Comprehensive Craniospinal Radiation for Controlling Central Nervous System Leukemia

Abstract

Purpose To determine the benefit of radiation therapy (RT) in resolution of neurologic symptoms and deficits and whether the type of RT fields influences central nervous system (CNS) control in adults with CNS leukemia. Methods and Materials A total of 163 adults from 1996 to 2012 were retrospectively analyzed. Potential associations between use of radiation and outcome were investigated by univariate and multivariate analysis. Results The median survival time was 3.8 months after RT. Common presenting symptoms were headache in 79 patients (49%), cranial nerve VII deficit in 46 (28%), and cranial nerve II deficit in 44 (27%). RT was delivered to the base of skull in 48 patients (29%), to the whole brain (WB) in 67 (41%), and to the craniospinal axis (CS) in 48 (29%). Among 149 patients with a total of 233 deficits, resolution was observed in 34 deficits (15%), improvement in 126 deficits (54%), stability in 34 deficits (15%), and progression in 39 deficits (17%). The 12-month CNS progression-free survival was 77% among those receiving CS/WB and 51% among those receiving base of skull RT (P = .02). On multivariate analysis, patients who did not undergo stem cell transplantation after RT and base of skull RT were associated with worse CNS progression-free survival. Conclusions Improvement or resolution of symptoms occurred in two thirds of deficits after RT. Comprehensive radiation to the WB or CS seems to offer a better outcome, especially in isolated CNS involvement.

Leptomeningeal metastasis from systemic cancer: Review and update on management

“…In addition, it is often considered impractical in the setting of a poor overall prognosis. Although it is not standard practice, craniospinal irradiation may be used in the setting of LM from hematologic malignancies because these are frequently highly radiosensitive …”

Craniospinal irradiation prior to stem cell transplant for hematologic malignancies with CNS involvement: Effectiveness and toxicity after photon or proton treatment

“…1 Although the natural history of leukemia/lymphoma has been known to include CNS disease, 2,3 recent advances in therapy leading to overall improved hematologic malignancy outcomes have increased the rates of patients presenting with this therapeutic challenge, primarily from poor CNS penetrance of cytotoxic and targeted therapy agents. 4,5 Although leukemia and lymphoma involving the CNS is generally associated with poor prognosis, 4–6 a prior study demonstrated that whole brain or craniospinal irradiation (CSI) still conferred a 12-month CNS progression-free survival rate of 77% in patients affected with acute leukemia.…”

“…4,5 Although leukemia and lymphoma involving the CNS is generally associated with poor prognosis, 4–6 a prior study demonstrated that whole brain or craniospinal irradiation (CSI) still conferred a 12-month CNS progression-free survival rate of 77% in patients affected with acute leukemia. 1 With the continued discovery of novel chemotherapeutic and targeted regimens and improved survival rates for patients with hematologic malignancies, there is an increased focus on optimizing treatment toxicity profiles and patient quality of life, along with local and systemic disease control. 7 …”

“…7 In the setting of relapse, however, although alternative systemic agents are typically considered (eg, thiotepa, intrathecal liposomal cytarabine), CNS-directed radiation therapy also offers a local treatment alternative for patients who have not responded to or need to recover from systemic treatment. 1 In the setting of stem cell transplant (SCT) for consolidation or salvage treatment, because standard conditioning regimens may also still not fully eradicate microscopic or gross disease across the blood brain barrier, CSI can play an especially important therapeutic role.…”

“…Compared with photon therapy, protons treat the target while reducing exit dose to surrounding normal tissues. 10 With the rarity of this disease presentation, as well as only recent emerging evidence for the effectiveness of CNS radiation in this group, 1 the safety profile and possible benefit of proton CSI in adult hematologic malignancy patients with CNS involvement before SCT has not been established. We conducted a retrospective analysis to compare the toxicity profiles and disease outcomes in an institutional cohort of adult leukemia and lymphoma patients treated with photon versus proton CSI.…”