Hyperf ractionated Craniospinal Radiation in Medulloblastoma

Abstract

From 1986 to 1991, 13 patients at Northwestern Memorial Hospital were entered onto a pilot study designed to test the feasibility of treating children with meduUoblastoma (11 patients) or primitive neuroectodermal tumors of the cerebral hemispheres (2 patients) with hyperfractionated craniospinal radiotherapy (HFxRT). Follow-up times ranged from 10 to 96 months with a median of 53 months. The patients were prospectively divided among three treatment arms depending on prior treatment history, if any, and degree of surgical resection. The 3 patients in group I had undergone gross total resection of the primary site, receiving 64.8 Gy to the primary site and 31.2 Gy directed to the craniospinal axis (CSA). Of these 3 patients, patient 1 had residual disease in the thoracic spine at T-10. The 8 patients in group II, who had gross residual disease remaining at the primary site, received 72 Gy to the primary site and 34 Gy to the CSA. Five of these eight patients in group II also received 8-in-1 chemotherapy. The 2 patients in group III had already failed chemotherapy and were then treated with 60 Gy to the primary site and 26 Gy to the CSA. Of the 11 patients in groups I and II, 7 of the 11 (64%) have never recurred. Two of the three group-I patients have not recurred, and 5 of the 7 group-II patients have not recurred. In addition, patient 7 (group II) remains alive after salvage with bone marrow transplant, following a local failure bordering the tentorium. Unfortunately, neither of the group-III patients could be salvaged with HFxRT. Acute/subacute toxicities included 7 cases of external auditory canal or skin desquamation, 2 cases of postradiation somnolence, and 1 case each of poor wound healing and neutropenia. Chronic toxicities included hypothyroidism in 2 patients and growth problems in 2 patients. Neuropsychologic complications affected only the 3 youngest patients in the study. Three patients developed neurologic sequelae attributed to radiation, including 1 with progressive urinary incontinence, 1 who developed a transient ischemic attack, and 1 who became progressively ataxic. Our research, although based on a small number of patients, suggests that hyperfractionated radiation therapy to craniospinal access is feasible and that the survival results are favorable. This treatment strategy should be further explored in a phase-III randomized trial.

Radiotherapy for medulloblastoma in children: A perspective on current international clinical research efforts

“…In one study, low dose HFRT to 30 Gy CSI without chemotherapy resulted in an unacceptably high rate of relapse in the supratentorial brain and leptomeninges [18]. Other studies, however, confirmed the feasibility of the approach [19] and one suggested increased efficacy in high-risk patients [20]. The UKCCSG, HIT, and SFOP all plan to investigate the role of HFRT in average risk patients.…”

Medulloblastoma: Experience of a single institution

“…The North American Groups have joined in an intergroup study comparing CCNU with cyclophosphamide combined with reduced radiation in both arms. The plans of the German Group are to ask a question regarding fractionation of radiotherapy (2,20). In any case, the efforts of multidisciplinary intense treatments have resulted in substantial improvement of survival in medu11oblastoma patients.…”

Aktuelle und zukünftige Strategien in der interdisziplinären Therapie von Medulloblastomen, supratentoriellen PNET und intrakraniellen Keimzelltumoren im Kindesalter

“…Nach den Ergebnissen einer Pilotserie von Halperin et al [44] und Marymont et al [63] konnte in vielen Fällen durch eine hyperfraktionierte Bestrahlung eine anhaltende komplette Remission bei jedoch geringen Patientenzahlen erreicht werden (siehe Tabelle 1), sodass dieses radiotherapeutische Konzept in der HIT-2000-Studie prospektiv untersucht wird.…”