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Zeng C, Yang Q, Li Z, Wei Z, Chen T, Deng M, Wang J, Wang J, Sun F, Huang J, Lu S, Zhu J, Sun X, Zhen Z. Treatment Outcome of Response-Based Radiation Therapy in Children and Adolescents With Central Nervous System Nongerminomatous Germ Cell Tumors: Results of a Prospective Study. Int J Radiat Oncol Biol Phys 2024; 119:858-868. [PMID: 38122991 DOI: 10.1016/j.ijrobp.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 11/08/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE The optimal dose and range of radiation therapy for central nervous system nongerminomatous germ cell tumors (NGGCTs) have not been uniformly established. Therefore, this study aimed to investigate the effect of individualized radiation therapy, based on the response to induction chemotherapy combined with surgery, on the prognosis of patients with NGGCTs. METHODS AND MATERIALS Based on the imaging examination and tumor markers after induction chemotherapy and pathologic results of second-look surgery, patients with NGGCT received different radiation therapy strategies, including 30.6 Gy whole ventricular irradiation + tumor-bed boost to 54 Gy, 30.6 Gy craniospinal irradiation + tumor-bed boost to 54 Gy, 36 Gy craniospinal irradiation + tumor-bed boost to 54 Gy, and 36 Gy craniospinal irradiation + 54 Gy tumor-bed boost with 45 Gy to metastatic spinal lesions. RESULTS A total of 51 patients were enrolled between January 2015 and March 2021, with a median age of 10.3 years. The 3-year event-free survival and overall survival (OS) of the entire cohort were 70.2% ± 6.9% and 77.5% ± 6.0%, respectively. The 3-year OS of patients achieving partial response after induction chemotherapy was higher than that of patients with stable disease (P = .03) or progressive disease (P = .002). The 3-year event-free survival and OS of the 18 patients receiving 30.6 Gy whole ventricular irradiation and 54 Gy tumor-bed boost were 88.9% ± 7.4% and 94.4% ± 5.4%, respectively. CONCLUSIONS The results suggest that an individualized radiation therapy strategy based on response to induction chemotherapy and surgery is a feasible and promising means of achieving reduction in dose and extent of radiation in patients while still providing good response.
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Affiliation(s)
- Chenggong Zeng
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Qunying Yang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Neurosurgery
| | - Zhuoran Li
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Zhiqing Wei
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Tingting Chen
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Meiling Deng
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Radiotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jian Wang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Neurosurgery
| | - Juan Wang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Feifei Sun
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Junting Huang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Suying Lu
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Jia Zhu
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology
| | - Xiaofei Sun
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology.
| | - Zijun Zhen
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology.
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Osuna-Marco MP, Martín-López LI, Tejera ÁM, López-Ibor B. Questions and answers in the management of children with medulloblastoma over the time. How did we get here? A systematic review. Front Oncol 2023; 13:1229853. [PMID: 37456257 PMCID: PMC10340518 DOI: 10.3389/fonc.2023.1229853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Treatment of children with medulloblastoma (MB) includes surgery, radiation therapy (RT) and chemotherapy (CT). Several treatment protocols and clinical trials have been developed over the time to maximize survival and minimize side effects. Methods We performed a systematic literature search in May 2023 using PubMed. We selected all clinical trials articles and multicenter studies focusing on MB. We excluded studies focusing exclusively on infants, adults, supratentorial PNETs or refractory/relapsed tumors, studies involving different tumors or different types of PNETs without differentiating survival, studies including <10 cases of MB, solely retrospective studies and those without reference to outcome and/or side effects after a defined treatment. Results 1. The main poor-prognosis factors are: metastatic disease, anaplasia, MYC amplification, age younger than 36 months and some molecular subgroups. The postoperative residual tumor size is controversial.2. MB is a collection of diseases.3. MB is a curable disease at diagnosis, but survival is scarce upon relapse.4. Children should be treated by experienced neurosurgeons and in advanced centers.5. RT is an essential treatment for MB. It should be administered craniospinal, early and without interruptions.6. Craniospinal RT dose could be lowered in some low-risk patients, but these reductions should be done with caution to avoid relapses.7. Irradiation of the tumor area instead of the entire posterior fossa is safe enough.8. Hyperfractionated RT is not superior to conventional RT9. Both photon and proton RT are effective.10. CT increases survival, especially in high-risk patients.11. There are multiple drugs effective in MB. The combination of different drugs is appropriate management.12. CT should be administered after RT.13. The specific benefit of concomitant CT to RT is unknown.14. Intensified CT with stem cell rescue has no benefit compared to standard CT regimens.15. The efficacy of intraventricular/intrathecal CT is controversial.16. We should start to think about incorporating targeted therapies in front-line treatment.17. Survivors of MB still have significant side effects. Conclusion Survival rates of MB improved greatly from 1940-1970, but since then the improvement has been smaller. We should consider introducing targeted therapy as front-line therapy.
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Affiliation(s)
- Marta P. Osuna-Marco
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
- Faculty of Experimental Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Laura I. Martín-López
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
| | - Águeda M. Tejera
- Faculty of Experimental Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | - Blanca López-Ibor
- Pediatric Oncology Unit, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
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Preradiation Chemotherapy for Adult High-risk Medulloblastoma: A Trial of the ECOG-ACRIN Cancer Research Group (E4397). Am J Clin Oncol 2019; 41:588-594. [PMID: 27635620 DOI: 10.1097/coc.0000000000000326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To assess the long-term outcomes and objective response (OR) to preradiation chemotherapy and radiation in adult high-risk medulloblastoma. MATERIALS AND METHODS In this prospective phase II trial, adults with high-risk medulloblastoma were treated with 3 cycles of preradiation cisplatin, etoposide, cyclophosphamide, and vincristine followed by craniospinal radiation (CSI). OR, progression-free survival (PFS), overall survival (OS), and toxicities were assessed. RESULTS Eleven patients were enrolled over a 6-year period. Six (55%) had subarachnoid metastases. Two (18%) had an OR to preradiation chemotherapy. Two (18%) progressed while on chemotherapy. Completion of CSI was not compromised. The OR rate after chemotherapy and radiation was 45% (5/11). Nonevaluable patients at both time-points weakened the response data conclusions. Median PFS was 43.8 months. Five-year PFS was 27%. Five-year OS was 55%. Nonmetastatic (M0) and metastatic (M+) patients had similar outcomes. CONCLUSIONS The OR to this preradiation chemotherapy regimen is lower than anticipated from the adult and pediatric literature raising a question about comparative efficacy of chemotherapy in different age groups. The OS achieved is similar to retrospective adult series, but worse than pediatric outcomes. Although this regimen can be administered without compromising delivery of CSI, our results do not provide support for the use of this neoadjuvant chemotherapy for adult medulloblastoma.
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Parkes J, Hendricks M, Ssenyonga P, Mugamba J, Molyneux E, Schouten-van Meeteren A, Qaddoumi I, Fieggen G, Luna-Fineman S, Howard S, Mitra D, Bouffet E, Davidson A, Bailey S. SIOP PODC adapted treatment recommendations for standard-risk medulloblastoma in low and middle income settings. Pediatr Blood Cancer 2015; 62:553-64. [PMID: 25418957 DOI: 10.1002/pbc.25313] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 09/16/2014] [Indexed: 01/11/2023]
Abstract
Effective treatment of children with medulloblastoma requires a functioning multi-disciplinary team with adequate neurosurgical, neuroradiological, pathological, radiotherapy and chemotherapy facilities and personnel. In addition the treating centre should have the capacity to effectively screen and manage any tumour and treatment-associated complications. These requirements have made it difficult for many low and middle-income countries (LMIC) centres to offer curative treatment. This article provides management recommendations for children with standard-risk medulloblastoma (localised tumours in children over the age of 3-5 years) according to the level of facilities available.
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Affiliation(s)
- Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Sun XF, Zhang F, Zhen ZJ, Yang QY, Xia YF, Wu SX, Zhu J, Lu SY, Wang J, Sun FF, Cai RQ, Chen Y, Li PF. The clinical characteristics and treatment outcome of 57 children and adolescents with primary central nervous system germ cell tumors. CHINESE JOURNAL OF CANCER 2014; 33:395-401. [PMID: 25011460 PMCID: PMC4135369 DOI: 10.5732/cjc.013.10112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Primary central nervous system germ cell tumors (CNS-GCTs) in children and adolescents have unique clinical features and methods of treatment compared with those in adults. There is little information about Chinese children and adolescents with CNS-GCTs. Therefore, in this study we retrospectively analyzed the clinical features and treatment outcome of Chinese children and adolescents with primary CNS-GCTs. Between January 2002 and December 2012, 57 untreated patients from a single institution were enrolled. They were diagnosed with CNS-GCTs after pathologic or clinical assessment. Of the 57 patients, 41 were males and 16 were females, with a median age of 12.8 years (range, 2.7 to 18.0 years) at diagnosis; 43 (75.4%) had non-germinomatous germ cell tumors (NGGCTs) and 14 (24.6%) had germinomas; 44 (77.2%) had localized disease and 13 (22.8%) had extensive lesions. Fifty-three patients completed the prescribed treatment, of which 18 underwent monotherapy of surgery, radiotherapy, or chemotherapy, and 35 underwent multimodality therapies that included radiotherapy combined with chemotherapy or surgery combined with chemotherapy and/or radiotherapy. PEB (cisplatin, etoposide, and bleomycin) protocol was the major chemotherapy regimen. The median follow-up time was 32.3 months (range, 1.2 to 139 months). Fourteen patients died of relapse or disease progression. The 3-year event-free survival (EFS) and overall survival rates for all patients were 72.2% and 73.8%, respectively. The 3-year EFS was 92.9% for germinomas and 64.8% for NGGCTs (P = 0.064). The 3-year EFS rates for patients with NGGCTs who underwent monotherapy and multimodality therapies were 50.6% and 73.5%, respectively (P = 0.042). Our results indicate that multimodality therapies including chemotherapy plus radiotherapy were better treatment option for children and adolescents with CNS-GCTs.
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Affiliation(s)
- Xiao-Fei Sun
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine; Department of Pediatric Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong 510060, P. R. China.
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Ajeawung NF, Wang HY, Kamnasaran D. Progress from clinical trials and emerging non-conventional therapies for the treatment of Medulloblastomas. Cancer Lett 2012; 330:130-40. [PMID: 23211539 DOI: 10.1016/j.canlet.2012.11.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 11/19/2012] [Accepted: 11/22/2012] [Indexed: 12/18/2022]
Abstract
Medulloblastomas are highly aggressive tumors of the cerebellum with an embryonal origin. Despite current treatment modalities which include a combination of surgery, chemotherapy and/or radiation, challenges still exist to effectively treat some patients, especially those within the younger age group. In an effort to find improved therapies, ongoing research led by world-wide teams have explored non-conventional therapeutic strategies, as well as examined the efficacy of several drugs in clinical trials among patients with Medulloblastomas. We outline in this article, recent advances on the efficacy and toxicity of numerous therapeutic agents including those that are DNA damaging agents, microtubules binding compounds, and those that are inhibitors of Topoisomerase and of the Notch and Hedgehog signaling pathway, which were assessed in recent Phase I and II clinical trials. Among these clinical trials, it is unfortunate that the outcomes were dismal with the majority of the patients with Medulloblastomas still succumbing to relapse after conventional therapies. Furthermore, it is yet to be established clearly the clinical efficacy of non-conventional therapies such as immunotherapy and gene therapy. Moreover, there is growing interest in proton therapy as a potential replacement for photon therapy, while high dose chemotherapy and autologous stem cell rescue may improve therapeutic efficacies. However, further research is needed to resolve the inherent toxicity from these novel therapeutic methods. In conclusion, novel therapies based on a better understanding of the biology of Medulloblastomas are pivotal in improving non-conventional therapies in the treatment of this deadly disease.
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Fouladi M, Gururangan S, Moghrabi A, Phillips P, Gronewold L, Wallace D, Sanford RA, Gajjar A, Kun LE, Heideman R. Carboplatin-based primary chemotherapy for infants and young children with CNS tumors. Cancer 2009; 115:3243-53. [PMID: 19484793 DOI: 10.1002/cncr.24362] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND A carboplatin-based chemotherapy regimen was used as primary postoperative therapy in infants with central nervous system (CNS) tumors to limit renal and ototoxicity and to target systemic exposure. METHODS Fifty-three patients aged <age 3 years with embryonal CNS tumor medulloblastoma (n = 20), ependymoma (EP, n = 21), choroid plexus carcinoma (CPCA, n = 5), and primitive embryonal neoplasms including atypical teratoid rhabdoid tumors (n = 7) were treated with cyclophosphamide, etoposide, and carboplatin. Radiation therapy was used only for residual disease at the end of chemotherapy or disease progression. RESULTS The response rate after 2 cycles of chemotherapy was 34% (complete response, 13.8%; partial response, 20.7%). Myelosuppression was the dominant toxicity; 2 patients had toxic deaths related to thrombocytopenia with trauma. The 5-year overall survival (OS) was 49% +/- 7%, and the progression-free survival (PFS) was 31% +/- 7%, with a median follow-up of 11.4 years (range, 5.2-15.0 years). For medulloblastoma, the 5-year PFS was 26% +/- 9%; for EP it was 33% +/- 10%; for CPCA it was 80% +/- 18%; and for primitive neuroectodermal and atypical teratoid rhabdoid tumors it was 0%. Localized EP patients with gross total resection who did not undergo radiotherapy had a 5-year PFS of 57% +/- 17% and OS of 71% +/- 16%. Two patients developed late second malignancies; 1 was associated with germline p53 mutation. CONCLUSIONS The results confirm that carboplatin has similar activity to cisplatin in otherwise similar regimens. Five-year survival data are comparable to those reported in other recent studies, including high-dose chemotherapy studies. Of note is the marked activity in CPCA and gross totally resected EP.
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Affiliation(s)
- Maryam Fouladi
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Jehanne M, Lumbroso-Le Rouic L, Savignoni A, Aerts I, Mercier G, Bours D, Desjardins L, Doz F. Analysis of ototoxicity in young children receiving carboplatin in the context of conservative management of unilateral or bilateral retinoblastoma. Pediatr Blood Cancer 2009; 52:637-43. [PMID: 19148943 DOI: 10.1002/pbc.21898] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Carboplatin plays an important role in the conservative management of retinoblastoma, but is associated with risk of ototoxicity in these young children whose sensory prognosis may be also compromised by their loss of vision. This retrospective study analyzed the impact of carboplatin on hearing in the context of conservative management of children with retinoblastoma. METHODS Data for 175 children treated at the Institut Curie between 1994 and 2002 were analyzed. RESULTS Median age at diagnosis was 8 months (0-60). Carboplatin was administered on 3 days (200 mg/m(2)/day) or 5 days (160 mg/m(2)/day) with etoposide and with diode-laser therapy at the dose of 560 mg/m(2) (chemothermotherapy). Median cumulative dose of carboplatin was 2,880 mg/m(2) (560-6,160). Ototoxicity was investigated by pure-tone audiometry and scored by Brock's grading scale before and after treatment. The median follow-up of hearing assessment was 5 years (1.8-11). Ototoxicity was detected in 8 children: 3 grade 1, 1 grade 2, and 2 grade 4. The two patients with grade 4 hearing-loss required a hearing aid. Two children developed bilateral high frequency hearing-loss, considered to be secondary to carboplatin but with less than Brock grade 1. Ototoxicity was observed for a median cumulative dose of carboplatin of 3,120 mg/m(2) (1,200-5,830). Only one child developed ototoxicity during treatment. All other cases were discovered after the last dose of carboplatin with a median interval of 3.7 years (0-7.6). No other risk factor for ototoxicity was able to account for these lesions. CONCLUSION Children receiving carboplatin require long-term audiometric follow-up.
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Allen J, Donahue B, Mehta M, Miller DC, Rorke LB, Jakacki R, Robertson P, Sposto R, Holmes E, Vezina G, Muraszko K, Puccetti D, Prados M, Chan KW. A phase II study of preradiotherapy chemotherapy followed by hyperfractionated radiotherapy for newly diagnosed high-risk medulloblastoma/primitive neuroectodermal tumor: a report from the Children's Oncology Group (CCG 9931). Int J Radiat Oncol Biol Phys 2009; 74:1006-11. [PMID: 19356859 DOI: 10.1016/j.ijrobp.2008.09.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 09/15/2008] [Accepted: 09/28/2008] [Indexed: 11/28/2022]
Abstract
PURPOSE To verify feasibility and monitor progression-free survival and overall survival in children with high-risk medulloblastoma and noncerebellar primitive neuroectodermal tumors (PNETs) treated in a Phase II study with preradiotherapy chemotherapy (CHT) followed by high-dose, hyperfractionated craniospinal radiotherapy (CSRT). METHODS AND MATERIALS Eligibility criteria included age >3 years at diagnosis, medulloblastoma with either high M stage and/or >1.5 cm(2) postoperative residual disease, and all patients with noncerebellar PNET. Treatment was initiated with five alternating monthly cycles of CHT (A [cisplatin, cyclophosphamide, etoposide, and vincristine], B [carboplatin and etoposide], A, B, and A) followed by hyperfractionated CSRT (40 Gy) with a boost to the primary tumor (72 Gy) given in twice-daily 1-Gy fractions. RESULTS The valid study group consisted of 124 patients whose median age at diagnosis was 7.8 years. Eighty-four patients (68%) completed the entire protocol according to study guidelines (within 9 months), and the median time to complete CSRT was 1.6 months. Major reasons for failure to complete CHT included progressive disease (17%) and toxic death (2.4%). The 5-year progression-free survival and overall survival rates were 43% +/- 5% and 52% +/- 5%, respectively. No significant differences were detected in subset analysis related to response to CHT, site of primary tumor, postoperative residual disease, or M stage. CONCLUSIONS The feasibility of this intensive multimodality protocol was confirmed, and response to pre-RT CHT did not impact on survival. Survival data from this protocol can not be compared with data from other studies, given the protocol design.
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Affiliation(s)
- Jeffrey Allen
- Departments of Pediatrics and Pathology, New York University Medical Center, New York, NY 10016, USA.
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McGregor LM, Spunt SL, Santana VM, Stewart CF, Ward DA, Watkins A, Laningham FH, Ivy P, Furman WL, Fouladi M. Phase 1 study of an oxaliplatin and etoposide regimen in pediatric patients with recurrent solid tumors. Cancer 2009; 115:655-64. [PMID: 19117350 PMCID: PMC2852396 DOI: 10.1002/cncr.24054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The combination of a platinating agent and etoposide has induced responses in various pediatric tumors. The study estimated the maximum tolerated dose (MTD) of an oxaliplatin and etoposide regimen in children with recurrent solid tumors. METHODS Oxaliplatin was administered on Day 1 and etoposide on Days 1 to 3 of each 21-day course. Cohorts of 3 to 6 patients were enrolled at 3 dose levels: 1) oxaliplatin at a dose of 130 mg/m(2) and etoposide at a dose of 75 mg/m(2), 2) oxaliplatin at a dose of 130 mg/m(2) and etoposide at a dose of 100 mg/m(2), and 3) oxaliplatin at a dose of 145 mg/m(2) and etoposide at a dose of 100 mg/m(2). Calcium and magnesium infusions were used at dose level 3 in an attempt to escalate the oxaliplatin dose past the single-agent MTD. RESULTS The 16 patients received a total of 63 courses. At dose level 1, dose-limiting epistaxis, neuropathy, and neutropenia occurred in 1 of 6 patients. No dose-limiting toxicity (DLT) occurred at dose level 2 (n = 6). At dose level 3, 2 of 4 patients experienced dose-limiting neutropenia; none experienced grade 3 or 4 acute neuropathy. Six patients required prolongation of the oxaliplatin infusion because of acute sensory neuropathy. Responses were observed in patients with medulloblastoma (1 complete response) and pineoblastoma (1 partial response); 3 others with atypical teratoid rhabdoid tumor, ependymoma, and soft tissue sarcoma had prolonged disease stabilization. CONCLUSIONS The MTD of this regimen was found to be oxaliplatin at a dose of 130 mg/m(2) given on Day 1 and etoposide at a dose of 100 mg/m(2)/d given on Days 1 to 3. Neutropenia was found to be the DLT. Calcium and magnesium infusions did not allow escalation of the oxaliplatin dose. The combination was well-tolerated and demonstrated antitumor activity.
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Affiliation(s)
- Lisa M McGregor
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA.
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Gandola L, Massimino M, Cefalo G, Solero C, Spreafico F, Pecori E, Riva D, Collini P, Pignoli E, Giangaspero F, Luksch R, Berretta S, Poggi G, Biassoni V, Ferrari A, Pollo B, Favre C, Sardi I, Terenziani M, Fossati-Bellani F. Hyperfractionated Accelerated Radiotherapy in the Milan Strategy for Metastatic Medulloblastoma. J Clin Oncol 2009; 27:566-71. [DOI: 10.1200/jco.2008.18.4176] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose With a view to improving the prognosis for patients with metastatic medulloblastoma, we tested the efficacy and toxicity of a hyperfractionated accelerated radiotherapy (HART) regimen delivered after intensive sequential chemotherapy. Patients and Methods Between 1998 and 2007, 33 consecutive patients received postoperative methotrexate (8 g/m2), etoposide (2.4 g/m2), cyclophosphamide (4 g/m2), and carboplatin (0.8 g/m2) in a 2-month schedule, then HART with a maximal dose to the neuraxis of 39 Gy (1.3 Gy/fraction, 2 fractions/d) and a posterior fossa boost up to 60 Gy (1.5 Gy/fraction,2 fractions/d). Patients with persistent disseminated disease before HART were consolidated with two myeloablative courses and circulating progenitor cell rescue. Results Patients were classified as having M1 (n = 9), M2 (n = 6), M3 (n = 17), and M4 (n = 1) disease. Seven patients younger than 10 years old who achieved complete response after chemotherapy received a lower dose to the neuraxis (31.2 Gy). Twenty-two of the 32 assessable patients responded to chemotherapy; disease was stable in five patients and progressed in five patients. One septic death occurred before radiotherapy. Eight patients experienced relapse after a median of 12 months. Fourteen of the 33 patients underwent consolidation therapy after HART. With a median 82-month survivor follow-up, the 5-year event-free, progression-free, and overall survival rates were 70%, 72%, and 73%, respectively. No severe clinical complications of HART have emerged so far. Conclusion HART after intensive postoperative chemotherapy, followed by myeloablative chemotherapy in selected cases, proved feasible in children with metastatic medulloblastoma. The results of our treatment compare favorably with other series treated using conventional therapies.
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Affiliation(s)
- Lorenza Gandola
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Maura Massimino
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Graziella Cefalo
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Carlo Solero
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Filippo Spreafico
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Emilia Pecori
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Daria Riva
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Paola Collini
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Emanuele Pignoli
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Felice Giangaspero
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Roberto Luksch
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Serena Berretta
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Geraldina Poggi
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Veronica Biassoni
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Andrea Ferrari
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Bianca Pollo
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Claudio Favre
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Iacopo Sardi
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Monica Terenziani
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
| | - Franca Fossati-Bellani
- From the Radiotherapy, Pediatrics, Pathology, and Physics Units, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Tumori; Neurosurgery Unit, Development Neurology Unit and Neuropathology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milano; Neuropathology, Università La Sapienza, Roma and Istituto Neuromed, Pozzilli; Acquired Lesions Unit, Istituto Eugenio Medea, Bosisio Parini; Pediatric Oncology Unit, Ospedale S
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13
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Okada S, Hongo T, Sakaguchi K, Suzuki K, Nishizawa S, Ohzeki T. Pilot study of ifosfamide/carboplatin/etoposide (ICE) for peripheral blood stem cell mobilization in patients with high-risk or relapsed medulloblastoma. Childs Nerv Syst 2007; 23:407-13. [PMID: 17226035 DOI: 10.1007/s00381-006-0282-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Revised: 06/17/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The purpose of this study is to evaluate the stem cell mobilization capacity, anti-tumor effect, and feasibility of ifosfamide/carboplatin/etoposide (ICE) for transplant-eligible patients with medulloblastoma. MATERIALS AND METHODS Six patients (23 months to 18 years old) with high-risk or relapsed medulloblastoma received one cycle of ICE, which consisted of ifosfamide at 1.8 g/m(2) for 5 days, carboplatin 400 mg/m(2) for 2 days, and etoposide 100 mg/m(2) for 5 days. Stem cells were mobilized with ICE followed by granulocyte colony-stimulating factor at 10 microg kg(-1) day(-1). RESULTS After one cycle of ICE, the median number of harvested CD34+ cells per apheresis session was 11.85 x 10(6) cells/kg (range, 0.2 to 71.2 x 10(6) cells/kg). Two patients obtained a complete response and three patients a partial response. All patients experienced severe myelosuppression, and three infectious toxicities were observed. CONCLUSIONS These results suggest that ICE is optimal for mobilizing stem cells, effective for high-risk or relapsed medulloblastoma, and tolerable with limited non-hematological toxicity.
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Affiliation(s)
- Shuichi Okada
- Department of Pediatrics, Hamamatsu University School of Medicine, Handayama 1-20-1, Hamamatsu, Japan.
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14
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Uesaka T, Shono T, Kuga D, Suzuki SO, Niiro H, Miyamoto K, Matsumoto K, Mizoguchi M, Ohta M, Iwaki T, Sasaki T. Enhanced expression of DNA topoisomerase II genes in human medulloblastoma and its possible association with etoposide sensitivity. J Neurooncol 2007; 84:119-29. [PMID: 17361331 DOI: 10.1007/s11060-007-9360-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Accepted: 02/16/2007] [Indexed: 10/23/2022]
Abstract
Medulloblastoma (MB) is the most common malignant neuroepithelial tumor of childhood. The DNA topoisomerase II (Topo II) inhibitor etoposide has been widely used for the treatment of MBs; however, it remains unknown whether MB cells are more sensitive to etoposide than other malignant neuroepithelial tumor cells. In this study, we tested the chemosensitivities of malignant neuroepithelial tumors (26 glioblastomas, 9 anaplastic astrocytomas, and 5 MBs) to etoposide and vincristine using the succinate dehydrogenase inhibition test and found that MB cells are more sensitive to etoposide and more resistant to vincristine than other tumor cells. We performed quantitative reverse-transcription polymerase chain reaction to evaluate the expression of genes related to etoposide sensitivity, and found co-overexpression of DNA topoisomerase II (Topo II) alpha and beta mRNA in MBs. In addition, the levels of Topo IIalpha and beta mRNA in these tumors correlated with etoposide sensitivity. Immunohistochemical studies using surgical samples of these tumors demonstrated that the percentages of Topo IIalpha immunopositive cells (Topo IIalpha labeling index) correlated with those of Ki-67 immunopositive cells (MIB-1 labeling index); however, neither the Topo IIalpha nor the MIB-1 labeling index correlated with the levels of Topo IIalpha mRNA or etoposide sensitivity. Based on these observations, Topo IIalpha and beta mRNA expression, but not the Topo IIalpha labeling index, might be a useful marker for sensitivity to etoposide in human malignant neuroepithelial tumors.
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Affiliation(s)
- Toshio Uesaka
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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15
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Bhatnagar A, Deutsch M. The Role for intensity modulated radiation therapy (IMRT) in pediatric population. Technol Cancer Res Treat 2007; 5:591-5. [PMID: 17121435 DOI: 10.1177/153303460600500606] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to evaluate our initial experience on the use of IMRT in children with tumors in eloquent or critical locations. Twenty-two children with a median age of 12 years (range 1-17) were treated using IMRT for tumors which were within 2 cm of a critical structure. The treatment locations were spine [2], head and neck [5], abdominopelvic [8], and intracranial [7]. Eighty-two percent (82%) of patients were treated with curative intent despite most patients having advanced or metastatic disease and two patients having previously received standard external beam radiation. IMRT was delivered with a 6MV linear accelerator using dynamic multileaf collimators with a median of six fields. The median follow-up was five months [1-21]. The median administered dose was 45 Gy. The median planning treatment volume (PTV) was 105.4 cc. For the intracranial lesions, the mean doses to the pituitary, brainstem, cochlea, optic nerve, and lens were 31%, 42%, 17%, 27%, and 6% of the total dose, respectively. For the head and neck tumors, the mean doses to the spinal cord and parotid glands were 47% and 49%, respectively. For the pelvic tumors, the mean dose to the bladder, rectum, and small bowel were 51%, 63%, and 22%, respectively. Local failure occurred in one patient. IMRT resulted in substantial sparing of surrounding critical structures and acceptable local control rate for these tumors in children. Further follow-up is needed to assess long-term local control and late effects.
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Affiliation(s)
- Ajay Bhatnagar
- University of Pittsburgh Medical Center, Department of Radiation Oncology, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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16
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Haluska M, Anthony ML. Osmotic Blood-Brain Barrier Modification for the Treatment of Malignant Brain Tumors. Clin J Oncol Nurs 2007; 8:263-7. [PMID: 15208820 DOI: 10.1188/04.cjon.263-267] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The blood-brain barrier (BBB) is a physiologic barrier that protects the brain from toxic substances, including most of the chemotherapeutic agents used today. The BBB may be partly responsible for the poor efficacy of chemotherapy for malignant primary or metastatic brain tumors. A technique of osmotic modification of the BBB, known as BBB disruption (BBBD), is used to increase the delivery of chemotherapy to the brain. This article discusses the technique of osmotic opening of the BBB, the national BBBD program, the role of nurses in the care and management of patients undergoing BBBD treatment, outcomes of this technique with a variety of brain tumors, and the future directions of the BBBD program.
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17
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Gajjar A, Chintagumpala M, Ashley D, Kellie S, Kun LE, Merchant TE, Woo S, Wheeler G, Ahern V, Krasin MJ, Fouladi M, Broniscer A, Krance R, Hale GA, Stewart CF, Dauser R, Sanford RA, Fuller C, Lau C, Boyett JM, Wallace D, Gilbertson RJ. Risk-adapted craniospinal radiotherapy followed by high-dose chemotherapy and stem-cell rescue in children with newly diagnosed medulloblastoma (St Jude Medulloblastoma-96): long-term results from a prospective, multicentre trial. Lancet Oncol 2006; 7:813-20. [PMID: 17012043 DOI: 10.1016/s1470-2045(06)70867-1] [Citation(s) in RCA: 657] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Current treatment for medulloblastoma, which includes postoperative radiotherapy and 1 year of chemotherapy, does not cure many children with high-risk disease. We aimed to investigate the effectiveness of risk-adapted radiotherapy followed by a shortened period of dose-intense chemotherapy in children with medulloblastoma. METHODS After resection, patients were classified as having average-risk medulloblastoma (< or = 1.5 cm2 residual tumour and no metastatic disease) or high-risk medulloblastoma (> 1.5 cm2 residual disease or metastatic disease localised to neuraxis) medulloblastoma. All patients received risk-adapted craniospinal radiotherapy (23.4 Gy for average-risk disease and 36.0-39.6 Gy for high-risk disease) followed by four cycles of cyclophosphamide-based, dose-intensive chemotherapy. Patients were assessed regularly for disease status and treatment side-effects. The primary endpoint was 5-year event-free survival; we also measured overall survival. This study is registered with ClinicalTrials.gov, number NCT00003211. FINDINGS Of 134 children with medulloblastoma who underwent treatment (86 average-risk, 48 high-risk), 119 (89%) completed the planned protocol. No treatment-related deaths occurred. 5-year overall survival was 85% (95% CI 75-94) in patients in the average-risk group and 70% (54-84) in those in the high-risk group (p=0.04); 5-year event-free survival was 83% (73-93) and 70% (55-85), respectively (p=0.046). For the 116 patients whose histology was reviewed centrally, histological subtype correlated with 5-year event-free survival (p=0.04): 84% (74-95) for classic histology, 77% (49-100) for desmoplastic tumours, and 57% (33-80) for large-cell anaplastic tumours. INTERPRETATION Risk-adapted radiotherapy followed by a shortened schedule of dose-intensive chemotherapy can be used to improve the outcome of patients with high-risk medulloblastoma.
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Affiliation(s)
- Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN 38105, USA.
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18
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Smits C, Swen SJ, Theo Goverts S, Moll AC, Imhof SM, Schouten-van Meeteren AYN. Assessment of hearing in very young children receiving carboplatin for retinoblastoma. Eur J Cancer 2006; 42:492-500. [PMID: 16376542 DOI: 10.1016/j.ejca.2005.11.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2005] [Revised: 08/10/2005] [Accepted: 11/07/2005] [Indexed: 11/20/2022]
Abstract
Children with retinoblastoma have increasingly been treated with carboplatin in the past decade. Ototoxicity is a known, possible, side-effect of carboplatin. Since retinoblastoma patients are very young and frequently have impaired vision, the evaluation of hearing loss is very important. The hearing status of 25 children with retinoblastoma treated with carboplatin (median cumulative dose 2,240 mg/m(2)) was evaluated in detail. Median age at first carboplatin administration was 7 months. The evaluation of hearing loss was performed by an age-appropriate measurement protocol consisting of tympanometry, otoacoustic emission measurements, auditory brainstem responses and (high-frequency) visual reinforcement audiometry (VRA) or play-audiometry. The median follow-up time after last carboplatin dose was 25 months (range 1-94 months). In none of the children was hearing loss detected after carboplatin administration. A measurement protocol that includes tympanometry, distortion product otoacoustic emission measurements and high-frequency VRA is recommended for young children receiving carboplatin or other ototoxic drugs.
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Affiliation(s)
- Cas Smits
- Department of Otolaryngology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
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19
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Jakacki RI, Feldman H, Jamison C, Boaz JC, Luerssen TG, Timmerman R. A pilot study of preirradiation chemotherapy and 1800 cGy craniospinal irradiation in young children with medulloblastoma. Int J Radiat Oncol Biol Phys 2004; 60:531-6. [PMID: 15380589 DOI: 10.1016/j.ijrobp.2004.03.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2003] [Revised: 03/04/2004] [Accepted: 03/11/2004] [Indexed: 11/25/2022]
Abstract
PURPOSE Craniospinal irradiation (CSI) is necessary in the treatment of medulloblastoma, although it results in significant long-term sequelae, particularly in young children. We prospectively evaluated the feasibility of giving preirradiation chemotherapy followed by 1800 cGy CSI to young children with localized medulloblastoma. METHODS AND MATERIALS Between January 1993 and July 1997, 7 consecutive patients (age, 20-64 months) with M0 medulloblastoma were enrolled. After surgical resection, patients received 4 months of multiagent chemotherapy followed by 1800 cGy CSI and 5400 cGy to the posterior fossa. RESULTS Median follow-up is 8.9 years. No patient developed progressive disease during chemotherapy. One patient developed widespread metastatic recurrence 2 months after completing radiation therapy and died. Two additional patients developed isolated frontal horn relapses 32 and 36 months after initial diagnosis and received further irradiation and chemotherapy. Both of these patients remain alive 7.1 and 3.6 years from the time of recurrence. Four of the six survivors have endocrine deficits. All of the survivors require special assistance in school. CONCLUSIONS Craniospinal irradiation doses of 1800 cGy may not be adequate to prevent exoprimary recurrences. Despite the CSI dose reduction, neuroendocrine and neurocognitive sequelae are substantial.
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Affiliation(s)
- Regina I Jakacki
- Division of Pediatric Hematology-Oncology, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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20
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Yuh GE, Loredo LN, Yonemoto LT, Bush DA, Shahnazi K, Preston W, Slater JM, Slater JD. Reducing Toxicity from Craniospinal Irradiation. Cancer J 2004; 10:386-90. [PMID: 15701271 DOI: 10.1097/00130404-200411000-00009] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We report on a radiation treatment technique that has reduced the dose to critical normal structures in children with medulloblastoma. PATIENTS AND METHODS Three children between the ages of 3 and 4 with stage M2 or M3 medulloblastoma were treated between 2001 and 2003 with craniospinal irradiation using protons. Patients received 36 cobalt gray equivalent to the craniospinal axis, then 18 cobalt gray equivalent to the posterior fossa. The cranium was treated with opposed lateral fields. The spine was treated with three matched posteroanterior fields, with the beam stopping just beyond the thecal sac. The posterior fossa was then treated with alternating posteroanterior, right posterior oblique, and left posterior oblique fields, with the beam stopping just proximal to the cochlea. The use of general anesthesia and pre-porting with diagnostic-quality x-rays allowed precise patient positioning. RESULTS Craniospinal irradiation delivered via conformal proton irradiation substantially reduced the dose to the cochlea and vertebral bodies and virtually eliminated the exit dose through thorax, abdomen, and pelvis. Despite concurrent chemotherapy, a clinically significant lymphocyte count reduction was not seen. Patients tolerated treatment well; acute side effects (e.g., nausea, decreased appetite, and odynophagia) were mild. All patients completed therapy without interruption. CONCLUSION Our proton-beam technique for craniospinal irradiation of pediatric medulloblastoma has successfully reduced normal-tissue doses and acute treatment-related sequelae. This technique may be especially advantageous in children with a history of myelosuppression, who might not other wise tolerate irradiation.
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Affiliation(s)
- Grace E Yuh
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California 92354, USA
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21
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Stewart CF, Iacono LC, Chintagumpala M, Kellie SJ, Ashley D, Zamboni WC, Kirstein MN, Fouladi M, Seele LG, Wallace D, Houghton PJ, Gajjar A. Results of a phase II upfront window of pharmacokinetically guided topotecan in high-risk medulloblastoma and supratentorial primitive neuroectodermal tumor. J Clin Oncol 2004; 22:3357-65. [PMID: 15310781 DOI: 10.1200/jco.2004.10.103] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the antitumor efficacy of pharmacokinetically guided topotecan dosing in previously untreated patients with medulloblastoma and supratentorial primitive neuroectodermal tumors, and to evaluate plasma and CSF disposition of topotecan in these patients. PATIENTS AND METHODS After maximal surgical resection, 44 children with previously untreated high-risk medulloblastoma were enrolled, of which 36 were assessable for response. The topotecan window consisted of two cycles, administered initially as a 30-minute infusion daily for 5 days, lasting 6 weeks. Pharmacokinetic studies were conducted on day 1 to attain a topotecan lactone area under the plasma concentration-time curve (AUC) of 120 to 160 ng/mL.h. After 10 patients were enrolled, the infusion was modified to 4 hours, with dosage individualization. RESULTS Of 36 assessable patients, four patients (11.1%) had a complete response and six (16.6%) showed a partial response, and disease was stable in 17 patients (47.2%). Toxicity was mostly hematologic, with only one patient experiencing treatment delay. The target plasma AUC was achieved in 24 of 32 studies (75%) in the 30-minute infusion group, and in 58 of 93 studies (62%) in the 4-hour infusion group. The desired CSF topotecan exposure was achieved in seven of eight pharmacokinetic studies when the topotecan plasma AUC was within target range. CONCLUSION Topotecan is an effective agent against pediatric medulloblastoma in patients who have received no therapy other than surgery. Pharmacokinetically guided dosing achieved the target plasma AUC in the majority of patients. This drug warrants testing as part of standard postradiation chemotherapeutic regimens. Furthermore, these results emphasize the importance of translational research in drug development, which in this case identified an effective drug.
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Affiliation(s)
- Clinton F Stewart
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, 332 N Lauderdale, Memphis, TN 38105-2794, USA
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22
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Brandes AA, Paris MK. Review of the prognostic factors in medulloblastoma of children and adults. Crit Rev Oncol Hematol 2004; 50:121-8. [PMID: 15157661 DOI: 10.1016/j.critrevonc.2003.08.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2003] [Indexed: 11/29/2022] Open
Abstract
Medulloblastoma (MB) is rare in adults, accounting for 1% of all primary tumours of the central nervous system (CNS). Based on the assumption that the disease pattern in adults is similar to that in children, adults with medulloblastoma are treated using paediatric protocols. Thanks to progress made in recent years, long-term survival is now possible, with overall ranging from 50 to 60% at 5 years and 40 to 50% at 10 years. However, effective therapy may have devastating long-term side effects, including neuro-psychic and neuro-endocrine sequelae and cognitive dysfunction, especially in young adults. Great interest has been expressed in new biological and molecular prognostic factors, which, combined with clinical variables, may allow a more satisfactory stratification of patients.
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Affiliation(s)
- Alba A Brandes
- Medical Oncology Department, University Hospital, Via Gattamelata 64, 35100 Padova, Italy.
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Merchant TE, Gould CJ, Xiong X, Robbins N, Zhu J, Pritchard DL, Khan R, Heideman RL, Krasin MJ, Kun LE. Early neuro-otologic effects of three-dimensional irradiation in children with primary brain tumors. Int J Radiat Oncol Biol Phys 2004; 58:1194-207. [PMID: 15001264 DOI: 10.1016/j.ijrobp.2003.07.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2002] [Revised: 07/18/2003] [Accepted: 07/25/2003] [Indexed: 11/15/2022]
Abstract
PURPOSE Central nervous system (CNS) irradiation can cause sensorineural hearing loss. The relationship between the dose to the cochlea and the development of hearing loss is unknown. Conformal radiation therapy (CRT) techniques facilitate accurate cochlear dosimetry. We modeled hearing threshold levels (HTL) after CRT in children with localized primary brain tumors (ependymoma, low- or high-grade astrocytoma, craniopharyngioma, or CNS germinoma) by using cochlear dose and clinical variables. PATIENTS AND METHODS We evaluated 72 children (median age, 9.5 years) with audiograms before and every 6 months after CRT (median follow-up, 16.6 months; range, 4.3-42.6 months). We used a mixed-effects model to predict change in hearing for each ear as a function of time, cochlear dose, and clinical variables. RESULTS Hearing was affected the greatest in patients with CSF shunts and pre-CRT ototoxic chemotherapy, enhanced by cochlear dose, and was more prominent on the right side. Hearing impairment after CRT alone occurred at low and intermediate frequencies in patients with shunts and supratentorial tumors when the cochlear dose exceeded 32 Gy. Patients with shunts and central supratentorial tumors developed intermediate-frequency hearing loss after CRT alone regardless of dose. CONCLUSIONS Hearing loss during the first 4 years after CRT alone is uncommon, although patients with shunts and supratentorial tumors appear to be at increased risk for low- and intermediate-frequency effects. CSF shunting and increased cochlear dose enhance the effect of ototoxic chemotherapy. If possible, the average cochlear dose should be <32 Gy over a 6-week course of treatment until more specific dose data become available.
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Affiliation(s)
- Thomas E Merchant
- Department ofRadiation Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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van den Berg H. Biology and therapy of malignant solid tumors in childhood. CANCER CHEMOTHERAPY AND BIOLOGICAL RESPONSE MODIFIERS 2003; 21:683-707. [PMID: 15338769 DOI: 10.1016/s0921-4410(03)21032-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Hendrik van den Berg
- Department of Paediatric Oncology, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, The Netherlands.
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Kellie SJ, Wong CKF, Pozza LD, Waters KD, Lockwood L, Mauger DC, White L. Activity of postoperative carboplatin, etoposide, and high-dose methotrexate in pediatric CNS embryonal tumors: results of a phase II study in newly diagnosed children. MEDICAL AND PEDIATRIC ONCOLOGY 2002; 39:168-74. [PMID: 12210445 DOI: 10.1002/mpo.10137] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chemotherapy is used as an alternative to irradiation or to minimize the irradiation exposure among infants with medulloblastoma or other CNS embryonal tumors. Adjuvant chemotherapy is commonly used in older children with high-risk medulloblastoma to improve survival or to allow a reduction in the craniospinal irradiation dose in standard-risk patients. However, optimal multimodality therapy, including the precise role of chemotherapy, has not been defined for these groups of patients. The objective of the present study is to assess the efficacy and toxicity of four postoperative courses of carboplatin, etoposide, and high-dose methotrexate in newly diagnosed children with medulloblastoma or other CNS embryonal tumors. PROCEDURE Twenty-eight children, aged from 0.3 to 15.9 years (median, 6.2 years) with post-operative measurable residual CNS embryonal tumors were enrolled, comprising medulloblastoma (n = 19), supratentorial PNET (n = 7), and pineoblastoma (n = 2). Post-operative chemotherapy comprised carboplatin 350 mg/m(2) and etoposide 100 mg/m(2) on Days 1 & 2, and methotrexate 8 g/m(2) on Day 3, repeated at 21-28-day intervals for a total of four courses. Therapy following completion of the initial Phase II study was influenced by patient age and investigator preference. RESULTS The combined complete response rate (CR, 7/19) and partial response rate (PR, 7/19) was 74% in patients with medulloblastoma, 89% for patients with PNET/pineoblastoma (CR, 2/9 and PR, 6/9), and for all patients it was 79%. Patients aged < 3 years at diagnosis had a combined PR and CR rate of 71% compared to 81% in patients aged > 3 years. Treatment was well tolerated although myelosuppression and thrombocytopenia were common. CONCLUSIONS The combination of carboplatin, etoposide, and high-dose methotrexate is highly active in pediatric patients with CNS embryonal tumors.
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Affiliation(s)
- Stewart J Kellie
- Oncology Unit, The Children's Hospital at Westmead and The University of Sydney, NSW, Australia.
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Athale UH, Stewart C, Kuttesch JF, Moghrabi A, Meyer W, Pratt C, Gajjar A, Heideman RL. Phase I study of combination topotecan and carboplatin in pediatric solid tumors. J Clin Oncol 2002; 20:88-95. [PMID: 11773158 DOI: 10.1200/jco.2002.20.1.88] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We conducted a phase I trial of escalating doses of topotecan (TOPO) in association with a fixed systemic exposure of carboplatin (CARBO) with or without granulocyte colony-stimulating factor (G-CSF) in children. PATIENTS AND METHODS Two separate cohorts of patients (pts) with solid tumors were studied: (A) pts with refractory or recurrent disease and (B) pts with no prior myelosuppressive therapy or newly diagnosed tumors for which there was no standard chemotherapy. CARBO was given on day 1 at an area under the curve of 6.5, followed by TOPO as a continuous infusion for 3 days; the starting dose of TOPO was 0.50 mg/m(2)/d. Cycles were repeated every 21 days. G-CSF was given at a dose of 5 microg/kg/d starting on day 4. RESULTS Forty-eight of 51 pts were assessable for toxicity. In group A, dose-limiting myelosuppression persisted despite de-escalation of TOPO to 0.3 mg/m(2)/d and use of G-CSF. In group B, the maximum-tolerated dose of TOPO was 0.5 mg/m(2)/d for 3 days, and 0.6 mg/m(2)/d for 3 days with G-CSF. No significant nonhematologic toxicities were observed. Among 46 pts assessable for response, one had complete response, five had partial response, and 18 had stable disease. CONCLUSION Although this combination possesses antineoplastic activity in pediatric solid tumors, hematologic toxicity precluded any meaningful TOPO dose escalation. The addition of G-CSF did not alter this. The potential for preservation of activity and diminution of toxicity with alternative sequences and schedules of administration (topoisomerase followed by alkylating or platinating agents) should be evaluated.
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Affiliation(s)
- Uma H Athale
- Department of Hematology-Oncology, Pharmaceutical Sciences, St Jude Children's Research Hospital, 332 N. Lauderdale, Memphis, TN 38105, USA
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Chastagner P, Bouffet E, Grill J, Kalifa C. What have we learnt from previous phase II trials to help in the management of childhood brain tumours? Eur J Cancer 2001; 37:1981-93. [PMID: 11597375 DOI: 10.1016/s0959-8049(01)00251-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Contrary to major advances in cure rates observed for almost all childhood cancers, progress in reducing brain tumour survival rates remains very limited. Although new drug development in oncology is founded on principles outlined in the organised methodology of phase I, II, and III trials, based on rigorous study design using standardised criteria, this approach has been applied very slowly in the field of neuro-oncology. There are multiple explanations for the paucity of well-conducted prospective clinical trials, such as the rarity and the heterogeneity of these tumours, and the reluctance of some investigators to enroll their patients in constraining trials. Data from the past two decades shows that several methodological problems preclude the drawing of any definite conclusions for the majority of drugs assessed. Among them, the necessity of a central neuropathological and neuroradiological review has been highlighted in, at least, two multicentric studies. Changes in histological diagnosis and grade have been reported in a proportion as high as 20%, and changes in response rate in 14% of the cases. This review of phase II trials for brain tumours reveals a wide array of sometimes arbitrary response definitions, that is if response is defined at all, and most series have enrolled small numbers of patients. We report on the different problems encountered in childhood brain tumours in these phase II trials, and their impact on phase III trials.
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Affiliation(s)
- P Chastagner
- Department of Paediatric Oncology, Hôpital d'Enfants, CHU Nancy, 54500, Vandoeuvre, France.
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Ashby LS, Shapiro WR. Intra-arterial cisplatin plus oral etoposide for the treatment of recurrent malignant glioma: a phase II study. J Neurooncol 2001; 51:67-86. [PMID: 11349883 DOI: 10.1023/a:1006441104260] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Twenty-five adults with recurrent malignant glioma were enrolled into a phase II clinical study. All patients had undergone surgical resection and had failed radiotherapy and first-line treatment with nitrosourea-based chemotherapy; five had failed second-line chemotherapy. Our objective was to test the efficacy of combining intra-arterially (i.a.) infused cisplatin and oral etoposide. Using conventional angiographic technique to access anterior/posterior cerebral circulation, cisplatin 60 mg/m2 was administered by i.a. infusion on day 1 of treatment. Oral etoposide 50 mg/m2/day was given days 1-21, with a 7 day rest interval between courses. Response to treatment was evaluated in 20 patients. Two patients with anaplastic astrocytoma had partial responses (PR) and six patients experienced stable disease (SD) for an overall response rate (PR +/- SD) of 40%. The median time to disease progression (MTP) following treatment for the responder subgroup was 18 weeks. The median survival time from treatment (MST) for the responders (n = 8) and non-responders (n = 12) was 56.5 weeks and 11 weeks, respectively. Combined i.a. cisplatin and oral etoposide was well-tolerated, but produced an objective response in only a minority of patients. Those considered responders (PR + SD) experienced significant survival advantage when compared to the non-responders. Nonetheless, i.a. delivery of chemotherapy is an expensive and technologically burdensome treatment for most patients to access, requiring proximity to a major center with neuro-oncological and neuroradiological clinical services. This is of special concern for patients suffering recurrent disease with progressive neurological symptoms at a time in their course when quality of life must be safeguarded and palliation of symptoms should be the therapeutic goal. Despite the efforts of previous investigators to use this combination of agents to treat recurrent malignant glioma, we cannot recommend the use of i.a. chemotherapy for salvage treatment of this disease.
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Affiliation(s)
- L S Ashby
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona 85013, USA
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Abstract
Medulloblastoma, the most common primary malignant brain tumor in children, is a radiosensitive and chemosensitive tumor. Nevertheless, medulloblastoma remains a management challenge for the clinical oncologist, because the optimal sequence and dosage for each treatment modality has not yet been defined. In addition, effective management strategies for medulloblastoma may result in profound neuroendocrine and neuropsychologic sequelae. In this article, we review the clinical and biologic prognostic factors for classifying medulloblastoma, current strategies for the management of this disease, and potential strategies to prevent or minimize long-term treatment sequelae.
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Affiliation(s)
- M Chintagumpala
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas 77030, USA
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Tornesello A, Mastrangelo S, Piciacchia D, Bembo V, Colosimo C, Di Rocco C, Mastrangelo R. Progressive disease in children with medulloblastoma/PNET during preradiation chemotherapy. J Neurooncol 2000; 45:135-40. [PMID: 10778729 DOI: 10.1023/a:1006133404936] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The overall prognosis in children with medulloblastoma/PNET has not significantly improved over the past decade. Intensive neoadjuvant chemotherapy has not yet adequately explored. We evaluated the short-term clinical results of an intensive chemotherapy regimen in high risk children with newly diagnosed MB/PNET, after surgery and before radiation. Twelve previously untreated patients with high-risk medulloblastoma/PNET, according to Chang's classification, were treated with the following chemotherapy regimen: high dose carboplatin 600 mg/m2/day on days 1 and 2; the same course was administered 4 weeks later. One month later, high dose cyclophosphamide 2 g/m2/day on days 1 and 2, followed by an identical course 4 weeks later. Vincristine 1, 5 mg/m2 i.v. was given on the first day of each course. Systemic evaluation of the disease included imaging of the entire neuraxis, including MRI of the entire spine. Out of 12 enrolled, 7 patients were able to be evaluated for a residual disease after surgery. After two cycles of high dose carboplatin, we noted 1 CR, 4 PR and 2 MR. After the subsequent two cycles of high dose cyclophosphamide we observed an additional response in 4 cases. On the other hand, 4 patients clearly showed evidence of PD immediately after the first course of cyclophosphamide (2 cases) or following the second course. Three of the 4 patients had shown respectively 1 CR and 2 PR after the second course of carboplatin. Whereas it was confirmed that 2 courses of high dose carboplatin is effective in high risk MB/PNET children, we observed an unacceptable number of PD during the subsequent high dose cyclophosphamide therapy. A review from the literature also suggests that, in general, the longer radiotherapy is delayed, the higher the incidence of PD. In the search for the optimal drug combination in "sandwich chemotherapy" for children with high risk MB/PNET, PD must be reduced to an acceptable incidence, since a high number of PD may significantly lower the probability of long-term survival.
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Affiliation(s)
- A Tornesello
- Division of Pediatric Oncology, Catholic University, Rome, Italy
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Schiavetti A, Varrasso G, Maurizi P, Trasimeni G, Carapella C, Castello MA. Metastatic medulloblastoma in 10-year-old girl treated successfully with chemotherapy without radiotherapy. J Neurooncol 2000; 45:55-60. [PMID: 10728910 DOI: 10.1023/a:1006365511379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We report a case of high risk medulloblastoma with leptomeningeal intracranial and spinal metastasis in a 10-year-old girl treated successfully with conventional prolonged chemotherapy without radiotherapy. This is a particular case of medulloblastoma that at onset did not receive standard therapy for medulloblastoma i.e. neither surgery nor craniospinal irradiation. This 10-year-old Chinese girl affected with localized medulloblastoma was previously treated at a medical department in China only with radiotherapy on the posterior fossa. When the child arrived in Italy with progressed metastatic medulloblastoma, she was treated with carboplatin/etoposide association i.v. followed by oral etoposide and partial surgery of the primitive mass. The schedule of chemotherapy was etoposide 300 mg/sqm followed by carboplatin 1000 mg/sqm in one day every 21-28 days for the first six courses, then etoposide 200 mg/sqm and carboplatin 600 mg/sqm in one day every 28-35 days for further 11 courses and oral etoposide 50 mg/sqm/day for ten consecutive days and one week interval between two cycles for one year. At present the girl is alive and disease-free, and has been off-therapy for 31 months. Interestingly, in this case a long-lasting complete remission was obtained without radiotherapy and without myeloablative chemotherapy. Oral etoposide played an important role in achieving a complete remission.
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Affiliation(s)
- A Schiavetti
- Department of Pediatrics, University La Sapienza, Rome, Italy
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Kun LE. Medulloblastoma--challenges in radiation therapy and the addition of chemotherapy. Int J Radiat Oncol Biol Phys 2000; 46:261-3. [PMID: 10661329 DOI: 10.1016/s0360-3016(99)00368-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Petrilli AS, Kechichian R, Broniscer A, Garcia RJ, Tanaka C, Francisco J, Lederman H, Odone Filho V, Camargo OP, Bruniera P, Pericles P, Consentino E, Ortega JA. Activity of intraarterial carboplatin as a single agent in the treatment of newly diagnosed extremity osteosarcoma. MEDICAL AND PEDIATRIC ONCOLOGY 1999; 33:71-5. [PMID: 10398179 DOI: 10.1002/(sici)1096-911x(199908)33:2<71::aid-mpo2>3.0.co;2-t] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Chemotherapy has dramatically improved the rates of cure and survival of patients with localized and metastatic osteosarcoma. Nonetheless, the number of chemotherapeutic agents active against osteosarcoma is limited to doxorubicin, cisplatin, high-dose methotrexate, and ifosfamide. Carboplatin, a cisplatin analogue, has been tested as a single agent in patients with recurrent osteosarcoma or as part of multiagent chemotherapy in newly diagnosed patients. PROCEDURE We tested the activity and toxicity of two cycles of intraarterial carboplatin as a "window therapy" (600 mg/m2 per cycle) in 33 consecutive patients with extremity osteosarcoma before the start of multiagent chemotherapy. Response was based on clinical (tumor diameter, local inflammatory signs, and range of motion) and radiological parameters (plain local films and arteriographic studies prior to drug administration). RESULTS Patients' age ranged between 8 and 18 years (median age 13 years). Primary tumor originated from the femur (15 patients), tibia (10 patients), fibula (4 patients), humerus (3 patients), and calcaneus (1 patient). Only 7 patients (21%) had metastatic disease at diagnosis (5 in the lung and 2 in other bones). A favorable clinical and radiological response was documented in 81% and 73% of the patients, respectively. Clinical and radiological progression occurred in 12% and 9% of the patients, respectively. Seventeen of the patients remain alive and disease-free. Survival and event-free survival at 3 years for nonmetastatic patients are 71% (SE = 9%) and 65% (SE = 9%), respectively; for metastatic patients, the figures are 17% (SE = 15%) and 14% (SE = 13%), respectively. CONCLUSIONS We conclude that carboplatin is an active agent in the treatment of newly diagnosed extremity osteosarcoma.
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Affiliation(s)
- A S Petrilli
- Department of Pediatrics, Universidade Federal De São Paulo, São Paulo, Brazil.
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Bouffet E, Baranzelli MC, Patte C, Portas M, Edan C, Chastagner P, Mechinaud-Lacroix F, Kalifa C. Combined treatment modality for intracranial germinomas: results of a multicentre SFOP experience. Société Française d'Oncologie Pédiatrique. Br J Cancer 1999; 79:1199-204. [PMID: 10098759 PMCID: PMC2362245 DOI: 10.1038/sj.bjc.6690192] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Conventional therapy for intracranial germinomas is craniospinal irradiation. In 1990, the Société Française d'Oncologie Pédiatrique initiated a study combining chemotherapy (alternating courses of etoposide-carboplatin and etoposide-ifosfamide for a recommended total of four courses) with 40 Gy local irradiation for patients with localized germinomas. Metastatic patients were allocated to receive low-dose craniospinal radiotherapy. Fifty-seven patients were enrolled between 1990 and 1996. Forty-seven had biopsy-proven germinoma. Biopsy was not performed in ten patients (four had diagnostic tumour markers and in six the neurosurgeon felt biopsy was contraindicated). Fifty-one patients had localized disease, and six leptomeningeal dissemination. Seven patients had bifocal tumour. All but one patient received at least four courses of chemotherapy. Toxicity was mainly haematological. Patients with diabetus insipidus (n = 25) commonly developed electrolyte disturbances during chemotherapy. No patient developed tumour progression during chemotherapy. Fifty patients received local radiotherapy with a median dose of 40 Gy to the initial tumour volume. Six metastatic patients, and one patient with localized disease who stopped chemotherapy due to severe toxicity, received craniospinal radiotherapy. The median follow-up for the group was 42 months. Four patients relapsed 9, 10, 38 and 57 months after diagnosis. Three achieved second complete remission following salvage treatment with chemotherapy alone or chemo-radiotherapy. The estimated 3-year survival probability is 98% (CI: 86.6-99.7%) and the estimated 3-year event-free survival is 96.4% (CI: 86.2-99.1%). This study shows that excellent survival rates can be achieved by combining chemotherapy and local radiotherapy in patients with non-metastatic intracranial germinomas.
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Affiliation(s)
- E Bouffet
- Service d'Oncologie Pédiatrique, Centre L Bérard, Lyon, France
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Zona G, de Tribolet N, Pizzolato G, Dietrich PY. Etoposide-carboplatin association as 'emergency' up-front chemotherapy in a case of life-threatening adult medulloblastoma. J Neurooncol 1998; 39:253-9. [PMID: 9821111 DOI: 10.1023/a:1005922625155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Medulloblastoma is a rare tumor in the adult population. Current therapies include surgery and irradiation. Unlike in children, chemotherapy is not commonly used, and its potential has poorly been investigated to date. We report the case of an adult patient with disseminated medulloblastoma and fulminant neurological deterioration, precluding craniospinal irradiation. Emergency chemotherapy consisting of carboplatin (400 mg/m2) and etoposide (500 mg/m2) with intrathecal (i.t.) administration of cytosar and hydrocortisone was initiated. Impressive clinical response was achieved after the first cycle of chemotherapy, with the complete disappearance of the lesions detected by MRI. After 3 courses of chemotherapy, the patient underwent craniospinal irradiation (36 Gy to the entire neuraxis and 54 Gy to the posterior fossa). Two years after surgery, the patient was well, with complete clinical recovery, and a new MRI confirmed the disappearance of the lesions. Given the dramatic efficacy of the etoposide-carboplatin association (combined with i.t. cytosar), this regimen has to be considered in an emergency setting and seems to be a very attractive candidate to be investigated as first line therapy for poor risk medulloblastoma in adults.
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Affiliation(s)
- G Zona
- Department of Neurosurgery, University Hospital, Geneva, Switzerland
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Urban C, Benesch M, Pakisch B, Lackner H, Kerbl R, Schwinger W, Oberbauer R. Synchronous radiochemotherapy in unfavorable brain tumors of children and young adults. J Neurooncol 1998; 39:71-80. [PMID: 9760072 DOI: 10.1023/a:1005966407408] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The prognosis of patients with incompletely resected malignant brain tumors is almost fatal. In an attempt to improve the outcome of children and young adults with unfavorable brain tumors an intensive multimodal therapeutic strategy was developed combining simultaneous (hyper)fractionated external beam irradiation and conventional adjuvant chemotherapy after initial surgery. 17 patients aged between 2.10 and 25.11 years were entered into the study. 16/17 patients were treated according to the German/Austrian Pediatric Brain Tumor Study Group multicenter trial HIT '91. They are not protocol patients of this HIT '91 trial. Induction chemotherapy consisted of 2 courses of ifosfamide (3 g/m2/d) on days 1-3, etoposide (150 mg/m2/d) on days 4-6, methotrexate (5 g/m2) on days 15 and 22, cisplatin (40 mg/m2/d) and cytarabine (400 mg/m2/d) on days 29-31. Three weeks after the last dose of cisplatin/cytarabine the second course of chemotherapy was started. The last patient entered into the study received a modified therapy containing ifosfamide, cisplatin and etoposide. Synchronously at a median of 12 days after initiation of chemotherapy 12/17 patients received local radiotherapy (6000-7040 cGy) to the brain and 5/17 patients craniospinal irradiation (3520 cGy with a tumor boost of 1400-2000 cGy). 4-6 weeks after completion of the second course of chemotherapy maintenance therapy was started with carmustine (CCNU) (75 mg/m2) and carboplatin (400 mg/m2) each on day 1 and vincristine (1.5 mg/m2) on day 1, 8, 15. This course was repeated eight times every six weeks. 9/17 patients are alive at a median follow-up of 25 months (range 5-50) with 4 complete remissions, 2 partial remissions and 1 stable disease lasting 42+ months. Two patients, who initially had stable disease, progressed, but are still alive at 31+ and 41+ months after diagnosis. Median progression-free survival and median overall survival is 19 and 36 months, respectively. Hematologic and methotrexate-induced toxicity were severe and resulted in one therapy-related death. However, radiotherapy concomitant to chemotherapy appears to be an effective method of treatment for brain tumors with poor prognosis, though toxicity is severe in some cases.
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Affiliation(s)
- C Urban
- Division of Pediatric Hematology/Oncology, University Children's Hospital, University of Graz, Austria.
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Kroll RA, Neuwelt EA. Outwitting the blood-brain barrier for therapeutic purposes: osmotic opening and other means. Neurosurgery 1998; 42:1083-99; discussion 1099-100. [PMID: 9588554 DOI: 10.1097/00006123-199805000-00082] [Citation(s) in RCA: 394] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE This article reviews historical aspects of the blood-brain barrier (BBB) and recent advances in mechanisms to deliver therapeutic agents across the BBB for the treatment of intracerebral tumors and other neurological diseases. METHODS The development of the osmotic BBB disruption procedure as a clinically useful technique is described. Osmotic BBB disruption is contrasted with alternative methods for opening or bypassing the BBB, including pharmacological modification of the BBB with bradykinin and direct intracerebral infusion. RESULTS Laboratory studies have played a fundamental role in advancing our understanding of the BBB and delivery of agents to brain. Preclinical animal studies will continue to serve an integral function in our efforts to improve the diagnosis and treatment of a number of neurological disorders. Techniques involving the modification of the BBB and/or blood-tumor barrier to increase delivery of therapeutic agents have been advanced to clinical trials in patients with brain tumors with very favorable results. CONCLUSION Improving delivery of agents to the brain will play a major role in the therapeutic outcome of brain neoplasms. As techniques for gene therapy are advanced, manipulation of the BBB also may be important in the treatment of central nervous system genetic disorders.
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Affiliation(s)
- R A Kroll
- Department of Neurology, Oregon Health Sciences University, Portland 97201, USA
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Abstract
For many years, chemotherapy has been utilized for the treatment of malignant brain tumors with minimal success. This particularly true with chemotherapy in adult malignant gliomas for which no new drug has been approved for use since the initial studies using nitrosoureas and procarbazine in the early 1960s. However, the results of more recent clinical trials research using newer agents appear to show improved outcome in some tumor types. Better understanding of the basic biology of these diverse tumors also have given rise to new treatment strategies, especially to drug development. A large number of new antineoplastic agents are now being tested in Phase I and II trials; they are very promising and soon may lead to new drug approvals. This review will discuss the results of completed trials for newly diagnosed and recurrent glioma in adults, as well as ongoing, new drug studies with these patients. A discussion of the more common pediatric brain tumors and the use of chemotherapy in that age group is also presented. Chemotherapy is often the primary treatment modality used to control tumor growth in newly diagnosed infants and young children, and it is in this setting that chemotherapy is particularly beneficial in reducing morbidity and increasing survival. As part of a multimodality approach that includes surgery and radiotherapy, chemotherapy has a significant role to play in the treatment of both adults and children with brain neoplasms.
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Affiliation(s)
- M D Prados
- Department of Neurosurgery, University of California, San Francisco 94117, USA.
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Bergman I, Jakacki RI, Heller G, Finlay J. Treatment of standard risk medulloblastoma with craniospinal irradiation, carboplatin, and vincristine. MEDICAL AND PEDIATRIC ONCOLOGY 1997; 29:563-7. [PMID: 9324345 DOI: 10.1002/(sici)1096-911x(199712)29:6<563::aid-mpo8>3.0.co;2-i] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Improved outcome for children with medulloblastoma requires new treatment protocols which incorporate chemotherapeutic agents that are capable of eradicating minimal residual disease in the primary posterior fossa site and in the leptomeninges and whose toxicities are tolerable. PROCEDURE We treated 25 children with nondisseminated medulloblastoma with complete or near complete surgical resection of the posterior fossa tumor, 3,600 cGy craniospinal irradiation (CSRT) and 5,400 cGy posterior fossa irradiation followed by adjuvant chemotherapy with carboplatin and vincristine. RESULTS The estimated 3-year progression-free survival (PFS) was 0.73 (S.E. +/- 0.09) compared with a 3-year PFS of 0.69 in historical controls treated with surgical resection and CSRT but without chemotherapy. Six relapses occurred outside the posterior fossa and one relapse occurred both in the posterior fossa and in the lateral ventricle. The major acute toxicities were myelosuppression, anorexia and neuropathy. CONCLUSIONS Our experience with this adjuvant chemotherapy regimen with carboplatin and vincristine, as used by us, does not encourage its adoption in future clinical trials.
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Affiliation(s)
- I Bergman
- Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, PA, USA. Bergman+@Pitt.edu
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Hartsell WF, Gajjar A, Heideman RL, Langston JA, Sanford RA, Walter A, Jones D, Chen G, Kun LE. Patterns of failure in children with medulloblastoma: effects of preirradiation chemotherapy. Int J Radiat Oncol Biol Phys 1997; 39:15-24. [PMID: 9300735 DOI: 10.1016/s0360-3016(97)00136-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate the effects of preirradiation chemotherapy on patterns of failure in children with medulloblastoma. METHODS AND MATERIALS Fifty-three patients (pts) with medulloblastoma were given preirradiation chemotherapy as initial postoperative treatment at St. Jude Children's Research Hospital from November 1984 to September 1993. Patients < or = 3 years of age (n = 23) received chemotherapy (CH) with delayed craniospinal irradiation (CSI). Children > or = 3 years with more advanced disease (T3b-T4, M+ or measurable residual after resection) were given CH followed by CSI (30 patients). Chemotherapy regimen depended on protocol, but usually included cis- or carboplatin and etoposide, +/- cyclophosphamide and vincristine. RESULTS Actuarial overall survival and event-free survival rates are 60% (95% confidence interval [41,79]) and 37% [19,55] at 5 years. Children < or = 3 at diagnosis: six of 23 pts completed CH without progression and received consolidative CSI; all six are alive with no evidence of disease (NED) at 2.4-9.1 years. Seventeen patients progressed during CH and were then given CSI. Sites of progression during CH were posterior fossa (PF) in 11 patients, neuraxis (NEUR) in 4, and PF+NEUR in 2. Following CSI, 7 patients are alive NED at 2.0-8.6 years; 10 patients died of progressive disease. Eleven patients had M0 disease at diagnosis; 8 (73%) progressed during CH, 3 in the neuraxis. Children > or = 3 at diagnosis: 20 of 30 patients completed pre-CSI CH without progression; 15 are alive NED at 1.3-9.2 years, and 5 showed post-CSI progression in the PF (n = 3), in the NEUR (n = 1) and in bone marrow (n = 1). Ten of the 30 (33%) patients progressed on CH (6 in NEUR, 4 in PF); 5 are alive and NED or with stable disease. Seventeen patients had M0 disease at diagnosis; 3 out of 17 (18%) progressed during CH, 2 in NEUR and 1 in an extraneural site. In the total group of 30 patients, 11 have had disease recurrence after completion of XRT. The actuarial rate of failure was 23 +/- 9% for the patients < or = 3 years of age and 21 +/- 8% for the older children when evaluated at 4 months after diagnosis (at the completion of chemotherapy in the older children but during the ongoing chemotherapy in the younger children). CONCLUSIONS In patients presenting with M0 disease and receiving pre-CSI chemotherapy, the risk of neuraxis progression seems to increase with duration of chemotherapy. The sites of progression during preirradiation chemotherapy are nearly equally divided between posterior fossa and other neuraxis sites. CSI salvage of patients progressing on chemotherapy is possible in approximately 50% of patients. Following CSI, neuraxis progression is more frequent than posterior fossa relapse.
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Affiliation(s)
- W F Hartsell
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Abstract
Brain tumors account for 20% of childhood cancers and provide a "frontier" in which improved disease control and functional outcome require coordinated, directed studies in neurosurgery, radiation therapy, and chemotherapy. Among the several brain tumor types common in children, the recent experiences in medulloblastoma, ependymoma, and tumors occurring in infants and very young children are reviewed in the context of recent clinical trials and ongoing investigations.
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Affiliation(s)
- L E Kun
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Marec-Bérard P, Khelfaoui F, Frappaz D, Carrie C, Zucker JM, Brunat-Mentigny M, Bouffet E. [Prolonged remission in a child with late brain metastasis of retinoblastoma]. Arch Pediatr 1996; 3:1001-5. [PMID: 8952796 DOI: 10.1016/0929-693x(96)81723-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Outcome of patients with retinoblastoma is strongly related to the extent of the disease at diagnosis. Thus, prognosis of extra-ocular retinoblastoma is poor and metastases to central nervous system are usually fatal. CASE REPORT An 8-year-old child presented with a late recurrence of bilateral retinoblastoma. Initial treatment had associated enuclation of the left eye and radiation therapy on the right. At time of tumour recurrence, clinical examination showed cervical lymph nodes. There was a large frontal metastasis on the CT scan and bone marrow examination showed a minimal involvement by malignant cells. The patient achieved complete remission with high dose etoposide and carboplatin; he subsequently underwent massive chemotherapy followed by bone marrow rescue, and received additional radiation therapy on the frontal and cervical areas. He is well, five years after relapse. CONCLUSIONS This case highlights efficacy of chemotherapy in advanced retinoblastomas. Intensive chemotherapy is a promising and potentially curative approach in the management of advanced or metastatic retinoblastomas.
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