Reirradiation of primary CNS tumors.
ABSTRACT Primary central nervous system (CNS) tumors are seldom reirradiated due to toxicity concerns and sparse clinical data regarding efficacy.
We retrospectively reviewed 34 patients with primary brain tumors retreated with fractionated external beam irradiation at the University of California, San Francisco from 1977-1993. Tumors included 15 medulloblastomas, 10 high-grade gliomas, 7 low-grade gliomas, and 2 meningiomas.
Initial course of radiation was radical in intent for all patients. Median age at initial diagnosis was 19.8 years (range: 3.6-67). Median interval between radiation courses was 16.3 months (range: 3.8-166). Median Karnofsky Performance Status (KPS) prior to reirradiation was 80 (range: 40-100). Reirradiation volumes overlapped previous treatment in 30 patients and were nonoverlapping in 4 patients. Fractionation schemes used were hyperfractionated in 17, conventionally fractionated in 9, and hypofractionated in 8. Cumulative maximum overlap dose within the CNS ranged from 43.2-111 Gy (median: 79.7 Gy). Retreatment was completed as planned in 27 out of 34 patients and modified or aborted in 7 (four tumor progression on retreatment, three patient request). As measured from the time of retreatment median progression free and overall survival was 3.3 and 8.3 months. Clinical and radiographic indices were stabilized or improved in about half of patients evaluable at a median of 3 months postretreatment. Complications (early or late) potentially attributable to retreatment were noted in 10 of 34 (29%) of patients. Overt necrosis was noted in 3 of 34 (9%) of patients and the actuarial risk of necrosis was 22% at 1 year following retreatment.
Reirradiation of primary central nervous system tumors was associated with only modest palliative and survival benefits in this retrospective review. Difficulties separating toxicity due to retreatment vs. tumor progression and limited patient survival following retreatment preclude definite conclusions regarding the safety of this practice.
SourceAvailable from: Maurizio Amichetti[Show abstract] [Hide abstract]
ABSTRACT: Despite the use of more effective multimodal treatments in high-grade glioma (HGG), the outcome of patients affected by this disease is still dismal and recurrence is a very common event. Many therapeutic approaches, alone or combined (surgery, drugs, targeted agents, immunotherapy, radiotherapy, supportive therapy), are available in the clinical armamentarium so far. The attitude of physicians is increasingly interventionist, but recurrent HGG still remains a very difficult scenario to be treated. Radiotherapy with different re-irradiation techniques is increasingly proposed as a therapeutic option with interesting results, even though the resulting duration of response is usually quite short. Most lesions re-recur locally, with inadequate identification and targeting of viable tumor being the most important cause of failure. Prognosis is affected by many patient-, tumor-, and treatment-associated prognostic factors. Radiotherapy is delivered with many advanced modalities: 3D-CRT, intensity-modulated radiation therapy, stereotactic fractionated radiotherapy, radiosurgery, and brachitherapy with or without chemotherapy administration. In order to evaluate the feasibility and efficacy of re-irradiation in this setting, we reviewed the PubMed and MEDLINE databases restricting the search to original reports published from January 1990 to June 2011. The search resulted in a total of 155 reports: 78 of them covering 2,688 patients treated with different irradiation modalities overall fulfilled the entry criteria. Radiation therapy demonstrated to be an acceptable option in recurrent HGG with good response rates and acceptable toxicity.12/2011; 3(4):4061-89. DOI:10.3390/cancers3044061
[Show abstract] [Hide abstract]
ABSTRACT: Introduction: Radiation-induced medulloblastoma is exceedingly rare. Four cases of adult medulloblastoma were previously reported to have occurred following whole brain or craniospinal irradiation. Development of systemic malignancies secondary to proton beam therapy is extremely uncommon, with a lifetime risk lower than 1 %. Methods and Results: A 39-year-old woman presented with gait instability and a right cerebellar mass following an 8-year latency period post-fractionated proton therapy for an acoustic neuroma. To date, no cases of new onset medulloblastoma have been reported following proton beam therapy. The differential diagnosis by imaging studies includes brain radiation necrosis. Conclusion: The current report highlights the possible, although rare, risks and complications associated with proton beam radiation. Further studies are needed to address issues related to the management and treatment of radiation-induced medulloblastomas.03/2012; 2(1). DOI:10.1007/s13566-012-0080-5
Article: Cerebral radiation necrosis.[Show abstract] [Hide abstract]
ABSTRACT: Cerebral radiation-induced injury ranges from acute reversible edema to late irreversible radiation necrosis (RN). Cerebral RN is poorly responsive to treatment, is associated with permanent neurological deficits and occasionally progresses to death. We review the literature regarding cerebral RN after radiotherapy for various brain and head and neck lesions and discuss its clinical features, imaging characteristics, pathophysiology and treatment. For new enhancing lesions on computed tomography or magnetic resonance imaging, apart from tumor progression or recurrence, RN needs to be considered in the differential diagnosis. Further studies are required to design chemoradiotherapy protocols that are effective in treating tumors while minimizing risk of RN. Current available treatments for RN, steroid and surgery, only relieve the mass effect. None of the experimental treatments to date have consistently been shown to reverse the pathologic process of RN.Asia-Pacific Journal of Clinical Oncology 10/2013; DOI:10.1111/ajco.12124 · 0.91 Impact Factor