Previous Cranial Irradiation Research Articles

Characterization of volumetric growth of intracranial meningiomas in Māori and Pasifika populations in New Zealand.

Māori and Pasifika populations in New Zealand have a higher incidence and prevalence of intracranial meningioma (IM). We sought to evaluate the volumetric growth rate of meningiomas under surveillance in these populations. From July 2002 to October 2020, 336 patients with a total of 408 IM underwent conservative management with serial radiological surveillance at Auckland City Hospital and met the criteria for the study. Inclusion criteria included: age >16 at diagnosis, ≥2 appropriate scans one or more years apart. Exclusion criteria included previous cranial irradiation, a diagnosis of Neurofibromatosis and prior treatment of meningioma. Demographic and clinical data were obtained from the electronic medical records. Imaging data were recorded from the first and last scans. We utilized open-source image processing software (3D Slicer) for semi-automated segmentation and volume calculation. Consistent with previous literature, we calculated the relative growth rate (RGR, %/year) and annual volume change (AVC, cm3 /year) over time. Four hundred and eight meningiomas were volumetrically characterized for a mean duration of 6.2 years. The Māori and Pasifika populations (n= 134/393) demonstrated a higher RGR (31.41 versus 14.33%/year) (P= 0.026) and AVC (2.05 versus 0.95 cm3 ) (P= 0.025) compared to the control population. They also presented at a younger age and had a higher rate of tumour multiplicity. Males represented only 17.6% of the cohort but exhibited a higher growth rate (AVC=2.52 cm3 /year) than females (AVC=0.99 cm3 /year) (P= 0034). Māori and Pasifika populations in New Zealand have a higher incidence and volumetric growth rate of IM compared to a control population. This warrants further clinical, histopathological and genomic analysis.

Final Height of Patients Who Underwent Bone Marrow Transplantation for Hematological Disorders During Childhood: A Study by the Working Party for Late Effects-EBMT

AbstractFew data are available on the long-term effect of bone marrow transplantation (BMT) on growth. This study examines those factors that play a role in the final height outcome of patients who underwent BMT during childhood. Data on 181 of 230 patients with aplastic anemia, leukemias, and lymphomas who had BMT before puberty (mean age, 9.8 ± 2.6 years) and who had reached their final height were analyzed. An overall decrease in final height standard deviation score (SDS) value was found compared with the height at BMT (P < 107) and with the genetic height (P < 107). Girls did better than boys, and the younger in age the person was at time of BMT, the greater the loss in height. Previous cranial irradiation + single-dose total body irradiation (TBI) caused the greatest negative effect on final height achievement (P < 104). Fractionation of TBI reduces this effect significantly and conditioning with busulfan and cyclophosphamide seems to eliminate it. The type of transplantation, graft-versus-host disease, growth hormone, or steroid treatment did not influence final height. Irradiation, male gender and young age at BMT were found to be major factors for long-term height loss. Nevertheless, the majority of patients (140/181) have reached adult height within the normal range of the general population.

External Validity of a Nomogram and Recursive Partitioning Analysis to Predict for Distant Brain Failure After Stereotactic Radiosurgery Alone for Brain Metastases: Multi-institutional Analysis

Patients (pts) with brain metastases (BM) treated with stereotactic radiosurgery (SRS) alone are at increased risk of distant brain failure (DBF). A nomogram and recursive partitioning analysis (RPA) designed to predict for DBF at 1 year (yr) after SRS alone from a single institution Canadian tertiary care hospital was recently published (Rodrigues et al., Radio and Oncol 2014). We sought to evaluate the external validity of these tools using a multi-institutional independent validation cohort (VC). The records of consecutive pts with BM treated with SRS alone at 2 tertiary care cancer institutes between 2005-2013 were reviewed. Inclusion criteria were identical to the Canadian study and included pts treated with initial SRS alone, up to 3 BM, and no previous cranial irradiation. The nomogram variables included age, number of BM, largest lesion volume (cc), and WHO performance status (PS) to calculate probability of 1-yr DBF using the Kaplan-Meier method. The RPA defined 3 risk categories (low [LR], intermediate [IR], and high risk [HR]) based on PS, age, and number of BM. Discrimination was assessed using Harrell’s c-index and calibration was assessed using calibration plots and correlation between expected and observed DBF. After exclusions, a total of 282 pts with 390 BM and 303 pts with 416 BM were eligible for the nomogram and RPA VC, respectively. Median age was 60 years old, median tumor volume was 1.35 cc, and median number of BM was 1. Primary disease site was lung 44%, melanoma 20.2%, breast 17.4%, renal 7.8%, GI 2.8%, and other 11.6%. One-year actuarial DBF for the nomogram VC was 50.9% compared to 43.9% in the Canadian study. The Harrell’s c-index for the DBF nomogram using the VC was 0.56 compared to 0.69 in the Canadian study, indicating poor discrimination ability. Calibration plots for the nomogram demonstrated good correlation between predicted and observed DBF (r2=0.92), but with systematic underestimation of DBF risk by an average of 19.6% across all risk levels. RPA risk groups LR, IR, and HR had 1-yr DBF rates of 39%, 62%, and 51.8%, compared to Canadian rates of 25.1%, 45.9%, and 69.1%, respectively. RPA risk groups did demonstrate significantly different actuarial DBF rates (log-rank p=0.0008), but IR had a higher 1-yr DBF rate than HR and would have been categorized as high risk in the Canadian publication (> 40%). The accuracy of the RPA classification was 53% compared with 75% in the Canadian study. In an independent multi-institutional cohort, the Canadian nomogram and RPA classification were not found to be externally valid, had limited ability to accurately differentiate DBF at 1-yr, and generally underestimated risk of DBF. We currently recommend caution in using these tools to predict individualized risk of 1-yr DBF after SRS alone.

Etiology of Hypopituitarism in Adult Patients: The Experience of a Single Center Database in the Serbian Population.

There are only a few published studies related to the population-based etiology of hypopituitarism. New risks for developing hypopituitarism have been recognized in the last 10 years. Aim. To present data regarding the etiology of hypopituitarism collected in a tertiary center over the last decade. This is a cross-sectional database study. Patients and Methods. We included 512 patients (pts) with hypopituitarism, with a mean age of 45.9 ± 1.7 yrs (range: 18–82; male: 57.9%). Results. Nonfunctional pituitary adenomas were presented in 205 pts (40.5%), congenital causes in 74 pts (14.6%), while acromegaly and prolactinomas were presented in 37 (7.2%) and 36 (7.0%) patients, respectively. Craniopharyngiomas were detected in 30 pts (5.9%), and head trauma due to trauma brain injury-TBI and subarachnoid hemorrhage-SAH in 27 pts (5.4%). Survivors of hemorrhagic fever with renal syndrome (HFRS) and those with previous cranial irradiation were presented in the same frequency (18 pts, 3.5% each). Conclusion. The most common causes of hypopituitarism in our database are pituitary adenomas. Increased awareness of the other causes of pituitary dysfunction, such as congenital, head trauma, extrapituitary cranial irradiation, and infections, is the reason for a higher frequency of these etiologies of hypopituitarism in the presented database.

Effects of sodium thiosulfate versus observation on development of cisplatin-induced hearing loss in children with cancer (ACCL0431): a multicentre, randomised, controlled, open-label, phase 3 trial

Sodium thiosulfate is an antioxidant shown in preclinical studies in animals to prevent cisplatin-induced hearing loss with timed administration after cisplatin without compromising the antitumour efficacy of cisplatin. The primary aim of this study was to assess sodium thiosulfate for prevention of cisplatin-induced hearing loss in children and adolescents. ACCL0431 was a multicentre, randomised, open-label, phase 3 trial that enrolled participants at 38 participating Children's Oncology Group hospitals in the USA and Canada. Eligible participants aged 1-18 years with newly diagnosed cancer and normal audiometry were randomly assigned (1:1) to receive sodium thiosulfate or observation (control group) in addition to their planned cisplatin-containing chemotherapy regimen, using permuted blocks of four. Randomisation was initially stratified by age and duration of cisplatin infusion. Stratification by previous cranial irradiation was added later as a protocol amendment. The allocation sequence was computer-generated centrally and concealed to all personnel. Participants received sodium thiosulfate 16 g/m2 intravenously 6 h after each cisplatin dose or observation. The primary endpoint was incidence of hearing loss 4 weeks after final cisplatin dose. Hearing was measured using standard audiometry and reviewed centrally by audiologists masked to allocation using American Speech-Language-Hearing Association criteria but treatment was not masked for participants or clinicians. Analysis of the primary endpoint was by modified intention to treat, which included all randomly assigned patients irrespective of treatment received but restricted to those assessable for hearing loss. Enrolment is complete and this report represents the final analysis. This trial is registered with ClinicalTrials.gov, number NCT00716976. Between June 23, 2008, and Sept 28, 2012, 125 eligible participants were randomly assigned to either sodium thiosulfate (n=61) or observation (n=64). Of these, 104 participants were assessable for the primary endpoint (sodium thiosulfate, n=49; control, n=55). Hearing loss was identified in 14 (28·6%; 95% CI 16·6-43·3) participants in the sodium thiosulfate group compared with 31 (56·4%; 42·3-69·7) in the control group (p=0·00022). Adjusted for stratification variables, the likelihood of hearing loss was significantly lower in the sodium thiosulfate group compared with the control group (odds ratio 0·31, 95% CI 0·13-0·73; p=0·0036). The most common grade 3-4 haematological adverse events reported, irrespective of attribution, were neutropenia (117 [66%] of 177 participant cycles in the sodium thiosulfate group vs 145 [65%] of 223 in the control group), whereas the most common non-haematological adverse event was hypokalaemia (25 [17%] of 147 vs 22 [12%] of 187). Of 194 serious adverse events reported in 26 participants who had received sodium thiosulfate, none were deemed probably or definitely related to sodium thiosulfate; the most common serious adverse event was decreased neutrophil count: 26 episodes in 14 participants. Sodium thiosulfate protects against cisplatin-induced hearing loss in children and is not associated with serious adverse events attributed to its use. Further research is needed to define the appropriate role for sodium thiosulfate among emerging otoprotection strategies. US National Cancer Institute.

Abstract TP230: Small Vessel Infarction as a Late Complication of Cranial Irradiation

Background and Purpose: Small vessel infarction after cranial irradiation is rare manifestation, whereas large vessel disease is well-known as a late complication. The purpose of this study is to investigate the clinical features of the small vessel infarction associated with the previous cranial irradiation. Patients and Methods: This is a retrospective chart review study of the patients presenting with small vessel infarction after cranial irradiation, retrieved from the single center database between 1998 and 2015. We reviewed the clinical characteristics, types and doses of irradiation, interval between first irradiation and first stroke, radiographic findings of the infarctions, and clinical courses. Results: Thirteen cases were identified, 12 men, 54 +/- 14 years of age at stroke onset. Underlying diseases for irradiation were 8 primary brain tumor, 4 metastatic brain tumor, 1 Leukemia, and 1 histologically undetermined brain tumor. Irradiation methods were 9 whole brain irradiation, 2 intensity modulated radiation therapy, and 2 local irradiation. Mean dose of irradiation was 51 +/- 10 Gy. Infarcted lesions were 8 corona radiata, 5 posterior limb of internal capsule, 1 thalamus. Mean time from first irradiation to first stroke was 14 +/- 14 years. Median NIHSS score at onset was 4 (min-max: 1-11), and median modified Rankin Scale at discharge was 3 (min-max: 1-4). One case had recurrence of infarction in the different territory of perforating artery, and one case had exacerbation due to infarction growth. Conclusions: Vasculopathy after irradiation also occurs in perforating arteries as well as in large vessels. Irradiation induced small vessel vasculopathy should be recognized as an important cause of stroke among brain tumor survivor.

Stereotactic Radiosurgery as Salvage for Brain Metastases From Small Cell Lung Cancer

Materials and Methods: 40 SCLC patients treated with Gamma Knife from 2004 to 2011 were identified (15 males and 25 females with a median age of 61.3 years (range 36-79)). Thirty-seven patients had previous WBRT or prophylactic cranial irradiation. Three metastases (range 1-18) were treated per patient with 12Gy to 20Gy prescribed to the 45%-55% isodose line. Local and regional recurrence were identified using MRI. Local recurrence required pathologic evidence or MR SPECT changes consistent with tumor.

16 MONTH‐OLD FEMALE WITH INTRAVENTRICULAR MASS

Pediatric meningiomas are rare and account for about 1.5% of all intracranial tumors. When compared to adults, intraventricular location of childhood meningiomas is four to ten times as high. Atypical pathology of these lesions is very uncommon and indicates an aggressive nature. They are usually associated with Neurofibromatosis 2 (NF2) or previous cranial irradiation. Here, we present an interesting case of an unusually large, congenital intraventricular meningioma of atypical pathology in a 16 month old child with subsequently diagnosed NF2. A brief review of literature is also presented with this case illustration.

Central hypothyroidism

Central hypothyroidism is defined as hypothyroidism due to insufficient stimulation by thyroid stimulating hormone (TSH) of an otherwise normal thyroid gland. It has an estimated prevalence of approximately 1 in 80,000 to 1 in 120,000. It can be secondary hypothyroidism (pituitary) or tertiary hypothyroidism (hypothalamus) in origin. In children, it is usually caused by craniopharyngiomas or previous cranial irradiation for brain tumors or hematological malignancies. In adults, it is usually due to pituitary macroadenomas, pituitary surgeries or post-irradiation. Fatigue and peripheral edema are the most specific clinical features. Diagnosis is established by the presence of normal to low-normal TSH on the background of low-normal thyroid hormones, confirmed by the thyrotropin releasing hormone stimulation test. Therapy includes use of levothyroxine titrated to improvement in symptomology and keeping free T4 in the upper limit of normal reference range.

Progression of disease in unilateral moyamoya syndrome

Progression of vasculopathy associated with moyamoya syndrome is extremely variable. The authors review their experience in patients with unilateral moyamoya syndrome to identify factors predictive of contralateral clinical and imaging-documented disease progression. The authors reviewed the clinical and imaging records of all patients with moyamoya syndrome and unilateral disease who underwent cerebral revascularization surgery between January 1985 and June 2006 by using a standardized surgical procedure, pial synangiosis. Of 235 surgically treated patients with moyamoya syndrome, 33 (14%) presented with unilateral disease (4 adults and 29 children). There were 16 female and 17 male patients, with an average age of 10.4 years (26.8 years for adults and 8.1 years for children; range 1.5-39 years). Twenty patients presented with left-sided disease and 13 with right-sided disease. The average follow-up after surgery was 5.3 years (3.1 years for adults and 5.6 years for children; range 1-16 years). During this period, 10 (30%) of 33 patients progressed to bilateral disease. The mean time until disease progression was 2.2 years (range 0.5-8.5 years). Factors associated with progression in this series included contralateral abnormalities on initial angiography, previous history of congenital cardiac anomaly, cranial irradiation, Asian ancestry, and familial moyamoya syndrome. Young age at diagnosis was associated with a more rapid rate of progression (age < 7 years, 0.9 years to progression and age >or= 7 years, 3.1 years to progression). Of patients with unilateral moyamoya syndrome, 30% will have progression of arteriopathy during long-term follow-up. In this series, the average time of progression from unilateral to bilateral angiographic disease was 2.2 years. Several factors, including contralateral abnormalities on initial imaging, congenital cardiac anomaly, previous cranial irradiation, Asian ancestry, and familial moyamoya syndrome, were associated with an increased risk of progression. Patients with known unilateral angiographic disease should undergo continued monitoring by using MR imaging and MR angiography at regular intervals. Treatment with pial synangiosis is safe and confers durable protection against stroke in patients with both bilateral and unilateral moyamoya syndrome.

Endocrine dysfunction and parameters of the metabolic syndrome after bone marrow transplantation during childhood and adolescence

Endocrine dysfunction and parameters of metabolic syndrome were assessed in 91 patients aged 4.3-32.5 years who underwent allogeneic or autologous BMT in childhood. Final short stature, found in five of the 35 patients who attained final height, was associated with the underlying disease (specifically, Fanconi anemia) (P=0.0013), previous cranial irradiation (P=0.0007), type of conditioning irradiation (P<0.05) and allogeneic BMT (P=0.05). Growth hormone deficiency (n=10) was associated with previous cranial irradiation (P<0.005) and conditioning total body irradiation (P<0.001). Twelve patients had primary hypothyroidism, one had hyperthyroidism and one papillary thyroid carcinoma. Hypothyroidism was associated with neck/mediastinal (P<0.005) and conditioning irradiation (P<0.05). Primary gonadal failure was found in 24 of the mature patients (62.5% females). Hypogonadism was associated with the underlying disease (especially hematological malignancies) (P<0.05), pretransplant treatment (P<0.05), irradiation conditioning (P<0.001), older age (P<0.005) and advanced pubertal stage at BMT (P<0.05). Obesity (body mass index >2 s.d.) was found in 4.4% and type II diabetes and impaired glucose tolerance in 3.3% each. Dyslipidemia was found in 27.9% of the 43 patients tested. These findings emphasize the need for long-term follow-up of endocrine and metabolic parameters in young patients after BMT in order to offer proper treatment and improve quality of life.

Long‐term follow‐up of relapsed childhood acute lymphoblastic leukaemia

We have reviewed the outcome after relapse in a cohort of 505 children with acute lymphoblastic leukaemia (ALL) seen at a single institution. The majority of relapses (74%) occurred within 3 years from diagnosis, and most involved the bone marrow alone or with overt extramedullary relapse. Early relapse was more common in children with T-ALL and those with unfavourable cytogenetics. Factors influencing second remission included length of first remission and type of relapse. Children who had not received previous cranial irradiation had a superior survival. The German relapse score involving length of first remission, site of relapse and immunophenotype was highly predictive of outcome: event-free survival with 95% confidence intervals at 6 years for patients who received modern treatment [intensive chemotherapy or bone marrow transplantation (BMT)] was 78% (51-92%) for standard risk, 41% (33-49%) for intermediate risk and 19% (10-31%) for highest risk. Retrospective comparison of BMT with chemotherapy showed no difference in the intermediate-risk group but a possible advantage in the highest risk group. Follow-up of 235 patients who relapsed after chemotherapy and received a third course of treatment showed an extremely high early attrition rate, but a small number of patients survived in third remission. We conclude that new approaches are needed to individualize therapy in intermediate-risk patients and to improve the outcome for those in the highest risk group. Only a small number of children can be treated effectively in third remission.

Neuropsychological outcome in long-term survivors of a childhood extracranial solid tumor who have undergone autologous bone marrow transplantation.

The purpose of this study was to evaluate neuropsychological and adaptive functioning of children who have undergone bone marrow transplantation (BMT) without previous cranial irradiation. In total, 76 children treated for an extracranial tumor with BMT without total body irradiation (TBI) were evaluated at least 5 years after the end of the treatment.Overall, their performance and skills were in the normal range and their professional and academic outcomes were satisfactory. Nevertheless, we observed a deleterious effect of deafness on verbal IQ associated with the previous administration of cisplatin during conventional chemotherapy. In addition, reading difficulties had arisen. This could be related to absence from kindergarten or primary school during hospitalization. Finally, in the younger subgroup, visual-perceptual skills were found to be more fragile.

Primitive neuroectodermal tumors in the central nervous system following cranial irradiation: a report of four cases.

Radiation induced intracranial neoplasms are uncommon but well described and include gliomas, meningiomas, and sarcomas. The development of primitive neuroectodermal tumors (PNETs) following prophylactic craniospinal irradiation has been infrequently reported previously. The authors present four additional cases of PNETs that developed after previous cranial irradiation. Four patients who had previously been irradiated were determined to have PNETs of the central nervous system characterized by histopathologic and immunohistochemical features. The average patient age at diagnosis of the initial tumors and cranial irradiation was 17 years. The PNETs developed 5, 11, 11, and 18 years after completion of radiation. Three patients had posterior fossa tumors, one pilocytic astrocytoma, one low grade astrocytoma, and one malignant ependymoma, which had been diagnosed and treated in childhood. Two of those patients developed supratentorial PNETs and the third a cerebellar hemispheric PNET. The fourth patient developed a posterior fossa PNET following irradiation for a temporal astrocytoma, which was initially diagnosed and resected at 37 years of age. Mean survival was 12 months after diagnosis. The development of PNETs after cranial irradiation may be more common than thought previously and should be considered in the differential diagnosis of irradiation induced neoplasms. Survival after diagnosis of these radiation induced PNETs was short, and this may reflect an inability to provide standard therapy used for primary PNETs.

Cataracts after autologous bone marrow transplantation in children

We recorded the incidence and degree of posterior subcapsular cataract (PSC) in 29 children who had undergone autologous (n = 28) or syngeneic (n = 1) bone marrow transplantation (BMT) due to haematologic or lymphoid malignancy. Conditioning prior to transplantation consisted either of a combination of chemotherapy and total body irradiation (TBI) (n = 21) or of chemotherapy only (n = 8). TBI was given in one fraction of 7.5 Gy. Nine patients had received previous cranial irradiation. The patients were followed for 4-10y (median 8 y) after transplantation. Of 29 patients, 22 developed PSC, all within 4 y after BMT. With the exception of one patient who developed unilateral PSC, all had received TBI. Conversely, 100% of those who received TBI developed PSC. In this group (+TBI), eight patients (38%) developed significant PSC, defined as best corrected visual acuity <0.8 in either eye. Six patients (10 eyes) have since needed surgical repair consisting of extracapsular cataract extraction and intraocular lens implantation. There was no clear relationship between previous cranial irradiation and cataract development, nor any other obvious baseline differences between those in the +TBI group who developed significant PSC and those who did not. Although effects of previous therapy cannot be ruled out, TBI appears to be the main cause of PSC in this group of patients. Twelve patients in the +TBI group had well-preserved visual acuity throughout the study, reflecting a slow progression of PSC. This compares favourably with previous reports of allogeneic BMT, possibly owing to less need for corticosteroids after autologous BMT. We conclude that the incidence of PSC was high after autologous BMT where the conditioning regimen included total body irradiation.

Cataracts after autologous bone marrow transplantation in children

We recorded the incidence and degree of posterior subcapsular cataract (PSC) in 29 children who had undergone autologous (n = 28) or syngeneic (n = 1) bone marrow transplantation (BMT) due to haematologic or lymphoid malignancy. Conditioning prior to transplantation consisted either of a combination of chemotherapy and total body irradiation (TBI) (n = 21) or of chemotherapy only (n = 8). TBI was given in one fraction of 7.5 Gy. Nine patients had received previous cranial irradiation. The patients were followed for 4-10 y (median 8y) after transplantation. Of 29 patients, 22 developed PSC, all within 4 y after BMT. With the exception of one patient who developed unilateral PSC, all had received TBI. Conversely, 100% of those who received TBI developed PSC. In this group (+TBI), eight patients (38%) developed significant PSC, defined as best corrected visual acuity < 0.8 in either eye. Six patients (10 eyes) have since needed surgical repair consisting of extracapsular cataract extraction and intraocular lens implantation. There was no clear relationship between previous cranial irradiation and cataract development, nor any other obvious baseline differences between those in the +TBI group who developed significant PSC and those who did not. Although effects of previous therapy cannot be ruled out, TBI appears to be the main cause of PSC in this group of patients. Twelve patients in the +TBI group had well-preserved visual acuity throughout the study, reflecting a slow progression of PSC. This compares favourably with previous reports of allogeneic BMT, possibly owing to less need for corticosteroids after autologous BMT. We conclude that the incidence of PSC was high after autologous BMT where the conditioning regimen included total body irradiation.

Bone mass after treatment for acute lymphoblastic leukemia in childhood.

To study bone mass after childhood acute lymphoblastic leukemia (ALL) and determine if reduced bone mass is related to previous therapy or endocrine status at follow-up. We studied 95 survivors of childhood ALL who were in first remission a median of 11 years (range, 3 to 23 years) after diagnosis and who had never been irradiated outside a cranial field. The bone mass was measured by dual-energy x-ray absorptiometry. The results were compared with data on 396 local controls. Adjusted for sex and age, the mean whole-body bone mineral content (BMC) and bone mineral areal density (BMDA) were both significantly reduced (0.4 SDs less than the predicted mean value). This was mainly caused by reduced bone mass in the 33 participants who were aged 19 years or older at follow-up. In these young adults, the mean height for age, bone area for height, and BMC for bone area were all significantly reduced. This indicated that the reduced whole-body bone mass was caused by both reduced bone size and reduced size-adjusted bone mass. Reduced bone size was related to previous cranial irradiation. Reduced size-adjusted bone mass was not significantly related to age at diagnosis or at follow-up, length of follow-up, cranial irradiation, cumulative dose of methotrexate or corticosteroids, or endocrine status at follow-up. The whole-body bone mass was reduced 11 years after diagnosis of childhood ALL. If these abnormalities remain, survivors of childhood ALL will have an increased risk for osteoporotic fractures later in life.

Overnight growth hormone concentrations are usually normal in pubertal children with idiopathic short stature--a Clinical Research Center study.

To estimate the incidence of low growth hormone (GH) concentration in children and adolescents with idiopathic short stature, overnight GH levels were measured in 167 subjects. The results were compared with data from 132 normal children of similar pubertal stage, bone age, or body mass index. The majority of short children had normal overnight GH concentrations in a distribution not significantly different from that observed in normal children. However, in 6% of children grouped by pubertal stage and in 13% of children grouped by bone age, overnight GH levels were below the 95% confidence limits of normal. The overnight GH levels were above normal in 6%. The observed frequencies of both low and high GH levels were significantly greater than expected (P < 0.001). However, when body mass index was included in the analysis, only 5% of the children had low GH measures, and only 4% had high GH measures (both not significant). This frequency of low overnight GH levels in short children is considerably less than that reported by others. Thus, these data do not support the hypothesis that a deficiency of spontaneous GH secretion is a common cause of short stature. We conclude that standard GH stimulation tests, despite their limitations, remain the best definitive test of GH secretion. Subsequent overnight GH studies may be useful, however, in selected clinical settings such as previous cranial irradiation or other central nervous system disorder.

Secondary tumours after prophylactic cranial irradiation

A 22 year old woman, who at the age of 6 years had prophylactic cranial irradiation for acute lymphoblastic leukaemia, presented with both astrocytoma of the brain and breast carcinoma. The link between the two solid tumours and previous cranial irradiation is discussed.

Carboplatin as second line treatment for recurrent or progressive brain metastases from small cell lung cancer

Patients with brain metastases from small cell lung cancer (SCLC) have a poor prognosis. Although most patients die from metastatic disease outside the central nervous system, this disabling metastatic site often needs treatment to mitigate the signs and symptoms of intracranial disease. The effect of carboplatin (400 mg/m 2 every 4 weeks) as second line treatment for recurrent or progressive brain metastases was studied in 20 SCLC patients. 19 patients could be evaluated: 16 by contrast enhanced brain computer tomography (CT) scan (2 patients had complete response, 6 partial response, 4 stable disease and 4 progressive disease) and 3 patients clinically, who had progressive disease. The objective response rate in the brain was 40% (95%CI:22–61%). The median response duration was 8 weeks (range 2–29). The median survival was 15 weeks (range 1–44). Previous cranial irradiation appeared to be beneficial for survival. There was only mild haematological and gastrointestinal toxicity. Carboplatin has activity against brain metastases and gives palliation in responding patients.