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675Treatment of intracranial germinoma with A cisplatinum-based chemotherapy and radioterapy limited to the tumor bed
S172 675
674 THE PRELIMINARY RESULTS OF HYPERFRACTIONATED RADIOTHERAPY IN CHILDREN WITH GROUP II1 AND IV RHABDOMYOSARCOMA Dllek UZAL, Eni$ C)ZYAR, L I_ale ATAHAN Hncettepe University, Department of Radiation Oncology, Ankara, Turkey. PURPOSE: A prospective tnal was initiated to evaluate the effect and the tolerability of hyperfractionated radiotherapy (HRT) in children with nonresected (Group lid and metastatic (Group IV) rhabdomyosarcoma (RMS). METHODS AND MATERIAL: Between April 1994 and July 1995, 10 children with unresectable RMS following induction chemotherapy with or without surgery (n:3) were treated by HRT in 1.1 Gy per fraction, (twice-a-day at 6 hours interval) to a total dose of 61 Gy and 2 patients under age 3 received 54 Gy with a dose reduction of 12 %. Follow-up ranges from 8-18 months (median:10) with no patient lost to follow up. RESULTS: Nine patients (75 %) are alive, five with no evidence of disease. 42 % (5/12) local control at 8 months has been obtained. 5 patients had complete response to radiotherapy, local failure was detected in one 12 months after radiotherapy. Four patients had patrol response, one of them underwent surgical resection aftel~-.tRT and she is disease free now. Three patients died of disease, two from lung metastasis, one from local tumor progression. HRT was associated with expected enhancement of acute reactions usually limited to Grade I and II which all settled down with conservative medical management. Treatment interruptions were not more than a few days. There is no significant late morbidity in patients followed more than one year. CONCLUSION: It is a preliminary report of an ongoing trial, thus it is early to make a definitive conclusion on the effectivity of HRT in local control of unresectable RMS however it seems to be effective and tolerable
L.Gandola, G.Cefalo, P.Navarria, M.C.Gianni, M.Massimino, R.Luksch, F.Fossati-Bellani, F.Lombardi. lstituto Nazionale Tumori, Milano 20133, Italy. Purpose. To evaluate if involved-field radiotherapy (IF-RT) in addition to platinum-based CT can spare whole CNS irradiation in intracranial germinoma, thus reducing severe sequelae in children. Patients and Methods. From 1990 to 1994, 7 pts (age 8-18 yrs) with histologically confirmed diagnosis (complete resection 2, partial resection 4, biopsy 1) entered the study. Tumor site was the pineal region in 6/7, and the suprasellar region in one. CNS dissemination was excluded by CFS citotogy and MRI in all pts. The 5 pus with subtotal surgery were treated according to the PEB regimen (Cisplatinum 20 rag/m2 x 5, Etoposide 100 rag/m2 x 5, Bleomycin 18 mg/m2 days 2 and 15, monthly) for two monthly cycles as primary CT, followed by IF-RT (45-50 Gy) and, in 3/5 pts, by 3 additional PEB. In the remaining 2 pts with totally resected tumor, 4 PEB cycles were administered as adjuvant CT along with IF-RT (30 and 40 Gy). in all pts RT fields were shaped to encompass the initial tumor volume with 2 cm margins. Results,lnitial CT induced a CR in the 5 pts with evidence of disease after surgery. 2/7 pts are alive in CCR at 54 and 62 rues from diagnosis. 5/7 pts showed disease recurrence at a median time of 20 rues. All disease recurrences occurred within the brain ventricles, but none at the initial site or within the RT fields. The 5 relapsed pts were salvaged by futher CT plus RT to the CNS (24-30 Gy). A R T boost (15-20 Gy) to relapse site was also delivered to 4/5 pts. 3/5 relapsed pus died of progressive disease 12, 21, 28 rues from recurrence, while 2/5 are alive in 2nd CR 14 and 39 rues from recurrence. Conclusions,These results confirm the high chemosensitivity of intracranial germinoma. However, in our small series, the PEB regimen associated with IF-RT was not able to spare whole CNS RT in curative treatment of this tumor (4-yr PFS 28%, S 57%). Furthermore, despite an aggressive salvage treatment 3/5 relapsed pts died of progressive disease.
677
676 MEDULLOBLASTOMA
T R E A T M E N T OF I N T R A C R A N I A L GERM1NOMA W I T H A CISPLAT1NUM-BASED CHEMOTHERAPY AND RADIOTERAPY LIMITED TO THE TUMOR BED
TREATMENT FAILURES FOLLOWING
POSTOPERATIVE CHEMORADIOTHERAPY DESIGNED ON PATIENT AGE AND TUMOR STAGE. L.Gandola, G.Cefalo, M.Massimino, P.Navarria, M.C.Gianni, R. Luksch, F. Fossati-Bellani, F. Lombardi. lstituto Nazionale Tumori, Milano 20133, Italy. Purpose. To evaluate if, following surgery, the delivery of intensive pre-radiation CT can: a) allow lower RT doses to neuraxis in 3-10 yr old children (Groun I), thus minimizing severe sequelae of standard dose (>30 Oy) RTi and b) improve prognosis of "high risk" pus (T3T4, MI-M3 according to Chang) older than 10 yrs (Groun 2). Patients and Methods. From 1985 to 1993, 34 Group I and 21 Group 2 pUs were treated with pre-radiation VCR 1.4 mg/m2 and highdose MTX 8 g/m2+CF rescue on days 1,8,22, and 29. Twelve additional "low risk "pts (TI-T2, M0,NED after surgery) older than 10 yrs (Grouo 3) received a standard pre-radiation CT with VCR 1.4 m g / m 2 (days 4,11) and i.t. MTX 10 mg/m 2 (days 1,8,15). Subsequent RT doses were: 54 Gy to the posterior fossa (PP') in all 67 pUs, 20 Gy to neuraxis in Grouo I , and 35 Gy to neuraxis in Group 2 and 3 pts. Maintenance CT (CCNU 80 mg/m2 q 9 wks and VCR 1.4 mg/m 2 q 3 wks) was given to all pus for one year. Results. Five-yr PFS was 42% in Grouo 1, 61% in Grouo 2 and 48% in Group 3 pts. In Group 1, 19/34 pus recurred: 5 to neuraxis outside PF among the 15 pus M0-NED (3-yr PFS 67%) and 14 (9 to neuraxis only and 5 also in PF) among the remaining 19 pts (M0-ED, M+- ED/NED). In Grouv 2. 7/21 pUs recurred: I in PF only, 4 to neuraxis, and 2 in both. Considering all Groun 1 and 2 pUs, PF relapses occurred in 7/27 pUs with ED after surgery and only in 1/28 pUs NED. In Group 3, 7/12 pUs recurred: 2 in PF only, 3 to neuraxis, and 2 in both. Conclusions. In this series, intensive CT plus low (20 Gy) dose RT to neuraxis were ineffective in controlling medulloblastoma in younger pUs, except for the subset of M0-NED children (73% relapses versus 30%). Results for "high risk" pts >10 yrs (5-yr PFS 61%) compared favorably with those of other series. The high relapse rate (7/12) among "low risk" pts >10 yr suggests that intensive CT may be indicated also in this subset of pts. Furthermore, after 54 Gy RT to the PF, the occurence of local relapse appears correlated with gross residual postoperative disease.
Postoperativ Radiotherapy of Medulloblastoma. Analysis of Recurrent Cases Kocsis B., Tak~icsi N.Z., N6meth Gy. National Institute ofOncelogy - Department of Radiotherapy Budapest, Hungary
Purpose:
The medulloblastoma occured most frequently in our material, therefore we retrospectwely evaluated the outcome of this patients regarding to the site of recurrences and metastases. Materials and Methods: A total of 33 consecutive children age 2-17 were postoperatively irradiated between October 1986 and April 1994 with linear accelerator with 6 or 9 MV x-ray. The radiotherapy started with craniospinal irradiation (CSI). 30 Cry total dose was delivered in low risk cases and 35 Gy in high risk cases. Futher 20 Gy was given to the posterior scala region. Results: 10 patients (30,3%) died. The cause of death by 6 patients was local recurrence, by 3 patients metastases within the central nervous system (CNS), by I patient pneumonia. Metastasis was registered in 5 cases (15%), including the above mentioned 3 exits. Two children are living with mild complains. The site of metastases: 1 suprasellar, 1 multiplex subependymal, 1 intraspinal, 1 multiplex CNS end 1 distant metastasis in the lilac bone. Local recurrence was observed in 8 cases at the site of primal, tumour. From these patients died 6, two are living without complain. The median survival rate was 33,5 months, ranged 3-96 months. The recidiva free survival was 21,1 months, ranged 3-69 months. Conclusion: local recurrence wasn't observed by the field junction. The postoperative radiotherapy is integrated part of the succesfull medulloblastoma therapy. It needs precisious field arrangement, accurate head immobilisation and careful field junction to avoid the overlapping and underdose.
674 THE PRELIMINARY RESULTS OF HYPERFRACTIONATED RADIOTHERAPY IN CHILDREN WITH GROUP II1 AND IV RHABDOMYOSARCOMA Dllek UZAL, Eni$ C)ZYAR, L I_ale ATAHAN Hncettepe University, Department of Radiation Oncology, Ankara, Turkey. PURPOSE: A prospective tnal was initiated to evaluate the effect and the tolerability of hyperfractionated radiotherapy (HRT) in children with nonresected (Group lid and metastatic (Group IV) rhabdomyosarcoma (RMS). METHODS AND MATERIAL: Between April 1994 and July 1995, 10 children with unresectable RMS following induction chemotherapy with or without surgery (n:3) were treated by HRT in 1.1 Gy per fraction, (twice-a-day at 6 hours interval) to a total dose of 61 Gy and 2 patients under age 3 received 54 Gy with a dose reduction of 12 %. Follow-up ranges from 8-18 months (median:10) with no patient lost to follow up. RESULTS: Nine patients (75 %) are alive, five with no evidence of disease. 42 % (5/12) local control at 8 months has been obtained. 5 patients had complete response to radiotherapy, local failure was detected in one 12 months after radiotherapy. Four patients had patrol response, one of them underwent surgical resection aftel~-.tRT and she is disease free now. Three patients died of disease, two from lung metastasis, one from local tumor progression. HRT was associated with expected enhancement of acute reactions usually limited to Grade I and II which all settled down with conservative medical management. Treatment interruptions were not more than a few days. There is no significant late morbidity in patients followed more than one year. CONCLUSION: It is a preliminary report of an ongoing trial, thus it is early to make a definitive conclusion on the effectivity of HRT in local control of unresectable RMS however it seems to be effective and tolerable
L.Gandola, G.Cefalo, P.Navarria, M.C.Gianni, M.Massimino, R.Luksch, F.Fossati-Bellani, F.Lombardi. lstituto Nazionale Tumori, Milano 20133, Italy. Purpose. To evaluate if involved-field radiotherapy (IF-RT) in addition to platinum-based CT can spare whole CNS irradiation in intracranial germinoma, thus reducing severe sequelae in children. Patients and Methods. From 1990 to 1994, 7 pts (age 8-18 yrs) with histologically confirmed diagnosis (complete resection 2, partial resection 4, biopsy 1) entered the study. Tumor site was the pineal region in 6/7, and the suprasellar region in one. CNS dissemination was excluded by CFS citotogy and MRI in all pts. The 5 pus with subtotal surgery were treated according to the PEB regimen (Cisplatinum 20 rag/m2 x 5, Etoposide 100 rag/m2 x 5, Bleomycin 18 mg/m2 days 2 and 15, monthly) for two monthly cycles as primary CT, followed by IF-RT (45-50 Gy) and, in 3/5 pts, by 3 additional PEB. In the remaining 2 pts with totally resected tumor, 4 PEB cycles were administered as adjuvant CT along with IF-RT (30 and 40 Gy). in all pts RT fields were shaped to encompass the initial tumor volume with 2 cm margins. Results,lnitial CT induced a CR in the 5 pts with evidence of disease after surgery. 2/7 pts are alive in CCR at 54 and 62 rues from diagnosis. 5/7 pts showed disease recurrence at a median time of 20 rues. All disease recurrences occurred within the brain ventricles, but none at the initial site or within the RT fields. The 5 relapsed pts were salvaged by futher CT plus RT to the CNS (24-30 Gy). A R T boost (15-20 Gy) to relapse site was also delivered to 4/5 pts. 3/5 relapsed pus died of progressive disease 12, 21, 28 rues from recurrence, while 2/5 are alive in 2nd CR 14 and 39 rues from recurrence. Conclusions,These results confirm the high chemosensitivity of intracranial germinoma. However, in our small series, the PEB regimen associated with IF-RT was not able to spare whole CNS RT in curative treatment of this tumor (4-yr PFS 28%, S 57%). Furthermore, despite an aggressive salvage treatment 3/5 relapsed pts died of progressive disease.
677
676 MEDULLOBLASTOMA
T R E A T M E N T OF I N T R A C R A N I A L GERM1NOMA W I T H A CISPLAT1NUM-BASED CHEMOTHERAPY AND RADIOTERAPY LIMITED TO THE TUMOR BED
TREATMENT FAILURES FOLLOWING
POSTOPERATIVE CHEMORADIOTHERAPY DESIGNED ON PATIENT AGE AND TUMOR STAGE. L.Gandola, G.Cefalo, M.Massimino, P.Navarria, M.C.Gianni, R. Luksch, F. Fossati-Bellani, F. Lombardi. lstituto Nazionale Tumori, Milano 20133, Italy. Purpose. To evaluate if, following surgery, the delivery of intensive pre-radiation CT can: a) allow lower RT doses to neuraxis in 3-10 yr old children (Groun I), thus minimizing severe sequelae of standard dose (>30 Oy) RTi and b) improve prognosis of "high risk" pus (T3T4, MI-M3 according to Chang) older than 10 yrs (Groun 2). Patients and Methods. From 1985 to 1993, 34 Group I and 21 Group 2 pUs were treated with pre-radiation VCR 1.4 mg/m2 and highdose MTX 8 g/m2+CF rescue on days 1,8,22, and 29. Twelve additional "low risk "pts (TI-T2, M0,NED after surgery) older than 10 yrs (Grouo 3) received a standard pre-radiation CT with VCR 1.4 m g / m 2 (days 4,11) and i.t. MTX 10 mg/m 2 (days 1,8,15). Subsequent RT doses were: 54 Gy to the posterior fossa (PP') in all 67 pUs, 20 Gy to neuraxis in Grouo I , and 35 Gy to neuraxis in Group 2 and 3 pts. Maintenance CT (CCNU 80 mg/m2 q 9 wks and VCR 1.4 mg/m 2 q 3 wks) was given to all pus for one year. Results. Five-yr PFS was 42% in Grouo 1, 61% in Grouo 2 and 48% in Group 3 pts. In Group 1, 19/34 pus recurred: 5 to neuraxis outside PF among the 15 pus M0-NED (3-yr PFS 67%) and 14 (9 to neuraxis only and 5 also in PF) among the remaining 19 pts (M0-ED, M+- ED/NED). In Grouv 2. 7/21 pUs recurred: I in PF only, 4 to neuraxis, and 2 in both. Considering all Groun 1 and 2 pUs, PF relapses occurred in 7/27 pUs with ED after surgery and only in 1/28 pUs NED. In Group 3, 7/12 pUs recurred: 2 in PF only, 3 to neuraxis, and 2 in both. Conclusions. In this series, intensive CT plus low (20 Gy) dose RT to neuraxis were ineffective in controlling medulloblastoma in younger pUs, except for the subset of M0-NED children (73% relapses versus 30%). Results for "high risk" pts >10 yrs (5-yr PFS 61%) compared favorably with those of other series. The high relapse rate (7/12) among "low risk" pts >10 yr suggests that intensive CT may be indicated also in this subset of pts. Furthermore, after 54 Gy RT to the PF, the occurence of local relapse appears correlated with gross residual postoperative disease.
Postoperativ Radiotherapy of Medulloblastoma. Analysis of Recurrent Cases Kocsis B., Tak~icsi N.Z., N6meth Gy. National Institute ofOncelogy - Department of Radiotherapy Budapest, Hungary
Purpose:
The medulloblastoma occured most frequently in our material, therefore we retrospectwely evaluated the outcome of this patients regarding to the site of recurrences and metastases. Materials and Methods: A total of 33 consecutive children age 2-17 were postoperatively irradiated between October 1986 and April 1994 with linear accelerator with 6 or 9 MV x-ray. The radiotherapy started with craniospinal irradiation (CSI). 30 Cry total dose was delivered in low risk cases and 35 Gy in high risk cases. Futher 20 Gy was given to the posterior scala region. Results: 10 patients (30,3%) died. The cause of death by 6 patients was local recurrence, by 3 patients metastases within the central nervous system (CNS), by I patient pneumonia. Metastasis was registered in 5 cases (15%), including the above mentioned 3 exits. Two children are living with mild complains. The site of metastases: 1 suprasellar, 1 multiplex subependymal, 1 intraspinal, 1 multiplex CNS end 1 distant metastasis in the lilac bone. Local recurrence was observed in 8 cases at the site of primal, tumour. From these patients died 6, two are living without complain. The median survival rate was 33,5 months, ranged 3-96 months. The recidiva free survival was 21,1 months, ranged 3-69 months. Conclusion: local recurrence wasn't observed by the field junction. The postoperative radiotherapy is integrated part of the succesfull medulloblastoma therapy. It needs precisious field arrangement, accurate head immobilisation and careful field junction to avoid the overlapping and underdose.