Standard-Risk Medulloblastoma Treated by Adjuvant Chemotherapy Followed by Reduced-Dose Craniospinal Radiation Therapy: A French Society of Pediatric Oncology Study

Abstract

Reduced-dose craniospinal radiation therapy can be proposed in standard-risk medulloblastoma provided staging and radiation therapy are performed under optimal conditions.

Outcomes of Surgery and Craniospinal Radiotherapy for Adult Patients with Medulloblastoma

“…There are studies suggesting that spinal dose could be deduced to 23.4 Gy in low risk pediatric patients with MB; however, this concept is controversial for adult group of patients. [17] In one study by Packer et al, pediatric patients with standard risk were administered weekly vincristine concurrently with 24.3 Gy irradiation at craniospinal field, and dose at posterior fossa was completed to 55.8 Gy with boost. Five year progression-free survival in these patients who received adjuvant vincristine, CCNU, cysplatine CT was determined as 79%.…”

Malignant Brain Tumors in Childhood

“…In many academic pediatric neurosurgical centers, it is a standard procedure to place a ventricular drain, as needed, at the time of S. The surgeon often can document reestablishment of CSF flow after fourth ventricular tumor resection. Later shunt insertion may be needed in 20% to 25% of children (111,112). A delayed shunt insertion approach provides physiologic CSF dynamics for the majority of children, avoiding potential late events related to a ventriculoperitoneal shunt.…”

Editorial

“…4,7 Fortunately, with multimodality therapy, including improvements in neurosurgery resulting in the majority of patients with nondisseminated tumors undergoing total or near-total resections, survival rates have significantly improved to the point that in some series 80% or more of patients can be expected to survive for 5 years, the majority cured of their disease. 5,[9][10][11]13 The second realization was the sobering understanding that the price paid for such survival rates is extremely high, especially in the very young child, as long-term neurocognitive sequelae are common. Studies initially emanating from Europe and then later from the US clearly demonstrated the overall poor level of intellectual functioning of these children and led to a reappraisal of the causes for such outcomes.…”

“…6,8,15,17 Whole brain radiotherapy, used as part of prophylactic craniospinal radiotherapy, has been incriminated as one of the most important factors resulting in decreased overall intelligence and neurocognitive function over time, and this recognition has led to the stepwise reduction in the dose of craniospinal radiation therapy, and most recently the volume of posterior fossa boost radiotherapy, in attempts to at least reduce the degree of cognitive decline. 9,11 The third devastating concern, which became increasingly apparent in the 1990s, is that many children with medulloblastoma developed posterior fossa mutism, which although often was poorly defined, affects a sizable proportion of patients, whether it be 25 or 40%, and possibly over one-half of those initially affected will have permanent long-term sequelae including balance difficulties, speech impairments, and likely cognitive challenges. 16,18 Although it is impossible to prove the "new" occurrence of this syndrome in retrospect, the senior author of the paper did carefully evaluate children through the 1980s and rarely saw this syndrome, despite evaluating over 100 patients with medulloblastoma who underwent operations at his primary institution and receiving consultations from all over the country.…”