Pediatric Radiation Oncology Research Articles

Pediatric Radiation Oncology in Germany: A Study of Availability and Application

Radiotherapy plays a pivotal role in many multimodal therapy concepts in pediatric oncology. However, the absolute number of irradiated children is estimated to be quite low. The aim of this study was to evaluate the availability and application of pediatric radiation oncology in Germany. In summer 2007, a standardized questionnaire was sent to all radiotherapy facilities in Germany. The questions regarded the structure of the departments, the number of irradiated children each year including the distribution of the different diagnoses, the number of curative treatments, inclusion in study trials, and existence of special contact persons for pediatric radiotherapy as well as technical aspects of irradiation of children. Answers to the questionnaires were obtained from 171 departments (77.4%). Of these, 67 (39%) stated to regularly treat children. These departments treated one to nine children in median each year (<5 children/year: 23 departments; >or=20 children: 15 departments). Most of these children suffered from brain tumors, Hodgkin's disease and acute lymphatic leukemia (ALL). Three-dimensional conformal radiotherapy was the most frequent treatment technique; special techniques like intensity-modulated radiotherapy (IMRT) or brachytherapy were rare. Due to quite low patient numbers treated in most radiotherapy facilities, individual experiences in pediatric radiation oncology can be assumed to be quite limited. As radiotherapy is part of multimodal therapy approaches in pediatric oncology and children treated with radiotherapy are at special risk for potential side effects, pediatric radiation oncology remains a sophisticated area. Therefore radiotherapy reference-institutions implemented by the therapy optimizing protocols are of fundamental importance.

Study protocol of the German "Registry for the Detection of Late Sequelae after Radiotherapy in Childhood and Adolescence" (RiSK)

BackgroundLate effects after radiotherapy in childhood and adolescence have mainly been characterized retrospectively with small patient numbers. However, these analyses are limited due to little information regarding organ dose levels in many cases. To overcome this limitation, the German Group of Paediatric Radiation Oncology (APRO) established the „Registry for the evaluation of late side effects after radiation in childhood and adolescence” (RiSK). The study protocol and the documentation forms are given in this publication.Methods/DesignRadiation parameters including detailed organ doses as well as toxicity evaluations are collected prospectively from centres all over Germany. Standardized documentation forms are used. These forms are given in an English and German version as additional files to this publication. Documentation is planned for all children who receive radiotherapy in one of the therapy trials of the "German Society of Paediatric Oncology and Haematology (GPOH)". The study started in a pilot phase in June 2001 in few centres. Since 2004 documentation has been performed all over Germany and is still on-going.DiscussionTo our knowledge, "RiSK" is the only multi-centre study that evaluates radiation associated side effects prospectively with detailed information about organ dose levels. With ongoing recruitment and prolongation of follow-up powerful data will be obtained in a few years. A broad use and international cooperation are welcome.

Anforderungen und Leistungsprofile der Arbeitsgemeinschaft Pädiatrische Radioonkologie (APRO): Eine Bestandsaufnahme und Darstellung zukünftiger Entwicklungen

Radiation therapy is an integral component in the management of childhood malignancies and undergoes a continuous process of optimization within the prospective trials of the GPOH. At present there are approximately 20 active protocols, some specifying radio-oncological study questions, in which about 500 to 600 children annually are given radiotherapy. The Pediatric Radiation Oncology Working Group (APRO) of the German Society for Radiation Oncology (DEGRO) represents the organizational link between GPOH and DEGRO. Their activities range from phrasing guidelines of radio-oncological therapy, through writing a protocol for a prospective study on radiation-induced late effects (RISK--in co-operation with GPOH, 695 patients registered so far) and organizing meetings for information transfer, to implementing radio-oncology within the prospective studies of the GPOH by establishing study chairs for radio-oncology when radio-oncological questions are a primary focus and/or to function as a reference institution for quality assurance. These activities also include individual case consultations outside the study proper. Twice annually the members of the APRO meet for an update on current knowledge and future directions where a representative of the GPOH is invited to contribute special aspects of pediatric oncology. In the future, modern technology (intensity modulated radiotherapy, proton therapy, inclusion of imaging in treatment planning) will be part of disease management in pediatric oncology. A working group for modern radiotherapy technology was established to enhance this development. Prospective studies of the GPOH with primary or secondary radio-oncological questions require the implementation of corresponding tasks (documentation, monitoring, etc.) in order to meet future demands on clinical trials and to achieve the aims of the protocol. Consequently adequate financial support is indispensable.

Register zur Erfassung von Spätfolgen nach Strahlentherapie im Kindes- und Jugendalter - erste Ergebnisse

Late effects after radiotherapy in childhood and adolescence have mainly been characterized retrospectively with small patient numbers. Therefore the German Group of Pediatric Radiation Oncology (APRO) established the "RegIster for the evaluation of late Side effects after radiation in childhood and adolescence" (RiSK). After a pilot phase starting in 2001 documentation has been performed all over Germany since 2004. This analysis shows the first results of "RiSK". Radiation parameters including detailed organ doses as well as toxicity evaluations were collected prospectively from centers all over Germany in the study center. Standardized documentation forms were used. Documentation is planned for all children who receive radiotherapy in one of the German pediatric therapy trials. Until December 31st 2006, 696 documentations of radiotherapy and 526 acute as well as 836 late follow-up documentation forms have been collected. Altogether, 41 patients with late grade 3 and 16 patients with late grade 4-side effects were identified. Side effects mainly concerned joints with functional impairment (after combined radiotherapy and surgery), the bowel, skin and subcutis as well as blood parameters under continued chemotherapy. Patients with late side effects of a higher grade were mainly treated for Ewing's or soft tissue sarcomas (n=235 patients), representing 33.8% of all patients in this study. Fortunately, up to now only a few late grade 3 or 4 side effects of radiotherapy are shown for almost 700 documented patients. For further results, especially for the characterization of dose-effect-relationships, this study has to be continued with a higher patient number and a longer follow-up.

Daily subcutaneous amifostine administration during irradiation of pediatric head and neck cancers

Five pediatric patients with head and neck cancers were treated with radiotherapy. Subcutaneous injections of 200 mg flat dose amifostine were given 30 min prior to radiation fractions. A total of 129 amifostine injections were done. Grade 3 nausea occurred three times and emesis only once. Hypotension, hypocalcemia, or allergic reactions following injections were not recorded. No grade 3 or 4 mucosal or skin reactions occurred. After 16 months, all patients were alive and disease-free. There were no grade 3 or 4 side effects of radiotherapy on follow-up. Further studies with more patients are required to determine the role of amifostine in pediatric radiation oncology, but these data should contribute to the clinical spectrum of amifostine use in pediatric oncology.

THE DEVELOPMENT OF A MULTIMEDIA WEB SITE FOR INSTRUCTION OF PEDIATRIC ONCOLOGY.

Purpose Deficiencies in pediatric oncology (PO) training for residents have been identified internationally. One of the main reasons for this is lack of exposure to pediatric patients during residency training. The goal of this project is to develop a series of Web-based learning modules to supplement current teaching in this area. Methods A Web-based survey was sent to Canadian radiation oncology (RO) program directors and Canadian RO residents. The survey was designed to identify the limitations of current training curriculum and supplemental materials to enhance it. Survey results guided Web site development. The curriculum was developed using teaching modules to focus on specific pediatric tumor sites. Modules followed a common format, reviewing the epidemiology, pathology, radiology, and treatment planning for each tumor. A self-assessment tool was included at the end of the modules, allowing learners to evaluate their grasp of topics. Results Survey results indicated a need for novel teaching methods in pediatric RO. One hundred percent (10/10) of Canadian RO program directors and 66% (69 of 106) of Canadian RO residents responded to the survey. More than 55% (38 of 69) of residents felt that teaching in pediatric RO was inadequate in comparison with other areas of RO. Fifty-five percent (15 of 27) of senior residents felt unprepared for questions in pediatric RO on qualifying board examinations. Over 90% (63 of 69) of respondents felt that a Web-based teaching tool would be a useful supplement to traditional teaching methods. Four modules have been written to date. Theses include brain tumors, sarcomas, Wilms9 tumor, and pediatric specialty tumors. Web development for the project is continuing. Efforts are being made to increase the use of problem-based learning and clinical skills in the Web site. Preliminary results indicate that users find this Web site useful to supplement their learning in PO. Conclusions This is a unique project utilizing Web-based learning modules to teach pediatric RO. This educational program will allow self-directed study in the area of pediatric RO, providing more effective learning of this challenging yet essential area of study.

Therapy-Associated Late Effects after Irradiation of Malignant Diseases in Childhood and Adolescence. Feasibility Analyses of a Prospective Multicenter Register Study

Radiogenic late effects in children and adolescents have been evaluated retrospectively in most analyses, with small patient numbers. The German Group of Pediatric Radiation Oncology (APRO) has generated a concept for a prospective evaluation of radiation-associated late effects in childhood. The aim of this study was to evaluate the feasibility of a nationwide central database for the documentation of radiation parameters and side effects of all children treated within therapy protocols of the German Society of Pediatric Oncology and Hematology (GPOH). A study center has been implemented in Muenster, the documentation has started in July 2001 in few centers in a pilot phase. Since February 2004 the documentation is done countrywide. Detailed documentation forms have been designed for treatment parameters and for doses applied at organs at risk. Furthermore, a uniform toxicity documentation, according to the RTOG/EORTC criteria, was chosen. Patients were reported from the study centers of the GPOH to the study center. All information was collected and analyzed in the study center. Till July 31, 2005, 438 documentations of radiation and 579 toxicity documentations of side effects have been collected in the study center. 46 centers for radiotherapy in Germany and one center each in Austria and in Switzerland took part in the documentation. The quality of documentation regarding completeness and plausibility fulfilled the expected criteria in most cases. This feasibility analysis showed that important information about organ dose levels and side effects was documented in a large number of patients (Figures 1 and 2). This prospective evaluation of radiotherapy and radiogenic side effects in children and adolescents will allow correlating doses at organs at risk and the incidence of acute and late sequelae in Germany. Further documentations and a longer follow-up are necessary to obtain powerful results.

Online pediatric oncology education: A novel teaching tool for oncology residents

9048 Background: Deficiencies in pediatric oncology training for residents have been identified internationally. A lack of training in pediatric oncology during residency is correlated with impaired outcomes for pediatric patients. There is a clear need for novel teaching tools to supplement training in pediatric oncology. Purpose: The goal of this project was to develop a series of multimedia web-based learning modules for the interactive instruction and review of pediatric oncology. A needs-based assessment of pediatric oncology training in Canadian radiation oncology residency programs was used to guide web-site development. Methods: A needs-based analysis was conducted via a web-based survey sent to all Canadian radiation oncology program directors and residents. The survey was designed to identify the limitations of current training curriculum in pediatric oncology. A multidisciplinary team, including pathologists, radiologists, medical physicists, radiation and medical oncologists, developed the web site curriculum. The site was designed using teaching modules to focus on pediatric tumour sites. Modules were developed using a common format, divided into chapters detailing specific tumour types. Each chapter reviewed relevant epidemiology, anatomy, pathology, radiology, and treatment for the tumor type. A self-assessment tool was included at the end of the modules. User satisfaction surveys were used for feedback. Results: 100% (10/10) of Canadian radiation oncology program directors and 66% (69/106) of Canadian residents responded to the survey. 56% (59/106) of resident respondents felt that teaching in pediatric radiation oncology was inadequate and 56% (20/36) of senior residents felt unprepared for questions in pediatric oncology on qualifying board exams. 90% (105/116) of respondents felt that a web-based teaching tool would be useful. The first module, pediatric neuro-oncology, has been completed. Results indicate users find this module useful for supplementing traditional training. Conclusions: There are no other interactive teaching tools in pediatric oncology. This unique web-based educational program will allow self-directed study in the area of pediatric oncology, providing more effective learning of this challenging yet essential area of study. No significant financial relationships to disclose.

Monitoring the growth effect of xenotransplanted human medulloblastoma in an immunocompromised mouse model using in vitro and ex vivo green fluorescent protein imaging

Medulloblastoma (MB) is one of the most common malignant brain tumors in children. It is a radiosensitive tumor. At 5 years after radical surgical excision and craniospinal axis irradiation, the tumor-free survival rate is from 50 to 70% [Halperin EC, Constine LS, Tarbell NJ, Kun LE. Pediatric radiation oncology (2005)]. In this study, we established xenotransplanted human MB (hMB) cells - isochromosome 17q - in a severe combined immunodeficiency (SCID) mouse model. We further transduced green fluorescent protein (GFP) into hMB cells to evaluate these hMB cells grafted in SCID mice. The result of an ex vivo GFP imaging system showed that a small lesion of the third-week-hMB-transplanted graft presented "green" signals with a clear tumor margin before any tumor-related symptoms were noted. We also demonstrated that the tumor progression could be monitored by GFP imaging for up to 12 weeks post-transplantation. This novel approach of GFP imaging assessment provides more accurate information of tumor status for experimental brain tumor studies. Because MB is sensitive to radiation and also response to chemotherapy, this SCID mouse model will be helpful for preclinical studies in the future.

261 Distributed radiotherapy — the use of telemedicine as a tool for decision making in paediatric radiation oncology ? a report from SWPR

Distributed radiotherapy - The use of telemedicine as a tool for decision making in paediatric radiation oncology ? : - A report from SWPR

33 Untangling the Web: Utilizing Multi-media Education for Pediatric Radiation Oncology Teaching

33 Untangling the Web: Utilizing Multi-media Education for Pediatric Radiation Oncology Teaching

Brief Report: Evaluation of an Interactive Intervention Designed to Reduce Pediatric Distress During Radiation Therapy Procedures

To evaluate the efficacy of an interactive intervention in reducing distress related to radiation therapy (RT) among pediatric cancer participants as measured by occurrence of sedation, observed behavioral distress (OBD), and heart rate (HR). Seventy-nine children receiving RT simulation were assigned randomly to a STARBRIGHT Hospital Pals group (i.e., interactive intervention group; IG) or modified control group (MCG). The interactive intervention included filmed modeling, exposure to an interactive Barney character, and passive auditory distraction. Children in the IG experienced significantly lower HR when compared with MCG participants. No differences were found in terms of sedation or OBD. The interactive intervention was effective at reducing RT-related distress (as measured by HR) and would be a useful tool in pediatric radiation oncology settings.

Subspecialty training and certification for radiation oncology

To address the recurring issues regarding subspecialty training and certification in radiation oncology, and using pediatric radiation oncology as an example, the authors considered the problem of inadequate case material for resident teaching. Potential solutions to the identified problems are addressed, and the roles of oversight committees and regulatory bodies are clarified. The problem of the nonuniform distribution of pediatric case material across residency programs cannot be solved by removing pediatric radiation oncology from the core radiation oncology educational curriculum or by offering fellowship training to those who may select it. As a result, the authors believe that subspecialty training and certification in radiation oncology is not a near-term possibility.

Overview of International Congress Of Pediatric Radiation Oncology, Lyon, 2003.

Pediatric Blood & CancerVolume 42, Issue 5 p. 396-397 Editiorial and Commentary Overview of International Congress of Pediatric Radiation Oncology, Lyon, 2003† Patrick R.M. Thomas MB, BS, FACR, Corresponding Author Patrick R.M. Thomas MB, BS, FACR [email protected] Countryside Cancer Center, Clearwater, FloridaCountryside Cancer Center, Clearwater, FL 33761.===Search for more papers by this author Patrick R.M. Thomas MB, BS, FACR, Corresponding Author Patrick R.M. Thomas MB, BS, FACR [email protected] Countryside Cancer Center, Clearwater, FloridaCountryside Cancer Center, Clearwater, FL 33761.===Search for more papers by this author First published: 01 February 2004 https://doi.org/10.1002/pbc.10476 † This manuscript was originally submitted to and accepted for publication in Medical & Pediatric Oncology by its Editor-in-Chief, Dr. G. D'Angio. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume42, Issue5May 2004Pages 396-397 RelatedInformation

Positron emission tomography in pediatric radiation oncology: integration in the treatment-planning process.

The application of PET imaging to pediatric radiation oncology allows new approaches to targeting and selection of radiation dose based not only on the size of a tumor, but also on its metabolic activity. In order to integrate PET into treatment planning for radiation oncology, logistical issues regarding patient setup, image fusion, and target selection must be addressed. Through prospective study, the role of PET in pediatric malignancies will be established for diagnosis, treatment, and surveillance. To explore the potential role of PET and its incorporation into treatment planning in pediatric radiation oncology, an example case of pediatric Hodgkin's disease is discussed.

Proceedings of the International Conference On Pediatric Radiation Oncology. Lyon, France, June 18-20, 2003.

Proceedings of the International Conference On Pediatric Radiation Oncology. Lyon, France, June 18-20, 2003.

Is there a future for pediatric radiation oncology?

Pediatric Blood & CancerVolume 42, Issue 5 p. 486-488 Epilogue Is there a future for pediatric radiation oncology?† Giulio J. D'Angio MD, Corresponding Author Giulio J. D'Angio MD Professor Emeritus, University of Pennsylvania, School of Medicine, Radiation Oncology, Philadelphia, PennsylvaniaProfessor Emeritus, University of Pennsylvania, School of Medicine, Radiation Oncology, 2 Donner Building, 34 Spruce Street, Philadelphia, PA 19104-4283.===Search for more papers by this author Giulio J. D'Angio MD, Corresponding Author Giulio J. D'Angio MD Professor Emeritus, University of Pennsylvania, School of Medicine, Radiation Oncology, Philadelphia, PennsylvaniaProfessor Emeritus, University of Pennsylvania, School of Medicine, Radiation Oncology, 2 Donner Building, 34 Spruce Street, Philadelphia, PA 19104-4283.===Search for more papers by this author First published: 15 December 2003 https://doi.org/10.1002/pbc.10475 † This manuscript was originally submitted to and accepted for publication in Medical & Pediatric Oncology by its Editor-in-Chief, Dr. G. D'Angio. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume42, Issue5May 2004Pages 486-488 RelatedInformation

Quantitative assessment of inter-clinician variability of target volume delineation for medulloblastoma: quality assurance for the SIOP PNET 4 trial protocol

Background and purpose: To assess inter-clinician variability amongst specialist paediatric radiation oncologists in delineating clinical target volumes for treating medulloblastoma as a quality assurance exercise prior to the introduction of the SIOP PNET 4 trial protocol of conformal radiotherapy to the posterior fossa and tumour bed. Patients and methods: Participants from 17 UK centres attended an educational meeting and then completed a clinical planning exercise to outline: (1) the whole posterior fossa and (2) the tumour bed. Quantitative analysis of the volumes, lengths, spatial positioning and axial planes for each individual was carried out and variation between individuals analysed. Results: Outlining of the posterior fossa was reasonably consistent, although most variation was seen in defining the superior border of the tentorium. A major difference was the decision whether or not to include the post-surgical meningocoele in the clinical target volume (CTV). The CTV for the tumour bed was under treated by all participants due to lack of inclusion of pre-operative tumour extent. Conclusions: This exercise demonstrated several ambiguities in the draft protocol and highlighted particular areas of inter-clinician variation. Consequently the protocol was revised and improved to take account of these findings. We recommend that planning exercises, in conjunction with education and training, should be implemented before the start of any new radiotherapy trial. In the future, the use of image transfer will allow prospective peer review of target volumes before treatment commences. These measures are essential to ensure that alterations in clinical practice are achieved in a uniform way.

Pediatric Radiation Oncology, Third Edition, 1999Edited by HalperinEdward C., ConstineLois S., TarbellNancy J., KunLarry E.. Lippincott Williams &amp; Wilkins, 227 East Washington Square, Philadelphia, PA 19106, USA. Price: US$155.00. ISBN: 0-7817-1500-8.

Book ReviewsPediatric Radiation Oncology, Third Edition, 1999 Mohammed Al ShabanaMD Mohammed Al Shabana Consultant, Pediatric Radiation Oncology, Department of Oncology, MBC-64, King, Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia Search for more papers by this author Published Online::1 Mar 2000https://doi.org/10.5144/0256-4947.2000.180aSectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionThis book is specifically devoted to the use of radiation therapy for the treatment of childhood cancers. The authors are well-recognized authorities in the field of pediatric oncology. Pediatric Radiation Oncology, published in 1999, is the third edition of the book, but a major revision has clearly been made to each chapter, with the inclusion of up-to-date references. Also, most of the chapters have CT scans and MRI pictures appropriately placed to further explain the text.The book consists of 22 chapters, with the first chapter reviewing the problem of cancer in children. Subsequent chapters deal with the different types of tumors in children, again with emphasis on the role of radiation therapy and the overall management of each tumor category. Chapter 19 deals with the late effects of cancer treatment in general, and chapter 20 deals specifically with secondary malignant neoplasms in children treated for cancer. The following chapter is a new one that reviews issues related to the sedation of children, with emphasis on monitoring the anesthetized child in the radiation therapy suite, and dealing with the ideal anesthetic for pediatric therapy. The chapter also explores anesthetic options for radiotherapy and discusses the complications of the child's underlying disease that dictates the anesthetic choice. Chapter 22 deals with immobilization, which is a very important link in the chain of treatment, planning and implementation.In my opinion, each chapter reflects controversies in the management of pediatric tumors, with all the major sides of an issue presented so that readers can form their own opinion. At the same time, the authors offer their opinion on many controversial topics, but are fair to alternate views. The book will be very useful to all radiation oncologists who do not practice radiation oncology on a regular basis, and also to fellows and residents in radiation oncology and pediatric oncology training programs. Previous article Next article FiguresReferencesRelatedDetails Volume 20, Issue 2March 2000 Metrics History Published online1 March 2000 InformationCopyright © 2000, Annals of Saudi MedicinePDF download

330 - The role of child life intervention in pediatric radiation oncology

330 - The role of child life intervention in pediatric radiation oncology