Prognostic Factors for Pediatric, Adolescent, and Young Adult Patients with Non-DIPG Grade 4 Gliomas: A Contemporary Pooled Institutional Experience

PURPOSE/OBJECTIVE(S)

WHO grade 4 gliomas are rare tumors in the pediatric and AYA (adolescent and young adult) population. In this study, we evaluate prognostic factors, toxicities, and outcomes in the pediatric versus AYA population.

MATERIALS/METHODS

This retrospective pooled institutional study included patients < 30 years old with grade 4 gliomas. Overall survival (OS) and progression free survival (PFS) were characterized using Kaplan-Meier and Cox regression analysis.

RESULTS

Ninety-seven patients (n = 20 < 15y, n = 77 ≥ 15y) were identified with a median age 23.9y at diagnosis. Most had biopsy-proven glioblastoma (91%) and the remainder had diffuse midline glioma, H3K27M-altered (9%). All patients received surgery and adjuvant radiotherapy. Median PFS and OS were 20.9 months and 79.4 months, respectively. Gross total resection was associated with better PFS in multivariate analysis [HR 2.00 (1.01-3.62), p = 0.023]. Age ≥15y was also associated with improved OS [HR 0.36 (0.16-0.81), p = 0.014] while female gender [HR 2.12 (1.08-4.16), p = 0.03] and K27M altered histology [HR 2.79 (1.11-7.02), p = 0.029] were associated with worse OS. Only 7% of patients experienced grade 2 toxicity during radiation. Sixty-two percent of patients experienced tumor progression, 28% local and 34% distant. Analysis of salvage treatment found reirradiation was not associated with improved OS, but second surgery and systemic therapy significantly improved survival from the time of tumor progression.

CONCLUSION

Age is a significant prognostic factor in WHO grade 4 glioma, which may reflect age-related molecular alterations in the tumor. Diffuse midline glioma was associated with worse OS compared to hemispheric glioblastoma; this may be related to lack of effective targeted therapies. Surgery and systemic therapy were effective salvage options that significantly improved outcome. Better understanding of prognostic factors may guide future treatment within this understudied patient population, and prospective studies are warranted.

Dose Reductions to Critical Brain Organs-at-Risk and Better Cognition in Children with Medulloblastoma Receiving Proton Therapy

PURPOSE/OBJECTIVE(S)

Our group previously demonstrated an improvement in cognition among children with medulloblastoma treated with proton therapy, as compared to photon therapy. However, the reason for this cognitive improvement was unclear. In this study, our aim was to determine whether dose to critical brain structures acted as a mediator of improved cognition in patients treated with proton therapy.

MATERIALS/METHODS

In this retrospective study, a cohort of 75 children with medulloblastoma from two institutions was assembled (39 photon, 36 proton). Included patients were treated with similar radiation and cognitive follow-up protocols. Study endpoints were verbal comprehension (VCI), perceptual reasoning (PRI), working memory (WMI), processing speed (PSI) indices and full-scale IQ (FSIQ). Brain structures were segmented and dose comparisons by RT modality were compared using independent t-tests. Linear mixed effects models with random intercepts were created to evaluate cognitive endpoints using R version 4.2.2.

RESULTS

Median follow-up from RT to last cognitive assessment was 4.8 years. Total dose, including RT boost, was slightly lower in the proton cohort than the photon cohort (mean, 54.6 Gy vs. 56.1 Gy, respectively, p < 0.001). Eleven children (31%) treated with proton therapy received 36 Gy CSI, while 6 children (15%) treated with photon therapy received 36 Gy CSI (p = 0.07). Children treated with proton therapy had reduced total doses to the brain (mean, D40), left and right temporal lobes (mean, D40, D50), and left and right hippocampi (mean, D40, D50 - see Table). After adjustment for age at RT and posterior fossa syndrome, higher whole brain mean dose and time since RT were associated with greater decrease in VCI (p = 0.033), higher left temporal D50 and time since RT with greater decrease in PRI (p = 0.031), higher whole brain D40 and time since RT with greater decrease in PSI (p < 0.001) and FSIQ (p = 0.030).

CONCLUSION

Our study demonstrates that proton therapy for patients with medulloblastoma reduces dose to normal brain tissues, which is associated with better intellectual outcomes. Children with medulloblastoma who undergo RT should be treated with proton therapy, if available.

Abstract P6-07-11: Is the prognosis of lymphotropic invasive micropapillary carcinoma worse than invasive ductal carcinoma?: A population-based study of 645 patients

Purpose: Invasive micropapillary carcinoma (IMPC) is an uncommon distinct variant of breast carcinoma and is associated with an increased risk for regional lymph node metastases. Therefore, IMPC is considered to have an unfavorable prognosis when compared to invasive ductal carcinoma (IDC). The prognostic factors for IMPC are not well characterized due to the relative scarcity of cases reported in the literature.

Methods: We analyzed the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database to evaluate prognostic factors of a population of 645 breast IMPC patients and 300,060 breast IDC patients reported between 2001 and 2008. Using univariate and multivariate analyses, hazard ratios (HR) were calculated for disease-specific (DSS) and overall survival (OS) for these patients using parameters such as patient age at diagnosis, histological grade, ER status, PR status, tumor size, and degree of lymph node positivity. Subset analysis of high grade, lymph node-positive patients was performed to compare DSS and OS between IMPC and IDC.

Results: The 5-year DSS and OS for IMPC patients were 92.1% and 84.6% compared to 5-year DSS and OS of 88.5% and 80.2% for IDC patients. At presentation, TNM staging of IMPC cases was similar to IDC except for a higher percentage of LN metastases (52.4% in IMPC vs. 34.7% in IDC). Of those with known estrogen receptor (ER) status, 84.2% of IMPC cases were ER-positive, which was associated with better DSS (Hazard Ratio (HR) 0.36, p &lt; 0.002) and OS (HR 0.62, p = 0.072). Patients with four or more positive lymph nodes had worse DSS (HR 7.1, p &lt; 0.0001) and OS (HR 3.2, p &lt; 0.0001) than node-negative patients, but those with one to three positive lymph nodes had similar DSS (HR 1.04, p = 0.96) and OS (HR 0.99, p = 0.97) as node-negative patients. In the subset of patients with high grade, node-positive breast carcinoma, patients with micropapillary histology had better DSS (p &lt; 0.03) and a trend towards better OS (p = 0.12) than high grade, node-positive invasive ductal carcinoma. This subset of IMPC patients also had a higher percentage of ER-positive tumors (77%) compared to IDC patients (56%).

Conclusions: While IMPC has a high propensity for lymph node metastasis, it has a disease-specific and overall prognosis that compares favorably to IDC. The higher percentage of hormone-receptor positivity may account for this survival advantage, even in high grade, node-positive disease. Therefore, estrogen-receptor-negativity or having four or more positive lymph nodes at presentation may potentially serve as prognostic markers for IMPC patients. In this study population, patients with one to three positive lymph nodes have DSS and OS similar to node-negative patients. Additional clinical studies are warranted to further investigate this observation. This is the largest study of IMPC to date, and these findings help our understanding of this uncommon histological variant of breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-11.

Extraneural metastasis of medulloblastoma

2065

Background: Medulloblastoma is the most common childhood intracranial tumor to spread extraneurally. Information regarding prognostic factors and best therapeutic approach of extraneural metastasis (ENM) of medulloblastoma is mostly limited to case reports. The purpose of this study was to perform a comprehensive literature review and analysis of reported cases dealing with ENM to identify the characteristics, prognostic factors, optimal treatment modalities, and survival of these patients. Methods: A PubMed search of English language articles from 1963–2007 was performed, yielding 47 articles with 119 patients. Factors analyzed included age, time interval to ENM, CNS involvement at the time of ENM, location of ENM, treatment, and outcome. Results: Location of ENM included bone in 84%, bone marrow in 27%, lung in 6%, liver in 6%, and lymph nodes in 15%. Of patients with available data regarding location of RT after ENM, 87% of patients received this treatment to the site of ENM. The 1-year disease free survival (DFS) and overall survival (OS) after the diagnosis of ENM was 35% and 42%, respectively. The 1-year OS for patients with and without radiotherapy (RT) after ENM was 58% and 35%, respectively (p = 0.019). For patients without CNS involvement at the time of ENM the 1-year OS for those treated with and without RT was 82% and 51%, respectively (p = 0.030), however RT did not significantly improve OS for those with CNS involvement. ENM in the lung or liver was found to be a negative prognostic factor (p = 0.002). 1-year OS of patients with time interval to ENM of <18 months was 25% while those with time interval greater than or equal to 18 months it was 61% (p = 0.001). Conclusions: Negative prognostic factors for patients with ENM include CNS involvement at the time of ENM, lung or liver involvement, and duration to ENM <18 months. Patients without CNS involvement who received RT after ENM had an OS and DFS benefit compared to those not receiving RT.

No significant financial relationships to disclose.

Computer visualization techniques (CVTs) foster evidence-based target delineation

Computer visualization techniques (CVTs) are an emerging technology that can organize all cancer specialists. This article describes CVTs' ability to maximize the currently untapped advantages of intensity modulated radiotherapy (IMRT). The visual speed and dynamic strategies inherent in CVTs improves IMRT by distilling vast amounts of anatomic, multimodal imaging, textual/meaning, and surgical/outcome data into a large, rigorous, standardized evidence base of storable target delineation plans. This ability to standardize strategies will allow the collection of meaningful evidence based outcome data.

The treatment of primary and metastatic renal cell carcinoma (RCC) with image-guided stereotactic body radiation therapy (SBRT)

PURPOSE

Brain metastases from renal cell carcinoma (RCC) have been successfully treated with stereotactic radiosurgery (SRS). Metastases to extra-cranial sites may be treated with similar success using stereotactic body radiation therapy (SBRT), where image-guidance allows for the delivery of precise high-dose radiation in a few fractions. This paper reports the authors' initial experience with image-guided SBRT in treating primary and metastatic RCC.

MATERIALS AND METHODS

The image-guided Brainlab Novalis stereotactic system was used. Fourteen patients with 23 extra-cranial metastatic RCC lesions (orbits, head and neck, lung, mediastinum, sternum, clavicle, scapula, humerus, rib, spine and abdominal wall) and two patients with biopsy-proven primary RCC (not surgical candidates) were treated with SBRT (24-40 Gy in 3-6 fractions over 1-2 weeks). All patients were immobilised in body cast or head and neck mask. Image-guidance was used for all fractions. PET/CT images were fused with simulation CT images to assist in target delineation and dose determination. SMART (simultaneous modulated accelerated radiation therapy) boost approach was adopted. 4D-CT was utilised to assess tumour/organ motion and assist in determining planning target volume margins.

RESULTS

Median follow-up was nine months. Thirteen patients (93%) who received SBRT to extra-cranial metastases achieved symptomatic relief. Two patients had local progression, yielding a local control rate of 87%. In the two patients with primary RCC, tumour size remained unchanged but their pain improved, and their renal function was unchanged post SBRT. There were no significant treatment-related side effects.

CONCLUSION

Image-guided SBRT provides excellent symptom palliation and local control without any significant toxicity. SBRT may represent a novel, non-invasive, nephron-sparing option for the treatment of primary RCC as well as extra-cranial metastatic RCC.

The treatment of primary and metastatic renal cell carcinoma (RCC) with stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS)

14572

Background: RCC is often regarded as a radio-resistant tumor. However, brain metastases from RCC have been successful treated with SRS. Therefore, metastases to extra-cranial sites may be treated with similar success using stereotactic body radiation therapy (SBRT), where image-guidance allows for the delivery of precise high dose radiation in a few fractions. We report our experience with SRS/SBRT in the management of primary and metastatic RCC. Methods: The image-guided Novalis radiation therapy system was used. Thirty patients with brain metastases were treated with SRS (16–22 Gy in a single fraction). Five of these patients underwent resection of their metastatic lesions after SRS and their pathology were reviewed. Twenty patients with extra-cranial metastatic lesions (orbits, head and neck, lung, mediatinum, sternum, clavicle, scapula, humerus, rib, spine, abdomen) and 2 patients with biopsy proven primary RCC (not surgical candidates), were treated with SBRT (24–32 Gy in 3–4 fractions over 1–2 weeks). All patients were immobilized in body cast and image-guidance was used for all fractions. 4D-CT was utilized in the treatment planning to assess tumor motion. Results: Of the 30 patients who received SRS to brain metastases, 25 showed decreasing or stable lesion size. Five patients showed an increase in size and underwent resection. Their pathology revealed necrosis in >99% of the specimen, with no viable RCC. Nineteen patients who received SBRT to extra-cranial metastases achieved symptom relief. One patient had local progression, yielding a local control rate of 95%. In the 2 patients with primary RCC, tumor size remained unchanged but their pain improved, and their renal function was unchanged post SBRT. There was no significant treatment related side-effect. Conclusions: Precise high dose radiation can cause significant tumor cell death in “radio-resistant” metastases from RCC. It also offers excellent local control and symptom palliation, without significant toxicity. Therefore, SBRT may represent a novel non-invasive, nephron-sparing option for the treatment of primary RCC as well as extra-cranial metastatic RCC. A prospective clinical trial using SBRT for primary and metastatic RCC is on-going.

No significant financial relationships to disclose.

Amiodarone and radiation therapy sequelae

With the aging of our population, amiodarone, a cardiac antiarrhythmic, is being used with increasing frequency. Anecdotal reports have appeared describing unexpected mucosal as well as cutaneous toxicity in patients treated concurrently with external beam radiotherapy and oral amiodarone. We retrospectively reviewed 12 years of experience at the University of Iowa Hospitals and Clinics and found 10 cases wherein amiodarone was taken concurrently with external beam radiation therapy. In our series, there were no missed treatment fractions because of unexpected acute sequelae. We conclude that amiodarone use does not preclude the delivery of therapeutic radiotherapy.

Relapsed Wilms tumor: is there a role for radiation therapy?

From 1968 to 1996, 21 of 97 (22%) patients with Wilms tumor treated at the University of Iowa Hospitals and Clinics relapsed after initial therapy. The most common sites of initial recurrence were the lungs in 12 (57%), abdomen in 3 (14%), bone in 3 (14%), and liver in 2 (10%). Treatment for recurrence included chemotherapy in 16, radiotherapy in 15 and surgery in 8. Radiotherapy was given to bilateral lungs of 8 previously untreated chests; total dose was 1,200 cGy to 1,500 cGy, with 2 patients receiving 1,000-cGy boost. One patient had abdominal radiotherapy after surgery for relapse; six patients had palliative radiotherapy to distant sites. The 1-, 3-, and 5-year postrelapse survivals were 62 +/- 11%, 38 +/- 11%, and 33 +/- 10%, respectively. Using Cox proportional-hazard regression models, abdominal recurrence (p = 0.0002; hazard ratio, 39.5) and initial stage IV disease (p = 0.019; hazard ratio, 6.27) were found to have a negative impact on postrelapse survival. Seven patients with previously nonirradiated chests are alive at a median follow-up of 123 months after relapse (range, 55--272 months); all had whole lung irradiation with or without chemotherapy at relapse for lung metastases. Radiotherapy was also found to be an effective treatment in the palliation of painful metastases.

Esthesioneuroblastoma: the University of Iowa experience 1978-1998

OBJECTIVE

Esthesioneuroblastoma is rare and the best treatment has yet to be defined. The purpose of this study is to analyze the natural history, treatment, and patterns of failure of esthesioneuroblastoma treated at one institution.

METHODS

Between 1978 and 1998, 13 patients with esthesioneuroblastoma were identified using the University of Iowa Tumor Registry. All patients were staged according to Kadish criteria. Mean follow-up was 6.3 years. Six patients had 5 or more years of follow-up and four had follow-up exceeding 9.5 years. One patient was lost to follow-up at 36 months.

RESULTS

No patients had Kadish stage A disease, five were stage B, and eight stage C. Overall actuarial 5- and 10-year survival rate was 61% and 24%, respectively. Disease-free survival rate at 5 and 10 years was 56% and 42%, respectively. Seven patients have died, three of intercurrent disease and three of disease progression, one with an unknown disease status. Six patients remain alive, three without evidence of disease and three have experienced a local or regional recurrence. Five patients who were initially controlled developed recurrence, three local only, one locoregional, and one regional and distant. Median time to failure was 96 months. All patients with follow-up exceeding 12 years have experienced either a local or regional recurrence. Survival after salvage therapy in these patients ranged from 3 to 12 years.

CONCLUSION

Esthesioneuroblastoma has a long natural history characterized by frequent local or regional recurrence after conventional treatment. Successful retreatment can lead to prolonged survival.

The local field in infratentorial ependymoma: does the entire posterior fossa need to be treated?

INTRODUCTION

In the past decade, there have been multiple reports indicating that the predominant problem in the curative treatment of intracranial ependymoma is local failure. As a result, many have recommended local field radiotherapy. For infratentorial ependymoma, there is controversy regarding what constitutes the local field. Some radiation oncologists advocate coverage of the entire posterior fossa, whereas others recommend radiotherapy to the tumor bed and a safety margin.

METHODS AND MATERIALS

From 1984 to 1998, 28 patients with posterior fossa ependymoma were diagnosed at our institution. There were 18 males and 10 females with a median age of 12 years (range, 2-81 years). Four patients (14%) had high-grade ependymoma and 3 (11%) had M+ disease at initial diagnosis. Gross total resection was achieved in 17 (61%) and postoperative radiotherapy (RT) was given to 22 (77%). Radiotherapy fields were craniospinal in 10, whole brain in 1, posterior fossa in 2, and tumor bed with a 2-cm. margin in 9. Median dose to the primary site was 54 Gy (range, 45-55 Gy). All 4 patients with high-grade ependymoma received craniospinal RT. Six patients did not receive RT after surgery. Magnetic resonance imaging (MRI) or computed tomography (CT) scans of the brain at initial diagnosis were compared to MRI or CT scans of patients at relapse to determine if the local relapse was in the tumor bed or nontumor bed posterior fossa. Median follow-up was 127 months (range, 14-188 months).

RESULTS

Six patients have relapsed. For the 11 patients who had craniospinal or whole brain radiotherapy (RT), 3 recurred (tumor bed 1, spine 1, nontumor bed posterior fossa + spine 1). Both patients who failed in the spine had high-grade tumors. Neither of the 2 treated with posterior fossa fields relapsed. For the 9 patients who had tumor bed RT alone and the 6 who did not receive RT, there were 3 relapses; all were in the tumor bed. There were no relapses in the nontumor bed posterior fossa.

CONCLUSION

For nondisseminated, low-grade infratentorial ependymoma, the radiotherapy volume does not need to include the entire posterior fossa. This information can be used to minimize late effects of RT in the era of three-dimensional (conformal) radiotherapy. No conclusion can be reached regarding the appropriate local field for high-grade infratentorial ependymoma because of the small number of patients.

Pixel analysis of MR perfusion imaging in predicting radiation therapy outcome in cervical cancer

The purpose of this study was to assess heterogeneity of tumor microcirculation determined by dynamic contrast-enhanced magnetic resonance (MR) imaging and its prognostic value for tumor radiosensitivity and long-term tumor control using pixel-by-pixel analysis of the dynamic contrast enhancement. Sixteen patients with advanced cervical cancer were examined with dynamic contrast-enhanced MR imaging at the time of radiation therapy. Pixel-by-pixel statistical analysis of the ratio of post- to precontrast relative signal intensity (RSI) values in the tumor region was performed to generate pixel RSI distributions of dynamic enhancement patterns. Histogram parameters were correlated with subsequent tumor control based on long-term cancer follow-up (median follow-up 4.6 years; range 3.8-5.2 years). The RSI distribution histograms showed a wide spectrum of heterogeneity in the dynamic enhancement pattern within the tumor. The quantity of low-enhancement regions (10th percentile RSI < 2.5) significantly predicted subsequent tumor recurrence (88% vs. 0%, P = 0.0004). Discriminant analysis based on both 10th percentile RSI and pixel number (reflective of tumor size) further improved the prediction rate (100% correct prediction of subsequent tumor control vs. recurrence). These preliminary results suggest that quantification of the extent of poor vascularity regions within the tumor may be useful in predicting long-term tumor control and treatment outcome in cervical cancer. J. Magn. Reson. Imaging 2000;12:1027-1033.

Long-term effects in children treated with radiotherapy for head and neck rhabdomyosarcoma

PURPOSE

To examine the long-term effects of treatment in children receiving radiotherapy for head and neck rhabdomyosarcoma.

METHODS

From 1967 to 1994, a total of 30 children with head and neck rhabdomyosarcoma received megavoltage radiotherapy at one institution. Seventeen patients (57%) have survived and have at least a 5-year follow-up. There were 11 males and 6 females, with a median age of 5.7 years (range 2.2-11.6) at the time of radiotherapy. Tumor location was orbit in 6 patients, infratemporal fossa in 4, paranasal sinuses in 2, and supraglottic larynx in 2; the nasopharynx, pterygopalatine fossa, and parotid gland were sites for the remaining children. All but 2 patients had tumors of embryonal histology. The Intergroup Rhabdomyosarcoma Study (IRS) Group was I in 2, II in 3, and III in 11 children; 1 patient had a recurrent tumor after surgery alone. Radiotherapy volume was the primary tumor or tumor bed in 13, tumor and whole brain in 3, and tumor and craniospinal axis in 1. Median radiotherapy dose to the primary site was 5,040 cGy (range 4,140-6,500) and to the whole brain was 3,000 cGy. All but 1 were treated with 150-200-cGy fractions; 1 patient received 250-cGy fractions for a tumor in the larynx. Chemotherapy was vincristine (V), actinomycin-D (A), and cyclophosphamide (C) in 10 patients, VAC + adriamycin in 2, VA in 1, VA + ifosfamide in 1, VC + adriamycin in 1, and none in 2. One patient had salvage chemotherapy consisting of cisplatin and etoposide. Median follow-up time was 20 years (range 7.5-33).

RESULTS

Late effects of treatment were seen in all patients and included facial growth retardation in 11, neuroendocrine dysfunction in 9, visual/orbital problems in 9, dental abnormalities in 7, hearing loss in 6, and hypothyroidism in 3. Intellectual and academic delays were documented in 3 patients who had received whole brain radiotherapy. While neuroendocrine, thyroid, dental, and cognitive sequelae were primarily attributed to radiotherapy, hearing loss was thought to be a direct result of tumor destruction and, in 1 case, cisplatin chemotherapy. Late effects at or beyond 10 years from radiotherapy were few, but severe, and included chondronecrosis, esophageal stenosis, second malignancy, and brain hemorrhage.

CONCLUSION

Late effects of treatment in children receiving radiotherapy for head and neck rhabdomyosarcoma are frequent. Although radiotherapy is a significant contributor of neuroendocrine, dental, thyroid, and cognitive toxicity, it is not usually implicated with hearing loss. Late toxicity of treatment beyond 10 years is not as frequent as those occurring within 10 years of therapy.

Comparison of posterior fossa and tumor bed boost in medulloblastoma

To quantify the difference between the area of brain irradiated using the posterior fossa boost (PFB) and tumor bed boost (TBB) in medulloblastoma, we studied 15 simulation radiographs of patients treated in our institution from 1990 and 1999. The PFB was compared with the TBB, which was defined as the tumor bed plus 2-cm margin as demonstrated by postoperative magnetic resonance imaging. The PFB field treated a mean area of 9.43 cm2 more brain than the TBB. In 3 patients (20%), the area of the brain in the TBB was larger than the PFB. In 11 patients (73.3%), the PFB field had more than 10% more brain than the TBB. The cochlea was in the PFB and TBB field in all patients. In more than two thirds of patients, the area of brain irradiated with the PFB was at least 10% greater than the TBB. Future studies are needed to determine whether the TBB can replace the PFB in patients with medulloblastoma.

Unresectable adenocarcinoma of the pancreas: patterns of failure and treatment results

We retrospectively reviewed the outcome of 36 consecutive patients seen in our department with nonmetastatic unresectable adenocarcinoma of the pancreas. There were 28 men and 8 women with a mean age of 63.7 years (range, 43-78 years). Radiation therapy (RT) was given to all patients. 5-Fluorouracil (5-FU) was given as a bolus (500-1000 mg/m2/day) during the first and last weeks of RT in 22 patients, whereas continuous 5-FU (225 mg/m2/day) was given to 3 patients. The median survival for all patients was 10 months. Overall survival for all patients at 1 and 3 years was 47.2% and 19.1%, respectively. The pancreas, peritoneum, liver, and lungs were components of failure in 66.7%, 33.3%, 14.8%, and 14.8%, respectively. Local control was a major problem in patients treated for unresectable pancreatic cancer. The results of this study confirm the dismal prognosis of these patients.

The significance of radiotherapy treatment duration in intracranial ependymoma

PURPOSE

To determine if radiation therapy treatment duration has an impact on the outcome of intracranial ependymoma.

METHODS AND MATERIALS

From 1965 to 1997, 34 patients with intracranial ependymoma were seen and treated with postoperative radiotherapy (RT). There were 26 male and 8 female patients with a median age of 14 years (range, 18 months to 60 years). Tumor location was infratentorial in 23 (67.6%) and supratentorial in 11 (32.4%). Pathology was low-grade in 25 (73.5%) and high-grade in 9 (26.5%). Two (5.9%) patients had M+ disease at initial diagnosis. Gross total resection was achieved in 12 (35.3%), subtotal resection in 19 (55. 9%), and biopsy alone in 3 (8.8%). Median RT dose to the primary site was 5400 cGy (range, 4500 cGy to 6600 cGy). The entire neuraxis was treated in 14 (41.2%), whole brain in 9 (26.5%), and the primary site alone in 11 (32.4%). Median radiotherapy treatment duration was 43 days (range, 26 to 122 days). Patients treated with craniospinal RT were more likely to have treatment duration of > or =50 days. Median follow-up was 108 months (range, 24 to 252 months).

RESULTS

The 5-, 10-, and 15-year overall survival rates were 71.5%, 63.3%, and 55.4%. Local control rates at 5, 10, and 15 years were 61.8%, 57.7%, and 57.7%. For patients with RT treatment duration <50 days, the 5-, 10-, and 15-year overall survivals were 85.5%, 78.9%, and 65.7% whereas for those with treatment duration > or = 50 days, the corresponding rates were 45.5%, 36.4%, and 36.4% (p = 0.01, log-rank test). Local control rate at 5, 10, and 15 years was 70.6% for patients with RT treatment duration <50 days and 45.5%, 36.4%, and 36.4% for patients with RT treatment duration > or =50 days (p = 0.05, log-rank test). Age, gender, tumor location, tumor grade, degree of surgical resection, RT volume, and RT dose (4500-5399 cGy vs. 5400-6600 cGy) were not found to have a statistically significant impact on overall survival, disease-free survival, or local control. The most common site of failure was local, found in 13 (38.2%) patients. Three patients also had spinal failure in addition to a primary site failure. There were no isolated nonprimary site brain or spine failures.

CONCLUSIONS

Radiation therapy treatment duration is an important prognostic factor for survival and local control with patients having treatment duration <50 days having a better outcome than those with treatment duration > or =50 days. Because the overwhelming site of failure was local, we recommend local field irradiation in patients with M0 disease.

Late effects in children treated with radiation therapy for Wilms' tumor

PURPOSE

To determine the frequency and types of late effects in children receiving radiation therapy (RT) for Wilms' tumor.

MATERIALS AND METHODS

From 1968 to 1994, 55 children received megavoltage RT at our institution as part of treatment for Wilms' tumor. A total of 42 (76.4%) have survived and have a minimum follow-up of 5 years. There were 25 female and 17 male patients with a median age at diagnosis of 48 months (range, 7-126 months). There were 12 Stage I, eight Stage II, 15 Stage III, six Stage IV, and one Stage V patient. RT was delivered to the hemiabdomen in 36 and whole abdomen in six patients. RT dose was 1000-1200 cGy (Group A) in 12, 1201-2399 cGy (Group B) in 11, and 2400-4000 cGy (Group C) in 19. Whole-lung RT was delivered to 13 patients either at diagnosis or pulmonary relapse. All patients received chemotherapy; the most common agents were actinomycin-D/vincristine/adriamycin in 13 and actinomycin-D/vincristine in 18. Median follow-up was 181 months (range, 60-306 months).

RESULTS

Of 42 patients, 13 (31.0%) did not have late effects of treatment. The number of patients who developed muscular hypoplasia, limb length inequality, kyphosis, and iliac wing hypoplasia were seven (16.7%), five (11.9%), three (7.1%), and three (7.1%), respectively. Scoliosis was seen in 18 (42.9%) with only one patient requiring orthopedic intervention. Median time to development of scoliosis was 102 months, with a range of 16-146 months. The actuarial incidence of scoliosis at 5, 10, and 15 years after RT was 4.8 +/- 3.3%, 51.8 +/- 9.0%, and 56.7 +/- 9.3%, respectively. Only one of 12 Group A patients developed scoliosis. The 10- and 15-year actuarial incidences of scoliosis for Group A and B patients were 37.7 +/- 12.4% and 37.7 +/- 12.4%, whereas for Group C patients the incidences were 65.8 +/- 12.0% and 74.4 +/- 11. 7% (p = 0.03, log rank test). The actuarial incidence of bowel obstruction at 5, 10, and 15 years was 9.5 +/- 4.5%, 13.0 +/- 5.6%, and 17.0 +/- 6.5%. Of 23 patients, five irradiated within 10 days of surgery and one of 19 irradiated after 10 days developed bowel obstruction (p = 0.09, log rank test). Three patients developed hypertension with normal blood urea nitrogen (BUN) and creatinine levels; another patient had chronic renal insufficiency in a nonirradiated kidney. One patient developed diffuse interstitial pneumonitis. Of the 19 female patients who have reached puberty, three have given birth, and 15 have regular and one has irregular menstrual periods. Four patients developed benign neoplasms; three were in the RT field (two osteochondroma, one lipoma) and one outside (cervical intraepithelial neoplasia II). There were three second malignancies (chronic myelogenous leukemia at 9 years, osteosarcoma at 11 years, and breast cancer at 25 years after initial diagnosis of nephroblastoma); both solid malignancies occurred in the RT field.

CONCLUSIONS

Late effects of therapy were seen in more than two thirds of children treated for Wilms' tumor. Children treated with lower doses (<2400 cGy) had a lower incidence of scoliosis compared with those who received more than 2400 cGy. There is also a suggestion that the incidence is lower in patients who received 1000-1200 cGy. Severe physical and functional deformity from RT was uncommon.

Posterior fossa boost in medulloblastoma: an analysis of dose to surrounding structures using 3-dimensional (conformal) radiotherapy

PURPOSE

The purpose of this study was to compare three different techniques of delivering the posterior fossa boost in patients with medulloblastoma.

METHODS AND MATERIALS

Five patients underwent CT simulation for treatment planning of the posterior fossa boost. For each slice, the posterior fossa was contoured in addition to the cochlea, non-posterior fossa brain, pituitary gland, mandible, parotid glands, thyroid gland, pharynx, and cervical spinal cord. For each patient, plans for three techniques of delivering the posterior fossa boost were compared. Technique A utilized parallel-opposed lateral fields using bony landmarks (2-dimensional radiotherapy); the other two techniques were planned using 3-dimensional radiotherapy. Technique B utilized a pair of coplanar wedged posterior oblique beams, whereas Technique C utilized a pair of posterior oblique fields and a vertex field. Dose-volume histograms (DVH) were obtained for each of the organs contoured and for each technique and patient. The maximum, minimum, and mean dose to each organ were determined using the DVH program in our treatment planning system.

RESULTS

In 3 of 5 patients, the planning target volume (PTV) was not included in the treatment field with Technique A. The cochlea received 100%, 50%, and 42% of the prescribed posterior fossa dose using Techniques A, B, and C respectively. The mean dose to the non-posterior fossa brain was highest with Technique C, intermediate with Technique A, and lowest for Technique B. The mean dose to the non-posterior fossa brain with Technique B was comparable to the mean non-posterior fossa brain dose delivered using parallel-opposed lateral fields based on the CT definition of the PTV. Likewise, mean dose to the pituitary gland was lowest for Technique B. Both Techniques B and C were associated with a higher mean dose to the thyroid gland, mandible, parotid glands, and pharynx.

CONCLUSIONS

The use of Technique B minimized the radiotherapy dose to the cochlea, pituitary gland, and non-posterior fossa brain. Contrary to what one may expect, conformal radiotherapy using Technique B did not deliver a higher dose to the non-posterior fossa brain over standard parallel-opposed lateral fields. Other advantages of conformal techniques B and C over 2-dimensional radiotherapy are the inclusion of the PTV in all patients and a lower mean dose to the pituitary gland. The main disadvantage of conformal Techniques B and C employed in our patients is a higher mean dose to the thyroid gland and other tissues in the neck.

Malignant neoplasms after treatment for metachronous bilateral Wilms' tumor: a literature review

Information regarding malignant neoplasms after treatment for metachronous bilateral Wilms' tumor is limited. A MEDLINE search was performed of all English-language articles from 1950 to 1997 pertaining to metachronous bilateral Wilms' tumor. A total of 108 different cases were identified and analyzed. Mean follow-up was 5.8 years after initial diagnosis of Wilms' tumor (range, 1 month to 25.6 years). Eleven of 63 evaluable children (17.5%) had a congenital anomaly. Four patients (3.7%) developed a malignant neoplasm after treatment of a metachronous bilateral Wilms' tumor. Three of 18 patients followed for at least 10 years developed a solid tumor, including two sarcomas in the irradiated areas. Two of the 4 children who developed a malignant neoplasm had a congenital anomaly. Malignant neoplasms after treatment for metachronous bilateral Wilms' tumor can occur. Health-care professionals caring for these patients should be aware of this late sequelae of treatment.

Resected pancreatic cancer treated with adjuvant radiotherapy with or without 5-fluorouracil: treatment results and patterns of failure

There are relatively little data regarding patterns of recurrence after curative resection and postoperative radiotherapy with or without 5-fluorouracil (5-FU) for patients with adenocarcinonima of the pancreas. Between 1978 and 1997, 41 patients underwent postoperative radiotherapy (RT) at Loyola-Hines Department of Radiotherapy. Of the 38 evaluable patients, 30 had RT + 5-FU and 8 had RT alone. Twenty-nine patients (76.3%) had a Whipple's resection, seven (18.4%) had distal pancreatectomy, and two (5.2%) had total pancreatectomy. Thirty-three (86.8%) of the 38 patients received > or =4,500 cGy to the tumor bed. Median survival for all patients was 21 months. The median survivals for patients who received RT + 5-FU and RT alone were 26 months and 5.5 months (p = 0.004). The most common site of failure was the liver, as seen in 79.2% of all recurrences. The peritoneum, other distant sites (lungs, bone, distant lymph nodes), and locoregional tumor bed were components of failure in 33.3%, 29.2%, and 25.0%, respectively. Locoregional failure alone was found in only one patient. Our median survival with postoperative RT + 5-FU is consistent with results reported by the Gastrointestinal Tumor Study Group and Mayo Clinic. Although patients who had RT + 5-FU had a better median survival than those who received RT alone, our RT-alone group had an inferior survival outcome compared to other published reports and may represent patient selection bias. Efforts in controlling this disease should be directed to prevention of intraabdominal relapse.

Medulloblastoma and supratentorial primitive neuroectodermal tumors: an institutional experience

BACKGROUND

To the authors' knowledge there are relatively few data concerning supratentorial primitive neuroectodermal tumors (PNET). The authors retrospectively reviewed all cases of PNET of the brain treated at the study institution to determine whether there was a difference in presentation, overall survival, and recurrence-free survival with regard to tumor location (supratentorium vs. posterior fossa).

METHODS

Between 1977-1996 33 patients with PNET were diagnosed and treated at 1 radiotherapy center. The median age of the patients was 9 years. The location of the tumor was in the posterior fossa in 25 patients and the supratentorium in 8 patients. The tumor had spread to the neuraxis in six patients; four patients with disseminated neuraxis disease had a supratentorial PNET and two had a posterior fossa PNET. All but three patients received craniospinal irradiation. The primary tumor received > or = 5000 centigray in 27 patients and chemotherapy was employed in 26 patients. The median follow-up was 60 months.

RESULTS

The 5-year overall and recurrence-free survival rates for all patients were 77.2% and 79.6%, respectively. The 5-year overall survival rates were 86.3% for patients with medulloblastoma (posterior fossa PNET) and 46.9% for patients with supratentorial PNET (P = 0.01, log rank test). For overall survival, prognostic factors included radiotherapy dose to the primary site, metastases (M) status, and location of the primary tumor. The 5-year recurrence free survival rates were 89.8% for patients with medulloblastoma and 46.9% for patients with supratentorial PNET (P = 0.003, log rank test). For recurrence free survival, prognostic factors included M status and primary tumor site location; radiation dose to the primary tumor site and patient gender were of borderline significance. In the ten patients with inadequate posterior fossa boost fields judged by Children's Cancer Group criteria, there were two failures, both of which were in the original tumor bed.

CONCLUSIONS

Supratentorial PNET has a worse overall survival and recurrence free survival than medulloblastoma. There is a suggestion that radiotherapy boosts in medulloblastoma may not need to encompass the entire posterior fossa because posterior fossa failures primarily are in the tumor bed. Larger studies with longer follow-up are needed to determine whether craniospinal irradiation followed by a boost to the tumor bed is adequate for medulloblastoma patients.

Trilateral retinoblastoma: is the location of the intracranial tumor important?

BACKGROUND

Trilateral retinoblastoma refers to bilateral retinoblastoma associated with an intracranial primitive neuroectodermal tumor in the pineal or suprasellar region. The purpose of this study was to review patient and tumor characteristics and treatment outcome in patients with trilateral retinoblastoma and to determine whether there is a difference in presentation or outcome according to the location of the intracranial tumor.

METHODS

A MEDLINE search of all English language articles pertaining to trilateral retinoblastoma published between 1977-1997 was performed. A total of 94 different cases were identified and analyzed.

RESULTS

The gender was male in 39 patients (41.5%), female in 50 patients (53.2%), and unknown in 5 patients (5.3%). Family history for retinoblastoma was positive in 44 patients (46.8%), negative in 39 patients (41.5%), and unknown in 11 patients (11.7%). The median age at the time of diagnosis of retinoblastoma was 6 months. The median time interval to the development of an intracranial tumor from the time of diagnosis of retinoblastoma was 21 months. In 78 patients (83.0%) the intracranial tumor was in the pineal region and in 16 patients (17.0%) it was in the suprasellar region. The median time interval from the time of diagnosis of retinoblastoma to the development of a pineal region tumor was 24 months whereas the median time interval for the development of a suprasellar region tumor was 1 month. At 6 months after the diagnosis of intraocular tumors, 6 of 61 children with pineal region tumors and 10 of 14 patients with suprasellar region tumors had developed intracranial disease (P = 0.005). Unilateral intraocular retinoblastoma associated with intracranial tumor was more likely to occur in patients with suprasellar region tumors than pineal region tumors (P < 0.015). The median survival after the diagnosis of an intracranial tumor was 6 months regardless of the location of the intracranial tumor. For patients who received no treatment for the intracranial tumor the median survival was 1 month whereas it was 8 months for those who received treatment. Children who were asymptomatic at the time of diagnosis of the intracranial tumor had a better overall survival than those who were symptomatic (P = 0.002).

CONCLUSIONS

The prognosis of children who develop trilateral retinoblastoma is dismal with current treatment strategies. Tumors of the suprasellar region present earlier than tumors of the pineal region after the diagnosis of intraocular tumors. Because patients who were asymptomatic at the time of diagnosis of intracranial disease had a better overall survival than those who were symptomatic, screening for intracranial tumors may be a valuable strategy in the management of patients with bilateral and/or hereditary retinoblastoma. [See editorial on pages 3-5, this issue.]

Diffuse malignant leptomeningeal gliomatosis in a child: a case report and review of the literature

Diffuse leptomeningeal gliomatosis is a rare condition characterized by glioma in the leptomeninges without a dominant mass lesion. The difficulty in diagnosis of this condition, its rarity. and its extensive nature have hampered its successful treatment. Most cases of primary diffuse leptomeningeal gliomatosis have occurred in adults. Reported here is a case of this condition in a 9-year-old girl; to the authors' knowledge, she is the youngest patient with diffuse leptomeningeal gliomatosis and the longest survivor of the malignant variety.

Controversies in the management of intracranial germinomas

Intracranial germinomas are uncommon tumors. In the past, patients have traditionally been diagnosed with a trial of focal radiotherapy without biopsy. If the tumor was radiosensitive, it was presumed to be a germinoma. Because of the minimal morbidity and mortality associated with microsurgical techniques, almost all patients now have a histologic diagnosis and can be treated appropriately. Radiation therapy has been employed for the past three decades in the curative management of this disease. The long-term results have been excellent; however, current approaches have explored the possibility of reducing or even eliminating radiation therapy. This article provides a brief overview of intracranial germinomas and explores the controversies in the surgical, radiotherapeutic, and chemotherapeutic management of this tumor.

The cranial-spinal junction in medulloblastoma: does it matter?

PURPOSE

Late effects of treatment in children and young adults with medulloblastoma can be influenced by the technique employed in radiating the craniospinal axis. The purpose of this study is to determine whether the placement of the cranial-spinal junction has an impact on dose to the cervical spinal cord and surrounding organs.

METHODS AND MATERIALS

Five patients underwent computed tomography (CT) simulation in the prone position for craniospinal irradiation. A dose of 36 Gy was prescribed to the entire neuraxis. The doses to the cervical spinal cord and surrounding organs were calculated using a cranial-spinal junction at the C1-C2 vertebral interspace (high junction) or at the lowest point in the neck, with exclusion of the shoulders in the lateral cranial fields (low junction). The volume of critical organs at risk, as well as dose to these structures using the cranial and spinal field(s) were outlined and calculated using the CMS FOCUS 3-dimensional treatment planning system.

RESULTS

The average dose to the cervical spinal cord was 11.9% higher than the prescribed dose with the low junction, and 6.7% higher with the high junction. However, doses to the thyroid gland, mandible, pharynx, and larynx were increased by an average of 29.6%, 75.8%, 70.6%, and 227.7%, respectively, by the use of the high junction compared to the low junction.

CONCLUSION

A higher dose to the cervical spinal cord can be minimized by using a high junction. However, this would be at the cost of substantially increased doses to surrounding organs such as the thyroid gland, mandible, pharynx, and larynx. This can be critical in children and young adults, where hypothyroidism, mandibular hypoplasia, and development of second malignancies may be a late sequela of radiation therapy.

Role of radiation therapy in parameningeal rhabdomyosarcoma

Radiation therapy plays a crucial role in the management of children with parameningeal rhabdomyosarcomas. Because of the close proximity to the skull base, most lesions are not amenable to complete surgical resection without mutilation, and treatment has primarily been chemoradiation. Adequate radiotherapy dose, coverage of the tumor, and knowledge of potential areas of invasion are of paramount importance as demonstrated by early data from the Intergroup Rhabdomyosarcoma Study Group. The timing, dose, and treatment volume for parameningeal rhabdomyosarcomas have evolved in the last 25 years in a continuous effort to find ways of maximizing local control while reducing possible late sequelae. Hyperfractionated radiation therapy is currently being tested against conventional dose radiation therapy for group III tumors. At present, approximately 70% of children treated for parameningeal rhabdomyosarcoma on the Intergroup Rhabdomyosarcoma Study are alive at 5 years compared with a 25% survival before the formation of multi-institutional cooperative group studies.

Results of treatment of patients with maxillary sinus carcinoma

BACKGROUND

Information regarding results of treatment and possible prognostic factors in patients with maxillary sinus carcinoma is limited.

METHODS

Between 1969-1995, 48 consecutive patients presented to the study department for curative treatment of maxillary sinus carcinoma. Tumor classification according to the American Joint Committee on Cancer staging system was T1 in 1 patient, T2 in 6 patients, T3 in 17 patients, and T4 in 24 patients. The N classification was NO in 43 patients, N2a in 1 patient, N2b in 3 patients, and N2c in 1 patient. Treatment to the primary site was comprised of surgery (Sx) and radiation therapy (RT) in 37 patients and RT alone in 11 patients.

RESULTS

There was a difference in disease free survival between patients who underwent Sx + RT compared with patients who received RT alone; combined therapy results were more favorable. The most common pattern of recurrence was in the primary site, which was found in 22 of 48 patients (45.8%). For patients who underwent Sx + RT, local control at 3 and 5 years was 65.2% and 59.2%, respectively; for patients who received RT alone, local control at both 3 and 5 years was 22.7%. There were 12 late complications found in 8 patients: fistula formation (5 patients), trismus (3 patients), osteonecrosis (1 patient), retinopathy (1 patient), cellulitis (1 patient), and nasal stenosis (1 patient).

CONCLUSIONS

The type of treatment to the primary site is an important determinant of disease free survival and local control. Failure at the primary site is the main problem in the curative treatment of patients with maxillary sinus carcinoma; efforts to improve survival in these patients should be directed toward improvement of local control.

Determination of the inferior border of the thecal sac using magnetic resonance imaging: implications on radiation therapy treatment planning

PURPOSE

To determine whether the traditional teaching of placing the caudal border of the spinal field at the S2-S3 interspace in children receiving craniospinal irradiation (CSI) is appropriate.

METHODS AND MATERIALS

Twenty-three children had magnetic resonance imaging (MRI) of the spine with gadolinium prior to craniospinal irradiation at one institution. Thecal sac termination using MRI was determined by drawing a perpendicular line from the point of convergence of dural margins to the corresponding vertebral body.

RESULTS

Location of thecal sac termination varied from mid-S1 to low S3 vertebral body, with the most frequent site at the upper S2 vertebral level. Only 2 of 23 (8.7%) children had thecal sac terminations below the S2-S3 interspace. For the nine patients with neuraxis disease, none had thecal sac terminations below the S2-S3 interspace. In seven of the nine patients who had neuraxis seeding at initial presentation, MRI of the spine after CSI was performed and showed that thecal sac termination was lower after radiation therapy in two children, higher in one, and the same in four.

CONCLUSIONS

In 2 of 23 children (8.7%), placement of the inferior border at the bottom of the S2 vertebral body would have missed the entire thecal sac. Treatment to the entire neuraxis with adequate coverage of distal spinal theca can be achieved by using MRI. Individualized spinal fields using the MRI may help minimize radiation scatter to the gonads while adequately covering the target volume.

Metachronous bilateral Wilms' tumor: the importance of time interval to the development of a second tumor

BACKGROUND

Information regarding survival and prognostic factors in children with metachronous bilateral Wilms' tumor is limited.

METHODS

A literature search of English language articles from 1950-1996 was performed. A total of 108 of 123 children with metachronous bilateral Wilms' tumor from 30 studies were evaluable for analysis. The children were classified according to the time interval to the development of a contralateral Wilms' tumor (< 18 months vs. > or = 18 months).

RESULTS

Kaplan-Meier analysis rates of overall survival for metachronous bilateral Wilms' tumor were 49.1% and 47.2% at 5 and 10 years, respectively. The median time interval to the development of a second tumor was 23.1 months. Of 106 children, 102 (96.2%) had a metachronous presentation of Wilms' tumor by 5 years. In children ages < 2 years and children ages 2-5 years, 95.2% and 93.9%, respectively, of contralateral tumors appeared within 60 months. For children ages > or = 5 years, all contralateral kidney tumors appeared by 54 months. Analysis of overall survival of patients with a time interval of < 18 months and > or = 18 months showed a 10-year survival of 39.6% and 55.2%, respectively (P = 0.024, log rank test).

CONCLUSIONS

Children with a metachronous bilateral Wilms' tumor who developed a contralateral tumor > or = 18 months from the initial diagnosis of Wilms' tumor had a better overall survival than children with a time interval of < 18 months. Children ages < 2 years at the initial diagnosis of Wilms' tumor did not have a longer period of risk for developing a contralateral kidney tumor than those ages > or = 2 years. Screening by abdominal ultrasound of the contralateral kidney for > 5 years after initial diagnosis of Wilms' tumor may not be necessary because > 95% of children had a time interval to the development of a second tumor of < or = 60 months.

The location of the prostatic apex on retrograde urethrography and its relationship to the bottom of the ischial tuberosities

To determine the proportion of patients undertreated if the inferior border of the prostate field is set at the bottom of the ischial tuberosities, we reviewed the ports of 80 patients with prostate cancer who had retrograde urethrography as part of simulation for radiation therapy. For the 75 evaluable urethrograms, the mean distance from the top of the urethrogram cone to the bottom of ischial tuberosities was 1.38 cm (range, -0.48-2.90 cm). A comparison of the inferior border defined by the bottom of the ischial tuberosities and retrograde urethrography showed that 47 of 75 (62.7%) patients would have been undertreated if a margin of 1.5 cm was employed, and the prostatic apex was thought to be directly above the urethrogram cone. If the apex was thought to be 1 cm above the cone, six of 75 (8.0%) patients would have been undertreated, using a margin of 1.5 cm. Although previously published reports have established that using the bottom of the ischial tuberosities as the inferior border of the prostate field results in 10-45% undertreatment, our findings, when adjusted for the variability of prostatic apex location and margin of normal tissue employed, indicate that only 8% may actually be undertreated.

Is prophylactic neck irradiation indicated in patients with squamous cell carcinoma of the maxillary sinus?

PURPOSE

To determine the proportion of patients with squamous cell carcinoma of the maxillary sinus who will fail in regional nodes without elective neck treatment and to identify any prognostic factors that may influence neck control.

METHODS AND MATERIALS

From 1971-1995, 42 consecutive patients with squamous cell carcinoma of the maxillary sinus were seen at our department for curative treatment. There were 35 males and 7 females, with a median age at diagnosis of 63.5 years (range, 42-77 years). One tumor was classified as T1, 5 had T2, 15 had T3, and 21 had T4 disease. Four of 42 patients (9.5%) had cervical lymphadenopathy at initial presentation. Thirty-three patients had surgical resection and radiotherapy and nine had radiotherapy alone. None of the 38 patients with clinical N0 necks received elective treatment to the cervical nodes.

RESULTS

Median overall survival was 30 months for all patients. Of the 38 patients with N0 disease, 11 (28.9%) had neck recurrence. Of the 11 neck failures, 9 were ipsilateral only, 1 was contralateral, and 1 had bilateral neck recurrence. The most common site of neck failure was in the upper neck (submandibular and jugulodigastric lymph nodes). Four of the 38 patients (10.5%) had isolated neck failure. Only tumor stage was found to be significant for neck relapse, with T1 and T2 doing worse compared to T3 and T4 tumors. Location of tumor (infrastructure vs. suprastructure), involvement of the oral cavity/oropharynx, nasal cavity, nasopharynx or orbit did not predict for cervical node relapse. Local control at the primary site was likewise not prognostic. The median overall survival for patients who remained N0 was 80 months and for those with initial cervical involvement or recurred in the neck without elective neck irradiation was 25 months (p = 0.05).

CONCLUSION

Based on the 28.9% rate of neck recurrence and the poor median survival of patients who recur in the neck, we recommend prophylactic ipsilateral neck irradiation in patients with T1-T4 squamous cell carcinoma of the maxillary sinus.

Radiotherapeutic management of medulloblastoma

Although craniospinal irradiation has been employed in children with medulloblastoma for the past 40 years, many issues concerning its use have been raised and examined, and some continue to be debated. Careful radiation technique includes adequate irradiation of the neuraxis with special attention to the cribriform plate region and termination of the thecal sac. Conventional-dose craniospinal radiation therapy, in combination with chemotherapy, is currently recommended for patients with high-risk medulloblastoma. The appropriate dose of radiation to the craniospinal axis when this modality is combined with chemotherapy for low-risk medulloblastoma remains to be defined. Long-term results of hyperfractionated radiation therapy are likewise awaited. In an effort to decrease late toxicity to the immature central nervous system, radiation therapy can be delayed in a proportion of infants by administering chemotherapy after maximal tumor debulking.

Splenic irradiation in the palliation of patients with lymphoproliferative and myeloproliferative disorders

INTRODUCTION

Splenic irradiation is an accepted mode of treatment for palliation of hypersplenism and splenic pain for patients with lymphoproliferative or myeloproliferative disorders. However, results are conflicting regarding the duration of palliation and the toxicity associated with this treatment.

METHODS

Twenty-five patients with lymphoproliferative or myeloproliferative disorders were treated with splenic irradiation for palliation of splenomegaly and pain. The spleen was measured and pain and toxicity were assessed during radiation therapy.

RESULTS

Splenomegaly and splenic pain decreased in 60 percent and 91 percent of patients, respectively. Radiation doses higher than 500 cGy appeared to be more effective than lower doses in reducing the spleen size in patients with chronic lymphocytic leukemia. Regression of splenomegaly and pain relief were maintained for less than one year and more than six months, respectively. Acute radiation toxicity resulted in the cessation of radiotherapy in two patients.

CONCLUSION

Splenic irradiation is effective in the short-term palliation of splenomegaly and pain and may be most useful in the subset of patients with a life expectancy of less than one year. Terminally ill patients with splenomegaly secondary to lymphoproliferative or myeloproliferative disorders may benefit from splenic irradiation to minimize pain and pressure symptoms in addition to possible reduction of narcotic use.

Local control in synchronous bilateral Wilms tumor

PURPOSE

To evaluate the role of radiation therapy (RT), chemotherapy (CT), and surgery in the local control of synchronous bilateral Wilms Tumor (WT).

METHODS AND MATERIALS

Between 1962 to 1993, 45 children were treated for bilateral WT; 38 patients with synchronous tumors were reviewed. Initial surgery depended on the era of treatment and included unilateral nephrectomy (N)/partial nephrectomy (PN) and contralateral PN in 6, unilateral N/PN alone in 7, and biopsy only in 25. Chemotherapy (CT) consisted of vincristine, actinomycin-D, and adriamycin in 32 and vincristine/ actinomycin-D in 6. Radiation therapy (RT) was given to 32 patients. Treatment included both kidneys in 20, unilateral kidney plus contralateral renal bed in 9, unilateral kidney in 2, and unilateral renal bed in 1. Follow-up was 16 months to 25 years (median: 6.3 years).

RESULTS

Local control (LC) has been maintained in 66 out of 76 sites (87%). For Stage I-II disease with initial N/PN, LC was 10 out of 12 with RT and 11 out of 11 without RT; for Stage III with initial N/PN, LC was 8 out of 9 with RT and 1 out of 1 without RT. Initial CT and RT was followed by delayed N/PN for 20 sites; LC was 15 out of 17 in post induction Stage I-II and 1 out of 3 in postinduction Stage III. In 23 sites undergoing biopsy and chemotherapy, LC was 19 out of 20 with RT and 1 out of 3 without RT. Seven of 23 sites had a complete response (CR) after induction CT, and LC was maintained in four out of four with RT and one out of three without RT. Univariate Cox Regression analysis demonstrated that sites receiving two drugs had a statistically significant increase in loco-regional relapse when compared to sites receiving three drugs (p = 0.004). Major morbidities related to multimodality therapy have included renal failure in one patient and small bowel obstruction requiring lysis of adhesions in two patients.

CONCLUSIONS

Local control does not seem to be compromised by renal conservation therapy. Local control is excellent in sites treated with radiation therapy in combination with three drug chemotherapy.

Current issues in the diagnosis and management of Wilms' tumor

Significant advances have been made in the treatment of children with Wilms' tumor. Whereas 50 years ago overall survival was less than 10%, current survival estimates approach 90%. This progress has been made possible by the cooperation of pediatric oncologists, surgeons, pathologists, radiation oncologists, and support personnel in their joint quest to find a cure for this intriguing childhood neoplasm. The next goals are to determine better treatment for patients with unfavorable histology tumors or recurrent disease and to identify patients who may not require adjuvant therapy. Also, the role of renal parenchymal-sparing resections needs to be defined further.

Postoperative irradiation of patients with malignant tumors of skull base

To better understand how to irradiate patients after skull-base surgery, the authors of this study analyzed the tumor recurrence patterns in 22 patients with various malignancies. Of these patients, 13 underwent craniofacial resection, 6 had infratemporal fossa resection, and 3 had temporal bone resection. The entire operative field was irradiated in 8 patients (total-field group), and part of the operative field was irradiated in 14 patients (partial-field group). Tumor regrew within the irradiated area in 25% of the total-field group and 14% of the partial-field group. Tumor appeared outside the operative field in 13% of the total-field group and 57% of the partial-field group. Recurrences appeared in contiguous sites in 5 patients, in the unirradiated scar in 5 patients, and in the lymph nodes in 4 patients. Based on the study findings, the authors state that irradiation of the entire operative field, including scars and potential areas of contiguous spread, may be necessary to maximize local control after skull-base surgery.