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BACKGROUND: Decreased peripheral lymphocyte counts are associated with outcome after RT in several solid tumors, though appear late during or after the radiation course and often correlate with other clinical factors. Here we investigate if absolute lymphocyte counts (ALC) are independently associated with recurrence in pediatric medulloblastoma early during RT. METHODS: We assessed 202 medulloblastoma patients treated between 2000 and 2016 and analyzed ALC throughout therapy, focusing on both early markers (ALC during week 1 – ALC(wk1); grade 3+ Lymphopenia during week 2 – Lymphopenia(wk2)) and late markers (ALC nadir). Uni- and multivariable regressions were used to assess association of clinical and treatment variables with ALC and of ALC with recurrence. RESULTS: Thirty-six recurrences were observed, with a median time to recurrence of 1.6 years (Range 0.2–10.3) and 7.1 years median follow-up. ALC during RT was associated with induction chemotherapy (p

Background Treatment for pediatric ependymoma includes surgical resection followed by local radiotherapy (RT). Proton RT (PRT) enables superior sparing of critical structures compared with photons, with potential to reduce late effects. We report mature outcomes, patterns of failure, and predictors of outcomes in patients treated with PRT. Methods One hundred fifty patients ( Results Median follow-up was 6.5 years. EFS, OS, and LC for the intracranial cohort (n = 145) at 7 years were 63.4%, 82.6%, and 76.1%. Fifty-one patients recurred: 26 (51.0%) local failures, 19 (37.3%) distant failures, and 6 (11.8%) synchronous failures. One hundred sixteen patients (77.3%) underwent gross total resection (GTR), 5 (3.3%) underwent near total resection (NTR), and 29 (19.3%) underwent subtotal resection (STR). EFS for the intracranial cohort at 7 years for GTR/NTR and STR was 70.3% and 35.2%. With multivariate analysis, the effect of tumor excision persisted after controlling for tumor location. There was no adverse effect on disease control if surgery to RT interval was within 9 weeks of GTR/NTR. Conclusion PRT is effective and safe in pediatric ependymoma. Similar to previous studies, GTR/NTR was the most important prognostic factor. Intervals up to 9 weeks from surgery to PRT did not compromise disease outcomes. There was no LC benefit between patients treated with >54 Gray relative biological effectiveness (GyRBE) versus ≤54 GyRBE.

Background Survivors of pediatric medulloblastoma experience long-term morbidity associated with the toxic effects of postoperative radiotherapy (RT). Proton RT limits radiation dose to normal tissues thereby reducing side effects of treatment while maintaining high cure rates. However, long-term data on disease outcomes and long-term effects of proton RT remain limited. Methods One hundred seventy-eight pediatric medulloblastoma patients treated with proton RT between 2002 and 2016 at the Massachusetts General Hospital comprise the cohort of patients who were treated with surgery, radiation therapy, and chemotherapy. We evaluated event-free survival (EFS), overall survival (OS), and local control using the Kaplan-Meier method. The cumulative incidence of brainstem injury and secondary malignancies was assessed. Results Median follow-up was 9.3 years. One hundred fifty-nine patients (89.3%) underwent a gross total resection (GTR). The 10-year OS for the entire cohort, standard-risk (SR), and intermediate/high-risk (IR/HR) patients was 79.3%, 86.9%, and 68.9%, respectively. The 10-year EFS for the entire cohort, SR, and IR/HR cohorts was 73.8%, 79.5%, and 66.2%. The 10-year EFS and OS for patients with GTR/NTR were 75.3% and 81.0% vs 57.7% and 61.0% for subtotal resection (STR). On univariate analysis, IR/HR status was associated with inferior EFS, while both anaplastic histology and IR/HR status were associated with worse OS. The 10-year cumulative incidence of secondary tumors and brainstem injury was 5.6% and 2.1%, respectively. Conclusions In this cohort study of pediatric medulloblastoma, proton RT was effective, and disease outcomes were comparable to historically treated photon cohorts. The incidence of secondary malignancies and brainstem injury was low in this cohort with mature follow-up.

Purpose/objective(s) CNS Atypical teratoid rhabdoid tumor (ATRT) are rare with poor outcomes. Despite known leptomeningeal spread no consensus exists regarding focal or craniospinal radiation (CSI), typically given after surgery and chemotherapy. We queried the Pediatric Proton/Photon Consortium Registry (PPCR), which prospectively collates tumor, treatment, and outcome data from all consenting pediatric patients treated with radiotherapy (RT) at 19 institutions, for impact of RT dose and volume. Materials/methods PPCR identified 65 evaluable ATRT patients (2012-2019). Overall survival (OS) analysis was performed using Kaplan Meier and log-rank P-values. Cox proportional hazards regression was used to determine hazard ratios among variable groups. Median follow-up was calculated using the reverse Kaplan Meier method. Results Median age was 6.7 years (range 2.6-21.4) and median follow-up was 23.4 months (1.3-70.7). Patients had surgery, chemotherapy and proton radiation. Thirty-three (51%) had initial gross total resection (GTR). Stage was M0 (88%), M+ (11%), or unknown (1%). Two-year OS (n = 65) was 64%; for M0 patients 65% and for M+ patients 38% (P = 0.5). For M0 patients, 48 (84%) had focal RT (median 54 Gy, 50.4-55.8 Gy) and 9 (16%) had CSI (median 36 Gy, 23.4-39.6 Gy) followed by boost (median 54 Gy, 52.2-55.8 Gy). Two-year OS (M0 patients) for focal RT was 63% and for CSI was 80% (HR 1.9, P = 0.5). Two-year EFS (M0) for focal RT was 51.9% and for CSI was 80% (HR 2.8, P = 0.3). There were 14 recurrences (4 local, 8 leptomeningeal, 2 combined) which occurred in M0 patients receiving focal RT compared to no recurrences for 9 M0 patients with CSI (P = 0.095). Local control at 2 years (n = 54, Table) with primary dose ≥ 54Gy (n = 33) was 100% compared to 84.2% for 50.4Gy (n = 21, P = 0.02). Local control with GTR (upfront or re-resection) was similar (n = 51, Table) to lesser surgery extent. In 7 M+ patients, 3 with focal RT are alive and 2 of 4 with CSI are alive. For all patients, risk of death (P = 0.8) and progression (P = 1.0) were not different for focal versus CSI. Overall risk of death was also not significant achieving GTR versus subtotal resection (STR) (HR 0.85, P = 0.7). Conclusion To our knowledge, this is the largest series of ATRT treated with RT and hypothesis generating for optimal radiation field (CSI or focal) in M0 patients and cumulative dose (50.4Gy or 54Gy). Practice patterns strongly favored focal RT and 54Gy showed improved local control. CSI may reduce risk of recurrence but few patients received CSI. Analyses of chemotherapy selection are pending. Further study of radiation field in ATRT will be challenging given prohibitive toxicity of CSI in infant brain tumors. Patterns of failure analyses of ACNS 0333, using high dose chemotherapy and focal RT in M0 ATRT with encouraging results, are warranted and in progress.

Background The purpose of this analysis is to report long-term health-related quality of life (HRQoL) among brain tumor survivors treated with proton therapy (PRT) at a very young age. Methods Fifty-nine children Results The median age was 2.5 years (range, 0.3–3.8) at PRT and 9.1 years (5.5–18) at last follow-up. The most common diagnoses were ependymoma (n = 22) and medulloblastoma (n = 7). Median follow-up is 6.7 years (3–15.4). Follow-up mean CSR and PPR scores were: total core (78.4 and 72.9), physical (82.9 and 75.2), psychosocial (76.0 and 71.6), emotional (74.4 and 70.7), social (81.2 and 75.1), and school (72.4 and 69.9). Parent-reported HRQoL fell within a previously defined range for healthy children in 37.5% of patients, and for children with severe health conditions in 45% of patients. PPR HRQoL was stable from baseline to last follow-up among all domains except for social functioning. History of gastrostomy tube was significantly associated with poorer CSR and PPR HRQoL on multivariable analysis. Ninety percent of children functioned in a regular classroom, 14 (36%) used a classroom aid, 9 (23%) used an outside tutor, and 18 (46%) had an individualized education plan. Conclusion Long-term HRQoL among brain tumor survivors treated with PRT at a very young age is variable, with over a third achieving HRQoL levels commensurate with healthy children. Key Points 1. One third of survivors reported long-term HRQoL scores comparable to those of healthy children. 2. Treatment for hydrocephalus or a feeding tube was associated with significantly lower HRQoL. 3. Total core HRQoL scores remained stable from baseline to last follow-up.

BACKGROUND To the authors' knowledge, health-related quality of life (HRQOL) outcomes are not well described in patients with medulloblastoma. The use of proton radiotherapy (RT) may translate into an improved HRQOL. In the current study, the authors report long-term HRQOL in patients with proton-treated pediatric medulloblastoma. METHODS The current study was a prospective cohort HRQOL study of patients with medulloblastoma who were treated with proton RT and enrolled between August 5, 2002, and October 8, 2015. Both child report and parent-proxy report Pediatric Quality of Life Inventory (PedsQL) surveys were collected at baseline during RT and annually thereafter (score range on surveys of 0-100, with higher scores indicating better HRQOL). Patients were dichotomized by clinical/treatment variables and subgroups were compared. Mixed-model analysis was performed to determine the longitudinal trajectory of PedsQL scores. The Student t test was used to compare long-term HRQOL measures with published means from a healthy child population. RESULTS Survey data were evaluable for 116 patients with a median follow-up of 5 years (range, 1-10.6 years); the median age at the time of diagnosis was 7.6 years (range, 2.1-18.1 years). At baseline, children reported a total core score (TCS) of 65.9, which increased by 1.8 points annually (P

BACKGROUND: Standard treatment for medulloblastoma in children over age 3 includes resection and radiotherapy, followed by chemotherapy. Some studies have found disease control decrements if chemotherapy was delivered before radiotherapy. However, these studies recommended radiation interruptions for hematologic toxicity, which were more severe in children receiving chemotherapy prior to craniospinal radiotherapy. We report outcomes of pediatric medulloblastoma patients treated post-operatively with radiotherapy-first (RT1) or chemotherapy-first CT1). POPULATION/ METHODS: 206 patients age 2–23 years with medulloblastoma were treated with proton radiotherapy from May 2000 to December 2016. We analyzed the effect of sequencing radiotherapy first (n=164) or chemotherapy first (n=42) after surgery on event-free (EFS) and overall survival (OS) controlling for known risk factors. RESULTS: Median follow-up was 5.8 years. Children who received CT1 sequencing were younger (p

Consistent follow-up and data collection are necessary to identify long-term benefits/detriments of proton radiotherapy. Obtaining comprehensive clinical follow-up can be difficult and time-intensive for proton centers. Here we evaluate what factors affect maximum follow-up time among MGH Pediatric Proton Consortium Registry (PPCR) participants.Enrollment in the PPCR was offered to any patient22 years receiving protons. Patients were excluded from analysis if they were taken off study due to death or withdrawal. Distance from MGH was calculated by the great-circle formula. We utilized both univariate and multivariate analyses to determine risk factors associated with follow-up time.333 PPCR patients enrolled between 10/2012 and 03/2017 were included. Median follow-up was 2.4 years (1-5.5), and median distance away from the proton center was 256.4 km (1.6-16,949.6). Distance from MGH significantly predicted follow-up time: patients living outside the Boston Metropolitan Statistical Area,121 km from the proton center, had average follow-up that was 0.53 years less compared to those living within 121 km (p = 0.0002). Loss in average follow-up was also associated with Medicaid insurance, treatment delay due to insurance, and non-White race. Those co-enrolled on a proton trial or seen at a facility had significantly increased follow-up by almost one year (p 0.0001).Patients living further from treating proton center have shorter follow-up durations. Increased distance from treating centers may adversely affect clinical outcomes research. Enhanced sharing of medical information among care providers and improved collection methods are needed to effectively evaluate the benefits of proton therapy.

BACKGROUND: Radiotherapy to the cochlea and cisplatin exposure are both associated with hearing loss (HL) in medulloblastoma survivors. Here we report late outcomes in survivors with ≥1 year audiogram testing. METHODS: Prospective medulloblastoma trial participants (clinicaltrials.gov: NCT01063114/NCT00105560) with ≥1 years of audiogram follow-up (FU, n=110 pts) comprised the study cohort. HL was graded using the SIOP-Boston ototoxicity scales (0-4) for each ear. Associations between grade 3 HL and mean cochlear radiation dose and cumulative cisplatin dose were evaluated. Target cisplatin dose was 450 mg/m2 but most patients did not receive full dose as dose reductions were used when ototoxicity was detected during chemotherapy. FINDINGS: Median follow-up was 4.0 years (range 1-10). At baseline, 10 ears (4.5%) had grade 3 HL. At latest FU, an additional 49 ears developed grade 3 HL (23.3%). There was no grade 4 HL. Median average cochlear dose across both ears was 29.9 Gy (20.8-50.6) and median cisplatin dose was 375.0 mg/m2 (60.0-583.0). Mean cochlear radiation dose for grade 3 HL (n=56) was 32.5Gy (24.1-47.0), compared with 31.8Gy (20.8-50.6, p=0.19). Mean cisplatin dose for grade 3 HL was 347.3mg/m2 (180.0-450.0), compared with 374.2mg/m2 for grade 0-2 ears (60.0-583.0, p=0.05). INTERPRETATION: Significant hearing deficits (SIOP-Boston grade 3) develop in approximately 23.3% of medulloblastoma patients. In this cohort, higher mean radiation dose did not affect HL rates. The lower mean cumulative cisplatin dose in pts with grade 3 HL suggests cisplatin ototoxicity is driving HL, and that host susceptibility may play a role.

Background/objectives The Pediatric Proton Consortium Registry (PPCR) was established to expedite proton outcomes research in the pediatric population requiring radiotherapy. Here, we introduce the PPCR as a resource to the oncology community and provide an overview of the data available for further study and collaboration. Design/methods A multi-institutional registry of integrated clinical, dosimetric, radiographic, and patient-reported data for patients undergoing proton radiation therapy was conceived in May 2010. Massachusetts General Hospital began enrollment in July of 2012. Subsequently, 12 other institutions joined the PPCR and activated patient accrual, with the latest joining in 2017. An optional patient-reported quality of life (QoL) survey is currently implemented at six institutions. Baseline health status, symptoms, medications, neurocognitive status, audiogram findings, and neuroendocrine testing are collected. Treatment details of surgery, chemotherapy, and radiation therapy are documented and radiation plans are archived. Follow-up is collected annually. Data were analyzed 25 September, 2017. Results A total of 1,854 patients have consented and enrolled in the PPCR from October 2012 until September 2017. The cohort is 55% male, 70% Caucasian, and comprised of 79% United States residents. Central nervous system (CNS) tumors comprise 61% of the cohort. The most common CNS histologies are as follows: medulloblastoma (n = 276), ependymoma (n = 214), glioma/astrocytoma (n = 195), craniopharyngioma (n = 153), and germ cell tumors (n = 108). The most common non-CNS tumors diagnoses are as follows: rhabdomyosarcoma (n = 191), Ewing sarcoma (n = 105), Hodgkin lymphoma (n = 66), and neuroblastoma (n = 55). The median follow-up is 1.5 years with a range of 0.14 to 4.6 years. Conclusion A large prospective population of children irradiated with proton therapy has reached a critical milestone to facilitate long-awaited clinical outcomes research in the modern era. This is an important resource for investigators both in the consortium and for those who wish to access the data for academic research pursuits.