Retreatment of recurrent adult medulloblastoma with radiotherapy: a case report and review of the literature

Abstract

IntroductionMedulloblastoma, the most frequent brain tumor in childhood, also occurs with a wide range of characteristics in adult patients. Late relapse is common in adult medulloblastoma, and the overall survival of relapsed patients usually ranges from 12 to 15 months. Treatment at recurrence is still debated and after reoperation includes stereotactic or normofractionated radiotherapy, and high-dose chemotherapy with autologous bone marrow transplantation.Case presentationWe report on the case of a 31-year-old Caucasian woman who underwent re-irradiation for a recurrence of medulloblastoma at nine years after first irradiation (56Gy), focusing on the radiobiological background and a review of previous studies involving re-irradiation of recurrent medulloblastoma. After surgical excision of the relapsed tumor and medical multi-agent treatment, the site of recurrence was treated using three-dimensional conformal radiotherapy to a total dose of 52.8Gy (1.2Gy/fraction/twice daily). A total biological equivalent dose of 224.6Gy (α:β = 2 Gy) was delivered to the posterior fossa (first and second treatments). No radionecrosis or local recurrence was evident at 18 months after re-irradiation.ConclusionRe-irradiation can be considered a possible and safe treatment in selected cases of recurrent medulloblastoma in adults. The reported radiobiological considerations could be useful in other cases involving re-irradiation of brain tumors.

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

“…TD 12 Gy2-year OS 45%, 13 patients received CTH; median OS 10 monthsNo radiation necrosisPadovani et al [22]5TD 28 Gy, fd 1.8 GyAll: concomitant temozolomide, 80% alive after mean FU of 25 monthsNo neurologic toxicityBugulione et al [13]1TD 52.8 Gy, fd 1.2 Gy/twice a dayAlive after 18 monthsNo radiation necrosisKeshavarzi et al [18]1TD 14 Gy in 1 fractionAlive after 12 monthsNo toxicityPrivitera et al [21]1TD 24 GyCTH + bevacizumab died with disease after 35 monthsNo radiation necrosisCieślak et al [14]1TD 45 Gy, fd 1.8 GyAlive after 15 monthsNo toxicity CTH chemotherapy, fd fraction dose, FU follow-up, HD high dose, min. minimum, OS overall survival, PBSCT peripheral blood stem cell transplantation, RT radiotherapy, SRS stereotactic radiosurgery, SRT stereotactic radiotherapy, TD total dose…”

“… Abe et al [ 11 ] 12 Median peripheral TD 20 Gy (normalization on isodose 50%) 2-year OS, 33% ± 14%; 3-year OS, 25% ± 13% (all patients received CTH after SRT, 5 + PBSCT); median OS, 19 months 1 case of brainstem edema, 1 patient died due to toxicity of CTH Massimino et al [ 23 ] 17 7 patients TD 20.2 Gy, fd 1.3 Gy, 3 patients TD 50 Gy 10/17 received RT, all HD CTH ± PBSCT; for whole group: 5-year OS 20%, median OS 41 months Not reported for RT Bauman et al [ 10 ] 14 Not specified for MB Median OS 11.5 months No radiation necrosis Chojnacka et al [ 19 ] 6 TD 40 Gy, fd 2 Gy Median OS 17.5 months, 1 death during FU (83% alive) No grade 3–5 toxicity Milker-Zabel et al [ 20 ] 20 Mean TD 24 Gy (SRT) or 15 Gy (SRS) 6-year OS, 35%; median OS, 73 months No late toxicity Patrice et al [ 12 ] 14 Median min. TD 12 Gy 2-year OS 45%, 13 patients received CTH; median OS 10 months No radiation necrosis Padovani et al [ 22 ] 5 TD 28 Gy, fd 1.8 Gy All: concomitant temozolomide, 80% alive after mean FU of 25 months No neurologic toxicity Bugulione et al [ 13 ] 1 TD 52.8 Gy, fd 1.2 Gy/twice a day Alive after 18 months No radiation necrosis Keshavarzi et al [ 18 ] 1 TD 14 Gy in 1 fraction Alive after 12 months No toxicity Privitera et al [ 21 ] 1 TD 24 Gy CTH + bevacizumab died with disease after 35 months No radiation necrosis Cieślak et al [ 14 ] 1 TD 45 Gy, fd 1.8 Gy Alive after 15 months No toxicity …”

Isolated Supratentorial Intraventricular Recurrence of Medulloblastoma

“…Homer-Wright rosettes may be seen 10) . Adults are more likely to have laterally-located tumors, which more often desmoplastic 5 10 21) . Both tumor types include markers of neuronal lineage, such as class III beta tubulin and MAP-2 neurofilaments, whereas more adult tumors will express GFAP 10 20) .…”

“…Occurrence in the adult population is also well documented, but only accounts for 1% of adult tumors 11) . Treatment includes surgical resection followed by radiotherapy of the entire neuro-axis and chemotherapy 4 5 19 23) .…”

Medulloblastoma: Intraventricular Recurrences

“…Recurrent meduloblastoma has poor outcome, although gets radiotherapy and chemotherapy. [4] Recurrence of this tumor is well recognized and may require salvage therapy. Time to recurrence typically occurs within two years of initial diagnosis in the pediatric population.…”