Fast track — ArticlesConformal radiotherapy after surgery for paediatric ependymoma: a prospective study
Introduction
Newer methods of delivering radiotherapy combined with advances in neurosurgery have increased tumour control and reduced side-effects in paediatric patients with localised ependymoma. Preliminary findings from contemporary series using conformal, intensity-modulated, and proton-beam radiotherapy support this conclusion, with reduced side-effects and improved rates of local tumour control, event-free survival (EFS), and overall survival.1, 2, 3, 4 These results are especially relevant because ependymoma is commonly diagnosed in young patients and radiotherapy avoidance has had limited success.5, 6, 7 Fear of radiation-related side-effects has driven radiotherapy avoidance and the use of chemotherapy in young children. Recent data suggest that 42% of patients might avoid irradiation for up to 5 years after diagnosis by use of chemotherapy.5 Others suggest that fewer than 22% might benefit from this approach6 and that the role of chemotherapy is unproven.8 At stake is overall survival and functional outcome; patients treated with postoperative radiotherapy have better EFS and overall survival than those treated with chemotherapy.
Improved disease control provides a new opportunity to assess prognostic factors, patterns of failure, and late effects of treatment. We previously reported on the use of conformal radiotherapy for ependymoma in a prospective trial that included 88 paediatric patients treated by use of a 10 mm margin around the target volume with a median follow-up of 38 months.4 The 3-year EFS estimate was 74·7% (95% CI 63·5–85·9), median age at irradiation was 3 years (range 1·1–22·9), and few side-effects were noted. In the current report, we describe our findings with extended follow-up of these original patients and extend our single-institution series to now include a total of 153 patients.
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Patients
Between July 11, 1997, and Nov 18, 2007, 153 patients were treated with conformal or intensity-modulated radiotherapy, with written informed consent from a parent or guardian. The data presented were current on April 20, 2008. The initial 88 patients were prospectively treated in a phase II trial, approved by the institutional review board (IRB), between July 11, 1997, and Feb 5, 2003. The study was amended, with IRB approval, to included similarly treated patients who were enrolled for
Results
Clinical and treatment characteristics are shown in table 1. All patients were treated with postoperative conformal radiotherapy. 35 of 153 patients (22·9%) received chemotherapy before conformal radiotherapy and 11 of 153 patients (7·2%) had a delay before treatment of more than 4·4 months because of complications, parental indecision, or planned observation. Two patients treated with chemotherapy and two observed after first surgery had local progression and underwent resection before
Discussion
This study highlights the long-term benefits—in terms of local tumour control, EFS, and overall survival—of gross-total resection (including undergoing second surgery as a requisite for patients with macroscopically incomplete resection after initial surgery) and high-dose postoperative radiotherapy for the treatment of children with localised ependymoma, even for those who are younger than 3 years. Although it is important to understand the pitfalls that limit a comparison between this and
References (31)
- et al.
Proton radiotherapy for childhood ependymoma: initial clinical outcomes and dose comparisons
Int J Radiat Oncol Biol Phys
(2008) - et al.
Intensity-modulated radiation therapy in childhood ependymoma
Int J Radiat Oncol Biol Phys
(2008) - et al.
Hyperfractionated radiotherapy and chemotherapy for childhood ependymoma: final results of the first prospective AIEOP (Associazione Italiana di Ematologia-Oncologia Pediatrica) study
Int J Radiat Oncol Biol Phys
(2004) - et al.
Primary postoperative chemotherapy without radiotherapy for intracranial ependymoma in children: the UKCCSG/SIOP prospective study
Lancet Oncol
(2007) - et al.
Postoperative radiation therapy for grade II and III intracranial ependymoma
Int J Radiat Oncol Biol Phys
(2005) - et al.
Hearing loss after radiotherapy for pediatric brain tumors: effect of cochlear dose
Int J Radiat Oncol Biol Phys
(2008) - et al.
A retrospective study of surgery and reirradiation for recurrent ependymoma
Int J Radiat Oncol Biol Phys
(2008) - et al.
Preliminary results from a phase II trial of conformal radiation therapy and evaluation of radiation-related CNS effects for pediatric patients with localized ependymoma
J Clin Oncol
(2004) - et al.
Postoperative chemotherapy without irradiation for ependymoma in children under 5 years of age: a multicenter trial of the French Society of Pediatric Oncology
J Clin Oncol
(2001) - et al.
Outcome for young children newly diagnosed with ependymoma, treated with intensive induction chemotherapy followed by myeloablative chemotherapy and autologous stem cell rescue
Pediatr Blood Cancer
(2007)