Pediatric Radiation Oncology Research Articles

Volume Modulated Arc Radiation Therapy: An Important Tool for Pediatric Radiation Oncology

Volume Modulated Arc Radiation Therapy: An Important Tool for Pediatric Radiation Oncology

An European survey to evaluate clinical practice of image-guided radiation therapy in children - On behalf of the participating members of the Pediatric Radiation Oncology Society and our projectbased consortium

Although the value of pediatric IGRT is widely acknowledged, there is no consensus on ‘best practice’. Our aim was to evaluate current pediatric IGRT practices in European radiotherapy institutes.

The Pediatric Radiation Oncology Society Working Group on Low- and Middle-Income Countries (PROS-LMIC) Strategic Plan to Advance Care, Education, and Research

The Pediatric Radiation Oncology Society Working Group on Low- and Middle-Income Countries (PROS-LMIC) Strategic Plan to Advance Care, Education, and Research

Dosimetric Analysis, Acute Toxicity and Long-Term Outcome of Craniospinal Irradiation Using Helical Tomotherapy in Children and Adults

To describe dosimetry, acute toxicity, long-term survival and risk of second malignancies in children and adults treated with helical Tomotherapy craniospinal irradiation (HT-CSI). From 2006 to 2019, 58 pts (age 2-47 years, median 14) were treated with HT-CSI. The most common histologies were medulloblastoma (n = 40), CNS embryonal tumor NOS (formerly PNET) (n = 9) and intracranial GCT (n = 3). Other neoplasms were ATRT, ependymoma, glioma and ALL. 33 pts (57%) presented with distant dissemination or liquoral involvement. Among non-metastatic pts, a gross total resection was not achieved in 36% of cases. The prescribed HT-CSI doses were 23.4-36 Gy (1.6-1.8 Gy/fr) according to age-, tumor- and stage-specific protocols. Cases were contoured at one Pediatric Radiation Oncology Unit according to pediatric RT guidelines. Adjuvant, concurrent/adjuvant, neoadjuvant, neoadjuvant/adjuvant and no CT was administered in 31%, 17%, 17%, 23%, 12% of pts, respectively. A dosimetric analysis for PTVs and OARs was performed. Acute side effects were recorded according to the CTCAE 4.0. Survival analysis was performed by the Kaplan–Meier method. 3 cases of acute cerebral edema were reported in pts with massive intracranial disease and spinal involvement with implanted shunts. Considering only 39 pts not receiving CT or in complete recovery from mielotoxicity prior to HT-CSI, hematological toxicity included G1-4 leukopenia (5%, 18%, 41%, 15%, respectively), neutropenia (21%, 21%, 31% and 8%), thrombocytopenia (41%, 10%, 10% and 10%) and anemia (39%, 13%, 3% and 3%). No other G3–4 toxicity was reported. Apart from alopecia, the other most common G1-2 acute toxicities were nausea/vomiting (58% of pts), dermatitis (28%), anorexia/asthenia (14%), dysphagia (12%) and stomatitis (10%). The 3-, 5- and 10-year OS was 76%, 64% and 49%, respectively. Apart from 4 pts showing progression despite therapy, relapse after HT-CSI occurred in 18 pts. Rates of 3-, 5- and 10-year PFS from the end of RT were 59%, 56% and 41%, respectively. No second primary cancer occurred. Survival for pts with medulloblastoma included 3-, 5- and 10-year OS of 88%, 77% and 63%, respectively, and 3-, 5- and 10-year PFS of 77%, 67% and 60%, respectively. In the medulloblastoma group the 10-year OS/PFS resulted 53/54%, 67/75% and 91/59% for pts <=14, 14-25 and >25 years-old, respectively. M-status, surgical resection extension and CT regimen seemed to be associated to survival in an age-dependent manner. HT-CSI acute toxicity was in line with Literature. Further efforts to correlate dosimetric and toxicity data are needed. Long-term survival for pts with medulloblastoma resulted related to age. Older pts seemed to benefit from not receiving reduced-dose RT and different CT regimens. At a follow-up up to 11.5 years from the end of HT-CSI, no second malignancy occurred.

A Visual Analytics Dashboard to Summarize Serial Anesthesia Records in Pediatric Radiation Treatment.

Young children who undergo radiation therapy may require general anesthesia to remain still during weeks of radiation sessions. On a typical day at our hospital, an anesthesia team will care for 10 patients in the radiation therapy suite, and each patient will have multiple prior anesthetic records. Daily review of prior anesthesia records is important to maintain anesthetic consistency and to identify potential improvement, yet our electronic health record (EHR) made such review time-consuming and cumbersome. This article aims to design a visual analytics interface that simultaneously displays data from multiple anesthesia encounters to support clinical consistency in medications and airway management. Documentation from the EHR is available in the clinical data warehouse following daily backups. A visual analytics interface was built to aggregate important components of multiple anesthesia encounters in pediatric radiation oncology on a single screen. The application was embedded in the EHR's anesthesia module and updated daily. Each anesthesia encounter was represented by a vertical line with the date at the bottom of the screen. Each vertical line was divided into sections corresponding to the medications, type of airway device, type of radiation oncology procedure, days between treatments, and recovery score and time. Information about the medications, airways, and procedures was shown with icon legends. This layout enabled users to quickly see the key components of multiple anesthetics and make inferences between, for example, the medications used and the recovery score. The dashboard provides a high-level summary of all radiation therapy anesthesia records for children receiving recurrent treatments. In this clinical scenario, it is desirable to replicate an optimal anesthetic approach for daily or near-daily treatments or adjust the anesthetic based on observed patterns.

Recommendations for the organisation of care in paediatric radiation oncology across Europe: a SIOPE–ESTRO–PROS–CCI-Europe collaborative project in the framework of the JARC

Disparities in survival and long-term side-effects from paediatric cancer are observed across European Society for Paediatric Oncology (SIOPE)–affiliated countries. The Joint Action on Rare Cancers (JARC) is a project supported by the European Union and member states aiming to formulate recommendations on rare cancers, including paediatric malignancies, to reduce inequalities and to improve health outcomes. Most paediatric cancers are treated by a combination of systemic agents, surgery and/or radiotherapy. Radiotherapy for children is becoming increasingly complex because of the growing availability of new modalities and techniques and the evolution in molecular biology. These added challenges have the potential to enhance disparities in survival and side-effects between countries, but also among centres in the same country. To tackle radiotherapy-related inequalities, representatives of SIOPE, European SocieTy for Radiotherapy and Oncology, Paediatric Radiation Oncology Society and Childhood Cancer International–Europe defined ‘standard’ and ‘optional’ levels to deliver Good Clinical Practice–compliant treatment in paediatric radiation oncology with a focus on patient-related care, education and training. In addition, more than 250 paediatric radiotherapy centres across the SIOPE-affiliated countries have been mapped. For a better understanding of resources in paediatric radiotherapy, JARC representatives are working on an online survey for paediatric radiation oncologists of each centre in SIOPE-affiliated countries. The outcome of this survey will give an insight into the strengths and weaknesses of paediatric radiotherapy across SIOPE-affiliated countries and can be relevant for European Reference Networks in terms of collaboration pathways and referrals in paediatric radiotherapy.

Radiotherapy practice for paediatric brain tumours across Europe and quality assurance initiatives: Current situation, international survey and future perspectives

AimThe aim of the study is to analyse radiotherapy quality assurance (RTQA) processes in the treatment of paediatric central nervous system (CNS) tumours across Europe. MethodsThe RTQA aspects of major past and current European trials for paediatric CNS tumours were reviewed based on study protocols and publications. A survey among radiation oncologists and paediatric oncologists about the practices of RTQA in paediatric CNS tumours across European countries was also performed. ResultsSeveral (inter)national initiatives to implement RTQA are being developed across Europe, with an apparent paradigm shift from retrospective to prospective RTQA. Experts from 21 of 29 contacted countries responded to the survey. National consensus guidelines for paediatric CNS tumours are available in 10 of 21 countries. Twenty-one of 33 experts believe that the level of involvement of paediatric radiation oncologists in the meetings and activities of the national paediatric oncology societies is adequate. Central storage of radiotherapy data is available in France, Germany and Denmark. RTQA programmes for paediatric brain tumours are available in 7 countries. Twelve of 21 experts believe that there is a well-established national referral network for the radiation treatment of paediatric patients in their respective countries. ConclusionAs a result of the review and survey, the following measures are proposed: (1) developing international RT guidelines for paediatric CNS tumours, (2) improving the collaboration between paediatric oncologists and paediatric radiation oncologists, (3) building a central storage system for RT data, (4) implementing international prospective RTQA platforms and (5) promoting European referral networks to reduce inequality.

The status of radiation oncology (RO) teaching to medical students in Europe

AimTo provide an overview of Radiation Oncology (RO) teaching to medical students around Europe. Materials and methodsAn electronic survey was sent to European academic teachers of RO. The survey focused on the teaching of RO to medical students throughout their undergraduate education. ResultsA total of 87 academic RO teachers from 29 countries were invited to participate in the electronic survey. Thirty-two surveys were completed by respondents from 19 European countries (response rate: 37%). The median number of hours devoted to RO teaching was 10 h (mean 16 h, range 2–60). The number of hours assigned to RO teaching was equal or inferior compared to medical oncology. In two institutions (6%) RO was delivered as a stand-alone course with an individual knowledge assessment. In 30 institutions (94%), the RO course was taught and/or assessed in a modular curriculum with other disciplines. Radiobiology, breast, lung, gastrointestinal, gynecologic malignancies, RO adverse events and palliative RO were taught in 80% of institutions. Pediatric RO, RO for benign conditions and economic topics were taught in less than 30% of institutions. In most institutions, classical written and oral examinations were used. Computer-based examinations and/or objective structured clinical examinations (OSCE) were seldom used. E-learning methods were available in less than 10% of institutions. A clerkship in RO department was available in 28 out of 32 institutions (87%), less than 5% of medical students were involved in research in RO during their undergraduate education. Strategies to encourage medical students to consider RO as a future career were offered in 53% of institutions. ConclusionsRO teaching to medical students was not uniform in Europe. RO teaching during undergraduate education in Europe was undervalued, and its knowledge and learning tools could be broadened and updated in the core curricula of medical students

Book Review: Pediatric Radiation Oncology

Book Review: Pediatric Radiation Oncology

Management of vertebral radiotherapy dose in paediatric patients with cancer: consensus recommendations from the SIOPE radiotherapy working group.

Inhomogeneities in radiotherapy dose distributions covering the vertebrae in children can produce long-term spinal problems, including kyphosis, lordosis, scoliosis, and hypoplasia. In the published literature, many often interrelated variables have been reported to affect the extent of potential radiotherapy damage to the spine. Articles published in the 2D and 3D radiotherapy era instructed radiation oncologists to avoid dose inhomogeneity over growing vertebrae. However, in the present era of highly conformal radiotherapy, steep dose gradients over at-risk structures can be generated and thus less harm is caused to patients. In this report, paediatric radiation oncologists from leading centres in 11 European countries have produced recommendations on how to approach dose coverage for target volumes that are adjacent to vertebrae to minimise the risk of long-term spinal problems. Based on available information, it is advised that homogeneous vertebral radiotherapy doses should be delivered in children who have not yet finished the pubertal growth spurt. If dose fall-off within vertebrae cannot be avoided, acceptable dose gradients for different age groups are detailed here. Vertebral delineation should include all primary ossification centres and growth plates, and therefore include at least the vertebral body and arch. For partial spinal radiotherapy, the number of irradiated vertebrae should be restricted as much as achievable, particularly at the thoracic level in young children (<6 years old). There is a need for multicentre research on vertebral radiotherapy dose distributions for children, but until more valid data become available, these recommendations can provide a basis for daily practice for radiation oncologists who have patients that require vertebral radiotherapy.

Proton beam therapy in pediatric oncology.

The advent of proton beam therapy (PBT) has initiated a paradigm shift in the field of pediatric radiation oncology, with increasing promise to alleviate both short-term and long-term toxicities. Given the dramatic rise in proton therapy centers in the United States, a discussion of the quality of evidence supporting its use in pediatric cancers is warranted. Proton radiotherapy appears to decrease the incidence and severity of late effects with the strongest evidence in pediatric brain tumor cohorts that shows benefits in neurocognitive, hearing, and endocrine outcomes. However, emerging data has shown that more conservative brainstem dose limits with protons compared with photons are required to limit brainstem toxicity; these modified recommendations have been incorporated into national cooperative group studies. Decreased toxicity in tumors outside of the CNS for PBT have also been reported in sarcomas, Hodgkin disease and neuroblastoma. Similarly, QoL outcomes are improved in brain tumor and other cohorts of patients treated with PBT. The collective findings demonstrate improved understanding and refinement of PBT in pediatric cancers. Data on QOL, toxicity and disease outcomes with PBT should continue to be collected and reported in order to understand the full extent of the risks and benefits associated with PBT.

Radiotherapy Advances in Pediatric Neuro-Oncology.

Radiation therapy (RT) represents an integral component in the treatment of many pediatric brain tumors. Multiple advances have emerged within pediatric radiation oncology that aim to optimize the therapeutic ratio—improving disease control while limiting RT-related toxicity. These include innovations in treatment planning with magnetic resonance imaging (MRI) simulation, as well as increasingly sophisticated radiation delivery techniques. Advanced RT techniques, including photon-based RT such as intensity-modulated RT (IMRT) and volumetric-modulated arc therapy (VMAT), as well as particle beam therapy and stereotactic RT, have afforded an array of options to dramatically reduce radiation exposure of uninvolved normal tissues while treating target volumes. Along with advances in image guidance of radiation treatments, novel RT approaches are being implemented in ongoing and future prospective clinical trials. As the era of molecular risk stratification unfolds, personalization of radiation dose, target, and technique holds the promise to meaningfully improve outcomes for pediatric neuro-oncology patients.

A Quality Initiative Improves the Treatment and Experience of Pediatric Radiation Oncology Patients

Nebraska Medicine, Omaha, Nebraska, is one of the primary academic health systems in the Midwest region, with 718 inpatient beds, a team of more than 1,000 physicians, and 40 specialty and primary ...

Planning target volume (PTV) margin practice patterns in adults and paediatrics among the Paediatric Radiation Oncology Society (PROS) members: an international survey

AbstractAimEvolving data are showing the need of considering smaller planning target volume (PTV) margin in paediatrics compared with adults treated for the same body site. This study proposed to evaluate the current patterns of practice regarding the PTV margin in paediatric patients compared with adult patients through an international survey.Materials and methodsA four-item questionnaire was created to address the PTV margins for paediatrics and adults as part of a comprehensive survey. International Paediatric Radiation Oncology Society (PROS) members were selected to partake and were contacted via email.ResultsIn total, 43 responded to the survey. The majority of the responders have written guidelines for PTV margin while the majority of those who have guidelines do not have separate guidelines for paediatrics. The implemented PTV margin for paediatric patients was in the majority 3–5 mm for the head region and 5–10 mm for the torso region and the difference from the PTV margin implemented in adults was not statistically significant.ConclusionThe majority of responders employ a series of site-specific PTV margin protocols that are applied to both adults and paediatrics, and do not take into consideration patient age or size. These results highlight the need of a separate policy for PTV margin in adults and paediatrics in every institution.

Image-Guided Radiotherapy in Paediatrics: A Survey of International Patterns of Practice

Background and purposeImage-guided radiation therapy (IGRT) is widely used in the treatment of various tumour types in both adult and paediatric patients. However, there are no international guidelines on its optimal use in paediatric radiotherapy. This study proposes to evaluate the current patterns of practice regarding IGRT policy in paediatric patients compared with adult patients through an international survey. Materials and methodsA five-item questionnaire was created to address IGRT protocols for paediatrics and adults. International Paediatric Radiation Oncology Society members were eligible to partake and were contacted via email (number = 119). ResultsForty-three members have responded to the survey. Most (65%) centres did not have separate written IGRT protocols for paediatric and adult patients. The imaging frequency used was the same for adults and paediatrics in up to 74% of the centres responded, and scanning parameters used were different in adults and paediatrics in 47% of the centres for central nervous system treatment. Different measures to decrease exposure dose from IGRT in paediatrics have also been explored. ConclusionDespite the extensive use of IGRT internationally, most centres use a series of site-specific protocols that fail to consider patient age or size. Given the desire to reduce radiation exposure in the paediatric patient cohort, further research is warranted to develop consensus guidelines on optimal IGRT use.

SIOPE – Brain tumor group consensus guideline on craniospinal target volume delineation for high-precision radiotherapy

ObjectiveTo develop a consensus guideline for craniospinal target volume (TV) delineation in children and young adults participating in SIOPE studies in the era of high-precision radiotherapy. Methods and materialsDuring four consensus meetings (Cambridge, Essen, Liverpool, and Marseille), conventional field-based TV has been translated into image-guided high-precision craniospinal TV by a group of expert paediatric radiation oncologists and enhanced by MRI images of liquor distribution. ResultsThe CTVcranial should include the whole brain, cribriform plate, most inferior part of the temporal lobes, and the pituitary fossa. If the full length of both optic nerves is not included, the dose received by different volumes of optic nerve should be recorded to correlate with future patterns of relapse (no consensus). The CTVcranial should be modified to include the dural cuffs of cranial nerves as they pass through the skull base foramina. Attempts to spare the cochlea by excluding CSF within the internal auditory canal should be avoided. The CTVspinal should include the entire subarachnoid space, including nerve roots laterally. The lower limit of the spinal CTV is at the lower limit of the thecal sac, best visible on MRI scan. There is no need to include sacral root canals in the spinal CTV. ConclusionThis consensus guideline has the potential to improve consistency of craniospinal TV delineation in an era of high-precision radiotherapy. This proposal will be incorporated in the RTQA guidelines of future SIOPE-BTG trials using CSI.

Pedijatrijsko radioterapijsko odeljenje - preporuke za optimalnu infrastrukturu i kadar

In multidisciplinary treatment of malignant diseases in pediatric population, radiotherapy with or without surgery, represents the basic modality of local treatment. Although the basic principles of radiotherapy in children are the same as in adults, it has its own specificity because it is applied to an organism in the phase of growth and development. Also, pediatric tumors differ from tumors in adults, so pediatric radiation oncologist has to have knowledge of pediatric oncology. Treatment of children with malignant diseases requires coordinated work of a multidisciplinary team: radiation oncologist, pediatrician, various specialty surgeons, pathologists, each of whom participates in the decision making on combined oncological treatment. Treatment decisions are necessary made in a multidisciplinary environment with the necessary knowledge of all members of the pediatric oncology team. Pediatric radiation oncology has its specifics and requirements in terms of infrastructure and organization. The basic requirements apply to rooms, equipment, staff, and procedures. Based on the international recommendations, the necessary radiotherapy equipment and its number, for the work with children, is defined. In the treatment of children it is recommended to use 3D conformal radiotherapy, or other advanced techniques, in order to avoid the irradiation of healthy tissues as much as possible. Monitoring early and late unwanted effects of radiotherapy is of great importance in treating children with malignant tumors. Also, a certain level of knowledge in the pathology of malignant diseases of children is necessary of all the members of radiotherapy team. Pediatric radiotherapy, as an extremely sophisticated and complex method of treatment, can therefore only be performed in hospitals and centers that can meet all of the above high standards and recommendations with the coordinated work of a multidisciplinary team with experience in pediatric oncology.

Recommendations for the treatment of children with radiotherapy in low- and middle-income countries (LMIC): A position paper from the Pediatric Radiation Oncology Society (PROS-LMIC) and Pediatric Oncology in Developing Countries (PODC) working groups of the International Society of Pediatric Oncology (SIOP).

Pediatric radiotherapy is a critical part of pediatric oncology protocols and the quality of the radiotherapy may determine the future quality of life for long-term survivors. Multidisciplinary team decision making provides the basis for high-quality care. However, delivery of high-quality radiotherapy is dependent on resources. This article provides guidelines for delivery of good quality radiation therapy in resource-limited countries based on rational procurement and maintenance planning, protocol development, three-dimensional planning, quality assurance, and adequate staff numbers and training.

Effects of Proton Center Closure on Pediatric Case Volume and Resident Education at an Academic Cancer Center

To analyze effects of closure of an academic proton treatment center (PTC) on pediatric case volume, distribution, and resident education. This was a review of 412 consecutive pediatric (age ≤18years) cases treated at a single institution from 2012 to 2016. Residents' Accreditation Council for Graduate Medical Education case logs for the same years were also analyzed. Characteristics of the patient population and resident case volumes before and after closure of the PTC are reported. Overall pediatric new starts declined by approximately 50%, from 35 to 70 per 6months in 2012 to 2014 to 22 to 30 per 6months in 2015 to 2016. Central nervous system (CNS) case volume declined sharply, from 121 patients treated in 2012 to 2015 to 18 patients in 2015 to 2016. In 2012 to 2014 our institution treated 36, 24, and 17 patients for medulloblastoma/intracranial primitive neuroectodermal tumor, ependymoma, and low-grade glioma, respectively, compared with 0, 1, and 1 patient(s) in 2015 to 2016. Forty-nine patients were treated with craniospinal radiation (CSI) from 2012 to 2014, whereas only 2 patients underwent CSI between 2015 and 2016. Hematologic malignancy patient volume and use of total body irradiation remained relatively stable. Patients treated when the PTC was open were significantly younger (9.1 vs 10.7years, P=.010) and their radiation courses were longer (35.4 vs 20.9days, P<.0001) than those treated after its closure. Resident case logs showed only a small decline in total pediatric cases, because the percentage of pediatric cases covered by residents increased after PTC closure; however, residents logged fewer CNS cases after PTC closure versus before. Overall pediatric case volume decreased after PTC closure, as did the number of patients treated for potentially curable CNS tumors. Our findings raise important questions regarding resident training in pediatric radiation oncology as these cases become increasingly concentrated at specialized centers.

Development of Pediatric Emergency Protocols and Communication Plans in Pediatric Radiation Oncology: Multidisciplinary Core Competencies.

Radiation therapy is an essential component of treatment for many pediatric cancers, yet the cost of maintaining a radiation facility at a dedicated pediatric center is often prohibitive. As a result, adult facilities treat pediatric patients where preparation for a pediatric emergency may be inadequate. The purpose of this quality improvement project was to develop a multidisciplinary emergency preparedness plan for a collaborative pediatric radiation oncology program at an adult community hospital with its partnering academic children's hospital. Using a cyclical process involving multidisciplinary collaboration that combines policy development, preparation, and team-building, the authors created the protocols and processes that would support the stabilization of a pediatric emergency and facilitate transfer to the partnering children's hospital. Further development of a communication plan outlines the flow of patient information through the multidisciplinary team during these transitions of care. Areas for future work include quantitative outcome measures to determine the effectiveness of the policies and procedures developed to prepare staff for pediatric emergencies.