Multi-institution prospective trial of reduced-dose craniospinal irradiation (23.4 Gy) followed by conformal posterior fossa (36 Gy) and primary site irradiation (55.8 Gy) and dose-intensive chemotherapy for average-risk medulloblastoma.

PURPOSE: Limiting the neurocognitive sequelae of radiotherapy (RT) has been an objective in the treatment of medulloblastoma. Conformal RT to less than the entire posterior fossa (PF) after craniospinal irradiation might reduce neurocognitive sequelae and requires evaluation. METHODS AND MATERIALS: Between October 1996 and August 2003, 86 patients, 3-21 years of age, with newly diagnosed, average-risk medulloblastoma were treated in a prospective, institutional review board-approved, multi-institution trial of risk-adapted RT and dose-intensive chemotherapy. RT began within 28 days of definitive surgery and consisted of craniospinal irradiation (23.4 Gy), conformal PF RT (36.0 Gy), and primary site RT (55.8 Gy). The planning target volume for the primary site included the postoperative tumor bed surrounded by an anatomically confined margin of 2 cm that was then expanded with a geometric margin of 0.3-0.5 cm. Chemotherapy was initiated 6 weeks after RT and included four cycles of high-dose cyclophosphamide, cisplatin, and vincristine. RESULTS: At a median follow-up of 61.2 months (range, 5.2-115.0 months), the estimated 5-year event-free survival and cumulative incidence of PF failure rate was 83.0% +/- 5.3% and 4.9% +/- 2.4% (+/- standard error), respectively. The targeting guidelines used in this study resulted in a mean reduction of 13% in the volume of the PF receiving doses >55 Gy compared with conventionally planned RT. The reductions in the dose to the temporal lobes, cochleae, and hypothalamus were statistically significant. CONCLUSION: This prospective trial has demonstrated that irradiation of less than the entire PF after 23.4 Gy craniospinal irradiation for average-risk medulloblastoma results in disease control comparable to that after treatment of the entire PF.

Unmet needs among adolescent cancer patients: a pilot study.

OBJECTIVE: Adolescents with cancer pose a unique challenge to current health systems and the professional working with them. Throughout the world, it is increasingly recognized that the needs of this particular group of patients may not be met through existing services within either the pediatric or adult systems. In Australia, this is a new area of research, and little is known about the unmet physical, psychological, and social needs of this patient group. This study reports the outcomes of a focus group conducted to explore these issues. METHODS: Six young people, with a mean age at diagnosis of 17 years and 6 months, participated in a 2-h focus group. A qualitative analytic approach was utilized to examine themes. RESULTS: The participants identified a number of concerns relating to three broad categories: information provision, treatment processes, and survivorship. SIGNIFICANCE OF RESULTS: The research findings support previously documented evidence that indicate gaps in cancer services provided to this age group. Importantly, these gaps can be narrowed by improving access to adolescent multidisciplinary teams and introducing specific training for health care professionals.

A modified technique for craniospinal irradiation in children designed to reduce acute and late radiation toxicity.

Craniospinal irradiation is an important technique for the treatment of a number of paediatric malignancies. The conventional technique uses photons for all fields and does not exploit the benefits of CT and computer planning systems. The present paper describes a modification of the conventional technique in which both photons and electrons are used for the spinal field (mixed-beam technique). Computed tomography images and a planning computer are used for the selection of field junctions, electron beam energy and dosimetry. The intention of the technique is to reduce radiotherapy toxicity. A discussion of the potential benefits is presented.

Cancer in adolescents and young adults: treatment and outcome in Victoria.

OBJECTIVES: To describe the location of treatment, recruitment to clinical trials and outcomes for adolescents and young adults treated for cancer in Victoria. DESIGN AND SETTING: Retrospective review of all adolescents and young adults aged 10-24 years diagnosed with cancer between 1992 and 1996, identified from the Victorian Cancer Registry. MAIN OUTCOME MEASURES: Treatment regimen (clinical trial, treatment protocol or neither), compliance with treatment and 5-year survival. RESULTS: Questionnaires were completed for 576 of 665 eligible adolescents and young adults (87% response rate). Recruitment into clinical trials decreased with increasing age. Adolescents aged 10-19 years were more likely to be recruited to a clinical trial if treated at a paediatric hospital. For all cancers, 5-year survival was similar across the age groups and was not influenced by the place of treatment. Only 1% of adolescents and young adults failed to complete planned therapy due to non-compliance. CONCLUSIONS: Despite a similar incidence of cancer to that in younger children, adolescents and young adults with cancer are poorly recruited into clinical trials in Victoria. Establishment of a cancer resource network in Victoria may provide information to both paediatric and adult oncologists about currently available clinical trials.

Retinoblastoma: review of 30 years' experience with external beam radiotherapy.

A review of the experience at the Peter MacCallum Cancer Centre (Peter Mac), Melbourne, Australia in treating retinoblastoma with external beam radiotherapy was conducted. Outcomes of particular interest were tumour control, vision preservation and treatment late effects. The review was restricted to patients that had intact eyes treated at Peter Mac from 1965 until 1997 with at least 2 years of follow up. Histories were reviewed regarding patient and tumour characteristics and treatment details. Thirty-five patients were identified in whom 47 eyes were treated. Of the tumours, 47% were Reese-Ellsworth stage IV or V and the majority of others were at high risk for vision loss because of tumour location. The radiation treatment technique became increasingly sophisticated during the study period. Radiation dose and fraction size have similarly evolved but most patients received 30-50 Gy. Since 1989, a highly accurate contact lens immobilization technique has been used to deliver 40 Gy in 20 fractions. Thirteen eyes required additional local therapy. Of the treated eyes, 34 (72%) remain intact and 74% of these have useful vision. One patient died from retinoblastoma and three from second malignant neoplasms. With modern radiotherapy, late toxicities other than growth arrest and non-progressive cataract did not occur during the study period. Tumour control was high and a very acceptable rate of organ and vision preservation was achieved in a relatively high-risk population. Modern radiotherapy continues to develop in an attempt to improve treatment accuracy and minimize late radiation toxicity.