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Gorelyshev S, Medvedeva O, Mazerkina N, Ryzhova M, Krotkova O, Golanov A. Medulloblastomas in Pediatric and Adults. Adv Exp Med Biol 2023; 1405:117-152. [PMID: 37452937 DOI: 10.1007/978-3-031-23705-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Medulloblastoma is the primary malignant embryonic tumor of the cerebellum and the most common malignant tumor of childhood, accounting up to 25% of all CNS tumors in children, but is extremely rare in adults. Despite the fact that medulloblastomas are one of the most malignant human tumors, it is worthy to note that a great breakthrough has been achieved in our understanding of oncogenesis and the development of real methods of treatment. The main objective of surgical treatment is a maximum resection of tumor with minimal impairment of neurological functions, in order to reduce the volume, remove tumor tissue, get the biopsy, and restore the cerebrospinal fluid flow. The progress of surgical techniques (using a microscope, ultrasound suction), anesthesiology, and intensive care has significantly decreased surgical mortality and increased radicality of tumor removal. Postoperative mortality is less than one percent in most studies, while neurological complications have been reported between 5-10%. Radiotherapy is the main method of treatment in patients older than 3 years, which dramatically improved the recurrence-free survival. Nevertheless, the radiation therapy without systemic chemotherapy leads to a high risk of systemic metastases. After the role of chemotherapy was statistically proven, investigations of the optimal combination of different chemotherapy regimens continued around the world. Currently, 80% of patients can already be cured, however, the quality of life of patients in the long-term period remains quite low, which depends on many factors including endocrinological, cognitive, neurological, and otoneurologic aspects. Thus, the main strategic goal of the development of neuro-oncology is to reduce the doses of radiation therapy to the CNS and the main task of international research is to optimize existing protocols and develop fundamentally new ones based on molecular genetic research in order to improve the quality of life.
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Affiliation(s)
- Sergey Gorelyshev
- Pediatric Neurosurgical Department, N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia.
| | - Olga Medvedeva
- Pediatric Neurosurgical Department, N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Nadezhda Mazerkina
- Pediatric Neurosurgical Department, N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Marina Ryzhova
- Department of Neuropathology, N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Olga Krotkova
- N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Andrey Golanov
- Department of Radiosurgery, N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
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De B, Florez MA, Ludmir EB, Maor MH, McGovern SL, McAleer MF, Grosshans DR, Chang EL, Mahajan A, Paulino AC. Late Effects of Craniospinal Irradiation Using Electron Spinal Fields for Pediatric Patients With Cancer. Int J Radiat Oncol Biol Phys 2023; 115:164-73. [PMID: 35716848 DOI: 10.1016/j.ijrobp.2022.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/02/2022] [Accepted: 06/06/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE For children, craniospinal irradiation (CSI) with photons is associated with significant toxic effects. The use of electrons for spinal fields is hypothesized to spare anterior structures but the long-term effects remain uncertain. We studied late effects of CSI using electrons for spinal radiation therapy (RT). METHODS AND MATERIALS Records of 84 consecutive patients treated with CSI using electrons for the spine at a single institution between 1983 and 2014 were reviewed. Median age at RT was 5 (range, 1-14) years. The most common histologies were medulloblastoma/primitive neuroectodermal tumor (59%) and ependymoma (8%). The median prescribed dose to the entire spine was 30 Gy (range, 6-45). A subset of 48 (57%) patients aged 2 to 14 at RT with clinical follow-up for ≥5 years was analyzed for late effects. Height z scores adjusted for age before and after CSI were assessed using stature-for-age charts and compared with a t test. RESULTS At median follow-up of 19 years (range, 0-38 years), the median survival was 22 years (95% confidence interval, 12-28 years) after RT, with 47 patients (56%) alive at last follow-up. On subset analysis for late effects, 19 (40%) patients developed hypothyroidism and 5 (10%) developed secondary malignancies. Other complications reported were esophageal stricture and periaortic hemorrhage in 1 and restrictive pulmonary disease in 1 patient. Median height z score before treatment was -0.4 (36th percentile; interquartile range, -1.0 to 0.0) and at last follow-up was -2.2 (first percentile; interquartile range, -3.1 to -1.6; P < .001). Of 44 patients with spinal curvature assessments, 15 (34%) had scoliosis with median Cobb angle 15° (range, 10°-35°) and 1 (2%) required surgery. CONCLUSIONS Frequent musculoskeletal toxic effects and predominantly decreased height were seen with long-term follow-up. Scoliosis and hypothyroidism were each seen in at least one-third of long-term survivors. However, clinically evident esophageal, pulmonary, and cardiac toxic effects were infrequent.
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Aldrich KD, Horne VE, Bielamowicz K, Sonabend RY, Scheurer ME, Paulino AC, Mahajan A, Chintagumpala M, Okcu MF, Brown AL. Comparison of hypothyroidism, growth hormone deficiency, and adrenal insufficiency following proton and photon radiotherapy in children with medulloblastoma. J Neurooncol 2021; 155:93-100. [PMID: 34596831 DOI: 10.1007/s11060-021-03847-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/18/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endocrine deficiencies are common following Craniospinal irradiation (CSI) in children with brain tumors, but empirical data comparing outcomes following proton (PRT) and photon radiation therapy (XRT) are limited. METHODS This retrospective chart review compared the incidence of hypothyroidism, Growth hormone deficiency (GHD), and Adrenal insufficiency (AI) in patients with medulloblastoma treated with XRT and PRT between 1997 and 2016. All patients received CSI and had routine endocrine screening labs to evaluate for thyroid dysfunction, GHD, and AI. We used proportional hazards regression to calculate hazard ratios (HR) and 95% confidence intervals (CI) comparing the development of hypothyroidism, AI, and GHD between radiation modalities, adjusting for age at diagnosis, sex, race/ethnicity, and CSI dose. RESULTS We identified 118 patients with medulloblastoma who were followed for a median of 5.6 years from the end of radiotherapy. Thirty-five (31%) patients developed hypothyroidism, 71 (66%) GHD, and 20 (18%) AI. Compared to PRT, XRT was associated with a higher incidence of primary hypothyroidism (28% vs. 6%; HR = 4.61, 95% CI 1.2-17.7, p = 0.03). Central hypothyroidism, GHD, and AI incidence rates were similar between the groups. CONCLUSIONS Primary hypothyroidism occurs less often after PRT CSI, compared to XRT CSI. This suggests that the thyroid and pituitary glands receive less radiation after spine and posterior fossa boost RT, respectively, using PRT.
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Affiliation(s)
| | - Vincent E Horne
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Kevin Bielamowicz
- Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rona Y Sonabend
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | - Arnold C Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Mehmet F Okcu
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Austin L Brown
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
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Hanaford AR, Alt J, Rais R, Wang SZ, Kaur H, Thorek DLJ, Eberhart CG, Slusher BS, Martin AM, Raabe EH. Orally bioavailable glutamine antagonist prodrug JHU-083 penetrates mouse brain and suppresses the growth of MYC-driven medulloblastoma. Transl Oncol 2019; 12:1314-1322. [PMID: 31340195 PMCID: PMC6657308 DOI: 10.1016/j.tranon.2019.05.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 05/13/2019] [Accepted: 05/13/2019] [Indexed: 12/22/2022] Open
Abstract
A subset of poor-prognosis medulloblastoma has genomic amplification of MYC. MYC regulates glutamine metabolism in multiple cellular contexts. We modified the glutamine analog 6-diazo-5-oxo-l-norleucine (DON) to mask its carboxylate and amine functionalities, creating a prodrug termed JHU-083 with increased oral bioavailability. We hypothesized that this prodrug would kill MYC-expressing medulloblastoma. JHU-083 treatment caused decreased growth and increased apoptosis in human MYC-expressing medulloblastoma cell lines. We generated a mouse MYC-driven medulloblastoma model by transforming C57BL/6 mouse cerebellar stem and progenitor cells. When implanted into the brains of C57BL/6 mice, these cells formed large cell/anaplastic tumors that resembled aggressive medulloblastoma. A cell line derived from this model was sensitive to JHU-083 in vitro. Oral administration of JHU-038 led to the accumulation of micromolar concentrations of DON in the mouse brain. JHU-083 treatment significantly increased the survival of immune-competent animals bearing orthotopic tumors formed by the mouse cerebellar stem cell model as well as immune-deficient animals bearing orthotopic tumors formed by a human MYC-amplified medulloblastoma cell line. These data provide pre-clinical justification for the ongoing development and testing of orally bioavailable DON prodrugs for use in medulloblastoma patients.
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Affiliation(s)
- Allison R Hanaford
- Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jesse Alt
- Johns Hopkins Drug Discovery, Johns Hopkins University School of Medicine
| | - Rana Rais
- Johns Hopkins Drug Discovery, Johns Hopkins University School of Medicine; Department of Neurology, Johns Hopkins University School of Medicine
| | - Sabrina Z Wang
- Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harpreet Kaur
- Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel L J Thorek
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; Department of Biomedical Engineering, Washington University, St. Louis, MO
| | - Charles G Eberhart
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD 21287; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, School of Medicine, Baltimore, MD 21287
| | - Barbara S Slusher
- Johns Hopkins Drug Discovery, Johns Hopkins University School of Medicine; Department of Neurology, Johns Hopkins University School of Medicine
| | - Allison M Martin
- Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, MD; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, School of Medicine, Baltimore, MD 21287.
| | - Eric H Raabe
- Division of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD 21287; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, School of Medicine, Baltimore, MD 21287.
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Lawson SA, Horne VE, Golekoh MC, Hornung L, Burns KC, Fouladi M, Rose SR. Hypothalamic-pituitary function following childhood brain tumors: Analysis of prospective annual endocrine screening. Pediatr Blood Cancer 2019; 66:e27631. [PMID: 30693650 DOI: 10.1002/pbc.27631] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Outcomes for childhood brain tumors are now associated with a five-year survival rate of 75%. Endocrine effects of brain tumors are common, occurring in 43% of patients by 10 years from tumor diagnosis. Optimal timing of screening for endocrinopathies remains undefined. We aim to identify incidence and timing of endocrinopathies following brain tumor diagnosis, to better refine screening guidelines. METHODS Retrospective chart review of patients referred to our hospital's neuro-oncology clinic for evaluation and treatment of brain tumors. Inclusion criteria were a positive history for brain tumor diagnosis and evaluation at our center. Data collection included demographics, tumor diagnosis, tumor therapy, and endocrinopathy diagnosis and timing. Laboratory data and clinical documentation were reviewed. RESULTS Four hundred nineteen subjects were included for analysis. Tumor locations included supratentorial 158 (38%), posterior fossa 145 (35%), suprasellar 96 (23%), and upper spinal cord 20 (5%). Only 61% had undergone endocrine screening. Forty-five percent of screened patients had endocrinopathies. Endocrinopathy diagnosis typically occurred within six years after tumor diagnosis. Tumor recurrence and repeated therapies increased the risk for endocrinopathies within the subsequent six years after tumor therapy. Higher rates of endocrinopathies were identified in patients who had received cranial irradiation for posterior fossa, supratentorial, or suprasellar tumors. CONCLUSION Endocrine screening should occur in childhood brain tumor survivors, particularly those who have received irradiation. Our study suggests that in children with brain tumors, the highest yield for finding a pituitary deficiency is within the first six years after tumor diagnosis and treatment. Screening should continue annually beyond six years, but with special attention in the subsequent six years after therapy for tumor recurrence. Prospective screening and endocrinology referral should be implemented in childhood brain tumor survivors.
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Affiliation(s)
- Sarah A Lawson
- Divisions of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Vincent E Horne
- Divisions of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marjorie C Golekoh
- Divisions of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lindsey Hornung
- Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karen C Burns
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maryam Fouladi
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Susan R Rose
- Divisions of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
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Prince EW, Balakrishnan I, Shah M, Mulcahy Levy JM, Griesinger AM, Alimova I, Harris PS, Birks DK, Donson AM, Davidson N, Remke M, Taylor MD, Handler MH, Foreman NK, Venkataraman S, Vibhakar R. Checkpoint kinase 1 expression is an adverse prognostic marker and therapeutic target in MYC-driven medulloblastoma. Oncotarget 2018; 7:53881-53894. [PMID: 27449089 PMCID: PMC5288228 DOI: 10.18632/oncotarget.10692] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/05/2016] [Indexed: 12/01/2022] Open
Abstract
Checkpoint kinase 1 (CHK1) is an integral component of the cell cycle as well as the DNA Damage Response (DDR) pathway. Previous work has demonstrated the effectiveness of inhibiting CHK1 with small-molecule inhibitors, but the role of CHK1 mediated DDR in medulloblastoma is unknown. CHK1, both at the mRNA and protein level, is highly expressed in medulloblastoma and elevated CHK1 expression in Group3 medulloblastoma is an adverse prognostic marker. CHK1 inhibition with the small-molecule drug AZD7762, results in decreased cell growth, increased DNA damage and cell apoptosis. Furthermore, AZD7762 acts in synergy with cisplatin in reducing cell proliferation in medulloblastoma. Similar phenotypic changes were observed with another CHK1 inhibitor, PF477736, as well as genetic knockdown using siRNA against CHK1. Treatments with small-molecule inhibitors of CHK1 profoundly modulated the expression of both upstream and downstream target proteins within the CHK1 signaling pathways. This suggests the presence of a feedback loop in activating CHK1. Overall, our results demonstrate that small-molecule inhibition of CHK1 in combination with, cisplatin, is more advantageous than either treatment alone, especially for Group 3 medulloblastoma, and therefore this combined therapeutic approach serves as an avenue for further investigation.
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Affiliation(s)
- Eric W Prince
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Ilango Balakrishnan
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Monil Shah
- University of Colorado School of Medicine, Aurora, CO, United States
| | - Jean M Mulcahy Levy
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Andrea M Griesinger
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Irina Alimova
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Peter S Harris
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Diane K Birks
- Division of Pediatric Neurosurgery, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Andrew M Donson
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Nathan Davidson
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Marc Remke
- DKFZ German Cancer Research Center, University Hospital Düsseldorf, Heidelberg, Germany
| | - Michael D Taylor
- Division of Neurosurgery, Program in Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto, ON, Canada
| | - Michael H Handler
- Division of Pediatric Neurosurgery, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Nicholas K Foreman
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States.,University of Colorado School of Medicine, Aurora, CO, United States.,Division of Pediatric Neurosurgery, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Sujatha Venkataraman
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Rajeev Vibhakar
- Department of Pediatrics and Section of Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States.,University of Colorado School of Medicine, Aurora, CO, United States.,Division of Pediatric Neurosurgery, Children's Hospital Colorado and University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
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Aloi D, Belgioia L, Barra S, Giannelli F, Cavagnetto F, Gallo F, Milanaccio C, Garrè M, Di Profio S, Di Iorgi N, Corvò R. Neuroendocrine late effects after tailored photon radiotherapy for children with low grade gliomas: Long term correlation with tumour and treatment parameters. Radiother Oncol 2017; 125:241-247. [PMID: 29037775 DOI: 10.1016/j.radonc.2017.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 09/08/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate neuroendocrine late effects in paediatric patients with low grade glioma (LGG) who underwent radiotherapy. METHODS AND MATERIAL We performed a retrospective evaluation of 40 children with LGG treated from July 2002 to January 2015 with external radiotherapy. Tumour locations were cerebral hemisphere (n=2); posterior fossa (n=15); hypothalamic-pituitary axis (HPA, n=15); spine (n=5). Three patients presented a diffuse disease. We looked for a correlation between endocrine toxicity and tumour and treatment parameters. The impact of some clinical and demographic factors on endocrinal and neuro toxicity was evaluated using the log-rank test. RESULTS The median follow-up was 52months (range: 2-151). Median age at irradiation was 6. The dose to the HPA was significantly associated with endocrine toxicity (P value=0.0190). Patients who received chemotherapy before radiotherapy and younger patients, showed worse performance status and lower IQ. The 5-year overall survival (OS) and progression free survival (PFS) rates were 94% and 73.7%, respectively. CONCLUSION Radiotherapy showed excellent OS and PFS rates and acceptable late neuroendocrine toxicity profile in this population of LGG patients treated over a period of 13years. In our experience, the dose to the HPA was predictive of the risk of late endocrine toxicity.
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Affiliation(s)
- Deborah Aloi
- Radio-Oncology Department - IRCCS A.O.U. San Martino-IST-National Institute for Cancer Research, Genoa, Italy
| | - Liliana Belgioia
- Radio-Oncology Department - IRCCS A.O.U. San Martino-IST-National Institute for Cancer Research, Genoa, Italy; Department of Health Science - DISSAL, University of Genoa, Italy
| | - Salvina Barra
- Radio-Oncology Department - IRCCS A.O.U. San Martino-IST-National Institute for Cancer Research, Genoa, Italy
| | - Flavio Giannelli
- Radio-Oncology Department - IRCCS A.O.U. San Martino-IST-National Institute for Cancer Research, Genoa, Italy
| | - Francesca Cavagnetto
- Medical Physics Department - IRCCS A.O.U. San Martino-IST-National Institute for Cancer Research, Genoa, Italy
| | - Fabio Gallo
- Medical Statistics, Department of Health Science-DISSAL, University of Genoa, Italy
| | - Claudia Milanaccio
- Pediatric Neuro-Oncology Department - IRCCS Giannina Gaslini, Genoa, Italy
| | - MariaLuisa Garrè
- Pediatric Neuro-Oncology Department - IRCCS Giannina Gaslini, Genoa, Italy
| | - Sonia Di Profio
- Pediatric Neuro-Oncology Department - IRCCS Giannina Gaslini, Genoa, Italy
| | | | - Renzo Corvò
- Radio-Oncology Department - IRCCS A.O.U. San Martino-IST-National Institute for Cancer Research, Genoa, Italy; Department of Health Science - DISSAL, University of Genoa, Italy
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De B, Beal K, De Braganca KC, Souweidane MM, Dunkel IJ, Khakoo Y, Gilheeney SW, DeAngelis LM, Menzel P, Patel SH, Wolden SL. Long-term outcomes of adult medulloblastoma patients treated with radiotherapy. J Neurooncol 2018; 136:95-104. [PMID: 29019042 DOI: 10.1007/s11060-017-2627-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 10/02/2017] [Indexed: 12/29/2022]
Abstract
Medulloblastoma (MB) is rare in adults and treatment guidelines are consequently not well-established. Few modern series have reported long-term follow-up and treatment sequelae. We examined long-term outcomes of adult MB patients at one institution. Records of 29 consecutive patients (18 male, 11 female) aged ≥ 18 years who received radiotherapy (RT) for primary MB from 1990 to 2016 were reviewed. Median age at diagnosis was 28 years (range 18-72 years). Seventeen patients were standard risk and 12 were high risk. Nineteen patients had gross total resection, seven had subtotal resection, and three had biopsy only. Median craniospinal irradiation and boost doses were 36 Gy (range 23.4-39.6 Gy) and 55.8 Gy (range 54-59.4 Gy), respectively. Of 24 patients receiving chemotherapy, 20 received concurrent + adjuvant and 4 received adjuvant only. At median follow-up of 9.0 years (range 1.1-20.5 years), five patients recurred: four in the posterior fossa and one in both the posterior fossa and above the tentorium. Five patients died: two of disease progression and three after possible treatment complications (seizure, lobar pneumonia, and multifactorial sepsis). At last follow-up, 23 patients were alive with no evidence of disease. Long-term effects include executive dysfunction (n = 17), weakness/ataxia (n = 16), and depression/anxiety (n = 13). Kaplan-Meier estimates of 10-year overall survival and failure-free survival are 83% (95% confidence interval [CI] 59-93%) and 79% (CI 55-91%), respectively. Despite encouraging disease control in this cohort, long-term sequelae may limit quality of life. Multimodality pediatric regimens using lower RT doses may be considered to reduce treatment-related morbidity.
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De Saint-Hubert M, Verellen D, Poels K, Crijns W, Magliona F, Depuydt T, Vanhavere F, Struelens L. Out-of-field doses from pediatric craniospinal irradiations using 3D-CRT, IMRT, helical tomotherapy and electron-based therapy. Phys Med Biol 2017; 62:5293-5311. [PMID: 28398210 DOI: 10.1088/1361-6560/aa6c9e] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Medulloblastoma treatment involves irradiation of the entire central nervous system, i.e. craniospinal irradiation (CSI). This is associated with the significant exposure of large volumes of healthy tissue and there is growing concern regarding treatment-associated side effects. The current study compares out-of-field organ doses in children receiving CSI through 3D-conformal radiotherapy (3D-CRT), intensity modulated radiotherapy (IMRT), helical tomotherapy (HT) and an electron-based technique, and includes radiation doses resulting from imaging performed during treatment. An extensive phantom study is performed, using an anthropomorphic phantom corresponding to a five year old child, in which organ absorbed doses are measured using thermoluminescent detectors. Additionally, the study evaluates and explores tools for calculating out-of-field patient doses using the treatment planning system (TPS) and analytical models. In our study, 3D-CRT resulted in very high doses to a limited number of organs, while it was able to spare organs such as the lungs and breast when compared to IMRT and HT. Both IMRT and HT spread the dose over more organs and were able to spare the heart, thyroid, bladder, uterus and testes when compared to 3D-CRT. The electron-based technique considerably decreased the out-of-field doses in deep-seated organs but could not avoid nearby out-of-field organs such as the lungs, ribs, adrenals, kidneys and uterus. The daily imaging dose is small compared to the treatment dose burden. The TPS error for out-of-field doses was most pronounced for organs further away from the target; nevertheless, no systematic underestimation was observed for any of the studied TPS systems. Finally, analytical modeling was most optimal for 3D-CRT although the number of organs that could be modeled was limited. To conclude, none of the techniques studied was capable of sparing all organs from out-of-field doses. Nevertheless, the electron-based technique showed the most promise for out-of-field organ dose reduction during CSI when compared to photon techniques.
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Mucci GA, Lesyshyn R, Grossman LB, Saiz A, Deluco T, Shen WV. Pediatric Medulloblastoma: a Case of Recurrent Disease and Resiliency. J Pediatr Neuropsychol 2017; 3:136-55. [DOI: 10.1007/s40817-017-0032-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Central nervous system tumors represent the most common solid malignancy in childhood. Improvement in treatment approaches have led to a significant increase in survival rates, with over 70% of children now surviving beyond 5 years. As more and more children with CNS tumors have longer survival times, it is important to be aware of the long-term morbidities caused not only by the tumor itself but also by tumor treatment. The most common side effects including poor neurocognition, endocrine dysfunction, neurological and vascular late effects, as well as secondary malignancies, are discussed within this article.
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Affiliation(s)
- Erika Roddy
- School of Medicine, University of California, San Francisco, CA, USA
| | - Sabine Mueller
- Department of Neurology, University of California, San Francisco, CA, USA Department of Pediatrics, University of California, San Francisco, CA, USA Department of Neurosurgery, University of California, San Francisco, CA, USA
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Eaton BR, Esiashvili N, Kim S, Patterson B, Weyman EA, Thornton LT, Mazewski C, MacDonald TJ, Ebb D, MacDonald SM, Tarbell NJ, Yock TI. Endocrine outcomes with proton and photon radiotherapy for standard risk medulloblastoma. Neuro Oncol 2015; 18:881-7. [PMID: 26688075 DOI: 10.1093/neuonc/nov302] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 11/03/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Endocrine dysfunction is a common sequela of craniospinal irradiation (CSI). Dosimetric data suggest that proton radiotherapy (PRT) may reduce radiation-associated endocrine dysfunction but clinical data are limited. METHODS Seventy-seven children were treated with chemotherapy and proton (n = 40) or photon (n = 37) radiation between 2000 and 2009 with ≥3 years of endocrine screening. The incidence of multiple endocrinopathies among the proton and photon cohorts is compared. Multivariable analysis and propensity score adjusted analysis are performed to estimate the effect of radiotherapy type while adjusting for other variables. RESULTS The median age at diagnosis was 6.2 and 8.3 years for the proton and photon cohorts, respectively (P = .010). Cohorts were similar with respect to gender, histology, CSI dose, and total radiotherapy dose and whether the radiotherapy boost was delivered to the posterior fossa or tumor bed. The median follow-up time was 5.8 years for proton patients and 7.0 years for photon patients (P = .010). PRT was associated with a reduced risk of hypothyroidism (23% vs 69%, P < .001), sex hormone deficiency (3% vs 19%, P = .025), requirement for any endocrine replacement therapy (55% vs 78%, P = .030), and a greater height standard deviation score (mean (± SD) -1.19 (± 1.22) vs -2 (± 1.35), P = .020) on both univariate and multivariate and propensity score adjusted analysis. There was no significant difference in the incidence of growth hormone deficiency (53% vs 57%), adrenal insufficiency (5% vs 8%), or precocious puberty (18% vs 16%). CONCLUSIONS Proton radiotherapy may reduce the risk of some, but not all, radiation-associated late endocrine abnormalities.
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Affiliation(s)
- Bree R Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Natia Esiashvili
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Sungjin Kim
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Briana Patterson
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Elizabeth A Weyman
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Lauren T Thornton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Claire Mazewski
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Tobey J MacDonald
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - David Ebb
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Shannon M MacDonald
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Nancy J Tarbell
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
| | - Torunn I Yock
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia (B.R.E., N.E.); Pediatrics, Emory University School of Medicine and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia (B.P., C.M., T.J.M.); Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California (S.K.); Pediatrics, Massachusetts General Hospital, Boston, Massachusetts (D.E.); Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts (B.R.E., E.A.W., L.T.T., S.M.M., N.J.T., T.I.Y.)
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Abstract
Intracranial tumors are the second most frequent malignancies in children and posterior fossa is a common location for these neoplasias during childhood. Recent advances in surgical techniques, radiotherapy and chemotherapy resulted in dramatic increase in the survival rates of these children, however they are still source of a significant morbidity and mortality. Endocrinological complications and late sequelae of childhood posterior fossa tumours are common among the survivors of these tumours and include growth retardation, hypothyroidism, pubertal disorders, gonadal dysfunction and osteopenia. These complications have significant impact on the quality of life of the survivors of childhood posterior fossa tumours. In this paper, the frequency, etiology, and management of these complications will be reviewed.
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Affiliation(s)
- Abdullah Bereket
- Marmara University Faculty of Medicine, Division of Pediatric Endocrinology, İstanbul, Turkey Phone: +90 216 411 64 18 E-mail:
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14
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Uday S, Murray RD, Picton S, Chumas P, Raju M, Chandwani M, Alvi S. Endocrine sequelae beyond 10 years in survivors of medulloblastoma. Clin Endocrinol (Oxf) 2015; 83:663-70. [PMID: 25952583 DOI: 10.1111/cen.12815] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/23/2014] [Accepted: 05/04/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Survival following treatment of paediatric medulloblastomas has significantly improved over the past few decades, but as a consequence, late effects, particularly endocrine sequelae, have been recognized. The complete picture of late effects, however, has been limited by short duration of follow-up. AIM To establish the evolution of endocrine sequelae in patients treated for medulloblastoma. METHODS Single-centre analysis of medulloblastoma treatment and endocrine sequelae in patients diagnosed between 1982 and 2002. RESULTS A total of 109 patients were treated for medulloblastoma, with various treatment modalities involving radio- and chemotherapy. Only 45 (41%) patients remained alive, and details of treatment and late effects were available for 35 (25 m). The median age at diagnosis was 8 (range 2-14) years, and the median follow-up was 18 (range 10-28) years. Growth hormone deficiency (GHD) was the most prevalent hormone deficiency (97%), followed by primary hypothyroidism (60%) and adrenocorticotrophic hormone (ACTH) deficiency (45·5%). The median time from end of treatment to loss of growth hormone was 1·7 (range 0·7-15) years, ACTH deficiency 2·9 (range 0·75-7·5) years and hypothyroidism 4·1 (range 0·7-11·4) years. Twenty-three percentage developed hypogonadism (17% primary and 6% secondary), whilst precocious puberty was seen in 20%. Endocrinopathies appeared to be more prevalent in those treated with concomitant chemotherapy and radiotherapy. CONCLUSIONS Prevalence of endocrine sequelae in medulloblastoma survivors is high, and evolution of endocrine dysfunction can occur as late as 15 years from treatment completion; hence, long-term close monitoring of growth, puberty and gonadal function is essential.
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Affiliation(s)
- Suma Uday
- Paediatric Endocrinology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Robert D Murray
- Endocrinology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan Picton
- Paediatric Oncology & Haematology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Chumas
- Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Midhu Raju
- Paediatric Oncology & Haematology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Manju Chandwani
- General Paediatrics, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sabah Alvi
- Paediatric Endocrinology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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15
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Clement SC, van Rijn RR, van Eck-smit BLF, van Trotsenburg ASP, Caron HN, Tytgat GAM, van Santen HM. Long-term efficacy of current thyroid prophylaxis and future perspectives on thyroid protection during 131I-metaiodobenzylguanidine treatment in children with neuroblastoma. Eur J Nucl Med Mol Imaging 2015; 42:706-15. [DOI: 10.1007/s00259-014-2967-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/28/2014] [Indexed: 11/25/2022]
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16
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Jung JH, Jung J, Kim SK, Woo SH, Kang KM, Jeong BK, Jung MH, Kim JH, Hahm JR. Alpha lipoic acid attenuates radiation-induced thyroid injury in rats. PLoS One 2014; 9:e112253. [PMID: 25401725 PMCID: PMC4234464 DOI: 10.1371/journal.pone.0112253] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 10/08/2014] [Indexed: 12/31/2022] Open
Abstract
Exposure of the thyroid to radiation during radiotherapy of the head and neck is often unavoidable. The present study aimed to investigate the protective effect of α-lipoic acid (ALA) on radiation-induced thyroid injury in rats. Rats were randomly assigned to four groups: healthy controls (CTL), irradiated (RT), received ALA before irradiation (ALA + RT), and received ALA only (ALA, 100 mg/kg, i.p.). ALA was treated at 24 h and 30 minutes prior to irradiation. The neck area including the thyroid gland was evenly irradiated with 2 Gy per minute (total dose of 18 Gy) using a photon 6-MV linear accelerator. Greater numbers of abnormal and unusually small follicles in the irradiated thyroid tissues were observed compared to the controls and the ALA group on days 4 and 7 after irradiation. However, all pathologies were decreased by ALA pretreatment. The quantity of small follicles in the irradiated rats was greater on day 7 than day 4 after irradiation. However, in the ALA-treated irradiated rats, the numbers of small and medium follicles were significantly decreased to a similar degree as in the control and ALA-only groups. The PAS-positive density of the colloid in RT group was decreased significantly compared with all other groups and reversed by ALA pretreatment. The high activity index in the irradiated rats was lowered by ALA treatment. TGF-ß1 immunoreactivity was enhanced in irradiated rats and was more severe on the day 7 after radiation exposure than on day 4. Expression of TGF-ß1 was reduced in the thyroid that had undergone ALA pretreatment. Levels of serum pro-inflammatory cytokines (TNF-α, IL-1ß and IL-6) did not differ significantly between the all groups. This study provides that pretreatment with ALA decreased the severity of radiation-induced thyroid injury by reducing inflammation and fibrotic infiltration and lowering the activity index. Thus, ALA could be used to ameliorate radiation-induced thyroid injury.
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Affiliation(s)
- Jung Hwa Jung
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Jaehoon Jung
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Soo Kyoung Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Seung Hoon Woo
- Department of Otolaryngology, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Ki Mun Kang
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Bae-Kwon Jeong
- Department of Radiation Oncology, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Myeong Hee Jung
- Biomedical Research Institute, Gyeongsang National University Hospital, Jinju, Gyeongnam, Republic of Korea
| | - Jin Hyun Kim
- Biomedical Research Institute, Gyeongsang National University Hospital, Jinju, Gyeongnam, Republic of Korea
- Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- * E-mail: (JHK); (JRH)
| | - Jong Ryeal Hahm
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
- * E-mail: (JHK); (JRH)
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17
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Bernát L, Hrušák D. Hypothyroidism after radiotherapy of head and neck cancer. J Craniomaxillofac Surg 2014; 42:356-61. [DOI: 10.1016/j.jcms.2013.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 08/29/2013] [Accepted: 09/13/2013] [Indexed: 12/18/2022] Open
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Jung YJ, Jeon YJ, Cho WK, Lee JW, Chung NG, Jung MH, Cho B, Suh BK. Risk factors for short term thyroid dysfunction after hematopoietic stem cell transplantation in children. Korean J Pediatr 2013; 56:298-303. [PMID: 23908670 PMCID: PMC3728449 DOI: 10.3345/kjp.2013.56.7.298] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 10/12/2012] [Accepted: 10/23/2012] [Indexed: 11/27/2022]
Abstract
Purpose The purpose of this study was to evaluate short-term thyroid dysfunction and related risk factors in pediatric patients who underwent hematopoietic stem cell transplantation (HSCT) during childhood. Methods We studied 166 patients (100 boys and 66 girls) who underwent HSCT at the Catholic HSCT Center from January 2004 through December 2009. The mean age at HSCT was 10.0±4.8 years. Thyroid function of the patients was tested before and during 3 months of HSCT. Results Out of 166 patients, 165 (99.4%) underwent allotransplantation. Acute graft-versus-host disease (GVHD, grades II to IV) developed in 76 patients. Conditioning regimens before HSCT include total body irradiation (n=57), busulfan (n=80), and reduced intensity (n=29). Forty-five (27.1%) had thyroid dysfunction during 3 months after HSCT (29 euthyroid sick syndrome [ESS], 6 subclinical hyperthyroidism, 4 subclinical hypothyroidism, 3 hypothyroxinemia, 2 overt hyperthyroidism, and 1 high T4 syndrome). In a univariate logistic regression analysis, age at HSCT (P=0.002) and acute GVHD (P=0.009) had statistically significant relationships with thyroid dysfunction during 3 months after HSCT. Also, in a univariate logistic regression analysis, ESS (P=0.014) showed a strong statistically significant association with mortality. Conclusion In our study 27.1% patients experienced thyroid dysfunction during 3 months after HSCT. Increase in age and acute GVHD may be risk factors for thyroid dysfunction during 3 months after HSCT. There was a significant association between ESS and mortality.
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Affiliation(s)
- You Jin Jung
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
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19
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Lannering B, Rutkowski S, Doz F, Pizer B, Gustafsson G, Navajas A, Massimino M, Reddingius R, Benesch M, Carrie C, Taylor R, Gandola L, Björk-Eriksson T, Giralt J, Oldenburger F, Pietsch T, Figarella-Branger D, Robson K, Forni M, Clifford SC, Warmuth-Metz M, von Hoff K, Faldum A, Mosseri V, Kortmann R. Hyperfractionated Versus Conventional Radiotherapy Followed by Chemotherapy in Standard-Risk Medulloblastoma: Results From the Randomized Multicenter HIT-SIOP PNET 4 Trial. J Clin Oncol 2012; 30:3187-93. [DOI: 10.1200/jco.2011.39.8719] [Citation(s) in RCA: 223] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose To compare event-free survival (EFS), overall survival (OS), pattern of relapse, and hearing loss in children with standard-risk medulloblastoma treated by postoperative hyperfractionated or conventionally fractionated radiotherapy followed by maintenance chemotherapy. Patients and Methods In all, 340 children age 4 to 21 years from 122 European centers were postoperatively staged and randomly assigned to treatment with hyperfractionated radiotherapy (HFRT) or standard (conventional) fractionated radiotherapy (STRT) followed by a common chemotherapy regimen consisting of eight cycles of cisplatin, lomustine, and vincristine. Results After a median follow-up of 4.8 years (range, 0.1 to 8.3 years), survival rates were not significantly different between the two treatment arms: 5-year EFS was 77% ± 4% in the STRT group and 78% ± 4% in the HFRT group; corresponding 5-year OS was 87% ± 3% and 85% ± 3%, respectively. A postoperative residual tumor of more than 1.5 cm2 was the strongest negative prognostic factor. EFS of children with all reference assessments and no large residual tumor was 82% ± 2% at 5 years. Patients with a delay of more than 7 weeks to the start of RT had a worse prognosis. Severe hearing loss was not significantly different for the two treatment arms at follow-up. Conclusion In this large randomized European study, which enrolled patients with standard-risk medulloblastoma from more than 100 centers, excellent survival rates were achieved in patients without a large postoperative residual tumor and without RT treatment delays. EFS and OS for HFRT was not superior to STRT, which therefore remains standard of care in this disease.
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Affiliation(s)
- Birgitta Lannering
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Stefan Rutkowski
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Francois Doz
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Barry Pizer
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Göran Gustafsson
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Aurora Navajas
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Maura Massimino
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Roel Reddingius
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Martin Benesch
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Christian Carrie
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Roger Taylor
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Lorenza Gandola
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Thomas Björk-Eriksson
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Jordi Giralt
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Foppe Oldenburger
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Torsten Pietsch
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Dominique Figarella-Branger
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Keith Robson
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Marco Forni
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Steven C. Clifford
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Monica Warmuth-Metz
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Katja von Hoff
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Andreas Faldum
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Véronique Mosseri
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
| | - Rolf Kortmann
- Birgitta Lannering and Thomas Björk-Eriksson, University of Gothenburg, Göteborg; Göran Gustafsson, Karolinska Institute, Stockholm, Sweden; Stefan Rutkowski and Katja von Hoff, University Medical Center Hamburg-Eppendorf, Hamburg; Torsten Pietsch, University of Bonn, Bonn; Monica Warmuth-Metz, University of Wuerzburg, Wuerzburg; Andreas Faldum, Institute for Biometry and Clinical Research, University of Munster, Munster; Rolf Kortmann, University of Leipzig, Leipzig, Germany; Francois Doz, Institut
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Sobol G, Musioł K, Kalina M, Kalina-Faska B, Mizia-Malarz A, Ficek K, Mandera M, Woś H, Małecka-Tendera E. The evaluation of function and the ultrasonographic picture of thyroid in children treated for medulloblastoma. Childs Nerv Syst 2012; 28:399-404. [PMID: 22080382 DOI: 10.1007/s00381-011-1625-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE Medulloblastoma (MB) is one of the most frequent and sensitive to radiation aggressive brain tumor in children. Abnormalities of the thyroid function are common complications of head and neck irradiation for childhood cancer. The aim of this study was to assess thyroid function in children treated for medulloblastoma according to the treatment protocol phase. PATIENTS AND METHODS Twenty-three children with MB were enrolled to this study. All patients underwent chemotherapy and radiotherapy to the whole craniospinal axis and boost with the conformal therapy restricted to the tumor bed to a total dose of 54 Gy. Thyroid function was evaluated based on thyroid-stimulating hormone (TSH), free thyroxine (fT4) levels controlled before MB treatment, directly after irradiation and at the end of the treatment protocol. Ultrasonography has been used to detect parenchymal abnormalities. RESULTS All patients presented normal thyroid hormone range before chemotherapy. Hypothyroidism was found in 12 patients in the course of treatment, in 2 patients hormone deficits diagnosed directly after irradiation, in 10 patients such condition was observed at the end of the whole therapy. All of these patients needed thyroid hormone substitution. None of them presented clinical symptoms of hypothyroidism. Ultrasound-detected abnormalities have been found in 20 patients. CONCLUSIONS It is crucial to monitor the functions of the thyroid gland in children treated for medulloblastoma because of the high risk of hypothyroidism resulting from the treatment. The change in the echogenicity of the thyroid gland may be an early marker for a dysfunction of this organ in children treated for medulloblastoma.
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Affiliation(s)
- G Sobol
- Department of Pediatric Oncology, Haematology and Chemotherapy, Medical University of Silesia, Upper Silesia Children's Care Health Centre, Katowice, Poland.
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Vogelius IR, Bentzen SM, Maraldo MV, Petersen PM, Specht L. Risk factors for radiation-induced hypothyroidism: a literature-based meta-analysis. Cancer 2011; 117:5250-60. [PMID: 21567385 DOI: 10.1002/cncr.26186] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 03/22/2011] [Accepted: 03/22/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND A systematic overview and meta-analysis of studies reporting data on hypothyroidism (HT) after radiation therapy was conducted to identify risk factors for development of HT. METHODS Published studies were identified from the PubMed and Embase databases and by hand-searching published reviews. Studies allowing the extraction of odds ratios (OR) for HT in 1 or more of several candidate clinical risk groups were included. A meta-analysis of the OR for development of HT with or without each of the candidate risk factors was performed. Furthermore, studies allowing the extraction of radiation dose-response data were identified for a meta-analysis of the dose-response curve. RESULTS Female gender (OR = 1.6; 95% confidence interval [CI], 1.3-1.9; P < .00001), surgery involving the thyroid gland (OR = 8.3; 95% CI, 5.7-12.0; P < .00001), or other neck surgery (OR = 1.7; 95% CI, 1.16-2.42; P = .006) were associated with a higher risk of HT. Caucasians were at higher risk of HT than African Americans (OR = 4.8; 95% CI, 2.8-8.5; P < .00001). The data showed association between lymphangiography and HT but with evidence of publication bias. There was a radiation dose-response relation with a 50% risk of HT at a dose of 45 Gy but with considerable variation in the dose response between studies. Chemotherapy and age were not associated with risk of HT in this analysis. CONCLUSIONS Several clinical risk factors for HT were identified. The risk of HT increases with increasing radiation dose, but the specific radiation dose response varies between the studies. The most likely cause of this heterogeneity is differences in follow-up between studies.
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Affiliation(s)
- Ivan R Vogelius
- Department of Radiation Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Chojnacka M, Skowrońska-Gardas A, Morawska-Kaczyńska M, Zygmuntowicz-Piętka A, Pędziwiatr K, Semaniak A. Craniospinal radiotherapy in children: Electron- or photon-based technique of spinal irradiation. Rep Pract Oncol Radiother 2010; 15:21-4. [PMID: 24376918 DOI: 10.1016/j.rpor.2010.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The prone position and electron-based technique for craniospinal irradiation (CSI) have been standard in our department for many years. But this immobilization is difficult for the anaesthesiologist to gain airway access. The increasing number of children treated under anaesthesia led us to reconsider our technique. AIM The purpose of this study is to report our new photon-based technique for CSI which could be applied in both the supine and the prone position and to compare this technique with our electron-based technique. MATERIALS AND METHODS Between November 2007 and May 2008, 11 children with brain tumours were treated in the prone position with CSI. For 9 patients two treatment plans were created: the first one using photons and the second one using electron beams for spinal irradiation. We prepared seven 3D-conformal photon plans and four forward planned segmented field plans. We compared 20 treatment plans in terms of target dose homogeneity and sparing of organs at risk. RESULTS In segmented field plans better dose homogeneity in the thecal sac volume was achieved than in electron-based plans. Regarding doses in organs at risk, in photon-based plans we obtained a lower dose in the thyroid but a higher one in the heart and liver. CONCLUSIONS Our technique can be applied in both the supine and prone position and it seems to be more feasible and precise than the electron technique. However, more homogeneous target coverage and higher precision of dose delivery for photons are obtained at the cost of slightly higher doses to the heart and liver.
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Affiliation(s)
- Marzanna Chojnacka
- Department of Radiotherapy, Maria Skłodowska Curie Memorial Cancer Centre - Institute, Wawelska 15, 00-973 Warsaw, Poland
| | - Anna Skowrońska-Gardas
- Department of Radiotherapy, Maria Skłodowska Curie Memorial Cancer Centre - Institute, Wawelska 15, 00-973 Warsaw, Poland
| | - Marzena Morawska-Kaczyńska
- Department of Medical Physics, Maria Skłodowska Curie Memorial Cancer Centre - Institute, Wawelska 15, 00-973 Warsaw, Poland
| | - Anna Zygmuntowicz-Piętka
- Department of Medical Physics, Maria Skłodowska Curie Memorial Cancer Centre - Institute, Wawelska 15, 00-973 Warsaw, Poland
| | - Katarzyna Pędziwiatr
- Department of Radiotherapy, Maria Skłodowska Curie Memorial Cancer Centre - Institute, Wawelska 15, 00-973 Warsaw, Poland
| | - Anna Semaniak
- Department of Medical Physics, Maria Skłodowska Curie Memorial Cancer Centre - Institute, Wawelska 15, 00-973 Warsaw, Poland
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Fangusaro JR, Littlejohn EE. Endocrine late effects: manifestations and treatments. Cancer Treat Res 2009; 150:155-82. [PMID: 19834668 DOI: 10.1007/b109924_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Miller MC, Agrawal A. Hypothyroidism in postradiation head and neck cancer patients: incidence, complications, and management. Curr Opin Otolaryngol Head Neck Surg 2009; 17:111-5. [PMID: 19373960 DOI: 10.1097/moo.0b013e328325a538] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe the incidence, risk factors, prevention, and management of hypothyroidism among patients treated with radiation and other modalities for head and neck cancers. RECENT FINDINGS Hypothyroidism may occur in up to 48% of patients treated for head and neck malignancies. It has been observed after radiation, surgery, and combined-modality therapies. The onset of hypothyroidism may be as early as 4 weeks and as late as 5 or 10 years after completion of therapy. It has been associated with poor wound healing, bleeding disorders, and a number of other potential complications germane to the practice of head and neck surgery. There is some evidence to suggest a protective role of hypothyroidism with respect to disease control survival in head and neck and other cancers. SUMMARY Hypothyroidism is common after treatment of head and neck cancers. Thyroid function studies should be obtained prior to and at regular intervals after treatment. Prompt recognition and intervention may prevent or reverse adverse physiological outcomes. Further studies are necessary to evaluate the role of permissive hypothyroidism in the context of treated head and neck malignancies.
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Mueller S, Chang S. Pediatric brain tumors: current treatment strategies and future therapeutic approaches. Neurotherapeutics 2009; 6:570-86. [PMID: 19560746 PMCID: PMC5084192 DOI: 10.1016/j.nurt.2009.04.006] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 04/11/2009] [Accepted: 04/13/2009] [Indexed: 01/19/2023] Open
Abstract
Pediatric CNS tumors are the most common solid tumors of childhood and the second most common cancer after hematological malignancies accounting for approximate 20 to 25% of all primary pediatric tumors. With over 3,000 new cases per year in the United States, childhood CNS tumors are the leading cause of death related to cancer in this population. The prognosis for these patients has improved over the last few decades, but current therapies continue to carry a high risk of significant side effects, especially for the very young. Currently a combination of surgery, radiation, and chemotherapy is often used in children greater than 3 years of age. This article will outline current and future therapeutic strategies for the most common pediatric CNS tumors, including primitive neuroectodermal tumors such as medulloblastoma, as well as astrocytomas and ependymomas.
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Affiliation(s)
- Sabine Mueller
- Department of Neurology, Division of Child Neurology, University of San Francisco, San Francisco, California, USA.
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Pettorini BL, Narducci A, de Carlo A, Abet F, Caldarelli M, Massimi L, Tamburrini G, Di Rocco C. Thyroid neoplasm after central nervous system irradiation for medulloblastoma in childhood: report of two cases. Childs Nerv Syst 2009; 25:631-4. [PMID: 19225785 DOI: 10.1007/s00381-009-0814-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Surgical excision combined with radio-chemotherapy represents the gold standard of therapy of medulloblastoma. The effectiveness of such a combined treatment has encouraged the use of radiotherapy even in young paediatric patients, in spite of the many adverse effects reported in literature, and, in particular, the increased risk of a second radioinduced malignancy. Irradiation is the well-known risk factor for development of benign and malignant thyroid tumours. Children are more exposed to this risk because of their thyroid gland is more sensitive to carcinogenic effect of ionising radiation. CASE REPORT Two children underwent radiotherapy for the treatment of a medulloblastoma when they were 3 and 4 years old, respectively. At the age of 20 and 23, both of them underwent the surgical excision of a papillary thyroid carcinoma, 20 and 17 years after the radiotherapeutic treatment, respectively. CONCLUSIONS Radioinduced thyroid tumours are a well-recognised nosographic entities due to the particular sensitivity of this gland to ionising radiations. However, only a few papers on radioinduced thyroid neoplasms after CNS irradiation have been published in the literature. We report on two additional cases of thyroid neoplasms following childhood CNS irradiation for the treatment of a posterior fossa medulloblastoma.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Carrie C, Grill J, Figarella-Branger D, Bernier V, Padovani L, Habrand JL, Benhassel M, Mege M, Mahé M, Quetin P, Maire JP, Baron MH, Clavere P, Chapet S, Maingon P, Alapetite C, Claude L, Laprie A, Dussart S. Online quality control, hyperfractionated radiotherapy alone and reduced boost volume for standard risk medulloblastoma: long-term results of MSFOP 98. J Clin Oncol 2009; 27:1879-83. [PMID: 19273707 DOI: 10.1200/jco.2008.18.6437] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine event free and overall survival, and long-term cognitive sequelae of children with standard-risk medulloblastoma (SRM) treated with hyperfractionated radiotherapy, conformal reduced boost volume without chemotherapy, and online quality assurance. PATIENTS AND METHODS Forty-eight patients (age 5 to 18 years) were included in the Medulloblastoma-Société Française d'Oncologie Pédiatrique (MSFOP 98) protocol (December 1998 to October 2001). Patients received hyperfractionated radiotherapy (HFRT; 36 Gy, 1 Gy/fraction twice per day) to the craniospinal axis followed by a boost to the tumor bed (1.5-cm margin) to a dose of 68 Gy. Records of craniospinal irradiation were reviewed before treatment started. Neuropsychologic evaluations were done according to the protocol (1, 3, 5, and 7 years after irradiation). Cognitive outcomes were followed longitudinally with full-scale intelligence quotient (FSIQ) obtained with age-adapted Wechsler scales. RESULTS After a median follow-up of 77.7 months, 6-year overall survival (OS) and event-free survival (EFS) rates for the cohort were 78% (95% CI, 66% to 90%) and 75%, respectively (95% CI, 62% to 87%). Thanks to quality control, 14 major deviations were detected. Annual full scale IQ decline was 2 points over a 6-year period. Predicted change in FSIQ points per year was 2.15 (95% CI, -1.24 to 3.51) with an intercept (ie, predicted FSIQ) of 93.57 at baseline. CONCLUSION HFRT protocol with conformal reduced boost and online quality control allows excellent long-term OS and EFS in the absence of chemotherapy. In addition, FSIQ drops seem to be less pronounced than previously reported with standard irradiation regimens.
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Affiliation(s)
- Helen A Shih
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA.
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Fossati P, Ricardi U, Orecchia R. Pediatric medulloblastoma: toxicity of current treatment and potential role of protontherapy. Cancer Treat Rev 2008; 35:79-96. [PMID: 18976866 DOI: 10.1016/j.ctrv.2008.09.002] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 08/30/2008] [Accepted: 09/03/2008] [Indexed: 11/25/2022]
Abstract
Post-operative craniospinal irradiation and systemic chemotherapy are both necessary in the treatment of pediatric medulloblastoma. Late toxicity is a major problem in long term survivors and significantly affects their quality of life. We have systematically reviewed the literature to examine data on late toxicity, specifically focusing on: endocrine function, growth and bone development, neurocognitive development, second cancers, ototoxicity, gynecological toxicity and health of the offspring, cardiac toxicity and pulmonary toxicity. In this paper, we describe qualitatively the kind of detected side effects and, whenever possible, try to assess their incidence and the relative role of craniospinal irradiation (as opposed to other treatments and to the disease itself) in producing them. Subsequently we examine the possible approach to reduce unwanted effects from craniospinal irradiation to target and non-target tissues and we consider briefly the role of hyperfractionation, tomotherapy and IMRT. We describe the characteristics of protontherapy and its potential for non-target tissues toxicity reduction reviewing the existing physical and dosimetric studies and the (still very limited) clinical experiences. Finally we propose intensity modulated spot scanning protontherapy with multiportal simultaneous optimization (IMPT) as a possible tool for dose distribution optimization within different areas of CNS and potential reduction of target tissues toxicity.
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Affiliation(s)
- Piero Fossati
- Institute of Radiological Sciences, University of Milan, Milano, Italy.
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Massimino M, Gandola L, Collini P, Seregni E, Marchianò A, Serra A, Pignoli E, Spreafico F, Pallotti F, Terenziani M, Biassoni V, Bombardieri E, Fossati-Bellani F. Thyroid-stimulating hormone suppression for protection against hypothyroidism due to craniospinal irradiation for childhood medulloblastoma/primitive neuroectodermal tumor. Int J Radiat Oncol Biol Phys 2007; 69:404-10. [PMID: 17601681 DOI: 10.1016/j.ijrobp.2007.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2006] [Revised: 03/17/2007] [Accepted: 03/20/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE Hypothyroidism is one of the earliest endocrine effects of craniospinal irradiation (CSI). The effects of radiation also depend on circulating thyroid-stimulating hormone (TSH), which acts as an indicator of thyrocyte function and is the most sensitive marker of thyroid damage. Hence, our study was launched in 1998 to evaluate the protective effect of TSH suppression during CSI for medulloblastoma/primitive neuroectodermal tumor. PATIENTS AND METHODS From Jan 1998 to Feb 2001, a total of 37 euthyroid children scheduled for CSI for medulloblastoma/primitive neuroectodermal tumor underwent thyroid ultrasound and free triiodothyronine (FT3), free thyroxine (FT4), and TSH evaluation at the beginning and end of CSI. From 14 days before and up to the end of CSI, patients were administered l-thyroxine at suppressive doses; every 3 days, TSH suppression was checked to ensure a value <0.3 mum/ml. During follow-up, blood tests and ultrasound were repeated after 1 year; primary hypothyroidism was considered an increased TSH level greater than normal range. CSI was done using a hyperfractionated accelerated technique with total doses ranging from 20.8-39 Gy; models were used to evaluate doses received by the thyroid bed. RESULTS Of 37 patients, 25 were alive a median 7 years after CSI. They were well matched for all clinical features, except that eight children underwent adequate TSH suppression during CSI, whereas 17 did not. Hypothyroidism-free survival rates were 70% for the "adequately TSH-suppressed" group and 20% for the "inadequately TSH-suppressed" group (p = 0.02). CONCLUSIONS Thyroid-stimulating hormone suppression with l-thyroxine had a protective effect on thyroid function at long-term follow-up. This is the first demonstration that transient endocrine suppression of thyroid activity may protect against radiation-induced functional damage.
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Affiliation(s)
- Maura Massimino
- Department of Pediatrics, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
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Abstract
The past decades have seen an increase in the survival rates of patients with standard-risk medulloblastoma. Efforts have, therefore, been focused on obtaining better results in the treatment of patients with high-risk tumors. In addition to consolidated therapies, novel approaches such as small molecules, monoclonal antibodies, and antiangiogenic therapies that aim to improve outcomes and quality of life are now available through new breakthroughs in the molecular biology of medulloblastoma. The advent of innovative anticancer drugs tested in brain tumors has important consequences for personalized therapy. Gene expression profiling of medulloblastoma can be used to identify the genes and signaling transduction pathways that are crucial for the tumorigenesis process, thereby revealing both new targets for therapy and sensitive/resistance phenotypes. The interpretation of microarray data for new treatments of patients with high-risk medulloblastoma, as well as other poor prognosis tumors, should be developed through a consensus multidisciplinary approach involving oncologists, neurosurgeons, radiotherapists, biotechnologists, bioinformaticists, and other professionals.
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Affiliation(s)
- Iacopo Sardi
- Department of Pediatrics, Onco-hematology and Neuro-surgery Units, University of Florence Medical School, A. Meyer Children's Hospital, Florence, Italy.
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Alterio D, Jereczek-Fossa BA, Franchi B, D'Onofrio A, Piazzi V, Rondi E, Ciocca M, Gibelli B, Grosso E, Tradati N, Mariani L, Boboc GI, Orecchia R. Thyroid disorders in patients treated with radiotherapy for head-and-neck cancer: a retrospective analysis of seventy-three patients. Int J Radiat Oncol Biol Phys 2006; 67:144-50. [PMID: 17084554 DOI: 10.1016/j.ijrobp.2006.08.051] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Revised: 08/19/2006] [Accepted: 08/21/2006] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the incidence of thyroid disorders and dose distribution to the thyroid in patients treated with radiotherapy for head-and-neck carcinomas. METHODS AND MATERIALS A retrospective evaluation of data from 73 patients treated for head-and-neck cancers in our department was performed. Thyroid function was evaluated mainly by the measurement of thyrotropin (thyroid stimulating hormone [TSH]). A retrospective analysis of treatment plans was performed for 57 patients. Percentages of thyroid glandular volume absorbing 10, 30, and 50 Gy (V10, V30, and V50 respectively) were considered for statistical analysis. RESULTS A majority of patients (61%) had a normal thyroid function whereas 19 patients (26%) had hypothyroidism. Mean thyroid volume was 30.39 cc. Point 3 (located at isthmus) absorbed lower doses compared with other points (p < 0.0001). Median values of V10, V30, and V50 were 92% (range, 57-100%), 75% (range, 28.5-100%), and 35% (range, 3-83%) respectively. Gender was associated with toxicity (presence of any kind of thyroid disorders) (p < 0.05), with females displaying higher levels of TSHr (relative TSH = patient's value/maximum value of the laboratory range) (p = 0.0005) and smaller thyroid volume (p = 0.0012) compared with male population. TSHr values were associated with thyroid volume, and the presence of midline shielding block in the anterior field was associated with relative free thyroxine (FT4r = patient's value/maximum value of the laboratory range) values. CONCLUSIONS Gender and thyroid volume seem to play an important role in the occurrence of thyroid toxicity, but further studies on dose-effect relationship for radiotherapy-induced thyroid toxicity are needed.
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Affiliation(s)
- Daniela Alterio
- Division of Radiation Therapy, European Institute of Oncology, Milan, Italy.
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Abstract
Cranial irradiation is used in the management of a diverse group of intracranial pathologies. However, if any part of the hypothalamic-pituitary axis is included in the radiation field, there is a risk of developing neuroendocrine dysfunction. Growth hormone is the most radiosensitive of the anterior pituitary hormones, followed by the gonadotropins, adrenocorticotropic hormone and thyroid-stimulating hormone. A number of factors determine both the occurrence and severity of hypothalamic-pituitary dysfunction, including: the dose of radiation received by the hypothalamic-pituitary axis (determined by a number of factors including total dose and fractionation schedule and ultimately expressed as the biological effective dose); length of time since cranial irradiation; age of the patient at the time of cranial irradiation; type of radiotherapy administered; and the different inherent radiosensitivities of the anterior pituitary hormones. These neuroendocrine abnormalities usually develop a number of years after the initial insult and, therefore, patients who have received cranial irradiation should receive annual endocrine assessments. The establishment of endocrine late-effect clinics for the survivors of childhood cancers have gone some way to addressing this problem; however, other groups of patients, particularly those receiving cranial irradiation in adult life, may not have systematic endocrine assessment.
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Affiliation(s)
- Mark Sherlock
- a Consultant Endocrinologist, University of Birmingham, Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK
| | - Andrew A Toogood
- b University of Birmingham, Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK.
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36
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Abstract
This review summarises current developments in radiation oncology and how they impact on the management of children with brain tumours. Improved understanding of radiobiology has led to attempts to improve the therapeutic ratio with hyperfractionated radiotherapy. Recent advances in planning and delivery of radiotherapy, including three-dimensional conformal radiotherapy, intensity modulated radiotherapy, and proton therapy allow a more precise localisation of the maximum dose region with maximum sparing of normal brain. Increasingly interactions between drugs and radiotherapy are exploited, but it is important to evaluate toxicity of combined modality therapy. The introduction of models to predict the impact of radiotherapy dose-volume parameters on long-term neuropsychological function will hopefully lead to further benefit with respect to sparing of normal tissue morbidity.
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Affiliation(s)
- Roger E Taylor
- Clinical Oncology, South West Wales Cancer Institute, Singleton Hospital, Swansea, West Glamorgan, SA2 8QA, UK.
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Abstract
Proton therapy may offer potential clinical advantages compared with conventional radiation therapy for many cancer patients. Due to the large investment costs for building a proton therapy facility, however, the treatment cost with proton radiation is higher than with conventional radiation. It is therefore important to evaluate whether the medical benefits of proton therapy are large enough to motivate the higher costs. We assessed the cost-effectiveness of proton therapy in the treatment of four different cancers: left-sided breast cancer, prostate cancer, head and neck cancer, and childhood medulloblastoma. A Markov cohort simulation model was created for each cancer type and used to simulate the life of patients treated with radiation. Cost and quality adjusted life years (QALYs) were used as primary outcome measures. The results indicated that proton therapy was cost-effective if appropriate risk groups were chosen. The average cost per QALY gained for the four types of cancer assessed was about pounds 10,130. If the value of a QALY was set to pounds 55,000, the total yearly net benefit of treating 925 cancer patients with the four types of cancer was about pounds 20.8 million. Investment in a proton facility may thus be cost-effective. The results must be interpreted with caution, since there is a lack of data, and consequently large uncertainties in the assumptions used.
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van Santen HM, van Dijk JE, Rodermond H, Vansenne F, Endert E, de Vijlder JJM, Haveman J, Vulsma T. Endocrine intervention during irradiation does not prevent damage to the thyroid gland. Thyroid 2006; 16:387-95. [PMID: 16646686 DOI: 10.1089/thy.2006.16.387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Radiation to the head-neck region may damage the thyroid gland, leading to hypothyroidism or thyroid carcinoma. Outcomes of radiation protection by lowering plasma thyroid-stimulating hormone (TSH) have thus far been ambiguous. Our aim was to evaluate the radioprotective effect of inhibiting the thyroid gland's activity during x-radiation. For this purpose, of 80 5-week old Wistar rats, 64 received cervical irradiation with 15 Gy (single dose). During irradiation, endocrine intervention was done, using thyroxine (T(4)), T(4) plus iodine, or iodine alone compared to placebo. During the endocrine interventions and follow-up, TSH and T(4) concentrations were measured periodically. Histologic examination of thyroid, pituitary gland, or the hypothalamus and any suspect lymph nodes, lungs, and liver was performed after 6 and 54 weeks. It was found that during the endocrine intervention, plasma levels of TSH were lower in rats given T(4) and higher in rats given iodine. After 6 and 54 weeks, no significant reduction in hypothyroidism or thyroid carcinoma was found between the different groups of rats given any endocrine intervention or no intervention. In conclusion, the administration of T(4), iodine or the combination during x-irradiation does not protect against radiation-induced thyroid damage.
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Affiliation(s)
- H M van Santen
- Department of Pediatric Endocrinology, Emma Children's Hospital, Academic Medical Centre, 1100 DE Amsterdam, The Netherlands.
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39
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Yoon IS, Seo JY, Shin CH, Kim IH, Shin HY, Yang SW, Ahn HS. Endocrine dysfunction and growth in children with medulloblastoma. Korean J Pediatr 2006. [DOI: 10.3345/kjp.2006.49.3.292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- In Suk Yoon
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Young Seo
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Il Han Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Seop Ahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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40
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Carrie C, Muracciole X, Gomez F, Habrand JL, Benhassel M, Mege M, Mahé M, Quetin P, Maire JP, Soum F, Baron MH, Clavere P, Chapet S, Gaci Z, Kolodie H, Maingon P, Vie B, Bernier V, Alapetite C, Hoffstetter S, Grill J, Lafay F. Conformal radiotherapy, reduced boost volume, hyperfractionated radiotherapy, and online quality control in standard-risk medulloblastoma without chemotherapy: Results of the French M-SFOP 98 protocol. Int J Radiat Oncol Biol Phys 2005; 63:711-6. [PMID: 15927408 DOI: 10.1016/j.ijrobp.2005.03.031] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Revised: 03/18/2005] [Accepted: 03/18/2005] [Indexed: 11/16/2022]
Abstract
PURPOSE Between December 1998 and October 2001, patients <19 years old were treated for standard-risk medulloblastoma according to the Medulloblastome-Société Française d'Oncologie Pédiatrique 1998 (M-SFOP 98) protocol. Patients received hyperfractionated radiotherapy (36 Gy in 36 fractions) to the craniospinal axis, a boost with conformal therapy restricted to the tumor bed (to a total dose of 68 Gy in 68 fractions), and no chemotherapy. Records of craniospinal irradiation were reviewed before treatment start. RESULTS A total of 48 patients were considered assessable. With a median follow-up of 45.7 months, the overall survival and progression-free survival rate at 3 years was 89% and 81%, respectively. Fourteen major deviations were detected and eight were corrected. No relapses occurred in the frontal region and none occurred in the posterior fossa outside the boost volume. Nine patients were available for volume calculation without reduction of the volume irradiated. We observed a reduction in the subtentorial volume irradiated to >60 Gy, but a slight increase in the volume irradiated to 40 Gy. No decrease in intelligence was observed in the 22 children tested during the first 2 years. CONCLUSION This hyperfractionated radiotherapy protocol with a reduced boost volume and without chemotherapy was not associated with early relapses in children. Moreover, intellectual function seemed to be preserved. These results are promising.
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Abstract
BACKGROUND As the number of long-term survivors of childhood cancer has grown, it has become increasingly clear that central nervous system therapy may have serious long-term effects on cognition and endocrine function. These complications have been studied most extensively in children with brain tumors and leukemia. REVIEW SUMMARY Children with acute lymphoblastic leukemia previously treated with cranial irradiation are at risk for cognitive decline. Chemotherapy-only regimens, which rely on high-dose frequently administered methotrexate, are also associated with producing cognitive dysfunction. Children irradiated for brain tumors are even more vulnerable. Risk factors include perioperative morbidity, young age, large-volume high-dose cranial irradiation, supra-tentorial location of tumor, moyamoya syndrome, and leukoencephalopathy. Cognitive decline is progressive over at least a decade. The most common radiation-induced endocrinopathies are hypothyroidism and growth hormone deficiency. Treatment effects on growth are multifactorial and include growth hormone deficiency,spinal shortening, precocious puberty, undetected hypothyroidism,and poor nutrition. Fifty percent to 80% of children treated with craniospinal radiation for brain tumors will experience growth failure. In hopes of reducing neurotoxicity, current treatments limit the dose and volume of radiation while adding chemotherapy. Results have not been uniformly positive, however, and may increase toxicity in some cases. CONCLUSIONS The standard of care in 2004 is that children who have been treated for brain tumors and leukemia should be monitored for cognitive and endocrine dysfunction. Until effective non-neurotoxic treatment is identified, long-term effects assessments are essential to maximize the quality of life of survivors of childhood cancer.
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Affiliation(s)
- Patricia K Duffner
- Department of Neurology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 219 Bryant Street, Buffalo, NY 14222, USA.
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42
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Daoud J, Siala W, Guermazi F, Besbes M, Frikha M, Ghorbel M, Drira M, Abid M. Hypothyroïdie après irradiation cervicale dans le traitement des cancers du nasopharynx et du sein : étude prospective à propos de 84 patients. Cancer Radiother 2005; 9:140-7. [PMID: 15946882 DOI: 10.1016/j.canrad.2005.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2005] [Revised: 02/17/2005] [Accepted: 03/10/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE 1/ To evaluate the incidence of hypothyroidism following radiotherapy in the management of breast and nasopharyngeal carcinomas, 2/ to define the role of a systematic post therapeutic screening. PATIENTS AND METHODS From January 1996 through March 2001 a systematic evaluation of the clinical and the biological thyroid function was performed on a cohort of 84 patients that received supraclavicular irradiation. Selected patients had either a mammary (37 cases) or a nasopharyngeal (47 cases) carcinoma. Initial work up included thyroid inspection and palpation, and biological tests: serum FT4 and TSH levels, radioimmunochemistry, completed by dynamic thyroid stimulation, using TRH, in case of border line low T4 or isolated high TSH levels. Tests were repeated every three months the first year, and then every six months. Replacement therapy with L Thyroxin was administered in case of hypothyroidism. RESULTS All selected patients had a normal function initially. With a mean two years follow up (1-5 years), 24 patients (29%) experienced hypothyroidism, half of whom (13 cases) being purely biological. Five patients (11%), with a nasopharyngeal carcinoma, presented also with associated pituitary failure. Clinical symptoms were minor or mild in all cases. Hypothyroidism was detected at a mean 21 months follow up. In 2 patients, hypothyroidism disappeared spontaneously within 6 months. Possible predictive factors were evaluated: age of the time of radiation, gender, percentage of irradiated thyroid, total dose, dose per fraction, tumour type and chemotherapy. Only age appeared significantly correlated with thyroid dysfunction (range: 10-30 years, P=0.002). CONCLUSION Hypothyroidism is a frequent and certainly underestimated complication following radiotherapy of the neck. In such patients, a systematic clinical and biological evaluation every three months the first year, and then every six months until five years is recommended.
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Affiliation(s)
- J Daoud
- Service de radiothérapie carcinologique du CHU Habib Bourguiba de Sfax, Tunisie.
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43
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Abstract
BACKGROUND Radiation therapy is an important component in the treatment of medulloblastoma; however, in many patients, it is associated with risk of late adverse events. Proton radiation therapy has potential to reduce the risk of adverse events compared with conventional radiation, but it is associated with a higher treatment cost. The objective of the current study was to assess the cost-effectiveness of proton therapy compared with conventional radiation therapy in the treatment of childhood medulloblastoma. METHODS The consequences of radiation therapy were evaluated using a Markov simulation model. Children age 5 years with medulloblastoma were followed. The patients were at risk of several types of adverse events, including hearing loss, intelligence quotient (IQ) loss, hypothyroidism, growth hormone deficiency (GHD), osteoporosis, cardiac disease, and secondary malignancies. The patients also were at risk of death and were divided into risk groups for normal death, death due to tumor recurrence, treatment-related cardiac death, treatment-related subsequent tumor death, or treatment-related other death. A review of the literature was conducted to estimate the parameters in the model. RESULTS The base-case results showed that proton therapy was associated with 23,600 in cost savings and 0.68 additional quality-adjusted life-years per patient. The analyses showed that reductions in IQ loss and GHD contributed to the greatest part of the cost savings and were the most important parameters for cost-effectiveness. CONCLUSIONS The results of the current study indicated that proton radiation therapy can be cost-effective and cost-saving compared with conventional radiation therapy in the treatment of children with medulloblastoma if the appropriate patients are selected for the therapy. However, there have been few long-term follow-up studies, and more much information on the long-term consequences of radiation therapy is needed.
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Affiliation(s)
- Jonas Lundkvist
- Medical Management Center, Karolinska Institutet, Stockholm, Sweden.
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44
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Abstract
Significant advances have been made in the diagnosis and treatment of childhood brain tumors. Gross total surgical resection combined with appropriate adjuvant therapies can achieve a high rate of disease control for low grade gliomas, ependymomas and medulloblastomas. High grade gliomas, tumors involving the optic apparatus or diencepahalic structures, diffuse brainstem lesions, and recurrent or metastatic disease still pose considerable therapeutic challenges. We review the current treatment strategies of the three most common types of pediatric brain tumors: gliomas, medulloblastomas and ependymomas, and discuss current and future diagnostic and therapeutic modalities.
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Affiliation(s)
- James T Rutka
- The Arthur and Sonia Labatt Brain Tumour Research Centre and Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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45
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Affiliation(s)
- Frank Saran
- Department of Radiotherapy, Royal Marsden Hospital NHS Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK.
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46
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Abstract
Despite their specific functional consequences, radiotherapy-induced thyroid abnormalities remain under-estimated and underreported. These sequelae may include primary or central hypothyroidism, thyroiditis, Graves' disease, euthyroid Graves' ophthalmopathy, benign adenomas, multinodular goitre and radiation-induced thyroid carcinoma. Primary hypothyroidism, the most common radiation-induced thyroid dysfunction, affects 20-30% of patients administered following curative radiotherapy to the neck region, with approximately half of the events occurring within the first 5 years after therapy. The relative risk of radiation-induced cancer (mainly well-differentiated tumours) is 15-53-fold higher than in non-irradiated population. The aetiology of radiation-induced thyroid injury includes vascular damage, parenchymal cell damage and auto-immune reactions. Total radiotherapy dose, irradiated volume of the thyroid gland, and the extent of prior thyroid resection are among the most important factors associated with the risk of hypothyroidism. The contribution of other treatment modalities (chemotherapy, endocrine therapy) as well as patient- and tumour-related factors is less clear. Reduction in radiation dose to the thyroid gland and hypothalamic/pituitary complex should be attempted whenever possible. New radiotherapy techniques, such as stereotactic radiosurgery, three-dimensional conformal irradiation, intensity modulated radiotherapy and proton therapy allow generally better dose distribution with lower dose to the non-target organs. The diagnostic approach to thyroid radiation injury includes baseline thyroid function assays in all patients undergoing thyroid or parasellar irradiation. Recommended follow-up procedures include at least annual evaluation with a history for symptoms of thyroid dysfunction, clinical examination, and measurement of thyroid hormones and thyrotropin. Management of overt hypothyroidism is based on hormone replacement therapy. Thyroid hormone therapy is also recommended in cases of subclinical hypothyroidism. Treatment of other radiation-induced thyroid disorders (thyroiditis, Graves' disease, thyroid cancer) is similar to that employed in spontaneously occurring conditions. Further improvements in radiotherapy techniques and progress in endocrine diagnostics and therapy may allow better prevention and management of radiation-related thyroid injury.
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Affiliation(s)
- Barbara A Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology, 435 via Ripamonti, 20141 Milan, Italy.
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47
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Xu W, Janss A, Packer RJ, Phillips P, Goldwein J, Moshang T. Endocrine outcome in children with medulloblastoma treated with 18 Gy of craniospinal radiation therapy. Neuro Oncol 2004; 6:113-8. [PMID: 15134625 PMCID: PMC1871981 DOI: 10.1215/s1152851703000462] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2003] [Accepted: 09/25/2003] [Indexed: 11/19/2022] Open
Abstract
Craniospinal radiation therapy (CSRT) combined with chemotherapy results in significant endocrine morbidity. Between 1987 and 1990, a trial using 18 Gy was conducted to treat 10 young children with medulloblastoma. There were 7 survivors. We compared the endocrine outcome in these children (group 18 Gy) to that of a comparable group treated with conventional doses of CSRT that ranged from 23 to 39 Gy (group CD). Both groups had an identical history of chemotherapy and tumor stage and were treated with recombinant growth hormone therapy (rhGH). The mean age of group 18 Gy at diagnosis was 4.0 years, and rhGH treatment was initiated in 6 children at age 9.2 years. Group CD (12 children) was diagnosed at a mean age of 5.8 years and rhGH started in 11 children at a mean age of 9.6 years. The dose of rhGH used in both groups was identical (0.3 mg/kg/wk). For group 18 Gy, adult heights and sitting heights (a mean standard deviation score of -1.01 +/- 1.11 and -1.62 +/- 1.16, respectively) were statistically greater (P < 0.05) than those for group CD (mean standard deviation score of -2.04 +/- 0.83 and -3.16 +/- 1.43, respectively). Moreover, adult heights of group 18 Gy were not different from midparental heights, unlike group CD, whose adult heights were less than midparental heights (P < 0.0001). Of other endocrine sequelae, 10 patients of the CD group were hypothyroid, 3 had adrenal insufficiency, 3 had hypogonadism, and 2 had early puberty. In contrast, within group 18 Gy, only 1 was hypothyroid (P = 0.006) and 1 had early puberty. We conclude that endocrine morbidity was significantly reduced with 18 Gy CSRT in young children with medulloblastoma.
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Affiliation(s)
| | | | | | | | | | - Thomas Moshang
- Address correspondence to Thomas Moshang Jr., Division of Endocrinology, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA (
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48
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Abstract
Endocrinopathies are significant consequences of childhood cancers and their treatments. The risk of developing these adverse events is related to the underlying disease and its treatment with cytotoxic drugs and radiation therapy. This article will explore the current literature about endocrine late effects of hypothalamic-pituitary, thyroid, and gonadal dysfunction, as well as osteoporosis and obesity.
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Affiliation(s)
- Laurie E Cohen
- Division of Endocrinology, Children's Hospital, Dana Farber Cancer Center, and Harvard Medical School, Boston, MAssachusetts 02115, USA.
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49
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Nuver J, Smit AJ, Postma A, Sleijfer DT, Gietema JA. The metabolic syndrome in long-term cancer survivors, an important target for secondary preventive measures. Cancer Treat Rev 2002; 28:195-214. [PMID: 12363460 DOI: 10.1016/s0305-7372(02)00038-5] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
With increasing numbers of cancer survivors, attention has been drawn to long-term complications of curative cancer treatment, including a range of metabolic disorders. These metabolic disorders often resemble the components of the so-called metabolic syndrome, or syndrome X, which is an important risk factor for the development of cardiovascular disease. The mechanisms behind the development of metabolic disorders in cancer survivors have not been fully elucidated. However, association studies in the general population have demonstrated correlations between the components of the metabolic syndrome on the one hand and hormonal deficiencies, hypomagnesaemia, and endothelial dysfunction on the other. These latter disorders are regularly reported following curative cancer treatment and could, therefore, be important aetiologic factors in the development of the metabolic syndrome in cancer survivors. This review discusses data on the associations between the metabolic syndrome and treatment-related complications in cancer survivors and possibilities for preventive measures.
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Affiliation(s)
- Janine Nuver
- Department of Medical Oncology, University Hospital Groningen, 9700 RB Groningen, The Netherlands
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50
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Abstract
The therapy for medulloblastoma/primitive neuroectodermal tumors of the central nervous system is surgery, followed by combination chemo-radiotherapy. The radiation field is the entire craniospinal axis, which is only avoided when treating infants. The treatment is, therefore, lengthy and toxic. Less aggressive therapy is given to patients who clinically appear to have less evidence of disease. Intensive basic research has begun to identify genetic factors of the disease, but these remain far from clinical application.
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Affiliation(s)
- Michael D Weil
- Sirius Medicine, LLC, 584 West Douglas Road, Fort Collins, CO 80524, USA.
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