Radiosurgery or hypofractionated stereotactic radiotherapy after craniospinal irradiation in children and adults with medulloblastoma and ependymoma

Abstract

PurposeTo assess the results and tolerance of radiosurgery/hypofractionated stereotactic radiotherapy performed after craniospinal irradiation for recurrent tumor.MethodsFourteen patients aged 3–46 years, diagnosed with medulloblastoma (10), anaplastic ependymoma (3), and primitive neuroectodermal tumor (1). All patients had craniospinal irradiation (CSI) with the total dose of 30.6–36 Gy and boost to 53.9–60 Gy either during primary or during second-line treatment. Twelve patients were irradiated with a single dose of 6–15 Gy (median 14.5 Gy). One received three fractions of 5 Gy and one six fractions of 5 Gy. In statistical analysis, the Kaplan-Meier method and log-rank test were used. The overall survival was calculated from the date of the end of stereotactic radiosurgery to the date of death or last contact.ResultsRecurrences were diagnosed after the median time of 16 months after the end of primary treatment. Eleven patients died during the follow-up. The follow-up for the 3 patients still alive was 6.7, 40.5, and 41.4 months, respectively. One- and 2-year overall survival (OS) was 70% and 39%. Patients who had ECOG performance status of 0 at the time of diagnosis of the disease trended to have better 2-year OS compared to those evaluated as ECOG 1 (p = 0.057). Treatment results were evaluable in 12 patients. Local control (stabilization or regression of the lesion) was achieved in 9 (75%). Overall disease progression was 67%. No patient developed radiation-induced necrosis. The treatment was well tolerated and no serious adverse effects were observed. Eleven patients were given steroids as a prevention of brain edema and four of them needed continuation of this treatment afterwards. In 7 patients, symptoms of brain edema were observed during the first weeks after reirradiation.ConclusionsStereotactic radiosurgery or hypofractionated stereotactic radiotherapy is an effective treatment method of the local recurrence after CSI and can be performed safely in heavily pre-treated patients.

Salvage Re-irradiation Options in Adult Medulloblastoma: A Case Report and Review of the Literature

“…The potential advantage of hypofractionation or radiosurgery lies in the possibility to improve local control rates in patients with macroscopic disease, providing more precise irradiation of a small area, with steep dose gradients that may lead to a lower exposure of nearby healthy structures. The use of stereotactic radiosurgery is favorably reported by Napieralska et al in a series of 14 patients treated with a median dose of 15 Gy in single or in three fractions, with no evidence of brain necrosis and promising results in terms of clinical outcomes (31).…”

“…External-beam radiotherapy can be offered either in a definitive setting or after maximal safe resection, despite most of the literature reports data concerning exclusive intent. To date, almost 300 cases of re-irradiation after craniospinal radiotherapy are reported in the literature (Table I), but it is hard to compare these data due to the heterogeneity of the in vivo 34: 1283-1288 (2020) cohorts; furthermore, different RT schedules are used with or without chemotherapy, and only a few reports are available on the use of stereotactic radiotherapy (17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32).…”

Polish Multi-Institutional Study of Children with Ependymoma—Clinical Practice Outcomes in the Light of Prospective Trials

“…The role of RTH as part of the treatment of recurrence has been investigated by many authors [ 68 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 ]. The use of stereotactic RTH or radiosurgery with a total dose of 9 to 36 Gy in one to few fractions, depending on the location of the recurrent tumour, the age of the patient, the time from the first RTH and the previous doses delivered to the nearby organs at risk, with encouraging results [ 70 , 72 , 74 , 75 , 76 , 77 , 78 , 79 ].…”

Two-Session Radiosurgery for Large Primary Tumors Affecting the Brain

“…Current dose recommendations for single-session radiosurgery by multiple series for primary brain tumors hovers around 15 Gy for most series [17][18][19][20][21][22]. As the allowable value depends on tumor volume or the organs at risk abutting the lesion, this is not always possible.…”

“…Open surgery can be associated with a risk of neurological deficit, and residuals usually warrant further treatment with radiation [12][13][14][15][16]. Radiosurgery has been an alternative to treat small tumor volumes with usual marginal dose prescriptions around 15 Gy for the treatment of pineal or other primary tumors in the brain; many studies report different local tumor control and survival [17][18][19][20][21][22]. In large tumors of the hypothalamus or in the pineal region that deform sensitive structures such as the visual pathway, thalamus, and brainstem, covering the lesion with the usual recommended dose can be difficult since the prescription dose is higher than the recommended tolerance levels of the OARs.…”