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Stern E, Ben-Ami M, Gruber N, Toren A, Caspi S, Abebe-Campino G, Lurye M, Yalon M, Modan-Moses D. Hypothalamic-pituitary-gonadal function, pubertal development, and fertility outcomes in male and female medulloblastoma survivors: a single-center experience. Neuro Oncol 2023; 25:1345-1354. [PMID: 36633935 PMCID: PMC10326472 DOI: 10.1093/neuonc/noad009] [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: 10/30/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Endocrine deficiencies, including hypothalamic-pituitary-gonadal axis (HPGA) impairment, are common in survivors of childhood and adolescent medulloblastoma. Still, data regarding pubertal development and fecundity are limited, and few studies assessed HPGA function in males. We aimed to describe HPGA function in a large cohort of patients with medulloblastoma. METHODS A retrospective study comprising all 62 medulloblastoma patients treated in our center between 1987 and 2021, who were at least 2 years from completion of therapy. HPGA function was assessed based on clinical data, biochemical markers, and questionnaires. RESULTS Overall, 76% of female patients had clinical or biochemical evidence of HPGA dysfunction. Biochemical evidence of diminished ovarian reserve was seen in all prepubertal girls (n = 4). Among the males, 34% had clinical or biochemical evidence of gonadal dysfunction, 34% had normal function, and 29% were age-appropriately clinically and biochemically prepubertal. The difference between males and females was significant (P = .003). Cyclophosphamide-equivalent dose was significantly associated with HPGA function in females, but not in males. There was no association between HPGA dysfunction and other endocrine deficiencies, length of follow-up, weight status, and radiation treatment protocol. Two female and 2 male patients achieved successful pregnancies, resulting in 6 live births. CONCLUSIONS HPGA dysfunction is common after treatment for childhood medulloblastoma. This is seen more in females, likely due to damage to the ovaries from spinal radiotherapy. Our findings may assist in counseling patients and their families regarding risk to future fertility and need for fertility preservation.
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Affiliation(s)
- Eve Stern
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Ben-Ami
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noah Gruber
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Toren
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Hematology-Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Shani Caspi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Hematology-Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Gadi Abebe-Campino
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Hematology-Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Michal Lurye
- Division of Pediatric Hematology-Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Michal Yalon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Hematology-Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Dalit Modan-Moses
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ronsley R, Crowell C, Irvine M, Kang M, Goldman RD, Erker C, Cheng S. Impact of Time to Diagnosis on Morbidity and Survival in Children With Malignant Central Nervous System Tumors. J Pediatr Hematol Oncol 2023; 45:e188-e193. [PMID: 35129148 DOI: 10.1097/mph.0000000000002424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/07/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim was to determine the impact of time to diagnosis (TTD) on morbidity and mortality and to identify factors associated with overall survival (OS) in pediatric patients with malignant central nervous system (CNS) tumors. METHODS This is a retrospective review of all malignant CNS tumors presenting to 2 tertiary care pediatric hospitals from 2000 to 2019. Cox proportional hazard model analysis outcomes included TTD and OS as well as morbidity; stratified by tumor category, age, relapse, and presence of metastatic disease. RESULTS There were 197 children with malignant CNS tumors (mean age 8.7 y, 61% male). Tumors included medulloblastoma (N=58, 29.4%), ependymoma (N=27, 13.7%), high-grade glioma (N=42, 21.3%), germ cell tumors (N=47, 23.9%), and other embryonal tumors (N=23, 11.7%). Median TTD from symptom onset was 62 (interquartile range: 26.5 to 237.5 d) and 28% had metastatic disease. Three-year progression free survival was 55% and 3-year OS was 73.1%. Increased OS was associated with increased TTD (parameter estimate 0.12; confidence interval [CI]: 0.019-7.06; P =0.019), high-grade glioma (hazard ratio [HR]: 2.46; CI [1.03-5.86]; P =0.042), other embryonal tumor (HR: 2.84; CI [1.06-7.56]; P =0.037), relapse (HR: 10.14; CI: 4.52-22.70; P <0.001) and metastatic disease (HR: 3.25; CI: 1.51-6.96; P =0.002). Vision change (HR: 0.58; CI: 0.313-1.06; P =0.078), hearing loss (HR: 0.71; CI: 0.35-1.42; P =0.355), and cognitive impairment (HR: 0.73; CI: 0.45-1.19; P =0.205) were not associated with TTD in this model. CONCLUSIONS Increased median TTD is associated with higher OS in pediatric patients treated for malignant CNS tumors. Tumor biology and treatment modality are more important factors than TTD for predicting morbidity and long-term outcomes in pediatric patients with CNS tumors.
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Affiliation(s)
- Rebecca Ronsley
- Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital
| | - Cameron Crowell
- Division of Hematology/Oncology, Department of Pediatrics, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Mike Irvine
- Clinical Research Support Unit, BC Children's Hospital Research Institute
| | - Mehima Kang
- Faculty of Medicine, University of British Columbia
| | - Ran D Goldman
- Pediatric Research in Emergency Therapeutics Program (PRETx.org) and the Division of Pediatric Emergency Medicine, Department of Pediatrics, British Columbia Children's Hospital, BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - Craig Erker
- Division of Hematology/Oncology, Department of Pediatrics, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Sylvia Cheng
- Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital
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Endocrinopathy After Treatment for Medulloblastoma: Results From the SJMB03 Trial of Risk-Adapted Radiation Therapy. Int J Radiat Oncol Biol Phys 2022:S0360-3016(22)03635-5. [PMID: 36563909 DOI: 10.1016/j.ijrobp.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 11/10/2022] [Accepted: 12/08/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE The objective of this study was to estimate the cumulative incidence of endocrinopathy in pediatric patients treated for medulloblastoma with surgery, risk-adapted photon craniospinal irradiation, and dose-intensive chemotherapy. METHODS AND MATERIALS Children and adolescents (n = 156) treated between 2003 and 2013 were evaluated for evidence of endocrinopathy. Clinical information and mean radiation dose to hypothalamus and thyroid were calculated and used to estimate cumulative incidence of growth hormone deficiency, hypothyroidism, adrenal insufficiency, hypogonadism, and precocious puberty. RESULTS The 5-year cumulative incidences were estimated for growth hormone deficiency, 68.9% (60.9%, 75.6%); hypothyroidism, 48.4% (95% confidence interval (CI), 40.2%-56.1%); adrenal insufficiency, 13.0% (95% CI, 8.3%-18.9%); hypogonadism, 33.9% (95% CI, 25.2%-42.7%); and precocious puberty, 2.0% (95% CI, 0.6%-5.4%). Growth hormone deficiency was associated with increased hypothalamus dose (hazard ratio [HR], 1.035; 95% CI, 1.010-1.061; P = .0055) in average-risk patients and cerebrospinal fluid shunt (HR, 2.532; 95% CI, 1.325-4.838; P = .0049) in high-risk patients. In average-risk patients, hypothyroidism was associated with younger age (HR, 0.902; 95% CI, 0.842-0.973; P = .0070), hypothalamus dose (HR, 1.039; 95% CI, 1.004-1.075; P = .0273), and thyroid dose (HR, 1.070; 95% CI, 1.008-1.136; P = .0263). In high-risk patients, hypothyroidism was associated with increased hypothalamus dose (HR, 1.068; 95% CI, 0.995-1.147; P = .0671) and thyroid dose (HR, 1.050; 95% CI, 1.000-1.104; P = .0515). Adrenal insufficiency was associated with increased hypothalamus dose (HR, 1.112; 95% CI, 1.058-1.170; P < .0001). Growth hormone deficiency incidence was higher when comparing patients treated with cerebrospinal fluid shunt versus those not having a shunt/extraventricular drain placed during initial surgery (HR, 1.712; 95% CI, 1.109-2.643). CONCLUSIONS Incidence and time to onset of clinically significant endocrinopathy after photon craniospinal irradiation for pediatric medulloblastoma is influenced by radiation dose to target organs and patient age at time of treatment. Advanced radiation therapy methods and dose-reduction strategies are needed to reduce the incidence of endocrinopathy.
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4
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Doknic M, Stojanovic M, Soldatovic I, Milenkovic T, Zdravkovic V, Jesic M, Todorovic S, Mitrovic K, Vukovic R, Miljic D, Savic D, Milicevic M, Stanimirovic A, Bogosavljevic V, Pekic S, Manojlovic-Gacic E, Djukic A, Grujicic D, Petakov M. Mapping the journey of transition: a single-center study of 170 childhood-onset GH deficiency patients. Endocr Connect 2021; 10:935-946. [PMID: 34259648 PMCID: PMC8428021 DOI: 10.1530/ec-21-0274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/14/2021] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To analyze metabolic parameters, body composition (BC), and bone mineral density (BMD) in childhood-onset GH deficiency (COGHD) patients during the transition period (TP). DESIGN Single- center, retrospective study was performed on 170 consecutive COGHD patients (age 19.2 ± 2.0 years, range 16-25) transferred after growth completion from two pediatric clinics to the adult endocrine unit. Two separate analyses were performed: (i) cross-sectional analysis of hormonal status, metabolic parameters, BC, and BMD at first evaluation after transfer from pediatrics to the adult department; (ii) longitudinal analysis of BC and BMD dynamics after 3 years of GH replacement therapy (rhGH) in TP. RESULTS COGHD was of a congenital cause (CONG) in 50.6% subjects, tumor-related (TUMC) in 23.5%, and idiopathic (IDOP) in 25.9%. TUMC patients had increased insulin and lipids levels (P < 0.01) and lower Z score at L-spine (P < 0.05) compared to CONG and IDOP groups. Patients treated with rhGH in childhood demonstrated lower fat mass and increased BMD compared to the rhGH-untreated group (P < 0.01). Three years of rhGH after growth completion resulted in a significant increase in lean body mass (12.1%) and BMD at L-spine (6.9%), parallel with a decrease in FM (5.2%). CONCLUSION The effect of rhGH in childhood is invaluable for metabolic status, BC, and BMD in transition to adulthood. Tumor-related COGHD subjects are at higher risk for metabolic abnormalities, alteration of body composition, and decreased BMD, compared to those with COGHD of other causes. Continuation of rhGH in transition is important for improving BC and BMD in patients with persistent COGHD.
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Affiliation(s)
- Mirjana Doknic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Correspondence should be addressed to M Doknic:
| | - Marko Stojanovic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Soldatovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Institute of Medical Statistics and Informatics, Belgrade, Serbia
| | - Tatjana Milenkovic
- Mother and Child Health Care Institute of Serbia ‘Dr Vukan Cupic’, Belgrade, Serbia
| | - Vera Zdravkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- University Children’s Clinic, Belgrade, Serbia
| | - Maja Jesic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- University Children’s Clinic, Belgrade, Serbia
| | - Sladjana Todorovic
- Mother and Child Health Care Institute of Serbia ‘Dr Vukan Cupic’, Belgrade, Serbia
| | - Katarina Mitrovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Mother and Child Health Care Institute of Serbia ‘Dr Vukan Cupic’, Belgrade, Serbia
| | - Rade Vukovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Mother and Child Health Care Institute of Serbia ‘Dr Vukan Cupic’, Belgrade, Serbia
| | - Dragana Miljic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragan Savic
- Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Mihajlo Milicevic
- Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Vojislav Bogosavljevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Sandra Pekic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Emilija Manojlovic-Gacic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Institute of Pathology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandar Djukic
- Department of Pathophysiology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Danica Grujicic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Milan Petakov
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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5
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Aljabab S, Rana S, Maes S, O'Ryan-Blair A, Castro J, Zheng J, Halasz LM, Taddei PJ. The Advantage of Proton Therapy in Hypothalamic-Pituitary Axis and Hippocampus Avoidance for Children with Medulloblastoma. Int J Part Ther 2021; 8:43-54. [PMID: 35127975 PMCID: PMC8768900 DOI: 10.14338/ijpt-21-00001.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Craniospinal irradiation (CSI) improves clinical outcomes at the cost of long-term neuroendocrine and cognitive sequelae. The purpose of this pilot study was to determine whether hypothalamic-pituitary axis (HPA) and hippocampus avoidance (HPA-HA) with intensity-modulated proton therapy (IMPT) can potentially reduce this morbidity compared with standard x-ray CSI. Materials and Methods We retrospectively evaluated 10 patients with medulloblastoma (mean, 7 years; range, 4-14 years). Target volumes and organs at risk were delineated as per our local protocol and the ACNS0331 atlas. An experienced neuroradiologist verified the HPA and hippocampus contours. The primary objective was CSI and boost clinical target volume (CTV) covering 95% of the volume (D95) > 99% coverage with robustness. Described proton therapy doses in grays are prescribed using a biological effectiveness relative to photon therapy of 1.1. The combined prescribed dose in the boost target was 54 Gy. Secondary objectives included the HPA and hippocampus composite average dose (Dmean ≤ 18 Gy). For each patient, volumetric modulated arc radiotherapy (VMAT) and tomotherapy (TOMO) plans existed previously, and a new plan was generated with 3 cranial and 1 or 2 spinal beams for pencil-beam scanning delivery. Statistical comparison was performed with 1-way analysis of variance. Results Compared with standard CSI, HPA-HA CSI had statistically significant decreases in the composite doses received by the HPA (32.2 versus 17.9 Gy; P < .001) and hippocampi (39.8 versus 22.8 Gy; P < .001). The composite HPA Dmean was lower in IMPT plans (17.9 Gy) compared with that of VMAT (21.8 Gy) and TOMO (21.2 Gy) plans (P = .05). Hippocampi composite Dmean was also lower in IMPT plans (21 Gy) compared with that of VMAT (27.5 Gy) and TOMO (27.2 Gy) plans (P = .02). The IMPT CTV D95 coverage was lower in IMPT plans (52.8 Gy) compared with that of VMAT (54.6 Gy) and TOMO (54.6 Gy) plans (P < .001) The spared mean volume was only 1.35% (19.8 cm3) of the whole-brain CTV volume (1476 cm3). Conclusion We found that IMPT has the strong potential to reduce the dose to the HPA and hippocampus, compared with standard x-ray CSI while maintaining target coverage. A prospective clinical trial is required to establish the safety, efficacy, and toxicity of this novel CSI approach.
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Affiliation(s)
- Saif Aljabab
- Radiation Oncology Department, King Saud University, Riyadh, Saudi Arabia
| | - Shushan Rana
- Radiation Oncology Department, University of Washington School of Medicine, Seattle, WA, USA
| | - Shadonna Maes
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | | | - Jackie Castro
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Jack Zheng
- Radiation Medicine Program, the Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Lia M. Halasz
- Radiation Oncology Department, University of Washington School of Medicine, Seattle, WA, USA
| | - Phillip J. Taddei
- Radiation Oncology Department, University of Washington School of Medicine, Seattle, WA, USA
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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6
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Zubarovskaya N, Bauer D, Ronceray L, Poetschger U, Kurzmann P, Lender C, Kuzmina Z, Lawitschka A. To Lighten the Burden of Cure: Thyroid Disease in Long-Term Survivors After TBI Conditioning for Paediatric ALL. Front Pediatr 2021; 9:798974. [PMID: 35127596 PMCID: PMC8809136 DOI: 10.3389/fped.2021.798974] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/20/2021] [Indexed: 01/29/2023] Open
Abstract
Thyroid disorders are well-studied after allogeneic haematopoietic stem cell transplantation (HSCT) following total body irradiation (TBI)-based conditioning, occurring in 15-30% of paediatric survivors. The toxic effect of TBI is known but data on the role of immunological dysregulation (ID) and chronic graft-versus-host-disease (cGvHD) are scarce. We studied functional and structural thyroid disorders in 97 paediatric ALL patients after TBI-based HSCT, assessing their correlation with patient/transplant characteristics including cGvHD, prolonged immunosuppression and ID. The 10- and 15-year cumulative incidence (CI) of functional disorders was 50 and 60%. Univariate analysis revealed TBI in 6 vs. 8 fractions (p = 0.01), an interval between ALL diagnosis and HSCT <1 year (p = 0.038), and the application of ATG (p = 0.044) as risk factors. The 10- and 15-year CI of structural disorders was 60 and 80%. No correlation between patient/transplant characteristics and structural disorders was observed. cGvHD, prolonged immunosuppression and additional radiotherapy were not associated with any thyroid disease. We observed a significant correlation between ID and the development of thyroid dysfunction in patients with structural changes (10-year CI: 77% for patients with ID vs. 56% without ID, p = 0.02). The impact of our results on thyroid follow-up evaluations and the significance of hormonal replacement therapy are discussed.
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Affiliation(s)
- Natalia Zubarovskaya
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Dorothea Bauer
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Leila Ronceray
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | | | | | - Carina Lender
- Department of Pediatrics, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Zoya Kuzmina
- Pulmonology Department, Ottakring Hospital, Vienna, Austria
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
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Han Y, Chen M, Wang H. Production of a SCID mouse model of medulloblastoma to explore the therapeutic value of targeting tumor driver genes. Exp Ther Med 2020; 21:108. [PMID: 33335571 PMCID: PMC7739861 DOI: 10.3892/etm.2020.9540] [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: 06/26/2019] [Accepted: 10/20/2020] [Indexed: 11/06/2022] Open
Abstract
Tumor driver genes are genes where structural or sequence mutations confer a selective advantage for cancer cells. The individualized targeting of tumor driver genes has become a topic of interest for tumor treatment. The prognosis for medulloblastoma (MB), a common type of malignant intracranial tumor found in children, is poor. The tumor driver genes and the corresponding targeted drugs remain to be studied. The present study analyzed tumor driver genes from tumor tissue and peripheral blood from one patient with nodular desmoplastic MB with Sonic Hedgehog activation and screened targeted drugs for the tumor driver genes. Additionally, MB tissue was successfully implanted into the SCID mouse which were then used for subsequent drug screening. The present study explored novel treatments for MB from the perspective of tumor driver genes, and may provide new ideas for choosing individualized targeted therapies for patients with MB.
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Affiliation(s)
- Yong Han
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Min Chen
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Hangzhou Wang
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
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8
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Xu Y, Sun Y, Zhou K, Xie C, Li T, Wang Y, Zhang Y, Rodriguez J, Zhang X, Shao R, Wang X, Zhu C. Cranial irradiation alters neuroinflammation and neural proliferation in the pituitary gland and induces late-onset hormone deficiency. J Cell Mol Med 2020; 24:14571-14582. [PMID: 33174363 PMCID: PMC7754041 DOI: 10.1111/jcmm.16086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 12/20/2022] Open
Abstract
Cranial radiotherapy induces endocrine disorders and reproductive abnormalities, particularly in long-term female cancer survivors, and this might in part be caused by injury to the pituitary gland, but the underlying mechanisms are unknown. The aim of this study was to investigate the influence of cranial irradiation on the pituitary gland and related endocrine function. Female Wistar rat pups on postnatal day 11 were subjected to a single dose of 6 Gy whole-head irradiation, and hormone levels and organ structure in the reproductive system were examined at 20 weeks after irradiation. We found that brain irradiation reduced cell proliferation and induced persistent inflammation in the pituitary gland. The whole transcriptome analysis of the pituitary gland revealed that apoptosis and inflammation-related pathways were up-regulated after irradiation. In addition, irradiation led to significantly decreased levels of the pituitary hormones, growth hormone, adrenocorticotropic hormone, thyroid-stimulating hormone and the reproductive hormones testosterone and progesterone. To conclude, brain radiation induces reduction of pituitary and reproduction-related hormone secretion, this may due to reduced cell proliferation and increased pituitary inflammation after irradiation. Our results thus provide additional insight into the molecular mechanisms underlying complications after head irradiation and contribute to the discovery of preventive and therapeutic strategies related to brain injury following irradiation.
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Affiliation(s)
- Yiran Xu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Yanyan Sun
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Henan, China
| | - Kai Zhou
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, China
| | - Cuicui Xie
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Tao Li
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yafeng Wang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yaodong Zhang
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, China
| | - Juan Rodriguez
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Xiaoan Zhang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruijin Shao
- Department of Physiology/Endocrinology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Xiaoyang Wang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Perinatal Center, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
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Zhu J, Feldman HA, Chordas C, Wassner AJ, Manley PE, Cohen LE. Undernutrition and Pubertal Timing in Female Survivors of Medulloblastoma and Other Embryonal Tumors. J Clin Endocrinol Metab 2020; 105:5876005. [PMID: 32706870 PMCID: PMC7442276 DOI: 10.1210/clinem/dgaa475] [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: 03/12/2020] [Accepted: 07/17/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Children with brain tumors may have pubertal onset at an inappropriately young chronologic age. Hypothalamic-pituitary irradiation ≥18Gy has been found to be a risk factor; age at irradiation is associated with pubertal timing. However, the underlying mechanisms are unknown. OBJECTIVE To determine the impact of body mass index (BMI) and catch-up growth on pubertal timing in females treated for medulloblastoma and other embryonal tumors. DESIGN, SETTING, AND PATIENTS Retrospective cohort analysis of 90 female patients treated for medulloblastoma and other embryonal tumors at Dana-Farber Cancer Institute/Boston Children's Hospital from 1996 to 2016. Eighteen individuals met inclusion criteria, with a mean ± SD follow-up period of 11.9 ± 3.4 years. MAIN OUTCOME MEASURES Multiple linear regression models for age at pubertal onset and bone age discrepancy from chronologic age at pubertal onset assessed the joint influences of age at irradiation, hypothalamic irradiation dose, undernutrition duration, BMI standard deviation score (SDS) at pubertal onset, and catch-up BMI SDS. RESULTS The mean ± SD age of pubertal onset was 9.2 ± 1.3 years and hypothalamic radiation dose was 31.9 ± 9.9 Gy. There was a direct relationship between age at irradiation and age at pubertal onset (β = 0.323 ± 0.144 [standard error] year per year; P = 0.04) that was significantly attenuated after adjusting for BMI SDS at pubertal onset (P = 0.5) and catch-up BMI SDS (P = 0.08), suggesting that BMI is a mediator. CONCLUSIONS Both absolute and catch-up BMI SDS at pubertal onset are significant mediators of pubertal timing and bone age discrepancy in pediatric medulloblastoma and other embryonal tumors, and thus, are targetable risk factors to optimize pubertal timing.
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Affiliation(s)
- Jia Zhu
- Division of Endocrinology, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Correspondence and Reprint Requests: Jia Zhu, MD Boston Children’s Hospital, Division of Endocrinology 300 Longwood Ave. Boston, MA 02115, USA.
| | - Henry A Feldman
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Christine Chordas
- Dana Farber / Boston Children’s Cancer and Blood Disorder Center, Boston, Massachusetts
| | - Ari J Wassner
- Division of Endocrinology, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Dana Farber / Boston Children’s Cancer and Blood Disorder Center, Boston, Massachusetts
| | - Peter E Manley
- Dana Farber / Boston Children’s Cancer and Blood Disorder Center, Boston, Massachusetts
| | - Laurie E Cohen
- Division of Endocrinology, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Dana Farber / Boston Children’s Cancer and Blood Disorder Center, Boston, Massachusetts
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10
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Mizumoto M, Oshiro Y, Pan H, Wang F, Kaste SC, Gajjar A, Chemaitilly W, Merchant TE. Height after photon craniospinal irradiation in pediatric patients treated for central nervous system embryonal tumors. Pediatr Blood Cancer 2020; 67:e28617. [PMID: 32715632 DOI: 10.1002/pbc.28617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND We modeled height after craniospinal irradiation (CSI) in pediatric patients with central nervous system (CNS) embryonal tumors to identify factors that impair stature. PROCEDURE During 1996-2012, 212 pediatric patients (131 male) with CNS embryonal tumors received postoperative CSI: 23.4 Gy (n = 147) or ≥36 Gy (n = 65), similar postirradiation chemotherapy, and were followed for at least 5 years without tumor progression or other event. The group was further characterized by age at CSI and hormone-replacement therapy received. Models were developed to identify factors associated with growth impairment and estimate final height. RESULTS With median follow up of 10.2 years (range 5.0-20.4 years), the mean final height z-scores at 18 years of age, compared to United States standards, were -1.3 for female and -1.5 for male survivors. Younger age at the time of CSI, higher CSI dose, and female sex were associated with height impairment. Factors associated with higher growth rates before 15 years of age were older age at CSI, male sex, CSI dose < 36 Gy, replacement therapy for growth hormone (GH) and central adrenal insufficiency, and white race. Growth after age 15 in male survivors was associated with treatment of gonadotropin deficiency. Linear mixed-effects models were developed using clinical factors to estimate final height, demonstrate the unique growth curve of this cohort, and interactions between clinical variable and radiation dose. CONCLUSIONS CSI significantly impaired height at current doses used to treat standard- or high-risk CNS embryonal tumors. Measures to reduce the impact of CSI on height should be sought, with our models serving as benchmarks.
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Affiliation(s)
- Masashi Mizumoto
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Radiation Oncology, University of Tsukuba, Ibaraki, Japan
| | - Yoshiko Oshiro
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Radiation Oncology, University of Tsukuba, Ibaraki, Japan
| | - Haitao Pan
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Fang Wang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Sue C Kaste
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Wassim Chemaitilly
- Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
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11
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Luo LY, Kramer K, Cheung NKV, Kushner BH, Modak S, Basu EM, Roberts SS, Wolden SL. Reduced-dose craniospinal irradiation for central nervous system relapsed neuroblastoma. Pediatr Blood Cancer 2020; 67:e28364. [PMID: 32608559 PMCID: PMC8279229 DOI: 10.1002/pbc.28364] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/12/2020] [Accepted: 04/07/2020] [Indexed: 11/07/2022]
Abstract
PURPOSE In patients with high-risk neuroblastoma, there is an increased recognition of relapse in the central nervous system (CNS). Craniospinal irradiation (CSI) has been an effective treatment but carries significant long-term complications. It is unclear whether reducing the CSI dose from 21 to 18 Gy can achieve similar CNS tumor control. PATIENTS AND METHODS A retrospective review of pediatric patients with CNS-relapsed neuroblastoma treated with CSI and boost to parenchymal lesions between 2003 and 2019 was performed. The goal was to assess CNS control comparing 18 Gy and 21 Gy regimens. RESULTS Ninety-four patients with CNS-relapsed neuroblastoma were treated with CSI followed by intraventricular compartmental radioimmunotherapy. Median age at the time of CNS disease was 4 years (range 1-13 years). Forty-one patients (44%) received 21 Gy CSI prior to an institutional decision to lower the dose; 53 patients (56%) received 18 Gy CSI. Seventy-nine patients (84%) received additional boosts. With a median follow up of 4.1 years for surviving patients, 2-year CNS relapse-free survival was 74% for 18 Gy group versus 77% for 21 Gy group, and 5-year CNS relapse-free survival was 66% for 18 Gy versus 72% for 21 Gy group, respectively (P = .40). Five-year overall survival rate was 43% in 18 Gy group versus 47% in 21 Gy group (P = .72). CONCLUSION For patients with CNS-relapsed neuroblastoma, CNS disease control is comparable between 18 Gy and 21 Gy CSI dose regimens, in conjunction with radioimmunotherapy and CNS penetrating chemotherapy. More than 65% of the patients remain CNS disease free after 5 years. The findings support 18 Gy as the new standard CSI dose for CNS-relapsed neuroblastoma.
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Affiliation(s)
- Leo Y. Luo
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Kim Kramer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Nai-Kong V. Cheung
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Brian H. Kushner
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Shakeel Modak
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Ellen M. Basu
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Stephen S. Roberts
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York 10065
| | - Suzanne L. Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York 10065,Corresponding author address: Suzanne L. Wolden, M.D., Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, Phone: 212-639-5148, Fax: 212-639-2417,
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12
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Functional cranio-spinal irradiation: A hippocampal and hypothalamic-pituitary axis sparing radiation technique using two IMRT modalities. Med Dosim 2019; 45:190-196. [PMID: 31843470 DOI: 10.1016/j.meddos.2019.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 01/17/2023]
Abstract
Cranio-spinal irradiation (CSI) treatment of embryonal tumors is associated with long-term endocrine and neuro-cognitive sequelae. As an example, the radiation regiment for standard risk medulloblastoma is 23.4 Grays (Gy) CSI followed by a boost of 30.6Gy to the tumor bed. We hypothesize that a novel CSI technique, which we named "Functional" CSI (F-CSI) can reduce the dose to the hypothalamic-pituitary axis (HPA) and hippocampi compared to standard CSI (S-CSI) without sacrificing coverage. In this study, we compared the efficacy of Volumetric Modulated Arc Therapy (VMAT) and Helical Tomotherapy (HT) in delivering this novel CSI technique. Plans were constructed from 10 patients with embryonal tumors previously treated at our institution. Target volumes and organs at risk were delineated as per our local protocol and the ACNS0331 Atlas. The HPA and hippocampi contours were verified by an experienced neuro-radiologist. Primary objective was to achieve a D95% to the prescribed dose of 23.4Gy for CSI and 30.6Gy for the boost. Dmean ≤18Gy was assigned to the HPA and hippocampi. A two-sided t-test was used for comparison. F-CSI in both modalities were able to achieve the D95% target coverage. Hot spots (D2%) were lower with HT for both the CSI component (p = 0.03) and boost component (p < 0.01). VMAT was able to achieve better conformality (p < 0.01). Compared to S-CSI, both F-CSI modalities were able to achieve a significant decrease in dose to the HPA and Hippocampi. The average S-CSI HPA and Hippocampi Dmean were 23.9Gy and 23.8Gy. In contrast, respective F-CSI Dmean were 13.9Gy and 17.2Gy in VMAT and 15Gy and 15.9Gy in HT. The average composite (F-CSI plus boost) Dmean to the HPA and hippocampi often exceeded 18Gy. Compared to S-CSI, F-CSI with VMAT and HT were capable of achieving acceptable coverage while sparing the HPA and hippocampi. However, the addition of the boost component often exceeded the mean dose of 18Gy. This may be overcome with more conformal modalities for the boost phase such as stereotactic radiotherapy or proton therapy.
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13
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Gebauer J, Higham C, Langer T, Denzer C, Brabant G. Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review. Endocr Rev 2019; 40:711-767. [PMID: 30476004 DOI: 10.1210/er.2018-00092] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.
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Affiliation(s)
- Judith Gebauer
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Thorsten Langer
- Division of Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Christian Denzer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Endocrinology and Diabetes, Ulm University Medical Center, Ulm, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.,Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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14
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Jalali R, Maitre M, Gupta T, Goda JS, Shah N, Krishna U, Swamidas J, Kannan S, Dutta D, Sarin R. Dose-Constraint Model to Predict Neuroendocrine Dysfunction in Young Patients With Brain Tumors: Data From a Prospective Study. Pract Radiat Oncol 2019; 9:e362-e371. [PMID: 30826479 DOI: 10.1016/j.prro.2019.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 01/26/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE We report on a possible dose-constraint model to predict long-term neuroendocrine dysfunction after cranial irradiation in children and young adults with benign and low-grade brain tumors treated with stereotactic conformal radiation therapy (RT) in a prospective clinical trial. METHODS AND MATERIALS Patients treated with stereotactic conformal RT (54 Gy in 30 fractions) were included for analysis if their co-registered planning computed tomography and magnetic resonance imaging scans were available, along with baseline and post-RT endocrine assessment for at least 2 years. The hypothalamus-pituitary axis (HPA) was contoured on the fused computed tomography-magnetic resonance imaging data set. Worsening of endocrine function was defined biochemically as a new onset endocrine deficit or worsening of preexisting endocrine deficit. Dosimetric indices of HPA, extracted using cumulative dose-volume histograms, were correlated with worsening endocrine function using logistic regression analysis. RESULTS A total of 51 patients (median age: 13 years; range, 5-25 years) were included. Worsening post-RT endocrine levels were seen in 27 of 51 patients (47%). Growth hormone was the most commonly affected (70%), followed by cortisol (44%), gonadotropin (40%), and thyroxine (7%). The mean of the maximum and minimum doses to HPA was 42.1 Gy and 35.7 Gy, respectively. For patients with worsening endocrine levels, the mean maximum dose to HPA was 46.6 Gy compared with 36.5 Gy in patients with stable functions. The mean minimum dose to HPA was also higher (40.5 Gy vs 29.6 Gy) in patients with endocrine dysfunction. Logistic regression analysis identified the volume of HPA receiving 50% of the prescribed dose as the only statistically significant parameter predicting endocrine dysfunction. A dose of ≥27 Gy to any volume of HPA was associated with a 4-fold increase in risk of endocrine dysfunction (odds ratio: 4.05; 95% confidence interval, 1.07-15.62; P = .038). CONCLUSIONS Our prospective longitudinal study demonstrates the feasibility of HPA avoidance using modern, high-precision, conformal RT techniques and correlates HPA dosimetry with neuroendocrine dysfunction. We suggest restricting HPA doses to <27 Gy to minimize the risk of post-RT neuroendocrine deficits.
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Affiliation(s)
- Rakesh Jalali
- Neuro Oncology Group, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India.
| | - Madan Maitre
- Neuro Oncology Group, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Tejpal Gupta
- Neuro Oncology Group, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Jayant S Goda
- Neuro Oncology Group, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Nalini Shah
- Department of Endocrinology, King Edward Memorial Hospital, Mumbai, India
| | - Uday Krishna
- Neuro Oncology Group, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Jamema Swamidas
- Department of Medical Physics, Tata Memorial Centre, Mumbai, India
| | - Sadhna Kannan
- Department of Biostatistics, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Mumbai, India
| | - Debnarayan Dutta
- Neuro Oncology Group, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Rajiv Sarin
- Neuro Oncology Group, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
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15
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Vatner RE, Niemierko A, Misra M, Weyman EA, Goebel CP, Ebb DH, Jones RM, Huang MS, Mahajan A, Grosshans DR, Paulino AC, Stanley T, MacDonald SM, Tarbell NJ, Yock TI. Endocrine Deficiency As a Function of Radiation Dose to the Hypothalamus and Pituitary in Pediatric and Young Adult Patients With Brain Tumors. J Clin Oncol 2018; 36:2854-2862. [PMID: 30118397 DOI: 10.1200/jco.2018.78.1492] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There are sparse data defining the dose response of radiation therapy (RT) to the hypothalamus and pituitary in pediatric and young adult patients with brain tumors. We examined the correlation between RT dose to these structures and development of endocrine dysfunction in this population. MATERIALS AND METHODS Dosimetric and clinical data were collected from children and young adults (< 26 years of age) with brain tumors treated with proton RT on three prospective studies (2003 to 2016). Deficiencies of growth hormone (GH), thyroid hormone, adrenocorticotropic hormone, and gonadotropins were determined clinically and serologically. Incidence of deficiency was estimated using the Kaplan-Meier method. Multivariate models were constructed accounting for radiation dose and age. RESULTS Of 222 patients in the study, 189 were evaluable by actuarial analysis, with a median follow-up of 4.4 years (range, 0.1 to 13.3 years), with 31 patients (14%) excluded from actuarial analysis for having baseline hormone deficiency and two patients (0.9%) because of lack of follow-up. One hundred thirty patients (68.8%) with medulloblastoma were treated with craniospinal irradiation (CSI) and boost; most of the remaining patients (n = 56) received involved field RT, most commonly for ependymoma (13.8%; n = 26) and low-grade glioma (7.4%; n = 14). The 4-year actuarial rate of any hormone deficiency, growth hormone, thyroid hormone, adrenocorticotropic hormone, and gonadotropin deficiencies were 48.8%, 37.4%, 20.5%, 6.9%, and 4.1%, respectively. Age at start of RT, time interval since treatment, and median dose to the combined hypothalamus and pituitary were correlated with increased incidence of deficiency. CONCLUSION Median hypothalamic and pituitary radiation dose, younger age, and longer follow-up time were associated with increased rates of endocrinopathy in children and young adults treated with radiotherapy for brain tumors.
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Affiliation(s)
- Ralph E Vatner
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Andrzej Niemierko
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Madhusmita Misra
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Elizabeth A Weyman
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Claire P Goebel
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - David H Ebb
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Robin M Jones
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Mary S Huang
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Anita Mahajan
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - David R Grosshans
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Arnold C Paulino
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Takara Stanley
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Shannon M MacDonald
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Nancy J Tarbell
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Torunn I Yock
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
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Bielamowicz K, Okcu MF, Sonabend R, Paulino AC, Hilsenbeck SG, Dreyer Z, Suzawa H, Bryant R, Adesina A, Dauser R, Mahajan A, Chintagumpala M. Hypothyroidism after craniospinal irradiation with proton or photon therapy in patients with medulloblastoma. Pediatr Hematol Oncol 2018; 35:257-267. [PMID: 30537887 DOI: 10.1080/08880018.2018.1471111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Craniospinal irradiation (CSI) often results in endocrine deficiencies in children with medulloblastoma due to irradiation of the hypothalamic-pituitary axis (HPA) or the thyroid gland. CSI with Proton radiation therapy (PRT) has the potential to decrease the risk of hypothyroidism by reduction in radiation dose to these organs. This study compares the risk for hypothyroidism in patients with medulloblastoma treated with Photon radiation therapy (XRT) or PRT. METHODS The records of patients with medulloblastoma diagnosed at a single institution between 1997 and 2014 who received CSI were, retrospectively, reviewed. Ninety-five patients (54 XRT and 41 PRT) who had baseline and yearly follow-up thyroid studies were included. We used interval censored Cox regression to calculate hazard ratios of developing any, primary, and central hypothyroidism. RESULTS With a median time to last thyroid studies post radiation of 3.8 years in PRT and 9.6 years in XRT, 33/95 (34.7%) patients developed hypothyroidism (median time to hypothyroidism: 2.6 years). Hypothyroidism developed in 25/54 (46.3%) who received XRT vs. 8/41 (19%) in the PRT group (HR =1.85, p = .14). Primary hypothyroidism developed in 15/95 (15.8%) patients: 12/54 (22.2%) after XRT and 3/41 (7.3%) after PRT (HR =2.1, p = .27). Central hypothyroidism developed in 17/95 (18.0%) patients: 13/54 (24.0%) after XRT and 4/41 (9.8%) after PRT (HR =2.16, p = .18). CONCLUSIONS The use of PRT in patients with medulloblastoma was associated with numerically lower but not significantly lower risk of hypothyroidism. Further studies including larger numbers and longer follow up must be performed to assess whether lower radiation doses achieved with PRT show statistically significant differences.
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Affiliation(s)
- Kevin Bielamowicz
- a Arkansas Children's Hospital, The University of Arkansas for Medical Sciences , Little Rock , Arkansas , USA
| | - M Fatih Okcu
- b Texas Children's Cancer and Hematology Centers , Houston , Texas , USA.,c Baylor College of Medicine, Texas Children's Hospital , Houston , Texas , USA
| | - Rona Sonabend
- c Baylor College of Medicine, Texas Children's Hospital , Houston , Texas , USA
| | - Arnold C Paulino
- d The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| | - Susan G Hilsenbeck
- e Baylor College of Medicine, Dan L Duncan Comprehensive Cancer Center , Houston , Texas , USA
| | - Zoann Dreyer
- b Texas Children's Cancer and Hematology Centers , Houston , Texas , USA.,c Baylor College of Medicine, Texas Children's Hospital , Houston , Texas , USA
| | - Hilary Suzawa
- b Texas Children's Cancer and Hematology Centers , Houston , Texas , USA.,c Baylor College of Medicine, Texas Children's Hospital , Houston , Texas , USA
| | - Rosalind Bryant
- b Texas Children's Cancer and Hematology Centers , Houston , Texas , USA.,c Baylor College of Medicine, Texas Children's Hospital , Houston , Texas , USA
| | - Adekunle Adesina
- c Baylor College of Medicine, Texas Children's Hospital , Houston , Texas , USA
| | - Robert Dauser
- c Baylor College of Medicine, Texas Children's Hospital , Houston , Texas , USA
| | | | - Murali Chintagumpala
- b Texas Children's Cancer and Hematology Centers , Houston , Texas , USA.,c Baylor College of Medicine, Texas Children's Hospital , Houston , Texas , USA
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17
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Taddei PJ, Khater N, Youssef B, Howell RM, Jalbout W, Zhang R, Geara FB, Giebeler A, Mahajan A, Mirkovic D, Newhauser WD. Low- and middle-income countries can reduce risks of subsequent neoplasms by referring pediatric craniospinal cases to centralized proton treatment centers. Biomed Phys Eng Express 2018; 4:025029. [PMID: 30038799 PMCID: PMC6054490 DOI: 10.1088/2057-1976/aaa1ce] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Few children with cancer in low- and middle-income countries (LMICs) have access to proton therapy. Evidence exists to support replacing photon therapy with proton therapy to reduce the incidence of secondary malignant neoplasms (SMNs) in childhood cancer survivors. The purpose of this study was to estimate the potential reduction in SMN incidence and in SMN mortality for pediatric medulloblastoma patients in LMICs if proton therapy were made available to them. For nine children of ages 2 to 14 years, we calculated the equivalent dose in organs or tissues at risk for radiogenic SMNs from therapeutic and stray radiation for photon craniospinal irradiation (CSI) in a LMIC and proton CSI in a high-income country. We projected the lifetime risks of SMN incidence and SMN mortality for every SMN site with a widely-used model from the literature. We found that the average total lifetime attributable risks of incidence and mortality were very high for both photon CSI (168% and 41%, respectively) and proton CSI (88% and 26%, respectively). SMNs having the highest risk of mortality were lung cancer (16%), non-site-specific solid tumors (16%), colon cancer (5.9%), leukemia (5.4%), and for girls breast cancer (5.0%) after photon CSI and non-site-specific solid tumors (12%), lung cancer (11%), and leukemia (4.8%) after proton CSI. The risks were higher for younger children than for older children and higher for girls than for boys. The ratios of proton CSI to photon CSI of total risks of SMN incidence and mortality were 0.56 (95% CI, 0.37 to 0.75) and 0.64 (95% CI, 0.45 to 0.82), respectively, averaged over this sample group. In conclusion, proton therapy has the potential to lessen markedly subsequent SMNs and SMN fatalities in survivors of childhood medulloblastoma in LMICs, for example, through regional centralized care. Additional methods should be explored urgently to reduce therapeutic-field doses in organs and tissues at risk for SMN, especially in the lungs, colon, and breast tissues.
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Affiliation(s)
- Phillip J Taddei
- Department of Radiation Oncology, Faculty of Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Nabil Khater
- Department of Radiation Oncology, Hôtel-Dieu de France Hospital, University of St. Joseph, P.O. Box 166830, Alfred Naccache Blvd, Beirut, Lebanon
| | - Bassem Youssef
- Department of Radiation Oncology, Faculty of Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon
| | - Rebecca M Howell
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Wassim Jalbout
- Department of Radiation Oncology, Faculty of Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon
| | - Rui Zhang
- Medical Physics Program, Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA, 70803, USA
- Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, LA, 70809, USA
| | - Fady B. Geara
- Department of Radiation Oncology, Faculty of Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon
| | - Annelise Giebeler
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Anita Mahajan
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Dragan Mirkovic
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Wayne D Newhauser
- Medical Physics Program, Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA, 70803, USA
- Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, LA, 70809, USA
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18
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Giantsoudi D, Seco J, Eaton BR, Simeone FJ, Kooy H, Yock TI, Tarbell NJ, DeLaney TF, Adams J, Paganetti H, MacDonald SM. Evaluating Intensity Modulated Proton Therapy Relative to Passive Scattering Proton Therapy for Increased Vertebral Column Sparing in Craniospinal Irradiation in Growing Pediatric Patients. Int J Radiat Oncol Biol Phys 2017; 98:37-46. [PMID: 28587051 PMCID: PMC5466873 DOI: 10.1016/j.ijrobp.2017.01.226] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 12/27/2016] [Accepted: 01/25/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE At present, proton craniospinal irradiation (CSI) for growing children is delivered to the whole vertebral body (WVB) to avoid asymmetric growth. We aimed to demonstrate the feasibility and potential clinical benefit of delivering vertebral body sparing (VBS) versus WVB CSI with passively scattered (PS) and intensity modulated proton therapy (IMPT) in growing children treated for medulloblastoma. METHODS AND MATERIALS Five plans were generated for medulloblastoma patients, who had been previously treated with CSI PS proton radiation therapy: (1) single posteroanterior (PA) PS field covering the WVB (PS-PA-WVB); (2) single PA PS field that included only the thecal sac in the target volume (PS-PA-VBS); (3) single PA IMPT field covering the WVB (IMPT-PA-WVB); (4) single PA IMPT field, target volume including thecal sac only (IMPT-PA-VBS); and (5) 2 posterior-oblique (-35°, +35°) IMPT fields, with the target volume including the thecal sac only (IMPT2F-VBS). For all cases, 23.4 Gy (relative biologic effectiveness [RBE]) was prescribed to 95% of the spinal canal. The dose, linear energy transfer, and variable-RBE-weighted dose distributions were calculated for all plans using the tool for particle simulation, version 2, Monte Carlo system. RESULTS IMPT VBS techniques efficiently spared the anterior vertebral bodies (AVBs), even when accounting for potential higher variable RBE predicted by linear energy transfer distributions. Assuming an RBE of 1.1, the V10 Gy(RBE) decreased from 100% for the WVB techniques to 59.5% to 76.8% for the cervical, 29.9% to 34.6% for the thoracic, and 20.6% to 25.1% for the lumbar AVBs, and the V20 Gy(RBE) decreased from 99.0% to 17.8% to 20.0% for the cervical, 7.2% to 7.6% for the thoracic, and 4.0% to 4.6% for the lumbar AVBs when IMPT VBS techniques were applied. The corresponding percentages for the PS VBS technique were higher. CONCLUSIONS Advanced proton techniques can sufficiently reduce the dose to the vertebral body and allow for vertebral column growth for children with central nervous system tumors requiring CSI. This was true even when considering variable RBE values. A clinical trial is planned for VBS to the thoracic and lumbosacral spine in growing children.
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Affiliation(s)
- Drosoula Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Joao Seco
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bree R Eaton
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - F Joseph Simeone
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hanne Kooy
- 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
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judith Adams
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- 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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19
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Eaton BR, Esiashvili N, Kim S, Patterson B, Weyman EA, Thornton LT, Mazewski C, MacDonald TJ, Ebb D, MacDonald SM, Tarbell NJ, Yock TI. Endocrine outcomes with proton and photon radiotherapy for standard risk medulloblastoma. Neuro Oncol 2015; 18:881-7. [PMID: 26688075 DOI: 10.1093/neuonc/nov302] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 11/03/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Endocrine dysfunction is a common sequela of craniospinal irradiation (CSI). Dosimetric data suggest that proton radiotherapy (PRT) may reduce radiation-associated endocrine dysfunction but clinical data are limited. METHODS Seventy-seven children were treated with chemotherapy and proton (n = 40) or photon (n = 37) radiation between 2000 and 2009 with ≥3 years of endocrine screening. The incidence of multiple endocrinopathies among the proton and photon cohorts is compared. Multivariable analysis and propensity score adjusted analysis are performed to estimate the effect of radiotherapy type while adjusting for other variables. RESULTS The median age at diagnosis was 6.2 and 8.3 years for the proton and photon cohorts, respectively (P = .010). Cohorts were similar with respect to gender, histology, CSI dose, and total radiotherapy dose and whether the radiotherapy boost was delivered to the posterior fossa or tumor bed. The median follow-up time was 5.8 years for proton patients and 7.0 years for photon patients (P = .010). PRT was associated with a reduced risk of hypothyroidism (23% vs 69%, P < .001), sex hormone deficiency (3% vs 19%, P = .025), requirement for any endocrine replacement therapy (55% vs 78%, P = .030), and a greater height standard deviation score (mean (± SD) -1.19 (± 1.22) vs -2 (± 1.35), P = .020) on both univariate and multivariate and propensity score adjusted analysis. There was no significant difference in the incidence of growth hormone deficiency (53% vs 57%), adrenal insufficiency (5% vs 8%), or precocious puberty (18% vs 16%). CONCLUSIONS Proton radiotherapy may reduce the risk of some, but not all, radiation-associated late endocrine abnormalities.
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Affiliation(s)
- Bree R Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Natia Esiashvili
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Sungjin Kim
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Briana Patterson
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Elizabeth A Weyman
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Lauren T Thornton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Claire Mazewski
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Tobey J MacDonald
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - David Ebb
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Shannon M MacDonald
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Nancy J Tarbell
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Torunn I Yock
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
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20
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Abstract
Intracranial tumors are the second most frequent malignancies in children and posterior fossa is a common location for these neoplasias during childhood. Recent advances in surgical techniques, radiotherapy and chemotherapy resulted in dramatic increase in the survival rates of these children, however they are still source of a significant morbidity and mortality. Endocrinological complications and late sequelae of childhood posterior fossa tumours are common among the survivors of these tumours and include growth retardation, hypothyroidism, pubertal disorders, gonadal dysfunction and osteopenia. These complications have significant impact on the quality of life of the survivors of childhood posterior fossa tumours. In this paper, the frequency, etiology, and management of these complications will be reviewed.
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Affiliation(s)
- Abdullah Bereket
- Marmara University Faculty of Medicine, Division of Pediatric Endocrinology, İstanbul, Turkey Phone: +90 216 411 64 18 E-mail:
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21
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Tallen G, Resch A, Calaminus G, Wiener A, Leiss U, Pletschko T, Friedrich C, Langer T, Grabow D, Driever PH, Kortmann RD, Timmermann B, Pietsch T, Warmuth-Metz M, Bison B, Thomale UW, Krauss J, Mynarek M, von Hoff K, Ottensmeier H, Frühwald M, Kramm CM, Temming P, Müller HL, Witt O, Kordes U, Fleischhack G, Gnekow A, Rutkowski S. Strategies to improve the quality of survival for childhood brain tumour survivors. Eur J Paediatr Neurol 2015; 19:619-39. [PMID: 26278499 DOI: 10.1016/j.ejpn.2015.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 07/05/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Tumours of the central nervous system (CNS) are the most frequent solid tumours and the second most frequent type of cancer in children and adolescents. Overall survival has continuously improved in Germany, since an increasing number of patients have been treated according to standardised, multicentre, multimodal treatment recommendations, trials of the German Paediatric Brain Tumour Consortium (HIT-Network) or the International Society of Paediatric Oncology-Europe (SIOP-E) during the last decades. Today, two out of three patients survive. At least 8000 long-term childhood brain tumour survivors (CBTS) are currently living in Germany. They face lifelong disease- and treatment-related late effects (LE) and associated socioeconomic problems more than many other childhood cancer survivors (CCS). METHOD We review the LE and resulting special needs of this particular group of CCS. RESULTS Despite their increasing relevance for future treatment optimisation, neither the diversity of chronic and cumulative LE nor their pertinent risk factors and subsequent impact on quality of survival have yet been comprehensively addressed for CBTS treated according to HIT- or SIOP-E-protocols. Evidence-based information to empower survivors and stakeholders, as well as medical expertise to manage their individual health care, psychosocial and educational/vocational needs must still be generated and established. CONCLUSION The establishment of a long-term research- and care network in Germany shall contribute to a European platform, that aims at optimising CBTSs' transition into adulthood as resilient individuals with high quality of survival including optimal levels of activity, participation and acceptance by society.
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Affiliation(s)
- Gesche Tallen
- Department of Paediatric Oncology/Haematology, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany; Department of Paediatrics, Faculty of Medicine, University of Calgary, 2888 Shaganappi Trail N.W., Calgary, Alberta T3B 6A8, Canada.
| | - Anika Resch
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Gabriele Calaminus
- Department of Paediatric Haematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Andreas Wiener
- Department of Paediatric Haematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Ulrike Leiss
- Medical University Vienna, Department of Paediatric and Adolescent Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Thomas Pletschko
- Medical University Vienna, Department of Paediatric and Adolescent Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Carsten Friedrich
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany; Division of Paediatric Oncology, Haematology and Haemostaseology, Department of Woman's and Children's Health, University Hospital Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany.
| | - Thorsten Langer
- Department of Paediatric Oncology/Haematology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Desiree Grabow
- German Childhood Cancer Registry (GCCR), Institute of Medical Biostatistics, Epidemiology, and Informatics (IMBEI), University Medical Center, University of Mainz, Gebäude 902, Obere Zahlbacher Straße 69, 55131 Mainz, Germany.
| | - Pablo Hernáiz Driever
- Department of Paediatric Oncology/Haematology, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Rolf-Dieter Kortmann
- Department of Radiation Oncology, University of Leipzig, Stephanstr. 9a, 04103 Leipzig, Germany.
| | - Beate Timmermann
- Particle Therapy Clinic at West German Proton Therapy Centre Essen, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Torsten Pietsch
- Institute of Neuropathology, University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany.
| | - Monika Warmuth-Metz
- Dept. of Neuroradiology, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Brigitte Bison
- Dept. of Neuroradiology, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Ulrich-Wilhelm Thomale
- Department of Paediatric Neurosurgery, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jürgen Krauss
- Department of Neurosurgery, Head Clinic, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Martin Mynarek
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Katja von Hoff
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Holger Ottensmeier
- University Children's Hospital Würzburg, Dept. of Paed. Haematology, Oncology, Josef-Schneider-Str. 2, 97080 Würzburg, Germany.
| | - Michael Frühwald
- Department of Paediatric Oncology/Haematology, Klinikum Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
| | - Christof M Kramm
- Division of Paediatric Haematology and Oncology, University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany.
| | - Petra Temming
- Paediatric Haematology/Oncology, Paediatrics III, University of Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Hermann L Müller
- Paediatric Oncology/Haematology, Klinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Str. 10, 26133 Oldenburg, Germany.
| | - Olaf Witt
- German Cancer Research Centre (DKFZ) and Department of Paediatric Oncology/Haematology, University of Heidelberg, Heidelberg, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany.
| | - Uwe Kordes
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Gudrun Fleischhack
- Paediatric Haematology/Oncology, Paediatrics III, University of Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Astrid Gnekow
- Department of Paediatric Oncology/Haematology, Klinikum Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
| | - Stefan Rutkowski
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
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Uday S, Murray RD, Picton S, Chumas P, Raju M, Chandwani M, Alvi S. Endocrine sequelae beyond 10 years in survivors of medulloblastoma. Clin Endocrinol (Oxf) 2015; 83:663-70. [PMID: 25952583 DOI: 10.1111/cen.12815] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/23/2014] [Accepted: 05/04/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Survival following treatment of paediatric medulloblastomas has significantly improved over the past few decades, but as a consequence, late effects, particularly endocrine sequelae, have been recognized. The complete picture of late effects, however, has been limited by short duration of follow-up. AIM To establish the evolution of endocrine sequelae in patients treated for medulloblastoma. METHODS Single-centre analysis of medulloblastoma treatment and endocrine sequelae in patients diagnosed between 1982 and 2002. RESULTS A total of 109 patients were treated for medulloblastoma, with various treatment modalities involving radio- and chemotherapy. Only 45 (41%) patients remained alive, and details of treatment and late effects were available for 35 (25 m). The median age at diagnosis was 8 (range 2-14) years, and the median follow-up was 18 (range 10-28) years. Growth hormone deficiency (GHD) was the most prevalent hormone deficiency (97%), followed by primary hypothyroidism (60%) and adrenocorticotrophic hormone (ACTH) deficiency (45·5%). The median time from end of treatment to loss of growth hormone was 1·7 (range 0·7-15) years, ACTH deficiency 2·9 (range 0·75-7·5) years and hypothyroidism 4·1 (range 0·7-11·4) years. Twenty-three percentage developed hypogonadism (17% primary and 6% secondary), whilst precocious puberty was seen in 20%. Endocrinopathies appeared to be more prevalent in those treated with concomitant chemotherapy and radiotherapy. CONCLUSIONS Prevalence of endocrine sequelae in medulloblastoma survivors is high, and evolution of endocrine dysfunction can occur as late as 15 years from treatment completion; hence, long-term close monitoring of growth, puberty and gonadal function is essential.
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Affiliation(s)
- Suma Uday
- Paediatric Endocrinology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Robert D Murray
- Endocrinology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan Picton
- Paediatric Oncology & Haematology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Chumas
- Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Midhu Raju
- Paediatric Oncology & Haematology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Manju Chandwani
- General Paediatrics, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sabah Alvi
- Paediatric Endocrinology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Vigneron C, Entz-Werlé N, Lutz P, Spiegel A, Jannier S, Helfre S, Alapetite C, Coca A, Kehrli P, Noël G. [Evolution of the management of pediatric and adult medulloblastoma]. Cancer Radiother 2015; 19:347-57; quiz 358-9, 362. [PMID: 26141663 DOI: 10.1016/j.canrad.2015.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 01/05/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
Medulloblastoma are cerebellar tumours belonging to the group of primitive neuroectodermal tumours (PNET) and are the most common malignant brain tumours of childhood. These tumours are rare and heterogeneous, requiring some multicentric prospective studies and multidisciplinary care. The classical therapeutic approaches are based on clinical, radiological and surgical data. They involve surgery, radiation therapy and chemotherapy. Some histological features were added to characterize risk. More recently, molecular knowledge has allowed to devise risk-adapted strategies and helped to define groups with good outcome and reduce long-term sequelae, improve the prognostic of high-risk medulloblastoma and develop new therapeutic tools.
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Affiliation(s)
- C Vigneron
- Département de radiothérapie, centre de lutte contre le cancer Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, BP 42, 67065 Strasbourg cedex, France
| | - N Entz-Werlé
- Service d'oncologie pédiatrique, CHU Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - P Lutz
- Service d'oncologie pédiatrique, CHU Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - A Spiegel
- Service d'oncologie pédiatrique, CHU Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - S Jannier
- Service d'oncologie pédiatrique, CHU Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - S Helfre
- Département de radiothérapie, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - C Alapetite
- Département de radiothérapie, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - A Coca
- Service de neurochirurgie, CHU Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - P Kehrli
- Service de neurochirurgie, CHU Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - G Noël
- Département de radiothérapie, centre de lutte contre le cancer Paul-Strauss, 3, rue de la Porte-de-l'Hôpital, BP 42, 67065 Strasbourg cedex, France; Laboratoire EA 3430, fédération de médecine translationnelle de Strasbourg (FMTS), université de Strasbourg, 4, rue Kirschleger, 67085 Strasbourg cedex, France.
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DeWire M, Green DM, Sklar CA, Merchant TE, Wallace D, Lin T, Vern-Gross T, Kun LE, Krasin MJ, Boyett JM, Wright KD, Wetmore C, Broniscer A, Gajjar A. Pubertal development and primary ovarian insufficiency in female survivors of embryonal brain tumors following risk-adapted craniospinal irradiation and adjuvant chemotherapy. Pediatr Blood Cancer 2015; 62:329-334. [PMID: 25327609 PMCID: PMC4402092 DOI: 10.1002/pbc.25274] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 08/21/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND Female survivors of central nervous system (CNS) tumors are at an increased risk for gonadal damage and variations in the timing of puberty following radiotherapy and alkylating agent-based chemotherapy. PROCEDURE Clinical and laboratory data were obtained from 30 evaluable female patients with newly diagnosed embryonal CNS tumors treated on a prospective protocol (SJMB 96) at St. Jude Children's Research Hospital (SJCRH). Pubertal development was evaluated by Tanner staging. Primary ovarian insufficiency (POI) was determined by Tanner staging and FSH level. Females with Tanner stage I-II and FSH > 15 mIU/ml, or Tanner stage III-V, FSH > 25 mIU/ml and FSH greater than LH were defined to have ovarian insufficiency. Recovery of ovarian function was defined as normalization of FSH without therapeutic intervention. RESULTS Median length of follow-up post completion of therapy was 7.2 years (4.0-10.8 years). The cumulative incidence of pubertal onset was 75.6% by the age of 13. Precocious puberty was observed in 11.1% and delayed puberty in 11.8%. The cumulative incidence of POI was 82.8%, though recovery was observed in 38.5%. CONCLUSIONS Treatment for primary CNS embryonal tumors may cause variations in the timing of pubertal development, impacting physical and psychosocial development. Female survivors are at risk for POI, a subset of whom will recover function over time. Further refinement of therapies is needed in order to reduce late ovarian insufficiency. Pediatr Blood Cancer 2015;62:329-334. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Mariko DeWire
- Division of Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Daniel M. Green
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Charles A. Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas E. Merchant
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Dana Wallace
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Tong Lin
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Tamara Vern-Gross
- Department of Radiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Larry E. Kun
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Matthew J. Krasin
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - James M. Boyett
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Karen D. Wright
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Cynthia Wetmore
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Alberto Broniscer
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Amar Gajjar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
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Denzer C, Hauffa B, Rohrer T, Brämswig H, Dörr HG. Störungen der Pubertätsentwicklung und der Fertilität. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-014-3173-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Treatment outcomes and late toxicities in patients with embryonal central nervous system tumors. Radiat Oncol 2014; 9:201. [PMID: 25209395 PMCID: PMC4261562 DOI: 10.1186/1748-717x-9-201] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 08/31/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Standard treatment strategies for embryonal central nervous system (CNS) tumors have not yet been established. We treated these tumors using an original chemoradiation therapy protocol; the clinical outcomes and toxicities were retrospectively evaluated. METHODS Twenty-four patients were enrolled including sixteen with medulloblastoma, four with supratentorial primitive neuroectodermal tumor (sPNET), three with atypical teratoid/rhabdoid tumor, and one with pineoblastoma. Immediately after diagnosis, all patients underwent surgery initially. They were then categorized as high- or average-risk groups independent of tumor type/pathogenesis. The average-risk group included patients who were aged ≥3 years at diagnosis, had non-metastatic disease at diagnosis (M0), and had undergone gross total resection. Other patients were categorized as the high-risk group; this group received more intensive treatment than the average-risk group, including high-dose chemotherapy with autologous stem-cell transplantation. All patients received craniospinal irradiation (CSI). The CSI dose was 23.4 Gy for M0 patients aged ≥5 years, 18 Gy for M0 patients aged <5 years, and 30-36 Gy for all patients with M + disease. The total dose to the primary tumor bed was 54 Gy. RESULTS The median follow-up time was 73.5 (range, 19-118) months. The 5-year progression-free survival (PFS) and overall survival (OS) rates were 71.1 and 88.9%, respectively in the average-risk group (n = 9) and 66.7 and 71.1%, respectively in the high-risk group (n = 15). The PFS and OS rates were not significantly different between the average- and high-risk groups. In patients with medulloblastoma only, these rates were also not significantly different between the average- and high-risk groups. Three of four patients with sPNET were disease free. The height standard deviation score (SDS) was significantly decreased at the last assessment relative to that at diagnosis (P < 0.0001). The latest median height SDS was -1.6 (range, 0.9 to -4.8), and the latest median full-scale intelligence quotient (FSIQ) score was 86 (range, 59-128). The CSI doses and age at the start of radiation therapy did not influence clinical outcomes, height SDSs, and FSIQ scores. CONCLUSIONS Our original protocol for patients with embryonal CNS tumors was feasible and yielded favorable clinical outcomes.
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Barnes N, Chemaitilly W. Endocrinopathies in survivors of childhood neoplasia. Front Pediatr 2014; 2:101. [PMID: 25295241 PMCID: PMC4172013 DOI: 10.3389/fped.2014.00101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 09/06/2014] [Indexed: 01/26/2023] Open
Abstract
Advancements in cancer treatments have increased the number of survivors of childhood cancers. Endocrinopathies are common complications following cancer therapy and may occur decades later. The objective of the current review is to address the main endocrine abnormalities detected in childhood cancer survivors including disorders of the hypothalamic-pituitary axis, thyroid, puberty, gonads, bone, body composition, and glucose metabolism.
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Affiliation(s)
- Nicole Barnes
- Division of Pediatric Endocrinology, Department of Pediatric Medicine, St. Jude Children's Research Hospital , Memphis, TN , USA
| | - Wassim Chemaitilly
- Division of Pediatric Endocrinology, Department of Pediatric Medicine, St. Jude Children's Research Hospital , Memphis, TN , USA ; Epidemiology and Cancer Control, St. Jude Children's Research Hospital , Memphis, TN , USA
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Lipshultz SE, Adams MJ, Colan SD, Constine LS, Herman EH, Hsu DT, Hudson MM, Kremer LC, Landy DC, Miller TL, Oeffinger KC, Rosenthal DN, Sable CA, Sallan SE, Singh GK, Steinberger J, Cochran TR, Wilkinson JD. Long-term cardiovascular toxicity in children, adolescents, and young adults who receive cancer therapy: pathophysiology, course, monitoring, management, prevention, and research directions: a scientific statement from the American Heart Association. Circulation 2013; 128:1927-95. [PMID: 24081971 DOI: 10.1161/cir.0b013e3182a88099] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Smee RI, Williams JR, De-Loyde KJ, Meagher NS, Cohn R. Medulloblastoma: progress over time. J Med Imaging Radiat Oncol 2012; 56:227-34. [PMID: 22498198 DOI: 10.1111/j.1754-9485.2012.02349.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Medulloblastoma is the most common central nervous system tumour in children aged 0-4 years, with 75% of cases occurring in patients <16 years, and rare in adults. The intent of this audit is to review a single centre's experience and to compare outcomes with other centres' outcomes. METHODS This Ethics approved retrospective audit evaluates the paediatric population aged <16 years who received radiotherapy as their initial or salvage treatment at the Prince of Wales Hospital Cancer Centre between 1972 and 2007. The primary and secondary end-points were progression-free survival (PFS) and cancer-specific survival (CSS), with comparisons made between patients treated before and after 1990, and the impact of high- and low-risk disease. RESULTS There were 80 eligible patients, 78 who had radiotherapy at initial presentation, and 2 at the time of recurrence. Median age was 6.5 years, 52 were boys and 28 were girls. Seventy-eight patients had a surgical procedure and ultimately received craniospinal radiotherapy. Of these 78 patients, 32 (40%) had a macroscopically complete resection. The 5-year PFS was 69.7%. The 5-year PFS for patients treated pre and post 1990 was 66.1% and 71.8%, respectively. The 5-year CSS for high- and low-risk patients was 61.1% and 78.4%, respectively. Ultimately, 33% of patients were dead due to disease. CONCLUSION This audit demonstrates those children referred to this facility for treatment have comparable survival to that of other major centres.
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Affiliation(s)
- Robert I Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Level 2, High Street, Randwick, NSW 2031, Australia
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Orgel E, Jain S, Ji L, Pollick L, Si S, Finlay J, Freyer DR. Hearing loss among survivors of childhood brain tumors treated with an irradiation-sparing approach. Pediatr Blood Cancer 2012; 58:953-8. [PMID: 21796767 DOI: 10.1002/pbc.23275] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 06/20/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intensive, irradiation-sparing chemotherapy regimens for malignant brain tumors have improved survival and neurocognitive outcomes in very young children. Platinum compounds are pivotal to this approach's success but are associated with hearing loss that markedly reduces quality of life for survivors. The purpose of this study was to determine the prevalence and severity of ototoxicity associated with Head Start and similar irradiation-sparing regimens. PROCEDURE A retrospective cohort study was conducted of children treated for malignant brain tumors at Children's Hospital Los Angeles using irradiation-sparing regimens. Patient and treatment characteristics were ascertained. Primary outcomes were post-treatment hearing status, need for hearing aids, and hearing threshold change. RESULTS Twenty-nine patients were evaluable. The most common diagnosis was medulloblastoma (n = 14). The median age at diagnosis was 2.0 years (range, 0.2-9.2). Median time from diagnosis to most recent hearing assessment was 1.1 years (mean 2.4; range, 0.2-17.5). Cumulative cisplatin and carboplatin dose was 281 ± 88 mg/m(2) and 1,205 ± 277 mg/m(2) , respectively. All patients had aminoglycoside exposure. Following treatment, 18 patients (62.1%) had abnormal hearing and 11 (37.9%) required hearing aids. At 4,000 Hz, statistically significant hearing loss was documented in the range of 30-40 dB. CONCLUSIONS While eliminating cranial irradiation has dramatically improved survival and neurocognitive and neuroendocrine outcomes in this population, clinically significant hearing loss is now the leading late effect due to the necessity of platinum-based chemotherapy. Our results document the need for audiometric monitoring and developing otoprotective strategies in this vulnerable population.
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Affiliation(s)
- Etan Orgel
- Children's Center for Cancer and Blood Diseases, Children's Hospital, Los Angeles, CA, USA
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Markant SL, Wechsler-Reya RJ. Personalized mice: modelling the molecular heterogeneity of medulloblastoma. Neuropathol Appl Neurobiol 2012; 38:228-40. [DOI: 10.1111/j.1365-2990.2011.01235.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Sobol G, Musioł K, Kalina M, Kalina-Faska B, Mizia-Malarz A, Ficek K, Mandera M, Woś H, Małecka-Tendera E. The evaluation of function and the ultrasonographic picture of thyroid in children treated for medulloblastoma. Childs Nerv Syst 2012; 28:399-404. [PMID: 22080382 DOI: 10.1007/s00381-011-1625-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE Medulloblastoma (MB) is one of the most frequent and sensitive to radiation aggressive brain tumor in children. Abnormalities of the thyroid function are common complications of head and neck irradiation for childhood cancer. The aim of this study was to assess thyroid function in children treated for medulloblastoma according to the treatment protocol phase. PATIENTS AND METHODS Twenty-three children with MB were enrolled to this study. All patients underwent chemotherapy and radiotherapy to the whole craniospinal axis and boost with the conformal therapy restricted to the tumor bed to a total dose of 54 Gy. Thyroid function was evaluated based on thyroid-stimulating hormone (TSH), free thyroxine (fT4) levels controlled before MB treatment, directly after irradiation and at the end of the treatment protocol. Ultrasonography has been used to detect parenchymal abnormalities. RESULTS All patients presented normal thyroid hormone range before chemotherapy. Hypothyroidism was found in 12 patients in the course of treatment, in 2 patients hormone deficits diagnosed directly after irradiation, in 10 patients such condition was observed at the end of the whole therapy. All of these patients needed thyroid hormone substitution. None of them presented clinical symptoms of hypothyroidism. Ultrasound-detected abnormalities have been found in 20 patients. CONCLUSIONS It is crucial to monitor the functions of the thyroid gland in children treated for medulloblastoma because of the high risk of hypothyroidism resulting from the treatment. The change in the echogenicity of the thyroid gland may be an early marker for a dysfunction of this organ in children treated for medulloblastoma.
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Affiliation(s)
- G Sobol
- Department of Pediatric Oncology, Haematology and Chemotherapy, Medical University of Silesia, Upper Silesia Children's Care Health Centre, Katowice, Poland.
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Abstract
PURPOSE OF REVIEW Medulloblastoma is the main primitive neuroectodermal tumour of the posterior fossa in childhood. The classical therapeutic approach consists of surgical resection, followed by craniospinal irradiation. Because of the good overall survival (75%), the main recent research efforts focus on refining the most relevant prognostic stratification and in decreasing the long-term sequelae. RECENT FINDINGS Thanks to the better understanding of the heterogeneity of medulloblastomas, clinical, histological and biological markers have been clearly identified and allow risk-adapted strategies. A subset of tumours of early childhood (<3-5 years), frequently associated with a Sonic Hedgehog signalling, might be cured without irradiation. In older children, several trials have demonstrated the safety of reduced craniospinal irradiation in standard risk tumours. Furthermore, the evidence of an excellent prognosis associated with a subset of tumours characterized by an activation of the WNT pathway leads to forthcoming de-escalating strategies. Reducing long-term sequelae also relies on new surgical approaches aiming at reducing the cerebellar injuries. Tremendous efforts have also been made in defining the most adapted irradiation doses and fields. Intensity-modulated radiotherapy and proton beam therapy might also influence the long-term neurological and endocrine defects of the patients. SUMMARY Histological and biological characteristics clearly define various prognostic groups within medulloblastomas; confirming the overall good outcome and reducing long-term sequelae are the main focus of current clinical trials.
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Siviero-Miachon AA, Monteiro CMDC, Pires LV, Rozalem AC, Silva NSD, Petrilli AS, Spinola-Castro AM. Early traits of metabolic syndrome in pediatric post-cancer survivors: outcomes in adolescents and young adults treated for childhood medulloblastoma. ACTA ACUST UNITED AC 2011; 55:653-60. [DOI: 10.1590/s0004-27302011000800022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVE: To analyze traits of metabolic syndrome (MetS) in medulloblastoma survivors. SUBJECTS AND METHODS: Sixteen childhood medulloblastoma survivors aged 18.0 (4.4) years, with history of craniospinal radiation therapy (RT) were compared with nine control subjects matched by age, gender, and body mass index, according to fat distribution, metabolic and cardiovascular variables. RESULTS: Medulloblastoma patients showed increases in waist circum-ference and its relationships (all p < 0.05), and HOMA1-IR (p = 0.006), which were modified by growth hormone (GH) secretion status. However, these increases were within normal range. CONCLUSIONS: Adolescent and young adult survivors of medulloblastoma showed centripetal fat deposition and decreased insulin sensitivity, associated with GH status. Pediatric brain tumor survivors following RT should be monitored for the diagnosis of MetS traits predisposing to cardiovascular disease.
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Mostoufi-Moab S, Grimberg A. Pediatric brain tumor treatment: growth consequences and their management. PEDIATRIC ENDOCRINOLOGY REVIEWS : PER 2010; 8:6-17. [PMID: 21037539 PMCID: PMC4148717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Tumors of the central nervous system, the most common solid tumors of childhood, are a major source of cancer-related morbidity and mortality in children. Survival rates have improved significantly following treatment for childhood brain tumors, with this growing cohort of survivors at high risk of adverse medical and late effects. Endocrine morbidities are the most prominent disorder among the spectrum of longterm conditions, with growth hormone deficiency the most common endocrinopathy noted, either from tumor location or after cranial irradiation and treatment effects on the hypothalamic/pituitary unit. Deficiency of other anterior pituitary hormones can contribute to negative effects on growth, body image and composition, sexual function, skeletal health, and quality of life. Pediatric and adult endocrinologists often provide medical care to this increasing population. Therefore, a thorough understanding of the epidemiology and pathophysiology of growth failure as a consequence of childhood brain tumor, both during and after treatment, is necessary and the main focus of this review.
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Affiliation(s)
- Sogol Mostoufi-Moab
- Department of Pediatrics, Divisions of Endocrinology and Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | - Adda Grimberg
- Department of Pediatrics, Division of Endocrinology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104
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Adamson DC, Shi Q, Wortham M, Northcott PA, Di C, Duncan CG, Li J, McLendon RE, Bigner DD, Taylor MD, Yan H. OTX2 is critical for the maintenance and progression of Shh-independent medulloblastomas. Cancer Res 2009; 70:181-91. [PMID: 20028867 DOI: 10.1158/0008-5472.can-09-2331] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OTX2 is a developmentally regulated transcription factor involved in early morphogenesis of the central nervous system. This gene is amplified and overexpressed in medulloblastoma cell lines, but the nature and extent of its genetic alterations in primary tumors have not been evaluated. Analysis of a large cohort of primary medulloblastomas revealed frequent focal copy number gain of a region minimally containing OTX2 as a single gene. OTX2 copy number gain was restricted to tumor subtypes that did not express a molecular signature of Wnt or Shh pathway activation. FISH analysis revealed copy number gain in a subset of cells within medulloblastoma samples, suggesting a late event in tumor progression. Gain of OTX2 copy number was associated with the presence of anaplastic histologic features and shorter survival in medulloblastoma patients. In support of a functional role, ectopic OTX2 expression enhanced proliferation and tumorigenicity of immortalized primary cells, whereas OTX2 knockdown in medulloblastoma cells prolonged the survival of animals bearing xenograft tumors. Mechanistic investigations revealed upregulation of MYC as a potential mechanism whereby OTX2 promotes tumor progression. Our findings define OTX2 as an important oncogenic driver in medulloblastoma.
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Affiliation(s)
- David C Adamson
- Department of Surgery, The Pediatric Brain Tumor Foundation Institute, and The Preston Robert Tisch Brain Tumor Center at Duke, Duke University Medical Center, Veterans Affairs Medical Center, Durham, North Carolina 27710, USA
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Patterson BC, Truxillo L, Wasilewski-Masker K, Mertens AC, Meacham LR. Adrenal function testing in pediatric cancer survivors. Pediatr Blood Cancer 2009; 53:1302-7. [PMID: 19637328 DOI: 10.1002/pbc.22208] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Central adrenal insufficiency is observed after cranial radiation therapy for cancer. Screening at risk patients is recommended, but the best screening strategy is unknown. METHODS A retrospective review of pediatric cancer survivors who underwent hypothalamic/pituitary/adrenal axis testing was conducted. Data included: cancer diagnosis, radiotherapy dose, other endocrinopathies, and adrenal function testing. Adrenal testing included sequential low-dose corticotropin test (LDCT) and standard-dose corticotropin test (SDCT). 8 a.m. serum cortisol levels were compared to LDCT results. LDCT results were compared by radiotheroapy dose and according to the presence of endocrine comorbidities. RESULTS Seventy-eight subjects (56% male, mean age at diagnosis 6.5 years) underwent testing. 67.9% had been treated with radiotherapy to the hypothalamus/pituitary. Mean time to diagnosis of adrenal insufficiency was 6.8 years after cancer diagnosis. Adequate adrenal function was found in 65% of patients by LDCT and 89% by SDCT. Only 21% of patients had basal serum cortisols collected at 8 a.m. Agreement between 8 a.m. baseline cortisol and LDCT was fair. Agreement between random baseline cortisol and LDCT was poor. Prevalence of central adrenal insufficiency diagnosed by LDCT increased with radiotherapy dose (8% for 10-19.9 Gy; 83% for >or=40 Gy) and the number of endocrine comorbidities. CONCLUSIONS In pediatric cancer survivors, central adrenal insufficiency was common even in patients receiving <40 Gy to the hypothalamus/pituitary. We recommend use of LDCT, not 8 a.m. serum cortisol to screen patients who received >30 Gy of radiotherapy and those with other central endocrinopathies.
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Affiliation(s)
- Briana C Patterson
- Division of Endocrinology, Department of Pediatrics, Emory University, Atlanta, Georgia, USA.
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From childhood to adulthood: long-term outcome of medulloblastoma patients. The Institut Curie experience (1980–2000). J Neurooncol 2009; 95:271-279. [DOI: 10.1007/s11060-009-9927-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2009] [Accepted: 05/24/2009] [Indexed: 10/20/2022]
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Padovani L, André N, Carrie C, Muracciole X. [Childhood and adult medulloblastoma: what difference?]. Cancer Radiother 2009; 13:530-5. [PMID: 19713143 DOI: 10.1016/j.canrad.2009.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 06/05/2009] [Indexed: 11/17/2022]
Abstract
Medulloblastoma is the most frequent childhood brain tumor (30%) but account only for less than 1% of adult brain tumor. The overall survival increased significantly during the last two decades with 80% of long survivors at five years whatever the stage. Most children who survive have significant neurocognitive sequelae. All children are included in national and international prospective studies which propose risk-adapted radiation therapy and chemotherapy after surgery. Quality control of radiotherapy leads to reduce significantly the risk of recurrence and has an impact on survival. Risks of late toxicity should be taken into account at the time of the treatment. Due to the rarety in adult population, no prospective studies and few data about late effects are available. Adult medulloblastoma is a therapeutic challenge and their therapeutic strategies are similar to pediatric protocols. In order to improve the understanding of adult disease and to homogenize the treatment, National Cancer Institute (INCa) stimulated the creation of web conference to discuss each case prospectively and to propose a protocol of treatment. A better comprehension of biological processes and abnormal cellular signalling pathways involved in medulloblastoma pathogenesis had led toward a new prognostic classification to adapt the therapeutic strategy and gives hope of new therapeutic tools.
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Affiliation(s)
- L Padovani
- Département de Radiothérapie, CHU de la Timone-Enfant, 13385 Marseille cedex 5, France.
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Laughton SJ, Merchant TE, Sklar CA, Kun LE, Fouladi M, Broniscer A, Morris EB, Sanders RP, Krasin MJ, Shelso J, Xiong Z, Wallace D, Gajjar A. Endocrine outcomes for children with embryonal brain tumors after risk-adapted craniospinal and conformal primary-site irradiation and high-dose chemotherapy with stem-cell rescue on the SJMB-96 trial. J Clin Oncol 2008; 26:1112-8. [PMID: 18309946 DOI: 10.1200/jco.2008.13.5293] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To estimate the cumulative incidence of specific hormone deficiencies and the influence of hypothalamic-pituitary (HP) axis radiation dose in a cohort of children with embryonal brain tumors treated with risk-adapted craniospinal irradiation (CSI), conformal primary site irradiation, and high-dose chemotherapy. PATIENTS AND METHODS Clinical data and HP axis radiation dosimetry data were obtained from 88 eligible children. All patients received regular endocrine follow-up that included screening tests of thyroid function and stimulation testing for growth hormone deficiency (GHD), and adrenocorticotropin hormone deficiency. RESULTS The cumulative incidence of GHD, thyroid-stimulating hormone (TSH) deficiency, adrenocorticotropic hormone deficiency, and primary hypothyroidism at 4 years from diagnosis was 93% +/- 4%, 23% +/- 8%, 38% +/- 6%, and 65% +/- 7%, respectively. Radiation dosimetry to the HP axis was associated only with the development of TSH deficiency; the 4-year cumulative incidence was 44% +/- 19% and 11% +/- 8% (P = .014) for those receiving more or less than the median dose to the hypothalamus (>or= 42 v < 42 Gy), respectively. The median dose of CSI for the average-risk (AR) patients was 23.4 and 39.6 Gy (36 to 40.5 Gy) for the high-risk patients. The estimated mean decline in height Z-score after radiation therapy was greater in high-risk patients (-0.65 units/yr) when compared with AR patients (-0.54 units/yr; P = .039). CONCLUSION Pediatric patients with CNS embryonal tumors are at high risk for treatment-related hormone deficiencies. GHD and primary hypothyroidism were diagnosed in a majority of subjects relatively soon after the completion of therapy. Radiation dose to the hypothalamus in excess of 42 Gy was associated with an increase in the risk of developing TSH deficiency.
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Affiliation(s)
- Stephen J Laughton
- Division of Neuro-Oncology, Department of Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Bar EE, Stearns D. New developments in medulloblastoma treatment: the potential of a cyclopamine–lovastatin combination. Expert Opin Investig Drugs 2008; 17:185-95. [DOI: 10.1517/13543784.17.2.185] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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42
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Spiller SE, Ditzler SH, Pullar BJ, Olson JM. Response of preclinical medulloblastoma models to combination therapy with 13-cis retinoic acid and suberoylanilide hydroxamic acid (SAHA). J Neurooncol 2007; 87:133-41. [PMID: 18060600 DOI: 10.1007/s11060-007-9505-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 11/26/2007] [Indexed: 11/27/2022]
Abstract
PURPOSE Current medulloblastoma therapy, surgery, radiation, and chemotherapy, is unacceptably toxic. However, 13-cis retinoic acid (RA) and SAHA, a histone deacetylase inhibitor, have each been shown to induce apoptosis in medulloblastoma cultures and mouse models. Both drugs cross the blood brain barrier, have been given safely to children, and achieve brain concentrations that are at or near therapeutic levels. Retinoic acid acts by transcriptionally activating bone morphogenetic protein-2 (BMP-2) and SAHA facilitates transcriptional activity through chromatin accessibility. We tested the hypothesis that these drugs additively induce BMP-2 transcription and apoptosis. EXPERIMENTAL DESIGN RA + SAHA induction of BMP-2 transcription and apoptosis in medulloblastoma cultures was evaluated. Subsequently the response of mouse medulloblastomas to these two agents in the presence and absence of cisplatin was evaluated. RESULTS BMP-2 transcription multiplied 3-fold with addition of RA to culture, and 7-fold with both agents. The IC50 of SAHA was reduced by 40% when low dose RA was added. Interestingly, a p38 MAP kinase inhibitor that partially blocks RA-induced apoptosis did not inhibit the activity of RA + SAHA. Flank D283 tumors in athymic mice had slower growth in the RA + SAHA arm than single drug or control arms. Intracranial tumors in ND2:SmoA1 mice treated with RA + SAHA + cisplatin showed a 4-fold increase in apoptosis over controls, and a 2-fold increase over animals receiving only SAHA or RA + SAHA. CONCLUSIONS RA + SAHA additively induce BMP-2 transcription and medulloblastoma apoptosis. The combination may act through a p38 MAPK independent mechanism. Efficacy increased with cisplatin, which has implications for clinical trial design.
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Affiliation(s)
- Susan E Spiller
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
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Yun KA, Lee YA, Shin CH, Yang SW, Shin HY, Ahn HS, Kim IH. Factors affecting the final adult height in survivors of childhood brain tumors. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.1.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kyong-Ah Yun
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Seop Ahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Il Han Kim
- Department of Therapeutic Radiology & Oncology, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Endocrinopathies are significant consequences of the treatment of childhood cancers. The risk of developing these adverse events is related to the underlying disease and its treatment with cytotoxic agents and radiation therapy. This article reviews hypothalamic-pituitary, thyroid, and gonadal dysfunction, as well as osteopenia-osteoporosis and obesity.
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Affiliation(s)
- Laurie E Cohen
- Division of Endocrinology, Children's Hospital Boston, Boston, MA 02115, USA.
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45
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Fangusaro JR, Jiang Y, Holloway MP, Caldas H, Singh V, Boué DR, Hayes J, Altura RA. Survivin, Survivin-2B, and Survivin-deItaEx3 expression in medulloblastoma: biologic markers of tumour morphology and clinical outcome. Br J Cancer 2005; 92:359-65. [PMID: 15655550 PMCID: PMC2361849 DOI: 10.1038/sj.bjc.6602317] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Survivin is an apoptotic inhibitor that is expressed at high levels in a variety of malignancies. Survivin has four known alternative splice forms (Survivin, Survivin-2B, Survivin-deltaEx3, and Survivin-3B), and the recent literature suggests that these splice variants have unique functions and subcellular localisation patterns. We evaluated 19 fresh-frozen paediatric medulloblastomas for the expression of three Survivin isoforms by quantitative PCR. Survivin was most highly expressed when compared with normal cerebellar tissue. We also investigated Survivin protein expression in 40 paraffin-embedded paediatric medulloblastoma tumours by immunohistochemistry. We found a statistically significant association between the percentage of Survivin-positive cells and histologic subtype, with the large-cell-anaplastic variant expressing Survivin at higher levels than the classic subtype. We also found a statistically significant relationship between the percent of Survivin-positive cells in the tumours and clinical outcome, with higher levels of Survivin correlating with a worse prognosis. In summary, our study demonstrates a role for Survivin as a marker of tumour morphology and clinical outcome in medulloblastoma. Survivin may be a promising future prognostic tool and potential biologic target in this malignancy.
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Affiliation(s)
- J R Fangusaro
- Center for Childhood Cancer Research, Columbus Children's Research Institute (CCRI), College of Medicine and Public Health, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
- Department of Pediatrics, College of Medicine and Public Health, The Ohio State University, Columbus, OH, USA
| | - Y Jiang
- Center for Childhood Cancer Research, Columbus Children's Research Institute (CCRI), College of Medicine and Public Health, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - M P Holloway
- Center for Childhood Cancer Research, Columbus Children's Research Institute (CCRI), College of Medicine and Public Health, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - H Caldas
- Center for Childhood Cancer Research, Columbus Children's Research Institute (CCRI), College of Medicine and Public Health, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - V Singh
- Center for Biopathology, Columbus Children's Research Institute, Columbus Children's Hospital and College of Medicine and Public Health, The Ohio State University, Columbus, OH, USA
| | - D R Boué
- Center for Biopathology, Columbus Children's Research Institute, Columbus Children's Hospital and College of Medicine and Public Health, The Ohio State University, Columbus, OH, USA
| | - J Hayes
- Department of Pediatrics, College of Medicine and Public Health, The Ohio State University, Columbus, OH, USA
| | - R A Altura
- Center for Childhood Cancer Research, Columbus Children's Research Institute (CCRI), College of Medicine and Public Health, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
- Department of Pediatrics, College of Medicine and Public Health, The Ohio State University, Columbus, OH, USA
- Center for Childhood Cancer Research, Columbus Children's Research Institute (CCRI), College of Medicine and Public Health, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA. E-mail:
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Abstract
Pediatric brain tumors are a challenging group of very divergent diseases. Considerable controversy exists concerning the accurate diagnosis and treatment of these patients. Aggressive therapy is often needed to cure aggressive and potentially lethal disease, yet late effects, especially injury to the developing brain, remain a profound problem. The discipline of pediatric neuro-oncology remains one of the most productive areas for continued clinical and basic research because of these and other challenges.
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Affiliation(s)
- Andrew W Walter
- Pediatric Hematology/Oncology and Neuro-Oncology, Thomas Jefferson Medical College, A. I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19899, USA.
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