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Aktekin EH, Kütük MÖ, Sangün Ö, Yazıcı N, Çaylaklı F, Erol İ, Sarıalioğlu F. Late effects of medulloblastoma treatment: multidisciplinary approach of survivors. Childs Nerv Syst 2024; 40:417-425. [PMID: 37698649 DOI: 10.1007/s00381-023-06146-1] [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: 07/30/2023] [Accepted: 09/05/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE Medulloblastoma is one of the brain tumors with increased life expectancy due to improvements in treatment approaches. Besides the promising results, various undesirable effects can be encountered. This study's aim is to review long-term follow-up outcomes of our cases with medulloblastoma. METHODS Age at diagnosis, histological type of medulloblastoma, resection extension, chemotherapy and radiotherapy schemes, follow-up duration, and endocrinological, neuropsychiatric, cardiological, auditory, and visual examination results were evaluated in 20 patients diagnosed between 2007 and 2018 and followed 5 years and more. RESULTS Twenty of 53 patients were included to the study. Eleven (55%) were male. Mean age at diagnosis was 6.95 years; mean age at the time of the study was 14 years. Mean follow-up time was 8.95 years. In terms of surgery, 14 (70%) were gross total, 1 (5%) was near total, and 2 (10%) were subtotal resection. In histopathological examination, 14 (70%) were classical medulloblastoma, 4 (20%) were desmoplastic medulloblastoma, and 1 (5%) was anaplastic medulloblastoma. With regard to endocrinological evaluation, 15 (75%) patients had hypothyroidism, 5 (25%) had growth hormone deficiency, 7 (35%) had clinical growth hormone deficiency, and 5 (25%) had sex hormone disorders. In neuropsychiatric examination, 11 (55%) patients had neurological sequelae, 18 (90%) patients had psychiatric issues, and 14 (70%) patients had two or more neuropsychiatric problems simultaneously. One (5%) patient had mitral valve insufficiency. Twelve patients (60%) had hearing loss. According to visual examination, 6 (30%) patients had refraction problem, 4 (20%) had cataract, and 1 (5%) had dry eye. CONCLUSION Careful monitoring of long-term side effects is important for improving the quality of life of medulloblastoma patients. Besides endocrinological and other somatic sequelae of the disease and treatment, increased neuropsychiatric problems showed us that only cure is not the issue while treating childhood medulloblastoma.
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Affiliation(s)
- Elif Habibe Aktekin
- Department of Pediatrics Division of Pediatric Hematology-Oncology, Baskent University, Adana, Turkey.
| | - Meryem Özlem Kütük
- Department of Child and Adolescent Psychiatry, Baskent University, Adana, Turkey
| | - Özlem Sangün
- Department of Pediatric Division of Pediatric Endocrinology, Baskent University, Adana, Turkey
| | - Nalan Yazıcı
- Department of Pediatrics Division of Pediatric Hematology-Oncology, Baskent University, Adana, Turkey
| | - Fatma Çaylaklı
- Department of Ear-Nose and Throat, Baskent University, Adana, Turkey
| | - İlknur Erol
- Department of Pediatrics Division of Pediatric Neurology, Baskent University, Adana, Turkey
| | - Faik Sarıalioğlu
- Department of Pediatrics Division of Pediatric Hematology-Oncology, Baskent University, Adana, Turkey
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Late Effects of Craniospinal Irradiation Using Electron Spinal Fields for Pediatric Patients With Cancer. Int J Radiat Oncol Biol Phys 2023; 115:164-173. [PMID: 35716848 DOI: 10.1016/j.ijrobp.2022.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/02/2022] [Accepted: 06/06/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE For children, craniospinal irradiation (CSI) with photons is associated with significant toxic effects. The use of electrons for spinal fields is hypothesized to spare anterior structures but the long-term effects remain uncertain. We studied late effects of CSI using electrons for spinal radiation therapy (RT). METHODS AND MATERIALS Records of 84 consecutive patients treated with CSI using electrons for the spine at a single institution between 1983 and 2014 were reviewed. Median age at RT was 5 (range, 1-14) years. The most common histologies were medulloblastoma/primitive neuroectodermal tumor (59%) and ependymoma (8%). The median prescribed dose to the entire spine was 30 Gy (range, 6-45). A subset of 48 (57%) patients aged 2 to 14 at RT with clinical follow-up for ≥5 years was analyzed for late effects. Height z scores adjusted for age before and after CSI were assessed using stature-for-age charts and compared with a t test. RESULTS At median follow-up of 19 years (range, 0-38 years), the median survival was 22 years (95% confidence interval, 12-28 years) after RT, with 47 patients (56%) alive at last follow-up. On subset analysis for late effects, 19 (40%) patients developed hypothyroidism and 5 (10%) developed secondary malignancies. Other complications reported were esophageal stricture and periaortic hemorrhage in 1 and restrictive pulmonary disease in 1 patient. Median height z score before treatment was -0.4 (36th percentile; interquartile range, -1.0 to 0.0) and at last follow-up was -2.2 (first percentile; interquartile range, -3.1 to -1.6; P < .001). Of 44 patients with spinal curvature assessments, 15 (34%) had scoliosis with median Cobb angle 15° (range, 10°-35°) and 1 (2%) required surgery. CONCLUSIONS Frequent musculoskeletal toxic effects and predominantly decreased height were seen with long-term follow-up. Scoliosis and hypothyroidism were each seen in at least one-third of long-term survivors. However, clinically evident esophageal, pulmonary, and cardiac toxic effects were infrequent.
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Chou B, Hopper A, Elster J, Crawford JR, McConnell K, Chang A, Mundt AJ, MacEwan I. Volumetric de-escalation and improved acute toxicity with proton craniospinal irradiation using a vertebral body-sparing technique. Pediatr Blood Cancer 2022; 69:e29489. [PMID: 34866330 DOI: 10.1002/pbc.29489] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/30/2021] [Accepted: 10/26/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE In growing children, craniospinal irradiation (CSI) has historically treated the entire vertebral body (VB) to avoid potential long-term spinal abnormalities. Vertebral body-sparing proton craniospinal irradiation (VBSpCSI) is a technique that spares the majority of the VB from significant irradiation, and long-term safety outcomes have been reported previously. This retrospective study reviews the acute toxicity profile of children treated with VBSpCSI in a cohort comparison with photon-based craniospinal radiotherapy (3DCRT). METHODS Thirty-eight pediatric CSI patients treated between 2008 and 2018 were retrospectively evaluated for treatment-related toxicity. Acute toxicity outcomes and acute hematologic profiles were compared according to treatment modality, either VBSpCSI or 3DCRT. Statistical analysis was performed using Fisher's exact test for toxicity. RESULTS Twenty-five patients received VBSpCSI and 13 patients received photon CSI. Mean patient age at treatment was 7.5 years (range 2-16). The cohorts were well matched with respect to gender, age, and CSI dose. Patients receiving VBSpCSI had lower rates of grade 2+ gastrointestinal (GI) toxicity (24% vs. 76.5%, p = .005), grade 2+ nausea (24% vs. 61.5%, p = .035), and any-grade esophagitis (0% vs. 38%, p = .0026). Patients treated with VBSpCSI had lower red blood cell transfusion rates (21.7% vs. 60%, p = .049) and grade 4+ lymphopenia (33.3% vs. 77.8%, p = .046). CONCLUSIONS VBSpCSI in children is a volumetric de-escalation from traditional volumes, which irradiate the entire VB to full or intermediate doses. In our study, VBSpCSI was associated with lower rates of acute GI and hematologic toxicities. Long-term growth outcomes and disease control outcomes are needed for this technique.
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Affiliation(s)
- Brian Chou
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Austin Hopper
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Jennifer Elster
- Department of Pediatric Hematology and Oncology, University of California - San Diego, San Diego, California, USA
| | - John R Crawford
- Department of Neurosciences and Pediatrics, University of California - San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Kristen McConnell
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Andrew Chang
- California Protons Cancer Therapy Center, San Diego, California, USA
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Iain MacEwan
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
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Indelicato DJ, Ioakeim-Ioannidou M, Grippin AJ, Bradley JA, Mailhot Vega RB, Viviers E, Tarbell NJ, Yock TI, MacDonald SM. Bicentric Treatment Outcomes After Proton Therapy for Nonmyxopapillary High-Grade Spinal Cord Ependymoma in Children. Int J Radiat Oncol Biol Phys 2021; 112:335-341. [PMID: 34597719 DOI: 10.1016/j.ijrobp.2021.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/24/2021] [Accepted: 09/22/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE Few studies report outcomes in children treated with radiation for nonmyxopapillary ependymoma of the spinal cord, and little evidence exists to inform decisions regarding target volume and prescription dose. Moreover, virtually no mature outcome data exist on proton therapy for this tumor. We describe our combined institutional experience treating pediatric classical/anaplastic ependymoma of the spinal cord with proton therapy. METHODS AND MATERIALS Between 2008 and 2019, 14 pediatric patients with nonmetastatic nonmyxopapillary grade II (n = 6) and grade III (n = 8) spinal ependymoma received proton therapy. The median age at radiation was 14 years (range, 1.5-18 years). Five tumors arose within the cervical cord, 3 within the thoracic cord, and 6 within the lumbosacral cord. Before radiation therapy, 3 patients underwent subtotal resection, and 11 underwent gross-total or near total resection. Two patients received chemotherapy. For radiation, the clinical target volume received 50.4 Gy (n = 8), 52.2 (n = 1), or 54 Gy (n = 5), with the latter receiving a boost to the gross tumor volume after the initial 50.4 Gy, modified to respect spinal cord tolerance. RESULTS With a median follow-up of 6.3 years (range, 1.5-14.8 years), no tumors progressed. Although most patients experienced neurologic sequela after surgery, only 1 developed additional neurologic deficits after radiation: An 18-year-old male who received 54 Gy after gross total resection of a lumbosacral tumor developed grade 2 erectile dysfunction. There were 2 cases of musculoskeletal toxicity attributable to surgery and radiation. At analysis, no patient had developed cardiac, pulmonary, or other visceral organ complications or a second malignancy. CONCLUSION Radiation to a total dose of 50 to 54 Gy can be safely delivered and plays a beneficial role in the multidisciplinary management of children with nonmyxopapillary spinal cord ependymoma. Proton therapy may reduce late radiation effects and is not associated with unexpected spinal cord toxicity.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Myrsini Ioakeim-Ioannidou
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Adam J Grippin
- 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
| | - Emma Viviers
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - 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
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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Martinez HR, Salloum R, Wright E, Bueche L, Khoury PR, Tretter JT, Ryan TD. Echocardiographic myocardial strain analysis describes subclinical cardiac dysfunction after craniospinal irradiation in pediatric and young adult patients with central nervous system tumors. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2021; 7:5. [PMID: 33531084 PMCID: PMC7856804 DOI: 10.1186/s40959-021-00093-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/25/2021] [Indexed: 11/26/2022]
Abstract
Background Craniospinal irradiation (CSI) is part of the treatment of central nervous system (CNS) tumors and is associated with cardiovascular disease in adults. Global myocardial strain analysis including longitudinal peak systolic strain (GLS), circumferential peak systolic strain (GCS), and radial peak systolic strain (GRS) can reveal subclinical cardiac dysfunction. Methods Retrospective, single-center study in patients managed with CSI vs. age-matched controls. Clinical data and echocardiography, including myocardial strain analysis, were collected at early (< 12 months) and late (≥ 12 months) time points after completion of CSI. Results Echocardiograms were available at 20 early and 34 late time points. Patients at the late time point were older (21.7 ± 10.4 vs. 13.3 ± 9.6 years) and further out from CSI (13.1 ± 8.8 vs. 0.2 ± 0.3 years). Standard echocardiographic parameters were normal for both groups. For early, CSI vs. control: GLS was − 16.8 ± 3.6% vs. -21.3 ± 4.0% (p = 0.0002), GCS was − 22.5 ± 5.2% vs. -21.3 ± 3.4% (p = 0.28), and GRS was 21.8 ± 11.0% vs. 26.9 ± 7.7% (p = 0.07). For late, CSI vs. control: GLS was − 16.2 ± 5.4% vs. -21.6 ± 3.7% (p < 0.0001), GCS was − 20.9 ± 6.8% vs. -21.9 ± 3.5% (p = 0.42), and GRS was 22.5 ± 10.0% vs. 27.3 ± 8.3% (p = 0.03). Radiation type (proton vs. photon), and radiation dose (< 30 Gy vs. ≥ 30 Gy) did not impact any parameter, although numbers were small. Conclusions Subclinical cardiac systolic dysfunction by GLS is present both early and late after CSI. These results argue for future studies to determine baseline cardiovascular status and the need for early initiation of longitudinal follow-up post CSI.
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Affiliation(s)
- Hugo R Martinez
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.,Present address: Division of Pediatric Cardiology, Heart Institute, Le Bonheur Children's Hospital, University of Tennessee Health and Science Center, Memphis, TN, USA
| | - Ralph Salloum
- Division of Oncology, Department of Pediatrics, University of Cincinnati College of Medicine, and Cancer and Blood Disorders Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Present address: Division of Hematology/Oncology/Bone Marrow Transplant Nationwide Children's Hospital Columbus, Columbus, OH, USA
| | - Erin Wright
- Present address: Division of Pediatric Cardiology, Heart Institute, Le Bonheur Children's Hospital, University of Tennessee Health and Science Center, Memphis, TN, USA.,Present address: Division of Hematology and Oncology, Showers Family Center for Childhood Cancer and Blood Disorders, Akron Children's Hospital, Akron, OH, USA
| | - Lauren Bueche
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Philip R Khoury
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Justin T Tretter
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Thomas D Ryan
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.
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