 0.1% of all tumors and less than 20% of all ocular diseases. These lesions in children and adults differ significantly in their incidence, tumor type, and treatment management. Although surgery and systemic therapies are commonly used in the management of these diseases, radiation therapy has become a widely used treatment for both benign and malignant tumors of the orbit. Radiotherapy is used as a definitive treatment to provide local control while avoiding morbidity associated with surgery for some tumors while it is used as an adjuvant treatment following surgical resection for others. For many tumors, radiation provides excellent tumor control with preservation of visual function. This article is dedicated for presenting the most common applications of orbital radiotherapy. A brief overview of the commonly available radiation therapy modalities is given. Dose constraint goals are reviewed and acute and long-term side effects are discussed. Orbital tumors covered in this article include optic glioma, ocular melanoma, retinoblastoma, orbital rhabdomyosarcoma, orbital lymphoma, and lacrimal gland tumors. Background information, indications for radiotherapy, and goals of treatment for each case example are described.
Collapse
Affiliation(s)
- Myrsini Ioakeim-Ioannidou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
33
|
Yahya N, Manan HA. Neurocognitive impairment following proton therapy for paediatric brain tumour: a systematic review of post-therapy assessments. Support Care Cancer 2020; 29:3035-3047. [PMID: 33040284 DOI: 10.1007/s00520-020-05808-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/30/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Proton therapy (PT), frequently utilised to treat paediatric brain tumour (PBT) patients, eliminates exit dose and minimises dose to healthy tissues that theoretically can mitigate treatment-related effects including cognitive deficits. As clinical outcome data are emerging, we aimed to systematically review current evidence of cognitive changes following PT of PBT. MATERIALS AND METHODS We searched PubMed and Scopus electronic databases to identify eligible reports on cognitive changes following PT of PBT according to PRISMA guidelines. Reports were extracted for information on demographics and cognitive outcomes. Then, they were systematically reviewed based on three themes: (1) comparison with photon therapy, (2) comparison with baseline cognitive measures, to population normative mean or radiotherapy-naïve PBT patients and (3) effects of dose distribution to cognition. RESULTS Thirteen reports (median size (range): 70 (12-144)) were included. Four reports compared the cognitive outcome between PBT patients treated with proton to photon therapy and nine compared with baseline/normative mean/radiotherapy naïve from which two reported the effects of dose distribution. Reports found significantly poorer cognitive outcome among patients treated with photon therapy compared with proton therapy especially in general cognition and working memory. Craniospinal irradiation (CSI) was consistently associated with poorer cognitive outcome while focal therapy was associated with minor cognitive change/difference. In limited reports available, higher doses to the hippocampus and temporal lobes were implicated to larger cognitive change. CONCLUSION Available evidence suggests that PT causes less cognitive deficits compared with photon therapy. Children who underwent focal therapy with proton were consistently shown to have low risk of cognitive deficit suggesting the need for future studies to separate them from CSI. Evidence on the effect of dose distribution to cognition in PT is yet to mature.
Collapse
Affiliation(s)
- Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, CODTIS, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, 50300, Kuala Lumpur, Malaysia.
| | - Hanani Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Cheras, 56000, Kuala Lumpur, Malaysia
| |
Collapse
|
34
|
Upadhyaya SA, Robinson GW, Onar-Thomas A, Orr BA, Billups CA, Bowers DC, Bendel AE, Hassall T, Crawford JR, Partap S, Fisher PG, Tatevossian RG, Seah T, Qaddoumi IA, Vinitsky A, Armstrong GT, Sabin ND, Tinkle CL, Klimo P, Indelicato DJ, Boop FA, Merchant TE, Ellison DW, Gajjar A. Molecular grouping and outcomes of young children with newly diagnosed ependymoma treated on the multi-institutional SJYC07 trial. Neuro Oncol 2020; 21:1319-1330. [PMID: 30976811 DOI: 10.1093/neuonc/noz069] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND This report documents the clinical characteristics, molecular grouping, and outcome of young children with ependymoma treated prospectively on a clinical trial. METHODS Fifty-four children (aged ≤3 y) with newly diagnosed ependymoma were treated on the St Jude Young Children 07 (SJYC07) trial with maximal safe surgical resection, 4 cycles of systemic chemotherapy, consolidation therapy using focal conformal radiation therapy (RT) (5-mm clinical target volume), and 6 months of oral maintenance chemotherapy. Molecular groups were determined by tumor DNA methylation using Infinium Methylation EPIC BeadChip and profiled on the German Cancer Research Center/Molecular Neuropathology 2.0 classifier. RESULTS One of the 54 study patients had metastases (cerebrospinal fluid positive) at diagnosis. Gross or near-total resection was achieved in 48 (89%) patients prior to RT. At a median follow-up of 4.4 years (range, 0.2-10.3 y), 4-year progression-free survival (PFS) was 75.1% ± 7.2%, and overall survival was 92.6% ± 4.4%. The molecular groups showed no significant difference in PFS (4-year estimates: posterior fossa ependymoma group A [PF-EPN-A; 42/54], 71.2% ± 8.3%; supratentorial ependymoma positive for v-rel avian reticuloendotheliosis viral oncogene homolog A [ST-EPN-RELA; 8/54], 83.3% ± 17.0%; and supratentorial ependymoma positive for Yes-associated protein [4/54], 100%, P = 0.22). Subtotal resection prior to RT was associated with an inferior PFS compared with gross or near-total resection (4-year PFS: 41.7% ± 22.5% vs 79.0% ± 7.1%, P = 0.024), as was PF-EPN-A group with 1q gain (P = 0.05). Histopathologic grading was not associated with outcomes (classic vs anaplastic; P = 0.89). CONCLUSIONS In this prospectively treated cohort of young children with ependymoma, ST-EPN-RELA tumors had a more favorable outcome than reported from retrospective data. Histologic grade did not impact outcome. PF-EPN-A with 1q gain and subtotal resection were associated with inferior outcomes.
Collapse
Affiliation(s)
- Santhosh A Upadhyaya
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Giles W Robinson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Arzu Onar-Thomas
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Brent A Orr
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Catherine A Billups
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Daniel C Bowers
- Departments of Pediatrics and Neurological Surgery, University of Texas Southwestern Medical School/Children's Health, Dallas, Texas, USA
| | - Anne E Bendel
- Department of Hematology Oncology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Tim Hassall
- Department of Medicine, Queensland Children's Hospital, South Brisbane, Australia
| | - John R Crawford
- Department of Neurosciences and Pediatrics, University of California San Diego and Rady Childrens Hospital, San Diego, California, USA
| | - Sonia Partap
- Department of Neurology & Division of Child Neurology, Stanford University, Palo Alto, California, USA
| | - Paul G Fisher
- Department of Neurology & Division of Child Neurology, Stanford University, Palo Alto, California, USA
| | - Ruth G Tatevossian
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Tiffany Seah
- Department of Medicine, University of Cambridge, London, UK
| | - Ibrahim A Qaddoumi
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Anna Vinitsky
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Gregory T Armstrong
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Noah D Sabin
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Christopher L Tinkle
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Paul Klimo
- Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee, USA.,Semmes-Murphey Clinic, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee and Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Danny J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - Frederick A Boop
- Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee, USA.,Semmes-Murphey Clinic, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee and Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - David W Ellison
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| |
Collapse
|
35
|
Greenberger BA, Yock TI. The role of proton therapy in pediatric malignancies: Recent advances and future directions. Semin Oncol 2020; 47:8-22. [PMID: 32139101 DOI: 10.1053/j.seminoncol.2020.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/11/2022]
Abstract
Proton radiotherapy has promised an advantage in safely treating pediatric malignancies with an increased capability to spare normal tissues, reducing the risk of both acute and late toxicity. The past decade has seen the proliferation of more than 30 proton facilities in the United States, with increased capacity to provide access to approximately 3,000 children per year who will require radiotherapy for their disease. We provide a review of the initial efforts to describe outcomes after proton therapy across the common pediatric disease sites. We discuss the main attempts to assess comparative efficacy between proton and photon radiotherapy concerning toxicity. We also discuss recent efforts of multi-institutional registries aimed at accelerating research to better define the optimal treatment paradigm for children requiring radiotherapy for cure.
Collapse
Affiliation(s)
- Benjamin A Greenberger
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Francis H. Burr Proton Therapy Center, Boston, MA.
| |
Collapse
|
36
|
Hidalgo ET, Snuderl M, Orillac C, Kvint S, Serrano J, Wu P, Karajannis MA, Gardner SL. Subgroup-specific outcomes of children with malignant childhood brain tumors treated with an irradiation-sparing protocol. Childs Nerv Syst 2020; 36:133-144. [PMID: 31375903 DOI: 10.1007/s00381-019-04305-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 07/08/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Molecular subgroups of pediatric brain tumors associated with divergent biological, clinical, and prognostic features have been identified. However, data regarding the impact of subgroup affiliation on the outcome of children with malignant brain tumors treated with radiation-sparing protocol is limited. We report long-term clinical outcomes and the molecular subgroups of malignant brain tumors in young children whose first-line treatment was high-dose chemotherapy without irradiation. METHODS Tumor subclassification was performed using the Illumina HumanMethylation450 BeadChip (450k) genome-wide methylation array profiling platform. Clinical information was obtained from chart review. RESULTS Methylation array profiling yielded information on molecular subgroups in 22 children. Median age at surgery was 26 months (range 1-119 months). Among medulloblastomas (MB), all 6 children in the infant sonic hedgehog (SHH) subgroup were long-term survivors, whereas all 4 children in subgroup 3 MB died. There was one long-term survivor in subgroup 4 MB. One out of five children with ependymoma was a long-term survivor (RELPOS). Both children with primitive neuroectodermal tumors died. One child with ATRT TYR and one child with choroid plexus carcinoma were long-term survivors. CONCLUSIONS The efficacy of high-dose chemotherapy radiation-sparing treatment appears to be confined to favorable molecular subgroups of pediatric brain tumors, such as infant SHH MB. Identification of molecular subgroups that benefit from radiation-sparing therapy will aid in the design of prospective, "precision medicine"-driven clinical trials.
Collapse
Affiliation(s)
- Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA.
| | - Matija Snuderl
- Department of Pathology, NYU Langone Health, New York, USA
| | - Cordelia Orillac
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA
| | - Svetlana Kvint
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA
| | | | - Peter Wu
- Department of Pathology, NYU Langone Health, New York, USA
| | - Matthias A Karajannis
- Pediatric Neuro-Oncology, Department of Pediatrics, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA
- Pediatric Neuro-Oncology Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center (MSKCC), New York, USA
| | - Sharon L Gardner
- Pediatric Neuro-Oncology, Department of Pediatrics, Hassenfeld Children's Hospital, NYU Langone Health, New York, USA
| |
Collapse
|
37
|
Abstract
In pediatric brain tumors, the intensification of chemotherapy has allowed for a reduction in radiotherapy (RT) volume to an involved field approach, particularly in patients with medulloblastoma. For patients with low-grade gliomas, the trend has remained to delay RT with chemotherapy; however, when RT is used, typically smaller clinical target volume margins are used. For patients with extracranial tumors, intensive chemotherapy to address systemic disease with local control is considered standard. Proton beam therapy shows significant promise in addressing both short-term and long-term toxicities in both central nervous system (CNS) and non-CNS pediatric tumors.
Collapse
Affiliation(s)
- Sujith Baliga
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Francis H. Burr Proton Therapy Center, 30 Fruit Street, Boston, MA 02114, USA
| | - Torunn I Yock
- Francis H. Burr Proton Therapy Center, 30 Fruit Street, Boston, MA 02114, USA; Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
38
|
Abstract
Proton beam therapy is a highly conformal form of radiation therapy, which currently represents an important therapeutic component in multidisciplinary management in paediatric oncology. The precise adjustability of protons results in a reduction of radiation-related long-term side-effects and secondary malignancy induction, which is of particular importance for the quality of life. Proton irradiation has been shown to offer significant advantages over conventional photon-based radiotherapy, although the biological effectiveness of both irradiation modalities is comparable. This review evaluates current data from clinical and dosimetric studies on the treatment of tumours of the central nervous system, soft tissue and bone sarcomas of the head and neck region, paraspinal or pelvic region, and retinoblastoma. To date, the clinical results of irradiating childhood tumours with high-precision proton therapy are promising both with regard to tumour cure and the reduction of adverse events. Modern proton therapy techniques such as pencil beam scanning and intensity modulation are increasingly established modern facilities. However, further investigations with larger patient cohorts and longer follow-up periods are required, in order to be able to have clear evidence on clinical benefits.
Collapse
Affiliation(s)
- Heike Thomas
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Centre (WTZ), West German, Germany
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Centre (WTZ), West German, Germany.,German Cancer Consortium (DKTK), Essen, Germany
| |
Collapse
|
39
|
Brainstem Injury in Pediatric Patients Receiving Posterior Fossa Photon Radiation. Int J Radiat Oncol Biol Phys 2019; 105:1034-1042. [PMID: 31472183 DOI: 10.1016/j.ijrobp.2019.08.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 08/09/2019] [Accepted: 08/15/2019] [Indexed: 01/23/2023]
Abstract
PURPOSE Brainstem necrosis is a rare, but dreaded complication of radiation therapy; however, data on the incidence of brainstem injury for tumors involving the posterior fossa in photon-treated patient cohorts are still needed. METHODS AND MATERIALS Clinical characteristics and dosimetric parameters were recorded for 107 pediatric patients who received photon radiation for posterior fossa tumors without brainstem involvement from 2000 to 2016. Patients were excluded if they received a prescription dose <50.4 Gy, a brainstem maximum dose <50.4 Gy, or had fewer than 2 magnetic resonance imaging scans within 18 months after radiation. Post-radiation therapy magnetic resonance imaging findings were recorded, and brainstem toxicity was graded using National Cancer Institute Common Terminology Criteria for Adverse Events, version 5. RESULTS The most common histologies were medulloblastoma (61.7%) and ependymoma (15.9%), and median age at diagnosis was 8.3 years (range, 0.8-20.7). Sixty-seven patients (62.6%) received craniospinal irradiation (median, 23.4 Gy; range, 18.0-39.6) as a component of their radiation therapy, and 39.3% and 40.2% of patients received an additional involved field or whole posterior fossa boost, respectively. Median prescribed dose was 55.8 Gy (range, 50.4-60.0). Median clinical and imaging follow-up were 4.7 years (range, 0.1-17.5) and 4.2 years (range, 0.1-17.3), respectively. No grade ≥2 toxicities were observed. The incidence of grade 1 brainstem necrosis was 1.9% (2 of 107). These patients were by definition asymptomatic and experienced resolution of imaging abnormality after 5.3 months and 2.1 years, respectively. CONCLUSIONS Risk of brainstem necrosis was minimal in this multi-institutional study of pediatric patients treated with photon radiation therapy for tumors involving the posterior fossa with no cases of symptomatic brainstem injury, suggesting that brainstem injury risk is minimal in patients treated with photon therapy.
Collapse
|
40
|
Abstract
PURPOSE OF REVIEW This review discusses the evidence base behind current and emerging strategies of management of intracranial and spinal ependymomas in children, with a particular focus on aspects of surgical techniques, challenges and complications. RECENT FINDINGS The cornerstone of management remains maximal safe resective surgery, which has repeatedly been shown to correlate with improved survival. This is followed by focal conformal radiotherapy, although good results using proton beam therapy, with the potential for diminished side effects, are emerging. The role of chemotherapy remains largely unproven for paediatric ependymoma. Despite optimal management strategies, many children with ependymoma suffer from tumour recurrence. The standard of care for paediatric ependymoma comprises surgery and radiotherapy. Results of ongoing clinical trials will help shape its management in order to leverage our increasingly sophisticated understanding of the genetic drivers behind these tumours into survival benefit for this challenging group of patients.
Collapse
Affiliation(s)
- Sebastian M Toescu
- Developmental Imaging and Biophysics Section, UCL-GOS Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.,Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.
| |
Collapse
|
41
|
Tensaouti F, Ducassou A, Chaltiel L, Bolle S, Habrand JL, Alapetite C, Coche-Dequeant B, Bernier V, Claude L, Carrie C, Padovani L, Muracciole X, Supiot S, Huchet A, Leseur J, Kerr C, Hangard G, Lisbona A, Goudjil F, Ferrand R, Laprie A. Feasibility of Dose Escalation in Patients With Intracranial Pediatric Ependymoma. Front Oncol 2019; 9:531. [PMID: 31293971 PMCID: PMC6598548 DOI: 10.3389/fonc.2019.00531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/31/2019] [Indexed: 12/25/2022] Open
Abstract
Background and purpose: Pediatric ependymoma carries a dismal prognosis, mainly owing to local relapse within RT fields. The current prospective European approach is to increase the radiation dose with a sequential hypofractionated stereotactic boost. In this study, we assessed the possibility of using a simultaneous integrated boost (SIB), comparing VMAT vs. IMPT dose delivery. Material and methods: The cohort included 101 patients. The dose to planning target volume (PTV59.4) was 59.4/1.8 Gy, and the dose to SIB volume (PTV67.6) was 67.6/2.05 Gy. Gross tumor volume (GTV) was defined as the tumor bed plus residual tumor, clinical target volume (CTV59.4) was GTV + 5 mm, and PTV59.4 was CTV59.4 + 3 mm. PTV67.6 was GTV+ 3 mm. After treatment plan optimization, quality indices and doses to target volume and organs at risk (OARs) were extracted and compared with the standard radiation doses that were actually delivered (median = 59.4 Gy [50.4 59.4]). Results: In most cases, the proton treatment resulted in higher quality indices (p < 0.001). Compared with the doses that were initially delivered, mean, and maximum doses to some OARs were no higher with SIB VMAT, and significantly lower with protons (p < 0.001). In the case of posterior fossa tumor, there was a lower dose to the brainstem with protons, in terms of V59 Gy, mean, and near-maximum (D2%) doses. Conclusion: Dose escalation with intensity-modulated proton or photon SIB is feasible in some patients. This approach could be considered for children with unresectable residue or post-operative FLAIR abnormalities, particularly if they have supratentorial tumors. It should not be considered for infratentorial tumors encasing the brainstem or extending to the medulla.
Collapse
Affiliation(s)
- Fatima Tensaouti
- ToNIC, Toulouse NeuroImaging Center, Universite de Toulouse, Inserm, Toulouse, France
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du, Cancer de Toulouse-Oncopole, Toulouse, France
| | - Anne Ducassou
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du, Cancer de Toulouse-Oncopole, Toulouse, France
| | - Léonor Chaltiel
- Department of Biostatistics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Stéphanie Bolle
- Department of Radiotherapy Oncology, Institut Gustave Roussy, Villejuif, France
| | - Jean Louis Habrand
- Department of Radiation Oncology, Centre Francois Baclesse, Caen, France
| | | | | | - Valérie Bernier
- Department of Radiation Oncology, Centre Alexis Vautrin, Vandœuvre-lès-Nancy, France
| | - Line Claude
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Christian Carrie
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | | | | | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancerologie de l'Ouest, Nantes, France
| | - Aymeri Huchet
- Department of Radiation Oncology, Centre Hospitalier et Universitaire, Bordeaux, France
| | - Julie Leseur
- Department of Radiation Oncology, Centre Eugéne Marquis, Rennes, France
| | - Christine Kerr
- Department of Radiation Oncology, Institut Regional du Cancer Montpellier, Val d'Aurelle, Montpellier, France
| | - Grégorie Hangard
- Department of Engineering and Medical Physics, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Albert Lisbona
- Department of Radiation Oncology, Institut de Cancerologie de l'Ouest, Nantes, France
| | - Farid Goudjil
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Régis Ferrand
- Department of Engineering and Medical Physics, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Anne Laprie
- ToNIC, Toulouse NeuroImaging Center, Universite de Toulouse, Inserm, Toulouse, France
- Department of Radiation Oncology, Institut Claudius Regaud, Institut Universitaire du, Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| |
Collapse
|
42
|
Ager BJ, Christensen MT, Burt LM, Poppe MM. The value of high-dose radiotherapy in intracranial ependymoma. Pediatr Blood Cancer 2019; 66:e27697. [PMID: 30865382 DOI: 10.1002/pbc.27697] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/07/2019] [Accepted: 02/15/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND We sought to evaluate the impact of adjuvant radiotherapy dose on overall survival (OS) after surgical resection for localized intracranial ependymoma. PROCEDURE The National Cancer Database (NCDB) was queried from 2004 to 2015 for patients of all ages with intracranial WHO grade II to III ependymoma treated with surgery and 4500 to 7000 cGy of adjuvant radiotherapy. Pearson χ2 test and multivariate logistic regression analyses were used to assess clinicodemographic factors and patterns of care. After propensity-score matching, OS was assessed with Kaplan-Meier analyses and doubly robust estimation with multivariate Cox proportional hazards modeling. RESULTS Of the 1153 patients meeting criteria, 529 (46%) received ≤ 5400 cGy and 624 (54%) received > 5400 cGy. At a median follow-up of 54.5 months, an OS benefit was observed for > 5400 cGy in pediatric patients aged 2-18 years (hazard ratio [HR] 0.53; 95% confidence interval [CI] 0.28-0.99, P = 0.047). No OS difference was found between ≤ 5400 cGy and > 5400 cGy in pediatric patients aged < 2 years (P = 0.819) or in adults (P = 0.180). Increasing age, WHO grade III, subtotal resection, and receipt of chemotherapy portended worse OS. Age 2 to 18 years, WHO III grade, supratentorial location, and receipt of chemotherapy were associated with receiving > 5400 cGy. CONCLUSION Adjuvant radiotherapy dose > 5400 cGy was associated with improved OS for children aged 2-18 years with WHO grade II-III intracranial ependymoma. No OS benefit was found with > 5400 cGy in adults or children less than two years of age.
Collapse
Affiliation(s)
- Bryan J Ager
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Lindsay M Burt
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| |
Collapse
|
43
|
The Role of Particle Therapy for the Treatment of Skull Base Tumors and Tumors of the Central Nervous System (CNS). Top Magn Reson Imaging 2019; 28:49-61. [PMID: 31022048 DOI: 10.1097/rmr.0000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Radiation therapy (RT) is a mainstay in the interdisciplinary treatment of brain tumors of the skull base and brain. Technical innovations during the past 2 decades have allowed for increasingly precise treatment with better sparing of adjacent healthy tissues to prevent treatment-related side effects that influence patients' quality of life. Particle therapy with protons and charged ions offer favorable kinetics with sharp dose deposition in a well-defined depth (Bragg-Peak) and a steep radiation fall-off beyond that maximum. This review highlights the role of particle therapy in the management of primary brain tumors and tumors of the skull base.
Collapse
|
44
|
Are further studies needed to justify the use of proton therapy for paediatric cancers of the central nervous system? A review of current evidence. Radiother Oncol 2019; 133:140-148. [DOI: 10.1016/j.radonc.2019.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/31/2018] [Accepted: 01/09/2019] [Indexed: 11/21/2022]
|
45
|
Haas-Kogan D, Indelicato D, Paganetti H, Esiashvili N, Mahajan A, Yock T, Flampouri S, MacDonald S, Fouladi M, Stephen K, Kalapurakal J, Terezakis S, Kooy H, Grosshans D, Makrigiorgos M, Mishra K, Poussaint TY, Cohen K, Fitzgerald T, Gondi V, Liu A, Michalski J, Mirkovic D, Mohan R, Perkins S, Wong K, Vikram B, Buchsbaum J, Kun L. National Cancer Institute Workshop on Proton Therapy for Children: Considerations Regarding Brainstem Injury. Int J Radiat Oncol Biol Phys 2019; 101:152-168. [PMID: 29619963 DOI: 10.1016/j.ijrobp.2018.01.013] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/21/2017] [Accepted: 01/01/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Proton therapy can allow for superior avoidance of normal tissues. A widespread consensus has been reached that proton therapy should be used for patients with curable pediatric brain tumor to avoid critical central nervous system structures. Brainstem necrosis is a potentially devastating, but rare, complication of radiation. Recent reports of brainstem necrosis after proton therapy have raised concerns over the potential biological differences among radiation modalities. We have summarized findings from the National Cancer Institute Workshop on Proton Therapy for Children convened in May 2016 to examine brainstem injury. METHODS AND MATERIALS Twenty-seven physicians, physicists, and researchers from 17 institutions with expertise met to discuss this issue. The definition of brainstem injury, imaging of this entity, clinical experience with photons and photons, and potential biological differences among these radiation modalities were thoroughly discussed and reviewed. The 3 largest US pediatric proton therapy centers collectively summarized the incidence of symptomatic brainstem injury and physics details (planning, dosimetry, delivery) for 671 children with focal posterior fossa tumors treated with protons from 2006 to 2016. RESULTS The average rate of symptomatic brainstem toxicity from the 3 largest US pediatric proton centers was 2.38%. The actuarial rate of grade ≥2 brainstem toxicity was successfully reduced from 12.7% to 0% at 1 center after adopting modified radiation guidelines. Guidelines for treatment planning and current consensus brainstem constraints for proton therapy are presented. The current knowledge regarding linear energy transfer (LET) and its relationship to relative biological effectiveness (RBE) are defined. We review the current state of LET-based planning. CONCLUSIONS Brainstem injury is a rare complication of radiation therapy for both photons and protons. Substantial dosimetric data have been collected for brainstem injury after proton therapy, and established guidelines to allow for safe delivery of proton radiation have been defined. Increased capability exists to incorporate LET optimization; however, further research is needed to fully explore the capabilities of LET- and RBE-based planning.
Collapse
Affiliation(s)
- Daphne Haas-Kogan
- Department of Radiation Oncology, Harvard Medical School and Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Daniel Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Harald Paganetti
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Anita Mahajan
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Torunn Yock
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Shannon MacDonald
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Maryam Fouladi
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kry Stephen
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John Kalapurakal
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stephanie Terezakis
- Department of Radiation Oncology, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Hanne Kooy
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - David Grosshans
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mike Makrigiorgos
- Department of Radiation Oncology, Harvard Medical School and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kavita Mishra
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Tina Young Poussaint
- Department of Radiology, Harvard Medical School and Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth Cohen
- Department of Pediatrics, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Thomas Fitzgerald
- Department of Radiation Oncology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Vinai Gondi
- Northwestern Medicine Chicago Proton Center, Chicago, Illinois
| | - Arthur Liu
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Dragan Mirkovic
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Radhe Mohan
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Kenneth Wong
- Children's Hospital of Angeles and University of Southern California Keck School of Medicine, Los Angles, California
| | - Bhadrasain Vikram
- Radiation Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Jeff Buchsbaum
- Radiation Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Larry Kun
- Department of Radiation Oncology, University of Texas Southwestern Medical School, Dallas, Texas.
| |
Collapse
|
46
|
Central nervous system ependymoma: clinical implications of the new molecular classification, treatment guidelines and controversial issues. Clin Transl Oncol 2019; 21:1450-1463. [PMID: 30868390 DOI: 10.1007/s12094-019-02082-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
Abstract
Ependymoma is an uncommon neuroepithelial tumor that may arise anywhere within the neuroaxis, both in children and in adults. It has been classically graded upon histopathological features, yet with limited clinical utility. Recently, DNA methylation profiling has provided a novel classification of ependymoma in nine molecular subgroups. This stratification method harbors prognostic value with supratentorial RELA-fusion and posterior fossa group A tumors showing a significantly shorter survival compared to the rest. Currently, the treatment of choice involves maximal safe resection and, in cases of residual disease, adjuvant conformal radiotherapy. Second-look surgery is also a feasible and recommended option for incompletely resected tumors. The role of chemotherapy is not yet established and can be considered in infants and children with relapsing disease or prior to re-intervention. Although targeted agents do not seem to play a role as adjuvant therapy, they are currently being tested for recurrent disease.
Collapse
|
47
|
Zapotocky M, Beera K, Adamski J, Laperierre N, Guger S, Janzen L, Lassaletta A, Figueiredo Nobre L, Bartels U, Tabori U, Hawkins C, Urbach S, Tsang DS, Dirks PB, Taylor MD, Bouffet E, Mabbott DJ, Ramaswamy V. Survival and functional outcomes of molecularly defined childhood posterior fossa ependymoma: Cure at a cost. Cancer 2019; 125:1867-1876. [PMID: 30768777 DOI: 10.1002/cncr.31995] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/02/2019] [Accepted: 01/10/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Posterior fossa ependymoma (PFE) comprises 2 groups, PF group A (PFA) and PF group B (PFB), with stark differences in outcome. However, to the authors' knowledge, the long-term outcomes of PFA ependymoma have not been described fully. The objective of the current study was to identify predictors of survival and neurocognitive outcome in a large consecutive cohort of subgrouped patients with PFE over 30 years. METHODS Demographic, survival, and neurocognitive data were collected from consecutive patients diagnosed with PFE from 1985 through 2014 at the Hospital for Sick Children in Toronto, Ontario, Canada. Subgroup was assigned using genome-wide methylation array and/or immunoreactivity to histone H3 K27 trimethylation (H3K27me3). RESULTS A total of 72 PFE cases were identified, 89% of which were PFA. There were no disease recurrences noted among patients with PFB. The 10-year progression-free survival rate for all patients with PFA was poor at 37.1% (95% confidence interval, 25.9%-53.1%). Analysis of consecutive 10-year epochs revealed significant improvements in progression-free survival and/or overall survival over time. This pertains to the increase in the rate of gross (macroscopic) total resection from 35% to 77% and the use of upfront radiotherapy increasing from 65% to 96% over the observed period and confirmed in a multivariable model. Using a mixed linear model, analysis of longitudinal neuropsychological outcomes restricted to patients with PFA who were treated with focal irradiation demonstrated significant continuous declines in the full-scale intelligence quotient over time with upfront conformal radiotherapy, even when correcting for hydrocephalus, number of surgeries, and age at diagnosis (-1.33 ± 0.42 points/year; P = .0042). CONCLUSIONS Data from a molecularly informed large cohort of patients with PFE clearly indicate improved survival over time, related to more aggressive surgery and upfront radiotherapy. However, to the best of the authors' knowledge, the current study is the first, in a subgrouped cohort, to demonstrate that this approach results in reduced neurocognitive outcomes over time.
Collapse
Affiliation(s)
- Michal Zapotocky
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatric Haematology and Oncology, Second Medical School, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Kiran Beera
- Programme in Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jenny Adamski
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatric Oncology, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Normand Laperierre
- Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Sharon Guger
- Department of Psychology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Laura Janzen
- Programme in Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Psychology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alvaro Lassaletta
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatric Hematology and Oncology, Child Jesus Hospital, Madrid, Spain
| | | | - Ute Bartels
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cynthia Hawkins
- Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stacey Urbach
- Division of Endocrinology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek S Tsang
- Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Peter B Dirks
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada.,Programme in Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael D Taylor
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada.,Programme in Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Donald J Mabbott
- Programme in Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.,Programme in Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
48
|
Steinmeier T, Schulze Schleithoff S, Timmermann B. Evolving Radiotherapy Techniques in Paediatric Oncology. Clin Oncol (R Coll Radiol) 2019; 31:142-150. [PMID: 30639254 DOI: 10.1016/j.clon.2018.12.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/06/2018] [Accepted: 12/06/2018] [Indexed: 12/31/2022]
Abstract
AIMS Childhood cancer is rare and survival of childhood cancer has increased up to 80% at 5 years after diagnosis. Radiotherapy is an important element of the multimodal treatment concept. However, due to growing tissue, children are particularly sensitive to radiation-related side-effects and the induction of secondary malignancies. However, radiotherapy techniques have continuously progressed. In addition, modern treatment concepts have been improved in order to minimise long-term effects. Today, radiotherapy is used for various tumour types in childhood, such as sarcomas and tumours of the central nervous system. MATERIALS AND METHODS External beam therapy with either photons or protons and brachytherapy are predominantly used for the treatment of childhood tumours. Technical developments and features, as well as clinical outcomes, for several tumour entities are presented. RESULTS The development of radiotherapy techniques, as well as risk-adapted therapy concepts, resulted in promising outcome regarding tumour control, survival and therapy-related side-effects. It is assumed that proton therapy will be increasingly used for treating children in the future. However, more data have to be collected through multi-institutional registries in order to strengthen the evidence. CONCLUSION The development of radiotherapy techniques is beneficial for children in terms of reducing dose exposure. As compared with other modern and highly conformal techniques, particularly proton therapy may achieve high survival rates and tumour control rates while decreasing the risk for side-effects. However, clinical evidence for modern radiotherapy techniques is still limited today. An optimal patient triaging with the selection of the most appropriate radiation technique for each individual patient will be an important goal for the future.
Collapse
Affiliation(s)
- T Steinmeier
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany; West German Proton Therapy Center Essen (WPE), Essen, Germany; West German Cancer Center (WTZ), Essen, Germany
| | - S Schulze Schleithoff
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany; West German Proton Therapy Center Essen (WPE), Essen, Germany; West German Cancer Center (WTZ), Essen, Germany
| | - B Timmermann
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany; West German Proton Therapy Center Essen (WPE), Essen, Germany; West German Cancer Center (WTZ), Essen, Germany; German Cancer Consortium (DKTK), Essen/Düsseldorf, Germany.
| |
Collapse
|
49
|
Imaoka T, Nishimura M, Daino K, Takabatake M, Moriyama H, Nishimura Y, Morioka T, Shimada Y, Kakinuma S. Risk of second cancer after ion beam radiotherapy: insights from animal carcinogenesis studies. Int J Radiat Biol 2019; 95:1431-1440. [PMID: 30495977 DOI: 10.1080/09553002.2018.1547848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Purpose: To review recent studies to better understand the risk of second cancer after ion beam radiotherapy and to clarify the importance of animal radiobiology therein. Results: Risk of developing second cancer after radiotherapy is a concern, particularly for survivors of childhood tumors. Ion beam radiotherapy is expected to reduce the risk of second cancer by reducing exposure of normal tissues to radiation. Large uncertainty lies, however, in the choice of relative biological effectiveness (RBE) of high linear energy transfer (LET) radiation (e.g. carbon ions and neutrons) in cancer induction, especially for children. Studies have attempted to predict the risk of second cancer after ion beam radiotherapy based on an assessment of radiation dose, the risk of low LET radiation, and assumptions about RBE. Animal experiments have yielded RBE values for selected tissues, radiation types, and age at the time of irradiation; the results indicate potentially variable RBE which depends on tissues, ages, and dose levels. Animal studies have also attempted to identify genetic alterations in tumors induced by high LET radiation. Conclusions: Estimating the RBE value for cancer induction is important for understanding the risk of second cancer after ion beam radiotherapy. More comprehensive animal radiobiology studies are needed.
Collapse
Affiliation(s)
- Tatsuhiko Imaoka
- Department of Radiation Effects Research, National Institute of Radiological Sciences (NIRS), National Institutes for Quantum and Radiological Science and Technology (QST) , Chiba , Japan.,Tokyo Metropolitan University , Tokyo , Japan.,QST Advanced Study Laboratory, QST , Chiba , Japan
| | - Mayumi Nishimura
- Department of Radiation Effects Research, National Institute of Radiological Sciences (NIRS), National Institutes for Quantum and Radiological Science and Technology (QST) , Chiba , Japan
| | - Kazuhiro Daino
- Department of Radiation Effects Research, National Institute of Radiological Sciences (NIRS), National Institutes for Quantum and Radiological Science and Technology (QST) , Chiba , Japan
| | - Masaru Takabatake
- Department of Radiation Effects Research, National Institute of Radiological Sciences (NIRS), National Institutes for Quantum and Radiological Science and Technology (QST) , Chiba , Japan.,Tokyo Metropolitan University , Tokyo , Japan
| | - Hitomi Moriyama
- Department of Radiation Effects Research, National Institute of Radiological Sciences (NIRS), National Institutes for Quantum and Radiological Science and Technology (QST) , Chiba , Japan.,Tokyo Metropolitan University , Tokyo , Japan
| | - Yukiko Nishimura
- Department of Radiation Effects Research, National Institute of Radiological Sciences (NIRS), National Institutes for Quantum and Radiological Science and Technology (QST) , Chiba , Japan
| | - Takamitsu Morioka
- Department of Radiation Effects Research, National Institute of Radiological Sciences (NIRS), National Institutes for Quantum and Radiological Science and Technology (QST) , Chiba , Japan
| | | | - Shizuko Kakinuma
- Department of Radiation Effects Research, National Institute of Radiological Sciences (NIRS), National Institutes for Quantum and Radiological Science and Technology (QST) , Chiba , Japan
| |
Collapse
|
50
|
Increase of pseudoprogression and other treatment related effects in low-grade glioma patients treated with proton radiation and temozolomide. J Neurooncol 2018; 142:69-77. [DOI: 10.1007/s11060-018-03063-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/24/2018] [Indexed: 12/22/2022]
|