International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationInfant Ependymoma in a 10-Year AIEOP (Associazione Italiana Ematologia Oncologia Pediatrica) Experience With Omitted or Deferred Radiotherapy
Introduction
Until 10 years ago, there was strong evidence that younger children with ependymoma had a higher risk of recurrence or adverse outcome, both after tailored treatment, frequently omitting or delaying radiotherapy (RT), and given specific biologic features (1). Nowadays, the cutoff age of 3 years for risk stratification (2), or 4 or 5 years in some studies (3), seems to coincide with undertreatment, more because of earlier concern about RT damaging the developing brain than because of any intrinsically more severe prognostic factors (4).
The protocols of the 1990s aimed to omit or delay RT in favor of upfront chemotherapy to spare surviving children the late effects of radiation 3, 5, 6, 7. Taking this approach, we treated 41 children under 3 years of age at the time of their diagnosis, and their outcome forms the subject of this study.
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Patients and Methods
Children with posterior fossa or supratentorial ependymoma were eligible for the study if they met the following criteria: (1) age under 3 years at diagnosis; 2) histologically proven ependymoma; (3) no previous exposure to chemotherapy (except for steroids) or RT; (4) normal cardiac, hepatic, and renal function; (5) a Lansky score exceeding 30. More than one surgical procedure was accepted to maximize resection before adjuvant treatment. The adjuvant chemotherapy protocols were approved by the
Results
From 1994 to 2003, 41 patients—(23 boys and 18 girls, with a median age of 22 months (range, 3–36 months)—were treated at 14 AIEOP centers. At the time of this report, the median follow-up for the surviving children was 100 months (range, 14–181 months). Patients were divided by age at diagnosis into three groups: 4 patients were under 1 year old, 22 were between 1 and 2 years old, and 15 were over 2 years old. Fourteen children were treated with regimen I, and the other 27 children were
Discussion
In the early 1990s, many multiinstitutional clinical trials on malignant brain tumors occurring in children under 3 years old were designed mainly with a view to postponing RT. This approach was prompted by the favorable results reported in 1993, for some histologic subtypes at least, by Duffner et al. (2), who used chemotherapy systematically for malignant brain tumors, deferring any RT until the child reached the age of 3.
The harmful effects of RT, which are particularly severe in young
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Supported in part by the Associazione Italiana per la Ricerca sul Cancro.
Conflict of interest: none.