Late Effects of Craniospinal Irradiation Using Electron Spinal Fields for Pediatric Patients With Cancer

De, Brian; Florez, Marcus A.; Ludmir, Ethan B.; Maor, Moshe; McGovern, Susan L.; Grosshans, David R.; Chang, Eric L.; Mahajan, Anita; Paulino, Arnold C.

doi:10.1016/j.ijrobp.2022.06.055

Cited by 5 publications

(8 citation statements)

References 49 publications

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“…Proton radiotherapy is expensive and Pakistan has not had any proton treatment thus far. The CSI with electrons has been found to spare interiorly lying organs and less late-age toxicity [9,21].…”

Section: Discussionmentioning

confidence: 99%

Comparison of Electrons and Photons Treatment Plans in Medulloblastoma Patients

Ghani¹,

Razzaq²,

Amjad³

et al. 2023

Indonesian Journal of Cancer

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Background: The treatment of medulloblastoma involves surgery, radiotherapy, and adjuvant chemotherapy. In radiotherapy, craniospinal irradiation (CSI) is prescribed, where two lateral cranial fields and one or two spinal beams are applied in CSI. Different multi-field techniques (coplanar and/or noncoplanar) are used to register the prescribed dose. The purpose of this study was to assess plan quality in terms of dose coverage of the spine with both photon and electron beam therapy and the sparing of organs at risks (OARs).Methods: Ten pediatric patients (ages 6 to 10 years) were immobilized in the prone position for simulation. The Clinical Target Volume (CTV) of the organ under treatment, Planning Target volume (PTV) of the organ under treatment, and OARs were contoured. Prowess Panther (v4.71) was used for dose computations. Two lateral parallel-opposed 6 MV photon cranial fields with the spinal beam(s) (either 6 Photons or 21 MeV electrons) were used in planning. Electron beams were added posteriorly on the spine with parallel-opposed cranial fields. The treatment plans were computed for 3600 c Gy in 21 fractions.Results: For comparable conformity number of electron versus photons beam plans (0.68 ± 0.41 versus 0.66 ± 0.47, is not significantly different at p < 0.05) and homogeneity index (1.22 ± 0.03 versus 1.25 ± 0.04, is significantly different at p < 0.05), the photon doses were higher for underlying OARs (heart, liver, and thyroid) and were lower for partially in-field organs (lungs and kidneys) compared to electrons.Conclusions: The underlying organs i.e., thyroid, heart, and liver receive a lesser dose in case of electrons, while partially in-field organs are exposed more compared to photons mainly due to the ballooning effect in electrons. The study shows that both electrons and photons can be used for CSI. However, the electron may be preferred due to its better sparing of underlying structures.

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Section: Discussionmentioning

confidence: 99%

Comparison of Electrons and Photons Treatment Plans in Medulloblastoma Patients

Ghani¹,

Razzaq²,

Amjad³

et al. 2023

Indonesian Journal of Cancer

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“…5,15 However, concerns for long-term adverse effects of neurocognitive, endocrine dysfunction, and secondary malignancies have long been raised. [6][7][8][9][10] Accordingly, da Silva et al (2010) attempted a chemotherapy-only strategy for 13 patients with localized CNS germinoma, aiming to spare them the long-term morbidity associated with radiotherapy. 20 Nevertheless, the chemotherapy-only strategy demonstrated inferior outcomes with a 6-year EFS of only 27% as nine patients relapsed.…”

Section: Discussionmentioning

confidence: 99%

“…5 However, radiotherapy is associated with several long-term toxicities, including neurocognitive dysfunction, central endocrinopathies, cerebral vasculopathy, musculoskeletal deformities, and secondary malignancies. [6][7][8][9][10][11][12] To minimize irradiationrelated toxicities, neoadjuvant chemotherapy with response-based reduced irradiation therapy dose and field has become the standard treatment for localized CNS germinomas. 5,13,14 The 2013 Third International CNS Germ Cell Tumor Symposium rejected a consensus statement suggesting that only CSI was sufficient for treating patients with metastatic germinoma, given the concern that it may impede the inclusion of neoadjuvant chemotherapy for the reduction of irradiation dose or field in the future clinical trials.…”

Section: Introductionmentioning

confidence: 99%

“…Craniospinal irradiation (CSI) alone cures most patients with metastatic CNS germinoma 5 . However, radiotherapy is associated with several long‐term toxicities, including neurocognitive dysfunction, central endocrinopathies, cerebral vasculopathy, musculoskeletal deformities, and secondary malignancies 6–12 . To minimize irradiation‐related toxicities, neoadjuvant chemotherapy with response‐based reduced irradiation therapy dose and field has become the standard treatment for localized CNS germinomas 5,13,14 .…”

Section: Introductionmentioning

confidence: 99%

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The role of neoadjuvant chemotherapy in the management of metastatic central nervous system germinoma: A meta‐analysis

Abu‐Arja,

Shatara,

Okcu

et al. 2023

Pediatric Blood & Cancer

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BackgroundThe role of neoadjuvant chemotherapy in treating patients with metastatic central nervous system (CNS) germinoma is controversial.MethodsWe compared the relapse‐free survival (RFS) of different treatment modalities by performing a meta‐analysis using published data. We summarized all data using standard descriptive statistics. We used the Kaplan–Meier method to estimate RFS and their corresponding 95% confidence intervals (CIs). We used the log‐rank test for the comparison of survival functions.ResultsWe identified 97 patients with a median age at presentation of 15 years (range: 7–38). Sites of metastasis were cerebrospinal fluid (CSF) disease only (n = 12), brain parenchyma (n = 18), spinal cord (n = 9), ventricular and CSF (n = 10), ventricular only (n = 31), and other (n = 17). The 3‐year RFS among patients who received any form of radiotherapy was 89% (95% CI: 83–96) compared with 0% for patients who received a chemotherapy‐only regimen (p = .001). Five‐year RFS among patients who received craniospinal irradiation (CSI) was 92% (95% CI: 84–100) compared with 76.4% (95% CI: 63–90) in the non‐CSI group (with or without neoadjuvant chemotherapy) (p = .014). Five‐year RFS of patients who received CSI less than 24 Gy with neoadjuvant chemotherapy was 100% compared with 92% (95% CI: 83–100) CSI dose greater than or equal to 24 Gy alone (p = .3).ConclusionsOur analysis does not support avoiding spinal irradiation among patients with radiographic metastatic CNS germinoma. Future studies are needed to confirm whether neoadjuvant chemotherapy will allow a reduction of irradiation dose without compromising survival.

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“…Hematologic and gastrointestinal toxicities are typically severe acute complications since the treatment includes entire vertebral bodies for growing children. Growing children can suffer from growth inhibition, lordosis, or scoliosis if the spine vertebrae receive asymmetric radiation doses [2][3][4]. Advanced proton therapy techniques, such as intensity modulated proton therapy [5], have the potential to conformally deliver high doses to brain and thecal sac and spare healthy tissues.…”

Section: Introductionmentioning

confidence: 99%

Quantification of radiation damage for proton craniospinal irradiation using magnetic resonance imaging

Chang

Goette

Kadom

et al. 2023

Medical Imaging 2023: Biomedical Applications in Molecular, Structural, and Functional Imaging

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Radiation doses delivered to entire vertebral bodies are current standard practice for the growing pediatric proton craniospinal irradiation (CSI) patients who are growing children. This procedure prevents patients from developing radiation-induced growth impairment, but it will cause hematopoietic marrow suppression. We aim to develop a noninvasive method to verify radiation damage to the marrow in spine vertebrae during fractional treatment using multiple magnetic resonance imaging (MRI) scans. We identified five pediatric patients who received proton CSI treatment with prescription relative biological effectiveness doses of 36 Gy for the spine. Each patient underwent multiple MRI scans during the treatment using T1-weighted sequences. Sagittal MR images were analyzed and focused on lumbar spine regions. Multi-Gaussian models were used to fit histograms from different MR images to quantify the radiation-induced damage to the bone marrow. MR images acquired before the treatment served as the reference to ensure no radiationinduced damage was found. After the treatment started, radiation-induced fatty marrow filtration showed in the vertebral bodies. We defined the radiation-induced damage based on the ratio between fatty marrow imaging pixels and total pixels in spine marrow, L1-L5 level. Damage fractions increased rapidly when the vertebral bodies received doses between 14 Gy and 34 Gy. The maximum damage happened approximately 40 days from the treatment start. After that, bone marrow regeneration was observed, and the damage fractions decreased. The proposed method can potentially achieve adaptative proton plan modification on the fly.

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Late Effects of Craniospinal Irradiation Using Electron Spinal Fields for Pediatric Patients With Cancer

Cited by 5 publications

References 49 publications

Comparison of Electrons and Photons Treatment Plans in Medulloblastoma Patients

Comparison of Electrons and Photons Treatment Plans in Medulloblastoma Patients

The role of neoadjuvant chemotherapy in the management of metastatic central nervous system germinoma: A meta‐analysis

Quantification of radiation damage for proton craniospinal irradiation using magnetic resonance imaging

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