1
|
Cappellano AM, Dassi N, Mançano BM, Epelman S, Almeida DB, Cavalheiro S, Dastoli PA, Alves MTS, Nicacio JM, Costa MDS, Silva FA, Aguiar SS, Figueiredo ML, Chen M, Silva NS, Finlay JL. Intracranial non-germinomatous germ cell tumors in children and adolescents: how can the experience from an uppermiddle-income country contribute to the worldwide effort to improve outcomes? Front Oncol 2024; 14:1308128. [PMID: 38500657 PMCID: PMC10947194 DOI: 10.3389/fonc.2024.1308128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/12/2024] [Indexed: 03/20/2024] Open
Abstract
Background Non-germinomatous germ cell tumors (NGGCT) accounts for one third of intracranial GCT. While the germinoma group have an excellent overall survival, the standard of practice for children with NGGCT is still under evaluation. Aims Describe the results of the of the Brazilian consortium protocol. Methods Since 2013, 15 patients with a diagnosis of NGGCT by histopathology and/or serum/cerebrospinal fluid (CSF) tumor markers, βHCG >200mlU/ml and/or positive alpha-fetoprotein were treated with neoadjuvant chemotherapy with carboplatin, cyclophosphamide and etoposide followed by ventricular radiotherapy (RTV) of 18Gy with boost (32Gy) to the primary site. Metastatic patients underwent craniospinal irradiation (CSI) and "slow responders" to the four initial cycles of CT, to autologous stem cell transplantation (ASCT) followed by CSI. Results Mean age, 13.1 years. Thirteen males. Primary sites: pineal (n=12), suprasellar (n=2) and bifocal (n=1). Four patients were metastatic at diagnosis. Eight patients had CSF and/or serum alpha-fetoprotein levels > 1,000ng/ml. Tumor responses after chemotherapy demonstrated complete in six cases and partial in seven, with "second-look" surgery being performed in five cases, and two patients presenting viable lesions being referred to ASCT. The main toxicity observed was hematological grades 3/4. Two patients with metastatic disease, one with Down Syndrome and AFP > 1,000ng/ml and the other with choriocarcinoma and pulmonary metastases, developed progressive disease resulting in death, as well as two other patients without evidence of disease, due to endocrinological disorders. Event-free and overall survival at 2 and 5 years were 80% and 72.7%, respectively, with a mean follow-up of 48 months (range, 7-107). Conclusions Despite the small number of patients, in our series, treatment with six cycles of chemotherapy and RTV with focal boost for localized disease (n=11) and ACST for identified slow responders (n=2) seem to be effective strategies contributing to the overall effort to improve outcomes of this group of patients.
Collapse
Affiliation(s)
- Andrea M. Cappellano
- Pediatric Oncology, Pediatric Oncology Institute-GRAACC/Federal University of São Paulo, São Paulo, Brazil
| | - Natalia Dassi
- Pediatric Oncology, Pediatric Oncology Institute-GRAACC/Federal University of São Paulo, São Paulo, Brazil
| | | | - Sidnei Epelman
- Pediatric Oncology, Hospital Santa Marcelina-TUCCA, São Paulo, Brazil
| | - Daniela B. Almeida
- Nursing Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Sergio Cavalheiro
- Neurosurgery Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Patricia A. Dastoli
- Neurosurgery Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Maria T. S. Alves
- Pathology Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Jardel M. Nicacio
- Neurosurgery Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Marcos D. S. Costa
- Neurosurgery Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Frederico A. Silva
- Radiology Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Simone S. Aguiar
- Pediatric Oncology, Pediatric Oncology Institute-GRAACC/Federal University of São Paulo, São Paulo, Brazil
| | - Maria L. Figueiredo
- Radiotherapy Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Michael Chen
- Radiotherapy Department, Pediatric Oncology Institute-GRAACC, Federal University of São Paulo, São Paulo, Brazil
| | - Nasjla S. Silva
- Pediatric Oncology, Pediatric Oncology Institute-GRAACC/Federal University of São Paulo, São Paulo, Brazil
| | - Jonathan L. Finlay
- Paediatric Oncology, The Ohio State University, Columbus, OH, United States
| |
Collapse
|
2
|
Yeoh TDYY, Nga V, Kimpo M, Lo SS, Vellayappan B. Intracranial Germ Cell Tumors. Semin Neurol 2023; 43:897-908. [PMID: 37963583 DOI: 10.1055/s-0043-1776763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Intracranial germ cell tumors are rare tumors occurring in adolescents and young adults, which include germinomas and non-germinomatous type germ cell tumors (NGGCT). In the past few decades, cooperative trial groups in Europe and North America have developed successful strategies to improve survival outcomes and decrease treatment-related toxicities. New approaches to establishing diagnosis have deferred the need for radical surgery. The 5-year event-free survival (EFS) is above 90% and even patients who present with metastatic germinoma can still be cured with chemotherapy and craniospinal irradiation. The combination of surgery, chemotherapy, and radiation therapy is tailored to patients based on grouping and staging. For NGGCT, neoadjuvant chemotherapy followed by delayed surgery for residual disease and radiotherapy can yield a 5-year EFS of 70%. Further strategies should focus on reducing long-term complications while preserving high cure rates.
Collapse
Affiliation(s)
- Teri Danielle You Ying Yeoh
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore
| | - Vincent Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Miriam Kimpo
- Department of Paediatrics, National University Hospital, Singapore
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore
| |
Collapse
|
3
|
Kremenevski N, Buchfelder M, Hore N. Intracranial Germinomas: Diagnosis, Pathogenesis, Clinical Presentation, and Management. Curr Oncol Rep 2023; 25:765-775. [PMID: 37036624 PMCID: PMC10256636 DOI: 10.1007/s11912-023-01416-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE OF REVIEW Intracranial germinomas constitute a rare brain tumor entity of unknown etiology, characterized by unique histopathology and molecular biology. In this manuscript, we review the literature focusing on the epidemiology, histopathology with molecular biology, clinical presentation with emphasis on tumor location, diagnostic workup, and current treatment strategies with related clinical outcomes of intracranial germinomas. RECENT FINDINGS Although the optimal treatment strategy remains a matter of debate, intracranial germinomas respond well to radiotherapy, chemotherapy, or a combination of both and are characterized by very high cure and survival rates. It is well-known that early discrimination of germinomas from other intracranial neoplasms facilitates the timely initiation of appropriate treatment, thereby contributing to the reduction of morbidity as well as mortality. Ongoing research will need to be directed towards discovering and refining reliable parameters for early diagnosis and evaluation of prognosis in patients with intracranial germinomas.
Collapse
Affiliation(s)
- Natalia Kremenevski
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany.
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Nirjhar Hore
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
4
|
Li S, Wang C, Chen J, Lan Y, Zhang W, Kang Z, Zheng Y, Zhang R, Yu J, Li W. Signaling pathways in brain tumors and therapeutic interventions. Signal Transduct Target Ther 2023; 8:8. [PMID: 36596785 PMCID: PMC9810702 DOI: 10.1038/s41392-022-01260-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 01/05/2023] Open
Abstract
Brain tumors, although rare, contribute to distinct mortality and morbidity at all ages. Although there are few therapeutic options for brain tumors, enhanced biological understanding and unexampled innovations in targeted therapies and immunotherapies have considerably improved patients' prognoses. Nonetheless, the reduced response rates and unavoidable drug resistance of currently available treatment approaches have become a barrier to further improvement in brain tumor (glioma, meningioma, CNS germ cell tumors, and CNS lymphoma) treatment. Previous literature data revealed that several different signaling pathways are dysregulated in brain tumor. Importantly, a better understanding of targeting signaling pathways that influences malignant behavior of brain tumor cells might open the way for the development of novel targeted therapies. Thus, there is an urgent need for a more comprehensive understanding of the pathogenesis of these brain tumors, which might result in greater progress in therapeutic approaches. This paper began with a brief description of the epidemiology, incidence, risk factors, as well as survival of brain tumors. Next, the major signaling pathways underlying these brain tumors' pathogenesis and current progress in therapies, including clinical trials, targeted therapies, immunotherapies, and system therapies, have been systemically reviewed and discussed. Finally, future perspective and challenges of development of novel therapeutic strategies in brain tumor were emphasized.
Collapse
Affiliation(s)
- Shenglan Li
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Can Wang
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinyi Chen
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanjie Lan
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weichunbai Zhang
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhuang Kang
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Zheng
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rong Zhang
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianyu Yu
- grid.24696.3f0000 0004 0369 153XDepartment of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenbin Li
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
5
|
Cai Y, Xiong Z, Xin C, Chen J, Liu K. Endoscope-Assisted Microsurgery in Pediatric Cases With Pineal Region Tumors: A Study of 18 Cases Series. Front Surg 2021; 8:641196. [PMID: 34414209 PMCID: PMC8368719 DOI: 10.3389/fsurg.2021.641196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 07/08/2021] [Indexed: 11/29/2022] Open
Abstract
Background: An endoscope-assisted technique was recently introduced to microsurgery (MS) and may compensate for the disadvantages of MS for deep-seated lesions. This study was performed to identify the effectiveness and safety of endoscopic-assisted microsurgery (EAM) and share our experience of EAM for pediatric cases with pineal region tumors. Method: We retrospectively analyzed the clinical data of consecutive pediatric cases with pineal region tumors treated by EAM or MS from January 2016 to June 2020. These data included the patient population, clinical manifestations, preoperative examination findings, surgical approach, pathological results, and clinical outcomes. The clinical outcomes were analyzed in the EAM group and MS group with a focus on the gross total resection (GTR) rate, postoperative hydrocephalus remission rate, and Karnofsky performance score (KPS). Studies on the surgical management of children with pineal region tumors in the last decade were reviewed. Result: Eighteen children successfully underwent tumor resection via MS (n = 8) or EAM (n = 10). The children's mean age was 11.4 ± 4.7 years, and the male to female ratio was 7:2. Seventeen patients (94.4%) complicated preoperative hydrocephalus, and 16 (88.9%) presented headache with nausea and/or vomiting. The pathological examination revealed germ cell tumors in 11 (61.1%) patients, neuroepithelial tumors in 4 (22.2%) patients, and a pineoblastoma, arachnoid cyst, and atypical teratoid rhabdoid tumor in 1 (5.6%) patient each. GTR was more commonly achieved in the EAM than MS group (80.0 vs. 50.0%, respectively), and the postoperative hydrocephalus remission rate was higher in the EAM than MS group (87.5 vs. 50.0%, respectively). At a mean follow-up time of 23.6 ± 11.5 weeks, the mean improvement of the KPS 6 months postoperatively was greater in the EAM than MS group (24.0 ± 9.7 vs. 17.5 ± 7.1 points, respectively). Conclusion: EAM combines endoscopic and microsurgical techniques and can be safely and effectively performed to achieve GTR of pineal region tumors in pediatric patients. In children with pineal region tumors who have obstructive hydrocephalus, EAM could improves hydrocephalus remission rates by checking and clearing the midbrain aqueduct under visualization.
Collapse
Affiliation(s)
- Yuankun Cai
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Zhongwei Xiong
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Can Xin
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Kui Liu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| |
Collapse
|
6
|
Lőcsei Z, Farkas R, Borbásné Farkas K, Sebestyén K, Sebestyén Z, Musch Z, Vojcek Á, Benedek N, Mangel L, Ottóffy G. Assessment of the results and hematological side effects of 3D conformal and IMRT/ARC therapies delivered during craniospinal irradiation of childhood tumors with a follow-up period of five years. BMC Cancer 2020; 20:702. [PMID: 32727407 PMCID: PMC7388493 DOI: 10.1186/s12885-020-07168-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/12/2020] [Indexed: 01/04/2023] Open
Abstract
Background Craniospinal irradiation (CSI) of childhood tumors with the RapidArc technique is a new method of treatment. Our objective was to compare the acute hematological toxicity pattern during 3D conformal radiotherapy with the application of the novel technique. Methods Data from patients treated between 2007 and 2014 were collected, and seven patients were identified in both treatment groups. After establishing a general linear model, acute blood toxicity results were obtained using SPSS software. Furthermore, the exposure dose of the organs at risk was compared. Patients were followed for a minimum of 5 years, and progression-free survival and overall survival data were assessed. Results After assessment of the laboratory parameters in the two groups, it may be concluded that no significant differences were detected in terms of the mean dose exposures of the normal tissues or the acute hematological side effects during the IMRT/ARC and 3D conformal treatments. Laboratory parameters decreased significantly compared to the baseline values during the treatment weeks. Nevertheless, no significant differences were detected between the two groups. No remarkable differences were confirmed between the two groups regarding the five-year progression-free survival or overall survival, and no signs of serious organ toxicity due to irradiation were observed during the follow-up period in either of the groups. Conclusion The RapidArc technique can be used safely even in the treatment of childhood tumors, as the extent of the exposure dose in normal tissues and the amount of acute hematological side effects are not higher with this technique.
Collapse
Affiliation(s)
- Zoltán Lőcsei
- Clinical Center, Department of Oncotherapy, University of Pécs, Édesanyák útja 17, Pécs, 7624, Hungary.
| | - Róbert Farkas
- Oncoradiology Center, Uzsoki Hospital, Uzsoki u. 29-41, Budapest, 1145, Hungary
| | - Kornélia Borbásné Farkas
- Unicersity of Pécs, Medical School, Institute of Bioanalysis, Szigeti út 12, Pécs, 7624, Hungary
| | - Klára Sebestyén
- Clinical Center, Department of Oncotherapy, University of Pécs, Édesanyák útja 17, Pécs, 7624, Hungary
| | - Zsolt Sebestyén
- Clinical Center, Department of Oncotherapy, University of Pécs, Édesanyák útja 17, Pécs, 7624, Hungary
| | - Zoltán Musch
- Clinical Center, Department of Oncotherapy, University of Pécs, Édesanyák útja 17, Pécs, 7624, Hungary
| | - Ágnes Vojcek
- Oncology Unit, Clinical Center, Department of Pediatrics Pécs, University of Pécs, József Attila út 7, Pécs, 7623, Hungary
| | - Noémi Benedek
- Oncology Unit, Clinical Center, Department of Pediatrics Pécs, University of Pécs, József Attila út 7, Pécs, 7623, Hungary
| | - László Mangel
- Clinical Center, Department of Oncotherapy, University of Pécs, Édesanyák útja 17, Pécs, 7624, Hungary
| | - Gábor Ottóffy
- Oncology Unit, Clinical Center, Department of Pediatrics Pécs, University of Pécs, József Attila út 7, Pécs, 7623, Hungary
| |
Collapse
|
7
|
Li D, Wen R, Gao Y, Xu Y, Xiong B, Gong F, Wang W. Pineal Region Gliomas: A Single-Center Experience with 25 Cases. World Neurosurg 2019; 133:e6-e17. [PMID: 31284062 DOI: 10.1016/j.wneu.2019.06.189] [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: 04/12/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pineal region glioma is a rare systematically reported tumor in the literatures, and little is known about its behavior, development, and best treatment strategies because of its complex anatomical relationship and rarity. OBJECTIVE We reviewed the outcomes of patients with pineal region gliomas in West China hospital in the past 5 years and searched the literature to add more information. As a result, key factors related to prognosis are identified. METHODS Twenty-five patients with pineal region gliomas were selected and information was collected about detailed medical history, imaging data, treatment methods, pathologic results, and latest neurosurgical radiologic progress during follow-up. RESULTS Pilocytic astrocytomas (20%) and glioblastomas (24%) were the most common pathologic subtypes. Twenty-three patients underwent open surgery, 3 Gamma Knife radiosurgery, and 4 whole-brain radiation therapy. Chemotherapy was applied to 3 patients. Low-grade gliomas tended to have a better prognosis than did high-grade. Karnofsky Performance Status at admission (≤60) was intimately associated with prognosis for low-grade gliomas. As for high-grade gliomas, patients whose age at admission was ≤30 years had a better prognosis than did older patients (>30 years). However, whatever the grade, there was no overall survival difference as to gender, gross total resection versus not gross total resection, preoperative maximal tumor diameter (≤4 vs. >4 cm), and time since first symptoms (≤30 vs. >30 days), and radiation therapy versus no radiation therapy. CONCLUSIONS Open surgery is the first-line strategy for pineal region gliomas with tolerable mortality and disability rate. Radiosurgery and chemotherapy can be applied as adjuvant or alternative methods when surgery is contraindicated.
Collapse
Affiliation(s)
- Denghui Li
- Neurosurgery Department of West China Hospital Affiliated to Sichuan University, Wuhou District, Chengdu, Sichuan Province, People's Republic of China
| | - Rong Wen
- Neurosurgery Department of West China Hospital Affiliated to Sichuan University, Wuhou District, Chengdu, Sichuan Province, People's Republic of China
| | - Yuan Gao
- Neurosurgery Department of West China Hospital Affiliated to Sichuan University, Wuhou District, Chengdu, Sichuan Province, People's Republic of China
| | - Yangyang Xu
- Neurosurgery Department of West China Hospital Affiliated to Sichuan University, Wuhou District, Chengdu, Sichuan Province, People's Republic of China
| | - Botao Xiong
- Neurosurgery Department of West China Hospital Affiliated to Sichuan University, Wuhou District, Chengdu, Sichuan Province, People's Republic of China
| | - Feilong Gong
- Neurosurgery Department of West China Hospital Affiliated to Sichuan University, Wuhou District, Chengdu, Sichuan Province, People's Republic of China
| | - Wei Wang
- Neurosurgery Department of West China Hospital Affiliated to Sichuan University, Wuhou District, Chengdu, Sichuan Province, People's Republic of China.
| |
Collapse
|
8
|
Abu Arja MH, Bouffet E, Finlay JL, AbdelBaki MS. Critical review of the management of primary central nervous nongerminomatous germ cell tumors. Pediatr Blood Cancer 2019; 66:e27658. [PMID: 30767415 DOI: 10.1002/pbc.27658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/06/2019] [Accepted: 01/27/2019] [Indexed: 12/28/2022]
Abstract
Multimodal strategies have significantly improved the outcomes for patients with central nervous system nongerminomatous germ cell tumors. Two large cooperative group studies have recently reported much improved outcomes compared with historical series. However, a substantial proportion of patients still attain inadequate responses to initial chemotherapy prior to irradiation, with adverse impact upon survival; optimal induction chemotherapy regimens and radiotherapy strategies are as yet unidentified. Outcomes for patients with relapsed disease remain poor. There is an obvious need to incorporate molecular studies within prospective clinical trials that will likely lead to the incorporation of targeted, more effective future treatment strategies.
Collapse
Affiliation(s)
- Mohammad H Abu Arja
- The Division of Hematology, Oncology and Blood and Marrow Transplant, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Eric Bouffet
- The Division of Hematology, Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan L Finlay
- The Division of Hematology, Oncology and Blood and Marrow Transplant, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Mohamed S AbdelBaki
- The Division of Hematology, Oncology and Blood and Marrow Transplant, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| |
Collapse
|
9
|
Seravalli E, Bosman M, Lassen-Ramshad Y, Vestergaard A, Oldenburger F, Visser J, Koutsouveli E, Paraskevopoulou C, Horan G, Ajithkumar T, Timmermann B, Fuentes CS, Whitfield G, Marchant T, Padovani L, Garnier E, Gandola L, Meroni S, Hoeben BAW, Kusters M, Alapetite C, Losa S, Goudjil F, Magelssen H, Evensen ME, Saran F, Smyth G, Rombi B, Righetto R, Kortmann RD, Janssens GO. Dosimetric comparison of five different techniques for craniospinal irradiation across 15 European centers: analysis on behalf of the SIOP-E-BTG (radiotherapy working group) . Acta Oncol 2018; 57:1240-1249. [PMID: 29698060 DOI: 10.1080/0284186x.2018.1465588] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Conventional techniques (3D-CRT) for craniospinal irradiation (CSI) are still widely used. Modern techniques (IMRT, VMAT, TomoTherapy®, proton pencil beam scanning [PBS]) are applied in a limited number of centers. For a 14-year-old patient, we aimed to compare dose distributions of five CSI techniques applied across Europe and generated according to the participating institute protocols, therefore representing daily practice. MATERIAL AND METHODS A multicenter (n = 15) dosimetric analysis of five different techniques for CSI (3D-CRT, IMRT, VMAT, TomoTherapy®, PBS; 3 centers per technique) was performed using the same patient data, set of delineations and dose prescription (36.0/1.8 Gy). Different treatment plans were optimized based on the same planning target volume margin. All participating institutes returned their best treatment plan applicable in clinic. RESULTS The modern radiotherapy techniques investigated resulted in superior conformity/homogeneity-indices (CI/HI), particularly in the spinal part of the target (CI: 3D-CRT:0.3 vs. modern:0.6; HI: 3D-CRT:0.2 vs. modern:0.1), and demonstrated a decreased dose to the thyroid, heart, esophagus and pancreas. Dose reductions of >10.0 Gy were observed with PBS compared to modern photon techniques for parotid glands, thyroid and pancreas. Following this technique, a wide range in dosimetry among centers using the same technique was observed (e.g., thyroid mean dose: VMAT: 5.6-24.6 Gy; PBS: 0.3-10.1 Gy). CONCLUSIONS The investigated modern radiotherapy techniques demonstrate superior dosimetric results compared to 3D-CRT. The lowest mean dose for organs at risk is obtained with proton therapy. However, for a large number of organs ranges in mean doses were wide and overlapping between techniques making it difficult to recommend one radiotherapy technique over another.
Collapse
Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Mirjam Bosman
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Yasmin Lassen-Ramshad
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Vestergaard
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Foppe Oldenburger
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jorrit Visser
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Efi Koutsouveli
- Department of Radiation Oncology, Hygeia Hospital, Athens, Greece
| | | | - Gail Horan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Beate Timmermann
- Clinic for Particle Therapy, West German Protontherapy Center Essen, University Hospital Essen, Essen, Germany
| | - Carolina-Sofia Fuentes
- Clinic for Particle Therapy, West German Protontherapy Center Essen, University Hospital Essen, Essen, Germany
| | - Gillian Whitfield
- The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK and The Children's Brain Tumour Research Network, University of Manchester, Royal Mancheste Children's Hospital, Manchester, UK
| | | | - Laetitia Padovani
- Department of Radiotherapy, Centre Hospitalier Universitaire de La Timone, Marseille, France
| | - Eloise Garnier
- Department of Radiotherapy, Centre Hospitalier Universitaire de La Timone, Marseille, France
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silvia Meroni
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Bianca A. W. Hoeben
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn Kusters
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Claire Alapetite
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Sandra Losa
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Farid Goudjil
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Henriette Magelssen
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Morten Egeberg Evensen
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Frank Saran
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Gregory Smyth
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Barbara Rombi
- Protontherapy Center, Azienda Provinciale per i Servizi Sanitari APSS, Trento, Italy
| | - Roberto Righetto
- Protontherapy Center, Azienda Provinciale per i Servizi Sanitari APSS, Trento, Italy
| | | | - Geert O. Janssens
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| |
Collapse
|
10
|
Calaminus G, Frappaz D, Kortmann RD, Krefeld B, Saran F, Pietsch T, Vasiljevic A, Garre ML, Ricardi U, Mann JR, Göbel U, Alapetite C, Murray MJ, Nicholson JC. Outcome of patients with intracranial non-germinomatous germ cell tumors-lessons from the SIOP-CNS-GCT-96 trial. Neuro Oncol 2018; 19:1661-1672. [PMID: 29048505 DOI: 10.1093/neuonc/nox122] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Following promising results to increase survival and reduce treatment burden in intracranial non-germinomatous germ cell tumors (NGGCTs), we conducted a European study using dose-intense chemotherapy followed by risk-adapted radiotherapy. Methods All patients received 4 courses of cisplatin/etoposide/ifosfamide. Non-metastatic patients then received focal radiotherapy only (54 Gy); metastatic patients received 30 Gy craniospinal radiotherapy with 24 Gy boost to primary tumor and macroscopic metastatic sites. Results Patients with localized malignant NGGCT (n = 116) demonstrated 5-year progression-free survival (PFS) and overall survival (OS) of 0.72 ± 0.04 and 0.82 ± 0.04, respectively. Primary tumor sites were: 67 pineal, 35 suprasellar, 5 bifocal, 9 others. One patient died postsurgery in clinical remission; 3 patients progressed during treatment and 27 (23%) relapsed afterward. Fourteen were local, 6 combined, and 7 distant relapses (outside radiation field). Seventeen of the 27 relapsed patients died of disease. Patients with metastatic disease (n = 33) demonstrated 5-year PFS and OS of 0.68 ± 0.09 and 0.75 ± 0.08, respectively; 1 patient died following progression on treatment and 9 (27%) relapsed afterward (5 local, 1 combined, 3 distant). Only one metastatic patient with recurrence was salvaged. Multivariate analysis identified diagnostic alpha-fetoprotein level (serum and/or cerebrospinal fluid level >1000 ng/mL, 19/149 patients, of whom 11 relapsed; P < 0.0003) and residual disease following treatment, including after second-look surgery (n = 52/145 evaluable patients, 26 relapsed; P = 0.0002) as significant prognostic indicators in this cohort. Conclusion In localized malignant NGGCT, craniospinal radiotherapy could be avoided without increased relapses outside the radiotherapy field. Chemotherapy and craniospinal radiotherapy remain the gold standard for metastatic disease.
Collapse
Affiliation(s)
- Gabriele Calaminus
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Didier Frappaz
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Rolf Dieter Kortmann
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Barbara Krefeld
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Frank Saran
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Torsten Pietsch
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Alexandre Vasiljevic
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Maria Luisa Garre
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Umberto Ricardi
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Jillian R Mann
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Ulrich Göbel
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Claire Alapetite
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - Matthew J Murray
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| | - James C Nicholson
- Radiation Oncology, Institut Curie, Paris, France; Paediatric Hematology/Oncology, University Children's Hospital Bonn, Bonn, Germany; Institute d'Hémato-Oncologie Pédiatrique, Centre Leon Berard, Lyon, France; Neuro-Oncology, G.Gaslini Children's Hospital, Genoa, Italy; ESPED University Düsseldorf, Düsseldorf, Germany; Radiation Therapy and Radio-oncology, University of Leipzig, Leipzig, Germany; Paediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany; Paediatric Oncology, Cambridge University Hospitals, Cambridge, UK; Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK; Institute of Neuropathology, Bonn, Germany; Department of Oncology, University of Turin, Turin, Italy; Department of Radiotherapy, Royal Marsden Hospital, Surrey, UK; Department of Neuropathology, Centre Leon Berard, Lyon, France
| |
Collapse
|
11
|
Wong KK, Ragab O, Tran HN, Pham A, All S, Waxer J, Olch AJ. Acute toxicity of craniospinal irradiation with volumetric-modulated arc therapy in children with solid tumors. Pediatr Blood Cancer 2018; 65:e27050. [PMID: 29630782 DOI: 10.1002/pbc.27050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 01/30/2018] [Accepted: 02/14/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Craniospinal irradiation (CSI) is an important part of curative radiation therapy (RT) for many types of pediatric brain or solid tumors. After conventional CSI, long term survivors may experience sequelae due to unintended dose to normal tissue. Volumetric modulated arc therapy (VMAT) CSI reduces off-target doses at the cost of greater complexity and error risk, and we describe our initial experience in a group of pediatric patients with solid tumors presenting with disseminated or recurrent disease. PROCEDURE Pediatric patients with brain tumors were identified at Children's Hospital Los Angeles from 2013 to 2015. Clinical characteristics, acute toxicity, and radiotherapy data were abstracted from their medical records. We identified 19 patients who received VMAT CSI. Quality assurance was performed with a cylindrical detector array and ion chamber measurements at the arc junctions. RESULTS Patients had medulloblastoma or supratentorial primitive neuro-ectodermal tumor (n = 14, 11 high risk), germ cell tumors (two), relapsed neuroblastoma (two), and atypical teratoid/rhabdoid tumor (one). The most common acute toxicity was hematologic, including leukopenia (11% grade [Gr] 2, 26% Gr 3, and 63% Gr 4), anemia (89% Gr 2), and thrombocytopenia (16% Gr 1-2, 26% Gr 3, and 37% Gr 4). Despite leukopenia, we encountered only two Gr 3 infections (urinary tract and lung). The majority required blood products (89% red blood cells and 68% platelets). Weight loss was also common (47% Gr 1 and 26% Gr 2). CONCLUSIONS VMAT CSI, along with chemotherapy and anesthesia, is feasible with supportive care. Daily image-guided RT improves accuracy and reduces the risk of spinal cord overdose without increasing treatment time. Further research is needed to determine whether reducing doses to organs, such as thyroid, heart, or hippocampus, offsets the risk of increased volume of low-dose irradiation.
Collapse
Affiliation(s)
- Kenneth K Wong
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California.,Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| | - Omar Ragab
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Hung N Tran
- Pediatric Neuro-Oncology, Department of Pediatrics, Kaiser Permanente, Los Angeles, California
| | - Anthony Pham
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sean All
- College of Medicine, University of Central Florida, Orlando, Florida
| | - Jonathan Waxer
- School of Medicine, Tulane University, New Orleans, Louisiana
| | - Arthur J Olch
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California.,Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| |
Collapse
|
12
|
Ajithkumar T, Horan G, Padovani L, Thorp N, Timmermann B, Alapetite C, Gandola L, Ramos M, Van Beek K, Christiaens M, Lassen-Ramshad Y, Magelssen H, Nilsson K, Saran F, Rombi B, Kortmann R, Janssens GO. SIOPE - Brain tumor group consensus guideline on craniospinal target volume delineation for high-precision radiotherapy. Radiother Oncol 2018; 128:192-197. [PMID: 29729847 DOI: 10.1016/j.radonc.2018.04.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 04/14/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To develop a consensus guideline for craniospinal target volume (TV) delineation in children and young adults participating in SIOPE studies in the era of high-precision radiotherapy. METHODS AND MATERIALS During four consensus meetings (Cambridge, Essen, Liverpool, and Marseille), conventional field-based TV has been translated into image-guided high-precision craniospinal TV by a group of expert paediatric radiation oncologists and enhanced by MRI images of liquor distribution. RESULTS The CTVcranial should include the whole brain, cribriform plate, most inferior part of the temporal lobes, and the pituitary fossa. If the full length of both optic nerves is not included, the dose received by different volumes of optic nerve should be recorded to correlate with future patterns of relapse (no consensus). The CTVcranial should be modified to include the dural cuffs of cranial nerves as they pass through the skull base foramina. Attempts to spare the cochlea by excluding CSF within the internal auditory canal should be avoided. The CTVspinal should include the entire subarachnoid space, including nerve roots laterally. The lower limit of the spinal CTV is at the lower limit of the thecal sac, best visible on MRI scan. There is no need to include sacral root canals in the spinal CTV. CONCLUSION This consensus guideline has the potential to improve consistency of craniospinal TV delineation in an era of high-precision radiotherapy. This proposal will be incorporated in the RTQA guidelines of future SIOPE-BTG trials using CSI.
Collapse
Affiliation(s)
| | - Gail Horan
- Department of Oncology, Cambridge University Hospitals, United Kingdom
| | - Laetitia Padovani
- Department of Radiation Oncology, Assistance Publique Hôpitaux de Marseille, France
| | - Nicky Thorp
- Department of Oncology, Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | | | - Claire Alapetite
- Radiation Oncology department and Proton Centre, Institute Curie, Paris and Orsay, France
| | - Lorenza Gandola
- Department of Radiation Oncology, Fondazione IRCCS-Istituto Nazionale dei Tumori, Milan, Italy
| | - Monica Ramos
- Hospital Universitari de la Vall d'Hebron, Barcelona, Spain
| | | | | | | | - Henriette Magelssen
- Department of Oncology, Oslo University Hospital (The Norwegian Radium Hospital), Norway
| | - Kristina Nilsson
- Department of Immunology, Genetics and Pathology, Experimental and Clinical Oncology, Clinical Oncology, Uppsala University Hospital, Sweden
| | - Frank Saran
- Department of Oncology, Royal Marsden Hospital, Sutton, United Kingdom
| | - Barbara Rombi
- Proton Therapy Center, Santa Chiara Hospital, Trento, Italy
| | - Rolf Kortmann
- Department of Radiation Oncology, University of Leipzig, Germany
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, and Princess Maxima Center for Pediatric Oncology, The Netherlands
| | | |
Collapse
|
13
|
Phi JH, Wang KC, Kim SK. Intracranial Germ Cell Tumor in the Molecular Era. J Korean Neurosurg Soc 2018; 61:333-342. [PMID: 29742886 PMCID: PMC5957323 DOI: 10.3340/jkns.2018.0056] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/02/2018] [Accepted: 04/16/2018] [Indexed: 12/15/2022] Open
Abstract
Intracranial germ cell tumors (iGCTs) are a heterogeneous group of tumors with peculiar characteristics clearly distinguished from other brain tumors of neuroepithelial origin. Diverse histology, similarity to gonadal GCT, predilection to one sex, and geographic difference in incidence all present enigmas and fascinating challenges. The treatment of iGCT has advanced for germinoma to date; thus, clinical attention has shifted from survival to long-term quality of life. However, for non-germinomatous GCT, current protocols provide only modest improvement and more innovative therapies are needed. Recently, next-generation sequencing studies have revealed the genomic landscape of iGCT. Novel mutations in the KIT-RAS-MAPK and AKT-MTOR pathways were identified. More importantly, methylation profiling revealed a new method to assess the pathogenesis of iGCT. Molecular research will unleash new knowledge on the origin of iGCT and solve the many mysteries that have lingered on this peculiar neoplasm for a long time.
Collapse
Affiliation(s)
- Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu-Chang Wang
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
14
|
Nagasawa DT, Lagman C, Sun M, Yew A, Chung LK, Lee SJ, Bui TT, Ooi YC, Robison RA, Zada G, Yang I. Pineal germ cell tumors: Two cases with review of histopathologies and biomarkers. J Clin Neurosci 2017; 38:23-31. [PMID: 28189312 DOI: 10.1016/j.jocn.2016.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/27/2016] [Indexed: 02/08/2023]
Abstract
Pineal germ cell tumors (GCTs) are primarily seen in pediatric and Asian populations. These tumors are divided into germinomatous and non-germinomatous GCTs (NGGCTs). GCTs are thought to arise by misplacement of totipotent stem cells en route to gonads during embryogenesis. Intracranial GCTs display an affinity to develop along the pineal-suprasellar axis and have variable manifestations dependent upon the location of the tumor. Management and outcomes are driven by histopathologies. In this study, we highlight two cases of pineal GCTs and present a review of the literature with an emphasis on histopathologies and biomarkers.
Collapse
Affiliation(s)
- Daniel T Nagasawa
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Carlito Lagman
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michael Sun
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Andrew Yew
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Lawrance K Chung
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Seung J Lee
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Timothy T Bui
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yinn Cher Ooi
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - R Aaron Robison
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, Los Angeles, CA, United States
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, Los Angeles, CA, United States
| | - Isaac Yang
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States; Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States; Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, United States.
| |
Collapse
|
15
|
Greenfield BJ, Jaramillo S, Abboud M, Mahajan A, Paulino AC, McGovern S, McAleer MF, Chintagumpala M, Okcu MF, Khatua S, Su J, Grosshans DR. Outcomes for pediatric patients with central nervous system germ cell tumors treated with proton therapy. Clin Transl Radiat Oncol 2016; 1:9-14. [PMID: 29657988 PMCID: PMC5893478 DOI: 10.1016/j.ctro.2016.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose We assessed outcomes after proton therapy (PT) for central nervous system germinomas or non-germinomatous germ cell tumors (NGGCTs) in children. Patients and methods We identified children with germ cell tumors of the central nervous system who received proton therapy in 2006–2009 and extracted information on tumor response, treatment failures, and toxicity. Results Of the 20 identified patients (median age 12 years [range 3–16]), 9 had germinoma and 11 NGGCTs; 19 patients received three-dimensional conformal PT and 1 scanning-beam PT. Fourteen patients had craniospinal irradiation (CSI), 4 had ventricular irradiation that excluded the 4th ventricle, and 2 had whole-ventricle irradiation. All received involved-field boosts. At a median follow-up interval of 5.6 years (range, 0.3–8.2 years), 1 patient with germinoma had an out-of-field failure in the 4th ventricle and 2 with NGGCT died from disease progression after CSI. Rates of local control, progression-free survival, and overall survival at 5 years were 89%, 89%, and 100% for patients with germinoma; corresponding rates for NGGCTs were 82%, 82%, and 82%. The most common late toxicity (9 patients [45%]) was endocrinopathy. Conclusions PT for CNS germ cell tumors is associated with acceptable disease control rates and toxicity profiles.
Collapse
Affiliation(s)
- Brad J Greenfield
- Baylor College of Medicine, The University of Texas MD Anderson Cancer Center, USA
| | - Sergio Jaramillo
- Baylor College of Medicine, The University of Texas MD Anderson Cancer Center, USA.,Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, USA
| | - Mirna Abboud
- Baylor College of Medicine, The University of Texas MD Anderson Cancer Center, USA
| | - Anita Mahajan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Susan McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Mary F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Murali Chintagumpala
- Baylor College of Medicine, The University of Texas MD Anderson Cancer Center, USA.,Texas Children's Cancer and Hematology Center, USA
| | - M Fatih Okcu
- Baylor College of Medicine, The University of Texas MD Anderson Cancer Center, USA.,Texas Children's Cancer and Hematology Center, USA
| | - Soumen Khatua
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, USA
| | - Jack Su
- Baylor College of Medicine, The University of Texas MD Anderson Cancer Center, USA.,Texas Children's Cancer and Hematology Center, USA
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, USA
| |
Collapse
|
16
|
Huang X, Zhang R, Mao Y, Zhou LF, Zhang C. Recent advances in molecular biology and treatment strategies for intracranial germ cell tumors. World J Pediatr 2016; 12:275-282. [PMID: 27351562 DOI: 10.1007/s12519-016-0021-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 04/13/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Intracranial germ cell tumors (IGCTs) are a group of rare pediatric brain tumors which include various subtypes. The current understanding of the etiology of the tumors and their optimal management strategies remain controversial. DATA SOURCES The data on IGCTs were collected from articles published in the past 20 years, and the origin and etiology of IGCTs at molecular level as well as the relative roles of varied treatment strategies in different prognosis groups according to Matsutani's classification were reviewed. RESULTS Recent cellular and molecular evidence suggests that IGCTs may arise from the transformation of endogenous brain cells; and findings in the molecular characterization of IGCTs suggest roles of CCND2, RB1, and PRDM14 in the pathogenesis of IGCTs and identify the KIT/RAS and AKT1/mTOR pathways as potential therapeutic targets in future. According to Matsutani's classification of IGCTs, the good prognosis group includes both germinomas and mature teratomas. For germinomas, both radiation alone and reduced-dose radiotherapy in combination with adjuvant chemotherapy are effective, while complete surgical excision is recommended for mature teratomas. In the intermediate prognosis group, immature teratoma has been successfully treated with gamma knife surgery. However, for intermediate prognosis IGCTs other than immature teratomas, gross total resection with adjuvant chemotherapy and radiotherapy or gamma knife surgery may be necessary to achieve cure. In the poor prognosis group, survival outcomes are unsatisfactory, and complete surgical resection combined with more intensive chemotherapy and radiotherapy remains the best available treatment option at this time. CONCLUSIONS IGCTs should be strictly classified according to their pathological categories before administering pathology-specific treatments. Although open microsurgical excision is the traditional surgical strategy for IGCTs, recent publications also support the role of endoscopic surgical options for pineal region IGCTs.
Collapse
Affiliation(s)
- Xiang Huang
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
| | - Rong Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
| | - Liang-Fu Zhou
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
| | - Chao Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
| |
Collapse
|
17
|
Sonabend AM, Bowden S, Bruce JN. Microsurgical resection of pineal region tumors. J Neurooncol 2016; 130:351-366. [PMID: 27193692 DOI: 10.1007/s11060-016-2138-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/02/2016] [Indexed: 11/26/2022]
Abstract
The extensive variety of possible histologic subtypes makes it imperative to establish a tissue diagnosis in patients with pineal region tumors. Management decisions regarding adjuvant therapy, prognosis, and follow-up strategies vary with the histologic diagnosis. Specialized surgical and stereotactic techniques have evolved to provide the neurosurgeon with an array of safe and effective options for obtaining a tissue diagnosis. Advanced microsurgical techniques combined with improved preoperative management and postoperative critical care methods have made aggressive surgical resection a mainstay of management. Aggressive surgical resection has resulted in excellent long-term prognoses for nearly all patients with benign tumors and a large percentage of patients with malignant tumors. However, pineal region surgery remains fraught with potential pitfalls, and these favorable results are dependent on an advanced level of surgical expertise.
Collapse
Affiliation(s)
- Adam M Sonabend
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Stephen Bowden
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA.
| |
Collapse
|
18
|
Han JW, Koh KN, Kim JY, Baek HJ, Lee JW, Shim KW, Cho J, Kim DS. Current Trends in Management for Central Nervous System Germ Cell Tumor. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2016. [DOI: 10.15264/cpho.2016.23.1.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jung Woo Han
- Division of Pediatric Hemato-Oncology, Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System
- Department of Pediatric Hemato-Oncology, Yonsei Cancer Center, Yonsei University Health System
| | - Kyung-Nam Koh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine & Asan Medical Center, Seoul
| | - Ji Yoon Kim
- Department of Pediatrics, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu
| | - Hee Jo Baek
- Department of Pediatrics, Chonnam National University Medical School, Chonnam National University Hwasun Hospital, Gwangju
| | - Ji Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kyu-Won Shim
- Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University Health System
| | - Jaeho Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Dong-Seok Kim
- Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University Health System
| |
Collapse
|
19
|
Jinguji S, Yoshimura J, Nishiyama K, Yoneoka Y, Sano M, Fukuda M, Fujii Y. Long-term outcomes in patients with pineal nongerminomatous malignant germ cell tumors treated by radical resection during initial treatment combined with adjuvant therapy. Acta Neurochir (Wien) 2015; 157:2175-83. [PMID: 26482943 DOI: 10.1007/s00701-015-2614-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 10/09/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND For pineal nongerminomatous malignant germ cell tumors (NGMGCTs), we mainly performed radical tumor resection during initial treatment combined with adjuvant therapy. METHODS We retrospectively analyzed 17 patients treated for pineal NGMGCTs between 1986 and 2007 at the University of Niigata. RESULTS Twelve patients underwent total or subtotal resection of their tumor via the occipital transtentorial approach. Five patients underwent partial resection, and four of them later underwent total resection by salvage surgery. After surgery, eight patients were treated with combined radiochemotherapy including whole-brain irradiation, two received radiation monotherapy, one had chemotherapy with local irradiation, and six were treated with chemotherapy alone. The median follow-up period for surviving patients was 179 months. The 10-year overall survival and progression-free survival rates for the radiochemotherapy group were both 75.0 % (two patients had a recurrence and died); the rates for other adjuvant therapies were 77.8 % (two died) and 22.2 % (seven had a recurrence), respectively. Radiochemotherapy was significantly associated with an increased rate of progression-free survival compared with the other adjuvant therapies (p = 0.0396). CONCLUSIONS For pineal NGMGCTs, initial treatment strategies including gross total resection of the tumor before or after whole-brain irradiation and chemotherapy provided good therapeutic outcomes. Obtaining complete remission of the primary tumor, irrespective of the timing of surgical resection (i.e., before or after adjuvant therapies), or complete response by neoadjuvant radiochemotherapy during an initial treatment appears to be essential for improving therapeutic outcomes of intracranial NGMGCTs.
Collapse
|
20
|
Cox MC, Kusters JM, Gidding CE, Schieving JH, van Lindert EJ, Kaanders JH, Janssens GO. Acute toxicity profile of craniospinal irradiation with intensity-modulated radiation therapy in children with medulloblastoma: A prospective analysis. Radiat Oncol 2015; 10:241. [PMID: 26597178 PMCID: PMC4657242 DOI: 10.1186/s13014-015-0547-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To report on the acute toxicity in children with medulloblastoma undergoing intensity-modulated radiation therapy (IMRT) with daily intrafractionally modulated junctions. METHODS Newly diagnosed patients, aged 3-21, with standard-risk (SR) or high-risk (HR) medulloblastoma were eligible. A dose of 23.4 or 36.0 Gy in daily fractions of 1.8 Gy was prescribed to the craniospinal axis, followed by a boost to the primary tumor bed (54 or 55.8 Gy) and metastases (39.6-55.8 Gy), when indicated. Weekly, an intravenous bolus of vincristine was combined for patients with SR medulloblastoma and patients participating in the COG-ACNS-0332 study. Common toxicity criteria (CTC, version 2.0) focusing on skin, alopecia, voice changes, conjunctivitis, anorexia, dysphagia, gastro-intestinal symptoms, headache, fatigue and hematological changes were scored weekly during radiotherapy. RESULTS From 2010 to 2014, data from 15 consecutive patients (SR, n = 7; HR, n = 8) were collected. Within 72 h from onset of treatment, vomiting (66 %) and headache (46 %) occurred. During week 3 of treatment, a peak incidence in constipation (33 %) and abdominal pain/cramping (40 %) was observed, but only in the subgroup of patients (n = 9) receiving vincristine (constipation: 56 vs 0 %, P = .04; pain/cramping: 67 vs 0 %, P = .03). At week 6, 73 % of the patients developed faint erythema of the cranial skin with dry desquamation (40 %) or moist desquamation confined to the skin folds of the auricle (33 %). No reaction of the skin overlying the spinal target volume was observed. CONCLUSIONS Headache at onset and gastro-intestinal toxicity, especially in patients receiving weekly vincristine, were the major complaints of patients with medulloblastoma undergoing craniospinal irradiation with IMRT.
Collapse
Affiliation(s)
- Maurice C Cox
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Johannes M Kusters
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Corrie E Gidding
- Department of Pediatric Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Jolanda H Schieving
- Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Erik J van Lindert
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Johannes H Kaanders
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Center for Pediatric Oncology, Utrecht, 3584, CX, The Netherlands.
| |
Collapse
|
21
|
Alken SP, D'Urso P, Saran FH. Managing teenage/young adult (TYA) brain tumors: a UK perspective. CNS Oncol 2015; 4:235-46. [PMID: 26118974 DOI: 10.2217/cns.15.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Tumors of the CNS are among the commonest malignancies occurring in teenage/young adult patients (i.e., those aged between 15 and 24 years). The treatment of this patient population is challenging. Adolescence and young adulthood are a turbulent period of life, with physical, emotional, social and cognitive changes. Best practice advocates their treatment in dedicated teenage/young adult units, with multidisciplinary team input and access to clinical trials. Treatment of CNS malignancies is dependent upon histological subtype and staging, with varying combinations of surgery, radiotherapy and chemotherapy used. Clinical trials directly targeted at this patient population are rare; treatments are based on pediatric protocols as studies have demonstrated improved outcomes in patients (with other malignancies) treated as such. Scope for improvement lies in minimizing patient risk of recurrence and long-term sequelae of treatment. Molecular characterization of tumors may provide further information.
Collapse
Affiliation(s)
- Scheryll P Alken
- Department of Neuro Oncology, Royal Marsden Hospital, Sutton, UK
| | - Pietro D'Urso
- Department of Neurosurgery, Salford Royal Hospital Foundation Trust, Salford, UK
| | - Frank H Saran
- Department of Neuro Oncology, Royal Marsden Hospital, Sutton, UK
| |
Collapse
|
22
|
Goldman S, Bouffet E, Fisher PG, Allen JC, Robertson PL, Chuba PJ, Donahue B, Kretschmar CS, Zhou T, Buxton AB, Pollack IF. Phase II Trial Assessing the Ability of Neoadjuvant Chemotherapy With or Without Second-Look Surgery to Eliminate Measurable Disease for Nongerminomatous Germ Cell Tumors: A Children's Oncology Group Study. J Clin Oncol 2015; 33:2464-71. [PMID: 26101244 DOI: 10.1200/jco.2014.59.5132] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This phase II trial evaluated the effect of neoadjuvant chemotherapy with or without second-look surgery before craniospinal irradiation on response rates and survival outcomes in children with newly diagnosed non-germinomatous germ cell tumors. PATIENTS AND METHODS Induction chemotherapy consisted of six cycles of carboplatin/etoposide alternating with ifosfamide/etoposide. Patients demonstrating less than complete response after induction chemotherapy were encouraged to undergo second-look surgery. Patients who did not achieve complete response or partial response after chemotherapy with or without second-look surgery proceeded to high-dose chemotherapy with thiotepa and etoposide and autologous peripheral blood stem-cell rescue before craniospinal irradiation. RESULTS The study included 102 patients treated between January 2004 and July 2008. Median age was 12 years, and 76% were male; 53.9% had pineal region masses, and 23.5% had suprasellar lesions. Sixty-nine percent of patients achieved complete response or partial response with neoadjuvant chemotherapy. At 5 years, event-free survival was 84% ± 4% (SE) and overall survival was 93% ± 3%. During the median follow-up of 5.1 years, 16 patients recurred or progressed, with seven deaths after relapse. No deaths were attributed to therapy-related toxicity. Relapse occurred at the site of primary disease in 10 patients, at a distant site in three patients, or both in one patient. In two patients, progression was detected by marker increase alone. Increased serum α-fetoprotein was a negative prognostic variable. Histologic subtype and increase of beta-human chorionic gonadotropin were not significantly correlated with worse outcomes. CONCLUSION Neoadjuvant chemotherapy with or without second-look surgery achieved high response rates contributing to excellent survival outcomes in children with newly diagnosed non-germinomatous germ cell tumors. This regimen should be included as a backbone for further studies.
Collapse
Affiliation(s)
- Stewart Goldman
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Eric Bouffet
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Paul G Fisher
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey C Allen
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patricia L Robertson
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Paul J Chuba
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bernadine Donahue
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Cynthia S Kretschmar
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tianni Zhou
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Allen B Buxton
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ian F Pollack
- Stewart Goldman, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Eric Bouffet, The Hospital for Sick Children, Toronto, ON, Canada; Paul G. Fisher, Lucile Packard Children's Hospital Stanford, Palo Alto; Cynthia S. Kretschmar, Children's Hospital Los Angeles, Los Angeles; Tianni Zhou, California State University, Long Beach; Allen B. Buxton, Children's Oncology Group, Monrovia, CA; Jeffrey C. Allen and Bernadine Donahue, New York University Langone Medical Center, New York, NY; Patricia L. Robertson, University of Michigan C.S. Mott Children's Hospital, Ann Arbor; Paul J. Chuba, St. John Hospital and Medical Center, Grosse Pointe, MI; and Ian F. Pollack, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
23
|
Lai IC, Wong TT, Shiau CY, Hu YW, Ho DMT, Chang KP, Guo WY, Chang FC, Liang ML, Lee YY, Chen HH, Yen SH, Chen YW. Treatment results and prognostic factors for intracranial nongerminomatous germ cell tumors: single institute experience. Childs Nerv Syst 2015; 31:683-91. [PMID: 25749900 DOI: 10.1007/s00381-015-2623-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 02/02/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE This study aimed to evaluate the treatment of intracranial nongerminomatous germ cell tumors (NGGCT) and to identify the prognostic factors for survival. METHODS Thirty-nine patients with nondisseminated NGGCTs, excluding those with pure mature teratomas, were treated between January 1985 and December 2010. Twenty-four patients received gross total or partial removal, 11 had excision biopsies, and 4 had no surgery. Radiotherapy was given postoperatively or definitively with a median tumor bed dose of 54 Gy (range 30-54) with or without craniospinal irradiation. All patients received ten cycles of adjuvant chemotherapy, vinblastine, bleomycin, etoposide, and cisplatin after radiotherapy, except for one with mixed anaplastic astrocytoma component who received oral temozolomide. Survival and prognostic factors were estimated by the Kaplan-Meier method and log-rank tests, respectively. RESULTS After a median follow-up of 77.7 months (range 14-336), the 6-year overall survival (OS) and progression-free survival (PFS) were 74.4 and 79.5 %, respectively. Inferior PFS was associated with lesions in the suprasellar region (p = 0.017), poor pathological features (p = 0.048), and with poor image (p < 0.0001) and tumor marker (TM) response (p = 0.003) to irradiation. Decreased OS was associated with lesions in the suprasellar region (p = 0.026) and with poor image (p < 0.0001) and TM response (p = 0.027) to irradiation. Neither the extent of surgery nor the radiation field was found to significantly influence survival. CONCLUSIONS By our multimodality approach, patients achieved comparable outcomes. Other than poor pathological features, patients with poor responses to radiotherapy are prone to early recurrence and inferior survival. These patients should be focused for more intensive adjuvant treatment.
Collapse
Affiliation(s)
- I-Chun Lai
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, No. 201, Sec.2, Shi-Pai Road, Taipei, 11217, Taiwan
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Radiation therapy in pediatric pineal tumors. Neurochirurgie 2015; 61:212-5. [PMID: 25612810 DOI: 10.1016/j.neuchi.2014.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 01/12/2014] [Accepted: 11/11/2014] [Indexed: 11/21/2022]
Abstract
Pineal tumor management in pediatric patients must be based on close co-operation between oncologists, surgeons, radiation oncologists, neurologists, ophthalmologists, and endocrinologists. Radiation therapy (RT) remains critical in most situations and should be assessed as soon as the diagnosis is made, in order to optimize the radiation technique. This paper will focus on RT modalities, indications, as well as modalities in main pediatric pineal tumors (germ cell tumors and pineal parenchyma tumors). RT modalities are presently being debated and new RT techniques (intensity-modulated RT, proton therapy etc.) that are now available for pineal lesions need to be evaluated. Radiation strategies are also controversial for germ cell tumors: cranio-spinal radiation versus chemotherapy followed by focal radiation, which also requires discussion.
Collapse
|
25
|
Frappaz D, Conter CF, Szathmari A, Valsijevic A, Mottolese C. The management of pineal tumors as a model for a multidisciplinary approach in neuro-oncology. Neurochirurgie 2014; 61:208-11. [PMID: 24863688 DOI: 10.1016/j.neuchi.2014.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 03/03/2014] [Accepted: 03/05/2014] [Indexed: 12/11/2022]
Abstract
The management of pineal tumors is a model for multidisciplinarity. Apart from an emergency situation that requires immediate shunting of cerebrospinal fluid (CSF), the initial discussion should involve at least a radiologist, a surgeon, a neurologist and an oncologist. The initial decision is whether obtaining a histological proof is obligatory. It depends on age and ethnicity, site (mono- or bifocality), presence of markers in serum as well as CSF, and/or of malignant cells in the CSF. In cases of marker elevation indicating a germ cell tumor, front line chemotherapy can avoid dangerous immediate surgery. When histological proof is required, the extent of surgery should be discussed, aiming either only at obtaining tissue or removal. If a germ cell tumor is detected, treatment will include a cisplatin-containing chemotherapy followed by focal or ventricular irradiation. Tumors of the pineal parenchyma will be treated according to grade, either by surgery alone (pinealocytoma) or chemo-radiotherapy (pinealoblastomas). Similarly, gliomas will be treated depending on their grade with several different possible lines in low grade, and usually radio-chemotherapy in high grade. A careful balance between improved survival rates and decreased long-term side effects will guide the decisions of all these specialists.
Collapse
Affiliation(s)
- D Frappaz
- Neuro-oncologie, centre Léon-Bérard, 28, rue Laennec, 69673 Lyon, France.
| | - C Faure Conter
- Institut d'hématologie et d'oncologie pédiatriques, 69673 Lyon, France
| | | | | | | |
Collapse
|
26
|
Robertson PL, Jakacki R, Hukin J, Siffert J, Allen JC. Multimodality therapy for CNS mixed malignant germ cell tumors (MMGCT): results of a phase II multi-institutional study. J Neurooncol 2014; 118:93-100. [DOI: 10.1007/s11060-013-1306-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 11/10/2013] [Indexed: 10/25/2022]
|
27
|
Saito R, Kumabe T, Kanamori M, Sonoda Y, Watanabe M, Mugikura S, Takahashi S, Tominaga T. Early response to chemotherapy as an indicator for the management of germinoma-like tumors of the pineal and/or suprasellar regions. J Clin Neurosci 2013; 21:124-30. [PMID: 24238633 DOI: 10.1016/j.jocn.2013.05.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 04/22/2013] [Accepted: 05/15/2013] [Indexed: 11/17/2022]
Abstract
Recent advances in diagnostic imaging and experience with germinomas may allow for the differentiation of central nervous system germinomas from other tumors based on clinical information, without histological verification. We retrospectively analyzed clinically diagnosed germinoma-like tumors of the pineal and/or suprasellar regions. This was done to evaluate the efficacy of our strategy of defining germinoma-compatible tumors based on good responses to initial chemotherapy. The responses to chemotherapy and survival of 34 consecutive patients with germinoma-like tumors who underwent initial treatment from July 2001 to October 2010 were analyzed. The minimum apparent diffusion coefficient (minADC) value and proton magnetic resonance spectroscopy (MRS) were evaluated in recent patients. Twelve patients with histologically verified germinomas and 18 with germinoma-compatible tumors showed early logarithmic decreases in tumor volume in response to initial chemotherapy, typical low minADC values and typical MRS characteristics, including increased choline/creatine ratios, decreased N-acetylasparate/creatine ratios, and large lipid peaks. These patients had good progression-free survival. The other four patients, with histologically verified non-germinomas, showed no response to chemotherapy, and one patient with a pineoblastoma showed a similar minADC value and MRS characteristics to those of patients with germinomas. The response to initial chemotherapy can be used to distinguish germinoma-compatible tumors from non-germinoma in patients with germinoma-like tumors of the pineal and/or suprasellar regions. The evaluation of minADC and proton MRS are useful for distinguishing germinomas from other tumors. However, a subset of non-germinomas may show similar characteristics to germinomas. The benefit of bypassing unnecessary surgical intervention can be achieved, at least in Asian populations with a high incidence of germinomas.
Collapse
Affiliation(s)
- Ryuta Saito
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshihiro Kumabe
- Department of Neurosurgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan.
| | - Masayuki Kanamori
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yukihiko Sonoda
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mika Watanabe
- Department of Pathology, Tohoku University Hospital, Sendai, Japan
| | - Shunji Mugikura
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shoki Takahashi
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
28
|
Aizer AA, Sethi RV, Hedley-Whyte ET, Ebb D, Tarbell NJ, Yock TI, Macdonald SM. Bifocal intracranial tumors of nongerminomatous germ cell etiology: diagnostic and therapeutic implications. Neuro Oncol 2013; 15:955-60. [PMID: 23640532 DOI: 10.1093/neuonc/not050] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients presenting with synchronous bifocal intracranial tumors (masses in the pineal and neurohypophyseal region), detectable human chorionic gonadotropin (hCG) levels (5-100 mIU/mL), and normal alpha feto-protein (AFP) levels (≤10 ng/mL) are often diagnosed empirically with pure germinoma. In such scenarios, pathologic confirmation is often deferred, given that bifocal nongerminomatous germ cell tumors (NGGCTs) are considered rare and because available literature and research protocols support such an approach. We sought to characterize the association between bifocal intracranial tumors and NGGCT histology. METHODS Seventy-one patients treated for intracranial germ cell tumors at Massachusetts General Hospital in 1998-2012 were identified. Patients presenting with synchronous bifocal disease were selected for further review. RESULTS Of the 71 patients presenting with intracranial germ cell tumors, 14 (19.7%) had synchronous bifocal disease. Of these 14 patients, 7 (50.0%) had germinoma, 3 (21.4%) had NGGCT, and 4 (28.6%) had hCG levels <200 mIU/mL and normal AFP levels and were treated without pathologic confirmation. Of the 3 patients with confirmed bifocal NGGCT, 2 had detectable hCG levels with AFP <10 ng/mL and 1 patient had a detectable hCG level with a modest elevation in AFP. CONCLUSIONS NGGCTs should be considered in the differential diagnosis for patients presenting with bifocal intracranial tumors. Given differences in the management of germinomas and NGGCTs, clinicians should strongly consider a biopsy in patients presenting with bifocal masses and normal or modestly elevated biomarkers. Misclassification of such cases as germinomas could result in undertreatment and a possible increased risk for recurrence.
Collapse
Affiliation(s)
- Ayal A Aizer
- Harvard Radiation Oncology Program, Boston, Massachusetts, USA
| | | | | | | | | | | | | |
Collapse
|
29
|
Bromberg JEC, Baumert BG, de Vos F, Gijtenbeek JMM, Kurt E, Westermann AM, Wesseling P. Primary intracranial germ-cell tumors in adults: a practical review. J Neurooncol 2013; 113:175-83. [PMID: 23526409 DOI: 10.1007/s11060-013-1114-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 03/12/2013] [Indexed: 11/28/2022]
Abstract
Primary intracranial germ-cell tumors are rare tumors primarily of adolescence, and literature on this disease in adults is scarce. The available evidence on intracranial germ-cell tumors is reviewed with a focus on adult patients whenever possible, and used to make suggestions for diagnosis and treatment. Diagnostic and treatment algorithms were developed to provide an evidence-based backbone to base treatment on in adult patients with a (suspected) primary intracranial germ-cell tumor.
Collapse
Affiliation(s)
- Jacoline E C Bromberg
- Department of Neuro-Oncology, Daniel den Hoed Cancer Center, Erasmus University Medical Center, P O Box 5201, 3008 AE, Rotterdam, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
30
|
Primary CNS germ cell tumors: current epidemiology and update on treatment. Med Oncol 2013; 30:496. [DOI: 10.1007/s12032-013-0496-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 02/02/2013] [Indexed: 10/27/2022]
|
31
|
Blakeley J, Grossman SA. Chemotherapy with cytotoxic and cytostatic agents in brain cancer. HANDBOOK OF CLINICAL NEUROLOGY 2012; 104:229-54. [PMID: 22230447 DOI: 10.1016/b978-0-444-52138-5.00017-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
32
|
Kusters JM, Louwe RJ, van Kollenburg PG, Kunze-Busch MC, Gidding CE, van Lindert EJ, Kaanders JH, Janssens GO. Optimal Normal Tissue Sparing in Craniospinal Axis Irradiation Using IMRT With Daily Intrafractionally Modulated Junction(s). Int J Radiat Oncol Biol Phys 2011; 81:1405-14. [DOI: 10.1016/j.ijrobp.2010.07.1987] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Revised: 07/16/2010] [Accepted: 07/20/2010] [Indexed: 10/18/2022]
|
33
|
Nakamura H, Makino K, Kochi M, Ushio Y, Kuratsu JI. Evaluation of neoadjuvant therapy in patients with nongerminomatous malignant germ cell tumors. J Neurosurg Pediatr 2011; 7:431-8. [PMID: 21456918 DOI: 10.3171/2011.1.peds10433] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors evaluated the effectiveness of a neoadjuvant therapy (NAT) consisting of combined chemo and radiotherapy followed by complete resection of the residual tumor in patients with nongerminomatous malignant germ cell tumors (NGMGCTs). METHODS The authors treated 14 consecutive patients in whom NGMGCTs were diagnosed based on elevated levels of the tumor markers α-fetoprotein, human chorionic gonadotropin, and the β-subunit of human chorionic gonadotropin (β-HCG). Chemotherapy and radiotherapy were performed, and after the serum tumor markers level was in the normal or near-normal range, the residual tumors were completely resected. RESULTS Residual tumors were confirmed in 11 of the 14 patients after NAT, and total removal was successful in 10 of the 11 patients. In the other patient the residual tumor could not be completely excised because it was attached to a deep vein. The follow-up duration ranged from 1.2 to 22.2 years. The 5-year event-free and total survival rates were 86% and 93%, respectively. Although 3 patients died, 2 of tumor recurrence and 1 of a radiation-induced secondary tumor (glioblastoma), the other 11 are alive and without evidence of tumor recurrence. CONCLUSIONS The authors consider their NAT protocol for NGMGCT to be highly effective in relation to survival for the patients with NGMGCT, but there are several quality of life issues that need to be resolved.
Collapse
Affiliation(s)
- Hideo Nakamura
- Department of Neurosurgery, Faculty of Medical and Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan.
| | | | | | | | | |
Collapse
|
34
|
|
35
|
Fujimaki T. Central nervous system germ cell tumors: classification, clinical features, and treatment with a historical overview. J Child Neurol 2009; 24:1439-45. [PMID: 19841431 DOI: 10.1177/0883073809342127] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Central nervous system germ cell tumors are neoplasms that affect children and young adults. They are subclassified into germinoma and nongerminomatous germ cell tumors. The latter include teratoma (mature teratoma, immature teratoma, teratoma with malignant transformation), choriocarcinoma, embryonal carcinoma, yolk sac tumors, and mixtures of these entities. Germinoma with syncytiotrophoblastic giant cells is a variant of germinoma. Germinomas respond well to radiation therapy, but late sequelae due to irradiation have been reported. The results of radiation treatment alone for nongerminomatous germ cell tumor are not satisfactory. Combination radiochemotherapy has been applied, and this yields a good outcome with less toxicity for germinomas and better survival of nongerminomatous germ cell tumors. This article also discusses other issues, including the controversy regarding spinal irradiation and the treatment of recurrent disease.
Collapse
Affiliation(s)
- Takamitsu Fujimaki
- Department of Neurosurgery, Saitama Medical University, Moroyama-Machi, Japan.
| |
Collapse
|
36
|
Primary, non-exophytic, optic nerve germ cell tumors. J Neurooncol 2009; 95:437-443. [DOI: 10.1007/s11060-009-9941-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 06/15/2009] [Indexed: 11/28/2022]
|
37
|
Kanamori M, Kumabe T, Tominaga T. Is histological diagnosis necessary to start treatment for germ cell tumours in the pineal region? J Clin Neurosci 2008; 15:978-87. [DOI: 10.1016/j.jocn.2007.08.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Revised: 08/05/2007] [Accepted: 08/07/2007] [Indexed: 10/21/2022]
|
38
|
|
39
|
Abstract
Tumors of the pineal region represent a diverse collection of tumors with a variety of natural histories. This diversity necessitates accurate histologic diagnosis to allow rational therapeutic planning. Evaluation of a pineal lesion should begin with craniospinal MRI and analysis of the cerebrospinal fluid (CSF). Whereas certainty of the histologic diagnosis is now a requirement for treatment in Western nations, some Asian centers continue to recommend a test dose of radiation therapy based on the high incidence of germinoma in those countries. If there is high clinical suspicion of a germinoma or tectal glioma, stereotactic or endoscopic biopsy may be pursued. All other lesions should be referred for open biopsy with microsurgical techniques. This approach provides adequate tissue for diagnosis, may be curative in low-grade tumors, and may substantially improve survival in patients with malignant tumors. If open surgery is not desired by the patient or practitioner, stereotactic or endoscopic biopsy may be followed by radiosurgery for localized, well-demarcated tumors. Radiation therapy is the first-line therapy for germinomas. Although the optimal radiation dosage and volume have not been decided, the current Children's Oncology Group trial may offer definitive evidence to address this dilemma in germ cell tumors. Evidence of CSF seeding requires craniospinal radiation and adjuvant chemotherapy regardless of tumor type. Diagnosis of any of the malignant tumors (non-germ cell tumors, pineoblastomas, and parenchymal tumors of intermediate determination) also requires craniospinal radiation (with local tumor doses of at least 50 Gy) and adjuvant chemotherapy (generally platinum based). Patients with tectal gliomas may undergo excision with or without postoperative radiation; however, they also may be observed with vigilant follow-up alone.
Collapse
Affiliation(s)
- Jaishri O Blakeley
- Brain Cancer Program, Johns Hopkins University, Cancer Research Building 2, 1550 Orleans Street, Suite 1M16, Baltimore, MD 21231, USA.
| | | |
Collapse
|
40
|
|
41
|
Schneider DT, Zahn S, Sievers S, Alemazkour K, Reifenberger G, Wiestler OD, Calaminus G, Göbel U, Perlman EJ. Molecular genetic analysis of central nervous system germ cell tumors with comparative genomic hybridization. Mod Pathol 2006; 19:864-73. [PMID: 16607373 DOI: 10.1038/modpathol.3800607] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The limited information available to date regarding the genetic alterations in germ cell tumors of the central nervous system has raised concerns about their biologic relationship to other germ cell tumor entities. We investigated fresh-frozen or archival tumor samples from 19 patients with central nervous system germ cell tumors (CNS-GCTs), including seven germinomas, eight malignant nongerminomatous germ cell tumors and four teratomas, using chromosomal comparative genomic hybridization to determine recurrent chromosomal imbalances. All 15 malignant CNS-GCTs and two of four teratomas showed multiple chromosomal imbalances. Chromosomal gains (median: 4 gains/tumor, range: 0-9 gains/tumor) were observed more frequently than losses (median: 1.6 losses/tumor, range: 0-6 losses/tumor). Gain of 12p, which is considered characteristic for germ cell tumors of the adult testis, was detected in 11 of 19 tumors and 10 of 15 malignant CNS-GCTs. In one tumor, gain of 12p was confined to an amplicon at 12p12, corresponding to the commonly amplified region on 12p. Other common gains were found on chromosome arms 1q and 8q (n = 9, each). Among the chromosomal losses, parts of chromosome 11 (n = 5), 18 (n = 4), and 13 (n = 3) were deleted most frequently. Notably, we observed no difference in the genetic profiles of germinomatous and nongerminomatous CNS-GCTs; however, the average number of imbalances was higher in the latter group. A meta-analysis comparing 116 malignant gonadal and extragonadal germ cell tumors revealed that the genomic alterations in CNS-GCTs are virtually indistinguishable from those found in their gonadal or other extragonadal counterparts of the corresponding age group. These data strongly argue in favor of common pathogenetic mechanisms in gonadal and extragonadal germ cell tumors.
Collapse
Affiliation(s)
- Dominik T Schneider
- Clinic of Paediatric Oncology, Haematology and Immunology, Heinrich-Heine-University, Düsseldorf, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
42
|
|
43
|
Zahn S, Sievers S, Alemazkour K, Orb S, Harms D, Schulz WA, Calaminus G, Göbel U, Schneider DT. Imbalances of chromosome arm 1p in pediatric and adult germ cell tumors are caused by true allelic loss: A combined comparative genomic hybridization and microsatellite analysis. Genes Chromosomes Cancer 2006; 45:995-1006. [PMID: 16897744 DOI: 10.1002/gcc.20363] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Previous studies on childhood germ cell tumors (GCTs) report highly variable frequencies of losses at chromosome arm 1p. Since deletions at 1p portend a poor prognosis in other embryonal tumors, this study aims to clarify the question of the frequency of true allelic loss at 1p and whether it constitutes a prognostic parameter. We analyzed 13 GCTs from different gonadal and extragonadal sites of children (4 teratomas, 9 malignant GCTs) and 18 GCTs of adolescents and adults (3 teratomas; 15 malignant GCTs) using automated microsatellite analysis with 23 polymorphic markers and chromosomal "high resolution" comparative genomic hybridization (HR-CGH). With this combined approach, we detected loss of heterozygosity (LOH) at 1p in 8/9 childhood malignant GCTs with concordant data from HR-CGH and microsatellite analyses. In contrast, LOH at 1p was not detected in childhood teratomas (0/4) and constituted a rare event in GCTs of adolescence and adulthood (3/18). The commonly deleted region was located at distal 1p36-pter, with a proximal boundary between the markers D1S450 and D1S2870. These data unequivocally demonstrate that deletion at 1p is common in childhood GCTs and results in allelic loss. This observation argues for the presence of a classical tumor suppressor at distal 1p. Considering the high frequency of LOH at 1p and the overall favorable prognosis of childhood GCTs, a prognostic impact of LOH at 1p in childhood GCTs appears unlikely. However, since two postpubertal tumors with LOH at 1p progressed, a prognostic relevance in this age group seems possible, warranting a prospective evaluation.
Collapse
Affiliation(s)
- Susanne Zahn
- Clinic of Pediatric Oncology, Haematology and Immunology, Heinrich-Heine-University, Düsseldorf, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Distelmaier F, Calaminus G, Harms D, Sträter R, Kordes U, Fleischhack G, Göbel U, Schneider DT. Ovarian small cell carcinoma of the hypercalcemic type in children and adolescents. Cancer 2006; 107:2298-306. [PMID: 16998935 DOI: 10.1002/cncr.22213] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Ovarian small cell carcinoma of the hypercalcemic type is a rare neoplasm that is associated with a poor prognosis. The objective of the current study was to investigate the clinicopathologic features of this tumor and to develop preliminary diagnostic and therapeutic guidelines. METHODS Between 1994 and 2005, 11 girls (ages 9-22 years) who were registered on the German Maligne Keimzelltumoren studies and the Kiel Pediatric Tumor Registry were analyzed. Prior to histopathologic review, 8 patients had been misdiagnosed with either germ cell tumor or juvenile granulosa cell tumor. RESULTS According to the International Federation of Gynecologic Oncology, 4 patients had Stage IA disease, 3 patients had Stage IC disease, and 4 patients had Stage III disease. After resection, 4 patients were followed without additional therapy, and all 4 patients developed recurrent disease after 3 to 11 months. Seven patients received adjuvant chemotherapy during first-line treatment. One patient with Stage III disease received additional regional deep hyperthermia. During first-line treatment, high-dose chemotherapy was received by 4 patients who achieved a complete response (CR) after conventional chemotherapy. All 4 of those patients remained in CR for 7 to 73 months, whereas the other 3 patients developed recurrent disease. Salvage treatment after recurrence or tumor progression consisted of surgery and chemotherapy. One patient received high-dose chemotherapy in 2nd CR and remained in 2nd CR. In total, 5 patients remained alive with no evidence of disease. CONCLUSIONS Patients with ovarian small cell carcinoma of the hypercalcemic type require multiagent chemotherapy during first-line treatment. High-dose chemotherapy may be used to consolidate the therapeutic success.
Collapse
Affiliation(s)
- Felix Distelmaier
- Clinic of Pediatric Oncology, Hematology, and Immunology, Heinrich-Heine University, Duesseldorf, Germany
| | | | | | | | | | | | | | | |
Collapse
|