Chronological Analysis of Acute Hematological Outcomes after Proton and Photon Beam Craniospinal Irradiation in Pediatric Brain Tumors

유규상,유정일,조성구,한영이,오윤진,임도훈,남희림,이지원,성기웅,신형진 대한암학회 2022 Cancer Research and Treatment Vol.54 No.3

PurposeThis study aimed to compare the early hematological dynamics and acute toxicities between proton beam craniospinal irradiation (PrCSI) and photon beam craniospinal irradiation (PhCSI) for pediatric brain tumors.Materials and Methods We retrospectively reviewed patients with pediatric brain tumors who received craniospinal irradiation (CSI). The average change in hemoglobin levels (ΔHb_avg), absolute lymphocyte counts (ΔALC_avg), and platelet counts (ΔPLT_avg) from baseline values was evaluated and compared between the PrCSI and PhCSI groups at 1 and 2 weeks after the initiation of CSI, 1 week before and at the end of radiotherapy, and 3-4 weeks after the completion of radiotherapy using t test and mixed-model analysis.Results The PrCSI and PhCSI groups consisted of 36 and 30 patients, respectively. There were no significant differences in ΔHb_avg between the two groups at any timepoint. However, ΔALC_avg and ΔPLT_avg were significantly lower in the PhCSI group than in PrCSI group at every timepoint, demonstrating that PrCSI resulted in a significantly lower rate of decline and better recovery of absolute lymphocyte and platelet counts. The rate of grade 3 acute anemia was significantly lower in the PrCSI group than in in the PhCSI group.Conclusion PrCSI showed a lower rate of decline and better recovery of absolute lymphocyte and platelet counts than PhCSI in the CSI for pediatric brain tumors. Grade 3 acute anemia was significantly less frequent in the PrCSI group than in the PhCSI group. Further large-scale studies are warranted to confirm these results.

Patterns of Failure Following Multimodal Treatment for Medulloblastoma: Long-Term Follow-up Results at a Single Institution

이동수,조재호,김세훈,김동석,심규원,유철주,한정우,서창옥 대한암학회 2015 Cancer Research and Treatment Vol.47 No.4

Purpose The purpose of this study is to investigate the long-term results and appropriateness ofradiation therapy (RT) for medulloblastoma (MB) at a single institution. Materials and MethodsWe analyzed the clinical outcomes of 106 patients with MB who received RT betweenJanuary 1992 and October 2009. The median age was 7 years (range, 0 to 50 years), andthe proportion of M0, M1, M2, and M3 stages was 60.4%, 8.5%, 4.7%, and 22.6%, respectively. The median total craniospinal irradiation (CSI) and posterior fossa tumor bed dose in102 patients (96.2%) treated with CSI was 36 Gy and 54 Gy, respectively. ResultsThe median follow-up period in survivors was 132 months (range, 31 to 248 months). Agradual improvement in survival outcomes was observed, with 5-year overall survival ratesof 61.5% in 1990s increasing to 73.6% in 2000s. A total of 29 recurrences (27.4%) developedat the following sites: five (17.2%) in the tumor bed; five (17.2%) in the posterior fossaother than the tumor bed; nine (31%) in the supratentorium; and six (20.7%) in the spinalsubarachnoid space only. The four remaining patients showed multiple site recurrences. Among 12 supratentorial recurrences, five cases recurred in the subfrontal areas. Althoughthe frequency of posterior fossa/tumor bed recurrences was significantly high amongpatients treated with subtotal resection, other site (other intracranial/spinal) recurrenceswere more common among patients treated with gross tumor removal (p=0.016). Therewas no case of spinal subarachnoid space relapse from desmoplastic/extensive nodularhistological subtypes. ConclusionLong-term follow-up results and patterns of failure confirmed the importance of optimal RTdose and field arrangement. More tailored multimodal strategies and proper CSI techniquemay be the cornerstones for improving treatment outcomes in MB patients.

Craniospinal irradiation for respiratory failure secondary to central nervous system Erdheim-Chester disease

Rahul N. Prasad,Peter J. Kobalka,Haley K. Perlow,Daniel M. Prevedello,Dukagjin M. Blakaj,Raju R. Raval,Joshua D. Palmer 대한방사선종양학회 2022 Radiation Oncology Journal Vol.40 No.2

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis typically featuring lower extremity osteosclerosis (96%) from Langerin-negative histiocytes with fibrosis. Central nervous system (CNS)-only disease is extremely rare, and particularly difficult to diagnose and manage. Neurologic complaints may be refractory to systemic therapy (ST), and the role of radiation therapy (RT) is undefined. We present a patient with ECD of the medulla complicated by respiratory failure and strength deficits with disseminated leptomeningeal disease (LMD) but not systemic disease, representing the first report of CNS-limited ECD with LMD. He received upfront craniospinal irradiation (CSI), representing a rare account of CSI for ESD, with marked clinical improvement resulting in extubation and improved strength. CSI facilitated excellent preservation of quality of life, and no treatment-related toxicity was observed prior to eventual, unrelated cardiopulmonary arrest. Thus, palliative CSI may augment ST by safely offering improved local control and symptomatic relief for CNS ECD.

Craniospinal Irradiation in Patients with CNS Germinoma: Dosimetric Evaluation of Supine LINAC Treatment and Helical Tomotherapy

Kim G,Kim CU,Cheon GS,Hong JY,Son SH,Lee JY,Lee YH,Lee JH,Kang YN,Yoon SC 대한방사선방어학회 2009 대한방사선방어학회 학술발표회 논문요약집 Vol.2009 No.11

Low-dose craniospinal irradiation as a definitive treatment for intracranial germinoma

Cho, Jaeho,Choi, Joong-Uhn,Kim, Dong-Seok,Suh, Chang-Ok Elsevier 2009 Radiotherapy and oncology Vol.91 No.1

<P><B>Abstract</B></P><P><I>Purpose:</I> To determine the optimal radiotherapy (RT) dose and volume for treatment of intracranial germinoma.</P><P><I>Materials and methods:</I> Eighty-one intracranial germinoma patients (33 pathologically-verified; 48 presumed by radiosensitivity testing) treated with RT alone between 1971 and 2002 were analyzed. The RT volume varied from focal (13) to whole brain (8), or to the entire neuraxis (60). All the cases after 1982 received craniospinal irradiation (CSI). Radiation dose was reduced gradually during the study period from 59 to 39.3Gy for primary tumors, and from 34.2 to 19.5Gy for the neuraxis. The median follow-up time was 120 months (48–260 months).</P><P><I>Results:</I> Five- and ten-year relapse-free survival rates were 98.8% and 94.1%, respectively. All the recurrences occurred in the patients who received local (4/13) or whole brain RT (1/8). None of the patients who received CSI suffered from a recurrence. Forty-six patients received 45Gy or less to the primary site and 22 patients received less than 20Gy to the spinal axis.</P><P><I>Conclusion:</I> Low-dose CSI-based RT should remain the standard treatment for intracranial germinoma. The RT dose can be reduced to 39.3Gy for primary tumor sites and to 19.5Gy for the spinal axis.</P>

수모세포종의 수술후 치료에 대한 임상적 고찰

김재성,김준상,조문준 충남대학교 의과대학 지역사회의학연구소 1998 충남의대잡지 Vol.25 No.2

Although craniospinal irradiation has been employed in children with medulloblastoma for the past 40 years, many issues concerning its use have been raised and examined, and some continue to be debated. Careful radiation technique includes adequate irradiation of the neuraxis with special attention to the cribriform plate region and the inferior portion of the frontal and temporal lobes. Conventional-dose craniospinal radiation therapy, in combination with chemotherapy, is currently recommended for patients with high-risk medulloblastoma. The appropriate dose of radiation to the craniospinal axis when this modality is combined with chemotherapy for low-risk medulloblastoma remains to be defined. Long-term results of hyperfractionated radiation therapy re likewise awaited.

전산화단층촬영모의치료장치를 이용한 배와위 두개척수 방사선치료 계획

이석(Suk Lee),김용배(Yong Bae Kim),권수일(Soo Il Kwon),추성실(Sung Sil Chu),서창옥(Chang Ok Suh) 대한방사선종양학회 2002 Radiation Oncology Journal Vol.20 No.2

목 적 : 척수에 전이가 가능한 뇌종양 치료를 위한 두개척수 방사선치료 시 복와위가 불가능한 경우 전산화단층촬영모의치료장치(volumetric spiral CT)와 가상모의 치료기(virtual simulator) 및 3차원 방사선치료계획장치를 이용하여 배와위로 두개척수 방사선치료계획 방법을 개발하고 기하학적 검증을 통하여 유용성을 고찰하고자 하였다. 대상 및 방법 : 2000년 5월에서 2001년 12월까지 연세암센터 방사선종양학과에서 배와위로 두개척수 방사선치료를 받은 환자 9명을 대상으로 하였다. 복와위가 불가능한 중증의 뇌종양 환자를 배와위로 하여 두경부는 두부고정틀(thermoplastic mask, Aquaplast??)로 고정시키고, 전신은 Vac-Loc?? (전성물산, 한국)으로 고정한 후 전산화단층촬영모의치료장치를 이용하여 전신체적영상(volumetric image)을 얻었다. 환자 자세의 재현성 확인 및 검증을 위해 두부에 세 개의 점과 전신에 기준선 및 기준점 등을 표시하였다. 이후 가상현실 영상(virtual fluoroscopy)에서 인체의 크기와 방향에 제약이 없고 치료 침대와 고정기구에 대한 시각장애를 제거함으로써 자유롭게 모의치료를 할 수 있었으며, 조사면과 빔을 결정하고 디지털화재구성사진(digitally reconstructed radiography, DRR)과 디지털화합성사진(digitally composited radiography, DCR)을 통하여 분해능이 좋은 화질의 투시 및 모의치료영상을 획득하였다. 기하학적 검증은 치료중심점 이동시 얻은 모의치료영상과 첫 치료 시에 얻은 조사면 검증 사진(port verification film) 등을 전산화단층촬영영상으로부터 재구성한 DRR 영상과 시각적, 정량적으로 비교, 분석하였다. 결 과 : 전산화단층촬영모의치료장치와 가상모의치료기 및 3차원 방사선치료계획 장치 등을 이용하여 복와위가 불가능한 환자의 두개척수 방사선 치료계획을 배와위로 원활히 수행할 수 있었다. 가상현실영상에서 대부분의 설계작업이 이루어지므로 환자의 자세고정을 요하는 시간은 전신체적 영상을 얻는 10분 이내이므로 환자의 불편을 줄일 수 있을 뿐 아니라 모의치료과정 중의 체위 변동 변수를 제거할 수 있었다. 또한 전산화단층촬영영상을 얻음으로써 중요정상조직인 안구, 척수 등을 정확하게 설정할 수 있었고, 조사면 결정과 차폐의 정확성을 증진시킬 수 있었다. 환자 자세 오차는 디지털화재구성사진과 치료 시마다 얻은 포트필름에서 치료중심점과 척수 사이의 거리를 측정하여 3 mm 이내의 정확성을 얻을 수 있었다. 결 론 : 전산화단층촬영모의치료장치로 체적영상을 얻고 가상현실모의치료계획으로 배와위 두개척수 방사선치료계획을 정확하고 용이하게 실현할 수 있었다. 따라서 배와위 두개척수 방사선치료는 복와위를 취할 수 없어서 치료가 힘든 소아환자, 전신상태가 좋지 않거나 기관절개술이 시행되어 있는 환자에서 유용한 방법임을 알 수 있었다. Purpose : In order to perform craniospinal irradiation (CSI) in the supine position on patients who are unable to lie in the prone position, a new simulation technique using a CT simulator was developed and its availability was evaluated. Materials and Methods : A CT simulator and a 3-D conformal treatment planning system were used to develop CSI in the supine position. The head and neck were immobilized with a thermoplastic mask in the supine position and the entire body was immobilized with a Vac-Loc. A volumetric image was then obtained using the CT simulator. In order to improve the reproducibility of the patients' setup, datum lines and points were marked on the head and the body. Virtual fluoroscopy was performed with the removal of visual obstacles such as the treatment table or the immobilization devices. After the virtual simulation, the treatment isocenters of each field were marked on the body and the immobilization devices at the conventional simulation room. Each treatment field was confirmed by comparing the fluoroscopy images with the digitally reconstructed radiography (DRR)/digitally composite radiography (DCR) images from the virtual simulation. The port verification films from the first treatment were also compared with the DRR/DCR images for a geometrical verification. Results : CSI in the supine position was successfully performed in 9 patients. It required less than 20 minutes to construct the immobilization device and to obtain the whole body volumetric images. This made it possible to not only reduce the patients' inconvenience, but also to eliminate the position change variables during the long conventional simulation process. In addition, by obtaining the CT volumetric image, critical organs, such as the eyeballs and spinal cord, were better defined, and the accuracy of the port designs and shielding was improved. The differences between the DRRs and the portal films were less than 3 ㎜ in the vertebral contour. Conclusion : CSI in the supine position is feasible in patients who cannot lie on prone position, such as pediatric patients under the age of 4 years, patients with a poor general condition, or patients with a tracheostomy.

항암치료와 관련된 백질뇌증 1례

유지숙(Jee Suk Yu),황세희(Se Hee Hwang),이백희(Beack Hee Lee),황용승(Yong Seung Hwang),안효섭(Hyo Seop Ahn) 대한소아신경학회 1993 대한소아신경학회지 Vol.1 No.1

Antineoplastic treatment-related leukoencephalopathy is defined as an entity in which acute or delayed changes in with matter, secondary to chemotherapy and/or radiation, produce cerebral, cerebellar, and/or brainstem dysfunction in the absence of demonstrable, causally microorganism. We experienced a case of antineoplastic treatment-related leukoencepholopathy in an 11 year-old girl who was diagnosed as having acute lymphoblastic leukemia when she was 8 years old. She had 3 episodes of isolated CNS relapse during maintenance chemotherapy. One month prior to admission, she had difficulties. in adaptation of new class and refused to go to school Six days prior to admission, she began to stammer over a few words and at that night, dysarthria became overt. Next morning, locomotor activities were slow and she was not able to salk without assistance and had right foot dragging. Brain MRI revealed diffuse demyelination in deep white matter with mild degree of diffuse ventricular dilatation and prominent subarachnoid space and sulcus. She had received craniospinal irradiation(whole brain 5,040 cGy, spine 1,350 cGy), intrathecal MTX 468mg, and intrathecal Ara-C 1,890mg. Supportive managements including L-tube feeding, steroid, and mannitolization were done without chemotherapy under the impression of antineoplastic treatment-related leukoencephalopathy. Bone marrow relapse was detected during admission. Her general conditions deteriorated and decorticate posture changed to decerebarte posture. She died at 54th hospital day but autopsy was not done.

Radiation Therapy of Intracranial Germinoma

노영주,장혜숙,최은경,김종훈,Nho Young Ju,Chang Hyesook,Choi Eun Kyung,Kim Jong Hoon The Korean Society for Radiation Oncology 1997 Radiation Oncology Journal Vol.15 No.3

목적 : 두개내 배아종은 방사선 치료로 완치율이 높은 종양이나 현재까지 적절한 방사선 조사량이나 조사 범위에 대한 원칙은 확립되지 알은 상태이다. 본 저자는 본원에서 방사선 치료를 시행한 환자들의 치료 성적과 재발 양상을 알고자 후향적 분석을 하였다. 대상 및 방법 : 1989년에서 1996년까지 방사선 치료를 시행한 23명의 환자를 대상으로 하였다. 이 중 21댕은 처음 진단시 본과에서 방사선 치료를 하였고 나머지 2댕은 재발 뒤 본과에서 방사선 치료를 받았다. 자기공댕영상상 5명에서 다말성종괴가 관찰되었고 7명에서 뇌실 내 전이 소견이 보였다. 뇌척추액검사를 시행한 15명중 3명에서 종양 세포가 관찰되었다. 종양지표검사상 6명에서 혈장이나 뇌척추액의 베타 응모성선자극 호르몬의 수치가 다소 상승되어 있었다. 21명은 전뇌척수조사를 받았고 2명은 전뇌실조사를 받았다. 결 과 23명 중 21명은 현재 중앙 추적 기간 4 년 시점에서 무병 상태로 관찰되고 있다. 치료 중 백혈구 감소가 3 또는 4단계인 환자는 7명이었고 방사선조사후 내분비 상태가 악화된 환자는 없었다. 전뇌척수조사를 받은 환자중 1명이 저신장으로 성장 호르몬 치료를 받고 있다. 결론 : 본원에서 치료한 두개내 배아종은 기존의 보고와 마찬가지로 높은 관해율을 보이고 있다. 치료 중이나 치료 후의 부작용의 정도와 빈도는 현시점에서 허용 범위에 있는 것으로 생각되었다. 두개내 배아종의 방사선 조사량과 조사 범위, 약물 치료에 관해서는 좀 더 연구가 필요할 것으로 생각된다. Purpose : Intracranial germinoma is the most radiocurable tumor of theprimary intracranial neoplasm. But, the optimum radiation dose and target volume remain controversial In this retrospective study, we analysed the spreading pattern at presentation and the pattern of the failure and survival of intracranial germinoma, Materials and Methods : From 1989 to 1996, 23 Patients were treated for intracranial germinoma at Department of Radiation Oncology, Twenty-one Patients were treated at their initial Presentation and 2 Patients were treated for recurrent disease. Six patients had multiple tumor masses on MRI and 7patients had ventricular seeding on MRI. The examination of cerebrospinal fluid cytology was done in 15 patients and 3 out of 15 patients had positive cerebrospinal cytology. In tumor marker study of $\alpha-FP\;and\;\beta-hCG$, 6 patients had mildly elevated $\beta-hCG$ in serum or cerebrospinal fluid. Twentyone Patients were treated with whole craniospinal axis irradiation and 2 Patients were given whole ventricular radiation therapy. The total dose was ranged between 4500cGy and 5600cGy to primary tumor site (median 5580cGy) Dose to the entire ventricular system ranged from 1980cGy to 3960 cGy (median 2700cGy) and dose to the spinal axis ranged from 2160cGy to 3900cGy (median 2700cGy) Results : Of 23 patients, 21 Patients are alive without evidence of diseasefor median 4 years follow-up. One Patient who had markedly elevated $\alpha-FP\;and\;\beta-hCG$, suffered from Persistent disease after radiation therapy and received 2 cycles of chemotherapy. She died 9 months after chemotherapy One patient who developed ventricular seeding after gamma-knife was treated with whole craniospinal irradiation, he died after 1 year due to probably brain necrosis. The hematologic toxicity of 3 or 4 grade were seen in 7 patients and patient's endocrinologic dysfunction was not deteriorated after radiation therapy. One patient had been treated with growth hormone replacement due to short stature. Conclusions : This retrospective study has confirmed the excellent result of radiation therapy in intracranial germinoma. The complication rate during or after radiation therapy is considered within acceptable range. ft is necessary to further investigate the optimal dose and treatment volume of radiation therapy. The role of chemotherapy in the treatment of intracranial germinoma should be further investigated.

The Effect of Intermittent Craniospinal Irradiation and Intrathecal Chemotherapy for Overt Meninggeal Leukemia

김인아(In Ah Kim),최일봉(Ihl Bhong Choi),정수미(Su Mi Chung),신경섭(Kyung Sub Shinn) 대한방사선종양학회 1993 Radiation Oncology Journal Vol.11 No.2

가톨릭대학교 의과대학 성모병원 치료방사선과에서 1988년부터 1992년도까지 적절한 중추신경계 예방요법후 뇌척수액내 재발을 경험한 급성 임파구성 백혈병 환자 7명을 대상으로 간헐적인 전중추신경계 방사선조사 및 척수강내 화학요법(IIIC)을 실시하였다. 추적관찰기간은 8개월에서 41개월이었고 그 중앙값은 20개월이었다. 7명의 대상환자중 3명이 다시 뇌척수액내 재발을 경험하였고, 중추신경계 관해유지기간은 각각 8, 9, 13, 20, 34, 36개월이었다. 무병 생존기 간은 2개월에서 36개월로 그 중앙값은 11개월이었다. 생존율은 8개월에서 41개월로 그 중앙값은 28개월이었다. 5명이 치료기간중 골수재발에 따른 패혈증 및 출혈로 사망하였고, 2명의 생존자는 치료종료 10개월 및 11개월째 다시 뇌척수액내 재발을 경험하였다. 치료결과를 향상시키기 위해서는 치료중 휴식기간을 단축시키고, 치료후에도 일정기간동안 척수강내 유지화학요법을 연장하여 실시하는등 치료계획의 변형이 필요할 것으로 사료되었다. Between 1988 and 1992, seven patients with overt meningeal leukemia who had received adequate central nervous system (CNS) prophylaxis were treated with intermittent craniospinal irradiation and intrathecal methotrexate (IIIC). Follow-up time ranged from 8 months to 41 months with median of 20 months. Three of 7 patients developed subsequent CNS relapse. CNS remission durations were 8, 9, 13, 20, 28, 34, 36 months from diagnosis of CNS leukemia for which IIIC was given. Disease free survival after CNS relapse ranged from 2 to 36 months with median of 11 months. Overall survival after CNS relapse ranged from 8 to 41 months with median of 28 months. Five patients died of sepsis and bleeding secondary to bone marrow relapse. Two patients are alive at present. But they developed recurrent CNS disease 10 to 11 months after completion of IIIC. To improve the outcome, modification of IIIC by reduction of rest period and prolonged administration of intrathecal chemotherapy after completion of IIIC are required.