Brainstem Injury in Pediatric Patients Receiving Posterior Fossa Photon Radiation

Christopher A. Devine, Kevin X. Liu, Myrsini Ioakeim-Ioannidou, Matthew Susko, Tina Y. Poussaint, Thierry A.G.M. Huisman, Mariam Aboian, Douglas Brown, Cierra Zaslowe-Dude, Avani D. Rao, Lawrence T. Orlina, Bhupendra Rawal, Sabine Mueller, Karen J. Marcus, Stephanie A. Terezakis, Steve E. Braunstein, Daphne A. Haas-Kogan

Research output: Contribution to journalArticlepeer-review

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Purpose: Brainstem necrosis is a rare, but dreaded complication of radiation therapy; however, data on the incidence of brainstem injury for tumors involving the posterior fossa in photon-treated patient cohorts are still needed. Methods and Materials: Clinical characteristics and dosimetric parameters were recorded for 107 pediatric patients who received photon radiation for posterior fossa tumors without brainstem involvement from 2000 to 2016. Patients were excluded if they received a prescription dose <50.4 Gy, a brainstem maximum dose <50.4 Gy, or had fewer than 2 magnetic resonance imaging scans within 18 months after radiation. Post–radiation therapy magnetic resonance imaging findings were recorded, and brainstem toxicity was graded using National Cancer Institute Common Terminology Criteria for Adverse Events, version 5. Results: The most common histologies were medulloblastoma (61.7%) and ependymoma (15.9%), and median age at diagnosis was 8.3 years (range, 0.8-20.7). Sixty-seven patients (62.6%) received craniospinal irradiation (median, 23.4 Gy; range, 18.0-39.6) as a component of their radiation therapy, and 39.3% and 40.2% of patients received an additional involved field or whole posterior fossa boost, respectively. Median prescribed dose was 55.8 Gy (range, 50.4-60.0). Median clinical and imaging follow-up were 4.7 years (range, 0.1-17.5) and 4.2 years (range, 0.1-17.3), respectively. No grade ≥2 toxicities were observed. The incidence of grade 1 brainstem necrosis was 1.9% (2 of 107). These patients were by definition asymptomatic and experienced resolution of imaging abnormality after 5.3 months and 2.1 years, respectively. Conclusions: Risk of brainstem necrosis was minimal in this multi-institutional study of pediatric patients treated with photon radiation therapy for tumors involving the posterior fossa with no cases of symptomatic brainstem injury, suggesting that brainstem injury risk is minimal in patients treated with photon therapy.

Original languageEnglish (US)
Pages (from-to)1034-1042
Number of pages9
JournalInternational Journal of Radiation Oncology Biology Physics
Issue number5
StatePublished - Dec 1 2019
Externally publishedYes

Bibliographical note

Funding Information:
Disclosures: A.D.R. receives a research grant from Augmenix. S.A.T. receives research grants from Elekta and ASELL. D.A.H-K. sits on the Clinical Advisory Board of Cellworks and receives research grants from Novartis. K.J.M receives royalties from Uptodate, is a member of the PDQ Editorial Board and is the Associate Editor of Pediatric Blood and Cancer.

Publisher Copyright:
© 2019


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