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Proton Radiation Therapy for Pediatric Craniopharyngioma
Poster Viewing Abstracts S725
Volume 90 Number 1S Supplement 2014 Results: The median age at diagnosis was 19 months (range, 4 - 55 months), with a median age at radiation of 23 months (range, 6 - 62 months). Thirteen received local radiation with a median dose of 50.4 (range, 9 - 54) Co-60 Gy equivalent (CGE). Nine received craniospinal radiation with a median craniospinal dose of 30.6 (range, 23.4 - 36.0) CGE and median brain tumor dose of 54 (range, 50.4 55.8) CGE. Twenty completed the prescribed radiation course. With median follow-up from diagnosis of 26.3 months for all patients (range, 2.5 - 52.7 months) and 38.2 months for alive patients (range, 8.0 - 52.7 months), the median progression-free survival was 24.8 months and median overall survival was 29.9 months. Of the 11 patients alive at last follow up, five (45%) developed hearing loss, three (27%) had neurocognitive difficulties, one (9%) had endocrine deficits, four (36%) had ophthalmologic problems, and three (27%) developed radiation necrosis. All three cases of necrosis resolved with steroids or bevacizumab. Conclusions: This study is the largest institutional report of proton radiation treatment of AT/RT. Preliminary outcomes in this young pediatric population are encouraging compared to historical results but further studies are warranted. Author Disclosure: S.L. McGovern: A. Employee; MD Anderson Cancer Center, Baylor College of Medicine. M. Okcu: A. Employee; Texas Childrens Hospital. M. Munsell: A. Employee; MD Anderson Cancer Center. D. Grosshans: A. Employee; MD Anderson Cancer Center. M.F. McAleer: A. Employee; MD Anderson Cancer Center. M. Chintagumpala: A. Employee; Texas Childrens Hospital. S. Khatua: A. Employee; MD Anderson Cancer Center. A. Mahajan: A. Employee; MD Anderson Cancer Center.
3306 Proton Radiation Therapy for Pediatric Craniopharyngioma R.B. Jimenez,1 J.Y. Chin,1 Y.D. Tseng,1 J. Adams,2 T.I. Yock,2 D. Ebb,2 N.J. Tarbell,2 and S.M. MacDonald2; 1Harvard Radiation Oncology Program, Boston, MA, 2Massachusetts General Hospital, Boston, MA Purpose/Objective(s): Radiation therapy (RT) can be used for pediatric craniopharyngioma in the definitive, adjuvant or salvage settings. Proton beam RT (3D-CPT) is particularly suited for these treatments due to the tumor’s proximity to eloquent areas of the brain. We report early clinical outcomes for a large cohort treated with 3D-CPT. Materials/Methods: We conducted a retrospective review of all pediatric patients (age < or Z 20 years) treated with surgery followed by adjuvant or salvage 3D-CPT for craniopharyngioma between August 2002 and August 2013 at our institution. Clinical characteristics, treatment course, local failure (LF), and treatment-related morbidity were recorded. Acute toxicity was rated using CTCAE, version 4.0. Late toxicity was assessed using neuroendocrine, neuro-ophthalmologic, and neuropsychiatric testing. Results: Among 56 patients (26 females and 30 males), median age at diagnosis was 8.2 years (range 1.4 - 20), and median age at radiation was 9.5 years (range 2.4 - 20.5). Mean largest dimension of the tumor at diagnosis was 3.5 cm. Most common presenting symptoms were headache (59%), visual impairment (45%) and endocrinopathies (34%). Patients underwent a median of 2 surgical interventions (range 1-6) prior to 3DCPT. At initial surgery, 20% of patients had near gross or gross total resection, 59% had subtotal resection, and 21% had biopsy and/or cyst decompression. RT was delivered in the adjuvant setting for 27 (48%) patients and for relapse in 29 (52%) patients. Median RT dose was 52.2 Gy (RBE) (range 45-54). Nine patients experienced cyst growth on treatment requiring either re-planning or cyst aspiration/surgical decompression. At a median of 31 months from completion of 3D-CPT (range 4-115 months), there were two LFs at 10 and 27 months. One patient received salvage surgery and pegylated interferon and has stable disease 5 years from LF; the second received salvage surgery alone and is without disease 4 years after LF. The most common acute toxicities were grade 1-2 headache (39%) and fatigue (36%). Only 4% developed acute grade 3 toxicity. Effect of tumor and combined modality treatment contributed to late toxicity including Moya moya syndrome (9%), mild to severe visual field deficits (45%), and presence of any endocrine dysfunction requiring exogenous hormone replacement (100%). The most common neuropsychiatric deficits were impaired processing speed and cognitive efficiency.
Conclusions: Surgery followed by adjuvant or salvage 3D-CPT results in excellent disease control for pediatric patients with craniopharyngioma. Severe acute toxicity is rare, but late toxicities from tumor, surgery, and 3D-CPT remain prevalent. Long-term endocrine and ophthalmology follow-up is necessary, and neuropsychological testing may help identify patients at risk for treatment-related learning and/or behavioral changes. Author Disclosure: R.B. Jimenez: None. J.Y. Chin: None. Y.D. Tseng: None. J. Adams: None. T.I. Yock: None. D. Ebb: None. N.J. Tarbell: K. Advisory Board; Spouse, Advisory Board of Procure. S.M. MacDonald: None.
3307 Mid-Treatment Magnetic Resonance Imaging in Pediatric Intracranial Low-Grade Gliomas Treated With Proton Beam Therapy R. Sreeraman,1 T. Vern-Gross,2 D.J. Indelicato,2 J. Bradley,2 S. Huh,2 and R. Rotondo2; 1Moffitt Cancer Center, Tampa, FL, 2University of Florida Proton Therapy Institute, Jacksonville, FL Purpose/Objective(s): Low-grade gliomas (LGG) are the most common pediatric central nervous system tumor. Radiation therapy is frequently indicated at the time of diagnosis or progression after prior therapy. Midtreatment magnetic resonance imaging (MRI) is commonly performed during the course of radiation treatment to monitor for tumor enlargement, which may require target adjustment and re-planning. The purpose of this study was to report our experience with mid-treatment MRI with regards to the incidence of clinically significant tumor growth during treatment requiring target adjustment and re-lanning. Materials/Methods: Between March 2007 and September 2013, 82 pediatric patients with LGG were treated with passively scattered proton beam therapy at our institution. Four patients were excluded due to spinal primary site, and 23 intracranial LGG patients were excluded as they had not undergone midtreatment MRI. The remaining 55 patients (mean age at time of RT, 9.9 years; range, 4.4 - 18.9 years) had completed mid-treatment MRI and were included in this analysis. Tumor locations were optic pathway / hypothalamic (n Z 25), cerebral (n Z 7), thalamic (n Z 6), cerebellum (n Z 6), brainstem (n Z 4), and tectal region (n Z 7). Thirty-seven patients had documented or presumed WHO grade 1 tumors, 4 patients had WHO grade 1-2 tumors, and 14 patients had WHO grade 2 tumors. Twenty-seven patients had prior chemotherapy. Patients received a median total dose of 54 CGE (range, 50.4 - 54 CGE) using a median clinical target volume (CTV) margin of 5 mm (range, 5 - 8 mm) and systematic MRI registration. Initial and mid-treatment gross tumor volumes (GTV) were calculated for each patient to determine changes in target volumes during treatment. Results: Median initial GTV and median mid-treatment MRI GTV were both 26.1 cc (range: 1 - 379 cc). Fifty-four of 55 patients (98%) did not demonstrate appreciable change in GTV volume. In 1 of 55 patients (2%), the mid-treatment MRI GTV expanded by greater than 50% and beyond the initial CTV margin. This patient was steroid-dependent due to emesis and had experienced tumor progression on 6 prior lines of chemotherapy. A pre-treatment MRI performed the day of CT simulation demonstrated rapid tumor growth compared to a study performed 1 month prior to the day of simulation. The change in tumor volume was deemed to be clinically significant and necessitated target adjustment and treatment re-planning. Conclusions: The incidence of mid-treatment target volume changes requiring treatment re-planning in pediatric patients undergoing radiation treatment for low-grade gliomas is very low (2%). Routine mid-treatment MRIs in this patient population may not be clinically warranted but should be considered for cases of rapidly progressive LGG on prior therapy. Author Disclosure: R. Sreeraman: None. T. Vern-Gross: None. D.J. Indelicato: None. J. Bradley: None. S. Huh: None. R. Rotondo: None.
3308 Radiation Therapy Provides Favorable Outcomes as Definitive Treatment for Ewing Sarcoma W. Haque, B. Ager, and S.S. Hatch; University of Texas Medical Branch, Galveston, TX
Volume 90 Number 1S Supplement 2014 Results: The median age at diagnosis was 19 months (range, 4 - 55 months), with a median age at radiation of 23 months (range, 6 - 62 months). Thirteen received local radiation with a median dose of 50.4 (range, 9 - 54) Co-60 Gy equivalent (CGE). Nine received craniospinal radiation with a median craniospinal dose of 30.6 (range, 23.4 - 36.0) CGE and median brain tumor dose of 54 (range, 50.4 55.8) CGE. Twenty completed the prescribed radiation course. With median follow-up from diagnosis of 26.3 months for all patients (range, 2.5 - 52.7 months) and 38.2 months for alive patients (range, 8.0 - 52.7 months), the median progression-free survival was 24.8 months and median overall survival was 29.9 months. Of the 11 patients alive at last follow up, five (45%) developed hearing loss, three (27%) had neurocognitive difficulties, one (9%) had endocrine deficits, four (36%) had ophthalmologic problems, and three (27%) developed radiation necrosis. All three cases of necrosis resolved with steroids or bevacizumab. Conclusions: This study is the largest institutional report of proton radiation treatment of AT/RT. Preliminary outcomes in this young pediatric population are encouraging compared to historical results but further studies are warranted. Author Disclosure: S.L. McGovern: A. Employee; MD Anderson Cancer Center, Baylor College of Medicine. M. Okcu: A. Employee; Texas Childrens Hospital. M. Munsell: A. Employee; MD Anderson Cancer Center. D. Grosshans: A. Employee; MD Anderson Cancer Center. M.F. McAleer: A. Employee; MD Anderson Cancer Center. M. Chintagumpala: A. Employee; Texas Childrens Hospital. S. Khatua: A. Employee; MD Anderson Cancer Center. A. Mahajan: A. Employee; MD Anderson Cancer Center.
3306 Proton Radiation Therapy for Pediatric Craniopharyngioma R.B. Jimenez,1 J.Y. Chin,1 Y.D. Tseng,1 J. Adams,2 T.I. Yock,2 D. Ebb,2 N.J. Tarbell,2 and S.M. MacDonald2; 1Harvard Radiation Oncology Program, Boston, MA, 2Massachusetts General Hospital, Boston, MA Purpose/Objective(s): Radiation therapy (RT) can be used for pediatric craniopharyngioma in the definitive, adjuvant or salvage settings. Proton beam RT (3D-CPT) is particularly suited for these treatments due to the tumor’s proximity to eloquent areas of the brain. We report early clinical outcomes for a large cohort treated with 3D-CPT. Materials/Methods: We conducted a retrospective review of all pediatric patients (age < or Z 20 years) treated with surgery followed by adjuvant or salvage 3D-CPT for craniopharyngioma between August 2002 and August 2013 at our institution. Clinical characteristics, treatment course, local failure (LF), and treatment-related morbidity were recorded. Acute toxicity was rated using CTCAE, version 4.0. Late toxicity was assessed using neuroendocrine, neuro-ophthalmologic, and neuropsychiatric testing. Results: Among 56 patients (26 females and 30 males), median age at diagnosis was 8.2 years (range 1.4 - 20), and median age at radiation was 9.5 years (range 2.4 - 20.5). Mean largest dimension of the tumor at diagnosis was 3.5 cm. Most common presenting symptoms were headache (59%), visual impairment (45%) and endocrinopathies (34%). Patients underwent a median of 2 surgical interventions (range 1-6) prior to 3DCPT. At initial surgery, 20% of patients had near gross or gross total resection, 59% had subtotal resection, and 21% had biopsy and/or cyst decompression. RT was delivered in the adjuvant setting for 27 (48%) patients and for relapse in 29 (52%) patients. Median RT dose was 52.2 Gy (RBE) (range 45-54). Nine patients experienced cyst growth on treatment requiring either re-planning or cyst aspiration/surgical decompression. At a median of 31 months from completion of 3D-CPT (range 4-115 months), there were two LFs at 10 and 27 months. One patient received salvage surgery and pegylated interferon and has stable disease 5 years from LF; the second received salvage surgery alone and is without disease 4 years after LF. The most common acute toxicities were grade 1-2 headache (39%) and fatigue (36%). Only 4% developed acute grade 3 toxicity. Effect of tumor and combined modality treatment contributed to late toxicity including Moya moya syndrome (9%), mild to severe visual field deficits (45%), and presence of any endocrine dysfunction requiring exogenous hormone replacement (100%). The most common neuropsychiatric deficits were impaired processing speed and cognitive efficiency.
Conclusions: Surgery followed by adjuvant or salvage 3D-CPT results in excellent disease control for pediatric patients with craniopharyngioma. Severe acute toxicity is rare, but late toxicities from tumor, surgery, and 3D-CPT remain prevalent. Long-term endocrine and ophthalmology follow-up is necessary, and neuropsychological testing may help identify patients at risk for treatment-related learning and/or behavioral changes. Author Disclosure: R.B. Jimenez: None. J.Y. Chin: None. Y.D. Tseng: None. J. Adams: None. T.I. Yock: None. D. Ebb: None. N.J. Tarbell: K. Advisory Board; Spouse, Advisory Board of Procure. S.M. MacDonald: None.
3307 Mid-Treatment Magnetic Resonance Imaging in Pediatric Intracranial Low-Grade Gliomas Treated With Proton Beam Therapy R. Sreeraman,1 T. Vern-Gross,2 D.J. Indelicato,2 J. Bradley,2 S. Huh,2 and R. Rotondo2; 1Moffitt Cancer Center, Tampa, FL, 2University of Florida Proton Therapy Institute, Jacksonville, FL Purpose/Objective(s): Low-grade gliomas (LGG) are the most common pediatric central nervous system tumor. Radiation therapy is frequently indicated at the time of diagnosis or progression after prior therapy. Midtreatment magnetic resonance imaging (MRI) is commonly performed during the course of radiation treatment to monitor for tumor enlargement, which may require target adjustment and re-planning. The purpose of this study was to report our experience with mid-treatment MRI with regards to the incidence of clinically significant tumor growth during treatment requiring target adjustment and re-lanning. Materials/Methods: Between March 2007 and September 2013, 82 pediatric patients with LGG were treated with passively scattered proton beam therapy at our institution. Four patients were excluded due to spinal primary site, and 23 intracranial LGG patients were excluded as they had not undergone midtreatment MRI. The remaining 55 patients (mean age at time of RT, 9.9 years; range, 4.4 - 18.9 years) had completed mid-treatment MRI and were included in this analysis. Tumor locations were optic pathway / hypothalamic (n Z 25), cerebral (n Z 7), thalamic (n Z 6), cerebellum (n Z 6), brainstem (n Z 4), and tectal region (n Z 7). Thirty-seven patients had documented or presumed WHO grade 1 tumors, 4 patients had WHO grade 1-2 tumors, and 14 patients had WHO grade 2 tumors. Twenty-seven patients had prior chemotherapy. Patients received a median total dose of 54 CGE (range, 50.4 - 54 CGE) using a median clinical target volume (CTV) margin of 5 mm (range, 5 - 8 mm) and systematic MRI registration. Initial and mid-treatment gross tumor volumes (GTV) were calculated for each patient to determine changes in target volumes during treatment. Results: Median initial GTV and median mid-treatment MRI GTV were both 26.1 cc (range: 1 - 379 cc). Fifty-four of 55 patients (98%) did not demonstrate appreciable change in GTV volume. In 1 of 55 patients (2%), the mid-treatment MRI GTV expanded by greater than 50% and beyond the initial CTV margin. This patient was steroid-dependent due to emesis and had experienced tumor progression on 6 prior lines of chemotherapy. A pre-treatment MRI performed the day of CT simulation demonstrated rapid tumor growth compared to a study performed 1 month prior to the day of simulation. The change in tumor volume was deemed to be clinically significant and necessitated target adjustment and treatment re-planning. Conclusions: The incidence of mid-treatment target volume changes requiring treatment re-planning in pediatric patients undergoing radiation treatment for low-grade gliomas is very low (2%). Routine mid-treatment MRIs in this patient population may not be clinically warranted but should be considered for cases of rapidly progressive LGG on prior therapy. Author Disclosure: R. Sreeraman: None. T. Vern-Gross: None. D.J. Indelicato: None. J. Bradley: None. S. Huh: None. R. Rotondo: None.
3308 Radiation Therapy Provides Favorable Outcomes as Definitive Treatment for Ewing Sarcoma W. Haque, B. Ager, and S.S. Hatch; University of Texas Medical Branch, Galveston, TX