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A Comparison of Clinical Outcomes of Adult and Pediatric Medulloblastoma
Poster Viewing Abstracts S277
Volume 87 Number 2S Supplement 2013 Purpose/Objective(s): The aim of our study was to assess the initial results provided by fractionated stereotactic radiation therapy (FSRT) for brain metastasis treated in our institution. Materials/Methods: Between June 2010 and October 2012, 76 lesions from 43 patients with a single or multiple (up to 5) intracranial metastasis were treated with FSRT as a primary treatment (24p), after surgical resection (7p) or after WBI failure (13p). Fractionation schedules were 7 5 Gy (n Z 28) and 5 5 Gy (n Z 15) when WBI or surgery have been performed prior to FSRT. Planning target volume enclosed the tumor or tumor resection cavity with a safety margin of 2-3 mm. Treatment was delivered by Novalis Ô 6D or Hi-Art Tomotherapy Ô linacs. Daily ExacTrac Ô or megavoltage computerized tomography images were obtained. Results: Median overall survival was 6.7 months, and 12-months survival was 19%. Median disease free survival was 5.18 months. Mean cause specific survival (CNS failure related) was 22.13 months. No correlation among RPA class and outcome was observed. Neither lesions’ size nor primary tumor histology was predictor of survival. No patient demonstrated toxicity grade 2 or higher. Conclusions: FSRT as a primary, postoperative or salvage treatment is a feasible and well tolerated approach for the management of single or multiple brain metastasis that could provide an effective treatment decreasing late toxicity related with WBI. Further research is needed to establish a comparison with WBI toxicity results in long term survivors. Author Disclosure: R. Moleron: None. P. Tavera: None. M. Garcia: None. R. Magallon: None. F.J. Valcarcel: None. C.A. Reguiro: None. J. Romero: None. I. Zapata: None. J. Velasco: None. A. De la Torre: None.
2192 Total Tumor Volume Predicts Mortality Following Radiosurgery for 5 or More Brain Metastases J.J. Compton, M.A. Henderson, C.S. Johnson, C.M. Desrosier, and K.M. McMullen; Indiana University Medical Center, Indianapolis, IN Purpose/Objective(s): Little formal guidance exists for radiosurgery (SRS) for >4 brain metastases. While there are retrospective series addressing experiences with SRS for >4 brain metastases, few have addressed the subject of SRS for patients with >4 metastases. In this retrospective study, we examined the relationship between integral brain doses and total tumor volume and their effect on morbidity and overall survival in patients undergoing gamma knife SRS for five or more lesions. Materials/Methods: All patients who were treated between 2002 and 2012 with SRS for >4 brain metastases were included. Patient demographics, prior whole brain radiation therapy information, dosimetric data, total tumor volume, and integral brain dose as defined in joules were collected. Descriptive statistics, Wilcoxon rank-sum test, Spearman’s correlation and Kaplan-Meier survival estimates were utilized for statistical analysis. Results: Out of 59 evaluable patients who met the entry criteria, the median number of metastases treated was 7 (range, 5-21). The average age was 53 years and 63% had a KPS of 80-90 at the time of treatment. The mean total tumor volume was 5.4 cc (range, of 0.1 - 44.2). The mean integral brain dose was 2.9J (range, 1-8.7). Fifty-one percent of patients had grade 0/1 side effects including fatigue or headache and 2 patients had grade 5 side effects. The Spearman correlation analysis showed no significant effect of number of metastases on integral brain dose, however, total tumor volume was significantly associated with integral brain dose (correlation coefficient 0.70, p < 0.0001). The median overall survival was 8.9 months (95% CI, 5.8-11.2 months). While there was not a significant association between number of metastases and OS (p Z 0.2130), there was a trend toward a significant association between increased integral brain dose and decreased OS (p Z 0.0732; HR, 1.20; 95% CI, 0.98-1.47) and a significant association between increased total tumor volume and decreased OS (p Z 0.0017; HR, 1.90; 95% CI, 1.27-2.83). Conclusions: In the setting of patients treated with SRS for >4 brain metastases, increased total tumor volume is significantly associated with decreased overall survival, while increased integral brain dose trends toward an association with decreased overall survival. Proportional hazard
ratio analysis reveals that the risk of death increases by a factor of 1.2 for every 1 Joule increase in integral brain dose. Likewise, for every 10 cc increase in tumor volume the risk of death increases by 1.90. Author Disclosure: J.J. Compton: None. M.A. Henderson: None. C.S. Johnson: None. C.M. Desrosier: None. K.M. McMullen: None.
2193 A Comparison of Clinical Outcomes of Adult and Pediatric Medulloblastoma S.R. Alcorn, O. Ishaq, J.R. Montgomery, S.A. Terezakis, M.D. Wharam, M. Lim, M. Holdhoff, L.R. Kleinberg, and K.A. Redmond; Johns Hopkins Hospital, Baltimore, MD Purpose/Objective(s): Given that medulloblastoma is relatively rare in adults, current practice is to extrapolate management from the pediatric population. We seek to compare outcomes and prognostic factors between pediatric and adult patients with medulloblastoma to guide management decisions in the adult population. Materials/Methods: All cases of medulloblastoma diagnosed at a single institution between January 1977 and August 2013 were obtained from the tumor registry. Adult patients were defined as age >17 years. Patients with age <3 years, >1.5 cm2 postoperative residual disease, or metastatic disease were categorized as high risk. T-tests and chi-square analyses compared patient and treatment characteristics between age categories, and overall survival (OS) and death-censored progression-free survival (PFS) were estimated using Kaplan-Meier curves and compared by log-rank tests. Results: One hundred eleven patients (31 adult and 80 pediatric) were included in the analysis. Median follow-up was 4.7 years (range, 0.5 to 30 years). The median age of adult patients was 27 years (range, 17.2 to 69.2 years), and the median age of pediatric patients was 8.7 years (range, 11.4 months to 16.9 years). Gender, race, risk category, histology, and extent of resection did not significantly differ between age cohorts. Tumor location in the fourth ventricle was less common in adults than in pediatrics (29% vs 65%, p Z 0.001), with no significant difference between groups for other tumor locations. Adults were less likely than pediatrics to receive adjuvant chemotherapy (57% vs 79%, p Z 0.006). Radiation dose to the tumor bed (55 Gy vs 54 Gy) and posterior fossa (52 vs 48 Gy) were similar between adults and pediatrics, respectively, but cranial (38 Gy vs 32 Gy) and spinal (36 Gy vs 30 Gy) doses were statistically higher for adults (both p < 0.001). OS at 3, 5, and 10 years was 73%, 64% and 34% for adults and 73%, 70% and 62% for pediatrics, respectively (p Z 0.11). PFS at 3, 5, and 10 years was 80%, 49%, and 39% for adults and 66%, 60%, and 51% for pediatrics, respectively (p Z 0.80). Conclusions: In this large review of all patients diagnosed with medulloblastoma at a single institution, both tumor features and treatment regimens varied by age cohort, with adults less likely to have fourth ventricle tumors, less likely to receive chemotherapy, and more likely to be treated to higher craniospinal radiation doses. Nonetheless, both OS and PFS were not statistically different between adult and pediatric populations, suggesting that current management of higher craniospinal radiation doses without chemotherapy is a reasonable approach for the adult population. Multi-institutional prospective evaluation of the treatment paradigm for this rare adult disease would be beneficial. Author Disclosure: S.R. Alcorn: None. O. Ishaq: None. J.R. Montgomery: None. S.A. Terezakis: None. M.D. Wharam: None. M. Lim: None. M. Holdhoff: None. L.R. Kleinberg: None. K.A. Redmond: None.
2194 Initial Results of Proton Therapy for Clival Chordoma M.W. McDonald,1 O.R. Linton,1 M.G. Moore,2 and M.V. Shah3; 1 Department of Radiation Oncology, Indiana University Health Proton Therapy Center, Bloomington, IN, 2Department of Otolaryngology/Head and Neck Surgery, Indiana University Health, Indianapolis, IN, 3 Department of Neurosurgery, Indiana University Health Neuroscience Center, Indianapolis, IN
Volume 87 Number 2S Supplement 2013 Purpose/Objective(s): The aim of our study was to assess the initial results provided by fractionated stereotactic radiation therapy (FSRT) for brain metastasis treated in our institution. Materials/Methods: Between June 2010 and October 2012, 76 lesions from 43 patients with a single or multiple (up to 5) intracranial metastasis were treated with FSRT as a primary treatment (24p), after surgical resection (7p) or after WBI failure (13p). Fractionation schedules were 7 5 Gy (n Z 28) and 5 5 Gy (n Z 15) when WBI or surgery have been performed prior to FSRT. Planning target volume enclosed the tumor or tumor resection cavity with a safety margin of 2-3 mm. Treatment was delivered by Novalis Ô 6D or Hi-Art Tomotherapy Ô linacs. Daily ExacTrac Ô or megavoltage computerized tomography images were obtained. Results: Median overall survival was 6.7 months, and 12-months survival was 19%. Median disease free survival was 5.18 months. Mean cause specific survival (CNS failure related) was 22.13 months. No correlation among RPA class and outcome was observed. Neither lesions’ size nor primary tumor histology was predictor of survival. No patient demonstrated toxicity grade 2 or higher. Conclusions: FSRT as a primary, postoperative or salvage treatment is a feasible and well tolerated approach for the management of single or multiple brain metastasis that could provide an effective treatment decreasing late toxicity related with WBI. Further research is needed to establish a comparison with WBI toxicity results in long term survivors. Author Disclosure: R. Moleron: None. P. Tavera: None. M. Garcia: None. R. Magallon: None. F.J. Valcarcel: None. C.A. Reguiro: None. J. Romero: None. I. Zapata: None. J. Velasco: None. A. De la Torre: None.
2192 Total Tumor Volume Predicts Mortality Following Radiosurgery for 5 or More Brain Metastases J.J. Compton, M.A. Henderson, C.S. Johnson, C.M. Desrosier, and K.M. McMullen; Indiana University Medical Center, Indianapolis, IN Purpose/Objective(s): Little formal guidance exists for radiosurgery (SRS) for >4 brain metastases. While there are retrospective series addressing experiences with SRS for >4 brain metastases, few have addressed the subject of SRS for patients with >4 metastases. In this retrospective study, we examined the relationship between integral brain doses and total tumor volume and their effect on morbidity and overall survival in patients undergoing gamma knife SRS for five or more lesions. Materials/Methods: All patients who were treated between 2002 and 2012 with SRS for >4 brain metastases were included. Patient demographics, prior whole brain radiation therapy information, dosimetric data, total tumor volume, and integral brain dose as defined in joules were collected. Descriptive statistics, Wilcoxon rank-sum test, Spearman’s correlation and Kaplan-Meier survival estimates were utilized for statistical analysis. Results: Out of 59 evaluable patients who met the entry criteria, the median number of metastases treated was 7 (range, 5-21). The average age was 53 years and 63% had a KPS of 80-90 at the time of treatment. The mean total tumor volume was 5.4 cc (range, of 0.1 - 44.2). The mean integral brain dose was 2.9J (range, 1-8.7). Fifty-one percent of patients had grade 0/1 side effects including fatigue or headache and 2 patients had grade 5 side effects. The Spearman correlation analysis showed no significant effect of number of metastases on integral brain dose, however, total tumor volume was significantly associated with integral brain dose (correlation coefficient 0.70, p < 0.0001). The median overall survival was 8.9 months (95% CI, 5.8-11.2 months). While there was not a significant association between number of metastases and OS (p Z 0.2130), there was a trend toward a significant association between increased integral brain dose and decreased OS (p Z 0.0732; HR, 1.20; 95% CI, 0.98-1.47) and a significant association between increased total tumor volume and decreased OS (p Z 0.0017; HR, 1.90; 95% CI, 1.27-2.83). Conclusions: In the setting of patients treated with SRS for >4 brain metastases, increased total tumor volume is significantly associated with decreased overall survival, while increased integral brain dose trends toward an association with decreased overall survival. Proportional hazard
ratio analysis reveals that the risk of death increases by a factor of 1.2 for every 1 Joule increase in integral brain dose. Likewise, for every 10 cc increase in tumor volume the risk of death increases by 1.90. Author Disclosure: J.J. Compton: None. M.A. Henderson: None. C.S. Johnson: None. C.M. Desrosier: None. K.M. McMullen: None.
2193 A Comparison of Clinical Outcomes of Adult and Pediatric Medulloblastoma S.R. Alcorn, O. Ishaq, J.R. Montgomery, S.A. Terezakis, M.D. Wharam, M. Lim, M. Holdhoff, L.R. Kleinberg, and K.A. Redmond; Johns Hopkins Hospital, Baltimore, MD Purpose/Objective(s): Given that medulloblastoma is relatively rare in adults, current practice is to extrapolate management from the pediatric population. We seek to compare outcomes and prognostic factors between pediatric and adult patients with medulloblastoma to guide management decisions in the adult population. Materials/Methods: All cases of medulloblastoma diagnosed at a single institution between January 1977 and August 2013 were obtained from the tumor registry. Adult patients were defined as age >17 years. Patients with age <3 years, >1.5 cm2 postoperative residual disease, or metastatic disease were categorized as high risk. T-tests and chi-square analyses compared patient and treatment characteristics between age categories, and overall survival (OS) and death-censored progression-free survival (PFS) were estimated using Kaplan-Meier curves and compared by log-rank tests. Results: One hundred eleven patients (31 adult and 80 pediatric) were included in the analysis. Median follow-up was 4.7 years (range, 0.5 to 30 years). The median age of adult patients was 27 years (range, 17.2 to 69.2 years), and the median age of pediatric patients was 8.7 years (range, 11.4 months to 16.9 years). Gender, race, risk category, histology, and extent of resection did not significantly differ between age cohorts. Tumor location in the fourth ventricle was less common in adults than in pediatrics (29% vs 65%, p Z 0.001), with no significant difference between groups for other tumor locations. Adults were less likely than pediatrics to receive adjuvant chemotherapy (57% vs 79%, p Z 0.006). Radiation dose to the tumor bed (55 Gy vs 54 Gy) and posterior fossa (52 vs 48 Gy) were similar between adults and pediatrics, respectively, but cranial (38 Gy vs 32 Gy) and spinal (36 Gy vs 30 Gy) doses were statistically higher for adults (both p < 0.001). OS at 3, 5, and 10 years was 73%, 64% and 34% for adults and 73%, 70% and 62% for pediatrics, respectively (p Z 0.11). PFS at 3, 5, and 10 years was 80%, 49%, and 39% for adults and 66%, 60%, and 51% for pediatrics, respectively (p Z 0.80). Conclusions: In this large review of all patients diagnosed with medulloblastoma at a single institution, both tumor features and treatment regimens varied by age cohort, with adults less likely to have fourth ventricle tumors, less likely to receive chemotherapy, and more likely to be treated to higher craniospinal radiation doses. Nonetheless, both OS and PFS were not statistically different between adult and pediatric populations, suggesting that current management of higher craniospinal radiation doses without chemotherapy is a reasonable approach for the adult population. Multi-institutional prospective evaluation of the treatment paradigm for this rare adult disease would be beneficial. Author Disclosure: S.R. Alcorn: None. O. Ishaq: None. J.R. Montgomery: None. S.A. Terezakis: None. M.D. Wharam: None. M. Lim: None. M. Holdhoff: None. L.R. Kleinberg: None. K.A. Redmond: None.
2194 Initial Results of Proton Therapy for Clival Chordoma M.W. McDonald,1 O.R. Linton,1 M.G. Moore,2 and M.V. Shah3; 1 Department of Radiation Oncology, Indiana University Health Proton Therapy Center, Bloomington, IN, 2Department of Otolaryngology/Head and Neck Surgery, Indiana University Health, Indianapolis, IN, 3 Department of Neurosurgery, Indiana University Health Neuroscience Center, Indianapolis, IN